Cementum forms a functional unit which is designed to maintain tooth support, integrity, and protection. Minor, non-pathological resorption defects on the root surface are generally reversible and heal by reparative cementum formation. Irreversible damage may occur when the cementum is exposed to the environment of a pocket or oral cavity.

1. CEMENTUM
PRESENTED BY,
DR. BEENA VIJAYAN PARVATHY
DEPT. OF PERIODONTOLOGY

2. • INTRODUCTION
• DEFINITIONS
• CEMENTOGENESIS AND MINERALIZATION
• PHYSICAL CHARACTERISTICS
• CHEMICAL CHARACTERISTICS
• CEMENTUM PROTEINS
• CLASSIFICATION
• CELLS OF CEMENTUM
• FUNCTIONS
• AGE CHANGES IN CEMENTUM
• CEMENTUM IN PERIODONTAL DISEASE
• ANOMALIES IN CEMENTUM
• CLINICAL CORRELATION
• REFERENCES
CONTENTS

3. • The normal periodontium provides the support necessary to
maintain teeth in function. It consists of four principal
components: gingiva, periodontal ligament, cementum
and alveolar bone.
• Cementum was first demonstrated microscopically by
Fraenkel and Raschkow (1835) and Retzius (1836), later
Bhaskar S N (1991). It was said as hard bone like tissue
covering anatomic roots of teeth by Newman et al (2006).
• The word Cementum comes from the Latin word “Cement”
which means “Quarried stone”.
INTRODUCTION

4. • Thin, calcified tissue of ectodermal origin covering the
roots of the teeth in which embedded collagen fibers
attach the teeth to alveolus.
(GPT, 2004)
• Calcified, avascular mesenchymal tissue that forms the
outer covering of the anatomic root.
(Carranza 11th Edition)
• Mineralized connective tissue that covers the roots of the
teeth.
(Listgarten 1st Edition)
DEFINITIONS

5. • Bone-like mineralized tissue lining the dentin of the root that
protects the root and also serves as an attachment surface
to anchor the PDL to the tooth.
(Diekwisch, 2001)
• Mineralized connective tissue, in part not unlike bone, that
covers the entire surface of antomical roots of teeth.
(Schroeder)
• Hard, avascular connective tissue that covers the root of the
teeth.
(TenCate’s)

7. CEMENTOGENESISANDMINERALIZATION
HERS derived from the inner & outer enamel
epithelium induces secretion of enamel
protein.
Sends inductive signal to ectomesenchymal
pulp cells to secrete pre-dentin by
differentiating into odontoblasts
Breaks occur in HERS
Ectomesenchymal cells from the inner portion
of the dental follicle come in contact with pre-
dentin by differentiating into cementoblasts
Cementoblasts lay down CEMENTUM

8. CEMENTOGENESIS

9. • Mineralization begins in the depth of precementum.
• Fine hydroxyapatite crystals are deposited, first between
and then within the collagen fibrils by a process that is
identical to the mineralization of bone tissue.
• The width of the precementum layer is about 3-5 µm.
• The process of establishing the appropriate condition for
crystallization & growth of the individual crystals in
cementum normally are extremely slow and extend over a
period of several months.
MINERALIZATION

10. • The development of cementum has been subdivided into:
(Bosshardt and Selvig,1997)
 Pre-functional stage(3.5-7.5yrs)
 Functional stage
 The Pre-functional portion of cementum is formed during root
development & is extremely long lasting process.
 The Functional development of cementum starts when the
tooth is about to reach the occlusal level & is associated with
the attachment of root to the surrounding bone & continues
throughout the life. During this stage, the adaptive and
reparative processes are carried out by the biological
responsiveness of cementum.

