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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 36  |  Issue : 2  |  Page : 88-90

A complex odontoma of the anterior maxilla associated with an unerupted maxillary central incisor: A rare entity


Department of Oral and Maxillofacial Surgery, Pacific Dental College and Hospital, Udaipur, Rajasthan, India

Date of Submission04-Mar-2021
Date of Decision18-Dec-2021
Date of Acceptance04-Aug-2022
Date of Web Publication16-Nov-2022

Correspondence Address:
Dr. Abhishek Shukla
Pacific Dental College and Hospital, Udaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jms.jms_46_21

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  Abstract 


Odontomas are the most common odontogenic tumors. They are usually asymptomatic and are often discovered during routine radiography. We report a case of complex odontoma in the maxillary anterior region that caused pain and prevented the eruption of a maxillary central incisor. This case is significant as there are very few reports of complex odontoma erupting in the maxillary anterior region of the oral cavity.

Keywords: Complex odontoma, excision, maxilla


How to cite this article:
Shukla A, Rai B, Gupta H, Gadhiya V, Patel K. A complex odontoma of the anterior maxilla associated with an unerupted maxillary central incisor: A rare entity. J Med Soc 2022;36:88-90

How to cite this URL:
Shukla A, Rai B, Gupta H, Gadhiya V, Patel K. A complex odontoma of the anterior maxilla associated with an unerupted maxillary central incisor: A rare entity. J Med Soc [serial online] 2022 [cited 2022 Nov 28];36:88-90. Available from: https://www.jmedsoc.org/text.asp?2022/36/2/88/361284




  Introduction Top


Odontoma is the most frequently occurring and slow-growing odontogenic benign tumor that is commonly seen in the age group of 11–20 years and is regarded as a hamartoma. Odontoma accounts for 22% of all odontogenic tumors.[1] The etiology behind odontomas is still unknown, but it is linked with various pathological conditions such as inflammatory processes, local trauma, cell rests of Serres (dental lamina remnants), mature ameloblasts, or due to some acquired anomalies (Hermann syndrome and Gardner's syndrome).[2] There are two distinct varieties of odontomas: complex odontoma and compound odontoma. Depending on the size, a complex odontoma is smaller in contrast to the compound type. The complex odontoma comprises a disordered mass of calcified tissue lined by a thin soft-tissue component, whereas the compound odontoma is distinguished by a radiopaque mass that is similar to the denticles enclosed by a thin soft-tissue capsule.[3] The prevalence of compound odontomas in permanent upper anterior teeth accounts for their early diagnosis as compared to the complex variant.[4] Compound odontomas exhibit a great predilection for the anterior maxilla, validating the theory proposed by Philipsen et al. that this region presents conditioned hyperactivity of the dental lamina,[5] favoring the development of compound type and supernumerary teeth. In cases associated with impacted teeth, the tumor is generally located on the eruption pathway of permanent teeth, avoiding the normal eruption of the related teeth. Consequently, impacted teeth can contribute to developing malocclusion.[5] This article presents a case report of a complex odontoma present over the anterior maxillary region with an unerupted maxillary central incisor along with its management and successful treatment outcome.


  Case Report Top


A 15-year-old female girl of Udaipur city india reported to the department of oral and maxillofacial surgery pacific dental college and hospital Udaipur. Her vital parameters were found to be within normal limits. No abnormalities were detected in other organ systems. There was no evidence of facial asymmetry. She was undergoing orthodontic treatment. The intraoral examination revealed a missing left central incisor and swelling present on the labial side of the same region. When palpated, the swelling was a well-defined, firm bony nodule measuring approximately 1 cm in diameter, fixed to the underlying tissue, and nontender. The presence of both buccal and lingual cortical plates could be appreciated.

