CASE REPORT
Intern A 組
組員: 余政輝 郭于慶 陳彥蓉 沈怡娟 指導醫師: 口腔病理科全體醫師
102/08/27
General data
Name OOO
Sex : Female
Age : 14 y/o
Native : 高雄市
Marital status : 未婚
Attending V.S. : OOO 醫師
First visit :07/23/2013
Chief Complaint
Asking for oral examination and evaluation of the painful swelling over the left mandibular area
08/03/2013
Present Illness
This 14 years old female has suffered from a painful swelling over the left mandible for 2 weeks, so her
mother brought her to the Pediatric Dental Department of our institution for examination.
Past Medical History
-
Underlying disease: (+)
1. Systemic Lupus Erythematosus 2. Neutropenic fever
- Hospitalization: (+)
1. SLE operation on 8/27/2012
- Surgery under GA: (-)
- Allergy: (-)
Intraoral Examination
Max Dimension: 2.2 x1.8 cm
Swelling: Tooth 33-35, buccal
aspect (tooth 33, 34: divergence, tooth 33-35: without caries)
Surface: Smooth, non-ulcerated with pinkish color
Consistency: Hard
Pain (+)
Tenderness (-)
Induration (-)
Left submandible, LAP(-) 08/03/2013 08/03/2013
Image finding – Panorex(102/07/23)
07/23/2013
There is a well-defined unilocular ovoid shaped mixed radiolucent-radiopaque lesion, with a corticated margin over the lower left canine-premolar area, extending from CEJ of 34 down to one-third of the mandibular body, and from mesial side of 33 root apex to the 35 root apex, measuring approximately 2.2 x 1.8 cm in maximum diameter. The lesion caused the tooth 33, 34 displacement, tooth 33 distal tilting and tooth 34 mesial tilting. Loss of lamina dura of distal side of tooth 33 root, 34 root, and 35 root apex was noted. In addition, tooth 33, 34 root divergence was noted. There’s no significant
influence on left mental foramen, and the inferior border of cortical bone was intact.
CT scan (102/08/02)
There is a well circumscribed hyperdense lesion with expanded the left aspect of mandible. The adjacent bony structures are intact.
<Axial view> <Coronal view>
Dental Finding
•
Impaction: Tooth 18,28,38,48•
Rotation: Tooth 22•
Mesial tilting: Tooth 34•
Distal tilting: Tooth 33•
Secondary caries: Tooth 15,36•
OD filling: Tooth 15(MO),36(DO)Past Dental History
- General routine dental treatment
- Attitude to dental treatment: Co-operative
Personal History
Risk factors related to malignancy
- Alcohol drinking (-)
- Betel quid chewing (-) - Cigarette smoking (-)
Special oral habits: Denied
Irritation: Denied
Working Diagnosis
Peripheral or Intrabony?
=> Intrabony
Our case Peripheral Intrabony
Mucosal lesion - + -
Induration - + -
Bony expansion + - +/- Cortical bone destruction - - +/-
Inflammation, Cyst or Neoplasm?
Inflammation
Our case Inflammation
Redness - +
Swelling + +
Local heat Unknown +
Pain + +
Multifocal - -
Skull involvement - -
Cyst or Neoplasm
Cyst or Neoplasm?
Cyst
Our case Cyst
Aspiration unknown +
Fluctuation unknown +/-
Well-defined border
+ +
Bone expansion + +/-
Cyst or Neoplasm?
Our case Inflammation
cyst Non-Inflammation cyst
Pain, tenderness Pain(+)
tenderness(-) + - Local heat unknown + - Color Pink to
normal Reddish Pink Progression Unknown Fast Slow Sclerotic margin + - +
Cyst or Neoplasm?
