3. 2016/01/09

8. There is a well-defined oval shaped homogeneous radioluopacity without corticated margin over right submandibular region, measuring approximately 0.5×0.4 cm in diameter. The density of radioluopaque is bone-like and not affects surrounding tissue. -Missing: Tooth 11, 12, 13, 14, 17, 18, 21, 22, 24, 25, 26, 27, 28, 35, 36, 38, 45, 46, 47, 48 -Crown: Tooth 43 -residual root: Tooth 15, 23, 34 -Impaction: Nil

9. There are several well-defined oval-shaped radioluopacities without corticated margin over right submandibular region, lingual side to mandible body, measuring approximately 0.5×0.4 cm to 0.1x0.1 cm in diameter. The density of radioluopaque is bone-like and not affects surrounding tissue.

11. Inflammation? Cyst or neoplasm? Benign or malignant? Working diagnosis

12. Inflammation, cyst, or neoplasm ？ Our caseInflammationCystNeoplasm ColorRed NormalVariable Fever-+-- ConsistencyRubbery Intrabony : hard Peripheral : Soft Variable ShapeRegularIrregularRegularIrregular Discharge++-+/- Pain++-+/- Ulceration---+/- MobilitymovableFixedIntrabony : fixed Peripheral : Fluctuation Fixed Duration???DaysYearsMonths

13. Benign or Malignant ? Our caseBenignMalignant BorderClear Unclear SurfaceSmooth Rough, smooth Ulceration--+/- Induration--+ Pain+-+/- Metastasis--+/- MobilityMovableMovable/fixedFixed Duration???Years/MonthsMonths

14. Intrabony or peripheral ？ → Our case is a Our caseIntrabonyPeripheral Bone expansion -+- Bony destruction -+- Consistency RubberyHardSoft, firm, rubbery… Peripheral imflammation or Benign peripheral cyst

15. Working diagnosis

16. WORKING DIAGNOSIS Most possible Least possible

18. Sialoliths Our case Sialoliths GenderFemale N/P Age64 y/o N/P Site Bilateral submandibular area most often develop within the ductal system of the submandibular gland V S/S Pain (+) Tenderness(+) Pus discharge(+) episodic pain or swelling of the affected gland, especially at mealtime V Size0.5 x 0.4 cm to 0.1 x 0.1 cm < 1 cm V Duration??? Slow Other features Rubbery swelling Swelling of the affected gland V Homogeneous RO RO (homogeneous or with a laminated structure) V

19. Calcified lymph nodes Our caseCalcified lymph nodes Gender Female N/P Age 64 y/o N/P Site Bilateral submandibular area Submandibular and superficial and deep cervical nodes (most common) V S/S Pain (+) Tenderness(+) Pus discharge(+) No S/S V Size 0.5 x 0.4 cm to 0.1 x 0.1 cmVaries Duration ??? Slow Other features Rubbery swelling hard, lumpy, round to oblong masses. Homogeneous RO Usually both RO and RL with mottled and irregular borders

20. Calcified atherosclerotic plaques Our case Calcified atherosclerotic plaques GenderFemaleMale Age64 y/o men in their 40s and women in their 50s to 60s. V Site Bilateral submandibular area common carotid : more laterally facial artery :simulate V S/S Pain(+) Tenderness(+) Pus discharge(+) asymptomatic Size 0.5 x 0.4 cm to 0.1 x 0.1 cm Variable V Duration???Slow Clinical features DM(+) V Tobacco(-)Tobacco(+) Smoking(-)Smoking(+)

21. Myositis ossificans Our case Myositis ossificans Genderfemalenone V Age64 y/oyoung adults X Site Bilateral submandibular area masseter (most common) temporalis medial and lateral pterygoid V S/S Pain(+) Tenderness(+) Pus discharge(+) Painful swelling tender V Size 0.5 x 0.4 cm to 0.1 x 0.1 cm Variable V Duration???Slow Clinical features Trismus(-)Trismus(+) Trauma(?)Trauma(+)

22. Phleboliths Our casePhleboliths Genderfemale N/P Age64 y/o N/P Site Bilateral submandibular area most commonly are found in hemangiomas V S/S Pain(+) Tenderness(+) Pus discharge(+) No S/S Size0.5 x 0.4 cm to 0.1 x 0.1 cmvaries Duration??? slow Other features Rubbery swelling swollen, throbbing, or discolored by the presence of veins or a soft tissue hemangioma V Homogeneous RO bull’s-eye or “target” appearance X

26. 2016/01/09 2016/01/04

31. Salivary gland, submandibular, right, excision, sialolith Salivary gland, submandibular, left, excision, sialolith

32. Discussion

33. introduction 1.most patients present with a single stone 2.Lustmann found that of 302 sialoliths studied, 79.8 per cent were 1 cm or less and only 7.6 per cent greater than 1.5 cm submandibular gland system80~90% parotid gland10~20% sublingual gland1%

34. case report

35. submandibular gland 1. viscous mucus 2. more alkaline pH 3. ascending course 4. narrow orifice

36. 1. 94.7% detected by using intra-oral radiology alone(Lustmann) 2. 20% unseen(Blatt)

37. sialography1.rarely indicated 2.suspected ductal stricture and obstruction without calcification ultrasoundunnecessary computed tomography magnetic resonance sialography.

38. moist heat intake of fluids sialagogues gentle massage

39. intraglandular sialoliths generally require removal of the gland 1.lingual n. 2.hypoglossal n. 3.haemorrhage

40. wire-basket4mmfiberoptic laser lithotripsy

41. differential diagnosis Mandibular torus Osteoma continuous, no pain Calcified lymph nodes Phleboliths and other vascular calcificationsvariocity Tuberculosis of lymph nodes or of the salivary gland itself Calcified atherosclerotic plaques in major blood vessels Myositis ossificanstrismus Metastasis from distinct calcifying neoplasms

46. Thank you for your listening!