指導醫師：陳玉昆醫師 暨口腔病理科全體醫師 Intern J組 吳觀宇 林宗慶 鄧光華 陳永恩 OM Case report 指導醫師：陳玉昆醫師 暨口腔病理科全體醫師 Intern J組 吳觀宇 林宗慶 鄧光華 陳永恩

General Data Name: o o o Gender: Female Age: 14 y/o Marital status: single Attending Staff: o o o醫師 First visit：2015/12/18 2015/12/18

Chief Complaint Tooth mobility and radiolucent image over upper left anterior area, referred to OS dpt. from LDC

Present Illness This 14 y/o girl observed tooth mobility over upper anterior area so she visited LDC for help. After x-ray checking, this 14-year-old girl was referred from local dental clinic to OS department due to radiolucent image over tooth 22, 23, 24 area. 2015/12/18 First visit at OS dpt. Cone beam computed tomography

OMF Examination MMO: 40 mm Lesion over tooth 22, 23, 24 Percussion, palpation, spontaneous pain (-) Tooth mobility (+) Bone expansion (+) Fluctuation (-) Soft tissue: normal, sinus tract (-), gumboil (-), induration (-) Tendency: firm Deny any traumatic history 2015/09/19

Past history Past medical history Underlying disease (-) Hospitalization (-) Surgery under GA (-) Allergy (-) Past Dental History General routine dental treatment Attitude to dental treatment: Co-operative

Personal History Risk factors related to malignancy Alcohol drinking (-) Betel-quid chewing (-) Cigarette smoking (-) Special oral habits: denied 無做RPD

Panorex (2015/12/18) There is a well-defined unilocular ovoid shaped radiolucence without corticated margin over upper left anterior area extending from mesial side of root of tooth 21 to the root of tooth 26 in horizontal dimension and extends from the root apex of tooth 22 to alveolar crest in vertical dimension, measuring approximately 3.5x2 cm in diameter. Left maxillary sinus and tooth 21, 22, 23, 24, 25 were involved in this lesion. Root displacement of tooth 22, 23, 24, 25 was observed, but there was no obvious external root resorption. Lamina dura and PDL space of tooth involved had disappeared.

Panorex (2015/12/18) Dental findings: -Endodontic condition: Nil -missing: Nil -Caries: Nil -Periodontal condition: Healthy -Calculus deposition: Nil -OD filling: Nil -Endodontic condition: Nil -Restoration (e.g. C & B): nil -tooth bud: 18 28 38 48

Periapical film (2015/12/28) There is a well-defined unilocular ovoid shaped radiolucence without corticated margin over upper left anterior area extending from mesial side of root of tooth 21 to the root of tooth 26 in horizontal dimension and extends from the root apex of tooth 22 to alveolar crest in vertical dimension, measuring approximately 3.5x2 cm in diameter. Tooth 21,22,23,24,25 were involved in this lesion. Root displacement of tooth 22,23,24,25 was observed, but there was no obvious root resorption. Lamina dura and PDL space of tooth involved had disappeared. Caries was over tooth 23 was noted.

Panorex (2016/02/26) Bone healing improved Lesion was shrinkage Decompression button dropped into the cyst

Panorex (2016/04/29) Decompression button still remained in the cyst but had displaced compare with 2016/02/26

Panorex (2016/05/13) The lesion and the decompression button was removed.

Cone Beam CT(2015/12/28)

Cone Beam CT(2015/12/28)

Working diagnosis

Inflammation? Inflammation Our case Color Red Normal Local Heat + - Swelling Consistency Rubbery Hard Pain Duration Days unknown

Intrabony or Peripheral? Our case Mucosal Lesion - + Bony Expansion +/- Destruction of Cortical Margin Consistency Hard Soft, firm, rubbery, …

Cyst ? Cyst Our case Well-defined Border + Bone Expansion +/- Shape Regular Aspiration Unknown Ulceration - Fluctuation

Benign or Malignant Neoplasm? Our case Border Well-defined Ill-defined Margin Smooth Irregular Sclerotic Margin + - Destruction of Cortical Margin -,+ Induration Pain Progression Slow Fast Unkown Metastasis

Differential diagnosis

Differential Diagnosis Adenomatoid odontogenic tumor, left maxilla Unicystic ameloblastoma, left maxilla Keratocystic odontogenic tumor, left maxilla Dentigerous cyst, left maxilla

