Pathology
Decompression of Odontogenic Cystic Lesions: Past, Present, and Future

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Tumors and cystic lesions of the jawbones have been described since the late 1600s and it took another 200 years for classification systems to appear in the medical, surgical, and dental literatures. In the late 1800s, Carl Partsch introduced cystostomy, a method by which the cyst is converted into a pouch by suturing its lining to the mucosa of the oral cavity. The purpose of this article is to analyze the history, present, and future of cystic conditions of the jaws and decompression, a modality of treatment that during the past few years has regained the attention of oral and maxillofacial surgeons and pathologists owing to its relative simplicity and effectiveness compared with other conservative options.

Section snippets

Early Descriptions of Odontogenic Entities

The texts by Bunting2 and Thoma,3 published in 1929 and 1941, respectively, were the epitome of work that had started 3 centuries previously, mostly with French and British doctors. For example, in 1671 Iean Scultet4 described cysts of the jaws as “liquid tumors.” The idea that a cyst was capable of exerting enough pressure to cause bony expansion was formed at that time.5 In 1746 Pierre Fauchard6 provided the first accurate description of an odontoma. In 1774 John Hunter7 described what seems

Classifying Odontogenic Tumors

Owing to the increased activity in research and the wide variety of reports on the subject in Europe and the Americas, in 1869 Paul Pierre Broca12 published Traité des tumeurs, where he suggested the first classification of OTs:

  • I.

    Ordinary odontomas

    • 1.

      Embryoplastic period

      • Embryoplastic odontomas

        • Fibroplastic

        • Fibrous

    • 2.

      Odonto-plastic period

      • Odonto-plastic odontomas

        • Cemental

        • Bulbar

    • 3.

      Crown formation period

      • Coronal odontomas

        • Cemental

        • Pulpal or dentinal

    • 4.

      Root formation period

      • Radicular odontomas

        • Cemental

        • Dentinal

  • II.

    Composed

Classification of Odontogenic Cysts

At the beginning of the 20th century, a myriad of tooth-related cystic conditions had been described and a classification system was urgently needed.17 In his 1937 oral diagnosis and treatment planning textbook, Thoma18 subdivided the classification of the follicular cyst in the following manner:

  • 1.

    Simple (without tooth formation)

  • 2.

    Dentigerous

  • 3.

    With odontoma

In 1949 he added a fourth category, the multiple cyst.19

Also in 1937, Hamilton Robinson,20 one of the most influential early oral pathologists in

Rise and Fall of Decompression: the Past

Understanding the behavior of benign and malignant conditions of the maxillofacial region has taken almost 4 centuries, if the work of Scultet4 is used as a starting point. Four hundred years of research have helped to not only undress these pathologies to the point of knowing them as they are, but also to understand how they are best treated. Long before World War II, investigators knew that odontogenic cysts and tumors had the potential to recur, regardless of the treatment modality used.

Reborn as the Phoenix: the Present

In 1991 an article by Brøndum and Jensen45 paved the way for the reintroduction of marsupialization and decompression, which recently had resurrected like the Phoenix. In 1996 Marker et al46 successfully decompressed 23 odontogenic keratocysts using small polyethylene tubes (Fig 6). They concluded that decompression resulted in new bone formation, thickening of the cyst wall, and conservation of bone and anatomic structures. Another interesting conclusion was that the keratocyst epithelium was

The Future of Decompression

Decompression, as any other treatment technique, is not a panacea. The benefits of this old method have been described and proved over the years, and as patients and surgeons become less aggressive, this technique will become more popular when indicated. Cases must be carefully selected and the surgeon has to weigh many factors, such as patient age, type of lesion and time of evolution, and the patient's cooperation.

A Closing Remark: Introduction and Acceptance of a Pleonasm

To the unprepared eye, the word pleonasm might be confused with neoplasm, but they are different! A pleonasm is the use of more words than necessary to convey meaning, as a fault of style or for emphasis. This seems to be the case of the expression odontogenic origin, which was introduced to the dental literature in the late 1970s. In this sense, Shafer's Textbook of Oral Pathology52, a book widely used in North American and Latin American dental schools, helped disseminate the pleonasm. In the

Acknowledgments

The artwork included in this article was done beautifully by Glenna Castro-Núñez, to whom the author expresses his most sincere gratitude. A word of gratitude is extended to the American Board of Oral and Maxillofacial Pathology, especially to Clarita Scioscia, for her invaluable assistance during the preparation of this article.

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