PERIODONTAL LIGAMENT

CONTENTS
 Introduction
 Definition
 Extent and shape
 Average width
 Development of pdl and principle fibers
 Histological structures of pdl
 Cellular components
 Extracellular components
 Connective tissue components
 Principle fibers of PDL.
 Blood supply of pdl
 Nerve supply of pdl
 Functions of pdl
 Age changes of pdl
 Pdl homeostasis
 Clinical consideration of pdl
 Conclusion
 Refences
 INTRODUCTION
 Periodontal ligament is the soft, richly vascular and cellular
connective tissue which surrounds the roots of teeth and joins the
root cementum with the socket wall.
 It is the soft tissue component of the PERIDONTIUM which
supports the tooth structure.
 DEFINITION
 Periodontal ligament is composed of a complex vascular & highly
cellular connective tissue that surrounds the tooth root & connects it to
the inner wall of the alveolar bone.
Carranza 11th edition
 The periodontal ligament (PDL) occupies the periodontal space, which
is located between the cementum and the periodontal surface of the
alveolar bone, and extends coronally to the most apical part of the
lamina propria of the gingiva .
Orban's 13th edition
 Soft, richly vascular and cellular connective tissue which surrounds the
roots of the teeth and joins the root cementum with the socket wall.
Lindhe 5th edition
 EXTENT AND SHAPE
 In the coronal direction it is continuous with lamina propria of
gingiva & is demarcated by the alveolar crest fibers.

 At the root apex it merges with the dental pulp.

 Periodontal ligament has the shape of an hour glass and is

narrowest at the mid root level.

 It ranges in width from 0.15-0.38 mm

 AVERAGE WIDTH
Depending on age

1. 11-16 years - 0.21mm

2. 32-52 years - 0.18mm
3. 51-67 years - 0.15mm

According to functional state of the tissues

1. Time of eruption - 0.1- 0.5mm

2. At function - 0.2-0.35mm
3. Hypo function - 0.1-0.15mm
 DEVELOPMENT OF PDL
 The development of the
periodontal ligament begins with
root formation prior to tooth
eruption.
 The continuous proliferation of
the inner and external enamel
epithelium forms the cervical loop
of the tooth bud.
 This sheath of epithelial cells
grows apically, in the form of
Hertwig’s epithelial root sheath,
between the dental papilla and the
dental follicle.
 At this stage, the sheath forms a circumferential structure
encompassing dental papilla separating it externally from dental
follicle cells.
 The dental follicle cells, located between the alveolar bone and
the epithelial root sheath, are composed of two sub- populations
 mesenchymal cells of the dental follicle proper and
 the perifollicular mesenchyme
As the root formation continues cells
in the perifollicular area ,gain
polarity and cellular volume and their
synthetic activity increases

Cells become elongated,contains

increased amount of rough
endoplasmic reticulum,mitochondria
and active golgi complexes

Actively synthesise and deposit

collagen fibrils and glycoprotiens in
developing periodontal ligament.
 The developing periodontal ligament, as well as the
mature periodontal ligament, contains undifferentiated
stem cells that retain the potential to differentiate into
osteoblasts, cementoblasts and fibroblasts.

[Development and general structure of the

periodontium , Moon- il cho &Philias R. Garant ,
Periodontology 2000, Vol. 24, 2000, 9–27]
DEVELOPMENT OF PRINCIPAL
FIBERS OF PERIODONTAL
LIGAMENT.
 The principal fibers, develop in conjunction with the
eruption of the tooth
Principle fibers
 Initially from the surface of bone and
cementum only a small number of fine,
brush-like radiating, thin collagen fibrils
can be seen.

 Gradually the number and thickness of

fibers entering the bone increase.

 The fibers originating from the

cementum are still short while those
entering from the bone gradually
become longer.

 The terminal portions of these fibers

carry finger–like projections
 The fibers originating from cementum
fuse in periodontal ligament space with
the fibers originating from the alveolar
bone.

