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Case Report

Cementoblastoma: A report of three new cases

Ravi Prakash a,*, Sankalp Verma b, Neha Agarwal c, Udita Singh c,Kuber Tyagi d

a Professor and Head of the Department, Oral Medicine and Radiology, Kothiwal Dental College and Research Centre,

Moradabad, UP, Indiab Senior Lecturer, Oral Medicine and Radiology, Kothiwal Dental College and Research Centre, Moradabad, UP, IndiacPost Graduate Student, Oral Medicine and Radiology, Kothiwal Dental College and Research Centre, Moradabad,

UP, IndiadSenior Lecturer, Oral Medicine and Radiology, Teerthankar mahavir Dental College and Research Centre,

Moradabad, UP, India

a r t i c l e i n f o

Article history:

Received 7 January 2013

Accepted 8 July 2013

Keywords:

Cementoblastoma

Mandible

Sunray appearance

* Corresponding author. C/o Dr. R. P. Singh (MUP, India. Tel.: þ91 (0) 9997119919.

E-mail addresses: sasan_ravi@rediffmail.

Please cite this article in press as: Prakas(2013), http://dx.doi.org/10.1016/j.ijd.2013

0975-962X/$ e see front matter ª 2013 Indiahttp://dx.doi.org/10.1016/j.ijd.2013.07.006

a b s t r a c t

Cementoblastoma is relatively a rare tumor of odontogenic ectomesenchyme origin

characterized by proliferating cementum like tissue, manifested as a bulbous growth

around and attached to the apex of the tooth root. This tumor accounts for 0.8%e2.6% of all

odontogenic tumors. We report three new cases of cementoblastoma in mandibular per-

manent first molar.

ª 2013 Indian Journal of Dentistry. All rights reserved.

1. Introduction interpretation in forming a diagnosis is highlighted. This

Cementoblastoma, also called as “true cementoma” or

“attached cementoma”was first described byDewey in 1927.1,2

It is relatively a rare tumor of odontogenic ectomesenchyme

origin characterized by proliferating cementum like tissue

occurring in juxtaposition to tooth roots.1 This tumor accounts

for 0.8%e2.6% of all odontogenic tumors.1 It manifests as a

bulbous growth around and attached to the apex of the tooth

root. The tumormost oftendevelopswithpermanent teeth but

in rare cases, can occur with primary teeth.3,4

We present three cases of cementoblastoma involving

permanent mandibular first molar. The importance of

adequate radiographic investigation and appropriate

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report also serves as a reminder that rare odontogenic tumors

may present initially in primary care and it is essential that all

practitioners are aware of them.5

2. Case report

2.1. Case 1

A 19-year-oldmale complained ofmild pain on chewing in the

left lower molar region since 6 months. The patient was in

good general health. An intraoral examination revealed a

swelling in the leftmandibular firstmolar region. The swelling

Home, Sarai Khalsa, Behind Head Post Office, Moradabad 244001,

m (R. Prakash).

oma: A report of three new cases, Indian Journal of Dentistry

l rights reserved.

Fig. 1 e (a) Radiopacity involving the roots of left mandibular first molar. (b) Panoramic radiograph demonstrating a well

defined radiopacity involving the roots of left mandibular first molar surrounded by a radiolucent halo. The radiopacity is

obscuring the root outlines. (c) Mandibular lateral cross-sectional occlusal radiograph showing radiating spicules of

cementoid material emanating from the central area and radiating towards the periphery giving a sunray appearance. (d)

Excised tumor mass along with extracted left mandibular second premolar and first molar.

i n d i a n j o u r n a l o f d e n t i s t r y x x x ( 2 0 1 3 ) 1e42

was bony hard and mildly tender. The left mandibular first

molar elicited a dull sound on percussion. A delayed response

on pulp sensibility testing was noted.

Intraoral periapical radiograph and panoramic radiograph

demonstrated a well defined radiopacity involving the roots of

left mandibular first molar surrounded by a radiolucent halo.

The radiopacity obscured the root outlines (Fig. 1a and b).

Mandibular lateral cross-sectional occlusal radiograph

showed radiating spicules of cementoid material emanating

from the central area and radiating towards the periphery

giving a sunray appearance. The cemental spicules weremore

Fig. 2 e (a) Histopathology of decalcified section revealing a tumo

and numerous reversal lines. (b) Ground section of the extracte

root apex.

Please cite this article in press as: Prakash R, et al., Cementoblast(2013), http://dx.doi.org/10.1016/j.ijd.2013.07.006

mineralized towards the centre, with individual spicules

appearing less radiopaque towards the periphery. Buccal and

lingual cortical plates were expanded and reduced to paper

thin margins (Fig. 1c). The tumor was excised along with the

extraction of left mandibular second premolar and first molar

(Fig. 1d). Histopathology of decalcified section revealed a

tumor composed of cementum like tissue, with irregular

lacunae and numerous reversal lines confirming the clinical

diagnosis of cementoblastoma (Fig. 2a). Ground section pre-

pared from extracted left mandibular first molar, showed

numerous cementocytes surrounding the root (Fig. 2b).

r composed of cementum like tissue with irregular lacunae

d tooth showing numerous cementocytes surrounding the

oma: A report of three new cases, Indian Journal of Dentistry

Fig. 3 e (a) Intraoral radiograph showing an ovoid mixed radiolucent-radiopaque mass attached to the root of the lower left

first molar with a radiolucent peripheral halo. (b) Excised tumor mass along with the extracted molar tooth.

i n d i a n j o u r n a l o f d e n t i s t r y x x x ( 2 0 1 3 ) 1e4 3

2.2. Case 2

A 25-year-oldmale complained ofmild pain on chewing in left

lower molar region since 3 months. His medical history was

non-contributory. The clinical examination revealed minimal

buccal and lingual cortical expansion in relation to permanent

left first and second mandibular molars. Teeth responded

normally with electric pulp testing. On intraoral periapical

radiograph, an ovoidmixed radiolucent-radiopaquemasswas

seen attached to the root of the lower left first molar with a

radiolucent peripheral halo (Fig. 3a). However, characteristic

sunray appearance was not evident in the occlusal radio-

graphs. Enucleation of the calcified mass along with the

extraction of the involved tooth was then performed (Fig. 3b).

