annals of international medical and dental research

7/18/2019 Annals of International Medical and Dental Research

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Original Article

Annals of International Medical and Dental Research, Vol (1), Issue (1) 3

An Experience with a Different Conservative Management

of Keratocystic Odontogenic TumorArun Kumar Goyal*, Vishal**, Mohsin Khan**, Ashish Kumar***, Apoorv Srivastava*** Prof & Head Department of Oral & Maxillofacial Surgery, Teerthanker Mahaveer Dental ollege & !e"earch entre

** Po"t #raduate, Department of Oral & Maxillofacial Surgery, Teerthanker Mahaveer Dental ollege & !e"earch entre

***Senior lecturer, Dept of Oral & Maxillofacial Surgery, Ha$ari%agh ollege Of Dental Science" nd Ho"pital

ABSTRACT

Background: The aim of our study is to share our experience with conservative management of odontogenic keratocyst,and also to study the role of carnoy’s solution in prevention of recurrence of small keratocystic odontogenic tumour (KCOT). Methods: 29 consecutive patients with 30 KCOT treated in department of Oral & Maxillofacial Surgery in TeerthankerMahaveer Dental college, Moradabad, UP. Initial biopsy was carried out in all patients and the OKCs were diagnosed afterhistological examination by the Oral Pathology Department. Out of 26 KCOT which were treated with enucleation alone, 14patients were subjected to additional burning of cyst epithelium by carnoy’s solution. 4 large OKC which might undergonepathological fracture were treated by two stage surgery marsupialization followed by enucleation. Results: The majority of

the lesions (17 patients, 56.7%) occurred in the mandibular third molar region. Recurrence occurred in 4 patients, in which 3of them were from enucleation group and one of marsuplization and enucleation group.All the caseswere monitoredcontinuously with panoramic radiographies and clinical evaluations.curettage of the remaining lesion. The average follow-upwas 15 months. Conclusion: Use of carnoy’s solution with enucleation has definite advantage over the conventionalenucleation. Further large KCOT can be conservatively treated with low morbidity with Marsupilization followed byenucleation successfully. The systematic and long-term post-surgical follow-up is considered to be a key element forsuccessful results.

Key Words: Carnoy’s solution, Marsupilization, Odontogenic Keratocyst

INTRODUCTION

The odontogenic keratocyst (OKC) is a cystic lesionof odontogenic origin, which is type ofdevelopmental cyst. It was first described in 1956 byPhillipsen[1] and it is well known for its highrecurrence rate.[2] Due to aggressive behavior andhigh recurrence rate nomenclature of keratocysticodontogenic tumour was given. For the same reason,many research regarding the optimum treatment arecarried out over the six decade.[1-8] The OKCaccounts for 11% of all cysts in the jaws and is mostcommonly located in the mandibular third molarregion. Radiographically, it can be either unilocularor multilocular lesion with or without a scallopedcontour. These characteristics are suggestive but notconsidered an unequivocal proof for the definitivediagnosis of OKC because other lesions may exhibit

similar features.[4] The rates of recurrence varyenormously, from a maximum of 62% to a minimum

Name & Address of Corresponding Author

Dr. VishalDept of OMFSNH-24, Teerthanker Mahaver Dental College & Hospital,TMU Moradabad, UP244001E mail: [email protected]

of 0%.[5] The most of recurrent cases occur within thefirst 5 years after treatment.[5-9] For this reason, most

surgeons advocate aggressive treatment includingcomplete removal with extension margins ormeticulous curettement of the surrounding tissues.[5] If enucleation is done alone then it has the highestrecurrence rates (range, 17% to 56%). To decreasethe recurrence potential, various adjunctive therapies

