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Presented by Saranya s PG student

INTRODUCTION CEMENTOGENESIS PHYSICAL CHARACTERISTICS CHEMICAL COMPOSITION CELLS OF CEMENTUM CLASSIFICATION OF CEMENTUM FUNCTION TYPES OF JUNCTION CEMENTUM RESORPTION AND REPAIR CLINICAL SIGNIFICANCE CONCLUSION REFERENCES

Cementum is the calcified, avascular mesenchymal tissue that forms the outer covering of the anatomic root - Carranza Cementum is the thin layer of calcified tissue

covering the dentin of the root and it is one of the four structures that support the tooth in the jaw - Berkovitz

Cementum: Is a hard bone like tissue covering the anatomic roots of the teeth. GENCO

Cementum Development - Cementogenesis

Root formation commences when the enamel organ has reached its final size .

The inner and outer cell layers of the enamel epithelium, which delineate the enamel organ, proliferate from the cervical loop to form Hertwigs epithelial root sheath.

Continuous

cell mitotic activity at the apical termination of Hertwigs root sheath leads to a coronoapical growth of this double cell layer.

Its

most apical portion, that is, the diaphragm, separates the dental papilla from the dental follicle.

Pre - functional development stage

where the Cementum is formed during root development. which takes place when the tooth is about to reach the occlusal level & continues throughout life.

Functional development stage

Cementum formation in developing teeth is preceded by the deposition of dentin along the inner aspect of Hertwigs Epithelial Root Sheath (HERS).

Once the 1st layer of radicular mantle dentin has been laid down by maturing odontoblasts & before mineralization of dentin reaches the inner epithelial cells, HERS becomes fragmented.

Cells from the dental follicle then penetrate the HERS & occupy the area next to the predentin.

The first Cementum deposited on the superficial layer of mantle dentin(hyaline layer)contains enamel matrix proteins.

This direct contact of dentin with the connective tissue of the dental follicle, stimulates the undifferentiated ecto - mesenchymal cells to differentiate into cementoblasts, which begin to produce collagen fibers

Associated with the attachment of the root to the surrounding bone and continues throughout life. It is mainly during the functional development that adaptive and reparative processes are carried out by the biological responsiveness of cementum, This in turn, influences the alterations in the distribution and appearance of the cementum varieties on the root surface with time.

Breakdown

of Hertwigs epithelial root sheath involves degeneration or loss of its basal lamina on the cemental side of continuity of the basal lamina is followed by the appearance of collagen fibrils and cementoblasts between epithelial cells of the root sheath

Loss

Some sheath cells migrate away from the dentin toward the dental sac become the epithelial rests of Malassez found in the PDL

The other sheath cells remain near the developing tooth, are incorporated into the cementum

Soon after the HERS breaks up undifferentiated mesenchymal cells from adjacent connective tissue differentiate into Cementoblasts. cells have numerous mitochondria, well formed golgi apparatus and large amount of granular endoplasmic reticulum.

These

Cementoblasts

synthesize collagen and protein polysaccharides which make up the organic matrix of the cementum.

Development of cellular cementum 2 stages

Early stage
Extrinsic fibres were few and intrinsic fibres were randomly arranged

Later stage
Extrinsic fibres were thicker and the intrinsic fibres appeared to encircle them

Development of acellular cementum

Epithelial cell rests showed a close relationship Development of acellular cementum is associated with the secretion of enamel matrix proteins ( EMP) by HERS preceded by the mineralization of the first layer of dentin adjacent to the root

HERS also secrete BSP, osteopontin and fibrillar collagen. Epithelial mesenchymal reaction leading to the development of cementoblasts. Enamel proteins and amelogenin are reported to be involved in epithelial mesenchymal reaction.

Cementum

is light yellow in color & distinguished from enamel by its lack of luster and its darker hue.
in color than dentin.

Lighter

Hardness

of fully mineralized cementum is less than that of dentin.

- Both Cellular & Acellular Cementum are permeable to a variety of materials, with that of Cellular being > Acellular Cementum.
of cementum with age. - ( Blayney et al., 1941).

