|Year : 2009 | Volume
| Issue : 2 | Page : 92-97
Large erupted complex odontoma
Vijeev Vasudevan1, V Manjunath1, Radhika Manoj Bavle2
1 Department of Oral Medicine and Radiology, Krishnadevaraya College of Dental Science and Hospital, Hunasamaranhalli, via Yelankha, Bengaluru-562 157, India
2 Department of Oral Pathology and Microbiology, Krishnadevaraya College of Dental Science and Hospital, Hunasamaranhalli, via Yelankha, Bengaluru-562 157, India
|Date of Web Publication||1-Dec-2009|
Department of Oral Medicine and Radiology, Krishnadevaraya College of Dental Science and Hospital, Hunasamaranhalli, via Yelankha, Bengaluru-562 157
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Odontomas are a heterogeneous group of jaw bone lesions, classified as odontogenic tumors which usually include well-diversified dental tissues. Odontoma is a term introduced to the literature by Broca in 1867. Trauma, infection and hereditary factors are the possible causes of forming this kind of lesions. Among odontogenic tumors, they constitute about 2/3 of cases. These lesions usually develop slowly and asymptomatically, and in most cases they do not cross the bone borders. Two types of odontoma are recognized: compound and complex. Complex odontomas are less common than the compound variety in the ratio 1:2.3. Eruption of an odontoma in the oral cavity is rare. We present a case of complex odontoma, in which apparent eruption has occurred in the area of the right maxillary second molar region.
Keywords: Complex odontoma, eruption, odontoma, radiopaque mass
|How to cite this article:|
Vasudevan V, Manjunath V, Bavle RM. Large erupted complex odontoma. J Indian Acad Oral Med Radiol 2009;21:92-7
| Introduction|| |
Odontoma belongs to the group of dentigenous tumors developing in jawbones in the stage of odontogenesis. According to the definition of WHO, it is a congenital developmental defect, resulting from the growth of completely differentiated epithelial and mesenchymal cells, in which all kinds of dental tissue occur. Similar to teeth, once fully calcified they do not develop further. ,,
Paul broca was the first person to use the term "odontoma" in 1867.He defined the term odontoma as "tumors formed by the over growth of transitory or complete dental tissues". Odontomas are hamartoma arising during normal tooth development, and they reach a fixed size.  According to the 1992 classification of the World Health Organization (WHO), two types of odontomas are acknowledged: (a) compound odontomas, consisting of malformations with representation of all dental tissues and exhibiting an orderly distribution in which numerous tooth-like structures known as denticles are found; and (b) complex odontomas, i.e., malformations in which all dental tissues are likewise represented, but showing a disorganized distribution. ,,,, The first is approximately twice as common as complex odontomas. 
Other types of odontomas are sometimes also seen, presenting combinations of the characteristics of compound and complex odontomas (i.e., mixed odontomas), while in other cases the lesions cannot be assigned to either of the two types (cystic adenomas). ,,
Odontomas are the most common maxillary tumors, and according to different sources in the literature account for 22- 67% of all odontogenic maxillary neoplasms. ,,,, As to their location, most are found in the areas of the upper incisors and canines, followed by the antero- and poster inferior regions. Complex odontomas are more often found in the area of the second and third lower molars. ,, An increased prevalence of these tumors is observed in children and adolescents, with few differences in relation to patient's sex. , These lesions are normally diagnosed by routine radiological studies in the second and third decades of life. ,,, With regard to their pathogenesis, odontomas have been associated with antecedents of trauma during primary dentition,  as well as with inflammatory and infectious processes, hereditary anomalies (Gardner's syndrome, Ekman-Westborg-Julin syndrome, basal cell nevus syndrome, familial colonic adenomatosis, Tangier disease or Hermann's syndrome,), odontoblastic hyperactivity, or alterations of the genetic components responsible for controlling dental development. ,,,
Radiologically, odontomas manifest as a dense radiopaque lesion surrounded by a thin radiotransparent halo.  In complex odontomas, the radiodense elements appear as irregular and disorderly masses with no similarity to dental structures. A typical feature is the identification of a solar X-ray image. , The management of choice is surgical excision followed by histological study to confirm the diagnosis. ,, The possibility of relapse exists when resection is carried out in the noncalcified stage of the lesion.  An exceptional situation is transmucosal eruption of an odontoma, i.e., exposure or appearance within the mouth of such lesions through the oral soft tissues. ,, The present study reports our experience with a case of erupted complex odontoma as an example of this infrequent entity.
