Present Illness

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Intern A 組 Case Report

INT：盧威利王瓈屏李存恩羅英睿指導醫師：林立民醫師、陳玉昆醫師、

王文岑醫師

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General Data

• Name : 林XX

• Sex : Male

• Age : 30 y/o

• Marital status : 未婚

• Attending V.S. : 陳俊明醫師

• First visit : 97.10.24

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Chief Complain

• Unhealing wound over maxilla and mandible about 3~4 months.

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Present Illness

• 97.10.13

P’t was referred form 博愛LDC to OM because of unhealing wound of 36, 46. Initial Imp: Periodontitis.

z

97.10.24 He was referred to OS for extraction of 47. After checking panorex, it showed radiolucence over R’t and L’t mandible post. area. And bone exposure were noted. Imp: Histocytosis lesion.

Incisional biopsy and extraction of 47 were performed.

• 97.10.31

H-P report : granulation tissue. We suggested him to follow up

in one month . However, he lost for F/U.

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Present Illness

z

98.3.20 P’t came to OS OPD for severe mobility of 38.Besides, the previous unhealing wound over 46,47,48 region

healed. Incisional biopsy was still suggested ,but P’t refused.

At the same day, simple extraction of 38 was performed.

z

98.9.14 Bone erosion was noted over 21 palatal area for few months. Besides, bilateral mandibular severe bony

destruction were noted. Impression: osteomyelitis R/O

Sarcoma over mandible and maxilla. Incisional biopsy over

21, 22 and L’t mandibular ramus were performed.

(6)

Present Illness

• 98.9.21

H-P report: pyogenic granuloma over anterior palatal and L’t mandibular ramus regions.

so we arranged GA routine and operation (excision

+ bone trimming) was arranged on 981006.

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Past History

• Past Medical History

– Major surgery (-)

– Hospitalization history (-)

– Denied any food and drug allergy – Denied any systemic disease

• Past Dental History

– General dental treatment

• Attitude to dental treatment : cooperative

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Personal History

• Risk factor related to malignancy

– Alcohol (+) – Betel quid (-)

– Cigarette (+) 10+ years

z Special oral habits :nil

z Drug abuse :unknown

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OMF Examination

• Intraoral (Mandible)

– Size : L’t 3x1 cm R’t 2x1 cm – Ulcerative-like

– Color : white and red – Tenderness : (-)

– Pain : (-)

– Numbness : (+): left side

98/9/28 98/9/28

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OMF Examination

• Intraoral (Maxilla)

– Size :

Palatal 2x2 cm

R’t posterior 1.5x1 cm – Bone exposure: (+)

– Tenderness : (-) – Pain : (-)

– Pus: (+),less

98/9/28 98/9/28

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2008.10.24

There existed a 2X3 cm radiolucency lesion around tooth 38 which invaded from surface, formed pooly demarcated borders and a hypodense band on mesial side, compressed mandibular canal on tooth 38 apical region and distal side might be

destruced.

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2008.10.24

Another 2X3 cm radiolucency existed on lower right molar side (tooth 46 47 48) showed more amorphrous shape than left side, wave liked border has noted, bigger hypodense triangular area involved tooth 45, and madibular canal compressed on

tooth 47 apical region.

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2008.10.24

The apical third of tooth 48 root couldn`t be identified, might be a pothological change or distoration of Panorex film.

Midline didn`t be on and manidible shifted to right side

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2008.10.24

• Dental finding:

1) Tooth loss:18 16 26 28 36 37 46 2) Periapical radiolucency:13 23

3) External root resorption:11 21 22 34 33 37 47

4) Widening of lamina dura: 12(mesial side) 11 21 22(combined uncommon root morphology) 24 27 35 45 (mesial side, and loss supported bone on distal side)

5) Prosthesis fabrication: 21 crown and post & core 6) Undefined pulp chamber and hyperdense

feature: tooth 17 27 38 47 48

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2009.09.14

A 2.5X5 cm uneven border radiolucency lesion on lower left molar region which invaded anterior border of ascending ramus had noted

Another 3X6 cm uneven border radioluncency lesion on lower right molar region involved tooth 48

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2009.09.14

• Both right and left ascending ramus has radioluncency lesion, 1X1.5 cm round shape on left side and 0.5X1 cm lunar shape on right side.

