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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 12  |  Issue : 1  |  Page : 6-10

Radiographic diagnosis and surgical management of compound composite odontome with supernumerary tooth and impacted central incisor – A rare case report


1 Department of Pediatric and Preventive Dentistry, Clove Dental, Delhi, India
2 Department of Pediatric and Preventive Dentistry, Kartik Dental Care, Gaur Yamuna City, Greater Noida, Uttar Pradesh, India
3 Department of Prosthodontics, ITS Dental College, Ghaziabad, Uttar Pradesh, India

Date of Submission05-Mar-2021
Date of Acceptance05-Feb-2022
Date of Web Publication30-Apr-2022

Correspondence Address:
Dr. Amit Kumar Pathak
Department of Pediatric and Preventive Dentistry, C/o Neeraj Kumar JHA, House No. 3598, Gali No. 96, B Block, Near Apex Public School, Sant Nagar, Burari, New Delhi - 110 084
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_9_21

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   Abstract 


Odontomas are the most frequent hamartomatous developmental abnormality. The condition is frequently associated with one or more unerupted teeth and is often detected through the failure of teeth to erupt at the expected time. Although most cases are found impacted within the jaw, there are instances where odontomas have erupted into the oral cavity. Majority of the odontomas are asymptomatic nonetheless these anomalies can cause delayed eruption, impaction, or even result in retention of primary teeth. Odontomas are atypical calcified conglomeration of dental tissues such as enamel, dentin, pulp, and cementum and emerge from odontogenic epithelium thus, they are mixed odontogenic tumor. According to the literature, its origin can be local trauma, infection, or genetic mutations, however, the exact cause is unknown. This case report presents a compound composite odontome in a 25-year-old patient along with its related clinical and radiological manifestations and the surgical management and emphasis on the early diagnosis and treatment planning.

Keywords: Impacted tooth, odontome, radiographic diagnosis, supernumerary tooth, surgical management


How to cite this article:
Ahmed F, Pathak AK, Banerjee S, Jainer R. Radiographic diagnosis and surgical management of compound composite odontome with supernumerary tooth and impacted central incisor – A rare case report. J Interdiscip Dentistry 2022;12:6-10

How to cite this URL:
Ahmed F, Pathak AK, Banerjee S, Jainer R. Radiographic diagnosis and surgical management of compound composite odontome with supernumerary tooth and impacted central incisor – A rare case report. J Interdiscip Dentistry [serial online] 2022 [cited 2022 Jul 3];12:6-10. Available from: https://www.jidonline.com/text.asp?2022/12/1/6/344468




   Clinical Relevance to Interdisciplinary Dentistry Top


The clinical case involves Oral Medicine and Radiology for a proper diagnosis, Oral & Maxillofacial Surgery for the enucleation of the odontome and Department of Orthodontics for proper alignment of the teeth.


   Introduction Top


Odontoma is the most common mixed intraoral odontogenic tumor leading to the progression of completely differentiated epithelial and mesenchymal cells which appear normal or defect in structure. The term odontoma refers to a lesion that has all the dental tissues such as enamel, dentin, pulp, and cementum. It is characterized by an unusual calcified mass of dental tissues such as enamel, dentin, pulp, and cementum, which is a developmental abnormality and are hamartomas rather than tumor.[1],[2]

Odontomas are generally found inside the first two decades of life with a mean age of 14.8 years. Odontomas are found more in males (59%) than females (41%). Compound odontomas are usually well-organized calcified dental tissues and appear-like well-formed tooth structures. Complex odontoma is unremarkable masses of dental tissues. Compound odontomas are more commonly found in the maxilla (67%) as compared to the mandible (33%) with more predilection in the anterior region of the maxilla (61%).[3],[4] Most of these abnormalities are found serendipity on routine dental radiographs where the patients complain of delayed eruption of the succedaneous tooth. Here, we report a case of compound-complex odontoma in a female patient with the retained deciduous tooth.


