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Localized Multiple Cemental Excrescences: A Rare Presentation of Hypercementosis

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Nadeem Jeddy at Dr.MGR Educational and Research Institute
Nadeem Jeddy
Radhika T at Thai Moogambigai Dental College, Dr.MGR Educational and Research Institute, Chennai
Radhika T
  • Thai Moogambigai Dental College, Dr.MGR Educational and Research Institute, Chennai
Krithika Chandrasekaran at Dr.MGR Educational and Research Institute
Krithika Chandrasekaran
Saravanan R
Saravanan R
Saravanan R
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Abstract

Hypercementosis is an abnormal thickening of cementum which may be generalized or localized. Localized hypercementosis is usually characterized by nodular enlargement of apical third of root. Hypercementosis in the form of multiple cemental spikes distributed throughout the entire length of root is a very rare finding. In this article, we report such a rare manifestation of localized hypercementosis affecting right maxillary third molar in a 24-year-old male. This finding was an accidental observation following a difficult extraction procedure as the spikes were not evident in the orthopantamogram. It is imperative that every dental practitioner be aware of several presentations of hypercementosis and ensure that such an entity is considered in the differential diagnosis of difficult extraction procedures as an Intraoral Periapical (IOPA) radiograph or even an Orthopantamogram (OPG) could not differentiate the root morphology.
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Journal of Clinical and Diagnostic Research. 2014 May, Vol-8(5): ZD16-ZD17
1616
DOI: 10.7860/JCDR/2014/8987.4367
Case Report
Localized Multiple Cemental
Excrescences: A Rare Presentation
of Hypercementosis
Dentistry Section
NADEEM JEDDY1, RADHIKA T.2, KRITHIKA C.3, SARAVANAN R.4, RAMACHANDRAN PRABAKAR5
Keywords: Hypercementosis, Localized, Cemental spikes
CASE REPORT
A 24-year-old male patient reported to a private Dental clinic for oral
prophylaxis. He also complained of pain in right lower back region
due to impingement of right upper back tooth on the mucosa of
the lower jaw. On intraoral examination, it was noted that 18 was
impinging on the mandibular alveolar mucosa distal to 47 during
occlusion. 38 and 48 were impacted. OPG revealed mesioangular
impaction of both mandibular third molars. Maxillary third molars
were completely erupted [Table/Fig-1]. His medical history was
noncontributory and vital signs were normal. Patient did not give
a history of any orthodontic treatment or any other major dental
procedures. His haemogram and blood sugar values were normal.
Extraction of all four third molars was planned. When extraction of
18 was attempted, there was resistance to the movement of the
tooth upon traction; but it was carefully and patiently manipulated
out of the socket and removed in toto. However, morphology of
all third molars appeared apparently normal on the pre-operative
radiograph and there was no associated pathology. The extracted
tooth in this case showed multiple calcified spike like projections (6
in number) on the mesiobuccal and distobuccal roots of 18 [Table/
Fig-2]. These spikes were seen on the buccal and palatal aspects
as well as the middle and apical thirds of both the buccal roots; the
palatal root however, did not have any cemental spikes. Intra oral
digital radiograph of the extracted tooth was taken to confirm the
nature of the spikes. The radiograph confirmed the presence of spike
like projections which were continuous with the external surface of
the root suggesting their origin from the cementum [Table/Fig-3].
The tooth showed no evidence of caries or attrition and appeared
ABSTRACT
Hypercementosis is an abnormal thickening of cementum which may be generalized or localized. Localized hypercementosis is usually
characterized by nodular enlargement of apical third of root. Hypercementosis in the form of multiple cemental spikes distributed throughout
the entire length of root is a very rare finding. In this article, we report such a rare manifestation of localized hypercementosis affecting
right maxillary third molar in a 24-year-old male. This finding was an accidental observation following a difficult extraction procedure as
the spikes were not evident in the orthopantamogram. It is imperative that every dental practitioner be aware of several presentations of
hypercementosis and ensure that such an entity is considered in the differential diagnosis of difficult extraction procedures as an Intraoral
Periapical (IOPA) radiograph or even an Orthopantamogram (OPG) could not differentiate the root morphology.
