Odontogenic Keratocyst: Difference between revisions
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|+ Summary of recurrence rates for different surgical methods in the management of odontogenic keratocysts - data from 5 large systematic reviews<ref>[https://doi.org/10.5125/jkaoms.2020.46.5.358 Titinchi F. Protocol for management of odontogenic keratocysts considering recurrence according to treatment methods. Journal of the Korean Association of Oral and Maxillofacial Surgeons. 2020 Oct 31;46(5):358-60.]</ref> | |+ Summary of recurrence rates (%) for different surgical methods in the management of odontogenic keratocysts - data from 5 large systematic reviews<ref>[https://doi.org/10.5125/jkaoms.2020.46.5.358 Titinchi F. Protocol for management of odontogenic keratocysts considering recurrence according to treatment methods. Journal of the Korean Association of Oral and Maxillofacial Surgeons. 2020 Oct 31;46(5):358-60.]</ref> | ||
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! Study !! Enucleation alone !! Enucleation & Peri-oestectomy !! Enucleation & Carnoy’s solution !! Enucleation & cryotherapy !! Marsupialization/decompression alone !! Decompression & residual cystectomy !! Resection | ! Study !! Enucleation alone !! Enucleation & Peri-oestectomy !! Enucleation & Carnoy’s solution !! Enucleation & cryotherapy !! Marsupialization/decompression alone !! Decompression & residual cystectomy !! Resection | ||
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| Al-Moraissi et al. (2017)<ref>[https://doi.org/10.1016/j.jcms.2016.10.013 Al-Moraissi EA, Dahan AA, Alwadeai MS, Oginni FO, Al-Jamali JM, Alkhutari AS, Al-Tairi NH, Almaweri AA, Al-Sanabani JS. What surgical treatment has the lowest recurrence rate following the management of keratocystic odontogenic tumor?: A large systematic review and meta-analysis. Journal of Cranio-Maxillofacial Surgery. 2017 Jan 1;45(1):131-44.]</ref>|| | | Al-Moraissi et al. (2017)<ref>[https://doi.org/10.1016/j.jcms.2016.10.013 Al-Moraissi EA, Dahan AA, Alwadeai MS, Oginni FO, Al-Jamali JM, Alkhutari AS, Al-Tairi NH, Almaweri AA, Al-Sanabani JS. What surgical treatment has the lowest recurrence rate following the management of keratocystic odontogenic tumor?: A large systematic review and meta-analysis. Journal of Cranio-Maxillofacial Surgery. 2017 Jan 1;45(1):131-44.]</ref>|| 23.10 || 17.40 || 11.50 || 14.50 || 32.30 || 14.60 || 8.40 | ||
|- | |- | ||
| de Castro et al. (2018)<ref>[[https://doi.org/10.1007/s00784-017-2315-8|De Castro MS, Caixeta CA, de Carli ML, Júnior NV, Miyazawa M, Pereira AA, Sperandio FF, Hanemann JA. Conservative surgical treatments for nonsyndromic odontogenic keratocysts: a systematic review and meta-analysis. Clinical oral investigations. 2018 Jun;22(5):2089-101.]]</ref>|| | | de Castro et al. (2018)<ref>[[https://doi.org/10.1007/s00784-017-2315-8|De Castro MS, Caixeta CA, de Carli ML, Júnior NV, Miyazawa M, Pereira AA, Sperandio FF, Hanemann JA. Conservative surgical treatments for nonsyndromic odontogenic keratocysts: a systematic review and meta-analysis. Clinical oral investigations. 2018 Jun;22(5):2089-101.]]</ref>|| 20.80 || NA || NA || NA || 18.50 || 11.90 || NA | ||
|- | |- | ||
