Jordi | Journal of Oral Diagnosis Online Submission Review an Article SOBEP - Sociedade Brasileira de Estomatologia e Patologia Oral
Volume 4 - 2019


Original Article

DOI: 10.5935/2525-5711.20180031

Compound odontoma associated to permanent teeth impaction in jaw: case report

Daniela Meneses-Santos1; Andre Silva Góis2; Klinger de Souza Amorim3; Ricardo Luiz Cavalcanti Albuquerque Junior4; Liane Maciel de Almeida Souza1

1. Universidade Federal de Sergipe - UFS, Dental School, Department of Dentistry, Aracaju, SE, Brazil
2. Maxillofacial surgeon, Center of Dental specialties, Aracaju, SE, Brazil
3. Universidade Estadual de Campinas -UNICAMP, Faculty of Dentistry of Piracicaba, Campinas, SP, Brazil
4. Universidade Tiradentes, Oral and Maxillofacial Pathology, Aracaju, SE, Brazil

Corresponding authors: Daniela Meneses Santos.
E-mail: danyymeneses@yahoo.com.br

Article received on November 16, 2018.
Article accepted on November 23, 2018.

 

ABSTRACT

The odontoma is a benign tumor of odontogenic origin, is considered a developmental malformation (hamartoma). The compound odontoma is formed by all tissues of a normal tooth arranged in an organized manner. Odontomas have slow growth and are not aggressive; most are asymptomatic, being diagnosed in routine radiographs. This study aims to present a case report of compound odontoma associated with impaction of permanent teeth in the jaw. Treatment opted for the surgical removal of the compound odontoma and permanent impacted teeth.

Keywords: Compound Odontoma; Impacted Teeth; Tooth Eruption; Mandible.

 

INTRODUCTION

Odontomas are odontogenics benigns tumors regarded as a development malformation rather than a true neoplasm1. The World Health Organization (WHO) ranked odontomas according to their histology in two types: the complex odontoma and the compound2. The Complex Odontoma is formed by several odontogenic tissues, which are arranged in a disorganized manner into a mass of calcified and mineralized dentin. Between the tissues may be observed enamel, cementum, small spaces containing pulp tissue and epithelial rest3,4. The Compound Odontoma is formed by all tissues of normal tooth neatly arranged5.

The etiology of odontoma is still discussed. Some predisposing factors have been suggested to explain its origin, such as the trauma of the tooth germ during development6, inflammatory and infectious processes and hereditary abnormalities (Gardner syndrome and Hermann syndrome)7.

Odontomas have slow growth and are not aggressive; most are asymptomatic, being diagnosed in routine radiographs with a radiopaque aspect1-6. The differential diagnosis of odontoma may be presented in the initial and intermediate stages, such as ossifying fibroma, periapical cementum dysplasia, adenomatoid odontogenic tumor and epithelial odontogenic calcifying cyst8. Radiographic, the compound odontoma may appear cluster of teeth, surrounded by a radiolucent area. By the other hand Complex odontomas reveal itself as opaque amorphous masses and also surrounded by a radiolucent zone9.

Compounds odontomas are commonly diagnosed on the anterior maxilla and resemble the structure of a tooth9. The compounds odontoma may be associated with impacted permanent teeth, and surgical removal would be the option to choose10. The prognosis after treatment is favorable with few cases of relapse11. The aim of this study is to report a case of compound odontoma associated with impaction of permanent teeth in the jaw and literature review.


CASE REPORT

A 18-year-old white female patient reported to maxillofacial surgery service of Dental Specialty Center, Aracaju / SE, Brazil for removal of impacted 3rd molars. During the anamnesis she did not report any systemic disease. At extra oral examination, the patient does not have facial asymmetry (Figures 1A-1B). However, the intraoral examination revealed asymptomatic bulging entrance in the gutter area in the lower-right premolar region (Figures 2A-2B). In the panoramic radiograph it is possible to observe the root resorption of the first deciduous lower molar, which was considered for the exodontia.


Figure 1. Extra oral examination (frontal 1A and lateral 1B view).


Figure 2. Intraoral examination (frontal 2A and oclusal 2B view).



In the panoramic radiographs was observed the existence of two primary teeth in the arch and the presence of a radio-opaque mass below those in the jaw right central incisor to 2nd premolar right. Moreover, it can be noticed the presence of two permanent teeth impacted just beneath the radio-opaque mass (Figure 3). The radiograph in lateral cephalometric can be observed radio-opaque mass and impacted dental element (Figure 4).


Figure 3. Panoramic X-ray showed radiopaque structures compatible with a provisional diagnostic of compound odontoma and the presence of two permanent teeth impacted just beneath the radio-opaque mass.


Figure 4. The radiograph in lateral cephalometric can be observed radio-opaque mass and impacted dental unit.



In computed tomography sagittal jaw section can be observed structures similar to the teeth. Right below it there are a 13 mm radiopaque lesion and two impacted teeth (Figures 5A-5B). Based on clinical and radiographic evaluation it was established the clinical initial diagnosis of odontoma. The patient received outpatient surgical indication under local anesthesia3-5.


