CASE REPORT

CASE REPORT

Intern F組 劉青穎 黃珊珊 莊涵芝 李昆峰 Date:101/02/27

Instructors:口腔病理科全體醫師

1

P ^ERSONAL D ^ATA

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2

C ^HIEF C ^OMPLAINT



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

3

P ^RESENT I ^LLNESS

 This 51 years old female felt swelling and pain over lower right posterior region

about three weeks. Then, she found the swelling become worse and went to LDC 101.01.05 for help. The dentist referred her to our OPD for further evaluation and treatment.

4

P ^AST M ^EDICAL H ^ISTORY

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5

P ^ERSONAL H ^ABITS

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



6

E ^XTRAORAL EXAMINATION



 Facial asymmetry (+)

 Tenderness (+)

 Pain (+)

7

I ^NTRAORAL EXAMINATION

 Swelling over R’t retromolar region

 Dimension：2cm *3 cm

 Surface：Smooth

 Consistency：Rubbery

 Color：White lines (biting irritation?)

 Mobility：Fixed

8

I ^NTRAORAL EXAMINATION

 Fluctuation (-)

 Induration (-)

 Pain (+)

 Tenderness (+)

 Bucco-lingual bony expansion over R’t mandibular body.

9

D ^ENTAL EXAMINATION

 Missing teeth：Tooth 18, 17, 26, 27

 Restoration：Tooth 11, 21, 47

 PFM Crown：Tooth 25

10

R ADIOGRAPHIC FINDINGS

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P ^{ANORAMIC RADIOGRAPH} (2012.01.06)

 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 4*3.8 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 1.5*1.5 cm in diameter, apical to tooth 34, 35.

12

P ^ERIAPICAL X- ^RAY (2012.01.06)



There is a horizontally

impacted tooth 48 with root resorption.

13

CT EXAMINATION (2012.01.12)



There is a lesion with solid and cystic component and

septum in the right mandibular angle.



The adjacent bony cortex over R’t mandible was expansile.

15

C ^{OMPUTED TOMOGRAPH} EXAMINATION

 Impression

 Size: 4.0*3.8*2.6 cm

 Suspect ameloblastoma.

 Dx: odontogenic keratocyst

16

D IFFERENTIAL

D ^IAGNOSIS

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D IFFERENTIAL D ^IAGNOSIS

 Inflammation, cyst or neoplasm?

 Benign or malignant?

 Peripheral or intrabony?

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I NFLAMMATION , ^{CYST OR NEOPLASM} ?



Redness: (-)



Swelling: (+)



Pain: (+)



Fever or local heat: (-)



Tenderness : (+)



Purulent drainage: (-)

19



Duration:



Unknown



2-3weeks with S/S



Consistency: Rubbery



Mobility: Fixed



Fluctuation: (-)



Induration: (-)

→Neoplasm or Cyst

B ^{ENIGN OR} M ^ALIGNANT ?

 Pain: (+)

 Tenderness: (+)

 Duration:

 Unknown

 2-3weeks with S/S

 Lymphadenopathy: (-)

 Ulceration: (-)

 Induration: (-)

 Paresthesia: (-)

 Mobility: Fixed

→Benign ₂₁

P ^{ERIPHERAL OR INTRABONY}



Bony destruction: (+)



Bony expansion: (+) → Intrabony

22

W ^{ORKING DIAGNOSES}

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W ^{ORKING DIAGNOSES}



The list (more possible→ less)



Neoplasm



Ameloblastoma



Keratocystic odontogenic tumor



Unicystic Ameloblastoma



Pindborg tumor



Odontogenic myxoma



Ameloblastic fibroma



Cyst



Dentigerous cyst

A MELOBLASTOMA

Our case Ameloblastoma

Gender Female M=F

Age 51 20-70 (average 40)

Site R’t mandible angle &

ramus Mandible (Molar region)

S/S Painful swelling

No paresthesia Painless swelling

Paresthesia is uncommon

Size 4* 3.8cm Variable

Radiograph

features Unilocular R/L

Ovoid shape with well- defined, corticated margin

Unilocular

Multilocular R/L

Scalloped, ill-defined ragged borders Soap bubble, honeycomb

Effects Impacted 48 with root resorption.

