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CASE REPORT
Year : 2015  |  Volume : 3  |  Issue : 2  |  Page : 76-78

Surgical management of a high ramal odontogenic keratocyst


Department of Oral and Maxillofacial Surgery, Faculty of Dental Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Date of Web Publication22-May-2015

Correspondence Address:
Dr. Neeraj Kumar Dhiman
Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-3841.157530

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  Abstract 

Odontogenic keratocysts (OKCs) are benign, they are often locally destructive and tend to recur after conservative surgical treatment. There has been a shift in the treatment modality from conservative procedures like marsupialization and enucleation to the more conventional surgical methods. However, the recurrence rate after marsupialization, followed by enucleation is not significantly higher than that after aggressive modalities. The goals of treatment should eliminate the potential for recurrence and minimize the surgical morbidity. Future treatment may involve molecular-based modalities, which may reduce or eliminate the need for aggressive surgical management. A case report is presented in which isolated OKC at the level of sigmoid notch is treated by surgical enucleation and chemical cauterization (with Carnoy's solution).

Keywords: Enucleation, mandible, odontogenic keratocyst, ramus


How to cite this article:
Dhiman NK, Jaiswara C, Kumar N, Pandey A. Surgical management of a high ramal odontogenic keratocyst. J Oral Maxillofac Radiol 2015;3:76-8

How to cite this URL:
Dhiman NK, Jaiswara C, Kumar N, Pandey A. Surgical management of a high ramal odontogenic keratocyst. J Oral Maxillofac Radiol [serial online] 2015 [cited 2019 Nov 20];3:76-8. Available from: http://www.joomr.org/text.asp?2015/3/2/76/157530


  Introduction Top


The term odontogenic keratocyst (OKC) was used first by Philipsen in 1956. [1] Earlier known as primordial cyst, which arose from remnants of dental lamina or the enamel organs before enamel formation (Robinson, 1945). [2] Keratinization occurs in the lining of cyst which can be predominantly parakeratinized or orthokeratinized. Found most commonly at the angle of mandible, with higher recurrence and malignant potential (in orthokeratinized variety). [3],[4]

The first clinical investigation to reveal a high propensity for recurrence was by Pindborg and Hansen. [5] There has been renewed interest over the past decade in the OKC, its treatment and potential existence as a benign odontogenic neoplasm as opposed to the more commonly believed aggressive odontogenic cyst. [6],[7]

Odontogenic keratocyst have a relatively higher recurrence and should be considered as a benign cystic neoplasm. [8],[9],[10] Shear attempted to provide further evidence in support of the OKC as a benign neoplasm as opposed to a cyst. [6],[7],[11] Here, a case of OKC present at the level of sigmoid notch and managed by enucleation and chemical cauterization is presented.


  Case Report Top


A 50-year-old male patient reported to us with the chief complaint of pain over left cheek region for last 3-4 months. Pain was mild in nature and slightly aggravated during chewing and mouth opening. There was no relevant medical history. Patient gives past dental history of extraction of upper and lower left back tooth for the same pain.

On extra oral examination, normal facial color, contour and texture was present. There was no obvious swelling observed over the left cheek or preauricular region. Temporomandibular joint examination was normal and there was no cervical lymphadenopathy. Intra orally 26, 38 were missing and 46 root stumps was present. No obvious swelling or alteration of mucosa over the left side gingiva, buccal mucosa, vestibule and retromolar region was present.

Orthopantomogram revealed well defined radiolucency just below the coronoid process and sigmoid notch involving anterior two-third of ramus [Figure 1]. Computed tomography scan shows well defined, expansile lytic lesion of dimension 2.2 cm × 2.2 cm in left mandibular ramus causing cortical thinning and expansion with no evidence of internal septation or internal solid content [Figure 2] and [Figure 3]. On aspiration with 18 gauge needle whitish fluid with cheesy consistency was aspirated. Type of aspirated fluid and clinical/radiological findings provisionally suggested OKC of left ramus of mandible. Treatment was planned to enucleate the cystic lining under local anesthesia (2% lignocaine with adrenaline) and chemical cauterization with Carnoy's solution to prevent recurrence.
Figure 1: Orthopantomogram showing cystic lesion in left ramus


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Figure 2: Three-dimensional view of cyst in ramus


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Figure 3: Computed tomography coronal view showing cystic margins


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Nerve block along with local infiltration was given, after anesthesia is achieved incision was given over ascending ramus and mucoperiosteal flap was reflected to expose the pathological site. Thinned anterior border of ramus was precisely osteotomised and cyst lining was exposed. Cystic lining was separated from the bone and removed in toto [Figure 4] followed by Carnoy's solution application for 5 min dampened in gauge piece, then irrigated with saline. Primary closure was done and cystic lining was sent for histopathological examination which confirmed our diagnosis of OKC [Figure 5]. Patient is asymptomatic clinically and radiographically for last 6 months.
Figure 4: Intra-operative pathological site after osteotomy and cyst lining removal


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Figure 5: Histopathologic picture of cyst lining


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  Discussion Top


Various surgical modalities have evolved in an attempt to reduce the recurrence rate. There has been a shift in the management paradigm from conservative methods like marsupialization and enucleation to the more conventional surgical procedure. Important determinants are patient's health, age, and either tumor is solitary or multiple, unilocular or multilocular, cyst location and presence of perforations.

