Part 1 – – basic basic information information

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初診科 初診科 Case Report Case Report

指導醫師 : 林立民醫師 陳玉昆醫師 王文岑醫師 陳靜怡醫師 報告人:實習H組

Int. 詹至翔 張閔傑 黃齡瑤 曾上純 洪郁文

A case of

ameloblastoma

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Part 1

Part 1 basic basic information information

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General Data General Data

z

Name : 陳新縣

z

Sex : male

z

Age : 52 y/o

z

Native : 台南縣

z

Marital status : 已婚

z

Occupation : 機械修理

z

Attending V.S. : 黃逸岳醫師

z

First visit : 96.06.08

(4)

Chief Complaint Chief Complaint

z

Tooth mobility of tooth 31 32 33 34

96/06/12 96/06/12

96/06/12

(5)

Present Illness Present Illness

The 52 y/o male suffered from the

episode of tooth 31 32 33 34 mobility about a month. He had visited 家禾 LDC for help

in the beginning of May in 2007. Then, periapical film was taken and the doctor

found the RL cystic lesion over mandibular symphysis area. Therefore, the doctor

referred him to our OPD for further examination and treatment.

(6)

Past History Past History

z

Past Medical History

– Anemia

– Denied any systemic disease – Denied any drug or food allergy – Hospitalization(-)

z

Past Dental History

– Extraction – OD

– Prosthesis

– Experience of dental treatment : fair

(7)

Personal History Personal History

z

Risk factors related to malignancy

–Alcohol:(+), ?瓶/天 –Betel quid:(-)

–Cigarette:(-)

z

P’t likes to eat spicy food.

(8)

Family History Family History

z

Hereditary disease: Nil

z

Family support : good

(9)

Intraoral

Intraoral Examination Examination

z mobility of tooth 31 32 33 34 - Duration : 1+ month

- Smooth surface

- Swelling over lingual side - Color : normal pink

- No discharge

- The adjacent mucosa seemed to be normal.

(10)

z Dental findings :

- Missing : 16, 18, 28, 38 - Bridge : 15x17 (metal) - Restoration : 46

- Tooth mobility : 31 32 33 34 grade(?)

Intraoral

Intraoral Examination Examination (cont.) (cont.)

(11)

Physical Examination Physical Examination

z EPT : Æ (+) ; Æ (-)

z Consistency : bony hard

z Fluctuation (-)

z Pain (-)

z percussion pain(-) Æ tooth 31 ~ 37

z Tenderness (-)

z Induration (-)

z Fever or local heat (-)

z Lower lip paresthesia (-)

z Lymphadenopathy (-)

3 1234

(12)

Radiographic Examination

Radiographic Examination (Panoramic film) (Panoramic film)

96/06/09

A well-defined, scallope-shaped, unilocular radiolucency without corticated margin over mandibular symphysis, extending from the medial side of

tooth 34 to the mesial side of tooth 43 and from middle third of tooth 33 root down to the 1/2 mandibular symphysis, measured approximately 4.0 x 2.0 cm in diameter. Lamina dura of involving root disappeared. Root

resorption was noted at tooth 33, 34 and the lesion didn’t involve in L’t mental foramen.

(13)

Radiographic Examination Radiographic Examination

96/06/09

z Dental findings:

- Missing : 16, 18, 28, 38 - Bridge : 15x17 (metal) - Filling : 46 - Root resorption : 33, 34 - Total bone loss : 15

- Generalized periodontotitis

z No other abnormalities were observed.

(14)

Radiographic Examination

Radiographic Examination ( ( Periapical Periapical film) film)

96/06/09 A well-defined, irregular shape,

unilocular radiolucency without corticated margin, extending distally to the mesial side of tooth 35 and up from the

alveolar crest. Lamina dura of involving root disappeared.

Root resorption was noted at tooth 33, 34. Besides, vertical expansion was seen at the

alveolar crest near 33 mesial side.

(15)

Radiographic Examination

Radiographic Examination ( ( Occlusal Occlusal film) film)

96/06/09

Teeth crowding over lower ant.

region

(16)

Treatment course (96/06/12)

z Biopsy :

bone perforation was noticed over

apex of tooth 41、42

z Aspiration :

clear with light

yellowish discharge

(17)

Part 2

Part 2 Working Working Diagnosis Diagnosis

(18)

Working diagnosis Working diagnosis

Inflammation? Cyst? Neoplasm?

- Fever or local heat (-) - Duration : 1+ month - well-defined RL - swelling (+)

- pain (-)

- normal pink

rule out inflammation

Cyst or Neoplasm

(19)

Working diagnosis Working diagnosis

Central ? Peripheral?