[Table/Fig-1]: Pre-operative panoramic radiograph showing erupted 18, 28, and
impacted 38, 48. All third molars appear apparently normal in morphology
[Table/Fig-2]: Extracted right upper third molar as viewed from the mesial aspect,
showing the presence of multiple cemental spikes on the buccal and palatal
aspects of the buccal roots.
[Table/Fig-3]: Digital intra oral radiograph showing the spikes which is continuous
with the cementum.
Journal of Clinical and Diagnostic Research. 2014 May, Vol-8(5): ZD16-ZD17 1717
www.jcdr.net Nadeem Jeddy et al., A Rare Presentation of Hypercementosis
Keywords: Hypercementosis, Localized, Cemental spikes
otherwise normal. Serial estimation of serum calcium, phosphorus,
alkaline phosphatase, T3, T4 and TSH levels were normal. The
extraction site healed uneventfully and there was no post- operative
complication.
DISCUSSION
Hypercementosis refers to an abnormal and prominent thickening
of cementum. It is a form of cemental hyperplasia which can
be generalized or localized. Generalized hypercementosis is
characterized by increased thickness of cementum involving all
teeth and is a classical feature of Paget’s disease. Other systemic
disturbances associated with hypercementosis include acromegaly,
arthritis, calcinosis, rheumatic fever and thyroid goiter [1].
Localized hypercementosis affects single tooth and usually presents
as generalized thickening of cementum with nodular thickening
of apical third of root. Cemental excrescences in the form of
spikes are an uncommon condition and a rare manifestation of
hypercementosis characterized by presence of small spikes or
outgrowths of cementum on root surface [2].
Cementum is a calcified avascular mesenchymal tissue that forms
outer covering of anatomic root of a tooth [3]. Abnormalities in
the thickness of cementum can range from Cemental aplasia or
hypoplasia (absence or paucity of cellular cementum) to Cemental
hyperplasia or hypercementosis (excessive deposition of cementum)
[1].
Hypercementosis is characterized by cementum formation beyond
the physiological limits of the tooth. Hypercementosis usually
occurs as a generalized thickening of the cementum with nodular
enlargement of the apical third of the root. Various reasons attributed
for hypercementosis include functional stress due to occlusal forces
[4], continuous dental eruption [5], incorporation of periodontal
cementicles during physiologic cementum deposition, reactionary
deposition in response to periapical inflammatory processes as well
as systemic factors such as atherosclerosis, acromegaly, deforming
arthritis, hypertrophic arthritis, thyroid diseases and Paget’s disease
[6]. Based on the macroscopic appearance, hypercementosis
is classified as a) Club shaped b) Focal and c) Circular cemental
hyperplasia [7].
Spike formation of cementum is an uncommon condition
characterized by the occurrence of small spikes or outgrowth of
cementum on the root surface. The occurrence of cemental spikes
has been attributed to excessive occlusal stress or excessive tension
from orthodontic appliance probably as a result of deposition of
irregular cementum in a focal group of fibers of the periodontal
ligament or coalescence of cementicles that adhere to the root or
the calcification of periodontal fiber at the site of insertion into the
cementum [8].
Functional stress cannot be considered as an etiological factor in our
case because the opposing mandibular third molar was impacted
and hence was not in occlusion with the tooth in question. Besides,
unlike the first molar, a third molar seldom bears the brunt of the
occlusal stress. The patient has not undergone any orthodontic
treatment which again rules out tension from orthodontic appliance
as an etiologic factor for cemental spikes in the present case. In
tooth without antagonist, hypercementosis usually presents as
nodular thickening of apical third of root and occurs as an attempt
to maintain the width of the periodontal ligament and to compensate
the accelerated eruption of tooth [8]. However, the present report is
also a tooth without antagonist whereas hypercementosis was in
the form of spikes rather than nodular enlargement of apical third of
the root. The fact that these cemental spikes were not visible on the
pre-operative panoramic radiograph added to our clinical dilemma
during the extraction procedure. Since this patient had no obvious
systemic contributory factors, the mechanism of spike formation in
the maxillary third molar in this patient cannot be explained in simple
terms and hence presumed to be idiopathic in nature.
CONCLUSION
This is a rare case of focal hypercementosis in the form of cemental
spikes. Although several cases of focal hypercementosis affecting
a mandibular molar have been reported in literature, our case is
unique in two aspects: firstly in the nature of the hypercementosis,
which was in the form of multiple spikes along the root surface and
secondly in the tooth affected, which was a maxillary third molar out
of occlusion with the opposing tooth.
