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Case Report

Hypercementosis: Review of literature and report

of a case of mammoth, dumbbell-shaped
hypercementosis
Vijay Raghavan, Chandan Singh1
Department of Oral Medicine and Radiology, Seema Dental College and Hospital, 1Private Practitioner, Rishikesh,
Uttarakhand, India

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.
Key words: Cementum, hypercementosis, osteocementum, Paget’s disease, radicular

Introduction 2. Inflammation at the apex of a tooth,

3. Traumatic occlusion, and

H
ypercementosis (cemental hyperplasia) is a non- 4. Systemic diseases such as Paget’s disease, toxic
neoplastic deposition of excessive cementum goiter, acromegaly, and gigantism.[2]
that is continuous with the normal radicular
cementum.[1] Although some cases of hypercementosis Hypercementosis may be isolated, involve multiple
are idiopathic, certain circumstances favor the association teeth, or appear as a generalized process. In a study
with hypercementosis, including the following: of more than 22,000 affected teeth, the mandibular
1. Supra-eruption of a tooth because of the loss of an molars were affected most frequently, followed by
antagonist tooth, This is an open access article distributed under the terms of the
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DOI: How to cite this article: Raghavan V, Singh C. Hypercementosis:
10.4103/0972-1363.167154
Review of literature and report of a case of mammoth, dumbbell-shaped
hypercementosis. J Indian Acad Oral Med Radiol 2015;27:160-3.

Address for correspondence: Dr. Vijay Raghavan, Department of Oral Medicine and Radiology, Seema Dental College and
Hospital, Rishikesh, Uttarakhand, India. E-mail: drvijayr53@gmail.com
Received: 22-12-2014 Accepted: 16-09-2015 Published: 12-10-2015

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Raghavan V and Singh C: Hypercementosis

the mandibular and maxillary second premolars and The varying thickness of the cementum deposited on
the mandibular first premolars. In this study, a 2.5% the roots has been discussed by several authors.[5-7] It is
mandibular prominence was noted.[1] In radiographs, generally recognized that two types of cementum are
the excess cementum may be of two types: deposited on the root surfaces. As stated by Orban,[8]
1. The secondary cementum is of the same density as
the primary cementum and dentin and
2. The secondary cementum appears less dense and is
clearly differentiated from the primary cementum
and dentin.[2]

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.[3]

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 Figure 1: Photograph of the extracted third molar
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 [Figures 2 and 3] showed large dumbbell-shaped
disto-buccal root with a clear outline of original root Figure 2: Radiograph of the extracted third molar showing deep proximal
within it. The excess tissue deposited was slightly less caries and dumbbell-shaped hypercementosis
radiopaque. The reported case emphasizes the need for
advising a radiograph in all cases prior to extraction.

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.[4] Under conditions which are
not understood, additional cementum is laid down
on the root. Generally speaking, excessive deposits of Figure 3: Radiograph of the extracted third molar from a different angle
cementum are fairly common, notably in adult teeth. showing the outline of original root within excess cementum deposited

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Raghavan V and Singh C: Hypercementosis

Kronfeld,[9] 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.[10]

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.[2]
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.[2]
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. [2] 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.[11]
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.[12]
Figure 4: Radiograph showing hypercementosis involving multiple
anterior teeth causing acquired concrescence
tooth in the socket more securely. [2] Sectioning of
the tooth may be necessary in certain cases to aid in
removal.[1]
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.[13]
Souza et al.[14] 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,[15,16] while no treatment is required for
hypercementosis.
Conclusion

On rare occasions, hypercementosis is so extensive as A very unusual case of mammoth, dumbbell-shaped

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
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.
Financial support and sponsorship
Nil.

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Raghavan V and Singh C: Hypercementosis

Conflicts of interest 9. Kronfeld R, Boyle PE. Histopathology of the Teeth and their
There are no conflicts of interest. Surrounding Structures. 3rd ed. Philadelphia: Lea & Febiger;
1949. p. 212-23.
10. Humerfelt A, Reitan K. Effects of hypercementosis on the
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