Histopathology, Diagnosis, Management and Treatment Outcomes of Cemental Tears: A Retrospective Observational Cohort Study

ABSTRACT

Introduction

Diagnosing cemental tears remains challenging, and treatment outcomes can be unpredictable; recommendations for their diagnosis and management are primarily based on case reports and anecdotal experience. Although a classification has been developed for cemental tears, its clinical applicability and importance have yet to be investigated and validated.

Aims and Objectives

This study aims to deepen our understanding of cemental tears through a comprehensive examination of a patient cohort, focusing on: (i) evaluating the cases based on the classification for cemental tears; (ii) assessing clinical presentations, radiographic features, and histopathological characteristics; and (iii) identifying factors that influence diagnosis, treatment approaches, and clinical outcomes.

Materials and Methods

This retrospective cohort study evaluated teeth diagnosed with cemental tears at the university's endodontic clinic from September 2019 to June 2024. The review included case histories, clinical, radiographic and histopathological findings, as well as the treatments performed and their outcomes. Descriptive statistics were used.

Results

Thirty‐seven patients with 45 teeth diagnosed with cemental tears were included. Majority of affected teeth (68.9%) had received previous treatment or undergone previously initiated therapy. Among those root treated, most (84.6%) exhibited adequate obturation. Pain, swelling and/or sinus tracts, as well as significant crestal bone loss, were detected in approximately half of the cases. Cone‐beam computed tomography (CBCT) scans and direct inspection successfully identified all affected teeth, whereas periapical radiographs (PR) only detected 60.0%. Histopathological analysis revealed cementum in all 37 cases comprising 45 teeth, bone in 11 cases, and cystic lesions in 5 cases. Unfavourable treatment outcomes were observed in 78.9% of teeth classified as Class 4–6. Across all classes, regenerative approaches using enamel matrix derivatives (EMD) achieved favourable outcomes in 44.4% of teeth treated, xenografts in 38.1%, and collagen membranes in 55.6%. Notably, none of the teeth in Classes 4–6 treated with EMD or xenografts demonstrated favourable outcomes.

Conclusion

CBCT scans, direct inspection, and histopathological examination demonstrated a higher detection rate compared to PR. Classification is a critical prognostic factor, with Classes 4–6 exhibiting poorer outcomes than others. The impacts of regenerative approaches on periradicular healing appear questionable.

1. Introduction

Cemental tears, a rare condition, present a significant clinical challenge in endodontic practice. While the exact cause of cemental tears remains unknown, factors such as age, traumatic dental injury, occlusal trauma, previous endodontic or periodontal treatment and inherent structural weaknesses have been suggested (Jeng et al. 2018; Lee et al. 2021).

Clinical detection of cemental tears is highly challenging. This could be complicated by their location on the root surface, potential involvement of multiple root surfaces, entrapment of torn fragments within the granulation tissues and the inability to separate fragments upon probing (Jeng et al. 2018; Lee et al. 2021). Although some clinical presentations associated with cemental tears have been commonly reported, including periodontal abscess, suppurating periodontal pockets, swelling and/or sinus tracts, bleeding on probing and increased tooth mobility, these features are not specific to cemental tears (Blum et al. 2013; Haney et al. 1992; Lin et al. 2010; Müller 1999; Pilloni et al. 2019; Tai et al. 2007; Watanabe et al. 2012; Xie et al. 2017). They can mimic other dental pathologies, leading to misdiagnosis as endodontic disease, periodontal disease, combined periodontal‐endodontic lesions, or vertical root fractures (Ong et al. 2019; Tulkki et al. 2006; Zhao et al. 2024).

Histopathological examination and direct inspection during surgical procedures are considered the gold standards for the definitive diagnosis of cemental tears, as they provide tissue‐based evidence (Lee et al. 2021). However, these detection methods are typically employed only after initial clinical or radiographic assessments suggest the possible presence of cemental tears, serving as confirmatory procedures rather than primary diagnostic tools. Therefore, initial diagnoses often depend on clinical signs, symptoms, and/or radiographic imaging; however, the diagnostic accuracy of these methods requires further investigation, and there remains a potential for misinterpretation and misdiagnosis (Lee et al. 2021; Tulkki et al. 2006; Watanabe et al. 2012; Xie et al. 2017). Misdiagnosis often results in futile treatment attempts, such as repeated root canal or periodontal treatments, or even unnecessary extractions, without addressing the underlying issue. Thus, early detection and accurate diagnosis of cemental tears are crucial for effective management and preventing unnecessary interventions that may exacerbate the condition.

The treatment approaches suggested in the literature include root canal treatment and periodontal treatment via non‐surgical and/or surgical means, intentional replantation or extraction (Lee et al. 2021). These recommendations were based on the isolated case reports (Blum et al. 2013; Brunsvold and Lasho 2000; Camargo et al. 2003; Chou et al. 2004; Haney et al. 1992; Kuwada et al. 2024; Lin et al. 2010; Ong et al. 2019; Tai et al. 2007; Tulkki et al. 2006; Watanabe et al. 2012; Xie et al. 2017). Guided regenerative approaches have also been suggested as potentially beneficial towards favourable periradicular healing (Blum et al. 2013; Camargo et al. 2003; Damasceno et al. 2012; Lin et al. 2010; Marquam 2003; Tulkki et al. 2006). However, scientific evidence is limited to guide the effective diagnosis and management of cemental tears and their associated pathology.

This study aimed to enhance our knowledge and understanding of cemental tears by focusing on: (i) evaluating diagnosed cases based on the classification developed for cemental tears; (ii) assessing clinical manifestations, radiographic features, and histopathological characteristics associated with cemental tears; and (iii) identifying factors that may influence diagnosis, treatment approaches and clinical outcomes.

2. Materials and Methods

2.1. Study Design and Sample Recruitment

This retrospective observational cohort study included patients diagnosed with cemental tears from all individuals referred to the endodontic clinics at a local university between September 2019 and June 2024, who underwent a comprehensive endodontic assessment comprising clinical examination, radiographic evaluation with periapical radiographs and CBCT scans of the affected tooth. The patient flow chart is shown in Figure 1. The diagnosis of cemental tears, including both clinical (pre‐operative) and histopathological, was confirmed by a senior endodontist, AL and an endodontic postgraduate resident, MT. Treatment procedures were carried out by either AL, the endodontic postgraduate residents pursuing a Master's Degree in Endodontics, or hospital dental officers holding the Master's Degree in Endodontics, all under the supervision of AL. Treatment outcomes were evaluated by the respective treatment providers, with final confirmation provided by AL. The study protocol received approval from the Institutional Review Board (IRB reference no: UW 22‐788) on 12 January 2023 (UW 22‐788). All participants provided written consent to participate in the study and to the use of their data for research purposes, including the collection and processing of histopathological specimens. This study was conducted in compliance with the Declaration of Helsinki. The reporting of this observational study follows the Preferred Reporting of Observational Studies in Endodontics (PROBE) 2023 guidelines.

FIGURE 1.

Flowchart illustrating the patient flow of this study.

