Cementum in Health and

Disease

CONTENTS

INTRODUCTION
DEFINITION
SIMILARITIES WITH BONE
CEMENTOGENESIS
PROPERTIES
CLASSIFICATION
CEMENTOENAMEL JUNCTION
CEMENTODENTINAL JUNCTION
THICKNESS
FUNCTION
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
APPLICATION IN FORENSIC ODONTOLOGY
CONCLUSION
REFERENCES

Introduction

Periodontium consists of investing layer and supporting tissues

of the tooth: gingiva, periodontal ligament, cementum and
alveolar bone.
Divided into 2 parts:
Gingiva : protects the underlying tissues
Attachment apparatus : composed of PDL, cementum and
alveolar bone
Cementum is considered a part of the periodontium because,
with the bone - supports fibres of PDL.
It was demonstrated microscopically in 1835 by 2 pupils of
Purkinje (Bhaskar SN, 1991)
Hard bone like tissue covering the anatomic roots of the teeth
(Newman et al, 2006) .

Word is derived from Latin word Caementum, quarried

stone- chips of stone used in making mortar (Nanci A, 2003).
Its a specialized mineralized tissue covering root surfaces and
occasionally small portions of crown of teeth
Has many features in common with bone tissue.

Definition

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 of periodontology).

Similarities with bone (Saygin et al, 2000)

Diseases that affect the bone, often alter cementums

properties as well. Eg. Pagets disease results in
hypercementosis, hypophosphatasia results in no cementum
formation, etc..
Composition is similar to that of bone
Differences are
Avascular
Lack Haversian canals
Not innervated
Exhibits little or no remodeling
Less readily resorbed therefore permits orthodontic
movement

Differences in physicochemical or biological properties

Properties of precementum
Increased density of Sharpeys fibers (particularly in
acellular cementum)
Proximity of epithelial cell rests to the root surface

Cementogenesis (Bosshardt and Selvig, 1997)

Formation of cementum can be subdivided into

Prefunctional developmental stage : formed during the root
development - 3.5 and 7.5 years - prefunctional
development is extremely long
Functional developmental stage : commences when the
tooth is about to reach the occlusal level
associated with attachment of root to bone
continues throughout life - adaptive and reparative
processes are carried out by the biological
responsiveness of cementum
influences the alterations in the distribution and
appearance of the cementum varieties on the root
surface with time.

Root formation

Cementoblast origin

Precursors of cementoblasts and PDL fibroblasts - dental

follicle
Factors within local environment regulate - cementoblasts of
cementum, fibroblasts of PDL or osteoblasts of bone tissue
Infiltrating dental follicle cells receive reciprocal inductive
signal from the forming dentin and differentiate into
cementoblasts
HERS cells may undergo epithelial-mesenchymal
transformation into cementoblasts during development
Extracellular matrix proteins - noncollagenous proteins found
in bone bone sialoprotein - precementoblast chemoattraction,
adhesion to root surface and cell differentiation.
Enamel proteins - to be involved in early cementogenesis.

Development of dentinocemental junction

Precementoblasts differentiate along external surface of

predentin into cementoblasts
Implant initial collagen fibrils (fibrous fringe) of cementum
matrix into predentin by extending numerous tiny
cytoplasmic processes
Leads - intimate interdigitation of 2 different fibril
populations - forming dentinocemental junction - gets
mineralized later
Intermediate cementum - interfacial layer between dentin and
cementum - observed particularly between acellular extrinsic
fiber cementum and dentin in rodent teeth and not in humans

Development of Primary (acellular)

cementum (Berkowitz et al,2002)

PDL fibers oriented more parallel to the root surface and not
gained any attachment to fibrous fringe.
Subsequent development of acellular cementum involves
Slow increase in thickness
Establishment of continuity between collagen fibers of the
periodontal ligament with those of the fibrous fringe at the
surface of root dentin
Continued slow mineralization of collagen
Establishment of continuity with PDL occurs only after tooth
has erupted into the mouth, when 2/3 of root has formed and
acellular cementum may be only about 10 m thick
Cementum lining tooth before this time - acellular intrinsic fiber
cementum

Once PDL fibers become attached, cementum - acellular

extrinsic fiber cementum.
Increases slowly and evenly throughout life at a rate of about 22.5 m per year
Mineralization of cementum
Does not appear to be controlled by cementoblasts
No matrix vesicles observed
Likely that presence of hydroxyapatite crystals in the
adjacent dentin initiates mineralization
Adjacent PDL fibroblasts, which are rich in alkaline
phosphatase, may also pay a role
Proceeds very slowly in a linear fashion, therefore no
evidence of a layer of precementum

Calcospherites not observed

As the initial formation of cementum is closely associated
with mineralization of predentin or hyaline layer, when
mineralization of initial root dentine is interfered with by
administration of drugs known as bisphosphonates, there is
inhibition of cementogenesis.
Cementogenesis
Occurs rhythmically periods of activity alternating with
periods of quiescence
Structural lines observed indicating the incremental nature
of formation
Periods of decreased activity associated with incremental
lines called incremental lines of Salter

These lines contain

higher content of
ground substance and
mineral and lower
content of collagen.
As acellular cementum
is formed slowly, the
incremental lines are
closer together than that
of cellular cementum
which is deposited
more rapidly.

