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IJSS Case Reports& Reviews | August 2014 | Vol 1 | Issue 312

Compound Odontoma Associated with ImpactedTeeth: A Case Report

Palak Jain Choudhary1

, Harshkant P Gharote2

, Kartik Hegde2

, Palak Gangwal1

1Postgraduate Student, Department of Oral Medicine and Radiology, Peoples College of Dental Science and Research Centre, Bhopal, Madhya

Pradesh, India, 2Reader, Department of Oral Medicine and Radiology, Peoples College of Dental Science and Research Centre, Bhopal, Madhya

Pradesh, India

Odontomas are developmental anomalies of the dental tissues and may interfere with the eruption of the associated tooth. Since, these

lesions are asymptomatic, they are usually detected in routine radiographs only. Early diagnosis, prompt clinical decision making followed

by a proper treatment at the right time, results in a favorable prognosis. Te present report describes the surgical management of a case

of compound odontoma in 11-year-old boy who presented with a complaint of missing tooth in maxillary anterior region. After the lesion

was surgically removed under local anesthesia, histopathological examination confirmed the diagnosis of compound odontoma. Te related

literature is also reviewed in this article.

Keywords:Compound odontoma, Delayed tooth eruption, Maxilla, Odontogenic tumors, Odontoma

tooth. Patient was asymptomatic, and his past dental and

medical history was not significant. Intraoral examination

revealed that 11, 12, and 13 had not erupted into the

oral cavity, but 21, 22, and 23 were present (Figure 1).

There was no sign of inflammation, pain or infection and

surrounding mucosa was normal. An intraoral periapical

radiograph revealed presence of 11 deep in alveolar bone.

The crown of the unerupted 11 was overlapped by tooth

like masses (Figure 2). Intraoral periapical radiograph

showed a collection of tooth-like structures with a narrow

radiolucent rim around. The orthopantomograph showed

multiple radio-opaque teeth-like structures in relation

to unerupted maxillary right central incisor surrounded

by a radiolucent band with smooth outer periphery

INTRODUCTION

Variation in the normal eruption of teeth is a common

finding, but significant deviations from normal should

alert the clinician to investigate further. It is suggested

that an individualized radiographic examination should

be performed for patients who present with clinical

evidence of delayed permanent tooth eruption or temporary

tooth displacement or retained deciduous teeth with or

without a history of previous dental trauma. This will

help the clinician rule out pathologies like odontoma. The

odontoma, a mixed odontogenic tumor emulating all thehard tissues products of a mature tooth germ, is almost

certainly the most common type of odontogenic tumor

or hamartomas.1WHO 2005, has classified two types as;

complex and compound odontomes, occurring in the ratio

of 1:2.2The majority of compound odontoma cases (74.3%),

are diagnosed before the age of 20 years,3during routine

radiographic examination, occurring commonly in the

anterior maxillary region. Thus, early diagnosis will

facilitate the clinician to adopt a simpler and less complex

approach of treatment for a beer prognosis. In spite of the

low frequency and good prognosis, there must be a close

follow-up of such lesions, because these lesions are reported

to be associated with conditions such as ameloblastoma,

adenomatoid tumor, and carcinoma.

CASE REPORT

An 11-year-old boy came to the department with the

chief complaint of non-eruption of the upper right front

Case Report

Corresponding Author:

Dr. Palak Jain Choudhary, H.No-111, Sagar Avenue, Ayoudhya Bypass, Bhopal, Madhya Pradesh, India. E-mail: [email protected]

Figure 1:Eruption bulge with missing permanent teeth

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IJSS Case Reports& Reviews | Vol 1 | Issue 3 13

Choudhary, et al.: Compound odontoma associated with impacted teeth

of follow-up (Figure 6). The patient was followed for 1 year

however there was no recurrence.

