- Email: [email protected]
A nodular mass of the anterior palatal gingiva
Vol. 102 No. 1 July 2006
CLINICOPATHOLOGIC CONFERENCE A nodular mass of the anterior palatal gingiva Sompid Kintarak, DDS, MS, PhD,a Patcharee Kumplanont, DDS,b Suparp Kietthubthew, BSc, MS,c and Supis Chungpanich, BSc, DDS, MS,d PRINCE OF SONGKLA UNIVERSITY AND HATYAI REGIONAL HOSPITAL (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:3-6)
CLINICAL PRESENTATION A 13-year-old Thai girl presented with a 5-month history of a slowly growing, asymptomatic nodular mass on her palatal interdental papilla between the maxillary right central and lateral incisors (Fig. 1). Examination revealed a 0.5 ⫻ 0.5 cm rubbery nodular mass covered by smooth, normal-appearing, pale pink mucosa. The patient denied any history of tenderness to palpation or paresthesia. She had a full complement of erupted permanent teeth. The adjacent teeth showed no caries or tooth mobility. An intraoral periapical radiograph revealed no obvious pathology (Fig. 2). Her medical history was unremarkable. Differential diagnosis This slowly enlarging asymptomatic nodular mass of the palatal gingiva was considered to most likely represent a reactive fibrous hyperplasia, either a focal fibrous hyperplasia or a peripheral ossifying fibroma. However, a benign neoplasm or hamartomatous lesion of connective tissue or odontogenic origin was also considered to be quite high on the differential diagnosis. a
Assistant Professor, Department of Stomatology, Faculty of Dentistry, Prince of Songkla University. b Oral Surgeon, Division of Oral and Maxillofacial Surgery, Department of Dentistry, Hatyai Regional Hospital. c Associate Professor, Department of Stomatology, Faculty of Dentistry, Prince of Songkla University. d Associate Professor, Department of Stomatology, Faculty of Dentistry, Prince of Songkla University. Received for publication Jul 11, 2005; returned for revision Dec 7, 2005; accepted for publication Jan 9, 2006. 1079-2104/$ - see front matter © 2006 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2006.01.018
Focal fibrous hyperplasia, or fibrous nodule, is the most common soft-tissue lesion of the oral cavity. It typically appears as a smooth-surfaced pink nodule that is similar in color to the surrounding mucosa. Peripheral ossifying fibroma typically presents as a pedunculated or sessile nodular mass that occurs exclusively on the gingiva. It generally arises from the interdental papilla. This lesion shows a peak prevalence between the ages of 10 and 19.1 Other reactive gingival proliferations such as pyogenic granuloma and peripheral giant cell granuloma were considered less likely, owing to the lesion’s color, consistency, and lack of ulceration. The pyogenic granuloma is considered to represent an exuberant tissue response to local irritation or trauma. It commonly presents as a red ulcerated and pedunculated lesion. The peripheral giant cell granuloma has a clinical appearance similar to the gingival pyogenic granuloma, although typically it has a reddish-purple color compared with the bright red of the typical pyogenic granuloma.1 Giant cell fibroma could also be considered, but it often shows a papillary surface and most commonly affects the mandibular gingiva. Oral focal mucinosis usually occurs on the gingiva and is generally less than 10 mm in diameter. However, it mostly occurs in adults and demonstrates a definite predilection for the mandibular buccal posterior gingiva.2 An osteocartilaginous choristoma would also be a consideration, although these lesions most commonly involve the tongue. They usually show no underlying osseous abnormality or calcification on the radiograph.3,4 Salivary gland choristoma of the gingiva has also been reported; however, it is an extremely rare phenomenon.5 Benign neoplasms presenting as a gingival nodule 3
4 Kintarak et al.
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Fig. 1. A nodular mass on the palatal gingiva between the maxillary left central and lateral incisors.