Radiological assessment

A cone-beam computed tomography was advised for the patient, which disclosed a radiopaque mass which was well-defined (about 1 cm × 1 cm) and surrounded by a thin radiolucent band, present just below the impacted left central incisor [Figure 1]. Based on this correlation of clinical and radiological investigation, a provisional diagnosis of an odontoma was made.
Figure 1: CT imaging showing large radiopaque mass with an associated impacted maxillary central incisor

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Differential diagnosis

The clinical and radiographic features suggested the diagnosis of odontoma, although other differential diagnoses included calcifying odontogenic cyst, calcifying odontogenic tumor, fibro-osseous lesion, ameloblastic fibro-odontoma, and osteoblastoma. Ossifying fibroma may closely mimic an odontoma but can be differentiated from it by the fact that it is well circumscribed and usually separates easily from its bony bed.

Treatment

After discussing all possible lines of treatments and consultation with the orthodontist, probable outcomes were explained to the patient and informed consent was signed by the patient's legal guardian. The patient was prescribed preoperative antibiotics and a corticosteroid. Surgical removal of the bony lesion together with exposure of the crown of the left maxillary central incisor under local anesthesia was planned. After following all the COVID-19 safety protocols and maintaining an aseptic environment, the lesion was approached intraorally by reflecting the mucoperiosteal flap on the labial surface. The bony lesion was sectioned into small parts to allow easy excision with minimal bone removal using a surgical bur and saline irrigation as a coolant [Figure 2]. The lesion was completely excised with its fibrous capsule after thorough curettage and wound toilet. Hemostasis was achieved with the labial flap repositioned and sutured using silk suture. Proper postoperative instructions and medications were given to the patient. A 7-day follow-up was recommended to exclude any postoperative complications. The specimen was transported for histopathological examination in 10% formalin to rule out odontoameloblastomas and ameloblastic fibro-odontomas, which have a strong radiographic resemblance to common odontomas.
Figure 2: Elevation of mucoperiosteal flap and removal of complex odontoma

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Outcome and follow-up

The diagnosis of a complex odontoma was confirmed by histopathological examination as there was the presence of mature dental tissues such as enamel, dentin, and cementum arranged as unstructured sheets. Components of the enamel organ were also present, and a large mature tubular dentin was apparently seen [Figure 3]. No clinical or radiographic evidence was found of a recurrence of the mass or any other related complications after 6 months of follow-up. The patient continues to be on regular follow-up.
Figure 3: Histopathology image displaying presence of mature dental tissues such as enamel, dentin, and cementum arranged as unstructured sheets

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  Discussion Top


Odontomas can be described as hamartomatous developmental malformations or lesions of odontogenic origin that are nonaggressive and emerge as small, solitary, or multiple radiopaque lesions that appear on routine radiographic examinations.[5],[6] In 1867, Paul Braco coined the term “odontoma” and defined it as a tumor developed by the overgrowth or transition of complete dental tissue. Odontomas are also known as “composite” because they consist of more than one type of tissue.[7] It is mostly manifested as asymptomatic and is diagnosed by routine radiographs of the site. The WHO in the year 2017 broadly classified odontomas into two types: compound and complex. Based on their clinical appearance in the oral cavity, odontoma can be categorized as central (intraosseous), peripheral (soft tissue or extraosseous), and erupted odontoma.[8] The central (intraosseous) type accounts for 51% of odontoma, with the compound type occurring in the anterior maxillary region and the complex type occurring in the posterior mandibular molar region[5] Peripheral odontomas are rare and occur in the soft tissue over the tooth-bearing area; the most commonly reported ones are of compound variety.[9] The erupted odontoma is found coronal to an erupting or impacted tooth or superficially in bone, and its presence may have justified its eruption into the oral cavity. Complex odontoma accounts for 5%–30% of all odontogenic tumors. Histologically, complex odontoma manifests as a disorganized mass of odontogenic tissues which is intermixed with cementum-like substances and dentinoid structures. Within the calcified mineralized masses, the pulp tissue, epithelial remnants, and enamel matrix are present.[1] It is reported that the ratio of compound to complex odontomas is 2:1 (Gomel and Seçkin, 1989; Kaneko et al., 1998; LópezAreal et al., 1992; Patiño Illa et al., 1995; Patiño Illa et al., Litonjua et al.,1995; Soluk Tekkesin et al., 2012; Hale et al., 1973).[2],[7],[9] Compound odontomas are usually located in the anterior maxilla, either above the crowns of unerupted teeth or between the roots of erupted teeth. Conversely, complex odontomas are generally found in the posterior mandible, about 10%–44% of a complex odontoma is associated with impacted teeth of the posterior mandible (Soluk Tekkesin et al., 2012; LópezAreal et al., 1992; Hale et al., 1973; Angiero et al., 2005; Sasaki et al., 2002; Lewandrowski et al., 1996). [4],[7],[10] In 45% of cases, the excision of the odontoma mass in the primary operation results in the eruption of the unerupted tooth.[10] There is the morphology of the tooth space available in the dental arch, location in the jaw, and age of the patient are several factors which determine the fate of the unerupted tooth.[11] As 27.6% of cases of odontoma are associated with cysts and there are many possible complications related to the cyst, the odontomas should be properly assessed and excised completely in case of any uncertainty of cystic transformation.[10] This warrants the removal of the odontomas. There have been very few cases of complex odontoma of the anterior maxilla reported in the literature and whose management also was reported as complete excision.


