gival plaque are involved in the pathogenesis of infra-

The Infrabony Pocket and its bony pockets.

Relationship to Trauma from Materials and Methods
The material consisted of 48 extracted teeth, most of
Occlusion and Subgingival them having been taken out because of advanced de-
structive periodontal disease. A condition for being in-
Plaque cluded in the material was that advanced vertical bone
rsorption could be observed in the radiograph and that
the bottom of the pocket
probing had established that
by was located apical to the level of the adjacent
alveolar
bone. This condition is usually spoken of as an infrabony
jens WaERHAUG* pocket. teeth lower molars, and out
Thirty-three of the were
^he angular bone defect connotes an oblique level of of these, 19 were hemisectioned. The remaining roots of
'he interdental septum systematically in
radiographs and
as observed in the latter group were followed up
as

'stologic sections. The infrabony pocket is a further many possible.

cases as
evelopment of the angular bone defect, and it may have patients had
All the been referred to the author for
ne, two or three walls. Particular attention was focused periodontal treatment.
n this
problem by Glickman and Smulow1 who, on the It is known that many of the referring dentists repeat-
asts of observations made in two autopsy cases con-
edly had carried out subgingival plaque control, although
cluded that "gingival inflammation and trauma from records of their treatment were not available. The author
Elusion are different types of pathologic processes had even made attempts to eliminate infrabony pockets
*hich participate a single disease, Periodontitis. To-
in by the open curettage technique in a few cases. the
Bether they exert combined acodestructive effect which Before the periodontal treatment was started, pa-
Produces angular bone defects and infrabony pockets", tients were instructed in personal plaque control, and at
tie
validity of this conclusion as far as the angular bone the time when the teeth were extracted, the oral hygiene
.
e'ect is concerned, has been questioned by the author standard was much better than it originally had been.
n a
study based on histologie sections from 106 inter-
Immediately prior to the extraction, a radiograph was
condi-
ntal spaces in 31 autopsy cases which had been ex- taken to ensure that the radiograph reflected the
arnined with particular regard to the etiology and path- tions on that particular day. The functional conditions
Senesis of destructive periodontal disease. It was found were analysed and recorded. The
records included ob-
interferences,
at the
angular bone defects were related toasdifferent servations on premature contacts, cuspal
Since the main pur-
Vels of the cementoenamel junction (CEJ), long as mobility, chewing habits and pain.
e junctional
epithelium ended there, and to different evaluate the role of
pose of the present study was to
Ve's of subgingival plaque when more or less attach- and pathogenesis of the
jiggling forces in the etiologyattention was paid to the
ant
,
had been lost. It is noteworthy that the angular
ec,s occurred equally often against the least as against
infrabony pockets, particular
direction of the horizontal force components. In case
e most
heavily loaded of two neighboring teeth. An there was a tight contact between the teeth, it was
Jection to the latter study may be that particular assumed that jiggling in a mesio-distal direction could
had not been paid to the direction and the not take place. This assumption was verified in two
j*"ention
'ure of the functional forces, i.e., whether or not they
cases
direction by
by measuring the mobility in mesio-distal The
to the jiggling type. To jiggle is defined by (500 p). mobility
ponged
t
assell's English dictionary as "to jerk or rock lightly
new
means
was
of O'LearyV mobility
found to be
meter
negligible. In those cases in whichforce
the
direction of the
ji'in tvPe f occlusal forces are
anC^ fro"' an<* tne
th se which are
contacts were not tight, the main
generally assumed to cause the angular was recorded during chewing movements.
ne defects. Unquestionably, jiggling movements of was classified within four
The degree of mobility
ie teeth have been produced experimentally by groups as: (1) Normal, (2) slightly increased. (3) mark-
of orthodontic appliances. By these appliances (4) excessively increased. To be in-
(^eans
'

edly increased and

horizontal mobility was increased by a factor of x4 cluded in the latter group, the tooth had to be mobile in
tQe *6 and axial mobility was created as well (for further an axial direction. In the beginning, attempts were
made
e'ails see Ericsson 19786). to estimate the mobility by means of a mobility meter.7
The purpose of the present study was to establish to
I I- I * but it had to be given up, because too many patients
H a' extent and in which way jiggling forces and subgin-
.

hesitated to cooperate in the experiment. Whereas it was

of the teeth
possible to estimate the degree of mobility
* with an acceptable margin of accuracy, it was impossible
Professor Hmeritus, Department of Periodonlology Dental Fac-
m to define clinical criteria which made it possible to
VI
University of Oslo. Geitmyrsvn 69, Oslo 4, Norway.
355
 J Periodont"'-
356 Waerhaug July. I'79
estimate the magnitude of the occlusal forces to which
the teeth had been exposed. Therefore, the observations
on occlusal interferences and
chewing habits were not
included in the final analysis.
As a preliminary to the extraction a mark was made
in the tooth surface at the gingival margin by means of
a sharp instrument or a bur. This was done to make it

possible to establish the location of the gingival margin

during the later examination of the extracted tooth.
Immediately following the extraction, the blood was
washed away by means of a dental spray, and supraal-
veolar soft tissue, which remained on the tooth, was
trimmed away because otherwise it would have obscured
the area of the junctional epithelium. Then the tooth was
stained for about 10 minutes in a 1% solution of Wasser-
blau, rinsed for 5 to 10 minutes in running water and air
dried. In some of the cases selected for photography, the
coloring of the plaque and the attachment fibers was not
sufficiently strong to give adequate contrast in the pho-
tograph. Therefore, some more stain was added to these
areas by means of a small brush. For further details

regarding the technique see Waerhaug 1974."

