口腔病理診斷科

(1)

口腔病理診斷科

Case Report

指導老師林立民教授陳玉昆主任王文岑醫師陳靜怡醫師報告組別 D91 實習I組

(2)

廖文暄卓宗德楊弘毅劉曜銘黃建揚曾懷廷

(3)

General data

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^{Name：陳O朵}

•

Gender：female

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^{Age：13 y/o}

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Residence：高雄市

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Marital status：unmarried

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Occupation：student

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Attending V.S.：沈也雄醫師

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First vist：96/05/7

(4)

Chief complaint

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R’t face swelling for 1 year

(5)

Present Illness - 96/05/07

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The 13 y/o girl felt her R’t face swelling getting larger and

larger for 1 year. It’s a slow growth, non-painful swelling mass, but she still felt

uncomfortable and went to the LDC for help.

•

The LDC dentist told her that there was a R-L lesion over

tooth 47 and suggested her coming our OPD for further

(6)

Past medical history

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Hepatitis, liver disease：Unknown

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Heart disease：Unknown

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Thyroid disease：Unknown

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Denied any other systemic disease

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Denied any drug and food allergy

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Hospitalization (-)

(7)

Personal history - Oral habits

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Risk factors related to malignancy

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Alcohol：(-)

-

Betel nut：(-)

-

Cigarette：(-)

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No other special hobbies

(8)

Intraoral examination

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Mucosa: nothing particular

• Bony expansion (+)

• Pain & Tenderness (-)

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Induration (-)

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No fistula & discharge

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^EPT:

-

17, 16, 15, 14 (-)

-

^{47 (+)}

(9)

Radiography examination - Panorex

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The panoramic film reveals 3 major abnormalities.

(10)

Radiography examination - Panorex (cont.)

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One is located in the R’t mandibular ramus. There is a irregular shape

monolocular circumcoronal radiolucency with a well-defined border and a thin corticated margin, extending superiorly to 5 mm below the sigmoid notch and inferiorly to the angle of the madible, and from the mesial part of ID canal to the area below roots of 47 with the submerged 48,

measuring approximately 50 x 47 mm in diameter.

•

It shows bony expansion over the R’t madbibular ramus, with the thinning of lower R’t cortical border as well as external oblique ridge. The ID canal has been downward displaced by the lesion.

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No root resorption and teeth displacement is noted.

(11)

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Another one is located in the R’t maxillary tuberosity. There is a

monolouclar circumcoronal radiolucency with a well-defined border and a thin corticated margin, extending superiorly to the infra-orbital area and inferiorly to the apex of 16 and 17, and from the most distal part of

maxillary tuberosity to the apex of impacted 13 with the high position 18, measuring approximately 46 x 58 mm in diameter.

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It also shows bony expansion over the R’t upper posterior area.

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There is no teeth displacement, but it seems to be roots resorption of the teeth 17, 16.

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The maxillary sinus is undistinguishable in the film.

(12)

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The last one is located in the L’t upper posterior area. There is a round shape monolocular radiolucency with a well-defined border and a thin corticated margin, extending superiorly to the infraorbital area and

inferiorly to the apical area of 25, 26, 27, and from the L’t maxillary tuberosity to the mesial side of root 26 with the high position 28, measuring approximately 27 x 30 mm in diameter.

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Mild bony expansion over L’t upper posterior area can be seen in the film.

Besides, roots resorption of 25, 26, 27 is noted.

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No teeth displacement is noted.

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The maxillary sinus is undistinguishable in the film.

(13)

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Condyle : Unremarkable, bilateral

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Other dental finding

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impacted teeth : 18, 13, 25, 28, 38, 48

(14)

Treatment course

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^96/05/14

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Aspiration & Incisional biopsy performed (R’t Upper &

lower posterior swelling)

(15)

Differential diagnosis

(16)

Inflammation, Cyst or Neoplasm ?

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Fever or local heat (-)

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No purulent drainage was present

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Bony expansion (+)

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Cortical destruction at R’t cortical border of body of mandible and external oblique ridge

Cyst or Neoplasm

(17)

Benign or Malignant ?

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^{Pain (-)}

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Tenderness (-)

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Smooth surface (+)

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Induration & ulceration (-)

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Lymphadenopathy (-)

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Slow growing (+)

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Well-defined margin (+)

Benign

(18)

Peripheral or Intrabony origin ?

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Mucosal lesion (-)

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Induration (-)

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Bony expansion (+)

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Cortical bone destruction (+)

Intrabony origin

(19)

Working Diagnosis

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Multiple odontogenic keratocyst

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Multiple central giant cell granuloma

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Multiple dentigerous cyst

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Multiple unicystic ameloblastoma

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Multiple ameloblastic fibroma

(20)

Odontogenic keratocyst

KEY: may be multiple, aspiration (+), clinical features, radiology features

(21)

Odontogenic keratocyst

臨床特徵

OKC Our case

Age &

gender

任何年紀都有可能

10 ~ 40歲佔60%

☺

Site 79%發生在下顎，其中50%發

生在molar region和ramus處

☺

Single or multiple

有可能Mulitlpe出現，特別是

伴隨其他疾病發生時

☺

Mucosa ^{通常沒有症狀}

☺

Pain &

tenderness

通常無痛覺，除非有壓迫到

神經才有麻木感

☺

Bony

expansion ^有可能

☺

Our case

OKC

(22)

Odontogenic keratocyst (cont.)

