Novel recurrence risk stratification of odontogenic keratocysts: A systematic review

THE MANAGEMENT OF TEETH IN ODONTOGENIC KERATOCYST AND AMELOBLASTOMA AND ITS PROGNOSTIC ROLE IN RECURRENCE: A SYSTEMATIC REVIEW AND META-ANALYSIS WITH TRIAL SEQUENTIAL ANALYSIS

INTRODUCTION

Odontogenic Keratocystic (OKC) and Ameloblastoma (AB) are pathological entities characterized by aggressive behavior, slow growth, local invasiveness, and high recurrence rates. The aim of this systematic review with meta-analysis and trial sequential analysis (TSA) is to assess the prognostic role of extracting involved teeth during the surgical enucleation of OKCs and ABs in terms of recurrence risk.

MATERIALS AND METHODS

A search was conducted in PubMed/Medline, Scopus, and Web of Science databases for studies reporting data on teeth extraction and recurrence rates. This systematic review was performed according to guidelines in the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Meta-analysis was performed using the Mantel-Haenszel method with a random-effects model due to heterogeneity. The TSA was conducted to control and reduce for type I and II errors of statistical analysis.

RESULTS

Six studies were identified and analyzed qualitatively and quantitatively. A total of 737 lesions (674 OKCs and 64 ABs) were included, of which 508 had involved teeth. The meta-analysis included 451 OKCs; 367 lesions were treated with teeth extraction, and in 141 cases, the teeth were preserved. The overall Risk Ratio was 0.17 (95% CI: [0.04, 0.74]; P < .0001) for OKCs. Quantitative analysis could not be performed for ABs.

CONCLUSION

The analysis revealed that tooth extraction contextually to the enucleation of the lesion reduces the risk of recurrence by approximately 83% in the OKCs; this appears to have the same trend for ABs, but more evidence is needed.

Treatment of benign maxillomandibular osteolytic lesions larger than 4 cm: A systematic review

OBJECTIVE

This systematic review aimed to assess the different treatments of benign maxillo-mandibular radiolucent bone lesions over 4 cm to propose a management algorithm.

STUDY DESIGN

A literature search was conducted using MEDLINE/PubMed, Scopus, Google Scholar, Virtual Health Library databases, and gray literature. Randomized or non-randomized clinical trials and case series with 10 or more patients with a minimum follow up of 1 year, published in French or English until August 2023, were included. The risk of bias was assessed for all papers included.

RESULTS

Of 1433 records identified, 22 were included in this review, reporting data from 1364 lesions. Ameloblastoma was the most common lesion (51.22%) and mandible was the most common site (81.21%). Initial conservative treatment was prevalent (71.04%). Recurrence was higher after conservative (13.8%) than after radical treatments (6.5%). Multilocularity, cortical perforation, dental element preservation were linked to a higher recurrence risk.

CONCLUSION

This study has shown importance of understanding specific characteristics and recurrence risk in benign maxillomandibular osteolytic lesions. Multidisciplinary team approval, personalized approach based on lesion type and patient are crucial. The presence of at least one risk factor could lead to therapeutic decision. Despite limitations, the study informed lesion management and provided precise recommendations.

Unwarranted intrusion of odontogenic cyst into the maxillary antrum

During the early growth phase, every individual is involved in a prolonged series of developmental processes in the maxillofacial region. Formation of cysts associated with such three-dimensional growth of the maxillofacial skeleton as well as deciduous and permanent tooth development. The origin of cystic jaw lesions may be odontogenic or non-odontogenic, developmental, or inflammatory and they are epithelial-lined or non-epithelial-lined cysts in nature. These cysts are considered to be aggressive cysts when they tend to grow rapidly and can cause significant damage to the surrounding bone and tissues if left untreated. Aggressive cystic lesion of the jaw needs special attention in order to prevent recurrences or even worsen and widespread disease. The management of the maxillary sinus requires individualisation based on its clinical and histopathological characteristics. Here, we report a case of an aggressive odontogenic cyst in a 30s-aged female patient in the left maxillary sinus with the literature review.

