Resective Osseous Surgery Question And Answers

Resective Osseous Surgery Question And Answers

• The objective of periodontal therapy is to maximize the longevity of the natural dentition in a healthy, functional, and pain-free status.
• Periodontal therapy can be broadly classified as nonsurgical and surgical therapy. Surgical therapy included access flap surgery and osseous surgery.
• Osseous surgery includes procedures that bring about changes in the alveolar bone to get rid of deformities induced by periodontal disease or other related factors.

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• Osseous surgery can either be additive/reconstructive/regenerative osseous surgery, where regenerative procedures are used to restore the alveolar bone to its original level, or subtractive/respective osseous surgery, which restores the pre-existing alveolar bone to the level present at the time of surgery or slightly more apical to the pre-existing level.

Question 1. Define resective osseous surgery. Discuss the rationale, techniques, indications an steps involved in osseous surgery. Add a note on healing.
Answer:

• The principles of osseous surgery in periodontal therapy were proposed by Schluger in 1949 and later by Ochsenbein in 1958 and Prichard in 1961.
• It was suggested that alveolar bone loss caused by inflammatory periodontal disease altered the outline of the alveolar crest, while the gingiva retained its original position and contour as determined by the osseous topography present before the bone loss occurred.
• This results in a discrepancy in the physiological relationship between the gingival and the alveolar bone.
• It was considered necessary to recontour the bone to recreate the original architecture to achieve minimal probing depth and reestablish an optimal gingival contour that followed the altered osseous contour.
• The technique of osseous resective surgery involves osteoplasty and osteotomy procedures to reestablish the marginal bone morphology around the teeth to recreate a healthy, beneficial architecture in a more apical position.

Osseous Surgery Can Either Be

1. Definitive osseous surgery where further osseous reshaping would not improve the overall outcome.
2. Compromised osseous reshaping where bone pattern cannot be improved without significant osseous removal would be detrimental to the overall result.

Osseous Surgery Rationale And Objective

1. Reduce pocket depth in shallow osseous defects by reshaping marginal bone to resemble that of the alveolar process undamaged by periodontal disease
2. Help maintain optimal oral hygiene (enable plaque control) for long-term maintenance of periodontal health.

Osseous Surgery Indications

1. Shallow to moderate bone defects (1–3 mm) esp, craters (two wall defects)
2. Crown lengthening
3. Ledge formation, Bulbous bone contour
4. Early furcation involvement.

Osseous Surgery Contraindications

1. Advanced attachment loss
2. Deep vertical/intrabony defects.

Osseous Surgery Procedure: The resective osseous surgery involves two basic procedures

1. Osteoplasty
2. Ostectomy.

Osteoplasty is a procedure that involves reshaping bone without removing tooth-supporting bone, while ostectomy involves procedures to remove the tooth-supporting bone. Osteoplasty generally precedes osteotomy.

Osteoplasty Technique Include

1. Vertical grooving
2. Radicular blending

Ostectomy Technique Includes

1. Flattening interproximal bone
2. Gradualizing marginal bone.

Instruments used in resective osseous surgery are

Hand Instruments

1. Rongeurs
2. Ochsenbein chisels
3. Interproximal fibers

Rotary Instruments: Carbide round bur.

Question 2. What are the sequence of steps in resective osseous surgery?
Answer:

• Flap design depends on the extent of probing depth, the amount of bone loss, and the position of the marginal gingiva.
• Following the elevation of a full-thickness mucoperiosteal flap and removal of granulation tissue, the bone is re-contoured by
• Vertical grooving. Vertical grooves are made on the radicular surface of the alveolar bone between adjacent teeth with the help of rotary instruments (carbide round bur).
• This reduces the thickness of the alveolar bone interproximally.

Osseous Surgery Indications

• Thick bony margins
• Shallow crater formations
• Radicular blending. Following vertical grooving the resultant ledges on the radicular surface is gradualized by radicular blending to provide a smooth blended surface
• Flattening interproximal bone. This procedure requires the removal of very small amounts of supporting bone with the help of chisels.
• Shallow hemiseptal defects
• Gradualizing marginal bone. This procedure is done to create positive bone architecture. It is done with the help of chisels, interproximal fies.
• Following the resective procedure, the flaps are replaced to cover the new bony margin and stabilized with the help of sutures.

Osseous Surgery Modifications To Basic Technique

• Facial Or Lingual Craters
  • Intrabony craters may be located on the facial or lingual/palatal of teeth rather than being restricted to interproximal sites.
  • Depending on the depth and lateral extent of the defects osteoplasty may be all that is needed.
  • Vertical bone height is reduced, but none of the removed bone is supporting bone.
• Combination or Funnel-Shaped Craters
  • If the facial or lingual crater involves the mesial or distal aspect of the tooth then a resective procedure as described above is performed.
  • Both the depth of the facial or lingual crater and the depth of the interproximal defect dictate the amount of bone that must be removed to create positive architecture.
• Lingual Or Buccal Version
  • The greatest depth of interproximal craters is not always in the mid-bucco-lingual position but may be located closer to either the buccal or lingual cortical plate.
  • Instead of removing an equal amount of the buccal and lingual/palatal bony walls, the defect can be ramped to the most involved side.
  • This protects the less involved side of the tooth. Even if the crater is located in the center of the buccal and lingual cortical plates it may be advantageous to ramp the defect to the lingual/palatal aspect.

Question 3. Describe healing following respective osseous surgery.
Answer:

• Healing takes 14–21 days (attachment of flap to bone) and maturation takes 6 months.
• The soft tissue flap is attached to the bone surface fist by a fibrin clot, then by granulation tissue, and finally by 1 month postoperative, the flap is attached by connective tissue fibers embedded into the new surface bone.
• Edema and intense cellular activity in the PDL space results in increased tooth mobility.
• There is dilation of the PDL blood vessels and resorption of the crystal aspect of the socket bone.
• Dentinal hypersensitivity to cold may occur after periodontal surgery because of the exposure of new root surfaces to the oral environment. Exposed bone undergoes surface necrosis and is resorbed followed by bone apposition. Remodeling of bone occurs over several months.

Conclusion

• The object of respective osseous surgery is to eliminate bony abnormalities so as to achieve the physiologic architecture of marginal alveolar bone conductive to gingival flap adaptation and minimal probing depth.
• The procedure results in predictable pocket reduction which helps the patient to maintain good oral hygiene and preserve width of the attached gingiva.