For Treatment of Odontogenic Keratocysts, Is Enucleation, When Compared to Decompression, a Less Complex Management Protocol?

doi:10.1016/j.joms.2014.11.001

Journal of Oral and Maxillofacial Surgery

Volume 73, Issue 4, April 2015, Pages 641-648

https://doi.org/10.1016/j.joms.2014.11.001 Get rights and content

Purpose

To determine whether the clinical management of odontogenic keratocysts (OKCs) is more complex in patients who undergo enucleation with or without adjuvant therapy than in patients who undergo decompression with or without residual cystectomy.

Materials and Methods

The authors implemented a retrospective cohort study and enrolled a sample composed of patients presenting for the evaluation and management of OKCs. The predictor variable was treatment group, classified as decompression with or without residual cystectomy versus enucleation with or without adjuvant therapy (Carnoy solution, cryotherapy, or peripheral ostectomy). The outcome variables were measurements of complexity of management, including total number of procedures, venue of procedure (operating room vs office), type of anesthesia, hospital admissions, and total number of follow-up visits. Data analyses were performed using univariate and bivariate statistics and a multiple linear regression model.

Results

The study sample was composed of 45 patients (66 OKC lesions) with a mean age of 43.3 years. Of the 66 OKCs treated, 34 (51.5%) were treated with decompression with or without residual cystectomy and 32 (48.5%) were treated with enucleation with or without adjunctive therapy. Larger lesions and lesions with radiographic evidence of cortical perforation were treated more often with decompression with or without residual cystectomy. Based on the multiple linear regression model, patients who underwent enucleation with or without adjuvant therapy compared with those who underwent decompression with or without residual cystectomy had on average 1) 1.1 fewer total procedures (P < .01), 2) 0.8 fewer total office procedures (P < .01), 3) 0.6 fewer local anesthesia procedures (P < .01), and 4) 4.8 fewer postoperative visits (P < .01). There was no difference in the number of general anesthesia procedures, office sedation procedures, or hospital admissions.

Conclusion

Given comparable recurrence rates, the increased complexity of managing OKCs with decompression with or without residual cystectomy might not be warranted. Enucleation with or without adjunctive therapy could be the more efficient treatment option.

Section snippets

Study Design and Sample

To address research objectives, the authors designed and implemented a retrospective cohort study. The study cohort was derived from the population of patients presenting to the Department of Oral and Maxillofacial Surgery at the Massachusetts General Hospital (Boston, MA) from February 2001 to April 2011 for the evaluation and management of keratocyst odontogenic tumors. The study was reviewed and approved by the Partners Healthcare Human Studies investigational review board (Massachusetts

Results

During the study interval, 46 patients with 69 OKCs were evaluated and treated at the study institution. One patient was excluded from the sample because of a diagnosis of nevoid basal cell carcinoma syndrome. The final sample was composed of 45 patients with 66 lesions (Table 1). The sample's mean age was 43.3 ± 21.9 years and 57.8% were men. Twenty patients (44.4%) had ASA status I and 25 (55.6%) had an ASA status of least II. Thirty-one (47.0%) lesions were previously untreated and 35

Discussion

Although many studies have compared the recurrence rates for the 2 treatments, no study to date has analyzed the differences in management complexity for enucleation with or without adjuvant therapy versus decompression with or without residual cystectomy. The purpose of this study was to analyze the management complexity for treatment of OKCs with enucleation with or without adjuvant therapy compared with decompression with or without residual cystectomy. The authors tested the null hypothesis

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Cited by (15)