have been tried, including the use of Carnoy’ssolution or peripheral ostectomy or, cryotherapy, orelectro-cautery.[5-9] Carnoy’s solution composed of 1g of ferric chloride (FeCl3) dissolved in 24 mL ofabsolute alcohol, 12 mL of chloroform and 4 mL ofglacial acetic acid.[6] Decompression ormarsupialization which is more conservative optionsin the treatment of KCOT is also becomingpopular.[10, 11] Marsupialization was first describedbyPartsch in 1882[12, 13] for the treatment of cysticlesions, through the creation of a surgical bonywindow through the buccal mucosa. Their bordersare then sutured to create an open cavity that

communicates with the oral cavity. This procedurerelieves pressure from the cystic fluid, allowingreduction of the cystic space and facilitating boneapposition to the cystic walls.[10-15] Decompressionand marsupialization are almost very similartechniques. The main difference lies in the creation ofa surgical window in the oral mucosa and cysticmembrane,[14] and in using a cylindrical device[11] (like the rubber of a dropper) or a rigid drain toprevent mucosal closure. This is done with theobjective of maintaining a continuous communicationbetween the oral cavity and the cyst cavity. Thedecompression technique allows the permeability of



Goyal et al Manage!ent of "eratocystic Odontogenic #u!or

Annals of International Medical and Dental Research, Vol (1), Issue (1) Page 1$

the cystic cavity because the union of the cystepithelial wall with the mucous membrane results inthe externalization of the lesion. In addition, after the

surgical intervention, the cystic lining tends tobecome thicker, which facilitates its removalcompletely after a second surgery. The use of thistechnique is acceptable possible KCOT treatments. In1971, Browne[16] described marsupialization as atechnique for the treatment of KCOT. In 1976,Tucker[14] first described the use of decompressionand secondary enucleation as a first-line treatmentoption for OKC. In 1991, Brøndum and Jensen[11]

reported a recurrence rate of 18% in 51 OKC patientsduring a 13-year period. Thirty-two of these patientswere treated with decompression of the lesion. Ofthese cases, 8 presented recurrence of the lesion.Additionally, when achieving a significant reductionof the lumen—which can be confirmed throughradiographic imaging—a secondary cystectomy was

justified to prevent recurrence of the lesion. Thosewho criticize the use of marsupialization ordecompression for the treatment of OKC argue thatthis technique does not allow a complete removal ofthe whole cystic covering, which would lead to acontinuation of epithelial proliferation and facilitatean increment of the recurrence.[5] Brøndum andJensen[11] were not in agreement with this argumentbecause recurrences was not observed by them inpatients treated by decompression with second stageenucleation. Several reports describe the use of

decompression to decrease the size of the cyst, afterwhich it is definitively enucleated.[10-16] Use of thesetechniques alone is not reported commonly when acomplete resolution of the OKC has beenachieved.[15, 16] Regarding the remaining epitheliumafter decompression of the lesion, August et al[15] reported the differentiation of the OKC epitheliumonce treatment is carried out. Through histochemicalanalyses based on Cytokeratin-10 tests, August etal[15] accomplished the pre-operatory identification ofthe lesion in 14 OKCs. After surgery, the sameanalysis was carried out again in thecystic epitheliumto determine whether the marsupialization or

decompression technique results inepithelialmodulation, which is associated with lowerrecurrencerates. It was observed that 64% of thepatients did notpresent Cytokeratin-10 in theanalyzed epithelium, which may have beencontributed to the lower rates of recurrence. Pogreland Jordan[17] reported the use of marsupialization asa definitive treatment of OKC. In this study, 10patients were treated exclusively withmarsupialization and decompression, achievingresolution of the lesions with a recurrence rate of0%.This study was done to report our experiencewith the surgical treatment of 30 OKCs, 26 small

which were treated either by enucleation alone or byenucleation and carnoy’s solution and four largeOKCs which were treated anticipating pathological

fracture based on marsupialization and enucleationwith reference to the recurrence rate.

