The periodontium is defined as those tissues supporting and investing the tooth and consists of the cementum, the periodontal ligament, the bone lining of the alveolus and that part of the gingiva facing the tooth. The term cementum is derived from the Latin term ³Cemaentum´ The Cementum is a hard, avascular, clcified connective tissue that covers the root dentin and gives insertion to the periodontal fibre bundle. It can be regarded as a ³bone of attachment´. It is pale yellow and softer than dentin. The thickness of cementum varies considerably and the coronal third may be only 16-60 µm thick. The apical third can be 200 µm or even thicker. The greatest thickness of the cementum is formed at the apex or the furcation area. Cementum is formed throughout life and is resistant to resorption.

Cemento Enamel junction (CEJ)
Three types of relationships 1. 2. Exist at the CEJ 60% - 65% cases, cementum overlaps the enamel 3. 30% there is an edge to edge butt joint and in 5% to 10% the cementum and enamel fail to meet

Cementodentinal junction 
The dentinal surface upon which the cementum is deposited is relatively smooth  Attachment between cementum and dentin is quite firm.

Dry weight basis  Permanent teeth contains about 45% in organic substance and 5055% organic material and water.  The inorganic portion consists mainly of calcium and phosphate in form of hydroxyapatite.  The mineralized component consists of thin, needle-shaped crystals of hydroxyapatite.  Account for approximately 61% by weight (33% by volume) of radicular cementum. The remaining fraction consists of organic matrix 27% by weight (31% by volume) and water 12% by weight (36% by volume). The degree of mineralization varies in different layers of cementum.  The cemental mineralization of teeth less in older subjects.  The organic portion of the cementum consists primarily of type I collagen and protein polysaccharides.

Primary Cementum Formation Hertwigs¶s epithelial root sheath initiates the differentiation of the root odontoblasts from the dental papilla. Before primary cementum can form, the root sheath must fragment to allow the follicular cells to reach the newly formed root surface. In this location, the follicular cells differentiate into cementoblasts. Once differentiated, they insert cytoplasmic processes into the unmineralized hyaline layer and begin to deposit collagen fibrils within it at right angles to the root surface. Cementoblasts then migrate away from the hyaline layer but continue to deposit collagen so that the fine fiber bundles lengthen. Once this primary cementum and its fibrous fringe are established, it is thought that the cementoblasts that form it drifts away from the cementum surface. This condition continues until the forming periodontal ligament fiber bundles become stitched to the fibrous fringe. At this point the ligament fibroblasts are thought to be responsible for further deposition of mineral on the root surface around and within the collagen fiber bundles, which explaining the slow but continuous increase of cementum of the root surface.

Secondary cementum formation
Cementoblasts initially lay down an organic matrix consisting of non collagenous proteins and collagen fibrils aligned roughly parallel to the root surface. This organic matrix becomes mineralized. At the same time, the cementoblasts become trapped in the matrix they are forming to occupy lacunae. Once in this situation, their secretory activity declines, and the cells become cementocytes. When the periodontal ligament becomes organized, cellular cementum continues to be deposited around the ligament fiber bundles, which become incorporated into the cementum is confined to the apical third of the tooth and interradicular regions of premolar and molar teeth.

Cementoblasts: Cementoblasts originate form the ectomesenchymal cells in the dental follicle surrounding the developing tooth. These cells have numerous mitochondria, a well formed golgi apparatus and large amount of endoplasmic reticulum. These cellsw line the cementoid tissue. Their cytoplasmic volume and basophilia may increase during periods of active cementogenesis.  Cementocytes: These are spider like cells incorporated into cellular cementum. They lie in lacunae. A typical cementocyte has numerous cell processes or canaliculi radiating from it¶s cell body. These processes may branch and they frequently anastomose with those of a neighboring cell.

The cytoplasm of cementum in the deeper layers, contain few organelles, the ER appears dilated and the mitochondria is scarse. These characteristics indicate that the cementocytes are either degenerating or marginally active cells.  Cementoclasts: Cementum is not remodeled but it can occur under certain circumstances and in these instances mononuclear cementoblasts or multinucleated giant cells, often located in howship¶s lacunae, are found on surface of cementum.

