|Year : 2020 | Volume
| Issue : 3 | Page : 308-311
A large complex infected odontome: Case report and review of literature
Jiji V Unni, Deepak Daryani, Vinod Kumar, MP Uthkal
Department of Oral Medicine and Radiology, Malabar Dental College and Research Centre, Edapal, Kerala, India
|Date of Submission||09-Jan-2020|
|Date of Decision||28-Jun-2020|
|Date of Acceptance||21-Jul-2020|
|Date of Web Publication||29-Sep-2020|
Dr. Jiji V Unni
Department of Oral Medicine and Radiology, Malabar Dental College And Research Centre, Edapal, Kerala
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Odontomas are benign, slow-growing, and nonaggressive tumors of the jaw. Odontomas are largely considered as hamartomatous lesions but their exact etiology is still a matter of debate. Odontomes are usually asymptomatic, but sometimes they may interfere with the eruption of the associated tooth leading to its impaction. This case report illustrates large symptomatic infected complex odontome in the left mandibular third molar region. Very interestingly, the patient presented with typical features mimicking osteomyelitis. Various investigations including cone-beam computed tomography (CBCT) were done to differentiate and localize the lesion. This article also discusses the various atypical presentations of odontome described in the literature so far and also the benefits of CBCT in terms of diagnosis and localization of odontomas, especially with respect to impacted tooth and mandibular canal.
Keywords: Cone-beam computed tomography, harmartoma, impacted tooth, odontome
|How to cite this article:|
Unni JV, Daryani D, Kumar V, Uthkal M P. A large complex infected odontome: Case report and review of literature. J Indian Acad Oral Med Radiol 2020;32:308-11
|How to cite this URL:|
Unni JV, Daryani D, Kumar V, Uthkal M P. A large complex infected odontome: Case report and review of literature. J Indian Acad Oral Med Radiol [serial online] 2020 [cited 2020 Oct 30];32:308-11. Available from: https://www.jiaomr.in/text.asp?2020/32/3/308/296582
| Introduction|| |
Paul Broca in 1867 introduced the term “odontoma” to designate odontogenic tumors formed by the excessive development of transitory or complete dental tissue. WHO classifies odontomas as compound and complex. Odontomas have no sex predilection, and mostly seen in the second decade of life. They are usually asymptomatic. Clinically associated with retention of deciduous teeth, noneruption of permanent teeth, pain, expansion of cortical bone, and tooth displacement. The compound odontomas are usually unilocular and contain multiple teeth-like bodies with enamel-capped crowns known as denticles, whereas in complex odontomes, there is no morpho-differentiation and the lesion appears as a single complex mass with haphazard distribution of enamel, dentine, and cementum. Most commonly seen in the maxillary anterior region. The incidence of complex odontome is between 5% and 30%.
The purpose of this paper is to discuss the various atypical presentations of odontoma described in the literature so far and also the benefits of cone-beam computed tomography (CBCT) in terms of diagnosis and localization of odontomas, especially with respect to impacted tooth and mandibular canal.
| Case Report|| |
A 26-year-old male patient reported with a complaint of swelling in the left posterior body of the mandible since 5 years. There was a sudden onset of pain reported 1 year before, which was associated with an extraoral swelling in that region. Pain was of a throbbing type that aggravated on chewing food. An intraoral swelling was also present that had a history of sudden onset which gradually progressed to reach the present state. No history of fever and malaise was reported.
Dental history revealed that a patient had consulted a dentist 5 years back, with a complaint of pain in the same region, followed by extraction of 36, 37. Following surgery, a mild swelling occurred and there was no improvement even after medication.
Extraoral examination revealed no facial asymmetry [Figure 1]; however, the ipsilateral submandibular lymph nodes were palpable and tender. There was no local rise in temperature.
Intraoral examination revealed missing 36, 37 and swelling of the residual ridge with lobulated mucosa on either side of the residual ridge region. The buccal vestibule in the region was partially obliterated. Pus discharge was seen through a sinus opening in the buccal alveolar mucosa. Adjacent to the punctum was a 5–6 mm depression in the buccal vestibule [Figure 2]. No eggshell crackling was present.
