CEMENTU

M IN
DISEASE
Presented By:
Dr. Dhwanit Thakore

Guided By:
Dr. Mihir Shah

INTRODUCTION
Cementum is not static
But rather demonstrates a wide range of
pathologic changes

Why Cementum Is So
Important.?

CONCEPT OF BIOLOGY OF CEMENTUM

In 1922 Gottlieb stated that
the apical migration of the
epithelium depends on the degree of
vitality of the cementum .it (the
epithelium) can only migrate apically with
the death of the cementum

What Is The Role Of

Cementum.?

Direct Toxic Effect (Endotoxins).

Indirect Effect Of Bacterial Products.
Morphological Changes
Biochemical Changes

Robinson. PJ. (1975) Possible Roles of Diseased Cementum in Periodontitis. J. Prev Dent (1975).

Changes in Cementum

Exposed Cementum
Unexposed Cementum

Changes In Exposed Cementum

Physical properties
Chemical composition
Permeability

Changes In Physical Properties:

Hardness :
o Exposed non carious cementum is
softer than unexposed cementum.

Changes In Chemical Composition

Inorganic

In exposed cementum
fluoride concentration of exposed
cementum:
(9180 ppm) is about
twice that of unexposed cementum
(5570 ppm).

Organic

Aminoacid composition - not demonstrated

Citrate content - significant

Ground
Substance

Not chemically analysed.

Changes In Permeability :
Dyes
Radioactive iodine

m in
Periodontit
is

Analysis Of Root Surface

Changes In Periodontitis
Surface
Structural

Surface Changes
Healthy cementum

Projection above the mineralized

plane

Most recently
exposed cementum

A partial filling in one of the

space between projections

Long time exposed

cementum

Complete covering of the normal

projection by flat sheet like
plaque & calculus

1-4 um thick Cuticle layer

Structural Changes
Presence of Pathologic Granules:
extend 3-12 um into the surface from
overlying plaque.

How the pathologic granules form?

Loss of structural
characteristics

Mineralization of
areas of
denatured
collagen

Decalcification

{C.C.Bass, oral surg. 1951,L.A.Benson oral. surg. 1963}

Structural Changes
Under transmitted light :
brown, highly refractile and morphologically
variable
lower refractive index than surrounding
cementum
10-50 micron thickness is seen near CDJ.
not seen in calcified ground sections of
teeth , seen only in frozen sections of
decalcified teeth
absolute alcohol : disappeared within 5 mins
seen in 96%of teeth examined
{C.C.Bass,oral. surg.1951,L.A.Benson ,oral. surg. 1963}
{Gary C.Armitage,Thomas M.Christie , JPR 1973}

Structural Changes
EM observations :

loss or decrease in cross banding of collagen

near the cemental surface
{selvig 1966, yamada 1968, furseth 1971}

vacuole like formations from 15-25 under

the cemental surface to 5 - 15 into the
dentin
1973 }

{Gary C.Armitage, Thomas M.Christie, JPR

 Granules appeared in 4 basic

morphologic patterns :
o
o
o
o

Grape like structure

Long chain aggregate
Small isolated vacuoles
A very long fissure like area

Garrett, JS. Cementum in periodontal disease Perio Abstr 23:6, 1975 [Review Article]

Areas of Demineralization :
The cementum may be softened and may
undergo fragmentation and cavitation.
{H.C.Herting JDR 1967}
Root surface caries progress around the teeth
{G.J.Mount Aus dent. j. 1986}
Appear as well defined yellowish or light brown
areas covered by plaque and have a soft or
leathery consistency on probing.
{O.Fejerskov , B.Nyvad 1986}

Areas Of Increased Mineralization:

The presence of a highly mineralized surface
layer in the cementum following exposure to
the external environment has frequently
been detected by
o
o
o
o

micro radiography,
chemical analysis,
electron microprobe analysis and
nuclear resonance reaction analysis.

This increased mineralization may be

increased by calcium and other ion derived
from saliva and crevicular fluid.

Chemical Changes
The mineral content of exposed cementum is
increased.
The following minerals
diseased root surfaces.
Calcium
Magnesium
Phosphate
Fluoride

are

increased

in

Cytotoxic Changes
Earlier What Clinicians
Cementu Bacterial penetration into the cementum
mBelieve???
Bound
can be found as deep as the cemento
Endotoxin
s

dentinal junction.

Permeation of bacteria is facilitated by the

occurrence of minifracture and cracks,
which sums to develop frequently in
exposed cementum.
Bacterial invasion into cementum & root
dentin is a common sequence to chronic
periodontal disease.
Aleo J.J. De Reuzis, FA; Farber, P.A; Varboncoeur, A.P,:
The presence and Biologic activity of Cementum Bound endotoxin J.Periodontal 45:672, 1974

Cytotoxic Changes
Daly et al in 1980..
LPS should deemed to be CEMENTUM ASSOCIATED
rather than cementum bound.