Figure 5. Computed tomography sagittal jaw section can be observed structures similar to the teeth.



The patient was sedated with 15 mg of midazolam 30 minutes before surgery. The patient underwent outpatient surgery under local anesthesia with 4% Articaine with epinephrine 1: 100.000. In the surgical procedure several similar small teeth fragments were removed along with impacted teeth (Figure 6). The material was sent for histopathology (Figure 7). Postoperatively was prescribed Prednisone 20mg (2 tablets as a single dose after 8 hours). Amoxicillin 500mg was prescribed (1 tablet every 8 hours for 7 days), Ibuprofen 600mg (1 tablet every 8 hours for 5 days) and dipyrone Sodium 500mg in case of pain. The patient was instructed to do mouthwash Chlorhexidine to 0.12% (twice a day for 1 minute). The patient recovered well without reporting swelling or pain and returned to remove synthesis after eight days material. The patient is in clinical follow-up for 15 months and the injury does not relapsed.


Figure 6. In the surgical procedure several similar small teeth fragments were removed along with impacted teeth.


Figure 7. Histological blade.



DISCUSSION

Odontomas are the most common type of benign odontogenic tumors of the oral cavity12,13. They are considered a malformation (hamartomas) instead of a neoplasm. According to the WHO, it is a congenital defect in development, resulting in the growth of epithelial and mesenchymal cells fully differentiated tissues in dental14. In meta-analysis was possible to observe the occurrence of odontomas of which 61.3% are composed of odontomas and 37% complex. As for location, most lesions appear in the maxilla (56%) and mandible (44%)15. Odontomas has no predilection for gender and can occur at any age. Other studies point to a higher incidence in the first two decades of life5,16. In this case, the girl reported 18 years of age.

Odontomas are usually asymptomatic, but can cause problems in the eruption of primary teeth17, and the impaction or eruption of permanent teeth delayed9,18,19. The most common odontoma's defects on the dentition are permanent impaction teeth, followed by prolonged retention of the deciduous teeth and the adjacent teeth of the arch20. The odontoma's treatment is the lesion surgical removal then the histopathological study to confirm the diagnosis1,13. Operative excision is the best choice, since the odontoma are well encapsulated and can be easily enucleated from the surrounding bone17. To not interfere on mandible development, the odontomas at the retro molar area must been removed carefully and preserving bone structure from the ramus front edge21. Another factor that should be noted is that the removal of the odontoma and impacted teeth associated should advocate a conservative approach in order to preserve bone tissue for rehabilitation purposes10.

According to some authors10, impacted teeth associated with odontomas should be preserved and repositioned in the arc where possible aiming to restore the good occlusion. Other authors20,22, mention that there is no general agreement on the best management for impacted teeth associated with odontomas. In this case, the removal of the impacted tooth was needed because of his position was not favorable to the eruption.

In the literature it is common to find where in addition the surgical removal of the orthodontic odontoma permanent tooth extrusion was performed in order to avoid the deleterious effects of occlusion9. The spontaneous eruption of an impacted tooth after the removal of a supernumerary tooth or odontoma will depend on several factors, including the depth of impaction and the angle of compression in relation to the midline23. Even when there is no space enough for the teeth eruption, it may be necessary to increase the vertical space of the neighboring teeth. But if there is no expectation of erupting, the teeth should be removed11.

Some authors1 agree that odontoma composed must be diagnosed and removed as early as possible when it is associated with an impacted tooth, contributing to restoration of a good occlusion. The literature shows a significant relationship between patient age, and the preservation of permanent tooth impacted associated with odontomas20, that is, the younger the patient improves prognosis in grating the repositioning of the standing tooth in the arch. The panoramic radiograph regularly can help at an earlier diagnose of these anomalies24. Since most cases of odontoma are radiographic findings, and asymptomatic, it may print deleterious effects on the permanent dentition when the diagnosis is late. A retrospective study comprised of 1056 panoramic of individuals between 4-12 years old has shown that 43.2% had about oral lesions, between such injuries: supernumerary teeth, impacted and odontomas25.

Surgical excision of odontoma in an outpatient setting under local anesthesia in systemically healthy patients is a recurring practice26. So, to control the patient's anxiety level was administered midalozolam27. The midazolam has anxiolytic and amnesic properties and can be used as a safe drug in controlling anxiety in oral surgery28.

In conclusion, surgical removal of the compound odontoma is indicated, and the impacted tooth should be evaluated as to the real chances of spontaneous or traction eruption. The prognosis after treatment is favorable with few cases of relapse. The detection of asymptomatic odontomas as radiographic findings may lead to late diagnosis of the injury. This delaying the necessary measures for the reestablishment of good occlusion with respect to the impacted permanent teeth. Radiographic evaluation by panoramic should be indicated for tracking odontomas and prevent impaction of permanent teeth.


CONSENT

The authors state that the patient described in the case report consented to the publication of this case.


CONFLICT OF INTEREST

The authors declare no conflict of interest in the publication of this work.


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