|Year : 2014 | Volume
| Issue : 2 | Page : 192-195
Erupting complex odontoma: Report of a rare case
Pinakapani Ramakrishna1, Nallan CSK Chaitanya2, Pavan Kumar Yellarthi3, Nisheeth Saawarn4
1 Department of Oral Medicine and Radiology, Government Dental College, Raipur, Chhattisgarh, India
2 Department of Oral Medicine and Radiology, Panineeya Mahavidyalaya Institute of Dental Sciences and Research Centre, Hyderabad, Telangana, India
3 Department of Oral Medicine and Radiology, Visakhapatnam, Andhra Pradesh, India
4 Department of Oral Medicine and Radiology, Peoples' College of Dental Sciences and Research Centre, Bhopal, Madhya Pradesh, India
|Date of Submission||30-Jun-2014|
|Date of Acceptance||30-Sep-2014|
|Date of Web Publication||30-Oct-2014|
Department of Oral Medicine and Radiology, Government Dental College, Rajbandhe Maidan, Raipur, Chhattisgarh - 492 001
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Odontomas are the most frequent hamartomatous lesions involving the oral cavity. The complex variant is an agglomerate of all dental tissues characterized by abnormal morphodifferentiation despite normal histodifferentiation. These are usually asymptomatic and are frequently associated with eruption disturbances. We report an unusual case of erupting complex odontoma associated with an impacted maxillary second molar.
Keywords: Complex odontoma, maxillary second molar, panoramic radiograph
|How to cite this article:|
Ramakrishna P, Chaitanya NC, Yellarthi PK, Saawarn N. Erupting complex odontoma: Report of a rare case
. J Indian Acad Oral Med Radiol 2014;26:192-5
|How to cite this URL:|
Ramakrishna P, Chaitanya NC, Yellarthi PK, Saawarn N. Erupting complex odontoma: Report of a rare case
. J Indian Acad Oral Med Radiol [serial online] 2014 [cited 2020 Mar 29];26:192-5. Available from: http://www.jiaomr.in/text.asp?2014/26/2/192/143700
| Introduction|| |
Odontomas are classified as hamartomatous malformations that are essentially made up of irregular masses of hard and soft tissues of odontogenic origin. Many still consider them as an odontogenic tumors composed of enamel, dentin, cementum, and pulp tissue.  Although its pathogenesis is debatable, both the ectomesenchymal and epithelial components of the developing tooth bud are present, exhibiting abnormal morphodifferentiation, despite normal histodifferentiation. 
The latest classification of the World Health Organization (WHO 2005) has placed odontomas under two types: Complex odontomas and compound odontomas. Odontomas are considered the most common odontogenic lesion, accounting for about 22-67% of all odontogenic tumors.  Clinically, they are asymptomatic and slow-growing, seldom reaching more than 3 cm in diameter.  A majority of the odontomas in the anterior segment of the jaw are compound odontomas (61%), whereas, the majority in the posterior segment are complex odontomas. 
We are presenting an unusual case of a complex odontoma erupting into the oral cavity, associated with an impacted permanent maxillary second molar in a 32-year-old female patient.
| Case Report|| |
A 32-year-old female patient reported to the Outpatient Department with a complaint of pain and mild swelling in the right upper back teeth region, since seven months. The patient revealed that the pain was dull in character and was causing occasional discomfort during mastication. The pain subsided by taking analgesics. Her medical and dental histories were noncontributory.
The extraoral examination was unremarkable. Intraorally, her permanent dentition was complete except for a missing right maxillary second molar tooth. Careful examination of this region revealed a well-defined solitary lesion measuring 1 cm in the greatest dimension, both mesiodistally and buccolingually, involving the alveolar ridge. The surface of the lesion had a nodular growth, with areas of inflammation because of trauma from the opposing mandibular tooth [Figure 1]. On palpation, mild tenderness was elicited in the area. The lesion was soft in consistency and showed no tendency to bleed. Gentle probing of the lesion demonstrated an underlying hard (calcified) tooth-colored material that was immobile, and whose dimensions were not recordable. A provisional diagnosis of an impacted right maxillary second molar was made.
