Uncovering the Mystery of Idiopathic Hypercementosis Associated with Other Dental Variations

@ 2025 | PUBLISHED BY GJR PUBLICATION, INDIA 9 Global Journal of Research in Dental Sciences ISSN: 2583-2840 (Online) Volume 05 | Issue 06 | Nov. – Dec. | 2025 Journal homepage: https://gjrpublication.com/gjrds/ Case Report Uncovering the Mystery of Idiopathic Hypercementosis Associated with Other Dental Variations *Dr. Nagaveni NB1, Dr. Sathya Prasad M2, Dr. Sahana R Kachattiyawar3, Dr. Indrani Manne4 1Specialist in Pediatric Dentistry, Academic Researcher and Professor, Garike Dental Care, Davangere, Karnataka, India. 2Senior Lecturer, Department of Conservative Dentistry and Endodontics College of Dental Sciences, Davangere, Karnataka, India. 3Post-Graduate student, Department of Oral Medicine and Radiology, Raja Rajeshwari Dental College and Hospital, Bangalore, Karnataka, India. 4BDS, DDS, Folsom, California, USA *Corresponding author: Dr. Nagaveni NB Specialist in Pediatric Dentistry, Academic Researcher and Professor, Garike Dental Care, Davangere, Karnataka, India. Introduction Cementum is the mineralized tissue which covers root surface of the tooth and supports the tooth to the underlying alveolar bone. The word ‘cementum’ is extracted from the Latin word ‘cement’ meaning the stone particles used to make mortar [1]. The important role of cementum in dental structure is to cover the root part of the tooth and provides attachment to the periodontal ligament fibers, for tooth stability. Under certain conditions like infection or mechanical stress, the production of cementum becomes excessive crossing normal physiological limits of the tooth [2]. This condition is called ‘Hypercementosis’ or ‘Cemental Hyperplasia.’ Hypercementosis is defined as ‘a condition characterized by an asymptomatic, rare, idiopathic and non-neoplastic condition showing an excessive deposition of cementum (calcified tissue) on the roots of one or more teeth.’ Most of the time, this condition is seen associated with systemic diseases like acromegaly, Paget’s disease, pituitary and thyroid related conditions, hypertrophic arthritis, deforming arthritis and atherosclerosis. However, idiopathic occurrence has also been reported [1-3]. They are two types of hypercementosis identified in the dental literature as localized and generalized with localized being the most frequently observed clinical entity (Table 1) [3]. Another classification categorized hypercementosis into focal, circular and club shape type [1]. Generalized hypercementosis is commonly exhibit as either transparent or dense type. In transparent type, the demarcation between the secondary and primary cementum and dentin can be clearly identified. Whereas in dense type the secondary cementum has the same density as the primary cementum and dentin [1-3]. The case described here, exhibited dense type in third molar and impacted premolar and transparent type in some teeth. In addition to the idiopathic nature, occurrence of hypercementosis is associated with numerous local factors like incorporation of periodontal cementicles during physiologic cementum deposition, reactionary deposition in response to periapical inflammatory condition, continuous tooth eruption and functional stress arising from occlusion forces [4,6]. Literature search revealed absence of prevalence studies about hypercementosis among different ethnic groups. This Abstract The aim of the present research paper is to show case occurrence of idiopathic generalised hypercementosis of different patterns in a 64-year-old female Indian patient. The article also illustrates presence of unique dental features and developmental anomalies like impaction of the mandibular second premolar and over-retained primary mandibular second molar which was in stable condition even at the age of 64 years. Radiographic evaluation also revealed the congenital agenesis of maxillary right and left third molars and mandibular right third molar and presence of severe root dilaceration (90-degree curve) in the mandibular left third molar. Keywords: Bulky Roots, Developmental malformation, Hypercementosis, Impacted mandibular second premolar, Non-syndromic patient, Over-retained primary Second molar. Global J Res Dent Sci. 2025; 5(6), 9-14 @ 2025 | PUBLISHED BY GJR PUBLICATION, INDIA 10 condition may see on the entire root portion of the tooth or involving only parts of a root [7]. The most commonly affected teeth by hypercementosis are the mandibular molars and the most frequently affected sites in a root are anatomical grooves, concavities on roots and furcation areas of multi-rooted teeth [8]. Occurrence of over-retained primary teeth (ORPT) also referred as ‘persistent primary teeth’ is a common clinical phenomenon encountered in children and adolescents and even in adults [9]. This phenomenon refers to the primary teeth that do not exfoliate at the expected normal period and remain in the mouth exceeding the typical shedding period/age. The main etiological factor for over retention of primary teeth is the congenital agenesis of permanent successors and their incidence has been documented differently among various populations. The highest reported prevalence was 59% [10]. However, other etiological factors for ORPT have been suggested such as dental caries, apical periodontitis, genetic