CEMENTUM

CONTENTS
• Introduction
• Definition
• Formation of cementum- cementogenesis
• Properties – mechanical and chemical
• Classification
• Cementoenamel junction
• Cementodentinal junction
• Thickness of cementum
• Functions
• Metabolism (turnover) at the tissue and molecular levels
• Age changes
• Resorption and repair

• Cementum in disease
– Developmental anomalies
– Regressive alterations of teeth
– Alterations resulting from periodontal pathology
– Neoplasms of the cementum
– Systemic diseases and its influence on cementum
• Cementum Regeneration
• Application in forensic odontology
• Conclusion
• References

INTRODUCTION
• Periodontium consists of :
– Investing layer
– Supporting tissues of the tooth

 Cementum is considered as a part of the periodontium
because, with the bone, it serves as the support for the
fibres of the periodontal ligament.

 It is the hard bone like tissue covering the anatomic roots
of the teeth (Newman et al, 2006) .

 Cementum is derived from the Latin word Caementum,
“quarried stone”, i.e. chips of stone used in making mortar
(Nanci A, 2003).

 Cementum was not known until 1835, when 2 pupils of
Purkinje demonstrated microscopically the presence of
cementum.

 Black in 1886 published a monograph on the periosteum
and periodontal membrane in which he has reported his
findings on cementum of teeth of animal and human
beings.

 In 1920, Gottlieb published a paper on cementum after
which the cementum was looked upon something more
than merely calcified outer covering of the root.

DEFINITIONS

 Cementum is the calcified, avascular mesenchymal tissue
that forms the outer covering of the anatomic root
(Newman et al, 2006).

 Cementum is the thin, calcified tissue of ectomesenchymal
origin covering the roots of the teeth (glossary, 1986).

chemical and structural characteristics with bone. supply. cementum has No direct vascular No innervation.• It is a specialized connective tissue that shares some physical. remodeling . but unlike bone. No lymphatic Only minor drainage.

CEMENTOGENESIS .

• The formation of cementum can be subdivided into a Prefunctional Functional .

75 to 7. . which ranges between 3.75 years for permanent teeth. Pre-functional developmental stage  This includes the formation of cementum during root development.

Functional developmental stage  This includes the formation of cementum when tooth is about to reach its occlusal plane or is at occlusal level. .  It is associated with attachment of root to the surrounding bone and its formation continues throughout life.

. ROOT FORMATION • Root formation commences when the enamel organ has reached its final size.apical growth of this double cell layer. proliferate from the cervical loop to form HERS. • Inner and outer cell layers of the enamel epithelium - delineate the enamel organ. • Continuous cell mitotic activity at the apical termination of HERS – corono.

• Its most apical portion. separates the dental papilla from the dental follicle. • Cells originating from the peripheral dental papilla differentiate into odontoblasts. . • The inner and outer cell layer of HERS is surrounded by a basement membrane. diaphragm.

. Hertwig’s root sheath becomes discontinuous.• Once the first matrix of radicular mantle dentin is formed by the maturing odontoblasts and before the mineralization of the dentin matrix reaches the inner epithelial cells.

.Epithelial cell remnants of Hertwig’s root sheath persist in the still developing and later in time in the aging periodontal ligament at an approximate distance of 30- 60μm remote from the root surface. where they are referred to as the epithelial rests of Malassez.

CEMENTOBLAST ORIGIN Differentiation of Formation of the cementoblasts from dentinocemental cementoprogenitor junction cells Dentin formation .

300 μm coronally from the advancing root edge and shifts in the apical direction while the root elongates. • Transplantation and 3H-thymidine studies…… • Thomas & Kollar……….narrow band encircling the forming root at its most apical portion. • Extends only 200.• The initiation of cementogenesis .. • Recent ultrastructural and immunohistochemical studies .

• A chemical substance produced in rat molar - chemoattractant for the cells of the dental follicle proper.cell migration towards the root surface and cementoblast differentiation are not known. Differentiation of cementoblasts • The nature and origin of the molecules that trigger . .

• Timed modulations in basement membrane composition could possibly act as inductive signals for cementoblast differentiation. indicate indeed that a mineralized tissue adhering to the developing dentinal root surface depends on the presence of basement membrane components. • Recombination experiments using murine molars…. ..but not proven scientifically.• “Interactions between the dental follicle proper and Hertwig's root sheath – differentiation of cementoblasts”……….

. • Although repeatedly suggested. it is still not clear whether and how the enamel related proteins secreted by HERS influence the initiation of cementogenesis.• Extracellular matrix proteins .noncollagenous proteins like bone sialoprotein and osteopontin.

Collagen fibrils of cementum come close to fibrils of dentin .leads to intimate interdigitation between two fibril populations. Development of dentinocemental junction Precementoblasts differentiate along the external surface of the predentin into cementoblasts - implant the initial collagen fibrils of the cementum matrix. Cementoblasts extend numerous tiny cytoplasmic processes into loosely arranged and not yet mineralized dentinal matrix. .

particularly between acellular extrinsic fiber cementum and dentin in rodents. An intermediate layer has frequently been observed.The mineralization of outer layer of dentin . .only after dentinal matrix is completely covered with collagen fibrils of cementum.

Development of primary cementum The root sheath fragments Here. . the follicular cells to allow follicular cells to differentiate into reach the newly formed cementoblasts root surface.

They insert cytoplasmic processes into the The cementoblasts then unmineralised hyaline migrate away from the layer and begin to deposit hyaline layer but continue collagen fibrils within it at to deposit collagen right angles to the root .

These cells also This first First-formed secrete non formed cementum . . surface.a collagenous cementum is mineralized proteins such as acellular. as the layer with a bone cells that form it fibrous fringe sialoprotein and remain on its extruding from osteocalcin. it.

it is thought that the cementoblast that is formed drifts away from the cementum surface.• Once this fibrous cementum and its fibrous fringe are established. . • This condition continues until the forming periodontal ligament fiber bundles become stitched to the fibrous fringe.

Secondary Cementum formation Once the tooth is in occlusion. Cementoblasts This organic more rapidly initially lay matrix then formed and down an becomes less organic matrix mineralized as mineralized consisting of a result of the form of non cementoblasts cementum is collagenous budding off deposited proteins and matrix around the collagenous vesicles. . apical third of fibrils the root.

Secondary Once in this cellular At the same situation. premolar and molar teeth. the secretory confined to the cementoblasts activity apical third of become declines. and the tooth and trapped in the the cells interradicular matrix. becomes regions of cementocytes. their cementum is time. .

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but varying greatly with tooth type. and type of cementum being formed . secondly.Zander & Hürzeler . root surface area. within the collagen fibrils. first between and. MINERALIZATION • Mineralization begins in the depth of precementum. • Linear rate of cementum deposition on single-rooted teeth is about 3 μm per year. . • Fine hydroxyapatite crystals are deposited.