Cortical bone expansion

Combine impacted tooth, esp. mandible 3^rd molar

Root resorption of adjacent tooth .

Cortical bone expansion (in large tumor)s ²⁵

A MELOBLASTOMA

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K ERATOCYSTIC O ^DONTOGENIC T ^UMOR

Our case Keratocyst Odontogenic Tumor

Gender Female Male

Age 51 10-40 (average 28)

Site R’t mandible angle &

ramus Mandible (posterior body and ascending ramus)

S/S Painful swelling Asymptomatic (usually)

Size 4* 3.8cm Variable

Radiograph

features Unilocular R/L

Ovoid shape with well- defined, corticated margin

Unilocular R/L with corticated margin Multilocular in large lesion.( scalloped shaped margin)

Effects Impacted 48 with root resorption.

Cortical bone expansion.

Grow in antero-posterior direction, without bony expansion.

Usually involve unerupted tooth.

Usually no root resorption of adjacent

tooth. ²⁷

K ERATOCYSTIC O ^DONTOGENIC T ^UMOR

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U ^NICYSTIC A MELOBLASTOMA

Our case Unicystic Ameloblastoma

Gender Female M=F

Age 51 85% under 30 (average 21)

Site R’t mandible angle & ramus Mandibule (Molar region)

S/S Painful swelling Asymptomatic, painless swelling in large lesion

Size 4* 3.8cm Variable

Radiograph

features Unilocular R/L

Ovoid shape with well- defined, corticated margin

Unilocular R/L

Well defined with corticated margin Effects Impacted 48 with root

resorption.

Cortical bone expansion

Combine impacted tooth, esp.

mandible 3^rd molar

Root resorption of adjacent tooth.

Cortical bone expansion is noticeble 29

U ^NICYSTIC A MELOBLASTOMA

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C ^{ALCIFYING EPITHELIAL} ODONTOGENIC TUMOR (P ^{INDBORG TUMOR} )

Our case Pindborg tumor

Gender Female M=F

Age 51 30-50 ( average 40)

Site R’t mandible angle &

ramus Mandible (posterior area)

S/S Painful swelling Painless, slow-growing swelling

Size 4* 3.8cm Variable

Radiograph

features Unilocular R/L

Ovoid shape with well- defined, corticated margin

Unilocular RL + RO (usually in Maxilla) Multilocular RL + RO

Relatively well-defined, scalloped margin Snow-driven

Effects Impacted 48 with root resorption.

Cortical bone expansion.

Usually involve impacted tooth.

Usually no root resorption of adjacent tooth.

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C ^{ALCIFYING EPITHELIAL} ODONTOGENIC TUMOR (P ^{INDBORG TUMOR} )

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O ^DONTOGENIC M ^YXOMA

Our case Odontogenic Myxoma

Gender Female M=F

Age 51 Young adult (25-30)

Site R’t mandible angle &

ramus Max/Man= ¾

Ramus, posterior teeth area S/S Painful swelling Asymptomatic for small lesion

Painless swelling for large lesion, Paresthesia(rare)

Size 4* 3.8cm Variable

Radiograph

features Unilocular R/L

Ovoid shape with well- defined, corticated margin

Unilocular R/L (small, anterior region) Multilocular R/L (large, posterior region) -- soap bubble, honeycomb, tennis racket Margin may be scalloped or irregular Effects Impacted 48 with root

resorption.

Cortical bone expansion.

Cortical bone expansion.

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O ^DONTOGENIC M ^YXOMA

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A MELOBLASTIC FIBROMA

Our case Ameloblastic Fibroma

Gender Female M>F

Age 51 0-19 ( Adolescent and children)

Site R’t mandible angle & ramus Mandible (posterior area) S/S Painful swelling Asymptomatic if small

Swelling if large.

Size 4* 3.8cm Variable

Radiograph

features Unilocular R/L

Ovoid shape with well- defined, corticated margin

Unilocular (usually in small) Multilocular

Well defined , may be sclerotic margin Effects Impacted 48 with root

resorption.

