seminar on resective osseous surgery

2. Presented by:
Shilpa Shivanand
III MDS

3. • Introduction
• History
• Terminology
• Rationale
• Normal alveolar bone morphology
• Factors in selection of technique
• Examination , Diagnosis and Treatment Planning

4. • Techniques
• Specific situations
• Summary
• References

6. Osseous surgery
Additive Resective
Bone grafts
GTR
Osteoplasty
Ostectomy

7. • Osseous surgery : necrotic or infected bone
• Kronfeld (1935) – all bone is healthy
• Schluger (1949) : father of osseous surgery
• Friedman (1955) : osteoplasty ,osteoectomy/ostectomy
• Goldman ,Cohen (1958) : classification of bone defects

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

9. •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.

10. • 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

11. • Subrtactive and additive osseous surgery
Additive osseous surgery
includes procedures directed
at restoring the alveolar bone
to its original level
subtractive osseous surgery is
designed to restore the form of
preexisting alveolar bone to the
level present at
the time of surgery or slightly more
apical to this level

12. • Architecture :
- Positive
- Flat
- Reverse / negative
- Ideal

13. Definitive osseous
reshaping
implies that further
osseous reshaping would
not improve the overall
result
Compromise osseous
reshaping
indicates a bone pattern
that cannot be improved
without significant osseous
removal that would be
detrimental to the overall
result

14. • One-wall angular defects usually need to be
recontoured surgically.
• Three-wall defects, particularly if they are narrow and
deep, can he successfully treated with techniques that
strive for new attachment and bone reconstruction.
• Two-wall angular detects can be treated with either
method, depending on their depth, width, and general
configuration

15. Pocket recurrence
Periodontal disease
Discrepancies in level &
shape of bone
Easley 1967

16. Reshape the marginal bone to resemble that of the
alveolar process undamaged by periodontal disease.

17. • Architecture  interproximal bone coronal to
labial/lingual/palatal  pyramidal
• Form of the interdental bone – tooth form, embrasure 
more tapered tooth: more pyramidal , wider
embaressure: flat
• CEJ – marginal bone – scalloping : more in anteriors than
posteriors

18. Craters and root trunk types
- Craters : shallow – 1-2mm
moderate : 3-4mm
deep : >5mm
- Amt of buccal bone removed – base of crater to root
trunk
- Root trunk : short, average & long
- Avg. 1.5 – 2mm CEJ to marginal bone (Orban, Wentz)
Ochsenbien 1986

19. • Maxillary molars :
• History : 1960s – buccal approach
• Disadvantages : buccal recession
- reversed architecture
- buccal radicular bone lost
- inadequate buccal interprox.space
• Palatal approach : Ochsenbein & Bohannan (1963)

20. • Shallow craters : 1-2mm
- Buccal to palatal slope ; concave
- Rarely flat topography
- Reduction : 10 0 to a horizontal line to base of crater
- Palatal radicular bone – apical to the interdental bone
- Buccal – radicular bone – thin

21. • Medium Craters – 3-4mm
- both palatal & buccal approaches
- Step 1- palatal reduction
- Step 2 – buccal reduction

22. • Deep craters : >5mm
- Buccal and palatal reduction
- Compromise
- Furcal involvement , recession
- Extraction?

23. • Maxillary Premolars :
- Bucco-lingual dimension of bone –thick
- Shallow well-like defects
- Osteoplasty
- Root concavities (Booker) – odontoplasty and early
pocket management

24. • Mandibular molars:
- Lingually tilted (Dempster et al 1963)- base of crater
lingual
- Root trunk length lingual > buccal
- Buccal gingiva scalloped > than lingual
- Lingual inclination to the slope
- Initial osteoplasty – ostectomy

25. • Short root trunks : 30-35% of teeth
- 1mm bone coronal to the furcation
- minimal bone reduction – osteoplasty
• Medium & Long root trunks :
- more favorable
• Deep craters : osteotomy + ostectomy – lingual slope

26. Ideal
correction
Interproxim
al crater
Bucally
placed
crater

27. • IDEAL
Early to moderate bone loss (2-3mm)
with moderate root trunk lengths , bony
defects – two walls

28. • Mandibular molars > Maxillary molars
• Loss of supporting bone
• Furcation exposure
• Reversed architecture

29. • Osteoplasty rapid bone loss in furcation area
“ BLOWOUT”
• Mand > max
• Buccal > lingual
• Treatment? Compromise.

30. • Clinical probing
• Radiographs
• Transgingival probing

33. Indications
1. Pocket elimination
2. Tori
3. Intrabony defects adjacent to edentulous ridges
4. Incipient furcation involvement
5. Thick, heavy ledges &/or exostosis
6. Shallow osseous craters
7. Enhanced flap placement with improved alveolar
contours

34. • Festooning – reduce buccal & lingual thickness of bone
interdentally
• Greater root prominence , minimum bone removal ,
smooth transition from radicular to interradicular space
• Intial step – reduce walls of small craters
• Instrument : no. 6, 8 or 10 bur + high speed handpiece+
copious irrigation
• Indication : shallow craters, thick bony ledges

37. • For thicker , heavier bone after vertical grooving
• Even flowing thin radicular surface – root prominences
and valleys
• Instrument : bur no. 6,8 or 10 – high speed handpiece.
• Back & forth motion
• Scribing : Ochsenbien chisels – 1 or 2
• Indication : shallow craters, thick ledges, Cl.1 & 2 FI

