Osseous Resection with Apically Positioned

Flaps. Chronic inflammatory periodontitis results in the loss of osseous tissue, destruction of osseous architecture, and creation of an intrabony lesion. The osseous tissue has no predictable or simple pattern of loss; the resorption may take the form of craters, hemiseptal defects, or well-like (troughlike) shapes. Craters in the interproximal areas (Fig. 5-24) are the most common type of lesion.

The objective of osseous resection is to shape the bone to form even contours. This is accomplished by leveling interproximal lesions, reducing osseous recontour lesions that are too wide and/or shallow for predictable repair or bony fill, thinning bony ledges, and eliminating or ramping crater defects. The result is intended to be a sound osseous base for gingival attachment and the elimination of pockets and excessive sulcular depth. Long-term studies have shown that although osseous resection surgery results in attachment loss and gingival recession, it is the most effective therapy for decreasing pocket depth, which can subsequently be maintained by the patient.

Technique. Before reflection of the flaps, the osseous topography of the lesion is assessed. After the area to be treated has been anesthetized, a peri-odontal probe is inserted into the pocket and forced through the epithelial attachment and connective tissue to the osseous crest. Multiple probings are made and the surface morphology is observed. This "sounding" of the bone provides a reasonable representation of the width and depth of the lesion and is helpful in designing the incision.

Inverse bevel incisions are made on the buccal and lingual or palatal surfaces, and full-thickness mucoperiosteal flaps are reflected to expose the osseous tissue. After the flaps are thinned and the lesions are thoroughly degranulated, the roots of the teeth are planed vigorously. Osseous resection is then accomplished by the combination of rotary instrumentation with carbide and/or diamond burs, chisels, and bone files. When osteoplasty of the in-terproximal sluiceways, furcation areas, and buccal and lingual bone is completed, the flaps are positioned at the crest of the bone in an apical position on the tooth. Surgical dressings are applied, and in 7 to 10 days, the patient is seen again for suture removal and dressing removal or change.

Two Wall Bony Defect

Fig. 5-22. Osseous defects. A, Three walls of bone present: at the lingual (1), distal (2), and buccal (3). B, Two walls of bone (1 and 2) in the coronal portion of the defect and three walls (1, 2, and 3) in the apical portion. C, The two coronal walls have been removed and the buccal surface of the bone recon-toured, leaving the apical three-walled defect to fill with bone after degranulation. (Redrawn from Carranza FA fr: Glickman's clinical periodontology, ed 7, Philadelphia, 1990, WB Saunders.)

Fig. 5-22. Osseous defects. A, Three walls of bone present: at the lingual (1), distal (2), and buccal (3). B, Two walls of bone (1 and 2) in the coronal portion of the defect and three walls (1, 2, and 3) in the apical portion. C, The two coronal walls have been removed and the buccal surface of the bone recon-toured, leaving the apical three-walled defect to fill with bone after degranulation. (Redrawn from Carranza FA fr: Glickman's clinical periodontology, ed 7, Philadelphia, 1990, WB Saunders.)

Mandibular Defect Background

Fig. 5-23. A, Degranulation of a mesial defect on the mandibular right canine. This is a three-walled defect, with approximately 9 mm of intrabony lysis. B, The defect has been filled (slightly overfilled) with autogenous iliac crest marrow coagulum. C, Sulcular depth of approximately 3 mm 4 months after surgery. D, Osseous fill at reentry 1 year after surgery. Note the rim of bone at the margin of a previously existing defect (arrow). E, 1 year after surgery there is a near-total fill of the defect. The rim of bone demarcates the margin of the previous intrabony lesion. F, Result of osseous grafting at the mesial of the canine 15 months after surgery. The gingival health and contours are excellent. Note the acrylic resin provisional restoration in place before the final restoration.

Fig. 5-23. A, Degranulation of a mesial defect on the mandibular right canine. This is a three-walled defect, with approximately 9 mm of intrabony lysis. B, The defect has been filled (slightly overfilled) with autogenous iliac crest marrow coagulum. C, Sulcular depth of approximately 3 mm 4 months after surgery. D, Osseous fill at reentry 1 year after surgery. Note the rim of bone at the margin of a previously existing defect (arrow). E, 1 year after surgery there is a near-total fill of the defect. The rim of bone demarcates the margin of the previous intrabony lesion. F, Result of osseous grafting at the mesial of the canine 15 months after surgery. The gingival health and contours are excellent. Note the acrylic resin provisional restoration in place before the final restoration.

Hemiseptal Defect
Fig. 5-24. A, Osseous ledge and a crater defect. B, Osseous recontouring. C, Final restoration 3 months after apical positioning of the flap.

Postsurgical Healing. Postsurgically, the healing of the periodontium must be considered before any restorative procedures are performed. Initial connective tissue and epithelial healing is complete at 4 to 6 weeks. Final tissue maturation and sulcus reformation, however, may not be complete until 6 months to 1 year after surgery.

If the margins of the restorations are to be placed in-trasulcularly (subgingivally) or at the gingival crest or if gingival displacement procedures are to be used in making the impression, waiting as long as possible postsurgically before attempting these procedures is recommended. If the restorative margins are to be placed at a suprasulcular (supragingival) position (which may not necessitate the use of a gingival displacement cord), these restorations may be started when the gingiva exhibits initial reepithelialization and a return to clinical health (approximately 4 to 6 weeks).

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  • Bisrat
    What is a sluiceways in osseous surgery?
    8 years ago
  • sago
    What is bone ossseous recontouring mesial and distal?
    7 years ago
  • Settimo
    Where is Osseous Bone tissue possitioned?
    7 years ago
  • Gorbaduc
    What to do with osseous area of resection of cmc?
    6 years ago

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