diseases, changed lifestyle habits, ectopic tooth eruption and developmental factors [11]. Primary teeth can stay stable for long period if there is agenesis of its successive permanent tooth. Among ORPT, the most commonly encountered tooth is the mandibular second molar followed by maxillary second molars [12]. A systematic review showed that adults with partial edentulism exhibited survival rate of primary teeth with agenesis of permanent successors of about 93% after 15 years follow-up period. It is also reported that primary second molars without successors can survive for a long time [13]. However, in the present case, the primary second molar was stable associated with its impacted permanent successor. Although ORPT is more frequent clinical entity observed, there is lack of literature showing the etiology, prevalence, clinical presentation and treatment strategies. Therefore, it is highly essential to create and increase awareness of this condition among general public, parents and general dental practitioners. The mandibular second premolar tooth is afflicted by various developmental malformations like congenital agenesis, supplemental supernumerary formation, morphological variations and impaction [14-25]. Among these, impaction is the most frequently found scenario and accounts for the third most impacted tooth after the third molar and the maxillary canines. The reported prevalence of impacted premolars varies between 0.2 to 0.7%, with no reported gender predilection and caused by combination of various local and systemic factors [26]. Systemic factors like calcium deficiency or vitamin D deficiency, dwarfism, endocrinal disorders such as hypothyroidism, down’s syndrome, cleidocranial dysplasia, genetic diseases and local factors like abnormal or ectopic positions of premolar tooth bud, lack of space in the jaw, ankylosed primary molars, shifting of the adjacent teeth and over-retaining of primary teeth play a significant role in impaction of the second premolars [27]. Most of the impacted premolars are asymptomatic and detected following routine radiographic examination. In the case reported here, impaction of the second premolar was observed following radiographic examination and the cause for its impaction may be due to over-retained primary second molar. Impacted premolars are located at different angulations and positions and hence carefully evaluated in detail considering its relation with adjacent anatomical structures during treatment planning [28]. Occurrence of individual dental anomaly or variation is a common phenomenon. However, occurrence of different dental anomalies associated with different dental variations is an uncommon phenomenon and needs to be reported. Therefore, the present unusual case was documented and drafted to add another rare dental variation to the ‘research quest’ which enables academic researchers to formulate new guidelines pertaining to this rare dental entity. Table 1: Types of Hypercementosis [26] Type of Hypercementosis Description Localized Hypercementosis involving single tooth. It is usually a reactive, inflammation dependent phenomenon identified on a single tooth. Most commonly seen in relation to periapical osteitis or due to loss of occluding antagonistic tooth. Generalized Hypercementosis involving all teeth. Most of the time it is an age dependent factor. Sometimes seen as pathognomonic factor associated with some underlying diseases like Paget’s disease of the bone. Case Details A 64-year-old female patient reported to a private dental clinic complaining of stains in her teeth. Patient had normal built according to her age and did not show any signs and symptoms of systemic, metabolic or endocrinal disorders. There was no family history showing any pathologic conditions and previous history of dental treatment. The details of intra oral and radiographic findings are elaborated in Table 2, and Figure 1. As patient did not have any other positive dental findings, only scaling was performed followed by periodic observation. Global J Res Dent Sci. 2025; 5(6), 18-23 @ 2025 | PUBLISHED BY GJR PUBLICATION, INDIA 11 Table 2: Demographic Details of Patient with Unusual Dental Features Age Gender Chief Complaint Intraoral Findings Radiographic Features (Figure 1) 64 Years Female Presence of stains in her teeth Complete teeth with moderate crowding in the anterior region. Over-retained primary mandibular left second molar. Clinical absence of mandibular left second premolar, and maxillary bilateral third molars and mandibular right third molar. Diffuse and dense type of hypercementosis in 35 and 38. Generalised Transparent hypercementosis except in mandibular incisors. 