Mechanical obstruction in mixed dentition: the challenge of multiple odontomas

Compound odontoma, although classified as a benign hamartoma, constitutes a formidable mechanical barrier during the mixed dentition phase. This case series explores a particularly complex clinical situation: the presence of multiple odontomas — organized dentoid structures — hindering the eruption of the maxillary central incisors. The resulting delayed eruption or prolonged retention of primary teeth are not merely radiological anomalies; they cause immediate aesthetic and functional impairments for the child.

The objective of this clinical presentation is to describe the conservative surgical management protocol applied to two pediatric patients (an 11-year-old girl and an 8.5-year-old boy). The study aims to demonstrate how precise lesion identification through 3D imaging (CBCT) allows for a targeted intervention. The hypothesis tested here is that early and meticulous excision of the odontoma is sufficient to restore the physiological eruption potential of the impacted permanent incisor. By removing the obstacle without immediate orthodontic traction, the practitioner can thus simplify clinical outcomes and preserve the integrity of adjacent dental structures.

Design and protocol of the case study

This series of clinical cases reports the surgical management of two pediatric patients within the Department of Pediatric Dentistry of Kozhikode:

• Population: An 11-year-old female patient presenting an impacted maxillary left central incisor (21) with a 2x2 cm swelling, and an 8-and-a-half-year-old boy presenting a prolonged retention of the 51 blocking the eruption of the 11.
• Diagnostic imaging: Initial evaluation used intraoral periapical (IOPA) and panoramic (OPG) radiographs. A cone beam computed tomography (CBCT) was systematically performed for the three-dimensional analysis of the dentoid structures, their capsule, and their relationship with the nasal cavities or the nasopalatine canal.
• Surgical protocol: The procedures were performed under local anaesthesia (2% lignocaine with 1:80,000 adrenaline). The protocol included a full-thickness mucoperiosteal flap, conservative bone guttering, removal of calcified denticles, and curettage of the site irrigated with physiological saline.
• Follow-up: Closure was performed using 3-0 silk sutures (removal at 7 days). The diagnosis was validated by histopathological examination, confirming the characteristic organization into enamel matrix, dentin, pulp, and cementum.

Surgical procedure results and radiographic analysis

The two clinical cases reported in this series highlight the mechanical impact of multiple compound odontomas on the eruption of permanent maxillary central incisors in children. The diagnosis was confirmed by three-dimensional imaging (CBCT) and histopathological examination.

Parameter	Case n°1 (11 years old, F)	Case n°2 (8.5 years, M)
Impacted tooth	Left central incisor (21)	Right central incisor (11)
Major clinical sign	2x2 cm swelling (hard, painless)	Prolonged retention of 51
Odontoma localization	Mesio-labial and palatal to the crown of 21	Under the crown of the 11
Particularity CBCT	Atteinte de la paroi latérale du canal nasopalatin	11 located at the root apex of 51

Radiographic and surgical observations (Case n°1)

The CBCT examination of the first case revealed an oblique inclusion of tooth 21, with a crown oriented towards the labial and inferior aspect. The odontomatous structures were grouped within a single capsule. Thinning of the palatal cortical plate was observed at the level of the nasopalatine canal. The procedure, performed under local anesthesia (lignocaine 2%, adrenaline 1:80,000), allowed the excision of multiple denticles through a conservative bone flap (guttering) extending from 11 to 23.

Radiographic and surgical observations (Case n°2)

For the second patient, the periapical radiograph initially identified radiopaque structures obstructing tooth 11. The CBCT specified the position of the permanent incisor, located at the level of the apex of the primary tooth (51). The crown of tooth 11 presented a labial position. The protocol consisted of the atraumatic extraction of tooth 51 followed by the enucleation of the calcified denticles. The permanent incisor was preserved without direct manipulation to promote its physiological eruption.

Histopathological analysis and follow-up

Microscopic examination of the excised specimens confirmed the diagnosis of compound odontoma, revealing a structured dental tissue organization:

• Organised enamel matrix.
• Dentine, pulp tissue and cementum arranged in a dentoid pattern.

