SPECIAL ARTICLE http://dx.doi.org/0.55/jkaoms.0.8..55 Nobuyoshi Tomomatsu, Narikazu Uzawa, Yasuyuki Michi, Kazuto Kurohara, Norihiko Okada, Teruo Amagasa Maxillofacial Surgery, Maxillofacial Reconstruction and Function, Division of Maxillofacial and Neck Reconstruction, Diagnostic Oral Pathology, Oral Restitution, Oral Health Sciences, Graduate School, Tokyo Medical and Dental University Abstract (J Korean Assoc Oral Maxillofac Surg 0;8:55-6) The odontogenic keratocyst (OKC) was originally classified as a developmental cyst, and OKCs were histologically divided into orthokeratotic (O-OKCs) and parakeratotic (P-OKCs) types. Clinical features differ between O-OKCs and P-OKCs with P-OKCs having a tendency to recur after surgical treatment. According to the revised histopathological classification of odontogenic tumors by the World Health Organization (005), the term keratocystic odontogenic tumor (KCOT) has been adopted to describe P-OKCs. In this retrospective study, we examined 86 KCOTs treated at the Maxillofacial Surgery Department of the Tokyo Medical and Dental University Hospital from 98 through 005. The patients ranged in age from 7 to 85 years (mean,.7) and consisted of 9 males and 9 females. The most frequently treated areas were the mandibular molar region and ramus. The majority of KCOTs in the maxillary region were treated by enucleation and primary closure. The majority of KCOTs in the mandibular region were enucleated, and the wound was left open. Marginal resection was performed in the 4 patients with large lesions arising in the mandible. In patients who were followed for more than a year, recurrences were observed in 9 of 0 lesions (5.8%). The recurrences were found at the margins of the primary lesion in contact with the roots of the teeth or at the upper margins of the mandibular ramus. Clinicians should consider aggressive treatment for KCOTs because the recurrence rate of P-OKCs is higher than that of other cyst types such as O-OKCs, dentigerous cysts, primordial cysts that were non-keratinized, and slightly keratinized stratified squamous epithelium. Although more aggressive treatment is needed for KCOTs as compared to other cystic lesions, it is difficult to make a precise diagnosis preoperatively on the basis of clinical features and X-ray imaging. Therefore, preoperative biopsy is necessary for selecting the appropriate treatment for patients with cystic lesions. Key words: Keratocystic odontogenic tumor, Odontogenic benign tumor, Odontogenic keratocyst, Odontogenic orthokeratocyst I. 제언 005년에치성종양 World Health Organization (WHO) 조직분류 가개정되어, 종래의치성각화낭종 (odontogenic keratocyst) 은낭종상피가착각화를보이는것을각화낭성치성종양 (keratocystic odontogenic tumor) 으로분류하여양성종양의하나로다루게되었다. 