COM February 2018 Diagnosis

Unilocular radiolucency with flecks of radiopacity between teeth #s 6 & 7

Can you make the correct diagnosis?
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This is a 14-year-old female who was referred by Dr. Johnson for the evaluation of a lesion in the right maxilla noted on a periapical radiograph after her general dentist noted loss of keratinized tissue with gingival erythema around tooth #7.

Case of the Month Summary

Calcifying odontogenic cyst (COC)

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The differential diagnosis of a jaw well-demarcated radiolucency with flecks of radiopacity should include calcifying odontogenic cyst. COC tends to occur around the third decade of life with an age range of 7-82 years. It occurs equally in the maxilla and mandible, usually anterior to the first permanent molar, though it has a predilection for occurrence in the maxilla in the younger age range which would consistent with this case. COC occurs equally in males and females. The age of the patient is on the young range but is still within the range. The histology is not consistent with COC.

Ameloblastic Fibro-Odontoma (AFO)

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The radiographic changes, the age of the patient are consistent with the diagnosis of ameloblastic fibro-odontoma and therefore this condition should be included on the differential diagnosis. AFO occurs most commonly in children in the first and second decade of life with mean of 10 years of age. Being present in the anterior jaw and between teeth argues against AFO since it is often associated with impacted teeth in the posterior jaws. AFO tends to occur more in the posterior jaw (maxilla and mandible) and with impacted or unerupted teeth. The gender is fine since AFO has equal gender predilection. Radiographic findings of AFO include an impacted/unerupted tooth with a well-defined, usually unilocular radiolucency around the crown of a tooth, similar to a dentigerous cyst. It may also present as a radiolucency containing radiopaque material ranging from flecks as is the case in this patient to small tooth-like structures. The histology is not consistent with AFO.

Adenomatoid odontogenic tumor (AOT)

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Adenomatoid odontogenic tumor (AOT) should be included high on the differential diagnosis given the age, gender and site of being more anterior maxilla. The majority of AOT cases are intra-osseous and follicular in type associated with an impacted tooth especially the canines’ maxilla and mandible, slightly more in the maxilla. This case is not associated with an impacted tooth but can still be considered for the diagnosis of AOT, the extra-follicular clinical sub-type which constitutes over 20% of all AOT cases. The extra-follicular type presents between teeth in form of a unilocular radiolucency with or without flecks of radiopacity. The histology is that of AOT and clinically this qualifies for extra-follicular type of AOT.

Compound Odontoma

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The age, gender and site are supportive of the clinical presentation of a compound odontoma. Compound odontomas can occur at any age, but is most common in the first two decades of life, with an average age of 14 to 18. It is slightly more common in females and more common in the maxilla, especially in the anterior maxilla. Odontomas are more commonly associated with unerupted/impacted teeth-more so is true with complex odontomas. Compound odontomas are more common in the anterior jaws, while complex odontomas in the posterior jaws. Radiographically, odontomas present as a well-circumscribed radiolucency resembling a dental follicle or dentigerous cyst with one or multiple radiopaque pieces resembling teeth. Compound odontomas tend to occur between teeth and tend to be composed of multiple small tooth-like structures. The radiographic presentation of flecks of radiopacity argues against this case being compound odontoma. The histology is not consistent with compound odontoma.

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