11. • The PDL fibers are oriented parallel to the root surface and
not attached to fibrous fringe.
• Slow increase in thickness and establishment of continuity
between collagen fibers of the PDL with fibrous fringes
occurs.
• This happens only after tooth has erupted into the mouth,
when 2/3 of root has formed.
• Thickness-10µm.
• This forms, Acellular intrinsic fiber cementum.
DEVELOPMENT OF PRIMARY (ACELLULAR)
CEMENTUM (BERKOWITZ ET AL,
2002)

12. • Appears in the apical region of the root at the time tooth
erupts.
• Seen in furcation areas of multirooted teeth also.
• Following the loss of continuity of HERS, large basophilic
cells in adjacent cells of dental follicle against surface of root
dentine differentiates. This form a distinct layer of
cementoblasts.
• These cementoblasts consists of more cytoplasm and
cytoplasmic processes.
• Cementoblasts secrete the collagen with ground substance
forms the intrinsic fibers of secondary, cellular cementum.
• They are oriented parallel to the root surface.
DEVELOPMENT OF SECONDARY
(CELLULAR) CEMENTUM

13. • HARDNESS < Dentine.
• COLOR: Light yellow with dull surface & lighter than
dentine.
• THICKNESS: Variable
Thinnest at CEJ (20-50µm)
Thickest towards APEX (150-200µm)
• PERMEABILITY:
Cellular cememtum > Acellular cementum.
with age.
PHYSICALCHARACTERISTICS
(BERKOWITZ ET AL, 2002)

14. DRY WEIGHT BASIS
o Organic content & water: 50-55%.
o Inorganic content (Calcium & phosphate as hydroxyapetite
crystals): 45-50%.
BY VOLUME
o Inorganic: 45%, Organic: 35%, Water: 20%
ORGANIC CONTENT
o Collagen fibers embedded in an interfibrillar ground substance
consisting of glycoproteins.
 Types of collagen :
Type I (90%), Type III (5%), Type V, Type IX, Type XIV
CHEMICALCHARACTERISTICS
(BERKOWITZ ET AL,2002) & (BOSSHARDT AND
SELVIG,1997)

15. 2 main sources of collagen fibers:-
1.Sharpeys fibers (Extrinsic) are the embedded portion of
the principal fibers of periodontal ligament and formed by
fibroblasts.
2.Fibers that belong to the cementum matrix (Intrinsic) and
produced by cementoblast.
o Non collagenous proteins.
o Cementum proteins.

16. INTERSPERCED BETWEEN COLLAGEN
FIBRILS
Glycosaminoglycans:
• Major GAGs: hyaluronic acid & keratan sulfate.
• Play major regulatory roles during cementum mineralization
and are associated with initial phase of cementum
formation.
Dermatan sulphate:
Chondroitin 4-sulphate:
CEMENTUMPROTEINS

17. NON COLLAGENOUS PROTEINS
Enzyme activity adjacent to CIFC is than AEFC and
thickness correlates (Groeneveld et al, 1995).
Alkaline phosphatase (Beertsen and Events, 1990):
• Play important role in skeletal mineralization.
• Regulate tissue turnover & cell proliferation, differentiation,
maturation.
• Major function is hydrolysis of inorganic pyrophosphate, a
potent inhibitor of hydroxyapitite formation.
• Plays key biological role in the mineralization of bone &
cementum.

18. Bone sialoprotein & Osteopontin:
• Play a major role in filling spaces created during collagen
assembly.
• Regulators of hydroxyapitite crystal nucleation and growth.
• Role in differentiation of cementoblast progenitor cells to
cementoblasts.
Osteonectin (Gage et al; 1989):
• Mainly secreted by osteoblasts.
• Important for mineralization process.
• Found in the PDL.

19. Osteocalcin (Mariotti, 1993):
• Also know as bone Gla protein (B.G.P) as it contains γ-
carboxyglutamic acid (Gal) residues.
• Mainly secreted by osteoblasts, regulate mineralization
process, prevent hypercalcification of the cementum
surface.
Fibronectin(Lukinmaa et al, 1991):
• Binds cells to components of extracellular matrix.
• Found in attachment site of PDL but not in cementum layer.
Vitronectin:

20. SPECIFIC PROTEINS
Insulin like growth factor-I:
• Ability of cell migration, adhesion, mitogenic activity &
differentiation, essential for periodontal regeneration.
• Cementum has the potential to regulate the metabolism &
turn over of surrounding tissues because of this growth
factor.
Cementum Attachment Protein (CAP):
• Promotes the attachment of gingival fibroblasts, endothelial
cells & smooth muscle cells.

