The document discusses principles of resective osseous surgery in periodontal therapy. It outlines the goals of reshaping alveolar bone to eliminate deformities caused by periodontal disease. This involves techniques like osteoplasty to reshape bone without removal and osteotomy to remove supporting bone. Specific procedures are described to correct issues like interdental craters, exostoses, and one-wall defects through techniques like vertical grooving, flattening interproximal bone, and gradualizing marginal bone. Factors in selecting patients and sites for resective surgery and postoperative care are also covered.

1. {
Resective osseous
surgery
chapter 60
CARANNZZA 12th
Dr Enas Musbah.

2. The principles of osseous surgery in
periodontal therapy were outlined by
Schluger (1949) and Goldman (1950).
 They pointed out that alveolar bone loss
caused by inflammatory periodontal
disease often results in an uneven outline
of the bone crest.
 the elimination of soft tissue pockets
often has to be combined with osseous
reshaping and the elimination of osseous
craters and angular bony
Osseous Surgery

3.  The discrepancies of bone and gingiva
to recurrences of pocket
 That is why we reshape the marginal bone to
resemble alveolar process undamaged by
periodontitis
 Usually we use apically displaced flap to
eliminate pocket and improves tissue contour.
 The end result is improve tissue contour to
provide easy maintainable environment
Rationale

4.  the more effective the periodontal maintenance
therapy,
the greater is the longitudinal stability of the surgical
result.
 The efficacy of osseous surgery therefore depends
on its ability to
affect pocket depth and to
promote periodontal maintenance for both patent and
the Periodontist.
Rationale ….cont…

5. {
1) The interproximal bone is
more coronal in position
than the labial or
lingual/palatal bone and
pyramidal in form
Normal Alveolar Bone
Morphology

6. {
 2. The form of the interdental
bone is depend on the tooth
form and the embrasure width.
 tapered tooth
more pyramidal the bony
 the wider the embrasure
 more flattened is the
interdental bone mesiodistally
and buccolingually.
Normal Alveolar Bone
Morphology…cont..

7. {
3.The position of the bony
margin mimics the contours of
the cementoenamel junction.
‘scalloping’ depend on root
form,
tooth and position within the
alveolus “dehiscense &
fenestration’
Normal Alveolar Bone
Morphology…cont..

9.  Osseous Surgery: defied 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.
 can be either additive or subtractive
in nature
Definitions……

10.  Additive Osseous Surgery eg bone graft
includes procedures directed at restoring the
alveolar bone to it’s original level.
 Subtractive Osseous Surgery
is designed to restore the form of pre-existing
alveolar bone to the level existing at the time of
surgery or slightly more apical to this level.
Additive Or Subtractive

11. Bone loss has been classified as either:
 Vertical bone loss.
 Horizontal bone loss results in a relative
thickening of marginal alveolar bone.
 Combination.

12.  brings about the ideal result of periodontal
therapy
 regeneration we reestablishment of the
periodontal ligament, gingival fibers, and the
junctional epithelium at a more coronal level.
Additive Osseous
Surgery

14.  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
RESECTIVE OSSEOUS
SURGERY

15. Osteoplasty: Reshaping of the alveolar process to
achieve a more physiologic form without removal of
supporting bone.
Ostectomy: The excision of a bone or portion of bone.
In periodontics, ostectomy is done to correct or reduce
deformities caused by periodontitis in the marginal
and interalveolar bone and includes the removal of
supporting bone
(other terms for supporting bone are: alveolar bone
proper, cribriform plate, and bundle bone)

16. { {
Tori
Tori

17. {
 are done when the other
method is not feasible
Subtractive Osseous Surgeries

21. {
 One wall Angular > Surgical
recontouring e.g.
one-wall defects and wide,
 3 Wall, Narrow & Deep >
New Attachment & Bone
Regeneration
Selection Based on
Morphology of Defects

22. {
 2 Wall Angular >
Depending on depth, width &
Configuration
Eg:
 shallow two-wall defects
 interdental craters
Selection Based on
Morphology of Defects

23.  Angular defects classified on basis of wall present as :

24. {

26. Terms that describe bone after reshaping:
• Ideal osseous form:
– The bone consistently more coronal on the interproximal surfaces
than on the facial and lingual surfaces. Similar interdental height,
with gradual, curved slops between interdental peaks.
• Flat architecture:
• Positive architecture:
• Negative architecture:

