CEMENTUM

INTRODUCTION
•Overview
•Cementum is the mineralised connective tissue that lines the root of the
•tooth, helping to attach the tooth, via the periodontal ligament, to alveolar
•bone. It has important junctions with enamel (cementum–enamel junction)
•and with dentine (cementum–dentine junction). Although a thin layer, it is
•formed continuously throughout life, allowing for readjustment of attaching
•periodontal ligament fibres. Its composition is similar to that of bone, its
•organic matrix consisting primarily of type I collagen. Different systems
•of classification of cementum exist that depend on the presence or
•absence of cells (acellular and cellular cementum) and/or the origin of its
•organic matrix (extrinsic, intrinsic and mixed fibre cementum and afibrillar
•cementum). Unlike bone, cementum is devoid of blood vessels and
•nerves and has only a very limited capacity for remodelling, allowing for
•orthodontic tooth movement.
Relation of tooth roots to the periodontium. Cementum is shown
on the root apex. It covers entire root surface overlying
dentin. (From Avery JK: Oral development and histology, ed 3,
Stuttgart, 2002, Thieme Medical.)
 Like
dentine, there is always a
thin layer (3–5 µm) of
uncalcified matrix on
the surface of the cellular
variety of cementum (see
page 414). This layer
of uncalcified matrix is called
B precementum or cementoid
(Figs 11.2 and
11.21). Similar in chemical
composition and physical
A properties to bone,
cementum is, however,
avascular and has no
C INNERVATION.

The relationship between cementum (B),

precementum (arrow), a layer of cementoblasts
(A) and the
periodontal ligament (C) (decalcified section; H
& E; ×200).
 B

E
E E

C A D
D D
C C
C

Ground longitudinal
section through a tooth
to show cementum (A) Three patterns for the arrangement of the cementum-
overlapping enamel (B). C enamel junction. C = cementum; D = dentine;
= E = enamel. See text for further details.
dentine (ground section;
×80). Courtesy Prof. A G S
Lumsden.
Physical properties
Cementum is pale yellow with a dull surface. It
is softer than dentine.
Permeability varies with age and the type of
cementum, the cellular variety
being more permeable. In general, cementum
is more permeable than
dentine. Like the other dental tissues,
permeability decreases with age.
The relative softness of cementum, combined
with its thinness cervically,
means that it is readily removed by abrasion
when gingival recession
exposes the root surface to the oral
environment. Loss of cementum in
such cases will expose dentine.
 B A

Scanning electron micrograph of the cementum–enamel

junction where the cementum overlaps the
enamel. A = cementum; B = enamel (SEM; ×250)
Chemical properties
Cementum contains on a wet-weight basis 65% inorganic material, 23%
organic material and 12% water. By volume, the inorganic material
comprises approximately 45%, organic material 33% and water 22%.
The degree of mineralisation varies in different parts of the tissue; some
acellular zones may be more highly calcified than dentine. The principal
inorganic component is hydroxyapatite, although other forms of calcium
are present at higher levels than in enamel and dentine. The hydroxyapatite
crystals are thin, platelike and similar to those in bone. They are on average
55 nm wide and 8 nm thick. Their length varies, but values derived from
sections cut with a diamond knife are underestimated due to shattering of
the crystals along their length. The crystallinity of the apatite in cementum
is lower than the other dental tissues and is demineralised more easily.
As with enamel, the concentration of trace elements tends to be higher
at the external surface. Indeed, fluoride levels in cementum are higher
than any of the other mineralised tissues. Fluoride levels are higher in
acellular than in cellular cementum.
Cementum
Cementum forming on a
developing root.
The organic matrix is primarily collagen. The collagen is virtually all type
I (although types III, V, VI and XII have been found in small quantities).
In addition, the noncollagenous elements are assumed to be similar to
those found in bone (see page 239). However, because of the difficulties
of obtaining sufficient material for analysis, less information is available.
Nevertheless, among the important molecules known to be present are bone
sialoprotein, dentine sialoprotein, fibronectin, tenascin and osteopontin
and possibly other cementum-specific elements that are conjectured to
be involved in periodontal reattachment and/or remineralisation. Such
molecules contain the well-recognised adhesion domain arginine-glycine-
aspartic acid that targets specific integrin receptors on cells. Sialoproteins
are located in the cementum matrix and osteopontin in the incremental lines.
 Classification of cementum
The various types of cementum encountered
may be classified in three
different ways: the presence or absence of cells,
the nature and origin of
the organic matrix, and a combination of both.

