9306_IPC_AAP_553360 11/29/00 5:30 PM Page 1761
Case Report
Treatment of Periodontal Destruction Associated With a
Cemental Tear Using Minimally Invasive Surgery
Stephen K. Harrel* and John M. Wright†
Background: A patient presented with moderate
probing depth, pain on occlusal contact, and a fis-
tula on a mandibular bicuspid. The probing depth
increased 2 mm over a 3-month period despite relief
of the occlusal trauma and resolution of the fistula. A
radiograph showed an apparent separation of the
cementum in the area of the pocket.
Methods: The lesion was treated using a minimally
invasive surgical approach to place a bone graft.
Results: The probing depth was reduced to 2 mm
with less than 1 mm of increased recession. A histo-
logic examination of the damaged calcified tissue con-
firmed that it was cementum.
Conclusions: The increasing probing depth asso-
ciated with a cemental tear seems to indicate that
this phenomenon contributed to loss of attachment
and bone. Removal of the detached cementum in
combination with bone grafting using a minimally
invasive surgical approach appears to have success-
fully corrected the periodontal destruction. J Perio-
dontol 2000;7l:1761-1766.
KEY WORDS
Periodontal attachment loss/etiology; periodontal
pockets/surgery; bone loss/etiology; dental
cementum; grafts, bone; surgical procedures,
minimally invasive.
* Private practice, Dallas, TX; Baylor College of Dentistry, TAMUS, Dallas,
TX.
† Department of Pathology, Baylor College of Dentistry, TAMUS.
J Periodontol • November 2000
Pathologic alteration of the cementum was once
thought to be a primary cause of periodontal break-
down.1 The concept of cementopathia has been dis-
carded in favor of the current concept of periodonti-
tis as a multifactorial disease.2 However, there are a
small number of case reports describing periodontal
breakdown associated with separation of the cemen-
tum from the underlying tooth structure.3-7 These
separations of the calcified tissues of the tooth are
known as cemental tears.8
The etiologic factors that lead to the tearing of the
cementum are not known. The factor most commonly
suggested is occlusal trauma.3,4,7,8 Occlusal trauma
is usually implicated due to clinical findings such as
wear facets or a history of parafunctional habits. There
are no known published reports of cemental tears
following a single episode of direct trauma to a tooth
such as a blow. It is possible that in some cases there
may be an imperfect attachment of the cementum to
the underlying dentin which predisposes these tis-
sues to separate under normal occlusal loading. It
has also been suggested that the age of the patient
may be a factor in cemental tears.4-6
Many of the case reports of cemental tears are
based on teeth that have been extracted.5,6 It appears
that the decision was made to manage a tooth with
the radiographic appearance of a cemental tear in
much the same way as a tooth with a radiographi-
cally detectable root fracture that involves the cemen-
tum and the dentin. On extracted teeth, the diagno-
sis of cemental tear has most frequently been made
by direct observation of the fractured area of cemen-
tum, rather than by histologic evaluation.5
Successful treatment of periodontal degeneration
associated with cemental tears has been reported.3,4,7
Haney et al. reported the successful treatment of a
deep pocket associated with a cemental tear using
a bone graft.3 Ishikawa et al. reported a series of 6
cases of treated cemental tears.4 While it was stated
that these cases healed uneventfully, there is no infor-
mation concerning postsurgical clinical data and it
is, therefore, impossible to determine whether these
cases had returned to clinically normal function with
reduced probing depths or were merely asympto-
matic. The most recently reported case used a mem-
1761
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Case Report
brane to successfully regenerate bone and minimize
probing depth.7 Unfortunately, this case relied on a
radiographic diagnosis of cemental tear and did not
include a histologic analysis of the fragment
removed.
The following is a report of a case of severe pro-
gressive bone and attachment loss associated with a
confirmed cemental tear. A bone graft placed using
a minimally invasive surgical technique was used to
successfully reduce pocket depth with a minimal loss
of tissue height.
CASE REPORT
The patient, a 63-year-old healthy white female, pre-
sented with a complaint of vague pain in the lower
left bicuspid area, mobility of tooth #20, and a “white
spot” on the buccal gingiva. She reported a history
of “bad gums” since her late teens, which had been
treated with various non-surgical treatment modali-
ties. There was no history of periodontal surgery.
A periodontal evaluation and charting were per-
formed. Recession of 2 to 4 mm from the cemento-
enamel junction (CEJ) was noted in multiple areas.
Three mm of recession was noted on the facial aspect
of tooth #20. Generalized pockets of 3 to 5 mm were
present. An isolated 6 mm pocket was noted on the
mesial facial aspect of #13, with a 5 mm pocket
noted on the distal facial aspect of #20. Class I (Glick-
man)9 bifurcation involvement was noted on #15 and
#18. Slight mobility was noted on all left maxillary and
mandibular posterior teeth. Severe mobility (Miller
Class II)10 was noted on #20. Initial occlusal contact
was noted between #15/16 and 18. A 5 mm vertical
discrepancy was noted between initial retruded con-
tact (centric relation) and normal intercuspation (cen-
tric occlusion). Additionally, a 3 mm anterior and a
2 mm lateral movement to the right was noted
between initial contact and centric occlusion. Heavy
lateral contacts were noted between the maxillary
and mandibular bicuspids, with fremitus noted on #20
in lateral movement. A fistula was noted on the buc-
cal gingiva between 19 and 20. Minimal gingival