21. • Binds selectively to periodontal ligament cells and supports
periodontal ligament cell attachment to root surfaces.
Cementum Protein-I:
• Synthesized by Hertwig’s epithelial root sheath cells.
• Play a role during the mineralization process.
• Present throughout the entire cementum surface
• Associated with the regulation of sialoprotein expression in
cementoblasts.
Enamel- Associated Proteins In Cementum:
• Synthesized by Hertwig’s epithelial root sheath cells.

22. • Results in the formation of a cellular- like tissue or bone with
the characteristics of cellular intrinsic fiber cementum.
• Functions: promotion of cell proliferation, differentiation & up
regulation of extracellular matrix production.
• Involved in root formation.
INORGANIC CONTENT
• Calcium & phosphate in the form of
hydroxyapitite(Ca10(Po4)6(OH)2).
• Trace elements like Copper, Fluorine, Iron, Lead, Potassium,
Silica, Sodium and Zinc in varying amounts.
• Cementum has the highest fluoride content.

23. BASED ON LOCATION
Radicular Cementum Coronal
Cementum
Found on the root surface Forms on the
enamel
covering the crown
CLASSIFICATION

24. ACELLULAR CEMENTUM
• Present on the cervical third or
half of root.
• Does not contain cells.
• Formed before the tooth
reaches the occlusal plane.
• More calcified
• Sharpey’s fibers are main
component which are inserted
at approximately right angles
onto the root surface.
• Rate of development is faster
• Incremental lines are wide apart
CELLULAR CEMENTUM
• Present mainly on apical third
of root.
• Contain cells called
cementocytes
• Formed after the tooth reaches
the occlusal plane.
• Less calcified
• Sharpey’s fibers occupy smaller
portion & occupy other fibers
that are arranged parallel to the
root surface.
• Slow
• Closer
BASED ON PRESENCE/ABSENCE OF CELLS
(BERKOWITZ ET AL, 2002)

26. EXTRINSIC
FIBRES
• Derived from PDL.
• Formed by fibroblast.
• Run in same direction of
the PDL principal fibers
i.e. perpendicular or
oblique to the root
surface
INTRINSIC FIBRES
• Derived from cementum.
• Formed by cementoblast.
• Run parallel to the root
surface and at right
angles to the extrinsic
fibers.
BASED ON ORIGIN OF MATRIX FIBRES
The area where both extrinsic and intrinsic fibers is called mixed fiber
cementum.

27. FIBRILLAR CEMENTUM:
Cementum with a matrix that contains well-defined fibrils of
type I collagen.
AFIBRILLAR CEMENTUM:
Cementum that has a matrix devoid of detectable type I
collagen fibrils. Instead, the matrix tends to have a fine,
granular consistency.
BASED ON PRESENCE OF COLLAGEN FIBRES

28. The classification system devised by
Owens and others in the 1970s was
accepted the most at that time , and was
summarized by Schroeder & Page.

29. Acellular afibrillar cementum (AAC)
Acellular extrinsic fiber cementum (AEC)
Cellular mixed stratified cementum (CMSC)
Cellular intrinsic fiber cementum (CIFC)
Hyaline layer of Hopewell-Smith (intermediate cementum)
SCHROEDERANDPAGECLASSIFICATION(1986)

30. 1. ACELLULAR AFIBRILLAR CEMENTUM (AAC):
• Consists of mineralized matrix.
• Contains neither cells nor extrinsic/intrinsic fibers.
• No function in tooth attachment.
• Formed by cementoblasts.
• Found in coronal cementum ie; cervical margin of the tooth.
• Less homogenous.
• Thickness : 1-15 μm.
• The enamel at cervical area not covered by reduced dental
epithelium before tooth eruption. The connective tissue of
the dental sac lay down cementum on the exposed enamel.

