INFLAMMATORY OKC: A CASE PRESENTATION Sharma S 1 , Mukherjee T 1 , - - PDF document

USDJ 2018 Volume 2 Issue 2

38 INFLAMMATORY OKC: A CASE PRESENTATION

Sharma S1, Mukherjee T1, Dadhwal H2, Chopra S2

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 The term “Odontogenic Keratocyst” was first coined by Philipsen in the year 1956. Later, in 1963, Pindborg and Hansen coined the term “keratocyst” and this terminology was used to describe any cyst with a large keratin content. 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. [1] Due to its doubtful nature as a cyst, an OKC may often mimic dentigerous cysts, lateral periodontal, radicular or residual cyst and often give an erroneous radiographical picture. Below, we discuss one such case. CASE PRESENTATION A female patient, Mrs. Surekha Devi, aged 40 years; reported to the Outpatient department of Oral and Maxillofacial Surgery on 23rd July

• 2018. The patient complained of a swelling on

her lower front tooth region since 1-2 months. On further questioning, the patient revealed that she was alright about 1 month back and started noticing pain and swelling on her lower front region, which subsided on taking medication [patient was unable to give any details about the medication she took at the time]. Then, about 20 days prior to reporting, she noticed the pain and swelling returning. The patient gave a history of extractions in the region about 3 months back. The lesion appeared to be approx. 1.5cmₓ2cm in

• diameter. Extraoral inspection, revealed swelling

in the lower front region; the skin over the lesion appeared normal and on palpating, the lesion appeared to be firm, fixed to the underlying tissues, and hard in consistency. Intraoral examination revealed missing right mandibular lateral incisor, right mandibular first molar, right maxillary first molar, left maxillary first and second molar and left mandibular posterior

• teeth. An OPG was advised to patient, which

revealed a lesion, approximately 2cm in width and 1-1.5cm in height, located in 31,41 and 42

• region. (Fig. 1) It was concluded that the cyst

may be a Ressidual cyst with respect to the right mandibular lateral incisor (42). The surgery was scheduled for the following day, the patient admitted to the hospital for pre-operative Intravenous Antibiotics [Inj Bluemox, 1000 mg (Blue Cross Laboratories Ltd.), Infusion Flagyl, 500mg (Jb Chemicals and Pharmaceuticals Ltd)]. Surgery was planned for the next day. Enucleation and excisional biopsy under local anaesthesia was planned. Bilateral Inferior alveolar nerve block was given with Lignocaine (1:2,00,000) and the right mandibular canine was first extracted as it was mobile (Grade III). A crevicular incision was placed extending from 33 region to 43, and bilateral vertical releasing incision was given to maximize exposure. A full

USDJ 2018 Volume 2 Issue 2

39

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

• ut from a small penetration in the lining. As the

curettage proceeded, we observed tunneling in the body of the mandible going posteriorly, 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

• dontogenic keratocyst.

Fig.1- OPG revealing the lesion and extent Fig.2- Incision and creation of bony window

• Fig. 3- Tunneling seen during curettage.

(Arrows depicting the direction of the tunnel) Fig.4- Wound closure

• Fig. 5- Histopathological section of the patient;

S- Surface epithelium, D- Daughter cyst, C- Corrugated epithelium DISCUSSION 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 S D C

USDJ 2018 Volume 2 Issue 2

40

with histopathological sections. OKC may present in the periapical region of vital tooth giving the appearance

• f a radicular cyst. [2] OKC is derived from the

rests of dental lamina, features mimicking those

• f benign neoplasms. It is often associated with

Nevoid Basal Cell Carncinoma Syndrome. The cyst may occur at any age, however it is extremely rarely seen in children under 10yrs of

• age. Also there is a sharp increase in incidence

in the 2nd decade and 5th decade of life. The mandible is more

• ftenly

involved in comparison to maxilla (approx.77%). One of the most important features of OKC is its growth in antero-posterior direction, in contrast to most

• ther cysts which results in buccal cortical
• expansion. Patients often complain about pain

and swelling, with or without discharge. Some may even complain of paresthesia. If associated with an unerupted tooth, it can often be misunderstood as a Dentigerous cyst.[3] In our case, clinically it was expected to be a residual cyst as the lesion was associated with the extracted right mandibular lateral incisor. Residual cyst is an inflammatory cyst which presents as a well defined lesion that can vary in size from a few millimetres to a few centimeters.[4] But, as we proceeded surgically, the lesion extended in a posterior direction which was more suggestive of OKC as it has a characteristic feature of expanding in an antero- posterior direction, which was later confirmed by histopathological examination. Histologically, the cystic lining was thick superimposed with inflammation. The connective tissue showed small islands of epithelium or daughter cysts confirming the diagnosis of odontogenic keratocyst (Fig 5). CONCLUSION In conclusion, OKC’s may be easily misdiagnosed, given its nature of origin. It may present with similar clinical presentations as radicular cyst when associated with vital tooth; dentigerous cyst when associated with unerupted tooth or even residual cyst when associated with a region of extracted tooth. OKC has been considered to be a benign neoplasm due to its aggressive nature. In our patient, we have

• bserved this as tunneling into the body of the

mandible, intraoperatively, during enucleation. A thorough history of the patient along with histological examination is important to reach a confirmed diagnosis.

REFERENCES 1. Passi D et al. Odontogenic Keratocyst or Keratocystic Odontogenic Tumour- Journey of OKC from Cyst to Tumour to Cyst Again: Comprehensive review with recent updates on WHO classification. International Journal of Current Research, 2017;Vol 9 (07): 54080-6. 2. Wright B A et al. Odontogenic Keratocyst presenting as Periapical disease. Oral Surg. Oct 1983; Vol 56: 425-9. 3. Shear M, Speight P M. Cysts of the Oral and Maxillofacial Regions. 6-58. 4. Rajendran R. Cysts and Tumours of Odontogenic

• Origin. Shafers Textbook of Oral Pathology, 5th
• edition. 357- 432.