Development of acellular afibrillar cementum

Deposited as a thin layer overlying enamel at the cervical

margin of the tooth
Presumably, the protection of the reduced enamel epithelium
overlying this enamel in an unerupted tooth is damaged or
lost
Adjacent connective tissue cells of the dental follicle then
come into contact with the enamel surface and are induced to
form cementoblasts
These secrete an afibrillar matrix that calcifies

Development of Secondary (cellular)

cementum

Secondary cementum appears in the apical region of the root at

time tooth erupts.
Also in furcation area of multirooted teeth.
Associated with increase in the rate of formation of the tissue
Following loss of continuity of the HERS, large basophilic cells
are seen to differentiate from adjacent cells of the dental follicle
against the surface of the root dentine form a distinct layer of
cementoblasts
These cementoblasts possess more cytoplasm and cytoplasmic
processes than the cells associated with acellular cementum
Basophilia is due to roughened endoplasmic reticulum their
presence suggests that cementoblasts secrete the collagen (together
with ground substance) that forms the intrinsic fibers of secondary,
cellular cementum

These fibers are oriented parallel to root surface

Due to increased rate of formation, thin unmineralized
precementum layer (about 5 m thick) will be present on the
surface of cellular cementum
Precementum is less mineralized than primary cementum
Multipolar mode of matrix secretion by the cementoblasts
will result in cells becoming incorporated into the forming
matrix thus called cementocytes
Incremental lines are more widely spaced due to increased
rate of formation

Properties

Physical properties: (Berkowitz et al, 2002)

Pale yellow with a dull surface
Softer than dentine
Permeability
cellular variety more permeable as the canaliculi in
some areas are contiguous with the dentinal tubuli
more permeable than dentine
decreases with age
Soft and thin cervically readily removed by abrasion
when gingival recession exposes the root surface to the
oral environment

Chemical properties: (Berkowitz et al, 2002) and Bosshardt and

Selvig,1997)

On a wet weight basis:

Inorganic 65%
Organic 23%
Water 12%
By volume:
Inorganic 45%
Organic -33%
Water -22%

Inorganic
Acellular cementum is more mineralized than cellular
cementum - presence of uncalcified lacunae and core of
Sharpeys fibers in cellular cementum and slow formation of
acellular cementum which allows longer direct contact of tissue
fluids
CDJ shows a zone of high mineral content and low organic
content delineated by zones of low mineral content on the
dentin and sometimes on cementum side
Principle inorganic component- hydroxyapatite
(Ca10(PO4)6(OH)2) with small amounts of amorphous calcium
phosphates present

These crystals are thin and plate like and similar to those in
bone and arranged parallel to the long axis of collagen fibril

Avg- 55nm wide and 8nm thick

Length varies
Minute size of mineral crystals allows for greater
capacity for adsorption of fluoride and other elements
and more readily decalcifies in the presence of acidic
conditions
Concentration of fluoride tends to be higher at the external
surface, conc. of 0.9% ash weight increases with age and
varies with the nutritional fluoride supply to the individual

Contains 0.5-0.9% Mg occupies the place of an equal

no. of Ca ions in hydroxyapatite crystal lattice

Similar to that of bone but half of that of dentine

Mg conc. appears to be lower at the surface than in deeper layers
of cementum

Contains 0.1-0.3% sulfur as a constituent of the organic

matrix
Trace elements Cu, Zn and Na

Organic
Collagen :
Primarily collagen type I and III, like in bone and
PDL
90% of organic matrix type I collagen and
approximately 5% - 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

Non collagenous proteins :

Glycolipids, glycoproteins or proteoglycans

Non-collagenous proteins are similar to that of bone - bone

sialoprotein and osteopontin both are phosphorylated and
sulfated glycoproteins

Bind tightly to collagenous matrices and

hydroxyapatite

Participate in mineralization process

Reveal cell attachment properties through tripeptide

sequence Arg-Gly-Asp that binds to integrins

Acellular cementum contains much more of these

than cellular cementum

Osteonectin another glycosylated protein

Found in extracellular matrix of mineralized

tissue

Close relation between osteonectin and

collagen seems to exist in mineralization
process

Enzyme alkaline phosphatase believed to participate in

cementum mineralization (Beertsen and Everts, 1990)

Supersaturation of phosphate ions, released from

organic phosphate esters, would result in the
precipitation of calcium phosphate salts

Although it exists in a plasma membrane bound

form, part of the enzyme may also be bound to
extracellular matrix

Enzyme activity adjacent to cellular intrinsic fiber

cementum is higher than that to acellular extrinsic
fiber cementum and thickness of the latter correlates
positively with the enzyme activity (Groeneveld et
al, 1995)

Glycoproteins fibronectin and tenascin more widely

distributed

High molecular weight and multifunctional proteins of

the extracellular matrix

Fibronectin binds cells to components of extracellular

matrix

During tooth development, both are present in the

basement membrane of HERS at the time of
odontoblast differentiation

Later, they are also found at the attachment site of

PDL to cementum but not in the cementum layer itself
(Lukinmaa et al 1991)

Enamel related proteins have been detected

Proteoglycans core protein to which sulfated
polysaccharides are covalently linked
chondroitin sulfate, dermatan sulfate and
hyaluronic acid

Classification (Berkowitz et al, 2002)

Based on presence or absence of cells

Cellular cementum:
Contains cells (cementocytes)
Found in the apical and interradicular areas and overlying
the acellular cementum
Formed after acellular - secondary cementum
Fast rate of matrix formation incremental lines farther
Presence of precementum
Spaces that the cementocytes occupy are called lacunae
and the channels that their processes extend along are the
canaliculi
Adjacent canaliculi are often connected and the processes
within them exhibit gap junctions

