Osseous Surgery and Reconstructions

RESECTIVE OSSEOUS SURGERYPresented by:Shilpa ShivanandIII MDS

Contents

Introduction History Terminology Rationale Normal alveolar bone morphologyFactors in selection of techniqueExamination , Diagnosis and Treatment Planning

TechniquesSpecific situations SummaryReferences

Introduction

Osseous surgery Additive Resective

History Osseous surgery : necrotic or infected bone Kronfeld (1935) all bone is healthySchluger (1949) : father of osseous surgeryFriedman (1955) : osteoplasty ,osteoectomy/ostectomyGoldman ,Cohen (1958) : classification of bone defects

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 of the gingiva & reshaping of the bone to eliminate the pocket and correct unphysiologic bone architecture.

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.

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

Subrtactive and additive osseous surgery

Additive osseous surgery includes procedures directed at restoring the alveolar bone to its original levelsubtractive osseous surgery is designed to restore the form of preexisting alveolar bone to the level present atthe time of surgery or slightly more apical to this level

Architecture : - Positive - Flat - Reverse / negative- Ideal

Selection of treatment techniques

Rationale : Pocket recurrencePeriodontal disease

Discrepancies in level & shape of bone

Easley 1967

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

Normal Alveolar bone Morphology: Architecture interproximal bone coronal to labial/lingual/palatal pyramidalForm of the interdental bone tooth form, embrasure more tapered tooth: more pyramidal , wider embaressure: flatCEJ marginal bone scalloping : more in anteriors than posteriors

Factors to considered : 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

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

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

Medium Craters 3-4mm - both palatal & buccal approaches - Step 1- palatal reduction - Step 2 buccal reduction

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

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

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

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

Ideal correctionInterproximal craterBucally placed crater

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

Overtreatment???Mandibular molars > Maxillary molarsLoss of supporting boneFurcation exposure Reversed architecture

Furcations & Osseous SurgeryOsteoplasty rapid bone loss in furcation area BLOWOUT Mand > max Buccal > lingual Treatment? Compromise.

Furcal invasions Incipient furcation ,shallow crater prognosis goodLong root trunk prognosis ? Distn. btw. furca & base of crater - gingival proliferation Diagnosis r/g s Clinical examination

Summary Gingiva Scalloped architecture greater health ??Thin , undulating, scalloped periodontium health Ostectomy reversed architecture

gingiva fibrotic, thick plaque retention

Diagnosis Clinical probing Radiographs Transgingival probing

Instruments

Techniques

Osteoplasty IndicationsPocket elimination ToriIntrabony defects adjacent to edentulous ridgesIncipient furcation involvementThick, heavy ledges &/or exostosisShallow osseous cratersEnhanced flap placement with improved alveolar contours

Vertical grooving 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 cratersInstrument : no. 6, 8 or 10 bur + high speed handpiece+ copious irrigationIndication : shallow craters, thick bony ledges

Radicular Blending For thicker , heavier bone after vertical groovingEven 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 2Indication : shallow craters, thick ledges, Cl.1 & 2 FI

Ostectomy Indications : Sufficient bone remaining for establishing physiologic contours without attachment compromise No aesthetic or anatomic limitationsElimination of interdental craters Intrabony defects not amenable to regeneration Horizontal bone loss with irregular marginal bone Moderate to advanced furcation involvements Hemisepta

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

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

Flattening Interproximal Bone : Removal of small amounts of supporting bone One walled interproximal defects / hemiseptaThree walled defect coronally placed one wall edge Contraindicated : large hemiseptal defects

Gradualizing Marginal bone : Removal of bony discrepancies Widows peaks Hand instruments Failure to remove

Horizontal groovingscribing

Moderate periodontitis

Heavy ledges and blunt interproximal septaeVertical groovingfestooningscribingostectomy

Interproximal crater with heavy ledgesOutline for horizontal groovingHorizontal grooving completeVertical grooving completeDirection of spheroidingSpheroiding completeOutline for scribed boneFinal after osteectomy

OthersExostoses osteoplasty followed by ostectomy Edentulous area- ramping One wall defect osteoplasty

Ramping

Basic Rules of Osseous Surgery

Healing after osseous surgery Caffesse et al (1968)

Conclusion : 0.06mm 1.2mmAmount of bone lost during ORS:

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

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

Soft tissue Response 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 1.23mmResolution of inflammation

Comparision of ORS & other periodontal therapiesKnowles 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

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

Biologic widthCrown lengthening procedures Ostectomy ?Maintain biologic width - 2.04mm

To sum up..Basic rules : Full thickness mucoperiosteal flap Scalloping anticipated ; prominent anteriorlyReflect patients own architectureScalloping & bone reduction reduces as interproximal area becomes broaderOsteoplasty before ostectomyPositive architecture when possibleHigh speed rotary instrument + copious irrigation

Only correct , not improve!!!!!!!

Conclusion 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.

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

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