Case Report

(1)

報告人: INT. H組 陳佳琪 盛毓為林典芸蔡文聖 指導醫師: 陳玉昆主任林立民教授

Case Report

(2)

General data

• Name: O O O

• Sex: Male

• Age: 13

• Native: 高雄

• Marital status: unmarried

• First visit: 103.08.12

• Attending staff: O O O醫師

(3)

Chief Complaint

• Referred from local dental clinic for

radiolucent image on right mandible molar area.

103.08.12 3

(4)

Present illness

• Local dental clinic

– Went to LDC for orthodontic treatment. The doctor took panoramic x-ray and noticed a

radiolucent image on un-erupted teeth 47, 48 area. Therefore, the doctor suggested patient to our OS OPD for further evaluation and

treatment.

4

(5)

Past History

• Past Medical History

– Drug and food allergy: (-) – Systemic disease: (-)

– Hospitalization: (-)

– Surgery under GA: (-)

• Past Dental History

– General routine dental treatment

– Attitude to dental treatment: co-operative

(6)

Personal History

• Denied any other dental oral habits

(7)

Extraoral examination

• Facial asymmetry: (-)

• Swelling: (-)

• MMO: 46mm

7

(8)

Intraoral examination

• Lesion:

– Overlying mucosa: normal – Expansion of mandible: (-) – Pain history: (-)

– Palpation pain: (-)

• Lower lip numbness (-)

103.08.12 8

(9)

X-ray finding

103.08.12 9

(10)

X-ray finding

• Lesion:

– Site:

right molar region of mandible

– Size: 23.8 X 20 mm – Shape: ovoid

– Radiodensity: radiolucency

– Border: well-defined with corticated margin – Internal structure: unilocular

– Effect on surrounding structure: displacement and impaction of teeth 47,48

downward displacement of mandibular canal ¹⁰

103.08.12

(11)

Differential diagnosis

11

(12)

Peripheral or Intrabony?

Our case Peripheral Intrabony Mucosal

lesion - + -

Induration Unknown + -

Bony

expansion - - +/-

Cortical bone

destruction - - +/-

→ Intrabony

¹²

(13)

Inflammation, Cyst or Neoplasm?

Our case Inflammation

Redness - +

Swelling - +

Local heat - +

Pain - +

→ Cyst or Neoplasm

13

(14)

Cyst or Neoplasm?

Our case Cyst

Aspiration Unknown +

Fluctuation - +/-

Well-defined

border + +

Bony expansion - +/-

14

(15)

Our case Inflammation cyst

inflammation Non- cyst

Pain,

tenderness - + -

Local heat - + -

Color Pink Reddish Pink

Progression Slow Fast Slow

Sclerotic

margin + - +

→ Non-inflammation cyst

15

(16)

Our case Benign Malignant Border Well-defined Well-defined Ill-defined

Sclerotic margin + + -

Destruction of

cortical margin - +/- +

Pain - - +

Induration Unknown - +

Swelling with intact

epithelium + + -

Progress Slow Slow Fast

Metastasis Unknown - +/-

→ Non-inflammation cyst or Benign tumor

16

(17)

Differential diagnosis

• Well –defined

• Unilocular radilucency

• Posterior mandible

• Young age

17

(18)

Differential diagnosis

• Unicystic ameloblastoma

• Dentigerous cyst

• odontogenic keratocyst

• Odontogenic myxoma

18

(19)

Working diagnosis

Our case Unicystic amelobalstoma

sex male none

Age 13 Young age, ave 23

Site Right mandibular molar area Post .Mandible

S/S no nil

size 2.3x2 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(-)

19

(20)

Our case Dentigerous cyst

sex male Male >female

Age 13 10~30

Site Right mandibular molar area Mandible (3 rd molar)

S/S no Usually asymptom,

swelling or pain if infected,

size 2.3x2 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 Clinical

Pain(-) Color: pink

Pain(-)

20

(21)

Our case Odontogenic keratocyst

sex male male

Age 13 10~40 yrs(60%)

Site Right mandibular molar

area Posterior Mandibular,

Mostly molar area(49%)

S/S no usually asymptomatic

Large: pain, swelling or drainage.

size 2.3x2 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

Pain(-) usually asymptomatic

others nil Seldom bone expansion ²¹

(22)

Our case Odontogenic myxoma

sex male None

Age 13 young adult,(25~30y/o)

Site Right mandibular molar

area Post. Mandible

S/S no asymptomatic

size 2.3x2 cm in diameter variable X-ray

features well-defined unilocular ovoid shaped radiolucency

with a sclerotic margins

Unilocular or multiocular radiolucency；irregular or scalloped margin；Larger lesions :painless expansion of the involved bone.

