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83]

Review Article

Cementoenamel junction: An insight

Kharidi Laxman Vandana, Ryana Kour Haneet

Department of Abstract:
Periodontics, College The location and nature of cemento‑enamel junction (CEJ) are more than descriptive terms used simply to
of Dental Sciences, describe some aspects of tooth morphology; however, CEJ gains a lot of clinical significance due to various
Davangere, Karnataka, measurements dependent on it. It may be necessary to determine the location and pathological changes occurring
India at CEJ to make a diagnosis and treat diseases pertaining to epithelial attachment and gingival margin. However,
the information related to CEJ is not discussed commonly. Hence, the present review paper provides an insight
on CEJ in both primary and permanent dentition.
Key words:
Cemento‑enamel junction, comparison, deciduous, permanent dentition

INTRODUCTION an irregular onset of formation and deposition

of cementum. Consequently, the relationship

O ne of the most important parameters for

assessing periodontal destruction is loss of
connective tissue attachment to the tooth root
surface.[1] The cemento‑enamel junction (CEJ)
Access this article online represents the anatomic limit between the
Website: crown and root surface[2] and is defined as the
www.jisponline.com area of union of the cementum and enamel at
DOI: the cervical region of the tooth.[3] In periodontal
10.4103/0972-124X.142437 research, attachment loss is considered to be
Quick Response Code: a more informative method of assessment of
periodontal disease for both cross‑sectional
and longitudinal studies. The clinical location
of CEJ which is a static landmark, serves as
an important anatomical site for measurement
of probing pocket depth (PPD) and clinical
attachment level (CAL) for both, a clinician and
an academician. However, the depth of scientific
information pertinent to CEJ is lacking compared
with its clinical significance. Hence, the present
review paper provides an insight on CEJ in both
primary and permanent dentition.
FORMATION OF CEJ
In the tooth bud, regions where enamel formation
is completed, the enamel organ gives rise to
Hertwig’s epithelial root sheath, composed of
two epithelial layers derived from the external
Address for and internal epithelia. The sheath is irregularly
correspondence: fragmented in time and space as it promotes
Dr. Kharidi Laxman Vandana, cementum deposition on the newly formed
Department of Periodontics, dentin. After this fragmentation, Hertwig’s
College of Dental epithelial root sheath also participates in
Sciences, Davangere,
cementogenesis and formation of the periodontal
Karnataka, India.
E‑mail: vanrajs@gmail.com ligament, giving rise to the epithelial rests
of Malassez. This irregular fragmentation
Submission: 09‑07‑2013 of Hertwig’s epithelial root sheath yields an
Accepted: 25‑11‑2013 equally irregular limit of cervical enamel and
between cementum and enamel at the CEJ
presents an irregular contour, as observed during
scanning electron microscope (SEM) analysis of
the primary teeth.
Fragmentation of Hertwig’s epithelial root sheath
and exposure of dentin covered by a thin layer of
intermediate cementum are fundamental for the
onset of cementogenesis. If Hertwig’s epithelial
root sheath is not fragmented, there will be
enamel deposition and it will be transformed into
reduced epithelium, thus preventing cementum
deposition on its surface.[4]
TYPES AND DISTRIBUTION OF CEJ
In CEJ area, three types of mineralized tissues
are present: Enamel, dentin and cementum.[2]
The CEJ is not a uniform line with a mild and
regular contour, but a complex line with a linear
and regular trajectory.[5] In the odontogenesis of
primary and permanent teeth all three types of
relationships between enamel and cementum
at the cervical region may occur which are
described as follows:
Pattern I
The cementum overlaps the enamel for a
short distance. This is seen in 60% of all teeth.
This type of overlapping occurs when the
enamel epithelium degenerates at the cervical
region thereby allowing the connective tissue
consisting of cementoblasts to contact the
enamel directly. The cementoblasts produce a
type of cementum called afibrillar cementum
which appears dense and laminated and
does not contain collagen fibers with 64  nm
periodicity [Figure 1a].

