牙科晨會報告

(1)

牙科晨會報告

陳玉昆副教授 : 高雄醫學大學口腔病理診斷

科

07-3121101~2755

yukkwa@kmu.edu.tw

100 100 年度十大病例報告年度十大病例報告 2012.07.27

2012.07.27

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Case 1 Case 1

Name: 李○○

Gender: Male Age: 47 歲

初診日期 : 100.07.21

Chief Complaint Chief Complaint Toothache over tooth 12 Present Illness

Present Illness

The 47 y/o male had tooth 12 PFM about 10 years. This morning, he went to LDC for help. Due to an ulcer over the left lateral

border of tongue for 3 months, the dentist suggested him to come to our OPD for further examination.

(3)

Past History Past History

Past Medical History

 Systemic diseases: HIV, 高血壓

 Denied any drugs or food allergies

Past Dental History

 General routine dental treatments

Personal Habits Personal Habits

Oral Risk Factors

 Alcohol drinking: (-)

 Betel-quid chewing: (-)

 Cigarette smoking: (-)

Denied other specific oral habits

(4)

An ulcer over the left lateral tongue border

 Max. Dimension: 0.6x0.3 cm

 Shape: Circular

 Base: Sessile

 Surface: Ulcerative

 Color: Pinkish

 Consistency: Firm

Intraoral Examination Intraoral Examination

 Mobility: Fixed

 Pain (+)

 Tenderness (-)

 Induration (+)

 Fluctuation (-)

 Discharge (-)

 Neck LAP (?)

(5)

Panorex Taking Panorex Taking

Clinical impression:

 Squamous cell carcinoma, left lateral tongue border

 Tuberculosis, left lateral tongue border

(6)

Excisional Biopsy Excisional Biopsy

Pathological diagnosis:

 Squamous cell carcinoma (grade 1), left lateral tongue border

(7)

Case 2 Case 2

Name ：林○○

Gender ： Female Age ： 19 歲

初診日期： 100.10.05

Chief Complaint Chief Complaint Swelling over left face Present Illness Present Illness

This 19 y/o female suffered from pain & swelling 3 days later after extraction of lower left third molar at 澎湖馬公 Hospital on

2011.08.30. The symptom and sign became worsen day after day.

She came back to 澎湖馬公 Hospital and the Dr referred her to our emergency department for further treatment.

(8)

Swelling over the left cheek

 Redness (-)

 Local heat (-)

 Pain (+)

 Tenderness (+)

 Mouth opening/

closing difficulty

 MMO: 20 mm≒

Extraoral Examination

(9)

 Pregnancy for 9+ weeks s/p RU486

 Hospitalization experience (-)

 Drug allergy: keto, rolace

Past Dental History

Past History Past History

Oral Risk Factors

Personal Habits

(10)

Panorex Taking Panorex Taking

There is an ill-defined, moth eaten, radiolucent lesion with ragged border over the left ramus, extending from condyle head to mandiblularangle and from ramus post. border to coronoid process, measured about 3.5 x 2.5 in diameter.

Involvement of left mandibular canal is also noted.

(11)

Clinical impression:

 Sarcoma, left mandibular ramus

Computerized Tomography Taking Computerized Tomography Taking

Axial view

Coronal view

(12)

Incisional Biopsy

(13)

Incisional Biopsy

(14)

Incisional Biopsy

(15)

Immunochemical Stainings Immunochemical Stainings

Keratin (-) Actin (-)

Desmin (-) Vimentin (+)

Pathological diagnosis:

 Osteogenic sarcoma (high grade), left ramus

(16)

Excisional Biopsy

(17)

Excisional Biopsy

(18)

Excisional Biopsy Excisional Biopsy

Pathological diagnosis:

 Osteosarcoma (high grade), left mandibular ramus

(19)

Case 3 Case 3

Name: 林○○

Gender: Female Age: 37 歲

初診日期 : 100.11.11

Chief Complaint Chief Complaint

Pain and swelling over left mandible for 2 weeks.