This study recruited patients who fulfilled the following criteria:

• –18 years or older.
• –American Society of Anaesthesiologists classification (ASA) I to III, unless otherwise specified in the exclusion criteria**.
• –Clinical documentation and records encompassing a comprehensive case history, clinical findings and radiographic interpretations were available.
• –Radiographic imaging records encompassing: (i) pre‐, intra‐, post‐operative and review digital PR; and (ii) diagnostic CBCT scans of the tooth of interest were available.
• –Histopathological confirmation of the biopsied hard tissue specimen as cemental tissue.
• –
  Periradicular radiolucent areas or infrabony defects around a tooth with:

  • –
    Unusual or abnormal radiopaque masses;
• –
  Pulpal status indicating:

  • –
    Positive or negative response to pulp sensibility tests for the teeth that had not previously received root canal treatment or undergone initiated therapy; or
  • –
    The presence of root canal filling for the teeth that were previously treated.
• –Persistent pain, swelling, or sinus tract despite appropriate periodontal and/or endodontic treatments (Note: The origin of the sinus tract was confirmed by tracing with a gutta‐percha (GP) tracer).
• –Persistent deep pocket with or without purulent discharge despite adequate periodontal and/or endodontic treatments.
• –Clinical and/or radiographic signs of progressive periodontal attachment loss despite adequate periodontal and/or endodontic treatments.
• –Differential diagnoses included periodontal‐endodontic lesion and vertical root fracture.
• –Able to give informed consent.

The patients with the following criteria were excluded from recruitment:

• –Younger than 18 years old.
• –ASA IV to VI.
• –Mentally or physically disabled**.
• –Pregnant or lactating women.
• –Patients who were immunocompromised or immunosuppressed.
• –Patients suffering from bleeding disorders or taking anticoagulants**.
• –Patients were taking anti‐resorptive drugs, such as bisphosphonates and denosumab**.
• –Patients who had received head and neck radiotherapy for cancer treatment **.
• –Split tooth.
• –Unable to give informed consent.

2.2. Data Collection

The patient's comprehensive data were gathered from various sources, including electronic clinical documentation and records, clinical photographs, PR, reconstructed CBCT imaging, haematoxylin and eosin (H&E)‐stained histological specimens and histopathological reports. The information compiled encompassed:

• –Source and reason for referral
• –Date of referral
• –Patient's chief complaint and history of complaints
• –Tooth of interest
• –Age
• –Gender
• –Medical history
• –Dental history, including any history of dental trauma
• –Clinical symptoms such as tenderness to percussion, tenderness to palpation, swelling and sinus tract (Note: The origin of the sinus tract was confirmed by tracing with a gutta‐percha (GP) tracer on a periapical radiograph)
• –Periodontal probing depth
• –Mobility and fremitus, if present
• –Presence of restorations and posts
• –Tooth wear assessment
• –Pulp sensibility test results, if applicable
• –Previous root canal treatment details, including the adequacy of root filling (i.e., homogenous root filling, extension 0–2 mm within the radiographic apex/apices, conformity to the canal path, absence of procedural errors and/or missed anatomy)
• –Assessment of crestal bone loss
• –Presence and extent of periapical or periradicular lesions
• –Classification of cemental tears, including their location, appearance and classification based on Lee et al. (2021) (Figure 2)
• –Clinical diagnosis
• –Treatment approaches, including procedures, materials used and intraoperative findings
• –Follow‐up reviews
• –Treatment outcomes
• –Histopathological findings

FIGURE 2.

Schematic representation and summary of the ‘classification of cemental tears’ based on (a) ‘classes’ and (b) ‘stages’. Red = fragment of cemental tear, blue = radiolucent area, yellow = alveolar bone, black = outline of a tooth and green = root canal system.

2.3. Radiographical Technique

The PR was taken by a digital phosphor‐plate sensor aided by a beam‐aiming device (Rinn XCP PSP Fit Phosphor Plate Holder System, Dentsply Sirona), using either Heliodent (Sirona, Bensheim, Germany) at the setting of 65 kV and 7 mA, or Planmeca ProSensor (Planmeca OY, Helsinki, Finland) at 63 kV and 8 mA using the paralleling technique with suitable exposure time depending on the tooth type and size of the patient. The VistaScan intraoral digital system (Durr Dental, Beitigheim‐Bissinger, Germany) scanned and produced the digital PR image. A high‐resolution CBCT scan was taken using Veraview X800 (J Morita Cooperation, Kyoto, Japan) at the setting of 40 mm × 40 mm field‐of‐view on ENDO mode with the exposure parameters of 90 kV, 3 mA, 0.08 mm voxel size, 360° rotation, and no more than 17.9 s exposure time, reformatted into 1.5 mm slice thickness. Images were displayed on an Apple computer, specifically a MacBook Pro (Apple Inc., Cupertino, CA, USA), with a screen resolution of 3024 × 1964 pixels. The imaging was viewed in a quiet room with closed curtains and blinds, and the overhead lights were turned off. PR images were presented using the Planmeca ROMEXIS viewer (Planmeca OY, Helsinki, Finland), while the CBCT was viewed using the One Volume Viewer software (J Morita Cooperation, Kyoto, Japan). Two assessors—a senior endodontist (AL) and a postgraduate endodontic resident (MT)—independently evaluated each case for the presence or absence of cemental tears. AL conducted prospective assessments throughout the study period, while MT performed retrospective evaluations to assess inter‐examiner reliability. They were permitted to enhance the images using various adjustment functions, including brightness, contrast and sharpness. The assessment was unblinded, as only cases identified by the treatment providers as potentially exhibiting radiographic evidence of cemental tears, based on either PR or CBCT images, or both, were included. Assessments focused on crestal bone loss, the presence and extent of periapical or periradicular lesions and the identification of cemental tears, including their appearance, location and classification as described by Lee et al. (2021). The opinion of a third assessor, a senior endodontist (CZ), was sought in cases of disagreement. All cases necessitated confirmation of radiographic evidence of cemental tears by the respective operators and AL before treatment, ensuring that patients received appropriate intervention for the identified cemental tears and associated pathologies.

2.4. Management Approaches

Patients diagnosed with cemental tears were informed of their treatment options: surgical intervention or extraction. They were informed that research on cemental tear treatments is limited, and that surgical treatment, with or without prior non‐surgical intervention, was offered as an attempt to treat the tooth without guaranteeing success. Should initial treatment fail, either surgical retreatment or extraction (as a last resort) will be provided. Ultimately, none of the patients chose extraction. The treatment approach was based on the recommendations outlined by Lee et al. (2021) and was performed by the designated treatment providers for each case. In summary, treatment was performed in 9 cases by endodontic postgraduate residents and in 4 cases by the hospital dental officers, all under the supervision of the senior endodontist, AL, who also serves as the Taught Postgraduate Programme Director. The remaining 24 cases were treated directly by AL herself. This involved a range of interventions, including non‐surgical root canal re/treatment, surgical root canal treatment (with apicectomy), surgical periodontal root debridement and intentional replantation, either as standalone procedures or in combination, as appropriate. In selected cases, regenerative approaches were employed, involving techniques such as bone grafting, membrane barrier placement and the application of biological factor (EMD), either individually or in combination, as appropriate. The decision to perform bone grafting and membrane barrier was influenced by specific criteria, including the presence of an infrabony defect (Sculean et al. 1999), cervical cortical bony plate thickness less than 3 mm (Song et al. 2013), a bony crypt size of 10 mm or larger (Pecora et al. 1995), through‐and‐through bony lesion (Taschieri et al. 2008) and the presence of periodontal‐endodontic lesions (Dietrich et al. 2003). Before commencing treatment, detailed discussions were conducted with the patients regarding the treatment plan and available options. This included an in‐depth explanation of the advantages and disadvantages, as well as potential risks and complications associated with each approach. Patient consent was obtained after ensuring they were fully informed about the proposed procedures. All patients provided their consent by signing an informed consent form.

