ISSN No: 2582-0559

LIGAPLANT- A REVOLUTIONARY CONCEPT OF PERIODONTIO-

INTEGRATED IMPLANTS

Dr. Neha Pritam, Dr. Amit De, Dr. D. Rambabu, Dr. Savan S. R., Dr. Swet Nisha

Department of Periodontics, Haldia Institute of Dental Sciences and Research, Banbishnupur, Balughata Rd, West Bengal

721645.

Address for Correspondence

Dr. Neha Pritam,

Postgraduate Student, Department of Periodontics,

Haldia Institute of Dental Sciences and Research,

Banbishnupur, Balughata Rd, West Bengal 721645.

Email id: nehapritam32@gmail.com

REVIEW ARTICLE

ABSTRACT

Missing tooth replacement is a patient’s demand dentists have
to  meet  without  fail.  Replacement  by  implants  has  gained  a
lot of popularity among patients nowadays. Oseeo-integrated
implants present a challenge of excessive stress accumulating
at  the  crestal  region  of  the  implants  leads  to  bone  loss
whereas,  periodontal-integrated  implants  i.e.,-  leadplants
have  the  potential  of  PDL  regeneration  thus  mimicking  the
natural  tooth  in  distributing  the  forces  throughout  the  length
of  the  root.  The  regenerated  periodontal  ligament  dissipates
these forces through the compression and redistribution of its
fluid elements, as  well as through its fiber system and hence
provides  shock  absorption  and  cushioning  effect  to  the
implant in response to these forces. Although it is a technique
sensitive  procedure,  leadplants  can  alleviate  problems  which
implant  usually  faces  such  as  infrasonic  defects,  gingival
recession of the missing tooth site. Thus, it can be understood
that  generating  a  periodontal-like  tissue  around  implants  is
possible and might be the future in the field of implant logy.
An  online  search  was  done  on  Google  Scholar  search
platform,  on  the  topic    of  leadplant.  Relevant  articles  have
been  referred  to  throw  some  light  on  this  concept.  This
review article includes references of publications from 1982-
2020,  which  is  related  to  promising  outcomes  of  use  of
periodontio-integrated implants over the conventional oseeo-
integrated ones.

KEYWORDS-

Dental implants, Periodontal Ligament,

Ligaplant, Periodontio-integrated implant.

Received:

12.03.2021

First Published:

02.09.2021

Accepted:

26.08.2021

Published:

27.09.2021

Volume No: 8, Issue No: 2

101

DOI: 1.37841/jidam_2021_V8_I3_02

Neha Pritam et al:

Ligaplant- A Revolutionary Concept Of Periodontio-Integrated Implants

ISSN No: 2582-0559

INTRODUCTION-

The periodontal ligament is composed of connective

tissue  which  is  highly  cellular  and  vascular,  that  surrounds
the  tooth  root  and  connects  it  to  the  inner  lining  of  the
alveolar  bone

. Apart from its physical, formative and

remodelling,  nutritional,  and  sensory  functions,  the
periodontal  ligament  also  provides  progenitor  cells  which
make  formation  and  remodelling  of  alveolar  bone  possible
which  then  plays  the  role  of  periodontium  in  the  alveolar
socket that holds and contains the root of the tooth

2, 3, 4, 5

The periodontal ligament attaches to cementum and the

alveolar  bone  and  primarily  consisting  of  collagen  fibres,
fibroblast, cement oblasts, osteoblasts, osteoclasts and their
progenitors.  The  ends  of  PDL  fibres  are  embedded  in
cementum  and  the  alveolar  bone  called  as  the  Sharpey’s
fibres  and  they  are  directed  perpendicular  to  the  tooth
surface.  This  type  of  arrangement  maintains  the  structural
integrity  of  the  PDL  and  also  enables  the  distribution  of
masticatory forces onto the alveolar bone

Regeneration of lost periodontium can be done by the

periodontal therapy especially in cases of severe destruction
where  attachment  to  tooth  has  been  lost.  Regeneration  of
periodontal  ligament  fibres  and  insertion  of  same  into  the
root  surface  leads  to  formation  of  new  attachment.  The
same concept of PDL regeneration has been carried out for
replacement of lost tooth on the surface of dental implants.

