Clinical Consideration of Two Patients with Cemental Tear based on Three-dimensional Diagnostic Imaging

<p> Purpose: A cemental tear is a type of root fracture in which part of the cementum exfoliates along the cemento-dentinal junction or the cementum growth line, resulting in local destruction of periodontal tissue. Because the symptoms are similar to those of periodontal disease and apical periodontitis, it is important to perform an accurate differential diagnosis. This report describes two cases in which different treatments were performed depending on the location of the cemental tear. We compare the degree of difficulty in imaging diagnosis and treatment planning using periapical radiography and cone-beam computed tomography (CBCT), and the related clinical considerations.</p><p> Case: In case 1, a 71-year-old male patient was found to have a deep periodontal pocket at the mesial and palatal sides of the maxillary left central incisor. Periapical radiography and CBCT examinations were performed, and a diagnosis of cemental tear was established from these findings. During flap surgery, the fragment of cementum was removed and debridement was performed, and the periodontal pocket depth was subsequently reduced. In case 2, a 76-year-old female patient was found to have a sinus tract in the gingiva between the maxillary right central incisor and the lateral incisor. The central incisor was slightly painful, and the periodontal pocket depths around the central and lateral incisors were 2-3 mm. A diagnosis of chronic apical periodontitis of the central incisor was established by periapical radiography, and root canal treatment was performed as usual, but the sinus tract did not disappear. Because abnormal findings in the root canal such as root fractures were not detected using a microscope, CBCT examination was performed taking into consideration the possibility of performing an apicoectomy. The CBCT images showed a low density area extending at the palatal and distal sides of the maxillary right central incisor, and there was no contact between the lesion and the apical foramen. Therefore, it was unlikely to be apical periodontitis in this case, but no diagnosis was reached. Although endodontic surgery was considered, the patient requested prompt and reliable healing, so the tooth was extracted and the lesion was removed. Examination of the extracted tooth revealed signs of a cemental tear on the palatal surface at the midpoint of the root, so a diagnosis was made of an inflammatory lesion associated with a cemental tear.</p><p> Conclusion: To determine the optimal treatment strategy for a cemental tear, it is important to choose a treatment option based on an understanding of the location and situation of the cemental tear, as well as the three-dimensional progression of the lesion.</p>