38 with severe root dilaceration. Impacted (Type 1-Vertical) 35. Over-retained 75 with distal root resorption. Congenital agenesis of 18, 28, and 48. Figure 1: Orthopantomograph depicting impacted (Type 1-Vertical) mandibular left second premolar with diffuse and dense or Grade 3 hypercementosis (red arrow), ORPT in relation to left second primary molar (yellow star), diffuse and dense or Grade 3 type of hypercementosis with severe root dilaceration in left third molar (red arrow). Transparent type hypercementosis was observed in remaining teeth expect mandibular incisors. Discussion Hypercementosis may be seen involving single tooth, or may involve multiple teeth or may represented as generalized form. This condition does not show any clinical signs and symptoms. It is diagnosed incidentally following a routine radiographic examination performed for some other purpose. On radiographs, hypercementosis appear as a different root morphology due to excessive deposition of cementum around a part of the root or whole root [1-3]. It does not change the biologic width between the root surface, alveolar bone and the periodontal ligament. Moreover, as both dentin and cementum exhibit the same radiodensity, it is difficult to evaluate the amount of deposited extra cementum on the root surface [4-6]. The affected root with hypercementosis exhibit a bulky root surrounded by a radiolucent periodontal ligament space with an adjacent intact lamina dura and appear as normal cementum as the radiopaque lamina dura and shadow of the periodontal membrane are present on the outer border of hypercemetosis. Most of the time this condition is recognised as an age-related phenomenon [8]. There are reports showing occurrence of hypercementosis on a root of unerupted tooth [7]. This is in agreement with the present case where the patient was in her sixth decade of life and involving impacted second premolar. Bernal Ruiz et al [7] determined prevalence and radiographic patterns of hypercementosis and also evaluated the relationship of this pathology with some local triggering factors among Mexican population. Hypercementosis was found in total of 194 patients (16% prevalence) with no relevant difference found between genders. There was a significant increase with respect to the presence of hypercementosis with respect to increase in the age of the patients (10% in 40 years, 20% in 40 to 60 years and 30% in > 60 years age group). In 75% of cases, hypercementosis was found more frequently in a diffuse pattern, 10% focal pattern and less form of sleeve-shaped morphology (5%). The hypercementosis was more prevalent in the mandible with left side being the most affected site constituting molars and premolars. In the case presented here, mandibular third molar and impacted second premolar exhibited diffuse pattern of hypercementosis Global J Res Dent Sci. 2025; 5(6), 18-23 @ 2025 | PUBLISHED BY GJR PUBLICATION, INDIA 12 and other teeth like left premolar and molars showed sleeve or transparent pattern [7]. It was also found that impaction of the tooth was considered possible local triggering factor. Both findings were recognized in the present case too. Microscopically hypercementosis appear as thick layers of cementum representing deposition of symmetric with increased basophilic lines which are parallel to dentin surface. In some cases, atypical cementum depositions are noticed in focal areas appearing as cementum projections [8]. On cone-beam computed tomography (CBCT) scan, hypercementosis will appear as a dark or light layer. Literature search revealed scanty publications on occurrence of idiopathic generalised hypercementosis associated with other unusual dental variations [8]. Therefore, to shed more light on a rare clinical entity like hypercementosis, the present article was drafted and it represents the first report on this combination of different dental anomalies. Scientists have shown that there is increased expression of ENPP1 expression in cementoblast of human and mouse control teeth. So, it is evident from this research that association of novel dental phenotype in GACI and ENPP1 genetic mutations with hypercementosis process [4]. Ohbayashi et al [6] investigated the incidence and predictors of hypercementosis in mandibular third molars using CBCT based on four severity grades as 0 – no hypercementosis around the root, 1 – hypercementosis surrounding less than half of the root surface, 2 – hypercementosis surrounding more than half of the root surface, and 3 – hypercementosis surrounding the entire root surface. The predictors evaluated were age, gender, impaction and occlusion. The results revealed that the severity of hypercementosis increased with age and the incidence was significantly lower for occluded teeth compared to teeth in non-occlusion [6]. In the current case, grade 3 hypercementosis was noticed and correlated positively with advanced age of 64 years. Presence of hypercementosis has clinical significance. Teeth associated with hypercemetosis requires modifications in some dental treatments like endodontic, orthodontic treatment and extractions [1-4]. Teeth with hypercementosis roots complicate endodontic microsurgery especially in the mandibular posterior region as surgical accessibility and visibility is compromised. A novel case report showed a computer-aided design or computer-aided manufacturing (CAD/CAM) surgical stent for guided root resection in a mandibular molar with hypercementosis in 38-year-old female patient [5]. Presence of hypercementosis has got dental anthropological significance too [7]. Different studies in dental anthropology have speculated a relation between the teeth as tools and hypercementosis. Masse et al investigated the different patterns of cementum apposition on archeological teeth along with its etiology using microtomography and confocal microscopy [7]. Following this investigation, four patterns of hypercementosis such as impacted, infected, hypofunctional and