A recurrence odontogenic keratocyst formation of mandible with distinctive features: a case report

Introduction and importance

Odontogenic keratocyst (OKC) is a distinctive form of developmental odontogenic cyst that deserves special consideration because of its specific clinical behaviour and histopathologic features. The clinical and radiographic features of OKC are indefinite; while some may be associated with pain, swelling or drainage, most of them are asymptomatic. This case reports rare radiographic and histopathological features of recurrence OKC.

Case presentation

A 47-years-old male patient presented with a main complaint of a painful mass in the oral cavity with a history of previous lesions that occurred in the posterior portion of the mandible related to extraction of impacted third molar. The oral examination revealed a swelling in the molar region of the right mandible with lingual plate expansion. The radiographic and histopathologic were consistent with the diagnosis of OKC. Consequently, the lesion was surgically removed, and no clinical or radiological recurrence was observed during the 8-month postoperative follow-up.

Clinical discussion

This case explained the clinical differences between OKC and other lesions and highlights the distinctive radiologic and microscopic features that a conflict with previous studies concerning the symptoms that may related to naevoid basal cell carcinoma syndrome, and revealed the proper treatment depending on the recurrence appearance and the treatment methods that used previously.

Conclusions

This case highlights a rare multilocular appearance of recurrent OKC in the mandible with no naevoid basal cell carcinoma syndrome related, supports the marginal resection as an effective procedure in the management of recurrent OKCs cases.

Evaluation of the relationship between the expression of AgNOR and Ki67 with the recurrence rate in central granulomatous giant cell lesions: A case-control

OBJECTIVES

Giant cell granuloma is a local nonneoplastic lesion that is divided into two categories, based on its site of occurrence: Central and peripheral giant cell granuloma. Central giant cell granuloma is an intraosseous lesion that has a tendency to recure even in surgically treated cases. Several studies have proven that there is an association between different lesions clinical behavior and their histological features. The aim of this study was to evaluate the expression of AgNOR and Ki67 in lesions with and without recurrency.

MATERIAL AND METHODS

Files and records of 35 patients who had been histologically diagnosed with central giant cell granuloma were investigated. Histological features were studied after performing AgNOR staining and Ki67 marker. The data were analyzed by chi-square, Fisher, and T-test.

RESULTS

Acquired data indicated that the count of AgNOR staining and Ki67 marker was significantly higher in lesions with recurrency than the lesions with no recurrency. The same results were attained from Ki67 intensity.

CONCLUSION

The current study indicated that AgNOR staining and Ki67 marker have prognostic value in predicting recurrency of central giant cell granuloma lesions.

Mandibular reconstruction after excision of recurrent odontogenic keratocyst using a novel mandibular distraction osteogenesis method- a case report

BACKGROUND

Odontogenic keratocyst is one of the most common benign odontogenic neoplasms with a high recurrence rate. Its resection has the potential to lead to mandibular segmental defects. In this case report, we describe a patient with odontogenic keratocyst who underwent radical resection using a novel distraction osteogenesis (DO) method to reconstruct mandibular segmental defect.

CASE PRESENTATION

This case report describes a 19-year-old woman with odontogenic keratocyst of the mandible that recurred after multiple curettages and eventually necessitated radical resection. Mandibular segmental defect after radical resection was reconstructed using a novel DO method that involved directly contacting the segment ends of the defect without the transport disk. However, the distractor broke during the retention period, and a molding titanium plate was used for fixation. This novel distraction method achieved mandibular reconstruction and restored mandibular function and contour.

Clinical indications for radical resection of odontogenic keratocyst: A systematic review