Classification based on the presence or

absence
of cells: cellular and acellular
cementum
Cellular cementum, as its name indicates, contains cells
(cementocytes);
acellular cementum does not. In the most common arrangement,
acellular
cementum covers the root adjacent to the dentine, whereas cellular
cementum is found mainly in the apical area and overlying the
acellular
cementum (Fig. 11.6). Deviations from this arrangement are common
and sometimes several layers of each variant alternate. Being formed
first, the acellular cementum is sometimes termed primary
cementum and
the subsequently formed cellular variety, secondary cementum.
Cellular
cementum is especially common in interradicular areas.
The spaces that the
cementocytes occupy in cellular
cementum are
called lacunae and the channels
that their processes extend
along are the
canaliculi Adjacent canaliculi are
often connected
and the processes within them
exhibit gap junctions. In ground
sections
the cellular contents are lost, air
and debris filling the voids
to give the dark appearance. In
thicker layers of cellular
cementum, it
is highly probable that many of
the lacunae do not contain vital
cells.
Cellular cementum from human
premolar. Note lacunae of
spider like cementocytes with
numerous canaliculi or cell pro-
cesses
 B

Lacunae and canaliculi in cellular

cementum. In this section,
Alternating acellular (A) and the preferential orientation of the
cellular cementum (B) (ground lacunae indicates that the external
section; ×60). surface is above and to the left
(ground section; ×500).
 Lamellar
bone has a regular
parallel alignment of
collagen into sheets
(lamellae) and
is mechanically strong.
It is highly organized in
concentric sheets with
a much lower
proportion of
osteocytes to
surrounding tissue.
Microscopic
appearance of
cellular cementum
with its
cementocytes
within their lacunae
(arrows), and the
canaliculi oriented
toward the
periodontal
ligament (PDL) for
nutrition. 
Young cementum deposition on root dentin. Some cementoblasts
become enmeshed in cementum matrix and develop into
cementocytes living in lacunae. (From Avery JK: Oral development
and histology, ed 3, Stuttgart, 2002, Thieme Medical.)
 RER
M

Cementoblasts on surface
of cementoid.
Mitochondria and
CEMENTOID granular endoplasmic
N reticulum are visible
(Electron micro-
graph; ×8000) (Courtesy S
D Lee, Ann Arbor,
Mich)Arrow indicates the
interface between
cementoblast and
cementoid.
TEM of a
cementocyte within
a lacuna. Note that
the
cementocyte
processes here
appear short only
because they extend
out of
the plane of section
(×4,500)
Acellular cementum appears relatively structureless (Fig. 11.7). In the
outer region of the radicular dentine, the granular layer (of Tomes) can
be seen and outside this, the hyaline layer (of Hopewell-Smith).. A dark
line may be discerned
between the hyaline layer and the acellular cementum; this may be
related
to the afibrillar cementum that is patchily present at this position.

In addition, their canaliculi are preferentially oriented

towards the periodontal ligament, their chief source of nutrition. Unlike
bone, the cementocytes are not arranged circumferentially around blood
vessels in the form of osteons (Haversian systems). In decalcified sections
(Fig. 11.2), the cellular contents of the lacunae are retained, albeit in a
shrunken condition.
The appearance of acellular cementum (A). B = hyaline layer
(of Hopewell-Smith); C = granular layer (of Tomes); D = root
dentine.
Note that the dark layer arrowed between the hyaline layer and
the
acellular cementum may be related to the afibrillar cementum
patchily
present at this position (ground section; ×200).
 A
B
A
B

Cellular cementum (B) overlying acellular Acellular cementum (A) overlying

cementum (A). Note cellular cementum (B)
the greater thickness of the cellular layer (ground section of the root; ×50).
(ground section; ×50).
Acellular cementum
(AC) has been
deposited on the
dentin (D). The
dentinocemental
junction (DCJ) is
prominent.
Periodontal ligament
(PDL) extends from
the cementum to the
alveolar bone (B)
Higher magnification
of the
dentinocemental
junction (DCJ),
acellular cementum
(AC), and periodonta
ligament (PDL)
shown in
Cementum is deposited in an irregular rhythm, resulting in unevenly
spaced incremental lines (of Salter; Fig. 11.13). Unlike enamel and dentine,
the precise periodicity between the incremental lines is unknown, although
there have been unsuccessful attempts to relate it to an annual cycle. In
acellular cementum, incremental lines tend to be close together, thin and
even. In the more rapidly formed cellular cementum, the lines are further
apart, thicker and more irregular. The appearance of incremental lines in
cementum is mainly due to differences in the degree of mineralisation,
but these must also reflect differences in composition of the underlying
matrix since, as shown in Fig. 11.13, the lines are readily visible in
decalcified sections. Recent evidence suggests that the incremental lines
are rich in osteopontin and that this might aid the cohesion of the
matrix
molecules at these sites.
 Incremental
lines (of
A Salter) in
cementum
(arrows). A =
B
cementocytes
; B = dentine
(decalcified
section;
picrothionin;
×75).
Courtesy Prof.
M M Smith.
Classification based on the nature and origin
of the organic matrix

