There is much too much confusion and “controversy” concerning odontogenic keratocysts (OKC) than there ought to be. Although this cyst can and does recur, it is not a tumor and does not invade into soft tissue. Its recurrences are mostly related to surgical imperfection which results from ripping or shredding the cyst to leave part of the lining behind which then redevelops into a recurrent cyst. A smaller percentage of “recurrences” are actually new primary keratocysts from other activated odontogenic rests. Most keratocysts can be cured by a wide access enucleation which removes the cyst in a single unit. Usually this can be accomplished from a transoral approach, but sometimes requires a transcutaneous approach. In no case should Camoy’s solution, cyrotherapy, phenol or bur reduction of the bony wall be necessary. However, a small percentage of OKCs do require a resection for cure. These are essentially those which are the large destructive multilocular ones that an enucleation would eventuate into a fracture or continuity defect or those that have “recurred” on multiple occasions. Many odontogenic tumors are actually hamartomas with limited growth: odontomas, ameloblastic fibrodontomas, ameloblastic fibromas, etc. However, ameloblastomas, odontogeneic myxomas, the calcifying epithelial odontogenic tumor and the ameloblastic fibrosarcoma which will microscopically mimic the harmartomatous ameloblastic fibroma are true invasive neoplasms. These require resections with 1-cm to 1.5-cm margins for cure. Despite such resections required to cure odontogenic true neoplasms, most all can be accomplished without creating a deformity, malocclusion, or significant neurosensory loss. In the mandible these tumors are removed en bloc for a predictable cure with a new nerve pull-back re-anastomosis technique which obviates the need for a nerve graft, returns 90% or more sensation and does not affect the cure. This is possible because of the inability of benign tumors to invade nerve sheaths as they instead merely displace the nerve. Combined with titanium reconstruction plates, this approach achieves a maximum in returning facial form, maintaining the residual occlusion, preparing for a definitive bone graft reconstruction and returning the highest percentage of useful neurosensory function. In addition, the troublesome resections that include the condyle need not result in a jaw deviation, malocclusion, prolonged jaw fixation, external pin fixation or a costochondral graft. With a retained disc, titanium condylar replacements in the adult and allogeneic (tissue bank) condylar replacements in children and teenagers permit long-term stable function without the complications noted in the classic “TMJ Prostheses,” thereby allowing immediate cosmetic and functional results to also be realized in patients who undergo a condylar extirpation.
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Aug 1, 2005
J A N Shepperd + 1
Open Access
