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CASE REPORTS |
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| Year : 2005 | Volume
: 23
| Issue : 3 | Page : 146-150 |
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Compound composite odontome associated with an unerupted deciduous incisor - A rarity
S Singh, Mousumi Singh, I Singh, D Khandelwal
Dept. of Oral and Maxillofacial Surgery, Kothiwal Dental College and Research Centre, Moradabad, India
Correspondence Address:
Mousumi Singh
Dept. of Pedodontics, Kothiwal Dental College and Research Centre, Moradabad - 244 001
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0970-4388.16889
 Abstract | | |
Odontomes are considered to be hamartomatous malformation rather than true neoplasm and are generally asymptomatic. Here is a case presentation of compound composite odontome with impacted deciduous teeth in an 11-year-old girl. A calcified mass was revealed in the radiograph and the case was finally diagnosed to be compound composite odontome. The mass was surgically excised.
Keywords: Composite odontome-compound and complex, Hybrid odontome, Impacted tooth, Multiple schizodontia
How to cite this article:
Singh S, Singh M, Singh I, Khandelwal D. Compound composite odontome associated with an unerupted deciduous incisor - A rarity. J Indian Soc Pedod Prev Dent 2005;23:146-50 |
How to cite this URL:
Singh S, Singh M, Singh I, Khandelwal D. Compound composite odontome associated with an unerupted deciduous incisor - A rarity. J Indian Soc Pedod Prev Dent [serial online] 2005 [cited 2022 Aug 11];23:146-50. Available from: http://www.jisppd.com/text.asp?2005/23/3/146/16889 |
Odontomes 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] Odontomes by definition alone refers to any tumor of odontogenic origin.[2] They are considered as developmental anomalies rather than true neoplasm.[1] The term 'odontoma' was coined by Paul Broca in 1867. Broca defined the term as tumors formed by the overgrowth or transitory of complete dental tissue.[3] Most of the odontomes are asymptomatic, although occasionally signs and symptoms relating to their presence do occur. These generally consist of unerupted or impacted teeth, retained deciduous teeth, swelling, and evidence of infection.[2] The most common location for impacted teeth associated with odontomes is the anterior maxilla.
Here, an interesting case of compound composite odontome along with clinical presentation, differential diagnosis, radiographic features, histopathological features, and surgical treatment is discussed.
| Case History | |  |
An 11-year-old girl patient reported to the Department of Pedodontics, Kothiwal Dental College and Research Centre, Moradabad, with a complaint of painless swelling in the left upper front teeth region, which was slowly growing for the last 8 months, while the contralateral side was normal [Figure - 1]. Her dental history revealed unerupted deciduous left central incisor and that the permanent successor erupted after the surgical intervention. Patient's family history was noncontributory.
On extraoral examination, the left side of the upper lip was found to be swollen. Intraoral examination revealed a well-defined swelling on labial aspect of 21 and 22, measuring about 1 x 1.5 cm, extending mesiodistally from labial frenum up to 2 mm in front of the canine eminence [Figure - 2]. Superio-inferiorly it extended approximately 1 mm above the marginal gingiva in relation to 21 and 22, up to the vestibular depth. Overlying mucosa was slightly blanched. A white spot was visible distal to the swelling and no intraoral sinus or secondary change was seen over the swelling. No inflammation of marginal gingiva and interdental papilla was present.
On palpation, swelling was bony hard in consistency, nontender, well defined, fixed to the underlying tissue, and was not mobile. Palpation over white spot suggested erupting tooth. Palatal aspect in relation to 12, 11, 21, 22 was normal [Figure - 3].
There was no regional lymphadenopathy. There was no anesthesia or paresthesia over the distribution of anterior and middle superior alveolar nerve. Aspiration had been tried but no fluid was aspirated.
On the basis of clinical examination, provisional diagnosis of odontome was made, along with differential diagnosis of erupting supernumerary tooth (mesiodens), cystic odontome, osteoma, and osteoblastoma.
Results of routine blood and urine investigations were normal.
Intraoral periapical radiograph of 11, 21 and 22 region suggested multiple irregular masses of calcified tissues present over the root of 21, 22 in the alveolar bone. These calcified irregular masses were separated in a few areas by a narrow radiolucent band with a smooth outer periphery. A tooth-like structure, which had a very short root, was present in between 21 and 22 along with pulp canal. Periodontal ligament space surrounding 22 was thickened. Another big calcified mass was present over the root apex and distal aspect of 21, resembling enamel and dentin. Root in this tooth-like structure was not clearly visible. A thin radiolucent line covering this tooth-like structure was also present [Figure - 4]. Orthopantomograph revealed multiple calcified irregular masses over the root of 21 and 22 in the alveolar bone, which were separated by thin radiolucent band in few areas. A tooth-like structure, which had a very short root, was present in between 21 and 22 along with the pulp canal. Periodontal ligament space surrounding 22 was thickened. The big calcified mass, which appeared like a crown was present near the nasal floor above the root apex of 21 [Figure - 5].
