ODONTOGENIC

KERATOCYST
--JAYALAKSHMI PREETHA MEYYANATHAN
CRI
 First described by Philipsen in 1956
 OKC is a dilemmatic odontogenic
developmental cyst of oral and maxillofacial
region which has gained very special attention
since the last 2 decades
 Rare
 Benign
 Locally aggressive
 Many prior attempts have been made to
classify these cysts from 1887 to finally WHO
2017.
 The most controversial decision in the 2017
classification was to move keratocystic
odontogenic tumour back into the cyst category
as OKC because the evidence supporting that
hypothesis of neoplasia is considered insufficient.
Evolution of OKC from cyst to tumour to cyst again based on
WHO classifications
 Dental cyst(JohnHunter,1774)
 Dermoid Cyst (Mikulicz,1876)
 Primordial cyst (Robinson,1945)
 Keratocystoma (Shear)
 Odontogenic keratocyst (Philisen,1956 and
PindborgandHansen,1963)
 Benign neoplasm(Toller,1967)
 Odontogenic keratocyst (WHO,1971)
 True benign cystic epithelial neoplasm(Ahlfors,1984)
 Odontogenic keratocyst (WHO,1992)
 Keratocystic odontogenic tumor(Benign neoplasm)(WHO,2005)
 Odontogenic keratocyst (WHO,2017)
Pathogenesis and clinical presentation:
 Origin: Most OKCs (60%)arise from dental lamina
rests or from the basal cells of oral epithelium and
are thus primordial origin OKCs and the remaining
40% arise from the reduced enamel epithelium of
the dental follicle and are thus dentigerous-origin
OKCs.
 Age and gender: It occurs at all ages with peak
incidence in 2nd and 3rd decades of life, with
male:female ratio of 1.6:1.
Site:
 most frequently in mandible than in maxilla
 It occurs mostly as intra osseous lesion though
peripheral counterpart also has been reported in
buccal gingiva at canine region of the mandible.
 In mandible it occurs usually in angle—ascending
ramus region(69%–83%)andoften the mandibular
cyst crosses the midline. Maxillary cyst may involves
sinus and nasal floor, premaxilla and maxillary third
molar region.
 OKC may also arise from TMJ.
 Multiple OKCs is the feature of Nevoid Basal Cell
Carcinoma(Gorlin syndrome)
Signs and Symptoms:
 Mostly asymptomatic, swelling appears late as the
cyst initially extends in the medullary cavity along
the path of least resistance, rather than expanding the
cortex (early stage).
 Pain, swelling with discharge and paraesthesia of the
lower lip and teeth(late stage)
 Displacement of teeth during expansion Maxillary
lesions get infected and are detected earlier than the
mandibular lesions due to their close proximity to
antrum
 Enlarging maxillary lesion produce displacement and
destruction of floor of orbit and proptosis of eye
 The expansion of the cyst is very minimal in the initial stage
and it is due to the classical characteristic of the cyst to grow
in anteroposterior direction in the medullary space of the
bone.
 Buccal expansion more common than the palatal or lingual
expansion.
 Percussion of teeth produce dull hollow sound
 Perforation of bony cortex seen during enlargement
 Associated with missing tooth (not always)
 Displacement of inferior alveolar canal in an abnormal
position(large lesions)
Syndromes associated with multiple OKC
 Nevoid Basal cell carcinoma syndrome(NBCCS),
 Gorlin goltz syndrome,
 Marfans syndrome,
 Ehlers danlos syndrome,
 Noonans syndrome,
 Orofacial digital syndrome,
 Simpson–Golabi–
Behmelsyndrome(Bakaeenetal.,2004;Gonzalez-
Alvaetal.,2008).
Radiological features
 well defined unilocular or multilocular(25%–40%) radiolucent
lesion with smooth margin (corticated margin in secondarily
infected cases) and has several radiological variants.
 Associated with teeth either in pericoronal, interradicular or
periapical or in association with missing teeth.
 Most commonly involve molar ramus area.
 Multilocular cystic lesion may appear as one large cyst with
few smaller daughter cyst.
 Borders: Smooth or scalloped suggesting unequal growth
activity.
 Buccal expansion with resorption of the lower cortical plate
sometimes with perforation of bone.
 Resorption of adjacent tooth root
RADIOGRAPHIC VARIANTS OF OKC
HISTOLOGIC FEATURES
1. Thin Stratified squamous epithelium lining with ribbon –like appearance typically
8-10 uniform layers thick.
2. Lacks of rete ridges/pegs.
3. Well defined basal cell layer having cuboidal or columnar cells arranged in
palisaded fashion described as “picket fence or tombstone appearance.”
4. A thin spinous cell layer which often shows direct transition from basal cell layer
(artefactual separation of epithelium from basement membrane) and spinous cell
layer intracellular edema.
5. Surface keratinisation which is corrugated and rippled and mostly parakeratosis
(keratinized cells with nuclei)
6. Cystic wall composed of fibrous connective tissue which is thin and usually
uninflamed.
7. Others findings are satellite cysts, daughter cysts (7-30%), solid epithelial
proliferation,odontogenic rests basal layer budding may be seen.fibrous
connective tissue wall may get mineralized and may include cholesterol crystals
and Rushton bodies.
Diagnosis :
 is usually radiological
 Biopsy-gold standard
 Aspirational biopsy of odontogenic keratocysts
contains dirty creamy white viscous fluid which is
pale in colour and contains keratotic squames.
(shimmering keratin crystals)
 Protein content of cyst fluid below 4.0g/100ml is
diagnostic of odontogenic keratocysts(majority of
content is albumin)
Differential Diagnosis
1. Histologically : myxoma, ameloblastoma,
central giant
cell granuloma, odontogenic cysts.
2. Radiographically : Dentigerous cyst (40%),
Residual cysts, radicular cyst, Lateral periodontal
cysts (25%),
Primordial cyst (25%), Globulomaxillary cyst
(10%), Unicystic ameloblastoma, A-V
malformation, Fibro-osseous lesion at initial
stages
MANAGEMENT OF
CYSTS
Management of cysts
Objectives of treating cyst
1.Complete elimination of the pathologic lesion
2.Cause minimal destruction and damage to the
surrounding soft and hard tissues
3.Restore normal function
Considerations before selection of treatment
Related teeth
 All the teeth related to the cyst and displaced by the cyst must be tested
for preoperative pulp vitality.
 The cysts must be separated carefully from the thin bone lamina
surrounding the apices of vital teeth.
 Most of the teeth continue to give vitality responses immediately after
removal of the cyst, some regain considerable sensitivity after a period of
months but a few remain insensitive permanently.
 There is a clinical impression that function stimulates more rapid bone
generation and it may be reasonable to retain teeth, even on a temporary
basis, to provide this stimulus to the alveolar and basal bone.
 In case of a keratocyst, eradication of the lesion is much more important
than preservation of related teeth and the teeth are not preserved at the
expense of incomplete removal of the cyst
Fracture and risk of fracture
Continuous and progressive enlargement of a cyst may
eventually lead to a pathological fracture. This is
indicated by a slight click, a brief increase in pain or
the sudden onset of mental nerve paraesthesia in case
of mandible. There is considerable potential for
regenerative bone growth after the release of intra
cystic pressure.
In case of fracture or risk of pathologic fracture (residual
basal bone after treatment is less than 1cm),
reinforcement with bone graft and reconstruction plate
is mandatory.
Inferior alveolar nerve involvement
Separation of cyst wall from the inferior alveolar neuro
vascular bundle can be accomplished with temporary or
no interruption of nerve function.
Principles of treatment selection
1.The lining should be removed or rearranged in order
to eliminate it from the jaw.
2.Thetoothgerm,the unerupted or partially erupted teeth
should be conserved as far as possible and should be
allowed to erupt.
3.Preservation of the adjacent vital structures like
neurovascular bundle, nasal orantral lining mucosa,etc.
Marsupialisation(cystotomy)
It is the earliest treatment used and was first described
by Partsch in1892. In this process a window of 1cm is
made into the cyst and lining is sutured to oral mucosa
process to convert the cyst into pouch so that cyst is
decompressed and it exposes the cystic lining into oral
environment. Mandibular cyst marsupialised into oral
cavity and maxillary cyst marsupialised into maxillary
sinus and nasal cavity. Cavity is then regularly packed
open with iodoform gauze coated with tincture benzoin
till endeosseous healing.
Advantages of marsupialisation
 It is a relatively simple procedure and poses no risk to the adjacent vital
structures.
 It does not create an oronasal or oroantral fistula.
 It consumes less time and there is less blood loss.

