Case Report

Compound Odontoma Associated with Impacted

Teeth: A Case Report
Palak Jain Choudhary1, Harshkant P Gharote2, Kartik Hegde2, Palak Gangwal1
Postgraduate Student, Department of Oral Medicine and Radiology, Peoples College of Dental Science and Research Centre, Bhopal, Madhya
Pradesh, India, 2Reader, Department of Oral Medicine and Radiology, Peoples College of Dental Science and Research Centre, Bhopal, Madhya
Pradesh, India
1

Odontomas are developmental anomalies of the dental tissues and may interfere with the eruption of the associated tooth. Since, these
lesions are asymptomatic, they are usually detected in routine radiographs only. Early diagnosis, prompt clinical decision making followed
by a proper treatment at the right time, results in a favorable prognosis. The present report describes the surgical management of a case
of compound odontoma in 11-year-old boy who presented with a complaint of missing tooth in maxillary anterior region. After the lesion
was surgically removed under local anesthesia, histopathological examination conrmed the diagnosis of compound odontoma. The related
literature is also reviewed in this article.

Keywords: Compound odontoma, Delayed tooth eruption, Maxilla, Odontogenic tumors, Odontoma

INTRODUCTION
Variation in the normal eruption of teeth is a common
finding, but significant deviations from normal should
alert the clinician to investigate further. It is suggested
that an individualized radiographic examination should
be performed for patients who present with clinical
evidence of delayed permanent tooth eruption or temporary
tooth displacement or retained deciduous teeth with or
without a history of previous dental trauma. This will
help the clinician rule out pathologies like odontoma. The
odontoma, a mixed odontogenic tumor emulating all the
hard tissues products of a mature tooth germ, is almost
certainly the most common type of odontogenic tumor
or hamartomas.1 WHO 2005, has classified two types as;
complex and compound odontomes, occurring in the ratio
of 1:2.2 The majority of compound odontoma cases (74.3%),
are diagnosed before the age of 20 years,3 during routine
radiographic examination, occurring commonly in the
anterior maxillary region. Thus, early diagnosis will
facilitate the clinician to adopt a simpler and less complex
approach of treatment for a be er prognosis. In spite of the
low frequency and good prognosis, there must be a close
follow-up of such lesions, because these lesions are reported
to be associated with conditions such as ameloblastoma,
adenomatoid tumor, and carcinoma.

tooth. Patient was asymptomatic, and his past dental and

medical history was not significant. Intraoral examination
revealed that 11, 12, and 13 had not erupted into the
oral cavity, but 21, 22, and 23 were present (Figure 1).
There was no sign of inflammation, pain or infection and
surrounding mucosa was normal. An intraoral periapical
radiograph revealed presence of 11 deep in alveolar bone.
The crown of the unerupted 11 was overlapped by tooth
like masses (Figure 2). Intraoral periapical radiograph
showed a collection of tooth-like structures with a narrow
radiolucent rim around. The orthopantomograph showed
multiple radio-opaque teeth-like structures in relation
to unerupted maxillary right central incisor surrounded
by a radiolucent band with smooth outer periphery

CASE REPORT
An 11-year-old boy came to the department with the
chief complaint of non-eruption of the upper right front

Figure 1: Eruption bulge with missing permanent teeth

Corresponding Author:
Dr. Palak Jain Choudhary, H.No-111, Sagar Avenue, Ayoudhya Bypass, Bhopal, Madhya Pradesh, India. E-mail: 6jainpalak@gmail.com

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Choudhary, et al.: Compound odontoma associated with impacted teeth

Figure 2: Intraoral radiograph of maxillary right front region showing tooth-like

structures

Figure 3: OPG showing unerupted tooth with enlarged follicular space and
denticles

Figure 5: Photomicrograph

Figure 6: 1 month follow-up showing erupting central incisor

of follow-up (Figure 6). The patient was followed for 1 year

however there was no recurrence.

