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Complex composite odontoma involving the maxilla and maxillary sinus
COMPLEX
COMPOSITE ODONTOMA AND MAXILLARY
INVOLVING SINUS
THE MAXILLA
Report of a Case ROBERT
W. CHRISTENSEN, D.D.S.,” PASADENA, CALIF.
T
HE odontoma is a tumor caused by neoplastic proliferation of the odontogenic cells of the tooth germ of both the epithelial and mesenchymal cells, which differentiate to the ameloblastic and odontoblastic stage; the organization fails to reach the normal state, so that tooth substance is put down in an abnormal manner. The formative tissue may be derived from proliferating epithelium from the enamel organ, from neoplastic development of the tooth germ of a normal tooth, or from a supernumerary sprout given off the dental lamina. In the format,ive stage it may be a fibrous tissue tumor known as an odontoblastoma. This tumor progresses until the odontoblastic and ameloblastic matrix is calcified, forming the complex composite odontoma which is the final stage in this particular tumor. The complex composite odontoma is one in which the calcified structures bear no great resemblance to the normal anatomic relation of the dental tissue. When the growth of the tumor cells has become exhausted and there is only calcified tooth substance present, the soft tissue, having ceased its activity, remains as a fibrous capsule around the tumor mass and aids the blood vessels and nerves which may enter the mass. The complex composite odontoma may be large or small ; it may be smooth, lobulated, or of an irregular shape. It sometimes forms around the crown of a normally developed, unerupted t,ooth, especially if it is formed from the coronal part of the dental follicle. One may find a greater amount of enamel, dentine, or cementum predominating, depending upon the activity of the individual cells which produce each type of tooth structure. The odontomas are benign tumors and are generally excised conservatively since metastatic propensity has not been reported, as might be expected in the case of an ameloblastic odontoma. Case Report On Aug. 18, 1955, 1 was called upon by the patient’s general treat an U-year-old white girl who had a large swelling in the left a slight bulging in that side of her face. *Member, Oral Pasadena, California.
Surgery
stuffs,
St. Luke
Hospital
1156
dentist maxilla
and Huntington
to examine and palate
Memorial
and and
Hospital,
Volume 9 Number I I
COMPLEX
COMPOSITE
1157
ODONTOMA
C. G., an 11-year-old student, was in no apparent distress. Oral examination revealed that the patient had all her permanent maxillary and mandibular teeth in normal occ~lu sion, with the exception of the third molars, which were unerupted, and the left maxilIar> A large bulging tumor first and second molar teeth, which were not present in the mouth, was seen in the left maxilla, extending from the cuspid to the hamular notch area. The massive, bony hard tumor extended from the midline of the palate labially to the infraIt had an intact overlying mucosa of orbital ridge and buccally to the malar process. normal texture and appearance. By visual inspection of the face, it was noted that the left infraorbital area appearetl slightly enlarged and the left eye was displaced superiorly approximately 5 mm., since the left pupil was 5 mm. superior to the right eye. A greater amount of sclera was visible wall of the under the left pupil (Fig. 1). With the aid of a nasal speculum, the latera left nasal passage was visualized and was found to project over to the mucosa of the septum on that side, due to the expansion of the tumor in the left maxillary sinus.
Fig. I.-Preoperative
photograph
taken one year prior to surgery
showing
elevation
of left eye%.
The patient, gave a long history of a gradual increase in the swelling of this area of the mouth, which had begun as long ago as she could remember. The mother stated that she noticed the displacement of the eye when the patient, was only 2 or 3 ,vears oIlI. From that time on, at varying intervals, the patient was taken for consultation to various general physicians and ophthalmologists who, according to the patient’s mother, had stakd that possible muscle-grafting procedures to reposition and direct the eye would he useful. The etiology had not been discovered. The patient had been fitted with glasses on three occasions to correct her double vision and astigmatism of the left eye. The patient had routine dental treatments, and dental roentgenograms on one occasion, but no meation was made of the tumor. Within the past year, she had been seen in consultation by an otorhinolaryngologist, but apparently the tumor was not observed. Only two months before this patient was referred to me, she was seen by another ophthalmologist without any mention ever being made of the presence of this t,umor. No skull roentgenograms had been taken. It was not until she visited a general dentist of this community that suspicion was aroused regarding the possible presence of the tumor,, and the patient, was then referred to the oral surgeon,
Fig. 2.-Preoperative
Fig.
