• 沒有找到結果。

初診科 初診科 Case Report Case Report

N/A
N/A
Protected

Academic year: 2022

Share "初診科 初診科 Case Report Case Report"

Copied!
49
0
0

加載中.... (立即查看全文)

全文

(1)

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

(2)

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 : 96.08.02

(3)

Chief Complaint Chief Complaint

Mobility and biting pain over tooth 46, 47 for 2 weeks.

Paresthesia over R’t lower lip

for half a year.

(4)

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.

(5)

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.

(6)

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.

(7)

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.

(8)

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

(9)

Personal History Personal History

z

Risk factors related to malignancy

–Alcohol:(-) –Betel quid:(-) –Cigarette:(-)

(10)

Family History Family History

z

Hereditary disease: Nil

z

Family support : good

(11)

Extraoral

Extraoral Examination Examination

- MMO: 39 mm (11~41)

- LAP(-)

- No facial asymmetry

- Numbness over right lower lip

- Duration : 6 months

(12)

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

(13)

- Biting pain (+) - Tenderness (-) - Induration (-)

- Unerupted teeth : 18, 28,38, 48 - Restoration : 16, 26, 36

- Tooth mobility :

46, 47 grade I~II

Intraoral

Intraoral Examination Examination (cont.) (cont.)

(14)

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 (-)

(15)

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.

(16)

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.

(17)

CT CT

1.

Prominent soft tissue is noted in the R`t Mand. Angle

2.

The adjacent bony structures are destructed

(18)

3. Enlarged lymph nodes (>1cm) are noted in right jugulodigastric and submandibular space.

(19)

Imp:

1.

Prominent soft tissue with

enhancement and bony destruction in the right mand. Angle. Susp:

ameloblastoma

Æ biopsy , DDx: SCC

2.

Enlarged lymph nodes in the right jugulodigastric and submandibular space

(20)

Incisional

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

(21)

Angiography Angiography

z

Imp:

1. Consistent with hemangioma with

feeders from right maxillary and facial artery.

(22)

Angiography

Angiography

(23)

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

(24)

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

(25)

Working diagnosis Working diagnosis

Central ? Peripheral?

- smooth surface - ill-defined RL

- adjacent mucosa - lingual bony expansion and Æ normal perforation

Central

(26)

„

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

(27)

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

(28)

Malignant tumor

Working diagnosisWorking diagnosis

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

(29)

Differential Diagnosis Differential Diagnosis 1 . Angiosarcoma

2. Non-Hodgkin’s lymphoma 3. Fibrosarcoma

4. Osteosarcoma

5. Ewing`s sarcoma

6. Chondrosarcoma

(30)

Angiosarcoma

Angiosarcoma

(31)

angiosarcoma

Our case Gender

Gender UnknownUnknown MaleMale

Race

Race

UnknownUnknown AsianAsian

Age Age

elderlyelderly 1515

Site

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

(32)

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

(33)

Non-Hodgkin’s lymphoma

(34)

Non-Hodgkin’s lyphoma

Our case Gender

Gender No abviousNo abvious differencedifference MaleMale

Race

Race

Any race Any race AsianAsian

Age Age

Primarily in adultsPrimarily in adults 1515

Site

Site

Buccal vestibule, posterior hard palate, gingiva

Mandibular body Mandibular body

Symptom

Symptom

Swelling (+) 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

(35)

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

(36)

Fibrosarcoma

Fibrosarcoma

(37)

fibrosarcoma

Our case

Gender M:F=1:1 Male

Race Any race Asian

Age

Young adult and children

15

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

(38)

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

(39)

Osteosarcoma

Osteosarcoma

(40)

Osteosarcoma Our case Gender

Gender

MaleMale MaleMale

Race Race

unknownunknown AsianAsian

Age Age

Average 33Average 33 1515

Site Site

Long bone

Maxilla = 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

(41)

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

(42)

Ewing`s sarcoma

Ewing`s sarcoma

(43)

Ewing’s sarcoma Our case Gender

Gender

MaleMale MaleMale

Race Race

WhiteWhite AsianAsian

Age Age

<20<20 1515

Site 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

(44)

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

(45)

Chondrosarcoma

Chondrosarcoma

(46)

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

(47)

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

(48)

Clinical impression Clinical impression

z Hemangioma R/O angiosarcoma

over R`t mandible body

(49)

Thanks for your attention!!!

參考文獻

相關文件

 Pano: There is a well-defined, not corticated, multilocular, scalloped radiolucency over left mandible body and symphysis, extending from the apex of tooth 42 to the distal side

There is a well-defined, unilocular radiolucency with corticated margin (lower margin of the lesion) over R’t mandibular body &amp; ramus, extending from distal side of tooth 46 to

corticated margin over the apex of tooth 32 to 46, extending from 32 root apex to mesial root apex of tooth 46 and from mandible alveolar ridge of 41 to 45 down to the

• There is a solitary well-defined corticated unilocular radiolucent shadows located in left mandibular body, measured about 2.0 x 3.0 cm in maximum diameter, extending from

mandible, extending from distal side of tooth 32 and the impacted tooth 33 to the mesial root of tooth 75 and the impacted tooth 35, measuring about 3.0 x 3.0 cm²..

There is a well-defined unilocular round shaped radiolucence with a corticated margin over the apex of tooth 32,33, which extending from mesial aspect of tooth 34 root apex to

posterior maxilla, extending from the distal side of tooth 24 to the left maxillary tuberosity, and from 2/3 height of left maxillary sinus to the left maxillary.. alveolar crest

margin over left posterior maxilla, extending from the distal side of tooth 24 to the mesial side of tooth 26 , and from the border of left maxillary sinus to the left