指導醫師：陳玉昆醫師 暨口腔病理科全體醫師 Intern I 組 何姿儀 黃鈴惟 潘嬿蓉 楊敬唯 2016/04/26

General Data Name ： OOO Gender ： Male Age: 56 y/o Marital status: Married Attending Staff: OOO 醫師 First visit ： 2015/09/09

Chief Complaint A radiolucent shadow on the left mandible on routine panorex examination at LDC

Present Illness This 56 y/o male patient went to LDC and a radiolucent shadow on the left mandible was noted on panoramic radiography. The patient was then referred to KMUH, OS department for further examination. The OS surgeon took another panorex and the patient was then arranged for operation in 2015/09/24.

OMF Examination MMO: 46 mm Pain (-) Bleeding (-) Palpation (-) No obvious expansion Fluctuation (-) EPT: Tooth 37 (+), 33(+) Deny any traumatic history 2015/09/19

Past history Past medical history Underlying disease (+), 恐慌症, 胃潰瘍 (10+ yrs ago) Hospitalization (-) Surgery under GA (-) Allergy (+), Voren Past Dental History General routine dental treatment Attitude to dental treatment: co-operative

Personal History Risk factors related to malignancy Alcohol (+), sometimes ( 威士忌 ) Betel quid (-) Cigarette (-) Special oral habits: Denied

Panorex (2015/09/09) There is a well-defined ovoid-shaped circumcoronal unilocular radiolucence with a corticated margin surrounded the CEJ of tooth 38 (inverted) over the left retromolar area, extending from mesial root of tooth 37 to left mandibular ramus area and from left mandibular cortical bone to alveolar crest, measuring approximately 1.5 x 2 cm in dimension. The lesion involved with tooth 37 and 38 with mild vertical bone expansion. And the left external oblique ridge was thinned. Also, the left inferior alveolar canal was displaced downward to inferior cortical bone, but the left mandibular cortical bone was not affected.

Panorex (2015/09/09) Dental findings: - Missing: Tooth 18, 27, 28, Caries: Nil - Periodontal condition: Generalized bony defect - Calculus: Nil - OD filling: Tooth 24, 26, 35, 36 - Endodontic condition: Tooth 32 endodontic treated - Restoration (e.g. C & B): Nil - Impaction: Tooth 38

Inflammation? InflammationOur case Color RedNormal Local Heat +- Swelling +- Consistency RubberyHard Pain +- Duration Daysunknown →Cyst or neoplasm

Cyst ? CystOur case Well-defined Border ++ Bone Expansion+/-+ ShapeRegular Aspiration +Unknown Ulceration -- Fluctuation +/-- → Cyst

Inflammation or Cyst? Inflammati on Cyst Non- Inflammati on Cyst Our case Sclerotic Margin -++ Pain+-- Local Heat+-- ColorRedNormal Progression FastSlow → Non-Inflammation Cyst

Benign or Malignant Neoplasm? Benign Tumor Malignant Tumor Our case BorderWell-definedIll-definedWell-defined MarginSmoothIrregularSmooth Sclerotic Margin +-+ Destruction of Cortical Margin -,++- Induration-+- Pain-+- ProgressionSlowFastSlow Metastasis-+- → Benign Tumor

Intrabony or Peripheral? IntrabonyPeripheralOur case Mucosal Lesion -+- Bony Expansion +/--+ Destruction of Cortical Margin +/--- ConsistencyHardSoft, firm, rubbery, … Hard → Non-Inflammation Cyst or Intrabony Benign Tumor

Differential Diagnosis Dentigerous cyst, tooth 38 Keratocystic odontogenic tumor, left retromolar area Unicystic ameloblastoma, left retromolar area Conventional ameloblastoma, left retromolar area

Dentigerous Cyst Our case Gender Male ≧ Female Male Age20~30 y/o56 y/o SiteMandibular 3 rd molarLeft posterior mandible S/S- (+,if infection)- Size> 3~4 mm1.5 x 2 cm Relative Density Unilocular RL with corticated margin MarginWell-defined Effect on adjacent structures Tooth impaction Displacement of inferior alveolar canal Tooth 38 impaction Displacement of left inferior alveolar canal

Keratocystic Odontogenic Tumor Our case Gender Male ≧ Female Male Age10~40 y/o56 y/o SitePosterior mandibleLeft posterior mandible S/SSwelling Straw color fluid - Size> 3 cm1.5 x 2cm Relative DensityUnilocular RL with corticated margin MarginWell-defined Effect on adjacent structures Displacement or root resorption of tooth Displacement of inferior alveolar canal Tooth 38 impaction Displacement of left inferior alveolar canal

Unicystic Ameloblastoma Our case GenderMale = FemaleMale Age23y/o56 y/o SitePosterior mandibleLeft posterior mandible S/S-- Size> 3 cm1.5 x 2 cm Relative DensityUnilocular RL with corticated margin MarginWell-defined Effect on adjacent structures Tooth impaction Displacement of inferior alveolar canal Thining of cortical bone Tooth 38 impaction Displacement of left inferior alveolar canal

