52. Osseous Surgery - I Osseous Resection

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osseous surgery- purpose indications and history	Guidelines for Ossous Surgery
anatomic factors to be considered in osseous surgery	the palatal approach to osseous surgery
lingual approach to mandibular osseous surgery	much bone is removed during osseous surgery
healing sequence in the hard and soft tissues following osseous surgery	healing if bone is left exposed
the optimal flap placement	osseous surgery compare to other treatment modalities
long-term results following osseous surgery

A. What is the purpose of osseous resective surgery? What are the indications? How have the principles of both hard tissue resection and soft tissue management changed over time?

Schluger S. Osseous resection - a basic principle in periodontal surgery. Oral Surg. Oral Med Oral Pathol 2:316-325, 1949.

Wilderman MN. Exposure of bone in periodontal surgery. Dent Clin NA 8:23-26, March 1964.

Ochsenbein C. Osseous resection in periodontal surgery. J. Periodontol. 29:15-26, 1958

Ochsenbein C: A primer for osseous surgery. Int J Periodont Rest Dent 6(1):8-47, 1986

Carnevale, G., Kaldahl, W: Osseous resective surgery. Periodontol, 2000, 22:59-87, 2000.

B. What anatomic factors should be considered when planning and performing flap surgery with osseous recontouring? Does this change our approach to osseous resection? In what situations should bony removal be modified or combined with other treatment options? What are the contraindications for osseous resection?

Goldman HM, Cohen DW: The infrabony pocket: Classification and treatment. J Periodontol. 29:272-291, 1958

Becker W, Ochsenbein C, Tibbetts L, Becker BE. Alveolar bone anatomic profiles as measured from dry skulls. J Clin Periodontol 24:727-731,1997.

Nevins M, Reiser G. The clinical management of periodontal osseous defects. Alpha Omegan 76(4):51-60,. 1983.

Ochsenbein C, Bohannan HM. The palatal approach to osseous surgery. I. Technique. J. Periodontol. 34:60-68, 1963.

Ochsenbein C, Bohannon HM: The palatal approach to osseous surgery. II. Clinical application. J. Periodontol. 35:54-68, 1964

Tibbetts LS, Ochsenbein C, Loughlin D: Rationale for the lingual approach to mandibular osseous surgery. Dent. Clin. N. Amer. 20:61-78, 1976

Nowzari, H: Aesthetic osseous surgery in the treatment of periodontitis. Periodontol 2000 27:8-28, 2001

Morris ML. Two approaches for interproximal osseous tapering. Periodontics 2:259- ,1964.

C. How much bone is removed during osseous surgery? How can this affect the soft tissue levels and overall stability of the tooth? Is all bone equally important for stability?

Friedman N. Periodontal osseous surgery: Osteoplasty and osteoectomy. J Periodontol 26:257-269, 1955.

Selipsky H. Osseous surgery: how much need we compromise? Dent Clin NA 20:79-106, 1976.

Caton J, Nyman S. Histometric evaluation of periodontal surgery. III. The effect of bone resection on the connective tissue attachment level. J. Periodontol. 52:405-409, 1981.

D. What instruments should we use for bone removal? Does it make a difference for short-term healing? Long-term healing?

Lobene RR, Glickman I. The response of alveolar bone to grinding with rotary diamond stones. J. Periodontol. 34:105-119, 1963

Horton JE, et al: The healing of surgical defects in alveolar bone produced with ultrasonic instrumentation, chisel and rotary bur. Oral Surg.Oral Med Oral Pathol 39:536-546, 1975.

Fister J, Gross B: A histologic evaluation of bone response to bur cutting with and without water coolant. Oral Surg.Oral Med Oral Pathol 49: 105-111, 1980.

Glick DA, Freeman E: Postsurgical bone loss following root planing by ultrasonic and hand instruments. J. Periodontol. 51:510-512, 1980.

Horton JE, Tarpley TM, Jacoway JR. Clinical applications of ultrasonic instrumentation in the surgical removal of bone. Oral Surg.Oral Med Oral Pathol 51:236-242, 1981.

E. Describe the healing sequence in the hard and soft tissues following osseous surgery both clinically and histologically. How long should we wait before assesing outcome of therapy?

Durwin A, et al: Healing after treatment of periodontal intraosseous defects. IV. Effect of a on-resective versus partially resective approach. J. Clin. Periodontol. 12:525-539, 1985.

Moghaddas H, Stahl SS. Alveolar bone remodeling following osseous surgery. A clinical study. J. Periodontol. 51:376-381, 1980.

Pennel BM, et al: Repair of the alveolar process following osseous surgery. J. Periodontol. 38:426-431, 1967

Wilderman MN, et al: Histogenesis of repair following osseous surgery. J. Periodontol. 41: 551-565, 1970.

F. How is healing different if bone is left exposed? Can soft tissue management during surgery influence the outcome?

Ratcliff PA, Raust GT: Interproximal denudation: A conservative approach to osseous surgery. Dent. Clin. North Am. 8:121-131, 1964.

Prichard JF. Present state of the interdental denudation procedure. J Periodontol. 48:566-569, 1977.

Machtei EE, Ben-Yehouda: The effect of post-surgical flap placement on probing depth and attachment level: a 2-year longitudinal study. J Periodontol. 1994 Sep;65(9):855-8.

G. How stable are the newly established bone levels of osseous recontouring? How stable are the long-term results following osseous surgery?

Matherson DG. An evaluation of healing following periodontal osseous surgery in monkeys. Int. J. Periodont. Rest. Dent. 8(5):9-39, 1988.

Lindhe J, Nyman S. Alterations of the position of the marginal soft tissue following periodontal surgery. J. Clin. Periodontol. 7:525, 1980.

H. How does osseous surgery compare to other treatment modalities?

Olsen CT, et al: A longitudinal study comparing apically repositioned flaps with and without osseous surgery. Int. J. Periodont. Rest. Dent. 5(4):11-33, 1985.

Kaldahl WB, Kalkwarf KL, Patil KD, Dyer JK, Bates RE: Evaluation of four modalities of periodontal therapy. J. Periodontol. 59: 783 -793, 1988

Donnenfeld OW, Hoag PM, Weissman DP. A clinical study on the effects of osteoplasty. J. Periodontol. 41:131-141, 1970.

Aeschilmann CR, Robinson PJ, Kaminski EJ. A short term evaluation of periodontal surgery. J. Periodontal Res. 14:182-184, 1979.

Persson GR, Falk H, Laurell L. A retrospective radiographic outcome assessment study of intrabony defects treated by osseous surgery or by bone graft procedures. J Clin Perio 27:104-108,2000.

Levy RM, Giannobile WV, Feres M, et al. The effect of apically repositioned flap surgery on clinical parameters and the composition of the subgingival microbiota: 12 month data. Int J Perio Rest Dent 22:209-219, 2002.

What is the purpose of osseous resective surgery? What are the indications? How have the principles of both hard tissue resection and soft tissue management changed over time?

Schluger, 1949 Article

Purpose: To present the principles of osseous resection in periodontal surgery. A historical opinion article based on 10 years of experience with osseous resection.

Discussion: Pocket elimination is the goal of surgery, but surgery should only be done when conservative means fail to resolve the pocket. Although pts can be managed for years with pockets, these pts frequently break down rapidly and require constant and meticulous office treatment. Patients treated by osseous resection are easier to maintain and are more stable. Gingivectomy and denudation alone are not sufficient for long term pocket elimination due to gingival regrowth. The goal of osseous resection is to re-contour the bone to prevent gingival regrowth & the reappearance of pockets.

Two techniques are presented with a discussion of the indications for these techniques.

1. Technique I involves a long sweeping incision apical to the deepest part of the pockets followed by soft tissue removal and osseous resection. This technique will leave some bone exposed and cause more post-op pain but is easier to perform.

2. Technique 2 begins with a gingivectomy followed by a reflection of the gingival flap and osseous resection to restore the physiologic contour to the bone.

Indications for these procedures were listed as:

- Resection of proximal and facial bone to form a gradual rise and slope in the bone over affected areas, allowing gingival conformation to that line and eliminating the pockets.

- To treat deep pockets on the mesial aspect of tipped second molars.

- To treat isolated deep pockets on a single tooth where the adjacent teeth have normal bone support.

- To treat deep buccal and lingual pockets where there is thick ledges or concavities over which the soft tissue will proliferate.

- To treat saucer-shaped interproximal pockets with a buccal or lingual spine of bone.

Contraindications to osseous resection include

- Too much supportive bone must be sacrificed from sound teeth

- Furcation exposure is probable.

BL: A historical opinion which suggests that pocket elimination by perio surgery with osseous resection leads to a more stable and easier to maintain dentition than conservative therapies which leave residual pockets. The condition of the hard tissue directly controls overlying soft tissue so that the bone must be re-contoured in the above situations to predictably eliminate pockets.

Wilderman, 1964 Article

Purpose: To discuss various types of periodontal surgery as they relate to alveolar bone exposure.

Discussion: Exposure of alveolar bone during surgery to correct gingival and osseous deformities is frequently necessary. The dentogingival complex and the alveolar bone must be considered in bone exposing operations. Bony exposure occurs interdentally, radicularly, and/or in the furcation. Both permanent and temporary bone exposure can occur.

