osseous respective surgery

1. Resective osseous surgery
Presented By
Dr. M. Shiva Shanker
II Year Post Graduate Student ,
Dept of Periodontics, Mamata Dental College.

2. contents
• Introduction
• Anatomical form of bone
• Osteoplasty and Ostectomy
• Surgical approaches
• Techniques
• Summary
• References

3. introduction

4. NORMAL ALVEOLAR BONE MORPHOLOGY

5. MORPHOLOGICALLY DESCRIPTIVE TERMS

6. BONE DESTRUCTION PATTERNS IN
PERIODONTAL DISEASE
• Horizontal defects
• Vertical or angular defects
• Osseous craters
• Reversed architecture
• Bony ledges
• Furcation involvements
• Exostoses
• Bulbous bone contours

7. • Horizontal defects:

8. • Vertical or angular defects:
• Angular defects are classified on the basis of number of osseous walls.
• One walled defect
• Two walled defect
• Three walled defect
• Combined osseous defect.

9. • Exostoses :

10. • Osseous craters:

11. • Bulbous bone contours:

12. • Ledges:

13. Reversed architecture:

14. • Furcation involvement:
• Widow’s peaks: peaks of bone typically remain at the facial
and lingual / palatal line angles of the teeth.

15. OBJECTIVES
• Resolution of gingival inflammation.
• Accessibility of instruments to root surface.
• Elimination of periodontal pocket.
• Correct abnormal gingiva and alveolar bone morphologic
characteristics that interfere with plaque control.
• Regeneration of periodontal apparatus destroyed by
periodontal disease.
• Create environment suitable to restorative and prosthodontic
treatment.
• Esthetic improvement.

16. SELECTION OF TREATMENT TECHNIQUE

17. RESECTIVE OSSEOUS SURGERY
• osseous surgery may be defined as the procedure by which
changes in the alveolar bone can be accomplished to rid it
of deformities induced by the periodontal disease process or
other related factors, such as exostoses and tooth supra
eruption.
• Terms
• Definitive osseous reshaping
• Compromise osseous reshaping

18. HISTORICAL REVIEW
• The earlier rationale for osseous resective surgery was that the
bone surface was considered infected or necrotic and has to be
removed.
• In the late 1800s and early 1900s many therapists (G.V.BLACK ,
A.D.BLACK , S.ROBICSEK , A.CRANE , H.KAPLAN , A.WARD ,
and W. ZIESEL) advocated gingivectomy surgery with denudation
of radicular and interproximal crestal bone followed by some
osseous removal.
• Most of the early pioneers in flap surgery (R.NEUMANN ,
A.CIEZYNSKI , and A.ZENTLER) also removed bone because its
surface was considered necrotic.
• The classic work by R.KRONFELD in 1935 proved that the bone
was not infected or necrotic and therefore did not need to be

19. • Goldman (1950): "The Development of Physiologic Gingival
Contours by Gingivoplasty"
• Schluger (1949), '"Osseous Resection—A Basic Principle in
Periodontal Surgery"
• Friedman (1955), "Periodontal Osseous Surgery: Osteoplasty
and Osteotomy"
• Prichard (1957), "The Infrabony Technique as a Predictable
Procedure"
• Goldman and Cohen (1958), "The Infrabony Pocket:
Classification and Treatment

20. • Ochsenbein (1958), "Osseous Resection in Periodontal
Surgery"
• Prichard (1961), Gingivoplasty , gingivectomy and osseous
surgery.
• Ochsenbein (1986), "A Primer for Osseous Surgery"

21. INDICATIONS
• Residual osseous defect remaining after regenerative
procedures.
• Class I or class II furcation involvement.
• Facilitates certain restorative/prosthetic dental procedures
• Fractured roots for removal.
• Bony exostoses, interdental craters, shelflike bone, bony
protruberance.
• Short anatomic crowns can be lengthened by a combination
of orthodontic tooth extrusion.
• Optimal crown length for cosmetic purpose.

22. CONTRAINDICATIONS
• Position of the external oblique line in the mandibular molar
area and maxillary sinus, which is very close to the osseous
defect and root proximity.
• A periodontal pocket of more than 8mm exists after initial
therapy.
• The bottom of osseous defect extends apically against
multiple tooth–root trunks.
• The deep intrabony defect is more than 3-4mm or the bottom
of the osseous defect is more than one half of the root
length from the cemento enamel junction.
• Extended tooth mobility.

