Periodontology 2000, Vol. 27, 2001, 8–28 Copyright C Munksgaard 2001Printed in Denmark ¡ All rights reserved

PERIODONTOLOGY 2000ISSN 0906-6713

Aesthetic osseous surgery in thetreatment of periodontitisHESSAM NOWZARI

Although defect or defect morphology continue to pre-vail as the basis for treatment in current periodonto-logy, diagnosis must be the basis for periodontal ther-apy (20). The periodontal therapist should aim at elim-inating the causative and contributing factors of thedisease. Based on diagnosis, the integration of repara-tiveproceduresmayleadtodefinitivetreatment,whichcanhelpmaintaintherapeuticresults(Fig.1)(20).

Regeneration of lost periodontal attachment (thatis, cementum, periodontal ligament and alveolarbone) remains an important goal of periodontaltherapy (5). However, the inductive events, whichregulate the differentiation and maturation of theperiodontal attachment tissues, are not well under-stood (30). Considering the complexity of organo-genesis in tooth development (32), it may be difficultto perceive that the mere placement of devices suchas membranes, allografts and growth factors in asubgingival site is sufficient to induce the formationof original periodontal tissue architecture.

‘‘Regenerative’’ surgical procedures continue to beperformed in hopes of an occasional dramatic result.Most such results are observed in isolated areas ofthe dentition associated with infrequently significantosseous repair. The nature of periodontal attach-ment after ‘‘regenerative’’ periodontal surgery is pro-posed to consist of de novo cementogenesis withinserting functional collagen fibers (10). However,‘‘regeneration’’ of the periodontium may mostly rep-resent a reparative process; that is cemental repair,connective tissue reattachment at those portions ofthe root not destroyed by periodontal disease or along junctional epithelium in sites effected by theperiodontal lesion (13).

The wide range of probing attachment gain ob-tained after periodontal therapy is probably due tothe complexity of the reparative process of peri-odontal wound healing (37). Partial versus completedestruction of cementum and the occurrence of spe-cific periodontal pathogens (Fig. 1, 2) may in partexplain the variability in the reparative potential ofperiodontal tissues.

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Although case reports of occasional striking re-sults are interesting, modern medicine requires con-sistency in treatment outcome. The ability to recog-nize pertinent differences between diseased peri-odontal sites of similar morphology might enableidentification of sites capable of generating clinicallysignificant attachment gains, with or without the ad-junctive use of special regenerative aids (Fig. 1, 2)(19). Otherwise, aesthetic osseous surgery is a surgi-cal treatment modality that may be used to effec-tively eliminate periodontal defects. Aesthetic oss-eous surgery maintains the coronal aesthetic posi-tion of the buccal gingiva, reduces probing depthand stabilizes periodontal attachment. A thoroughunderstanding of the biological principles andproper execution of the surgical technique result inthe achievement of superior results.

Preventive medicine

Post-treatment shallow periodontal sites provide re-duced risk of future breakdown compared to deepperiodontal sites (14). Aesthetic osseous surgery im-proves access to diseased radicular surfaces for dailyoral hygiene by the patient and maintenance by thetherapist. Post-treatment mechanical access tocausative factors by the patient is consistent with thegoal of preventive medicine. Also, the main purposeof regular visits to therapist would be the preser-vation of the dentition in a state of health, comfortand function, rather than the active treatment of re-infection as a result of residual or recurrent peri-odontal pockets.

Microbiological evaluation ofosseous surgery

The microbiological effectiveness of osseous surgeryhas been evaluated by Nowzari et al. (18) and Tuanet al. (34). Nowzari et al. (18) reported that peri-

Aesthetic osseous surgery

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Nowzari

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Aesthetic osseous surgery

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Nowzari

Fig. 1. A. Clinical appearance of a 28-year-old woman di-agnosed with post-juvenile periodontitis. She was infectedby the putative periodontal pathogens A. actinomycetem-comitans and B. forsythus. B. Maxillary occlusal view.C. Mandibular occlusal view. D. Radiographic examina-tion. Note extensive attachment loss, periapical peri-odontitis associated with mandibular left central incisorand open contacts. E. Maxillary right buccal view. Noteinflammation, plaque and heavy calculus. F. Maxillaryright palatal view. Note inflammation, plaque and heavycalculus. G. Maxillary anterior palatal view. Note in-flammation and loss of interproximal papillae. H. Maxil-lary anterior buccal view. Note inflammation, egression oflateral incisor and loss of interproximal papillae. I. Man-dibular anterior buccal view. Note inflammation, plaqueand heavy calculus. J. Mandibular anterior lingual view.Note inflammation, plaque and heavy calculus. K. Radio-graphic examination of mandibular anterior quadrant.

