Abstract
Background: Odontomas are among the most common odontogenic tumors and are generally considered as hamartomatous odontogenic lesions. These tumors can be histopathologically divided into complex odontomas and compound odontomas based on their composition. Odontomas show a slow growing behavior and typically lack characteristic symptoms. The standard surgical treatment for large odontogenic tumors is a mandibular (continuity) resection followed by primary or secondary plastic reconstruction. Case Report: A 22-year-old male presented to the Department of maxillofacial surgery with an increasing feeling of pressure in the left mandible. An orthopantomogram revealed a large complex odontoma rg 038. Instead of mandible continuity resection an alternative minimally invasive technique/approach (intraoral) with a trapezoidal bone flap for the enucleation of an odontoma of the mandibular angle with subsequent flap reimplantation and osteosynthesis was performed. Conclusion: Surgical enucleation of large mandibular odontoma with a continuity resection through an extraoral approach represents the surgical standard treatment of this entity. The present case report describes an alternative minimally invasive technique/approach. This technique may reduce surgical risks of the continuity resection through an extraoral approach (nerve damage, scarring) and can improve the long-term stability of the mandible by bone preservation.
Along with ameloblastomas, odontomas are among the most common odontogenic tumors (1). Odontomas are benign tumors with a mixed epithelial-ectomesenchymal origin and are considered hamartomatous odontogenic lesions (2). Odontomas usually develop in a late stage of false odontogenesis and therefore consist of different odontogenic components. Consequently, odontomas can be histopathologically divided into complex odontomas and compound odontomas based on their composition (2). Odontomas can be found in both the maxilla and mandible. The compound odontoma in particular is often located in the anterior maxilla, whereas the complex odontoma is primarily located in the posterior mandible (2, 3).
A large proportion of these benign odontogenic tumors are diagnosed around the age of 20. As a rule, these tumors show a slow growing behavior while lacking characteristic symptoms. Odontomas may become clinically noticeable in the context of tooth eruption disorders (4). In individual cases, this can lead to an increased feeling of pressure with subsequent development of pain in the respective anatomical region (4). If an odontoma is suspected, radiological imaging (orthopantomogram, cone beam computed tomography scan, computed tomography-scan) can represent added value throughout the diagnostical process. Odontoma often appears radiologically as a sharply demarcated bony shadowing tumor within the respective jawbone, often associated with an impacted tooth (4, 5). The complex odontoma appears as an unorganized, inhomogeneous, partly cloudy mass in the orthopantomogram (5). The compound odontoma can present itself as an organized tumor made up of all natural tooth components (3-5). The final diagnosis can be reached through histopathological tissue processing. As an odontogenic tumor, the odontoma consists in particular of enamel, dentin, cementum, and pulp with a surrounding connective tissue capsule (2). Depending on the symptoms and severity of the odontoma, a distinction can be made between a conservative approach (clinical and radiological follow-up) and a surgical approach in the sense of enucleation (6, 7).
Depending on the location and extent of the odontoma, in some cases prophylactic osteosynthesis must be carried out in the respective jaw section as part of surgical enucleation. In the case of large odontogenic tumors of the mandibular angle in particular, a mandibular (continuity) resection with primary/secondary plastic reconstruction is sometimes necessary (8).
However, the present case report demonstrates that even with extensive odontomas of the mandibular angle, a minimally invasive technique using a crestal bone flap through an intraoral approach is an alternative for the surgical therapy of this entity. Written informed consent was obtained from the patient.
Case Report
The present case report describes a 22-year-old male who presented to the Department of Oral and Maxillofacial Surgery in the Army Hospital Hamburg for the surgical removal of wisdom teeth. In the last few weeks, the patient has felt an increasing feeling of pressure, especially in the area of the lower left jaw. The patient’s extended medical history was unremarkable. The clinical examination revealed an adult set of teeth with a clearly thickened, indolent bone structure in the area of the lower jaw rg 037 with vestibular emphasis. An orthopantomogram showed the impacted teeth 18, 28, 38, and 48 as well as a sharply defined bone-dense shadow coronal to tooth 38 (Figure 1).
Orthopantomogram showing the impacted teeth 18, 28, 38, and 48. Furthermore, in the area of the left mandible in position 037, a sharply delineated bone-dense shading can be found coronal to tooth 38.
In addition, a cone beam computed tomography of the affected region was performed, which revealed the spread of the finding rg 038 with close relation to the inferior alveolar nerve (Figure 2). Due to the clear radiological findings, a complex odontoma rg 038 was suspected. Squamous cell carcinoma, ameloblastoma and/or metastasis were considered as differential diagnosis for this finding. The odontoma as well as the impacted teeth 18, 28, and 48 and the new growth in the area of the jaw angle were removed under general anesthesia.
Preoperative cone beam computed tomography in an axial section shows the spread of the odontoma rg 038 close to the inferior alveolar nerve.