0. s., 0. M., & 0. I’.
CHRISTENSEN
1158
Z.-Preoperative
lateral
lateral
Nuvember. 1956
roentgenogram of skull showing and maxillary sinus.
roentgenogram of maxilla periphery of tumor.
massive
showing
tumor
Arst
involving
and third
max :illa
molars
at
COMPLEX Roentgen Examination.--Lateral grams of the skull were taken.
COMPOSITE
0I)ONTOMA
and posteroanterior
Water’s
1159 projection
roentgeno-
The lateral view of the skull showed that a very large, homogenously radiopaque tumor mass, the density of cortical bone, was occupying the region of the left maxilIar>sinus and maxilla (Fig. 2). The diameter of the tumor was approximately A to 7 cm. Two teeth were identifiable at the superior periphery of the mass. One was in the anterior infraorbital ridge area which corresponded t,o t,he missing first molar and the other was at the posterior borler of the orbit and its tmuntlary with the tumor. This tooth was developed only in the coronal section and possibly representetl the third molar. These teeth appearetl to be incorporated in the bounllary of the tumor mass (Fig. 3). Snperiorly, the mass was in close proximity with the inferior boundary of the left orbil.
Fig. 4.-Preoperative posteroanterior maxilla anti maxillary
roentgenogram of skull showing tumor mass fllling sinus and encroaching on orbit and nosr.
left
The tumor was seen protruding on its anterior surface through the infraorbital antl canine Tn its posterior tlirection it hat1 enlargeci and entirely fillet1 fossa areas of the maxilla. the normal conlines of the maxillary sinus ant1 the alveolar an(I tuberoxity area of the maxilla. It also extended over the root apices of the two premolars and the cuspid of the left maxilla. The posteroanterior Water’s view showed the mass filling the entire left maxillary sinus; it protruded laterally into the malar process and medially through the nasal antral wall to occlude against the left side of the nasal septum (Fig. 4). The anterior molar
CHRISTENSEN
0. S., 0. M., & 0. P. November, 1956
tooth was seen lying in a posterior oblique direction in the bone between the lateral nasal process and the orbit. The right maxillary sinus was homogenously opaque, which may represent effusion in this area or perhaps merely failure of pneumatization. Routine periapical full-mouth dental roentgenograms were in harmony with the findings on the skull films. sinus,
Roentgen conchsion: with encroachment
Complex composite odontoma of left maxilla and maxillary on nasal and orbital spaces. Possibly right maxillary sinusitis.