Clinical

Pain(-) asymptomatic others mild buccal & lingual bony

expansion May displace or cause

resorption of the teeth ²²

(23)

Clinical Impression

1. Ameloblastoma 2. Dentigerous cyst

23

(24)

Treatment Course

• 103.08.12:

 incisional biopsy & decompression button insertion

24

(25)

• 103.08.18:

 H-p report: unicystic ameloblastoma

• 103.08.23, 103.09.16, 103.11.11, 104.01.16

 Follow up and N/S irrigation

25

Treatment Course

Size: 23.8 X 20 mm 103.08.12 103.11.11

Size: 22.4 X 15.4 mm 104.02.04

Size: 21.3 X 11.7 mm

(26)

Pre-operation treatment

• 103.08.12

– Size: 23.8 X 20 mm

• 104.02.04

– Size: 21.3 X 11.7 mm – Tooth movement

– Lower border bone

density ↑ ²⁶

(27)

• 104.02.04:

 Follow up and examination

 Arranged operation under GA on 104.02.13

27

Treatment Course

103.08.12 104.02.07

(28)

Treatment plan

• Operation under GA on 104.02.13:

– Excision + bone trimmy + tooth 38,47,48 surgical extraction

28

(29)

Post-operation x-ray

104.02.14 29

(30)

H-P report

• Pathologic diagnosis:

– Bone, mandible, tooth 48 apical area, excision, ameloblastoma follicular

30

(31)

Treatment of an extensive unicystic ameloblastoma in a

7-year-old child: the best approach?

Discussion-

31

(32)

• Introduction

• Case report

• Discussion

32

(33)

Introduction

• Ameloblastoma is a benign, locally-invasive neoplasm that consists of proliferating

odontogenic epithelium.

• Unicystic ameloblastomas

– relatively younger age

– typically unilocular on radiography – macroscopically cystic in nature

– respond better to conservative treatment

• In children resection causes important

functional and aesthetic damage as a result of alterations to craniofacial development.

33

(34)

Case report

• Age: 7

• Sex: female

• Site: right body and ramus of the mandible

• Symptom : pain(-), tenderness(-),

dysphagia(-), dysphonia(-), dyspnoea(-), trauma(-)

34

(35)

Case report

• On examination there was a large, well- circumscribed mass in the right body and ramus of the mandible, covered with

normal mucosa, which measured 11 × 6

× 4 cm. There were no local skin

changes, and palpation indicated a well- circumscribed, painless, and hard lesion.

35

(36)

Case report

• a well-defined, unilocular, hypodense lesion that extended from the posterior body to the right condyle .

36

(37)

Case report

• needle aspiration of which produced a yellowish liquid.

37

(38)

Case report

• Provisional diagnosis: cystic lesion

• Treatment: Marsupialisation

– considering the extent of the lesion and involvement of the condyle.

– Under local anaesthesia, fragments of the

mucosa and cystic capsule were removed and the remainder was sutured around the entire surgical window to maintain a permanent

communication between the lumen and the oral cavity.

38

(39)

Case report

• Histopathological examination:

• cystic lining with preameloblast-like tall columnar cells in the basal layer.

• There was intraluminal proliferation of the

odontogenic epithelium in a plexiform pattern

• Diagnosis: Unicystic ameloblastoma

39

(40)

Case report

• Twenty months after marsupialisation

– her facial asymmetry had regressed

– signs of remodelling of the mandibular bone

• Under general anaesthesia and through an intraoral approach the remainder of the lesion was completely enucleated, with peripheral osteotomy to ensure complete removal of the margins.

• No adjuvant treatment was given

40

(41)

Case report

41

(42)

Discussion

• The treatment of unicystic ameloblastoma – Radical treatment : resection of the lesion

followed by insertion of reconstructive plates – Condylar prosthesis

– Resection of the mandibular condyle in children can cause appreciable dentofacial

deformities,which may result in impairment of mastication, swallowing, speech, and facial

symmetry, which directly influences their quality of life.

42

(43)

Discussion

• The treatment of unicystic ameloblastoma

– Conservative treatment:

• enucleation followed by application of Carnoy’s solution

• marsupialisation followed by enucleation

– Marsupialisation can be effective, as it preserves the mandibular contour and growth, particularly when the condyle is affected by tumour.

– In this case the mandible started to remodel by 36 months, and there were no signs of

recurrence^.

