the predispose factor, clinical characteristics and treatment outcome of cemental tear

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The Predispose Factor, Clinical Characteristics and Treatment Outcome of Cemental Tear

Presentb00402026王章蓉b00402001孟慶恩b01402020許明翰

Advisor鄭景暉醫師

Sample Histology Biopsy Treatment

Outline

• Introduction• What is Cemental Tear

• Literature Review

• Clinical Characteristics and Diagnostic Challenge

• Specific Aim

• Experimental Design

• Result

• Conclusion

2Introduction Specific Aim Exp. Design Result Conclusion

What is cemental tear

• Detachment of a fragment of cementum from the root

• The separation of cementum may be complete with displacement of a fragment into the periodontal ligament or it may be incomplete with cementum fragment partially attached to the roots.

• The detached cementum may be reunited to the root surface. Or may be completely resorbed or may undergo partial resorption followed by addition of new layers

Introduction Specific Aim Exp. Design Result Conclusion

What’s Cemental tear? Case 1

• 47-year-old female

• left mandibular first molar.

• Angular bony defect containing 3 radiopaque cemental tear fragments on mesialcervical

• This is like a periodontal lesion.



• A 76-year-old man

• left mandibular central incisor.

• periapical radiolucency and radiolucent fracture line over the apical region of the root

• Endodontic lesion



• 58-year-old male

• The mandibular central incisor

• A cemental tear on the labial surface to mesial aspect near root apex .

• U-shaped lesion as mentioned in prior reports


Clinical view and radiographic view


Clinical Characteristics and Diagnostic Challenge

• Diagnostic challenge:• It looks like a solely periodontal or periapical infection

• Major clinical characteristics of teeth with cemental tears • tissue swelling

• localized deep pocket

• periapical lesion


Past report

• The presence of a concave surface fragment in left mandibular second premolar was first mentioned and later named as U-shaped fragment offending >1 root surface. -- Haney et al

• The radiopaque ‘‘foreign body’’ was noted on the distal root surface of periapical radiographs. --Tulkki et al

• The sheet-like cemental fragments appeared simultaneously on the buccal, distal, and palatal aspects of the root during surgical exploration. --Camargo et al

• The apicocoronal location of cemental tear was noted by using radiographic images. -- Ishikawa et al


Past report

Clinical finding Predisposing factor

Deep periodontal pocket Age

Rapid attachment loss Occlusal overloading/trauma

Vertical bony defect Impaired tissue repair

Prior endodontic treatment Failure of endodontic treatment

Sinus tract Marked attrition

Thicker cementum


Past report

Suspected Factor

Prior reports This Study

Common Age, traumatic history, sinus tract, pocket depth, attrition, EPT result, periodontal bony destruction, prior root canal treatment, apical bone loss

Different Sex, tooth type, abscess, prosthesis, antagonist(healthy tooth/bridge/crown/removable denture), postcore in root

Specific Aim

• To sum up the predisposing factor of cemental tear

• To evaluate the morphology, apicocoronal location, and the histologic characteristics of cemental tear

• To evaluate the treatment outcome of cemental tear


14

Biopsy(9)

Excluded(2)

Biopsy(7)

No Biopsy(22)

No Biopsy(4)

Direct Inspection

(3)

No Biopsy(11)

Biopsy(26)

Excluded(5)

Operation(15)

Biopsy(19)

Direct Inspection(28)

No Biopsy(9)

Direct Inspection

(7)

Surgery(42)

Non-Surgery(29)

Extraction(43)

Sample(114)

Histology (54)

Confirmed (71)

Treatment(33)

Suspected Sample(114)


Experimental Design

Statistic Analysis

1987~2008, 4 medical centersCollection Criteria:(1) Radiopacity of separated root structure (2) persistent periapical radiolucency even

after endodontic treatment(3) Recurrent periodontal inflammation after

periodontal treatment

15

Biopsy(9)

Excluded(2)

Biopsy(7)

No Biopsy(22)

No Biopsy(4)

