resective osseous surgery

1. RESECTIVE OSSEOUS SURGERY
Viola Esther
IIIyr PG

2. INTRODUCTION
The aim of surgical periodontal pocket therapy is
to eliminate or reduce the periodontal pocket depth, to
achieve a healthy periodontium and to create a
periodontal tissue architecture that facilitates the self
performed oral hygiene measures by the patient.
The ideal method to treat periodontal pocket and
periodontal bony defects is regeneration of periodontium
Other method is to remove the walls of the bony
defect and removal of associated pocket wall,
thereby recontouring the bone and placing the gingiva
in a more apical position.

3. “Resective osseous surgery” 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. CARRANZA

4. HISTORY
1.Goldman (1950),“The Development of Physiologic Gingival Contours
by Gingivoplasty”
2. Schluger (1949), “Osseous Resection—A Basic Principle in
Periodontal Surgery”
3. Friedman (1955), “Periodontal Osseous Surgery: Osteoplasty and
Ostectomy”
4. Prichard (1957), “The Infrabony Technique as a Predictable
Procedure”
5. Goldman and Cohen (1958), “The Infrabony Pocket: Classification
and Treatment”
6. Ochsenbein (1958), “Osseous Resection in Periodontal Surgery”
7. Ochsenbein (1986), “A Primer for Osseous Surgery”

5. TERMINOLOGY
OSSEOUS SURGERY :
• Aspect of periodontal surgery which deals with the
modification of the bony support of the teeth
( World Workshop – 1989)
• Friedman : surgical removal & reshaping of the bone to
eliminate the pocket and correct unphysiologic bone
architecture.

6. •Sims and Carranza (1996) : procedure by which
changes in the alveolar bone can be accomplished to
rid it of deformities induced by periodontal disease
process or other related factors – exostosis & tooth
supraeruption.
• Glossary of Periodontal terms : (1992) periodontal
surgery involving modification of the bony support of
the teeth.

7. • Osteoplasty : reshaping of the alveolar process to
achieve a more physiological form without removal of
supporting bone .
• Ostectomy : bone that is part of the attachment
apparatus, is removed to eliminate a periodontal
pocket and establish gingival contours that will be
maintained .
Friedman 1955

8. NORMALALVEOLAR BONE
MORPHOLOGY

9. MORPHOLOGICALLY DESCRIPTIVE
TERMS

10. CLASSIFICATION OF OSSEOUS SURGERY
• Additive/Regenerative
• Substractive/Resective
▫ Definitive
▫ Compromised

11. OBJECTIVES OF RESECTIVE OSSEOUS
SURGERY
• The primary objective of resective osseous
surgery is to remove osseous deformities and
creation of physiological contour of the gingiva.
• Elimination of periodontal pockets and
the creation of shallow gingival sulcus that can
be readily maintained by the patient.
• To create a periodontal tissue contour that
permits to accomplish effective plaque control.

12. • To create gingival contour that closely matches
the contour of gingiva after healing.
• To permit primary closure of the flap margins.
• To create additional crown length for proper
construction of restorations.

13. INDICATIONS
Carranza
• To recontour bone that forms part of the outer
wall of the pocket
• To prevent recurrence of the pocket
• To reshape the alveolar crest, establishing a
normal fiber arrangement.

14. World Workshop in Periodontics
• Buccal or lingual bony ledges, tori
• Intrabony defects associated with tilted molars
• Shallow buccal or lingual intrabony defects
• The elimination of deep interproximal defects to
achieve physiological contour
• Incipient furcation involvement
• For improvement of alveolar contours for flap
adaptation

15. • Shallow intrabony defects around a tooth with sufficient
periodontal support
• Existence of non supporting bone that could affect a
periodontal pocket or hinders flap adaptation
- Thick alveolar bone margin
- Shelf like bone
- Bony protruberance
- Exostosis
- Interdental craters
-Thick alveolar bones around the intrabony
defect

16. • Residual osseous defect after regenerative therapy
• Irregularity of bone morphology related to hemisection
or root amputation
• Clinical crown lengthening for restorative/ prosthetic
treatment
• Deep caries or crown fracture extending subgingivally
• Class I and Class II furcation involvement

17. 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.