38. Indications :
1. Sufficient bone remaining for establishing physiologic
contours without attachment compromise
2. No aesthetic or anatomic limitations
3. Elimination of interdental craters
4. Intrabony defects not amenable to regeneration
5. Horizontal bone loss with irregular marginal bone
6. Moderate to advanced furcation involvements
7. Hemisepta

39. • Advantages :
- predictable pocket elimination
- establishment of physiologic gingival & osseous
architecture
- favorable prosthetic environment
• Disadvantages :
- Loss of attachment
- esthetic compromise
- increased root sensitivity

40. • Contraindications:
- insufficient attachment or where ostectomy may
unfavorably alter the prognosis of the tooth
- anatomic limitations
- esthetic limitations
- effective alternative treatment

41. • Removal of small amounts of supporting bone
• One walled interproximal defects / hemisepta
• Three walled defect –coronally placed one wall edge
• Contraindicated : large hemiseptal defects

42. • Removal of bony discrepancies – Widow’s peaks
• Hand instruments
• Failure to remove…

43. Horizont
al
grooving
scribing

44. Moderate
periodontitis

45. Heavy ledges and
blunt interproximal
septae
Vertical
grooving
festooning
scribing ostectom
y

47. Interproximal crater with
heavy ledges
Outline for horizontal
grooving
Horizontal grooving
complete
Vertical grooving
complete
Direction of spheroiding Spheroiding complete
Outline for scribed
bone
Final after osteectomy

48. • Exostoses – osteoplasty followed by ostectomy
• Edentulous area- ramping
• One wall defect – osteoplasty

50. • Rule 1: A full-thickness mucoperiosteal flap should
be used whenever osseous resective 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.

51. • Rule 3: Osteoplasty generally precedes
ostectomy.
• Rule 4: Osseous resective 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.

52. • Caffesse et al (1968)
Bone deposition – remodeling
Inflammatory response – superficial
necrosis of alveolar crest
Osseous surgery

53. Conclusion : 0.06mm – 1.2mm
• Amount of bone lost during ORS:
Authors
• Selipsky 1976
• Aeschlimann
1979
• Moghaddas &
Stahl 1980
• Carnevale et al
‘94
Surgery
• ORS
• ORS
• ORS
• ORS
Bone removed
• 0.6mm
• 0.22mm
• Avg.0.06-
0.22mm
• 0.62- 1.04mm

54. Crestal bone loss from resorption after ORS:
- Aeschlimann et al (1979) : 0.28mm
- Moghaddas & Stahl (1980) : 6 months – 0.23mm to 0.88mm
- Smith et al (1980) : 0.2mm -0.3mm – 5yrs
- Pennel (1967) & Wilderman ( 1970) : 0.8mm

55. Bone loss and remodeling after flap elevation
without osseous resective surgery :
- Donnenfeld et al 1964, 1970 : 0.6 – 1mm
- Wood et al 1973 : 0.62mm , 0.98mm
- Felts & McKenzie 1964 : minimal
Pfeifer 1967, Wood 1973 – no clear clinical advantage

56. • Recession
- Becker et al 1988 : 0.95 – 2.77 mm after 1 yr
- Kaldahl et al 1988 : 1.72 mm after 1 yr
• Probing depth
- Bragger , Kaldahl, Carnevale : average reduction –
1.23mm
• Resolution of inflammation

57. • Knowles et al. (1979) , Ramjford et al. (1987),
Rosling et al (1983)
- Compared gingival curettage, pocket elimination tech.
with ORS & elimination by MWF
- >4-5mm – MWF > ORS
- 7 mm > ORS – gain in CAL , reduced probing depths
- 3 yrs : no difference btw the three therapies

58. Rosling et al 1976, 1983 , Smith et al 1980:
- Apically repositioned flap with & without ORS
- ORS – long term – less probing
Becker et al 1988 , Kaldahl et al 1990 :
- non surgical therapy & ORS : no clinically significant
difference

59. • Crown lengthening procedures
• Ostectomy ?
• Maintain biologic width - 2.04mm

60. Basic rules :
1. Full thickness mucoperiosteal flap
2. Scalloping – anticipated ; prominent anteriorly
3. Reflect patient’s own architecture
4. Scalloping & bone reduction reduces as interproximal
area becomes broader
5. Osteoplasty before ostectomy
6. Positive architecture when possible
7. High speed rotary instrument + copious irrigation

61. • Osteoplasty – enhance tissue placement
- tissue adaptation at suturing
• Ostectomy – eliminate intrabony pocket
OSSEOUS RESECTIVE SURGERY  minimal probing
depths
and gingival tissue morphology that facilitates good oral
hygiene and periodontal health.

62. References
• Carranza 10th ed.
• Page and Schluger 2nd ed.
• Cohen – Atlas of Cosmetic & Reconstructive
periodontal Surgery – 2nd ed.
• The role of resective periodontal surgery in the
treatment of furcation defects. Massimo Desanctis ,
Perio 2000 Vol 22, 2000

63. • Osseous Resective Surgery – Carnavale & Kaldahl,
Perio 2000, vol.22 ,2000
• Osseous resective surgery: Long-term case report ,
Checchi et al , IJPRD 2008.
• Osseous Resection in Periodontal Surgery, Ochsenbejn