Fig. 3. Photomicrograph showing 3 tooth germs completely embedded in the soft tissue; 2 were in late bell stage of tooth development (hematoxylin-eosin, original magnification 40⫻).
was absent in the present case.10 The peripheral adenomatoid odontogenic tumor occurs almost exclusively in the anterior maxillary gingiva. In a recent review of 18 reported cases, the mean age was found to be 13 yrs.11 The peripheral variant of the calcifying odontogenic cyst accounts for about 25% of cases of extraosseous odontogenic tumors and usually arises in the sixth decade of life. This lesion often has a papillary surface.12 Fig. 2. Periapical radiograph showing no obvious pathology.
would include benign mesenchymal tumors, such as neural tumors, and peripheral odontogenic tumors, such as peripheral ameloblastoma, peripheral adenomatoid odontogenic tumor, peripheral calcifying odontogenic cyst, and peripheral odontogenic fibroma. Intraoral neurilemmoma is generally considered to be more common than neurofibroma.6,7 However, recent studies have shown similar incidences of neurilemmoma, neurofibroma, and palisaded encapsulated neuroma in the oral cavity.8,9 Thus, neurofibroma and palisaded encapsulated neuroma should be considered along with neurilemmoma in the differential diagnosis. The most common peripheral odontogenic tumor is the peripheral ameloblastoma. However, peripheral ameloblastomas typically affect middle-aged patients and have a predilection for the mandibular gingiva.1 The surface of the peripheral ameloblastoma often shows a papillary, pebbly, or warty appearance which
Diagnosis The lesion was totally excised and submitted for histopathologic examination. No bony involvement was observed at the time of surgery. The clinical diagnosis was “irritation fibroma.” The specimen measured 1.0 ⫻ 1.0 ⫻ 1.0 cm and was processed for routine hematoxylin and eosin staining. Microscopic examination revealed 3 developing tooth germs (Fig. 3) which were completely embedded within the surrounding connective tissue. Two of the 3 tooth germs were at the late bell stage, showing a high degree of histodifferentiation of the dental organ (Fig. 4). Inner and outer dental epithelium, stratum intermedium, stellate reticulum, enamel, dentin, and dental papilla were clearly evident. Strands and islands of odontogenic epithelium were noted within the surrounding fibrous connective tissue. Final diagnosis The final diagnosis, based on the histopathologic findings and clinical presentation, was peripheral developing odontoma. In light of the final diagnosis, the
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Fig. 4. A, High-power photomicrograph of one of the tooth germs, showing dentin formation (hematoxylin-eosin, original magnification 250⫻). B, High-power photomicrograph of one of the tooth germs, showing enamel formation (hematoxylin-eosin, original magnification 250⫻).
periapical radiograph was reexamined to see if any evidence of calcification could be seen. On retrospective examination, a subtle radiopacity could be detected inferior to the contact point between the right central and lateral incisors, corresponding to the soft-tissue location of the lesion. Healing of the biopsy site was uneventful. No evidence of recurrence was noted at the patient’s 18-month follow-up. DISCUSSION In the present case, 3 developing tooth germs were located in a nodular mass on the palatal side of the interdental papilla between the right central and lateral incisors in a 13-year-old girl. Two of these dental
Kintarak et al. 5
structures were in the late bell stage of tooth development. In view of the histopathologic and clinical findings, a diagnosis of peripheral compound odontoma was considered most appropriate. The odontoma is the most common odontogenic tumor, although it is widely considered to represent a hamartoma or malformation of dental tissues rather than a true neoplasm.1 Most cases occur in an intraosseous location. Extraosseous odontomas are rare. A review of the literature revealed only 9 cases13-20 of supernumerary teeth or odontomas occurring peripherally in gingival soft tissue. Only 2 of these13,14 presented as palatal masses, as in the present case. These were diagnosed as “ectopic softtissue mesiodens.” Diekmann et al.13 described a cone-shaped supernumerary tooth within a pedunculated mass on the palate, just lateral and posterior to the incisive papilla in a 3-year-old boy. Lin et al.14 reported a tooth germ in a swelling on the palatal aspect of the left deciduous central incisor in a 17month-old boy. Both cases presented as single well formed teeth which were composed of varying amounts of ameloblasts, enamel, enamel matrix, dentin, predentin, odontoblasts, and dental papilla. Recurrence of peripheral odontoma has not been documented. It is believed that both mesiodens and odontomas represent different manifestations of a similar underlying altered developmental process. The most common location for a supernumerary tooth is the maxillary anterior incisor region, where it is termed a mesiodens. A recent retrospective radiographic review of 256 mesiodens21 established that the majority (73%) of mesiodens occur singly and are primarily (89%) located on the palatal aspect of the dental arch. The simultaneous occurrence of 2 or 3 mesiodens was noted in only 26% and 1% of cases, respectively. Compound odontomas consist of many separate small denticles, with a marked predilection for the maxillary anterior region. A recent retrospective review from Japan of 39 odontomas22 revealed that most were identified during the mixed or early permanent dentition stages and were predominantly located in the maxillary central and lateral incisor region. The predilection of both mesiodens and compound odontomas for the anterior maxilla suggests that this area may be predisposed to disturbed odontogenesis.23 In summary, we describe a rare case of a peripheral odontoma presenting as a nodular soft tissue mass of the maxillary anterior gingiva. Simple surgical excision was curative. Recurrence of the peripheral odontoma has not been documented.