| Chrcanovic and Gomez (2017)<ref>[https://doi.org/10.1016/j.jcms.2016.11.010 Chrcanovic BR, Gomez RS. Recurrence probability for keratocystic odontogenic tumors: an analysis of 6427 cases. Journal of Cranio-Maxillofacial Surgery. 2017 Feb 1;45(2):244-51.]</ref> || | | Chrcanovic and Gomez (2017)<ref>[https://doi.org/10.1016/j.jcms.2016.11.010 Chrcanovic BR, Gomez RS. Recurrence probability for keratocystic odontogenic tumors: an analysis of 6427 cases. Journal of Cranio-Maxillofacial Surgery. 2017 Feb 1;45(2):244-51.]</ref> || 22.50 || 18.60 || 5.30 || 20.90 || 28.70 || 18.60 || 2.20 | ||
|- | |- | ||
| Johnson et al. (2013)<ref>[https://doi.org/10.1016/j.oooo.2011.12.028 Johnson NR, Batstone MD, Savage NW. Management and recurrence of keratocystic odontogenic tumor: a systematic review. Oral surgery, oral medicine, oral pathology and oral radiology. 2013 Oct 1;116(4):e271-6.]</ref> || | | Johnson et al. (2013)<ref>[https://doi.org/10.1016/j.oooo.2011.12.028 Johnson NR, Batstone MD, Savage NW. Management and recurrence of keratocystic odontogenic tumor: a systematic review. Oral surgery, oral medicine, oral pathology and oral radiology. 2013 Oct 1;116(4):e271-6.]</ref> || 25.60 || NA || 7.90 || 30.30 || NA || 15.80 || 6.30 | ||
|- | |- | ||
| Kaczmarzyk et al. (2012)<ref>[https://doi.org/10.1016/j.ijom.2012.02.008 Kaczmarzyk T, Mojsa I, Stypulkowska J. A systematic review of the recurrence rate for keratocystic odontogenic tumour in relation to treatment modalities. International journal of oral and maxillofacial surgery. 2012 Jun 1;41(6):756-67.]</ref> || | | Kaczmarzyk et al. (2012)<ref>[https://doi.org/10.1016/j.ijom.2012.02.008 Kaczmarzyk T, Mojsa I, Stypulkowska J. A systematic review of the recurrence rate for keratocystic odontogenic tumour in relation to treatment modalities. International journal of oral and maxillofacial surgery. 2012 Jun 1;41(6):756-67.]</ref> || 26.09 || 18.18 || 50 || NA || 40 || NA || 0 | ||
|- | |- | ||
| Average || | | Average || 23.60 || 18.10 || 18.70 || 21.90 || 29.90 || 15.20 || 4.20 | ||
|- | |- | ||
|} | |} |
Revision as of 14:38, 1 December 2021
- Benign but aggressive intraosseous lesions of odontogenic origin
- Reclassified back to odontogenic keratocyst in the WHO 2017 classification (previously classified as keratocystic odontogenic tumour [KCOT] from 2005 to 2017)[1]
- Subtypes:
- Odontogenic Keratocyst (OKC) - parakeratinised
- Orthokeratinised Odontogenic Keratocyst (OOKC)
Epidemiology
- Account for 5-10% of jaw cysts
- Peak incidence 20-30yrs
- ♂ > ♀ (slightly)
- Commonest site — angle of the mandible
- 70-80% occur in the mandible
- 50% at the angle of the mandible
Clinical Features
- Usually asymptomatic (commonly incidental findings)
- When large/infected can cause pain/swelling/discharge/pathological fracture/tooth displacement/buccal expansion
- Characteristic insidious pattern of growth
- Unlike other cysts, OKCs do not have a high internal pressure ∴ they preferentially expand along the medullary cavity (the path of least resistance)
- A cyst in the mandible may extend through much of the ramus and body without significant expansion of the jaw
- Clinical signs often fail to appear until the cyst is well advanced
- Usually solitary cysts (consider Nevoid basal-cell carcinoma syndrome (Gorlin-Goltz Syndrome))
- High recurrence rate
Differential Diagnosis
Memory Aid - Multilocular lesions of the mandible (MACHO) |
---|
|
- Other cysts of the jaws
- Radiological differentials:
- Odontogenic myxoma
- Ameloblastoma
- Central giant-cell granuloma
- Haemangioma/Vascular malformations
- Adenomatoid odontogenic tumor
- Dentigerous cyst
- Histological differentials:
Aetiology and Pathogenesis
Aetiology