The histopathological findings confirmed the diagnosis of

cementoblastoma.

2.3. Case 3

A 30-year-old female presented with swelling and dull pain in

lower left molar region since 3 months. Her medical history

Fig. 4 e Cropped panoramic radiograph showing round

mixed radiolucent-radiopaque mass was seen attached to

the root of the lower left first molar with a radiolucent rim

at the periphery.

Please cite this article in press as: Prakash R, et al., Cementoblast(2013), http://dx.doi.org/10.1016/j.ijd.2013.07.006

was unremarkable. Clinical examination revealed a swelling

in buccal vestibule with normal overlying mucosa extending

from premolar to molar region .The teeth in the region were

vital. On panoramic radiograph, a round mixed radiolucent-

radiopaque mass was seen attached to the roots of the lower

left first molar with a radiolucent rim at the periphery (Fig. 4).

Occlusal radiograph revealed expansion of buccal cortical

plates without any radiating spicules. Enucleation of the

calcified mass with the extraction of the involved tooth was

performed. Histopathological findings were consistent with a

diagnosis of cementoblastoma.

3. Discussion

Cementoblastoma is a slow growing, benign odontogenic

tumor arising from cementoblasts.6 In W.H.O classification of

odontogenic tumors, cementoblastoma has been classified as

one of the cementoma lesions which also includes giganti-

form cementoma, peripheral florid dysplasia and cementify-

ing fibroma.4 In 1974, Cherrick and his colleagues established

definitive criteria for this lesion that included a bulbous

growth of cementum on the root of the tooth, tendency to

expand the bony plates of the jaws and active histologic

appearance. All three of our cases fulfilled these criterias.7

The tumor is most commonly found in the second and

third decades of life. All three of our cases were in the second

decade. Male predominance has also been reported. Two of

our patients were male while one was female. Virtually all

cementoblastoma occur in premolar-molar region, more

commonly in themandible thanmaxilla.1,2,7e9 All three of our

cases involved the permanent mandibular first molars.

The radiological features of this tumor are characteristic. It

probably develops in three distinct stages. The first stage is

uncalcified matrix stage which is characterized by develop-

ment of a circular radiolucent area at the apex of the vital

tooth where in most cases half of the root length may get

resorbed by radiolucent mass. The second stage is called as

cementoblastic stage which begins with appearance of radi-

odense material in the centre of the lesion with a radiolucent

band surrounding the lesion.7 The third stage is the mature

stage where the lesion is completely radiopaque.

oma: A report of three new cases, Indian Journal of Dentistry

i n d i a n j o u r n a l o f d e n t i s t r y x x x ( 2 0 1 3 ) 1e44

The mass should also be examined from occlusal aspect.

This view shows expansion of both buccal and lingual cortical

plates. A characteristic finding observed is the presence of

radiating spicules of cementoid material towards the periph-

ery giving a sunray or spoke wheel appearance. The spicules

are more mineralized towards the centre.7e9 This appearance

was observed in our first case.

Cementoblastoma is histopathologically characterized by

formation of sheets of cementum like tissue containing many

reversal lines, irregular lacunae and cellular fibrovascular

stomata.2

Treatment of choice is complete removal of the lesion with

extraction of the associated tooth, root amputation with

tumor removal or curettage of the lesion without extraction of

tooth. The prognosis is excellent.10,11

Conflicts of interest

All authors have none to declare.

r e f e r e n c e s

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Please cite this article in press as: Prakash R, et al., Cementoblast(2013), http://dx.doi.org/10.1016/j.ijd.2013.07.006

review of the literature. Oral Surg Oral Med Oral Pathol OralRadiol Endod. 2004;97:53e58.

2. Brannon RB, Fowler CB, Carpenter WM, Corio RL.Cementoblastoma: an innocuous neoplasm? Aclinicopathologic study of 44 cases and review of theliterature with special emphasis on recurrence. Oral Surg OralMed Oral Pathol Oral Radiol Endod. 2002;93:311e320.

3. Lemberg K, Hagstro J, Rihtniemi J, Soikkonen K. Benigncementoblastoma in a primary lower molar, a rarity.Dentomaxillofac Radiol. 2007;36:364e366.

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8. Matteson SR. Benign tumors of the jaws. In: White SC,Pharoah MJ, eds. Oral Radiology: Principles and Interpretation. 4thed. Toronto: Mosby; 2000:401e402.

9. Farman AG, Kohler WW, Nortje CJ, Van Wyk CW.Cementoblastoma: report of case. J Oral Surg. 1979;37:198e203.

10. Pyann BR, Sands TD, Bradley G. Benign cementoblastoma: acase report. J Can Dent Assoc. 2001;67:260e262.

11. Biggs JT, Benenati FW. Surgically treating a benigncementoblastoma while retaining the involved tooth. J AmDent Assoc. 1995;126:1288e1290.

oma: A report of three new cases, Indian Journal of Dentistry