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CEMENTUM

Dr. Raina Khanam

MDS 1st year DEPARTMENT OF PERIODONTICS
 CONTENTS
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 INTRODUCTION
 DEFINITION
 COMPOSITION
 PROPERTIES
 CLASSIFICATION
 PERMEABILITY OF CEMENTUM
 CEMENTOENAMEL JUNCTION
 CEMENTODENTINAL JUNCTION
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 CLINICAL CONSIDERATIONS
#HYPERCEMENTOSIS
#CEMENTICLES
#CEMENTOMA
#CEMENTAL HYPERPLASIA AND HYPERTROPHY
#ANKYLOSIS
# CENTAL RESORPTION
 CEMENTUM REPAIR
 EXPOSURE OF CEMENTUM TO ORAL
ENVIRONMENT
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INTRODUCTION
 PERIODONTIUM
Pulp cavity
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Enamel
Cementum Dentin

Gingiva
PDL

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

Apical foramen
Alveolar vessels
& nerves
 Definition
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According to Carranza
“It is the calcified avascular mesenchymal tissue that
forms the outer covering of the anatomic root.”
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 Its primary function is to provide attachment to the

fibers of the periodontal ligament to the roots of the
teeth.

 first demonstrated microscopically in 1835 by two

pupils of Purkinje.

 begins at the cervical portion of the tooth at the CEJ

and continues to the apex of the root.
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 It is also known as Substantia Ossea

 It is yellow in colour and is derived from the dental

follical.

 Unlike bone, it is avascular and does not have the

ability to remodel and is generally more resistant to
resorption than the bone.
 CEMENTOGENESIS
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 During tooth development the dental papilla gives rise to

odontoblasts and the dental pulp while the dental follicle
gives rise to Cementum, PDL and alveolar bone.

 For cementogenesis to begin the Hertwig’s epithelial

root sheath must fragment.

 Once the root sheath disintegrates the underlying newly

formed dentine comes in contact with the
undifferentiated cells of the dental follicle.
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This stimulates the activation of cementoblasts

which lay down the matrix and begin
cementogenesis.
 COMPOSTION OF CEMENTUM
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INORGAN COMPOSI
ORGANIC IC TION

INORGANIC COMPONENTS:
 Hydroxyapatite – 45% to 50%

 which is less than that of bone 65%, enamel 97%,

and in dentin 70%.

 ORGANIC COMPONENTS
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 Water-12%
 Organic- 23% and Inorganic-65%

 Type I collagen (up to 90%of organic content) and

protein polysaccharides (proteoglycans).

 Other collagen associated with cementum include

type III, V, VI and XII.
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 Non-Collagenous proteins include–alkaline

phosphate, bone sialoprotein, fibronectin,
osteocalcin, osteonectin, Osteopontin,
proteoglycans, vitronectin and several growth
factors.
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CELLS OF CEMENTUM
 Cementoblasts : They synthesize collagen and

protein polysaccharides that form the organic

matrix of Cementum.

 Cementocytes: During the formation of

Cementum, some cementoblasts become
incorporated into the cemental matrix. These cells
lie in spaces known as lacunae.
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FIBERS OF CEMENTUM
 Extrinsic: They are incorporation of the

periodontal ligament fibers also known as

SHARPEY’S fibers. They run in the same direction
as the principle fibers.
 Intrinsic: They are produced by cementoblasts

and run parallel to the root surface.

 CLASSIFICATION
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PRIMARY
TIME OF
FORMATION SECONDARY

CELLULAR PRESENCE OR ABSENCE OF

ACELLULAR CELLS

EXTRINSIC
BASED ON FIBERS INTRINSIC
 ACELLULAR CEMENTUM
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 It is first to be formed & covers approximately the

cervical third or half of the root.

 It does not contain any cells.

 This cementum is formed before the tooth reaches

the occlusal plane.

 Its thickness ranges from 30 to 230 µm.

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 Sharpey’s fibers comprises most of the structure

of acellular cementum, which has a principal role
in supporting the tooth.

 Most fibres are inserted at approximately right

angles into the root surface & penetrate deep into
the cementum, while others enter from several
different directions.
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A: Acellular cementum (primary )

B: Cellular Cementum (secondary)
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 Size, number & distribution of acellular cementum

increases with the function of teeth.

 Sharpey’s fibers are completely calcified in

acellular cementum, with the mineral crystals
oriented parallel to the fibrils as in dentin & bone.

 In 10 – 50 µm wide zone near cementodentinal

junction, sharpey’s fibers are partially calcified.
 CELLULAR CEMENTUM
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 It is formed after the tooth reaches the occlusal

plane.

 It is more irregular and contains cells within its

matrix called cementocytes.

 The cementocytes are present in individual spaces

called lacunae that communicate with each other
through a system of anastomosing canaliculi.
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 It is less calcified than the acellular cementum.