MATERIALS AND METHODS

Twenty-nine patients (17 females, 12 males) with atotal of 30 OKCs attended the Department of OMS inTeerthanker Mahaveer Dental College between 2011and 2014. Basal cell nevus syndrome patients withmultiple OKCs were not included in our study. Onepatient with 2 OKCs in different anatomic locations,without clinical features of Gorlin Syndrome, wereincluded too. In this study, the age range was 15 to 49years (average, 30 years). All the OKCs werediagnosed by histologic examination by the OralPathology Department. All lesions were diagnosed byradiographic images and clinical features andpreoperative biopsy, confirmed postoperatively byhistopathologic report. Of total 30 OKC 4 large OKCwas treated with decompression followed byenucleation, 12 patient was treated with enucleationalone and rest 14 patient were treated withenucleation and Carnoy’s solution also initial biopsyand decompression of the cyst was carried out on thesame day if possible. Under local anesthesia (2%lidocaine with epinephrine 1:200,000), Four patientswere lost during follow up, but were assumed

asymptomatic and were included in non-recurrencegroup.Group 1 Simple enucleationUnder local anesthetic, a horizontal incision wasmade in the alveolar ridge with a #15 scalpel. Amuco-periosteal flap was obtained with exposure ofthe cystic cavity. The secondary curettage of thecavity was carried out with a Lucas’s bone curetteand the cavity was irrigated with saline solution.Finally, the flap was closed with 4.0 silk suture(Johnson & Johnson, Ethicon, Brazil). Simpleenucleation and carnoy’s solution. Patient’s follow-up at 7, 15, and 30 days with clinical and serial

panoramic radiographs was done.Group 2 Enucleation followed by destruction ofcystic lining by carnoy’s solutionAfter removal of cyst, remaining mucosal lining wasburned using carnoy’s solution and was sutured.(c) Marsupialization followed by enucleationWhen the cyst was large where enucleation alonemay not be able to remove complete cyst lining, flapwas raised and bony window was created, wheneverit was possible [Figure 1, 2 and 3].Cystic lining wassutured with the mucosa, and an iodophore dressingwas given [Figure 4], which was changed biweeklyfor 2 weeks and weekly for 12 weeks. Secondary




Annals of International Medical and Dental Research, Vol (1), Issue (1) Page 1%

curettage of the surrounding tissues was carried outafter the decompression phase, once radiographicevaluation confirmed reduction in size of the lesion

[Figure 5].The postoperative care included the use ofparacetamol via oral for pain control. Amoxycillin500 mg (oral), thrice a day was prescribed for 5 daysfor all the patients. Careful monitoring was based onmonthly panoramic radiographies and clinical visitsto determine lesion size regression as an effect ofdecompression and bone formation [Fig1].Postoperative care included oral acelofenac withparacetamol, amoxicillin or clindamycin (inpenicillin-allergicpatients). In those cases wheretreatment of the lesion consisted of enucleation only,a procedure similar to the one described above wasused. Patients received follow-up with clinical andserial panoramic radiographs at 7, 15, and 30 days.Ninety days after the procedure is done, patients weremonitored periodically every 6 months.

Figure 1: Pre-op OPG (Orthopantomogram).

Figure 2: Intra-operative.

Figure 3: Intra op after cortical perforation

RESULTS

Of total 30 OKC most of the lesions (17 lesions,56.7%) occurred in the mandibular third molar

region. The most common histologic pattern ofKCOT was parakeratinized (70%). Five KCOTpresented satellite cysts and had the parakeratinizedpattern. Four OKCs were treated by marsupializationand curettage of the remaining lesion, KCOT byenucleation and curettage only and remaining 12 byenucleation and curettage with burning of cyst liningby carnoy’s solution. The mean time fordecompression was 8.5 months varied from 4 to 12months. Recurrence occurred in 4 patients, in which3 of them were from enucleation group and one ofmarsuplization and enucleation group. All recurrencecases were submitted to enucleation/curettage and

peripheral osteotomies of the remaining bone cavity.The average follow-up for the 28 cases were 15months.

Figure 4: Post-op OPG after Iodophore dressing.