inflammation was noted in all areas.
A small gutta percha point was inserted into the
fistula and a periapical radiograph was taken. The
radiograph showed generalized horizontal bone loss
with vertical bone loss noted between #19/20. An
apparent separation of tooth structure, suggestive of
a cemental tear, was noted on the distal aspect of
#20. The gutta percha point did not extend to the
apparent cemental tear.
The differential diagnosis was: 1) complete root
1762 Cemental Tear-Associated Periodontal Destruction
fracture, 2) cemental tear, or 3) pulpal infection. An
electronic pulp test was performed and all teeth in the
lower left quadrant gave normal vitality readings.‡
The normal vitality reading and the lack of hot or
cold sensitivity were felt to argue against pulpal
involvement. Additionally, it was felt that if the source
of the fistula were pulpal in nature, the gutta percha
point would have extended to the tooth surface. It
could not be determined if the separation of tooth
structure noted in the radiograph was a complete root
fracture or a cemental tear. Given the severe mobil-
ity of #20 and the occlusal discrepancies noted, it
was felt that the most likely diagnosis was complete
root fracture.
Initial treatment consisted of occlusal adjustment
to eliminate the discrepancy between initial contact
and centric occlusion. Additionally, the lateral occlusal
contacts were modified to minimize the fremitus on
#20. Immediately following the occlusal adjustment,
the patient indicated that her mouth felt much better
and that the lower left bicuspid area no longer felt
“different.” Due to the presence of a fistula and the
patient’s extended travel schedule which prevented
immediate follow up and treatment, she was placed
on cephlexin 500 mg every 8 hours for 7 days. The
patient was told to return for re-evaluation of her peri-
odontal condition as soon as her travel schedule
would allow.
The patient was seen for re-evaluation approxi-
mately 90 days after initial treatment. She indicated
that she had no pain or “different” feeling in the lower
left since treatment was performed. She continued
to be aware of the looseness of #20. She was also
aware of a depression in the region previously occu-
pied by the fistula. Clinical evaluation revealed that
the fistula was no longer present. The probing depth
on the distal aspect of #20 was noted to be approx-
imately 2 mm deeper (7 mm) than at the original
evaluation. The mobility of #20 was noted to have
decreased, but it was still considered to have mod-
erate mobility. Fremitus was no longer noted on #20.
With the exception of #20, no mobility was noted on
any teeth in the lower left quadrant. A new radiograph
(Fig. 1) revealed an obvious separation of tooth struc-
ture on the distal aspect of #20. The radiograph was
strongly indicative of a cemental tear. However, it
could not be determined if this cemental separation
was associated with a complete root fracture (i.e.,
fracture of the cementum and dentin) or if it was an
independent finding. It was felt that root fracture con-
‡ Analytical Technology, Redmond, WA.
Volume 71 • Number 11
9306_IPC_AAP_553360 11/29/00 5:30 PM Page 1763
Figure 1.
Preoperative radiograph showing extensive bone loss associated with
an apparent cemental tear (indicated by an arrow) on the distal
aspect of tooth #20.
tinued to be the most likely diagnosis based on occlusal
trauma and the continued mobility of the tooth.
The patient was informed of the questionable prog-
nosis of #20, and the options of extraction with
implant placement, extraction and fixed partial den-
ture, or exploratory surgery with a possible regener-
ative procedure were discussed. The patient elected
to have the exploratory surgery performed in an
attempt to retain the tooth. Figure 2 shows a preop-
erative photograph of the surgical site. Note that
recession of 3 mm was present on the facial aspect
of #20 prior to surgical treatment.
A minimally invasive surgical (MIS) approach was
utilized to gain access to the area between 19 and
20.11-13 The MIS surgical approach consists of a very
limited surgical access incision that does not extend
beyond the immediate area of bone loss. The small
flaps are retracted only enough to allow the debride-
ment of the bony lesion using specialized instruments.
Care is taken to preserve the blood supply of the
small flaps. The MIS approach has been shown to
produce apparent bony regeneration similar to more
traditional procedures and to help preserve papillary
contours and tissue height.
J Periodontol • November 2000
Case Report
Figure 2.
A preoperative view of the surgical site. Preoperative gingival
recession of 3 mm was present. A 7 mm pocket was noted on the
distal aspect of tooth 20.The healed (no longer patent) fistula can
be seen between teeth 19 and 20.
As the site was debrided, several small pieces of
white calcified material were removed with the gran-
ulation tissue. It could not be determined if these
represented calculus or fractured pieces of cemen-
tum. Following initial debridement, a partially
detached piece of tooth structure was noted on the
distal aspect of #20 (Fig. 3). A 2 × 3 mm piece of
what appeared to be cementum was removed intact
from the distal root surface of #20 (Fig. 4). This
hard tissue was submitted for microscopic evaluation.
Following removal of this material, the root surface
was planed smooth with curets and a high-speed
finishing bur. The broken cemental edge was elimi-
nated (Fig. 5). The root surface was visualized under
high magnification and a fracture of the root could
not be detected. The root surface was treated with
citric acid for 30 seconds; freeze-dried demineralized
bone mixed with tetracycline HCl was placed in the
bony defect and covered with a resorbable mesh.§
§ Vicryl Mesh, Ethicon Inc., Somerville, NJ.
Harrel, Wright 1763
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Case Report

