Case report

A case of mistaken identity: periapicai cementai

dyspiasia in an endodontlcaily treated tooth
Wileox LR, Walton RE. A case of mistaken identity: periapicai
cemental dyspiasia in an endodonticaliy treated tooth. Endod
Dent Traumatol 1989; 5: 298-301.
Abstract - A case of a patient with a history of root canal
treatment and re-treatment and a persistent periapieal radiolucency is reviewed. Following surgery, biopsy material was submitted and diagnosed as periapieal eemental dyspiasia (PCD).
With careful diagnosis, PCD should be readily differentiated
from endodontic pathosis, thus avoiding unnecessary root canal
treatment. In this case, surgery was necessary to rule out other
inflammatory disease or benign odontogenie entities.

Periapicai cemental dyspiasia (PCD) (eommonly

referred to as eementoma) is estimated to occur in
2-3 teeth per 1000 (1). It occurs most often in Blaek
females, and in the fourth deeade of life (1, 2). It
predominates in the mandibular anterior region and
is usually an accidental (serendipitous) finding on
routine radiographs.
PCD is benign and represents the abnormal
growth of mesenchymal elements of the periodontal
ligament. As both cementum and bone are produced by ligamental eells, either of these mineralized tissues may be found in the lesion.
The lesion is deseribed as having 3 developmental
stages, each with certain radiographie characteristics (3, 4). The first, or osteolytic stage, involves the
proliferation of cementoblasts with aecompanying
resorption of alveolar bone. There is loss of periodontal ligament and lamina dura. In the second
stages droplets of eementum are deposited in the
lesion and may give the lesion a mixed radiolucent
and radiopaque appearance. In the third stage,
calcification occurs and a definite radiopacity is evident, which may be bordered by a thin radiolucent
line.
Endodontic periapicai pathosis tends to have 3
characteristie findings: a "hanging drop" appearance; a loss of lamina dura; and is centered over
the apex regardless of the angulation of the radiograph (5). In addition, there should be an etiology
for the necessary accompanying pulp necrosis. PCD
can mimic radiographic endodontic pathosis; inaccurate or careless differential diagnosis may result
298

Lisa R. Wiicox, Richard E. Waiton

Department of Endodonfics, Collage of Dentistry,
Universify of Iowa, Iowa Cify, Iowa, USA

Key words: cementoma: apical granuloma: periapicai lesion.

Dr. Lisa R. Wilcox, College of Dentistry, University
of Iowa, Iowa City, IA 52242, USA
Accepted tor ptiblication June 28, 1989.

Fig. 1. Preoperative radiograph. Note apparently underftlled

mesiaf canal.

Periapicai cementai dyspiasia

i n inappropriate treatment. The following case illustrates such a situation.
Case report
T h e patient, a 26-year-old white female, presented
with the chief complaint of occasional mild pain
t o mastication associated with the mandibular left
canine (tooth 22). The patient took no medication
a n d denied any systemic illnesses, including cardiovascular, renal, pulmonary, allergic, or infectious
disease. Her dental history was unremarkable except for a history of root canal treatment 5 years
earlier, in another city. At the time, she had experieneed one episode of brief sensitivity to cold in the
lower anterior region. The teeth were not carious,
restored, or traumatically injured. Apparently, a
radiograph had been made, a radiolucency was
noted, and no additional diagnosis was done. Based
o n radiographic appearance, root canal treatment
was completed on tooth 22. The patient's reeords
were unavailable for review.
Two years later, the periapicai radiolucency was

Fig. 3. Apparent healing at 2-NLai lecall. Ihe lamina dura is

present and the lesion has resolved.

I Fig. 2. Immediate postoperative radiograph, after apieoeetomies

I" a n d retrograde amalgam restorations. The lesion was removed
i; a n d submitted for biopsy.

