Clinical Research

Cemental Tear: Clinical Characteristics and

Its Predisposing Factors
Hsueh-Jen Lin, DDS, MS,* Chiu-Po Chan, Specialist, DDS† Chu-Yen Yang, MS,‡ Chen-Tsai Wu, DDS,*
Yi-Ling Tsai, DDS, MS,§ Chi-Chia Huang, DDS, MS,k Kuen-Dah Yang, DDS, MS,*
Chiu-Chun Lin, DDS, MS,¶ Shu-Hui Chang, PhD,‡ and Jiiang-Huei Jeng, DDS, PhD§

Abstract
Introduction: Cemental tears often show characteris-
tics mimicking a periapical or periodontal lesion. This
leads to difficulty in the early diagnosis of cemental
tears. Methods: In this multicenter study, 71 teeth
with cemental tears being confirmed by direct inspec-
tion or histological examination were included. For
each case, demographic data, dental history, clinical
and radiographic findings, and the results of explor-
atory surgery were recorded and analyzed. Results:
Maxillary or mandibular incisors (76.1%) were most
frequently affected by cemental tears. Univariate analysis
of predisposing factors found that teeth with cemental
tears occurred more commonly in men (77.5%) and
patients older than 60 years of age (73.2%). Analysis of
clinical characteristics showed that teeth with cemental
tears were prone to have abscess formation (66.2%),
a deep pocket >6 mm (73.2%), positive vitality test
(65.3%), healthy antagonist teeth (84.3%), and moderate
to severe attrition (77.9%). About 56.3% of cemental
tears could be detected on preoperative radiographs.
Further analysis of radiographic findings showed that
teeth with cemental tears were more likely to have peri-
odontal bone destruction (85.9%) or periapical bone
destruction (64.8%). Conclusions: Endodontists and
dentists may avoid misdiagnosis and unnecessary treat-
ment of teeth with cemental tears if they can properly
evaluate the radiographs and pulp vitality of teeth as
well as know the predisposing factors and clinical charac-
teristics of teeth with cemental tears in advance. (J Endod
2011;37:611–618)
Key Words
Cemental tear, clinical characteristic, etiology, predis-
posing factor, radiographic finding
A cemental tear is a specific type of root surface fracture infrequently seen in clinical
dental practice (1, 2). Recently, cemental tears are suggested to be a factor for
periodontal or periapical tissue destruction (1–3). The cemental tear–associated
lesion often presents itself on the radiograph as a periapical lesion or a periodontal
lesion with angular bone loss along the root surface with variable extension,
resulting in a deep probing defect because of attachment loss in some cases (1–6).
To rule out the presence of an endodontic-periodontal lesion, the standard of care
requires pulp vitality tests and careful radiographic examination to aid in the diagnosis
and treatment options. There is sometimes a periapical or periodontal lesion present
with an additional finding of broken-off cementum-attachment tissue complex. Interest-
ingly, it was unclear which came first, the periodontal/periapical lesion or the ‘‘cemental
tear’’ (1–5).
Cemental tears primarily affect single-rooted teeth, particularly incisors and
premolars (4). Only three cases of cemental tears involving molar teeth are reported
(5, 6). A cemental tear is defined as a complete or incomplete separation within the
root surface along the cementodentinal interface or along an incremental line
(1–7). The cemental tear is different from vertical root fracture (VRF), which affects
the long axis of the root and involves the root canal space. The mechanism by which
cemental tears develop is currently not fully clear, but several etiologic factors
including age, trauma, occlusal overloading, thicker or higher fragility of cementum,
and previous periodontal treatment have been reported (1–5, 8–12). It seems that
scaling, previous periodontal treatments, and tooth extraction may occasionally
damage the cementum, resulting in detachment of some part of the cementum from
the dentinal surface (2, 5, 13). Additional factors that may predispose to cemental
tears include the presence of structural weakness at the cementum-dentin interface,
the decreased strength of dentin because of fatigue with increasing age, and prior
endodontic therapy (2, 11, 14–16). However, the mechanisms responsible for the
development of cemental tears are mostly conjecture. The reason for the current
state of knowledge results from few studies, limited sample sizes, and difficulty of
early diagnosis. Collectively, over the past 30 years, fewer than 15 cemental tear–
related articles involving a total of 35 teeth have been published (6, 17) (Table 1).
An early differential diagnosis between cemental tear and true periapical/peri-
odontal lesions may facilitate early treatment and thus improve the prognosis of the
disease. We hypothesized that age, sex, tooth type, occlusal trauma, pulp vitality, prior
endodontic treatment, post/core insertion, and attrition are the predisposing factors for