How reliable are follow-up studies on odontogenic keratocysts?
2023, International Journal of Oral and Maxillofacial Surgery
Follow-up studies on odontogenic keratocysts have reported widely varying recurrence rates. This raises the question of how reliable these studies are and how the results should be interpreted. The aim of this study was to critically assess the information from all follow-up studies published since 2004 against a set of criteria to determine how thorough the study was. These criteria include the exclusion of the orthokeratinized variant, exclusion of cysts associated with nevoid basal cell carcinoma syndrome, and appropriate reporting of dropouts. A search of four electronic databases covering the years 2004–2022 was performed. Only studies with a sufficient follow-up period (covering a range of 1–8 years) were included. Studies with fewer than 40 cases were excluded. Fourteen relevant studies were identified in the literature search. The vast majority of these studies had considerable shortcomings, giving rise to serious doubts about the validity of their recurrence rate results. Of note, these studies have often been included in meta-analyses that report on the best treatment options to reduce the tendency of recurrences. The results of this review strongly suggest that multicentre studies with strict protocols should be performed to advance knowledge of the presentation of recurrences, both the timing and frequency.
What Is the 5-year Incidence of Recurrent Disease of Odontogenic Keratocysts?
2023, Journal of Oral and Maxillofacial Surgery
There is no consensus on the ideal treatment of odontogenic keratocysts (OKCs). Certain risk factors may modify the disease recurrence rate. The purpose of this study was: 1) to estimate the incidence of OKC recurrence in a statistically rigorous manner; and 2) to identify risk factors associated with OKC recurrence.
The investigators designed and implemented a retrospective cohort study and enrolled a sample derived from the population of patients presenting to the Department of Oral and Maxillofacial Surgery outpatient clinics at the University of Washington School of Dentistry and Harborview Medical Center for evaluation and management of OKCs between January 1, 2010, and December 31, 2020. Predictor variables included demographics (age, gender), radiographic characteristics (location of lesion, locularity, size, and cortical perforation), and type of operation performed (decompression + cystectomy, enucleation ± adjuvant therapy, or resection). The primary outcome variable was time to recurrent disease, defined as the time from treatment to radiographic or clinical evidence of a new lesion (recorded in months). Kaplan-Meier analysis was used to estimate median time to recurrence, and Cox proportional hazards models were used to identify covariates statistically associated with recurrent disease (P ≤ .05).
The sample was composed of 60 subjects with 63 previously untreated lesions. Eight subjects (13%) developed a recurrent lesion during the study interval with a median time to recurrence of 31 (interquartile range, 24 to 48) months. One of the 8 recurrences occurred within 12 months of treatment and 7 of the 8 recurrences occurred more than 21 months after treatment. Based on using Kaplan-Meier analysis, the 5-year incidence of disease recurrence was estimated to be 34%. Lesions with cortical perforation were 8.3 times more likely to recur (95% confidence interval [1.7, 41.3]; P-value = .01), and multilocular lesions were 10.6 times more likely to recur (95% confidence interval [1.3, 86.9]; P-value = .03). The sample size was the limiting factor to performing regression analyses.
Virtually every publication on OKCs to date reports frequencies of disease recurrence rather than applying appropriate survival analyses commonly used to estimate outcomes in cancer research. Failure to use the appropriate statistical analyses underestimates the risk of disease recurrence. Our study is no exception. The estimated frequency of disease recurrence during the study interval was 13% (8/60). When survival analyses are applied that account for varying months of follow-up, the incidence of disease recurrence is 34 per 100 per 5 years. We recommend the application of time-to-event analyses in the study of disease entities with the potential for recurrence.
Precise locating and cutting of the bone lid with a digital template during the treatment of large mandibular cysts: A case series study
2021, Journal of Cranio-Maxillofacial Surgery
Citation Excerpt :
The molar region of the mandible was a high-risk area, followed by the anterior region of the maxilla (Tamiolakis et al., 2019). Enucleation is the most commonly used surgical procedure because the cyst can be removed entirely to reduce recurrence, and postoperative care is easy to perform (Kinard et al., 2015). However, there is a disadvantage in that the lateral bone must be removed during the operation to gain access and expose the cyst clearly (Pappalardo and Guarnieri, 2014).
The aim of the study was to investigate the efficacy and safety of a digital template in the bone lid technique during enucleation of large mandibular cysts.
Six patients were enrolled in this study. Patients' preoperative CT data were collected to design and produce the digital templates. The bone lids were located and cut under the guidance of the digital templates, and then replanted and fixed following cyst enucleation. Postoperative clinical symptoms were observed and recorded from postoperative days 1–7. The follow-up visits were set at 3, 6, and 12 months. The cystic lesions were exactly and fully exposed without the need for secondary bone removal. The contours of the mandibles recovered well, with excellent sealing of the defects. Apart from one case with postoperative infection and one case with 2-month numbness of the lower lip, no other complications occurred. Six months after the surgery, patients’ appearance and function were well-restored.
A digital template in the bone lid technique during enucleation of large mandibular cysts was effective and safe.
Management of Large Radicular Lesions Using Decompression: A Case Series and Review of the Literature
2019, Journal of Endodontics
The purpose of this study was to report the clinical efficacy of decompression for 3 cases with large periapical lesions and to review technique details. Three cases with large periapical cystic lesions were treated with decompression after root canal treatment. A traditional decompression technique was used for the first case. After aspiration, mucogingival incision, irrigation, and incisional biopsy, a pediatric endotracheal tube was sutured in place and kept for 3 weeks for lesion debridement. An aspiration/irrigation technique was adopted for the second case. An 18-G needle with a syringe was used to aspirate the cystic lesion. Two needles were then inserted into the lesion; copious saline irrigation was delivered from 1 needle and until clear saline was expressed from the other. For the third case, decompression was accomplished with a surgical catheter that was subsequently replaced with a gutta-percha plug after 1 month. None of the 3 cases underwent complete enucleation and root-end surgery. Healed lesions or lesions in healing were observed after 1 to 2 years. Based on the presented cases and published case reports on decompression, a literature review was provided covering indications, technique details, modification, and prognosis of decompression in endodontics. For large periapical cystic lesions, conservative decompression may be used for certain cases before or in lieu of apical surgery. Decompression enables healing of large, persistent periapical lesions after root canal treatment.
How well do we manage the odontogenic keratocyst? A multicenter study
2019, Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
The aim of this study was to answer the following clinical questions: Among patients treated for odontogenic keratocysts (OKCs), what is the overall 5-year disease-free rate, and what factors are associated with disease recurrence?
We implemented a multicenter retrospective cohort study composed of patients presenting for the evaluation and management of previously untreated OKCs. The predictor variables were grouped into demographic, medical, radiographic, and operative categories. The primary outcome variable was time to lesion recurrence. Data analyses were performed by using bivariate analysis and univariate or multivariate Cox proportional hazards models.
The study sample was composed of 231 OKCs. Of these, 57 (24.7%) were treated with decompression with residual cystectomy, 86 (37.2%) with enucleation without adjuvant therapy, and 78 (33.8%) with enucleation with peripheral ostectomy. There were 44 recurrences (19%), with a median time to recurrence of 26.7 months (range 15.8–49.8).
This multicenter study is the largest study analyzing disease recurrence after treatment of OKCs by using appropriate statistical analysis for a time-to-event outcome (disease recurrence). The 5-year disease-free estimate was 29%. Mandibular lesions, multilocular lesions, and lesions treated with decompression and residual cystectomy were associated with recurrence.
Triangular radiolucent lesion of the mandible
2016, Journal of the American Dental Association
Citation Excerpt :
However, if the lesion is resected, the recurrence rate can be virtually zero.2,4,6 Treatment remains a controversial topic because there are no randomized controlled experiments in the literature but generally ranges from simple enucleation with or without the use of adjunctive treatment (Carnoy solution, cryotherapy, or peripheral ostectomy) to more aggressive surgical resection.4,7,8 However, for larger mandibular lesions, especially with vital structures at risk of injury, decompression might be the preferred therapy.8