 When the tooth , following eruption

,comes in contact with its antagonist
tooth and starts to function ,the principal
fibers become organized in bundles and
run continuously from bone to
cementum.
HISTOLOGICAL STRUCTURE
The periodontal ligament is formed of :-

Cellular Extracellular Connective

components components tissues
 Fibres components
 Synthetic cells 1.Collagen fibers
 Blood vessels
 Resorptive cells 3.Oxytalan fibers
 Lymphatic
 Progenitor cells 4.Elastic fibers drainage
 Epithelial cell  Ground substance  Nerves
 Defense cells 1.Proteoglycans  Cementicles
2.Glycosaminoglycans
3.Glycoprotein
CELLULAR COMPONENTS
 SYNTHETIC CELLS
Basic properties

 For a cell to produce protein it must transcribe RNA

,synthesize ribosomes in nucleolus and transport them to the
cytoplasm ,increase its complement of RER and golgi bodies
for translation and transport of protein,and it should get
adequate energy supply by mitochondria.
 FIBROBLAST
 They are the predominant cells in pdl making about 65% of
cells.

 periodontal ligament fibroblasts near the cementum are derived

from the ectomesenchymal cells of the investing layer of the
dental papilla, while fibroblasts near the alveolar bone are
derived from perivascular mesenchyme.
 Pdl fibroblast have well developed cytoskeleton with
prominent actin network.Presence of actin network
also endows the periodontal ligament fibroblast with
degree of contractility,with which it can exert
tractional forces on extracellular matrix.

 Fibroblast of pdl are interconnected by gap and

adherens type of junction.
 FUCTIONS OF FIBROBLASTS
 Fibroblasts are capable of both synthesis and resorption.

 They produce structural connective tissue proteins collagen and

elastin as well as glycoprotein and glycosaminoglycan.

 They also produce proteinase, cytokines, and growth factors.

 They are responsible for formation and remodeling of pdl fibers .

 The presence of collagen resorbing fibroblasts in a normal
functioning periodontal ligament indicates resorption of
fibers occurring during remodeling of periodontal ligament

 They maintain width by preventing encroachment of bone

and cementum into periodontal space.

 Generate force for tooth eruption because of their contraction

action with the help of actin,fibronectin,integrin.
 OSTEOBLASTS
 The osteoblasts covers the periodontal surface of alveolar
bone.
 Alveolar bone constitute a modified endosteum and not a
periosteum.
 Although technically situated within the PDL, osteoblasts are
properly associated with their respective function of bone
formation.
 It may be either functional or resting, depending on the
functional state of the ligament.
 FUNCTION OF
OSTEOBLAST.
 Osteoblasts help in the synthesis of alveolar bone
 CEMENTOBLAST
 These cells line the surface of
cementum ,but are not regularly
arranged as osteoblasts.
 These cells are often
indistinguishable from
periodontal fibroblasts apart
from their location near to the
cementum surface.
 Cells actively deposits cellular
and acellular cementum.
RESORPTIVE CELLS
OSTEOCLASTS
 These cells helps in bone Resorption
 These are multinucleated giant cells having numerous nuclei.
 The part of plasma membrane lying adjacent to the bone being
resorbed is termed as ruffled border
 Resorption process :ruffled border

acidic ph by active pumping of protons by osteoclasts

Resorption
 CEMENTOCLASTS
 They are Cementum resorbing cells.

 Cementoclasts are occasionally found in the PDL.

 Cementum is not remodeled in the fashion of alveolar bone

and pdl, but it undergo continues deposition during life.
 FIBROBLASTS
 They show rapid degeneration of collagen by fibroblast
phagocytosis and that is the basis for fast turnover of collagen
in periodontal ligament.
 Studies has shown that degradation of collagen include both
intracellular and extracellular events
 Extracellular degradation involves collagenase ,MMPIV,
GELATINASE which causes denaturation of collagen in
physiological condition.
 Intracecllular degradation: Here fibroblast phagocytose the
collagen fibers and degrade them by lysosomal cystiene
protienases of lysosomal granules present in them.
 PROGENAITOR CELLS
 Progenitor cells are the undifferentiated mesenchymal cells,
which have the capacity to undergo mitotic division and
replace the differentiated cells dying at the end of their life
span or as result of trauma.