Osteonectin Osteonectin is an acid phosphate containign glycoprotein rich in cysteine, which is mainly secreted by osteoblasts (Gage et al; 1989) it is composed of a single polypeptide chain and has a strong affinity for calcium ions (Sage and Borstein, 1991) important for mineralization process. It has been found in the periodontal ligament, particularly strongly around the Sharypey¶s fibers, at the attachment sites between the ligament, alveolar bone and the cementum. Osteocalcin It is also called as bone gla protein as it ontains K-carboxyglutamic acid (gla) residues. It is mainly secreted by osteoblasts (Mariotti, 1993), role in the mineralization process. The expression of osteocalcin by the cells lining the tooth root surface has been shown during root development in mice (D¶Errico et al, 1997)

Bone sialoprotein protein It also known as BSP II. It is a phosphoglycoprotein containing up to 20% of sialic acid residues (Bilezikian et all 1996). Primarily found in the bone. It is expressed by cells lining the root surface at early stage of cementogenesis during tooth development. The cementoblasts appear to secrete this protein onto the root surface, which then becomes covered by cementum. So they may serve as attachment factor since it has an affinity for collagen fibers and enhances the attachment of osteoblasts and fibroblasts to plastic surface. Osteopontin It is also termed as BSP I due to its high sialic acid content, and is a glycoprotein. It is found primarily Mac-Neil et al, 1995 suggested that it functions as an inhibitor of mineralization during periodontal ligament development. D¶Errico reported that it was expressed by the cells lining the tooth root surface.

1. Based on location a. Radicular cementum ± it accounts for the bulk of cementum in humans b. Coronal cementum ± it is cementum over enamel in humans it is thin and poorly developed but it is better developed in herbivorous animals. 2. Based on time of formation a. Primary cementum formed before tooth eruption b. Secondary cementum formed after tooth eruption 3. Based on it¶s cellularity a. Acellular cementum ± which lacks embedded cells. b. Cellular cementum ± in which cells are located with in the mineralized matrix. 4. Based on the presence or absence of collagenous fibrils a. Afibrillar cementum ± it lacks dense array of collagen fibrils although rare isolated fibrils will be presented b. Fibrillar cementum ± Contians well defined densely packed collagen fibrils in it¶s matrix.

5. Based on the origin of collagenous fibrils a. b. Intrinsic fibers ± which are formed due to cementoblasts activity. Extrinsic fibers ± incorporation of the periodontal ligament fibers.

Schroder in 1986 gave the classification of cementum as: 1. 2. 3. 4. 5. Acellular afibrillar cementum Acellular extrinsic fiber cementum Cellular mixed fiber cementum Cellular intrinsic fiber cementum Intermediate cementum

Extensive variation in surface topography of cementum can be observed with scanning electron microscope (SEM). Resting cemental surfaces, where mineralization is more or less complete, exhibit low rounded projections known as cemental mounts. Cemental surfaces with actively mineralizing fronts have numerous small openings. Represent unmineralized cores of fibers.

1. Acellular Afibrillar Cementum (Aac): Found deposited on mature enamel surfaces. It may be deposited during tooth formation, during tooth eruption or after it. Appears as cemental spurs or cementum islands on the crown of erupted teeth. This type of cementum is probably of little significance as it is not involved in fiber insertion and tooth anchorage. It represents an aberration of the developmental process in which part of the reduced enamel epithelium disaggregates and allows cells from the dental follicle to interact with the exposed enamel matrix, leading to cementum deposition.

2. Acellular Extrinsic Fiber Cementum (Aefc): It contains densely packed collagen fibres that project in a perpendicular manner from the cementum matrix into the periodontal ligament. This type of cementum forms on the newly synthesized dentin surfaces after dissolution of the Hertwigs epithelial root sheath and the subsequent exposure of the root surface to the dental follicle cells. Once the PDL fiber bundles are formed and connected to the fibrous fringe bundles of the primary acellular intrinsic fiber cementum, further deposition of mineral about and within the bundles result in the formation of acellular extrinsic fiber cementum, which becomes the principal tissue of attachment. It extends from the cervical margin of the tooth and covers at least two thirds of the root.

