Case Report
報告者: Intern I 組 陳冠霖 陳穎萱 姜孔浩
指導醫師: 陳玉昆主任 林立民教授
1
General data
Name : O O O
Sex : Male
Age : 53 y/o
Native : 屏東
Marital status : 已婚
Attending V.S.: O O O醫師
First visit : 103/2/18
Chief Complaint
Malodor over right upper posterior teeth area
103/8/30
3
Present Illness
102/1
18 ext. in LDC -> OAC to 成大H surgery -> secondary surgery (p’t reject)
103/02/18
OAC for 1 year, arrange CT
103/3/4
CT：Partial resection of the right Mx. Alveolar process and the R’t aspect of the hard palate
4
Past History
Past Medical History
• Systemic disease: (-)
• Hospitalization (+)
• Surgery under GA: (+)
• Drug and food allergy : (-)
Past Dental History
• General routine dental treatment
Attitude to dental treatment: cooperative
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Personal History
Risk factors related to malignancy
• Alcohol (+) 2 bot/day, 20y, permit
• Betel quid (-)
• Cigarette (+) 1.5 pack/day, 20y, permit
Special oral habits: denied
Irritation: denied
OMF Examination
MMO=50 mm
16 17 mobility
Blowing test (+)
103/8/30
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Image Finding – Pano 103/02/18
Image Finding – CT 103/3/4
Impression：
1) Partial resection of the right maxillary alveolar process and the right aspect of the hard palate.
2) Right frontal, bilateral ethmoid and maxillary sinusitis.
3) Enlarged lymph nodes in the bilateral jugulo-digastric spaces. Suspect reactive lymphadenopathy.
4) Non-specific small lymph nodes (<1cm) in the submental, the right submandibular, the bilateral jugulo-digastric, and the posterior cervical spaces.
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DIFFERENTIAL DIAGNOSIS
Image finding
Well – defined
Cloudy image
Partial resection of the right maxilla alveolar process and the right aspect of the hard palate
Differential diagnosis
Oralantral communication (or fistula), right maxilla
Sinusitis, right maxillary sinus
Radicular cyst, tooth 17
Working diagnosis
Our case OAC
sex Male No predilection
Age 53 Older (over 40)
Site Upper right posterior 1st and 2nd upper molar teeth extraction
S/S Bite pain Usually not painful unless
secondary sinusitis develops X-ray features
(of risk factor)
Cloudy image - Large sinus
- Large and unfavourable shaped roots extending into
the sinus
- Hypercementosis Clinical features Non healing socket Non healing socket
Working diagnosis
Our case (Maxillary) sinusitis
sex Male No predilection
Age 53 No predilection
Site Upper right posterior All of the sinus
S/S Bite pain Acute: fever, pain over temporal,
cheek periorbital, toothache
size fixed
X-ray features Cloudy image Chronic: cloudy, increased
density due to antrolith Clinical features Non healing socket Chronic: swelling
Working diagnosis
Our case Redicular cyst
sex Male No predilection
Age 53 No predilection
Site Upper right posterior Entire quadrant perapical
S/S Bite pain Typically no symptoms unless
there is an acute inflammatory exacerbation
size fixed Gradually enlarged
X-ray features Cloudy image Radioculency
Clinical features Non healing socket - Swelling
- Adjacent teeth mobility
Impression
Oral antral communication, R’t Mx
Sinusitis, right maxillary sinus
103/2/18
Treatment Course
103/3/19
ENT OP : bilateral multiple sinusectomy
Post ENT surgery – Pano 103/6/3
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Treatment Course
OS OP: Ext. 16 17 + local flap
Pre-operation survey
Chest PA View (103/8/23) Impression
1) Fibrocalcified lesions at right upper lung
2) Right apical pleural thickening 3) Atherosclerosis of tortuous aorta
4) Scoliosis & spondylosis of thoracolumbar spine
21
Pre-operation survey
EKG Diagnosis: (103/8/25)
■Normal Tracing
OS Operation 103/9/4
103/9/4 OS OP: Ext. 16 17 + local flap
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Post OS surgery – Pano 103/9/5
H-P report
Pathologic diagnosis:
Bone, maxilla, right, excision, fibrous hyperplasia and chronic inflammation
Bone, maxilla, right, excision, vital bone fragment
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DISCUSSION
Introduction
Oroantral Communication (OAC):
uncommon complication in oral surgery
maxillary first molar
the second molar
third molar
bicuspid
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Introduction
defects of <5 mm: close spontaneously
larger communications: surgical closure (better within 24 to 48 hours)
Introduction
Cause of OAC:
anatomic proximity of the root apices to the sinus floor
dentoalveolar infections
destruction of a portion of the sinus by cysts or benign or malignant tumors
Paget’s disease
Trauma and dentoalveolar or implant surgery
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Introduction
methods of surgical OAC : depends on…
amount and condition of the tissue available for repair
the size and location of the defect
our study: evaluated the reliability of two OAC closure techniques
Materials and Methods
20 OAC patients
10 : buccal advancement flaps(BAFs)
10 : palatal rotation–advancement flaps(PRAF)
same surgeon
1 and 3 months post-OP
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buccal advancement flaps
broad-based trapezoid mucoperiosteal flap
cleaning the fistula
alveolar bone was smoothed
flap was advanced and sutured to the palatinal tissue with silk suture
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palatal rotation–advancement flap
full-thickness mucoperiosteal flap
anterior extension of the flap
measuring the distance of the arc of flap rotation
width of flap depends on bony defect and angle of rotation
After op : surgical splint for 1 week
35
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Results
19/20 healed uneventfully
donor site of the palatal flap completely healed 3 months post-op
grafts were not necessary
no flap necrosis except 1 undergone Caldwell–Luc procedure and the palatal island flap technique
39
in this case, a second surgical intervention was performed
autogenous cartilage graft was harvested from the ear
the graft was placed in the bone defect
soft tissue closure was obtained with a palatal advancement flap
41
Discussion
BAF:
defect < 5 mm
immediate OAC
easy to perform
shallow vestibular sulcus after op interfere with prosthodontic rehabilitation
43
Discussion
PRAF :
defect > 5 mm
greater palatine artery : good blood supply
length/width ratio is important
Conclusion
OAC if not diagnosed and managed improperly oroantral fistula and maxillary sinusitis
choice of closure procedure : depends on…
1. amount and condition of the tissue available for repair
2. the size and location of the defect
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醫學倫理討論
醫學倫理
生命的神聖性(Sanctity of life)
六大原則
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Tom Beauchamp &James Childress 六大原則 - 1979
1. 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。
2. 誠信原則(Veractity):醫師對其病人有「以誠信相對待」的義務。
3. 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。
4. 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。
5. 保密原則(Confidentiality):醫師對病人的病情負有保密的責任。
6. 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。
行善原則
OAC 影響患者生命品質, 要盡量降低所可能發生之 併發症
誠信原則
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。
清楚告知病人抽菸對於手術術後的影響
自主原則
充分說明病情、治療計畫、風險以及開刀和不開 刀的利弊之後，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。
若有其他種治療選項也須讓患者知悉並自主選擇
不傷害原則
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。
保密原則
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
公義原則
手術的必要性？
手術的外部成本？
施行此手術時是否會排擠到其他更需要醫療資源 之患者？
醫學倫理總結
在病歷撰寫方面（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
詳盡告知義務，使患者清楚知道自己目前的處境
在進行治療之前，須讓病人充分了解目前以及之 後的療程內容，在自主同意之下簽署同意書
應在不違反醫學倫理的原則之下進行治療的行為
