Alveolar Bone in health and disease

1. P R E S E N T E D B Y
D R . S H E E M A
1 S T Y E A R P G
1
Alveolar bone in health and
diseases
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2. Contents
2
 Introduction and development
 Molecular biology of
development
 Alveolar bone
 Structure and composition
 Cells
 Matrix
 Remodeling
 Resorption
 Osteoimmunology
 Bone destruction caused by
gingival inflammation
 Radius of action
 Lipopolysaccharides mediated
bone destruction
 Effect of Prostaglandins on
bone
 Trauma from occlusion
 Bone in periodontitis
 Bone loss patterns
 Therapeutic approaches to
treat pathological bone loss
 Bone graft materials
 Guided bone regeneration
 Conclusion
 References
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3. Introduction and development
3
 Endochondral ossification
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4. 4
 Intramembranous ossification
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5. Sutural bone formation
5
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6. Molecular biology
6
 TGF-β
 Reddi et.al – BMPS
 Differentiation
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7. Alveolar bone
7
“ Alveolar process is defined as the part of the maxilla and
mandible that form and support the tooth socket”
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8. Structure of the alveolar bone
8
 Alveolar bone proper
 Supporting alveolar bone
 Cortical plates
 Spongy bone
 Interdental septum
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9. Periosteum and endosteum
9
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10. Fenestration and Dehiscences
10
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11. Composition
11
 Osteoblasts
 Osteocytes
 Osteoclasts
 Matrix components
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12. Osteoblasts
12
 Mesenchymal origin – Scherft JP, Groot CG 1990
 Organic matrix – type I collegen
 Actin, myosin and cytoskeleton proteins
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13. Formation
13
 Pluripotent stromal cells – Inducible osteoprogentior cells
(IOPC’s)
 BMP’s + growth factors – determined osteoprogenitor cells
(DOPC’s)
 Mature osteoblasts
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14. Function
14
 Bone formation
 Type I and V collagen
 Ground substances
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15. Stimulus of various substances
15
 Parathyroid hormone
 Vitamin D3
 Growth hormones
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16. Osteocytes
16
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17. Osteoclasts
17
 Greek word – bone and broke
 Howship’s lacunae
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18. Formation
18
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19. Matrix
19
 Organic matrix -35% of dry weight
 Inorganic matrix - 60-70% of dry weight
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20. Matrix
20
 Collagen :
 Type I > 95%
 Type V 5 %
 Type III and type XII – (Lukinmaa 1992)
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21. Non collagenous proteins
21
 Osteocalcin:
 Also know as bone gla protein
 Regulates mineral maturation of bone
 Calcium binding protein
 Regulated by Vit D3 and PTH
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22. Osteopontin and bone sailoprotein
22
 BSP – mineralizing tissues
 Osteopontin – generalized distribution
 Vit D3 – up regulates Osteopontin, suppress BSP
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23. Osteonectin / SPARC
23
 25%
 Calcium binding glycoprotein
 Regulates cell adhesion
 Proliferation & modulation of cytokines
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24. Proteoglycans
24
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25. Bone Remodeling
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25

26. 26
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27. Factors effecting Remodeling
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27
 PTH
 Calciton
 Vit D3
 Cytokines
 Platelet – derived growth factor
 IGF
 FGF
 Androgen
 Estrogen
 Progesterone
 Insulin

28. Bone resorption
28
 Tencates 1994 – sequence of events in resorption process
 IL-I
 IL-6
 TNF α
 CSF
 Prostaglandins
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29. Stimulators Inhibitors
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 IL 1
 IL 6
 TNF α
 PTH
 Vit D3
 M-CSF
 RANK
 RANKL
 OPG
 Estrogen
 Androgen
 Calciton
 INF gamma
29
Mediators and inhibitors of bone resorption