Cementocytes are more widely dispersed and more

randomly arranged
Canaliculi preferentially oriented towards PDL - chief
source of nutrition
Once embedded cementocytes become relatively
inactive
Their cytoplasmic/nuclear ratio is low
Sparse organelles responsible for energy
production and for synthesis
Some unmineralized matrix may be seen in the
perilacunar space
Border with dentine clearly demarcated

Acellular cementum:
Appears relatively structureless no cells.
First formed primary cementum
Covers the root adjacent to the dentine more in the
cervical 2/3
Slower rate of matrix formation
Incremental line closer
Precementum virtually absent

Border with dentin not clearly demarcated

Based on the nature and origin of the organic matrix

Cementum derives its organic matrix from 2 sources
Extrinsic fibers: from the inserting Sharpeys fibers of
the periodontal ligament perpendicular or oblique to
root surface
Intrinsic fibers: from cementoblasts run parallel to root
surface and approximately at right angles to extrinsic
fibers
Mixed fiber cementum: both the above fibers are present

Based on presence or absence of cells and the nature and

origin of the organic matrix Schroeders classification
(Newman et al, 2006)

Acellular afibrillar cementum (AAC):

Contains neither cells nor extrinsic or intrinsic
collagen fibers
Only mineralized ground substance
Product of cementoblasts
Found as coronal cementum
Thickness 1-15m

Acellular extrinsic fiber cementum (AEFC):

Composed almost entirely of densely packed bundles of
Sharpeys fibers
Product of fibroblasts and cementoblasts
Cervical third of roots but may extend farther apically
Thickness 30-230m
Cellular mixed stratified cementum (CMSC):
Composed of extrinsic (Sharpeys) and intrinsic fibers
May contain cells
Co-product of fibroblasts and cementoblasts
Primarily in the apical third, apices and in furcation areas
Thickness 100-1000m

Cellular intrinsic fiber cementum (CIFC):

Contains cells, but no extrinsic collagen fibers
Formed by cementoblasts
Fills resorption lacunae
Intermediate cementum:
Poorly defined zone near cementodentinal junction of
certain teeth that appears to contain cellular remnants
of Hertwigs sheath embedded in calcified ground
substance

Cementoenamel junction (Newman et al, 2006)

Cementum overlaps enamel 60-65%

Edge-to-edge butt joint 30%
Cementum and enamel fail to meet 5-10%
In this case, gingival recession may result in accentuated
sensitivity because of exposed dentin

Cementodentinal junction

Terminal apical area of cementum where it joins the internal

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

Thickness (Berkowitz et al, 2002)

Varies at different levels of the root

Thickest at the root apex and interradicular areas of
multirooted teeth 50-200m (may exceed to 600m)
Thinnest cervically 10-15m
Thickest in distal side than mesial due to mesial drift
Between ages 11 and 70 thickness increases 3 fold 95m
at 20yrs and 215m at 60yrs (Zander and Hurzler, 1958)
Impacted teeth have thin cementum

Function

Its contiguous with the periodontal ligament on its outer

surface and is firmly adherent to dentine on its deep surface
gives attachment to collagen fibers of the periodontal
ligament
Maintains the tooth in functional position in the mouth
Maintains the integrity of the root

Metabolism (turnover) at the tissue and

molecular levels (Bosshardt and Selvig, 1997)

Cementum is excluded from metabolic processes of the body

Variety of noncollagenous proteins are stored in the mineralized
matrix of the cementum, among which those specific for
cementum are
Cementum derived attachment protein mediates attachment
of connective tissue cells
Cementum derived growth factor during root resorption and
surgical instrumentation, proteins exposed to root surface
could possibly influence the initiation of repair process by
cell migration, division, attachment and differentiation
Fluoride accumulates in the surface layer which is exposed to the
circulating tissue fluids in the periodontal ligament

Age changes (Bosshardt and Selvig, 1997)

Continuous deposition:
Cementum formation continues throughout life unless
disturbed by periapical or periodontal pathology
Deposited at a linear rate (Azaz et al, 1974)
More cementum is formed apically than cervically
Cementum thickness shows variations among tooth
groups and surfaces
Thick layers may form in root surface grooves and
furcations of multirooted teeth
Great variations in incremental lines indicate that rate of
cementum formation may vary

Changes in tooth position may exert temporal and spatial

variations in pressure and tension on root and bone
surfaces biological responsiveness of cementoblasts to
these stimuli may influence the rate as well as pattern of
cementum deposition maintaining the tooth in proper
position and relation to adjacent teeth
Nonfunctioning, impacted teeth appear to have thicker
cementum and structural architecture is different
Impacted teeth Sharpeys fibers may be nearly
completely absent in the cementum and it is built up
mainly by intrinsic fibers arranged parallel to root surface

Physiological activity of cementocytes:

No. of cells that become incorporated into cementum matrix
while its formation is proportional to the rate of cementum
deposition
Cementocytes close to cementum surface may resemble
cementoblasts but the amount of cytoplasm is reduced and they
contain less endoplasmic reticulum and fewer mitochondria
Most well developed cell processes point towards root surface
indicate that exchange of metabolites through cellular intrinsic
fiber cementum is limited
In deeper layers of CIFC, more advanced nuclear and
cytoplasmic changes may occur or lacunae may appear empty
could be due to starvation or consequence of age

