Odontology (2010) 98:173–176 © The Society of The Nippon Dental University 2010

DOI 10.1007/s10266-010-0121-8

CASE REPORT

Hsueh-Jen Lin · Chiu-Po Chan · Chen-Tsai Wu

Jiiang-Huei Jeng

Cemental tear on a mandibular second molar: a case report

Received: August 4, 2009 / Accepted: January 30, 2010

Abstract A cemental tear is a special kind of root fracture Key words Cemental tear · Mandibular molar · Periodontal
that may cause rapid and localized periodontal destruction. attachment loss · Guided tissue regeneration · Osseous graft
Most cemental tears have been reported on bicuspids and
incisors. Here we present a case of cemental tears on both
the right mandibular first and second molars. The patient Introduction
was a 72-year-old man who showed gingival swelling and a
deep pocket over his right mandibular second molar as well
A cemental tear is the complete separation of cementum
as a deep periodontal pocket on the distolingual aspect of
along the cementodentinal junction. Cemental tears are
the first molar. During exploratory flap surgery, a detached
usually accompanied by marked periodontal or periapical
root fragment on the mesial side of the second molar and a
destruction.1–5 Previous studies have found that they affect
small root fragment on the lingual surface of the first molar
mainly single-rooted teeth, particularly the incisors and pre-
were found and removed for biopsy. After histopathological
molars.4 Only one previous report demonstrated a cemental
examination, both root fragments were confirmed to be
tear on the mandibular first molar.5 To date, no cemental
cemental tears. The periodontal defects were treated by
tear on the second molar has been reported.1–9 Separations
osseous grafting and guided tissue regeneration. A postop-
of cementum at an early stage cannot be detected solely by
erative probing depth of 4 mm on the second molar was
radiographs. However, when cemental tears become
recorded at 3 months and remained stable for 5 years.
detached from the root surfaces, they can be diagnosed by
Where marked periapical and periodontal bony destruction
sequential radiographs.2–4,8,9 Hence, comprehensive clinical
are present, a cemental tear should be considered as a pos-
and radiographic examinations in combination with an
sible diagnosis, even in the molar teeth, for early treatment
exhaustive history are important for early diagnosis and
to improve prognosis.
treatment of this disease entity. In reality, on the basis of
radiographic evaluation, the presence of cemental tears can
be suspected only. A definitive diagnosis of the lesion can
be made only after surgical removal of the cemental tears,
H.-J. Lin · C.-T. Wu
Dental Department, Show Chwan Memorial Hospital, Changhua, direct inspection of the extracted teeth, and histopathologi-
Taiwan, R.O.C. cal examination of the fractured root fragments. Here, we
H.-J. Lin · J.-H. Jeng (*)
present a case of cemental tears on the mandibular first and
Graduate Institute of Clinical Dentistry and Department of second molars. Two cemental fragments were observed in
Dentistry, College of Medicine, National Taiwan University and two adjacent mandibular molars, which unexpectedly led to
National Taiwan University Hospital, No. 1, Chang-Te Street, Taipei periodontal destruction and delay of diagnosis. If the peri-
100, Taiwan, R.O.C.
odontal destruction caused by cemental tears on mandibu-
Tel. +886-2-23123456 ext. 67755; Fax +886-2-23821212
e-mail: jhjeng@ntu.edu.tw or benson86778231@yahoo.com.tw lar molars can be diagnosed and treated earlier, it may be
possible to prevent further periodontal breakdown and to
C.-P. Chan (*)
Department of Periodontics, Chang Gung Memorial Hospital and preserve the tooth for a longer period.
Chang Gung University, 199, Tung-Hua North Road, Taipei 105,
Taiwan, R.O.C.
Tel. +886-2-27135211 ext. 3535
e-mail: carol@adm.cgmh.org.tw Case report