Figure 5: Post-Op after 6 months showing decrease in cystsize




Annals of International Medical and Dental Research, Vol (1), Issue (1) Page 1&

DISCUSSION

Many authors have shown the successful treatment of

large KCOT using marsupialization.[10,11,15,16]

. Thistreatment does require a cooperative patient who willirrigate the cyst on a regular basis and will follow upregularly. For this reason, only a select group ofpatients may be suitable for this treatment. Thebenefit of this treatment over more conventionalapproaches (enucleation, en-bloc resection) lies in theminimal surgical morbidity. In addition, associatedstructures such as the inferior alveolar nerve anddeveloping teeth are less vulnerable todamage.[10,12,17] The decompression andmarsupialization techniques are based on theexteriorization of the cystic cavity and result in

communication with the oral cavity.

[11, 14]

Thisprocess relieve pressure of the cystic fluid and allowsshrinkage of the cystic space and the apposition ofbone to the cystic walls. There are many casesreported in literature which advocates use ofmarsupialization to decrease the size of the cyst, afterwhich it was definitively enucleated in secondsurgery. Partsch in the late 1800 described the use ofmarsupialization for the treatment of cystic lesions.Although our study sample was small but Carnoy’solution is definitely more effective in preventingrecurrence of KCOT. In this study, only one case hasrecurrence in unconventional approach and overallfour cases had recurrence. The secondary treatment,based in curettage associated to the peripheralosteotomy, has been accomplished in all of the cases.The main advantage of the conservative treatment isthe preservation of bone and teeth, fact that it iscovered of great importance if we consider that mostof the patients are young. These procedures are lesstraumatic for the patient, eliminating medication andhospitalization expenses, and in most cases, avoidany reconstruction through autogenous grafts orextensive reconstructions. In most of the cases inwhich the recession is the elected treatment, the needof accomplishing the reconstruction of the jawthrough grafts of autogenous bone is imperative.

Usually these reconstructions are accomplished in asecond surgery, which translates into largerdiscomfort for the patient, and increase of themorbidity, increments in the costs of the treatment,and time of recovery, among others. Time of durationof the decompression treatment (1 to 14 months) isone of the disadvantages of this technique. In fact,this is one of the main causes of abandonment of thetreatment by the patient because of loss of interest inproper irrigation treatment and attendance of periodiccontrols. In spite of being a technique that requiresprolonged postoperative treatment and specialconsiderations (like the ones mentioned above), and

even a second surgical procedure in order to curettethe remaining cystic cavity, it is a technique thatallows the professional to offer the correct treatment

and save hospital expenses that would increase withother, complicated procedures that require generalanesthesia and hospitalization. The recurrence rateobserved among our sample was 14%. In comparisonwith other important published studies.[4, 9, 11, 16-19] Weobtained results within the average with a moreconservative approach. If we sum up the advantagesof a conservative approach, like the one we suggest,versus a more radical treatment, the marsupializationtreatment protocol stands up as an equally effective,cheaper, and simpler procedure for the treatment ofOKC if the patient can be closely monitored andperiodically evaluated (clinically andradiographically). Several studies suggest that thelargest number of recurrences of OKC occur duringthe first 5 years after the initial treatment period(about 70%).[20,21] For this reason the annualradiographic control of these patients isrecommended for an undetermined time.[5,22,23]

CONCLUSION

We conclude that use of carnoy’s solution withenucleation has definite advantage over theconventional enucleation. Further large KCOT can beconservatively treated with low morbidity withMarsupialization followed by enucleationsuccessfully. The systematic and long-term post-surgical follow-up is considered to be a key elementfor successful results.

REFERENCES

'( Philipsen HP. On “keratocysts” in the jaws. Tandlaege-bladet1956;60:963–80.

)( Pindborg JJ, Hansen J: Studies on odontogenic cyst epitheliumII. Clinical and roentgenographic aspects of odontogenickeratocysts. Acta Pathol Microbiol Scand 1963;58:283-7.

( Voorsmit RA, Stoelinga PJ, van Haelst UJ. The managementof keratocysts. J Maxillofac Surg 1981; 9(4): 228-36.

