JUNG, LEE, AND PARK
J Oral Maxillofac Surg
Decompression of Large Odontogenic
Keratocysts of the Mandible
Young-Soo Jung, DDS, MSD,* Sang-Hwy Lee, DDS, MSD, PhD,† Hyung-Sik Park, DDS, MSD, PhD‡
Various treatment methods for odontogenic keratocysts
(OKCs) have been reported ranging from conservative
to radical surgery.1-8 Because of its nature and high
recurrence rate, the treatment goal of OKC is the pre-
vention of recurrence. Therefore, more aggressive sur-
gery including resection of the involved bone with bone
graft or aggressive curettage of the cystic bony cavity has
been recommended.2,4,5 Moreover, when a surgeon
considers the ideal strategy for reconstructing the defect
related to an OKC, it might be difficult to select the best
option from resection with bone graft, enucleation with
bone graft, or secondary bony regeneration. Because of
the complications after radical treatment, marsupializa-
tion or decompression has been suggested as a more
conservative treatment even though there is the neces-
sity of frequent follow-ups.1,3,6,9-12 However, decom-
pression for a large OKC is a simple modality for induc-
ing new bone formation.
During the last 3 years, 2 cases of large OKCs involv-
ing the mandible were treated conservatively with a
special appliance for decompression, and bone regener-
ation was induced successfully without recurrence.
Report of Cases
CASE 1
A 39-year-old man presented with a large OKC of the
mandible extending from the left second molar to the right
Received from the College of Dentistry, Yonsei University, Seoul,
Korea.
*Assistant Professor, Department of Oral and Maxillofacial Sur-
gery, Oral Science Research Center.
†Associate Professor, Department of Oral and Maxillofacial Sur-
gery, Oral Science Research Center, Brain Korea 21 Project for
Medical Science.
‡Professor and Chairman, Department of Oral and Maxillofacial
Surgery, Oral Science Research Center.
Address correspondence and reprint requests to Dr Park: De-
partment of Oral and Maxillofacial Surgery, College of Dentistry,
Yonsei University, 134 Shinchon-Dong, Seodaemoon–Gu, Seoul,
Korea, 120-752; e-mail: hspark709@yumc.yonsei.ac.kr
© 2005 American Association of Oral and Maxillofacial Surgeons
0278-2391/05/6302-0019$30.00/0 lllll
doi:10.1016/j.joms.2004.07.014
267
63:267-271, 2005
second premolar region (Fig 1). Scalloped margins were
also shown in several areas of the lesion. The right canine,
the left lateral incisor, and the left canine were displaced
laterally. In the axial computed tomography (CT) scan, a
well-defined intrabony soft tissue lesion was observed with
expanded and thinned buccal and lingual cortical bones.
Discontinuity of the bone was observed in some areas of the
lesion (Fig 2). A decompression technique was undertaken
not only to reduce the cystic size but also to reinforce the
thin cortical surface. Two holes were made and rubber
tubes were placed for decompression. On the 15th day after
surgery, a custom made decompression appliance with 2
tubes was applied (Fig 3), and the patient was taught how
to self-irrigate frequently using a 30 cc syringe and normal
saline. A dramatic reduction in the size of the lesion and
remodeling of the adjacent bone was noted in an orthopan-
tomogram and CT scan 1 year after the initial surgery (Figs
4, 5). Subsequently, residual enucleation and curettage of
the cyst were carried out without any bone graft. The final
biopsy at the time of definitive surgery was OKC, which had
partial transformation of the lining into normal squamous
epithelium. The follow-up CT after 18 months (Fig 6), and
the 2 years and 6 months’ follow-up panoramic radiograph
showed complete bone healing (Fig 7).
CASE 2
A 21-year-old woman presented with a large OKC ex-
tending from the right mandibular ramus to the left first
molar area with scalloped margins, an impacted right
canine at the symphysial region, a horizontally impacted
right third molar displaced superiorly, and the external
root resorptions of the right first and second premolars
(Fig 8). The CT scans revealed that the cortical bones of
FIGURE 1. Panoramic radiograph in case 1 showing a well-defined
radiolucent lesion from the left second molar to the right second
premolar region of the mandible with scalloped margins and displac-
ing the anterior teeth.
Jung, Lee, and Park. Decompression of Large OKCs of the Man-
dible. J Oral Maxillofac Surg 2005.
268 DECOMPRESSION OF LARGE OKCS OF THE MANDIBLE