Permanent Bone Exposure: Usually results in exposed bony plate that becomes necrotic followed by the osteoclastic phase resulting in early resorption of this necrotic bone. End result is the removal of necrotic bone and some of the viable bone underneath it. The osteoblastic phase is where the bulk of bone formation occurs. In the radicular area, only about 50% of the necrotic bone is regained, whereas in the furcation & interdental areas may show complete restoration of bone. Bone exposure during mucogingival surgery that denudes soft tissue may result in loss of 2 to 4 mm of crestal bone after healing.

Temporary Bone Exposure: Occurs as a result of full thickness flap procedures. Bone resorption usually occurs on the periosteal surface of the alveolar bone from day 4 to 8 post-op. At day 10 to day 21, bone apposition occurs at previous areas of resorption. Bone loss is usually insignificant.

No Exposure: To prevent bony exposure, a partial thickness flap is used, with the outer flap excised. Disadvantage is the lack of visibility & access to bone.

Author supports the use of temporary bone exposure for access to osseous defects and Sx. The amount of bone lost is insignificant and coverage of bone greatly aids in the reduction of post-op pain.

Ochsenbein, 1958 Article
Purpose: Discussion article on osseous resection
DISC: - Osteoplasty- removal of non-supporting bone (festooning, and allowing a more physiologic resting of the gingiva).
- Osteectomy- removal of supporting bone
- Most common deformity due to periodontal disease is blunted interproximal bone. This occurs mostly in posterior areas because of the wider bucco-lingual dimension. Craters are the advanced lesions of blunted interproximal bone.
- Crater walls should be eliminated and the remaining bone should be festooned. Author believes that ramping should be done on the buccal bone for better accessibility for oral hygiene, and also because of better access during surgery.
- He also believes that multiple interproximal craters are the most difficult to do osseous surgery on
- He discusses "Segmentation Reduction," (grooving the bone vertically as a guide when doing osseous resection and festooning. Removing bone in segments, this is done for thick buccal or lingual bone). Round Carbide burs are more efficient at removing bone than diamond burs, but hand instruments rather than rotary instruments should be used to remove supporting bone, to avoid damaging the tooth.
BL: Gingivectomy alone is an insufficient treatment that will likely lead to recurrence if angular defects are present. Osseous resection is needed so that the gingiva will lay on the bone in a more physiologic, self-cleansing manner. Defines ostectomy and discusses segmentation reduction.

Ochsenbein 1986: Article guidelines for osseous

Purpose: To present guidelines for osseous surgery.

Discussion: knowledge of anatomy of teeth and osseous defects is imperative to determine where osseous should be utilized.

Craters: shallow 1-2 mm, medium 3-4 mm, deep 5+ mm

The amount of bone that can be removed depends on the relationship between depth of the IPx defect and molar root trunk. Generally, the root trunk determines the amount of bone coronal to furcation. If

marginal bone is 1.5-2.0 mm apical to CEJ, then knowledge of root trunk can help predict how much bone can be removed without exposing furcation.

Maxillary molars root trunks: short 3mm, average 4 mm, long 5 mm. Mandibular root trunks short 2mm, average 3 mm, long 4 mm.

Radiographs cannot be used to accurately visualize defects because of anatomical limitations. They are more accurate for mandible but still have limitations.

Maxillary molars: Ochsenbein and Bohannon described palatal approach for treatment of maxillary craters. Disadvantages of buccal aspect to reduce craters: 1) buccal recession, 2)reversed architecture,

3) sacrifice of buccal radicular bone, and 4) inadequate space between the molars.

Maxillary molar shallow craters (1-2mm) can usually be eliminated by palatal approach only: Flatten the palatal aspect of the crater then carefully slope ~10^o. Adjust radicular bone so that flat-positive architecture is achieved.

Maxillary molar medium craters (3-4mm) and deep craters(>5mm) generally need both palatal and buccal approach: the amount of resection depends on root trunk length (if complete elimination of the defect would result in furcation exposure or reverse architecture, only partial crater elimination should be attempted). Resect palatal first, same principles as shallow. Buccal cannot be reduced to a level that would create furcation involvement or negative architecture. 1^st molars more likely to have short root trunks. Deep craters will always have some kind of osseous compromise as eliminating the crater would create excessive bone loss.

Maxillary premolars: craters are usually located on palatal area and can be treated with palatal approach. Max 1^st premolar is a challenging tooth to treat. Access is poor for OH because the root is concave. Fortunately the greatest PD is usually found palatally and many shallow craters are amendable to palatal reduction. If crater has medium depth, buccal reduction will also become necessary. The buccal aspect of the interdental crater should be reduced gradually and carefully because gingival recession may create an esthetic problem.

Maxillary anterior area: flap approach and curettage are indicated. Minimal flap retraction, precise incision, careful root preparation and proper flap adaptation will influence the result. Osseous surgery should be avoided, unless full coverage restorations are being considered.

Mandibular molars: usually “overtreated” on buccal aspect and “undertreated” on lingual aspect due to difficult access. Mandibular 1^st and 2^nd molars have a lingual inclination of approximately 20 . Due to the lingual inclination factor, the greater dimension of the lingual root trunk and the flat lingual architecture, craters should be managed with the lingual approach when possible. The same considerations as the one applied to max molar area (crater depth and root trunk length) determine the treatment. In most cases, a compromised tx may be necessary, including acceptance of reverse architecture because of the shorter root trunks and lingual inclination. Be careful to not overtreat the buccal and undertreat the lingual.

A very important negative occurrence is what is known as a “blowout” of the furcation. This is where osteoplasty into incipient furcations leads to rapid and extensive bone destruction in the interradicular area. This generally occurs on the buccal furcations of mandibular molars, often on those with short root trunks. When the interdental buccal bone is on the same level as the furcation, any reduction of the crater from the buccal will result in negative architecture. The buccal bone may be thinned but any of its height is to be avoided.

Observation of the gingival architecture prior to beginning surgery can give an idea of how much scallop is needed when creating positive architecture. Often patients have flatter gingival architecture in the posterior. As the bone height of the interdental bone is reduced, the mesiodistal dimension of the bone is increased. As the mesiodistal distance increases the bone and gingiva accept a flatter morphology. So, a scalloped pre-operative gingival architecture will accept a much flatter architecture post-surgically.

Vertical grooving in the posterior is not always a natural occurrence, but creating subtle sluiceways so that the papilla sits in a protected interdental position is often done with osseous. Take care to not have too deep of grooves in the presence of craters that can remove the buccal aspect and cause reverse architecture.

BL; 2 important factors must be taken into consideration when a resective surgery in the molar area is performed: root trunk length and crater depth. Although the goal is to create positive architecture, each situation needs to be evaluated to leave an adequate amount of supporting bone while minimizing rebound pocket depths. Osseous resection should use anatomic landmarks combined with basic principles to successfully manage periodontal defects., such as mand molas and lingual inclination

Carnevale, 2000 Article

P: Historical and current review of osseous resective surgery.

Osseous surgery: periodontal surgery involving modification of the bony support of the teeth.

Osteoplasty: reshaping of the alveolar process to achieve a more physiological form without removal of supporting bone.

Ostectomy: the excision of bone or portion of a bone. In periodontics, ostectomy is done to correct or reduce deformities caused by periodontitis in the marginal and intra-alveolar bone and includes the removal of supporting bone.

Indications and endpoints of osseous resective surgery

Osteoplasty is used to treat buccal and lingual bony ledges or tori, shallow lingual or buccal intrabony defects, thick interproximal areas and incipient furcation involvements that do not necessitate removing supporting bone

Ostectomy used to treat shallow (1–2 mm deep) to medium (3–4 mm deep) intrabony and hemiseptal osseous defects and correct reversals in the osseous topography

Osseous resective surgery is the combined use of both osteoplasty and ostectomy to re-establish the marginal bone morphology around the teeth to resemble ‘‘normal bone with a positive architecture’’. The endpoints of osseous resective surgery are minimal probing depths and a gingival tissue morphology that enhances good self-performed oral hygiene and periodontal health. Osseous resective surgery is also utilized in preprosthetic, restorative and cosmetic surgery to increase the clinical crown length.

Surgical technique

Soft Tissue

The primary scalloped incision of the apically positioned flap can be intrasulcular or at various distances from the gingival margin. The flap is thin and of even thickness with the final position of its margins at the level of the osseous crest (apically positioned flap margin); the interproximal areas are generally not covered by gingival tissues and therefore heal by secondary intention. If there is ‘‘inadequate’’ keratinized tissue, the primary incision should be intrasulcular and the flap apically positioned at the osseous crest. Vertical releasing incisions can facilitate the final tissue position. Specific considerations are made when osseous resective surgery is performed in areas of aesthetic concern. The papilla preservation technique in association with a thinned palatal flap can be used in such cases

Hard tissue management

Osseous resective surgery reshapes the abnormal bone topography, caused by periodontitis to a form that resembles normal physiological alveolar anatomy. All the walls of bone of an intrabony or hemiseptal defect are removed so that the prior apically located base of the defect is now even with the adjacent bone. The interproximal region may dictate bone removal in a way that creates an asymmetrical slope. Mandibular molars usually tilt lingually and therefore the lingual furcation, as well as the lingual cementoenamel junction, is in a more apical location than the corresponding buccal area. Thus, more of the lingual wall of bone is removed, rather than the facial, (that is, ramping). A similar situation may exist with the maxillary molars, and the ramping can be either towards the palate or buccal area depending on the location of the interproximal defects. A reversal of the bony architecture is often present as a result of periodontitis or ostectomy performed to eliminate the osseous walls of an intrabony or hemiseptal interproximal defect. This anatomical situation is the reverse of normal and its correction is performed by removing the facial and/or lingual bone over the roots to a level where its radicular osseous margin is apical to the inter-proximal bone level. Abnormally thick bony anatomy over a tooth or several teeth is thinned to a more normal width during osseous resective surgery

Metal and coarse diamond burs in high- and low speed handpieces, chisels, files and rongeurs have been advocated to perform osseous resective surgery. Several studies have histologically evaluated the wound-healing response in animal models when experimental defects and cuts were made utilizing various instruments.