| Case Report|| |
A 19-year-old, apparently healthy female patient reported to the department of oral medicine and radiology, Krishna Devaraya College of Dental Sciences and Hospital, with painful swelling in the right middle third of the face of one week duration. Her medical history was unremarkable. On history examination, she revealed that the pain was intermittent from past one year, with similar episodes. Clinically, there was gross facial asymmetry with diffuse smooth swelling in the right maxillary region [Figure 1]. Mouth opening was adequate. Intraoral examination of the region revealed the presence of a hard mass measuring about 2.5 cm in mesiodistal and 2 cm buccolingual dimension, of yellowish-white color, calcified appearance and presenting an irregular and porous surface resembling dentin, associated to maxillary right molar region with a breach in the corresponding alveolar mucosa through which pus extruded and apparent absence of the right maxillary first, second and third molar noted [Figure 2]. The buccal and lingual cortices were expanded and hard. Patient gave a history that the mass is erupted in to oral at the age of 13 years. The provisional diagnosis of infected odontogenic cyst (dentigerous cyst) associated with impacted molars was made.
Complementary tests (orthopantomography, periapical X-rays, waters view, occlusal view and computed tomography) were requested to evaluate the lesion, its precise location and relation to adjacent structures. A panoramic radiograph showed a uniformly dense irregular radiopacity (about 3 × 3.5 cm); in the right superior alveolar ridge extending superiorly in close proximity to the maxillary sinus with a well-defined radiolucent halo surrounded the radiopacity except in the inferior area where it erupted into the oral cavity [Figure 3]. Orthopantomography, waters view and occlusal radiograph revealed a close relation between the maxillary sinus, and the tumor mass [Figure 4] and [Figure 5]. Computed tomography confirmed this relation [Figure 6]. Considering the clinical and radiologic presentations, a diagnosis of infected erupted complex odontoma was determined.
Under general anesthesia, access to the mass was achieved via an intraoral approach by performing a sulcus incision and raising a full thickness flap. The lesion was excised along with the sinus lining [Figure 7], though a communication with the maxillary sinus was identified intraoperatively - this being expected, due to the intimate relation of the sinus to the tumor lesion [Figure 8]. The surgical wound was closed by mobilizing buccal pad fat and palatal reliving incision. The patient was instructed on postoperative care. No postoperative complications were noted [Figure 9] and [Figure 10]. The histological study confirmed the diagnosis of complex odontoma [Figure 11].
| Discussion|| |
Odontoma is the most common type of odontogenic tumor, although some authors prefer to refer it as hamartoma, not a true tumour.  Complex odontomas tend to occur in the posterior region of the jaw and compound odontomas are more common in the anterior maxilla. , They may be discovered at any age, although less than 10% are found in patients over 40 years of age. Although they are commonly asymptomatic, clinical indicators of odontoma may include retention of deciduous teeth, non eruption of permanent teeth, pain, expansion of the cortical bone and tooth displacement. In the present case, pain was the first symptom, probably due to secondary infection, , which can occur because of replacement of bone by a large amount of avascular hard tissue. Eruption of an odontoma through the mucosa could allow invasion of oral microorganisms into the bone due to lack of adequate adhesion between bone and odontoma because of the absence of periodontal ligament.  Odontomas can measure anywhere from a few millimeters to many centimeters in their greatest dimension. The largest found in a human weighed 0.3 kg. ,
Clinically, odontomas  are either complex or compound, and are classified as:
- Intraosseous - these odontomas occur inside the bone and may erupt (erupted odontoma) into the oral cavity. To date, 13 cases of the erupted variety have been described in the literature ,
- Extra osseous or peripheral - odontomas occurring in the soft tissue covering the tooth-bearing portions of the jaws.