OOOOE July 2006
6 Kintarak et al. REFERENCES 1. Neville BW, Damm DD, Allen CM, Bouquot JE, Oral and maxillofacial pathology. 2nd ed. Philadelphia: WB Saunders; 2002. p. 447–52, 618-9, 631-2. 2. Aldred MJ, Talacko AA, Ruljancich K, Story RD, Newland S, Chen ST, et al. Oral focal mucinosis: report of 15 cases and review of the literature. Pathology 2003;35:393-6. 3. Tosios K, Laskaris G, Scully C. Benign cartilaginous tumor of the gingiva. A case report. Int J Oral Maxillofac Surg 1993;22:231-3. ¨ nal T, Bir Y. Osteocartilaginous choristoma of the 4. Seçkin T, U gingiva. Dent Update 1996;23:248-9. 5. Ledesma-Montes C, Fernández-López R, Garcés-Ortíz M, Portilla-Robertson J, Hernández-Guerrero C. Gingival salivary gland choristoma. A case report. J Periodontol 1998;69:1164-6. 6. Cawson RA, Binnie WH, Speight PM, Barrett AW, Wright JM, editors. Lucas’s pathology of tumors of the oral tissues. 5th ed. London: Churchill Livingstone; 1998. p. 278. 7. Cawson RA, Odell EW, eds. Cawson’s essentials of oral pathology and oral medicine. 7th ed. Edinburgh: Churchill Livingstone; 2002. p. 281. 8. Chrysomali E, Papanicolaou SI, Dekker NP, Regezi JA, Francisco S. Benign neural tumors of the oral cavity. A comparative immunohistochemical study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:381-90. 9. Jordan RC, Regezi JA. Oral spindle cell neoplasms. A review of 307 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:717-24. 10. Reichart PA, Philipsen HP, editors. Odontogenic tumors and allied lesions. London: Quintessence; 2004. p. 59-67. 11. Philipsen HP, Reichart PA. Adenomatoid odontogenic tumour: facts and figures. Oral Oncol 1998;35:125-31. 12. Odell EW, Morgan PR, editors. Biopsy pathology of the oral tissues. London: Chapman & Hall Medical; 1998. p. 403-4. 13. Diekmann SL, Cohen DM, Gutz DP. Ectopic soft-tissue mesio-
14. 15.
16. 17.
18.
19. 20. 21.
22.
23.
dens. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1982;53:391-4. Lin C-C, Chen R-J, Lai S. Ectopic soft-tissue mesiodens. Report of a case. J Oral Med 1986;41:124-5, 133. Dubuk AN, Selvig KA, Tellefsen G, Wikesjo UM. Atypically located paramolar. Report of a rare case. Eur J Oral Sci 1996;104:138-40. Siar CH, Nor GM. Peripheral complex odontome with ghost cell epithelium. A case report. Ann Dent 1989;48:6-7. Giunta JL, Kaplan MA. Peripheral, soft tissue odontomas. Two case reports. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1990;69:406-11. Castro GW, Houston G, Weyrauch C. Peripheral odontoma: report of case and review of literature. ASDC J Dent Child 1994;61:209-13. Ledesma-Montes C, Perez-Bache A, Garcés-Ortiz M. Gingival compound odontoma. Int J Oral Maxillofac Surg 1996;25:296-7. Ide F, Shimoyama T, Horie N. Gingival peripheral odontoma in an adult: case report. J Periodontol 2000;71:830-2. Asaumi JI, Shibata Y, Yanagi Y, Hisatomi M, Matsuzaki H, Konouchi H, et al. Radiographic examination of mesiodens and their associated complications. Dentomaxillofac Radiol 2004;33:125-7. Tomizawa M, Otsuka Y, Noda T. Clinical observations of odontomas in Japanese children: 39 cases including one recurrent case. Int J Paediatric Dent 2005;15:37-43. Budnick SD. Compound and complex odontomas. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1976;42:501-6.
