Erupted Complex Odontoma: A Case Report
The odontoma corresponds to the most common odontogenic tumor found in the oral cavity and is considered by some authors just as a developmental anomaly. Histologically two types of odontoma are determined: compound and complex. Both undergo a second classification considering the location: (1) central odontoma have intra-bone location, (2) peripheral odontoma have extra-bone location, usually in soft tissues like muscles, gums and mucosa, and (3) erupted odontoma show themselves exposed to the oral cavity, may cause painful symptoms due to inflammation, which is the rarest in the literature. The most frequent location is intraosseous, in exceptional cases odontoma erupts in the oral cavity. This article reports a rare case of complex odontoma that is in eruptive process in the oral cavity, being detected by radiographic findings and indicated as a treatment to surgical removal of the same. Confirmation of diagnosis came through the histopathologic examinations performed.
Keywords: Central Odontoma; Complex Odontoma; Developmental Anomaly; Erupted Odontoma; Odontogenic Tumor; Peripheral Odontoma;.
Paula Dantas Vieira, Emanuel Mendes Sousa, Silvan Correa, Clarinda Pires de Carvalho Mello, Clélea de Oliveira Calvet, Clarissa Lopes Vieira. Erupted Complex Odontoma: A Case Report. International Journal of Oral & Maxillofacial Pathology; 2014:5(2):33-36. ©International Journal of Oral and Maxillofacial Pathology. Published by Publishing Division, Celesta Software Private Limited. All Rights Reserved.
Odontomas are characterized as benign developmental anomalies and the most common type of odontogenic tumors, representing about 20% of the maxillo-mandibular tumors.1 In them, dental tissues can be seen, but presented in a different arrangement of the tooth structure, often as single and intraosseous lesions, and can also be seen as multiple lesions or in the dental arch.2 They are associated with the permanent teeth in children, adolescents and young adults, although they may appear at any age. Most of them are diagnosed in the second decade of life.3,4
According to the classification of the World Health Organization (WHO), the complex odontoma has disordered dental tissues, forming a single solid mass.5 Its prevalence is low and there is no preference about race or sex.6 About its discussed etiology, some theories mention the local trauma, infection, heredity or genetic disorders as etiological factors. They affect both sexes although many authors have reported a slight predilection for males.2,7 Clinically the odontoma is characterized as asymptomatic lesions, but may show signs and symptoms associated, such as infection, retention of permanent teeth, swelling, diastema, bad position and malformation of adjacent teeth.8 Between the pathologies that are associated with dental inclusion in the oral cavity, the odontoma is the most frequent.9 With variable sizes and slow growth, the odontoma are predisposed to be located in maxillary incisors and canines, followed by all the mandible. They are usually diagnosed at routine radiographic examination or by the patient searching the dentist due to the delay in tooth eruption.5,10 There are three types of odontoma clinically recognized: (1) central odontoma, (2) peripheral odontoma, and (3) considered erupted odontoma, being associated with impacted teeth positioning coronal to the tooth, thus allowing their exposure to the oral cavity.11 Generally, this exposure can cause pain, inflammation of adjacent soft tissue or even infection associated.3
Radiographically, they have very distinctive aspects. In particular, the complex odontoma is characterized by a single calcified mass, also surrounded by a narrow radiolucent line.12 It has a more difficult diagnosis, compared to the compound odontoma, since the complex odontoma has many differential diagnosis with other radiopaque lesions as osteoma, focal sclerosing osteomyelitis, cementoblastoma, cementifying periapical dysplasia and ossifying fibroma.2
About histopathological features the complex odontoma resembles small rooted teeth in a loose fibrous matrix. It is formed in major, for mature tubular dentin surrounding circular cracks or cavities containing mature enamel, which are removed during decalcification. Their potential for keratinisation is observed in the epithelial cells of the enamel of some odontoma.12 The treatment option for the odontoma, regardless of classification, is its conservative surgical removal, being suggested the histopathological analysis because of the similarity with the ameloblastic fibroma and ameloblastic odontoma.13,14 An early diagnosis associated with a properly surgical procedure made on time results in a favorable prognosis without risks of relapse.15
Thus, we present a case of erupted complex odontoma, diagnosed and treated at the Pediatric Dentistry Clinic of the University CEUMA (UNICEUMA), Brazil.
Patient C.A.D., 11 years-old, male, attended the Pediatric Dentistry Clinic of the University Ceuma (Uniceuma), São Luís, Maranhão, Brazil, accompanied by his mother, who reported that her son had complained of pain related to the eruption of the left upper canine. During the interview, it was not found any relevant characteristic to the case. At the intra-oral examination it was observed that apparently the left upper canine was in eruption process, since its cusp was present in the oral cavity, surrounded by an inflammatory process, causing swelling, redness gum with pain symptoms.
