Compound Odontoma - Diagnosis and Treatment: Three Case Reports

Resident: Adam J. Bottrill
Date: 22DEC10
Region: Providence
Article title: Compound Odontoma - Diagnosis and Treatment:
Author(s): Branca Heloisa de Oliveira
Journal: Pediatric Dentistry
Page #s: 151-157
Vol:No Date: 23:2 2001
Major topic: Compound Odontoma
Minor topic(s): NA
Type of Article: Case Studies
Main Purpose: This paper describes 3 cases of compound odontomas diagnosed in children due to dislodgement or over-retention of primary anterior teeth and/or swelling of the cortical bone.

Key points in the article discussion:

I. General:

A. Odontomas: developmental anomolies formed of enamel and dentin with possible , variable amounts of pulpal and cement tissue. Can show anatomical similarity to teeth, in which case it labeled "compound." When it forms an irregular mass, described as "complex"

B. Major Characteristics of Compound and Complex Odontomas:




















C. Ameloblastic fibro-odontoma: General features of ameloblastic fibroma but with evidence of enamel and dentin.
1. 10yo
2. Central/Intraosseous tumors
3. Posterior Mandible
4. Well-defined, uni/multilocular radiolucent defect with variable amount of (dental) radiodense material.
5. Tx: Conservative surgical enucleation with GREAT prognosis.

D. Ameloblastic Fibrosarcoma: malignant counterpart of the ameloblastic fibroma. Usually a "re-diagnosis" of a progressing existing lesion.
1. 27.5 yo
2. Ill-defined, destructive radiolucent lesion that suggests malignant process.
3. Pain and swelling along with rapid clinical growth.
4. Tx: Radical surgical excision.
5. Long-term prognosis unsure.

E. Odontoameloblastoma: VERY RARE... with ameloblastomatous components with odontoma-like component.
1. Mandible of young patients
2. Radiolucent, destructive process that contains calcified structures.
3. Tx: Surgical resection. (curettaged lesions may reccur)
4. RARE... no known prognosis

II. Case I

A. 5 yo white female.
B. Presented with changing position of upper left primary central incisor (labially displaced and intruded). No Hx of trauma.
C. Radiographic exam: compound odontomas in palate.
D. Tx: Surgical resection. 3 tooth-like structures found within lesions.
E. When permanent teeth erupted, upper incisors proclined and midline is shifted.
F. Removable appliance used to improve position.

III. Case II

A. 12 yo female
B. Presented complaining of excess volume of gingiva in the area of upper right anterior region. No Hx of trauma.
C. Radiographic exam: compound odontoma buccal to the root of upper permanent lateral incisor.
D. Tx: Surgical resection. 7 tooth-like structures found.
E. 1 yr F/U confirmed that lateral incisor had returned to normal position. No recurrence of lesion.

IV. Case III

A. 11 yo male.
B. CC of overretained primary central incisor despite presence of permanent dentition elsewhere in the mouth.
C. Radiographic exam: odontoma-like lesion in the buccal region of primary incisor root.
D. Impacted corresponding permanent incisor.
E. Tx: Surgical removal with multiple tooth-like structures present.
F. Orthodontic device used to expose and guide tooth into place.
G. 3 years to bring into place with uneven gingival margins and incisal edge.

V. Discussion

A. The three cases were all diagnosed early and radiographically prior to excision. All found in the anterior maxilla.
B. One patient suffered trauma in the area. Some researchers claim trauma may contribute to odontoma development.
C. Delayed diagnosis (evident in case III) may result in complete root formation/impaction and necessitate surgical exposure.
D. Ideally, surgical removal of odontomas should occur when the roots of adjacent permanent teth are about half-formed.

VI. Conclusions

A. Evidence suggests that an individualized radiographic examination of any pediatric patient that presents clinical evidence of delayed permanent tooth eruption or temporary tooth displacement should be performed.
B. Early diagnosis of odontomas allows adoption of a less complex and less expensive treatment and ensures better prognosis.

Assessment of article: Good background and history of the pathology. I don't believe the author overstepped any bounds or made any rash conclusions based on these three cases. I know this may be hard to believe, but I don't have any complaints. Likey.

Pediatric Squamous Cell Carcinoma: Case Report and Literature Review

Resident: Roberts

Date: 12/22/10

Title: Pediatric Squamous Cell Carcinoma: Case Report and Literature Review

Author: Sidell, Douglas, et al

Journal: Laryngoscope

Year: 2009

volume: 119

pages: 1538 - 1541

Case report and Discussion:

A six year old male was referred to the University of California, Los Angeles head and neck clinic by oral surgery with a 2 month history of an enlarging oral lesion involving the anterior gingiva with extension to the hard palate. The lesion was initially noted by the patients dentist, who extracted a tooth near the mass. Persistence of the lesion after tooth extraction led to a consultation by oral surgery for biopsy. The biopsy results were initially interpreted as SCC. A follow up review was performed by a multidisciplinary team and a second review of the biopsy revealed an inconclusive result as to the diagnosis. A second deep tissue biopsy was obtained, This biopsy indicated invasive, well-differentiated, exophytic SCC with perineural and angiolymphatic invasion. An MRI and CT scan performed demonstrated a 2.7 x 3.0 cm poorly marginated infiltrative mass involving the gingival aspect of the superior alveolar ridge and the adjacent bony marrow, to the right of the midline. Evaluation of the neck revealed multiple small sub-centimeter lymph nodes. The patient denied dysphagia, pain, weight loss, bleeding or loosing of teeth.

