Alveolar bone

Alveolar bone
Copyright ©2021 Periowiki.com
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JAW BONE
(I) Alveolar
bone /alveolar
process
(II) Basal bone

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Chugh et al: Quantitative assessment of interradicular bone density in the maxilla and mandible:
implications in clinical orthodontics. Progress in Orthodontics 2013 14:38.

The alveolar process is the portion of the
maxilla and mandible that forms and supports
the tooth sockets (alveoli).
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Alveolar process –
-forms when the tooth erupts.
-disappears gradually after the tooth is lost.
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Alveolar process function –
-To provide osseous attachment to the
forming periodontal ligament.
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The alveolar process consists of :-
1) External plate of cortical bone
2) Alveolar bone proper
3) Cancellous trabeculae

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(I) Alveolar process
1) External plate of cortical bone :-
i) Formed by – i) haversian bone and
ii) compacted bone lamellae
ii) Most of the facial and lingual portions
of the sockets are formed by compact
bone alone.

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Outer and inner
cortical plates

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2) Alveolar bone proper :-
i) inner socket wall of thin, compact bone
ii) Has haversian system (0steons)
iii) Seen as lamina dura in radiographs
iv) Histologically, it contains a series of openings (cribri
form plate) through which neurovascular bundles link the
periodontal ligament with the central component of the
alveolar bone, the cancellous bone.

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3) Cancellous trabeculae:-
i) present between these two compact layers
ii) act as supporting alveolar bone.
iii) The interdental septum consists of cancellous supporting
bone enclosed within a compact border.
iv) Cancellous bone surrounds the lamina dura in apical,
apicolingual and interradicular areas.
v) more cancellous bone exists in the maxilla than in the
mandible Copyright ©2021 Periowiki.com

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Cancellous
trabeculae

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Bone cells

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1) Osteoblast-
Bone cells
i) Lays down bone matrix that is nonmineralized
osteoid.
ii) While new osteoid is being deposited, the older
osteoid located below the surface becomes
mineralized as the mineralization front advances.

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2) Osteocytes -
i) are enclosed within spaces called lacunae
ii) extend processes into canaliculi that radiate from the
lacunae
iii) canaliculi form an anastomosing system through the
intercellular matrix of the bone, which brings oxygen
and nutrients to the osteocytes through the blood and
removes metabolic waste products.

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Huang, X., Xie, M., Xie,Y. et al.The roles of osteocytes in alveolar bone destruction in
periodontitis. JTransl Med 18, 479 (2020).

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3) Osteoclasts -
i) Osteoclasts originate from hematopoietic
tissue.
ii) Are formed by the fusion of mononuclear cells of
asynchronous populations.

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Osteoclasts when
active
Osteoclasts possess
elaborately
developed ruffled
border
Osteoclast - ruffled
border secretes
hydrolytic enzymes
Osteoclast –
Hydrolytic enzymes
digest organic
portion of the bone
3) Osteoclasts
Osteoclasts activity and morphology
of the ruffled border - can be modified
and regulated by - parathormone
(indirectly) and calcitonin.
Osteoclast membrane has receptors
for these hormones.

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(I) Alveolar process 3) Osteoclasts
Resorptive process (Ten Cate) -:
1. Osteoclasts attachment to the mineralized bone surface.
2.This creates sealed acidic environment through action of the
proton pump
3. Resulting in bone demineralization.
4.Thus, exposing the organic matrix and degradation of amino
acids by the released acid phosphatase and cathepsine.
5. Sequestering of mineral ions and aminoacids within the
osteoclast

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Bone consists of :-
Inorganic matter
Organic matrix

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(I) Alveolar process Bone consists of :-
Inorganic matter –
-Consists of 2/3 rd of bone .
- Minerals present are – calcium, phosphate, along with
hydroxyl, carbonate, citrate and
trace amounts of other ions 44 such
as sodium, magnesium and fluorine.
- Mineral salts - hydroxyapatite crystals of ultramicroscopic
size and constitute approximately two thirds
of the bone structure.

