CLINICAL SIGNIFICANCE

OF
DENTAL ANATOMY,
HISTOLOGY,
PHYSIOLOGY,
AND OCCLUSION
SHARON ISIDRO-ALVAREZ, DMD, PhD

Our Lady of Fatima University

College of Dentistry
PERIODONTIUM
 Periodontium
is a connective tissue structure with its stratified squamous epith.
• attaches the teeth to the maxilla and mandible.
• provides a continually adapting structure for the support of the
teeth during functions.

2 mineralized CT of Periodontium
1. Cementum and alveolar bone
2. Fibrous Connective Tissue- periodontal ligament and lamina
propia.

Its attaches to the jaw by alveolar bone to the dentin of the tooth
root by cementum.
 Periodontium
DIVIDED INTO 2
1. Gingival Unit consisting
of free gingiva and alveolar
mucosa
2.Attachment Apparatus-
cementum, periodontal
ligament and alveolar
process
 PERIODONTIUM
Pulp cavity
Enamel
Cementum Dentin

Gingiva
PDL

Alveolar bone
Cementum
Sharpey's fibers Periodontal
ligament
Attachment Root canal
organ
Alveolar bone

Apical foramen
Alveolar vessels
& nerves
 Periodontium (forms a
specialized fibrous joint called
Gomphosis)
• Cementum
• Periodontal Ligament
• Alveolar bone
• Gingiva facing the tooth
 Cementum
It is a hard avascular connective
tissue that covers the roots of
teeth
Cementum

Cementum is a thin layer of

hard dental tissue covering
the anatomic roots of teeth
and is formed by cells known
as cementoblasts, which
develop from
undifferentiated mesen-
chymal cells in the
connective tissue of the
dental follicle.
 Cementum

Physical properties
• Cementum is light yellow and slightly
lighter in color than dentin.
• Cementum is slightly softer than
dentin
• Cementum is avascular
• It is formed continuously throughout
life because as the superficial layer of
cementum ages, a new layer of
cementum is deposited to keep the
attachment intact.
• Has the highest fluoride content of all
mineralized tissues
Cementum

• with a dull surface

• Cementum is more permeable than other dental tissues

• Relative softness and the thinness at the cervical portion means

that cementum is readily removed by the abrasion when gingival
recession exposes the root surface to the oral environment
Cementum
Varies in thickness: thickest in
the apex and

Distribution
In the inter-radicular areas of
multirooted
teeth, and thinnest in the
cervical area

10 to 15 µm in the cervical areas

to
50 to 200 µm (can exceed > 600
µm) apically
Cementum

Chemical properties
CEMENTUM
50-55% 45-50%
ORGANIC MATTER HYDROXYAPATITE
+ WATER CRYSTALS

COLLAGEN

CELLS
PROTEIN
POLYSACCHARIDES
Cementum

Composition of Cementum
Cementocytes
• Cells of cementum
that are embedded in
the calcified matrix

• Located in LACUNAE
Cementum

cementogenesis
CEMENTOGENESIS
Cementum
CEMENTOGENESIS

cementogenesis
ROOT DEVELOPMENT
STAGE

1. Matrix formation
2. Mineralization
Cementum
CEMENTOBLASTS

cementogenesis
• Formative cells of the cementum
• Embryonically, cells are derived from the dental
sac or follicle (from ectomesenchyme)
• Located in the PDL
• UMC from PDL may
Differentiate into
cementoblasts
Cementum
Development of Cementum
FORMATION OF CEMENTUM:

Hertwig’s epithelial root sheath (HERS) –

(Extension of the inner and outer dental

cementogenesis
Epithelium) forms and grows apically

HERS sends inductive signal to ectomesen-

chymal pulp cells to secrete predentin by
differentiating into odontoblasts. Root dentin
forms.

HERS becomes interrupted.

Ectomesenchymal cells from the inner portion

of the dental follicle come in with predentin by
differentiating into cementoblasts

Cementoblasts lay down cementum.

 Cementum
CEMENTOGENESIS

cementogenesis
1. Matrix formation
• Matrix is composed of
– Proteins
– Ground substance
– Water
– Non-collagenous proteins
Produced by cementoblasts
or fibroblasts
Cementum

CEMENTOGENESIS
The uncalcified matrix of
cementum is called
cementoid.
It is lined by cementoblast.
• Connective tissue fibers from
the PDL are embedded in
the cementum and serve to
attach tooth to surrounding
bone (Bone bundle)
• These embedded fibers are
known as Sharpey`s fibers.
 Cementum
CEMENTOGENESIS

cementogenesis
2. Mineralization
• When thin layer of cementoid is
formed, mineral salts from the tissue
fluid of PDL is deposited as HA
crystals along the collagen fibers.
• As cementum thickens, collagen
fibers from the PDL becomes
incorporated in the cementum.
 Cementum

CEMENTOGENESIS
• Organic portion of cementum
composed of collagen and matrix.

