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Osseous Resective Surgery: Long-term Case Report

Luigi Checchi, MD, DDS* The principles of osseous surgery in Monica Mele, DDS** periodontal therapy were set forth by Vittorio Checchi, DDS*** Schluger1 in 1949 and subsequently by Giovanni Zucchelli, DDS**** Ochshenbein2 in 1958 and Prichard3 in 1961. Schluger4 suggested that alve- olar bone loss caused by inflamma- tory produced an altered outline of the bony crest, but This case report evaluated the long-term effects of osseous resective therapy in that the gingiva retained an attach- the treatment of a patient with moderately advanced periodontal disease. In ment “memory” aroused by bone and 1984, the patient underwent initial therapy followed by a periodontal surgical bony spicules left in situ. According to phase consisting of osseous recontouring with an apically positioned flap. After 20 this understanding, gingival contour years, in 2003, the patient presented with a traumatic complication. An explorato- ry surgery revealed a fracture on the roof of the pulp chamber on the maxillary left is determined by the underlying first molar. The buccal roots were resected, preserving the palatal root, and a osseous topography and the anatomy reevaluation of the long-term outcome of osseous resective surgery was per- of adjacent dental surfaces; for this formed. It is suggested that the positive treatment result is the consequence of reason, it was considered necessary to the reestablishment of tissue morphology favorable for and plaque recontour the bone to recreate the control by the patient. (Int J Periodontics Restorative Dent 2008;28:367–373.) original architecture to achieve minimal probing depth and reestablish an opti- mal gingival contour. The technique of osseous resective surgery is the combined use of both osteoplasty and 5 *Professor, Department of and Implantology, Alma Mater Studiorum, ostectomy to reestablish the marginal Bologna University, Italy. bone morphology around the teeth **Resident, Department of Periodontology and Implantology, Alma Mater Studiorum, to recreate healthy, beneficial archi- Bologna University, Italy. tecture6 in a more apical position. ***Research Doctorate, Biomedical Technologies Applied to Odontostomatological Sciences, Second University of Naples, Italy. This report shows the long-term ****Associate Professor, Department of Periodontology and Implantology, Alma Mater (20 years) clinical results of a patient Studiorum, Bologna University, Italy. treated with an apically positioned flap

Correspondence to: Prof Luigi Checchi, Via S. Vitale 59, 40125 Bologna, Italy; fax: 0039 with osseous contouring aimed to 051439 1718; e-mail: [email protected]. achieve a favorable bony architecture.

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Fig 1 (left) Preoperative radiograph in 1984. Subgingival and enamel pearls can be seen distally on the maxillary left premolars and second and third molars.

Fig 2 (right) Buccal view showing the heal- ing of gingival tissue after initial therapy.

Fig 3 (left) Buccal view after osteoplasty and ostectomy.

Fig 4 (right) Healing at 5 months. The buccal tissue appears uniformly pale and pink, the consistency is firm and stippled in texture, and some tissue rebound is present between the first and second molars.

Case report Maxillary left posterior sextant in 1984 A 43-year-old Caucasian man was referred to the Department of The maxillary left posterior sextant Periodontology at the University of exhibited 20% to 30% bone loss in the Southern California for treatment of molar area. There were furcation inva- periodontal disease. Clinical examina- sions on the first, second, and third tion revealed moderate supra- and molars. Subgingival calculus and/or subgingival calculus. The buccal gin- enamel pearls were seen distally on giva appeared pink in color and was the second premolar and third molar firm in consistency, with a large amount (Figs 1 and 2). of keratinized tissue. Interdental papil- The diagnosis was generalized lae were cratered and materia alba was moderate periodontitis,7 with associ- present. The posterior sextants had ated primary . The many old alloy restorations, and some overall prognosis was considered were overcontoured. Radiographic good provided that the patient main- examination revealed approximately tained proper oral hygiene, received 20% to 30% horizontal bone loss. new restorations, and followed a good

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Fig 5 (left) Clinical view in 2003 showing extrusion of the third molar and an increase of on the distal root of the first molar.

Fig 6 (right) Fracture on the pulp roof overhanging the mesial root.

recall program for supportive peri- and ostectomy were carried out, leav- probably because it is more difficult to odontal therapy. ing a residual defect of 4 mm between keep that area free from plaque (Fig 4). At that time, the treatment plan the first and second molars and 2 mm was as follows: between the second and third molars (Fig 3). Continuous sling sutures with Maxillary left posterior sextant 1. Initial therapy consisting of scaling 4.0 silk were used, and a periodontal in 2003 and root planing with oral hygiene pack was placed. The patient was instruction given tetracycline (250 mg every 6 In 2003 (after 20 years), the patient 2. Reevaluation hours for 6 days). presented to the Department of 3. Pocket reduction surgery The overall prognosis at that time Periodontology at the University of was good. The original goal of pocket Bologna, with moderate pain and a In March of 1984, the patient reduction was achieved, creating a sit- temporary filling on the first molar (Fig underwent osseous surgery with bone uation in which the patient could main- 5). After the filling was removed, a frac- contouring and an apically positioned tain a plaque-free environment. The ture was observed on the roof of the flap.8 Buccal and palatal full-thickness healing was uneventful. The buccal tis- pulp chamber. Thus, it was decided to flaps were raised, and all granulation sue appeared uniformly pale and pink. perform exploratory surgery (Fig 6). tissue was removed. All teeth were Some tissue rebound was evident scaled and root planed. Osteoplasty between the first and second molars,

