PMC7863995_01
a) Preoperative clinical intraoral photo showing buccal bulging opposite to the area of impacted left maxillary canine.
b) preoperative panoramic radiograph showing impacted left maxillary canines and two radiopaque masses distal to it.
c) preoperative periapical radiograph showing impacted canine, supernumerary tooth and radiopaque mass.
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On Intraoral clinical examination, both the maxillary canines were missing as well as the third molars, and there was a bulge on the buccal cortex of the missing maxillary left canine, which was asymptomatic ( Figure 1a). Panoramic radiograph revealed the presence of an impacted maxillary left canine and two small radiopaque masses distal to the impacted canine ( Figure 1b) and the periapical radiograph showed that the apical mass is a supernumerary tooth and the coronal mass is a rounded denticle like mass ( Figure 1c).
a) Coronal cone-beam computed tomography (CBCT) scan showing impacted left maxillary canine, supernumerary tooth and odontoma with continuous follicular space
b) Three-dimensional CBCT reconstruction showing palatal impacted maxillary left canine together with supernumerary tooth and odontoma
c) Sagittal CBCT scan showing odontoma occlusal to supernumerary tooth
d) Sagittal CBCT scan showing the proposed gubernacular canal (white arrow).
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There was a very small well defined rounded denticle like mass positioned distal to tooth #22 and coronal to the impacted supernumerary tooth (crown only), preventing its eruption. ( Figure 2a, b, c).
Intra-operative clinical picture showing surgical procedures to extract impacted maxillary left canine, supernumerary and odontoma
a) Labial approach to expose the odontoma.
b) Exposing the supernumerary tooth
c) Palatal approach to extract the impacted maxillary left canine
d&
e) Measuring size of odontoma, supernumerary tooth and follicular tissue.
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By access from the palatal region, the impacted canine was sectioned horizontally and extracted ( Figure 3 a, b, c), then the whole area was irrigated using normal saline and the flap was stitched back to its original position. Macroscopically, the calcified mass measured 0.7 x 0.5 x 0.3 cm ( Figure 3 d), while the soft tissue mass measured 1.9 x 0.4 x 0.3 cm ( Figure 3e).
Histopathologic examination of the excised mass showed a tooth-like structure with dentin (long arrow), and enamel matrix (short arrow) confirming the diagnosis of compound odontoma (
Figure 4 a,b). Histological examination for the soft tissue mass showed odontogenic epithelial lamina arranged in islands and cords and surrounded by collagenous connective tissue which confirms the diagnosis of gubernacular tissue (
Figure 4c) (100X).
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Histopathologic examination of the excised mass showed a tooth-like structure with dentin, and some enamel matrix confirming the diagnosis of compound odontoma ( Figure 4 a,b). Histological examination for the soft tissue mass showed epithelial lamina surrounded by collagenous connective tissue which confirms the diagnosis of gubernacular tissue ( Figure 4c).