Cemental Tears Related to Severe Localized Periodontal Diseasetal Disease
Michael A. Brunsvold, DDS, MS • David J. Lasho, DDS, MS
Cemental tears should be considered as a potential etiology
for the development of accelerated periodontitis in localized sites.1-4
Since cementum anchors periodontal ligament fibers that connect the tooth root to
bone, it is an essential aspect of the periodontium. The cementum also
influences periodontal repair and regeneration.5,6 Cemental tears
presumably contribute to periodontal destruction by upsetting the microflora of
the normal gingival sulcus in a manner similar to that of subgingival
overhanging restorations.7
While cemental tears may be caused by occlusal traumatism or
traumatic injuries, their etiology is not well established. They occur within
exposed as well as unexposed cementum, and may be a result of complete
separation along the cementodentinal junction or a partial split within the
incremental lines of cementum.8,9
Histological evidence suggests that cemental tears often
occur along the cementodentinal junction.3 A layer with glycoprotein
properties has been noted along the cementodentinal border,10 and
fiber continuity has not been proven to exist between the dentin and cementum.
The findings indicate that interconnection between the cementum and the dentin
may be weaker than it is between the cementum and the fibers of the periodontal
ligament.
Although no demographic information is available with regard
to the prevalence of cemental tears within specific populations, they may be
more common in older patients.2 The literature indicates that these
abnormalities may occur more frequently than reported and often remain
undiagnosed. Due to the presence of superimposed tooth structure, cemental
tears cannot be radiographically detected on the facial or lingual root
surfaces.
Treatment alternatives for periodontal lesions associated
with cemental tears include root planing,2 debridement with bone
grafting,1 guided tissue regeneration,4 and extraction.3
The method selected for treatment is contingent upon the severity of the
periodontal destruction. Guided tissue regeneration has been utilized to treat
rapidly progressive periodontitis associated with a cemental tear.4
In this instance, a nonresorbable barrier was used to treat a three-wall
intrabony lesion, and fragmentation of new cementum was not noted following 3
years of treatment. Resolution of the defect was noted clinically and
radiographically.4
The repair potential of cemental tears is reduced by
bacterial colonization as a result of exposure to the oral environment in a
periodontal pocket. Calculus attachment has also been reported in incomplete
cemental separations.8 Cemental fragments are not always visually
evident, and tactile sensation must be utilized to locate the soft granulation
tissue that remains in the socket. Residual infection may cause complications
when a cemental tear is completely separated from the root and remains
undiagnosed within the periodontal tissues following tooth extraction.
Case Presentation
A 60-year-old male patient in good systemic health required
emergency treatment of a loose and painful mandibular incisor. The patient had
been previously treated with periodontal surgery and was periodically monitored
every 4 months. A periapical radiograph revealed a large periapical lesion that
could be probed to 10 mm in depth on the facial and lingual surfaces (Figure
1A). While the radiographic pattern of bone loss was localized and severe, it
was not indicative of periodontal bone destruction. An unusual calcified body
was noted on the radiograph near the apex of the affected tooth. Since the
incisor had a Class III mobility, it was extracted and temporarily replaced by
a natural tooth crown, which was bonded to the adjacent teeth. The bone lesion
failed to heal following 8 months of treatment (Figure 1B), and a draining
fistula was noted at the facial aspect of the extraction site (Figure 2). A
retained cemental tear was diagnosed and the area was reentered via a small
facial flap (Figure 3). The loose fragment of cementum was removed and the area
healed uneventfully. Healing was complete at the 2-year follow-up and no signs
or symptoms of infection were noted. A bonded fixed partial denture was
utilized to replace the provisional restoration (Figures 4 and 5).
Discussion
The postoperative residual infection occurred as a result of
a residual cemental fragment in the extraction site following tooth removal.
When extraction is indicated, location and removal of all fragments are vital.
Retention of cemental fragments should be considered as a potential cause of
unusually extended healing periods.
Although many localized lesions of periodontal destruction
caused by cemental tears can be successfully treated with traditional
periodontal procedures, nonsurgical treatment of lesions associated with
cemental tears may increase the potential of residual contamination. Complete
removal of the cementum fragment is required to avoid subsequent complications.
Debridement of the lesion is indicated for most periodontal surgical treatment
modalities in order to reduce resultant infection. Cemental tears can cause
rapid localized periodontal disease, and complete uneventful healing is
dependent on the total removal of cementum fragments.
*Associate Professor, Department of Periodontics, The
University of Texas Health Science Center at San Antonio, San Antonio, Texas.
**Assistant Professor, Department of Periodontics, The
University of Texas Health Science Center at San Antonio, San Antonio, Texas.
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