Treatment procedures typically included raising a full‐thickness mucoperiosteal flap with or without a relieving incision, identifying and removing semi‐ or fully detached cemental tear fragments after osteotomy, and enucleating granulation tissue. The affected root surfaces were subsequently debrided and smoothed using periodontal hand curettes or engine‐driven burs for surface irregularities that were too pronounced. This was done to minimise sharp edges that could potentially cause mechanical irritation to the surrounding tissue and to eliminate any potential plaque‐retentive sites. For teeth treated with surgical root canal treatment, procedures including apical root resection, retrograde preparation and filling were carried out. The retrograde filling material used was hydraulic calcium silicate cement, including MTA Angelus (Angelus, Londrina, PR, Brazil), iRoot BP (Innovative Bioceramix Inc., Vancouver, Canada), Biodentine (Septodont, Saint‐Maur‐des‐Fossés, France), or ProRoot MTA (Dentsply Sirona, York, Pennsylvania, USA), if applicable. When EMD was used, the root surface was treated with 24% EDTA (Straumann PrefGel, Biora AB, Sweden) before the application of EMD (Straumann Emdogain, Biora AB, Sweden). For cases that received regenerative techniques, procedures usually included the use of BioGide (Geistlich Pharma AG, Wolhusen, Switzerland) with or without xenograft placement, such as BioOss (Geistlich Pharma AG, Wolhusen, Switzerland) and Cerabone (Botiss biomaterials GmbH, Zossen, Germany) bone grafts. The flap was then repositioned with 4‐0, 5‐0, or 6‐0 sutures using materials like Vicryl (Ethicon, Johnson & Johnson, New Jersey, USA), Seralene (SERAG‐WIESSNER GmbH & Co. KG, Naila, Germany), Ethilon (Ethicon, Johnson & Johnson, New Jersey, USA), or Prolene (Ethicon, Johnson & Johnson, New Jersey, USA). Antibiotics were prescribed for either three (250–500 mg amoxicillin, 375–625 mg amoxicillin and clavulanic acid) or four (150–300 mg clindamycin) times a day for 5–7 days, when a xenograft and/or collagen membrane was placed, or when the operation time was prolonged, to reduce the risk of post‐operative infection. Analgesics (e.g., paracetamol), and/or anti‐inflammatory medications (e.g., ibuprofen, etoricoxib, mefenamic acid) were prescribed as needed. Chlorhexidine 0.2% mouthwash was typically included in the prescription.

2.5. Histopathological Examination

The affected root surface was mechanically debrided during the treatment procedures, and the granulation tissue was enucleated by curettage. Hard tissue fragment/s and sizeable soft tissue specimens collected were immediately placed into a bottle containing 10% formalin solution. Root surfaces and the periradicular area were thoroughly inspected to ensure the complete removal of semi‐detached or fully detached hard tissue fragment/s, aided by methylene blue staining if needed. After the treatment, the specimens were sent to the laboratory for histopathological processing, including decalcification, paraffin fixation, serial sectioning at a thickness of 5 μm, haematoxylin and eosin (H&E) staining and polarised microscopic evaluation. The local pathological laboratories' pathologists conducted histopathological examinations of the biopsied soft tissue specimens and documented the results in the reports. Two assessors—a senior endodontist (AL) and a postgraduate endodontic resident (MT)—examined the biopsied hard tissue specimens retrospectively, with support from an oral pathologist to resolve any cases of uncertainty. The assessors were unblinded, as only cases with clinical and radiographic evidence of cemental tears underwent further treatment, during which hard tissue fragments were collected. The assessors were also aware of the treatment modalities delivered for most cases.

The histological slides of the hard tissue specimens were placed on the stage of the polarising microscope (Olympus BX51P Polarising Microscope, Olympus Corporation, Tokyo, Japan). The polariser and analyser lenses were oriented to allow the polarised light to pass through the specimens. Examination was carried out under magnifications of ×5, ×10 and ×20, and representative images of the specimens were captured. Each specimen underwent a thorough examination to discern the distinctive histological features characteristic of the following tissues:

• Cementum—incremental lines, cementum apposition lines, various cellular components and lacunae with or without cementocytes.

• Dentine—dentinal tubules, incremental lines and birefringent effects.

• Alveolar bone—lamellar bone, woven bone, trabecular bone, Haversian canals and osteocytes within the mineralised bone tissue.

• Granulation tissue was analysed by examining the cellular composition (predominantly chronic inflammatory cells and fibroblasts), neo‐blood vessels and fibrous connective tissue matrix.

• Blood clot—fibrin strands and trapped red blood cells.

2.6. Treatment Review and Outcome Assessment

All cases underwent a minimum 12‐month follow‐up, unless signs and symptoms of post‐treatment disease, i.e., unfavourable healing outcome, occurred earlier. The treatment providers conducted clinical reviews to assess for any clinical signs and symptoms, including tenderness to percussion, palpation, swelling, sinus tracts, mobility and periodontal probing depths. Radiographic findings were compared with baseline and prior reviews, if available, to assess changes in periradicular radiolucency or bone fill. The treatment outcomes for the teeth were classified as either (i) favourable outcomes—indicating complete healing, healing in progress, healing by scar tissue and/or periodontal clinical attachment gain; this outcome demonstrated the absence of clinical abnormalities (such as tenderness to percussion, palpation, swelling or sinus tract), periodontal probing depths of no greater than 3 mm with no increased mobility, re‐establishment of normal periapical periodontal ligament space, reduction in periapical or periradicular radiolucency, absence of emerging radiolucency in bone grafted lesions and/or bone fill in infrabony defects; (ii) unfavourable outcomes—encompassing post‐treatment disease, periodontal abscess, persistent or loss of periodontal clinical attachment, or extraction due to clinical signs and symptoms; or (iii) asymptomatic functional retention—refers to a tooth that shows no subjective symptoms, such as pain or swelling, despite the presence of persistent, emerging, or enlarging radiolucent lesions evident on radiographs. Clinically, there should be no tenderness to percussion, palpation, or swelling; a sinus tract may or may not be present. Periodontal probing depths may remain unchanged or decrease, although they might still be greater than 3 mm, and tooth mobility may also remain unchanged or decrease. For cases not treated by AL, the treatment providers evaluated the treatment outcomes, which were further confirmed by AL prospectively during the study period.