Disadvantages of marsupialisation
 Pathological lining of the cyst cavity,if left behind might pose a cause for
development of neoplastic changes in the future.
 Healing can be delayed in cases of large cyst in older patients and cyst
perforating the palatal mucosa.
 It has to be regularly irrigated to prevent infection.
 Prolonged healing time.
 Regular cleansing of the cavity is needed failing which may lead to infection.
 Inconvenience for patients.
 Formation of tissue pockets that may lodge food material.
Modifications
1.Waldron’sprocedure—Marsupialisation followed by
enucleation
2.Marsupialization by opening into the maxillary
sinus or nose: This procedure can be applicable in case
of an extensive cyst of the maxilla that occupies a
large portion of the antrum.
Enucleation(cystectomy)
 Enucleation involves complete removal of the cyst lining
and its contents.
 Intraoral approach is usually the method of choice for
enucleation although rarely an extraoral approach through
the submandibular skin may be indicated.
Indications
•Smallcysts
•Small or large cysts not endangering vital structures or risk
of pathologic fracture
•Cysts as odontogenic keratocysts that have a high recurrence
rate
Advantages of enucleation
•Entire cystic lining is removed making the entire pathologic
tissue available for microscopic study.
•Rapid healing occurs as the wound is closed primarily.
Disadvantages of enucleation
•In young people, tooth germ or unerupted teeth involved with
the cyst are extracted or removed with the lining of the cyst.
•Pathological jaw fractures can occur in case of enucleation of
a large cyst.
•The procedure endangers the adjacent vital structures.
•Directobservationofwoundhealingasincaseofmarsupialisationi
snotpossible
 Enucleation with primary closure

