Resective Osseous Surgery
Question 1. What are osseous defects? What is osseous surgery write in detail about resective osseous surgery?
Answer. Osseous defects are those defects, which are formed as a result of destruction of alveolar bone due to periodontal disease.
Osseous surgery: 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.
Resective Osseous Surgery
It is the procedure designed to restore the form of preexisting alveolar bone to the level existing at the time of surgery or slightly more apical to this level is known as resective osseous surgery.
Resective Osseous Surgery Objectives
- Removal of osseous defects
- Correction of bone morphology
- To create harmonious relation between gingiva and alveolar bone by eliminating periodontal pockets.
- To create a favorable postoperative gingival morphology
Read And Learn More: Periodontics Question And Answers
Steps in Resective Osseous Surgery
Following are the steps which are suggested for the respective osseous surgery:
- Vertical grooving
- Radicular blending
- Flattening inter proximal bone
- Gradualizing marginal bone
Vertical Grooving
- Vertical grooving is carried out to reduce the thickness of the alveolar housing as well as to provide relative prominence to the radicular aspects of teeth.
- It gives continuity from the interproximal surface onto the radicular surface.
- This is the first step of the resective process as it can define the general thickness and subsequent form of the alveolar housing.
- Vertical grooving should be performed with rotary instruments, such as round carbide burs.
- Advantages of vertical grooving are most apparent with thick bony margins, shallow crater formations, or other areas that require proximal osteoplasty and minimal ostectomy.
- It is contraindicated in areas with close roots or thin alveolar housing is present.
Radicular Blending
- It is the second step of the osseous resective technique and is an extension of vertical grooving procedure.
- Radicular blending is an attempt to visualize the bone over the entire radicular surface to give the best results from vertical grooving.
- This gives a smooth, blended surface for good flap adaptation.
- Radicular blending is necessary if vertical grooving is very minor or if the radicular bone is thin or fenestrated.
- Vertical grooving and radicular blending are osteoplastic techniques that do not remove supporting bone.
- Shallow crater formation, thick osseous ledges of bone in the radicular surfaces and class I and early class II furcation involvements are treated almost entirely with these two steps.
Flattening of Inter-proximal Bone
- Flattening of the interdental bone requires the removal of very small amounts of supporting bone.
- It is indicated when interproximal bone levels vary horizontally.
- Most of the indications for this step are one-walled interproximal defects or hemiseptal defects.
- Omission of flattening in such cases results in increased pocket depth on the most apical side of the bone loss.
- Flattening of interdental bone is not necessary with interproximal crater formations or flat interproximal defects.
- This procedure is best used in defects which are coronally placed, one-walled edge of a predominantly three-walled angular defect, and it can be helpful in obtaining good flap closure and improved healing in the three-walled defect.
- Limitation of this step is with resective osseous surgical therapy in general, is in the treatment of advanced lesions.
- Large hemiseptal defects would require removal of inordinate amounts of bone to provide a flattened architecture, compromised osseous architecture is the only logical solution.
Gradualizing Marginal Bone
- Final step in osseous resection technique is an ostectomy process.
- Removal of bone is minimal but necessary to provide a sound, regular base for the gingival tissue to flow.
- 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 interdental area. This leads to the process of selective recession and subsequent pocket reduction incomplete.
- This step of the procedure also requires gradualization and blending on the radicular surface.
- Both osteotomy procedures should be performed with proper care so as not to produce nick or grooves on the roots.
- When radicular bone is thin, it is extremely easy to overdo this step.
- In various hand instruments, such as chisels and curettes, are preferable to rotary instruments for gradualizing marginal bone.
Placement of Flap and Closure
- After the completion of osseous resection, the clinician positions and sutures the flaps.
- Flaps can be replaced at their original position, to cover the new bony margin, or they may be apically positioned.
- Replacing the flap in areas that previously had deep pockets may result initially in greater postoperative pocket depth.
- Positioning the flap apically to expose marginal bone is one method of altering the width of the gingiva. However, such flap placement results in more postsurgical resorption of bone and patient discomfort than of the newly created bony margin which was covered by the flap.
- Positioning the flap to cover the new margin minimizes postoperative complications and results in optimal postsurgical pocket depths.
- Suturing may be accomplished using a variety of different suture materials and suture knots.