3. Cellular mixed fiber cementum (Cmfc): It contains both collagen fibers and calcified matrix and appears to be synthesized solely by the cementoblasts. A distinct feature of this cementum is the presence of the intrinsic collagen fibers produced by the cementoblasts that run parallel to the root surface. In addition to theses, some extrinsic sharpey¶s fibers can be also seen. Thus, CMFC consists of both acellular extrinsic fiber cementum and cellular intrinsic fiber cementum that alternate and appear to be deposited in irregular sequence upon one another. With organization of the PDL, future deposition of cellular cementum incorporates ligament fiber bundles of the PDL, thereby creating CMFC. It consitutes the bulk of secondary cementum.

Acellular cementum A E F C

Cellular cementum





4. Cellular intrinsic fiber cementum (Cifc): Component of cellular mixed stratified cementum, CIFC is considered to be a form of reparative cementum. This type of cementum is commonly associated with the repair of resorptive defects and healing of root fractures. The principles cells involved in the synthesis of this type of cementum. 5. Acellular intrinsic fiber cementum (Aifc): It is a acellular variant of cellular intrinsic fiber cementum that is also deposited during adaptive responses to external forces. It forms without leaving cells behind. (Bosshardt and Schroeder 1990)

6. Intermediate cementum: It is a form of secondary cellular intrinsic fiber cementum restricted to the apex of the tooth. It is not involved in tooth attachment and has no functional significance. 7. Mixed stratified cementum: It describes a layered arrangement of apical cementum that consists of alternate layers of acellular extrinsic and cellular fiber cementum. This layered pattern may simply represent alternating mineralization occurring upon successive waves of cellular intrinsic fiber cementum deposited in response to adaptive needs.

This procedure was first done by hanes and Polson in 1989. For the preparation of cementum specimens from normal root surfaces, the remnants of the periodontal ligament fibers were removed from the root surface with 12 strokes of Gracey curet. The remaining cementum on the root was not removed. Following implantation into incisional wounds, epithelial migration was observed adjacent to non-acid treated cementum surfaces and was associated with extrusion and exfoliation of these control specimens. In contrast, the surface demineralization experimental specimens remained within the connective tissue and had a cell and fiber attachment system established within 10 days. Demineralized cementum had more fibers attached per unit area than did demineralized dentin surfaces.

Actinomyces species may penetrate small distance into cementum and bacterial products such as lipopolysaccharides may contaminate it. However, the penetration of these products into the cementum appears to be superficial (Moore et al, s1986). Many Gram negative bacteria have the ability to attach to gram positive bacteria in the cementum and the epithelial cells (Slots and Genco, 1984). This ability is an important factor in their colonization of the subgingival environment and also allows them to colonize the surface cells of pocket epithelium bacterial invasion of the cementum and radicular dentin was thought by early investigators to be an important factor in the pathogenesis of periodontal disease. Miller (1890) described bacteria invading the radicular dentin of periodontally diseased tooth.

Cementum specimens were harvested from areas on the root surfaces beneath deposits of calculus. Calculus was removed carefully with an ultrasonic scaler, so that the underlying root surface was not gouged. Unlike the observations on root dentinal surface, a distinct zone of demineralization of surface was not apparent on periodontitis affected cementum surface following acid treatment surface. In addition, epithelial down growth and connective tissue cell and fiber attachment did not differ between experimental and control surfaces at any time. The findings of this study suggested that the periodontitis affected root surface inhibited the demineralization effects of citric acid.

Citric acid treatment of cementum from normal root surfaces produced a fibrillar surface morphology that was consistent with the exposure of a fibrillar, collagen substrate. Periodontitis affected cementum, however, was not appreciably altered in appearance, having only a faintly mat-like surface texture. These findings suggest that calculus affected cementum undergoes changes that reduce the effects of demineralizing agents.