치성각화낭종은 956년 Philipsen 에의해보고된이래, 높은재발률과침윤성등종양으로서의성격이다수보고되었다 6. 종양으로분류된이유로는본병변의발현에암억제유전자의하나인 patched Nobuyoshi Tomomatsu Maxillofacial Surgery, Maxillofacial Reconstruction and Function, Division of Maxillofacial and Neck Reconstruction, Graduate School, Tokyo Medical and Dental University, -5-45 Yushima Bunkyo-ku, Tokyo -8549, Japan TEL: +8--580-5500 FAX: +8--580-098 E-mail: tomomatsu.mfs@tmd.ac.jp CC This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 유전자의관여가인정되는점, 진행성및재발성의성격을보유하고있는점, 기저세포모반증후군을동반하여다발성으로발생하는경우가있는점 7, 치질골을파괴하여주위연조직에파급되는점, 기저세포층직상의세포증식활성이높은점, 그리고상피이형성을볼수있다는점등을들수있다. 지금까지다수의치성각화낭종의재발에관한임상적검토가진행되어그원인에대해서도여러견해가보고되었다. 재발률은.0% 부터 6.5% 로폭넓게보고되고있으며 4,8 7, 그원인으로낭낭포 (daughter cyst), 상피섬 (epithelial island) 의존재, 낭종벽표피세포의활발한증식능등이거론되고있지만, 얇은낭종벽때문에적출시발생하는상피조직의잔존이원인이라는지적도다수보고되고있다,7 9. 이에본연구는과거 5년간본과에서진단하고치료한단발성의악골낭종을새로운 WHO 분류에준하여재분류한후, 각화낭성치성종양으로분류된것을대상으로임상적검토를실시하였다. *Some points of this article was reported at the 5th Japanese Meeting of Oral and Maxillofacial Surgery in Oct, 006. *This article was published in Japanese Journal of Oral and Maxillofacial Surgery and secondary publication was permitted each other between Korea and Japan. 55
J Korean Assoc Oral Maxillofac Surg 0;8:55-6 II. 연구대상및방법 98년부터 005년까지 5년간동경의과치과대학치학부부속병원악안면외과외래 ( 구제구강외과 ) 의임상, 병리조직학적진료를통해각화낭성치성종양으로진단된단발 86증례를대상으로하였다. 다발성증례에관해서는이번해석에서제외하였다. 그러나각화낭성치성종양의진단기준에관해서는신 구분류법에애매한부분이있어일정한진단기준을적용할 필요가있었다. 즉, 각화낭성치성종양은 005년의분류개정에의해양성종양으로서다뤄지게되었지만, 이는단지명칭이바뀐것만이아니라진단기준에도다소변경된부분이있다. 각화양식이정각화인편평상피로부터이뤄지는것은이범주에포함하지않으며, 정각화를띠는악골내낭종을치성정각화낭종 (odontogenic orthokeratocyst) 으로분류하고, 각화낭성치성종양은각화양식이착각화를띠는것에한정시켰다. 이러한두가지각화양식의차이에따라임상증상은달라져, 착각화를띠는것은정각화보다재발 Fig.. The classification of odontogenic tumors/cyst by World Health Organization (WHO). Nobuyoshi Tomomatsu et al: Clinical study of keratocystic odontogenic tumors. J Korean Assoc Oral Maxillofac Surg 0 Fig.. The histopathological classications of odontogenic tumors. A. Parakeratotic type. B. Orthokeratotic type. C. Non-keratotic type ( 00, scale bar:00 μm). Nobuyoshi Tomomatsu et al:. J Korean Assoc Oral Maxillofac Surg 0 56
을초래하는경우가많았다 0. 그런데이번새로운분류에 는치성상피성낭종의조직분류에관한언급은없기때문 에새로운견해가도출될때까지이전 99 년의조직분류 를적용키로한다. 애매한종래의치성각화낭종과원시성 낭종, 함치성낭종의진단기준분류에이번새로운분류까 지더할경우, 낭종상피가착각화를띠는것은각화낭성치 성종양으로분류되지만그외정각화를띠는낭종과단발 성으로각화경향이매우경미한낭종의분류는불분명해 진다. 이에본연구에서는아래의기준에준하여분류하였 다,.(Figs., ) 치성각화낭종, 원시성낭종, 함치성낭종중 착각화를띨경우각화낭성치성종양으로, 정각화인경우는 치성정각화낭종으로, 단발성으로각화경향이매우경미하 며매복치를포함하지않는경우는원시성낭종, 매복치를 포함하는것은함치성낭종으로분류하였다. 또한착각화를 띠더라도각화경향이경미한경우는원시성낭종, 함치성 낭종으로분류하였다. 각화양식이혼재하는경우에는보 다명확하게나타나는양식에준하여분류하였다. 치료성적및재발에대해서는 년이상경과관찰이가 능했던 0 증례에대해검토하였다. 또한같은기간내에 본과에서진단, 치료를실시한치성정각화낭종 7 증례, 원 시성낭종 0증례, 함치성낭종 5증례, 에나멜상피종 5 증례의대소비에대해서도일부비교, 검토를실시하였다. 