Reprint requests: Dr. Sompid Kintarak Department of Stomatology Faculty of Dentistry Prince of Songkhla University Hatyai, Songkhla 90112, Thailand [email protected]
CLINICOPATHOLOGIC CONFERENCE A nodular mass of the anterior palatal gingiva Sompid Kintarak, DDS, MS, PhD,a Patcharee Kumplanont, DDS,b Suparp Kietthubthew, BSc, MS,c and Supis Chungpanich, BSc, DDS, MS,d PRINCE OF SONGKLA UNIVERSITY AND HATYAI REGIONAL HOSPITAL (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:3-6)
CLINICAL PRESENTATION A 13-year-old Thai girl presented with a 5-month history of a slowly growing, asymptomatic nodular mass on her palatal interdental papilla between the maxillary right central and lateral incisors (Fig. 1). Examination revealed a 0.5 ⫻ 0.5 cm rubbery nodular mass covered by smooth, normal-appearing, pale pink mucosa. The patient denied any history of tenderness to palpation or paresthesia. She had a full complement of erupted permanent teeth. The adjacent teeth showed no caries or tooth mobility. An intraoral periapical radiograph revealed no obvious pathology (Fig. 2). Her medical history was unremarkable. Differential diagnosis This slowly enlarging asymptomatic nodular mass of the palatal gingiva was considered to most likely represent a reactive fibrous hyperplasia, either a focal fibrous hyperplasia or a peripheral ossifying fibroma. However, a benign neoplasm or hamartomatous lesion of connective tissue or odontogenic origin was also considered to be quite high on the differential diagnosis. a
Assistant Professor, Department of Stomatology, Faculty of Dentistry, Prince of Songkla University. b Oral Surgeon, Division of Oral and Maxillofacial Surgery, Department of Dentistry, Hatyai Regional Hospital. c Associate Professor, Department of Stomatology, Faculty of Dentistry, Prince of Songkla University. d Associate Professor, Department of Stomatology, Faculty of Dentistry, Prince of Songkla University. Received for publication Jul 11, 2005; returned for revision Dec 7, 2005; accepted for publication Jan 9, 2006. 1079-2104/$ - see front matter © 2006 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2006.01.018
Focal fibrous hyperplasia, or fibrous nodule, is the most common soft-tissue lesion of the oral cavity. It typically appears as a smooth-surfaced pink nodule that is similar in color to the surrounding mucosa. Peripheral ossifying fibroma typically presents as a pedunculated or sessile nodular mass that occurs exclusively on the gingiva. It generally arises from the interdental papilla. This lesion shows a peak prevalence between the ages of 10 and 19.1 Other reactive gingival proliferations such as pyogenic granuloma and peripheral giant cell granuloma were considered less likely, owing to the lesion’s color, consistency, and lack of ulceration. The pyogenic granuloma is considered to represent an exuberant tissue response to local irritation or trauma. It commonly presents as a red ulcerated and pedunculated lesion. The peripheral giant cell granuloma has a clinical appearance similar to the gingival pyogenic granuloma, although typically it has a reddish-purple color compared with the bright red of the typical pyogenic granuloma.1 Giant cell fibroma could also be considered, but it often shows a papillary surface and most commonly affects the mandibular gingiva. Oral focal mucinosis usually occurs on the gingiva and is generally less than 10 mm in diameter. However, it mostly occurs in adults and demonstrates a definite predilection for the mandibular buccal posterior gingiva.2 An osteocartilaginous choristoma would also be a consideration, although these lesions most commonly involve the tongue. They usually show no underlying osseous abnormality or calcification on the radiograph.3,4 Salivary gland choristoma of the gingiva has also been reported; however, it is an extremely rare phenomenon.5 Benign neoplasms presenting as a gingival nodule 3
4 Kintarak et al.
OOOOE July 2006
Fig. 1. A nodular mass on the palatal gingiva between the maxillary left central and lateral incisors.
Fig. 3. Photomicrograph showing 3 tooth germs completely embedded in the soft tissue; 2 were in late bell stage of tooth development (hematoxylin-eosin, original magnification 40⫻).
was absent in the present case.10 The peripheral adenomatoid odontogenic tumor occurs almost exclusively in the anterior maxillary gingiva. In a recent review of 18 reported cases, the mean age was found to be 13 yrs.11 The peripheral variant of the calcifying odontogenic cyst accounts for about 25% of cases of extraosseous odontogenic tumors and usually arises in the sixth decade of life. This lesion often has a papillary surface.12 Fig. 2. Periapical radiograph showing no obvious pathology.
