Name : XXX

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(1)

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

(2)

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

(3)

Referred from LDC because of a radiolucent

image over left mandible was found during routine oral examination

(4)

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

(5)

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

(6)

Risk factors related to malignancy

Alcohol: (-)

Betel quid: (-)

Cigarette: (-)

Other specific oral habits : Denied

Bite irritation : Denied

(7)

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)

(8)

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

(9)

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.

(10)
(11)

Left lower posterior area

3.0 X 3.0 cm, dome shape, bony hard consistency, normal mucosa color

Tenderness (-)

Pain(-)

Lip numbness (+)

Bone expansion (+)

(12)

Multilocular radiolucency with bony destruction

 Intrabony lesion

(13)

Our case Peripheral <Intrabony>

Mucosal lesion - + -

Induration - + -

Bony expansion + - +-

Cortical bone destruction

+ - +-

 Intrabony

(14)

Our case Inflammation

Redness - +

Swelling + +

Local heat Unknown +

Pain - +

Due to panorex finding : large multilocular RL destruction lesion cyst or neoplasm

(15)

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

+ - +

(16)

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

(17)

(1) Ameloblastoma

(2) Keratocystic odontogenic tumor (3) Odontogenic myxoma

(4) Central giant cell granuloma

(18)

Our case Ameloblastoma

Gender Female Equal

Age 25 30~70

Site Mandible (molarascending ramus)

Mandible (molarascending 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

(19)

Our case KCOT(larger)

Gender Female Slight male

Age 25 10~40

Site Mandible

(molarascending 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

(20)

Our case Odontogenic myxoma

Gender Female Slight female

Age 25 10~50 (mean25~30)

Site Mandible

(molarascending 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

(21)

Our case Nonaggresive

(most) Aggressive

Gender Female Female

Age 25 <30

Site Mandible (molarascending 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

(22)

Recurrent ameloblastoma over left mandible and ramus

(23)
(24)

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

(25)

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

(26)

A multilocular cystic lesion (7.0x5.5x3.0 cm) with bony

expansion at left mandibular body.

DDx: ameloblastoma, keratocystic

odontogenic tumor

(27)

A multilocular cystic

lesion (7.0x5.5x3.0cm) with cortical

breakthrough at left mandibular ramus.

DDx: ameloblastoma, keratocystic

odontogenic tumor.

Recommend clinical

correlation.

(28)

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.

(29)

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

(30)

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

(31)

101/09/17 (The day of operation)

General condition:fair

Operation:

1. Marginal Resection 2. Cystic enucleation 3. Curettage

4. IMF

(32)

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

(33)

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

(34)

101/9/19-9/23

- Oral irrigation everyday

- Keep follow-up for general condition(stable) - No special complaint

(35)

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

(36)
(37)

Local removal of tumor by instrumentation in direct contact with the lesion

Used for very benign types of lesion

(38)

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

(39)

Lesion is known to be aggressive

When total removal by enucleation, curettage, or both would be difficult

(40)

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

(41)
(42)

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 )

(43)

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)

(44)

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)

(45)

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

(46)

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

(47)

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。

雖然是為了滿足自主原則,但應該要讓病人早日

接受事實並把整個left mandible移除,並預防與減

少recurrence的機率

(48)

Figure

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