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Resective osseous surgery
Resective osseous surgery
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  2. 2. INTRODUCTION The aim of surgical periodontal pocket therapy is to eliminate or reduce the periodontal pocket depth, to achieve a healthy periodontium and to create a periodontal tissue architecture that facilitates the self performed oral hygiene measures by the patient. The ideal method to treat periodontal pocket and periodontal bony defects is regeneration of periodontium Other method is to remove the walls of the bony defect and removal of associated pocket wall, thereby recontouring the bone and placing the gingiva in a more apical position.
  3. 3. “Resective 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. CARRANZA
  4. 4. HISTORY 1.Goldman (1950),“The Development of Physiologic Gingival Contours by Gingivoplasty” 2. Schluger (1949), “Osseous Resection—A Basic Principle in Periodontal Surgery” 3. Friedman (1955), “Periodontal Osseous Surgery: Osteoplasty and Ostectomy” 4. Prichard (1957), “The Infrabony Technique as a Predictable Procedure” 5. Goldman and Cohen (1958), “The Infrabony Pocket: Classification and Treatment” 6. Ochsenbein (1958), “Osseous Resection in Periodontal Surgery” 7. Ochsenbein (1986), “A Primer for Osseous Surgery”
  5. 5. TERMINOLOGY OSSEOUS SURGERY : • Aspect of periodontal surgery which deals with the modification of the bony support of the teeth ( World Workshop – 1989) • Friedman : surgical removal & reshaping of the bone to eliminate the pocket and correct unphysiologic bone architecture.
  6. 6. •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.
  7. 7. • 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
  10. 10. CLASSIFICATION OF OSSEOUS SURGERY • Additive/Regenerative • Substractive/Resective ▫ Definitive ▫ Compromised
  11. 11. OBJECTIVES OF RESECTIVE OSSEOUS SURGERY • The primary objective of resective osseous surgery is to remove osseous deformities and creation of physiological contour of the gingiva. • Elimination of periodontal pockets and the creation of shallow gingival sulcus that can be readily maintained by the patient. • To create a periodontal tissue contour that permits to accomplish effective plaque control.
  12. 12. • To create gingival contour that closely matches the contour of gingiva after healing. • To permit primary closure of the flap margins. • To create additional crown length for proper construction of restorations.
  13. 13. INDICATIONS Carranza • To recontour bone that forms part of the outer wall of the pocket • To prevent recurrence of the pocket • To reshape the alveolar crest, establishing a normal fiber arrangement.
  14. 14. World Workshop in Periodontics • Buccal or lingual bony ledges, tori • Intrabony defects associated with tilted molars • Shallow buccal or lingual intrabony defects • The elimination of deep interproximal defects to achieve physiological contour • Incipient furcation involvement • For improvement of alveolar contours for flap adaptation
  15. 15. • Shallow intrabony defects around a tooth with sufficient periodontal support • Existence of non supporting bone that could affect a periodontal pocket or hinders flap adaptation - Thick alveolar bone margin - Shelf like bone - Bony protruberance - Exostosis - Interdental craters -Thick alveolar bones around the intrabony defect
  16. 16. • Residual osseous defect after regenerative therapy • Irregularity of bone morphology related to hemisection or root amputation • Clinical crown lengthening for restorative/ prosthetic treatment • Deep caries or crown fracture extending subgingivally • Class I and Class II furcation involvement
  17. 17. CONTRAINDICATIONS • Position of the external oblique line in the mandibular molar area and maxillary sinus, which is very close to the osseous defect and root proximity. • A periodontal pocket of more than 8mm exists after initial therapy. • The bottom of osseous defect extends apically against multiple tooth–root trunks. • The deep intrabony defect is more than 3-4mm or the bottom of the osseous defect is more than one half of the root length from the cemento enamel junction. • Extended tooth mobility.
  18. 18. • Operating in the aesthetic zone. • Removal of supporting bone during ostectomy will unduly compromise the attachment of teeth at the edge of the operative field. • Where a risk of root caries is considered high. • Cases where patients have experienced problems controlling root hypersensitivity.
