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| CASE REPORT |
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| Year : 2014 | Volume
: 5
| Issue : 1 | Page : 59-62 |
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Peripheral odontoma: A case report
Bhawarlal Chanaram, Ramkumar Hemalatha, Rajendran Vijayakumar, Haridoss Selvakumar
Department of Pedodontics and Preventive Dentistry, SRM Dental College, Ramapuram, Chennai, Tamil Nadu, India
| Date of Web Publication | 19-Mar-2014 |
Correspondence Address:
Bhawarlal Chanaram
25, Palavedu Road, Mittanamamallee, I.A.F Avadi, Chennai - 55, Tamil Nadu
India
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DOI: 10.4103/0976-433X.129076 
Odontomas refers to any tumor of odontogenic origin. The well-differentiated epithelial and mesenchymal cell gives rise to ameloblast and odontoblast which lays down enamel, dentin and pulpal tissue of the odontoma. The enamel thus laid is in an abnormal pattern and is considered as a developmental anomaly rather than true neoplasm. Odontomas are hamartomatous developmental malformations of odontogenic origin which manifest as denticles, or amorphous masses comprising of the dental tissues. Although a majority of odontomas are intraosseous; there are case reports of odontomas that erupted into the oral cavity. Even less common are peripheral or soft-tissue odontomas, only a few of which have been reported to date. They commonly occur in the pre-maxillary region and associated complications include delayed or uneruption of permanent teeth, retention of the primary teeth and dentigerous cyst formation. Management usually requires surgical removal of the odontoma and the impacted tooth followed by subsequent orthodontic intervention to correct the malocclusion. The present case report describes a case of peripheral odontoma that was present in the alveolar mucosa of a 12-year-old female patient who reported with a chief complaint of unerupted left maxillary lateral incisor. The diagnosis, complications, treatment and prognosis of this entity will be discussed. Keywords: Hamartoma, maxilla, peripheral odontoma, unerupted lateral incisor
How to cite this article:
Chanaram B, Hemalatha R, Vijayakumar R, Selvakumar H. Peripheral odontoma: A case report. SRM J Res Dent Sci 2014;5:59-62 |
| Introduction | |  |
The term "Odontoma" was coined by Paul Broca in 1867. Odontomas are considered as the developmental anomalies resulting from the growth of completely differentiated epithelial and mesenchymal cells that give rise to ameloblast and odontoblast. These tumors are formed of enamel and dentin but they can also have variable amount of cementum and pulp tissue. [1],[2] Although the lesions are usually intraosseous, there have been a few isolated reports of odontomas that have erupted into the oral cavity. Still rarer are "peripheral" or "soft-tissue odontomas," of which only a few have been reported to date. [3] Odontomas rarely erupt into the oral cavity. Since 1980, only 17 cases have been reported; eight were complex odontomas and nine were compound odontomas. [4]
In this case report, a 12-year-old patient with compound odontoma localized in the alveolar mucosa was treated surgically which allowed the eruption of permanent teeth, is described.
| Case Report | | |
A 12-year-old female patient reported to the Department of Pedodontics and Preventive dentistry, SRM Dental College, with a chief complaint of missing left upper front teeth. History revealed that the corresponding primary teeth had exfoliated six months back with no sign of eruption of permanent teeth. There was no history of trauma, deformities or swelling of maxillofacial region; her medical history was non-contributory. Clinical examination extra-orally revealed a bilaterally symmetrical face. No abnormality was detected in relation to upper and lower lips. On intraoral examination, no abnormality was detected in relation to labial mucosa, buccal mucosa, vestibule, floor of the mouth and gingiva. Also there was clinically missing maxillary left lateral incisor [Figure 1], the overlying alveolar mucosa was normal, maxillary primary canine exhibited grade III mobility and no other abnormal findings was elicited. A periapical radiograph of the region [Figure 2] showed multiple radiopaque masses in relation to crown of maxillary left lateral incisor. The root formation of the lateral incisor was not completed and root of 63 was resorbed. A panoramic radiograph [Figure 3] revealed absence of similar radiopaque mass in other regions. An occlusal radiograph [Figure 4] showed a radiopaque mass, which was labially placed. Based on clinical and radiologic evaluation, a provisional diagnosis of odontoma was obtained along with a differential diagnosis of peripheral ossifying fibroma, cementoblastoma, osteoid osteoma and cement ossifying fibroma. Surgical excision of odontoma mass was planned under local anesthesia. The mucoperiosteal flap towards labial aspect of 22 region was elevated, which revealed presence of numerous denticles [Figure 5] The crown of unerupted permanent lateral incisor was also present at the superior border of the lesion [Figure 6]. The entire mass was carefully excised, left deciduous canine was also extracted and the area was irrigated with povidone iodine solution. The flap was placed back and held in position with the help of 3-0 silk sutures. Macroscopically the specimen resembled rudimentary tooth [Figure 7]. Histopathological investigation confirmed the diagnosis of compound odontoma [Figure 8]. Since the root formation of lateral incisor was not completed, it was allowed to erupt on its own .Spontaneous eruption was seen after 6 month follow-up [Figure 9]. | Figure 1: Intraoral view showing unerupted left maxillary lateral incisor
