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G組
Int. 洪紹紘 林美萍 李俊生 許家維 郭芳嘉
General Data General Data
•
Name : 曾韻升•
Sex : 男•
Age : 15 y/o•
Native : 高雄•
Marital status : 未婚•
Occupation : 學生•
Attending V.S. : 陳俊明 醫師•
First visit : 96.08.02Chief Complaint Chief Complaint
• Mobility and biting pain over tooth 46, 47 for 2 weeks.
• Paresthesia over R’t lower lip
for half a year.
Present Illness
Present Illness - - 1 1
z 96.01
The 15y/o boy suffered from paresthesia over R’t lower lip.
z 96.06
He went to Dr. 文藝的LDC for help. After taking panorex, the dentist found nothing particular.
z 96.07初
He went to see a herbal doctor. The herbal
doctor taught him 指壓, but it still didn’t work.
Present Illness
Present Illness - - 2 2
z 96.07中旬
He found mobility and biting pain over 46, 47.
z 96.07.27
He went to Dr.文藝的LDC and periapical film of 46, 47 was taken. Dr.文藝 suspected the boy had immune problem. Therefore, Dr.文藝 referred him to Dr.賴聖宗 for further
examination and treatment.
Present Illness
Present Illness - - 3 3
z
96.08.02 first visited our OPD(OS) 1. Panorex was taken.
2. OE : 46 Æ floating tooth, mobility grade II 47 Æ mobility grade I
45~47 buccal & lingual bone expansion 3. Plan : (1) refer to 小兒科 for evaluation
(2) 安排CT scan (3) 安排biopsy
4. P‘t的母親有提及P’t曾經刷牙後, 在45~47部位有
牙齦出血並流血不止的情形.Present Illness
Present Illness - - 4 4
z 96.08.03
CT examination was performed.
z 96.08.07
# Incisional biopsy was performed at 47 buccal
gingiva.
#
Easy bleeding for 47 buccal gingiva after biopsy Æ
電刀止血z 96.08.14
Angiography was performed.
Past History Past History
• Past Medical History
– Denied any systemic diseases
– Denied any drug or food allergies
• Past Dental History
– OD
– scaling
- attitude for dental tx: cooperative
Personal History Personal History
z
Risk factors related to malignancy–Alcohol:(-) –Betel quid:(-) –Cigarette:(-)
Family History Family History
z
Hereditary disease: Nilz
Family support : goodExtraoral
Extraoral Examination Examination
- MMO: 39 mm (11~41)
- LAP(-)- No facial asymmetry
- Numbness over right lower lip
- Duration : 6 months
Intraoral
Intraoral Examination Examination
- 45, 46, 47 buccal & lingual bony expansion
- Smooth surface
- Swelling over 46 47 lingual and vestibular side
- Color : normal pink - No discharge
- The adjacent mucosa seems to be normal.
- rebound tooth
- gingiva of 46 47 area seems bleeding easily
96/08/02
- Biting pain (+) - Tenderness (-) - Induration (-)
- Unerupted teeth : 18, 28,38, 48 - Restoration : 16, 26, 36
- Tooth mobility :
46, 47 grade I~IIIntraoral
Intraoral Examination Examination (cont.) (cont.)
Physical Examination Physical Examination
z Consistency : soft ~ rubbery
z Fluctuation (-)
z Pain (-)
z biting pain(+) Æ tooth 46 47
z Tenderness (-)
z Induration (-)
z Fever or local heat (-)
z R`t Lower lip paresthesia (+)
z Lymphadenopathy (-)
Radiographic Examination
Radiographic Examination (Panoramic film) (Panoramic film)
96/08/02
z There is an ill-defined diffused radiolucency with ragged border over the right mandibular body extending from distal aspect of tooth 47 to distal aspect of tooth 44 and from the inferior border of right mandible up to alveolar crest between tooth 46 and 47, measuring approximately 6 × 4 cm in diameter.
z Tooth 45 , 46 , 47 & distal of 44 loss of the dental lamina dura and displacement of tooth 46 & 47 are noted . Tooth 46 floating in air is noted. In addition ,
thinning of right mandible cortex and missing of inferior alveolar canal are noted too.
Radiographic Examination Radiographic Examination
96/08/02
z
Dental findings:
- Filling : 16, 26, 36
- bone loss of alveolar crest between tooth 46 & 47 , - angular bony defect of 46 mesial , tooth 46&47
displacement
z
No other abnormalities were observed.
CT CT
1.
Prominent soft tissue is noted in the R`t Mand. Angle2.
