Resective osseous

surgery
Ass. Prof. Elena Firkova, DDS, PhD
Department of Periodontology
FDM - Plovdiv
 Osseous surgery – the procedure by
which the changes in the alveolar bone are
accomplished to rid it of deformities
induced by the periodontal disease process
or other related factors such as exostoses
and tooth supraeruptions
 The goal of osseous resective
therapy:

To reshape the marginal bone to resemble

that of the alveolar process undamaged by
periodontal disease
Normal alveolar bone morphology
❑ The interproximal bone – more
coronal than the labial or lingual
/palatal bone &pyramid in form
❑ The form of interdental bone –
function of the tooth form and the
embrasure width; more tapered the
tooth – more pyramidal bony form
❑ The position of the bony margin –
mimics the CEJ
❑ Teeth with prominent roots and
displaced to the facial or lingual side
may have fenestrations or dehiscence
❑ Molars – less scalloping and more flat
profile than bicuspids and incisors
 Classification of bone defects according to the number of
remaining walls (Goldman et al, 1954)

• 3 osseous walls (e.g. proximal, buccal and lingual)

• 2 osseous walls (e.g. buccal and lingual; buccal and proximal)
• 1 osseous wall (e.g. proximal; buccal; lingual)
• Combinations
 Glickman’s classification ( 1964) – specific description of bone
deformities:

• Osseous crater;
• Bulbous bony contours;
• Hemisepta;
• Inconsistent margins;
• Ledges.
 Classification system: revisited

1. Suprabony defects
2. Infrabony defects
a) Craters
b) Intrabony defects (1-, 2-, 3-wall defect and combination)
3. Other bone defects
a) Bulbous bone contour
b) Ledge
c) Reversed architecture
d) Fenestartion
e) Dehiscence
4. Interradicular defects (furcations)
a) Grade I
b) Grade II
c) Grade III
d) Grade IV
 Horizontal defects
Bone is reduced in height, but the bone margins remains
roughly perpendicular to the tooth surface
 Vertical defects
Bone loss is in an oblique direction, the base of the
defect is located apical to the surrounding bone

Angular defects have accompanying infrabony pocket

3-wall defect

Small 3-Wall Defect

Deep 3-Wall Defect

 1-wall defect
Most common: presence of a proximal wall with the buccal and
lingual walls destroyed

Advanced bone loss in premolar/molar area. On tooth 45, the facial wall of bone is reduced almost to
the level of the mesial pocket (*). A portion of the lingual plate of bone remains intact. The facial root
surface and the interdental spaces could be covered with soft tissue to the cementoenamel junction,
masking the defect clinically
 Interdental crater
• It is created when the crest of the interalveolar septum
between the buccal and lingual cortical plates is resorbed.
• The interdental crater is the predominant lesion of the lower
posterior segment
• The most frequently found defect caused by periodontal
disease that affects the alveolar process.
 Reversed architecture
the radicular bone on the labial or lingual aspects of the tooth is
in a more coronal position than the adjacent interdental bone

Produced by loss of interdental bone, including the facial, lingual

plates or both, without concomitant loss of radicular bone, thereby reversing the
normal architecture.
Such defects are more common in
maxilla.
 Bony ledges
Plateau like bone margins caused by resorption of thickened
bony plates
Furcation involvement
Exostoses
Exostoses – preprosthetic ostectomy
 Selection of treatment
techniques

The morphology of the osseous defect largely determines the

treatment technique

1-wall angular defects – surgical recontouring

3-wall defects (narrow and deep) – bone regeneration
2-wall defects – either method, depending on their depth, width
and general configuration
Osteoplasty - reshaping the bone without removing tooth-
supporting bone.

Ostectomy (or osteoectomy) - removal of tooth-supporting bone.