Periodontal ligament having regenerative capacity and

thus  this  concept  is  used  to  formulate  tissue  engineered
periodontal  ligament  cells  on  the  implant  surface  thus
mimicking  the  natural  tooth.  This  forms  the  new  emerging
era  in  the  field  of  dentistry  with  implant  and  periodontal
ligament together known as ligaplant

7, 8

HISTORICAL BACKGROUND

For the development of possible periodontal ligament

around an implant, several experiments have been carried
out and a lot of research was put to work i.e., for the
creation of a bio-root, which would provide ideal conditions
for the implant-supported treatments in future

9, 10

Nyman et al.

in 1982 explained that the periodontal

ligament and its cells have the capability to restore the
connective tissue attachment. Nunez et al.

(2012) have

further confirmed the regenerative potential of periodontal
ligament-derived cells in his principle study.

A study was conducted by Buseretal in 1990, in which

he found that the periodontal ligament cells could be a
source of regeneration as they have the ability to cover the
surface of dental implants during healing period.

Several in vivo experiments have demonstrated the

formation  of  cementum-like  tissue  with  an  intervening
periodontal ligament, when the dental implants were placed
in proximity to tooth roots by Buser et al.(1900),  Caiazza et
al.  (1991),  Warrier  et  al  (1993).  The  possible  explaination
of  this  event  appeared  to  be  due  to  the  migration  of
cementoblast  and  periodontal  ligament  fibroblast  precursor
cells towards dental implants due to contact or proximity of
these cells to those of implants

This potential of customized periodontal biomimetic

hybrid scaffolds for engineering human tooth-ligament
interfaces to be applied clinically has been demonstrated by
Park et al

. There is indeed a growing body of evidence

validating the significant potential of the in vivo formation
of ligamentous attachments to the biomaterials.

Piatelli et al. 1994 evaluated the potential of different

cells of the forming tooth bud to induce formation of dental
hard tissues and PDL around titanium implants and showed
it is positive result.

Takata et al.,

in 1994 in an animal study examined

whether  connective  tissue  attachment  could  occur  on
implant  materials  by  repopulating  periodontal  ligament
derived  cells  and  found  that  while  new  connective  tissue
attachment was seen on bioactive materials such as bioglass
and  hydroxyapatite,  little  or  no  cementum  deposition  was
seen  on  bioinert  materials  such  as  titanium  alloy  and
partially  stabilized  zirconium,  i.e.,  the  formation  of  new
connective  tissue  attachment  was  due  to  the  bioactivity  of
the  materials.  Choi,(2000)

placed implants with the

cultured  autologous  periodontal  ligament  cells  in  the
mandibles of the dogs and histologically revealed that after
3  months  of  healing,  a  layer  of  cementum-like  tissue  with
inserting  collagen  fibers  had  been  achieved  on  some
implant  surfaces,  demonstrating  that  cultured  periodontal
ligament cells can form tissue resembling a true periodontal
ligament around implants

OSSEOINTEGRATED IMPLANTS VERSUS

PERIODONTIO-INTEGRATED IMPLANTS

Eliminating localized bone loss around osseo-

integrated implants is a clinical challenge yet to be
overcomed

. Excessive stress accumulating at the crestal

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ISSN No: 2582-0559

region  of  the  implants  leads  to  bone  loss  at  this  region18.
This concentration of stresses at the crestal region is mainly
because of the lack of the periodontal ligament in that area,
which  is  essential  for  distribution  of  the  forces  throughout
the length of the root. Periodontal ligament has it as one of
its  functions  to  dissipate  these  forces  through  the
compression and redistribution of its fluid elements, as well
as  through  its  fiber  system  and  hence  providing  shock
absorption and cushioning effect to the teeth in response to
these forces

. Furthermore, the periodontal ligament has a

sensitive  proprioceptive  mechanism  and  is  therefore  it  is
capable of detecting and reacting to various range of forces
applied  to  the  teeth.  When  these  forces  are  transmitted
through  the  periodontal  ligament,  they  result  in  the
remodelling of the alveolar bone to allow tooth movements
(as  seen  in  orthodontics)  or  in  the  widening  of  the
periodontal  ligament  space  leading  to  an  increase  in  tooth
mobility  in  response  to  excessive  forces  (e.g.,  occlusal
trauma)

