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Predictive factors for alveolar fenestration and dehiscence
Accepted Manuscript Title: Predictive factors for alveolar fenestration and dehiscence Author: A-M. Grimoud V.E. Gibbon I. Ribot PII: DOI: Reference:
S0018-442X(17)30016-1 http://dx.doi.org/doi:10.1016/j.jchb.2017.03.005 JCHB 25469
To appear in: Received date: Accepted date:
15-2-2016 12-3-2017
Please cite this article as: Grimoud, A.-M., Gibbon, V.E., Ribot, I.,Predictive factors for alveolar fenestration and dehiscence, Journal of Comparative Human Biology (2017), http://dx.doi.org/10.1016/j.jchb.2017.03.005 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Predictive factors for alveolar fenestration and dehiscence A-M. Grimouda,*, V.E. Gibbonb, I. Ribotc a
Université Toulouse 3 Paul Sabatier, Faculté d’Odontologie, 3 chemin des maraîchers, 31062
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Toulouse cedex 9, France
Centre hospitalier et universitaire de Toulouse, Cité de la santé, 20-24 rue du Pont St Pierre b
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31 052 Toulouse cedex
Department of Human Biology, Faculty of Health Sciences, University of Cape Town,
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Observatory, Cape Town, South Africa
Département d'Anthropologie, Université de Montréal, CP 6128 Succursale centre-ville,
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Montréal QC H3C 3J7, Canada
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Received 15 February 2016, accepted 12 March 2017
* Corresponding author. tel.: +33 (0)5 61 77 78 32, fax: +33 (0)5 61 77 79 85
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E-mail address: [email protected] / [email protected]
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Abstract The purpose of this study was to evaluate the distribution and incidence of two forms of alveolar bone resorption known as fenestration and dehiscence across time and space. To
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accomplish this a Medieval French population was studied and the results were compared with other studies to examine incidence and distribution of alveolar bone resorption. Thus, 1175 teeth were analysed for 81 individuals, from an agropastoral Medieval (12th–14th
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century) archaeological site of Vilarnau located in the South of France. Tooth presence and absence as well as dental alveolar resorption were recorded. A new standardised
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methodological approach to record alveolar resorption is presented and can be used for any skeletonised series. Measurements of dehiscence were made in the midline on each root in
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relation to the cemento-enamel junction and fenestration was considered as resorption restricted to alveolar bone. Through analyses of the distribution and incidence of alveolar bone resorption over-time in a Medieval French population, along with nine other studies, we
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present a list of predictive factors for alveolar bone resorption. Among these factors tooth position and function were the most important; anterior teeth were more commonly affected,
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bone resorption was more common on the labial/buccal versus palatal/lingual surfaces, fenestration was also more common on the maxilla and dehiscence on the mandible (p ≤
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0.001). These patterns do not vary through time or space, and therefore, provide predictive factors for health practitioners in oral therapy to improve patient recovery and post oral
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treatment success.
Résumé
Il nous paraît intéressant, d’apporter de nouvelles informations, quant à l’incidence et à la répartition de la résorption alvéolaire, tant en Anthropologie qu’en thérapeutique dentaire. Notre étude a pour but d’évaluer la répartition et l’incidence des deux types de résorption alvéolaire, la déhiscence et la fenestration, dans une population médiévale française, et de comparer nos données à celles déjà établies par des travaux antérieurs, dans un large éventail de populations, au cours de différentes époques. Nous présentons une nouvelle approche méthodologique, standardisée et reproductible. Nous avons étudié 1175 dents appartenant à 81 individus, d’une population agropastorale médiévale (12e – 14e siècle) provenant du site archéologique de Vilarnau, dans le sud de la France. Nous avons relevé les dents présentes et absentes, ainsi que les déhiscences et les
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3 fenestrations de l’os alvéolaire maxillaire. La mesure des déhiscences a été réalisée, sur chaque racine, à partir du milieu de la ligne de jonction amélo-cémentaire, et les fenestrations correspondaient à une résorption limitée de l’os alvéolaire. Nos résultats montrent que, la répartition est symétrique, les fenestrations plus
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fréquemment présentes au niveau du maxillaire et les déhiscences au niveau de la mandibule (p ≤ 0.001) ; fenestrations et déhiscences étant plus fréquentes au niveau antérieur.
Ainsi, cette étude donne la répartition et l’incidence de la résorption de l’os alvéolaire pour
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une population médiévale et les compare aux données établies dans d’autres études, le schéma
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an
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restant sensiblement le même au cours du temps et dans l’espace des populations.
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Introduction Alveloar bone resorption is an important indicator of oral status among different types of bone lesions. We have focused our reseach on two forms: dehiscence - cortical bone resorption that denudes root surface, and fenestration - a circumscribed cortical resorption that
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does not affect the marginal edge. In both cases, the resorption is located on the labial/buccal versus palatal or lingual surfaces (Abdelmalek and Bissada, 1973; Edel, 1981; Elliot and
Bowers, 1983; Lampley, 2010; Larato, 1972; Rupprecht et al., 2001; Stahl et al., 1963; Tal,
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1983). Successful treatments in orthodontics, periodontology and implantology, require the presence of complete alveolus. Alveolar bone resorption investigation is essential when
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making treatment decisions to avoid failure (Becker et al., 1999; Fuhrmann et al., 1995; Lampley, 2010; Leung et al., 2010; Nimigean et al., 2009; Steigmann and Wang, 2006; Yagci
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et al., 2012) and to consider bone grafting before implant placement (Chiapasco and Zaniboni, 2007; Sarnachiaro et al., 2016; Veis et al., 2004). For these reasons there has been an increase in research devoted to the presence of alveolar dehiscence and fenestration (Becker et al.,
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1999; Evangelista et al., 2010; Fuhrmann et al., 1995; Yagci et al., 2012). The aim being to determine areas of the mouth most frequently affected and those that present the greatest
Steigmann and Wang, 2006).
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potential of alveolar resorption, as a complicating factor (Agarwal, 2010; Leung et al., 2010;
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Predictive factors of the alveolar bone resorption process have been investigated as the impact of maxillary alveolar bone thickness on resorption incidence (Chiapasco and Zaniboni,
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2009; Edel, 1981; Elliot and Bowers, 1983; Ghassemian et al., 2012; Jorgić-Srdjak, 1998; Temple et al., 2016) and regarding other predictive factors of alveolar resorption, such as age (Rupprecht et al., 2001; Tal, 1983), sex (Rupprecht et al., 2001), trauma via dental wear (Edel, 1981; Ezawa et al., 1987; Larato, 1970; Nimigean et al., 2009; Rupprecht et al., 2001; Stahl et al., 1963; Urbani et al., 1991), and anatomical context (Abdelmalek and Bissada, 1973; Davies et al., 1974; Nimigean et al., 2009; Stahl et al., 1963; Tal, 1983). In modern populations, risk factors also include tooth crowding and, in some cases of post orthodontic treatment, alveolar plate perforation due to the torque movement effect (Handelman, 1996). Another excellent repository of information regarding alveolar bone resorption are archaeological skeletons. However, few studies have used skeletal collections to examine bone resorption in the form of dehiscence and fenestration. With this in mind, archaeological skeletal collections enable us to observe de visu dental bone plate status (Ezawa et al., 1987; Newman, 1998; Urbani et al., 1991; Vodanović et al., 2012a,b).
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5 Due to the best visual ability to identify alveolar bone resorption, without the complication of soft tissues and radiography, analysing skeletonised jaws from past populations are an effective and simple way to record reliable information. Through an evaluation of the incidence and topographical distribution of alveolar bone dehiscence and fenestration from an
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unstudied archaeological Medieval French population, and correlated with existing published information, we aim to improve the predictive factors for alveolar bone resorption and
whether they vary through time and geographical location. Using a biocultural and population
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comparative approach we aim to improve knowledge required in contemporary oral therapy
concerning alveolar bone status. In order to accomplish this, as described by Vodanović et al.,
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(2012b) intially a new adaptation to current methods is required for standardisation to any
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skeletonised series.
Materials and methods
Adult skeletal remains were studied from the agropastoral Medieval (12th–14th century)
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French archaeological site of Vilarnau, located close to Perpignan on the Mediterranean coast in the South-West of France. Archaeological evidence suggests that subsistence at Vilarnau
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was dominated by agriculture, with the typical trio of Mediterranean regions: wheat or poorer cereals, vines and olive trees. Fruit trees, leguminous plants and pulses were grown especially
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along the banks of the river Tet. The woods favoured sheep and goat rearing and provided wood for fire. The diet was complemented by cheese and meat from livestock, poultry, cattle
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and fish. Salt was also easily obtained from the nearby coast. The excavation of the site of Vilarnau in 1996, centred around its church was supervised by O. Passarrius from the French Archaeological Preventive Research Institute (Institut de la Recherche Préventive Archéologique, INRAP) (Passarrius, 2006). The cemetery included burials of 955 individuals, 648 adults with a balanced sex ratio and 307 immature individuals, with ages at death ranging from the perinatal period to adolescence. An analysis of the sample age structure suggests life expectancy was about 30 years (Passarrius, 2006). This sample was previously studied for preservation levels (Lucas et al., 2010), dental wear quantity and direction (Grimoud et al., 2012), and also indications of oral status - caries incidence and diet - (Grimoud et al., 2011). Only adult individuals presenting a dental arch and belonging to preservation levels one and three were used, as described by Vodanović et al. (2005). By using macroscopic examination of individuals we selected only samples with perfectly smooth bone surfaces
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6 without any signs of bioerosion (Trueman, 2002) or periodontitis (Vodanović et al., 2012a). We examined 115 dental arches from 81 individuals. There were 43 maxillae with 421 teeth and 72 mandibles with 754 teeth - including 34 paired jawbones. To record the presence of dehiscence and fenestration a total of 1175 teeth embedded in alveolar sockets were studied.
