CASE REPORT

https://doi.org/10.5005/jp-journals-10077-3267
Journal of South Asian Association of Pediatric Dentistry
Volume 6 | Issue 2 | Year 2023

Compound Odontoma in Anterior Maxilla in a 10-year-old Pediatric Patient: A Case Report with 44 Denticles Extracted

Priyanka Aggarwal¹, Kopal Singh² https://orcid.org/0000-0002-9341-1743, Pallavi Anand³, Pulkit Jhingan⁴, Manvi Malik⁵, Shivani Mathur⁶

^1-6Department of Pediatric and Preventive Dentistry, I.T.S Centre for Dental Studies and Research, Ghaziabad, Uttar Pradesh, India

Corresponding Author: Kopal Singh, Department of Pediatric and Preventive Dentistry, I.T.S Centre for Dental Studies and Research, Ghaziabad, Uttar Pradesh, India, Phone: +91 8879316848, e-mail: dr.kopalsingh21@gmail.com

Received on: 14 March 2023; Accepted on: 19 April 2023; Published on: 23 August 2023

ABSTRACT

Background: Odontomas are the most common odontogenic hamartomas worldwide. These can be compound or complex.

Case description: A 10-year-old male child reported a chief complaint of delayed eruption of permanent teeth in the upper front tooth region. Clinical examination revealed unerupted 21 and 22 with retained deciduous lateral incisors.

Further, an orthopantomogram (OPG) was done, which revealed the presence of multiple small radiopaque teeth-like structures in the apical region of the retained deciduous lateral incisor 62 surrounded by a narrow radiolucent halo. Cone-beam computed tomography (CBCT) was done as a confirmatory test.

A final diagnosis of compound odontoma was made, and conservative surgical enucleation was the treatment of choice.

A total of 44 denticles were removed along with the follicle. They were sent for a biopsy, which confirmed the diagnosis as compound odontoma.

Conclusion: It is crucial to diagnose these tumors early for a better prognosis.

How to cite this article: Aggarwal P, Singh K, Anand P, et al. Compound Odontoma in Anterior Maxilla in a 10-year-old Pediatric Patient: A Case Report with 44 Denticles Extracted. J South Asian Assoc Pediatr Dent 2023;6(1):86-90.

Source of support: Nil

Conflict of interest: None

Keywords: Case report, Compound odontoma, Cone-beam computed tomography, Odontoma, Odontogenic tumor, Surgical removal, 44 denticles.

INTRODUCTION

Broca, in 1867 devised the term “odontoma” and defined it as “tumors formed by the overgrowth or transitory of complete dental tissue.” They are the most common benign odontogenic tumors, which account for 22% of all odontogenic tumors.¹

These tumors originate from well-differentiated epithelial and mesenchymal cells that form ameloblastic and odontoblastic cells.² The epithelial and mesenchymal cells differentiate into functional ameloblasts and odontoblasts, which lays down irregular quantities of enamel, dentin, and pulp of the odontoma. However, this abnormal form of enamel and dentin is usually not present in an organized manner due to the lack of morphodifferentiation stage of the development of teeth.

The cause of the formation of odontomas is unknown, but various pathological conditions, like local trauma, inflammatory and/or infectious processes, mature ameloblasts, cell rests of Serres, or due to hereditary anomalies have been suggested as possible etiology.³^,⁴ Odontomas are usually asymptomatic and are diagnosed during a routine examination. However, there can be signs and symptoms indicating the presence of odontoma. Some common complaints reported are the absence of permanent teeth, retained deciduous teeth, intra/extraoral swelling, or infection. Literature states two types of odontomas—compound and complex with a prevalence of 9–37 and 5–35%, respectively, wherein compound odontomas resemble tooth structures anatomically.⁵ These are painless, nonaggressive having limited growth potential with the anterior maxilla being the most prominent site.

The majority of odontomas get neglected and are usually diagnosed during routine radiographic examination. The manual or visual technique is not yielding for the diagnosis of odontomas.⁶

Consequently, radiographic examination, including orthopantomogram (OPG) and cone-beam computed tomography (CBCT), is necessary to evaluate the position and extent of the odontoma and examine the cortical bone thinning/expansion owing to the presence of odontoma.

