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CRANIOFACIAL
GROWTH II
L.M CHAPTER 4

DR.REEM ALDHURGHAM
ASSISTANT PROFESSOR
DCLINDENT, UK
MORTHRCS (EDINBURGH)

DR. REEM ALDHURGHAM

The Cellular Basis of Tooth Movement

The basis of ortho movement is:

The ability of the PDL to respond to mechanical load by remodelling of the alveolar bone and
allowing movement of the tooth through bone.

When optimum force is applied; Force

Bone is laid down where the PDL is under tension.

Bone is resorbed from areas where the PDL is compressed.

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The Cellular Basis of Tooth Movement

Force
Compression
Tension

more less
more less
more less
Bone deposition more less Bone resorption
more less
more less

DR. REEM ALDHURGHAM

The Periodontal Ligament

The PDL consists of several different cell types surrounded by type 1 collagen and oxytalan
fibres and a ground substance consisting of proteoglycans and glycoproteins.
There are four main cell types:
1. Fibroblasts: responsible for producing and degrading the PDL fibres.
2. Cementoblasts: responsible for producing cementum.
3. Osteoblasts: responsible for bone production and coordination of bone deposition and
resorption.
4. Osteoclasts: responsible for bone resorption.
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The Periodontal Ligament Cont.

There are also some small islands of cells, known as:

the cell rests of Malassez, which are left following original root formation and
macrophages, responsible for dealing with dead cells and debris.
The PDL has a high turnover rate and requires a good blood supply Superior and inferior
alveolar arteries forms a dense network of capillaries, or plexus, within the PDL around the
tooth, occupying up to half of the periodontal space.

DR. REEM ALDHURGHAM

Cells Involved In Bone Homeostasis

There are three main cell types involved in bone

homeostasis:
1. Osteoblasts:
Orchestrate the production of the inorganic matrix
of bone and its mineralization.
Recruit and activate osteoclasts and are the main
regulators of bone homeostasis.
During normal function, they control the balance
b/w bone resorption and deposition.
Can be surrounded by mineralized bone and
become osteocytes.
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Cells Involved in Bone Homeostasis Cont.

2. Osteocytes:
Communicate with each other via cytoplasmic extensions in
canaliculi in the bone.
Responsible for detecting mechanical load on the bone.

3. Osteoclasts:
Large multinucleate cells
Responsible for resorption of bone.
Found on bone surfaces undergoing active resorption in pits
called Howship’s lacunae.
DR. REEM ALDHURGHAM

Cells Involved in Bone Homeostasis Cont.

The organic matrix of bone consists of type 1 collagen fibres, proteoglycans, and many growth
factors.
Bone contains more growth factors than any other tissue, which may in part explain its
capability for regeneration, repair, and remodeling.
Many of the growth factors and signaling molecules shown to be associated with bone
homeostasis play an active role in the bone remodeling associated with ortho tooth
movement.

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DR. REEM ALDHURGHAM

Cellular Events in Response to Mechanical Loading

Application of mechanical load, e.g, a force on a tooth from an ortho appl, affects the PDL by
causing fluid movement in the PDL space and by stretching and compressing of the collagen
fibers and extracellular matrix (ECM).
This leads to deformation of the alveolar bone.
The distortions in the PDL and alveolar bone are detected by the cells (fibroblasts,
osteoblasts, and osteocytes), which are connected to the ECM by proteins known as integrins
in their cell walls.
There is also evidence that cell shape influences activity;
Rounded cells exhibiting catabolic (destructive or resorptive) behavior and
Flat cells exhibiting anabolic (building or depositing) behavior.
It is possible that changes in cell shape in the PDL is at least partly responsible for the chain of
events seen when the PDL is under compression or tension.
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Possible Chain of Cellular Events When PDL is Subjected to a Compressive

Load
The mechanical load causes strain in the ECM of the PDL and in alveolar bone, causing fluid flow in both tissues.
The strain in ECM is sensed by PDL cells.
Osteocytes in the bone also sense the mechanical force by fluid flow through the canaliculi (microscopic canals connecting the osteocytes).
Osteocytes respond to mechanical deformation by producing bone morphogenetic proteins (BMPs) and other cytokines which activate osteoblasts.
Fibroblasts respond by producing matrix metalloproteinases (MMPs).
Osteoblasts respond by producing prostaglandins (e.g. PGE-2) and leukotrienes.
Osteoblast production of PGE-2 and leukotrienes leads to an elevation of intracellular messengers. These cause the osteoblast to produce interleukin-1
(IL-1) and colony stimulating factor (CSF- 1) and an increase in receptor activator of nuclear factor (RANKL).
Macrophages respond to mechanical deformation by increasing production of IL-1.
IL-1 production by osteoblasts and macrophages also increases the production of RANKL by the osteoblast.
RANKL and CSF-1 cause increased attraction and proliferation of blood monocytes which fuse to form osteoclasts. RANKL also stimulates the osteoclasts
to become active.
The osteoblasts bunch up to expose the underlying osteoid and produce MMPs to degrade the osteoid and to give the osteoclasts access to the
underlying mineralized bone. The osteoblasts also produce osteopontin (OPN) which causes the osteoclasts to attach to the exposed bone surface.
The osteoclasts resorb the bone by excreting hydrogen ions into the matrix, softening the hydroxyapatite crystals, and then use proteases such as
cathepsin K to break down the ECM.
The osteoblasts also produce inhibitors of some enzymes and cytokines (e.g. TIMPs and OPG to ensure that bone resorption is carefully controlled).