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(I) Alveolar process Bone consists of :-
Organic matrix –
-Consists of 1/3 rd of bone .
- Collagen type I - 90%
- Noncollagenous proteins – present in small amounts
such as -:
Osteocalcin,
Osteonectin,
Bone morphogenetic protein,
Phosphoproteins, and
Proteoglycans

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(I) Alveolar process Development
Osteoblasts Produce
Matrix
vesicles
Contain
Alkaline
phosphatase
Jump
starts
Hydroxyapetite
crystal
nucleation
Grow and
develop to form
coalescing bone
nodules
fast-growing
nonoriented
collagen fibers
give rise
to :-
Substructure of
woven bone
Later through bone
deposition, remodeling and
secretion of oriented
collagen fibers in sheets
mature lamellar
bone

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Mature lamellar bone
1)The hydroxyapatite crystals are generally aligned with
their long axes parallel to the collagen fibers
2 )Appear to be deposited on and within the collagen fibers
in mature lamellar bone.
3) In this fashion, bone matrix is able to withstand the heavy
mechanical stresses applied to it during function.
Development

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The alveolar bone develops around each tooth follicle
during odontogenesis.
When a deciduous tooth is shed, its alveolar bone is
resorbed.
The succedaneous permanent tooth moves into place,
developing its own alveolar bone from its own dental
follicle.
(I) Alveolar process Development

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Bone tissue remodeling and renewal
Alveolar bone tissue is constantly changing in its internal
organization, yet it retains approximately the same form
from childhood through adult life.
Osteoblasts bone deposition is balanced by osteoclast bone
resorption during tissue remodeling and renewal.
A major pathway of bony changes in shape, resistance to
forces, repair of wounds, and calcium and phosphate
homeostasis in the body.

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Local influences
• Functional
requirements
on the tooth
• Age related
changes in bone
cells.
Systemic
influences
• Parathyroid
hormone
• Calcitonin
• Vitamin D3

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Part I Blood
calcium
decrease
is mediated by
receptors on the
chief cells of the
parathyroid glands
PTH stimulates
osteoblasts to
release interleukin 1
and 6
Leukemia inhibiting factor
(LIF), secreted by
osteoblasts, coalesce
monocytes into
multinucleated
osteoclasts
which stimulates
monocytes to
migrate into the
bone area
which resorb bone,
releasing calcium ions
from hydroxyapatite into
the blood, normalizing
calcium blood level

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Part II
Feedback
mechanism
Normal blood
calcium levels turns
off the parathyroid
gland secretion of
PTH
Osteoclasts
resorb organic
matrix and
hydroxyapatite
The collagen
breakdown from
the organic matrix
releases various
osteogenic
substrates
Osteogenic
substrates covalently
bound to collagen,
which stimulates
osteoblasts
differentiation
Ultimate
bone
deposition

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Manifested in the following three areas of alveolar bone :-
Adjacent to PDL
Periosteum of facial
and lingual plates
Endosteal surface of
the marrow spaces

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Socket wall :- consists of dense lamellated
bone, arranged in -
Bundle bone haversian
systems

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Socket wall :-
-Bundle bone :
. Characterized by thin lamellae
arranged in layers parallel to the
root, with intervening
appositional lines.
. Localized within alveolar bone
proper.
. Present adjacent to Periodontal
ligament contains greater number
of sharpey’s fibers.
PL - periodontal ligament.
B1 – darkly stained lamellar
bone
B2 - Bundle bone
Numerous white lines in B2
– are Sharpey’s fibers.