From the *Dental Department, Show Chwan Memorial Hospital, Changhua; †Department of Periodontics, Chang Gung Memorial Hospital and Chang Gung University,
Taipei; ‡Biostatistics Laboratory, College of Public Health, National Taiwan University, Taipei; §Graduate Institute of Clinical Dentistry and Department of Dentistry, College of
Medicine, National Taiwan University and National Taiwan University Hospital, Taipei; kDepartment of Dentistry, Cardinal Tien Hospital, Taipei; and ¶Department of Dentistry,
Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
Drs Lin, Chan, and Chang contributed equally to this work.
Supported by grants from Chang Gung Memorial Hospital (CMRPG390021) and the National Science Council of Taiwan.
Address requests for reprints to Dr Jiiang-Huei Jeng, Department of Dentistry and School of Dentistry, National Taiwan University Hospital and National Taiwan
University Medical College, No. 1, Chang Te Street, Taipei, Taiwan. E-mail address: jhjeng@ntu.edu.tw
0099-2399/$ - see front matter
Copyright ª 2011 American Association of Endodontists.
doi:10.1016/j.joen.2011.02.017

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Clinical Research
Lin et al.

TABLE 1. Reports of Cemental Tear Cases Published in the English Language Literature
Radiographic
Author Age (Sex) Tooth type Type of study finding Biopsy Findings and suspected factors
Haney et al (1992) (8) 79 (F) 35 Case report Yes Yes Vital tooth, over bridge abutment tooth, with
vertical bony defect. Occlusal overloading
or trauma and age are factors
Ishikawa et al (1996) (5) 72 (M) 11 Case report Yes No 5/6 fractured over cervical and 1/6 fractured in
55 (M) 11 Yes No apical area, aging and occlusal strain are
69 (M) 11 & 21 Yes No factors.
68 (F) 25 Yes Yes
67 (M) 35 Yes Yes
54 (M) 36 Yes No
Leknes (1996) (1) None 17 teeth Observational study Yes (partly) Yes (1) 8/17 with vital pulp, 9/17 with prior
endodontic treatment. Rapid attachment
loss noted.
€ ller (1999) (7)
Mu 50 (F) 43 Case report Yes No Rapid periodontal breakdown with deep
pocket and three-wall bony defect.
Occlusal trauma due to clenching.
Harrel and Wright (2000) (17) 63 (F) 35 Case report Yes Yes Deep pocket, sinus tract, traumatic occlusion,
marked attrition
Camargo et al (2003) (9) 61(M) 21 Case report No No Deep pocket and sinus tract, failure of prior
endodontic treatment, apical cementum
tear.
Marquam (2003) (12) 71(M) 21 Case report No No Asymptomatic, nonbleeding, narrow deep
pocket. Trauma, occlusal overloading,
thicker cementum, age.
Chou et al (2004) (4) 52 (M) 15 Case report Yes Yes Pain and deep pocket with cervical cemental
tear. Occlusal trauma, age, impaired tissue
repair capacity, 43% cases with prior
endodontic treatment
Lyons et al (2005) (16) 31 (M) 12 Case report No No With endodontic treatment.
Tulkki et al (2006) (2) 79 (F) 45 Case report Yes Yes Vital tooth with deep pocket and periodontal
bone loss. Age, trauma or trauma from
occlusion.
JOE — Volume 37, Number 5, May 2011