Radiologically, odontomas manifest as a dense radiopaque lesion surrounded by a thin radio transparent halo. Three developmental stages can be identified, based on the radiological features and degree of calcification of the lesion at the time of diagnosis. Thus, the first stage is characterized by radio transparency due to the absence of dental tissue calcification, while the second or intermediate stage presents partial calcification, and the third or classically radiopaque stage exhibits predominant tissue calcification with the aforementioned surrounding radio transparent halo.  The tendency toward relapse is greater when the lesion is removed in the noncalcified tissue stage. ,
Compound odontomas show an irregular radiopaque image with variations in contour and size, composed of multiple radiopacities corresponding to the so-called denticles. In the complex type of lesion, radiopacity is not specific; rather, a disorganized, irregular single or multiple mass is identified. In both cases (compound and complex odontomas), a radiotransparent halo corresponding to the connective tissue capsule is present. ,,
In the presence of an X-ray image compatible with odontoma, a differential diagnosis must be established with lesions of inter root location, such as focal residual osteitis, cementoma, calcifying epithelial odontogenic tumors, adenomatoid odontogenic tumors, supernumerary teeth, cementing fibroma or benign osteoblastoma. If the lesion is located at pericoronal level, the differential diagnosis should be established with adenomatoid odontogenic tumors, calcifying epithelial odontogenic tumors, ameloblastic fibrodentinoma or odontoameloblastoma. In the maxillary sinus, the lesion can be confused with sinusitis, periapical infection with antral polyp formation, antral mycosis, displaced teeth or roots, foreign bodies, peripheral osteoma, benign mesenchymal neoplasms, papilloma inversus or antral sarcoma or carcinoma. ,
In our case study of mature complex odontoma which is erupted and in close proximity to the maxillary sinus, all differential diagnosis pertaining to lesions of maxillary sinus and odontomas of pericoronal region should be considered.
Microscopically, compound odontomas consist of a fibrous connective tissue sac surrounding the denticles. The dental tissues that conform these denticles comprise a central core similar to pulp tissue, surrounded by primary dentin and covered with partially demineralized enamel and primary cement. , Complex odontomas in turn show primary or immature dentin as a predominant component, though enamel is also found, exhibiting two possible types of distribution: in a highly calcified area close to the central core, or in a hypocalcified zone with immature enamel. Immature cement is also observed, together with the external connective tissue capsule surrounding the lesion.  These lesions are not usually asymptomatic. In effect, complex odontomas can cause slight bone expansion - a characteristic that distinguishes them from compound odontomas which cause important expansion.
In some cases of erupted odontoma, the patient may refer pain and present suppuration, ,, though normally no evidence of inflammation or infection is present and no enlarged lymph nodes are observed. ,,, Erupted odontomas are more often found in the upper maxilla, ,,, though cases have also been described in the mandible - particularly in the molar region.  In a review conducted by Susana et al, a number of cases of erupted odontomas were found, though all corresponded to compound lesions. They also found that odontomas are twice as common in females as males. 
A very infrequent situation in relation to odontomas is eruption of the lesion into the mouth, as if an erupting tooth were involved. The mechanism of odontoma eruption appears to be different from tooth eruption because of the lack of periodontal ligament in odontoma. Therefore, the force required to move the odontoma is not linked to the contractility of fibroblasts, as is the case for teeth. Although there is no root formation in odontoma, its increasing size may lead to the sequestration of the overlying bone and, hence, occlusal movement or eruption. The increase in the size of the odontoma over time produces a force sufficient to cause bone resorption. 
