PERIODONTIUM surrounding the root of the tooth we have three different tissues ..

1-cementum which covers the root 2-the alveolar bone which surrounds the root 3 -And between them the tissue that binds the tooth to the bone which is called the periodontal ligament PDL Periodontium is the first of all tissues that surrounds and supports the root of a tooth It includes four tissues that function in attaching the tooth to the surroundings ,three of these tissues are related to the root.. Cementum ,periodontal ligament ,alveolar bone one of them is slightly above the root which is the Gingivae that covers part of the crown in a healthy tooth

Cementum its the least known among periodontium tissues and all mineralized tissues ,they are still having researches its not as well known as enamel and dentin Thin layer of calcified tissue covering the root in the Human teeth we may sometimes see cementum covering the crown of some teeth in some animals E.g herbivorous, like cows ,horses, its important for them because its an adaptation to their diet , they are continuous eaters thats why all the time their teeth are worn out ,, and for these surfaces that are subject in continuous wearing ,we need rough surfaces or irregular to make it easy to grind so to have a rough surface we need cementum in addition to enamel and dentin Important .. Now How this happens ..? The margins of enamel remain very raised because enamel is hard but the areas of dentin are slightly depressed and the areas of cementum are very much depressed that makes the surface very rough and irregular which gives a good mechanical property for eating to these animals their diet which is grass, and because grass has a very low nutritional value ,they want to get the maximum benefit so in order for them to get the maximum benefit they have to grind it to fine pieces thats why they have to continue grinding all the time ,if the surfaces become very flat or the crown of the teeth is made only of one material they will not be able to grind and die of hunger It varies in thickness .. thick at the apex (50-200 micrometer) & inter radicular regions (at the division of the roots) but it tends to be thin cervically (Look at the previous picture)
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Its contiguous (continuous with the PDL) , its always in contact with the PDL Its firmly attached to root dentin thats why its not easily separated from root dentin, remember that cementum is thin cervically ,suppose that this tooth has undergone some form of gum recession ( ) then part of the root will be exposed if the person that has exposure of root uses a tooth brush horizontally then it will erode the cementum , there will be areas of exposed dentin in those people and dentin is innervated so it will cause pain and sensitivity when they eat something cold or whatever, especially in old females for example when they exposed to cold wind , because females brush their teeth regularly which lead to removing part of the cementum then part of the dentine will be exposed which is sensitive , its good for them to use sensodine tooth paste which helps in blocking dentinal tubules that were exposed ,which reduced the amount of sensitivity Its also highly responsive mineralized tissue ,in contrast enamel is not responsive because its a dead tissue If you do something to enamel it will not respond but if you do something to cementum it will respond Which leads maintenance of root integrity, E.g if a tooth got subjected to some trauma and part of the cementum was lost , this part can be replaced because its able to build up the lost areas ,this happens when the trauma is minor when there is a big area of cementum lost it will be difficult to be replaced -maintenance of the functional position of the tooth ,because cementum is responsive sometimes when the opposing tooth is lost, E.g we have mandibular tooth and the opposing maxillary is lost so the tooth will not be in contact with any tooth in the opposing arch , the tooth may erupt slightly and becomes above the upper teeth or above the occlousal plane which is called supra eruption , for example when the tooth is 1 mm above its place because the opposing tooth is lost, cementum will be build up at the apex we will find 1 mm of thickness at the apex because cementum is very responsive

-tooth repair and regeneration ,very important in orthodontics because the orthodontist moves the tooth from one location to another this movement will undergo some reabsorption of cementum because its very responsive, the part of cementum that has been lost because of this movement can be replaced and this is very important ,,if this property doesnt happen in the tooth there will not be anything called orthodontics Cementum is Slowly formed throughout life similar to dentine ,which allows continual reattachment of the PDL All the time the fibers of PDL are detached and reattached which is called remodeling ,its important for the health of the PDL,this is due to the feature of cementum which is the continous build up Cementum can be regarded as a mineralized component of PDL, its a connective tissue that can be mineralized Precementum is a thin mineralized layer on the surface of cellular cementum Reminder We have .. Cellular cementum which is build up very fast usually we have at the surface of this cementum, precementum (similar to predentine) its the last part of cementum that is formed but its not mineralized and its going to be mineralized later on and Acellular cementum which is build up very slowly we dont have precementum