Neoplasm
Our
case Benign Malignant
Border Well defined Well defined Poorly defined
Sclerotic margin + + -
Destruction of cortical margin - +/- +
pain + - +
Induration - - +
Swelling with intact epithelium + + -
Lymphadenopathy - - +/-
Progress Unknown Slow Fast
Metastasis - - +/-
Non-inflammation cyst or Benign tumor
Working Diagnosis
Cemento-ossifying fibroma
Focal cemento-osseous dysplasia
Calcifying epithelial odontogenic tumor
Calcifying odontogenic cyst
Fibrous dysplasia
Differential Diagnosis
Cemento-ossifying fibroma
Our case Cemento-ossifying fibroma
Gender Female Female
Age 14 20~40
Site Left mandibular canine
and premolar region Mandibular premolar-molar region Symptom and
Sign Painful swelling Painless swelling
Jaw expansion + +
Teeth
displacement + +
Cemento-ossifying fibroma
Radiologic features
Our case Cemento-ossifying fibroma Density Mixed lesion (RL+RO) Mixed lesion (RL+RO)
Border Well-defined with
corticated margin Well-defined with corticated margin R/L rim is uncommon
shape Unilocular Unilocular
Root divergence
or resorption + +
Focal cemento-osseous dysplasia
Our case Focal cemento-osseous dysplasia
Gender Female Female
Age 14 20~60 (mean=38)
Site Left mandibular canine
and premolar region Posterior mandible Symptom and
Sign Painful swelling Asymptomatic
Size 2.2X1.8 cm <1.5 cm
Focal cemento-osseous dysplasia
Radiologic features
Our case Focal cemento-osseous dysplasia
Density Mixed lesion (RL+RO) Mixed lesion (RL+RO) Border Well-defined with
corticated margin Well-defined with a thin peripheral RL rim, but usually slightly irregular
shape Unilocular Unilocular
Calcifying epithelial odontogenic tumor (CEOT)
Our case CEOT
Gender Female Both
Age 14 30~40 (mean=40)
Site Left mandibular canine
and premolar region Posterior mandible Symptom and
Sign Painful swelling Painless, slow-growing swelling
Jaw expansion + +
Calcifying epithelial odontogenic tumor (CEOT)
Radiologic features
Our case CEOT
Density Mixed lesion (RL+RO) Mixed lesion (RL+RO) Border Well-defined with
corticated margin
Well-defined scalloped 20%corticated border
20% ill-defined
shape Unilocular Unilocular or multilocular (honeycomb)
Driven snow appearance Combine
impacted tooth - Often mandibular 3rd molar
Calcifying odontogenic cyst (Gorlin cyst)
Our case Gorlin cyst
Gender Female Both
Age 14 10~30 (mean = 33)
Site Left mandibular canine
and premolar region Most in the incisor and canine areas (65 %)
Symptom and
Sign Painful swelling Asymptomatic
Jaw expansion + +
Root resorption
or divergence + +/-
Calcifying odontogenic cyst (Gorlin cyst)
Radiologic features
Our case Gorlin cyst
Density Mixed lesion (RL+RO) RL
(RL+RO) 1/3~1/2 Border Well-defined with
corticated margin Well-defined
shape Unilocular Unilocular
Occasionally multilocular Combine
impacted tooth - About 1/3 cases
Canine
Fibrous dysplasia (monostotic)
Our case Fibrous dysplasia
Gender Female Both
Age 14 10~20
Site Left mandibular canine
and premolar region Maxilla Symptom and
Sign Painless swelling Painless swelling
Jaw expansion + +
Displacement of
mandibular canal - Superior displacement
Hormone related Unknown +
(Do not progress beyond puberty)
Fibrous dysplasia
Radiologic features
Our case Fibrous dysplasia Density Mixed lesion (RL+RO) Ground glass
Border Well-defined with
corticated margin Poorly-defined shape Unilocular
Clinical impression
Cemento-ossifying fibroma over tooth 33,
34, 35 area
Treatment Course
Treatment course
Incisional biopsy, under LA
Surgical plan: Excision and tooth 34 extraction
Follow up: Wound healing and
bone density evaluation
Treatment course
101/7/23 first visit to Pedo Dept
- Gingival swelling near tooth 33, 34
- Panorex taking: Well circumscribed radiolucency with radiopacity in the left mandibular area
- Refer to OS Dept
Treatment course
101/07/23 first visit to OS:
- L’t mandible: Bony expansion
- Arrange incisional biopsy on 102/07/26
102/07/26
- Incisional biopsy
- Histopathological report: Bone, mandible, left, incision, cemento-ossifying fibroma
102/08/02
- Arrange excision under GA on 102/08/07
Treatment course
102/08/07 operation
- Excision and tooth 34 extraction - Specimen was sent to H-P report
Treatment course
102/08/08 post operation panorex taking
Compared to panoramic film taken on 102/07/23, the tooth 34 was extracted. The border of the operation site was smooth after excision.