Permeability

ORGANIC PORTION & WATER (50-55%)

INORGANIC PORTION
(45-50%)

Organic

matrix composed of type I ( 90%) and type III (5%) collagens . fibers constitute the bulk of the cementum, mainly composed of type I collagen . III collagen appears to coat the type I collagen of sharpeys fibers

Sharpeys

Type

Non-collagenous

proteins present are bone sialoprotein, fibronectin, dentin sialoprotein, tenascin, osteopontin and osteonectin.
cell attachment and cell migration.

Promote

Stimulate

protein synthesis of gingival fibroblasts and periodontal ligament cells. major role in the differentiation of cementoblast progenitor cells to cementoblasts

Play

Cementum Attachment Protein (CAP)


Collagenous

proteins 56kDa to 65kDa Promote the adhesion and spreading of mesenchymal cells with osteoblasts and periodontal ligament fibroblasts. Located in matrix of mature cementum & in cementoblast Act as marker to differentiate from bone.

Cementum derived growth factor


Enhance

the proliferation of the gingival fibroblasts and periodontal ligament cells Cementum is rich in GAG, predominantly chondroitin sulphate additionally dermatan sulphate & hyaluronan.

Hydroxyapatite (45% to 50%)


HA- bone(65%), enamel (97%), dentin (70%) Thin and plate-like and similar to those in bone. Average 55nm wide and 8 nm thick. Also contains calcium, fluoride, magnesium, carbonate, citrate.

CEMENTOBLASTS
Origin :

Are cemento progenitor cells synthesising collagen & protein polysaccharide (proteoglycans) which make up the organic matrix of cementum. Arise from the dental follicle proper which is ectomesenchymal in origin - a derivative of the cranial neural crest. (Tencate, 1971)

Differentiation: The fibrogenic cells of the dental follicle are either fibroblasts / mesenchymal cells.
Tend

to become differentiate into cementoblasts as they invade, approach & align themselves along the external border of the dentin to form cementogenic layer.

Form

a single / multicellular layer.

The

components of multilayered cells are more flattened than that of single cells mitochondria, an extensive network of surrounding well developed Golgi system & ribosomes.

Contain

34

Cellular Intrinsic Formed by cementoblasts derived Fibre Cementum

from the dental follicle

Acellular Extrinsic Fibre Cementum

Formed by the cementoblasts derived from the HERS

Cementoblasts forming CIFC

Cementoblasts forming AEFC

Express receptors for parathormone (parathormone Receptor Protein) which have a regulatory role in cementogenesis Osteopontin and osteocalcin are expressed Synthesize osteonectin

Do not show these receptors

Expresses only osteopontin

Synthesize osteonectin

In

the differentiation of cementoblasts growth factors belonging to the TGF family including BMP, transcription factor- core binding factor 1( cbfa1), signaling molecule epidermal growth factor ( EGF) are involved.
downregulates signals transduction from ligands such as TGF- and EGF to control cell differentiation.

EGF

Prostaglandin

E2 enhance differentiation of cementoblasts by activating protein kinase signaling pathway.

CAP,BSP

and osteopontin help in the attachment of selected cells to the newly forming tissue.

The apical 1/2 or 1/3rdof the root is covered with cellular cementum. The number of cementocytes in the matrix is variable. Cementum that is formed rapidly generally possesses wider lamellae & more cementocytes.

In the apical 1/3rd,cementoblasts trapped in rapidly calcifying cemental matrix, later, differentiate into cementocytes.

These

locate in spaces termed lacunae & have numerous cytoplasmic processes coursing in canaliculi, that are preferentially directed towards the periodontal ligament. is how cementocytes derive their nutrition from periodontal ligament & contribute to the vitality of this mineralized tissue.

This

While

adjacent canaliculi of neighboring cells communicate frequently, the processes remain independent. Thus, the metabolites progress mostly by diffusion through the canaliculi of cellular cementum.

They

are multinucleated giant cells, which are indistinguishable from osteoclasts.

Responsible

for root resorption that leads to primary teeth exfoliation & also in the permanent dentition in mesial surfaces in compliance with mesial migration & may occur due to occlusal trauma & orthodontic therapy.

Embryologically
According to location on teeth ( Kronfield 1928).