Cortical bone expansion.

Usually involve impacted tooth.

35

36

D ^{ENTIGEROUS CYST}

Our case Dentigerous cyst

Gender Female M>F (slight)

Age 51 10-30

Site R’t mandible angle &

ramus Mandible (posterior area)

S/S Painful swelling Asymptomatic, Painless swelling( unless infected)

Size 4* 3.8cm Usually larger than 4mm in diameter

Radiograph

features Unilocular R/L

Ovoid shape with well- defined, corticated margin

Unilocular RL with corticated margin.

Effects Impacted 48 with root resorption.

Cortical bone expansion.

Usually involve impacted mandibular 3^rd molar.

Cyst usually attach the tooth at the CEJ margin.

Usually with root resorption and displacement of the adjacent tooth.

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38

C ^{LINICAL IMPRESSION}



Ameloblastoma, R’t mandible body and ramus



Dentigerous cyst, tooth 48

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T ^{ENTATIVE TREATMENT PLAN}

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T ^{ENTATIVE TREATMENT PLAN}



After D.D.(i.e. Ameloblastoma)



Enucleation of the lesion together with removal of the unerupted tooth 48 and tooth 47

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T ^{REATMENT PROCEDURE}

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T ^{REATMENT PROCEDURE}

101.01.06



Take X-ray



Incisional biopsy under local anesthesia



Arrange CT with and without contrast



Rx:



Amoxicllin 500mg

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Panadol 500mg QID * 5days



Strocain

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T ^{REATMENT PROCEDURE}

101.01.18



HP report:



Bone, mandible, tooth 48, incision, dentigerous cyst



Local treatment with remove suture and GI topical application



Rx: Panadol 500mg 8# PRN

101.01.20



Arrange OP on 2/8

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2/3 GA routine examination

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2/6 admit to the 13EN ward

T ^{REATMENT PROCEDURE}

101.02.03



Preoperative examination

101.02.08 (in the OR)



Surgical procedure:



bone tumor excision + extraction of the tooth 38, 47,48



trimming the bony cavity and sharp edge

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P ^{ANORAMIC RADIOGRAPH} (2012.02.11)

 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 4*3.8 cm in diameter. 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 1.5*1.5 cm in diameter, ~0.5 cm apical to tooth 34, 35.

48

T ^{REATMENT PROCEDURE}

101.02.17



S/P OP HP report:



Bone, mandible, right ,enucleation, unicystic ameloblastoma



Suture removal and impression



N.V: Obturator placement

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醫學倫理討論

顏面重建之倫理議題探討

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O ^{UR CASE}



Benign neoplasm



 保守治療，縮小手術範圍，保持顏面美觀



如復發



 需做更積極的治療，切除範圍為加大(e.g.: en block)



 顏面外觀缺損生活品質受影響、心理衝擊



 顏面重建有其必要性

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口腔癌顏面重建很重要

【臺灣時報／記者廖國雄／高雄報導】 2012/01/04

高雄醫學大學附設醫院昨公布癌症重建團隊十年成果，其中口腔癌病友術後顏面缺損或組織功 能障礙者，接受顯微皮瓣重建手術成功率達九十五%。

高醫整形外科主任張高評表示，每年至少有百位口腔癌術後病友，接受高醫顯微皮瓣重建手術 整容，順利重返職場及家庭生活的病例。這些人現身說法，成為宣導「及時就醫，勇敢接受外 科手術治療」的活廣告。

根據國民健康局公布的最新資料顯示，口腔癌居全國癌症十大死因第五位，其中男性癌排名第 四位，發病年齡以四十至六十歲為最常見，此年紀為家中的經濟支柱，一旦罹病對家庭整體狀 況影響甚鉅。

張高評指出，高醫每年新增口腔癌友人數，是全台灣醫學中心排名前三名，從二00 二至二00 九年資料庫分析，發現病患就醫診斷為第三期及第四期居多，其中第四期人數在八年期間增加 二倍多。

