2009.12.28 INT C 陳其財 任心如 林雅敏 陳哲偉 詹明毅
GENERAL DATA
GENERAL DATA GENERAL DATA
• Personal data
– Name : 黃XX黃 – Gender : Male
Age : 32 – Age : 32
– Native : 屏東
– Occupation : 工
– First Visit : 98/05/13
GENERAL DATA GENERAL DATA
• Chief Complaint
– refer from LDC for extraction 38
GENERAL DATA GENERAL DATA
• Present Illness
– This 32 y/o patient felt discomfort over 38
area about 2 months ago He came to LDC for area about 2 months ago.He came to LDC for help.The doctor referred him to our OPD for extraction of the 38 impaction.p
GENERAL DATA GENERAL DATA
• Past medical history : y
– Hospitaliztation history (+)
– Denied any food and drug allergyDenied any food and drug allergy – Denied any systemic disease
• Past Dental History
– General dental treatment
• Attitude to dental treatment :
– CooperativeCooperative
GENERAL DATA GENERAL DATA
• Personal data
– Risk factor related to malignancyRisk factor related to malignancy
• Alcohol : unknown
• Betel nut : unknown
• Betel nut : unknown
• Cigarette : unknown
• Other habit : unknown
X-ray findings
There is a well-defined unilocular ovoid shaped radiolucence with a corticated outline extending from CEJ of impacted tooth 38 to half of ramus and from 2cm under sigmoid g p g notch to the furcation of impacted tooth 38,measuring approximately 3x2 cm.
Filling :18 17 13 12 11 21 24 37 38 46 47 missing :15 26 48 Restorarion :16x14 25x27 35 36 44 45 impaction :28 38 Restorarion :16x14 25x27 35 36 44 45 impaction :28 38
There is a well-defined radiolucence lesion over posterior and superior of impacted tooth 38 The distal root and crown of
superior of impacted tooth 38. The distal root and crown of tooth38 is involved and the lamina dura of them was
disappear.
There is a well-defined unilocular ovoid shaped radiolucence with a corticated outline extending from CEJ of impacted
with a corticated outline extending from CEJ of impacted tooth 38 to 3/4 of ramus and from 1cm under sigmoid notch to the mesial root of tooth 38,measuring approximately 4x2.5 cm The inferior alveolar canal is involved The root
cm. The inferior alveolar canal is involved. The root
resorption is noted.
C omputed T omography
P it E i i T h
P ositron E mission T omography
PET PET
是異於傳統加馬照相機的新一代核子醫學儀 器 它利 –是異於傳統加馬照相機的新一代核子醫學儀 器，它利
用正子同位素產生互毀反應後所射出的成對加馬輻射 線來作為成像的原理
線來作為成像的原理
–PET影像資料如配合動脈血中正子同位素藥物濃度資料 以代謝模式加以運算，可求得單位組織代謝速率
正子攝影配合氟 標記葡萄糖作為放射藥劑 可進行 –正子攝影配合氟-18標記葡萄糖作為放射藥劑，可進行
體內器官組織的代謝評估，臨床上可用於腫瘤造影、
心肌存活評估及癲癇病灶定位
心肌存活評估及癲癇病灶定位
PET PET
例如 使用FDG可測得每單位組織每分鐘代謝多少分子 –例如：使用FDG可測得每單位組織每分鐘代謝多少分子 的葡萄糖， 使用15O-水可測定每單位組織的血流、血 量等
量等
–由於惡性腫瘤常表現出比正常或良性組織更高的代謝，
所以可用氟-18葡萄糖正子攝影來偵測惡性腫瘤，運用 的時機包括良惡性病灶的鑑別、治療前分期、治療中 再分期、治療效果的評估及治療後復發的追踨等。
再分期 治療效果的評估及治療後復發的追踨等。
Difference diagnosis
Difference diagnosis Difference diagnosis
Intra-bony or peripheral
Intra bony or peripheral
Inflammation or cyst or neoplasm
Benign or malignant
Intra-bony or peripheral origin?
Intra-bony or peripheral origin?
c Mucosal lesion : (-) d Induration : unknown e Bony destruction : (+)
f B i ( )
f Bony expansion : (-)
CENTRAL
(but can’t rule out peripheral origin)
Inflammation? Cyst? Neoplasm?