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(I) Alveolar process Bone marrow
Red bone marrow
-Contains hematopoietic tissue
- Embryo and newborn
- With increasing age, undergoes a physiologic change to
the fatty or yellow inactive type of marrow.
- accompanied by resorption of bony trabeculae

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(I) Alveolar process Bone marrow
Red bone marrow foci examples:-
Maxillary
tuberosity
Maxillary
premolar &
molar areas
Mandibular
premolar &
molar areas
Mandibular
symphysis
Ramus angle

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(I) Alveolar process Periosteum
Covers the outer bone surface
Outer layer - rich in blood vessels and nerves and
composed of collagen fibers and fibroblasts
Bundles of periosteal collagen fibers penetrate the
bone, binding the periosteum to the bone.
Inner layer - composed of osteoblasts surrounded
by osteoprogenitor cells, which have the potential
to differentiate into osteoblasts

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(I) Alveolar process Endosteum
Lines the internal bone
cavities
Composed of a single layer
of osteoblasts and
sometimes a small amount
of connective tissue.

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(I) Alveolar process Periosteum & Endosteum

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Interdental
septum
Bordered by socket
wall cribriform plates
of approximating
teeth
Consists of
Cancellous
bone
Bordered by
facial and
lingual
cortical plates

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Maxillary molars
66.6% cases -
cribriform
plate and
cancellous bone
20.8% cases –
cribriform plate
only
mandibular
second premolars
and first molars
85% cases -
cribriform plate
and cancellous
bone.
15% cases –
cribriform plate
alone
Interdental septum

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(I) Alveolar process Interdental septum
Boneless "window" between adjoining close
roots of molars.

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The distance between the crest of the alveolar bone and
the cementoenamel junction -:
• In young adults
0.75 and 1.49mm (average
1.08mm)
• Distance increases with age
• However, this phenomenon may
not be as much a function of age as
of periodontal disease.
2.81mm

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The mesiodistal and faciolingual dimensions and shape of
the interdental septum are governed by:-
-Tooth size
- Convexity of the crowns of the two approximating teeth.
- Position of the teeth in the jaw
- Degree of tooth eruption.

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(I) Alveolar process Osseous topography
1) Bony contour - conforms to the root prominence.
- show intervening vertical depressions
tapering towards the margin.
2) Facial and lingual bony plates – height and thickness are
affected by :-
i) teeth alignment
ii) root to bone angulation
iii) occlusal forces

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3) In case of teeth in labial version –
labial bone margins are :- i) thinned to knife edge
ii) accentuated arc form in the direction of apex
iii) located farther apically compared to the teeth
in alignment.
4) In case of teeth in lingual version –
Facial bony plate
- thicker than normal
Facial bone margins
-Blunt
-Rounded
-Horizontal rather than arcuate

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• bone margin is
located farther
apically on the
roots
3) Acute angle
between Root
to palatal
bone
• There is thickening
of cervical portion
of facial alveolar
plate.
4) As a
reinforcement
against
occlusal forces

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1)Isolated areas of root is
denuded of bone
2) Intact Marginal bone
3) Root covered with :-
-Periosteum
- overlying gingiva
4) Denuded areas
extend through the
marginal bone.
Dehiscences
Fenestration

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5) 20% of cases, frequently bilateral , often facial bone
commonly on anterior teeth.
6) Micorscopic finding – lacunar resorption at the margins
7) Predisposing factors –
i) prominent root contours,
ii) malposition,
iii) labial protrusion of the root combined with thin bony
plate
(I) Alveolar process Fenestrations and Dehiscences

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(II) Basal bone
1) Portion of the jaw located apically but unrelated to the teeth
2)As the tooth root forms and the surrounding tissues develop
and mature, alveolar bone merges with the separately
developing basal bone and the two become one continuous
structure.
3)Although alveolar bone and basal bone have different
intermediate origins, both are ultimately derived from neural
crest ectomesenchyme

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4) Mandibular basal bone begins mineralization at the exit
of the mental nerve from the mental foramen,
5) Maxillary basal bone begins mineralization at the exit of
the infraorbital nerve from the infraorbital foramen.
(II) Basal bone

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Physiologic Migration of theTeeth
With time and wear, the proximal contact areas of the teeth
are flattened and the teeth tend to move mesially.
This is referred to as physiologic mesial migration.
By age 40, it results in a reduction of about 0.5 cm in the
length of the dental arch from the midline to the third
molars.