DISCUSSION

Odontomas are most common variety of mixed odontogenic

tumors, in which enamel and dentin are formed when

both the epithelial and mesenchymal components undergo

functional differentiation.4 The abnormal pattern of

enamel and dentin are laid down because the organization

of the odontogenic cells fails to reach a normal state of

morphodifferentiation. They are hamartomatous lesions

rather than true neoplasms.5

The term odontoma was coined by Paul Broca in 1867.6

Its incidence has been reported to be as 22-67% of all

odontogenic maxillary neoplasms.7Frequently impacted by

odontomas are canines, followed by upper central incisors

and third molars, there are with few cases being related to

missing teeth. These tumors can be found anywhere in the

dental arches and are generally intra-osseous. However,

they may erupt into the oral cavity occasionally. They

may occur at any age and in any gender; however, most

cases are detected in the first two decades of life on routine

radiographs.8The neighboring teeth may be affected in

(Figure 3). The clinical-radiological findings are suggestive

of compound odontoma. Surgery was performed to remove

the lesions and three mineralized structures showing a

tooth-like appearance were found within them (Figure 4).

The specimen was sent for histopathological examination.

The H and E stained decalcified section showed admixture

of dentinal tissues arranged in a haphazard manner

with serrated borders (Figure 5) confirming the clinical-

radiographic diagnosis of complex odontoma. The healing

was uneventful, and no post-operative complications were

noted. The crown of 11 was clinically visible after 1 month

Figure 3:OPG showing unerupted tooth with enlarged follicular space and

denticles

Figure 2:Intraoral radiograph of maxillary right front region showing tooth-like

structures

Figure 4:Denticles visible on surgical exposure

Figure 5:Photomicrograph

Figure 6:1 month follow-up showing erupting central incisor

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IJSS Case Reports& Reviews| August 2014 | Vol 1 | Issue 314

70% cases by pathologic changes such as, malformation,

malposition, devitalization, aplasia, and delayed eruption.

They may also undergo cystic transformation.

1914 Gabellet al.gave the first classification according to

the developmental origin as epithelial, composite (epithelial

and mesodermal)and connective tissue.9,10Later in 1946

Thoma and Goldman classified them as:

Geminated composite odontomes-two or more well-

developed teeth fused together

Compound composite odontomes-consists of more or

less rudimentary teeth

Complex composite odontomes-are calcified structure

that has no great resemblance to the normal anatomical

arrangement of dental tissues

Dialated odontomes-there is marked enlargement of the

crown or root part of the tooth

Cystic odontomes- is normally encapsulated by fibrous

connective tissue in a cyst or in a wall of cyst.9,11

Then WHO in 19927 based on the degree of morpho

differentiation classified odntomes as compound odontoma

with at least superficial anatomic resemblance to teeth

as all the dental tissues are represented in an orderly

fashion. While in a complex odontoma there is lile or no

morphologic resemblance to normal tooth formation. They

have also been classified clinically as:

Intra-osseous (central)-they occur within the bone and

may erupt into the oral cavity and represents 51% of

all odontogenic tumors. Occurs predominantly in the

anterior maxilla and mandibular molar areas Extra osseous (peripheral)-they occur in the soft tissue

covering the tooth bearing areas of the jaws12

Rarely, intra-osseous odontomas may facilitate their

eruption into the oral cavity when located coronally to

an impacted or erupting tooth or superficially in bone.

Here they are referred to as erupted odontomas.12

Majority of compound odontomas are located in the anterior

region of the maxilla and diagnosis is frequently made on

the basis of the failure of a permanent tooth to erupt as in

the present case. In 40-50% of cases, an impacted permanent

tooth is associated with the compound odontoma.10

Complex odontomes are located in the mandible especially

in the posterior areas. The compound odontoma is a

malformation in which all the dental tissues are in a

more orderly paern so that the lesion consists of many

tooth-like structures. They appear twice more frequently

than complex odontomas.6They are usually asymptomatic,

have slow growth, and seldom exceed the size of a tooth, but

can cause expansion of the cortical bone when grows large

in size. Based on the data of the survey by Philipsen et al.

the relative frequency of the compound odontoma is 9-37%

of all odontogenic tumors. The average age at diagnosis

is 17.2 years (range 0.5-73 years).10 75% of all case are

diagnosed at around age 20 years, and it is slightly more

common in males as compared to female (1.2:1).