值得注意的是，口腔癌發生率逐年增加，五年發生率增加三十八％，死亡率提高十五％，多半 病人因拖延就醫，到院已確診是第四期。導致第四期病人數佔四十八％，造成就醫因腫瘤過大 或顏面頰部組織嚴重破損致口內外相通，顯見口腔癌的早期診斷與治療對社會及家庭影響的重 要性。

張高評表示，所有病人因口腔癌接受大範圍病灶切除且傷口無法直接縫合而導致顏面缺損或組 織功能障礙者，除非病人本身的條件無法承受此手術者外，都建議接受高成功率及高滿意度的

顯微皮瓣重建手術 52

日新月異的醫療重建技術



顯微皮瓣重建手術



自體移植，較無倫理爭議



須損失身體其他部位組織



臉部移植



可修補更大範圍的顏面缺損



排斥風險



有複雜的醫學倫理爭議

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從「變臉」移植探討 相關倫理評估準則

◎高雄長庚外科部部主任 郭耀仁

◎前高雄長庚精神科主治醫師 林皇吉

長庚醫訊 第三十三卷第二期 101年2月1日發刊

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「變臉」移植相關倫理



臉部移植在倫理學上的爭議方興

未艾



針對該術式的倫理學議論



比起在手術技術上、免疫學上的探 討要來的多

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移植的利益與風險評估

 客觀衡量工具(Universityof Louisville的團隊)

 The American Journal of Bioethics Volume 4, Issue 3, 2004 “On the Ethics of Facial Transplantation Research”

 研究不同族群對於臉部移植的意見與看法

 研究對象: 臉部創傷者、截肢者、正接受免疫抑制劑的腎 臟移植者、從事移植的外科醫師、一般健康自願者等。

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移植的利益與風險評估



納入研究的對象均願意為臉部移植承受較高的風險，甚至高於 接受腎臟移植



免疫抑制劑的20 項風險以及假設有50%的排斥率仍有超過 70%以上研究對象願同意臉部移植



結論:



讓當前的臨床工作者理解各族群對於臉部移植的觀點



強化該術式在臨床上施行的需要性

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創新臨床術式的倫理準則

一.

創新術式的科學背景



準備工作上必須已臻完備

二.

進行創新術式的技巧與經驗



足夠的學識、經驗、技巧以及充分的技術能力，以確保可以安全有效 的進行

三.

公開的揭示計畫，並接受公評

四.

進行創新術式機構的倫理風氣



非源自於該機構及執行者為了醫院或個人的聲譽、專業技術的肯定

五.

充足的動物試驗

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創新臨床術式的倫理準則

六.

充分知情同意的接受術式者

七.

對於該創新治療存在有重要需求

八.

主管單位的規範與核准

九.

風險與利益的評估

o

充分告知接受術式的預期利益及可能出現的風險

十.

接受術式對象的身分及相關資訊的保密

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對於開始安排臉部移植手術的建議

一、訓練嚴謹、準備充分、經驗老到的醫療團隊 二、合理合宜的個案選擇

三、充分的知情同意

四、嚴謹的社會心理及過去病史的評估

五、善體人意及經驗豐富專業人員對於捐贈家庭的介入與後續協助 六、捐贈大體的顏面重建與尊嚴維護

七、後續持續個案醫療及社會心理適應的追蹤與處遇

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C ^ONCLUSION

 臉部移植手術牽涉的醫療、社會心理適應的議題空前的 複雜與深遠

 臉部--代表身分認同的重要部分





 醫療不只是醫”病”,術後的生活品質，心理、社會的健 康也很重要

61

C ^ONCLUSION



Our case:



先以保守的手術治療，以保存病人的顏面外觀



須密切的回診追蹤



發現復發:



須告知其手術範圍對顏面的影響



討論顏面重建的必要性及手術方式



後續的病程追蹤及輔導(心裡、社會)

62

R ^EFERENCES



長庚醫訊 第三十三卷第二期 101年2月1日發刊--從「變臉」移 植探討相關倫理評估準則



The American Journal of Bioethics, 4(3): 1–12, 2004--On the Ethics of Facial Transplantation Research



臺灣時報／高雄報導 2012/01/04--口腔癌顏面重建很重要

63

T ^{HANK YOU}

FOR YOUR ATTENTION !!