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Fig 7 Radiograph showing the amount of Fig 8 Buccal view during the exploratory Fig 9 Healing 3 months after osseous bone left on the second molar and the pres- surgery showing a similar position of bone resective surgery and extraction of the distal ence of enamel pearl distally on the third on the two premolars, an increase of bone and mesial roots. The palatal root was pre- molar, as well as its extrusion. recession on the distal root of the first pared for prosthetic reconstruction. molar, and bone loss on the mesial root of the second molar.

The clinical comparison between ison of the two buccal sides showed a the two buccal sides (1984 vs 2003) similar position of the bone on the two showed extrusion of the third molar premolars, an increase of bone reces- and an increase in gingival recession sion on the distal root of the first molar, on the distal root of the first molar (Figs and 1 mm of bone loss on the mesial 4 and 5). root of the second molar (Figs 3 to 8). Radiographic comparison showed As a result of these clinical findings, it an absence of calculus, the presence of was decided to resect both the mesial an enamel pearl distally on the third and distal roots on the first molar, pre- molar along with its extrusion, bone serving the palatal root (Fig 9). The loss mesially on the second molar, and root was then re-prepared and a pro- bone loss distally on the first molar visional restoration was provided. The (Figs 1 to 7). definitive restoration was placed after Full-thickness buccal and palatal 3 months of healing. flaps were elevated. Surgical compar-

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Discussion dominant mode of failure is related to either endodontic or technical com- The objective of periodontal therapy is plications such as root fracture, as to maximize the longevity of the nat- opposed to periodontal failure.11 ural dentition and maintain a healthy, Restorative preparations modify functional, and pain-free status. the natural relationship between cusp Periodontal treatment can successfully and fossa and consequently increase achieve this goal; indeed, the low rates masticatory stress effects.12 Hiatt13 of tooth mortality in patients treated reported that fractures resulting from with conventional therapy are in clear Black Class I preparations represent contrast to the rates of tooth loss 39% of all incomplete coronal/radic- occurring in untreated populations or ular fractures, and the percentage is in patients treated but not followed even higher for teeth with a reduced up with continuing maintenance care.9 . Olsen et al10 reported increased The patient presented 19 years recurrence of probing depth in sites after his active periodontal treatment treated by apically positioned flaps with a temporary filling on the first without osseous resective surgery than molar in place of an amalgam restora- in those with osseous resective surgery. tion. After removal of the filling, a frac- The sites treated with osseous resec- ture was evident, and so the site was tive surgery had greater reduction of surgically reentered and the involved probing depth in the 5-year report of roots were removed. eight patients. Clinical attachment lev- It was impossible to perform con- els in sites treated by osseous resective servative treatment to preserve the surgery were located significantly more entire first molar, but there are several apically at the 5-year examination (3.9 studies on the efficacy of resective ther- mm versus 3.5 mm). apy in the treatment of furcation The present case report suggests defects.14 Furcation lesions are partic- that the results of osseous resective ularly difficult to treat by nonsurgical surgery can be maintained over a techniques. The anatomic characteris- period of 20 years. The maintenance tics of the areas involved, such as the of all teeth in the maxillary left poste- size of the furcation entrance, the pres- rior sextant, including molars with fur- ence of root concavities, and the cation invasions, was promoted by the uneven surface of the roof of the fur- patient’s plaque control and compli- cation, can make adequate instru- ance with recommended supportive mentation of the interradicular area periodontal therapy. extremely difficult, even when using After 20 years, the patient pre- an open-flap technique. sented with trauma at the first molar; however, this tooth had a healthy peri- odontium, although the attachment level was at a more apical position. Various root resection and root ampu- tation studies suggest that the pre-

