Supernumerary Tooth in the Nasal Cavity Case Report Nazal

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Supernumerary Tooth in the Nasal Cavity Case Report Nazal Powered By Docstoc
					OLGU RAPORU (Case Report)
                                             Hacettepe Diş Hekimliği Fakültesi Dergisi
                                               Cilt: 34, Sayı: 3-4, Sayfa: 42-45, 2010

  Supernumerary Tooth in the Nasal Cavity:
              Case Report

                 Nazal Kavitede Süpernumere Diș:
                           Olgu Raporu
       *Serdar UYSAL, DDS, PhD, *Özden KANSU, DDS, PhD, *Hilmi KANSU, DDS, PhD,
                      *Hacettepe University Faculty of Dentistry Department of Oral Diagnosis and Radiology

                    ABSTRACT                                                                    ÖZET

Ectopic eruption of a tooth into the nasal cavity is                Dişin nazal kaviteye sürmesi nadirdir ve genellikle
rare and mostly diagnosed during clinical or radi-                  rutin klinik ve radyografik muayene esnasında tanı
ographical examination. A 15-year-old male patient                  konulur. 15 yaşındaki erkek hasta Oral Diagnoz ve
was admitted to the Department of Oral Diagnosis                    Radyoloji Kliniğine dental muayene için başvurdu.
and Radiology clinic for dental examination. Dental                 Bir ay önce dişlerine travma geldiği dental hikaye-
history revealed a previous trauma to the teeth one                 sinden öğrenildi. İntraoral muayenesinde sol maksil-
month before. Intraoral examination showed the                      ler santral dişin eksikliği görüldü ve radyografik mua-
absence of the maxillary left central incisor, and radi-            yenede (panoramik ve periapikal) nazal kavitede diş
ographic examination (panoramic and periapical)                     benzeri radyoopak yapı izlendi. Kesin tanı için bilgi-
showed a radiopaque tooth-like structure in the nasal               sayarlı tomografi taraması yapıldı. Nazal dişin teda-
cavity. For the definitive diagnosis computed tomog-                visi teşhis edildiği anda çekimdir. Asemptomatik
raphic scanning was obtained. Extraction of the nasal               nazal diş de çekilmelidir veya en azından radyogra-
tooth is the treatment modality when it is diagno-                  fik olarak takip edilmelidir. Radyografik tanı nede-
sed. Asymptomatic nasal tooth should also be remo-                  niyle nazal dişin çekimi önerildi. Ancak hastanın ve
ved or at least followed radiographically. Based on                 ebeveynlerin çekimi kabul etmemesi nedeniyle nazal
radiographic diagnosis, surgical removal of the nasal               dişin periodik klinik ve radyografik takibine karar
tooth was suggested. However, as the patient and his                verildi. Periapikal, okluzal ve panoramik radyogra-
parents rejected extraction, periodic follow-up with                fi eksik dişlerin araştırılmasında temel incelemeler-
clinical and radiographic examination was decided to                dir. Gerektiğinde gelişmiş teknikler de (bilgisayarlı
be applied. Periapical, occlusal and panoramic radi-                tomografi gibi) yardımcıdır.
ography are fundamental techniques in investigation
and management of missing tooth. When required,
advanced techniques (like computed tomography) are
also helpful.

                      KEYWORDS                                                         ANAHTAR KELİMELER
    Nasal tooth, periapical radiography, panoramic                   Nazal diş, periapikal radyografi, panoramik radyografi,
         radiography, computed tomography                                             bilgisayarlı tomografi

