CYSTS OF THE MAXILLA CONNECTED WITH 
THE TEETH. WITH REPORT OE A CASE. 
BY 
FRANK W. JAY, M.D., 
OP CHICAGO, ILL. 
FROM 
THE MEDICAL NEWS, 
April 6, 1895. [Reprinted from The Medical News, April 6, 1895.] 
CYSTSOF THE MAXILLA CONNECTED WITH 
THE TEETH, WITH REPORT OF A CASE. 
By FRANK W. JAY, M.D., 
OF CHICAGO, ILL. 
Cysts of the maxilla, resulting from the prolifera- 
tion in the substance of the bone of the epithelial 
cells composing a tooth-matrix which has not made its 
way to its normal situation in the alveolar process, 
but which has remained imbedded in the bone, are 
not a strange pathologic condition to the surgeon or 
the pathologist. Cyst-formation resulting from the 
displaced matrix of a tooth is of scientific interest 
because of its bearing upon Cohnheim’s theory of 
tumor formation by cell-proliferation from a matrix 
of embryonal cells. In the case of a dentigerous 
cyst there is an inclusion in the mesoblastic bone 
of the epithelial cells of the tooth-matrix, which cells 
at some subsequent period undergo proliferation 
that may be typical or atypical, and become pro- 
ductive of a neoplasm that in almost every instance 
is a cyst. In the production of a dentigerous cyst, 
however, there is no necessity for the presence of 
the matrix of embryonal cells insisted upon by 
Cohnheim as being essential in the production of a 
true tumor. The cells composing the matrix may 
be typical in every respect, and are productive 
of a cyst l>ecause they are compelled to carry out 2 
their life-history in an abnormal situation, with re- 
tention of fluid in the cavity produced during the 
attempt at tooth-formation. There is no pro- 
gressive and atypical growth of the epithelial struc- 
ture characteristic of a true cystoma. This variety 
must be classified as retention-cysts, but they differ 
materially from what are at the present time described 
as retention-cysts, e. g., in which there is occlusion of 
the outlet of some otherwise normal secreting struc- 
ture, with consequent retention, the most frequently 
met examples of which are the sebaceous cysts or 
wens. The retention-cysts due to inclusion of epi- 
thelial cells in the mesoblast should be called 
retention-cysts from inclusion, in contradistinction to 
the retention-cysts from occlusion. 
Another variety of dentigerous cysts that must be 
differentiated pathologically from the retention- 
cysts just described is produced when the epithelial 
cells composing the imbedded tooth-matrix serve 
as a true tumor-matrix, and by exhibiting an atyp- 
ical and lawless proliferation, perhaps without the 
slightest evidence of tooth-formation, become pro- 
ductive of a true proliferating cystoma, with the 
formation of numerous cyst-cavities. In the sim- 
ple variety, i. e., the retention-cyst, from an in- 
cluded tooth-matrix the progressive enlargement 
is due to tension, as the contents of the cyst in- 
crease, and, while there is the same influence of 
tension exerted in the true cystoma, there is what 
is more important and characteristic, /. e., the 
increase in the epithelial neoplasm as the result 
of the unlimited cell-proliferation. 
We therefore divide cysts of the maxilla result- 3 
ing from displaced tooth-matrices into the follow- 
ing two varieties : 
Unilocular dentigerous cysts, resulting from the 
matrix of a temporary or permanent tooth failing 
to find its way to the alveolar border of the jaw, 
and the cells of which matrix have subsequently 
undertaken the completion of their inherited capac- 
ity, viz., the formation of a perfect tooth, with the 
various pathologic conditions possible to result from 
even a typical cell-proliferation in this abnormal 
situation. Such a cyst is not necessarily a true 
tumor, but may be simply “ a retention of fluid 
between the cuticular dentis and the crown of the 
tooth, distending the tooth-follicle into a cyst lined 
with epithelium, and containing in some part of its 
wall, or, more rarely, free in its cavity, a more or 
less completely developed tooth, or even teeth.” 
