口腔病理及影像診斷科 Case Report

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口腔病理及影像診斷科 Case Report

報告組別:Intern L 報告日期 : 101.08.27

指導醫師:林立民醫師、陳玉昆醫師、

王文岑醫師、陳靜怡醫師

組員:顏德文、陳柏屹、温易宏、謝韶摭、紀勝元

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General Data

• Name: XXX

• Sex: Male

• Age: 46 y/o

• Native: 台灣

• Marital status: 已婚

• Attending V.S.:陳俊明醫師

• First visit: 101.02.07

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Chief Complaint

• Swelling over L’t posterior mandible for 2 days

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Present Illness

• This 46 y/o male found a swelling mass over left lower edentulous area 2 days ago. He

went to LDC for help. The dentist suggested

him to our OPD for further examination and

Tx .

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Intra-Oral Examination

• Red and swelling over L’t mandibular area

• Size:2.5x2cm

• Surface: Smooth

• Base: Sessile

• Shape: Dome

• Color: Red

• Mobility: Fixed

• Pain(+)

• Tenderness, induration, lymphadenopathy (-)

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Past History

• Past medical history

– Denied any systemic disease

– Denied any drug or food allergy

• Past dental history

– General routine dental treatment

• Attitude to dental treatment: Cooperation

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Personal Habits

• Risk factor related to malignancy

• Alcohol:(+) 25years, I pack/day

• Betel quid: (+) 1-2year, I pack/day , quit

• Cigarette: (+) 20years, 2-3 bottle/day

• Special oral habits : Denied

• Bite irritation : Denied

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Dental examination

• Missing: Tooth 16, 17, 18, 24, 26, 32, 35, 36, 37,3 8, 48

• C&B: None

• Restorations: None

• General plaque and calculus deposition

• Tooth 25 tooth: Mobility grade III

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Panorex finding

• There is a solitary well-defined corticated unilocular radiolucent shadows located in left mandibular body, measured about 2.0 x 3.0 cm in maximum diameter, extending from distal of mental foreman to middle of body and from edentulous ridge to close to lower margin of mandible with 0.2cm. The left mandibular canal is pushed down.

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Occlusal film finding

• There is a well-defined corticated unilocular radiolucent shadows

located in left mandibular body measured about 2.8 x 1.8cm range from near buccal margin to lingual margin and distal from 34 to retromolar region. No buccal-lingual bony

expansion.

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Differential Diagnosis

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Differential Diagnosis

• Intrabony / peripherial lesion?

– X-ray: Large size radiolucence bony lesion – Mucosal lesion(-)

Intrabony lesion

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Differential Diagnosis

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Inflammation, Cyst or Neoplasm?

• Reddish(+)

• Swelling(+)

• Local Heat(-)

• Pain(+)

• Aspiration(perforation): pus(-)

 Inflammation? Infection?

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Cyst ?

• Well-defined radiolucency

• Aspiration

Developmental or inflammation cyst?

• Pain (+), local heat (-)

• Sclerotic margin (slow progression)

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Neoplasm?

• Destruction with bony expansion

• Well-defined

• Swelling with intact epithelium

• Probable : benign Neoplasm

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Summary

• Inflammatory cyst or infected odontogenic tumor

• Intrabony benign tumor

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Cyst -Working diagnosis

• Cyst

• Well-defined

• Round shaped

• Unilocular radiolucence

• Post. Mandible

– Residual cyst

– Simple bone cyst

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Residual cyst

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Simple bone cyst

(traumatic bone cyst)

• False cyst

• Doesn’t have an epithelial lining

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Simple bone cyst

(traumatic bone cyst)

• Clinical features

– 常見於下顎premolar / molar area

– usually no symptoms , but 20% with painless swelling

– Vital teeth

– 常見於10~20歲,超過35歲之後少見

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Simple bone cyst

• radiographic feature

– Well-defined round shape radiolucenct defect

– 1~10cm in diameter, usually not over 3cm

– No root resorption

– 在牙根之間形成scalloped

appearance(常出現但非診

斷依據)

