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ODONTOGENIC

KERATOCYST
HISTORY

The term primordial cyst was first mentioned
in 1945 by Robinson, because the cysts were
believed to have a more primordial origin
because they arose from remnants of dental
lamina or the enamel organs before enamel
formation had taken place.
Philipsen (1956).
CLINICAL FEATURES:

Age: Any age.
Sex: Frequently males than in females.
Site: The mandible is involved more
frequently than maxilla.
CLINICAL PRESENTATION:

Patients with odontokerato cysts complain of
pain, swelling or discharge. Occasionally
they experience parasthesia of the lower lip or
teeth.
Some patients have been unaware of the lesion.

Accidental findings.
Cyst is sometimes painless because the
keratocyst tends to extend in the medullary
cavity and clinically observable expansion of
the bone occurs late.
Voorsmit (1984) Lund (1985) have described
the occurrence of large keratocyst, which
involved the maxillary sinus led to
displacement of floor of the orbit and
proptosis of the eye balls. Neurological
symptoms are occasionally seen.
One third of maxillary cysts cause buccal
expansion, but palatal expansion was very
rarely seen.
Classification of OKC

MAIN (1970) has classified odontogenic keratocyst
depending on its position.
Envelopmental : When OKC embraces an adjacent
unerupted tooth.
Replacement: When OKC forms in the place of normal
tooth.
Extraneous: When OKC forms in the ascending ramus
away from teeth.
Collateral: When OKC forms adjacent to the roots of the
teeth.
Follicular OKC :
According to Altini and Cohen, A tooth surrounded by its
follicle erupts into a keratocyst cavity in the same way as it
would erupt into the mouth.

Toller regarded as benign neoplasms.

Foresell (1980) Rate of growth varies from
2 to14mm a year.
Growth rate is slow in patients
over 50 years of age.
The epithelium of keratocyst shows
a higher rate of proliferation

Toller (1970) osmolatity of the cyst fluid
in enlargement of the keratocysts
ENLARGEMENT

Collagenolytic activity with in the fibrous
capsule cause resorption of bone.
Keratocyst contains

Low quantities of protein (High molecular
weight)
Predominantly albumin and small
quantities of immunoglobulins.
Other Fluids like
Glycosaminoglycans
Heparin sulphate

RADIOLOGICAL FEATURES:
Small round ,ovoid shape.
Distinct sclerotic margins
Scalloped margins - may be mis-interpreted as
multilocular lesions.
Unilocular or multilocular.
Downward displacement of the inferior
alveolar canal and resorption of the lower
cortical plate of mandible may be seen as well
as perforation of bone.
Occasionally pathological features.
PATHOGENESIS

Derived from odontogenic epithelium.
Rests of dental lamina or dental lamina.
Consists of epithelium lining + connective tissue
wall.
Epithelium is stratified squamous and keratinized
and 5 to 8 cell thickness without retepegs.
Parakeratin or orthokeratin.
Basal layer well defined palisaded basal layer
consists of columnor or cuboidal cells.
Connective tissue consists of daughter cyst or
satellite cysts
SURGICAL MANAGEMENT OF
ODONTOGENIC
KERATOCYST

Several authors suggested that odontogenic
keratocyst should be considered as Benign
Cystic Tumor.
CONVENTIONAL SURGICAL
OPTION

Conservative methods
Enucleation
Marsupilization
Less than optimal results.

Including curettage, peripheral Osteotomy,
Removal of overlying mucosa in cases of
cortical perforations and
osseous resections
ENUCLEATION AND
CURETTAGE

Simple cyst enucleation is not advocated.
Recurrence rate high
Enucleation of cyst as single piece reduce the
recurrence rate.
Ramus and angle regions are difficult.
ENUCLEATION AND
PERIPHERAL OSTEOTOMY

Peripheral osteotomy is primarily used as an
adjunctive for osseous removal when
resection can be avoided.
As cyst size increases, the cyst borders may
become irregular or scalloped or surgical
access to the cyst may become compromised.
Rotating instruments - burs

Dye the residual cystic bony cavity with
methylene blue to ensure that the entire cavity
has received treatment beyond simple
enucleation. (Depth is not conformed).
OSSEOUS RESECTION

Perhaps the most extensive form of treatment
indicated for the management. Of select
odontogenic keratocyst that of osseous
resection, marginal or segmental.

Zero recurrence rate.
Indications:

Thin cystic lining.

In the conjunction with poor access.

Frequent multilocular or scalloped edges.
THE USE OF LIQUID NITROGEN
CRYOTHERAPY IN THE MANAGEMENT OF
ODONTOGENIC KERATOCYST
For centuries, extreme cold has been used
clinically to destroy the cells.
Robert Boyle has been credited with reporting
more than 300 years ago that freezing could
be used to destroy cells.
Cryosurgery is not simply the application of
the freezing temperature to tissues. The aim
of cryosurgery is to kill and destroy cells.
RESPONSES OF ORAL
TISSUES TO CRYOSURGERY
Oral mucosa
Any oral mucosa that comes in contact with
liquid nitrogen becomes necrotic. The
necrotic tissue not evident immediately. After
thawing, normal tissue and the tissues that has
been frozen appear identical.
By 3 days the tissues become necrotic and
often the underlying bone is exposed.

Odontogenic keratocyst treated with
enucleation and cryosurgery, the most
common complication of wound dehiscence -
wound healed after routine oral saline rinses
BONE
One of the unique advantages of cryosurgery
is that frozen bone loses its vitality but
remains its skeletal properties.

With in 40 to 72 hours the cellular elements
with in the bone undergo necrosis.