   Case Report Top


A 25-year-old female patient reported to the clinic with the chief complaint of esthetic concerns in the front region. Her medical history was not significant. Thorough intraoral examination was done, and it was found that the patient had retained the left deciduous central incisor # 61 [Figure 1]. Extraoral examination revealed no facial asymmetry. Initially, a provisional diagnosis of missing or impacted 21 was made. Intraoral periapical radiograph revealed multiple radiopaque and conical tooth-like structures above the crown of the unerupted permanent central incisor [Figure 2] and orthopantomogram (OPG) was advised [Figure 3]. After analyzing, the OPG patient was advised to go for cone-beam computed tomography (CBCT) to confirm the diagnosis [Figure 4] and [Figure 5].
Figure 1: Preoperative view

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Figure 2: Preoperative intraoral periapical radiograph

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Figure 3: Orthopantomogram

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Figure 4: Different view of same CBCT

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Figure 5: Cone-beam computed tomography view

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CBCT scan was performed with CS 9300 scanner at resolution (0.2 mm × 0.2 mm × 0.2 mm). Three-dimensional, cross-sectional, and panoramic images with cross-sectional interval = 1 mm revealed retained deciduous tooth #61 noted with root resorption till the cervical third. Mesioangular impacted supernumerary-like tooth structure was noted in the left anterior maxillary alveolus region; caudal to impacted #21. Conical-shaped tooth crown was noted.

Thinning of adjoining labial-palatal cortices was noted. Focal area of partially contiguous multiple tooth-like radiodensities consisting of enamel, dentin, and central pulp-like tissue noted in the left anterior maxillary alveolus region caudal to impacted #21 and cranial-mesial to impacted supernumerary tooth. Distinct peripheral radiolucent capsule noted that is contiguous with pericoronal radiolucency of the supernumerary tooth. Thinning-intermittent effacement and mild compression of the anterolateral wall of the nasopalatine canal were noted. Acute labial dilaceration of prominent root was noted. This led to the confirm diagnosis of compound composite odontome.

Surgical procedure

Routine blood investigation was carried out. After taking the consent of the patient extraction of retained #61, odontome, supernumerary tooth (conical shape), and impacted tooth # 21 was planned under local anesthesia. Perioral structures were prepared with Betadine, and a triangular mucoperiosteal flap was reflected in the regions of 11, 21, and 22 to expose the bone. A window was made in the bone using a straight, slow-speed handpiece bearing a round tungsten carbide bur under normal saline irrigation [Figure 6]. Denticles around 6 in number were removed [Figure 7] along with the follicle, and bony sharp margins were trimmed and thorough irrigation of the enucleated site was done following which intraoral periapical radiograph (IOPA) was taken [Figure 8]. Bone Graft-Osseograft (Demineralized bone matrix [DMBM] 0.25 g Vial) and Membrane-Healiguide (Guide Tissue Regeneration [GTR] 15 mm × 20 mm) were placed for improving the prognosis of the site for implant placement [Figure 9] after which the IOPA was taken [Figure 10] and then, the flap was repositioned and three interrupted sutures were given using 3-0 silk suture material to close the wound edges [Figure 11]. Postoperative follow-up was uneventful. Ground section of the Odontoma [Figure 12] confirmed the diagnosis for Compound Composite Odontomas. Postoperative follow-up was uneventful [Figure 13].
Figure 6: Intraoperative

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Figure 7: Surgically removed multiple varied size denticles, supernumerary tooth and retained 61 and impacted 21

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Figure 8: Postoperative intraoral periapical radiograph

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Figure 9: Bone graft and membrane placement

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Figure 10: Intraoral periapical radiograph after the placement of bone graft and membrane

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Figure 11: After suture placement

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Figure 12: Ground section of odontome

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Figure 13: Post-operative orthopantomogram after 10 months of surgery

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   Discussion Top


Odontomas are the most common, asymptomatic, odontogenic tumor encountered at any age but frequently seen in the first and second decades of life. In 1867, Paul Broca coined the term “Odontoma.” In 2005, based on the morphology and radiographic features WHO classified odontoma into two types: compound and complex.[5] The present case report was diagnosed as compound odontoma based on the radiographic findings which were further confirmed through CBCT. In our case, the lesion encountered at the anterior maxilla which was the most common location as per literature with buccal cortical bone expansion reflecting the vestibular obliteration and this contributed to the discovery of the lesion. In 70% of the odontomas, the adjacent teeth lead to pathological changes such as devitalization, malformation, malposition, aplasia, impaction, and delayed eruption.[6] In our case, malposition of the left permanent central incisor was noted. Complete surgical removal is the treatment of choice for odontomas. However, for surgeons, it might be a channeling, as most odontomas are associated with normal adjacent tooth structures. Small and localized odontomas are easy to remove, but large odontomas require a complex treatment approach such as osteoplasty, reconstruction of soft tissue, and dental prosthesis.[7] In the present case, the surgical extraction of multiple denticles and complete enucleation of soft tissue was performed.