 Sharpey’s fibers make up a smaller portion of cellular

cementum and are separated by collagen fibers.

 Sharpey’s fibers may be completely or partially calcified.

 It may have a central, uncalcified core surrounded by a

calcified border.
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 Both acellular & cellular cementum are arranged in

lamellae separated by incremental lines parallel to
the long axis of the root (Incremental lines of
Salter).

 These lines represent “rest periods” in cementum

formation & are more mineralized than the adjacent
cementum.
 ACELLULAR EXTRINSIC FIBER
CELLULAR MIXED
STRATIFIED
CELLULAR
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INTRINSIC
FIBERS
 Based on these findings, Schroeder has classified
cementum as follows:

ACELLULAR AFIBRIL

INTERMEDDIATE
 ACELLULAR AFIBRILLAR CEMENTUM
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(AAC)

 No cells, no extrinsic fibers, no intrinsic fibers,

except for a mineralized ground substance.
 It is a product of Cementoblasts. It is found in
coronal cementum with a thickness of 1 to 15µm.
 ACELLULAR EXTRINSINC FIBER
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CEMENTUM (AEFC):

 Composed entirely of densely packed bundles of

sharpey’s fibers.

 Lack cells. Its thickness is between 30 to 230µm.

 It is a product of fibroblasts & cementoblasts.

 It is found in the cervical third of roots in humans

but may extend farther apically.
 CELLULAR MIXED STRATIFIED
27 CEMENTUM (CMSC):

 Composed of extrinsic, intrinsic fibers and cells.

 co product of fibroblasts and Cementoblasts.

 Appears primarily in the apical third of the roots,

the apices and the Furcation areas.

 Its thickness ranges from 100 to 1000µm.

 CELLULAR INTRINSINC FIBER
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CEMENTUM (CIFC):

 It is composed of cells but no extrinsic collagen

fibers.

 It is a product of Cementoblasts.

 It fills resorption lacunae.

 INTERMEDIATE CEMENTUM
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 Hyaline layer of Hopewell Smith

 Poorly defined zone near the cemento-dentinal
junction of certain teeth that appears to contain
cellular remnants of Hertwig’s sheath embedded in
calcified ground substance.
 PERMEABILITY OF CEMENTUM
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 In very young animals, acellular & cellular

cementum are very permeable & permit the
diffusion of dyes from pulp & external root surface.

 In cellular cementum the canaliculi in some areas

are contiguous with dentinal tubuli.

 The permeability of cementum diminishes with

age.
 CEMENTOENAMEL
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JUNCTION
Three types of relationships involving the Cementum may
exist at the CEJ
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Three types:
 In about 60% to 65% cases cementum overlaps enamel.

 In about 30% cases an edge to edge butt joint exists.

 In about 5% to 10% cases enamel and cementum fail

to meet. In such cases gingival recession may result in
sensitivity due to exposed dentine
 CEMENTODENTINAL JUNCTION
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 The terminal apical area of cementum where it

joins the internal root canal dentin.

 When root canal treatment is performed, the

obturating material should be at CDJ.

 No increase or decrease in the width of CDJ with

age; its width appears to remain relatively stable; it
is 2 to 3µm wide.
 THICKNESS OF CEMENTUM
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 Cementum deposition is a continuous process that

proceeds at varying rates throughout life.

 It is more rapid in apical regions, where it

compensates for tooth eruption, which itself
compensates for attrition.

 Thickness of cementum on the coronal half of root

varies from 16 to 60µm.
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 It attains its greatest thickness in apical third & in

furcation areas(upto 150 – 200m).

 It is thicker in distal surfaces than in mesial surfaces

because of functional stimulation from mesial drift
over time.
 AGE CHANGES IN
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CEMENTUM
 Decreased permeability of cementum

 Width of cementum increases with age; greater at

the apical and furcation areas. This may cause
obstruction of apical foramen.

 The surface of cementum becomes irregular due to

calcification of fiber bundles attached to the
surface.
 HYPERCEMENTOSIS
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 CLINICAL
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FEATURES:
 It refers to a prominent thickening of cementum.

 It occurs as a generalized thickening of cementum,

with nodular enlargement of apical third of root.

 It appears in the form of spike like excrescences

created by either coalescence of cementicles that
adhere to the root or calcification of periodontal
fibers at the site of insertion into cementum.
 RADIOGRAPHIC FEATURES:
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 Radiolucent shadow of periodontal ligament.

 Radiopaque lamina dura seen on outer border of an

area of hypercementosis.
 ETIOLOGY:
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 The spike like type of hypercementosis results from

excessive tension from orthodontic appliances or
occlusal forces.

 Generalized hypercementosis occurs in teeth

without antagonists & Paget’s disease.