Note extensive bone loss, periapical periodontitis andopen contacts. L. Microbiological examination. M. Treat-ment plan sequencing. N. Maxillary right surgical appear-ance – palatal view. Note extensive periodontal intraosse-ous lesions. O. Maxillary left surgical appearance – buccalview. Note extensive periodontal intraosseous lesions.P. Maxillary left after suture removal – buccal view.Q. Maxillary left 7 years after treatment – buccal view.Treatment included periodontal aesthetic surgery.R. Maxillary anterior – buccal view. Note reconstructionof interproximal papillae. Treatment included periodontalaesthetic surgery and orthodontic movement of maxillaryanterior teeth to eliminate intraosseous lesions. S. Maxil-lary and mandibular left sextants – buccal view. Treatmentincluded periodontal aesthetic surgery and orthodonticmovement of mandibular teeth prior to implant place-ment. T. Two implants are inserted to restore absent teeth.U. Radiographic examination of maxillary right 7 yearsafter treatment. Note periodontal repair without the useof so-called regenerative devices. This example illustratesthe importance of diagnosis in the prognosis of peri-odontal treatment. V. Radiographic examination of maxil-lary left 7 years after treatment. Note periodontal repairwithout the use of so-called regenerative devices.W. Radiographic examination of mandibular anteriorquadrant 7 years after treatment. Note periodontal repair,disappearance of periapical periodontitis and closure ofopen contacts. X. Radiographic examination of mandibu-lar right 7 years after treatment. Y. Full-mouth radio-graphic examination 7 years after treatment. This ex-ample illustrates the importance of diagnosis in the prog-nosis of periodontal treatment and execution ofperiodontal aesthetic surgery.

odontal sites treated by definitive osseous surgeryexhibited no remaining periodontal pocket of Ø5mm depth at 3 to 12 months post-surgery and virtu-ally no putative periodontal pathogens were de-tected at the sites treated by osseous surgery (Tables1, 2). In contrast, multiple deep periodontal pocketsof Ø5 mm depth were measured in patients treatedonly by nonsurgical periodontal debridement, as-sociated with high levels of putative periodontal

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pathogens, including motile rods, Actinobacillusactinomycetemcomitans, Prevotella intermedia, Pep-tostreptococcus micros, Propionibacterium species,Porphyromonas gingivalis and spirochetes (Tables 1,2).

Tuan et al. (34) reported that, in patients affectedby adult periodontitis, apically positioned flapsurgery by elimination of interproximal craters wassuperior to non-osseous flap surgery in reducing ini-

Aesthetic osseous surgery

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Nowzari

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Aesthetic osseous surgery

Fig. 2. A. Radiographic examination of a 46-year-old wo- multi-rooted molars during healing. I. Maxillary left surgi-man diagnosed with advanced adult periodontitis and cal view. Note intraosseous periodontal lesion at buccalspecific infection. B. Radiographic examination of maxil- site of the second molar. J. Osteoplasty eliminated thelary left sextant. Enteric gram-negative rods have infected lesion. Osteoplasty or ostectomy follows double-scallopedmesial site of the first molar. C. Clinical appearance of morphology to preserve the integrity of the periodontalmaxillary left – palatal view. D. Clinical appearance of attachment at the furcation area. K. Maxillary left palatalmaxillary left – buccal view. E. Microbiological examina- surgical view. Note extensive periodontal intraosseoustion. F. Treatment plan sequencing. G. Palatal scalloped lesion at mesial of the first molar. L. After soft tissueincision. The incision starts at a distance from the gingival plasty, osteoplasty and ostectomy, buccal flap is apicallymargin and is aimed apically at the osseous tissue. The positioned with the use of periosteal continuous suture.scalloped incision removes the inflamed tissue and M. Clinical appearance 1 week after surgery. Note the ab-creates a thin flap margin for adaptation to the dentoalve- sence of supragingival plaque during healing phase.olar unit. Due to the lack of soft tissue flexibility in the N. Clinical appearance after 2 years – buccal view. O. Pala-palate, a definitive scalloped incision should be per- tal flap was apically positioned 0.5 mm to 1 mm apical toformed. The shape of the incision follows the radicular the osseous crest. P. Clinical appearance at 1 week. Notemorphology and the depth should be at the level of palatal the absence of supragingival plaque during the healingosseous crest or slightly apical to that after osteoplasty phase. Q. Clinical appearance after 2 years – palatal view.and ostectomy are accomplished. H. Buccal double-scal- R. Radiographic examination after 2 years. Note peri-loped and scalloped incisions start at a distance from the odontal repair at the mesial site of the first molar and thegingival margin and are aimed apically at the osseous elimination of intraosseous defect without the use of atissue to remove the inflamed tissue and create a flap so-called regenerative device. This example illustrates themargin for adaptation to the dentoalveolar unit. Double- importance of diagnosis in the prognosis of the peri-scalloped incision creates a triangular soft tissue within odontal treatment and the appropriate integration of hardthe healthy gingiva that protects the furcation area of and soft tissue reparative procedures.

