An evidence-based surgical algorithm for management of odontogenic keratocyst

Comparing 5-Fluorouracil Versus Modified Carnoy's Solution for the Treatment of Odontogenic Keratocysts: A Systematic Review and Meta-Analysis

PURPOSE

The primary aim of this study was to compare time to odontogenic keratocyst (OKC) recurrence with 5-fluorouracil (5-FU) versus modified Carnoy's solution (MCS) following enucleation and curettage and peripheral ostectomy. The secondary aim was to compare the frequency (%) of permanent peripheral nerve injury characterized by hypoesthesia and neuropathic pain present at 12 months or more after surgery with 5-FU versus MCS.

METHODS

The Cox hazard ratio was calculated to compare time to recurrence between the 2 groups. To compare the frequencies of permanent nerve damage, we fitted a fixed-effects model to the data and calculated the risk ratio. Other variables collected were sex, age, follow-up time, and cyst size.

RESULTS

No significant differences in sex, age, follow-up time, and cyst size were found. The median follow-up time for all patients was 60 months (range: 12-180 months, Q1 = 32 months, Q3 = 86 months, interquartile range = 54 months). Of the 114 patients treated with MCS, 27 recurrences with a median recurrence time of 42 months (range = 12-108 months, Q1 = 26.3 months, Q3 = 54 months, interquartile range = 27.7 months) were recorded; no recurrences were observed among the 99 patients treated with 5-FU (hazard ratio = 0.02, 95% CI = 0.00018-0.16, P = 2.27e-07). Of the 112 patients treated with MCS, there were 20 (17.86%) instances of permanent peripheral nerve injury; of the 98 patients treated with 5-FU, there were 7 (7.14%) instances of permanent peripheral nerve injury (risk ratio = 0.44, 95% CI = 0.20-0.97, P = .04).

CONCLUSION

The results of this meta-analysis significantly favored 5-FU over MCS for lower OKC recurrence and peripheral nerve injury, supporting the use of 5-FU as the superior adjuvant following enucleation and curettage and peripheral ostectomy for the treatment of OKCs.

Management and recurrence of the odontogenic keratocyst: an overview of systematic reviews

MATERIALS AND METHODS

An extensive literature search among six eletronic databases and Grey Literature was used to identify systematic reviews (S) that could respond if: in individuals diagnosed with OKC (P), is there any influence of the treatment method (I/C) on the recurrence rate of the lesion (O)? After evaluating all titles and abstracts and then applying the eligibility criteria, the included studies were read in full, and data were extracted based on a standardized sheet ordered in the PICO sequence. The assessment of the quality of the systematic reviews included, was determined by AMSTAR2, and final synthesis were descriptively made based on the results and quality of the systematic reviews.

RESULTS

From a total of 19 included systematic reviews, it was observed that the most used treatment for OKC was enucleation, followed by enucleation with adjuvant techniques and marsupialization. The mean percentage of recurrence was 16,2%, and the highest OKC recurrence rate was 43.2% after simple enucleation. The use of adjuvant techniques promoted reductions in OKC recurrence rates. The overall methodological quality of systematic reviews was critically low, and this parameter demonstrate the need for more studies to facilitate the choose of the treatment.

CONCLUSION

Despite being the most used treatment, simple enucleation is related to the highest rate of recurrence, except when performed after marsupialization/decompression. In addition, the use of adjuvant techniques has a strong impact on reducing the likelihood of recurrence. However, these findings are not conclusive because of the critically low quality of the systematic reviews.

Conservative management of multiple odontogenic keratocysts in a child with nevoid basal cell carcinoma syndrome: A case report

BACKGROUND

Nevoid basal cell carcinoma syndrome (NBCCS) is an autosomal dominant multisystemic disorder characterized by the presence of multiple odontogenic keratocysts (OKC), which are a hallmark feature of the syndrome. The treatment of these OKC poses challenges due to their high recurrence rates and the myriad of management options available.

CASE REPORT

We describe here a case of NBCCS diagnosed in an 11-year-old girl who presented with multiple OKC in the jaws. Chest and cranial radiographs showed no abnormalities in the ribs and the cerebral falx, respectively. Cephalometric analysis indicated mandibular retrusion, a skeletal class II relationship, and a convex profile. The treatment approach involved a personalized strategy tailored for each cyst, comprising marsupialization followed by enucleation. This approach aimed to minimize surgical trauma and to reduce the risk of recurrence. The patient underwent regular follow-up appointments, demonstrating successful outcomes with no signs of recurrence or de novo OKC observed over a 32-month period.

CONCLUSION

Clinicians should consider lesion characteristics and patient cooperation when determining treatment strategies for the optimization of outcomes for children and adolescents with NBCCS and multiple OKC.

Odontogenic Keratocyst With Moderate Epithelial Dysplasia: A Rare Entity

We present a rare case of odontogenic keratocyst (OKC) with moderate epithelial dysplasia in a 47-year-old male patient. He presented with a history of pain and swelling on the right side of his face for the past three months. The radiograph revealed multi-locular radiolucency involving the ramus, coronoid process, and condylar process of the right mandible. We have discussed the cytology, incisional biopsy, radiological investigations, surgical management, reconstruction, excisional biopsy report, and follow-up of this rare entity.

