OM Case Report

(1)

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指導醫師：陳玉昆醫師、陳靜怡醫師

•

報告者：Intern I組

2013.05.28

OM Case Report

(2)

General Data

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Name : 柳O O

•

Sex : male

•

Age : 36 y/o

•

Native :台灣

•

Marital status : married

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Attending V.S. : O O O 醫師

•

First visit : 102.05.17

(3)

Chief Complaint

•

Swelling over left lower molar region for 2~3 weeks.

102.05.17

(4)

Present Illness

•

This 36 y/o male has found a swelling mass over his left mandible area in 97.8. And he accepted biopsy in 台大H, the report was ameloblastoma and he came to OS OPD of KMUH in 97.9.16 and asked Dr. O O O for advice.

Later he accepted tumor surgery at 台北馬偕 in 97.12.

In 102.05, he noticed swelling over tooth 37 buccal

region for 2~3 weeks, so he came to KMUH OS dept for clinical examination in 102.05.17.

(5)

Intra-oral Examination

• Site: Tooth 35, 36 edentulous ridge and tooth 37 region

• Size: 2 x 2.5 cm

• Color: Normal mucosa coverage

• Surface: Smooth and intact

• Consistency: Firm

• Shape: Dome, sessile

• Bone expansion: (+)

• Local heat/fever: (-)

• Tenderness/Pain: (-)

• Paresthesia: (-)

• Fluctuation (-)

• Fixed

101.06.2 7

(102.05.17)

(6)

RADIOGRAPHIC

EXAMINATION

(7)

Panorex film

(102.05.17)

There is a well-defined, multilocular, radio-lucency, lesion with corticated margin, lesion over tooth 35, 36 edentulous area, extending from distal side of tooth 34 to tooth 38

apical area, and from upper border to lower border of the mandibular body, measuring approximately 4.6 x 2.82 cm in diameter. Tooth 37 upward displacement and tooth 38 root buccal displacement were noted Inferior alveolar canal upper border missing and corticated bone of lower border of mandibular body thininng. Vertical bony expansion of upper border of the left madibular body between tooth 34 and tooth 37 was noted.

(8)

Past Medical History

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Denied any underlying disease

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Denied any food or drug allergies

•

Hospitalization: +, tumor excision in 馬偕H at 97.12

•

Surgery under GA: +, tumor excision in 馬偕H at 97.12

(9)

Past Dental History

• Operative Dental Treatment

–

Composite resin restoration on tooth 11, 12,

–

Amalgam restoration 22, 25, 46

–

Tooth extraction of tooth 35, 36

•

Attitude to general dental treatment: co-operative

(10)

DIFFERENTIAL

DIAGNOSIS

(11)

• Left posterior mandibular area

• 2 x 2 cm, dome shape, firm consistency, normal mucosa color

• Tenderness (-)

• Pain(-)

• Lip numbness (-)

• Bone expansion(+)

Peripheral or Intrabony

(12)

• Multilocular radiolucence with bony destruction

 Intrabony lesion

(13)

(1) Ameloblastoma

(2) Keratocystic odontogenic tumor (3) Odontogenic myxoma

(4) Central giant cell granuloma

Working Diagnosis

(14)

Our case peripheral [ Intrabony ]

Mucosal lesion

- + -

Induration

- + -

Bony expansion

+ - +-

Cortical bone destruction

+ - +-

Intrabony

(15)

Our case Inflammation

Redness - +

Swelling + +

Local heat - +

Pain - +

Due to panorex finding:

large multilocular RL destruction lesion

Inflammation, cyst or neoplasm

cyst or

neoplasm

(16)

Our case Cyst

Fluctuation - + -

Well defined border + +

Bone expansion + + -

Our case Inflammation

cyst [ Non-inflammation cyst ]

Pain, tenderness - + -

Local heat - + -

Color Pink Reddish Pink

Progression Slow Fast Slow

Sclerotic margin + - +

Cyst or Neoplasm

(17)

Our case [ Benign ] Malignance Border Well-defined Well-defined Ill-defined

Margin Smooth Smooth Irregular

Sclerotic margin + + -

Destruction of cortical margin

+ -+ +

progressive Slow Slow Fast

Swelling with intact epithelium

+ + -

Pain - - +

Induration - - +

Non-Inflammation cyst or Benign tumor

(18)

