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 Table of Contents  
REVIEW ARTICLE
Year : 2019  |  Volume : 11  |  Issue : 6  |  Page : 334-339

Odontoma- An Unfolding Enigma


1 Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, College of Dentistry, Jouf University, Sakaka, Kingdom of Saudi Arabia
2 Department of Preventive Dentistry, College of Dentistry, Jouf University, Sakaka, Kingdom of Saudi Arabia

Date of Web Publication26-Nov-2019

Correspondence Address:
Dr. Rakhi Issrani
Department of Preventive Dentistry, College of Dentistry, Jouf University, Sakaka
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_115_19

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  Abstract 

Odontomas are thought to be hamartomatous malformations in which enamel, dentin, and pulp, and occasionally cementum, is present in a disorganized form. It develops by the completely differentiated epithelial and mesenchymal cells that form ameloblasts and odontoblasts respectively. With no gender predilection and often asymptomatic, it is usually discovered accidentally on a routine radiographic study. They may be related with malformation, aplasia, malposition, delayed eruption of associated teeth and sometimes cystic changes. In these cases, Cone Beam Computed Tomography (CBCT) provides several advantages over conventional radiographs regarding diagnosis and treatment planning. Enucleation is the treatment of choice for these tumors and relapse is very uncommon. This paper highlights the etiology, classification, clinical/radiologic/histopathologic features and treatment options available for odontomas. Although much is known about odontomas but sometimes it presents as an enigma to a dental practitioner that needs to be unfolded with the use of radiography that acts as an indispensable tool in routine dental clinical examination.

Keywords: Enucleation, Hamartomatous, Odontoma


How to cite this article:
Prabhu N, Issrani R, Patil S, Srinivasan A, Alam MK. Odontoma- An Unfolding Enigma. J Int Oral Health 2019;11:334-9

How to cite this URL:
Prabhu N, Issrani R, Patil S, Srinivasan A, Alam MK. Odontoma- An Unfolding Enigma. J Int Oral Health [serial online] 2019 [cited 2019 Dec 12];11:334-9. Available from: http://www.jioh.org/text.asp?2019/11/6/334/271771


  Introduction Top


The term odontoma was coined by Pierre Paul Broca in 1867, who described the term as tumors formed by the disproportionate transitory or full growth of dental tissues.[1] Because of their slow growth and nonaggressive behavior, these are classified as benign tumors.[2] They are proposed to be developmental anomalies formed by the improper growth of completely differentiated epithelial and mesenchymal cells.[3],[4],[5] Currently, the World health Organization has categorized odontoma as an odontogenic tumor that is comprised of epithelium and odontogenic ectomesenchyme with or without formation of mineralized dental tissues.[6]

Epidemiologically, odontomas are the most frequent odontogenic tumors, accounting for 22%–67% of all maxillary tumors.[7] Buchner et al.[8] examined a sample of 1088 odontogenic tumors and reported an incidence rate of 75.9% of the total. Ragezi et al.[9] examined a sample of 706 jaw tumors and reported that odontomas constituted 67% of their sample.


  Etiology and Classification Top


The etiology of these tumors is unknown, but trauma and infection at the site of lesion is proposed to be an ideal condition for its appearance.[10],[11],[12] It is formed because of either increased proliferation of the dental lamina and its remnants (called laminar odontoma) or multiple schizodontia.[13],[14] Hitchin[15] suggested that odontomas are inherited because of mutagen or interference, possibly occurring postnatal, with the genetic control of tooth development. They may also manifest as part of many syndromes such as basal cell nevus syndrome, Gardner syndrome, familial colonic adenomatosis, Tangier disease, Hermann syndrome, or odontoma-dysphagia syndrome.[16],[17]

Odontomas can be classified into different types of tumors depending on various factors[18],[19],[20],[21],[22],[23],[24],[25] [Table 1].
Table 1: Different classification schemes of odontoma

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  Clinical Features Top


Clinically, odontomas mostly manifest themselves during the first two decades of life, and the mean age at the time of diagnosis is 14 years.[25] The gender predilection is not specified as different studies show different results. In some studies, females are shown to be affected more, whereas in other studies, males are found to have higher incidence.[26],[27],[28],[29] Consecutively, some studies report no differences between males and females.[30],[31] Gender predilection has been observed individually in the compound and complex odontomas. The compound odontomas showed male predilection, whereas the complex odontomas were found to be slightly more common in females.[16]

Compound odontoma is almost twice as common as complex odontoma and is frequently seen in anterior maxilla, whereas complex odontoma is seen most commonly in the posterior mandible.[26],[27],[29],[32] A sidewise comparison of jaws shows a slight predilection on the right side of the mandible as compared with the left side. The most common sites in the decreasing order of prevalence are anterosuperior region, anteroinferior zone, and posteroinferior sectors.[16],[33] Isolated cases of erupted and extragnathic odontomas were recorded in the maxillary sinus, mastoid region, nasal cavity, and floor of the orbit.[12],[19],[23],[24]