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 | Figure 2: Intraoral periapical radiograph of 21 and 22 region shows multiple calcified tissues in relation to crown of unerupted 22
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 | Figure 3: OPG showing impacted 22 and calcified mass in relation to crown of 22
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 | Figure 4: Occlusal radiograph showing calcified mass labially placed in relation to crown of 22
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 | Figure 5: Mucoperiosteal flap towards labial aspect of 22 was elevated, which revealed presence of numerous denticles
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 | Figure 6: Crown of unerupted permanent lateral incisor seen at the superior border of the lesion
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| Discussion | | |
Odontomas are hamartomas of aborted tooth formation, which account for 22% of the odontogenic tumors. [5] Complex and compound odontoma are two types of odontomas recognized based on gross, radiographic and microscopic features. [6] The odontomas that are comprised of dental tissue elements are arranged so that they resemble recognizable teeth or tooth like structures, which are referred to as compound types, whereas complex type odontomas consist of a mass or masses of disorganized dental tissues without any semblance of functional arrangement. [2] According to their position within the jaws, odontomas may be intraosseous and extraosseous or peripheral odontomas. [6] Approximately, 10% of all odontogenic tumors of the jaws are compound odontomas. [7] The incidence of compound odontoma ranges between 9% and 37% and the complex odontoma is between 5% and 30%. [7] Odontomas are discovered during the second and third decades of life. The compound odontoma is slightly more common than the complex odontoma, which in turn is more common than the ameloblastic odontoma. The majority of odontomas in the anterior segment of the jaws are compound composite in type (61%), whereas the majority in the posterior segment is complex composite in type (34%). [6] Interestingly both type of odontomas occurs more frequently on the right side of the jaw than on the left (compound 62%, complex 68%). [6] The etiology of odontomas is unknown. It has been related to various pathological conditions, like local trauma, inflammatory and/or infectious processes, mature ameloblasts, cell rests of Serres (dental lamina remnants) or due to hereditary anomalies (Gardner's syndrome, Hermann's syndrome), odontoblastic hyperactivity, alterations in the genetic component responsible for controlling dental development. [6] They are odontomas discovered during the first two decades of life and there is no significant gender predilection. They often remain asymptomatic and undiscovered until revealed by routine radiography where they characteristically appear as dense, radiopaque masses. Sometimes clinical indicators of their presence may include bone expansion, pain and tooth displacement or unerupted normal teeth. Enucleation is curative and recurrence is not a problem. Compound odontoma is more common in the anterior segment of the jaw (61%). [8] The differential diagnosis includes peripheral ossifying fibroma, cementoblastoma, osteoid osteoma and cemento-ossifying fibroma. The definitive diagnosis of peripheral ossifying fibroma is based on histologic examination with the identification of cellular connective tissue and the focal presence of bone or other calcifications. [9] In our case histologic features were suggestive of compound odontoma. A cementoblastoma presents as a well-defined radio-opaque mass attached to the tooth root and surrounded by a radiolucent rim, [10] but in our case it was not associated with the roots. Osteoid osteomas are characterized by a small ovoid or round radiolucent area surrounded by a rim of sclerotic bone; the central radiolucency exhibits some calcification. [10] Cemento-ossifying fibroma presents as a well-defined radiolucency with increasing flecks of calcification as it matures; it is not surrounded by a radiolucent rim and it is diffuse with normal bone. [11] Also, none of these is associated with an impacted tooth, in contrast to our case where it was associated with impacted lateral incisor. Odontomas often cause disturbances such as, impaction or delayed eruption, retention of primary teeth, or abnormalities in the position of the teeth such as tipping or displacement of adjacent teeth. Nine percent of unerupted teeth are associated with odontoma. [12] Pain, swelling and infection were the most common symptoms. Thirteen cases presented with an impacted tooth associated with the lesion. Odontoma has a limited growth potential; it should be removed completely to prevent relapse. [12] Sreedharan et al. suggested that to prevent impaction of permanent adjacent to the odontomas, it should be removed when the permanent teeth exhibit one half of their root development. [13] When the odontoma is positioned entirely external to the alveolar bone, gradual maturation of a peripheral odontoma may lead to its unaided eruption into the oral cavity; [14] however, in this case surgical excision of the mass was planned since it was obstructing the eruption of lateral incisor. In a review of 47 cases of unerupted maxillary incisors, spontaneous eruption of teeth occurred in 50% of cases after surgical removal of odontoma. [12] Hence in our case after surgical removal of the odontoma, the lateral incisor was allowed to erupt spontaneously without orthodontic intervention. The permanent lateral incisor erupted in the oral cavity after six months.