31. • Confined to coronal half of the root .
• Its formation commences shortly after crown formation is
completed.
• Formed by fibroblast & cementoblasts.
• Thickness- 30-230 μm.
• Composed of densely packed bundles of sharpey’s fibers
& lack cells.
• Only type of cementum seen in single rooted teeth.
• Has the potential to adapt to functionally dictated alterations
such as mesial tooth drift.
2.ACELLULAR EXTRINSIC FIBER
CEMENTUM(AEC)

32. 3. CELLULAR MIXED STRATIFIED
CEMENTUM(CMSC)
• Composed of extrinsic (sharpey’s fibers) & intrinsic fibers.
• Contain cells.
• Co- product of fibroblasts & cementoblasts.
• Appears primarily in apical 3rd of roots, apices & furcation
areas.
• Thickness- 100-1000 μm.
• With light microscope its easily identified because:
o It includes cementocytes within lacunae, with processes in
canaliculi directed towards PDL.
o Its laminated structure.
o The presence of cementoid on its surface.

33. CELLULAR MIXED STRATIFIED
CEMENTUM(CMSC)

34. • Contains cells & intrinsic collagen fibers.
• Formed by cementoblasts.
• Fills the resorption lacunae.
• Very minor role in attachment.
• Seen in middle to apical 3rd & inter radicular cementum.
4. CELLULAR INTRINSIC FIBER CEMENTUM(CIFC)

35. • Sometimes dentine is separated from cementum by a zone
known as the intermediate cementum layer.
• It does not resemble either dentine or cementum.
• Usually it is present in the apical two thirds of the roots of
molars and premolars, rarely seen in incisors or deciduous
teeth.
• It is believed that this layer represents areas where cells of
Hertwig’s epithelial root sheath become trapped in a rapidly
deposited dentine or cementum matrix.
• Sometimes the intermediate cementum is found as a
continous layer & at times found only in isolated areas.
• Thickness-10µm.
5. HYALINE LAYER OF HOPEWELL-SMITH
(INTERMEDIATE CEMENTUM)

37. CEMENTOBLAST
S
CEMENTOCYTES CEMENTOCLASTS
Originate from the
ectomesenchymal
cells
in the dental follicle
surrounding the
developing tooth.
Spider like cells
incorporated into
cellular cementum.
Resemble
osteoclasts.
Synthesize collagen
& protein
polysaccharides.
Lie in lacunae. Mononuclear cells,
found on the surface of
cementum
Have numerous
mitochondria, a well-
defined
Golgi apparatus
& large amounts of
Cytoplasmic vol &
density of cytoplasmic
organelles is reduced
when compared to
cementoblasts.
Role- Resorption &
Repair.
CELLSOF CEMENTUM

38. CEMENTOBLASTS CEMENTOCYTES CEMENTOCLASTS

39. • Cementum overlaps enamel: 60%
• Cementum just meets enamel: 30%
• Small gap between cementum and enamel: 10%
CEMENTOENAMEL JUNCTION
(NEWMAN ET AL,
2006)

40. • The cementum is attached to the dentin firmly.
• CDJ is scalloped in deciduous teeth and is smooth in
permanent teeth.
• Sometimes cementum and dentin is separated by an
intermediate layer.
• Width appears to be stable even as age increases.
• About 2-3 μm wide.
CEMENTODENTINAL JUNCTION

41. • Along the external surface of predentin, the
precementoblasts differentiate into cementoblasts.
• Tiny cytoplasmic processes from initial collagen fibrils of
precementum attaches to the predentin.
• Intimate interdigitation of two different fibril populations
forms dentinocemental junction which gets mineralized later.
DEVELOPMENT OF
DENTINOCEMENTAL JUNCTION

42. • Referred to as “ Incremental lines of Salter”.
• Represent rhythmic periodic deposition of cementum.
• Appear as dark lines running parallel to root surface .
• Seen in both acellular & cellular cementum but more
prominent in acellular cementum.
• Highly mineralized areas with less collagen & ground
substance.
INCREMENTAL LINES OF CEMENTUM

43. • Extensive variation in surface topography of cementum can be
observed with scanning electron microscope (SEM).
• Resting cemental surfaces, where mineralization is more or
less complete, exhibit low rounded projections known as
cemental mounts.
• Cemental surfaces with actively mineralizing fronts have
numerous small openings.
• Represent unmineralized cores of openings.
NORMAL FEATURES OF CEMENTUM