It is mandatory for every dental practitioner to be aware of such a rare
variety of localized hypercementosis. Cemental spikes, however rare
or undetectable, should be considered in the differential diagnostic
possibilities of any tooth that poses a considerable difficulty during
extraction.
REFERENCES
[1] Newman, Takei, Klokkevold and Carranza. Carranza’s Clinical Periodontology:
South Asia Edition, 1st ed.India: Elsevier Publishers: 2013. pp 35.
[2] Rajendran R, Sivapathasundaram B. Regressive alterations of the teeth. In:
Rajendran R, Sivapathasundaram B (editors). Shafer’s text book of oral pathology,
6th ed. Noida: Elsevier Publishers: 2009. pp 585-6.
[3] Shantipriya Reddy. Essentials of Clinical Periodontology and Periodontics.2nd ed.
New Delhi: Jaypee Publishers: 2008. pp 26.
[4] Comuzzie AG, Steele DG. Enlarged occlusal surfaces on first molars due to severe
attrition and hypercementosis: examples from prehistoric coastal populations of
Texas. Am J Phys Anthropol.1989; 78:9-15.
[5] Azaz B, Michaeli Y, Nitzan D. Aging of tissues of the roots of nonfunctional human
teeth. Oral Surg. 1977; 43:572-8.
[6] Soni NN. A microradiographic and polarized light study of cementum in Paget’s
disease. J Oral Med. 1969; 24:27-30.
[7] Pinheiro BC, Pinheiro TN, Capelozza ALA, Consolaro A. A scanning electron
microscopic study of hypercementosis. J Appl Oral Sci. 2008; 16(6): 380-4.
[8] Newman MG, Takei H, Klokkevold PR, Fermin A. The normal periodontium. In:
Newman MG, Takei H, Klokkevold PR, Fermin A (editors). Carranza’s clinical
Periodontology. 11th ed. China: Elsevier: Saunders; 2007. pp 77.
PARTICULARS OF CONTRIBUTORS:
1. Professor and Head, Department of Oral Pathology, Thai Moogambigai Dental College, Golden George Nagar, Chennai, India.
2. Reader, Department of Oral Pathology, Thai Moogambigai Dental College, Golden George Nagar, Chennai, India.
3. Reader, Department of Oral Medicine, Thai Moogambigai Dental College, Golden George Nagar, Chennai, India.
4. Professor, Department of Orthodontia, Thai Moogambigai Dental College, Golden George Nagar, Chennai, India.
5. Professor and Head, Department of Orthodontia, Thai Moogambigai Dental College, Golden George Nagar, Chennai, India.
NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Radhika T.,
Reader, Department of Oral Pathology, Thai Moogambigai Dental College, Golden George Nagar, Chennai-600107, India.
Phone: 91-9566016165, E-mail: radhikasashi26@gmail.com
FINANCIAL OR OTHER COMPETING INTERESTS: None.
Date of Submission: Feb 17, 2013
Date of Peer Review: Mar 09, 2013
Date of Acceptance: Mar 29, 2014
Date of Publishing: May 15, 2014
... [20] In the literature, the possible relationship of hypercementosis with various etiological factors has been mostly presented as case reports. [3,15,21] Some of these factors have been revealed by studies on skeletal bones from prehistoric age and 17 th -19 th centuries. [17,19,22] To the best of our knowledge, there is no clinical study in the literature that investigated possible etiological factors involved in hypercementosis collectively and in a large population. ...
... To date, a large number of cases of hypercementosis have been reported in the literature, [2,3,15,21] but there are few studies on its prevalence. [1,17,18,23] Variable prevalence has been reported that include 0.6% in the Iranian population [18] , 1.3% in the German population [17] , 4.82% in the Arab population, [23] and 2.4% in a study on a southeastern Turkish population. ...
... The literature on the etiology and pathogenesis of hypercementosis is scarce, [12] and its possible association with various etiological factors is often presented as case reports. [2][3][4][14][15][16]21,29] The association of hypercementosis with occlusal forces is often based on prehistoric studies and skeletal studies in the 17 th -19 th centuries. [19,22] Bruxism and occlusal trauma have been cited among the factors closely associated with hypercementosis. ...
