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Compound odontoma: a case study. (Short Reports).

Introduction

Odontogenic tumors are often asymptomatic and usually discovered upon radiographic examination. This case study describes an odontogenic tumor found in a college student who was not aware of its presence. A compound type odontoma was discovered when diagnostic radiographs were exposed. The patient was referred to an oral surgeon for evaluation.

Patient history

A 26-year-old male presented for oral examination and prophylaxis in the dental hygiene clinic at a Midwestern university. He was in good physical health with no significant findings recorded on the medical history. His personal history revealed that he grew up in Turkey where he had received sporadic oral health care. He came to the United States to attend graduate school and was concerned about his oral health. The dental history revealed that his last dental visit was two years ago, and he could not remember the date of his last dental radiographs. He reported frequently having sore and tender gingivae and bleeding when brushing.

Oral and radiographic exam

Intraoral findings included inflamed gingiva, 4 to 6 mm pockets in the posterior areas, and bleeding upon probing. Several carious lesions were detected as well as a missing maxillary left canine. A complete radiographic survey was prescribed both for caries and periodontal assessments and revealed numerous areas of decay and moderate periodontal involvement. A radiopacity was noted in the radiographs coronal to the unerupted permanent maxillary left canine (Figure 1). The appearance of the lesion was that of three small, immature "toothlets" surrounded by a thin radiolucent zone. It was asymptomatic with no pain, swelling, or other visible manifestation of the lesion in the oral cavity. The patient was unaware of the presence of the lesion. Based upon radiographic appearance, a diagnosis of compound type odontoma was made.

[FIGURE 1 OMITTED]

Review of the Literature

Prevalence

Odontomas are the most common odontogenic tumors, comprising approximately 70% of all odontogenic tumors. (1) The odontoma is perhaps more aptly defined as a hamartoma than a true neoplasm. Hamartomas are tumor-like lesions composed of an overgrowth of mature cells and tissues normally present in the affected part. (2) The odontoma is most often associated with an unerupted or impacted tooth. The failure of a permanent tooth to erupt is the most common clinical manifestation. (3) Because they are composed of more than one type of tissue, odontomas are considered mixed odontogenic tumors. They are commonly found alone or in association with one of the numerous other mixed tumors or dental abnormalities. Odontomas are usually detected in adolescents and young adults and are divided into two basic types--compound or complex. (1,3,4)

Odontogenic tumors in general are relatively rare; however, odontoma is one of the most common of the group. (5) Frequencies in geographic areas vary, but of odontogenic tumors examined in larger American, Canadian, and German populations, odontoma was most frequently reported--73.8%, 56.4%, and 57.8%, respectively. (6) In a study of a Turkish population, 20% of the odontogenic tumors were odontomas. (6) Phillipsen et al. reported the frequency of compound odontomas among odontogenic tumors was 9 to 37%, still citing it as the most common among odontogenic lesions/malformations. (7)

Clinical presentation

Compound odontomas present clinically as small, multiple, immature, or rudimentary teeth on dental radiographs. (8) Complex odontomas do not resemble tooth forms, but appear as indistinguishable radiopaque masses. Both types are composed of enamel, dentin, cementum, and pulp tissues and usually produce no symptoms. Compound odontomas present most often in the maxillary anterior region but can be found in any site. In contrast, complex odontomas are found primarily in the posterior aspect of the mandible and are sometimes larger than the compound type. (4,9)

Associated abnormalities

Odontomas can be found in association with other dental abnormalities, such as the calcifying odontogenic cyst (COC). (10) The COC is usually a unicystic lesion. About 20% display the features of COC with those of a small complex or compound odontoma. (4) In a case involving a 14-year-old male, Sikes, Ghali, and Troulis reported a complex odontoma found with a COC. (11) Another case involving a 6-year-old male had included COC in the differential diagnosis of a lesion in which the authors reported as frequently being associated with odontomas. (10)

