Complex Odontome of Maxilla – A Case Report

¹Dr. Gutta Mounika, ²Dr. Ankitha Masa, ³Dr. Sreekar Katru, ⁴Dr. Vinolia Sharon Mallolu

¹,²,³,⁴Post Graduate Student, Lenora Institute of Dental Sciences, Department of Oral Medicine & Radiology, Rajahmundry, Andhra Pradesh, India

**Citation of this Article:** Dr. Gutta Mounika, Dr. Ankitha Masa, Dr. Sreekar Katru, Dr. Vinolia Sharon Mallolu, “Complex Odontome of Maxilla – A Case Report.” IJDSCR – February – 2023, Vol. – 5, Issue - 1, Page No. 25-31.

**Copyright:** © 2023, Dr. Gutta Mounika, et al. This is an open access journal and article distributed under the terms of the creative commons attribution noncommercial License. This allows others to remix, tweak, and build upon the work non commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

**Corresponding Author:** Dr. Gutta Mounika, Post Graduate Student, Lenora Institute of Dental Sciences, Department of Oral Medicine & Radiology, Rajahmundry, Andhra Pradesh, India

**Type of Publication:** A Case Report

**Conflicts of Interest:** Nil

ABSTRACT

Odontomas are the most common variety of odontogenic tumors and derived from differentiated epithelial and mesenchymal cells. Odontomas have been classified as benign odontogenic tumours and are subdivided into complex and compound odontomas morphologically. These are the hamartomatous proliferation of enamel, dentin, cementum and pulp. Complex odontomas are usually located in the posterior region of mandible which resembles the size of the tooth.

The present article reports a case of complex odontoma involving the maxilla in a 38-year-old male patient reported to the department of Oral Medicine & Radiology with pain in the upper left back tooth region since 1 year. The etiopathogenesis, clinical, radiographic and histologic findings along with the differential diagnoses and treatment modalities were discussed.

KEYWORDS

Complex Odontome, Maxilla, Odontogenic tumour.

INTRODUCTION

Odontomas are the benign hamartomatous proliferation of enamel, dentin, cementum and pulp, most often found during the routine radiological examination. These are mixed odontogenic tumours, composed by mineralized tissue of ectomesenchymal origin.¹ The term odontoma was coined by Pierre Paul Broca in 1867, and described that these tumours occur due to the disproportionate transitory or full growth of dental tissues.²Odontomas constitute about 22% of all odontogenic tumours of the jaws. These are present during the second and third decades of life.

According to World Health Organization, based on organization and degree of alteration of odontogenic cells, odontomas are classified as Compound and Complex. Compound odontome exhibits morphological and histological differentiation
containing amorphous dental structures, whereas
complex odontome presents only histological
differentiation containing a solid mass of dental soft
and hard tissues which are haphazardly arranged and
do not resemble the morphology of a tooth.³

Reporting here, is a case of Complex odontoma in a
male patient aged 38 years involving the left maxilla
diagnosed with radiographic and histopathological
examination.

## CASE REPORT

A 38-year-old male patient reported to the department of Oral Medicine and Radiology, Lenora Institute of Dental Sciences, Rajanagaram with a chief complaint of pain in the upper left back tooth region since 1 year. On eliciting history of present illness the patient was apparently normal 3 months back. History of swelling which started as small peanut and gradually increased to attain present size. There was associated history of pain which was sudden in onset, mild, intermittent, non-radiating type, aggravated on taking food substances and relieved temporarily on taking medication. However, there was no history of paresthesia and secondary changes. On general and physical examination, patient was conscious, coherent, cooperative and well oriented in the dental chair with normal gait, erect posture, moderately built and nourished and all the vital signs were within the normal limits.

Extra oral examination revealed a diffuse swelling
measuring approximately 2×1.5 cm in size in relation
to left middle one third of the face (Figure 1)
extending anteroposteriorly 1.5 cm from the ala of the
nose on left side to 1cm in front of the tragus of left
the ear and superoinferiorly extending from the malar
region to 0.5 cm above the line joining the corner of
the mouth to the tragus of the ear. The skin over the

swelling was appeared to be stretched and the skin
surrounding the swelling was normal without any
surface ulcerations and visible pulsations. On
palpation, all the inspectory findings like site, size,
shape & extensions were confirmed and the swelling
was firm to hard in consistency, non-tender, with no
local rise of temperature and was non compressible,
non-reducible and non-pulsatile.