 Cementum is deposited adjacent to inflamed

periapical tissue.
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Some important other systemic condition where

generalized Hypercementosis can be seen:
1. Acromegaly
2. Arthritis
3. Calcinosis
4. Rheumatic fever
5. Thyroid goiter
 CEMENTICLES
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 These are globular masses of acellular cementum

 Generally less than 0.5mm in diameter, round lamellated

cemental bodies that may lie free or attached within the
periodontal ligament.

 They exhibit concentric appositional layers of afibrillar

and/or fibrillar cementum.

 It is mostly found in aging persons or at the site of

trauma.
 Types
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Free – with in PDL space

Attached- fused to cellular cementum
Interstitial –(totally incorporated in the cementum)

. 
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 It has been postulated that cementicles

originate from foci of degenerating cell or
epithelial rests in periodontal ligament.

 Not of clinical significance unless they

become exposed to oral environment where
they may act as sites for plaque retention. 
 CEMENTOMA
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 It is also known as benign cemtoblastoma or

cemental dysplasia.
 These are cemental masses situated at the apex of

the root which are slowly growing

odontogenic neoplasm and may
cause bone expansion.
 CEMENTAL HYPERTROPHY AND
HYPERPLASIA
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CEMENTAL It is the overgrowth in the

●

HYPERPLA nonfunctional teeth and it is not

correlated with increased function.
SIA

CEMENTAL It is the overgrowth in

●

HYPERTRO Cementum that improves the

functional qualities.
PHY
 ANKYLOSIS
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 Fusion of cementum & alveolar bone with

obliteration of periodontal ligament is termed
ankylosis.
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CAUSES:
 Faulty replantation & transplantation of teeth in which

periodontal ligament is damaged.

 Embedded teeth.

 Chronic periapical infection.

 Trauma to deciduous teeth.

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CLINICAL FEATURES:
 Ankylosed teeth lack physiologic mobility of normal teeth.

 Ankylosed teeth have a special metallic percussion sound &

if ankylotic process continues, they will be in infraocclusion.

RADIOGRAPHICALLY:
 Resorption lacunae are filled with bone, and

 the periodontal ligament space is missing.

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 Ankylosis results in resorption of the root and its

gradual replacement by bone tissue; for this reason
reimplanted teeth that ankylose will loose their
roots after 4 to 5 years and will be exfoliated.
 TREATMENT:
 No predictable treatment can be suggested.

 Treatment modalities range from a conservative approach

such as restorative intervention to surgical extraction of
affected tooth.

If a primary tooth was ankylosed,

If the onset is early
Extraction is recommended with placement of a space
maintainer.

If the onset is late

Can build up with composite to occlusal plan.

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 If a permanent tooth is ankylosed,
Build up with restorative material to maintain contacts.

Opposing teeth should never be allowed to supra

eruption.

If ankylosis occurs in multiple teeth, a segmental alveolar

bone osteotomy and bone graft may be needed.

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 CHANGES IN ANKYLOSED
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TEETH
 As the periodontal ligament is replaced with bone
in ankylosed teeth proprioception is lost because
pressure receptors in the periodontal ligament are
deleted or do not function correctly.

 Physiological drifting and eruption of teeth can no

longer occur and thus the ability of the teeth and
peridontium to adapt to altered force levels or
directions of force is greatly reduced.
 CEMENTUM RESORPTION
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- Trauma from occlusion

- Orthodontic movement

LOCAL - pressure from malaligned

erupting teeth
FACTORS
- cyst ,tumor, embedded teeth

-replanted and transplanted teeth

- periapical and periodontal disease

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- calcium deficiency

- hypothyroidism
SYSTEMIC
-Paget’s disease
FACTORS
- deficiency of vitamin A & D

-hereditary fibrous osteodystrophy

 CEMENTUM REPAIR
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 It requires the presence of viable connective tissue.

 If epithelium proliferates into an area of resorption,

repair will not take place.

 It can occur in devitalized as well as vital teeth.

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Anatomic Repair:
The root outline is re-established as it was before
cemental resorption. Generally occurs when the
degree of destruction is low.

Functional Repair :
In the case of large cemental resorption or
destruction, repair does not re-establish the same
anatomic contour as before, because only thin layers
of acellular and cellular cementum are deposited
over the concavity created by cemental resorption.
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 To maintain the width of periodontal ligament, the

adjacent alveolar bone grows and takes the shape of
defect following the root surface. This is done to
improve the function of tooth, thus called functional
repair.
 EXPOSURE OF CEMENTUM TO ORAL
ENVIRONMENT
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 Cementum becomes exposed to the oral environment

in cases of:
Gingival Recession
Loss of attachment in pocket formation

 Bacterial invasion of cementum occurs frequently

in periodontal disease.

 Cementum caries can develop.

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THANK YOU