Download Management of permanent maxillary central incisor impacted by

Fidalgo, et al.
2010
Braz J Health, 2010; 1: 215-221
Management of permanent maxillary central incisor
impacted by odontoma-like malformation:
48 months follow up
Manejo do incisivo central superior permanente impactado por odontoma:
48 meses de acompanhamento
Tatiana Kelly da Silva Fidalgo 1, Cristiana Aroeira Oliveira1, Marcia Pereira Alves dos
Santos 2, João Alfredo Farinhas 3, Laura Guimarães Primo 4
1
1PhD student, Universidade Federal do Rio de Janeiro, Departamento de Odontopediatria e Ortodontia, Rio de Janeiro,
RJ, Brasil; 2PhD in Dentistry, Universidade Federal do Rio de Janeiro, Departamento de Odontopediatria e Ortodontia,
Rio de Janeiro, RJ, Brasil; 3Master of Dentistry, Universidade Federal do Rio de Janeiro, Departamento de
Odontopediatria e Ortodontia, Rio de Janeiro, RJ, Brasil, 4Associate Professor, Universidade Federal do Rio de Janeiro,
Departamento de Odontopediatria e Ortodontia, Rio de Janeiro, RJ, Brasil
Abstract
This report describes management of delayed eruption of a central incisor caused by odontoma-like malformation. An 8year-old girl was referred to pediatric dentistry clinic due to failure of the maxillary central incisor. Patient suffered a
dental trauma at 36 months of age. Radiographic examination revealed an odontoma-like malformation. The odontomas
were surgically removed. Since spontaneous eruption of the maxillary right central incisor did not occur during the
subsequent twelve months after odontomas removal, surgery was carried out to expose tooth crown and to bond
orthodontic button on the unerupted tooth to traction it. After 48 months, permanent central incisor presented signals of
pulp vitality as well as the others adjacent teeth. Orthodontic management was successfully performed for correct
alignment of central incisor impacted by odontoma-like malformations.
Key words: Odontoma; Traumatism; Orthodontic management; Children.
Resumo
Este relato descreve o manejo de um incisivo central com atraso de erupção causada por um odontoma. Uma menina de
8 anos de idade foi encaminhada devido à atraso na erupção mesmo após realização de ulotomia. Paciente sofreu um
trauma aos 36 meses de idade. O exame radiográfico revelou a presença de odontoma que foram removidos
cirurgicamente. Uma vez que não ocorreu a erupção espontânea do incisivo central superior direito durante os 12 meses
vitalidade pulpar, bem como outros dentes adjacentes. O manejo ortodôntico foi realizado com sucesso para o
alinhamento correto do incisivo central impactado por um odontoma.
Palavras-chave: Odontoma; Traumatismo; Tratamento ortodôntico; Criança
Brazilian Journal of Health
v. 1, n. 3, p. 215-221, Setembro/Dezembro 2010
Page
dente incluso para posterior tracionamento. Após 48 meses, o incisivo central superior permanente apresentava sinais de
215
subseqüentes, foi realizada uma cirurgia para expor a coroa do dente e para colagem de um botão ortodôntico sobre o
Fidalgo, et al.
Case Report
An odontoma is a mixed tumor,
known
as
hamartoma
consisting
A 10-year-old Caucasian girl was
of
referred to the Pediatric Dentistry Clinic of
mineralized dental tissue malformations by
the Federal University of Rio de Janeiro in
ameloblasts and odontoblasts synthesis and
Brazil with a main complaint of lack of the
differs from a true neoplasm.1Among the
permanent maxillary right central incisor.
lesions found in the anterior region, 56% of
Her mother’s answers to anamnesis questions
the cases are located in maxilla.
is an asymptomatic lesion
3, 4
2
Generally
that is usually
and revealed that at 36 months the patient
suffered
an
intrusion
of
her
primary
found by chance and is often associated with
maxillary right central incisor but did
the delayed eruption of permanent teeth.2, 5, 6
received any treatment. When she was eight
Odontoma etiology is unknown, but it
years old, her primary maxillary right central
is believed that factors such as infections,
incisor was over retained and it was removed.
genetic mutations
Since the succedaneous tooth did not erupt,
and traumatisms
are
2
implicated. Traumatic injuries in primary
an
ulotomy
was
dentition during the developmental stages of
procedure was ineffective. Consequently the
a succedaneous permanent tooth interfere
child was referred to Pediatric Dentistry
with its future growth due to the close
Clinic. Medical history gave no relevant
relationship between the apices of primary
information
teeth and the buds of permanent teeth.7
classification was ASA I.
and
performed,
the
but
physical
this
status
Intrusion and avulsion are the most common
A clinical examination revealed a
trauma associated with development of
mixed dentition, absence of caries lesions,
permanent sucessors.1,8 Depending on the
lack of the permanent maxillary right central
morphogenesis of tooth development, could
incisor, and its space partially lost. Oclusal
develop a malformation tooth , such as
and periapical radiographic exams showed
enamel
crown
three radiopaque mineralized masses with
dilacerations and less frequently, odontoma
unspecific shapes (Figure 1) similar to an
could occur. 4, 7
odontoma-like
hypoplasia,
root
and
The aim of this case report is to
technique
9
malformation.