44. • Anchorage.
• Functional adaptation.
• Repair.
FUNCTIONS

45. • Provide ancourage of the tooth in its alveolus:
accompanied collagen fiber bundles of the periodontal
ligament, are embedded in the cementum during
cementogenesis.
• EXAMPLE- in hypophosphatasia, loosening and premature
loss of anterior deciduous teeth occurs. The exfoliated teeth
are characterized by an almost total absence of cementum.
ANCHORAGE

46. • Continuous deposition of cementum is of functional
importance.
• Cementum is not resorbed under normal conditions.
• As the most superficial layer of cementum ages, a new layer
is deposited that keeps the attachment apparatus intact.
• It maintains occlusal relationships,
As tooth erupts, to compensate the lost substance, deposition
of new cementum occurs at apical root area.
FUNCTIONAL ADAPTATION

47. • Serves as a major reparative tissue for root surfaces.
• Damage to roots such as fractures and resorptions can be
repaired by the deposition of new cementum
• Generally occur when the degree of destruction is low.
• The root outline is re-establised as it was before cemental
resorption.
• To maintain the width of periodontal ligament, the adjacent
alveolar bone grows and takes the shape of the defect
following the root surface. This is done to improve the
function of tooth.
REPAIR

49. Other functions include:
• Serves periodontal ligament space.
• Walling in filled canals.
• Sealing of necrotic pulps.
• Protection of the subjacent dentinal tubules.

50. Healing /sealing of canal by the cementum

51. • Resorption is carried out by multinuclear odontoclasts &
may continue into the root dentine.
• Cementum is less susceptible to resorption than bone.
• Permanent teeth do not undergo physiologic resorption as
do primary teeth.
• Appears microscopically as bay like concavities in the root
surface.
• It is not necessarily continuous & may alternate with periods
of repair & deposition of new cementum.
• The newly formed cementum is demarcated from the root by
a deep staining irregular line, termed as reversal line.
RESORTION OF CEMENTUM

52. Local conditions
 Trauma from occlusion
 Orthodontic movement
 Cysts & Tumours
 Pressure from malaligned erupting
teeth.
 Periapical & Periodontal disease
Systemic conditions
 Ca deficiency.
 Hypothyroidism.
 Paget’s disease.
Idiopathic conditions

53. COMPARISON OF BONE AND
CEMENTUM
Cementum is similar to bone in its: (Saygin et al, 2000)
o Organic fibrous frame work
o Ground substance
o Crystal type
o Developmental process
o Reorganizational capabilities
o Chemical composition
Diseases that affect bone, often alter cementum’s properties
as well.
Eg:- Paget’s diseases results in hypercementosis,
hypophosphatasis results in no cementum formation.

54. BONE CEMENTUM
70% made of inorganic salts. 46% made of inorganic salts.
Type I collagen found in organic
matrix.
Type I and II collagen found in
organic matrix.
Not permiable. Relatively permiable.
Undergoes remodelling. Does not undergo remodelling.
Vascular Avascular
Have Haversian canals. Lack Haversian canals.
Innervated Not innervated
Comparatively faster resorption. Less readily resorbed.

55. • Smooth surface becomes irregular.
• Continuous deposition of cementum occurs with age in the
apical area.
• Deposited at linear rate(Azaz et al, 1974).
• Cementum resorption active for a period of time and then
stops for cementum deposition creating - reversal lines.
• Resorption of root dentin occurs with aging which is covered
by Cemental repair.
AGECHANGESIN CEMENTUM
(BOSSHARDT AND SELVIG, 1997)

57. CEMENTUMIN PERIODONTALDISEASE

58. • Loss of collagen fiber insertion.
• Contamination by bacteria and or endotoxins.
• Alterations in mineral density and composition.
• Lack of chemotactic stimuli for periodontal regeneration.
• Apical migration of the junctional epithelium.
PATHOGENIC CHANGES IN CEMENTUM

