組 員 : 蔡 承 翰 張 碩 夫 謝 亞 錚 羅 宏 德 指 導 醫 師 : 口 腔 病 理 科 全 體 醫 師
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口病 CASE REPORT
General Data
•
Name: 陳O O•
Sex: Female•
Age: 52y/o•
Native: 高雄市•
Marital status: 已婚•
Attending V.S.: O O O 醫師•
First visit: 8/7/2013Chief Complaint
A radiolucency lesion was found at LDC in
8/7/2013, and the patient visited our dental
department for further help.
Present Illness
•
This 40 years old woman suffered from a radiolucency lesion over
tooth 31 32 apical area on periapical film 1 years ago. So, doctor of
local dental clinic suggested him come to the dental department of
our institution for further treatment.
Intraoral Examination
Max dimension : 1.5 x 2 cm
Location: Tooth 31, 32 buccal gingiva
Surface: smooth
Consistency: hard
Pain (-)
Non-tender
Non-ulcerated
Intraoral Examination
Dentition (tooth 32-33):
1. Tooth vitality : (+)
2. Percussion pain: (+/-)
3. Palpation pain: (-)
Past History
Past medical history
Underlying disease: (-)
Hospitalization: (-)
Surgery under GA: (-)
Allergy: (-)
Past Dental History
General routine dental treatment
Attitude to dental treatment : Co-operative
Personal History
Risk factors related to malignancy
Alcohol drinking:(-)
Betel quid chewing:(-)
Cigarette smoking:(-)
Other special oral habits: Denied
Image finding – Panorex(102/8/7)
There is a well-defined unilocular round shaped radiolucence with a corticated margin over the apex of tooth 32,33, which extending from mesial aspect of tooth 34 root apex to mesial aspect of tooth 32 root apex and from apical third of tooth 33 down to one-third of the mandibular body, measuring approximately 1.5 X 2 cm in diameter.
The lesion caused the tooth 32,33 displacement, tooth 32 distal tilting and tooth 33 mesial tilting. In addition, tooth 32,33 root divergence was noted. There’s no significant influence on left mental foramen, and the inferior border of cortical bone was intact.
Image finding – Panorex(102/8/7)
There is a unilocular round shaped radiopaque lesion over the right retromolar area, which extending from dital root of tooth 47 root apex to the end of the retromolar pad and from the retromolar area down to the superior border of mandibular canal,
measuring approximately 1 X 1.2 cm in diameter.
Image finding-Occlusal film(102/8/8)
There is no cortical bone expansion,and tilting of 32,33 is noted.
Image finding – Cone beam CT(102/8/12)
Image finding – Cone beam CT(102/8/12)
Image finding – Cone beam CT(102/8/12)
Image finding – Cone beam CT(102/8/12)
There is a well-defined unilocular round-shaped radiolucence. Resorption of cortical bone on buccal side is noted .
Image finding – Cone beam CT(102/8/12)
Image finding – Cone beam CT(102/8/12)
Image finding – Cone beam CT(102/8/12)
Image finding – Cone beam CT(102/8/12)
There is a unilocular round-shaped radiopaque lesion.The adjacent bony structures are intact.
Working Diagnosis
Peripheral or Intrabony?
=> Intrabony
Our case Peripheral Intrabony
Mucosal lesion - + -
Induration - + -
Bony expansion - - +/-
Cortical bone destruction + - +/-
Inflammation, Cyst or Neoplasm?
Inflammation
Our case Inflammation
Redness - +
Swelling - +
Local heat Unknown +
Pain - +
Multifocal - -
Skull involvement - -
Cyst or Neoplasm
Cyst or Neoplasm?
Cyst
Our case Cyst
Aspiration Unknown +
Fluctuation - +/-
Well-defined border
+ +
Bone expansion - +/-
Cyst or Neoplasm?
Our case Inflammation
cyst Non-
Inflammation cyst
Pain,
tenderness pain-
tenderness- + -
Local heat Unknown + -
Color Pink to
normal Reddish Pink
Progression Slow Fast Slow
Sclerotic
margin + - +
Cyst or Neoplasm?
