the indications, rationale and the surgical procedure have been explained

1. Resective osseous
surgery

2.  The damage resulting from periodontal disease
manifests in variable destruction of the tooth
supporting bone.
 The effects of the thickening and the
development of vertical defects leave the
alveolar bone with countless combinations of
bony shapes.
 If these various topographic changes are to be
altered to provide a more physiologic bone
pattern, a method for osseous recontouring
must be followed.

3.  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.
 Osseous surgery can be either additive or
subtractive in nature.
 Additive osseous surgery includes procedures
directed at restoring the alveolar bone to its original
level, whereas 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.

4. Additive and subtractive osseous surgery

5. 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.
• Three-wall defects, particularly if they are narrow
and deep, can be successfully treated with
techniques that strive for new attachment and
bone reconstruction.
• Two-wall angular defects can be treated with
either method, depending on their depth, width,

6. RATIONALE
 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 technique is performed in combination with
apically positioned flaps, and the procedure
eliminates periodontal pocket depth and improves
tissue contour to provide a more easily

7. NORMAL ALVEOLAR BONE
MORPHOLOGY
The characteristics of a normal bony form are as
follows:
 1. The interproximal bone is more coronal in
position than the labial or lingual/palatal bone
and pyramidal in form.
 2. The form of the interdental bone is a function
of the tooth form and the embrasure width.
 3. The position of the bony margin mimics the
contours of the cemento-enamel junction

9. TERMINOLOGY
 Procedures used to correct osseous defects
have been classified in two groups:
osteoplasty and ostectomy.
 Osteoplasty refers to reshaping the bone
without removing tooth-supporting bone.
 Ostectomy includes the removal of tooth-
supporting bone.

10. • Positive architecture and negative architecture
refer to the relative position of interdental bone
to radicular bone.
• The architecture is said to be "positive" if the
radicular bone is apical to the interdental bone.
• The bone is said to have "negative" architecture
if the interdental bone is more apical than the
radicular bone.
• Flat architecture is the reduction of the
interdental bone to the same height as the
radicular bone.

11. Diagram of types of bony architecture.
A,Positive bony architecture. B, Flat bony architecture.
C,Reversed, or negative, bony form.

12. 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 of bone
removed during resection.
 The technique of ostectomy is best applied to
patients with early to moderate bone loss (2-3 mm)
with moderate-length root trunks that have bony
defects with one or two walls.
 Patients with advanced attachment loss and deep
intrabony detects are not candidates for resection to
produce a positive contour.

13.  Two-walled defects, or 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.
 The interdental loss of bone exposes the proximal
aspects of both adjacent teeth.

14. Effect of correction of craters.

15.  Ostectomy to a positive architecture requires the
removal of the line-angle inconsistencies , as
well as some of the facial, lingual, and palatal
and interproximal bone.
 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.
 This architecture, devoid of sharp angles and
spines, is conducive to the formation of a more
uniform and reduced soft tissue dimension
postoperatively.
 Patients with deep, multiwalled defects are not
candidates for resective osseous surgery.

16. METHODS OF RESECTIVE
OSSEOUS SURGERY
 The reshaping process is fundamentally an
attempt to gradualize the bone sufficiently to
allow soft tissue structures to follow the contour
of the bone.
 When all soft tissue is removed around the
teeth, there may be larger exotoses, ledges,
troughs, craters, vertical defects, or
combinations of these defects.

17. OSSEOUS RESECTION
TECHNIQUE
 The following sequential steps are
suggested for resective osseous surgery:
 1. Vertical grooving
 2. Radicular blending
 3. Flattening interproximal bone
 4.Gradualizing marginal bone

18. Instruments used in osseous surgery. A, Rongeurs: Friedman
B, Carbide round burs. Left to right, Friction grip, surgical length
friction grip, and slow-speed handpiece. C, Diamond burs.
D, Interproximal files: Schluger and Sugarman. E, Back-action chisels.
F, Ochsenbein chisels.

19. Vertical Grooving
 Vertical grooving is designed to reduce the
thickness of the alveolar housing and to provide
relative prominence to the radicular aspects of the
teeth.
 It is the first step of the resective process
because it can define the general thickness and
subsequent form of the alveolar housing.

20.  This step is usually performed with rotary
instruments, such as round carbide burs or
diamonds.
 The advantages of vertical grooving are most
apparent with thick bony margins, shallow
crater formations, or other areas that require
maximal osteoplasty and minimal ostectomy.
 Vertical grooving is contraindicated in areas
with close roots or thin alveolar housing.