Philipsen, Reichart, and Praetorius discussed in great length the interrelationship between compound/complex odontomas and ameloblastic fibroma, ameloblastic fibro-odontoma, and ameloblastic fibrodentinoma. They report considerable confusion in the literature discussion concerning the interrelationship of the odontomas and other odontogenic tumors. (7) The ameloblastic fibroma is considered a true mixed tumor with histology of neoplastic odontogenic tissues. There are discrepancies in its diagnosis, and early reports of the lesion may actually have been lesions in the early developing stages of odontoma formation. The ameloblastic fibro-odontoma has the general features of an ameloblastic fibroma but also contains enamel and dentin. Like the ameloblastic fibroma, the fibro-odontoma is thought by some to be a stage in the development of an odontoma and is therefore not always classifed as a separate lesion. The ameloblastic fibro-dentinoma is similar to the previous two, except that it contains primarily dentinal tissues as its calcified component and is considered a variant of the ameloblastic fibro-odontoma. All three can be associated with an impacted tooth or dental structures in the form of toothlets or masses of enamel and dentin. (4) Their relation to the odontoma is further supported by a statement in the introduction to the World Health Organization's classification of mixed odontogenic tumors. This statement points out the possibility that some of the lesions presently classified separately are simply chronological stages in the development of a single type of tumor. (7)

Discussion

Radiographic features

A presumptive diagnosis of compound odontoma is usually determined by radiographic appearance alone and is seldom confused with any other lesion. (4) Clumped together, the radiopaque toothlets often exhibit a thin, radiolucent rim around the periphery. They are discovered on radiographs either incidentally or in search of a cause for a missing tooth. (4,9) In contrast to the patient radiograph exposed in this case study, Figure 2 shows another example of a compound odontoma. The lesion is larger, consisting of several toothlets and therefore more radiopaque. As in this case study, it was discovered in the canine area but in the opposite arch.

[FIGURE 2 OMITTED]

Complex odontomas, on the other hand, appear radiographically as more or less amorphous, solitary conglomerates, of calcified material. Larger, indistinct radiopacities--rather than toothlike structures--are usually apparent. (9,11) They exhibit a haphazard arrangement of the dental tissues and are found primarily in the posterior aspect of the mandible. (4,7) Unlike compound odontomas, complex odontomas are not diagnosed by radiographic appearance alone but require histologic verification. Other lesions included in the differential diagnosis are osteoma, ossifying fibroma, and cementoblastoma. (3,8,9)

Histopathology

To establish a definitive diagnosis, suspected odontomas, both compound and complex, must be examined microscopically. Histologically, the compound odontoma will often have normal appearing enamel, dentin, cementum, and pulp. (8,9) Odontogenic epithelium, odontoblasts, and mesenchymal pulp tissue also may be present. (12) The complex odontomas consist largely of mature tubular dentin. The dentin surrounds circular structures of enamel matrix and is surrounded by a periphery of cementum and a fibrous capsule. The haphazard arrangement of the dental tissues is responsible for its indistinguishable clinical appearance. Occasionally, a dentigerous cyst may arise from the epithelial lining of the fibrous capsule of a complex odontoma. (4)

Conclusions and Recommendations

Treatment for both forms of odontoma is usually surgical excision. (1) Both compound and complex odontomas are well encapsulated and easily enucleated from the surrounding bone. There is general agreement that odontomas should be excised due to the possibility of developing a dentigerous cyst or other neoplasms and the manner in which such tumors influence the growth and development of the bone and dentoalveolus. (9,10,12) However, a Japanese study found it difficult to conclude that all odontomas should be excised. The authors felt more research was needed in this area before resection becomes an automatic supposition of practitioners. (13)

The patient's dentist in this case study appears to adhere to the ideas of the Japanese researchers. When contacted for recall, the patient reported he received the necessary restorative care from his previous dentist in Turkey. When consulting with her about the apparent odontoma in the radiographs, she assured him it was harmless and advised against its removal. Further attempts at recall by the dental hygiene clinic were not possible, as the patient had transferred to another university after returning to the states for completion of graduate studies.

