報告者： Intern Group K 指導醫師：陳玉昆 主任 林立民 醫師
及口腔病理科全體醫師
2015.06.30
1
Name : OOO
Sex : Female
Age : 37 y/o
Native : 高雄市
Marital status : Single
Attending staff : OOO醫師
First visit : 104/05/22
2
Referred fromOO LDC due to R’t lower lesion over tooth 38 area.
104/05/22
3
This 37 y/o female went to OO dental clinic for routine dental examination on 2015/05/15
and Dr. OOO found the radiolucency image over the tooth 38 area. Therefore, Dr. OOO referred the P’t to OS Dr.OOOfor further evaluation and treatment.
4
Past medical history
Underlying disease: Denied
Hospitalization: Denied
Surgery under GA: Denied
Allergy: Denied
6
Past Dental History
General routine dental treatment
Attitude to dental treatment: Co-operative
Risk factors related to malignancy
Alcohol (+), socially
Betel quid (-)
Cigarette (-)
Special oral habits: Denied
Irritation: Denied
7
Facial asymmetry (+)
MMO = 40mm
8
Surface: Smooth
Consistency: Soft to firm
Color: Pink
Pain (-)
Tenderness (-)
104/05/22
9
10
There is a well-defined unilocular ovoid shaped circumcoronal radiolucency with corticalted margin over the impacted tooth 38 of the posterior mandibular body, extending from the mesial side of the mesial root apex of tooth 37 to the mesial part of the left ramus and from the middle third of tooth 37 down to the mandibular canal, measuring approximately 1cm x 1.5cm in diameter. Tooth 38 was pushed down near the left mandibular angle. The inferior alveolar canal was pushed downward.
103/05/28
•Tooth missing:12 26
•Prosthesis: 25x27
•Restoration: 16,17,36,37
11
2015/05/22
Impression
1) No overt radiological evidence of active cardiopulmonary disease.
2) Minimal thoracolumbar scoliosis.
12
EKG Diagnosis: Normal Tracing
13
Working diagnosis
14
Inflammation, cyst, or neoplasm?
Benign or malignant?
Central or peripheral?
15
Our case Inflammation
Redness - +
Swelling - +
Local heat - +
Pain - +
16
Our case Cyst
Aspiration Unknown +
Fluctuation + +/-
Well-defined border + +
Bony expansion - +/-
17
Our case Benign Malignant Border Well-defined Well-defined Ill-defined
Sclerotic margin + + -
Destruction of
cortical margin - +/- +
Pain - - +
Induration - - +
Swelling with
intact epithelium + + -
Progress Slow Slow Fast
Metastasis Unknown - +/-
18
→ Our case is a Cyst or neoplasm
Differential diagnosis
19
Differential diagnosis
20
Dentigerous cyst
Keratocystic odontogenic tumor
Unicystic ameloblastoma
P.679~681 in Oral and Maxillofacial Pathology, third edition 21
Our case Dentigerous cyst
Gender female Male >female
Age 37y/o 10~30 y/o
Site Mandible (third molar) Mandible (third molar) V
S/S no Usually asymptomatic,
swelling or pain if infected,
V
size 1x1.5 cm in diameter Average size 3cm~4cm X-ray features well-defined unilocular
ovoid shaped radiolucency with a
sclerotic margins
well-defined, smooth, unilocular, corticated
margin, impacted tooth V Clinical features Color: pink
Pain(-)
Color: pink
Pain(-) V
P.507~509 in Oral and Maxillofacial Pathology, third edition 22
Our case Keratocystic odontogenic tumor
Gender female Male >female
Age 37y/o 10~40 yrs(60%) V
Site Mandible (third molar) Posterior Mandibular,
Mostly molar area(49%) V
S/S no usually asymptomatic
Large: pain, swelling or drainage.