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: This project was supported in part by the Massachusetts General Hospital Department of Oral and Maxillofacial Surgery Education and Research Fund (to B.E.K.), the Center for Applied Clinical Investigation (to S.-K.C. and T.B.D.), and the Massachusetts General Physicians Organization (to S.-K.C, M.A., and T.B.D.).

: Conflict of Interest Disclosures: Dr. Dodson is a consultant to AAOMS. None of the other authors reported any disclosures.

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PathologyFor Treatment of Odontogenic Keratocysts, Is Enucleation, When Compared to Decompression, a Less Complex Management Protocol?

Purpose

Materials and Methods

Results

Conclusion

Section snippets

Study Design and Sample

Results

Discussion

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

Br J Oral Maxillofac Surg

Br J Oral Maxillofac Surg

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

J Craniomaxillofac Surg

J Oral Maxillofac Surg

Oral Surg Oral Med Oral Pathol

Int J Oral Maxillofac Surg

J Oral Maxillofac Surg

J Oral Maxillofac Surg

Int J Oral Maxillofac Surg

J Oral Maxillofac Surg

Br J Oral Maxillofac Surg

Br J Oral Maxillofac Surg

J Craniomaxillofac Surg

J Maxillofac Surg

J Craniomaxillofac Surg

Pathology
For Treatment of Odontogenic Keratocysts, Is Enucleation, When Compared to Decompression, a Less Complex Management Protocol?