Resective Osseous Surgery: A Tool in Restoring Smile A Case Report

MM Dayakar*, Prakash G Pai**, A Abhilash***

Abstract
The successful integration of aesthetics and function does not emerge by chance. This is achieved as a result of meticulous recontouring of clearly defined anatomic parameters and their subsequent incorporation into the prosthesis. To achieve physiologically scalloped bone anatomy, osseous topography must be corrected. The removal of both, alveolar bone proper (ostectomy) and the supporting bone (osteoplasty) from the concerned teeth with utilization of the apically positioned flap forms osseous resective surgery. Not often we get opportunity to perform all the steps involved viz. vertical grooving, radicular blending, flattening of interproximal bone and gradualizing the marginal bone in resective osseous surgery. This therapeutic procedure is an effective tool in the armamentarium of any clinician to achieve desired youthful and attractive smile as seen in the present case. Key Words : Resective osseous surgery, Gummy smile, Crown lengthening procedure, Aesthetics osseous surgery

INTRODUCTION

smile is said to be a biggest secret of dealing with people. A friendly look, a kindly smile and one good act, makes life worthwhile. Humans have an unstoppable urge to be liked and appreciated. And smile is used to create good, positive first impressions. The first thing people notice on a persons face is the eyes, the mouth and the smile (or lack thereof). But not every person is gifted with beautiful smile. High smile line, defective osseous topography and poor restorative margins make patient smile less appealing. Fortunately this can be corrected. Osseous recontouring must be followed in order to correct various topographic changes resulting from periodontal disease and to provide a more physiologic bone pattern. Additive osseous surgery includes procedures directed in restoring bone to its original level where as subtractive osseous surgery is designed to restore the form of preexisting alveolar bone to the level present at the time of surgery or slightly apical to this level. Recontouring of the bone is only logical treatment choice in some cases despite the fact that this procedure induces loss of radicular bone in healing phases. Resective osseous surgery is also used to facilitate some restorative, prosthetic procedures and means for producing optimal crown length for cosmetic purpose. Thorough knowledge of the periodontium is a pre*Professor and Head; **Reader; ***Post Graduate Student, Department of Periodontics, K.V.G. Dental College, Kurunjibhag, Sullia. 474

requisite for resective osseous surgery to be performed correctly.

CASE REPORT
A 38 year old female patient reported with a chief complaint of gummy unaesthetic smile. The anterior tooth showed poor aesthetics with defective margins (Fig. 1). Resective osseous surgery followed by prosthetic replacement with metal free ceramic restoration. An internal bevel incision, crevicular incision and vertical incision extending beyond the mucogingival junction was done to reflect apically displaced flap (Fig. 2). Vertical grooving was done to provide relative prominence to the radicular aspects and to get continuity from the interproximal surface to the radicular surface. This was followed by radicular blending, which an extension of vertical is grooving, as an attempt to gradualize the bone on the entire radicular surface and provide smooth blended surface for smooth adaptation (Fig. 3). Flattening of the interproximal bone was done to level the interproximal bone horizontally and Gradualizing marginal bone provided a sound regular base for gingival tissue to follow (Fig. 4). Both vertical grooving & radicular blending are purely osteoplasty procedures where as flattening of the interproximal bone and gradualizing marginal bone are ostectomy procedures. Replacement of the flaps was done apically with the aid of sutures and the teeth were temporized (Fig. 5). Sutures were removed after 1 week and were allowed for conditioning of the gingival margins. Final metal free ceramic crowns were given
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Fig. 1 : Gummy smile with defective restorative margins. The amount of surgical crown lengthening needed was marked.

Fig. 2 : Internal bevel incision for to raise an apically displaced flap.

Fig. 3 : Vertical grooving & radicular blending.

Fig. 4 : Flattening of the interproximal bone and gradualizing of the marginal bone.

Fig. 5 : Suturing, temporization and post operative healing after 7 days.

Fig. 6 : Final Restoration with restored smile.

after 6 months (Fig. 6).

