指 導 醫 師 : 林 立 民 醫 師 、 陳 玉 昆 醫 師 、 陳 靜 怡 醫 師 報 告 者 : I N T E R N K 組
吳 郁 畇 、 蔡 沛 倫 、 張 庭 豪 、 龔 立 揚 報 告 日 期 : 2 0 1 4 . 0 6 . 2 4
OM Case Report
General data
Name : 蔡 O 萍
Sex : female
Age : 36 y/o
Native : 台灣
Marital status : single
Attending V.S. : 李坤宗 醫師
First visit : 2014.06.03Chief complaint
Left cheek swelling over 2 months, and left lo wer lip numbness for about one year.Present illness
This 36-year-old female patient suffered from left cheek swelling for two months and left lo wer lip numbness occasionally in the past one year, so she came to our OPD for further exami nation and treatment.Intraoral examination
Site: Tooth 37 mesial aspect to anterior ear area, and from maxilla buccal vestibule to mandible buccal vestibule.
Size:5.0x7.0 cm
Color: Normal mucosa coverage
Surface: Smooth and intact
Consistency: Firm
Shape: Dome, sessile
Palpation: rubbery
Bone expansion: (+)
Tenderness/Pain: (-)
Paresthesia: (+)
Fluctuation (-)
Fixed
Past medical history
Denied any underlying disease
Denied any food or drug allergies
Hospitalization (-)Past dental history
General routine dental treatment
Orthodontic treatment
Attitude to dental treatment : co-operativePersonal history
Risk factor related to malignancy
Alcohol (-)
Betel quid (-)
Cigarette (-)Special oral habits : denied
Radiographic examination
Panorex (2014.06.03)
There is a multilocular well-defined border radiolucency with part ial corticated margin over left mandible angle, with expansion of cor tex. Extending from 36 meisal root to mandible angle, and from 2/3 he ight of ascending ramus to mandible lower border, measuring approxima tely 5.0 x 7.0 cm in diameter. Left mandible canal is being pressed d own, while mental foramen does not affected by the lesion. Root resor ption over tooth 36 distal root and tooth 37 is noted.
Differential diagnosis
Peripheral or Intrabony
Left posterior mandibular area
5 x 7 cm, dome shape, firm consistency, norma l mucosa color
Tenderness (-)
Pain(-)
Lip numbness (+)
Bone expansion(+)Multilocular radiolucence with bony destructio n
→ intrabony lesion
Our case periphera
l intrabony
Mucosal lesion - + -
Induration - + -
Bony expansion + - +-
Cortical bone
destruction + - +-
→intrabony
Peripheral or Intrabony
Inflammation, Cyst or Neoplasm
Our case inflammation
Redness - +
Swelling + +
Local heat - +
pain - +
Due to panorex finding:
Large multilocular RL destruction lesion
→ cyst or neoplam
Cyst or Neoplasm
Our case cyst
Fluctuation - +-
Well defined border + +
Bone expansion + +-
Our case Inflammation
cyst Non-
inflammation cyst
Pain, tenderness - + -
Local heat - + -
Color pink Reddish Pink
Progression slow Fast Slow
Sclerotic margin + - +
Our case Benign Malignance Border Well-defined Well-defined ill-defined
Margin smooth smooth Irregular
Sclerotic margin + + -
Destruction of
cortical margin + +- +
Progressive slow slow Fast
Swelling with
intact epithelium + + -
Pain - - +
induration - - +
→Non-inflammation cyst or benign
tumor
Working diagnosis
1.
Ameloblastoma (conventional type)2.
Keratocystic odontogenic tumor3.
Central giant cell granuloma4.
