DILATED ODONTOMA. DESCRIPTION OF THE CLINICAL CASE

ABSTRACT

Odontomas proved to be benign tumors but malignancy is also possible in about 5% of cases. Therefore, the most effective preventive measure consists of early diagnosis, thorough dental examination, radiographic study of patients with signs of delayed eruption, absence or temporary displacement of teeth, regardless of the presence of trauma in the medical history. This is most relevant for children and adolescents.

АННОТАЦИЯ

Несмотря на то, что одонтомы – это доброкачественные опухоли, примерно в 5% случаев возможно их озлокачествление. Эффективной мерой их профилактики является ранняя диагностика, тщательный осмотр стоматолога, рентгенография пациентов с признаками задержки прорезывания, отсутствия или временного смещения зубов, вне зависимости от наличия травмы в истории болезни. Это наиболее актуально для детей и подростков.

Keywords: dilated odontoma, invagination, extraction, diagnostics.

Ключевые слова: дилатированная одонтома, инвагинация, экстракция, диагностика.

The dilated odontoma occurs during development of tooth a part of enamel body acts or invaginates in a tooth nipple. Just after completion of development the affected and deformed tooth (expanded odontoma) contains the cavity in whole or in part covered by enamel, radiologically reminding tooth in tooth (dens in dente). The World Health Organization classifies this pathology as odontogenous tumor-like formations and distinguishes two forms of firm odontomas. All of them are characterized by chaotic location of different tissues of tooth: enamels, dentine, cement, pulp.

Odontoma is commonly assessed as a benign tumor of mixed genesis, consisting of a conglomerate of various, soft and hard tissues that form teeth and periodontal. Different components are found in the structure of the tumor - the epithelial islets of Malasse, parts of enamel, dentin, cement and pulp, individual elements of the mucous membrane. The odontoblastic activity of cells is the main cause of composite odontoma formation. It is the odontoblastic activity which leads to pathological changes in dental buds at the time of their growth and formation. And although these neoplasms are considered to be benign, in 4.0-5.7% of cases odontomas can develop into a malignant tumor [3, p. 84].    

The invaginated tooth occurs in permanent teeth of children and adolescents and has no sexual predisposition, the upper lateral incisor or upper anterior tooth being more often affected, as well as bilateral one [1, P. 49-50].

The causes of odontomas development remain not fully understood and studied, but however the following risk factors are usually distinguished:

1. injuries, bruises, jawbone cracks;

2. chronic infections of the jaw, oral cavity and nasopharynx (e.g. periodontitis, tonsillitis, jawbone osteomyelitis);

3. genetic predisposition to similar neoplasms [1, P. 51-52].

The degree of invagination may manifest as a small fossa on the palatal surface of the affected tooth. Over time, plaque and food residues accumulate in the defect, as a result of which tooth decay often occurs, which is followed by necrosis of the tooth pulp, abscesses or granulomas formation.

Teeth with extensive invaginations are often barrel-shaped, spike-shaped, or conical in form. The bulge in the cervical region can be expanded or divided into two parts, as well as have the shape of a tubercle.

The anomalies are often marked as symmetrical ones, so it is necessary to examine the eponymous tooth on the opposite side of the jaw. Since there is a repetition of the anomaly within one family, in case an anomaly is detected in one member of the family, it is necessary to examine other family members at the time of other abnormalities occurrence.

Sometimes the unfavorable shape of the tooth crown leads to slow the teething or retraction of the tooth.

In case the invagination is connected with a periodontal at the apex of the root, then pulpitis may develop as a result of a secondary ascending infection. Therefore, with such an anomaly, early diagnosis and preventive measures are extremely important.

Even in the absence of any complaints and symptoms in the area of such teeth, when invagination is detected or during subsequent preventive examinations, it is necessary to check the viability of the tooth pulp (it’s sensitivity), as well as regularly conduct X-ray control is recommended [6, P. 275].

Radiographs do not always recognize odontomas, and therefore only computed tomography is performed to confirm the presence of invagination. Today, Cone-Beam Computed Tomography (CBCT) allows a three-dimensional study of teeth with complex or abnormal anatomy of the root canals [4].

Treatment is primarily aimed at prevention, that is, at preserving the viability of the tooth pulp (it’s vitality). Treatment proves to be sometimes not simple one and depends on many factors: the viability of the pulp, and the condition of the periapical tissues; cross-country ability of the channels, complexity of the structure; functions and aesthetics [5].

