Persistent Pain After Root Canal — Cemental Tear Found by Surgery
Patient Profile
Adult Palos Verdes Estates patient with lingering bite and chewing discomfort in the lower anterior region and recurring infection
Clinical Challenge
Persistent symptoms and a buccal sinus tract suggested incomplete healing post-root canal treatment.
Approach
Microscope-assisted surgical exploration identified and repaired a cemental tear on teeth #24 and #25.
Outcome
Successfully addressed the root cause with positive initial recovery and ongoing monitoring.
Treatment Details
The referring dentist had completed root canal treatment on teeth #24 and #25 several months prior, but the patient returned with unresolved bite sensitivity and a draining sinus tract on the buccal gingiva. CBCT imaging revealed periapical radiolucency with thinning of the buccal cortical plate — findings that didn't fully explain why the canals appeared well-obturated.
Surgical Protocol
We raised a full-thickness mucoperiosteal flap under local anesthesia to expose the root apices of both teeth. Under 16x microscope magnification, the root surfaces were inspected systematically.
- Key Finding: A vertical cemental tear extending 4-5mm along the root surface of #24, with a loose cementum fragment partially separated from the root.
- Granulation Tissue: Inflammatory tissue had infiltrated the tear defect, creating a pocket of chronic infection invisible on any radiograph.
- Fragment Removal: The loose cementum fragment was elevated and removed with microsurgical curettes under direct visualization.
Why the Root Canal Didn't Solve It
The original endodontic treatment was technically adequate — the canals were properly cleaned and filled. But a cemental tear is an external root defect. No amount of intra-canal treatment addresses a fracture or tear on the outside of the root surface. This distinction is critical: the problem was structural, not endodontic.
Clinical Assessment
Cemental tears are among the most difficult endodontic diagnoses because they don't appear on conventional periapical radiographs and often present identically to failed root canal treatment. Even CBCT can only suggest the possibility — definitive diagnosis requires direct surgical visualization.
Diagnostic Reasoning
- Sinus Tract Persistence: A sinus tract that doesn't resolve after technically sound root canal treatment strongly suggests an extra-radicular cause — fracture, external resorption, or cemental tear.
- CBCT Pattern: Periapical radiolucency with buccal plate erosion in a well-treated tooth pointed to a surface-level defect rather than missed canal anatomy.
- Probing: Normal periodontal probing depths ruled out vertical root fracture extending to the sulcus.
Why Surgery Was the Only Option
Non-surgical retreatment would have been futile — the canals were already adequately treated. The cemental tear exists on the external root surface, accessible only through a surgical approach. Without exploration, this patient would have continued with chronic symptoms and eventually faced extraction.
Key Takeaways
Clinical Insights
- Cemental Tears Mimic Endodontic Failure: When a well-treated tooth doesn't heal, consider structural causes on the root surface — not just missed canals.
- CBCT Suggests, Surgery Confirms: Advanced imaging narrows the differential, but only direct visualization under the microscope provides a definitive diagnosis of cemental tears.
- Sinus Tracts Are Diagnostic Clues: A persistent sinus tract after adequate root canal treatment is a red flag for extra-radicular pathology requiring surgical exploration.
When to Refer for Surgical Exploration
- Persistent symptoms or sinus tract despite technically adequate root canal treatment.
- CBCT showing periapical pathology that doesn't correlate with canal quality.
- Buccal bone loss or cortical plate thinning in a non-periodontal pattern.
Bottom Line: When a tooth doesn't heal after root canal treatment, the answer isn't always retreatment. Surgical exploration can uncover hidden causes like cemental tears that no amount of canal work would fix.
Clinical Disclaimer: These cases are presented for educational purposes and published with appropriate patient consent. Patient identifying information has been removed in compliance with HIPAA regulations. Individual results may vary. All radiographic images and case descriptions represent actual patient treatment outcomes.
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