chÈn ®o¸n h×nh ¶nh u x¬ng hµm ths. lª ngäc tuyÕn
TRANSCRIPT
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chÈn ®o¸n h×nh ¶nh u x ¬ng hµm
ThS. Lª Ngäc TuyÕn
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Tumeurs maxillo-mandibulaires
• Th êng gÆp • Gióp chÈn ®o¸n ph©n biÖt u lµnh vµ
u ¸c.
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§Æc ®iÓm l©m sµng• Khèi • BiÕn d¹ng x ¬ng nh×n ho¨c sê thÊy• §au Ýt• ChÌn Ðp c¸c c¬ quan l©n cËn• Lung lay r¨ng• GÉy x ¬ng bÖnh lý• Ph¸t hiÖn t×nh cê trªn phim
panoramic
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C¸c ph ¬ng tiÖn chÈn ®o¸n h×nh ¶nh
• Phim Panoramique
• TDM
• IRM
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Panoramique dentaire
• C¸i tæng qu¸t ®Çu tiªn
• ChÈn ®o¸n x¸c ®Þnh trong phÇn lín c¸c tr êng hîp
– Suffisant dans très grande majorité des cas
• Gîi ý ®Õn lµnh tÝnh/ ¸c tÝnh
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TDM
• Cho thÊy c¸c cÊu tróc gi¶i phÉu l©n cËn
• Ch©n r¨ng• Lµnh tÝnh/ ¸c tÝnh• X©m lÊn – Trong x ¬ng– Vá x ¬ng– PhÇn mÒm– Caractère pluriloculaire
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IRM
• IRM >> TDM møc ®é x©m lÊn• Trong x ¬ng • PhÇn mÒm • Di c¨n
• Cho th¨m kh¸m/ ®iÒu tra vÒ hãa liÖu ph¸p
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Scintigraphie TC 99 m( NhÊp nh¸y ®å)
• NÕu nghi ngê nhiÒu x ¬ng
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Tæn th ¬ng mét hoÆc nhiÒu x ¬ng
• NÕu nhiÒu tæn th ¬ng trªn mét x ¬ng• Chérubisme• Kystes épidermoïdes (syndrome de Gorlin)• Lymphome• Histiocytose X
• Tæn th ¬ng trªn nhiÒu x ¬ng kh¸c nhau• Lésion secondaire• Dysplasie fibreuse• Granulome éosinophile• Myélome (Scinti négative)
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X¸c ®Þnh vÞ trÝ cña u
• Orientation Dic• U hiÕm– Kyste médian mandibulaire– Kyste médian alvéolaire– Kyste du canal naso-palatin– Kyste globulo-maxillaire entre incisive latérale et
canine– Tumeurs nerveuses : le long du CM
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Giíi h¹n cña u
• Nettes
• Liseré d’ostéocondensation
• Bords flous plutôt lésion agressive
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Néi dung bªn trong
• §ång nhÊt• Kh«ng ®ång nhÊt– Nang– Cßn c¸c bÌ x ¬ng– Vïng canxi hãa– Vïng cã tæ chøc cña r¨ng• cementaire• dentinaire
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Tæn th ¬ng vá x ¬ng
• U lµnh : kh«ng bÞ ph¸ hñy (souffle)
• U ¸c : ph¸ hñy vá x ¬ng, mµng x ¬ng vµ x©m lÊn phÇn mÒm
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Ph¶n øng mµng x ¬ng
• U lµnh : ®Òu, tr¬n nh½n
• ¸c tÝnh : xï x×, h×nh tia
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X©m lÊn phÇn mÒm
• = ¸c tÝnh
• Trõ mét vµi u nh : améloblastome
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Liªn quan ®Õn ch©n r¨ng
• Liªn quan ®Õn mÇm r¨ng hoÆc r¨ng r¨ng bao gåm : =/- kyste dentigère mais aussi améloblastome, kyste épidermoïde
• §Èy r¨ng l©n cËn = bénin
• Tiªu ch©n r¨ng = bénin mais aussi plasmocytome malin
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BÉy gi¶i phÉu
• Image radio-claire : cavité idiopathique de Stafne
• Maladie de Paget
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Gi¶i phÉu bÖnh
• L©m sµng vµ XQ lµnh tÝnh = kh«ng cÇn biopsie
• L©m sµng vµ XQ ¸c tÝnh = cÇn biopsie
• PhÉu thuËt : lµm sinh thiÕt
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• Nang
• U lµnh
• U ¸c
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nang
–Nang do r¨ng
–Nang kh«ng do r¨ng
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Nang do r¨ng
• Nang nhiÔm trïng– Nang ch©n r¨ng– Nang bªn – Nang sãt
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Nang do r¨ng
• Kystes dentigères– Ou Kyste folliculaire– Ou Kyste corono-dentaire– Ou Kyste péricoronaire
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Nang do r¨ng
• Kystes épidermoïdes– Restes épithéliaux de la lame dentaire– Image radio-claire et liseré condensé– Syndrome de Gorlin : naevomatose basocellulaire
et anomalie osseuse
