JICDRO is a UGC approved journal (Journal no. 63927)

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CASE REPORT
Year : 2010  |  Volume : 2  |  Issue : 2  |  Page : 95-97

Implant-based rehabilitation of a large mandibular odontogenic keratocyst with 7-year follow-up


Department of Oral and Maxillofacial Surgery, Sinhgad Dental College and Hospital, Pune, India

Date of Web Publication20-Apr-2012

Correspondence Address:
Adwait U Kulkarni
Trimurti Hospital, Vadgaon Budruk, Sinhagad Road, Pune
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2231-0754.95276

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   Abstract 

Odontogenic keratocyst is a unique cyst because of its locally aggressive behavior, high recurrence rate, and characteristic histological appearance. In this case report we present a 25-year-old male patient with a large odontogenic keratocyst and treatment with enucleation and chemical cauterization followed by dental implants with a 7-year follow-up.

Keywords: Implant, keratocyst, mandible


How to cite this article:
Garde JB, Kulkarni AU, Dadhe DP. Implant-based rehabilitation of a large mandibular odontogenic keratocyst with 7-year follow-up. J Int Clin Dent Res Organ 2010;2:95-7

How to cite this URL:
Garde JB, Kulkarni AU, Dadhe DP. Implant-based rehabilitation of a large mandibular odontogenic keratocyst with 7-year follow-up. J Int Clin Dent Res Organ [serial online] 2010 [cited 2019 Jun 24];2:95-7. Available from: http://www.jicdro.org/text.asp?2010/2/2/95/95276


   Introduction Top


Odontogenic keratocyst is by far the most challenging of all cysts of the maxillofacial region in terms of its aggressive nature and high rate of recurrence and postexcision reconstruction. The keratocyst has a particular tendency to recur after surgical treatment. [1],[2] The recurrence rate in various reported series is found to vary between 11% and 62%. [3] Possible reasons for recurrences are occurrence of satellite cysts which are retained during enucleation procedures and thin and fragile lining which causes difficulty to enucleate completely. [2],[3],[4]

Because of the high recurrence rate, simple enucleation is not considered to be sufficient. Excision of the lesion along with a small margin of surrounding bone would be a more reasonable plan. However, in cases where the cyst size is excessively large and may be crossing the midline, wide excision or, for that matter, even enucleation may result in morbid aftermath. In such cases, reconstruction entails a major surgery like free fibular grafting with its own set of associated complications. [3] In such cases and in extremes of age, the aforementioned surgical modality may not be a viable option. Hence, in such cases decompression of the cyst to allow for reduction in size which is followed by enucleation and chemical cauterization seems acceptable. This permits regeneration of bone, which can be monitored and used as a base for rehabilitation of the patient's cosmesis and function using endosseous implants. [4]


   Case Report Top


A 25-year-old male reported to our OPD with a chief complaint of swelling in the lower jaw since 1 year. The patient had already undergone incisional biopsy at another maxillofacial center and on the diagnosis of odontogenic keratocyst had been advised mandibular resection and reconstruction using microvascular fibula graft. The biopsy was repeated and the diagnosis was confirmed. The radiograph (OPG) showed a multilocular cystic lesion extending from ramus of the mandible to the parasymphysis on the left side. Associated with the lesion was an impacted third molar displaced to the posterior border of ramus on the same side. The lesion appeared to have involved the inferior border of the mandible, making it impossible to save the same at this stage [Figure 1].
Figure 1: Diagnostic OPG

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Taking the age of the patient and the associated morbidity of mandibular resection and microvascular fibular reconstruction into account, it was decided to adopt a novel approach that combined an age-old technique with one of the latest technical advances in dentistry.

At the site where the biopsy was taken, i.e., left premolar region at the depth of the buccal sulcus, the bony window measuring approximately 5mm in diameter was left patent. Through this tube, an indigenously fabricated decompression tube fashioned out of a needle cap was inserted and fixed using stay sutures. The patient was instructed in self-irrigation of the cavity and oral hygiene maintenance.