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Vandana and Haneet: Cementoenamel junction: An insight
c
a b d
Figure 1: (a) Pattern I - the cementum overlapping the enamel for a short distance,
(b) Pattern II - an end-to-end approximating cemento-enamel junction, (c) Pattern
III - there is absence of connecting enamel and cementum so that the dentin is
an external part of the surface of the root, (d) Pattern IV - enamel overlapping
cementum
Pattern II
An end‑to‑end approximating CEJ. In this case, cementum
and enamel meet at a butt joint. It is seen in about 30% of
teeth [Figure 1b].
Pattern III
There is the absence of contact between enamel and cementum
and hence that the dentin is an external part of the surface of
the root.[6] It is seen in 10% of teeth. This occurs when enamel
epithelium in the cervical portion of the root is delayed
in its separation from dentine. In this situation, the CEJ is
absent[7] [Figure 1c].
Pattern IV
A yet another pattern seen is the overlapping of the enamel on
cementum.[4] This was observed under an optical microscope.[8]
It is seen in about 1.6% of teeth[9] [Figure 1d].
Although, one of these patterns may predominate in an
individual tooth, all forms can be present when traced
circumferentially.[10]
From an embryological standpoint, odontogenesis does
not explain the fourth possible type of CEJ, namely enamel
over cementum; since cementogenesis is initiated only after
completion of enamel formation. Presence of enamel over
cementum may be observed in ground sections, according to
the thickness and plane of sectioning. Muller and van Wyk,[11]
demonstrated that, this in fact is caused by an optical illusion.
Conversely, Ceppi et  al.,[2] observed rare micro regions of
enamel over cementum during SEM analysis of primary teeth.
Hence, the existence of this pattern (i.e., enamel overlapping
cementum) is controversial.
CURVATURE OF CEJ
The curvature of CEJ follows a variable pattern and is
dependent upon the height of the contact area above the
crown cervix and also upon the diameter of the crown
labiolingually or buccolingually.[12] In general, teeth have a
greater proximal cervical line curvature on the mesial, which
is about 1 mm more than the distal [Figure 2a and b]. Proximal
cervical line curvatures are greatest on the mesial surfaces of
central incisors and tend to get smaller when moving toward
the last molar [Figure 2a, c and d], where there may be no
curvature at all. On many posterior teeth, the cervical line is
550 Journal of Indian Society of Periodontology - Vol 18, Issue 5, Sep-Oct 2014
a b c
d e f
Figure 2: (a) Curvature of cemento-enamel junction on the mesial aspect of
maxillary central incisor, (b) Curvature of cemento-enamel junction on the distal
aspect of maxillary central incisor, (c) Curvature of cemento-enamel junction on the
mesial aspect of maxillary first premolar, (d) Curvature of cemento-enamel junction
on the mesial aspect of maxillary first molar, (e) Curvature of cemento-enamel
junction on the buccal aspect of mandibular first molar, (f) Curvature of cemento-
enamel junction on the lingual aspect of mandibular first molar
in a more occlusal position on the lingual than on the facial
surface [Figure 2e and f].[13] The curvature of CEJ is more
pronounced on the interproximal aspect than the buccal aspect;
hence, the measurement of CAL becomes compromised on the
interproximal aspect.
RELATIONSHIP OF GINGIVAL MARGIN TO THE
CERVICAL LINE
Clinically, in a 25‑year‑old patient with healthy gingiva, the
gingival margin approximately follows the curvature of the
cervical line. However, it is not always at the level of the cervical
line because of the eruption process or recession of the gingiva.
In a 10‑year‑old with a healthy gingival status, the gingival