• The mineral crystals reach mature size within 1 to 4 μm from the calcification front. .• The width of the precementum layer in the human is about 3-5 μm.

which exhibit a more complete degree of mineralization. • In addition. • Contrast to the intrinsic fibers and to the Sharpey's fibers in acellular extrinsic fiber cementum. • Studies . .Cellular mixed stratified cementum generally has a lower mineral content than acellular extrinsic fiber cementum.• The distribution of mineral within the mature tissue shows a great deal of variability. the Sharpey's fibers of cellular mixed stratified cementum generally retain an unmineralized core.

the mineral content of this tissue.• Although additional cementum is laid down throughout life. once formed. which increases in mineral content and root transparency with age by obliteration of the dentinal tubules. . does not seem to change significantly with age. • This is unlike root dentin.

Molecular and cell biology of cementum • There is accumulating histological evidence that cementum formation is critical for appropriate maturation of the periodontium. . both during development as well as that associated with regeneration of periodontal tissues.

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Molecular factors associated with cementum .

Ligand-receptor binding results in activation of effector molecules that act as intracellular relay systems to trigger gene expression .

.• Future studies directed at determining the specific adhesion molecules and signalling pathways regulating cementoblast maturation will thus aid in enhancing understanding of root development and thus in the design of appropriate therapies for activating cementoblasts during regenerative therapies.

 Softer and more permeable than dentin. PHYSICAL PROPERTIES  Pale yellow with dull surface. JDR 1941). . Traumatic injury leads to fracture.  Relatively brittle.R. permeability decreases with age.  Permeable to dyes and radioactive substances.Wasserman. Blayney. F. (J.

 It is also less readily resorbed a feature that is important for permitting orthodontic tooth movement. .  Relative softness combined with thinness cervically means it is readily removed by abrasion when gingival recession exposes root surface to oral environment. Distinguished from enamel due to its darker hue and luster.

The properties of precementum.• The reason for this feature is unknown but it may be related to: Differences in physicochemical or biological properties between bone and cementum. The increased density of Sharpey’s fibers (particularly in acellular cementum) The proximity of epithelial cell rests to the root surface. .

CHEMICAL PROPERTIES On a wet weight basis: By volume: • Inorganic – 65% • Inorganic – 45% • Organic – 23% • Organic -33% • Water – 12% • Water -22% .

55nm wide and 8nm thick.hydroxyapatite (Ca10(PO4)6(OH)2) with small amounts of amorphous calcium phosphates present. Inorganic component  Principle inorganic component. .  Avg.  These crystals are thin and plate like and similar to those in bone and arranged parallel to the long axis of collagen fibril.

 Concentration of fluoride tends to be higher at the external surface – increases with age and varies with the nutritional fluoride supply to the individual. .  Trace elements – Cu. Zn and Na.

like in bone and PDL  90% of organic matrix – type I collagen and approximately 5% . Organic component  Collagen  Primarily collagen type I and III.type III  Wang et al suggested that type I fibrils are coated by type III collagen whereas some other authors suggest that both the collagens are co – localized in the same fibril. .

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Non Collagenous proteins  Cementum is rich in glycoconjugates. (Bone sialoprotein and ostepontin).  Both are phosphorylated and sulfated glycoprotein.  Reveal cell attachment properties. which represent glycolipids. .  Bind tightly to collagenous matrices and hydroxyapatite.  They participate in mineralization process.  They are similar to that present in bone. and harbors a variety of other proteins. glycoproteins or proteoglycans.

• Osteonectin is another glycosylated protein found in the extracellular matrix of mineralized tissues. .and cellular intrinsic fiber cementum-producing cementoblasts and cementocytes. • An immunohistochemical study of human cementum showed that osteonectin is expressed by acellular extrinsic fiber cementum.

• The proteoglycans of cementum are small proteins like chondroitin sulfate. dermatan sulfate and hyaluronic acid.• The two glycoproteins fibronectin and tenascin are more widely distributed high-molecular weight and multifunctional proteins of the extracellular matrix. .

a very small protein found in abundance in the extracellular matrices of bone. • The enzyme activity adjacent to cellular intrinsic fiber cementum is higher than that to acellular extrinsic fiber cementum.• Osteocalcin. appears to be involved in the mineralization process. • The enzyme alkaline phosphatase is believed to participate in cementum mineralization. and the thickness of the latter correlates positively with the enzyme activity. . dentin and cementum.

CLASSIFICATION OF CEMENTUM

Based on the location Based on cellularity

Acellular cementum
Coronal cementum
(primary)
Cellular cementum
Radicular cementum
(secondary)

 Based on presence or absence of collagen fibrils in
organic matrix

 Fibrillar cementum

 Afibrillar cementum

 Classification system devised by Owens in 1970 and
summarized recently by Schroders and Page

 Acellular Afibrillar Cementum. (AAC )

 Acellular Extrinsic Fiber Cementum. (AEFC)

 Cellular Mixed Stratified Cementum. (CMSC)

 Cellular Intrinsic Fiber Cementum. (CIFC)

 Intermediate cementum.

Acellular cementum

increase with function. covers approx cervical 3rd or half the root. {M.M. • 30 – 230 microns thick composed mostly of sharpey’s fibres. • Most of them inserted at right angles to the root surface. no.Inoue.• First to be formed. whose size. JDR 1962} . • Forms before the tooth reaches occlusal surface.Akiyoshi.

• Sharpey’s fibres are completely calcified with mineral crystals oriented parallel to fibrils in dentin except in a 10- 50 micron wide zone near CDJ where they are only partially calcified. • Peripheral portions of Sharpey’s fibres in actively mineralizing cementum are more calcified than interior regions. A.{S.a layer of precementum .J.Jones.Boyde 1972 } • Lining the surface .

Cellular cementum .

• In ground sections the cellular contents are lost. • It is less calcified than acellular type.Ishikawa. air and debris filling the voids to give the dark appearance.• Adjacent canaliculi are often connected.{J.Yamamoto JDR 1964 } . M. and the processes within them exhibit gap junctions.

scand. {Knut A. • They may be completely/partially calcified or have a central uncalcified zone surrounded by a calcified border.• Sharpey’s fibres occupy a smaller portion of cellular cementum & are separated by other fibres that are arranged either parallel to root surface or at random. odontol. • Deposition of cellular cementum is more rapid than acellular cementum. Selvig Acta. 1965} .

1964} • At ultrastructural level.• Cementocytes near PDL are younger than those near the dentin.A.Selvig} .limits cemental resorption. {J. • The layer of precementum . cellular cementum contains more irregularly arranged collagen fibrils than acellular cementum.{K.B.Stern .

• These lines represent “rest periods” in cementum formation and are more mineralized than the adjacent cementum. .• Both acellular and cellular cementum are arranged in lamellae separated by incremental lines of Salter parallel to the long axis of the root.

