|Year : 2015 | Volume
| Issue : 1 | Page : 160-163
Hypercementosis: Review of literature and report of a case of mammoth, dumbbell-shaped hypercementosis
Vijay Raghavan1, Chandan Singh2
1 Department of Oral Medicine and Radiology, Seema Dental College and Hospital, Rishikesh, Uttarakhand, India
2 Private Practitioner, Rishikesh, Uttarakhand, India
|Date of Submission||22-Dec-2014|
|Date of Acceptance||16-Sep-2015|
|Date of Web Publication||12-Oct-2015|
Department of Oral Medicine and Radiology, Seema Dental College and Hospital, Rishikesh, Uttarakhand
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Hypercementosis is a non-neoplastic condition in which excessive cementum is deposited in continuation with the normal radicular cementum. Although some cases of hypercementosis are idiopathic, this condition is associated with several local and systemic factors such as supra-eruption of a tooth, inflammation at the apex of a tooth, traumatic occlusion, Paget's disease, etc. Hypercementosis may be isolated, involve multiple teeth, or appear as a generalized process. Posterior teeth are more commonly involved. The radiographic appearance of hypercementosis is an altered shape of the root with maintenance of normal relationship of the shadows of the periodontal membrane and lamina dura. The histologic study of teeth with hypercementosis shows that the cementum formed is usually osteocementum (acellular cementum). The differential diagnosis may include any radiopaque structure that is seen in the vicinity of the root, such as a dense bone island or mature cemento-osseous dysplasia. Patients with hypercementosis require no treatment. Because of a thickened root, occasional problems have been reported during the extraction of an affected tooth. Herein, an interesting case of a mammoth, dumbbell shaped hypercementosis associated with maxillary third molar is reported.
Keywords: Cementum, hypercementosis, osteocementum, Paget′s disease, radicular
|How to cite this article:|
Raghavan V, Singh C. Hypercementosis: Review of literature and report of a case of mammoth, dumbbell-shaped hypercementosis. J Indian Acad Oral Med Radiol 2015;27:160-3
|How to cite this URL:|
Raghavan V, Singh C. Hypercementosis: Review of literature and report of a case of mammoth, dumbbell-shaped hypercementosis. J Indian Acad Oral Med Radiol [serial online] 2015 [cited 2019 Sep 18];27:160-3. Available from: http://www.jiaomr.in/text.asp?2015/27/1/160/167154
| Introduction|| |
Hypercementosis (cemental hyperplasia) is a non-neoplastic deposition of excessive cementum that is continuous with the normal radicular cementum.  Although some cases of hypercementosis are idiopathic, certain circumstances favor the association with hypercementosis, including the following:
- Supra-eruption of a tooth because of the loss of an antagonist tooth,
- Inflammation at the apex of a tooth,
- Traumatic occlusion, and
- Systemic diseases such as Paget's disease, toxic goiter, acromegaly, and gigantism. 
Hypercementosis may be isolated, involve multiple teeth, or appear as a generalized process. In a study of more than 22,000 affected teeth, the mandibular molars were affected most frequently, followed by the mandibular and maxillary second premolars and the mandibular first premolars. In this study, a 2.5% mandibular prominence was noted.  In radiographs, the excess cementum may be of two types:
- The secondary cementum is of the same density as the primary cementum and dentin and
- The secondary cementum appears less dense and is clearly differentiated from the primary cementum and dentin. 
Root areas affected by hypercementosis are separated from the periapical bone by a normal-appearing periodontal ligament space; the surrounding lamina dura appears normal as well. 
| Case Report|| |
A 49-year-old male patient reported with the chief complaint of moderately severe pain related to upper right last tooth. Patient was unable to chew from the right side because of severe pain associated with chewing. Clinical examination revealed deep proximal caries in third molar which was supra-erupted and tender to percussion. Diagnosis of acute periapical periodontitis related to 28 was made and extraction of the offending tooth was advised. Radiograph was not advised as diagnosis was obvious and the third molar was supra-erupted.
What was expected to be a simple extraction turned out to be the most difficult one. Lot of effort and time was required to luxate the tooth, and removal in a single piece was achieved after 40 min. The extracted tooth [Figure 1] had a mammoth disto-buccal root in the shape of dumbbell. The radiograph of the extracted tooth [Figure 2] and [Figure 3] showed large dumbbell-shaped disto-buccal root with a clear outline of original root within it. The excess tissue deposited was slightly less radiopaque. The reported case emphasizes the need for advising a radiograph in all cases prior to extraction.
|Figure 2: Radiograph of the extracted third molar showing deep proximal caries and dumbbell-shaped hypercementosis|
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|Figure 3: Radiograph of the extracted third molar from a different angle showing the outline of original root within excess cementum deposited|
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| Discussion|| |
Cementum resembles bone in that it is not a static tissue but is constantly resorbed or replaced. Fragments are lost in injuries which are too slight to fracture the root or to produce definite clinical evidence. In periodontal disease, cementum may be resorbed and replaced. Passive eruption is partly due to the addition of cementum to the apex of the root. None of these changes appear in radiographs and it is only the gross abnormalities which do.  Under conditions which are not understood, additional cementum is laid down on the root. Generally speaking, excessive deposits of cementum are fairly common, notably in adult teeth. The varying thickness of the cementum deposited on the roots has been discussed by several authors. ,, It is generally recognized that two types of cementum are deposited on the root surfaces. As stated by Orban,  Kronfeld,  and others, one may distinguish between primary or acellular cementum and, on the other hand, secondary or cellular cementum. Acellular cementum is observed as a fairly thin layer covering the dentin of the root. Secondary cementum is, as a rule, deposited as a layer covering the acellular cementum. Under normal conditions the secondary or cellular cementum is formed notably in the bifurcation area and in the middle and apical thirds of the root. 