- smooth surface - well-defined RL - adjacent mucosa - bone expansion

Æ normal - Root resorption - bone perforation

Central

(20)

Cyst ? Neoplasm?

- Fluctuation(-) - Lower Tooth mobility - Aspiration (+) - Bone perforation

- well-defined RL - Bone expansion - Induration (-) - Root resorption - adjacent mucosa Æ normal

- Lymphadenopathy (-) - Duration : 1+ month - paresthesia (-)

- Smooth surface - pain(-)

- tenderness(-)

Cyst Or Benign tumor (cystic change)

Working diagnosis Working diagnosis

(21)

„

Cyst (central type)

Odontogenic nonodontogenic

Radicular cyst

Odontogenic keratocyst

Glandular odontogenic cyst Dentigerous cyst

Simple bone cyst

Aneurysmal bone cyst

Teeth nonvital(EPT-) Teeth mobility & root resorption

Aspiration:clear to yellow Scalloped-shape margin

No-associtated uneruption teeth

Rule out

Working diagnosis Working diagnosis

(22)

Cyst

Clinical feature - EPT(-) : 31 ~ 34 - Smooth surface

- Adjacent mucosa Æ normal - Swelling(+)

- tooth mobility

- Color : normal pink

- Consistency : bony hard - Fluctuation (-)

- Duration : 1+ month - Pain (-)

- Percussion pain(-) - Tenderness (-)

- Induration (-)

- Aspiration (+) Æ clear with light yellowish discharge

X-ray feature

- Periapical radiolucency - well-defined RL without

corticated margin - bone expansion

- Lamina dura of involving root disappear

- Root resorption

Radicular cyst

Odontogenic keratocyst

Glandular odontogenic cyst

Working diagnosis Working diagnosis

(23)

„

Neoplasm (central type)

Odontogenic nonodontogenic

Ameloblastoma(solid type) Unicystic ameloblastoma Cemento-ossifying fibroma Cemento-ossifying dysplsia

Central giant cell granuloma Hemangioma

Teeth nonvital(EPT-) Teeth mobility & root resorption

Aspiration:clear to yellow

Rule out

Teeth nonvital(EPT-) Teeth mobility & root resorption

Aspiration(+):clear to yellow

Working diagnosis Working diagnosis

(24)

Benign tumor

Working diagnosisWorking diagnosis

X-ray feature

- Periapical radiolucency - well-defined RL without

corticated margin - bone expansion

- Lamina dura of involving root disappear

- Root resorption

Clinical feature - EPT(-) : 31 ~ 34 - Smooth surface

- Adjacent mucosa Æ normal - Swelling(+)

- tooth mobility

- Color : normal pink

- Consistency : bony hard - Fluctuation (-)

- Duration : 1+ month - Pain (-)

- Percussion (-) - Tenderness (-) - Induration (-)

- Lymphadenopathy (-)

- Aspiration (+) Æ clear with light yellowish discharge

Conventional solid ameloblastoma (cystic change)

Unicystic ameloblastoma

Conventional solid ameloblastoma (cystic change)

Unicystic ameloblastoma

(25)

z

Radicular cyst

z

Odontogenic keratocyst (OKC)

z

Glandular odontogenic cyst

Cyst

(26)

z

Conventional solid ameloblastoma (cystic change)

z

Unicystic ameloblastoma

Benign tumor

(27)

Part 3

Part 3 – –

Differential

Differential Diagnosis Diagnosis

(28)

Differential Diagnosis Differential Diagnosis

z

Conventional solid ameloblastoma (cystic change)

z

Unicystic ameloblastoma

z

Radicular cyst

z

Odontogenic keratocyst (OKC)

z

Glandular odnotogenic cyst

(29)

Conventional solid

Conventional solid ameloblastoma ameloblastoma (cystic change)

(cystic change)

(30)

Conventional solid

ameloblastoma Our case AgeAge 30~7030~70 5252

Gender

Gender No predilectionNo predilection MaleMale

SiteSite Md. MolarMd. Molar--ramusramus Md. AnteriorMd. Anterior Symptom

Symptom Painless swellingPainless swelling Painless swellingPainless swelling

Margin Margin

WellWell--defined with defined with corticated margin corticated margin

WellWell--defined defined

without corticated without corticated

margin margin

(31)

Conventional solid

ameloblastoma Our case XX--ray featureray feature MultilocularMultilocular oror

Scalloping

Scalloping unilocularunilocular

Scalloping Scalloping

unilocular unilocular Bony expansion

Bony expansion ++ ++

root

root resorptionresorption ++ ++ other

other Associated with Associated with unerupted

unerupted toothtooth

--

(32)

Unicystic

Unicystic ameloblastoma ameloblastoma

(33)