전치부에서는최대지름이 4 치아이상, 구치부에서는 치 Table. The distribution of sex and age Age 0-9 0-9 0-9 0-9 40-49 50-59 60-69 70-79 80- Sex Male Female (%) 6 6 8 7 6 4 9 9 8 7 9 9 4 (.) 5 (8.8) 64 (4.4) (6.7) 0 (0.8) 6 (8.6) 8 (4.) 6 (.) (.) 86 (00) Nobuyoshi Tomomatsu et al:. J Korean Assoc Oral Maxillofac Surg 0 아이상의병변을대병변으로, 그보다작은병변을소병변 로분류하여각병변의대소비 ( 대병변 / 소병변 ) 를비교하였 다. 통계학적분석은 검정 (Yates 의보정 ) 및 Fisher 의직접 확률검정을이용하여 P<0.05 를유의한것으로보았다. III. 결 과. 발생빈도 ( 연령 성비 발생부위 ) 86 증례의초진시연령은 7 세부터 85 세까지분포하고 있었고평균연령은.7 세였다. 연령별로는 0 대 64 증례 (4.4%), 0 대 5 증례 (8.8%), 0 대 증례 (6.7%) 의순으 로나타났다. 성별은남성이 9 증례, 여성이 9 증례로차이 가없었다.(Table ) 발생부위는상악 4 증례, 하악 45 증 례로하악구치부로부터하악지에걸쳐발생한것이 증 례 (59.7%) 로가장많았다.(Table ) 상악의발생부위는대 구치부가많았다.. 임상소견 ( 증상 X 선소견 ) 증상으로는종창이 70 증례 (7.6%) 로가장많았고, 동통 6 증례 (9.4%), 배농 8 증례 (9.7%), 위화감 8 증례 (4.%), 개구장애 7 증례 (.8%), 치아의동요 증례 (0.5%) 의순서 였다. 한편무증상으로 X 선사진에서발견된것은 46 증 례 (4.7%) 였다.(Table ) X 선소견은단방성이 07 증례 Table. Presenting symptoms Symptom Number (%) Swelling Pain Drainage Feeling of wrongness Trismus Tooth mobility Asymptomatic (found incidentally by x-ray examination) 70 (7.6) 6 (9.4) 8 (9.7) 8 (4.) 7 (.8) (0.5) 46 (4.7) 86 (00) Nobuyoshi Tomomatsu et al:. J Korean Assoc Oral Maxillofac Surg 0 Table. The distribution of location Maxilla 0 (0.8%) Molar~sinus Premolar Incisor and canine 6 (.%) 7 (.8%) Others (the range of lesion is more than two area) 8 (4.%) 4 (.0%) Molar~ramus Premolar Incisor and canine Others Mandible (59.7%) 8 (4.%) 4 (.%) (.8%) Extending over both sides 8 (4.%) 45 (78.0%) Nobuyoshi Tomomatsu et al:. J Korean Assoc Oral Maxillofac Surg 0 57
J Korean Assoc Oral Maxillofac Surg 0;8:55-6 (57.5%), 다방성이 6 증례 (.%) 였다. 병변과관련된매복 치의존재유무는매복치가있는경우가 0 증례 (54.8%), 매복치가없는경우가 8 증례 (44.%) 였다.(Table 4). 치료법과치료성적 본과에서수술을실시한후, 년이상경과관찰을실시 한 0 증례의치료법, 치료성적의결과를 Table 5 에나타 내었다. 상악의경우 0 증례모두적출후일차폐쇄하였고, Table 4. Radiografic findings Tumor variant Unilocular Multilocular Unknown Number 07 (57.5%) 6 (.%) 7 (9.%) 86 (00%) Impacted tooth Containing Non Unknown Number 0 (54.8%) 8 (44.%) (.%) 86 (00%) Nobuyoshi Tomomatsu et al:. J Korean Assoc Oral Maxillofac Surg 0 Table 5. Treatment results (recurrence/number) Maxilla Mandible Enucleation with marsupialization Enucleation (close) Marginal ostectomy 0/0 (0%) 4/0 [/9] (.%) - 4/0 (.%) 4/8 (5/5) (6.9%) / (.%) 0/4 (0%) 5/90 (6.7%) 4/8 (6.9%) 5/ (5.%) 0/4 (0%) 9/0 (5.8%) Upper section- [ ]: with radical operation of maxillary sinus, ( ): enucleation after marsupilization. Under section- recurrence rate. Nobuyoshi Tomomatsu et al:. J Korean Assoc Oral Maxillofac Surg 0 그중 9 증례는상악동근치수술을병행하였다. 하악은 90 증례중 8 증례에대해적출후개방창의술식을사용하였 다. 이러한 8 증례중병변이컸던 5 증례에대해서는개창 요법을실행한후에적출하였다.(Fig. ) 나머지 7 증례중 증례는적출후폐쇄창, 4 증례는악골변연절제술을실행하 였다. 매복치의경우, 맹출가능한것으로판단되는영구치 는보존을원칙으로하였고, 지치는모두발치하였다. 