Oral Biol Res 2018; 42(4): 248-253  https://doi.org/10.21851/obr.42.04.201812.248
Treatment of the cemental tear
Ye-Sol Park , Jae-Hong Lee , and Seong-Nyum Jeong*
Department of Periodontology, Daejeon Dental Hospital, College of Dentistry, Wonkwang University, Daejeon, Korea
Correspondence to: Seong-Nyum Jeong, Department of Periodontology, Wonkwang University Daejeon Dental Hospital, Wonkwang University School of Dentistry, 77 Dunsan-ro, Seo-gu, Daejeon 35233, Korea. Tel: +82-42-366-1141, Fax: +82-42-366-1115, E-mail:seongnyum@wonkwang.ac.kr
Received: November 6, 2018; Revised: November 15, 2018; Accepted: November 21, 2018; Published online: December 31, 2018.
© Oral Biology Research. All rights reserved.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract

Cemental tears are uncommon form of root fracture that can lead to rapid localized periodontal attachment loss. Studies have described periodontal breakdown as being associated with the separation of the cementum from the underlying tooth structure. The aim of this case report is to assess the outcome of treatment of cemental tear with several surgical treatment regimens. Three patients with cemental tear were treated with different surgical method. In all three cases, the cemental tear occurred on maxillary right central incisors. In each case, the root fragment were removed, the localized defect was treated using different surgical methods including guided tissue regeneration and bone graft followed by scaling and root planting. In all three cases, symptoms subsided after the treatment and clinical attachment level was improved up to 2 mm at 3 month after surgery. Both conventional and regenerative periodontal surgery could achieve successful outcomes.

Keywords: Dental cementum, Periodontal attachment loss, Periodontal pocket, Tooth fractures
INTRODUCTION

Cemental tear is an atypical form of root fracture which is defined as a complete separation of cemental fragment along the cementodentinal junction or a partial split in the cementum along an incremental line [1,2]. Cemental tears are categorized as localized tooth-related factors, and may be an influential factor that modifies or predispose to plaque-induced gingival disease and/or periodontitis [1,3,4]. Other such factors include enamel pearls [5], cervical enamel projections [6,7], developmental proximal or palatal grooves [8-10], root fractures [11].

Periodontal involvement in relation to cemental tears typically presents as asymptomatic periodontal pocketing of sudden onset and rapid progression, followed by localized attachment loss [12-14]. Radiologically, it may be supported by a partial or complete separation of the cemental fragment and concomitant alveolar bone loss [2,4]. Although there are not so many studies reported so far, several studies say that various periodontal treatment modalities can treat cemental tears and the resulting defects [15-18].

The objective of the present case report was to evaluate the short-term clinical outcome of treatment of cemental tear with several surgical treatment regimens including guided tissue regeneration (GTR) and bone graft followed by scaling and root planing.

CASE

Case 1: The patient was treated by open flap debridement (OFD) only

A 52-year-old female patient visited in the chief complaint of gingival swelling and pain of maxillary right central incisor tooth (#11), and had no specific medical history. Clinically, wear facet on maxillary right (#11) and left (#21) central incisor labial aspects were found and there was palatal marginal gingival swelling and redness (Fig. 1A, Fig. 1B). We could detect cemental tear on the mesial root surface of #11 and found related clinical symptoms of rapid periodontal tissue breakdown (Fig. 1C). To eliminate the occlusal trauma, we performed occlusal adjustment on lingual aspect of #11. After the mucoperiosteal flap was elevated, the cemental fragment was removed along with degranulation and root debridement on the defect (Fig. 2A-C). Flap was repositioned and interrupted suture was done (Fig. 2D) and stitch-out was done after 1 week. At 3 months follow-up appointment postoperatively, favorable healing state was seen in the treated site both clinically and radiographically (Fig. 2E, Fig. 2F).

Fig. 1.

Initial intraoral photograph & radiograph of case 1 patient. (A) Labial gingival swelling and redness of of the maxillary right central incisor were found at first visit. (B) There was palatal marginal gingival swelling and redness was also detected around of the maxillary right & left central incisors. (C) Cemental tear is shown on the radiograph (red arrow).


Fig. 2.

