Cementum Clinical Correlation PDF

Cementum related Clinical correlation Presented by: Rawan Itani 201900113 Submitted to: Dr. Hagar Sherif Abdelfattah Abdelnaby Oral biology  Table of Contents 01 Introduction 04 Developmental anomalies 02...

Cementum related Clinical correlation Presented by: Rawan Itani 201900113 Submitted to: Dr. Hagar Sherif Abdelfattah Abdelnaby Oral biology  Table of Contents 01 Introduction 04 Developmental anomalies 02 05 Systemic conditions Structures of that influence cementum cementum 03 Function 06 Clinical applictaion  01 Introduction What is cementum? Cementum is the calcified avascular mesenchymal tissue which forms the outer layer of root surface It begins at the cervical portion of the tooth (CEJ) and continues to the apex Cementum is considered as part of the periodontium apparatus It plays an important role in anchoring teeth to the bone via periodontal ligament. Physical properties Hardness is less than dentin Color: light yellow in color can be distinguished from enamel as it has darker hue while its lighter than dentin Thinnest part is at the cemento-enamel junction (20- 50 µm) and the thickest part is toward the apex (150- 200µm) Permeability of cellular cementum is greater than the acellular cementum (more permeable from the dentin and PDL side) With age this permeability decreases Composition Cementum is basically composed from organic and inorganic part 50-55% makes up the organic 45-50% makes up the inorganic Inorganic consist of calcium phosphate in form of hydroxyapatite crystals Organic content consist of collagen protein and polysaccharides fibers (mainly collagen type I & type III) The 2 main sources of collagen : sharpy’s fibers (extrinsic) which are portion of fibers that are embedded in PDL formed by the fibroblast fibers belongs to the cementum matrix (intrinsic) and produced by fibroblast  Classification of cementum Based on Location Cellularity Fibers Coronal Cellular Extrinsic Radicular Acellular Intrinsic  Acellular and cellular cementum Features Acellular cementum (primary) Cellular cementum (secondary) Formation Before tooth reaches occlusal plane Forms after tooth reaches occlusal plane Cells No cell Contains cementocyte Location Cervical or half part of the root Apical portion Rate of Slow Faster formation Calcification More calcified Less calcified Fibers Sharpy’s fibers Less fibers Regularity Regular Irregular Thickness 30-50µm 1 to several µm Function For anchorage and attachment to Contribute to the length of root pdl during growth Repair and regeneration Presence or absence of fibers Fibrillar cementum is when cementum contains well defined densely packed collagen fibrils in its matrix Afibrillar cementum it is when cementum lacks dense collagen fibers Acellular afibrillar Acellular intrinsic Acellular Cellular mixed Cellular intrinsic cementum: fiber cementum: extrinsic fibers: stratified fiber cementum First formed Densley packed cementum: No cells or fibers cementum sharpey’s fibers Has the two types contains Have mineralized The collagen produced by of fibers extrinsic cementocytes with ground substance fibers are fibroblast and and intrinsic also no extrinsic fibers It is a produced by produced by cementoblast Produced by formed by cementoblast cementoblasts Mainly in the cementoblast and cemntoblast fills Mainly found as the before PDL cervical third fibroblast resorption lacunae coronal cementum formation thickness of 30- Mainly found in the thickness (1-5 µm) After 15-20µm of 230 micron apical third cementum is furcation areas formed the thickness of 100- fibrous fringe 1000 microns attaches to PDL only  02 Structures in cementum Cemento-enamel junction The junction between enamel of the crown and cementum of root is called CEJ Fusion of cementum and enamel Overlapping: cementum overlaps enamel most common Edge to edge: cementum meets enamel butt joint Gap cementum: is separated from enamel It is important to note that in case no union between enamel and cementum and upon gingival recession the exposure of dentine will lead to hypersensitivity Cemento-enamel junction Clinical significance Used as a reference point in healthy individuals the junctional epithelial attachment is at the level of CEJ Used to calculate the clinical attachment loss Determine the rate pf progression in periodontal disease Cemento-dentinal junction The terminal apical area of the cementum where it joins the internal root canal dentin is known as the cemento-dentinal junction. It forms an interface between two very different mineralized tissues When root canal