  Conclusion Top


An odontoma is a nonaggressive lesion usually identified by routine radiological examination. The clinical features may vary from no symptoms to nerve paresthesia. Complex odontomas are seen rarely when compared to other odontomas. Complex odontomas should be surgically excised because they are manifested by the expansion of cortical plates and, if left untreated, can lead to pathological fracture of the bone and cause a tooth to remain unerupted, which would further progress to a malocclusion.

Acknowledgment

The patient involved in this case report agrees to allow her X-rays and clinical photos to be used for scientific purposes and has signed consent for it.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pillai A, Moghe S, Gupta MK, Pathak A. A complex odontoma of the anterior maxilla associated with an erupting canine. BMJ Case Rep 2013;2013:bcr2013200684.  Back to cited text no. 1
    
2.
Abdul M, Pragati K, Yusuf C. Compound composite odontoma and its management. Case Rep Dent 2014;2014:107089.  Back to cited text no. 2
    
3.
Zoep Z, Joseph T, Varma B, Mungara J. A compound composite odontoma associated with unerupted permanent incisor – A case report. J Indian Soc Pedod Prev Dent 2004;22:114-7.  Back to cited text no. 3
    
4.
de Oliveira BH, Campos V, Marçal S. Compound odontoma – Diagnosis and treatment: Three case reports. Pediatr Dent 2001;23:151-7.  Back to cited text no. 4
    
5.
da Silva VA, Pedreira RP, Sperandio FF, Nogueira DA, de Carli ML, Hanemann JA. Odontomas are associated with impacted permanent teeth in orthodontic patients. J Clin Exp Dent 2019;11:e790-4.  Back to cited text no. 5
    
6.
Naville BW, Damm DD, Allen CM, Chi AC, Oral and Maxillofacial Pathology. 2nd ed. Philadelphia, Pa, USA: WB Saunders; 2002. p. 631-2.  Back to cited text no. 6
    
7.
Bagewadi SB, Kukreja R, Suma GN, Yadav B, Sharma H. Unusually large erupted complex odontoma: A rare case report. Imaging Sci Dent 2015;45:49-54.  Back to cited text no. 7
    
8.
Serra-Serra G, Berini-Aytés L, Gay-Escoda C. Erupted odontomas: A report of three cases and review of the literature. Med Oral Patol Oral Cir Bucal 2009;14:E299-303.  Back to cited text no. 8
    
9.
Vlcek D, Reichart PA, Bosshardt DD, Sleiter R, Bornstein MM. Prevention of the eruption of an upper later incisor by a compound odontoma. Case report. Schweiz Monatsschr Zahnmed 2012;122:1147-60.  Back to cited text no. 9
    
10.
Spini PH, Spini TH, Servato JP, Faria PR, Cardoso SV, Loyola AM. Giant complex odontoma of the anterior mandible: Report of case with long follow up. Braz Dent J 2012;23:597-600.  Back to cited text no. 10
    
11.
Vengal M, Arora H, Ghosh S, Pai KM. Large erupting complex odontoma: A case report. J Can Dent Assoc 2007;73:169-73.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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