(Hektoen.) 
This variety is the cogener of a cyst resulting 
from retention of a Graafian follicle in the stroma of 
the ovary, with accumulation of fluid in the cavity 
by transudation and mucous degeneration of the 
epithelial cells lining the cyst-cavity, and which has 
an entirely different pathology from a multilocu- 
lar or proliferating cystoma of the ovary, which 
also arises from the retention of a Graafian follicle, 
but which is an allied condition to the second variety, 
e. g., the multilocular or proliferous dentigerous cysts, 
which the imbedded epithelial cells constitute a 
true tumor-matrix, and by exhibiting unlimited pro- 
liferating capacity, give rise to a constant and pro- 
gressive extension of the epithelial neoplasm in the 
substance of the jaw. This variety must be con- 4 
sidered as a true cystoma. We have not included 
in this classification of dentigerous cysts those found 
in connection with the roots of the erupted teeth. 
According to Magitot, they are due to inflamma- 
tory processes, with retention of the product of such 
inflammation in the apical cavity. 
Dentigerous cysts may, of course, become carcin- 
omatous, as may an epithelial structure in any lo- 
cality. 
There are interesting points in the pathology of 
cysts resulting from the inclusion of epithelial cells 
in the mesoblast that will call for solution in the 
future. The simple dermoids and branchial cysts 
have as interesting a relation to Cohnheim’s theory 
of tumor-formation as have the dentigerous cysts 
and the cysts of the ovary. We may well ask, for 
instance, which of the branchial cysts to call tumors 
and which simply retention-cysts. To be sure, 
the epithelial cells are displaced in every case; 
but being where they are they show no atypical 
tendencies when they exhibit a lawful prolifera- 
tion and continue to line the cyst-cavity as its 
size increases from distention. As the lumen of 
a varicose vein increases, the endothelial cells still 
continue to cover its interior; it takes an increased 
number to do so, and new endothelial cells are pro- 
duced, but this does not allow the pathologist to 
classify the new endothelial cells as a variety of endo- 
thelioma. At the present stage of our knowledge 
concerning the etiology of tumor-formation, these 
differences strike one as very theoretic, but the his- 
tology of the future will demonstrate them to be real. 
The clinical differences are well drawn between 5 
the retention-cysts from inclusion and the true 
proliferating cystomata. As an example, we may 
call attention to a branchial fistula, perhaps congen- 
itally established. Here there is no retention, and 
consequently no development of a cyst, and if the 
fistula does not become occluded there will be no 
swelling unless infection occurs, because the prolifera- 
tion of the epithelial cells lining the fistula does not 
give rise to a new-growth. This cannot be considered 
characteristic of a tumor. In the retention-cyst from 
inclusion the contents of the cyst do not represent 
the products of cell-proliferation. The fluid accumu- 
lates from transudation and perhaps secretion by the 
lining of the cyst; this is not characteristic of a true 
tumor.1 
The case I desire to report is interesting and in- 
structive from the fact that the cyst was the result of 
an imbedded supernumerary tooth-matrix, and the 
cyst-cavity was a considerable distance from the 
alveolar border of the jaw. In consequence of these 
conditions, the case illustrates some important facts 
regarding the diagnosis of the rarest form of cysts of 
the maxilla connected with the teeth, viz., dentig- 
erous cysts arising from a displaced supernumerary 
tooth-matrix. 
