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Endodontic treatment of a cementoblastoma
Endodontic treatment of a cementoblastoma Report of a case Albert C. Goerig, Lieutenant Colonel, DC, USA,* Joseph T. Fay Colonel, DC, USA,** and Edwin King, D.D.S., Cedar Falls, Iowa
The benign cementoblastoma (true cementoma, osteoblastoma, giant osteoid osteoma) appears to be a true neoplasm of functional cementoblasts which proliferate at the apex of teeth to form an expansile tumor. It remains intimately attached to the tooth roots and occasionally involves the root canals themselves. Although the pulpal tissue remains vital, treatment has historically consisted of extraction of the involved tooth along with extirpation of the tumor. This mode of therapy for the benign cementoblastoma should not be confused with the entity called periapical cemental dysplasia (that is cementoma, periapical osteofibroma or osteofibrosis, cementifying fibroma, localized fibro-osteoma, and periapical fibrous dysplasia). In this latter lesion the treatment consists of simply recognizing the condition and establishing a schedule for periodic evaluation of the patient. In the case presented here enucleation of the cementoblastoma and endodontic therapy were selected as treatment modalities, despite the presence of buccal and lingual expansion of the cortical plates. There has been no recurrence of this growth during the 4-year follow-up period. (ORAL SURC. 58~133-136, 1984)
C
ementoblastoma (true or attached cementoma, benign centoblastoma, benign osteoblastoma, giant osteoid osteoma) is a benign jaw neoplasm which fuses with the cementum of the involved tooth.‘-) This lesion is distinct from the common “cementoma” (periapical fibrous dysplasia, periapical cemental dysplasia), the latter being a reactive periapical process.Clinically, this entity is characterized by slow-growing bony expansion, with no cortical bone destruction. The tumor may or may not be associated with pain. I,* There have been no reported cases demonstrating paresthesia or anesthesia, as would be anticipated in the case of an aggressive tumor.2 The age range in most published reports is from 8 to 30 years, with no significant sex predilection.4 The premolar-first molar area is reported to be the most common location in 80% of all cases.’ The involved teeth are usually vital, although some teeth The opinions or assertions expressed herein are those of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. *Commander and Chief of Endodontics, 124th Medical Detachment (DSD), APO NY 09189 Muenchweiler, West Germany. **Chief, Pathology Department, and Deputy Commander, 10th Medical Library, APO NY 09180, Landstuhl, West Germany. ***Oral and Maxillofacial Surgeon in private practice, Cedar Falls, Iowa.
Fig.
1.
Radiographdepicting the original lesion.
may be nonresponsive to the pulp test. This negative result may be caused by the disruption of normal neutral impulses by the tumor expansion around the root apex,* resulting in nerve and vascular compression. Radiographically, the lesion is classically seenas a solitary radiopacity confluent with the root(s) of the involved tooth.* The lesions may present a “sunburst” or “root trunk” appearance surrounded by a thin radiolucent line. Microscopically, the benign cementoblastoma is characterized by the presenceof multiple ovoid bodies that frequently fuse together 133
134
Goerig, Fay, and King
Fig. 2. The molar tooth immediately after endodontic therapy and prior to removal of the tumor.
Fig. 4. Radiograph depicting the completed endodontic procedure with the tumor enucleated.
and resemble cementurn. The amount of calcification frequently is dependent upon the maturity (age) of the lesion. These globules usually show evidence of reversal lines and can appear similar to secondary cellular cementum or giant cementicles. The softtissue component can be diversified in appearance, varying from scanty to highly cellular. When these cemental trabeculae are bordered by a very active plump cementoblastic proliferation, these lesions can be indistinguishable from the benign osteoblastoma or giant osteoid osteoma. Some focal areas are so actively prolific that a diagnosis of osteosarcomahas been considered. Detailed clinical and radiographic information is absolutely necessary to make an accurate diagnosis, as it is with all osteous tumors. The fact that the lesion is surrounded by a radiolucent border and is easily separated from the surrounding bone greatly assists the pathologist in arriving at a diagnosis.
Oral Surg. August, 1984
Fig. 3. A full mucoperiosteal flap was developed to expose the surgical area.