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1-15 microns thick. . • The acellular afibrillar cementum consists of a mineralized matrix. Acellular afibrillar cementum • No cells / fibres • Only mineralized ground substance • Product of cementoblasts • Found in coronal cementum .

the structure of acellular afibrillar cementum is less homogeneous. the acellular afibrillar cementum stands out by its basophilia and its more or less uniform appearance. .• Under the light microscope. • Deposited as isolated patches over minor areas of enamel and dentin. • In the electron microscope . • The areas and location of acellular afibrillar cementum vary from tooth to tooth and along the cementoenamel junction of the same tooth.

.• The cells responsible for the formation of acellular afibrillar cementum have still not been determined with precision. • Its formation commences at the end of enamel maturation and continues for an unknown period of time.

• Found in cervical 3rd of the roots but can extend farther apically. • Product of cementoblasts & fibroblasts.Acellular extrinsic fibre cementum • No cells. • 30-230 microns thick { H. • Densely packed extrinsic Sharpey’s fibers.E. 1986 } .Schroeder.

• This type of cementum corresponds with primary acellular cementum – covers cervical 2/3rds of the root. • The extrinsic fibres seen in ground sections may have unmineralized cores. . • It is therefore formed slowly and the root surface is smooth. • The fibres are generally well mineralized.

• Densely packed extrinsic sharpey’s fibres & intrinsic fibres. • Product of cementoblasts & fibroblasts. Cellular mixed stratified cementum (CMSC) • Contains cells. . • 100-1000 microns thick. • Found in apical 3rd of the roots and apices and in furcation areas.

• This type of cementum is composed only of intrinsic fibres running parallel to the root surface. this variety fills resorption lacunae. • In humans. . Cellular intrinsic fibre cementum • Contains cells • No extrinsic fibres • Product of cementoblasts.

sometimes intrinsic fibre cementum is formed more slowly and cells are not incorporated .• Although intrinsic fibre cementum is generally cellular due to the rapid speed of formation. .(acellular intrinsic fibre cementum).

.El Mostehy. cellular debris.Stallard. {M.E.R. R. Intermediate cementum • It is an ill defined zone near cementodentinal junction of certain teeth. JPR 1968}. appears to contain cells. remnants of HERS embedded in calcified ground substance. It was described by Hopewell Smith in 1903 as intermediate cementum since its structure and function were not well understood.

Slavkin in 1976 studied the nature of this layer & concluded that it contained enamel like proteins secreted by cells of root sheath to the root surface. . Owens in 1972 suggested that this layer was a form of dentin.Based on tetracycline staining studies.

. • This observation has gained much significance because the reparative cementum that forms after root planing does not seem to get attached to the root surface as in case of primary cementum.• It has now been concluded that the hyaline layer contains epithelial derived enamel like proteins & has an important role in the attachment of cementum to the dentin surface.

• The tertiary cementum is deposited more thickly at the subgingival region.rapid consecutive deposition of a tertiary cementum overlying the secondary cementum at the subgingival region. Tertiary cementum • Studies have shown . just as the tooth emerged from the alveolus. resulting in asymmetrical. lenticular incremental growth lines. .

• Rapid formation of the tertiary cementum at the subgingival region would greatly contribute to the maintenance of proper tooth structure and prevent propagation of enamel cracks on the occlusal surface.• In the subgingival region. as well as provide a site for the epithelial attachment. the tertiary cementum showed a dramatic increase in thickness compared with the secondary cementum covering the middle (alveolar) portion of the embedded tooth. .

Cementum repairs root fracture. Cementum causes sealing of necrotic pulp (apical occlusion). . It serves to maintain the width of periodontal ligament space at the apex. cementum It assists in maintaining occlusal relation by maintaining a balance between attrition and eruption.Functions It provides anchorage of tooth to alveolus of (sharpeys fibers). It protects the sub adjacent dentinal tubules.

CEMENTOENAMEL JUNCTION  The cementum at and immediately subjacent to the cementoenamel junction (CEJ) is of particular clinical importance in root-scaling procedures.  Three types of relationships involving the cementum may exist at the CEJ. .

. CEMENTODENTINAL JUNCTION  Terminal apical area of cementum where it joins the internal root canal dentin.

 No increase or decrease of width of the CDJ with age – remains relatively stable.  Here the fibrils intermingle between cementum and dentin. . Obturating material in RCT should be at the CDJ.  CDJ – 2-3 µm wide.

cellular and acellular cementum is very permeable and permits the diffusion of dyes from pulp and external root surface. . • The permeability of cementum diminishes with age. the canaliculi in some areas are contiguous with dentinal tubules. • In cellular cementum. PERMEABILITY OF CEMENTUM • In very young animals.

1. JDR 1958}. • It is essential for. CEMENTUM DEPOSITION AND THICKNESS • Continuous deposition of cementum that proceeds at various rates throughout life {M.A.Compensatory eruption of teeth.Zander . it permits rearrangement of PDL fibres during tooth movement . Normal mesial drift. 2.

the lines are further apart. • In the more rapidly formed cellular cementum. . resulting in unevenly spaced incremental lines (of Salter). thin and even. incremental lines tend to be close together. • In acellular cementum. and more irregular.• Deposited in an irregular rhythm. thicker.

• Cementum thickness was 67% thicker on distal with a range of 30 to 107%.16 to 60 micron. .apical 3rd (150- 200 microns).• Thickness of cementum in the coronal half of root . • Greatest thickness .

• Cementum thickness becomes greater with age in both mesial and distal surfaces. JCP 1990 } • Between ages 11-70.Polson . with greatest increase in the apical region. A. . • More thick on distal surface probably because of functional stimulation from mesial drift {R Dastmalchi. average thickness increases 3 fold.

• Cementum thickness shows characteristic variations among tooth groups and tooth surfaces. • Deposited at a linear rate. . • Tendency for cementum to reduce root surface concavities. AGE CHANGES CONTINUOUS DEPOSITION • Continues throughout life unless disturbed by periapical or periodontal pathology.

• Great variations in width of incremental layers . • The biological responsiveness of cementoblasts to these stimuli .the rate as well as pattern of cementum deposition.that the rate of cementum formation may vary from time to time. impacted teeth – thicker cementum . • Nonfunctioning.

PHYSIOLOGICAL ACTIVITY OF CEMENTOCYTES • Deposition of cellular intrinsic fiber cementum .by the entrapment of cementoblasts as they become surrounded by the matrix which they have formed. • Number of cells that become incorporated is proportional to the rate of cementum deposition. .

R in surface cementocytes which resemble cementoblasts. System of Density of cells in interconnecting CIFC is much lower canaliculi is more than in the bone sparse. Reduced amount of mitochondria and E.• The exchange of metabolites through cellular intrinsic fiber cementum is limited. .

more advanced nuclear and cytoplasmic changes may occur. . Erasquin & Muruzibal . Early studies of root permeability .indicated that the dentinocemental junction represents a barrier against permeation of substances experimentally applied to the root surface.• In deeper layers of CIFC .necrosis of cells in the deep layers of cementum after root canal treatment in the molar teeth of rats. or the lacunae may appear empty.

