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："— 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：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：
2General data Name : 蔡O萍 Sex : female Age : 36 y/o Native :台灣 Marital status : singleAttending V.S. : 李坤宗 醫師First visit :
3Chief complaintLeft cheek swelling over 2 months, and left lower lip numbness for about one year.
4Present illnessThis 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.
5Intraoral examination Site: Tooth 37 mesial aspect to anterior ear area, and from maxilla buccal vestibule to mandible buccal vestibule.Size:5.0x7.0 cmColor: Normal mucosa coverageSurface: Smooth and intactConsistency: FirmShape: Dome, sessilePalpation: rubberyBone expansion: (+)Tenderness/Pain: (-)Paresthesia: (+)Fluctuation (-)Fixed
6Past medical history Denied any underlying disease Denied any food or drug allergiesHospitalization (-)
7Past dental history General routine dental treatment Orthodontic treatmentAttitude to dental treatment : co-operative
8Personal history Risk factor related to malignancy Alcohol (-) Betel quid (-)Cigarette (-)Special oral habits : denied
10Panorex( )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.
12Peripheral or Intrabony Left posterior mandibular area5 x 7 cm, dome shape, firm consistency, normal mucosa colorTenderness (-)Pain(-)Lip numbness (+)Bone expansion(+)
13Multilocular radiolucence with bony destruction → intrabony lesion
14Peripheral or Intrabony Our caseperipheralintrabonyMucosal lesion-+IndurationBony expansion+-Cortical bone destruction→intrabony
15Inflammation, Cyst or Neoplasm Our caseinflammationRedness-+SwellingLocal heatpainDue to panorex finding:Large multilocular RL destruction lesion→ cyst or neoplam
16Non-inflammation cyst Cyst or NeoplasmOur casecystFluctuation-+-Well defined border+Bone expansionOur caseInflammation cystNon-inflammation cystPain, tenderness-+Local heatColorpinkReddishPinkProgressionslowFastSlowSclerotic margin
17→Non-inflammation cyst or benign tumor Our caseBenignMalignanceBorderWell-definedill-definedMarginsmoothIrregularSclerotic margin+-Destruction of cortical margin+-ProgressiveslowFastSwelling with intact epitheliumPaininduration→Non-inflammation cyst or benign tumor
22Odontogenic myxoma Our case Odontogenic myxoma Gender Female Slight femaleAge3610~50 (mean 25~30)SiteMandible (molar area)Max.:Man.=3:4 or3:7(tooth-bearing areas)Paresthesia+RareSwelling-DrainageRadiographyWell-defined, soap bubble multilocular, corticated marginOften well-defined, unilocular or multilocular, may with corticated marginBony expansionTeeth displacement/ root resoprtiondurationslow
23CLINICAL IMPRESSIONAmeloblastoma, acanthomatous type, left mandibular angle to ramus
24Treatment plan1. aspiration with 19G needle under block anesthesia --> yellowish clear fluid --> culture x I2. 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 packing3.check CT scan.
25CT ( )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.
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 fragmentGross 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 changeGross 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 37B:lesion wall (soft)C: distal gingiva 37Microscopic 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.
30Introduction = Partsch operation Create a surgical window in the wall of the cystEvacuate the contentsMaintain continuity between cyst and the oral cavity, maxillary sinus, or nasal cavity1.又稱為Partsch術式 2.簡單的說就是將原本是一個完整的cavity打開並且製造出一個開口3.移除內含物4.讓囊腫的內襯上皮與口腔、上顎竇或鼻腔的黏膜表皮維持連續性
31IntroductionCyst is only removed a piece to produce the window → the remaining of the cyst left in situBenefits：Decrease intra-cystic pressurePromote shrinkage of the cyst and bone fillUse：As the sole therapyAs a preliminary step when with enucleation介紹1.會移除囊腫的一小部份來開窗2.好處:減低囊腫內壓、有助於囊腫縮小3.可以單獨使用或是為接續的剜除術先縮小囊腫的尺寸
32Indication When enucleation may cause injury or unnecessary sacrifice When surgical approach is difficultAssistance in eruption of teethAlternative to enucleation for p’t with ill healthVery large cysts → marsupialization first適應症:1.當只執行剜除術時會造成過多的傷害或不必要的犧牲2.當進行手術的路徑有障礙時3.有助於牙齒的萌發4.當病患的狀況差，不適合執行剜除術時5.囊腫很大，則優先考慮造袋術以減少囊腫的尺寸
33Advantages Simple Spare vital structures from damage 優點: 1.術式簡單 2.能將傷害降到最低，特別是一些重要的神經或血管
34DisadvantagesPathologic tissue is left in situ , without thorough histologic examinationp’t inconvenience: the cavity traps food debrisirrigate the cavity several times every day with a syringe.缺點1.即使是取下了window的部分去病理檢驗,但仍有許多病變的組織留在原處,無法全面性的做組織切片檢查2.造袋術會產生 一個cavity,就會有食物殘渣引發感染的可能,因此病患要時常用syringe去沖洗，造成病患的不便