X-ray 特徵

OKC Our case

性質 Radiolucency

☺

Margin Well-defined with corticated

margin

☺

Effect on adjacent structure

OKC中40%屬於含牙囊腫，

因為推擠產生牙齒阻生，鄰近的牙齒也有可能因此而有

牙根吸收的情形

☺

Other feature

OKC難以直接從x-ray判斷，需符合：

1. Intrabony

2. Odontogenic 3. 有角化組織

Our case

OKC

(23)

Central giant cell granuloma

KEY: may be multiple, clinical features, radiology features

(24)

Central giant cell granuloma

臨床特徵

CGCG Our case

Age &

gender

任何年紀都有可能，60%發

生在30歲之前；女性比例高

☺

Site ^發生在mandible，通常是

前牙區，而且會超過中線

☹

Single or multiple

通常是single lesion，除非伴隨其他疾病，例如：

hyperparathyroidism或 cherubism

△

Mucosa 若是腫大比較嚴重，有可能

可以在mucosa發現突起mass

☺

Pain &

tenderness ^{通常無痛覺}

☺

Bony

☺

Our case

CGCG

(25)

Central giant cell granuloma (cont.)

X-ray 特徵

CGCG Our case

性質 Radiolucency

☺

Margin Well-defined without

corticated margin

☹

比較侵犯性的CGCG可能會有牙根吸收和cortical

perforation的情形

☺

Other feature

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Nonaggressive CGCG：通常無症狀、無痛、

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生長緩慢Aggressive CGCG：疼痛、生長快、有牙根和骨頭的破壞和吸收

Our case

CGCG

(26)

Dentigerous cyst

KEY: clinical featyres, radiology features, aspiration (+)

(27)

Dentigerous cyst

臨床特徵

Dentigerous cyst Our case

Age &

gender ^{男性發生率稍高一些}^{10~30歲之間}

☺

Site ^好發於：Mand. 3rd molar,

Max. 3rd molar, Max. canine

☺

Single or multiple

比較常出現single lesion，

multiple出現的機率稍低

△

Mucosa ^{一般不會造成表面}傷害，除非有其他因素導致^mucosa的

發炎反應

☺

Pain &

tenderness ^{通常無痛覺}

☺

Bony

expansion ^{有可能，緩慢擴大}

☺

Our case

Dentigerous cyst, bilateral

(28)

Dentigerous cyst (cont.)

X-ray 特徵

Dentigerous cyst Our case

性質 Unilocular radiolucency

☺

margin

☺

有可能有tooth displacement

和root resorption的情況

☺

Other feature

Dentigerous cyst有可能將未萌發的牙齒推擠到很遠的位置去，例如把下顎molar推擠到下方mand. border或是ascending ramus；上顎牙齒被推擠到floor of orbit的位置

Our case

Dentigerous cyst, bilateral

(29)

Unicystic ameloblastoma

KEY: aspiration (+), clinical features, radiology features

(30)

Unicystic ameloblastoma

臨床特徵

Unicystic

ameloblastoma Our case

Age &

gender

年輕人，平均約23歲

沒有性別方面的偏向

☺

Site molar-ramus region^{最常出現在下顎}

☺

Single or

multiple ^通常不會^{multiple出現}

☹

Mucosa ^{通常沒有症狀}

☺

Pain &

tenderness Asymptomatic, painless

☺

Bony expansion

有可能

特別是lesion比較大時

☺

Our case

Unicystic

ameloblastoma

(31)

Unicystic ameloblastoma (cont.)

X-ray 特徵

Unicystic

ameloblastoma Our case

性質 Unilocular radiolucency

☺

margin

☺

有可能出現

tooth displacement

和root resorption的情形

☺

Other feature ^通常是slow growth的lesion，而且會和下顎 3rd molar的impaction有關

Our case

Unicystic

ameloblastoma

(32)

Ameloblastic fibroma

KEY: clinical features, radiology features

(33)

Ameloblastic fibroma

臨床特徵

Ameloblastic fibroma Our case

Age &

gender

年輕人，通常小於20歲

男性比率稍微高一些

△

Site ^好發於posterior mandible

body或ascending ramus

☺

Single or

multiple ^通常不會^{multiple出現}

☹

Mucosa ^{通常沒有症狀，較大}^{能會看到腫起的}soft tissue ^lesion可

outline

☺

Pain &

tenderness ^{通常無痛覺，}asymptomatic

☺

Bony

☺

Our case

Ameloblastic fibroma

(34)

Ameloblastic fibroma (cont.)

X-ray 特徵

Ameloblastic fibroma Our case

性質 Unilocular or multilocular

Radiolucency

☺

Margin Well-defined

may be corticated margin

☺

可能造成tooth displacement

和unerupted tooth有關

☺

Other feature ^{有可能生長到很大的}size，導致body of

mandible和ascending raums都被involve其中

Ameloblastic fibroma Our case

(35)

Final impression

Multiple odontogenic Keratocyst ^,

over lower R’t mand. body and ramus, upper R’t

& L’t posterior area

(36)

Further differential diagnosis

Multiple odontogenic keratocyst

Nevoid basal cell carcinoma syndrome

(Gorlin syndrome)

(37)

Gorlin syndrome

Our case

Multiple OKC

☺

Multiple basal cell carcinoma

?

Epidermal cysts of skin

?

Palmar/plantar pits

?

Calcified flax cerebri

?

Enlarged head circumference

?

Rib anomalies

?

Mild ocular hypertelorism

?

Spina bifida occulta

?

Nevoid basal cell carcinoma syndrome (Gorlin syndrome)

(38)

Suggest further examination

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Clinical facial appearance

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Skin condition

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Skeletomuscle examination

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Radiology examination

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Gene examination

(39)

Thank you for your attention!

口腔病理診斷科