General Data

(1)

May 25^th, 2009

指導老師：林立民

指導老師：林立民教授、陳玉昆教授、陳玉昆主任、主任、

王文岑

王文岑醫師、陳靜怡醫師、陳靜怡醫師醫師 報告者

報告者 I tI t I組I組林蔚庭黃文信林蔚庭黃文信 報告者：

報告者：Intern IIntern I組組林蔚庭、黃文信、林蔚庭、黃文信、

孫婉菁、郭芯妤 孫婉菁、郭芯妤

(2)

General Data

y

Name : 張XX G d F l

y

Gender : Female

y

Age : 17

y

Native : 嘉義

y

Occupation : Student

y

Marital status : 未婚

y

Attending V.S. : 陳玉昆醫師Attending V.S. : 陳玉昆醫師

y

First visit :98/05/04

(3)

Chief Complaint p

y

Tooth 14 & 15 mobility increase and a swelling mass on the palatal side of tooth 14 & 15 for at least 6

on the palatal side of tooth 14 & 15 for at least 6 months

(4)

Present Illness

y

This 17 y/o female suffered from the above episode for at least 6 months She found that her mass was for at least 6 months. She found that her mass was larger and larger in these days. She went to LDC for help recently because she felt painful over the right help recently because she felt painful over the right upper posterior area. And then, the dentist suggested her to go to the medical center for further evaluation. e o go o e ed ca ce e o u e e a ua o So she came to our OPD for examination.

(5)

Past Historyy

y Past Medical History

y Denied any drug or food allergy

y Denied any systemic disease

y Hospitalization (+) due to severe fever, many years ago

y Past Dental History

y General dental treatment

y Attitude to dental treatment: cooperative

(6)

Personal Historyy

y Alcohol: (-) y Betel nut : (-) y Cigarette : (-) y Cigarette : (-)

y Other special oral habits: (-)

(7)

Intraoral Examination

y An hard dome-shaped

il ith th

sessile mass with smooth surface was found over

th l t l id f t th the palatal side of tooth 14 & 15, measuring

about 2 2 cm

about 2 × 2 cm

(8)

Physical Examination y

y

Pain (+)

y

Tenderness (+)

y

Tenderness (+)

y

Induration (-)

y

Fluctuation ( )

y

Fluctuation (-)

y

Mobility of mass: fixed

y

Mobility of teeth: grade I:15

y

Mobility of teeth: grade I:15

y

Fever or local heat (-)

y

L h d th ( )

y

Lymphadenopathy (-)

y

Duration: at least 6 months EPT ( ) ( )

y

EPT:14(-), 15(-)

(9)

(10)

Panoramic film Finding Panoramic film Finding Panoramic film Finding Panoramic film Finding

y

There is a mixed radiolucent and radiopaque lesion with well defined sclerotic margin and it looks like with well-defined sclerotic margin, and it looks like cotton wood. The lesion is over right hard palate extending from the mesial side of tooth 15 to the extending from the mesial side of tooth 15 to the

middle of the tooth 13, measuring approximately 2x2 cm in diameter. Besides, the R’t sinus is not so clear.

c d a e e es des, e s us s o so c ea Maybe, the right sinus is involvement.

(11)

Periapical

Periapical film Finding film Finding Periapical

Periapical film Finding film Finding

y

there is discontinuity of lamina dura of tooth 14 and 15 which are pushed away in different direction

15 which are pushed away in different direction movement by the lesion .

(12)

Occlusal

Occlusal film Finding film Finding Occlusal

Occlusal film Finding film Finding

y

No more specific finding in occlusal film because of anatomic structure

anatomic structure.

(13)

Di i i

Disease origin : Disease origin : 1.

1. Peripheral or intra Peripheral or intra--Bony origin p p Bony origin y y g g 2.

2. Inflammation or cyst or neoplasm Inflammation or cyst or neoplasm B i li

B i li 3.

3. Benign or malignant Benign or malignant

(14)

Peripheral or Intra

Peripheral or Intra--bony origin? bony origin?

y Induration: (-)

B d t ti ( )

y

Bony destruction: (+)

y

Bony expansion: (+)

Intra

Intra--bony origin bony origin

(b t t l t i h l (b t t l t i h l (but cannot rule out peripheral

(but cannot rule out peripheral origin

origin completely) completely)

(15)

Inflammation or Cyst or Inflammation or Cyst or Inflammation or Cyst or Inflammation or Cyst or Neoplasm?