A provisional diagnosis of compound composite odontome was made. Patient was admitted to the hospital and was prepared under local anesthesia. A crevicular incision was made in relation to labial aspect of 21, 22 and 24, followed by two vertical relieving incisions. The mucoperiosteal flap was elevated towards the labial aspect of maxilla, which revealed the presence of numerous denticles [Figure - 6]. The crown of unerupted deciduous left central incisor was also present at the superior border of lesion. The whole bunch was carefully excised [Figure - 7]. Sharp bony margins were rounded off, the area was irrigated with povidone-iodine solution, and the flap was placed back and held in position with the help of 3-0 silk sutures [Figure - 8]. The tissue was sent for histopathological evaluation. Macroscopically, the specimen consisted of a piece of irregular mass. The decalcified cut surface shows numerous tooth-like structures that were arranged irregularly.
| Histopathological Features | | |
The tissue was processed and stained with hematoxylin and eosin stain. The stained section revealed:
1. Mature tubular dentin.
2. Dentin enclosing hollow circular structures. These hollow structures contain enamel that was lost during decalcification.
3. A thin layer of cementum was present at the periphery of the mass.
| Discussion | | |
The term odontome by definition alone refers to a tumor of odontogenic origin. In a broad sense, it means a growth with both the epithelial and mesenchymal components exhibiting complete differentiation with the result that functional ameloblast and odontoblast form enamel and dentin. This enamel and dentin were usually laid down in an abnormal pattern because the organization of odontogenic cells failed to reach the normal state of morphodifferentiation.[2]
It was in 1867 that Paul Broca first used the term 'odontome'.
In 1914, Gabell, James, and Payne grouped odontome according to their developmental origin: epithelial, composite (epithelial and mesodermal) and connective tissue. In 1946, Thoma and Goldman formulated a classification as follows:[3],[4]
• Geminated composite odontomes - two or more, more-or-less well-developed teeth fused together.
• Compound composite odontomes - made up of more-or-less rudimentary teeth.
• Complex composite odontomes - calcified structure, which bears no great resemblance to the normal anatomical arrangement of dental tissues.
• Dilated odontomes - the crown or root part of tooth shows marked enlargement.
• Cystic odontomes - an odontome that is normally encapsulated by fibrous connective tissue in a cyst or in wall of cyst.
According to W.H.O. classification,[5] odontomes can be divided into three groups:
1. Complex odontome - when the calcified dental tissues are simply arranged in an irregular mass bearing no morphologic similarity to rudimentary teeth.
2. Compound odontome - composed of all odontogenic tissues in an orderly pattern that results in many teeth-like structures, but without morphologic resemblance to normal teeth.
3. Ameloblastic fibro-odontome - consists of varying amounts of calcified dental tissue and dental papilla like tissue, the later component resembling an ameloblastic fibroma. The ameloblastic fibro-odontome is considered as an immature precursor of complex odontome.
There are essentially two types of odontomes:[5],[6]
1. Complex composite odontome;
2. Compound composite odontome.
A new type known as Hybrid odontome is also reported by some authors.
| Complex Composite Odontome | | |
The WHO classification defines this lesion as 'a malformation in which all dental tissues are represented, individual tissues being mainly well formed but occurring in more or less disorderly pattern'.
| Compound Composite Odontome | | |
The WHO classification defines this lesion as 'a malformation in which all the dental tissues are represented in a more orderly pattern than in the complex odontome, so that the lesion consists of many tooth-like structures. Most of these structures do not morphologically resemble the teeth in the normal dentition, but in each one enamel, dentin, cementum, and pulp are arranged as in normal tooth'.
The literature is flooded with a number of interesting case reports.[7] The bilaterally occurring compound odontome in maxillary sinus was first reported by Bland Sutton in 1888. A historical case of complex composite odontome was discovered by Bland Sutton in 1922. It was abnormally sized, that is, 7.6 x 6.2 x 3.9 cm and weighing 883 g. Herrman (1957) reported a case of compound composite odontome, which contained 2000 denticles. Multiple compound odontomes of maxilla and mandible were reported by Thomson et al. in 1968. Manil (1974) used the term odontome syndrome in a case that had multiform odontome both in maxilla and mandible. Regezi et al. in their review of 706 cases of odontogenic tumors found that odontomes comprised of approximately 65% of odontogenic tumors making them the commonest type.[6] Philipsen, Reichart and Praetorius reported the incidence of compound odontome between 9 and 37%, and the incidence of complex odontome between 5 and 30%.[8]
The exact etiology of odontome is unknown.[2],[5] However, it has been suggested that trauma and infection may lead to the development of such a lesion.[2] It had been suggested by Hitchin, that odontomes are inherited or are due to a mutagene or interference, possibly postnatal, with the genetic control of tooth development.[9]
The etiology of odontome is that most result from extraneous odontogenic epithelial cells.[10] When these buds are divided into several particles they may develop individually to become numerous, closely positioned malformed teeth or tooth-like structure. When the buds develop without such uncommon division and consists of haphazard conglomerates of dental tissues, they may develop into complex odontome. However the transition from one type to another is commonly associated with varying degrees of morphodifferentiation or histodifferentiation or both, and it is often difficult to differentiate between both the types.[3],[11]
Recently, Philipsen et al., put forth the hypothesis that formation of a compound odontome is pathogenically related to the process producing hyperdontia, 'Multiple Schizodontia' or locally conditioned activity of dental lamina.[8]
Approximately 10% of all odontogenic tumors of the jaws are compound odontomas. The compound odontoma is slightly more common than the complex odontoma, which in turn is more common than the ameloblastic odontoma. It is of interest to note that 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%). Interestingly, both type of odontomas occurred more frequently on the right side of the jaw than on the left. (Compound 62%, Complex 68%).[2] There is no gender predilection and odontomas can occur at any age.