treatment is performed, the obturating material should be at the cemento-dentinal junction No increase or decrease in the width of the cemento- dentinal junction with age its width appears to remain relatively stable. Cemento-dentinal junction Clinical significance It furnishes a medium for attachment of collagen fibers, which binds the tooth to the alveolar bone. Its continuous deposition helps in achieving crown length lost due to attrition and maintains occlusal relationship. It serves as a major reparative tissue for root surfaces, thereby maintaining integrity of the root surfaces. Intermediate cementum A thin layer of hard tissue its is an ill defined zone near the cemento-dentinal junction intermediate between cementum and dentin of certain teeth that appears to contain cellular remnants of Hertwig’s epithelial root sheath Predominantly seen in the apical two third of roots in molars and premolars rarely seen in incisors and primary teeth It does not exhibit the characteristic feature of either dentin or cementum It is produced by alternations in phases of cementogenesis Function: seals the surface of sensitive root dentin It contains enamel like proteins which help in the attachment of cementum to dentin  03 Function of cementum  Anchorage Adaptation It furnishes a medium for Continuous deposition attachment of collagen of cementum as a form fibers that bind the tooth to of adaptation according the alveolar bone to tooth movement. mainly the primary With increase in age cementum (acellular) is wear of teeth is responsible for this function common so to maintain cementum acts as avascular the vertical dimension connective tissue new layer is deposited Repair Mainly the secondary cementum (cellular) is responsible for repair and it is to maintain the integrity of root surface 2 types of repair according to the amount of damage to root surface anatomic repair is mainly when the defect is small and when the former outline is re-established functional repair : it is in case of larger defect only a thin layer of cementum is deposited on the surface here the normal root outline is not reconstructed In such areas the PDL space is restored to its normal width by formation of bony projections to maintain the proper function Cementum resorption Cyst tumors Paget’s disease Systemic factors Embedded teeth Hypophosphatasia Trauma from Calcium deficiency local factors occlusion Hereditary fibrous Excessive osteodystrophy orthodontic force Periapical or periodontal disease Teeth without functional antagonist Replanted teeth Types is either based on location or degree of persistence: internal cemental resorption – external cemental resorption Transient or progressive cemental resorption Cementum resorption & orthodontic tooth movement Reasons for relative resistance of cementum to resorption Cementum is more resistant to resorption than bone, and it is for this reason orthodontic tooth movement is made possible The difference in the resistance of bone and cementum to pressure may be caused by the fact that bone is richly vascularized whereas cementum is avascular, thus degenerative processes are much more easily effected by the interference with circulation in bone, whereas cementum with its slow metabolism (as in other avascular tissues) it is not damaged by a pressure equal to that exerted on bone. When tooth is moved by an orthodontic force bone is resorbed on side of pressure and new bone is formed on the side of tension The surface layers of cementum contains more fluoride than does bone tissue, resulting in great resistance to the dissolution in acids produced by the osteoclast. Age changes Cementum deposition is continuous throughout life, it is more at the apical areas This deposition slows in older ages Cementum is permeable in both directions this permeability decreases with age The smooth surface of cementum becomes more irregular due to calcification of some fibers  04 Developmental anomalies  Hypercementosis Definition: Its is also known as cementum hyperplasia refers to the thickening of cementum it can be localized or generalized Causes: Teeth without antagonist Teeth with pulpal or periodontal infections Clinical features: Seen mainly in adults Permanent teeth are more prone to be affected Clinical presentation: Vital tooth is not sensitive to percussion Generalized thickening of cementum with nodular enlargement The apical third roots will appear large Spikes can be formed on cementum in case of excessive occlusal force trauma  Hypercementosis Radiographic appearance: Thickening and blunting seen