All the teeth were carefully examined under the ster-
eomicroscope. Particular interest was focused on the
relationship between the plaque front and the remaining
attachment fibers, and the distances were recorded. In
examining the radiographs, interest was focused on the
distance from the tooth surface to the opposite vertical
wall of the infrabony pocket. In the present context, it
was found useless to
apply sophisticated statistical meth-
ods on the measurements so they are given as
averages
and ranges.

Results
The age distribution of the patients may be seen in
Table I. All the main observations made in the
present
material are illustrated in Figs 1 to 10. The
legends are
presented as case reports, and they should be consulted
to secure a complete understanding of the
problems. It
is important to appreciate that the radiographs are taken Figure 1. Second mandibular molar in 63-year- old fen""*:
in a bucco-lingual direction, whereas most of the Patient treated by author for 30 years, last time some 15 }'e ,

pho- ago. Referring dentist had carried out curettage treatmentse .

tographs of the extracted teeth are taken in a mesio-

.

times in order to gain new attachment in 3-wall infrabony p0'

distal or disto-mesial direction. On the basis of what is Gingiva slightly inflamed with a purulent secretion from the di ^
seen in the two categories of illustrations, the reader pocket. Mobility slightly increased and limited to bucco-Unp1
should attempt to develop a three-dimensional direction. Hemisectioned root photographed from disto-Ung"
of image side, below left, andfrom disto-buccal side, below right. Pictu
mounted together to show plaque-front in depth of pocket
Table I. Age Distribution of the 48 Patients rectly. Distance from subgingival plaque front to attach'"
Number of pa- fibers is 0.4 mm disto-buccally, showing that curettage treat"1
Age group (years) tients
here had been a complete failure. Disto-lingually, the distance
2.0 mm showing that curettage here had resulted in a widening J
20 to 29 2 the area of the junctional epithelium. Note that 0.4 to 2.0
30 to 39 5
40 to 49 12
an unusually great variation in distance
from plaque to perio" ,
tal membrane. Radiographie picture in apical region is influen
50 to 59 18
60 to 69 10
by periapical problems because of necrotic pulp. Distance j
70 to 79 1
plaque covered distal surface to opposite vertical wall of infra"
pocket varied between 1.2 and 2.5 mm. Mesial root was
Total 48
filled, adequate plaque control introduced and pockets elimina
Within 7 months mobility was reduced to normal.
Figure 2. First rieht mandibular molar in 58-year-old male. Personal plaque control good and gingivae healthy. Normal mobility,
'""ed to bucco-lingual direction because of tight contact with neighboring teeth. Radiograph slightly retouched to bring out contrasts
fich otherwise would
Radicular side (left)
have been discernible in reproduction. Mesial root removed by hemisection, stained and photographed j
not
rom

and buccal and mesial side (right). To left, lines are drawn from plaque in bifurcation area on mesial root to
corresn--- //m' fmm borderline nrpnnmtion in radioeraoh corresponding
radiograph to corresponding
-ponding landmarks in radiograph. To right,
J- *-_u_l t- ., /;., is drawn
one line .<
from hnrAoriine nf of preparation
on tooth surface. Distance jrom
landmarks on root; another line is
-

drawn from base of infrabony pocket corresponding

to landmarks
on extracted root to
foque front to attachment fibers varies between 0.7 and 1.0 mm. In bifurcation distance from plaque as observed 8 and distancefrom
ne as meas"red
measured in radiograph was about
abo. 2.0 On mesial surface, distance from plaquefront to apex was mm,
baseas
!asee of infrabony (radiograph)
infrabony pocket (radiograph)
pocket to apex
mm.
was 7 mm, indicating that bone had reached to upper periodontal pertodontal fibers, which is
is not

is a result of radiographie errors, such projection and variation in thickness of bone in bucco-lingual direction
be ^he discrepancy
as
on mesial root surface to vertical wall of infrabony pocket is about
1.9
>*niUSe fbl'clue 'eve' of bone. Note that distance from plaque without loss attachment and development of
fo, Following hemisectioning,
distal root has functioned as abutment for bridge further of below
mesial surface has probably initiated infrabony pocket by bringing plaquefront deeply
Sinr y defects for years. Overhang
6 on
g'val margin beyond reach ofpatients' plaque control.