Treatment course
102/08/08 specimen HP report
Pathologic diagnosis:
Bone, mandible, left, excision, cemento- ossifying fibroma
Discussion
Cemento-ossifying fibroma of the mandible:
a case report and review of literature
Year:2011| volume:2 | Issue:3| page :197-199|Indian J Stomatol
Abstract
Cemento-ossifying fibroma: Fibro-osseous neoplasm and non-odontogenic tumors
Derived from mesenchymal blast cells of PDL:
Form fibrous tissue, cementum and bone, or combination
Radiological perspective: Well defined, unilocular radiotransparency, as radiotransparent image
with central opacifications, or as multilocular transparencies
Introduction
Benign mesenchymal odontogenic lesion
Categorized under fibro-osseous lesions: fibrous dysplasia, osseous dysplasia, ossifying fibroma, cemento-ossifying fibroma and cemento-
dysplasia
Fibro-osseous lesions of the cranial and facial bones: Benign ,grow slowly, similar
histopathological features as fibrous dysplasia, ossifying fibroma, and cemento-osseous
dysplasia
Case
A 23-year-old male patient reported to the clinics with a chief complaint of swelling in the left side of the lower jaw since 6 months. The swelling was gradually increasing in size and was not associated with pain. There was no significant
medical and dental history
Case
Clinical examination
1. Oval shaped swelling, approximately 5x2 cm in size in lower left premolar and molar region
2. Mild bicortical expansion with bowing of the inferior border of mandible
3. The swelling was non-tender, bony hard in consistency with intact overlying mucosa.
4. There was no paresthesia
Case
CT
Large irregular expansile lesion measuring 5.5 x1.9 cm with bicortical expansion and destruction of buccal cortex of mandible with intact lower border of mandible
Case
Histopathology
Histological section showing diffused areas of ossification and calcifications in stroma
Case
Surgical resection of the tumor, with
reconstruction of the mandible was done under general anesthesia.
Discussion
Fibro-osseous neoplasm
Non-odontogenic tumors derived from the multipotent mesenchymal blast cells of the periodontal origin
Form fibrous tissue, cementum and bone, or a combination of such elements.
Discussion
A slow growing intra-bony mass
In the mandibular premolars and molars region and in the ascending ramus
Usually asymptomatic
Women > men
20~40 y/o
Children: Juvenile aggressive cemento-ossifying fibroma
Discussion-treatment
Uncomplicated cases: enucleation of the lesion with curettage
Large-sized cementifying and ossifying fibroma:
Mono-bloc resection with bone reconstruction
Radiotherapy is contraindicated
Prognosis is fair
Recurrence: 28% of patients with mandibular central cemento-ossifying fibromas
Conclusion
When surgical treatment is carried out at an early age, cemento-ossifying fibroma seldom recur.
Their successful management therefore depends largely on the establishment of accurate clinical diagnosis aided by extensive investigation and careful interpretation of radiographs.