Cementum reactions to physiological tooth movement and

occlusal forces:
Presence of cementum on impacted teeth indicates that
occlusal forces are not necessary to stimulate cementum
deposition
In posterior teeth, cementum is markedly thicker on the
distal than on the mesial root surface indicating
relationship to mesial drift
Cementum like bone is dynamically responsive and its
growth may be stimulated by tensional forces
Cementum thicker in areas exposed to tensional forces

Resorption and repair (Bosshardt and Selvig, 1997)

Types of resorption:
Physiological root resorption : normal phenomenon of
deciduous teeth during tooth shedding
Causes for resorption of permanent teeth
pathological like infectious, systemic diseases like calcium
deficiency, hypothyroidism, hereditary fibrous
osteodystrophy and Pagets disease or tumors
nonpathological like trauma (mechanical, chemical or
thermal) or sustained overcompression of the PDL
idiopathic
Root resorption classified according to location as
Internal
External

According to degree of persistence

Transient
Progressive
Root surface more resistant to resorption than bone
No. of teeth resorbed and severity of resorption are markedly
increased by orthodontic treatment
Appears microscopically as bay like concavities in the root surface
Multinucleated giant cells and large mononuclear macrophages are
generally found adjacent to cementum
May extend into underlying dentin
Not necessarily continuous, may alternate with periods of repair
and deposition of new cementum, new cementum is demarcated
from the root by a deeply staining irregular line - reversal line

Repair:

Following detachment of odontoclasts from the root

surface, cementogenic cells repopulate the Howships
lacunae and attach the initial repair matrix to a thin
decalcified layer of residual and exposed collagen fibrils
Basophilic and electron dense reversal line forms at the
fibrillar junction
Deposited repair matrix resembles cellular intrinsic fiber
cementum
Cementum repair requirea viable connective tissue

Can occur in devitalized and in vital teeth

CEMENTUM IN DISEASE

Developmental anomalies

Concrescence (Shafer et al, 2006)

Form of fusion which occurs after root formation

Teeth are united by cementum
Thought to arise as a result of traumatic injury or
crowding of teeth with resorption of interdental bone, so
that 2 roots are in approximate contact and become fused
by deposition of cementum
May occur before or after tooth eruption
Diagnosed radiographically
Extraction of 1 may result in the extraction of the other

Ectopic enamel (Neville et al, 2002)

Presence of enamel in unusual locations, mainly tooth rooth

Enamel pearl :
Hemispheric structures consisting entirely of enamel or
contain underlying dentin and pulp tissue
Project from surface of root, more in maxillary molars
Thought to arise from localized bulging of odontoblastic
layer bulge may provide prolonged contact between
HERS and developing dentin, triggering induction of
enamel formation

Majority occur in furcation area or CEJ

Precludes normal periodontal attachment with connective
tissue and a hemidesmosomal junction probably exists
less resistant to breakdown, once separation exists rapid
loss of attachment
Conducive to plaque retention and inadequate cleansing

Cervical enamel projections :

Represent dipping of enamel from CEJ toward the bifurcation
More in mandibular molars buccal surface
Correlated positively to localized loss of periodontal
attachment with furcation involvement
Have been associated with development of inflammatory
cysts histopathologically identical to periapical cysts
develop along buccal surface over the bifurcation called
buccal bifurcation cysts
Both cases meticulous oral hygiene to prevent localized loss of
periodontal support
Sometimes removal of the enamel is advised to achieve a more
durable periodontal attachment

Hypercementosis (Neville et al, 2002)

Nonneoplastic deposition of excessive cementum that is

continuous with the normal radicular cementum
Radiographically thickening or blunting of the root, surrounded
by radiolucent PDL space and adjacent intact lamina dura
Also appears in form of spike-like excrescences called cemental
spikes created by either coalescence of cementicles to the root or
calcification of PDL fibers
May be isolated, may involve multiple teeth or may appear as a
generalized process
Premolar teeth involved most frequently
Occurs predominantly in adulthood and frequency increases with
age

Factors associated
Local factors
Abnormal occlusal trauma
Adjacent inflammation
Unopposed teeth (eg. Impacted, embedded, without
antagonist)
Systemic factors
Acromegaly and pituitary gigantism
Arthritis
Calcinosis
Pagets disease of bone
Rheumatic fever
Thyroid goiter

Histopathologically
Periphery of root demonstrates deposition of an excessive
amount of cementum over the original layer of primary
cementum
Excessive cementum may be hypocellular or exhibit areas of
cellular cementum that resemble bone(osteocementum)
Often arranged in concentric layers
May be applied over the entire root or be limited to the apical
portion
Use of polarized light clearly separates dentin and cementum
Treatment require no treatment, certain cases extraction has
been difficult where sectioning of the tooth may be required

Ankylosis (Shafer et al, 2006)

Cessation of continued eruption

Anatomic fusion of tooth cementum or dentin with alveolar bone
Other terms infraocclusion, secondary retention, submergence,
reimpaction and reinclusion
Pathogenesis is unknown and may be secondary to disturbances from
Changes in local metabolism
Trauma
Injury
Chemical or thermal irritation
Local failure of bone growth
Abnormal pressure from the tongue