(Dustmulchi 1990) • It is suggested that cementum responds dynamically to tensional forces resulting in its growth.CEMENTUM REACTION TO PHYSIOLOGICAL TOOTH MOVEMENT AND OCCLUSAL FORCE • The deposition of cementum on impacted tooth indicates that occlusal force is not necessary for cementum deposition. • In human posterior teeth cementum is thicker on distal than on mesial root surface indicating a relation to mesial drift. .

METABOLISM (TURNOVER) AT THE TISSUE AND MOLECULAR LEVELS Bone Cementum .

. According to Bosshardt and Selvig Cementum is excluded from metabolic processes of the body.

2.During root resorption and surgical instrumentation. 1. attachment and differentiation. Cementum-derived growth factor .• A variety of noncollagenous proteins are stored in the mineralized matrix of cementum. Cementum derived attachment protein . . division.that mediates the attachment of connective tissue cells. proteins exposed to the root surface and/or released from cementum and dentin could possibly influence the initiation of the repair process by cell migration.

• Fluoride accumulates in the surface layer of cementum • Exposed to the circulating tissue fluids in the periodontal ligament • F ion reacts aggressively with hydroxyapatite • Fluoride concentrates near the surface and shows limited diffusion into deeper layers of the tissue .

• Root caries as well seems to progress in a similar pattern.• The relatively high fluoride content of the surface layer compared with deeper layers of cementum and root dentin may help explain why any root resorption tends to be of an undermining character. .

• Some factors . RESORPTION AND REPAIR • Physiological root resorption .trauma (mechanical. chemical or thermal) or sustained overcompression of the periodontal ligament .infectious and systemic diseases as well as tumors • Non pathological causes:.induce root resorption on teeth of either dentition • Pathological causes:. normal in deciduous dentition.

Pathological or Physiological. . Internal or External.Root resorption may be of following types. Idiopathic. Transient or Progressive.

. • When the resorptive activity of odontoclasts has ceased and the stimulus for new odontoclast recruitment disappears. they become filled by repair cementum. • Root resorption is brought about by cells called odontoclasts.• Root surface is more resistant to resorption than alveolar bone but may occur because of local or systemic factors or without any apparent etiology.

• These cells and their respective repair tissues – resembles AEFC and CIFC on growing human roots. cementogenic cells repopulate the Howships lacunae and attach the initial repair matrix to a thin and decalcified layer of residual and exposed collagen fibrils. . REPAIR • Following detachment of odontoclasts from root surface.

• Eventually. a basophilic and electron-dense reversal line forms at the fibrillar junction. . • Subsequently deposited repair matrix usually resembles cellular intrinsic fiber cementum formed on non- resorbed roots.

tumors • Hypothyroidism Idiopathic • Teeth without functional • Hereditary fibrous antagonists osteodystrophy • Embedded. • Periapical disease • Periodontal disease . replanted. • Calcium deficiency • Cysts. ` Local factors • Trauma from occlusion • Orthodontic movement • Pressure from malaligned erupting Systemic factors teeth. transplanted • Paget’s disease teeth.

.• Cementum resorption appears microscopically as bay like concavities in root surfaces with multinucleated giant cells & mononuclear macrophages.

• Cementum repair requires presence of viable connective tissue & hence can occur in vital as well as non vital teeth.  may alternate with periods of repair and deposition of new cementum. .  demarcated from the root by a deeply staining irregular reversal line which delineates the border of previous resorption. • Resorption is not necessarily continuous.• Resorption is usually painless process.

most roots of permanent teeth still show small.g. • The cause – may be microtrauma. localized areas of resorption. with orthodontic loading). .• Although cementum is less susceptible to resorption than bone under the same pressures (e.

– Formative cell – cementoblasts – Lines resembling .incremental lines – Zone of uncalcified repair tissue . .precementum.• The repair tissue resembles cellular cementum.

• The width of the uncalcified zone of reparative cementum (15 μm) is greater than that for precementum. • Calcific globules are present. • Degree of mineralization is less (as judged by electron density). . suggesting that mineralization is not proceeding evenly. • Crystals are smaller.

. the root outline is not reconstructed and a bay like recess remains. • In these areas sometimes periodontal space is restored to its normal width by formation of bony projection this is referred to as functional repair. • When only a thin layer of cementum is deposited on the surface of deep resorption. Functional v/s Anatomic repair • After resorption has ceased. damage is usually repaired by formation of cellular or acellular cementum or by alternate formation of both this is referred to as anatomic repair.

Periodontology 2000. Internet sources. Periodonotology 2000. . volume 13. 1997. 7. 4. “Development of Coronal Cementum in Hypsodont Horse Cheek Teeth” . Orbans book of histology 6. Bartold – connective tissues 3. Carranza’s Clinical Periodontology – 10th and 11th edition 2. volume 24.THE ANATOMICAL RECORD 297:716–730 (2014). 5. REFERENCES 1. 2000.

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CEMENTUM IN DISEASE .

Contents • Changes in cementum during periodontal pocket formation • Local conditions leading to changes in cementum • Systemic diseases leading to changes in cementum • Developmental anomaly of cementum • Neoplasms of cementum • Cemental aberrations • Cementum regeneration • Summary • Conclusion .

• Cementum plays an important role in maintaining the integrity of tooth against developing periodontal disease. • In the treatment of periodontal disease. management of diseased cementum is vital as any chance of reattachment must be remote if diseased cementum is left behind. .

portion Dissolution of the Cemental Resorption dentinoenamel splitting junction Hypermineraliza Demineralization tion . Diminution in Softer root Removal of • Cementum is not static but rather demonstrates a wide the organic surface collagen range of pathologic changes.

• Aloe et al………….. . • Willoughby and Di Rosa………… • There is strong evidence to indicate that diseased cementum can cause cell and tissue damage.

There are morphological and biochemical changes in the cementum interfering with the repair of normal connective tissue attachment.There is a direct toxic effect by the bacterial products. Indirect effect of bacterial products. . There are biochemical changes in the collagenous structure of cementum initiating an autoimmune response.

.. etc. sometimes resulting in pulpal pathology. • Cementum is sufficiently permeable to be penetrated by organic substances. inorganic ions & bacteria. . root caries. Exposure to oral environment • Cementum becomes exposed to oral environment in gingival recession & as a result of loss of attachment in pocket formation. leading to hypersensitivity to thermal changes / tactile stimulation.

Changes in the Periodontium During Pocket Formation………. cause pain & complicate the periodontal treatment. . • The root surface wall of the periodontal pocket often undergoes various changes that are significant because they may perpetuate the periodontal infections. • A Periodontal pocket is defined as a ‘pathologically deepened gingival sulcus’.

chemical and cytotoxic changes.• The root surface suffers structural. • Structural changes include: – Presence of pathologic granules – Areas of increased mineralization – Areas of demineralization .

