Management and recurrence of

keratocystic odontogenic tumor: a

systematic review.

 A cyst is a pathological fluid filled cavity

lined by epithelium or occasionally by
neoplastic tissue
The term keratocyst was coined by
Philipsen in 1956.
In the WHO classification of head and neck
tumours from 2005, odontogenic
keratocyst was reclassified and renamed
to keratocystic odontogenic tumour

 Keratocystic odontogenic tumor (KCOT) is

a unique lesion because of its locally
aggressive behavior, high recurrence rate,
and characteristic histologic appearance.
Management of KCOT remains
controversial owing to multiple different
treatment protocols with varying
recurrence rates

Modalities have been used in the

management of KCOT:
Decompression,
Marsupialization,
Peripheral ostectomy with application of
Carnoys solution, or liquid nitrogen
cryotherapy; with most options
supplementing the enucleation technique

 To date, no randomized controlled trials

have been undertaken to establish which
treatment modality provides the lowest
recurrence rate.
A systematic review by Blanas et al,
published in 2000, included studies from
1970 to 1998

 The aim of this current systematic

review was to provide an update on
the management and recurrence
rates of KCOT.
The data from 1999 to 2010 were
analyzed and compared with the
data from Blanas et al.

The data were then combined to provide a

current consensus on management and uptodate recurrence rates for the different
treatment modalities.

MATERIAL AND METHODS

Blanas keratocyst, odontogenic cyst,
basal cell naevus syndrome, keratin, and
cyst to identify articles that discussed
treatment or prognosis of KCOT.
To compare the same inclusion criteria and
standards were used in this current review,
as described by Blanas et al.

 Using the keywords described in the

preceding paragraph, 2736 articles were
identified. Limiting the search between the
1999 and 2010 produced 206 articles, with
28 articles having consecutive cases. Eight
articles met the inclusion criteria, which
were then analyzed using the 8 standards

Treatment Modalities
Curettage is the method where the wall of the
cyst cavity is surgically scraped with the
removal of its contents
Enucleation is the removal of a lesion intact
(followed by mechanical curettage using methylene blue as a marking
agent, followed by a 3-minute application of Carnoys solution (a tissue
fixative)
The general chemical make-up of Carnoys solution is a ratio of
absolute alcohol (6 mL)
chloroform (3 mL),
glacial acetic acid (1 mL),
and ferric chloride (1 g).
The original description on the use of Carnoys solution was to
place it into the cyst cavity before enucleation; however, most
clinicians apply it to the bony cavity after enucleation

 Marsupialization (decompression)
is the process of exteriorizing the
internal cyst contents by resecting
the superficial wall and suturing the
cut edges of the remaining wall to
adjacent mucosa
Resection refers to either
segmental resection or marginal
resectionmainly undertaken in the
mandible

Radical enucleation involves removal of the

entire cyst lining together with any associated
overlying mucosa, followed by extensive cavity
curettage with reduction of the surrounding bone

Decompresion + Enucleation + Peripheral Osteotomy

To date, we have treated some 29 lesions utilizing this modified

technique of decompression, enucleation, and peripheral ostectomy.
Our follow-up period varies, with six of these patients now followed for
longer than 5 years and the shortest only followed for 4 months. To
date, we have not seen any recurrences

DISCUSSION
Treatment of KCOT remains a controversial
subject, and several treatment options are
available to the surgeon.
Carnoys solution is popular, the average
depth of bone penetration depends on the
duration of application (1.54 mm after 5
minutes).
It prevent recurrence caused by the
presence of satellite cysts, budding of
the cyst lining, or remnants of cyst
epithelium remaining after enucleation

 Some authors suggest using the

marsupialization technique to reduce the
size of the KCOT and then proceed to
surgical enucleation of the remaining cyst
structure.
This 2-stage technique does not affect the
recurrence rate young patient

 Recurrence of KCOT occurs for several

reasons, incomplete removal of the cystic
lesion allows new cyst formation or
epithelial islands in the wall of the original
cyst remain in the surrounding bone or
soft tissue.
New KCOTs can also develop from the
basal layer of the oral epithelium

Treatment Recommendations
1. Simple enucleation of the KCOT is not endorsed
because of the high recurrence rate.
2. A small KCOT where the margins can be
accessed may be enucleated with adjunctive
measures, such as Carnoys solution.
3. A large, expanding KCOT is best treated with a 2stage approach. Marsupialization first, followed
by enucleation and adjunctive measures to
decrease the surgical injury to the patient.
4. Marginal or segmental resection offers the
lowest recurrence rate.
(It is not advocated as a primary treatment modality for
most tumors because of its morbidity and the benign
nature of the disease)

CONCLUSIONS
The goals of management include
elimination of the pathology and decrease
potential recurrence while minimizing
harm to the patient
Enucleation with Carnoys solution
provides the least recurrence (4.8%) from
any of the conservative techniques.
Resection provides the lowest recurrence
rate (1.85%), yet causes the most
suffering to the patient.