bone loss patterns

BONE LOSS & PATTERNS OF BONE

DESTRUCTION

CONTENTS INTRODUCTION

CAUSES OF BONE DESTRUCTION IN PERIODONTAL DISEASE Extension of gingival inflammation Trauma from occlusion Systemic disorders

FACTORS DETERMINING BONE DESTRUCTION IN PERIODONTAL DISEASE

BONE DESTRUCTION PATTERNS IN PERIODONTAL DISEASE

LESIONS CAUSING ALVEOLAR BONE DESTRUCTION

CONCLUSION

REFERENCES

Introduction Periodontitis

Bone loss past pathologic experience

Bone formation Bone

resorption

Blood calcium

Receptors on chief cells of PTH

Release of PTH

IL-1,

IL-6

LIF

Release calcium

Osteogenic substrates

BONE COUPLING

Osteoblasts

MonocytesOsteoclasts

Bone

Introduction

RANKL,

M-CSF

Introduction

Mechanisms of bone destruction

Osteolysis (Halisteresis) (Von Recklinghausen F 1910)

Non-cellular resorption

Vascular resorption (Jaffe HL 1930)

Osteoclasis (Lacunar resorption) (McClean FC, Urist

MR 1961)

Causes of bone destruction Gottlieb & Orban 1938 “senile atrophy”

Male patient aged 67 years old.O/E: generalized class 1 gingival recession with generalized interdental bone loss. No periodontal pockets probed or tooth mobility observed.

Causes of bone destruction

Systemic disorders

Trauma from occlusion

Extension of gingival inflammation

BONE DESTRUCTION CAUSED BY EXTENSION OF GINGIVAL INFLAMMATION

Gingivitis Periodontitis

Bacterial composition (Lindhe J et al 1980)

Cellular composition (Seymour & associates 1978, 1979)

Immunologic activity (Ruben M 1981)

Bone destruction caused by extension of gingival inflammation

Spread of inflammation

Gingiva

Blood vessels, collagen fibres

Alveolar bone

Marrow spaces


Bone destruction = Bone necrosis (Kronfeld R 1935)

Amount of infiltrate correlates with the degree of bone loss

Distance from the apical border of the infiltrate correlates

with number of osteoclasts (Rowe DJ 1981, Lindhe J 1978)


Pathways of spread of inflammationA B

A – Interproximally

B – Facially& lingually


Radius of action

Garant and Cho 1979

Page and Schroeder 1982 (based on Waerhaug’s

experiments 1980)

Tal H 1984 – human patients

1.5 – 2.5 mm


Rate of bone loss (Loe & associates 1986)

~ 0.2 mm a year for facial surfaces

~ 0.3 mm a year for proximal surfaces

Rapid progression of periodontal disease

(~ 8%)CAL = 0.1 to 1mm

yearly

Moderately progressive disease

(~ 81%)CAL = 0.05 to 0.5mm

yearly

Minimal progression of periodontal disease

(~ 11%)CAL = 0.05 to 0.09mm

yearly


Periods of bone destruction

Page and Schroeder 1982 – inflammation

Seymour GJ 1979 – B-lymphocytes

Newman MG 1979 – microflora

Saglie RF 1987 – bacterial invasion + host defense

Periods of inactivity

Periods of activity

Potential pathways for interaction between factors

in plaque and alveolar bone resulting in alveolar bone loss

Gingival tissueRelease or

activation of soluble mediators

Bacterial plaqueSoluble factor(s)

Alveolar bone

Bone progenitor

cell

Osteoclast

3

1 245


Hausmann E 1974


Bone formation in periodontal disease

Retards the rate of bone loss

Newly formed osteoid more resistant to resorption than

mature bone (Irving JT 1969)

Buttressing bone formation

Affects the outcome of treatment

BONE DESTRUCTION CAUSED BY TRAUMA FROM OCCLUSION

In the absence of inflammation

When combined with inflammation

Glickman’s concept (1965, 1967)

Waerhaug’s concept (1979)

BONE DESTRUCTION CAUSED BY SYSTEMIC DISORDERS

Bone factor concept (Glickman I 1951)

The systemic regulatory influence upon the response of

alveolar bone is termed the “bone factor” in periodontal

disease.

Systemic factors

Local factors

Bone destruction caused by systemic disorders

Role of “bone factor” in determining diagnosis and

prognosis

Positive bone factor

Negative bone factor

Patient’s age

Gingival inflammation &

occlusal disharmony

Bone loss

Bone destruction caused by systemic disorders

Clinical implications

Positive bone factor in a 42-year old female with gingival inflammation and poor oral hygiene but minimal bone loss.

Negative bone factor in a 41-year old female with gingival inflammation and poor oral hygiene but severe bone loss.