Primary & Secondary


- Radicular cementum- found on root surfaces. - Coronal Cementum to Cementum that forms on the enamel covering the crown.

Types of Cementum

On the basis of cellularity (Gottlieb 1942).


Schroder(1986) classifiction based on cellularity & organisation of collagen fibres

- Acellular / Primary Cementum. - Cellular / Secondary Cementum.


- Acellular afibrillar cementum. - Acelluar extrinsic fiber cementum. - Acellular intrinsic fiber cementum.(1990) - Cellular intrinsic fiber cementum. - Cellular mixed stratified cementum -Intermediate cementum

Based on the origin of the collagen matrix

- Extrinsic. - Intrinsic. - Mixed.

Refers

to cementum lacking embedded cells. First formed cementum, covers approximately the cervical or of the root & does not contain cells.

Formed

before tooth reaches the occlusal plane.

Thickness

ranges from 30 230m. - Schroeder, (1986).

Sharpeys

fibers make up most of the structure of acellular cementum, which has a principle role in supporting the tooth.

Most fibers are inserted at angles into the root surface.

They are completely calcified with mineral crystals oriented parallel to the fibrils, except in a 10 50 m wide zone near the CEJ, where they are only partially calcified.
Also contains intrinsic collagen fibrils that are calcified and are irregularly arranged / parallel to the surface. - Schroder, (1980).

Is

formed after tooth reaches the occlusal plane.

Is

more irregular & contain cells (cementocytes) in individual spaces (lacunae). calcified than acellular cementum.

Less

Sharpeys

fibers occupy a smaller portion of cellular cementum. They are separated by other fibers that are arranged either parallel to the root surface or at random.

Thickness

of cellular cementum is greater than acellular.

Both

cellular & acellular cementum are arranged in lamellae separated by incremental lines, parallel to the long axis of the root. lines represent rest periods in cementum formation & are more mineralized than the adjacent cementum (Romanos 1992) & termed the Incremental lines of Salter.

These

Incremental lines of Salter in cementum

Acellular Cementum
Formation Cells Location Rate of formation Forms before tooth reaches occlusal plane Does not contain any cells Coronal portion of root Slow

Cellular Cementum
After tooth reaches occlusal plane Contains cementocytes Apical portion of root Rapid

Incremental lines

More & close

Sparse & wide

Acellular Cementum
Precementum
Calcification Sharpeys fibers Regularity of fibers Thickness Absent More calcified More Regular

Cellular Cementum
Present Less calcified Less Irregular

20 50m near the cervical Thickness of 1 several mm. region &150 200m near the apex.

Contains neither cells, nor extrinsic / intrinsic fibers, apart from a mineralized ground substance. It is a product of cementoblasts, found deposited on the enamel over small areas of the dental crown just coronal to the CEJ. Thickness is about 1 - 15 m.

Composed almost entirely of densely packed bundle of Sharpey's fiber and no cells.

A product of fibroblasts and cementoblasts,

Found

on the cervical of roots, but may extend further apically..

Cementoblasts that differentiate in close advancing root edge.

produce proximity

AEFC to the

Thickness

is between about 30 - 230 m & continues to grow in thickness (1.5 - 3 m / year) as long as the adjacent periodontal ligament remains undisturbed.

During

root development, the first formed cementoblasts align along the newly formed, but not yet mineralized, mantle dentin surface & exhibit fibroblastic characteristics. Deposit collagen fibrils within it so that dentin & cementum fibers intermingle.

Initially

AEFC consists of mineralized layer with a short fringe of collagen fibers implanted perpendicular to the root surface. then migrate away from the surface but continue to deposit collagen so that a fine fiber bundle lengthens & thickens.

Cementoblasts

These

cells also secrete non collagenous matrix proteins that fill in the spaces between the collagen fibers.

Only

after the first 15 20 m have formed, the intrinsic fibrous fringe become connected to the PDL. fiber bundles.

The overall degree of mineralization of this cementum is about 45 60%. AEFC has the potential to adapt to functionally dictated alterations such as mesial tooth drift.