+( Stoelinga JWP. Long-term follow-up on keratocysts treated

according to a defined protocol. In J Oral Maxillofac Surg2001; 30(1):14-25.

( Bataineh AB, al Qudah M. Treatment of mandibularodontogenic keratocysts. Oral Surg Oral Med Oral Pathol OralRadiol Endod. 1998;86(1):42-7.

-( Marx RE. Diane S. Oral and maxillofacial pathology: arationale for diagnosis and treatment. Chicago: Quintessence;2003.

.( Shear M. The aggressive nature of the odontogenic keratocyst:is it a benign cystic neoplasm? Part 2. Proliferation and geneticstudies. Oral Oncol. 2002;38(4):323-31.

/( Shear M. The aggressive nature of the odontogenic keratocyst:Is it abenign cystic neoplasm? Part 3. Immunocytochemistry ofcytokeratinand other epithelial cell markers. Oral Oncol2002;38:407-11.




Annals of International Medical and Dental Research, Vol (1), Issue (1) Page 1'

0( Blanas N, Freund B, Schwartz M, Furst IM. Systematic reviewof the treatment and prognosis of the odontogenic keratocyst.Oral Surg Oral Med Oral Pathol Oral Radiol Endod2000;90(5):553-8.

'1( Marker P, Brøndum N, Clausen PP, Bastian HL. Treatment oflarge odontogenickeratocysts by decompression and latercystectomy: A long-term follow-up and a histologic study of23 cases. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 1996;82:122–31.

''( Brondum N, Jensen VJ. Recurrence and decompressiontreatment: A long-term follow-up of forty-four cases. OralSurg Oral Med Oral Pathol 1991;72:265-270.

')( Partsch C. Über Kiefercysten. Dtsch Mschr Zahnheilk1892;10:271-304.

'( Partsch C. Zur Behandlung der Kiefercysten. Dtsch MschrZahnheilk 1910;28:252-260.

'+( Tucker WM, Pleasants JE, MacComb WS: Decompression andsecondary enucleation of a mandibular cyst: Report of a case. JOral Surg 1972;30:669-73.

'( August M, Faquin WC, Troulis MJ, Kaban LB.Dedifferentiation ofodontogenic keratocyst epithelium aftercyst decompression. J Oral Maxillofac Surg 2003;61(6):678-83.

'-( Browne RM. The odontogenic keratocyst. Histological featuresand their correlation with clinical behaviour. Br DentJ 1971;131(6):249–259.

'.( Pogrel MA, Jordan RC. Marsupialization as a definitivetreatment for the odontogenic keratocyst. J Oral MaxillofacSurg 2004; 62 (6): 651-5.

'/( August M. Marsupialization as a definitive treatment for theodontogenic keratocyst. J Oral Maxillofac Surg 2004;62:655-61.

'0( August M, Faquin WC, Troulis MJ, Kaban LB. J Oral

Maxillofac Surg. 2003;61(6):678-83.)1( Brannon RB. The odontogenic keratocyst. A clinicopathologic

study of 312 cases. Part II. Histologic features. Oral Surg OralMed Oral Pathol 1977;43(2):233-55.

)'( Partridge M, Towers JF. The primordial cyst(odontogenickeratocyst): its tumour like characteristics andbehaviour. Br JOral Maxillofac Surg 1987;25:271-9.

))( Blanchard SB: Odontogenic keratocysts: review of theliterature and report of a case. J Periodontol 1997; 68:306-11.

)( Chuong R, Donoff RB, Guralnick W. The odontogenickeratocyst. J Oral Maxillofac Surg 1982;40 (12):797-802.

How to cite this article: Goyal AK, Vishal, Khan M, Kumar

A, Srivastava A. An experience with a different conservative

management of Keratocystic odontogenic tumor. Ann. of Int.

Med. & Den. Res. 2015;1(1):13-7.

Source of Support: Nil, Conflict of Interest: None declared

annals of international medical and dental research

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