General Physical Findings.-The general physical findings mere essentially negative with the exception of the local condition. The left orbital contents were displaced superiorly approximately 5 mm. The pupils reacted normally to light and were of normal size. The patient complained of double vision in the left eye. Lungs were normal to auscultation, percussion, and x-ray examination. Heart sounds were normal, The blood pressure was 116/68, pulse rate was 70 per minute, and oral temperature was 98.4” F. There was no palpable lymphadenopathy. The patient’s general appearance and condition were excellent. Laboratory Findings.-The hematologic examination performed on Aug. 18, 1955, showed 4,750,OOO erythrooytes and 5,700 leukocytes, of which 68 per cent were polymorphonuclear neutrophils, 25 per cent were lymphocytes, 4 per cent were eosinophils, and 3 per cent were monocytes. The hemoglobin was 14.5 grams. Bleeding and clotting times were normal. Platelets were normal. Urinalysis was negative. Operation.-On Aug. 18, 1955, the patient was admitted to St. Luke Hospital for On Aug. 19, 1955, she was given routine premeditation and prepared for surgery. surgery. Under intravenous Pentothal sodium and curare with nasoendotracheal gas and oxygen anesthesia, the mouth was opened and a bite block was placed between the molar teeth on the right side. A gauze throat pack was placed securely around the endotracheal tube The mouth was then swabbed vigorously with aqueous Zephiran in the oral pharynx. chloride solution, An incision was made with a scalpel through the mucoperiosteum from posterior to the left tuberosity, running anteriorly along the alveolar crest and adjacent Next, a vertical incision was extended from beto the premolars, cuspid, and incisors. tween the central incisors superiorly through the mucoperiosteum under the lip and adThe mucoperiosteum was retracted, labially and jacent to the lateral nasal bony wall. buccally, with a sharp periosteotome, off the maxillary process, exposing some intact cortical bone over a large bulging massive tumor of this area. The mucoperiosteum was retracted up to the infraorbital ridge, with care being taken not to injure the infraorbital vessels and nerve. This also exposed the entire base of the malar process to the zygomatic arch. The palatal mucoperiosteum was reflected and retracted medially to the midline of the palate. At this point the over-all size of the exposed surface of the tumor could be visualized. The thin overlying cortical bone was flaked off the tumor with a hand chisel. The tumor was found to be ebony hard, with a lobulated external surface. It was resected by surgical carbide burrs and surgical carbide chisels mounted in the Impactor. It was removed in probably several hundred pieces. There was a fibrous membrane around most of this tumor which varied in thickness from microscopic to 2 mm. The most abundant fibrous sac was found extending from the coronal section of what I believe was the maxillary left first molar, and this tissue continued around the adjacent tumor. There was no evidence of a second molar, but the third was placed high in the posterior aspect of the tumor. The tumor was found to involve the entire maxillary sinus; it was bounded by a flaky, fragmented wall of bone below the entire orbit, and had eroded the lateral nasoantral wall and protruded medially to press on the nasal septum. It protruded into the facial tissues and left only a somewhat frail infraorbital ridge with its intact vessels and nerve. It had eroded through the central portion of the malar process. Approximately one-third of the palatine bone was necessarily removed during surgery. The left maxillary second premolar was sacrificed to aid in adequately visualizing and resecting this tumor.
Volume
COMPLEX
9
Uumber II The tumor volutions peripheral
had to be removed
COMPOSITE: in so many
of its borders, its tremendous fibrous sac. It was virtually
1161
ODONTOMA pieces because of the lobulations
anti con-
size, its extreme hardness, and the fineness of its impossible to see fibrous tissue within this tumor.
At the completion of the resection of this tumor and the involved maining Ilone edges were rounded with a bone file and rongeur.
teeth,
the
W-
3 feet in length was packed iu A s-inch pet,rolatum gauze pack approximately layers in the cavity and carried through an incision in the nasal mucoperiosteum OII~ through the nose. The oral flaps were repositioned and sutured with approximately fifteen Gauze packs were placed in the mouth over the oral interrupted 0000 Dermalon sutures. The gauze packs were removetl from the pharynx and the patient was taken to wound. the recovery room where, when she awoke, the extubation was accomplished. The strip of petrolatum gauze extending from the nose was clipped with a safety pin am1 iape(l to the bridge of the nose.
fig.
5.--Postoperative
lateral
roentgenogram
(in reverse)
of skull
showing
tumor
compbt(‘ly
tTmOVed.
On Aug. 20, The patient, was operative days. St. Luke Hospital nary thrombosis,
1955, the patient was in slight tliscomfort and edema was only moderare. given Combiotic, 0.5 Gm., intramuneularly twice daily for five po-‘tOn Aug. 21, 1955, the patient’s Z-year-old father was admitted UIW IO with a diagnosis of pneumonia, but rlieti the next day of an acute (!ori)
The patient was retained in the hospital until Aug. 26, 1955, at her mother’s request, so that the funeral of her father would be past before she went home. The girl was Iold of the tragedy on the day of the funeral and held up remarkably well under the circumstances. The patient was seen in my office on Aug. 29, Sept. 6, and Sept. 12, 1955, and onethird of the anti-al pack was withdrawn from the nostril on each of these days. Sutures were removed on Sept. 6, 1955. New skull roentgenograma were taken on $ug. 29, IM:?, and showed the tumor entirely removed (Figs. 5 and 6).