Another reason for odontoma eruption could be the bony remodeling of the jaws. However, for this to occur dental follicle is required, although indirectly, as it provides both the conductance and chemoattraction for the osteoclasts necessary for tooth eruption. Immunocytochemical investigations have indicated that a pattern of cellular activity involving both reduced dental epithelium and the follicles is associated with tooth eruption. The reduced dental epithelium initiates a cascade of intercellular signals by expressing epidermal growth factor b and transforming growth factor. These factors, in turn, stimulate the follicular cells to produce colony-stimulating factor, which recruits osteoclasts to the follicle. The reduced dental epithelium also secretes proteases, which assist in the breakdown of the follicle to produce a path of least resistance. ,
This epithelial signaling could explain the remarkable consistency of eruption times, as it is likely that the dental epithelium is programmed as part of its functional life cycle10. However, in the case of odontomas erupting into the oral cavity, the mechanism behind the eruption times remains uncertain as some odontomas erupt at a young age and others at an older age. 
Erupted odontomas are most often seen in older people. Thus, it is likely that resorption of the edentulous part of the alveolar process plays a role, but it is also possible that reactive growth of the capsule contributes to this phenomenon.  Eruption at a young age is possible through bone remodeling that might have resulted from the presence of dental follicles. 
In this article, the case described is of infected erupted odontoma, taking into account both its clinical course and diagnosis, together with the treatment, and is similar to those reported in the literature. Radiographically, such lesions may be mistaken for various other lesions. This kind of lesions can be associated with disturbed teeth eruption, can displace the adjacent teeth, or give rise to a dentigerous cyst. Therefore, the absence of the tooth in the dental arch during examination, after its physiological eruption time, should always induce to seek the reason of this condition. The radiological evaluation is then indicated, which can disclose not only the impacted tooth but also the presence of odontoma
The treatment of choice according to most consulted authors is surgical removal. In general, the prognosis of these tumors is very favorable, with a scant tendency toward relapse.
| References|| |
|1.||Kozarzewska M, et al. Z¹b zatrzymany i zêbiak - opis przypadku. Nowa Stomat 1998;7. |
|2.||Niedzielska I, et al. Zêbiak mieszany ¿uchwy. Czas Stomat 2001;40. |
|3.||King N, Wu I. The management of impacted tooth due to an odontoma. Dental Asia 2002:18-23. |
|4.||Gurdal P, Seckin T, Odontomas. Quintessence International. 2001;32. |
|5.||Patiño Illa C, Buenechea Imaz R, Berastegui E, Gay Escoda C. Odontoma compuesto: Aplicación de la regeneración ósea guiada con membrana absorbable de colágeno en un defecto de dos corticales. Av Odontoestomatol 1997;13:447-52. |
|6.||Kaneko M, Fukuda M, Sano T, Ohnishi T, Hosokawa Y. Microradiographic and microscopic investigation of a case of complex odontoma. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85:131-4. |
|7.||López-Areal L, Silvestre Donat F, Gil Lozano J. Compound odontoma erupting in the mouth: 4- year follow-up of a clinical case. J Oral Pathol Med 1992;21:285-8. |