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Nang kh«ng do r¨ng
• Nang khe– Nang khe gi÷a r¨ng cöa bªn vµ r¨ng
nanh– Nang gi÷a x ¬ng hµm dø¬i hoÆc hµm
trªn
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Nang kh«ng do r¨ng
• Kystes du canal naso-palatin– Origine discutée– Lacune médiane rétro incisive, forme de cœur et
liseré
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U lµnh tÝnh
• U cã nguån gèc do r¨ng– U nguån gèc biÓu m« r¨ng– U nguån gèc trung m« r¨ng– U nguån gèc c¶ biÓu m« vµ trung
m« r¨ng
• U cã nguån gèc kh«ng do r¨ng
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Tumeurs bénignes d’origine dentaire
• T épithéliales = améloblastome• T dérivée des améloblastes• 15-30 tuæi• 85% gÆp ë gãc hµm x ¬ng hµm d íi• Lµnh tÝnh
– Khëi ®Çu trong x ¬ng– Phång x ¬ng
• §au, lung lay r¨ng,nhiÔm trïnggÉy x ¬ng, bourgeonnement tumoral
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Tumeurs bénignes d’origine dentaire
• T épithéliales = améloblastome• Radiologie– Image kystique, uniloculaire, contours nets, +/-
dent incluse– Image multiloculaires• Bulles de savon• Nid d’abeille
– Vaste image lacunaire =/- cloisons
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Tumeurs bénignes d’origine dentaire
• T épithéliales = améloblastome• PhÇn mÒm gi·n do x©m lÊn (IRM)– Par invasion = malignité locale
• Risque de dégénérescence : épithélioma
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Tumeurs bénignes d’origine dentaire
• T mésenchymateuse– Myxomes odontogènes– Cémentomes– Cémentoblastomes
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Tumeurs bénignes d’origine dentaire
• T mésenchymateuse et épithéliale = odontomes• = hamartomes• H×nh ¶nh XQ râ• C¶n quang• Chu vi râ
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Tumeurs bénignes d’origine non dentaire
• T osseuses– Ostéome ostéoïde, ostéoblastome– Ostéome +++
• T cartilagineuse– Chondrome– Ostéochondrome– Chondroblastome– Fibrome –chondro-myxoïde
• T conjonctive– Dysplasie fibreuse– T à cellules géantes– Chérubinisme
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Tumeurs malignes
• D’origine dentaire– Carcinome odontogénique– sarcome odontogénique = exceptionnelles
• D’origine non dentaire– Ostéosarcome– Hématosarcomes– Lésions secondaires
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Tumeurs malignes
• Ostéosarcome• Cellules tumorales élaborent du tissu ostéoïde• 50 % : 10-20 ans• Radiologie :– Kh«ng cã ranh gií râ– Vá x ¬ng ®øt ®o¹n– H×nh ngän löa– Mµng x ¬ng s©m lÊn
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Ostéosarcome
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Chondrosarcome
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Tumeurs malignes
• Hématosarcomes • lymphome Hodgkinien ou non : Lésions osseuses
perméatives
• Lymphome de Burkitt : zones d’ostéolyse, ruptures corticales, spicules perpendiculaires périoste
• Myélome multiple : lacunes à l’emporte pièce
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Tumeurs malignes
• Lésions secondaires• Lésions lytiques• Lésions condensantes : prostate, sein, poumon• Contexte +++
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CONCLUSION
• Imagerie = panoramique dentaire
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CONCLUSION
• Tomodensitométrie
– X¸c ®Þnh u vøi cÊu tróc gi¶i phÉu xung quanh
– Liªn quan víi ch©n r¨ng– X©m lÊn cña u• Trong x ¬ng• PhÇn mÒm
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CONCLUSION
• IRM
– Extension tumorale si lésion d’allure agressive• Endo osseux• Parties molles
– X¸c ®Þnh u liªn quan víi ®Çu khíp
– Theo dâi hãa trÞ liÖu
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CONCLUSION• Tæn th ¬ng mét hay nhiÒu buång• Tæn th ¬ng ®¬n lÎ hay nhiÒu x ¬ng• Giíi h¹n cña tæn th ¬ng• Thµnh phÇn bªn trong ®ång nhÊt hay kh«ng• Vá x ¬ng• Ph¶n øng mµng x ¬ng• X©m lÊn phÇn mÒm• Liªn quan víi ch©n r¨ng• Liªn quan víi mÇm r¨ng, hoÆc r¨ng ngÇm• Tiªu ch©n r¨ng• VÞ trÝBENIN / MALIN : hypothèses diagnostiques
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