Root Apical Third and Canal Morphology of Teeth with Hypercementosis
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original article Root apical third and canal morphology of teeth with hypercementosis Liliana Aparecida Pimenta de BARROS1 Bethânia Camargo PINHEIRO2 Rogério Albuquerque AZEREDO1 Alberto CONSOLARO3 Tiago Novaes PINHEIRO4 ABSTRACT aminers and submitted to Kappa agreement test. The data obtained was compared through non-parametric Kruskal- Objective: This study aims at studying the influence of Wallis one-way analysis of variance test, and the Dunn test hypercementosis over root and root canal morphology us- was applied for individual comparisons. Results: The root ing different methods of observation (clearing technique, clearing examination showed higher frequency of club radiography, stereomicroscopy and optical microscopy). shaped hypercementosis (65%) followed by focal hyperce- Methods: 130 teeth were selected for morphological com- mentosis (35%). Teeth with hypercementosis showed sig- parative evaluation; all teeth were previously radiographed nificant increase in the presence of apical deltas (53.3%). and stereomicroscopically evaluated. Out of these, 60 teeth A higher frequency of root canal constrictions (55%), and with hypercementosis and 30 without it were selected for changes in the original root canal path (46.6%) were also clearing technique evaluation. The analysis was based on observed. Microscopic evaluation supports the influence of aspects such as: type of hypercementosis; root canal num- hypercementosis over the morphological characteristics of ber and configuration; root surface and presence of apical root apical third formation. Conclusions: These findings foramen and apical deltas. The remaining 20 teeth with hy- show the existence of a complex root canal anatomy at percementosis were microscopically compared to 20 teeth the apical third of teeth with hypercementosis, which may with normal root formation by means of the Hematoxylin hinder root canal treatment. and Eosin (H.E.) staining technique, so as to study the ce- mentum deposition pattern and morphological aspects of Keywords: Hypercementosis. Dental pulp cavity. the root canal. The evaluation was performed by two ex- Endodontics. How to cite this article: Barros LAP, Pinheiro BC, Azeredo RA, Consolaro A, Pi- » The authors report no commercial, proprietary or inancial interest in the prod- nheiro TN. Root apical third and canal morphology of teeth with hypercementosis. ucts or companies described in this article. Dental Press Endod. 2013 Sept-Dec;3(3):23-31. doi: http://dx.doi.org/10.14436/endo033en(023-031)oar. Submitted: August 17, 2013. Revised and accepted: August 18, 2013. 1 Associate professor, Federal University of Espírito Santo (UFES). 2PhD in Endodontics, School of Dentistry — University of São Paulo/Bauru. Contact address: Tiago Novaes Pinheiro 3Full professor of Pathology, USP. Rua Conde de Anadia, 23 – Yellow Tower – Ap. 404, Parque 10 CEP: 69.055-691 – Manaus/AM – Brazil 4Oral Pathology, University of the State of Amazonas (UEA). E-mail: [email protected] © 2013 Dental Press Endodontics 23 Dental Press Endod. 2013 Sept-Dec;3(3):23-31 [ original article ] Root apical third and canal morphology of teeth with hypercementosis Introduction deposition can contribute to the formation of multiple Hypercementosis is characterized by excessive foramina during cementum deposition resulting from deposit of cementum beyond the physiologic limits hypercementosis, thus originating the apical deltas.1,9 of the teeth, promoting an abnormal thickness of the The lack of recent studies related to this subject, apex that becomes round-shaped and/or with a mac- added to potential endodontic implications, inspire the roscopically altered appearance. assessment of morphological differences in the apical The incidence of hypercementosis by race or popu- third of the root and the root canal of teeth with hyper- lation group has not yet been established. Gardner and cementosis. The present study applied different meth- Goldstein1 studied the frequency of the phenomenon ods to perform these morphological observations and in 137 individuals, with 529 teeth being compromised a comparative study was established among them in by the process. Their study reported an average of 3.8 order to judge their diagnostic value. teeth with hypercementosis per individual, with a mean age of 47.3 years old and whose most affected teeth Material and Methods were the premolars. Another study demonstrated tooth The 130 teeth examined in this study were se- root hypercementosis in 84% of a collection compris- lected from the teeth bank of the routine archives of ing 104 skeletons of Barbadian slaves from XVII to one of the author’s laboratory of Oral Pathology. The XIX centuries.2 Additionally, root hypercementosis