CEMENTUM IN HEALTH AND DISEASE

INTRODUCTION:
The periodontium consists of the investing layer and supporting tissues of the tooth: gingiva, periodontal ligament, cementum and alveolar bone. It has been divided into 2 parts: Gingiva: protects the underlying tissues Attachment apparatus: composed of periodontal ligament, cementum and alveolar bone. Cementum is considered a part of the periodontium because, with the bone, it serves as the support for the fibres of the periodontal ligament. It is the hard bone like tissue covering the anatomic roots of the teeth (Newman et al, 2006) . Cementum is derived from the Latin word Cementum, Quar, stone, i.e. chips of stone used in making mortar (Nanci A, 2003). The cementum is a specialized mineralized tissue covering the root surfaces and occasionally small portions of the crown of the teeth. It has many features in common with bone tissue. It was demonstrated microscopically in 1835 by 2 pupils of Purkinje (Bhaskar SN, 1991)
Begins at the cervical portion of the tooth at the Cementoenamel junction and continues to the apex.

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, 1986).

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 o Avascular o Lack Haversian canals o Not innervated o Exhibits little or no remodeling o Less readily resorbed therefore permits orthodontic movement o Differences in physicochemical or biological properties o Increased density of Sharpeys fibers (particularly in acellular cementum) o Proximity of epithelial cell rests to the root surface

Development of Cementum

Cementogenesis (Bosshardt and Selvig, 1997)

Formation of cementum can be subdivided into Prefunctional developmental stage: formed during the root development. Since the formation of human tooth roots occurs over an extended period of time ranging between 3.5 and 7.5 years for permanent teeth, the prefunctional development is an extremely long lasting process. Functional developmental stage: commences when the tooth is about to reach the occlusal level, is associated with the attachment of the root to the surrounding bone and continues throughout life. It is during this period that adaptive and reparative processes are carried out by the biological responsiveness of cementum, which in turn, influences the alterations in the distribution and appearance of the cementum varieties on the root surface with time.
Once dentin formation is underway, break occurs in the Hertwigs epithelial root sheath allowing newly formed dentin to come in direct contact with Connective tissue of dental follicle. These connective tissue cells differentiate into Cemento blasts and start cementum deposition along the dentinal surface.

Root formation:
Root formation starts when the enamel organ has reached its final size and the inner and outer cell layers of the enamel epithelium proliferate from the cervical loop to form Hertwigs epithelial root sheath. Its most apical portion, that is the diaphragm, separates the dental papilla from the dental follicle. Cells originating from the peripheral dental papilla differentiate along the internal basement membrane of the diaphragm into odontoblasts (epithelial-mesenchymal interaction). Once the first matrix of radicular dentin is formed by the maturing odontoblasts and before the mineralization of the dentin matrix reaches the inner epithelial cells, HERS becomes discontinuous. HERS is not evident as a conspicuous layer during cementum formation.

Physical characteristics Light yellow Lack luster Lighter than dentin Less mineralized as compared to Enamel and Dentin. (Schroeder, 1991) More mineralized as compared to alveolar bone. (Schroeder, 1991) Human cementum is present in a thin layer. More permeable than dentin

Composition of Cementum 1. 2. 1. 2. Inorganic content (45-50% by volume): Calcium and phosphorus as Hydroxyapatite crystals (55nm wide, 8nm thick). Has highest fluoride content out of all the mineralized tissues. Organic content (50-55% by volume): Type I collagen 95%. Type III collagen 5%. It coats type - I collagen of Sharpeys fibres.

