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CEMENTUM

Guided by
Dr. shrutima

Presented by
R.uday bhaskar

CONTENTS

INTRODUCTION
DEFINITION
PHYSICAL PROPERTIES
CLASSIFICATIONS
COMPOSITION OF CEMENTUM
PROTIENS
TOOTH DEVELOPMENT
CEMENTOGENESIS
THEORIES

ANATOMY
INTERMEDIATE CEMENTUM
CEMENTO-DENTINAL JUNCTION
CEMENTO-ENAMEL JUNCTION
ROLE OF CEMENTUM IN PERIODONTAL HEALTH

AGE CHANGES
RESORPTION AND REPAIR
CHANGES IN DISEASED CEMENTUM
CEMENTUM REGENERATION
SYSTEMIC DISEASES CAUSING DEFECTIVE
CEMENTUM FORMATION
CLINICAL CONSIDERATIONS
CONCLUSION

INTRODUCTION

Cementum

The term cementum is derived from the Latin term caementum


meaning quarried stone or chips of stone used for making mortar

It is also called as Substantia Ossea

It is the hard avascular connective tissue that covers roots of the teeth
and serves primarily to invest and attach the principal periodontal
ligament fibers.

CEMENTUM IS VERY SIMILAR TO BONE.

Diseases that affect the properties of bone, often alter cementums


properties as well.

The composition of cementum is similar to that of bone. Cementum is


approximately 50% hydroxyapatite and 50% collagen and
noncollagenous proteins.

CEMENTUM DIFFERENT FROM BONE

NOT
Innervated,
Exhibit little or no remodeling
Avascular

PHYSICAL PROPERTIES
1.Colour - Pale yellow
2.Softer and more permeable than dentin
3.Relatively brittle
4.Distinguished from enamel due to its darker hue and luster
5.The relative softness of cementum, combined with its thinness
cervically, means that it is readily removed by abrasion when gingival
recession exposes the root surface to the oral environment

COMPOSITION OF CEMENTUM
Organic 50%

Inorganic 50%

90% organic Type I Collagen


Type III high concentration during

regeneration

Mainly apatite crystals


Mainly calcium and development and
phosphorous

Type XII bind Type I with non collagenous

matrix protiens
Trace amounts of Type V,VI, XIV

Trace element-highest fluoride


content among all the mineralized
tissues

COLLAGEN

Functions:
Interacts with the non collagenous proteins and provide a scaffold
for the accommodation of mineral crystals.

Promotes cell attachment

Maintains the integrity of both soft and hard connective tissues,


during development as well as in repair.

NON COLLAGENOUS PROTEINS

Bone sialoprotein and osteopontin

Osteonectin ( SPARC)

Fibronectin (FN) and tenascin

Osteocalcin

BMPs

Cementum- derived attachment protein (CAP)

Cementum-derived growth factor

ROLE OF NON COLLAGENOUS PROTEINS

Matrix deposition

Initiation and regulation of mineralization.

Matrix remodeling.

DEVELOPMENT OF CEMENTUM
divided into

pre-functional

functional

Occurs during root development.

Commences when the tooth reaches the


occlusal plane.

During this time, primary


distribution of main cementum
varieties is determined.

Adaptive and reparitive processes are


carried out.

TOOTH DEVELOPMENT

HERTWIGS EPITHELIAL ROOT SHEATH

Cementogenesis

CEMENTOCYTE

The spaces that the cementocytes, occupy in cellular cementum are


called lacunae, and the channels that their processes extend along are
the canaliculi

They communicate with each other through a network of cytoplasmic


processes (arrows) running in canaliculi in the cementum.
The cementocytes also communicate with the cementoblasts on the
surface through cytoplasmic processes.
The presence of cementocytes allows transportation of nutrients
through the cementum, and contributes to the maintenance of the
vitality of this mineralized tissue.

CEMENTOID

CEMENTOID TISSUE

THEORIES
Classical theory

Von Brunns Theory (1891)

Phenotypic Transformation

Stahl and Slavkin Theory (1972)

Cementoblasts that derive from follicular cells express osteopontin,


osteocalcin. Those derive from HERS express osteopontin only.

SEQUENCES OF CEMENTOGENESIS
1.
2.

Proliferation of hertwig's epithelial root sheath cells;


Differentiation of odontoblasts from ectomesenchymal cells (cranial
neural crestderived) of the dental papilla mesenchyme;

3.

Deposition of dentine matrix (e.G. Type I collagen and dentine


phosphoproteins) and mineralization;

4.

Degeneration of epithelial sheath cells;

5.

The formation of cell-matrix interactions between mineralized dentine and


mesenchymal cells of the dental sac resulting in the differentiation of
cementoblasts; and

6.