Similar to bone ,however Bone is vascular while cementum is not Bone is innervated while cementum is not ,although it contain cells but cementum as cementum is not vascular Cementum also less rapidly reabsorbed compared with bone , if theres a movement for a tooth from one location to another the bone which is existing in the area of movement will be reabsorbed but cementum will not be reabsorbed as strongly as bone ,E.g if we have 5 mm reabsorption of bone but we may have 0.1 mm reabsorption of cementum and this is important in orthodontics because if they both have the same rate , when the tooth moves there will be reabsorption bone and also of reabsorption of cementum ,cementum will be lost and there will be detached because centum play a major role in attaching the tooth ..if the rate of reabsorption of cementum was equal to the rate of reabsorption of bone orthodontics will not have existed ,because in orthodontics there is just a little reabsorption of cementum which can be replaced later on thats why the good orthodontist is the one who gives the tooth a very sufficient time at least from one and half to two years!

Cement-Enamel Junction They are related in three patterns ..

Pattern one .. cementum overlaps enamel for a short distance this is the most dominant pattern it occours in 60% of sections Pattern two .. enamel meet cementum at butt joint (edge to edge) this happens in 30% of sections Pattern three .. enamel fails to meet cementum so there will be an area of exposed dentin this area is very sensitive thats why they have healthy periodontium but they have sensitivity because dentin has dentinal tubules which will be exposed to the environment it occurs in 10% of people Remember ~ cementum covers enamel in 60% and not Enamel covers cementum ~

Physical Properties Pale yellow .. thats why when cementum is exposed due to gingival recession with age and part of the root is exposed ,our teeth will start to look ugly because the color of cementum is yellow which is not very acceptable it makes our teeth uglier when we grow in age , also its softer than dentin, when we apply the same force on dentine there will be less amount of reabsorb when we apply the same force on cementum .. this important in herbivorous animals Permeability -varies with age and type of cementum -decreases with age .. because we start to have the dentin that involves in closure to the dentinal tubules -cellular cementum is more permeable than Acellular cementum ..because cellular contains cells and these cells have many processes that exist in canals that can let fluids pass -cementum is more permeable than dentine although dentine contain tubules Readily removed by abrasion after gingival recession, after the recession of the gingivae when the cementum is exposed it can be lost easily

Chemical properties By weight By volume Inorganic 65% 45% Organic 23% 33% Water 12% 22%

Compared with enamel that has 95 -96% by weight and dentine that has 70% Hydroxyapatite crystals similar to those in bones More concentration of trace elements Floride (F) at surface ,more than the deep areas of cementum Floride levels is higher in acellular cementum ,because usualy acellular cementum occours in the cervical portion of the root in that area it can be exposed to saliva to the outer atmosphere more than the deep areas at the apex thats why it accepts more floride Collagenous organic matrix , primarily type 1 ..which is similar to dentine and bone but not enamel because the organic material in enamel is not collagenous its enamlin and amelogenin Molecules involved in PDL fiber reattachment We have number of molecules that exist in cementum .. Examples .. bone sialoprotin ,osetoponti & cementum specific elements these function in the detached and reattachment remodeling of the PDL fibers

Classification of cementum According to the presence or absent of cells .. >>Cellular cementum if it contains cells >>Acellular cementum if it doesnt contain cells
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According to the nature and origin of organic matrix .. >>Extrinsic fiber cementum if the fibers from extrinsic which means from the periodontal ligament not from the cementoblast >>intrinsic fiber cementum if the fibers arise from within or from the cementoblast it self >>mixed fiber cementum if the fibers are from external and internal Note : we can have any type of combination between these types for instance we can have cellular and extrinsic fibers at the same time Acellular cementum .. -Its the most common located adjacent to dentine ,usually this pattern located cervically and also at the deep areas of cementum -It doesnt have any structure because we dont see cells inside it , we can have special type of Acellular cementum called Afibirllar in this time there is no cells and also there is no fibers Afibrillar cementum -Exists between Acellular cementum and the hyaline layer (of hopewell-smith) -it covers cervical enamel -Mineralized GS -results because of the loss of reduced enamel epithelium (REE), REE is a tissue that covers enamel after enamel has been completed and this tissue is important to prevent the exposure of the enamel to the surrounding ,when a part of enamel which is still inside bone is exposed to the dental follicle cells, enamel as a tissue will induce the undifferentiated cells of the dental follicle and become cementoblast, and this will lay down cementum on the surface of enamel ,this happens only on the cervical portion ,sometimes in the cervical portion we lose REE,so we will see enamel in contact to the surrounding this will lead to the
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differention of the cementoblast and this is will lay down cementum on that portion of enamel