INTRODUCTION                                               Periapical radiographic examination showed
                                                       the empty socket of maxillary left central incisor
    Ectopic teeth may present itself in many re-
                                                       and a radiopacity in the left nasal cavity (Figure
gions of the maxillofacial skeleton. Teeth may
                                                       1). Because of this appearance, a panoramic
erupt to various locations such as the maxillary
                                                       radiograph was taken. The radiograph showed
sinus, mandibular condyle, coronoid process1,
                                                       a radiopaque tooth-like structure in the left na-
orbits, palate, and nasal cavity2. Eruption of a
                                                       sal cavity. Based on the detection of root and
tooth into the nasal cavity is a rare occasion and
                                                       pulp canal, a preliminary diagnosis of a nasal
occurs in only 0.1–1 % of the population and is
                                                       tooth was made (Figure 2). An impacted man-
mostly diagnosed during routine clinical or ra-
                                                       dibular left second premolar was also noted on
diographical examination3. The identification of
                                                       the panoramic radiograph. The patient reported
the condition is important, as it has the potential
                                                       no complaint in the nasal cavity. However, for
to cause serious morbidity4. In case of a tooth in
                                                       the definitive diagnosis, computed tomographic
the nasal cavity, the signs and symptoms vary
                                                       (CT) scanning was obtained. Coronal and axial
from nasal congestion, obstruction, discharge,
                                                       CT imaging revealed the following: a tooth-like
and epistaxis, to mild fever and facial pain, and
                                                       radiopacity in the left nasal cavity, hypertrophy
sometimes it can appear as incidental finding on
                                                       of the nasal conchaes, deviation of the nasal sep-
dental radiographs2.
                                                       tum to the right and thickenning of the maxil-
   This report presents a rare case of asymp-          larysinus mucosa (Figures 3 and 4). Nasal bor-
tomatic supernumerary tooth erupted into the           ders were regular and no adjacent bone destruc-
nasal cavity which was diagnosed incidentally.         tion was observed.
                                                           The clinical and radiographic findings, risks/
                                                       benefits of surgery, long-term prognosis of the
    A 15-year-old male patient (B.T.) was admit-       affected tooth and the dental treatment plan
ted to the Department of Oral Diagnosis and Ra-        were discussed. Suggested treatment involving
diology for dental examination and treatment of        extraction of the tooth was rejected by the pa-
absent maxillary left central incisor. The patient’s   tient and his parents. Asymptomatic nature and
medical history was unremarkable. Clinical eval-       lack of complaint was the main reasons. Hence,
uation indicated that the patient was a healthy        periodic follow-up with clinical and radiographic
adolescent with no other physical abnormalities.       examinations was recommended. Also, another
Dental history revealed a previous trauma to the       treatment plan for impacted premolar was deter-
anterior teeth occuring one month earlier. It was      mined for the patient.
learned that the left maxillary central incisor was
extracted by himself due to its excessive mobility.    DISCUSSION
No other history of trauma could be obtained.
Initial examination of the mandible, temporo-              Ectopic eruption in the dental environment
mandibular joint, facial bones and zygomaxil-          is common, whereas eruption into other sites
lary complex were within normal limits. Intra-         is rare3. The etiology of nasal teeth remains
oral examination revealed absence of maxillary         obscure5. Many theories have been proposed,
left central incisor. There were no evidences of       including developmental disturbances such as
significant edema and tenderness. In the maxil-        cleft palate, teeth displaced by trauma, cysts, in-
lary and mandibulary anterior region percussion,       fection, eruption secondary to crowding of the
palpation sensitivity, and mobility tests were nor-    dentition, persistent deciduous teeth, or dense
mal. Also, there was no significant periodontal        bone and genetic factors2. Another hypothesis
pocketing and electrical pulp tests were positive      is that the supernumerary tooth is an inverted
in the anterior region.                                mesiodens that grows into the floor of the nasal

                           FIGURE 1
Periapical radiograph showing the supernumerary tooth in the
                                                                                          FIGURE 4
                        nasal cavity.
                                                               Axial CT image showing the supernumerary tooth in the nasal cavity.

                                                               cavity5. Kirmier et al.6 reviewed the literature and
                                                               discussed 25 well-documented cases. Majority of
                                                               cases consisted of one tooth as in our case. They
                                                               documented that in 82 % of cases, associated
                                                               symptoms were also present. However, there
                                                               was no symptom in our case.
                                                                   In the presented case, there was no missing
                                                               tooth in the maxilla except left central incisor
                          FIGURE 2
                                                               which was extracted by the patient himself. We
     The appearance of the supernumerary nasal tooth in the
                   panoramic radiograph.
                                                               considered that intranasal radiopacity was a su-
                                                               pernumerary tooth. Although, there was a trau-
                                                               ma, regular nasal borders on CT images ruled
                                                               out the possibility of a displaced tooth. There
                                                               was no other trauma history in the past, so trau-
                                                               ma has not been considered as an etiologic fac-
                                                               tor in our case.
                                                                  When nasal masses are identified, the differ-
                                                               ential diagnosis should also include nasal foreign
                                                               bodies, rhinoliths, bony sequestrae, neoplasms,
                                                               odontomas, calcifying odontogenic cysts and
                                                               exostoses3. The diagnosis of nasal tooth can be
                                                               determined from clinical and radiographic exami-
                                                               nations. Clinically, nasal tooth presents itself as
                                                               hard white masses, located in the nasal cavity and
                                                               surrounded by granulation tissue and debris. Ra-
                          FIGURE 3                             diographic examination may be helpful, but does
 Coronal CT image showing the supernumerary tooth in the       not always confirm the diagnosis of nasal tooth
                     nasal cavity.                             because they may appear only as a nonspecific