Fig.
0. S.. 0. M., & 0. I’. November, 1956
CHRISTENSEN
1162
pative
Fig. ‘I.-Postoperative
posteroanterior
photograph
roentgenogram removed.
of mouth
showing
of
closure
skull
showing
and healing
1
,ompletely
of area of surgery.
COMPLEX
COMPOSITE
ODONTOMA
1163
The patient’s postoperative recovery has been uneventful with the without any perforation (Fig. 7). The patient has been checked in my the past six months without any complications developing. The double tion of the left eye have corrected themselves (Fig. 8). The patient is normally without the use of her glasses. Her general dentist is in the a removable denture to replace the missing teeth.
Fig. S.--Postoperative Pathology molar
tooth,
(2)
photograph
Report.-The soft tissue
of patient’s
face showing
normal
oral wound
position
specimen was iu three major forms: from tumor, and (3) tumor, left nlaxilla
closed
office monthly- for vision and elevaable to see almost process of making
of left eye.
( I ) maxillary ant1 maxillary
t,hirll sinus.
Gross: 1. This is a deformed jacent soft tissue. 2. This
specimen
molar
consists
tooth
with
of a flattened,
an easily roughly
avulsecl
enamel
8 mm. fragment
cap anti adof soft
tissutn.
3. The specimen consists of 51 grams of l)on>- tissue in which there are over 200 irregular fragments of both fairly normal-appearing bone and abortive tooth elements. The majority are 0.5 to 1.0 cm. in greatest dimension, mass measures eight to ten measuring up to 2.0 em.; one hemispherical The occlusal surface 3.5 by 2.0 ~IJ- 1.5 cm. ant1 caontains one molar tooth. of this crown projects through a thin, tough, fibrous membrane to contact other abortive tooth structure within the tumor mass. This later material submitted for decalcification. Multiple irregular secation of extremely dense hyprrt,rophic: trabecular .!?diicroscopic : bone includes irregular nodular elements showing abortive tooth format,ion, with enamel rods and dentinal tubules showing areas of well-defined tooth formation. However, the architec-ture of the individual tooth remnants is poorly maintained. These sitruetures alp in very close apposition with intervening septa of extremely sclerotic Ilone in which there is a. random There is nothing suggestive of malignant pattern of cement lines and some fibrous marrow. change. Diagnosis
: Complex composite
odontoma,
left maxilla
and maxillary
antrum.
1164
CHRISTENSEN
0. S., O.M., & O.P. November, 1956
Discussion I think that we can safely state that this tumor probably developd from the enamel organ of the first molar, which underwent neoplastic proliferation and excited surrounding mesenchymal tissues to aid in forming this mass. Perhaps the second molar was engulfed in this process, or perhaps it was the One thing to be sure, we can believe that this tumor was etiological factor. very mature and unable to progress much farther in its growth pattern.
Summary A case of a very large complex composite odontoma in an ll-year-old girl has been presented. The tumor was resected surgically from the left maxilla and maxillary sinus. Healing was uneventful and the patient’s symptoms of ocular pressure not only were relieved following surgery, but corhas resulted rected themselves to a large degree. No oral-antral perforation following surgery and the patient will be able to wear a normal partial denture to replace missing teeth.
References 1. Thoma, Kurt H.: Oral Pathology, St. Louis, 1954, The C. V. Mosby Company. 2. Thoma, Kurt H.: Oral Surgery, St. Louis, 1952, The C. V. Mosby Company. 3. Orban, Balint: Oral Histology and Embryology, St. Louis, 1944, The C. V. Mosby Company. 4. Mead, Sterling V.: Oral Surgery, St. Louis, 1954, The C. V. Mosby Company. 90 NORTH OAKLAND AVE.