tial periodontal pocket depths and maintaining shal-low probing depths. Post-treatment, A. actinomyce-temcomitans and P. gingivalis were not detected inpatients treated by osseous surgery. In contrast, A.actinomycetemcomitans, P. gingivalis and Bacteroidesforsythus were recovered in many post-treatmentperiodontal samples of patients treated by non-oss-eous surgery.

Nowzari et al. (18) and Tuan et al. (34) found thatosseous surgery yielded better suppression of P. in-termedia, Fusobacterium species, P. micros andCampylobacter rectus. In fact, nonsurgical mechan-ical debridement and non-osseous surgery had vir-tually no effect on the recovery of subgingival Fusob-acterium species, P. micros and C. rectus.

In 1985, Olsen et al. (33) reported that periodontal

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pocket depths remained significantly reduced for atleast 5 years after osseous surgery. Periodontalpocket depths of sites treated with flap curettagesurgery returned to pre-treatment levels before theend of 5 years. Osseous surgery resulted in signifi-cantly more reduction of bleeding upon probingthan non-osseous surgery. Olsen et al. (33) andNowzari et al. (18) found significant reductions ofgingival bleeding following osseous surgery. Since re-peated gingival bleeding is a major indicator of riskfor future periodontal breakdown (14), osseoussurgery gives rise to a post-surgical environment thatis more supportive of stable periodontal conditions.

The microbiological findings provide an expla-nation for the differing clinical outcome followingosseous and non-osseous surgery or nonsurgical

Nowzari

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Aesthetic osseous surgery

Fig. 3. A. Radiographic examination of a 46-year-old wo- margin for adaptation to the dentoalveolar unit. G. Afterman diagnosed with advanced adult periodontitis. soft tissue plasty, osteoplasty and ostectomy, buccal flap isB. Radiographic examination of the maxillary anterior apically positioned with the use of periosteal continuousquadrant. Note extensive radiographic bone loss. C. Clin- suture to enhance the depth of the vestibule, move apicallyical appearance. Note supragingival plaque and heavy cal- the muscle insertions and increase the zone of keratinizedculus. D. Buccal double-scalloped and scalloped incisions tissue. H. Clinical appearance 1 week after surgery. Notestart at a distance from the gingival margin and is aimed the absence of supragingival plaque during healing phase.apically at the osseous tissue to remove the inflamed tissue I. Clinical appearance after 2 years – buccal view. Note theand create a flap margin for adaptation to the dentoalve- aesthetic appearance, increase in the vestibular depth, api-olar unit. Double scalloped incision creates a triangular cal positioning of the muscle insertion and enhanced zonesoft tissue within the healthy gingiva that protects the fur- of keratinized tissue. J. Palatal flap was apically positionedcation area of multi-rooted molars during healing. E. Pala- 0.5 mm to 1 mm apical to the osseous crest. K. Clinical ap-tal scalloped incision. The incision starts at a distance from pearance at 1 week. Note the absence of supragingivalthe gingival margin and is aimed apically at the osseous plaque during the healing phase. L. Clinical appearancetissue. Due to the lack of soft tissue flexibility in the palate, after 2 years – palatal view. Aesthetic osseous surgery pro-a definitive scalloped incision should be performed. The vides postsurgical shallow probing depths by creating anshape of the incision follows the radicular morphology and osseous architecture similar to gingival morphology wherethe depth should be at the level of palatal osseous crest or osteoplasty and ostectomy places the lingual osseous crestslightly apical to that after osteoplasty and ostectomy are in an apical position that corresponds to the deepest partaccomplished. F. Palatal scalloped incision. The scalloped of the osseous defect. The buccal osseous crest maintains aincision removes the inflamed tissue and creates a thin flap coronal aesthetic position.