개창 요법의 5 증례중 증례 (6.9%) 에서축소가확인되었고, 증례에서는크기변화를볼수없었다.(Table 6) 상악증례에서는 0 증례중 4 증례에서재발이인정되었 고, 하악증례에서는적출후개방창술식의경우 8 증례 중 4 증례 (6.9%) 에서, 적출후폐쇄창술식의경우 증례 중 증례에서재발이인정되었다. 변연절제를실시한 4 증 례에서는재발이인정되지않았다. 전체증례의재발률은 0 증례중 9 증례 (5.8%) 였다. 또한개창요법과재발과의 관계를살펴본결과, 개창요법을실행한 5 증례중 5 증례 (4.%) 에서, 개창요법을실행하지않고적출방법을실행 한 48 증례중 9 증례 (8.8%) 에서재발이인정되었다. 개창 요법의실행이적은재발경향을보였지만, 통계학적으로 유의차는인정되지않았다 (P=0. 8). Table 6. The effect of marsupialization Number Recurrence Recurrence rate (%) Enucleation after marsupialization Effective* Non-effective Only enucleation 5 48 8 5 9 4 4..6 5.4 8.8 6.9 *Effective case: after the marsupialization, lesion reduced. Nobuyoshi Tomomatsu et al:. J Korean Assoc Oral Maxillofac Surg 0 Fig.. A case that treated by enucleation after the marsupialization. A. First examination. B. months after the marsupialization (before the encleation). C. 6 months after the enucleation. D. year after the enucleation. Nobuyoshi Tomomatsu et al: Clinical study of keratocystic odontogenic tumors. J Korean Assoc Oral Maxillofac Surg 0 58
4. 재발시의증상및 X 선소견 매복치 크기와치료성적 수술후의경과관찰기간과재발과의관계를 Table 7 에 나타내었다. 경과관찰기간은 년부터 7 년까지로, 평균 년 개월이었다. 또한재발까지의기간은 년 4 개월부터 년 개월까지로, 평균 6 년 5 개월이었다. 재발시증상은 Table 7. The correlation between the follow-up period of 0 cases and recurrence Follow-up period Recurrence Non-recurrence ~ year ~ year ~5 year ~8 year ~0 year ~5 year 5 year~ 4 5 9 8 4 4 8 4 0 0 cases: follow-up periods is more than year. Nobuyoshi Tomomatsu et al:. J Korean Assoc Oral Maxillofac Surg 0 Table 8. Symptoms at the recurrence Symptom Number Location of recurrence Number Swelling 4 In the jaw bone 8 Pain Around the root tip 7 Feeling of wrongness The upper of ramus 4 Asymptomatic (found Other (in the bone) 7 incidentally by x-ray examination) 9 Soft tissue 9 Nobuyoshi Tomomatsu et al:. J Korean Assoc Oral Maxillofac Surg 0 종창 4 증례, 동통 증례, 위화감 증례, 기타 증례에대해 서는증상없이경과관찰중에 X 선사진에서발견된것이 대부분이었다.(Table 8) 재발부위는 9 증례중 8 증례가 악골에서재발하였으며, 그중 7 증례가낭종에인접한잔존 치의치근부에서 (Fig. 4), 4 증례가하악지상부에서재발하 였다.(Fig. 5) 연조직의재발도 증례인정되었다. X선소견과재발과의관련에대해 Table 9에제시하였다. X선소견에서다방성을띠는증례에서는 4증례중 증 례 (5.6%) 에서, 단방성의경우 59 증례중 8 증례 (.6%) 에 재발이인정되어다방성증례는단방성증례에비해재발 의예가약간많았지만통계학적으로차이는인정되지못 했다 (P=0.00). 매복치와재발과의관계는불분명한 증례 를제외한나머지를검토하였다. 병변과관계가있는매복 치를동반한 5 증례에서는 7 증례 (.5%) 에서, 그외동반 하지않는 66 증례에서는 증례 (8.%) 에서재발이인정 Table 9. The correlation between radiografic finding and recurrence Recurrence Number Recurrence rate (%) Tumor variant (P=0.00) Impacted tooth (P=0.660) Size (P=0.7) Unilocular Multilocular Unknown Containing No Known Large Small 59 4 8 5 66 69 5 8 0 7 0 4 5.6 5.6.5 8. 0. 9.8 Size: large size is more than 4 tooth in anterior area, or more than tooth in posterior area. Nobuyoshi Tomomatsu et al:. J Korean Assoc Oral Maxillofac Surg 0 Fig. 4. The recurrence case (the recu rrence location is root tip of the tooth). A. First examination. B. After the enucleation. C. Recurrence ( years and 8 months after the enucleation). D. Marginal ostectomy. Nobuyoshi Tomomatsu et al: Clinical study of keratocystic odontogenic tumors. J Korean Assoc Oral Maxillofac Surg 0 59
