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Odontogenic Keratocyst The Pathological Outcomes Related to Symptomatic Impacted Third Molars and Follicles as found in a Private Practice in South Africa By Brian Mark Berezowski Dissertation presented for the degree of Doctor of Philosophy (Surgery) at the University of Cape Town University of Cape Town Supervisors: Professor D. Kahn CH.M.F.C.S (SA) Professor VM Phillips PhD Date: November 2013 The copyright of this thesis vests in the author. No quotation from it or information derived from it is to be published without full acknowledgement of the source. The thesis is to be used for private study or non- commercial research purposes only. Published by the University of Cape Town (UCT) in terms of the non-exclusive license granted to UCT by the author. University of Cape Town INDEX Page Declaration ................................................................................................................................ iv Abstract ..................................................................................................................................... v Acknowledgements ................................................................................................................. vii List of Tables ......................................................................................................................... viii List of Graphs ............................................................................................................................x List of Figures ......................................................................................................................... xii Chapter 1 Content: Hypothesis and Aims of the study: ...........................................................xviii Chapter 2 Content: Review of the literature.............................................................................. xix Chapter 3 Content: Patients, Methods and Materials ............................................................... xxi University of Cape Town Chapter 4 Content: Results ..................................................................................................... xxii Chapter 5 Content: Discussion ................................................................................................ xxiii Chapter 6 Content: Conclusion .............................................................................................. xxiv Chapter 7 Content: References .............................................................................................. xxiv Chapter 8 Content: Addendum ............................................................................................... xxiv ii Chapters Chapter 1 Hypothesis and Aims of the study ............................................................................... 1 Chapter 2 Review of the literature .............................................................................................. 3 Chapter 3 Patients, Methods and Materials ............................................................................... 59 Chapter 4 Results ..................................................................................................................... 67 Chapter 5 Discussion..............................................................................................................117 Chapter 6 Conclusion..............................................................................................................130 Chapter 7 References.............................................................................................................132 Chapter 8 Addendum..............................................................................................................149 University of Cape Town iii Declaration I, the undersigned, hereby declare that the work contained in this dissertation is my own original work and that I have not previously in its entirety or in part submitted it at any University for a degree. Signature: Date: November 2013 University of Cape Town iv ABSTRACT The management of impacted third molar teeth remains controversial and unresolved. Arguments in favour and against removal of impacted third molar teeth are plentiful and convincing.Most publications do not specify whether the patient suffered systemic or local symptoms. Pathological lesions associated with impacted third molar teeth have been studied to a limited extent. Previous studies have been restricted to relatively small numbers of patients. The aim of this study primarily was to review pathological reports of all symptomatic third molar teeth removed in a private practice, and to use the data to support or refute routine removal of third molar teeth. All patients who underwent third molar tooth removal for symptoms,either systemic or local ,in a private practice over a twenty year period between 1987 and 2007 were included in the study. Specimens were sent for histological assessment by Oral Pathologists. The patient records were reviewed retrospectively.University of Cape Town A total of 3427 third molar teeth were included in the study. There were 68.75% specimens which had some sort of pathology. Only 0.3% of specimens were reported as normal dental follicular tissue. There were 31.25% specimens of hyperplastic follicular tissue which was considered non pathologic as they consisted of normal dental follicular tissue with a mild chronic inflammatory cell infiltrate. However the 68.75% pathologic lesions consisted of 14.44% specimens with early v dentigerous cysts, 8.11% with dentigerous cysts, 42.80% of paradental cysts and the remainder with other pathologies. The majority of the patients were in the second and third decades and mostly female. The age distribution of the patients suggested a progression from hyperplastic follicular tissue with a peak occurring at 17 years, to early dentigerous cysts at 19 years, to dentigerous cysts at 21 years. Paradental cyst formation, with a peak incidence at 19 years of age formed a large number of the pathological lesions found, and accounted for a large number of patients seeking treatment, owing to the symptoms associated. This study represents an analysis of the largest number of symptomatic third molar teeth submitted for histological assessment known. The data obtained was used to review the guidelines for the management of third molar teeth. From this study it can be concluded that symptomatic impacted third molar teeth should be removed early in the third decade in order to avoid general or local symptoms suffered by these patients The role of the Oral Pathologist in the accurate diagnosis and treatment of patients was emphasized. University of Cape Town vi ACKNOWLEDGEMENTS I wish to thank the following people: My wife Cacilië, and my children Rafael and Romelio for their love, support, encouragement and tolerance allowing me to complete this work. Professor Delawir Kahn my supervisor for his technical guidance, help and encouragement to complete this thesis. Professor Vincent Michael Phillips, my supervisor and mentor for his enduring encouragement, guidance and enthusiasm. My son, Rafael Berezowski for his invaluable computer assistance and patience. Ms C Moore and Mrs J Athersmith for their secretarial assistance. Dr.TJ van Wyk Kotze for his organization of the data involved and statistical analysis. Dr Neil Hodges for his radiographic assistance. To my late parents and brother for encouraging me to acquire a superior education. To the Department of Surgery of the University of Cape Town, who encouraged and allowed this study to be performed, and recognized the benefits for the medical and dental professions and education. University of Cape Town vii List of Tables Chapter 2 Page Table (1): Risks and morbidity following removal of impacted third molar teeth ......................... 17 Table (2): Cysts of the Oral and Maxillofacial Regions. Shear M, Speight P. Fourth edition. Blackwell 2007..........................................................................................................................24 Table (3): Table (3). WHO histological classification of odontogenic tumors. IACR, Lyon France 2005 .....................................................................................................................26 Chapter 3 Table (4): Frequency distribution of the number of specimens contributed………………..... …..64 University of Cape Town Chapter 4 Table (5): Age distribution and pathological changes of 3rd molar teeth .................................... 67 viii Table (6): Gender distribution of patients with pathological changes in 3rd molar teeth .............. 68 University of Cape Town ix List of Graphs Chapter 4 Page Graph (1): Pathoses found in the 3rd molar area in this study .................................................... 70 Graph (2): Comparison between present study and Curran et al study (2002) ......................... 71 Graph (3): Number of hyperplastic follicular tissue vs age. ....................................................... 74 Graph (4): Number of hyperplastic follicular tissue vs position and gender ............................... 75 Graph (5): Number of early dentigerous cysts vs age................................................................ 80 Graph (6): Number of early dentigerous cysts vs position and gender ..................................... 81 Graph (7): Age distribution vs number of cases of dentigerous cysts ....................................... 87 University of Cape Town Graph (8): Gender distribution and position vs
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