59. • In normal cementum, the collagen fibers are embedded in the
cementum.
• These fibers are destroyed in pathological pocket wall with the
exposure of cementum.
• Exposed in cases of gingival recession leading to pocket
formation.
• Collagen remnants of Sharpey’s fibers in cementum undergo
degeneration creating a environment favorable for penetration
of bacteria.
• The mineral content of exposed cementum increases.
EXPOSURE OF CEMENTUM TO THE ENVIORNMENT

61. • Firm scaling strokes used to remove sub gingival calculus,
also remove a small amount of cementum resulting in some
notching of root.
NECROTIC CEMENTUM:
• Cementum exposed by apical migration of junctional
epithelium is altered by exposure to sub gingival plaque
within the pocket.
• May become hyper mineralized, demineralized or necrotic.

62. • Lopez et al, 1980 it is necessary to remove all the diseased
cementum exposed to the pocket to eliminate its potential
for inducing inflammation.
• Nyman et al, 1986 intentional root cementum removal is not
necessary for optimal postoperative healing.
• Removal of cementum during root planning process has
been questioned due to possible sequelae of root sensitivity.
• Also, it is thought that cementum removal is not necessary
to remove endotoxin because it is weakly adherent to
cementum.
(Wilson & Kieser; 1988, Hughes & Smales,
1986, Smart, Wilson, Daves & Kieser, 1990)

63. PRESENCE OF PATHOLOGIC GRANULES(Carranza and
Newman, 1996)
• Reported by Bass, 1951.
• Areas where collagen degeneration or collagen fibers not
been mineralized initially.
• Granules extend 3-12µm into the surface of cementum.
• Morphological Pattern:
 Grape like structure
 Long chain aggregated
 Small isolated vacuoles
 Very long fissure like area (Garrett, 1975)

64. According to Gottlieb (1946) the persistence of precementum
layer with its cementoblasts was essential for the integrity of
the tooth.
Hitchin(1973,1975) has reported that patients with
Epidermolysis bullosa and Cleido-cranial dysostosis showed
changes in cementum.
The changes he found appeared to be in accord with
Gottlieb’s (1946) views on cementum formation but altered
by hypersensitivity to mechanical stress in one instance and
a disturbance of bone resorption in the other.

65. • Detoxify and demineralize the root surface (citric acid)
• Selective removal of hydroxyapatite and exposure of the
collagenous matrix of the root surface (EDTA)
• Inhibition of collagenolytic activity (tetracycline HCL)
• Enhances cellular responses (migration and attachment)
• Prevents epithelial down-growth
• Improves retention of different biomolecules to exposed
collagen
• Expresses a cementoblast phenotype for colonizing cells.
CHEMICAL ROOT SURFACE
TREATMENT – EFFECTS ON
CEMENTUM

66. 1.CONCRESENCE(Shafer et al,2006):
• Form of fusion which occurs after the root formation has
been completed.
• Here the teeth are united by cementum only, as a result of
traumatic injury or crowding of teeth with resumption of the
interdental bone so that the two roots are in approximate
contact and become fused by deposition of cementum
between them.
• Concresence can occur before or after teeth have erupted
and usually involves two teeth.
ANOMALIESOFCEMENTUM

68. 2. CEMENTICLES:
• Globular masses of cellular cementum less than 0.05mm in
diameter which form within the periodontal ligament.
• May lie free within the periodontal ligament(free
cementicles) or become fused to the radicular cemental
surface(sessile or attached cementicles).
• Originate from degenerating cells or epithelial cell rests in
the periodontal ligament.

70. 3.HYPERCEMENTOSIS (Cemental hyperplasia)
(Neville et al, 2002):
• Abnormal thickening of cementum.
• It is largely an age related phenomenon
• May affect all teeth of the dentition (Generalized), or be
confined to a single tooth or even effect only parts of one teeth
(Localized).
• Localized hypercementosis may sometimes be observed in
areas in which enamel drops have developed on the dentin.
• Such knob like projections are designated as excementosis.
• The thickening of cementum is often observed on teeth that are
not in function.

71. • If the overgrowth improves the functional qualities of the
cementum, it is termed as cementum hypertrophy.
• If the overgrowth occurs in non-functional teeth or if it is not
correlated with increased function, it is termed cemental
hyperplasia.

