Presentation on theme: "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."— Presentation transcript:
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： OM Case Report
General data Name : 蔡 O 萍 Sex : female Age : 36 y/o Native : 台灣 Marital status : single Attending V.S. : 李坤宗 醫師 First visit :
Chief complaint Left cheek swelling over 2 months, and left lower lip numbness for about one year.
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.
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
Past medical history Denied any underlying disease Denied any food or drug allergies Hospitalization (-)
Past dental history General routine dental treatment Orthodontic treatment Attitude to dental treatment : co-operative
Personal history Risk factor related to malignancy Alcohol (-) Betel quid (-) Cigarette (-) Special oral habits : denied
Panorex ( ) 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.
Peripheral or Intrabony Left posterior mandibular area 5 x 7 cm, dome shape, firm consistency, normal mucosa color Tenderness (-) Pain(-) Lip numbness (+) Bone expansion(+)
Multilocular radiolucence with bony destruction → intrabony lesion
Our caseperipheralintrabony Mucosal lesion-+- Induration-+- Bony expansion Cortical bone destruction → intrabony Peripheral or Intrabony
Inflammation, Cyst or Neoplasm Our caseinflammation Redness-+ Swelling++ Local heat-+ pain-+ Due to panorex finding: Large multilocular RL destruction lesion → cyst or neoplam
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+-+
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
Working diagnosis 1. Ameloblastoma (conventional type) 2. Keratocystic odontogenic tumor 3. Central giant cell granuloma 4. Odontogenic myxoma
CLINICAL IMPRESSION Ameloblastoma, acanthomatous type, left mandibular angle to ramus
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.
CT ( ) 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.
組織名稱： Mandible, left 臨床診斷： Odontogenic tumor 腫瘤代碼： 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.
組織名稱： Mandible lesion wall; gingiva 37 distal 臨床診斷： Odontogenic tumor 腫瘤代碼： 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.
─ MARSUPIALIZATION Discussion
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
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
Indication When enucleation may cause injury or unnecessary sacrifice When surgical approach is difficult Assistance in eruption of teeth Alternative to enucleation for p’t with ill health Very large cysts → marsupialization first
Advantages Simple Spare vital structures from damage
Disadvantages Pathologic tissue is left in situ, without thorough histologic examination p’t inconvenience: the cavity traps food debris irrigate the cavity several times every day with a syringe.
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
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
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
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
Enucleation after marsupialization
Introduction Enucleation is frequently done after marsupialization Combined approach ： Reduce morbidity Accelerate complete healing of the defect
Indication Same as indications listed for marsupialization alone When the cyst does not totally obliterate after marsupialization When the p’t find difficult to clean
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
Disadvantages The total cyst is not removed initially for pathologic examination. However, subsequent enucleation may then detect any occult pathologic condition.
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)
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.
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
Marsupialization of unicystic ameloblastoma: A conservative approach for aggressive odontogenic tumors
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
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
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
Post-treatment No signs of recurrence even at 30 months of follow-up
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
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)
Post-treatment The lesion was completely healed without any sign of recurrence 2 years post the complete enucleation procedure
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
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