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SHORT COMMUNICATION
Year : 2012  |  Volume : 2  |  Issue : 1  |  Page : 44-46

Fused root stump mimicking cemental growth/cementicle


1 Department of Periodontics, Sudha Rustagi College of Dental Sciences and Research, Faridabad, India
2 Department of Oral Pathology and Microbiology, Sudha Rustagi College of Dental Sciences and Research, Faridabad, India

Date of Web Publication22-Mar-2012

Correspondence Address:
Himanshu Khashu
Department of Periodontics, Sudha Rustagi College of Dental Sciences and Research, Faridabad
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5194.94193

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   Abstract 

Many developmental or pathological anomalies can occur within the periodontium which may affect the attachment levels on the tooth structure. These anomalies may lead to or predispose the tooth to periodontitis or may affect the outcome of treatment provided to them. A case is reported of a 28-year-old male with attachment loss, recession and furcation involvement in a nonvital tooth, associated with a root stump concrescence, mimicking a cemental growth.

Keywords: Attachment loss, cementicle, concrescence, developmental anomaly, fusion


How to cite this article:
Khashu H, Yadav J, Baiju C S. Fused root stump mimicking cemental growth/cementicle. J Interdiscip Dentistry 2012;2:44-6

How to cite this URL:
Khashu H, Yadav J, Baiju C S. Fused root stump mimicking cemental growth/cementicle. J Interdiscip Dentistry [serial online] 2012 [cited 2019 Sep 17];2:44-6. Available from: http://www.jidonline.com/text.asp?2012/2/1/44/94193


   Introduction Top


A variety of calcified mass attached to the root surface are seen in various diseases and condition. These attachments may be a developmental anomaly or a pathosis attaching to the root surface after tooth development and eruption.

Most of the development anomalies have attachment of PDL to them as they are formed at the time of root development, for example cementicle.

However, some attachments are formed at a later age and may still have attachments like hypercementosis. Vice versa certain calcified masses formed during development but may still not have attachment, for example enamel pearl.

The interest in calcified cemental bodies attached to the root surface is more important as they may cause attachment loss leading to localized periodontitis, in absence of other etiological factors, and/or may aggravate the attachment loss in an existing disease/condition. There are some anomalies in which the adjacent roots may get joined to each other or may mimic two joined teeth, without actual attachment. These are Fusion, Gemination, Concrescence and Supernumerary roots. [1],[2]


   Case Report Top


A male patient aged 28 years, reported to the department of periodontics with swelling and draining sinus present at the furcal area in relation to the lower right first molar.

On clinical examination it revealed poor oral hygiene; grade 2 Furcation in relation to 46 [Figure 1]a with abscess and swelling in relation to the buccal aspect of 46. The buccal surface also revealed overhanging restoration and class 2 recession measuring approx. 5 mm from the adjacent marginal gingiva in relation to the mesial root of 46, mimicking a dehiscence type of defect [Figure 1]b.
Figure 1: (a) Probe showing definitive grade 2 furcation involvement. (b) Probe in place showing recession on mesiobuccal root. (c) Lopa shows periapical radiolucencies around the roots with improper RCT. No visible radio opacity on the roots. (d) RCT repeated with 46

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Iopa revealed improperly obturated root canals, with grade 2 Furcation involvement continuous with bone loss in relation to mesial and distal root. Large periapical radiolucency was also seen along the root apices [Figure 1]c.

The patient was advised analgesics (Ibuprofen Brufen - Abbott Pharmaceuticals, India), antibiotics (Ciplox -TZ - Cipla India Ltd) and a 0.12% chlorhexidine gluconate mouthwash (Periogard - Colgate Palmolive India ltd.) for 7 days. After 5 days phase 1 therapy including SRP was done, complete with oral hygiene instructions. The patient was then referred to Department of Conservative dentistry and endodontics for a repeat root canal treatment of 46 [Figure 1]d.

After a gap of 2 weeks, a full-thickness mucoperiosteal flap was raised from canine to the third molar. Upon debridement and removal of faulty restoration [Figure 2]a, a cemental growth mimicking an attached root piece, was observed on the mesiobuccal root of 46. It measured about 4 mm in length and 2 mm in width [Figure 2]b.
Figure 2: (a) Faulty restoration removed (b) Cementicle-like projection (c) Projection removed root planing done (d) Sutures placed

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A cutting disc (Flex single sided diamond disc, MDT ltd. Afula, Israel) was used to slice off the growth with care being taken not to involve the healthy root structure and to maintain the root anatomy [Figure 2]c. The growth was preserved in 10% formalin and sent to the department of oral pathology for a decalcified and ground section.