Present Illness Present Illness

This 37 y/o female felt uncomfortable over lower left anterior to posterior teeth for 3 weeks. She didn't care about it until the swelling was noted 2 weeks ago. She visited LDC on 100.11.11.

After dental X-ray examination at LDC, a lesion over left

mandible was found. She was referred to our OPD for further evaluation.

(20)

Gingival swelling and ridge expansion from tooth 32 to 37

 Max. Dimension: 8x4 cm

 Color: Pink

 Consistency: Firm to hard

 Fluctuation (-)

 Induration (-)

 Pain (+)

 Tenderness (+)

Intraoral Examination

(21)

Personal Habits Personal Habits

Oral Risk Factors

Past History Past History

 Denied any systemic disease

Past Dental History

(22)

There is a well-defined, non-corticated, multilocular, scalloped radiolucency over left mandible body and symphysis, extending from the apex of tooth 42 to the distal side of tooth 37 and from alveolar crest to inferior border of

mandibular body, measured 7x3 cm in diameter. There is bony expansion of alveolar crest and mandbular border in vertical direction.

Panorex Taking

(23)

There is a well-defined, soap-bubble,

multilocular radiolucency extending from tooth 32 to the posterior area. Buccal-lingual bony expansion is noticed. Suspect tooth 34 35 buccal version.

Occlusal Film Taking Occlusal Film Taking

Periapical Films Taking Periapical Films Taking

There is a well-defined, multilocular, soap-

bubble radiolucency extending from the mesial side of tooth 42 to the distal side of tooth 37. External root resorption of tooth 31- 35, 37 is noted.

Clinical impression:

 Keratocystic odontogenic tumor, leftt mandibular body

 Ameloblastoma, leftt mandibular body

(24)

Incisional Biopsy Incisional Biopsy

Pathological diagnosis:

 Keratocystic odontogenic tumor, left mandibular body

Cystic lining Lumen

Capsule

(25)

Excisional Biopsy Excisional Biopsy

Cystic lining

Lumen Capsule

Cystic

degeneration

Tumor islands

(26)

Excisional Biopsy Excisional Biopsy

Pathological diagnosis:

 Ameloblastoma, left mandibular body

Granular cells

Squamous metaplasia Ameloblastic-

like cells

Stellate reticulum- like cells

(27)

Case 4 Case 4

Name: 林○○

初診日期 : 101.01.06

Swelling and pain over right lower posterior area for 2~3 weeks.

This 51 years old female felt swelling and pain over lower right posterior region about three weeks ago. Then, she found the

swelling become worse and went to LDC for help, and the dentist suggested her to come to our OPD for further evaluation and

treatment.

(28)

 Denied any systemic diseases

28

Personal Habits Personal Habits

Oral Risk Factors

Denied other specific oral habits Past Dental History

Past History

(29)

Extraoral Examination Extraoral Examination

Swelling over R’t lower face

 Facial asymmetry (+)

 Tenderness (+)

 Pain (+)

 Induration (-)

 Pain (+)

 Tenderness (+)

 Bucco-lingual bony expansion over R’t mandibular body Swelling over R’t retromolar region

 Max Dimension: 3x2 cm

 Surface: Smooth

 Consistency: Rubbery

 Color: White lines (biting irritation?)

 Mobility: Fixed

 Fluctuation (-)

Intraoral Examination

(30)

Panorex Taking Panorex Taking

There is a well-defined, unilocular radiolucency with corticated margin (lower margin of the lesion) over R’t mandibular body & ramus, extending from distal side of tooth 46 to anterior-half of ramus, and from upper one third of mandible ramus to lower one third of mandibular body, measured approximately 4x3.8 cm in diameter. Horizontal

impacted tooth 48 with distal root resorption (adjacent to distal side of root of tooth 47) is circumscribed within the lesion. Destruction of right external oblique ridge &

downwards displacement of right inferior alveolar canal are also noted. There is a round, well-defined homogenous radiopaque mass, measured about 1.5x1.5 cm in diameter, apical to tooth 34, 35.