Bacterial endotoxin: a role in chronic inflammatory

periodontal disease? *C. G. DALY, **G. J. SEYMOUR AND J. B. KJESER
Journal of Oral Pathology 1980: 9:1-15

Ultrastructural Changes In
Periodontal Attachment:
Zone I A zone of intact connective tissue
fiber attachment to cementum in the apical
and middle regions of the gingival
attachment of the root.
Zone II A zone of partial destruction of the
connective tissue fibers 0.5 to 1.0 mm
beneath epithelial attachment.

Selvig, KA. Ultrastructural Changes in Cementum and Adjacent Connective

Tissue in Periodontal Disease. ACTA Odont. Scand. 24:459, 1966

Ultrastructural Changes In
Periodontal Attachment:
Zone III - A zone of complete destruction of
connective tissue in a narrow area
beneath the junctional epithelium.
Zone IV - Epithelial lining of cementum. A
space of 0.1 to 0.2 um containing some
granular material but not recognizable
fibrils can be seen between the epithelial
cells & the cementum at more cervical
levels.

ALTERATIONS OF CEMENTUM

Hypercementosis
Ankylosis
Root fracture
Root sensitivity
Root caries
Abrasion
Cemental tear

Hypercementosis

Factors associated with Hypercementosis

Local factors :
a) Abnormal occlusal trauma
b) Adjacent inflammation
c) Unopposed teeth
(implanted / embedded without antagonist)
Systemic factors:
a) Acromegaly & pituitary gigantism
b) Arthritis
c) Calcinosis
d) Pagets disease of bone
e) Rheumatic fever
f) Thyroid goiter.
g) Vitamin-A deficiency.

Ankylosis
Fusion
of
cementum
and
alveolar
bone
with obliteration
of
periodontal
ligament
is
termed
as
ankylosis.

Root fracture :

Root sensitivity

Root caries :

Abrasion :

Cemental Tears :
Detachment of fragment of cementum
from the root surface is known as a
cemental tear

Developmental Anomalies :
Enamel projection
Enamel pearls
Cementicles

Enamel projection
Focal apical extensions of the coronal enamel
beyond the normally smooth cervical margin
and on to the root of the tooth.

Classification of Cervical
Enamel Projections
Grade I: The enamel projection extends from the
cementoenamel junction of the tooth toward the
furcation entrance.
Grade II: The enamel projection approaches the
entrance to the furcation.
Grade III: The enamel project actually extends
horizontally into the furcation.
Masters DH, Hoskins SW: Projection of cervical enamel into molar furcations.
J Periodontal 1964;35:49.

Enamel Pearls
Small, focal excessive mass of
enamel on surface of the tooth.
Enemaloma/Enamel drop

Cementicles
These are globular masses of acellular cementum.

Generally less than 0.5 mm in diameter

Neoplasm of cementum
Cementoma
Benign cementoblastoma (true
cementoma)
Gigantiform cementum

Cementoma

Periapical Cemental Dysplasia

Periapical Osteofibroma
Osteofibrosis Cementifying fibroma
Localized fibro-osteomaCementoblastoma
Periapical fibrous Dysplasia.

adiographic features
II. Cementoblastic

I. Osteolytic phase
phase
III. Mature phase

BENIGN CEMENTOBLASTOMA
(True Cementoma):
A true neoplasm of functional
cementoblasts which form a large
mass of cementum or cementum like
tissue on the tooth root.

Radiographic features

Gigantiform Cementum

Diseases Of Systemic Disorders

Affecting Cementum
CLEIDOCRANIAL DYSPLASIA:
o absence of cellular cementum on the erupted teeth in
both dentition, with no increased thickening of primary
acellular cementum.

HYPOPHOSPHATASIA:
o Absence of cementum

HYPERPITUITARISM:
o hypercementosis


CONCLUSION
The dynamic features of cementum are
particularly highlighted by its repair
potential. However Irreversible damage
may occur when the cementum surface
becomes exposed to environment of a
periodontal pocket, and the oral cavity. But
the ultimate goal of true periodontal
regeneration
after
treatment
for
periodontitis has revived vigorously the
interest in this unique mineralised tissue.

REFERENCES :

Carranza F.A., Newman M.G. :Clinical Periodontology, 8 th Edition, 1996. Pg.36-40.

Newman Takei Carranza : Clinical Periodontology, 10 th Edition.
Periodontology 2000 : Vol 13, 24.
Tencate A.R. : Oral Histology, Development, Structures and Function, 6 th Edition,
240-258.
Orbans Oral Histology and Embryology, 11 th Edition, 175-197
Ramfjord S.P., Kerr D.A., Ash M.M.:World Work Shop in Periodontics, 1966. 43-44.
Schluger S., Yuodelis R.A., Page R.C.: Periodontal diseases, 2 nd Edition, 1990. Pg.3842.
Tencate A.R.: The development of the periodontium a largely ectomesenchymally
derived unit. P2000. 1997:13:9-19
MacNeil and Somerman : Development and Regeneration of Periodontium. Parallels
and Contrasts. P2000.1999:19:8-20.
Genco, Goldman, Cohen: Contemporary periodontics. 6 th Edition.
Clinical Periodontology and Implant Dentistry 5 th Edition Jan Lindhe.
Int. J.Dev.Biol.45:695-706
Review Articles

Thank You!