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
Part 1
Part 1 – – basic basic information information
General Data General Data
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Name : 陳新縣
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Sex : male
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Age : 52 y/o
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Native : 台南縣
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Marital status : 已婚
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Occupation : 機械修理
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Attending V.S. : 黃逸岳醫師
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First visit : 96.06.08
Chief Complaint Chief Complaint
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Tooth mobility of tooth 31 32 33 34
96/06/12 96/06/12
96/06/12
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.
Past History Past History
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Past Medical History
– Anemia
– Denied any systemic disease – Denied any drug or food allergy – Hospitalization(-)
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Past Dental History
– Extraction – OD
– Prosthesis
– Experience of dental treatment : fair
Personal History Personal History
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Risk factors related to malignancy
–Alcohol：(+), ?瓶/天 –Betel quid：(-)
–Cigarette：(-)
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P’t likes to eat spicy food.
Family History Family History
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Hereditary disease: Nil
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Family support : good
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.
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.)
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
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.
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.
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.
Radiographic Examination
Radiographic Examination ( ( Occlusal Occlusal film) film)
96/06/09
Teeth crowding over lower ant.
region
Treatment course (96/06/12)
z Biopsy :
bone perforation was noticed over
apex of tooth 41、42
z Aspiration :
clear with light
yellowish discharge
Part 2
Part 2 – – Working Working Diagnosis Diagnosis
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
Working diagnosis Working diagnosis
■
Central ? Peripheral?
- smooth surface - well-defined RL - adjacent mucosa - bone expansion
Æ normal - Root resorption - bone perforation
Central
■
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
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
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
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
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
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Radicular cyst
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Odontogenic keratocyst (OKC)
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Glandular odontogenic cyst
Cyst
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Conventional solid ameloblastoma (cystic change)
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Unicystic ameloblastoma
Benign tumor
Part 3
Part 3 – –
Differential
Differential Diagnosis Diagnosis
Differential Diagnosis Differential Diagnosis
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Conventional solid ameloblastoma (cystic change)
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Unicystic ameloblastoma
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Radicular cyst
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Odontogenic keratocyst (OKC)
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Glandular odnotogenic cyst
Conventional solid
Conventional solid ameloblastoma ameloblastoma (cystic change)
(cystic change)
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
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
--
Unicystic
Unicystic ameloblastoma ameloblastoma
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
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 --
Radicular
Radicular cyst cyst
Radicular Cyst Our case Gender
Gender Male (Slightly)Male (Slightly) MaleMale RaceRace UnspecificUnspecific AsianAsian
AgeAge Medium age(30Medium age(30～～50 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
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
Odontogenic
Odontogenic Keratocyst Keratocyst
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
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 ++
Glandular
Glandular odontogenic odontogenic cyst cyst
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(+)
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
Clinical impression Clinical impression
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