RESECTIVE OSSEOUS SURGERY............................................

ROS

1. Resective Osseous Surgery Presented by: Dr Divjot Guided by: Dr Kumar Saurav Singh

2. CONTENTS: INTRODUCTION HISTORY TERMINOLOGY FACTORS IN SELECTION OF TYPE OF ROS EXAMINATION METHODS TECHNIQUES CONCLUSION REFERENCES

3. HISTORY: Schluger (1949)- “ osseous resection ”- A Basic Principle in periodontal surgery. Goldman(1950)- “the development of physiologic gingival contour by gingivoplasty ” Friedman(1955)- “ Periodontal osseous surgery”: osteoplasty and ostectomy.

4. Introduced the importance of bony contour during soft tissue gingivectomies. Surgical removal of the gingiva and reshaping of the bone to eliminate the pocket and correct unphysiological bone architecture.

5. INTRODUCTION: Periodontal destruction often leads to alveolar bone destruction. This bone loss has been classified as “vertical” or “horizontal” 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 .

6. TERMINOLOGIES Subtractive osseous surgery : Designed to restore the form of preexisting alveolar bone to the level at the time of surgery or slightly more apical Additive osseous surgery : Includes procedure directing at restoring alveolar bone to its original level

7. ARCHITECTURE INTERDENTAL BONE RADICULAR BONE RADICULAR BONE INTERDENTAL BONE RADICULAR BONE INTERDENTAL BONE POSITIVE FLAT NEGATIVE

8. Osseous form is considered to be “ideal” when the bone is consistently more coronal on the interproximal surfaces than on the facial and lingual surfaces. The ideal form of the marginal bone has similar interdental height, with gradual, curved slopes between interdental peaks

9. OSSEOUS DEFECTS Is periodontal regeneration effective in a long-term maintenance of teeth with advanced periodontitis? A case report:2007

10. HORIZONTAL BONE LOSS: CLASSIFICATION BY GLICKMAN(1958) GRADE I-incipient bone loss GRADE II-partial bone loss(cul-de-sac) GRADE III-through and through opening GRADE IV- involvement of soft tissue- gingival recession exposing the furcation view

11. VERTICAL BONE DEFECTS: CLASSIFICATION BY TARNOW AND FLETCHER (1984) SUB-CLASS A= 0-3mm SUB-CLASS B = 4-6mm SUB-CLASS C = >7mm

12. KARN ET AL CLASSIFIFCATION 1984 To describe irregular defects CRATERS- involves on only one side TRENCH- involves 2 or 3 sides MOAT- involves 4 sides: circumferential defect CRATERS MOAT

13. OSSEOUS SURGERY ADDITIVE RESECTIVE

14. INDICATIONS: pocket elimination Tori reduction Intrabony defects adjacent to edentulous ridge Incipient furcation involvement Thick heavy ledges and exostoses Shallow osseous craters Small intra bony defects

15. CONTRA-INDICATIONS: Areas of insufficient remaining attachment Anatomic limitations(prominent ridge) Aesthetic limitations(anteriorly, high smile line)

16. OSTEOPLASTY: It is a plastic procedure by which non supporting bone is reshaped to achieve a physiologic gingival and osseous contours. Osteoplasty includes the techniques of radicular blending OSTETECTOMY: It is the plastic removal of radicular and interradicular supporting bone to eliminate osseous deformities Done by the technique of spheroidng or parabolizing

17. RATIONALE: 1) PERIOODNTAL DISEASE 2) DISCREPENCIES IN LEVEL AND SHAPE OF BONE 3)POCKET RECURRENCE

18. EXAMINATION: Periodontal probing and exploration pocket depth greater than that of a normal gingival sulcus, the location of the base of the pocket relative to the mucogingival junction and attachment level on adjacent teeth, the number of bony walls the presence of furcation defects. Transgingival probing, or sounding, under local anesthesia confirms the extent and configuration of the intrabony component of the pocket and of furcation defects

19. Instruments: Rongeurs Interproximal files Ochsenbein chisels Friction grip Burs

20. Sequential steps :

21. Vertical
 Grooving: reduce the thickness of the alveolar housing relative prominence to the radicular aspects of the teeth provides continuity from the interproximal surface onto the radicular surface .