The aim of this study was to identify clinico pathological indications for radical resection of odontogenic keratocysts (OKCs) in the literature and formulate clinical guidelines for the management of OKCs based on these findings. A systematic review of the literature was undertaken in September 2021 in PubMed/Medline, Scopus, Web of Science, Google Scholar, and Cochrane databases. The following MeSH Keywords terms were used in the search strategies: (odontogenic keratocyst) OR (keratocystic odontogenic tumor) OR (primordial cyst) AND (treatment) OR (Radical resection) OR (Resection of OKC) OR (Treatment methods). Eligibility criteria included publications of clinical studies on histologically confirmed OKCs which underwent radical resection. Studies with less than 5 OKCs, experimental studies, epidemiological studies, studies that included orthokeratinized odontogenic cyst, and review papers were excluded. Ten studies on OKCs reporting on segmental or marginal resections were identified and analyzed qualitatively. Of the total of 221 OKCs that underwent radical resection, 67 OKCs were primary, 30 were recurrent, and the remaining were unclear whether they were primary or recurrent. Segmental mandibulectomy was performed in 131 OKCs, marginal mandibulectomy in 87 OKCs, and 3 OKCs were treated by partial maxillectomy. The main indications for radical resection were multilocular appearance, large OKCs (> 5 cm), multiple recurrent OKCs with or without cortical perforation, and malignant transformation. In conclusion, radical resection has its place in the management of OKC. It is indicated when there is an aggressive lesion with bony perforation, involvement of the pterygoid musculature or skull base, and malignant transformation. The surgeon should aim to identify these features to manage OKC appropriately and to prevent multiple recurrences. Clinical guidelines for the management of OKCs are proposed.

Calcifying odontogenic cyst combined with odontogenic keratocyst: report of a case and review of the literature

INTRODUCTION AND IMPORTANCE

Odontogenic lesions composed of two or more separate odontogenic cysts are uncommon. The calcifying odontogenic cyst (COC) and odontogenic keratocyst (OKC) are odontogenic cysts that exhibit some neoplastic features. Concurrence of these lesions is extremely rare. We report a rare case of COC combined with OKC in a patient and review the relevant literature systemically.

CASE PRESENTATION

In this article, we present a case report of an 18-year-old boy patient with no medical history whose chief complaint was facial asymmetry. A painless swelling in the right side of the posterior mandible was observed. Histopathological and radiographic investigations revealed a combined odontogenic lesion composed of inflamed OKC with COC.

CLINICAL DISCUSSION

Long-lasting debates on the true nature of OKC and COC, whether cystic or neoplastic, has been existed so far. Their genetic-derived mechanisms can justify the concurrent occurrence of these cysts in a patient. The treatment plan for this lesion included decompression followed by enucleation, curettage, and application of Carnoy's solution.

CONCLUSION

We reported a rare case of an inflamed OKC with COC-like features. Based on the literature, the coincidence of these two odontogenic cysts has been reported for the third time here.

What Is the 5-year Incidence of Recurrent Disease of Odontogenic Keratocysts?

PURPOSE

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.

METHODS

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).

RESULTS

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.

CONCLUSIONS

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.

Odontogenic keratocystic can be misdiagnosed for a lateral periodontal cyst when the clinical and radiographical findings are similar

Lateral periodontal cyst (LPC) and odontogenic keratocystic (OK) are two osteolytic lesions of the jaw with different local invasiveness and percentage of recurrence. The aim of this study was to highlight the attention on the differential diagnosis of these lesions that sometimes can have unexpected location and can lead doubts on diagnosis, therapy, and follow-up. A 34-year-old man presented to our department with a complaint of soft pain in the vestibular aspect of left mandibular second premolar and left mandibular first molar. Vital teeth in the left mandible, no mucosal swelling, and no drainage were observed. The CBCT showed a well circumscribed hypodensity area, extending between 3.5 and the apex of mesial root of 3.6. No displacement and no resorption of the roots were notified. Upon clinical and radiographical examination, a provisional diagnosis of LPC was made and enucleation of the lesion and histological examination were planned. Histologically, a cystic wall partially lined by a keratinizing squamous epithelium was observed. Surrounding and within the lesion, there was a chronic inflammatory infiltrate also of granulomatous type and with cholesterol clefts. Based on these findings, the diagnosis of odontogenic keratocystic was done. Radiolucent lesions in the premolar and canine region are frequently clinically and radiographically misdiagnosed. The identification of keratocyst in a location preoperatively favoring a lateral periodontal cyst should be suspected and biopsy must be considered in all cases to establish the nature of the lesion, the best surgical treatment, and the follow-up appointments.