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This sample was comprised of 21 females, 35 males and 25 individuals of indeterminate sex, and was divided into three age categories: 15-19 years (10 individuals), 20-30 years (16 individuals), and over 30 years (55 individuals).
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To assess our results in a broader context we compiled published data from nine additional studies that used similar recording parameters for incidence and distribution of fenestration
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and dehiscence (Table 1). The inclusion criteria of the nine selected studies were data tables with maxillary and mandibular percentages of dehiscence and fenestration from all teeth
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found in the anterior and posterior portions of the mouth (Abdelmalek and Bissada, 1973; Edel, 1981; Elliot and Bowers, 1983; Evangelista et al., 2010; Jorgić-Srdjak, 1998; Nimigean
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et al., 2009; Rupprecht et al., 2001; Urbani et al., 1991; Yagci et al., 2012).
Methods
Due to methodological variation to characterise and diagnose dehiscence and fenestration,
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including ruling out alveolar margin resorption and vertical pockets, a new suitable, reliable
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and reproducible method of diagnosis for archaeological samples is required (Vodanović et al., 2012b). We present an adaptation of the Elliot and Bowers’ (1983) method described as
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follows: (i) fenestration as a circumscribed defect in the cortical plate exposing the buccal or lingual root surface (Fig. 1A), and (ii) dehiscence as absence of alveolar cortical plate, exceeding one half of the root length and involving the alveolar margin, with alveolar septa situated at the very least 5 mm from the cemento-enamel junction (CEJ) (Fig. 1B). Thus, dehiscence affects the alveolar margin unlike fenestration. Elliott and Bowers (1983) suggest that fenestration may be a stage in the development of dehiscence. As to the minimum height chosen for dehiscence we chose greater than 5 mm relative to the CEJ, whereas others suggest 4 mm (Davies et al., 1974) or 2 mm (Tal, 1983; Urbani et al., 1991; Jorgić-Srdjak, 1998; Nimigean et al., 2009) and some use a graded scale (Abdelmalek and Bissada, 1973). This variability in diagnoses between studies made it difficult to define the initial stage of dehiscence, especially as the alveolar margin is only located from 3 to 4 mm to the CEJ. This area overlaps the physiological space from 2 mm to 4 mm from the edge of the alveolar margin to the CEJ (Ghassemian et al., 2012). It is for these reasons that a new method of dehiscence diagnosis was required (Fig. 1B, C). Taking into account the physiological space
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7 between the CEJ and alveolar crest, and not to confuse dehiscence and alveolar physiological status the distance of alveolar bone septa was set at a minimum of 5 mm from the CEJ relative to continuing eruption due to dental wear. This was used to establish an anatomical point in the middle of the CEJ to record the resorption height and if a root is denuded. The level of
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bone resorption was established by measuring from the CEJ at the mid-height of the total root length.
Care was taken to ensure that recorded defects were not produced by another external
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factor such as plaque build up evidenced by calculus, irregular margins due to postmortem
damage, increased distance between from the CEJ and the alveolar margin because of over-
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eruption due to oclusal wear process. Also we differentiate fenestration from alveolar resorption due to abscess fistulae through the alveolar bone plate and periodontitis lesions
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(Vodanović et al., 2012a). In the case of postmortem alveolar bone destruction, the edge surrounding the bone defect would not be soft but rather irregular and exposed bone tissue would be whither than the external bone surface.
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This sample was examined by Grimoud for tooth presence and both antemortem and postmortem absence, as well as, buccal and palatal vs lingual presence of fenestration and dehiscence on available teeth. The data will be presented using the four quadrants of the oral
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cavity – quadrants 1 and 2 corresponding respectively to the right and left sides of maxilla and
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3 and 4 to the left and right sides of mandible - and the 2 digit dental system of the International Dental Federation (FDI) (Grimoud et al., 2012).
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The macroscopic examination was conducted under suitable light, using a graduate dental probe to evaluate the alveolar bone height in the middle of the buccal and palatal vs lingual surface. To ensure the recording method was reliable and to improve recording precision an intra/inter observer correlation test was conducted (the correlation coefficient was considered unsuitable at r ≤ 0.90). The measurement variability was assessed on 20 jaws, the material was re-measured three times over three weeks. The accuracy of the obtained measurements was demonstrated by an insignificant level of variation. The recorded data were analysed using the SPAD software at the Toulouse anthropological center. The χ2 test was used to examine differences between maxillary and mandibular dehiscence and fenestration and it was considered significant at p ≤ 0.05.
Results
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8 Teeth presence and absence were recorded (Fig. 2). On the maxilla, 64.09% (441/688) of the teeth were present, 9.15% (63/688) were lost antemortem (AMTL), 24.70% (63/688) postmortem (PMTL) and the incisors were most commonly lost (65.51%, 111/172). On the mandible, 68.83% (770/1152) of the teeth were present, 7.19% (83/1152) were lost
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antemortem and 25.34% (282/1152) postmortem and the incisors were the most often lost (56.58%, 97/172). Overall, the maxillary and mandibular profiles of teeth present and absent in this study were similar. Given the high percentage of absent incisors for each studied
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variable we calculated the average percentage for all four teeth and each incisor was given the
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average value.
Dehiscence and fenestration
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The results for dehiscence and festration in the studied sample are presented in Figure 3 and tabulated in Table 1. For dehiscence in the maxilla and mandible, the teeth most often affected were incisors, canines and first molars, and the least were third molars and
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premolars. Similar findings were found with fenestration: the teeth most commonly affected were incisors, canines and first molars, and fenestration was least common on premolars, second and third molars. On the maxilla the pattern of fenestration and dehiscence were
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super-imposable for incisors, second left premolars and molars. The average percentage of
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maxillary teeth with fenestration (18.95%, 83/441) was greater than dehiscence (12.7%, 56/441). The anterior versus posterior region respectively on the maxilla had a higher
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percentage of dehiscence (17.64%, 22/123) versus (10%, 32/318); and fenestration (22%, 27/123) versus (16.59%, 53/318). On the mandibular teeth the average percentage of dehiscence (17.70%, 136/770) was higher than fenestration (3.5%, 27/770), and the anterior region versus the posterior respectively displayed a higher percentage of dehiscence (25.15%, 59/235) versus (13.23%, 71/535); and for fenestration (11.87%, 28/235) versus (0.80%, 4/535).
Overall, alveolar bone resorption was recorded in 99% of cases on the labial/buccal versus 1% on the palatal/lingual surface. In multiradicular teeth with alveolar resorption, the greatest presence of dehiscence was observed on the mesial root of the first maxillary molar, whose anatomical position was more buccal than the distal one. Statistical significance was found of differences between maxilla and mandible for fenestration (p ≤ 0.01), but not for dehiscence (p = 0.08). When comparing alveolar bone resorption between age groups, a slight and insignificant increase of dehiscence in individuals older than 30 years was noted.
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9 Cross-study comparison Through analysis of results across ten studies (Table 1), including ours, the following characteristics of dehiscence and fenestration were highlighted. The average range of alveolar bone resportion incidence was 12% to 29%, except for two studies, one with lower incidence
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around 3% (Abdelmalek and Bissada, 1973) and the other higher around 50% (Jorgić-Srdjak, 1998). Similar distributions of both dehiscence and fenestration were found, dehiscence most commonly affected the mandible (7/10) (Abdelmalek and Bissada, 1973; Edel, 1981; Elliot
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and Bowers, 1983; Evangelista et al., 2010; Jorgić-Srdjak, 1998; Rupprecht et al., 2001;
Urbani et al., 1991) and fenestration the maxilla (8/10) (Abdelmalek and Bissada, 1973; Edel,
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1981; Elliot and Bowers, 1983; Jorgić-Srdjak, 1998; Nimigean et al., 2009; Rupprecht et al., 2001; Urbani et al., 1991; Yagci et al., 2012). The teeth most frequently affected were the
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canines (9/10) (Abdelmalek and Bissada, 1973; Edel, 1981; Elliot and Bowers, 1983; Evangelista et al., 2010; Jorgić-Srdjak, 1998; Nimigean et al., 2009; Rupprecht et al., 2001; Urbani et al., 1991) and first molars (7/10) (Abdelmalek and Bissada, 1973; Edel, 1981; Elliot
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and Bowers, 1983; Nimigean et al., 2009; Rupprecht et al., 2001; Urbani et al., 1991). No matter the methods used (macroscopy or tomography) these studies and ours demonstrate that the anterior teeth are most affected by dehiscence and fenestration. Third molars displayed the
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lowest level of alveolar resorption (6/10) (Abdelmalek and Bissada, 1973; Edel, 1981;
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Nimigean et al., 2009; Rupprecht et al., 2001; Urbani et al., 1991). The profiles for maxillary fenestration and mandibular dehiscence on the canines and first molars were super-imposable.