FIGURE 4. One year after decompression, a panoramic radiograph

in case 1 showing decreased size and bone healing of the lesion.
Jung, Lee, and Park. Decompression of Large OKCs of the Man-
dible. J Oral Maxillofac Surg 2005.

months after decompression, enucleation and curettage

of the cyst with the extraction of impacted canine were
performed under general anesthesia. The final biopsy
report was an OKC, which had similar cyst lining before
decompression (Fig 12). The patient did not show any
abnormality in the clinical and radiographic examination
FIGURE 2. In the axial CT scan, a well-defined intrabony lesion of conducted 2 years and 4 months after decompression
case 1 was observed. Buccal and lingual cortical bones were ex- (Fig 12).
panded and thinned. At some points of the lesion, discontinuity of the
bone was seen.
Jung, Lee, and Park. Decompression of Large OKCs of the Man- Discussion
dible. J Oral Maxillofac Surg 2005.
Cysts of the jaws can be treated using 1 of the
following surgical modalities: enucleation, marsupial-
the buccal and lingual side and the inferior border were ization, or decompression and secondary enucle-
expanded and thinned. Partial discontinuity of the bone
was found on the buccal and lingual cortical bones (Fig
9). The patient was treated with cyst decompression with
tube drains accompanying the biopsy at the previous
bony defect and the same contralateral area. A similar
decompression appliance to that used in case 1 was
placed intraorally and the patient was taught how to
perform frequent self-irrigation. After 1 year of decom-
pression, the follow-up panoramic radiograph and CT
scan showed remarkable bony healing and a reduction of
the size of the cystic lesion (Figs 10, 11). Thirteen

FIGURE 5. One year after decompression in case 1, a CT scan

FIGURE 3. A decompression appliance with 2 tubes worn in the showing a reduction in the size of the lesion and a remodeling of the
patient’s mouth in case 1. lost bone.
Jung, Lee, and Park. Decompression of Large OKCs of the Man- Jung, Lee, and Park. Decompression of Large OKCs of the Man-
dible. J Oral Maxillofac Surg 2005. dible. J Oral Maxillofac Surg 2005.
JUNG, LEE, AND PARK 269

FIGURE 8. Panoramic radiograph in case 2 showing a well-defined

radiolucent lesion from the right mandibular ramus to the left first molar
area with scalloped margins, an impacted right canine at the symphy-
sis region, horizontally impacted right third molar locating superiorly,
and an external root resorption of the right first and second premolars.
Jung, Lee, and Park. Decompression of Large OKCs of the Man-
dible. J Oral Maxillofac Surg 2005.

and the Brosch procedure.2,4,5 The Brosch procedure

involves decortication-like removal of the overlying
buccal cortical plate and enucleation through an oral
approach in the management of large multilocular
FIGURE 6. Eighteen months’ follow-up CT in case 1 showing a cyst OKC in the molar, angle, and ramus regions of the
that has almost disappeared.
mandible.4 Others have used Carnoy’s solution,
Jung, Lee, and Park. Decompression of Large OKCs of the Man-
dible. J Oral Maxillofac Surg 2005. which is a tissue fixative to tan the cyst before and
after its enucleation.15,16 This was 1 of the aggressive
ation.13,14 However, for OKCs, various surgical treat- treatments performed because it is often followed by
ments have been used because of the high frequency excision of the overlying oral mucosa in cases with
of recurrence, which is known to be as high as cortical perforation. Enucleation complemented by
62.5%.7,8 Various histologic and clinical features have
been reported.1-4,8,10 Thin keratinized epithelium,
daughter cysts, and epithelial remnants of the dental
lamina can be addressed after treatment. The aggres-
sive growth potential of the OKC epithelium can also
be another factor when determining the appropriate
treatment. Complete removal is very difficult in the
multilocular case.
To reduce the high recurrence rate, some authors
have recommended radical surgery such as resection