Direct Inspection

(3)

Operation(15)


No Biopsy(9)

Direct Inspection

(7)

Biopsy(19)

Biopsy(26)

Excluded(5)

No Biopsy(11)

Sample(114)

Histology (54)

Confirmed(71)

Treatment(33)

Surgery(42)

Non-Surgery(29)

Extraction(43)


Scaling Root Planning Endodontic Treatment

Flap Surgery Debridement Bone Graft, GTP

Poor/unpredictable prognosis Unfavorable response to treatment Personal choice

16

Biopsy(9)

Excluded(2)

Biopsy(7)

No Biopsy(22)

No Biopsy(4)

Direct Inspection

(3)

Operation(15)


No Biopsy(9)

Direct Inspection

(7)

Biopsy(19)

Extraction(43)

Non-Surgery(29)

Sample(114)

Histology (54)

Confirmed(71)

Treatment(33)

Biopsy(26)

Excluded(5)

No Biopsy(11)

Surgery(42)


Crack (2) Bone (2) Processing error (1)

17

Biopsy(9)

Excluded(2)

No Biopsy(4)

Direct Inspection

(3)

Operation(15)


No Biopsy(9)

Direct Inspection

(7)

Biopsy(19)

Biopsy(26)

Excluded(5)

No Biopsy(11)

Extraction(43)

Surgery(42)

Sample(114)

Histology (54)

Confirmed(71)

Treatment(33)

No Biopsy(22)

Biopsy(7)

Non-Surgery(29)


18

Biopsy(9)

Excluded(2)

Biopsy(7)

No Biopsy(22)

No Biopsy(4)

Direct Inspection

(3)

No Biopsy(11)

Biopsy(26)

Excluded(5)

Operation(15)

Non-Surgery(29)

Surgery(42)

Sample(114)

Histology (54)

Confirmed(71)

Treatment(33)

Biopsy(19)


No Biopsy(9)

Direct Inspection

(7)

Extraction(43)


19

Biopsy(7)

No Biopsy(22)

No Biopsy(11)

Biopsy(26)

Excluded(5)

Surgery(42)

Biopsy(19)


No Biopsy(9)

Direct Inspection

(7)

Non-Surgery(29)

Sample(114)

Histology (54)

Confirmed(71)

Treatment(33)

Biopsy(9)

Excluded(2)

No Biopsy(4)

Direct Inspection

(3)

Operation(15)

Extraction(43)


VRF (2)

20

No Biopsy(22)

No Biopsy(11)

Excluded(5)

No Biopsy(9)

Excluded(2)

No Biopsy(4)


Operation(15)

Sample(114)

Treatment(33)

Histology (54)

Surgery(42)

Non-Surgery(29)

Biopsy(26)

Biopsy(19)

Biopsy(9)

Biopsy(7)

Direct Inspection

(7)

Direct Inspection

(3)

Extraction(43)

Confirmed(71)


21

No Biopsy(22)

No Biopsy(11)

Excluded(5)

No Biopsy(9)

Excluded(2)

No Biopsy(4)


Operation(15)

Sample(114)

Treatment(33)

Confirmed(71)

Biopsy(7)

Direct Inspection

(7

Direct Inspection

(3)

Surgery(42)

Non-Surgery(29)

Biopsy(26)

Biopsy(19)

Biopsy(9)

Extraction(43)

Histology (54)


22

No Biopsy(22)

No Biopsy(11)

Excluded(5)

No Biopsy(9)

Excluded(2)

No Biopsy(4)


Operation(15)

Sample(114)

Histology (54)

Biopsy(19)

Biopsy(9)

Direct Inspection

(7)

Direct Inspection

(3)

Confirmed(71)

Extraction(43)

Non-Surgery(29)

Biopsy(26)

Biopsy(7)

Surgery(42)


Treatment(33)

Outline

• Introduction

• Specific Aim

• Experimental Design

• Result

• Conclusion


Who had a greater chance to get cemental tear?