|8.||Patiño Illa C, Berini Aytés L, Sánchez Garcés MA, Gay Escoda C. Odontomas complejos y compuestos: Análisis de 47 casos. Arch Odontoestomatol 1995;11:423-9. |
|9.||Shafer WG, Levy BM, editors. Tratado de patología bucal. México DF: Interamericana; 1987. p. 313-5. |
|10.||Cohen DM, Bhattacharyya I. Ameloblastic fibroma, ameloblastic fibro-odontoma and odontoma. Oral Maxillofac Surg Clin North Am 2004;16:375-84. |
|11.||Iwamoto O, Harada H, Kusukawa J, Kameyama T. Múltiple odontomas of the mandible: a case report. J Oral Maxillofac Surg 1999;57:338-41. |
|12.||Gomel M, Seçkin T. An erupted odontoma: case report. J Oral Maxillofac Surg 1989;47:999-1000. |
|13.||Ragalli CC, Ferreira JL, Blasco F. Large erupting complex odontoma. Int J Oral Maxillofac Surg 2000;29:373-4. |
|14.||Ferrer Ramírez MJ, Silvestre Donat FJ, Estelles Ferriol E, Grau García Moreno D, López Martínez R. Odontoma following eruption in the mouth. Med Oral 2001;6:269-75. |
|15.||Curie RC, Mecer EJ, Alan L. Complex odontoma of the maxillary sinus: report of a case. J Oral Surg 1975;33:45-8. |
|16.||Widad FA, Putrus ST. Erupted odontoma. Oral Surg Oral Med Oral Pathol 1985;59:225-6. |
|17.||Faus LV, Camps AI, Pascual MA, Paricio MJ. Diagnóstico del odontoma compuesto. A propósito de dos casos clínicos. Rev Eur Odontoestomatol 1990;5:325-8. |
|18.||Liu K-Kuang, Hsiao Ching-Kai, Chen Hung-An, Tsai Min-Ywan. Orthodontic correction of a mandibular first molar deeply impacted by an odontoma: A case report. Quintessence Int 1997;28:381-5. |
|19.||Giunta JL, Kaplan MA. Peripheral soft tissue odontomas. Oral Surg Oral Med Oral Pathol 1990;69:406-11. |
|20.||Amado Cuesta S, Gargallo Albiol J, Berini Aytés L, Gay Escoda C. Review of 61 cases of odontoma. Presentation of an erupted complex odontoma. Med Oral 2003;8:366-73. |
|21.||Calatrava L, editor. Lecciones de patología quirúrgica oral y maxilofacial. Madrid: Oteo; 1979. p. 455-6021. |
|22.||Neville BW, Damm DD, Allen CM, Bouquot JF. Odontogenic cysts and tumors. In: Oral and maxillofacial pathology. 2 nd ed. Philadelphia (PA): WB Saunders; 2002. p. 631-2. |
|23.||Tuzum MS. Orofacial pain associated with an infected complex odontoma. case report. Aust Dent J 1990;35:352-4. |
|24.||Vengal M, Arora H, Ghosh S, Pai KM. Large erupting complex odontoma: a case report. 2007;73:169-73. |
|25.||Mupparapu M, Singer SR, Rinaggio J. Complex odontoma of unusual size involving the maxillary sinus: report of a case and review of CT and histopathologic features. Quintessence Int 2004;35:641-5. |
|26.||Wood NK, Goaz PW, Lehnert J. Mixed radiolucent-radiopaque lesions associated with teeth. In: Wood NK, Goaz PW, editors. Differential diagnosis of oral and maxillofacial lesions. Singapore: Harcourt Brace and Company Asia Pte Ltd; 1998. p. 289-314. |
|27.||Junquera L, de Vincente JC, Roig P, Olay S, Rodriguez-Recio O. Intraosseous odontoma erupted into the oral cavity: an unusual pathology. MedOral Patol Oral Cir Bucal 2005;10:248-51. |
|28.||Giunta JL, Kaplan MA. Peripheral soft tissue odontomas. Oral Surg Oral Med Oral Pathol 1990;69:406-11. |
|29.||Ide F, Shimoyama T, Horie N. Gingival peripheral odontoma in an adult: case report. J Periodontol 2000;71:830-2. |
|30.||Ten Cate AR, Nanci A. Physiologic tooth movements: eruption and shedding. In: Nanci A, editor. Ten Cate's oral histology: development, structure and function. St. Louis (MO): Mosby; 2003. p. 275-98. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]