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Periodontal Osseous Defects: a Review 1Bharath Chandra GNR, 2KL Vandana

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Periodontal Osseous Defects: a Review 1Bharath Chandra GNR, 2KL Vandana CODSJOD Bharath Chandra GNR, KL Vandana 10.5005/jp-journals-10063-0028 REVIEW ARTICLE Periodontal Osseous Defects: A Review 1Bharath Chandra GNR, 2KL Vandana ABSTRACT The bone loss in periodontal disease occurs at local Periodontitis is an inflammatory process affecting the perio- sites, but it is regulated by both systemic and local factors. dontal tissues caused by multi-factorial origin. Among all the Bone resorption is probably the most critical factor in peri- characteristic signs of periodontal disease, loss of support from odontal attachment loss leading to eventual tooth loss.2 alveolar boneis the one which usually represents theanatomical Radiographically it is diagnosed by evidence of "bone sequela to the progression of periodontitis apically.The bone loss which is induced by periodontitis occur either single or in loss" around the tooth. Normally the crest of alveolar different combination forms. The identification of these osseous bone is situated between 0.4 to 1.97 mm approximately defects on surgical exposure of bone is clinically challenging apically to the cemento-enamel junction (CEJ) of thatpar- as the osseous and it becomes imperative for a clinician to ticular tooth.3 understand these defects and categorize them well to have The bone loss which is induced by periodontitis i.e better therapeutic approaches. Intimate knowledge of all these periodontal osseous defects associated with periodontal osseous defects occur either single or in different combi- disease is essential. So this review is aimed at classification nation forms. The identification of these osseous defects and deep insight which will be helpful for proper diagnosis and on surgical bone exposure is clinically challenging as the treatment of periodontal osseous defects. osseous surgeries are based on this diagnosis. It becomes Keywords: Alveolar process, Bone resorption, Periodontitis. imperative for a clinician to understand these defects How to cite this article: Chandra GNRB, Vandana KL. and categorize them well to have better periodontic Periodontal Osseous Defects: A Review. CODS J Dent therapeutic approaches. 2017;9(1):22-29. Periodontal osseous defects (POD) is an important Source of support: Nil clinical reality, however, it’s classification and description Conflict of interest: None are not being dealt in regular universally accepted text books. Hence, an attempt is made in this review paper to revisit, modify and describe various aspects of POD INTRODUCTION for the first time in literature. Periodontium is composed of both soft and hard tissues in which alveolar bone is the part which forms and also Incidence and Prevalence supports the teeth in both maxilla and mandible. Alveolar The changes which are observed in the alveolar process bone formation occurs as the eruption of tooth takes place architecture may differ in form, distribution and degree in order to facilitate the osseous attachments to the peri- within same individual at different sites as well as odontal ligament and disappears once the tooth is lost.1 between individuals. Alveolar bone has its embryological origin from the The prevalence of vertical defect was higher in male initial condensation of ecto-mesenchyme around the patients (14.95%) when compared to female patients (8.2%) early tooth germ. The alveolar process house the teeth and also it was rare in patients with dental awareness and exist as long as teeth are present in it. The sharpey’s (de Toledo et al 2012).4 Vertical defects are commonly fibres are embedded in the alveolar bone proper which is associated with posterior teeth (Baljoon et al.),5 with the the compact bone, compromised of oral and buccal corti- higher prevalence in mandibular posterior teeth (33.8%) 1 cal plates and the cancellous bone located between them. (Vrotsos et al., Kasaj et al.).6,7 Vertical defects are commonly associated with molars with higher prevalence of crater formation (26.5%), 1Senior Lecturer, 2Senior Professor followed by circumferential defects (23.4%) and 3 wall 1Department of Periodontics, Panineeya Mahavidyalaya Institute defects (20.08%) (Wu et al.).8 of Dental Sciences, Hyderabad, Telangana, India 2Department of Periodontics, College of Dental Sciences, Osseous Defects Davangere, Karnataka, India Corresponding Author: KL Vandana, Senior Professor, Definition: Osseous defects are defined as the alterations in Department of Periodontics, College of Dental Sciences, the morphology of the alveolar bone (GPT). These occur Davangere, Karnataka, India, Phone: +919448393364, e-mail: normally (anatomic variations) and disease induced. [email protected] As these defects act a crucial role either in initiating or 22 