BL: Osseous resective surgery has been and remains one of the principal periodontal treatment modalities because of its proven success.

What anatomic factors should be considered when planning and performing flap surgery with osseous recontouring? Does this change our approach to osseous resection? In what situations should bony removal be modified or combined with other treatment options? What are the contraindications for osseous resection?

Goldman 1958 Article

P: To discuss the classification and treatment of the infrabony pocket.

R: This historical article describes a classification system of infrabony pockets as follows:

I. Three osseous walls

A. Proximal, buccal and lingual walls

B. Buccal, mesial and distal walls

C. Lingual, mesial and distal walls

Four osseous Walls - buccal, lingual, mesial and distal

II. Two osseous walls

A. Buccal and lingual walls (crater)

B. Buccal and proximal walls

C. Lingual and proximal walls

III. One osseous wall

A. Proximal wall

B. Buccal wall

C. Lingual wall

IV. Combination

A. 3 walls + 2 walls

B. 3 walls + 2 walls + 1 wall

C. 3 walls + 1 wall

D. 2 walls + 1 wall

The type of infrabony defect which develops is dependent on a variety of factors. Tooth anatomy and position, occlusal trauma, and form of periodontitis. The objective of therapy is the elimination of the infrabony pocket and to establish a sulcus as close to zero as possible. Tooth anatomy conducive to food impaction, uneven marginal ridges, tilting of teeth and occlusal trauma should be corrected before the operative procedure to secure a new attachment is attempted. The authors advocate curettage of the infrabony component and GV of the supra-g component for 3 wall defects and ostectomy-osteoplasty for one and two wall defects.

BL: An article of historical importance describing a classification system for infrabony defects as well as insight on the etiology and treatment for these lesions.

Becker 1997 Article

Purpose: To classify bone anatomy on the maxillary anterior region into alveolar morphotytpes and to relate tooth form to bone anatomy, and to evaluate the presence of dehiscences and fenestrations in the maxillary anterior sextant.

Materials and methods: 111 Caucasian adult human skulls were evaluated. Age and sex of each skull was not ascertained. Each skull should have 6 maxillary anterior teeth in occlusion with the corresponding mandibular teeth. Three examiners evaluated each skull.

Skulls were classified as flat, scalloped or pronounced scalloped according to the buccal alveolar anatomy. They were evaluated for dehiscences and fenestrations. 10 skulls from each category were selected for bone height measurements. Teeth dimensions from all skulls were measured. Statistical analysis was performed.

Result/BL: Mean distance from mid – buccal alveolar crest to the interdental bone height was statistically significantly different for the three anatomic morphotypes (flat 2.1mm, scalloped 2.8mm and pronounce scalloped 4.1mm). Differences for fenestrations (0.5/skull for flat and scalloped and 1.2/skull for pronounced scalloped) and dehiscences (average 3.5 per skull) were not significant between groups.

Frequency of fenestrations reported in this and previous (O’Connor 1963) studies indicate that implants placed directly into extraction sockets may have an increased possibility of implant surface exposure.

Serious esthetic changes in bone and mucosal anatomy may result after extractions in patients with thin – scalloped profiles.

Flat bone anatomy had a slight tendency for greater tooth length when compared with the other two groups, and tooth width for the pronounced scalloped group was narrower than the other two groups. CW/L ratio showed a tendency for a decrease in ratios between the flat to pronounced scalloped groups. In this study ratios for canines, lateral and central were 0.80, 0.72 and 0.90 respectively. Measurements were not corrected for incisal wear or attrition.

Nevins 1983 Article

The clinical management of periodontal osseous defects

Discussion

- Must correlate probing depths with radiographs to visualize the bony topography before surgery

-The clinician must realize that is possible to mask interproximal defects by superimposing the buccal onto the lingual wall.

-The x-ray is essentially a periodontal diagnostic aid to measure the level of the interproximal and interradicular alveolar crest.

-The most common periodontal lesion is the interproximal crater that is boundaried by a buccal and lingual wall of bone and the surfaces of approximating teeth on the proximal. It’s often overlooked due to superimposed image on an x-ray. This is why is important to probe under the contact point.

-The routine classification of defects is misleading. The terms contained and non contained are more descriptive. A fresh extraction socket is the most contained osseous defect. The next will be a three-wall defect and so forth.

-Before deciding upon substraction or addition of bone as desired therapy, the defect must be properly prepared.

-The goals of debridement are categorized as follows

-Elimination of al infected granulation tissue from the osseous lesion

-Preparation of the inner osseous surface of the lesion

-Preparation of the root surface.

-It is routine to wait at least 4-6 months before contemplating the results of bone graft.

-Many bone grafts result in less than complete regeneration.

-Most periodontal osseous defects offer a morphologic combination being more contained in the base and less in their entry. It is reasonable to do substraction therapy at the uncontained portion and addition in the most contained area.

-The green stick fracture as and autogenous graft provides continuity of blood supply.

-Synthetic bone grafting materials are defined as alloplastic. There are two general categories, resorbable (Synthograft) and non resorbable (Periograft).

Ochsenbein and Bohannan, 1963 Article

Purpose: 1.To discuss poor or reverse ging architecture on the buccal aspect of maxillary molar teeth, to suggest application from wound healing studies in this area, and

2. To introduce the palatal approach to osseous surgery.

Definitions:

1. Normal (positive) architecture = interproximal bone at a more coronal level than that on the buccal and lingual root surfaces, with the same pattern reflected in the overlying gingiva;

2. Reverse (negative) architecture = IP bone at a more apical level than the alveolar crest of the buccal or lingual gingival margin areas. Routine osseous Sx has sought to eliminate IP craters (which have reverse architecture).

Problems associated with the buccal approach:

a. reverse gingival architecture and post-op bulbous interradicular papilla;

b. denudation of buccal radicular surfaces; creation of buccal furcation exposure.

c. buccal recession

d. inadequate buccal embrasure space.

Technique: Attempt is made to preserve and maintain buccal bone height. Gross reduction of the crater wall is done from the palatal.

The palatal approach: It is not a substitute for buccal osseous surgery

(If osseous problem exist on the buccal aspect of maxillary molars, may require bevelling of thick buccal plate or hollowing out of an interdental area for a proper sluiceway). **Discretion and caution**

1. The buccal bone is sometimes thin (cortical plate+alveolar bone). Root fenestrations and dehiscences are common. Bone resorption might be less in the palatal aspect, & more reformation (because it is thicker).

2. When viewed from the palatal, max molars can be considered single rooted. Also, adequate access & visibility without cheek & tongue interference, wider embrasure space due to divergence of palatal roots, stimulating & cleansing effect of the tongue. Also, there is frequently a root proximity problem involving the DB root of 1M and MB root of 2M which limits osseous resection and creates improper proper papillary housing.

Most of the advantages cited for the palatal approach on the maxillary teeth were not seen as present in the mandibular arch.

BL: This historical, opinion article suggests the palatal approach to osseous Sx achieves pocket elimination with fewer problems. Advantages of this approach include elimination of reverse architecture, less denudation of buccal radicular surfaces, & less buccal recession. These are all problems with the buccal approach.

Ochsenbein and Bohannan (1964) Article

P: To describe a surgical procedure involving the palatal approach to osseous surgery, especially in the maxillary molar area.

Discussion: The authors introduce the article by saying the palatal approach is not a substitute for buccal bone surgery. The main difference between the palatal and buccal approach is that the gross reduction of the interdental deformity is performed from the palatal aspect rather than the buccal, in an attempt to avoid: 1) reverse gingival architecture and subsequent post-operative development of a bulbous interdental papilla, 2) Denudation of the buccal radicular surfaces, 3) buccal recession, 4) inadequate buccal embrasure space. The amount of the buccal bone that will be removed depends on, and is inversely related to the depth of the interproximal deformity.

They classify interdental craters into 4 groups

Class I: 2-3mm osseous concavity with thick B and L walls with gradual slop

Class II: 4-5mm concavity with thinner walls and a more abrupt slope

Class III: 6-7mm cater with a wide orifice and sharp drop from the margin to a wide, flat base

Class IV: Concavity with variable depth with very thin walls. The base is often wider than the

orifice.

