Dx: Odontoma

KEY FACTS

Terminology Definition: Tumor that produces mature enamel, dentin, cementum, and pulp tissue Imaging Compound: Small tooth-like structures surrounded by radiolucent (low-density) rim Complex: Amorphous mineralized (radiopaque) mass surrounded by radiolucent (low-density) rim Location Tooth-bearing area: May be pericoronal Maxilla: Commonly near canine crown; preferred location for compound odontomas Mandible: Most common in molar region; preferred location for complex odontomas
Above IAN canal

High-density structures similar to or more dense than adjacent teeth Surrounded by cortical boundary with uniform low-density rim within cortex Top Differential Diagnoses For compound odontoma = supernumerary teeth Usually single well-formed tooth For complex odontoma = cemento-ossifying fibroma Not as dense as odontoma Clinical Issues Most common odontogenic tumor Often interferes with eruption of permanent teeth Diagnostic Checklist Consider: Multiple supernumerary teeth (cleidocranial dysplasia and Gardner syndrome) Check for uneven dilation of soft tissue capsule that would signal infection or dentigerous cyst formation if pericoronal
TERMINOLOGY

Synonyms
Compound odontoma, odontome, compound composite odontoma, complex odontoma, complex composite

odontoma, odontogenic hamartoma, calcified mixed odontoma, cystic odontoma, dilated odontoma Definitions Tumor that produces mature tooth structures: Enamel, dentin, cementum, pulp tissue Hamartoma of well-differentiated tooth structure 2 main types Compound:Looks like many little teeth Complex:Amorphous mineralized mass with no resemblance to teeth
IMAGING

General Features Best diagnostic clue

Compound odontoma

Small tooth-like structures surrounded by radiolucent (low density) rim Multiple well-differentiated mini-teeth (denticles)
Complex odontoma

Amorphous mass of tooth-density material that may be similar to or exceed density of adjacent teeth Surrounded by a corticated, low-density rim

If infected Low-density capsule may be widened Cortex may be thickened Surrounding bone is sclerotic Location Tooth-bearing areas: May be multiple &/or pericoronal Maxilla Most common anteriorly near canine crown More common location for compound odontomas Mandible Most common in molar region Above inferior alveolar nerve (IAN) canal (where tooth would normally develop) More common location for complex odontomas Size: Varies dramatically: Small (mm) up to 6 cm or more in diameter Morphology Compound Varying number of small, deformed teeth Complex Amorphous, generally homogeneously dense material Appears as clump of cotton Difficult to make out denticles or separate components of tooth structure Radiographic Findings Radiography Surrounded by cortical boundary with uniform low-density rim within cortex High-density structures similar to or more dense than adjacent teeth Dilated odontoma has been described Single calcified structure with central low-density area Resembles donut Intraoral plain film Differentiation of enamel, dentin, pulp, and PDL components can be made Minute changes to adjacent teeth such as external resorption can be visualized Extraoral plain film Panoramic Mesiodistal extent of lesion (not faciolingual) Relationship to adjacent teeth Effect on eruption of adjacent teeth can be determined CT Findings CBCT Possible expansion of facial or lingual cortices of jaws Will best show relationship to incisive canal (in anterior maxilla) Can be located within or partially within canal Will best show relationship to IAN canal (in mandible) Pushes canal inferiorly Imaging Recommendations Best imaging tool
CBCT

Shows relationship to adjacent structures in all dimensions Can determine degree of impaction of tooth, if present, as well as faciolingual inclination of impacted tooth
DIFFERENTIAL DIAGNOSIS

Supernumerary Teeth (Hyperdontia) Usually single, well-formed tooth

If multiple, they are of normal tooth shape and size and usually separate from one another Tooth can be of normal size or can be smaller (microdont) May be erupted into oral cavity or impacted
Cemento-ossifying Fibroma Less dense than complex odontoma

Not usually associated with unerupted teeth Develops in young adults (juvenile variant has been described) Not self-limiting: Does not stop growing at end of odontogenesis
Periapical Cemental Dysplasia (PCD)

Late-stage PCD resembles complex odontoma Usually multiple Centered around apices of teeth Irregular sclerotic border and low-density rim Middle-aged women of African or Asian descent more likely to develop
Ameloblastic Fibro-odontoma

Tooth structure is seen within larger low-density lesion Calcifications do not make up majority of lesion, as in odontoma Not self-limiting: Does not stop growing at end of odontogenesis
Idiopathic Osteosclerosis Radiopacity with no low-density rim

Can have ragged borders

Sclerosing Osteitis

Odontogenic inflammation is causative factor so located at apex Associated with nonvital or inflamed tooth Widened periodontal ligament space between radiopacity and tooth but no low-density rim
Osteoma

Usually less-dense radiopacity with no low-density rim Can have exophytic presentation with peduncle
PATHOLOGY

General Features Associated abnormalities: Odontomas have been reported in association with dentigerous cyst, adenomatoid odontogenic tumor, keratocystic odontogenic tumor, and calcifying odontogenic cyst Staging, Grading, & Classification Benign odontogenic tumor Mixed odontogenic epithelial and odontogenic mesenchymal tumor Hamartoma of dental tissues Gross Pathologic & Surgical Features
Compound

Separate tiny tooth-like structures that may or may not be fused

Complex

Clump of dentin-like material

CLINICAL ISSUES

Presentation Most common signs/symptoms: Lack of eruption of tooth Clinical profile Most common odontogenic tumor Prevalence exceeds all other odontogenic tumors combined Often interferes with eruption of permanent teeth May be associated with dentigerous cyst Demographics Age 2nd decade Usually found when investigative radiography is done because tooth fails to erupt Gender: No sex predilection Natural History & Prognosis Begins forming while normal dentition is forming Stops forming when normal tooth development ends Are not locally invasive Some may erupt into oral cavity If excised, they do not recur Treatment Simple excision Consider proximity to adjacent structures when excising
DIAGNOSTIC CHECKLIST

Consider Multiple supernumerary teeth (cleidocranial dysplasia and Gardner syndrome) Cemento-ossifying fibroma Image Interpretation Pearls Most common type of odontogenic tumor Prevalence exceeds all other odontogenic tumors combined (so more likely an odontoma than anything else) Reporting Tips Comment on effect on adjacent teeth Displacement Aplasia Malformation Impaction Check for uneven dilation of soft tissue capsule that would signal infection or dentigerous cyst formation if pericoronal Report on condition of surrounding bone and communication with crestal bone in cases of suspected infection