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Chapter #60

Hisham AlShorman
Rawda Zeyad AlZereini
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it's most often a combination of horizontal and vertical loss).Horizontal 2. Before. resulting in reconstruction of the interdental and periapical . 2. the area has been flapped and thoroughly instrumented. immediately after subtractive osseous surgery. Horizontal bone loss generally results in a relative thickening of the marginal alveolar bone because bone tapers as it approaches its most coronal margin. gingival fibers. The effects of this thickening and the development of vertical defects leave the alveolar bone with countless combinations of bony shapes. 1 year after additive 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 exostosis and tooth supraeruption. .Vertical (in fact. it implies regeneration of lost bone and reestablishment of the periodontal ligament. Chapter 60: Resective Osseous Surgery Generally. they are not indicative of the alveolar housing of the tooth before the disease process and do not reflect the overlying gingival architecture. Additive and subtractive osseous surgery. bony deformities are not uniform. Bone loss: 1. and B.  brings about the ideal result of periodontal therapy. and D. the osseous wall of the two adjoining infrabony pockets has been removed. A.Additive:  includes procedures directed at restoring the alveolar bone to its original level. and junctional epithelium at a more coronal level. Osseous surgery can be: 1.bone. Before.  provides an alternative to additive methods and should be used when additive procedures are not feasible. C.Subtractive:  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.

 More than any other surgical technique. Therefore. and general configuration. width.  Three-wall defects. RATIONALE:  Osseous resective surgery necessitates following a series of strict guidelines for proper contouring of alveolar bone and subsequent management of the overlying gingival soft tissues. depending on their depth.SELECTION OF TREATMENT TECHNIQUE: The morphology of the osseous defect largely determines the treatment technique to be used:  One-wall angular defects usually need to be recontoured surgically. . which could be treated with a different surgical approach. except for one-wall defects and wide. Thus its value as a surgical approach is limited by the presence.  Two-wall angular defects can be treated with either method. particularly if they are narrow and deep. osseous resective surgery is performed at the expense of bony tissue and attachment level. quantity.  The techniques discussed here for osseous resective surgery have limited applicability in deep intrabony or hemiseptal defects. along with interdental craters. and shape of the bony tissues and by the amount of attachment loss that is acceptable. shallow two-wall defects. can be successfully treated with techniques that strive for new attachment and bone reconstruction.  Osseous surgery provides the purest and surest method for reducing pockets with bony discrepancies that are not overly vertical and also remains one of the principal periodontal modalities because of its long-term success and predictability. osseous defects are treated with the objective of obtaining optimal repair by natural healing processes.  Osseous resective surgery is the most predictable pocket reduction technique.

 The major rationale for osseous resective surgery is based on the tenet that discrepancies in level and shapes of the bone and gingiva predispose patients to the recurrence of pocket depth postsurgically.  The goal of osseous resective therapy is to reshape the marginal bone to resemble that of the alveolar process undamaged by periodontal disease. The interproximal bone is more coronal in position than the labial or lingual/palatal bone and pyramidal in form.  Although this concept is not universally accepted. the ability of dental professionals to maintain the periodontium in a state free of gingivitis and periodontitis is more predictable in the presence of shallow sulci. recontouring of bone is the only logical treatment choice in some cases. and the procedure induces loss of radicular bone in the healing phase. the more pyramidal is the bony form. 3. the more flattened is the interdental bone mesiodistally and buccolingually.  The wider the embrasure.  The more effective the periodontal maintenance therapy.  The technique is performed in combination with apically positioned flaps. 2. The position of the bony margin mimics the contours of the cementoenamel junction. The efficacy of osseous surgery therefore depends on its ability to affect pocket depth and to promote periodontal maintenance. The form of the interdental bone is a function of the tooth form and the embrasure width:  The more tapered the tooth. as well as tooth position within the alveolus . and the procedure eliminates periodontal pocket depth and improves tissue contour to provide a more easily maintainable environment. Likewise.  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. Teeth with prominent roots or those displaced to the facial or lingual side . the greater is the longitudinal stability of the surgical result. This "scalloping" of the bone on the facial surfaces and lingual/palatal surfaces is related to tooth and root form. NORMAL ALVEOLAR BONE MORPHOLOGY: 1. The distance from the facial bony margin of the tooth to the interproximal bony crest is more flat in the posterior than the anterior areas.

may also have fenestrations or dehiscences. or osteoectomy: includes the removal of tooth-supporting bone. The molar teeth have less scalloping and a more flat profile than bicuspids and incisors. and sounding before flap surgery. configuration.  Ostectomy. Photograph of a healthy bony periodontium in a skull. . Although a slight amount of attachment may have been lost.  Although these general observations apply to all patients. this skull demonstrates the characteristics of normal . A: Bony fenestration. probing.  Osteoplasty: refers to reshaping the bone without removing tooth- supporting bone. One or both of these procedures may be necessary to produce the desired result. B: Bony dehiscence. TERMINOLOGY:  Procedures used to correct osseous defects have been classified in two groups: osteoplasty and ostectomy. These deformities can and should be detected by palpation. the bony architecture may vary from patient to patient in the extent of contour.form Effects of tooth position on facial bony contours. and thickness. These variations may be both normal and healthy.

