|Year : 2022 | Volume
| Issue : 2 | Page : 208-212
Management of compound odontoma with 70 denticles and impacted lateral incisor over an 8-year follow-up
J Jeevarathan1, NC Jananivinodhini1, A Ponnudurai1, M VijayaKumar1, Kanthaswamy A Chidambaranathan2
1 Department of Pedodontics and Preventive Dentistry, Sree Balaji Dental College and Hospital, Bharath University, Chennai, Tamil Nadu, India
2 CRA Dental Clinic, Chennai, Tamil Nadu, India
|Date of Submission||25-Mar-2022|
|Date of Decision||05-Jun-2022|
|Date of Acceptance||08-Jun-2022|
|Date of Web Publication||15-Jul-2022|
Dr. J Jeevarathan
Department of Pedodontics and Preventive Dentistry, Sree Balaji Dental College and Hospital, Bharath University, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Odontomas are benign developmental tumors formed by the improper growth of completely differentiated epithelial and mesenchymal cells of odontogenic origin. The etiology of odontoma is unknown and it is detected during routine radiographic examination. The ideal management is early detection and surgical enucleation. The commonly associated clinical problems of odontomas are delayed exfoliation of primary teeth, delayed eruption or impaction of permanent teeth, displacement of teeth, root resorption, congenital missing, and widening of follicular space. Here, we describe a unique case of compound odontoma with a high number of denticles managed based on a definite decision support system over 8 years. An 8-year-old boy with 70 denticles in the left maxillary region underwent enucleation. On periodic follow-up, the associated impacted lateral incisor was extruded orthodontically.
Keywords: Impacted teeth, multiple compound odontomas, orthodontic extrusion, retained primary teeth
|How to cite this article:|
Jeevarathan J, Jananivinodhini N C, Ponnudurai A, VijayaKumar M, Chidambaranathan KA. Management of compound odontoma with 70 denticles and impacted lateral incisor over an 8-year follow-up. J Indian Soc Pedod Prev Dent 2022;40:208-12
|How to cite this URL:|
Jeevarathan J, Jananivinodhini N C, Ponnudurai A, VijayaKumar M, Chidambaranathan KA. Management of compound odontoma with 70 denticles and impacted lateral incisor over an 8-year follow-up. J Indian Soc Pedod Prev Dent [serial online] 2022 [cited 2022 Aug 17];40:208-12. Available from: http://www.jisppd.com/text.asp?2022/40/2/208/351038
| Introduction|| |
Odontomes are mixed odontogenic tumors in which both epithelial and mesenchymal components undergo functional differentiation to form enamel and dentin. The term “odontome” was coined by Pierre Paul Broca in 1867 and he defined the term as tumors formed by the overgrowth or transitory of complete dental tissue. The etiology of odontoma is unknown but genetic factors, family history, and environmental causes such as trauma and infection have been suggested. They have also been associated with syndromes such as Basal nevus cell syndrome, Gardner syndrome, familial colonic adenomatosis, Tangier disease, Herrmann syndrome, or Odontoma–dysphagia syndrome. Odontomas can occur in any age group but are most commonly reported in the second decade of life and there is no significant difference between gender predilection.
The WHO (2005) classified odontomas into compound and complex. The compound odontoma forms multiple irregular teeth-like structures (denticles) which are arranged in a more orderly pattern, whereas the complex odontoma forms all dental tissues but occurs in a less organized pattern. There are numerous scientific reports documenting the variations in the number of denticles in both compound and complex types of odontomas.,, The majority of odontomas in the anterior segment of the jaws is compound in type (61%), whereas the majority in the posterior segment is complex in type (34%). Both types of odontomas occurred more frequently on the right side of the jaw than on the left (compound 62% and complex 68%). The compound odontome most frequently occurred in the incisor cuspid region of the upper jaw in contrast to the complex odontome which was commonly found in the molar and premolar region of the mandible. Henceforth, odontome is often associated with unerupted or impaction of permanent teeth.
