66
指指指指 : 指指指指指 指指指指指指 指指指指指 、、 指指指 :INTERN K 指 指指指 指指指指 指指指指 指指指 、、、 指指指指 2014.06.24 OM Case Report

指導醫師 : 林立民醫師、陳玉昆醫師、陳靜怡醫師 報告者 :INTERN K 組 吳郁畇、蔡沛倫、張庭豪、龔立揚 報告日期: 2014.06.24 OM Case Report

Embed Size (px)

Citation preview

  • Slide 1

: :INTERN K 2014.06.24 OM Case Report Slide 2 General data Name : O Sex : female Age : 36 y/o Native : Marital status : single Attending V.S. : First visit : 2014.06.03 Slide 3 Chief complaint Left cheek swelling over 2 months, and left lower lip numbness for about one year. Slide 4 Present illness This 36-year-old female patient suffered from left cheek swelling for two months and left lower lip numbness occasionally in the past one year, so she came to our OPD for further examination and treatment. Slide 5 Intraoral examination Site: Tooth 37 mesial aspect to anterior ear area, and from maxilla buccal vestibule to mandible buccal vestibule. Size:5.0x7.0 cm Color: Normal mucosa coverage Surface: Smooth and intact Consistency: Firm Shape: Dome, sessile Palpation: rubbery Bone expansion: (+) Tenderness/Pain: (-) Paresthesia: (+) Fluctuation (-) Fixed Slide 6 Past medical history Denied any underlying disease Denied any food or drug allergies Hospitalization (-) Slide 7 Past dental history General routine dental treatment Orthodontic treatment Attitude to dental treatment : co-operative Slide 8 Personal history Risk factor related to malignancy Alcohol (-) Betel quid (-) Cigarette (-) Special oral habits : denied Slide 9 Radiographic examination Slide 10 Panorex (2014.06.03) There is a multilocular well-defined border radiolucency with partial corticated margin over left mandible angle, with expansion of cortex. Extending from 36 meisal root to mandible angle, and from 2/3 height of ascending ramus to mandible lower border, measuring approximately 5.0 x 7.0 cm in diameter. Left mandible canal is being pressed down, while mental foramen does not affected by the lesion. Root resorption over tooth 36 distal root and tooth 37 is noted. Slide 11 Differential diagnosis Slide 12 Peripheral or Intrabony Left posterior mandibular area 5 x 7 cm, dome shape, firm consistency, normal mucosa color Tenderness (-) Pain(-) Lip numbness (+) Bone expansion(+) Slide 13 Multilocular radiolucence with bony destruction intrabony lesion Slide 14 Our caseperipheralintrabony Mucosal lesion-+- Induration-+- Bony expansion+-+-+- Cortical bone destruction +-+-+- intrabony Peripheral or Intrabony Slide 15 Inflammation, Cyst or Neoplasm Our caseinflammation Redness-+ Swelling++ Local heat-+ pain-+ Due to panorex finding: Large multilocular RL destruction lesion cyst or neoplam Slide 16 Cyst or Neoplasm Our casecyst Fluctuation-+-+- Well defined border++ Bone expansion++-+- Our caseInflammation cyst Non- inflammation cyst Pain, tenderness-+- Local heat-+- ColorpinkReddishPink ProgressionslowFastSlow Sclerotic margin+-+ Slide 17 Our caseBenignMalignance BorderWell-defined ill-defined Marginsmooth Irregular Sclerotic margin++- Destruction of cortical margin ++-+-+ Progressiveslow Fast Swelling with intact epithelium ++- Pain--+ induration--+ Non-inflammation cyst or benign tumor Slide 18 Working diagnosis 1. Ameloblastoma (conventional type) 2. Keratocystic odontogenic tumor 3. Central giant cell granuloma 4. Odontogenic myxoma Slide 19 Ameloblastoma Our caseAmeloblastoma GenderFemaleEqual Age3630~70 SiteMandible (molar area)Mandible (molar ascending ramus) Paresthesia+Uncommon Swelling++ Drainage-+-+- RadiographyWell-defined, soap bubble multilocular, corticated margin Well-defined, unilocular or multilocular, corticated margin Bony expansion++ Teeth displacement/ root resoprtion ++ durationslow Slide 20 Keratocystic odontogenic tumor Our caseKCOT GenderFemaleSlight male Age3610~40 SiteMandible (molar area)Mandible (posterior body and ascending ramus) Paresthesia+Pain Swelling++ Drainage-+ RadiographyWell-defined, soap bubble multilocular, corticated margin Well-defined, unilocular or multilocular, corticated margin Bony expansion+- Teeth displacement/ root resoprtion ++ durationslow Slide 21 Central giant cell granuloma Our caseNon- aggressive Aggressive GenderFemale Age36 Slide 22 Odontogenic myxoma Our caseOdontogenic myxoma GenderFemaleSlight female Age3610~50 (mean 25~30) SiteMandible (molar area)Max.:Man.