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Physiologic Migration of theTeeth
Alveolar bone is reconstructed in compliance with the
physiologic mesial migration of the teeth.
Bone resorption is increased in areas of pressure along the
mesial surfaces of the teeth, and new layers of bundle bone
are formed in areas of tension on the distal surfaces.

What are the various mechanisms of
bone resorption in periodontitis?
Ans-
 Lipopolysaccharide (LPS) induced disease leads to the
initiation of a local host response in gingival tissues that
involves recruitment of inflammatory cells, generation of
prostanoids and cytokines, elaboration of lytic enzymes,
and activation of osteoclasts.
 Specifically, LPS increases osteoblastic expression of
RANKL, IL-1, PGE2, andTNF-α, each of which is known to
induce osteoclastic activity, viability, and differentiation
(M. A.Taubman et al 2005; P. Mark Bartold ,T. E. van Dyke 2013; E. J.
Ohlrich, M. P. Cullinan, G. J. Seymour 2009).
Copyright ©2021 Periowiki.com 56

Ans-
 A variety of immune associated cell populations are responsible for the
pathogenic processes in periodontal tissues, including specific CD4+ T cells,
recruited monocytes, macrophages, and fibroblasts.
 These produce cytokines (TNF-α, IL-1 β, etc.) within the lesion, which can be
monitored and detected in the circulating GCF.
 In turn, these cytokines are pivotal to the destructive cascade and ultimately
trigger the production of MMPs, prostaglandins, and osteoclasts.

Ans-
 Th1-type T lymphocytes, B cell macrophages, and neutrophils promote bone loss
through upregulated production of proinflammatory mediators and activation of
the RANK-L expression pathways.
 The end result is irreversible damage to the tooth supporting soft tissues and
alveolar bone (J.-L. Saffar, J.-J. Lasfargues, and M. Cherruau 1993; A. Holmlund,
L. Hänström, and U. H. Lerner 2004; J. L. Ebersole et al 2013).

Mikihito Kajiya, Gabriela Giro, Martin A. Taubman, Xiaozhe Han, Marcia P.A. Mayer and Toshihisa Kawai. Role of
periodontal pathogenic bacteria in RANKL-mediated bone destruction in periodontal disease. Journal of Oral Microbiology
2010, 2: 5532 - DOI: 10.3402/jom.v2i0.5532

Mikihito Kajiya, Gabriela Giro, Martin A. Taubman, Xiaozhe Han, Marcia P.A. Mayer and Toshihisa Kawai. Role of
periodontal pathogenic bacteria in RANKL-mediated bone destruction in periodontal disease. Journal of Oral
Microbiology 2010, 2: 5532 - DOI: 10.3402/jom.v2i0.5532

Mikihito Kajiya, Gabriela Giro, Martin A. Taubman, Xiaozhe Han, Marcia P.A. Mayer and Toshihisa Kawai. Role of periodontal
pathogenic bacteria in RANKL-mediated bone destruction in periodontal disease. Journal of Oral Microbiology 2010, 2: 5532 -
DOI: 10.3402/jom.v2i0.5532
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Mikihito Kajiya, Gabriela Giro, Martin A. Taubman, Xiaozhe Han, Marcia P.A. Mayer and Toshihisa Kawai. Role of periodontal
pathogenic bacteria in RANKL-mediated bone destruction in periodontal disease. Journal of Oral Microbiology 2010, 2: 5532 -
DOI: 10.3402/jom.v2i0.5532
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ALVEOLAR BONE DESTRUCTION IN
PERIODONTITIS
 Many years ago, researchers discovered significantly
enhanced RANKL content, along with downregulated
OPG levels, in alveolar bone in periodontitis (Liu D, Xu JK,
Figliomeni L, Huang L, Pavlos NJ, Rogers M, et al. 2003).
 As the RANKL/OPG ratio increases, the quantity of
osteoclasts increases accordingly, and the bone
resorption area expands (Boyce BF, Xing L 2008).
 For a long time, it was thought that, T/B cells were the
primary sources of RANKL in periodontitis (Kanzaki H et al
2016; KawaiT et al 2006).