Following surgical excision, healing was considered satisfactory in both patients. No signs of recurrence were noted during postoperative follow-ups, and the potential for spontaneous eruption of the incisors was maintained thanks to the removal of the mechanical obstruction.

Clinical analysis: Removing the obstacle to release the eruption potential

These two clinical cases illustrate the direct impact of compound odontomas — these hamartomas organized into miniature denticles — on the eruption kinetics of maxillary central incisors. In the first case (11-year-old girl), CBCT imaging revealed a severe oblique impaction of tooth 21 due to a cluster of odontogenic structures housed within a single capsule. The second case (8.5-year-old boy) shows that simple retention of the primary tooth can mask a more complex mechanical obstacle. The key takeaway here is the correlation between early surgical excision and the maintenance of physiological eruption potential.

The decisive contribution of CBCT and surgical management

The precision of the CBCT allowed for the localization of the denticles in relation to adjacent structures (nasopalatine canal, nasal cavity) and the definition of the root angulation of the impacted incisors. Clinically, the conservative approach through targeted bone milling allowed for the removal of the odontomas without compromising the pericoronal sac or the integrity of the permanent tooth. Although the sample is limited to two patients, the results confirm that in the absence of other developmental anomalies, the removal of the physical barrier is often sufficient to restore a favorable eruption pathway, thereby reducing the immediate need for complex orthodontic tractions.

Cette série de cas cliniques démontre que l'exérèse chirurgicale précoce de multiples odontomes composés chez deux patients (8,5 et 11 ans) permet de lever l'obstruction mécanique empêchant l'éruption des incisives centrales. La préservation systématique des dents permanentes incluses, malgré des positions complexes ou la proximité de structures sensibles comme le plancher nasal, a permis d'initier un potentiel d'éruption spontanée sans complications postopératoires.", "conclusion": "This clinical case series demonstrates that early surgical excision of multiple compound odontomas in two patients (8.5 and 11 years old) allows for the removal of the mechanical obstruction preventing the eruption of the central incisors. Systematic preservation of the impacted permanent teeth, despite complex positions or proximity to sensitive structures such as the nasal floor, enabled the initiation of spontaneous eruption potential without postoperative complications.

In concrete terms, for the practitioner:

• CBCT Diagnosis: Systematically use 3D imaging to precisely locate the denticles in relation to the permanent tooth follicle and adjacent structures (nasopalatine canal, nasal cavity) before the procedure.
• Follicular preservation: Limit curettage to the calcified structures of the odontoma without manipulating the impacted tooth to maximize the chances of physiological eruption and reduce the need for immediate orthodontic traction.
• Early intervention: Act as soon as an eruption delay or abnormal primary tooth persistence is detected to simplify overall management and improve long-term aesthetic results.

Technical lexicon of the study

Compound odontoma: Benign odontogenic hamartoma derived from differentiated epithelial and mesenchymal cells. It is characterised by an ordered tissue organisation forming miniature tooth-like structures.

Hamartomatous malformation: Developmental anomaly rather than a true neoplasm, consisting of dental tissues (enamel, dentine, cementum and pulp) that have reached full maturation but are arranged in an abnormal way.

Denticles: Small calcified entities of varying sizes and densities, morphologically similar to teeth, contained within the fibrous capsule of the odontoma and acting as a mechanical obstacle to eruption.

Bone guttering: Conservative surgical removal technique of the alveolar bone allowing the exposure and extraction of calcified structures while preserving the integrity of the underlying impacted permanent tooth.

Delayed exfoliation: Prolonged retention of a primary tooth (such as the primary central incisor 51 in the study) beyond its normal physiological shedding period, often associated with the impaction of the permanent successor.

CBCT (Cone Beam Computed Tomography): Three-dimensional imaging used to precisely locate the position of denticles and the inclination of impacted incisors (e.g., roots directed towards the floor of the nasal cavities or the nasopalatine canal).

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