was specimens were kept in 10% formalin solution, placed found in 10 out of 54 specimens gathered from prehis- into small containers and labeled for identification. toric coastal populations of Texas, USA.3 A consent for using human tissue was obtained from The etiology of hypercementosis is attributed to an Institutional Review Board. several conditions such as functional stress due to oc- In selecting the sample, the following diagnostic cri- clusion forces; continuous dental eruption; incorporation teria were applied: cementum formation beyond the of periodontal cementicle during physiologic cementum physiologic limits of the teeth, with changes in root deposition; inflammatory reactional deposition; as well morphology that could be macroscopically detectable. as systemic factors such as atherosclerosis, acromegaly, The sample comprised 80 teeth with hypercementosis arthritis, thyroid diseases and Paget’s disease.1-13 and 50 without it. Out of these specimens, 60 teeth with Alterations in root morphology due to hypercemen- hypercementosis and 30 without it were selected for tosis comprise club shape hypercementosis, which re- analysis with the clearing technique. Out of the 40 re- sults from cementum deposition in all root surfaces; maining teeth, 20 with hypercementosis and 20 without focal hypercementosis, globular cementum deposition it were selected for microscopic analysis. in one of the root surfaces; and circular cementum hy- The specimens with hypercementosis were addition- perplasia (CCH), cementum lateral deposition on the ally classified by means of stereomicroscopy according root surface without affecting the apex.14 to their morphological characteristics, including the Hypercementosis does not radiographically alter the type of hypercementosis, the surface, the longitudinal biologic space relationship between the root surface, root axis and the visualization of the apical foramen. periodontal ligament and the alveolar bone. Although hy- After this classification, the teeth were radiographed percementosis can be identified through common radio- with a 70Kvp and 7,5mA x-ray device (Dabi-Atlante, SP, graphic techniques, the latter do not allow one to estimate Brazil), with a 16-cm cone, during an exposition period the amount of extra cementum in the affected root since of 0.5 seconds. The radiographic films used were Kodak dentin and cementum have the same radiodensity.1,15 Ultraspeed DF-58 (Eastman Kodak, NY, USA) and the Microscopic studies of hypercementosis report thick radiographic developing process used was the tempera- layers of cementum characterized by deposition of ture-time one during a 3.5-minute developing period. symmetric, highly basophilic lines parallel to the den- The radiographs were examined by two independent- tinal surface. Occasionally, atypical cementum deposi- ly trained observers using an X-ray viewer and magnify- tions are identified in focal areas as external cementum ing lens (2X) in a dark room. The radiographic aspects of projections. The presence of blood vessels and nervous the alterations in root radiodensity between the cemen- filaments associated with irregular apical cementum tum and the dentin at the apical third were considered. © 2013 Dental Press Endodontics 24 Dental Press Endod. 2013 Sept-Dec;3(3):23-31 Barros LAP, Pinheiro BC, Azeredo RA, Consolaro A, Pinheiro TN Additionally, the morphological aspects of the root Root canal clearing was established as a standard for all such as number, distribution and surface, as well as the morphological aspects studied. direction, acquired due to hypercementosis, and root Statistical analysis was carried out by means of canal breadth at the apical third were also considered. the non-parametric Kruskal-Wallis one-way analysis The 50 teeth without hypercementosis were used as of variance test which was used to determine if there comparative basis. were significant differences between the hyperce- The 90 teeth chosen for this part of the study mentosis and no hypercementosis group. The Dunn (60 with and 30 without hypercementosis) were divided test was applied for individual comparisons. Differ- into groups of maxillary molars, mandibular molars, ences were considered significant at P < 0.05. maxillary premolars, mandibular premolars, maxil- The 40 remaining specimens were divided into two lary anterior teeth and mandibular anterior teeth. Each groups: A = 20 teeth with hypercementosis; B = 20 group comprised 10 teeth with hypercementosis and 5 teeth without hypercementosis, with 5 maxillary molars, teeth without it. 5 mandibular molars, 5 maxillary premolars and 5 man- Access cavities were prepared and the teeth were dibular premolars in each group. The root apical third of immersed in 5% sodium hypochlorite solution for 24 the specimens were sectioned for histochemical proce- hours,