margin may cover some of the anatomic crown of the tooth
enamel; in older subjects who have had periodontal disease or
periodontal therapy resulting in gingival recession, the gingiva
may not cover the entire anatomic root (cementum).[13] These
observations suggest that the level of the gingival margin
relative to CEJ is age related.
CEJ IN THE PRIMARY DENTITION
Detailed information on the morphology of the CEJ in all
groups of primary teeth is not available so far; the reports
available are limited to analysis of some specimens.[2]
Morphological/anatomical features of CEJ
Information on CEJ of primary teeth is limited. A study done
by Leonardi et al.,[14] investigated this area by means of SEM
and highlighted prevalence of overlapping cementum on the
enamel and an edge‑to‑edge relationship. No gaps between
enamel and cementum were observed. The CEJ appeared as a
40‑60 µm broad sinuous band and the cementum was reported
to be acellular, as in permanent teeth, but thinner and rougher.
Near the CEJ, calcium spherites (calcified sharpey’s fibers) were
observed with a diameter from 2 to 10 µm, which attributed to
the rough appearance.[2]
In the odontogenesis of primary and permanent teeth, all three
types of relationships between the enamel and cementum
at the cervical region may occur.[2] The CEJ was considered
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Vandana and Haneet: Cementoenamel junction: An insight
regular when a linear contour was observed without a zigzag
or zipper‑like aspect. The CEJs of all primary teeth groups
were morphologically similar, without specific characteristics.
The CEJ was linear and uniform in some areas, yet presented
repeated mild undulations in others. In many specimens, the
undulations were anfractuous and presented marked twisting,
leading to the formation of cementum and enamel islets. In
some teeth, the CEJ undulations were small and repeated,
simulating a zipper‑like appearance. A total of 39 specimens
presented cervical foramina, regardless of the tooth group
and CEJ type.[15]
The CEJ of primary teeth should be protected by the gingival
connective tissue.[16] The continuous passive eruption and
growth vectors of the jaws displace the primary teeth from
their original position and expose the CEJ to the oral cavity
of 6‑to 10‑year‑old children.[17] Bimstein et al.,[18] in their study
reported that on the root surfaces of two primary teeth without
evidence of periodontitis which were extracted for orthodontic
reasons, no resorption lacunae nor cuticle or bacteria were
found. At the CEJ area of teeth from children with prepubertal
periodontitis they highlighted dense colonies of short and long
filaments, resorption lacunae and crystals of calcium oxalate
dihydrate (4‑5 µm).
Prevalence of types of CEJ
Investigating the CEJ of primary teeth, Carvalho et  al.,[8]
described that 42% of teeth presented cementum over enamel,
41% exhibited the edge‑to‑edge relationship and 12% presented
gaps between enamel and cementum. According to the results
in percentages reported by these authors, no primary tooth
presented more than one type of relationship between enamel
and cementum. In the study by Ceppi et al.,[2] root cementum
and enamel edge to‑edge interrelation was the most frequent
type observed in overall samples [Figure 1b], root cementum
overlapping enamel tissues was observed in more than
one‑third of the CEJ area [Figure 1a], whereas exposed dentin
was a rare observation [Figure 1c]. In few, small and rare areas,
enamel overlapped cementum [Figure 1d].[2] The CEJ appeared
as a sinuous line. Cervical cementum appeared rough owing
to the presence of calcified Sharpey’s fibers that was referred
as calcium spherites.[14] At the bottom of the gaps, the dentinal