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Therefore, tooth position and function appear to be the primary predictive risk factors, and fenestration can also progress to dehiscence with age.
Discussion
Through this study we established objective criteria for recording alveolar bone resorption (dehiscence and fenestration) on skeletonised jaws. Due to the availability of archaeological samples for study, having an easy and effective method to follow allows for better data comparisons in the future. This new standardised method to diagnose alveolar dehiscence and fenestration on dry maxillary bones provides a clear antomical point of reference, easy to visualise bone resorption measurement and location. It also includes physiological variation of the distance from the CEJ to alveolar bone crest. It also clearly defines the elements for differential diagnosis of fenestration and dehiscence. This newly developed method was applied to this sample from Medieval France, and the obtained results in comparison with the
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10 other studies revealed several patterns of incidence and distribution for alveolar bone resoprtion. Tooth position and function seem to be the primary predictive factors. Considering the main resorption locations at the canine and first molar, these correlate well with thin labial/buccal alveolar bone covering the roots (Elliot and Bowers, 1983; Larato, 1970; Stahl et
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al., 1963; Temple et al., 2016). Additionally, crown and root anatomy are adapted to their function during mastication. For example, over the mastication cycle, canines are highly
stressed by lateral movements of the mandible and first molars undergo heavy pressure (Van
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Beek, 1983). This pressure and stress over one’s lifetime is why there is an association with
alveolar resorption and increasing age (Stahl et al.,1963). The areas of the mouth more prone
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to alveolar bone resorption have naturally thinner bone to begin with, for example within the labial and buccal regions compared to the palatal and lingual, the anterior aspect of the tooth
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or mouth compared to the posterior.
Although the topographical distribution of fenestration and dehiscence has been analysed, by tooth position in alveolar bone and their incidence in contemporary and archaeological
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populations all over the world, (Edel, 1981; Evangelista et al., 2010; Larato, 1970; Nimigean et al., 2009; Rupprecht et al., 2001; Tal, 1983; Urbani et al., 1991; Yagci et al., 2012), most data come from non-European populations and no previous data are available from France.
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Therefore, these results present the first findings for a French population and also the only
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sample from the Late Middle Ages. In comparison with other studies, we have found several commonalities in the incidence and distribution of fenestration and dehiscence summarised
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above. Despite the differences in recording between the studies, the patterns observed do not vary much. This demonstrates that the incidence and distribution of alveolar bone resorption remains fairly constant between populations from different regions around the world and the patterns transcend time.
Our percentages were lower than those found in contemporary populations by Rupprech et al. (2001) in dry skulls of North Americans and by Evangelista et al. (2010) in Germans. This is likely due to dental crowding relative to food consistency (Kaifu et al., 2003). Thus, in accordance with other investigations in dry skulls (Abdelmalek and Bissada, 1973; Edel, 1981; Elliot and Bowers, 1983; Tal, 1983) or in the living (Evangelista et al., 2010; Yagci et al., 2012), our observation suggests that alveolar dehiscence and fenestration are a common feature in populations through time. One of the few studies on children (Larato, 1972), aged from two to five, reports that fenestration or dehiscence were observed in 12% of 176 skulls and were only located on the labial anterior region. Interestingly, this is also the most commonly affected area for historic and contemporary adults (Evangelista et al., 2010; Yagci
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11 et al., 2012), which is likely higher due to tooth crowding and orthodontics (Garib et al., 2010; Handelman, 1996; Viazis et al., 1990). With regard to the life expectancy of the sample being relatively young at 30 years’, we note that carious lesions did not affect, or very rarely affected deciduous teeth and teeth were
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not heavily worn (Grimoud et al., 2012). In a contemporary population age has been reported to affect alveolar bone resorption distribution and incidence (Ghassemian et al., 2012). Therefore, given the relatively low life expectancy in our sample, the resorption level
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recorded for this sample could differ from samples with a higher age-at-death distribution. Despite this possibility, our results do appear to correlate well with other studies with
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incidence between 12%-29%, except for two outliers, 3% (Abdelmalek and Bissada, 1973) and 50% (Jorgić-Srdjak et al., 1998). Based on these results and the fact that our findings
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correlate well with the other studies, despite being from different time periods and geographic locations, it has been suggested that the age-at-death being young in our sample did not significantly affect the outcomes.
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The torque process, used for moving teeth in orthodontic treatments, has been assessed and linked by orthodontists to iatrogenic effect i.e., a buccal anterior alveolar table perforation (Garib et al., 2010; Handelman, 1996). Relating this to the medieval period, the use of the
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incisors to cut up hard food and possibly as a tool, could cause a slight torque effect in
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relationship to the high incidence of fenestration on the anterior versus posterior bone alveolar plates. This hypothesis seems even better supported especially when knowing that there is an
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increase in fenestration where the bone thickness is reduced, as it is in the anterior area of the mouth compared with the posterior region (Temple et al., 2016). As stated previously, studying the incidence and distribution of both forms of alveolar bone resoption is vital, as they increase risk of failure of oral treatments. The results of this study on areas of the mouth and their predicative factors for being sensitive to bone resorption can be used by oral practitioners, in order to better predict the stability of alveolar bone status pre- and post-treatment (Becker et al., 1999 ; Ghassemian et al., 2012; Handelman, 1996). It would be interesting to investigate clinical cases of gingival recession and fenestration in orthodontic treatment (Viazis et al., 1990) versus those without treatment.
Acknowledgements The authors wish to acknowledge the high scientific assistance of Marjan Ghassemian
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12 and would like to express their indebtedness to, André Sevin, Olivier Passarrius, Richard Donat and Otto Graf. Also we would like to thank the reviewers for their valuable comments and suggestions. Funding: The rescue excavations of the Vilarnau site were funded by the French Ministry of Culture, the Languedoc–Roussillon region, the General Council of the
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Pyrénées - Orientales Department, the city of Perpignan, the University of Perpignan-Via Domitia and the Pyrénées-Orientales Archaeological Association.
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Jorgić-Srdjak, K., Plančak, D., Bošnjak, D., Azinović, Z., 1998. Incidence and distribution of dehiscences and fenestrations on human skulls. Coll. Antropol. 22(S), 111-116.
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Kaifu, Y., Kasai, K., Townsend, G.C., Richards, L.C., 2003. Tooth wear and the “design” of human dentition: a perspective from evolutionary medicine. Yrbk Phys. Anthropol. 46, 4761.
Lampley, J., 2010. Prevalence and distribution of facial alveolar bone fenestration in the anterior dentition: a cone beam computed tomography analysis. Thesis, University of Southern California, Los Angeles. Larato, D.C., 1970. Alveolar plate fenestration and dehiscences of human skull. Oral Surg. 29, 816-819. Larato, D.C., 1972. Alveolar plate defects in children skulls. J. Periodontol. 43, 502-503. Leung, C.C., Palomo, L., Griffith, R., Hans, M.G., 2010. Accuracy and reliability of conebeam computed tomography for measuring alveolar bone height and detecting bony dehiscences and fenestrations. Am. J. Orthod. Dentofacial Orthop. 137, 109-119.
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14 Lucas, S., Sevin, A., Passarius, O., Grimoud, A-M., 2010. Study of dental caries and periapical lesions in a Medieval population of the southwest France: visual and radiographic inspection of differences. Homo – J. Comp. Hum. Biol. 61, 359-372. Newman, H., 1998. Do not confuse the bone loss of periodontitis with root exposure to
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supereruption. Factors affecting the lifespan of the human dentition in Britain prior to the seventeenth century. Br. Dent. J. 184, 242-246.
Nimigean, V.R., Nimigean, V., Bencze, M.A., Dimcevici-Poesina, N., Cergan, R., Moraru, S.,
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2009. Alveolar bone dehiscences and fenestrations: an anatomical study and review. Rom. J. Morphol. Embryol. 50, 391-397.
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Passarrius, O., 2006. Vilarnau: Etude archéologique d’un village et d’un cimetière paroissial en Roussillon (IXe- XVe siècles). Thesis paper 06TOUR2012, Université de Tours, Tours.
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Rupprecht, R.D., Horning, G.M., Nicoll, B.K., Cohen, M.E., 2001. Prevalence of dehiscences and fenestrations in modern American skulls. J. Periodontol. 72, 722-729. Sarnachiaro, G.O., Chu, S.J., Sarnachiaro, E., Gotta, S.L., Tarnov, D.P., 2016. Immediate
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implant placement into extraction sockets with labial plate dehiscence defects: A clinical case series. Clin. Implant Dent. Relat. Res. 18, 821-829. doi: 10.1111/cid.12347.
skulls. Periodontics 1, 99-102.
