Cementum Malformations-Diagnostic Dilemma: Study in Western Maharashtra Population.

AIM: The present study was study to observe incidence of cemental malformations related to mandibular molar roots.
MATERIALS AND METHODS: All cases requiring radiographs of mandibular molars reporting to author during 2011-2019 were included in this study. Mandibular molars had been observed for any radiographic malformations. Any such alterations were noted.
RESULTS: Author has screened about 522 intraoral periapical radiographs in this study. A total of 63 cases of root malformations reported with two cases of cementoma were observed in this study. Both these cases were diagnosed as benign cementoblastoma (BC) on excisional biopsy.
CONCLUSION: In this study, we have observed that incidence of cemental malformations is 1.2% and of BC is 0.38% as compared to overall incidence of 1%-6% in Western Maharashtra. Copyright:

INTRODUCTION

Mandibular molars are always an area of interest for root pathologies. Pathologies associated with molars range from root dilacerations to involvement in KOT. Errors in the development of root alone or error in the development of the entire tooth can lead to root malformations.[1]

Root formation is controlled by Hertwig's epithelial root sheath (HERS). HERS stimulates radicular dentin formation. It also itself take part in cementum development.[2]

This study was done with an aim to judge the incidence of root malformations related to mandibular molar teeth in the population of Western Maharashtra for the first time.

MATERIALS AND METHODS

This study was carried out on outpatients reporting to principal investigator. All patients reporting to authors on private basis requiring intraoral periapical radiographs of mandibular molars had been included in this study. A total of 522 Intra Oral Periapical Radiographs (IOPA) radiographs had been screened by authors over [Tables 1 and 2] a period of 8 years. All radiographs were screened for malformations. The root outline, gross morphology, and any abnormality related to root of mandibular molars have recorded. All radiographs had been returned to patient after recording. All the records were assessed for any alterations in root morphology reported. The root morphologic alterations were categorized into seven categories, namely, roots dilacerations concrescence, accessory cusp, crown dilacerations, taurodontism, enamel pearl, and cementoma during assessment. All radiographs were assessed by naked eyes on X-ray viewer. The assessment was carried out by two observers in double-blind manner to prevent bias.

Table 1

Age distribution of samples

Age groups ( years of age)	Samples
12-20	45
20-30	69
30-40	82
40-50	95
50-60	94
60-70	82
Above 70	55
Total	522

Table 2

Sex distribution of samples

Sex	Samples
Male	203
Female	319

Reporting of the radiographs with possible malformation was done by separate observer. The root outline was checked for cemental malformations or alterations.

We had found out benign cementoma in two cases. These require surgical intervention. Detailed history of these twp patients was recorded. First of it was a 75-year-old female native of Karad, state of Maharashtra in India. Gnawing pain in the left mandibular back tooth region was present since 6 months. The pain was mild. Buccal swelling was seen in the left lower molar region measuring about 1 cm. Radiopaque mass of 1.5 cm was seen in relation to root of 36. Radiolucent line was seen around the radioopacity [Figure 1]. Vitality test was done using electric pulp tester which revealed vital 36. No other abnormalities were detected except poor oral hygiene.

Figure 1

Radiograph of the area demonstrated a circular radiopaque mass, associated with the root of the 36

The lesion was provisionally diagnosed as cementome based on radiographic picture. Surgical options explained to the patient. Surgical removal with enucleation of lesion associated was planned. Envelop flap was planned after giving sulcular incision. Differentiation of the lesion from underlying bone was done. The lesion had perforated the buccal cortex. Margins of the lesion seemed to be detached from adjacent bone. Tooth was subjected to mild buccal pressure. Enucleation of the mass was done along with the tooth [Figure 2]. Bone cavity was packed with gel foam for hemostasis. Noncarious mandibular molar was seen on gross examination. Spherical bony mass was seen attached to root apex. The mass attached was bony hard on palpation. A specimen radiograph was taken which shown resorption of the apical third of the root. Mass seemed to be fused with root cementum with no demarcation [Figure 3]. Histologically, the lesion consisted of broad trabeculae of cellular cementum. Cemental islands were observed in vascular stroma. Multinucleated cementoclasts can be appreciated. Radiating columns of cementum seen at periphery. Postoperative healing took place uneventfully.

Figure 2

The tooth with the associated mass attached in toto

Figure 3

A radiograph of the specimen had revealed resorption of the apical third of the root

Second case reported was of 68-year-old male patient with complaints of pain and swelling in 38 regions for 5 days. On clinical examination, there was no caries associated with 37 and 38. Thirty-eight were tender on percussion and were having Grade I mobility. The patient do not had any prodromal symptoms. On orthopentamogram, 38 were appeared to be morphologically atypical [Figure 4]. The radiographic picture was depicting extreme distal tilt in the distal root of 38. The coronal pulp chamber was seemed to be obliterated by radiographic overlap. The furcation area of 38 was seemed to have radiopaque extention toward apical area, which seemed to be an additional underdeveloped root. The periapical area related to both the roots of 38 was showing radiolucent lesion measuring about 1 by 1 cm. The radiolucency was not corticated deleting possibilities of cyst. The mesial root of 38 was dilacerated at an angle of almost 90°. The remaining teeth were seemed to be normal.

