Large eruption complex odontome in a Saudi patient

Discussion

Erupting odontomas are initially intra osseous or central odontomas that later on become extra osseous or erupted. However, the mechanism behind the eruption in the case of erupting odontomas remains uncertain as some odontomas erupt at a young age and others at an older age. To date, most of the reported erupted odontomas are related to non-erupted teeth; it may, therefore, be postulated that the eruptive force of these teeth plays an important role in odontoma eruption.4 Eruption at a younger age is therefore possible through bone remodeling that might have resulted from the presence of dental follicles.3 The mechanism of odontome eruption appears to be different from tooth eruption because of the lack of the periodontal ligament in the odontome. Therefore, the power required for the eruption of odontomas is not linked to the contractility of fibroblasts, as is the case for teeth. Although there is no root formation in the odontome, its increasing size may lead to the sequestration of the overlying bone and hence, leads to eruption.5 The increase in size of the odontoma over time produces a force sufficient to cause bone resorption.3 Another reason for odontoma eruption could be the bony remodeling of the jaws. However, for this to occur a dental follicle is required, although indirectly, as it provides both the conductance and chemo attraction for the osteoclasts necessary for tooth eruption. Immunocytochemical investigations have indicated that the pattern of cellular activity involving both reduced dental epithelium and the follicles is associated with tooth eruption. The reduced dental epithelium initiates a cascade of intercellular signals by expressing epidermal growth factor β and transforming growth factor. These factors, in turn, stimulate the follicular cells to produce colony-stimulating factor, which recruits osteoclasts to the follicle. The reduced dental epithelium also secretes proteases, which assist in the breakdown of the follicle to produce a path of least resistance. The epithelial signaling could, therefore, explain the remarkable consistency of eruption times as it is likely that the dental epithelium is programmed as part of its functional life cycle.3 While in elderly cases where eruption odontomas were not related to impacted teeth or are located in edentulous ridges it was postulated that it is likely that resorption of the edentulous part of the alveolar process plays a role, but it is also possible that reactive growth of the capsule contributes to this phenomenon.2,5

To date, only 23 cases of erupted odontomas have been documented in the literature with the first case being described in 1980 by Rumel et al.1 Histopathologically, of the 23 reported cases of erupted odontoma, an almost equal frequency was noted of complex odontomas with 12 cases being diagnosed as compound odontomas2,4-9 as compared with 11 complex odontomas.2,3,6 Fifteen females (65%) were more affected as compared with 7 males (30%), with one case where the patient’s age and gender were not determined.2-10 The patients’ age ranged from 9 to 65 years, with a mean age of about 26 years confirming an age prediction of these lesions between the second and third decades of life.2,7 The clinical signs and symptoms of erupting odontoma includes association with delayed eruption, impaction and/or altered eruption of adjacent teeth in over 66% of the cases due to the obstruction of the eruptive trajectory of these adjacently related teeth.2,3,6,10 Pain, swelling, infection, and adjacent tissues suppuration were the most common symptoms, due to the spontaneous emergence of odontomas into the oral cavity and the exposure of the tumor through the oral mucosa inflammation of the adjacent soft tissues, or infection associated with suppuration.2,3,5,6 Other symptoms include anesthesia in the lower lip, swelling in the affected area, and even facial asymmetry.3 Pain as the first symptom was rarely reported, and it is probably due to secondary infection that can occur because of replacement of bone by a large amount of avascular hard tissue.3 The secondary infection may also be due to the explosion of an odontoma through the mucosa that allows the invasion of oral micro-organisms into the bone due to lack of adequate adhesion between bone and odontoma, due to absence of periodontal ligament. Other reported signs and symptoms including; pain, swelling, tongue irritation,3 facial asymmetry,3 malocclusions,2,6 halitosis,2 and recurrent infections were recorded.2,3 The age of the reported case is 24 years, which agrees with the average age of the reported cases that showed that the eruption of odontomas are more common between the second and third decade of life.2,6 Furthermore, the patient’s male gender adds more to the frequency of males (33), as compared with 62.5 females in the reported series.5-9

Histopathologically, our reported case added another complex odontoma case to equalize the frequency of complex odontoma as compared with the compound ones in the published series.5-9 Reviewing the reported cases of eruption odontome, most of them are of small size with the exception of only 2 cases that closely resemble our case in size and being large enough to be examined both visually and manually; these are the cases reported by Junquera et al2 and Vengal et al.3 The case of Vengal et al3 shares a great similarity with our case in both size, presentation, location, as well as diagnosis, while the case reported by Junquera et al2 was a maxillary lesion in the area of upper second molar tooth. Similarly; our reported case agrees with other cases where erupted odontomas, especially if they are of a large size and present with associated repeated infection, halitosis, displacement, and impaction of related teeth.2-10

In conclusion, a rare case of large erupted complex odontoma in a 24-year-old Saudi patient is presented. Pain, repeated infection, and halitosis were the most commonly reported symptoms. The eruption odontoma was located distal to the lower right second molar tooth associated with an impacted distally placed third molar. The related gingival tissues are inflamed in relation to the rough surface of the odontome. The treatment carried out was excision of the lesion and disimpaction of the wisdom tooth under local anesthesia. The case presented represents the third large eruptive odontome that can be examined both manually and visually. The presenting signs and symptoms and the value of radiographic and histopathological examination in achieving proper diagnosis is emphasized.