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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 12  |  Issue : 2  |  Page : 182-186

Odontoma in a young and anxious patient associated with unerupted permanent mandibular cuspid: A case report


1 Complex Operative Unit of Stomatological Surgery in Developmental Age, University of Campania Luigi Vanvitelli, Naples, Italy
2 Multidisciplinary Department of Medical-Surgical and Dental Specialties, University of Campania Luigi Vanvitelli, Naples, Italy
3 Department of Orthodontics, Faculty of Dentistry, Cranio Maxillofacial Research Center, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran

Date of Submission30-Oct-2019
Date of Acceptance16-Dec-2019
Date of Web Publication28-Mar-2020

Correspondence Address:
Dr. Paola Martina Marra
Complex Operative Unit of Stomatological Surgery in Developmental Age, University of Campania Luigi Vanvitelli, Naples.
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_287_19

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  Abstract 

Odontomas are among the most frequent odontogenic tumors of the jaws that generally appear as single or multiple teeth-like radiopaque lesions. As reported in the literature, they often interfere with tooth eruption and are usually discovered by routine panoramic radiographs. This case report shows a compound odontoma and the associated impaction of the underlying mandibular permanent right cuspid in an ASA II 10-year-old male Caucasian patient. Treatment plan involved surgical excision with histopathological analysis. No signs and symptoms were observed over 6 months of follow-up.

Keywords: Compound Odontoma, Impacted Tooth, Unerupted Mandibular Cuspid


How to cite this article:
Marra PM, Nucci L, Abdolreza J, Perillo L, Itro A, Grassia V. Odontoma in a young and anxious patient associated with unerupted permanent mandibular cuspid: A case report. J Int Oral Health 2020;12:182-6

How to cite this URL:
Marra PM, Nucci L, Abdolreza J, Perillo L, Itro A, Grassia V. Odontoma in a young and anxious patient associated with unerupted permanent mandibular cuspid: A case report. J Int Oral Health [serial online] 2020 [cited 2020 May 28];12:182-6. Available from: http://www.jioh.org/text.asp?2020/12/2/182/281494


  Introduction Top


Odontomas are odontogenic tumors of the jaws, defined as dental hamartomas because they are composed of both ectomesenchymal and epithelial elements with a different structure of cells. These tumors are usually asymptomatic, so most of the times they are discovered by routine radiographs.[1]

In the World Health Organization (WHO) classification of 2005, an odontoma can be classified as compound or complex.[2] Compound odontomas have enamel, dentin, and cementum appearing as distinct dental tissues, but there may be no complete demarcation of denticles. According to the literature, it usually takes place in the anterior maxilla. In complex odontoma, there is an irregular radiopaque area, where no elements are detectable. A line of corticalization splits these lesions from the normal bone. Its most frequent location is the mandible.[3]

Etiology is largely unknown, but hereditary, trauma, developmental issues, and infections have been proposed as the possible causes.[4] They can appear at every age, but the majority is discovered in the first two decades of life. Odontomas have no sex predilection, though some authors reported a slight predilection in males (59%).[3]

The treatment is generally surgical excision. An endodontic or orthodontic treatment may be indicated to manage the possible side effects. These benign masses usually show a positive evolution without relapse.[3],[4]

This case report correlates a compound odontoma, found in the anterior region of mandible, with an unerupted permanent mandibular cuspid in a 10-year-old ASA II patient.[5] The lesion was excised and the patient was followed up for a period of 6 months.


  Case Presentation Top


A 10-year-old Caucasian boy and his parents came to the Complex Operative Unit of Stomatological Surgery in Developmental Age of University of Campania Luigi Vanvitelli, in Naples, for a routine check. Patient’s and family’s general and stomatological anamnesis did not show any relevant data, as episodes of acute or chronic oral infections.

Intraoral examination revealed a mixed dentition, asymmetric dental arches, short lingual and hypertrophic maxillary frenulum, lower midline left deviation, proclination of the upper and lower incisors, presence of the lower right primary lateral incisor despite the eruption of all permanent mandibular incisors, absence of lower right permanent cuspid lost during a fall, and a poor hygiene with some caries [Figure 1].
Figure 1: Initial intraoral photos of the patient, showing mixed dentition, asymmetric dental arches, short lingual and hypertrophic maxillary frenula,and poor hygiene with some caries

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Moreover, extraoral examination did not show asymmetries, lesions, or face alterations. Mandibular tissues between the lower right primary lateral incisor and lower right first bicuspid were asymptomatic and did not show thickening. Therefore, an orthopantomography [Figure 2] has been requested, from which emerged an odontoma-like lesion. A cone beam computed tomography (CBCT) was requested [Figure 3] in order to differentiate the different structures, to make differential diagnosis with supernumerary teeth, and to provide location and size indications of the mass and its relationship with the other anatomical structures.
Figure 2: Initial panoramic X-ray suggesting a compound-odontomalike lesion in the anterior right side of the mandible, associated with the unerupted lower right permanent cuspid; the tooth’s crown is located between the neoplasm and the primary and permanent teeth

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,
Figure 3: Initial CBCT showing an irregular mass of 5 mm that extends in both vestibular and lingual directions. The proximity of the mass to the permanent cuspid’s crown is evident

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The CBCT revealed an irregular mass of 5 mm between lower right primary lateral incisor and lower right first bicuspid. This unknown structure progressed in both vestibular and palatal directions, and the lower right permanent cuspid below the mass showed an initial inclination of 40°.