On intra oral examination, a roughly oval, solitary,
hard swelling was seen irt 26, 27 region with
vestibular obliteration irt 26,27 region (Figure 2). Pit
and fissure caries irt 18, 36, 38, deep dental caries irt
37 and missing 25,28,46 were found. Based on the
history and above-mentioned clinical findings a
provisional diagnosis of partially erupted
supernumerary tooth irt 26,27 region, chronic pulpitis
irt37, chronic generalized gingivitis and partially
edentulous irt 25,28,46 was given and a clinical
differential diagnosis of dentigerous cyst and erupting
odontomewas considered as there was missing 28.
Intra oral periapical radiograph irt26,27 revealed a
radiopacity measuring approximately 2×2.5 cm
extending from the mesial aspect of 26 to the
tuberosity region (Figure 3a).

OPG revealed a well-defined radiopacity with the
radiodensity similar to that of tooth and surrounded by
radiolucent area with the sclerotic border involving
the left posterior maxilla measuring approximately
2x2.5 cm extending from the 26 region to the
maxillary tuberosity and superoinferiorly extending
0.5 cm below the zygoma to the alveolar ridge
inferiorly (Figure 3b).

Based on these radiological findings a radiological
diagnosis of complex odontoma involving the left
maxilla on the posterior region was given and for the
sake of radiological differential diagnoses
ameloblastic fibro odontoma, cemento ossifying fibroma, periapical cemento osseous dysplasia and idiopathic osteosclerosis were considered. Complete surgical excision (Figure 4) of the lesion was done in the Department of Oral and Maxillofacial Surgery and the excised specimen was sent for histopathological examination which revealed numerous dentinal tubules in cross section and longitudinal section (Figure 5). Areas of fibrous connective tissue surrounding the dentinal tubules resembling the capsule and connective tissue core resembling the pulp is evident conforming the diagnosis of complex odontoma involving the left posterior maxilla. The patient was followed up after 15 days.

DISCUSSION

Odontomas are benign and slow growing tumors arising from tooth forming elements, either mesenchymal or a mixture of epithelial and mesenchymal elements. These tumors were first classified by Gabell et al in 1914, according to their developmental origin as epithelial, composite and connective tissue.⁴ The etiology of odontomas are idiopathic origin but it is suggested that the dental impaction, trauma, presence of local infection, diastema, and malformation could trigger the formation of an odontoma. When the deposition of enamel and dentine during the development of tumor is in such a way that the resulting structure show an anatomic similarity to normal teeth, the lesion is classified as a compound odontoma. Whereas, in complex odontoma there is deposition of simple irregular mass occurring in irregular pattern. Compound odontoma is more common than complex odontoma.⁵The possible reported sequelae of odontoma are: The displacement and malformation of neighbouring teeth, diastema, anodontia, and the

pressure exerted by the odontoma, which can cause pain, devitalization, and dental absorptions.⁶

Odontomas are classified into compound and complex odontomas according to WHO (2017). Compound odontomas appear as tooth like masses and occur in both males and females equally, whereas the complex odontomas present as non-descript masses of dental tissues, shows the female prediction and present during second and third decade of life. Complex odontomas are found most commonly in the mandibular posterior region in contrast to the present case which was seen in the maxillary posterior region in a male patient during the second decade of life and most of the compound odontomas are seen in the anterior maxilla.⁷

Odontome can occur three ways by interference with the mechanism where genes control tooth formation, a mutation in the genes concerned and inheritance of those abnormal genes. Odontomas are asymptomatic with retention of deciduous teeth, non-eruption of permanent teeth, pain, expansion of the cortical bone and tooth displacement. Other symptoms include paresthesia and swelling. Compound odontomas seldom cause bony expansion but complex odontomes often cause slight or even marked bony expansion.⁸

Odontomas can be radiographically categorized into three stages depending on the amount of calcification i.e Radiolucent stage, Intermediate stage and Radiopaque stage. Complex odontome appears as a radiopacity situated in the bone, having greater density than that of bone and equal or greater than that of tooth surrounded by a radiolucent halo. Compound odontome appears as a cluster of small shapeless dense masses having no resemblance to a tooth in shape depending upon the size of the mass and the presence of two or more tooth like masses having conical
enamel like capped crowns with fusion of radiolucent portions.⁹

