Research Article ISSN 2639-9490

Oral Health & Dental Science

Management of Impacted Mandibular Lower Canine Associated with

Odontoma: Interdisciplinary Approach
Hayder A. Hashim1, Abdulmuean AL-Gahtani2, Noof AL-Obaidli1 and Mohamed H. Hashim3

Hamad Medical Corporation, Rumaila Hospital, Hamad

1
Correspondence:
*
Dental Centre, Orthodontic Division.
Professor Hayder Abdallah Hashim, Hamad Medical Corporation,
Head of Dental department, Hamad Medical Corporation, AL-
2 Rumaila Hospital/ Hamad Dental Centre, Orthodontic Division,
Khor Hospital. E-mail: [email protected].

3
University of Khartoum, Dental College. Received: 12 Jan 2024; Accepted: 25 Feb 2024; Published: 03 Mar 2024

Citation: Hashim HA, AL-Gahtani A, AL-Obaidli N, et al. Management of Impacted Mandibular Lower Canine Associated with
Odontoma: Interdisciplinary Approach. Oral Health Dental Sci. 2024; 8(2); 1-8.

ABSTRACT
Odontomas are common benign calcified tumors and the most prevalent type of odontogenic tumors. They can
be categorized into complex and compound odontomas. Typically, odontomas do not cause any symptoms and
are often incidentally discovered. However, in certain instances, they may present with signs and symptoms. The
management of odontomas involves early detection, histopathological examination, and surgical removal of the
affected tissues. This case report presents a 12-year-old female patient with delayed eruption of the lower right
permanent canine in comparison to the corresponding tooth on the left side. Radiographic examination revealed a
radiopaque image surrounded by a radiolucent area in the right buccal segment between the right lateral incisor
and right first premolar. The clinical diagnosis was determined to be a compound odontoma. Interestingly, the
radiograph also showed a completely developed impacted right mandibular canine situated horizontally near the
lower border of the mandible, beneath the odontoma. This article highlights a case of impacted permanent canine
associated with an odontoma and provides a brief overview of odontomas and impacted canines. It emphasizes
the interdisciplinary approach between an orthodontist and an oral surgeon for the successful management of
such cases. Early diagnosis and proper coordination between these specialists are crucial in achieving optimal
outcomes for the patient.

Keywords In a retrospective study conducted by An et al. [3], 73 cases of

Impaction, Odontoma, Interdisciplinary approach, Surgical impacted permanent teeth associated with odontomas were
removal. evaluated. The majority of odontomas (84.9%) were treated with
surgical removal, and the impacted permanent teeth linked to
Introduction and Review of Literature odontomas were managed through various approaches. Surgical
Odontoma is classified as a benign odontogenic tumor that removal was the most common treatment method (53.2%), followed
belongs to the group of odontogenic epithelial tumors involving by orthodontic treatment (25.5%) and surgical repositioning
the formation of mineralized tissues [1,2]. However, despite its (6.4%). In some cases, impacted teeth were successfully saved
tumor classification, odontomas are clinically regarded as tumor- through orthodontic treatment, surgical repositioning, or allowing
like formations (hamartomas of dental tissues) or developmental for normal eruption, amounting to 23 teeth in total. The study
anomalies, rather than true odontogenic neoplasms. They are most found that all impacted teeth were preserved in patients under 9
commonly identified during the second decade of life and are years old, whereas all impacted teeth were removed in patients
typically found in the anterior region of the maxilla [3]. Odontomas over 30 years old. Only 7% of the cases exhibited spontaneous
are frequently asymptomatic and are often linked to the abnormal eruption of impacted teeth. Tooth impaction refers to a situation
eruption of neighboring teeth [4]. Among odontogenic tumors, in which a tooth does not erupt properly due to a mechanical
odontomas make up approximately 22% of cases [5].