23. ADVANTAGES
• Reliable
• Short term (8-12 weeks)
• Obtain gingiva-alveolar bone morphology that facilitates easy
maintenance

24. DISADVANTAGES
• Attachment loss
• Root exposure
• Compromising esthetics
• Strong possibility of hypersensitivity
• Strong possibility of root surface caries
• Possibility of phonetic impediment

25. EXAMINATION AND TREATMENT
PLANNING
• Signs and symptoms of periodontitis, inflamed gingiva with
plaque and calculus, increased flow of GCF and bleeding on
probing and exudation are commonly found in suitable
patients.
• Pocket depth greater than normal gingival sulcus, base of
the pocket relative to the mucogingival junction and the
number of bony walls, presence of furcation defects should
be observed.

26. Gingival examination:
• Physiologic gingival contour
• Clinical attachment level
• Width of the attached gingiva
• Thickness of the gingiva

27. • Transgingival probing
•

28. • Routine dental radiographs donot accurately document the
extent of bony defects.
• Well made radiographs provide useful information about
interproximal bone loss, caries, and root trunk length and root
morphology.

29. BASIC RULES OF OSSEOUS SURGERY
• Rule-1 A full-thick ness mucoperiosteal flap should be
raised.
• Rule- 2a. The scalloping of the flap should anticipate the
final underlying osseous contour, which is more prominent
anteriorly and decreases posteriorly.
• Rule -2b. The scalloping of the flap should reflect the
patient’s own healthy gingival architecture.
• Rule-2c. The degree of tissue and bone scalloping is
reduced, as the interproximal area becomes broader as a

30. • Rule-3. Osteoplasty generally precedes Ostectomy
• Rule-4. Osseous resective surgery whenever possible should
result in a positive osseous architecture.
• Rule-5. High-speed rotary instrumentation should never be
used adjacent to the teeth for fear of nicking and damaging
the teeth and should always be used with a generous spray.
• Rule-6. The final bony contours should approximate the
expected healthy postoperative gingival form with no attempt
to improve upon it.

31. ARMAMENTARIUM
• A number of rotary and hand instruments have been used for
osseous resective surgery.
• Rotary for osteoplastic steps
• Hand for ostectomy steps

33. TECHNIQUE
• Procedures used to correct osseous defects have been
classified in two groups:
• Osteoplasty: refers to reshaping the bone without removing
tooth-supporting bone.
• Ostectomy: removal of tooth supporting bone.

34. Osteoplasty:
• Def; It is a plastic procedure by which non supporting bone is reshaped
to achieve a physiological gingival and osseous contours.
Indications
• Pocket elimination
• Tori reduction,
• Intra bony defects adjacent to edentulous ridges
• Incipient furcation involvement
• Thick heavy ledges and exostoses
• Shallow osseous craters
• Small intra bony defects

35. • Osteoplasty includes
the techniques of
grooving or festooning
(ochsenbein, 1958) and
radicular blending
(carranza, 1984).
• Vertical grooving or
festooning is designed
to reduce the buccal
and lingual thickness
of bone interdentally.

36. • These grooves are carried to the line angles of adjacent
teeth and determine the buccolingual width of the bone.
• Using a round no. 6, 8 or 10 bur in a high speed handpiece
with copious amounts of water, the grooves are cut.

37. • Once the vertical grooves are
completed , radicular blending
is begun , using the same
size bur. The bur is moved
with sweeping stokes as if
one were painting, back and
forth ,rising over the root
prominences and falling into
depressions created by
grooves.
• This is continued until an even
flowing osseous form is
created .

38. • Upon completion of radicular blending , a flat crest of bone
is left interproximally at the same level as the radicular
surfaces.
• Generally this is not acceptable because the gingival tissue
will inherently form a scalloped contour with a pyramidally
shaped papilla regardless of underlying bony contours.
• The end result if no further osseous surgery is done will be
a residual tissue pocket of 4-5mm.