mechanical debridement. The failure to effectivelycontrol periodontal pathogens might account for thenegligible decline in the number of gingival bleedingsites in patients treated by non-osseous surgery ornonsurgical mechanical debridement, whereas theimproved microbiological status with osseoussurgery may be related to shallow probing depths re-sulting from osteoplasty and ostectomy. The micro-

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biota of shallow periodontal sites is very similar tothat of supragingival plaque (14). Also, more effectivesubgingival cleaning by brushing and flossing canchange the pocket microbiota from one containinghigh proportions of gram-negative anaerobes to onepredominated by streptococci and other gram-posi-tive species with little or no periodontopathic poten-tial (14).

Nowzari

Table 1. Demographics and clinical parameters of patients treated by osseous surgery in comparison topatients treated by nonsurgical periodontal debridement

Mean no. of sites Mean no. of sitesAge in years No. of teeth with probing with bleeding on Mean plaquemean (range) mean (range) depth Ø5 mm probing (range) index (range)

Treatment group n Sex SD SD (range) SD SD SD

Osseous surgery 20 11 F 38.5 26.9 0 1.9 0.32(29–50) (18–31) (0–4) (0.07–0.6)

5.9 3.0 1.4 0.1

Nonsurgical periodontal 22 5 F 53.7 23.7 23.0 15.5 0.52debridement (29–69) (18–30) (8–44) (7–26) (0.17–0.92)

8.8 3.8 8.9 6.5 0.2

Source: Nowzari et al. (18).

Table 2. Subgingival microbiota of patients treated by osseous surgery or by nonsurgical periodontaldebridement at 3 to 12 months post-treatmenta

Patients treated by Patients treated byosseous surgery nonsurgical periodontal

Organismsb (nΩ20) debridement (nΩ22)

No. positive, No. positive,mean % mean %

A. actinomycetemcomitans 0 5, 0.7

P. gingivalis 0 9, 12.3

P. intermedia 0 19, 9.6

B. forsythus 0 11, 2.8

C. rectus 0 16, 3.9

Capnocytophaga species 0 7, 4.0

Fusobacterium species 1, 0.1 21, 6.3

P. micros 0 19, 10.3

Propionibacterium species 0 0

Beta-hemolytic streptococci 0 3, 0.9

enteric gram-negative rods 0 1, 0.5

M. dentalis 0 0

Motile rods 1, 0.4 15, 11.2

Yeasts 0 1, ,0.01

Spirochetes 0 6, 1.3

P. gingivalis DNA probe positive 2, 10.0c 15, 68.2

B. forsythus DNA probe positive 2, 10.0c 14, 63.6a 0% of a bacterial species denotes that the organism comprises less than 0.01% of the cultivable microflora. A. actinomycetemcomitans and yeasts grown

on selective medium are listed with lower percentage of occurrence.b Samples are pooled.c No., % positive.Source: Nowzari et al. (18).

Principles of aesthetic osseous surgery

The principles of modern aesthetic osseous surgeryare based on therapeutic methods described by Wid-man in 1918 (36), Black in 1924 (3), Carranza in 1935(4), Schluger in 1949 (29), Friedman in 1955 (7), Och-senbein & Bohannan in 1963 (23), and Ochsenbeinin 1986 (24).

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Flap designs and incisions in aestheticosseous surgery

Periodontal flaps are full thickness (mucoperiosteal)(Fig. 4–8) or a combination of full and partial thick-ness (mucosal) (Fig. 2, 3). In both situations, softtissue is reflected to expose the underlying osseousstructures for recontouring. Surgical flap design may

Aesthetic osseous surgery

Fig. 4. A. Clinical appearance of mandibular right sextant gingival adaptation. A well-declined buccolingual inter-in a 45-year-old male smoker. Probing depths of 6 mm proximal slope prevents interdental gingival proliferationdistal of the first molar and mesial of the second molar and bridging that ultimately lead to pocket reformation.are measured. B. Surgical appearance. Note the 3-mm- D. Clinical appearance after 3 years. Double-scalloped in-deep interproximal crater between the first and second cision and double-scalloped ostectomy created triangularmolars. C. Osteoplasty and 2- to 4-mm double-scalloped soft tissue that protects the furcation area. Double-scal-lingual ostectomy have provided a 15 æ declining buccolin- loped ostectomy preserved the integrity of the periodontalgual slope to provide buccolingual transition space for attachment at the furcation area.

apically preserve the buccal periosteum (partialthickness) when the flap is to be positioned apically(Fig. 2, 3). The periosteal suturing stabilizes the flapin an apical position.