In normal cementum the collagen fibers are embedded in the cementum. These fibers are destroyed in pathological pocket wall with the exposure of cementum. Collagen remnants of Sharpey¶s fibers in cementum undergo degeneration creating a environment favorable for penetration of bacteria. Bacterial penetration into the cementum can be found as deep as the CDJ and may also enter the dentinal tubules penetration and growth of bacteria leads to fragmentation and breakdown of the cementum surface and result in areas of necrotic cementum separated form the tooth by masses of bacteria. These changes manifested clinically as softening of cementum surface which is usually asymptomatic but painful when probe penetrates the area.

Areas of increased mineralization on exposure to oral cavity as a result of mineral and organic components at cemental saliva interface. The mineral content of exposed cementum increases. Microhardness remains unchanged. This hypermineralized surface increases the tooth resistance to decay. Areas of demineralization are commonly related to root caries. Exposure to oral fluorides and bacterial plaque results in proteolysis of embedded remnants of Sharpey¶s fibers. The cementum may be softened and undergo fragmentation and condensation. Active lesion appears as well defined yellowish or light brown areas frequently covered by plaque and a softened and leathery consistency on probing. Inactive lesions are well defined darker lesions smooth surface and harder consistency on probing. A.Viscosus, A naslundii, S. mutans, S salivarius and S. Sanguis are the microorganisms usually involved in root caries.

Gottleib (1923) suggested defects in cementum to be the central cause of disease. Ruben and Shapiro (1978) and Lindslong and Blomlof carried out a comparative histological study on teeth from patients with healthy teeth and those with diseased roots in localized and generalized aggressive periodontitis patients. They found that generalized aggressive periodontitis patients had extensive areas of defects which were defects in cementum formation rather than pathology of pocket.

Changes in cementum after instrumentation
Firm scaling strokes used to remove subgingival calculus also remove a small amount of cemetnum resulting in some notching of root surface.

Necrotic Cementum
Cementum exposed by apical migration of junctional epithelium is altered by exposure to subgingival plaque within the pocket. It may become hypermineralized, demineralized (in case of root caries) or necrotic.

Cementum deposition appears to be continuous throughout life, a direct relationship has been shown between age and cementum thickness. Cementum deposition is less near CEJ and greater in apical areas. Cemental deposition slows in old age. In addition, the attachment of cementum to dentin may be weakened. The frequent cemental tears seen in specimens of aging humans may be related to age changes in the ground substance of cementum or reduced vascular supply or to thickened and less extensible ligament fibers embedded in cementum. Suprring of cementum is sometimes the result of fusion of calcospheroid bodies near cementum or of calcification of epithelial rest aggregates.

There are certain anomalies in cementogenesis that may have an impact on the susceptibility of teeth to periodontal diseases and treatment of affected teeth. 1. Enamel projection: Occur in localized areas, particularly in furcations of mandibular teeth. It is suggested that projections may predispose the teeth to periodontal defect involving the furcation 2. Enamel Pearls: This anomaly consists of globules of enamel on the root surface in the cervical region. They resemble small pearls upto several millimeters in diameter. They appear to form as a result of localized failure of Hertwig¶s root sheath to separate from the dentin surface. They mimic calculus clinically and radigraphically, they cannot be sealed off and elimination can only be accomplished by grinding. Large pearls may contain pulp extensions.


Cementicles: These are globular masses of acellular cementum, generally less than 0.5 mm in diameter which form within periodontal ligament. It has been postulated that cementicles originate from foci of degenerating cell or epithelial rests in periodontal ligament. Cementicles are not not of clinical significance unless they become exposed to oral environment where they may act as sites for plaque retention.


