報告組別:Intern Group A 報告日期 : 101.09.24
指導醫師:林立民醫師、陳玉昆醫師、
王文岑醫師、陳靜怡醫師
組員:蕭維榮、梁鍶潔、黃冠倫、柳懷禧
Name : XXX
Sex: Female
Age: 25 y/o
Native: 台灣
Marital status: 未婚
Attending V.S.: XXX醫師
First visit: XXX.XX.XX
Referred from LDC because of a radiolucent
image over left mandible was found during routine oral examination
03/30/2005 (in XXXXH.)
- Ameloblastoma s/p cystic enucleation under GA - Left inferior alveolar nerve had been sacrificed
04/2005 to 10/2010 (in XXXXH.) - Kept f/u
- A RL image over the same site appeared again during this time,
but the doctor decided to keep f/u
- Moved to Kaohsiung on 10/2010, and then lost f/u
06/05/2012
- Referred from LDC, taking panorex and CT scan - CT report: suspected recurrent ameloblastoma - Arranged OP on 09/17/2012
Past Medical History
- Hospitalization: (+), ameloblastoma over left ramus s/p cystic enucleation + complicated odontectomy of tooth 38 - Surgery under GA: (+), as above
- Systemic diseases: denied - Drug or food allergy: denied
Past Dental History
- General routine dental treatment
Attitude to dental treatment
: Cooperative
Risk factors related to malignancy
◦ Alcohol: (-)
◦ Betel quid: (-)
◦ Cigarette: (-)
Other specific oral habits : Denied
Bite irritation : Denied
Missing: Tooth 28 35 38 48
C&B: Tooth 11 21 22
Restorations: Tooth 14 15 17 25 26 45 47
Caries: Tooth 36 37
MMO: 40mm (Tooth 11 to 41)
• Site: L’t mandible
• Size: 3.0 x 3.0 cm
• Shape: Dome
• Color: Normal-mucosa
• Consistency: Bony hard
• Pain: (-)
• Tenderness: (-)
• Lip numbness: (+), left, due to previous surgery
• Tooth mobility: tooth 35 (-), 36 (-), 37 (-)
• Bone expansion: (+), buccolingual direction over left mandible
101.09.16
There is a well-defined multilocular round-shaped radiolucency with sclerotic margin over left mandible, extending from root apex of 35 to
inferior border of cortex of left ascending ramus and from 0.5cm inferior to sigmoid notch down to the inferior border of cortex of left mandible,
measuring 7.0x5.5cm in size. Bone expansion over left retromolar area is noted. Left alveolar canal was not visible due to previous surgery. Left inferior cortical margin still intact. Non-vital tooth 35, 36, 37 is noted in contact with the lesion without root resorption.
Left lower posterior area
3.0 X 3.0 cm, dome shape, bony hard consistency, normal mucosa color
Tenderness (-)
Pain(-)
Lip numbness (+)
Bone expansion (+)
Multilocular radiolucency with bony destruction
Intrabony lesion
Our case Peripheral <Intrabony>
Mucosal lesion - + -
Induration - + -
Bony expansion + - +-
Cortical bone destruction
+ - +-
Intrabony
Our case Inflammation
Redness - +
Swelling + +
Local heat Unknown +
Pain - +
Due to panorex finding : large multilocular RL destruction lesion cyst or neoplasm
Our case Cyst
Fluctuation - +-
Well + defined border + +
Bone expansion + +-
Our case Inflammation cyst Non-inflammation cyst Pain,
tenderness
- + -
Local heat Unknown + -
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
+ -+ +
progressive Slow Slow Fast
Swelling with intact epithelium
+ + -
Pain - - +
Induration - - +
Non-Inflammation cyst or Benign tumor
(1) Ameloblastoma
(2) Keratocystic odontogenic tumor (3) Odontogenic myxoma
(4) Central giant cell granuloma
Our case Ameloblastoma
Gender Female Equal
Age 25 30~70
Site Mandible (molarascending ramus)
Mandible (molarascending ramus)
Paresthesia - uncommon
Awelling + +
Drainage - +
Shape
Well-defined, smooth, soap bubble multilocular,
corticated margin
Well-defined, smooth, honeycomb multilocular,
corticated margin
Bony expansion + +
Teeth
displacement /root resorption
+ +
Duration Slow Slow
Our case KCOT(larger)
Gender Female Slight male
Age 25 10~40
Site Mandible
(molarascending ramus)
Mandible (posterior body and ascending ramus)
Paresthesia - pain
Swelling + +
Drainage - +
Shape
Well-defined, smooth, soap bubble multilocular,
corticated margin
Well-defined, smooth, multilocular, corticated margin
Bony expansion + -
Teeth displacement
/root resorption + +
Duration Slow Slow
Our case Odontogenic myxoma
Gender Female Slight female
Age 25 10~50 (mean25~30)
Site Mandible
(molarascending ramus)
Max.:Mand.=3:4 or 3:7 (tooth-bearing areas)
Paresthesia - -
Swelling + -
Drainage - -
Shape
Well-defined ,smooth, soap bubble multilocular,
corticated margin
Often well-defined, unilocular or multilocular, may with corticated
margin
Bony expansion + +
Teeth displacement
/root resorption + +
Duration Slow Slow
Our case Nonaggresive
(most) Aggressive
Gender Female Female
Age 25 <30
Site Mandible (molarascending ramus)
Mandible (anterior region) frequently cross the midline
Paresthesia - - Pain
Swelling + - +
Drainage - - -
Shape
Well-defined, smooth, soap bubble multilocular,
corticated margin
Well-defined, unilocular or multilocular, noncorticated
margin
Bony expansion + - +
Teeth
displacement/root resorption
+ - +
Duration Slow Slow Rapid
Recurrent ameloblastoma over left mandible and ramus
2005~2010
Received treatment in XXXXH.