- Developmental cyst - arises from dental lamina and its remnants (cell rests of Serres)
- Can be sporadic or syndromic
- Syndromic cases:
- Associated with mutation/inactivation of PTCH gene (which activates SHH pathway)
- 5% occur as part of Nevoid basal-cell carcinoma syndrome (Gorlin-Goltz Syndrome)
Pathogenesis
- Mutation of PTCH
- PTCH is a tumour suppressor gene that encodes the PTCH protein
- PTCH protein is a receptor for sonic hedgehog (SHH)
- In adult tissue, SHH plays a role in cell cycle regulation (SHH dysfunction is implicated in various cancer types)
- ↓ PTCH gene activity → release of the break on cell cycle (mediated by SHH) → ↑ proliferative activity in epithelial lining of keratocysts
- This increase in proliferative activity causes enlargement of the cyst by mural growth (as opposed to osmotic growth seen in other cysts)
- Increase in proliferative activity may also contribute to recurrence rates
- Mural growth of cysts
- Growth is by extension of finger-like processes into marrow spaces rather than by expansion (growth is said to be "neoplastic")
- Growth of the wall is faster than the expansion of cyst cavity ∴ the lining becomes folded
- Cyst enlarges slowly along the pathway of least resistance
Investigations
Laboratory Investigations
Aspiration of cyst contents may be helpful for analysis of protein content (biochemistry) and keratinization (cytology)
Imaging
Plain film
- Well defined radiolucent area with a sharply demarcated and corticated bony wall
- Radiographically usually multilocular
- Unilocular lesions tend to have a scalloped margin
- When multilocular, can mimic ameloblastoma if many locules exist
- Can mimic other cysts
- 40% in a ‘dentigerous’ position
- Adjacent roots/teeth may become displaced by large cysts, but usually the cyst will extend around the roots and inferior alveolar nerve without displacing them or causing significant expansion
Computed Tomography
- Can facilitate diagnosis, and 3D characterisation for surgical planning
Histopathology
- Biopsy is the diagnostic investigation of choice (OKCs have a consistent and unique appearance)
- Features:
- Epithelium
- Regular stratified squamous epithelium
- 5-8 cells thick
- Palisaded basal layer (cells are columnar in shape)
- Lack rete ridges
- Often have artifactual separation from basement membrane
- Corrugated surface which can be parakeratinized (83%), orthokeratinized (10%) or both (7%)
- Thin fibrous capsule
- Satellite (daughter) cells
- Particularly seen in those with NBCCS
- Cyst contents
- Fluid has protein content <4g/ dL
- High mitotic activity
- Inflammatory changes
- Inflamed cysts show hyperplastic epithelium which is no longer characteristic of OKCs and can have resemblance to radicular cysts instead
- A larger biopsy is needed to confirm OKC if there is inflammation
- Epithelium
Management
- !Controversial topic¡
- Diagnosis must be confirmed by biopsy
- Treatment considerations:
Unilocular + small multilocular lesions
- Conservative enucleation and bone curettage
- Difficult to ensure all of cyst lining is removed ∵ friable capsule + complex outline of cyst
- Epithelial remnants and satellite/daughter cysts can easily be left behind after enucleation
- It is currently considered that enucleation alone is an inadequate form of treatment and needs to be used in combination with adjuvant methods (see below)
Large cyst extending around muti-rooted teeth
- Difficult to completely remove, teeth may have to be sacrificed to ensure complete removal
