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

Abstract

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.

Successful regenerative response of a severe bone defect in a right lower central incisor affected by a cemental tear

“…2 Each simple regenerative approach is recommended for Classes 3 and 5 and Stage A with a narrow 3-walled intrabony defect or crater. 2 In fact, a case of treatment for cemental tear of Class 6/Stage C, for which the combined approach of application of enamel matrix derivative (EMD) and placement of Bio-Oss was applied, has been reported. 2 Thus, combined regenerative treatment is, in general, recommended in Class 3/Stage C-case instead of a simple regenerative treatment.…”

“…2 In fact, a case of treatment for cemental tear of Class 6/Stage C, for which the combined approach of application of enamel matrix derivative (EMD) and placement of Bio-Oss was applied, has been reported. 2 Thus, combined regenerative treatment is, in general, recommended in Class 3/Stage C-case instead of a simple regenerative treatment. However, single regenerative treatment with a biologic regenerative factor was chosen in the present case of Class 3/Stage C because #25 had extensive labial bone defect with the labial center deep periodontal pocket.…”

“…This was diagnosed as a case of cemental tear accompanied by severe periodontitis. According to the new three‐dimensional classification of cemental tears, 2 this case was classified as Class 3 (clinically inaccessible, infrabony and/or dehiscence, no apical involvement)/Stage C (cemental tear and the associated bony defect involves 3 surfaces of the root). The clinical symptoms and the results of the examinations suggested periodontal treatment (surgical removal of cemental fragments and granulomatous tissue, biopsy of removed tissues, and periodontal regenerative therapy with rhFGF‐2), but not endodontic treatment.…”

“…A cemental tear, the detachment of cementum from the root surface, may cause periodontal breakdown, although its pathogenesis has not been fully elucidated 1–3 . A cemental tear often mimics periapical periodontitis, vertical root fracture, or an endodontic‐periodontal lesion 2,4–8 . Therefore, interpretation of the images of dental X‐rays and cone‐beam computed tomography (CBCT) and of clinical examinations, including pulp vital testing and measurement of periodontal pocket depth, needs to be carefully conducted to distinguish a cemental tear from the other lesions 2,4–6,9–12 …”

“…A cemental tear, the detachment of cementum from the root surface, may cause periodontal breakdown, although its pathogenesis has not been fully elucidated 1–3 . A cemental tear often mimics periapical periodontitis, vertical root fracture, or an endodontic‐periodontal lesion 2,4–8 .…”