Acta Clin Croat 2021; 60:146-152 Case Report

doi: 10.20471/acc.2021.60.01.22

ODONTOMAS: PEDIATRIC CASE REPORT

AND REVIEW OF THE LITERATURE
Tomislav Ćabov1, Petra Nola Fuchs1,3, Ana Zulijani2,
Lucija Ćabov Ercegović3 and Srđan Marelić4

1
Department of Oral Surgery, University of Rijeka, Faculty of Dental Medicine, Rijeka, Croatia;
2
Department of Oral Surgery, Rijeka University Hospital Centre, Rijeka, Croatia;
3
Zagreb Dental Polyclinic, Zagreb, Croatia;
4
Private Orthodontic Practice, Rijeka, Croatia

SUMMARY – Odontomas are benign odontogenic tumors formed from epithelial and mesen-
chymal cells. They are mostly associated with disorders of tooth eruption, causing impaction and/or
delayed tooth eruption, and are an accidental finding on routine radiological examination. The aim of
this paper is to present current findings in the etiology and treatment of odontomas, as well as the
clinical and radiographic features, describing a case that is rarely found in the literature. A case of
multiple complex odontoma in the mandible of an 11-year-old boy is presented, causing impaction of
the first permanent right molar, 46. The treatment consisted of surgical enucleation of the multiple
complex odontoma with preservation of the impacted tooth, monitoring clinically and radiologically
its spontaneous eruption followed by final orthodontic alignment. Odontomas are not an everyday
part of clinical practice and given that they are most commonly associated with permanent tooth
impaction, it is extremely important to have knowledge of their clinical and radiological features.
Early diagnostics and appropriate treatment result in better diagnosis, thus increasing the possibility
of preserving the impacted teeth.
Key words: Odontogenic tumors; Odontoma; Tooth, impacted; Pediatric dentistry

Introduction not representing a true neoplasm1-5. The incidence of

odontogenic tumors ranges from 0.002% to 0.1%, with
The term ‘odontoma’ was first introduced by Paul odontomas being the most common odontogenic tu-
Broca in 1867 and was originally used for any tumor mors (20%-67%), most commonly diagnosed in the
and/or tumor-like lesion of odontogenic origin1. Over first two decades of life regardless of gender2,4,6-9. The
years, as a consequence of new insights, the term odon- etiology of odontoma is poorly known, although some
toma has changed its meaning, and since 2017 it has studies have identified local trauma, inflammatory
been classified according to the World Health Organi- processes, and chronic infections during odontogene-
zation (WHO) in a group of benign mixed epithelial sis as possible factors. Other possible factors include
and mesenchymal odontogenic tumors2. However, it is genetic background, such as odontoblastic hyperactiv-
defined as tumor-like malformations (hamartomas) ity, or hereditary syndromes such as Gardner’s syn-
consisting of hard and soft dental tissues, enamel and drome and Hermann’s syndrome1-3,8,10. According to
dentine with different proportions of pulp and cement, many studies, odontomas generally do not cause sub-
jective disturbances, but often cause interference in
Correspondence to: Ana Zulijani, DMD, Department of Oral Sur- tooth eruption, and are diagnosed accidentally through
gery, Rijeka University Hospital Centre, Krešimirova 40, HR-
51000 Rijeka, Croatia
routine radiological examinations as a radiopaque
E-mail: ana.zulijani@gmail.com zone separated by a radiolucent zone from the sur-
Received January 18, 2021, accepted February 24, 2021 rounding bone2,6,8,9.

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T. Ćabov et al. Odontoma: pediatric case report

The WHO divides odontomas into complex occur in any area, however, compound odontomas are
(CxOD) and compound (CpOD) odontomas, given mostly located in the anterior maxilla (81.8%), where-
the organization and degree of differentiation of odon- as complex odontomas are most commonly located in
togenic cells2-4,6-8. Complex odontoma consists of cal- the posterior mandible (63%) and in the anterior max-
cified dental tissue less differentiated than normal illa (16%)2,4. Therapy of choice is surgical removal of
dental tissue, and makes an amorphous mass separated the entire odontoma with a low likelihood of recur-
by connective tissue from the surrounding bone. Com- rence2.
pound odontoma consists of a large number of dental
structures that resemble normal dental tissue, only in a
smaller dimension, many tooth rudiments separated Case Report
by connective tissue that at the same time separates the An 11-year-old boy presented to the Department of
entire structure from the surrounding bone2. They can Oral Surgery, Rijeka University Hospital Centre, re-
ferred by an orthodontist for an unknown amorphous
mass visible on the orthopantomogram in the mandible
that was causing impaction of the first right permanent
molar. Patient medical history excluded trauma or in-
fection, with no family history of odontoma.
Extraoral examination revealed no facial asymme-
try. Intraoral clinical examination revealed a stage of
mixed dentition with decayed deciduous teeth and ab-
sence of the first right mandibular permanent molar,
46. Slight expansion of the cortical bone from the ves-
tibular and lingual side was present in the area of the
first right mandibular permanent molar, with solid
consistency and without symptoms (Fig. 1). On the
performed orthopantomogram, a radiopaque well-de-
fined mass was observed above the crown of the first
right mandibular permanent molar, of similar intensity
Fig. 1. Intraoral photograph before the surgery. of calcified dental tissues, surrounded by a radiolucent

Fig. 2. Orthopantomogram showed a radiopaque mass on the right side

of the mandible above the impacted 46.