Figure 4.
Gross view of the cementum removed from the root surface.

Figure 3.
Torn cementum, still partially attached to the root surface, can be
seen, at the arrow, on the distal aspect of tooth 20.

The gingival tissue was closed using 4-0 plain gut

in a vertical mattress suture. No periodontal dress-
ing was used. The patient was placed on doxycycline
100 mg a day for 7 days. A 0.12% chlorhexidine
rinse was used twice a day for 10 days. The patient
had an uneventful postoperative course. At the 4-
week postoperative visit, the soft tissue had healed
well, completely covering the bone graft site and the
patient was asymptomatic.
Histologic evaluation revealed a linear strip of an
eosinophilic matrix (Fig. 6). The peripheral layer was
acellular. Centrally, there were occasional lacuna
which were devoid of cells. The matrix contained no
discernible tubules, and it refracted light during polar-
ization microscopy, which suggested that the matrix
was collagenous. The overall morphology of the spec-
imen and its histologic structure confirmed that the
specimen was cementum.
Figure 5.
The patient was placed on a 4-month periodontal The cemental tear has been removed and the root surface has been
maintenance schedule but did not comply with this smoothed in preparation for the placement of freeze-dried
schedule. She did not return for postsurgical evalu- demineralized bone.
ation until 8 months after surgery. At this visit (Fig.
7), the pocket on the distal facial aspect of #20 was resenting an increase in recession of 1 mm or less.
noted to have a 2 mm probing depth, and no clini- The patient indicated that she was asymptomatic and
cally detectable mobility was noted. Recession of 3 was no longer aware of any sensation in the lower left
to 4 mm was noted on the facial aspect of #20, rep- quadrant. A periapical radiograph revealed an appar-

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Case Report
ent increase in bone height and
there was no evidence of a root
fracture or cemental tear.

