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Case Report

指導老師 口腔病理科全體醫師 指導老師:口腔病理科全體醫師

Intern A 組

李羽婕 鍾佳霖 蕭建志 張修源 陳泓誠 李羽婕,鍾佳霖,蕭建志,張修源,陳泓誠

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General data General data

N 何XX

• Name: 何XX

• Gender: 女

• Native : 台灣

• Age: 12 Age: 12

• Marital status : 未婚

Attending V S 吳崇維醫師

• Attending V.S. : 吳崇維醫師

• First visit : 90.10.04

• 本次報告初診日期: 97.07.11

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Chief complaint Chief complaint

A R L i R’t dibl b d

• A R-L image over R’t mandible body was

noted during routine examination at Pedo

department

(4)

Present illness Present illness

• 97.7.11

The 12 y/o female went to our pedo OPD for routine oral examination. A RL lesion over R’t

S f

mandible was noted. So, she was refered to OS OPD for further examination under the

i i f d i

impression of dentigerous cyst.

• 97.9.1

Biopsy and decompression were done under IVGA. H-P reports was Dentigerous cyst. p g y

• 97.9.5~10.31:irrigation and follow up: the size of lesion remains the same and OP was

of lesion remains the same, and OP was

arranged at 97.12. 26

(5)

Past history Past history

• PMH

1. Mild mental retarded

2 Denied food or drug allergy 2. Denied food or drug allergy

3. vetricular septum defect, diaphragmatic hernia 4. Complete RBBB(完全性右束支傳導阻滯)

5. Left arm dermoid cyst with infection(OP on 97.11.1) y ( )

• PDH

1 Experience of regular dental treatment: acceptable 1. Experience of regular dental treatment: acceptable

(OD, endo tx, FM Scaling…etc) 2 O l h i A t bl

2.Oral hygiene: Acceptable

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Personal habits Personal habits

Ci tt S ki ( )

• Cigarette Smoking (-)

• Alcohol (-)

• Betel nuts (-)

• Special oral habits (-) Special oral habits ( )

(7)

OMF examination OMF examination

• Caries: (-) ( )

• Tooth 43: impacted

• Tooth 41 42 tilt to distal side

• Tooth 41.42 tilt to distal side

• Tooth 44.45 tilt to mesial side

• Midline shift to right

• Angle class III(L’t and R’t) g ( )

• Bony exophytic mass at lower R’t mandible tooth 43-44 area (both labial and lingual side) tooth 43 44 area (both labial and lingual side)

• There is a decompression button at right lower buccal side

buccal side

(8)

Physical examination Physical examination

• Consciousness: clear ,E4V5M6

• Vital signs: normal

• Head and face: symmetric appearance, y pp , deformity(-) ??

• Nose: normal Nose: normal

• Skin: normal

E l

• Eyes: normal

• Chest: normal

• Abdomen: normal

• CNS: normal CNS: normal

• Extremities: R’t side paralysis??

(9)

Image finding

970711

• Main x-ray finding:

There is a well-defined radiolucent lesion over right anterior mandible, extending from 45 root apex to 34 root apex ,from residual 84 alveolar crest to lower border of p p

mandible, measuring about 4.5 cm x 4 cm in size .The lesion involves impacted 43 , extending to mesial root apex and distal CEJ. The lower border of right mandible becomes thining.

•Dental finding:

Residual primary tooth: 65 75 84 Tooth bud :38 48 Erupting tooth:17 25 27 35 37 47 Missing tooth:18 28

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Image finding

970901

•Main x-ray finding:

There is a well-defined, round-shaped unilocular mixed radiolucent/radiopaque lesion with corticated margin over right anterior mandible, extending from alveolar crest of 84 to lower border of mandible, and from 32 root apex to 45 mesial root apex, approximately 4 cm x 4cm in size. The lesion involves impacted 43,

extending to mesial root apex and disatal CEJ. Snowflake calcifications are present in the radiolucent area.

