This action might not be possible to undo. Are you sure you want to continue?
Craniofacial Biology - Lecture #33 – Cementum 5/1/14 (lecture given 5/2/13)
Slide 1 – Introduction
Dr. Ronald Craig – (begins mid-sentence) …the periodontal connective tissue attachment apparatus, right, so
that’s cementum, periodontal ligament, alveolar bone. We’ve also talked about formation of the dental
gingival junction, or otherwise called the gingival connective tissue attachment briefly. That’s cementum into
which fibers attach to go out into the gingiva, so that’s coronal to the periodontal connective tissue
attachment, and then there’s this epithelium that’s attached to the two surface junctional epithelium, and
that’s called epithelial attachment. So you got three different attachments to the teeth. So let’s begin a
discussion of each one of the component of periodontal tissue, so we’ll spend about 40-45 minutes on
cementum and then the big one is periodontal ligament because it has a lot of stuff in there. Then we’ll talk a
little bit about alveolar bone, my understanding is that you’ve got a lot of bone biology so you probably don’t
need much more, only that which is associated with alveolar bone. And then we’ll have two hours on gingiva,
gingival connective tissue and epithelium, because if you understand the biology there’s a lot of neat things
you can do for your patients, gingivally, gingival surgery and stuff like that. So let’s talk a little bit about
cementum. So I think of cementum as being the last frontier of the human body. There’s not a lot of it, so it’s
really har to study, and we rally don’t have a good cell culture system, we haven’t been able to coulture
cementoblasts in plate. We really don’t have any proteins or genes that are characteristic of cementum,
there’s a couple on the horizon, but they’re not really great. So because of lacking a cell model system, not
having a lot of the extracellular matrix to begin with, and not have any markers for cementum, we really don’t
understand cementum very much. Of course, you have to have cementum to ha during evolution of our
species, so all that’s kind of combined together to sort of make cementum sort of an unknown field. But an
important one, because if you’re gonna get a periodontal connective tissue attachment apparatus on teeth or
on biomaterials, and that’s where everybody is kind of looking now, can I get a periodontal connective tissue
attachment apparatus on the implants. Now implants are good, but they can’t move, they don’t do the things
teeth do, can I get a periodontal connective tissue attachment apparatus on dental implants then I can do all
the things with dental implants that I can do with teeth, so people are kind of focused on this and we’ll talk a
little bit about that next week.
Slide 2 - Cementum
So right now let’s talk about cementum as a tissue, I think I’ve got some summary slides here.
Slide 3 – Components
We know a bout the functions of the periodontium. We know all these things are just to recapitulate. So
here’s the gingival epithelium up here, so right in here this area is not attached to the tooth surface, cause
that’s called sulcus, if it’s not inflamed it’s called a sulcus, if it’s inflamed it’s called a pocket. We haven’t
talked about pathology yet, so all this is sulcus, so sulcular epithelium and then junctional epithelium is
attached to the tooth surface, so all this is junctional epithelium, and classically, the junctional epithelium
should terminate at the cementoenamel junction, and this cartoon has kind of missed that here. But you can
kind of see it in the actual section. So in health, junctional epithelium terminates at the cementoenamel
junction which is right here. So this is the epithelial attachment, epithelial cells are attaching to the enamel
surface. Down here you have cementum and you have these fibers that are going down to the gingiva, so
that’s the gingival connective tissue attachment, and here’s the alveolar crest, this is kind of unusual, usually
the alveolar crest is lower down. So fibers that go down from cementum through the periodontal ligament to
the alveolar crest are called periodontal connective tissue attachment apparatus. So there’s 3 different ways
of attaching tissue to a natural tooth, and we’ll compare this with dental implants, as implants are getting
more and more kind of important.
Slide 4 – Components
And we already talked about some of the components.