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obstruction, causing it to remain unerupted beyond its expected When odontomas are identified as the cause of impaction, the
eruption time [6]. The occurrence of impacted primary teeth in preferred treatment involves surgical removal in both primary
the population ranges from 1.3% to 8.9%, with a notably higher and permanent dentition. Early removal of odontomas without
incidence observed among siblings [7-9]. However, the primary disturbing the underlying tooth germ can result in spontaneous
mandibular molars are affected more frequently than maxillary eruption of the impacted teeth. However, in some instances,
molars, with the former being impacted over 10 times as often as orthodontic traction may be required [17,26,27]. Additionally, in
the latter [10]. certain cases, the impacted teeth underlying the odontomas may
be extracted concurrently with the removal of the odontomas [28].
Pediatric dentists encounter the problem of permanent tooth Moreover, in patients where only the odontoma is removed, the
impaction more frequently than that of primary teeth. The primary molar is typically kept under observation to monitor its
occurrence of impaction in anterior primary teeth is exceptionally eruption.
rare. Similarly, total impaction is an infrequent condition [11-
13]. Impaction can be categorized as primary, where the teeth fail In the literature, there have been a few reported cases of complete
to erupt at all (referred to as primary failure of eruption), or as impaction of permanent mandibular canine caused by odontoma.
secondary, where previously erupted teeth become impacted again The objective of this paper is to present the management approach
due to various factors. Primary failure of eruption is diagnosed when employed for a patient with complete impaction of permanent
the unerupted tooth is covered by intact mucosa, and radiographic mandibular canine caused by odontoma.
images reveal the tooth to be deeply embedded in the jawbone
[14]. Secondary failure of eruption occurs when a permanent tooth Case Report
is unable to erupt due to factors such as retained deciduous teeth, A 12-year-old female patient sought dental care due to a toothache
odontomas, cystic lesions, or supernumerary teeth. Impaction can on her lower left side. A pantographic radiograph revealed deep
be attributed to both systemic and local factors [15]. caries on tooth lower left permanent first molar alongside the
presence of an odontoma and an impacted lower permanent canine.
Local factors encompass developmental abnormalities such The lower left permanent first molar tooth underwent endodontic
as malposition, dilaceration, ankylosis, tumors, odontoma, treatment. After finishing the endodontic treatment, the patient was
dentigerous cysts, and supernumerary teeth. On the other hand, referred to an oral surgeon for the removal of the odontoma and
systemic-genetic factors may be associated with conditions like the impacted lower right permanent canine. Following the surgical
cleidocranial dysostosis and hypopituitarism [16,17]. Odontomas procedure, the patient was directed to the orthodontic department
have been identified as a significant cause of impacted primary for closing the space left by the extracted right permanent canine
teeth in early reported cases [15]. Odontoma is classified as an and addressing teeth crowding. Notably, the patient's medical
odontogenic tumor that frequently leads to disruptions in tooth history showed no significant influence on her dental condition.
eruption, including impaction, delayed eruption, or retention The patient was referred to the first author for completion of the
of primary teeth [18,19]. The literature has documented various orthodontic treatment. No photograph taken before treatment.
locations of odontomas in association with primary molars, such as Figure 1 showed the time of receiving the case. Revaluation of the
between the roots of a lower right second primary molar, between case was done and suggesting extraction of upper right permanent
the crowns of the upper first and second primary molars, above first premolar in order to achieve class I molar and canine on the
the crown of the lower right second primary molar, and above the right side (compensatory extraction).
unerupted upper second primary molar [20].
Intra oral examination
They are included under the benign calcified odontogenic tumors. Intraoral examination revealed that the patient is in the late mixed
Odontomas are basically classified into two types, complex and dentition stage. All the permanent teeth erupted except 13, 23 and
compound odontomas. Various theories or etiological factors are 43. Lower left first molar was endodontically treated.
been quoted for the occurrence of Odontomas. Generally, they are
asymptomatic. Occasionally, signs and symptoms relating to their Radiographic findings
presence do occur. The sole management depends upon the early Panoramic image revealed the presence of all permanent teeth
diagnosis, histopathological examination and excision of these in both jaws as well as impacted lower right permanent canine
tissues [21-24]. Various treatment options are available for impacted and presence of odontoma surrounded by radiolucent area. Lower
deciduous or permanent teeth, and these include extraction of the left first molar was endodontically treated. Upper right and left
primary tooth with subsequent follow-up without intervention. permanent canines were in the right path of eruption. All upper
However, it is crucial to closely monitor the eruption process [25]. and lower third molars roots were not developed. The mandibular
Another treatment approach involves surgical exposure or surgical right permanent canine with 2/3 of root development was pushed
repositioning, with or without orthodontic traction. In certain very close to the lower border of the mandible. Based on these
cases, surgical removal of the impacted permanent tooth may be radiographic findings, the patient's dental condition is complex
necessary [26]. and may require a multidisciplinary approach involving an
orthodontist, oral and maxillofacial surgeon, and possibly an oral

