CONTENTS

•Introduction

•Physical characteristics

•Composition •Classification of cementum

•Cementogenesis •Mineralization

•Cementum associated cells

•Cementoenamel junction

•Cementodentinal junction

•Functions of cementum

•Developmental anomalies of cementum

•Abnormalities of cementum

•Conclusion

INTRODUCTION

It is a Calcified, Avascular mesenchymal tissue that forms the outer covering of the anatomic root.
(Carranza 11th edition). First demonstrated in 1835 by FRANKE & RASCHKOV, two pupils of purkinje.
Begins at the cervical portion of the tooth at the cementoenamel junction and continues to the apex.
There are two main types-

- Acellular ( primary)

- Cellular ( secondary)

Both consist of interfibrillar matrix and collagen fibrils.

PHYSICAL CHARACTERISTICS

• Hardness < Dentin. • Light yellow in color and lacks luster. • Lighter in color than dentin, however
it may not be distinguished on basis of color alone. • Permeability of cellular cementum is greater
than that of acellular cementum. With age, the permeability of cementum decreases. • Thinnest at
CEMENTOENAMEL JUNCTION (20-50 um) • Thickest towards the APEX (150-200 um)

COMPOSITION

• Dry weight basis: – 45-50% inorganic substances which consists of calcium and phosphate in the
form of hydroxyapetite crystals. – 50-55% organic material and water. • Organic matrix of
cementum consists of : – Type I collagen ( 90%) – Type III collagen ( 5% ) – Non collagenous proteins.

• By volume:  45% inorganic  35% organic  20% water

• Two main sources of collagen fibers 1. Sharpeys fibers ( Extrinsic) are the embedded portion of the
principal fibers of periodontal ligament and formed by fibroblasts. 2. Fibers that belong to the
cementum matrix ( intrinsic) and produced by cementoblast. • Due to its lower crystallinity of
mineral component : – has the highest Flouride content – Readily decalcifies in the presence of
acidic conditions.

Non collagenous

• Non- collagenous proteins- play important role in matrix deposition, initiation and control of
mineralization and matrix remodelling. Include: Bone sialoprotein, osteopontin,tenascin,
fibronectin, osteocalcin . • Proteoglycans- Chondroitin sulphate,hyaluronate, heparan sulfate,
biglycan and osteoadherin.

Growth factors- TGFß, bone morphogenetic proteins (BMP’s),Platelet derived growth factors,
Osteoprotegerin (OPG).

Cementum derived growth factor seen exclusively in cementum.  is an insulin like molecule. 
Enhance proliferation of gingival fibroblasts and periodontal ligament cells.

CLASSIFICATION

• ACELLULAR CEMENTUM

• CELLULAR CEMENTUM

ACELLULAR CEMENTUM

• Term acellular is UNFORTUNATE because as a living tissue Cells are an integral part. • However
some layers do not incorporate cells while other layers do not contain such cells in their lacunae. •
First to be formed. • Sharpeys fibers make most of the structure.

• Forms during root formation before tooth reaches occlusal plane. • Covers approx. cervical 1/3rd
(coronal portion)of the root. • Does not contain any cells. • More calcified. • Formation is slow •
Arrangement of collagen fibers are more organized

CELLULAR CEMENTUM

• Forms after the eruption of tooth once it reaches occlusal plane. • Its formation is also in response
to the functional demands. • Sharpeys fibers occupy a smaller portion. • Contains cementocytes in
lacunae that communicate with each other by canaliculi.

• Covers apical 2/3rd of the root • Contains cementocytes • Its deposition is more rapid • Collagen
fibers are irregularly arranged.

SHROEDER & PAGE CLASSIFICATION

1986 • Classified CEMENTUM on the basis of : – LOCATION – MORPHOLOGY – HISTOLOGICAL

APPEARANCE
1. Acellular Afibrillar Cementum (AAC) 2. Acellular Exrinsic Fiber Cementum (AEFC) 3. Cellular
Intrinsic Fiber Cementum (CIFC) 4. Cellular Mixed Stratified Cementum (CMSC) 5. Intermediate
Cementum

Acellular Afibrillar Cementum (AAC) • FIBERS -ABSENT • CELLS- ABSENT • FORMED BY-
CEMENTOBLASTS • LOCATION- CORONAL CEMENTUM • THICKNESS- 1-15μm

Acellular Extrinsic Fiber Cementum (AEFC) • FIBERS- DENSELY PACKED BUNDLES OF SHARPEY’S
FIBRES • CELLS-ABSENT • FORMED BY –FIBROBLASTS & CEMENTOBLASTS • LOCATION -CERVICAL
THIRD OF ROOT • THICKNESS - 30-230μm