Neoplasm?

y

Fever or Local heat: (-)

y

Lymphadenopathy: ( )

y

Lymphadenopathy: (-)

y

Pus discharge : (-)

y

Duration: at least 6 months

y

Duration: at least 6 months

y

Fluctuation (-)

y

Consistency: firm

y

Consistency: firm

y

Mobility of mass: fixed

Neoplasm eop as

(16)

Neoplasm

Neoplasm Benign or malignant? Benign or malignant?

y

Pain: (+)

y

Tendeness: (+)Tendeness: (+)

y

Induration: (-)

y

Lymphadenopathy: (-)

y

Lymphadenopathy: ( )

y

X-ray finding: marginÆ well-defined

mixed RL & RO lesion mixed RL & RO lesion

B i

Benign

(fibro osseous lesions)

(fibro-osseous lesions)

(17)

1. 1. Ossifying Ossifying fibroma fibroma 1.

1. Ossifying Ossifying fibroma fibroma 2.

2. Fibrous dysplasia Fibrous dysplasia 3.

3. Osteoblastoma Osteoblastoma

(18)

bov

^{Our case} Ossifying fibroma

Gender Female Female > Male (5:1)

b

Age 17 y/o Wide age range (20~40)

Pain

Tooth 14 & 15 mobilit ↑

Asymptomatic P i l lli Symptom Tooth 14 & 15 mobility↑

Dome shape swelling mass

Painless swelling

Displacement of the teeth Facial asymmetry

Site 15,16 area Mandible

Molar &premolar area

Color Normal mucosa Normal mucosa

Size 2 × 2 cm

Surface smooth Smooth

Duration At least 6 months Slow growth

Induration - -

d

Tenderness + -

LAP - -

(19)

Our case Ossifying fibroma X-ray finding

Radiodensity Mixed RL & RO lesion Mixed radiolucent-radiopaque Low density (cotton-wool

appearance) border

Well-defined Well-defined unilocular

Thin, radiolucent line, Effects on

surrounding

Bony expansion

Displacement of teeth

Bony expansion

Displacement of teeth Lamina dura missing

structures Lamina dura missing

Resorption of teeth

(20)

Our case Fibrous dysplasia

Gender Female Female

≒

Male

Age 17 y/o 20~30

i P i l lli

Symptom

pain

Tooth 14 & 15 mobility↑

Painless swelling

Site 15, 16 area Maxilla >mandible

Size 2 × 2 cm -

Surface Smooth Smooth

Duration At least 6 months Slow growth

Induration - -

Tenderness + -

LAP - -

(21)

Our case Fibrous dysplasia X-ray finding

Radiodensity Mixed RL & RO lesion Ground glass appearance

border Well-defined illl-defined

border Well defined illl defined

Effects on surrounding

Bony expansion

Displacement of teeth

Bony expansion

Lamina dura missing

↑

d it f th b f th k ll g

structures

↑

density of the base of the skull

Displace the sinus floor superiorly

(22)

Osteoblastoma Osteoblastoma

Our case Osteoblastoma

Gender Female Male

Age 17 y/o <30

Frequency <1%

(mostly in spine and long bone) Symptom Pain

Tooth 14 & 15 mobility↑

Pain which can not relief by aspirin

Site 15, 16 area Mandibular posterior region

C l N l N l

Size 2 × 2 cm 2~4cm

Induration - Induration

Tenderness + +

LAP -

(23)

Osteoblastoma Osteoblastoma Os eob as o a Os eob as o a

Our case Osteoblastoma

http;//www.pathconsultddx.com

(24)

1. 1. Ossifying fibroma Ossifying fibroma 2.

2. Fibrous dysplasia Fibrous dysplasia 3.

3. Osteoblastoma Osteoblastoma 3.

3. Osteoblastoma Osteoblastoma

(25)

EPT

Biopsy

(26)

EPT

EPT ^98/05/09 ^{9 / 5/ 9}

y

Tooth 11: (+) 5 T th ( )

y

Tooth 12: (+) 9

y

Tooth 13: (-)

y

Tooth 14: (-)

y

Tooth 15: (-)

y

Tooth 16: (-)

(27)

Biopsy

Biopsy p y p y ^98/05/09 ^{9 / 5/ 9}

y

Incisional biopsy was performed over

the palatal side of tooth 14 & 15

at OS Department

of tooth 14 & 15

at OS Department.

y

Specimen sent to OM Department for HP exam

Ch k d di i d

y

Check wound condition and remove suture on 98/05/16.

h k / /

y

Check HP report on 97/05/23

(28)

Biopsy ^97/05/23

Main findings in HP report:

The specimen submitted consists of 6 hard tissue fragments in 1 bottle, fixed in formalin, measuring up to 0.3x0.3x0.3 cm in size.

bottle, fixed in formalin, measuring up to 0.3x0.3x0.3 cm in size.

Grossly, they are whitish in color and rubbery in consistency. All for section. The slide contains two identical groups of irregular-

h d d l ifi d h d ti i Mi i ll it i

shaped decalcified hard tissue specimens. Microscopically, it is characterized by prominent formation of osteoid tissue and

imature bone. Increased cellularity and vascularity of fibrous y y stroama and lots of osteoblast-like cells distributing along the margin of bone trabeculae are noted. Based upon the above findings it shows osteoblastoma