Surgical procedure and postoperative radiograph of case 1 patient. (A) Flap elevation. (B) Degranulation & root debridement. (C) Removed ce­mental fragment. (D) Everting Suture. (E) Postoperative 3 months photograph. (F) Postoperative 3 months radiograph.


Case 2: The patient was treated by GTR technique

A 63-year-old female patient visited in the chief complaint of fistula formation of #11 buccal gingiva. Clinically, gingival swelling with sinus tract on #11 distolabial attached gingiva was found, and there was anterior deep bite tendency (Fig. 3A). We detected the cemental tear on the distal side of the #11 in the periapical radiograph (Fig. 3B). To eliminate the occlusal trauma, we performed occlusal adjustment on lingual aspect of #11 and confirmed the loss of fremitus. Surgical removal of the cemental fragment along with flap operation was planned. After flap elevation including vertical incision, cemental fragment was removed from the #11 distal defect. The localized defect was treated by OFD along with degranulation, and root planning (Fig. 4A-C).

Fig. 3.

Initial intraoral photograph & radiograph of case 2 patient. (A) Sinus tract was formed at distolabial side of the maxillary right central incisor and anterior deep bite was shown also in photograph. (B) Cemental tear is shown on the distal root surface of the maxillary right central incisor.


Fig. 4.

Photographs and radiograph of surgical procedure and postoperative healing of case 2 patient. (A) The sinus tract is still present on the day of surgery at the distolabial area of the maxillary right central incisor. (B) The root surface area where is cementum torned is designated by black arrows. (C) Degranulation and root planing was done. (D) Resorbable membrane adaptation. (E) Suture was completed. (F) Stitch-out was done. (G) Postoperative 3 months photograph. (H) Postoperative 3 months radiograph.


Resorbable collagen membrane (Bio-Gide; Geistlich Pharma AG, Wolhusen, Switzerland) was prepared and applicated to the defect by the concept of GTR principle and suture was done (Fig. 4D, Fig. 4E). After 2 weeks, we removed suture material (Fig. 4F). At 3 months postoperatively, successful outcome was seen both clinically and radiographically (Fig. 4G, Fig. 4H)

Case 3: The patient was treated by GTR combined with bone graft

A 50-year-old male patient visited with a chief complaint of fistula formation on #11 gingiva (Fig. 5A), and had a history of hypertension, diabetes, hyperlipidemia being in treatment with medication for disease control. On the radiograph, the presence of the cemental tear in the mesial aspect of #11 root was observed (Fig. 5B). GTR using a collagen membrane combined with bone graft was planned for the site of the defect. After the flap elevation and removal of the cemental fragment, we perfomed degranulation and root planning (Fig. 6A-C), then applied a xenobone graft material (Bio-Oss; Geistlich Pharma AG) in the intrabony defect and covered a resorbable collagen membrane (Geistlich Bio-Gide) on the grafted defect site and suture was done (Fig. 6D, Fig. 6E). At 2 weeks postoperatively, stitch-out was done and good healing state of the treated site was observed (Fig. 6F). The healing was uneventful and attachment level was improved at 3 months after periodontal surgery

Fig. 5.

Initial intraoral photograph & radiograph of case 3 patient. (A) Fistula can be seen at the mesiolabial area of the maxillary right central incisor due to cemental tear (red arrow). (B) Cemental tear is designated by red arrow on the radiograph.


Fig. 6.

Photographs of surgical procedure and postoperative healing of case 3 patient. (A) Flap was elevated. (B) Removed cemental fragment. (C) Degranulation & root planing was done. (D) The defect was filled with Xenograft & covered with resorbable membrane. (E) Suture was done. (F) Stitch-out. The sinus tract was disappeared.


The overall result was summarized in Table 1. In all cases, clinical symptoms subsided after the treatment and periodontal pocket depth was reduced with the increased recession. Clinical attachment level was gained up to 2 mm with a mean of 0.70 mm gain.

