CASE REPORT
指導老師:口腔病理科全體醫師
報告者:Intern H 陳雨瑄 潘琪方 林慧能 李敏綱 蘇哲弘
報告時間:2013.4.26
Case Presentation
GENERAL DATA
• Name : OOO
• Gender : Female
• Age : 11 years old
• Native : Kaohsiung
• Date of visit : 19/09/2012
• Attending VS : XXX醫師
11 / 10 / 2012
Chief Complaint
• Referred from LDC, ask for further examination of a swelling mass over lower left posterior region for months
11 / 10 / 2012
Present Illness
• This 11 years old girl had suffered from a painless swelling mass over left lower posterior region for months . She went to LDC for help and was referred to Ta-Tung Hospital on 19 /09 / 2012.
After physical examination and X-ray taking , it showed a swelling nodule with intact mucosa coverage and bony hard consistence
over buccal side of left mandible from tooth 73 to tooth 75, about 2.0 x 2.5 cm². The panoramic film revealed that a well-
circumscribed mixed lesion encasing 34 tooth germ under tooth 32 to tooth 36 with displacement of 33 and 35 tooth germ. Cone-
beam CT was arranged in Ta-Tung Hospital on 17 / 10 / 2012. And
she was referred to KMU for operation.
Extra-oral Examination
• Facial asymmetry: (+),
chin deviation to left while closing
• No obvious swelling
Frontal View
Occlusal View
Intra-oral Examination
• Color: normal-mucosa coverage
• Surface: smooth and intact
• Consistence: bony-hard
• Shape: nodule
• Bone expansion: (+)
• Local heat / fever: (-)
• Tenderness / Pain: (-)
• Paresthesia: (-)
Past Medical History
• Systemic disease : denied
• Hospitalization : urticaria, 3 year-old
• Hereditary disease : denied
( Her mother is a silent carrier of Thalassemia )
• Current medication : denied
• Food / Drug allergy : unknown
Past Dental History
• Operative dental treatment
--amalgam restoration on tooth 55, 64, 65, 85
• Attitude to general dental treatment: co-operative
Radiographic
examination
•
A well-defined radiolucent image with scallop-shaped margin containing radiopacities over tooth 74, 75 apical region
09 / 19 / 2012
Periapical film
• Bone expansion over left mandible (buccao-lingual dimension) pressing 33 tooth bud toward midline
09 / 19 / 2012
Occlusal film
09 / 19 / 2012
• A well-circumscribed unilocular radiolucent defect containing amount of radiopaque material and encasing 34 tooth bud which was pushed toward border line over left
mandible, extending from distal side of tooth 32 and the impacted tooth 33 to the mesial root of tooth 75 and the impacted tooth 35, measuring about 3.0 x 3.0 cm²
Panoramic film
10 / 19 / 2012
Panoramic film
09 / 19 / 2012 10 / 19 / 2012
• Compared with the original panoramic film taken on 09 / 19 / 2012,
the mixed lesion didn’t showed obvious size decreasing after tooth
74 extraction and decompression button set up
Cone-beam CT
Examination
Sagittal Section
Target without bone PA view
Working Diagnosis
Ameloblastic Fibro-Odontoma Calcifying Odontogenic Cyst
Adenomatoid odontogenic tumor Complex Odontoma
Calcifying epithelium odontogenic tumor
Ameloblastic Fibro-Odontoma
Our case Ameloblastic fibro-odontoma
Gender
Female
No predilectionAge
11
Average 10Site
Left parasymphysis
Posterior mandible Clinical findings:-Pain -Ulcer -Consistency
(-)
(-)
Bony-hard
(-)
(-)
Unknown
X-ray findings
Unilocular R-L with R-O
Unilocular R-L with R-O Inclusion ofunerupted tooth
Yes
YesDuration
Many months
Many yearsAmeloblastic Fibro-Odontoma
Our case
Ameloblastic Fibro-odontoma
Calcifying Odontogenic Cyst
Our case Calcifying Odontogenic Cyst
Gender
Female
Age
11
20~30 (mean age=33)Site
Left parasymphysis