Unicystic

ameloblastoma Our case Gender

Gender Male Male Male Male Age Age 2nd decade (23) 2nd decade (23) 5252

Site

Site 90% 90% mandmand. Post. area . Post. area Md. AnteriorMd. Anterior Symptom

Symptom AsymptomaticAsymptomatic

Painless swelling Painless swelling

Painless swelling Painless swelling Margin

Margin WellWell--defined with defined with corticated margin corticated margin

WellWell--defined defined

without corticated without corticated

margin margin

(34)

Unicystic

ameloblastoma Our case

XX--ray featureray feature unilocularunilocular Scalloping Scalloping unilocularunilocular Density

Density radiolucenceradiolucence radiolucenceradiolucence Bony

Bony

expansion expansion

++ ++

root

root resorptionresorption ++ ++ Effects on

Effects on surrounding surrounding

structure structure

No effect No effect

Large lesion Large lesion ––

bony expansion bony expansion

Root

Root resorptionresorption

Bony expansion and Bony expansion and perforation

perforation other

other Associated with Associated with unerupted

unerupted toothtooth --

(35)

Radicular

Radicular cyst cyst

(36)

Radicular Cyst Our case Gender

Gender Male (Slightly)Male (Slightly) MaleMale RaceRace UnspecificUnspecific AsianAsian

AgeAge Medium age(30Medium age(3050 50 y/oy/o)) 5252

SiteSite apex of apex of nonvitalnonvital tooth tooth MandibularMandibular ant. ant.

Symptom

Symptom Asymptomatic

Secondary infection or too large Æ swelling

Swelling(+) Swelling(+) Fluctuation(

Fluctuation(--)) Aspiration(+) Aspiration(+)

Pain(

Pain(-) Tenderness(-) Tenderness(--)) Smooth surface

Smooth surface

(37)

Radicular Cyst Our case Margin

Margin wellwell-defined, with -defined, with corticated margin corticated margin

wellwell--defined, without defined, without corticated margin corticated margin XX--ray ray

feature feature

Unilocular Scalloping unilocular SizeSize Usually >Usually > 2cm2cm 4.0 x 2.0 cm4.0 x 2.0 cm Density

Density RadiolucencyRadiolucency RadiolucencyRadiolucency Effects on

Effects on surrouding surrouding

structure structure

no effects no effects

Or teeth displacement, Or teeth displacement,

tooth

tooth resorptionresorption,, bone expansion bone expansion

Root

Root resorptionresorption Bone expansion Bone expansion

and perforation and perforation

(38)

Odontogenic

Odontogenic Keratocyst Keratocyst

(39)

OKC Our case AgeAge Wide rangeWide range

(10(10~~40 40 y/oy/o >> 60%)60%)

5252 Gender

Gender Male (Slightly)Male (Slightly) MaleMale SiteSite Posterior Posterior mandibularmandibular

bodybody++ramusramus

Mandibular

Mandibular ant. ant.

Symptom

Symptom asymptomasymptom or pain, or pain, swelling,

swelling, draingedrainge

Painless Painless

swelling swelling Bone

Bone expansion expansion

Rare,

Rare, 通常是通常是AA--PP方向的方向的 extension

extension

bone expansion bone expansion

XX--ray ray feature feature

Unilocular

Unilocular//multilocularmultilocular ScallopingScalloping Unilocular Unilocular

(40)

OKC Our case Density

Density RadiolucenceRadiolucence RadiolucenceRadiolucence

Margin Margin

WellWell--defined with defined with corticated margin corticated margin

WellWell--defined defined without corticated without corticated

margin margin Root

Root resorption resorption

RareRare ++

(41)

Glandular

Glandular odontogenic odontogenic cyst cyst

(42)

GOC Our case AgesAges Middle age adult Middle age adult

(Avg:49y/o) (Avg:49y/o)

5252 Gender

Gender unknownunknown MaleMale SiteSite Strong predilection:Strong predilection:

Jaw anterior region Jaw anterior region (many cross midline ) (many cross midline )

Mandibular Mandibular

ant.

ant.

Symptom

Symptom Small lesion may Small lesion may asymptomatic asymptomatic Large

Large --may pain and may pain and parethesia

parethesia(+)(+)

Pain(

Pain(--) ) swelling(+) swelling(+)

(43)

GOC Our case Bone

Bone expansion expansion

Large(+)

Large(+) bony bony

expansion expansion and and

perforation perforation XX--ray ray

feature feature

Unilocular Unilocular// multilocular

multilocular more more commonly

commonly

Scalloping Scalloping Unilocular Unilocular

(44)

Clinical impression Clinical impression

z

Ameloblastoma, intraoral,

mandibular symphysis area,

apex of tooth 42 ~ 35

(45)

~Thanks

~Thanks for for your your attention attention

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