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Puzzle Case: A Fistula Tracing to the Root with a Vital Pulp

Terry Pannkuk, DDS, MScDDiagnostic Puzzles, Recall Observations, All by Date


A full mucoperiosteal flap was released and revealed a dehiscence of the root showing pits consistent with a cemental tear

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A Surgical Exploratory Flap Revealed a Cemental Tear

Conclusion to puzzle case.

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Possible diagnosis- Cemental tear. Camargo PM et al. Int J Periodont Restor Dent
2003;23:79-85. Prognosis- favorable. treatment. Exploratory surgery.

This is another great interesting case. I have mulled over this over the past night and reviewed the article by Camargo (and others since his publication) regarding cemental tear. It certainly could be a cemental tear - my only hesitancy is that there is a mention of a deep perio pocket with concomitant pain/discomfort with patients who present (and were finally diagnosed with) a cemental tear in several of the articles that I was able to access openly online.

-Cemental tear: A case report with nonsurgical periodontal therapy, Damasceno et al, Rev Odonto Cienc 2012;27(1):74-77);
-Persistent endodontic lesion due to complex cementodentinal tears in a maxillary central incisor—a case report, Tai et al, OOOO 2007;103:e55-e60)}

Understandably, The pain presentation, of course, can be different in each patient.

Initially, I was wondering why these teeth were splinted and if there was trauma previously (either occlusion/or injury). The splinting will definitely cloud sensibility testing. If available, I believe that a high resolution CBCT would possibly help in diagnosis to determine the extent of the LEO (if it is a LEO).

RAD: #8 On the PA with the GP cone, I seem to see a radiolucency overlying the mesial portion of #8 root. The longer I stare at it, the clearer it becomes! I still see a corticated mesial border around #9 in this film. Perhaps there is a tract from #8 exiting over #9 - considering the zig-zag bending of the GP cone -it may not have been able to find the true path to #8?

#9 - Preoperative film: I see a tear drop shaped RL at the mesioapical portion (as noted in the comments) - Perhaps this could be a cyst? (Lateral periodontal cyst: Pathways of the Pulp 9th ed, Pg 659). Predilection for males in their 5th-7th decade of life, several cases noted in anterior maxilla.

#9 Final film: I see a mesial RL and perhaps the beginning of a midroot distal RL. Possible mid root fracture?

Diagnosis: #8: Very hesitant to indicate if there is any endodontic disease associated with #8 without further testing/CBCT/exploratory surgery of #9.

#9: Possible root fracture (while maintaining vitality?), cemental tear, foreign body (tooth pick/popcorn), or cystic lesion. DDX of cyst: Lateral periodontal cyst, Nasopalatine duct cyst (not heart shaped, however), OKC (KOT).

Treatment plan:
CBCT (ltd FOV) anterior maxilla
Re-eval #8 vitality
Exploratory surgery #9 to determine status of the root and/or if there is a cyst. Enucleation of cyst/#9 resection if indicated (tear)

#8: If endodontic disease w/out fracture - good
#9: Fracture: Poor, Cemental tear - good, Cyst: good

Excellent analysis Keith, Ashley, You were spot on with your assessment. Many of our elderly patients pass away before we can perform a long term recall analysis and learn from these rare cases. I tried to get as much information as possible from the referring dentist but as far as I know the tissues healed and he had no further problems in the area. This is the only cemental tear case I've treated in my practice in 30 years. My colleagues claim that these cases are very difficult to treat successfully so I won't be presumptuous and claim that this represents a successful outcome. The initial surgical debridement simply resulted in initial healing and we know very little about the long term stability of the result. My personal take home lesson was to always take photos of fistula healing for documentation. Digital film is cheap. It was laziness on my part to not take a clinical photo of the healing one month after surgery figuring I would get a better recall image 6 months later but he never returned. I'll give you guys each a free Implant Town Hall webinar registration for adding so eloquently to the discussion of this case, adding references and figuring it out. Thanks.

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