- The sutures should be placed with minimal tension to approximate the flaps, prevent their separation, and maintain the position of the flaps.
Postoperative Maintenance
- Remove the non resorbable sutures such as silk after l week of healing. Some of the newer synthetic materials can be left up to 3 weeks or longer.
- During suture removal the periodontal dressing, if present, should be removed, and the surgical site is gently cleansed of debris by cotton pellet dampened with saline.
- After suture removal is done, the surgical site is examined carefully, and any of the excessive granulation tissue is removed by sharp curette.
- For maintenance of the surgical site in a plaque-free state, provide the patient with postsurgical maintenance instructions.
- Chlorhexidine digluconate can be a valuable adjunct to postsurgical maintenance.
- A second postoperative visit should be kept at second or third week, and during the visit surgical site is lightly debrided for good results.
- Professional prophylaxis for complete plaque removal should be done every 2 weeks until healing is complete or the patient is maintaining appropriate levels of plaque control.
- Before starting with dental restorations, it is advisable to wait for at least 6 weeks postoperatively.
Question 2. Write short note on osseous resective surgery.
Or
Write short note on resective osseous surgery.
Or
Write short note on steps for osseous resective surgery.
Or
Write the indications, contraindications and steps in resective osseous surgery.
Or
Explain steps of resective osseous surgery.
Answer.
Resective Osseous Surgery
It is the procedure designed to restore the form of preexisting alveolar bone to the level existing at the time of surgery or slightly more apical to this level is known as resective osseous surgery.
Steps in Resective Osseous Surgery
Following are the steps which are suggested for the respective osseous surgery:
- Vertical grooving
- Radicular blending
- Flattening interproximal bone
- Gradualizing marginal bone
Vertical Grooving
- Vertical grooving is carried out to reduce the thickness of the alveolar housing as well as to provide relative prominence to the radicular aspects of teeth.
- It gives continuity from the interproximal surface onto the radicular surface.
- This is the first step of the resective process as it can define the general thickness and subsequent form of the alveolar housing.
- Vertical grooving should be performed with rotary instruments, such as round carbide burs.
- Advantages of vertical grooving are most apparent with thick bony margins, shallow crater formations, or other areas that require proximal osteoplasty and minimal ostectomy.
- It is contraindicated in areas with close roots or thin alveolar housing is present.
Radicular Blending
- It is the second step of the osseous resective technique and is an extension of vertical grooving procedure.
- Radicular blending is an attempt to visualize the bone over the entire radicular surface to give the best results from vertical grooving.
- This gives a smooth, blended surface for good flap adaptation.
- Radicular blending is necessary if vertical grooving is very minor or if the radicular bone is thin or fenestrated.
- Vertical grooving and radicular blending are osteoplastic techniques that do not remove supporting bone.
- Shallow crater formation, thick osseous ledges of bone in the radicular surfaces and class I and early class II furcation involvements are treated almost entirely with these two steps.
Flattening of Interproximal Bone
- Flattening of the interdental bone requires the removal of very small amounts of supporting bone.
- It is indicated when interproximal bone levels vary horizontally.
- Most of the indications for this step are one-walled interproximal defects or hemiseptal defects.
- Omission of flattening in such cases results in increased pocket depth on the most apical side of the bone loss.
- Flattening of interdental bone is not necessary with inter-proximal crater formations or flat interproximal defects.
- This procedure is best used in defects which are coronally placed, one-walled edge of a predominantly three-walled angular defect, and it can be helpful in obtaining good flap closure and improved healing in the three-walled defect.
- Limitation of this step is with resective osseous surgical therapy in general, is in the treatment of advanced lesions.
- Large hemiseptal defects would require removal of inordinate amounts of bone to provide a flattened architecture, compromised osseous architecture is the only logical solution.
Gradualizing Marginal Bone
- Final step in osseous resection technique is an ostectomy process.
- Removal of bone is minimal but necessary to provide a sound, regular base for the gingival tissue to flow.
- 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 interdental area. This leads to the process of selective recession and subsequent pocket reduction incomplete.
- This step of the procedure also requires gradualization and blending on the radicular surface.
- Both osteotomy procedures should be performed with proper care so as not to produce nick or grooves on the roots.
- When radicular bone is thin, it is extremely easy to overdo this step.