Slide 5 – Classification
So, cementum, there’s nomenclature that has to go, has to be presented, and it’s kind of confusing, so I’m
gonna try to give you an easier way of sorting kinds of cementum in your mind. So some people classify
cementum by time of formation, why? I don’t know. But primary cementum is that which is formed before the
tooth erupts into the oral cavity. And secondary cementum isi that this forms after the tooth erupts into the
oral cavity. Biochemically, cell biology, clinically, it doesn’t have any real relevance. So I’m just giving that to
you for your background. Location, some people classify cementum by where it’s found on the tooth. So, you
can have radicular cementum which is on the tooth root, or sometimes you can get some cementum on the
enamel surface. So what we think is that the reduced enamel epithelium – in humans – may break down,
allowing cells of the dental follicle to attach, or to contact that enamel surface, and that induces cementum
formation. So those of you who have little children, as their six year molars erupt, if you kind of pry their little
mouths open and take a look, sometimes you’ll see this chalky-whitish flaky material on the apical 1/3 of their
crowns, and that’s little flecks of cementum formation where the reduced enamel epithelium broke down.
Some species like cown horses and ungulate, they exploit the differences in density between enamel, dentin
and cementum to make an ecer-renewing surface to grind grasses with. So if you look at a cow molar nad all
of you should as dentists know about every tooth in the entire animal kingdom, there are these sort of
elongated – they look like a washboard, and if you look at the surface of the cow molar, it has like a layer, or
zone of enamel, then a layer or a zone of dentin, then a layer or a zone of cementum. And as the cow grinds
grains and stuff, the cementum wears faster than the dentin and the dentin wears faster than the enamel, so
you always have like a sharp surface to grind against, which is kind of neat. So those are ungulates. So that’s
called coronal cementum. So if the cementum is found on the crown of the tooth, that’s called coronal
cementum. That really doesn’t have much interest for us.
For some reason, in our profession we’ve really gotten into this idea of acellular cementum versus cellular
cementum. And I’ve already kind of told you that there’s some suspicion that acellular cementum may be
distinct from cellular cementum. So acellular cementum is the first cementum that’s laid down during tooth
formation. And over that acellular cementum surface, you can get cementum that has incorporated into it,
cementocytes, so it’s called cellular cementum. (inaudible student question) No. so this is why is throw out
that kind of idea, and you’ll see why in a second. And cellular cementum tends to form on the apical 1/3 of the
root surface, but it can form in other places. So what I tend to like, and most people in the profession tend to
like is the following classification system.
Slide 6 – Classification
So all cementums can either have no cells in it, or it can have cells, and all cementums can either have fibers
attaching into it from the periodontal ligament or from the gingiva, that’s called the extrinsic fibers of dental
cementum. They’re cemented into the cementum matrix and they either go out into the gingiva or into the
periodontal ligament. Or if there’s no periodontal ligament, say if it’s coronal cementum, there’s nothing to
attach to, so there are no fibers, it’s afibrillar. Ad so you can mix and match those two guys together and you
can kind of accurately describe what kind of cementum you’re dealing with. So the first cementum that’s laid
down as the tooth root forms doesn’t have any cells, so it’s acellular, but it has fibers in it. So it’s acellular
fibrillar cementum. On top of that may form a cementum that has cells incorporated in it so it’s cellular, but it
still has the fibers associating into it, so it’s cellular fibrillar cementum. We get back to our friend the cow, the
cementum that’s on the tooth surface in the cow’s mouth, what kind of cementum would it be? Would it have
cells or no cells? No cells, can’t live out there, can’t live in the barnyard. Would it have fibers or no fibers?
Nothing to attach to, so it has no fibers. So it’s acellular afibrillar cementum. Now to get back to your question,
we’ll see that it’s actually possible to regenerate down cementum. So the people who came up with that
previous classification system of primary and secondary, they didn’t know that you can regenerate, they came
up with that terminology before we understood how to actually regenerate lost tissue. So it doesn’t really
make much sense. So that’s why we kind of go with cells and fibers together.
Slide 7 – Dental development
And we’ve already kind of talked about all this, right?
Slide 8 – Hertwig’s
And we’ve talked about Hertwig’s epithelial root sheath.