101/06/05
Discomfort over 36 37 region for 4-5 days
Clinical examination
Panorex taking
101/06/29
Ask for treatment of left mandible lesion
Arrange for CT scan
Check CBC, WBC, Urea N, Creatinine
101/07/20
Ask for CT report
Left cheek mild swelling
101/09/07
Treatment plan of left mandible ameloblastoma was made sure
Panorex taking
101/09/11
Treatment plan of left mandible ameloblastoma and GA routine was made sure
A multilocular cystic lesion (7.0x5.5x3.0 cm) with bony
expansion at left mandibular body.
DDx: ameloblastoma, keratocystic
odontogenic tumor
A multilocular cystic
lesion (7.0x5.5x3.0cm) with cortical
breakthrough at left mandibular ramus.
DDx: ameloblastoma, keratocystic
odontogenic tumor.
Recommend clinical
correlation.
101/06/05 101/09/07 Enlargement of the lesion(8.0x6.0cm) and more
bony destruction could be seen on X-ray. Tooth 33 and 34 are involved in the lesion, without root resorption. The lesion expanded nearer to
sigmoid notch and inferior border of cortex of left ascending ramus.
EKG
CBC
Urine routine examination
Glucose
Blood test: GOT, GPT, UN, CRTN, Na, K, Cl, GGT, Prothrombin time, Partial thromboplastin time
Chest PA
B型肝炎E抗原檢查-酵素免疫
B型肝炎表面抗原檢查-酵素免疫
C型肝炎病毒抗體
101/09/15
Admission
OP on 101/09/17
101/09/16
Pre-operation:
1. Consult anesthesia department and ENT department 2. Full mouth scaling
3. Require patient NPO since midnight the day before surgery
Reconstruction plate fabrication
101/09/17 (The day of operation)
General condition:fair
Operation:
1. Marginal Resection 2. Cystic enucleation 3. Curettage
4. IMF
101/09/18
Throat pain after operation
Facial swelling over left cheek
Post-op panorex taking
Check lab data (higher WBC CRP, lower RBC Hgb Hct)
Check wound condition
Removal of NG tube
Oral irrigation for oral hygiene control
101/09/18
Lesion removed and extraction of tooth 33, 34, 35, 36, 37.
Cortex of left mandible body and ramus remain intact, and the lesion near inferior border of left cortex and near
sigmoid notch was noted remained. Splinting of teeth 16 to 25, and 32 to 46 were noted. A radiopacity in left
ascending ramus was noted, suspect as a foreign body
101/9/19-9/23
- Oral irrigation everyday
- Keep follow-up for general condition(stable) - No special complaint
101/9/23
- Discharged from hospital - Keep f/u in OPD
- Remove suture s/p 2 weeks in OPD
- Follow and pending post-OP H-P report
Local removal of tumor by instrumentation in direct contact with the lesion
Used for very benign types of lesion
Resection: Removal of a tumor by incising through uninvolved tissues around the tumor, thus
delivering the tumor without direct contact during instrumentation
Marginal resection: Resection of a tumor without disruption of the continuity of the bone
Lesion is known to be aggressive
When total removal by enucleation, curettage, or both would be difficult
Lesion and 1-cm bony margins
Full thickness mucoperiosteal flap
Section the bone and remove segment
If tumor perforated the cortical plate
- sacrifice soft tissue to eradicate tumor
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 )
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)
病人已了解自己的病狀 ,治療方法(f/u ,手術) 復發 的可能性 ,併發症(如病人第一次在慈濟開刀時移除 掉IAN等 )
自主原則 (Autonomy)
在發病的第一次 (2005年)選擇開刀, 在2006年病 人隨著醫師的建議選擇長期觀察, 在2012年病人選 擇做第二次的手術。
自主原則 (Autonomy)
病人的症狀包含了大部分的left mandible. 第一線治 療牙科醫師選擇En bloc resection並使用
reconstruction plate來重建. 並且這樣大範圍的切除 是必要的.
行善原則(Beneficence): 預防傷害:應該預防傷害 或惡行, 移除傷害:應該移除傷害或惡行
考慮到病人是年紀26歲的女生,到外觀會是影響病 人心理的因素, 並可選擇保守性的手術切除範圍 (只 移除掉有病狀的bone 留下一小部分來維持外觀)
不傷害原則(Non-maleficence)
自主原則(Autonomy)
行善原則(Beneficence): 利益和福祉
因中途改變手術計畫, 因此沒有用到reconstruction plate
公義原則(Justice)
並且還有可能會有bone fracture加上復發時再開刀而 用到的資源和人力
公義原則(Justice)
最後,整個治療過程不只是關心到病人的身體上的病 狀,也包含病人生活上的品質與心理上的照顧,符合 全人照顧的考量
經過執行的Treatment course可檢討到 :
讓病人了解症狀的嚴重性,並持續的f/u,可能會 減少到手術範圍
在2012年6月發現症狀時,應緊急治療減少手術 範圍,也可以多保留一些牙齒。