When the imbedded matrix is that of a permanent 
tooth eruption does not take place, and the examin- 
1 The etiology, pathology, and treatment of cysts of the maxilla 
connected with the teeth are thoroughly treated in the chapter 
in Holmes’ “ System of Surgery,’’ devoted to surgical diseases 
connected with the teeth, which was written originally by S. James 
A. Salter, F.R.S. A paper containing a resume of the literature 
was published by Hektoen in the Annual Report of Cook County 
Hospital of Chicago for the year ending 1890. 6 
ation will show an absence of the tooth from its nor- 
mal situation in the alveolar process, and the history 
will reveal to the surgeon that this tooth never made 
its appearance. A dentigerous cyst arising from the 
imbedded matrix of a temporary tooth will have the 
history of absence of a deciduous tooth and subse- 
quent interference with the passage of the correspond- 
ing permanent tooth in its journey to the alveolar 
process of the jaw. Consequently the absence of a 
tooth from its normal location in the alveolar pro- 
cess is the guide-post pointing to the diagnosis of a 
dentigerous cyst. It is evident that this history and 
sign are absent when the imbedded matrix is that 
of a supernumerary tooth. The degree of displace- 
ment of the matrix and the location of the resulting 
cyst will have some influence on the diagnosis, es- 
pecially when the teeth are normal in number. In 
the case here reported the cyst-cavity was situated in 
the palatine process of the superior maxilla, and had 
no apparent connection with the teeth. In such a 
condition the diagnosis will be difficult, and probably 
a simple conjecture. Cases have been reported in 
which the cyst was situated in the palate bone, and 
even in the orbit. 
The imbedding and displacement of a tooth ma- 
trix are due to one or more of the following causes: 
a perfect tooth may be prevented from reaching the 
alveolus by the retention of a temporary tooth ; the 
tooth may develop too deeply in the bone; it may 
grow in a wrong direction ; the development of the 
fang may become arrested, or there may be some 
diminution in the size of the space in the alveolar 
border. (Salter.) 7 
A projK-T diagnosis is of considerable importance, 
as is illustrated by the numerous cases that have 
been subjected to resection of the affected bone 
under a diagnosis of sarcoma, and in fact, if the 
case is allowed to progress, especially in the prolif- 
erating cystomata, this treatment may be called for 
even under a correct diagnosis. If a simple dentig- 
erous cyst opens externally through pressure atrophy 
exerted upon the surrounding bone, the relief of 
tension will put an end to the progressive enlarge- 
ment of the bone. In the proliferating cystomata 
this is not the case, and progressive extension of 
the disease will still go on, unless the suppurative 
process has destroyed the entire tumor-matrix. In 
either variety we have the relief of tension and the 
addition of an infection with pus-microbes. In 
the simple unilocular variety the pathologic con- 
dition now consists of an infected cavity of the 
maxilla, which may or may not contain an infected, 
more or less perfectly developed tooth, and a sinus 
that remains open and discharging, or that closes 
and opens at varying intervals. 
The case reported was one of a simple dentigerous 
cyst in the condition described, and in such cases a 
proper diagnosis is not required to lead the surgeon 
to institute the proper treatment, viz.: opening the 
cavity in the bone, removing the infected unabsorb- 
able body, disinfecting the bone-cavity and treating 
it in one of the several ways, viz.: by packing with 
gauze, and allowing it to heal by granulation ; or 
by endeavoring to secure a rapid definite healing; 
by packing with Senn’s decalcified bone chips; or 
by allowing it to fill by Schede’s blood-clot. 8 
The difficulty of preventing post-operative wound- 
infection in the cavity of the mouth will make the 
packing of the cavity with gauze the only practical 
method to adopt. 