H.-J. Lin, C.-P. Chan and J.-H. Jeng contributed equally to this A healthy 57-year-old man came to our dental department
manuscript. in December 1988. His chief complaint was gingival swelling
174

and abscess in his right mandibular second molar. He had
no history of drug allergy and denied all major systemic
diseases. His dental history revealed that he had received
routine periodontal maintenance care at our dental clinic
since 1984. He denied any history of traumatic injury to the
teeth. No history of betel quid chewing was mentioned
despite his preference for chewing hard food. Generalized
pockets of 5–6 mm were detected. A narrow, 8-mm-deep
pocket was noted on the mesiobuccal aspect of the right
mandibular second molar. The periapical radiographs
showed generalized horizontal bone loss. The tentative
diagnosis was adult periodontitis. Initial treatment consisted
of oral hygiene instruction, scaling, root planing, subgingival
curettage, and flap surgery. Five years later, because of
aggressive periodontitis in the same region, the patient
received a second flap surgery along with osseous grafting.
In May 2001, another 7 years later, swelling with purulence
recurred at the previously affected tooth. Radiographic
examination revealed an angular bony defect on the mesial
side of the second molar. Within this radiolucent lesion, a
radiopaque fragment was found on the mesial aspect of the
second molar (Fig. 1A). The most likely diagnosis was
cemental tear. Since the patient had been operated on twice,
he refused any further surgical intervention. Root planing
was therefore carried out followed by oral hygiene
instruction.
In June 2003, this now 72-year-old patient came to our
dental clinic again for swelling and pain in the same region.
Vitality test results for all teeth in the right mandibular
quadrant were normal. Periodontal examination and chart-
ing were performed. A 2-mm gingival recession was noted
on the buccal aspect of the second molar. Probing depth of
the right lower quadrant teeth was less than 4 mm except
that a 6-mm pocket on the distolingual aspect of the first
molar and a 9-mm pocket on the mesiobuccal aspect of the
second molar were observed. A class III bifurcation involve-

Fig. 1. A Radiograph of right

mandibular molars taken in May
2001. There was an angular bony
defect on the mesial side of the
second molar. Within the defect,
a radiopaque fragment was
located adjacent to alveolar
bone (arrow). B A radiograph
taken in June 2003 indicates the
presence of extensive bony
destruction in the first molar,
and an angular bony defect on
the mesial aspect of the second
molar. Between the bony defect
and alveolar bone, a radiopaque
fragment (arrow) is discernible
in the radiograph. C The
fragments were removed from
the two molars during flap
surgery. Arrow, fragment of the
first molar; arrowhead, fragment
of the second molar. D
Microscopic examination of the
fragment from the first molar
confirmed the structure of
acellular cementum
(hematoxylin and eosin stain,
×100). E The histopathological
image of the root fragment from
the second molar revealed the
presence of acellular cementum
and overlying inflamed tissue
(hematoxylin and eosin stain,
×100). F A radiograph taken in
July 2008 demonstrated no
further bony destruction. The
postoperative periodontal
parameters of the first and
second molars remained stable
for 5 years