COMPOSITE ODONTOMA AND MAXILLARY
INVOLVING SINUS
THE MAXILLA
Report of a Case ROBERT
W. CHRISTENSEN, D.D.S.,” PASADENA, CALIF.
T
HE odontoma is a tumor caused by neoplastic proliferation of the odontogenic cells of the tooth germ of both the epithelial and mesenchymal cells, which differentiate to the ameloblastic and odontoblastic stage; the organization fails to reach the normal state, so that tooth substance is put down in an abnormal manner. The formative tissue may be derived from proliferating epithelium from the enamel organ, from neoplastic development of the tooth germ of a normal tooth, or from a supernumerary sprout given off the dental lamina. In the format,ive stage it may be a fibrous tissue tumor known as an odontoblastoma. This tumor progresses until the odontoblastic and ameloblastic matrix is calcified, forming the complex composite odontoma which is the final stage in this particular tumor. The complex composite odontoma is one in which the calcified structures bear no great resemblance to the normal anatomic relation of the dental tissue. When the growth of the tumor cells has become exhausted and there is only calcified tooth substance present, the soft tissue, having ceased its activity, remains as a fibrous capsule around the tumor mass and aids the blood vessels and nerves which may enter the mass. The complex composite odontoma may be large or small ; it may be smooth, lobulated, or of an irregular shape. It sometimes forms around the crown of a normally developed, unerupted t,ooth, especially if it is formed from the coronal part of the dental follicle. One may find a greater amount of enamel, dentine, or cementum predominating, depending upon the activity of the individual cells which produce each type of tooth structure. The odontomas are benign tumors and are generally excised conservatively since metastatic propensity has not been reported, as might be expected in the case of an ameloblastic odontoma. Case Report On Aug. 18, 1955, 1 was called upon by the patient’s general treat an U-year-old white girl who had a large swelling in the left a slight bulging in that side of her face. *Member, Oral Pasadena, California.
Surgery
stuffs,
St. Luke
Hospital
1156
dentist maxilla
and Huntington
to examine and palate
Memorial
and and
Hospital,
Volume 9 Number I I
COMPLEX
COMPOSITE
1157
ODONTOMA
C. G., an 11-year-old student, was in no apparent distress. Oral examination revealed that the patient had all her permanent maxillary and mandibular teeth in normal occ~lu sion, with the exception of the third molars, which were unerupted, and the left maxilIar> A large bulging tumor first and second molar teeth, which were not present in the mouth, was seen in the left maxilla, extending from the cuspid to the hamular notch area. The massive, bony hard tumor extended from the midline of the palate labially to the infraIt had an intact overlying mucosa of orbital ridge and buccally to the malar process. normal texture and appearance. By visual inspection of the face, it was noted that the left infraorbital area appearetl slightly enlarged and the left eye was displaced superiorly approximately 5 mm., since the left pupil was 5 mm. superior to the right eye. A greater amount of sclera was visible wall of the under the left pupil (Fig. 1). With the aid of a nasal speculum, the latera left nasal passage was visualized and was found to project over to the mucosa of the septum on that side, due to the expansion of the tumor in the left maxillary sinus.
Fig. I.-Preoperative
photograph
taken one year prior to surgery
showing
elevation
of left eye%.
The patient, gave a long history of a gradual increase in the swelling of this area of the mouth, which had begun as long ago as she could remember. The mother stated that she noticed the displacement of the eye when the patient, was only 2 or 3 ,vears oIlI. From that time on, at varying intervals, the patient was taken for consultation to various general physicians and ophthalmologists who, according to the patient’s mother, had stakd that possible muscle-grafting procedures to reposition and direct the eye would he useful. The etiology had not been discovered. The patient had been fitted with glasses on three occasions to correct her double vision and astigmatism of the left eye. The patient had routine dental treatments, and dental roentgenograms on one occasion, but no meation was made of the tumor. Within the past year, she had been seen in consultation by an otorhinolaryngologist, but apparently the tumor was not observed. Only two months before this patient was referred to me, she was seen by another ophthalmologist without any mention ever being made of the presence of this t,umor. No skull roentgenograms had been taken. It was not until she visited a general dentist of this community that suspicion was aroused regarding the possible presence of the tumor,, and the patient, was then referred to the oral surgeon,
Fig. 2.-Preoperative
Fig.
