1. Dr. Bouquot, Oral Injuries
Fall, 2011
The vertical radiolucency cemental tear: histopathology & Radiology
Jerry Bouquot,* Scott Makins,* Samuel Dorn,* Gary Blum **
* University of Texas, Houston
** Private Practice of Periodontology, Houston, Texas
Dr. J. E. Bouquot, Professor & Chair
Department of Diagnostic Sciences. Room 3.094b
University of Texas School of Dentistry at Houston
6516 M.D. Anderson Blvd., Houston, TX 77030 ;

2. The cemental tear the history
© Drs. Bouquot J, Makins S, Dorn S, Blum G, AADR, 2012
The cemental tear the history
First reported in 1992
Separation of cementum
from underlying root dentin
-- Sharpey's fiber connection to
cementum is stronger than
cementum-dentin bond
-- Environmental defect?
-- Developmental defect?
Rare? Only 13 cases reported
Etiology: unknown
-- Trauma?
-- Acute biting episode?
-- Bruxing?
↑ susceptibility with ↑age
Maybe: artifact from extraction
-- 12 of 13 reported cases were diagnosed after extraction
Cementum
PDL
Dentin

3. The cemental tear embryology of CDJ
© Drs. Bouquot J, Makins S, Dorn S, Blum G, AADR, 2012
The cemental tear embryology of CDJ
Cementum layer forms on root dentin
with first dentin mineralization
Initial attachment of cemental fibrils to dentin surface begins at this point
With initial attachment: intermingling of cemental and dentinal fibrils occurs
-- Only in sporadic places
With advanced cementogenesis: initial cementum layer becomes the fibril-poor cemento-dentinal junction (“A” in lower photo), i.e. the weakest link in the connection
In this area: new cemental fibrils attach to initial cementum layer, not directly onto dentinal fibrils
-- Hence: paucity of fibril-fibril connections
-- Hence: “adhesive” is main attachment
Cementum
CDJ
Dentin A
Dentin
Cementum

4. The cementum tear embryologic reason for CDJ tear
© Drs. Bouquot J, Makins S, Dorn S, Blum G, AADR, 2012
The cementum tear embryologic reason for CDJ tear
From the embryonic perspective, then, one would expect a traumatic tear to most readily occur at the level of the very first cementum layer
Which is exactly what is seen
One of our cases: thin layer of dentin on inner surface of cemental fragment
Occlusal trauma: should put most stress on middle & lower root surface
Which is what is seen
Dentin
Cementum

5. The cemental tear CDJ tears after development
© Drs. Bouquot J, Makins S, Dorn S, Blum G, AADR, 2012
The cemental tear CDJ tears after development
Cementum becomes thicker over time
-- Especially in the apical region
Cementum is layered intermittently as a
person ages
-- Concentric rings of different densities
-- Cemental annulation ( used in
mammals to estimate age)
-- Not produced/calcified uniformly
throughout the year
-- Not uniformly calcified
It seems reasonable, then, to expect
cemental tears to occur in the less
calcified layers of cementum
-- Not addressed in the literature
How about the adhesive strength in areas of repaired dentin?
How about strength in areas of cementum repair?
Dentin
Cementum

6. The cemental tear 14 cases: methods & materials
© Drs. Bouquot J, Makins S, Dorn S, Blum G, AADR, 2012
The cemental tear 14 cases: methods & materials
Convenience sample from our practices
-- Collected over a 5 year period
All biopsy cases: diagnosed prior to extraction
Dx made by biopsy:
-- Must have embedded sliver of cementum
-- 11 cases: chronic fibrosing osteomyelitis
-- 3 cases: intramedullary fibrous scar
Cementum slivers (arrows) A A B A B
Biopsy of above lesion

7. The cemental tear 14 cases: typical histopathology
© Drs. Bouquot J, Makins S, Dorn S, Blum G, AADR, 2012
The cemental tear 14 cases: typical histopathology
Biopsies all showed moderately dense to very dense fibrous tissue with small to large number of chronic inflammatory cells
-- No acute inflammation was seen
-- No foreign body reaction to the cementum
If moderate fibrosis & ↑ inflammatory cells: osteomyelitis
If ↑ fibrous density & ↓ inflammatory cells; fibrous scar
Vertical radiolucency
(Appears artifactually to be outside lamina dura)
Biopsy of above lesion (arrows = cementum)
Dx: Chronic fibrosing osteomyelitis)