Adenomatoid odontogenic tumor Our case Gender Female > Male Female Age 10~19 y/o 14 y/o Site Maxilla > mandible Left maxilla S/S - Size < 3cm 3.5 x 2cm Relative Density Unilocular RL Unilocular RL without corticated margin Margin Well-defined Effect on adjacent structures Tooth impaction/ displacement Tooth 22~26 Left sinus

Unicystic Ameloblastoma Our case Gender Male = Female Female Age 23 y/o 14 y/o Site Posterior mandible Left maxilla S/S - Size > 3cm 3.5 x 2cm Relative Density Unilocular RL with corticated margin Unilocular RL without corticated margin Margin Well-defined Effect on adjacent structures Tooth impaction Displacement of inferior alveolar canal Thining of cortical bone Tooth 22~26 Left sinus

Keratocystic Odontogenic Tumor Our case Gender Male ≧ Female Female Age 10~40 y/o 14 y/o Site Posterior mandible Left maxilla S/S Swelling Straw color fluid - Size > 3cm 3.5 x 2cm Relative Density Unilocular RL with corticated margin Unilocular RL without corticated margin Margin Well-defined Effect on adjacent structures Displacement or root resorption of tooth Displacement of inferior alveolar canal Tooth 22~26 Left sinus

Dentigerous Cyst Dentigerous Cyst Our case Gender Male ≧ Female Female Age 20~30 y/o 14 y/o Site Mandibular 3rd molar Left maxilla S/S - (+, if infection) - Size > 3~4mm 3.5 x 2cm Relative Density Unilocular RL with corticated margin Unilocular RL without corticated margin Margin Well-defined Effect on adjacent structures Tooth impaction Displacement of inferior alveolar canal Tooth 22~26 Left sinus

Treatment course

Treatment course 2015/12/18 2015/12/25 First visit at OS dpt. Cone beam computed tomography 2015/12/25 Decompression button placement Incisional biopsy Pus culture under local anesthesia (H-P report: Bone, maxilla, left, incision, infected odontogenic cyst / Pus culture: Anaerobic bacteria was not isolated and no growth on aerobic culture).

2015/12 ~ 2016/02 routine follow-up and normal saline irrigation. 2016/02/26 Check panorex : Bone healing was okay Lesion was shrinkage Decompression button dropped into the cyst

2016/05/12 Operation of cyst enucleation under general anesthesia Post OP

Pathologic diagnosis Bone, maxilla, left, enucleation, infected odontogenic cyst 高雄醫學大學附設中和紀念醫院 口腔病理科病理檢查報告 口腔病理編號： KMUOP-16-0859 病歷號碼： 3039598-2 病人姓名： 余采芳 年齡： 14 Yrs. 性別： 女 送檢單位： 13EN骨科，口外科病房 送檢醫師： 陳裕豐 收到時間： 5/12'16 15:00 報告時間： 5/16'16 16:27 組織名稱： Maxilla, left 臨床診斷： Developmental odontogenic cyst 腫瘤代碼： Pathologic diagnosis: Bone, maxilla, left, enucleation, infected odontogenic cyst Gross Examination: The specimen submitted consists of 4 soft tissue fragments in 2 bags, measuring up to 4.1 x 2.0 x 0.5 cm in size, in fresh state. Grossly, they are gray to brownish in color and rubbery in consistency. All for section and labeled as follows: Jar 0. A1-3: left maxillary cyst B: upper left ridge fistula Microscopic Examination: The slides contain two identical groups of irregular-shaped soft tissue specimens. Microscopically, sections A1-3 are characterized by a space surrounded by odontogenic epithelial lining and heavily inflammed fibrous wall. Cholesterol clefts are also found. Section B is characterized by inflammed granulation tissue with infiltration of chronic inflammatory cells. Based upon the above findings, sections A1-2 shows infected odontogenic cyst and section B shows chronic inflammation. Ching-Yi Chen 陳靜怡 口病專醫字第 000069 號 輸入人員： 張博雅

Adenomatoid odontogenic tumor of the mandible: review of the literature and report of a rare case Jörg GK Handschel, Rita A Depprich1, André C Zimmermann1, Stefan Braunstein2 and Norbert R Kübler1 Published: 24 August 2005 Head & Face Medicine 2005

Adenomatoid odontogenic tumor (AOT) is a rare odontogenic tumor which is often misdiagnosed as odontogenic cyst

Epidemiology mean age : 13.2 years Female : male = 2.3 : 1 Maxilla : mandible = 2.6 : 1 prevalence of odontogenic tumors between 1.2% in caucasian and 9% in black african patients

Clinical features asymptomatic swelling slowly growing often associated with an unerupted tooth Unerupted permanent canine are the theeth most often involved in AOTs.