FIGURE 9. Preoperative axial CT scan in case 2 revealed expanded

FIGURE 7. Panoramic radiograph in case 1 showing an almost and thinned buccal and lingual cortical bones. The discontinuity of the
disappeared lesion at the 2-years and 6-months’ follow-up. bone was partially found.
Jung, Lee, and Park. Decompression of Large OKCs of the Man- Jung, Lee, and Park. Decompression of Large OKCs of the Man-
dible. J Oral Maxillofac Surg 2005. dible. J Oral Maxillofac Surg 2005.
270
FIGURE 10. One year after decompression, a decreased size of the
cyst was observed in a panoramic radiograph in case 2.
Jung, Lee, and Park. Decompression of Large OKCs of the Man-
dible. J Oral Maxillofac Surg 2005.
cryotherapy for an OKC has also been recom-
mended.8,17 Otherwise, a more conservative ap-
proach such as marsupialization or decompression
with or without secondary enucleation was suggested
for treating OKCs.3,6,9-12,18 The recurrence rate after
conservative treatment was reported as low as those
rates comparable to other procedures except for re-
section.4-9,12,15,16,18,19
Marsupialization implies that the oral mucosa is
allowed to fold into a defect and is sutured to the
cyst lining; thus the cystic epithelial lining is trans-
formed into normal mucous membrane by evagina-
tion from an adjacent area.13 If the transformation
of the cystic epithelium and the reduction of the
degree of keratinization of an OKC are ensured by
long-term decompression as a modification of mar-
FIGURE 11. One year after decompression, follow-up CT scan in
case 2 showed a thickened bone wall and a smaller cystic lesion.
Jung, Lee, and Park. Decompression of Large OKCs of the Man-
dible. J Oral Maxillofac Surg 2005.
DECOMPRESSION OF LARGE OKCS OF THE MANDIBLE
FIGURE 12. The 2-years and 6-months’ follow-up panoramic radio-
graph in case 2 showing a disappeared lesion.
Jung, Lee, and Park. Decompression of Large OKCs of the Man-
dible. J Oral Maxillofac Surg 2005.
supialization, it can be a suitable treatment modal-
ity for an OKC. Brondum and Jensen6 and Marker et
al12 reported that the histologic transformation af-
ter a cystotomy for decompression and enucleation
afterward showed that decompression changed an
aggressive to either less aggressive OKC or to a
nonkeratocyst of 44% to 60%. This histologic trans-
formation and decreased size of the cyst make it
easier to complete the secondary enucleation. How-
ever, the first case of the 2 presented cases showed
partial transformation of the lining into a more
normal epithelium after decompression but final
pathologic diagnosis was OKC. In the second case,
the cyst lining both before and after decompression
was similar and showed OKC (Fig 13).
Decompression or marsupialization, as a conser-
vative treatment for a large OKC, can save the
anatomic structures including the adjacent teeth,
the inferior alveolar canal, and the maxillary sinus.
By relieving the intracystic pressure, the size of the
FIGURE 13. In case 2, the final microscopic feature after decom-
pression showed OKC, which was similar to before decompression.
Jung, Lee, and Park. Decompression of Large OKCs of the Man-
dible. J Oral Maxillofac Surg 2005.
LIM ET AL
cyst is reduced, which can induce the eruption of
impacted teeth and new bone formation.3,6,9-12,17
Recently, the treatment regimen for large kerato-
cysts has been changed to this conservative method
to save the vital structures.9,12,17 The disadvantages
of decompression are that 2 surgical procedures
are needed and it requires a longer period of time.12
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J Oral Maxillofac Surg
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