Cellular Intrinsic Fiber Cementum (CIFC) • FIBERS - INTRINSIC FIBRES • CELLS - PRESENT • FORMED
BY - CEMENTOBLASTS • LOCATION - RESORPTION LACUNAE

Cellular Mixed Stratified Cementum (CMSC) • FIBERS- EXTRINSIC SHARPEY’S & INTRINSIC FIBRES •
CELLS - PRESENT • FORMED BY - FIBROBLASTS & CEMENTOBLASTS • LOCATION - APICAL 1/3rd OF
ROOT & FURCATION • THICKNESS - 100 -1000μm

INTERMEDIATE CEMENTUM

• CELLS - CELLULAR REMNANTS OF HERTWIGS SHEATH • LOCATION – CEMENTODENTINAL

JUNCTION • THICKNESS - 10μm

CEMENTOGENESIS (Berkovitz) Formation of cementum is known as cementogenesis

Cementum formation takes place along the entire root.

At the advancing root edge, HERTWIG’S EPITHELIAL ROOT SHEATH (HERS), which is derived from
the extension of inner and outer enamel epithelium releases enamel proteins.

HERS possibly sends inductive message to the ectomesenchymal cells of pulp.

 These ectomesenchymal cells of pulp now differentiate into odontoblasts and produce a layer of
predentin along the inner aspect of HERS.

 Once dentin formation is underway, breaks occur in HERS.

 Therefore the inner layer of dental follicle comes in contact with predentin.

 Cells of the dental follicle now differentiate into CEMENTOBLASTS which are the main cells
responsible for cementum formation.

 Cementoblasts synthesize organic matrix which is uncalcified and called as cementoid tissue or
precementum

Uncalcified cemental matrix – cementoid

Formation of Cementum
PTHrP: parathyroid hormone–related protein; BMP: bone morphogenetic protein CSF: colony-
stimulating factor; EGF: epidermal growth factor BSP: bone sialoprotein; OC: osteocalcin; OPN:
osteopontin.

Regeneration versus development: events and cells. While similar events occur during development
and regeneration of tissues, there are clear differences in cell types involved and in some of the
factors promoting cell types involved and in some of the factors promoting cell

MINERALIZATION

• Mineralization begins in the depth of precementum. • Fine hydroxyapatite crystals are deposited,
first between and then within the collagen fibrils by a process that is identical to the mineralization
of bone tissue. • Zander & Hurzeler examined the thickness of cementum on extracted human teeth
from individuals of varying ages & concluded that the mean,linear rate of cementum deposition on
single-rooted teeth is about 3 pm per year, (but varying greatly with tooth type, root surface area,
and type of cementum being formed).

• A similar rate has been found for acellular extrinsic fiber cementum in premolars and in
nonfunctioning, impacted teeth • The width of the precementum layer is about 3-5 um. • Process of
establishing the appropriate condition for crystallization & growth of the individual crystals in
cementum normally are extremely slow and extend over a period of several months

The development of cementum has been subdivided into:

 Pre-functional stage

 Functional stage  Prefunctional portion of the cementum is formed during root development & is
extremely long lasting process.

 The functional development of cementum, commences when the tooth is about to reach the
occlusal level & is associated with the attachment of root to the surrounding bone & continues
throughout life. It is mainly during this stage that adaptive & reparative processes are carried out by
the biological responsiveness of cementum.

CEMENTUM ASSOCIATED CELLS Cementoblasts

Cementocytes

CEMENTOBLAST S  Derived from dental follicle.  Transformation of mesenchymal cells of dental

follicle.  Cemento-progenitor cells synthesize collagen and protein polysaccharide.  These cells
have numerous mitochondria, a well formed Golgi- apparatus and large amounts of granular
endoplasmic reticulum.

Histological observation of areas of root resorption has shown that cementoblasts can arise
wherever viable dentin is exposed to the soft tissue of the periodontal ligament. Induction of
cementoblasts from periodontal ligament cells can apparently take place throughout life, as
evidenced by physiological areas of cemental repair.
 Cellular turnover among cementoblasts is slow compared with that in the osteoblasts that line the
alveolus.

 Furthermore, it appears that cementoblasts are capable of altering their rate of cementum
deposition.

CEMENTOCYTES

 Cementocytes in lacunae and the channels in which their processes extend are called the
canaliculi.

 The central cell mass may appear rounded or oval & diameter ranges from 8-15 um.

 The cytoplasm is palely basophilic and the nucleus is centrally located.

Cementocytes communicate with each other through a system of anastomosing canaliculi

radiating from their body

CEMENTO ENAMEL JUNCTION

The junction between the cementum and enamel at the cervical region of the tooth is termed
Cemento-Enamel junction

 In about 60% cases cementum overlaps the cervical end of enamel.