The outer portion of the periodontal pocket wallis transformed into attached gingiva. Removal ofpocket epithelium by a scalloped internal bevel in-cision promotes healing, with a tight adherence ofhealthy connective tissue to the dentoalveolar unit,and can increase the width of attached gingiva.

It should be emphasized that intracrevicular andcrestal incisions are not consistently effective in theremoval of diseased crevicular epithelium (6, 15).Scalloped incisions performed in aesthetic osseoussurgery preserve a healthy interdental soft tissue byplacing the interproximal incisions in an apical posi-tion and effectively eliminate the papillary epi-thelium.

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Palatal scalloped incision

First, a palatal scalloped incision is made. The in-cision starts at a distance from the gingival marginand is aimed apically at the osseous tissue. The scal-loped incision removes the inflamed tissue andcreates a thin flap margin for adaptation to thedentoalveolar unit following osteoplasty and ostec-tomy. The coronal portion of the incision containsthe epithelium of the pocket and granulomatoustissue and will be discarded (Fig. 9). The palatal scal-loped incision provides the interproximal soft tissuefor primary flap adaptation.

Due to the lack of soft tissue flexibility in the pal-ate, a definitive scalloped incision should be per-formed (Fig. 8, 9). A sulcular incision or an incisionmade at the gingival margin result in the residualpresence of a pocket by preserving the granulo-

Nowzari

Fig. 5. A. Surgical appearance prior to aesthetic osseoussurgery. As no vertical incision is usually utilized, the ex-tension of the flap is an essential notion in aesthetic oss-eous harmonization. Soft and hard tissue harmony, fromthe distal of the terminal tooth to the incisor zone, is thekey to long-term prognosis. B. Surgical appearance afterosteoplasty and ostectomy. Mid-buccal scalloped ostecto-my would recreate the interproximal papilla by providingenough discrepancy between the buccal and interproxi-mal tissue heights. C. Clinical appearance at the end oftreatment. Note recreation of interproximal papillae.

matous tissue and extending the flap coronal to thedentoalveolar junction. The shape of the incision fol-lows the radicular morphology and the depth shouldbe at the level of or slightly apical to the palatal oss-eous crest after osteoplasty and ostectomy are ac-complished.

Once the palatal flap is reflected, direct clinical ex-amination of the osseous morphology provides ad-ditional diagnostic information to finalize the designof the buccal gingival flap.

Lingual incision

Lingual double-scalloped and scalloped incisionsstart at a distance from the gingival margin and areaimed apically at the osseous tissue to remove theinflamed tissue and create a flap margin for adap-tation to the dentoalveolar unit. The double-scal-loped incision creates a triangular soft tissue withinthe healthy gingiva that protects the furcation areaof multi-rooted molars during healing. Ostectomyfollows double scalloped morphology as well, to pre-serve and improve the integrity of the periodontalattachment at the furcation area. The coronal gran-ulomatous tissue portion of the incision is discarded.

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A major limiting factor for lingual incision is thewidth of keratinized tissue available at the time ofsurgery. A limited zone of keratinized tissue prohibitsa definitive scalloped incision. Consequently, thescalloped incision may have to be made at a morecoronal position. Preservation of 2 to 3 mm of kera-tinized tissue may be used as a general guideline.

Buccal incision

Buccal double-scalloped and scalloped incisionsstart at a distance from the gingival margin and areaimed apically at the osseous tissue to remove theinflamed tissue and create a flap margin for adap-tation to the dentoalveolar unit. As described above,the double-scalloped incision creates a triangularsoft tissue within the healthy gingiva that protectsthe furcation area of multi-rooted molars duringhealing. Ostectomy follows double-scalloped mor-phology as well, to preserve the integrity of the peri-odontal attachment at the furcation area. The co-ronal granulomatous tissue portion of the incision isdiscarded. The scalloped incision restores the healthand the aesthetic aspect of the periodontium by re-

Aesthetic osseous surgery

moving the granulomatous tissue and increasing thewidth of attached gingiva as healing progresses.