The possibility of lesions like the odontoma supports the practice of recommending baseline radiographic surveys for all dental patients. Even in the apparent absence of caries or periodontal problems, the possibility of discovering lesions such as the odontoma or other abnormalities warrants exposing radiographs beyond a simple set of bitewing films. The dental hygienist should thoroughly evaluate all areas in the survey, beyond bone level and caries, noting changes in trabecular patterns of bone, as well as other abnormal radiolucencies and radiopacities.

References

(1.) Sapp JP, Eversole LR, & Wysocki GP: Contemporary Oral and Maxillofacial Pathology. Duncan LL, ed. St. Louis, Mosby-Year Book, Inc., 1997, p. 147-48.

(2.) Stedman's Concise Medical Dictionary for the Health Professions. 4th ed. Baltimore: Lippincott Williams and Wilkins; 2001. Hamartoma; p. 425.

(3.) Ibsen OA, Phelan, JA: Oral Pathology for the Dental Hygienist, 3rd ed. Kuhn SA, ed. Philadelphia, WB Saunders Co., 2000, p.268-9.

(4.) Neville BW, Damm DD, Allen CM, & Bouquot JE: Oral and Maxillofacial Pathology. 2nd ed. Philadelphia, WB Saunders Co., 2002, p. 626-32.

(5.) Mosqueda-Taylor, A, Ledesma-Montes, C, Caballero-Sandoval, S, Portilla-Robertson, J, Ruiz-Godoy Rivera, LM, & Meneses-Garcia, A: Odontogenic tumors in Mexico. A collaborative retrospective study of 349 cases. Oral Surg, Oral Med, Oral Pathol, Oral Radiol, and Endod 1997; 84(6): 672-75.

(6.) Lu, Y, Xuan, M, Takata, T, Wang, C, He, Z, Zhou, Z, Mock, D, & Nikai, H: Odontogenic tumors. A demographic study of 759 cases in a Chinese population. Oral Med, Oral Pathol, Oral Radiol, and Endod 1998; 86(6): 707-14.

(7.) Philipsen, HP, Reichart PA, & Praitorius F: Mixed odontogenic tumours and odontomas. Considerations on interrelationship. Review of the literature and presentation of 134 new cases of odontomas. Oral Oncology 1997; 33(2):86-99.

(8.) Regezi JA, Sciubba, JJ: Oral Pathology-Clinical Pathologic Correlations. 3rd ed. Philadelphia, WB Saunders Co., 1999, p.350-1.

(9.) Iannucci-Haring J: Case study #7. RDH 1990; 10:10,12.

(10.) Steinberg M J, Herrera AF, & Frontera Y: Mixed radiographic lesion in the anterior maxilla in a 6-year-old boy. J Oral Maxillofac Surg 2001; 59:317-21.

(11.) Sikes JW, Ghali GE, & Troulis MJ: Expansile intraosseous lesion of the maxilla. J Oral Maxillofac Surg 2000; 58:1395-1400.

(12.) Eversole LR: Clinical Outline of Oral Pathology. 3rd ed. Cook D, ed. Malvern, PA, Lea & Febiger, 1992, p.304-5.

(13.) Tanaka N, Murata A, Yamaguchi A, & Kohama G: Clinical features and management of oral and maxillofacial tumors in children. Oral Surg, Oral Med, Oral Pathol, Oral Radiol, and Endod 1999; 88(1): 11-15.

Sherri Lukes, RDH, MS, is a faculty member in the Dental Hygiene Program at Southern Illinois University-Carbondale. Kendall Wachter, DMD, is dental chief of staff for the student emergency dental service at Student Health Programs, also at Southern Illinois University-Carbondale.
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Author:Lukes, Sherri M.; Wachter, Kendall M.
Publication:Journal of Dental Hygiene
Geographic Code:1USA
Date:Jan 1, 2003
Words:1879
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