Several entities must be considered in the clinical and microscopic differential diagnosis of this tumor, among which are fibrous dysplasia, florid osseous dysplasia, ossifying fibroma, osteoma, condensing osteitis, hypercementosis, osteitis deformans (Paget’s disease), osteoblastoma, osteiod osteoma, and osteogenic sarcoma. Many of these entities can be excluded only if the pathologist receives a complete clinical workup, including laboratory studies and good-quality radiographs. Because the benign cementoblastoma has been considered to be a truly neoplastic entity, the treatment usually recommended consists of removal of the tumor along with the attached tooth. Iv3 In the following case a more conservative approach was used. Root canal treatment was completed in the involved molar tooth, followed by apicoectomy and enucleation of the expansile lesion. CASEREPORT
A 19-year-old black male patient was referred to the endodontic section with an asymptomatic, dense radiopaque lesion intimately associated with the apex of the mesial root of the lower left first molar (Fig. 1). Clinical examination of the oral cavity revealed normal-appearing oral mucosa with minimal expansion of the buccal and lingual plates in the mandibular left molar area. Radiographic examination of the area revealed a 1.8 X 2.0 cm radiopaque mass attached to the mesial root of the mandibular left first molar. There was a thin radiolucent line surrounding the mass. Following induction of local anesthesia, root canal instrumentation and obturation of the canal were completed (Fig. 2). Root canal treatment is necessarybecausethe tooth will be devitalized by the apicoectomy, and this procedure would eventuate in petiapical pathosis. A full
Endodontic treatment of a cementoblastoma 135
Volume 58 Number 2
Fig.
Fig.
5. Focally bizarre nuclei that were interpreted as being degenerative in nature.
6. Photomicrograph showing highly cellular areas with a pleomorphic appearance.
mucoperiosteal flap was developed to expose the surgical area. The overlying cortical bone was removed (Fig. 3), and the expansile growth was then readily accessible.The lesion was divided into four sections and removed. An apicoectomy was performed on the mesial root and the flap was sutured to place (Fig. 4). Pathology
report
The histologic sections revealed a decalcified cemental tumor composedperipherally of a thin fibrous connective tissue capsule and more centrally of ovoid globules of cementum-like material. Most of these calcified trabeculae are surrounded by plump-appearing cementoblasts containing plentiful amounts of cytoplasm. Focally pleomor-
phic bizarre nuclei were noted; however, these were interpreted as being a degenerative phenomenon (Fig. 5). The lesion was noted to be highly vascular, with numerous blood vesselsappearing to be of the capillary type. In the more cellular areas there is little cementum (osteoid) formation, and these atypical areas can be mistakenly diagnosed as being sarcomatous (Fig. 6). Peripherally, the cemental trabeculae are noted to extend outwardly in a parallel configuration. Follow-up
The patient had an uneventful post-operative course, with no recurrence during the 4-year follow-up period (Fig. 7).
136 Goerig, Fay, and King
Oral Surg. August, 1984
The benign cementoblastoma should not be confused with the entity called periapical cemental dysplasia, as the latter requires no active invasive treatment beyond periodic observation. The authors are indebtedto Mrs. Connie Lindsay for typing this clinical report. REFERENCES 1. Cherrick HM, King OH, Lucatorto FM, Suggs DM: Benign cementoblastomas; a clinicopathologic evaluation, ORAL SURG 37: 54-63, 1974.
2. Abrams AM, Kirby JW, Melrose RJ: Cementoblastoma; a clinical-pathologic study of seven new cases. ORAL SURG 38: Fig. 6. Boneregenerationand the radiographicappearance4 yearsfollowing the initial therapy. SUMMARY
A case is presented in which a benign cementoblastoma was treated with conventional, conservative therapy. There has been no reported recurrence of this lesion throughout a 4-year period.
394-403, 1974. 3. Shafer WG, Hine MK, Levy BM: A textbook of oral
pathology, ed. 4, Philadelphia, 1983, W.B. Saunders Company, p. 303. 4. Hamner JE, Scofield HH, Cornyn J: Benign fibro-osseous jaw lesions of periodontal origin; an analysis of 249 cases. Cancer 22: 861-878, 1968. Reprint requests to.