The maxillary first molar is typically more difficult to treat due to the entrance of the furca only having 2-3mm of bone coronal to it, compared to the second molar. The second molar has a furcation entrance further away from the CEJ than the first, and the curve of the maxillary arch puts the second molar in a more apical position. Also, there is typically more bone covering the buccal roots of a second molar.

Osseous resection with this approach eliminates/reduces the palatal wall as long as it is within limits of acceptable architecture and the buccal wall

Class I: is left intact

Class II: is reduced 2-3mm

Class III: reduction should stop when interdental and marginal bone are at the level of the

bifurcation

Class IV: authors recommend if the wall is very thin, to not reflect a flap/ reflect minimally on

buccal to maintain blood supply as reflecting periosteum does cause resorption.

Advantages of this approach: When viewed from the palatal maxillary molars can be considered single rooted, preserves the buccal wall of the defect thus preventing the opening of an uninvolved buccal furcation, creates wider interproximal embrasures for better access and visibility for the operative procedures, as well as for homecare. Most advantages cited for the maxillary teeth are not present in the mandibular arch.

Tibbetts 1976 Article lingual approach to

Purpose: To introduce the rationale for the lingual approach to mandibular osseous surgery, as well as discuss anatomic patterns of the mandible and tooth inclinations.

M&M: The authors studied the anatomy of many skulls.

Discussion: It is often that insufficient osseous reduction is performed in the mandible, usually due to difficult access. Craters were the most common defect found. The buccal marginal bone height is higher than the lingual, due to the axial inclination of the teeth. Reduction of craters from the buccal will result in sacrificing excessive interdental bone height. The incidence of bone defects involving the interprox and lingual aspect of the mandibular premolar and molar region is probably the highest in the mouth; this area also is a prime target for ledging due to pocket formation. Most of the reduction of lingual bone is osteoplasty, while more supporting bone is usually removed on the buccal. Vestibular depth of buccal bone in molars is often quite shallow, so limited amount of osteoplasty / osteoectomy may be performed. Lingual embrasures are usually wider than on the buccal, and with adequate reduction of mylohyoid ridge, greater access for OH is provided.

Concusion: The buccal bone is over-treated most times, while the lingual side is left under-treated. Although more surgically challenging, the lingual approach to osseous surgery has many benefits and should be brought into consideration by clinicians.

Nowzari 2001: Article

P: to explain the principles and surgical technique for aesthetic osseous surgery

D: Aesthetic osseous surgery is a surgical treatment modality that may be used to effectively eliminate periodontal defects. It maintains the coronal aesthetic position of the buccal gingiva, reduces probing depths and stabilizes periodontal attachment levels. Incisions may be FTF or combination as long as underlying osseous contours are exposed. For combination flap, the split thickness aspect is along the apical portion of the buccal flap to preserve the buccal periosteum but still allow apical positioning. For maxillary anterior, possible that no buccal flap or a flap not reflected past MGJ may be used. Palatal incisions should be scalloped and thinned to follow radicular morphology--depth should be at level of or slightly apical to palatal osseous crest after osteoplasty and ostectomy. Lingual incision should also be scalloped if KG allows; however, preservation of 2-3mm KG should be used as a guideline. Distal extension of incisions to allow for reflection. If verticals are used to reduce mesial extension, should extend the lingual or palatal flap more mesially than vertical buccal incision. Vertical incisions should have a cutback component to reduce tension at closure.

Craters are the most common type of bony defect encountered. Knowledge of the molar root trunk lengths shows that most craters can be managed appropriately with osseous recontouring. Shallow post-treatment periodontal sites provide reduced risk of future breakdown. Aesthetic osseous surgery improves access to diseased radicular surfaces for daily oral hygiene by the patient and maintenance by the therapist. Pre- and post-plaque control is crucial for a successful result. As the aim is to increase access for patient to maintain dentition, the role of plaque control and regular visits to the therapist are needed to preserve the dentition in a state of health, comfort and function.

BL: shallow post treatment periodontal sites reduce risk for future breakdown. Osseous surgery can be used to improve the periodontal health, but knowledge of anatomic factors that impact the esthetic result is crucial.

Cr: this article is not actually about aesthetic osseous surgery, it’s actually same principles for osseous surgery with several pictures of the authors work, majority of which is posterior. Not sure why his is more aesthetic….

Morris 1964 Article

P: Discuss two methods, simple tapering or ramping of septal bone in conjunction with soft tissue surgery.

D: 1. Gingivectomy-gingivoplasty, then expose septum with individual vertical incisions through which a bur or stone is inserted for ramping. 2. Internal bevel incision to remove interproximal tissue to expose bone. If removal of this internal wedge of tissue does not sufficiently expose the septum further reflection at the interproximal area is accomplished without vertical incisions. After bone ramping the tissues are approximated with interrupted sutures. Dressing is rarely necessary. Author said these techniques should most often be employed in anterior regions where there is thin tapered facial and lingual bone adjacent to bulky thick septa.

How much bone is removed during osseous surgery? How can this affect the soft tissue levels and overall stability of the tooth? Is all bone equally important for stability?

Friedman, 1955
P: To define osteoplasty and ostectomy and present indications for each procedure.

D: Osteoplasty: A procedure in which the periodontal pocket is eliminated and the bone is reshaped in order to achieve physiologic contour. The reshaped bone is not part of the attachment apparatus and thus no bone support is lost.

Indications for osteoplasty – buccal and palatal bone (width):

· Deep interproximal pockets on the posterior teeth involving the buccal interdental bone

· Pockets on the buccal, lingual, and palatal surfaces where resorption of the bone results in thick ledges

· Tilted mandibular 2^nd molars. (mesially tilted)

Osteoectomy: The pocket is eliminated with removal of some of the bony support.

Indications for osteoectomy – interproximal bone:

· Interproximal bony craters - treat by ramping

· Extremely deep interproximal pockets

· Shallow infrabony pockets

Methods of performing osseous surgery

1. Modified Widman Flap is most frequently used for both osteoplasty and osteoectomy

2. Full flap- used infrequently since the MWF is better suited to achieve results in most situations

3. Use of Diamond stones without a flap: i.e. a gingivectomy where the gingiva is perforated so the bone can be accessed.

BL: Osteoplasty is the technique where the bone is reshaped w/o losing bony support, whereas osteoectomy is where the bone support is removed.

Selipsky 1976 Article

P: To discuss bone support that is sacrificed after osseous surgery, mobility after osseous surgery, and the need for splinting.

Research study: multiple bone defects were completely corrected to attain positive architecture in a group of patients using buccal and lingual apically positioned flaps. All patients showed moderate to severe periodontal breakdown. Results showed that ostectomy removed 0.6 mm of supporting bone height per tooth on a circumferential average. Loss of interproximal bone support was negligible, except where severe angular or hemiseptal defects were present, where 1 to 2 mm of supporting bone was occasionally removed interproximally. The greatest amount of supporting bone resected was over midbuccal, midlingual or palatal surfaces adjacent to interproximal surfaces. This is to be expected if positive architecture is to be attained. Removal of buccal or lingual bone is less important for tooth support than is the removal of interproximal bone because interproximal bone gives more support in terms of surface area than does buccal or lingual bone, especially posteriorly.

The concern with reduction in supporting bone is whether this can cause an increase in tooth mobility. A commonly observed phenomenon following periodontal surgery is an immediate increase in tooth mobility. Teeth initially loosened after osseous surgery, but gradually returned to or below pre-surgical mobility levels by the end of one year. This happened without any form of splinting; all that was needed was time and a healthy environment.

The requirements for permanent stabilization after periodontal surgery can be estimated before surgery within six months of curettage, plaque control and occlusal adjustments. If tooth mobility at this stage is acceptable to the patient and the therapist, it is likely that no splinting will be required after surgery as tooth mobility will most probably return unaided to this level or better if simply given the time and a healthy environment (plaque and inflammation free).

Rational osseous correction does not seem to result in secondary trauma from occlusion.

BL: Osseous surgery, if properly done, in reasonably selected cases, results in minimal loss of bone support and a good clinical result. Mobility decreases to pre-surgical levels within a year post-surgery.

Caton 1981 Article

Purpose: To evaluate the effect of surgical elimination of the osseous walls of angular bony defects on the connective tissue attachment and alveolar bone levels on monkeys.

Materials and methods: Thirty-six contralateral pairs of periodontal pockets were produced on the maxillary and mandibular central incisors and first molars, the maxillary and mandibular central incisors and first molars, the maxillary first and mandibular second bicuspids in four young adult male Rhesus monkeys. Three months after pocket production, all test and control teeth were scaled and plaque control was initiated. After 3 weeks on side of the jaw were subjected to the following surgical procedure while the other remained as the unoperated control. In the test group mucoperiosteal flaps were reflected beyond the MGJ. All soft tissue was removed, bony walls of one-, two- and three- wall defects were eliminated. After root planing flaps were apically positioned and sutured. Periodontal dressing was placed and penicillin was administered intramuscularly for 14 days. Two weeks after surgery all test and control teeth were scaled and polished every 60 days until the animals were killed 1 year after surgery.

Sections were cut and prepared for histologic examination under light microscope and distance for CEJ to bone crest and apical end of junctional epithelium was measured.

Result: Mean connective tissue attachment level apical to the CEJ was 3.74mm on the surgically treated teeth and 3.29mm on the control teeth. Surgical procedure produced a significant loss of connective tissue attachment compared to the unoperated side.