The initial deposition of cementum matrix by mesenchyme-derived


cementoblasts and subsequent mineralization

FACTORS REGULATING CEMENTOGENESIS

GROWTH FACTORS

-TRANSFORMING GROWTH FACTOR


PDGF, IDGF,

FIBROBLAST GROWTH FACTOR


ADHESION MOLECULES BONE SIALOPOTIEN
OSTEOPONTIN
ENAMEL/EPITHELIAL PROTIENS
COLLAGEN
GLA PROTIENS
TRANSCRIPTION FACTORS RUNx-2 (Run related transcription)
OSTERIX
SIGNALLING MOLECULES OSTEOPROTEGRIN,RANKL

CLASSIFICATION
Classification based on the nature and origin of the
organic matrix
Classification based on the presence or absence of cells
Classification based on the presence or absence of cells
and on the nature and origin of the organic matrix

EXTRINSIC FIBRES & INTRINSIC FIBRES .

CELLULAR AND ACELLULAR CEMENTUM


Acellular cementum covers the root adjacent to
the dentine, also called primary cementum
Cellular cementum is found mainly in the apical area
and overlying the acellular cementum, also called
secondary cementum

cellular cementum develops, the formative cells


(the cementoblasts) become embedded in the
tissue as cementocytes.

Schroeders (1992) classification


Acellular Afibrillar Cementum (AAC)
Acellular Extrinsic Fiber Cementum (AEFC)
Cellular Intrinsic Fiber Cementum (CIFC)
Acellular intrinsic Fiber Cementum (AIFC)
Cellular Mixed Stratified Cementum (CMSC)

ACELLULAR AFIBRILLAR CEMENTUM


Believed

to be A developmental

anomaly
When cementocytes meet the smooth

surface of enamel it produces AAC.


Thickness : 1-15 m
Location : coronal cementum
Consists

of

mineralized

ground

substance produced by cementoblasts

ACELLULAR EXTRINSIC FIBER CEMENTUM


(AEFC)
Aligning of the cementoblast on the

newly formed dentin.


Secretion of collagen in unipolar
manner
Inter digitation of the collagen with
dentinal collagen, which was not yet
mineralised
Continuation
of
deposition

lengthening and thickening


of
collagen
Secretion of non collagenous proteins
fills the space between collagen
fibers and regulate mineralization.

Activity continues until about 15-20 of cementum is formed


Thereafter secretion of non collagenous proteins only.
No cementoid exists on the surface of acellular extrinsic fiber

cementum
Growth rate of AEFC is 0.005-0.01 / day
Overall mineralization is about 45 60%.

Location : cervical 3 rd of root

It is a product of fibroblasts and cementoblasts

CELLULAR INTRINSIC FIBER CEMENTUM


(CIFC)
It is formed only after at least half

the root is formed (not in incisors


and canines)
It is formed more rapidly (about 30
times than acellular cementum)
Similar to acellular cementum this
cementum forming cementoblast
extend
cell
processes
to
unmineralized
predentin
and
deposit collagen fibrils
Intermingling of collagen fibrils.
Secretion of non collagenous
proteins.

In contrast to acellular cementum cementoid is seen


Cells secrete in relatively rapid multipolar mode
As cementum formation progresses cementoblasts become entrapped
Collagen fibrils are haphazard during rapid formation but later they

get oriented parallel to the root surface.


It is a product of cementoblasts

CELLULAR MIXED STRATIFIED CEMENTUM

Thickness 100-1000 m

Location apical 3 rd and in furcation areas

It is aproduct of fibroblasts and cementoblasts

ANATOMY

Thickness 20-50 at cervical region


150-200 apical region

INCREMENTAL LINES
The appearance of incremental lines in cementum
is mainly due to differences in the degree of
mineralisation
Cementum is deposited in an irregular rhythm,
resulting in unevenly spaced incremental lines
In acellular cementum, incremental lines tend to
be close together, thin and even.
In cellular cementum, the lines are further apart,
thicker, and more irregular.

CEMENTO-DENTINAL JUNCTION

INTERMEDIATE CEMENTUM
Consists of cellular remnants of HERS embedded in a calcified ground
substance

Cementum
Intermediate cementum
Root dentin

CEMENTO-ENAMEL JUNCTION

ROLE OF CEMENTUM IN PERIODONTAL HEALTH

Supporting tooth

Width of PDL space

Repair

Maintaining occlusal relationship

Role in orthodontic treatment

AGE CHANGES

CONTINUOUS DEPOSITION

Cementum formation on the roots of human teeth continues


throughout life
More cementum is formed apically

PERMEABILITY

Diminishes with age

DEVELOPMENTAL AND ACQUIRED ANOMALIES


ASSOCIATED WITH CEMENTOGENESIS
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.