visible signs of gingivitis. Normal

lGURt 3 Lower right second mandibular molar in 46-year-old female. Oral hygiene perfect and no
with first molar. Patient had been under
"fusion and articulation, normal mobility limited to bucco-lingual direction, tight contact carried
Per'odontal treatment for several years. Serious attempt to gain reattachment by curettage out infrabony pocket distal
in on

bring out contrasts which

SUrface. Two years later tooth extracted because of periodontal abscess. Radiograph slightly retouched to side
"^rwise
Ucc-l
would nothave been discernible in reproduction. Tooth seen from buccal side (left) and distolingual
be discerned. Lines
(right). radiograph
In
are drawn to corresponding points on
(B)
and lingual (L) bone margin of three-wall infrabony pocket can
racted tooth Subgingival plaque covers distal surface to distance of 0.9 mm from periodontal membrane. By comparing measurement
"
,, Oracled tooth and in radiograph, it
could be established that bone had been resorbed to a distance of about 1.5 mm below plaque.
J'four surfaces plaque-free above gingival margin. Note that efficient use of interdental brush on distal surface
had removed plaque to
y"ce of about I 0 mm below gingival margin, thus explaining why gingiva was clinically healthy there in spite
abscess in the depth of the pocket. Curettage treatment had been a complete failure since subgmgival plaque
of the presence of a
had been
Rodontal
formed on Only on surface is offunctional epithelium wider than normal.
most curetted
of surfaces. lingual area

357
 LINE_OF_HEJ}I^ECT lON__
VAULTF,FURCfrTV0

Warned No^ tr Z^
S?f "oW.7of mestai ^ bucco-lingual
' tiIledf0^, Ugh, with second premolar. Gingiva
contact
direction. Attempts made gain nei attachment by curetta*
rSml */Z y7
ZTrTf remo val
"""^
">- by hemisection.
root
'
surface, facing infrabony pocket,
Mesial
to
left and dis'"'
shown to

cuZtZmTnZ faded buccal aspect ofpocket, ofJunctional epithelium about indicating effect of curetta*3
r
tod In area is 2 mm some

Z lZJS^Zh^^
70^2?^^^"*
q-U^red t00thlSUrface PP
granU'T"
perticai wall of infrabony pocket
to
'iSSUe
r^ovedfrom WaS
infrabony pocket.
radiograph
as measured in
Distance from tooth bole estimated to
was

to
made radiograph and tooth, subgingival plaque appeared have reached
11ns
about / co^armlmfaluremen<s
0.5
from base of infrabony pocket. Following
mm
in

hemisectioning, distal
on extracted
has functioned well for Shears and firm.
root
to
is

y_niNGIVAL MARGIN

Figure 5. Lowerfirst and second molar in 56-year-old male. Excellent personal plaque -use" control, no signs of gingivitis. Slightly incre
mobility in bucco-lingual direction. Mesial root of second molar removed by hemisection and its mesial surface shown to right. 0j
root is fractured. Subgingival plaque reaches to 0.2 mm from periodontal membrane in
depth of pocket. Shape of three-wall infra ^
pocket clearly related to surface and borderline of subgingival plaque. Little, if any, plaque was calcified. Interdental brush has ren ^
plaque to distance of about 2 mm below gingival margin on buccal part of mesial surface, thus explaining absence of visible ging'\
spite of large amounts of plaque in deeper part of infrabony pocket. Remaining root has functioned well for 4 years without J"
development of angular defects; mobility is normal.
358
Volume 50 The Pocket 359
Number 7 Infrabony
-
~M- ^BUCCAL

y
RH 6. First mandibular molar in 51-year-old male. Purulent secretion from distal pocket, but gingiva otherwise
oc, in centric occlusion and markedly increased mobility in bucco-lingual direction; tight contact with second premolar
hea'^Pr^"r'
ff^aph
retouched to bring out details that otherwise would not have been discernible in reproducn. Extracted tooth
"ightty ^nfromimpuil
5* deft) and from buccal side (right). Distal root completely covered with plaque
^preserved on both sides; note that interradicular septum andperiodontal
and calculus. In upper par,
0ffaUn'2Z%h%
membrane space are clearly discernible in radiograph in
area where a granulomaus present
Responding area. On mesial root, periodontal membrane well maintained except for apical
2 and 3 mm. Three-dimensional
Dis'ancefrom plaque and calculus-covered root to vertical wall of infrabony pocket varies between
arehitec,ure of infrabony pocket corresponds very well with surface and borderline of subgingival plaque.

teeth extracted. Mobility

1. Second mandibular molar in 61-year-old male. Personal plaque control inadequate. Neighboring
Rl;
'

mesial side (left) andfrom interradicular side

df^y increased, mainly in bucco-lingual direction. Mesial root extracted
Placlue covers lingual half of tooth to distance of 0.4 to 0.6 mm
and
from
shown from
remaining attachment fibers
about
and to about 1.0 mm from
2 mm. Note that distance
ipe
"ulp is vital. Distance from plaque covered lingualaround part of root to vertical wall of infrabony pocket
f'Oin aP'cc,l
fr
plaque front to wall of infrabony pocket lingual part of apex is also about 2 mm. Corresponding to remaining
_ _ _L J:_j in ....../_-L_1 and indicated
:_I-
by stippled
part of root, periodontal membrane space can be discerned to original radiograph
ott h r_._
-.

tili'
fibers
1_'
in buccal
_ _.

hile"'ment
" '

lingualplaque-covered part of tooth, although

_

eVen "'' f bifurcation it can befollowed. Infrabony pocket is located adjacent

rQ/''%raPb mesial and distal location. Marginal borderline of alveolar crest on lingual
o-
side-(AC) indicated in radiograph
-