A)Access to the cyst has been indicated in red,for deroofing of the cyst and exposure
of the cystic lining.
(B)Cyst enucleated along with extraction of the tooth if indicated and mucoperiosteal
flap repositioned and sutured.
Enucleation with open packing

This technique is preferred in cases of infected large

cyst where in primary closure of the cyst might lead to
break down of the wound and interfere with healing.
Enucleation and curettage
It denotes scrapping of the cyst cavity within exact thickness of
surrounding bone by hand instruments.Recurrence rate is highest with
this method(9%–62%). Adjuncts such as Carnoy’s solution or
cryotherapy may be used along with it.

Enucleation and peripheral ostectomy

It involves enucleation of the cyst along with an inexact thickness of
surrounding bone by powered rotary instruments. Methyleneblue dye can
be used to mark the bone.
Enucleation and chemical cauterisation
After enucleation Carnoy’s solution is applied into the cavity.Carnoy’s
solution was first used as a medicament in surgery by Cutler and
Zollingerin 1933. It is a powerful fixative, haemostatic and a cauterising
agent which penetrates cancellous spaces in the bone and devitalises and
fixes the left out epithelial remnant cells. Its average depth of bone
penetration of this solution is to a depth of 1.54mm, nerve penetration to
0.15mm,and mucosa to a depth of 0.51mm after 5min of application.
Enucleation and cryotherapy
Liquid nitrogen has the ability to devitalise bone in situ
and leave osseous inorganic framework untouched. It
acts by direct damage from intracellular and
extracellular ice crystal formation leading to cell death.
Also it creates osmotic and electrolytes disturbance in
cell. After enucleation, cystic cavity is sprayed with
liquid nitrogen twice for 1 min, with 5min thaw
between freezes.
Resection
Resection is to either do a marginal
resection(surgical removal of a lesion intact and a
small area of uninvolved bone, maintaining the
continuity of the bone)or a segmental
resection(surgical removal of a segment of the
mandible without maintaining the continuity of the
bone)in the mandible where as in maxilla the
resections are classified as partial
maxillectomy(alveolectomy)or subtotal or total
maxillectomies. Resections have the lowest
recurrence rate(0%) but the highest morbidity rate
because reconstructive measures are necessary to
restore0jawfunctionandaesthetics.
Treatment modalities for KCOT:
Treatment of OKC depend on patient age, size and
location of cyst, soft tissue involvement and histological
variant of lesion. Treatments are usually classified as
conservative like
 Enucleation with or without curettage and
 marsupialization and

aggressive like
 peripheral ostectomy and
 chemical curettage with Carnoy’s solution, cryotherapy,
or electrocautery and
 Resection
Recurrence of OKC/KCOT:
It has high recurrence rate ranging from 25-60%. Recurrence rates reduced when
more meticulous surgical treatment is done. Majority of cases reported recurrence
within 5 years post treatment. The mean time of recurrence for males was found to
be 4years and for females it came out to be 7 years. There have been few cases
where recurrence was reported even after 10 years also. So long term follow up in
necessary. The causes and factors responsible for KCOT recurrence are :
1. Incomplete removal of cystic lining
2. Thin and friable nature of epithelial lining,
3. Higher level of cell proliferative activity in the
epithelium.
4. Budding in the basal layer of the epithelium
5. Bony perforation.
6. Adherence to adjacent soft tissue.
7. Supraepithelial and Subepithelial split of the epithelial
lining.
8. Parakeratinization of the surface layer
9. Ramnants of dental lamina epitelium not associated
with original OKC and development of new OKC in the
adjacent area.
10. Growth of new OKC from satellite cyst /daughter
cyst/remnants/cell rests.
1.enucleation 30 %
2.enucleation + carnoy’ solution: 9 %
3.enucleation + peripheral ostectomy 18 %
4.enucleation + carnoy’ solution + peripheral
ostectomy 8%
5.enucleation + cryotherapy 38 %
6.marsupialization 33%
7.marsupialization + cystectomy 13 %
8.Resection 0%
Advanced and future treatment modalities Due to
the recent advances and thus determination of
molecular basis of this entity, a new novel
methodology concentrating on molecular aspects
has been devised. The SHH pathway can be
blocked at different levels, and SHH inhibitors
could serve as attractive antitumour agents.
Thank You!!!!