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Stahl, S.S., Cantor, M., Zwig, E., 1963. Fenestration of the labial alveolar plate in human
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Steigmann, M., Wang, H.L., 2006. Esthetic buccal flap for correction of buccal fenestration defects during flapless implant surgery. J. Periodontol. 77, 517-522.
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Tal, H., 1983. Alveolar dehiscences and fenestrations in dried South African Negro mandibles. Am. J. Phys. Anthropol. 61, 173-179. Temple, K.E., Schoolfield, J., Noujeim, M.E., Huynh-Ba, G., Lasho, D.J., Mealey, B.L., 2016. A cone beam computed tomography (CBCT) study of buccal plate thickness of the maxillary and mandibular posterior dentition. Clin. Oral Impl. Res. 27, 1072-1078. Trueman, C.N., 2002. The long-term survival of bone : the role of bioeerosion. Archaeometry 44, 373-382.
Urbani, G., Lombardo, G., Filippini, P., Nocini, P.F., 1991. Dehiscence and fenestration: study of distribution and incidence in a homogeneous population model. Stomat. Medit. 11, 113-118. Van Beek, G.C., 1983. Dental Morphology: An Illustrated Guide, 2nd ed. Wright, Bristol. Veis, A.A., Tsirlis, A.T., Parisis, N.A., 2004. Effect of autogenous harvest site location on the outcome of ridge augmentation for implant dehiscences. Int. J. Periodont. Restor. Dent. 24, 155-163.
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15 Viazis, A.D., Corinaldesi, G., Abramson, M.M., 1990. Gingival recession and fenestration in orthodontic treatment. J. Clin. Orthod. 24, 633-636. Vodanović, M., Brkić, H., Šlaus, M., Žlejko, D., 2005. The frequence and distribution of caries in the mediaeval population of Bijelo Brdo in Crotia (10th-11th century). Arch. Oral
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Biol. 50, 669-680. Vodanović, M., Galić, I., Zukanović, A., Knežević, M., Novak M., Šlaus, M., Brkić, H.,
2012a. Periodontal diseases at the transition from the late antique to the early medieval
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period in Croatia. Arch. Oral Biol. 57, 1362-1376.
Vodanović, M., Galić, I., Zukanović, A., Knežević, M., Novak M., Šlaus, M., Brkić, H.,
period in Croatia. Arch. Oral Biol. 57, 401-412.
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2012b. Orthidontic anomalies and malocclusion in Late Antique and Early Mediaeval
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Yagci, A., Veli, I., Uysal, T., Ucar, F.I., Ozer, T., Enhos S., 2012. Dehiscence and fenestration in skeletal Class I, II, and III malocclusions assessed with cone-beam
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computed tomography. Angle Orthod. 82, 67-74.
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Legends for Figures Fig. 1. Observation of alveolar bone resorption: (A) fenestration on the labial plate of mandibular incisors: (1) marginal crest not affected by (2) the circumscribed resorptions;
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(B) complete dehiscence on the maxillary canine and first premolar labial/buccal plate: (1) cemento enamel junction (CEJ), (2) septa to at the most 5mm from CEJ, (3) physiological
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space from 2 to 4 mm between CEJ and alveolar crest, (4) the resorption, measured from the CEJ in the middle of the root reaches at least the half height of the total root length;
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(C) complete dehiscence on the mandibular first molar: (1) CEJ, (2) septa to at the most 5 mm from CEJ, (3) physiological space from 2 mm to 4 mm between CEJ and alveolar crest, (4) the resorption, measured from the CEJ in the middle of the root reaches at least the half height
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of the total root length.
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Fig. 2. Percentage of teeth present and absent relative to tooth number on the maxilla and mandible.
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mandible.
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Fig. 3. Percentage of dehiscence and fenestration relative to tooth number on the maxilla and
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Fig.1
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Fig 2.
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Fig 3.
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Table 1. Comparative percentages of incidence and distribution of dehiscence and fenestration according to tooth type
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Incisors Premolars Molars Canines Central lateral 1st 2d 1st 2d Number of teeth: 1175 19.8 16.2 15.9 4.1 4.5 27.9 13.4 15.8 20.2 29.0 15.5 5.9 44.3 15.5 18.1 13.9 43.5 15.6 6.9 31.1 12.6 12.8 3.1 1.8 6.7 3.3 15.1 25.3 9.5 4.3 25.7 10.3 13.4 15.8 10.6 Number of teeth : 819 3.8 1.8 3.5 1.8 1.0 7.6 2.2 36.6 12.4 5.4 5.0 14.1 8.5 4.6 12.7 5.8 4.3 6.8 2.5 7.3 5.9 4.2 9.3 11.5 9.4 8.0 5.3 2.2 5.2 6.7 10.4 6.4 4.5 14.1 4.8 7.2 6.1 Number of teeth: 467 -* 4.5 17.4 1.9 4.5 42.6 9.6 1.3 14.4 6.1 3.8 2.6 40.6 18.1 0.6 5.2 0.6 2.2 5.4 0.2 16.0 1.3 0.9 2.3 16.2 8.6 1.7 17.1 2.9 7 5.5 Number of teeth: 2176 3.4 0.9 0.9 0.9 14.7 5.0 3.5 4.3 6.9 5.2 1.8 3.5 8.0 5.5 4.0 1.8 3.3 3.3 7.9 1.9 1.7 1.7 3.4 3.4 0.6 4.8 3.4 1.3 6.7 2.5 2.2 3.5 3.5 2.8
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Our Results Dehiscence Maxilla Fenestration Dehiscence Mandible Fenestration Total defects Anterior/posterior Rupprecht et al., 2001 Dehiscence Maxilla Fenestration Dehiscence Mandible Fenestration Total defects Anterior/posterior Nimigean et al., 2009 Dehiscence Maxilla Fenestration Dehiscence Mandible Fenestration Total defects Anterior/posterior Abdelmalek & Bissada, 1983 Dehiscence Maxilla Fenestration Dehiscence Mandible Fenestration Total defects Anterior/posterior
Dental morphotypes
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Studies of dehiscence and fenestration
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Total defects 3rd 5.4 1.8
10.5 18.9 17.7 3. 5
1.5 2.3 0 0 0.9
3.1 11.1 5.7 6.2
0.6 0.1
5.9 6.1 6.0 6.0
1.0 0.7 0.7 0.6
0.8 5.3 3.8 2.7
29.4 21.2
14.2 11.9
12.0 12.0
6.1 6.5
12.1
6.9 9.9 33.4 4.4 13.6
15.3 8.2 4.8 7.1
3.6 19.4 13.2 7.9 11.0
9.2 11.7 7.5 9.5
55.4 24.7 51.8 14.7 36.6
32.5 10.2 48.2 4.8 23.9
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4.6 15.6 7.2 6.9
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10.6 5.0 3.9
2.9 5.4 29.5 16.8 13.6
8.2
4.8 6.9 17.5 9.7
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4.3 6.6 5.4
50.5 24.2 50.7 12.3 34.4
9.0 39.3 9.5 41.6 10.2 25.1 30.0
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11.2 17.3 39.7 10.2 19.6
Number of teeth: 1153 20.4 24.1 3.9 5.7 7.2 3.9 10.3 8.4 10.4 7.2 Number of teeth: 2205 16.1 6.1 35.1 1.1 14.9 4.2 1.8 17.6 6.3 Number of teeth: 990 10.3 9.7 47.3 2.9 7.5 2.9 4.4 5.2 17.4 9.0 Number of teeth: 2038 30.8 33.1 11.7 5.3 33.2 31.4 6.6 8.1 20.6 19.5 19.9
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6.7 15.5 5.3 13.0 10.1
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2.8 5.8 11.9 5.1
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Elliott & Bowers, 1983 Dehiscence Maxilla Fenestration Dehiscence Mandible Fenestration Total defects Anterior/posterior Urbani et al., 1991 Dehiscence Maxilla Fenestration Dehiscence Mandible Fenestration Total defects Anterior/posterior Edel, 1981 Dehiscence Maxilla Fenestration Dehiscence Mandible Fenestration Total defects Anterior/posterior Jorgic-Srdjak, 1998 Dehiscence Maxilla Fenestration Dehiscence Mandible Fenestration Total defects Anterior/posterior
2.6 8.3 2.5 3.7 4.3
2.5 9.6 10.6 5.7
6.1 11.2 12.7 9.8
9.1 8.3 4.3
3.7 1.7 1.3
2.9 10.5 11.7 3.2
3.0 25.6 2.1 10.2
3.8 3.0 3.4
5.6 17.1 7.7 6.5
25.7 10.4 34.6 5.3 4.0
13.4 6.2 32.7 9.7 15.5
35.1 12.8 40.5 8.9
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17.3 21 22.5
13.4 14.9
22.7 14.2
47.9 49.4
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18.7 17.9 17.1 22.3 18.0
18.4 18.0 16.5 12.4 18.9
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13.3 18.2 17.5 25.3 16.3
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9.4 10.5 24.3 21.0 16.3
17.5
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15.6 10.4 22.1 14.3 20.9
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20.9 7.6 26.9 11.8 16.7
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26.7 9.2 21.3 12.9 15.6
12.6 32.4 18.1 24.7 26.7
Number of teeth: 4319 10.4 18.2 7.4 16.2 9.2 9.9 8.9 3.9 17.6 8.9 13.7 Number of teeth: 3444 4.4 17.0 7.1 25.4 7.0 2.7 19.1 16.9 12.6 15.5 15
11.2 11.6 5.4 6.0 14.8
** ** ** ** **
14.2 14.2 14.3 14.2
4.1 10.2 2.6 12.4 17.0
** ** ** ** **
14.5 14.6 14.4 16.1
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Evangelista et al., 2010 Dehiscence Maxilla Fenestration Dehiscence Mandible Fenestration Total defects Anterior/posterior Yagci et al., 2012 Dehiscence Maxilla Fenestration Dehiscence Mandible Fenestration Total defects Anterior/posterior
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The shaded areas have the highest percentages of fenestration and dehiscence, a non-recorded defect is denoted as -; and unobserved teeth as **
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14.2 14.2
14.5 15.2
S0018-442X(17)30016-1 http://dx.doi.org/doi:10.1016/j.jchb.2017.03.005 JCHB 25469
To appear in: Received date: Accepted date:
15-2-2016 12-3-2017
Please cite this article as: Grimoud, A.-M., Gibbon, V.E., Ribot, I.,Predictive factors for alveolar fenestration and dehiscence, Journal of Comparative Human Biology (2017), http://dx.doi.org/10.1016/j.jchb.2017.03.005 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1