In periapical radiograph, there was an impaction of the left upper canine positioned above the ectopic bicuspids. In the location that would be correct for left upper canine, it was observed a calcified element, similar to a tooth, containing in its interior a uniform radiopaque image, surrounded by a radiolucent image (Figure 1). In order to determine the best location of the lesion, additional radiographs were made, as the occlusal incidence and Clark’s technique, where the vestibular position was determined. Based on clinical and radiographic findings, we obtained the diagnostic hypothesis of erupted complex odontoma. Thus, it was determined the surgical removal of the lesion and subsequent histopathological analysis.
In the histopathological examination the surgical specimen showed macroscopically the cystic form, measuring 2.8cm in diameter, yellowish-white color and firm consistency (Figure 2). Under microscopic analysis, histological sections showed calcified tissue resembling cementum and dentin, interspersed with loose connective tissue similar to the pulp (Figure 3). Surrounding the area of mineralized tissue, it was observed a capsule of denser connective tissue, in which inflammatory cells were seen with a predominance of lymphocytes and plasma cells (Figure 4). Thus, the diagnostic confirmation of odontoma was obtained. After the period of postoperative follow-up, the patient was referred for orthodontic assessment in order to investigate the possible orthodontic traction of the impacted left upper canine.
Odontomas are lesions that also have questioned its definition in the literature and are considered by some authors as odontogenic tumor with higher incidence in oral pathology. However, other authors prefer to define it only as a developmental anomaly (hamartoma). Queiroz et al.16 reported that the odontomas are odontogenic tumors in which it is composed of tissues with mesenchymal and epithelial origin, which undergo functional differentiation. Pimenta et al.11 associated odontoma with developmental anomalies, also being formed by the complete differentiation of specific cells. In most cases, the odontomas present asymptomatic form, being diagnosed by routine radiographic findings or when they are made in order to determine the absence of an erupting permanent tooth.4 Serra-Serra, Berin-Aytés and Gay-Escoda,3 in their clinical cases, reported that the odontoma was diagnosed by a radiographic finding, the same happened in the case described here.
The odontoma can be compound or complex, being the compound odontoma presents with a higher incidence in the anterior maxilla and the complex in the posterior mandible.3 In relation to its location, odontoma also suffer a classification, being basically recognized as central odontoma (intraosseous), peripheral odontoma (extra-osseous) and erupted odontoma.11 The intraosseous type is more frequently reported. In exceptional cases, can be seen as extra-osseous or in occlusion in the oral cavity.2 The cases of erupted odontoma are rare. Only seventeen cases have been reported in the literature, which was first reported in 1980. Of them, nine were compound odontoma, the others being represented by eight complex odontoma. Among the seventeen cases, thirteen had an impacted tooth associated.3
Figure 1: Diagnostic periapical x-rays showing the odontoma in the region of left upper canine.
Figure 2: Macroscopic vision of the removed specimen.
The erupted odontomas are most often seen in older people, probably the growth reaction of the capsule contributing to this phenomenon, as well as the process of reabsorption from the edentulous alveolar process. However, the eruption at a young age is also possible, due to the presence of the dental follicle resulting in bone remodeling. It is probably that the mechanism of eruption of odontomas present differently from the dental eruption, not related to contractility of fibroblasts, as the odontoma, unlike teeth, do not have periodontal ligament.17 This case can be considered as a rare form of a complex odontoma which is available in the oral cavity unlike most cases, being associated with the upper left canine, with the injury in the process of eruption in the oral cavity of a 11 years-old patient. Often the complex odontoma is shown in the posterior mandible, being reported more frequently when intraosseous and, when its eruption in the oral cavity is reported, there is a greater susceptibility in older patients.
Figure 3: Calcified tissues remembering dentin and cement, interspersed by loose connective tissue similar to pulp (H&E; 4x)
Figure 4: Capsule denser connective tissue, inflammatory cells seen with predominance of lymphocytes and plasma cells (H&E; 10x)
The surgical removal of odontoma is always considered as the most appropriate conduct, and is of fundamental importance in cases associated with tooth retention in order to establish proper occlusal condition.18 Thus, radiographic examinations, both panoramic, periapical and occlusal incidences are determinants, not only in diagnostic reasons but also for surgical planning, which aims to accurately delineate the tumor and its location in relation to adjacent structures.15 In this proper case, the Clark’s technique was added in this radiographic protocol, which confirmed the location of the lesion.
