Hypercementosis - Excessive Deposition of Cementum on Tooth Roots

What Is Cementum?

Cementum is the calcified covering of a tooth root. Its deposition is an ongoing process that occurs at different rates throughout life. Cementum formation occurs most quickly in the apical regions, where it compensates by tooth eruption, which compensates for attrition (loss of tooth structure due to tooth-on-tooth contact). The cementum thickness on the coronal half of the root ranges from 16 to 60 microns, which is roughly the thickness of a hair. The apical third and furcation areas have the greatest thickness (150 to 200 microns). It is thicker on distal surfaces than on mesial surfaces, which is most likely due to functional stimulation from mesial drift over time. Between the ages of 11 and 70, the average thickness of the cementum triples, with the greatest increase occurring in the apical region. Cementum thickness abnormalities can range from the absence or scarcity of cellular cementum (cemental aplasia or hypoplasia) to excessive cementum deposition (cemental hyperplasia or hypercementosis).

What Is Hypercementosis?

Hypercementosis is a non-neoplastic condition characterized by overproduction or increased proliferation of cementum on the tooth root. It can affect a single tooth or several teeth. The condition is asymptomatic and is discovered through a radiographic examination. This can cause mild to severe misshaping of the tooth root, giving it a bulbous or lobular appearance. With thelamina dura and periodontal ligament(a ligament that anchors the tooth to the jaw bone) space visible around the excess cementum, it will appear slightly less radiopaque than thedentin (tooth layer below the enamel).The additional cementum usually has a smooth outline, but it can also be irregular. Although the exact cause is unknown, hypercementosis could be a reaction to inflammation or a loss of function of a supra erupted tooth due to the absence of an opposing tooth.

What Can Hypercementosis Do to Your Teeth?

Hypercementosis has been linked to fractured teeth or teeth in heavy occlusion. Although the majority of cases are idiopathic, several local and systemic factors have been linked to this condition. Asymptomatic hypercementosis is usually discovered during routine examination and does not require treatment. However, dental radiographs such as orthopantomography and periapical films can detect it. Cementum spike formation is a rare condition characterized by the appearance of small spikes or outgrowths of cementum on the root surface. Cemental spikes have been linked to excessive occlusal stress or tension from orthodontic appliances, most likely as a result of irregular cementum deposition in a focal group of periodontal ligament fibers, coalescence of cementiclesthat adhere to the root, or calcification of periodontal fiber at the site of insertion into the cementum. The biological width between the root surface, the periodontal ligament, and the alveolar bone is not altered by hypercementosis.

What Are the Causes of Hypercementosis?

Inflammation secondary to pulpal or periodontal disease, occlusal trauma, tooth mobility, tooth transplantation, and root fracture repair has all been linked to hypercementosis. Some of the systemic conditions associated with it are-

• Goiter.

• Acromegaly (a disorder caused due to increase in the production of growth hormone).

• Arthritis.

• Rheumatic fever.

• Gardner's syndrome (a genetic disorder characterized by multiple colorectal polyps).

• Calcinosis (calcium salts are deposited in the skin and subcutaneous tissue).

• Vitamin A deficiency.

• Paget's disease (a chronic disease of the skeleton).

Except for Paget's disease, which is strongly linked to this condition, the majority of the other conditions have a weak association. In patients with a specific history and clinical findings, other systemic factors associated with hypercementosis can be ruled out. In endodontic practice, tooth root hypercementosis is a common finding.

What Are the Types of Hypercementosis?

Hypercementosis can be found at the root apex, any part of the root surface, or the entire root surface, and it is classified morphologically into the following types:

• Club-shaped.

• Circular cemental hyperplasia.

• Diffuse hypercementosis, in which the root takes on the shape of a club.

• Focal or localized hypercementosis is confined to a single root surface.

What Are the Clinical and Radiographical Features of Hypercementosis?

Radiographically, affected teeth show thickening or blunting of the root, but determining the exact amount of increased cementum can be difficult because cementum and dentin have similar radiodensities. In addition, the radiolucent PDL (periodontal) space and the adjacent intact lamina dura surround the enlarged root. On rare occasions, the enlargement may be significant enough to indicate the presence of a cementoblastoma. However, cementoblastoma is usually distinguished by associated pain, cortical expansion, and continued enlargement. Hypercementosis can be isolated, involve multiple teeth, or manifest as a systemic condition.

What Are the Histopathological Features of Hypercementosis?

The root's periphery has an excessive amount of cementum deposited over the original layer of primary cementum. Excess cementum may be hypocellular or have cellular cementum areas that resemble bone (osteo cementum). The material is frequently arranged in concentric layers and may be applied over the entire root or only to the apical portion. Distinguishing between dentin and cementum is often difficult with routine light microscopy, but viewing the section with polarized light helps to distinguish between the two different layers.

How Can Hypercementosis Be Diagnosed?

• Radiographic Appearance: Excessive buildup of tooth density material (cementum) around the entire or parts of the tooth root.

• When there is hypercementosis, the difference in density between dentin and cementum (which is usually not visible) becomes visible.

• It could be irregular or smooth.

• A bulbous enlargement of the root is observed.

• Location: It can be limited to the apical third of the tooth root or can extend the entire length of the tooth root.

• The mandible is affected twice as frequently.

• Molars are the most affected, followed by premolars.

• Preferred Imaging Modality: Periapical radiography allows for a more accurate assessment of the periodontal ligament (PDL) space and the lamina dura relationship.

What Is the Differential Diagnosis of Hypercementosis?

Any radiopaque structure seen near the root, such as a dense bone island or mature cemento-osseous dysplasia(jaw disorder in which normal bone is replaced by connective tissue matrix), may be considered in the differential diagnosis. The presence of a periodontal membrane space around the hypercementosis is the distinguishing feature. There may be a resemblance to a small cementoblastoma. Hypercementosis may appear on a severely dilacerated root on rare occasions.

Conclusion:

Hypercementosis patients usually do not require treatment. However, cemental deposits cause bulbous enlargements on the roots, which can impede extractions, especially if adjacent teeth become fused (concrescence). It may also cause pulpal necrosis (pulp tissue death)by obstructing blood supply through theapical foramen. In the occasional complications, where the extraction of an affected tooth due to a thickened root is obstructed, tooth sectioning may be required to help in removal.