Clark’s
was used in order to identify the
mal position, which located it in the
malformation associated with permanent
vestibular region of the permanent maxillary
maxillary right central incisor and its 48
right incisor. Thus, surgical removal of the
months follow-up.
odontoma was planned.
Page
describe the management of odontoma-like
216
Introduction
2010
Brazilian Journal of Health
v. 1, n. 3, p. 215-221, Setembro/Dezembro 2010
Fidalgo, et al.
Figure 1: A - Occlusal radiograph showing three radiopaque masses.
B - Periapical image of complex odontoma associated with crown of
right maxillary central incisor.
The odontoma-like malformation was
removed
local
anesthesia
Figure 2: Radiographic image at the
start of orthodontic traction.
using
composite
a
light-cure
(TransbondTM
orthodontic
XT;
3M
(Lidocaine 2%, epinephrine 1:100.000, DFL,
Unitek/ESPE, Monrovia, USA). We bonded
Rio de Janeiro, RJ, Brasil) and under
orthodontic edgewise brackets (Morelli, Rio
conscious sedation due to patient non
de Janeiro, RJ, Brasil) on the permanent
cooperative behavior, with nitrous oxide. For
maxillary left central and right
conscious sedation, firstly it was introduced
incisors for anchorage and we used a push
100% oxygen for 2 minutes followed by
coil spring to recover lost space (Figure 2).
titration of nitrous oxide in 10% intervals.
Only the permanent maxillary right lateral
During nitrous oxide/oxygen analgesia, the
and left central incisors were used for
concentration of nitrous oxide was 20%.
anchorage for final alignment (Figure 3).
When
was
After thirteen months, the space has been
removed, nitrous oxide concentration was
recovered, the teeth aligned correctly and
decreased until the nitrous oxide flow is
then
terminated, thus 100% oxygen was delivered
removed (Figure 4).
odontoma-like
malformation
orthodontic
appliances
were
The child returned for follow up visits
Spontaneous
the
every three months, when we examined the
permanent maxillary right central incisor was
periodontal tissue health and carried out cold
expected during the subsequent four months;
thermal pulp vitality tests (Endo-Ice, Hygenic
however radiographic images showed a
Corp., Akron, Ohio). After 48 months, all the
slightly dilacerated root of the impacted
teeth involved in the treatment presented
tooth.
occur
signals of pulp vitality. Radiographic image
spontaneously, we carried out a second
showed a slightly dilacerated root, although
surgery to expose the tooth crown and to
clinically it presented without pathological
bond an orthodontic button on the unerupted
alterations (Figure 5).
Since
eruption
eruption
did
of
not
Brazilian Journal of Health
v. 1, n. 3, p. 215-221, Setembro/Dezembro 2010
217
for 5 minutes.
the
lateral
Page
surgically
tooth,
2010
Fidalgo, et al.
2010
Figure 3: Clinical image at the end of orthodontic traction.
Figure 4: A and B - Radiographic and clinical images of the right maxillary central incisor after 13 months of
orthodontic traction.
Figure 5: Right maxillary central incisor after 48 months. A – Radiographic image showing slight dilacerations on right
central incisor. B - Clinical image showing no pathological alterations.
DISCUSSION
in
primary
dentition during the developmental stages of
relationship between the apices of primary
teeth and the buds of permanent teeth.7
the succedaneums permanent tooth interfere
Intrusion and avulsion are the most
with its future growth due to the close
common trauma associated with development
developmental malformations of permanent
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v. 1, n. 3, p. 215-221, Setembro/Dezembro 2010
218
injuries
Page
Traumatic
Fidalgo, et al.
Depending
the
incisor presented over retention and its
morphogenesis of tooth development, it
successor did not erupt as expected. Removal
could result on tooth malformations, as
of the odontoma-like malformation without
enamel
disturbing the underlying tooth germ was the
hypoplasia,
dilacerations
root
and
on
and
less
crown
frequently,
odontoma.4,7
treatment goal.
