指導醫師：林立民醫師、陳玉昆醫師、陳靜怡醫師 報告者：Intern L 組 林晏任、蔡昀蓁、柯琪恩、葉才瑋 報告日期：2014.07.29
General Data
Name : O O O
Sex : Male
Age : 14 years old
Native : Unknown
Marital status : 未婚
Attending staff: O O O醫師
First visit : 103/07/04
Chief Complaint
Ask for examination of a suspected odontoma in the region of upper left posterior area.
Present Illness
This 14-year-old male was informed that he didn’t have tooth 27 eruption by a LDC
dentist, so he took panorex film and CT
scan, and the dentist told him it may be an odontoma and suggested him to come to our OPD for further treatment.
103/07/04
Intraoral examination
Missing tooth: Tooth 27
Bone expansion (+)
Tenderness/Pain +
Paresthesia: Unknown
Ulcer (-)
Normal appearance of palatal muocosa and no
abnormal findings for teeth over left posterior maxilla
103.7.4
Extraoral examination
• No obvious swelling over the facial area
Past medical history
Past Medical History
Systemic diseases (-)
Hospitalization (-)
Surgery under GA (-)
Food & drug allergies (-)
Past dental history
Routine dental treatment
Attitude to dental treatment: Co-operative
Personal History
Risk factor related to malignancy
Alcohol drinking (-)
Betel quid chewing (-)
Cigarette smoking (-)
Special oral habits: Denied
Family history:
Similar facial profile in relatives: Unknown
Radiographic examination - 1
There is a well-defined homogenous radiopacity with radiolucent rimming containing high position impaction 27 with corticated margin over the left
posterior maxilla, extending from the distal side of tooth 24 to the left maxillary tuberosity, and from 2/3 height of left maxillary sinus to the left maxillary
alveolar crest of molar area, measuring approximately 3.3x3.0 cm. The inferior border of left maxillary sinus seems to not be continuous, may be affected by the lesion. Root resorption on tooth 26 is not obvious.
Radiographic examination - 2
Missing tooth: Tooth 28
Operative dentistry: Tooth 16,36,46 Unerupted tooth: Tooth 18,38,48
Peripheral or Intrabony
Left posterior maxillary area
Pain (+)
Tenderness (+)
Induration (-)
Bone expansion (+)
Intrabony or peripharal
Our case Peripheral Intrabony
Mucosal lesion - + -
Induration - +/- +
Bony expansion + - +/-
Bone destruction + - +-
→Intrabony
Inflammation, Cyst or Neoplasm
Our case Inflammation
Redness - +
Swelling + +
Local heat - +
Pain +
Our case Cyst
Fluctuation - +/-
Well defined border + +
Bone expansion + +-
Due to panorex finding:
Large homogeneous RO destruction lesion
→ tumor or cyst
Our case Inflammatory cyst
Non-inflammatory cyst
Pain, tenderness + + -
Local heat - + -
Color Pink Reddish Pink
Progression Slow Fast Slow
Sclerotic margin + - +
Our case Benign Malignance Border Well-defined Well-defined Ill-defined
Margin Smooth Smooth Irregular
Sclerotic margin + + -
Destruction of cortical
margin - +- +
Progression Slow Slow Fast
Swelling with intact
epithelium + + -
Pain + - +
Induration - - +
Non-inflammatory cyst or benign tumor
Differential diagnosis
Ameloblastic fibro-odontoma
Complex odontoma
Ossifying fibroma
Calcifying epithelial odontogenic tumor
Ameloblastic fibro-odontoma
Our case AFO
Gender male equal
Age 14 0~20
Site Maxillary (molar area) Posterior, especially mandible
Paresthesia + -
Swelling + +
Drainage - -
Radiography Well-defined, RO mass with RL rim,
corticated margin Unerupted tooth
Well-defined
Unilocular RL with RO mass Unerupted tooth involved
Bony expansion + +
Teeth displacement/
root resoprtion + +
Duration Sow Slow
Our case
Complex odontoma
Our case Odontoma complex
Gender male equal
Age 14 0~20 (mean:14)
Site Maxillary (molar area) Molar area