Predictive factors for alveolar fenestration and dehiscence A-M. Grimouda,*, V.E. Gibbonb, I. Ribotc a
Université Toulouse 3 Paul Sabatier, Faculté d’Odontologie, 3 chemin des maraîchers, 31062
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Toulouse cedex 9, France
Centre hospitalier et universitaire de Toulouse, Cité de la santé, 20-24 rue du Pont St Pierre b
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31 052 Toulouse cedex
Department of Human Biology, Faculty of Health Sciences, University of Cape Town,
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Observatory, Cape Town, South Africa
Département d'Anthropologie, Université de Montréal, CP 6128 Succursale centre-ville,
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Montréal QC H3C 3J7, Canada
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Received 15 February 2016, accepted 12 March 2017
* Corresponding author. tel.: +33 (0)5 61 77 78 32, fax: +33 (0)5 61 77 79 85
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E-mail address: [email protected] / [email protected]
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2
Abstract The purpose of this study was to evaluate the distribution and incidence of two forms of alveolar bone resorption known as fenestration and dehiscence across time and space. To
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accomplish this a Medieval French population was studied and the results were compared with other studies to examine incidence and distribution of alveolar bone resorption. Thus, 1175 teeth were analysed for 81 individuals, from an agropastoral Medieval (12th–14th
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century) archaeological site of Vilarnau located in the South of France. Tooth presence and absence as well as dental alveolar resorption were recorded. A new standardised
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methodological approach to record alveolar resorption is presented and can be used for any skeletonised series. Measurements of dehiscence were made in the midline on each root in
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relation to the cemento-enamel junction and fenestration was considered as resorption restricted to alveolar bone. Through analyses of the distribution and incidence of alveolar bone resorption over-time in a Medieval French population, along with nine other studies, we
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present a list of predictive factors for alveolar bone resorption. Among these factors tooth position and function were the most important; anterior teeth were more commonly affected,
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bone resorption was more common on the labial/buccal versus palatal/lingual surfaces, fenestration was also more common on the maxilla and dehiscence on the mandible (p ≤
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0.001). These patterns do not vary through time or space, and therefore, provide predictive factors for health practitioners in oral therapy to improve patient recovery and post oral
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treatment success.
Résumé
Il nous paraît intéressant, d’apporter de nouvelles informations, quant à l’incidence et à la répartition de la résorption alvéolaire, tant en Anthropologie qu’en thérapeutique dentaire. Notre étude a pour but d’évaluer la répartition et l’incidence des deux types de résorption alvéolaire, la déhiscence et la fenestration, dans une population médiévale française, et de comparer nos données à celles déjà établies par des travaux antérieurs, dans un large éventail de populations, au cours de différentes époques. Nous présentons une nouvelle approche méthodologique, standardisée et reproductible. Nous avons étudié 1175 dents appartenant à 81 individus, d’une population agropastorale médiévale (12e – 14e siècle) provenant du site archéologique de Vilarnau, dans le sud de la France. Nous avons relevé les dents présentes et absentes, ainsi que les déhiscences et les
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3 fenestrations de l’os alvéolaire maxillaire. La mesure des déhiscences a été réalisée, sur chaque racine, à partir du milieu de la ligne de jonction amélo-cémentaire, et les fenestrations correspondaient à une résorption limitée de l’os alvéolaire. Nos résultats montrent que, la répartition est symétrique, les fenestrations plus
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fréquemment présentes au niveau du maxillaire et les déhiscences au niveau de la mandibule (p ≤ 0.001) ; fenestrations et déhiscences étant plus fréquentes au niveau antérieur.
Ainsi, cette étude donne la répartition et l’incidence de la résorption de l’os alvéolaire pour
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une population médiévale et les compare aux données établies dans d’autres études, le schéma
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restant sensiblement le même au cours du temps et dans l’espace des populations.
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4
Introduction Alveloar bone resorption is an important indicator of oral status among different types of bone lesions. We have focused our reseach on two forms: dehiscence - cortical bone resorption that denudes root surface, and fenestration - a circumscribed cortical resorption that
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does not affect the marginal edge. In both cases, the resorption is located on the labial/buccal versus palatal or lingual surfaces (Abdelmalek and Bissada, 1973; Edel, 1981; Elliot and
Bowers, 1983; Lampley, 2010; Larato, 1972; Rupprecht et al., 2001; Stahl et al., 1963; Tal,
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1983). Successful treatments in orthodontics, periodontology and implantology, require the presence of complete alveolus. Alveolar bone resorption investigation is essential when
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making treatment decisions to avoid failure (Becker et al., 1999; Fuhrmann et al., 1995; Lampley, 2010; Leung et al., 2010; Nimigean et al., 2009; Steigmann and Wang, 2006; Yagci
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et al., 2012) and to consider bone grafting before implant placement (Chiapasco and Zaniboni, 2007; Sarnachiaro et al., 2016; Veis et al., 2004). For these reasons there has been an increase in research devoted to the presence of alveolar dehiscence and fenestration (Becker et al.,
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1999; Evangelista et al., 2010; Fuhrmann et al., 1995; Yagci et al., 2012). The aim being to determine areas of the mouth most frequently affected and those that present the greatest
Steigmann and Wang, 2006).
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potential of alveolar resorption, as a complicating factor (Agarwal, 2010; Leung et al., 2010;
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Predictive factors of the alveolar bone resorption process have been investigated as the impact of maxillary alveolar bone thickness on resorption incidence (Chiapasco and Zaniboni,
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2009; Edel, 1981; Elliot and Bowers, 1983; Ghassemian et al., 2012; Jorgić-Srdjak, 1998; Temple et al., 2016) and regarding other predictive factors of alveolar resorption, such as age (Rupprecht et al., 2001; Tal, 1983), sex (Rupprecht et al., 2001), trauma via dental wear (Edel, 1981; Ezawa et al., 1987; Larato, 1970; Nimigean et al., 2009; Rupprecht et al., 2001; Stahl et al., 1963; Urbani et al., 1991), and anatomical context (Abdelmalek and Bissada, 1973; Davies et al., 1974; Nimigean et al., 2009; Stahl et al., 1963; Tal, 1983). In modern populations, risk factors also include tooth crowding and, in some cases of post orthodontic treatment, alveolar plate perforation due to the torque movement effect (Handelman, 1996). Another excellent repository of information regarding alveolar bone resorption are archaeological skeletons. However, few studies have used skeletal collections to examine bone resorption in the form of dehiscence and fenestration. With this in mind, archaeological skeletal collections enable us to observe de visu dental bone plate status (Ezawa et al., 1987; Newman, 1998; Urbani et al., 1991; Vodanović et al., 2012a,b).
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5 Due to the best visual ability to identify alveolar bone resorption, without the complication of soft tissues and radiography, analysing skeletonised jaws from past populations are an effective and simple way to record reliable information. Through an evaluation of the incidence and topographical distribution of alveolar bone dehiscence and fenestration from an
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unstudied archaeological Medieval French population, and correlated with existing published information, we aim to improve the predictive factors for alveolar bone resorption and
whether they vary through time and geographical location. Using a biocultural and population
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comparative approach we aim to improve knowledge required in contemporary oral therapy
concerning alveolar bone status. In order to accomplish this, as described by Vodanović et al.,
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(2012b) intially a new adaptation to current methods is required for standardisation to any
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skeletonised series.