Stewart and 22 (M) 11 Case report No Yes Trauma history, sinus tract, failure of prior
McClanahan (2006) (10) endodontic treatment.
Tai et al (2007) (3) 79 (F) 21 Case report Yes Yes Age, heavy occlusal force, prior failed
endodontic treatment.
F, female; M, male.

cemental tears, and most of these data can be obtained by careful clin-
ical and radiographic examinations. Thus, the goal of this retrospective
multicenter study was to clarify the clinical features of cemental tears;
their distribution among teeth; and their correlation with pulp vitality,
prior endodontic treatment, and post/core placement.
Materials and Methods
Study Setting
Data for this study were obtained from the Multicenter Cemental
Tear Study (MCTS) at four hospitals, including Chang Gung Memorial
Hospital, National Taiwan University Hospital, Show Chwan Memorial
Hospital, and Cardinal Tien Hospital. The MCTS registered teeth were
classified as highly suspicious of cemental tears between May 1987
and October 2008 based on one of the following criteria: (1) a discern-
able radiopacity of separated root structure with a concomitant loss of
adjacent periodontal or periapical bone on preoperative radiographs
(Figs. 1 and 2) (3, 6); (2) teeth had clinical signs and symptoms
and/or persistent periapical radiolucency even after endodontic
treatment or retreatment, with or without the presence of suspected
radiopaque cementum-like structure (3); and (3) teeth had recurrent
periodontal inflammation and/or periodontal bone destruction even
after scaling, root planing and curettage, or surgical intervention,
with or without a suspicious radiopacity that separated root structure
on preoperative radiographs (6). In the MCTS, the structured dental
chart for each tooth with a possible cemental tear was designed to
record the potential predisposing factors and clinical characteristics.
All the samples were evaluated together by three certified periodontists
or endodontists (H.J.L., C.P.C., and J.H.J.) with consistency to confirm
the presence of cemental tears before the inclusion of cases for data
analysis in this study.
Clinical Research
Data Collection
A total of 114 teeth with suspicious cemental tears were collected
in this MCTS. Twenty-nine teeth were treated by nonsurgical treatments
in which seven specimens were obtained for biopsy to prove the pres-
ence of cemental tears (Fig. 3). Forty-two teeth received apical or peri-
odontal surgery, and 31 specimens were subsequently obtained. Of
these 31 specimens, one was excluded because of a processing error,
four were diagnosed to be VRF or bone, and only 26 were confirmed to
be cemental tears by histological examination (Fig. 3). Forty-three teeth
were extracted because of a poor/unpredictable prognosis, an unfavor-
able response to nonsurgical treatment (ie, scaling, root planing,
endodontic treatment, and so on), or a personal choice by the patients.
Thirty-eight teeth were confirmed to have cemental tears by direct
inspection of the fractured cementum fragment and the root surface
of the extracted teeth to see whether the fractured cementum fragment
fit on the fractured root surface of the extracted teeth or by histological
examination of the fractured cementum fragment (the specimen)
(Fig. 3).
Therefore, 71 teeth with cemental tears were finally analyzed for
predisposing factors and clinical characteristics by reviewing the
MCTS registration documents and the dental records. The predisposing
factors included age, sex, tooth type, traumatic injury, occlusal trauma,
hard food chewing habit, absence or presence of a prosthesis, antago-
nist teeth, dentition, attrition, prior root canal treatment, and post/core
placement. The recorded clinical characteristics included the chief
complaint, a sinus tract condition, swelling (abscess), pocket depth,
a tooth response to electric pulp testing, the presence of a radiopaque
cementum-like fragment on the side of roots on preoperative radio-
graphs, periodontal or periapical bone destruction, and the accuracy
of the diagnosis.

Figure 1. (A) A 59-year-old man with a cemental tear (arrow) and a VRF (arrowhead) on his right lower first molar and left lower first molar, respectively.
(B) Periapical radiography showing a possible cemental tear (arrow) on the distal root surface of tooth #46 of the 84-year-old male patient. (C) Histological
examination of the suspicious hard tissue specimen in B showing a cemental tear with attached granulation tissue. (D) Periapical radiography exhibiting
a VRF with mesial displacement of the fractured root fragment (arrowhead) on tooth #36 of the 84-year-old male patient.