Surgery also resulted in a significant loss of interdental crestal bone height 4.04mm on the test group and 3.43mm, as well as in loss in height of supracrestal soft tissue. Distance from gingival margin to the apical end of the JE was 2.28mm on the operated teeth and 3.20mm in the control teeth.

A significant loss of connective tissue attachment and crestal bone height occurred in these teeth whose supporting bone before surgery was the wall of the adjacent angular defect.

BL: Osseous surgery, involving resection of the bone of angular defects, where these bone walls constitute supporting bone for adjacent teeth, must be carefully planned.

Lobene 1963 Article

Purpose: to investigate the response of the alveolar bone to artificial contouring by rotary diamond stones.

Materials and methods:

-Periodontal tissues of maxillary and mandibular premolars and mandibular first molars of mongrel dogs.

-All animals had generalized chronic marginal gingivitis with an accumulation of supragingival calculus.

-Acrylic stents were made, unembellished gingivectomy performed, and then a flap was elevated and buccal bone exposed.

-Experimental areas

-Buccal bone was contoured using mounted coarse diamond stone rotating at slow speed and water irrigation. The bone at the margin was thinned but not reduced in height. Areas were sutured.

-Interproximal contouring, the buccal bone was ground in the interdental areas so as to produce accentuated sluice-ways but bone was not reduced in height. Flaps were sutured and periodontal pack placed.

-Animals were sacrificed at 14 and 28 days and histology was performed.

Results

-There were no apparent differences in the gross appearance of the operated control and experimental areas

-Findings indicate that grinding did not effect a notable change in the bone level at 7 and 14 days after operation. However at 21 and 28 days the height of the bone was notably reduced in experimental areas (1.7mm -1.2mm). In control areas the loss of buccal bone height was slight and ranged from 0 – 0.5mm.

- Microscopic findings revealed a more severe necrosis in the maxilla. By 28 days post-op, reduction of bone up to 40% in the experimental sites as compared to unoperated ctrls, and the width of the gingiva attached to the roots was almost twice that of controls in experimental sites.

Discussion

-The findings indicate that grinding with a diamond stone is injurious to alveolar bone. It causes bone necrosis and impairs postoperative healing and leads to reduction of bone height. The bone contour cannot be predetermined by reshaping during periodontal treatment.

The ultimate contour of the buccal bone is determined by the trabeculae of new bone formed in the course of healing, long after the sx grinding procedure.

Horton et al, 1975 Article

P: To compare the effects of an ultrasonic instrument, a low speed rotary bur & Sx chisel (w/ water cooling), on bony healing after surgical removal of bone.

M&M: 10 dogs had full thickness flaps in both max & mand w/3 defects produced in the buccal bone. 3x3x2mm defects were in buccal aspect of alv crest w/standard P3 ultrasonic insert, Stout #1 chisel or 557 crosscut bur on slow speed. The animals were sacrificed at 0,3,7,14,28,56 & 90 days post-op. block sections obtained.

R: Immediately following surgery, the chisel had an irregularly cut bony surface, w/the ultrasonic producing an even more irregular surface. The bur produced the smoothest surface as viewed microscopically. At day 3, defects caused by chisel and ultrasonic showed fibrous, vascular granulation tissue which had almost completely replaced the clot. The initial clot with PMN infiltration remained in the fissure bur defect. At day 7, there was more osteoblastic activity seen w/ chisel & least w/ bur. Rate of healing best w/ chisel, then ultrasonic, & slowest w/ bur. By 28 to 56 days the healing was the same for the three methods of osseous resection. By 90d there was considerable bone remodeling, w/ no difference b/t the three.

BL: The defect was smoothest with a bur, but faster healing with a chisel and ultrasonic. Definite differences in rate of healing in defects by bur were noted up to 14 days. After 14 days, there was no difference in rates of healing the three

Fister and Gross, 1980 Article

P: To investigate histologically, the degree of bone necrosis and associated inflammatory response, as well as determining the rate of healing after instrumentation of alveolar bone with burs with and without a water coolant.

M&M: 3 mongrel dogs were used. Bilateral flap reflection on lateral aspect of the body of the mandible. Six vertical cuts 1cm in length and 1 cm apart were made on each quad of the mandible with no.8 surgical carbide bur with a slow speed. The cuts were alternated with and without saline irrigation. A total of 36 cuts were placed all by the same operator. The dogs were killed and histological specimens were obtained at 1 hour, 1 day, 3days, 1 week, 2 weeks, and 3 weeks.

R: 1 hour: Revealed no significant difference between sites.

1 day: The non-irrigated site showed clot retraction seen from bony surfaces, irrigated sites were adherent to bony walls.

3 days: Non-irrigated site still had marked clot retraction, osteoblasts viable on both sites, so there was no bone necrosis on either side.

1 week: The non-irrigated site had less organization, less capillary and fibroblast formation. 2 weeks: Dense fibrous connective tissue with little bone in non-irrigated sites, while immature woven bone was consistently found in irrigated sites.

3 weeks: Bone formed in all sites but less mature, with more cellularity in non-irrigated sites. All post-operative wounds healed uneventfully.

BL: Non-irrigated sites showed delayed clot formation, displayed clot retraction from the bony walls and delayed bone healing (about 1 week slower). Results of this study indicate that osseous necrosis can be avoided when water coolant is not used.

Glick 1980 Article

P: To determine whether the ultrasonic scaler has a more positive or negative impact on post-op bone level compared to hand curettes.

M&M: 9 adult cats in study had a notch made into the enamel of each of their canines. FTF flap performed and soft tissue tags removed with hand curettes. UR and LL canines planed clinically smooth with ultrasonic scaler, while the other two canines were planed with hand curettes. Bone level measured with caliper from the notch in enamel. At 3 months, re-entry performed and measurements recorded.

R: All canines lost significant bone due to the procedure (around 0.3mm). However, there was no significant difference between the two groups.

BL: There is no difference in bone loss after open flap scaling and planing between ultrasonic and hand instrumentation.

Horton 1981 Article

P: To evaluate the application of ultrasonic instrumentation in the surgical removal of osseous tissue and report histologic and clinical observations.

M&M: Equal number of men and women participated in the study. All of them were healthy except for teeth requiring extraction and/or teeth with periodontal disease. Ultrasonic instruments (standard P3 and P9 inserts) were used for removal of bone during surgical extractions of 19 teeth from 16 patients. The bone fragments were used for histologic evaluation. Also, clinical evaluation of the ultrasonic instrument in removing osseous tissue were made in treatment of 50 patients presenting with periodontal disease requiring osseous management. Flaps were reflected, alveolar bone was exposed and ultrasonic instruments were used for ostectomies and osteoplasties.

R: Histologic observations:

· Irregular cut edge of bone fragment with the use of P3 insert.

· No residual debris within these areas.

· Bone on the apical surface, which was planed, appeared smooth.

· Osteocytes residing within lacunae in immediate proximity to the cut surface.

· Periodontal tissue underlying and adjacent to areas of removed bone showed no alterations.

· No effect on vascular channels, no disruption in orientation of subjacent periodontal fiber bundles.

Clinical observations:

· Both P3 and P9 removed bone without difficulty.

· Hemorrhage was minimal.

· Cavitation of water spray kept the bone surface moist. No interruption was needed.

· Minimal postoperative discomfort and uneventful healing.

BL: Ultrasonic instruments are capable of removing mineralized tissue with ease and efficiency. In clinical practice, healing is uneventful and there is reduced patient discomfort. All in all, the use of ultrasonic instrumentation in the surgical removal of bone may prove a promising addition to the clinician’s armamentarium.

Describe the healing sequence in the hard and soft tissues following osseous surgery both clinically and histologically. How long should we wait before assesing outcome of therapy?

Durwin 1985 Article

P: To compare two surgical approaches in the treatment of deep intraosseous periodontal defects. The first approach was non-resective (no osseous tissue was removed) and the second was partially resective (removal of some supporting bone).

M&M: 16 patients, ages 19-74 with deep intraosseous defects were included. 26 defects with probing depth 7mm were included in the study. The depths of the corresponding osseous defects, as revealed during surgery were 5mm. All patients received initial therapy (OHI and SC/RP). The initial phase of the treatment extended from 7-38 weeks (mean 18 weeks) prior to surgery. Clinical parameters were assessed (PI, PD, REC, probing attachment level, probing bone level). During surgery, the number of tooth surfaces involved, osseous defect circumference, number of osseous walls of defect, depth of osseous defects and immediate postoperative probing depths were measured. 2 types of surgical procedures were performed: resective and non-resective. In either case, inverse bevel incision was made followed by reflection of FTF. Granulation tissue removed, roots were planed. Defects assigned to partially respective approach were treated by osseous resection. Roots surfaces were treated by a 3min topical application of citric acid. The flaps in both groups were thinned and apically positioned. 6 months post-op clinical parameters were evaluated.

