Surgical Management of a Huge Odontoma in a 32‑Year‑Old Female Patient: Our Clinical Experience

[Downloaded free from http://www.urjd.org on Thursday, August 04, 2016, IP: 139.5.44.134]

CASE REPORT

Surgical Management of a Huge Odontoma in a 32‑year‑old Female Patient: Our Clinical Experience

Hemant Ashok Baonerkar, Meena Vora, Khushal Desai, Vinaya Kashid1 Departments of Oral and Maxillofacial Surgery and 1Conservative Dentistry and Endodontics, YMT Dental College and Hospital, Kharghar, Navi Mumbai, Maharashtra, India

ABSTRACT Odontomas are the most common benign odontogenic tumors. They are usually asymptomatic and are mostly discovered during the routine radiographic investigation. Histologically, they are hamartomas composed of different dental tissues that grows slowly are benign and behave in a nonaggressive manner. We hereby report a case of a 32‑year‑old female patient, who reported to our Department of Oral and Maxillofacial Surgery with a hard, nonpainful swelling in the lower right posterior region of the jaw.

KEY WORDS: Benign tumors, complex/compound odontomas, mandibular neoplasms, odontomas, radiopaque mass

INTRODUCTION unilocular, and they are separated from the normal bone by a well‑defined cortical line.[1] A complex odontoma “Paul Broca,” was the first person to use the term presents as an amorphous conglomeration of dental odontoma in 1867, who defined the term odontoma as a tissues consisting of enamel, dentin, pulp, cementum, tumor formed by the overgrowth of transitory or complete and enamel organ.[1] The treatment plan of choice dental tissues. is surgical removal of the lesion in toto, followed by histopathological study for final diagnosis. We hereby Odontomas are slow growing benign neoplasms present a case of a rare complex odontoma covering on representing about 22% of the odontogenic tumors found an impacted mandibular third molar in a 32‑year‑old in the jaws.[1] They develop from the epithelial as well as female patient. mesenchymal components of the tooth bud producing enamel and dentin.[1] They can occur anywhere in both the mandible or maxilla without any predilection for age CASE REPORT or sex, although they are usually found in conjunction A 32‑year‑old female patient reported to Department of with primary teeth.[2] Oral and Maxillofacial Surgery with a chief complaint of pain and mild swelling in the lower right posterior region Radiographically, odontomas are classified as complex of the jaw since 2–3 months [Figure 1]. The patient had and compound odontomas. The complex odontomas not undergone any treatment for the same. are less common than compound variety in a ratio of 1:2.[3] Complex odontomas are found in the posterior mandibular region, over impacted teeth and can Address for Correspondence: reach several centimeters. These lesions manifest Dr. Hemant Ashok Baonerkar, as a radiopaque solid mass with nodular elements, “Atharva”, Rl‑8, Milap Nagar, Midc Residential Area, Dombivali (East), Navi Mumbai, Maharashtra, India. [1] surrounded by a fine radiolucent rim. These are usually E‑mail: [email protected]

This is an open access article distributed under the terms of the Creative Commons Access this article online Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited Quick Response Code and the new creations are licensed under the identical terms. Website: www.urjd.org For reprints contact: [email protected]

DOI: How to cite this article: Baonerkar HA, Vora M, Desai K, Kashid V. 10.4103/2249-9725.174977 Surgical management of a huge odontoma in a 32-year-old female patient: Our clinical experience. Univ Res J Dent 2016;6:68-71.

