ORAL HEALTH EVIDENCE-BASED PRACTICE PROGRAM
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Title Recurrence Rates of Odontogenic Keratocysts Decreased With Aggressive Surgical Resection
Clinical Question In a patient pre-operatively diagnosed with an odontogenic keratocyst (OKC), does aggressive surgical therapy (i.e. resection) produce a lower recurrence of OKC compared to conservative surgical treatment (marsupialization or enucleation)?
Clinical Bottom Line Although more aggressive surgery of odontogenic keratocysts (OKCs) such as bone resection has generally resulted in the lowest recurrence rates (0%), the high surgical morbidity associated with resection has influenced surgeons to approach OKCs with more conservative surgical treatment even though multiple operations may be necessary. Evidence has not provided a general agreement on a uniform treatment plan that imparts the most treatment benefits.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 22445416Kaczmarzyk/2012180 patients in 2 studies Systematic review of non-randomized trials
Key resultsOnly two retrospective studies were included with a total of 108 lesions. The level of evidence used was not of high quality. Recurrence rates for six different treatment modalities were as follows: Resection 0%, Enucleation with peripheral ostectomy and Carnoy’s solution 0%, Enucleation with peripheral ostectomy 18.18%, Enucleation alone 26.09%, Marsupialization 40%, and Enucleation with Carnoy’s Solution 50%. Mean follow-up years was 5.30. Overall recurrence rate was 23.15% (95% CI: 15.19-31.11%).
#2) 22771402Johnson/2013362 lesions from 8 studiesSystematic review of non-randomized trials
Key resultsEnucleation with Carnoy’s solution had a recurrence rate of 7.9%, while enucleation with other adjunctive measures (such as curettage, ostectomy, and excision of overlying mucosa) had the highest rate of 30.3%. Marsupialization and resection had the lowest recurrences with a rate of 4.8% and 6.3%, respectively. Simple enucleation had a rate of 25.6%. Curettage alone was not reported in this review. Follow-up periods varied among studies. No randomized clinical trials were identified in the selection process.
#3) 11077375Blanas/200014 studiesSystematic review of non-randomized trials
Key resultsFourteen case series were systematically reviewed. Resection had the lowest recurrence rate (0%), but highest morbidity risk, while simple enucleation had the highest recurrence rate (28.7%). Enucleation with Carnoy’s is another less invasive option with a lower recurrence rate (1.6%) than simple enucleation. Other treatment modalities are curettage (19.2%) or marsupialization (24.4%). Follow-up periods varied among studies.
Evidence Search ("odontogenic cysts"[MeSH Terms] OR ("odontogenic"[All Fields] AND "cysts"[All Fields]) OR "odontogenic cysts"[All Fields] OR ("odontogenic"[All Fields] AND "keratocyst"[All Fields]) OR "odontogenic keratocyst"[All Fields]) AND ("surgical procedures, operative"[MeSH Terms] OR ("surgical"[All Fields] AND "procedures"[All Fields] AND "operative"[All Fields]) OR "operative surgical procedures"[All Fields] OR ("surgical"[All Fields] AND "treatment"[All Fields]) OR "surgical treatment"[All Fields]) AND systematic[sb]
Comments on
The Evidence
Validity: There is a substantial degree of variability among individual studies and on an individual patient/lesion basis, including the patient follow-up period. This variability hinders the ability to quantitatively analyze data and provide a magnitude of difference between the various treatment modalities. All three systematic reviews utilized comprehensive searches and detailed selection criteria for their literature reviews. Only a limited number of studies were included due to a high risk of bias, low-level evidence, and inadequate descriptions of treatment or follow-up period. No randomized controlled clinical trials were found during the search process. Perspective: From the three systematic reviews, there were only retrospective studies identified and included. For future studies, it may be beneficial to perform or include prospective investigations in order to better control the variables and assign an adequate follow-up period through the assembly of an inception cohort.
Applicability Surgeons are commonly faced with the issue of whether to surgically approach an OKC in a conservative manner and decrease the risk of morbidity, but risk higher recurrence rates, or approach an OKC in an aggressive manner via resection and maximally decrease the risk of recurrence, but risk patient morbidity. Although resection has the lowest recurrence rate, it has been suggested that resection be limited to OKCs that have invaded the cortical plate, that have recurred 3 or more times, or when long-term follow-up is unlikely. “Marsupialization is the most conservative method of treatment for OKCs, [but] enucleation remains the most commonly used” (Kaczmarzyk, 2012). It would be important to weigh out the associated benefits and risks of each procedure on an individual patient basis according to OKC location and size, presence or absence of infection, mucosal involvement, associated teeth, patient’s age and risk status, surgical experience and training, etc.
Specialty/Discipline (Oral Medicine/Pathology/Radiology) (Oral Surgery)
Keywords odontogenic keratocyst, keratocystic odontogenic tumor, enucleation, marsupialization, resection, surgical treatment
ID# 3016
Date of submission: 03/12/2016spacer
E-mail fuentess3@livemail.uthscsa.edu
Author Selina Fuentes
Co-author(s)
Co-author(s) e-mail
Faculty mentor/Co-author Robert R. Lemke, DDS, MD, PA
Faculty mentor/Co-author e-mail robertlemke@mac.com
Basic Science Rationale
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