=3:4 or3:7 (tooth-bearing areas) Paresthesia+Rare Swelling+- Drainage-- RadiographyWell-defined, soap bubble multilocular, corticated margin Often well-defined, unilocular or multilocular, may with corticated margin Bony expansion++ Teeth displacement/ root resoprtion ++ durationslow Slide 23 CLINICAL IMPRESSION Ameloblastoma, acanthomatous type, left mandibular angle to ramus Slide 24 Treatment plan 1. aspiration with 19G needle under block anesthesia --> yellowish clear fluid --> culture x I 2. complicated extraction of tooth 37 and incisional biopsy was done from tooth 37 wound, H-P exam (hard x1 --> tooth 37 x1 ; soft x2 --> wall of lesion x1 ; distal gingiva of tooth 37 x1), N/S irrigation, placed one decompression(Marsupialization) device with suture (1 sitich), gauze packing 3.check CT scan. Slide 25 CT (2014.06.09) An unilocular expansile lesion of tooth-bearing portion of jaw at left mandibular body (5.7x2.7x3.2 cm) with expansion of cortex, homogeneous tumor matrix and dislodgment of teeth is noted. Small soft tissue nodule was not identified in the neck spaces.The paranasal sinuses were clear.The orbits appeared unremarkable. The skull base, including the foramina lacerum and ovale, were not eroded. Slide 26 HISTO-PATHOLOGIC EXAMINATION Slide 27 Mandible, left Odontogenic tumor Pathologic diagnosis: Bone, mandible, tooth 37, left, extraction, tooth fragment Gross Examination: Additional report of decalcified hard tissue specimen for section A. Microscopic Examination: Microscopically, it shows tooth fragment in section A. Slide 28 Mandible lesion wall; gingiva 37 distal Odontogenic tumor Pathologic diagnosis: Bone, mandible lesion wall, left, ameloblastoma, acanthomatus change, Oral cavity, gingiva 37 distal, lower left, incision, minimal histological change Gross Examination: The specimen submitted consists of 2 soft tissue fragments and 1 hard tissue fragment in 3 bottles,measuring up to 1.5 x 1.2 x 1.0 cm in size, fixed in formalin. Grossly, they are light brown and white in color and bony hard and rubbery in consistency. All for section and labeled as follows: Jar 0. A: tooth 37 B:lesion wall (soft) C: distal gingiva 37 Microscopic Examination: The slides contain two identical groups of irregular-shaped soft tissue specimens.Microscopically, it shows ameloblastoma, acanthomatus change in section B, minimal histological change in section C. Slide 29 MARSUPIALIZATION Discussion Slide 30 Introduction = Partsch operation Create a surgical window in the wall of the cyst Evacuate the contents Maintain continuity between cyst and the oral cavity, maxillary sinus, or nasal cavity Slide 31 Introduction Cyst is only removed a piece to produce the window the remaining of the cyst left in situ Benefits Decrease intra-cystic pressure Promote shrinkage of the cyst and bone fill Use As the sole therapy As a preliminary step when with enucleation Slide 32 Indication When enucleation may cause injury or unnecessary sacrifice When surgical approach is difficult Assistance in eruption of teeth Alternative to enucleation for pt with ill health Very large cysts marsupialization first Slide 33 Advantages Simple Spare vital structures from damage Slide 34 Disadvantages Pathologic tissue is left in situ, without thorough histologic examination pt inconvenience: the cavity traps food debris irrigate the cavity several times every day with a syringe. Slide 35 Technique (Prophylactic adminstration of systemic antibiotics) Anesthetization Aspirate comfirms the presumptive diagnosis of cyst Incision: circular or elliptical large window(1cm ) thin bone v.s. thick bone Remove a window of lining pathologic examination Slide 36 Contents of cyst are evacuated If cystic lining is thick enough suture to oral mucosa otherwise, cavity packed with gauze with tincture of bezoin or antibiotic ointment for 10 to14 days Slide 37 Marsupialization Cyst of maxilla Where cyst will be brought to the exterior: Oral cavity Maxillary sinus or nasal sinus Cyst has destroyed a large portion of maxilla & encroached on antrum or nasal cavity approach from facial alveolus second unroofing to antrum or nasal cavity oral opening closed continuous with respiratory lining of the antrum or nasal cavity Slide 38 Marsupialization Rarly used as sole form In most instances, enucleation is done after Marsupialization. In dentigerous cyst, no residual cyst may exist to be remeoved once the tooth has erupted into the dental arch. If futher surgery is contraindicated, marsupialization can be performed alone without future enucleation. The cavity may or may not obliterate totally Slide 39 Enucleation after marsupialization Slide 40 Introduction Enucleation is frequently done after marsupialization Combined approach Reduce morbidity Accelerate complete healing of the