. The osseointegrated dental implants on the other

hand, physiologically differ  from  natural teeth as they  lack
periodontal  ligament  support  and  hence  when  loaded
mechanically,  evoke  a  peculiar  sensation,  which  has  been
termed as osseoperception

10, 21

Patients with osseo-integrated implants will be feeling

tangible  sensation  only  when  a  force  greater  than  that
required to evoke sensation in natural teeth is applied. Thus,
the ability of dental implants to adapt to occlusal trauma is
reduced  due  to  this  lack  of  periodontal  proprioceptive
mechanism,  resulting in  micro  fractures of the crestal bone
which would eventually cause bone loss.

Moreover, osseointegrated implants with teeth presents

a  biomechanical  challenge  due  to  the  differential  support
and  mobility  provided  by  the  implant  and  the  tooth,
consequently  showing  a  higher  rate  of  failures  and
complications22.    However,  when  tooth-implant  supported
restorations  would  be  fabricated  using  support  from
periodontio-integrated implants higher success rates can be
expected due to similar resilience of tissues supporting teeth
and implants.

Figure 1: Diagram showing difference between natural
tooth, osseo-integrated implant and ligaplant.

PROCEDURE TO OBTAIN THE LIGAPLANT

Temperature-responsive culture dishes prepartion:

Polystyrene culture dishes were spread with N-

isopropylacylamide monomer in 2-propanaol solution. Then
these  dishes  were  then  subjected  to  electron  beam
irradiation with an Area Beam Electron Processing System.
These  temperature-responsive  polymer-grafted  (poly  N-
isopropylacrylamide)  dishes  were  subjected  to  cold  water
and  rinsed  to  remove  ungrafted  monomer  and  sterilized
with ethylene oxide

Cells isolation and cell culture:

An extracted tooth is taken as the source of human

periodontal  cells  and  is  isolate  from  the  same.  Periodontal
tissue  is  scraped  from  the  middle  third  of  the  root  after
extraction,  with  a  scalpel  blade.  The  harvested  tissue  is
placed into culture dishes containing = Dulbecco’s modified
Eagle’s minimal essential medium, supplemented with 10%
fetal  bovine  serum  and  100units/mL  of  penicillin
streptomycin.  These  outgrowth  cells  are  then  cultured  in  a
humidified  atmosphere  of  5%  CO₂  at  37°C  for  48  hours
which  will allow attachment  of the cells to the dishes. The
dishes  are  washed  to  eliminate  debris  and  the  medium  is
changed  at  intervals  of  three  times  a  week.  For  the
harvestation  of  the  cell  sheet,  human  periodontal  ligament
cells  are  plated  on  temperature-  responsive  culture  dishes(
35 mm in diameter) at a cell density of 1x10⁵ and cultured
at  37°C  supplemented  with  50mg/mL  ascorbic  acid  2-
phosphate,

10nM

dexamethasone

and

10nM

ᵝ-

glycerophosphate that function as an osteo-differentiation
medium

2, 23

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C. Culture of PDL cells in a Bioreactor:

Hydroxyappatite (HAP) coated titanium pin was placed

in a hollow plastic cylinder leaving a gap of 3mm around
the pin. Culture medium was continuously pumped through
the gap. Single cells suspension (periodontal ligament cell
suspension), obtained from human, and are seeded first into
plastic vessels under a flow of growth medium for duration
of 18 days

2, 23

PRECAUTIONS WHILE PREPARING

LIGAPLANT

Proper sterilization protocols must be maintained
throughout the procedure

7, 24

Proper culturing and cell growth is necessary;
otherwise it may to the formation of non- periodontal
ligament cell types.