 Exhibit some classical cytological features of stem cells –

small size ,responsiveness to stimulating factors and slow
cycle time.
 These cells are located in perivascular region and have a
small close faced nucleus and little cytoplasm.
 They remain even after the formation of pdl and give rise
to pdl fibroblast, cementoblasts, osteoblast.
 When cell division occurs, one of the daughter cells
differentiate into functional type of connective tissue
cells. The other remaining cells retain their capacity to
divide.
 PERIODONTAL LIGAMENT
STEM CELLS
 Periodontal ligament stem cells (PDLSCs), which reside in the
perivascular space of the periodontium, possess characteristics of
mesenchymal stem cells and are a promising tool for periodontal
regeneration.

 In 2004 Seo et al. successfully isolated multipotent periodontal

ligament stem cells (PDLSCs) from human impacted third molars
and these cells could differentiate into periodontal ligaments,
alveolar bone, cementum, peripheral nerves, and blood vessels
Factors That Influence Stem Cell
Properties of PDLSCs
 Tissue origin

 Donor age

 Culture methods and conditions

 Growth factors

[Wenjun Zhu, and Min Liang Periodontal Ligament Stem

Cells: Current Status, Concerns, and Future Prospects Stem Cells
International Volume 2015 , 1-11 pages]
 EPITHELIAL CELL RESTS OF
MALASSEZ
 These cells are the remnants of Hertwig’s
Epithelial Root Sheath which disintegrates during
root development.

 They are found close to cementum.

 These cells exhibit monofilaments and are attached

to each other by desmosomes.

 The epithelial cells are isolated from connective

tissue by a basal lamina.
 Contain keratinocyte
growth factors.

 Can proliferate and

participate in formation of
peri apical cysts and
lateral root cysts.
 DEFENCE CELLS
MAST CELLS

They are relatively small ,round or oval cell having diameter of about 12 to
15µm.

They are often associated with blood vessels.

When the cell is stimulated it degranulates .The granules have been shown to
contain heparin,histamine,serotonin.

Mast cell histamine plays a role in inflammatory reaction,it has been shown
that mast cell degranulate in response to antigen – antibody formation on
their surface.
MACROPHAGES

 In the pdl macrophages play a dual role:

 Phogocytosing dead cells

 Secreting growth factors that regulate the proliferation of

adjacent fibroblast.
EXTRACELLULAR SUBSTANCE
 Extra cellular substance comprises the following:

1. Fibers
a) Collagen b) Oxytalan

2. Ground Substance
a) Proteoglycans b) Glycoproteins
 COLLAGEN FIBERS
 Its basically a Protein composed of different amino acids.
 Collagen is responsible for maintenance of framework and tone of
tissue.
 the production of collagen fibers are as follows:

molecule released by fibroblasts are the tropocollagen

which contains three polypeptide chains intertwined to form helix.
Tropocollagen molecules are aggregated longitudinally
to form protofibrils, which are subsequently laterally arranged to form
collagen fibrils.
 Half life of collagen fibers is between 3 to 23 days and collagen imparts a unique
combination of flexibility and strength to tissue

 Vitamin C help in formation and repair of collagen.

 There are different types of collagen fibers, of which type I, III, IV, V, VI, XII are
present in pdl.
 TYPE I COLLAGEN

 Its the main type of collagen which makes more than

70% of pdl collagen.

 It is uniformly distributed in ligament.

 It is low in hydroxylysin and glycosylated hydroxylysin.

 It provides tensile strength.

 TYPE III COLLAGEN
 It makes around 20%of collagen fibers.

 It is High in hydroxyproline, low in hydroxylysin and cysteine.

 It is Covalently linked to type 1 collagen throughout the tissue and is found at

the periphery of Sharpey's fibers attachments into alveolar bone.

 Function
 It helps in collagen turnover,
 Helps in tooth mobility
 It makes up the collagen fibril diameter.
 TYPE IV COLLAGEN

 Type IV doesn’t form fibril and is found in basement

membrane of neurovascular bundles and epithelial
cell rests in pdl.