Periodontal ligament might act as a barrier that prevents

osteoblasts from applying bone directly onto cementum, ankylosis
could arise from a variety of factors that result in a deficiency of
this barrier could be due to trauma or genetically decreased
periodontal ligament gap
Other theories point to a disturbance between normal root
resorption and hard tissue repair
Several investigators believe genetic predisposition has a
significant influence and point to monozygotic twins who
demonstrate strikingly similar patterns of ankylosis
Clinical and radiographic features
May occur at any age, mainly 7-18 years
Most commonly involved tooth mandibular primary 1st molar

Occlusal plane is below that of adjacent dentition

Sharp solid sound on percussion when more than 20% of the
root is fused to bone
Radiographically absence of periodontal ligament space,
but the area of fusion is often in the bifurcation and
interradicular root surface making radiographic detection
difficult
Ankylosed teeth that are allowed to remain in position
adjacent teeth incline towards it leading to occlusal and
periodontal problems
Opposing tooth exhibits overeruption
It also leads to impaction of the underlying permanent tooth

Treatment
Fail to respond to orthodontic treatment
When an underlying permanent successor is present, extraction
should not be performed until it is obvious that exfoliation is not
proceeding normally or adverse occlusal changes are developing
In permanent teeth or primary teeth without underlying
successors prosthetic buildup can be placed to augment the
occlusal height
Luxation of affected permanent teeth may be attempted with
extraction forceps to break the ankylosis subsequent inflammatory
reaction may result in the formation of a new fibrous ligament in the
area of previous fusion reevaluation in 6 months is mandatory

Regressive alterations of teeth (Shafer et al, 2006)

Abrasion :
Pathologic wearing away of tooth substance through some
abnormal mechanical process
Usually occurs on exposed root surfaces
Robinson stated that the most common cause of abrasion is the
use of an abrasive dentifrice
Modern dentifrices are not sufficiently abrasive and can cause
remarkable wear of cementum and dentin if toothbrush carrying
it is injudiciously used, particularly in horizontal direction
V-shaped or wedge shaped ditch on root side of CEJ in teeth with
some gingival recession angle formed in lesion - sharp and
dentin appears highly polished
Improper use of dental floss and toothpicks may produce lesions
on proximal exposed root surface

Cementicles :
Small foci of calcified tissue, not necessarily true cementum, which
lie free in the PDL of lateral and apical root areas
Exact cause is unknown
Mostly represent areas of dystrophic calcification and thus are an
eg. of regressive or degenerative change
Develop by
Calcification of epithelial cells enlarge by further deposition
of calcium salts in the adjacent surrounding connective tissue
continued peripheral calcification may result in eventual union
or even inclusion of the cementicle in the root cementum or
alveolar bone pattern of calcification is of a circular
lamellated structure. Only when embedded in the cementum, it
may impart a roughened globular outline to the root surface

Focal calcification of connective tissue between Sharpeys bundles

with no apparent central nidus occurs as small round or ovoid
globules of calcium salts
Small spicules of cementum torn from the root surface cemental
tears or fragments of bone detached from the alveolar plate, if
lying free in the PDL may resemble cementicles, particularly after
they have undergone some remodeling through resorption and
repair
Calcification of thrombosed capillaries in PDL, as Mikola and
Bauer pointed are analogous to phleboliths too small to be seen
on radiographs 0.2-0.3mm in diameter
Clusters of cementum may form and the apices these have been
regarded as a cementoma particularly as they unite through interstitial
deposition of bone or cementum
No clinical significance

Root caries
Defined by Hazen et al as soft progressive lesion that is found anywhere on
the root surface that has lost connective tissue attachment and is exposed to
the oral environment
Dentitions of older age group with significant gingival recession and
exposed root surfaces
Was earlier referred to as caries of cementum
Initiates on mineralized cementum and dentin surfaces which have greater
organic component than enamel
Frequently on buccal and lingual surfaces of roots
Dental plaque and microbial invasion are an essential part of the cause and
progression of the lesion
Organisms filamentous
Microorganisms appear to invade the cementum either along Sharpeys
fibers or between bundles of fibers

Since cementum is formed in concentric layers and presents a

lamellated appearance, microorganisms tend to spread laterally
between various layers
After decalcification of cementum, softening and destruction of
the remaining matrix takes place
Later invasion of microorganisms into dentinal tubules matrix
destruction pulpal involvement
Westbrook et al as there are less dentinal tubules per unit area in
root than in crown, there is difference in rate of caries progression
and amount of dentinal sclerosis present
According to Katz et al most frequently affected teeth are
mandibular molars, next the mandibular premolars and then the
maxillary cuspids, interproximal areas were mostly affected in the
maxillary arch and the buccal surface in mandibular arch

Attachment of calculus
Zander in 1953 investigated calculus attachment and observed
four types of attachment (Shafer et al, 2006)
Attachment to the secondary cuticle
Attachment to microscopic irregularities in the surface of
cementum corresponding to previous location of Sharpeys
fibers
Penetration of microorganisms of calculus matrix into
cementum
Attachment into areas of cementum resorption
Calculocementum: Calculus embedded deeply in cementum may
appear morphologically similar to cementum (Newman et al)

Alterations resulting from periodontal

pathology (Bosshardt and Selvig, 1997)

Effect of gingival inflammation

Subsurface alteration :
Alterations in structure and composition of its organic
and inorganic components consequential to pathological
changes
Longstanding presence of inflammatory process in
gingival connective tissue results in net loss of collagen
and in breakdown of dentogingival fibers - enzymatic
breakdown of collagen fiber is obvious in the gingival
soft tissue and extension of this process into the hard
tissue of the root, with loss of collagen cross-banding and
dissolution of mineral crystals has also been described
surface limited with diffuse transition to subjacent
unaffected tissue

