Cemental Tear: A Case Report of a Rare Root Fracture

Dentinal microcracks and cemental tears related to chemo-mechanical root canal instrumentation: a micro-CT Cadaver Study

BACKGROUND

The prevalence of radicular defects after root canal instrumentation is unresolved. This study used micro-CT to assess the relationship between the formation of radicular defects and chemo-mechanical instrumentation in a cadaver model.

METHODS

Maxillary and mandibular molars (n = 24) were sectioned from cadaver specimens as a tissue block containing the teeth, alveolar bone and attached mucogingival tissues. After a baseline micro-CT scan (13.45 μm), the specimens were distributed into 3 groups (n = 8 molars): Reciproc^® , ProTaper Next™ and Mtwo^® . Micro-CT scans of each specimen were obtained after access, glide path and preparation with each instrument. The pre-operative and final post-operative micro-CT cross-sectional images of the roots were screened by two blinded examiners to identify any pre-existing and new radicular defects. Pre-existing and new radicular defects were examined histologically.

RESULTS

Overall, 16 pre-existing radicular defects were identified in 12 of the 24 molars (50%). Most of these were cemental tears (87.5%), and not true dentinal microcracks. New dentinal microcracks were observed in the post-operative micro-CT scans of only 3 canals (3.9%; 3/77). However, only one of these defects was found to be present histologically.

CONCLUSIONS

Within the limitations of the study, chemo-mechanical instrumentation did not routinely promote the formation of radicular defects.

Cemental tear: Literature review, proposed classification and recommendations for treatment

Cemental tears are an important condition of relevance to Endodontics but are often overlooked. A cemental tear is the partial or complete detachment of the cementum from the cemento-dentinal junction or along the incremental line within the body of cementum. The limited attention received is most likely due to the limited awareness amongst dental professionals and challenges in accurately diagnosing them, resulting in misdiagnosis and erroneous treatment. The aim of this review is to describe the: (i) epidemiology and predisposing factors; (ii) clinical, radiographic and histological features and (iii) the clinical management and treatment outcomes of cemental tear. The review included 37 articles published in English that comprised eight observational studies and 29 case reports. The prevalence of cemental tears was reported to be lower than 2%; whilst the incidence remains unknown. Internal factors due to the inherent structural weakness of cementum and its interface with the dentine, and external factors that are associated with stress have been proposed as the two mechanisms responsible for the development and propagation of cemental tears. Predisposing factors that have been implicated were tooth type, gender, age, previous root canal treatment, history of dental trauma, occlusal trauma and excessive occlusal force; however, evidence is limited. Common clinical and radiographic manifestations of cemental tears resemble the presentations of primary endodontic diseases, primary periodontal diseases and combined endodontic-periodontal lesions. Clinical management tended to focus on complete removal of the torn fragments and periodontal treatment, often combined with regenerative treatment. In this article, a new classification for cemental tears is developed that consists of classes 0 to 6 and stages A, B, C and D based on the: (i) location and accessibility of the torn cemental fragment; (ii) the pattern and extension of the associated bony defect in relation to the root length and (iii) the number of root surface/s affected by the cemental tear/s and the associated bony defect. Recommendations for treatment strategies are also provided and linked to the classification to aid in streamlining the process of treatment decision making.

Cemental tear: An overlooked finding associated with rapid periodontal destruction. A case series

Cemental tear is defined as cementum fragment completely or partially detached from the root surface, and it has been associated with localized rapid periodontal breakdown. Although history of trauma and/or attrition may be risk factors, the etiopathology of cemental tear remains unknown. This case series aims to discuss the clinical, radiographic and histopathologic features of cemental tears to aid clinicians in making differential diagnosis. Three teeth from three patients presenting a periradicular lesion underwent an exploratory surgery to determine the cause and provide treatment. Soft and hard tissue biopsies were obtained from each lesion and forwarded for histopathologic evaluation. Two patients received a guided tissue regeneration (GTR) procedure, which allowed the tooth to be retained. One patient received an extraction with simultaneous guided bone regeneration (GBR) due to a hopeless prognosis of the tooth. The results after histopathologic evaluation yielded a final diagnosis of cemental tear for all three patients. Cemental tears may be overlooked, and therefore, they should be included in the differential diagnosis of periapical periodontitis, endodontic-periodontal lesion and vertical root fracture (VRF).

Cemental Tear on Maxillary Anterior Incisors: A Description of Clinical, Radiographic, and Histopathological Features of Two Clinical Cases

In this case report, three teeth with complete or incomplete cemental tear in two patients were presented. Even though periapical radiograph could detect cemental tear in these three teeth, the cone-beam computed tomography scanning clearly revealed the pattern of the cemental tear, which was later confirmed by histopathological examination. Therefore, this case report shows the benefits of incorporating both cone-beam computed tomography and histopathological examination to diagnose cemental tear.