Slide 9 – HERS
But what we didn’t talk about was this intermediate cementum layer. So the inner cell layer of Hertwig’s
epithelial root sheath is biosynthetic and then it makes this wonderful matrix called intermediate cementum,
and after it makes that matrix it pulls away, or it appears to pull away, it loses contact with this – probably a
better term – loses contact with that intermediate cementum layer, and some of the cells fenestrate and in
come these cells from the dental follicle and attach at the intermediate cementum layer. And they
differentiate in the cementoblasts. So since the first step in development and if you want to regenerate lost
periodontal connective tissue attachment apparatus is the development of cementum, or the deposition of
cementum, people all over the world really kind of focused in on what’s the induction factor for cementum
formation. So there was a person, Harold Slavkin, was past dean of USC dental school, general dentist. He’s
also the past director of the national association of Dental Research, and Harold’s a general dentist, and
Harold’s golden fleece, if you will, is to create a tooth, a whole tooth, and put it back into people, because he’s
tired of doing fillings, he’d rather just regenerate a lost tooth. And Harold is a very charismatic man. I
remember once USC was playing UCLA and you know how in halftime they’ll have like faculty members being
interviewed, and so there I am and I’m having an adult beverage, and I’m watching the game on New Years
Day, and all of a sudden, there’s Harold Slavkin, and he has this long hair, so he sort of looks like the MGM lion
in a way, and he’s talking about, “what we’re gonna do is clone these cells and combine them together and
we’re gonna put them back in people’s mouths”, and I’m like wow. Along his pathway to bioengineering a
tooth, he had to clone genes that are associated with enamel formation. So he was trying to clone the
amelogenin gene. So the amelogenin gene is like the devil’s own protein. So it’s like 72kD protein and you can
isolate it from forming tooth buds and you can see it on your polyacrylamide gel, and you cut out the 72kD
protein, and you can send it for amino acid analysis, and they tell you oh you didn’t give me a 72, you gave me
a ladder of peptides, so the protein itself is autoproteolytic, so it dissolves itself. So Harold felt, if I can’t
sequence it that way so what I’ll do is I’ll make monoclonal antibodies against all the little peptide fragments
and I’ll pull out the CNDA clones with my monoclonal antibodies. So as the story goes, he had this enormous
room filled with post docs looking at microscope sections of developing teeth, making sure that the
monoclonal antibodies that he was generating against amelogenin actually lit up the forming crown of the
tooth. So in walks my friend, he’s not my friend he’s kind of like my mentor, Lars Hammerstrom from Sweden,
everything comes form Sweden, and Lars worked at that time at the Karalinska Institute, those are the people
who give out the Nobel prizes, so Lars is very interested in cementum formation, so he takes a sabbatical at
USC and he sees all these guys looking at these microscopes and he’s not interested in the crowns, he’s
interested right here, and lo and behold he starts to see that these antibodies against amelogenin and
amelogenin peptide light up the intermediate cementum layer. Everyone was looking at the crown, Lars was
looking at the roots.. so Lars, typical Swedish guy, zips his mouth, packs his bags, thanks Harold very much,
goes back to the Karolinska Institute, 5 years later comes out with a company. So Lars is not a molecular
biologist, he couldn’t get a molecular biologist, so what he does is he goes to England or to Denmark, or they
did, and there are these slaughterhouses with these pigs, the English love bacon, so there’s lots of these
slaughterhouses, and some of the pigs that come through are pregnant, so they take the fetuses and they
dissect out the developing teeth and with a very simple extraction protocol they extract out the amelogenin.
So it’s pig amelogenin and amelogenin peptides, about 90% of this is that, and he bursts on the scene with a
company, a product, and he calls this product, Emdogain, enamel matrix derivative, and Lars said they threw
in the gain because it sounded good, and all it is, is an extraction, rather crude extraction of developing pig
enamel. So it’s 90% amelogenin, amelogenin-like peptides, 10% sort of uncharacterized. And what you do
during periodontal surgery, and I’ll show you some of this when we talk about periodontal regeneration, is you
apply it to the root surface, just before you close up, and it induces acellular cementum formation, so it’s an
inductive factor for acellular cementum, so one of the components that is present in the intermediate
cementum layer is amelogenin and amelogenin-like peptides. (student question: who won that football game).