 Functions
 maintain the integrity of pdl ,by anchoring the elastic
system to the vasculature.
 TYPE V COLLAGEN

 Coats the cell surface and other type of

collagen.

 Increases in amount in periodontal

inflammatory disease.

 Promotes cell attachment and migration.

 TYPE VI COLLAGEN

 It is a Short chain molecule.

 It Ramifies the extracellular matrix ,but it is not

directly associated with major banded collagen
fibrils.

 Functions
 It maintains the integrity and elasticity of the
extracellular matrix.
 TYPE XII COLLAGEN
 Attaches to type I collagen and mediates binding of
other connective tissue elements.

 Believed to occur within PDL only when PDL is

fully functional.

 Functions
 Alignment & organization of pdl fibers .
 PRINCIPAL FIBERS

 They are The most important elements of PDL

 They are of collagenous nature and follow a wavy

pattern.

 They are thought to contribute to the regulation of

mineralization and to tissue cohesion at sites of
increased biomechanical strain.
 PRINCIPAL FIBERS
 They can be divided into three groups
 Gingival fibers.
 Trans septal or interdental ligament.
 Alveolodental ligament which is subdivided into the following five groups:
1- Alveolar crest group.
2- Horizontal group.
3- Oblique group.
4-Apical group.
5- Inter radicular group
 GINGIVAL FIBERS
 Dento-gingival fibers: extend from the cervical cementum into the gingiva.
 Alveolo-gingival group: extends from the alveolar crest into the gingiva.
 Circular group: a small group of fibers that encircles the tooth and interlaces with the outer
fibers.
 Dento-periosteal fibers: they extend from the cementum directed over the bone crest and
then incline apically between the periosteum of the alveolar bone and the gingiva.
FUCTION

They form a rigid cuff around the tooth that can add
stability and resist gingival displacement.
 TRANSSEPTAL FIBERS
 It connects two adjacent teeth.
 The FIBERS runs from the
cementum of one tooth over the
crest of the alveolus to the
cementum of the adjacent tooth.
 Function:
 Resists mesial and distal movements
 tooth separation.
 They are reconstructed even after
the destruction of alveolar bone
resulting from periodontal disease.
 THE ALVEOLODENTAL FIBERS
1.Alveolar crest group:
 They radiate from the crest of the
alveolar process and attach themselves to
the cervical part of the cementum.
 Function: they resists vertical and
intrusive forces.
2.Horizontal group:
 The fiber bundles run from the
cementum to the bone at right angle to
the long axis of the tooth.
 Function: resists horizontal and tipping
forces.
3. OBLIQUE GROUP OF FIBERS
 The fiber bundles run obliquely.
 Their attachment in the bone is
somewhat coronal (higher) than the
attachment in the cementum.
 The greatest number of fiber
bundles are found in this group.
 Function:
 Performs the main support of the
tooth against masticatory forces.
 Resists vertical and intrusive forces.
4. Apical group:
 The bundles radiate from the
apical region of the root to the
surrounding bone
 Function: resists vertical
force.
5. Inter radicular group:
 The bundles radiate from the
inter radicular septum to the
furcation of the multirooted
tooth.
 Function: resists vertical and
lateral forces.
 OXYTALIN FIBERS
 These are immature elastic (pre-
elastic) fibers
 They tend to run in an axial
direction, one end being
embedded in bone or cementum
and the other in the wall of blood
vessels.
 At the apical region they form a
complex network.
 They help to Regulate vascular
flow
 They Develop new in the
regenerated pdl.
 INDIFFERENT FIBER PLEXUS

 Small collagen fibers associated with the larger

principal collagen fibers .
 Run in all directions, forming a plexus.
 It was Described by Shackleford, 1971
 Once the tooth has erupted into clinical occlusion such
an intermediate plexus is no longer seen in ground
sections.
 SHARPEY’S FIBERS
 The terminal portion of principal fibers of periodontal ligament that
are inserted into cementum and alveolar bone are called as
SHARPEY’S FIBERS

 The mineralised parts of sharpey s fibers in alveolar bone appears as

projecting stubs covered with mineral clusters.