Depending on size, location and behavior treatment should be decided for either incisional or excisional biopsy. Conventional options for surgery include enucleation and curettage, enucleation and peripheral ostectomy, enucleation and liquid nitrogen therapy, enucleation and Carnoy's solution, osseous resection without (rim ostectomy/marginal resection) or with (segmental resection) continuity defect. [12]

Carnoy's solution is a mixture of absolute alcohol (60%), chloroform (30%), glacial acetic acid (10%), and ferric chloride (1 g dissolved in 24 ml of absolute alcohol) that penetrates bone to a predictable time dependent depth without injuring the neurovascular structures. A 5 min application penetrates bone to a depth of 1.54 mm, nerve to a depth of 0.15 mm, and mucosa to a depth of 0.51 mm. Because most residual cells and daughter cysts from locally recurrent lesions are adjacent to the main lesion, it is likely that fixation of vital bone need only extend for 2-3 mm beyond the enucleated lesion. [13],[14]


  Conclusion Top


The advised treatment strategy and protocol for the management of OKC give rise to a low number of recurrent OKC. Still recurrence occurs if OKC is treated like ordinary cyst or despite excision of overlying mucosa there may still be epithelial islands or even micro cysts which develop into new keratocyst. However, a long follow-up is needed to observe the recurrence for any treatment modality.

 
  References Top

1.
Philipsen HP. Om keratocystedr (Kolesteratomer) and kaeberne. Tandlaegebladet 1956;60:963-71.  Back to cited text no. 1
    
2.
Robinson HBG. Classification of cysts of the jaws. Am J Ortho Oral Surg 1945;31:370-5.  Back to cited text no. 2
    
3.
Browne R, Gough NG. Malignant change in the epithelial lining odontogenic cysts. Cancer 1972;29:1199-207.  Back to cited text no. 3
    
4.
Wright JM. The odontogenic keratocyst: Orthokeratinized version. Oral Surg 1981;51:609-18.  Back to cited text no. 4
    
5.
Pindborg JJ, Hansen J. Studies on odontogenic cyst epithelium 2. Clinical and roentgenologic aspects of odontogenic keratocysts. Acta Pathol Microbiol Scand 1963;58:283-94.  Back to cited text no. 5
    
6.
Shear M. The aggressive nature of the odontogenic keratocyst: Is it a benign cystic neoplasm? Part 1. Clinical and early experimental evidence of aggressive behaviour. Oral Oncol 2002;38:219-26.  Back to cited text no. 6
    
7.
Shear M. The aggressive nature of the odontogenic keratocyst: is it a benign cystic neoplasm? Part 3. Clinical and early experiment evidence of aggressive behavior. Oral Oncol 2002;38:407-15.  Back to cited text no. 7
    
8.
Howell RE, Handlers JP, Aberle AM, Abrams AM, Melrose RJ. CEA immunoreactivity in odontogenic tumors and keratocysts. Oral Surg Oral Med Oral Pathol 1988;66:576-80.  Back to cited text no. 8
    
9.
Ogden GR, Chisholm DM, Kiddie RA, Lane DP. p53 protein in odontogenic cysts: Increased expression in some odontogenic keratocysts. J Clin Pathol 1992;45:1007-10.  Back to cited text no. 9
    
10.
Barreto DC, Gomez RS, Bale AE, Boson WL, DeMarco L. PTCH gene mutations in odontogenic keratocysts. J Dent Res 2000;79:1418-22.  Back to cited text no. 10
    
11.
Shear M. The aggressive nature of the odontogenic keratocyst: is it a benign cystic neoplasm? Part 2. Clinical and early experiment evidence of aggressive behavior. Oral Oncol 2002;338:323-31.  Back to cited text no. 11
    
12.
Gold L, Upton GW, Marx RE. Standardized surgical terminology for the excision of lesions in bone: An argument for accuracy in reporting. J Oral Maxillofac Surg 1991;49:1214-7.  Back to cited text no. 12
    
13.
Voorsmit RA, Stoelinga PJ, van Haelst UJ. The management of keratocysts. J Maxillofac Surg 1981;9:228-36.  Back to cited text no. 13
    
14.
Voorsmit RA. The incredible keratocyst: A new approach to treatment. Dtsch Zahnarzil 1985;40:641-4.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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