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OM case report


Academic year: 2022

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OM case report

Reporter:Intern G 組 中山正雄

林哲生 張綺真 楊理涵

Instructor:口病科全體醫師 Date:102.3.26


General Data

Name : 李XX

Sex : 女

Age : 55 y/o

Native : 高雄

Marital status : married

Attending V.S. : XXX 醫師

First visit : 102/01/02



Chief Complaint

Mass over right upper posterior area for 5 years and referred from dental department of KMTTH for surgical intervention



Present Illness

This 56 y/o female patient suffered from a

swelling mass over upper right posterior hard palate for more than 5 years. She felt the mass was slowly growing recently so she went to 第一 門診 for help, then the doctor suggested her to the dental department of KMTTH further

treatment .

But the dental department of KMTTH referred

her to our hospital (KMUH) for further treatment.

So, she comes to our OPD on 102/02/22.


Past History

Past Medical History

- Hospitalization : (+) Hysterectomy,


- Surgery under GA : (+) Hysterectomy,


- Systemic diseases : Denied

- Drug or food allergy : Penicillin, tetracycline

Past Dental History

- General routine dental treatment

Attitude to dental treatment: Co-operation


Personal History

Risk factors related to malignancy

• Alcohol: (-)

• Betel quid: (-)

• Cigarette: (-)

Other specific oral habits : Denied

Irritation : Denied


Intraoral Examination-1

Torus was noted

→Site : Upper middle hard palatal area → Color : Pinkish

→Mobility : Fixed →Shape : Dome →Size : 2X2cm →Surface : Smooth →Consistency : Hard →Pain : (-)

→Tenderness : (-) →Induration : (-)



Intraoral Examination-2

A large mass was noted

→Site : Right upper posterior hard palate area and adjucent to right side of torus

(from tooth 24 mesial side to 27 distal side) → Color : Pinkish with areas of bluish color

→Mobility : Fixed →Shape : Dome →Size : 4X3cm →Surface : Smooth →Consistency : Firm →Pain : (-) →Tenderness : (-) →Induration : (-)




Panorex view (102.01.02)

There is a well-defined oval shaped radiolucency with corticated margin over right palatal molar region,

extending from tooth 16 mesial side to 17 distal side, and from 17 occlusal side to 17 apical side,

measured approximately 2x1.5 cm in diameter.


Panorex view (102.01.02)

Dental findings

 Missing tooth : 18,28,32,33,34,35,36,37,38,47,48

 Prosthesis : 1) Crown : 14

 2)Crown and bridge : 31-x-x-x-x

 OD : 24(O),35(D)

 Periodontal condition : Horizontal bony resorption


Image Finding-Panorex(102.01.02)

TMJ: N/P bilateral

Idiopathic osteosclerosis was noted over 42,44,45(root apex area) and left posterior mandibular body


Differential Diagnoses


Classification of the lesion

Inflammation, neoplasm or cyst

Benign or malignant

Intrabony or peripheral


Classification of the lesion

Our case features :

– Site : Hard palate – Gender : Female – Age : 55

– Consistency : Firm – Progressive : Slow


Our case Inflammation Neoplasm Cyst


Pinkish Red Variable Yellow or


Fever or local heat

(-) (+) (-) (-)

Consistency Firm Rubbery Variable Rubbery

Ulceration (-) (-) (-)/(+) (-)

Duration More than 5 years

Days to Months

Months to years Years

Mobility Fixed

(in palate)


(in palate)

Fixed (in palate)


(in palate)

Pain (-) (+) (-)/(+) (-)

Inflammation ? Neoplasm ? Cyst ?



Our case Benign Malignancy

Surface Smooth Smooth Rough

X-ray margin Well-defined Well-defined Poor-defined

Progressive Slow-


Slow Variable

Pain - +/- +/-

Induration (in palate)

- Hard to define Hard to defined

Mobility (in palate)

Fixed Fixed Fixed

Benign or Malignancy ?

→ Benign should be considered


Peripheral or intrabony?

Our case Peripheral Intrabony X-ray margin Well-defined - Well-defined


destruction or


+ - +

 Intrabony


Differential diagnosis

1) Cemento-ossifying fibroma (early stage)

2) Unicystic intraosseous ameloblastoma

3) Central giant cell granuloma (early stage)

4) Fibrous dysplasia (early stage)


1.Cemento-Ossifying fibroma

Our case COF

Gender Female Female

Age 55 20-40

Site Hard palate Posterior mandible

Pain (-) (-)

Ulcer (-) (-)

Consistency Firm Firm


expansion (+) (+)


Our case COF


2. Unicystic Ameloblastoma

Our case Ameloblastoma

Gender Female none

Age 55 20~70

Site Hard palate Posterior mandible

Pain (-) (-)

Ulcer (-) (-)

Consistency Firm Firm


expansion (+) (+)


Our case



3. Central giant cell granuloma

Our case Giant cell tumor

Gender Female Female

Age 55 <30(60%)

Site Hard palate Mandible

Pain (-) (-)

Ulcer (-) (-)

Consistency Firm Firm


expansion (+) (+)


4. Fibrous dysplasia

Our case Fibrous dysplasia

Gender Female none

Age 55 0~20

Site Hard palate Maxilla

Pain (-) (-)

Ulcer (-) (-)

Consistency Firm Firm


expansion (+) (+)


Our case

Fibrous dysplasia


Clinical impression

Lesion 1:

Torus palatinus

over midline of hard palate

Lesion 2:

Cemento-ossifying fibroma (early

stage) over right posterior palate


Treatment course

102.1.2 First visit -at KMTTH

Arranged OP on 102/03/07

102.3.7 OP: Remove bone tumor and Torus palatinus and 17 ext

102.3.22 f/u


Final Diagnosis


Torus palatinus

over midline of hard palate



over right hard palate





一種道德思考、判斷和決策,以倫理學的 觀點出發,以期能做出對病人最有利益、




病人發現病灶有增大現象 => 第一門診就 診 => 轉診至大同 => 轉診至高醫



初診日期為2/1,並無先做biopsy,而至 2/22才排3/7 OP處理病人的問題





是否因為耗費較多時間在各個醫院轉診過程之 中,而造成病灶較慢被診斷

病人的病灶已經持續很長一段時間,若沒有突然急 遽的變化應該對診斷影響不大

病人由門診轉至地區醫院再轉至教學醫院,是 否可以因此獲得較精確的診斷與較好的治療

病人應該可以藉由轉診獲得專科醫師較專業的建議 與比較完整的治療評估



沒有先做切片確定診斷,而是決定直接排 手術治療

如果OP完之後的結果發現並非臨床診斷的良性 病灶,是否有可能因此延遲治療

病灶在臨床表徵上看起來應該是良性的,故選擇直 接手術摘除




間隔時間較長,如果病灶有突然加速加劇的變 化可能影響到病人的治療及預後

病人在就診之前病灶已經持續有5年以上的時間,都 沒有明顯的變化,最近病人覺得有變化也是緩慢的



Thanks for your attention !!



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