OS OS - - OM combined OM combined meeting
meeting
報告者 報告者 : : 高郁勛 高郁勛 陳靜怡 陳靜怡
指導醫師 指導醫師 : : 黃逸岳醫師 黃逸岳醫師 陳玉昆醫師 陳玉昆醫師 王文岑醫師
王文岑醫師
報告日期 報告日期 : 95/12/21 : 95/12/21
General data General data
Name :
Name : 林 林 XX XX Sex :
Sex : 男 男
Age : 17 y/o Age : 17 y/o
Occupation: student Occupation: student
Native :
Native : 高雄縣 高雄縣 Attending V.S. : Attending V.S. : 黃逸岳醫師
黃逸岳醫師
First visit :95/09/19
First visit :95/09/19
Chief Complaint Chief Complaint
Painless swelling over upper left
Painless swelling over upper left gingiva gingiva for more than one week
for more than one week
Present Illness Present Illness
The 17 y/o male patient didn
The 17 y/o male patient didn ’ ’ t have t have
uncomfortable experience of oral cavity uncomfortable experience of oral cavity
before. On 95/09/16, his aunt found that a before. On 95/09/16, his aunt found that a
mass occupied on his upper left
mass occupied on his upper left gingiva gingiva . . The mass didn
The mass didn ’ ’ t make him painful or t make him painful or
uncomfortable. Then he was brought to uncomfortable. Then he was brought to XX XX 內兒科診所 內兒科診所 for help. After clinical for help. After clinical
examination, the doctor referred him to our examination, the doctor referred him to our
OPD for further treatment.
OPD for further treatment.
Past History Past History
Past Medical History Past Medical History
– – Enuresis with medication at our Urological Enuresis with medication at our Urological department for 5 years
department for 5 years
– – Depressive disorder with medication at our Depressive disorder with medication at our Psychological department for 2 years
Psychological department for 2 years – – Denied any other systemic disease Denied any other systemic disease – – Denied any drug or food allergy Denied any drug or food allergy
Past Dental History Past Dental History
– – OD, Endo OD, Endo
– – Experience to dental treatment: fair Experience to dental treatment: fair
Personal History Personal History
Personal hobbies:
Personal hobbies:
– – Alcohol: Alcohol : ( ( - - ) Betel quid: ) Betel quid : ( ( - - ) Cigarette: ) Cigarette : ( ( - - ) )
Occupation: student Occupation: student
Education:
Education: 高二 高二 Marital status: ( Marital status: ( - - ) )
Economic state:
Economic state: 尚可 尚可
Psychic status: cooperative
Psychic status: cooperative
Family history Family history
Family support:
Family support:
– – 自 自 89 89 年起就住在兒童之家 年起就住在兒童之家 – – 姑姑平時也會照顧日常生活 姑姑平時也會照顧日常生活
Contributory to the problem: unknown Contributory to the problem: unknown
改嫁
P’t
Review of Systems Review of Systems
嘴巴 嘴巴 : : 牙齦流血 牙齦流血 ( ( 刷牙 刷牙 ) ) 呼吸道 呼吸道 : : 咳嗽 咳嗽 , , 痰 痰
腸胃道 腸胃道 : : 胃口不好 胃口不好 ( ( 不愛吃肉 不愛吃肉 ) ) 泌尿道 泌尿道 : : 夜尿 夜尿
No significant finding in other systemic No significant finding in other systemic
review
review
Physical Examination Physical Examination
Conscious: Clear Conscious: Clear
Vital sign:
Vital sign:
– – Pulse: 73/min Temp. : 36.4 Pulse: 73/min Temp. : 36.4 ° ° C C
Resp. Rate: 18/min B.P. : 104/61 mm/Hg Resp . Rate: 18/min B.P. : 104/61 mm/Hg
General appearance:
General appearance:
– – B.H. :171.5cm ; B.W. :49.5kg B.H. :171.5cm ; B.W. :49.5kg
Head and face: symmetric appearance
Head and face: symmetric appearance
Physical Examination Physical Examination
Eye: Eye:
– – Conjunctiva: not pale Conjunctiva: not pale – – Sclera: not Sclera: not icteric icteric
– – EOM: normal EOM: normal
Ear:
Ear: no hearing impairment no hearing impairment
Nose:
Nose: patent patent
Throat:
Throat: no discharge no discharge
Neck:
Neck: LAP( LAP( - - ) ; JVE( ) ; JVE( - - ) ; supple; free extension ) ; supple; free extension
Physical Examination Physical Examination
Chest:
Chest:
– – Symmetric expansion Symmetric expansion – – H.S. : no murmur, RHB H.S. : no murmur, RHB – – B.S. : clear B.S. : clear
Abdomen:
Abdomen:
– – Soft, no palpable mass Soft, no palpable mass
– – Normal active bowel sound Normal active bowel sound
Extremities:
Extremities: free extension, no pitting edema free extension, no pitting edema
Cranial nerve:
Cranial nerve: N.P. N.P.
