Resective osseous surgery In perio sem.pptx

Resective osseous surgery

1. RESECTIVE OSSEOUS SURGERY Presented by- Dr. Nihal Abbas PG - 3 rd year 1

2. Contents Introduction Definition History Selection of treatment Rationale Normal Alveolar Bone Morphology Terminologies Factors in Selection of Resective Osseous Surgery Examination and Treatment Planning Osseous Resection Technique Flap Placement and Closure Postoperative Maintenance Post op healing Landmark studies of relevance Case Discussion Conclusion 2

3. INTRODUCTION Damage resulting from periodontal disease manifests in variable destruction of the tooth-supporting bone. B ony deformities – not uniform not indicative of the alveolar housing of the tooth before the disease process do not reflect the overlying gingival architecture. 3 Carranza’s Clinical Periodontology 3 rd south asia edition.

4. 4 Combination In fact R elative thickening of the marginal alveolar bone because bone tapers as it approaches its most coronal margin. Pathway of inflammation travels directly into t he PDL space. Carranza’s Clinical Periodontology 3 rd south asia edition.

5. DEFINITION 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 .” 5 Carranza’s Clinical Periodontology 3 rd south asia edition.

6. History Schluger (1949) – “Osseous Resection – A Basic Principle in Periodontal Surgery” Friedman (1955) – “ Periodontal Osseous Surgery : Osteoplasty & Osteotomy” Ochsenbein (1958) – “ Osseous Resection in Periodontal Surgery” Ochsenbein (1986) – “ A Primer for Osseous Surgery” 6 Peeran , Syed & Ramalingam , Karthikeyan . (2021). 51. Periodontal Resective Osseous Surgery.

7. 7 The principles of osseous surgery in periodontal therapy were re-iterated by Goldman (1950). Pierre Fauchard in 1776 made reference: ‘‘if however the bone is carious then it must be uncovered to its whole extent and the cure carried out’’ Schluger (1949) - “ Osseous resection- A basic principle in periodontal surgery” Goldman and Cohen (1958)- “ The infrabony pocket : Classification and treatment “ Ochsenbein (1958 )- “ Osseous resection in periodontal surgery” Ochsenbein (1986) – “ A primer for osseous surgery “ Peeran , Syed & Ramalingam , Karthikeyan . (2021). 51. Periodontal Resective Osseous Surgery.

8. 8 Carranza’s Clinical Periodontology 3 rd south asia edition.

9. 9 OSSEOUS SURGERY Carranza’s Clinical Periodontology 3 rd south asia edition.

10. 10 Carranza’s Clinical Periodontology 3 rd south asia edition.

11. Selection of Treatment Technique One-wall angular defects - need to be recontoured surgically. Three-wall defects - if they are narrow and deep, can be successfully treated with techniques that strive for new attachment and bone reconstruction. Two-wall angular defects - treated with either method, depending on their depth, width, and general configuration. 11 Therefore, except for one-wall defects and wide, shallow two-wall defects, and interdental craters, osseous defects are treated with the objective of obtaining optimal repair by natural healing processes. Shukla S, Chug A, Mahesh L, Singh S, Singh K. Optimal management of intrabony defects: current insights. Clin Cosmet Investig Dent. 2019 Jan 17;11:19-25. doi : 10.2147/CCIDE.S166164. PMID: 30697083; PMCID: PMC6340362.

12. Rationale Osseous surgery provides - purest & surest method for reducing pockets with bony discrepancies that are not overly vertical and also remains one of the principal periodontal modalities because of its long-term success and predictability . Most predictable pocket reduction technique . However , more than any other surgical technique, osseous resective surgery is performed at the expense of bony tissue and attachment level . 12 M ajor rationale B ased on the tenet that discrepancies in level and shapes of the bone and gingiva predispose patients to the recurrence of pocket depth post surgically Carranza’s Clinical Periodontology 3 rd south asia edition.

13. T o reshape the marginal bone to resemble that of the alveolar process undamaged by periodontal disease. 13 Goal Carranza’s Clinical Periodontology 3 rd south asia edition.

