PERIODONTIUM

Gingiva

Cementum Periodontal ligament Root canal Alveolar bone

The periodontium is defined as those tissues supporting and investing the tooth and consists of:
1. 2. 3. 4.

Cementum Periodontal ligament (PDL) Bone lining the alveolus Parts of the Gingiva facing the tooth

All of these tissues has ectomesenchymal origin.

The other bone It is a hard avascular connective tissue that covers the roots of teeth

Cementum is the calcified,avascular mesenchymal tissue that forms the outer covering of the anatomic root It begins at the cervical portion of the tooth at the cemento-enamel junction and continues to the apex. Cementum furnishes a medium for the attachment of collagen fibers that bind the tooth to surrounding structures.

Hardness is less than that of dentin. Light yellow in color.

Can be distinguished from enamel by its lack of luster & its darker hue.
Semi-permeable to a variety of materials. Highest % - fluoride
9

50-55% of weight organic material and water. Collagen fibrils Protein polysaccharides (proteoglycans) 45-50% inorganic material. Hydroxylapatite (calcium & phosphate) Various trace elements, (Fluor, copper, zinc etc.) the highest fluoride concentration of all tooth tissue

Presence or absence of cells

Two types of cementum are recognized depending on the presence or absence of cells, and they are therefore known as: acellular cementum acellular afibrilar cementum (over enamel) acellular fibrilar (extrinsic fiber) cementum and cellular fibrilar (intrinsic fiber) cementum Both forms are deposited in layers and the deposition probably continues throughout life.

The collagen fibrils of cementum are of two kinds: The first group is made up of the embedded parts of the principal fibers of the periodontal Ligament, which are known as sharpey's fibers (extrinsic group). They formed by the fibroblasts of the periodontal ligament. The other group of collagen fibrils, which constitute the intrinsic group, are formed by the cementoblasts and are found between the sharpey's fibers arranged either randomly or parallel to the surface of the cement.

Acellular C. consists of calcified intercellular substance and embedded collagen fibers from the Acellular C. extrinsic group (sharpey's fibers). The remainder fibers are from the intrinsic group and run perpendicular to the sharpey's fibers. In dried ground section the sharpey's fibers disintegrate and appear dark.

Dentin

It predominates in the coronal half of the root. It may also cover the root from cemento-enamel-junction to the apex, but always the apical third of the root is predominant cellular.

Dentin

CC

Dentin

AC

During the calcification cementoblasts are incorporated in the cementum. The cells become cementocytes. They lie in spaces designated as lacunae. Atypical cementocyte has numerous cell processes, or canaliculi, radiating from its cell body mainly toward the PDL (the source of nutrition). Cementocytes have less activity than cementoblasts. They are irregularly distributed throughout the thickness of CC.

Cementocytes

Dentin

PDL

Cementocytes Dentin

Cementodentinal

junction

Cellular cementum

Cementocytes

PDL side

Lacunae and canaliculi

It is a less mineralized type of C., which is formed after tooth is in occlusion. It is more frequent on the apical half o the root. It is always formed on the surface of acellular cementum. It is less in anterior teeth, but thicker in multi-rooted teeth. Sometimes the cellular cementum covers the inner wall of dentin forming a lining of the root canal.

The cellular cementum has only about 60% of its collagen fibers derived from sharpey's fibers. The remainder fibers are intrinsic fibers.

CEMENTUM
Canaliculus GT Lacuna of cementocyte

Dentin
Acellular cementum Cellular cementum Hyaline layer (of Hopewell Smith) Granular layer of tomes

Dentin with tubules

Cementoblast and cementocyte Cementocytes in lacunae and the channels that their processes extend are called the canaliculi Cementoid: Young matrix that becomes secondarily mineralized Cementum is deposited in increments similar to bone and dentin

Acellular afibrillar cementum - Contains neither cells nor extrinsic or intrinsic collagen fibers, except for mineralized ground substance. Coronal cementum.(1-15um) Acellular extrinsic fiber cementum - Composed almost entirely of densely packed bundles of Sharpeys fibers. Cervical third of roots. (30230um) Cellular mixed stratified cementum - Composed of extrinsic & intrinsic fibers & may contain cells. Co-product of cementoblasts & fibroblasts. Apical third of roots, apices & furcation areas. (1001000um)

29

Cellular intrinsic fiber cementum Contains cells but no extrinsic collagen fibers. Formed by cementoblasts. It fills resorption lacunae.

Intermediate cementum - Poorly defined zone near the cementodentinal junction. Contains cellular remnants of Hertwigs sheath embedded in calcified ground substance.

30

Incremental lines of Salter Cementodentinal junction Cementoenamel junction Sharpey's fibers Cementicles

In both acellular and cellular cement incremental lines run roughly parallel with the root surface. These are formed by fiber-free amorphous substance and represent intervals between successive deposition of cement and are called incremental Lines of Salter. Histochemical study indicates that the incremental lines are highly mineralized areas with less collagen and more ground substance.

Annulus (or anulus), being the Latin for "ring", is a term used to describe various ring-shaped objects

It takes place in two phases: Matrix formation Mineralization There are 3 cell types responsible for the cementogenesis: Cementoblasts Cementocytes Fibroblasts All of these cells are differentiated ectomesenchymal cells.

Root development begins after the crown is formed. Root formation precedes by

deposition of dentin along

HERS derives from the corono-apical extension of the inner and outer dental epithelium.