Comparison of Five Different Treatment Approaches of Mandibular Keratocystic Odontogenic Keratocyst (OKC): A Retrospective Recurrence Analysis of Clinical and Radiographic Parameters

The odontogenic keratocyst (OKC) is a benign but locally aggressive growing lesion that infiltrates the bone and surrounding tissue. It is characterized by high rates of recurrence along with rapid growth. Different forms of partly successful treatment therapies are reported. The retrospective study at hand examined 114 patients with OKC treated over a period of 20 years. Data extracted includes gender, age, location, previous treatment for the lesion, surgery, outcome, recurrence rate and follow-up. 63.1% of the patients underwent cystectomy, 22.5% by cystectomy and carnoy solution, 7.2% by cystectomy, and curettage, 4.5% by cystostomy and 2.7% by partial resection. In this study, no significant differences could be observed regarding the surgical method. Most recurrences occurred with 91.9% in the mandible with an average size of 5.5 cm2 and increased in women. Within a mean follow-up time of 3.6 years the recurrence rate was 36.9%, on average after 36 months. Recurrences were most frequently diagnosed at the age of 31-50 (43.9%). Despite numerous studies, there is still no unanimous opinion on an effective therapy for OKC. However, precise resection of OKC can be facilitated by preoperative 3D-imaging and virtual planning.

Safety and efficacy of adjunctive therapy in the treatment of odontogenic keratocyst: a systematic review

The odontogenic keratocyst (OKC) is a common cystic lesion in the jaw. Its management, however, is highly debated with no consensus on the best treatment option. Clinicians base their approach on treatment efficacy and associated morbidity. Management often consists of enucleation with peripheral ostectomy and adjunctive therapy to prevent recurrence. The aim of our systematic review was to evaluate the safety and efficacy of these different modalities. Embase, Medline, and Cochrane were searched according to the PRISMA guidelines for articles that presented non-syndromic patients with histopathologically confirmed OKC treated with 5-fluorouracil (5FU), Carnoy's solution (CS), or modified Carnoy's solution (MCS) as adjunctive therapy after enucleation and peripheral ostectomy. The outcomes of interest were safety (measured as adverse events) and efficacy (expressed as recurrence). Risk of bias was evaluated using the Newcastle-Ottawa scale. Four studies were included and 62 patients were evaluated. The results show that recurrence occurred only in patients treated with MCS. Reported adverse events were mostly limited to paraesthesia that could be permanent (in the CS and MCS treatment groups) or transient (across all adjunctive therapies). With the prohibition of CS, both MCS and 5FU are promising replacement adjunctive therapies. From a safety and efficacy perspective we consider 5FU, which was associated with the lowest recurrence and fewest adverse events, to be the most viable option. More high-evidence prospective studies, such as randomised controlled trials, with a longer follow-up period are necessary to draw definite conclusions.

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.

Effectiveness of different treatments for odontogenic keratocyst: a network meta-analysis

Odontogenic keratocysts (OKC) are benign but aggressive lesions. As there is a lack of well randomized clinical studies assessing the effectiveness of the different treatment options for OKC, a network meta-analysis (NMA) was performed to identify the best treatment option with the lowest recurrence rate. An electronic search was performed following the PRISMA guidelines to identify all clinical studies comparing treatment options against enucleation alone. The outcome variable was recurrence. The predictor variables were treatments. The eight included treatments were: enucleation with peripheral ostectomy/curettage (E + PO/curettage); enucleation with cryotherapy (E + CRYO); enucleation with/without PO followed by modified Carnoy's solution (E ± PO+MCS); enucleation with PO and with topical 5-fluorouracil (E + PO+5FU); enucleation with/without PO followed by original Carnoy's solution (E ± PO+CS); marsupialization alone (MARS); marsupialization followed by secondary enucleation with/without PO (MARS+2°E ± PO); and resection. The odds ratio was used to estimate the recurrence rate. A frequentist NMA was performed using Stata software. A total of 2989 patients in 40 studies were included. Both direct pairwise meta-analysis and NMA showed that E + 5FU+PO was significantly superior to E ± PO+MCS. However, no statistically significant difference was found between E ± PO+CS vs E + 5FU+PO, E ± PO+MCS, and resection, respectively (all very low quality evidence). The three most effective treatments in reducing the recurrence rate were E + PO+ 5FU (98.1%; very low quality evidence), resection (83.5%; very low quality evidence), and E ± PO+CS (63.8%; moderate quality evidence). The findings from this study suggest that CS remains the most effective fixative agent after enucleation and PO until proven otherwise. Additionally, 5FU appears to be an effective method with promising results that needs further research. Finally, the efficacy of MCS remains controversial; further in vivo and in vitro studies are required to determine new protocols. As this NMA included retrospective studies, the results should be interpreted with great caution (level of evidence: type III).