Baonerkar, et al.: Surgical management of an odontoma

Intraoral examination revealed a palpable swelling anesthesia, and infiltration of lignocaine hydrochloride present in the lower 48 region measuring approximately with adrenaline 1:80,000, as the tooth could not be left 2 cm × 3 cm with buccal cortical expansion without behind as per the patient’s age, the growth potential had displacement of adjacent teeth. The mucosa overlying the been lost for eruption of the third molar. region was intact [Figure 2]. The required written consent was obtained from the The orthopantomography revealed a well‑defined patient as well as anesthesia. The patient was investigated radiopaque mass behind lower 47 [Figure 3]. for routine blood investigation as well as the required Cross‑sectional mandibular occlusal radiography showed radiographic investigation. buccal cortical expansion. The orthopantomogram showed the radiopaque mass surrounded by a thin The patient was taken to the operation theatre and was radiolucent rim with a completely impacted mandibular draped, cleaned, and prepared under the complete aseptic third molar below the radiopaque mass and without any protocol for the surgical procedure. Local infiltration was damage to the inferior alveolar nerve bundle. also given near tooth no 46, 47 on the Buccal aspect.

Considering the clinical and radiographic presentation, a A wards incision was taken a full thickness, a differential diagnosis of complex odontoma, ameloblastic mucoperiosteal flap was reflected in the 48 region. fibro‑odontoma, and other fibro‑osseous lesion was The bone covering the benign tumor was removed in considered. sweeping motion using an HP 6 round carbide bur and a micromotor. The odontoma was demarcated completely The treatment planned for the patient was complete and luxated from the surrounding bone with the help of excision of the hyperdense radiopaque mass along with the removal of the impacted tooth under general

Figure 2: Preoperative intraoral view

Figure 1: Preoperative facial profile of patient showing extra oral swelling on right angle of mandible

Figure 3: Preoperative orthopantomogram showing huge odontoma in right third molar region Figure 4: Surgically intraoral odontoma exposed

Universal Research Journal of Dentistry · January-April 2016 · Vol 6 · Issue 1 69 [Downloaded free from http://www.urjd.org on Thursday, August 04, 2016, IP: 139.5.44.134]

Baonerkar, et al.: Surgical management of an odontoma

Figure 5: Empty socket after excision of odontoma and third molar Figure 6: Excised specimen extraction

Figure 8: Specimen measured approximately 1 inch Figure 7: Postoperative wound closure DISCUSSION coupland elevator. The entire tumor was removed in toto, and the tooth was also extracted completely [Figures 4-8]. Odontomas, consider as a most common type of odontogenic tumors, although some prefer to refer it as The area was then cleaned and irrigated with betadine hamartomas, not a true tumor. The complex odontoma and normal saline, debridement was done with the help tends to occur in the posterior mandibular region of the of a curette, and the wound was closed using a 3.0 black jaw compared to compound odontoma, which are more silk suture material [Figure 7]. The suturing was done common in the anterior maxilla.[4,5] in a routine interrupted fashion. The patient was put on routine antibiotics, anti‑inflammatory, and analgesics for It presents with a radiopacity which is well defined and 3 days as a routine protocol and was recalled after 1 day situated in the bone, but with the density that is greater for follow‑up. than bone and equal or greater than that of a tooth. It contains the foci of various density.[6] The radiolucent halo The specimen was sent for histopathological examination of odontoma is typically surrounded by a thin sclerotic and after the examination, the reports confirmed the line surrounds radiopacity. diagnosis as complex odontoma overlying an impacted third molar. Root canal treatment was done for 47 for Odontomas have been associated with not only trauma its good prognosis by our endodontist. The patient was during primary dentition, but also with the inflammatory followed up for 6 months [Figure 9]. and infectious process, hereditary anomalies (Gardener’s

70 Universal Research Journal of Dentistry · January-April 2016 · Vol 6 · Issue 1 [Downloaded free from http://www.urjd.org on Thursday, August 04, 2016, IP: 139.5.44.134]

Baonerkar, et al.: Surgical management of an odontoma

distributed among males and females but the complex one has a 60% female predilection .[10]