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• Lamina dura is disappeared or discontinuous over 32~45 teeth. Roots of 41, 42 tilt mesially , and roots of tooth 44 45 31 tilt distally. The lower border of mandible becomes thinning, bony expansion is noted.

• Sinus: N.P.

• Condyle: N.P.

• Dental finding:Dental finding:

Residual primary tooth: 65 75 84 Tooth bud :38 48 Erupting tooth:17 25 27 35 37 47 Missing tooth:18 28

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Image finding

971003 971003

Tooth 84 had been extracted during surgery in 97.09.01 The lesion was the same as 97.09.05

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Image finding Image finding

971031

Th l i th 97 09 05

The lesion was the same as 97.09.05

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CT CT

97 11 04 97.11.04

• CT was performed 97.12.16

• Water’s view、cephalometry were performed. Water s view cephalometry were performed.

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1、Disease origin : intra-bony or peripheral origin g y p p g 2、inflammation or neoplasm

3、Benign or malignant

DIFFERENTIAL DIAGNOSIS

3 Benign or malignant

(19)

intra-bony or peripheral origin?

I d ti k

• Induration : unknown

• Bony destruction (+) y ( )

• Bony expansion (+)

• Intra-bony origin

(20)

inflammation or neoplasm?

inflammation or neoplasm?

• Fever or Local heat:( )

• Fever or Local heat:(-)

• Pus discharge : unknown

• Duration: more than 6 months Lymphadenopathy:unknown

• Lymphadenopathy:unknown

• Induration:unknown

• Neoplasm p

(21)

Benign or malignant?

Benign or malignant?

• Mobility : (-) y ( ) • Facial n. palsy :(-)

• Ulceration: (-)

• Induration:unknown

p y ( )

• Lymphadenopathy:

unknown

• Duration : months

• Pain:(-) ?

• Margin:well-defined ( )

Benign

Benign

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1、Adenomatoid odontogenic tumor over right mand. body 2、Calcifying odontogenic cyst (Gorlin cyst)

3、Central odontogenic fibroma 4、Cemento-ossifying fibroma 5 A l bl ti fib

5、Ameloblastic fibroma

6、Calcifying epitheial odontogenic tumor (Pindborg tumor) 7、Central giant cell granuloma

WORKING DIAGNOSIS

7 Central giant cell granuloma

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adenomatoid odontogenic tumor

Our case AOT

Gender female Female: male= 2:1

Age 12 y/o 10~19 y/o, Average 16 y/o

Symptom & sign ??

Site Right mandibular anterior Maxi.: g mand.=2:1

area Anterior jaw(90%)

number unilocular unilocular

Radiography Fine(snowflake) calcifications

Complete R-L or R-L+R-O foci(snowflake)

Marging Well-defined Well-defined

Tooth involvement Embedded tooth of 43(R-L extend apically along

apical third)

Involve the crown of an unerupted tooth(R-L

extend apically along the apical third) extend apically along the

root past CEJ

(24)
(25)

calcifying odontogenic cyst (Gorlin cyst)

Our case Gorlin cyst

Our case Gorlin cyst

Gender female ?

Age 12 y/o Average 33 y/o (from infant to

Age 12 y/o Average 33 y/o (from infant to

elder, more neoplastic variants, more younger)

S t & i ? I t t

Symptom & sign ? Intraosseous or extraosseous (localized gingival masses)

Site Right Mand. over 65%--ant. Area

pericoronal of 43

Size 4 X 3 cm Most between 2~4 cm

N b il l U il l

Number unilocular Unilocular

radiography Fine (snowflake) calcifications

Radiolucency (R-O, irregular calcifications or tooth-like densities--1/3~1/2)

Margin Well-defined Well-defined

Tooth

involvement

Embedded tooth of 43(R-L extend apically along apical third

R-L involve unerupted tooth--1/3 (most often a canine)

(26)
(27)

Central odontogenic fib

fibroma

Our case Central odontogenic fibroma

G d f l F l

Gender female Female

Age 12 y/o 4~80 y/o(mean age 40 y/o)

S & ??

