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指導老師:口腔病理科全體醫師

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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

(2)

Case Presentation

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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

(4)

Chief Complaint

• Referred from LDC, ask for further examination of a swelling mass over lower left posterior region for months

11 / 10 / 2012

(5)

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.

(6)

Extra-oral Examination

• Facial asymmetry: (+),

chin deviation to left while closing

• No obvious swelling

(7)

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: (-)

(8)

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

(9)

Past Dental History

• Operative dental treatment

--amalgam restoration on tooth 55, 64, 65, 85

• Attitude to general dental treatment: co-operative

(10)

Radiographic

examination

(11)

A well-defined radiolucent image with scallop-shaped margin containing radiopacities over tooth 74, 75 apical region

09 / 19 / 2012

Periapical film

(12)

• Bone expansion over left mandible (buccao-lingual dimension) pressing 33 tooth bud toward midline

09 / 19 / 2012

Occlusal film

(13)

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

(14)

10 / 19 / 2012

Panoramic film

(15)

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

(16)

Cone-beam CT

Examination

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Sagittal Section

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Target without bone PA view

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Working Diagnosis

Ameloblastic Fibro-Odontoma Calcifying Odontogenic Cyst

Adenomatoid odontogenic tumor Complex Odontoma

Calcifying epithelium odontogenic tumor

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Ameloblastic Fibro-Odontoma

Our case Ameloblastic fibro-odontoma

Gender

Female

No predilection

Age

11

Average 10

Site

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 of

unerupted tooth

Yes

Yes

Duration

Many months

Many years

(146)

Ameloblastic Fibro-Odontoma

Our case

Ameloblastic Fibro-odontoma

(147)

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 unerupted

tooth

Yes

Yes (canine)

Root resorption /divergence of

adj.teeth

Yes

(Divergence of adj. teeth)

Yes

(148)

Calcifying Odontogenic Cyst

Our case Calcifying Odontogenic Cyst

(149)

Adenomatoid odontogenic tumor

Our case Adenomatoid odontogenic tumor

Gender

Female

Female

Age

11

10~19

Site

Left parasymphysis

Anterior maxilla

Pain

(-)

(-)

Ulcer

(-)

(-)

Consistency

Bony-hard

unknown

Rate

-

3%~7% of all odontogenic

tumors

(150)

Adenomatoid odontogenic tumor

Our case

Adenomatoid odontogenic tumor

(151)

Complex Odontoma

Our case Complex Odontoma

Gender

Female

(-)

Age

11

10~20

Site

Left parasymphysis

Molar region of jaw

Pain

(-)

(-)

Ulcer

(-)

(-)

Consistency

Bony-hard

hard

Duration

Many months

Many years

Rate

-

Most common of odontogenic

tumors

(152)

Complex Odontoma

Our case Complex Odontoma

(153)

Calcifying epithelium odontogenic tumor

Our case Calcifying epithelium odontogenic tumor

Gender

Female

(-)

Age

11

30~50

Site

Left parasymphysis

Posterior mandible body

Pain

(-)

(-)

Ulcer

(-)

(-)

Consistency

Bony-hard

unknown

Duration

Many months

Many years

Rate

-

<1% of odontogenic tumors

(154)

Calcifying epithelium odontogenic tumor

Our case Calcifying epithelium

odontogenic tumor

(155)

Clinical impression

Ameloblastic fibro-odontoma

(156)

Treatment Course

(157)

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

(158)

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

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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

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Surgical extraction of tooth 73, 75

Enucleation over the tumor and the un-erupted tooth 34

Curettage over the bone wall

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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 )

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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

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Treatment course

101.11.17

Post-OP 2nd day: Paresthesia / Lip numbness: (-)

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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

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101.12.21

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101.12.21

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Treatment course

101.12.28~102.4.12

Prostheses follow up: ok

(168)

102.03.04 in Ta-tung hospital

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醫學倫理與病人安全

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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

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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)

(172)

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。

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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

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未成年, 由監護人代理

父母代理行使權力?

父母擁有兒童?

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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︰

與未成年人同居之祖父母。

與未成年人同居之兄姊。

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。

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Conclusion

對於病患,除了考慮疾病的治療外,也應該同時將癒

後之生活品質納入考量。

(177)

Thank you for your attention!!!

參考文獻

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