Odontogenic myxomaAmeloblastoma
Our case Ameloblastoma
Gender Female Equal
Age 36 30~70
Site Mandible (molar
area) Mandible
(molar→ascending ramus)
Paresthesia + Uncommon
Swelling + +
Drainage - +-
Radiography Well-defined, soap bubble
multilocular, corticated margin
Well-defined, unilocular or multilocular,
corticated margin
Bony expansion + +
Teeth
displacement/ root resoprtion
+ +
duration slow slow
Keratocystic odontogenic tumor
Our case KCOT
Gender Female Slight male
Age 36 10~40
Site Mandible (molar
area) Mandible (posterior body and ascending
ramus)
Paresthesia + Pain
Swelling + +
Drainage - +
Radiography Well-defined, soap bubble multilocular,
corticated margin
Well-defined, unilocular or multilocular, corticated margin
Bony expansion + -
Teeth
displacement/ root resoprtion
+ +
duration slow slow
Central giant cell granuloma
Our case Non-
aggressive Aggressive
Gender Female Female
Age 36 <30
Site Mandible (molar
area) Mandible (anterior region)
Paresthesia + - Pain
Swelling + - +
Drainage - - -
Radiography Well-defined, soap bubble
multilocular, corticated margin
Well-defined, unilocular or multilocular, non-
corticated margin
Bony expansion + - +
Teeth
displacement/ root resoprtion
+ - +
duration slow slow rapid
Odontogenic myxoma
Our case Odontogenic myxoma
Gender Female Slight female
Age 36 10~50 (mean 25~30)
Site Mandible (molar
area) Max.:Man.=3:4 or3:7 (tooth-bearing areas)
Paresthesia + Rare
Swelling + -
Drainage - -
Radiography Well-defined, soap bubble multilocular,
corticated margin
Often well-defined, unilocular or multilocular, may
with corticated margin
Bony expansion + +
Teeth
displacement/ root resoprtion
+ +
duration slow slow
CLINICAL IMPRESSION
Ameloblastoma, acanthomatous type, left mandib ular angle to ramusTreatment plan
1. aspiration with 19G needle under block anes thesia --> yellowish clear fluid --> culture x I
2. complicated extraction of tooth 37 and inci sional biopsy was done from tooth 37 wound, H- P exam (hard x1 --> tooth 37 x1 ; soft x2 -->wall of lesion x1 ; distal gingiva of tooth 37 x1), N/S irrigation, placed one decompression (Marsupialization) device with suture (1 sitic h), gauze packing
3.check CT scan.CT (2014.06.09)
An unilocular expansile lesion of tooth-bearing portion of jaw at le ft mandibular body (5.7x2.7x3.2 cm) with expansion of cortex, homoge neous tumor matrix and dislodgment of teeth is noted. Small soft t issue nodule was not identified in the neck spaces.The paranasal sin uses were clear.The orbits appeared unremarkable.
The skull base, including the foramina lacerum and ovale, were not e roded.
HISTO-PATHOLOGIC EXAMINATION
組織名稱: Mandible, left
臨床診斷: Odontogenic tumor
腫瘤代碼:
Pathologic diagnosis:
Bone, mandible, tooth 37, left, extraction, tooth fragment Gross Examination:
Additional report of decalcified hard tissue specimen for section A.
Microscopic Examination:
Microscopically, it shows tooth fragment in section A
.
組織名稱: Mandible lesion wall; gingiva 37 distal
臨床診斷: Odontogenic tumor
腫瘤代碼:
Pathologic diagnosis:
Bone, mandible lesion wall, left, ameloblastoma, acanthomatus change, O ral cavity, gingiva 37 distal, lower left, incision, minimal histological chan ge
Gross Examination:
The specimen submitted consists of 2 soft tissue fragments and 1 hard tissu e fragment in 3 bottles,measuring up to 1.5 x 1.2 x 1.0 cm in size, fixed in f ormalin. Grossly, they are light brown and white in color and bony hard and r ubbery in consistency.
All for section and labeled as follows: Jar 0.
A: tooth 37
B:lesion wall (soft) C: distal gingiva 37 Microscopic Examination:
The slides contain two identical groups of irregular-shaped soft tissue speci mens.Microscopically, it shows ameloblastoma, acanthomatus change in section B , minimal histological change in section C.