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Possible Chain of Cellular Events When PDL is Subject to Tension

In areas of tension, the osteoblasts are flattened and the osteoid remains unexposed.
Cells in the PDL increase the amount of a specific secondary messenger (extracellular signal-
related kinase (ERK)) in response to tension.
ERK signaling induces the expression of RUNX-2 which in turn causes an increase in
osteoblast number, possibly by inducing differentiation of fibroblasts into osteoblasts.
Osteoblasts clump into groups, secreting collagen and other proteins composing the organic
matrix, then produce hydroxyapatite, which mineralizes the matrix resulting in new bone.

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Four basic stages of tooth movement have been described:

1. Matrix strain and fluid flow in the PDL and alveolar bone.
2. Cell strain, secondary to matrix strain and fluid flow.
3. Cell activation and differentiation.
4. Remodeling of the PDL and alveolar bone.

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Cellular Events Associated with Excess Force

If the force applied to a tooth exceeds the pressure in the capillaries (30 mmHg, or around 50
g) blood vessels will be occluded nutrient supply to the PDL will reduce cell death in
the compressed PDL ‘hyalinized’ (as it takes on a glass-like appearance due to sterile necrosis)
There are no osteoblasts to recruit osteoclasts to resorb the bone in the expected way It
takes several days for cells to migrate from undamaged areas.
Eventually osteoclasts appear in the adjacent marrow spaces and resorb the bone from
underneath the necrotic area (Undermining resorption).
Where hyalinization and undermining resorption occur, there is a delay in tooth movement of
10–14 days.
The clinical implications of excessive force are more discomfort for the patient, an increased
risk of root resorption, and the risk of loss of anchorage.
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Hyalinized Area Due To Excessive Force

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Anchorage: is the resistance to unwanted tooth movement.

Loss of anchorage may occur due to inadequate tx planning, but
may also occur due to excessive force levels being applied to the
teeth.
When an excessive force is applied to a tooth, it won’t move
initially; however, there is still force being applied to the teeth
providing anchorage causing anchorage loss.

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What is the optimum force for tooth movement?

This will vary between different teeth and types of movement.
It depends on the area of the PDL that the applied force is
spread across.
E.g, a low force should be used to intrude a tooth, where the
force is concentrated in a small area at the apex.
A higher force can be used to bodily move teeth, where the
force is spread across the whole side of a tooth root.

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Optimal Force Levels for Different Tooth Movements

Type of tooth movement Approximate force (grams)

Tipping 50–75
Bodily movement 100–150
Root uprighting 75–125
Extrusion 50–100
Intrusion 15–25

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Cellular Events During Root Resorption

External apical root resorption is a complex inflammatory process that occurs in virtually all pts undergoing
tx with ortho appl’s
Odontoclasts are the cells responsible for the resorption of mineralized dental tissue, they are similar, but
not identical to, osteoclasts.
In mild cases of orthodontically induced root resorption (OIRR), only small areas of cementum are resorbed
and these areas are repaired with cellular cementum once the ortho force has stopped.
In more severe cases, the apical portion of the root is removed by odontoclast activity and the root length is
decreased. The remaining dentine will be recovered by cementum, but the root will remain shortened.
There is increasing evidence to suggest that OIRR is more likely where force levels are excessive, especially in
areas of compression.

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Summary
Cellular basis of tooth movement
Ortho tx would not be possible without the ability of the alveolar bone to remodel.
The cells of the PDL are responsible for the bone remodeling and, hence, tooth movement.
The osteoblast is the bone-forming cell and is responsible also for the recruitment and activation of osteoclasts (bone-
resorbing cells).
Many different growth factors and signaling molecules are now known to be involved in bone turnover during ortho tooth
movement with the RANK/RANKL/OPG osteoclast programme being the most important.
Excessive force can cause cell death and hyalinization of the PDL. This leads to a time delay (10–14 days) before the bone is
removed by undermining resorption and then tooth movement can continue. Clinically this can lead to pain, root resorption,
inefficient tooth movement, and anchorage loss.

Root resorption
Root resorption occurs in most pts undergoing ortho tx.
The cell responsible for the removal of cementum and dentine is the odontoclast.
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Any Questions?

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