0. s., 0. M., & 0. I’.
CHRISTENSEN
1158
Z.-Preoperative
lateral
lateral
Nuvember. 1956
roentgenogram of skull showing and maxillary sinus.
roentgenogram of maxilla periphery of tumor.
massive
showing
tumor
Arst
involving
and third
max :illa
molars
at
COMPLEX Roentgen Examination.--Lateral grams of the skull were taken.
COMPOSITE
0I)ONTOMA
and posteroanterior
Water’s
1159 projection
roentgeno-
The lateral view of the skull showed that a very large, homogenously radiopaque tumor mass, the density of cortical bone, was occupying the region of the left maxilIar>sinus and maxilla (Fig. 2). The diameter of the tumor was approximately A to 7 cm. Two teeth were identifiable at the superior periphery of the mass. One was in the anterior infraorbital ridge area which corresponded t,o t,he missing first molar and the other was at the posterior borler of the orbit and its tmuntlary with the tumor. This tooth was developed only in the coronal section and possibly representetl the third molar. These teeth appearetl to be incorporated in the bounllary of the tumor mass (Fig. 3). Snperiorly, the mass was in close proximity with the inferior boundary of the left orbil.
Fig. 4.-Preoperative posteroanterior maxilla anti maxillary
roentgenogram of skull showing tumor mass fllling sinus and encroaching on orbit and nosr.
left
The tumor was seen protruding on its anterior surface through the infraorbital antl canine Tn its posterior tlirection it hat1 enlargeci and entirely fillet1 fossa areas of the maxilla. the normal conlines of the maxillary sinus ant1 the alveolar an(I tuberoxity area of the maxilla. It also extended over the root apices of the two premolars and the cuspid of the left maxilla. The posteroanterior Water’s view showed the mass filling the entire left maxillary sinus; it protruded laterally into the malar process and medially through the nasal antral wall to occlude against the left side of the nasal septum (Fig. 4). The anterior molar
CHRISTENSEN
0. S., 0. M., & 0. P. November, 1956
tooth was seen lying in a posterior oblique direction in the bone between the lateral nasal process and the orbit. The right maxillary sinus was homogenously opaque, which may represent effusion in this area or perhaps merely failure of pneumatization. Routine periapical full-mouth dental roentgenograms were in harmony with the findings on the skull films. sinus,
Roentgen conchsion: with encroachment
Complex composite odontoma of left maxilla and maxillary on nasal and orbital spaces. Possibly right maxillary sinusitis.