PERIODONTITIS
 However, recent evidence has proven that osteocytes
produce a large proportion of RANKL during bone
remodeling in periodontitis (Nakashima T et al 2011; Xiong J et al
2011)
 Induction of periodontitis stimulated a seven-fold
increase in RANKL expression in murine osteocytes,
consistent with the increased osteoclast number and
bone resorption (Pacios S et al 2015).
 Through the utilization of transgenic model mice,
scholars have observed the unique activity of osteocyte-
produced RANKL in periodontitis bone resorption (Graves
DT et al 2018).

PERIODONTITIS
How osteocytes bring about alveolar bone
destruction in periodontitis?
Ans-
I. The altered secretory function of osteocytes in
periodontitis.
II. Potential effect of premature osteocyte senescence on
bone remodeling in periodontitis.
III. Osteocyte apoptosis in periodontitis.

I. The altered secretory function
of osteocytes in periodontitis.

Osteocytes generate more sclerostin and Dickkopf-related protein 1 (DKK1)
in periodontitis

 Dickkopf-related protein 1 (DKK1) is a type of endogenous secretory protein mainly
produced by osteocytes.
 Both sclerostin and DKK1 can negatively mediate osteoblastogenesis and
osteoblastic activity by interrupting Wnt/β-catenin signaling, and they compete with
WNT proteins for binding to the extracellular regions of low-density lipoprotein
receptor-related protein-5/6 (LRP5/6) on osteoblasts (Li X et al 2005;Tan X et al 2018).
 DKK1 also has a catabolic function and decreases the expression of OPG by inhibiting
the Wnt/β-catenin signaling pathway, leading to an increased local ratio of
RANKL/OPG in osteocytes, which increase osteoclastogenesis and osteoclast activity
and promotes bone absorption (Wijenayaka AR et al 2011; Tian X et al 2011; Hesse E
et al 2019; Goes P et al 2019).
 DKK1 can enhance the sclerostin expression induced byTNF-α in osteocytes to inhibit
osteoblast activity and impair bone formation (Heiland GR et al 2010).

II. Potential effect of premature osteocyte
senescence on bone remodeling in periodontitis

III. Osteocyte apoptosis in periodontitis

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Many factors determine the degree of alveolar bone resorption as well as
maxillary sinus pneumatisation, such as:-
1) prosthetic rehabilitation,
2) tooth loss,
3) muscular activity,
4) age,
5) gender,
6) metabolic disease
Ulm et al 1995
GretheJonasson , IngmarieSkoglund, MarianneRythén. The rise and fall of the alveolar
process: Dependency of teeth and metabolic aspects. Archives of oral biology
2018;96:195-200.

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The alveolar bone has a unique capacity to follow a tooth’s spontaneous
and orthodontic movements.
The mandibular alveolar process has the skeleton’s fastest bone
metabolism.
Early detection of osteoporosis and fracture risk is possible in
the mandible.
Mandibular bone morphology can predict osteoporotic (not mandibular)
fractures.
Maintaining mandibular teeth is important.
GretheJonasson , IngmarieSkoglund, MarianneRythén. The rise and fall of the alveolar
process:Dependency of teeth and metabolic aspects. Archives of oral biology
2018;96:195-200.

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Alberto Monje, Hsun‐Liang Chan, Pablo Galindo‐Moreno, Basel Elnayef, Fernando Suarez‐Lopez
del Amo, Feng Wang, Hom‐Lay Wang. Alveolar Bone Architecture: A Systematic Review and
Meta‐Analysis. J Periodontol 2015;86(11):1231-1248.
What is the need for evaluating alveolar bone micro-
architecture and its modifiers?
Because there is a need for studying bone characteristics systematically for a better
understanding of :-
planning (i.e., timing of placement and loading) and
outcomes of implant therapy.