(31)

Periapical Films Taking Periapical Films Taking

 Keratocystic odontogenic tumor, right mandibular body

 Ameloblastoma, right mandibular body

There is a horizontally impacted tooth 48 with external root resorption.

There is a buccal expansile lesion with solid and cystic component in the right

mandibular body.

Computerized Tomography Taking Computerized Tomography Taking

Axial view Coronal view

Axial view

(32)

Incisional Biopsy Incisional Biopsy

Pathological diagnosis:

 Odontogenic cyst, right mandibular body

Cystic lining Lumen

Capsule

(33)

Excisional Biopsy Excisional Biopsy

Pathological diagnosis:

 Ameloblastoma, right mandibular body

(34)

Case 5 Case 5

Name: 陳○○

初診日期 : 101.04.11

A swelling over L’t posterior mandible for 1 week.

This 59 y/o female received periodontal tx. at 署屏 H. for several months. Last week, the dentist found out that there

was a swelling mass over L’t posterior mandible, and suggested her to visit our OPD for further examination.

(35)

Past History Past History

 Systemic diseases: 高血壓

Past Dental History

Personal Habits Personal Habits

Oral Risk Factors

(36)

Intraoral Findings Intraoral Findings

 Max. Dimension: 3x2 cm

 Color: Pink

 Surface: Smooth

 Base: Sessile

 Shape: Dome

 Consistency: Rubbery

 Fluctuation (-)

 Mobility: Fixed

 Pain (-)

 Tenderness (-)

 Paresthesia (-, lip tongue)

(37)

Panorex Taking Panorex Taking

There is a well-defined multilocular irregular shaped radiolucence with corticated margin, contains fine radiopaque extending from the distal root of tooth 38 up to half of left ramus area, and from left retromolar area down to mandibular body, measured about 3.0 x 2.0 cm in diameter.

 Desmoplastic ameloblastoma, left retromolar area

(38)

Incisional Biopsy

(39)

Immunochemical Stainings Immunochemical Stainings

Keratin (+) for both clear and epithelial-like cells (+) control

(40)

Histochemical Stainings Histochemical Stainings

Pathological diagnosis:

 Pindborg tumor (clear cell type), left retromolar area Mucicarmine

stain (-)

PAS (-) PASD (-) Congo red (+)

(41)

Excisional Biopsy

(42)

Immunochemical Staining Immunochemical Staining

Keratin (+)

(43)

Histochemical Stainings Histochemical Stainings

Congo red (+)

Pathological diagnosis:

 Pindborg tumor (clear cell type), left retromolar area

PAS (-) PASD (-)

Mucicarmine stain (-)

(44)

Case 6 Case 6

Name: 江○○

初診日期 : 101.04.06

Pain over right anterior region of mandible for 3 days.

This 30 y/o female patient suffered from pain and discomfort over tooth 43-44 region for 3 days, and so came to our OPD seeking help.

(45)

 Size: 2x2 cm buccal of tooth 43, 44 (percussion pain)

 Surface: Smooth

 Consistency: Hard

 Color: Normal tissue color

 Mobility: Fixed

 Pain (+)

 Tenderness (-)

 Suspect bony expansion

101.04.06

Intraoral Examination

(46)

46

Personal Habits Personal Habits

Oral Risk Factors

Past History

(47)

There is a well defined ovoid shaped unilocular radiolucent lesion mixed with radio-opacities located at lower right premolar area. The lesion extends from the root apex of tooth 41 to distal of root of tooth 44, and extends from middle third of roots of 43, 44 down to the lower border of mandible, measured about 2 x 2.7 cm in diameter. Multiple ghost images near the bilateral lateral sinus walls due to bilateral ear rings are also

noted

Panorex Taking

(48)

External root resorption (-) Loss of lamina dura: Tooth 44 Tooth displacement: Tooth 44

Periapical Film Taking Periapical Film Taking

Occlusal Film Taking Occlusal Film Taking

There is a well-defined unilocular lesion of mixed radiolucency and radio-opacity with buccal & lingual bony expansion, measured 3cmx2.5cm in diameter, extending from mesial of tooth 42 to mesial of tooth 46.