CODSJOD Periodontal Osseous Defects: A Review progressing the disease, alveolar architecture influences Fenestrations the occurrence of disease induced defects. Various classi- The areas in which the root is devoid or denuded of fications for osseous defects are Goldman and Cohen,9 supporting alveolar bone and the surface of the root is Pritchard,10 classification by Clarke,11 Papapanou and covered by periosteum of bone, overlying gingiva and in Tonetti12 proposed as shown in Table 1. these type of defects we can see the intact marginal bone Considering the short comings of the existing classi- and generally seen as isolated areas. fications on osseous defects, by this review an attempt Dehiscence: These are the areas with denuded bone where is made to propose a new classification of periodontal marginal boneis lost. They are seen often on the facial osseous defects. The newly proposed classification of bone compared to lingual and common in the anterior 13 POD by Vandana and Bharath includes the various teeth compared top osterior teeth with bilateral fre- types of POD categorized under specific heading which quency. The predisposing factors are prominent contours is clinically applicable and easy to comprehend which is of roots, malpositions, and protrusion of the root labially shown in Flow Chart 1. combined with covering of thin bony plate (Fig. 2). Nomenclature of Periodontal Osseous Defects of These defects are considered to be important as they the Alveolar Process can play a role in changing or even complicating the outcome of periodontal surgery.2 They can occur either Developmental Osseous Defects or Abberations in the maxilla or mandible with varied distribution as The Bulbous Bone Contours: The enlargements in bone described earlier in which fenestrations are more com- monly show prevanlencein the maxilla approximately which are caused because of exostoses, buttressing bone 74.679% while dehiscences are mostly seen in the man- formation and sometimesas an adaptation to function14 dible approximately 71.613%.16 (Fig 1). Of all the affected teeth fenestrations are more The Exostoses: Exostoses are out growths of varied shape prevalent in the posterior maxilla regions approximately and size in the bone which can also occur as sharp ridges, 49.036% and dehiscences are more prevalent in the nodules either large or small, projections which may be anterior mandibular region approximately 15.631%. The appeared as spikes, or in any one of these combinations.15 most often affected teeth by fenestration are the maxil- Fenestrations and Dehiscence: These can be developmental lary first molar (42.62%), mandibular first molar (16.02%) or due to diseases. and maxillary first premolar (14.42%) and the most often Flow Chart 1: The modified classification of periodontal osseous defects (POD) by Vandana and Bharath13 COD Journal of Dentistry, January-June 2017;9(1):22-29 23 Bharath Chandra GNR, KL Vandana Table 1: Various classifications of osseous defects Goldman and Cohen9 B. Vertical defects 1. Three osseous walls. l Three walls A. Proximal, buccal and lingual walls l Two walls B. Buccal, mesial and distal walls l One wall c. Lingual, mesial and distal walls l Combination with a different number of walls at the various 2. Two osseous walls levels of the defects. A. Buccal and lingual (crater) walls C. Furcation Defects B. Buccal and proximal walls l Class I or incipient C. Lingual and proximal walls l Class II or partial l 3. One osseous wall Class III or through and through. A. Proximal wall Note: This classification is relatively better conceptualised, how- B. Buccal wall ever, still lacks the necessary systematic approach. The disease C. Lingual wall induced marginal bone architecture such as positive architecture, negative architecture, and flat architecture are missing. The no- 4. Combination menclature such as crater and hemisepta are not included. A. Three walls plus two walls B. Three walls plus two walls plus one wall Perio2000: Classifications are generally based upon specific mor- phological criteria and are aimed at guiding clinicians with their Note: This classification concentrates only on disease induced os- seous defects which don’t include furcation defects. Developmen- diagnosis, treatment and prognosis. A first level of classification tal defects are not included. differentiates between suprabony defects, infrabony defects, and 12 Pritchard 196510 has classified those osseous defects caused by interradicular or furcation defects. periodontal disease as interproximal craters, Inconsistent margins, Hemisepta, Furca invasions, Intrabony defects (infrabony defects with three osseous walls), and combinations of those defects. These absorptive lesions may also be complicated by anatomic aberrations of the alveolar process, i.e. thick marginal ledges, exotoses, and tori. Additional anatomic aberrations
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