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Objective: The aim of this study was to investigate the prevalence and types of hypercementosis and the frequency of possible etiological factors in a large sample of Turkish central Anatolian population. Subjects and methods: A cross-sectional study was performed using panoramic radiographs of 1176 randomly selected adult patients with an age range of 18-96 years, who presented to the Department of Oral and Maxillofacial Radiology of the Faculty of Dentistry, Cumhuriyet University (Sivas, Turkey) for dental care. Patients were questioned about the presence of systemic diseases. Panoramic radiographs of the patients were examined for the presence and types of hypercementosis (diffuse, focal and shirt sleeve cuff) and the frequency of local factors that may be associated with hypercementosis. Chi-square and t-tests were used for statistical analysis. Results: Hypercementosis was detected in 128 of 1176 patients. In total, 85.6% of the teeth with hypercementosis had a diffuse, 7.5% had a focal, and 6.8% had a shirt sleeve cuff type. Hypercementosis was observed most frequently in the mandibular (P < 0.05) and the premolar region. Gender-related differences were nonsignificant (P > 0.05). Atherosclerosis, osteoporosis, and multiple diseases were reported more frequently in individuals with hypercementosed teeth (P < 0.05). While idiopathic origin (39.3%), bruxism (30%), and inflammation (24.37%) were the most prevalent local etiological factors, impacted teeth (1.25%) and history of trauma (0.62%) were less common. Conclusion: The prevalence of hypercementosis was 10.8% in the study population. The lesions were more common in the mandibule. Idiopathic origin was the most common factor associated with hypercementosis.
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... [8] Radiographically, the teeth affected by hypercementosis show thickening of the root, surrounded by radiolucent periodontal ligament space, and intact lamina dura. [1,3,4,9] In turn, cementoblastoma is a calcified mass attached to the dental root, with loss of contour due to root resorption and fusion with tumor. [1,2,4,7] The present work was aimed to demonstrate the clinical and imaging characteristics of a clinical case with focus on the diagnosis of hypercementosis by using radiographic, magnetic resonance imaging (MRI). ...
... Cementum is an adaptable component of the periodontium, which can respond to functional changes during its development, with its formation being characterized by apposition during the final stage of the tooth's life. [5,9] In some cases, there is an excessive deposition of nonneoplastic cementum along the normal root cementum, giving rise to hypercementosis. [1,4,9] Lower molars are the most affected teeth, followed by lower premolars and upper second premolars, being predominant in adults. ...
... [5,9] In some cases, there is an excessive deposition of nonneoplastic cementum along the normal root cementum, giving rise to hypercementosis. [1,4,9] Lower molars are the most affected teeth, followed by lower premolars and upper second premolars, being predominant in adults. [4,5] In the present case, the patient was 29 years old and had her lower first molar (tooth #36) affected -characteristics suggestive of a possible diagnosis of hypercementosis, according to the literature. ...
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Cementum is an adaptable component of the periodontium which can respond to functional changes throughout its development, with its formation being characterized by apposition during the final stage of the tooth's life. In some cases, this formation occurs in excess, giving rise to hypercementosis, or other lesions (e.g., cementoblastoma) often presenting similar clinical and imaging features, but they are actually distinct entities requiring different approaches. The objective of the present study is to demonstrate the clinical and imaging characteristics of a case based on a differential diagnosis of these entities. Accurate diagnosis through detailed examination and adequate interpretation of imaging characteristics is essential for appropriate and successful therapy.
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... 17 En cuanto al tratamiento, no se establece uno estrictamente debido a que carece de sintomatología, no obstante, al presentarse una condición inflamatoria pulpar irreversible, su tratamiento es fundamentalmente endodóncico; y si no existe ninguna causa, no amerita ningún tratamiento. [18][19][20] Para la elaboración de este trabajo de revisión bibliográfica, se procede primeramente a realizar una búsqueda profunda de artículos científicos relacionados con la hipercementosis en bibliotecas, buscadores virtuales y revistas científicas como lo son Scielo, PubMed, Google académico, OMS, entre otras, con palabras claves como «hipercementosis», cemento dental, «Hyperocementosis», «Dental cement» y más. De la misma manera, se procedió a buscar libros de patología dental y relacionada al tema en la biblioteca de odontología de la Universidad Católica de Cuenca. ...