A major limiting factor for buccal incision is thewidth of keratinized tissue available at the time ofsurgery. A limited zone of keratinized tissue prohibitsa definitive scalloped incision. Consequently, thescalloped incision may have to be made at a morecoronal position. Preservation of 2 to 3 mm of kera-tinized tissue may be used as a general guideline.However, the periodontal surgeon incises the buccalgingival flap in such a way as to compensate for theremoval of osseous tissue and to benefit from thehealing originating from the periodontal ligamentand endosteum for increasing the soft tissue height(21).

Distal extension

As no vertical incision is usually utilized, the distalextension of the flap, well beyond the mucogingivaljunction distal to the tuberosity or retromolar pad,is a prerequisite for flap flexibility and access to oss-eous tissues (Fig. 8). Distal incisions start within theattached gingiva and follow the underlying osseoustissue beyond the mucogingival line. A distal exten-sion confined to attached gingiva prohibits flapflexibility, access and visibility and may jeopardizethe blood supply due to trauma of the flap. Distalextension beyond the mucogingival junction is anessential notion in aesthetic osseous surgery.

When a vertical incision is used to reduce the me-sial extension of the buccal flap, the lingual or pala-tal flaps are extended more mesially than the verticalbuccal incision. The vertical incision is not placed inthe center of an interdental papilla or over the mid-radicular surface. Rather, the incision is made at theline angles of a tooth to include the papilla in thegingival flap.

The vertical incision is composed of a horizontalcomponent at the coronal part, an internally curvedcomponent at the mid-part and a cut-back compo-nent at the apical part within the mucosa.

The horizontal component improves tissue adap-tation at closure. Internally curved and cut-backcomponents provide flap flexibility and reduce thetension by increasing the length of the incision.

Mesial extension

Lingual or palatal flaps can be extended to the in-cisor area and buccal flaps to the premolar–caninearea. The mesial extension of the lingual and palatalflaps along with the distal extension of the buccal

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and lingual and palatal flaps permit access for oss-eous harmonization of the entire quadrant. The peri-odontal surgeon should not limit the periodontalflap to a small number of teeth. Soft and hard tissueharmony over the entire quadrant, from the distal ofthe terminal tooth to the incisor zone, is the key toa good long-term prognosis.

The thickness of gingival flap must be measuredbefore the flap is reflected to the final position. Theperiodontal surgeon will have more control to thinthe flap prior to the complete reflection. A mobileflap is difficult to trim. Well-executed flaps are essen-tial to prevent pocket recurrence and reinfection.

Maxillary anterior teeth

For maxillary anterior teeth no buccal flap or a flapnot reflected beyond the mucogingival junction maybe utilized. However, in the palate, a definitive, hori-zontal, scalloped incision should be performed. Theshape of the incision follows the radicular mor-phology and the depth should be at the level of thepalatal osseous crest or slightly apical to that afterosteoplasty and ostectomy are accomplished. Thepalatal flap usually provides enough access for notonly palatal but also interproximal osseous recon-touring.

The palatal sulcular incision or an incision madeat the gingival margin would not improve the aes-thetics of the buccal soft tissue. On the contrary, thepocket re-formation by preserving the granulo-matous tissue and pocket epithelium and extendingthe flap coronal to the dentoalveolar junction wouldprohibit a buccopalatally inclined interproximalslope. Over its entire length, the interdental heightof the osseous tissue should be coronal to the palatalradicular bone.

Osteoplasty and ostectomy inesthetic osseous surgeryRationale and technique

Although flap surgery provides access to radicularstructures (27), it does not provide optimal softtissue plasty, osteoplasty-ostectomy (7) and tissueadaptation. After flap surgery, unlike the contours ofthe alveolar osseous crest, the form of the gingivaltissue follows the scalloped pattern of the cemento-enamel junction. Consequently, discrepancies be-tween gingival tissue and the underlying alveolararchitecture leads to the recurrence of periodontalpockets and possibly reinfection (7, 16, 23, 24).

Nowzari

Aesthetic osseous surgery provides postsurgicalshallow probing depths by creating an osseous archi-tecture that mimics that of gingival morphology,whereas osteoplasty and ostectomy places the lin-gual osseous crest in an apical position that corre-sponds to the deepest part of the osseous defect (Fig.4, 6, 8, 9). Preservation of the buccal osseous crestensures a coronal aesthetic position. Interproximalalveolar bone assumes a 10 æ to 15 æ declining buccol-ingual slope to provide buccolingual transition spacefor gingival adaptation. A well-declined buccolingualinterproximal slope prevents interdental gingivalproliferation and bridging with the risk of pocket re-formation (7, 16, 23, 24).

