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Cemental Tears Related to Severe Localized Periodontal Diseasetal Disease

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.

 References

  1. Haney JM, Leknes KN, Lie T, et al. Cemental tear related to rapid periodontal breakdown: A case report. J Periodontol 1992;63(3):220-224.
  2. Ishikawa I, Oda S, Hayashi J, Arakawa S. Cervical cemental tears in older patients with adult periodontitis: Case reports. J Periodontol 1996;67(1):15-20.
  3. Leknes KN. The influence of anatomic and iatrogenic root surface characteristics on bacterial colonization and periodontal destruction: A review. J Periodontol 1997;68(6):507-516.
  4. Muller HP. Cemental tear treated with guided tissue regeneration: A case report 3 years after initial treatment. Quint Int 1999;30(2):111-115.
  5. Somerman MJ, Sauk JJ, Foster RA, et al. Cell attachment activity of cementum: Bone sialoprotein II identified in cementum. J Perio­dontal Res 1991;26(1):10-16.
  6. McAllister B, Narayanan AS, Miki Y, Page RC. Isolation of a fibroblast attachment protein from cementum. J Periodontal Res 1990;25(2):99-105.
  7. Lang NP, Kiel RA, Anderhalden K. Clinical and microbiological effects of subgingival restorations with overhanging or clinically perfect margins. J Clin Periodontol 1983;10(6):563-578.
  8. Moskow B. Calculus attachment in cemental separations. J Periodontol 1969;40(3):125-130.
  9. el Mostehy MR, Stallard RE. Intermediate cementum. J Periodontal Res 1968;3(1):24-29.
  10. Yamamoto T, Wakita M. Initial attachment of principal fibers to the root dentin surfaces in rat molars. J Periodontal Res 1990;25(2):113-119.
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