The Importance of the Three-Dimensional Image in the Early Diagnosis of Cementoblastoma

doi:10.4236/ojrad.2012.21002

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Open Journal of Radiology, 2012, 2, 10-13

http://dx.doi.org/10.4236/ojrad.2012.21002 Published Online March 2012 (http://www.SciRP.org/journal/ojrad)

The Importance of the Three-Dimensional Image in the

Early Diagnosis of Cementoblastoma

Tânia Mara Pimenta Amaral1, Cláudia Silami de Magalhães2, Allys o n Nog u e i r a2,

Ricardo Alves Mesquita1, João Batista de Freitas1, Maria Cássia Ferreira Aguiar1*

1Department of Oral Pathology and Surgery, School of Dentistry, Universidade Federal de Minas Gerais,

Belo Horizonte, Brazil

2Department of Restorative Dentistry, School of Dentistry, Universidade Federal de Minas Gerais,

Belo Horizonte, Brazil

Email: *[email protected], [email protected]

Received December 29, 2011; revised January 27, 2012; accepted February 4, 2012

ABSTRACT

The cementoblastoma is a very rare odontogenic neoplasm characterised by the formation of cementum-like tissue in

connection with the root of a tooth. An 18-year-old boy was referred to the Clinic of Oral Pathology of the School of

Dentistry, Universidade Federal de Minas Gerais, Brazil, complaining of an irradiating, itching pain from the region of

the lower right first molar. He reported that the symptoms began three months prior, with a gradual increase in intensity

during this period. Th e pain episod es were of sh ort dur ation, with characteristics o f toothach e originating fro m the pulp.

Upon intra-oral clinical examination, an open bite and slight increase in volume at the buccal alveolar region of the

lower right first molar was observed. He also reported palpation and percussion pain symptoms in this region. Electrical,

heat and cold pulp vitality te sts were performed, and the tooth was vital. Periapical and panoramic radiographs sho wed

radiolucent images with diffuse, poorly defined borders at the mesial root periapex extending to the interradicular re-

gion suggesting an inflammatory periapical lesion. In this early presentation, the three-dimensional image was funda-

mental to the final diagnosis of cementoblastoma.

Keywords: Cementoblastoma; Cone Beam CT; Dental Radiography

1. Case Report

An 18-year-old boy was referred to the Clinic of Oral

Pathology of the School of Dentistry, Universidade Fede-

ral de Minas Gerais, Brazil, complaining of an irradiating,

itching pain from the region of the lower right first molar.

He reported that the symptoms began three months prior,

with a gradual increase in intensity during this period.

The pain episodes were of short duration, with character-

ristics of toothache originating from the pulp. There was

a gradual increase in pain intensity during this period.

His medical history was non-contributory. The physical

examination showed a well-developed, well-nourished

boy. On extraoral evaluation, his expression and the co-

lour of his face were normal.

The oral ex amination reve aled an open bite and s evere

pain upon palpation in the mucosa lining the apices of

the lower right first molar. The tooth was non-mobile and

sensitive to percussion test. A slight bony swelling and

tenderness in the right lower posterior buccal gingival

tissue were observed. The gingival tissue had a normal

aspect (Figure 1(a)). There was no history of previous

infection associated with this tooth. A periapical and a

panoramic radiograph revealed a slight radiolucent area

that showed images of ill-defined margins related to the

tooth root, associated with a mild bony sclerosis around

the periapex of the lower right first molar and with

thickening of the periodontal space of the distal root. The

trabecular bone at the interradicular region of the lower

right first molar tooth was slightly different from the al-

veolar trabecular bone adjacent to the mesial and distal

roots of the lower right first molar. In addition, there was

a radiolucent image, which was diffuse and poorly de-

fined, in the furcation area (Figure 1(b)). Based on the

clinical and radiologic features of the lesions, a periapical

change of inflammatory origin was suspected, but the

tooth responded positively to electrical, heat and cold

tests of vitality. In order to see major detail of the bone

lesion and to obtain the lesion dimensions, cone-beam

computed tomography (CBCT) was performed.