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Residual cyst

• Clinical feature

– Its associated tooth has been lost

– Occurs in alveolar process or edentulous area of mandibular body , but sometimes it was found in lower ramus

– >20y/o higher incidence – Male:femal=3:2

– Maxilla>mandible

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Residual cyst

• Radiographic feature

– Well-definded

– Corticated border – Round to elliptic

radiolucency

– can be large enough to cause jaw expansion and asymmetry

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Working diagnosis

Our case Residual cyst Simple bone cyst

Gender Male M:F=3:2 Slightly male

Age 46 Any age 10~20, seldom > 35

S/S Swelling(+) No symptom unless

acute inflammation

1.Painless swelling 2.Usually no s/s

Site Post. mandible variety mandible

Size 2X3 cm Variable size 1~10 cm

Shape Round Usually round Scallop projection to

the root(?)

Radiography Well-defined unilocular RL

Well-defined unilocular RL

Well-defined unilocular RL

Margin Corticated Usually corticated

Affect to adjacent tooth

Edentulous area Previously tooth extraction,

edentulous area

Vital , show no resorption

Bony expansion Bony expansion(+ -) seldom Bony expansion

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Benign Malignant

Pain Non-tenderness

No ulceration Smooth surface

A well-defined, regular RL/RO sclerotic margin

**Probably benign

Neoplasm Working diagnosis

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Neoplasm Working diagnosis

• Intrabony benign tumor

– 1.Unicystic Ameloblastoma

– 2.Keratocystic Odontogenic tumor (KCOT)

– 3.Focal cememto-osseous dysplasia

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1.Unicystic Ameloblastoma

• No sex predilection

• Age predilection:

average:23 y/o

• No racial predilection

• Site predilection: posterior mandibular

• No symptom and sign

• Circumscribed unilocular RL

• Combine impacted tooth

• Most commom

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KCOT

• Sex predilection:

male≧female

• Age predilection: 10~40 y/o

• No racial predilection

• Site predilection:

posterior madibular

• Well-defined with sclerotic margin unilocular RL

• No adjacent tooth root

resorption

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Focal cememto-osseous dysplasia

• Sex predilection:

female

• Age predilection:

20~60y/o, average:

38

• Site predilection:

posterior mandible

• No racial

predilection

• Size:<1.5cm

• No symptom

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Clinical impression

• Ameloblastoma over left mandibular body

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Pathological Report

• KCOT, left mandibular body, incision,

101/02/10

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Treatment Procedure

• 101/02/07

 Red and swelling over L’t mandibular area, pain was also noted, X- ray presented with R/L lesion

- impression : residual cyst, odontogenice tumor ,over Left mandible

- medication (Amoxicillin,Strocain,Panadol) for 3 days

101/02/10

 Red and swelling over L’t mandibular area, pain was also noted, X-ray presented with R/L lesion

 Check tooth 11 x-ray shows : periodontitis - block anesthesia biopsy performed

- specimen sent to HP examination

- medication(Amoxicillin,Strocain,Panadol) for 3 days

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Treatment Procedure

• 101/02/13

 Decompression button over left lower posterior buccal side (noted that decompression-button dislodged)

 Pus(-), fluid(+), mixed with a lot of debris , some blood , brown color - intra-oral irrigation with normal saline for 3 cups

- GI application

• 101/02/17

- HP report : keratocystic odontogenic tumor - suture remove and oral irrigation

- home care education

• 101/02/24

- oral irrigation , home care OK

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Treatment Procedure

• 101/03/30

 Wound OK, no swelling

- oral irrigation, home care OK

- local treatment , next visit for panorex

• 101/05/04

 Wound OK , no swelling

 Check panorex : bone regeneration - oral irrigation, home care OK

- local treatment, next visit for panorex

• 101/06/29

 Wound OK, no swelling

- oral irrigation, home care OK

- local treatment, next visit(8月初)for panorex

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Treatment Procedure

• 101/08/03

 Wound OK, no swelling , home care OK

 Check panorex : bone healing OK

 Tooth 47 periodontitis

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Figure

Updating...

References

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