Complex Odontoma at an Unusual Site in a Child: A Case Report

BACKGROUND

Odontoma is considered as hamartomatous malformation formed by the overgrowth of dental tissue or transitory of complete dental tissue.¹ It is usually asymptomatic and generally associated with unerupted or impacted teeth. However, it can be seen in association with retained deciduous teeth also.² Based on the microscopic and radiographic features, it is broadly divided into compound odontoma and complex odontoma. Morphologically and anatomically, compound odontoma is a tooth-like structure whereas complex odontoma does not show any similarity to the tooth.^3,4 Odontoma is the most common odontogenic tumor of benign origin and usually present in the posterior mandible.⁵ Due to the absence of symptoms, these are diagnosed usually on the routine radiograph.⁶ Rarely, it shows symptoms like an expansion of the cortical plate, displacement of the adjacent tooth.⁷ In this article, a case of odontoma in the anterior mandibular canine region is discussed, which was symptomatic. Surgical removal opted as the treatment of choice.

CASE DESCRIPTION

A 5-year-old male child reported in the department of pedodontics and preventive dentistry with a chief complaint of swelling in the anterior mandibular region. The parent gave the history that the swelling was initially small in size and increased in size gradually over some time. He had no history of pain and discomfort. On clinical examination, a well-defined circumscribed swelling in the right buccal region with missing 83 (Fig. 1). However, no discharge was inspected. On palpation, the swelling was non-tender and hard in consistency, and expansion of the cortical plate also present. The patient was advised to take an intraoral periapical radiograph, occlusal, and panoramic radiograph. On the radiographs, it appeared as multiple dense radio-opaque structures contained in a radiolucent cavity surrounded by a corticated border (Figs 2 to 4). Inferior to that, a radio-opaque structure 83 was noted and 43 was also present apically to the 83. On the occlusal radiograph expansion of the cortical plate was evident (Fig. 4). Based on the clinical and radiographic findings, it was provisionally diagnosed as complex odontoma. Differential diagnoses of this condition included odontoma, dentinoma, osteoblastic stage cementoblastoma and odonto-ameloblastoma, ameloblastic fibro-odontoma, ameloblastic fibroma.

MANAGEMENT

Treatment of choice was complete enucleation of the odontoma and associated soft tissue. Required investigations were obtained and the procedure was started. After administration of adequate local anesthesia crevicular and vertical releasing incision, a full-thickness mucoperiosteal flap is reflected to visualize the area. After selective removal of the bone, multiple white denticles like structures were visible. All these structures were removed and the mucoperiosteal flap was repositioned (Figs 5 and 6). A suture was placed and prescribed suitable antibiotics and analgesics for 5 days and recalled after 1 week for suture removal. Available sample sends for the histopathological examination and later confirmed as odontoma.

The healing of the surgical site was uneventful. A periodic follow-up was planned.

DISCUSSION

Odontomes are raised due to the growth of both epithelial and mesenchymal components of dental lamina remnants.⁸ These are inherited through postnatal mutant gene interference that controls tooth development.⁹ Satish observed that 22% of all the odontogenic tumors are odontomas.¹⁰ The incidence of compound odontoma ranges between 9% and 37% and that of complex odontoma between 5% and 30%, respectively.¹¹

Odontoma is usually observed in the second and third decades of life rarely in the first decades of life too.⁸ In the presented case, the patient was in the first decades of life.

A common occurrence of the complex odontoma is the posterior mandible and usually asymptomatic. Only in few cases, swelling and delayed eruption were reported.⁵ In this case, it formed in the anterior mandibular canine region with swelling and it hindered the eruption of the primary canine as it is inferior to the odontome. Giant complex odontoma in the anterior mandible was presented by Spini et al. and Gill and Yadav also discussed complex odontoma associated with mandibular incisor tooth.^12,13 Gauging the literature, the presentation of complex odontoma in the canine region was rarely noted.

Complex odontomes are appeared as irregular radiopaque masses with no resemble the dental structure. Initially, the lesion appears as a radiolucent lesion due to lack of calcification, in the intermediate stage partial calcification will occur and it appreciates on the radiograph as a mixed lesion and in the final stage, it appears as a radio-opaque surrounded by a radiolucent halo.¹⁴

Histopathological examination is usually used for the confirmation of the odontome. Histopathologically, complex odontomas are composed of a mixture of dental tissues, mainly forming a single homogeneous mass of immature dentin, enamel, enamel matrix, cement, and pulp tissue in a random fashion.¹⁵ A connective tissue capsule similar to the dental follicle is usually associated with it.¹⁶

In earlier days, odontoma was considered as odontogenic tumor and treated with radicular resection of the affected area. Now the concepts about odontoma have changed, and it is considered as hamartomatous malformation. Selective removal of the denticles and associated connective tissue capsule is the preferred treatment option for the odontome.¹⁷

It is important to do the proper diagnosis and timely management of the odontomes to reduce the complication like delayed or failure of eruption and bone abnormalities.

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