Cementum derives its organic matrix from

two sources: from the inserting
Sharpey fibres of the periodontal ligament
and from the cementoblasts.
It is therefore possible to classify
cementum according to the nature and
origin of the fibrous matrix.
 When derived from the periodontal ligament,
the fibres are referred to as the extrinsic fibres.
Sharpey fibres
continue into the cementum in the same
direction as the principal fibres
of the ligament (i.e., perpendicular or oblique to
the root surface; see page
212). When derived from the cementoblasts, the
fibres are referred to as
intrinsic fibres. These run parallel to the root
surface and approximately
at right angles to the extrinsic fibres. Where
both extrinsic and intrinsic
fibres are present, the tissue may be termed
mixed fibre cementum.
Classification based on the presence or
absence of cells and on the nature and origin
of the organic matrix
This classification, which is becoming more widely used, contains
several
types of cementum. For human teeth, two main varieties of
cementum are
found – acellular extrinsic fibre cementum (AEFC) and cellular
intrinsic
fibre cementum (CIFC). AEFC is located mainly over the cervical half
of the root and constitutes the bulk of cementum in some teeth (e.g.,
in
premolars). AEFC is the first formed cementum (see pages 409–413)
and
layers attain a thickness of approximately 15 µm.
Acellular
cementum
Cementoblasts
(CB) and
cementoid (CD)
on the surface of
acellular
cementum (AC)
 AEFC

PLFB

PLFB
AEFC
AEFC
CIFC
CIFC
PLFB

SEMs of fractured surface of root illustrating acellular

extrinsic fibre cementum (AEFC). PLFB = inserting periodontal ligament
fibre bundles; CIFC = underlying cellular intrinsic fibre cementum
Sharpey’s fibers (SF) in
acellular cementum
 D
C
C

D
B
A B
Electron microscopic appearance of the insertion of
Sharpey fibres into cementum. (A) Ground section showing that the
inserting collagen fibres darken as they enter the cementum due to their
partial mineralisation. (B) Decalcified section showing the grouping of
collagen into a bundle and collagen cross banding. C = cementum; D
= periodontal ligament
Acellular extrinsic fibre cementum
For this type of cementum all the collagen is
derived as Sharpey fibres
from the periodontal ligament (the ground
substance itself may be produced
by the cementoblasts). This type of cementum
corresponds with primary
acellular cementum and therefore covers the
cervical two-thirds of the
root. It is formed slowly and the root surface
is smooth
The fibres are generally well mineralised. As
shown
the extrinsic fibres seen in ground sections
may
have unmineralised cores. These may be lost
during preparation of a
ground section and replaced with air or
debris. This results in the total
internal reflection of transmitted light, giving
the appearance of thin
black lines.
 When derived from the
periodontal ligament,
the fibres are referred
to as the extrinsic
fibres. These Sharpey
fibres
continue into the
cementum in the same
direction as the
principal fibres
of the ligament (i.e.,
perpendicular or
Extrinsic fibres in ground sections. The arrows oblique to the root
indicate that the core of the extrinsic fibre surface;
bundle
has been lost during preparation of the ground
section and replaced with air or debris
 SEMs of
fractured
surface of root
showing the
appearance
of cellular
intrinsic fibre
cementum
(CIFC). Note the
absence
of Sharpey fibres
and the parallel
distribution of
the bundles of
mineralised
CIFC
intrinsic fibres
[A,B, ×470; inset
shows that
Sharpey
fibres (SF) can
occasionally be
seen inserting
into CIFC
 Cellular intrinsic fibre
cementum)
This type of cementum is
composed only of intrinsic fibres
running
parallel to the root surface. The
absence of Sharpey fibres means
that
intrinsic fibre cementum has no
role in tooth attachment. It may
be found
in patches in the apical region. It
may be a temporary phase, with
extrinsic
SEM showing the appearance of intrinsic fibre fibres subsequently gaining a
cementum at the surface of the root apex. Note reattachment, or may represent
the
a permanent
absence of Sharpey fibres and the parallel
distribution of the bundles of mineralised
region without attaching fibres.
intrinsic fibres (anorganic
preparation; ×150).
 B
A
B

