CASE HISTORY-9

Name:ANAS OPD NO:174441/04

Age: 24 years Occupation: student
Religion: muslim Sex: Male
Date: 22/10/17 Address: Sandila

CHIEF COMPLAINT - Patient complains of swelling in left lower back region of the jaw
since 9 months

HISTORY OF PRESENT ILLNESS - Patient was asymptomatic 9 months back than he

noticed swelling in left lower back region of the jaw. Initially swelling was small in size and
gradually increased as present without any others symptoms. After few days of swelling he went
to nearest private clinic for treatment and took medication but not relived.

PAST DENTAL HISTORY - No relevant past dental history present

PAST MEDICAL HISTORY - Patient visited 3 months back in private dental clinic for same
but not relived.

FAMILY HISTORY - No history of any disease running in the family

PERSONAL HISTORY -
Habits-
Patient has a mixed diet and no ill habits are present
Clenching and Bruxism habit- absent
Oral Hygiene habit- patient uses toothbrush and toothpaste to clean her teeth
once in a day at morning in for 2 – 5 minutes in a
horizontal manner
GENERAL CLINICAL EXAMINATION
Patient is conscious , co operative and well oriented with time place and person
Built- Well built
Gait- normal
Skin -normal
Nourishment -well nourished
Pallor - absent
Icterus - absent
Clubbing -absent
Cyanosis - absent

Vital signs
Pulse: 74 per minute
Blood pressure: 120/90 mm of Hg
Temperature: 98 degree Farenheit
Respiratory rate: 16/min

EXTRAORAL EXAMINATION
1. Facial asymmetry
2. LIPS: Competent
3. TMJ:
Mouth opening- 44 mm
Movements- normal
Sounds- clicking/crepitus- absent
Tenderness- absent
Dislocation- absent
Sub luxation- absent
4. LYMPH NODES: no abnormality detected
INSPECTION - On inspection a solitary swelling present on left lower back 1/3rd region of the
face with ill defined and diffused border with irregular in shape and size was 2.0-1.5 cm, extends
mesio-laterally 1.0 cm away from right corner of the lip to 1.5 cm in front of preauricular region
and superior-inferiorly 1.5 cm below from ala-tragus line to 0.5 cm included inferior border of
mandible. Overlying skin of both swelling was normal, no pulsation and no any other history.

PALPATION - On palpation all inspectory findings confirmed, Non-tender, no raised localized

temperature firm in consistency

INTRAORAL EXAMINATION
1. SOFT TISSUES
a. Labial mucosa- normal
b. Labial vestibule- normal
c. Buccal mucosa- normal
d. Buccal vestibule- normal

e. Tongue- dorsum of the tongue was normal with no loss of papillae

f. Lips- normal
g. Hard palate- normal
h. Soft palate- normal
Uvula is normal
i. Floor of mouth- normal
j. Gingival condition : normal

2. HARD TISSUE
TEETH
I. Teeth present-
11,12,13,14,15,16,17,21,22,23,24,25,26,27,31,32,33,34,35,36,37
41,42,43,44,45,46,47
II. Teeth missing-
III. Hypoplasia/ other developmental defects- absent
 IV. Attrition/ Abrasion/Erosion/ Abfraction- absent
V. Caries- absent
VI. Mobility- absent
VII. Discoloured teeth/ # teeth- absent
VIII. Presence of deep bite

AREA OF CHIEF COMPLAINT -

Inspection:
On inspection a solitary swelling present in lower left vestibular region in left lower back region
of the jaw irt 44,45,46,47, it size was approximate 3.0 x1.5 cm with ill defined borders and oval
in shaped it extends mesio-distally distal aspect of 44 to mesial aspect of 47 and superior-
inferiorly marginal gingiva to buccal vestibule. Overlying mucosa normal

Palpation:
on palpation all inspectory findings confirmed, non tender, no localized temperature raised, firm
in consistency no egg shell cracking appearance and no any discharge

PROVISIONAL DIAGNOSIS/CLINICAL DIAGNOSIS-

Ameloblastoma

DIFFERENTIAL DIAGNOSIS-

Unicystic ameloblastoma,
Residual cyst,
Odontogenic myxoma

INVESTIGATIONS-
1. RADIOGRAPH-
OPG
2. FNAC :
RADIOGRAPHIC INTERPRETATION-

OPG:
Shows multiloculer radiolucency is seen left mandible region .Extension of radiolucency
,anterior body of mandible to inferior angle of the mandible .Superior involving sigmoid notch
to inferior cortical border of mandible .Internal structure mixed radiolucency is seen ,thick septa
is form .Internal resorption of ramus of the mandible extension superior cortical border to
posterior sigmoid notch to anterior body of mandible

RADIOGRAPHIC DIAGNOSIS

Ameloblastoma
Odontogenic myxoma

HISTOPATHOLOGY REPORT -

Strands and few islands of odontogenic epithelial cells arranged in dense connective tissue
stroma .Thin odontogenic epithelial lining covering fibrous connective tissue

FINAL DIAGNOSIS-
Desmoplastic Ameloblastoma

& Unicystic Ameloblastoma

TREATMENT PLAN:

Surgical removal of lesion

 RADIOGRAPH

EXTRAORAL PHOTOGRAPH

PROFILE PHOTOGRAPH
INTRAORAL PHOTOGRAPH

PRE -OP

RADIOGRAPH

OPG
CT
INTRA-OPE

SPECIMEN