radiopaque lesion on or near the nasal cavity3. In                   diagnosed, the treatment of nasal tooth is extrac-
our case, both periapical and panoramic radio-                       tion because of potential morbidity. Asymptom-
graphs revealed a radiopaque tooth-like structure                    atic tooth should be removed or at least followed-
in the nasal cavity. CT scanning is helpful in local-                up radiographically3. As our patient did not ac-
ising nasal tooth and planning their treatment7,8.                   cept the extraction, we decided to follow-up the
In order to determine the exact location of the ra-                  patient clinically and radiographically.
diopaque mass, CT scanning was performed by
obtaining the coronal and axial slices. CT images                    CONCLUSION
confirmed a tooth-like radiopacity in the nasal
                                                                        In cases of nasal teeth, the use of conventional
cavity. This density was not compatible with oth-
                                                                     and advanced radiographic techniques is helpful.
er lesions in the nasal cavity. Crown of the super-
numerary tooth may be in atypical form, or odon-
toma may develop around the crown of the tooth.
As surgical removal of intranasal radiopacity was                    1.    Avcu N, Buyukkopru D, Kansu O, Dural S. Severe
                                                                           hypodontia and asymptomatic bilaterally ectopic impacted
not carried out, the differential diagnosis of odon-                       teeth in the coronoid processes: A case report. Quintessence
toma was not confirmed by histopathological ex-                            Int 2004; 35: 582-583.
amination. Nasal tooth can present itself with a                     2.    Smith RA, Gordon NC, De Luchi SF. Intranasal Teeth.
variety of signs and symptoms, including mild fa-                          Report of two cases and review of the literature. Oral Surg
                                                                           Oral Med Oral Pathol 1979; 47: 120-122.
cial pain, mild fever, unilateral nasal obstruction,
                                                                     3.    Lee JH. A nasal tooth associated with septal perforation:
recurrent epistaxis, headache, rhinitis caseosa,                           A rare occurrence. Eur Arch Otorhinolaryngol 2006; 263:
external deviation of the nose, foul-smelling, se-                         1055-1056.
rous or purulent rhinorrhea, crusting of the nasal                   4.    Sanei-Moghaddam A, Hyde N, Williamson P. Endoscopic
mucosa, septal abscess, oronasal fistula, septal                           removal of a supernumerary tooth from the nasal cavity in
                                                                           an adult. Br J Oral Maxillofac Surg 2009; 47: 484-485.
perforation, nasal congestion9. It is important to
                                                                     5.    Murty PS, Hazarika P, Hebbar GK. Supernumerary nasal
identify it, as it has the potential to cause seri-                        teeth. Ear Nose Throat J 1988; 67: 128-129.
ous morbidity4. If a nasal tooth is asymptomatic,                    6.    Kirmeier R, Truschnegg A, Payer M, Malyk J, Daghighi
it can appear as an incidental finding on dental                           S, Jakse N. The supernumerary nasal tooth. Int J Oral
radiographs as it is in our case3.                                         Maxillofac Surg 2009; 38: 1219-1222.
                                                                     7.    Tung TC, Chen YR, Chen CT, Lin CJ. Full intrusion of a
   Extraction can be done either transnasally or                           tooth after facial trauma. J Trauma 1997; 43: 357-359.
transpalatally. The tooth should be removed un-                      8.    Chen A, Huang JK, Cheng SJ, Sheu CY. Nasal teeth: report
der general anaesthesia to control any possible                            of three cases. Am J Neuroradiol 2002; 23: 671-673.
epistaxis2. However, if the tooth is associated                      9.    Nastri AL, Smith AC. The nasal tooth. Case report. Aust
                                                                           Dent J 1996; 41: 176-177.
with osteomyelitis, an intraoral fistula, or septal
deviation, other approaches including debride-
ment or septoplasty may be necessary3. When

                                  Geliş Tarihi : 13.09.2010               Received Date : 13 September 2010
                                  Kabul Tarihi : 29.12.2010               Accepted Date : 29 December 2010

                                                   CORRESPONDING ADRESS

                                                 Serdar UYSAL, DDS, PhD
                      Hacettepe University, Faculty of Dentistry, Department of Oral Diagnosis and Radiology,
                            Tel: +90 312 305 22 09 Fax: +90 312 305 42 21 E mail: suysal@hacettepe

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