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the odontogenic keratocyst ( okc ) is a cystic lesion of odontogenic origin , which is classified as a developmental cyst derived from the dental lamina .
okc is known for its rapid growth and its tendency to invade the adjacent tissues including bone .
it has a high recurrence rate and is associated with the basal cell nevus syndrome .
the distribution between sexes varies from equality to a male to female ratio of 1.6:1 , except in children .
okcs may occur in any part of the upper and lower jaw , with the majority occurring in the mandible , most commonly in the angle of the mandible and ramus .
the okc involves approximately 11% of all cysts in the jaws and is most often located in the mandibular ramus and angle .
this lesion can be associated , although not in all cases , with an impacted third molar .
radiographically , okcs demonstrate a well - defined unilocular or multilocular radiolucency with smooth and often corticated margins .
okcs tend to grow in an anteroposterior direction within the medullary cavity of the bone without causing obvious bone expansion .
okcs of the maxilla are smaller in size compared to those of the mandible . when they are large , they tend to expand bone .
these lesions can also present as a small and oval radiolucency between teeth , simulating a lateral periodontal cyst .
they can also appear as a radiolucency simulating radiographic presentation of the residual apical periodontal cyst .
histologic features of these cysts were subsequently described by shear and by pindborg and hansen .
the keratocyts are classified as a developmental epithelial cyst and comprise approximately 11% of all cysts of the jaws .
ahlfors . found a mean age of 41 years at the time of diagnosis in 255 patients .
there appeared to be two incidence peaks between 25 and 34 years , and 55 and 64 years of age .
the histologic features of okcs include a thin epithelial lining , usually consisting of fewer than six cell layers in a corrugated tissue composed of thin , irregular bundles of collagen , and often contain islands of epithelium that may represent daughter cysts . in many cysts , there is a tendency for the epithelium to separate from the underlying cyst wall .
histopathologically , they typically show a thin , friable wall , which is often difficult to enucleate from the bone in one piece , and have small satellite cysts within fibrous wall . therefore , okcs often tend to recur after treatment .
okcs contain a dirty white , viscoid suspension of keratin , which has an appearance of pus , but without an offensive smell .
the following are used to test the presence of keratin . 
 the smear should be stained and examined for keratin cells.electrophoresis
reveals low protein content , which is mostly albumin.total protein is found to be below 4 g/100 ml . 
 
a 11-year - old female patient reported to the outpatient department of modern dental college and research center , indore , in may 2010 , with a complaint of swelling on the right side of the chin that caused considerable asymmetry of the face [ figure 1 ] .
as narrated by her father , the swelling was noted 6 weeks previously , while its size increased gradually , but progressively .
intraoral examination was painless and caused no alteration in sensation over the mental nerve distribution .
the labio buccal sulcus was obliterated [ figure 2 ] by a bony swelling and fluctuation was elicited in its center .
bony expansion extended from 72 to 46 lingually and the overlying mucosa showed normal texture .
the adjacent teeth were all mobile and were assigned grade ii to grade iii mobility . the radiographs taken were ( ortho pantomo gram ( opg ) , intra oral peri apical ( iopa),12fnx017fnx016 ) and chest x - ray [ figure 2 ] .
( 71,72,73,74,81,82,83 ) fine needle aspiration cytology ( fnac ) was done and pus was thick in consistency .
electrophoresis of the cystic fluid demonstrated low soluble protein content ( < 3.75 g/100 ml ) .
tentative diagnosis of okc was made and confirmed later by histologic examination of the surgical specimen .
the cross - section showed parakeratinized stratified squamous epithelium with uniform thickness in most areas and with a prominent palisading basal layer , which was consistent with the preoperative diagnosis of okc .
the operation was performed under general anesthesia by enucleation of the cyst , according to the principle of partsch ii .
facial asymmetry on right side of face large odontogenic keratocyst involving an impacted canine with unilocular and scalloped borders intraoral view showing obliteration of the labio - buccal sulcus under all aseptic precautions in the operation theater , general anesthesia was given to the patient .
degloving incision was made 6 - 8 mm below the attached gingiva [ figure 4 ] .
mucoperiosteal flap was raised and then small perforation was made for aspiration of cystic contents and impacted canine was exposed [ figure 5 ] .
then , the cystic linings was removed and impacted teeth were removed [ figures 6 and 7 ] and curettage was done with carnoy 's solution [ figure 9 ] .
the site was closed with betadine soaked gauze pack and their borders are then sutured to create an open cavity that communicates with the oral cavity [ figure 8 ] .
degloving incision marked 6 - 8 cm away from attached gingival small perforation with exposure of impacted canine composed of thin , irregular bundles of collagen , contains islands of epithelium that may represent daughter cyst lining was removed intact after curettage , betadine soaked gauze pack placed in the cavity extraction of impacted canine
under all aseptic precautions in the operation theater , general anesthesia was given to the patient .
