|Year : 2017 | Volume
| Issue : 1 | Page : 28-32
Dental rehabilitation of patient with complex odontoma: A case report and review of literature
Parit Ladani, Angad Shetye, Megha Shah
Swiss Cleft and Craniofacial Centre, BSES MG Global Hospital, Andheri, Mumbai, Maharashtra, India
|Date of Web Publication||13-Feb-2018|
Dr. Angad Shetye
Swiss Cleft and Craniofacial Centre, BSES MG Global Hospital, Andheri, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Odontomas are the most common odontogenic tumors. These tumors are asymptomatic and are generally diagnosed on radiographic examination. The sole management depends on the early diagnosis, histopathological examination, and excision of the pathological tissue. This article presents surgical management of excision complex odontoma in 22-year-old female patient followed with prosthetic rehabilitation with dental implants for replacement of missing teeth. After excision, bone grafts may be necessary depending on the need for further treatment. The present case emphasizes that new bone formation can take place without using any graft materials for the placement of dental implants in a cases of benign pathology.
Keywords: Bone regeneration, complex odontoma, dental implants, odontoma
|How to cite this article:|
Ladani P, Shetye A, Shah M. Dental rehabilitation of patient with complex odontoma: A case report and review of literature. J Dent Implant 2017;7:28-32
|How to cite this URL:|
Ladani P, Shetye A, Shah M. Dental rehabilitation of patient with complex odontoma: A case report and review of literature. J Dent Implant [serial online] 2017 [cited 2020 Jan 24];7:28-32. Available from: http://www.jdionline.org/text.asp?2017/7/1/28/225399
| Introduction|| |
Odontomas are hamartomas of aborted tooth formation which account for 22% of the odontogenic tumors. They are the most common benign odontogenic tumors of epithelial and mesenchymal origin.
In general, odontomas occur more often in the permanent dentition. The lesions tend to be located between the roots of erupted teeth or between the deciduous and permanent teeth. Anterior maxilla, followed by anterior mandible and posteroinferior regions are the most common locations.
About 70% of odontomas are associated with pathologic changes such as impaction, malpositioning, aplasia, malformation, and devitalization of adjacent teeth. Compound odontoma is twice as common when compared to complex odontoma. Complex odontomas occur in mandibular 1st and 2nd molar region with slight or marked bony expansion.
Treatment of odontomas consists of simple enucleation and curettage. Care should be taken, not to harm adjacent teeth or damage the adjacent vital structures. The impacted tooth can be extracted or repositioned, orthodontic treatment or the tooth can be left for spontaneous eruption and postsurgical clinical and radiological evaluation is done to know the course of these teeth. On excision of odontoma along with the extraction of impacted tooth, the clinicians face a challenge for dental rehabilitation of the patient for not only for extracted tooth but also for missing teeth.
We present a case of a large complex odontoma with mandibular 3rd molar and missing 1st and 2nd mandibular molars. A complete surgical excision of the lesion was done along with the extraction of mandibular 3rd molar. The adequate bone formation was achieved without the use of any additional autogenous grafts or alloplastic materials to regain the integrity of bone structure, and the prosthetic rehabilitation of the patient was done with dental implants for replacement of missing teeth.
| Case Report|| |
A 22-year-old female patient was referred to our oral and maxillofacial surgery unit with the chief complaint of pain and swelling in the lower right back tooth region of the jaw for 6 months [Figure 1]. The patient gave a history of extraction of tooth with right mandibular 1st molar (46) 10 days back from a local dental practitioner. The patient had no other relevant medical history. The right submandibular lymph nodes were palpable and tender. Intraoral examination revealed healing socket with mandibular 1st molar 46 and slightly expanded buccal cortex distal to the mandibular first molar (46) with the apparent absence of the right mandibular 2nd (47) and 3rd molars (48) [Figure 2]. There was no pus discharge or any sinus tract formation.
|Figure 1: Preoperative view of swelling in lower right back tooth region of the jaw|
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|Figure 2: Intraoral view showing healing socket with mandibular 1st molar 46 and missing mandibular 2nd and 3rd molars|
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A panoramic radiograph was done which showed a well-circumscribed radiopaque lesion with density similar to calcified dental tissues, present coronal to impacted 48 with incompletely formed roots and missing mandibular 2nd molar and extraction socket of mandibular 1st molar [Figure 3] Based on clinical and radiographic presentations, a provisional diagnosis of complex odontoma was made. Surgical excision of the lesion with extraction of impacted 48 was planned under general anesthesia.
|Figure 3: Panaromic radiograph showing a well-circumscribed radiopaque lesion|
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After intubation, the patient was prepared as per routine surgical protocol. An intraoral incision was taken and the flap was raised to expose the angle and the body of mandible [Figure 4] As the mandibular 3rd molar was close to the lower border of mandible, a reconstruction plate was fixed along the lower border of mandible posteriorly from ramus of mandible and extending anteriorly up to 1st premolar 44, through trans buccal approach to prevent fracture of the mandible.