The axial, sagittal and coronal planes showed a hy-

perdense, heterogeneous image, with irregular borders,

located at the interradicular region and attached to the

mesial and distal roots of the lower right first molar as-

*Corresponding author.

T. M. P. AMARAL ET AL. 11

Figure 1. (a) Intraoral view of the left lower quadrant

showing discrete swelling and a normal oral mucosa; (b) A

slight radiolucent area that showed images of ill-defined

margins related to the tooth root. A radiolucent point sug-

gests involvement of the furcation region; (c) A axial image

showed a slight cortical expansion and perforation of the

cortical buccal bone; (d), (e) The sagittal and coronal im-

ages showed a hyperdense, heterogeneous image of irregu-

lar borders associated with the hypodense line. The lesion

attached to the roots at an early stage of development; (f)

Tissue with a compact arrangement, presenting basophilic

deposits, interspersed with loose, cellularised connective

tissue that was poorly vascularised; (g) Surgical specimen

showing cementum-like tissue in connection with the root of

the right lower first molar (arrows); (h) Radiological follow-

up. Newly formed trabecular bone in the region of the lower

right first molar.

sociated with the hypodense line, represented in the to-

mographic image. The axial plane showed a slight corti-

cal expansion and perforation of the cortical buccal bone.

The CBCT images showed no root resorption (Figures

1(c), (d) and (e)). Osteoblastoma and osteosarcoma were

proposed as diagnostic hypotheses. Accordingly, we con-

ducted an incisional biopsy, which showed mineralised

tissue with a compact arrangement, presenting basop hilic

deposits, interspersed with loose, cellularised, poorly va-

scularised connective tissue (Figure 1(f)). Multinucle-

ated giant cells were observ ed in proximity to the minera-

lised tissue. Based on the clinical findings (imaging and

histopathology), a diagnosis of benign cementoblastoma

was made. Surgical removal of the lesion and the tooth

was performed; a peripheral osteotomy was also per-

formed. The piece was sent for histopathologic evalua-

tion, which confirmed the diagnosis (Figure 1(g)). The

patient returned for the consultation proservation six

months after surgery. A periapical radiograph showed no

evidence of recurrence (Figure 1(h)).

2. Discussion

Cementoblastoma is a slow-growing, benign odontogenic

tumour that arises from cementoblasts. Cementoblastoma

is rare and accounts for less than 1% of all odontogenic

tumours [1,2], exhibiting a relatively limited tendency to

recur and with unlimited growth potential [3,4]. This

tumor is characterised by the formation of cementum-like

tissue in connection with the ro o t of a tooth an d primarily

affects young adults in the second and third decades of

life [1,5]. Some studies have reported that cementoblas-

toma arises slightly more frequently in males [6], others

reported a predominance in females [1], whereas others

have foun d no difference between t he s ex es [7].

The mandible is the preferential site of occurrence,

with the first molar tooth being the most common tooth

involved [5,8]. Cementoblastomas associated with pri-

mary teeth are extremely rare lesions [3]. Expansion and

perforation of the cortex are n oted in a higher prop ortion

of patients with recurrent cementoblastoma [9]. Some

patients may also complain of associated pain with vary-

ing degrees of intensity and occasional paresthesia. The

pain is caused by occlusal pressure resulting from extru-

sion of the tooth caused by pressure from the tumor [10],

other patients may be completely asymptomic [11]. The

clinical and radiographic features may be varied, causing

difficulties in definitive diagnosis and patient manage-

ment. The diagnosis is rarely made before significant

bone expan s i on occurs [12].

In the present case, the radiographic presentation was

not the classic presentation reported by other authors: a

radiopaque mass most often fused with the root or roots

of a tooth, surrounded and limited peripherally by a ra-

diolucent halo [1,13]. On the contrary, the two-dimen-

sional image of the lower right first molar presented an

ill-defined radiolucent image associated with mild scle-

rosis. Based on these images, the diagnosis formulated was

an inflammatory cyst or a granuloma and focal cemento-

osseous dysplasia (FCOD) [6,12]. Inflammatory condi-

tions of the pulp were differentiated by performing tests

of pulp vitality, such as the electrical, heat and cold tests.