Cells of Cementum: 1. Cementoblasts 2. Cementocytes 3. Cementoclasts Cementoblasts Soon after Hertwigs sheath break up, undifferentiated mesenchymal cells from adjacent tissue differentiate into cementoblasts. Cementoblasts synthesize collagen and protein polysaccharides (Proteoglycans) which make up the organic matrix of cementum. These cells have numerous mitochondria, a well formed Golgi apparatus and large amount of granular endoplasmic reticulum. Cementocytes The cells incorporated into cellular cementum are called cementocytes, and are similar to osteocytes. Cementocytes lie in spaces designated as lacunae. A typical Cementocyte has numerous cell processes or canaliculi radiating from its cell body. These processes may branch and they frequently anastomose with those of neighboring cells. The central cell mass may appear rounded, oval or squamoid. Diameter range from 8 to 15 um. The cytoplasm is pale basophilic and the nucleus is centrally located. The cytoplasm of cementocytes in deeper layer of cementum contains few organelles. The endoplasmic reticulum appears dilated and mitochondria are sparse. These characteristics indicate that cementocytes are either degenerating or are marginally active cells. At a depth of 60um or more, cementocytes show definite signs of degeneration, such as cytoplasmic clumping and vesiculation. In the deeper layers cementocytes appear to be empty suggesting complete degeneration of cementocytes. Cementoclasts: Cementoclasts resemble osteoclasts.

These are multinucleated giant cells often located in the lacunae and are found on the surface of the cementum 1. 2. 3. 1. 2. They are responsible for extensive root resorption, during: Mesial migration of tooth Occlusal trauma Orthodontic therapy This type of root resorption may lead to Primary tooth exfoliation Localized cemental resorption

Cementoid Tissue: The uncalcified matrix is called cementoid. Mineralization of cementoid is a highly ordered event & not the random precipitation of ions into an organic matrix. Fibers from periodontal ligament are embedded in the cementum & serve to attach the tooth to surrounding bone. Their embedded portions are known as Sharpeys fibers.

Classification of Cementum: Based upon: Time of formation. (Gottleib 1942) OR Presence or absence of cells within its matrix Schroeders classification

Classification of Cementum depending upon the Time of Formation. Acellular / Primary cementum First formed cementum before tooth reaches occlusal level. No cells present. Covers cervical third/half of the root. Thickness - 30 230 microns. Consists of abundant Sharpeys fibres arranged irregularly or parallel to root surface. Border with dentin not clearly demarcated. Rate of development relatively slow. Cellular / Secondary cementum

Formed after tooth reaches occlusal plane. Contain cementocytes in lacunae which communicat through canaliculi. Relatively lesser amount of Sharpeys fibres. Less calcified

Schroeders Classification: Acellular afibrillar cementum : Important part of attachment apparatus as it connects the tooth to alveolar bone proper. Cells or extrinsic/intrinsic collagen fibers are absent. Contains Mineralized ground substances. Product of cementoblasts. Found in coronal cementum. Thickness 1 -15 u.

Acellular extrinsic fiber cementum No cells present. Densely packed bundles of Sharpeys fibers are present. Product of cementoblasts and fibroblasts. Found in cervical third of roots. Thickness 30 to 230 u.

Cellular mixed stratified cementum Contains cells and Both intrinsic and extrinsic fibres are also present. Co-product of cementoblasts and fibroblasts. Present in apical third, apices and furcation areas. Laid down throughout the functional period of the tooth. Thickness 100 to 1000u

Cellular intrinsic fiber cementum Contains cells No extrinsic fibers present Formed by cementoblasts, cementocytes and intrinsic fibres. Fills resorption lacunae

Intermediate cementum Poorly defined zone near cementodentinal junction Contains cellular remnants of Hertwigs Epithelial Root Sheath. It is not involved in tooth attachment. No functional significance.

Cemento-Dentinal Junction (CDJ): Defn: The terminal apical area of cementum where it joins the internal root dentin is called cementodentinal junction. The obturating material should be at CDJ during root canal treatment. Width of CDJ is 2 to 3u and remains relatively stable. In approx. 30% of all teeth cementum meets the cervical end of enamel In 10% cases enamel and cementum do not meet which can cause accentuated sensitivity because of exposed dentin In about 60% cases cementum overlaps the cervical end of enamel.

