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1. BONE LOSS &
PATTERNS OF
BONE
DESTRUCTION

2. 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

3. Introduction
 Periodontitis
 Bone loss  past pathologic experience
Bone
formation Bone
resorption

4. Receptors on chief cells of PTH
Release of PTH
Release calcium
Osteogenic substrates
BONE COUPLING
Osteoblasts
Monocytes
Osteoclasts
Bone
Introduction
 Blood calcium

5. 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)

6. 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.

7. Causes of bone destruction

8. 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)

9. Bone destruction caused by extension of gingival inflammation
 Spread of inflammation
Gingiva
Blood vessels, collagen fibres
Alveolar bone
Marrow spaces

10. Bone destruction caused by extension of gingival inflammation
 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)

11. Bone destruction caused by extension of gingival inflammation
 Pathways of spread of inflammation
A B
A – Interproximally
B – Facially& lingually

12. Bone destruction caused by extension of gingival inflammation
 Radius of action
 Garant and Cho 1979
 Page and Schroeder 1982 (based on Waerhaug’s
experiments 1980)
1.5 – 2.5 mm
 Tal H 1984 – human patients

13. Bone destruction caused by extension of gingival inflammation
 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

14. Bone destruction caused by extension of gingival inflammation
 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

15. Gingival tissue
Release or
activation of
soluble mediators
Bacterial plaque
Soluble factor(s)
Alveolar bone
Bone
progenitor
cell
Osteoclast
3
1 2
4
5
Bone destruction caused by extension of gingival inflammation
 Potential pathways for interaction between factors
in plaque and alveolar bone resulting in alveolar bone loss
Hausmann E 1974

16. Bone destruction caused by extension of gingival inflammation
 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

17. 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)

18. The systemic regulatory influence upon the respo
alveolar bone is termed
BONE DESTRUCTION CAUSED BY SYSTEMIC DISORDERS
 Bone factor concept (Glickman I 1951)
nse of
the “bone factor” in periodontal
disease.
Local factors
Systemic factors

19. 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

20. 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.

21. Factors determining bone
destruction in periodontal
disease
 Normal variation in alveolar bone

22. Interdental
septa
Alveolar
plates
Root & root
trunk anatomy
Root position
Teeth
alignment
Root
proximity
Factors determining bone destruction in periodontal disease

23. Factors determining bone destruction in periodontal disease
 Exostoses
 Nery EB 1977 – palatal exostoses (40%)
 Buttressing bone formation (Lipping)
 Food impaction

24. 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)

25. Bone destruction patterns in periodontal disease
I. Goldman HM, Cohen DW (1958)
Suprabony defect
Intrabony defect
• One-wall
• Two-wall
• Three-walls
• Combined

26. Bone destruction patterns in periodontal disease
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

27. Bone destruction patterns in periodontal disease
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

28. Bone destruction patterns in periodontal disease
IV. Grant DA, Stern IB, Listgarten MA (1988)
defects
A. Vestibular, lingual or palatal
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:
1. Class I or incipient
2. Class II or partial
3. Class III or through and through

29. Bone destruction patterns in periodontal disease
V. Papapanou NP, Tonetti MS (2000)

30. Bone destruction patterns in periodontal disease
 Horizontal bone loss
 Vertical or angular defects

31. Bone destruction patterns in periodontal disease
 Vertical or angular defects (Nielsen JI 1980)
 Prevalence rate: 60% of persons
 Commonly seen involving interproximal surfaces

32. Bone destruction patterns in periodontal disease
Three – wall defect
 Sarati et al (1968), Larato DC (1970) – posterior segment

33. Bone destruction patterns in periodontal disease
Two – wall defect
 Crater-like – most common
 Non-crater – like

34. Bone destruction patterns in periodontal disease
One – wall defect
 Hemiseptal defect

35. Bone destruction patterns in periodontal disease
Combined defect

36. Bone destruction patterns in periodontal disease
 Osseous craters
Interproximal crater
with heavy ledges.
Pre-op & post-op.

37. Bone destruction patterns in periodontal disease
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)

38. Bone destruction patterns in periodontal disease
 Trench
 Moat
 Ramp
 Plane

39. Bone destruction patterns in periodontal disease
 Bulbous bone contours
Pre-operative buccal
view
Pre-operative
occlusal view
Post-operative
buccal view

40. Bone destruction patterns in periodontal disease
 Ledges
Blunted interdental
septa with bone
ledges
Small crater with
heavy ledges
Hemisepta with
heavy ledges

41. Bone destruction patterns in periodontal disease
 Reversed architecture
Positive Flat Negative
Negative
architecture

42. Bone destruction patterns in periodontal disease
 Fenestrations and dehiscences
Dehiscence
Fenestrations

43. Bone destruction patterns in periodontal disease
 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

44. Bone destruction patterns in periodontal disease
 Classification by Glickman (1953)
Grade I Grade II
Grade III Grade IV

45. 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

46. Conclusion
Alveolar bone destruction
Characteristic sign of periodontal disease
Main cause of tooth loss

47. 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.

48. References
 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.