Excision of the lesion was done in toto and was separated from mandibular 3rd molar [Figure 5]. The extraction of 48 was then completed. Sharp bony spicules were nibbled and primary closure of the surgical site was done without any bone grafting. A 2 cm × 4 cm calcified lesion along with 3rd molar [Figure 6] was sent for histopathology examination which confirmed that the lesion was complex odontoma. Postoperative panoramic radiograph was done which showed the reconstruction plate along with intact lower border of mandible [Figure 7].
|Figure 7: Postoperative panaromic radiograph showing recon plate along with intact lower border of mandible|
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The patient was followed up at regular intervals and radiographs were taken. A radiopacity was observed in the region of the defect indicating good bone formation at 9 months [Figure 8]. A prosthetic rehabilitation was then done by placement of two dental implants 5 mm × 11.5 mm in the region of 46 and 47 [Figure 9]. Adequate amount of bone formation on the buccal and lingual aspect of the defect resulted in good primary stability of the implant. On 4-month follow-up, showed adequate bone formation around the implants [Figure 10] and the implants were uncovered and restorative procedure was performed with fixed metal-ceramic crowns and a proper occlusion was established [Figure 11].
|Figure 8: Postoperative 9 month panaromic radiograph showing radio-opacity in the region of the defect indication bone formation|
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|Figure 10: 4-month follow-up showing adequate bone formation around the implants|
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| Discussion|| |
Odontomas are benign odontogenic tumors, characterized by their slow growth and nonaggressive behavior. The complex odontomas are usually located in the posterior mandible, while composite odontomas are more often found in the anterior maxilla.
Most odontomas appear as small intraosseous lesions of calcified odontogenic tissues. Their growth is accomplished by gradual mineralization of the odontogenic tissue reaching a so-called mature stage when they are totally calcified. From that point, new episodes of growing are improbable. Because of this, odontomas are recognized as nonaggressive lesions with a limited growth potential.,
Complex odontoma is usually a hard painless mass. Most of these lesions are discovered accidentally on radiographic examination. The common signs and symptoms include missing permanent teeth and swelling as seen in our case, the patient had swelling and missing mandibular 2nd molar. The presence of odontomas may also lead to malpositioning or displacement of adjacent teeth, aplasia, malformation, and devitalization of adjacent teeth. Budnick found that 61% of cases are associated with impacted teeth.
Surgical removal with or without denudation of the impacted teeth has been usually performed for treatment of odontoma. The treatment options comprise surgical extraction, and surgical repositioning, orthodontic treatment or leaving the tooth for spontaneous eruption and postsurgical clinical and radiological controls to evaluate the course of these teeth.
Iatrou et al. in 2010 did a retrospective analysis of the characteristics, treatment, and follow-up of 26 odontomas in Greek children. All the odontomas were surgically removed, and related impacted permanent teeth were either left to erupt spontaneously, orthodontically guided into occlusion or were removed. They concluded that the impacted posterior teeth, the decision to maintain or remove them should depend entirely on the case; in their study, a majority of the posterior teeth were heavily involved with the tumor or severely malpositioned and had to be removed. In our case, the impacted tooth was malpositioned along the lower border of mandible, hence the tooth was extracted.
In the modern era, dental implants are extensively used for replacement of missing teeth. Adequate amount of bone formation is required in the area of defect for successful implant rehabilitation. There are still controversies on the use of graft materials before implant placement in large bony defects.
Review of literature presents several factors that may influence the process of bone formation. These include the development of new bone from periosteum , which serve the direct source of osteogenic cells, from scattered devitalized bony particles which serve as osteoinductors for mesenchymal cells in surrounding soft tissue, from mandibular stumps which also serve the direct source of osteogenic cells. It has been suggested that functional or mechanical stress on the stabilized stumps, immobilization, and a young age may have an influence in this bony regeneration process. In our case on post excision of the lesion, the cavity lined by periosteum was left intact. The cavity was closed primarily without placement of any bone graft material. As the patient was followed up an adequate amount of bone formation was seen.
Lee et al. in 2015 in two cases of large compound odontomas, used compound odontomas as graft material prepared chairside using a modified ultrasonic technology to fill the bone defects after enucleation of the lesion. They concluded that the two clinical cases showed favorable wound healing without complications, and good bony support for future dental implants or orthodontic treatment could be achieved.
Keeping into consideration the rare recurrence of the lesion and adequate bone formation in the area of the defect, a prosthetic rehabilitation was done by placement of dental implants. To the best of our knowledge, there has been no reported case in literature, of dental rehabilitation of the patient with implants following excision of odontoma.
Postplacement of implant, healing of the surgical site was uneventful which was followed by prosthetic rehabilitation.
| Conclusion|| |
This paper highlights that despite the large clinical manifestation, surgical excision of the lesion and closure of the defect primarily, leaving the periosteum intact, a good amount of bone formation can be achieved without the use of any bone graft material and prosthetic rehabilitation can be achieved with the dental implants.
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.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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