Conventional Ameloblastoma Coventional Ameloblastoma Our case GenderMale = FemaleMale Age20~70 y/o56 y/o SitePosterior mandibleLeft posterior mandible S/S-/Bone expansion- Size> 3 cm1.5 x 2cm Relative DensityUnilocular RL with corticated margin (multilocular: soap-bubble) Unilocular RL with corticated margin MarginWell-defined Effect on adjacent structures Tooth impaction/ displacement Root resorption Invasion of inferior alveolar canal Thinning of cortical bone Tooth 38 impaction Displacement of left inferior alveolar canal

Clinical Impression Dentigerous cyst, tooth 38 Keratocystic odontogenic tumor, left retromolar area

Treatment Course 2015/09/09 Panorex taking Unilocular radiolucency, left posterior mandibular body Arrange surgery in Sep. 24, 2015 TF 2015/09/24 Surgery, enucleation and extraction, tooth /10/07 Routine check for oral cyst after surgery

Treatment plan Enucleation and extraction, tooth 38 Bone graft, left mandibular body Post-operation

Pathologic diagnosis Bone, mandible, tooth 38, enucleation, dentigerous cyst

Abstract We treated the dentigerous cyst arised from deeply impacted mandibular third molar with orthodontic extraction combined with the marsupialization therapy. This orthodontic-surgical procedure reduced the risk of nerve damage and pathological fracture of the mandible.

Dentigerous cyst 1. Painless, localized and progressive enlargement of the jaw 2. Associated with an impacted tooth 3. Displacement of adjacent teeth 4. Destruction of the bone 5. Resorption of roots 6. Pathological fractures (rarely)

Dentigerous cyst 1. Dentigerous cysts are the most common type of developmental odontogenic cysts. 2. Attached to the enamel–cementum junction of the tooth cervix and encloses the crown of the unerupted tooth (most commonly third molars and maxillary canines)

Marsupialization therapy 1. Prevent the complications associated with a large odontogenic cyst 2. Promote the spontaneous eruption of the involved tooth

IndicationContraindication Deep location of the impacted tooth (at the base of the mandible) Association with the inferior alveolar nerve Risk of pathological fracture Aged over 10 years Ankylosed tooth

Orthodontic extraction combined with the marsupialization therapy 1. Facilitate the extraction 2. Reduce the possibility of pathological fractures 3. Reduce the risk of damage to the inferior alveolar nerve

Case Report A healthy 33-year-old woman enucleation of cyst with the extraction of tooth combined surgical-orthodontic treatment and marsupialization of the cyst

Procedure Local anesthesia Window was created distally to the second molar Exposed crown of impacted third molar

Procedure Teeth adjacent to the third molar were bonded with fixed orthodontic (0.16 x 0.22 inch rectangular stainless steel)

Procedure A button was bonded to the buccal surface of the third molar

Procedure The third molar a spring was designed and placed in the auxiliary tube of the second molar Extrusive force was applied with elastic thread between the spring and the third molar button 1 month after

Procedure Sufficient extrusion of the tooth and shrinkage of the cyst Because the crown of the second molar became an obstacle on the eruption pathway, the orthodontic extrusion failed at the cervical level of the second molar 4 months after

Procedure Second surgical operation was performed to extract the tooth and enucleate the cyst under local anesthesia. 3 months after the extraction

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。

Tom Beauchamp &James Childress 六大原則 行善原則 (Beneficence) ：醫師要盡其所能延長病人之 生命且減輕病人之痛苦。 >>>>> ( 預防囊腫惡化來延長生命，並在療程中後會給 病人止痛藥，挖掉的空洞以補骨加強癒合 ) 2. 誠信原則 (Veractity): 醫師對其病人有「以誠信相對待」 的義務。 >>>>> ( 病人詢問病情，醫師術前診斷的建議跟術後告 知病理報告結果 ) 3. 自主原則 (Autonomy): 病患對其己身之診療決定的自主 權必須得到醫師的尊重。 >>>>> ( 獲得病人自我同意手術方式才用手術來移除 )

Tom Beauchamp &James Childress 六大原則 不傷害原則 (Nonmaleficence): 醫師要盡其所能避免病 人承受不必要的身心傷害。 >>>>> ( 術中小心移除囊腫，並注意不傷到下齒槽神經， 補骨加速生長來減輕骨頭斷裂的風險 ) 5. 保密原則 (Confidentiality): 醫師對病人的病情負有保密 的責任。 >>>>> ( 病歷資料皆在醫院紀錄，無帶出醫院情形 ) 6. 公義原則 (Justice): 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。 >>>>> ( 未有兩位以上口外主治醫師同時治療，病房照護 上藥物使用皆依醫療標準使用劑量，也未有臨時插刀 來進行手術 )