The adjacent bony structures are destructed3. Enlarged lymph nodes (>1cm) are noted in right jugulodigastric and submandibular space.
Imp:
1.
Prominent soft tissue withenhancement and bony destruction in the right mand. Angle. Susp:
ameloblastoma
Æ biopsy , DDx: SCC
2.
Enlarged lymph nodes in the right jugulodigastric and submandibular spaceIncisional
Incisional biopsy biopsy
z
H-P report:– Imp: hemagioma, capillary. buccal
gingiva. lower right.
– However , it is only a superficial biopsy
and what is the possible histological
picture of the intrabony area remains to
be investigated
Angiography Angiography
z
Imp:1. Consistent with hemangioma with
feeders from right maxillary and facial artery.
Angiography
Angiography
Working diagnosis Working diagnosis
■
Inflammation? Cyst? Neoplasm?
- Fever or local heat (-) - Duration : 6 months - ill-defined RL
- swelling (+) - pain (-)
- Numbness over left lower lip - normal pink
inflammation
Rule out Cyst or Neoplasm
■ Cyst ? Neoplasm?
- ill-defined RL - Lower Tooth mobility -Fluctuation(-) - Bony expansion and - Duration : 6 months perforation
- Induration (-) - inferior alveolar canal - adjacent mucosa Æ normal missing
- Lymphadenopathy (+) - Numbness over right lower lip - Smooth surface
- Bitting pain(+) - pain (-)
- tenderness(-)
neoplasm
Working diagnosis Working diagnosis
Working diagnosis Working diagnosis
■
Central ? Peripheral?
- smooth surface - ill-defined RL
- adjacent mucosa - lingual bony expansion and Æ normal perforation
Central
Neoplasm (central type)Benign tumor Malignant tumor
Working diagnosis Working diagnosis
-ill-defined diffused RL with ragged border -6 months
-lingual bony expansion & perforation -inferior alveolar canal missing
Malignant tumor
Working diagnosisWorking diagnosis■ CT & X-ray feature - ill-defined diffused RL
with ragged border
- Lingual bony expansion and perforation
- Lamina dura of involving root disappear
- tooth 46 floating in air - bone loss of alveolar crest
between tooth 46 & 47 -Tooth 46 , 47 displacement -Lymphadenopathy (+)
■ Clinical feature - EPT: ?
- Smooth surface
- Adjacent mucosa Æ normal - Swelling(+)
- tooth mobility 46, 47 - Color : normal pink
- Consistency : soft ~ rubbery - Fluctuation (-)
- Duration : 6 months
- Numbness over right lower lip - Bitting pain (+)
- Pain (-)
- Percussion (-) - Tenderness (-) - Induration (-) -Bleeding tendency
1.Angiosarcoma 4.Fibrosarcoma
2. Osteosarcoma 5.Chondrosarcoma 3.Ewing`s sarcoma 6.Lymphoma
1.Angiosarcoma 4.Fibrosarcoma
2. Osteosarcoma 5.Chondrosarcoma
3.Ewing`s sarcoma 6.Lymphoma
Malignant tumor
Working diagnosisWorking diagnosis1.Angiosarcoma 4.Fibrosarcoma
2. Osteosarcoma 5.Chondrosarcoma 3.Ewing`s sarcoma 6.Lymphoma
1.Angiosarcoma 4.Fibrosarcoma
2. Osteosarcoma 5.Chondrosarcoma
3.Ewing`s sarcoma 6.Lymphoma
Differential Diagnosis Differential Diagnosis 1 . Angiosarcoma
2. Non-Hodgkin’s lymphoma 3. Fibrosarcoma
4. Osteosarcoma
5. Ewing`s sarcoma
6. Chondrosarcoma
Angiosarcoma
Angiosarcoma
angiosarcoma
Our case Gender
Gender UnknownUnknown MaleMale
Race
Race
UnknownUnknown AsianAsianAge Age
elderlyelderly 1515Site
Site
Head and neck (>50%) Scalp and forehead most common, oral quite rare.Mandible is the most common in oral.