Ameloblastoma

Our case Ameloblastoma

Gender Male Equal

Age 36 30~70

Site Mandible (molar region) Mandible (molar→ascending ramus)

Paresthesia - Uncommon

Swelling + +

Drainage - +/-

Radiography

Well-defined, smooth, soap bubble multilocular,

corticated margin

Well-defined, unilocular or multilocular, corticated margin

Bony expansion + +

Teeth displacement

/root resorption + +

Duration Slow Slow

(19)

Keratocystic Odontogenic Tumor

Our case KCOT (larger)

Gender Male Slight male

Age 36 10~40

Site Mandible (molar region) Mandible (posterior body and ascending ramus)

Paresthesia - pain

Swelling + +

Drainage - +

Radiography

corticated margin

Well-defined, smooth, unilocular or

multilocular,corticated margin

Bony expansion + -

Teeth displacement

Duration Slow Slow

(20)

Odontogenic myxoma

Our case Odontogenic myxoma

Gender Male Slight female

Age 36 10~50 (mean25~30)

Site Mandible (molar region) Max.: Mand.=3:4 or 3:7 (tooth-bearing areas)

Paresthesia - Rare

Swelling + -

Drainage - -

Radiography

Well-defined ,smooth, soap bubble multilocular,

corticated margin

Often well-defined, unilocular or multilocular, may with corticated

margin

Bony expansion + +

Teeth displacement

Duration Slow Slow

(21)

Central giant cell granuloma

Our case Nonaggresive (most) Aggressive

Gender Male female

Age 36 <30

Site Mandible(molar region) mandible (anterior region) frequently cross the midline

Paresthesia - - pain

Swelling + - +

Drainage - - -

Radiography

corticated margin

Well-defined, unilocular or

multilocular, non-corticated margin

Bony expansion + - +

Teeth displacement

/root resorption + - +

Duration Slow Slow Rapid

(22)

CLINICAL IMPRESSION

(23)

• Ameloblastoma, left mandibular

body

(24)

• After incisional biopsy on 102.05.17, the histopathologic report indicated

ameloblastoma, plexiform over left mandible

(25)

AMELOBLASTOMA

Discussion

(26)

• Introduction

• Clinical and radiographic features

• Histopathologic Features

• Surgical management

Ameloblastoma

(27)

• One kind of epithelial odontogenic tumor

• They may arise from:

 rests of dental lamina

 developing enamel organ

 epithelial lining of an odontogenic cyst

 basal cells of the oral mucosa

Introduction of ameloblastoma

(28)

• Three different clinicoradiographic situations

 Conventional solid or multicystic (86%)

 Unicystic (13%)

 Peripheral (i.e., Extraosseous) (I %)

(29)

 soap bubble

Our Case: Conventional multicystic

(30)

• Equal prevalence in 30 y/o ~ 70 y/o

• No significant gender predilection

• No racial predilection

• About 85% cases occur in the mandible,

especially in the molar-ascending ramus area

• About I5% cases occur in the posterior maxilla

Clinical and Radiographic Features of

Conventional Ameloblastoma

(31)

• Often asymptomatic

• Painless swelling or expansion of the jaw is usual

• Buccal and lingual cortical expansion is frequent

• Resorption of the roots of teeth adjacent to the tumor is common

• Margins of these R-L lesions often show irregular

scalloping

(32)

• Follicular type

• Plexiform type

• Acanthomatous type

• Granular cell type

• Basal cell type

• Desmoplastic type

Histopathologic Features of

Conventional Ameloblastoma

(33)

Follicular type Plexiform type

圖片來源:高雄醫學大學口腔病理科教學網 http://oralpathol.dlearn.kmu.edu.tw/

(34)

Follicular type Plexiform type

(35)

Conventional Ameloblastoma (plexiform type)

• Fibrous stroma

• Stellate reticulum

• Ameloblast-like cell

 High-columnar

 Reverse polarity

 Basement membrane

(36)

• Types of surgical operations used for the removal of jaw tumors

 Enucleation & Curettage

 Marginal (i.e., Segmental) resection

 Partial resection

 Total resection (maxillectomy, mandibulectomy)

 Composite resection

Surgical management of

Conventional Ameloblastoma

(37)

Marginal (i.e., Segmental) resection

Partial resection

(38)

(39)

• The conventional ameloblastoma tends to

infiltrate the intact cancellous bone before bone resorption becomes radiographically evident.