Paresthesia + -
Swelling + +
Drainage - +
Radiography Well-defined, RO mass with RL rim,
corticated margin Unerupted tooth
Well-defined
Unilocular RL with RO mass Unerupted tooth involved
Bony expansion + +
Teeth displacement/
root resoprtion + +
Duration Slow Slow
Our case
Ossifying fibroma
Our case OF
Gender male Female
Age 14 30~50
Site Maxillary (molar area) Posterior, mandible
Paresthesia + -
Swelling + +
Drainage - -
Radiography Well-defined, RO mass with RL rim,
corticated margin Unerupted tooth
Well-defined unilocular
RO mass involved
Bony expansion + +
Teeth displacement/
root resoprtion + -
Duration Slow Slow
Our case
Calcifying epithelial odontogenic tumor
Our case CEOT
Gender male equal
Age 14 30~50
Site Maxillary (molar area) Mandible (posterior)
Paresthesia + -
Swelling + +
Drainage - -
Radiography Well-defined,
RO mass with RL rim, corticated margin
Unerupted tooth
Well-defined
Uni / multi-locular RL
(unilocular more common in maxilla) Associated with impacted tooth
Bony expansion + +
Teeth
displacement/ root resoprtion
+ +
Duration Slow Slow
Our case
Clinical Impression
Ameloblastic fibro-odontoma, left posterior maxilla
Ameloblastic fibro-odontoma
Clinical presentation
Age: 1st & 2nd decades
Region: posterior, mandible
Jaw expansion may present
Asymptomatic
Ameloblastic fibro-odontoma
Benign
Slow growing
Painless
Expansile
Inhibit tooth eruption or displace
Ameloblastic fibro-odontoma
Radiographic feature
Well-defined
Unilocular RL with RO mass
Unerupted tooth involved
Ameloblastic fibro-odontoma
Histology
Lobulated, cellular mesenchymal component with proliferating odontogenic epithelium in cords and islands
Enamel matrix, dentin formation associated with odontoma
Ameloblastic fibro-odontoma
Treatment
Conservative surgical excision/curettage
Prognosis
Excellent
Treatment plan
First visit: 103 / 7 / 04
Arrange OP, GA routine
CT image
Treatment plan
A sclerotic well-defined mass lesion (2.80 x 1.95 x 2.58 cm) in the left maxillary sinus arises from inferior and posterior border of the maxillary sinus. with kind of bone expansion, homogeneous tumor matrix with capsule is noted.
Right ethmoid and sphenoid sinusitis DDx: cementoma, ossifying fibroma
Treatment plan
OP: 103 / 07 / 09
Routine p’t identification check
Time out
Routine aseptic and draping procedure
Prophylactic antibiotic
Throat pack, OP start
Intrasulcular incision from 26 to 27 distal
Triangular flap reflection
Bone tumor excision , sent for HP exam
Sinus membrane intact
Complicated extraction of 27
Copious N/S irrigation
Gelfoam soaking
Suture with 3-0 vicryl
Throat pack out, OP ended
Histo-pathologic examination -1
組織名稱： Maxilla, left
臨床診斷： Benign neoplasm
腫瘤代碼： (M-9290/0)
Pathologic diagnosis:
Bone, maxilla, left, excision, ameloblastic fibro-odontoma
Gross Examination
The specimen submitted consists of 2 soft tissue fragments and more the 10 hard tissue fragments in 2 bags, measuring up to 2.0 x 1.5 x 0.9
cm in size, fixed in formalin. Grossly, they are whitish and brownish in color, rubbery and bony hard in consistency.
All for section and labeled as follows: Jar O.
A: 左上顎tumor capsule B1-3: 左上顎TUMOR B1: tumor
B2-3: tumor and tooth
Histo-pathologic examination -2
Microscopic Examination:
The slides contains two identical groups of irregular-shaped soft and decalcified hard tissue specimens.
Microscopically, it is characterized by
ameloblast-like tumor islands infiltrated in immature fibrous stroma and dense fibrous tissue in section A. Sections B1-3 are
characterized by complex and compound odontoma and a tooth crown.