The patient’s parents signed the informed consent. The treatment plan was based on a surgical approach to remove the mass. Before surgery, blood exams and cardiological and anesthetic examinations were performed. The patient was classified as ASA II due to the presence of epileptic phenomena, tension and anxiety, and absence of compliance. Therefore, it was chosen to proceed with balanced general anesthesia.

The anesthetic protocol, for this patient who weighed 60 kg, included the following:

  • Premedication with midazolam (3 mg/kg)


  • Propofol during the operating time (3 mg/kg), using an intravenous infusion delivery system


  • Intravenous betamethasone (4 mg/kg), dexamethasone (4 mg/kg), metoclopramide (10 mg/kg), amoxicillin/clavulanic acid (2 g/100 mL), paracetamol (1 g/kg), and ketorolac (30 mg/kg)


  • Local anesthesia.


An incision was performed from the distal part of lower right primary lateral incisor to the distal part of lower right first bicuspid. The mass was accessed through the removal of the vestibular cortical using piezosurgery. The site was preserved and constantly irrigated, protecting all nearby structures and teeth. The denticles extracted were four [Figure 4], which were smaller than normal teeth with a conical shape.
Figure 4: The four denticles extracted during surgery. Their morphology was not similar to the morphology of normal teeth, in that they were smaller and with a conical shape

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Finally, the flap was jointed with 4-0 non-resorbable suture, which was removed after 1 week. After waiting for the patient to wake up and for the end of local anesthesia’s effect, a vitality test was performed on the adjacent teeth to check if any damages occurred during the surgery.

Histopathological analysis revealed a non-oriented disorganized micro-fragments consisting of cement and dentin confirming the diagnosis of compound odontoma [Figure 5]. All sections were observed under a light microscope at 200× magnification.
Figure 5: Representative sections of the compound odontoma characterized by non-oriented disorganized micro-fragments consisting of cement and dentin. All sections were observed under a light microscope at 200Å~ magnification

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Patient’s parents had been informed about the need of orthodontic treatment, but for personal reasons, they preferred to wait few months before starting.

After 1 month, a new panoramic X-ray [Figure 6] was asked; cuspid’s inclination increased by 4° and its crown appeared very close to the apexes of the lower right central and lateral incisors.
Figure 6: Final panoramic X-ray showing the transmigration of the lower right permanent cuspid

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Six months after surgery, parents agreed to start the orthodontic treatment, so a new CBCT [Figure 7] was asked to identify canine’s location in order to perform its surgical exposure and hooking. This three-dimensional examination showed a root resorption of the lower right lateral incisor and the vestibular position of the canine that touches the adjacent tooth.
Figure 7: CBCT 6 months after surgery, showing the absence of the odontoma and the lateral incisor’s root resorption

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  Discussion Top


An elevated grade of morphodifferentiation characterizes these compound lesions.[6] The radiographic discovery of odontomas is based on their development stage and degree of mineralization. At the beginning, there is radiolucency because of the absence of calcification.[7],[8] Then, a partial calcification is observed, and at the end, it is possible to detect a mass generally similar to a radiopaque area surrounded by connective tissue.[8]

This case report agrees with literature reporting that compound odontomas are more frequently diagnosed in male subjects,[6] during the first two decades of life,[7] but unlike most studies, in this case, the anatomic region implicated was the anterior region of mandible and not the maxilla.[8]

According to Abrahams and McClure,[4] conservative surgical enucleation followed by curettage was the treatment of choice, especially when it concerns pediatric patients.

As can be seen from the first and second Panoramic X-rays, in only 1 month, the inclination and angulation of the lower right permanent cuspid was got worse by 4°. According to Mupparapu,[9] the type 1 of his classification of intraosseous transmigration and ectopic eruption of mandibular canines included canines positioned mesio-angularly across the midline within the jawbone, labial or lingual to anterior teeth, with the tooth’s crown portion across the midline. In this case, the canine is mesio-angulated with the crown near the 4.2. So, due to the uncertain prognosis of this tooth, the timely surgical and subsequent orthodontic approach was fundamental to avoiding further damages.