73. Appearance:
• Occurs as a generalised thickening of 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 the
periodontal fibres at the site of insertion into the cementum.
• It is usually associated with situations like
- teeth without antagonist
- teeth with pulpal and periapical infections

74. • Hypercementosis of entire dentition may be seen in patients
with Paget's disease.
• Other systemic disturbances include acromegaly, calcinosis,
thyroid goiter, arthritis etc.
Treatment:
• Hypercementosis itself does not need treatment.
• It could pose a problem if an affected tooth requires
extraction.
• In multirooted tooth, sectioning of tooth may be required
before extraction.

75. 4.HYPOPLASIA (Cemental aplasia):
• Absence or paucity of cellular cementum.
5. HYPOPHOSPHATASIA:
• Due to an inborn error of metabolism.
• The basic disorder is a deficiency of enzyme alkaline
phosphatase in serum or tissues.
• This is characterised by loosening and premature exfoliation of
deciduous teeth mainly anteriors.
• Exfoliated teeth microscopically show complete absence of
cementum or isolated areas of abnormally formed cementum.

76. 6.ANKYLOSIS(Shafer et al, 2006):
• Fusion of cementum and alveolar bone with
obliteration of periodontal ligament.
• Results in resorption of root and its
replacement by bone tissue.
• It occurs due to:-
1) Cemental resorption
2) Chronic periapical inflammation
3) Tooth replantation
4) Occlusal trauma
5)Around embedded teeth

77. Clinically:
1. Lack of physiologic mobility which is diagnostic sign of
ankylotic resorption.
2. As the periodontal ligament is replaced with bone in
ankylosis, proprioception is lost because pressure
receptors in periodontal ligament are deleted or not
function correctly.
3. Teeth have special metallic percussion sound.
4. If the process continues teeth will be in infraocclusion.

78. Radiographically:
• Resorption lacunae are filled with bone.
• Periodontal ligament space is missing.
Treatment:
• No predictable treatment can be suggested.
• Treatment modalities range from a conservative approach,
such as restorative intervention to surgical extraction of
affected tooth.

79. 7. CEMENTAL TEARS:
• Detachment of a fragment of cementum from the root
surface.
• Separation of cementum, may be complete with
displacement of a fragment into the periodontal ligament or
it may be incomplete with cementum fragment partially
attached to the roots.
• Detached cementum, may be reunited to the root surface by
new cementum or may be completely resorbed or may
undergo partial resorption followed by addition of new

81. 8. ENAMEL PEARLS:
• If some HERS cells remain attached to forming root surface,
they can produce focal deposits of enamel like structures
called ENAMEL PEARLS.
Clinical significance
• They are plaque retentive structures.
• Promote periodontal disease.
• They look similar to calculus, but cannot be scaled off.
• Only grinding will help in elimination.

82. 9.Cementopathia:
In 1923, Gottlieb reported a patient with fatal case of
influenza and disease called Diffuse atrophy of bone.
• Characterized by loss of collagen fibers in PDL and their
replacement by loose connective tissue and extensive bone
resorption resulting in the widened PDL space
• Gottlieb attributed this condition to inhibition of continuous
cementum formation which he considered essential for
maintenance of PDL fibers.
• He then termed the disease as CEMENTOPATHIA.

83. 10.CALCULOCEMENTUM(Newman et al):
Calculus embedded deeply in cementum may appear
morphologically similar to cementum.
11. ROOT CARIES:
12.ABRASION:

84. 1.BENIGN CEMENTOBLASTOMA(True Cementoma):
• A true neoplasm of functional cementoblasts which form a
large mass of cementum or cementum like tissue on the
root.
• No sex predilections and frequently seen under age of
25yrs.
• Mandibular 1st permanent molar, most affected.
• Other includes, Mandibular 2nd and 3rd molar, bicuspids,
maxillary bicuspids and 1st,2nd and 3rd molars.
• Slow growing, asymptomatic and may cause cortical bone
expansion.
• Radiographically, well circumscribed dense radioopaque
mass surrounded by thin, uniform radiolucent line attached
NEOPLASMS OF CEMENTUM
(SHAFER ET AL, 1997)