Even though odontomas have a nonaggressive nature, these must be surgically excised to avoid future complications like cystic formulation, interference in eruption patterns, and destruction of cortical bone. Customarily, odontomas are enucleated with minimal risk of recurrence, and thereby, conservative surgical enucleation is the treatment of choice, along with supportive medical care.

After culminating the shreds of evidence, the purpose of the present case report is to convey the method of examination and diagnosis clinically and radiographically (OPG and CBCT) followed by treatment of compound odontoma in a 10-year-old pediatric patient.

CASE DESCRIPTION

A 10-year-old male patient reported to the Department of Pediatric and Preventive Dentistry with the chief complaint of delayed eruption of permanent teeth in the upper front tooth region. The patient was asymptomatic and did not reveal any relevant medical history, past dental history, or history of trauma. On clinical examination, the upper central and lateral incisors were missing (21 and 22) with retained deciduous lateral incisors (62). There was no intra/oral swelling associated (Fig. 1A).

Figs 1A to M: (A) Preclinical picture depicting retained 62; (B) OPG shows multiple radiopaque structures in relation to 62 and 63; (C) and (D) CBCT records depicting multiple teeth-like structures with radiolucent halo along with its location and extent; (E) and (F) Intraoperative clinical picture showing raised flap and capsulated odontomas; (G) 44 segments of odontomas, biopsy container, and extracted deciduous teeth; (H) and (I) Picture showing platelet-rich fibrin in a container and at the surgical site, respectively; (J) and (K) Postoperative clinical picture showing sutured surgical site; (L) and (M) 1-week follow-up clinical picture following suture removal

For further examination and adequate diagnosis, OPG and CBCT were done. The OPG revealed the presence of a conglomerate of numerous tiny radiopaque teeth-like structures in the apical region of the retained deciduous lateral incisor (62) surrounded by a narrow radiolucent halo (Fig. 1B). There is a disrupted eruption of permanent upper central and lateral incisors (21 and 22). Comparably, the CBCT report revealed the following findings (Figs 1C and D):

Evidence of a huge radiopaque/radiolucent lesion in the maxilla, noted at the level of cervical-mid-apical alveolus extending from the midline in relation to 21 till the mesial aspect of 64 or developing 24.
The pathology is surrounded by a radiolucent capsule.
The internal structure is homogenously mixed radiopaque and radiolucent with multiple small teeth-like structures with density resembling enamel, dentin, and pulp.
The lesion measures approximately 15.3 × 17.0 × 13.6 mm in its greatest anteroposterior and superoinferior and buccolingual dimensions.
The margins are well-defined with a radiolucent halo.
The odontoma is associated with an unerupted/impacted lateral incisor. The lateral incisor, 22, is noted to be impacted with the long axis oriented labio-palatally. It is in the developing stage with an open apex.
There are retained 61 and 21 are noted to be below the occlusal level/impacted.
There is evident bicortical thinning and mild buccopalatal cortical expansion at the level of the cervical-mid-apical alveolus.
The lesion in the medial aspect is causing thinning of the lateral cortex of the incisive canal.

The final diagnosis was concluded to be compound odontoma based on the clinical and radiographic examination. It was decided to remove the odontoma using conservative surgical enucleation. Cleaning and debridement of the surgical site were done, followed by local anesthesia in relation to the anterior and posterior maxilla region. A full-thickness mucoperiosteal flap palatally extending from midline towards deciduous first molar (63 and 64) region (Figs 1E and F). After exposing the site, denticles were appreciated with its capsule. A total of 44 denticles of various shapes and sizes were extracted from the site (Fig. 1G). Retained primary lateral incisor and canine (62 and 63) were also extracted. Due to the marked thinning of the cortical plates, platelet-rich fibrin (PRF) was placed in the cavity to enhance osteoprogenitor cells in the host bone, which in turn boosts healing and tissue regeneration (Figs 1H and I). PRF was prepared by centrifuging 5 mL of whole blood drawn from the child’s arm. The blood was put in a sterile test tube without anticoagulant and centrifuged a 3000 rpm for 10 minutes.

After the placement of PRF and thorough irrigation, the flap was stabilized and sutured using 3–0 Vicryl (Figs 1J and K). The denticles were then sent for histopathological examination, and the biopsy report confirmed the diagnosis as compound odontoma (Figs 2 and 3). Postoperative medications and care measures were explained. The patient was further recalled after a week for the removal of sutures (Figs 1L and M). Additionally, a periodic follow-up of 3 months is decided to evaluate the eruption of 21 and 22. The parents of the patient mentioned have given consent for the case report.