JOE — Volume 37, Number 5, May 2011 Characteristics and Predisposing Factors of Cemental Tears 613
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Figure 2. (A) A typical preoperative radiograph showing a cemental tear (arrow) on tooth #11 of a 46-year-old male patient. (B) A clinical picture of tooth #11
exhibiting gingival inflammation (arrowhead) and narrow deep pocket. (C) The removed cemental tear fragment. (D) Histological picture of the cemental tear
shown in C (original magnification, 200). (E) A typical preoperative radiograph showing the presence of three cemental tears on teeth #11 and #21 (arrows) in
a 66-year-old female patient. (F) A histological picture of the cemental tear obtained from tooth #21 in E (original magnification, 200).

Data Recording Statistical Analysis

The dataset was transferred into an Excel (Microsoft, Seattle, WA)
spreadsheet in which all the variable records were typed into spread-
sheets for two times and checked by one examiner to ensure the accu-
racy of the data record. Table 2 displays a more detailed grouping of
each variable.
We first calculated the frequency distribution for predisposing
factors and clinical characteristics using a pivot table (Excel). Descrip-
tive and univariate analyses were then performed using SPSS 15.0 soft-
ware for Windows (SPSS Inc, Chicago, IL). Specifically, the basic
characteristics of teeth with cemental tears were explored using the