Materials and methods
Adult skeletal remains were studied from the agropastoral Medieval (12th–14th century)
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French archaeological site of Vilarnau, located close to Perpignan on the Mediterranean coast in the South-West of France. Archaeological evidence suggests that subsistence at Vilarnau
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was dominated by agriculture, with the typical trio of Mediterranean regions: wheat or poorer cereals, vines and olive trees. Fruit trees, leguminous plants and pulses were grown especially
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along the banks of the river Tet. The woods favoured sheep and goat rearing and provided wood for fire. The diet was complemented by cheese and meat from livestock, poultry, cattle
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and fish. Salt was also easily obtained from the nearby coast. The excavation of the site of Vilarnau in 1996, centred around its church was supervised by O. Passarrius from the French Archaeological Preventive Research Institute (Institut de la Recherche Préventive Archéologique, INRAP) (Passarrius, 2006). The cemetery included burials of 955 individuals, 648 adults with a balanced sex ratio and 307 immature individuals, with ages at death ranging from the perinatal period to adolescence. An analysis of the sample age structure suggests life expectancy was about 30 years (Passarrius, 2006). This sample was previously studied for preservation levels (Lucas et al., 2010), dental wear quantity and direction (Grimoud et al., 2012), and also indications of oral status - caries incidence and diet - (Grimoud et al., 2011). Only adult individuals presenting a dental arch and belonging to preservation levels one and three were used, as described by Vodanović et al. (2005). By using macroscopic examination of individuals we selected only samples with perfectly smooth bone surfaces
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6 without any signs of bioerosion (Trueman, 2002) or periodontitis (Vodanović et al., 2012a). We examined 115 dental arches from 81 individuals. There were 43 maxillae with 421 teeth and 72 mandibles with 754 teeth - including 34 paired jawbones. To record the presence of dehiscence and fenestration a total of 1175 teeth embedded in alveolar sockets were studied.
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This sample was comprised of 21 females, 35 males and 25 individuals of indeterminate sex, and was divided into three age categories: 15-19 years (10 individuals), 20-30 years (16 individuals), and over 30 years (55 individuals).
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To assess our results in a broader context we compiled published data from nine additional studies that used similar recording parameters for incidence and distribution of fenestration
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and dehiscence (Table 1). The inclusion criteria of the nine selected studies were data tables with maxillary and mandibular percentages of dehiscence and fenestration from all teeth
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found in the anterior and posterior portions of the mouth (Abdelmalek and Bissada, 1973; Edel, 1981; Elliot and Bowers, 1983; Evangelista et al., 2010; Jorgić-Srdjak, 1998; Nimigean
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et al., 2009; Rupprecht et al., 2001; Urbani et al., 1991; Yagci et al., 2012).
Methods
Due to methodological variation to characterise and diagnose dehiscence and fenestration,
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including ruling out alveolar margin resorption and vertical pockets, a new suitable, reliable
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and reproducible method of diagnosis for archaeological samples is required (Vodanović et al., 2012b). We present an adaptation of the Elliot and Bowers’ (1983) method described as
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follows: (i) fenestration as a circumscribed defect in the cortical plate exposing the buccal or lingual root surface (Fig. 1A), and (ii) dehiscence as absence of alveolar cortical plate, exceeding one half of the root length and involving the alveolar margin, with alveolar septa situated at the very least 5 mm from the cemento-enamel junction (CEJ) (Fig. 1B). Thus, dehiscence affects the alveolar margin unlike fenestration. Elliott and Bowers (1983) suggest that fenestration may be a stage in the development of dehiscence. As to the minimum height chosen for dehiscence we chose greater than 5 mm relative to the CEJ, whereas others suggest 4 mm (Davies et al., 1974) or 2 mm (Tal, 1983; Urbani et al., 1991; Jorgić-Srdjak, 1998; Nimigean et al., 2009) and some use a graded scale (Abdelmalek and Bissada, 1973). This variability in diagnoses between studies made it difficult to define the initial stage of dehiscence, especially as the alveolar margin is only located from 3 to 4 mm to the CEJ. This area overlaps the physiological space from 2 mm to 4 mm from the edge of the alveolar margin to the CEJ (Ghassemian et al., 2012). It is for these reasons that a new method of dehiscence diagnosis was required (Fig. 1B, C). Taking into account the physiological space
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7 between the CEJ and alveolar crest, and not to confuse dehiscence and alveolar physiological status the distance of alveolar bone septa was set at a minimum of 5 mm from the CEJ relative to continuing eruption due to dental wear. This was used to establish an anatomical point in the middle of the CEJ to record the resorption height and if a root is denuded. The level of
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bone resorption was established by measuring from the CEJ at the mid-height of the total root length.
Care was taken to ensure that recorded defects were not produced by another external
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factor such as plaque build up evidenced by calculus, irregular margins due to postmortem
damage, increased distance between from the CEJ and the alveolar margin because of over-
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eruption due to oclusal wear process. Also we differentiate fenestration from alveolar resorption due to abscess fistulae through the alveolar bone plate and periodontitis lesions
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(Vodanović et al., 2012a). In the case of postmortem alveolar bone destruction, the edge surrounding the bone defect would not be soft but rather irregular and exposed bone tissue would be whither than the external bone surface.
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This sample was examined by Grimoud for tooth presence and both antemortem and postmortem absence, as well as, buccal and palatal vs lingual presence of fenestration and dehiscence on available teeth. The data will be presented using the four quadrants of the oral
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cavity – quadrants 1 and 2 corresponding respectively to the right and left sides of maxilla and
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3 and 4 to the left and right sides of mandible - and the 2 digit dental system of the International Dental Federation (FDI) (Grimoud et al., 2012).
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The macroscopic examination was conducted under suitable light, using a graduate dental probe to evaluate the alveolar bone height in the middle of the buccal and palatal vs lingual surface. To ensure the recording method was reliable and to improve recording precision an intra/inter observer correlation test was conducted (the correlation coefficient was considered unsuitable at r ≤ 0.90). The measurement variability was assessed on 20 jaws, the material was re-measured three times over three weeks. The accuracy of the obtained measurements was demonstrated by an insignificant level of variation. The recorded data were analysed using the SPAD software at the Toulouse anthropological center. The χ2 test was used to examine differences between maxillary and mandibular dehiscence and fenestration and it was considered significant at p ≤ 0.05.
Results
Page 7 of 22
8 Teeth presence and absence were recorded (Fig. 2). On the maxilla, 64.09% (441/688) of the teeth were present, 9.15% (63/688) were lost antemortem (AMTL), 24.70% (63/688) postmortem (PMTL) and the incisors were most commonly lost (65.51%, 111/172). On the mandible, 68.83% (770/1152) of the teeth were present, 7.19% (83/1152) were lost
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antemortem and 25.34% (282/1152) postmortem and the incisors were the most often lost (56.58%, 97/172). Overall, the maxillary and mandibular profiles of teeth present and absent in this study were similar. Given the high percentage of absent incisors for each studied
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variable we calculated the average percentage for all four teeth and each incisor was given the
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average value.
Dehiscence and fenestration
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The results for dehiscence and festration in the studied sample are presented in Figure 3 and tabulated in Table 1. For dehiscence in the maxilla and mandible, the teeth most often affected were incisors, canines and first molars, and the least were third molars and
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premolars. Similar findings were found with fenestration: the teeth most commonly affected were incisors, canines and first molars, and fenestration was least common on premolars, second and third molars. On the maxilla the pattern of fenestration and dehiscence were
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super-imposable for incisors, second left premolars and molars. The average percentage of
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maxillary teeth with fenestration (18.95%, 83/441) was greater than dehiscence (12.7%, 56/441). The anterior versus posterior region respectively on the maxilla had a higher
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percentage of dehiscence (17.64%, 22/123) versus (10%, 32/318); and fenestration (22%, 27/123) versus (16.59%, 53/318). On the mandibular teeth the average percentage of dehiscence (17.70%, 136/770) was higher than fenestration (3.5%, 27/770), and the anterior region versus the posterior respectively displayed a higher percentage of dehiscence (25.15%, 59/235) versus (13.23%, 71/535); and for fenestration (11.87%, 28/235) versus (0.80%, 4/535).
Overall, alveolar bone resorption was recorded in 99% of cases on the labial/buccal versus 1% on the palatal/lingual surface. In multiradicular teeth with alveolar resorption, the greatest presence of dehiscence was observed on the mesial root of the first maxillary molar, whose anatomical position was more buccal than the distal one. Statistical significance was found of differences between maxilla and mandible for fenestration (p ≤ 0.01), but not for dehiscence (p = 0.08). When comparing alveolar bone resorption between age groups, a slight and insignificant increase of dehiscence in individuals older than 30 years was noted.
