PMC7006551_01
(a) Pre-operative PA radiograph. Three gutta-percha traced three different sinus tracts to the periradicular radiolucency. (b) The PA radiograph taken immediately after surgical removal of detached cementum and apicoectomy where MTA was used as retrograde filling
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F1
The PA radiographic view (Fig. 1a) showed casted post crown with previous RCT of a sufficient length and density. During the surgery, extensive granulation tissue and a few prickle-like hard tissues were found, curetted, and collected for biopsy before apicoectomy with retrograde filling (Fig. 1b).
Axial image of CBCT. Arrow indicates complete cemental tear. Dotted arrow: Incomplete cemental tear where the cementum detaches from the root surface
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F2
Morita, Osaka, Japan) (Fig. 2) showed extensive bone loss on apical, mesial, distal, and buccal aspects of the root, leaving the coronal part of the palatal bone intact.
Photomicrographs of cemental tear. (a) A fragment of cellular cementum with presence of lacunae and cementocytes. (b) Remnants of periodontal ligament (arrows) were attached on the surface of the cementum. Incremental lines (arrowheads) in the cementum fragment. Asterisks: Areas of resorption
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F3
The histopathological examination of the hard tissue fragments revealed cellular cementum (Fig. 3) consistent with the radiographic findings of a torn cementum.
Photomicrographs of periapical lesion. (a) A cystic lesion. (b) Inflamed fibrous cyst wall lined by epithelium. Arrows: Non-keratinized stratified squamous epithelium. Arrowhead: Microbial colony. (A: Scale bar, 500 microm. B: Scale bar, 100 microm)
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F4
Histological evaluation of the soft tissue lesion (Fig. 4) obtained from the periradicular region showed a cystic lesion lined by non-keratinized stratified squamous epithelium and backed by chronically inflamed fibrous cyst wall, supporting a diagnosis of radicular cyst.
PMC7006551_02
Pre-operative PA radiograph. A gutta-percha traced the buccal sinus tract to the periradicular lesion on maxillary left permanent central incisor
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F5
The PA radiograph (Fig. 5) showed previous RCT on maxillary left permanent central incisor with acceptable length and density.
Axial view of CBCT on maxillary right and left permanent central incisor. Arrowheads: Partial cemental tear. Thin arrow: Complete cemental tear. Thick arrows: The cementum remained attached on the root
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F6
Morita, Osaka, Japan) (Fig. 6) showed extensive periradicular bone loss around both teeth.
Photographic view showing the extracted maxillary right permanent central incisor. White arrowhead: Partial cemental tear. Black arrows: Cemental line. Asterisks: Calculus deposited on the root surface. Black arrowhead: The soft tissue attached on the root surface
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F7
Calculus and plaque were observed especially on the mesial mid-root region of the extracted maxillary right permanent central incisor (Fig. 7).
Photographic view showing the extracted maxillary left permanent central incisor. White arrowhead: Partial cemental tear. Black arrows: Cemental line. White dotted arrow: Complete cemental tear obtained from the socket after removal of maxillary left permanent central incisor. Black arrowheads: Soft tissue attached on the root surface
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F8
A prickle-like hard tissue was observed on extraction of maxillary left permanent central incisor (Fig. 8).
Photomicrograph of periapical lesion showing inflamed cystic lesion with evidence of epithelial lining. Arrows: Non-keratinized stratified squamous epithelium. (Scale bar, 100 microm)
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F9
The histopathological examination of the soft tissue lesion (Fig. 9) showed inflamed fibrous connective tissue wall lined by non-keratinized stratified squamous epithelium, confirming a diagnosis of radicular cyst.
Photomicrograph of a dentin fragment with attached cementum. A thin layer of fibrous connective tissue representing periodontal ligament was adhered to the cemental surface (arrows). D: Dentine, CC: Cellular Cementum [Scale bar (inset), 100 microm]
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F10
The decalcified section of the hard tissue fragment that was detached from the tooth root consisted of dentine with attached cementum (Fig. 10).
(a) Histological section of tooth root. (b-d) Histological findings along the root surface. C: Cementum, D: Dentine, M: Microbial colonies, R: Remnant of root filling material, PDL: Periodontal ligament. Arrowheads: Detachment of cementum from root dentine. Arrows: Deposition of cellular cementum indicative of cemental repair. Asterisks: Denuded root surface
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F11
Whereas, the decalcified section of the extracted teeth showed cemental tear involving multiple sites along the root surface (Fig. 11), corroborating a diagnosis of combined cemental and cementodentinal tears. Deep periodontal pocket was reflected by the presence of microbial deposits along the root surface (Fig. 11d).