The surgical site was thoroughly irrigated with normal saline and the flaps were approximated and sutured (Ethicon - 3-0 Mersilk, reverse cutting, ¾ circle. Johnson and Johnson Ltd., Aurangabad, India.) [Figure 2]d. The patient was prescribed Ibuprofen 400 mg for 3 days. The patient was put on 0.12% chlorhexidine gluconate mouthwash for 2 weeks and was recalled for follow-up. A second stage of surgery was planned for gaining attachment with the help of bone graft and GTR membrane along with a coronaly advanced flap.

The healing was uneventful, and the sutures were removed after 7 days [Figure 3]a. However, the patient lost further interest as his presenting complaints of swelling and draining sinus were cured. He did not report for further treatment.
Figure 3: (a) Two week postoperative. (b) Ground section of the specimen. (c) Stained section of the specimen. (d) Ground section in phase contrast

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The pathology report was indicative of normal root morphology of a tooth root stump.


   Discussion Top


The literature defines cementicle as a "calcified masses which are adherent to or detached from the root surfaces." [3],[4]

The attached ones may grow over a period of time due to further cemental deposition. However, the literature does not mention of a spine like growth of cementum.

Occasionally calcified bodies are found adjacent to the enamel within the periodontium which have no connection with the origin of enamel drop and cementicles. They are formed due to occasional single senile ameloblast displaced into the periodontium and provoking the calcification of the surrounding tissues, which gives the appearance of a small cemental body. Since genuine cementicles are formed by cementoblasts, these atypical cementum bodies may be called "Pseudocementicles". [4]

Also cementicles are development anomalies and therefore they have attachment of PDL to them. In this case, however, the fused piece showed no attachment and a recession was noted along its entire length.

According to the histopathological slide, the specimen showed a spherical root cone with presence of a pulp cavity, dentine surrounding the pulp canal and a cemental wall which showed flat surface from where it was detached from the permanent root [Figure 3]b-d.

Based on the lab report and decalcified specimen a diagnosis was made of "Root Stump Concrescence".

A concrescence can be described as the joining of the cementum of one root to the cementum of the adjacent root, either as a developmental anomaly or as a result of chronic inflammatory conditions in the periradicular areas, primarily of endodontic origin. [5],[6]

The points to ponder are,

  • Was the root stump a part of developmental anomaly or a result of post inflammatory condition? The second choice seems more apt as the tooth was carious and endodonticaly treated, though unsatisfactorily. Also if it was a part of developmental anomaly it would not have an isolated pulp cavity. It would also in that case have PDL attachment and alveolar socket covering it complete with gingiva.
  • Was the concrescence limited to the apical third of the deciduous root stump or was it a complete root of second deciduous molar which later exfoliated leaving behind only that part of the root which was attached? The first choice seems to be better in this case as a complete root might have held together leading to nonexfoliation of the deciduous tooth.
  • Did the concrescence take place with the unshedded complete E, or the E shed off leaving behind a root stump which was in the vicinity of the mesiobuccal root of the permanent first molar and later got attached to the root because of the localized inflammatory conditions? The second choice seems apt in this case as the root stump of a deciduous tooth is often left unshedded and submerged due to the wide angle of separation between the deciduous roots.
There is a shortage of literature on the subject of root stump concrescence of a deciduous tooth to the root of a permanent tooth. It is important to detect and treat these abnormal attachments as the may lead to faster bone and attachment loss on the affected root surface, similar to cemento-enamel projections.


   Conclusions Top


Root concrescence is an uncommon condition in which a fully formed tooth is attached to another fully formed tooth via cementum. This condition is often detected during surgical therapy, either periodontal or exodontia, where it presents as a challenge for extraction and may complicate the outcome.

However, root stump concrescence is an unusual condition which if left untreated may result in alveolar dehiscence further apically, and loss of attachment leading to localized periodontitis

 
   References Top

1.Neville D.W, Damm D.D, Allen C.M, Bouquot J.E. Oral and Maxillofacial Pathology. 2 nd ed. Amsterdam: Elsevier; 2005.  Back to cited text no. 1
    
2.Rajendran R, Shivapatha Sundharam. Shafer, Hine, Levy: Shafer's Textbook of Oral Pathology. 5 th ed. India: Elsevier; 2006.  Back to cited text no. 2
    
3.Mikola OJ, Bauer WH. Cementicles and fragments of cementum in periodontal membrane. Oral Surg Oral Med Oral Pathol 1949;2:1063-74.  Back to cited text no. 3
[PUBMED]    
4.Kalinins V. Origin of enamel drops and cementicles in the teeth of rodents. J Dent Res 1952;31:582-90.  Back to cited text no. 4
    
5.Killan CM, Kroll TP. Dental twinning anomalies; Nomenclature enigma. Quintessence Int 1990;21;571-6.  Back to cited text no. 5
    
6.Levitas TC. Gemination, fusion, twinning and concrescence. ASDC J Dent Child 1965;32:93-100.  Back to cited text no. 6
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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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   Discussion
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