| Abstract|| |
A young female sought treatment for a painful swelling in the right mandibular posterior region for the past 1 month with severe halitosis and paresthesia of right lower lip. Past history revealed that #46 was impacted due to an odontogenic tumor and an unsuccessful attempt was made to remove the impacted teeth and the tumor. A warm, tender, mild extra-oral diffuse swelling with right side cervical lymphadenopathy present. Intra-orally, there was a missing crown of 46 with a diffuse, tender buccal cortical expansion with a draining sinus. Imaging studies revealed a radiopaque lesion with a well-defined and rounded radiolucent halo. A provisional diagnosis of acute suppurative osteomyelitis was made and the remaining roots along with the radio-opaque material removed in toto via an open approach method and the entire area reconstructed with autograft harvested from rib. Histopathologically lesion was diagnosed to be a complex composite odontome. The challenges of diagnosis and the implication are discussed.
Keywords: Odontoma, Osteomyelitis, Impacted first molar, diagnostic challenge
|How to cite this article:|
Balaji S M, Balaji P. Large odontome compressing inferior alveolar nerve – A case report. Indian J Dent Res 2021;32:124-6
| Background|| |
Odontogenic tumors are rare and diverse lesions. Some of them, like odontomes and ameloblastoma are relatively more common, while lesions like cementoblastoma are rare. Odontomes are common benign odontogenic tumors arising from the epithelial and mesenchymal tissues of dental apparatus and often believed to be hamartomas. Usually these lesions are asymptomatic, presenting instead of a third molar or a supernumerary tooth. When sufficiently large they may cause cortical bone expansion, pain, facial asymmetry, impede eruption of another tooth or cause compression of the inferior alveolar nerve.
Radiology and histopathology aids in diagnosis and often the treatment of choice is complete surgical excision.,, Literature suggests that odontome involving permanent mandibular molars are rare. It is not uncommon for such lesions to be presenting to general dental practitioners. In such situations, diagnosis and management poses a substantial clinical challenge. This manuscript aims to report a case of mandibular odontome arising instead of a second molar and causing impaction of first molar and compression on the inferior alveolar nerve. The case was misdiagnosed as odontogenic tumor and an unsuccessful removal was attempted with the lesion and roots of the teeth being left in situ. The management of such a condition is presented.
| Case Report|| |
A 24-year-old, otherwise healthy female patient presented with a painful lesion in the right mandible for the past 2 weeks [Figure 1]a and [Figure 1]b. History reveals that 18 months back, patient sought treatment for a missing molar tooth. An exploratory imaging revealed an impacted first molar, partially formed second molar. Also, a well-defined completely radiopaque shadow of size 33.1 mm anterior-posteriorly, 21.6 mm superior-inferiorly and 20.7 mm bucco-lingually. The mass had a variable radiodensity surrounded by a peripheral radiolucent rim, pushing the teeth 47 as well as the inferior alveolar nerve canal.
|Figure 1: (a and b) Pre-operative view showing mild swelling due to associated buccal cortical expansion. (c-e) Imaging studies revealed a radiopaque lesion with a well-defined and rounded radiolucent halo, associated with the roots of the first molar involving the mandibular canal|
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The nerve canal was intimately in contact with the inferior surface of the lesion, at the region where the lesion was at its highest width. Further anteriorly, the nerve canal was seen to be located medial to the crown and roots of impacted 47. A working diagnosis of odontome was made. Patient was informed of the proximity of the mass to the nerve. Lesion and teeth were attempted for removal. However, the removal was incomplete, with removal of crown of 46, and parts of the lesion. The operating surgeon had to drill through the calcified mass to reach the impacted 46. The lesion was later diagnosed as cementoblastoma elsewhere.
Subsequently, the patient was advised to seek treatment from a specialty center after the diagnosis. Patient was lost to medical follow-up till date, as the patient remained asymptomatic.
At presentation, there was a mild extra-oral swelling, right-side cervical lymphadenopathy, severe halitosis and a recently developing parasthesia. Intra-orally, there was a missing crown of 46, intact 47 with spacing and an associated buccal cortical expansion with diffuse margins that was tender on palpation and with a draining sinus.