LTC Albert C. Goerig 124th Medical Detachment (DSD) APO NY 09189
The benign cementoblastoma (true cementoma, osteoblastoma, giant osteoid osteoma) appears to be a true neoplasm of functional cementoblasts which proliferate at the apex of teeth to form an expansile tumor. It remains intimately attached to the tooth roots and occasionally involves the root canals themselves. Although the pulpal tissue remains vital, treatment has historically consisted of extraction of the involved tooth along with extirpation of the tumor. This mode of therapy for the benign cementoblastoma should not be confused with the entity called periapical cemental dysplasia (that is cementoma, periapical osteofibroma or osteofibrosis, cementifying fibroma, localized fibro-osteoma, and periapical fibrous dysplasia). In this latter lesion the treatment consists of simply recognizing the condition and establishing a schedule for periodic evaluation of the patient. In the case presented here enucleation of the cementoblastoma and endodontic therapy were selected as treatment modalities, despite the presence of buccal and lingual expansion of the cortical plates. There has been no recurrence of this growth during the 4-year follow-up period. (ORAL SURC. 58~133-136, 1984)
C
ementoblastoma (true or attached cementoma, benign centoblastoma, benign osteoblastoma, giant osteoid osteoma) is a benign jaw neoplasm which fuses with the cementum of the involved tooth.‘-) This lesion is distinct from the common “cementoma” (periapical fibrous dysplasia, periapical cemental dysplasia), the latter being a reactive periapical process.Clinically, this entity is characterized by slow-growing bony expansion, with no cortical bone destruction. The tumor may or may not be associated with pain. I,* There have been no reported cases demonstrating paresthesia or anesthesia, as would be anticipated in the case of an aggressive tumor.2 The age range in most published reports is from 8 to 30 years, with no significant sex predilection.4 The premolar-first molar area is reported to be the most common location in 80% of all cases.’ The involved teeth are usually vital, although some teeth The opinions or assertions expressed herein are those of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. *Commander and Chief of Endodontics, 124th Medical Detachment (DSD), APO NY 09189 Muenchweiler, West Germany. **Chief, Pathology Department, and Deputy Commander, 10th Medical Library, APO NY 09180, Landstuhl, West Germany. ***Oral and Maxillofacial Surgeon in private practice, Cedar Falls, Iowa.
Fig.
1.
Radiographdepicting the original lesion.
may be nonresponsive to the pulp test. This negative result may be caused by the disruption of normal neutral impulses by the tumor expansion around the root apex,* resulting in nerve and vascular compression. Radiographically, the lesion is classically seenas a solitary radiopacity confluent with the root(s) of the involved tooth.* The lesions may present a “sunburst” or “root trunk” appearance surrounded by a thin radiolucent line. Microscopically, the benign cementoblastoma is characterized by the presenceof multiple ovoid bodies that frequently fuse together 133
134
Goerig, Fay, and King
Fig. 2. The molar tooth immediately after endodontic therapy and prior to removal of the tumor.
Fig. 4. Radiograph depicting the completed endodontic procedure with the tumor enucleated.
and resemble cementurn. The amount of calcification frequently is dependent upon the maturity (age) of the lesion. These globules usually show evidence of reversal lines and can appear similar to secondary cellular cementum or giant cementicles. The softtissue component can be diversified in appearance, varying from scanty to highly cellular. When these cemental trabeculae are bordered by a very active plump cementoblastic proliferation, these lesions can be indistinguishable from the benign osteoblastoma or giant osteoid osteoma. Some focal areas are so actively prolific that a diagnosis of osteosarcomahas been considered. Detailed clinical and radiographic information is absolutely necessary to make an accurate diagnosis, as it is with all osteous tumors. The fact that the lesion is surrounded by a radiolucent border and is easily separated from the surrounding bone greatly assists the pathologist in arriving at a diagnosis.
Oral Surg. August, 1984
Fig. 3. A full mucoperiosteal flap was developed to expose the surgical area.
