The treatment of the OKC remains controversial. 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. There is no consensus on adequacy of appropriate treatment of this lesion. Recurrence occurs due to the following reasons. The first reason involves incomplete removal of the original cyst's
lining. 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. Bramley recommends the use of radical surgery
with resection and bone transplantation. Decompression or marsupialization seem to be more conservative options in the treatment of OKC. Marsupialization was first described by Partsch in 1882 for the treatment of cystic lesions. 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.