Cervical root resorption :

Development of large root resorption defect in cervical region is,
most likely, triggered by inflammatory processes in adjacent
connective tissue
Such resorption generally has an undermining character
Tooth is resorbed after the alveolar bone immunity to
resorption has been linked to presence of an uncalcified, vital
layer of precementum on root surface
Another explanation could be because cementum is avascular
Odontoclasts take their origin from bone marrow and cannot
attack the root surface as fast as the osteoclasts reach the
bone surface

Exposure to oral environment

Bacterial contamination:
Obvious alterations may occur following exposure of
cementum to the environment of periodontal pocket or
oral cavity
Root surface wall of periodontal pockets is significant
as they may perpetuate periodontal infection, cause
pain and complicate periodontal treatment
The root cementum suffers structural, chemical and
cytotoxic changes.

Structural changes: (Carranza and Newman, 1996)

Presence of Pathologic Granules:

First reported by Bass,1951

Represent areas of collagen degeneration or areas where

collagen fibrils have not been mineralized initially

These granules extend 3-12 m into the surface of cementum

from overlying plaque

Granules appeared in 4 basic morphologic patterns:

Grape like structure
Long chain aggregate
Small isolated vacuoles
Very long fissure like area (Garrett, 1975)

Areas of increased mineralization:

Probably a result of an exchange, on exposure to oral cavity, of

minerals and organic components at cementum-saliva interface

Microhardness remains unchanged

Development of highly mineralized superficial layer may

increase the tooth resistance to decay

Hypermineralized zones are detectable by electron microscopy

and are associated with increased perfection of the crystal
structure and organic changes suggestive of a subsurface
cuticle seen in microradiographic studies as a layer 10-20m
thick with areas as thick as 50m

Lack of preferred crystal orientation

Crystals are more densely packed and appeared as

distinct, tablet shaped, polygonal structures (Selvig, 1969)
No decrease in mineralization found in deeper areas,
therefore indicating that increased mineralization does not
come from adjacent areas
Increase in calcium, magnesium, phosphorus and fluoride
(Wirthlin et al, 1979)
Loss of, or reduction in, the cross-banding of collagen
near the cementum surface and subsurface condensation
of organic material of exogenous origin have also been
reported

Areas of demineralization

Commonly related to root caries

Exposure to oral fluid and bacterial plaque results in

proteolysis of the embedded remnants of Sharpeys fibers

Cementum may be softened and may undergo

fragmentation and cavitation

Progress around teeth and appear as well defined

yellowish or light brown areas, covered by plaque and
have a soft or leathery consistency on probing

Dominant microorganism - actinomycosis viscosus

Root caries may be the cause of toothache in patients with

periodontal disease and no evidence of coronal decay

Areas of cellular resorption of cementum and dentin

Common in roots unexposed by periodontal disease

Symptom free

As long as root is covered by PDL, they are likely to

undergo repair

If root is exposed before repair occurs, these areas appear

as isolated cavitations that penetrate into dentin

Chemical changes:
Mineral content is increased
Following minerals are increased in diseased root surfaces
Calcium
Magnesium
Phosphate
Fluoride
Exposed cementum may absorb calcium, phosphorus and
fluoride from its local environment forming a highly
calcified layer that is resistant to decay
This ability of cementum to absorb substances may be
harmful if the absorbed materials are toxic

Cytotoxic Changes:
Bacterial penetration into the cementum can be found as deep
as the cemento dentinal junction - facilitated by the
occurrence of minifracture and cracks of cemetum or a
common sequence to chronic periodontal disease
Bacterial lypopolysaccharide have been detected in the 4070m deep surface of periodontally diseased roots
Bacterial endotoxins have also been detected in the cemental
wall of periodontal pockets, whether the toxin is actually
absorbed to or trapped in the tissue has not been established
Reduced opacity, cavitation and partial decalcification
extending as deep as 300m without any loss of surface
contour can exist

These imperfections can harbour endotoxin on a

submicroscopic basis and serve as a substrate for
inflammatory exudate.
Components of this exudate can include substance such as
histamine, bradykinin, high molecular weight
immunoglobulins IgG, IgA, IgM and complement
Endotoxin which has been found in the cementum also may
act to produce direct labializations of the lysozomal enzyme
found within the cells of the tissue which then spill out into
the tissues to effect their resorptive activities

Cementum may act to perpetuate the destructive effects of

periodontal disease by acting as a reservoir for potentially
destructive material.
Aleo et al observed that endotoxin was found to be present in
the cementum of untreated periodontally involved teeth having
30% or more loss of supporting bone. The biologic effects of
this cementum - bound endotoxin, studied in vitro
concentration as low as 0-30 mg/ml of culture medium, were
effective in depressing cell proliferation and viability
When compared to endotoxin form E-coli the cementum
bound endotoxin was found to be more toxic. Either biologic
activities of endotoxins studied are not present to an equal
degree, or the cementum bound material contain heat resistant
toxic substances (Aleo et al, 1974)

Surface changes (SEM descriptions) (Garrett, 1975)