 The number and size of Sharpey's fibers varies with functional status
of the teeth.
 GROUND SUBSTANCE
 Fills the space between the fibers and cells

COMPOSITION
 Consists of a biochemically complex, highly hydrated,
semisolid gel.
 Water content of 70%
 Glycosaminoglycan's – hyaluronic acid, proteoglycans like versican,
decorin.
 Glycoproteins -- fibronectin , laminin , vibronectin ,tenascin.
 PROTEOGLYCANS
 They are Large group of anionic macromolecules that consists
of a protein core to which hexose amine are attached.
 Two proteoglycans are identified in pdl: Proteodermatan
sulfate and proteoglycan containing chondroitin sulfate
hybrids
 FUNCTIONS
a. Cell adhesion
b. Cell-cell & cell- matrix adhesion
c. Cell repair
d. Binding to various growth factors
 GLYCOPROTEIN
 The primary function of these molecules is to bind cells to
extracellular elements.
 The Most widely studied is FIBRONECTIN
 They Exists in one form as an insoluble connective tissue
matrix protein which promotes the attachment and
subsequent spreading of cells that bind to a fibronectin –
collagen complex.
 the attachment and spreading of cells within the PDL
collagen matrix is a pre requisite for both alignment of
collagen fibers and for cell migration.
 CEMENTICLES
 They are calcified masses , adherent to or
detached from root surfaces.
 They represent dystrophic calcification .
 They develop from calcified epithelial rests,
calcified Sharpey's fibers, around small
spicules of cementum or alveolar bone
traumatically displaced into pdl.
 Generally they are less than 0.5 mm and are
found in 35% of human roots and in older
ages.
 They may interfere with periodontal
treatment.
 BLOOD SUPPLY TO PDL
 Inferior & superior alveolar
arteries to the mandible &
maxilla reaches the PDL from 3
sources:
1. Apical vessels (Dental artery)
2. Trans alveolar vessels
[penetrating vessels from alveolar
bone]
3. Intraseptal vessels
(anastomosing vessels from the
gingiva)
 The arterioles in pdl ranges from diameter of 15 - 50µm.

 Pdl has some specialised features in vascullature namely,the presence of large

number of fenestrtions in cappillaries and cervical plexus of capillary loops

 These fenestrated capillary beds have an increased capacity of diffussion and

filtration. These functios are related to the high metabolic requirement of pdl
because of high rate of turnover.
 NERVE SUPPLY OF PDL
 The nerve supply of periodontal ligament comes from
either the inferior or superior dental nerves which are the
branches of second and third division of fifth cranial
nerve (trigeminal nerve) and follow same path as blood
vessels.
 Bundles of nerve fibers run from the apical region of the
root towards the gingival margin.
 Nerves enter the ligament horizontally through multiple
foramina in the bone.
 The pdl has functionally 2types of nerve fibers: sensory and autonomic .

 Sensory fibers are associated with nociception and mechanoception , with

touch ,pressure, pain and proprioceptive sensations.

 Autonomic fibers are associated with pdl vessels.

 The nerve fibers are of either large diameter and myelinated or small
diameter in which they may or maynot be myelinated.

 Larger diameter fibers appear to be concerned with discernment of pressure

and small diameter one with pain.
 Pdl mechanoceptors exhibit directional sensitivity as they respond to a
force applied to the crown in particular direction( their conduction
velocity place them in Aβ group of fibers)

 It is said that 75% of mechanoceptors of pdl have their cell bodies in

trigeminal ganglion and remaining 25% cell bodies in mesencephalic
nucleus.

 Encapsulated pressure receptors and acini form fine pain receptors are
seen in greatest number which function during mastication.
 LYMPHATIC DRAINAGE
OF PDL
 Lymphatics supplement the venous drainage system.
 3rd molars are drained to jugulodigastric lymph node
and the mandibular incisors to the submental lymph
nodes.
 the lymphatics of other mandibular teeth pass through
alveolar bone to inferior dental canal and then to the
submandibular lymph nodes.
 The maxillary teeth drain into deep cervical lymph
nodes.
FUNCTIONS OF PDL

1. Physical
2. Formative and Remodeling
3. Nutritive
4. Sensory
 PHYSICAL FUNCTIONS
 It provides a soft tissue ‘CASING’ to protect the vessels and
nerves from injury by mechanical forces .