Hypercementosis: Hypercementosis is a non neoplastic deposition of excessive cementum that is continuous with the normal radicular cementum. It occurs predominantly in adulthood, and the frequency increases with age. Hypercementosis can be classified as:

Abnormal occlusal trauma,  Unopposed teeth (e.g. impacted, embedded, without antagonist)  Adjacent inflammation

Acromegaly and pituitary gigantism  Arthritis  Calcinosis  Paget¶s disease (Generalized hypercementosis)  Rheumatic fever  Thyroid goiter  Vitamin A deficiency

Radiographically, affected teeth demonstrate a thickening or blunting of root. The enlarged root is surrounded by radiolucent ligament space and adjacent intact lamina dura premolar teeth are most commonly affected. 5. Ankylosis: Eruption continues after the emergence of the teeth to compensate for the masticatory wear and the growth of the jaws. The cessation of eruption after emergence is termed as ankylosis and occur from an anatomic fusion of the tooth cemetnum or dentin with alveolar bone. Other terms for this in the literature are infraocclusion, secondary retention, submergence, reimpaction and reinclusion. Pathogenesis disturbances from changes in local metabolism, traums, injury, chemical or thermal irritation, local failure of bone growth and abnormal pressure from tongue the periodontal ligament might act as a barrier that prevents osteoblasts form applying bone directly into the cementum.

Ankylosis may occur at any age clinically they are most obvious if the fusion develops during the first two decades of life. The most commonly involved tooth is primary first molar, the majority of cases occuring in the mandible. A sharp, solid sound may be noted on percussion of the involved teeth. Radiographically, absence of periodontal ligament space may be noted; Ankylosed teeth lead to a number of dental problems The adjacent teeth often incline towards the affected tooth, with the development of subsequent occlusal and periodontal problems. In addition the opposing teeth often show supra eruption. Occasionally, the ankylosed teeth lead to impaction of the underyling permanent teeth.

6. Hypophosphatasia: It is a rare familial disease, characterized by incomplete bone mineralization. This condition was first described by Rathbun 91984) and is characterized by low levels of serum kidney and bone alkaline phosphatase and elevated levels of phosphoethanolamine in serum and urine (Watanabe et al, 1993) Radiographically, the teeth appear to have a characteristic ³shell´ appearance poorly formed and haphazardly arranged periodontal ligament (Listgarten and Houpt. 1969). The pathological alterations are due to insufficient levels of alkaline phosphatase. This enzyme is a key step in the production of a competent organic matrix in both bone and cementum. The decreased production and activity of this enzyme is likely to result in accumulation of inorganic phosphate, which inhibits mineralization. This leads to defective cementogenesis and formation of an incompetent attachment apparatus, making the teeth more prone to exfoliation and the root surfaces more susceptible to bacterial colonization (baab et al, 1986)

Based on clinical radiographic and histological features, bony lesions of cementum were classified by Pinborg et al in 1971 as: 1. Periapical cemetnal dysplasia
2. Benign cementoblastoma 3. Cementifyign fibroma 4. Gigantiform cementoma 5. Cemento ± osseous dysplasia.

The dental cementum and normal periodontal cells covering the root surface have been reported to contain a potent collegenase inhibitor, which forms a protective barrier against root resorption. Resorption of the mineralized tissues occur if clastic cells obtian access to the mineralized tissue by a break in this barier or when the precementum is mechanically damaged or scraped off. The mineralized or denuded root areas attract resorbing cells to colonize the damaged areas of root. Cementum of erupted as well a unerupted teeth is a subject to resorptive changes that may be of microscopic proportion or insufficiently extensive to present a radiographically detectable alterations in root contour. Microscopic cementum resorption is very common. In one study conducted by Henry and Winmann, it occurred in 236 of the 261 teeth ie; about 90.4%.t he average number of resorption areas per tooth was 3.5 about 76.8% of these sites were located in the apical third of the root, 19.2% in the middle third and 4% in the gingival third. About 70% of all resorption areas were confined to the cementum involving the dentin. The various causes of cemental resorption are:-

Local factors of cementum resorption: 1. Trauma from occlusion 2. Orthodontic movement 3. Pressure from malaligned teeth, cysts and tumors, 4. Teeth without functional antagonist 5. Embedded teeth 6. Replanted and transplanted teeth 7. Periapical disease 8. Periodontal disease Systemic conditions predisposing to or inducing resorption are: 1. Calcium deficiency 2. Hypothyroidism 3. Hereditary fibrous osteodystrophy 4. Paget¶s disease.

