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2. medicine
3. surgery

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

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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

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mucosa color
Tenderness (-)
Pain(-)
Lip numbness (+)
Bone expansion(+)
Multilocular radiolucence with bony destruction
→ intrabony lesion
Peripheral or Intrabony
Mucosal lesion
Our case
-
Induration
Bony expansion
+
+
-
+-
Cortical bone
destruction
+
-
+-
→intrabony
peripheral 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
Cyst or Neoplasm
Our case
cyst
Fluctuation
-
+-
Well defined border
+
+
Bone expansion
+
+-
Our case
Inflammation
cyst
Noninflammation
cyst
Pain, tenderness
-
+
-
Local heat
-
+
-
Color
pink
Reddish
Pink
Progression
slow
Fast
Slow
Sclerotic margin
+
-
+
Our case
Benign
Malignance
Border
Well-defined
Well-defined
ill-defined
Margin
smooth
smooth
Irregular
Sclerotic margin
+
+
-
Destruction of
cortical margin
+
+-
+
Progressive
slow
slow
Fast
Swelling with intact
epithelium
+
+
-
Pain
-
-
+
induration
-
-
+
→Non-inflammation cyst or benign tumor
Working diagnosis
Ameloblastoma (conventional type)
2. Keratocystic odontogenic tumor
3. Central giant cell granuloma
4. Odontogenic myxoma
1.
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
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
slow
Central giant cell granuloma
Our case
Nonaggressive
Aggressive
Gender
Female
Female
Age
36
<30
Site
Mandible (molar area)
Mandible (anterior region)
Paresthesia
+
-
Pain
Swelling
+
-
+
Drainage
-
-
-
Radiography
Well-defined, soap
bubble multilocular,
corticated margin
Bony expansion
+
-
+
Teeth displacement/
root resoprtion
+
-
+
duration
slow
slow
rapid
Well-defined, unilocular or
multilocular, non-corticated
margin
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
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.
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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


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
Indication
 When enucleation may cause injury or unnecessary

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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
Advantages
 Simple
 Spare vital structures from damage
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.
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
 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
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
Enucleation after marsupialization
Introduction
 Enucleation is frequently done after
marsupialization
 Combined approach：


Reduce morbidity
Accelerate complete healing of the defect
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
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
Disadvantages
 The total cyst is not removed initially for pathologic
examination.
 However, subsequent enucleation may then detect
any occult pathologic condition.
Technique
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)
1.
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.
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
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
1.
2.
3.
4.
5.
6.
7.
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
THANK YOU FOR YOUR
ATTENTION!