2, 14, 15
As has been reported in
previous studies, the recurrence of an
Odontomas often disturb the eruption
of teeth and can cause retention of primary
odontoma is uncommon10, 16 even though, we
followed up the patient during 48 months.
teeth or abnormalities in tooth position, such
Usually, after odontoma removal the
as tipping or displacement of adjacent teeth
impacted tooth erupts normally until Nolla’s
and delayed eruption
of a permanent
stage 6. However, if the impacted tooth does
tooth,10,11 generally it is the cause of
not erupt, exposure of the tooth crown and
2
odontoma recognizing. In a study with 39
orthodontic traction should be applied. The
cases in Japanese children, the most frequent
observation
causes of odontoma’s discover were delayed
eruption usually is approximately 3 months
tooth eruption (49%), retention of the
after removal of the odontomas.12 About
primary teeth (28%), incidentally found on
9.0% of odontoma removals are followed by
radiographs (20%) and swellings of the jaw
orthodontic treatment.2 In the present case, 4
(3%).12
months after the removal of the odontomas
Katz13
reported
that
period
for
impacted
tooth
odontoma
the tooth had not erupted. Therefore an
diagnostic is apparently associated with age
orthodontic traction was performed and the
and location. According to Kaugars,
10
the
tooth alignment was successfully.
percentage of odontomas in the molar region
When an obstruction to tooth eruption
gradually increases with each successive
is detected, it must be removed and
decade of life. Those lesions from incisor
orthodontic treatment should be performed
locations are diagnosed and treated at an
when there is inadequate space in the dental
earlier age than those from the canine or third
arch for the proper positioning of a retained
molar regions. In the current case, the
tooth.17 In some cases spontaneous eruption
odontoma-like malformation was the cause of
can be observed after odontoma removal.18 In
delayed eruption of a permanent successor,
the present case, the patient was referred to
since the parents did not ask for treatment
the pediatric dentist at 8 years old and the
after the traumatic injury. The absence of any
eruption did not occur because formation of
radiographic follow up resulted in late
the root of the impacted tooth was complete
discovery of the abnormality and only
and provided little eruptive force.17,19 Thus,
occurred when the primary maxillary central
we carried out a surgery, under nitrous oxide
Brazilian Journal of Health
v. 1, n. 3, p. 215-221, Setembro/Dezembro 2010
219
8
Page
sucessors.1,
2010
Fidalgo, et al.
due to children difficult behavior,20
2.Hidalgo-Sanchez O, Leco-Berrocal MI, MartinezGonzalez JM. Metaanalysis of the epidemiology and clinical
manifestations of odontomas. Med Oral Patol Oral Cir Bucal
2008;13:E730-734.
to
expose the impacted tooth crown and to
traction orthodontically. In similar cases that
dental
root
is
under
formation,
2010
after
3.Amado Cuesta S, Gargallo Albiol J, Berini Aytes L, Gay
Escoda C. Review of 61 cases of odontoma. Presentation of
an erupted complex odontoma. Med Oral 2003;8:366-373.
odontoma removal surgery, there is chance of
spontaneous eruption. If it does not occur, the
4.Ferrer Ramirez MJ, Silvestre Donat FJ, Estelles Ferriol E,
Grau Garcia Moreno D, Lopez Martinez R. Recurrent
infection of a complex odontoma following eruption in the
mouth. Med Oral 2001;6:269-275.
ideal conduct is to perform ulotomy or
ulectomy and wait for spontaneous eruption.
The pediatric dentist must be knowledgeable
about
the
treatment
most
efficient
for each
disturbance
and
5.Neville BW DD, White DK, editors. Color atlas of clinical
oral pathology, 2nd ed. Baltimore: Williams & Wilkins
1999: 414-5.
suitable
dental development
scenario
and
to
6. Kuchler EC, Fidalgo TKS, Farinhas JA, Costa MC.
Developmental dental alterations in permanent teeth after
intrusion of the predecessors: clinical and microscopic
evaluation. Dent Traumatol 2010 (in press).
intervene
adequately.
Since odontomas represent a large
proportion of odontogenesis lesions, it is
1.
necessary to establish early diagnosis and
7. Andreasen JO. Injuries to developing teeth. In: Andreasen
JO, Andreasen FM, editors. Textbook and Colour Atlas of
Traumatic Injuries to the Teeth, 3rd edn. Copenhagen:
Munksgaard 1994:457–94.
treatment. In the present case report, we must 2.
3.
highlight that the sequelae caused by the
8. Budnick SD. Compound and complex odontomas. Oral
Surg Oral Med Oral Pathol 1976;42:501-506.
4.
trauma in primary dentition was managed by 5.
removing the odontoma-like malformation
and reestablishing the esthetics and function
of the impacted tooth.
6.
7.
8.
9.
Acknowledgments
The
authors
would
like
to
thank
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________________________________________
Recebido em: 08/08/2011
Aceito em: 24/02/2012
Endereço para Correspondência:
Laura Guimarães Primo
Disciplina de Odontopediatria da FO-UFRJ
Caixa Postal: 68066 - Cidade Universitária - CCS
CEP: 21941-971 - Rio de Janeiro, RJ –Brasil.
E-mail: [email protected]
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caused by intrusion of primary incisor--a case report. Dent
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v. 1, n. 3, p. 215-221, Setembro/Dezembro 2010