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Alberto Monje, Hsun‐Liang Chan, Pablo Galindo‐Moreno, Basel Elnayef, Fernando Suarez‐Lopez
del Amo, Feng Wang, Hom‐Lay Wang. Alveolar Bone Architecture: A Systematic Review and
Meta‐Analysis. J Periodontol 2015;86(11):1231-1248.
Results:
A total of 800 articles were initially identified.
After abstract/full‐text review, 24 articles were included in the systematic review,
of which 23 were also included in the quantitative analysis.
Weighted mean (WM) of total bone volume (TBV) was 0.365 (95% confidence
interval = 0.278 to 0.452), higher in the maxillary/mandibular anterior sites than the
maxillary/mandibular posterior sites.
However, great variations existed within each anatomic location.
Additionally,WMTBV was lower in atrophic sites than non‐atrophic sites.
TBV was correlated negatively with trabecular spacing (R2 = 0.11).
Conclusions:
Systematic review suggests that the TBV might not be different between the
defined anatomic locations.
However, the atrophy status might influenceTBV.

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Clinical relevance of assessing trabeculation pattern in the dental profession
• Indicates a need to exercise
prudence when drilling for
implants because of increased
heating and consequently
increased risk of local necrosis
(Friberg B, JemtT, Lekholm U.1991)
Dense
trabeculation
• A periapical radiograph revealing
sparse trabeculation may indicate
a need for cortical fixation and
long duration of the healing
process before the implant can be
loaded (Friberg B, EkestubbeA,
Mellstrom D, Sennerby L. 2001).
Sparse
trabeculation

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A different
tissue reaction
could be
expected when
teeth are
moved with
sparse or dense
trabeculation.
This could be
supported by the
findings that rats
with lower initial
bone density have a
faster orthodontic
tooth movement
than rats with
significantly higher
initial bone density
(BridgesT, King G,
MohammadA 1988)
Orthodontic
tooth movement
is faster in
lactating rats on
a calcium-
deficient diet
than in rats on a
normal diet (Goldie
RS, KingGJ 1984)
In Adult orthodontics

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Dense trabeculation implies that extraction and surgical extirpation of
wisdom teeth are more complicated and probably more difficult to
obtain full anesthesia.
Grethe Jonasson, Marianne Rythén. Alveolar bone loss in osteoporosis: a loaded and
cellular affair? Clinical, Cosmetic and Investigational Dentistry 2016:8.

Alveolar bone loss in Osteoporosis
Grethe Jonasson, Marianne Rythén. Alveolar bone loss in osteoporosis: a loaded and cellular affair? Clinical,
Cosmetic and Investigational Dentistry 2016:8.

Measurements of compact bone in the
mandible for assessment of osteoporosis
Dual X-ray absorptiometry method, which is the gold standard for
diagnosis of osteoporosis, has low radiation, but for the jawbones, it is
only applicable in edentulous individuals, and therefore other
methods have been developed (Grethe Jonasson, Marianne Rythén 2016)
Maxillary bone consists mostly of trabecular bone, and compact bone
is too thin for use as an osteoporosis indicator. Maxillary trabecular
bone has been assessed but not as frequently as the mandible due to
the difficulty of finding astandard site (Lindh C, Obrant K, Petersson A.
2004; Southard KA, SouthardTE 1994).