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 Figure 1: Illustrate the patient during treatment and canine space closure.

pathologist. The treatment plan will likely involve addressing Figure 3 depicted removal of the odontoma and the impacted
the impacted lower right permanent canine tooth, evaluating lower right canine. There was a round shaped radiolucent area
and managing the odontoma, and considering the position of the after surgical removal of both the odontoma and the impacted
mandibular right permanent canine Figure 2. lower right canine.

Diagnosis
The provisional diagnosis was; Class I malocclusion type 1
associated with impacted Lower permanent canine due to presence
of odontoma tumor impeding the eruption of the right mandibular
permanent canine.

Treatment Objectives
a) Removal of the impacted right mandibular permanent canine
and the odontoma.
b) Regular follow‑up every 6 months to monitor the new bone
formation
c) Orthodontic treatment
Figure 2:
Surgical Procedure
Patient was referred to the oral and maxillofacial surgery
department. The odontoma and the impacted lower right canine
were surgically removed under general anesthesia (Figure 3). It is
important for the patient to follow post-operative care instructions
provided by the surgeon to promote proper healing and reduce the
risk of complications. This may include maintaining good oral
hygiene, taking prescribed medications, avoiding certain foods
that could disrupt the surgical site, and attending scheduled follow-
up appointments.

Post-surgical and follow ups

The recovery was uneventful and intraoral healing was satisfactory.
Patient was followed‑up regularly to monitor new bone formation.
After the odontoma and the impacted canine are removed, the
body initiates a healing response. The surrounding bone begins to
Figure 3:
fill in the space left by the removed structures through a process

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called bone remodeling. During this healing phase, the radiolucent steel provides more stiffness and control, which is beneficial for
area may appear on radiographs as the bone fills in and remodels fine-tuning tooth positions during the finishing phase. It's important
to restore normal bone architecture. At 9 months follow‑up after to emphasize that the choice of arch wires and the treatment plan
surgery; another OPG was done. The radiograph revealed the can vary depending on individual patient needs.
presence of new bone formation Figure 4.
Retention phase
The patient has been advised to wear both upper and lower vacuum
retainers throughout the entirety of the first year, with exceptions
made only for eating or consuming hot beverages. Moving into the
second year, the patient has ceased wearing the retainers during
the day but continues to wear them nightly before bed. However,
if the patient encounters resistance when inserting the retainer,
it suggests that the bone and periodontal fibers have not fully
stabilized. In such cases, it is recommended that the patient resume
wearing the retainers throughout the day until they can be inserted
without any resistance, indicating proper organization of the bone
and periodontal tissues.