-
only oft
suggests -f,-.- -J--
abutment for 7 years.
hemisectioning distal root has become firm and functioned as a bridge
v dnt
oiled line. After
Relationship Between the Subgingival Plaque and the
^SlJe'nfrabony pocket with its content of granulation
and the tooth surface with its subgingival plaque. Remaining Attachment Fibers
On all the extracted teeth a fairly close congruence
J.Ventually,this picture should be correlated with the
"Action of the occlusal forces. could be observed between the plaque front and the
 Figure 8 First mandibular molar in 39-year-old male.
pertodontal
Plaque control poor, severe gingivitis, purulent secretion from pocket, pai"/"'
abscess and excessive mobility. Mesial root removed
by hemisection and photographed from distal surface tfacM
interradicuar space) left and mesial surface right. Roo, covered with plaque except
for two small islands of attachment fibers on disd
and buccal surface his noteworthy that these attachment
fibers fixed tooth so well that the sectioned mesial root could not be removed
n^frnerS'i C?V<;redJ5 jurface Halfofthe tooth, large amounts of calculus under the plaque are also clearly visible in the radiograph-
rooTehllZnlT6
ZomlTJT 0fPC,ke'Sfnd production
' PP " of
of adequate plaque
months, and it is considered suitable for use as a bridge abutment.
infrabony pocket is 3 mm. Following roo, canal therapy of,he dista
control mobility was reduced to only a slightly increased level within i

Figure 9. Maxillaryfirst premolar in 32-year-oldfemale. Case diagnosed by referring dentist as periodontosis combined with traum0
occlusion. Personal plaque control excellent at time of extraction, but had not always been
good. No signs of gingival infiammai ^
Mobility slightly to markedly increased mainly in a bucco-lingual direction with the pressure being on the buccal side. Tooth
scaled during last 10 years, the last time about 4 months before
rePea,ef
extraction. Tooth shown from distal surface (left) and mesial sUfj
c(
^,
(right). Subgingival plaque control highly successful on buccal half of tooth where no supragingival nor subgingival
plaque preS j
is
width ofjunctional epithelium here is 2.5 mm. Subgingival scaling hadfailed completely on lingual halfof tooth where
to distance of 0.4 to 0.5 mm from remaining attachment fibers. Note efficient tooth cleaning by patient had removed
plaque refof ,

subgingival
P' ye
for distance of 0.5 to 1.0 mm below gingival margin, thus explaining lack of clinical signs of gingivitis. By comparing measurement " ,
in radiograph and on extracted tooth, subgingivalplaque was estimated to have been located about 1.0 mm from deepest part of infra
pocket. Corresponding to buccal part of root periodontal membrane space can be discerned and indicated by dotted line. Note ^
infrabony pocket is located on lingual side which was stretch-not pressure-side.
360
Vlurne 50 Pocket 361
Number 7 The Infrabony

GURli . Mandibular first molar in Patient had been treatedfor traumatic occlusion with removable splints in
40-year-old female.
a>V' Mb'h'y markedly increased in all directions. Personal plaque control excellent. Nomesialvisible sign of gingivitis, although there
i'Ois a Purulent shown mesial and distal surfaces of root and to right mesial and distal
secretion from the mesial pocket. left
To is
on root surfaces. In radiograph,
j
7ace of distal root. Lines are drawn from reference point in radiograph to correspondng areas
is well
on,al membrane is clearly discernible in upper part offurcation which is to be expected since periodontal membrane can
preServed on the tooth space facing furcation. On the mesial and distal surfaces periodontal space be
the
Se " " surfaces (center left and right)the attachment On mesial surface, subgingivalplaque
'he
it elated toradiographbone corresponding
and on parts of tooth surfaces fibers are seen.
On the buccal surfaces, subgingival plaque communicates with plaque around apices. Distance from
angular defect. facing
''cvered tooth surfaces to opposite alveolar bone as measured in radiograph is about 2.0 to 2.5 mm. On surfaces
intrrad'cular space, distance closest attachment fibers is 2.4 mm, which is considerably larger than normal, and which
is from plaque to
about 2 mm which is within
the result of mutual enhancement of destructive activity, since distance between the two roots is
^obably
range of destructive activity of subgingival plaque.
Table II. Distance from Plaque-front to Closest Attachment Fibers on
^maining attachment fibers (Figs. 1 to 10). Correspond-
the 48 Tooth Surfaces Corresponding lo the Deepest Part of the Infrabony
es^'stancethebetween
to of the
deepest part
these
the
infrabony pockets,
landmarks varied between
two
Pocket
Average

and 2.0 mm, the average being 0.53 mm (Table II). Range
mm
e carried
subgingival plaque control which had beenhad mm

0.2-2.2 0.53
^ut by the referring dentist or by the author,
substantially increasing the distance be-
not

t^nir'buted to
plaque front and the remaining attachment
Table [II. Distance from Subgingival Plaque* to Opposite Wall of
^eeners thealthough effect occasionally could be ob-
some
Infrabony Pocket as Measured in Radiographs of the
48 Cases

