✓ Osseous surgery

“The procedure by which changes in the alveolar bone

can be accomplished to rid it of deformities induced by the
periodontal disease or other related factors, such as exostosis
and tooth supra eruption.”

Additive
Subtractive
Additive osseous surgery:

✓ Procedures directed at restoring the alveolar bone to its

original level

✓ Ideal result of periodontal therapy

✓ Regeneration of lost bone and reestablishment of the

periodontal ligament, gingival fibres and junctional
epithelium at a more coronal level

REGENERATIVE OSSEOUS SURGERY

Subtractive osseous surgery:

✓ 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

✓ Alternative to additive methods

✓ Should be resorted to when the latter are not feasible

RESECTIVE OSSEOUS SURGERY

Selection of treatment technique:
✓ Morphology of osseous defect

✓ One walled angular defect- recontoured surgically

✓ Three walled narrow and deep defects - new attachment and

bone regeneration

✓ Two walled angular defects - regenerative or resective

depending on their depth, width and general configuration
Rationale of resective osseous surgery:

✓ Discrepancies in level and shapes of the bone and gingiva

predispose patients to the recurrence of pocket depth post
surgically

✓ An attempt to gradualize the bone sufficiently to allow soft

tissue structure to follow contour of bone

✓ In combination with apically displaced flaps

✓ Eliminates periodontal pocket depth, improves tissue

contour to provide a more easily maintainable environment
Goal:

✓ Reshaping the marginal bone to resemble the alveolar

process undamaged by periodontal disease

✓ Apically displaced flaps used -->

✓Eliminates periodontal pockets

✓Improves tissue contour to provide an easy, maintainable

environment
Terminology:

✓ Osteoplasty

✓ Ostectomy

✓ Positive Architecture

✓ Negative architecture

✓ Ideal architecture

✓ Definitive osseous reshaping

✓ Compromise osseous reshaping

Osteoplasty :

“ Reshaping of the alveolar process to achieve a more

physiologic form without removal of supporting bone”

Ostectomy:

“ Excision of bone or portion of a bone, in periodontics,

ostectomy is done to correct or reduce deformities caused by

periodontitis and includes removal of the supporting bone”

 Types of bony contours:
 Positive Architecture :

When radicular bone is apical

to interdental bone

 Negative architecture :

When interdental bone is

more apical to radicular bone

 Flat architecture :
Interdental bone at the same
height as radicular bone
Ideal :

Bone is consistently more coronal on the interproximal surface

than on the facial and lingual surface

Definitive osseous reshaping

Further reshaping would not improve the overall result

Compromise osseous reshaping

Bone pattern that can not be improved without significant

compromise in the overall result
Indication of resective osseous surgery:

✓ One walled angular defects

✓ Buttressing bone formation

✓ Reverse architecture

✓ Inconsistent bony margins

✓ Shallow craters

✓ Furcation defects

✓ Crown lengthening for restorative dentistry

Contraindication of resective osseous surgery:

✓ Close proximity of roots to maxillary antrum or the ramus

✓ Age

✓ Systemic health

✓ Improper oral hygiene

✓ High caries index

✓ Extreme root sensitivity

✓ Advanced periodontitis

✓ Unacceptable esthetic result

Advantages:
✓ Predictability
✓ Complete elimination of periodontal pockets
✓ Obtaining ideal bone form

Disadvantages:
✓ Loss of valuable supporting bone
✓ Gingival recession
✓ Lengthy unpleasant post surgical recovery
✓ Post surgical recovery
Examination prior to resective osseous surgery:

Transgingival probing:
✓ Local anesthesia

✓ Probe walked along the tissue-tooth interface

✓ Operator feels the bony topography

✓ Probe passed horizontally through the tissue, to provide 3D

information with regard to bone contours
(thickness,height+shape of the underlying bone)
Clinical and radiographic assessment:

✓ Pockets with irregular depths in the adjacent areas of the

same tooth/adjacent teeth

✓ Angular bone loss

✓ Irregular bone loss

Instruments used in resective osseous surgery:
✓ Hand instruments
✓Rongeurs – Friedman and Blumenthal
✓Interproximal files – Schluger and Sugarman
✓Back action chisel
✓Oschenbein chisel

✓ Rotary instruments
✓Carbide round burs
✓Slow speed hand piece
✓Diamond burs

✓ Combination of both
 H
A
N Back
Rongeurs – action
D chisel
Friedman
I
N
S
T
R
U
M Oschenbein
Interproximal
files – E
Schluger and chisel
N
Sugarman
T
S
Back action Oschenbein
chisel
chisel
✓ Rotary instruments:
Technique for osseous resective procedure:

✓ Vertical grooving
Osteoplasty

✓ Radicular blending

✓ Flattening interproximal bone

Ostectomy
✓ Gradualizing marginal bone

All steps are not necessary

Vertical grooving:

✓ First step

✓ Reduce the thickness of alveolar housing

✓ Provides continuity from interproximal surface into radicular

surface

✓ Rotary instruments (round carbide/ diamond burs)

VERTICAL GROOVING
Indications:

✓ Thick bony margins

✓ Shallow craters

✓ Grade I and II furcations

Contraindications :

✓ Close root proximity

✓ Thin alveolar housing

Radicular blending:

✓ Second step

✓ Gradualizes the bone over the entire radicular surface

✓ Provides a smooth, blended surface for good flap adaptation

✓ Indications – same as vertical grooving

✓ Step I and 2 purely osteoplastic

Flattening of the interproximal bone:

✓ Removal of very small amounts of supporting bone

✓ One walled defects or hemiseptal defects

✓ Combined defects (coronally one walled and apically three walled )

✓ Contraindicated in advanced defects

✓ Ostectomy procedure

✓ Hand instrument
Radicular blending and Flattening
Inter-proximal bone
 Gradualizing bone margin

✓ Final step
✓ Ostectomy procedure
✓ Minimal bone removal
to provide sound
regular base for
gingival tissue to
follow
✓ Hand instrument
✓ “Widows Peaks” – bony contour which causes the tissue to

rise to a higher level than the base of bone loss in interdental

areas.

✓ Causes selective recession and incomplete pocket reduction

Correction of craters:

✓ 1. Conversion of Concavity to convexity

✓ 2. Ramping- to which side ?

✓Depends upon

✓Levels of buccal &lingual walls

✓ Maxilla-palatal aspect

✓ Mandible –lingual aspect

✓ Thickness of buccal &lingual walls

Correction of hemiseptum:

✓ Difficult to treat

✓ Shallow & moderate- resection of the remaining wall to the

base of defect
Situation that complicates osseous reshaping:

✓ Large hemiseptal defects

✓ One walled defects next to edentulous areas(ramping)

✓ Exostosis

✓ Malpositioned teeth

✓ Supraerupted teeth
 Healing:

✓ Initiation of inflammatory response

✓ Necrosis of alveolar crest

✓ Osteoclastic resorption of bone (bone deposition and

remodeling)

✓ Repair and remodeling

THANK YOU…