V
size 1 x 1.5 cm in diameter Varies X-ray features Well-defined unilocular
ovoid shaped radiolucency with a sclerotic margins
Well-defined unilocular radioluceny with smooth and often corticated margin
25~40% unerupted tooth involved
V
Clinical features Color: pink Pain(-)
Usually asymptomatic
V
P.683~686 in Oral and Maxillofacial Pathology, third edition
23
Our case Unicystic ameloblastoma
Gender female none
Age 37y/o Young age, average 23
Site Mandible (third molar) Post .Mandible
V
S/S no Nil
size 1x1.5 cm in diameter Average size 4.3cm~6.3cm X-ray features Well-defined unilocular
ovoid shaped radiolucency with a sclerotic margins
Well-defined, smooth, unilocular
radiolucency with corticated margin V Clinical features Color: pink
Pain(-)
Color: pink
Pain(-) V
P.702~710 in Oral and Maxillofacial Pathology, third edition
Keratocystic odontogenetic tumor over tooth 38
Impaction of tooth 18 28 48
24
Cystic enucleation + Complicated odontoectomy, 38
2015/05/22 25
2015/05/22
Surgery
1. Routine patient identification check and time out
2. Patient was put in supine position, GA with NETT intubation
3. Routine aseptic and OMS draping procedures were done
4. Prophylactic antibiotic: Cefazolin(1g) 1 vial + Aq- dest 20 ml IV was injected.
5. Throat pack in and OP started
6. Intrasulcular incision from tooth 37 mesial and
vertical incision over 37 distal side. 26
Surgery
7. Flap reflection
8. Bone window created over 37 root area and bone tumor excision were done.
9. Complicated odontectomy of 38
10. Copious N/S irrigation
11. Sutured the flap in position with 3-0 Vicryl.
12. Throat pack out and OP ended.
27
Pre-OP OP
28
2015/05/22
2015/06/10 2015/06/10
2015/05/22 2015/06/10
29
2015/06/11
臨床診斷： Developmental odontogenic cyst Pathologic diagnosis:
Bone, mandible, tooth 38, left, excision, dentigerous cyst Gross Examination:
The specimen submitted consists of 1 soft tissue fragment in 1 bag, measuring 2.0 x 1.0 x 0.2 cm in size,
in fresh state. Grossly, it is reddish in color and rubbery in consistency.
All for section. Jar 0.
Microscopic Examination:
The slide contains two identical groups of irregular-shaped soft tissue specimens.
Microscopically, it shows dentigerous cyst.
30
104/6/19
Wound condition: stable
Explained H-P report
Suture remove, topical treatment with G-I
Reinforce home care
Post op 3 months F/U, check x-ray
31
Journal
Characteristics Of Bony Changes And Tooth Displacement In The Mandibular Cystic Lesion Involving The Impacted Third Molar
Jin-Hyeok Lee, Sung-Min Kim, Hak-Jin Kim, Kug-Jin Jeon, Kwang-Ho Park, and Jong-Ki Huh
32
Similar radiographic features often leads to unsuspected postoperative histologic findings contradicting the predicted lesion based on radiographic finding
33
Most common mandibular odontogenic lesion:
1. Dentigerous cyst (DC)
2. Keratocyst odontogenic tumor (KCOT)
3. Ameloblastoma (AB)
34
Correlation between the histopathologic and radiologic characteristics of cystic and cystic- appearing lesions
35
81 patients of the 262 patients between
September 2005 and April 2014 in Gangnam Severance Hospital
Panoramic & CT findings of the mandibular cystic lesions with impacted mandibular third molar(IMTM)
36
1. Displacement of the IMTM
1) Mesio-distal (MD) displacement and direction of IMTM
2) Bucco-lingual (BL) displacement of the IMTM
2. Calculation of lesion size
3. Growth pattern of mandibular cystic lesions
1) Anterior-posterior growth pattern
2) BL growth pattern
4. Occurrence of cortical bone expansion and loss of bony continuity
5. Root resorption
6. Statistical analysis
37
Mesio-distal (MD) displacement and direction of IMTM
B: downward C: backward D: back-upward
38
Bucco-lingual (BL) displacement of the IMTM
A: no displacement B: lingual displacement C: buccal displacement
39
Anterior-posterior growth pattern
A: Back-upward B: Downward C: Down-forward
D: Down-forward and back-upward
40
BL growth pattern
A. Buccal
B. Bucco-lingual C. Lingual
41
Age and sex distributions according to pathologic diagnosis
42
Displacement type of impacted mandibular third molar
MD: DC group << non-DC group
BL: only 7.9% (5/63) of cases exhibited lingual displacement, and 1.6% (1/63) of cases exhibited buccal displacement
43
Ratio between bucco-lingual (BL) width and mesio-distal (MD) width of lesions
BL/MD: AB> OKC > DC
44
Growth pattern of mandibular cystic lesions
MD: DC : most down-forward
AB & OKC : down-forward and back-upward BL: no significant difference
45
Occurrence of cortical bone expansion and loss of bony continuity on computed tomography image
Bone expansion : non-DC group > DCs Loss of bony continuity: non-DC > DCs
46
Root resorption of the adjacent second molar on computed tomography
No significant difference
47
The anatomic position, growth period, and lesion size can lead to differences in lesion morphology, and the different growth patterns of the lesions can influence displacement of the impacted tooth
48
Prevalence of tumors and cystic lesions
associated with 9,994 impacted third molars, cystic lesions were more commonly observed (2.31%; n=231) than tumorous lesions.