tubuli were clearly opened on the surface [Figure 1a]. Often,
however, they were partially covered by delicate material,
probably representing thin layers of intermediate cementum.[5]
CEJ IN PERMANENT TEETH
The CEJ was initially studied by Choquet in 1899 who analyzed
ground sections of permanent teeth under light microscopy.[19]
The first comprehensive report on the morphology of the CEJ
in all groups of permanent teeth by SEM was published by
Neuvald and Consolaro.[19] Several relationships between
cementum and enamel as mentioned in previous sections may
be observed along the CEJ of a single tooth.[6] It is expected
that cervical and root surface lesions involving the CEJ will
become more prevalent along with the predicted increase in
the numbers of potentially dentate elderly.[20] Researchers have
encountered this problem in the past and have mentioned the
difficulty of obtaining teeth with cementum present on the roots
and with no forceps injury at the CEJ. There is little information
on the SEM appearance of CEJ.[20]
Journal of Indian Society of Periodontology - Vol 18, Issue 5, Sep-Oct 2014 551
Schroeder and Scherle,[21] while observing enamel extensions
and scalloping of CEJ, stated that the distribution of the
three hard tissues found at the CEJ region is unpredictable
and irregular on a single tooth and between contralateral
teeth.
Grossman and Hargreaves,[20] in their study on 18 permanent
teeth showed cementum overlap relationship at CEJ, with the
cementum directly or indirectly attached to the underlying
enamel. They also demonstrated edge to edge contact of
cementum to enamel.
In young adults, the CEJ of permanent teeth is covered by
the gingival tissue and is in contact with the connective
tissue’s extracellular matrix.[4,21] After the third decade of life,
continuous passive tooth eruption compensates for wear at
the incisal and occlusal aspects. The CEJ is then located in the
gingival sulcus. The exposure to the oral environment may lead
to dentin hypersensitivity upon ingestion of hot, cold, sweet or
salty foods. Tooth abrasion and erosion in adults are initiated
after the CEJ is exposed to the oral cavity.[21]
DIFFERENCES IN CEJ OF PRIMARY AND
PERMANENT DENTITION
• The cementum is reported to be acellular in primary teeth
as in permanent teeth, but thinner and rougher
• In permanent teeth the CEJ is placed at the bottom of the
gingival sulcus, whereas in primary teeth, the CEJ is placed
more apical as the epithelial junction is at the equator of the
crown.[2] The clinical implication of this anatomic feature
could be protection toward decay of the cervical region and
in fact, dentinal sensitivity is rarely observed in the primary
dentition[14]
• Scarcity of gaps between cementum and enamel, globosity
of crown, apical placement of CEJ are the possible protective
factors towards decay in the primary dentition[2]
• Primary teeth present a smaller number of incremental lines
and have a thinner calcification, clinically implying that the
smaller thickness of cementum and possibly of enamel,
may allow the passage of greater amount of chemicals,
including bleaching agents, when applied both externally
and internally in primary teeth[5]
• The pattern enamel overlapping cementum is not discussed
in relation to permanent dentition.
VARIOUS METHODS OF CEJ LOCATION
Methods for location of CEJ include following two kinds:
• Conventional
• Modified
In conventional methods we have:[22,23]
• Visual
• Tactile
• By straight explorer
• By periodontal probe; examiner feels for the cervical
line with the tip of the probe[24]
• Radiographic
• Intraoral periapical (IOPA) radiograph
• Bite wings
• RVG.[25]
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Vandana and Haneet: Cementoenamel junction: An insight