Acta Clin Croat, Vol. 60, No. 1, 2021 147

T. Ćabov et al. Odontoma: pediatric case report

Fig. 3. CBCT scan of the posterior right mandible prior to the surgery: cross section shows
two radiopaque masses located one below another and underneath them a non-erupted
tooth; a thinned buccal cortical bone, two well-limited radiopaque masses.

Fig. 4. Intraoral photographs of the surgery: odontoma in the region of the 46

after reflection full-thickness buccal flap (left panel); residual bone cavity after removal
of the odontomas, without disturbing the impacted 46 (right panel).

zone that separated it from the surrounding bone, and dibular permanent molar confirmed the presence of
hypodontia of the second left mandibular premolar, 35 two irregular radiopaque well-defined amorphous
(Fig. 2). masses, one above another and above the tooth crown
A cone beam computed tomography (CBCT) im- 46, measuring approximately 14x12 mm (Fig. 3).
age of the lower jaw in the area of the first right man- Based on radiographic and clinical features, a provi-

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T. Ćabov et al. Odontoma: pediatric case report

sional diagnosis of multiple complex odontomas was tion of the impacted tooth followed. If spontaneous
established. In agreement with the orthodontist, surgi- eruption would not occur, an orthodontic-surgical ap-
cal procedure was planned to remove odontomas un- proach is a treatment option to preserve impacted per-
der general anesthesia, after which spontaneous erup- manent teeth, surgical exposure and orthodontic trac-
tion of teeth.
The surgery was carried out under general anesthe-
sia. A full thickness buccal mucoperiosteal flap was
raised and using carbide bur, with abundant irrigation
of the saline solution, the thin overlying of cortical
bone was removed. A clearly limited complex odon-
toma was exposed, circumscribed by a connective tis-
sue capsule (Fig. 4).
The two complex odontomas were completely re-
moved, leaving a cavity with exposure of the tooth
crown of impacted tooth 46 (Fig. 5). The edges of the
bone were rounded, and the wound was washed with
saline and sutured with 4/0 silk (Fig. 6).
Fig. 5. Complex odontomas removed by the surgery. The postoperative course was uneventful. Histo-
pathologic examination confirmed the provisional di-
agnosis of complex odontoma. Orthopantomogram
taken six months after the surgery showed spontane-
ous eruption of the impacted tooth 46 (Fig. 7). The
impacted tooth had been monitored clinically and ra-
diologically until it was placed in the dental arch, fol-
lowed by orthodontic treatment due to malposition of
the tooth (Fig. 8).

Discussion
In this case, two complex odontomas are shown,
localized above the crown of the first right mandibular
Fig. 6. Intraoral photograph after the surgery: permanent molar causing its impaction. Complex
the flap was closed with 3.0 silk sutures. odontomas are most commonly found in lower jaws in

Fig. 7. Orthopantomogram taken six months after the surgery.