2.7. Statistical Analysis

Descriptive statistics were used to summarise data and outcomes at both the patient and tooth levels. Additionally, the detection rate of cemental tears was calculated based on PR, CBCT, histopathological findings and direct inspection. Inter‐examiner reliability was assessed for the determination of pre‐operative radiographic assessment and histopathological evaluation using the kappa statistic.

3. Results

A total of 37 patients with 45 teeth diagnosed with cemental tears were included in the study.

3.1. Distribution of Teeth With Cemental Tears

Among the 45 teeth studied, 24 (53.3%) belonged to females with a mean age of 64.8 years (range: 34–90 years), and 21 (46.7%) belonged to males with a mean age of 65.7 years (range: 40–84 years) (Table S1). The distribution by tooth type is as follows: 22 maxillary incisors (48.9%), 3 maxillary canines (6.7%), 1 maxillary premolar (2.2%), 1 maxillary molar (2.2%), 8 mandibular incisors (17.8%), 1 mandibular canine (2.2%), 6 mandibular premolars (13.3%) and 3 mandibular molars (6.7%). The majority of affected teeth were anterior teeth, totalling 34 (75.5%), followed by premolars with 7 (15.6%) and molars with 4 (8.9%) (Table 1).

TABLE 1.

Summary of the distribution of teeth with cemental tears.

	No. of teeth (%) with cemental tears (n = 45)
Gender
Females	24 (53.3)
Males	21 (46.7)
Classification
Class 1	6 (13.3%)
Class 2	11 (24.4%)
Class 3	8 (17.8%)
Class 4	13 (28.9%)
Class 5	4 (8.9%)
Class 6	3 (6.7%)
Tooth type
Maxillary
Incisor	22 (48.9)
Canine	3 (6.7)
Premolar	1 (2.2)
Molar	1 (2.2)
Mandibular
Incisor	8 (17.8)
Canine	1 (2.2)
Premolar	6 (13.3)
Molar	3 (6.7)
Anterior	34 (75.5)
Premolars	7 (15.6)
Molars	4 (8.9)
History of dental trauma
Yes	14 (31.1)
No	31 (68.9)
Clinical signs and symptoms
Pain
Yes	20 (44.4)
No	25 (55.6)
Swelling and/or sinus tract
Yes	20 (44.4)
No	25 (55.6)
Mobility
No	30 (66.7)
Grade 1	12 (26.7)
Grade 2	2 (4.4)
Grade 3	1 (2.2)
Crestal bone loss
No or mild (30% or less)	18 (40.0)
Moderate (40%–60%)	3 (6.7)
Severe (70% or above)	24 (53.3)
Periodontal probing depths
No or mild (3 mm or less)	25 (55.6)
Moderate (4–5 mm)	10 (22.2)
Severe (6 mm or above)	10 (22.2)
Pulpal status
History of previous endodontic treatment	26 (57.8)
Adequate root filling	22 (84.6)
Inadequate root filling	4 (15.4)
History of previously initiated therapy	5 (11.1)
Untreated	14 (31.1)
Vital	10 (71.4)
Non‐vital	3 (28.6)
Unknown	1 (7.1)
Vertical root fractures
Yes	4 (8.9)
No	41 (91.1)
Treatment
Combined non‐surgical root canal re/treatment + surgical endodontic +/ periodontal intervention	16 (35.6%)
Non‐surgical root canal re/treatment + intentional replantation	1 (2.2%)
Surgical periodontal root debridement	13 (28.9%)
Surgical root canal treatment alone (including apicectomy)	11 (24.4%)
Combined surgical endodontic + periodontal interventions	4 (8.9%)
Extraction	0 (0.0%)

Dental trauma history was noted in 14 teeth (31.1%). Pain was reported in 20 teeth (44.4%). Similarly, swelling and/or sinus tract were also observed in 20 teeth (44.4%). Most teeth, i.e., 30 teeth (66.7%), exhibited no increased mobility, 12 teeth (26.7%) with grade 1 mobility, 2 teeth (4.4%) with grade 2 mobility and 1 tooth (2.2%) with grade 3 mobility. Severe crestal bone loss (70% or above) was found in 24 teeth (53.3%), primarily those classified as Class 3 or above, followed by no or mild (30% or less) crestal bone loss in 18 teeth (40.0%) and moderate (40%–60%) crestal bone loss in 3 teeth (6.7%). The majority of teeth, i.e., 25 teeth (55.6%), had no or mild (≤ 3 mm) periodontal probing depths, while 10 teeth (22.2%) had moderate probing depths (4–5 mm) and 10 teeth (22.2%) had severe probing depths (6 mm or above) (Table 1).

Of all the teeth analysed, 26 (57.8%) had a history of previous endodontic treatment, 5 (11.1%) had undergone previously initiated therapy and 14 (31.1%) were untreated. Regarding previous endodontic treatment, 4 teeth (15.4%) had inadequate root fillings, while 22 (84.6%) had adequate root fillings. Among the untreated teeth, 10 (71.4%) were diagnosed as vital, 3 (28.6%) as non‐vital, and 1 (7.1%) with an unknown pulpal status due to the inability to perform pulp sensibility tests on a crown. Additionally, 4 teeth (8.9%) were diagnosed with vertical root fractures. The predominant approach involved combined surgical endodontic and periodontal interventions with or without prior non‐surgical root canal treatment, accounting for 20 (44.5%) of the treated teeth. In contrast, either surgical endodontic or periodontal interventions accounted for only 24 (53.3%) of the treated teeth, while intentional replantation accounted for 1 (2.2%) (Table 1).

3.2. Detection of Cemental Tears Using Various Diagnostic Methods

Periapical radiographs identified 27 teeth (60.0%), while CBCT scans, direct inspection and histopathological analysis successfully identified all teeth (100%) with cemental tears (Table 2). Figure 3 shows Tooth 11 (Class 2, Stage C) and 12 (Class 1, Stage B), where cemental tears were not visible on the PR but were identified on CBCT scans. In contrast, Figure 4 depicts a case of Tooth 11 (Class 6, Stage C) where cemental tears were detected on both PR and CBCT imaging. Typical cemental specimens are shown in Figures 3, 4, 5. Histopathological analysis also revealed the presence of bone in 11 cases (20.7%) (Figure 3) and cystic lesions in 5 cases (13.5%).

TABLE 2.

Detection of cemental tears using various diagnostic methods.

Methods	No. of teeth (%) with cemental tears (n = 45)
Periapical radiograph	27 (60.0)
CBCT	45 (100.0)
Direct inspection	45 (100.0)
Histopathological	45 (100.0)

FIGURE 3.

