Chief Complaint

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口病 CASE REPORT

指導醫師：陳玉昆醫師陳靜怡醫師王文岑醫師

Intern L 組 2013/07/30

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General Data

 Name : 李XX

 Sex : Male

 Age : 21 years old

 Native : 台中

 Marital status : 未婚

 Attending V.S. : XXX 醫師

 First visit : 101/11/21

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Chief Complaint

 Referred from 文藝 LDC for further examination due to a cyst around tooth 48 (101/11/21)

101/11/21

(4)

Present Illness

101/11/21

This 21 years old male complained of pus discharge and pain over tooth 48, so he went to 文藝 LDC for examination.

At 文藝 LDC, a radiolucent cystic lesion was found over tooth 48 so he was referred to our oral surgery out-patient department for further treatment.

(5)

Past Medical History

 Underlying disease: (-)

 Hospitalization: (+), Pneumonia

 Surgery under GA: (-)

 Allergy: (-)

(6)

Past Dental History

 General routine dental treatment

 Attitude to dental treatment : co-operative

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Personal History

 Risk factors related to malignancy

 Alcohol：(-)

 Betel quid：(-)

 Cigarette：(-)

 Special oral habits : denied

 Irritation : denied

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Intraoral Examination

 Location:

 Dimension:

 Color: Pink

 Consistency: ?

 MMO: 52mm (11 to 41)

 Pain: (+)

 Tenderness: ?

 Pus discharge: (+), from ?

101/11/21

8

(9)

Intraoral Examination

 Dentition (Tooth 45-47):

 Mobility: ?

 Percussion pain: ?

 Palpation pain: ?

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Extraoral Examination

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Radiographic Examination

There is a multilocular(2 loculations) well-defined round shaped corticated radiolucencywith laterally, medially, upward, and downward bony expansion. This radiolucencyalso contained embedded tooth 48 inside, and the distal and mesialroots of tooth 47, distal root of tooth 46 were also contained. The radiolucencywas extending from the lateral border to the medial border of ramus, up to the coronoidprocess and down to the inferior border of mandibularbody, in mandibularbody, it extended from the mandibularangle to tooth 46 mesialroot periapicalarea without involving the mental foramen. Besides, the right mandibularcanal was downward displaced and narrowing, and there was a root resorptionover the distal and mesialroots of tooth 47 and 46. Approximately measuring 77.5 x31.6mm in dimension.

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Working Diagnosis

(13)

Our case Peripheral Intrabony

Mucosal lesion - + -

Induration - + -

Bony expansion + - +-

Cortical bone destruction

+ - +-

Intrabony

(14)

Inflammation, cyst or neoplasm

Our case Inflammation

Redness - +

Swelling + +

Local heat Unknown +

Pain + +

Cyst or neoplasm

(15)

Cyst or Neoplasm

Our case Cyst

Fluctuation Unknown +-

Well defined border + +

Bone expansion + +-

Our case Inflammation cyst

Non-Inflammation cyst

Pain, tenderness + + -

Local heat Unknown + -

Color Pink Reddish Pink

Progression Unknown Fast Slow

Sclerotic margin + - +

(16)

Our case Benign malignance

Border Well-defined Well-defined Ill-defined

Margin Smooth Smooth Irregular

Sclerotic margin + + -

Destruction of cortical margin + -+ +

Progressive Unknown Slow Fast

Swelling with intact epithelium + + -

Pain + - +

Induration Unknown - +

Non-inflammation Cyst

or Benign tumor

(17)

Working Diagnosis

(1) Unicystic ameloblastoma , right ramus

(2) Keratocystic odontogenic tumor , right ramus (3) Ameloblastic fibroma , right ramus

(4) Dentigerous cyst , right ramus

(5) Granular cell odontogenic tumor , right ramus

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Differential Diagnosis

(19)

Unicystic ameloblastoma

Our case Unicystic ameloblastoma

Gender Male Equal

Age 21 Second decade

Site Mandible (Molar → ascending ramus)

Mandible (Molar → ascending ramus)

Paresthesia Pain Uncommon

Swelling + +

Drainage + +/-

Radiography Well-defined , corticated margin

Well-defined, unilocular or multilocular, corticated margin

Bony expansion + +

Teeth displacement /root resorption

+ +

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Unicystic ameloblastoma

Unicystic ameloblastoma our case

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Keratocystic odontogenic tumor

Our case KCOT (larger)

Gender Male Slight male

Age 21 10~40

Mandible (posterior body and ascending ramus)

Paresthesia Pain Pain

Swelling + +

Drainage + +

Well-defined, smooth, unilocular or multilocular, corticated margin

Bony expansion + -

+ +

(22)

Keratocystic odontogenic tumor

KCOT our case

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Ameloblastic fibroma

Our case Ameloblastic fibroma

Gender Male Male

Age 21 Under 20

Posterior mandible (70%)

Paresthesia Pain Pain +/-

Swelling + + (large)

Drainage + -

Well-defined RL with a sclerosis margin

Bony expansion + +

+ +/-

(24)

Ameloblastic fibroma

Ameloblastic fibroma our case

(25)

Dentigerous cyst

Our case Dentigerous cyst

Gender Male Slight male

Age 21 10~30

Mandible (Often involved third molar)

Paresthesia Pain Painless

Swelling + +

Drainage + +

Well-defined, smooth, corticated margin

Bony expansion + +/-

+ -

(26)

Dentigerous cyst

Dentigerous cyst our case

(27)

Granular cell odontogenic tumor

Our case Granular cell odontogenic tumor

Gender Male Female

Age 21 40

Mandible (Premolar→Molar)

Paresthesia Pain Painless

Swelling + +

Drainage + +

Well-defined , corticated margin

Bony expansion + +

+ -

(28)