18. • Operating in the aesthetic zone.
• Removal of supporting bone during ostectomy will
unduly compromise the attachment of teeth at the edge
of the operative field.
• Where a risk of root caries is considered high.
• Cases where patients have experienced problems
controlling root hypersensitivity.

19. DIAGNOSIS
• History
• Clinical probing
• Radiographs
• Transgingival probing/Bone sounding

20. Bone sounding

21. TREATMENT PLAN
1. Solution for Active Periodontal Disease
2. Correction of Deformities
3. Facilitate performance of other dental procedures

22. FACTORS INFLUENCING TREATMENT PLAN
Types of bone defect
• Horizontal defects
• Vertical or angular defects
• Osseous craters
• Reversed architecture
• Bony ledges
• Furcation involvements
• Exostoses
• Bulbous bone contours

23. 4
Angular defect Exostoses
Crater Bulbous bony contours
.

24. 4
• Ledge Reverse Architecture

25. Root form & trunk

26. Tooth inclination

27. INSTRUMENTATION
Rotary instruments
B, Carbide round burrs : friction grip, surgical-
length friction grip, and slow speed
hand-piece.
C, Diamond burrs.
Hand instruments
A, Rongeurs: Friedman (top) and 90-degree
D, Interproximal files: Schluger and Sugarman.
E, Back-action chisels.
F, Ochsenbein chisels.

28. BASIC PRINCIPLES OF RESECTIVE OSSEOUS
SURGERY
• Rule 1: A full-thickness mucoperiosteal flap should
be used whenever resective osseous surgery is
contemplated.
• Rule 2a: The scalloping of the flap should anticipate
the final underlying osseous contour, which is most
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.

29. • Rule 3: Osteoplasty generally precedes
ostectomy.
• Rule 4: Resective osseous surgery should,
whenever possible, result in a positive osseous
architecture.
• Rule 5: High-speed rotary instrumentation
should never be used adjacent to 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 on it.
Cohen

30. STEPS INVOLVED IN OSSEOUS RESECTION
• OSTEOPLASTY
▫ Vertical grooving
▫ Radicular blending
• OSTECTOMY
▫ Flattening interproximal bone
▫ Gradualising marginal bone
▫ (horizontal grooving, scribing, hand instrumentation)

33. Flap management
• Adapt over the alveolar process
• Thinning of flap
• Esthetic areas- papilla preservation techniques
• Palatal defect-palatal approach

34. MANAGEMENT OF OSSEOUS DEFECTS
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35. 35/
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36. Management of deep craters
36

38. Management of palatal osseous defects

39. Heavy ledges and
blunt interproximal
septae
Vertical
grooving
festooning
scribing ostectomy
Management of blunt interdental septa

40. Management of bony ledges

41. Bone contouring in one wall
vertical defect

42. Management of multiple osseous
defects

43. Management of edentulous ridge
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44. Bone contouring in exostoses

45. Management of furcation involvement
• Tunnel preparation
• Root resection
• Hemisection

46. HEALING AFTER OSSEOUS SURGERY
• Caffesse et al (1968)
Bone deposition – remodeling
Inflammatory response – superficial
necrosis of alveolar crest
Osseous surgery

47. STUDIES REGARDING RESECTIVE OSSEOUS
SURGERY
Pennel et al reported measurements of 34
teeth from 20 patients with postsurgical healing
intervals ranging from 14 to 545 days. The
average posthealing reduction of the alveolar
crest was 0.54 mm.

48. Donnenfeld et al evaluated three
patients after an osteoplasty. Measurements
made immediately after the osseous surgery and
at re-entry 6 months later revealed a mean
interradicular bone loss of 0.6 mm and a mean
radicular bone loss of 1 mm.

49. Moss assessed the effect on the viability of
the bone surrounding bur contact and found less
damage adjacent to cuts made with highspeed
burs as opposed to lower-speed burs.
Horton et al reported that bony defects made
by a chisel had a more rapid rate of healing than
those made by a 557 cross-cut fissure bur in a
low-speed handpiece.

50. CONCLUSION
The main objective of resective osseous
surgery this therapy is achieving periodontal soft
and hard tissue architecture which is most
conducive for self oral hygiene maintenance by
the patient.
Resective osseous surgery provides the surest
method of reducing pockets with an intrabony or
hemiseptal osseous component of 3 mm or less,
albeit at the expense of some attachment in the
neighboring less involved sites.