Osseous Resective Surgery

Dr. Vinay Bhide
Authored by:
Dr. Vinay Bhide
Dr. Jim Lai
Authored by:
Dr. Jim Lai

Introduction

The periodontal disease process results in destruction of the alveolar bone. The pattern of osseous destruction is not uniform, but rather, quite variable in nature. From a clinical perspective, periodontal tissue destruction is manifested by clinical attachment loss with formation of deep periodontal pockets with associated bleeding on probing. The elimination or reduction of the periodontal pocket is one of the goals of periodontal therapy. This is largely dependent on reestablishment of physiologic osseous contours and correction of deformities in the alveolar bone surrounding the involved teeth. Reducing or eliminating periodontal pockets is thought to enhance the patient’s ability to practice optimal oral hygiene and plaque removal and to also improve in-office debridement procedures during recall therapy appointments.

Osseous resective surgery is the most predictable surgical treatment modality for achieving stable pocket reduction1. Gingival surgery alone is ineffective in reducing periodontal pockets with an intraosseous component. The surface topography of alveolar bone is not indicative of the surface form of the overlying gingiva. Osseous resective surgery comprises a series of carefully orchestrated steps for appropriate re-contouring of alveolar bone and management of the overlying soft tissues. Osseous resective surgery can be defined as a procedure to modify osseous support either by reshaping the alveolar bone to achieve physiologic form without the removal of supporting bone (osteoplasty) and/or by the removal of some alveolar bone (ostectomy), thus changing the position of the crestal bone relative to the tooth root2.

Historical Basis

Prior to 1935, bone associated with periodontal disease was considered infected or necrotic and surgical removal of this affected bone was the most accepted treatment. Kronfeld’s research demonstrated that control of inflammation was critical to treating periodontitis and that the underlying bone was neither necrotic nor infected3. In addition to the introduction of the gingivectomy technique4, there was a decline in osseous resective surgery. However, recurrence of pockets after gingivectomy became a concern and led to renewed interest in osseous resective surgery. The recurrence of pockets and regrowth of soft tissue following the gingivectomy procedure was due its inability to follow irregular contours of osseous deformities5. In this regard, it was suggested that because bone remodels at a slower rate compared to soft tissue, contouring of bone was necessary to facilitate gingival conformity. It was further emphasized that gingival contour does not necessarily follow osseous contour since the soft tissues tended to follow a scalloped contour even in the presence of underlying osseous irregularities6. It has been suggested that osseous resective surgery involves osteoplasty and ostectomy and with emphasis on the importance of recontouring underlying bone and pocket elimination in order to achieve proper gingival architecture.

Alveolar Bone Morphology

In order to correctly perform osseous resective surgery, an understanding of normal periodontal bone morphology is necessary. Normal osseous architecture generally has the following characteristics:

  1. Interdental bone is pyramidal in form and in a more coronal position to the labial or palatal/lingual bone.
  2. Tooth form and embrasure width influence the form of the inter-dental bone. Tapered teeth tend to be associated with a more pyramidal osseous form. Wider embrasure spaces are associated with a flatter inter-dental osseous form.  
  3. The contour of the marginal bone follows the contour of the cemento-enamel junction (CEJ) which leads to “scalloping” of bone on the facial and palatal/lingual surfaces of the tooth.  

Terminology

The following terms are important to know when discussing osseous resective surgery:

Osteoplasty: Reshaping of the alveolar bone to achieve a more physiologic form without removal of alveolar bone proper.

Ostectomy: The excision of a bone or portion of bone. In periodontics, ostectomy is done to correct or reduce deformities caused by periodontitis in the marginal and interalveolar bone and includes the removal of bone that is attached to the tooth.

The above procedures may be required individually or in combination depending on the situation to obtain the desired surgical result. 

Positive architecture: Refers to the situation whereby radicular bone is at an apical level to the interdental bone.

Negative architecture: The opposite of positive architecture, i.e. situation whereby interdental bone is more apical relative to the radicular bone. 

Flat architecture: This occurs when both the interdental and radicular bone are at the same level. 

One of the major goals of osseous resective surgery is to re-establish positive architecture of the underlying bone as this is thought to be favourable for periodontal health and maintenance. 

Definitive osseous reshaping: when further osseous contouring will not significantly improve the surgical result. 

Compromised osseous reshaping: refers to the situation when additional bone removal in order to attain ideal osseous architecture is not done as this would significantly compromise the support of a tooth or teeth.

Indications of Osseous Resective Surgery

Indications for osseous resective surgery include5:

  1. When gingivectomy alone fails to reduce the periodontal pocket
  2. Deep isolated periodontal pockets
  3. Mesial aspect of tipped molar teeth.
  4. Saucer-shaped interproximal pockets.
  5. Deep, isolated pockets

According to the literature5 overlying soft tissues generally 'tolerate' variations in alveolar bone height up to 30 degrees (or 60 degrees in cases of prominent roots. Furthermore, thick edges of bone around teeth should be thinned to a knife-edge margin to permit tension-free tissue adaptation against the osseous tissues during flap closure. Importantly, however, it must be recognized that despite the evident importance of developing positive or at least favourable architecture of alveolar bone, resective surgery is contra-indicated if bone removal requirements are so large as to have a negative impact on the bone support and architecture of bone adjacent to nearby teeth and/or will result in furcation exposure of those teeth or the teeth involved in the primary site of surgery. 