Case No. 8—Tooth 11 (Class 2, Stage C) and 12 (Class 1, Stage B): (i) PR did not show cemental tears, while CBCT axial, frontal and sagittal views revealed cemental tears indicated by white arrows, (ii) The surgically removed fragments consisting of acellular cementum (white arrow) with a lamellar structure and underlying dentine (green arrow) exhibiting dentinal tubular structures (haematoxylin and eosin stain; scale bar 200 μm); (iii) The surgically removed fragments consisting of necrotic bone with emptied lacunae (left) and vital bone demonstrating cementocytes in the lacunae with sparse granulation tissue (right) (haematoxylin and eosin stain; scale bar 200 μm); (iv) Intra‐surgical clinical image showing a detached cemental tear indicated by a white arrow, along with a post‐operative PR, and (v, vi) A 15‐ and 28‐month review PRs exhibiting complete apical healing, indicating a favourable treatment outcome.

FIGURE 4.

Case No. 37—Tooth 11 (Class 6, Stage C): (i) Cemental tears were identified on both the PR and the CBCT scan (note: Cemental tears indicated by white arrow), (ii) Post‐surgical PR with bone graft after complete crack reduction from the root apex, (iii) PR and clinical view at 3‐month review with recurrent swelling showing bone graft particles extruded through the sinus tract resembling ‘pop‐corn’ (indicated by yellow arrow), (iv) PR at 5‐month review (i.e., 2 months after the enucleation of loose bone graft), (v) PR demonstrates a reduction in the periapical lesion compared to the pre‐operative radiograph, with surrounding bone exhibiting increased radiopacity with diffuse border; and the 16‐month clinical review indicating favourable healing progress and (vi) The surgically removed fragments consisting acellular cementum with lamellar structure (haematoxylin and eosin stain; scale bar 200 μm).

FIGURE 5.

Case No. 21—Tooth 12 (Class 4, Stage B): (i) Pre‐operative PR with sinus tract tracing and CBCT scans (cemental tear indicated by white arrow), (ii) PR after non‐surgical root canal treatment, (iii) Pre‐surgical clinical view illustrating soft tissue swelling, extracted tooth with cemental tear indicated by white arrow, and the torn fragment, (iv) PR after intentional replantation, (v) Clinical view with recurrent swelling within 1 month, (vi) The surgically removed fragment consisting acellular cementum showing lamellar structure, and sparse granulation tissue (haematoxylin and eosin stain; scale bar 200 μm), (vii) Clinical views during second surgical intervention with apical surgery revealing extensive external root resorption and exposure of gutta percha root filling (indicated by blue arrow), and post‐operative PR after repairing the defect with Biodentine and (viii) PR and clinical view at 7‐month review, indicating favourable healing.

3.3. Classifications, Treatment Approaches and Outcome of Teeth Diagnosed With Cemental Tears

Following the conclusion of treatment, patients were scheduled for follow‐up appointments, ranging from 1 to 3 weeks postoperatively and at varying intervals thereafter. The review period ranged from 1 to 55 months, with a mean duration of 17.2 months for the 37 cases, encompassing 45 teeth. Of these, 33 teeth (73.3%) were reviewed for at least 12 months, while the remaining 12 (26.7%) had less than 12 months of follow‐up due to (i) unfavourable healing observed within 12 months (n = 10 teeth), (ii) favourable healing following a second treatment after initial unfavourable treatment response diagnosed within 12 months (n = 1 tooth; Figure 5), or (iii) favourable healing of an adjacent tooth to one with unfavourable healing diagnosed within 12 months (n = 1 tooth).

For treatment outcomes, 22 teeth (48.9%) showed favourable results after initial treatment (Figure 3), whereas 25 teeth (55.6%) showed favourable results only after retreatment (Figures 4 and 5; Table 3). Although overall unfavourable outcomes were found in 20 teeth (44.4%), including those that had been retreated, 14 of these failed cases (70.0%) remained in asymptomatic functional retention (Table 3). Upon combining Class 1–3 cases, 23 out of 25 cases (92.0%) demonstrated favourable outcomes, with one case (Case No. 24) showing an unfavourable outcome due to an associated vertical root fracture of an adjacent tooth, and another developing apical radiolucency and swelling (Table 3). In contrast, among the combined Class 4–6 cases, only 2 out of 20 teeth (10.0%) demonstrated favourable outcomes, and both achieved this after retreatment; 13 of them (65.0%) remained in asymptomatic functional retention (Table 3).

TABLE 3.

Summary of the classifications, treatment approaches and outcome of the 37 cases with 45 teeth diagnosed with cemental tears.

