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Archive for the ‘CBCT’ Category

I uploaded these two videos of my diagnosis:

This is a stack of cone-beam computer tomography slices, shown at 5 frames per second.

And this is a 3D-volume rendering of the lower part of my skull (from the previous slices):

You can also go directly to both of these via these URLs:

Ameloblastoma: stack of cone-beam computer tomography slices (100pct qual jpg, 5fps)
Tilted Axial Rotation of Lower Face Showing Ameloblastoma in Left Mandible (100pct qual jpg, 5fps)

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Pop!

Today I ate lunch with my manager. He likes to schedule one-on-one lunches about once month to see how we’re doing. I was under instructions from my oral surgeon to not eat anything hard.

Fish, I figured, would be okay. I will not name the name of the place I ate at, because it wasn’t there fault and the food was actually tasty.

Maybe I was stupid and didn’t realize the gravity of my situation. But I was trying to be careful and cautious. I made sure that I didn’t eat anything that was hard, because I didn’t want to break my jaw. And the coleslaw seemed pretty soft.

So were almost done and sitting around when I was eating very small bites of the coleslaw. I tried consciously chew with my right side, but maybe I messed up.
And I heard a loud pop in my jaw. The pop reverberated throughout my skull and I was absolutely horrified. I had never had anything like that happen before. It was so surreal. But it didn’t hurt, it didn’t swell and nothing seemed to happen.

Except that when I pushed in on my backmost molar, it hurt. The deep tearing pain, like when I had my biopsy. That pain was so horrible that I immediately withdrew my finger from my mouth. I was able to pull it together and get back to work, but I called my oral surgeon’s office, just in case.

And I made the appointment with the orthopedist, which I will be going to this coming Tuesday.

My oral surgeon’s office asked me where I was, then told me to come by and they’d take an X-ray. So they took a panoramic X-ray and emailed the X-ray to the on-call oral surgeon. The assistent there looked over my jaw, mouth, felt around. She told me that I was keeping the biopsy site clean and it had healed really well. That was encouraging. Then she had me close my teeth together so she could see if my molars were closing flat. I asked her why and she said that if there is a fracture, sometimes the bone snapping will tilt the teeth so that they don’t meetup evenly. She said it was like snapping a stick, then trying to bend it back to the position it was in before. With the stick being slightly askew now and non-straight.

But she didn’t find anything out of the ordinary. They apparently took bone from the bottom of my mandible, because she touched an area which hurt surprisingly more than it should have and mentioned something about the biopsy there. I’m actually not sure where they took biopsy bone from. I was numbed up, but felt sharp digging tearing pains just from my bone. Truly unpleasant, as mentioned in my earlier post.

As it turned out, the oral surgeon on-call would take 20 minutes or so to get to a place where they could look at the X-rays, so I was to wait around. Since I was already there, I thought to address the issue of why I wasn’t getting my copy of the CB CT scan data. I was promised a copy of the CD. I had already stopped by earlier on the way into work to talk to them about it, but they could get ahold of the person who did the CT scan. So I remembered while I was there and brought it up and they called over to the imaging place.

And here’s the rub. One copy was sent to the oral surgeon, one copy was sent to my dentist. I really didn’t care if my dentist received a copy, that’s fine. In fact I want him to have a copy. But the imaging people said that I had to pay $25 AND get a signed authorization from the ordering doctor.

What? This is data from my own body. Data that I actually paid for, because the imaging place doesn’t file insurance. Uggh. $25 is probably going to be a drop in the bucket compared to what this whole ordeal is going to cost me in the long run. So I bore this indignity.

I was quite happy to get my radiographic data. It made me fill like things were a little more defined.

And I saw the tumor in my jaw. Actually, it’s a CT scan, which shows bone (it uses X-rays as well). So what I really saw was the lack of bone in my jaw and how much was missing. And I even got the raw Dicom (DCM) files, which is awesome. I’ll post some of graphics from these later on.

I went back to work after that and started playing with the application they had on disc to read the DCM graphics files. I thought the UI had kind of a clunky interface, but it had quite a bit of features once you got use to it. A guy at work who actually did an internship doing volumetric rendering of DICOM files, so we talked about that quite a bit. He told me about ImageJ.

The oral surgeon’s office called me back and told me that there might have been a really tiny fracture, but that they’d give me antibiotics anyways. And DON’T CHEW. Trust me, I was more than happy to comply.

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This came in the mail today:


[Patient] is 31 years old and presented for evaluation of radiolucent area in his posterior left mandible on December 4, 2008, as referred by his dentist, [Dentist]. A multi-centimeter diameter lesion was noted in the left ramus and was not associated with pain or anesthesia. There was notable expansion of the mandibular ramus and external oblique region. An incisional biopsy of the area was performed under local anesthesia on December 8, 2008, and submitted to Baylor College of Dentistry Oral Pathology Services for evaluation. The pathology report revealed an ameloblastoma within his mandible. A cone-beam image CT scan was performed on December 12, 2008, and I have reviewed that scan today. The lesion is large and extends from the anterior portion of the mandible in the distal first molar region to the posterior extent of it in the mid ramus below the mandibular condyle. There is significant expansion of the mandible, thinning of the cortices and root resoprtion of tooth #18. There is a possible perforation to the soft tissues on some of the lingual areas. There inferior alveolar nerve appears to be within very thin bone and displaced to the inferior quarter of the mandible.

[Patient] enjoys excellent general health. He is GI intolerant to erythromycin. Otherwise, he received a tonsillectomy at 8 years old, wisdom teeth extraction at 18 and partial gingivectomy for periodontal maintenance during the past year.

IMPRESSION:

  1. Patient is a 31-year-old man in good general health
  2. Ameloblastoma, large, left posterior mandible.

TREATMENT RECOMMENDATIONS

  1. Inform patient regarding the clinical findings and nature of his lesion. We have discussed this prior and we will do so more in great detail in the near future.
  2. Obtain articulated study models for a reference guide for his dental occlusion. This may be performed by his dentist.
  3. Surgery, left mandible:
    1. Partial mandibulectomy with removal of tooth #19 and tissue distal with maintenance of the mandibular condyle
    2. Autologous, cortical cancellous bone graft from the iliac crest to mandible with rigid bone plate fixation
    3. These procedures will be performed in a hospital operating room while the patient receives general anesthesia. An orthopedic surgeon will be consulted for harvesting of the bone graft.

Aspects of the details of the surgery will be discussed with the patient in the near future. Such topics will include the expected permanent anesthesia of the inferior alveolar nerve due to its ablation as well as aspects of reconstruction, limitation of function and need for long term rehabilitation. In the long term, dental implants maybe be used to replace the #19 and #18. Complex vestibuloplasty as well as other bone graft augmentation may be performed after the patient has healed over 1 year following these surgeries. He will need follow up care and the discussion of possible recurrence of the ameloblastoma cannot be ruled out.

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