Several entities must be considered in the clinical and microscopic differential diagnosis of this tumor, among which are fibrous dysplasia, florid osseous dysplasia, ossifying fibroma, osteoma, condensing osteitis, hypercementosis, osteitis deformans (Paget’s disease), osteoblastoma, osteiod osteoma, and osteogenic sarcoma. Many of these entities can be excluded only if the pathologist receives a complete clinical workup, including laboratory studies and good-quality radiographs. Because the benign cementoblastoma has been considered to be a truly neoplastic entity, the treatment usually recommended consists of removal of the tumor along with the attached tooth. Iv3 In the following case a more conservative approach was used. Root canal treatment was completed in the involved molar tooth, followed by apicoectomy and enucleation of the expansile lesion. CASEREPORT
A 19-year-old black male patient was referred to the endodontic section with an asymptomatic, dense radiopaque lesion intimately associated with the apex of the mesial root of the lower left first molar (Fig. 1). Clinical examination of the oral cavity revealed normal-appearing oral mucosa with minimal expansion of the buccal and lingual plates in the mandibular left molar area. Radiographic examination of the area revealed a 1.8 X 2.0 cm radiopaque mass attached to the mesial root of the mandibular left first molar. There was a thin radiolucent line surrounding the mass. Following induction of local anesthesia, root canal instrumentation and obturation of the canal were completed (Fig. 2). Root canal treatment is necessarybecausethe tooth will be devitalized by the apicoectomy, and this procedure would eventuate in petiapical pathosis. A full
Endodontic treatment of a cementoblastoma 135
Volume 58 Number 2
Fig.
Fig.
5. Focally bizarre nuclei that were interpreted as being degenerative in nature.
6. Photomicrograph showing highly cellular areas with a pleomorphic appearance.
mucoperiosteal flap was developed to expose the surgical area. The overlying cortical bone was removed (Fig. 3), and the expansile growth was then readily accessible.The lesion was divided into four sections and removed. An apicoectomy was performed on the mesial root and the flap was sutured to place (Fig. 4). Pathology
report
The histologic sections revealed a decalcified cemental tumor composedperipherally of a thin fibrous connective tissue capsule and more centrally of ovoid globules of cementum-like material. Most of these calcified trabeculae are surrounded by plump-appearing cementoblasts containing plentiful amounts of cytoplasm. Focally pleomor-
phic bizarre nuclei were noted; however, these were interpreted as being a degenerative phenomenon (Fig. 5). The lesion was noted to be highly vascular, with numerous blood vesselsappearing to be of the capillary type. In the more cellular areas there is little cementum (osteoid) formation, and these atypical areas can be mistakenly diagnosed as being sarcomatous (Fig. 6). Peripherally, the cemental trabeculae are noted to extend outwardly in a parallel configuration. Follow-up
The patient had an uneventful post-operative course, with no recurrence during the 4-year follow-up period (Fig. 7).
136 Goerig, Fay, and King
Oral Surg. August, 1984
The benign cementoblastoma should not be confused with the entity called periapical cemental dysplasia, as the latter requires no active invasive treatment beyond periodic observation. The authors are indebtedto Mrs. Connie Lindsay for typing this clinical report. REFERENCES 1. Cherrick HM, King OH, Lucatorto FM, Suggs DM: Benign cementoblastomas; a clinicopathologic evaluation, ORAL SURG 37: 54-63, 1974.
2. Abrams AM, Kirby JW, Melrose RJ: Cementoblastoma; a clinical-pathologic study of seven new cases. ORAL SURG 38: Fig. 6. Boneregenerationand the radiographicappearance4 yearsfollowing the initial therapy. SUMMARY
A case is presented in which a benign cementoblastoma was treated with conventional, conservative therapy. There has been no reported recurrence of this lesion throughout a 4-year period.
394-403, 1974. 3. Shafer WG, Hine MK, Levy BM: A textbook of oral
pathology, ed. 4, Philadelphia, 1983, W.B. Saunders Company, p. 303. 4. Hamner JE, Scofield HH, Cornyn J: Benign fibro-osseous jaw lesions of periodontal origin; an analysis of 249 cases. Cancer 22: 861-878, 1968. Reprint requests to.
LTC Albert C. Goerig 124th Medical Detachment (DSD) APO NY 09189