Case no. and ref	Tooth	Classification	Treatment approach	Treatment outcome	EMD	Bone graft	Membrane barrier	Review duration from last tx
								(first tx)
1. WTK‐H21302	21	Class 1, Stage A	reNSRCT + SRCT	Favourable	√	√		12 m
2. LYY‐H19764	21	Class 1, Stage B	reNSRCT + SRCT	Favourable		√	√	12 m
3. AYC‐P350372	21	Class 2, Stage A	SRCT	Favourable			√	18 m
4. LKM‐P018201	21	Class 2, Stage B	SRCT	Favourable			√	15 m
5. CWS‐P304513	42	Class 1, Stage B	SPT	Favourable		√		17 m
6. SYY‐P363749	44	Class 2, Stage B	SRCT	Favourable	√			13 m
	45	Class 1, Stage A	SRCT	Favourable	√			13 m
7. HMY‐H26827	13	Class 2, Stage C	SRCT	Favourable			√	15 m
8. CLM‐P332518	11	Class 2, Stage C	SRCT	Favourable	√			28 m
	12	Class 1, Stage B	SPT	Favourable				28 m
9. CWC‐H28571	13	Class 2, Stage C	NSRCT + SRCT	Favourable				12 m
10. CKSS‐P368313	36	Class 2, Stage C	reNSRCT + SRCT	Favourable	√			13 m
11. WYB‐P341769	21	Class 2, Stage D	First tx: NSRCT + SRCT	First tx: Unfavourable a , d	√	√	√	4 m
			Second tx: reSRCT	Second tx: Unfavourable a	√	√	√	15 m (19 m)
			Third tx: reNSRCT + surgical bone graft removal	Third tx: Favourable				35 m (54 m)
12. HWF‐P354525	21	Class 2, Stage D	reNSRCT + SRCT	Favourable	√			13 m
				Avulsed				20 m
13. PPC‐H28506	31	Class 2, Stage D	SRCT	Favourable	√			13 m
14. THC‐H29027	31	Class 2, Stage D	reNSRCT + SRCT	Favourable			√	12 m
15. CCF‐P040064	46	Class 3, Stage B	SPT	Favourable	√	√	√	12 m
16. SWH‐H21744	21	Class 3, Stage C	SPT	Favourable	√	√	√	21 m
17. LHF‐P345905	21	Class 3, Stage C	SPT	Favourable	√	√		19 m
18. CYL‐P000432	44	Class 3, Stage D	NSRCT + SPT	Favourable	√	√	√	37 m
	45	Class 3, Stage C	NSRCT + SPT	Favourable	√	√	√	37 m
19. HKL‐P268331	16	Class 3, Stage D	SPT	Favourable				13 m
20. WFY‐P351438	23	Class 4, Stage B	SRCT + SPT	Unfavourable b ; asymptomatic functional retention	√			14 m
21. LMFF‐H31945	12	Class 4, Stage B	First tx: NSRCT + intentional replantation	First tx: Unfavourable a , d	√			1 m
			Second tx: SRCT (EIRR)	Second tx: Favourable			√	7 m (13 m)
22. LSM‐P370443	21	Class 4, Stage B	SRCT + SPT	Unfavourable a , d	√			6 m
	11	Class 1, Stage A	SPT	Favourable				7 m
23. CYF‐P333159	11	Class 4, Stage C	SRCT	Unfavourable a , c , d	√			25 m
24. CSH‐P360085	31	Class 4, Stage C	NSRCT + SRCT	Unfavourable c ; asymptomatic functional retention		√	√	12 m
	32	Class 4, Stage C	SRCT	Unfavourable c (VRF); asymptomatic functional retention		√	√	12 m
	33	Class 3, Stage B	SPT	Unfavourable b ; asymptomatic functional retention		√	√	12 m
25. CKK‐P351260	45	Class 4, Stage C	NSRCT + SPT	Unfavourable b , d (extracted)	√	√		7 m
26. YYN‐H18769	22	Class 4, Stage C	SRCT	Unfavourable b , c ; asymptomatic functional retention		√	√	3 m
27. CCF‐P349717	31	Class 4, Stage D	NSRCT + SRCT	Unfavourable c				30 m
	41	Class 3, Stage B	SPT	Unfavourable a , b , c				30 m
28. HSL‐P357070	35	Class 4, Stage D	First tx: reNSRCT + SPT	First tx: Unfavourable a , b , c , d	√	√		6 m
			Second tx: SRCT + bone graft removal	Second tx: Unfavourable c ; asymptomatic functional retention	√			19 m (25 m)
	36	Class 4, Stage D	NSRCT + SPT	Unfavourable b ; asymptomatic functional retention	√	√		19 m
29. FFL‐P359819	31	Class 4, Stage D	NSRCT + SRCT	Unfavourable c ; asymptomatic functional retention		√	√	12 m
30. XHJ‐P356931	21	Class 4, Stage D	reNSRCT + SRCT	Unfavourable a , c ; asymptomatic functional retention		√	√	6 m
31. LKM‐P148021	14	Class 5, Stage A	SPT	Unfavourable b ; asymptomatic functional retention	√			10 m
32. LSY‐P192710	11	Class 5, Stage B	SPT	Unfavourable a , b ; asymptomatic functional retention	√			10 m
33. NWS‐P341899	21	Class 5, Stage B	SPT	Unfavourable b	√	√		4 m
				Cervical root fracture				9 m
34. CF‐P365450	11	Class 5, Stage C	SPT	Unfavourable b ; asymptomatic functional retention	√			11 m
35. YWP‐P350023	21	Class 6, Stage C	First tx: SRCT + SPT	First tx: Unfavourable b , c , d	√	√	√	10 m
			Second tx: re SRCT + SPT + bone graft removal	Second tx: Unfavourable b ; asymptomatic functional retention	√			34 m (44 m)
36. LLC‐P322888	11	Class 6, Stage C	First tx: SRCT	First tx: Unfavourable a , c	√	√		3 m
			Second tx: surgical bone graft removal + antibiotic dressing	Second tx: Favourable				16 m (19 m)
37. HKC‐P356219	21	Class 6, Stage C	SRCT + SPT	Unfavourable b ; asymptomatic functional retention	√			6 m

Note: Favourable outcome: after initial tx = 22/45; include retreatment = 25/45. Unfavourable outcome: 20/45. Asymptomatic functional retention: 14/20.

Abbreviations: EIRR, external inflammatory (infection‐related) root resorption; EMD, enamel matrix derivatives; m, months; NSRCT, non‐surgical root canal treatment; reNSRCT, non‐surgical root canal retreatment; SPT, surgical periodontal root debridement; SRCT, surgical root canal treatment; tx, treatment; VRF, vertical root fracture.

^a Swelling and/or sinus tract.

^b Persistently deep (≥ 3 mm) or worsened probing depths.

^c Emerging or enlarging periradicular radiolucency.

^d Pain.

3.4. Treatment Efficacy of Regeneration Methods According to the Classification of Cemental Tears

Treatment efficacy of the regeneration method used (EMD, xenografts and membranes) based on the classification of cemental tears is summarised in Table 4. When EMD was applied, 12 out of 13 (92.3%) teeth in Class 1–3 showed favourable outcomes, while none of the 14 (0.0%) teeth in Class 4–6 demonstrated favourable outcomes. Xenograft placement resulted in markedly higher favourable outcomes in Class 1–3 cases, i.e., 8 out of 10 (80.0%) teeth compared to Class 4–6 cases, i.e., 0 out of 11 (0.0%) teeth (Table 4). Additionally, the use of collagen membrane barriers led to a higher rate of favourable outcome in Class 1–3 cases (9 out of 11 teeth; 81.8%) compared to Class 4–6 cases (1 out of 7 teeth; 14.2%) (Table 4).

TABLE 4.

Summary of the treatment efficacy of regeneration methods (EMD, xenografts, and membranes) according to the classification of cemental tears.

Classification (no. of teeth with cemental tears)	EMD		Xenografts		Membrane barrier
	No. of treated teeth	Favourable treatment outcome (%)	No. of treated teeth	Favourable treatment outcome (%)	No. of treated teeth	Favourable treatment outcome (%)
Class 1, Stage A (n = 3)	2	2 (100.0%)	1	1 (100.0%)	0	n/a
Class 1, Stage B (n = 3)	0	n/a	2	2 (100.0%)	1	1 (100.0%)
Class 2, Stage A (n = 1)	0	n/a	0	n/a	1	1 (100.0%)
Class 2, Stage B (n = 2)	1	1 (100.0%)	0	n/a	1	1 (100.0%)
Class 2, Stage C (n = 4)	2	2 (100.0%)	0	n/a	1	1 (100.0%)
Class 2, Stage D (n = 4)	3	2 (66.7%)	1	0 (0.0%)	2	1 (50.0%)
Class 3, Stage B (n = 3)	1	1 (100.0%)	2	1 (50.0%)	2	1 (50.0%)
Class 3, Stage C (n = 3)	3	3 (100.0%)	3	3 (100.0%)	2	2 (100.0%)
Class 3, Stage D (n = 2)	1	1 (100.0%)	1	1 (100.0%)	1	1 (100.0%)
Class 4, Stage B (n = 3)	3	0 (0.0%)	0	n/a	1	1 (100.0%)
Class 4, Stage C (n = 5)	2	0 (0.0%)	4	0 (0.0%)	3	0 (0.0%)
Class 4, Stage D (n = 5)	2	0 (0.0%)	4	0 (0.0%)	2	0 (0.0%)
Class 5, Stage A (n = 1)	1	0 (0.0%)	0	n/a	0	n/a
Class 5, Stage B (n = 2)	2	0 (0.0%)	1	0 (0.0%)	0	n/a
Class 5, Stage C (n = 1)	1	0 (0.0%)	0	n/a	0	n/a
Class 6, Stage C (n = 3)	3	0 (0.0%)	2	0 (0.0%)	1	0 (0.0%)
Total n = 45	27	12 (44.4%)	21	8 (38.1%)	18	10 (55.6%)

In cases with unfavourable outcomes, retreatments were provided on 5 teeth, including the removal of bone grafting materials in 3 of them (Table 3, Figure 4). Subsequently, favourable outcomes were achieved in 3 cases, and asymptomatic functional retention was maintained in the remaining 2 cases. One case developed a recurrent chronic apical abscess within 1 month after intentional replantation (Figure 5v). During retreatment, extensive external apical inflammatory root resorption was observed involving the denuded area from the previous cemental tear (Figure 5vii). After retrograde preparation and filling, including the coverage of the resorbed surface with bioceramic material, clinical signs and symptoms resolved. In this study, two cases were eventually lost due to dental trauma (Table 3).