35Technique (Prophylactic adminstration of systemic antibiotics) AnesthetizationAspirate comfirms the presumptive diagnosis of cystIncision: circular or elliptical large window(1cm ↑)thin bone v.s. thick boneRemove a window of liningpathologic examination手術方法1.除非病患身體情況不佳,不然一般不使用預防性抗生素2.麻醉3.利用抽吸的方式,來驗證原先假定的囊腫診斷,如果是的話就可實行造袋術4.&5切口為圓形或橢圓形,造一個大的開口若骨頭膨大變薄:則可由骨頭切入囊腫腔,並將開口處組織送檢若骨頭很厚:則小心用鑽針或骨鉗移除骨頭,也是將開口處的組織送檢
36Contents of cyst are evacuated If cystic lining is thick enoughsuture to oral mucosaotherwise, cavity packed with gauze with tincture of bezoin or antibiotic ointment for 10 to14 days6.之後就是將囊腫的內容物給排出7.如果cyst lining夠厚且允許,可沿著開口周圍將囊腫縫到口腔黏膜上否則,cavity內需填塞安息香酊或抗生素紗布約十到十四天,以防止口腔黏膜的癒合超越囊腫腔的開口,那兩星期後順利的話 囊腫的開口會與口腔黏膜癒合再一起
37Marsupialization Cyst of maxilla Where cyst will be brought to the exterior:Oral cavityMaxillary sinus or nasal sinusCyst 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上顎的造袋術1.造口有兩個選擇:口腔:像之前所述的上頷竇或鼻腔2.當囊腫破壞上顎大部分區域且侵犯到上顎竇或鼻腔則可以從齒槽頰側去處理打通上顎竇或鼻腔將口腔的開口關閉使囊腫內腔上皮與上顎竇或鼻腔上皮相連
38Marsupialization 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 totally1.造袋術一般少單獨使用2.多數的病例都是造袋術使用完後接著做摘除術3. dentigerous cyst 牙齒萌發後會消失 又或是病人身體情況不允許則不會做進一步手術Cyst可能不會完全長平,但維持清潔應也不會發生太大問題
40Introduction Enucleation is frequently done after marsupialization Combined approach：Reduce morbidityAccelerate complete healing of the defect1.通常於造袋術後進行剜除術2.合併使用能減少復發率，也可以增進傷口的癒合
41Indication Same as indications listed for marsupialization alone When the cyst does not totally obliterate after marsupializationWhen the p’t find difficult to clean適應症1.部分適應症跟造袋術相同2.當造袋術後囊腫還未被徹底移除時則進行剜除術3.當病患有清潔上的困難時
42AdvantagesMarsupialization phase: simple procedure that spare adjacent vital structuresEnucleation phase: the entire lesion becomes available for histological examinationThe development of a thickened cystic lining secondary enucleation easier造袋術加上enucleation的優點和缺點和前面說的造袋術差不多優點：造袋術時期：術式簡單，可確保周邊構造不會被傷害到Enucleation時期：整個lesion可以拿去做病理檢查而在術式中可以使囊腫的cystic lining增厚，讓後續的手術可以容易整個拿乾淨
43DisadvantagesThe total cyst is not removed initially for pathologic examination.However, subsequent enucleation may then detect any occult pathologic condition.缺點是沒辦法一開始就將整個病灶拿去化驗，不過之後enucleation的時候可以解決這個問題
44Technique Marsupialization of the cyst Osseous healing Cyst decreased to complete surgical removalEnucleation (when bone is covering adjacent vital structure: prevents injury and jaw fracture)1.先做造袋術2.等骨頭癒合3.等囊腫縮小到可以方便手術移除的大小4.enucleation,要等骨頭長到周邊重要構造上面，可以保護在手術的時候不會傷到，也可以降低術中造成骨折的機會
45Techniquecommon 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.5.造袋術執行的時候會將口腔黏膜的上皮和囊腫的上皮縫在一起，而在enucleation的時候需要將這個部分連同囊腫移除，所以我們需要做elitical incision，將我們造的窗口環繞切下，而且需要切到骨頭的深度。再將囊腫慢慢撥到腔室裡面移除出來。
46TechniqueCyst enucleated oral soft tissue must be closed. may require soft tissue flapcannot close completely packing (strip gauze and antibiotic ointment). Change repeatedly until granulation tissue has obliterated the opening and epithelial closed over the wound6.在囊腫移除之後，軟組織需要完全覆蓋，所以有的時候會需要做flap。7.如果沒辦法完全覆蓋，則可以使用紗布加上抗生素藥膏作packing，不過需要常換，直到肉芽組織和上皮癒合蓋住傷口。
47Marsupialization of unicystic ameloblastoma: A conservative approach for aggressive odontogenic tumors
48Case 1A 17 year-old male patient a painless swelling in the right mandibular premolar region without any sign of sensory impairmentPanoramic 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
50TreatmentUnder local anesthesia, an incisional biopsy was performed→ luminal type UA The lesion was decompressed between two premolar teethScheduled for radiographic follow-up after an interval of three months
51Treatment Marsupialization Enucleated with peripheral ostectomy (18months later)The apical portions of the teeth were resectedAllogenic bone graft material was placed in the cavity
52Post-treatment No signs of recurrence even at 30 months of follow-up
53Case2 A 52 year old woman with healthy edentulous Asymptomatic swelling on her left mandibleX-ray finding→A well-defined unilocular radiolucent on the left mandibular ramus with an unerupted third molarHistopathologic findings→granular UA with mural invasion
54Treatment Decompression of the lesion with incisional biopsy Acrylic obturator was madeMarsupialization Impacted tooth and the lesion was enucleated with peripheral ostectomy (18 months later)
55Post-treatment The lesion was completely healed without any sign of recurrence 2 years post the complete enucleation procedure
56DiscussionMarsupialization→reducing the size of the lesion to ease total removalUA with aggressive histologic behavior might be successfully treated with marsupialization with subsequent enucleationThis approach can be considered as an alternative to resection
57ReferenceSampson DE, Pogrel MA. Management of mandibular ameloblastoma: the clinical basis for a treatment algorithm. J Oral Maxillofac Surg 1999;57:1074-7Robinson 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;17:541-6.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;26:214-8Abaza 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