Clinically, odontomes are generally asymptomatic, usually remain small, rarely exceeding the diameter of the tooth. Occasionally it does become large and may produce expansion of bone with consequent facial asymmetry. This is particularly true if dentigerous cyst develops around the odontome. Signs and symptoms associated consist of unerupted teeth or impacted teeth, retained deciduous teeth, swelling and incidence of infection.[2]
Radiographically, the compound odontome appears as a collection of tooth-like structures of varying size and shape surrounded by a narrow radiolucent zone. The complex odontome appears as a calcified mass with a radio density of tooth structure, which is also surrounded by narrow radiolucent rim.[1],[10] All the radiographic features, suggestive of compound odontome were also present in our case.
The usual location of osteoma is the mandible. In this case swelling was present in the maxillary anterior region. Radiographically, osteoma presents with well-defined, dense radio opaque mass,[10] which is not the same in this case. Most often, ameloblastic fibro odontome is associated with impacted tooth. In this case there was no impacted permanent tooth in anterior maxilla. Radiographically, in ameloblastic fibro odontome, the amount of radiolucent internal structure exceeds the radio opaque structure.[10] In this case, multiple radio opaque structures were present in the anterior maxilla, which were separated by thin radiolucent band in few areas. Cystic odontome increase in size slowly and cause large expansion of bone,[8] which is not seen in our case.
Odontomas are treated by conservative surgical enucleation and there is little possibility of recurrence.[12] Kaban states that odontomas are easily enucleated, and adjacent teeth that may have been displaced by the lesion are seldom harmed by surgical excision because they are usually separated by a septum of bone.[3],[13] An odontoma has a limited growth potential, but it should be removed because it contains various tooth formulations that can predispose to cystic change, interference with eruption of permanent teeth and cause considerable destruction of bone. Literature review suggests that radiographic examination of all pediatric patients that present clinical evidence of delayed permanent tooth eruption or temporary tooth displacement, with or without history of previous dental trauma should be performed. Early diagnosis of odontomas allows adoption of a less-complex and less-expensive treatment and ensures better prognosis.
| References | | |
| 1. | Neville, Damm, Allen, Bouquot; Oral and Maxillofacial Pathology; Second edn. Saunders 2004;631-2.  |
| 2. | Shafer. Hine and Levy: A Text Book of Oral Pathology; Fourth Edition; W.B. Saunders & Co 1993;308-12. |
| 3. | Batra Puneet, Gupta Shweta, Rajan Kumar, Duggal Ritu, Hariparkash. Odontomes-Diagnosis and Treatment: A 4 Case Report; JPFA 2003;19:73-6. |
| 4. | Thoma KM, Goldman HM. Oral Pathology, 5th edn. St Louis, The CV Mosby Company 1960. p. 1221-2. |
| 5. | Kramer IRH, Pindborg JJ, Shear M. Histological Typing of Odontogenic Tumour. WHO. International Histological Classification of Tumours; Second Edition; Berlin Springer 1992:16-21. |
| 6. | Supriya Pande, Ganvir SM, Hazarey VK. Recurrent Odontome- A Rarity. JIDA 2003;74:115-8. |
| 7. | Kharbanda OP, Saimbi CS, Kharbanda Renu. Odontome- A Case Report. JIDA 1986;58:269-71. |
| 8. | Philipsen HP, Reichart PA, Praetorious F. Mixed Odontogenic Tumors & Odontomas. Considerations on Interrelationship. Review of Literature and Presentation of 134 New Cases of Odontomas. Oral Oncol 1997;33:86-99. |
| 9. | Hitchin A.D. The etiology of the calcified composite odontomes. Br Dent J 1971;130:475. |
| 10. | White, Pharaoh. Oral Radiology - Principles and Interpretation; Fourth Edition; Mosby 2000;395-7. |
| 11. | Piattelli A, Perfetti G, Carrano A. Complex odontome as a periapical and interradicular radioopacity in a primary molar. Journal of Endodontics 1996;22:561-3. |
| 12. | Areal-Lopez I, Silvestre DF, Gil LJU. Compound odontome erupting in the mouth; four year follow up of a clinical case. J Oral Pathol 1992;21:285-8. |
| 13. | Kaban LB. Pediatric Oral and Maxillofacial surgery Philadelphia:Saunders; 1990. p. 111-2. |
Figures
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8]
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