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Odontomas are the most common odontogenic tumours constituting about 21%–67% of all benign odontogenic tumours.1 2 Considered as hamartomas of aborted tooth formation rather than true neoplasms, they are asymptomatic, negligibly common in women and diagnosed during the second decade of life. Although several factors such as local trauma, infection, growth pressure, hereditary and developmental influences have been suggested in the aetiology of odontomas, the exact cause remains uncertain.
Based on radiographic and microscopic findings, odontomes are broadly classified as compound and complex types, the former being more common in occurrence.3 4 The compound odontomas arise in the anterior maxilla, while the complex odontomas have a predominance in the posterior mandibular region.
Radiographically, compound odontomes exhibit tooth-shaped structures surrounded by a radiolucent zone, while complex odontomas present as radiopaque masses with a radiolucent zone.5 Odontomas are rarely symptomatic, commonly associated with retained deciduous teeth and interfere with the eruption of their successors. Though odontomas are common, multiple odontomas are rare and are usually associated with systemic syndromes such as Gardner syndrome, basal cell nevus syndrome, familial colonic adenomatosis, Herrmann syndrome and Bader syndrome. Consequently, early diagnosis of these tumours is important, especially when multiple, as they may be one of the earlier manifestations of such syndromes, thereby improving the prognosis and proper management of more severe manifestations.6 7
A teenage girl reported to a dental clinic with multiple missing and maligned teeth. An orthopantomogram revealed bilateral impacted maxillary canines and multiple radio-opaque masses on the upper and lower jaw bilaterally. A provisional diagnosis of multiple complex odontoma was given. A detailed family history and general examination ruled out possible congenital syndromes.
Cone beam CT (CBCT) revealed four radiopaque tooth-like structures present on the palatal aspect of maxillary right second premolar and first molar in close proximity to the roots (figure 1A–C). One radiopaque mass was present on the palatal aspect of retained left maxillary canine. In the mandible, one radiopaque mass was present on the lingual aspect of canine and first premolar on either side. Based on the clinical presentation and radiological evidence, a differential diagnosis of complex odontoma, calcifying epithelial odontogenic cyst and cemento-ossifying fibroma was given. Under intravenous conscious sedation, surgical removal of the radiographic masses was done using local anaesthesia. For removal of teeth-like structures and maxillary lesions, a palatal flap was raised from first molar on right-side to the second premolar on the left-side by preserving the nasopalatine nerve (figure 2B). For removal of the mandibular lesions, lingual mucoperiosteal flap was raised and tooth-like structures were removed preserving the lingual nerve and achieving haemostasis.
Seven solid, tooth-like materials (figure 2A) subjected to decalcification showed evidence of mature enamel, dentin and cementum intermingled with pulp-like tissue in a haphazard arrangement along with ghost cells (figure 2C). Histopathological analysis confirmed the diagnosis of multiple complex odontomas. Follow-up after 2 years showed no evidence of recurrence or any other pathological changes. The impacted maxillary canines have been retracted with the help of orthodontic therapy.
I was always very conscious of my missing canines and the crowding in my teeth and would never show my teeth and smile, so I decided to visit a dentist for consultation. I was surprised to find I had multiple teeth which were removed surgically. I’m glad I was able to find it before there were any complications. Now I am halfway through with the correction of my teeth alignment, and I am already smiling confidently.
Early diagnosis and prompt management of odontomes is necessary to adopt less complex treatment, avoid displacement and devitalisation of adjacent teeth and ensure better prognosis.
Cone beam CT imaging is recommended to precisely localise the odontomes, their vicinity to vital structures including tooth roots and to evaluate remnant bone continuity and volume to plan for appropriate surgical approach.
Histopathological differentiation of odontomas from other bone-related lesions such as fibrous dysplasia, ossifying fibroma, adenomatoid odontogenic tumour, calcifying epithelial odontogenic tumour, ameloblastic fibro-odontoma and odonto ameloblastoma is crucial for treatment planning.
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Contributors VS and RR contributed to the drafting of the manuscript. PS performed the surgery and contributed to the drafting of the manuscript. HTC was the pathologist who diagnosed the case and contributed to the approval of the final draft of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.