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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.

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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:

1 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

2 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 :

3 Chief complaint Left cheek swelling over 2 months, and left lower lip numbness for about one year.

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.

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

6 Past medical history Denied any underlying disease Denied any food or drug allergies Hospitalization (-)

7 Past dental history General routine dental treatment Orthodontic treatment Attitude to dental treatment : co-operative

8 Personal history Risk factor related to malignancy Alcohol (-) Betel quid (-) Cigarette (-) Special oral habits : denied

9 Radiographic examination

10 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.

11 Differential diagnosis

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(+)

13 Multilocular radiolucence with bony destruction → intrabony lesion

14 Our caseperipheralintrabony Mucosal lesion-+- Induration-+- Bony expansion Cortical bone destruction → intrabony Peripheral or Intrabony

15 Inflammation, Cyst or Neoplasm Our caseinflammation Redness-+ Swelling++ Local heat-+ pain-+ Due to panorex finding: Large multilocular RL destruction lesion → cyst or neoplam

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+-+

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

18 Working diagnosis 1. Ameloblastoma (conventional type) 2. Keratocystic odontogenic tumor 3. Central giant cell granuloma 4. Odontogenic myxoma

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

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

21 Central giant cell granuloma Our caseNon- aggressive Aggressive GenderFemale Age36<30 SiteMandible (molar area)Mandible (anterior region) Paresthesia+-Pain Swelling+-+ Drainage--- RadiographyWell-defined, soap bubble multilocular, corticated margin Well-defined, unilocular or multilocular, non-corticated margin Bony expansion+-+ Teeth displacement/ root resoprtion +-+ durationslow rapid

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

23 CLINICAL IMPRESSION Ameloblastoma, acanthomatous type, left mandibular angle to ramus

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.

25 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.

26 HISTO-PATHOLOGIC EXAMINATION

27 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.

28 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.

29 ─ MARSUPIALIZATION Discussion

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

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

32 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

33 Advantages Simple Spare vital structures from damage

34 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.

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

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

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

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

39 Enucleation after marsupialization

40 Introduction Enucleation is frequently done after marsupialization Combined approach :  Reduce morbidity  Accelerate complete healing of the defect

41 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

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

43 Disadvantages The total cyst is not removed initially for pathologic examination. However, subsequent enucleation may then detect any occult pathologic condition.

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)

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.

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

47 Marsupialization of unicystic ameloblastoma: A conservative approach for aggressive odontogenic tumors

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

49

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

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

52 Post-treatment No signs of recurrence even at 30 months of follow-up

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

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)

55 Post-treatment The lesion was completely healed without any sign of recurrence 2 years post the complete enucleation procedure

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

57 Reference 1. Sampson DE, Pogrel MA. Management of mandibular ameloblastoma: the clinical basis for a treatment algorithm. J Oral Maxillofac Surg 1999;57: Robinson L, Martinez MG. Unicystic ameloblastoma: A prognostically distinct entity. Cancer 1977;40: Lau SL, Samman N. Recurrence related to treatment modalities of unicsytic ameloblastoma: a systematic review. Int J Oral Maxillofac Surg 2006;35: Ackermann GL, Altini M, Shear M. The unicystic ameloblastoma: A clinicopathological study of 57 cases. J Oral Pathol 1988;17: 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: 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: Contemporary Oral and Maxillofacial Surgery, 6th edition, part V: management of oral pathologic lesions, P

58 醫學倫理討論

59 Tom Beauchamp &James Childress 六大原則 行善原則 (Beneficence) :亦即醫師要盡其所能延長病人之 生命且減輕病人之痛苦。 2. 誠信原則 (Veractity) :亦即醫師對其病人有「以誠信相對 待」的義務。 3. 自主原則 (Autonomy) :亦即病患對其己身之診療決定的 自主權必須得到醫師的尊重。 4. 不傷害原則 (Nonmaleficence) :亦即醫師要盡其所能避免 病人承受不必要的身心傷害。 5. 保密原則 (Confidentiality) ,亦即醫師對病人的病情負有 保密的責任。 6. 公義原則 (Justice) ,亦即醫師在面對有限的醫療資源時, 應以社會公平、正義的考量來協助合理分配此醫療資源給 真正最需要它的人。

60 行善原則 做了 Decompression 後是否有減輕 p’t 的脹痛感?或是 使 p’t 更不舒服? → 有減輕 swelling 的情形,且沒有造成 p’t 更不舒服。

61 誠信原則 是否有清楚的向病人說明清楚疾病病程、治療計畫、 預後、風險?  對於病人疾病嚴重程度是否有誠實的通知,盡到告知 的義務? → 已告知病人。

62 自主原則 充分說明病情及治療計畫、風險之後,是否有讓病人 充分自主的選擇治療計畫?  → 已充分說明。 在做麻醉以前,是否有說明完整之後再請病人自主的 簽名同意? → 已充分說明。

63 不傷害原則 手術過程中,是否有造成不必要醫源性的傷害?  → 尚未手術。 是否有詳實的說明治療計畫,並讓病人對於治療計畫 沒有疑問 ? → 減輕病人的心理壓力也是一種不傷害的原則。

64 保密原則 告知的對象 1. 本人為原則 2. 病人未明示反對時,亦得告知其配偶與親屬 3. 病人為未成年人時,亦須告知其法定代理人 4. 若病人意識不清或無決定能力, 應須告知其法定代理 人、配偶、親屬或關係人 5. 病人得以書面敘明僅向特定之人告知或對特定對象不 予告知

65 公義原則 手術的必要性?

66 醫學倫理總結 在病例撰寫方面 ( 病兆描述, 治療計畫, 病人態度 ) 應書寫 詳盡, 使治療過程有詳實的記錄及治療順利。  在進行治療之前, 須請病人簽屬同意書 應在不違反醫學倫理的原則之下進行治療的行為

67 THANK YOU FOR YOUR ATTENTION!


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