USDJ 2018 Volume 2 Issue 2 INFLAMMATORY OKC: A CASE PRESENTATION Sharma S 1 , Mukherjee T 1 , Dadhwal H 2 , Chopra S 2 1 PG Student , 2 Reader , 3 Professor , Department of oral & Maxillofacial surgery , HIDS, Paonta Sahib Abstract: OKC is one of the most commonly encountered cysts of the oral cavity and yet just as easily misdiagnosed. The OKC has been a subject of several controversies because of its apparent neoplastic behavior. In 2005, WHO classifications of head and neck tumors added OKC as a benign neoplasm of the head and neck, and proposed the term “Keratocystic Odontogenic Tumour”(KCOT). However, in 2017, OKC was re -classified as a cystic lesion in WHO classification of Head and Neck Pathology. The aim of this article is to provide one of the many varied presentations of OKC; mimicking a residual cyst in the form of a case presentation. INTRODUCTION swelling returning. The patient gave a history of The term “Odontogenic Keratocyst” was first extractions in the region about 3 months back. The lesion appeared to be approx. 1.5cmₓ2cm in coined by Philipsen in the year 1956. Later, in 1963, Pindborg and Hansen coined the term diameter. Extraoral inspection, revealed swelling “keratocyst” and this terminology was used to in the lower front region; the skin over the lesion describe any cyst with a large keratin content. appeared normal and on palpating, the lesion The OKC has been a subject of several appeared to be firm, fixed to the underlying controversies because of its apparent neoplastic tissues, and hard in consistency. Intraoral behavior. In 2005, WHO classifications of head examination revealed missing right mandibular and neck tumors added OKC as a benign lateral incisor, right mandibular first molar, right neoplasm of the head and neck, and proposed maxillary first molar, left maxillary first and the term “Keratocystic Odontogenic second molar and left mandibular posterior Tumour”(KCOT). However, in 2017, OKC was teeth. An OPG was advised to patient, which re-classified as a cystic lesion in WHO revealed a lesion, approximately 2cm in width classification of Head and Neck Pathology. [1] and 1-1.5cm in height, located in 31,41 and 42 Due to its doubtful nature as a cyst, an OKC region. (Fig. 1) It was concluded that the cyst may often mimic dentigerous cysts, lateral may be a Ressidual cyst with respect to the right periodontal, radicular or residual cyst and often mandibular lateral incisor (42). The surgery was give an erroneous radiographical picture. Below, scheduled for the following day, the patient we discuss one such case. admitted to the hospital for pre-operative CASE PRESENTATION Intravenous Antibiotics [Inj Bluemox, 1000 mg A female patient, Mrs. Surekha Devi, aged 40 (Blue Cross Laboratories Ltd.), Infusion Flagyl, years; reported to the Outpatient department of 500mg (Jb Chemicals and Pharmaceuticals Oral and Maxillofacial Surgery on 23 rd July Ltd)]. 2018. The patient complained of a swelling on Surgery was planned for the next day. her lower front tooth region since 1-2 months. Enucleation and excisional biopsy under local On further questioning, the patient revealed that anaesthesia was planned. Bilateral Inferior she was alright about 1 month back and started alveolar nerve block was given with Lignocaine noticing pain and swelling on her lower front (1:2,00,000) and the right mandibular canine region, which subsided on taking medication was first extracted as it was mobile (Grade III). [patient was unable to give any details about the A crevicular incision was placed extending from medication she took at the time]. Then, about 20 33 region to 43, and bilateral vertical releasing days prior to reporting, she noticed the pain and incision was given to maximize exposure. A full 38
USDJ 2018 Volume 2 Issue 2 thickness mucoperiosteal flap was elevated to expose the affect region.(Fig. 2) Using a round bur, a bony window was created to expose the cyst lining. A curette was used to detach the cystic lesion from its surrounding bony margins. A thick creamy material oozed out from a small penetration in the lining. As the curettage proceeded, we observed tunneling in Fig. 3- Tunneling seen during curettage. the body of the mandible going posteriorly, (Arrows depicting the direction of the tunnel) apical to the premolars (34,35) (Fig. 3). This provided us with the first scope of doubt that the lesion may not be a residual cyst. The specimen was sent for histopathological examination. The wound was irrigated with saline and betadine solution and closure was done.( Fig.4) The patient was discharged and advised to continue medication as prescribed and regular follow up. The histopathological sections revealed presence of inflammatory odontogenic keratocyst. Fig.4- Wound closure S Fig.1- OPG revealing the lesion and extent D C Fig. 5- Histopathological section of the patient; S- Surface epithelium, D- Daughter cyst, C- Corrugated epithelium DISCUSSION Fig.2- Incision and creation of bony window OKC is a cyst with varied clinical presentation, which makes it controversial. Wright et al, presented 4 cases where they were able to isolate Odontogenic Keratocyst presenting as a Periapical lesion, which were confirmed only 39
USDJ 2018 Volume 2 Issue 2 with histopathological sections. OKC may connective tissue showed small islands of present in the periapical region of vital tooth epithelium or daughter cysts confirming the giving the appearance diagnosis of odontogenic keratocyst (Fig 5). of a radicular cyst. [2] OKC is derived from the rests of dental lamina, features mimicking those of benign neoplasms. It is often associated with CONCLUSION In conclusion, OKC’s may be easily Nevoid Basal Cell Carncinoma Syndrome. The cyst may occur at any age, however it is misdiagnosed, given its nature of origin. It may extremely rarely seen in children under 10yrs of present with similar clinical presentations as age. Also there is a sharp increase in incidence radicular cyst when associated with vital tooth; in the 2 nd decade and 5 th decade of life. The dentigerous cyst when associated with unerupted mandible is more oftenly involved in tooth or even residual cyst when associated with comparison to maxilla (approx.77%). One of the a region of extracted tooth. OKC has been most important features of OKC is its growth in considered to be a benign neoplasm due to its antero-posterior direction, in contrast to most aggressive nature. In our patient, we have other cysts which results in buccal cortical observed this as tunneling into the body of the expansion. Patients often complain about pain mandible, intraoperatively, during enucleation. and swelling, with or without discharge. Some A thorough history of the patient along with may even complain of paresthesia. If associated histological examination is important to reach a with an unerupted tooth, it can often be confirmed diagnosis. misunderstood as a Dentigerous cyst.[3] In our case, clinically it was expected to be a REFERENCES 1. Passi D et al. Odontogenic Keratocyst or residual cyst as the lesion was associated with Keratocystic Odontogenic Tumour- Journey of the extracted right mandibular lateral incisor. OKC from Cyst to Tumour to Cyst Again: Residual cyst is an inflammatory cyst which Comprehensive review with recent updates on presents as a well defined lesion that can vary in WHO classification. International Journal of size from a few millimetres to a few Current Research, 2017;Vol 9 (07): 54080-6. 2. Wright B A et al. Odontogenic Keratocyst centimeters.[4] But, as we proceeded surgically, presenting as Periapical disease. Oral Surg. Oct the lesion extended in a posterior direction 1983; Vol 56: 425-9. which was more suggestive of OKC as it has a 3. Shear M, Speight P M. Cysts of the Oral and characteristic feature of expanding in an antero- Maxillofacial Regions. 6-58. 4. Rajendran R. Cysts and Tumours of Odontogenic posterior direction, which was later confirmed Origin. Shafers Textbook of Oral Pathology, 5 th by histopathological examination. edition. 357- 432. Histologically, the cystic lining was thick superimposed with inflammation. The 40
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