One or both of these procedures may be necessary to produce

the desired result.
• Ostectomy – best applied to patients with early to moderate
bone loss (2 to 3 mm) with moderate-length root trunks that
have bony defects with 1 or 2 walls

• Patients with advanced attachment loss and deep intrabony

defects are not candidates for resection!
Objectives

• Resolution of gingival inflammation

• Accessibility of instruments to root surfaces
• Elimination of periodontal pockets
• Correct alveolar bone morphologic characteristics that
interfere with plaque control
• Create environment suitable to restorative and prosthodontic
treatment
• Esthetic improvement
Osteoplasty

Indications

1. Pocket elimination
2. Tori
3. Intrabony defects adjacent to edentulous ridges
4. Grade I furcation involvement
5. Thick, heavy ledges and exostoses
6. Shallow osseous craters
7. Enhanced flap placement with improved alveolar contours
 Ostectomy
Sufficient bone remaining for establishing
physiologic contours without attachment loss!!!

Indications
1. Residual bone defects remaining after regenerative
procedures
2. Intrabony defects not amenable to regeneration
3. Horizontal bone loss with irregular marginal bone
4. Class I and moderate class II furcation involvement
5. Bony exostoses, interdental craters, bony protuberances
6. Optimal crown length for cosmetic purpose
Contraindications

- insufficient attachment or where ostectomy may unfavorably

alter the prognosis of the tooth;

- anatomic and esthetic limitations;

- excessive tooth mobility;

- effective alternative treatment.

Advantages
- predictable pocket elimination;
- establishment of physiologic gingival and osseous contours;
- favorable prosthetic environment.

Disadvantages
- loss of attachment;
- esthetic compromise;
- increased root sensitivity.
 Instruments
• Rotary (osteoplasty) and hand (ostectomy) instruments
• Lasers
An osseous resective surgery bur kit (Brassler, USA), including different sized round
burs made of diamond coarse and carbide.
The end-cutting bur 957c-H207C is used to remove supporting bone around the
tooth without damaging the root surface.
A back action chisel (Rhodes 36–37 Hu-friedy, USA) is used in a dry mandible to
demonstrate how to perform fine ostectomy. The blade of the instrument is placed on
the radicular bone and moved backwards toward the root to eliminate the supporting
bone involved in the defect.
Technique – suggested steps
Not all of them are necessary in each case!!!
➢Vertical grooving
➢Radicular blending
➢Flattening of the interproximal bone
➢Gradualizing marginal bone
Vertical grooving
Goals:
➢To reduce the thickness of alveolar housing and to provide
continuity from the interproximal surface into the radicular
surface
➢1st step; usually – rotary instruments

Indicated in:
➢Thick bony margins, shallow craters

Contraindicated in:
➢Areas with close root proximity or thin alveolar housing
Radicular blending
• 2nd step, continuation of 1st step

Goal:
➢To gradualize the bone over the entire radicular surface and to
provide a smooth, blended surface for good flap adaptation

➢Step 1 and 2 – purely osteoplastic procedures

Flattening of the interproximal
bone
• Requires removal of very small amount of supporting bone

Indicated in:
➢When interproximal bone levels vary horizontally (one-walled
and combined defects)
Gradualizing marginal bone
• Minimal bone removal, necessary to provide a regular base for
the gingival tissue to follow
• Failure to do so – results in “widow’s peaks”; and then –
selective recession and incomplete pocket reduction
Basic rules of osseous surgery
1. A full-thickness mucoperiosteal flap should be used
- The scalloping of the flap should anticipate the final underlying
osseous contour which is most prominent anteriorly and decrease
posteriorly;
- The scalloping of the flap should reflect the patient’s own healthy
gingival contour;
- The degree of tissue and bone scalloping is reduced as the
interproximal area becomes broader as a result of bone loss;
- Releasing incisions – may be necessary to gain better visibility or
to easily position the flap at the end of the surgery
2. Root debridement and removal of
granulation tissue
3. Identification and measurement of the
defect
4. Osteoplasty/ostectomy
Step 1. Reducing the interproximal bone
thickness (grooving)

