口腔病理診斷科

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(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

Name:陳O朵

Gender:female

Age:13 y/o

Residence:高雄市

Marital status:unmarried

Occupation:student

Attending V.S.:沈也雄 醫師

First vist:96/05/7

(4)

Chief complaint

R’t face swelling for 1 year

(5)

Present Illness - 96/05/07

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

Hepatitis, liver disease:Unknown

Heart disease:Unknown

Thyroid disease:Unknown

Denied any other systemic disease

Denied any drug and food allergy

Hospitalization (-)

(7)

Personal history - Oral habits

Risk factors related to malignancy

-

Alcohol:(-)

-

Betel nut:(-)

-

Cigarette:(-)

No other special hobbies

(8)

Intraoral examination

Mucosa: nothing particular

• Bony expansion (+)

• Pain & Tenderness (-)

Induration (-)

No fistula & discharge

EPT:

-

17, 16, 15, 14 (-)

-

47 (+)

(9)

Radiography examination - Panorex

The panoramic film reveals 3 major abnormalities.

(10)

Radiography examination - Panorex (cont.)

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.

No root resorption and teeth displacement is noted.

(11)

Radiography examination - Panorex (cont.)

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.

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

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

The maxillary sinus is undistinguishable in the film.

(12)

Radiography examination - Panorex (cont.)

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.

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

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

No teeth displacement is noted.

The maxillary sinus is undistinguishable in the film.

(13)

Radiography examination - Panorex (cont.)

Condyle : Unremarkable, bilateral

Other dental finding

-

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

(14)

Treatment course

96/05/14

-

Aspiration & Incisional biopsy performed (R’t Upper &

lower posterior swelling)

(15)

Differential diagnosis

(16)

Inflammation, Cyst or Neoplasm ?

Fever or local heat (-)

No purulent drainage was present

Bony expansion (+)

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

Cyst or Neoplasm

(17)

Benign or Malignant ?

Pain (-)

Tenderness (-)

Smooth surface (+)

Induration & ulceration (-)

Lymphadenopathy (-)

Slow growing (+)

Well-defined margin (+)

Benign

(18)

Peripheral or Intrabony origin ?

Mucosal lesion (-)

Induration (-)

Bony expansion (+)

Cortical bone destruction (+)

Intrabony origin

(19)

Working Diagnosis

Multiple odontogenic keratocyst

Multiple central giant cell granuloma

Multiple dentigerous cyst

Multiple unicystic ameloblastoma

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

expansion 有可能

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

Effect on adjacent structure

比較侵犯性的CGCG可能會 有牙根吸收和cortical

perforation的情形

Other feature

-

Nonaggressive CGCG:通常無症狀、無痛、

-

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 Well-defined with corticated

margin

Effect on adjacent structure

有可能有tooth displacement

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 Well-defined with corticated

margin

Effect on adjacent structure

有可能出現

tooth displacement

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

expansion 有可能

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

Effect on adjacent structure

可能造成tooth displacement

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

Clinical facial appearance

Skin condition

Skeletomuscle examination

Radiology examination

Gene examination

(39)

Thank you for your attention!

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