Bone Loss

BONE LOSS AND PATTERNS OF BONE
LOSS
Presented By : Hetvi Mehta

Guided by : Dr. Kunal Sir
CONTENTS
Introduction.
Bone Destruction Caused By The Extension Of Gingival

Inflammation.
Bone Destruction Caused By Trauma From Occlusion.
Bone Destruction Caused By Systemic Disorders.
Factors Determining Bone Morphology In Periodontal Diseases.
Bone Destruction Patterns.

INTRODUCTION
The bone that forms and supports
the tooth is called alveolar process.
The height and density of alveolar

bone is normally maintained by
equilibrium.
Regulated by local and systemic

factors between bone formation
and resorption.
When resorption exceeds

formation both height and density
are reduced.
CAUSES OF BONE DESTRUCTION ON
PERIODONTAL DISEASES
Extension of gingival inflammation
Trauma from occlusion
Systemic disorders
EXTENSION OF GINGIVAL INFLAMMATION
 Most Common Cause
 Due to extension of inflammation from marginal gingiva

to supporting periodontal tissues.
 “Periodontitis is always preceded by gingivitis but not all

gingivitis progress to periodontitis”
 The transition from gingivitis to periodontitis is associated

with changes in composition of bacterial plaque
Histopathology
 Gingival inflammation extends along the collagen fiber
bundles
 Follows the course of the blood vessels through the loosely
arranged tissues around them into the alveolar bone
Pathway Of Spread Of Inflammation
Gingival Inflammation
Marrow spaces
Replaced by leukocytes and fluid exudates, new blood vessels

and proliferating fibroblasts
Increase in osteoclasts and mononuclear cells
Thinning of bone trabeculae and enlargement of the marrow spaces
Destruction of the bone and reduction in bone height
Replacement of fatty bone marrow with the fibrous type

(around the resorption areas)
Radius Of Action
 Bone resorption factors may need to be present in the
proximity of the bone surface to exert their action
 Range of effectiveness is 1.5-2.5 mm within bacterial

plaque can induce loss of bone
 Beyond 2.5 mm there is no effect
 Inteproximally angular defect can appear

only in spaces that are wider than 2.5mm
Rate Of Bone Loss
Study of Sri lanka : by Loe et al (1986)
Rate of bone loss :
 Facial surfaces : average about 0.2mm/year
 Proximal surfaces : average about 0.3mm/year

Periods Of Destruction
 Periodontal destructions occurs in an episodic,
intermittent manner with periods of inactivity that
alternate with destructive period.
 Results in loss of collagen and alveolar bone and the

deepening of periodontal pocket.
 Periods of destructive activity are associated with

subgingival ulceration and acute inflammatory reaction
that results in the rapid loss of alveolar bone.
Mechanisms Of Bone Destruction
DIFFERENTIATION OF
BONE PROGENITOR
CELLLS INTO
OSTEOCLAST
BACTERIA
BONE INHIBITION OF
L OSTEOBLASTS
DESTRUCTIO
N HOST
MEDIATED
RELEASE PGE2 , IL-1α ,
IL-β , TNF-α
BONE DESTRUCTION CAUSED BY TRAUMA
FROM OCCLUSION
 Can occur in presence or absence of inflammation
 In absence of inflammation, the changes caused by TFO vary from

increased compression and tension of the periodontal ligament
and increased osteoclasis of alveolar bone to necrosis of
periodontal ligament and bone and resorption of bone and tooth
structure.
 These changes are
reversible once the
offending forces are
removed.
 Persistent TFO results in

funnel shaped widening
of PDL with resorption of
bone.
When it is combined with inflammation, trauma from occlusion
aggrevates bone destruction caused by inflammation and
results in Bizarre bone patterns.
BONE DESTRUCTION CAUSED BY SYSTEMIC
DISORDERS
 Possible relationship between periodontal bone loss and
systemic disorders
 Osteoporosis : loss of bone mineral content and structural

bone changes. Risk factors – ageing, smoking, etc.
 Osteopenia : tooth mobility and tooth loss
 Hyperparathyroidism
 Leukopenia
FACTORS DETERMING BONE MORPHOLOGY IN
PERIODONTAL DISEASE
1. NORMAL VARIATION OF ALVEOLAR BONE :
 Thickness, width, crestal angulations of interdental septa

 Thickness of the facial and lingual alveolar plate
 Presence of fenestrations and dehiscences
 Alignment of teeth
 Root and root trunk anatomy
 Root position within alveolar process
 Proximity within another tooth surface
2. EXOSTOSES
 Exostoses are overgrowths of bone of varied size and shape
 Palatal exostoses – 40% of human skull
 They can occur as small nodules, sharp ridges, spike-like
projections or any combination of these
 Exostoses reported in rare cases as depending after the
placement of free gingival grafts
Buccal exostosis along upper left alveolar ridge