Granular cell odontogenic tumor

our case

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Clinical Impression

 Unicystic ameloblastoma , right ramus

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Treatment course

 Aspiration and Decompression button：

Extract tooth 47 & 48, and set 2 decompression button Under LA , and biopsy

 Surgical plan：

Enucleation of lesion and complicated extraction of tooth 46 under GA

 Follow up ： 1. Wound healing 2. Bone density

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Treatment course

 101/11/21, referred from 文藝LDC for further TX Aspiration & Decompression button &Biopsy

 101/12/19, F/U and biopsy

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Treatment course

 Histology report(101/11/21)

Infected odontogenic cyst

 Histology report(101/12/19)

unremarkable tooth structure and scanty fibrous tissue

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Treatment course

 102/1/23, 2/20, 4/24, 6/19：F/U with pano taking

102/1/23 102/2/20

102/4/24

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Treatment course

 102/7/4, Surgical plan

Enucleation and complicated extraction of tooth 46

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Treatment course

 102/7/4, Surgical plan

Enucleation and complicated extraction of tooth 46

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Treatment course

 Histology report(102/7/4) Pathologic diagnosis：

Unicystic Ameloblastoma

(bone, mandible, right, enucleation)

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Discussion

Marsupialization of unicystic ameloblastoma: A conservative approach for aggressive odontogenic tumors

Year : 2011 | Volume: 22 | Issue : 5 | Page : 709-712

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Abstract

 In this report, we have presented two cases of

Uas(unicystic ameloblastoma), both of which were successfully managed with enucleation

following marsupialization.

 The patients were free of the condition and did not show any signs of recurrence on radiographic follow-ups even after 30 months of the final procedure.

Indian Journal of Dental Research Year : 2011 | Volume : 22 | Issue :

5 | Page : 709-712

38

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Case 1

 A 17 year-old male patient was referred to the clinic with the chief complaint of a painless swelling in the right

mandibular premolar region without any sign of sensory impairment.

5 | Page : 709-712

39

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Case 1

 Under local anesthesia, an incisional biopsy was

performed and the lesion was decompressed between

two premolar teeth and left uncovered with the aid of an acrylic stent.

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Case 1

 Histopathological

evaluation of the lesion revealed luminal type UA without any tumor

cells within the cyst wall.

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Case 1

 The patient was scheduled for radiographic follow-up after an interval of three months.

 Post 18 months of marsupialization, the diminished lesion was completely enucleated with peripheral

ostectomy

to ensure complete removal of the margins.

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Case 1

 There were no signs of recurrence even at 30 months of follow-up.

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Case 2

 A 52 year old healthy edentulous woman , complaining of a slow growing swelling in the region of the ramus of the left mandible, without any signs of sensory

disturbance.

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44

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Case 2

 Simultaneous decompression of the lesion with

incisional biopsy was carried out and an acrylic obturator

was made to keep the lesion uncovered.

 A solid growth with a diameter of 1 cm which developed through the lumen of the cystic cavity was detected and removed.

5 | Page : 709-712

45

(46)

Case 2

 Histopathologic findings of the lesion revealed granular

UA with mural invasion.

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Case 2

 Post 18 months of marsupialization, the impacted tooth and the regressed lesion was enucleated, and peripheral ostectomy was performed

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Case 2

 At 30 month follow-up, the lesion was completely healed without any sign of recurrence.

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48

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Discussion

 Lau and Samman reviewed treatment modalities for UA and reported that the highest recurrence rate (30.5%) was

observed with single enucleation, while the lowest (3.6%) was observed with resection.

 They also found that recurrence rate was decreased (18%) when marsupialization

was applied prior to curettage.

5 | Page : 709-712

49

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Discussion

 Give better response to conservative treatments (Classified by Ackermann)

 subtype 1: unilocular cystic luminal

 subtype 2: intraluminal with a solid growth inside lumen of the cystic lesion

 More aggressive treatment options could be considered for subtype 3(intraluminal growth with mural invasion within adjacent tissues) lesions for UA.

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(51)

Discussion

 It has been suggested that an incisional biopsy should be done to determine the histopathologic subtype, for a

thorough management of UA.

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51

(52)

Conclusion

 Clinicians should also perform a close radiographic

follow-up and consider radical treatment options in case of suspicious radiographic changes during the

marsupialization follow-up period.

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(53)

 Removal of solid structures within the lesion during incisional biopsy

 More aggressive enucleation with peripheral ostectomy

 Accurate endodontic management of teeth in the area of the pre-existing lesion

→ help in improving the treatment outcome.

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Conclusion

53

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醫學倫理討論

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Tom Beauchamp &James Childress 六大原則- 1979

1.行善原則(Beneficence)：亦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)：亦即醫師對其病人有「以誠信相對待」的義務。

3. 自主原則(Autonomy)：亦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)：亦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)，亦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。

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行善原則

 做Decompression button後是否有減輕p’t 的脹痛感？或是使p’t更不舒服？

 手術的介入時機是否恰當？

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誠信原則

 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？

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自主原則

 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？

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不傷害原則

 手術過程中，是否有造成不必要醫源性的傷害？

 若詳實的說明治療計畫，並讓病人對於治療計畫沒有疑問，使心理壓力不那麼

大，

其實也可以算是一種不傷害原則

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保密原則

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

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公義原則

 手術的必要性？

 住院時間是否太長？

 藥物的必要性？

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醫學倫理總結

 在病例方面(病兆描述,治療計畫,病人態度)

應書寫詳盡, 使治療過程有詳實的記錄及治療順利

 在進行治療之前,須請病人簽屬同意書

 應在不違反醫學倫理的原則之下進行治療的行為

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