614 Lin et al. JOE — Volume 37, Number 5, May 2011

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Examined samples
.008), and patients without a hard food chewing habit (42/68,
(n = 114)
61.8%, P = .052, marginal significance) (Table 2). Maxillary or
mandibular incisors (54/71, 76.1%, P < .0001) and teeth with occlusal
trauma (33/52, 63.5%, P = .052, marginal significance) were more
frequently affected by cemental tears. Moreover, most of the teeth
Extraction Non-surgery Surgery with cemental tears had no previous history of traumatic injury (57/
(n = 43) (n = 29) (n = 42) 63, 90.5%, P < .0001) (Table 2).
Further analyses of clinical characteristics showed that teeth with
cemental tears were prone to have swelling or abscess formation (47/
Direct inspection Operation Biopsy No
71, 66.2%, P = .006), a deep pocket >6 mm (52/71, 73.2%, P <
(28) (15) (7) biopsy
.0001), a positive vitality test (32/49, 65.3%, P = .032), no prosthesis
(22) (55/71, 77.5%, P < .0001), healthy antagonist teeth (59/70, 84.3%,
P < .0001), integral dentition or intact posterior occlusal support
(43/65, 66.2%, P < .0001), and moderate to severe attrition (53/68,
Biopsy No
77.9%, P < .0001) (Table 2). About 56.3% (40/71) of the cemental
(19) biopsy
(9)
Excluded (2) Biopsy No tears could be detected before operation on preoperative radiographs
--VRF (2) (31) biopsy as revealed by the presence of radiopaque cementum-like fragments
(11) adjacent to the root trunk. The presence of cemental tears was subse-
Direct inspection quently confirmed by direct inspection or histological examination. In
(7) addition, analyses of radiographic findings also showed that teeth with
cemental tears were more likely to have periodontal bone destruction
Excluded (5) (61/71, 85.9%, P < .0001), periapical bone destruction (46/71,
--Crack (2) 64.8%, P = .013), no previous history of root canal treatment (54/
--Bone (2) 71, 76.1%, P < .0001), and no post/core in the root canal (64/71,
--Processing 90.1%, P < .0001) (Table 2).
Biopsy No error (1)
(9) biopsy
(4) Discussion
The evidence base for the clinical characteristics of cemental
Biopsy tears is limited in the current literature (4). Previous reports have
Direct inspection
(26) shown that most cemental tears reveal clinical characteristics
(3) mimicking periodontal and periapical lesions, and, thus, endodontic
treatments will be conducted or even has been conducted but in vain
(3–5, 9). Therefore, dentists should be familiar with this disease
Figure 3. The sampling scheme. The bold/underlined numbers indicate the
numbers of finally analyzed samples. entity and regularly evaluate the vitality of teeth with suspicious
cemental tears to avoid unnecessary root canal treatment. Clinically,
a radiopaque foreign body should be suspected to be a cemental
descriptive analysis. To investigate the atypical prospects among all the tear by radiographic evaluation or surgical exploration. Repeated
groups of each of the predisposing factors and clinical characteristics, radiographs taken at varied angulations can detect most cemental
a series of the chi-square goodness-of-fit tests were conducted to test for tears localized on the mesial or distal aspect of roots. In this
a fit of a discrete, uniform distribution. study, cemental tears were presented as radiopaque fragments on
the mesial or distal root surfaces of 40 teeth (56.3%) on
Results preoperative radiographs (Table 2). However, some cemental tears
In this study, 43 of the 114 teeth were excluded for various reasons may be present on the labial/lingual (palatal) aspects of tooth roots
such as VRF (two cases), cracked roots (two cases), necrotic bones and cannot be easily identified on preoperative radiographs. Never-
(two cases), histological processing failure (one case), and radio- theless, the accurate diagnosis of cemental tears should be confirmed
graphic examination only (36 cases). Of the 71 teeth with cemental by histological examination or direct inspection of the fractured
tears, 10 were diagnosed by a direct inspection of the fractured cementum fragment and the root surface of the extracted teeth like
cementum fragment and the root surface of the extracted teeth, and the 71 cases analyzed in this study.
61 were diagnosed by histological examination (Fig. 3). All the biopsy In the present study, the (Poisson) chi-square goodness-of-fit test
specimens showed a fragment of cementum that fractured near or along was used to test for the fit of a discrete, uniform distribution in which all
the cementodentinal junction, suggesting that it was not an artifact the subgroups of each variable are equally likely under the null hypoth-
caused by periodontal treatment. Maxillary incisors (n = 28) were esis of a discrete, uniform distribution. The results suggest that variables
most frequently affected followed by the mandibular incisors (n = such as age, sex, tooth type, and attrition are the major predisposing
26), maxillary premolars (n = 7), mandibular molars (n = 7), factors for cemental tears. Cemental tears occurred frequently on inci-
mandibular premolars (n = 2), and maxillary molars (n = 1). In sors and in men or aged persons. These results were generally consis-
this study, none of the canines were affected by cemental tears tent with those reported in previous studies (Table 1). Previous reports
(Tables 2 and 3). suggested that occlusal trauma and clenching are possibly predisposing
The average age of the 71 patients with cemental tears was 66.3  factors for cemental tears (1–5, 8–12). This study found that prosthesis
12.6 years. Univariate analysis of predisposing factors found that teeth fabrication and loss of posterior occlusal support did not increase the
with cemental tears occurred more frequently in men (55/71, 77.5%, risk of cemental tears. Interestingly, moderate to severe tooth attrition
P < .0001), patients older than 60 years of age (52/71, 73.2%, P = had a significant association with cemental tears, but occlusal trauma

