Diagnosing and Treating Cemental Tears and Cervical Projections

Teeth are composed of three hard tissue layers: enamel, dentin, and cementum. Anatomical or physical alterations of these hard tissue layers, such as cemental tears and cervical enamel projections, have the potential to cause periodontal and/​or bony destruction.¹

Cemental tears are incomplete or complete fractures of cementum that lead to the subsequent detachment of cementum from the cementodentinal junction. They may also arise from a partial detachment within the cementum layer itself.² Clinically, cemental tears can mimic a root fracture, periodontal lesion, or endodontic lesion.³ Because these types of root surface fractures are not very well understood, nor are they easily identifiable, cemental tears are commonly omitted from the differential diagnosis.

Cervical enamel projections are caused by the continued activity of ameloblasts following the formation of the clinical crown. These tapered, triangular extensions of enamel extend from the cementoenamel junction (CEJ) into the furcation region.⁴ Because connective tissue will not form a true attachment to enamel, a periodontal defect usually arises.⁵

This article will discuss the incidence, etiology, diagnosis, and treatment of cemental tears and cervical enamel projections.

Incidence of Cemental Tears

The overall incidence of cemental tears is low. However, with the aid of periapical radiographs and cone-beam computed tomography (CBCT), cemental tears have been observed in 0.89% to 1.9% of patients.^6,7 Cemental tears are most commonly found in men older than age 60.^1,8 However, other researchers have been unable to find any correlation between cemental tears and patient age or gender.⁶

Cemental tears can be found on both maxillary and mandibular teeth, with a predilection for incisors up to 74.1%.⁹ Maxillary incisors tend to be the most affected, with a 47.6% incidence.¹⁰ In addition, cemental tears have been found along all surfaces of the root, including the cervical, middle, and apical thirds of roots.¹ Among cemental tears, 77.6% are found near the cementodentinal junction, and 22.4% occur within the cemental layer itself. Most (79.6%) of cemental tears are found on the proximal root surfaces.⁹

Cemental tears have an average width of 2.2 to 10 mm and a thickness of 0.9 to 6 mm.^9,11 Clinically, the resulting bone loss from cemental tears can mimic other periodontal conditions, thereby complicating both diagnosis and treatment planning. Specifically, cemental tears tend to form a periodontal pocket that resembles localized periodontitis, apical periodontitis, and/​or a vertical root fracture. Radiographic findings have shown that cemental tears are associated with periodontal bone destruction in 85.9% of cases and periapical bone destruction in 64.8% of cases.⁹

Etiology of Cemental Tears

The etiology of cemental tears has been attributed to both internal and external factors. Internal factors include the inherent structural weakness of cementum, which becomes even weaker during the aging process.^2,12 According to Jeng et al,¹ cementum increases in thickness throughout the lifespan, depending on the root position and tooth type. Older adults experience a decrease in the adhesion of proteoglycans between dentin and cementum as well as a reduction in the regulation of periodontal ligament stretching, which can lead to cemental tears.¹ Older adults also have a weaker adhesion between the cementum and dentin layers in comparison to the outer cementum and associated periodontal ligament fibers, which can result in cemental tearing. Other age-related factors include a lowered capacity for repair, increased strength of principal fibers, and reduced occlusal support.¹³

External factors that may cause cemental tears are dental trauma and occlusal forces, such as parafunctional habits, inadequate and/​or severe occlusal loading, and/​or excessive tensional forces. The posterior teeth are often lost before the anterior teeth, which leads to increased forces on the anterior teeth. Because anterior teeth seem to be more affected by cemental tears than posterior teeth, protrusive and/​or lateral forces are likely to be involved in the development of cemental tears.¹² Although some authors have proposed that previous endodontic treatment might be a predisposing factor for cemental tears, they are most often associated with teeth with vital pulps that have not undergone endodontic treatment.¹

Once a cemental tear has formed, it can act as a foreign body and induce localized inflammation in the surrounding periodontium and alveolar bone. The fragment of cementum is also capable of causing mechanical irritation, which is intensified by occlusal forces and mastication, thereby generating a self-sustaining inflammatory response.¹⁰ Eventually, this process can lead to a periodontal pocket that may not only communicate with the oral environment, but also extend toward the apex of the tooth. This pocket has the potential to harbor microbial pathogens. As a result, any exposed dentinal tubules, lateral canals, or the apical foramen itself can be invaded by these microbial pathogens, which, in turn, could exacerbate the periodontal and/​or pulpal inflammation.^11,14

Diagnosis of Cemental Tears

The diagnosis of cemental tears is challenging due to their inherent ability to mimic periodontal and periapical lesions. One diagnostic feature is tissue swelling associated with periodontal and/​or periapical breakdown.⁶ Cemental tears often present with an asymptomatic deep periodontal probing depth that has sudden progression, bleeding on probing, suppuration, tooth mobility, and localized attachment loss.^1,11

Radiographically, cemental tears appear as radiopaque sheet-like, prickle-like, or tear-like fragments possibly associated with a lateral radiolucent lesion that resembles other etiologies such as lateral canal infections, root fractures, resorption, and lateral periodontal cysts.¹¹ When conventional radiographs are used, the observation of a vertical radiopaque fragment, which appears parallel to the adjacent root surface, is diagnostic for a cemental tear (Figure 1).¹⁵