Physical Examination Physical Examination
Mouth:
Mouth:
- - Teeth: Teeth:
Missing: 23 Missing: 23
Retained primary tooth: 63 Retained primary tooth: 63 O.D.: 16, 24, 26, 46
O.D.: 16, 24, 26, 46 Vitality test:
Vitality test:
-- 21, 24, 25: positive response21, 24, 25: positive response -- 22: negative22: negative
–– Occlusion:Occlusion:
Class I molar relation Class I molar relation Overbite: 2 mm ;
Overbite: 2 mm ; overjetoverjet: 2 mm: 2 mm
–– MMO:MMO: 51 mm ( from 11 to 41)51 mm ( from 11 to 41)
–– No No masticatorymasticatory muscle tendernessmuscle tenderness
Physical Examination Physical Examination
- - A swelling mass over A swelling mass over left side of maxilla
left side of maxilla
opposed to teeth 21~25:
opposed to teeth 21~25:
Buccal
Buccal gingivagingiva, vestibule , vestibule and palatal
and palatal gingivagingiva
Mucosa is intact, pink in Mucosa is intact, pink in color
color
No discharge from No discharge from gingiva
gingiva sulcussulcus Pain(
Pain(--), Tenderness(), Tenderness(--)) Firm in consistency Firm in consistency
No percussion pain of No percussion pain of teeth 21 to 25
teeth 21 to 25
Image finding
Image finding – – Skull PA and Skull PA and Lateral (95/10/05)
Lateral (95/10/05)
Image finding
Image finding – – Skull PA and Skull PA and Lateral (95/10/05)
Lateral (95/10/05)
Image finding
Image finding – – Water Water ’ ’ s view s view (95/10/05)
(95/10/05)
Image finding
Image finding – – Water Water ’ ’ s view s view (95/10/05)
(95/10/05)
Image finding
Image finding – – Panorex Panorex (95/09/19)
(95/09/19)
Image finding
Image finding – – Occlusal Occlusal film film (95/09/19)
(95/09/19)
Impression Impression
Dentigerous
Dentigerous cyst cyst Adenomatoid
Adenomatoid odontogenic odontogenic tumor tumor Keratocyst
Keratocyst Calcifying
Calcifying odontogenic odontogenic tumor tumor Unicystic
Unicystic ameloblastoma ameloblastoma
Incisional
Incisional biopsy biopsy
Aspiration: yellowish in Aspiration: yellowish in
color
color
Incisional
Incisional Biopsy Biopsy
No: KMUOP
No: KMUOP - - 06 06 - - 1864 1864 Date: 2006.09.19
Date: 2006.09.19
Specimen: 2 soft tissue fragments Specimen: 2 soft tissue fragments
Size: 1.0 x 0.7 x 0.3 cm Size: 1.0 x 0.7 x 0.3 cm
Color: Brownish Color: Brownish
Consistency: soft
Consistency: soft
HP Report
HP Report -- -- Incisional Incisional Dentigerous
Dentigerous cyst cyst
Bone, Maxilla, Impacted 23, Incision Bone, Maxilla, Impacted 23, Incision
Radiography
wall
Epi.