R: Probing depth was reduced from 7.9 to 5.3mm (1.1mm attachment gain, 1.5mm rec) in the non-resected group and from 7.5 to 4mm in the partially resected group (0.7mm attachment gain, 2.8mmrec). The mean gain in attachment was 1.1mm for non-resected group and 0.7mm for partially resected group (slightly more in the non-resected group). The results in probing bone level showed a mean gain of 1.2mm in the non-resected group and 0.7mm in the partially resected group (slightly more in the non-resective group). The adjacent tooth surfaces demonstrated some loss of probing attachment level and probing bone level for both groups. The mean loss of probing attachment level ranged from 0.1 to 0.9mm for the non-resected group and from 1.2 to 1.5mm for the partially resected group (slightly more in partially resected group).

BL: The results after six months comparing a non-resective and partially resective approach to the treatment of deep intraosseous defects demonstrated limited differences between the two procedures. Both treatment modalities resulted in a mean gain for both probing attachment level and probing bone level of approximately 1mm. Thus, the amount of regeneration seems to be modest following both procedures. Finally, tooth surfaces adjacent to the defect sites showed a general loss of probing attachment and probing bone levels for both treatment groups with the greatest loss occurring in the partially resected group.

Moghaddas, 1980 Article

P: To provide additional human data about alveolar bone remodeling following osseous surgery.

M+M: 17 pts (8M, 9F, 23-60 yrs old) and “normal medical history” with advanced periodontitis included in study. Pts received pre-surgery tx of SRP and occlusion adjustment id any traumatic occlusion present. All achieved adequate OH before surgery. Initial PD varied from 4-7 mm, and only posterior segments were used. Sequence of surgery: FTF, osseous surgery performed (osteoplasty/ostectomy), pictures taken, bone height measured with a stent, alginate impression taken, and flaps sutured apically. OH maintenance every 2 weeks. Group 1 (8 pts) had reentry after 3 months, and Group 2 (9 pts) was reentered after 6 months. Measurements were taken at interradicular, radicular, and furcation sites.

NSSD in mean amount of bone resected at osseous recontouring between the two groups.

The mean interradicular crestal bone loss was 0.38 mm for the 3-month group and 0.23 mm for

the 6-month group; the mean radicular crestal bone loss was 0.84 mm for the 3-month group and 0.55 mm for the 6-month group; the mean crestal loss on the furcation sites was 0.79 mm for the 3-month group and 0.88 mm for the 6-month group. The differences between 3 and 6-month values within specific sites were NSSD. In each comparison between mean bone loss and zero bone loss, the differences were SS. Crestal bone loss in radicular and furcation sites was greater than in interradicular sites at 3 and 6 months, but only SSD between furcation and interradicular sites. In the casts it was seen that the recontoured alveolar bone was further remodeled in favor of scalloping. Also, interradicular sluiceways resulted in smooth surface or buttressing bone (45/78 buttressing bone). At 4 sites, fenestrations that were not altered became dehiscences at re-entry.

BL: This study confirms that bone remodeling continues after osseous surgery.

Pennel et al, 1967 Article

P: To determine if any alteration occurred to the level of the alveolar crest following a mucoperiosteal flap reflection with osseous resection.

M&M: 34 tth from 20 pts scheduled for full mouth extractions with slight to moderate perio involvement were included. After MPF reflection, osseous reduction was performed- 1mm with a hand chisel. The root was notched with a Brad parker before and after reduction, the flap then was positioned to cover the alveolar process and 1-2mm of the root. Standardized measurements were made from photos after surgery and at selected intervals between 14 and 545 days (photos taken again).

R: The average reduction in the height of the alveolar bone crest was 0.54mm (range: 0 to 3.8mm) and the average square area of bone loss was 2.8 sq mm (range: 0 to 12.5 mm2).

C: 14-545 days?

Wilderman 1970 Article

Purpose: To investigate the detailed sequence of the histogenesis of repair in human, in the tissues covering the root after a mucoperiosteal flap and an osseous surgery (osteoplasty and osteoectomy) procedure.

Materials and methods: 23 teeth from 23 individuals, 35 to 68 years of age, scheduled for full – mouth extractions. The teeth had PDs were between 1 – 5mm, and included 5 central incisors, 9 lateral incisors, 4 cuspids, 1 bicuspids from the maxillae and 1 mandibular cuspid.

A notch was created across the gingival margin, internal beveled incisions and two verticals were utilized and mucoperiosteal flaps were elevated. The thickness of the alveolar process was estimated as thin, medium or thick.

A horizontal notch 5mm apical to the alveolar crest and two vertical grooves were created on the exposed bone as boundaries for bone reduction. Approximately 1mm of bone was removed (osteoectomy) and the tooth was notched on the bone level before and after the osteoectomy. Flaps were then replaced and sutured to cover the bone and 1-2mm of tooth root. No specific changes were made to the individual’s home care procedures. Specimens were taken at time periods of 0 hours to 545 days after surgery. Sections were examines under light microscopy.

Results: Six specimens were rated as thin, 6 as thick and 11 as medium according to the bone thickness prior to surgery. According to the histological healing process specimens were classified in ten groups.

Group II – 0 Hour: Flap was adapted to bone and tooth surface. The reduced vestibular bone was evident by its rough surface and basophilic staining.

Group III – 1 Week: Epithelium of the gingival margin attaches to the tooth. Zone of proliferating young connective tissue was evident between bone and flap surface. Young connective tissue was also present beneath the coronal part of the flap and the tooth surface. The new capillaries, fibroblasts and mesenchymal cells came from the cut PDL and connective tissue of the mucoperiosteal flap. Absence of osteocytes in the bone immediately beneath the surgically reduced vestibular bone surface indicated some bone necrosis. Inflammation present, little or no osteoclastic activity. No bone apposition.

Group IV – 2 Weeks: Formation of collagen. Vascularity and inflammatory cells concentration was decreased at this time. Lymphocytes was the predominant cell type and the epithelium on the tooth displayed evidence of proliferating in an apical direction along the tooth root. No osteoclastic activity, bone formation evident in isolated areas.

Group V – 3 Weeks and Group VI – 1month: Similar histological characteristics between these two groups. Inflammatory process continued to subside. The amount of collagen fiber formation continued to increase in the maturing healing connective tissue. Epithelium continued to proliferate apically and osteblastic activity reached its peak one month after surgery. The apposition of bone on the reduced bone crest indicated the bone repair was in a coronal direction. Osteoclastic activity was almost complete at the one month post-operative time period.

Group VII – 2 months: Inflammatory process was minimal to nonexistent unless a plaque or deposit was present on the tooth root that was exposed to the oral cavity. For the first time some fiber bundles immediately adjacent to the periosteal surface were embedded into the recently formed bone and osteoid tissue. Osteoblastic activity continued a slower rate and only a small amount of bone was being added to the alveolar crest at this time. Formation on cementum in the reduced bone level notch was present for the first time.

Group VIII – 3 months: Predominate finding was the presence of collagen fiber bundles in the connective tissue repair area. Majority of fibers and bundles at this time were parallel to the tooth root and the vestibular surface of the alveolar bone. Slight bone formation at the crest and considerably more in the periodontal surfaces and bone surfaces outlining the marrow spaces, but had completed subsided along the periosteal surface. Some modeling resorption was evident on the periosteal bone surface at the most apical area of surgical bone reduction. Some specimens displayed evidence of root resorption that had occurred at earlier post – operative time periods.

Group IX – 6 months: For the first time the collagen bundles in the repaired connective tissue inserted into the root. Cementoid on the root surface above the most apical notch (the one created after bone removal) was evident for the first time at 5 months. Slight or no bone apposition. Six-month specimens revealed a definite periosteum over the entire periosteal bone surface.

Group X – 1 – or + year: Collagen bundles of 9-month specimen were arranged and inserted at right angles into the root. Epithelium was proliferating along the root. Inflammation because of bacterial plaque was present. Slight or no bone apposition. Bone was mature in the form of haversian systems.

Parakeratosis of the crevicular epithelium was seen only in the 18 – month postoperative specimen.

Amount of bone loss in one and two – weeks postoperative time groups was between 4.47 and 0.14 mm with a mean of 1.2mm and the greatest loss in the specimens classified as thin. Bone apposition from the three-week period till the end of the experiment varied form 1.15mm to 0.14mm with an average of 0.4mm.

Thus the difference of 0.8mm represents the average reduction of bone crest as the result of surgery and healing (max of 3.1mm and min of 0.11mm).

-The marrow spaces provide an excellent surface of young connective tissue necessary for repair. This study indicated that cancellous bone was not present in any of the specimens classified a thing and not present in some of the medium bone specimens.

How is healing different if bone is left exposed? Can soft tissue management during surgery influence the outcome?

Ratcliff 1964 Article

Purpose: to present an effective approach to the therapy of periodontal pockets with limited osseous defects.

Discussion: Interproximal Denudation

- To reproduce the characteristics of the healthy periodontium: knife edge margins, conical papillae and adequate zone of AG. This is done by exposing the interproximal bony defect but not exposing the bone on the buccal or lingual surfaces where the alveolar bone may be thin.

Steps

1. A gingivectomy is performed; soft tissue is removed from buccal and lingual surfaces often beyond pocket depths and may expose bony process.

2. An interproximal triangular incision is made on the buccal or lingual from mesial and distal root line angles to a point sufficiently apical to provide adequate length for an interdental groove and adequate zone of attached gingiva. Soft tissue reflected and removed with the papilla.