─ M A R S U P I A L I Z A T I O N
Discussion
Introduction
= Partsch operation
Create a surgical window in the wall of the cyst
Evacuate the contents
Maintain continuity between cyst and the ora l cavity, maxillary sinus, or nasal cavityIntroduction
Cyst is only removed a piece to produce the wi ndow → the remaining of the cyst left in situ
Benefits :
Decrease intra-cystic pressure
Promote shrinkage of the cyst and bone fill
Use :
As the sole therapy
As a preliminary step when with enucleation
Indication
When enucleation may cause injury or unnecessa ry sacrifice
When surgical approach is difficult
Assistance in eruption of teeth
Alternative to enucleation for p’t with ill h ealth
Very large cysts → marsupialization firstAdvantages
Simple
Spare vital structures from damageDisadvantages
Pathologic tissue is left in situ , without th orough histologic examination
p’t inconvenience: the cavity traps food deb risirrigate the cavity several times every day wi th a syringe.
Technique
(Prophylactic adminstration of systemic antibiotic s)
Anesthetization
Aspirate comfirms the presumptive diagnosis of cyst
Incision: circular or elliptical large window(1 cm ↑)
thin bone v.s. thick bone
Remove a window of lining pathologic examination
Contents of cyst are evacuated
If cystic lining is thick enoughsuture to oral mucosa
otherwise, cavity packed with gauze with tincture of bezo in or antibiotic ointment for 10 to14 days
Marsupialization
Rarly used as sole form
In most instances , enucleation is done after Marsupialization .
In dentigerous cyst , no residual cyst may exi st to be remeoved once the tooth has erupted i nto the dental arch.
If futher surgery is contraindicated, marsupia lization can be performed alone without future enucleation.The cavity may or may not obliterate totally
Enucleation after marsupialization
Introduction
Enucleation is frequently done after marsupial ization
Combined approach :
Reduce morbidity
Accelerate complete healing of the defect
Indication
Same as indications listed for marsupializatio n alone
When the cyst does not totally obliterate afte r marsupialization
When the p’t find difficult to cleanAdvantages
Marsupialization phase: simple procedure that spare adjacent vital structures
Enucleation phase: the entire lesion becomes a vailable for histological examination
The development of a thickened cystic lining secondary enucleation easier
Disadvantages
The total cyst is not removed initially for p athologic examination.
However, subsequent enucleation may then dete ct any occult pathologic condition.Technique
1.
Marsupialization of the cyst2.
Osseous healing3.
Cyst decreased to complete surgical removal4.
Enucleation (when bone is covering adjacent v ital structure: prevents injury and jaw fract ure)Technique
5.
common epithelial lining (epithelial bridge) must be removed completely with the cystic li ning an elliptical incision completely enc ircling the window must be made down to sound bone stripping the cyst from the window to cystic cavity.Technique
6.
Cyst enucleated oral soft tissue must be c losed. may require soft tissue flap7.
cannot close completely packing (strip gau ze and antibiotic ointment). Change repeated ly until granulation tissue has obliterated t he opening and epithelial closed over the wou ndMarsupialization of unicystic ameloblastoma: A conservative approach for aggressive odontogenic tum ors
Case 1
•
A 17 year-old male patient a painless swellin g in the right mandibular premolar region wit hout any sign of sensory impairment•
Panoramic view of the patient revealed a well defined radiolucent area extending from the r ight lateral incisor to the distal root of th e first molar toothTreatment
•
Under local anesthesia, an incisional biopsy was performed→ luminal type UA•
The lesion was decompressed between two premo lar teeth•
Scheduled for radiographic follow-up after an interval of three monthsTreatment
•
Marsupialization•
Enucleated with peripheral ostectomy (18month s later)•
The apical portions of the teeth were resecte d•
Allogenic bone graft material was placed in t he cavityPost-treatment
•
No signs of recurrence even at 30 months of follow-upCase2
•
A 52 year old woman with healthy edentulous•
Asymptomatic swelling on her left mandible•
X-ray finding→A well-defined unilocular radi olucent on the left mandibular ramus with an unerupted third molar•
Histopathologic findings→granular UA with mu ral invasion
Treatment
•
Decompression of the lesion with incisional b iopsy•
Acrylic obturator was made•
Marsupialization•
Impacted tooth and the lesion was enucleated with peripheral ostectomy (18 months later)Post-treatment
•
The lesion was completely healed without any sign of recurrence 2 years post the complete enucleation procedureDiscussion
•
Marsupialization→reducing the size of the le sion to ease total removal•
UA with aggressive histologic behavior might be successfully treated with marsupialization with subsequent enucleation•
This approach can be considered as an alterna tive to resectionReference
1. Sampson DE, Pogrel MA. Management of mandibular ameloblastoma: the clinical basis for a treatment algorithm. J Oral Maxillofac Surg 1999;57:1074-7
