CODSJOD

Bharath Chandra GNR, KL Vandana 10.5005/jp-journals-10063-0028

REVIEW ARTICLE

Periodontal Osseous Defects: A Review

1
Bharath 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
better therapeutic approaches. Intimate knowledge of all
The bone loss which is induced by periodontitis i.e
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%)
cal plates and the cancellous bone located between them.1 (Vrotsos et al., Kasaj et al.).6,7
Vertical defects are commonly associated with molars
with higher prevalence of crater formation (26.5%),
1
Senior Lecturer, 2Senior Professor followed by circumferential defects (23.4%) and 3 wall
1
Department of Periodontics, Panineeya Mahavidyalaya Institute defects (20.08%) (Wu et al.).8
of Dental Sciences, Hyderabad, Telangana, India
2
Department 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
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 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
POD by Vandana and Bharath13 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

3. One osseous wall l 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
10
Pritchard 1965 has classified those osseous defects caused by interradicular or furcation defects.12
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 of the alveolar process are iso-
lated areas in which the root is denuded of bone to a varying ex-
tent. If the marginal bone remains intact, such denuded areas are
called fenestrations; if such areas involve marginal bone, they are
termed dehiscences.
Note: The osseous defects are being just named without a orga-
nized structural classification

Classification by Clarke11
A. Vestibular, lingual or palatal structures or defects
l Normal anatomic structures
(a) External oblique ridge
(b) Retromolar triangle
(c) Mylohyoid ridge
(d) Zygomatic process
l Exostoses and tori
(a) Mandibular lingual tori
(b) Buccal and posterior palatal exostoses
l Dehiscence
l Fenestrations
Note: The term supra bony defect is not appropriate or misleading,
l Reverse osseous architecture i.e., no defect exists above the bone.

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Periodontal Osseous Defects: A Review

Fig. 1: Bulbous bone contours Fig. 2: Pathologic fenestration irt 11, dehiscence irt 12

affected teeth by dehiscence are the mandibular canine reversed and these type of defects are most commonly
(40.645%), mandibular first premolar (18.06%) and maxil- seen in the maxilla2 (Fig. 3).
lary canine (17.41%).16 Flat architecture: The marginal bone loss occurs in such a
Acquired Osseous Defects way that both interdenytal crest and midfacial and mid-
lingual margins remain at same level.2 Due to periodontal
Alveolar Bone formation disease, the marginal bone remains thin or thickened
The Buttressing Bone (Lipping) formation: Alveolar bone either with positive architecture, negative architecture,
formation at some instances occurs to buttress the bony and flat architecture.these marginal bone alterations
trabeculae which are weakened due to bone resorption can be restricted to either 2 to 3 teeth or whole segment/
and if it occurs within the jaw, termed as central but- quadrant may be involved.
tressing bone formation and if it occurs on the external Marginal Gutter: The shallow linear defect which is
surface of bone, termed as peripheral buttressing bone present in between the marginal alveolar bone of the
formation which usually causes bulging of the contour radical cortical plate or inter-dental alveolar bone14
of bone, termed as lipping, which at sometimes may (Figs 4 and 5).
accompany the production of osseous craters and angular Ledges : These are plateau-like margins of bone which
bone defects.17 are caused due to resorption of the thickened bone plates
Alveolar Bone loss usually the buccal\labial bone2 (Fig. 6).
Buccal and lingual/palatal Furcation Involvement: The furcation involvement usually
refers to the periodontal disease invasion of bifurcation
Marginal Defects: The Architecture is a commonly used
or trifurcation of a multirooted teeth. The most common
term in periodontics to describe gingival and/or bony
form.2 In physiologic architecture concept the bone or sites are usually the mandibular first molars and the
soft tissue form includes positive architecture in a vertical involvement of maxillary teeth increase with age.18
dimension, bucco-lingual contours devoid of exostoses,
ledges, interradicular grooves and interdental bonecrest
is always coronal to the midfacial bone.The marginal bone
shows scalloping and festooning .the buccal lingual bone
presents as tapering margin.2
Positive architecture is the marginal bone loss which
occurs in such a way that the interdental gingiva or
bone crest is coronally located tomargins of their mid-
facial or midlingual surfaces. Reverse architecture is
the marginal bone loss which occurs in such a way that
the interdental gingiva or bone crest is apically located
to themargins of their midfacial or mid-lingual levels.2
These type of defects are produced by loss of interdental
bone, including the facial and/or lingual plates without
loss of radicular bone and thus the normal architectureis Fig. 3: Reverse architecture irt 12,11,21,22

