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
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.
C
opyright © 2012 SciRes. OJRad

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. 12
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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