Among tumors, AB was the most commonly observed (0.41%, n=41) and was identified as the most common odontogenic tumor
49
MD displacement of IMTMs(Panorax)
If Yes OKC or AB No DCs
50
BL displacement of IMTMs (CT axial view)
1. Lingual displacement >> buccal displacement
2. DC and non-DC group was not statistically significant
51
OKC exhibits a faster growth pattern. AB is also known to be relatively invasive and aggressive.
BL/MD ratio: non-DC groups > DCs group
52
MD growth direction of lesion DC group: unilateral growth
BL growth direction of lesion DCs: lingual side(22.4%).
OKC & AB: simultaneous BL growth(100%)
53
Bone expansion and loss of bony continuity OKC & AB > DCs
54
Root resorption rates
OKC & AB: 66.7%
DCs: 58.3%
Not useful for differential diagnosis
55
Mandibular cystic lesions with IMTM
1st considered: dentigerous cyst
When the third molar displacement and cortical bone absorption are observed
KCOT or AB should be considered
56
57
1. 生命的神聖性(Sanctity of life)：
2. 行善原則(Beneficence)：醫師要盡其所能延長病人之生命且
減輕病人之痛苦。
3. 誠信原則(Veractity):醫師對其病人有「以誠信相對待」的義務。
4. 自主原則(Autonomy):病患對其己身之診療決定的自主權必須 得到醫師的尊重。
5. 不傷害原則(Nonmaleficence):醫師要盡其所能避免病人承受 不必要的身心傷害。
6. 保密原則(Confidentiality):醫師對病人的病情負有保密的責任。
7. 公義原則(Justice): 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。
58
• 在《聖經》的第一篇<創世紀>中,上帝告訴以色列人說:「上帝 按他自己的形象造人。」 「你將是神聖的,因為我是神聖的。」
「生命神聖」觀即由此衍生而得。
• 該觀點主張人的生命是無條件的,有價值及神聖的,人繼承了上帝 的品質,包括一切價值的來源-內具的善 (intrinsic goodness),因 此必須受到尊重。
• 藉此瞭解他個人生命的原真,而認知他個人存活在世上的主要工 作和生活的目的,找到個人存在的意義、價值、目的與任務。
做了Excision 後是否有減輕病人的疼痛感？
或是使病人更不舒服？
→有完整去除病灶區域並拍照記錄術後情形。
並告知術後傷口會疼痛，但持續癒合後疼痛 會逐漸緩解
60
對於患者的疾病嚴重程度是否有確實地通知，
盡到告知的義務？
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？
→皆以已告知病人後，經同意才進行手術。
61
充分說明病情及治療計畫、風險之後，是否 有讓病人充分自主地選擇治療計畫？
→病人及家屬選擇並同意醫師的建議。
在做全身麻醉以前，是否有說明完整之後再
請病人自主的簽名同意？
→已充分說明並與家屬溝通。
62
是否有先完整瞭解病人的病史?
→治療前有完整蒐集病史資料，並與病患溝 通後擬定進一步的治療計畫
手術過程中，是否有造成不必要的醫源性的
傷害？
→沒有不必要醫源性傷害。
63
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
64
手術的必要性？
→ Dentigerous cyst最佳的治療方式是 sugical excision，將病灶完整的清除
(enucleation)才能將復發率(recurrence rate) 降到最低。
65
在病例撰寫方面(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
66
P.679~681,P.683~686,P.702~710, in Oral and Maxillofacial Pathology, third edition
PubMed Search: Dentigerous cyst [title]
67
68