Supra-eruption of a tooth because of an antagonist is accompanied by hypercementosis, apparently as a result of an inherent tendency for the maintenance of the normal width of the periodontal membrane.  Periapical inflammation resulting from pulpal infection sometimes stimulates excessive formation of cementum. The cementum is not laid down at the apex of the tooth directly adjacent to the area of inflammation. Instead, the cementum is laid down on the tooth surfaces at some distance from the apex of the tooth, forming a collar-shaped hypercementosis. The collar shape results from the fact that irritation from chronic apical periodontitis decreases with increasing distance from the apex. At a certain point, it acts as a stimulant for cementum formation, rather than as an inhibitor. 
Rushton and Cooke (1959) stated that mild traumatic occlusion may cause hypercementosis. In rare cases, excessive occlusal trauma may lead to the formation of serrated hypercementosis (cemental spikes) which follows the course of Sharpey's fibers.  As with resorption, a direct causal relationship with periodontal diseases is not proven, but hypercementosis is seen occasionally on teeth with bone loss. It may be a response to inflammation or to the increased occlusal loading on a tooth with attachment loss. 
Osteitis deformans or Paget's disease of bone is a generalized skeletal disease characterized by deposition of excessive amounts of secondary cementum on the roots of the teeth and by the apparent disappearance of the lamina dura of the teeth, as well as by other features related to the bone itself. Although the bone changes are the most prominent features of the disease, generalized hypercementosis should always suggest the possibility of the presence of osteitis deformans. 
On rare occasions, hypercementosis is so extensive as to cause the fusion of two or more adjacent teeth, by a layer of cementum, a condition termed as acquired concrescence [Figure 4]. Teeth with hypercementosis have no significant signs or symptoms. The only practical clinical significance of hypercementosis is the difficulties that may be encountered in extracting such teeth. This may indicate the true biologic significance of hypercementosis, which probably is to anchor the tooth in the socket more securely.  Sectioning of the tooth may be necessary in certain cases to aid in removal. 
|Figure 4: Radiograph showing hypercementosis involving multiple anterior teeth causing acquired concrescence|
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The differential diagnosis may include any radiopaque structure that is seen in the vicinity of the root, such as a dense bone island or mature cemento-osseous dysplasia. The differentiating characteristic is the presence of the periodontal membrane space around the hypercementosis. There may be a resemblance to a small cementoblastoma. Occasionally, a severely dilacerated root may have the appearance of hypercementosis. 
Souza et al.  reported an atypical case of hypercementosis with similarities to cementoblastoma. According to them, cementoblastoma and hypercementosis are lesions associated with tooth roots that may, in some circumstances, challenge the clinician on their diagnosis. Although hypercementosis and cementoblastoma are typical conditions with distinct clinical evolution, atypical cases may present diagnostic difficulties. Because cementoblastoma is a neoplasm with unlimited growth potential, the usual treatment is complete surgical removal, , while no treatment is required for hypercementosis.
| Conclusion|| |
A very unusual case of mammoth, dumbbell-shaped hypercementosis in a 49-year-old male patient is reported. Literature on hypercementosis is reviewed. Etiology, radiographic appearances, and differential diagnosis are discussed. Importance of pre-extraction radiographs in all cases is stressed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology. 3 rd
ed. New Delhi: Elsevier; 2009. p. 96-7.
Langlais RP, Langland OE, Nortje CJ. Diagnostic Imaging of the Jaws. 1 st
ed. Philadelphia: Williams & Wilkins; 1995. p. 187-9.
Haring JI, Howerton LJ. Dental Radiography. Principles and Techniques. 3 rd
ed. New Delhi: Saunders; 2007. p. 489-90.
Worth HM. Principles and Practice of Oral Radiologic Interpretation. 1 st
ed. Chicago: Year Book Medical Publishers; 1963. p. 178-81.
Dewey KW. Normal and pathological cementum formation. Dent Cosmos 1926;68:560-85.
Kronfeld R. The biology of cementum. J Am Dent Assoc 1938;25:1451-61.
Thoma KH, Goldman HM. The pathology of dental cementum. J Am Dent Assoc 1939;26:1943-53.
Orban B. Oral Histology and Embryology. St. Louis: C.V. Mosby; 1944. p. 151-71.
Kronfeld R, Boyle PE. Histopathology of the Teeth and their Surrounding Structures. 3 rd
ed. Philadelphia: Lea & Febiger; 1949. p. 212-23.
Humerfelt A, Reitan K. Effects of hypercementosis on the movability of teeth during orthodontic treatment. Angle Orthod 1966;36:179-89.
Horner K, Rout J, Rushton VE: Interpreting Dental Radiographs. 1 st
ed. London: Quintessence Publishing Co. Ltd.; 2002. p. 86.
Rajendran R, Sivapathasundharam B. Shaffer's Textbook of Oral Pathology. 5 th
ed. New Delhi: Elsevier; 2006. p. 585-7.
White SC, Pharoah MJ. Oral Radiology. Principles and Interpretation. 4 th
ed. St. Louis: Mosby; 2000. p. 334-5.
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.
Larsson A, Forsberg O, Sjögren S. Benign cementoblastoma - Cementum analogue of benign osteoblastoma? J Oral Surg 1978;36:299-303.
Ulmansky M, Hjørting-Hansen E, Praetorious F, Haque MF. Benign cementoblastoma. A review and five new cases. Oral Surg Oral Med Oral Pathol 1994;77:48-55.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]