Thomas M.Christie JPR 1973} • May represent areas of collagen degeneration / areas where collagen fibrils had not been fully mineralized initially. . • Heaviest in cementum near CDJ.Armitage. Presence of pathologic granules • Presence of pathologic granules was observed with optical & EM {Gary C.

• In some areas they are small and isolated measuring 1µ or less. the granules are brown.• Under transmitted light. • In other areas the granules are arranged in clumps 2-6 µ across. highly refractile and morphologically variable. .

oral.oral. L.Bass. 1963} .• The granules are not seen in calcified ground sections of teeth. • Only in frozen sections of decalcified teeth with root surface exposed to oral environment. surg.1951.Benson . {C. surg.C.A.

• When sections were immersed in absolute alcohol. .oral. differential staining of granules was not successful. • Also.A. 1963} • Seen in 96%of teeth examined.Benson . {L. the granules disappeared within 5 mins. surg.

15µ into the dentin. Furseth 1971 }. Yamada 1968. .• In EM observations. the most consistent morphologic change is a loss or decrease in cross banding of collagen near the cemental surface {Selvig 1966. • In all exposed specimens there are vacuole like formations from 15-25µ under the cemental surface to 5 .

• The vacuoles appear to consist of multiple small lobulated voids filled with a faintly staining homogeneous material. • 4 basic patterns are seen Racemose Long chain Small Very long or grape like isolated fissure like like aggregates vacuoles areas clusters .

• The granules and vacuoles – have a similar distribution – are in the same size range – have the same basic shape – found in the same specimens.• There are 4 reasons why vacuoles observed in exposed cementum at the EM level are believed to be the cemental granules observed by Bass and Benson at light microscopic level. .

where they became masked by mineral crystals and ground substance deposited within and around them.Zone I • Fibrils – 500 to 800 A. • Individual fibres – separated by 200 to 500 A. • Collagen fibrils could be traced from the periodontal membrane into the calcified tissue. .

• The distance between the component fibrils .5 to 1 mm beneath the epithelial attachment and extended to within a small distance from the most apically located epithelial cells.< 500 A in diameter • Bundles of thin fibrils which differed from the typical collagen fibrils – between the collagen fibrils. .1000 A or more • The tissue space between the loose bundles of collagen fibrils . leaving the cementum surface denuded.granular debris • The number of intact fibrils attached to the cementum decreased rapidly toward the cervical direction.Zone II • Encountered 0. • Fibrils .

in others the surface appeared more irregular. • Abundant granular and agranular leukocytes • In some of the specimens the denuded cementum surface had a wavy to smooth outline. .Zone III • Immediately below the epithelial attachment • No collagen fibrils or microfibrils could be traced from the periodontal membrane into the cementum.

.Zone IV • The cemental surface of the extreme apical epithelial cells were closely adapted to the root surface • This space contained some granular material but no recognizable fibrils.

.{Knut A. • The hyper mineralized zones detectable by EM are associated with increased crystal structure & organic changes suggestive of a subsurface cuticle. Selvig JDR 1969} • These zones have varying thickness of 10 – 50 micron. Areas of increased mineralisation • Probably a result of an exchange on exposure to the oral cavity of minerals & organic components at the cementum-saliva interface.

Consistent A loss/ reduction in cross banding of collagen changes near cementum surface found in this zone A subsurface condensation of organic material of exogenous origin .

. this zone may be more or less generally present on the exposed root surface or may be completely absent. • Thus.• The development of a hypermineralized zone apparently depends on the ionic concentration of inorganic elements in the local environment.

• The cementum of periodontally involved teeth.increased fluoride content. • The high fluoride content of the surface layer . . • This may explain why the mineral crystals in this zone are extremely resistant to acid demineralization in vitro. and in particular the hypermineralized surface zone .contributes to the subsurface and undermining character of the demineralization process in cementum caries.

These changes included a decreased electron density due to reduction in number and size of the mineral crystals. Loss of typical collagen structure in the affected zone was observed. The studies showed dissolution of the connective tissue fibres and their attachment to the cementum. 2. The remaining crystals at the surface of the calcified tissue were smaller than those found in deeper regions of the cementum.Ultrastructural changes with the cementum (SELVIG 1973) 1. 3. . 4.

7. The specimens which showed alterations of the cementum below the level of the epithelial attachment also exhibited similar alterations of the hard tissue adjacent to the pocket epithelium.5. .5 micron wide layer at the surface of the hard tissue. 6. The process of cementum alteration did not reach the cemento-dentinal junction in any of the specimens studied.1 to 0. In some sections the mineral crystals were densely packed in a 0. while the subjacent layers were almost devoid of crystals.

root caries tend to progress around rather into tooth {G.C. • Exposure to oral fluid & plaque results in proteolysis of embedded remnants of Sharpey’s fibres. Areas of demineralization • Commonly related to root caries. {H.J. cementum may be softened./undergo fragmentation/cavitation. 1986} and may lead to sensitivity/pulpal exposure in severe cases.Herting JDR 1967} • Unlike enamel caries. . j.Mount Aus dent.

F. Chemical changes • Mineral content of exposed cementum is increased.D.Aleo.{J. micro hardness however remains unchanged.Vandersall} . • Exposed cementum may absorb P.J. from its local environment forming a highly calcified layer resistant to decay.C. Ca.

stated that the periodontally involved cementum characteristically showed a distinct radiopaque surface layer of varying width maximum upto 40µ.5% of dry weight compared to 25.A. E.7% in healthy teeth • ↑P content 12.1% in healthy teeth • ↑ F content .6% of dry weight compared to 12.Selvig .In microradiographic analysis K.Hals 1977. They concluded that the zone of high radiopacity at the surface of exposed cementum showed • ↑ Ca+Mg content 27.

Cytotoxic changes • Hatfield et al in 1971 first described the cytotoxic effect of diseased root surface in tissue cultures. • O’ Leary suggested that LPS was absorbed on to or penetrated into periodontally involved cementum. • Demonstrated – morphological changes like vacuolization and clumping of chromatin. .

De Renzis .G.Farber} • When root fragments from teeth with periodontal disease are placed in tissue culture they induce irreversible morphologic changes in the cells of the culture.Aleo.Baumhammers.Daly . {J.A. P. G. 1971} . arch.Hatfield . F.Seymour JCP 1982} • In addition bacterial products such as endotoxins have also been detected in cementum wall of periodontal pocket. biol.A. {C. A.oral. J. {C.• Bacterial penetration can be found as deep as near CDJ.G.J.

M.{J.Aleo. diseased root fragments induce an inflammatory response.De Renzis JP 1974 -1975 } • When reimplanted in oral mucosa of the patient. J.Lopez.A.{N. F.• Diseased root fragments also prevent in vitro attachment of human gingival fibroblasts.Belvederessi JP 1980 } .J.

Surface morphology of the tooth wall of periodontal pockets .