The patient was followed up monthly with sequential OPG investigation. The lesion showed radiographic evidence of decompression followed by decrease in size. Surprisingly, over the following 4 months there was also evidence of restoration of normal osteologic anatomy like inferior alveolar canal and inferior border of the mandible.

At the end of 4 months, the patient was taken under general anesthesia and the cyst was enucleated through the transoral approach. Following enucleation, the residual bone was immediately treated with Carnoy's solution applied for 5 minutes [Figure 2]. The wound was irrigated and closed in layers. Postoperative recovery was uneventful and the patient was discharged from the ward. Monthly follow-up was resumed and the evident bone regeneration monitored.
Figure 2: Post decompression enucleation and chemical cauterization

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Over the next 6 months the bone showed no evidence of recurrence of the cyst. On the contrary it showed regeneration attaining almost premorbid alveolar height. At this stage, the patient was taken up for implant placement. Three endosseous implants were placed under local anesthesia. The implants showed satisfactory osseointegration and were exposed 2 months later for abutment placement. At this juncture, another, single unit, immediate loading implant was added to enhance the loading capacity [Figure 3].
Figure 3: Implants placed in regenerated bone

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The postoperative recovery after this surgery too was uneventful and the permanent prosthesis was duly placed.

The patient was asked to follow-up every 6 months to rule out recurrence of cyst and failure of implants. A seven-year follow-up of the patient till date has proven no incidence of either.


   Discussion Top


Odontogenic keratocyst continues to be an enigma for effective management. Several schools of thought have been proposed for its effective management but none has proven to be foolproof. [3],[4] In managing such an entity, emphasis has to be laid on elimination of diseased tissue, prevention of recurrence, minimize morbidity, and restoration of function and aesthetics close to the normal. [3] In an endeavor to achieve the above goals, we used a technique describe as Waldron's procedure where a large cyst was first decompressed to allow for cessation of its expansion followed by reduction in size. Once the size was reduced to acceptable levels, it was enucleated and the residual bone was treated with a tissue fixative, namely Carnoy's solution. [3] The bone showed good regenerative potential after that and was allowed to attain the size and texture close to normal where after it was successfully used anchor endosseous implants that enabled effective prosthetic rehabilitation. [1],[2][,4],[5],[6] It is our opinion that this technique can be used in patients with large odontogenic keratocysts at either extremes of age where comorbidity of additional donor site, operative time, extraoral scar, and reliable bone available for implant placement are defining factors.

 
   References Top

1.Barry CP, Kearns GJ. Case report-odontogenic keratocysts: Enucleation, bone grafting and implant placement: an early return to function. J Ir Dent Assoc 2003;49:83-8.  Back to cited text no. 1
[PUBMED]    
2.Jeffery C. Markt Implant prosthodontic rehabilitation of a patient with nevoid basal cell carcinoma syndrome: A clinical report. J Prosthetic Dent 2003;89:436-42.  Back to cited text no. 2
    
3.Pitak-Arnnop P, Chaine A, Oprean N, Dhanuthai K, Bertrand JC, Bertolus C. Management of odontogenic keratocysts of the jaws: A ten-year experience with 120 consecutive lesions. J Craniomaxillofac Surg 2010;38:358-64.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Tolstunov L, Treasure T. Surgical treatment algorithm for odontogenic keratocyst: combined treatment of odontogenic keratocyst and mandibular defect with marsupialization, enucleation, iliac crest bone graft, and dental implants. J Oral Maxillofac Surg 2008;66:1025-36.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Thyne GM, Hunter KM. Primary reconstruction of the mandible with iliac bone and titanium implants following resection of a recurrent odontogenic keratocyst. N Z Dent J 1994;90:56-9.  Back to cited text no. 5
[PUBMED]    
6.Işler S, Demircan S, Can T, Cebi Z, Baca E. Immediate implants after enucleation of an odontogenic keratocyst: An early return to function. J Oral Implantol 2010. [in press0 ].  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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