Symptom & sign ?? smaller :asymptomatic,

Larger :bony expansion teeth loosening Site Right mandibular anterior area Maxillary 45%

Mandible : posterior area:29%

anterior:8%

number unilocular Unilocular or multilocular

Radiography Fine(snowflake) calcifications R-L ,12% radiopaque flecks Margin Well-defined, corticated Well-defined, many corticated Tooth involvement Embedded tooth of 43(R-L

t d i ll l i l

1/3 associated with unerupted

t th Oft t ti

extend apically along apical third)

teeth .Often root resorption and divergence

(28)
(29)

cemento-ossifying fibroma cemento ossifying fibroma

Our case C.O.F

Gender female Female > male

Age 12 y/o Average 10~30 y/o

S t & i ? P i l lli

Symptom & sign ? Painless swelling

Site Right Mand. over pericoronal of 43

Mand premolar and molar > >max.

of 43 molar max.

Size 4 X 3 cm ?

Number unilocular Unilocular

radiography Fine(snowflake) calcifications Radiolucency+radiopacity

Marging Well-defined Well-defined

Tooth involvement Imbedded tooth of 43(R-L extend apically along apical third

Root divergence

involvement or resorption of roots

third of roots

(30)
(31)

Ameloblastic fibroma

Our case Ameloblastic fibroma

Gender Female Male

Age 12 y/o Middle-age

Symptom & sign ?? Small ameloblastic fibroma is asympomatic; larger tumors are associated swelling of the jaws Site Right mandibular Posterior mandible jaw

Site Right mandibular

anterior area

Posterior mandible jaw

(70%);posterior maxilla (23%)

number unilocular Unilocular or multilocular

Radiography Fine(snowflake) calcifications

may be sclerotic; ameloblastic

fibroma may involve a considerable portion of the body and ascending ramus of mandible

Margin Well-defined Well-defined

T th i l t E b dd d t th f 43 75% f i i t d

Tooth involvement Embedded tooth of 43 (R-L extend apically along apical third)

75% of cases is associated uneruped tooth

(32)
(33)

Calcifying epithelial odontogenic

t (Pi db t )

tumor(Pindborg tumor)

O Pi db t

Our case Pindborg tumor

Gender Female Female =male

A 12 / A 30 50 /

Age 12 y/o Average 30~50 y/o

Symptom & sign ? Painless ,slow growing

swelling Site Right Mand. over pericoronal

of 43

2/3 Mand posterior area

Size 4 X 3 cm ?

Size 4 X 3 cm ?

Number unilocular multilocular

radiography Fine(snowflake) calcifications Radiolucency+radiopacity radiography Fine(snowflake) calcifications Radiolucency+radiopacity

Margin Well-defined Well-defined

T th i l t I b dd d t th f 43(R L I t d t th ( d 3rd Tooth involvement Imbedded tooth of 43(R-L

extend apically along apical third

Impacted tooth (mand.3rd molar)

(34)
(35)

Central Giant Cell Granuloma

Our case Central giant cell granuloma

Gender Female Female

Age 12 y/o 2~80 ,60% before age 30

Symptom & sign ?? Most asymptomatic,

painless bone expansion Minor pain,paresthesia Site Right mandibular anterior

area

Anterior jaw

number unilocular Unilocular or mutilocular

number unilocular Unilocular or mutilocular

Radiography Fine(snowflake) calcifications

R-L ,not specially diagnostic

Margin Well-defined Well-defined, generally

noncorticated Tooth involvement Imbedded tooth of 43(R-L Not specially Tooth involvement Imbedded tooth of 43(R-L

extend apically along apical third)

Not specially

(36)
(37)

Clinical impression--- Clinical impression---

Adenomatoid odontogenic tumor g

over right mandibular body

(38)

THANKS FOR YOUR

ATTENTION!!!

Figure

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References

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