The history and examination of the case revealed 
the following : The patient is a healthy farmer, aged 
forty-six years. Upon examination a sinus is found just 
to the right of the median line, at the reflection of the 
mucous membrane from the jaw to the upper lip, 
leading directly backward for an inch into a cavity 
situated in the palatine process of the superior max- 
illa and between the roof of the mouth and the floor 
of the right nasal fossa. An examination in these 
localities demonstrates convexities that correspond 
to the location of the cavity found in the bone with 
the probe. There is no enlargement on the anterior 
surface of the jaw, nor can craquement be elicited 
over the cavity. Discharge of pus is constant but 
slight. Injection of hydrogen dioxid into the sinus 
demonstrates the absence of any other opening into 
the cavity in the bone. The man’s teeth are nor- 
mal in number, location, and appearance, and are 
only remakable for their perfection. The sinus is 
an inch and a-half directly above the first right 
incisor. The patient remembers that the eruption of 
his permanent teeth was devoid of abnormality, and 
his parents say that his milk-teeth made their 
appearance and gave way to the permanent teeth in 
an apparently normal manner. His permanent in- 
cisors appeared at seven years of age, and the other 
teeth appeared without incident. On August 18, 
1867, he received a severe blow on the upper jaw, 
and to which he attributed an enlargement of the 
bone on the roof of the mouth that he discovered in 
1870, and that corresponded to the swelling now 
present, and that has, according to the patient’s state- 9 
ment, remained without change in size since he first 
discovered it. The increase in size probably has 
been so gradual that it has not been apparent to 
him. I cannot imagine the sudden discovery of a 
swelling of the size found in the roof of the mouth 
at the present time. 
In 1873, without any history of pain or dis- 
comfort, fluctuating swelling made its appearance 
beneath the mucous membrane covering the ante- 
rior surface of the upper jaw; the center of this swell- 
ing was a little below the situation of the present 
sinus. This swelling was incised by a physician, and 
the patient says a thimbleful of black, clotted blood 
escaped. The incision healed in a few days, and at- 
tention was not even attracted to this locality until 
1881, when there was a recurrence of a similar fluc- 
tuating swelling that made its appearance in the same 
locality and in the same painless manner as in 1875. 
This was incised, healed in a few dajs, and there 
was no recurrence till 1884, when the same treat- 
ment was gone through, and this same cycle of pain- 
less swelling, incision, discharge of dark fluid, with 
subsequent rapid healing, was repeated a number of 
times between 1884 and 1892, the intervals gradually 
lessening. In 1892 the swelling was for the first 
time painful, and upon incision pus was evacuated. 
The physician in attendance made a larger incision 
than had been made at any other time and packed 
the cavity beneath the mucous membrane with 
gauze, but did not at that time express the opinion 
that there was a lesion of the bone. Since then the 
sinus has remained open and discharging, and the 
affection has been painless. 
A diagnosis was not made further than to conclude 
that there was an infected cavity in the bone which 
should be opened, disinfected, and drained. An 
operation was, therefore, advised. Under ether 10 
the anterior wall of the cavity was chiseled away, 
making an opening the size of a nickel five-cent 
piece. This cavity was the size of a hickory-nut, 
and the walls, which consisted of porous bone, 
were thoroughly curetted. During the curetting an 
imperfectly formed tooth of the size of a grain of 
corn was removed, which gave the appearance of 
the crown of an incisor covered on all but one of 
its surfaces with a slightly discolored dentine that 
was eroded in spots. The tooth was fixed in the 
wall of the cavity, but upon what aspect was not 
determined. The finding of this tooth made the 
diagnosis. However, it must be remarked that 
while the presence of a tooth in any stage of devel- 
opment in a cavity in the maxilla makes a diagnosis 
of some variety of dentigerous cyst imperative, the 
converse is not the case, for there may be the pro- 
duction of a most progressive cystoma from a tooth- 
matrix without the slightest exhibition of tooth- 
formation. In such a case the microscopic examina- 
tion of the lining of the cavity would demonstrate 
the presence of epithelial cells, unless, as before 
mentioned, the cyst-cavity had become infected 
with pus microbes, and the epithelial structure had 
been destroyed by their action. 
The cav.ty was packed with iodoform-gauze and 
healed rapidly. It was situated in the palatine process 
of the superior maxilla, and its size was compensated 
for by the convex projections found in the roof of 
the mouth and the floor of the right nasal fossa. The 
cavity was evidently produced by the interosseous 
tension resulting from the cyst-formation, and pro- 
ducing a bulging of the bone in the direction of 
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