Resective osseous surgery

Bone loss has been classified as either:

1. Vertical bore loss.
2. Horizontal bone loss results in a relative thickening of marginal
alveolar bone
3. Combination.

Osseous surgery:
It is 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.

Types:
1. Resective (subtractive):
Procedure directed to restore the form of preexisting alveolar bone to the level
existing at the time of surgery or slightly more apical to this level.
2. reconstructive (additive):
Procedures directed at restoring the alveolar bone to its original level.

Selection of treatment technique:

Morphology of osseous defects will determine the treatment technique:
1. Three-wall defect  bone regeneration.
2. Two-wall defect  both regeneration and resection.
3. One-wall defect  resection.
4. Interdental crater  resection.

Rationale:
The goal of osseous resective surgery is reshaping of the marginal bone to
resemble the alveolar process undamaged by periodontal disease.
- The technique is performed in combination with apicaly displaced flap,
and the procedure eliminates periodontal pocket depth and improve the
tissue contour to provide a more easily maintainable environment.
- It is proposed that the conversion of the periodontal pocket to a
shallow gingival sulcus enhances the patient’s ability to remove plaque
and oral debris from the dentition.
- The efficacy of osseous surgery is dependent on its ability to affect
pocket depth and promotes periodontal maintenance.

Normal alveolar bone morphology:

1. The interproximal bone is more coronal in position than labial or
lingual/ palatal bone and pyramidal in form.
2. The form of interdental bone is a function of the tooth form and the
embrasure width.
o More tapered tooth  more pyramidal bony form.
o Wider embrasure  more flattened interdental bone
mesiodistally and buccolingually.

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 3. The position of the bony margin mimics the contours of the
cementoenamel junction.
Osteoplasty: it is reshaping of bone without removing the supporting bone.
Osteoectomy: it is reshaping of bone with removal of supporting bone.

Morphological descriptive terms:

Ideal osseous form:

The bone consistently more coronal on the interproximal surfaces than on the facial
and lingual surfaces. Similar interdental height, with gradual, curved slops between
interdental peaks.

Flat architecture:
The interdental bone at the same level with radicular bone.

Positive architecture:
The interdental bone at the level coronal to radicular bone.

Negative architecture:
The interdental bone at the level apical to radicular bone.

Procedure:
 Soft tissue palpation.
 Radiographic examination.
- Provide information about the interproximal bone loss, the presence of
angular bone loss.
- It does not identify the presence of periodontitis, not accurately
document the extent of bony defect or the number of bony walls remains.
- It can indicate the presence of intrabony pocket when:
1. Angular bone loss.
2. Irregular bone loss.
3. Pocket of irregular depth in adjacent areas of the same tooth or
adjacent teeth are found.

 Probing.
It reveals the presence of:
1. Pocket depth greater than that of normal gingival sulcus.
2. The location of the base of pocket relative to the mucogingival
junction and attachment level on adjacent teeth.
3. The number of bony walls.
4. The presence of furcation defects.

 Trans-gingival probing (sounding):

- Under local anesthesia confirms the extent and configuration of the
intrabony component of the pocket or furcation defects.
- The probe walks along the tissue-tooth interface to feel the bony
topography.
- The probe may pass horizontally through the tissue to provide three-
dimensional information regarding bony contours.

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  Apicaly displaced flap.
 Osseous resection.
Osseous resection technique:
Instrument:
1. Rongeurs.
2. Carbide burs.
3. Diamonds bur.
4. Interproximal files (Schlugar and Sugarman).
5. Back action chisel.
6. Ochsenbein chisel.

Technique:
1. Vertical grooving (osteoplasty):
- It is the first step because it can define the general thickness and
subsequent form of alveolar housing.
- It is usually done by rotatory instruments as carbide or diamond burs.
- it is designed to:
1. Reduce the thickness of the alveolar housing.
2. Provide relative prominence to the radicular aspect of the teeth.
3. Provide continuity from interproximal surface onto the radicular
surface.

Indications:
1. Thick, bony margins, shallow crater formations.
2. Areas require maximal osteoplasty and minimal osteoctomy.

Contraindication:
Areas with close root proximity or thin alveolar housing.

2. Radicular blending (osteoplasty):

- It is an attempt to gradualize the bone over the entire radicular surface to
provide the best results from vertical grooving.
- It provides smooth, blended surface for good flap adaptation.

Indications:
Thick ledges of bone on the radicular surface.

Contraindication:
Minor vertical grooving or thin, fenestrated radicular bone.

Both vertical grooving and radicular blending may be used for treatment of:
1. Shallow crater formation.
2. Thick osseous ledges of bone in radicular surface.
3. Class I and early class II furcation involvement.

3. Flattening Interproximal bone (osteoctomy):

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 Removal of very small amount of supporting bone.

Indications:
1. Interproximal bone varies horizontally.
2. One-walled interproximal defect.
4. Gradualizing marginal bone (osteoctomy):
- Minimal bone removal to provide a sound, regular base for gingival
tissue to follow.
- Failure to remove the widow peak (Peaks of bone remain at the facial,
lingual/ palatal line angles of the teeth) allows the tissue to rise to higher level
than the base of the bone loss in the interdental area.
- Hand instruments as chisel and curette are favorable over rotatory
instruments.

Specific osseous reshaping situation

The osseous corrective procedures are applied to shallow craters with heavy
faciolingual ledges

Correction of one walled hemiseptal defect:

- The bone should reduce to the level of the most apical portion of the
defect.
- It required removal of some bone on the side with greatest coronal
bony height. This result in significant reduction in attachment on relatively
unaffected adjacent teeth to eliminate the defect.
- If the tooth has one wall defect on both its mesial and distal surfaces,
the severely affected tooth may be extruded by orthodontics during disease
control to minimize the need for resection of bone from the adjacent teeth.
- If one walled defect occurs next to edentulous area, the edentulous
ridge is reduced to the level of the osseous defect.

In case of exostoses, malpositioned or supraerupted

tooth:
- Osteoplasty to eliminate the exostoses or reduce the buccal/ lingual
bulk of bone.
- It is common to incorporate adegree of vertical grooving during
reduction of the bony ledges, since it facilitate the process of blending the
redicular bone into interproximal areas.
- Previous 4 steps.

In the absence of ledges or exostoses:

- Reduction of interdental walls of craters and the one-walled
component of angular defects and wells, and grooving into sites of early
involvement.
- The walls of the crater may reduced at the expense of the buccal,
lingual or both walls.

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- The reduction should be made to remove the least amount of alveolar
bone required to produce a satisfactory form, prevent furcation and blend the
contour with adjacent tooth.
- The selective reduction of bony defects by ramping the bone to the
palatal or lingual to avoid involvement of the furcations.

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