DISCUSSION

Figure 4: Denticles visible on surgical exposure

(Figure 3). The clinical-radiological findings are suggestive

of compound odontoma. Surgery was performed to remove
the lesions and three mineralized structures showing a
tooth-like appearance were found within them (Figure 4).
The specimen was sent for histopathological examination.
The H and E stained decalcified section showed admixture
of dentinal tissues arranged in a haphazard manner
with serrated borders (Figure 5) confirming the clinicalradiographic diagnosis of complex odontoma. The healing
was uneventful, and no post-operative complications were
noted. The crown of 11 was clinically visible after 1 month

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Odontomas are most common variety of mixed odontogenic

tumors, in which enamel and dentin are formed when
both the epithelial and mesenchymal components undergo
functional differentiation. 4 The abnormal pattern of
enamel and dentin are laid down because the organization
of the odontogenic cells fails to reach a normal state of
morphodierentiation. They are hamartomatous lesions
rather than true neoplasms.5
The term odontoma was coined by Paul Broca in 1867.6
Its incidence has been reported to be as 22-67% of all
odontogenic maxillary neoplasms.7 Frequently impacted by
odontomas are canines, followed by upper central incisors
and third molars, there are with few cases being related to
missing teeth. These tumors can be found anywhere in the
dental arches and are generally intra-osseous. However,
they may erupt into the oral cavity occasionally. They
may occur at any age and in any gender; however, most
cases are detected in the first two decades of life on routine
radiographs.8 The neighboring teeth may be aected in
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Choudhary, et al.: Compound odontoma associated with impacted teeth

70% cases by pathologic changes such as, malformation,

malposition, devitalization, aplasia, and delayed eruption.
They may also undergo cystic transformation.
1914 Gabell et al. gave the first classification according to
the developmental origin as epithelial, composite (epithelial
and mesodermal)and connective tissue.9,10 Later in 1946
Thoma and Goldman classified them as:
Geminated composite odontomes-two or more welldeveloped teeth fused together
Compound composite odontomes-consists of more or
less rudimentary teeth
Complex composite odontomes-are calcified structure
that has no great resemblance to the normal anatomical
arrangement of dental tissues
Dialated odontomes-there is marked enlargement of the
crown or root part of the tooth
Cystic odontomes- is normally encapsulated by fibrous
connective tissue in a cyst or in a wall of cyst.9,11
Then WHO in 1992 7 based on the degree of morpho
dierentiation classified odntomes as compound odontoma
with at least superficial anatomic resemblance to teeth
as all the dental tissues are represented in an orderly
fashion. While in a complex odontoma there is li le or no
morphologic resemblance to normal tooth formation. They
have also been classified clinically as:
Intra-osseous (central)-they occur within the bone and
may erupt into the oral cavity and represents 51% of
all odontogenic tumors. Occurs predominantly in the
anterior maxilla and mandibular molar areas
Extra osseous (peripheral)-they occur in the soft tissue
covering the tooth bearing areas of the jaws12
Rarely, intra-osseous odontomas may facilitate their
eruption into the oral cavity when located coronally to
an impacted or erupting tooth or superficially in bone.
Here they are referred to as erupted odontomas.12
Majority of compound odontomas are located in the anterior
region of the maxilla and diagnosis is frequently made on
the basis of the failure of a permanent tooth to erupt as in
the present case. In 40-50% of cases, an impacted permanent
tooth is associated with the compound odontoma. 10
Complex odontomes are located in the mandible especially
in the posterior areas. The compound odontoma is a
malformation in which all the dental tissues are in a
more orderly pa ern so that the lesion consists of many
tooth-like structures. They appear twice more frequently
than complex odontomas.6 They are usually asymptomatic,
have slow growth, and seldom exceed the size of a tooth, but
can cause expansion of the cortical bone when grows large
in size. Based on the data of the survey by Philipsen et al.
the relative frequency of the compound odontoma is 9-37%
14