 It helps in transmission of occlusal forces to the bone

 It gives attachment of teeth to bone.

 It helps in maintenance of gingival tissues in their proper

relationship to the teeth.

 It provides resistance to impact of occlusal forces

 SHOCK ABSORPTION : tensional theory & viscoelastic theory

 FORMATIVE AND
REMODELLING
 Cells have the capacity to resorb & synthesize the extracellular
substance of the CT ligament, alveolar bone & cementum.
 Participate in physiologic tooth movement & in repair of
injuries.
 PDL is constantly undergoing remodeling old cells and fibers
are broken down and replaced by new ones.
NUTRITIVE FUNCTION
 PDL supplies nutrients to the cementum, bone,
and gingiva by way of blood vessels and provides
lymphatic drainage.

 Rich vascular plexus at apex & in the cervical part

of the ligament

 Rich network of arcades are more evident in the

PDL space adjacent to the bone than to cementum
 SENSORY FUNCTION
 Periodontal ligament provides the most efficient
proprioceptive mechanism(allows organism to detect
the application of most delicate forces to the teeth)
 4 types of neural terminations are seen
1. Free nerve endings – pain [ whole length of the
pdl ]
2. Ruffini like mechanoreceptors (apical area)
3. Meissner’s corpuscles - mechanoreceptors
(middle 3rd)
4. Spindle like pressure and vibration endings
(apex)
PDL HOMEOSTASIS

 A remarkable capacity of the pdl is that it

maintains its width more or less despite the fact,
that it is squeezed in between two hard tissues.

 Various molecules are secreted that can regulate

the extent of mineralization and prevent the
fusion of root with sorrounding bone.
 The various molecules are:-
 MSX2 protein - prevents the osteogenic differentiation of fibroblast.
 The balance between the activities of BONE SIALOPROTEIN AND
OSTEOPONTIN .
 MATRIX ‘GLA’ PROTEIN ,an inhibitor of mineralization present in the
periodontal tissues.
 RGD CEMENTUM ATTACHMENT PROTEIN, a collagen associated protein.
 TGF-β – downregulate osteoblastic differentiation of pdl cells.
 PROSTAGLANDINS - inhibit mineralized bone nodule formation and prevent
mineralization.
(Orban’s Oral histology and embryology ,13th edition)
 PDL SPACE RADIOGRAPHIC
APPEARANCE
 Thin radiolucent line interposed between the radiopaque
lamina dura of alveolar bone &radiopaque cementum.
 0.4 – 1.5mm .
 AGE CHANGES IN PDL

 The cell number and cell activity decreases with aging.

 One of the prominent changes seen in the calcified tissues of

periodontium, the bone and the cementum is scalloping and
the PDL fibers are attached to the peaks of these scallops than
over the entire surface as seen in a younger periodontium.

 This remarkable changes affect the supporting structures of

the teeth.
 decrease in the number of collagen fibers, pdl fibers
and cellularity.[ Grant et al 1986]
 decrease in collagen synthesis [Johnson et al 1973]
 increase in collagen fibrosis.[Grant and Bernick 1972
]
 reduction in vascularity.
 Replacement of pdl space by fat cells and interstitial
cells.
 CLINICAL CONSIDERATIONS
 PDL thickness varies in different individuals and in different teeth in the
same person and in different locations on the same tooth .

 Acute trauma to the periodontal ligament like accidental blows or rapid

mechanical destruction may produce pathologic changes such as
resorption of the cementum, tearing of fiber bundles, hemorrhage and
necrosis .

 Orthodontic tooth movement depends on resorption and formation of

tooth bone and periodontal ligament .These activities can be stimulated by
properly regulated pressure and tension.
GUIDED TISSUE REGENRATION

 The method for prevention of epithelial migration along the

cemental wall of the pocket and maintaining space for clot
stabilization is a technique called guided tissue regeneration(
GTR ).

