The keratocystic odontogenic tumour (KOT) which was previous known as the odontogenic keratocyst is a benign but locally aggressive tumour known for its high recurrence rate. A wide range of treatment options have been reported including enucleation alone, enucleation with curettage, enucleation with adjunctive therapy (Carnoy’s solution, cryotherapy, and peripheral ostectomy), marsupialisation or decompression with or without secondary cystectomy and adjunctive therapy, and resection.
The aim of this review was to identify the best surgical treatment with the lowest recurrence rate for keratocystic odontogenic tumours (KOTs)
Methods
Searches were conducted in the PubMed, Ovid MEDLINE, Cochrane CENTRAL and Google Scholar databases. Prospective randomised controlled clinical trials (RCTs) , controlled clinical studies (CCS), either prospective or retrospective, and case series on patients having surgical treatment for KOT (primary or recurrence) with at least 1 year follow up were considered.
Two reviewers independently screened studies, abstracted data and assessed risk of bias using the Newcastle-Ottawa Scale. The recurrence rate of KOTs was pooled and reported as event rates with corresponding 95% confidence intervals.
Results
- 35 studies were included.
- There were no randomised controlled trials
- The overall weighted pooled recurrence rate of all included studies was 16.6% (95%CI; 12.3%-22%).
- Weighted pooled recurrence rate for difference surgical approaches are shown in the table below
| Treatment | No. of studies | No of KOTs | Recurrence rate (95%CI) |
| Enucleation alone | 17 | 891 | 23.1% (17.3% – 30.2%) |
| Enucleation with curettage | 8 | 378 | 17.4% (11.2% – 26.1%) |
| Enucleation and Carnoy’s solution | 16 | 549 | 11.5% (6.8% – 18.8%) |
| Enucleation plus liquid nitrogen cryotherapy | 6 | 173 | 14.5% (5.1% – 34.9%) |
| Marsupialization alone | 8 | 63 | 32.3% (16.9% – 52.8%) |
| Decompression followed by residual cystectomy | 9 | 141 | 14.6% (9.2% – 22.3%) |
| Resection | 7 | 92 | 8.4% (3.5% – 18.8%) |
Conclusions
The authors concluded
radical resection remains the sure option for obtaining the lowest recurrence with KOTs. We believe that in an attempt to achieve the least possible morbidity, resections should be reserved for multiple recurrent lesions and possibly syndromic cases. However, to achieve the least recurrence, enucleation with application of Carnoy’s solution or cryotherapy is the first-line treatment for primary KOTs. Additionally, marsupialisation (where indicated) must be followed by secondary cystectomy to minimize recurrence.
Comments
A number of systematic reviews of treatments for KOT have been conducted since 2000 (Dental Elf – 2nd Jul 2014) including a Cochrane review (Dental Elf – 10th Nov 2015). However, all the reviews are hampered to a greater of lesser extent by the fact that no randomised controlled trials have been conducted to compare one treatment approach against another. This latest review has conducted a fairly extensive search of a number of databases and included 35 studies meeting their criteria finding that the overall pooled recurrence rate was 16.6% (95%CI; 12.3 – 22). This compares to an estimated probability of recurrence of 21.1% (95%CI; 18.4- 23.7) estimated by Chrcanovic et al in another recent review and comparisons with other approach between the two reviews are shown in the table below.
| Treatment | Al-Moraissi et al
Recurrence rate (95%CI) |
Chrcanovic et al
Probability of recurrence (95%CI) |
| Enucleation with curettage | 17.4% (11.2% – 26.1) | 22.5% (19.1 – 26.0) |
| Enucleation and Carnoy’s solution | 11.5% (6.8 – 18.8) | 5.3% (2.9 – 7.7) |
| Enucleation plus liquid nitrogen cryotherapy | 14.5% (5.1 – 34.9) | 20.9% (8.4 – 33.3) |
| Marsupialization alone | 32.3% (16.9 – 52.8) | 28.7% (17.7 – 39.8) |
| Resection | 8.4% (3.5 – 18.8) | 2.2% (0.2 – 4.3) |
A majority of the included studies (27) in this review were retrospective so the underlying quality of the primary studies in this and the Chrcanovic et al review mean that these estimates should be interpreted with caution. High quality prospective studies are needed to clarify the most effective treatment and the recurrence rates for this troublesome tumour.
Links
Primary paper
Al-Moraissi EA, Dahan AA, Alwadeai MS, Oginni FO, Al-Jamali JM, Alkhutari AS, Al-Tairi NH, Almaweri AA, Al-Sanabani JS. What surgical treatment has the lowest recurrence rate following the management of keratocystic odontogenic tumor?: A large systematic review and meta-analysis. J Craniomaxillofac Surg. 2017Jan;45(1):131-144. doi: 10.1016/j.jcms.2016.10.013. PubMed PMID: 27955959.
Other references
Chrcanovic BR, Gomez RS. Recurrence probability for keratocystic odontogenic tumors: An analysis of 6427 cases. J Craniomaxillofac Surg. 2016 Nov 19. pii: S1010-5182(16)30285-2. doi: 10.1016/j.jcms.2016.11.010. [Epub ahead of print] PubMed PMID: 28011178.
Dental Elf – 10th Nov 2015
Dental Elf – 2nd Jul 2014
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