Incisor & canines (65%) Clinical findings:-Pain -Ulcer -Consistency
(-)
(-)
Bony-hard
(-)
(-)
Unknown
X-ray findings
Unilocular R-L with R-O
Unilocular R-L with R-O Inclusion of uneruptedtooth
Yes
Yes (canine)Root resorption /divergence of
adj.teeth
Yes
(Divergence of adj. teeth)
YesCalcifying Odontogenic Cyst
Our case Calcifying Odontogenic Cyst
Adenomatoid odontogenic tumor
Our case Adenomatoid odontogenic tumor
Gender
Female
FemaleAge
11
10~19Site
Left parasymphysis
Anterior maxillaPain
(-)
(-)Ulcer
(-)
(-)Consistency
Bony-hard
unknownRate
-
3%~7% of all odontogenictumors
Adenomatoid odontogenic tumor
Our case
Adenomatoid odontogenic tumor
Complex Odontoma
Our case Complex Odontoma
Gender
Female
(-)Age
11
10~20Site
Left parasymphysis
Molar region of jawPain
(-)
(-)Ulcer
(-)
(-)Consistency
Bony-hard
hardDuration
Many months
Many yearsRate
-
Most common of odontogenictumors
Complex Odontoma
Our case Complex Odontoma
Calcifying epithelium odontogenic tumor
Our case Calcifying epithelium odontogenic tumor
Gender
Female
(-)Age
11
30~50Site
Left parasymphysis
Posterior mandible bodyPain
(-)
(-)Ulcer
(-)
(-)Consistency
Bony-hard
unknownDuration
Many months
Many yearsRate
-
<1% of odontogenic tumorsCalcifying epithelium odontogenic tumor
Our case Calcifying epithelium
odontogenic tumor
Clinical impression
Ameloblastic fibro-odontoma
Treatment Course
Treatment Plan
Surgical treatment plan
• Enucleation, curettage and extraction of tooth 73, 75, 34 under GA
• Reconstruction treatment plan
• Obturator fabrication for wound coverage
Follow up
• Wound healing
• Recurrence or transformation
• Eruption of tooth 33 and 35
- surgical exposure and forced eruption if needed
Treatment course
101.10.19
Referred from 大同H. to OS dept. for further treatment
H.P. report(大同): Ameloblastic fibroodontoma
101.11.15
Enucleation, curettage and extraction of tooth 73, 75, 34 under GA
H.P. report: Ameloblastoma fibroodontoma
•
Flap design:
- Intra-sulcular incision from tooth 31 to tooth 36 - Vertical incision on tooth 31(M) and tooth 36(D)
- Regular trapezoid flap reflection over left mandible
•
Surgical extraction of tooth 73, 75
•
Enucleation over the tumor and the un-erupted tooth 34
•
Curettage over the bone wall
35 tooth germ
Remaining bone wall
•
After the tumor was enucleated, the bone wall and 35, 33 tooth germ
could be seen
( 33 tooth germ was covered in the picture )•
After the tumor mass was enucleated,
the specimen with irregular capsule
surface and the un-erupted tooth 34
(pointed by needle) was seen, about
2.5 x 4.5 cm²
Treatment course
101.11.17
Post-OP 2nd day: Paresthesia / Lip numbness: (-)
Treatment course
101.11.23~12.21
Post-op follow up : Paresthesia / Lip numbness: (-)
101.12.07
Referred to prostho. department for obturator fabrication
101.12.21
Obturator delivery
101.12.21
•
101.12.21
Treatment course
101.12.28~102.4.12
Prostheses follow up: ok
102.03.04 in Ta-tung hospital
醫學倫理與病人安全
醫學倫理與病人安全
• 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
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)
臨床案例討論
一位11歲的未成年女性患者因左側下顎有不明隆起,
轉診至口腔外科。切片結果為ameloblastic fibro-
odontoma, 由監護人同意後為其施行手術移除病灶。
自主原則(Autonomy)
未成年, 由監護人代理行使
不傷害原則(Non-maleficence)
權衡利害原則
行善原則(Beneficence)
預防 / 移除傷害
公義原則(Justice)
本案例無相關
•
未成年, 由監護人代理
父母代理行使權力?
父母擁有兒童?
監護人
民法第一千零九十一條(監護人之設置)
未成年人無父母,或父母均不能行使、負擔對於其未成年子女之權利、義務時,應置監護人。
但未成年人已結婚者,不在此限。
民法第一千零九十四條(法定監護人)
父母均不能行使、負擔對於未成年子女之權利義務,或父母死亡而無遺囑
指定監護人時,依左列順序定其監護人︰
一 與未成年人同居之祖父母。
二 與未成年人同居之兄姊。
三 不與未成年人同居之祖父母。
民法第一千零九十七條(監護人之職務)
除另有規定外,監護人於保護、增進受監護人利益之範圍內,行使、負擔父母對於未成年子女 之權利、義務。
Conclusion