J Korean Assoc Oral Maxillofac Surg 0;8:55-6 되었지만, 매복치와재발과의관련은통계학적으로명확하 지않았다 (P=0.660). 또한병변이큰증례 ( 전치부에서는 4 치이상, 구치부에서는 치이상 ) 와그보다작은증례를비 교한결과, 큰증례 69증례중 4증례 (0.%) 에서, 작은증례 5증례중 5증례 (9.8%) 에서재발이인정되어통계학적차이가없기는했지만큰증례에재발이많은경향을보였다 (P=0. 7). Table 0. The correlation between cystic tumor/cyst and size of lesion (5 years: 98-005) Number Large Small Ratio a: keratocystic odonotogenic tumor b: odontogenic orthokeratocyst c: primordial cyst d: dentigerous cyst e: ameloblastoma 86 7 0 5 5 7 6 77 07 0 69 5 46 48.70 0.55 0.50 0.6.5 Ratio: large/small. P-value: a-b: 0.049, a-c: 0.000, a-d: 0.000, b-e: 0.05, c-e: 0.000, d-e: 0.000. Nobuyoshi Tomomatsu et al:. J Korean Assoc Oral Maxillofac Surg 0 5. 각화낭성치성종양과유사병변과의비교과거 5년간본과에서진단, 치료를실시한각화낭성치성종양은 86증례, 치성정각화낭종은 7증례, 원시성낭종은 0증례, 함치성낭종은 5증례, 에나멜상피종은 5 증례로그대소비 ( 대병변 / 소병변 ) 를비교하였다.(Table 0) 각화낭성치성종양의대소비는.70, 치성정각화낭종은 0.55, 원시성낭종은 0.50, 함치성낭종은 0.6, 에나멜상피종은.5였다. 각화낭성치성종양과에나멜상피종의대소비는치성정각화낭종, 원시성낭종, 함치성낭종의대소비와 Table. The correlation between keratocystic odontogenic tumor and odontogenic orthokeratocyst Keratocystic odontogenic tumor (86) Odontogenic orthokeratocyst (7) Age/sex (P=0.5, 0.48) Location (P=0.47) Size (P=0.049) Symptom (P=0.7) Radiografic finding (P=0.5, 0.05) Treatment Recurrence rate (P=0.64) Male : female= : Average age:.7 peak: 0-0 Maxilla (.0%), mandible (78.0%) molar~ramus (59.7%) Large : small=7 : 69 Swelling (7.6%), pain (9.4%) Found incidentally by x-ray (4.7%) Unilocular (57.5%), multilocular (.%) Impacted tooth (54.8%) Maxilla: nucleation (close) Mandible: nucleation with marsupialization 9/0: 5.8% Male : female=0 : 7 Average age: 6.5 peak: 0-0 Maxilla (5.%), mandible (64.7%) Large : small=6 : Swelling (7.6%), pain (7.6%) Found incidentally by x-ray (4.%) Unilocular (8.%), multilocular (7.6%) Impacted tooth (70.6%) Maxilla: nucleation (close) Mandible: nucleation with marsupialization 0/7: 0% P-value: between keratocystic odontogenic tumor and odontogenic orthokeratocyst. Nobuyoshi Tomomatsu et al:. J Korean Assoc Oral Maxillofac Surg 0 Fig. 5. The recurrence case (the recurrence location is the upper of the ramous). A. First examination. B. 8 months after marsupialization, before the enucleation. C. Reccurence ( years and 8 months after the enucleation). Nobuyoshi Tomomatsu et al: Clinical study of keratocystic odontogenic tumors. J Korean Assoc Oral Maxillofac Surg 0 60