2. Robinson L, Martinez MG. Unicystic ameloblastoma: A prognostically distinct entity. Cancer 1977;40:2278-85.
3. Lau SL, Samman N. Recurrence related to treatment modalities of unicsytic am eloblastoma: a systematic review. Int J Oral Maxillofac Surg 2006;35:681-90.
4. Ackermann GL, Altini M, Shear M. The unicystic ameloblastoma: A clinicopatho logical study of 57 cases. J Oral Pathol 1988;17:541-6.
5. Furuki Y, Fujita M, Mitsugi M, Tanimoto K, Yoshiga K, Wada T. A radiographic study of recurrent unicystic ameloblastoma following marsupialization. Repor t of three cases. Dentomaxillofac Radiol 1997;26:214-8
6. Abaza NA, Gold L, Lally E. Granular cell odontogenic cyst: A unicystic amelo blastoma with late recurrence as follicular ameloblastoma. J Oral Maxillofac Surg 1989;47:168-75.
7. Contemporary Oral and Maxillofacial Surgery, 6th edition, part V: management of oral pathologic lesions, P.454-458
醫學倫理討論
Tom Beauchamp &James Childress 六大原則 - 1979
1. 行善原則 (Beneficence) :亦即醫師要盡其所能延長病人之生命且 減輕病人之痛苦。
2. 誠信原則 (Veractity) :亦即醫師對其病人有「以誠信相對待」的 義務。
3. 自主原則 (Autonomy) :亦即病患對其己身之診療決定的自主權必 須得到醫師的尊重。
4. 不傷害原則 (Nonmaleficence) :亦即醫師要盡其所能避免病人承 受不必要的身心傷害。
5. 保密原則 (Confidentiality) ,亦即醫師對病人的病情負有保密的 責任。
6. 公義原則 (Justice) ,亦即醫師在面對有限的醫療資源時,應以社 會公平、正義的考量來協助合理分配此醫療資源給真正最需要它的人
。
行善原則
做了 Decompression 後是否有減輕 p’t 的脹痛感?或是使 p’t 更不舒服?
→ 有減輕 swelling 的情形,且沒有造成 p’t 更不舒服
。
誠信原則
是否有清楚的向病人說明清楚疾病病程、治療計畫、預後、風險?
對於病人疾病嚴重程度是否有誠實的通知,盡到告知的義務?
→ 已告知病人。
自主原則
充分說明病情及治療計畫、風險之後,是否有讓病人充分自主的選擇治療計畫?
→ 已充分說明。
在做麻醉以前,是否有說明完整之後再請病人自主的簽名同意?
→ 已充分說明。
不傷害原則
手術過程中,是否有造成不必要醫源性的傷害?→ 尚未手術。
是否有詳實的說明治療計畫,並讓病人對於治療計畫沒有疑問 ?
→ 減輕病人的心理壓力也是一種不傷害的原則。
保密原則
告知的對象
1. 本人為原則
2. 病人未明示反對時,亦得告知其配偶與親屬 3. 病人為未成年人時,亦須告知其法定代理人
4. 若病人意識不清或無決定能力 , 應須告知其法定代 理人、配偶、親屬或關係人
5. 病人得以書面敘明僅向特定之人告知或對特定對象 不予告知
公義原則
手術的必要性?醫學倫理總結
在病例撰寫方面 ( 病兆描述 , 治療計畫 , 病人態度 ) 應書寫詳盡, 使治療過程有詳實的記錄及治療順利。