The ideal form of the marginal bone has similar interdental height.  Terms that relate to the thoroughness of the osseous reshaping techniques include “definitive” and “compromise. not as description of a morphologic feature. This bone is considered to have ideal form. Skull photograph of healthy periodontium.  “negative” architecture if the interdental bone is more apical than the radicular bone. Note the shape of the alveolar bone housing. curved slopes between interdental peaks. These terms all relate to a preconceived standard of ideal osseous form. positive. and ideal.”  Definitive osseous reshaping implies that further osseous reshaping would not improve the overall result. Positive architecture and negative architecture refer to the relative position of interdental bone to radicular bone.  Terms that describe the bone form after reshaping can refer to morphologic features or to the thoroughness of the reshaping performed . . flat. It is more coronal in the interproximal areas.  Compromise osseous reshaping indicates a bone pattern that cannot be improved without significant osseous removal that would be detrimental to the overall result.  References to compromise and definitive osseous architecture can be useful to the clinician.Examples of morphologically descriptive terms include negative. with gradual.  Osseous form is considered to be “ideal” when the bone is consistently more coronal on the interproximal surfaces than on the facial and lingual surfaces. but as terms that express the expected therapeutic result.  “positive” if the radicular bone is apical to the interdental bone. with a gradual slope around and away from the tooth.  Flat architecture is the reduction of the interdental bone to the same height as the radicular bone.

To simulate a normal architectural form. occur at the expense of the interseptal bone. A. or negative. Flat bony architecture. C. The interdental loss of bone exposes the proximal aspects of both adjacent teeth. or craters. Bony lesions have been classified according to their configuration and number of bony walls. so much bone would have to be removed that the survival of the teeth could be compromised. These shallow-to-moderate bony defects can be effectively managed by osteoplasty and osteoectomy. Reversed.  Patients with advanced attachment loss and deep intrabony defects are not candidates for resection to produce a positive contour. FACTORS IN SELECTION OF RESECTIVE OSSEOUS SURGERY: The relationship between the depth and configuration of the bony lesion(s) to root morphology and the adjacent teeth determines the extent that bone and attachment is removed during resection. they have buccal and lingual/palatal walls that extend from one tooth to the adjacent tooth. B. Positive bony architecture. See the A and B in the figure below. The buccal-lingual interproximal contour that results is opposite to the contour of the cementoenamel junction of the teeth. bony form.  Two-walled defects.  The technique of ostectomy is best applied to patients with early to moderate bone loss (2 to 3 mm) with moderate-length root trunks that have bony defects with one or two walls. As a result. .

The result is therefore the tendency to replicate the attachment contour on the tooth. See E and F in the figure below. the soft tissue tends to bridge the embrasure from the most coronal height of the bone on one tooth to the most coronal heights on the adjacent teeth.  Patients with deep.  However.  Proponents of osseous resection to create a positive contour believe that this architecture. The therapeutic result is less pocket depth and increased ease of periodontal maintenance by the patient. See C and D in the figure below. or negative. which may subsequently resorb with a tendency to rebound without gain in attachment over time. The interproximal soft tissues invest these peaks of bone. When the technique is properly applied to appropriate patients.  The extent of attachment loss during resection to a positive architecture has been measured. this means that the technique is best applied to interproximal lesions 1 to 3 mm deep in patients with moderate-to-long root trunks.  Although the production of a reversed architecture minimizes the amount of ostectomy that is performed. The result is a loss of some attachment on the facial and lingual root surfaces but a topography that more closely resembles normal bone form before disease. is conducive to the formation of a more uniform and reduced soft tissue dimension postoperatively. the mean reduction in attachment circumferentially around the tooth has been determined to be 0. results in attachment loss at the proximal line angles and the facial and lingual aspects of the affected teeth without affecting the base of the pocket. Osseous resection applied to two-wall intrabony defects (craters). the most common osseous defects. devoid of sharp angles and spines. This resulting anatomic form is reversed.  The amount of attachment lost from the use of ostectomy varies with the depth and configuration of the treated osseous defects.  During healing. and palatal and interproximal bone. as well as some of the facial.6 mm at six probing sites. In practical terms. If the facial and lingual plates of this bone are resected. Interproximal pocket depth can recur. multiwalled defects are not candidates for resective osseous surgery. architecture. lingual.  Ostectomy to a positive architecture requires the removal of the line-angle inconsistencies (widow’s peaks). confining resection only to ledges and the interproximal lesion results in a facial and lingual bone form in which the interproximal bone is located more apically than the bone on the facial or lingual aspects of the tooth. or dentist. See C and D in the figure below. the resultant interproximal contour would become more flattened or ovate. Peaks of bone typically remain at the facial and lingual/palatal line angles of the teeth (widow’s peaks). Two-walled defects (craters) are the most common bony defects found in patients with periodontitis. They are better treated with regenerative therapies or by . it is not without consequences. dental hygienist.

a predictable amount of pocket reduction that can enhance oral hygiene and periodic maintenance 2. enamel pearls.In addition the osseous resection technique permits recontouring of bony abnormalities.proper assessment for restorative procedures (e. crown lengthening). excessive bony exostosis and circumferential defects. .g. tori.It also preserves the width of the attached tissue while removing granulomatous tissue and providing access for debridement of the radicular surfaces. perforations. 2.assessment of restorative overhangs and tooth abnormalities (e. respective osseous surgery achieves a physiologic architecture of marginal alveolar bone conducive to gingival flap adaptation with minimal probing depth.. as well as gradualize excessive bony ledges.  Its substantial benefits include: 1.g. early furcation involvement. Summary:  Although osseous surgical techniques cannot be applied to every bony abnormality or topographic modification.  The advantages of this surgical modality include: 1. irregular alveolar bone. enamel projections.  When properly performed. it has been clearly demonstrated that properly used osseous surgery can eliminate and modify defects. combining osteoplasty to reduce bony ledges and to facilitate flap closure with new attachment and regeneration procedures. including hemiseptal defects.. and ledges. fractures). 3.

. Therefore resective osseous surgery can be an important technique in the armamentarium necessary to provide a maintainable periodontium for periodontal patients.