As many pediatric patients experience anxiety and fear of dental treatments, as in this case, sometimes general anesthesia is the only possible way to face this kind of situations.[10],[11] Propofol is one of the most ordinarily used anesthetic drug for procedural sedation in pediatric patients.[12] Moreover, this patient was classified as ASA II, was epileptic, and was very apprehensive. The postoperative period was without complications, also thanks to micro-vibrations of piezosurgery, which is usually used both in childhood and adulthood.[13],[14],[15] No nausea and excessive somnolence were noted after surgery. The denticles were completely removed, as can be seen in the second OPT and CBCT. The patient was discharged 180 minutes after the operation and came 1 week later to remove the suture points.

The probability of recurrence is quite low, because they are treated by conservative surgical approach. Furthermore, well-timed discovery and surgical enucleation followed by an accurate curettage are needed to avoid complications such as tooth loss and cystic variations.


  Conclusion Top


A case of an anxious and fearful patient with compound odontoma has been discussed using a specific anesthetic protocol according to his health general disorder. Surgical approach is the election treatment for this intraosseous lesion. Odontomas can cause impaction, malposition, and dislocation of proximal teeth. It is possible to mitigate these effects through early diagnosis and early surgical intervention that could alleviate the impact of complications.

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 initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgement

The authors thank the anonymous reviewers for their insightful suggestions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Poli PP, Creminelli L, Grecchi E, Pieriboni S, Menozzi G, Maiorana C. Anxiolysis in the surgical management of a compound odontoma in a pediatric patient. Case Rep Dent 2019;2019:1385150.  Back to cited text no. 1
    
2.
Praetorius F, Piattelli A. Odontogenic tumours. In: Barnes L, Eveson JW, Reichart P, Sindransky D, editors. World Health Organization Classification of Tumours: Pathology and Genetics of Head and Neck Tumours. Lyon, France: IARC Press; 2005.  Back to cited text no. 2
    
3.
Trejo-Remigio DA, Jacinto-Alemán LF, Leyva-Huerta ER, Navarro-Bustos BR, Portilla-Robertson J. Ectodermal and ectomesenchymal marker expression in primary cell lines of complex and compound odontomas: A pilot study. Minerva Stomatol 2019;68:132-41.  Back to cited text no. 3
    
4.
Abrahams JM, McClure SA. Pediatric odontogenic tumors. Oral Maxillofac Surg Clin North Am 2016;28:45-58.  Back to cited text no. 4
    
5.
Irlbeck T, Zwißler B, Bauer A. [ASA classification: Transition in the course of time and depiction in the literature]. Anaesthesist 2017;66:5-10.  Back to cited text no. 5
    
6.
Isola G, Cicciù M, Fiorillo L, Matarese G. Association between odontoma and impacted teeth. J Craniofac Surg 2017;28:755-8.  Back to cited text no. 6
    
7.
Owens BM, Schuman NJ, Mincer HH, Turner JE, Oliver FM. Dental odontomas: A retrospective study of 104 cases. J Clin Pediatr Dent 1997;21:261-4.  Back to cited text no. 7
    
8.
Katz RW. An analysis of compound and complex odontomas. ASDC J Dent Child 1989;56:445-9.  Back to cited text no. 8
    
9.
Mupparapu M. Patterns of intra-osseous transmigration and ectopic eruption of mandibular canines: Review of literature and report of nine additional cases. Dentomaxillofac Radiol 2002;31:355-60.  Back to cited text no. 9
    
10.
Practice guidelines for moderate procedural sedation and analgesia 2018: A report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology. Anesthesiology 2018;128:437-79.  Back to cited text no. 10
    
11.
Vetter TR. A comparison of midazolam, diazepam, and placebo as oral anesthetic premedicants in younger children. J Clin Anesth 1993;5:58-61.  Back to cited text no. 11
    
12.
Veselis R, Kelhoffer E, Mehta M, Root JC, Robinson F, Mason KP. Propofol sedation in children: Sleep trumps amnesia. Sleep Med 2016;27-28:115-20.  Back to cited text no. 12
    
13.
Vercellotti T, Nevins ML, Kim DM, Nevins M, Wada K, Schenk RK, et al. Osseous response following resective therapy with piezosurgery. Int J Periodontics Restorative Dent 2005;25:543-9.  Back to cited text no. 13
    
14.
Grassia V, D’Apuzzo F, Ferrulli VE, Matarese G, Femiano F, Perillo L. Dento-skeletal effects of mixed palatal expansion evaluated by postero-anterior cephalometric analysis. Eur J Paediatr Dent 2014;15:59-62.  Back to cited text no. 14
    
15.
Grassia V, d’Apuzzo F, DiStasio D, Jamilian A, Lucchese A, Perillo L. Upper and lower arch changes after mixed palatal expansion protocol. Eur J Paediatr Dent 2014;15:375-80.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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