Treatment Result
The post-treatment results indicated the following:
a. Closure of the lower right canine space:
Figure 4: Presence of new bone formation at the surgical site. The space left by the impacted lower right canine was closed,
likely due to the mesial movement (towards the midline) of the
Orthodontic Treatment adjacent premolars and the first molar. This means that the teeth
Orthodontic treatment using the MBT prescription with a 0.022- adjacent to the missing canine (premolars and first molar) were
inch slot size. Specific sequence of arch wires for the different repositioned to fill in the gap left by the impacted tooth.
phases as follows:
b. Class III molar relationship on the right side:
Leveling and Alignment Phase: A Class III molar relationship means that the lower molars are
During this initial phase, the primary goal is to align the teeth and positioned more forward than the upper molars. This might be the
level the arches. The two arch wires commonly used are: result of the mesial movement of the lower premolars and first
A. 0.016 Nitinol Round Arch wire: Nitinol is a flexible, nickel- molar. The Class III molar relationship is not the ideal occlusion,
titanium alloy wire that allows for gentle tooth movement during and it can affect the alignment of the jaw and how the teeth come
the early stages of treatment. together during chewing and biting.
B. 0.016 Stainless Steel Round Arch wire: Stainless steel is a stiffer
wire that provides more control and helps to further align the teeth. c. Class I relationship on the left side:
The upper left canine and first molars were in a Class I relationship,
Space Closure Phase: which is the normal and ideal molar relationship. In a Class I
In this phase, any spaces between teeth are closed, and further relationship, the upper first molar occlude just behind the lower
alignment is achieved. The arch wires used in this phase are: first molar, allowing for proper occlusion and function.
A. 0.016x0.022 Stainless Steel Square Arch wire: This Square-
shaped arch wire provides better torque control and is often used d. Good intercuspation:
for fine adjustments during the space closure phase. Intercuspation refers to the way the upper and lower teeth occlude
B. 0.017x0.022 Nitinol Rectangular Arch wire: Nitinol is still used together when biting down. Good intercuspation means that the
in this phase for its flexibility and ability to apply gentle forces upper and lower teeth fit together properly, allowing for effective
during space closure. chewing and proper distribution of biting forces.

Finishing Phase: e. Normal overjet and overbite:

The finishing phase is the last stage of treatment where fine Normal overjet and overbite indicate that the teeth are properly
adjustments are made to achieve the final alignment and occlusion. aligned vertically and horizontally.
The arch wires commonly used are:
A. 0.019x0.025 Nitinol Rectangular Arch wire: Nitinol is still The post-treatment photograph findings showed the following:
preferred for its flexibility and ability to maintain gentle forces Figure 5 revealed the result of the treatment as follows:
during the final adjustments. Front view
B. 0.019x0.025 Stainless Steel Rectangular Arch wire: Stainless showed normal overbite and midline and normal transverse dimension.

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 Figure 5: Illustrate the result after treatment showing canine space closure on the right side.

Lateral view
The patient displays a Class I molar relationship on the left side and
a Class III relationship on the right side. The Canine relationship is
Class I on the left and Class II on the right. The overjet is normal
on the left side while it is slightly increased on the right side.

Occlusal view
It was observed that both the upper and lower arches exhibit an
oval shape.

The Post-Treatment Radiographic Findings Showed the

Following:
Figure 6: Illustrates the outcome after a 4-year period following treatment.
Radiolucent areas of the Odontoma and impacted canine covered
with organized bone. The inclination of the lower right lateral
incisor and first premolar were corrected spontaneously after
removal of the Odontoma and finishing the inclination after
orthodontic treatment. The post-treatment radiographic findings
show positive outcomes after the removal of the odontoma and
impacted canine. The radiolucent areas observed previously,
which represented the spaces left by the removed structures, have
now been filled with organized bone. This indicates successful
healing and bone regeneration in the surgical sites. Additionally,
there was spontaneous correction of the inclination of the lower
right lateral incisor and first premolar after the removal of the
odontoma and the completion of orthodontic treatment. The Figure 7: Illustrates the outcome after finishing the treatment.
correction of the inclination likely resulted from the combined
effects of the surgical removal of the odontoma, the orthodontic
Figure 7 Exhibited the result after treatment (Five years); that
treatment, and the natural response of the surrounding dental and
the radiolucent area due to the removal of the Odontoma and the
bone structures.
impacted lower permanent canine was completely replaced by
A radiolucent region that resulted from the removal of the new bone growth as well as improvement of the roots of the first
Odontoma and the impacted lower permanent canine has been premolar and lateral incisor on the right side.
replaced by new bone growth. Additionally, the roots of teeth
lower right first premolar and lower right lateral incisor are now Discussion
parallel to each other as indicated with the small arrows (Figure 6). Tooth impaction is more commonly observed in permanent
dentition and rarely in primary dentition [28,29]. There are limited
reports in the literature regarding odontomas associated with