39. Ostectomy
• Def; It is the plastic removal of radicular and interradicular
supporting bone to eliminate osseous deformities.
Indications
• Sufficient bone remaining for establishing physiologic contours
without attachment compromise
• No esthetic or anatomic limitations
• Interdental craters
• Intrabony defects not amenable to regeneration
• Horizontal bone loss with irregular marginal bone height
• Moderate to advanced furcation involvements
• hemisepta

40. Contraindications
• Areas of insufficient remaining attachment or where ostectomy
might unfavourably alter the prognosis of the adjacent teeth
• Anatomic limitations (prominent external oblique ridge ,
zygomatic arch)
• Esthetic limitations (anteriorly , high smile line etc)
Advantages
• Predictable pocket elimination
• Establishment of physiologic gingival and osseous architecture
• Establishment of a favorable prosthetic environment

41. Disadvantages
• Loss of attachment
• Esthetic compromise
• Increased root sensitivity

42. • Ostectomy is done by the technique of spheroiding or parabolizing.
• Parabolizing is the removal of supporting bone to produce a
positive gingival and osseous architecture.
• This can be achieved by
Horizontal grooving
Scribing
Hand instrumentation

43. • Horizontal grooving is the
technique by which a small
round bur in a high speed
hand piece is placed
interproximally at the base of
the osseous defect and
drawn buccally and lingually.
This flattens the interproximal
area in a buccolingual
direction but not in a
mesiodistal direction.

44. • Scribing is the technique
by which high speed
rotatory instrumentation is
used to outline on the
radicular bone , that bone
which is to be removed by
hand instrumentation.
• This provides a visual
outline that facilitates the
use of hand chisels for
final bone removal.

45. Before and after osseous resection

46. FLAP PLACEMENT AND CLOSURE
• Flap may be replaced to their original level to cover the new
bony margin or they may be apically positioned.
• Replacing the flap in the areas that previously had pockets
may result initially in greater post operative pocket depth,
although a selective recession may diminish the depth over
time.

47. • Positioning the flap to expose the marginal bone is one
method of altering the width of the gingiva, but results in
more post surgical resorption of bone and patient discomfort.
• Sutures should be placed with minimal tension to coapt the
flaps, prevent their separation and maintain the position of
the flaps.

48. POSTOPERATIVE MAINTENANCE
• Nonresorbable suturing materials should be removed one
week after healing. Newer synthetic material can be left for
upto of 3 weeks. Resorbable sutures will get resorbed by 1-
3 weeks .
• Suture removal should be accomplished without dragging
contaminated portions of the suture through the periodontal
tissues. This is done by lightly compressing the soft tissues
immediately adjacent to the suture. Suture is then cut at the
gingival surface.

49. • Chlorhexidine digluconate is a valuable adjunct to postsurgical
maintenance.
• Professional prophylaxis should be done every two weeks
until healing is complete or the patient is maintaing
appropriate levels of plaque control. It is usually advisable to
wait minimum period of six weeks before beginning dental
restorations.

50. SPECIFIC OSSEOUS RESHAPING
SITUATIONS
• One wall hemiseptal defects-Bone to be reduced to the level
of most apical portion of the defect.
• One wall defects next to edentulous spaces-Edentulous ridge
is reduced to the level of osseous defects.
• Dilacerated roots, root proximity, and furcations- Compromised
by osseous surgery.

51. • The walls of the crater may be reduced at the expense of
the buccal , lingual or both walls. The reduction should be
made to remove the least amount of alveolar bone required
to
• produce a satisfactory form,
• prevent the therapeutic invasion of furcations
• blend the contours with the adjacent teeth.
• The selective reduction of bony defects by “ramping” the
bone to the palatal or lingual to avoid involvement of
furcations has been advocated by Ochsenbein and
Bohnnan(1964).

52. • if a tooth in a surgical field has one-walled defects on both
its mesial and distal surfaces, the severely affected, tooth
may be extruded by orthodontic therapy to eliminate the need
for resection of bone from the adjacent teeth.
• Heavy ledges-Osteoplasty first to eliminate any exostoses or
reduce the buccal/lingual bulk of the bone.

53. Crown lengthening
• Restoration of fractured , severely decayed , partially erupted , worn or
poorly restored teeth is often difficult.
• Periodontal exposure or prophylactic lengthening of these teeth must
adhere to certain biologic principles and an adequate biologic width must
be maintained.
• Biological width is the term applied to the dimensional width of the
dentogingival junction (epithelial attachment and underlying connective
tissue ) .
• Garguilo et al 1961 quantified this as almost a constant 2.04mm
(epithelial attachment is 0.97mm and connective tissue is 1.07mm) with a

54. • Biological width is defined as the sum of the combined supracrestal fibers
, the junctional epithelium and the sulcus (Nevins & Skurow 1984).
• Biological width should be 3mm when measured from the crest of bone.
• Tooth lengthening procedures often employ some combination of tissue
removal , osseous surgery and orthodontics.
• The amount of tooth structure exposed (4mm) must be enough to permit
proper tooth preparation and account for an adequate marginal placement.
• Impingement of the restoration on this zone results in bone resorption.