• sharpeys fibers
– collagenous principal fibers of
the periodontal ligament
embedded in both cementum
and alveolar bone to attach the
tooth to alveolus.

– Principal fibers of periodontal

ligamnt continue to course into
surface layer of cementum as
Sharpey’s fibers
 Cementum

CEMENTOGENESIS
• Organic portion of cementum
composed of collagen and matrix.

• sharpeys fibers
– collagenous principal fibers of
the periodontal ligament
embedded in both cementum
and alveolar bone to attach the
tooth to alveolus.

– Principal fibers of periodontal

ligamnt continue to course into
surface layer of cementum as
Sharpey’s fibers
 Hyaline layer of Hopewell-Smith
Cementum (Intermediate Cementum)
First layer of cementum is actually
formed by the inner cells of the HERS
and is deposited on the root’s surface
is called intermediate cementum or
Hyaline layer of Hopewell-Smith

Deposition occurs before the HERS

disintegrates. Seals of the dentinal
tubules

Intermediate cementum is situated

between the granular dentin layer of
Tomes and the secondary cementum
that is formed by the cementoblasts
(which arise from the dental follicle)

Approximately 10 µm thick and

mineralizes greater than the adjacent
dentin or the secondary cementum
Cementum Roles of Cementum

1) It covers and protects the root dentin

(covers the opening of dentinal tubules)

2) It provides attachment of the periodontal

fibers

3) It reverses tooth resorption

4) Compensates for tooth attrition

Cementum Clinical Correlation

Cementum is more resistant to resorption: Important in permitting

orthodontic tooth movement
Cementum
Classification of Cementum
• Presence or absence of cells
• Origin of collagenous fibers of the matrix
• Prefunctional and functional
 Cellular and Acellular Cementum
Cementum
1. Acellular layer of cementum is
living tissue that does not
incorporate cells into its structure
and usually predominates on the
coronal half of the root

2. cellular cementum contains

cementoblasts (inside the
lacuna) and is often formed on
the apical half.

A: Acellular cementum (primary cementum)

B: Cellular Cementum (secondary cementum)
 Primary and Secondary Cementum
Cementum
1. Primacy Cementum
• Represents cementum that is
formed before the tooth is
established in occlusiom

2. Secondary Cementum
• Represents all the cementum
that is formed after the tooth
comes in occlusion.
• Continuously forms all through
out life.
 A: Acellular cementum
B: Hyaline layer of Hopwell-Smith
C: Granular layer of Tomes
D: Root dentin

Cellular: Has cells

Acellular: No cells and has no structure

Cellular cementum usually overlies acellular cementum

 Classification Based on the Nature and
Cementum Origin of Collagen Fibers

Collagen fibers of Organic matrix is derived form 2 sources:

1. Periodontal ligament (Sharpey’s fibers)
2. Cementoblasts

Extrinsic fibers if derived from PDL. These are in the same

direction of the PDL principal fibers i.e. perpendicular or
oblique to the root surface

Intrinsic fibers if derived from cementoblasts. Run parallel to

the root surface and at right angles to the extrinsic fibers

The area where both extrinsic and intrinsic fibers is called

mixed fiber cementum
Cementum
Acellular Extrinsic Fiber Cementum (AEFC-Primary Cementum)

• Located in cervical half of the root and constitutes the bulk of cementum
• The collagen fibers derived from Sharpey’s fibers and ground substance
from cementoblasts
• Covers 2/3rds of root corresponding with the distribution of primary
acellular cementum
• Principal tissue of attachment
• Function in anchoring of tooth
• Fibers are well mineralized
Cementum
Primary acellular intrinsic fiber
• First cementum
• Primary cementum
• Acellular
• Before PDL forms
• Cementoblasts
• 15-20μm
Cementum Acellular afibrillar

• : cervical enamel
• Forms the coronal cementum
• Acellular extrinsic: Cervix to practically the whole root
(incisors, canines) increasing in thickness towards the
apical portion 50à200μm
• Cellular: Apical third, furcations
 Cellular Intrinsic fiber
Cementum cementum

• Cementum that normally fills the resorption lacunae

• Contains cementoblasts and collagen fbers produced by
cementoblasts.
 Cellular Mixed fiber
Cementum cementum

• Cementum that is found at the apical third of the root,

apices and furcation areas of multi-rooted teeth.
• It contains cellular components and collagen fibers derived
from cementoblasts and PDL
Cementum
CE junction
The “OMG” rule