Herewith, we present a case of long-term management of compound odontome with 70 denticles and associated impacted lateral incisor by orthodontic extrusion over an 8-year follow-up based on a decision support system [Figure 1].
|Figure 1: A decision support system for the management of the unerupted tooth|
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| Case Report|| |
An 8-year-old male patient was referred to the department of pedodontics and preventive dentistry, from a private clinic for the management of an unerupted upper left lateral incisor. Medical history was noncontributory but past dental history revealed that he had undergone extraction of 55 and 64 and a stainless steel crown in 65. Clinical examination confirmed the presence of retained deciduous upper left lateral incisor with no evidence of mobility. There was no visible or palpable expansion of the cortical bone. Intraoral periapical radiograph revealed the presence of multiple radiopaque masses resembling tooth-like structures apical to 62. Orthopantamograph also confirmed the same and 22 was positioned at the same level as 23 [Figure 2]. The management of the unerupted tooth was planned as per the decision support system. The patient underwent preoperative laboratory tests showing normal ranges and informed consent for the surgical procedure was obtained. Under general anesthesia, a full-thickness mucoperiosteal flap was elevated on the upper left quadrant and 70 odontomes of different sizes [Figure 3] along with 62 were removed without disturbing the underlying permanent teeth. As 22 was in Nolla stage seven, the patient was advised to be in periodic review every 6 months to monitor the eruption of 22. Intraoral periapical radiographs taken after 12 months showed continuous eruption of the lateral incisor with no other abnormalities in the periapical area [Figure 4]. On periodic follow-up over 4 years, all the permanent teeth erupted except 22. Clinical and routine radiographic examination was done and a cone-beam computer tomogram confirmed the labial position of the impacted 22 [Figure 5]. Study models showed the upper midline shifted toward the left side and 3.5 mm of space discrepancy for the eruption of 22. Since the development of 22 was in Nolla stage ten, orthodontic management of the same was decided considering the position and location. All the teeth were bracketed using a 022 McLaughlin, Bennett, Trevisi (MBT) system and initial leveling and alignment were completed using 0.012 and 0.016 NiTi wires. A surgical closed-flap eruption procedure was planned for extrusion of impacted 22. Under local anesthesia, a complete full-thickness flap was elevated to expose the impacted left lateral incisor which was then bracketed. A tie wire was attached to the bracket of 22 and the other end was attached to the 0.020 SS Archwire and it was periodically activated until the tooth was visible in the oral cavity [Figure 6]. The final alignment of the lateral incisor was completed without any complications [Figure 7] but the midline shift was only partially corrected. As the patient was very much satisfied with the outcome, debonding followed by an Essix retainer was delivered and reviewed periodically.
|Figure 2: Panoramic radiograph showing odontomes and apically placed lateral incisor and canine|
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|Figure 5: CBCT image showing the labial position of the lateral incisor, CBCT: Cone-beam computed tomography|
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|Figure 6: Midorthodontic treatment showing extrusion of the lateral incisors|
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| Discussion|| |
Odontomas are odontogenic tumors frequently seen in the oral cavity but due to their limited and slow growth, they are considered to be hamartomas in which all dental tissues (epithelial and mesenchymal cells) are represented, rather than benign neoplasm. They are usually asymptomatic as they can remain within bone for many years without producing clinical manifestations. The common associated clinical problems of odontomas are delayed exfoliation of primary teeth, delayed eruption or impaction of permanent teeth, displacement of teeth and roots, root resorption, congenital missing, and widening of follicular space. However, in our case, it was diagnosed as there was a delay in exfoliation of the upper left primary lateral incisor, and associated delay in the eruption of the upper left lateral incisor as the contralateral tooth erupted almost a year back.