Disadvantage is pathological fracture
To overcome the problem use bone graft after
cryosurgery for all most all lesions, regardless
of size.
Recommended a soft diet for 8 to 10 weeks.

The presence of bone graft seems to aid with
healing of the soft tissue
TEETH:
Consideration also must be given to the effect of
cryotherapy on teeth.
The effect of cryotherapy on adult human teeth.
Chronic inflammatory changes and
spontaneous recovery
If tooth buds present prevent the odontogenesis.
Inform patients the teeth in bone adjacent to the
cryosurgical site will most likely remain
asymptomatic.

Direct contact with liquid nitrogen --effects are
unknown (RCT )


INFERIOR ALVEOLAR NERVE
Nerve sheath and axon were both affected.
The connective tissue of the sheath remained
as a collagenous tube, the nerve re-vitalization
began approximately 12 days after injury.
Normal nerve architecture was restored by 25
to 30 days.
Patient showed altered sensation post-
operatively ,improvement in sensation was
observed after 91 days
ORAL CRYO-SURGICAL
TECHNIQUES

Prediction of extra oral sites is

Under general anesthesia

All exposed skin should be covered with
moist towels
Enucleation

Careful enucleation.

Removal of involved teeth.

Excision of overlying mucosa.

Surgeon should not be tempted to retain teeth
Exposure and retraction of intra
oral soft tissue
For protection of normal tissue.

To avoid possible damage to surrounding
tissue.
A recurrence that is most likely secondary to
retractor placement.

Moist gauze and tongue blades can be placed
between the cavity and mucosa.
CRYOSURGICAL TECHNIQUE

Cryoprobe with water-soluble jelly.

Liquid nitrogen spray
Cryoprobe with water-soluble
jelly

Fill the defect with water-soluble jelly. The
nitrogen oxide Cryoprobe is activated once it
is immersed in the jelly filled cavity.

The freeze process is continued for 2 minutes
perform 3 times.
Advantages

Can freeze an irregular, gravity dependent
portion the cavity can be performed
Liquid nitrogen spray

Liquid nitrogen boils at 196 on the other
hand nitrous oxide at 89.7C.

Carbon dioxide at 78.5C each of these
liquids is capable of achieving the critical
temperature of -20C necessary for cellular
death.
Cryosurgical indication for managing
the odontogenic keratocyst

Recurrent odontogenic keratocyst.
Large complex mandibular lesions.
Conventional treatment might involve vital
structures.
Non-complaint patient.
EXCISION OF THE
OVERLYING, ATTACHED
MUCOSA, IN CONJUNCTION
WITH CYST ENUCLEATION
AND TREATMENT OF BONY
DEFECT WITH CARNOY
SOLUTION
Paul J.W. Stocklingh MD, DDS]
O.M.S. Clin. N. 15 (2003)
Recurrence 20% to 60%
Enucleation or curettage massuplialization
give rise to higher recurrence rates.
Wright JM. Odontokeratocyst; ortho
keratinized variant (Oral Surgery 1981; 51:
609-615).
Para-keratinized variant recurrence rate
47.8.
Ortho keratinized 2.2%
DIAGNOSIS

Approximately 60% of all Odontogenic
keratocysts are located in the 3rd molar region
extending into the ascending ramus.

40% in tooth bearing area maxilla and
mandible
TYPICAL RADIOGRAPHIC
FEATURES:

Scalloped margins.
Uni or multi locular appearance.
Features may be difficult to identify in the
maxilla, in which over projections of the
maxillary sinus or nasal cavity tends to mask
the sometimes suffle radiographic signs.
Ordinary odontokeratocysts
Amelobalstoma present the same radiographic
features
Decompression and
marsupialization.
M. Anthony Pogrel, O.M.S. Clin. N
Am,. 15 (2003)
Suggested by Partsch in German literature.
This treatment was put forward at that time as
a definitive treatment for cysts.
It consists of the removal of the overlying
epithelium and bone and deroofings the cyst.
If possible suture the cyst lining to the oral
epithelium with initial packing of the cyst to
keep the hole open.
MARSUPIALIZATION

Para-keratinized Odontokeratocysts was
opened widely so that the residual cystic
cavity becomes a pouch. Where possible the
cyst lining was sutured to mucosa, and no
attempt was made to remove any of the cystic
lining apart from which is needed to remove
as part of deroofing procedure. Maxillary
cysts were marsupliazed into the oral cavity
DISCUSSION

From this study, para-keratinized version of
the Odontokeratocyst may restore completely
after true marsupialization. Teeth with in the
cyst also may become upright and erupt.
No failures were reported.
RECURRENCE

There was no correlation between the size or
location of the cyst and its tendency to recur.
No age correlation also
Browne (1970) could find no statistically
significant correlation between the
frequency of recurrence and the age of the
patient location of the cyst, the method of
treatment, the nature of cyst lining and the
presence of cortical perforations.
Satellite cysts (Removal)
Recurrences were more frequent with cysts
in patients with the naevoid based cell
carcinoma syndrome than with cysts is
patients without the syndrome.
Radiographic multilocular had a higher
recurrence rate than those with a unilocular
appearance. (Scalloped Margins).
Some instances new cyst rather than
recurrence.
VARIOUS REASONS FOR
RECURRENCE
Satellite cysts, which are retained during an
enucleation procedure.
Keratocyst linings are very thin and fragile
particularly when the cyst is large, more difficult
to enucleate. So portions of lining may left
behind and constitute the origin of recurrence.
An attempt to save vital adjacent teeth or nerves
during the operation may lead to incomplete
eradication and hence to recurrence.
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