Mandibular
Mandibular body body
Symptom
Symptom• early lesion : simple bruise
•Bleeding tendency
•Rebound tooth
••Swelling(+)Swelling(+)
••Numbness over R`tNumbness over R`t lower lip
lower lip
••Mobility of tooth 46,47Mobility of tooth 46,47
••46, 47 gingival bleeding 46, 47 gingival bleeding easily
easily
••Fluctuation(-Fluctuation(-))
••Pain(-Pain(-) Tenderness() Tenderness(--))
••Smooth surfaceSmooth surface
angiosarcoma Our case Margin
Margin illill-defined diffused RL -defined diffused RL ill-ill-defined diffused defined diffused RL with ragged RL with ragged
border border
XX--ray featureray feature illill--defined diffused RL defined diffused RL illill--defined diffused defined diffused RL RL
SizeSize variable 6.0 x 4.0 cm6.0 x 4.0 cm
Density
Density Radiolucency RadiolucencyRadiolucency
Effects on Effects on surrouding surrouding
structure structure
•Bone destruction and expansion
•Floating teeth
••teeth displacementteeth displacement
••Bone expansion and Bone expansion and perforation
perforation
••Thinning of Thinning of
mandible inferior mandible inferior
cortical border cortical border
•Inferior alveolar canal missing
•Floating teeth
Non-Hodgkin’s lymphoma
Non-Hodgkin’s lyphoma
Our case Gender
Gender No abviousNo abvious differencedifference MaleMale
Race
Race
Any race Any race AsianAsianAge Age
Primarily in adultsPrimarily in adults 1515Site
Site
Buccal vestibule, posterior hard palate, gingivaMandibular body Mandibular body
Symptom
SymptomSwelling (+) in boggy consistency
Vague pain or discomfort Paresthesia (+)
Tenderness (+/-) Ulceration (+/-)
••Swelling(+)Swelling(+)
••Numbness over R`t Numbness over R`t lower lip
lower lip
••Mobility of tooth 46,47Mobility of tooth 46,47
••46, 47 gingival bleeding 46, 47 gingival bleeding easily
easily
••Fluctuation(-Fluctuation(-))
••Pain(Pain(--) Tenderness() Tenderness(--))
••Smooth surfaceSmooth surface
Non-Hodgkin’s lymphoma Our case Margin
Margin Ill-Ill-defined without corticated defined without corticated margin
margin
illill--defined diffused RL defined diffused RL with ragged border with ragged border XX--ray featureray feature zRounded or multiloculated
lacking a defining outer cortex
zInvasive border
zPeriosteal reaction not common
illill--defined diffused RL defined diffused RL
SizeSize variablevariable 6.0 x 4.0 cm6.0 x 4.0 cm Density
Density Entire radiolucencyEntire radiolucency RadiolucencyRadiolucency
Effects on Effects on surrouding surrouding
structure structure
zzExpansion of the bone, and Expansion of the bone, and perforate the cortical plate perforate the cortical plate
zzDestroy the cortex of the Destroy the cortex of the neurovascular canal
neurovascular canal
zzGrow in the PDL of mature teethGrow in the PDL of mature teeth
zzThe involved teeth displaced in The involved teeth displaced in an occlusal direction and
an occlusal direction and exfoliated
exfoliated
••teeth displacementteeth displacement
••Bone expansion and Bone expansion and perforation
perforation
••Thinning of mandible Thinning of mandible inferior cortical border inferior cortical border
•Inferior alveolar canal missing
•Floating teeth
Fibrosarcoma
Fibrosarcoma
fibrosarcoma
Our case
Gender M:F=1:1 Male
Race Any race Asian
Age
Young adult and children15
Site Most in mandibular premolar-molar region
Mandibular body
Symptom
Swelling (+) Pain(+)
Paresthesia (+) Tenderness (+/-)
May invade soft tissue , cause bulky lesion.
Pathology fracture
•Swelling(+)
•Numbness over R`t lower lip
•Mobility of tooth 46,47
•46, 47 gingival bleeding easily
•Fluctuation(-)
•Pain(-) Tenderness(-)
•Smooth surface
fibrosarcoma Our case Margin
Margin Ill-defined without corticated margin ill-ill-defined diffused RL with defined diffused RL with ragged border
ragged border
XX--ray featureray feature zRounded or multiloculated lacking a defining outer cortex
zInvaded border
zSaucer – like depression (peripheral type)
ill-ill-defined diffused RL defined diffused RL
SizeSize variable 6.0 x 4.0 cm6.0 x 4.0 cm
Density
Density Entire radiolucency RadiolucencyRadiolucency
Effects on Effects on surrouding surrouding
structure structure
zExpansion of the bone, and perforate the cortical plate
zDestroy the cortex of the neurovascular canal
zThe involved teeth may displaced , resorption or floating in air.
