A case of dentigerous cyst

報告人: Int. J組 林柏穎 施柏穎 林可蔓 王盛弘 20150526 指導醫師: 陳玉昆主任 林立民教授

OM Case Report

A case of dentigerous cyst

General data

 Name: X X X

 Sex: Male

 Age: 54

 Native: 高雄

 Marital status: Married

 First visit: 104.04.29

Attending staff: X X X醫師

Chief Complaint

 Referred from 802 hospital Dr. X X X for

mass over left mandibular body area for a period.

Present illness

 802 hospital

-This 54 y/o male complaint about a mass over left

mandible and was referred from 802 hospital Dr. X X X for mass over left mandibular body area for a period.

Past History

 Past Medical History

 Drug and food allergy: (-)

 Systemic disease: DM(+), HbA1c =7

 Hospitalization: (+),乳突瘤

 Surgery under GA: (+)

 Past Dental History

 General routine dental treatment

Attitude to dental treatment: co-operative

Personal History

 Cigarette smoking (+)

 Alcohol drinking (-)

 Betel-quid chewing (-)

Extraoral examination

 Facial asymmetry: (+),outer skin with mass over auricular area

 Swelling: (-)

 Fluctuation(+)

 Tenderness(-)

Intraoral examination

 Lesion:

Overlying mucosa: Normal

Expansion of mandible (+), ascending ramus deformation

Palpation pain (-)

 Lower lip numbness (-)

X-ray finding

CBCT

CBCT

X-ray finding

 Lesion:

 Site:

Left molar region up to ramus of mandible

 Maximum dimension: 4 x 3 x cm

 Shape: ovoid

 Radiodensity: unilocular radiolucency

104.04.29

X-ray finding

 Border: well-defined with corticated margin

 Internal structure: unilocular radiolucency image

 Effect on surrounding structure: displacement and inverted embedded tooth 38, surrounding the left mandibular canal

Differential diagnosis

Differential diagnosis

Peripheral or Intrabony?

Our case Peripheral Intrabony

Mucosal lesion - + -

Induration - + -

Bony

expansion - - +/-

Cortical bone

destruction - - +/-

Inflammation, Cyst or Neoplasm?

Our case Inflammation

Redness - +

Swelling - +

Local heat - +

Pain - +

→ Cyst or Neoplasm

Cyst or Neoplasm?

Our case Cyst

Aspiration Unknown +

Fluctuation + +/-

Well-defined

border + +

Bony 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 Malignant Border Well-defined Well-defined Ill-defined

Sclerotic margin + + -

Destruction of

cortical margin - +/- +

Pain - - +

Induration - - +

Swelling with

intact epithelium + + -

Progress Slow Slow Fast

Metastasis Unknown - +/-

→ Non-inflammation cyst or Benign

Differential diagnosis



Well –defined



Unilocular radilucency



Posterior mandible



Old age

Differential diagnosis

 Dentigerous cyst

 Odontogenic keratocyst

 Unicystic ameloblastoma

Working diagnosis

Our case Dentigerous cyst

sex male Male >female

Age 54 10~30

Site Left mandibular molar area Mandible (3 rd molar)

S/S no Usually asymptom, swelling or

pain if infected,

size 4x3 cm in diameter Average size 3cm~4cm

X-ray features well-defined unilocular ovoid shaped radiolucency with a

sclerotic margins

well-defined, smooth, unilocular, corticated margin,impacted tooth

Our case Odontogenic keratocyst

sex male male

Age 54 10~40 yrs(60%)

Site Left mandibular molar area

Posterior Mandibular, Mostly molar area(49%)

S/S no usually asymptomatic

Large: pain, swelling or drainage.

size 4x3 cm in diameter varies

X-ray features well-defined unilocular ovoid shaped radiolucency

with a sclerotic margins

Well-defined unilocular

radiolucent with smooth and often corticated margin

25~40% unerupted tooth involved Root resorption is less common Clinical

features

Color: pink Pain(-)

usually asymptomatic

Our case Unicystic ameloblastoma

sex male none

Age 54 Young age, ave 23

Site Right mandibular molar area Post .Mandible

S/S no nil

size 4x3 cm in diameter Average size 4.3cm~6.3cm X-ray features well-defined unilocular ovoid

shaped radiolucency with a sclerotic margins

well-defined, smooth, unilocular ,corticated

margin Clinical

features

Color: pink Pain(-)

Color: pink Pain(-)

Clinical Impression

1.