in roots with roundation of apex Management Hypercementosis itself does not need treatment Treatment of the primary etiology Complication: could posse a problem if the affected tooth requires extraction and in multirooted teeth sectioning may be needed localized generalized  Cemental tear Definition: It is the detachment of a fragment of cementum from the root surface It could be either complete displacement of a fragment into PDL or incomplete partially attached to roots Etiology: acute trauma from occlusion Diagnosis: characteristic feature which present radiographically “prickle like body” Clinical significance: It may be one of the contributing factors in the progression of adult periodontitis Cemental tears demonstrate a greater loss of attachment compared to intact surfaces They can be misdiagnosed as cementicles if they were lying free in the PDL Management: its basically self limiting since the detached cementum can be reunited at the root surface by new cementum deposition  Cementicles Globular mass of cellular cementum less than 0.05 mm that forms with in the PDL May lie free in the PDL or attached to the radicular surface It originates from the degenerating cells or epithelial rests in PDL More commonly found in the apical and middle third in cementum Types: free cementicles Sessile or attached Interstitial or embedded cementicles  Ankylosis It is the fusion of cementum and alveolar bone with complete obliteration of the pdl Resorption of root and gradual replacement by bone More common in primary dentition Etiology: Chronic periapical infection Tooth reimplantation Occlusal trauma  Ankylosis Clinical presentation: Lack of physiologic mobility Metallic sound upon percussion Loss of the proprioceptors due to the loss of PDL Infraocclusion appearance Radiographic appearance: Resorption lacunae are filled with bone Missing PDL space Treatment: No treatment Special consideration during extraction fear of either tooth fractur or alveolar bone fracture  Concrescence Fusion of teeth by fusion of cementum Etiology: Traumatic injury Crowding of teeth in area during the apposition and maturation stage of development Special considerations and precautions during extraction (complicated)  05 Systemic conditions that influence cementum Hypophosphatasia Hypophosphatasia (HPP) is a rare, inherited metabolic disorder caused by mutations in the ALPL gene Which encodes tissue-nonspecific alkaline phosphatase (TNSALP). This enzyme is essential for bone and dental mineralization. Mutations in the ALPL gene lead to deficiency in TNSALP activity, which interferes with the formation of hydroxyapatite crystals in bones and teeth. Oral signs are among the earliest and most notable features of hypophosphatasia, often seen before skeletal symptoms. Premature Dental Alveolar bone Oral pain and tooth loss hypoplasia deficiency discomfort Hypophosphatasia Treatment for hypophosphatasia (HPP) varies based on disease severity, patient age, and specific symptoms: Enzyme replacement therapy Pain Relief: medications such as nonsteroidal anti-inflammatory drugs (NSAIDs). Physical Therapy: low-impact exercises (e.g., swimming) help maintain muscle strength and joint flexibility, reduce discomfort, and improve mobility. Orthopedic Surgery Dental Management preventive and supportive Dental Care: regular dental visits and proactive care (fluoride treatment, sealants) are crucial to prevent decay and preserve oral health. Prosthetics and Implants: Removable or fixed prosthetics may help manage tooth loss, especially in children who experience early loss of primary teeth. Supplementation Vitamin D and Calcium Lifestyle Modifications Paget disease It is characterized by enhanced resorption of bone. Etiology viral infection inflammatory cause autoimmune connective tissue and vascular disorder. Clinical features Age: Middle age Gender: Both males and females are affected. Involvement of facial bone. MAXILLA: progressive enlargement, alveolar ridge widened, palate flattened, tooth become loosened. MANDIBLE: findings are similar but not as severe as maxilla. Radiographic findings Cotton wool appearance of paget’s bone. Generalized hypercementosis of teeth Histologic feature Jigsaw or mosaic pattern. Treatment No specific treatment Hyperpituitarism Also known as gigantism childhood version of growth hormone excess and it is characterized by the general symmetrical overgrowth of the body parts Clinical presentation prognathic mandible frontal bossing dental malocclusion interdental spacing Intraoral radiograph hypercementosis of the roots. Acromegaly