I don’t know I was probably having some adult beverages, I don’t remember. You know just to see someone
who I knew being interviewed blew my mind away, you know a dental research that’s the guy to do it. He is
so charismatic. Why’d you ask me that question? Obstructed my chain of thought.
So, this com so who is company was called Biora, and it was bought out by the Strauman company. So when
you get out to the clinic floor, and you have a chance to assist in the perio clininc or in oral surgery and you
see the surgeon ask for Emdogain, you kind of have an idea of what they’re asking for. So part of this strange
matrix that’s out there is amelogenin or amelogenin-like peptides. And a lot of people couldn’t understand
this but it makes sense, because the inner epithelial layer of Hertwig’s Epithelial Root Sheath is really an
extension of the enamel organ. And what does the inner cell layer of the enamel synthesize? Well, it
synthesizes all the enamel proteins, amelogenins, enamelins, all those that you’ve learned about. And so
again, and this is recapitulation again, so some of the events that occur during enamel formation are during
Student question: is Emdogain used during practice? A: I use a lot of it, and when we talk about regeneration
I’ll talk to you why, it has a lot of advantages. My only concern is that Lars Hammerstrom came up with it first.
I hate that, because that was my idea, and I hate it when people have my idea and thy make off with it, and I
hate it, but when people have my idea before I have my idea, that even gets me more!
Slide 10: Cell rests of Malassez
So, cell rests of Malassez, the periodontal ligament in many ways is a unique suture, there’s nothing like it in
the rest of the body, so why do we have these epithelial cells present? And when I went to dental school and I
used to sit over there, no, I went to Penn, but I always used to sit in the back, but I remember cell rests of
Malassez and so I raised my hands and I said what do they do? And the professor, first he was upset at me,
and then he said well that’s the source for periodontal cysts. What? I mean I’m keeping something in my body
for pathology? That doesn’t make sense to me. And to this day, we don’t know why we have the cell rests of
Malassez in the adult periodontal ligament. However, we will show you that you can regenerate lost
periodontal tissue connective attachment apparatus. And in order, and there’s an epithelial mesenchymal
interaction that occurs during development. So what I believe is that those epithelial cell rests of Malassez are
there to provide inductive factors that are necessary for cementum formation. Ok.
Slide 11: Types of cementum
Ok, so what types of cementum are there? So there’s intermediate cementum which is a misnomer. So this is
an epithelial product so it’s not really a cementum. Cementum is a product of mesenchyme, not epithelium.
So intermediate cementum is a misnomer. There’s acellular fibrillar cementum, there’s cellular fibrillar
cementum. And when you get in the clinic, there’s clinical slang, you’ll hear people talking about affected
cementum. What the heck is affected cementum? So if you have pathology, if you have periodontitis, if you
have a periodontal pocket, and now, exposed to that periodontal pocket is the root surface, cementum is sort
of porous, its not as mineralized as dentin or bone, and it picks up bacteria or bacterial products, and it
becomes this affected cementum. And you’ll learn something called scaling and root planing, and the
objective of scaling and root planing is to remove affected cementum from that surgical site ok? so affected
cementum is sort of a clinical slang term for cementum that’s picked up bacterial products.
Slide 12: Types of cementum
We’ve already talked about that, there’s the Lars Hammerstrom thing. We’ve already seen these slide of
acellular fibrillar cementum.
Slide 13: Types of cementum
And we’ve already seen these slides of cellular cementum.
Slide 14-15-16: Types of cementum
And we’ve seen this slide of cellular cementum.