 Cemento-ossifying fibroma, tooth 43-45 areas

(49)

Incisional Biopsy Incisional Biopsy

Pathological diagnosis:

 Cemento-ossifying fibroma, tooth 43-45 areas

Cemeticles

(50)

Case 7 Case 7

Name: 丁○○

初診日期 : 100.10.12

She felt water entering her nasal cavity during drinking after extraction of left upper posterior teeth a year ago.

This 47 y/o female suffered from oro-antral fistula after

extraction of tooth 25 a year ago. So, she came to our OPD for evaluation and further treatment. During our oral examination, we discovered a swelling mass over upper left posterior hard palate.

(51)

Intraoral Examination Intraoral Examination

 Max. Dimension: 2x1.5 cm

 Shape: Dome

 Color: Red

 Surface: Smooth

 Pain: (-)

 Tenderness: (-)

 Induration: (-)

 Mobility: Fixed

 Fluctuation: (-)

 Ulcer: (-)

 Border: Well-defined; extending from tooth 24(D) to 27 (D-1cm) and from cervical margin of involved teeth to hard palate

(52)

Past History Past History

Past Dental History

 Oroantral fistula

Oral Risk Factors

Personal Habits

(53)

There is a well-defined soft tissue shadow extending from tooth 23 distal to residual root 27 distal, measured approximately 2.0x1.5cm in diameter; cloudy appearance of left maxillary sinus.

Panorex Taking Panorex Taking

Clinical impression:

 Pleomorphic adenoma, left hard palate

 Sinusitis, left maxillary sinus

(54)

Incisional Biopsy

(55)

Immunohistochemical Staining Immunohistochemical Staining

Pathological diagnosis:

 Pleomorphic adenoma, left hard palate

S-100 (+)

(56)

Case 8 Case 8

Name: 呂○○

初診日期 : 100.12.08

A recurrent swelling mass over left face.

This 57 y/o male is a victim of pleomorphic adenoma over left cheek receiving excision in 97.04.17. He was then lost follow up but noting a mass over left cheek got enlarged gradually in the recent 2 weeks.

(57)

Past History Past History

 Excision of pleomorphic adenoma (L’t buccal) in 97.04.17

Past Dental History

Oral Risk Factors

Personal Habits

(58)

Swelling over left face

 Consistency: Rubbery & hard

 Pain (+)

 Tenderness (+)

Extraoral Examination Extraoral Examination

Intraoral Examination Intraoral Examination

 Consistency: Rubbery & hard

 Fluctuation (-)

 Induration (-)

 Pain (+)

 Tenderness (+)

(59)

There is an ill-defined radiolucence over left maxilla, extending form apex of tooth 23 to mesial side of tooth 28, and from alveolar crest to the left maxillary sinus, measured approximately 4.0 cm x 5.0 cm. The left maxillary sinus seems cloudy compared to right maxillary sinus. The left maxillary sinus floor is

extremely thin. The left zygomatic arch is invaded.

Panorex Taking

(60)

There is an enlarging soft tissue mass with calcifications in the left masticatory and buccal space with invasion of left maxillary sinus and zygomatic arch.