In modified methods we have:[7,26,27] SEM examination of the surface textures of enamel

(e.g., hypoplastic enamel, perikymata), exposed dentin and
Computer linked electronic constant pressure probes
cementum at the CEJ and topographic contours of the various
• Florida probe
CEJ hard‑tissue relationships reveals structural features that
• Inter probe/Perio probe
would appear to facilitate attachment of bacterial biofilms and
• Birek probe/Toronto automated probe
if left undisturbed, the transition to dental calculus.[34]
• Jeff coat probe/Foster miller probe.

The comparison between various methods of detection of CEJ
is presented in Table 1.
ALTERNATES TO CEJ
• With the difficulties in identifying CEJ in studies on disease
progression or the effect of periodontal treatment on the
attachment level, other landmarks were explored for a valid
clinical attachment measurement
• Osborn et al. introduced the occlusal surfaces or the incisal
edge of the tooth as a reference for the CAL[32]
• Pihlstrom [33] studied the reproducibility of relative
probing attachment level measurements using a stent
as a reference point and concluded that stents increase
the intra‑ and inter‑examiner reproducibility and
are therefore useful in studies evaluating treatment
modalities. The second measurement per site is probably
not independent of primary measurement, if the time
difference is not wide.
CLINICAL IMPLICATIONS
CEJ a significant landmark for probing the level of the
attachment of fibers to the tooth root in the presence of
periodontal disease
The different patterns of CEJ have clinical significance in the
presence of disease, e.g., gingivitis, recession of the gingiva
with exposure of the CEJ, loss of attachment of the supporting
periodontal fibers in periodontitis, cervical sensitivity,
caries and erosion; and also placement of margins of dental
restorations.
The location of CEJ to measure CAL is a critical situation
clinically as discussed by Vandana and Gupta,[35] in their study,
where the distance between stent and CEJ was measured before
and after reflection of flap. The percentage increase in over
and under estimation of CEJ to stent measurement during flap
reflection was clinically evident than equivalent measurement.
CEJ a landmark to diagnose cervical enamel projections (CEPs)
The CEJ serves as an important reference for diagnosis of
CEPs. These are the extensions of enamel from the CEJ onto the
root surface. Masters and Hoskins,[36] classified these unusual
anatomical structures based on the degree of extension of
enamel beyond the CEJ and depending on their location in
relation to furcation topography.
Enamel extension apical to the normal CEJ level is a risk
factor for periodontal disease because the periodontal fibers
embedded in the cementum to support the tooth, are not
in their usual position and thus, do not act as barrier to the
advancement of periodontal disease. In effect, the epithelial
attachment over the surface of the enamel, which does not have
this kind of attachment, may become detached in the narrow
and difficult‑to‑clean bifurcation area because of plaque and
calculus, increasing the vulnerability to periodontal disease.
CEJ and dental surface defects
CEJ serves as an important reference landmark in diagnosis
and treatment of dental surface defects. In situations where CEJ
is not identifiable clinicians encounter difficulty in accurately
measuring the depth and width of recessions during diagnostic
phase and during surgical phase in precisely locating the

Table 1: Comparison of conventional and modern methods of CEJ detection

Feature Conventional methods Modified methods
Visual Tactile Radiographic (IOPA/bite Computer linked
wing/RVG) constant pressure probes
Method of Visual inspection of Feeling of catch at the Demarcation between a more Abrupt changes in the
identification cervical area will reveal a cervical region when radiodense enamel and less acceleration of the probe
line demarcating enamel the probe moves from radiodense root cementum in movement (recorded on a
from root cementum a smoother enamel to a the cervical region of teeth graph) indicate when the
rougher root surface probe meets the CEJ[28]
Difficulty in Liable to visual error Difficult to identify when Several factors may affect the The main disadvantage
identification due to lack of clear obscured by calculus or clarity or the observation of is that these probes can
demarcation.[29] Difficult restorations.[2] Additional CEJ such as different width deem root roughness or
to identify when difficulty is faced differences of the enamel root surface irregularities
located subgingivally or at interdental tooth of the two sides, amalgam as the CEJ.[28]
obscured by calculus or surface,[30] and teeth of or composite restorations,
restorations.[26] posterior segment and crown morphology. The
Blind method Blind method alveolar bone, tooth material
overlap, and rotations are
additional factors that might
interfere with the identification
of the CEJ.[31]
Based on radiodensities
Reproducibility Very poor Poor Poor Good but suffer from
limitations
CEJ – Cemento‑enamel junction; IOPA – Intraoral periapical; RVG – Radiovisiography