Dentigerous cyst, tooth 38

Treatment Course

•

104.05.18



Tooth 38 complicated odontoectomy + Incisional biopsy + Decompression

button placement insertion



103.05.21:



H-p report: Dentigerous cyst

27

Treatment Course

 104.05.20:

 Follow up, N/S irrigation and BI application

 104.05.25:

 Follow up, N/S irrigation and BI application

28

Discussion

Outcome of a Dentigerous Cyst following Decompression using a Removable Appliance: A Case Report OHDM-vol.13-No.1-March 2014

Basak Durmus, Barhan Pekel, Faysal Ugurlu, Ilknur Tanboga

Introduction

 Dentigerous cysts develop around the unerupted tooth, in the absence of an inflammatory stimulus .

 Occur frequently in the lower jaws of patients aged 6–12 years.



Reduced enamel epithelium derived from the tooth-forming organ



Radiographic - it appears as a round or

void, well-defined unilocular

 In this case, managing a large dentigerous cyst in a child using a customised

Decompression removable appliance.

Case

 A 7-year-old female, in good general health with no significant medical history.

 Revealed mixed dentition, swelling in the left mandibular region and tenderness over lower left second primary molar with an

 well-defined unilocular radiolucency

approximately 3×3 cm in size under the primary left mandibular molar area

extending to the lower border of the mandible.

 From distal side of the tooth 34 to the

 2 cm long, 2.5 mm wide hole over the cyst from the lower left second primary molar.

 the tooth 75 and tooth 35, to which the

cystic lumen was attached, were extracted.

 Histopathology revealed

- stratified squamous non-keratinized epithelium

with a fibrous connective tissue&

inflammatory cell.

 Dentigerous cyst was confirmed

 Resin projection was adjusted to fit the socket of the extracted tooth

 Antibiotics and analgesics & irrigation was needed.

 6-monthes follow up

 The bone density increased and bone trabeculation was seen at the end of the first year .

 2-years follow up

Discussion

 Marsupialization or decompression is a

conservative technique that attempts to relieve the intracystic pressure by creating an accessory cavity.

 The conservative approach needs a longer healing period and good patient cooperation.

Discussion

 It has marked advantages:

it is minimally invasive

there are no severe complications (infection)

it conserves bone and important anatomic structures(inferior alveolar nerve and

mandibular canal)

Discussion



In comparison with traditional

decompression techniques, this case

used a customised appliance.

Discussion

 It was easy to apply.

 The patient or his/her parents can irrigate the area

 Daily recalls are not necessary.

 It can be converted into a space retainer to prevent space loss

Discussion

 The resin projection of the appliance was used to decompress the cystic lesion and to prevent the entry of food debris into the cyst cavity. It also prevented the formation of fibrous tissues.

 The appliance was not used only as an obturator;

it also served as a space maintainer.

Discussion

 The cooperation of the patient and parents was fundamental to the success of the treatment, as they complied with the postoperative oral hygiene measures fully.

Conclusion

 Conservative treatment is a useful

treatment for an extensive dentigerous cyst.

 Depending on the size and location of the dentigerous cyst, the age of the patient, and relationship to vital structures

Reference

 Oral and maxillofacial pathology ,Third edition, Neville Damn Allen Bouquot

 Outcome of a Dentigerous Cyst following

Decompression using a Removable Appliance: A Case Report, Basak Durmus, Barhan Pekel, Faysal Ugurlu, Ilknur Tanboga

醫學倫理討論

醫學倫理

 生命的神聖性(Sanctity of life)

 六大原則

Tom Beauchamp &James Childress 六大原則 - 1979

1. 行善原則(Beneficence)：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):醫師對其病人有「以誠信相對待」的義務。

3. 自主原則(Autonomy):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):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):醫師對病人的病情負有保密的責任。

6. 公義原則(Justice): 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

 Decompression 的做法能降低二次手術危險

誠信原則

 對於患者的疾病嚴重程度是否有確實地通知，

盡到告知的義務？

 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？

→皆以已告知病人後，經同意才進行手術。

自主原則

 充分說明病情及治療計畫、風險之後，是否

有讓病人充分自主地選擇治療計畫？

→病人及家屬選擇並同意醫師的建議。

 在做全身麻醉以前，是否有說明完整之後再

請病人自主的簽名同意？

→已充分說明並與家屬溝通。

不傷害原則

 是否有先完整瞭解病人的病史?

→治療前有完整蒐集病史資料，並與病患溝 通後擬定進一步的治療計畫

 手術過程中，是否有造成不必要的醫源性的

傷害？

→沒有不必要醫源性傷害。

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？

→Dentigerous cyst最佳的治療方式是 sugical excision，將病灶完整的清除

(enucleation)才能將復發率(recurrence rate) 降到最低。Decompression 降低手術難度及 併發症

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

THANK YOU FOR YOUR ATTENTION!