COD Journal of Dentistry, January-June 2017;9(1):22-29 25

Bharath Chandra GNR, KL Vandana

Fig. 4: Gutter irt 13 palatally Fig. 5: Mid palatally intrabony defect with palatal groove irt 22

The denuded areas of furcation involvemen may Interproximal Defects

be covered by the walls of the pocket or may be visible
Horizontal defects: Horizontal pattern of boneloss in perio-
clinically and the furcation involvement is determined
dontal disease is the most common type in which the height
by exploration with a blunt probe usually naber’s probe
of the bone is reduced with the margin of bone roughly
along with a blast of warm air simultaneously in order
remainining perpendicular to surface of tooth and the
to facilitate bettervisualization.2
facial and lingual plates, the interdental septum are also
Furcation involvement is classified as grades I to IV
based on the amount of destruction of tissues.2 In grade I affected but may not be to an equalextent around the same
lesion is seen as incipient bone loss, in grade II furcation tooth.2
lesion is seen as partial boneloss (cul-de-sac), in grade Plane: The term plane is applied if both the alveolar
III the lesion is the total bone with through-and-throug bone and supporting bone are lost approximately to the
hopening of the furcation is present and in grade IV the same extentin such a manner that the defect margins are
lesion is similar to grade III, but the lesion is with gingival located at same level.19
recession thus the furcation invovlvmentis exposed and Ramp: The term ramp is applied to deformity which
viewed clinically. results if both alveolar bone and its supporting bone
The pattern of destruction infurcation involvement are lost to the approximately same extent such that the
varies with the degree of involvement and in different margins of the defect are located at different levels.19
cases and alveolar bone loss around each root may be Vertical Bone Loss: Alveolar bone loss which occur in an
either horizontal or angular, and frequently a crater may oblique direction and leavesa hollowed out thorough in
develop in the interradicular region2 (Figs 7 and 8). the bone along the rootis called as vertical or angular

Fig. 6: Ledge irt 15 Fig. 7: Grade 2 furcation involvement of with flat marginal
architechture.

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Periodontal Osseous Defects: A Review

Fig. 8: Grade 2 furcation involvement Fig. 9: Hemiseptum irt 23 (1 wall intrabony defect)

bone loss. In these defect base is present apical to the confined within the facial and lingual bony walls. In
surrounding alveolar bone. These angular defects have this type of defect the facial/buccal and lingual/ palatal
accompanying infrabony pockets in most of the instances walls are of unequal height. Craters are also classified by
and these type of pockets usually have an angular defect the number of osseous walls (i.e., a one-, two-, or three-
underlying them. Further these angular or vertical defects walled) or combination bone defects also exist.14 These
are classified upon on presence of remaining osseous type of bone defects are frequently found about one third
walls as three wall defects which are bordered by one of all bone deformities or defects and about two thirds
tooth surface and three osseous surfaces, two wall defects of mandibular bone defects and these defects are seen
(inter dental craters) which are bordered by two tooth twice as common in posterior segments than in anterior
surfaces and two bone or osseous surfaces (one facial and segments.20
one lingual) and one wall defects which are bordered by The suggested reasons for such high prevalence of
two tooth surfaces, and bone surface (facial or oral) and inter-dental craters are as follows: (i) as these areas show
soft tissue2 (Fig. 9). increased plaque accumulation as well as are difficult to
clean; (ii) the flat or concave facio-lingual morphology of
Hemisepta the interdental septum in mandibular molars may favor
the formation of craters and the vascular patterns from
A vertical or angualar bone defect in the presence of adja-
gingiva to alveolar crest may also provide a pathway for
cent roots such that only half of theinterdental septum
extension of inflammation and formation of craters.20
is remained on one tooth is termed as hemiseptum.The
Trench and Moat: When bone loss involves either two
remaining half of an inter-dental septum forms the proxi-
or three confluent surfaces of same tooth then the term
mal surface or wall of a one walled intrabony defect.2
rench is applied and when the bone loss involves all four
The interdental septum is shared by two adjacent
surfaces of a tooth, then the term moat is applied.19
teeth. The hemisepta in relation to any tooth refines to
The periodontal treatment outcomes are assessed
the half of the septum adjacent to this specific tooth root
quantitatively based on defect angulations and depth
is lost.
defects in radiographs and there are certain classifica-
These one wall vertical defect occurring interdentally
tions of defects radiographically given by Steffensen
is called hemiseptum which can generally be seen on the
and Weber, 21 Papapanou and Wennstrom, 22 Cortel-
radiograph but sometimes vertical defects which may be
lini and Tonetti23 and Tsitoura et al.24 as shown in the
present on facial or buccal and lingual or palatal surfaces
Table 2.
are not seen on radiographs and surgical exposures are
the better way for determining the presence of defect and
also the configuration of vertical bone defects.2
Osseous Defects Model (Figs 10 and 11)
Osseous Craters: Craters are cup- or bowl-shaped alveolar To facilitate the descriptive visualization of various
defects in inter-alveolar bone with bone loss approxi- periodontal osseous defects in a mandible will serve as
mately equal on the contiguous roots or the concavities realistic demonstrable model. The true osseous defects
present in the crest of inter-dental alveolar bone and are morphology detection is possible only on surgical
COD Journal of Dentistry, January-June 2017;9(1):22-29 27
Bharath Chandra GNR, KL Vandana