85. • Histologically, composed of sheets of cementum with
reversal lines scattered throughout.
• Treatment by extraction of tooth, rare recurrence.
2.PERIAPICAL CEMENTAL DYSPLASIA:
• Also called as, Cementoma; Periapical Osteofibroma;
Osteofibrosis; Cementifying fibroma; Localized fibro-
osteoma; Cementoblastoma; Periapical fibrous Dysplasia.
• Common in 20yrs.
• Occurs in PDL around apex of the tooth in mandibular
incisors.
• Asymptomatic, when near mental nerve causes pain,
paresthesia and even anesthesia.

86. 3.CENTRAL CEMENTIFYING FIBROMA:
• Neoplasm of bone.
• Histologicaly contains collagen fibres interspersed by large
numbers of active, proliferating fibroblasts or cementoblasts.
4.GIGANTIFORM CEMENTUM(Familial Multiple
Cementoma):
• Contains highly calcified acellular cementum.
5.FOCAL CEMETOOSSEOUS DYSPLASIA:
• Histologically, trabeculae of woven bone and cementum like
material are interspersed throughout the fibrous framework.

87. Age estimation from incremental lines of cementum:
• (Kagerer and Grupe) suggested age estimation from
acellular cementum.
• Authors claimed an accuracy of within 2 or 3 yrs of
chronological age.
• Cementocytes a fruitful source of DNA.
• Cementum resists DNA degradation in comparision to other
tissues with respect to the intra and inter-individual variation
of histological and anatomical structures.
APPLICATION IN FORENSIC
ODONTOLOGY

88. • The importance of cervical third of the cementum is that it
contains acellular extrinsic fiber cementum and its
regeneration is considered to be the gold standard for
periodontal regeneration.
• Such tissue regeneration is achieved by biomimicking the
physical and mechanical properties of the tissue, which
serves as a scaffold in nature.
• Application of Insulin-like growth factor.
• Application of BMP-2.
• Direct gene transfer of platelet-derived growth factor-B
stimulates the regeneration of cementum.
CEMENTUM REGENERATION

89. • In periodontal pockets, pathologically exposed cementum,
undergoes alterations, this interferes with healing.
• Root planning leads to hypomineralised cementum.
• Scaling produces are painles, if cementum is removed, this
leads to dentin is exposure causing root hypersensitivity.
• Precementum acts as the natural barrier to excessive apical
migration of junctional epithelium.
•Subsurface alteration occurs on gingival inflammation.
CLINICAL CORRELATION

90. • Cementum forms a functional unit which is designed to
maintain tooth support, integrity, and protection.
• Minor, non-pathological resorption defects on the root
surface are generally reversible and heal by reparative
cementum formation.
• Irreversible damage may occur when the cementum is
exposed to the environment of a pocket or oral cavity.
CONCLUSION

91. 1. Carranza’s clinical periodontology 10th Edition.
2. Orban’s oral histology and embryology. 12th Edition.
3. Thomas M. Hassell;Tissues and Cells of the Periodontium;
Periodontology 2000, Vol. 3, 1993, 9–38.
4. Dieterd. Bosshardt & Knut A. Selvig; Dental cementum: the
dynamic tissue covering of the root; Periodontology 2000.
Vol.13, 1997, 41-75.
5. M I Cho et al;Development and general structure of the
periodontium: Periodontology 2000, Vol. 24, 2000, 9–27.
6. Higinio Azrate et al;Cementum proteins: Role in
cementogenesis, biomineralization, periodontium formation
and regeneration. Periodontology 2000, Vol.67, 2015.
REFERENCES

92. 6. Hussam Mansour, Oliver Krebs, Jan Peter Sperhake,
Christa Augustin, Till Koehne, Michael Amling, Klaus
Püschel; Cementum as a source of DNA in challenging
forensic cases; Journal of Forensic and Legal Medicine.
7. Shafer’s Textbook of Oral Pathology 8th Edition.
8. Oral ad Maxillofacial Pathology (Neville) 3rd Edition.