• Recurrence rates of 50% to 90% have been

reported in various studies after curettage.

(40)

• Marginal resection is the most widely used

treatment, but recurrence rates of up to 15% have been reported.

• Many surgeons advocate that the margin of the resection should be at least 1 cm past the

radiographic limits of the tumor.

(41)

Our Case

(42)

• Recurrence often takes many years to become

clinically manifest, so 5-year disease-free periods

do not indicate a cure.

(43)

醫學倫理與顏面重建

(44)

醫學倫理與顏面重建

• 醫學倫理：一種道德思考、判斷和決策，以

倫理學的觀點出發，以期能做出對病人最有利益、最能符合道德倫理規範的醫療決策

• 醫病關係的轉變：醫師中心模式轉變為病人

中心模式 (physician-centered model →

patient centered model

(45)

醫學倫理原則

• 由Tom Beauchamp & James Childress在1979提出

• 自主原則(Autonomy)

• 不傷害原則(Non-maleficence)

• 行善原則(Beneficence)

• 公義原則(Justice)

(46)

自主原則 (Autonomy)

• 原則：一位具理性思考能力的病人，在完

全瞭解醫療處置方針的利弊得失下，有權決定自己的行為，包括決定及選擇醫療專業人員和治療方式

• ^臨床意義

1) 病人之自主行為不應遭受他人之操控或干預

2) 指醫療人員應提供充分且適當之資訊，以促

成病人針對診療方式主動作一抉擇

(47)

不傷害原則 (Non-maleficence)

• 源自希波克拉底之醫師誓約，即醫師之職

責：「最首要的是不傷害」

• 原則：不殺害病人、不能侵害病人權益和

福祉以及平衡利害得失，使痛苦減到最低

• 臨床意義

1) 醫療上是必須的，或是屬於醫療適應症範圍，因所施行的各種檢查或治療而帶來的傷害應符合不傷害原則

2) 權衡利害原則 → 兩害相權取其輕

3) ^{保護病人的生命安全}

(48)

行善原則 (Beneficence)

• 原則：行善原則包括不傷害原則的反面義務

(不應該做的事)和確有助益的正面義務(應該做的事)，包括維護和促進病人的健康、利益和福祉，為基本倫理原則，也是醫護人員的基本義務

• ^臨床意義

1) 勿施傷害：不得故意對他人施予傷害或惡行

2) 預防傷害：應該預防傷害或惡行

3) 移除傷害：應該移除傷害或惡行

4) 維持善行：應該致力於行事或維持善行

(49)

公義原則(Justice)

• 原則：強調資源合理分配、賞罰分明以及合

乎正義之事。醫療上公平原則指基於正義與公道，以公平合理的態度來對待病人、病人家屬和受影響的社會大眾

• ^臨床意義

1) 公平地分配不足的資源

2) ^{尊重病人的基本權利}

3) 尊重道德允許的法律,法律之前人人平等

4) 先來先服務與急重症優先

(50)

臨床案例討論

• Segmental resection對病患顏面部的影響及術後顏面之重建

• Ameloblastoma之高復發率

• 我們的Case中，因patient的

ameloblastoma範圍很大，假如想將復發率降到最低，需進行segmental

resection的手術步驟，對patient的顏面

部將造成極大的影響。

(51)

Segmental resection

(52)

Ameloblastoma之高復發率

• 若切除不夠乾淨，則復發率高達90%

• Ghandhi et al：(41 cases of ameloblastoma)

 Conservative groups recur—76.2％；

radical--0％

(53)

此案例違背了哪些原則?

• 行善原則：醫師可能並未叮嚀病患必須持續

密切的回診追蹤或提醒病患其嚴重性，導致

病患lost follow up約五年後再度復發時已經

長得太大而必須進行更大範圍的切除。

(54)

總述

• 當我們發現病患得到像Ameloblastoma這種容易復發的疾病時，我們應該要提醒並告知病患容易復發的特性，因此需要長期密切追蹤，

假如復發，早點發現可以進行叫小範圍的切

除，不要等病灶長太大再來治療，這樣會造

成的後果等等，讓病患清楚並有警惕心，如

此較不容易發生lost follow up的情形。

(55)