  19. 19. DIAGNOSIS • History • Clinical probing • Radiographs • Transgingival probing/Bone sounding
  20. 20. Bone sounding
  21. 21. TREATMENT PLAN 1. Solution for Active Periodontal Disease 2. Correction of Deformities 3. Facilitate performance of other dental procedures
  22. 22. FACTORS INFLUENCING TREATMENT PLAN Types of bone defect • Horizontal defects • Vertical or angular defects • Osseous craters • Reversed architecture • Bony ledges • Furcation involvements • Exostoses • Bulbous bone contours
  23. 23. 4 Angular defect Exostoses Crater Bulbous bony contours .
  24. 24. 4 • Ledge Reverse Architecture
  25. 25. Root form & trunk
  26. 26. Tooth inclination
  27. 27. INSTRUMENTATION Rotary instruments B, Carbide round burrs : friction grip, surgical- length friction grip, and slow speed hand-piece. C, Diamond burrs. Hand instruments A, Rongeurs: Friedman (top) and 90-degree D, Interproximal files: Schluger and Sugarman. E, Back-action chisels. F, Ochsenbein chisels.
  28. 28. BASIC PRINCIPLES OF RESECTIVE OSSEOUS SURGERY • Rule 1: A full-thickness mucoperiosteal flap should be used whenever resective osseous 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.
  29. 29. • Rule 3: Osteoplasty generally precedes ostectomy. • Rule 4: Resective osseous 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. Cohen
  30. 30. STEPS INVOLVED IN OSSEOUS RESECTION • OSTEOPLASTY ▫ Vertical grooving ▫ Radicular blending • OSTECTOMY ▫ Flattening interproximal bone ▫ Gradualising marginal bone ▫ (horizontal grooving, scribing, hand instrumentation)
  31. 31. Flap management • Adapt over the alveolar process • Thinning of flap • Esthetic areas- papilla preservation techniques • Palatal defect-palatal approach
  33. 33. 35/ 34
  34. 34. Management of deep craters 36
  35. 35. Management of palatal osseous defects
  36. 36. Heavy ledges and blunt interproximal septae Vertical grooving festooning scribing ostectomy Management of blunt interdental septa
  37. 37. Management of bony ledges
  38. 38. Bone contouring in one wall vertical defect
  39. 39. Management of multiple osseous defects
  40. 40. Management of edentulous ridge 43 /3 4
  41. 41. Bone contouring in exostoses
  42. 42. Management of furcation involvement • Tunnel preparation • Root resection • Hemisection
  43. 43. HEALING AFTER OSSEOUS SURGERY • Caffesse et al (1968) Bone deposition – remodeling Inflammatory response – superficial necrosis of alveolar crest Osseous surgery
  44. 44. STUDIES REGARDING RESECTIVE OSSEOUS SURGERY Pennel et al reported measurements of 34 teeth from 20 patients with postsurgical healing intervals ranging from 14 to 545 days. The average posthealing reduction of the alveolar crest was 0.54 mm.
  45. 45. Donnenfeld et al evaluated three patients after an osteoplasty. Measurements made immediately after the osseous surgery and at re-entry 6 months later revealed a mean interradicular bone loss of 0.6 mm and a mean radicular bone loss of 1 mm.
  46. 46. Moss assessed the effect on the viability of the bone surrounding bur contact and found less damage adjacent to cuts made with highspeed burs as opposed to lower-speed burs. Horton et al reported that bony defects made by a chisel had a more rapid rate of healing than those made by a 557 cross-cut fissure bur in a low-speed handpiece.
  47. 47. CONCLUSION The main objective of resective osseous surgery this therapy is achieving periodontal soft and hard tissue architecture which is most conducive for self oral hygiene maintenance by the patient. Resective osseous surgery provides the surest method of reducing pockets with an intrabony or hemiseptal osseous component of 3 mm or less, albeit at the expense of some attachment in the neighboring less involved sites.