Contains

both collagen fibers & calcified

matrix. It is the co product of cementoblasts & fibroblasts and consists of both extrinsic & intrinsic fibers.

Appears

primarily in the apical third of the roots & in furcation areas. of AEFC and CIFC that alternate & appear to be deposited in irregular sequence upon one another. - Schroeder, (1993). 0.1 0.5 m / year.

Consists

Deposit

Contains

cells but no extrinsic (Sharpey's) fibers.

A more rapidly formed & less mineralized variety of cementum.


is deposited on unmineralized dentin surface near the advancing root edge.

(CIFC)

Formed

by cementoblasts & fills resorption lacunae (resorptive cementum.)

Can

easily repair a resorptive defect of the root due to its capacity to grow faster than any other form of cementum.

An acellular variant of cellular intrinsic fiber cementum that is also deposited during adaptive responses to external forces (i.e.,) slow deposition rate. cells are not engulfed in their matrix - Bosshardt & Schreoder, (1990) .

Extrinsic Fiber Derived from the sharpeys fibers

Intrinsic Fiber Derived from the cementoblasts

Mixed Fiber
Both extrinsic and intrinsic fibres present

Extrinsic

fibers Sharpeys fibres continue into the cementum in the same direction as the principle fibers of the PDL

Intrinsic

fibres run parallel to the root surface and at right angles to extrinsic fibres

Cementum

deposition is a continuous process that proceeds at varying rates throughout life. coronal half of the root varies from 16m to 60m
Apical third to furcations - 150m 200m.

It

is thicker on the distal surface than on the mesial, consequent to functional stimulation from mesial drift over time (Polson.A et al 1990). more rapid in the apical region where it compensates for attrition (passive eruption).

Is

Between

the ages of 11 & 70, the average thickness 3 fold, with the greatest in the apical area.

Functions:
Anchorage Adaptation Repair

Primary

function is to give attachment to collagen fibers of the periodontal ligament.

It

is a highly responsive mineralized tissue maintaining the integrity of the root, helping to maintain the tooth in its functional position in the mouth.

Adaptation:

Cementum may be viewed as a tissue that makes the

functional adaptation of teeth possible.

Deposition of cementum in the apical area can compensate for loss of tooth substance from the occlusal wear.

As the most superficial layer of cementum ages, a new layer of cementum will be deposited to keep the attachment apparatus intact.

Repair:

Serves as a major reparative tissue for root surfaces. to roots like fractures and resorptions can be

Damage

repaired by new cementum.


Protects

the root dentin.

CEMENTOENAMEL JUNCTION (Noyes etal 1938)

Cementum overlaps enamel

The

terminal apical area of the cementum where it joins the internal root canal dentin

There

is no change in the width of CDJ with age

CDJ

is 2-3m wide

It

is often reported that an intermediate layer exists between cementum and dentine and this layer is involved in anchoring periodontal fibres to dentine

Intermediate cementum/Innermost cementum layer/Superficial layer of root dentin.

After

periodontal surgery, the cementum regenerate, but shows a space between regenerated cementum and dentine indicating the absence of a true union.

Permanent

teeth do not undergo physiologic resorption as do primary teeth. Cementum is less susceptible to resorption than bone. 70% of all resorption areas were confined to the cementum without involving the dentin.

Resorption

is carried out by multinucleated odontoclasts.

More

fluoride content in cementum than bone and the surface of the cementum is covered by a layer of tightly packed collagen fibres, therefore the mineralized surface is inaccessible makes it less susceptible for resorption.

Appears

microscopically as bay like concavities in the root surface Multinucleated giant cells and large mononuclear macrophages are found adjacent to cementum undergoing resorption. Resorptive process may extend into the underlying dentin and even into the pulp, but it is usually painless. Resorption is not continuous and may alternate with periods of repair and deposition of new cementum.

The

newly formed cementum is demarcated from the root by a deeply staining irregular line Reversal line. Reversal lines contain a few collagen fibers Contains highly accumulated proteoglycans with glycosaminoglycans. Embedded fibres of the PDL reestablish a functional relationship in the new cementum.