Fig. 10: Osseous defects model Fig. 11: Individual osseous defects

exposure. The radiographic interpretation is often • The tooth root is always one of the walls of POD.
incomplete and the treatment protocol is decided only • Never try to name the interproximal wall as mesial
on surgical exposure.13 or distal, however address it as interproximal wall.13

How to identify, the Osseous Defects on Surgical

To which Tooth the POD belongs to?
Exposure
• The periodontal osseous defects can be expressed sep- The POD belongs to tooth where the root is exposed by
arately as interproximal and buccal\lingual\palatal pocket formation. Exception to this statement is two wall
defects so that the treatment of osseous defects can be osseous crater where in buccal and lingual osseous walls
considered individually. In any given case occurrence are present where in the roots of both adjacent teeth are
of different types of defects are common. exposed.13
• Interproximal periodontal osseous defects (IPOD) Crater: How to assess the levels of osseous walls: (Fig. 12)
• For any tooth root, the maximum number of osseous To assess if both buccal and lingual walls of a crater
walls can be present are three. are at same height or at different heights, a periodontal
• Identify the number of osseous walls in relation to probe is kept horizontally touching both the alveolar
periodontal defect of a particular tooth side. crests, if it remains in same plane, the alveolar crests are
Table 2: Radiographic classification of osseous defects at same levels and if not they are at different levels. This
simple procedure will assist in the treatment protocol of
Steffensen and Weber21 classified based on radiographic craters with osseous wall at different levels. This step
intrabony defect angle as
assists the visual examination of the clinician to confirm
a. Small angles (0–45°) the bone levels of the crater.13
b. Wide angles (45–90°). Combined defects: The apical part of combined defect will
Papapanou and Wennstrom22 classified depending on the usually have higher number of alveolar bone walls than
depth of the defect in to the total number of walls which are present coronally.
a. Degree 1–2 mm The depth of the defect: Defect depth is measured from
b. Degree 2–2.5 to 4 mm
c. Degree 3–>4.5 mm
Cortellini and Tonetti23 classified based on radiographic defect
angle in to
a. Narrow angle was defined as defect of 25° or less
b. Wide angle was defined as defect of 37° or more
Tsitoura et al.24 classified based on radiographic defect angle
into
a. Narrow defect angle–Defect angle of 22° or less
b. Intermediate defect angle–Defect angle between 22° to 36°
c. Wide defect angle–Defect angle of 36° or more
Fig. 12: How to assess crater

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Periodontal Osseous Defects: A Review