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Long-term studies15–20 of resective Conclusions therapy have demonstrated a high suc- cess rate with nonsurgical and nonroot This case report of a patient with a removal resective therapies. Several thick periodontium suggests the fol- studies15,16,18,19 observed multiple lowing: forms of periodontal therapy. The response to treatment of individual • Resective osseous surgery is a valid patients was evaluated by considering therapeutic option. the number of teeth lost during the • The positive treatment outcome was observation period. This allowed for a the consequence of the reestablish- classification of patients into three cat- ment of a tissue morphology favor- egories: a well-maintained group (lost able for oral hygiene and plaque con- 0 to 3 teeth), downhill group (lost 4 to trol by the patient. 9 teeth), and extreme downhill group • After 20 years, the partial loss of the (lost 10 to 23 teeth). Hirschfield and first molar was not strictly the result Wasserman15 examined the periodon- of periodontal causes. tal condition of 600 patients who were previously treated in a private practice It is difficult to compare the clinical for 15 to 53 years (mean: 22 years). The results of studies in the surgical litera- well-maintained group consisted of 499 ture because of differences in terms of patients (83.2%), the downhill group patients, protocols, use of controls, consisted of 76 patients (12.6%), and observation periods, and randomiza- the extreme downhill group consisted tion.21,22 However the studies reviewed of 25 patients (4.2%). During the main- in this article suggest a surgical strategy tenance phase, 7.1% of all teeth were with long-term clinical results: the use lost for periodontal causes, and 31.6% of osseous surgery with an apically of molars presenting furcation involve- positioned flap, a technique that ment were lost. The majority of these improves access for plaque control by teeth were in patients in the downhill the patient. and extreme downhill groups, whereas 19.3% belonged to the well-maintained group. In a recent study,9 it was found that the annual rate for tooth loss caused by periodontal disease during the main- tenance phase was 0.07 per year. The results suggest that periodontal ther- apy with osseous surgery in combina- tion with supportive periodontal ther- apy appears to be an effective protocol for decreasing tooth mortality in patients with significant periodontal destruction of the attachment appara- tus and active periodontitis.

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Acknowledgment 11. Bender IB, Freedland B. Adult root frac- ture. J Am Dent Assoc 1988;107:413–419. The authors thank Steven Schonfeld, former 12. Agar JR, Weller RN. Occlusal adjustment chairman of periodontology, University of for initial treatment and prevention of the Southern California, for editing this manuscript. cracked tooth syndrome. J Prosthet Dent 1988;60:145–147. 13. Hiatt WH. Incomplete crown-root fracture References in pulpar-periodontal disease. J Perio- dontol 1973;44:369–379.

1. Schluger S. Osseous resection: A basic 14. Carnevale G, Pontoriero R, Di Febo G. principle in periodontal surgery. Oral Surg Long-term effects of root resective thera- 1949;2:316–325. py in furcation-involved molars. J Clin Periodontol 1998;25:209–214. 2. Ochsenbein C. Osseous resection in peri- odontal surgery. J Periodontol 1958;29: 15. Hirschfield L, Wasserman B. A long-term 15–26. survey of tooth loss in 600 treated perio- dontal patients. J Periodontol 1978;49: 3. Prichard J. , 225–237. and osseous surgery. J Periodontol 1961; 10:275–282. 16. Goldman MJ, Ross IF, Goteiner D. Effect of periodontal therapy on patients main- 4. Schluger S. The surgical approach to pock- tained for 15 years or longer. A retrospec- et elimination. N Y J Dent 1952;22: tive study. J Periodontol 1986;57:347–353. 391–399. 17. Ross IE, Thompson RH. A long-term study 5. Friedman N. Periodontal osseous surgery: of root retention in the treatment of max- Osteoplasty and ostectomy. J Periodontol illary molars with furcation involvement. J 1955;26:257–269. Periodontol 1978;49:238–244. 6. Prichard J. Reflection on osseous therapy. 18. Wood WR, Greco GW, McFall WT Jr. Tooth Int J Periodontics Restorative Dent 1986;6: loss in patients with moderate periodonti- 5–6. tis after treatment and long-term mainte- 7. Armitage GC. Development of a classifi- nance. J Periodontol 1989;60:516–520. cation system for periodontal disease and 19. McFall WT Jr. Tooth loss in 100 treated conditions. Ann Periodontol 1999;4:1–6. patients with periodontal disease. A long- 8. Ramfjiord S, Nisle R. The modified Wid- term study. J Periodontol 1982;53:539–549. man flap. J Periodontol 1974;45:601–607. 20. Wang H, Burgeti F, Shyr Y, Ramfjord S. The 9. Checchi L, Montevecchi M, Gatto MRA, influence of molar furcation involvement and Trombelli L. Retrospective study of on future clinical periodontal attach- loss in 92 treated periodontal patients. J ment loss. J Periodontol 1994;65:25–29. Clin Periodontol 2002;29:651–656. 21. Palcanis KG. Surgical pocket therapy. Ann 10. Olsen CT, Ammons WF, Van Belle G. A Periodontol 1996;1:589–617. longitudinal study comparing apically 22. Carnevale G, Kaldahl WB. Osseous resec- repositioned flaps, with and without tive surgery. Periodontol 2000 2000;22: osseous surgery. Int J Periodontics 59–87. Restorative Dent 1985;4:11–33.

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