Histopathology
Diagnosis Diagnosis
Dentigerous
Dentigerous cyst over left side of maxilla cyst over left side of maxilla and impaction of tooth 23
and impaction of tooth 23
Enuresis with medication control Enuresis with medication control
Depressive disorder with medication Depressive disorder with medication
control
control
Oral and Maxillofacial Surgical Oral and Maxillofacial Surgical
Condition Condition
MMO: 51mm (from 11 to 41) MMO: 51mm (from 11 to 41) Airway: patent, no discharge Airway: patent, no discharge
Neck: Free extension, supple Neck: Free extension, supple
No teeth loosening No teeth loosening
– – Retained primary tooth 23 Retained primary tooth 23
Systemic problems:
Systemic problems:
– – Enuresis Enuresis
– – Depressive disorder Depressive disorder
Treatment Plan Treatment Plan
Pre Pre - - operation: operation:
–– Arrange Arrange endodonticendodontic treatment of tooth 22treatment of tooth 22
Operation plans:
Operation plans:
1.1. Decompression:Decompression:
Self care of decompression device Self care of decompression device Frequency of OPD follow up
Frequency of OPD follow up
2.2. EnucleationEnucleation + extraction of teeth 23 63 + bone graft+ extraction of teeth 23 63 + bone graft
Post operation:
Post operation:
–– Wound careWound care
–– Regular OPD follow upRegular OPD follow up
Treatment course Treatment course
Operation on 95/10/12:
Operation on 95/10/12:
–– MucoperiostealMucoperiosteal flap flap reflection
reflection
Bony perforation over 21 Bony perforation over 21 apical region (previous apical region (previous biopsy site)
biopsy site)
Labial cortical bone was Labial cortical bone was similar with eggshell in similar with eggshell in thickness
thickness
–– Increased the size of Increased the size of window (opposed to 22 window (opposed to 22
and 63) and 63)
Treatment course Treatment course
–– Incision the roof of the Incision the roof of the lesion
lesion ÆÆ sent for Hsent for H--P P examexam
–– Chemical cauterization via Chemical cauterization via soft tissue window
soft tissue window
4% phenol (2 minutes/time, 4% phenol (2 minutes/time, 3 times), then N/S irrigation 3 times), then N/S irrigation 95% alcohol (2 minutes/time, 95% alcohol (2 minutes/time, 2 times), then N/S irrigation 2 times), then N/S irrigation
–– Extraction of 63Extraction of 63
Treatment course Treatment course
–– Enucleated the main lesion Enucleated the main lesion and impacted 23
and impacted 23
No evidence of
No evidence of oro-oro-nasal nasal and and orooro-antral-antral
communication communication
Palatal mucosa was intact Palatal mucosa was intact
–– Placed Placed TriositeTriosite (artificial (artificial bone graft, 2ml/bottle, 4 bone graft, 2ml/bottle, 4 bottles) over the defect bottles) over the defect –– Suture the wound Suture the wound
Post Post - - operation operation panorex panorex (95/10/14)
(95/10/14)
Post Post - - operation operation panorex panorex (95/10/14)
(95/10/14)
Treatment course Treatment course
Post operation:
Post operation:
– – Wound condition: Wound condition:
No evidence of oozing No evidence of oozing
No evidence of discharge from nostril No evidence of discharge from nostril Mild to moderate swelling of left face Mild to moderate swelling of left face
– – Discharge from our ward on 10/17 (post Discharge from our ward on 10/17 (post - - op op 5th day)
5th day)
Treatment course Treatment course
OPD follow up:
OPD follow up:
–– On 95/11/20 (post operation On 95/11/20 (post operation 6 weeks) :
6 weeks) :
Little discharge from 21 22 Little discharge from 21 22 labial
labial gingivagingiva ÆÆ suspect suspect rejection of bone graft rejection of bone graft