Computerized Tomography Taking Computerized Tomography Taking

Clinical impression:

 Recurrent pleomorphic adenoma, left masticatory &

buccal spaces

 Carcinoma ex pleomorphic adenoma, left masticatory

& buccal spaces

Axial view Coronal view

(61)

Excisional Biopsy (97.04.17)

(62)

Excisional Biopsy (97.04.17) Excisional Biopsy (97.04.17)

Chondroid formation Osseous formation

(63)

Immunohistochemical Staining Immunohistochemical Staining

Pathological diagnosis:

 Pleomorphic adenoma, left buccal mucosa

S-100 (+)

(97.04.17)

(64)

Excisional Biopsy (101.12.29) Excisional Biopsy (101.12.29)

S-100 (+)

Pathological diagnosis:

Pleomorphic adenoma (recurrent), L’t masticatory &

buccal spaces

Capsule invasion Hyalination &

myxomatous change

Condroid tissue

(65)

Case 9 Case 9

Name: 蘇○○

初診日期 : 101.05.09

A mass over the left mouth floor.

This 60 y/o patient came to our OPD due to a swelling mass over the left mouth floor for at least half a year.

(66)

66

Personal Habits Personal Habits

Oral Risk Factors

Past History

(67)

Intraoral Examination Intraoral Examination

 Max. Dimension: 2.5×2.5 cm

 Color: Pink

 Consistency: Rubbery

 Tenderness (-)

 Bony expansion (+)

 Pain (+)

 Numbness (+) over

left tongue & left lower lip

(68)

Panorex Taking Panorex Taking

There are 2 ill-defined unilocular round shaped radiolucencies over mandibular There are 2 ill-defined unilocular round shaped radiolucencies over mandibular symphysis area extending from apex of tooth 33 right to distal aspect of 42 and symphysis area extending from apex of tooth 33 right to distal aspect of 42 and from inferior mandibular border up to half of alveolar bone, measured

from inferior mandibular border up to half of alveolar bone, measured

approximately 2×2 cm and 1×0.5cm in diameter. The larger one causes destruction approximately 2×2 cm and 1×0.5cm in diameter. The larger one causes destruction of the lower cortical bone of mandibular symphysis.

of the lower cortical bone of mandibular symphysis.

(69)

There is an ill-defined unilocular round shaped radiolucence with

radiopacity over the

mandibular symphysis area extending from apex of 33 right to apex of tooth 42 &

from lingual side of mandible to half of

mandible in bucco-lingual dimension, measured

approximately 2.5×2 cm in diameter. Destruction of the lower cortex of

mandibular symphysis is noted.

Occlusal Fiom Taking

(70)

Bony destruction of mandibular symphysis and bilateral mandibular bodies

Computerized Tomography Taking Computerized Tomography Taking

Clinical impression:

 Salivary gland malignancy (adenocystic carcinoma, mucoepidermoid carcinoma), left mouth floor

involving mandibular symphysis & parasymphysis

Axial view

Coronal view

(71)

Incisional Biopsy Incisional Biopsy

Pathological diagnosis:

 Adenoid cystic carcinoma, left mouth floor

Cribriform pattern of tumor cells

(72)

Excisional Biopsy Excisional Biopsy

Perineural invasion

Perineural invasion Tumor embolism

(73)

Excisional Biopsy Excisional Biopsy

Pathological diagnosis:

 Adenoid cystic carcinoma, left mouth floor, mandible

Muscle invasion Bone

invasion

(74)

Case 10 Case 10

Name: 林○○

初診日期 : 101.06.20

A nodule over right upper lip.

A painless, non-tender submucosal swelling, measured about 0.3 cm in diameter, over the right upper lip.

(75)

75

Personal Habits Personal Habits

Oral Risk Factors

Past History

(76)

Intraoral Examination Intraoral Examination

 Max. Dimension: 0.3 cm

 Shape: Dome

 Color: Pink

 Surface: Smooth

 Pain: (-)

 Tenderness: (-)

Clinical impression:

 Benign minor salivary gland tumor, right upper lip

 Induration: (-)

 Mobility: Fixed

 Fluctuation: (-)

 Ulcer: (-)

(77)

Excisional Biopsy Excisional Biopsy

Pathological diagnosis:

 Actinomycosis, right upper lip

Sulfur granule Sea of PMNs

(78)