•Radiolucency lesion on tooth 22 was larger than 081024

• Tooth 38 loss

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2009.10.05

F:\林義辰\091005.tif

Both lesion on right and left ascending ramus had became larger, the right side lesion expanded backward to posterior area of ascending ramus and band liked lesion on left side got wider.

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2009.10.07

Region from conial angle to conoroid process and condyle on left side, the whole left ascending ramus showed hypodense homogenerously.

The lower right region became hypodense homogenerously, but seems more dense than left side.

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2009.10.07

A 1.5x3 cm amorphrous,groud glass liked, multilocular radiolucency on region from tooth 42 to tooth 33.

Tooth loss:17 21 22 23 24 25 27 35 48

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CT findings

Imaging findings (980914) CT of Oral Cavity

Impression：

1) Mild soft tissue with extensive osteolytic lesions in the bilateral mandibular bodies.

Suspect gingival cancer with bony destruction.

Disease entities other than malignancy to be surveyed.

Please correlate with clinical presentation.

2) Suspect metastatic lymphadenopathies in the level IA, the bilateral IB and IIA.

3) Small visible lymph nodes in the bilateral posterior cervical spaces.

4) Bilateral maxillary sinusitis.

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CT images

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CT images

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CT images

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CT images

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CT images

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CT images

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Inflammation or neoplasm ?

• Both maxilla and bilateral mandible

– Tenderness : (-) – Pain : (-)

– Bone destruction: (+)

– Numbness : (+): left mandible – Pus: (+),less, only on maxilla

=> Neoplasm

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Benign or malignant neoplasm?

• Both maxilla and bilateral mandible

– Tenderness : (-) – Pain : (-)

– Numbness : (+): left mandible

– Ill defined RL with ragged, irregular border.

• Image Finding – CT

– Mild soft tissue with extensive osteolytic lesions in the bilateral mandibular bodies.

– Small visible lymph nodes in the bilateral posterior cervical spaces

=> Malignant

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Peripheral or intrabony origin?

• Unhealing wound over bilateral mandible posterior area.

• Bone erosion was noted over 21 palatal area

• Bilateral mandible severe bony destruction were noted.

¾Massive lesion

==> Peripheral or intrabony origin

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Working Diagnosis

• Langerhan’s Cell Disease

• Metastatic carcinoma

• Multiple myeloma

• Multiple brown giant cell Lesion(Central giant cell granuloma)

• Florid cementoosseous dysplasia

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Langerhan’s Cell Histiocytosis

– Histiocytosis X

– Langerhan’s cell disease – Idiopathic histiocytosis – Eosinophilic granuloma

– Langerhan’s cell granuloma

• Acute disseminated LCD

• Chronic disseminated LCD

• Chronic localized LCD

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Langerhan’s Cell Histiocytosis

Our case Langerhan’s Cell Histiocytosis

gender Male Male predilection in adult

age 30 y/o 1.5~15y/o

frequency 50% younger than 15

symptom Unhealing wound+ pus discharge

Dull pain and tenderness with bone lesion, loosening of the teeth site Multiple area in the

mouth(17,21,37,47)

10~20％ occur in the jaw , posterior area, alveolar process

(chronic L. type)

color White and red Red

Shape Ulceration Ulceration or dome shaped

size 3*1,2*1.5,2*1cm -

induration - -

Surface Ulceration -

tenderness - +

LAP - +/- in adult

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Langerhan’s Cell Histocytosis