Based on the history and clinical examination, a provisional diagnosis of infected extraction socket was given. The differential diagnoses considered was infected residual cyst. Infected odontogenic tumors were also considered as rarities.
Pulp vitality tests revealed that all teeth were vital.
Culture and sensitivity of the pus from the sinus opening resulted in the isolation of Staphylococcus aureus which was sensitive to clindamycin and resistant to amoxycillin/clavulanic acid. Hence, tablet clindamycin was advised 300 mg once daily for 7 days.
The orthopantomograph showed an irregular radio-opaque mass in the left mandibular posterior region surrounded by a radiolucent halo with irregular outer periphery, along with a posteroinferiorly displaced third molar toward the inferior border of mandible. The radiolucent halo was hazy and irregular suggestive of an infection. Inferiorly, the impacted 3rd molar was superimposed on the inferior alveolar nerve canal [Figure 3].
|Figure 3: Orthopantomograph showed an irregular radio-opaque mass in the left mandibular posterior region surrounded by a radiolucent halo.|
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To find out the exact location, extent of the lesion, and also the proximity of the impacted 3rd molar to the inferior alveolar nerve canal, a CBCT was advised.
Cone-beam computed tomography analysis
A well-defined radiolucency with impacted tooth and multiple calcifications was seen in the mandibular left posterior region. Impacted 38 was seen with dilacerated roots and multiple ill-defined radio opacities in the disto-occlusal surface. In the coronal view, the root of 38 was seen in close approximation with the lower border of the mandible with no breach in the continuity. Axial section demonstrates bicortical expansion and breach in the continuity of buccal cortical plate. Expansion of lower border with respect to 38 was also seen. Mandibular canal seemed to be widened in the left quadrant and it was passing through the furcation area with respect to 38 in the sagittal view [Figure 4]. Radiographic diagnosis of complex odontome was given.
|Figure 4: CBCT image showing a well-defined radiolucency with impacted tooth and multiple calcifications superimposed by inferior alveolar canal in the mandibular left posterior region|
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Patient was informed regarding the possibility of paraesthesia and after taking informed consent,
the lesion along with 38 was extracted under local anesthesia [Figure 5]. After the left mandibular nerve block, rotational movements were done using the cryer and gently elevated the mass in pieces from the tooth and surrounding bone.
The extracted mixed tissue lesion was measuring approximately 5 × 5 × 4 cm, which was fixed in formalin, stained with H and E stain and studied under a microscope [Figure 6].
Histopathological examination revealed thin fibrous connective tissue with odontogenic epithelium. Many irregular masses of globular calcifications were also noted suggestive of complex odontome [Figure 7].
|Figure 7: Histopathological examination revealed thin fibrous connective tissue with odontogenic epithelium|
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The patient was recalled after 1 week for suture removal and was found to be symptomatic with paresthesia (tingling sensation) in the left premolar region. A 3-month recall of patient also showed persistence of sensory loss or paresthesia and a well-healed-rounded edentulous ridge.
A postoperative radiograph was taken after 3 months.
| Discussion|| |
Odontomas are considered as hamartomas of aborted tooth formation rather than true neoplasm. They are the most common odontogenic tumors that constitute 22% of all the odontogenic tumors of the jaws and the benign tumors that contain various component tissues of the teeth.
The exact etiology of odontomas is unknown. It has been associated with many factors like local trauma, infection, family history, and genetic mutation as in Gardener's and Hermann's syndrome. The majority of cases (83.9%) occur before the age of 30.
Odontomas mostly are incidental findings during routine radiographic examinations. However, in this case, the patient reported with a pus discharge mimicking osteomyelitis clinically.
A thorough literature search reveals some rare symptomatic presentations of odontoma summarized in [Table 1].
| Conclusion|| |
Odontomas are usually in the inactive stage, but in some cases, it can pose a threat by displacement of teeth and secondary infections. CBCT remains the best imaging method for diagnosing odontomas and making accurate treatment planning. With its ability of 3D visualization, virtual imaging, and accurate measurement software tools, CBCT can exactly detect bony expansions, perforations, proximity of the mandibular canal with the lesion, and impacted tooth. This has also led to better surgical management and better prognosis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]