Surgical-implantological Therapy of a Keratocyst of the Mandible

Case report: A 26-year-old patient with an unremarkable medical history presented to Münster University Hospital with persistent complaints after an alio loco abscess incision in region 47. The orthopantomogram showed a sharply delimited, uniform radiolucency in region 46-48, which led to the suspicion of a cyst. Cystectomy and surgical removal of tooth 48 was performed. The pathohistological result revealed the presence of an odontogenic keratocyst. After 10 months, a local recurrence occurred, which was treated by a new cystectomy. After 4 months, a fistula appeared again, and the CT scan showed renewed osteolysis in the right mandible. A partial mandibular resection with reconstruction by iliac crest followed. After 9 months the metal was removed, and after another 11 months without recurrence 2 implants were inserted. 3 months later, 2 crowns were inserted.
Discussion: According to the current WHO classification of head and neck tumours, the odontogenic keratocyst belongs to the group of developmental odontogenic cysts. It is the third most common jaw cyst and occurs particularly in the region of the lower wisdom teeth. In terms of age distribution, there is a peak incidence between the ages of 20 and 30. Men are more frequently affected. Symptoms often first appear as a result of a secondary infection. The treatment of choice is cystectomy. Here, the recurrence rate is 25%. With surgical resection, it is less than 2%. It is unclear whether and when implantological treatment can be carried out after cyst treatment. However, functional rehabilitation is not possible without implants. The use of autologous bone remains the gold standard. What is certain is that the integration of the bone graft must be waited for. Regular radiological and clinical follow-up is obligatory.
Conclusion: In this case, the iliac crest augmentation and subsequent implant placement made it possible to insert two fixed implant-supported crowns. Due to the risk of recurrence, careful patient information and regular follow-up are required. A universal therapy concept cannot be propagated for odontogenic keratocysts.