would include benign mesenchymal tumors, such as neural tumors, and peripheral odontogenic tumors, such as peripheral ameloblastoma, peripheral adenomatoid odontogenic tumor, peripheral calcifying odontogenic cyst, and peripheral odontogenic fibroma. Intraoral neurilemmoma is generally considered to be more common than neurofibroma.6,7 However, recent studies have shown similar incidences of neurilemmoma, neurofibroma, and palisaded encapsulated neuroma in the oral cavity.8,9 Thus, neurofibroma and palisaded encapsulated neuroma should be considered along with neurilemmoma in the differential diagnosis. The most common peripheral odontogenic tumor is the peripheral ameloblastoma. However, peripheral ameloblastomas typically affect middle-aged patients and have a predilection for the mandibular gingiva.1 The surface of the peripheral ameloblastoma often shows a papillary, pebbly, or warty appearance which
Diagnosis The lesion was totally excised and submitted for histopathologic examination. No bony involvement was observed at the time of surgery. The clinical diagnosis was “irritation fibroma.” The specimen measured 1.0 ⫻ 1.0 ⫻ 1.0 cm and was processed for routine hematoxylin and eosin staining. Microscopic examination revealed 3 developing tooth germs (Fig. 3) which were completely embedded within the surrounding connective tissue. Two of the 3 tooth germs were at the late bell stage, showing a high degree of histodifferentiation of the dental organ (Fig. 4). Inner and outer dental epithelium, stratum intermedium, stellate reticulum, enamel, dentin, and dental papilla were clearly evident. Strands and islands of odontogenic epithelium were noted within the surrounding fibrous connective tissue. Final diagnosis The final diagnosis, based on the histopathologic findings and clinical presentation, was peripheral developing odontoma. In light of the final diagnosis, the
OOOOE Volume 102, Number 1
Fig. 4. A, High-power photomicrograph of one of the tooth germs, showing dentin formation (hematoxylin-eosin, original magnification 250⫻). B, High-power photomicrograph of one of the tooth germs, showing enamel formation (hematoxylin-eosin, original magnification 250⫻).
periapical radiograph was reexamined to see if any evidence of calcification could be seen. On retrospective examination, a subtle radiopacity could be detected inferior to the contact point between the right central and lateral incisors, corresponding to the soft-tissue location of the lesion. Healing of the biopsy site was uneventful. No evidence of recurrence was noted at the patient’s 18-month follow-up. DISCUSSION In the present case, 3 developing tooth germs were located in a nodular mass on the palatal side of the interdental papilla between the right central and lateral incisors in a 13-year-old girl. Two of these dental
Kintarak et al. 5
structures were in the late bell stage of tooth development. In view of the histopathologic and clinical findings, a diagnosis of peripheral compound odontoma was considered most appropriate. The odontoma is the most common odontogenic tumor, although it is widely considered to represent a hamartoma or malformation of dental tissues rather than a true neoplasm.1 Most cases occur in an intraosseous location. Extraosseous odontomas are rare. A review of the literature revealed only 9 cases13-20 of supernumerary teeth or odontomas occurring peripherally in gingival soft tissue. Only 2 of these13,14 presented as palatal masses, as in the present case. These were diagnosed as “ectopic softtissue mesiodens.” Diekmann et al.13 described a cone-shaped supernumerary tooth within a pedunculated mass on the palate, just lateral and posterior to the incisive papilla in a 3-year-old boy. Lin et al.14 reported a tooth germ in a swelling on the palatal aspect of the left deciduous central incisor in a 17month-old boy. Both cases presented as single well formed teeth which were composed of varying amounts of ameloblasts, enamel, enamel matrix, dentin, predentin, odontoblasts, and dental papilla. Recurrence of peripheral odontoma has not been documented. It is believed that both mesiodens and odontomas represent different manifestations of a similar underlying altered developmental process. The most common location for a supernumerary tooth is the maxillary anterior incisor region, where it is termed a mesiodens. A recent retrospective radiographic review of 256 mesiodens21 established that the majority (73%) of mesiodens occur singly and are primarily (89%) located on the palatal aspect of the dental arch. The simultaneous occurrence of 2 or 3 mesiodens was noted in only 26% and 1% of cases, respectively. Compound odontomas consist of many separate small denticles, with a marked predilection for the maxillary anterior region. A recent retrospective review from Japan of 39 odontomas22 revealed that most were identified during the mixed or early permanent dentition stages and were predominantly located in the maxillary central and lateral incisor region. The predilection of both mesiodens and compound odontomas for the anterior maxilla suggests that this area may be predisposed to disturbed odontogenesis.23 In summary, we describe a rare case of a peripheral odontoma presenting as a nodular soft tissue mass of the maxillary anterior gingiva. Simple surgical excision was curative. Recurrence of the peripheral odontoma has not been documented.
