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：2014.06.24

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 : 2014.06.03

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

Radiographic examination

Panorex(2014.06.03) 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.

Differential diagnosis

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

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

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

Non-inflammation cyst Cyst or Neoplasm Our case cyst Fluctuation - +- Well defined border + Bone expansion Our case Inflammation cyst Non-inflammation cyst Pain, tenderness - + Local heat Color pink Reddish Pink Progression slow Fast Slow Sclerotic margin

→Non-inflammation cyst or benign tumor Our case Benign Malignance Border Well-defined ill-defined Margin smooth Irregular Sclerotic margin + - Destruction of cortical margin +- Progressive slow Fast Swelling with intact epithelium Pain induration →Non-inflammation cyst or benign tumor

Working diagnosis Ameloblastoma (conventional type) Keratocystic odontogenic tumor Central giant cell granuloma Odontogenic myxoma

Ameloblastoma Our case Ameloblastoma Gender Female Equal Age 36 30~70 Site Mandible (molar area) Mandible (molar→ascending ramus) Paresthesia + Uncommon Swelling Drainage - +- Radiography Well-defined, soap bubble multilocular, corticated margin Well-defined, unilocular or multilocular, corticated margin Bony expansion Teeth displacement/ root resoprtion duration slow

Keratocystic odontogenic tumor Our case KCOT Gender Female Slight male Age 36 10~40 Site Mandible (molar area) Mandible (posterior body and ascending ramus) Paresthesia + Pain Swelling Drainage - Radiography Well-defined, soap bubble multilocular, corticated margin Well-defined, unilocular or multilocular, corticated margin Bony expansion Teeth displacement/ root resoprtion duration slow

Central giant cell granuloma Our case Non-aggressive Aggressive Gender Female Age 36 <30 Site Mandible (molar area) Mandible (anterior region) Paresthesia + - Pain Swelling Drainage Radiography Well-defined, soap bubble multilocular, corticated margin Well-defined, unilocular or multilocular, non-corticated margin Bony expansion Teeth displacement/ root resoprtion duration slow rapid

Odontogenic myxoma Our case Odontogenic myxoma Gender Female Slight female Age 36 10~50 (mean 25~30) Site Mandible (molar area) Max.:Man.=3:4 or3:7 (tooth-bearing areas) Paresthesia + Rare Swelling - Drainage Radiography Well-defined, soap bubble multilocular, corticated margin Often well-defined, unilocular or multilocular, may with corticated margin Bony expansion Teeth displacement/ root resoprtion duration slow

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 (2014.06.09) 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.

HISTO-PATHOLOGIC EXAMINATION

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.

Discussion ─Marsupialization

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 1.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

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 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

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 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

Advantages 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

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. 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

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 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

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 6.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

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 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

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 1.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

Enucleation after marsupialization 造袋術後進行的剜除術

Introduction Enucleation is frequently done after marsupialization Combined approach： Reduce morbidity Accelerate complete healing of the defect 1.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

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 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

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 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

Disadvantages The 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

Technique Marsupialization of the cyst Osseous healing Cyst decreased to complete surgical removal Enucleation (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

Technique 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. 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。

Technique Cyst enucleated  oral soft tissue must be closed. may require soft tissue flap cannot close completely  packing (strip gauze and antibiotic ointment). Change repeatedly until granulation tissue has obliterated the opening and epithelial closed over the wound 6.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。

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

Reference Sampson DE, Pogrel MA. Management of mandibular ameloblastoma: the clinical basis for a treatment algorithm. J Oral Maxillofac Surg 1999;57:1074-7 Robinson L, Martinez MG. Unicystic ameloblastoma: A prognostically distinct entity. Cancer 1977;40:2278-85. Lau SL, Samman N. Recurrence related to treatment modalities of unicsytic ameloblastoma: a systematic review. Int J Oral Maxillofac Surg 2006;35:681-90. 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;26:214-8 Abaza NA, Gold L, Lally E. Granular cell odontogenic cyst: A unicystic ameloblastoma with late recurrence as follicular ameloblastoma. J Oral Maxillofac Surg 1989;47:168-75. Contemporary Oral and Maxillofacial Surgery, 6th edition, part V: management of oral pathologic lesions, P.454-458

醫學倫理討論

Tom Beauchamp &James Childress 六大原則 - 1979 1.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。

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。

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。

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。

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。

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

公義原則 手術的必要性？

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

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