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unerupted primary teeth [30,31]. Although CBCT offers several the lower border of the mandible. This positioning indicates that
advantages and benefits over periapical and OPG radiographs. It the odontoma likely caused a disruption in the typical path of
also provides a three-dimensional view of the affected area as well eruption for the permanent canine tooth. Furthermore, the fact
as allowing for better visualization and evaluation of the condition. that the root apex of the impacted tooth was completely closed
However, in the present case report, Orthopantomograph (OPG) suggests that spontaneous eruption of the impacted tooth is not
was only used for diagnostic imaging. possible. Root apex closure is an essential factor in the eruption
process, and once the apex is closed, it hinders the tooth's ability
Considering the minimal radiation exposure discussed earlier, to move and erupt naturally. Given the horizontal position of
it is practical to choose for an OPG examination to promptly the impacted tooth and the complete closure of its root apex, it
detect and localize potential abnormalities such as odontoma, becomes imperative to consider appropriate dental interventions,
congenital absence of teeth, cystic lesions, and supernumerary such as surgical exposure and orthodontic treatment, to facilitate
teeth. Once diagnosed, an appropriate treatment plan can be the proper alignment and eruption of the affected permanent
formulated. Further and interestingly, orthodontic therapy is not canine. These treatments aim to guide the tooth into its correct
usually necessary because most odontomas are very small and position and restore proper function and aesthetics. However,
its influence on occlusion is negligible and improvement without in this case the impacted canine was removed surgically under
orthodontic therapy can take place [32,33]. However, in this case general anesthesia. The surgical procedure completed without any
report extraction of the impacted permanent canine and removal of complications. The canine space was closed orthodontically. The
the odontoma were performed followed by orthodontic treatment patient refused the compensatory extraction of the upper right first
to close the extraction space. premolar. This leads to finishing the upper right canine occlude
between lower right lateral incisor and lower right first premolar.
Katz carried out a comprehensive survey conducted in the United As previously stated, the patient's age was 13 years old, which
States examined the rates of odontoma detection. The findings of falls within the age ranges investigated in the study conducted by
the analysis demonstrated that approximately one-third of all cases An et al. [3]. According to their findings, all impacted teeth were
were diagnosed in children aged between 11 and 15 years, while
retained in patients under 9 years old, while all impacted teeth were
the detection rate in children below the age of 5 years was notably
extracted in patients over 30 years old. Given that the patient in the
low, accounting for only 2% of all cases [34]. However, in the
present case report, the age of the patient was 13 years old when present case report is 13 years old, their age doesn't exactly align
the Odontoma was detected. The impaction of primary molars with either age group outlined in An et al.'s study. Consequently,
gives rise to various issues within the dental arch, including space our case report presents a distinct and divergent situation from the
loss, tilting of adjacent teeth, over-eruption of the opposing teeth, observations made by An et al. [3].
and failure of permanent teeth to erupt [10,14,35].
It's important to note that case reports often describe individual
Odontomas are characterized by their slow growth and non- experiences or observations that may not fully align with larger
aggressive behavior. They enlarge during the normal development studies or general trends. Individual variations and factors specific
phase of the dentition and cease to grow after maturation of the to the patient may have influenced the treatment decision in this
associated corresponding teeth [1,36]. Papers on odontomas particular case. To draw more definitive conclusions about the
generally appear in the literature as either case reports or as optimal management of impacted teeth in patients of different
contributions to studies on larger series of odontogenic tumours. ages, further research and larger studies considering a broader age
Few studies focus on odontomas only. These include 104 cases range would be necessary.
reported from Brazil [37] and seventy-three -73- cases from Korea
[3], The only comprehensive clinic-pathological study on the The correction of the distally inclined lower right first premolar and
African continent featured 19 cases reported from Libya in 2013 mesially inclined lower right lateral incisor appears to be a direct
[3,37-39].
outcome of both Odontoma removal and subsequent orthodontic
intervention. Orthodontic procedures are designed to correct
The above mention studies reported that most odontomas are
dental misalignments and optimize tooth positioning. Through
reported as incidental findings on radiographs taken for other
indications such as delayed eruption of one or more permanent the removal of the Odontoma and the application of orthodontic
teeth or the retention of a deciduous tooth [3,37-39]. The literature techniques, it is probable that the orthodontist successfully
on odontomas occasionally reports cases where patients experience addressed the misaligned orientations of teeth lower right first
symptoms such as pain, swelling, expansion of the bone cortex, premolar and lower right lateral incisor, leading to enhanced
and displacement of teeth [40]. In the present case, the patient alignment and a more favorable occlusal relationship. The healing
sought dental care due to a toothache on lower left permanent first process (Figure 8) can take several weeks to months or years,
molar, which was endodontically treated. depending on the individual's healing capacity and the extent of the
surgical procedure. Regular follow-up visits with the oral surgeon
In the present case, the observed displacement of the lower right or oral and maxillofacial surgeon will be necessary to monitor the
permanent canine was unique, as it was horizontally located near healing progress and ensure there are no complications.