General Physical Findings.-The general physical findings mere essentially negative with the exception of the local condition. The left orbital contents were displaced superiorly approximately 5 mm. The pupils reacted normally to light and were of normal size. The patient complained of double vision in the left eye. Lungs were normal to auscultation, percussion, and x-ray examination. Heart sounds were normal, The blood pressure was 116/68, pulse rate was 70 per minute, and oral temperature was 98.4” F. There was no palpable lymphadenopathy. The patient’s general appearance and condition were excellent. Laboratory Findings.-The hematologic examination performed on Aug. 18, 1955, showed 4,750,OOO erythrooytes and 5,700 leukocytes, of which 68 per cent were polymorphonuclear neutrophils, 25 per cent were lymphocytes, 4 per cent were eosinophils, and 3 per cent were monocytes. The hemoglobin was 14.5 grams. Bleeding and clotting times were normal. Platelets were normal. Urinalysis was negative. Operation.-On Aug. 18, 1955, the patient was admitted to St. Luke Hospital for On Aug. 19, 1955, she was given routine premeditation and prepared for surgery. surgery. Under intravenous Pentothal sodium and curare with nasoendotracheal gas and oxygen anesthesia, the mouth was opened and a bite block was placed between the molar teeth on the right side. A gauze throat pack was placed securely around the endotracheal tube The mouth was then swabbed vigorously with aqueous Zephiran in the oral pharynx. chloride solution, An incision was made with a scalpel through the mucoperiosteum from posterior to the left tuberosity, running anteriorly along the alveolar crest and adjacent Next, a vertical incision was extended from beto the premolars, cuspid, and incisors. tween the central incisors superiorly through the mucoperiosteum under the lip and adThe mucoperiosteum was retracted, labially and jacent to the lateral nasal bony wall. buccally, with a sharp periosteotome, off the maxillary process, exposing some intact cortical bone over a large bulging massive tumor of this area. The mucoperiosteum was retracted up to the infraorbital ridge, with care being taken not to injure the infraorbital vessels and nerve. This also exposed the entire base of the malar process to the zygomatic arch. The palatal mucoperiosteum was reflected and retracted medially to the midline of the palate. At this point the over-all size of the exposed surface of the tumor could be visualized. The thin overlying cortical bone was flaked off the tumor with a hand chisel. The tumor was found to be ebony hard, with a lobulated external surface. It was resected by surgical carbide burrs and surgical carbide chisels mounted in the Impactor. It was removed in probably several hundred pieces. There was a fibrous membrane around most of this tumor which varied in thickness from microscopic to 2 mm. The most abundant fibrous sac was found extending from the coronal section of what I believe was the maxillary left first molar, and this tissue continued around the adjacent tumor. There was no evidence of a second molar, but the third was placed high in the posterior aspect of the tumor. The tumor was found to involve the entire maxillary sinus; it was bounded by a flaky, fragmented wall of bone below the entire orbit, and had eroded the lateral nasoantral wall and protruded medially to press on the nasal septum. It protruded into the facial tissues and left only a somewhat frail infraorbital ridge with its intact vessels and nerve. It had eroded through the central portion of the malar process. Approximately one-third of the palatine bone was necessarily removed during surgery. The left maxillary second premolar was sacrificed to aid in adequately visualizing and resecting this tumor.
Volume
COMPLEX
9
Uumber II The tumor volutions peripheral
had to be removed
COMPOSITE: in so many
of its borders, its tremendous fibrous sac. It was virtually
1161
ODONTOMA pieces because of the lobulations
anti con-
size, its extreme hardness, and the fineness of its impossible to see fibrous tissue within this tumor.
At the completion of the resection of this tumor and the involved maining Ilone edges were rounded with a bone file and rongeur.
teeth,
the
W-
3 feet in length was packed iu A s-inch pet,rolatum gauze pack approximately layers in the cavity and carried through an incision in the nasal mucoperiosteum OII~ through the nose. The oral flaps were repositioned and sutured with approximately fifteen Gauze packs were placed in the mouth over the oral interrupted 0000 Dermalon sutures. The gauze packs were removetl from the pharynx and the patient was taken to wound. the recovery room where, when she awoke, the extubation was accomplished. The strip of petrolatum gauze extending from the nose was clipped with a safety pin am1 iape(l to the bridge of the nose.
fig.
5.--Postoperative
lateral
roentgenogram
(in reverse)
of skull
showing
tumor
compbt(‘ly
tTmOVed.
On Aug. 20, The patient, was operative days. St. Luke Hospital nary thrombosis,
1955, the patient was in slight tliscomfort and edema was only moderare. given Combiotic, 0.5 Gm., intramuneularly twice daily for five po-‘tOn Aug. 21, 1955, the patient’s Z-year-old father was admitted UIW IO with a diagnosis of pneumonia, but rlieti the next day of an acute (!ori)
The patient was retained in the hospital until Aug. 26, 1955, at her mother’s request, so that the funeral of her father would be past before she went home. The girl was Iold of the tragedy on the day of the funeral and held up remarkably well under the circumstances. The patient was seen in my office on Aug. 29, Sept. 6, and Sept. 12, 1955, and onethird of the anti-al pack was withdrawn from the nostril on each of these days. Sutures were removed on Sept. 6, 1955. New skull roentgenograma were taken on $ug. 29, IM:?, and showed the tumor entirely removed (Figs. 5 and 6).