Local trauma and infection at the place of the lesion can

offer ideal conditions for its appearance. However, genetic

predisposition by inheritance, mutant gene or interferencehas also been suggested. Laminar odontoma arise from an

exuberant proliferation of the dental lamina or its remnants or

can be a result of multiple schizodontia, i.e. a locally accustomed

hyperactivity of dental lamina.13 It may also be associated

with the Gardners syndrome of intestinal polyposis or the

rare odontoma dysphagia syndrome.14Primary dentition if

traumatized (intrusion and avulsion)during the developmental

stages of a succedaneous permanent tooth interferes with its

future growth due to the close relationship between the apices

of primary teeth and the buds of permanent teeth.15

Differential diagnosis includes ameloblasticfibroodontoma,

ameloblasticfibroma and odonto ameloblastoma. The lesions

may also occur as part of few conditions, such as Gardner

syndrome, basal cell nevus syndrome, familial colonic

adenomatosis, tangier disease, or Hermann syndrome.6

Radiographically odontomas have characteristic features

which depend on their stage of development and degree

of mineralization.

First stage: A radiolucency due to lack of calcification

Intermediate stage: Partial calcification is observed

Third stage: The lesion usually appears as radiopaque

masses surrounded by radiolucent areas correspondingto the connective tissue histologically.16

The lesions of compound odontoma are usually unilocular

and frequently appears as a collection of numerous

radiopaque, miniature tooth-like structures known as

denticles.17Composite odontoma appears as a calcified

mass with a radiodensity similar to tooth structure; both are

further surrounded by a narrow radiolucent zone.

Histopathologically, odontomas are composed essentially

of mature dental tissues that is enamel, dentin, cementum,

and pulp tissue and may be arranged in discrete tooth-likestructures (compound odontoma)or as unstructured sheets

(complex odontoma). The bulk of the tumor usually consists

of normal appearing dentin with a fibrous capsule and a

supporting fibrous tissue in a small amount.4As odontomas

include epithelial and mesenchymal tissue they can undergo

cystic degeneration of the enamel organ after partial or

total development of the crown, and can transform into

dentigerous cyst. The cystic transformation of the follicle

associated with the unerupted tooth may also occur when

its eruption is impeded by the odontoma.4

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IJSS Case Reports& Reviews | Vol 1 | Issue 3 15


Ghost cell keratinization is occasionally seen in the

enamel-forming cells of some odontomas. Surrounding

hard tissue calcification leads to reduced oxygen supply

by walling-off effect which in turn causes metaplastic

transformation of odontogenic epithelium leading to cell

death and keratinization. This pathogenesis was later ruled

out, and many other concepts were put forth in due time.

Treatment of choice comprises surgical extraction, along

with any associated soft tissues, fenestration, orthodontic

traction or periodic simple watching along with clinical and

radiographic examination to appraise the path of eruption

of teeth.10Recurrences are rare.

CONCLUSION

Odontomas are more commonly associated with impacted

teeth and rarely erupt into the oral cavity. Even though

these lesions are benign in nature, they can give rise to

inflammation, pain and infection when they erupt in the

mouth. Early detection and treatment of odontomas could

increase the possibility of preservation of the impacted teeth.

The treatment of choice is surgical removal of the odontoma,

followed by histological analysis. As was demonstrated

by this report, early diagnosis of odontomas on a routine

radiographic examination allows adoption of a less complex

and less expensive treatment and ensures beer prognosis.

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odontome. J Oral Maxillofac Pathol 2009;13:47-50.

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How to cite this article: Choudhary PJ, Gharote HP, Hegde K, GangwalP. Compound Odontoma Associated with Impacted Teeth: A Case Report.IJSS Case Reports & Reviews 2014;1(3):12-15.

Source of Support:Nil, Conflict of Interest:None declared.

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