Average
erved in its outer part (Figs 1, 3, 4 and 9). Range
to is noteworthy that some of the
patients by means mm mm

1-3 1.8
k thbrush,
and particularly with the round interdental
extracted tooth.
.^rush, had been able to remove the subgingival plaque As verified
* on

the coronal 1 to 2 mm of the pocket (Figs 3, 5, 6, and

s '
Seelegends). reached the alveolar crest or even beneath it. This
Exact measurementof the distance from the plaque impression obviously resulted from radiographie
the
errors.
ntobserved on the extracted tooth to the alveolar
as The distance from the subgingival plaque to opposite
st as observed in the
radiograph could not be made wall of the infrabony pocket as measured in the radio-
j. r varied between 1 and 3 mm (Figs 1 to 10), the
k obvious reasons. However, by comparing distances graphs
etween landmarks on the extracted tooth and land- average 1.8 mm (Table III).
being
In six instances among which is the case illustrated in
/ks in the radiograph, it could be estimated that the the tooth
border of the alveolar crest had never been farther Figure 3, a gingivectomy was carried out beforewas
^'cal the plaque than about 2 mm (Figs. 2 and 4). was hemisectioned and the granulation tissue exca-
^ aymet,from
in many cases of deep infrabony pockets the vated from the infrabony pocket. By comparing the
easurement suggested that the plaque front had width of the curet (1.2 mm) with the distance from the