비교시통계학적으로의미가있어본종양과에나멜상피종은발견시치성정각화낭종, 원시성낭종, 함치성낭종에비해큰병변이많은것을알수있었다 (P<0.05). 또한이번분류를통해종래의치성각화낭종은각화낭성치성종양과치성정각화낭종으로재분류되었다. 임상적차이에대해검토한결과를 Table 에제시하였다. 통계학적검토결과, P값은각각성별 0.5, 연령 0.48, 발생부위 0.47, X선소견의단방성의비율 0.5, 매복치의유무 0.05으로통계학적의미는없었지만, 초진시의병변크기에대해서는 0.049로유의하여본종양이치성정각화낭종에비해발견시큰증례가많은것을알수있었다. 또한재발률에관해서는 P값이 0.64로의미가없었다. 이는각화낭성치성종양 (0증례) 과비교시치성정각화낭종의증례수가 7증례로대단히적기때문에통계학적차이를인정받지못한것으로생각한다. IV. 고 찰 005년에치성종양에관한 WHO 조직분류가개정되어종래의치성각화낭종은낭종외장상피가착각화를띠는것은각화낭성치성종양으로분류되어양성종양의하나로다뤄지게되었다. 지금까지치성각화낭종의재발에관한통계학적검토는다수보고된바있고, 그원인에대해서도다수의견해가피력되었다,,9,. 그러나상피가착각화를띠는각화낭성치성종양만을다룬연구보고는그다지많지않다. 이러한까닭에과거 5년간본과에서진단, 치료를실시한단발증례의낭종성병변을재검토하여새로운분류기준에준한각화낭성치성종양에대해검토하였다.. 성차 연령각화낭성치성종양을포함한종래의치성각화낭종에대한보고를살펴보면, 성차를인정하지않는것 4, 남성에약간많다는것,4,,8,, 등이있지만각화낭성치성종양의자체실험증례에서는전혀성차가인정되지않았다. 연령의경우, 종래의치성각화낭종에서는일반적으로 0 0대에많은것으로알려져있다. 자체실험증례에서연령분포는 7세부터 85세까지폭넓게분포하여다른보고와마찬가 지로 0 0대가많았으며, 평균.7세였다.. 부위지금까지치성각화낭종은하악, 특히지치부에호발하는것으로보고되었다,,8,9,. 각화낭성치성종양에한정시킨자체실험증례에서도 86증례중 45증례 (78.0%) 가하악에서발생하였고, 그중에서도하악대구치부로부터하악지부에많았다. 상악증례에서는대구치부로부터상악동에걸친부위가많았다.. 임상증상지금까지치성각화낭종의임상증상에는감염등으로인한이차적증상도포함되어종창, 동통, 배농, 개구장애의순으로다수인정된다고보고된반면, 무증상으로증대하여 X선검사에서우연히발견되는증례도적지않다는보고도있다,4,. 각화낭성치성종양에한정시킨자체실험증례에서도종창, 동통을증상으로하는증례가많았지만 ( 합계 57.0%), 무증상으로 X선검사를통해우연히발견된증례도 4.7% 를차지하였다. 4. X선소견지금까지치성각화낭종의 X선화상은단방성이비교적많은것으로알려졌다 (6 80%),8,9,,. 각화낭성치성종양의자체실험증례에서도단방성 (57.5%) 은다방성 (.%) 에비해약간많아종래의보고와같은경향을보였다. 병변에인접한매복치는종래의치성각화낭종에서 49.5 56.% 가인정되었다는보고,,9,,4 가있었으며, 자체실험증례에서도 54.8% 로종래의치성각화낭종의보고와거의일치하였다. 5. 재발재발에관해서는이전부터많은보고가있었다. 그러나상피의착각화혹은정각화의구분없이치성각화낭종으로보고된다수의자료중각화낭성치성종양의진단기준에 Table. The comparison of the treatment result of keratocystic odontogenic tumor Report year Reporter Number Recurrence Recurrence rate (%) Follow-up period 988 988 000 00 007 Harada, et al. Hatake, et al. Matuki, et al. Hoon, et al. This report 9 0 The other reports were the treatment result of odontogenic keratocyst, but the author calculated as keratocystic odontogenic tumor. Nobuyoshi Tomomatsu et al:. J Korean Assoc Oral Maxillofac Surg 0 5 77 9 45.5. 4. 58. 5.8 - More than 6 months More than 6 months More than year More than year 6
J Korean Assoc Oral Maxillofac Surg 0;8:55-6 합치되는것만을발췌하여 Table 에제시하였다 4,8 7. 자체실험증례에서의재발률은 5.8% 로, 종래의보고 (4. 58.%),4,5,9 와비교할때관찰기간이상이하다는전제하에자체실험증례의재발률은반드시높은수치는아니었다. 또한, 치성정각화낭종 7증례에서재발은인정되지않았다. 정각화를띠는치성각화낭종의재발은 0.% 라는보고 9,,0 가있으며, 자체실험증례에서도동일하였다. 재발원인에대해이전의보고에서는병변의일괴적출곤란에따른상피조직의잔존이주된재발의요인으로여겨져왔다,8,9. 재발부위는鵜 등 이보고한것 ( 치성각화낭종 ) 처럼낭종에인접한잔존치의치근부가많았으며, 이번검토에서도 9증례중 7증례가이에해당되었다. 이로인해병변에인접한치아의처리가문제로대두된다. 재발을방지하는관점에서인접치를발치해야한다는보고도있지만, 새로운논의를필요로한다 5. 또한하악구치부로부터하악지상부, 근돌기에이르는큰병변의경우하악지상부에재발한경우가 4증례있었으며, 이는적출하기어려운부위에기인하는것으로생각한다. X선소견과재발과의관련에대해横 등 의보고에의하면크기그자체에차이는없다고한다. 그러나자체실험증례에서는작은병변의증례 ( 병변의최대지름이구치부에서는 치미만, 전치부에서는 4치미만 ) 의재발이 9.8% 인것에비해, 큰병변의증례에서는 0.