Attachment of the periodontal

ligament fibres to cementum.
The fibres of the periodontal
Fibre orientation in acellular and cellular ligament (B) are seen to run into
cementum. The root the organic
surface is seen in polarised light, the different matrix of precementum (A)
colours reflecting different
orientations of the collagen fibres. A = acellular
cementum; B = cellular
cementum
Mixed fibre cementum
For this third variety of cementum, the collagen fibres of the organic matrix
are derived from both extrinsic fibres (from the periodontal ligament) and
intrinsic fibres (from cementoblasts). The extrinsic and intrinsic fibres
can be readily distinguished. First, the intrinsic fibres run between the
extrinsic fibres with a different orientation. Indeed, the fewer the number
of intrinsic fibres in mixed fibre cementum, the closer the extrinsic fibre
bundles. Second, the fibre bundles are of different sizes: the extrinsic
fibres are ovoid or round bundles about 5–7 µm in diameter; the intrinsic
fibres are 1–2 µm in diameter.

If the formation rate is slow, the cementum may be termed acellular

mixed-fibre cementum and is generally well mineralised. If the formation
rate is fast, the cementum may be called cellular mixed-fibre cementum
and the fibres are less well mineralised (especially their cores).
 owards the (A) The
oot apex, appearance of
nd in the mixed fibre
urcation cementum. A
reas of light
multirooted micrograph to
eeth, show the
he AEFC alternating
nd the CIFC distribution of
re acellular
ommonly extrinsic
resent in fibre
lternating cementum
ayers (AEFC) and
nown cellular
s cellular intrinsic fibre
mixed cementum
tratified (CIFC),
ementum forming
cellular mixed
stratified
cementum
(CMSC)
(Ground
section;
 SEM of the surface of a root
showing the appearance of
mixed fibre cementum. A =
B mineralised intrinsic fibres
A (present here
in small amounts); B =
B mineralised extrinsic fibres.
A Note the smaller
dimensions of the intrinsic
fibre bundles (anorganic
A preparation; ×3,000).
 Sharpey’s fibers

CEMENTUM Ultrastructural view

of cementodentinal
junction of human
inci-
sor. In this
tangential section,
Sharpey’s fibers are
visible as
discrete bundles of
collagen fibrils

CEMENTO-DENTINAL
JUNCTION
 A

C A
B B

Intermediate cementum (A) near the

Intermediate cementum (A). B = root cementum–dentine junction.
dentine. C = cellular cementum B = granular layer
(demineralised
section; picrothionin; ×75). Courtesy Prof.
M M Smith.
Afibrillar cementum
The extrinsic, intrinsic and mixed fibre cementum types all contain
collagen
fibres. However, there is a further type of cementum that contains
no
collagen fibres. This afibrillar cementum is sparsely distributed and
consists
of a well-mineralised ground substance that may be of epithelial
origin.
Afibrillar cementum is a thin, acellular layer (difficult to identify at
the light
microscope level), which covers cervical enamel or intervenes
between
fibrillar cementum and dentine. Afibrillar cementum is thought to be
formed at this site following the loss of the reduced enamel
epithelium
Cementum–dentine junction
The nature of the cementum–dentine junction is of particular
importance,
being of interest biologically because it forms an interface (a ‘fit’)
between
two very different mineralised tissues that are developing
contemporarily.
It is also of clinical importance because of the processes involved in
maintaining tooth function while repairing a diseased root surface. The
cementum–dentine junction appears components (including dermatan
sulphate and collagen fibrils).

It is often reported that an ‘intermediate layer exists between

cementum and dentine and that this layer is involved in ‘anchoring’ the
periodontal fibres to the dentine
Indeed, it appears
that the term has even been used to describe the hyaline layer of dentine.
Ultrastructural appearance of cementum
This varies with the level of the tissue examined. Near the periodontal
surface (Fig. 11.25), cementum is not homogeneous because of
ongoing
calcification and the presence of Sharpey fibres. The calcification of
precementum is probably initiated in the early phases by the presence

of the underlying root dentine mineral and continues on, and around, the
collagen fibres (both those formed by the cementoblasts and those included
as attachment fibres from the periodontal ligament). The outer part of
the cementum, where Sharpey fibres predominate, may be considered
as calcified periodontal ligament. Unlike dentine, no calcospherites are
present within precementum.