3.5. Inter‐Examiner Reliability

Inter‐observer agreement, measured by kappa scores, was substantial for periapical radiographs (PR) at 0.68, nearly perfect for CBCT scans at 0.89 and perfect for histopathological evaluation at 1.00.

4. Discussion

The detailed analysis of clinical and radiographic characteristics, along with treatment modalities for cemental tears, has been rarely reported in previous literature. This clinical study, for the first time, compared the rates of PR and CBCT in detecting cemental tears, using histopathological findings and direct inspection as the gold standard for confirming cemental tears. The importance of classifying cemental tears and their impact on treatment outcomes was also assessed, revealing several noteworthy findings that are discussed below.

In agreement with other studies, incisors were the predominant tooth type found with cemental tear/s (66.7%), consisting primarily of maxillary incisors (48.9%) (Table 1) (Keskin and Güler 2017; Qari et al. 2019). Anterior teeth accounted for the highest number of teeth diagnosed with cemental tears, with a frequency of 75.6% (Table 1), which also aligns with other researchers' findings (Leknes et al. 1996; Lin et al. 2011). This might have been due to clinicians and patients prioritising resource allocation to diagnose and treat anterior teeth, given their aesthetic importance, despite facing challenges with non‐healing after treatment. Consequently, this increased focus likely led to more accurate diagnosis, treatment and documentation of cemental tears in anterior teeth. However, our findings contrast with a recent retrospective cohort study by Zhao et al. (2024), which reported the highest prevalence of cemental tears in molar teeth at 71.4%. This discrepancy may be attributed to the broader, more heterogeneous patient population in their study. In contrast, our research focused specifically on patients referred to endodontic clinics with strict inclusion criteria, which may have led to different prevalence patterns. This study did not demonstrate an apparent gender predilection, consistent with results reported in other studies (Lin et al. 2011; Keskin and Güler 2017; Özkan and Özkan 2020).

Although pain, swelling and sinus tracts, as well as severe crestal bone loss were not uncommon, none of these clinical manifestations can be considered pathognomonic of the cemental tears. Interestingly, most affected teeth did not show increased mobility, deep periodontal probing depths, or a history of dental trauma. It was speculated that cases with increased mobility and deep periodontal probing depths could be misdiagnosed as originating from periodontal disease, reducing the likelihood of referral for endodontic assessment. The results of this study demonstrated that diagnosing cemental tears should not depend solely on clinical signs and symptoms.

In this study, one‐third of the teeth diagnosed with cemental tears were untreated, among which over 70.0% were vital, in agreement with Zhao et al. (2024). These findings raised concerns about initial endodontic misdiagnosis and inappropriate treatment decisions. The prevalence of teeth with a history of previous endodontic treatment was 57.8%, notably higher than the 22% previously reported (Lee et al. 2021). This difference may be attributed to regional variations in the study population and the nature of the referral clinic, which tends to attract more cases of perceived ‘failed endodontic treatments’ for consultation and management in this study. Interestingly, almost 85% of treated cases with cemental tears had root fillings of adequate quality. This suggests the inherent biological trade‐off in attaining a densely compacted root filling without voids, as the instruments and techniques used during obturation can exert stress on the root structure (Saw and Messer 1995). Such stress may lead to crack formation within the cementum and around the cemento‐dentinal junction, which is often an intended outcome to achieve a homogeneously compacted root filling, as seen on post‐operative radiographs.

This study demonstrated that CBCT scans and direct inspection have a higher chance of detecting the presence and extent of cemental tears than PRs. The latter identified cemental tears in only 60.0% of cases, aligning with findings reported by other researchers (Jeng et al. 2018; Lee et al. 2021; Nagata et al. 2016; Ong et al. 2019). This was expected, given the limitations of 2‐dimensional radiographs in identifying cemental tears (Haney et al. 1992; Lin et al. 2011; Qari et al. 2019). However, multiple periapical radiographs taken at different angulations might improve the chance of detecting cemental tears, but this approach was not employed in this study. As a result, the detection rate of PR may have been underestimated. In all cases, cemental fragments were observed during surgery due to their distinct clinical appearance and partial attachment/detachment on the root surface. However, differentiating between fully detached hard tissue fragments embedded within granulation tissue as either bone, dentine, or cemental tissue can be challenging, highlighting the vital role of histopathological examination in definitive diagnosis (Figure 3).

Several notable clinical findings were observed during surgery. It was common for 3‐dimensional radiographic assessments to underestimate the actual number of cemental tears compared to direct surgical inspection. This may explain why the extension and severity of many bony defects appeared disproportionately larger relative to the number and size of radiopaque masses detected radiographically. Therefore, accurately determining prognosis with current diagnostic tools can be difficult without exploratory surgery, as there is a risk of underestimating the extent of cemental denudation on the root surface. Some cemental tears were firmly attached to the bony defect wall or embedded within the connective tissue beneath the flap, which could not have been detected or removed without surgical intervention. Any remaining cemental tears could have severe consequences (Brunsvold and Lasho 2000; Ong et al. 2019). Thus, a surgical approach involving open flap debridement or periradicular surgery is likely more effective in ensuring complete removal of cemental tears.

In a few cases, signs of infection from initial treatment resolved after the removal of bone graft materials (Table 3; Figure 4). Drawing from findings in a systematic review and meta‐analysis of implant studies, bone graft has been identified as a significant risk factor for implant failure, suggesting a potentially detrimental effect on bone healing (Clauser et al. 2022). However, several limitations were identified with the included studies, including: (i) heterogeneity across studies due to varied study design, (ii) the use of diverse bone graft materials, including autografts, allografts, xenografts and synthetic grafts and (iii) possible neglect of confounding factors like bruxism and smoking (Clauser et al. 2022). In this cohort study, the suitability of xenograft for the morphologies of infrabony defects observed in Class 4–6 cases might be a potential confounding factor, although the existing literature supports its use for the regeneration of infrabony defects (Sculean et al. 2003, 2004). This issue warrants further investigation in future clinical research. On the other hand, strict aseptic protocols were rigorously followed, and systemic antibiotics were routinely prescribed for patients undergoing grafting procedures throughout the study. Consequently, the likelihood of secondary infection of the bone graft was expected to be minimal, albeit not impossible. It is hypothesised that cemental denudation exposes a large area of dentinal tubules, creating a communication pathway between the pulpal space and the periodontium. This interface can serve as a protected environment for harbouring microbial infections that are resistant to treatment. Consequently, bacteria and their byproducts can ingress and egress through the exposed dentinal tubules in the affected area (Love and Jenkinson 2002), as illustrated in Figure 5. This process may have sustained and perpetuated the inflammatory response in the surrounding periradicular area (Seltzer et al. 1963). The presence of xenografts not only acts as a foreign body but also serves as a niche for biofilm formation and retention, thereby sustaining an extraradicular infection that is resistant to access and eradication by the host immune system.