362 Waerhaug
tooth surface to the vertical wall of the pocket, it could
be estimated roughly that the distance never was less
than about 1.5 mm and seldon more than 2.5 mm.
Orientation of the Infrabony Pockets in Relation
Direction of the Occlusal Forces
As mentioned in the Materials and Methods section,
all the infrabony pockets as observed radiographically
were located mesially or distally. However, the clinical
examination revealed that some of them also continued
onto the buccal and/or lingual surface. In 39 of the 48
cases the possibility of tooth movement in a mesio-distal
direction could be excluded because tight contact with
one or both of the neighboring teeth did not allow
excursions in a mesio-distal direction. In the remaining
9 cases, mesio-distal movements were theoretically pos-
sible, but the clinical examination revealed that the
excursions were mainly oriented in a bucco-lingual di-
rection in connection with lateral movement of the man-
dible.
Degree of Mobility
The degree of mobility was recorded in only 36 cases
(Table IV). It was found to be excessively increased in
four cases, markedly increased in six cases, slightly in-
creased in 11 cases, and in the remaining 15 cases it was
within normal limits.
Fateof Remaining Hemisectioned Roots
The fate of the remaining root of 12 of the 19 hemi-
sectioned lower molars observed for 1 to 10 years
was
(Table V). Three roots had to be extracted because of
periapical involvement and one root because of extreme
mobility. The examination of the extracted root showed
that both supra and subgingival plaque control had been
inadequate. In the remaining eight cases the mobility
decreased to normal or very close to normal, and the
roots functioned well without further development of
angular bone defects or infrabony pockets.
Table IV. Degree of Mobility of 36 of the 48 Teeth
Degree of mobility Number of teeth
Normal
.
Slightly increased
Markedly increased
Excessively increased
Total.
Table V. Fate of 12 of 19 Hemisectioned Roots Which Were Observed
Over 1 to 10 Years
Extracted . 4
Number of years in function
I to 4.
5 to 8.
9 to 10.L*L*ii
Total
J. Periodont"'-
July. I'7'
Since periodontosis and trauma from occlusion are
sometimes coupled it may be mentioned that three of the
cases fitted fairly well into the diagnosis juvenile Perio-
dontitis. However, except for the fact that the infrabony
to the
pockets develop at an earlier stage in life than usual,
there was nothing to indicate that these cases differed
basically from the remaining ones.
Discussion
It should be kept in mind that the present material is
highly selected insofar as most of the teeth were extracted
because of the advanced Periodontitis, which was asso-
ciated with the development of the infrabony pockets-
However, this should not minimize its value for the
particular purpose for which it is used, rather the opp0'
site. Furthermore, most of the teeth were lower molars
This does not permit drawing the conclusion that infra'
bony pockets develop more frequently on lower molars
than on the remaining teeth. The reason is more likely
to be that infrabony pockets do not show up as easily '"
radiographs of upper molars, and single-rooted teeth are
not so often extracted, because they can be more easily
saved by adequate periodontal treatment.
The close congruence between the subgingival plaque
front and the remaining attachment fibers corroborates
earlier observations regarding the role of subgingiva
of loss of perio-
plaque in the etiology and pathogenesis
dontal fiber attachment,2, 9 10
and it shows that the
sequence of histological events is also the same in infra-
bony pockets.
The most pertinent observation which was made i"
the present material was that a fairly close three-dimen-
sional relationship existed between the front and surface
of the subgingival plaque and the architecture of the
intrabony pocket (Tables II, III). One of the great ad-f
vantages of the particular technique used here is that
makes it possible to correlate the observations made 'n
the radiograph with those made on the extracted tooth
One may ask if more information about the infrabon.y
pocket could be gained by removing all the granulation
tissue from it. To some extent that is right, but the
obvious shortcoming of this approach is that the clinician
15
will not be able to correlate the shape of the bone defec
with the distribution of the subgingival plaque, simp'^
11
6 because he cannot see it and he cannot probe it. Onty
4 one who is aware of the presence of the subging'v
36 plaque will be able to appreciate that its toxic substance5
will induce osteoclastic activity when it grows closer |
the bone than about 0.5 mm, and that its activity ^
decrease with increasing distance until an equilibri11
between rsorption and apposition will be reached at
distance of 2 to 2.7 mm as has been observed in autops.
material.2
2
4 Although direct measurement of the distance fr
2 plaque to bone along the tooth surface could not
made in the present material, the indirect measuremen
12 in the radiographs and on the extracted teeth indicate
vlume 50
Number 7
values which were well within the limits of 0.5 to
was observed in autopsy material.2
In the present context it was interesting to note that
'he distances from the plaque-covered tooth surfaces to
uie vertical walls of the as measured
infrabony pockets
'n the
radiographs were also found to range within the
Sarne limits (Table III). Also, these measurements cor-
respond very well with previous observations in two
autopsy cases in which the distance from subgingival
Plaque to bone as measured in the histologie sections
^as found to be 2 mm. This shows that the plaque has
about the same capacity to induce bone rsorption at a
r'ght angle to the tooth surface as it has along the same
surface.
The limited distance over which plaque is able to
'nduce bone rsorption in the three dimensions explains
'he characteristic architecture of the infrabony pockets.
n case the distance between two teeth is less than 1.5 to
2 mm,
subgingival plaque on only one of them will cause
an level of the interdental septum, i.e. an angular
oblique
ne defect. For a true infrabony pocket to develop, the
'nterdental septum must be thicker than 2 mm.
.
Another pertinent question to be answered in the
Present context is why subgingival plaque grows faster
ln an
apical direction on some teeth and some tooth
s"rfaces than on others. There are at least four valid
reasons:
'
Variation in the efficacy of the personal plaque con-
trl on the various tooth surfaces. A great number of
ePidemiological surveys have shown that personal
P'*ndaque control is most efficient on the vestibular surfaces
poorest on the interproximal surfaces. Whereas ef-
Clent toothbrushing on the vestibular and lingual sur-
ges will prevent subgingival plaque from being formed
the re, the lack of interdental cleaning will allow the
P'aque to grow freely into the pockets between the teeth.
"h a fairly ordinary speed of 0.5 per day the plaque
,rnt will advance about 5 mm below the gingival margin
jn