DISCUSSION
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, albeit at a more apical position. 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. Besides the treatment of intrabony and hemiseptal defects, osseous resective surgery is also utilized in pre prosthetic, restorative and cosmetic surgery to increase the clinical crown length and/or to re-establish an adequate zone of natural root surface for the gingival attachment. 1 Aesthetic osseous surgery maintains the coronal aesthetic position of the buccal gingiva reduces probing depths and stabilizes periodontal attachment levels. Both prior and after osseous surgery, excellent plaque control is indispensable for the restoration of interproximal tissue height. Aesthetic periodontal osseous surgery should not be offered to patients who do not meet high standards of oral hygiene. Weekly post-surgical recall for 4 to 6 weeks and monthly thereafter for 1 year may be required to ensure optimal conditions for periodontal
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wound healing. Contraindications for aesthetic osseous surgery include deep buccal defects, deep craters, deep three-wall defects and deep circumferential defects. Numerous studies support that periodontal sites treated by definitive osseous surgery exhibited no remaining periodontal pocket of 5 mm depth at 3 to 12 months post-surgery and virtually no putative periodontal pathogens were detected at the sites treated by osseous surgery. In contrast, multiple deep periodontal pockets of 5 mm depth were measured in patients treated only by nonsurgical periodontal debridement, associated with high levels of putative periodontal pathogens, including motile rods, Actinobacillus actinomycetemcomitans, Prevotella intermedia, Peptostreptococcus micros, Propionibacterium species, Porphyromonas gingivalis and spirochetes.2 Periodontal surgical procedures by their nature carry with them an attendant risk of developing complications, including infection. Antibiotic prophylaxis has not been shown to offer an advantage in preventing postoperative infections or affecting the outcome of periodontal surgery involving gingivectomy, osseous resective, mucogingival, osseous graft, or implant procedures. In addition, infection rates following periodontal surgery when no antibiotics were used have been reported to be low, ranging from less than 1% to 4.4% for routine
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periodontal surgery and 4.5% following implant surgery. Osseous resective surgery had 2.14% of infection rate.3 Before definitive prosthetic crowns are made the gingival tissues must be fully mature and conditioned and restored with provisional crowns. Conditioning of the gingival margins by means of provisional crowns results in highly aesthetic restorations that fit accurately with the gingival tissues the lips and the face. Only after achieving this perfect balance we can apply these results to the final restorations.4 The restorative and the periodontal elements such as incisial length, incisial plane, incisial profile, incisial display, tooth shape and colour, tooth proportion, tooth to tooth proportion, gingival architecture and gingival display should be considered in creation of pleasing smile. The length of the incisial edge to the maxillary incisor is critical for aesthetic outcome. This should be determined by the upper lip position, lower lip position on smiling, phonetics the golden proportion and the height to width ratio.5 Regardless of the choice of restorative material, the clinician has three possibilities in terms of margin placement: supragingival, equigingival or subgingival margin placement. Subgingival margin are usually placed to achieve best anterior restorative aesthetics and the most likely reason for recession is placement of the margin in unstable tissue. Disturbance of the sulcular tissue has the potential to trigger the recessive process and change the gingival margin. In addition to sulcus depth, thick fibrotic gingiva is more resistant to recession than thin fragile gingival and the scalloped gingival form is more prone to recession than is the flat gingival form.6

CONCLUSION
This unique case report describes resective osseous technique with all sequential steps. The steps were followed meticulously to expedite reshaping procedure as well as to minimize removal of bone. The substantial benefits of resective osseous surgery include proper assessment for procedures like crown lengthening ,for assessment of restorative overhangs and tooth defects like enamel pearl, perforations etc. The clinical challenge consists of ensuring aesthetic goals to be preserved through various therapeutic phases facilitating definitive restoration that satisfies all functional and esthetic requirements. Acknowledgement I like to acknowledge Dr.Anitha Dayakar for helping me during the clinical procedure and preparing this article in this form.

REFERENCES
1. 2. 3. Carnevale G, et al. Osseous resective surgery. Periodontol 2000 2000; 22 : 59-87. Nowzari H. Aesthetic osseous surgery in the treatment of periodontitis. Periodontol 2000 2001; 27 : 8-28. Powell CA, et al. Post-Surgical Infections: Prevalence Associated With Various Periodontal Surgical Procedures. J Periodontol 2005; 76(3) : 329-33. Silvestri M, et al. Periodontal and Prosthetic Restoration of Anterior Maxilla: A Case Report. Int J Periodontics Restorative Dent 2006; 26(3) : 233-7. Ohyama H, et al. Recreating aesthetic smile a multidisciplinary approach. Int J Periodontics Restorative Dent 2007; 27(1) : 61-9. Spear F . Using margin placement to achieve the best anterior restorative esthetics. J Am Dent Assoc 2009; 140 (7): 920-6.

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