The early diagnosis of odontoma is important for the prevention of dental and craniofacial development problems, since a favorable prognosis depends on this early diagnosis followed by specific treatment in the correct moment. Thus, the professional staff should be aware of the importance of clinical and radiographic examinations in order to diagnose development abnormalities as soon as possible.
We would like to thank Ms.Ana Cléa Feitosa Pestana, by creation of the histological slides and Professor Benedita de Jesus Leite Nunes, for the assistance in surgery.
1.Dr.Paula Dantas Vieira, ST, 2.Dr.Emanuel Mendes Sousa, ST, 3.Dr.Silvan Correa, Professor of Bucomaxillofacial Surgery, 4.Dr.Clarinda Pires de Carvalho Mello, Professor of Pathology, 5.Dr.Clélea de Oliveira Calvet, Professor of Pathology, 6.Dr.Clarissa Lopes Vieira, Professor of Stomatology, Department of Dentistry, University Ceuma (UNICEUMA), Rua Josué Montello, São Luís, Brazil.
1. Mendonça J, Lima C, Böing F, Bento L, Santos A. The giant complex odontoma in the body of the mandible: a case report. Rev Cir Traumatol BucoMaxilofac. 2009;9(2):67-72.
2. Patriarca C. Complex odontoma erupted. Rev Assoc Paul Cir Dent. 2008;3(62):228-31.
3. 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;6(14):299-303.
4. Nóia C, Júnior J, Pinto J, Rodrigues M. Compound-complex odontoma: a case report. UFES Rev Odontol. 2008;4(10):59-63.
5. Silva L, Bastos A, Lima J, Araújo M. Tooth eruption after surgical removal of na odontoma. Odontol Clín-Cient. 2007;1(6):97-102.
6. Alves PM, Santos P, Cavalcanti A, Queiroz L, Souza L. Clinical-histopathologic study of 38 odontomas. Rev Odontol UNESP. 2008;4(37):357-61.
7. Ali Azhar DF, Kota MZ, El-Nagdy S. An unusual erupted complex composite odontoma: a rare case. Case Rep Dent. 2013;2013:106019.
8. Weismann R, Júnior A, Panarello A, Beltrão R. Complex odontoma: 12 years – case report. Rev ABO Nac. 2006;14(2):105-7.
9. Passeto M, Filho V, Gabrielli M, Hochuli-Vieira E, Gabrielli M. Impacted lower central incisor associated with a compound odontoma: a case report. Rev ABO Nac. 2005;13(5):301-3.
10. Tejasvi MLA, Babu BB. Erupted compound odontomas: a case report. J Dent Res Dent Clin Dent Prospects. 2011;5(1):33-6.
11. Pimenta R, Teixeira R, Prata-Tacchelli D, Barros M, Capp L, Moretti R. Odontoma: a case report. ACDC em ação. 2007;2(19):4-5.
12. Cé P, Prazeres C, Santos F, Woltmann M. Complex odontoma: atypical clinical case report. RFO. 2009;14(1):56-60.
13. Pires L, Krüger M, Viana E, Kramer P, Ferreira S. Odontoma: state of art and case report. Stomatos. 2007;13(24):21-9.
14. Spini PH1, Spini PH, Servato JP, Faria PR, Cardoso SY, Loyola AM. Giant complex odontoma of the anterior mandible: report of case with long follow up. Braz Dent J 2012;23(5):597-600.
15. Losso E, Pizzatto E, Ulbrich L. Complex odontoma associated to a primary maxillary canine: case report. RSBO. 2009;6(2):204-7.
16. Queiroz A, Silva F, Stuani A, Arnez M, Bosatto M. Compound odontoma in pediatric dental patience: diagnosis and treatment. Rev Inst Ciênc Saúde. 2005;2(23):163-8.
17. Manoj Vengal M, Honey Arora B, Sujoy Ghosh B, Keerthilatha M Pai M. Large Erupting Complex Odontoma: A Case Report. JCDA. 2007;73(2):169-72.
18. Freitas D, Freitas V, Mol V, Neto L, Mol V. Dental element impacted by compound odontoma. Rev Bras Cir Cabeça Pescoço. 2009;38(3):198-9.
Dr.Clarissa Lopes Vieira,
Rua Rio Anil, Qd. 7, Cond.,
Mar Del Plata, Casa 25, Recanto dos Vinhais,
São Luís – MA, Brazil-65070-018.
Ph: 55(98) 3236-7680/(98) 8897-1977
Source of Support: Nil, Conflict of Interest: None Declared.