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(1)

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

(2)

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 : 2014.06.03

(3)

Chief complaint

Left cheek swelling over 2 months, and left lo wer lip numbness for about one year.

(4)

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.

(5)

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

(6)

Past medical history

Denied any underlying disease

Denied any food or drug allergies

Hospitalization (-)

(7)

Past dental history

General routine dental treatment

Orthodontic treatment

Attitude to dental treatment : co-operative

(8)

Personal history

Risk factor related to malignancy

Alcohol (-)

Betel quid (-)

Cigarette (-)

Special oral habits : denied

(9)

Radiographic examination

(10)

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.

(11)

Differential diagnosis

(12)

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(+)

(13)

Multilocular radiolucence with bony destructio n

→ intrabony lesion

(14)

Our case periphera

l intrabony

Mucosal lesion - + -

Induration - + -

Bony expansion + - +-

Cortical bone

destruction + - +-

→intrabony

Peripheral or Intrabony

(15)

Inflammation, Cyst or Neoplasm

Our case inflammation

Redness - +

Swelling + +

Local heat - +

pain - +

Due to panorex finding:

Large multilocular RL destruction lesion

→ cyst or neoplam

(16)

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 + - +

(17)

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

(18)

Working diagnosis

1.

Ameloblastoma (conventional type)

2.

Keratocystic odontogenic tumor

3.

Central giant cell granuloma

4.

Odontogenic myxoma

(19)

Ameloblastoma

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

(20)

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

(21)

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

(22)

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

(23)

CLINICAL IMPRESSION

Ameloblastoma, acanthomatous type, left mandib ular angle to ramus

(24)

Treatment 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.

(25)

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.

(26)

HISTO-PATHOLOGIC EXAMINATION

(27)

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

.

(28)

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.

(29)

─ M A R S U P I A L I Z A T I O N

Discussion

(30)

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 cavity

(31)

Introduction

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

(32)

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 first

(33)

Advantages

Simple

Spare vital structures from damage

(34)

Disadvantages

Pathologic tissue is left in situ , without th orough histologic examination

p’t inconvenience: the cavity traps food deb ris

irrigate the cavity several times every day wi th a syringe.

(35)

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

(36)

Contents of cyst are evacuated

If cystic lining is thick enoughsuture to oral mucosa

otherwise, cavity packed with gauze with tincture of bezo in or antibiotic ointment for 10 to14 days

(37)

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

(38)

Enucleation after marsupialization

(39)

Introduction

Enucleation is frequently done after marsupial ization

Combined approach :

Reduce morbidity

Accelerate complete healing of the defect

(40)

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 clean

(41)

Advantages

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

(42)

Disadvantages

The total cyst is not removed initially for p athologic examination.

However, subsequent enucleation may then dete ct any occult pathologic condition.

(43)

Technique

1.

Marsupialization of the cyst

2.

Osseous healing

3.

Cyst decreased to complete surgical removal

4.

Enucleation (when bone is covering adjacent v ital structure: prevents injury and jaw fract ure)

(44)

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.

(45)

Technique

6.

Cyst enucleated  oral soft tissue must be c losed. may require soft tissue flap

7.

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 nd

(46)

Marsupialization of unicystic ameloblastoma: A conservative approach for aggressive odontogenic tum ors

(47)

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 tooth

(48)
(49)

Treatment

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 months

(50)

Treatment

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 cavity

(51)

Post-treatment

 No signs of recurrence even at 30 months of follow-up

(52)

Case2

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

 

(53)

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)

(54)

Post-treatment

 The lesion was completely healed without any sign of recurrence 2 years post the complete enucleation procedure

(55)

Discussion

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 resection

(56)

Reference

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

(57)

醫學倫理討論

(58)

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

(59)

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

(60)

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。

(61)

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。

(62)

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。

(63)

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

(64)

公義原則

手術的必要性?

(65)

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。

在進行治療之前 , 須請病人簽屬同意書

應在不違反醫學倫理的原則之下進行治療的行為

(66)

THANK YOU FOR YOUR ATTENTION

!

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