- May require decompression first followed by enucleation
- Decompression is a modified marsupialization technique which causes the cyst to decrease significantly in size and the cystic lining becomes thicker resembling oral mucosa that allows for easier enucleation
- This method decreases the levels of IL-1α which regulates epithelial cell proliferation in OKC; hence, there is immune-histochemical evidence that decompression is superior to enucleation alone
Very large cyst
- Resection and bone reconstruction (free-flap)
- Resection provides the least recurrences
Adjuvant treatment to enucleation
- Peripheral ostectomy
- Aggressive form of adjuvant therapy where methylene blue is utilised to stain any cystic remnants and a rosehead bur is used to remove these
- Carnoy's solution
- Chemical curettage that causes cell necrosis of the cystic lining
- Cryotherapy (liquid nitrogen)
- Liquid nitrogen causes cell necrosis of the cystic lining
Suggested Management Protocol
Prognosis and Complications
- Recurrence:
- High recurrence rate (up to 60%)
- Higher in NBCCS and presence of satellite cells
- Lower in orthokeratinised odontogenic keratocysts
Study | Enucleation alone | Enucleation & Peri-oestectomy | Enucleation & Carnoy’s solution | Enucleation & cryotherapy | Marsupialization/decompression alone | Decompression & residual cystectomy | Resection |
---|---|---|---|---|---|---|---|
Al-Moraissi et al. (2017)[3] | 23.10 | 17.40 | 11.50 | 14.50 | 32.30 | 14.60 | 8.40 |
de Castro et al. (2018)[4] | 20.80 | NA | NA | NA | 18.50 | 11.90 | NA |
Chrcanovic and Gomez (2017)[5] | 22.50 | 18.60 | 5.30 | 20.90 | 28.70 | 18.60 | 2.20 |
Johnson et al. (2013)[6] | 25.60 | NA | 7.90 | 30.30 | NA | 15.80 | 6.30 |
Kaczmarzyk et al. (2012)[7] | 26.09 | 18.18 | 50 | NA | 40 | NA | 0 |
Average | 23.60 | 18.10 | 18.70 | 21.90 | 29.90 | 15.20 | 4.20 |
Follow-up
References
- ↑ El-Naggar AK, Chan JK, Grandis JR. WHO classification of head and neck tumours. 2017. ISBN: 9789283224389
- ↑ Titinchi F. Protocol for management of odontogenic keratocysts considering recurrence according to treatment methods. Journal of the Korean Association of Oral and Maxillofacial Surgeons. 2020 Oct 31;46(5):358-60.
- ↑ Al-Moraissi EA, Dahan AA, Alwadeai MS, Oginni FO, Al-Jamali JM, Alkhutari AS, Al-Tairi NH, Almaweri AA, Al-Sanabani JS. What surgical treatment has the lowest recurrence rate following the management of keratocystic odontogenic tumor?: A large systematic review and meta-analysis. Journal of Cranio-Maxillofacial Surgery. 2017 Jan 1;45(1):131-44.
- ↑ [Castro MS, Caixeta CA, de Carli ML, Júnior NV, Miyazawa M, Pereira AA, Sperandio FF, Hanemann JA. Conservative surgical treatments for nonsyndromic odontogenic keratocysts: a systematic review and meta-analysis. Clinical oral investigations. 2018 Jun;22(5):2089-101.]
- ↑ Chrcanovic BR, Gomez RS. Recurrence probability for keratocystic odontogenic tumors: an analysis of 6427 cases. Journal of Cranio-Maxillofacial Surgery. 2017 Feb 1;45(2):244-51.
- ↑ Johnson NR, Batstone MD, Savage NW. Management and recurrence of keratocystic odontogenic tumor: a systematic review. Oral surgery, oral medicine, oral pathology and oral radiology. 2013 Oct 1;116(4):e271-6.
- ↑ Kaczmarzyk T, Mojsa I, Stypulkowska J. A systematic review of the recurrence rate for keratocystic odontogenic tumour in relation to treatment modalities. International journal of oral and maxillofacial surgery. 2012 Jun 1;41(6):756-67.