Advantages of Osseous Resective Surgery 7

  1. Visualization and accessibility of osseous defects
  2. Minimal treatment time
  3. Ease of technique
  4. Elimination of additional surgical sites

Disadvantages of Osseous Resective Surgery

  1. Loss of attachment
  2. Gingival recession
  3. Post-operative sensitivity
  4. Increased mobility of tooth/teeth in area treated

Factors to Consider Prior to Performing Osseous Resective Surgery

  1. Length and shape of the roots
  2. Location and dimension of the defect(s)
  3. Width of supporting bone
  4. Root prominence
  5. Relationship of the intraosseous defects to adjacent teeth and other anatomic structures, e.g. palatal exostoses.

The major determinant of the extent of bone resected is the relationship between the configuration and depth of the osseous defect to the root morphology and adjacent teeth. Osseous defects are classified according to their configuration and number of osseous walls containing the defect8. Osteoplastly and ostectomy could effectively be used to treat 1 or 2-walled osseous defects around teeth with early-moderate bone loss and moderate-length root trunks, and create a positive osseous architecture9,10. Patients with severe bone loss and deep intra-osseous defects were not considered suitable candidates for osseous resection as the amount of bone which would have to be removed to attain positive architecture would further compromise the attachment, and consequently, survival of the tooth.

Examination and Treatment Planning Associated with Osseous Resective Surgery

A comprehensive periodontal examination is necessary in order to determine whether osseous resective surgery can be used as a potential treatment modality. Periodontal probing is an essential component of this examination. Thorough and careful periodontal probing can confirm the presence of:

  1. periodontal probing depth in excess of that of normal gingival sulcular probing depth (0-4 mm).
  2. relationship of the base of the pockets to the mucogingival junction and attachment levels on adjacent teeth  
  3. number of osseous walls
  4. furcation involvement.

Transgingival probing or bone sounding, under local anesthesia, allows one to better appreciate the osseous topography of intraosseous or furcation defects 11. This is especially useful just prior to flap reflection. The sounding procedure involves inserting the probe into the sulcus and “walking” it along the tissue-tooth interface in order for the clinician to feel the osseous topography. It is also useful to sound horizontally through the overlying tissues as this gives three-dimensional information about the underlying osseous contours.

Dental radiographs can also be used adjunctively to provide further information pertaining to the extent of interproximal bone loss, the presence of angular bone loss, caries, root trunk length, and root morphology. Radiographs also provide a means to evaluate therapeutic success and longitudinal stability of the patient. Radiographs do not, however, accurately determine the extent of osseous defects or the number of osseous walls present on the facial or palatal/lingual walls. In fact, a 2-wall interproximal crater defect between teeth where both the facial and lingual/palatal bone walls are present, may oftentimes not be detected radiographically. Thus, both clinical and radiographic examinations must be employed together to accurately determine and diagnose the presence of intra-osseous defects.

Technique for Osseous Resective Surgery

Instruments: combination of hand and rotary instruments can be used for osseous resective surgery

Technique: the following steps are recommended in sequence to perform osseous resective surgery:

  1. Vertical grooving
  2. Radicular blending
  3. Flattening interproximal bone
  4. Gradualizing marginal bone

Although every step may not always be required, it is necessary to follow the sequence as this facilitates the recontouring as well as minimizes the risk of removing excess bone.  

  1. Vertical grooving – this is the first step of the resective process and is a purely osteoplastic technique. The purpose of vertical grooving is to reduce the thickness of the alveolar bone while at the same time providing relative prominence to the tooth roots (also known as “festooning”). Rotary instruments (carbide or diamond) are generally used to accomplish this critical first step. Vertical grooving is contra-indicated in areas with close root proximity or thin alveolar bone.  
  2. Radicular blending – this is the second step of the resective process and is a continuation of the vertical grooving process. Like vertical grooving, radicular blending is also a purely osteoplastic technique. The purpose of this procedure is to provide a smooth, gradualized bone contour over the entire radicular surface. Gradualize bone over the entire radicular surface.

    Both vertical grooving and radicular blending compise the bulk of the osseous resective process. These first two steps can be almost entirely used to treat shallow crater defects, thick osseous ledging on the radicular surface, incipient and early Class II furcation involvements.

  3. Flattening of the Interproximal Bone – this step is indicated when interproximal bone levels vary horizontally and requires the removal of minimal supporting bone. This step requires some degree of ostectomy. Indications for this step include one-walled interproximal defects or hemiseptal defects. However, this step is contra-indicated for large defects whose ideal correction would require significant bone removal thereby compromising the periodontal support of the tooth; thus, compromised osseous architecture is acceptable is such situations.  
  4. Gradualizing Marginal Bone – this is the final step of the osseous resective process and is necessary for providing a well-contoured base for the gingival tissue to follow. It is a process requiring ostectomy and thus caution must be exercised in order not to remove excess bone. Consequently, various hand instruments such as bone chisels and curettes can be used in conjunction with rotary instrumentation.  