Acta Clin Croat, Vol. 60, No. 1, 2021 149

T. Ćabov et al. Odontoma: pediatric case report

ment, so they usually do not exceed 10 to 20 mm in

size6-8,17. In the literature, some cases of extremely large
odontomas that caused cortical bone expansion and
consequently facial asymmetry are described3,17-20. The
most common localization of odontoma is the anterior
part of the jaws4,6,13.
Clinically, they can be divided into intraosseous
and extraosseous odontomas, and according to some
studies, central and peripheral odontomas, that is,
odontomas located within the bone and odontomas
located within the soft tissue10,21. Intraosseous odonto-
mas can rarely erupt into the oral cavity over time,
Fig. 8. Occlusal views during orthodontic treatment. whereas extraosseous odontomas are a very rare entity
and tend to break out inside the oral cavity. Erupted
the area of the second and third molars8. In the litera- odontoma is a third variety of odontomas in clinical
ture, cases of multiple complex odontomas have been classification1,3. In the literature, several cases of erupt-
rarely reported10. Odontomas, as in this case, are most ed odontoma into the oral cavity have been reported,
commonly diagnosed on radiography examination most commonly associated with pain and infection of
taken to determine the cause of missing or malposition the surrounding mucosa8,18,19,21,22.
of an individual tooth, more frequently in permanent Radiological odontomas can be divided by devel-
dentition than in deciduous dentition1,6,9,11-13. For the opment stages based on calcification. Completely ra-
same reason, it is recommended for them to be re- diolucent odontomas, that is, the absence of mineral-
moved early in order to allow proper spontaneous ization is really described in the literature. The second
eruption of teeth in dental arch. The treatment of stage is characterized by partial calcification; and in
odontoma is surgical and may be associated with orth- the final development stage, mature odontomas are
odontic therapy, i.e. malocclusion correction or orth- mostly a compound of calcified dental tissue sur-
odontic traction of an impacted tooth caused by the rounded by radiolucent zone10,11,14.
presence of odontoma7,14. In the case presented, surgi- The treatment of odontoma includes surgical re-
cal removal of the odontoma was indicated, as well as moval of the lesion with a small percentage of recur-
monitoring of spontaneous eruption of the affected rence, which occurs in case of incomplete enucle-
tooth. ation2,5-7,11. The case presented had no recurrence. In
Odontomas are the most common odontogenic tu- the literature, two-stage surgical management is de-
mors, and according to the WHO, two types can be scribed for large odontomas where the risks of patho-
distinguished, complex and compound odontomas. logic fracture and damage to vital anatomic structures
Some studies describe another type of odontoma, are higher10,15,23,24. Since odontomas are in most cases
mixed odontomas, as a combination of the characteris- an obstacle to the emergence of permanent teeth,
tics of compound and complex odontomas8,15. Com- causing permanent tooth impaction, there is no gen-
pound odontomas are more commonly diagnosed in eral agreement for the treatment of an impacted tooth
the population than complex odontomas, at a 2:1 ratio, in the literature. The possible options include extract-
although some studies have reported an equal preva- ing the impacted tooth, surgical repositioning, surgical
lence7,8,13,16. They are mostly diagnosed accidentally in exposure of the impacted tooth with or without orth-
the second decade of life, with a peak around 14 years odontic tooth extraction, and clinical and radiological
of age5-7. Odontomas are mostly asymptomatic, usually monitoring of the impacted tooth until its spontane-
associated with delayed eruption of teeth or impacted ous eruption14. There are several clinical investigations
tooth, and may later cause swelling, cortical bone en- focused on the diagnosis of impacted teeth. The suc-
largement, or pain. They are characterized by slow and cess rate of preservation ranges from 45% to 75.8%
limited growth, meaning that they grow until the mo- with or without surgical exposure of the crown and
ment when dental tissue has completed its develop- orthodontic traction of the affected teeth, depending

150 Acta Clin Croat, Vol. 60, No. 1, 2021

T. Ćabov et al. Odontoma: pediatric case report

on the study8,11,14. Spontaneous eruption has been de-   3. Akerzoul N, Chbicheb S, El Wady W. Giant complex odonto-
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tumors and lesions treated in a single specialist oral and maxil-
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Sažetak

ODONTOMI: PEDIJATRIJSKI PRIKAZ SLUČAJA I PREGLED LITERATURE

T. Ćabov, P. Nola Fuchs, A. Zulijani, L. Ćabov Ercegović i S. Marelić

Odontomi su dobroćudni odontogeni tumori nastali od epitelne i mezenhimne osnove. Najčešće su povezani s poreme-
ćajima u nicanju zuba, uzrokujući impakciju i/ili zakašnjelo nicanje zuba te su slučajan nalaz prilikom rutinskih radioloških
snimaka. Cilj ovoga rada je prikazati dosadašnja saznanja u etiologiji i liječenju odontoma, kao i kliničke i radiografske zna-
čajke, prikazujući slučaj koji se rijetko može naći u literaturi. Prikazan je slučaj višestruko složenog odontoma u mandibuli
11-godišnjaka, što uzrokuje impakciju prvog trajnog desnog kutnjaka, 46. Liječenje se sastojalo od kirurške enukleacije više-
struko složenog odontoma uz očuvanje zahvaćenog zuba. Nakon operativnog zahvata klinički i radiološki se pratilo spontano
nicanje impaktiranog zuba do konačnog ortodontskog ispravljanja položaja zuba. Odontomi nisu svakodnevni dio kliničke
prakse, a s obzirom na to da su najčešće povezani s impakcijom trajnih zuba veoma je važno poznavati njihove kliničke i
­radiološke značajke. Rano dijagnosticiranje i primjereno liječenje rezultiraju boljom dijagnozom, povećavajući tako moguć-
nost očuvanja impaktiranih zuba.
Ključne riječi: Odontogeni tumori; Odontom; Impaktirani zub; Dječja stomatologija

152 Acta Clin Croat, Vol. 60, No. 1, 2021