3-D view of the ultrastructural level
Landay et al 1971 showed numerous surface projections
above cemental plane in normal cementum
Landay 1972 areas exposed to periodontal disease
At base of pocket most recently exposed cementum
showed partial filling in spaces between projections
Cementum which has undergone longer exposure showed
complete covering of normal projections with what
appeared to be flat sheet of calculus
No holes or spaces where Sharpeys fibers had been once

Surface morphology of the tooth wall of periodontal pockets:

(Newman et al,2006)

The following zones can be found

Cementum covered by calculus
Attached plaque, which covers calculus and extends apically
from it to a variable degree, probably 100 to 500 m
Zone of unattached plaque that surrounds attached plaque &
extends apically to it
Zone of attachment of junctional epithelium to tooth - The
extension of this zone, which in normal sulci is more than 500
m, is usually reduced in periodontal pockets to less than 100
m
Zone of semidestroyed connective tissue fibers apical to
junctional epithelium

Zones 3,4 & 5 compose - plaque free zones seen in extracted

teeth.
The total width of the plaque free zone varies according to
type of tooth (It is wider in molars than incisors) and the
depth of the pocket (It is narrower in deeper pockets).
Term plaque-free zone refers only to attached plaque because
unattached plaque contains a variety of gram-positive coli
and various gram negative morphotypes including cocci,
rods, filaments, fusiforms and spirochetes. Most apical zone
contains predominantly gram-negative rods and cocci.

Neoplasms of the cementum (Shafer et al, 1997)

Benign cementoblastoma (True Cementoma):

Probably a true neoplasm of functional cementoblasts
which form a large mass of cementum or cementum like
tissue on the tooth root.
Clinical features:
Frequently, under age of 25 years
No significant sex predilections
Mandibular first permanent molar - most frequently
affected tooth
Other teeth involved - mandibular second and third
molars, bicuspids, maxillary bicuspids and first, second
and third molars

Associated tooth is vital unless coincidentally involved

Lesion is slow growing and may cause expansion of
cortical plates of bone, but is usually otherwise
asymptomatic
Radiographic features:
Tumor mass is attached to tooth root
Appears as a well circumscribed dense radioopaque mass
often surrounded by a thin, uniform radiolucent line
Outline of the affected root is generally obliterated
because of resorption of root and fusion of the mass to the
tooth.

Histologic features:
Main bulk of tumor mass is composed of sheets of
cementum like tissue, sometimes resembling secondary
cellular cementum, but, other times being deposited in a
globular pattern resembling giant cementicles
Reversal lines scattered throughout this calcified tissue are
quite prevalent
Variable soft-tissue component consisting of fibrillar,
vascular & cellular elements
Many cemental trabeculae in areas of activity are bordered
by layers of cementoblast
Away from these trabecular surfaces, cementoclasts may be
evident

Frequently microscopically indistinguishable from the benign

osteoblastoma or giant osteoid osteoma - discussed by Larsson et al
Some areas are so cellularly active that they bear strong
resemblance to osteosarcoma
Periphery of tumour generally shows a soft tissue cellular layer
resembling capsule - here cemental trabeculae are almost arranged
at right angles
Treatment and prognosis :
Because of tendency for expansion of the jaw, it is believed that
extraction of the tooth is justified despite the fact, that the pulp is
vital recurrence rare
Distinguish from severe hypercementosis or chronic focal sclerosing
osteomyelitis (i.e., condensing osteitis) both of which may
superficially resemble

Periapical cemental dysplasia

Other names
Cementoma
Periapical Osteofibroma
Osteofibrosis
Cementifying fibroma
Localized fibro-osteoma
Cementoblastoma
Periapical fibrous Dysplasia.
Etiology
Unknown
Suggested to occur as a result of mild chronic trauma or
traumatogenic occlusion

Clinical feature :
Age - 20 years common
More common in females and more often in mandible
Lesion occurs in PDL around the apex of the tooth usually
mandibular incisor
Almost asymptomatic, when localized near the mental foramen
appear to impinge mental nerve and produce pain, paresthesia and
even anaesthesia
Histologic and radiographic features:
The lesion progress through three distinct stages:
Osteolytic phase: Periapical bone is replaced by a fibrous
connective tissue, there is fibroblastic proliferation that may
contain small foci of osteoid formation Radiographically a
radiolucent area

Cementoblastic phase: Islands and spicules of cementum

like matrix form within the connective tissue
Radiographically calcification in radiolucent area

Mature stage: The lesion is predominantly composed of

irregular cementum like material, which is densely
mineralized. Roentenogram has a well defined
radioopacity that is usually bordered by a thin radiolucent
line or band
Treatment and Prognosis :
Periodic observation, since its harmless, under no
circumstances should one extract the tooth or institute
endodontic procedures or otherwise disturb the tooth unless, for
reasons not related to the condition

Central cementifying fibroma

Neoplasm of the bone

Close histogenetic relationship between central cementifying
fibroma and central ossifying fibroma
Clinical features:
Common in young and middle aged adults, avg-35 yrs
Females : males = 2:1
Marked predilection for mandible
Generally asymptomatic until growth produces noticeable
swelling and mild deformity
Displacement of teeth may be an early feature
Relatively slow growing tumour, the cortical plates of
bone and overlying mucosa or skin are intact

Radiographic features:
Variable depending upon stage of development
Well circumscribed, demarcated from surrounding bone
Early stages appears radiolucent
As tumor matures increasing calcification radiolucent areas
becomes flecked with opacities until it appears as an extremely
radioopaque mass
Displacement of adjacent teeth is common
Have a centrifugal growth pattern grow by expansion in all
directions
When it reaches the inferior border of mandible, produces an
expansion thats in continuity with outline of tumor mass