Change in clinical parameters after periodontal surgery

 VariableProbing pocket depth (mm) (distal, middle, mesial)Gingival recession (mm) (distal, middle, mesial)Clinical attachment loss (mm) (distal, middle, mesial)



Pre-TxPost-TxPre-TxPost-TxPre-TxPost-Tx
Case 13 5 83 4 61 1 02 2 24 6 85 6 8
Case 28 3 56 3 30 1 00 1 08 4 56 4 3
Case 33 5 83 4 51 1 11 1 24 6 94 5 7
Post−Pre Tx0–3 (mean=1.32) Reduction0–2 (mean=0.62) Recession0–2 (mean=0.70) Gain

Tx, treatment.

Clinical symptoms subsided after the treatment and periodontal pocket depth was reduced up to 3 mm with increased recession. Clinical attachment level was gained up to 2 mm with a mean of 0.70 mm gain.


DISCUSSION

The etiology of cemental tear has not been elucidated yet. Occlusal trauma and/or overloading is the most commonly reported cause and considered the most plausible ones, followed by wear of facet, parafunction habit, and age of patient [4,19]. It is supported by the fact that the patient age is more than middle age in previous studies including this study. Moreover, as in Case 2, if the trauma caused by abnormal occlusion is continuously applied to the teeth, the possibility of cemental tear is likely to increase. As the previous case reports say that cemental tears primarily affect single-rooted teeth, particularly incisors and premolars [2,17], all the cemental tears occurred on upper central incisors in this study.

The treatment of periodontal involvements associated with cemental tear has a wide range from non-surgical periodontal therapies to combined regeneration procedures, to final extraction if poor prognosis [12,13,16,18]. On the other hand, when a cemental tear is solely a radiographic finding without any accompanying symptoms or signs, invasive intervention may not be necessary and can be maintained with conservative follow-up [15]. Scaling and root planing alone, or in conjunction with soft tissue curettage, OFD [1,2], GTR [16] and osseous grafting alone [14], and combined regenerative procedures [17,18] were suggested for treatment of defects associated with cemental tear in previous reports. We should focus on the fact that the studies reporting successful treatment results included a common procedure to remove the separated root fragments in the treatment plan [15,16]. Within follow-up periods from 3 months, as in this case, to 7 years, through the surgical treatment plans described above, including the removal of cemental tear and the treatment of related periodontal defects, could provide satisfactory results and favorable prognosis for both patients and clinicians [2,4]. Fundamentally, when the torn cementum is exposed in the periodontal pocket,it should be removed to prevent accumulation of dental plaque [1,2,11]. We could get the successful outcomes by both conventional and regenerative periodontal surgery in this study. At 3 months follow-up appointment postoperatively, favorable healing state was seen in the treated site both clinically and radiographically.

However, the follow-up report of the clinical results including the present study, after treatment of cemental tear is limited to the short period [12,13]. Therefore it can be a limit to the absence of long-term results. In addition, the size of the cemental fragment isolated from the root was not consistently considered in the previous studies [15,17], while the relative size of the lost structure compared to the total root surface area has not been addressed in the literature [14,20,21]. In order to overcome these limitations, it is necessary to standardize the shape and size of cemental tears and the size of the separated cemental fragment, and long-term follow-up and longitudinal studies should be performed in a large number of cases. An early differential diagnosis between cemental tear and true periapical/periodontal lesion and initiation of proper treatment of cemental tear seems to be key factors for saving the involved tooth.

ACKNOWLEDGEMENTS

This study was supported by Wonkwang University in 2018.

CONFLICTS OF INTEREST

The authors declare that they have no competing interests.