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Supporting alveolar bone sacrificed per tooth afterosseous surgery averages only 0.6 mm (31). Also, os-tectomy is mainly performed on midlingual or mid-palatal radicular surfaces and averages only 1 mm(31). The integrity of buccal and interproximalattachment is preserved or improved (Fig. 6, 8).

Indications and contraindications

Aesthetic osseous surgery can be accomplishedwhere periodontitis is associated with interdentalosseous craters, intraosseous defects, irregular hori-zontal attachment loss and moderate furcation in-volvement. Osseous craters are the most common

Aesthetic osseous surgery

Fig. 6. A. Radiographic examination of a 32-year-old wo-man diagnosed with adult periodontitis. Note the intraos-seous defect and heavy calculus associated with the firstmandibular molar. B. Clinical appearance – buccal view.

C. Clinical appearance – lingual view. Mesial and distal offirst molar present 6-mm periodontal probing depth.D. Surgical appearance – lingual view. Note the 2- to 3-mm-deep osseous lesion distal and mesial of the first mo-lar. E. Osteoplasty/ostectomy places the lingual osseouscrest in an apical position that corresponds to the deepestpart of the osseous defect. A 15 æ declining buccolingualslope provides buccolingual transition space for gingivaladaptation. F. Surgical appearance – buccal view.G. Double-scalloped ostectomy preserves the integrity ofthe periodontal attachment at the furcation area. H. Clin-ical appearance – buccal view. Osseous surgery providespostsurgical shallow probing depths of 0.5 to 1 mm bycreating an osseous architecture similar to gingival mor-phology. I. Clinical appearance – lingual view. A well-de-clined buccolingual interproximal slope prevents inter-dental gingival proliferation and bridging that ultimatelylead to pocket reformation.

Fig. 7. A. Surgical appearance of a mandibular first molar ment loss. B. Osseous surgery provides an osseous archi-in a 55-year-old man. Periodontitis is characterized by a tecture similar to gingival morphology.deep intraosseous furcation defect and irregular attach-

type of periodontal defects and constitute about onethird of all osseous defects (Fig. 8, 9) and two thirdsof all mandibular osseous defects (16, 17). The highfrequency of osseous craters emphasizes the import-

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ance of knowledge on technical aspects of aestheticosseous surgery in periodontal therapy.

The type of crater and the relationship of the baseof the crater to the root trunk dictate the type and

Nowzari

Fig. 8. A. Clinical appearance of maxillary right in a 52- odontitis. C. Aesthetic osseous surgery eliminated theyear-old man diagnosed with adult periodontitis – palatal palatal wall of the osseous defect and palatal ostectomyview. B. Interproximal osseous crater characterized peri- ensured apical positioning of the radicular osseous crest

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Aesthetic osseous surgery

degree of osteoplasty and ostectomy. Craters areclassified as shallow (1 to 2 mm), medium (3 to 4mm) and deep (5 mm and more) (24). Root trunksare classified as short (3 mm), average (4 mm) andlong (5 mm or more) in the maxilla and short (2mm), average (3 mm), and long (4 mm or more) inthe mandible (24).

The following mean root trunk lengths have beenmeasured for maxillary molars in a Caucasian popu-lation (12). First molars: 4.1 mm on the buccal, 4.7mm on the mesial and 4.7 mm on the distal aspect.Second molars: 4.3 mm on the buccal, 6.4 mm onthe mesial and 4.8 mm on the distal aspect. First mo-lars present 90% medium or long buccal root trunk,91% medium or long mesial root trunk and 83% me-dium or long distal root trunk. Second molars pres-ent 82% medium or long buccal root trunk, 84% me-dium or long mesial root trunk and 84% medium orlong distal root trunk. First molars with short buccalroot trunks represent only 10% (12).