Page 8 of 22
9 Cross-study comparison Through analysis of results across ten studies (Table 1), including ours, the following characteristics of dehiscence and fenestration were highlighted. The average range of alveolar bone resportion incidence was 12% to 29%, except for two studies, one with lower incidence
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around 3% (Abdelmalek and Bissada, 1973) and the other higher around 50% (Jorgić-Srdjak, 1998). Similar distributions of both dehiscence and fenestration were found, dehiscence most commonly affected the mandible (7/10) (Abdelmalek and Bissada, 1973; Edel, 1981; Elliot
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and Bowers, 1983; Evangelista et al., 2010; Jorgić-Srdjak, 1998; Rupprecht et al., 2001;
Urbani et al., 1991) and fenestration the maxilla (8/10) (Abdelmalek and Bissada, 1973; Edel,
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1981; Elliot and Bowers, 1983; Jorgić-Srdjak, 1998; Nimigean et al., 2009; Rupprecht et al., 2001; Urbani et al., 1991; Yagci et al., 2012). The teeth most frequently affected were the
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canines (9/10) (Abdelmalek and Bissada, 1973; Edel, 1981; Elliot and Bowers, 1983; Evangelista et al., 2010; Jorgić-Srdjak, 1998; Nimigean et al., 2009; Rupprecht et al., 2001; Urbani et al., 1991) and first molars (7/10) (Abdelmalek and Bissada, 1973; Edel, 1981; Elliot
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and Bowers, 1983; Nimigean et al., 2009; Rupprecht et al., 2001; Urbani et al., 1991). No matter the methods used (macroscopy or tomography) these studies and ours demonstrate that the anterior teeth are most affected by dehiscence and fenestration. Third molars displayed the
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lowest level of alveolar resorption (6/10) (Abdelmalek and Bissada, 1973; Edel, 1981;
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Nimigean et al., 2009; Rupprecht et al., 2001; Urbani et al., 1991). The profiles for maxillary fenestration and mandibular dehiscence on the canines and first molars were super-imposable.
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Therefore, tooth position and function appear to be the primary predictive risk factors, and fenestration can also progress to dehiscence with age.
Discussion
Through this study we established objective criteria for recording alveolar bone resorption (dehiscence and fenestration) on skeletonised jaws. Due to the availability of archaeological samples for study, having an easy and effective method to follow allows for better data comparisons in the future. This new standardised method to diagnose alveolar dehiscence and fenestration on dry maxillary bones provides a clear antomical point of reference, easy to visualise bone resorption measurement and location. It also includes physiological variation of the distance from the CEJ to alveolar bone crest. It also clearly defines the elements for differential diagnosis of fenestration and dehiscence. This newly developed method was applied to this sample from Medieval France, and the obtained results in comparison with the
Page 9 of 22
10 other studies revealed several patterns of incidence and distribution for alveolar bone resoprtion. Tooth position and function seem to be the primary predictive factors. Considering the main resorption locations at the canine and first molar, these correlate well with thin labial/buccal alveolar bone covering the roots (Elliot and Bowers, 1983; Larato, 1970; Stahl et
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al., 1963; Temple et al., 2016). Additionally, crown and root anatomy are adapted to their function during mastication. For example, over the mastication cycle, canines are highly
stressed by lateral movements of the mandible and first molars undergo heavy pressure (Van
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Beek, 1983). This pressure and stress over one’s lifetime is why there is an association with
alveolar resorption and increasing age (Stahl et al.,1963). The areas of the mouth more prone
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to alveolar bone resorption have naturally thinner bone to begin with, for example within the labial and buccal regions compared to the palatal and lingual, the anterior aspect of the tooth
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or mouth compared to the posterior.
Although the topographical distribution of fenestration and dehiscence has been analysed, by tooth position in alveolar bone and their incidence in contemporary and archaeological
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populations all over the world, (Edel, 1981; Evangelista et al., 2010; Larato, 1970; Nimigean et al., 2009; Rupprecht et al., 2001; Tal, 1983; Urbani et al., 1991; Yagci et al., 2012), most data come from non-European populations and no previous data are available from France.
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Therefore, these results present the first findings for a French population and also the only
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sample from the Late Middle Ages. In comparison with other studies, we have found several commonalities in the incidence and distribution of fenestration and dehiscence summarised
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above. Despite the differences in recording between the studies, the patterns observed do not vary much. This demonstrates that the incidence and distribution of alveolar bone resorption remains fairly constant between populations from different regions around the world and the patterns transcend time.
Our percentages were lower than those found in contemporary populations by Rupprech et al. (2001) in dry skulls of North Americans and by Evangelista et al. (2010) in Germans. This is likely due to dental crowding relative to food consistency (Kaifu et al., 2003). Thus, in accordance with other investigations in dry skulls (Abdelmalek and Bissada, 1973; Edel, 1981; Elliot and Bowers, 1983; Tal, 1983) or in the living (Evangelista et al., 2010; Yagci et al., 2012), our observation suggests that alveolar dehiscence and fenestration are a common feature in populations through time. One of the few studies on children (Larato, 1972), aged from two to five, reports that fenestration or dehiscence were observed in 12% of 176 skulls and were only located on the labial anterior region. Interestingly, this is also the most commonly affected area for historic and contemporary adults (Evangelista et al., 2010; Yagci
Page 10 of 22
11 et al., 2012), which is likely higher due to tooth crowding and orthodontics (Garib et al., 2010; Handelman, 1996; Viazis et al., 1990). With regard to the life expectancy of the sample being relatively young at 30 years’, we note that carious lesions did not affect, or very rarely affected deciduous teeth and teeth were
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not heavily worn (Grimoud et al., 2012). In a contemporary population age has been reported to affect alveolar bone resorption distribution and incidence (Ghassemian et al., 2012). Therefore, given the relatively low life expectancy in our sample, the resorption level
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recorded for this sample could differ from samples with a higher age-at-death distribution. Despite this possibility, our results do appear to correlate well with other studies with
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incidence between 12%-29%, except for two outliers, 3% (Abdelmalek and Bissada, 1973) and 50% (Jorgić-Srdjak et al., 1998). Based on these results and the fact that our findings
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correlate well with the other studies, despite being from different time periods and geographic locations, it has been suggested that the age-at-death being young in our sample did not significantly affect the outcomes.
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The torque process, used for moving teeth in orthodontic treatments, has been assessed and linked by orthodontists to iatrogenic effect i.e., a buccal anterior alveolar table perforation (Garib et al., 2010; Handelman, 1996). Relating this to the medieval period, the use of the
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incisors to cut up hard food and possibly as a tool, could cause a slight torque effect in
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relationship to the high incidence of fenestration on the anterior versus posterior bone alveolar plates. This hypothesis seems even better supported especially when knowing that there is an
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increase in fenestration where the bone thickness is reduced, as it is in the anterior area of the mouth compared with the posterior region (Temple et al., 2016). As stated previously, studying the incidence and distribution of both forms of alveolar bone resoption is vital, as they increase risk of failure of oral treatments. The results of this study on areas of the mouth and their predicative factors for being sensitive to bone resorption can be used by oral practitioners, in order to better predict the stability of alveolar bone status pre- and post-treatment (Becker et al., 1999 ; Ghassemian et al., 2012; Handelman, 1996). It would be interesting to investigate clinical cases of gingival recession and fenestration in orthodontic treatment (Viazis et al., 1990) versus those without treatment.
Acknowledgements The authors wish to acknowledge the high scientific assistance of Marjan Ghassemian
Page 11 of 22
12 and would like to express their indebtedness to, André Sevin, Olivier Passarrius, Richard Donat and Otto Graf. Also we would like to thank the reviewers for their valuable comments and suggestions. Funding: The rescue excavations of the Vilarnau site were funded by the French Ministry of Culture, the Languedoc–Roussillon region, the General Council of the
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Pyrénées - Orientales Department, the city of Perpignan, the University of Perpignan-Via Domitia and the Pyrénées-Orientales Archaeological Association.
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References
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dehiscence and fenestration in dry human Egyptian jaws. J. Periodontol. 44, 586-588. Agarwal, V., 2010. Fenestration and dehiscence in a non-vital tooth – a case report. J. Clin.
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Becker, W., Dahlin, C., Lekholm, U., Bergstrom, C., van Steenberghe, D., Higuchi, K., Becker B. E., 1999. Five-year evaluation of implants placed at extraction and with
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skulls. J. Clin. Periodontol. 1, 107-111. Edel, A., 1981. Alveolar bone fenestrations and dehiscences in dry Bedouin jaws. J. Clin. Periodontol. 8, 491-499.
