In January 2007, the patient, a 21-year-old male with tooth fracture sustained during a football game was referred to Center for Dental Specialties Visioli, Cascavel, Parana, Brazil. This study followed the Declaration of Helsinki on medical protocol and ethics. During the interview, the patient reported no history suggestive of presence of a tumor in the maxillary sinus. The affected tooth was the maxillary left central incisor. After clinical and periapical radiographic examination, a vertical fracture of the tooth root was diagnosed. The proposed treatment was the atraumatic removal of the root and the immediate installation of a dental implant with an immediate temporary prosthesis.
At physical examination, the absence of maxillary left second and third molars and a swelling of the alveolar process with a firm consistency and obliteration of the vestibular sulcus were noted. The soft tissue had normal color and patient denied pain. Panoramic radiographs revealed a solid radiopaque mass involving the left alveolar ridge, maxillary sinus, and orbit [Figure 1].
Axial and multiplanar reconstructed computed tomography images [Figures 2-4] revealed a hyperdense mass extending from the alveolar ridge to the middle third of the maxillary sinus with extension to the orbital roof.
The differential diagnosis for the lesion includes calcifying odontogenic cyst, calcifying odontogenic tumor, ameloblastic fibroma, fibro-odontoma, and fibro-osseous lesion. Excisional biopsy of the lesion was performed.
One hour prior to surgery patient was given decadron 40 mg intravenous (IV), 1 g kefazol IV, plasil 20 mg IV, nalbuphine hydrochloride IV, and 750 mg acetaminophen (Tylenol ; Cilag Farmaceutica Ltda., Sao Paulo, SP, Brazil) for pain management. Extraoral and intraoral antisepsis was performed with polyvinylpyrrolidone-iodine 10-2.0% chlorhexidine solution and 0.12% chlorhexidine rinse for 1 min, respectively. The operation was performed with the patient under hypotensive general anesthesia.
The surgical procedure was initiated with an intrasulcular incision, from the maxillary left first premolar until the first molar and continued on the tuberosity. A relaxing incision was performed on the mesial of the premolar to allow a mucoperiosteal flap raise to expose the very superficially located mass [Figure 5]. Surgical approach was performed using a spherical drill and a #702 tapered stem, and several blocks of the lesion were removed [Figure 6] and submitted for histopathological examination. During surgery, it was observed that the impacted teeth (second and third molars) exhibited an apparent change in shape and size. Surgical cavity was totally smoothened and no complementary treatment was necessary. The flap was repositioned and closed with interrupted stitches.
Subjects were prescribed analgesics LISADOR 3 days + AMOXI 500, 7 days + FLAGYL 400, 5 days + omeprazol 40, 7 days, periogard 12 days. For 3 days and antibiotics (amoxicillin 500 mg, 3 times a day) for 1-week and instructed to use 0.12% chlorhexidine rinse twice daily for 1-week.
The area healed uneventfully.
Histopathological examination of the excised mass showed irregularly arranged dental hard tissues with areas of cell rich pulpal tissue. Clear spaces and clefts representing the mature enamel that is lost in the process of decalcification are often seen confirming the diagnosis of a complex odontoma [Figure 7].
Two years after lesion removal, panoramic radiographic demonstrated occurrence of bone repair in the treated area and did not reveal any signs of recurrence [Figure 8].