hyperfunctional teeth were identified. Therefore, it is identified that the type of hypercementosis can help in identifying the oral health status of an individual called by the term ‘paleopathology’ and masticatory activity of individuals [7]. Based on this anthropological classification, the hypercementotis of the present case was classified into impacted and either hypo or hyperfunctional hypercementosis. The study of fossil hominins mainly involving Neanderthals were known for their use of anterior teeth as tools with substantial occurrence of hypercementosis in their teeth. Pertaining to ORPT, it is explored that apart from congenital agenesis of permanent successors, other factors also influence survival status of ORPT. However, in the current case, although permanent successor was present the primary second molar was persistent and stable even at the age of 64. The survival rates also differ in different primary teeth such as molars and canines [9]. A recent cohort study investigated the factors related to the survival of retained primary teeth among 138 patients (88 female and 50 male) from Nagasaki University hospital [9]. The total number of retained primary teeth found was 274 with survival rates of 62% at 10 years and 53% at 20 years. Regarding treatment of ORPT, different treatment modalities have been explained in the literature and it depends on the condition of retained tooth and patient’s age [10]. Some authors explains that ORPT should not be preserved rather it should be extracted followed by implant treatment [10]. However, there are reports which state that function of ORPT should be preserved as much as possible [11]. A systematic review showed that ORPT are ideal in children and adolescents where in the success rate of implant placement is low [13]. A 2003 study, evaluated the long-term changes with ORPT in adults [10]. The mean age at the initial examination was 36 years and mean age at the final examination was 48 years. Among 28 ORPT, following initial examination, 24 were found continue to function whereas only 4 were lost at mean age of 51 years. Authors also noticed that the average shortening of all primary root lengths was found negligible [10]. Hence it was concluded that retaining healthy primary mandibular second molars is a viable alternative treatment. Hence in our case too, as the second primary molar was stable, the tooth was retained without advising extraction. Literature search revealed different types of angulations of impacted mandibular second premolar teeth ranging from vertical, mesio-angular, disto-angular or horizontal, transverse or bucco-lingual positions [26]. Among these, buccolingual or transverse is an extremely rare type and requires three-dimensional imaging modalities for better appreciation. Recently Arsyad and Muchlis [26] proposed a new classification system on impacted mandibular second premolars based on its position within the alveolar bone (Table 3). According to this classification, the impacted premolar of the current case was categorized as type 1 or vertical. Global J Res Dent Sci. 2025; 5(6), 18-23 @ 2025 | PUBLISHED BY GJR PUBLICATION, INDIA 13 Table 2: New Classification of Impacted Mandibular Second Premolar [26] Type of Premolar Impaction Description Type 1 (0-degree inclination) Located straight or vertical Type 2 (Mesial inclination) Located in the body of the mandible below the apex of the molar teeth. Type 3 (Distal inclination) Located below the apex of the canine or incisors on same side and does not cross the dental midline. Type 4 (Mesial inclination) A transmigrated premolar crossing the dental midline and located below the apex of incisors. Extremely rare finding Type 5 (Horizontal/90-degree inclination) Extremely rare finding Type 6 Located on the ascending part of ramus or coronoid process Type 7 (Inverted position/180-degree inclination) Extremely rare finding The treatment strategies for the impacted premolars varies from observation, relocation, intervention, surgical removal, position of the impacted tooth, depth of the tooth and its relation with adjacent anatomic structures [27-30]. Intervention includes extraction of the primary molar and relocation refers to the surgical repositioning of an impacted premolar using orthodontic traction. A novel published case report [27] described the surgical removal of the mandibular left second premolar which was in close proximity to the mental nerve followed by PRF application. Authors highlighted the rare occurrence of the mandibular second premolar impaction, the diagnostic accuracy of CBCT in identifying the close relation with the mental nerve and the advantages of PRF to obtain optimal wound healing in a 44-year-old female patient [27]. Another case report showed that conservative management could be considered as an optimal treatment option for asymptomatic impacted premolars emphasizing periodic observation is an effective approach in carefully selected cases, when there is no evidence of associated pathology [29]. Only symptomatic impacted premolars should be treated with surgical interventions as evident from the literature. Based on this fact even in the present case, no treatment was advised as the impacted premolar was asymptomatic and not associated with any pathology. 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