Bone Destruction Patterns In Periodontal Disease

Periodontal disease alters the morphologic features of the bone in addition to reducing bone height. An understanding of the nature and pathogenesis of these alterations is essential for effective diagnosis and treatment.

Horizontal Bone Loss

Horizontal bone loss is the most common pattern ol bone loss in periodontal disease. I he bone is reduced in height, but the bone margin remains roughly perpendicular to the tooth surface. The interdental septa and facial and lingual plates are affected, but not necessarily to an equal degree around the same tooth (I ig. 23-12, A).

Bone Deformities (Osseous Defects)

Different types of bone deformities can result from periodontal disease. These usually occur in adults and have been reported in human skulls with deciduous dentitions.'0 Their presence may be suggested on radiographs, but careful probing and surgical exposure of the areas is required to determine their exact conformation and dimensions.

Vertical or Angular Defects

Vertical or angular defects are 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 (see 1 igs. 23-12, /*; 23-13; and 23-14). In most instances, angular defects have accompanying infrabony pockets; such pockets always have an underlying angular defect.

Angular defects are classified on the basis of the number of osseous walls.1 \ngular defects mas have one, two, or three walls digs. 23-15 to 23-17). The number of walls in the apical portion of the defect may be greater than that in its occlusal portion, in which case the term combined osseous defect is used d ig. 23-18).

Vertical defects occurring interdentally can generalK be seen on the radiograph, although thick, bony plates sometimes may obscure them. Angular defects can also appear on fac ial and lingual or palatal surfaces, but these defects are not seen on radiographs. Surgical exposure is the only sure way to determine the presence and configuration of vertical osseous defects.

Vertical defects increase with age.'*""" Approximate!) 60% of persons with interdental angular defects have only a single defect.48 Vertical defects detected radiographically have been reported to appear most commonly on the distal surfaces'8 and mesial surfaces. I lowever, three-wall defects are more frequently found on the mesial surfaces of upper and lower molars.

Hie three-wall vertical defect was originally called an intra bony defect.11 I'his defect appears most frequently on the mesial aspects of second and third maxillary and mandibular molars. The one-wall vertical detect is also called a hemiseptum.

* The term infrabony was later expanded to designate all vertical defects.

Hemiseptum

Fig. 23-15 One-, two-, and three-walled vertical defects on right lateral incisor. A, Three bony walls: distal (1), lingual (2), and facial (3). B, Two-wall defect: distal (1) and lingual (2). C, One wall defect: distal wall only (1).

One Wall Alveolar Bone Defect

Fig. 23-15 One-, two-, and three-walled vertical defects on right lateral incisor. A, Three bony walls: distal (1), lingual (2), and facial (3). B, Two-wall defect: distal (1) and lingual (2). C, One wall defect: distal wall only (1).

Fig. 23-13 Angular (vertical) defects of different depths. Fig. 23-14 Angular defect on the mesial surface of the first molar.

Note also the furcation involvement

Defect Angular Wall

Fig. 23-16 One-wall vertical defect on the mesial surface of the Fig. 23-17 Circumferential vertical defect in relation to the upper left lateral incisor and 1 \ -wall defect (distal wall and halt of the lateral incisor and canine, labial wall) on the distal surface ol the right lateral incisor.

Fig. 23-16 One-wall vertical defect on the mesial surface of the Fig. 23-17 Circumferential vertical defect in relation to the upper left lateral incisor and 1 \ -wall defect (distal wall and halt of the lateral incisor and canine, labial wall) on the distal surface ol the right lateral incisor.

Hone I oss iitiJ Pattern* of Pone Di stinction ■ ( I IAN I K 23 365

Osseous Craters
Fig. 23-18 Combined type of osseous defect. Because the facial wall is half the height of the distal (I) and lingual (2) walls, this is an osseous defect with three walls in its apical half and two walls in the occlusal half.

Fig. 23-19 Diagrammatic representation of an osseous crater in a faciolingual section between two lower molars. Left, Normal bone contour. Right, Osseous crater.

Crater Interdental
Fig. 23-20 A, Exostosis in the facial aspect. B, Exostosis in the palatal aspect. Note also the circumferential defect in the second molar.

Osseous Craters

Osseous craters are concavities in the crest of the interdental bone confined within the facial and lingual walls (Fig. 23-lc>). Craters have been found to make up about one third (35.2%) of all defects and about two thirds (62%) of all mandibular defects. I hex are twice as common in posterior segments as in anterior segments.42*'"

The heights of the facial and lingual crests of a crater have been found to be identical in 85% of cases, with the remaining 15% being nearlx equally divided between higher facial crests and higher lingual crests.' The following reasons for the high frequency of interdental craters have been suggested:

• The interdental area collects plaque and is difficult to clean.

• I he normal flat or even concave faciolingual shape ot the interdental septum in lower molars max favor crater formation.

• Vascular patterns from the gingiva to the center of the crest may provide a pathway for inflammation.4,MI""

Bulbous Bone Contours

Bulbous bone contours are bony enlargements i aused by exostoses, adaptation to function, or buttressing bone formation d ig. 23-20). They are found more frequently in the maxilla than in the mandible.