Following above episode, it shows ameloblastic fibro-odontoma
Case report
Iran J Otorhinolaryngol., Seyed Ali Banihashem Rad, Apr 2014
Present illness
An 11-year-old girl was referred to the Department of Oral and Maxillofacial Surgery, Mashhad Dental School, Iran for evaluation of a facial swelling of 6 months duration.
Past medical history
History of systemic disease or trauma: (-)
Food or drug allergies: unknown
Hospitalization: unknown
Attitude to dental treatment: unknown
Examination
Extra oral examination:
An asymptomatic swelling on the right side of the maxilla without s/s of
inflammation.
Intra oral examination:
A bony hard bulge was palpable in the maxillary vestibule.
Missing 2nd molar
A well-defined, radiolucent lesion in the maxillary sinus which contained several radiopaque materials of varying sizes and shapes
The maxillary second molar is involved
Treatment
Under general anesthesia an incision was made intraorally.
A full thickness flap from second incisor to the tuberosity was reflected.
After bone removal of the sinus wall,
access to the lesion was completed. The lesion and the impacted second molar
were enucleated.
Post-treatment
The panoramic view of the patient 4 weeks after surgery
Post-treatment
The panoramic view of the patient 12 weeks after surgery. The right second premolar is in eruption
Post-treatment
Postoperatively, after twelve months, no evidence of residual or recurrent
disease was found
Reference
http://www.ncbi.nlm.nih.gov/pmc/articles/
PMC3989876/
Tom Beauchamp &James Childress 六大原則 - 1979
1.行善原則(Beneficence)：亦即醫師要盡其所能延長病人之 生命且減輕病人之痛苦。
2. 誠信原則(Veractity)：亦即醫師對其病人有「以誠信相對 待」的義務。
3. 自主原則(Autonomy)：亦即病患對其己身之診療決定的 自主權必須得到醫師的尊重。
4. 不傷害原則(Nonmaleficence)：亦即醫師要盡其所能避免 病人承受不必要的身心傷害。
5. 保密原則(Confidentiality)，亦即醫師對病人的病情負有保 密的責任。
6. 公義原則(Justice)，亦即醫師在面對有限的醫療資源時，
應以社會公平、正義的考量來協助合理分配此醫療資源給 真正最需要它的人。
行善原則
做了Excision 後是否有減輕p’t的疼痛感？或是 使p’t更不舒服？
→有減輕swelling的情形，術後傷口會疼痛，但傷 口有持續癒合，等到完全恢復後不會有疼痛現 象。
誠信原則
是否有清楚的向病人說明清楚疾病病程、治療
計畫、預後、風險？
對於病人疾病嚴重程度是否有誠實的通知，盡
到告知的義務？
→已告知病人。
自主原則
充分說明病情及治療計畫、風險之後，是否有
讓病人充分自主的選擇治療計畫？
→已充分說明。
在做全身麻醉以前，是否有說明完整之後再請
病人自主的簽名同意？
→已充分說明。
不傷害原則
手術過程中，是否有造成不必要醫源性的傷害？
→沒有不必要醫源性傷害。
是否有詳實的說明治療計畫，並讓病人對於治
療計畫沒有疑問?
→有詳實說明並取得病患同意。
保密原則
告知的對象 1. 本人為原則
2. 病人未明示反對時，亦得告知其配偶與親屬 3. 病人為未成年人時，亦須告知其法定代理人
4. 若病人意識不清或無決定能力, 應須告知其法定 代理人、配偶、親屬或關係人
5. 病人得以書面敘明僅向特定之人告知或對特定 對象不予告知
公義原則
手術的必要性？
→病灶太大，且已經有脹痛現象產生，建議手術切除。
醫學倫理總結
在病例撰寫方面(病兆描述,治療計畫,病人態度) 應書寫詳盡， 使治療過程有詳實的記錄及治療 順利。
在進行治療之前,須請病人簽屬同意書
應在不違反醫學倫理的原則之下進行治療的行
為