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Vandana and Haneet: Cementoenamel junction: An insight
gingival margin when suturing. Moreover, the accurate
evaluation of clinical outcome of root coverage procedure is
if difficult at the end of therapy or if CEJ is lacking. Based on
these observations, Pini‑Prato et al., classified dental surface
defects based on the criteria of presence or absence of CEJ.[37]
Role of CEJ in gingival recession management
During routine clinical practice, recording an identifiable CEJ
is of paramount importance for measuring recession depth
and evaluating treatment outcome after treatment. In teeth
with gingival recession, affected by cervical abrasive trauma
involving both enamel and root cementum, identifying CEJ
is a difficult task. In such situations, a line separating enamel
from coronal dentin is confused for anatomic CEJ. This error in
localization of CEJ makes desired root coverage unobtainable
because the most coronal portion of the exposed dentin
belongs to anatomic tooth crown. Zucchelli et al., considered
clinical CEJ to substitute anatomic CEJ when it is no longer
identifiable on teeth with recession, to predetermine the line
of root coverage, which may improve the final outcome of
mucogingival surgery, allow for a more esthetic treatment of
cervical abrasion associated with gingival recession and meet
patient demands even when local conditions are not favorable
to accomplish a good esthetic result. By the same authors, it
was proposed that the clinical CEJ can be used as a guideline
for the apical preparation of the composite restoration in cases
of deep abrasion defects associated with gingival recession.[38]
Implications in restorative dentistry
The presence of gaps with dentin exposure in all junctions
of primary teeth indicates the need for special care upon
placement of clamps, wedges and stainless steel crowns,
application of restorative materials, utilization of extractors and
gingival retractors, surgical curettage at the cervical region of
unerupted teeth and specifically during internal and external
tooth bleaching. Even though these procedures are routinely
performed in dental clinic, special care should be taken with
the CEJ area to avoid dentin hypersensitivity and external
cervical resorption.[5]
In the oral environment, the CEJ may be subjected to the action
of chemicals from foods, oral hygiene products and dental
materials especially tooth bleaching agents, widely used on
permanent teeth than on primary teeth. Physical agents such
as tooth‑brushing, dental instruments and clamps also may
change the relationship between mineralized dental tissues
at the CEJ, with important clinical consequences. Similarly,
morphology of the CEJ also should be considered in cavity
preparations and restorations.[5] The greater exposure of the
CEJ of primary teeth to the oral environment is related to more
than tooth attrition. Bimstein et al.[23] in their study reported that
facial growth increases the distance between the CEJ and the
alveolar bone crest in a specific manner. Even if the primary
teeth do not present incisal wear, the CEJ is exposed to the oral
environment with the increase of age.
Thus, all in all, identification and location of CEJ serves various
purposes which can be summarized as follows:
• CEJ is used as a fixed/static landmark to measure CAL/
PPD or periodontal destruction[21]
• To assess alveolar bone destruction by measuring CEJ‑bone
crest distance[39]
Journal of Indian Society of Periodontology - Vol 18, Issue 5, Sep-Oct 2014 553
• To study furcation by finding out furcation CEJ distance,[40]
thus helping in treatment planning for furcation
involvements[41]
• To measure gingival recession,[16] which is helpful to
determine the dimensions of graft needed to cover it
• For bi‑laminar grafting procedures for coverage of multiple
shallow gingival recession[42]
• For development of a system to assess visible and hidden
gingival recession[43]
• CEJ is important for placement of various membranes
during surgical procedures
• In case of wasting diseases, tooth resorption often starts at
CEJ
• Caries in primary teeth is limited more often at CEJ than
the contact point[44]
• Enamel spurs projecting from CEJ into the furcation act as
etiological factors for periodontal disease[45]
• The furcal surface closest to the CEJ of the tooth is the
most susceptible area to bone denudation as a result of
periodontal disease.[45]
Thus, the location and nature of the CEJ are more than
descriptive terms used simple to describe some aspects of tooth
morphology; they have definite clinical significance. It may be
necessary to determine the nature, location and pathological
changes occurring at the CEJ to make a diagnosis of and to
treat, for example, cervical caries, keeping in mind that the CEJ
generally lies apical to the epithelial attachment and gingival
margins in young adults.[7]
CONCLUSION
Due to the variable nature of the anatomy of CEJ differing
with different tooth types and surfaces of teeth; and due to the
subgingival location of CEJ, a clinician confronts great difficulty
in exact identification and location of this important landmark,
due to which the clinical measurements are jeopardized;
leading to lack of intra and inter‑examiner reproducibility
while measuring clinical parameters in periodontal studies like
CAL which are of utmost significance in periodontal studies.
Thus, the clinical applicability of CEJ as a standard reference
point either in establishing a diagnosis or evaluation of
prognosis should be comprehended critically and remains to
be questionable over the centuries. The information related to
CEJ in both permanent and primary dentition are significantly
neglected as against to its clinical utility for diagnosis and
clinical implication. Therefore, the present review throws light
on various aspect of CEJ. However, further elaborate research
should be devoted to study CEJ using SEM analysis of all teeth
types, with evaluation of the prevalence of types of CEJ.
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How to cite this article: Vandana KL, Haneet RK. Cementoenamel
junction: An insight. J Indian Soc Periodontol 2014;18:549-54.
Source of Support: Nil, Conflict of Interest: None declared.