Cellular Cementum

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 Its the Most common pattern at The Apical area of the tooth In the Inter-radicular areas, between the roots Also Overlying Acellular dentine Note .. The Difference between cellular and Acellular is Cementocytes,these are cells present within cellular cementum These Cementocytes Are Inactive Present In lacunae appear dark in ground section, GS They have Processes present in canaliculi Also these Processes connected via gap junctions When the cell is becomes inside cementim is called cementocyte ,while its outside its called osteoblast this location of the cells depends on the activity of the cells ,when the cell is very active and produce cementum in different regoins it will be surrounded by cementum because it secrets cementum in all directions cementocyte, but when the cells gives cementum and moves back it will be away from cementum cementoblast which is not very active as cementocyte

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Important ,,

Cementocytes vs. osteocytes

Cementocytes Are More widely dispersed, which means the distance between cells are big but osteocytes are very close to each other Cementocytes are Randomly arranged but the osetocytes are regular and they occur at the region of bone lamellae The Canaliculi oriented towards PDL ,because cementum is not vascular and they want nutrition they cant get it from dentine because dentin is mineralized

Osteocytes Bone is vascular ,these cells can find nutrients from everywhere ,so the canaliculi are spread in different directions Osteon Haversian system
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Organized cells Circumferential lamellae,the cells are existed within this lamellae

Relationship between Acellular & Cellular cementum Look at the first picture .. More common pattern Is to have the Acellular at the cervical area Acellular closer to dentine,than cellular Cellular find most commonly apically Cellular find most commonly covers acellular

Less common patterns Alternating, when we have Acellular ,cellular ,Acellular ,Cellular across the thickness of cementum it can occur but not very common And sometimes Acellular overlies cellular, (very rare)

Extrinsic & intrinsic fiber cementum Extrinsic fiber cementum Are Fibers derived from inserting Sharpys fibers of PDL
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Are more important because they are the actual fibers that function in attachment Intrinsic fiber cementum Fibers derived from cementoblasts Run parallel to the root surface at right angles to extrinsic fibers, because they are not very important in attachment

Acellular extrinsic fiber cementum its one of the different type of cementum that we can see ,it doesnt contain cells and the fibers of this cementum is from the PDL AEFC Its usually Over the cervical half or the cervical 2/3s of the root Usually the Bulk of cementum in premolars from this type Its First formed cementum Its Thickness of 15 m All collagen are from Sharpys fibers,thats why all collagen are involved in attachment of the tooth GS from cementoblasts, cementoblast can only produce GS,but the fibers of this cementum is from the fibroblast (the cells in the PDL) the Fibers are well-mineralized

Cellular intrinsic fiber cementum Usually when cementum is cellular its intrinsic fibers ,because sharpys fibers are the fibers that are derived from PDL , are inserted to the deep portion of cementum , at the outer portion of cementum usually cementum provide some thickness without being involved in attachment ..
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 CIFC Fibers deposited by cementoblasts Fibers run parallel to root surface ,so they dont function in attaching the tooth No role of tooth attachment , but they provide thickness for protection Its find In the apical 1/3 & inter-radicular areas May be

Temporary extrinsic fibers gain reattachment, they sometimes may inter inside and gain attachment and with time the fibers will penetrate to the cementum and become extrinsic fibers again Permanent without attaching fibers , so no fibers will get inside so it will remain extrinsic all the time

Acellular intrinsic fiber cemetum If cementum forms slowly CIFC Cellular mixed stratified cementum When there is an Alternating AEFC with CIFC,its called cellular mixed stratified cementum It presents at the Root apex Also Fraction areas Mixed-fiber cementum When the Collagen fibers derived from

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Extrinsic fibers Intrinsic fibers Intrinsic fibers run between the extrinsic fibers, extrinsic fibers are perpendicular to the surface and between these them ,intrinsic fibers are parallel to the surface It can be divided to Two types depending on the rate of formation -Acellular mixed-fiber cementum In this case its Well mineralized fibers -Cellular mixed-fiber cementum Less well mineralized fibers

Incremental lines

Similar to enamel and dentine cementum is built incrementally increment by increment between one increment and another we can identify a line called incremental line ,but in a cementum they are very irregular not like enamel and dentin where they are very regular
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 So Irregular rhythm of deposition Its Not related to activity & quiescence ,in enamel and dentine incremental lines are related to period of activity and periods of rest Its Related to -Difference in the degree of mineralization , the area when we see incremental line this means this area has different degree of mineralization of the close area -Difference in the Composition of organic matrix Imprecise periodicity, it means we dont have the periodic appearance of these incremental lines and the measurement of the distance will not be the same between another pair of incremental lines ,due to the irregularity Acellular tends to be closer, thinner & regular lines Cellular tends to be farther apart, thicker & irregular lines,the rate of deposition tends to be very fast thats why it tends to go irregular