 In approx. 30% of all teeth cementum meets the cervical end of enamel.

 In 10% cases enamel and cementum do not meet which can cause accentuated sensitivity because
of exposed dentin.

 In about 1.6% of cases enamel overlaps cementum.

four TYPES OF RELATIONSHIP EXIsTS

Journal of Indian Society of Periodontology - Vol 18, Issue 5, Sep-Oct 2014

VARIOUS METHODS OF CEJ LOCATION • Methods for location of CEJ include following two kinds: –
Conventional – Modified A. In conventional methods we have: • Visual • Tactile • By straight
explorer • By periodontal probe; examiner feels for the cervical line with the tip of the probe •
Radiographic • Intraoral periapical (IOPA) radiograph • Bite wings • RVG

B. In modified methods we have: • Computer linked electronic constant pressure probes – Florida
probe – Inter probe/Perio probe – Birek probe/Toronto automated probe – Jeff coat probe/Foster
miller probe.

Journal of Indian Society of Periodontology - Vol 18, Issue 5, Sep-Oct 2014

THE CEMENTO-DENTINAL JUNCTION (CDJ)

 The terminal apical area of cementum where it joins the internal root dentin is called
cementodentinal junction or CDJ  The nature of CDJ is of particular importance, being of interest
biologically because it forms an interface (a fit) between two very different mineralized tissues. It is
also of clinical importance because of the processes involved in maintaining tooth function while
repairing a diseased root surface.  Width of CDJ is 2 to 3um and remains relatively stable

FUNCTIONS

• ANCHORAGE

• ADAPTATION

• REPAIR and RESORPTION

ANCHORAGE

• To furnish a medium for the attachment of collagen fibers that bind the tooth to alveolar bone.

• Connective tissue attachment to the tooth impossible without cementum.

• EXAMPLE- in hypophosphatasia, loosening and premature loss of anterior deciduous teeth occurs.
The exfoliated teeth are characterized by an almost total absence of cementum

ADAPTATION

• Continuous deposition of cementum is of functional importance. – Cementum is not resorbed

under normal conditions. – As the most superficial layer of cementum ages, a new layer is deposited
that keeps the attachment apparatus intact.

REPAIR

• Serves as a major reparative tissue for root surfaces. • Damage to roots such as fractures and
resorptions can be repaired by the deposition of new cementum.

RESORPTION OF CEMENTUM • Cementum although is less susceptible to resorption than bone. •

Resorption is carried out by multinuclear odontoclasts & may continue into the root dentine. • Acc.
To a study approx 70% of all resorption areas were confined to the cementum without involving the
dentin.

• Local Factors For Resorption – Trauma from occlusion. – orthodontic movement – pressure from
malaligned erupting teeth, – cysts, and tumors; – Teeth without functional antagonists; – embedded
teeth; – replanted and transplanted teeth; – Periapical and periodontal disease.

Cemental resorption associated with excessive occlusal forces. A, Low-power histologic section of
mandibular anterior teeth. B, High-power micrograph of apex of left central incisor shortened by
resorption of cementum and dentin. Note partial repair of the eroded areas (arrows) and cementicle
at upper right

• SYSTEMIC FACTORS – calcium deficiency, – hypothyroidism, – hereditary fibrous osteodystrophy, –

Paget's disease.

• IDIOPATHIC
• Cementum resorption appears microscopically as baylike concavities in the root surface. •
Multinucleated giant cells and large mononuclear macrophages are generally found adjacent to
cementum undergoing active resorption. • Cementum repair can occur in devitalized as well as in
vital teeth. • Resorption occurs most commonly in apical third then middle third followed by gingival
third.

DEVELOPMENTAL ANOMALIES ASSOCIATED WITH CEMENTOGENISIS

CEMENTICLES

• Are small, globular masses of cementum found in approx 35% of human roots. • May not be
always attached to the cementum surface but may be located free in Pdl. • These may result from
microtrauma, when extra stress on sharpeys fibers causes a tear in the cementum. • Are more
commonly found in apical & middle third of root and in root furcation areas

• May develop from calcified epithelial rests; around small • spicules of cementum or alveolar bone
traumatically displaced • into the periodontal ligament; from calcified • Sharpey's fibers; and from
calcified, thrombosed vessels • within the periodontal ligament

ENAMEL PEARLS

If some HERS cells remain attached to forming root surface, they can produce focal deposits of
enamel like structures called ENAMEL PEARLS.

Clinical significance

They are plaque retentive structures. Promote periodontal disease. They look similar to calculus,
but cannot be scaled off. Only grinding will help in elimination.