30. Alveolar bone in diseases
30
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31. Osteoimmunology
31
 Relation between immune system and bone metabolism –
osteoimmunology
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32. Macrophage colony stimulating factor
32
 M-CSF – Osteoclasts development and activation
 Produced – Osteoblasts
 Osteoclstogenesis
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33. RANK and RANKL
33
 RANK- Receptor Activator for Nuclear factor Kappa B
 RANKL - Receptor Activator for Nuclear factor Kappa B Ligand
 RANK + RANKL = osteoclasts formation
 RANKL upregulated by TNF α and IL-1 (Lopes.J 2009)
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34. RANK and RANKL
34
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35. RANK and RANKL
35
 Elevated expression in inflamed periodontal tissue – Cochran DL
2008
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36. Osteoprotegerin (OPG)
36
 Natural inhibitor of RANKL
 Blocks RANK + RANKL
 OPG produced by PDL cells, gingival fibroblasts and epithelial
cells (Kanzaki 2002)
 Reduced OPG adjunct to granulation tissue (Crotti 2003)
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37. RANKL and OPG ratio
37
 Increased ratio in inflamed tissues
 Increased RANKL
 Decreased OPG
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38. Bone destruction caused by gingival inflammation
38
 Gingival inflammation extends along the collagen fiber bundles
and follow the course of the blood vessels through the loosely
arranged tissue around them into the alveolar bone – Hansen ER
1966
 Bone destruction in periodontal disease is not a process of bone
necrosis – Kronfeld 1935
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39. Path of inflammation
39
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40. Radius of action
40
 Garant and Cho 1979 –factor may need to present closely
 Page and Schroder 1982 – 1.5-2.5mm
 Large defects greatly exceeding 2.5 mm from tooth – presences
of bacteria in tissue – Sagelie R 1983
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41. Rate of bone loss
41
 Loe et.al 1986 – study in Sri lankan tea labors
 Bone loss 0.2mm on facial and 0.3mm for proximal surface per
year
 8% rapid bone loss – 0.1-1.0mm
 81% moderate bone loss – 0.05-0.5
 11% minimal bone loss – 0.05-0.09
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42. Lipopolysaccahrides mediated bone destruction
42
 LPS – initiation of host response
 Recruitment of immuno-inflammatory cells and activation of
Osteoclasts – Genco CA 2004
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43. Effect of Prostaglandins
43
 PG bone loss associated with periodontitis – Zubery et al 1998
 NSAID’s less bone loss – Willams RL 1985
 NSAID’s reduces development of gingivitis and alveolar bone
loss – Howell 1993
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44. Trauma from occlusion
44
 Trauma in absence of inflammation
 Trauma combined with inflammation
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45. 9/16/2016
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 Glickman’s concept(1965)
 The pathway of the spread of a plaque-associated gingival lesion can be
changed if forces of an abnormal magnitude are acting on teeth
harboring subgingival plaque
 Waerhaug’s concept(1979)
 Angular bony defects & infrabony pockets occur equally at periodontal
sites of teeth which are not affected by TFO

46. Bone loss in periodontitis
46
 Chronic periodontitis
 Aggressive periodontitis
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47. Bone in Diabetes
47
 Diabetes decreases gene expression of osteoblasts – Bouillon
1991
 AGE’s inhibits osteoblast differentiation – Mc Carthy et al 2001
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48. Bone destruction patterns
48
 Horizontal bone loss
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49. 49
 Vertical or angular bone defects
 Lindhe 1982 – vertical defects increases with age
 Glickman 1961- 3 wall defect, mesial lower molars
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50. 50
Goldman and Cohen 1958
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51. Osseous craters
51
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52. Bulbous bone contour
52
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53. Reverse bone architecture and ledges
53
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54. Exostoses
54
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55. Trench
55
 Loss of alveolar bone and a portion of supporting alveolar bone
in two or three surface of tooth
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56. Moat
56
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57. Ramp
57
 Loss of alveolar bone and supporting bone, but margins
being at different levels
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58. Furcation involvement
58
 Larato 1970 – mandibular 1st molar most common maxillary pre
molars least common
 No. furcation involvement increases with age
 Tal H 1984 – high prevalence in upper molars
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59. Classification
59
 Irving Glickman 1953
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60. 60
 Hamp, Nyman & Lindhe`s Classification (1975)
 Horizontal destruction of supporting bone
Class I, II, III
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61. 61
 Tarnow and Fletcher(1984)
 Grade A – Vertical loss of 1 – 3mm
 Grade B – Vertical loss of 4 – 6 mm
 Grade C – Vertical Loss of 7 + mm
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62. Bone loss after flap surgery
62
 2mm of flap reflection – 0.5mm bone loss
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63. Bone around implant
63
•Osseointegration
•Osseoperception from bone
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64. Therapeutic approaches to treat pathological bone loss
64
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65. 65
 NSAID’s
 Bisphosphonates
 TNF α antagonists
 Interleukin antagonists
 RANK / RANKL interaction inhibitors (DENOSUMAB –
monoclonal antibody)
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66. Bone grafts
66
 Auto grafts
 Allografts
 Xenografts
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67. Guided bone regeneration
67
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68. Conclusion
68
 In healthy bone processes are coupled by complex interplay of
osteoblasts and osteoclasts along with local and systemic
biochemical, as well as biomechanical factors. Knowledge of
bone loss and its causes associated with periodontal disease gives
us insight for successful treatment
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69. References
69
 Carranza 10th edition
 Orbans – Text book of oral histology 12th edition
 Lindhe 5th edition
 Connective tissue of periodontium – Mark Bartold, Sampath narayana
 Molecular and cellular biology of alveolar bone. Jaro and McKee.
Perio2000; 24; 2000; 99-126.
 The extracellular matrix of periodontium. Angelo Mariotti, Perio
2000:3,1993;39-63
 Mechanism and control of pathologic bone loss in periodontitis, Mark
Bartold Perio 2000: 53, 2010, 55-69
 Mechanism of alveolar bone destruction in periodontitis. Schwartz,
perio 2000:14,1997, 158-172
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