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Sex Quantity Ratio P Value

Female 16 22.5 <0.001

Male 55 77.5

Age Quantity Ratio P-value

<60 19 26.8 0.08

60~70 13 18.3

70~80 29 40.9

>80 10 14.1

Attrition Quantity Ratio P Value

Intact 7 10.3 <0.001

Mild 8 11.8

Moderate 30 44.1

Severe 23 33.8

Hard food chewing

Quantity Ratio P-value

No 42 61.8 0.52

Yes 26 38.2

Occlusaltrauma


No 19 36.5 0.52

Yes 33 63.5

Old male patients are prone to have cementum tear


Cemental Tear vs. Vertical Root Fracture?

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Tooth type Quantity Ratio P Value

Max. incisor 28 39.4 <0.001

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

Post -core Quantity Ratio P Value

No 64 90.1 <0.001

Yes 7 9.9

Prior RCT Quantity Ratio P Value

No 54 76.1 <0.001

Yes 17 23.9

1. Most VRF occur in teeth with RCT and post-core prosthesis

2. VRF appear mostly in premolar and molar

Prosthesis Quantity Ratio P Value

No 55 77.5 <0.001

Yes 16 22.5


Cementum tear vs. Perio problem


Peri bone loss(x-ray)

Quantity Ratio P Value

No 10 14.1 <0.001

Yes 61 85.9

Pocket depth Quantity Ratio P Value

<3mm 6 7.2 <0.001

3mm~6mm 13 18.3

>6mm 52 85

1.Bone loss is shown in cementum tear

2.The location of the bone loss follow by where the cementum tear occur.

Apical bone loss


No 25 35.2 0.013

Yes 46 64.8

Apicocoronallocation


Cervical 1/3 7 13.2 .0076

Middle 1/3 24 45.3

Apical 1/3 22 41.5

Cemental tear vs. Endo problem

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Sinus tract Quantity Ratio P-value

No 40 56.3 0.286

Yes 31 43.7

abscess Quantity Ratio P-value

No 24 33.8 0.006

Yes 47 66.2

EPT Quantity Ratio P-value

Negative 17 34.7 0.032

Positive 32 65.3

With the symptoms of abscessand sinus tract, cemental tear is easily confused with pulpal inflammation .


Location vs. Cemental tear fragment type

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Coronal and middle third Apical third

P-shape 52.8%(28/53) 47.2%(25/53)

U-shape 33.3% (6/18) 66.7% (12/18)


What is the key factor to good prognosis?

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Coronal and middle third(P-shape)

Apical third(U-shape)

Prognosis 60.0% in the coronal third66.7% in the middle third

11.1%

Two reasons of the poor prognosis:

1.Difficulty in cleaning all the fragments2.Possibly extension


Conclusion: How to Different Diagnose Cemental Tear?

Cemental Tear Endodontic problem

Periodontics Vertical Root Fracture

abscess + + +/- +/-

Bone loss + - + +/-

Pulp involvement - + - +

Tooth type Anterior teeth

Prosthesis - +


Reference

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• MS, H.-J. L. D., DDS, C.-P. C., MS, C.-Y. Y., DDS, C.-T. W., MS, Y.-L. T. D., MS, C.-C. H. D., MS, K.-D. Y. D., et al. (2011). Cemental Tear: Clinical Characteristics and Its Predisposing Factors. Journal of Endodontics, 37(5), 611–618. doi:10.1016/j.joen.2011.02.017

• PhD, H.-J. L. D. M. S.-H. C. P. M.-C. C. M. P. Y.-L. T. D. M. C.-P. C. D. P. C.-P. C. D. J.-H. J. D., PhD, S.-H. C., PhD, M.-C. C. M., MS, Y.-L. T. D., PhD, C.-P. C. D., DDS, C.-P. C., & PhD, J.-H. J. D. (2012). Clinical Fracture Site, Morphologic and Histopathologic Characteristics of Cemental Tear: Role in Endodontic Lesions. Journal of Endodontics, 38(8), 1058–1062. doi:10.1016/j.joen.2012.04.011