8. The cemental tear 14 cases: demographics, location
© Drs. Bouquot J, Makins S, Dorn S, Blum G, AADR, 2012
The cemental tear 14 cases: demographics, location
8 men, 6 women
Mean age = 66 years
Age range: years of age
Most common site: maxillary incisors
Least common site: premolars,
mandibular incisors
10 cases: apical half of root
All cases: viable tooth with pain
-- Noticed most during
occlusal pressure
4 cases Rx for pain via RCT,
prior to biopsy, despite pulp
testing viable

9. The cemental tear 14 cases: demographics, location, symptoms
© Drs. Bouquot J, Makins S, Dorn S, Blum G, AADR, 2012
The cemental tear 14 cases: demographics, location, symptoms
Subject
ID #
Age
(Years)
Gender
Location
(Tooth #)
Pain? 1 61 M 6
Yes 2 52 7 3 79 8 4 56 18 5 57 19 9 65 91 53 F 10 69 11 80 12 13 24 14 87
Summary:
Avg. 66
8M:6F
100%

10. The central tear Radiographic examples (RCT done after the tear)
© Drs. Bouquot J, Makins S, Dorn S, Blum G, AADR, 2012
The central tear Radiographic examples (RCT done after the tear)
Arrows point to vertical radiolucencies
Right hand case = J-shaped radiolucency
Left hand case: perforation in lamina dura (small arrow) allowed inflammation to extend into medullary spaces

11. The central tear Radiographic example
© Drs. Bouquot J, Makins S, Dorn S, Blum G, AADR, 2012
The central tear Radiographic example
Arrows point to vertical radiolucency with torn cementum

12. The central tear Radiographic examples (RCT done after the tear)
© Drs. Bouquot J, Makins S, Dorn S, Blum G, AADR, 2012
The central tear Radiographic examples (RCT done after the tear)
Arrows point to vertical radiolucencies
Right hand case: tooth was viable to electric pulp test; when tooth was finally extracted it showed extensive tearing of cementum from the apex to the top of the furcation (see insert)

13. The central tear Radiographic example (RCT done after the tear)
© Drs. Bouquot J, Makins S, Dorn S, Blum G, AADR, 2012
The central tear Radiographic example (RCT done after the tear)
Yellow arrows point to cementum slivers
White arrows point to vertical radiolucency
Left hand case: root resorption has occurred beneath the torn cementum

14. The central tear Radiographic examples
© Drs. Bouquot J, Makins S, Dorn S, Blum G, AADR, 2012
The central tear Radiographic examples
Arrows point to cementum slivers (all teeth are viable)

15. The cemental tear histopathology of teeth with tears
© Drs. Bouquot J, Makins S, Dorn S, Blum G, AADR, 2012
The cemental tear histopathology of teeth with tears

16. The cemental tear histopathology of teeth with tears
© Drs. Bouquot J, Makins S, Dorn S, Blum G, AADR, 2012
The cemental tear histopathology of teeth with tears

17. The cemental tear histopathology of teeth with tears
© Drs. Bouquot J, Makins S, Dorn S, Blum G, AADR, 2012
The cemental tear histopathology of teeth with tears

18. The cemental tear histopathology of teeth with tears
© Drs. Bouquot J, Makins S, Dorn S, Blum G, AADR, 2012
The cemental tear histopathology of teeth with tears

19. The cemental tear 14 cases: treatment
© Drs. Bouquot J, Makins S, Dorn S, Blum G, AADR, 2012
The cemental tear 14 cases: treatment
4 cases: Rx with endodontic therapy (unsuccessfully) for pain, prior to cemental
tear diagnosis
2 cases: developed deep periodontal pockets
2 cases: Rx successfully without extraction
12 cases: extraction

20. The cemental tear conclusions
© Drs. Bouquot J, Makins S, Dorn S, Blum G, AADR, 2012
The cemental tear conclusions
Cemental tears appear to be a phenomenon of persons > 50 years of age
This study does not prove etiology
At least some cemental tears are not resorbed in vivo
These produce symptomatic, low grade chronic inflammation with fibrosis
These are characterized by a vertical radiolucency adjacent to the root
Depending on presentation, extraction of the affected tooth may not be necessary