27. {
The bone consistently
more coronal on the
interproximal surfaces
than on the facial and
lingual surfaces.
Similar interdental
height, with gradual,
curved slops between
interdental peaks.
Ideal osseous form

28. {
The interdental
bone at the same
level with radicular
bone
Flat architecture

29. {
The radical bone is
apical to the
Interdental bone.
Positive architecture

30. {
The interdental
bone is more apical
than the radicular
bone.
Negative architecture

31. Terms that
describe bone
after reshaping:
Ideal osseous
form
Flat architecture:
Positive
architecture:
Negative
architecture

33. Terms that relate to the thoroughness of the osseous
reshaping techniques include “definitive” and
“compromise.”
 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.
 References to compromise and definitive osseous
architecture can be useful to the clinician as terms that
express the expected therapeutic result.
thoroughness of the
osseous reshaping techniques

34. • Procedure use to correct osseous defect have been classified
into two group:
– Osteoplasty: it is reshaping of bone without removing the
supporting bone.
– Osteoectomy: it is reshaping of bone with removal of supporting
bone.
Terminology

35. • The technique ostectomy is best applied to patient
with early to moderate bone loss(2-3mm)with
moderate –length root trunks that have bony defect
with one or two wall defect.
• Patient with advanced attachment loss and deep
intrabony defect are not candidate for the
procedure
• Two wall defects, or craters, occur at the expense of
the interseptal bone. As a result they have lingual
and buccal wall that extend from one tooth to the
adjacent tooth, the bacco-lingual contour that result
is opposite to contour of the CEJ of the teeth.
Factor in selection of
resective surgery

42. {
A and B, Diagram of facial
and interproximal bony
contours after flap
reflection.
Note the loss of some
interproximal bone and
cratering. C and D, Line
angles; this is only
Osteoplasty and has
resulted in a reversed
architecture.
E and F, Ostectomy on the
facial and lingual bone
and the removal of the
residual widow's peaks to
produce a positive bony
architecture
Effect of correction of craters

43. {
In crater if the facial
and lingual plate of
this bone is resected ,
the resultant
interproximal
contour would
become more
flattened

44.  If confining resection to ledges and the
interproximal lesion result in 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. The result would be
reversed or negative architecture

47. • Although the reversed architecture minimizes
the amount of ostectomy that is preformed , it
is not without consequences ( widow’s peaks)
facial and lingual line angel (attachment loss)
resorb the peak = pocket
• For the positive architecture ostectomy is
required to remove the widow’s peak as well
as some of the facial , lingual and palatal and
interproximal bone. and this will gives the
topography that resembles normal bone form
before disease .

49.  Probing and exploration are key aspects of the
examination
 Probing reveals the presence of :
 Pocket depth
 Base of pocket relative to mucogingival
junction and attachment level on the adjecent
teeth.
 Number of bony wall defects.
 The presence of furcation defect.
Examination and treatment
planning

50.  Trans-gingival probing (sounding):
 Under local anesthesia confirms the extent and
configuration of the intrabony component of the pocket
or furcation defects.
 The probe walks along the tissue-tooth interface to feel
the bony topography.
 The probe may pass horizontally through the tissue to
provide three-dimensional information regarding
bony contours

51.  Radiograph ( two dimension) cannot accurately
document the number of bony walls and the
presence or extend of bony lesion on the facial
/buccal or lingual/palatal walls.
 Well made radiograph provide useful
information about the extend of interproximal
bone loss, angular bone loss, caries, root trunk
length, and the root morphology.

52. • After oral hygiene instruction and
debridement , the response of the patient to
these treatment procedures is evaluated by
reexamination and recording the changes in
the periodontium.
• Because the extend of periodontal involvement
may vary from tooth to tooth in the same
patient.
• After resolution of edema and swelling, will
result in return to normal pocket depth and
configuration.