• MS, H.-J. L. D., PhD, M.-C. C. M., PhD, S.-H. C., DDS, C.-T. W., MS, Y.-L. T. D., PhD, C.-C. H. D. M., MS, S.-F. C., et al. (2014). Treatment Outcome of the Teeth with Cemental Tears. Journal of Endodontics, 40(9), 1315–1320. doi:10.1016/j.joen.2014.05.012

Thank you

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Appendix: Statistic of cementum fragment


Sex Quantity Ratio P-value

Female 14 25.9 .0004

Male 40 74.1

age Quantity Ratio P-value

<50 9 16.7 <.0001†

50~60 6 11.1

60~70 11 20.4

70~80 21 38.9

>80 7 13.0

Tooth type Quantity Ratio P-value

Incisor 40 74.1 <.0001

Premolar 8 14.8

Molar 6 11.1

Length Quantity Ratio P-value

0 <X <3 mm 16 30.8 <.0001

3 <X <6 mm 31 59.6

X >6 mm 5 9.6

Width Quantity Ratio P-value

0 <X <4 mm 21 40.4 <.0001

2<X <4 mm 28 53.8

X >4 mm 3 5.8

Thickness Quantity Ratio P-value

0 <X <0.5mm 8 15.4 .0002

0.5<X <1 mm 18 34.6

1<X <1.5 mm 23 44.2

X >1.5 mm 3 5.8

Appendix: Statistic of cementum fragment


Shape Quantity Ratio P-value

P-shape 41 77.4 .0004

U-shape 12 22.6

Mesiodistallocation


Proximal 43 79.6 <.0001

Buccal 4 7.4

palatal 7 13.0



Cervical 1/3 7 13.2 .0076

Middle 1/3 24 45.3

Apical 1/3 22 41.5

Appendix: Histological examination


Histologic split site


Cementodentinaljunction

38 77.6 .0001†

In cementum 11 22.4

Shape Quantity Ratio P-value

Granulation tissue

48 92.3 <.0001†

Radicular cyst 4 7.7

Appendix: The correlation between cementum tear’s characteristics


Variables Sex age Tooth type Radiopaque image


Dentition

Sinus tract .0059

Pain .0578

Attrition .0034

Fragment length

Fragment width .0465

Fragment thickness .0952 .0038


.0019 <.00001

Fragment shape .0426

Separation mode .0780

Histologic split site .0875

Accuracy .0295 <.00001

Technique .0168


• Older people without sinus tract：73.2%

• Younger(<60 years) ：46.6%


Variables Sex age Tooth type

Radiopaque image


Dentition

Sinus tract .0059

Pain .0578

Attrition .0034


• Review part I：88% has mild ~severe attrition



Radiopaque image


Dentition

Sinus tract .0059

Pain .0578

Attrition .0034

Attrition Quantity Ratio P Value

Intact 7 10.3 <0.001

Mild 8 11.8

Moderate 30 44.1

Severe 23 33.8




Radiopaque image


Dentition

Surgical Examination

Fragment length


Fragment thickness

.0952 .0038


.0019 <.00001

Older people：3.9% (2/51) Younger people：89.6% (17/19)





Dentition


Fragment length




.0019 <.00001

incisor:：42.6%(< 3mm)/ 50% (3-6mm)Premolar：77.8% < (3mm)Molar：57.1%(>6mm)





Dentition


Fragment length




.0019 <.00001

incisor:：52.8%(28/53)Preamolar：0%(0/11)Molar：28.6% (2/7)





Dentition


Fragment shape .0426

Separation mode .0780

Histologic split site .0875

piece-shaped fragments ：52.8%(28/53) middle third U-shaped fragments : 66.7% (12/18) apical third





Dentition

Accuracy .0295 <.00001

Technique .0168

52.8% (28/53 ) incisors can be diagnosis accurately

80.0% (36/45) of teeth could be correctly diagnosis when x-ray show fragments

the predispose factor, clinical characteristics and treatment outcome of cemental tear

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