% 의재발률을보였다. Forssell 등 6 은재발증례의 70% 가 X선검사에서최대지름 4 cm 이상으로, 큰병변이재발률이높다고보고하였으며자체실험증례도같은결과였다. 또한, 매복치의존재에차이가없다는보고,7 나포함하지않는쪽이재발률이높은경향이라는보고 4 도있다. 자체실험증례에서는매복치를포함하지않는쪽에약간많은재발이인정되었지만, 통계학적으로유의차는볼수없었다. 재발까지의기간은수술후 5년이내라는보고,,4 가많지만, 자체실험증례에서는재발 9증례중 0증례는 5년이내, 9증례는 5년을넘겨재발하였다. Brannon 9 의보고와마찬가지로자체실험증례에서도 8년을넘겨재발한증례가 4증례있어, 수술후의경과관찰기간은 0년이상이바람직한것으로여겨진다. 본과에서는상악의경우적출후폐쇄창, 하악은적출후개방창으로처치하는경우가대부분으로, 적출후처치법에따른재발률의차이는인정되지않았다. 큰병변에대한개창요법의 5증례중축소효과가인정된것은 증례 (6.9%) 로, 하악하연이나하악관보존이가능한점에서개창요법의유용성에대해서는이후상세한검토가필요할것으로생각한다. 또한, 하악골구역절제술및하악골변연절제술은침습이크지만자체실험증례에서도대단히낮은재발빈도를보임으로써큰재발병변의경우에적극적으로적용할만하다하겠다. 6. 각화낭성치성종양과유사병변과의비교 X선소견, 임상소견만으로본질환을진단하는것은곤란하다. 이에본질환과기타낭종성질환, 에나멜상피종의 X선사진상에서의대소비를조사한결과, 각화낭성치성종양과에나멜상피종은병변의최대지름이큰증례가치성정각화낭종, 원시성낭종, 함치성낭종과비교시유의차를갖는다수인점을확인하였다. 이조건은진단의스크리닝으로서유용할것으로생각한다. 본검토에서치성정각화낭종은 7증례로소수이지만재발증례는인정되지않았으며, 원시성낭종와함치성낭종을합친재발률은 0.% 로대단히낮았다. 이와비교시각화낭성치성종양의재발률은 5.8% 로확연히높았다. 치료전생검을통해확정진단을받을것을권하는보고도있어 5,8,8, 본연구에서도수술전생검을거쳐확정진단을받은각화낭성치성종양의경우는재발률이높았기때문에근치성의높은치료를실시할필요가있다. 즉, 병변에근접한치아의발치, 보다큰개창의실시, 병변적출후의주위골삭제등을적극적으로시행하는쪽이바람직한것으로생각한다. 또한에나멜상피종의개창반복요법처럼첫번째수술은가급적적출후개방창으로하여뼈의회복을기다린다음두번째수술에서주위골과함께병변을절제하는술식도검토할필요가있다고여겨진다. 또한술후의경과관찰기간에관해서도재발률의정도, 재발시기의관점에서 0년이상의경과관찰은필요하다고하겠다. 한편수술전생검을통해비각화성의함치성낭종과원시성낭종, 정각화성의치성정각화낭종의경우인접치의처리에서도보다보존가능한방향으로진행시켜악골 치아를가능한한온존시키는치료로충분히치유될가능성이높으며, 이와동시에수술후의경과관찰기간도단축가능할것으로생각하지만, 향후증례수를늘려검토해나갈필요가있다. V. 결 어과거 5년간각화낭성치성종양으로진단된단발증례 86증례에대해임상적검토와함께유사악골병변과비교한결과이하의결론을얻게되었다.. 각화낭성치성종양에대하여 ) 발생빈도에성차는없었으며, 초진시연령은 0 0대가많았다. ) 부위는상악 4증례, 하악 45증례였으며, 상악에서는대구치부로부터상악동에걸쳐서, 하악에서는대구치부로부터하악지부가많았다. 6
) 증상으로는종창 (7.6%), 동통 (9.4%) 등이많았고, 무증상 (X선검사를통해우연히발견하는경우 : 4.7%) 도적지않았다. 4) X선소견으로는단방성이다방성에비해약간많았다. 병변과관련이있는매복치는 54.8% 에서인정되었다. 5) 치료법으로는상악에서는적출후폐쇄창, 하악에서는적출후개방창으로한증례가많았지만치료성적에명확한차이는없었다. 6) 재발과 X선소견으로서의단방성 다방성, 매복치아의유무, 크기에관해서는통계학적으로는차이를인정받지못했다. 7) 수술후 년이상의관찰기간을갖는 0증례에대해검토한결과, 재발률은 5.8% 였다. 재발까지의기간은 년 4개월로부터 년 개월로, 0년이상의경과관찰이바람직하다고생각한다.. 각화낭성치성종양과유사병변과의비교 ) X선사진상에서의대소비비교에서각화낭성치성종양과에나멜상피종은치성정각화낭포, 원시성낭종, 함치성낭종과비교시큰병변이차지하는비율이의미있게많았다. ) 각화낭성치성종양 ( 재발률 : 5.8%) 과치성정각화낭종 ( 재발률 : 0.0%) 의재발률에통계학적으로의미있는차이는없었다. 이는치성정각화낭종의증례수가적기때문으로생각되며 (7증례), 이후증례수를늘려검토해갈필요가있다. ) 큰낭종성병변의경우, 생검에서확정진단으로표피가착각화를나타내는각화낭성치성종양은보다근치성의높은수술방식을택하는것이바람직하다고생각한다. References. Barnes L, Eveson JW, Reichart P. World Health Organization classification of tumours, pathology and genetics of tumours of the head and neck. Lyon: International Agency for Research on Cancer; 005:06-7.. Philipsen HP. Keratocysts in the jaws. Tandlaegeblader 956;60: 96-80.. 原田昌和, 山元学. 当科における過去 8 年間の歯原性角化嚢胞症例の検討. 日口外誌 988;4:657-6. 4. Ahlfors E, Larsson A, Sjögren S. The odontogenic keratocyst: a benign cystic tumor? J Oral Maxillofac Surg 984;4:0-9. 