Odontogenic keratocyst is a common cystic lesion of the jaw which arises from the remnants of the dental lamina.

The biological behaviour similar to a benign neoplasm. A distinctive lining of 6 10 cells in thickness Exhibits a basal cell layer of palisaded cells A surface of corrugated parakeratin.

The term odontogenic keratocyst was introduced by Philipsen (1956)

Described as keratocyst, because of a large extent keratin formation.

It has been renamed as Benign Keratocystic Odontogenic Tumour(KCOT). WHO 2005

Arises from rests of the dental lamina basal layer of the oral epithelium Primordium of the developing tooth germ or enamel organs. Cystic degeneration of the cells of the stellate

reticulum in a developing tooth germ ( before its

calcification starts ).

AGE Mostly second and third decade of life. SEX Males are more affected than females. SITE > Mostly in relation to mandible ( 75%) than maxilla. 50% - angle of the mandible.

Aggressive in nature. high recurrence risk. may occur in association with nevoid basal cell carcinoma syndrome. Solitary cystscommon (5% to 15% of all odontogenic cysts); recurrence rate 10% to 30% Multiple cysts5% of OKC patients; recurrence greater than with solitary cysts Syndrome-associated, multiple cysts5% of OKC patients; recurrence greater than with multiple cysts

 Small OKC lesions Asymptomatic Discovered only during the course of a radiographic examination. Large OKC lesions May be asymptomatic If symptomatic, pain,swelling, along with mobility and displacement of teeth, or with discharge. Paresthesia of lower lip. There is often one tooth missing from the dental arch. OKCs tends to grow in antero-posterior direction within the medullary cavity of the bone without causing obvious bony expansion.

Multilocular radiolucent areas with a typical soap bubble appearance. Can be unilocular with a well corticated margin Many lesions cross the mandibular midline . Demonstrate a well defined round or oval radiolucent area with smooth margins and sometimes scalloped. Can cause pathologic fracture, perforation of the cortical plates of the jaw.

OKC MULTILOCULAR APPEARANCE

Panoramic view of lesions in both jaws from multiple nevoid basal cell carcinoma syndrome.

Detail from panoramic radiograph showing homogeneous radiolucency that surrounds roots of right premolar and molar. The definitive diagnosis awaits histopathology in such cases.

Odontogenic keratocyst: note lack of jaw expansion and lack of tooth resorption by this large well-delineated homogeneous radiolucency crossing the midline of the mandible (topographic occlusal view).

Extraneous Replacemental

Collateral
Envelopmental

HISTOPATHOLOGY:
Epithelium: Stratified squamous epithelium
Parakeratinized (80%) or Orthokeratinized (20%) Corrugated epithelium 5-8 cell layer thick No rete ridges (rete pegs) Basal cells are columnar to cuboidal & show palisading arrangement.

Connective tissue wall:

Fibrous capsule of the cyst is usually thin. Few to Many daughter/satellite cysts are seen. Absence of inflammatory cell infiltration.

(Neville, Brad Neville. Oral and Maxillofacial Pathology, 2nd Edition. Elsevier, 2002. 15.1.2.1).

Dentigerous cyst Ameloblastoma Odontogenic myxoma Simple bone cyst Lateral periodontal cyst / Botryoid odontogenic cyst Residual cyst

Stepwise approach (a) History (b) Clinical examination (c) Radiographic examination (d) Aspiration (e) Biopsy

A. History

previous history of swelling, trauma, surgery

B. Clinical

findings

Symptoms : pain, swelling. Enlargement of jaw bone. palpation crepitus / fluctuation, pathologic fractures. caries, tooth vitality, displacement, crowding, missing tooth, resorption or delayed eruption of teeth.

Alterations in the function of peripheral sensory nerves. Secondary infections.

C. Radiographic Examination

Intra Oral Periapical Films

Topographic occlusal view

Extra-Oral Lateral oblique view

Posterior-Anterior Projection
Occipitomental view / Waters view Orthopantomograph

 Gives accurate measurement of the extent of the lesion Exact localization of areas of perforation through the cortex Assessment of soft tissue involvement Very helpful in large lesions in

maxilla, particularly where extension of the lesion to the cranial base is suspected.

D. ASPIRATION:
Indications (1) To rule out vascular lesions (2) To collect specimen for culture / sensitivity, cytology studies. (3) Insight into possible diagnosis

Aspiration Findings : Pale yellow inspissated material, dirty creamy / cheesy material Protein content of cystic fluid less than 4gm/100ml

E. BIOPSY

Elimination of cystic lining. Decompression of the intracystic pressure. Preservation of the teeth. Preservation of important anatomical structures. Prevention of recurrence of cyst.

Reasons for treatment of cysts of oral cavity : Increase in size Infection weaken the jaw Cysts undergo changes Cysts can prevent eruption of teeth.

