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Dr. Harshavardhan Patwal
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Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

Jan 22, 2018

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Page 1: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

Dr. Harshavardhan Patwal

Page 2: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

Introduction: Periodontitis is differentiated from gingivitis

by loss of attachment accompanied by bone loss.

The alveolar bone is never stable. A continuous process of resorption and

formation occurs in the alveolar bone

Page 3: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

There is a balance between resorption and formation. But when resorption exceeds formation the bone density and height are reduced.

Bone level is an indication of the past pathologic changes.

Soft tissue changes are indicative of the present inflammatory changes.

Page 4: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

Bone loss

Gingivitis Periodontitis. Periodontitis is always preceded by gingivitis,

but not all gingivitis progresses to periodontitis.

Page 5: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal
Page 6: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

The transition from gingivitis to periodontitis – why should it happen?

1. Change in the composition of bacterial plaque- increase no of motile organisms and spirochetes and decrease in cocci.

2. Cellular composition of infiltrated connective – T cell lesion is a “contained gingivitis” lesion. When it become a lesion predominated by B cells it becomes a destructive lesion. (Seymour et al 1978,1979).

Page 7: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

3. Recurrent episodes of acute destruction over time. (Heijl et al 1976). Experimental animal study by placing silk ligature in the sulcus.

4. Host resistance- includes immunologic activity, width of the attached gingiva, degree of fibrosis, reactive fibrogenesis and osteogenesis, fibrin-fibrinolytic system.

Page 8: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

Pathway of spread of inflammation influences the “Pattern of bone destruction”.

Pathway of spread of inflammation has been studied primarily through “Histopathologic studies”.

Page 9: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

Gingival inflammation connective tissue infiltrate spreads along the blood vessels and collagen fiber bundles towards the bone.

Page 10: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

Transseptal fibers are destroyed during the spread of inflammation of towards bone.

But they are reformed at a lower level. After inflammation reaches bone it spreads

into the marrow spaces. Marrow changes- leukocyte and fluid

infiltrate, new blood vessels, osteoclastic cells increase in number and the bone surface is lined with Howship’s lacunae.

Page 11: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

In the marrow, resorption occurs inside the spaces resulting in the reduction in bone height.

Bone destruction is not a process of necrosis. It is carried out by viable cells.

The amount of infiltrate co-relates with level of bone destruction.

The distance between the apical margin of infiltrate co-relates with no of osteoclasts at the alveolar crest.

Page 12: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

Garant and Cho: reported that locally produced factors induce bone destruction.

Page and Schroeder: range of effectiveness is 1.5 to 2.5 mm- bacterial plaque can cause damage.

For angular defect to form the width of the inter-dental bone should be more than 2.5 mm (Tal 1984).

Large defects exceeding 2.5 mm may be produced by the presence of bacteria in the tissues.

Page 13: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

Loe et al 1986- untreated periodontitis in Sri Lankan tea laborers: annual rate of bone loss is 0.2 mm in the facial aspect and 0.3 mm in the inter-proximal aspect.

Loe et al identified three sub-groups of patients with periodontal disease:

8%- rapid attachment loss- annual attachment loss of 0.1 to 1mm.

Page 14: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

81% of individuals –moderate progression of periodontal disease, annual attachment loss of 0.05 to 0.5 mm.

11% of individuals- minimum or no progression of Periodontal disease, annual attachment loss of 0.05 to 0.09 mm.

Page 15: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

Chronic periodontitis is characterized by “periods of destruction and inactivity or quiescence”.

During periods of destruction- there is a loss of collagen and alveolar bone.Theories proposed for onset of destructive periods:

Subgingival ulceration and acute inflammation (Schroeder and Lindhe, 1980).

T cell to B Cell Lesion shift.(Seymour et al 1979). Increase number of unattached, motile , gram negative

pocket flora. (Newman MG, 1979). Tissue invasion by one or more of the following bacteria.

(Saglie et al 1987).

Page 16: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal
Page 17: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

Areas of bone formation: adjacent to resorption areas, and a little away – Buttressing bone formation.

Intermittent pattern of resorption is seen in periodontal disease.

The basic aim in periodontal therapy- to remove the stimulus for resorption.

