Resective Osseous Surgery Dr. Manal Bazina

Resective Osseous Surgery Osseous surgery: the procedure by which changes in the alveolar bone can be accomplished to rid it of deformities induced by the periodontal disease or other related factors, such as exostoses .

Bone destruction patterns in periodontal diseases: 1- Horizontal bone loss 2- Bone deformities (osseous defects) * vertical, angular defect * osseous crater * bulbous bone contour * reverse architecture * ledge * furcation involvement

CEJ-Alveolar Crest (Parallel) 1- Horizontal bone loss CEJ-Alveolar Crest (Parallel)

CEJ-Alveolar Crest (X Parallel) 1- Angular bony defect CEJ-Alveolar Crest (X Parallel)

2- Angular bony defect angular bony defect

2- Angular bony defect Combined type

2- Osseous crater Concavities in the interdental bone confined within the F. & L. walls Two-walled defects/craters occur at the expense of the interseptal bone. As a result, they have buccal and lingual/palatal walls that extend from one tooth to the adjacent tooth.

3- bulbous bone contour

4- Reverse architecture

5- Ledges

6- Furcation involvement

Resective Osseous Surgery Osseous surgery *addictive (reconstructive) restoring the alveolar bone to its original level *subtractive (resective) restoring the form of the pre-existing alveolar bone to the level present at the time of the surgery or slightly apical to this level

Osseous surgery *subtractive *addictive

Selection of treatment technique: According to the morphology of the osseous defect One-wall angular defects→→→ recontoured Three wall defects (narrow and deep) →→ reconsturcted Two-wall angular defects can be treated with either method, depending on their depth, width, and general configuration.

Rationale 1. to reshape the marginal bone to resemble that of the alveolar process undamaged by periodontal disease (the purest, surest and most predictable method for reducing pockets with bony discrepancies) 2. to enhance the patient’s ability to remove plaque and oral debris 3. to achieve more effective maintenance therapy and greater longitudinal stability

Normal alveolar bone morphology: 1. The interproximal bone is more coronal in position than the labial or lingual bone and pyramidal in form 2. the form of the interdental bone is a function of the tooth form and the embrasure width (ex: the more tapered the tooth, the more pyramidal is the bony form; the wider the embrassure, the more flattened is the interdental bone)

3. the postion of the bony margin mimics the contour of the CEJ 3. the postion of the bony margin mimics the contour of the CEJ. less “scalloping” and a more flat profile in the posterior than the anterior region

Normal alveolar bone morphology:

Terminology: for procedures *ostectomy: reshaping the bone including removal of tooth-supporting bone *osteoplasty: reshaping the bone without removal of tooth-supporting bone

Terminology: for bone form *positive architecture: radicular bone apical to interdental bone *negative (reverse) architecture: interdental bone apical to radicular bone *flat architecture: interdental bone equal to radicular bone *ideal osseous form: interproximal bone coronal to facial & lingual bone similar interdental bone level gradual slope

Terminology: *positive architecture *flat architecture *negative (reverse) architecture

ideal osseous form

Factors in selection of resective osseous surgery the relationship between the depth and configuration of the bony lesions to the root morphology and the adjacent teeth determines the extent that bone and attachment is removed during surgery *candidate: 1 or 2-wall bony defect early to moderate bone loss (2-3mm) moderate-length root trunk

Examination and treatment planning Procedure: Soft tissue palpation (condition of gingiva) Radiographic examination Probing 1.pocket depth 2.the location of the base of the pocket . relative to MGJ 3.attachment loss 4.furcation defects Trans-gingival probing (sounding)

radiographs to examine: 1. interproximal bone loss 2 *radiographs to examine: 1.interproximal bone loss 2.angular bone loss 3.caries 4.root trunk length 5.root morphology

Trans-gingival probing (sounding): Used to assess the level of alveolar bone, presence of angular defects and osseous craters Performed immediately before surgery. After L.A the periodontal probe is inserted into the pocket & walked along the tissue-tooth interface to feel the bony topography. The probe may be passed horizontally through the tissue to provide three-dimensional information regarding bony contours.

Osseous resection techniques: A full thickness mucoperiosteal flap should be used whenever osseous resective surgery is contemplated *instruments: ostectomy: hand (rongeur, back-action chisel, Oshsenbein chisel) osteoplasty: rotary (carbide round bur, diamond bur)

INSTRUMENTS

Osseous resection techniques: *sequences (steps): 1- Vertical grooving 2- Radicular blending 3- Flattening interproximal bone 4- Gradualizing marginal bone

Resective Osseous Surgery:

Osseous resection techniques: *vertical grooving: It is the first step because it can define the general thickness and subsequent form of alveolar housing. It is usually done by rotary 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 aspects of the teeth 3. provide continuity from the interproximal surface onto the radicular surface

Indications: - thick, bony margins, shallow crater formations contra-indication: close roots or thin alveolar housing

radicular blending: * 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 radicular surface * contra-indications: when vertical grooving is minor or the radicular bone is thin or fenestrated

grooving+ blending→→→ osteoplasty it’s enough for shallow crater, thick osseous ledge of bone on the radicular surface and Class I & early Class II furcation involvement

flattening interproximal bone (ostectomy): * Removal of very small amount of supporting bone *indications: 1-walled interproximal defect (hemiseptal defect) *contra-indications: advanced hemiseptal defect ( compromised osseous architecture)

Gradualizing marginal bone (ostectomy): * minimal bone removal to provide a sound, regular base for gingival tissue to follow. * Hand instruments as chisel and curette are favorable over rotatory instruments. (to remove “widow’s peak”)

widow peaks Are small bony discrepancies on the gingival line angles.

Flap placements and closure: After resection the flaps are positioned and sutured. Flaps may be replaced to their original position to cover the new bony margin, or they may be apically positioned. The sutures should be placed with minimal tension.

Post operative maintenance: A second post operative visit is often performed at the second or third week, and surgical site is slightly debrided. It takes 14 to 21 days for the attachment of flap to the underlying bone. Wait 6 weeks after the surgery for dental restorations.

SPECIFIC OSSEOUS RESHAPING SITUATIONS: Correction of one-walled hemiseptal defects: - bone reduction to the level of the most apical portion of the defect. - If one-walled defects occur next to an edentulous space, the edentulous ridge is reduced to the level of the osseous defect (ramping)

Reduction of hemisepta by ramping A, bone defect mesial to the tilted molar. B, Defect reduced by "ramping" angular bone.

In case of exostoses, malpositioned or supraerupted tooth: all 4 steps of resective surgery are performed

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