1. Marsupialization (decompression)
2. Enucleation / Curettage 3. Peripheral osteotomy 4. Marginal mandibulectomy 5. Segmental resection of the jaw

MARSUPIALIZATION:
PRINCIPLE :

Surgical window in the wall of cyst , evacuation of the cystic contents which decreases intra cystic pressure and promotes shrinkage of the cyst and bone fill. Only a part of mucosa or bone is removed to create a window.

INDICATIONS:

Age : In young child In elderly. Proximity to vital structures Eruption of teeth Size of cyst Vitality of teeth

ADVANTAGES :

Simple procedure.
Spares vital structures. Allows eruption of teeth. Prevents pathological fractures. Reduces operating time. Reduces blood loss. Helps shrinkage of cystic lining.

Alveolar ridge is preserved.

DISADVANTAGES :

Pathologic tissue left in situ. Histological examination of entire cystic lining is not done. Prolonged healing time. Inconvenience to patient.

Periodic irrigation of cavity.

Regular adjustments of plug. Periodic changing of pack.

Secondary surgery may be needed.

Risk of invagination and new-cyst formation.

WALDRONS METHOD (1941) PARTSCH II Two stage technique: 1st marsupialization Enucleation when the cavity becomes smaller. Indications: Bone has covered the adjacent vital structures. Adequate bone fill. Difficult to cleanse the cavity. For detection of any occult pathologic condition.

ADVANTAGES :
Development of a thickened cystic lining Spares adjacent vital structures

Combined approach reduces morbidity

Accelerated healing process.

DISADVANTAGES:
Second surgery required.

PRINCIPLE :
Enucleation allows for the cystic cavity to be covered by mucoperiosteal flap and the space fills with blood clot, which will eventually organize and form normal bone.

ADVANTAGES :

Primary closure of wound. Healing is rapid. Post-op care is reduced. Thorough examination of entire cystic lining.

DIADVANTAGES :

After primary closure, observation of healing of cavity not possible. Removal of large cysts will weaken the mandible, making it prone to jaw fracture. Damage to adjacent vital structures. Pulpal necrosis.

PERIPHERAL OSTECTOMY :

Adjunct to enucleation or marginal mandibulectomy Remaining bony bed is treated to eliminate any residual neoplastic cells.

Adjacent soft tissue nerves and vessels protected,12 mm of bone removed from the entire bony bed. Methylene blue (1% aqueous solution) used to stain the uneven surface of bony bed, reducing risk of missing uneven portion, primary closure done under antibiotic coverage.

CRYOTHERAPY :

Liquid nitrogen by spray or probe --destroy soft tissue When the probe is used a medium such as surgical jelly assist in transmitting the low temperature to all regions of bony bed. Applied for 2 min After complete thawing, cycle is repeated. The medium is removed, before closing wound After enucleation or curettage - chemical or thermal cautery phenol, carnoys solution.

CAUTERY:

Composition

Absolute alcohol Chloroform Glacial acetic acid Ferric chloride

6ml 3ml 1ml 1gm

Mechanism It enters the bony trabeculae inaccessible to enucleation & causes the charring of epithelium or fixes the tissue. It destroys the daughter cyst which is one of the most important cause for recurrence. Application cotton pellets soaked in carnoys solution is kept in the cystic cavity for 3 -5 minutes. Followed by irrigation with normal saline. Depth of penetration Soft tissue 3-5 mm Hard tissue 1.5 -3 mm

4. EN BLOC RESECTION:

Removal of lesion together with bony margins of 1 cm (10mm) of the uninvolved bone. Here bony continuity is disrupted and periosteum is involved. Intra oral approach is used for lesions anterior to the ramus of the mandible. Extra oral approach used for lesions involving the ramus of the mandible.

RECURRENCE : varies from 5-62 % It is more often in the mandibular lesions, particularly those in the posterior body & ascending ramus Recurrence occur usually within 5 yrs of surgery Why OKC recur?? Tendency to multiplicitysatellite cyst formation Incomplete removal of lining because lining is thin & fragile & also attachment between two is weak predisposition to form OKC from Dental lamina rests Proliferation of basal cells of oral epithelium to form OKC Long term clinical & radiographic follow up is necessary

HISTORY & CLINICAL FINDINGS

SMALL
ACCESSIBLE ENUCLEATION/ CURETTAGE

PERIPHERAL OSTECTOMY CRYOTHERAPY

CYST

CARNOYS SOLUTION

OKC

LARGE
INACESSIBLE CYST

MARSUPLIALIZ ATION (DECOMPRESS ION)

RECURRENT CYST DIAGNOSTIC PROCEDURE

ENBLOC/ SEGMENTAL RESECTION