Panoramic radiographic examination [Figure 2] revealed a well-defined radiopaque mass involving the region of the right maxillary posterior teeth, posterior to the first molar. The permanent maxillary second molar was impacted. The radiopaque structure was irregular, exhibiting a thin radiolucent zone surrounding it. The internal structure was wholly radiopaque, suggestive of an irregular mass of calcified tissue, except for a radiolucent area at the most posterior aspect of the mass. The degree of radiopacity exceeded that of the adjacent tooth structure. Differential diagnoses that were considered included complex odontoma, cemento-ossifying fibroma, ameloblastic fibro-odontoma, periapical cemental dysplasia, and enostosis.
|Figure 2: Cut section of a panoramic radiograph revealing the complex odontoma and an impacted maxillary molar tooth|
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The lesion [Figure 3] and the impacted maxillary second molar were surgically excised under local anesthesia, the edges of the bone were smoothened, rinsed with saline, and sutured. The postoperative course was uneventful. The excised specimen was sent for histopathological examination. The histopathological examination revealed disorganized dental tissue constituting irregular dentin masses and multiple hollow circular spaces with pulp tissue and enamel matrix. Sections also revealed proliferating odontogenic epithelium in a scanty stroma [Figure 4]. The above findings were consistent with the diagnosis of a complex odontoma.
| Discussion|| |
It was Paul Broca in 1867, who first used the term 'Odontoma'. He defined the term as, "a tumor formed by overgrowth of transitory or complete dental tissues".  Of late, the WHO has classified odontomas as odontogenic tumors of the odontogenic epithelium with odontogenic mesenchyme with or without hard tissue formation.  The WHO classification defines the complex odontoma as, "a malformation in which all the dental tissues are represented, individual tissues being mainly well formed but occurring in a more or less disorderly pattern".  At present, three clinical variants of odontomas are recognized - central (intraosseous), peripheral (extraosseous), and erupted odontomas.  The erupted odontoma is an intraosseous odontoma that erupts into the oral cavity,  whereas, the peripheral one occurs only in the soft tissue covering the tooth-bearing portion of the jaw. 
The etiology of the odontoma is unknown. Theories proposed include infection, local trauma, familial history, hereditary anomalies, odontoblastic hyperactivity, and molecular events responsible for controlling tooth development. ,
Clinically, odontomas are asymptomatic. They are usually associated with retention of deciduous teeth, noneruption of permanent teeth, occasional pain, mild expansion of the cortical bone, and tooth displacement.  Pain and swelling are the most common symptoms when odontomas are erupting or have just erupted. Our patient had also presented with similar signs and symptoms. Odontomas do not show any gender predilection and are usually detected in the second decade of life.  Although complex odontomas tend to occur more in the posterior regions of the mandible, they can occur in other regions of the jaw. 
The radiological findings of odontoma depend on the stage of development and degree of mineralization. The initial stages are characterized by radiolucency, because of the absence of calcification. The intermediate stage has a mixed radiopaque and radiolucent appearance, whereas, the last stage appears predominantly radiopaque, and is surrounded by a radiolucent rim corresponding to the connective tissue, histologically. The presence of thin sclerotic margins adjacent to the radiolucent rim resembles the corticated border seen in a normal tooth crypt. 
On the basis of the presenting clinical features and radiographic findings in our patient, a diagnosis of complex odontoma was made. They differ from cemento-ossifying fibromas, as they are more radiopaque and have a tendency to associate with unerupted molar teeth. Odontomas occur more among younger patients as compared to cemento-ossifying fibromas. Although periapical cemental dysplasia might resemble the complex odontoma, they are usually multiple and centered on the periapical region of the teeth. In addition, the periphery of cemental dysplasia usually has a wider uneven sclerotic border. Differentiating ameloblastic fibro-odontoma (AFO) from a developing odontoma might be difficult, but generally these tumors have a greater soft tissue component (radiolucency) than the odontoma. A complex odontoma usually has a mass of disorganized tissue in its center, whereas, the AFO usually has multiple, scattered, mature, and small pieces of dental hard tissue. Also, the AFO occurs in older individuals as compared to the complex odontoma. Regions of enostosis, although radiopaque, do not have a soft tissue capsule, as seen in odontomas. 
Conservative surgical enucleation is by and large the most sought after treatment of choice, as odontomas are rarely seen as being large, and no cases of recurrence have been reported.  In the present case, the lesion was totally and carefully removed without causing damage to the adjacent structures. About 70% of the odontomas, if left untreated, are associated with pathological changes such as - impaction, malpositioning, aplasia, malformation, and devitalization of the adjacent teeth.  An unusual case of sellar compound odontoma that induced hypophysis disruption, and therefore, hypothyroidism, diabetes, and growth retardation in a nine-year-old child, has also been reported. 
In conclusion, odontomas are common hamartomatous lesions occurring mostly in the second decade of life with no gender predilection. Clinically, they are often asymptomatic, might cause occasional pain and swelling, and rarely facial asymmetry. Most often they are the reason for impacted, malpositioned, aplasia, malformation, and devitalization of adjacent teeth. Thus, an oral diagnostician should keep odontomas as a priority in their differential diagnoses in the above-mentioned clinical situations.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]