Functions of Cementum: Anchorage. Attachment. Adaptive and reparative function. Walling in filled canals. Sealing of necrotic pulps by occluding apical foramen. Protecting underlying dentin.

Cementum Resorption: Systemic causes: Calcium deficiency. Vitamin A,C D deficiency. Hypothyroidism. Hereditary fibrous osteodystrophy. Pagets disease.

Local causes: TFO Orthodontic movement Pressure from malaligned eruptive teeth Cysts and tumours Teeth without functional antagonist Embedded teeth Replanted and transplanted teeth Periapical disease Periodontal disease

Cementum Repair: Cementum resorption is not necessarily 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, termed as Reversal line, which delineates the border of previous resorption. In most cases of repair there is a tendency to reestablish the former outline of the root structure. This is called anatomic repair. However, if only a thin layer of cementum is deposited on the surface of a deep resorption, the root outline is not reconstructed and a bay like recess remains. In such areas sometimes it is restored by formation of bony projection so that proper functional relationship will result. This is called functional repair.

Cementum In Disease:
Enamel Pearls: These anomalies consists of globules of enamel on the root surfaces in the cervical region. They appear to form as a result of the localized failure of Hertwigs root sheath to separate from the dentin surface, thereby allowing cementogenesis to proceed. The adhering epithelium becomes amelogenetic and deposits circumscribed globules of enamel which in turn may become covered with a layer of fibrillar cementum.

Hypercementosis: Hypercementosis refers to a prominent thickening of the cementum characterized by the deposition of excessive amounts of secondary cementum on root surfaces. Appears in the form of spike like excrescences (cemental spike) created by either the coalescence of cementicles that adhere to the root or calcification of periodontal fiber at sites of insertion into cementum. Factors associated with Hypercementosis: Local factors Abnormal occlusal trauma Adjacent inflammations, Unopposed teeth (impacted, embedded without antagonist)

Systemic factors Acromegaly & Pituitary gigantism Arthritis Pagets disease of bone, Rheumatic fever, Thyroid goiter

Ankylosis:

It is the fusion of the cementum and alveolar bone with obliteration of periodontal ligament.
Etiology: Chronic periapical inflammation Tooth replantation Occlusal trauma Around embedded teeth. Clinical features: Lack physiologic mobility. Metallic percussion sound.

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

Periapical Cemental Dysplasia: It is a self limiting abnormality and is therefore not a true neoplasm. These lesions predominantly involve lower anterior periapical region. Affected people are between ages of 30 to 50 when the lesions are first detected. They are not the result of pulp degeneration and the affected teeth are vital. It is an asymptomatic condition that is usually discovered when radiographs are taken for other purposes.

Histology of Periapical Cemental Dysplasia: The lesion progress through three distinct stages.

1. Osteolytic phase: Periapical bone is replaced by a fibrous connective tissue; there is fibroblastic proliferation that may contain small foci of osteoid formation. 2. Cementoblastic phase: Islands and spicules of cementum like matrix form within the connective tissue.

3. Mature stage: The lesion is predominantly composed of irregular cementum like material which is densely mineralized. Benign Cementoblastoma: It is a slow growing neoplasm of Cementoblast that form a mass of hard tissue at the apex of the tooth. It eventually forms a bulbous mass that is firmly attached to the tooth root. It occurs most commonly on the mandibular first molar, affects both the sexes equally and is seen in 20 to 25 years of age patients. Although, the tumor has a margin of soft connective tissue between the lesion and alveolar bone, enucleation of the lesion maybe incomplete and lesion recurs in up to 50% of case.

Conclusion: In particular, Cementum besides its indispensable role in tooth attachment to the surrounding alveolar bone, root cementum has important adaptive and supportive functions. The features of cementum are crucial for maintaining occlusal relationship and for the integrity of the root surfaces and its functions in tooth support.