5. Shear M. The aggressive nature of the odontogenic keratocyst: is it a benign cystic neoplasm? Part. Clinical and early experimental evidence of aggressive behaviour. Oral Oncol 00;8:9-6. 6. Shear M. The aggressive nature of the odontogenic keratocyst: is it a benign cystic neoplasm? Part. Proliferation and genetic studies. Oral Oncol 00;8:-. 7. Gorlin RJ, Goltz RW. Multiple nevoid basal-cell epithelioma, jaw cysts and bifid rib. A syndrome. N Engl J Med 960;6:908-. 8. Pindborg JJ, Hansen J. Studies on odontogenic cyst epithelium.. clinical and roentgenologic aspects of odontogenic keratocysts. Acta Pathol Microbiol Scand 96;58:8-94. 9. Brannon RB. The odontogenic keratocyst. A clinicopathologic study of cases. Part I. Clinical features. Oral Surg Oral Med Oral Pathol 976;4:54-7. 0. Brannon RB. The odontogenic keratocyst. A clinicopathologic study of cases. Part II. Histologic features. Oral Surg Oral Med Oral Pathol 977;4:-55.. 横林敏夫, 横林康夫. 歯原性角化嚢胞の再発に関する検討. 日口外誌 984;0:8-47.. 岩渕博史, 矢郷香. 歯原性角化嚢胞の角化のタイプによる臨床病理学的相違. 日口外誌 996;4:70-5.. 鵜澤成一, 喜代崎郁子. 歯原性角化嚢胞に関する臨床的研究 再発に関する因子について. 日口外誌 00;49:9-8. 4. 松木謙直, 市原秀記. 歯原性角化嚢胞 9 症例の臨床病理学的検討. 日口外誌 000;46:-4. 5. Myoung H, Hong SP, Hong SD, Lee JI, Lim CY, Choung PH, et al. Odontogenic keratocyst: Review of 56 cases for recurrence and clinicopathologic parameters. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 00;9:8-. 6. Morgan TA, Burton CC, Qian F. A retrospective review of treatment of the odontogenic keratocyst. J Oral Maxillofac Surg 005;6:65-9. 7. Chirapathomsakul D, Sastravaha P, Jansisyanont P. A review of odontogenic keratocysts and the behavior of recurrences. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 006;0:5-9. 8. 飯野光喜, 松田耕策. 歯原性角化嚢胞 4 症例の臨床ならびに病理組織学的検討. 日口外誌 989;5:964-7. 9. 畑毅, 細田超. 歯原性角化嚢胞の臨床病理組織学的検討. 日口外誌 988;4:470-84. 0. Crowley TE, Kaugars GE, Gunsolley JC. Odontogenic keratocysts: a clinical and histologic comparison of the parakeratin and orthokeratin variants. J Oral Maxillofac Surg 99;50:-6.. 武田泰典, 高田隆. WHO による歯原性腫瘍の新たな組織分類とそれに関連する上皮性嚢胞について. 日口外誌 006;5:54-6.. 重松久夫, 鈴木正二. 歯原性角化嚢胞の治療とその再発に関する臨床病理学的検討. 日口外誌 998;44:0-0.. 永峰浩一郎, 江場光芳. 当講座における過去 年間の歯原性角化嚢胞症例の検討. 日口外誌 99;7:85-6. 4. Browne RM. The odontogenic keratocyst. Clinical aspects. Br Dent J 970;8:5-. 5. 榎本昭二, 岩佐俊昭. 原始性嚢胞 (Primordialcysts) の臨床的研究. 日口外誌 977;:-8. 6. Forssell K, Sorvari TE, Oksala E. An analysis of the recurrence of odontogenic keratocysts. Proc Finn Dent Soc 974;70:5-40. 7. Bataineh AB, al Qudah M. Treatment of mandibular odontogenic keratocysts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 998;86:4-7. 8. Brøndum N, Jensen VJ. Recurrence of keratocysts and decompression treatment. A long-term follow-up of forty-four cases. Oral Surg Oral Med Oral Pathol 99;7:65-9. 6