JOE — Volume 37, Number 5, May 2011 Characteristics and Predisposing Factors of Cemental Tears 615
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TABLE 2. Univariate Analysis of Predisposing Factors and Clinical Characteristics for the 71 Cases of Cemental Tears
Analyzed Chi-square test
Predisposing factors samples N (%) statistic* DF P value
Demography
Sex 21.423 1 <.0001†
Female 16 (22.5)
male 55 (77.5)
Age (y) 11.873 3 .008†
<60 19 (26.8)
6070 13 (18.3)
7080 29 (40.9)
>80 10 (14.1)
Clinical data
Tooth type 61.085 5 <.0001†
Max. incisor 28 (39.4)
Max. premolar 7 (9.9)
Max. molar 1 (1.4)
Mand. incisor 26 (36.6)
Mand. premolar 2 (2.8)
Mand. molar 7 (9.9)
Past dental history
Traumatic injury 41.286 1 <.0001†
No 57 (90.5)
Yes 6 (9.5)
Occlusal trauma 3.769 1 .052
No 19 (36.5)
Yes 33 (63.5)
Hard food chewing 3.765 1 .052
habit
No 42 (61.8)
Yes 26 (38.2)
Clinical symptoms and
signs
Sinus tract 1.141 1 .286
No 40 (56.3)
Yes 31 (43.7)
Abscess 7.451 1 .006†
No 24 (33.8)
Yes 47 (66.2)
Clinical examination
Pocket depth 51.916 2 <.0001†
&3 mm 6 (8.5)
36 mm 13 (18.3)
S6 mm 52 (73.2)
Electric pulp test 4.592 1 .032†
Negative 17 (34.7)
Positive 32 (65.3)
Prosthesis 21.423 1 <.0001†
No 55 (77.5)
Yes 16 (22.5)
Antagonist 131.943 3 <.0001†
Healthy tooth 59 (84.3)
Bridge 4 (5.7)
Crown 6 (8.6)
Removable 1 (1.4)
denture
Dentition‡ 23.539 4 <.0001†
0 23 (35.4)
1 1 (1.5)
3 20 (30.8)
4 10 (15.4)
5 11 (16.9)
Attrition 22.706 3 <.0001†
Intact 7 (10.3)
Mild 8 (11.8)
Moderate 30 (44.1)
Severe 23 (33.8)
Radiographic
examination
Periodontal bone 36.634 1 <.0001†
loss
No 10 (14.1)
Yes 61 (85.9)
(Continued )

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TABLE 2. (Continued )
Analyzed Chi-square test
Predisposing factors samples N (%) statistic* DF P value
Apical bone loss 6.211 1 .013†
No 25 (35.2)
yes 46 (64.8)
Prior root canal 19.282 1 <.0001†
treatment
No 54 (76.1)
yes 17 (23.9)
Post/core in root 45.761 1 <.0001†
canal
No 64 (90.1)
Yes 7 (9.9)
Diagnosis accuracy 1.141 1 .286
Preoperative 71 40 (56.3)
Postoperative 31 (43.7)
DF, degree of freedom.
*Goodness-of-fit test.
†
Statistical significance.
‡
0, integral dentition; 1, missing tooth beside the specimen without being restored; 2, missing tooth beside the specimen and had been restored; 3, partial posterior tooth missing but vertical occlusal support
remained; 4, unilateral posterior teeth missing and lost vertical occlusal support unilaterally; 5, bilateral posterior teeth missing and lost vertical occlusal support bilaterally.