defect Slide 41 Indication Same as indications listed for marsupialization alone When the cyst does not totally obliterate after marsupialization When the pt find difficult to clean Slide 42 Advantages Marsupialization phase: simple procedure that spare adjacent vital structures Enucleation phase: the entire lesion becomes available for histological examination The development of a thickened cystic lining secondary enucleation easier Slide 43 Disadvantages The total cyst is not removed initially for pathologic examination. However, subsequent enucleation may then detect any occult pathologic condition. Slide 44 Technique 1. Marsupialization of the cyst 2. Osseous healing 3. Cyst decreased to complete surgical removal 4. Enucleation (when bone is covering adjacent vital structure: prevents injury and jaw fracture) Slide 45 Technique 5. common epithelial lining (epithelial bridge) must be removed completely with the cystic lining an elliptical incision completely encircling the window must be made down to sound bone stripping the cyst from the window to cystic cavity. Slide 46 Technique 6. Cyst enucleated oral soft tissue must be closed. may require soft tissue flap 7. cannot close completely packing (strip gauze and antibiotic ointment). Change repeatedly until granulation tissue has obliterated the opening and epithelial closed over the wound Slide 47 Marsupialization of unicystic ameloblastoma: A conservative approach for aggressive odontogenic tumors Slide 48 Case 1 A 17 year-old male patient a painless swelling in the right mandibular premolar region without any sign of sensory impairment Panoramic view of the patient revealed a well defined radiolucent area extending from the right lateral incisor to the distal root of the first molar tooth Slide 49 Slide 50 Treatment Under local anesthesia, an incisional biopsy was performed luminal type UA The lesion was decompressed between two premolar teeth Scheduled for radiographic follow-up after an interval of three months Slide 51 Treatment Marsupialization Enucleated with peripheral ostectomy (18months later) The apical portions of the teeth were resected Allogenic bone graft material was placed in the cavity Slide 52 Post-treatment No signs of recurrence even at 30 months of follow-up Slide 53 Case2 A 52 year old woman with healthy edentulous Asymptomatic swelling on her left mandible X-ray finding A well-defined unilocular radiolucent on the left mandibular ramus with an unerupted third molar Histopathologic findings granular UA with mural invasion Slide 54 Treatment Decompression of the lesion with incisional biopsy Acrylic obturator was made Marsupialization Impacted tooth and the lesion was enucleated with peripheral ostectomy (18 months later) Slide 55 Post-treatment The lesion was completely healed without any sign of recurrence 2 years post the complete enucleation procedure Slide 56 Discussion Marsupialization reducing the size of the lesion to ease total removal UA with aggressive histologic behavior might be successfully treated with marsupialization with subsequent enucleation This approach can be considered as an alternative to resection Slide 57 Reference 1. Sampson DE, Pogrel MA. Management of mandibular ameloblastoma: the clinical basis for a treatment algorithm. J Oral Maxillofac Surg 1999;57:1074-7 2. Robinson L, Martinez MG. Unicystic ameloblastoma: A prognostically distinct entity. Cancer 1977;40:2278-85. 3. Lau SL, Samman N. Recurrence related to treatment modalities of unicsytic ameloblastoma: a systematic review. Int J Oral Maxillofac Surg 2006;35:681-90. 4. Ackermann GL, Altini M, Shear M. The unicystic ameloblastoma: A clinicopathological study of 57 cases. J Oral Pathol 1988;17:541-6. 5. Furuki Y, Fujita M, Mitsugi M, Tanimoto K, Yoshiga K, Wada T. A radiographic study of recurrent unicystic ameloblastoma following marsupialization. Report of three cases. Dentomaxillofac Radiol 1997;26:214-8 6. Abaza NA, Gold L, Lally E. Granular cell odontogenic cyst: A unicystic ameloblastoma with late recurrence as follicular ameloblastoma. J Oral Maxillofac Surg 1989;47:168-75. 7. Contemporary Oral and Maxillofacial Surgery, 6th edition, part V: management of oral pathologic lesions, P.454-458 Slide 58 Slide 59 Tom Beauchamp &James Childress - 1979 1. (Beneficence) 2. (Veractity) 3. (Autonomy) 4. (Nonmaleficence) 5. (Confidentiality) 6. (Justice) Slide 60 Decompression pt pt swelling pt Slide 61 Slide 62 Slide 63 ? Slide 64 1. 2. 3. 4. , 5. Slide 65 Slide 66 ( , , ) , Slide 67 THANK YOU FOR YOUR ATTENTION!