Enamel Pearls:

This anomaly consists of globules of enamel on the root surface in


the cervical region.

They resemble small pearls up to 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 radigraphicall y, 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
Cause : Extra stress on sharpeys fibers causes a tear in cementum
Micro Trauma
Common in the apical and middle third of the root and in root furcation
areas.

HYPERCEMENTOSIS:
Local factors

Abnormal occlusal trauma,

Unopposed teeth (e.g. impacted, embedded, without antagonist)

Adjacent inflammation

Systemic factors

Acromegaly and pituitary gigantism


Arthritis
Pagets disease (Generalized hypercementosis)
Rheumatic fever
Thyroid goiter
Vitamin A deficiency

ANKYLOSIS

Ankylosis may occur at any age clinically they are most common

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

RESORPTION AND REPAIR

Cementum formation --- continuous process

More cementum is deposited apically than cervically. Thicker layers


may form in the root surface grooves & in furcations.

In the cementum of impacted teeth, sharpeys fibres may be nearly


completely absent & may be built up mainly of intrinsic fibres
arranged parallel to the root surface.

In the posterior teeth, cementum deposition is thicker on the distal


side than on the mesial, indicating a relationship to mesial drift

RESORPTION
Local factors

Trauma from occlusion

Orthodontic movement

Pressure from malaligned teeth, cysts and tumors

Teeth without functional antagonist

Embedded teeth

Replanted and transplanted teeth

Periapical disease

Periodontal disease

Systemic conditions

Calcium deficiency

Hypothyroidism

Hereditary fibrous osteodystrophy

Pagets disease.

Microscopic appearance:
Baylike concavities in the root surface.
Multinucleated giant cells and large mononuclear macrophages are
present adjacent to cementum undergoing active resorption.
Cementoclasts: They resemble osteoclasts and are occasionally found in
normal functioning periodontal ligament.
They are responsible for extensive root resorption that leads to primary
teeth exfoliation and localized cemental resorptions seen in adult dentin.

REPAIR

After resorption has ceased, the damage is usually repaired

Anatomic repair

Functional repair.

HOW CEMENTUM IS RESISTANT TO RESORPTION?

Avascular

Fluoride

Densely packed collagen

Parathormone

CEMENTUM REGENERATION

Most common outcome is the formation of new tissue that resembles


cementum or bone

Does not interdigitate with the root surface

Periodontal regeneration

Systemic and local factors

The role of local factors is especially relevant in cementum

The recruited cells will be induced to differentiate into cementoblasts

SYSTEMIC DISEASES CAUSING DEFECTIVE


CEMENTUM FORMATION

PAPILLON-LEFVRE SYNDROME

Rare inherited condition

Characterized by hyperkeratotic skin lesions

Microscopic changes reported include marked chronic inflammation


of the lateral wall of the pocket

Extremely thin cementum.

HYPOPHOSPHATASIA

Rare familial skeletal disease

Reduced Serum alkaline phosphatase

Gingival inflammation

Reduced cementum formation.

CLEIDOCRANIAL DYSPLASIA

Developmental anomaly - affecting the skeleton and teeth (affects


the skull, clavicle and dentition).

A paucity or complete absence of cementum due to defective


formation of cellular cementum on both erupted and un erupted teeth

Prolonged retention of deciduous teeth, subsequent delayed eruption


of succedaneous teeth as well as numerous un erupted supernumerary
teeth.

HYPOPITUTARISM

Reduced pituitary hormones ----- the growth hormone

Dwarfism but have a relatively well proportioned body.

Decreased cementum formation is associated with hypopituitarism.

ALTERATIONS RESULTING FROM PERIODONTAL


PATHOLOGY

ROOT SURFACE CHANGES IN POCKET

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 Sharpeys fibers in
cementum undergo degeneration creating a environment favorable
for penetration of bacteria.

Viable bacteria have been found in the roots of 87% of periodontally


diseased non carious teeth.

Bacterial penetration into the cementum can be found as deep as the


CDJ and may also enter the dentinal tubules.

Bacterial products such as endotoxins have been detected in the


cementum wall of the periodontal pocket.

These changes manifested clinically as softening of cementum


surface which is usually asymptomatic but painful when probe
penetrates the area.

EXPOSURE TO THE ORAL ENVIRONMENT


Hypermineralization

Areas of increased mineralization at cemental saliva interface.

The mineral content of exposed cementum increases. Microhardness


remains unchanged. This hypermineralized surface increases the
tooth resistance to decay.

CLINICAL CONSIDERATIONS

ORTHODONTIC MOVEMENT

Orthodontic movements when in proper magnitude do not affect the


cementum because cementum, with its slow metabolism is not
damaged by a pressure equal to that exerted on bone.

when the forces exceed, cemental resorption occurs on the pressure


side while deposition takes place on the tension side.

