#14 Causes of alveolar bone loss.pdf

Causes of alveolar bone loss Jafar Naghshbandini DDS, MS Diplomate of American Board of Periodontology  Special thanks whoever taught me a word make me his servant Dr. Raul caffesse Dr. Jim Simon  I. Extension of gingival inflammation...

Causes of alveolar bone loss Jafar Naghshbandini DDS, MS Diplomate of American Board of Periodontology  Special thanks whoever taught me a word make me his servant Dr. Raul caffesse Dr. Jim Simon  I. Extension of gingival inflammation II. Trauma from occlusion III. Systemic factors IV. Orthodontic treatment Causes of V. Periodontitis alveolar bone VI. Periodontal abscess VII. Food impaction loss VIII. Overhanging restoration IX. Adjacent tooth extraction X. Ill-fitting prosthesis Extension of gingival inflammation The most common cause of bone destruction in periodontal disease is extension of inflammation from the marginal gingiva into the supporting PD tissue. Periodontitis is always preceded by gingivitis, but not all gingivitis progresses to periodontitis The transition from gingivitis to periodontitis is associated with changes in composition of bacterial plaque.  Extension of gingival inflammation The most common pathway The transition from gingivitis to periodontitis is: The inflammatory invasion of bone surface and the initial bone loss. This transition is associated with changes in composition of bactrerial host and resistance of host. In advances stages of disease, the number of motile organism and spirochete increases, whereas the coccoid rods and straight rods decreases The lesion presents with most pathogenic bacteria, inflammatory cell infiltrate, lesion becoming more destructive with conversion of T- lymphocyte to B-lymphocytic lesion. Extension of gingival inflammation 1. Interproximally from gingiva into bone 2. From bone into periodontal ligament 3. From gingiva into periodontal ligament Extension of gingival inflammation 1. Facially and lingually from gingiva along the outer periosteum 2. From periosteum into bone 3. From gingiva into periodontal ligament Extension of gingival inflammation in to the marrow space 1. Gingival inflammation 2. Marrow spaces replaced by leucocytes and fluid exudates, new blood vessels and proliferating fibroblasts -Increase in osteoclasts and mononuclear cells -Thinning of bone trabeculae and enlargement of marrow spaces -Destruction of bone and reduction of bone height - Replacement of fatty bone marrow with fibrous type  Histopathology Extension of Area of inflammation occurs inflammation along blood vessels extends from gingiva and between into suprabony area collagen bundles Inflammation extending Extension of from pocket area inflammation into between collagen fibres, which are partially center of interdental destroyed septum  Histopathology Con… Inflammation from gingiva penetrates transseptal fibers and enters the bone around blood vessels in the center of septum Cortical layer at the top of septum are destroyed and inflammation penetrates into bone marrow. Re-formation of trans-septal fibers Recreated transseptal fibers above the bone margin, partially infiltrated by inflammatory process Extension of inflammation to crestal bone surface  Radius of Action 1.5 to 2.5mm within which a bacterial plaque can induce loss of bone For interproximal angular defect space have to be greater than 2.5 mm because in narrow spaces bone is entirely destroyed leading to horizontal bone defects Large defects exceeding 2.5mm can be seen in aggressive periodontitis and Pappilon-lefevre syndrome  Rate of Bone loss in individual with no oral hygiene -facial surface: 0.2mm a year -proximal surface: 0.3 mm a year Extension of gingival inflammation The most common cause of bone destruction in periodontal disease is extension of inflammation from the marginal gingiva into the supporting PD tissue. Periodontitis is always preceded by gingivitis, but not all gingivitis progresses to periodontitis The transition from gingivitis to periodontitis is associated with changes in composition of bacterial plaque.  