Fig.
0. S.. 0. M., & 0. I’. November, 1956
CHRISTENSEN
1162
pative
Fig. ‘I.-Postoperative
posteroanterior
photograph
roentgenogram removed.
of mouth
showing
of
closure
skull
showing
and healing
1
,ompletely
of area of surgery.
COMPLEX
COMPOSITE
ODONTOMA
1163
The patient’s postoperative recovery has been uneventful with the without any perforation (Fig. 7). The patient has been checked in my the past six months without any complications developing. The double tion of the left eye have corrected themselves (Fig. 8). The patient is normally without the use of her glasses. Her general dentist is in the a removable denture to replace the missing teeth.
Fig. S.--Postoperative Pathology molar
tooth,
(2)
photograph
Report.-The soft tissue
of patient’s
face showing
normal
oral wound
position
specimen was iu three major forms: from tumor, and (3) tumor, left nlaxilla
closed
office monthly- for vision and elevaable to see almost process of making
of left eye.
( I ) maxillary ant1 maxillary
t,hirll sinus.
Gross: 1. This is a deformed jacent soft tissue. 2. This
specimen
molar
consists
tooth
with
of a flattened,
an easily roughly
avulsecl
enamel
8 mm. fragment
cap anti adof soft
tissutn.
3. The specimen consists of 51 grams of l)on>- tissue in which there are over 200 irregular fragments of both fairly normal-appearing bone and abortive tooth elements. The majority are 0.5 to 1.0 cm. in greatest dimension, mass measures eight to ten measuring up to 2.0 em.; one hemispherical The occlusal surface 3.5 by 2.0 ~IJ- 1.5 cm. ant1 caontains one molar tooth. of this crown projects through a thin, tough, fibrous membrane to contact other abortive tooth structure within the tumor mass. This later material submitted for decalcification. Multiple irregular secation of extremely dense hyprrt,rophic: trabecular .!?diicroscopic : bone includes irregular nodular elements showing abortive tooth format,ion, with enamel rods and dentinal tubules showing areas of well-defined tooth formation. However, the architec-ture of the individual tooth remnants is poorly maintained. These sitruetures alp in very close apposition with intervening septa of extremely sclerotic Ilone in which there is a. random There is nothing suggestive of malignant pattern of cement lines and some fibrous marrow. change. Diagnosis
: Complex composite
odontoma,
left maxilla
and maxillary
antrum.
1164
CHRISTENSEN
0. S., O.M., & O.P. November, 1956
Discussion I think that we can safely state that this tumor probably developd from the enamel organ of the first molar, which underwent neoplastic proliferation and excited surrounding mesenchymal tissues to aid in forming this mass. Perhaps the second molar was engulfed in this process, or perhaps it was the One thing to be sure, we can believe that this tumor was etiological factor. very mature and unable to progress much farther in its growth pattern.
Summary A case of a very large complex composite odontoma in an ll-year-old girl has been presented. The tumor was resected surgically from the left maxilla and maxillary sinus. Healing was uneventful and the patient’s symptoms of ocular pressure not only were relieved following surgery, but corhas resulted rected themselves to a large degree. No oral-antral perforation following surgery and the patient will be able to wear a normal partial denture to replace missing teeth.
References 1. Thoma, Kurt H.: Oral Pathology, St. Louis, 1954, The C. V. Mosby Company. 2. Thoma, Kurt H.: Oral Surgery, St. Louis, 1952, The C. V. Mosby Company. 3. Orban, Balint: Oral Histology and Embryology, St. Louis, 1944, The C. V. Mosby Company. 4. Mead, Sterling V.: Oral Surgery, St. Louis, 1954, The C. V. Mosby Company. 90 NORTH OAKLAND AVE.