Still present when she was examined on referral by

an endodontist. The tooth was re-treated conventionally because of the persistence of the lesion, with
the supposed etiology being an apparent underfilling of the mesial canal. After re-treatment, the
patient had occasional twinges of mild pain. A 2year recall examination showed no change in the
radiographie appearanee of the lesion. It had remained as a well-eireumseribed lesion approximately 10 mm in diameter with peripheral hyperostotic
borders. The periapicai lamina dura was not intact.
Two roots were present and appeared adequately
obturated, exeept that the mesial root appeared to
be filled well'short of the-radiographic apex.
Clinical examination was negative for swelling or
sinus tracts. There was slight tenderness to palpation and percussion. There was no mobility or
probing depths greater than 2 mm. Clinical diagnosis was chronic apical periodontitis. Surgery was
recommended to the patient because of the improbability of successful re-treatment.
The area was anesthetized and a full thickness
triangular flap reflected. The buecal cortical plate
was intact so a bony window was created. The
299

Wiicox & Waiton

lesion was easily removed. The consistency of the
lesion was granular, and there was less hemorrhage
than is normally ereated in removing inflammatory
lesions. Apicoectomies with retrograde amalgam
restorations were performed. Healing was uneventful.
The biopsy report gave the diagnosis as a fibroosseous lesion: periapieal eemental dyspiasia. Histologically, the seetions showed cellular fibro-collagenous connective tissue containing numerous, variably sized, rounded to irregularly shaped to occasionally linear masses of mineralized tissue. The
larger masses eontained cytes within lacunae. Areas
of peripheral blasts were also seen on the calcified
masses. The mineralized tissue had an irregular
woven appearance under polarized light. There was
no indieation of inflammation.
At 2-year recall, the patient was asymptomatic.
There was no pain to percussion or palpation, no
mobility or probing depths greater than 2 mm. The
lesion had completely healed and the lamina dura
had regenerated in the apical area.

Fig. 5. High niagiiilication of histopathologie specimen. Centered

i.s a mass of mineralized tissue. Note ihe woven appearanee, the
enelosed eytes in laeunae, and peripheral blasts. H & E (original
magnification: x 160).

Discussien

Fig. 4. Histopathologic speeimen. Note the masses of mineralized

tissue (arrows) within a fibrous, uninOamed stroma. This is a
charaeteristie appearance ofa fibro-osseous lesion. H & E (original magnification: x 6 0 ) .

300

This case illustrates the importance of careful diagnosis prior to root canal treatment. Many radiographie entities mimic endodontic periapieal inflammatory lesions, including normal anatomy, malignancies, and benign odontogenic and nonodontogenie tumors (5). These non-endodontie
entities are usually diflerentiated by determining
pulp responsiveness. In virtually all instances, the
pulp of a tooth must be necrotic in order to cause
enough apical bone resorption to be seen as a periapieal inflammatory lesion. Therefore, if the tooth
responds to pulp testing, root canal treatment will
not be effective in resolving the lesion.
A case is presented in which the prineipal diagnostic test (i.e., pulp vitality) could not be performed due to previous endodontic treatment and
laek of a reliable history. While absence of repair
beeause of inadequate root canal treatment could
not be ruled out as a factor, presumably root canal
treatment had been initiated, based on radiographic

Periapicai cementai dyspiasia

findings

alone.

The

periapicai

entity

that

was

treated originally was actually periapicai cemental

.

'

J r

dyspiasia.
RofOrOnCeS
L CHAUDHRY AP, SPINK J H , GORLIN RH. Periapieal fibrous

dyspiasia (cementoma). J Oral Surg 1958; 16: 483-8.

2. ZEGARELLI EV, KUTSCHER AH, NAPOLI N , IURONO F,

HOFFMAN P The cemenloma. Oral Surg Oral Med Oral Pathol

{.J^T?'^' , , ,

,,

, , r

i ,

3 SHAFER WG, HINE MK, LEVY BM. A textbook of orat pathology.

3rd ed. Philadelphia: WB Saunders, 1974; 267-8.

4. HOFFMAN S,JACOWAYJR, KROLLS SO. Intraosseous andparo^''^"' tumors of the jaws. Washington, DC: Armed Forces Institute of Pathology, 1987; 133-5.
5. TORABINEJAD M, WALTON RE. Pulp and periapicai pathosis.

In: WALTON RE, TORABINEJAD M , eds. Principles and practice

of endodontics. Philadelphia: WB Saunders, 1989; 53-68.

301