degloving incision was made 6 - 8 mm below the attached gingiva [ figure 4 ] .
mucoperiosteal flap was raised and then small perforation was made for aspiration of cystic contents and impacted canine was exposed [ figure 5 ] .
then , the cystic linings was removed and impacted teeth were removed [ figures 6 and 7 ] and curettage was done with carnoy 's solution [ figure 9 ] .
the site was closed with betadine soaked gauze pack and their borders are then sutured to create an open cavity that communicates with the oral cavity [ figure 8 ] .
degloving incision marked 6 - 8 cm away from attached gingival small perforation with exposure of impacted canine composed of thin , irregular bundles of collagen , contains islands of epithelium that may represent daughter cyst lining was removed intact after curettage , betadine soaked gauze pack placed in the cavity extraction of impacted canine
treatments are generally classified as conservative and aggressive . conservative treatment generally includes simple enucleation , with or without curettage , using spoon curettes of marsupialization . aggressive treatment generally includes peripheral ostectomy , chemical curettage with carnoy 's solution and resection . some surgeons believe that the cyst can be properly treated with enucleation if the lesion is removed intact
. however , complete removal of the okc can be difficult because of the thin , friable epithelial lining , limited surgical access , skill and experience of the surgeon , cortical perforation , and the desire to preserve adjacent vital structures .
the goals of treatment should involve eliminating the potential for recurrence while also minimizing the surgical morbidity .
secondly , it involves growth of a new okc from small satellite cysts of odontogenic epithelial rests left behind by the surgical treatment .
the third reason involves the development of an unrelated okc in an adjacent region of the jaws , which is interpreted as a recurrence .
marx and stern believe that the two most common reasons for recurrence are incomplete cyst removal and new primary cyst formation .
the majority of cases of recurrence occur within the first 5 years after treatment . because of the problematic nature of these cysts
, many attempts have been made to reduce the high recurrence rate by improved surgical techniques .
this technique is based on the externalization of the cyst through the creation of a surgical window in the buccal mucosa and in the cystic wall .
their borders are then sutured to create an open cavity that communicates with the oral cavity .
this procedure relieves pressure from the cystic fluid , allowing reduction of the cystic space and facilitating bone apposition to the cystic walls .
currently , treatment involving careful and aggressive enucleation with close follow - up has been advocated for the okc .
john and james described the use of enucleation in conjunction with a chemical cauterizing agent and excision of overlying mucosa as a means of reducing recurrence .
because the lining of the okc is characteristically thin and friable , removal of the cysts in one piece may be difficult .
great care must therefore be taken to ensure complete removal of the cyst lining , without leaving behind remnants attached to the adjacent bone or soft tissue .
the high recurrence rate associated with okcs is a result of satellite cysts confined to the fibrous walls of the okcs .
it should be emphasized that if the fibrous capsule is completely removed , no satellite cysts will be retained to serve as a nidus for recurrence . in view of the possible recurrence of the cysts from basal cell proliferation and because of the fragility of the cyst wall and the presence of satellite cysts , the osseous walls of the defect are abraded with coarse surgical or acrylic burs to ensure that residual peripheral cystic tissue is removed .
enucleation is not always easy because the lining may be extremely thin and friable , and access in the depths of the mandible may be limited .
multilocular cysts with bony trabeculae present special problems , in as much as it is difficult to remove the lining in one piece .
enucleation with excision of the soft tissue overlying the okcs has been proposed in an attempt to reduce the incidence of recurrence .
a number of authors advocated the use of tanning with carnoy 's solution ( absolute alcohol , chloroform , glacial acetic acid , and ferric chloride ) before enucleation of the cysts .
this procedure is often followed by excision of the overlying mucosa in continuity with the lesion .
the okc has been the subject of much debate over the last 50 years with respect to its origin , its growth , and treatment modalities .
the obvious advantages of our treatment techniques are as follows : 
 eradication of the pathologic lesion , reduction of the potential for recurrence andpreservation of the continuity of the mandible , thus maintaining jaw function and shape . 
 
eradication of the pathologic lesion , reduction of the potential for recurrence and preservation of the continuity of the mandible , thus maintaining jaw function and shape .
although odontogenic keratocysts ( okcs ) are benign , they are often locally destructive and tend to recur after conservative surgical treatment . 
 they must therefore be distinguished from other cysts of the jaw . 
 keratocysts possess outpouchings and microscopic daughter cysts from which recurrences may arise . 
 histologic examination is essential for diagnosis since the appearances on roentgenograms and at operation usually do not reveal the true nature of the lesion . since many non - dental surgeons and pathologists are unaware of okcs , a case is presented in which surgical treatment was by original conservative method . 
 decompression causes a reduction in the cyst volume with new bone formation so that the structures impinged upon ( e.g. , teeth , nerves ) are completely free .