22. Vertical grooves Instruments: Round carbide or diamond burs Indications : bony margins, shallow crater formations with thick bony margins. Contraindications : close roots or thin alveolar housing

23. RADICULAR BLENDING: 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

24. Radicular blending Indications: 1) same as vertical grooving Contraindications: 1)vertical grooving is very minor 2) radicular bone is thin or fenestrated

25. Flattening interproximal bone: Removal of very small amounts of vertical bones Used in defects that have a coronally placed, one-walled edge of a three-walled angular defect Improves flap closure and healing in three-walled defects

26. Flattening interproximal bone: Indications: 1) one-walled interproximal defects or hemiseptal defects. Contraindications: 1) inter-proximal crater formations 2) flat interproximal defects

27. Gradualizing marginal bone: Ostectomy step No bony discrepancies should be left in the interdental or marginal or interradicular area otherwise the pocket reduction process remains incomplete A widows peak should be left and blend on the radicular root surface area

28. The reduction should be made to remove the least amount of alveolar bone required to (1) produce a satisfactory form, (2) prevent the therapeutic invasion of furcations (3) blend the contours with the adjacent teeth. The selective reduction of bony defects by “ramping” the bone to the palatal or lingual to avoid involvement of the furcations has been advocated by Ochsenbein and Bohannan18 Tibbetts et al.

29. SPECIFIC OSSEOUS RESHAPING SITUATIONS: Correction of one wall hemi septal defects is by reducing the bone level as apical as possible. If one-walled defects occur next to an edentulous space, the edentulous ridge is reduced to the level of the osseous defect: RAMPING The walls of the crater may be reduced at the expense of the buccal, lingual, or both walls.

30. CRATERS:

31. FLAP PLACEMENT AND CLOSURE: Repositioned to the original position or apically

32. POST OPERATIVE MAINTENECE: Nonresorbable sutures such as silk are usually removed after 1 week of healing Resorbable sutures maintain wound approximation for varying periods of 1 to 3 weeks or more After suture removal the surgical site is examined carefully, and any excessive granulation tissue is removed with a sharp curette. the surgical site is gently cleansed of debris with a cotton pellet dampened with saline

33. BASIC RULES OF OSSEOUS SURGERY: When properly performed, resective osseous surgery achieves a physiologic architecture of marginal alveolar bone for to gingival flap adaptation with minimal probing depth.

34. RULE 1: A full thickness mucoperiosteal flap should be raised whenever osseous resective surgery is planned.

35. RULE 2: The scalloping of the flap should anticipate the final underlying osseous contour, which is most prominent anteriorly and decreases posteriorly. The scalloping of the flap should reflect the patients own healthy gingival architecture. The degree of the tissue and bone scalloping is reduced as the interproximal area becomes broader as a result of bone loss.

36. RULE 3: Osteoplasty generally precedes ostectomy

37. RULE 4: Osseous resective surgery should result in a positive architecture

38. RULE 5: 1) High speed rotatry instruments should never be used adjacent to the teeth. 2) Copious irrigation should be maintained

39. RULE 6: The final bony contours should approximate the expected healthy postoperative gingival form, with no attempt to improve on it.

40. FibReORS aims to shift the base of the intrabony defect to a more coronal position, thus making it shallower and more easily eliminated with minimal resection of supporting bone. In addition, the apical migration of the gingival margin is reported to be less pronounced with FibReORS as compared with traditional ORS

41. CONCLUSION Although osseous surgical techniques cannot be applied to every bony abnormality or topographic modification, it has been clearly demonstrated that properly used osseous surgery can eliminate and modify defects, as well as gradualize excessive bony ledges, irregular alveolar bone, early furcation involvement, excessive bony exostosis, and circumferential defects.

42. TAKE HOME MESSAGE: The goal is to establish contours that existed naturally (physiologically), with the assumption that this will facilitate hygiene and long-term maintenance.

43. REFERENCES: Carranza 10 th edition Cohen 4 th edition Schluger S: Osseous resection: a basic principle in periodontal surgery, Oral Surg Oral Med Oral Pathol 2:316, 1949. David F. Levine & Greg Filippelli (1999) A Review of Osseous Resective Surgery, Journal of the California Dental Association, 27:2, 125-132, DOI: 10.1080/19424396.2016.12221105

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