In the present case, odontoma was diagnosed in a 25-year-old female patient on a routine radiographic examination, following patient's chief complaint of retained deciduous upper front tooth. An intraoral radiograph was taken to rule out missing permanent central incisor and revealed several tooth-like structures above the crown of the unerupted permanent central incisor causing delay in the eruption of the tooth. Reported studies show that compound odontomas often occur more frequently in the anterior maxilla in the incisor and canine region on the right side of the jaw which is confirmed in the present case.[8] The case described in the study was diagnosed as odontoma on the premise of clinical signs and radiographic findings. Differential diagnosis must be established with ameloblastic fibroma, ameloblastic fibroodontoma, and odontoameloblastoma. Syndromes that can be associated with odontomas are Gardner's syndrome, familial colonic adenomatosis, Herrmann syndrome, and basal cell nevus syndrome.[9]

Surgical enucleation of odontoma by removing the connective tissue capsule that encircles it is the best approach to allow the eruption of the permanent tooth. In the present case, surgical exposure followed by enucleation was done and the number of denticles removed during enucleation of odontoma was seven in number. However, there are cases where 232 denticles have been removed,[7] after which tooth was left in place because it is advised that in the case of an impacted tooth related to odontoma, and it is always better to wait for 3 months for the eruption of the impacted tooth. In case the impacted tooth fails to erupt after 3 months, it is recommended for surgical exposure followed by orthodontic traction. On the other hand, impacted teeth are frequently reported to be extracted simultaneously with the odontoma.[10] In this case, the permanent central incisor was not retrievable as it was horizontally impacted; therefore, it was removed together with the compound odontoma to rehabilitate the patient with an implant-supported prosthesis. After extraction, the bony defect was filled using bone graft Osseograft (DMBM 0.25 g Vial) and membrane Healiguide (GTR 15 mm × 20 mm) was placed for improving the prognosis of the site for implant placement which will be done after completion of orthodontic treatment.


   Conclusion Top


The patient should carefully observe the eruption and exfoliation pattern of their dentition and any alteration in the pattern should be consulted at the earliest. Regular examination is necessary to find out the cause for delay. Odontoma is one of the rare causes for delayed eruption of permanent anterior teeth and its immediate surgical intervention along with orthodontic treatment with regular follow-up is quintessential.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Shafer WG, Hine MK, Levy BM. A Textbook of Oral Pathology. 4th ed. Philadelphia: Saunders; 1997. p. 308-11.  Back to cited text no. 1
    
2.
Sreedharan S, Krishnan IS. Compound odontoma associated with impacted maxillary incisors. J Indian Soc Pedod Prev Dent 2012;30:275-8.  Back to cited text no. 2
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3.
Yadav M, Godge P, Meghana SM, Kulkarni SR. Compound odontoma. Contemp Clin Dent 2012;3:S13-5.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Shafer WG, Hine MK, Levy BM. Shafer's Textbook of Oral Pathology. Philadelphia, Pa, USA: WB Saunders; 1983.  Back to cited text no. 4
    
5.
Iatrou I, Vardas E, Theologie-Lygidakis N, Leventis M. A retrospective analysis of the characteristics, treatment and follow-up of 26 odontomas in Greek children. J Oral Sci 2010;52:439-47.  Back to cited text no. 5
    
6.
Suri L, Gagari E, Vastardis H. Delayed tooth eruption: Pathogenesis, diagnosis, and treatment. A literature review. Am J Orthod Dentofacial Orthop 2004;126:432-45.  Back to cited text no. 6
    
7.
Uma E. Compound odontoma in anterior mandible – A case report. Malays J Med Sci 2017;24:92-5.  Back to cited text no. 7
    
8.
Salgado H, Mesquita P. Compound odontoma – Case report. Rev Port Estomatol Med Dent Cir Maxilofac 2013;54:161-5.  Back to cited text no. 8
    
9.
Otsuka Y, Mitomi T, Tomizawa M, Noda T. A review of clinical features in 13 cases of impacted primary teeth. Int J Paediatr Dent 2001;11:57-63.  Back to cited text no. 9
    
10.
Angiero F, Benedicenti S, Parker S, Signore A, Sorrenti E, Giacometti E, et al. Clinical and surgical management of odontoma. Photomed Laser Surg 2014;32:47-53.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]



 

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