Cemental tear: To know what we have neglected in dental practice

Cemental tear is a special kind of root surface fracture, contributing to periodontal and periapical breakdown. However, it is a challenge for doctors to diagnose, resulting in delayed or improper treatment. We reviewed the predisposing factors, location, radiographic/clinical characteristics, diagnosis and treatments of cemental tears. From the literature, patients with cemental tear were mainly males, over 60 year-old. Possible predisposing factors include gender, age, tooth type, traumatic occlusal force and vital teeth. Cemental tears were common in upper and lower anterior teeth, single or multiple, and can be present in cervical, middle and apical third of roots. Morphology of cemental tears can be either piece-shaped or U-shaped. Clinically, cemental tear shows a unitary periodontal pocket and signs/symptoms mimicking localized periodontitis, apical periodontitis and vertical root fractures. Treatment of cemental tears include scaling, root planning, root canal treatment, periodontal/periapical surgery, guided tissue regeneration, bone grafting, and intentional replantation. Recurrence of cemental tear is possible especially when the fracture involves root apex. Extraction is recommended for teeth with poor prognosis. In conclusion, cemental tears can involve both periodontal and periapical area. Dentists should understand the predisposing factors and clinical features of cemental tears for early diagnosis/treatment to prevent bone loss/tooth extraction.

Cemental Tear in an Autotransplanted Tooth That Had Been Functioning for 15 Years

INTRODUCTION

Cemental tears have been described as specific types of root surface fractures that are seen infrequently but can cause rapid collapse of the periodontal tissue. However, to the best of the authors' knowledge, cases of cemental tears in autotransplanted teeth and their recovery by autotransplantation have not been reported previously. This case report presents the clinical and histopathologic features of a rare case of a cemental tear that occurred on an autotransplanted tooth. This meant a total long-term treatment course of 20 years involving two separate treatment procedures.

CASE PRESENTATION

In 1995, the mandibular left second molar of a 40-year-old woman was extracted, and autogenous tooth transplantation was performed simultaneously using a third molar from the same side. Good clinical and radiologic progress was observed for >10 years after tooth transplantation. After discovery of a vertical bone defect in the distal area in 2006, conservative periodontal treatment was conducted on the diseased periodontal pocket over the course of several years. In 2010, autogenous tooth transplantation and a subsequent histopathologic examination of the extracted tooth were performed. After recovery treatment, a 5-year follow-up examination provided good results.

CONCLUSIONS

This case report concerns the suspected contributing factors of cemental tears and the recovery treatment. When cemental tears are suspected after radiographic and other clinical examinations, interventional surgical treatment should be performed immediately. When autogenous tooth transplantation is performed, following careful consideration of the advantages and disadvantages of appropriate treatment and proper selection, continuous monitoring should be a prerequisite because of the possible occurrence of cemental tear.

Regenerative Treatment of a Cemental Tear Using Enamel Matrix Derivatives: a Ten-Year Follow-up

A patient presented with chronic periapical periodontitis on tooth 45. The root canal was re-treated and a wide apical perforation was closed with MTA® as an apical plug. At reevaluation six month later, the tooth presented with increased mobility, bleeding on probing and probing pocket depths of 9 mm. Despite good periapical healing radio graphically, the tooth showed signs of localized marginal bone loss that was diagnosed as being due to a cemental fracture. The tooth was splinted, a muco-periostal flap was raised and the fragment of cementum was removed. The defect was treated in a regenerative approach, using enamel matrix derivatives (EMD). Six month after therapy, the probing pocket depths decreased to values of ≤ 3 mm and a defect fill was radiographically visible. The 10-year follow up showed a stable situation.

It can be concluded that the occurrence of a local delamination of the root surface may contribute to the development of plaque-induced periodontal destruction. Its removal and the regenerative conditioning of the root surface with EDTA and EMD may result in a, at least partial, resolution of the problem and regeneration of bone at the affected the site.

Multiple cemental tears

A cemental tear is a pathologic condition in which a complete or incomplete separation of the cementum occurs along the root surface and is usually accompanied by a deep periodontal pocket. Past articles report that the incidence of cemental tears has usually been limited to 1 tooth per individual. We encountered a clinical case with cemental tears involving 14 teeth in 1 individual. Multiple cemental tears in 1 individual have not been previously described in the dental literature. We present the clinical and pathologic features of this rare case and suggest that the probable cause of multiple cemental tears is structural weakness of the cementum.