Imaging studies revealed a radiopaque lesion with a well-defined and rounded radiolucent halo, associated with the roots of the first molar involving the mandibular canal [Figure 1]c, [Figure 1]d, [Figure 1]e. A provisional diagnosis of acute suppurative osteomyelitis was made and the remaining roots along with the radio-opaque material removed in toto via an open approach method. The alveolar socket was thoroughly debrided of all granulation tissues, reconstructed with rib graft and sutured. Appropriate antibiotics and painkillers were provided.
The excised lesion was brownish and gritty in nature [Figure 2]a, [Figure 2]b, [Figure 2]c. Histopathologically, the lesion showed areas of vital and sequestered bones with basophilic reversal lines, surrounded by a stoma of fibrovascular tissue that exhibited interlacing necrotic bony trabeculae admixed with severe inflammatory cells composed of neutrophils, lymphocytes, plasma cells and foamy histiocytes, Also, the lesional tissues showed benign odontogenic tumor made of dentin and cementum as well as spaces suggestive of enamel spaces. There were areas showing odontogenic lining epithelium in association with fibrovascular connective tissues. Some of the foci of odontogenic epithelium that was in association with inflammatory cells exhibited ameloblastomatous proliferation [Figure 3]a, [Figure 3]b, [Figure 3]c, [Figure 3]d, [Figure 3]e, [Figure 3]f. A final diagnosis of complex composite odontome was made. As the tooth removal procedure involved complete excision of the lesion and curettage was done; only follow-up was advised. Patient remained lesion free for 12 months and continues to be in follow-up.
|Figure 2: (a) Bony defect following complete removal of radio-opaque material, (b) Bone defect reconstructed with rib graft and fixed with Titanium screw, (c) Excised specimen|
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|Figure 3: (a and b) Low power view of the lesion showing calcified structures of dental hard tissue, primitive odontogenic lining, active bone remodeling areas, inflammatory cells consistent with active suppuration (10X, H&E stain), (c and d). Section showing the dental apparatus with enamel spaces, dentin like material, and pulp core. (10X, H&E), (e) High power view of dentin-like structure showing dentinal tubules in cross-section. (40X, H&E), (f) Proliferation of the odontogenic lining in an ameloblastomatous fashion in association with chronic inflammation. (40X, H&E)|
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| Discussion|| |
The current case involves an odontome in the mandibular permanent first-second molar region, which is a rare location for odontomes. Though odontomes are the most common odontogenic tumours, they are more commonly associated with the canine and third molars than the first molar. Childhood trauma cannot be ruled out as a causative factor. According to reports, early trauma to dental apparatus can cause the formation of an odontome instead of a tooth, and such a developing odontome could also act as a physical barrier preventing the eruption of the right permanent mandibular 1st molar.
It is difficult to diagnose a mandibular radiopaque lesion in a young adult, that is in place of a missing tooth. Unfortunately, prior to presentation, an attempt had been made to remove the impacted adjacent tooth through the lesion, as in the current case. This could have served as a source of infection that subsequently turned into a suppurative osteomyelitis after 18 months. This inflammation, or pus, may have a negative impact on the adjacent nerve, resulting in paresthesia.
During surgery, the multiple teeth like elements were observed in the mass, prompting to revisit the diagnosis to an odontome, later confirmed by histopathology. Additionally there was ameloblastomatous proliferation in the lining, which could be related to the long standing inflammation and infection. The observation of the ameloblastomatous proliferation warrants further investigation as well as careful follow-up.
The case posed a challenge in diagnosis rather than management. Odontogenic tumors are known for diagnostic challenges, especially when there is not so normal histopathological presentation., In the present case, a simple straight forward diagnosis was missed leading to subsequent complications. It was the intra-operative observation and later histopathological findings that helped to arrive at the diagnosis. Based on presentation, simple odontogenic tumors such as odontome can pose a significant diagnostic challenge.
| Conclusion|| |
A case of misdiagnosed and managed odontome associated with permanent mandibular 2nd molar is presented. The successful identification of the odontome and the later rehabilitation of the lesion are presented. Uncommon presentation of common odontogenic tumors may pose surgical misadventure and the operating surgeon needs to correlate the clinical and radiological findings to successfully manage the case.
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.
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Conflicts of interest
There are no conflicts of interest.
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Dr. S M Balaji
Director and Consultant Oral and Maxillofacial Surgeon, Balaji Dental and Craniofacial Hospital, 30, KB Dasan Road, Teynampet, Chennai - 600 018, Tamil Nadu
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]