Class 2, Stage A Cemental Tear Mimicking Apical Periodontitis: A Case Report

A cemental tear is a rare condition that can closely mimic endodontic and periodontal diseases, making accurate diagnosis challenging. Early identification is essential to ensure appropriate treatment and to avoid unnecessary or ineffective interventions. A 75-year-old woman presented with discomfort and a sinus tract associated with the mandibular right lateral incisor (tooth 42 (Universal #26)). Clinical examination showed no periodontal pocket, and conventional periapical radiographs showed a periapical radiolucency. Based on these findings, the initial diagnosis was symptomatic apical periodontitis, and root canal therapy was performed. However, the lesion did not improve. Cone-beam computed tomography (CBCT) then showed a cemental tear on the labial aspect of the root, classified as Class 2, Stage A, and the treatment plan was revised to include surgical intervention. Root-end surgery and removal of the cemental fragment resulted in good healing. Histopathologic examination demonstrated granulation tissue consistent with a periapical granuloma and bacterial colonies on the detached cemental fragments. This case highlights the diagnostic difficulty of differentiating apical periodontitis from Class 2, Stage A cemental tears located on the buccolingual aspect without a periodontal pocket, particularly in elderly patients and in cases involving incisors. Clinicians should maintain a high index of suspicion for a cemental tear when clinical signs and symptoms fail to improve after root canal treatment and consider the use of CBCT to improve diagnostic accuracy. In addition, in elderly patients with incisors and suspected occlusal trauma, CBCT imaging before starting root canal treatment should also be considered in selected cases to facilitate early and accurate diagnosis.