... 19 Nadeem, Radhika, Krithika, Saravanan y Ramachandran mencionan que la hipercementosis localizada va afectar a un solo diente y va a presentar como un ensanchamiento del cemento con engrosamientos nodulares en el tercio apical de la raíz, en forma de picos, siendo una condición poco común y se presentan raramente por la presencia de pequeños picos o crecimientos del cemento en la raíz. 20 Raghavan V et al. declaran que los traumatismos leves de la oclusión pueden causar hipercementosis, mientras que Souza et al. informan sobre un caso atípico de hipercementosis que son semejantes con el cementoblastoma debido a que son lesiones relacionadas con raíces dentales. 23,24 Para Siguas y Castro observan imágenes radiopacas de cuatro milímetros de diámetro compatibles con la hipercementosis y con una lesión cariosa coronal extensa con aparente compromiso pulpar, donde se aprecia un descenso progresivo del grosor a nivel de tercio cervical y medio. ...
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... In base alla storia medica e orale del paziente, non è stato possibile riscontrare alcun fattore eziologico associato all'ipercementosi [11,12]. Tuttavia questo lavoro fornisce un contributo importante per l'approfondimento di una condizione tanto sottostimata e spesso non diagnosticata, in particolare dal punto di vista istologico. ...
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... This disproportionate deposition of cementum causes abnormal thickening of the tooth apex which gives the roots a rounded appearance. 12,13 This abnormality can occur only at the tip of the tooth root or on the entire root surface. In addition, it can occur in only one tooth or involve many teeth. ...
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... Radiographically, alterations on the anatomy of the dental roots are observed with preserved-support structures, both the periodontal space and the hard lamina (1) . Considering the etiology of hypercementosis, local factors include dysfunctional occlusion and periapical pathosis, whereas systemic factors comprise Paget's disease of bone, acromegaly, rheumatic fever, deforming arthritis and thyroid disease (2)(3)(4)(5) . ...
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Newman and Carranza's Clinical Periodontology
Book
  • Jul 2018
From basic science and fundamental procedures to the latest advanced techniques in reconstructive, esthetic, and implant therapy, Newman and Carranza's Clinical Periodontology, 13th Edition is the resource you can count on to help master the most current information and techniques in periodontology. Full color photos, illustrations, radiographs and videos show you how to perform periodontal procedures, while renowned experts from across the globe explain the evidence supporting each treatment and lend their knowledge on how to best manage the outcomes. Access to the Expert Consult website provides fully-searchable online chapters and unique case-based clinical scenarios that mimic the new format of credentialing exams. The Expert Consult platform also includes a wealth of resources to enhance understanding, such as: a periodontal pathology atlas, virtual microscope, animations, case reports, videos, audio slides, review questions, reference lists, and much more. It's the perfect resource for dental students, periodontal residents, and clinicians alike!
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Aging tissues of the roots of nonfunctional human teeth (Impacted Canines)
Article
  • May 1977
  • Oral Surg Oral Med Oral Pathol
In order to examine the aging of dentin and cementum, seventy-two impacted human canines, nonfunctional and not affected by external factors, such as attrition, abrasion, caries, etc., were surgically extracted. Ground sections were prepared and the areas of sclerotic dentin and cementum were measured with the aid of a planimeter and expressed as a percentage of the total root area. It was found that there is a significant increase in sclerotic dentin and apposition of cementum with an increase in age.
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Enlarged Occlusal Surfaces on First Molars Due to Severe Attrition and Hypercementosis: Examples from Prehistoric Coastal Populations of Texas
Article
  • Jan 1989
During an examination of prehistoric samples from the Texas coast, individuals consistently exhibited a suite of traits on the first molars that included severe wear, hypercementosis, and resorption of the buccal margin of the alveolus. The occlusal surface of the tooth was worn below the cervical margin, with the subsequent incorporation of the buccal surface of the buccal roots into the occlusal plane. This expanded occlusal surface, which extends the buccal surface beyond the normal edge of the tooth, is composed of a combination of original enamel, secondary dentin, and cementum. There is a marked rounding of the buccal aspect of the occlusal surface. These conditions were noted in both maxillary and mandibular first molars. The resorption of alveolar bone surrounding the buccal roots resembles resorption associated with periodontal infection and is thought to be the result of severe levels of stress being applied to this portion of the dentition.
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