Page 18: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

Changes can be produced in the presence or absence of inflammation:

In absence of inflammation: Angular bone loss pattern- as a result of an attempt by the periodontal ligament to adapt to the excessive occlusal forces.

In presence of inflammation: TFO aggravates the bone destruction caused by the periodontal disease.

Page 19: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

Local and systemic factors regulate the physiologic equilibrium of the bone.

Generalized tendency for bone resorption exists- bone loss initiated by the local inflammatory process is magnified.

This is called “Bone Factor Concept”. Proposed by Glickman (1950).

Osteoporosis, skeletal deformities (Hyperparathyroidsm, leukemia).

Page 20: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

Normal variations in alveolar bone:thickness, width, crestal angulation, thickness of the facial and lingual plates, presence of fenestration and dehiscence, alignment of the teeth, root position in the alveolar complex.

Exostoses: small nodules, large nodules, spike like projections.

Page 21: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

Trauma from occlusion. Buttressing bone formation. Food impaction. Localized aggressive periodontitis.

Page 22: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

Two broad patterns of bone loss: Horizontal and Vertical/ angular.

Horizontal bone loss: most common pattern of bone loss, bone is reduced in height and is roughly perpendicular to the root surface. The inter-dental septa and the facial and lingual plates are affected.

Page 23: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

Bone deformities / Osseous defects: Vertical or angular defects. Osseous craters. Bulbous bone contours. Reversed architecture. Ledges. Furcation involvement.

Page 24: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

Defn: those that occur in an oblique direction, leaving a hollowed out trough in the bone alongside the root; the base of the defect is located apical to the surrounding bone.

Usually associated with an intrabony pocket.

Page 25: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

Goldman and Cohen ,1958: classified the vertical defects based on the number of osseous walls present.

One wall defect/ hemiseptum. Two wall defect. Three wall defect. Combined osseous defects.

Page 26: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal
Page 27: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal
Page 28: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal
Page 29: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

Vertical defects can be seen when present; in the inter-dental area in a radiograph.

Three wall defects have been noted particularly in the mesial surfaces of upper and lower molars.

Combined osseous defects: the number of walls in the apical portion of the defect are more than in the coronal portion of the defect.

Page 30: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

Osseous craters: Defn: are concavities in the crest of the inter-

dental bone confined within the facial and lingual walls.

They constitute one third of all defects (35.2%) and two thirds (62%) of all mandibular defects.

They are twice as common in the posterior than anterior region.

Facial and the lingual plates are:Equal in height- 85% of the cases, remaining 15 % of cases – higher buccal or lingual plates.

Page 31: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

High frequency of the inter-dental craters: The inter-dental area collects plaque and is

difficult to clean. Normal flat or concave shape of the inter-

dental septum in lower molars may favor crater formation.

Vascular patterns from gingiva to center of the inter-dental crest.

Page 32: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

Bulbous bone contours: Exostoses, buttressing bone formation.Reversed architecture: Loss of inter-dental bone including the facial and

lingual plates without a concomitant loss of the radicular bone.

Ledges: Plateau like bone margins caused by resorption of

the thickened bony plates.

Page 33: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal
Page 34: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal
Page 35: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal
Page 36: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal
Page 37: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

Furcation Involvement: Defn: invasion of the bi- furcation and the

tri- furcation areas of multi-rooted teeth by periodontal disease.

Mandibular first molars are the most common sites affected.

Four gradings are there for the horizontal component.

Page 38: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

H/P: Early stage- widening of the PDL space,

cellular and inflammatory fluid exudate. Epithelial proliferation into furcation area. Extension of inflammation to the bone-

resorption of the bone and reduction of the bone height.

Page 39: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal
Page 40: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

Factors influencing furcation involvement: TFO. Root trunk length. Cervical enamel projections. Enamel pearls.

Page 41: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal

Extension of inflammation from gingiva to bone- bone loss ( periodontitis onset).

Pathway of spread influences pattern of bone loss. Influence of systemic states on locally induced

alveolar bone loss- Glickman’s bone factor concept. Bone loss patterns- horizontal and vertical. Osseous defects- vertical defects, craters etc.

Page 42: Bone loss and patterns of bone destruction- Dr Harshavardhan Patwal