Trauma

from occlusion Orthodontic movement Pressure from malaligned erupting teeth Cysts and tumors Teeth without functional antagonists Embedded teeth Replanted and Transplanted teeth Periapical disease Periodontal disease

Calcium

deficiency

Hypothyroidism

Hereditary
Pagets

fibrous osteodystrophy

disease

Prominent

thickening of the cementum. Localized to one tooth or affect the entire dentition. An age related phenomenon.

Excessive

proliferation of cementum may occur in

neoplastic and non-neoplastic conditions like benign cementoblastoma, cementifying fibroma, periapical cemental dysplasia, florid cemento-osseous dysplasia and other fibro - osseous lesions

Occurs as a generalized thickening of the cementum, with nodular enlargement of the apical third of the root.

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 fibers at the sites of insertion into the cementum.

If

the over growth improves the functional qualities of the cementum; it is termed as cemental hypertrophy.
the overgrowth occurs in non - functional teeth / if it is not correlated with increased function, it is termed Hyperplasia. embedded calcified round bodies are found in localized areas of hyperplastic cementum.& are designated excementosis, & develop around degenerated epithelial rests.

If

Sometimes,

The

spike like type of hypercementosis generally results from excessive tension from orthodontic appliances or occlusal forces. Hypercementosis of the entire dentition may occur in patients with Paget's disease.

Systemic

disturbances that may lead to hypercementosis may include: Acromegaly Arthritis Calcinosis Rheumatic fever Thyroid goiter

1. 2.

3.
4. 5.

Does

not require treatment. This may complicate if an affected tooth requires extraction.

CEMENTAL APLASIA
A rare

condition in which there is a reduction in the activity of tissue non-specific alkaline phosphatase Characterized by reduction in the formation of cementum, affects both cellular and acellular cementum The attachment of PDL is affected, results in the premature loss of teeth

ANKYLOSIS
Fusion

of the cementum and alveolar bone with obliteration of the periodontal ligament. Ankylosis occurs in teeth with cemental resorption, which suggests that it may represent a form of abnormal repair.

Ankylosis

also may develop after chronic periapical inflammation, tooth replantation and occlusal trauma and around embedded teeth. Ankylosis results in resorption of the root and its gradual replacement by bone tissue. For this reason, reimplanted teeth that ankylose will lose their roots after 4 to 5 years and exfoliate.

As

the PDL is replaced with bone, the proprioception is lost Because the receptors are deleted or do not function correctly Physiologic drifting and eruption of teeth can no longer occur. So the ability of the periodontium to adapt to the altered force levels is greatly reduced Radiographically resorption lacunae are filled with bone and PDL space is missing

Calcified

bodies in the PDL. that are adherent to or detached from the root surface. Its diameter rarely exceeds 0.2 mm.

Develop

from calcified epithelial rests, around small spicules of cementum / alveolar bone traumatically displaced into PDL.,

From

calcified Sharpeys fibers and thrombosed vessels within the PDL.

Detachment

of fragments of cementum from the root surface is known as Cemental tear, which may be complete or incomplete.

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.

These

are masses of cementum generally situated apical to teeth to which they may or may not be attached. are considered either odontogenic neoplasms / developmental malformations. more frequently in females than males.

They

Occurs

Seen

more commonly in mandible as compared to maxilla.

Radiographically,

the lesion appears as a discrete, dense, radio-opaque mass in which isolated radiolucent markings may be seen.

Cementum

is the mineralized dental tissue covering the anatomic roots of human teeth, which forms the integral part of the periodontium that supports the tooth in the socket. The normal periodontium is a unique and complex structure that has distinct functions and capable of adaptation, repair and regeneration.

Carranzas

Clinical Periodontology, 10th edition, Newman, Takai,Klokkevold,Carranza. Pgs 75-79 Oral Anatomy, Histology and Embryology, 4th edition,. B.K.B. Berkovitz, G.R. Holland, B.J Moxham, pgs 169 -178 Orbans Oral Histology and embryology, 12th edition, pgs 137-154

Ten Cates Oral Histology, Development, structure and function, 7th edition, Antonio Nanci, pgs 239-253. Dental cementum: the dynamic tissue covering of the root. Periodontology 2000. Vol. 13, 1997, 41-75

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