••teeth displacementteeth displacement
••Bone expansion and Bone expansion and perforation
perforation
••Thinning of mandible Thinning of mandible inferior cortical border inferior cortical border
••Inferior alveolar canal Inferior alveolar canal missing
missing
••Floating teethFloating teeth
Osteosarcoma
Osteosarcoma
Osteosarcoma Our case Gender
Gender
MaleMale MaleMaleRace Race
unknownunknown AsianAsianAge Age
Average 33Average 33 1515Site Site
Long boneMaxilla = Mandible
Mandibular body Mandibular body
Symptom Symptom
•Pain
•Mobility
•Numbness
•Swelling
•Smooth
••Swelling(+)Swelling(+)
••Numbness over R`t Numbness over R`t lower lip
lower lip
••Mobility of tooth 46,47Mobility of tooth 46,47
••46, 47 gingival bleeding 46, 47 gingival bleeding easily
easily
••Fluctuation(-Fluctuation(-))
••Pain(-Pain(-) Tenderness() Tenderness(--))
••Smooth surfaceSmooth surface
Osteosarcoma
Our case Margin Irregular ill-
defined border
ill-defined diffused RL with ragged border X-ray
feature
sunburst ill-defined diffused RL
Size variable variable 6.0 x 4.0 cm Density RO, RL or mixed Radiolucency
Effects on surrouding
structure
•Bone expansion
•Bone penetration
•PDL space widening
•Root resorption
•Periosteum reaction
•teeth displacement
•Bone expansion and perforation
•Thinning of mandible inferior cortical border
•Inferior alveolar canal missing
•Floating teeth
Ewing`s sarcoma
Ewing`s sarcoma
Ewing’s sarcoma Our case Gender
Gender
MaleMale MaleMaleRace Race
WhiteWhite AsianAsianAge Age
<20<20 1515Site Site
Long bone, pelvis, rib, mandible(1~2%)Mandibular body Mandibular body
Sympto Sympto m m
•Pain
•Mobility
•Numbness
•Swelling
•smooth
••Swelling(+)Swelling(+)
••Numbness over R`t Numbness over R`t lower lip
lower lip
••Mobility of tooth 46,47Mobility of tooth 46,47
••46, 47 gingival bleeding 46, 47 gingival bleeding easily
easily
••Fluctuation(-Fluctuation(-))
••Pain(-Pain(-) Tenderness() Tenderness(-)-)
••Smooth surfaceSmooth surface
Ewing’s sarcoma
Our case
Margin Irregular ill-defined border
ill-defined diffused RL with ragged border
X-ray feature Onion skin ill-defined diffused RL
Size 6.0 x 4.0 cm
Density Radiolucency Radiolucency
Effects on surrouding
structure
•Bone expansion
•Bone penetraction
•Periosteum reaction
•teeth displacement
•Bone expansion and perforation
•Thinning of mandible inferior cortical border
•Inferior alveolar canal missing
•Floating teeth
Chondrosarcoma
Chondrosarcoma
Chondrosarcoma Our case Gender
Gender F : M = 1 : 1F : M = 1 : 1 MaleMale RaceRace White more than other racesWhite more than other races AsianAsian
AgeAge At any ageAt any age 1515
SiteSite Maxilla : anterior region
Mandible : 1. coronid process 2. condylar head and neck 3. symphyseal region
Mandibular body Mandibular body
Symptom Symptom
Swelling (+) Hemorrage(+) Firm or hard mass
Sensory nerve deficits, proptisis
Visual disturbance
Trismus when occur in TMJ
••Swelling(+)Swelling(+)
••Numbness over R`t Numbness over R`t lower lip
lower lip
••Mobility of tooth 46,47Mobility of tooth 46,47
••46, 47 gingival bleeding 46, 47 gingival bleeding easily
easily
••Fluctuation(Fluctuation(--))
••Pain(Pain(--) Tenderness() Tenderness(--))
••Smooth surfaceSmooth surface
Chordrosarcoma Our case Margin Well-defined and at times
corticated. Sometimes ill-defined
ill-defined diffused RL with ragged border
X-ray feature 1.round,ovoid,lobulated
2.ground-glass appearance 3. moth-eaten with island of residual bone
ill-defined diffused RL
Size variable 6.0 x 4.0 cm
Density mixed radiopaque and radiolucent appearance
Radiolucency
Effects on surrouding
structure
-- at mandible : alveolar process expanded
--at maxilla : maxillary sinus may be pushed.
--at condyle : remodeling , expansion,erosion ,
--near tooth : resorption and displacement
•teeth displacement
•Bone expansion and perforation
•Thinning of mandible inferior cortical border
•Floating teeth
Clinical impression Clinical impression
z Hemangioma R/O angiosarcoma
over R`t mandible body
Thanks for your attention!!!