ROOT PLANING
Root Planing arrests disease progression, remove infection
According to Jan Lindhe & H. Rylander, Root Planing removes the
softened cementum, resulting in a hard & smooth root surface.
Ruben, et al., (1975) suggested that the therapeutically debrided &
planed root surface initially undergoes superficial demineralization &
resorption of the cemental matrix that involves embedded collagens &
reticular fibers.
This is because of the acidic & enzymatic activity of post surgical
inflammation, occurring 48 hrs after surgery.

ROOT BIOMODIFIERS

Root planing / Root conditioning -- antecedent to mesenchymal


cell migration & attachment onto the exposed root surface.

Root conditioning can be done by using:

Acids (citric acid, HCL, Lactic acid & EDTA)

Fibronectin

Enamel matrix proteins.

CONCLUSION

Cementum is probably the least understood of all dental tissues. But


this does not lessen its 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.

REFERENCES

Text book of Clinical Periodontology; 10 th edition. Carranza


Cementum &Periodontal Wound Healing and
Regeneration
Wojciech.J.Grzesik, A .S.narayanan

Critical reviews of oral biology and medicine 2002;13(6) 474-84.


Oral Cells and Tissues P. R. Garant
Biology of the Periodontal Connective Tissues,Bartold, Mark and
Narayanan, A. Sampath.

Orban's Oral Histology and Embryology


Ten Cate's Oral Histology Development, Structure, and Function
Cementum : A Dynamic structure,Periodontology 2000, Vol. 41,
2006, 196217

THANK YOU

DIFFERENCE B/W BONE AND CEMENTUM


NOT

Innervated,

Exhibit Little Or No Remodeling

Avascular

2 Unique Cementum Molecules: Cementum


Attachment Protein (Cap) And Igf

PHYSIOLOGICAL ACTIVITY OF
CEMENTOCYTES
Deposition of cellular intrinsic fiber cementum is
characterized by the entrapment of cementoblasts
cementum on human teeth is, however, much
lower than in bone tissue.
Cementocytes close to the cementum surface may
resemble cementoblasts
In deeper layers of cellular intrinsic fiber
cementum lacunae may appear empty.

PHYSIOLOGICAL TOOTH MOVEMENT


AND OCCLUSAL FORCES
occlusal forces are not necessary to stimulate
cementum deposition.
mesial drift
Tensional forces
orthodontic tooth movement
Appositional layers of bone lining
Dynamically responsive

DO ENAMEL ASSOCIATED PROTIENS


REGENERATE CEMENTUM ?
mimic the way these materials behave in normal
tooth development
Schonfield and Slavkin in 1977
enamel like material was formed in the root
surface prior to cementum formation
cellular cementum contains proteins

coronal cementogenesis
Hammarstrom in a buccal dehiscence monkey
model in 1977
human experimental defect by Heijl in 1997
cellular cementum in experimentally prepared
root surfaces

CAN GUIDED TISSUE REGENERATION


AND BONE GRAFTING REGENERATE
CEMENTUM??

Millipore membranes
First guided tissue regeneration membranes
Grafting material
Question ??
Cellular cementum that is usually poorly attached
to the dentin surface

Periodontal healing with guided tissue


regeneration
therapy occurs in two stages.
first stage
Second phase
Conclusion

CELLULAR TISSUE ENGINEERING FOR


CEMENTUM REGENERATION

recolonization of periodontal ligament cells


Therapeutic approach removal of cells from PDL
pilot study
bone marrow mesenchymal stem cells
Hertwigs epithelial root sheath
Cementoblasts

PERI-IMPLANT CEMENTAL SURFACE


The absence of cementum in the implant surface
Buser and associates
Further research is now going on an attempt to
obtain a layer of cementum around the implant
and thus improve its longevity.

EFFECT OF NUTRITION ON DEFECTIVE


CEMENTUM FORMATION

VITAMIN D DEFICIENCY

Calciferol

Deficiency

Periodontal tissues

PROTEIN DEFICIENCY
Hypoproteinemia

CERVICAL ROOT RESORPTION.

Large root resorption defects

Hyperplastic gingivitis

MIGRATION

Fibronectin

Laminin

ATTACHMENT
1.
2.

Integrins
Fibronectin

3.
4.

Bone sialo protein and Osteopontin


Laminin

PROLIFERATION

TGF-

IGF and GH

DIFFERENTIATION

Bone morphogenetic protein-3

Insulin-like growth factor and proteoglycans

Transcription factor, core binding transcription factor 1/osteoblastspecific transcription factor 2/RunX2/ Cbfa1