Management and 5-year follow-up of tooth with bilateral cemental tear and complete pulp canal obliteration

Abstract

The aim of this study is to report a rare case of bilateral cemental tear in a completely calcified tooth with successful dental management. A 60-year-old male reported with pain in the upper right central incisor. Radiographic examination revealed complete calcific obliteration of the root canal, inflammatory root resorption of apical third, and bilateral cemental tear and traumatic occlusion. Tooth mobility was within physiologic limits and 3-mm probing depth. Endodontic treatment of the tooth was carried out with intracanal calcium hydroxide therapy. The tooth was relieved of traumatic occlusion, scaling and root planning was carried out. As the tooth did not have any periodontal pocket, the maintenance phase was advised, and the tooth was kept under observation. After a follow-up of 5 years, the nonsurgical periodontal therapy showed satisfactory clinical and radiographic outcome.

INTRODUCTION

Cemental tear has been described as a rare periodontal condition characterized by a total or partial separation of cementum.[1] Cemental tears can be either piece-shaped or U-shaped in morphology and are seen as radiopaque fragments inside the periodontal ligament.[2] Clinical examination usually shows a unitary periodontal pocket and signs/symptoms mimicking localized periodontitis, apical periodontitis, and vertical root fractures. Cemental tears usually occur in patients older than 60 years of age (73.2%), with more proneness to abscess formation (66.2%), more commonly in men (77.5%), and more commonly in the anterior teeth (76.1%).[3]

Due to a small number of cases documented in the literature, the most available documentations are majorly case reports. We present the first documentation in endodontic literature of a bilateral cemental tear in an upper right central incisor, successfully managed with a nonsurgical approach.

CASE REPORT

A 73-year-old patient reported with pain and swelling associated with the upper right central incisor for the past 3 days [Figure 1b]. The patient gave a history of direct dental trauma to the same tooth 20 years back. Radiographic examination revealed complete calcific obliteration of the root canal and inflammatory root resorption of the apical third [Figure 1a]. A single cemental fragment on mesial aspect (about 5-mm long) was seen while the distal aspect of the root was divided into an apical segment (about 6-mm long) attached to the root and a coronal fragment (about 2-mm length) which was projecting into gingival crevice. Tooth mobility in 11 was within physiologic limits, showing 3-mm probing depth with no suppurative sites. Traumatic occlusion was present in 11 and 21. Access opening was done under magnification and a single canal was located. Biomechanical preparation was completed to an apical size of 60K file with a step-back technique. Obturation was done with lateral condensation technique with zinc oxide eugenol sealer after 2 weeks of intracanal calcium hydroxide dressing. Cemental fragment projecting in the gingival crevice was removed with the aid of locking pliers, under local anesthesia, without opening flap as it was readily accessible. Histopathological examination of the fragment confirmed the presence of detached cementum piece. Scaling and root planning were carried out. As the tooth did not have any periodontal pocket, the maintenance phase was advised. The tooth was relieved of traumatic occlusion and kept under observation to monitor the increase or decrease in pocket depth.

Figure 1.

(a) Complete calcification of the root canal, the presence of bilateral cemental tear (yellow arrows). (b) Swelling in the apical third of 11 (yellow arrow). (c) Immediate posttreatment radiograph, with walking bleach placed. (d) 5-years follow-up showing normal periapex and arrested periodontal bone loss

At 1-month recall, the walking bleach technique was used to bleach the tooth [Figure 1c]. The patient was called after 1 year for a check-up for which the patient did not visit. When the patient visited after 5 years, the upper right central incisor was asymptomatic, had tooth mobility within normal limits and 3-mm probing depth. Radiographic examination revealed no further bone loss, the absence of root resorption, and sustained bone level [Figure 1d].

DISCUSSION

Jeng et al. have described cemental tear as a special kind of root surface fracture, contributing to periodontal and periapical breakdown.4 Treatment approaches recommended include: scaling and root planning open flap debridement, bone graft, regenerative periodontal treatment, and extraction in cases of poor prognosis. The percentage of healed cemental tear cases located in the apical, middle, and cervical third of roots was 11.1%, 66.7%, and 60.0%, respectively, in a study by Lin et al. conducted on 33 teeth.[2]

In the context of the currently reported case, as part of the cementum fragment was exposed to the oral environment and the probing depth was 3 mm, only nonsurgical treatment was performed. This approach demonstrated the clinical and radiographic success as shown in the 5 years follow-up later. Conservative intervention was considered based on the rationale that the removal of the fragments would require exposure of almost all root surfaces, further threatening the already compromised bone support of the root attributable to postsurgical boss of the cervical bone. The exposed root dentin showed no evidence of external root resorption. The detached mesial fragment was not exposed to the oral cavity and was not associated with the pocket formation. Nonsurgical treatment was cost-effective, time effective, and required minimal surgical intervention.

This case was further complicated by the presence of a completely obliterated pulp with no discernible canal and external root resorption of the apical third rendering the prognosis poor to questionable. Our case had a successful outcome with absence of pathologic tooth mobility, periapical lesion and root resorption in a long term observation period of 5 years.

CONCLUSION

Nonsurgical approach can be used to successfully manage cemental fragments without direct communication with the oral cavity and can increase the long-term retention of such teeth.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.