14. Normal Alveolar Bone Morphology Characteristics of a normal bony form: I nterproximal bone is more coronal in position than the labial or lingual-palatal bone and pyramidal in form . F orm of the interdental bone is a function of the tooth form and the embrasure width. P osition of the bony margin mimics the contours of the cementoenamel junction. 14 Carranza’s Clinical Periodontology 3 rd south asia edition.

15. Terminology Osteoplasty - reshaping the bone without removing tooth-supporting bone . Ostectomy / osteoectomy - removal of tooth-supporting bone. 15 (2017) Textbook of Periodontics : Bathla Shalu /Resective Osseous Surgery

16. 16 Positive architecture - Radicular bone is apical to the interdental bone. Flat architecture - reduction of the interdental bone to the same height as the radicular bone Negative architecture - Interdental bone is more apical than the radicular bone. Carranza’s Clinical Periodontology 3 rd south asia edition.

17. Osseous form is considered to be “ideal” - bone is consistently more coronal on the interproximal surfaces than on the facial and lingual surfaces. Ideal form of the marginal bone has similar interdental height, with gradual, curved slopes between interdental peaks . 17

18. 18 W idow’s peaks Sghaireen MG, Al- Zarea BK, Al- Shorman HM, Al- Omiri MK. Clinical measurement of the height of the interproximal contact area in maxillary anterior teeth. Int J Health Sci ( Qassim ). 2013 Nov

19. Definitive osseous reshaping implies -further osseous reshaping would not improve the overall result. Compromise osseous reshaping indicates - bone pattern that cannot be improved without significant osseous removal that would be detrimental to the overall result. 19 Carranza’s Clinical Periodontology 3 rd south asia edition.

20. Factors in Selection of Resective Osseous Surgery O stectomy - best applied - moderate bone loss (2 to3 mm) with moderate-length root trunks that have bony defects with one or two walls. O steoplasty & O stectomy - shallow to moderate bony defects. 20 Carranza’s Clinical Periodontology 3 rd south asia edition.

21. Examination and Treatment Planning Periodontal probing and exploration - key aspects of the examination. Careful probing reveals the presence of : pocket depth greater than that of a normal gingival sulcus location of the base of the pocket relative to the mucogingival junction attachment level number of bony walls presence of furcation defects. Transgingival probing, or sounding, using local anesthesia confirms the extent and configuration of the intrabony component of the pocket and of furcation defects. 21 Kolte , Rajashri & Kolte , Abhay & Mahajan, Aaditi . (2014). Assessment of gingival thickness with regards to age, gender and arch location. Journal of Indian Society of Periodontology. 18. 478-81. 10.4103/0972-124X.138699.

22. Radiographs cannot accurately document - number of bony walls and the presence or extent of bony lesions on the facial, buccal or lingual-palatal walls . Well-made radiographs provide useful information about extent of interproximal bone loss presence of angular bone loss c aries root trunk length root morphology. 22 Clinical Periodontology & Implant Dentistry 6th edition - Niklaus P. Lang & Jan Lindhe .

23. Resective osseous surgery is also used to facilitate certain restorative and prosthetic dental procedures. Dental caries can be exposed for restoration fractured roots of abutment teeth can be exposed for removal bony exostoses and ridge deformities can be altered in contour to improve the performance of removable or fixed prostheses 23 Carranza’s Clinical Periodontology 3 rd south asia edition.

24. Osseous Resection Technique Instrumentation 24

25. 25 Rongeurs Carbide round burs. Friction grip, surgical-length friction grip slow-speed handpiece . Diamond burs Essentials of Clinical Periodontology & Periodontics 3rd edition - Shantipriya Reddy

26. 26 Interproximal files: Schluger and Sugarman . Back-action chisels. Ochsenbein chisels Essentials of Clinical Periodontology & Periodontics 3rd edition - Shantipriya Reddy

27. 27 The piezoelectric surgical instrument has been used successfully in osseous resective surgery Piezosurgery’s cutting action is selective, that is, cuts only mineralized tissues while sparing soft tissues. Selective cutting is made possible by the application of ultrasonic frequencies between 24 and 36 kHz. Essentials of Clinical Periodontology & Periodontics 3rd edition - Shantipriya Reddy

28. Bone contouring in flap surgery 28

29. 29 Bone contouring in interdental craters Vandana , K. L. and Bharath Chandra Gnr . “Periodontal Osseous Defects: A Review.” (2017).