–– N/S irrigation to wash the N/S irrigation to wash the infected bone graft
infected bone graft
–– No progress of graft No progress of graft
rejection during later F/U rejection during later F/U
Excisional
Excisional Biopsy Biopsy
No.: KMUOP
No.: KMUOP - - 06 06 - - 2044 2044 Date: 2006.10.12
Date: 2006.10.12 Specimen
Specimen
1. 1 Main lesion with tooth 23 1. 1 Main lesion with tooth 23
2. 1 Soft tissue fragment 2. 1 Soft tissue fragment
-- -- labeled as labeled as “ “ tissue before tissue before phenol treated
phenol treated ” ”
Gross
Gross – – Main Lesion Main Lesion
Size
Size (Excluding tooth)(Excluding tooth):: -- 3.4x2.4x1.7 cm3.4x2.4x1.7 cm
Color Color
-- BrownishBrownish Consistency Consistency -- RubberyRubbery
Crown of tooth 23 Crown of tooth 23
---- surrounded by the surrounded by the lesion
lesion
Gross
Gross – – Hemisection Hemisection
(1)(1)Cystic
part Solid
mass
Tooth 23
Gross
Gross – – Hemisection Hemisection
(2)(2)Cystic part Cystic part 1.Dimension 1.Dimension
–– 2.0x1.8 cm2.0x1.8 cm 2.Color
2.Color –– BrownishBrownish 3.Consistency
3.Consistency –– RubberyRubbery 4.Content
4.Content –– a little brownish a little brownish fluid
fluid
Solid part 1.Dimension
– 1.5x1.0 cm 2.Color – White
3.Consistency – Firm
Gross
Gross – – 交界 交界 點 點
Capsule Cyst
and
Tumor Tumor
and Tooth Tooth and Cyst (CEJ)
Radiograph
Radiograph -- -- Gross Gross
Tumor
Slide
Slide -- -- Gross Gross
AOT
DC
Odontoma - like area AOT
DC
Microscope
Microscope – – 交 交 界點 界點
DC
AOT AOT
Tooth
DC
Tooth
Odontoma -like area
Possible Effect of Phenol Possible Effect of Phenol
No significant difference in microscopic No significant difference in microscopic
morphology morphology
Incision Before After
Final Diagnosis Final Diagnosis
Adenomatoid
Adenomatoid odontogenic odontogenic tumor arising tumor arising from
from dentigerous dentigerous cyst cyst (AOT ex DC)
(AOT ex DC)
Bone, Maxilla, Impacted 23, Bone, Maxilla, Impacted 23,
Enucleation
Enucleation
Discussion Discussion
Treatment methods of
Treatment methods of dentigerous dentigerous cyst: cyst:
–– EnucleationEnucleation and removal of associated toothand removal of associated tooth –– CurettageCurettage
–– MarsupializationMarsupialization // Decompression// Decompression
Possibility of eruption of associated tooth Possibility of eruption of associated tooth
Rare recurrence
Rare recurrence
Discussion Discussion
Management of surgical defect : Management of surgical defect :
– – Bone graft Bone graft
– – Packing with Packing with iodoform iodoform gauze gauze
Hemostasis Hemostasis
Decrease dead space Decrease dead space
Discussion Discussion
Cauterization agent:
Cauterization agent:
– – Local fixation of tissue Local fixation of tissue – – Ensures Ensures hemostasis hemostasis – – Carnoy’ Carnoy ’ s s solution: solution:
First suggested by Cutler and
First suggested by Cutler and ZollingerZollinger in 1933in 1933 Made up of:
Made up of:
–– Chloroform 3 mlChloroform 3 ml
–– Absolute alcohol 6 mlAbsolute alcohol 6 ml –– Glacial acetic acid 1 ml Glacial acetic acid 1 ml –– Ferric chloride 1 gmFerric chloride 1 gm
Discussion Discussion
Conventional method of using cauterization Conventional method of using cauterization agent:
agent:
–– Usually treat the bony defect of cystic lesion Usually treat the bony defect of cystic lesion afterafter enucleation
enucleation // excision// excision
–– Penetrate the cancellousPenetrate the cancellous bone to a depth of 1.5mmbone to a depth of 1.5mm
1.54mm after 5 minutes 1.54mm after 5 minutes 1.81mm after 1 hour 1.81mm after 1 hour