Neoplasm
Our
case Benign Malignant
Border Well-defined Well-defined Poorly-defined
Sclerotic margin + + ─
Destruction of cortical margin ─ +/─ +
Pain ─ ─ +
Induration ─ ─ +
Swelling with intact epithelium + + ─
Lymphadenopathy ─ ─ +/-
Progress Slow Slow Fast
Metastasis ─ ─ +/-
Non-inflammation cyst or Benign tumor
Working Diagnosis
Cemento-osseous dysplasia (early stage)
Cemento-ossifying fibroma
Odontogenic fibroma
Fibrous dysplasia
Differential Diagnosis
Florid cemento-osseous dysplasia(early stage)
Our case Florid cemento-osseous dysplasia (early stage)
Gender female female
Age 40 >30歲
Site Left mandibular canine
and lateral incisor Multiple lesions, including anterior mandible
Symptom and
Sign Asymptomatic Asymptomatic
Size 1.5X2.0 cm
Teeth vitality + +
Florid cemento-osseous dysplasia(early stage)
Radiographic features
Our case Florid cemento-osseous dysplasia(early stage)
Density RL RL
Border Well-defined with
corticated margin Well-defined with corticated margin
shape Unilocular Unilocular
Cemento-ossifying fibroma
Our case Cemento-ossifying fibroma
Gender female female
Age 40 20~40
Site Left mandibular canine
and lateral incisor Mandibular premolar-molar region Symptom and
Sign Asymptomatic Painless swelling
Jaw expansion - +
Teeth
displacement + +
Cemento-ossifying fibroma
Radiographic features
Our case Cemento-ossifying fibroma
Density RL Mixed lesion(RL+RO)
Border Well-defined with
corticated margin Well-defined with corticated margin R/L rim is uncommon
shape Unilocular Unilocular
Root divergence
or resorption + +
Odontogenic fibroma
Our case Odontogenic fibroma
Gender Female Female
Age 40 4~80(mean=40)
Site Left mandibular canine
and lateral incisor mandible Symptom and
Sign Asymptomatic Asymptomatic
Teeth vitality + +
Root divergence
or resorption + +
Odontogenic fibroma
Radiographic features
Our case Odontogenic fibroma
Density RL RL
Border Well-defined with
corticated margin Well-defined with corticated margin shape Unilocular Unilocular or multilocular
Fibrous dysplasia(monostotic)
Our case F.D.
Gender female both
Age 40 10~20
Site Left mandibular canine
and lateral incisor Maxilla
Symptom and
Sign Asymptomatic Painless swelling
Displacement of
mandibular canal - Superior displacement
Hormone related unknown +
(do not progress beyond puberty)
Fibrous dysplasia
Radiographic features
Our case F.D.
Density RL Ground glass
Border Well-defined with
corticated margin Poorly-defined
shape Unilocular
Clinical impression
Cemento-osseous dysplasia (early stage) over
tooth 32
Treatment course
102.08.07
Referred from for a lesion found in routine X-ray exam one year ago
Arrange to biopsy in OS
Treatment course
102.08.08
occlusal film and cone beam CT taking
Arrange surgery under general anesthesia
102.08.09
Pre-OP full mouth scaling
102.08.12
Admission for operation
Treatment course
102.08.14
OP day
Bone tumor excision
Treatment course
102.08.19
Pathologic diagnosis:
Bone,mandible,left,enucleation,cemento-osseous dysplasia
102.09.22
Suture removal and topical application of BI
Florid cemento-osseous
dysplasia
INTRODUCTION
Fibro-osseous lesion
Site: jaw bone
Age:mid-aged
Radiographic:multi-quadrant radiopaque cementum-like masses
Usually asymptomatic
Biopsy is usually not recommended
CASE REPORT
P.I.
A 45-year-old female patient presented to our
department with a chief complaint of pain in the left
molar region of the mandible for 1 month. The patient
was otherwise healthy, and her physical examination
showed no significant abnormality.
Intraoral examination
Caries: Tooth 36
Missing: Tooth 18,28,37,38,48
Previous endo. tx: Tooth 36
X-ray finding
Discussion
Pathogenesis obscure
Theories:
1. Proliferation of the fibroblastic mesenchymal stem cells
2. Reactive or dysplastic changes in PDL
3. Trauma from occlusion
Discussion
D.D.
1.FGC(familial gigantiform cementoma )
Autosomal trait genetic disease
Affect mostly children
Often crosses the midline
Without gender predilection
Need surgery
Discussion
D.D.
2. Gardener's syndrome
Skeletal changes
Skin tumors
Dental anomalies
Discussion
D.D.
3. Paget's disease
Affect mostly white males
More of polyostotic with pathognomonic increase in
serum alkaline phosphatase level
Discussion
D.D.
4. Cemento-ossifying fibroma
More buccolingual expansion
Discussion
D.D.
5. Chronic diffuse sclerosing osteomyelitis
Unilateral
Soft-tissue swelling,
Fever
Lymphadenopathy affecting primarily mandible
Conclusion
FCOD is diagnosed principally by its clinico- radiological features
If asymptomaticno surgical treatment is required
Long term follow-up
醫學倫理討論
六大原則
Tom Beauchamp &James Childress
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。
誠信原則(Veractity):
醫師對其病人有「以誠信相對待」的義務。
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。
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。
保密原則(Confidentiality):
醫師對病人的病情負有保密的責任。
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
協助合理分配此醫療資源給真正最需要它的人。
行善原則(Beneficence)
考慮到持續破壞骨頭可能性甚至惡性的變化
病患能夠較免於提心吊膽
誠信原則(Veractity)
清楚詳細地並且以病人能理解的語言,告知病人手術中可能遭 遇的風險和術後會有的疼痛及不方便
估計所需要費用和住院時間的說明
自主原則(Autonomy)
告知病情狀況後,尊重病人及家屬的決定,決定是否開刀移除 病兆
手術同意書、全身麻醉同意書等等
不傷害原則(Nonmaleficence)
病兆以外的正常組織
無菌控制
保密原則(Confidentiality)
病情以對本人說明為原則,尊重病的隱私權
考慮病人年紀或病情嚴重度等等
公義原則(Justice)
是否有手術的必要