Figs 2A to D: (A) and (B) Ground section of the tooth shows hard tissue brown in color resembling enamel, with hypocalcified structures such as enamel rods, enamel tufts, and enamel lamellae; (C) and (D) There is the presence of S-shaped dentinal tubules suggestive of secondary dentin or reactionary dentin

Fig. 3: Soft tissue section at 40× magnification shows the presence of immature connective tissue stroma suggestive of undifferentiated mesenchymal cells

At 6 months follow-up, on clinical examination, the partially erupted upper central incisor appreciated. In the radiographic examination, root development of the upper lateral incisor was seen with Nolla’s stage VIII (two-thirds root completed). The patient was advised tongue blade therapy for erupting upper central incisor to intercept developing single tooth crossbite, and periodic follow-up was advised (Figs 4 and 5).

Fig. 4: Clinical picture showing erupting upper central incisor (21) at 6 months follow-up

Fig. 5: Radiographic picture showing root development of upper lateral incisor (22) at 6 months follow-up

DISCUSSION

Odontomas and compound odontomas account for 22–10%, respectively, of all odontogenic tumors of the jaws. The most common site for compound and complex odontomas are anterior (61%) and posterior (34%) segments, respectively.⁷^,⁸

Normally, odontomas exhibit several variations in regard to age, gender, and the number of denticles. The higher prevalence is seen in patients with mean ages of 14.8 and 20.3 years for complex and compound odontomas, respectively. Also, it shows slightly higher predilection in males (59%) that in females (41%). These are usually asymptomatic and nonaggressive, with the most common clinical presentation associated with impacted or retained primary teeth, in turn leading to the impaction of successive permanent teeth.²^,⁹

In the present case, the tumor was detected first in a conventional OPG radiograph, followed by a CBCT investigation to eliminate the confusion with other tumors like cemented tumors and to evaluate the size and extent of the tumor in buccolingual and mesiodistal dimensions. It was also inferred that the path of eruption of upper left central and lateral incisors is deviated, which is usually a common characteristic in odontomas.

To facilitate the eruption of the permanent tooth, the treatment of choice is surgical enucleation of the odontoma. Therefore, based on previous pieces of evidence, enucleation of compound odontoma was done, preserving the proximal structures from unnecessary injury.¹⁰^,¹¹ On the grounds of previous recommendations, which state that one should wait for 3 months after surgical removal of odontome for the eruption of an impacted tooth, in the current case, the patient was therefore recalled after 3 months for reevaluation. If the impacted tooth fails to erupt, further it is recommended that it should be surgically exposed with or without orthodontic intervention.¹²

Previously, a review conducted by Amado-Cuesta et al., concluded that the number of denticles in an odontoma was in the range of 4–28.³ Another case report extracted 37 denticles in an encapsulated compound odontoma. Although, in the present case, 44 denticles were extracted, and histopathological evaluation was done confirming compound odontoma with hypocalcified structures such as enamel rods, enamel tufts, and enamel lamellae, and formation of reactionary dentin.

To promote healing and enhance tissue regeneration, PRF was placed at the surgical site. This is in accordance with previous in vitro and in vivo studies where PRF demonstrated safe and promising results without contradictory findings in promoting wound healing.³

The interpretation of the present case report affirms the definite diagnosis of compound odontoma with the use of CBCT and histopathological evaluation. In addition, it emphasizes the importance of timely diagnosis and treatment for an eruption of impacted permanent teeth.

CONCLUSION

Delayed eruption of permanent teeth provoked the parents to dental check-ups, which further yields the diagnosis of compound odontoma supporting conventional radiographs (OPG) and advanced imaging like CBCT techniques. An unfamiliar number of denticles were extracted, followed by healing of the surgical site with PRF coagulum. It is inferred that odontomas in the majority are asymptomatic and neglected. Therefore, thorough periodic dental check-ups and examinations can summon the clinical and radiographic findings of ailment of any sort. For the same, pediatric dentists must be intimated with adequate diagnosis, advanced imaging, and treatment planning to provide the best dental care to the patient.

ORCID

Kopal Singh https://orcid.org/0000-0002-9341-1743

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