Radiographic features AOT frequently resemble other odontogenic lesions such as dentigerous cysts calcifying odontogenic cysts calcifying odontogenic tumors globule-maxillary cysts Ameloblastomas odontogenic keratocysts ..

well-circumscribed unilocular radiolucency associated with the crown and often part of the root of an unerupted tooth Displacement of neighbouring teeth due to tumor expansion is much more common than root resorptions

Pathohistological features WHO defined the AOT as a tumor of odontogenic epithelium with duct-like structures and with varying degrees of inductive change in the connective tissue

Treatment and prognosis Conservative surgical enucleation intrabony defects caused by AOT : guided tissue regeneration with membrane technique is suggested Recurrence of AOT is exceptionally rare prognosis is excellent

Case report 23-year-old man Diagnosed a cyst with a ectopic lower right canine tooth by an x-ray Absence of the tooth 43 3 cm unicystic radiolucent image with a comparatively clear demarcation. The tooth 43 was located on the floor of this process. No resorption of the root apices was observed

General anesthesia the lesion was enucleated and afterwards filled with pelvic spongiosa Histological examination: Solid tumor and cyst formation The epithelium is in the form of whorled masses of spindle cells as well as sheets and plexiform strands. Rings of columnar cells give rise to duct-like appearance (Fig. 3).

No evidence of recurrence and no apical resorption of the adjacent teeth could be observed

醫學倫理討論

醫學倫理 生命的神聖性(Sanctity of life) 六大原則

生命的神聖性(Sanctity of life) 起源 生命應該是相對的，每個生靈都該是平等的，沒有所謂的低賤與高貴之分，所以彼此是要相互尊重，不可被輕視的。 每一個個人都是上帝依照祂的形象所創造的原由上，因之每一個人都是上帝關愛珍惜的對象，也因人類生命具有上帝的形象因之是神聖的，不可侵犯必須尊敬的. 總而言之，因為上帝是神聖的，人有了祂的形象，就承受了生命的神聖性，是故人是獨特的 生命神聖性具有 Imago Dei 的信念表示生命主權並不在人，而是創造主給予人類的信託，超乎人類的估價與權力。人類並不是他的主人，但因信託的關係，人類必須負責來珍惜生命，維護它並發展生命的潛能。 http://www.tma.tw/magazine/ShowRepID.asp?rep_id=1556

Tom Beauchamp &James Childress 六大原則1979 Sanctity of life (生命的神聖性)。 1.. Justice(公義原則): 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。 2. Confidentiality (保密原則):醫師對病人的病情負有保密的責任。 3. Veractity(誠信原則):醫師對其病人有「以誠信相對待」的義 4. Nonmaleficence (不傷害原則):醫師要盡其所能避免病人承受不必要的身心傷害。 5. Autonomy (自主原則):病患對其己身之診療決定的自主權必須得到醫師的尊重。 6. Beneficence (行善原則)：醫師要盡其所能延長病人之生命且減輕病人之痛苦。

行善原則(Beneficence) Q: 做完治療後，是否可以改善病人的症狀，如果沒有改善，該如何? A: 在術前要先告知病人目前病情狀況、提供合適的治療計畫、說明術後可能的情形、以及手術成功或失敗的機率 對於處置沒有把握，將病人交付給更專業的醫師 ->目的皆是以病人的利益為最大基準

誠信原則(Veractity) 對於患者的疾病嚴重程度是否有確實地通知，盡到告知的義務？ 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？ 皆已告知病人後，經同意才進行手術

自主原則(Autonomy) 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地選擇治療計畫？ →病人及家屬選擇並同意醫師的建議。 在做全身麻醉以前，是否有說明完整之後再請病人自主的簽名同意？ →已充分說明並與家屬溝通。 病人有知及選擇的權利， 醫師不包括決定的功能

不傷害原則(Nonmaleficence) 是否有先完整瞭解病人的病史? →治療前有完整蒐集病史資料，並與病患溝通後擬定進一步的治療計畫 手術過程中，是否有造成不必要的醫源性的傷害？ →沒有不必要醫源性傷害。

保密原則(Confidentiality) 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

正義原則(Justice) 手術的必要性？ → Dentigerous cyst最佳的治療方式是sugical excision，將病灶完整的清除(enucleation)才能將復發率(recurrence rate) 降到最低。

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

Thanks for your comment