Cementum overlaps enamel 60%

Cementum just meets enamel 30%

Small gap between cementum and enamel 10%

 CEMENTUM and enamel at the
Cementum CEJ
 Clinical Correlation

Cementum thickness can increase on the root end to

compensate for attritional wear of the occlusal or
incisal surface and passive eruption of the tooth.
 Clinical Correlation
Abrasion, erosion, caries, scaling, and restoration finishing and
polishing procedures can denude dentin of its cementum
covering, which can cause the dentin to be sensitive to various
stimuli (e.g., heat, cold, sweet substances, sour substances).
Cementum Clinical Correlation

Cementum joins enamel to form the CEJ. In about

10% of teeth, enamel and cementum do not meet,
and this can result in a sensitive area
 Aging of Cementum
1. Smooth surface becomes irregular due
to calcification of ligament fiber bundles
where they are attached to cementum
2. Continues deposition of cementum occurs
with age in the apical area.
[Good: maintains tooth length; bad:
obstructs the foramen
3. Cementum resorption. Active for a period
of time and then stops for cementum
deposition creating reversal lines
4. Resorption of root dentin occurs with aging
which is covered by cemental repair
 Cementicles
• Calcified ovoid or round nodule found
in the PDL
• Single or multiple near the cemental surface
• Free in ligament; attached or embedded
in cementum
• Aging and at sites of trauma

Origin: Nidus of epithelial cell that are

composed of calcium phosphate and
collagen to the same amount as
cementum (45% to 50% inorganic
and 50% to 55% organic)
 Cemental Repair
Protective function of cementoblasts after
resorption of root dentin or cementum

Resorption of dentin and cementum due

to trauma (traumatic occlusion, tooth
movement, hypereruption)

Loss of cementum accompanied by loss

of attachment

Following reparative cementum

deposition attachment is restored
 Clinical Correlation

Cellular cementum is similar to bone but has no nerves.

Therefore it is non-sensitive to pain. Scaling produces
no pain, but if cementum is removed, dentin is exposed
causes sensitivity

Cementum is resistant to resorption especially in younger

Patients. Thus, orthodontic tooth movement causes alveolar
one resorption and not tooth root loss
 Clinical Correlation
The cementodentinal junction is a relatively smooth area in the
permanent tooth, and attachment of cementum to dentin is firm,
but this is not understood completely yet.
 Clinical Correlation

Cementum is capable of repairing itself to a limited degree

and is not resorbed under normal conditions. Some
resorption of the apical portion of the root can occur,
however, if orthodontic pressures are excessive and
movement is too fast
 Clinical Correlation

FORMATION AND PROGRESSION OF DENTAL CARIES

IN CEMENTUM
Root caries is a soft, progressive lesion that is found
anywhere on the root surface that has lost its connective
tissue attachment and is exposed to the environment.

• Root caries occurs at or apical to the CEJ.

 Clinical Correlation

FORMATION AND PROGRESSION OF DENTAL CARIES

Most common reasons for their occurrence is gingival
recession

With advanced age, there is more gingival recession,

which leaves the root surface exposed to the oral
environment and leads to an increase in the root caries
rate.
GINGIVAL RECESSION
is the apical migration of marginal
gingiva as well as the fact that the
latter is gradually displaced away
from the cementoenamel junction,
thereby exposing the root surface
to the oral environment
ORAL MUCOSA
ORAL MUCOSA or ORAL MUCOUS MEMBRANE
is the moist lining of the oral cavity that is continuous
with the exterior surface of the skin on one end and the
pharynx on the other end.
 ORAL MUCOSA
• - mucous membrane covers all structure except clinical crowns of the teeth.

2 LAYERS OF ORAL MUCOSA

1. Stratified Squamous Epithelium – Lining epithelium

2. Supporting Connective Tissue – Lamina propria
 FUNCTIONS OF ORAL MUCOSA
1. Protection - of deeper tissues against mechanical
forces and surface abrasion.
2. Sensation – temperature, touch and pain,
reflexes, and taste buds.
3. Secretion – by salivary glands of saliva.
4. Temperature regulation.
 ORAL MUCOSA

1. Masticatory
mucosa
2. Lining mucosa
3. Specialized
mucosa
 Oral mucosa classifications
1. Lining mucosa
– buccal mucosa, labial mucosa, alveolar
mucosa, floor of the mouth, ventral
tongue, soft palate
– non-keratinized stratified squamous
epithelium
– soft, moist, ability to stretch and
compress

2. Masticatory mucosa
– attached gingiva, hard palate, dorsal
tongue
– rubbery, resilient
– keratinized or parakeratinized stratified
squamous epithelium