3. Ready access for planning of the proximal root surface as well as for evaluating the bony defects.

4. To remodel interproximal osseous tissue, a round bur or chisel is used.

5. Reverse architecture is now corrected

6. An inadequate zone of attached gingiva on the buccal or lingual may be a postoperative problem. This can be corrected by periosteal fenestration.

7. The wound is maintained with a surgical dressing.

Advantages

-Correction of bony defects including reverse architecture.

-Prevention of loss of alveolar bone by flap procedures.

-Creation of an increased zone of attached gingiva.

-Minimum post op sequelae

Disadvantages

-More meticulous contouring of the bone is possible with conventional flap technique

-There is no increase in the zone of attached gingiva on the buccal or lingual surfaces.

-The vestibular fornix is not deepened as with gingival repositioning.

-Areas of interproximal denudation do not heal by first intention.

Prichard, 1977 Article

P: Review article on the present state of interdental denudation procedure (described by Ratcliff and Raust in 1964).

Disc: The author discusses the pros and cons of leaving or removing the interdental papilla leaving the inter-alveolar bone bare. Removal of it guarantees pocket elimination interproximally whereas retention of the papilla even when trimmed approximately often results in less than ideal pocket reduction and the necessity for gingivoplasty on a 2^nd stage. The time needed to prepare & suture the finely trimmed papillae can be detrimental to the marginal bone that is exposed.

TECHNIQUE: Author suggests a slightly scalloped initial incision (to orient soft tissues to the interproximal). Interproximal areas are completely denuded. After debridement, flaps are repositioned, and sutured, but not tightly “draped”. Dressing is applied (never packed) over a tent of foil to preserve the denuded spaces with bony defects, with the hope of healing by regeneration instead of repair.

Proper Interdental denudation results in improved resolution of intrabony bone defects via resorption (when no graft is used). Interdental denudation completely removes the inflamed interdental tissue, & the surgical trauma may stimulate bone repair.

Cons for this technique: 1) when bone graft is being placed and soft tissue coverage is needed; 2) esthetics in anterior region.

BL: Interdental denudation is a rational viable treatment for pocket reduction and resolution of intrabony defects. He also states that interdental denudation does not result in increased post-op pain and slowers the healing only slightly.

Machtei, 1994 Article

P: To explore the optimal postsurgical flap placement with respect to final probing depth and changes in clinical attachment level

M&M: 12 patients with moderate to severe periodontitis. PD and CAL were recorded. Mean initial PDs ranged between 3.12-5.33 mm with some sites exhibiting deep pockets up to 11 mm. Osseous surgery performed. To record the flap position immediately postoperatively, sounding depth measurements were recorded. Suture removal at 1 week. SPT every 3 months. PD and CAL were measured at 2 years postoperatively.

R: Positive correlation was found between immediate postoperative sounding measurements and PD after 2 years. The greater the mean sounding depth, the deeper the mean pocket depth is 2 years later. CAL changes over 2-year period showed only weak inverse correlation. Comparison was made. When a threshold of < 3 mm was selected, mean PD (2.52 mm) was significantly smaller compared to sites where postoperative sound depth was > 4 mm (3.58 mm). These differences were statistically significant.

BL: The flaps should be secured to the underlying periodontium at or slightly coronal to the bone crest but not exceeding 3 mm.

How stable are the newly established bone levels of osseous recontouring? How stable are the long-term results following osseous surgery?

Matherson 1988 Article

Purpose: To determine the maintenance of surgically produced osseous contours in monkeys and the influence of the resultant bony profile on overlying soft tissue morphology.

M&M: The following surgical procedures were performed on 3 young adult Macaca rhesus monkeys: 1) mucoperiosteal flap (no osseous surgery), 2) interdental osteoplasty 3) osseous resection. Following sacrifice at intervals of 1 week and 6 months, the tissues were processed for histologic study and evaluated microscopically and macroscopically. Macroscopic evaluation was accomplished by three-dimensional plexigloss reconstruction and wax model reconstruction.

R: Radicular areas: the postoperative position of the alveolar crest is dependent on the amount of supporting bone between cortical plate and alveolar bone. The greatest amount of alveolar crest regeneration and reattachment following osseous resection occurred in maxillary premolar vestibular areas and in all palatal areas. The surgically produced osseous morphology has been maintained in every radicular area regardless of the position of the alveolar crest. The soft tissue morphology was influenced by the radicular bone contour. Interdental areas: The surgically produced osseous morphology is maintained in the interdental areas. However, osseous resection in conjunction with reshaping procedures appears to be more effective in maintaining surgical contour than interdental osteoplasty alone. Interdental osteoplasty resulted in closer approximation of soft tissue peaks and a greater convexity of osseous profile. Following osseous resection, the interdental soft tissues reflect the underlying osseous contour when sufficient interproximal space exists between the contact area and the level of the alveolar process.

BL: The alveolar process is capable of maintaining surgically produced osseous contour and soft tissue form is a reflection of this contour.

Lindhe and Nyman, 1980 Article

P: to examine if the position of gingival margin on the buccal surface of teeth had changed in patients who following periodontal surgery were enrolled in a supervised maintenance care program for 10-11 years

M&M: 43 patients, 26-64 years old. >50% bone loss. Received periodontal surgery (APF including osseous surgery). Maintenance every 3-6 mos. Followed up 10 to 11 years (supervised maintenance care program). Measurements were taken from all buccal surfaces (GM-CEJ) to nearest 1 mm, prior sx, after initial healing and after 10-11years.

R: Apical shift of gingiva following perio sx (before 3 mm, 2 months after surgery 5.5 mm). The change in KG and non-KG sites was similar. Minor (1mm) coronal creep after 10 years. KG and non-KG sites reacted similarly. The frequency of buccal KG units decreased immediately following surgery but increased again to the final examination.

BL: Osseous surgery was effective up to 10 years. Zone of KG may not be essential, gingival recession is common after surgery. Gingival margin is often apically positioned, and some minor coronal creep occurs over 11 years.

How does osseous surgery compare to other treatment modalities?

Olsen 1985, Article

P: To compare clinical results of areas treated with flap surgery with and without osseous surgery.

M&M: 12 patients with moderate periodontal disease were included. Pre-op pocket depths ranged from 1-8mm. Initial therapy (OHI, sc/rp, occlusal adjustment) was completed for every patient. Baseline data was collected. Split-mouth surgery was done with posterior sextants being randomly assigned either osseous recontouring or flap curettage procedure. Patients were placed on 6 month recalls for 2 years and then on 3 month recall program. Parameters recorded: PI, GI, MOB, KG, PD, REC, CAL, sounding index.

R: Plaque and gingival inflammation were significantly reduced 6 months post-op. No difference between the two types of sx. Over the course of the 5-year recall program, plaque scores returned to pre-sx levels. Total gingival width remained greater in flap curettage areas after 5 years and the mean values remained stable over the entire course of the study. Both types of surgeries resulted in greater gingival width as compared to pre-op values. The level of the gingival margin remained more apical in osseous sx than in flap curettage sx at all time intervals, the difference was SS. No difference in attachment length between the two tx modalities. Both types of sx reduced PDs 6 month post-op. Greater PD reduction in areas treated with osseous sx At 6 months IPx PDs were a mean 2.3mm for osseous sx and 2.5 for flap curettage. At five years, mean IPx PD is nearly equal to pre-op values in areas treated with flap curettage. However, IPx PDs in areas treated with osseous sx remained reduced at a SS level. Pre-op PDs were subdivided: 1-3mm, 4mm, 5mm, 6-8mm. The deeper the pocket was pre-op, the more effective osseous recontouring was at reducing and maintaining PD. By 5 years, there are 2.3 times as many bleeding 4+ mm pockets in areas treated with flap curettage sx as in areas treated with osseous. In 6-8mm PD areas, 30% of the pockets returned to pre-op levels in flap curettage areas versus 5% in areas treated with osseous sx. There were no significant changes in bone levels at any time intervals or between the two treatments except that osseous recontouring values are consistently more apical.

CON: Both flap sx and osseous recontouring sx resulted in significant pocket reduction at 6 months post-op, over the course of 5 years of follow-up, PDs in areas treated with flap sx returned to their pre-op values, whereas PDs in areas treated with osseous remained significantly reduced as compared to their pre-op values. Osseous recontouring was more effective in reducing PD , especially for PDs 5-8mm pre-operartively. The position of the free gingival margin remained significantly more apical in areas treated with osseous than flap sx. The level of bone was only borderline more apical in areas treated with osseous. No significant difference in attachment levels between the 2 therapies.

Kaldahl, 1988 Article

P: To longitudinally compare the clinical effects on the periodontium of different treatment modalities: coronal scaling (CS), root planing (RP), modified Widman surgery (MW), and flap with osseous resection surgery (FO).

M+M: 82 pts (30F, 52M, mean 43.5 years old) systemically healthy w/ moderate to advanced periodontitis (75 completed the study). 2,090 teeth total, were treated in a split-mouth design where each of the 4 quadrants had a different treatment received. Quad A received CS only; Quad B received CS and RP; Quad C received CS, RP and MW; Quad D receiving CS, RP, and FO. The therapy was performed in 3 phases.

Phase 1: the teeth designated to receive RP, MW, and FO were root planed and the teeth designated to receive CS were scaled only coronally with no subgingival instrumentation. Each patient had to have MOL > 80% during Phase 1 to continue in the study.