If the clinical and radiological examinations indicate the presence of invagination, but no pathological changes are detected, then preventive measures must be applied. It is recommended to seal the invagination with a composite or material to seal the fissures.

In case the viability of the tooth pulp is preserved, but the radiograph shows a rarefaction in the periapical tissue area, it can be concluded that an infection penetrated the invagination, and there is a passage with a periodontal tissue in the apical or lateral region (it’s type III invagination according to the Ohlers classification). In such cases, the so-called treatment of invagination is indicated [5].

Once the pulp viability is preserved, oroparodontal passage is cleaned and, depending on the situation, it is closed using a composite, gutta-percha and siler, or MTA. Since the invagination inside is lined with enamel, the possibilities of using conventional tools to develop root canals are quite limited.

One more invagination is tooth with non-viable (devital) pulp and, possibly, with rarefaction in the periapical tissue area. This most often occurs in type II invaginations, when, as a result of tissue retraction, the infection penetrates the pulp of the tooth and leads to its necrosis. In such cases, endodontic treatment should be carried out both in the area of ​ the pulp of the tooth, and in the area of ​ ​ invagination [2, 5].

As a result of complete grinding of invagination, one wide root canal is formed, which makes it possible to properly disinfect and seal the root canal.

If it is not possible to eliminate invagination, then it can be very difficult to develop a root channel. In this case, treatment is carried out, both invagination and the root canal, which is located circularly between invagination and the walls of the root of the tooth. Additional difficulties can arise due to the wide apical opening or thin walls of the root.

In endodontic treatment, calcium hydroxide-based materials are used to temporarily seal the canal in order to maintain a disinfecting effect. It is recommended to use thermoplastic methods to obtain a three-dimensional and sealed root seal [2, P. 1754; 5].

To pre-close the wide apical opening, some authors recommend apexification, that is, filling the root canal with calcium hydroxide-based materials and leaving a temporary seal for several months. Currently, it is also recommended to use MTA (Mineral Trioxide Aggregate, Dentsply/Maillefer, Ballaigues, CH), which is highly biocompatible [7, p. 420].

After the endodontic treatment is completed, a sealed and anti-bacterial restoration of the tooth crown is carried out. Subsequently, it is necessary to conduct regular dispensary control.

Surgery is performed in three ways:              

- enucleation (the odontoma and the damaged tooth are completely removed);

- curettage (tumor scraping is carried out with a special tool);

- resection (the jaw fragment is removed in case of extensive damage or recurrence of the tumor).

Tooth extraction with a dens invaginatus abnormality is only necessary in rare cases. Tooth removal surgery is shown only in cases where it is impossible to conduct endodontic treatment either by conservative or surgical methods in the following cases: supercomplete teeth (mesiodens); insufficient opportunity to restore the clinical crown of the tooth; too abnormal the internal structure or external shape of the roots and a very wide apical opening.

Clinical case. The mother and 12-year-old child received an appointment for severe pain in the mandible on the right with irradiation to the head and formation of a fistula on the oral mucosa in the tooth area 4.6.

The examination revealed 4.6, 4.7 intact teeth. Probing, temperature and percussion reactions were painless. Tooth 4.7 was in the tearing stage.

Additional X-ray examination revealed no pathology. The patient was diagnosed with acute pericoronitis in the tooth area 4.7 (К05.22).

The prescribed treatment was not effective and later a fistula formed.

Figure 1.                    Figure 2.

X-ray examination didn’t reveal any pathology (Figure 1,2).

Periostotomy with fistula revision was performed, granulation was performed, but the source of inflammation was not detected. And only after conducting and careful study of CBCT was it found: death of the sprout zone, an extensive periapical focus of bone destruction with destruction of the external cortical plate of bone tissue, anomaly of the shape of the roots of the tooth 4.7, unclosed apical holes in the area​, the formation of an oval shape in density similar to the tissues of the tooth.

The patient was diagnosed with chronic retrograde tooth periodontitis 4.7 (K04.5). Delated odontoma (Invaginated tooth 4.7) K00.25.

Tooth 4.7 was removed, well curettage and hemostasis were performed.

Figure 3.                            Figure 4.                      Figure 5.

Curettage and hemostasis were performed (Figure 3,4,5)

The above clinical case demonstrates the need for a thorough comprehensive examination of both children, and adults in order to identify and optimal treatment of this pathology.

Early diagnosis helps to avoid more complex and expensive treatment, provides a better prognosis, minimizes the risk of recurrence, and avoids tooth removal. The basis of prevention is a regular visit to a dentist, sanitation of foci of chronic infection, regular medical examinations.

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