 GTR consists of placing barriers of different types (

membranes ) to cover the bone & periodontal ligament, thus
temporarily separating them from gingival epithelium and
connective tissue.
 periodontal ligament cells have the potential for regeneration of attachment
apparatus of the tooth.

 Excluding the epithelium and the gingival connective tissue from the root surface
during the post surgical healing phase not only prevents epithelial migration into
the wound but also favors repopulation of the area by the cells from the
periodontal ligament and the bone. This helps in regeneration of the lost peridontium
and good outcome of the treatment.
 NEOPLASMS ARISING
FROM PDL
 Cemento-ossifying fibroma

 Reactive fibro-cemento-osseous lesions of PDL origin:

1.Periapical cemento-osseous dysplasia (PCD)
2. Focal cemento-osseous dysplasia
3. Florid cemento-osseous dysplasia
 The Inflammatory diseases of the pulp
progress to the apical periodontal
ligament and replace its fiber bundles
with granulation tissue leading to what
is called as periapical granuloma.

 periapical granuloma contains

epithelial cells that undergo
proliferation and produce a periapical
cyst.
PERCUSSION TEST
 A Positive response to percussion indicates the
presence of inflammation of pdl .
 Fusion of alveolar bone and cementum with
obliteration of the periodontal ligament is termed
Ankylosis.

 It may develops after chronic periapical

inflammation, in replanted avulsed teeth,
occlusal trauma and around embedded teeth.

 Clinically ankylosed tooth sounds DULL or

WOODY on percussion. Before extraction such
tooth require X-ray to facilitate surgical extraction.
 CHANGES IN PDL SPACE
Increase in pdl space Decrease in pdl space

 In inflammatory conditions  Hypercementosis

 apical periodontitis
 Fibrous dysplasia
 Periapical cyst
 Periapical abscess  Hypo function of the
 chronic Osteomyelitis tooth
 Osteo radio necrosis  Tooth which has lost its
 Malignant conditions antagonist
 Squamous cell carcinoma
 Paget's disease
 Fibrosarcoma
 Chondrosarcoma
 Metastatic tumor's
 Osseo integration is an intimate bone to implant contact
without presence of PDL in between.

 There is no pdl around implants. Because the principal

proprioception of the natural dentition comes from the pdl,
its absence in implant reduces tactile sensitivity & reflex
function.
 IN CASES OF TOOTH
AVULSION.
 Choice of treatment of an avulsed teeth is related to the condition
of the periodontal ligament cells. The condition of the cells is
depending on the storage medium and its time out of the mouth,.

 After a dry time of 60 min or more, all periodontal ligament (PDL)

cells are nonviable and will eventually lead to complications .

 Several studies have show that extra oral time more than 20
minutes will drastically reduce the prognosis of the replanted
avulsed tooth.
 It is important for the clinician to roughly assess the condition of the cells
by classifying the avulsed tooth into one of the following three groups
before starting treatment:

 • The PDL cells are most likely viable (i.e., the tooth has been
replanted immediately or after a very short time at the place of
accident).

 • The PDL cells may be viable but compromised. The tooth has
been kept in storage medium (e.g., tissue culture medium, HBSS,
saline, milk, or saliva and the total dry time has been <60 min).

 • The PDL cells are non-viable. Example : when the total extra-oral
dry time has been more than 60 min regardless of if the tooth was
stored in an additional medium or not, or if the storage medium was
non-physiologic.
 ENDO PERIO LESIONS

 Depending on the pathway of spread of the disease, the lesion can be diagnosed.

 When an endodontic problem extends into periodontium through periapical and

accessory canals it is referred as endo perio lesion.

 A true combined lesions are those that develop individually and join together
later .
TRAUMA FROM OCCLUSION
 When occlusal forces exceed the adaptive capacity of the periodontium tissue
leading to the injury of the tissue is termed as TFO.
 The common causes are high filling, bruxism, poorly planned orthodontic treatment
and prosthetic replacements etc.