30. 30 Bone contouring in exostoses Vandana , K. L. and Bharath Chandra Gnr . “Periodontal Osseous Defects: A Review.” (2017).

31. 31 Bone contouring in one-wall vertical defect Vandana , K. L. and Bharath Chandra Gnr . “Periodontal Osseous Defects: A Review.” (2017).

32. Sequential steps 32

33. Sequential steps 33 Carranza’s Clinical Periodontology 3 rd south asia edition.

34. Vertical Grooving To reduce the thickness of the alveolar housing and to provide relative prominence to the radicular aspects of the teeth. P rovides continuity from the interproximal surface onto the radicular surface. First step of the resective process because it can define the general thickness and subsequent form of the alveolar housing. P erformed with rotary instruments, such as round carbide burs or diamonds. 34 Carranza’s Clinical Periodontology 3 rd south asia edition.

35. 35 Advantages - most apparent with thick bony margins, shallow crater formations, or other areas that require maximal osteoplasty and minimal ostectomy . Contraindicated - in areas with close roots or thin alveolar housing. Carranza’s Clinical Periodontology 3 rd south asia edition.

36. Radicular Blending Second step of the osseous reshaping technique, is an extension of vertical grooving. It is an attempt to gradualize the bone over the entire radicular surface to provide the best results from vertical grooving. Provides a smooth, blended surface for good flap adaptation. Naturally, this step is not necessary if vertical grooving is very minor or if the radicular bone is thin or fenestrated. 36 Carranza’s Clinical Periodontology 3 rd south asia edition.

37. Both vertical grooving and radicular blending - purely osteoplastic techniques that do not remove supporting bone. In most situations, these two procedures compose the bulk of resective osseous surgery. Treated almost entirely with these two steps: S hallow crater formations thick osseous ledges of bone on the radicular surfaces Grade I and early Grade II furcation involvements 37 Carranza’s Clinical Periodontology 3 rd south asia edition.

38. Flattening Interproximal Bone 38 R emoval of very small amounts of supporting bone. Indicated - when interproximal bone levels vary horizontally. Step is typically not necessary with interproximal crater formations or flat interproximal defects. Best used in one walled defects or hemiseptal defects It is also used in three – walled angular defect Carranza’s Clinical Periodontology 3 rd south asia edition.

39. Limitations : Large hemiseptal defects would require removal of inordinate amounts of bone to provide a flattened architecture that will compromise the osseous architecture. 39

40. Gradualizing Marginal Bone F inal step in the osseous resection technique is also an ostectomy process. Bone removal is minimal but necessary to provide a sound, regular base for the gingival tissue to follow. Failure to remove small bony discrepancies on the gingival line angles allows the tissue to rise to a higher level than the base of the bone loss in the interdental area. 40 When the radicular bone is thin, it is extremely easy to overdo this step, to the detriment of the entire surgical effort. For this reason, various hand instruments, such as chisels and curettes, are preferable to rotary instruments for gradualizing marginal bone. Carranza’s Clinical Periodontology 3 rd south asia edition.

41. Flap Placement and Closure Flaps - original position, to cover the new bony margin OR they may be apically positioned. Replacing the f lap 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 . Positioning the flap to cover the new margin minimizes postoperative complications and results in optimal postsurgical pocket depths. 41 S utures should be placed with minimal tension to coat the flaps , prevent their separation, and maintain the position of the flaps . Sutures placed with excessive tension rapidly pull through the tissues. Carranza’s Clinical Periodontology 3 rd south asia edition.

42. Postoperative Maintenance Suture removal – after 1 to 3 weeks Periodontal dressing -if present - is removed S urgical site is gently cleansed of debris with a cotton pellet dampened with saline . Excessive granulation tissue is removed with a sharp curette . Patient is provided with postsurgical maintenance instructions & i nstruments needed to maintain the surgical site in a plaque free state. Plaque suppressive agent - C hlorhexidine digluconate 42 Carranza’s Clinical Periodontology 3 rd south asia edition.