| Conclusion | | |
Though odontoma has limited growth potential, it has to be removed to prevent complications. Whenever a child presents with missing teeth, radiographic examination should be done to rule out any other pathology. Though odontomas are benign in nature, their eruption into the oral cavity can give rise to pain, inflammation and infection. The treatment of choice is surgical removal of the odontoma, followed by histological analysis. In the case of odontomas associated to impacted teeth, the latter should be preserved in wait of spontaneous eruption of the succeeding tooth. The esthetic appeal along with psychological support thus initiated can prove to be of aid rendered for the patient among their peer groups. Early diagnosis of odontomas allows adoption of a less-complex and less-expensive treatment and ensures better prognosis.
| References | | |
| 1. | Shafer. Hine and Levy: A text book of Oral Pathology. 4 th ed. Philadelphia: W.B. Saunders; and Co 1993. p. 308-12. 
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| 2. | Damm N, Bouquot A. Oral and maxillofacial pathology. 2 nd ed. Philadelphia: Saunders and Co; 2004. p. 631-2.
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| 3. | Castro GW, Houston G, Weyrauch C. Peripheral odontoma: Report of case and review of literature. ASDC J Dent Child 1994;61:209-13.
|
| 4. | 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;14:299-303.
|
| 5. | Bhaskar SN. Odontogenic tumors of jaws in synopsis of oral pathology. 7 th ed. United States: Mosby; 1986. p. 292-303.
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| 6. | V Satish, Maganur C Prabhadevi, Rajesh Sharma Odontome: A Brief Overview International. J Clin Pediatr Dent 2011;4:177-85.
|
| 7. | Philpsen HP, Reichert PA, Ractorious F. Mixed odontogenic tumors and odontomas. Considerations on interrelationship. Review of literature and presentation of 134 new cases of odontomas. Oral Onocol 1997;33:86-7.
|
| 8. | Betts A, Camilleri GE. A review of 47 cases of unerupted maxillary incisors. Int J Paediatr Dent 1999;9:285-92.
|
| 9. | García de Marcos JA, García de Marcos MJ, Arroyo Rodríguez S, Chiarri Rodrigo J, Poblet E. Peripheral ossifying fibroma: A clinical and immunohistochemical study of four cases. J Oral Sci 2010;52:95-9.
|
| 10. | Vengal M, Arora H, Ghosh S, Pai KM. Large erupting complex odontoma: A case report. J Can Dent Assoc 2007;73:169-73.
|
| 11. | De Oliveria BH, Compas V, Marcal S. Compound odontoma - diagnosis and treatment: Three case reports. Pediatr Dent 2001;23:151-7.
|
| 12. | Batra P, Gupta S, Rajan Kumar, Duggal R, Hariprakash. Odontomes-diagnosis and treatment. A Case Report. JPFA 2003;19:73-6.
|
| 13. | Sreedharan S, Krishnan IS. Compound odontoma associated with impacted maxillary incisors. J Indian Soc Pedod Prev Dent 2012;30:275-8.
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| 14. | Ide F, Shimoyama T, Horie N. Gingival peripheral odontoma in an adult: Case report. J Periodontol 2000;71:830-2.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
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