 Increase in the pdl space, angular bone defects, thickening of lamina dura, mobility,
pain on chewing and percussion are the common clinical and radiographical features
of TFO
 It is very important to check for high points after permanent filling to prevent TFO.
 EFFECT OF HYPER & HYPO
GLYCAEMIA ON PDL
 Nishimura et al, in1998, Showed that PDL cells are
susceptible to hyper & hypoglycaemia.
 Hyperglycaemia – increased expression of fibronectin receptor
→ results in reduced cellular adhesion & motility → tissue
impairment.
 Hypoglycaemia – decreased expression of fibronectin receptor
→ lowers the viability & ultimately results in cell death &
hence tissue impairment
 HEALING OF PDL

 Healing begins as soon as inflammation starts.

 When the irritants are removed from the root canal space or
periapical area by non surgical or surgical endodontic
therapy, inflammatory mediators are no longer produced
 The inflammatory cells which are already present are
inactivated by body’s immune system to prevent
continuation of inflammation.
 This step precedes healing of the lesion.
 Healing is largely by regeneration and to some extent by
repair.

 Local tissue resident cells involved in periapical wound

healing are osteoblasts and bone marrow stromal cells in
alveolar bone and multipotent stem cells in periodontal
ligament.

 The extracellular matrix and growth factors (i.e., IGF-1,

FGFs, EGF, BMP, TGF-β, PDGF) are capable of inducing
proliferation, migration, attachment, and differentiation of
multipotent stem cells in the periodontal ligament.
After root canal therapy:

 Unwanted cells causing excessive fibrosis are removed

 Regeneration of new PDL-

damaged PDL fibers are removed by macrophages, new

fibers proliferate from newly formed fibroblasts which are
differentiated from pdl stem cells and gets attached to root surface

 Regeneration of cementum

multipotent stem cells of PDL differentiate into

cementoblasts like cells lay down cementoid tissue on root surface
denuded of PDL
 New alveolar bone formation

proliferation and differentiation of MULTIPOTENT STEM

CELLS OF PDL AND MESENCHYMAL CELLS IN THE INNER
LAYER OF PERIOSTEUM into osteoblast and forms bone matrix.

 Finally newly formed PDL will undergo remodeling into mature

PDL.

 Newly formed Sharpey's fibers gets inserted to newly formed

cementum and alveolar bone.

 Hence, regeneration of damaged PDL along with alveolar bone and

cementum is complete.
 PERIODONTAL LIGAMENT
STEM CELLS [ PDLSC’s ]
 These are the stem cell population that are of pdl origin and has the potential to
differentiate cementoblasts, osteoblasts and odontoblasts and many other
periodontium related synthetic cells.

 It has been successfully isolated from extracted teeth and ex vivo expanded
PDLSC’S are capable of regenerating a typical cementum/PDL- Like
structure when transplanted into immunocompromised mice using
hydroxyapatite/tricalcium phosphate as a carrier.

 They are of great value in regenerative endodontics and a lot of experiments

are conducted worldwide to use its potential for maximum level.

 CONCLUSSION
 The periodontal ligament is a fibrous connective tissue forming important
part of the periodontium. Without it, the tooth is support less .

 The thorough knowledge of the pdl is required for the good diagnosis and
better treatment of the diseased teeth and the periodontium.

 Stem cells of the periodontal ligament are pluripotential and helps in the
regeneration of all the components of periodontium and tooth, lost in the
periodontal and caries disease.

 A better understanding of cell and molecular biology of developing and

regenerating periodontium, pulp and other hard tissues of the teeth offers
newer avenues to regenerate the parts of the tooth and periodontium.
REFRENCES

 Orban‘s Oral histology and embryology - 12 th edition

 Tencate‘s Oral histology – 6 th edition
 Carranza’s clinical periodontology – 10 th edition
 Fundamentals of Periodontics, 2nd Edition, by Thomas G.
 Wilson, Kennath S, Kornman Hassel TM. Tissues and cells
of periodontium. Periodontol 2000, Vol. 3, 1993, 9-38.
 The Periodontium - Hubert E Schroeder
THANK YOU