3. BUTTRESSING BONE FORMATION
 Bone formation occurs in an attempt to buttress bony

trabeculae weakened by resorption
 When it occurs :
- within the jaw, it is termed central buttressing bone
formation
-on external surface, it is referred to as peripheral buttressing
bone formation
4. FOOD IMPACTION
Interdental bone defects occur where proximal contact is
abnormal or absent. In such areas food impaction results in
inverted bone architecture
5. AGGRESSIVE PERIODONTITIS
Aggressive periodontitis usually results in attachment and bone
loss around incisors and first molars
Vertical or angular bone defects – first molars
BONE DESTRUCTION PATTERNS IN
PERIODONTAL DISEASE
1. HORIZONTAL BONE LOSS
 The most common pattern of
bone loss
 Bone is reduced in height, but

the bone margin remains
approximately perpendicular to
the surface
 Interdental septa , facial and

lingual cortical plates are affected
2. Vertical / Angular Bone Loss :
Occur in 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
Vertical bone defect in relation to lower first molar

3. OSSEOUS CRATERS
 Concavities in the crest of interdental bone confined within
facio-lingual walls
Reasons :
 Plaque accumulation and difficulty to clean
 Normal concavity in lower molars
 Vascular patterns from gingival to crest, a pathway for
inflammation
4. BULBOUS BONE CONTOUR
Bony enlargements
Caused by exostosis, adaptation to function or buttressing

bone formation.
Found more frequently in maxilla.

5. REVERSED ARCHITECTURE
 Produced by loss of interdental bone, facial and lingual
plates without concomitant loss of radicular bone
 May occur in necrotizing ulcerative periodontitis
 Maxilla more affected than mandible

6. LEDGES
Plateau-like bony margins

Caused by resorption of thickened bony plates
6. FURCATION INVOLVEMENT
Involvement of bifurcations or trifurcations of
multirooted teeth by periodontal disease
SITE – most common in mandibular molars, least

common in maxillary premolar.
CLASSIFICATION : GLICKMAN’S (1953)
GRADE 1 : incipient bone loss
Suprabony pocket involving the soft tissue
GRADE 2 : partial bone loss (cul-de-sac)

Bone destroyed in one or more surfaces of furcation, parts of PDL and
alveolar bone remains intact
GRADE 3 : total bone loss

With through and through opening of furcation, facial or lingual or both
of furcations cannot be seen because of soft tissue coverage
GRADE 4 : grade 3 + gingival recession

Exposing the furcation to view
CONCLUSION
Although periodontitis is an infectious disease of
the gingival tissue, changes that occur in bone are
crucial because destruction of bone is responsible
for bone loss
Bone loss patterns associated with periodontal

disease is varied and the type of management
depends upon the type of loss

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BONE LOSS AND PATTERNS OF BONE

Presented By : Hetvi Mehta

Bone Destruction Caused By The Extension Of Gingival

Bone Destruction Caused By Trauma From Occlusion.

Bone Destruction Caused By Systemic Disorders.

Factors Determining Bone Morphology In Periodontal Diseases.

Bone Destruction Patterns.

The height and density of alveolar

Regulated by local and systemic

When resorption exceeds

Extension of gingival inflammation

Trauma from occlusion

 Due to extension of inflammation from marginal gingiva

 “Periodontitis is always preceded by gingivitis but not all

 The transition from gingivitis to periodontitis is associated

Replaced by leukocytes and fluid exudates, new blood vessels

Increase in osteoclasts and mononuclear cells

Thinning of bone trabeculae and enlargement of the marrow spaces

Destruction of the bone and reduction in bone height

Replacement of fatty bone marrow with the fibrous type

 Range of effectiveness is 1.5-2.5 mm within bacterial

 Beyond 2.5 mm there is no effect

 Inteproximally angular defect can appear

Rate of bone loss :

 Facial surfaces : average about 0.2mm/year

 Proximal surfaces : average about 0.3mm/year

 Results in loss of collagen and alveolar bone and the

 Periods of destructive activity are associated with

 Can occur in presence or absence of inflammation

 In absence of inflammation, the changes caused by TFO vary from

 Persistent TFO results in

 Osteoporosis : loss of bone mineral content and structural

 Osteopenia : tooth mobility and tooth loss

1. NORMAL VARIATION OF ALVEOLAR BONE :

 Thickness, width, crestal angulations of interdental septa

Buccal exostosis along upper left alveolar ridge

 Bone formation occurs in an attempt to buttress bony

 Bone is reduced in height, but

 Interdental septa , facial and

Occur in oblique direction

Leaving a hollowed-out trough

The base of the defect is

Vertical bone defect in relation to lower first molar

Caused by exostosis, adaptation to function or buttressing

Found more frequently in maxilla.

 May occur in necrotizing ulcerative periodontitis

 Maxilla more affected than mandible

Plateau-like bony margins

SITE – most common in mandibular molars, least

GRADE 2 : partial bone loss (cul-de-sac)

GRADE 3 : total bone loss

GRADE 4 : grade 3 + gingival recession

Bone loss patterns associated with periodontal

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