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 713-500-4420; Jerry.Bouquot@uth.tmc.edu; bouquot@aol.com

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

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

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

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

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

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)

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: 52 - 91 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

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%

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

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

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)

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

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)

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

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

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

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

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

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