3. Specialized
– dorsal tongue surface
– associated with the lingual papillae
 Oral Mucosa
I. LINING OF THE ORAL MUCOSA - mucosal
membrane = epithelium + connective tissue
-derived from the ectoderm

a. epithelium = stratified squamous

b. connective tissue = lamina propria

c. in between these tissues = basement membrane

 LAMINA PROPIA

• varies in thickness
and supports the
epithelium
• -attached to the
periosteum of the
alveolar bone
• -Dense thick firm
connective tissue
containing
collagenous fibers.
 SUBMUCOSA

• - consist of connective tissue

varying in density and thickness.
• -Attaches the mucous membrane to
the underlying bony structures.
• -thin loose connective tissue with
muscle and collagenous fibers
different areas varying from 1
another in their structure.
• -contains:
– Glands, blood vessels, nerve
and adipose tissue.
GINGIVA
 GINGIVAL UNIT
1. Free gingiva
gingiva from the marginal crest to the
level of the base of the gingival sulcus.
2. Gingival Sulcus
Space between the tooth and free
gingiva.
3. Gingival/ Interdental Papillae
Outer aspect of gingiva in each gingival
embrasure
4. Free gingival groove
Is a shallow groove that runs parallel to
the marginal crest of the free gingiva.
5.Attached gingiva
Dense connective tissue with its
keratinized stratified squamous
epithelium etend from level of the
depth of the gingival sulcus.
 GINGIVAL UNIT
• 5. Mucogingival Junction
-dense network of collagenous
fibers connects the attached
gingiva firmly to the
cementum and the
peroisteum of the alveolar
process.

6. Alveolar Mucosa
- thin, soft tissue that is
loosely attached to the
underlying alveolar bone.
 II. ATTACHMENT APPARATUS
• ATTACHMENT APPARATUS- the tooth
root is attached to the alveolus (bony
socket) by periodontal ligament.

1.Cementum
-hard tissue with a calcified intercellular
substance covering the anatomical roots of
Teeth

2.Periodontal Ligament
- this ligament is a complex, soft CT
containing numerous cell, blood vessel,
nerve fibers and ground substance.
3.Alveolar Process
-Thin of compact bone with many openings.
-part of the maxilla and mandible
- Supports the sockets

4. Alveolar Bone Proper

- Inner wall of the bony socket, consist of
thin lamella of bone that surrounds the
root of the tooth and gives attachment to
Sharpey’s Fibers.

5. Supporting Alveolar Bone

- Which surrounds the alveolar bone proper
and support the socket.
 Clinical Correlations
• Clinically, the level of the
gingival attachment and
gingival sulcus is an
important factor in
restorative dentistry.
• Soft tissue health must be
maintained by teeth having
the correct form and
position to prevent
recession of the gingiva
and possible abrasion and
erosion of the root surfaces.
 Clinical Correlations
• The margin of a tooth
preparation should not be
positioned subgingivally
(at levels between the
marginal crest of the free
gingiva and the base of the
sulcus) unless dictated by
caries, previous restoration,
esthetics, or other
preparation requirements
 Stipplings of the gingiva

Consists of small indentations into the mucosal

surface.
 Age changes
• Smoother
• Dryer
• Atrophic friable
• Epithelium becomes thinner
• Reduction in filiform papillae
• Vascular changes
 Permeability of oral mucosa

Epithelium is impermeable, but due to thinness of some

regions, some substances may be able to penetrate the
barrier. Floor of the mouth is the thinnest.
Toxins and antigens produced by microorganisms may be
able to penetrate the DGJ.
 Permeability of oral mucosa

Epithelium is impermeable, but due to thinness of some

regions, some substances may be able to penetrate the
barrier. Floor of the mouth is the thinnest.
Toxins and antigens produced by microorganisms may be
able to penetrate the DGJ.
 Permeability of oral mucosa

Epithelium is impermeable, but due to thinness of some

regions, some substances may be able to penetrate the
barrier. Floor of the mouth is the thinnest.
Toxins and antigens produced by microorganisms may be
able to penetrate the DGJ.
 PERIODONTAL LIGAMENT
Functions of PL

1.Attachment and support

2. Sensory
3. Nutritive
4.Homeostatic

Principal Fibers of the Ligament

-bundles of collagen fibers
-serves to attach the cementum to the alveolar bone
-acts as cushion to suspend and support the tooth.
 SUPPORTING ALVEOLAR BONE

• Made up to parts:

1.Cortical Plate
-Compact bone inner and outer plate of alveolar process

2. Spongy bone
-Fills the areas between plates and alveolar bone proper.

Bone is composed of 65% inorganic material, 35 % organic

material.