Figure 4

Radiograph case 2

The provisional diagnosis was made of cementoma on characteristic radiographic picture. Surgical removal with enucleation of lesion associated was planned. Envelop flap was planned after giving sulcular incision. Differentiation of the lesion from underlying bone was done. The lesion had perforated the buccal cortex. Margins of the lesion were seemed to be detached from adjacent bone. Tooth was subjected to mild buccal pressure. Enucleation of the mass was done along with the tooth [Figure 5]. Bone cavity was packed with gel foam for hemostasis.

Figure 5

The tooth with the associated mass attached in toto

Statistical analysis

The data were analyzed using the statistical software SPSS version 20 (SPSS, Inc., Chicago, IL, USA). Descriptive statistics were used to summarize the results.

RESULTS

The observations for the IOPA radiographs were classified in seven categories, namely, root dilacerations concrescence, accessory cusp, crown dilacerations, taurodontism, enamel pearl, and cementoma. The number of samples showing these malformations has been mentioned in Table 3 and Graph 1. Root dilacerations was observed to be the most common root anomaly with the incidence of about 8%. Taurodontism was observed to be second most common with the incidence of 1.5%. Concrescence was observed as third most common anomaly in this study with the incidence of 0.95%. Enamel pearl was observed in 0.76% of cases, while cementoma and accessory cusp were observed in 0.38% of cases. The results were analyzed by separate analyzer to avoid investigator's bias.

Table 3

Cemental malformations incidence observed

Cemental anomaly	n (%)
Root dilacerations	42 (8.04)
Concrescence	5 (0.95)
Accessory cusp	2 (0.38)
Crown dilaceration	0 (0)
Taurodontism	8 (1.5)
Enamel pearl	4 (0.76)
Cementoma	2 (0.38)
Total	63 (12.06)

Graph 1

Cemental malformations distribution among root malformations

DISCUSSION

Errors in development of root alone or error in the development of the entire tooth can lead to root malformations.[1] Cementum malformations are not encountered routinely. Symptom-free malformations seldom go unnoticed. These malformations were diagnosed on routine radiographic examination by dentist. Many times, area of interest for the radiograph is completely different than the malformations.

In this study, we have found seven morphological alterations of teeth. The incidence observed was between 0.38% and 8.04%. These malformations have not been classified in this population in any previous studies.

In both the cases of cementoma, the patient was symptomatic. Both the teeth were free from caries. No periodontal involvement or mobility was noticed. The excised specimen had shown that the cementoma was attached to the tooth root without any line of demarcation. This was suggestive of source of lesion being cementum.

The benign cementoblastoma (BC) comprises about 1%–6.2% of all odontogenic tumors. It is true neoplasm of cementum origin according to the WHO.[3] It generally occurs in younger age group. Dewey in 1927 gave the first description.[1] It is attached to the roots of teeth. First molar in the lower jaw is most frequently associated with this. Mandibular second premolars are second most common. Mesenchymal tissue is responsible for BC.[4] It is seen in the ratio of 3:1 in mandible when compared to maxilla. Cementoblastoma associated with an impacted or partially impacted tooth is rare.[1]

Pain and swelling may be present if at all, it is symptomatic.[4] It has unlimited growth potential.[3] Expansion or swelling of the jaw segment or compression of the inferior alveolar nerve is also reported in literature. Radiographic radiopacity surrounded by a peripheral radiolucent halo is a characteristic feature.

Only five cases in 56,836 samples of BC were reported in over the 10-year period from 1990 to 1999, inclusive in a survey of the diagnostic biopsy service at the faculty of dentistry of the University of Toronto Mild pain and Bony Swelling are most common symptoms reported. No racial or gender predilection was reported.[5] A single tooth in the premolar–molar area was reported in 90% of cases.

Pathognomonic radiographic appearance is seen in BC. Well-defined solitary circular radiopacity surrounded by a radiolucent halo been observed.[6] The lesion is fused to root(s) of the associated tooth. Root resorption may be seen. Mixed radiolucent-radiopaque quality often with a radiating pattern is seen.

CONCLUSION

In this study, we have observed the incidence of cemental malformations is 1.2% and of BC is 0.38% as compared to overall incidence of 1%–6% in Western Maharashtra. This incidence we have calculated was among 522 IOPA screened personally by author during span of 8 years. More long-term screenings of larger population need to be done.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.