Local conditions leading to changes in cementum .

cementum undergoes resorption. new cells. removal of damaged tissues. • If injury is severe. bone and cementum are formed. Changes in cementum during TFO • The injured tissues . . fibres. • Fibroblasts with collagen fibres get embedded in cementum & extend into newly formed bone.increased reparative activity. • Cementum gets deposited along eroded dentinal surfaces during reversibility of TFO.

when the forces exceed. . with its slow metabolism is not damaged by a pressure equal to that exerted on bone. cemental resorption occurs on the pressure side while deposition takes place on the tension side. • However. Cementum Changes During Orthodontic Movement • Orthodontic movements when in proper magnitude do not affect the cementum because cementum.

• Therefore. calculus and / or any other plaque retentive factors. to remove these from the root surface. Changes During Therapy……. the basic treatment modality in any type of periodontitis is ‘Root planing’. . various root surface changes occur due to bacterial deposits on. ROOT PLANING:- • In periodontitis.

arrests disease progression & aids in the removal of the nidus of infection. Rylander. resulting in a hard & smooth root surface.• Thorough root planing of diseased root surfaces. • According to Jan Lindhe & H. ‘Root Planing’ removes the softened cementum. .

Changes due to Laser therapy • Regardless of wavelength choice. energy densities exceeding 125 to 150 J/cm2 have been shown to severely alter root surfaces. .

– globules of melted and re-solidified root mineral and – a generalized porosity of laser exposed areas that likely results from vaporization of organic matrix and generation of escaping gases.• Physical alterations are most commonly characterized by – crater formation. . melting and cracking of root cementum and dentin. • The continuous wave CO2 laser readily produces carbonization.

• Morlock et al.Er:YAG laser caused chalky and micro- irregular appearance without melting and carbonization of the root surface with cementum ablation. • Frentzen et al. in 2002 demonstrated that Er:YAG laser (100/120 mJ/pulse) can result in increased loss of cementum and dentin as compared to mechanical debridement. . • Aoki et al. in 1992 – Nd:YAG laser caused surface pitting and crater formation with charring of the root surface.in 1994.

. repair will not take place. Fracture of the Root • Cementum is repaired by deposition of new cementum and requires the presence of new viable connective tissue. • If epithelium proliferates into that area. • Cementum repair can occur in both vital as well as non- vital teeth.

. Ankylosis • Fusion of the cementum and alveolar bone with obliteration of the periodontal ligament is termed as ankylosis. • This condition is relatively uncommon and occurs most commonly in the primary dentition.

Causes • Chronic periapical inflammation • Tooth with cemental resorption • Tooth replantation • Occlusal trauma • Around the embedded teeth .

 Lack of physiologic mobility of the normal teeth  Special metallic percussion sound  Infraocclusion  Proprioception is lost  Physiologic drifting and eruption of the teeth can no longer occur .

Radiographically: • Resorption lacunae are filled with bone and the periodontal ligament space is missing. Treatment : • No treatment required but can cause problem during extraction of such teeth. .

Systemic Conditions Leading to Changes in Cementum…. ..

(Rushton. • A study showed a paucity or complete absence of cementum due to defective formation of cellular cementum on both erupted and unerupted teeth. subsequent delayed eruption of succedaneous teeth as well as numerous unerupted supernumerary teeth. • Prolonged retention of deciduous teeth. Cleidocranial Dysplasia • It is a developmental anomaly affecting mainly the skeleton and teeth (affects the skull.A1956). clavicle and dentition). M. .

. • Decreased cementum formation is associated with hypopituitarism. there is reduced pituitary hormones specially the growth hormone. Hypopituitarism • In this. • Individuals with this condition show dwarfism but have a relatively well proportioned body.

Hypophosphatasia • Hypophosphatasia is caused by a mutation in the tissue specific alkaline phosphatase gene. • Cementum appears rough and irregular. . & reduced cementum formation. • Ultra structurally. • Deficiency in alkaline phosphatase characterized by premature loss of primary teeth. all islands of cementum show well defined collagen fibrils embedded in organic matrix.

• Deposition of excessive amnts of sec. Paget’s Disease • Is a generalised skeletal disease associated with hypercementosis. cementum on the apical thirds of the teeth. .

Acromegaly • Is a relatively rare disease. in which there is hypersecretion of the GH after the closure of the epiphyseal plate. • Oral manifestations include: hypercementosis periodontal diseases. .

Aggressive periodontitis • 1928 Gottlieb termed this disease as “ deep cementopathia” – attributing this condition to the inhibition of the continuous cementum formation. • Studies – root surfaces of teeth extracted from patients with LAP have been found to have hypoplastic or aplastic cementum. .

Developmental anomaly of cementum .

• Teeth are united by cementum only. • As a result of traumatic injury or crowding of teeth with resorption of the interdental bone so that the two roots are in approximate contact and become fused by the deposition of cementum. Concrescence • It occurs after the root formation has been completed. .

• Difficulty during extraction. • Can be diagnosed radiographically.• Generally involves only two teeth. .

Neoplasms of cementum .

with no sex predilection. • The lesion normally occurs under the age of 25 yrs. Benign cementoblastoma • Benign cementoblastoma is a true neoplasm of functional cementoblasts that form large masses of cementum like material on the root surface. . • Mandible 3 fold more commonly affected than maxilla.

appears as a dense radio – opaque mass often surrounded by a thin radiolucent line. • Treatment . . there’s a recurrence.Extraction of the tooth along with complete removal of growth.• Usually slow growing & asymptomatic. • Radiographically. failing which.

.2nd -3rd decade • Mandibular lower anterior teeth • Usually harmless. • Considered either an odontogenic neoplasm or malformation. Periapical cemental dysplasia • Masses of cementum generally situated apical to teeth • May / may not be attached to root surface • More in females .

Cementoblastic – mixed radiolucent &radiopaque areas representing newly laid cemental masses 3. Osteolytic – radiolucent areas at the root apex. . Mature – completely radiopaque areas representing mature cementum at the apex. representing fibrous tissue at the apex 2.• Radiographically 3 stages :- 1.

Cemental Aberrations .

• It may be localized to one tooth or affect the entire dentition. HYPERCEMENTOSIS • It refers to a prominent thickening of the cementum. .

rheumatic fever and thyroid goitre.Paget’s disease. .excessive tension from orthodontic appliances or occlusal forces. arthritis. calcinosis.Etiology :  Spikelike type generally .  In teeth with low-grade periapical irritation arising from pulp disease.  In teeth without antagonists.  Systemic diseases like acromegaly.  Generalised hypercementosis of the entire dentition .

.Features : o It occurs as a generalised thickening of the cementum with nodular enlargement of the apical third of the root. o It also appears in the form of spike like excrescences (cemental spikes) created by either the coalescence of cementicles that adhere to the root or the calcification of periodontal fibres at the sites of insertion into the cementum.

. enveloping it as it would in normal cementum.Radiographically: • The radiolucent shadow of the periodontal ligament and the radiopaque lamina dura are always seen on the outer border of an area of hypercementosis.

• Multirooted teeth might require tooth sectioning before extraction. .Treatment : • It itself does not require any treatment but it could pose a problem if an affected tooth requires extraction.