Phase 2: (4 weeks after completion of phase 1) the designated teeth received MW or FO surgery. Surgery performed only teeth that had PD of 5mm or greater.

Phase 3: maintenance therapy every 3 months (for 2 years). Clinical measurements were taken prior to initiation of therapy, four weeks after phase 1 therapy, ten weeks after phase 2, and at following years one and two of maintenance therapy. They consisted of probing depth measurements (PD), recession and probing attachment levels. Data were grouped by severity of PD (1-4 mm; 5-6 mm; > 7 mm) after exam 1 (initial) and exam 2 (after phase 1 therapy)

R: All 4 therapy modalities resulted in a decrease of mean PD with the FO producing the greatest decrease followed by MW, RP, and CS. The deeper the initial PD, the greater the amount of PD reduction produced by each modality. In the shallow severity (1-4 mm) category, FO created a loss of mean probing attachment (- 0.66 mm), while sites treated with CS and RP showed an initial gain of probing attachment that was subsequently lost. In the moderate severity (5- 6 mm) category RP and MW produced the greatest gain of mean probing attachment ( +0.6 mm). RP, MW and FO produced similar gain in the deep severity (> 7 mm) category (+1.4 mm). FO created the most gingival recession followed by MW, RP and CS.

BL: Osseous resection surgery produces the greatest decrease in probing depth, followed by MWF, RP, and CS. FO should be used to decrease probing depths in areas w/ moderate and deep severity of perio disease and avoided in shallow sites to avoid loss of attachment.

Donnenfeld et al, 1970 Article
P: To evaluate the effects of osteoplasty: reshaping of bone that is not part of the attachment apparatus.
M&M: 4 pts w/ moderate to severe chronic p-itis. Split-mouth design using posterior sextants that had similar pocket depths and alveolar changes. The experimental side had osteoplasty to thin the marginal crest, groove and taper the interradicular septa and establish scallops to correct reverse architecture. No attempts were made to eliminate intraosseous defects but they were thoroughly debrided. The control side had no contouring. Adjacent teeth were notched for reference point on the mesial aspect of teeth in question. Flaps were reapproximated and sutured at the root surface (no APF). Re-entry surgery at 6 months. Traditional impressions as well as those of exposed alveolar bone at the time of surgery were utilized as well as intraoperative measurements.
R: Three out of the 4 pts consented to re-entry surgery. Data was from 22 teeth from 3 pts. All pockets were eliminated for all teeth, in experimental and control, with the mean pocket depth reduction of 1.3 mm for control (pockets reduced from 3.3 mm to 2.0 mm) and 1.4 mm for experimental (pockets reduced from 3.5 to 2.1). There was an apical shift of the epithelial attachment for all patients by 6 months (0.6 mm in control, 1.0 mm in experimental). Mean loss of interproximal bone height was 0.6 mm for control and 0.4 mm for experimental, whereas mean loss of radicular bone was 0.8 mm for control and 1.0 mm for experimental. There was NSD for any for the measurements b/w control and experimental.
D: Consistently, a greater loss of attachment occurred on the experimental side but was not statistically significant. The full thickness flap and degranulation was enough to eliminate pockets w/o osteoplasty, and contributed to the apical migration of the epithelial attachment and loss of alveolar bone. Once opened, it was observed that the control segments showed remodeling that was similar to the objectives of osteoplasty. For patients with thick bony shelves, grinding will only reduce width, but if there is thin bone it can also bring about a reduction in height. In one patient, this brought about a furcation involvement where one did not previously exist.
The amount of bone loss from osteoplasty, though not statistically sig different, could combine with that of the natural process to cause greater bone loss than intended.
BL: R

eflecting a full thickness flap can cause bony reshaping as a natural part of the healing response, where natural repair can accomplish much of what osteoplasty is intended to do.

Aeschilmann 1979 Article

Purpose: To evaluate by means of multiple parameters the short-term effect of periodontal surgery with and without bone recontouring.

Materials and methods: Parameters used: Gingival Index (Loe & Silness 1963), Oral Hygiene Index (Greene & Vermillion 1960), measurements of vertical bone height using study models of the alveolar bone and probe depth measurements with a force controlled probe.

Ten patients with chronic periodontitis with no known systemic diseases. 20-58 years old, 8 females and 2 males. They had at least two lesions in their maxillary right and left posterior sextants more than 5mm and the degree of periodontal destruction was similar between the two sextants.

Initial documentation except for the measurements included study models, clinical photographs and radiographs.

Four weeks after initial therapy (SRP, gingival curettage and OHI) surgery was performed and measurements were taken before it. During the surgery full thickness flaps were elevated in buccal and palatal side including osseous recontouring only on the left side, and flaps were apically repositioned and sutured.

On the facial of the maxillary left sextant impressions of the alveolar bone were made using a polyether material prior to osseous recontouring, after osseous and four months later during the surgical re-entry procedure.

On the right side impressions were taken during the first surgical procedure and during the re-entry procedure. Measurements of the bone levels were taken from the casts.

In both groups patients were recalled for oral prophylaxis every 3 weeks for 4 months.

Results: There was a reduction in both OHI and GI for both sextants after pre-surgical and surgical treatment.

At 4 months GI for left segment was significantly lower than the right.

PD reduction was 2.4 ±.12mm for the right side and 2.05 ± .11mm for the left.
On the right side there was a mean vertical bone loss of 0.16mm. On the left side there was an average of 0.22mm bone loss as direct result of bone recontouring and an additional bone loss of 0.28mm during the 4 month post – surgical period, total of 0.5mm.
BL: Apically repositioned flap reduces periodontal pockets effectively with or without bone recontouring, but elimination of bony defects resulted in greater pocket reduction.
Elevating any type of flap result in bone resorption.
Degree

of bone remodeling is less predictable when bone recontouring has not been performed.

Persson 2000 Article

Purpose: to assess radiographically on a local site basis the long-term outcomes of surgical treatment of intrabony defects treated with either osseous surgery or by open flap debridement surgical procedures using DFDBA

Material and Methods

-60 patients enrolled in a supportive care program following surgical treatment of intrabony defects.

-In 36 patients had been treated with osseous surgery, 24 patients treated with bone graft procedures using DFDBA

-Post Surgery X-ray at 4.5 and 9.6 years

Results

-In osseous surgery group a small amount of bone fill was found 0.2mm (SD=/-0.9)NSS

-In the bone graft group a small and significant amount of bone fill was obtained 0.5mm SD=/-0,9

- Crestal resorption in osseous was 1.7mm and MFW w/ DFDBA 1.5mm w/ mean remaining defect of 2.0 mm w/ osseous sx ( baseline 6.3mm) and 2.5 w/ DFDBA (baseline 7.4mm). Results at 5 and 10 year exams did not change significantly.

-The amount of bone fill was within the range of measurement errors there for no clinically significant differences between outcomes of osseous and grafting.

BL: The use of DFDBA in conjunction with surgical treatment of intra-bony defects did not enhance the outcome in terms of radiographically detectable bone fill as compared with osseous surgery. Both resulted in some loss of crestal bone height but no further loss at the base of vertical defect.

Levy et al, 2002 Article

P: To compare the clinical and microbiologic effects of initial preparation and initial preparation followed by apically repositioned flap surgery.

M/M: 18 chronic periodontitis subjects, 25-71 years old, with at least 8 sites with PD > 4 mm and 8 sites with attachment loss > 3 mm. Subjects received initial preparation including SRP & OHI, followed by APF Sx with osseous resection at sites with PD > 4 mm after 3 months. Postsurgical evaluation at 7 & 14 days; clinical/microbial monitoring with supra/subgingival scaling at 3, 6, 9, 12 months. Clinical assessments of plaque accumulation, gingival redness, suppuration, BOP, pocket depth, & CAL were made at 6 sites per tooth. Subgingival plaque samples were taken from the mesial aspect of each tooth at baseline, after initial preparation, and 3, 6, 9, 12 months after APF surgery. Counts of 40 subgingival species determined in each plaque sample. Total of 220 teeth were treated surgically; 49% were multi-rooted.

R: Significant reduction was seen in mean PD and % of sites exhibiting gingival redness & BOP in both categories.

- A mean attachment level significantly increased for both groups, but the increase was greater at the surgically treated sites.

- Bacterial load was significantly reduced at both sites from baseline, especially for red complex (Tf, Pg, Td) & some orange complex (C.rectus{w.rectus} C.gracilis{W.rectus}). Other orange complex bacteria (Fusobacterium, Eubacterium, P. nigrescens) were reduced in greater numbers by surgical therapy.

- Mean reduction of red complex bacteria at 12 months was between 78-83% for initial preparation and 90-93% for initial preparation + surgery. Mean reductions achieved 3 months postsurgery were in general maintained to the 12-month monitoring visit

- The major bacterial reductions occurred after the surgical phase, even with the sites not received surgery

D: Both SRP & SRP + Sx improved clinical parameters. Both forms of therapy were effective up to one year after treatment, especially with reduction of red complex bacteria.

BL: Reducing PD with APF & osseous Sx might decrease pathogenic bacteria throughout the entire mouth, which might be important for sustaining periodontal stability.