53.  In patient with moderate to advanced
periodontitis and bony defects, although the
overt sign of periodontitis may be reduced,
may display a persistence of pocket depth
bleeding on probing and suppuration. These
sign may indicate the presence of residual
plaque and calculus inability to instrument
deep pocket or patient unwillingness to
preform adequate oral hygiene

55.  Osseous resective surgery is also used to
facilitate certain restorative and prosthetic
dental procedure.
 Caries
 Fracture root of abutment teeth can be exposed
for removal.
 Bony exostoses
 Short anatomic crown can be lengthened

56. {
piezoelectric
surgical
instrument
STEPS IN RESECTIVE
OSSEOUS SURGERY

57. { {
Rongeurs Low Speed Burs

58. { {
Schluger and Sugarman Back-action chisels

59. {Ochsenbein chisels

60. Technique:
• VERTICAL GROOVING
• RADICULAR BLENDING
• FLATTENING INTERPROXIMAL BONE
• GRADUALIZING MARGINAL BONE
STEPS IN RESECTIVE OSSEOUS SURGERY continued

61. • It is the first step because it can define the general thickness
and subsequent form of alveolar housing.
• It is usually done by rotatory instruments as carbide or
diamond burs.
• it is designed to:
– Reduce the thickness of the alveolar housing.
– Provide relative prominence to the radicular aspect of the teeth.
– Provide continuity from interproximal surface onto the radicular
surface.
• Indications:
– Thick, bony margins, shallow crater formations.
– Areas require maximal osteoplasty and minimal osteoctomy.
• Contraindication:
– Areas with close root proximity or thin alveolar housing.
Vertical grooving (osteoplasty):

63. - 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 the radicular surface.
• Contraindication:
– Minor vertical grooving or thin, fenestrated radicular bone.
• Both vertical grooving and radicular blending may be used for
treatment of:
– Shallow crater formation.
– Thick osseous ledges of bone in radicular surface.
– Class I and early class II furcation involvement.
Radicular blending (osteoplasty):

65. – Removal of very small amount of supporting bone.
• Indications:
 Interproximal bone varies horizontally.
 One-walled interproximal defect.
Flattening Interproximal bone
(osteoctomy)

66. • Minimal bone removal to provide a sound,
regular base for gingival tissue to follow.
• Failure to remove the widow peak (Peaks of
bone remain at the facial, lingual/ palatal line
angles of the teeth) allows the tissue to rise to
higher level than the base of the bone loss in
the interdental area.
• Hand instruments as chisel and curette are
favorable over rotatory instruments.
Gradualizing marginal bone
(osteoctomy):

74. Osseous Contouring In Interdental Craters - I

75. Osseous Contouring In Interdental Craters - II

76. Osseous Contouring In Exostoses - I

77. Osseous Contouring In Exostoses - II

78. Osseous Contouring In One Wall Vertical Defect - I

79. Osseous Contouring In One Wall Vertical Defect – I I

80.  Correction of one walled hemiseptal defect:
 The bone should reduce to the level of the most apical
portion of the defect.
 If one walled defect occurs next to edentulous
area, the edentulous ridge is reduced to the
level of the osseous defect.
Specific osseous reshaping situation

81.  Osteoplasty to eliminate the exostoses or reduce the buccal/ lingual
bulk of bone.
 It is common to incorporate a degree of vertical grooving during
reduction of the bony ledges, since it facilitate the process of
blending the redicular bone into interproximal areas.
 Previous 4 steps.
In case of exostoses, malpositioned or supraerupted tooth:

83. Exostoses – Surgical Planning

84.  Reduction of interdental walls of craters and
the one-walled component of angular defects
and walls, and grooving into sites of early
involvement.
 The walls of the crater may reduced at the
expense of the buccal, lingual or both walls.
 The reduction should be made to remove the
least amount of alveolar bone required to
produce a satisfactory form, prevent
furcation and blend the contour with
adjacent tooth.
 The selective reduction of bony defects by
ramping the bone to the palatal or lingual to
avoid involvement of the furcations.
In the absence of ledges or exostoses:

85. Interproximal osseous ramping. A. Presurgical view with 6 mm probing depth on
mesial of first molar. B. Deep two-wall intrabony defect between the second premolar
And first molar, hemiseptal defect between the two premolars and lingual exostosis.
C. Osseous resective surgery eliminated the interproximal osseous defects by ramping
to the lingual, corrected the reversed osseous topography and removed the osseous
ledges. D. Normal scalloped gingival morphology and good health 6 months after
osseous resective surgery

86.  Replacing the flap in areas that previously had
deep pockets may result initially in greater
postoperative pocket depth, although a
selective recession may diminish the depth
over time. minimizes postoperative
complications
 Positioning the flap apically to expose marginal
bone is results in more postsurgical resorption
of bone and patient discomfort
Flap Placement and Closure

87.  Suturing may be accomplished using a variety
of different suture materials and suture knots

88. Thanks
Pre-Surgical Photograph Post Surgical – 1Year