and a hard food chewing habit only have marginally significant it is nearly impossible that the force/stress from a post can bypass the
correlation with cemental tears. The definitive impact factors for the dentin and simply impact the dentin-cementum interface. Although VRF
induction of cemental tears are intriguing for further investigations. occurs mainly in nonvital teeth (especially those with post/core), some
Prior endodontic treatment and post/core placement have been VRFs may also occur in vital teeth (12.3%) (18, 19). VRF occurs mainly
linked to the elevated risk of VRF (18). On the contrary, we found in posterior teeth (83.3%), nonvital teeth (88%), and the patients
that most of the teeth with cemental tears showed positive response between 40 and 60 years of age (55%) (18), but cemental tears had
to pulp vitality test. Moreover, root canal treatment and post/core fabri- a predilection for occurrence in anterior teeth (76.1%), vital pulp teeth
cation showed little association with the cemental tears. It is not unex- (65.3%), and aged person (73.2% >60 years of age) in this study.
pected that a VRF has intimate association with post placement because Although all VRF teeth should be extracted, teeth with cemental tears
had high potential to be successfully treated by total removal of cemental
TABLE 3. Distribution of the 114 Enrolled and the 71 Finally Analyzed fragments by surgical or nonsurgical methods. Therefore, the differen-
Cemental Tear Cases in Different Tooth Types tial diagnosis between cemental tears and VRF is important for the selec-
tion of a proper treatment. More cases have to be collected in order to
Enrolled sample Finally analyzed
(n = 114) sample (n = 71) understand the exact outcome of teeth with cemental tears treated by
Tooth types No. (%) No. (%) different methods.
Chou et al (4) have reported that 43% of teeth with cemental tears
#11 19 (16.7) 11 (15.5)
#12 6 (5.3) 5 (7.0)
receive root canal treatment. Previous studies also showed the failure of
#13 1 (0.9) 0 (0.0) endodontic treatment for several teeth with cemental tears (3–5, 9). In
#14 4 (3.5) 4 (5.6) this study, there were some cemental tear cases that were preoperatively
#15 5 (4.4) 1 (1.4) diagnosed to be a solely root canal infection (apical periodontitis),
#16 0 (0.0) 0 (0.0) especially when no marked cemental tear was detected on
#17 0 (0.0) 0 (0.0)
#21 17 (14.9) 11 (15.5) radiographs. In these cases, nonsurgical root canal treatment or
#22 1 (0.9) 1 (1.4) retreatment are often performed by local dentists or endodontists but
#23 0 (0.0) 0 (0.0) in vain. Thus, the patients were referred to the hospitals participating
#24 4 (3.5) 1 (1.4) in this MCTS for further treatment. Apical surgery, intentional
#25 2 (1.8) 1 (1.4)
#26 2 (1.8) 1 (1.4)
replantation, or extraction is often considered to be the treatment of
#27 0 (0.0) 0 (0.0) choice to explore the lesion and confirm the diagnosis. In these
#31 16 (14.0) 11 (15.5) cases, the total removal of cemental tears (especially those located
#32 4 (3.5) 3 (4.2) on the buccal/lingual or palatal side of the root) is crucial for the
#33 0 (0.0) 0 (0.0) success of apical surgery or intentional replantation. The dentists
#34 2 (1.8) 1 (1.4)
#35 3 (2.6) 1 (1.4) likewise should understand more about cemental tears in advance in
#36 2 (1.8) 1 (1.4) order to improve the prognosis of those teeth with cemental tears.
#37 0 (0.0) 0 (0.0) Clinically, swelling (abscess formation), deep periodontal
#41 18 (15.8) 12 (16.9) pockets, and periodontal bone destruction are the primary charac-
#42 1 (0.9) 0 (0.0)
#43 0 (0.0) 0 (0.0)
teristics of teeth with cemental tears. These findings were generally
#44 0 (0.0) 0 (0.0) consistent with those reported in previous studies (Table 1). We
#45 1 (0.9) 0 (0.0) further found that most teeth with cemental tears showed marked
#46 4 (3.5) 4 (5.6) periodontal bone destruction (85.9%) or periapical bone destruc-
#47 2 (1.8) 2 (2.8) tion (64.8%) on preoperative radiographs depending on the lateral
Total 114 (100.0) 71 (100.0)
or apical location of cemental tears, respectively. Some early cases

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with cemental tears located on the lateral aspect of the root may
show lateral lesions on radiographs. If these affected teeth were
nonvital, it was necessary to differentiate cemental tears from peri-
radicular infection disseminated from lateral canals or a pure
chronic periodontal lesion. Clinically, when the pulp status can
be easily evaluated by vitality tests or test cavity, unnecessary
endodontic treatment can be avoided. However, potential difficulties
are present when it is needed to evaluate the vitality of teeth with
calcified pulp in aged persons or of teeth with crown restoration.
In cemental tear cases with periapical lesion, endodontic treatment
should be performed followed by apical surgery and removal of
cemental tears.
In conclusion, our results show that age, sex, tooth type, and attri-
tion are the significant predisposing factors for teeth with cemental
tears. Tissue swelling, narrow deep pocket, the predilection for vital
teeth, periodontal/periapical bone destruction, and the presence of
a radiopaque fragment on the root surface are the major clinical char-
acteristics of teeth with cemental tears. Accurate early diagnosis may be
helpful for the selection of a proper treatment. Further studies of more
cases are needed to improve our understanding for the outcome of
cemental tear cases treated by different methods.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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JOE — Volume 37, Number 5, May 2011