PDL formation is favoured by a cushion of appropriate
thickness,  but  on  the  other  hand,  the  prolonged  cell
culturing  may  favour  the  appearance  of  non-PDL  type
of  cells.  The  bioreactor  has  been  constructed  with  the
aim to resemble the PDL situation during cell growth in
order  to  preserve  the  cell  differentiation  state  and  to
obtain adequate cell stimulation

Micromechanical movements of the growth medium is
necessary for firm attachment of the cells to the
implant

Cells  are  placed  and  positioned  into  a  narrow  space
between the ligaplant and surrounding hollow cylinder.
It  is  thereby  expected  that  the  phenotype  of  PDL  is
favoured  by  a  tight  attachment  of  cells  to  the  implant.
Thus,  minute  mechanical  movements  of  the  medium
flow  should  be  present  in  the  preparation  of  ligaplants
and  space  present  in  between  the  implants  and  the
culture should be optimal

Adequate duration of surface treatment must be
maintained for the success of the ligaplant which will
bring big improvements to the implant system

ADVANTAGES

Ligaplants have the advantage of mimicking the
anatomy of natural teeth which has periodontal
ligament around it along with the alveolar process

Ligaplants

become

firmly

integrated

without

interlocking  and  without  direct  bone  contacts,  despite
the initial fitting being loose in order to spare the PDL
cell cushion. Formation of bone began and movements
of  ligaplants  inside  the  bone  suggested  of  an  intact
tissue  communication  occurring  between  bone  and  the
implant surface

2, 25

Ligaplants can alleviate problems with implant  usually
faces  such  as  infrabony  defects,  gingival  recession  of
the  missing  tooth  site.  Thus  it  is  possible  to  be
applicable  in  periodontal  bony  defects,  where
conventional implants could not be installed.

In cases leading to peri-implantis, amount of bone loss
is reduced.

DISADVANTAGES

It’s a technique sensitive procedure. Hence, proper care
must be taken.

High cost. It is known to be costly procedure because
of limited facilities and members to perform this
research

Host acceptance of the implant or PDL growth in the
socket cannot be predicted. It may also lead to failure
of implant by the host

One  should  be  cautious  while  culturing  the  ligaplants
about  the  proper  maintenance  of  temperature,  duration
of  culture  etc.  All  of  these  make  it  a  cumbersome
procedure

RECENT STUDIES ON LIGAPLANTS

In 2005, researchers such as Akira et al. Parlar et al.,

Jahangir et al. also explored the effect of remaining PDL
and the feasibility of the the PDL around a dental
implant

28,29,30

The phenomenon of a tooth getting replaced by a dental

implant  relies  on  the  mechanical  and  biological  capability
of the anatomical substitute and its ability to restore the lost
physiological  functions.  L  Carvalho  et  al.  [2006]
determined  the  PDL  effects  on  the  dynamic  load  transfer
mechanism, from the tooth to the alveolar bone, evaluating
the  equivalent  dynamic  stiffness  of  the  ligament  structure.
In  this  study,  a  porcine  fresh  mandible  with  a  tooth  was
used, experimental procedure was carried out to identify the
dynamic  transmissibility  of  the  entire  system.  The
transmissibility  function  provided  information  about  the
stiffness  and  damping  of  the  PDL,  information  that  can
assist the design of an improved dental implant system

In a yet another study done by Marei (2009),

implantation  of  titanium  fixture  with  porous  hollow  root-
form  poly  (DL-Lactide-co-Glycolide)  scaffold  seeded  with
autogenous  bone  marrow-derived  mesenchymal  stem  cells
in  goats  showed  periodontium-like  tissue  with  newly
formed  bone  both  at  10  days  and  after  1  month,
substantiating that undifferentiated mesenchymal stem cells
were  capable  of  differentiating  to  provide  the  three  critical

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ISSN No: 2582-0559

tissues required for periodontal tissue regeneration:
Cementum, bone and periodontal ligament around the
titanium implants

Gault et al. 2 in 2010 did a scientific breakthrough by

demonstrating for the first time the tissue engineering of the
periodontal  ligament  and  cementum-like  structures  on  oral
implants  in  humans,  to  encourage  the  forming  of  implant-
ligament  biological  interfaces  or  ligaplants  which  are
capable of true and functional loading. In the research-work
carried  out  by  Gault,  it  was  found  that  the  periodontal
ligament fibroblasts could be harvested from hopeless teeth
of  mature  individuals  and  could  be  cultured  in  bioreactors
to  preserve  their  state  of  differentiation.  In  total  eight
implants  were  inserted  and  out  of  them,  one  was  still  in
place and  functioning even after 5 years and even showed
substantial  bone  regeneration  in  the  adjacent  bone  defect  2
years  post  implantation.  Thus  it  can  be  implied  that  in
future,  the  clinical  use  of  ligaplants  might  also  be  able  to
help avoid bone grafting, or its expense, inconvenience and
discomfort to the patient.