is characterized by an acquired progressive somatic disfigurement, mainly involving the face and extremities, and also many other organs, associated with systemic manifestations. Dental radiograph may demonstrate large pulp chambers and excessive deposition of cementum on the roots. Neoplasm of cementum Cementifying fibroma Cementoblastoma Composed of fibrous tissue that Benign neoplasm of functional contains a variable mixture of bony cementoblasts which form a large mass trabeculae, cementum like structures of cementum or cementum-like tissue or both. on the tooth root. Origin of these tumors is either Clinical features odontogenic or from periodontal Age: under age of 25 years. ligament. Site: mostly in mandible (1st premolar) Clinical features Slow growing, may cause expansion of Age: 3rd and 4th decades of life. cortical plates. Gender: Female more affected Radiographic finding Site: Mandibular premolar and molar well circumscribed dense radio-opaque area mass often surrounded by a thin, Rarely cause any symptoms and are uniform radiolucent line. detected upon radiographic Treatment examination. Extraction of the affected tooth even Radiographic finding lesion is well defined and unilocular it though this tooth is vital as it might may appear completely radiolucent, cause expansion of jaws or more often varying degrees of radiopacity. Treatment Enucleation of the tumor Cementoblastoma Cementifying fibroma  06 Clinical importance and application  Cementum and Periodontal Health In periodontal diseases like gingivitis and periodontitis, cementum is closely involved in the following ways: Root Planning and Scaling: When a patient has periodontal disease, bacterial plaque and calculus can accumulate on the tooth surface, including the cementum. This causes inflammation in the supporting structures of the tooth. Root planning (a deep cleaning procedure) removes not only calculus but also any infected or roughened cementum. After root planning, some of the cementum may regenerate naturally Careful attention is needed to avoid excessive removal of healthy cementum , which may not fully regenerate, leading to continued periodontal attachment loss. This can result in mobility or even tooth loss. Guided Tissue Regeneration (GTR): Uses barrier membranes or growth factors such as enamel matrix proteins, to stimulate new cementum, periodontal ligament, and bone formation. Significant for patients with advanced periodontal disease, enabling functional restoration of lost tooth-supporting tissues.  Cementum and Tooth Sensitivity One of the most common clinical challenges related to cementum is tooth sensitivity, often caused by the exposure of cementum due to gingival recession When the gingiva pull away from the tooth, the cementum becomes exposed, and this layer is much softer than enamel, making it more vulnerable to abrasion, thermal sensitivity, and decay. And when the dentin is not fully covered by cementum this will lead to more sensitivity and root caries since dentin is more prone to caries than cementum  Cementum and Tooth Sensitivity Desensitizing agents: These are applied to the exposed cementum to block the dentinal tubule which helps reduce sensitivity. (Potassium Nitrate, Fluoride Compounds Calcium Phosphate compounds, Oxalates…) Restorative procedures: In severe cases, covering the exposed cementum with composite resin or glass ionomer restorations can protect the root surface and prevent sensitivity. Soft tissue grafting: For more severe cases of gum recession, connective tissue grafting or free gingival grafting may be performed to cover the exposed cementum and restore gum tissue Conclusion Cementum is 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 the oral cavity Cementum is essential to both the functional stability and treatment outcomes of teeth in various clinical scenarios. Whether it’s in managing periodontal health, treating tooth sensitivity, conducting restorative procedures, or handling trauma, cementum's role in tooth attachment, regeneration, and healing is indispensable. It requires careful management, particularly in procedures involving root surfaces, to ensure long-term dental health. THANK YOU Any questions Refereces NEWMAN AND CARRANZA’S CLINICAL PERIODONTOLOGY AND IMPLANTOLOGY 14th edition Carranza’s periodontology 10th Edition Lee, A. H., Neelakantan, P., Dummer, P. M., & Zhang, C. (2021). Cemental Tear: Literature review, proposed classification and recommendations for treatment. International Endodontic Journal, 54(11), 2044–2073. https://doi.org/10.1111/iej.13611