alveolar crest to the base of the defect and CEJ to base 6. Vrotsos JA, Parashis AO, Theofanatos GD, Smulow JB.
of the defect. Prevalence and distribution of bone defects in moderate
and advanced adult periodontitis. J Clin Periodontol 1999;26:
Clinical transfer of Proof of Delivery 44-48.
7. Kasaj A, Vasiliu Ch, Willershausen B. Assessment of alveolar
Periodontal osseous defects have to be interpreted as oral
bone loss and angular bony defects on panoramic radio-
buccal/facial and interproximal defects as the treatment
graphs. Eur J Med Res 2008;13:26-30.
protocol has to be extended to both of them. 8. Wu SK, Yeh HC, Chan CP. The prevalence and distribution
The physiologic architecture of the bone is responsible of bone defects in patients with moderate to advanced peri-
for contour and knife edge gingival margin and disease odontitis. Chang Gung Med J 2001;24:423-430.
induced alterations of marginal bone influences the gin- 9. Goldman HM, Cohen WD. The Infrabony Pocket; classifica-
gival morphology specially the bulbous bony contour. tion and treatment. J Periodontol 1958;29:272-291.
In case of bulbous bony contour either developmental 10. Pritchard J. The infrabony pocket classification. J Advanced
Periodontal Disease. 2nd ed. W. B. Saunders, Philadelphia.
or acquired produces gingival enlargement clinically. The
1972; 558–565.
clinician has to ascertain whether the gingival enlarge-
11. Clarke M, Bueltman K. Anatomic considerations in periodon-
ment per se by the transgingival probing method. tal surgery. J Periodontol 1971;42:610-625.
If it is gingival enlargement, the thickness will be 12. Papapanou PN, Tonetti MS. Diagnosis and epidemiology of
increased. If it is due to bony enlargement the gingival periodontal osseouslesions. Periodontol 2000;22:8-21.
enlargement remains same and the contributing factor 13. Vandana KL, Bharath Chandra GNR, Sadanand K. Classifica-
as bulbous bony contour. tion of Periodontal Osseous Defects. In: Vandana KL, editor.
Identification and nomenclature of POD is confusing. Periodontal osseous defects an Insight, 1st ed. Republic of
Maldova: Lambert academic publishers; 2017. p. 8-9.
Many a times there is no agreement amongst clinicians
14. Manson JD, Nicholson K. The distribution of bone defects in
due to inconsistencies in classification and various over-
chronic periodontitis. J Periodontol 1974;45:2:88-92.
lapping terminologies. To some extent, the present paper 15. Nery EB, Corn H, Eisenstein IL. Palatal exostoses in the molar
provides amicable solution to clinicians to comprehended region. J Periodontol 1977;48:663.
POD better.13 16. Nimigean VR, Nimigean V, Bencze MA, Dimcevici-Poesina
N, Cergan R, Moraru S. Alveolar bone dehiscences and fen-
CONCLUSION estrations: an anatomical study and review. Rom J Morphol
Periodontal osseous defects (POD) are an interesting Embryol 2009;50:391-397.
17. Glickman I, Smulow J. Buttressing bone formation in the
part in periodontal destruction which was been never
periodontium, J Periodontol 1965 Sep;36(5):365-70.
dealt to its finer aspects. A first attempt to comprehend
18. Larato DC. Some anatomical factors related to furcation
the information and to expressit is the main objective of involvements. J Periodontol 1965;46(10):608.
this review. 19. Karn KW, Shockett HP, Moffitt WC, Gray JL. Topographic clas-
sification of deformities of the alveolar process. J Periodontol
REFERENCES 1984;55:336-340.
1. Joseph P Fiorellini, David M Kim, Satoshi o Ishikawa. The 20. Saari JT, Hurt WC, Briggs NL. Periodontal bony defects on
tooth‐supporting structures. In: FA Carranza, editor. Clinical the dry skull. J Periodontol 1968;39:278.
periodontology, 10th ed. Newdelhi: Elsivier publishers; 2007. 21. Steffensen B, Weber HP. Relationship between the radio-
pp. 68-92. graphic periodontal defect angle and healing after treatment.
2. Fermin A Carranza and Henry H Takei. Bone loss and pat- J Periodontol 1989;60:248-254.
terns of bone destruction. In: FA Carranza, editor. Clinical
22. Papapanou PN, Wennstrom JL. The angular bony defect
periodontology. 10th ed. Newdelhi: Elsivier publishers; 2007.
as indicator of future alveolar bone loss. J Clin Periodontol
pp. 452-66.
1991;18:317-322.
3. Hausmann E, Allen K, Clerehugh V. What alveolar crest level
23. Cortellini P, Tonetti M. Radiographic defect angle influences
on a bite-wing radiograph represents bone loss? J Periodontal
the outcomes of GTR therapy in intrabony defects. 77th
1991;62:570-572.
4. De Toledo BE, Barroso EM, Martins AT, Zuza EP. Prevalence general Session of the IADR, Vancouver,Canada, March
of periodontal Bone Loss in Brazilian Adolescents through 1999:10-13.
interproximal radiography. Int J Dent 2012:;2012:1-5. 24. Tsitoura E, Tucker R, Suvan J, Laurell L, Cortellini P, Tonetti M.
5. Baljoon M, Natto S, Bergstorm J. Occurrence of vertical bone Baseline radiographic defect angle of the intrabony defect as a
defects in dentally aware individuals. Acta Odontol Scand prognostic indicator in regenerative periodontal surgery with
2003;61:47-51. enamel matrix derivative. J Clin Periodontol 2004;31:643-647.

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