FCOD cannot be distinguished radiographically from an

early developing cementoblastoma; both would be asso-

ciated with vital teeth. The biopsy of FCOD will yield

gritty haemorrhagic fragments of tissue because the le-

sion is difficulty to separate from the adjacent bone [13].

T. M. P. AMARAL ET AL.

A few authors have reported a more radiolucent form

of the lesion, and they assumed that it represented an

early uncalcified matrix stage [14]. Depending on the

stage of maturation, the radiological appearance and cli-

nical interpretation may vary. Occasionally, transitional

zones are present between the tumour mass and the tooth

substance, so radiographically, opacity gradations at the

tumour root structure are hazy and indistinct. Immature

lesions are radiolucent, and the differential diagnosis

might include an inflammatory cyst, osseous dysplasia,

central giant cell lesion or ameloblastom a [8,15].

Radiographically, the cementoblastoma is adhered to

the apical or lateral area of the root and appears as a

dense radiopaque mass, well defined and circumscribed

by a thin radiolucent and uniform halo [9,15]. Radio-

graphic image aspects (such as signs of root resorption,

loss of contour of the root, obliteration of the periodon tal

space) associated with the vitality of the involved tooth

are precise, pathognomonic signs [3,16]. All of these

signs can be seen in two-dimensional images, but that is

not what occurred in the present case: root resorption and

loss of contour of the root were not visualized. Therefore,

in early lesions, when the two-dimensional images d o not

show defined characteristics, three-dimensional images

become necessary. The CBCT images showed no root

resorption, however, the CBCT in the axial, coronal and

sagittal planes showed, in detail, lesion attach ment to the

roots at an early stage, discrete jaw expansion and perfo-

ration of the cortex, which facilitated diagnosis. These

features associated with the histopathological picture

allowed the final diagnosis.

In its histological aspects cementoblastoma may some-

times resemble osteoblastoma, or atypical osteosarcoma,

and may be difficult to distinguish from these tumours.

Osteoblastoma and cementoblastoma are essentially iden-

tical histologically; the only distinguishing feature is the

attachment of cementoblastoma to the root of the tooth

[1,5,17-19]. In cases of osteoblastoma, the symptoms of

pain are reduced with the use of a non-narcotic analgesic.

The osteoblastoma produces a round, well-demarcated,

lytic radiolucent lesion surrounded by a zone of reactive

sclerosis [12]. In contrast to the osteoblastoma, the ce-

mentoblastoma is an odontogenic tumour that recapitu-

lates cementum deposition, similar to what occurs during

formation in the late stages of odontogenesis [12]. His-

tologically, the cementoblasts in cementoblastoma may

be plump with pleomorphic and hyperchromatic nuclei;

however, mitotic figures are not seen in cementoblas-

toma like they are in osteosarcoma [20]. Differentiation

of the aforementioned lesions from cementoblastoma

requires correlation with radiographic findings, including

proximity of the lesion to the roots as well as clinical

information, such as age, gender, location and symptoms.

Such an approach will allow the clinician to make a de-

finitive diagnosis of these lesions [21].

The usual treatment for cementoblastoma is complete

surgical excision because the tumour has the potential for

unlimited growth. Extraction of the associated tooth is

necessary because of the fusion of the lesion to the root

cementum, even though the pulp may be vital [8,9,15].

Although this type of early lesion is rarely seen two-

dimension image, it is important to increase the aware-

ness of this condition among dentists. In conclusion, be-

cause of the characteristics of cementoblastoma, the

CBCT images are a resource of fundamental importance

for evaluation of pathognomonic features related to fu-

sion of the tumour at the root of the tooth in the early

stages of dev elopment.

3. Acknowledgements

This study was supported by grants from the National

Council for Scientific and Technological Development—

CNPq 302711/2010-4, FAPEMIG PPM-00516-11 and

Pró-Reitoria de Pesquisa da Universidade Federal de

Minas Gerais. Dr. Aguiar, and Dr. Mesquita are research

fellows of CNPq.

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