X-ray finding Our case Langerhan’s Cell

Histocytosis Border

Well-defined without

a corticated margin

Ill-defined or Well-defined with or without a corticated

margin

Radiodensity

Multiple RL Multiple RL

Effect on surrounding structures/adjucent

teeth

Floating in air, scooped out

appearance

Pouch-out RL, scooped out, floating in air appearance,

loosen of teeth

Unilocular/

multilocular

Irregular Irregular

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Metastatic carcinoma

Our case Metastatic carcinoma

gender Male No sexual predilection,or slight F>M

age 30 y/o 50~80y/o

frequency 1~3% of all matastasis

Pain(+/-), paralysis, fixed with surrounding t.

site Multiple area in the mouth(17,21,37,47)

95% in madible, premolar and molar area

color White and red -

Shape Ulceration Nodular and smooth

size 3*1,2*1.5,2*1cm -

induration - -

tenderness - -

LAP - +/- in adult

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Metastatic carcinoma

X-ray finding Our case Meta CA

Border

Well-defined without a corticated margin

Many

Radiodensity

Multiple RL Many

Effect on surrounding structures/adjucent

teeth

appearance

Pouch-out RL, honeycomb appearance, loosen of teeth

Unilocular/

multilocular

Irregular Many

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Metastatic carcinoma

Male Female

Lung Breast

Prostate Adrenal gland

Kidney Colorectal area

Bone Genital organs

Adrenal gland Thyroid gland

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Multiple myeloma

Our case Multiple myeloma

gender Male Male

age 30 y/o 60~70y/o

frequency Uncommon(1% in all malignancies)

Mainly: bone pain

Others: fatique, fever, metastatic calcification

site Multiple area in the mouth(17,21,37,47)

jaws

color White and red ?

Shape Ulceration ?

size 3*1,2*1.5,2*1cm -

induration - -

tenderness - +

LAP - ?

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Multiple myeloma

X-ray finding Our case Multiple myeloma

Border

Well-defined without a corticated margin

Ill-defined, ragged border

Radiodensity

Multiple RL Punched-out radiolucency

Effect on surrounding structures/adjucent

teeth

appearance

?

Unilocular/

multilocular

Irregular Irregular, multiple

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Central giant cell granuloma

Our case Central giant cell granuloma

gender Male Female

age 30 y/o 60% before 30 y/o( 2~80y/o)

frequency -

Asymptomatic, painless expansion site Multiple area in the

mouth(17,21,37,47)

Mandible, anterior portion frequently cross the midline

Shape Ulceration ?

size 3*1,2*1.5,2*1cm 5*5~>10 cm

induration - -

tenderness - +

LAP - ?

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Central giant cell granuloma

X-ray finding Our case Central giant cell granuloma Border

a corticated margin

Well-defined, non-corticated margin

Radiodensity

Multiple RL RL

Effect on surrounding structures/adjucent

teeth

appearance

?

Unilocular/

multilocular

Irregular Unilocular/Multilocular

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Cemento-osseous dysplasia, florid type

Our case Cemento-osseous dysplasia, florid type

gender Male Female

age 30 y/o Middle age~the elderly

frequency Most common fibro-osseous lesion

in clinical practice symptom Unhealing wound+ pus

discharge

Asymptomatic site Multiple area in the

mouth(17,21,37,47)

Bilateral, extensive in all posterior four quadrants.

Shape Ulceration ?

size 3*1,2*1.5,2*1cm 5*5~>10 cm

induration - -

tenderness - +

LAP - ?

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Cemento-osseous dysplasia, florid type

X-ray finding Our case Cemento-osseous

dysplasia, florid type Border

a corticated margin

Well-defined, non-corticated margin

Radiodensity

Multiple RL RL to RL/RO to RO

Effect on surrounding structures/adjucent

teeth

appearance

Root resorption

Unilocular/

multilocular

Irregular Multilocular

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Final Diagnosis

• Langerhan’s cell disease, hard palate and bilateral mandible.

• Metastatic carcinoma

• Multiple myeloma

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