ment of the first molar and a class II bifurcation involve-
ment of the second molar were detected. Slight tooth
mobility was noted in all right mandibular posterior teeth
with the exception of the second molar, which showed
Miller class II mobility.10 A periapical radiograph revealed
an extensive horizontal bony defect of the first molar and
an angular bone defect between the first and second molars.
A radiopaque fragment of tooth structure approximating
the alveolar bone was discernible (Fig. 1B). According to
these findings, the lesion of first molar was diagnosed as
periodontitis and the lesion of the second molar was diag-
nosed as periodontitis associated with cemental tears.
During removal of granulation tissue in flap surgery, surpris-
ingly, in addition to a root fragment found on the mesial
aspect of the second molar, another cemental fragment was
observed on the distolingual of the first molar (Fig. 1C).
After removal of the two fragments, root planing, bone
grafting, and guided tissue regeneration were performed.
The fractured root fragments were sent for histopathologi-
cal examination. Microscopic observation revealed the
presence of acellular cementum overlying inflamed tissue
and confirmed the two root fragments to be cemental tears
(Fig. 1D, E). By the 3-month follow-up, the surgical site had
healed uneventfully. A postoperative probing depth of
4 mm with 2 mm of recession in the second molar was
recorded. Five years after the operation, a radiograph
showed that the periodontal condition in the molar region
was generally stable (Fig. 1F).
Discussion
Cemental tears have not previously been reported in man-
dibular second molars. Only one case occurring in the man-
dibular left first molar has been heretofore reported.5 This
report describes clinical aspects, diagnosis, and treatment of
cemental tears in the mandibular second molar. Clinically,
a number of diagnostic procedures such as patient history,
clinical symptoms, periodontal examination, pulp test,
radiographic examination, and exploratory surgery should
be used.1–5 However, early diagnosis of cemental tears is
often difficult because the clinical signs precede the radio-
graphic changes. Only when the fractured fragment detaches
from the root surface does it become discernible on a radio-
graph, as with the second molar of this case. However, if the
fragments are located on the buccal or lingual surfaces, they
cannot be easily identified on radiographs, as demonstrated
by the first molar of this case. In such cases, the diagnosis of
cemental tear can be confirmed only during flap surgery.
There are three ways to confirm a diagnosis of cemental
tear: radiographic examination, surgery with direct inspec-
tion of the tooth fragment; and histological examination of
the removed cemental tear.1,3 In this report, a tentative diag-
nosis of cemental tear was made on the basis of radio-
graphic examination and during flap surgery. Moreover, the
presence of acellular cementum, cementoblasts, and peri-
odontal ligaments in the biopsy specimens further con-
firmed the diagnosis.
175
The predisposing factors to cemental tear include age,
traumatic injury, occlusal trauma, and increased thickness
and fragility of the cementum caused by increased mineral-
ization.1–5 In this case, the cemental tears were on the lingual
side of the distal root of the mandibular first molar and on
the mesial side of the second molar. While this case was
sequentially followed for more than 10 years because of
periodontitis, the patient had a habit of chewing hard food
and all his posterior teeth revealed severe attrition. On the
basis of these findings, we considered that the lesion was
probably caused by occlusal trauma. However, multiple
nonsurgical and emergency treatments were performed
over 15 years, and it is possible that the nonsurgical treat-
ments and subsequent abscesses may have caused the even-
tually confirmed cemental tears. More studies are necessary
to clarify the etiologic factors of cemental tear.
When the periodontal lesion caused by a cemental tear
communicates with the oral cavity, the fractured fragment
can be completely removed by early scaling and root planing
to promote tissue healing. Sometimes, bone grafting with
guided tissue regeneration can successfully treat a cemental
tear with angular bony destruction.2,3,5 Removal of the
cemental tear, osseous grafting, and guided tissue regenera-
tion procedures were performed in this case. The periodon-
tal status of the affected molars remained stable for 5 years.
Another report suggested that once a periodontal lesion
associated with a cemental tear extends to the periapical
area, the prognosis of the tooth becomes unpredictable.
Under this circumstance, a combination of periodontal
treatment and root canal therapy can be tried, or the tooth
should be extracted.4
In summary, this case indicates that, even in mandibular
molars, cemental tears should be considered as a possible
etiology when sudden swelling, rapid and site-specific peri-
odontal attachment loss, or bony destruction are observed.1
Careful clinical examination as well as inspection of radio-
graphs is important for early diagnosis and treatment.
Moreover, surgical exploration and biopsy may be neces-
sary to confirm the diagnosis.
References
1. Leknes KN, Lie T, Selvig KA. Cemental tear: a risk factor in peri-
odontal attachment loss. J Periodontol 1996;67:583–8.
2. Tulkki MJ, Baisden MK, McClanahan SB. Cemental tear: a case
report of a rare root fracture. J Endod 2006;32:1005–7.
3. Camargo PM, Pirih FQM, Wolinsky LE, Lekovic V, Kamrath H,
White SN. Clinical repair of an osseous defect associated with a
cemental tear: a case report. Int J Periodontics Restorative Dent
2003;23:79–85.
4. Chou J, Rawal YB, O’Neil JR, Tatakis DN. Cementodentinal tear:
a case report with 7-year follow-up. J Periodontol 2004;75:1708–
13.
5. Ishikawa I, Oda S, Hayashi J, Arakawa S. Cervical cemental tears
in older patients with adult periodontitis. Case reports. J Periodon-
tol 1996;67:15–20.
6. Müller HP. Cemental tear treated with guided tissue regeneration:
a case report 3 years after initial treatment. Quintessence Int 1999;
30:111–5.
176
7. Stewart ML, McClanahan SB. Cemental tear: a case report. Int
Endod J 2006;39:81–6.
8. Tai TF, Chiang CP, Lin CP, Lin CC, Jeng JH. Persistent endodontic
lesion due to complex cementodentinal tears in a maxillary central
incisor: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2007;103:e55–60.
9. Lyons CT, Peacock ME, Cuenin MF, Swiec GD, Dickey DJ. Severe
localized periodontal destruction associated with cervical cemental
separation. Gen Dent 2005;53:212–4.
10. Armitage GC. Clinical evaluation of periodontal diseases. Peri-
odontology 2000 1995;7:39–53.