It is believed that HERS induce the formation of the root dentin. Ectomesenchymal cells of the dental pulp differentiate into odontoblasts to form the first layer of root dentin. Just before degeneration of the Hertwig`s root sheath, a thin cell-free layer of cementum is formed on the surface of dentin: intermediate cementum.

After degeneration of the epithelial root sheath ectomesenchymal cells from the inner portion of the dental follicle differentiate and become cementoblasts.

The mineralization begins after forming the first layer of matrix. Ca and Ph ions from the tissue fluid are deposited into the matrix and arranged as hydroxylapatite crystals parallel to the fibrils. Sometimes crystals can be seen clustered into groups of nucleation centers as found in bone.

INTERMEDIATE CEMENTUM: Intermediate cementum is a thin, acellular, amorphous layer of hard tissue approximately 10 micron thick. It is deposited by the inner layer of the epithelial cells of the root sheath. Deposition occurs immediately before the epithelial root cells disintegrate as a sheet and migrate away from the root into the periodontal tissue. The remnants of this sheath are called cells of malassez

intermediate cementum Cementoblasts

Remnants of the Hertwig`s root sheath, which disintegrate into the PDL are the Malassez cells.
intermediate cementum

CEJ CDJ

Smooth in permanent teeth. Scalloped in deciduous teeth.

Dentin is separated from cementum by a zone known as the intermediate cementum layer.
This layer is predominantly seen in apical two-thirds of roots of molars & premolars.

44

45

The relation between, cementum and enamel at the cervical region of teeth is variable. In approximately 30% of all teeth, cementum meets the cervical end of enamel in a relatively sharp line.

In about 10% of the teeth, enamel and cementum do not meet. Presumably this occurs when enamel epithelium in the cervical portion of the root is delayed in its separation from dentin

In such cases these is no cementoenamel junction. Instead, a zone of the root is devoid of cementum and is, for a time, covered by reduced enamel epithelium.

In approximately 60% of the teeth, cementum overlaps the cervical end of enamel for a short distance. This occurs when the enamel epithelium degenerates at its cervical termination, permitting connective tissue to come in direct contact with the enamel surface.

50

Cementicles are small-mineralized bodies, which may be found in the periodontal ligament. They may be attached to the cementum or the alveolar bone, or occur free in the periodontal ligament. When present, cementicles are generally found about all or most of the teeth. Cementicles may be formed by mineralization of degenerating epithelial rests or thrombosed vessels.

53

54

to bind the tooth to alveolar bone.

 Hypercementosis

Cementicles
Cementoma

Hypercementosis: It is an abnormal thickening of cementum, may be diffuse or circumscribed. It may affect all teeth of the dentition, be confined to a single tooth, or even affect only Parts of one tooth. If the overgrowth improves the functional qualities of the cementum, it is termed a cementum hypertrophy. If the overgrowth occurs in nonfunctional teeth, it is termed hyperplasia (e.g. ostitis deformans paget).

Localized hypercementosis

Generalized hypercementosis

In Localized hypertrophy prong like extension of cementum may be formed. This condition frequently is found in teeth that are exposed to great stress (ortho) (compensatory cementum). This extension of cementum provide a larger surface area for the attaching fibers; thus a firmer anchorage of the tooth to the surrounding alveolar bone is assured.

Localized hypercementosis may some times due to periapical inflammation. Here the hyperplasia is circumscribed and surrounds the root like a cuff.

The resorptive activity may have been initiated by trauma from occlusion, orthodontic forces or for unknown reasons. Generally, the defect is repaired by rapid deposition of cellular cementum once the initiating factor is removed.

LOCAL FACTORS

Systemic factors.
Calcium deficiency Hypothyroidism Hereditary fibrous osteodystrophy Pagets disease

Trauma from occlusion Orthodontic movement Pressure from malalligned Erupting teeth. Cyst and tumour Teeth without functional antagonist Embeded teeth Periapical disease

Fusion of cementum and alveolar bone with obliteration of the periodontal ligament Occurs after chronic periapical inflammation,tooth replantation and occlusal trauma. Clinically ankylosed teeth lack physiologic mobility of normal teeth Teeth usually have special metallic percussion sound

Cementicles
Calcified ovoid or round nodule found in the PDL Single or multiple near the cemental surface Free in ligament; attached or embedded in cementum Aging and at sites of trauma Origin: Nidus of epithelial cell that are composed of calcium phosphate and collagen to the same amount as cementum (45% to 50% inorganic and 50% to 55% organic)

Cemental Repair
Protective function of cementoblasts after resorption of root dentin or cementum Resorption of dentin and cementum due to trauma (traumatic occlusion, tooth movement, hypereruption) Loss of cementum accompanied by loss of attachment Following reparative cementum deposition attachment is restored

WHY DOES ROOT-PLANING CAUSE SENSTIVITY?

Clinical Correlation
Cellular cementum is similar to bone but has no nerves. Therefore it is nonsensitive to pain. Scaling produces no pain, but if cementum is removed, dentin is exposed causes sensitivity

Clinical Correlation
Cementum is resistant to resorption. Thus, orthodontic tooth movement causes alveolar one resorption and not tooth root loss.

Aging of Cementum
1. Smooth surface becomes irregular due to calcification of ligament fiber bundles where they are attached to cementum Continues deposition of cementum occurs with age in the apical area. [Good: maintains tooth length; bad: obstructs the foramen 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

2.

3.

4.

ROOT PLANING ROOT CONDITIONING

Curettes Remove diseased cementum + remaining calculus Scaling only calculus