Odontomas can be either compound or complex type, depending on the presence of odontogenic tissue. Compound odontomas show more predilection in the region of the anterior maxilla as seen in our case too, whereas the complex odontomas were more common in the mandibular anterior region. The occurrences on the right side of the arch are very common but in our case, it was on the left side. The number of denticles in compound odontoma varies in occurrence either as single or multiple. In our case, there were 70 intraosseous denticles were present. Hoang et al. reported a giant compound odontoma in the right mandibular canine region which comprised more than 100 denticles. In 2019, a group of surgeons in Saveetha dental college, India, reported the removal of 526 denticles from a 7-year-old child from the right mandibular region which was reported only in a few magazines and not in a scientific journal. Sharma et al. and Sharifi Rayeni et al. reported 37 and 62 denticles of compound odontoma in the right upper maxillary area., The treatments of choice for odontomas are surgical removal followed by a histological examination to confirm the diagnosis of the same. In our case, it was surgically removed and histological examination of the same confirmed it as multiple compound odontomas.
The optimal management of any impacted tooth should aim at conservation and repositioning of the same in the arch. According to An et al., the various treatments that have been carried out on the impacted teeth associated with the odontomes are surgical removal, orthodontic retraction, repositioning, no treatment, or regular follow-up. Here, in this case, we developed a decision support system for the management of the unerupted tooth considering the following factors such as interference due to physical obstruction, eruption pathway, developmental anomalies of the unerupted tooth, and stage of root development. After removal of the multiple odontomes which was the physical obstruction in our case, the upper left lateral incisor was not removed considering the age of the patient and Nolla stage of tooth development. At the age of 14, all the permanent teeth erupted but the upper left lateral incisor was impacted. The reason for the failure of eruption of the lateral incisor could be due to complete root closure and inadequate space in the dental arch. Orthodontic traction of lateral incisor was decided as a therapeutic approach for the patient as recommended by de Oliveira et al.
Clinical examination and cone-beam computed tomography confirmed the labial presence of the tooth. There are various labial approaches for the surgical exposures of the impacted teeth-like window/excisional approach/open technique, closed-flap approach, tunnel, and apically repositioned flaps. The position of the crown from the alveolus determines the type of surgical flap technique for exposure. The flap designs for surgical exposure should preserve the band of the attached gingiva and should guide the tooth to erupt through its natural path of eruption. If the crowns of the unerupted teeth are located apical to the mucogingival junction, the closed eruption technique will be ideal, as the open and apical repositioned flap might result in loss of excessive bone and very difficult to perform. A window or excisional approach can be performed only when sufficient gingiva is present, to provide at least 2–3 mm of attached gingiva over the erupted tooth. In our case, as the lateral incisor was apical to the mucogingival junction, we opted for the closed eruption technique. Various force elements can be used to extrude the impacted tooth into the arch including ligature wire, elastomeric chains, rubber bands, elastic threads, various springs, and even magnetic forces have been advocated. During surgical exposure and orthodontic traction of any impacted tooth, care must be taken to ensure that the periodontal attachment follows the tooth as it is guided into the arch. In this case, ligature wire was used and it was periodically activated until it erupted into the oral cavity. Similarly, a case of impacted central incisor associated with 50 denticles was managed surgically and extruded orthodontically using ligature wire immediately after diagnosis in a 10-year-old boy.
A space discrepancy of about 3.5 mm was required for the alignment of the impacted tooth when compared with the erupted contralateral lateral incisor. As the space requirement was very minimal, the incisor was completely aligned by dentoalveolar expansion in the anterior segment with fixed orthodontics. The patient was very much satisfied with the outcome of the result without much change in his profile even though there was 2 mm of midline shift still persist.
| Conclusion|| |
Odontomas are common odontogenic tumors usually associated with eruption disturbances in the permanent dentition. Hence, early diagnosis and surgical enucleation are the ideal management. However, meticulous follow-up both clinically and radiographically after enucleation plays a key role in the assessment of the associated eruption disturbances. The proposed decision support system will help to decide the long-term management based on the eruption pathway, developmental anomalies of the unerupted tooth, and stage of root development after enucleation.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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