Inflammation? Cyst? Neoplasm?
c F l l h t k
c Fever or local heat : unknown d Pain : (+) ( )
e Lymphadenopathy : unknown f Pus discharge : ( )
f Pus discharge : (-) g Duration : 2 months
CYST CYST
(but can’t rule out NEOPLASM)
(if Neoplasm) Benign or malignant
(if Neoplasm) Benign or malignant
c M bilit ( ) c Mobility : (-)
d Ulceration : (-)
BENIGN
( ) e Induration : (-)
f Duration : 2 months
BENIGN
f Duration : 2 months g Pain : (+)
h Numbness: (-)
i Lymphadenopathy : unknown
i Lymphadenopathy : unknown
j Margin : well-defined
Working Diagnosis
WORKING DIAGNOSIS
<CYST>
Od t i K t t
Odontogenic Keratocyst Periapical Cyst
<NEOPLASM>
Unicystic Ameloblastoma Unicystic Ameloblastoma
Ameloblastic Fibroma
Odontogenic Fibroma
Odontogenic Fibroma
Odontogenic Keratocyst g y
Odontogenic Keratocyst Our Case Age gender 10~40 y/o slight male 32 y/o male
Age, gender 10 40 y/o, slight male 32 y/o, male X-ray Well-defined uni- or
multilocular R-L
Well-defined unilocular R-L Jaw 60~80% in mandible,
unerupted tooth
L’t mandibular ramus
Pain Small: painless Pain
Pain Small: painless Large: pain
Pain
Growth Slowly growing Slowly growing (6 months : 2x3 cm Æ 2 5x4 cm)
2x3 cm Æ 2.5x4 cm) Swelling Bony expansion and
thinning of cortical plates
No bony expansion
Effects on tooth
Less root resorption No root resorption
Periapical Cyst
Periapical cyst Our case
Site unspecific L’t mandible
body and ramus body and ramus
Gender unspecific Male
Ageg unspecificp 32 y/oy
Size Vary in size About 2 x 3 cm
Symptom / -No s/s, unless there is an acute P’t felt Symptom /
Sign
No s/s, unless there is an acute inflammatory exacerbation.
-Large size：swelling and mild sensitivity -Movement of adjacent teeth are possible
P t felt
uncomfortable
j p
Pain Often：(-)
Inflammation：(+)
(+)
Radiographic Features
- A round radiolucency encircles the affected tooth apex.
- Loss of the lamina dura along the
dj t t
An ovoid RL involved distal root of tooth 38 adjacent root
- Root resorption is common
Unicystic Ameloblastoma
Unicystic Ameloblastoma Our case
Site More than 90% in L’t mandible body
Posterior Mandible and ramus
Gender unspecific Male
A M t i ’t 32 /
Age -Most common in younger p’t -About 50% diagnosed during
10~20 y/o
Average age：23 y/o
32 y/o
-Average age：23 y/o
Size Vary in size About 2 x 3 cm
Symptom / -Often asymptomatic P’t felt uncomfort Symptom /
Sign
Often asymptomatic
-Large lesions may cause a painless swelling of the jaws
P t felt uncomfort
Pain ( ) (+)
Pain (-) (+)
Radiographic Features
Circumscribed radiolucency Combine impacted tooth
An ovoid RL involved distal root of tooth 38 p
(often Md. 3rd molar)
Ameloblastic Fibroma
Ameloblastic Fibroma Our case Site The most common in the
posterior mandible(about 50%)
L’t mandible body and ramus
Gender Male > female Male
Gender Male female Male
Age Most common in the 0~20 y/o 32 y/o
Size Vary in size About 2 x 3 cm
Symptom / Sign
SmallÆasymptomatic
LargeÆswelling of the jaws
P’t felt uncomfort
Pain ( ) (+)
Pain (-) (+)
Radiographic Features
Well-defined unilocular or Multilocular RL
An ovoid RL involved distal Combined impacted teeth (about 75%) root of tooth 38
Central odontogenic fibroma
Central odontogenic fibroma Our case
Gender female Male
A M 40 / 32 /
Age Mean age: 40 y/o 32 y/o
Symptom - Uncomfortable
Site Mandible, post. L’t mandible body
Site Mandible, post. L t mandible body
and ramus
Size - About 4x2.5 cm
Outline Small lesion: unilocular Large lesion: mutilocular
unilocular
border Well defined with a Well defined with border Well-defined with a
sclerotic border
Well-defined with corticated border
shape ovoid
Effect on surrounding structure
Root resorption Root divergence
Large lesion:bony expansion
Involved distal root of tooth 38
Large lesion:bony expansion teeth lossening
Clinical impression Clinical impression
• Odontogenic keratocyst, left mandibular
ramus
Discussion
Treatment course Treatment course
• 98.05.13
– First visit :asking for 38 extraction – X-ray finding : dentigerous cyst
Suggest OP – Suggest OP
• 98.11.27
– OP :enucleation+ 38 extraction+ bone graft OP :enucleation+ 38 extraction+ bone graft
• 98.12.08
– Specimen report: salivary duct carcinoma p p y
• 98.12.11
– OP: Wide excision (partial mandibulectomy)
Salivary duct carcinoma Salivary duct carcinoma
– uncommon highly malignant tumor – mean age : 56 years (older man)g y ( ) – Site:
• parotid gland parotid gland
• submandibular salivary gland
• minor salivary glands in the maxilla minor salivary glands in the maxilla
Salivary duct carcinoma Salivary duct carcinoma
– 27% of the tumors
• arose from pre-existing pleomorphic adenoma
– perineural and lymphatic invasion (common)
(common)
– Distant metastasis
( t f f il )
(most common cause of failure )