55. • In crown lengthening
there are two
methods , coronal
extension and apical
extension.

56. • Apical extension of the crown is achieved by surgery such as
gingivectomy and apically positioned flap surgery with and
with out osseous resection.
• Coronal extension is achieved by surgical or orthodontic
extrusion and post and core.

58. osseous changes from osseous
resective surgery and flap surgery
• The quantity of supporting bone removed by ostectomy
varies according to the depth of the intrabony defect, the
position of the intrabony defect, the mesio-distal width of the
interproximal area, the general anatomy of the area (thin-
thick) and the relative position in the dental arch (incisors-
molars).
• Selipsky (1976) demonstrated that even though a
considerable amount of bone is removed on one surface of
the tooth, the mean bone reduction per tooth is negligible.
Tooth mobility also increased after surgery but gradually
returned to or below the presurgical level by the end of 1
year.

59. • Aeschlimann et al (1979) by measuring stone models made
from impressions taken on ten patients before and
immediately after osseous recontouring in conjunction with
apically positioned flap, reported a mean bone height removal
of 0.22mm.
• Smith et al. (1980) examining the results of "carefully defined
and standardized“ osseous resective surgery performed on 12
patients with moderate periodontal destruction, reported that
the mean height of marginal bone removed was 1.2mm.

60. • Carnevale & Fuzzi (1995),performing osseous resective
surgery in 14 patients with the objective of lengthening
clinical crowns, removed a mean marginal bone height of
0.62 mm in the interproximal areas and 1.04mm on the
buccal or lingual surfaces.
• The mean height of bone removed during osseous resective
surgery, as reported by the different authors (selipsky 1976,
smith 1980) varied from 0.06 to 1.2mm.

61. Remodeling of nonsupporting bone after
osseous resective surgery
• The quantity of bone remodeling after osseous resective
surgery has not been reported, but there is a general
agreement that thin bone is more affected than thick bone
(Pennel , wildermann MN).
• Pennel et al.(1967) stated that "in patients where the alveolar
bone was initially classified as thin, osseous reduction
rendered the bone far thinner than would be necessary or
desirable in a therapeutic procedure“.

62. • Wilderman et al.(1970) also stated that microscopic evidence
indicated that more bone loss and less bone repair occurred
in the thin alveolar bone specimens while the reverse was
true in the thick alveolar bone specimens.

63. Bone loss and remodeling after flap elevation
without osseous resective surgery
• The quantities of supporting bone loss and remodeling that
have been reported range from no resorption to 0.8 mm loss
of supporting bone. (Ramfjord SP , Smith , Wilderman).
• Differences in the wound-healing response between full
thickness and partial thickness mucoperiosteal flaps have
been reported, with neither having a clear clinical advantage
over the other.(Pfeifer , Wood , Donnenfeld).

64. conclusion
• The results from osseous resective surgery are technique
sensitive.
• It has limited use in treating cases with very deep intrabony
or hemiseptal defects, which should be treated with a
different surgical approach.
• If osseous resective surgery is used in advanced lesions, a
compromise in the amount of probing depth reduction should
be expected.

65. references
• Carranza, resective osseous surgery, pg no 950-967.
• Rose and mealey, Resective osseous surgery, pg no 502-552.
• Grant, periodontal osseous resection, pg no 838.
• Prichard, Periodontal osseous surgery, pg no-437.
• Soft tissue regrowth following Fiber Retention Osseous Resective
Surgery or Osseous Resective Surgery. A multilevel analysis,
Francesco Cairo, JCP 2015.
• Osseous resective surgery with and without fibre retention
technique in the treatment of shallow intrabony defects: a split-
mouth randomized clinical trial, Mario Aimetti, JCP 2015.
• The Use of a Disclosing Agent During Resective Periodontal
Surgery for Improved Removal of Biofilm, open dental journal,
2012.