Due to the young age of the patient, a mandibular continuity resection was avoided and a minimally invasive intraoral approach was chosen instead (Figure 3, Figure 4). Using a crestal trapezoidal bone window rg 038, the odontoma, along with the impacted tooth 38, was extracted through enucleation, with exposure and protection of the inferior alveolar nerve (Figure 4). Furthermore, after tumor removal, the trapezoidal bone flap was reinserted and a prophylactic mini-plate osteosynthesis was carried out in the area of the left jaw angle (Figure 5). Histopathological tissue processing revealed a complex odontoma with no signs of malignancy (Figure 6). Tubular dentin with surrounding and enclosed fibrous stroma (black arrows) with nests and strands of ameloblastic epithelium (asterisks) and production of enamel matrix (red arrow) were found, ruling out the remaining differential diagnosis.
Intraoperative picture showing the odontoma in left mandibular angle after removal of the trapezoidal bone flap through an intraoral approach.
Intraoperative picture showing the status after complete removal of the odontoma. The trapezoidal shape of the osseous approach before flap reinsertion can be observed.
Postoperative orthopantomogram showing the complete removal of the impacted teeth 18, 28, 38, and 48 as well as the removed odontoma in the area of the left mandibular angle with inserted mini plate osteosynthesis along the linea obliqua. The two screws in the middle of the plate fix the trapezoidal bone flap.
Histopathology. Tubular dentin with surrounding and enclosed fibrous stroma (black arrows) with nests and strands of ameloblastic epithelium (asterisks) and production of enamel matrix (red arrow). The cleft-like empty structures (white arrow) correspond to originally mature enamel that was demineralized during histological processing. (Hematoxylin and Eosin after EDTA-demineralization, 20× magnification).
Initially, postoperatively, the patient showed slight hypesthesia of the left inferior alveolar nerve. Throughout the clinical follow-up, the hypesthesia showed signs of resolution, with no evidence of recurrence of the odontoma six months postoperative.
Discussion
The incidence of odontogenic tumors is up to 2% (9). Since the odontoma is a benign tumor, the prognosis for this odontogenic tumor after complete resection is very good. Recurrences after complete enucleation of odontoma are unlikely due to the fact that these benign tumors result from a malformation in the late phase of odontogenesis (2, 4, 6). This also often requires self-limiting growth, which can form the basis for a conservative approach (watchful-waiting strategy). Should the findings and symptoms progress during the conservative treatment of odontoma, surgical therapy can be carried out at any time. The spectrum of enucleation ranges from a partly mandibular resection to mandibular continuity resection (6, 8). 3D virtual operation planning with the production of computer aided design/computer aided manufacturing (CAD/CAM) planned resection templates can add value with regard to surgically precise tumor removal while preserving the bone, nerve, and other soft tissue structures (10, 11).
However, in the case of large odontomas, an extraoral approach is often required (e.g., submandibular) with the typical surgical risks (e.g., damage to the ramus marginalis mandibulae) and visible cervical scars. An alternative surgical treatment with regard to the described complications is the intraoral approach using a crestal-marginal incision in the area of the mandibular molars up to the area of the ramus mandibulae. Histologically, the morphology of a complex odontoma consists of tubular dentin, aggregates of enamel (matrix) as well as pulp tissue, slightly differentiating it from other benign tumors of the head and neck (5, 8).
Furthermore, in this case report, the enucleation was achieved via a trapezoidal designed crestal bone window with subsequent osteosynthesis of the reimplanted bone flap in the mandible. With regard to the preservation of bone structures, this can provide added value in terms of long-term stability of the mandible. However, these favorable conditions cannot always be achieved, especially in large odontomas. Sometimes complex and large osteotomies are required in order to achieve a complete excochleation.
Both the minimally invasive approach and the 3-D planned mandibular box resection can sometimes ensure that the inferior alveolar nerve is preserved (10). Regardless of the surgical technique, postoperative complications can include wound dehiscence, infections of the bone and surrounding soft tissue, as well as loosening of the osteosynthesis material and/or secondary fractures of the respective jaw area. The follow up of this entity usually consists of a clinical and radiological imaging (orthopantomogram). However, recurrences after complete enucleation are rare.
Conclusion
Odontomas are among the most common benign odontogenic tumors. Surgical enucleation of a mandibular odontoma with a continuity resection through an extraoral approach represents the surgical gold standard of this entity. The present case report describes an alternative minimally invasive technique/approach (intraoral) with a trapezoidal bone flap for the enucleation of an odontoma of the mandibular angle with subsequent flap reimplantation and osteosynthesis. In this manner, well-known surgical risks associated with the extraoral approach, such as nerve damage and scarring, can be avoided, and long-term mandibular stability can be enhanced through bone preservation.
Footnotes
Authors’ Contributions
KOH, WB, FB, and FD treated the patient and revised the article. FD researched the scientific literature, provided radiological findings, and wrote the article. AZK provided histopathological findings. All Authors gave final approval for publication.
Conflicts of Interest
The Authors have no relevant financial or non-financial interests to disclose in relation to this report.
Funding
The Authors declare that no funds, grants, or other support were received during the preparation of this manuscript.
- Received May 4, 2024.
- Revision received May 30, 2024.
- Accepted May 31, 2024.
- Copyright © 2024 The Author(s). Published by the International Institute of Anticancer Research.
This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY-NC-ND) 4.0 international license (https://creativecommons.org/licenses/by-nc-nd/4.0).
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