30 years,10 i.e. at age forty there will be a corresponding
Ss of attachment
interproximally, whereas little if any
a"achment is lost buccally and lingually. As long as the
aque front advances with the same speed on the two
j^ighboring teeth, an interdental crater will develop.
Owever, the plaque has advanced further on one
if
th than on its neighbor, there will be an angular bone
e'ect or an infrabony pocket.
k
Dental restorations. An overhang (Fig. 2) may have
**
^een left below the gingival margin on one of the neigh-
rmg teeth and not on the other, and with the overhang
^nies the plaque front.11 There is reason to assume that
ental restorations, placed below the gingival margin,
Cntribute substantially to the development of infrabony
control (scaling) on
Inadequate subgingival plaque
0>,e of the tooth others is another
and not
the
surfaces on
rnrnon reason for the development of infrabony pock-
* This is what had happened in the cases illustrated in
'gures 1, 3-7, and 9.
TheInfrabonv Pocket 363
2.7 as 4. Different time of eruption of neighboring teeth. In
case of juvenile Periodontitis even a different time of
eruption of two neighboring teeth may lead to infrabony
pockets between them. In such cases the subgingival
plaque front may advance with a speed of as much as 2
per day,1" which may amount to about 4 mm in 6
years. By the time the second molars and the cuspids
erupt, the subgingival plaque may be 4 mm below the
gingival margin on the first molars and on the lateral
incisors, and in a few years an angular bone defect or an
infrabony pocket may develop adjacent to these teeth.
This is what is fairly commonly seen in cases of juvenile
Periodontitis.9'1H
Only when the clinician appreciates that there are
many logical reasons why the plaque front has advanced
further on one tooth or one tooth surface than on the
others will he be able to understand why a infrabony
pocket has taken a particular shape. Even extremely
complicated radiographie bone configurations, such as
those seen in the radiographs of Figures 5 to 10 are easy
to explain when they are viewed with knowledge of the
distribution of the subgingival plaque on the teeth.
The next problem to be evaluated was in what way
and to what extent traumatic occlusal forces had contrib-
uted to the development of the infrabony pockets, or to
the modification of their architecture. In experimental
investigations on this problem angular bone defects
developed on surfaces which were oriented at a right
angle to the direction of the force, and preferably on the
pressure side. This location of the bone rsorption is to
be expected and can be explained as being the result of
compression of the periodontal membrane within the
alveolus, possibly combined with necrosis and subse-
quent hematogeneous infection of the necrotic tissue.12
In the present material the infrabony pockets did not
develop on the pressure side but rather on the surfaces
that were parallel to the direction of the occlusal forces,
i.e., mesially or distally, when the forces were oriented
bucco-lingually. Thus, there was no logical way of ex-
plaining how trauma from occlusion could have contrib-
uted to their development, even if it had been docu-
mented that such forces really had been in operation.
But only in four cases was the mobility excessive or
comparable to that reported in the experimental cases.
Whereas the typical architecture of the infrabony
pockets could be explained easily as being the result of
subgingival plaque alone, it was impossible to conceive
how functional forces could have contributed to that
particular shape. One possibility might be that the trau-
matic forces could stimulate the growth and progression
of the subgingival plaque in the depth of the infrabony
pocket, and that this activation could be independent of
the direction of the forces. But the fact still remains that
in the majority of the cases, the tooth mobility was
normal or very close to normal.
The fact that eight out of the 12 observed hemisec-
tioned roots (Table V) functioned well without further
development of angular bone defects or infrabony pock-
 364
Waerhaug
ets for periods varying
between 1 and 10 years, lends
support the
to conclusion that trauma from occlusion
had not contributed to the pathogenesis of the original
infrabony defects. Some of the roots which had been
markedly, or excessively mobile, immediately following
the hemisectioning, became firm after some months such
as was the case illustrated in Figure 10, in
spite of the
fact that the single root with reduced bone support had
to carry the load intended for the two roots.
This brings up the question as to what extent increased
mobility correctly reflects the severity of destructive peri-
odontal disease in general and trauma from occlusion in
particular. Out of the 36 cases in which the degree of
mobility was estimated, the mobility was found to be
normal in 15 instances and only slightly increased in 11
instances. It is noteworthy that the mobility in the cases
shown in Figures 2-4 was normal and was only slightly
increased in the cases shown in Figures 1, 5 and 7. This
despite the presence of extensive bone rsorption and an
infrabony pocket on one or more of the surfaces. Only
in the case illustrated in Figure 8 was the mobility
excessively increased. The reasons for this discrepancy
are simple: (1) If the infrabony pocket is
strictly limited
to one or two of the four surfaces of single-rooted teeth
(Fig. 7) there still may be two or three surfaces on which
there has been little, if any, bone loss. Further, if the
gingiva is kept healthy on these surfaces by adequate
plaque control, there will be no inflammation to increase
the mobility in the periodontal membrane below the
gingival complex and the tooth may be firm or slightly
mobile. (2) In the case of multirooted teeth, the infrabony
pocket may be localized to only one of the roots, whereas
the other root or roots may be supported by a healthy
periodontium displaying a normal mobility. If so, the
firm root(s) will obscure the potential mobility of the
involved root. This discrepancy between degree of mo-
bility and the loss of attachment is particularly pro-
nounced on maxillary molars with three roots where the
patient has maintained adequate plaque control buccally
and lingually, and where the trifurcation has been in-
vaded by plaque interproximally. Such teeth may exhibit
normal mobility until the subgingival plaque and the
bone destruction has reached the apex in the furcation
area.
The observations made in this material have revealed
clearly that the diagnosis of advanced periodontal disease
is associated with major difficulties. This is because the
etiologic factors are invisible to the clinician and so are
some of the most important symptoms. Other
symptoms
are totally misleading. Thus, the cause of the harmless
marginal gingivitis, the supragingival plaque, is visible,
whereas the cause of destructive submarginal gingivitis,
the
subgingival plaque, is invisible. The symptoms of
marginal gingivitis, the bleeding, the redness and the