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 Figure 8: The healing process after removal of the Odontoma and the impacted canine as well as canine space closure.

In most cases, the radiolucent area gradually becomes less apparent Conclusions
over time as the bone continues to heal and remodel. Follow- • The management of this patient condition emphasizes the
up imaging, such as panoramic X-rays or Cone-beam computed interdisciplinary approach between an orthodontist and an oral
tomography (CBCT), may be taken at specific intervals to assess surgeon for the successful management of such cases.
the healing and bone regeneration accurately. If the radiolucent • Early diagnosis and proper coordination between these
area persists or if there are any concerns during the healing specialists are crucial in achieving optimal outcomes for the
process, the patient should promptly inform their oral surgeon for patient.
further evaluation and management. The surgeon will determine if • It is essential to report any impacted teeth and dental
any additional measures or interventions are necessary to ensure a abnormalities like Odontomas to ensure proper oral health and
successful outcome and optimal healing. function.
• In this case, the combined approach of Odontoma removal and
Overall, the treatment appears to have successfully closed the orthodontic treatment contributed to positive changes in tooth
impacted tooth space and achieved satisfactory alignment and alignment and bone healing.
occlusion on the left side. A Class I molar and canine relationship • Regular follow-up visits and post-treatment evaluations are
is evident on the left side, whereas on the right side, there is a necessary to monitor the stability and long-term success of the
Class III molar relationship and a relative Class II relationship treatment outcomes.
of the canine. This occurs as a result of the patient's decision to
decline extraction of the upper right first premolar. This intended Acknowledgement
compensatory extraction, aimed at achieving a normal overjet The authors would like to express their gratitude to Jane Baldovino
and a Class I molar and relatively class I canine relationship on for her assistance during the management of this patient. Her
the right buccal segment, which was not carried out. However, support has been invaluable throughout the process.
due to the surgical removal of the impacted lower right canine,
proper positioning of the upper right canine is impeded. Instead References
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