Histologically odontomes are well-delineated, roughly spherical mass with a haphazard arrangement of a mature hard dental tissues and the degree of morphodifferentiation varies from lesion to lesion. There is also a dentine of an irregular variety, cementum in small amounts and admixture of dentine with round or ovoid spaces containing pulp tissue, enamel epithelium and remnants of enamel matrix. Odontomas can also manifest as part of syndromes, such as Gardner syndrome, basal cell nevus syndrome, familial colonic adenomatosis, Tangier disease, or Hermsyndrome. Such association was not seen in the presented case.¹⁰,¹¹

Differential diagnoses of ameloblastic fibro odontoma, cemento ossifying fibroma, periapical cemento osseous dysplasia and idiopathic osteosclerosis can be considered wherecomplex odontomas differ from cemento-ossifying fibromas by their tendency to associate with unerupted molar teeth and they usually are more radiopaque than cemento-ossifying fibromas. A complex odontoma, usually has one mass of disorganized tissue in the center, whereas the ameloblastic fibro-odontoma will usually have multiple scattered mature small pieces of dental hard tissue. The mature stage of periapical cemental dysplasia (PCD) may resemble complex odontomas but lesions are usually multiple with the epicenter located near the periapical region of lower anterior teeth. The periphery of cemental dysplasia usually has a wider uneven sclerotic border, whereas odontomas have a well-defined cortical border and usually the soft tissue capsule is more uniform and better defined with odontomas than in cemental dysplasia. Another interesting finding is that the Periapical cemental

dysplasia's are most commonly seen in females and occur in middle age. Dense bone islands, although radiopaque, do not have a soft tissue capsule, as is seen with odontomas.¹²

The treatment and management of the odontoma includes surgical enucleation. The fibrous capsule facilitates removal of the lesion from the surrounding bone, and the frequency of recurrence is minimal, the prognosis is excellent.¹³ As it is a capsulated tumour, special care should be taken to remove it totally in order to avoid a relapse which is commonly present in complex odontomas.

## CONCLUSION

As odontomas represent a large proportion of odontogenic tumors affecting the jaws, often interfere with eruption of adjacent permanent teeth, have the tendency to predispose to cystic change leading to the destruction of alveolar bone to a considerable extent, adequate knowledge regarding the clinical and radiological features of odontomas are essential for the early diagnosis and the appropriate treatment to abate the disfigurement and to restore the bony contours and hence the better esthetics.

Conflicts of interest: There are no conflicts of interest
Financial support: Nil

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LIST OF FIGURES

<figure><img src="image_1.png" /><figcaption>Figure 1: Extra oral swelling involving left middle one third of the face</figcaption></figure>
<figure><img src="image_2.png" /><figcaption>Figure 2: Intra oral view depicting vestibular obliteration in 27 regions</figcaption></figure>

<figure><img src="image_3.png" /></figure>

Figure 3a & 3b: Intra Oral Periapical Radiograph showing the radiop opacity mesial to 26 involving the posterior maxilla encroaching the tuberosity region (3a).

OPG showing well defined radiopaque mass involving the left posterior maxilla measuring approximately 2×2.5 cm showing radiodensity similar to that of adjacent tooth (3b)

<figure><img src="image_4.png" /></figure>

<figure><img src="image_5.png" /><figcaption>Figure 4: Excised specimen</figcaption></figure>
<figure><img src="image_6.png" /><figcaption>Figure 5: Histopathologic picture of complex odontoma</figcaption></figure>

LEGENDS

Figure 1: Extra oral swelling involving left middle one third of the face

Figure 2: Intra oral view depicting vestibular obliteration in 27 regions

Figure 3a: Intra Oral Periapical Radiograph showing the radiopacity distal to 26 involving the posterior maxilla encroaching the tuberosity region (3a).

Figure 3b: OPG showing well defined radiopaque mass involving the left posterior maxilla measuring approximately 2x2.5 cm showing radiodensity similar to that of adjacent tooth (3b).

Figure 4: Excised specimen

Figure 5: Histopathologic picture of complex odontoma.