. . from calcified Sharpey’s fibers and thrombosed vessels within the PDL.2 mm. Cementicles • Calcified bodies in the PDL. around small spicules of cementum / alveolar bone traumatically displaced into PDL. • Develop from calcified epithelial rests. that are adherent to or detached from the root surface & its diameter rarely exceeds 0.

.

. Cemental tears • Detachment of fragments of cementum from the root surface is known as ‘Cemental tear’. • It is also seen in acute trauma from occlusion. which may be complete or incomplete. • It is seen on the tension side in occlusal traumatism.

.• Detached cementum may be reunited by – new cementum formation or – may be completely resorbed – undergo partial resorption followed by the addition of new cementum & embedding of collagen fibers.

Cementum regeneration .

• The formation of cementum is a key event in development of the root and supporting periodontium. • Cementum serves as the biological and structural link between the inert root surface and the cellular and collagenous network of the periodontal ligament. .

the root surface upon which new cementum formation is desired was. when regenerative therapies are employed.• Bosshardt & Selvig – 3 types of cementum • Acellular cementum – most affected in moderate periodontal lesions • Advanced lesions – cellular cementum • Thus. often covered by acellular cementum. . in preceding periods of health.

REGENERATION OR REPAIR ..• Ten Cate……….

the manner by which acellular extrinsic fiber cementum attaches or fuses to the underlying dentin surface may be unique.cellular cementum – bone like tissue. specific cell. . • In addition. that is. substrate and extracellular matrix conditions which exist during root development may facilitate a functional dentin-cementum union.• Acellular cementum – odontogenic tissue • On a controversial front…….

• Functional capacity and relevance of "the regenerated periodontium“????? .cellular cementum not fuse to dentin in a manner similar to that observed during development.• Presence of tears or separations between dentin and newly formed cementum .

STRATEGIES FOR PERIODONTAL REGENERATION/REPAIR • Root surface biomodification • Guided tissue regeneration and bone grafting • Molecular approaches for cementum regeneration •Enamel matrix protein derivatives • Cellular tissue engineering for cememtum regeneration .

• The process of periodontal tissue regeneration starts at the moment of tissue damage by means of growth factors and cytokines released by the damaged connective tissue and inflammatory cells. • It is well accepted that in order to improve periodontal healing. . root planing or root conditioning is a necessary antecedent to mesenchymal cell migration and attachment onto the exposed root surface.

(Aleo et al. 1974. Adriaens et al. 1975. (Aleo et al. Root surface biomodification • Periodontitis affected root surfaces .hypermineralized and contaminated. Poison & Caton 1982) . 1988) • This renders the surface non biocompatible to cells associated with periodontal healing.

. 1984).• Scaling and root planing partly removes calculus and contaminated root cementum leaving a smear layer covering the instrumented surface (Polson et al.

Smear layer .

• These agents are believed to induce cementogenesis increasing cementum apposition and enhance attachment either by connective tissue ingrowth and/or demineralization (Garrett et al. . 1984).• Hence chemical root surface conditioning was introduced using a variety of agents. 1978. Willeyetal.

bound proteins Detoxify. Possible actions of root modifying agents: Exposure and opening of dentinal tubules(Hanes et al. 1991) Produces a zone of demineralization Exposes cementum. Enhances the binding of extracellular matrix glycoprotein fibronectin to dentin . decontaminate and demineralise the root surface Enlarges dentinal tubules into which healing connective tissue can enter.

• EDTA . 1989). • Citric acid functions by a combination of these 2 mechanisms.low pH and dissolves or erodes a mineralized surface (Biomlof & Lindskog 1995a).exerts its demineralizing effect through chelating divalent cations. . • Phosphoric acid . • Tetracycline .low pH in concentrated solution acts as a calcium chelator and its application results in enamel and root surface demineralization (Al-Ali et al.

which is of lower strength. • Use of phosphoric acid has proven devastating to the vitality of periodontal tissues while citric acid. Studies …. does not exert its devitalising effect to the same penetration depth in contrast to a supersaturated solution of EDTA which does not impair vitality when applied to periodontal tissues (Blomlof & Lindskog 1995b). .. tetracycline or EDTA to modify the root surface provides no clinical significant benefit for regeneration in patients with chronic periodontitis. • A systematic review performed by Mariotti suggested that the use of citric acid.

Role of GTR and Bone Grafts in cementum regeneration .

. which excludes the apical migration of gingival epithelial cells and provides an isolated space for the inward migration of periodontal ligament cells. using Millipore membranes. • Nyman et al.• Melcher’s concept…. osteoblasts and cementoblasts. . introduced the concept of a membrane barrier.

absorbable membranes made of collagen or polylactic and citric acid.• The first generation GTR membranes were nonabsorbable and made of polytetrafluoroethylene. • Studies on experimentally induced periodontal defects in monkeys .GTR was capable of inducing the formation of new bone and cementum. such as Gore-Tex. . • The second generation . which eliminated the need for surgical membrane retrieval.

barrier types Augmentation materials + GTR in Furcation defects Augmentation + GTR in intrabony defects .barrier types Furcation defects . Intrabony defects – GTR vs OFD analysis systematic review Furcation defects – GTR vs OFD (Murphy K et al 2003) Intrabony defects .A meta.

maturation proceeds over • Deposition of acellular time. The periodontal healing with guided tissue regeneration therapy occurs in two stages. . • Result in a regenerated • Transient root cementum similar to resorption/demineralizati pristine cementum as on. The first stage The second phase • An initial healing phase • A remodeling process. • Formation of a blood clot. cementum on the root surface and • Formation of connective tissue.

several clinical studies have demonstrated that GTR is a successful treatment modality for periodontal reconstructive surgery and it has become an accepted procedure in most periodontal practices. .• In conclusion. either by itself or in combination with other treatment modalities.

Bone grafts • Histological studies showed that demineralized freeze- dried bone allografts support the formation of a new attachment apparatus in intrabony defects.. however. • Controlled clinical trials. have demonstrated more modest success. • Bone replacement grafts (e. .g. autografts and allografts) have resulted in substantial bone fill as evidenced by many case studies and reports.

• Nevertheless. • The best treatment .bone grafts with barrier membranes. these strategies are directed mainly to enhance alveolar bone and periodontal ligament repair and have the problems that they do not address cementogenesis and therefore do not completely regenerate the architecture of the original periodontium.• The available data indicate that alloplastic grafts - periodontal repair rather than regeneration. .

• Dexamethasone and BMPs. • Insulin-like growth factor. Molecular approaches for cementum regeneration • It is suggested that growth factor molecules are produced during cementum formation and then stored in the mature cementum matrix with the potential to induce periodontal repair or regeneration when needed. • Basic fibroblast growth factor. • Platelet-derived growth factor. • Transforming growth factor-b1. .

