Fourteen-year study of the management of the odontogenic keratocyst. Are adjunctive therapies all they are cut out to be?

Odontogenic keratocysts (OKC) are benign, developmental, locally-aggressive odontogenic cystic lesions with a high risk of recurrence. As such, the most effective treatment modalities remain controversial. The mainstay of treatment remains enucleation with or without decompression. The use of adjunctive therapies is widely reported. Our aim was to review our experience of OKCs and therefore identify the treatment modality, if there is any single one, with the lowest rate of recurrence. We also aimed to identify any common themes linking those patients experiencing cystic recurrence. Data were collected on 50 patients treated at UHCW NHS Trust over a 14-year period (2005-2018) via an anonymised database. Surgical pathways were analysed, including details of the location of the cysts and the use of adjunctive therapies, namely; mechanical debridement, cryotherapy, and the use of Carnoy's solution. Fifty-six keratocysts, both primary (91%, n = 51) and recurrent (9%, n = 5) were included. A total of 6% of patients had a pre-existing diagnosis of Gorlin-Goltz Syndrome (n = 3). Enucleation was performed in an approximately 3:1 ratio to decompression with secondary enucleation (n = 41:15). Twenty-seven percent of patients had adjunctive therapies (n = 15). There was a 12% recurrence rate (n = 6) found only within the group of primary cysts that had been enucleated only. Notably, there were no recurrences in those cysts that had undergone adjunctive therapy. None of the cysts that underwent initial decompression or marsupialisation recurred. Following surgical intervention, no tertiary recurrent cysts were detected postoperatively. This study demonstrated the advantage of establishing a correct diagnosis prior to definitive treatment. Initial decompression in selected patients followed by enucleation, along with adjunctive therapies showed a benefit in reducing recurrences. However, in the absence of high-quality evidence for the most effective management of odontogenic keratocysts, finding a common approach will remain controversial.