高雄醫學大學附設中和紀念醫院口腔病理診斷科

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高雄醫學大學附設中和紀念醫院口腔病理診斷科X光報告單 患者姓名：蘇 XX 病歷號碼：2XXX19X-2 性別：女年齡：51 送檢醫師：賴聖宗攝影日期：2006/9/26 報告日期：2006/10/16

臨床診斷：benign neoplasm over R’t maxilla 攝影方式： □ periapical

□ cephalometry

□ others

■ panoramic

□ occlusal

□ TMJ view

□ sialography

X 光診斷：(1) Calcifying odontogenic cyst over R't maxilla (2) Osteosclerosis over L’t lower retromolar area

Main X-ray findings：This Panoramic film reveals 3 major abnormalities.

1. One is a well-defined ovoid, irregular border unilocular radiolucency over R't upper maxilla with a foci of calcification and part of corticated margin around root apex of 11, 12.

This lesion extending from the distal side of 15 to the apex of 21 and from middle third of root 13 superior to the lower part of R’t sinus which may be extended to the nasal cavity, measuring approximately 3x4 cm in diameter. It contains a foci of calcification causing root resorption and loss of lamina dura of 15, 13, 12, 11.

2. There iare also two well-defined round shaped R-O shadows over L’t posterior mandible. One is near the apex of 36 distal root, measured about 0.5x0.5cm,whereas another is just beneath the L’t oblique ridge, measured 0.3x0.3cm. The degree of R-O is equivalent to the cortical bone of mandible border. And, it doesn’t cause any effect to the surrounding tissue.

Sinus: a well-defined ovoid R-L is seen over R't maxilla which extend to the R't side sinus and nasal cavity

Condyle: the size of L't condyle head is slightly bigger than R't but no other remarkable finding

Dental findings：

□ Tooth abnormality

□ Caries

■ Periodontal condition(generalized horizontal bony destruction)

□ Calculus

■ Missing tooth: 18,17,14,24,25,26,28,38,37,35,34,45,47,48

■ Endodontic condition: 15,13,12,11,21,22,23,36,33,32,31,43,44 (incomplete endo)

■ Restoration (e.g. C & B):

■ Filling (e.g. amalgam): 16,13 (r-o surround crown, may be cement

□ Residual root:

■ Others: 36 (PDL widening)

Clerk：

Intern：李幸耘 Resident：

V.S.：陳玉昆 Index：184 - 393 - 512 ; 259 - 393 - 392

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Comments:

1. If you know the history of the patient having receiving surgery for ameloblastoma over the right maxilla, the X-ray diagnosis may also include surgical defect whiles the radiopaque shadow may be healed bone.

Also, radicular cyst may need to be considered.

2. The location of osteosclerosis should be ‘under the apex of tooth 37’/

3. It should be noted that the left sinus floor has been disappeared.