Post‐surgical assessments showed poor periradicular healing in Class 4–6 cases, which commonly featured apico‐marginal bony defects and crestal bone loss (Lee et al. 2021). This finding aligns with the results of endodontic microsurgery outcome studies, which reported a significantly lower rate of periradicular healing in cases with periodontal‐endodontic lesions compared to those with solely endodontic lesions (Kim et al. 2008; Song et al. 2011). The removal of granulation tissue and cemental tears inevitably led to extensive infrabony defects with apico‐marginal communication to the oral cavity, increasing the tooth's susceptibility to factors that might negatively impact treatment outcomes, notably biofilm‐induced infections comprising a complex and diverse microbial community (Gomes et al. 2015; Li et al. 2014).

4.1. Limitations of This Study and Future Directions

The key limitations of this retrospective observational cohort study are the absence of assessor blinding and the lack of standardised treatment protocols. This unblinded approach may have introduced bias, potentially leading to an overestimation of cemental tear detection across various diagnostic methods, since their presence was a primary focus of the research. However, our team is currently undertaking a diagnostic accuracy study to address the limitations related to assessor blinding. Despite the best efforts to minimise procedural bias, variations in operator experience and skill remained potential factors that could influence treatment outcomes. The treatment approach was continually adjusted and refined throughout the study based on identified factors that could impact treatment outcomes. For example, upon realising that bone grafts might have impeded bone healing and contributed to treatment failure as early as 3 months, modifications were made to the protocol to exclude bone grafts. However, whether this effect was specific to xenografts or applicable to other types of bone grafts, such as autografts or allografts, remained unknown and could be an area for future clinical research. Exploring alternative biological therapeutic approaches, such as platelet‐derived growth factor or platelet‐rich fibrin clot, bone morphogenetic proteins, and fibroblast growth factor, may be necessary, given the limited efficacy of EMD demonstrated in this study. The inconsistent review intervals also posed challenges in monitoring the healing progress over time. This underscores the importance of consistent and close monitoring in cases with increased clinical attachment loss to prevent failures resulting from inadequate maintenance care.

Due to the absence of control or randomisation, this study is susceptible to inherent biases and limitations commonly found with observational studies. While emphasising the importance of conducting randomised clinical trials to establish a more robust evidence base and refine management protocols, the feasibility of such trials may be limited by the rarity of these cases. Although the results of this cohort study were based on descriptive analysis due to the limited sample size, they provide valuable preliminary data revealing meaningful trends and patterns in clinical outcomes and prognoses related to the classification and effects of different treatment modalities. Therefore, this study is an initiative towards future collaborative, large‐scale, multi‐centre clinical trials that can support statistical analyses and potentially lead to the design of randomised controlled clinical trials. This would enable a more thorough validation of the observed trends and patterns from the current study.

Although some studies have categorised cemental tears based on their location along the root—which are classified as coronal, middle, or apical—our authors found it almost impossible to clinically assign the tears to a single specific region (Lin et al. 2014; Zhao et al. 2024). This is because cemental tears often extend over varying lengths and frequently occur in multiple and different locations on the root surfaces of a single tooth, making the classification proposed by Lee et al. (2021) for cemental tears more clinically relevant. This is the first clinical study conducted according to the classification developed for cemental tears. The classification includes two subtypes: primary ‘Classes’ and secondary ‘Stages’. However, the small number of cases representing specific primary and secondary subtype combinations hampers our ability to identify meaningful trends or patterns on ‘Stages’ (Table 4), as the authors caution that any conclusions drawn from interpreting the ‘Stages’ in isolation may be misleading. This limitation is expected to be addressed as more cases are collected in the future. Several concerns have been raised regarding the application of the classification to clinical cases. Classes 5 and 6 represent cemental tears detectable through periodontal probing; however, in some instances, detection was only possible when the area was anesthetised, as probing of deep and inflamed sites could inflict considerable discomfort in patients. When cemental tears were only minimally detached from the root surface, they could easily be overlooked during probing, regardless of their location. This could lead to misclassification and underestimation of Class 5 and 6 cases, potentially affecting prognosis assessments and treatment planning. Moreover, multiple tears may coexist on a single tooth, affecting different root surfaces to varying degrees; however, the classification assigns only the most severe ‘Class’ and ‘Stage’ to each tooth. Fortunately, it is unlikely to cause significant issues, as the prognosis of a tooth is usually influenced by the sites most severely affected. Although the current study suggests that ‘Classes’ is an important prognostic factor, future clinical studies are required to validate the observed trends and patterns from this study. Despite all the limitations mentioned, this study should lay the groundwork for developing more effective treatment strategies and research protocols for this complex condition.

5. Conclusion

Although torn cemental fragments often present with persistent signs such as pain, swelling, sinus tract formation or severe crestal bone loss, relying solely on clinical findings is insufficient for reliable diagnosis. CBCT scans are recommended to enhance the detection of cemental tears, but surgical exploration remains crucial for prognosis prediction and complete removal through direct inspection. The classification of cemental tears significantly impacts treatment outcomes; cases categorised as Class 4–6 tend to have unfavourable prognoses regardless of the treatment approach. Caution is advised with the use of xenografts, as their effectiveness in promoting favourable healing responses remains questionable.

Author Contributions

Conceptualisation: A.H.C.L. and C.Z. Data curation: A.H.C.L. and M.Z.T. Formal analysis: A.H.C.L. and M.C.M.W. Investigation: A.H.C.L. Methodology: A.H.C.L., C.Z. and M.C.M.W. Project administration: A.H.C.L. Resources: A.H.C.L. and M.Z.T. Supervision: C.Z. and M.C.M.W. Validation: A.H.C.L. and M.Z.T. Visualisation: A.H.C.L. and C.Z. Writing – original draft preparation: A.H.C.L., C.Z. and M.C.M.W. Writing – review and editing: A.H.C.L. and C.Z.

Funding

Patients treated by the endodontists and hospital dental officers were funded by the local hospital, and patients treated by the endodontic residents were self‐funded.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Table S1: Summary of demographic distributions and clinical findings of the 37 cases with 45 teeth diagnosed with cemental tears.

Table S2: Summary of the radiographic findings, direct inspection and histopathological examinations of the 37 cases with 45 teeth diagnosed with cemental tears.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.