ABNORMALITIES OF CEMENTUM

Cemental Hyperplasia or Hypercementosis –  Refers to abnormal thickening of cementum.

 It is largely an age related phenomenon

 It can be – Localized to one tooth Generalized- affect the entire dentition.

• If the overgrowth improves the functional qualities of the cementum, it is termed as cementum
hypertrophy.

• If the overgrowth occurs in nonfunctional teeth or if it is not correlated with increased function, it
is termed cemental hyperplasia.

Appearance:  Occurs as a generalised thickening of cementum, with nodular enlargement of the

apical third of the root  It also appears in the form of spike like excrescenses (cemental spikes)
created by either the coalescence of cementicles that adhere to the root or the calcification of the
periodontal fibres at the site of insertion into the cementum

Hypercementosis

 It is usually associated with situations like –

teeth without antagonist

teeth with pulpal and periapical infections

 Hypercementosis of entire dentition may be seen in patients with Paget's disease.

 Other systemic disturbances include acromegaly, calcinosis, thyroid goiter, arthritis etc.

Treatment: Hypercementosis itself does not need treatment.

It could pose a problem if an affected tooth requires extraction.

In multirooted tooth, sectioning of tooth may be required before extraction.

Cemental aplasia or hypoplasia: Absence or paucity of cellular cementum.

Hypophosphatasia  Hypophosphatasia is due to an inborn error of metabolism.The basic disorder

is a deficiency of enzyme alkaline phosphatase in serum or tissues.

 This is characterised by loosening and premature exfoliation of deciduous teeth,mainly anteriors.

 Exfoliated teeth microscopically show complete absence of cementum or isolated areas of

abnormally formed cementum.

 Cemental Tear : The detachment of a fragment of cementum is described as a cemental tear.

Cemental tears have been reported in the periodontal literature associated with localized, rapid
periodontal breakdown.

Cemental Tear

ANKYLOSIS  Fusion of cementum and alveolar bone and obliteration of the periodontal ligament
is called ankylosis. Results in resorption of root and its replacement by bone tissue.  This condition
is uncommon.  Occurs in teeth with cemental resorption.  It represents a form of abnormal repair.

Ankylosis can also occur after:

Chronic periapical infection

Tooth reimplantation

Occlusal trauma

Around embedded teeth.

More common in primary dentition

Clinically: 1.Lack of physiologic mobility which is diagnostic sign of ankylotic resorption.

2. As the periodontal ligament is replaced with bone in ankylosis, proprioception is lost because
pressure receptors in periodontal ligament are deleted or not function correctly.
3. Teeth have special metallic percussion sound.

4. If the process continues teeth will be in infraocclusion.

Radiographically:  Resorption lacunae are filled with bone.

 Periodontal ligament space is missing.

Treatment:

 No predictable treatment can be suggested.

 Treatment modalities range from a conservative approach,such as resotorative intervention to

surgical extraction of affected tooth.

EXPOSURE OF CEMENTUM TO ORAL ENVIRONMENT • Exposed in cases of gingival recession leading

to pocket formation. • Permeable to be penetrated by organic substances, inorganic ions and
bacteria.

Leading to fragmentation & breakdown of cementum & resulting in areas of necrotic cementum
seperated from tooth by masses of bacteria

Bacterial penetration found as deep as cemento dentinal junction

Collagenous remnants of sharpeys fibers undergo degeneration

Creating environment for bacterial penetration

87% viable bacteria found in roots of periodontally non carious teeth

As pocket deepens

Collagen fibers destroyed Cementum exposed to oral environment

CONCLUSION

Cementum forms a functional unit which is designed to maintain tooth support, integrity, and
protection.

Minor, non-pathological resorption defects on the root surface are generally reversible and heal by
reparative cementum formation.

Irreversible damage may occur when the cementum is exposed to the environment of a pocket or
oral cavity.

REFERENCES

 Carranza’s clinical periodontology (10th & 11th edition)  Jan Lindhe – Text Book Of Clinical
Periodontology (4th edition)  Orban’s –Text Book Of Oral Histology And Embryology 11th & 13th
edition  Tencates – Text Book Of Oral Histology (10th edition) • A Color Atlas & Text Of Oral
Anatomy & Embryology – 2nd Edition B.K.B Berkovitz
 PERIO 2000 - Dental cementum: the dynamic tissue covering of the root. Dieterd . Bosshard &t
Knuta . Selvig

 Journal of Indian Society of Periodontology - Vol 18, Issue 5, Sep-Oct 2014

 PERIO 2000 - Molecular and cell biology of cementum Nazan E. Saygin, William V.
Giannobile&martha J. Somerman