Resective osseous surgery

Presented By

Dr. M. Shiva Shanker

II Year Post Graduate Student ,

Dept of Periodontics, Mamata Dental College.

contents

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

introduction

NORMAL ALVEOLAR BONE MORPHOLOGY

MORPHOLOGICALLY DESCRIPTIVE TERMS

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

• Horizontal defects:

• 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.

• Exostoses :

• Osseous craters:

• Bulbous bone contours:

• Ledges:

Reversed architecture:

• Furcation involvement:

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

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 prosthodontictreatment.

• Esthetic improvement.

SELECTION OF TREATMENT TECHNIQUE

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

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 removed.

• 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: Osteoplastyand Osteotomy"

• Prichard (1957), "The Infrabony Technique as a Predictable Procedure"

• Goldman and Cohen (1958), "The Infrabony Pocket: Classification and Treatment

• Ochsenbein (1958), "Osseous Resection in Periodontal Surgery"

• Prichard (1961), Gingivoplasty , gingivectomy and osseous surgery.

• Ochsenbein (1986), "A Primer for Osseous Surgery"

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.

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.

ADVANTAGES

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

DISADVANTAGES

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

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.

Gingival examination:

• Physiologic gingival contour• Clinical attachment level• Width of the attached gingiva• Thickness of the gingiva

• Transgingival probing

•

• 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.

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 result of bone loss.

• 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.

ARMAMENTARIUM

• A number of rotary and hand instruments have been used for osseous resective surgery.

• Rotary for osteoplastic steps • Hand for ostectomy steps

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.

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

• Osteoplasty includes the techniques of grooving or festooning (ochsenbein, 1958) and radicular blending (carranza, 1984).

• Vertical grooving or festooning is designed to reduce the buccaland lingual thickness of bone interdentally.

• 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 handpiecewith copious amounts of water, the grooves are cut.

• 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 .

• 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 pyramidallyshaped 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.

Ostectomy• Def; It is the plastic removal of radicular and interradicularsupporting 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

Contraindications• Areas of insufficient remaining attachment or where ostectomymight 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

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

• 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 groovingScribingHand instrumentation

• 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 buccolingualdirection but not in a mesiodistal direction.

• 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.

Before and after osseous resection

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.

• Positioning the flap to expose the marginal bone is onemethod of altering the width of the gingiva, but results inmore post surgical resorption of bone and patient discomfort.

• Sutures should be placed with minimal tension to coapt theflaps, prevent their separation and maintain the position ofthe flaps.

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.

• 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 maintaingappropriate levels of plaque control. It is usually advisable to wait minimum period of six weeks before beginning dental restorations.

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.

• 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).

• 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.

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 sulcus depth of 0.69mm.

• 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.

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

• 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.

osseous changes from osseousresective surgery and flap surgery• The quantity of supporting bone removed by ostectomyvaries 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.

• 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.

• Carnevale & Fuzzi (1995),performing osseous resectivesurgery 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 resectivesurgery, as reported by the different authors (selipsky 1976, smith 1980) varied from 0.06 to 1.2mm.

Remodeling of nonsupporting bone afterosseous resective surgery

• The quantity of bone remodeling after osseous resectivesurgery 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“.

• 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.

Bone loss and remodeling after flap elevationwithout 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).

conclusion

• The results from osseous resective surgery are technique sensitive.

• It has limited use in treating cases with very deep intrabonyor 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.

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.