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13 Fuhrmann, R.A.W., Wehrbein, H., Langen, H.J., Diedrich, P.R., 1995. Assessment of the dentate alveolar process with high resolution computed tomography. Dentomaxillofac. Radiol. 24, 50-54. Garib, D.G., Yatabe, M.S., Ozawa, T.O., da Silva, O.G., 2010. Alveolar bone morphology
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Grimoud, A-M., Lucas, S., Sevin, A., Georges, P., Passarrius, O., Duranthon, F., 2011. Frequency of dental caries in four historical populations from the Chalcolithic to the
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14 Lucas, S., Sevin, A., Passarius, O., Grimoud, A-M., 2010. Study of dental caries and periapical lesions in a Medieval population of the southwest France: visual and radiographic inspection of differences. Homo – J. Comp. Hum. Biol. 61, 359-372. Newman, H., 1998. Do not confuse the bone loss of periodontitis with root exposure to
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15 Viazis, A.D., Corinaldesi, G., Abramson, M.M., 1990. Gingival recession and fenestration in orthodontic treatment. J. Clin. Orthod. 24, 633-636. Vodanović, M., Brkić, H., Šlaus, M., Žlejko, D., 2005. The frequence and distribution of caries in the mediaeval population of Bijelo Brdo in Crotia (10th-11th century). Arch. Oral
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Biol. 50, 669-680. Vodanović, M., Galić, I., Zukanović, A., Knežević, M., Novak M., Šlaus, M., Brkić, H.,
2012a. Periodontal diseases at the transition from the late antique to the early medieval
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period in Croatia. Arch. Oral Biol. 57, 1362-1376.
Vodanović, M., Galić, I., Zukanović, A., Knežević, M., Novak M., Šlaus, M., Brkić, H.,
period in Croatia. Arch. Oral Biol. 57, 401-412.
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2012b. Orthidontic anomalies and malocclusion in Late Antique and Early Mediaeval
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Yagci, A., Veli, I., Uysal, T., Ucar, F.I., Ozer, T., Enhos S., 2012. Dehiscence and fenestration in skeletal Class I, II, and III malocclusions assessed with cone-beam
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te
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computed tomography. Angle Orthod. 82, 67-74.
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Legends for Figures Fig. 1. Observation of alveolar bone resorption: (A) fenestration on the labial plate of mandibular incisors: (1) marginal crest not affected by (2) the circumscribed resorptions;
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(B) complete dehiscence on the maxillary canine and first premolar labial/buccal plate: (1) cemento enamel junction (CEJ), (2) septa to at the most 5mm from CEJ, (3) physiological
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space from 2 to 4 mm between CEJ and alveolar crest, (4) the resorption, measured from the CEJ in the middle of the root reaches at least the half height of the total root length;
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(C) complete dehiscence on the mandibular first molar: (1) CEJ, (2) septa to at the most 5 mm from CEJ, (3) physiological space from 2 mm to 4 mm between CEJ and alveolar crest, (4) the resorption, measured from the CEJ in the middle of the root reaches at least the half height
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of the total root length.
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Fig. 2. Percentage of teeth present and absent relative to tooth number on the maxilla and mandible.
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mandible.
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Fig. 3. Percentage of dehiscence and fenestration relative to tooth number on the maxilla and
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17
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Fig.1
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Fig 2.
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Fig 3.
Page 19 of 22
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Table 1. Comparative percentages of incidence and distribution of dehiscence and fenestration according to tooth type
ed
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Incisors Premolars Molars Canines Central lateral 1st 2d 1st 2d Number of teeth: 1175 19.8 16.2 15.9 4.1 4.5 27.9 13.4 15.8 20.2 29.0 15.5 5.9 44.3 15.5 18.1 13.9 43.5 15.6 6.9 31.1 12.6 12.8 3.1 1.8 6.7 3.3 15.1 25.3 9.5 4.3 25.7 10.3 13.4 15.8 10.6 Number of teeth : 819 3.8 1.8 3.5 1.8 1.0 7.6 2.2 36.6 12.4 5.4 5.0 14.1 8.5 4.6 12.7 5.8 4.3 6.8 2.5 7.3 5.9 4.2 9.3 11.5 9.4 8.0 5.3 2.2 5.2 6.7 10.4 6.4 4.5 14.1 4.8 7.2 6.1 Number of teeth: 467 -* 4.5 17.4 1.9 4.5 42.6 9.6 1.3 14.4 6.1 3.8 2.6 40.6 18.1 0.6 5.2 0.6 2.2 5.4 0.2 16.0 1.3 0.9 2.3 16.2 8.6 1.7 17.1 2.9 7 5.5 Number of teeth: 2176 3.4 0.9 0.9 0.9 14.7 5.0 3.5 4.3 6.9 5.2 1.8 3.5 8.0 5.5 4.0 1.8 3.3 3.3 7.9 1.9 1.7 1.7 3.4 3.4 0.6 4.8 3.4 1.3 6.7 2.5 2.2 3.5 3.5 2.8
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Our Results Dehiscence Maxilla Fenestration Dehiscence Mandible Fenestration Total defects Anterior/posterior Rupprecht et al., 2001 Dehiscence Maxilla Fenestration Dehiscence Mandible Fenestration Total defects Anterior/posterior Nimigean et al., 2009 Dehiscence Maxilla Fenestration Dehiscence Mandible Fenestration Total defects Anterior/posterior Abdelmalek & Bissada, 1983 Dehiscence Maxilla Fenestration Dehiscence Mandible Fenestration Total defects Anterior/posterior
Dental morphotypes
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Studies of dehiscence and fenestration
Page 20 of 22
Total defects 3rd 5.4 1.8
10.5 18.9 17.7 3. 5
1.5 2.3 0 0 0.9
3.1 11.1 5.7 6.2
0.6 0.1
5.9 6.1 6.0 6.0
1.0 0.7 0.7 0.6
0.8 5.3 3.8 2.7
29.4 21.2
14.2 11.9
12.0 12.0
6.1 6.5
12.1
6.9 9.9 33.4 4.4 13.6
15.3 8.2 4.8 7.1
3.6 19.4 13.2 7.9 11.0
9.2 11.7 7.5 9.5
55.4 24.7 51.8 14.7 36.6
32.5 10.2 48.2 4.8 23.9
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4.6 15.6 7.2 6.9
ed
10.6 5.0 3.9
2.9 5.4 29.5 16.8 13.6
8.2
4.8 6.9 17.5 9.7
pt
4.3 6.6 5.4
50.5 24.2 50.7 12.3 34.4
9.0 39.3 9.5 41.6 10.2 25.1 30.0
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11.2 17.3 39.7 10.2 19.6
Number of teeth: 1153 20.4 24.1 3.9 5.7 7.2 3.9 10.3 8.4 10.4 7.2 Number of teeth: 2205 16.1 6.1 35.1 1.1 14.9 4.2 1.8 17.6 6.3 Number of teeth: 990 10.3 9.7 47.3 2.9 7.5 2.9 4.4 5.2 17.4 9.0 Number of teeth: 2038 30.8 33.1 11.7 5.3 33.2 31.4 6.6 8.1 20.6 19.5 19.9
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6.7 15.5 5.3 13.0 10.1
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2.8 5.8 11.9 5.1
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Elliott & Bowers, 1983 Dehiscence Maxilla Fenestration Dehiscence Mandible Fenestration Total defects Anterior/posterior Urbani et al., 1991 Dehiscence Maxilla Fenestration Dehiscence Mandible Fenestration Total defects Anterior/posterior Edel, 1981 Dehiscence Maxilla Fenestration Dehiscence Mandible Fenestration Total defects Anterior/posterior Jorgic-Srdjak, 1998 Dehiscence Maxilla Fenestration Dehiscence Mandible Fenestration Total defects Anterior/posterior
2.6 8.3 2.5 3.7 4.3
2.5 9.6 10.6 5.7
6.1 11.2 12.7 9.8
9.1 8.3 4.3
3.7 1.7 1.3
2.9 10.5 11.7 3.2
3.0 25.6 2.1 10.2
3.8 3.0 3.4
5.6 17.1 7.7 6.5
25.7 10.4 34.6 5.3 4.0
13.4 6.2 32.7 9.7 15.5
35.1 12.8 40.5 8.9
Page 21 of 22
17.3 21 22.5
13.4 14.9
22.7 14.2
47.9 49.4
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18.7 17.9 17.1 22.3 18.0
18.4 18.0 16.5 12.4 18.9
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13.3 18.2 17.5 25.3 16.3
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9.4 10.5 24.3 21.0 16.3
17.5
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15.6 10.4 22.1 14.3 20.9
pt
20.9 7.6 26.9 11.8 16.7
20
26.7 9.2 21.3 12.9 15.6
12.6 32.4 18.1 24.7 26.7
Number of teeth: 4319 10.4 18.2 7.4 16.2 9.2 9.9 8.9 3.9 17.6 8.9 13.7 Number of teeth: 3444 4.4 17.0 7.1 25.4 7.0 2.7 19.1 16.9 12.6 15.5 15
11.2 11.6 5.4 6.0 14.8
** ** ** ** **
14.2 14.2 14.3 14.2
4.1 10.2 2.6 12.4 17.0
** ** ** ** **
14.5 14.6 14.4 16.1
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Evangelista et al., 2010 Dehiscence Maxilla Fenestration Dehiscence Mandible Fenestration Total defects Anterior/posterior Yagci et al., 2012 Dehiscence Maxilla Fenestration Dehiscence Mandible Fenestration Total defects Anterior/posterior
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Ac
The shaded areas have the highest percentages of fenestration and dehiscence, a non-recorded defect is denoted as -; and unobserved teeth as **
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14.2 14.2
14.5 15.2