There are several differences with regard to adult and pediatric SCC of the oral cavity that have been described. Unlike adults, there is no sexual predilection for children. It has also been described as being more aggressive and is thought to carry a worse prognosis than the adult version. Although exposures such as alcohol and tobacco are commonly suggested as possible links to the etiology, this is not the case in pediatrics. Some identified possible causes have been linked to some genetic conditions such as xeroderma pigmentosum, keratitis, icthyosis, and deafness syndrome. A condition called Fanconi anemia, an aplastic anemia is said to add a 50 fold increase to all cancers. Other predisposing factors include polyvinyl chloride(found in plastics), the Epstein Barr virus and the human papilloma virus.

In pediatric populations, SCC accounts for fewer than 2% of all head and neck malignancies. The most frequent location for it to be found is on the tongue or the lip. The diagnosis of SCC is based on a histological biopsy and the method of treatment is a wide local resection while attempting to avoid the significant impact of radiotherapy in the pediatric population. This case documents the youngest person to have been found with SCC.

Assessment: Good article, I hope to never have to tell some poor mom or dad that their child has this.

12/22/2010 Delayed tooth eruption associated with an ameloblastic fibro-odontoma (AF-O)

Resident: J. Hencler
Date: 12/22/2010

Article title: Delayed tooth eruption associated with an ameloblastic fibro-odontoma (AF-O)
Author: Flaitz DDS, MS; Hicks MD, DDS, MS, PhD

Journal: Pediatric Dentistry-23:3, 2001
Major topic: Oral Pathology
Type of Article: Case Report

Main Purpose:
Describe the clinical and radiographic features of an AF-O in a young child and discuss an age appropriate differential diagnosis.

Case History:
A healthy, 31 month-old Hispanic boy was referred for evaluation of an unerupted left mandibular primary canine (#M). EOE revealed mild facial asymmetry of the lower1/3. IOE revealed both buccal and lingual cortical expansion of the left mandible with lingual displacement of the lateral incisor and distal displacement of the molars. Palpation revealed an asymptomatic, hard enlargement covered by normal mucosa. A periapical radiograph demonstrated a localized radioluceny with dilacerations of the mesial root of the primary first molar and posterior displacement of the developing premolar. An occlusal radiograph reveals an expansile, mixed radiolucent/radiopaque lesion surrounding the crown of an inferiorly displaced, unerupted canine. Based on these findings, the child was referred for surgical excision under GA. Histopathological finding included a tumor with cords/islands of odontogenic epithelium, conglomerate foci of enamel and dentin, and tiny tooth-like structures. Loose and cellular connective tissue stroma resembled a dental papilla and a well formed primary canine was associated with the tumor. A diagnosis of AF-O was made on these microscopic findings.

Key points in the article discussion:
The AF-O is an uncommon odontogenic tumor that resembles an ameloblastic fibroma and a complex odontoma. Most cases occur in children with a mean age between 8-11 years-old but cases as young as 9 months have been reported. AF-O occurs equally in both jaws but favors the anterior region in the maxilla and the posterior region in the mandible. Typically, a slow growing tumor, common clinical findings include painless swelling and failure of one or more teeth to erupt. Radiographic presentation varies from unilocular to multilocular radiolucency with well-defined margins and variable amounts of radiopaque material. The irregular or globular calcifications are usually located in the center of the lesion. Treatment of AF-O usually involves conservative curettage. Large lesions may require a surgical splint to prevent jaw fracture. Recurrences following conservative surgery are uncommon and the prognosis is excellent for this tumor.

Differential Diagnosis:
Other odontogenis lesions in children that present as radiolucent lesions with irregularto globular radiopacities include the adenomatoid odontogenic tumor (AOT), the calcifying odontogenic cyst (COC), and the complex odontoma.
(1) The complex odontoma is the most common and usually occurs in the first 2 decades of life. Considered to be a developmental anomaly or hamartoma the complex odontoma has a predilection for the pericoronal molar region. Most odontomas are asymptomatic and are diagnosed because of delayed eruption of a tooth. A developing odontoma may be difficult to distinguish from an AF-O, both radiographically and microscopically. An important difference between an odontoma and AF-O is that odontoma is smaller and minimally expansile. Local curettage is recommended treatment and recurrence is rare.
(2) AOT occurs predominantly in children during the 2nd decade with delayed tooth eruption as a symptom. This benign tumor has a distinct preference for the anterior jaws, in particular, the maxillary canine region. Many AOTs are small and don’t produce clinically significant distortion of the surrounding bone. AOTs typically present as a well-delineated, unilocular radiolucency around the crown of a developing tooth with fine flecks of calcification referred to as a “snowflake appearance”. EXT of involved tooth and enucleation of the tumor are the recommended treatment. Recurrences are rare.
(3) COC is an uncommon lesion that exhibits variable clinical presentation. Although cystic, benign and malignant neoplastic subtypes are defines. When COC occurs in young children, the cystic type is most common and usually associated with an odontoma. This cystic lesion usually occurs in the anterior region of the jaws with a peak incidence in the second and third decades. Radiographic features of COC include a unilocular or multilocular radiolucency that is associated with an unerupted tooth in 1/3 of cases. Approximately half of all COCs are associated with irregular or tooth-like opacities; however, if associated with an odontoma, calcifications are a constant feature. Asymptomatic expansion of the cortical bone, along with root resorption or divergence may be seen. In general, COC occurring in young children are treated by simple enucleation with uncommon recurrence.

Assessment of article: Very interesting case report including a detailed differential diagnosis. This was a good review of oral lesions that we should consider when a patient presents with an unerupted primary tooth.