Slide 17: Cementum Composition
So what’s the composition of cementum? So cementum is very, I kind of think of cementum as kind of a
stripped down version of bone. So everything that’s been biochemically found in cementum has been found in
bone. However, proteins found in bone are not, some of them are not present in cementum. So the function
of cementum is to attach fibers of the periodontal ligament to the root surface. We don’t use cementum for
calcium homeostasis, we don’t use cementum for remodeling, we use alveolar bone to move teeth. So we
kind of think of cementum as a bone matrix, if you will, that’s really been stripped down to attach teeth in
your head. So the protein matrix is mostly collagen type I and there’s some other collagens in there like type
III. The matrix between the fibrils are the typical proteins you’d see in bone, glycoprtoeins, osteonectins, bone
sialoprotein is present in cementum, osteopontin and those reversal lines are present in cementum, some
cytokines. But there’s nothing to my knowledge that’s really been unique as far as cementum extracellular
Slide 18: Cementoblasts
We’ve already had this picture of two happy cementocytes. They’re laying down cementum matrix that’s
being mineralized. Cementing in these fibers of the periodontal ligament into the cementum matrix.
Slide 19: Cementum formation
And then we’ve already had this picture of these fibers here, being cemented in by these hydroxyapatite
crystals into this cementum matrix.
Slide 20: Resorption
Cementum resorption. So what happens if the pulp of the tooth becomes necrotic, or it becomes infected. So
bacterial antigens, bacteria themselves, or necrotic tissue, necrotic peptide son the tissue itself begin to leak
into the periodontal ligament, so this begins an inflammatory response. And cells start to appear that look
identical to osteoclasts, begin to resorb this matrix in an effort to debride that wound, to get rid of the
necrotic tissue and/or the infected material from inside that root canal. So quite frequently when teeth
become necrotic you’ll see areas of resorption, and these are so called cementoclasts, or odontoclasts. But
they’re really osteoclasts working on a different kind of matrix.
Slide 21: Cementum formation
One of the characteristics of cementum is that it doesn’t remodel under non-pathologic situations. So here is
the dentin and this is the tooth, and here is cementum matrix, mostly acellular. You can see these reversal
lines that are rich in osteopontin. Here is the periodontal ligament, and here is one osteon, and here is
another osteons of the alveolar bone, and you can kind of see this area is being resorbed into the osteons. So
this tooth is kind of moving in this direction, it’s kind of moving towards me, because the alveolar bone is
being resorbed. The periodontal ligament, as we will learn, kind of keeps the same width during tooth
movement, and the cementum does not resorb, so tooth movement, under health, is solely a property of the
resorption of alveolar bone and not cementum.
Slide 22: Anomalies
Ok, and to finish up, some variations in cementum formation. So well talk about the cementoenamel junction,
enamel projections, enamel pearls, cementicles, and finally hypercementosis, and then we’re done for today.
Slide 23: CEJ
The cementoenamel junction, the relationship of cementum and enamel and the cementum can vary, and this
is stuff you have to know, why? I have no idea but it shows up on standardized exams. So, that’s weird. Ok,
this is backwards and I think it’s corrected in your blackboard site. So this is C, it says A but it’s C. so the most
common relationship is the overlap of cementum onto the enamel surface. So make a correction if that’s not
corrected in your powerpoint. So a gap can occur between the cementum and the enamel, and that only
occurs about 10% of the time. and then a But junction occurs about 30% of the time. now there is some
clinical relevance to this, because there is a disease, a type of periodontitis that afflicts people right at puberty,
it used to be called localized juvenile periodontitis, now it’s called aggressive periodontitis, but it occurs right
at puberty, and there were some theories once upon a time that it occurs on specific teeth because of this gap
junction, but that’s never been proven. But you need to remember that the most common form of junction is
overlapping of cementum. The least common is a gap, and intermediate is an abutment of the two matrices.
(inaudible student question) So I guess you can call this for coronal cementum, yeah, because it’s at the
crown. Is the enamel ever on top of cementum? No, not to my knowledge. And it wouldn’t make sense
developmentally, would it? Because development occurs in an apical to cervical direction. So you always
finishing enamel before you’re starting cementum, because you have to have Hertwig’s ERS. Good question.