–– May impede bone healing and damage the vital May impede bone healing and damage the vital structure (neurovascular bundle, sinus membrane) structure (neurovascular bundle, sinus membrane) –– Before enucleationBefore enucleation, tends to damage the epithelial , tends to damage the epithelial
lining
lining ÆÆ affect to H-affect to H-P diagnosisP diagnosis
Discussion Discussion
The present case:
The present case:
– – Cauterization agent: 4% phenol Cauterization agent: 4% phenol – – Before Before enucleation enucleation : :
Destroy lining epithelium of cystic lesion Destroy lining epithelium of cystic lesion
–– Decrease possibility of recurrenceDecrease possibility of recurrence
Fibrous change of cyst wall
Fibrous change of cyst wall ÆÆ become dense in become dense in consistence
consistence
–– Easily excise the cystic lesion from the adjacent soft tissue Easily excise the cystic lesion from the adjacent soft tissue (sinus membrane, site of cystic perforation, neurovascular (sinus membrane, site of cystic perforation, neurovascular bundle)
bundle)
No harm to the bony surface and
No harm to the bony surface and neurovascular neurovascular bundle (mandible)
bundle (mandible)
Clinical Features Clinical Features
DCDC AOTAOT This caseThis case Incidence
Incidence 20%20%
(jaw cyst) (jaw cyst)
3~7%3~7%
(odontogenic(odontogenic tumor)tumor)
XX
AgeAge 1010--3030
(wide range) (wide range)
10-10-1919
(69%) (69%)
1717
Gender
Gender MaleMale
(slight) (slight)
Female Female
(F:M=2:1) (F:M=2:1)
MaleMale
SiteSite MdMd 8, Mx8, Mx 33 MxMx ant. (3)ant. (3) Tooth 23Tooth 23 Symptom
Symptom AsymptomaticAsymptomatic AsymptomaticAsymptomatic AsymptomaticAsymptomatic XX--rayray UnilocularUnilocular R/LR/L
Surrounding Surrounding Unerupted
Unerupted toothtooth
Unilocular
Unilocular R/LR/L Unerupted
Unerupted tooth, tooth, 75%75%
Calcification, Calcification,
33%~66%
33%~66%
Unilocular
Unilocular R/LR/L Impacted 23 Impacted 23
DC: dentigrous cyst; AOT: adenomatoid odontogenic tumor; R/L: radiolucency
Dentigerous
Dentigerous Cyst Cyst
Pathogenesis Pathogenesis
-- -- uncertain, fluid accumulation uncertain, fluid accumulation between
between REE REE and tooth crown and tooth crown Transformation of
Transformation of odontogenic odontogenic epithelial lining
epithelial lining
-- -- genesis: unknown genesis: unknown
-- -- incidence: rare incidence: rare
Lesions Arising From Lesions Arising From
Dentigerous
Dentigerous cyst cyst
Non Non - - aggressive benign tumor aggressive benign tumor -- -- AOT AOT
Aggressive benign tumor Aggressive benign tumor -- -- Mural Mural ameloblastoma ameloblastoma
Malignant tumor Malignant tumor
-- -- Squamous Squamous cell carcinoma cell carcinoma Mucoepidermoid
Mucoepidermoid carcinoma carcinoma
(from mucus (from mucus cells in the lining of DC)cells in the lining of DC)
AOT Ex DC in Literatures AOT Ex DC in Literatures
Bravo et al, 2005
Bravo et al, 2005 Takahashi et al, 2001Takahashi et al, 2001 This caseThis case
AgeAge 1414 MM Mx, 23Mx, 23
Swelling with sharp Swelling with sharp
painpain Unilocular
Unilocular R/L, 23 R/L, 23 crown surrounded crown surrounded Expanding to sinus Expanding to sinus
2222 1717
Gender
Gender MM MM
SiteSite Mx, 28Mx, 28 Mx, 23Mx, 23 Symptom
Symptom Painless swelling, Painless swelling, nasal obstruction nasal obstruction
Painless swelling Painless swelling
XX--rayray UnilocularUnilocular R/L , 28 R/L , 28
surrounded surrounded
Unilocular
Unilocular R/L, 23 R/L, 23 crown surrounded crown surrounded
Other
Other Expanding to sinusExpanding to sinus //
Total 6 cases
Vallejo et al, 1998: 12 y/o male; Warter et al, 1990: 8 y/o male Tajima et al, 1992; 1988, J Philipp Dent Assoc.