- In various hand instruments, such as chisels and curettes, are preferable to rotary instruments for gradualizing marginal bone.
Indications of Resective Osseous Surgery
- In one walled angular defects.
- In patients with thick bony margins.
- In patients having shallow crater formations.
Contraindications of Resective Osseous Surgery
- Anatomic factors, such as close proximity of roots to the maxillary antrum of ramus.
- In geriatric patients.
- In patients with improper oral hygiene.
- In patients with high caries index.
- In patients with extreme root sensitivity.
- In patients with advanced periodontitis.
- In cases with unacceptable aesthetic result.
Question 3. Write short note on osteoplasty and ostectomy.
Answer.
Osteoplasty
Osteoplasty refers to reshaping the bone without removing tooth supported bone.
In osseous resective surgery vertical blending and radicular grooving are the osteoplasty procedures.
Osteoplasty Indications
- For removing exostosis.
- For tori reduction.
- In early grade I furcation lesion.
- To contour alveolar ridge to make room for pontics.
- In open furcation in tunneling procedure.
Ostectomy
Ostectomy refers to the removal of tooth supporting bone.In osseous resective surgery flattening of interproximal bone and gradualizing marginal bone are the ostectomy steps.
Ostectomy Indications
- In crown lengthening.
- In exposure of sound dentin which is apical to dental caries or fractures.
- In opening interradicular spaces for treatment of furcation involvement.
- In horizontal bone loss with irregular margins.
- In hemiseptum defects.
- To eliminate interdental craters.
Ostectomy Contraindications
- In extended tooth mobility.
- Esthetic limitations such as high smile line.
- In areas of insufficient remaining bone.
- Presence of more than 8 mm infrabony pockets or bone loss which extends more than one half of the root length.
Question 4. Define and classify osseous surgery. Discuss the resective osseous surgery in detail.
Answer. Osseous surgery is defined as “procedure to modify bone support altered by periodontal disease either by reshaping the alveolar process to achieve physiologic form, without the removal of alveolar supporting bone or by removal of some alveolar bone, thus changing the position of crestal bone relative to tooth root”. American Academy of Periodontology.
Classification of Osseous Surgery
Depending on the relative position of the interdental bone to radicular bone, osseous surgery is of following types:
- Positive architectures when the radicular bone is apical to the interdental bone.
- Negative architecture: lf the interdental bone is more apical than the radicular bone.
- Flat architecture: It is the reduction of interdental bone to the same height as radicular bone.
- Ideal: When the bone is consistently more coronal on the interproximal surface than on the facial and lingual surfaces.
Depending on the thoroughness of the osseous reshapingtechniques, osseous surgery is of following types:
- Definitive osseous reshaping: Implies that further reshaping would not improve the overall result.
- Compromise osseous reshaping: It indicates a bone pattern that cannot be improved without significant osseous removal that would be detrimental to the overall result.
Osseous surgery can also be:
- Additive: Directed toward restoring the bone to original levels.
- Subtractive: It is designed to restore the form of the pre-existing alveolar bone to the level existing at the time of surgery or slightly apical to this level.
Question 5. Enumerate osseous defects. Define resective osseous surgery. Write in detail about osseous resective surgery.
Answer.
Enumeration of Osseous Defects
According to Goldman & Cohen (1958)
- One-walled defect
- Two-walled defect
- Three-walled defect
- Combined defect
According to Glickman (1964)
- Osseous/interdental craters
- Hemiseptal defects
- Infrabony defects
- Bulbous bone contour
- Inconsistent margins and ledges (plateau like bony margins)
- Reversed architecture
According to Prichard (1967)
- Interproximal crater
- Inconsistent margins
- Hemisepta
- Furcation invasion
- Intrabony defects
- Combination
According to Manson and Nicholson
- Thickened margins
- Interdental crater
- Hemiseptum
- Infrabony defect with 3 osseous walls
- Infrabony defect with 2 osseous walls
- Infrabony defect with one osseous wall other than hemiseptum
- Marginal gutter
- Furcation involvement
- Irregular bony margins
- Dehiscence
- Fenestration
- Exostosis
Resective Osseous Surgery
It is the procedure designed to restore the form of preexisting alveolar bone to the level existing at the time of surgery or slightly more apical to this level is known as resective osseous surgery.
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