21. Drawing of bony topography in moderate periodontitis with
interdental craters. B, Vertical grooving, the first step in correction
by osseous reshaping

22. Radicular Blending
• Radicular blending is an extension of vertical
grooving.
• It is an attempt to gradualize the bone over the
entire radicular surface to provide the best results
from vertical grooving.
• This provides a smooth, blended surface for good
flap adaptation.
• Both vertical grooving and radicular blending are
purely osteoplastic techniques that do not remove
supporting bone.

23.  Shallow crater formations, thick osseous
ledges of bone on the radicular surfaces and
class 1 and early class II furcation
involvements are treated almost entirely with
these two steps.

24. Flattening Interproximal Bone
 Flattening of the interdental bone requires the
removal of very small amounts of supporting
bone.
 It is indicated when interproximal bone levels
vary horizontally.
 most of the indications for this step are one-
walled interproximal defects or hemiseptal
defects.

25.  The limitation of this step is in the treatment of
advanced lesions.
 Large hemiseptal defects would require
removal of inordinate amounts of bone to
provide a flattened architecture, and the
procedure would be too costly in terms of bony
support.

26. Radicular Blending &
Flattening

27. Gradualizing Marginal Bone
 The final step in the osseous resection
technique is also an ostectomy process.
 Bone removal is minimal but necessary to
provide a sound, regular base for the gingival
tissue to follow.
 Peaks of bone typically remain at the facial and
lingual/palatal line angles of the teeth (widow’s
peaks).
 Failure to remove small bony discrepancies on
the gingival line angles (widow's peaks) allows
the tissue to rise to a higher level than the base
of the bone loss in the interdental area.

29.  The two ostectomy steps should be
performed with great care so as not to
produce nicks or grooves on the roots.
 Various hand instruments, such as chisels
and curettes, are preferable to rotary
instruments for gradualizing marginal bone.

30. Gradualizing the marginal bone. Note the area of the
furcation on the first molar where the bone is preserved

31. FLAP PLACEMENT AND
CLOSURE
 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 to coapt the flaps, prevent their
separation, and maintain the position of the
flaps.

32.  Suture removal may be done after one week.
 After suture removal, the surgical site is
examined carefully, and any excessive
granulation tissue is removed with a sharp
curette.
 The patient is provided with postsurgical
maintenance instructions.

33.  Healing should proceed uneventfully,
with the attachment of the flap to the
underlying bone being completed by 14
to 21 days.
 Maturation and remodeling can continue
for up to 6 months.

34. Bone contouring in flap surgery.
A, B,and C, Bone contouring in interdental craters.
D and E, Bone contouring in exotoses.
F and G, Bone contouring in one-wall vertical defect.

36. Diagrammatic representation of bone irregularities in periodontal
disease. The thick line is the proposed correction of the defect.
Note the flattening of the interproximal bone between the molars and
the protection of the furcal bone on the first molar. Facial crest height is
reduced in both interproximal areas to the depth of the defect.

37. A and B, Preoperative views of the buccal and lingual surfaces. C and D,
Preoperative and postoperative views of the buccal osseous recontouring of
class I buccal furcation defects, a moderate crater between the two molars, and
a deep 1-2-3—walled defect at the mesial of the first involvements. D, Buccal
aspects of these lesions were corrected with osteoplasty and a small amount of
ostectomy.

38. E and F, Preoperative and postoperative views of the lingual osseous management.
E, Notice the combination 1-2-3—walled defect between the second bicuspid and first
molar, as well as the irregular pattern of bone loss with ledging. F, These defects were
corrected by osteoplasty and ostectomy, except for the deep defect at the mesial surface
of the molar. This area was resected until the residual defect was of two and three walls
only and left to repair.
G and H, Buccal and lingual 5-year postoperative views of tissue configuration. Note the
residual soft tissue defect between the bicuspid and first molar.

39. Reduction of a one-wall angular defect.
A, Angular bone defect mesial to the tilted molar.
B, Defect reduced by "ramping" angular bone.

40. Osseous Contouring In Interdental Craters - I

41. Osseous Contouring In Interdental Craters - II

42. Exostoses – Surgical Planing

43.  Osseous surgery is an effective treatment for
patients with moderate bone loss and craters
up to 3 mm deep and/or early furcation
defects, as well as for bone contour
irregularities such as exostoses and ledges.
 It results in some attachment loss, but by
developing bone contours that parallel healthy
gingival margin shapes, it gives a stable, new
periodontium that can be maintained for
years.

44.  The advantages of this surgical modality
include a predictable amount of pocket
reduction that can enhance oral hygiene
and periodic maintenance.
 It also preserves the width of the attached
tissue, while removing granulatous tissue
and providing access for debridement of the
radicular surfaces.

45. Thank you