CBCT Reveals Tonsillolith and Locates Ectopic Premolar
A male patient, 10 years old, presented to our orthodontic practice for examination and consultation. Medical history was unremarkable. Clinical examination revealed that the patient was in the late mixed dentition phase. His mild Class II malocclusion with spacing did not warrant beginning orthodontic treatment at that time. However, a screening panoramic radiograph was taken to check eruption and dental development.
The panoramic radiograph showed multiple radiopacities superimposed over the right ramus of the mandible. The largest radiopacity was round in shape and located distal to the developing right mandibular third molar. The other two small radiopacities were irregular and superimposed on the right mandibular foramen areas. The radiopacities appeared to be of cortical bone or calcifications. The maxillary left canine was mesio-palatally angled, and the mandibular second premolars appeared to be ectopically positioned (especially #29). From the panoramic radiograph, the differential interpretations included calcifications of the right palatine tonsil or reactive bone hyperplasia, such as enostoses or idiopathic osteosclerosis. The large radiopacity could represent a complex odontoma since there was a radiolucent band.
A 17 cm x 13.5 cm Cone Beam Computed Tomography (CBCT) scan (CS 9300C, Carestream Dental, Atlanta, Georgia) was taken to elicit more information in regards to the location and size of the radiopacities. The CBCT revealed that the ?lesions? were actually one multi-loccular lesion, located in the right pharyngeal area, rather than in the mandible or ramus. The lesion was quite large and dense.
Referral was immediately made to an Otorhinolaryngologist at Children?s Hospital of Orange County. After clinical examination and review of the CBCT, removal of the lesion was recommended. A very large right superior tonsillar concentration (2 cm diameter) and the tonsils were surgically removed. The patient recovered from the procedure without incident. Tonsils are filled with crevices where bacteria and other materials, including dead cells and mucus, can become trapped. Tonsilloliths are formed when this trapped debris calcifies. The calcifications are composed of salts such as hydroxyapatite or calcium carbonate apatites and other magnesium salts. Differential diagnosis of tonsilloliths includes foreign body, calcified granuloma, malignancy, or rarely, isolated bone which is derived from embryonic branchial arches. While small concretions in the tonsils are common (up to 10% of the population), true tonsilloliths are more rare. On the CBCT scan, it was clear that #29 was erupting lingually, almost horizontally.
We routinely use our CS 9300C to take panoramic radiographs to screen for pathological lesions, dental eruption variance and tooth anomalies, and anatomical deviations. Once something unusual is identified, the CBCT is an invaluable tool to narrow the differential diagnosis or provide a definitive diagnosis. Prior to utilizing a CBCT, we were often left to infer or speculate rather than arrive at strong conclusions. Our treatment plans and diagnoses are heavily influenced by CBCT data in many cases. Due to the clarity of the images and sheer breadth of data, we are able to elicit accurate information and superior treatment plans to better serve our patient population. While not every patient receives a routine CBCT scan, when used selectively it is an invaluable tool in our practice. There had been no prior indications, and the patient was asymptomatic but would probably have become symptomatic in the future. Due to its large size, the tonsillolith could have promoted recurrent tonsillar infections and may have led to pain, abscess formation, ulceration, dysphagia and halitosis. It could have also have been aspirated and led to pulmonary complications. The patient and parents were quite relieved to have quickly and efficiently arrived at a definitive diagnosis and treatment modality.
We are also now able to anticipate the challenges associated with the eruption direction of #29, and will intervene when appropriate.
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