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Case 23794

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Impacted / delayed / malpositioned / extra teeth

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Canaray 23794

1. Complex odontome

A mixed radiolucent radiopaque entity that contains flecks of calcified material with a similar appearance to enamel is present at site 37. This entity has a well-defined radiolucent border, and is positioned at the lingual aspect of the mandibular alveolar process. This appearance is suggestive of the presence of a complex odontome distal to tooth 36, which is partially responsible for the impaction of tooth 37.

2. Rule out central hemangioma prior to biopsy

The posterior left mandibular body exhibits a multilocular appearance that extends from the distal surface of tooth 35 to the mesial surface of the posteriorly displaced tooth 37. The mandibular alveolar process has been locally expanded in this region and the mandibular nerve has been inferiorly displaced.

There are several pathologic entities that have a multilocular appearance in the posterior mandible (such as an ameloblastoma or a central giant cell granuoluma). However, the possibility of a central hemangioma cannot be ruled out, and it may be prudent to exclude this entity from the differential diagnosis prior to biopsy via a medical CT scan with contrast or an MRI.

Sagittal views of posterior 3rd quadrant

These sagittal cross-sectional images demonstrate the extension of the multilocular entity beyond the mesial border of this small field CT scan. The distal root apex of tooth 36 exhibits slight resorption, but the periodontal ligament space and lamina dura remain intact and normal. Tooth 37 has been distally displaced, but exhibits a normal follicle and no damage to its lamina dura or periodontal ligament space. The inferior displacement of the left mandibular nerve canal is evident in these images.

Axial views of posterior third quadrant

These axial cross-sectional images demonstrate the localized fusiform buccolingual expansion that is present in the posterior third quadrant. The lingual position of the complex odontome in the alveolar process is evident in these images, as is the maintenance of the lamina dura and periodontal ligament spaces around teeth 36 and 37.

Coronal views of posterior third quadrant

These coronal cross-sectional images demonstrate the enlarged bone marrow spaces in the posterior third quadrant, which has produced a multilocular appearance in this region. The mild resorption of the distal root of tooth 36 is evident in these images, as is the inferior displacement of the left mandibular nerve canal.

Large field scan confirms extent of pathologic entity in posterior 3rd quadrant

A large field scan of the posterior 3rd quadrant was made in order to fully capture the pathologic entity in the posterior 3rd quadrant. The mesial extent of the entity is the root apex of tooth 35 and the distal extent of the entity is the mesial surface of tooth 37. The superior extent of the entity is the superior border of the mandibular alveolar process at site 37. The inferior extent of the entity is the inferior mandibular border.