 The largest proportion of mandibular compact bone is
situated in the inferior cortex, which is well imaged on
panoramic radiographs.
 The mandibular cortical index (MCI) is the most
frequently used method in osteoporosis studies (Klemetti E,
Kolmakov S, Kroger H 1994;White SC,Taguchi A, Kao D, et al 2005).

mandibular cortical index
(MCI-1)
• normal cortex
• having a relatively even
endosteal margin
(MCI-2)
• moderately eroded
cortex (MCI-2) with
semilunar defects
(MCI-3)
• severely eroded cortex
(MCI-3) with heavy
endosteal porosities.
• The severely eroded
inner cortex in MCI-3
creates difficulties
when measuring cortex
thickness.
• Therefore, a computer-
based method has been
developed
Compact bone lying distal to the mental foramen is categorized by three groups

Grethe Jonasson, Marianne Rythén. Alveolar bone loss in osteoporosis: a loaded and cellular
affair? Clinical, Cosmetic and Investigational Dentistry 2016:8.

 A severely eroded compacta is associated with osteoporosis
(Bollen AM 2000; Okabe S, Morimoto Y, Ansai T, et al. 2008) but not consistently
with fracture (Jonasson G et al 2013;AnsaiT, et al. 2008).
 Compact bone loss is seen ~20 years later than trabecular bone
loss, which can be seen in females as young as 38 years old
(Jonasson G et al 2013; Jonasson G et al 2011).
 The thickness of the basal compacta increases up to the age of 50
years and decreases significantly thereafter (Jonasson G et al 2013).
 A cortex thickness <3 mm is associated with osteoporosis (Devlin H,
Allen PD, Graham J, et al 2007; Okabe S, Morimoto Y, Ansai T, et al.2008) but not
fracture (Jonasson G et al 2013; Okabe S, MorimotoY, Ansai T, et al. 2008).

Measurements of trabecular bone in the
Grethe Jonasson, Marianne
Rythén. Alveolar bone loss in
osteoporosis: a loaded and
cellular affair? Clinical,
Cosmetic and Investigational
Dentistry 2016:8.

How is trabecular bone structure assessed
radiographically?
Answer - by
 The thickness of the trabeculae,
 The spacing between trabeculae,
 trabecular connectivity (White SC, Rudolph DJ 1999; Verheij JG, Geraets
WG, van der Stelt PF, et al.2009).
 Measuring trabecular volume by computed tomography
and magnetic resonance.

What is the three step visual index used for?
Ans:
 It was initially meant for bone evaluation before implant
treatment (Lindh C, Petersson A, Rohlin M. 1996) but the index has
been proven a valuable indicator for osteoporosis risk
(Lindh C, Horner K, Jonasson G, et al. 2008; Jonasson G, Jonasson L, Kiliaridis S 2007)
and for fracture risk assessment (Hassani-Nejad A, Ahlqwist M,
Hakeberg M, Jonasson G. 2013).

How does the three step visual index assess trabecular pattern?
Ans-
 Index classifies the mandibular premolar bone, which is the standard
site, as having either sparse, mixed dense plus sparse, or dense
trabecular bone.
 Sparse trabeculation has large intertrabecular spaces in most of the
alveolar processes, especially in the crestal, dentate, and premolar area.
Dense trabeculation has small inter-trabecular spaces and well-
mineralized trabeculae in the entire radiographed area.
 Mixed dense plus sparse trabeculation is mostly dense crestally and
sparse apically.

How does the three step visual index assess trabecular
pattern?
Ans-
 In case of uncertainty, the mixed category is chosen. Most important
is identifying individuals with sparse trabeculation because of their
high fracture risk.
 Dense trabeculation is protective.
 Most individuals have mixed dense and sparse trabeculation in the
mandible; BMD varies greatly in this trabeculation group and
fracture risk is moderate.
 The older the participants, the better the fracture prediction
(Jonasson G et al 2011; Jonasson G et al 2013).

How does the three step visual index assess trabecular
pattern?
Ans-
Grethe Jonasson, Marianne Rythén. Alveolar bone loss in osteoporosis: a loaded and cellular affair?
Clinical, Cosmetic and Investigational Dentistry 2016:8.

90
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Friberg B, Ekestubbe A, Mellstrom D, Sennerby L. Branemark implants
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