cementum resorption appears microscopically as bay like concavities in the root surface. Multinucleated giant cells and large mononuclear macrophages are generally found adjacent to the cementum undergoing active resorption. The resorptive process may extend into the underling dentin. Cementum resorption is not necessary continuous and may alternate with periods of repair and deposition of new cementum. The newly formed cementum is demarcated from the root by a deeply stainign line termed as the reversal line. Which delineates the border of the previous resorption. Embedded fibers of the periodontal ligament reestablish a functional relationship with the new cemenntum cementum repair requires the presence of viable connective tissue. If the epithelium proliferates into the area of resorption, repair will not take place. Cementum repair can occur in devitalized as well as vital teeth.

After resorption has ceased, the damage is usually repaired, either by formation of acellular or cellular cementum or by both.

Changes in the root surface wall of the periodotnla pocket interfere with new attachment. Several substance have been used in attempts to better condition the root surface for attachment of new connective tissue fibers. Although acid treatment was used in 19th century, register and Burdick (1975) re credited with the revival of this technique. Having tested several acids including citric acid and hydrochloric acid, they concluded that citric acid was the most effective and least toxic of all acids tested.

In animals, they noted widening of the orifice of dentinal tubules (creating a ³blunderluss´ effect) and on healing, the cementum formed within these tubules. They referred to this cementum as ³cementum pins´. They further speculated that citric acid may expose the collagen fibrils that may ³splice´ with collagen fibrils in the flap or graft. Other researchers have given credibility to the theory of ³Collagen Splicing´ (Codelli 1991). Register and Burdick further noted an accelerated healing and accelerated cementogenesis as well as connective tissue attachment when citric acid was used. Citric acid has been found to remove the smear layer normally found after root planning. It citric acid may produces a root more amendable to attachment.

Regenerative cementogenesis on previously diseased root surface is most unpredictable. The most common outcome is the formation of new tissue that is the formation of new tissues that resembles cementum or bone, is cellular and contains collagen fibres which are not functionally attached to previously diseased root surfaces. In order for periodontal regeneration to occur, the conditions of cementogenesis present initial formation should be duplicated. Evidence indicates that systemic and local factors are likely to participate in the regeneration process. The role of local factors is especially relevant in cementum which like other calcified strucutres, stores a variety of growth factors and adhesion molecules yet it does not regenerate readily (macNeiland, Somerman 1993). These molecules are likely to be the motivating force to recruit cells to the dentinal surface, select or induce the cementoblast phenotype, permit their attachment to the dentinal surface and encourage their proliferation.

Enamel matrix derivative (EMDOGAIN). Enamel matrix proteins were first demonstrated on the root analogue surfaces of rabbit incisors by Schonfield and Slavkin in 1977. Their origin is based on the experiments that showed that the inner layer of the epithelial root sheath had a secretory stage and that enamel like material was formed in the root surface prior to cementum formation. It was also shown that the cellular cementum contains proteins that are immunologically related to proteins present in the enamel matrix. Further support to importance of enamel derived proteins in cementum development comes from the fact that coronal cementogenesis seems to be initiated by exposure of cells of dentla follicle to developing enamel.

The ability of enamel matrix protein to induce cementum formation and periodontal regeneration was firs tinvestigated by Hammarstrom in a buccal dehiscence monkey model in 1977. The ability of EDM to produce periodontal regeneration in buccal dehiscence model was also tested in human experimental defect by Heijl in 1997. Studies have shown that EMD will stimulate the regeneration of firmly attached a cellular cemetum in experimentally prepared root surfaces and will also produce complete regeneration of periodontal ligament.

Cementum is probably the least understood of all dental tissues. But this does not lessen it¶s role in the periodontal attachment apparatus. With the development of newer concepts of regenerative cementogenesis and role of cementum in implants, the need for us to better understand this basic tissue should be understood and implemented.

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