Other Lesions Associated Other Lesions Associated
with AOT with AOT
COC: 2 cases
COC: 2 cases CEOT: 24 casesCEOT: 24 cases
Duration
Duration 2 months2 months //
CaseCase ZeitounZeitoun et al, 1996et al, 1996 Miyake et al, 1996Miyake et al, 1996
AgeAge 3535 MM MdMd ant.ant.
Painless swelling with Painless swelling with
sharp pain sharp pain Unilocular
Unilocular R/L with B/L R/L with B/L bony expansion and
bony expansion and areas areas of calcification
of calcification
1616 Gender
Gender FF
SiteSite Mx, 21Mx, 21
Symptom
Symptom Painless swelling, nasal Painless swelling, nasal obstruction
obstruction
X-X-rayray UnilocularUnilocularR/L , 28 R/L , 28
surrounded surrounded
Pathogenesis of AOT Pathogenesis of AOT
Origin Origin
1. Remnants of Dental lamina or 1. Remnants of Dental lamina or
epithelial rests epithelial rests
2. Enamel organ epithelium(REE) 2. Enamel organ epithelium(REE)
Nature Nature 1. An
1. An odontogenic odontogenic tumor tumor
(Neville, text book)(Neville, text book)2. A benign, non
2. A benign, non - - invasive hamartoma invasive hamartoma, , not a true
not a true neoplasm neoplasm
(Philisen(Philisen et al, 1998)et al, 1998)WHO Classification WHO Classification
A mixed
A mixed odontogenic odontogenic neoplasm neoplasm
-- -- an epithelial tumor with an inductive an epithelial tumor with an inductive effect on the
effect on the odontogenic odontogenic ectomesenchyme
ectomesenchyme
AOT infrequently produce
AOT infrequently produce dentinoid dentinoid
material and rarely enamel matrix
material and rarely enamel matrix
Classification of AOT Classification of AOT
Central
Central – – 96% 96%
1. Follicular 1. Follicular
(F) 73%
(F) 73%
-- -- This case This case
2. 2. Extrafolloicular Extrafolloicular (E) (E) Peripheral (P)
Peripheral (P) – – 4% 4%
Gingiva
Gingiva
Predilections of AOT Predilections of AOT
Age Age – – second decade, 69% second decade, 69%
Gender
Gender – – female, 1.9:1 female, 1.9:1 1. Race
1. Race – – Asian, 3:1 Asian, 3:1 2. Type
2. Type – – Peripheral, 14:1 Peripheral, 14:1 Site
Site – – Mx Mx ant., 2.1:1(Mx:Md) ant., 2.1:1(Mx:Md) Unerupted
Unerupted tooth tooth -- -- Canine Canine
Differential Diagnosis of AOT Differential Diagnosis of AOT
Follicular type Follicular type
---- dentigerousdentigerous cyst cyst
Extrafollicular
Extrafollicular typetype
---- radicularradicular cyst, lateral cyst, lateral periodontal cyst, etc.
periodontal cyst, etc.
Peripheral type Peripheral type
gingival fibrous lesions, ex:
gingival fibrous lesions, ex:
fibroma
fibroma, , epulisepulis. .
Differences In Radiograph Differences In Radiograph
“ “ Snowflake Snowflake ” ” appearance appearance -- -- foci of foci of
calcification, calcification,
33%~66%
33%~66%
May extend
May extend apically apically past the CEJ in
past the CEJ in follicular type follicular type
CEJ
Histological Features Histological Features
Duct-Duct-like structurelike structure ---- odontogenicodontogenic originorigin
“Tumor droplets“Tumor droplets”” in the central of the rosette or in the central of the rosette or swirled structure
swirled structure
–– eosinophiliceosinophilic amorphous hyaline material,amorphous hyaline material, 1. 1. AmyloidAmyloid--likelike
2. Enamel matrix or
2. Enamel matrix or dentinoiddentinoid materialmaterial
Calcification Calcification