swelling are visible, sometimes spectacular, whereas the
chronic inflammation in the soft tissue wall of the pocket
facing the subgingival plaque, i.e., the destructive sub-
J. Periodontol-
July. 19"
marginal gingivitis, is invisible; and if adequate supra-
gingival plaque control is maintained even the marginal
gingivitis disappears, leaving the impression that the
destruction was noninflammatory13' (Figs. 2, 3, 5, 6, 9,
14
and 10). The sequelae of the destructive Periodontitis,
the bone loss and the lysis of the periodontal membrane
fibers, will allow a steadily increasing mobility to occlusal
forces that remain constant, and sooner or later the tooth
will start to jiggle, i.e. to rock to and fro on lateral
excursions and forward movement of the mandible. A'
a certain stage of bone loss and
lysis of the attachment
fibers, even a touch with the tongue will cause jiggling-
The jiggling is visible, sometimes spectacular, and it gives
the immediate impression that the increased mobility is
the consequence of excessive occlusal forces and that the
jiggling caused the bone loss rather than the other way
around. Obviously, such a substitution of cause for effect
brings a formidable amount of confusion into the diag-
nosis of advanced periodontal disease and even more
into the treatment. To treat one of the symptoms of
destructive periodontal disease, the increased mobility'
by grinding or hiding it by splinting, will not stop the
apical migration of the plaque and the further develop-
ment of infrabony pockets.
Summary and Conclusions
The role of trauma from occlusion and subgingival
in the pathogenesis of the infrabony pocket as
plaque
observed in the radiograph was studied in 48 teeth which
had to be extracted because of advanced periodontal
disease. Prior to extraction the teeth were examined with
regard to the degree of mobility and the direction of the
horizontal components of the masticatory forces. Follow-
ing extraction, the teeth were stained and examined
under the stereomicroscope. When the tooth is ade-
quately stained, the subgingival plaque and the remain-
ing attachment fibers can be distinguished easily frorn
the area of the junctional epithelium. The observations
which were made on the extracted teeth were then
correlated with what could be seen in the radiograph-
The following major observations were made:
In the depth of the infrabony pocket there was a close
congruence between the front of the subgingival plaque
and the borderline of the remaining attachment fibers-
the distance varying between 0.2 and 2.0 mm. There was
also a close relationship between the front of the subgin-
gival plaque and the alveolar crest adjacent to the tooth
as well as between the surface of the subgingival plaque
and the opposite vertical wall of the infrabony
the distances ranging between 1 and 3 mm.
pocke'-
The horizontal forces were mainly or exclusively rl'
ented bucco-lingually, whereas the infrabony pockets
the
were located mesially or distally, i.e. parallel to
direction of the force and not at a right angle to it aS
observed in experimental studies.3"6
The mobility of the teeth adjacent to which infrabony
pockets developed was normal in 42% of the case5-
'flume 50 The Infrabony Pocket 365
^mber 7
References
sl'ghtly increased in 31%, and only in
*as
11% of the cases
1. Glickman, L, and Smulow. J. B.: Effect of excessive
it excessively increased. in
ta 19 cases the infrabony pocket located on one
was occlusal forces upon the pathway of gingival inflammation
T the roots of lower molars which were removed by humans. J Periodontol 36: 141, 1965.
2. Waerhaug, J.: The angular bone defect and its relation-
ternisection. In eight of the 12 cases, which were ob- occlusion and subgingival plaque. In press.
ship to trauma from1979.
erved for periods from 1 to 10 years, the remaining root J Clin Periodont,
3. Wentz, F. M., Jarabak, I., and Orban. .: Experimental
functioned well without further development of angular
ne defects or infrabony pockets. All of them became occlusal trauma imitating cuspal interferences. J Periodontol
29: 117, 1958.
markedly firmer as a consequence of successful perio- 4. Svanberg, G., and Lindhe. J.: Experimental tooth hyper-
stal treatment. Three of the four remaining roots were mobility in the dog. A methodological study. Odontol Rev
24:
e*tracted because of periapical problems. 269, 1973. from
There was no evidence to indicate that trauma from 5. Lindhe, J., and Svanberg. G.: Influence of trauma
the
occlusion on progression of experimental Periodontitis in
delusion had been involved in the pathogenesis of the Periodont 1: 3 1974.
Beagle dog. J Clin Periodontal
lr,frabony pockets. 6. Ericsson, J.: tissue reactions to jiggling and
orthodontic forces. Academic dissertation. Department of Per-
ihe Following Conclusions Were Drawn: iodontology and Orthodontics, University of Gothenburg.
The presence in the radiograph of an infrabony pocket Sweden.
7. O'Leary, T. J., and Rudd, K. D.: An instrument for
suggests that subgingival plaque covers the tooth surface measuring horizontal tooth mobility. Periodontics 1: 249, 1963.
l a distance of 1 to 2 mm from its
apical limitation, and 8. Waerhaug, J.: A method for the evaluation of periodontal
1975.
on extracted teeth. J Clin Periodont 2: 160,
"at the
plaque caused the bone rsorption.onThe reasons
teeth
problems
9. Waerhaug. J.: Subgingival plaque and loss of attachment
*hy subgingival plaque is located deeper some
in periodontosis as observed in autopsy material. J Periodontol
arid some tooth surfaces than on others are: (1) Varia-
47: 636. 1976.
uns in the efficacy of personal plaque control on the 10. Waerhaug, J.: Subgingival plaque and loss of attachment
Various surfaces. (2) The presence of subgingival resto- in periodontosis as evaluated on extracted teeth. J Periodontol
at'ons. (3) Variations in the time of eruption of two 48: 125. 1977.
neighboring teeth. 11. Waerhaug, J.: Presence or absence of plaque on subgin-
The infrabony pocket as radiograph
observed in the gival restorations Scand J Dent Res S3: 193. 1975.
12. Waerhaug, J., and Hansen, E. R.: Periodontal changes
es not diagnosis: trauma from occlusion.
justify the incident to prolonged occlusal overload in monkeys. Acta
The degree of mobility does not necessarily reflect the Odontol Scand 24: 91, 1966.
estructiveness of the periodontal condition, nor the 13. Waerhaug, J.: Healing of the dento-epithelial junction
^gn itude of the force to which a tooth has been ex- following subgingival plaque control. II As observed on ex-
tracted teeth. J Periodontol 49: 119. 1978.
Posed. patho-
14. Waerhaug, J.: The furcation problem, etiology,
^The diagnosis of destructive periodontal diseasefactors
rrriidable problems because both the etiologic
poses
genesis, diagnosis, therapy
accepted for publication.
prognosis.
and J Clin Periodont.

tld the main clinical symptoms are invisible and intan- 15. Waerhaug, The interdental brush
J.: and its place in
ale for the clinician and some of the symptoms are and and bridge dentistry. J Oral Rehabil 3:
operative crown

Pleading. 107, 1976.