43

(44)

Discussion

• Lau and Samman reported that the recurrence rates for unicystic ameloblastomas

– 3.6% after resection

– 30.5%after enucleation alone

– 16% after enucleation followed by application of Carnoy’s solution

– 18% after marsupialisation with or without further treatment

44

(45)

Discussion

• Seintou et al reported a recurrence rate – 29.4% after enucleation or excision

– several other series have shown that resection is the treatment followed by the lowest recurrence rate

• However, the recurrence rates after marsupialisation cannot be considered to be high, and the

management is less invasive.

• The mean period to recurrence reported by some

studies is five years, which suggests that all patients should be followed up in the longterm.

45

(46)

Discussion

• Resection seems to be excessive for

unicystic ameloblastoma, which behaves much better than the solid variant, and in children the conservative approach offers good aesthetic results and maintains their craniofacial development.

• The question that remains is whether the treatment that offers the lowest rate of

recurrence is the best for children.

46

(47)

Management of unicystic ameloblastoma of the

mandible in a 5-year old child

Ongkila Bhutia, Ajoy Roychoudhury, Ankit Arora, and Saumya Mallick Natl J Maxillofac Surg. 2013 Jul-Dec; 4(2): 232–234.

Discussion-

47

(48)

• Unicystic ameloblastoma (UA) was first

described by Robinson and Martinez in 1977 as a special type of ameloblastoma

• rarely seen in first decade

• usually appears very similar to a non-neoplastic odontogenic cyst and is frequently clinically

misdiagnosed as dentigerous cyst

• histological confirmation is mandatory

• Needs different treatment approach and long term follow-up due to its chances of recurrence

Introduction

48

(49)

• Unicystic ameloblastoma (UA) was first described by Robinson and Martinez in 1977 as a special type of ameloblastoma

Introduction

49

(50)

• A 5-year-old boy presented to our unit Center for Dental Education and

Research, All India Institute of Medical Sciences, New Delhi, India

• Chief complaint: painless hard swelling in the lower chin region of 3 months duration

Case report

50

(51)

Extra oral examination

• facial asymmetry with diffuse swelling over the chin region

• Swelling was found to be approximately 2 cm × 2 cm in size

• skin was normal in color and texture with no evidence of sinus/fistula

51

(52)

Intra oral examination

• adequate mouth opening with intact deciduous dentition

• Swelling was extended from right deciduous molar to left canine

• Mucosa overlying was normal in color

• Swelling was non-tender, non-pulsatile, bony hard, non- fluctuant, non-compressible on palpation

• Expansion of both, buccal as well as lingual cortical plates

• aspiration from the swelling yielded cystic color fluid

52

(53)

Panoramic radiographic

• unilocular well-defined radiolucent lesion extending from lower deciduous first

mandibular molar to right lower canine with evidence of roots resorption

53

(54)

Treatment

• made the provisional diagnosis of UA

• Enucleation of the cyst with extraction of the involved teeth followed by application of

Carnoy's solution for 3 min over the cavity was planned under general anesthesia (GA)

• Patient has been on regular follow-up since 2 years, patient is doing well with no signs of recurrence

54

(55)

Discussion

• UA is considered a variant of the solid or

multicystic ameloblastoma, accounting for 6% to 15% of all intra osseous ameloblastomas

• difficult to distinguish dentigerous cysts from UA clinically

• Presence of lingual cortical plate expansion, cystic fluid on aspiration and presence of root resorption of teeth in panoramic radiograph

helped us in making the preoperative diagnosis of UA over the dentigerous cyst without

incisional biopsy ⁵⁵

(56)

Discussion

• Enucleation alone yielded the highest recurrence rate among all treatments

• Marsupialization together with other

treatments resulted in an 18% of recurrence rate

• Enucleation with application of Carnoy's

solution and the extraction of closely related adjacent teeth has resulted in a recurrence rate of 16%

56

(57)

Discussion

• The recurrence rate could even lower than reported, if the closely related teeth with

tumor are extracted

• To preserve the tooth without damage, tumor remnants may be left around the tooth apex or root and these may lead to recurrence

57

(58)

Carnoy's solution

• is a fixative composed of 60% ethanol,

30% chloroform and 10% glacial acetic acid

• The success of the application of Carnoy's

• solution after enucleation was thought to be due to both its penetration and fixation action

• apply the solution with cotton applicators or ribbon gauze for 3-5 min, rinse the bony

cavity

58

(59)

醫學倫理討論

59

(60)

醫學倫理

• 生命的神聖性(Sanctity of life)

• 六大原則

(61)

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。

61

(62)

行善原則

• Decompression 的必要性?

62

(63)

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。

63

(64)

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。

64

(65)

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。

65

(66)

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

66

(67)

公義原則

• 手術的必要性？

→unicystic ameloblastoma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。

67

(68)

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

68

(69)

THANK YOU FOR YOUR ATTENTION!

69