In case of a very thin buccal/lingual bone –

minimal or no osteoplasty
In case of thick bony ledges – aggressive
bone recontouring

A diamond coarse round bur (Brassler, USA) used to perform

osteoplasty.
• Step 2: radicular blending - for a
smooth and blended surface (also
known as a sluice-way profile) to
enhance flap adaptation

• Step 3: ostectomy - one wall,

craters, or other defects should be
removed and interpoximal and
radicular bone designed to achieve
a positive architecture. Hand
instruments are used (Ochsenbain
chisel, back action chisel)

A back action chisel

• Step 4: correction of the interdental area.
The presence of a crater or a one-wall defect may be managed
according to the location and anatomy of the tooth, either by a
complete flattening of the crest or by a palatal/lingual approach

• Step 5: suturing.
Flap is placed apical to the pre-operative margins.
• Vertical or horizontal mattress suture
• Sling suture
❑ Osseous surgery should
whenever possibly result in a
positive osseous architecture.

❑ High-speed rotary instrument

should never be used adjacent to
the teeth and should always be
used with a lot of cooling liquid.

❑ The final bony contours should

approximate the expected
healthy postoperative gingival
form, with no attempt to
improve it.
Clinical case presentation

Woman, 46 yrs
Chief complain – swelling, pain, bleeding 23 - 24

Systemically healthy
2 times per year – regular check-up and SRP
11 PPD
Suppuration
4 weeks after SRP + systemic antibiotic
Treatment plan

Osteoplasty & Ostectomy of thick bony margins

GTR (autogenous bone chips + xenograft +membrane)
 Crown lengthening
• Restoration of fractures, severely decayed, partially erupted,
worn or poorly restored teeth is often difficult
• Periodontal exposure – lengthening – must follow certain
biologic principles and an adequate biologic width must be
maintained

• Biologic width – the dimensional width of dentogingival

junction (JE+CT fibers)

• Garguilo et al – quantified this as almost a constant 2.04 mm (JE – 0.97mm;

CT – 1.07; sulcus depth – 0.69 mm)

• Biological width should be 3 mm when measured from the

crest of the bone
• Impingement of this zone results in bone resorption
Resective osseus
surgery
Correction of gingival smile
• Gummy smile – excessive gingival display above 3 mm during
smiling or speaking

• Etiology:
- plaque or drug-induced gingival enlargement
- short or hyperactive upper lip;
- vertical excess of maxillary bone;
- short clinical crowns;
- altered or delayed passive eruption;
- combinations.
 Clinical crown lengthening:
a surgical procedure designed to increase the extent of supragingival
tooth structure for restorative or esthetic purposes by apically
positioning the gingival margin, removing supporting bone, or both.

The final objective is to obtain a positive osseous architecture

2-3 mm from the CEJ or proposed restorative crown margin
with a minimum 3 mm of keratinized tissue remaining.

Done with:
Apically displaced flap
Osseous resective surgery
Conventional crown
lengthening a) Baseline

b) External
bevel incision
c) Intrasulcular
incision

d) Gingival collar
removal
e) Full-thickness flap raised
f) Osteotomy and osteoplasty
g) Checking the distance of the alveolar crest to CEJ
e) Flap positioned and sutured apically
 Flapless esthetic clinical crown
lengthening
Possible if:
- adequate band of keratinized tissue
- a thin bone is present.

In this procedure, sulcular or inverted beveled incisions are performed

on the anterior teeth requiring crown lengthening

This may be facilitated with the assistance of a diagnostic wax-up, a

clinical mock-up, and an acrylic individual surgical guide since it assists
the picturing of the future position of gingival margins and restorations’
shape (when indicated).
(a) - baseline

(b) - clinical mock-up

positioned determining the
future gingival margin and
guiding the external
beveled incisions

(c) - removal of gingival

collars

(d) - osteotomy via the

gingival sulcus with
microchisel

(e) - no sutures
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