Period of Destruction Occurs in episodic, intermittent manner with period of inactivity or quiescence Results in loss of collagen and alveolar bone resulting in deepening of periodontal pocket The reason for onset, not clarified Some theories have been put forward Period of Destruction The recurrence of episode of acute destruction over time may be one mechanism leading to progressive bone loss in marginal gingivitis. The extension of inflammation is modified by A. pathogenic potential of plaque or resistance of host B. Width of attached gingiva C. Degree of fibrosis of gingiva D. Peripheral reactive fibrogenesis and osteogenesis E. “ walling off “ by fibrin-fibrinolytic system  Normal variation in alveolar bone: The anatomic features that affect bone destructive pattern in periodontal disease includes: The anatomic The thickness, width and crestal angulation features that affect of interdental septa bone destructive The thickness of facial and lingual alveolar plates pattern in Presence of fenestrations and dehiscence periodontal disease The alignment of teeth Root and root trunk anatomy Root position within the alveolar process Proximity with another tooth surface  Osseous defects classification Glickman (1964) 1. Osseous craters 2. Hemiseptal defects 3. Infrabony defects 4. Bulbous bone contours 5. Inconsistent margins and Ledges 6. Reversed architecture (1967) Prichard expanded Glickman’s classification by including furcation involvement, anatomic aberrations of alveolar process, exostoses & tori, dehisence & fenestrations.  Classification Con…. GOLDMAN AND COHEN (1958) > Horizontal defects Supra bony pocket (Glickman’s) Infra bony pocket 1. Class I > Infra bony defect 2. Class II 1. one walled defect 3. Class III 2. two walled defect > Vertical defects (Tarnow & 3. three walled defect Fletcher) 4.combined defect 1. Sub-class A > Craters 2. Sub-class B Inter radicular defects 3. Sub-class C  Horizontal Bone Loss Most common pattern of bone loss Bone is reduced in such a way that the bone margin is approximately perpendicular to the teeth surface Interdental septa and facial and lingual plates of bone are affected, but not necessarily to an equal degree around the same tooth Horizontal Bone Loss  Vertical or Angular defects Vertical/ Angular defects occur in an oblique direction. This creates a hollowed-out trough in the bone alongside the root. The base of the defect is located apical to the surrounding bone. In most instances, angular defects have an accompanying intrabony periodontal pockets. Vertical or Angular defects Types of Angular Defects Classified based on the number of osseous walls…. (Goldman & Cohen) 1. One walled defects 2. Two walled defects 3. Three walled defects 4. Combined osseous defects Types of Angular Defects Types of Angular Defects A. Three walled defect (intrabony defect)  Three wall defect (Intra bony defect ) B. Two walled defect Two wall defect C. One walled defect (Hemiseptum) One wall defect (hemi septum) D. Combined Osseous Defect Combined defect  Vertical defects occurring interdentally can generally be seen on the radiograph. Thick bony plates sometimes may obscure them. Vertical Angular defects of facial and lingual or palatal defects surfaces are not seen on radiographs Surgical exposure is the only way to determine the presence and configuration of vertical osseous defects Surgical exposure  Vertical defects increases with age Approximately 60% of people with interdental angular defects have only single Vertical defect. Radiographically detected defects appear defects most often on the distal and mesial surfaces However, three-wall defects are more frequently found on the mesial surfaces of upper and lower molars.  Horizontal defects Vertical or angular defects BONE Osseous craters DESTRUCTION Reversed architecture PATTERNS IN PERIODONTAL Bony ledges DISEASE Furcation involvements Exostoses Bulbous bone contours Radiographic appearances of periodontal health and disease The crest of the alveolar ridge is 0.5 to 2.0 mm apical to the cemento-enamel junction. Radiographic appearances of posterior region The crest of the alveolar ridge will be flatter. When evaluating the bone level in the posterior follow these steps: 1. Identify the location of the cemento-enamel junction of two adjacent teeth 2. Imagine a line between these two points 3. Compare this line to the line of the crest of the alveolar ridge 4. Normal horizontal bone level: Both lines between the two adjacent teeth are parallel and the bone is 2.0 mm or less apical from the cemento-enamel junction 1. Identify the location of the cemento-enamel junction of two adjacent teeth. 2. Imagine a line between these two points 2. Compare this line to the line of the crest of the alveolar ridge Treatment of bone defects