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Periodontal and Bone Response to Normal Function

 Periodontal Ligament Structure and Function
 Response to Normal Function
 Role of the Periodontal Ligament in Eruption and Stabilization of the Teeth

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 Orthodontic treatment is based on the principle that if prolonged pressure is applied to a tooth, tooth movement will occur as

the bone around the tooth remodels. Bone is selectively removed in some areas and added in others.

 In essence, the tooth moves through the bone carrying its attachment apparatus with it, as the socket of the tooth migrates.

 Because the bony response is mediated by the periodontal ligament, tooth movement is primarily a periodontal ligament

phenomenon.

 Forces applied to the teeth can also affect the pattern of bone apposition and resorption at sites distant from the teeth,

particularly the sutures of the maxilla and bony surfaces on both sides of the temporomandibular (TM) joint.

 In addition, it is possible now to apply force to implants in the maxilla or mandible to influence growth at maxillary sutures and

at the mandibular condyle.

 Thus the biologic response to orthodontic therapy includes not only the Response of the periodontal ligament but also the

Response of growing areas distant from the dentition.

 In this chapter, the response of periodontal structures to orthodontic force is discussed first, and then the response of skeletal

areas distant from the dentition is considered, drawing on the background of normal growth provided in Chapters 2 through 4.

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1. Periodontal Ligament Structure and Function
 Each tooth is attached to and separated from the adjacent alveolar bone by a heavy collagenous supporting
structure, the periodontal ligament (PDL).
 Under normal circumstances, the PDL occupies a space approximately 0.5 mm in width around all parts of the
root.
 By far the major component of the ligament is a network of parallel collagenous fibers, inserting into cementum of
the root surface on one side and into a relatively dense bony plate, the lamina dura, on the other side.
 These supporting fibers run at an angle, attaching farther apically on the tooth than on the adjacent alveolar bone.
This arrangement, of course, resists the displacement of the tooth expected during normal function (Figure 8-1).
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 Although most of the PDL space is taken up with the collagenous fiber bundles that constitute the ligamentous
attachment, two other major components of the ligament must be considered.
 These are :
(1) Cellular elements, including mesenchymal cells of various types along with vascular and neural elements and
(2) Tissue fluids.
Both play an important role in normal function and in making orthodontic tooth movement possible.
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 The principal cellular elements in the PDL are undifferentiated mesenchymal cells and their progeny in the form of
fibroblasts and osteoblasts.

 The collagen of the ligament is constantly being remodeled and renewed during normal function.

 The same cells can serve as both fibroblasts, producing new collagenous matrix materials, and fibroclasts,
destroying previously produced collagen.1

 Remodeling and recontouring of the bony socket and the cementum of the root is also constantly being carried
out, though on a smaller scale, as a response to normal function.

 Fibroblasts in the PDL have properties similar to osteoblasts, and new alveolar bone probably is formed by
osteoblasts that differentiated from the local cellular population. 2

 Bone and cementum are removed by specialized osteoclasts and cementoclasts, respectively.
 These multinucleated giant cells are quite different from the osteoblasts and cementoblasts that produce bone
and cementum.
 Despite years of investigation, their origin remains controversial. Most are of hematogenous origin; some may be
derived from stem cells found in the local area.3
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 Although the PDL is not highly Vascular, it does contain blood vessels and cells from the vascular system.
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 Nerve endings are also found within the ligament
 both the unmyelinated free endings associated with perception of pain and
the more complex receptors associated with pressure and positional information (proprioception).
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 Finally, it is important to recognize that the PDL space is filled with fluid; this fluid is the same as that found in all
other tissues, ultimately derived from the vascular system.
 A fluid-filled chamber with retentive but porous walls could be a description of a shock absorber, and in normal

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 function, the fluid allows the PDL space to play just this role.

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2. Response to Normal Function

 During masticatory function, the teeth and periodontal structures are subjected to intermittent heavy forces. Tooth
contacts last for 1 second or less; forces are quite heavy, ranging from 1 or 2 kg while soft substances are being
chewed, up to as much as 50 kg against a more resistant object.
 When a tooth is subjected to heavy loads of this type, quick displacement of the tooth within the PDL space is
prevented by the incompressible tissue fluid. Instead, the force is transmitted to the alveolar bone, which bends in
response.
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 The extent of bone bending during normal function of the jaws is often not appreciated (and other skeletal elements
of the body).
 The body of the mandible bends as the mouth is opened and closed, even without heavy masticatory loads. Upon
wide opening, the distance between the mandibular molars decreases by 2 to 3 mm.
 In heavy function, individual teeth are slightly displaced as the bone of the alveolar process bends to allow this to
occur, and bending stresses are transmitted over considerable distances.
 Bone bending in response to normal function generates piezoelectric currents (Figure 8-2) that appear to be an
important stimulus to skeletal regeneration and repair (see further discussion later in this chapter).
 This is the mechanism by which bony architecture is adapted to functional demands.
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 Very little of the fluid within the PDL space is squeezed out during the first second of pressure application. If
pressure against a tooth is maintained, however, the fluid is rapidly expressed, and the tooth displaces within the
PDL space, compressing the ligament itself against adjacent bone. Not surprisingly, this hurts.

 Pain is normally felt after 3 to 5 seconds of heavy force application, indicating that the fluids are expressed and
crushing pressure is applied against the PDL in this amount of time (Table 8-1).

 The Resistance provided by tissue fluids allows normal mastication, with its force applications of 1 second or less,
to occur without pain.
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 Although the PDL is beautifully adapted to resist forces of short duration, it rapidly loses its adaptive capability as
the tissue fluids are squeezed out of its confined area.
 Prolonged force, even of low magnitude, produces a different physiologic response—remodeling of the adjacent
bone.
 Orthodontic tooth movement is made possible by the application of prolonged forces. In addition, light prolonged

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 forces in the natural environment—forces from the lips, cheeks, or tongue resting against the teeth—have the
same potential as orthodontic forces to cause the teeth to move to a different location (see the discussion of equilibrium
factors in Chapter 5).

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3. Role of the Periodontal Ligament in Eruption and Stabilization of the Teeth

 The phenomenon of tooth eruption makes it clear that forces generated within the PDL itself can produce tooth
movement.
 After a tooth emerges into the mouth, further eruption depends on metabolic events within the PDL, including but
perhaps not limited to formation, cross-linkage, and maturational shortening of collagen fibers (see Chapter 3).
 This process continues, although at a reduced rate, into adult life.
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 A tooth whose antagonist has been extracted will often begin to erupt again after many years of apparent
quiescence.
 The continuing presence of this mechanism indicates that it may produce not only eruption of the teeth under
appropriate circumstances but also active stabilization of the teeth against prolonged forces of light magnitude.
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 It is commonly observed that light prolonged pressures against the teeth are not in perfect balance, as would
seem to be required if tooth movement were not to occur (Figure 8-3).
 The ability of the PDL to generate a force and thereby contribute to the set of forces that determine the equilibrium
situation, probably explains this.
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 Active stabilization also implies a threshold for orthodontic force, since forces below the stabilization level would
be expected to be ineffective.
 The threshold, of course, would Vary depending on the extent to which existing soft tissue pressures were already
being resisted by the stabilization mechanism.

 In some experiments, the threshold for orthodontic force, if one was found at all, appeared extremely low.

 In other circumstances, a somewhat higher threshold, but still one of only a few grams, seems to exist.

 The current concept is that active stabilization can overcome prolonged forces of a few grams at most, perhaps
up to the 5 to 10 gm/cm2 often observed as the magnitude of unbalanced soft tissue resting pressures.

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