In certain situations, where conventional bone removal may lead to compromised support of the tooth or exposure of a furcation, “ramping” the bone to the palatal or lingual has been advocated to avoid or reduce the risk of furcation involvement 9, 10, 12, 13.

Flap Replacement and Closure

Following osseous resective surgery, the elevated mucoperiosteal flaps may be replaced to their initial positions, to cover the bone at its new level, or they may be apically repositioned to expose marginal bone. Ideally, it is recommended that flaps be repositioned to cover the bone at its new level as this has been shown to be associated with decreased post-operative discomfort and desired post-surgical probing depth reduction.

Closure of flaps can be attained with either resorbable or non-resorbable sutures. The recommended suturing technique involves a continuous vertical mattress sling pattern as this allows the operator to achieve close approximation between the flaps and the underlying bone.

Post-operative maintenance

Patient should be seen no more than 2 weeks following surgery for a post-operative visit and suture removal (if necessary). Optimal plaque control is critical for long-term stability of the surgical result. In the immediate post-operative period, chlorhexidine gluconate (0.12%) rinsing may be used adjunctively to proper toothbrushing, flossing and/or use of interdental brush. Generally, rinsing isn't recommended until about 24 postoperatively. Professional prophylaxis is recommended every 2 weeks until healing is complete and the patient is able to maintain acceptable oral hygiene in the surgically-treated areas. 

Long Term Healing Following Osseous Resective Surgery

Osteoblasic activity was still present at 1 year post-operatively14. Bone remodeling following osseous surgery was characterized by an initial crestal bone loss of 1.2 mm followed by 0.4 mm of new bone apposition – resulting in an average crestal height reduction of 0.8 mm. A key determinant of the amount of post-operative bone loss was bone thickness; thicker bone exhibited less resorption than thin bone. 

Long Term Outcomes and Efficacy of Osseous Resective Surgery

A 5-year study demonstrated that osseous surgery for 75 patients with advanced periodontal disease is highly effective and that maintenance of optimal oral hygiene and frequent recalls are very important for long-term stability15. Sixty-one of 75 patients were examined 9 years later and found that the results obtained at 5 years post-operatively were maintained at the 14-year mark in most patients16. 

Summary and Conclusions

When osseous resective surgery is properly applied, it is a highly effective mode of definitive periodontal treatment. Although the very nature of this surgical treatment modality induces loss of attachment, it is a predictable method of achieving reduction of periodontal osseous defects, long-term periodontal stability, and may improve accessibility for optimal oral hygiene and homecare practices. In addition to being used to treat periodontal disease, osseous resective surgery may also be used to facilitate certain restorative procedures, i.e. crown lengthening. Lastly, the clinician must consider the benefits, risks, and magnitude of the osseous defect(s) to be treated in order to choose the most appropriate technique to attain a favourable treatment outcome.

 

References: 

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American Academy of Periodontology Glossary of Periodontic Terms. 2001.

Kronfeld R. The condition of the alveolar bone underlying periodontal pockets. J Periodontol 1939;6: 22.

Orban B. Gingivectomy or flap operation? J Am Dent Assoc 1939;26: 1276

Schluger S. Osseous resection--a basic principle in periodontal surgery. Oral Surg 1949;2:316.

Friedman N. Periodontal Osseous Surgery: osteoplasty and ostectomy. J Periodontol 1955;26:257.

Siebert J. Treatment of infraosseous lesions by surgical resection procedures. In Stahl SS, ed. Periodontal surgery: Biologic Basis and Technique. Springfield, Ill: Charles C. Thomas, 1976.

Goldman HM, Cohen DW. The infraosseous pocket: Classification and treatment. J Periodontol 1958;29: 272.

Ochsenbein C, Bohannan H. The palatal approach to osseous surgery. I. Rationale. J Periodontol 1963;34:60.

Ochsenbein C, Bohannan H. The palatal approach to osseous surgery. I. Rationale. J Periodontol 1963;34:60.

Easley J. Methods of determining alveolar osseous form. J Periodontol 1967;38:112.

Tibbetts L, Ochsenbein C, Loughlin D. Rationale for the lingual approach to mandibular osseous surgery. Dent Clin North Am 1976;20(1):61.

Tibbetts L, Ochsenbein C, Loughlin D. Rationale for the lingual approach to mandibular osseous surgery. Dent Clin North Am 1976;20(1):61.

Lindhe J, Nyman S. The effect of plaque control and surgical pocket elimination on the establishment and maintenance of periodontal health. A longitudinal study of periodontal therapy in cases of advanced disease. J Clin Periodontol 1975;1:67.

Lindhe J, iNyman S. Long-term mantenance of patients treated for advanced periodontal disease. J Clin Periodontol 1984;11:504