Reversed Architecture

Reversed architecture defects are produced by loss of interdental bone, including the facial plates, lingual plates,

Reversed Architecture
Fig. 23-21 Reversed architecture Left, Probe in the deep infrabony pocket on the mesial surface ol the maxillary premolar. Right, Elevated flap shows irregular bone margin with notching of interdental bone.
Reversed Architecture Periodontal
Fig. 23-22 Labial ledge produced by interproximal resorption.

or both, without concomitant loss of radicular bone, thereby reversing the normal architecture (Fig. 23-21). Such defects are more common in the maxilla.|M

Ledges

Ledges are plateau-like bone margins caused by resorption of thickened bony plates (Fig. 23-22

Furcation Involvements

The term furcation involvement refers to the invasion of the bifurcation and trifurcation of multirooted teclh by periodontal disease. Ihe prevalence of furcation-involved molars is not clear." '1 Whereas some reports32 indicate that the mandibular first molars are the most common sites and the maxillary premolars are the least common, others'" have found higher prevalence in upper molars. I'he number of furcation involvements increases with age.l- u

I he denudeci furcation may be visible clinically or covered by the wall of the pocket. The extent of involve ment is determined by exploration with a blunt probe, along with a simultaneous blast of warm air to facilitate visualization (Figs. 23-23 and 23-24).

Furcation involvements have been classified as grades I. II, III. and IV according to the amount of tissue destruction. Grade I is incipient bone loss, grade II is partial bone loss (cul-de-sac), and grade III is total bone loss with through-and-through opening of the furcation. Grade IV is similar to grade III, but with gingival recession exposing the furcation to view.

Microscopically, furcation involvement presents no unique pathologic features. It is simply a phase in the rootward extension of the periodontal pocket. In its early stages, a widening of the periodontal space occurs, with cellular and fluid inflammatory exudation (Fig. 23-25), followed by epithelial proliferation into the furcation area from an adjoining periodontal pocket (Fig. 23-26). Extension of the inflammation into the bone leads to resorption and reduction in bone height (Fig. 23-27). The bone destructive pattern may produce horizontal loss, or angular osseous defects associated with infrabony pockets may exist (Figs. 23-28 and 23-29). Plaque, calculus, and bacterial debris occupy the denuded furcation space.

Ffie destructive pattern in a furcation involvement varies in different cases and with the degree of involvement. Bone loss around each individual root may be horizontal or angular, and very frequently a c rater develops in the interradicular area. Probing to determine the presence of these destructive patterns must be done horizontally and vertically around each involved root and in the crater area to establish the depth of the vertical component.

Furcation involvement is a stage of progressive periodontal disease and has its same etiology. I he difficulty, and sometimes the impossibility, of controlling plaque in furcations are responsible for the presence of extensive lesions in this area. N

Hone Loss and I'at Urns of Hone Destruction ■ ( IIAPIT.K 23 367

Furcation Involvement Images

Fig. A, Partially stippled gingiva covering the furcation area of the lower first molar B, Flap eleva tion reveals furcation involvement.

Cul Sac Furcation Involvement
Fig. 23-24 A, Furcation area barely covered by gingival tissue. B, Flap elevation reveals partial lurcation involvement.
Mandibular Furcations
Fig. 23-2S Furcation area in a mandibular molar The periodontal space is widened. There is edema, slight leukocytic infiltration ot the periodontal ligament (P), and an area of resorption (R) at the margin of the bone (8)
Connective Tissue Proliferation
Fig. 23-26 Furcation area showing proliferation of epithelium (l)t edema and degeneration of connective tissue, bone loss, and destruction of cement urn (C) and dentin with irregularly hoi lowed-out lacunae along the dentinal surface (R)
Periodontal Bone Tissue Degeneration
Fig. 23-27 Furcation involvement. Maxillary first molar showing pronounced bone loss, inflammation, and epithelial proliferation (E). Bacterial debris is shown at R. Note the different height of bone between Ihe mesial surface (left) and the furcation area (arrow).
Moderate Periodontal Bone Loss
Fig. 23-28 Different degrees of furcation involvement in a human autopsy specimen. Moderate involvement is found in the third molar; a more advanced lesion in the second molar, and a very severe lesion in the first molar, exposing almost the entire mesial root.

I he role ol trauma from occlusion in the etiology of furcation lesions is controversial. Some assign a key role lo trauma, believing that furcation areas are most sensitive to injury from excessive occlusal forces.1* Others deny the initiating effect of trauma and consider that inflammation and edema caused by placjue in the furcation area lend to extrude the tooth, which then becomes traumatized and sensitive.

Trauma from occlusion has been suspected as a contributing etiologic factor in cases of furcation involve-

Gingival Crater
Fig. 23-29 Crater-like osseous defect in trifurcation of a molar.

ment with craterlike or angular deformities in the hone and especially when bone destruction is localized to one of the roots.

Other factors that may play a role are the presence of enamel projections into the furcation/' which occurs in about 13% of multirooted teeth, and the proximity of the furcation to the cementoenamel junction, which occurs in about 75% of cases of furcation involvement.1*

The presence of accessory pulpal canals in the furcation area may extend pulpal inflammation to the furcation11; this possibility should be carefully explored, particularly when mesial and distal bone retain their normal height. Accessory canals connecting the pulp chamber floor to the furcation have been found in 36% of maxillary first molars, 12% of maxillary second molars, 32% of mandibular first molars, and 24% of mandibular second molars.

The diagnosis of furcation involvement is made by clinical examination and careful probing with one of the specially designed probes (see ( hapter 30). Radiographic examination of the area is helpful, but lesions can be obscured by angulation of the beam and the radiopacity of neighboring structures (see < hapter '»I).

For more detailed clinical considerations in the diagnosis and treatment of furcation involvements, see Chapters 30 and 64.

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