References
  1. Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol 1999;4:1-6. doi:10.1902/annals.1999.4.1.1
    Pubmed CrossRef
  2. Chou J, Rawal YB, O'Neil JR, and Tatakis DN. Cementodentinal tear: a case report with 7-year follow-up. J Periodontol 2004;75:1708-1713. doi:10.1902/jop.2004.75.12.1708
    Pubmed CrossRef
  3. Blieden TM. Tooth-related issues. Ann Periodontol 1999;4:91-97. doi:10.1902/annals.1999.4.1.91
    Pubmed CrossRef
  4. Nagata M, Nagata M, Kanie T, and Shima K. Clinical and histologic aspects of cervical cemental tear as a risk for periodontal diseases. Clin Adv Periodontics 2016;6:167-174. doi:10.1902/cap.2016.150075
    CrossRef
  5. Goldstein AR. Enamel pearls as contributing factor in periodontal breakdown. J Am Dent Assoc 1979;99:210-211. doi:10.14219/jada.archive.1979.0258
    CrossRef
  6. Grewe JM, Meskin LH, and Miller T. Cervical enamel projections: prevalence, location, and extent;with associated periodontal implications. J Periodontol 1965;36:460-465. doi:10.1902/jop.1965.36.6.460
    CrossRef
  7. Hou GL, and Tsai CC. Cervical enamel projection and intermediate bifurcational ridge correlated with molar furcation involvements. J Periodontol 1997;68:687-693. doi:10.1902/jop.1997.68.7.687
    Pubmed CrossRef
  8. Leknes KN, Lie T, and Selvig KA. Root grooves: a risk factor in periodontal attachment loss. J Periodontol 1994;65:859-863. doi:10.1902/jop.1994.65.9.859
    Pubmed CrossRef
  9. Andreana S. A combined approach for treatment of developmental groove associated periodontal defect. A case report. J Periodontol 1998;69:601-607. doi:10.1902/jop.1998.69.5.601
    Pubmed CrossRef
  10. Bacić M, Karakas Z, Kaić Z, and Sutalo J. The association between palatal grooves in upper incisors and periodontal complications. J Periodontol 1990;61:197-199. doi:10.1902/jop.1990.61.3.197
    Pubmed CrossRef
  11. Polson AM. Periodontal destruction associated with vertical root fracture. J Periodontol 1977;48:27-32. doi:10.1902/jop.1977.48.1.27
    Pubmed CrossRef
  12. Marquam BJ. Atypical localized deep pocket due to a cemental tear: case report. J Contemp Dent Pract 2003;4:52-64.
    Pubmed
  13. Brunsvold MA, and Lasho DJ. Cemental tears related to severe localized periodontal disease. Pract Periodontics Aesthet Dent 2000;12:536. 539-540
    Pubmed
  14. Haney JM, Leknes KN, Lie T, Selvig KA, and Wikesjö UM. Cemental tear related to rapid periodontal breakdown: a case report. J Periodontol 1992;63:220-224. doi:10.1902/jop.1992.63.3.220
    Pubmed CrossRef
  15. Ishikawa I, Oda S, Hayashi J, and Arakawa S. Cervical cemental tears in older patients with adult periodontitis. Case reports. J Periodontol 1996;67:15-20. doi:10.1902/jop.1996.67.1.15
    Pubmed CrossRef
  16. Müller HP. Cemental tear treated with guided tissue regeneration: a case report 3 years after initial treatment. Quintessence Int 1999;30:111-115.
    Pubmed
  17. Harrel SK, and Wright JM. Treatment of periodontal destruction associated with a cemental tear using minimally invasive surgery. J Periodontol 2000;71:1761-1766. doi:10.1902/jop.2000.71.11.1761
    Pubmed CrossRef
  18. Camargo PM, Pirih FQ, Wolinsky LE, Lekovic V, Kamrath H, and White SN. Clinical repair of an osseous defect associated with a cemental tear: a case report. Int J Periodontics Restorative Dent 2003;23:79-85. doi:10.11607/prd.00.0503
    CrossRef
  19. Lin HJ, Chan CP, Yang CY, Wu CT, Tsai YL, Huang CC, Yang KD, Lin CC, Chang SH, and Jeng JH. Cemental tear: clinical characteristics and its predisposing factors. J Endod 2011;37:611-618. doi:10.1016/j.joen.2011.02.017
    Pubmed CrossRef
  20. Lin HJ, Chang MC, Chang SH, Wu CT, Tsai YL, Huang CC, Chang SF, Cheng YW, Chan CP, and Jeng JH. Treatment outcome of the teeth with cemental tears. J Endod 2014;40:1315-1320. doi:10.1016/j.joen.2014.05.012
    Pubmed CrossRef
  21. Jeng PY, Luzi AL, Pitarch RM, Chang MC, Wu YH, and Jeng JH. Cemental tear: to know what we have neglected in dental practice. J Formos Med Assoc 2018;117:261-267. doi:10.1016/j.jfma.2017.09.001
    Pubmed CrossRef


This Article


Funding Information

Services
Social Network Service

e-submission

Archives