Slide 24: Enamel Projections
So sometimes in localized areas, what localized areas? So sometimes on the straight lingual of maxillary
incisors, usually lateral incisors, or at the entrance to furcations on molars, there’s a little tongue of enamel
that goes into that area, it’s called an enamel projection. And what it is, it’s failure of the enamel organ to
cease amelogenesis and consequently you can’t have HERS. So the first time I saw this was a young patient
and I’m supposed to do a perio exam, and I’m charting, and all of a sudden on the lingual of both lateral
incisors I get a 9mm pocket on this 18 year old, perfectly healthy, what’s going on? And the perio probe as well
learn, gives you a lot more information than just a pocket reading, it tells you the consistency of the root
surface, and the root surface felt very very hard, like enamel, and there wasn’t a lot of inflammation around
either, so this was an enamel projection. So here’s the dentin, here’s cementum, cementum up here, so this
area is where enamel was in life, and over it is sort of this reduced enamel epithelium, so these cells continued
to form enamel along that surface of the root, kind of setting that patient up for periodontal disease, because
as it turns out, epithelial cells don’t resist inflammation as well as a periodontal connective tissue attachment
apparatus does. So these are enamel projections, failure of the enamel organ to halt synthesis, and failure of
the HERS to then induce periodontal connective tissue attachment formation. Treatment for this, is usually
flap the area, take out the diamond and plasty away the enamel, suture everything back up and the patient is
usually fine, but you have to be able to identify that.
Slide 25: Enamel Pearls
Enamel pearl, so the enamel pearl is an enamel projection, but it’s really very exuberant in the amount of
enamel that’s been formed in this area, and notice that this is an entrance to a furcation, and you’ll see these
in radiographs, and if these occur further down, they can give you real problems in extracting the tooth. So
anyway, I know this comes from a male patient, how do I know that? So this is a male tooth (joke). And if you
kind of look at this tooth a lot, you kind of get the idea that it looks like an elephant in a way, so here are the
tusks and here are the legs, and here are the two ears of the elephant and sort of the trunk. Does it look like
an elephant to you or am I nuts? Ok, I guess I never got over Harold Slavkin being on national TV. Ok, so that’s
enamel pearl, enamel projections.
Slide 26: Cementicles
The other anomaly is something called cementicles. Careful now, we’re talking about cementicles. And
cementicles can either be sessile or out in the periodontal ligament or attached right to the cementum
formation, and if you kind of take a look at these guys in cross section, they seem to have these little
concentric areas here, so what we think is happening here is these are cell rests of Malassez that for whatever
reason have become reactivated, and perhaps they’re synthesizing amelogenin, and there is a stem cell
population in the periodontal ligament, when it senses amelogenin starts to lay down acellular cementum. So
we believe cementicles are reactivation of the cell rests of Malassez.
Slide 27: Hypercementosis
And finally, in patients that have Paget’s disease of bone, and it’s very common in elderly patients. You’ll take
a radiograph, and you’ll notice that they apical portions of their roots are really bulbous, kind of enlarged, and
this is all due to hypercementosis, an exorbitant amount of cellular fibrillar cementum formation, usually on
the apical third.
Slide 28: Hypercementosis
And this is a biopsy, right? So here’s a premolar, and this is all cellular fibrillar cementum that’s formed around
the apices of these roots. And of course, you have to kind of know this before you pick up your extraction
instruments because this can give you some real problems during extractions.
Slide 29: Summary
Ok, so what’s the summary? So cementum is the first of the periodontal connective tissue attachment to be
formed, so people have really focused in on cementogenensis, where the inductive factors, amelogenin,
amelogenin-like peptides appear to be one. Sole function of cementum appears to be to insert PDL fibers into
the tooth surface. It’s not used to calcium homeostasis, it’s not used for remodeling, as bone is. It’s not
associated with blood vessel formation, relatively avascular. So it seems to be a stripped down version of
alveolar bone. We talked about the different types of cementum that can be found and we talked a little bit
about anomalies. So have a good weekend.
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue listening from where you left off, or restart the preview.