Histologic features:
Composed of many delicate interlacing collagen fibers
interspersed by large numbers of active, proliferating
fibroblasts or cementoblasts
Many small foci of basophilic masses of cementum-like
tissue irregularly round, ovoid or slightly elongated
As lesion matures, islands increase in no. enlarge and
coalesce
Treatment and prognosis:
Should be excised conservatively
Recurrence is rare

Gigantiform cementum (Familial Multiple Cementoma)

Very rare condition which may or may not prove to be distinct

entity
Clinical features:
Onset at young age
Develops slowly and involves all four jaw quadrants
Radiographic features:
Diffuse radioopaque masses scattered throughout the jaw,
sometimes expanding the jaw
Described as consisting of dense, highly calcified, almost
totally acellular cementum which is poorly vascularized and
frequently becomes infected with ensuing suppuration and
sequestration

Focal cementoosseous dysplasia

Benign lesion, occupies a portion of the spectrum between

periapical and florid cemento osseous dysplasia
Posterior mandible is predominant site
Asymptomatic and detected only on radiographic examination
Smaller than 1.5 cm in diameter
May occur on dentulous and edentulous areas
Histologic feature:
Tissue consists of fragments of cellular mesenchymal tissue
composed of spindle shaped fibroblasts and collagen fibers
with numerous small blood vessels
Trabeculae of woven bone and cementum like material are
interspersed throughout the fibrous framework

Systemic diseases and its

influence on cementum (Shafer et al,
2006)

Cleidocranial dysplasia

Characterized by abnormalities of the skull, teeth jaws and

shoulder girdle and occasionally stunting of the long bones
Oral findings - prolonged retention of deciduous teeth and
subsequently delay in eruption of the succedaneous teeth
Roots of the teeth are often short and thinner than usual
and may be deformed
Surprising and unexplained feature was the absence of
cellular cementum on the erupted teeth in both dentition,
with no increased thickening of primary acellular
cementum

Hypophasphatasia

Hereditary disease due to deficiency of enzyme alkaline

phosphatase in serum or tissues and excretion of
phosphoethanolamine in urine
Earliest manifestation - may be loosening and premature loss
of deciduous teeth, chiefly incisors
Teeth present a unique appearance characterized by the
absence of cementum, presumably, as a result of
cementogenesis, so that there is no sound functional
attachment of the tooth to bone by PDL accounts for
spontaneous exfoliation of deciduous teeth. Occasionally a
foci of poorly formed cementum may be found on some teeth.

Hyperpituitarism

Increase in no. of granules in acidophilic cells or an adenoma

of anterior lobe of the pituitary gland gigantism or
acromegaly
Enlargement of jaws- mainly mandible, macroglossia,
anterior openbite
Root of posterior teeth enlarge as result of hypercementosis may be the result of functional and structural demands on
teeth, instead of a secondary hormonal effect
Supraeruption of the posterior teeth may occur in an attempt
to compensate for the growth of the mandible

Hypothyroidism (Neville et al, 2002)

Cretinism in infants or myxedema in adults

Decreased levels of thyroid hormone
Clinical features lethargy, dry coarse skin, swelling of face
and extremities, husky voice, constipation, weakness and
fatigue, bradycardia, hypothermia
Oral findings enlarged tongue, teeth my fail to erupt if
developed during childhood, in adults external resorption of
roots may occur

Hyperparathyroidism

Excess production of PTH, usually occurs in response to low

levels of serum calcium
Clinical features
Stones renal calculi, metastatic calcifications involving
other soft tissues
Bones subperiosteal resorption of phalanges of index
and middle fingers, loss of lamina dura around teeth and
root resorption, brown tumor which is dark reddish brown
color of tissue specimen because of abundant hemorrhage
and hemosiderin deposition in th tumor ground glass
appearance radiographically
Abdominal groans due to duodenal ulcers

Pagets disease of bone (Neville, 2002)

Multicentric benign tumor of osteoclasts has been suggested

Characteristic deformities of skull, jaw, back, pelvis and legs
Facial appearance leontiasis ossea
Ground glass change in alveolar bones
Loss of lamina dura and root resorption
Generalized hypercementosis sometimes

Application in forensic
odontology

Age estimation from incremental lines of

cementum

Kagerer and Grupe suggested the possibility of age

estimation from acellular cementum
Used mineralized unstained cross sections of teeth, preferably
mandibular central incisors and third molars
Authors claimed an accuracy of within 2 or 3 yrs of
chronologic age
Pathologic state of periodontium may compromise the
precision of ageing
Hypermineralized bands gave an indication of events such as
pregnancies, skeletal trauma, and renal disorders

CONCLUSION (Bosshardt and Selvig, 1997)

The periodontal tissues form a functional unit designed to

maintain tooth support and protection. In particular,
cementum by virtue of its structural and dynamic qualities,
provides tooth attachment and maintenance of occlusal
relationship. These multiple functions are fulfilled by the
biological activity and reactivity of cementoblast, which
deposit two collagen containing varieties of cementum with
completely different properties.

The discovery of variety of non collagenous proteins in

cementum has opened a new research area of great
therapeutic potential, cementum specific matrix proteins cementum derived growth and/or attachment factors may
result in accelerated wound healing and in controlled
neocementogenesis following periodontal regenerative
surgery.

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