43. Second postoperative visit - second or third week S urgical site - lightly debrided for optimal results. Professional prophylaxis for complete plaque removal should be done every 2 weeks until healing is complete. 43 Carranza’s Clinical Periodontology 3 rd south asia edition.

44. Healing should proceed uneventfully, with the attachment of the flap to the underlying bone completed in 14 to 21 days. Maturation and remodeling can continue for up to 6 months. It is usually advisable to wait at least 6 weeks after completion of healing of the last surgical area before beginning dental restorations. 44 For those patients with a major cosmetic concern, it is wise to wait as long as possible to achieve a postoperative soft tissue position and a stable sulcus. Carranza’s Clinical Periodontology 3 rd south asia edition.

45. 45 In radicular & interdental bone areas, loss of bone occurs during the initial healing stages Interdental areas - which have cancellous bone, the subsequent repair stage results in total restoration without any loss of bone Radicular bone - If thin & unsupported by cancellous bone, bone repair results in loss of marginal bone. Post op healing

46. 46 Luigi Checchi et al in 2008 Checchi L, Mele M, Checchi V, Zucchelli G. Osseous resective surgery: long-term case report. Int J Periodontics Restorative Dent. 2008 Aug;28(4):367-73. PMID: 18717375. S tudies of relevance.

47. Case Discussion 47

48. 48 Bone should be reduced to the level of the most apical portion of the defect. It requires removal of some bone on the side with the greatest coronal bony height . Results in loss in attachment on relatively unaffected adjacent teeth to eliminate the defect. If the tooth has 1-wall defect on both of its medial & distal surfaces, the severely affected tooth may be extruded orthodontically during disease control to minimise the need for resection of bone from the adjacent teeth. If one-walled defects occur next to an edentulous space, the edentulous ridge is reduced to the level of the osseous defect. CORRECTION OF ONE-WALLED HEMISEPTAL DEFECT Periobasics (Author: Nitin Saroch )

49. 49 CORRECTION OF EXOSTOSES , MALPOSITIONED OR SUPRAERUPTED TOOTH Osteoplasty is done to eliminate the exostoses or reduce the buccal or lingual bulk of bone . It is common to incorporate a degree of vertical grooving during reduction of the bony ledges, since it facilitates the process of blending the radicular bone into interproximal areas. Periobasics (Author: Nitin Saroch )

50. Conclusion The results from osseous resective surgery are technique sensitive. It has limited use in treating cases with very deep intrabony or hemiseptal defects, which should be treated with a different surgical approach. If osseous resective surgery is used in advanced lesions, a compromise in the amount of probing depth reduction should be expected. 50

51. 51 Carranza’s Clinical Periodontology 3 rd south asia edition . Peeran , Syed & Ramalingam , Karthikeyan . (2021). 51. Periodontal Resective Osseous Surgery . Shukla S, Chug A, Mahesh L, Singh S, Singh K. Optimal management of intrabony defects: current insights. Clin Cosmet Investig Dent. 2019 Jan 17;11:19-25. doi : 10.2147/CCIDE.S166164. PMID: 30697083; PMCID: PMC6340362. (2017) Textbook of Periodontics : Bathla Shalu /Resective Osseous Surgery Sghaireen MG, Al- Zarea BK, Al- Shorman HM, Al- Omiri MK. Clinical measurement of the height of the interproximal contact area in maxillary anterior teeth. Int J Health Sci ( Qassim ). 2013 Nov Kolte , Rajashri & Kolte , Abhay & Mahajan, Aaditi . (2014). Assessment of gingival thickness with regards to age, gender and arch location. Journal of Indian Society of Periodontology. 18. 478-81. 10.4103/0972-124X.138699. Clinical Periodontology & Implant Dentistry 6th edition - Niklaus P. Lang & Jan Lindhe . Essentials of Clinical Periodontology & Periodontics 3rd edition - Shantipriya Reddy Vandana , K. L. and Bharath Chandra Gnr . “Periodontal Osseous Defects: A Review.” (2017 ). Checchi L, Mele M, Checchi V, Zucchelli G. Osseous resective surgery: long-term case report. Int J Periodontics Restorative Dent. 2008 Aug;28(4):367-73. PMID: 18717375. Periobasics (Author: Nitin Saroch ) REFERENCES

52. Thank you! 52