Factors determining bone destruction in periodontal disease

Normal variation in alveolar bone

Interdental septa

Alveolar plates

Root & root trunk anatomy Root position

Teeth alignment

Root proximity



Exostoses

Nery EB 1977 – palatal exostoses (40%)

Buttressing bone formation (Lipping)

Food impaction

Bone destruction patterns in periodontal disease

Classification

I. Goldman HM, Cohen DW (1958)

II. Prichard JF (1965)

III. Karn KW (1983)

IV. Grant DA, Stern IB, Listgarten MA (1988)

V. Papapanou NP, Tonetti MS (2000)


I. Goldman HM, Cohen DW (1958)

Suprabony defectIntrabony defect• One-wall• Two-wall• Three-walls• Combined


II. Prichard JF (1965)

1. Thickened margin

2. Interdental crater

3. Hemiseptum

4. Infrabony defect with three osseous walls

5. Infrabony defect with two osseous walls

6. Infrabony defect with one osseous wall

7. Marginal gutter

8. Furcation involvement

9. Irregular bone margin

10. Dehiscence

11. Fenestration

12. Exostosis


III. Karn KW (1983)

1. Crater

2. Trench

3. Moat

4. Ramp

5. Plane

6. Cratered ramp

7. Ramp into crater or trench

8. Furcation invasions


IV. Grant DA, Stern IB, Listgarten MA (1988)

A. Vestibular, lingual or palatal defects associated with:

1. Normal anatomic structures • External oblique ridge • Retromolar triangle • Mylohyoid ridge • Zygomatic process

2. Exostosis and tori• Mandibular lingual tori • Buccal and posterior palatal exostosis

3. Dehiscences

4. Fenestrations

5. Reverse osseous architecture

B. Vertical defects:

1. Three walls

2. Two walls

3. One wall

4. Combination with a different number of walls at the various levels of the defect.

C. Furcation defects:

5. Class I or incipient

6. Class II or partial

7. Class III or through and through


V. Papapanou NP, Tonetti MS (2000)


Horizontal bone loss

Vertical or angular defects


Vertical or angular defects (Nielsen JI 1980)

Prevalence rate: 60% of persons

Commonly seen involving interproximal surfaces


Three – wall defect Sarati et al (1968), Larato DC (1970) – posterior segment


Two – wall defect Crater-like – most common

Non-crater – like


One – wall defect Hemiseptal defect


Combined defect


Osseous craters

Interproximal crater with heavy ledges. Pre-op & post-op.


Saari et al (1968) – most common defect

i. Vulnerability of the col (Cohen 1959)

ii. Plaque retentive

iii. Interdental bony configuration (Manson 1963)

a. Spread of inflammation (Weinmann 1941, Goldman 1957)

b. Cancellous trabeculation is more reactive (Amprino &

Marotti 1964)


Trench

Moat

Ramp

Plane


Bulbous bone contours

Pre-operative buccal view

Pre-operative occlusal view

Post-operative buccal view


Ledges

Blunted interdental septa with bone

ledges

Small crater with heavy ledges

Hemisepta with heavy ledges


Reversed architecture

Positive Flat Negative

Negative architecture


Fenestrations and dehiscences

DehiscenceFenestrations


Furcation involvement

Stage in the progress of tissue destruction

Increases with age (Larato DC 1970, 1975)

Horizontal / angular bone loss evident

Factors contributing to furcation involvement


Classification by Glickman (1953)

Grade I Grade II

Grade III Grade IV

Lesions causing alveolar bone destruction

Osteoporosis – ground glass appearance

Paget’s disease – cotton-wool appearance

Fibrous dysplasia – multilocular cystic pattern

Cherubism

Cysts & tumors – cortical thinning

Conclusion

Alveolar bone destruction

Characteristic sign of periodontal disease

Main cause of tooth loss

References Newman MG, Takei HH, Klokkevold PR, Carranza FA.

Carranza’s Clinical Periodontology. 10th edition. Saunders Company.

Glickman I. Clinical Periodontology. 4th Edition. WB Saunders

Company.

Lindhe J, Lang NP, Karring T. Clinical Periodontology and Implant

Dentistry. 5th edition. Blackwell Munksgaard.

Goldman HM, Cohen DW. Periodontal Therapy. 6th Edition. The CV

Mosby Company. 1988.

Genco RJ, Goldman HM, Cohen DW. Contemporary Periodontics.

The CV Mosby Company. 1990.

Manson JD. Bone morphology and bone loss in periodontal

disease. J Clin Periodontol 1976; 3: 14-22.

Schwtarz Z et al. Mechanisms of alveolar bone destruction in

periodontitis. Periodontology 2000 1997; 14: 158.1 72.

Goldman HM, Cohen DW. The infrabony pocket: classification

and treatment. J Periodontol 1958; 10: 272-291.

Karn KW et al. Topographic classification of deformities of the

alveolar process. J Periodontol 1984; 5: 336-340.

Papapanou NP, Tonetti MS. Diagnosis and epidemiology of

periodontal osseous lesions. Periodontol 2000 2000; 22: 8–21.

References

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bone loss patterns

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