At deeper levels), closer to the

cementum–dentine junction, acellular cementum resembles peripheral
dentine and a demarcation is often difficult to see. The small channels seen
at this level may be canaliculi derived from more superficial cementocytes,
but some may be the terminals of dentinal tubules that traverse the border
between the two tissues.
 Near the periodontal
surface (Fig. 11.25),
cementum is not
homogeneous because of
ongoing
calcification and the
presence of Sharpey fibres.
The calcification of
precementum is probably
initiated in the early phases
by the presence
of the underlying root dentine
mineral and continues on, and
around, the
collagen fibres (both those
formed by the cementoblasts and
those included
as attachment fibres from the
periodontal ligament). The outer
part of
Appearance of cementum near the the cementum, where Sharpey
periodontal surface fibres predominate, may be
considered
as calcified periodontal ligament.
 At deeper levels (Fig.
11.26), closer to the
cementum–dentine
junction, acellular
cementum resembles
peripheral
dentine and a
demarcation is often
difficult to see. The small
channels seen
at this level may be
canaliculi derived from
more superficial
cementocytes,
but some may be the
terminals of dentinal
tubules that traverse the
Appearance of cementum near border
between the two tissues.
the cementum–dentine
junction
Resorption and repair of cementum
Although cementum is less susceptible to resorption than bone under the
same pressures (e.g., with orthodontic loading), most roots of permanent
teeth still show small, localised areas of resorption (Figs 11.27–11.29).
The cause of this is not known but may be associated with microtrauma.
The resorption is carried out by multinucleated odontoclasts (see page
173) and may continue into the root dentine. It has been suggested
that the different levels of fluoride in cementum and bone (higher in
cementum) may explain why cementum is less susceptible to resorption
Alternatively, the greater resistance to resorption might relate to the
fact
that the surface of the cementum is covered by a layer of tightly
packed
collagen and therefore the mineralised surface is relatively inaccessible.
The unmineralised surface layer of collagen thus protects against the action
of odontoclasts. It has also been suggested that cementoblasts lining the
root surface do not retract from this surface in response to parathormone
and that therefore the surface is not exposed to odontoclasts.
The surface of a root showing
localised area of resorption of
cementum (
 CIFC-CELLULAR INTRINSIC FIBRE CEMENTUM
CMFC-CCELLULAR MIXED FIBRE
CEMENTUM
CB-CEMENTOBLASTS,RL-REVERSAL LINE,D- DENTIN
 A Repair of
cementum
following a localised
region of root
resorption. A =
acellular cementum;
D B = root
B dentine; C = reversal
line separating
repair tissue from
underlying dental
tissues; D =
C periodontal
ligament;
 C
D

An
irregular, and dark-
staining, reversal line
B separates the repair
A tissue from
the underlying dental
tissues.
Fig .shows an infilled
area where
dentine has been
resorbed.

Demineralised section of root showing

infilled area of repair cementum (A). B =
reversal line; C
= dentine; D = cementum
Cementicles are mineralized bodies
of cementum found either attached
to the cemental root surface or
lying free in the periodontal
ligament (see Figure 14-11). They
form from the apposition
of cementum around cellular debris
in the periodontal ligament
(PDL), possibly as a result of
microtrauma to Sharpey’s fibers.
They become attached or fused
from the continued apposition of
cementum, and thus may interfere
with periodontal treatment, as well
as being noted on radiographs.

 Cementicle attached to the

cemental surface within the
periodontal ligament (arrow
 Cementicles (Fig. 11.30)
are small, globular
masses of cementum
found
in approximately 35% of
human roots. They are
not always attached to
the cementum surface
but may be located free
in the periodontal
ligament.
Cementicles may result
from microtrauma,
when extra stress on the
Sharpey
fibres causes a tear in
the cementum. They are
more common in the
apical
and middle third of the
SEM appearance of a cementicle (arrowed). This
root and in root
cementicle is attached to the root surface (×1,000).
furcation areas.
Hypercementosis is the excessive production of cellular
cementum, which mainly occurs at the apex or apices of the
tooth (Figure 14-12). It may be noted on radiographs as a
radiopaque (or lighter) mass at each root apex. This condition
can result from occlusal trauma caused by occlusal forces and
during certain pathological conditions (at a generalized level as
noted with Paget’s disease), such as chronic periapical
inflammation. It may also be a compensatory mechanism in
response to attrition to increase occlusal tooth height.
However, such deposits form bulbous enlargements on the
roots and may interfere with extractions, especially if adjacent
teeth become fused (concrescence). It may also result in pulpal
necrosis by blocking blood supply via the apical foramen.
 Hypercementosis

 Hypercementosis at the root apices due to traumatic

occlusal forces on mandibular molar
Ground section of tooth
apex of root showing
apical
foramen: part of root
canal (RC) closed by
layer of cementum (C)
at
the apical foramen
(AF). Cementum at the
apex is thick and
cellular.
Tomes’ granular layer
(TGL) between dentin
(D) and cementum is
clearly visible
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