Resorption & repair of cementum Less susceptibility to resorption than bone ,E.g if there is a newton force on cementum and the same Newton force on bone ,theres more resorption on bone which is important in orthdodontics Localized resorption areas occur

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 Could be caused by micro trauma,(a minor trauma) May continue to root dentine Usually caused By multinucleated odontoclasts ,odotoclast are eater cells that eat dentin and also cementum Resorption can be repaired not like resorption in enamel which cannot be repaired ,also in dentine resorption cannot be repaired but in dentine if we lose one layer from above another layer will form inside ,in cementum if theres a loss for a small layer it can replace itself ,so Resorption areas filled by mineralized tissue (resembles cellular cementum)

Reversal line ,the area between resorption and depostion similar to the reversal line in bone,because we always have remodeling resorption and deposition so theres always reversal lone which represents the end of resorption and the begin of deposition

Reparative cementum vs. cementum Usually reparative cementum is Wider uncalcified zone, which is called precementum Also its Less mineralized Smaller crystals Sometimes we can see Calcific globules are present Note : Differences are related to different speed of formation

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When we see the end of the teeth cementum is not covers the root from only outside it also extends to cover the inside part(the last part) of the canal ,thats why its called dental pulp ,that means that PDL is always associated with cementum ..so periodontal ligaments surrounds the tooth and also inters inside area ,for that reason in endodontics when we cleen the pulp of the tooth we have to consider this difference which is about 1mm Remember , that the apex of the tooth doesnt contain pulp ,it contains periodontal ligament ,so in dentistry so I always consider the distance that related to cementum ,so theres an area that we dont clean because its not a pulp its a periodontal ligament Periodontal ligament PDL Dense fibrous connective tissue Occupies the area between the root of the tooth and the walls of the alveolar socket Derived from the dental follicles Continuous with the connective tissue of the gingiva above the alveolar crest The dental pulp at the apical foramen ,when theres a infection inside the pulp it can spread and infect the Periodontal tissue ,in many of the cases of many people that have pulpitis two or three days then this pain disappears because the pulp got necrosis, these people think that the problem is over which is not true! ,, necrosis ( means there are germs and bacteria inside the pulp) and this can spread to the outside and affect the periodontal ligament with pain while biting ,if it is left without treatment there will be facial swelling Periodontal ligament space
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Its the space where a periodontal ligament exists Its Variable in width, the average is 0.2 mm It looks like hourglass ) ( in shape, the thinnest area of the periodontal ligament is in the half way of the root Its Reduced in (unerupted)& non-functional teeth , (non functional means not reach the opposing contact with the other tooth Its Increased in teeth subjected to heavy occlusal stress, like biting forcefully (clenching) Narrows slightly with age Narrower in permanent teeth than in deciduous

Functions of PDL Attachment the tooth to the bone this is the main function It Has a role in tooth eruption and support ,the remodeling (the attachment and reattachment) has a force to push the tooth Its cells repair the alveolar bone & cementum, because we always have undifferentiated cells that differentiate to osteoblast to reabsorb bone or to cementoblast to reabsorb cementum The Neurological control of mastication through its mechanoreceptors that sends information to the brain about the amount of load in the mandible , also in PDL ligaments there are receptors prpyoreceptor that sends information to the brain about the position and the amount of load in the mandible Components of PDL Fibers,which are collagen
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 Ground substance Cells Fibers of PDL Collagen Type I (70% of fibers) Type III (20% of fibers) is Found in the periphery of Sharpys fibers and the attachment into alveolar bone Small amounts of type V, VI as well as basement membrane collagen IV & VII associated with the epithelial rests Highest turnover of collagen is in PDL Turn over its the break down and the rebuilt of fibers its: Higher near apex because the apex is subjected toward the load Even across the width of PDL The turnover rate is the same to the area close to the bone and the area close to the apex Rate could be related to the amount of occlusal stress

Oxytalan ( only in humans) ,which is another firber protein found or elastin Attached into cementum May have a role in tooth support