OOOOE July 2006
6 Kintarak et al. REFERENCES 1. Neville BW, Damm DD, Allen CM, Bouquot JE, Oral and maxillofacial pathology. 2nd ed. Philadelphia: WB Saunders; 2002. p. 447–52, 618-9, 631-2. 2. Aldred MJ, Talacko AA, Ruljancich K, Story RD, Newland S, Chen ST, et al. Oral focal mucinosis: report of 15 cases and review of the literature. Pathology 2003;35:393-6. 3. Tosios K, Laskaris G, Scully C. Benign cartilaginous tumor of the gingiva. A case report. Int J Oral Maxillofac Surg 1993;22:231-3. ¨ nal T, Bir Y. Osteocartilaginous choristoma of the 4. Seçkin T, U gingiva. Dent Update 1996;23:248-9. 5. Ledesma-Montes C, Fernández-López R, Garcés-Ortíz M, Portilla-Robertson J, Hernández-Guerrero C. Gingival salivary gland choristoma. A case report. J Periodontol 1998;69:1164-6. 6. Cawson RA, Binnie WH, Speight PM, Barrett AW, Wright JM, editors. Lucas’s pathology of tumors of the oral tissues. 5th ed. London: Churchill Livingstone; 1998. p. 278. 7. Cawson RA, Odell EW, eds. Cawson’s essentials of oral pathology and oral medicine. 7th ed. Edinburgh: Churchill Livingstone; 2002. p. 281. 8. Chrysomali E, Papanicolaou SI, Dekker NP, Regezi JA, Francisco S. Benign neural tumors of the oral cavity. A comparative immunohistochemical study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:381-90. 9. Jordan RC, Regezi JA. Oral spindle cell neoplasms. A review of 307 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:717-24. 10. Reichart PA, Philipsen HP, editors. Odontogenic tumors and allied lesions. London: Quintessence; 2004. p. 59-67. 11. Philipsen HP, Reichart PA. Adenomatoid odontogenic tumour: facts and figures. Oral Oncol 1998;35:125-31. 12. Odell EW, Morgan PR, editors. Biopsy pathology of the oral tissues. London: Chapman & Hall Medical; 1998. p. 403-4. 13. Diekmann SL, Cohen DM, Gutz DP. Ectopic soft-tissue mesio-
14. 15.
16. 17.
18.
19. 20. 21.
22.
23.
dens. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1982;53:391-4. Lin C-C, Chen R-J, Lai S. Ectopic soft-tissue mesiodens. Report of a case. J Oral Med 1986;41:124-5, 133. Dubuk AN, Selvig KA, Tellefsen G, Wikesjo UM. Atypically located paramolar. Report of a rare case. Eur J Oral Sci 1996;104:138-40. Siar CH, Nor GM. Peripheral complex odontome with ghost cell epithelium. A case report. Ann Dent 1989;48:6-7. Giunta JL, Kaplan MA. Peripheral, soft tissue odontomas. Two case reports. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1990;69:406-11. Castro GW, Houston G, Weyrauch C. Peripheral odontoma: report of case and review of literature. ASDC J Dent Child 1994;61:209-13. Ledesma-Montes C, Perez-Bache A, Garcés-Ortiz M. Gingival compound odontoma. Int J Oral Maxillofac Surg 1996;25:296-7. Ide F, Shimoyama T, Horie N. Gingival peripheral odontoma in an adult: case report. J Periodontol 2000;71:830-2. Asaumi JI, Shibata Y, Yanagi Y, Hisatomi M, Matsuzaki H, Konouchi H, et al. Radiographic examination of mesiodens and their associated complications. Dentomaxillofac Radiol 2004;33:125-7. Tomizawa M, Otsuka Y, Noda T. Clinical observations of odontomas in Japanese children: 39 cases including one recurrent case. Int J Paediatric Dent 2005;15:37-43. Budnick SD. Compound and complex odontomas. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1976;42:501-6.
Reprint requests: Dr. Sompid Kintarak Department of Stomatology Faculty of Dentistry Prince of Songkhla University Hatyai, Songkhla 90112, Thailand [email protected]