Cemental tears located on the buccal and/​or lingual aspect of the root are particularly challenging to identify on a periapical radiograph. As a result, cemental tears may be overlooked, and unless the cemental tear itself is addressed, healing is unlikely.^6,16 Therefore, a small field-of-view CBCT should be used in conjunction with traditional radiographs to aid in the diagnosis of cemental tears. As an added benefit, CBCT imaging can offer information regarding the extent of the cemental detachment from the CEJ.²

The early detection of cemental tears is unlikely because typically no symptoms are associated with newly formed tears.¹⁶ But, when a periodontal pocket develops and the tissue becomes inflamed, then palpation, percussion, and mobility testing can help identify an affected tooth.¹ Whenever sinus tracts or localized periodontal breakdown are present, cemental tears must be considered in the differential diagnosis. In addition, clinicians should critically evaluate radiographs for the presence of a possible cemental tear.¹

Although clinical and radiographic examination and/​or explora­tory surgery can aid in the diagnosis of a cemental tear, only histo­pathological analysis can provide a definitive diagnosis. A biopsy can be obtained during scaling and root planing, or by periodontal and/​or apical surgery.¹ Histologically, cemental tears contain cementum lamellae, cementoblasts, and adhered periodontal ligament fibers. Frequently, histological samples of cemental tears are also accompanied by granulation tissue or a radicular cyst.¹⁷

Treatment of Cemental Tears

Treatment options for cemental tears depend on the location of the cemental tear, prognosis of the tooth, severity of periodontal involvement, pulp vitality status, and patient preference.¹ Teeth with a poor prognosis due to severe bone or attachment loss should be extracted as seen in Figure 2.¹⁸ Conversely, if a cemental tear presents without any attachment loss or signs or symptoms, then the tooth can be monitored and no immediate intervention may be necessary.^18,19

When cemental tears are accessible and located in the coronal third of the root surface, traditional scaling and root planing without periodontal surgery is a viable treatment option.⁶ However, nonsurgical periodontal treatment alone risks leaving behind cemental fragments, which may result in delayed or nonhealing.¹⁵ Another option for treating coronally located cemental tears is periodontal surgery with open flap debridement (Figure 3).¹⁵ During surgery, the cementum fragments are removed and the root surface is smoothed.²⁰ Compared to nonsurgical treatment, surgical intervention is associated with a 30% higher success rate.⁹

When cemental tears occur in the apical third of the root and are accompanied by pathosis, then apical surgery in conjunction with root canal therapy is indicated (Figure 4).¹ Studies suggest that the addition of guided tissue regeneration — with or without bone grafting — can aid with periodontal healing.¹ For a cemental tear that is not surgically accessible, intentional extraction, root resection, defect repair, and replantation may be considered as alternate treatment options.

Once treatment is completed, the external factors that may have contributed to the cemental tear, such as traumatic occlusion, should be addressed. Thus, occlusal adjustment and night guard fabrication are recommended to prevent recurrence.³ Then, maintenance and follow-up appointments are necessary to evaluate for healing and to monitor the overall status of the tooth.

Cervical Enamel Projections

Cervical enamel projections are more commonly found on mandibular molars than in maxillary molars.^21,22 Studies have shown that cervical enamel projections in molars have an overall incidence of 8.6% to 32.6%, with mandibular second molars having the highest incidence of 51%.^5,22 Cervical enamel projections occur more frequently on the buccal aspect of the tooth (70.9%) than the lingual surface (27%), but they can be present on both the buccal and lingual surfaces concurrently (22%).⁴ Cervical enamel projections are more common in men, with an incidence of 77.4% to 87.5%, compared to a broader range of incidence for women at 20.4% to 91.5%.^4,21

Cervical enamel projections are divided into three grades:

Grade I: The cervical enamel projection extends from the CEJ toward the furcation.

Grade II: The cervical enamel projection approaches the entrance of the furcation.

Grade III: The cervical enamel projection extends into the furcation (Figure 5).^5,23

Grade I projections are more common than Grades II or III and cervical enamel projections have been associated with furcation involvement in 87.5% of cases.^21,22

Because cervical enamel projections favor an epithelial attachment over a connective tissue attachment, they are highly susceptible to bacterial colonization and attachment loss.⁴ Localized periodontal breakdown results from plaque accumulation and the inability of the patient to effectively maintain oral hygiene in the area.⁵

Clinically, a cervical enamel projection presents as a localized periodontal pocket in the furcation area of a molar. Cervical enamel projections can be subsequently diagnosed with an explorer, periodontal probe, surgical intervention, or radiograph.

The treatment of a cervical enamel projection involves flap elevation and odontoplasty.⁵ The overarching goal is to remove the ectopic enamel to allow for reattachment.²⁴ This can be performed with a diamond bur, piezoelectric ultrasonic scaler, or periodontal bur. Diamond burs produce the smoothest root surface, but they also cause the most damage to the adjacent tooth structures and periodontal tissues. Periodontal burs create smooth root surfaces and do not damage adjacent structures.²⁵ In addition to odontoplasty, periodontal regenerative therapy has been suggested to treat the osseous defects associated with the cervical enamel projections.⁵

Although dentinal hypersensitivity is a potential risk, odontoplasty — with or without regenerative therapy — followed by supportive periodontal maintenance is currently the preferred treatment option for cervical enamel extensions.²⁶

Conclusions

Cemental tears and cervical enamel projections can both result in periodontal destruction and bone loss. Awareness of these lesions and accurate diagnosis will aid the clinician in arriving at the most predictable and appropriate treatment options for the patient.

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References

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From Decisions in Dentistry.Jan/Feb 2024; 10(1):28-31