DISCUSSION
There are few reports of cemental
tears in the literature and many of
these reports lack histologic veri-
fication of the cemental tear diag-
nosis. The current case report fol-
lows for several months the
progression of symptoms, increase
in probing depth, and apparent
radiographic bone loss associated
with a cemental tear. There is radi-
ographic evidence of cemental
separation and the torn cementum
is shown in situ, still attached to
the tooth surface. Further, histo-
logic verification that the tissue in
question is cementum is pre-
sented. Thus, all elements indicate
that the tearing of the cementum
Figure 6. can be a causative factor in pocket
Photomicrograph of the tissue removed from the distal aspect of tooth 20. Histologic evaluation formation and loss of bone. Fur-
revealed a linear piece of cementum (hematoxylin and eosin stain; original magnification ×66). thermore, this case demonstrates
that with the removal of the torn
cementum, regenerative therapy
can be successfully used to treat the existing bone
loss.
In this case, the patient presented for periodontal
treatment with an existing cemental tear. She denied
any knowledge of a specific traumatic incident involv-
ing the tooth. However, there was evidence of occlusal
trauma on the left side of the patient’s mouth. There
was considerable discrepancy between the retruded
jaw position and centric occlusion. During the slide
from retruded to centric positions, considerable stress
was placed on the left bicuspids. Fremitus, indicat-
ing occlusal stress during routine movements, was
also noted in lateral movement from the centric
occlusal position.
While it is not possible to demonstrate that occlusal
discrepancies or occlusal trauma caused the tear in
the cementum and the subsequent periodontal bone
loss, in the authors’ opinion, a possible cause of the
separation between the cementum and the underly-
ing tooth structure was traumatic occlusion and pos-
Figure 7. sible flexion of the root structure. At the initial exam-
The surgical site 8 months postoperative.There has been less than a ination, the tooth with the cemental tear had only a
1 mm increase in recession, and the probing depth distal to #20 is
5 mm pocket and minimal gingival inflammation.
now 2 mm.
Despite this, a mobility of greater than 2 mm in a

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Case Report
buccal lingual direction was noted. Additionally, sig- 6. Leknes KN. The influence of anatomic and iatrogenic
nificant wear facets were noted on this tooth. While root surface characteristics on bacterial colonization
and periodontal destruction: A review. J Periodontol
it could be argued that the mobility was in response
1997;68:507-516.
to the cemental tear instead of a response to exces- 7. Muller HP. Cemental tear treated with guided tissue
sive occlusal stress, the wear facets indicate long- regeneration: A case report 3 years after initial treat-
term occlusal trauma with attrition of the tooth struc- ment. Quintessence Int 1999;30:111-115.
ture. The authors feel that the most likely scenario is 8. Moskow BS. Calculus attachment in cemental separa-
tions. J Periodontol 1969;40:125-130.
one of excessive occlusal forces, over a long period
9. Glickman I. Clinical Periodontology, 4th ed. Philadel-
of time, causing the cementum to separate from the phia: W.B. Saunders; 1965:596-597.
tooth surface with subsequent bone loss and 10. Miller SC. Textbook of Periodontia, 1st ed. Philadelphia:
increased probing depth. It should be pointed out that Blakiston; 1938.
all theories on the cause of cemental tears are spec- 11. Harrel SK. A minimally invasive surgical approach for
periodontal bone grafting. Int J Periodontics Restora-
ulative and no cause-effect relationship has been
tive Dent 1998;18:161-169.
established. 12. Harrel SK. A minimally invasive approach for peri-
It is unlikely that the cause of cemental tears and odontal regeneration: Surgical technique and obser-
the clinical effects from cemental tears will ever be vations. J Periodontol 1999;70:1547-1557.
fully elucidated. Carrying out a controlled clinical trial 13. Harrel SK, Nunn M, Belling CM. Long-term results of
a minimally invasive surgical approach for bone graft-
to study cemental tears would be difficult if not impos-
ing. J Periodontol 1999;70:1558-1563.
sible. Therefore, it is likely that cemental tears will
only be documented by case reports. It is felt that Send reprint requests to: Dr. Steve K. Harrel, 10246 Mid-
this report showing radiograpic separation of the way Road, #B, Dallas, TX 75229. Fax: 214/350-6383;
cementum, in situ clinical verification of tooth struc- e-mail: skh1@airmail.net
ture separation, and histologic verification of the tis-
Accepted for publication April 27, 2000.
sue as cementum clearly demonstrates that cemen-
tal tears may cause periodontal breakdown and bone
loss. The absence of a specific incidence of trauma
to the tooth and the presence of mobility and occlusal
wear as indications of long-term trauma from occlu-
sion suggest that trauma from occlusion may be a
cause of cemental tearing and subsequent bone loss.
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1. Gottlieb B. The new concept of periodontoclasia. J Peri-
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2. Offenbacher S. Periodontal disease: Pathogenesis. Ann
Periodontol 1996;1:821-878.
3. Haney JM, Leknes KN, Lie T, Selvig KA, Wikesjö U.
Cemental tear related to rapid periodontal breakdown:
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4. Ishikawa I, Oda S, Hayashi J, Arakawa S. Cervical
cemental tears in older patients with adult periodonti-
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