of all odontogenic tumors. The average age at diagnosis

is 17.2 years (range 0.5-73 years).10 75% of all case are
diagnosed at around age 20 years, and it is slightly more
common in males as compared to female (1.2:1).
Local trauma and infection at the place of the lesion can
oer ideal conditions for its appearance. However, genetic
predisposition by inheritance, mutant gene or interference
has also been suggested. Laminar odontoma arise from an
exuberant proliferation of the dental lamina or its remnants or
can be a result of multiple schizodontia, i.e. a locally accustomed
hyperactivity of dental lamina.13 It may also be associated
with the Gardners syndrome of intestinal polyposis or the
rare odontoma dysphagia syndrome.14 Primary dentition if
traumatized (intrusion and avulsion)during the developmental
stages of a succedaneous permanent tooth interferes with its
future growth due to the close relationship between the apices
of primary teeth and the buds of permanent teeth.15
Dierential diagnosis includes ameloblastic fibroodontoma,
ameloblastic fibroma and odonto ameloblastoma. The lesions
may also occur as part of few conditions, such as Gardner
syndrome, basal cell nevus syndrome, familial colonic
adenomatosis, tangier disease, or Hermann syndrome.6
Radiographically odontomas have characteristic features
which depend on their stage of development and degree
of mineralization.
First stage: A radiolucency due to lack of calcification
Intermediate stage: Partial calcification is observed
Third stage: The lesion usually appears as radiopaque
masses surrounded by radiolucent areas corresponding
to the connective tissue histologically.16
The lesions of compound odontoma are usually unilocular
and frequently appears as a collection of numerous
radiopaque, miniature tooth-like structures known as
denticles.17 Composite odontoma appears as a calcified
mass with a radiodensity similar to tooth structure; both are
further surrounded by a narrow radiolucent zone.
Histopathologically, odontomas are composed essentially
of mature dental tissues that is enamel, dentin, cementum,
and pulp tissue and may be arranged in discrete tooth-like
structures (compound odontoma)or as unstructured sheets
(complex odontoma). The bulk of the tumor usually consists
of normal appearing dentin with a fibrous capsule and a
supporting fibrous tissue in a small amount.4 As odontomas
include epithelial and mesenchymal tissue they can undergo
cystic degeneration of the enamel organ after partial or
total development of the crown, and can transform into
dentigerous cyst. The cystic transformation of the follicle
associated with the unerupted tooth may also occur when
its eruption is impeded by the odontoma.4
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Choudhary, et al.: Compound odontoma associated with impacted teeth

Ghost cell keratinization is occasionally seen in the

enamel-forming cells of some odontomas. Surrounding
hard tissue calcification leads to reduced oxygen supply
by walling-o eect which in turn causes metaplastic
transformation of odontogenic epithelium leading to cell
death and keratinization. This pathogenesis was later ruled
out, and many other concepts were put forth in due time.

5.

6.

7.
8.

Treatment of choice comprises surgical extraction, along

with any associated soft tissues, fenestration, orthodontic
traction or periodic simple watching along with clinical and
radiographic examination to appraise the path of eruption
of teeth.10 Recurrences are rare.

CONCLUSION
Odontomas are more commonly associated with impacted
teeth and rarely erupt into the oral cavity. Even though
these lesions are benign in nature, they can give rise to
inflammation, pain and infection when they erupt in the
mouth. Early detection and treatment of odontomas could
increase the possibility of preservation of the impacted teeth.
The treatment of choice is surgical removal of the odontoma,
followed by histological analysis. As was demonstrated
by this report, early diagnosis of odontomas on a routine
radiographic examination allows adoption of a less complex
and less expensive treatment and ensures be er prognosis.

9.

10.

11.
12.

13.

14.
15.

16.

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How to cite this article: Choudhary PJ, Gharote HP, Hegde K, Gangwal
P. Compound Odontoma Associated with Impacted Teeth: A Case Report.
IJSS Case Reports & Reviews 2014;1(3):12-15.

Source of Support: Nil, Conflict of Interest: None declared.

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