Our Case Journal
sex Female Male
age 14 23
site Mandibular canine-
premolar region Mandibular premolar-molar region
symptom and
sign Painful swelling Painless swelling
size 2.2 X 1.8 cm 5.2 X 2.2 cm
Bony expansion + +
Treatment Excision Mono-bloc resection
醫學倫理討論
醫學倫理
•
醫學倫理:一種道德思考、判斷和決策,以倫 理學的觀點出發,以期能做出對病人最有利益、最能符合道德倫理規範的醫療決策
Tom Beauchamp &James Childress 六大原則 - 1979
1.行善原則(Beneficence):即醫師要盡其所能延長病人之生命且減輕病人之痛苦。
2. 誠信原則(Veractity):即醫師對其病人有「以誠信相對待」的義務。
3. 自主原則(Autonomy):即病患對其己身之診療決定的自主權必須得到醫師的尊重。
4. 不傷害原則(Nonmaleficence):即醫師要盡其所能避免病人承受不必要的身心傷 害。
5. 保密原則(Confidentiality),即醫師對病人的病情負有保密的責任。
6. 公義原則(Justice),亦即醫師在面對有限的醫療資源時,應以社會公 平、正義的考量來協助合理分配此醫療資源給真正最需要它的人。
行善原則 (Beneficence)
•
行善原則包括不傷害原則的反面義務(不應該做的事)和確有助益的正面義 務(應該做的事),包括維護和促進病人的健康、利益和福祉,為基本倫理 原則,也是醫護人員的基本義務•
臨床意義(1) 勿施傷害:不得故意對他人施予傷害或惡行 (2) 預防傷害:應該預防傷害或惡行
(3) 移除傷害:應該移除傷害或惡行
(4) 維持善行:應該致力於行事或維持善行
做Excision後是否有減輕p’t的疼痛感?或是使p’t更不舒服?手術的介入時 機是否恰當?
誠信原則(Veractity)
是否有清楚的向病人說明清楚疾病病程、治療計畫、
預後、風險?
對於病人疾病嚴重程度是否有誠實的通知,盡到告
知的義務?
自主原則 (Autonomy)
•
一位具理性思考能力的病人,在完全瞭解醫療處置方針的利弊得失下,有權決定自己的行為,包括決定及選擇醫療專業人員和治療方式
•
臨床意義(1) 病人之自主行為不應遭受他人之操控或干預
(2)指醫療人員應提供充分且適當之資訊,以促成病人針對診療方式主動作 一抉擇
在說明病情及治療計畫、風險之後,是否有讓病人充分自主的選擇治療 計畫?在做麻醉以前,是否有說明完整之後再請病人自主的簽名同意?
不傷害原則 (Non-maleficence)
•
原則:不殺害病人、不能侵害病人權益和福祉以及平衡利害得 失,使痛苦減到最低
•
臨床意義(1)醫療上是必須的,或是屬於醫療適應症範圍,因所施行的各種檢查或治療 而帶來的傷害應符合不傷害原則
(2)權衡利害原則 → 兩害相權取其輕 (3)保護病人的生命安全
手術過程中,是否有造成不必要醫源性的傷害?詳實的說明解釋治療計畫,
並且讓病人對於治療計畫沒有疑問,使得心理方面壓力不那麼大,也是 一種不傷害原則
保密原則(Confidentiality)
告知的對象 1. 本人為原則
2. 病人未明示反對時, 亦得告知其配偶與親屬 3. 病人為未成年人時, 亦須告知其法定代理人
4. 若病人意識不清或無決定能力, 應須告知其法定 代理人.配偶.親屬或關係人
5. 病人得以書面敘明僅向特定之人告知或對特定 對象不予告知
公義原則 (Justice)
•
原則:強調資源合理分配、賞罰分明以及合乎正義之事。醫療上公平原則指基 於正義與公道,以公平合理的態度來對待病人、病人家屬和受影響的社 會大眾
•
臨床意義(1) 公平地分配不足的資源 (2) 尊重病人的基本權利
(3) 尊重道德允許的法律及法律之前人人平等 (4) 先來先服務與急重症優先
手術的必要性?住院時間是否太長?藥物的必要性?
臨床案例討論
本案例符合自主原則 病人已了解自己的病狀 ,治療
方法,手術過程及術後復發 的可能性及併發症,並且有 簽麻醉同意書。
本案例符合行善原則 預防傷害+移除傷害
(Excision operation)
本案例符合不傷害原則 詳實的說明解釋治療計畫以
減輕病人心理壓力
本案例符合保密原則 病人為未成年人時, 有告知其
法定代理人(母親)