Christgau et al. . • PDGF + bone allografts in Class II furcations & interproximal intrabony defects.only high doses of these factors gave rise to a statistically significant increase in alveolar bone formation. Do¨ri et al. b.• Clinical trials . • PRP . 2007). 2005. 2006a.combined with different types of grafting materials and barrier membranes. has also been used in regenerative periodontal therapy (Okuda et al.

. • Combined application did not enhance alveolar bone regeneration or new attachment formation over and above that obtained by separate applications of the two BMPs.• The expression of both BMP-2 and BMP-7 during periodontal tissue morphogenesis suggests that optimal therapeutic regeneration may require the combined use of the two BMPs.limited cementum formation but greater amounts of mineralized bone and osteoid. • BMP-7-treated molar furcation defects in baboons - substantial cementogenesis • BMP-2 .

A fast degradation and fast release of BMP-2 induced bone formation to a greater extent. whereas cementum formation was significantly greater with the slow degrading and slow releasing BMP gelatin carrier.• Studies . . • Whether these findings apply to humans in an inflamed environment is unknown.

chrondrogenesis. – with subsequent osteogenesis. • Results .• Jin et al. • Suggesting that this genetic engineering approach may be useful in alveolar bone regeneration. . used adenoviruses containing BMP-7 to transduce dermal fibroblasts that were then used to treat mandibular alveolar bone defects in a rat wound repair model. – cementogenesis and – bridging of the periodontal bone defects.

Role of enamel associated proteins in cementum regeneration • Based on the presence of enamel proteins in acellular cementum. it was thought that these proteins may play a role in the repair/regeneration of periodontal tissues destroyed by periodontal disease. . • This idea was tested by adding enamel proteins or purified enamel matrix derivative to surgically produced periodontal defects in monkeys.

which has been marketed by Biora.. Consisting of hydrophobic enamel matrix proteins extracted from porcine developing enamel. under the name of Emdogain. – firmly attached to the dentin and – with collagenous fibers extending towards newly formed alveolar bone.• On histological analysis – almost complete regeneration of acellular cementum. . Inc.

Food and Drug Administration for use in achieving periodontal regeneration in angular bony defects. • Histologic evidence of periodontal regeneration has been shown in a human dehiscence model after application of enamel matrix derivative. .• Enamel matrix derivative (EMD) has been approved by the U.S.

.. 1997a). enamelin. • Two enzymes MMP-20 (Fukae et al 1998) and EMSP1 (encystation-mediating serine proteinase) (Simmer et al. and sheathlin (Hu et al. 2001). • TGF-β1 and BMP-2 and BMP-4 have been detected immunologically (Kawase et al.• The major fraction of the enamel matrix proteins - amelogenins (Brookes et al.. 1995). 1998).. 1995). . • Three matrix proteins. • The second largest component of the enamel matrix proteins is the enamelins (Brookes et al.amelogenin..

.

Studies….
1. One study – mouse recombinant amelogenin can increase
attachment and proliferation of mouse periodontal
ligament cells.

2. A post-translational modified recombinant ameloblastin
had an effect similar to that of amelogenin on periodontal
ligament cells.

3. Amelogenin – bone sialoprotein and BMP-2

4. Ameloblastin – de novo expression of BMP-3

• Histological studies revealed that treatment with
Emdogain is unpredictable, resulting in the

– formation of cellular cementum rather than acellular
cementum, and

– this cementum was only partially attached to the root
surface, similar to the cementum formed with the use
of guided tissue regeneration.

Cellular tissue engineering for cementum
regeneration

The to place
removal them back then to
of onto the cover the
autologou exposed area with
culture of
s cells root an
the cells
from the coated artificial
in vitro
patient’s with basement
periodont chemoattr membran
al actant e
ligament factors

• The ability of cementoblasts and dental follicle cells to
promote periodontal regeneration in a rodent
periodontal fenestration model was analyzed recently.

• Results - cementoblast-treated and carrier alone-treated
defects showed complete bone bridging and PDL
formation.

• No new cementum was formed along the root surface in
either group.

.• Further research is required in this field…. .

provides tooth attachment and maintains occlusal relationship. Summary • Cementum is a part of periodontal attachment apparatus. which deposit two collagen containing varieties of cementum with completely different properties. • These multiple functions are fulfilled by the biological activity and reactivity of cementoblasts. & by virtue of its structural dynamic qualities. .

faster apically than cervically. . cementum covering of the root ↑ in thickness throughout life. Unless disturbed.  Chemical composition is almost similar to bone.  The dynamic features of cementum are particularly highlighted by its repair potential.

non .pathological resorption defects on the root surface are generally reversible and heal by reparative cementum formation. cementum may undergo alterations in structure as well as in the composition of its organic and inorganic components consequential to pathological changes.  In diseased periodontium. Minor. .

the application of cementum derived growth factor / attachment factors may result in accelerated wound healing & in controlled neo – cemento genesis following periodontal regeneration therapy. . The discovery of a variety of non – collagenous proteins in cementum has opened new vistas for research .

S & Pitaru) .(A. pre & post cementogenesis will provide pertinent information necessary for establishing the function of these proteins during root development .Narayanan . permitting new & improved periodontal treatment that could greatly diminish the effects of periodontal disease.(a 56k Da protein)along with their receptors. (Sommerman et al) • Spatial & temporal localisation of these proteins. What’s new ??? • Numerous studies support the possibility that cementum derived attachment proteins. are expressed in a unique fashion during cementogenesis. predicting that their precisely timed expression is critical to cementum formation. So.

(Bruno-Carmona Rodriguez et al ) .• Human cementoblastoma derived protein. named Cementum Protein-1 (CEMP 1)-expressed by cementoblasts & progenitor cells localised in the periodontal ligament. may play a crucial role as a local regulator of cementoblast differentiation and cemental matrix mineralisation.

. Conclusion • In the light of emerging evidence. • The structural integrity & unique biochemical composition of the cemental matrix are severely compromised in periodontal disease & the provisional matrix generated during periodontal healing is different from cementum. we can hypothesize that the local environment of the cemental matrix plays a pivotal role in maintaining the homeostasis of the periodontium. • Rapid strides made in basic science research indicate that the ultimate goal of true periodontal regeneration may become possible.

Lamontm acneil& marthaj. 196–217 4. Somerman Development and regeneration of the periodontiurn: parallels & and contrasts. 2. References 1. 3. Bartold. Vol. 1999. Periodontology 2000. Periodontology 2000. 19. Vol. sampath narayan. Carranza. Margarita Zeichner-David Regeneration of periodontal tissues: cementogenesis revisited. biology of periodontal connective tissue. R. 2006.text book on clinical periodontology. 41. 8-20 .10 th edition.

5. Somerman Molecular and cell biology of cementum Periodontology 2000. Shafer’s textbook of oral pathology – 7th edition. Vol. Giannobile&martha j. william v.36. . Periodontology 2000. 6. 2000. 2004. Vol. Akira Aoki et al. Saygin. 24. 7. 73–98. Nazan e. Lasers in nonsurgical periodontal therapy.