CONCLUSION

Odontomas, they rarely erupt into the oral cavity and mostly associated with impacted teeth. Despite their benign nature, however, they may cause relative pain, infection, inflammation of the associated region, and pericoronitis of the overlying mucosa with a different Figure 9: Six months postoperative orthopentomogram clinical appearance. The treatment of choice is surgical enucleation of odontoma followed by histopathological analysis. In the case of odontoma associated with syndrome, Hermann’s syndrome), odontoblastic impacted tooth, the tooth should be preserved in situ, hyperactivities, and alterations in genetic components when a favorable path of eruption exists for the passive responsible for controlling dental developments.[7,8] eruption of the impacted tooth into the oral cavity. According to Hitchin, odontomas are inherited through Declaration of patient consent a Mutant gene or interference possibly postnatal with The authors certify that they have obtained all appropriate genetic control of the tooth development.[3] patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/ their images and The recommended treatment of the odontoma is other clinical information to be reported in the journal. through a conservative approach. As enucleation and The patients understand that their names and initials will curretage of the odontomas are curative, chances for recurrence are less if any portion of the lesion is left not be published and due efforts will be made to conceal unexcised, and such residues may remain unchanged their identity, but anonymity cannot be guaranteed. throughout life. Financial support and sponsorship Nil. The eruption of odontomas through mucosa may allow invasion of many oral microorganisms into the bone Conflicts of interest due to the lack of adequate adhesion between bone and There are no conflicts of interest. odontoma, because of the absence of periodontal ligament. Odontoma can measure approximately a few millimeters to many centimeters in their greatest dimension. The largest REFERENCES odontoma found in human weighed around 0.3 kg.[5] 1. Srivastava A, Annaji AG, Nyamati SB, Singh G, Shivakumar GC, Sahana S. Complex odontoma in both the jaws: A rare case report. Removal of large odontomas with the help of sagittal split J Orofac Res 2012;2:56‑60. osteotomy has also been described by Rittersma and van 2. Vengal M, Arora H, Ghosh S, Pai KM. Large erupting complex odontoma: A case report. J Can Dent Assoc 2007;73:169‑73. Gool in 1979. The advantage of SSO to gain access to large 3. Hitchin AD. The aetiology of the calcified composite odontomes. Br lesions of the mandible, rather than the usual technique of Dent J 1971;130:475‑82. 4. Neville BW, Damm DD, Allen CM, Bouquot JF. Odontogenic cysts and creating a large bony defect, includes less risk of intra‑ or tumors. In: Oral and Maxillofacial Pathology. 2nd ed. Philadelphia (PA): post‑operative fracture of the mandible and the possibility WB Saunders; 2002. p. 631‑2. of attaining primary wound healing.[9] 5. Mupparapu M, Singer SR, Rinaggio J. Complex odontoma of unusual size involving the maxillary sinus: Report of a case and review of CT and histopathologic features. Quintessence Int 2004;35:641‑5. Odontomas have the racial predilection with a higher 6. Cohen DM, Bhattacharyya I. Ameloblastic fibroma, ameloblastic reported incidence of around 65% of all odontogenic tumor fibro‑odontoma, and odontoma. Oral Maxillofac Surg Clin North Am 2004;16:375‑84. occurring in Caucasians and 6.67% in Chinese . Incidence 7. Ragalli CC, Ferreria JL, Blasco F. Large erupting complex odontoma. is low in Africans, whereas the majority of the odontogenic Int J Oral Maxillofac Surg 2000;29:373‑4. [10] 8. Ali Azhar D, Kota MZ, El‑Nagdy S. An unusual erupted complex tumors in the North America are odontomas. composite odontoma: A rare case. Case Rep Dent 2013;2013:106019. 9. Casap N, Zeltser R, Abu‑Tair J, Shteyer A. Removal of a large odontoma A mean age of diagnosis is around 14.8 years for compound by sagittal split osteotomy. J Oral Maxillofac Surg 2006;64:1833‑6. 10. Sharma U, Sharma R, Gulati A, Yadav R, Gauba K. Compound odontomas and 16 years for complex odontomas was composite odontoma with unusual number of denticles – A rare entity. found. Compound odontomas are almost equally Saudi Dent J 2010;22:145‑9.

Universal Research Journal of Dentistry · January-April 2016 · Vol 6 · Issue 1 71