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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 5  |  Issue : 3  |  Page : 90-93

Hypercementosis: Diagnostic imaging by radiograph, cone-beam computed tomography, and magnetic resonance imaging


1 Department of Morphology, Faculty of Medicine, Federal University of Ceara, Fortaleza, Brazil
2 Department of Dentistry, State of Piaui University, Parnaíba, PI, Brazil
3 Department of Dentistry, Federal University of Ceará, Campus Sobral, Sobral, CE, Brazil
4 Department of Radiology Dentistry and Orthodontics, University of São Paulo City, UNICID, São Paulo, Brazil
5 Department of Diagnosis and Surgery, São José dos Campos Dental School, UNESP, São Paulo, Brazil

Date of Web Publication18-Dec-2017

Correspondence Address:
Dr. Antonione Santos Bezerra Pinto
Rua Maria Teresa Dutra, 90, CEP 64202-338, Parnaíba, PI
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jomr.jomr_27_17

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  Abstract 


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.

Keywords: Cone-beam computed tomography, hypercementosis, magnetic resonance imaging, oral diagnosis


How to cite this article:
Pinto AS, Carvalho MS, de Farias AL, da Silva Firmino B, da Silva Dias LP, Neto JM, da Silva AM, Castro FA, Costa AL, De Castro Lopes SL. Hypercementosis: Diagnostic imaging by radiograph, cone-beam computed tomography, and magnetic resonance imaging. J Oral Maxillofac Radiol 2017;5:90-3

How to cite this URL:
Pinto AS, Carvalho MS, de Farias AL, da Silva Firmino B, da Silva Dias LP, Neto JM, da Silva AM, Castro FA, Costa AL, De Castro Lopes SL. Hypercementosis: Diagnostic imaging by radiograph, cone-beam computed tomography, and magnetic resonance imaging. J Oral Maxillofac Radiol [serial online] 2017 [cited 2020 Jun 6];5:90-3. Available from: http://www.joomr.org/text.asp?2017/5/3/90/221078




  Introduction Top


The dental-maxillomandibular complex is subject to the development of several pathologies, and among them, some present with identical features despite distinct clinical evolution, which requires different approaches. Atypical conditions can make both diagnosis and treatment a challenge as they may cause extensive morbidity and mortality.[1],[2] Hypercementosis is a condition in which nonneoplastic cementum is excessively deposited along the root portion, affecting one or more teeth and changing dental morphology as well as normality patterns. This condition is associated with local and/or systemic factors, but the majority of the cases are of idiopathic nature.[1],[3] Hypercementosis occurs predominantly in adults and its frequency increases with age, most likely due to cumulative exposure to influential factors. In general, no treatment is needed and a follow-up is enough. A correct diagnosis, including differential diagnosis with others lesions, is crucial as there may be other alterations (e.g., cementoblastoma).[3],[4],[5]

Cementoblastoma can resemble radiographically with hypercementosis. Cementoblastoma is the ectomesenchymal benign odontogenic tumor which is relatively rare. This condition is observed as a neoplastic mass of cementum growing slowly along the tooth's root and unknown etiology, as in most of the odontogenic tumors.[2],[6],[7],[8] Its incidence is higher between the second and third decades of life, with no gender predominance.[2],[8] In the majority of the cases, the treatment consists of surgical extraction of affected teeth with increased calcified volume.[1],[2],[4],[6],[7],[8] The amount of removal is closely associated with relapse.[2],[4],[6],[8] Due to their similarity, cementoblastoma and hypercementosis can be confounded with each other, but they are differentiated by certain features such as pain and/or expansion of cortical bones.[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). and cone-beam computed tomographic (CBCT) images. Due to the shapes of this lesion, the imaging examination plays an important role in the evaluation of its specific conditions and anatomical structures (mainly CBCT and MR), enabling better investigation for determining a final diagnosis and consequently an adequate treatment, thus avoiding interventions harmful and/or unnecessary to the patient.[10]


  Case Report Top


A 29-year-old female patient attended the private clinic for routine radiographic examination. During anamnesis, the patient reported chronic headache. On clinical intra- and extraoral examinations, no abnormal changes were found [Figure 1].
Figure 1: Intraoral clinical examination showing no unusual increase in cortical bone

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Periapical radiographic examination showed a radiopaque area involving the apical region of the distal root of tooth #36, with intact maintenance of periodontal ligament and lamina dura [Figure 2].
Figure 2: Periapical radiograph showing radiopaque halo around the root of tooth #36

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CBCT was performed by means of a scanner (GXCB-500™, powered by i-CAT ®) operating with FOV of 16 × 6.0 and voxel of 0.2 mm to better evaluate the relationship between lesion and alveolar bone. Through panoramic reconstruction and slices, one can observe a hyperdense image showing mineralized tooth tissues at the apical region within the limits of buccal and lingual cortical bones, whereas no expansive characteristics common to cementoblastoma were found either [Figure 3].
Figure 3: Cross-sectional slices showing hyperdense image at the root region, where no expansion of cortical bone was observed

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The patient underwent MRI examination for evaluation of her chronic headache. MRI was performed by means of a machine with 8-inch coil (Sigma, 1.5. Tesla, General Electric, Milwaukee, USA). The resulting images were used for evaluation of the lesion under study, showing a hypointense signal limited to medullary bone [Figure 4]. Based on patient's history, clinical features and imaging characteristics, a follow-up treatment of the case was planned.
Figure 4: Different magnetic resonance images showing hypo-intense signal associated with the distal root of tooth #36 limited to medullary bone

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  Discussion Top


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.[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.