Rinaldi and Arana Chavez in 2010 showed results by

doing an animal study that that thin cementum like layer
formed at longer times after implantation at the areas in
which the PDL was in contact with the implant.

The clonogenic potential of human dental and

periodontal tissues such as the dental pulp and the PDL and
their  potential  for  tooth  and  periodontal  repair  and/or
regeneration  was  discussed  by  Javier  Caton  et  al.  (2011).
They  also  proposed  novel  therapeutic  approaches  using
stem  cells  or  progenitor  cells,  which  are  targeted  to
regenerate the lost dental or periodontal tissue

Lately, Kano et al.(2012) suggested that implants

surrounded  by  periodontal  ligament-like  tissue  could  be
developed,  when  immediately  after  the  extraction,  tooth-
shaped  hydroxyl-apatite  coated  titanium  implants  were
placed  into  the  tooth  socket  where  some  periodontal
ligament still remained; maintenance of original periodontal
tissue domains most likely being the cause of prevention of
osseointegration of the implants

Kiong and Arjunkumar in 2014 stated that ligaplants as

tooth replacement have decisive advantages as compared
with osseointegration devices, due to their periodontal
tissue regeneration

It was confirmed by Kaoro washio et al. (2018) that

PDL-derived cells cultured with osteoinductive medium had

the ability to induce cementum formation. Structure similar
to  periodontium  was  formed  around  a  titanium  implant,  an
environment similar to one existing around a natural tooth.
Dental implants combined with a cell sheet technique when
clinically  applied,  might  come  out  to  be  feasible  as  an
alternative  implant  therapy.  Moreover,  application  of  this
technique  may  act  as  an  innovative  role  in  not  only  just
periodontal,  but  also  other  fields  of  dentistry  such  as
prosthetic and orthodontic etc

35, 36

The phenomenon of regenerating the lost periodontal

tissues  has  been  one  of  the  most  important  subjects  in  the
research  area.  Since  it’s  discovery,  Kengo  Iwasaki  et  al.
[2019] used periodontal ligament stem cells (PDLSCs), and
transplanted into periodontal  bony defects to examine their
regenerative

potential.

Periodontal

defects

were

successfully regenerated using periodontal ligament stem
cell sheets, fabricated by cell sheet engineering in animal
models, and for which clinical human trials are underway

36,

CONCLUSION

Since the ligaplant is not tightly fitted to its site, the

ligaplant  surgery  is  relatively  easy.  Ligaplant  is
advantageous compared to osseosintegration devices, due to
their  periodontal  tissue  regeneration  capability.  Patients
however  also  have  the  advantage  of  not  going  through  the
inconvenience and discomfort of bone grafting, instead they
can go for ligalants for a better outcome.

A major concern remains in the form of rational

application of stem cell based tissue-engineering technology
to  be  practiced  in  clinics.  Apart  from  being  a  technique
sensitive procedure, tissue engineering applications requires
a  considerable  amount  of  cost  and  time.  Although,  a
predictable  and  feasible  method  for  producing  dental
implants  with  periodontal-like  ligament  has  not  been
innovated,  it  has  now  been  understood  that  generating  a
periodontal-like tissue around implants is possible and is the
coming  future  in  the  field  of  implant  logy.  This
revolutionary  approach  to  develop  periodontal-integrated
implants;  however,  opens  up  exciting  possibilities  for  both
periodontologists  and  oral  implantologists  and  offers  many
interesting  possibilities  of  utilizing  ready-made,  off-the-
shelf  biological  tooth  replacements  that  could  be  delivered
to serve as hybrid-material-living oral implants to patients.

FINANCIAL SUPPORT AND SPONSORSHIP

Nil

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ISSN No: 2582-0559

CONFLICTS OF INTEREST

There are no conflicts of interest.

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