Cemental tears : a new classification, retrospective observational and clinical cohort study

Abstract

Cemental tears represent a clinically significant but unfamiliar condition in endodontics, marked by the complete or partial detachment of cementum within the cemental structure or around the cemento-dentinal junction. Despite their clinical importance, the epidemiology, aetiologies, pathophysiology, predisposing factors, treatment modalities, and outcomes of cemental tears remain poorly understood due to their rarity and limited scientific evidence. Three studies have been undertaken to advance the comprehension of this uncommon phenomenon. The first study reviewed the epidemiology, aetiologies, manifestation, and management of cemental tears based on 37 articles. A new classification for cemental tears is proposed based on Class 0-6 and Stage A-D. Classification is subsequently linked to the treatment strategies in a step-by-step clinical approach, as appropriate.

A retrospective observational study was conducted on 445 patients/cases with the following objectives: (i) determine the prevalence of cemental tears using high-resolution, small field-of-view (FOV) cone-beam computed tomography (CBCT) scan and digital periapical radiographs (PR) among patients referred to a University Postgraduate Endodontic Clinic; (ii) categorise the identified cases with cemental tears based on the new classification proposed; and (iii) evaluate predisposing factors associated with cemental tear occurrence. Cemental tears were identified in 25 cases, resulting in a prevalence of 5.6%. Fifteen cases (60%) were visible on intraoral PR and CBCT, while the remaining ten were only detectable on CBCT. Most cases (72%) with cemental tears had undergone root canal treatment initiation or completion. Factors such as incisors, increased tooth mobility, severe crestal bone loss, and root fillings of adequate quality were significantly associated with a higher prevalence of cemental tears.

In the meantime, a clinical cohort study was conducted aiming to (i) evaluate cemental tears through the new classification and provide detailed insights from forty diagnosed cases, (ii) enhance comprehension of the clinical manifestations, radiographic characteristics, and histopathological features related to cemental tears, while investigating the sensitivity of their diagnostic value; and (iii) investigate the factors that may impact the diagnosis, treatment, and outcomes of cemental tears. Information about case histories, clinical evaluations, radiographic assessments, histopathological findings, prognosis, treatment approaches, and outcomes with reference to the new classification system were collated. Most cases (70.8%) with cemental tears had undergone root canal treatment initiation or completion, predominantly affecting those with adequate obturation. More than half of the affected teeth exhibited pain (55%), swelling and/or sinus tracts (57.5%), and severe crestal bone loss (52.1%); whereas increased tooth mobility and deep periodontal probing depths were not prevalent features. CBCT scans and direct inspection identified all (100%) cases, whilst periapical radiographs only detected 55% of cases. Histopathological findings indicated the presence of cementum in all 36 hard tissue specimens examined, bone in 13 cases, and cystic lesions in 5 cases, with chronic inflammatory cell infiltration being a common feature. Class 4, 5, and 6 cases exhibited unfavourable treatment outcomes in about 74% of cases across various treatment modalities, compared to only 4% in Class 1, 2, and 3 cases. This highlights the critical role of classification as a prognostic factor influencing treatment outcomes. The impact of regenerative approaches on periradicular healing remains inconclusive, with a potential adverse effect observed when xenograft is used.