Hypercementosis may be of idiopathic nature or be associated with local or systemic factors.[9] In the present case, it is possible to note on the periapical radiograph a radiopaque area surrounding the apical region of the distal root of tooth #36, with periodontal ligament and lamina dura being preserved. Thus, this information is corroborated by the literature, which shows that hypercementosis is generally evidenced on radiographic images showing thickened root surrounded by radiolucent periodontal ligament space and lamina dura intact.[1],[4],[9] In the majority of the cases, only a follow-up is needed rather than any treatment.[4]

Cementoblastoma is a rare odontogenic tumor originating from neoplastic cementoblasts in the periodontal ligament. This lesion is a tissue mass resembling the cementum, which will eventually reach the tooth's root.[1],[4],[7] In the present case, the patient's age and lesion location were corroborated by other studies in the literature, since cementoblastoma occurs more frequently in the second and third decades of life, with no gender predominance and mainly affecting lower molars and premolars. In addition, half of the cases involve permanent lower first molars.[4],[7],[8] These data have led to a differential diagnosis of benign cementoblastoma. Radiographically, this odontogenic tumor consists of a well-defined dense radiopaque mass fused with one or more roots and surrounded by a thin radiolucent line, thus simulating a hypercementosis.[1],[4],[6],[7],[8] Some signs such as root resorption, loss of root contour, disruption of lamina dura, bone expansion, pain and pulp vitality of the affected teeth are characteristic features of cementoblastoma. All these characteristics are corroborated by the findings observed in the present clinical case since radiographs show intact lamina dura and no root resorption. Therefore, all these data support a diagnosis of hypercementosis. The treatment of cementoblastoma consists of extracting the calcified volume and affected tooth.[1],[4],[7],[8] CBCT was performed for a better evaluation of the lesion as it enabled us to observe hyperdensity within the limits of the buccal and lingual cortical bones, including the presence of intact lamina dura and absence of root resorption, thus suggesting a diagnosis of hypercementosis. Due to the shapes of these lesions, CBCT becomes very important for the evaluation of their specific conditions and observation of their anatomical structures, thus allowing a better investigation for diagnosis to avoid incorrect interventions.[10]

Radiographically, hypercementosis and cementoblastoma are two lesions which can be confounded with each other, but they can be differentiated by the greater aggressiveness of the latter, which requires different ways of treatment.[1],[8] In the present case, the possible presence of cementoblastoma was ruled out based on the characteristics provided by clinical and imaging examinations, since disruption of lamina dura, expansion of cortical bone, root resorption and pain would all be necessary for a diagnosis of odontogenic tumor. Therefore, these clinical features are supported by the literature regarding the diagnosis of hypercementosis. MRI is neither a method of choice nor a routine examination for this type of lesion, and consequently, there are a few related studies using MRI in the literature. However, MRI provides a description of the lesion characteristics based on intensity signals, and as such, it can be an important resource for both dentistry and medicine. This method allows for a differential diagnosis of hypercementosis, which in general requires no aggressive intervention, differently from other pathological conditions (e.g., cementoblastoma).[10]

The evaluation for a correct diagnosis is a key for a successful treatment of the case. Detailed anamnesis and correct interpretation of imaging examinations will guide toward an adequate treatment since hypercementosis, and cementoblastoma are distinct entities with similar clinical and imaging characteristics, thus requiring different interventions, that is, a more conservative treatment for the former and a more invasive treatment for the latter depending on the extension of the lesion.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Napier Souza L, Monteiro Lima Júnior S, Garcia Santos Pimenta FJ, Rodrigues Antunes Souza AC, Santiago Gomez R. Atypical hypercementosis versus cementoblastoma. Dentomaxillofac Radiol 2004;33:267-70.  Back to cited text no. 1
    
2.
Xu L, Liu Y, Luo J, Jiang M, Guo W, Zheng G, et al. Analysis of clinical and imaging findings in cementoblastoma. Hua Xi Kou Qiang Yi Xue Za Zhi 2015;33:419-22.  Back to cited text no. 2
    
3.
Zaitoun H, Kujan O, Sloan P. An unusual recurrent cementoblastoma associated with a developing lower second molar tooth: A case report. J Oral Maxillofac Surg 2007;65:2080-2.  Back to cited text no. 3
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4.
Shoor H, Sujir N, Mutalik S, Pai KM. Hypercementosis: A rare finding in a patient with systemic lupus erythematosus. BMJ Case Rep 2014;2014. pii: bcr2013202370.  Back to cited text no. 4
    
5.
Zhou J, Zhao Y, Xia C, Jiang L. Periodontitis with hypercementosis: Report of a case and discussion of possible aetiologic factors. Aust Dent J 2012;57:511-4.  Back to cited text no. 5
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Subramani V, Narasimhan M, Ramalingam S, Anandan S, Ranganathan S. Revisiting cementoblastoma with a rare case presentation. Case Rep Pathol 2017;2017:8248691.  Back to cited text no. 6
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Nuvvula S, Manepalli S, Mohapatra A, Mallineni SK. Cementoblastoma relating to right mandibular second primary molar. Case Rep Dent 2016;2016:2319890.  Back to cited text no. 7
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Urs AB, Singh H, Rawat G, Mohanty S, Ghosh S. Cementoblastoma solely involving maxillary primary teeth – A rare presentation. J Clin Pediatr Dent 2016;40:147-51.  Back to cited text no. 8
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Jeddy N, Radhika T, Krithika C, Saravanan R, Prabakar R. Localized multiple cemental excrescences: A rare presentation of hypercementosis. J Clin Diagn Res 2014;8:ZD16-7.  Back to cited text no. 9
    
10.
El Achkar VN, Lopes SL, Pinto AS, do Prado RF, Kaminagakura E. Imaging aspects of palatal torus in cone beam computed tomography and magnetic resonance: Case report. Acta Stomatol Croat 2016;50:359-64.  Back to cited text no. 10
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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