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Important ,,, Principal fibers of PDL Fibers exist as bundles (principal fibers) running in different orientations in different regions These are.. Dentoalveolar crest fibers Dento means tooth, alveolar crest means the crest of the bone They attach the tooth to the crest of the bone We have Horizontal fibers as we go down Then they become Oblique fibers Then we have the Apical fibers Then Interradicular fibers,which are between the toots From crest of interradicular septum to furcation Note : we have another type of fibers but not related to periodontal ligament ,these fibers connect the tooth to the gingivae which is called dentogingival fibers

Sharpys fibers they represent the end of the periodontal ligament fibers
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Principal fibers that either embedded into cementum or bone More numerous but smaller at cemental end They have Mineralized and unmineralized parts ,the mineralized are embedded in cementum

Ground substance of PDL 60% of PDL by volume Main components Hyaluronate GAGs Proteoglycans Glycoproteins Functions of GS Ion and water binding & exchange Control of collagen fibrillogenesis(the formation of the collagen fibers) & fiber orientation -Tooth support & eruption because of high tissue fluid pressure in these areas

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Cells of PDL types of cells exist in the periodontal ligament , They are derived from dental follicle..which is calcified in three zones 1-the zone close to the tooth ,the cells here become cementoblast 2-the intermediate zone ,the cells here become fibroblast 3-the outer layer ,the cells here bcome osteoblast

Fibroblasts, Its smiliar to any fibroblast in a connective tissue Fusiform cells with many processes Functions secretion and turnover of fibers Regeneration of tooth support apparatus,(that means the fibers are resorbed and built again) that is important to maintenance to the health of these fibers Adaptive responses to mechanical loading,if there is a mechanical loading this lead to resorption of some areas of periodontal ligament, and building another area of periodontal ligament so its under turnover all the time

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Cementoblasts -Cement-forming cells lining cemental surface, These are the cells that give cementum ,they occour in the surface because once they are integrated in cementum they are called cementocytes They are Cuboidal cells Osteoblasts Bone-forming cells lining tooth socket They Resemble cementoblasts Cementoclasts & osteoclasts Resorbing cells Located at Howships lacunae,because they resorbe Epithelial rests cells, -These cells is due to the break down of the epithelial rooth sheath due to the exposure of newly formed root dentin , these cells are surrounded by a basement membrane ,,anyy epithelial cell located inside mesenchayeml area should be surrounded by a basement membrane because this basement membrane is a limiting membrane it prevents these cells from interaction from the surroundings otherwise it will go interaction They are Cuboidal cells that stain deeply They present Close to cemental surface Defence cells.. Like

Macrophages Mast cells

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 Eosinophils

Blood vessels of PDL Separate from those entering pulp,so they are different groups Some from alveolar bone through foramina opening in the periodontal ligament Some from pulp through accessory canals Major vessels lie between principal fiber bundle close to alveolar bone,usually the big blood vessels are close to the bone not to the tooth Capillary plexus around the tooth Crevicular plexus of capillary loops,which is near the gingivae named clevicular because that area between the gingivae and the tooth is called clevicular groove Veins do not follow arteries but drain into intraalveolar venous networks

Innervation of PDL

Sensory Nociception that receive stimuli of pain Mechanoreception Sensitivity to occlusal loads the proprioreceptors in the mandibular teeth that tells the brain about the postion of the mandible , when the mandible is

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elevated up ..they guide the mandible into the correct intercuspation Autonomic Associated with blood vessels Alveolar process o The alveolar process develops during the eruption of teeth ,this sentence is related to primary teeth .. in primary teeth bone forms at the same time and with the root and it can grow with little surrounding bone but in permanent teeth bone is already existing and it need to go inside bone o Grows at a rapid rate at the free border o Proliferates at the alveolar crest o No distinct boundary exists between the body of the maxilla or mandible and the alveolar process, its difficult to determine the lines o If teeth are lost the alveolar bone disappears they are present to maintenance for the teeth one the tooth is lost the bone will be lost ,this means that the bone surrounding exists as long as the tooth exist ,E.g if someone lost his teeth at 50 and didnt put a denture later on there will be so much reabsorption

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Development of bony crypt Reminder .. primary teeth when they erupt usually are not surrounded by too much bone Each primary tooth is related to lingual extension forming the permanent ,first the permanent tooth is located lingual to the primary tooth ,then the tooth is going to grow above and becomes bigger and bigger ,then it goes down until it remains below the tooth ,but most of the time it remains lingual to the tooth for anterior tooth but for posterior tooth it goes below or between the roots of that deciduous molar

But always Deciduous tooth & permanent successor initially share crypt,but later they both of them will have their own bony crypt Bone subsequently forms to encase permanent tooth

Sorry for any mistakes ,, Alaa Adas

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