Odontomas have slow growth and rarely exceed the size of a tooth, but when odontomas become large, these tumors can cause cortical bone expansion.[34],[35] At full maturity, the size of the tumor is usually 1–2 cm in diameter; however, tumors up to 6 cm in size have also been reported.[25] Among these, intraosseous odontoma is the most common odontogenic tumor together with ameloblastomas. The peripheral type of tumor in both the compound and complex odontomas, however, is very rare, although the compound type is a little more common than the complex one.[36] Odontomas are usually asymptomatic but sometimes may show symptoms like the retention of permanent teeth, in which the odontoma interferes with eruption.[37],[38] In such cases, the maxillary incisors and canines are the most frequently affected teeth.[37] The other manifestations, although rare, might be the agenesis of permanent teeth, pain, inflammation, or infection associated with suppuration.[30],[33],[38],[39] They can remain undiagnosed in an intra-bony location for years, without causing any kind of symptoms.[40]

[Table 2] shows various studies highlighting the clinical features of odontomas.[26],[27],[28],[29],[30],[31],[32],[33],[41],[42]
Table 2: Retrospective studies highlighting the clinical features of odontomas

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  Radiographic Features Top


More than half of the odontoma cases (57%) are diagnosed during routine radiological examination, usually between 10 and 19 years of age.[43],[44] Odontomas can be radiographically categorized into three different development stages depending on the degree of calcification. The first stage is characterized by a radiolucent appearance due to the lack of calcification followed by an intermediate stage in which the lesion is partially calcified.[23] In the final stage, the odontoma shows radio-opacity with foci of variable density surrounded by a radiolucent halo and a thin sclerotic line. The radiolucent halo is the connective tissue capsule of a normal tooth follicle, whereas the thin sclerotic line resembles the corticated border seen in a normal tooth crypt.[45] As compared with the conventional radiographs, cone beam computed tomography (CBCT) provides several advantages regarding diagnosis and treatment planning of odontomas because of its property to enable the three-dimensional multiplanar reconstruction of the scanned site as shown in the case report by Hossein et al.[46] where the conventional radiographic images in the maxillary anterior region revealed the presence of an impacted maxillary right central incisor with the malformed crown, but on CBCT an odontoma in close proximity to the crown of an impacted tooth was observed.


  Histological Features Top


Histologically, odontoma comprises dental hard and soft tissues such as dentin, cementum, pulp tissues with odontoblastic cells, and enamel matrix.[33] The mature enamel is predominantly made of inorganic tissue that is lost during the process of decalcification and so it appears as an empty space. The compound odontoma shows tooth-like structures with central cores of pulp tissues that are covered in dentin shells and partially covered by enamel surrounded by a fibrous capsule similar to the follicle surrounding a normal tooth, whereas the complex odontoma is composed of disorganized conglomerates of enamel, dentin, enamel matrix, cementum, and pulp tissue.[47] Ghost cells may be seen along with spherical dystrophic calcification, enamel concretions, and sheets of dysplastic dentin.[33],[48] There is hardly any difficulty in diagnosing either complex or compound odontoma.[49] The literature review reveals that odontomas display amelogenin expression, bone morphogenetic proteins, and have broad stromal immunoreactivity of tenascin.[50]

Differential diagnosis includes ameloblastic fibroma, ameloblastic fibro-odontoma, and odontoameloblastoma[11],[16] and also assessment should be made for association with any syndrome in case of multiple lesions or simultaneous occurrence of other lesions such as intestinal polyposis. According to Kramer et al.,[19] the failure in tooth eruption may lead to thickening of tooth follicle that might give similar appearance to that of an odontogenic fibroma or myxoma.


  Treatment Top


Early diagnosis of odontomas in primary dentition is crucial for prevention of complications like failure of eruption of permanent teeth, cystic changes and bone destruction. Early detection also ensure less expensive treatment and better prognosis.[51],[52] The treatment options include surgical extraction and surgical repositioning, orthodontic treatment or leaving the tooth for spontaneous eruption and postsurgical clinical, and radiological follow-up to assess the course of these teeth.[53] Small-sized odontomas do not pose any difficulty during removal; however, the proximity to nearby structures must be considered to prevent unnecessary injury to them.[54] There is little probability of recurrence.[34]


  Conclusion Top


Odontomas represent a large proportion of odontogenic lesions. They can impede eruption of permanent teeth and hence interfere with arch-forms or occlusion, thus necessitating their timely diagnosis and management. Hence, sufficient knowledge regarding the odontoma is imperative to establish correct diagnosis and treatment. In addition to conventional radiography, CBCT is the better imaging method to evaluate odontomas for proper treatment planning and management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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Introduction
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