The following mean root trunk lengths have beenmeasured for mandibular molars in a Caucasianpopulation (12). First molars: 3.3 mm on the buccaland 4.3 mm on the lingual aspect. Second molars:3.3 mm on the buccal and 3.8 on the lingual aspect.First molars present 84% medium or long buccalroot trunk and 87% medium or long lingual roottrunk. Second molars present 92% medium or longbuccal root trunk and 92% medium or long lingualroot trunk (12).

in relation to the interdental bone. Interproximal alveolarbone assumed a 15 æ declining buccopalatal slope to pro-vide buccolingual transition space for gingival adaptation.The well-declined buccolingual interproximal slope pre-vents interdental gingival proliferation and bridging,which ultimately lead to pocket reformation. D. Clinicalappearance after 9 years – palatal view. Osseous surgeryprovided postsurgical shallow probing depths of 0.5 to 1mm by creating an osseous architecture similar to gingivalmorphology. E. Clinical appearance of maxillary right –buccal view. F. Periodontitis was characterized by intraos-seous lesion buccal and distal of second molar. Note nega-tive osseous architecture between first molar and secondpremolar. G. After aesthetic osseous surgery, the buccalosseous crest maintains a coronal position. Osteoplastyeliminated the second molar intraosseous lesion. Buccaldouble-scalloped ostectomy on the molars and minor os-tectomy on premolar provided positive architecture.H. Clinical appearance after 9 years – buccal view. Oss-eous surgery provided postsurgical shallow probingdepths of 1 mm to 2 mm by creating an osseous architec-ture similar to gingival morphology.

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Because of the high percentage of maxillary andmandibular molars presenting medium and longroot trunks and the high incidence of shallow andmedium osseous craters (12, 16, 17, 24), the majorityof periodontal defects can be eliminated by aestheticosseous surgery (Fig. 6). Osteoplasty eliminates thelingual and palatal wall of the osseous defect andlingual and palatal ostectomy ensures an apical posi-tioning of the radicular osseous crest in relation tothe interdental bone. After ostectomy, longer roottrunks provide sufficient remaining periodontalattachment coronal to furcations.

Medium craters require a more pronounced inter-proximal buccolingual and palatal slope and radicu-lar ostectomy. It should be emphasized that in maxil-lary molars the mid-palatal root presents no fur-cation and that the lingual root trunks’ length of thefirst and second mandibular molars are on average1 mm and 0.5 mm longer, respectively, than the buc-cal root trunk.

Minor buccal double-scalloped ostectomy on themolars and single-scalloped ostectomy on premolarsprovide positive bony architecture and can eliminatethe need for excessive lingual or palatal ostectomy.Mid-buccal scalloped or double-scalloped ostecto-my would give the illusion of interproximal papillaby creating enough discrepancy between the buccaland interproximal tissue heights (Fig. 5).

Elimination of shallow intraosseous defects, ir-regular horizontal attachment loss and moderatefurcation involvement follow the same principles(Fig. 7). However, orthodontic periodontal move-ment best treats intraosseous defects (11, 27). Toeliminate or reduce inflammation, periodontalsurgery may precede the orthodontic movement.After the completion of orthodontic movement, aes-thetic osseous surgery may still be indicated to fi-nalize the treatment.

By stretching the gingival fiber apparatus duringeruptive movement, tension is imparted to the entireosseous housing of the tooth, stimulating osseousapposition at the alveolar crest (2) and elimination ofthe intraosseous defect (35). The eruptive movementalso increases the zone of attached gingiva (2, 35), asthe mucogingival junction remains stable when thegingival margin migrates coronally (1).

It should be noted that a great healing potentialof periodontal intra-osseous lesions has been re-ported by Prichard (25, 26), Goldman (8) Goldman &Cohen (9). Rosling et al. (28) also found a mean gainof 3.5 mm probing attachment and 80% bone fill insites maintained on high levels of oral hygiene afterperiodontal surgery. Rosling et al. (28) observed

Nowzari

Fig. 9. A. Clinical appearance of maxillary left in a 49-year- formed. C. Once palatal flap is reflected, direct clinical ex-old man diagnosed with chronic periodontitis – palatal amination of osseous morphology provides additional di-view. Periodontitis was characterized by interproximal agnostic information to finalize osseous recontouring.pocket depths of up to 8 mm. B. Palatal scalloped incision Note the presence of our interproximal medium crater.starts at a distance from the gingival margin and is aimed D. Aesthetic osseous surgery eliminated the palatal wall ofapically at the osseous tissue. The scalloped incision re- the osseous defect and palatal ostectomy ensured apicalmoves the inflamed tissue and creates a thin flap margin positioning of the radicular osseous crest in relation tofor adaptation to dentoalveolar unit following osteoplasty the interdental bone. No buccal ostectomy was per-and ostectomy. Due to the lack of soft tissue flexibility in formed.the palate, a definitive scalloped incision should be per-

bone fill in all osseous lesions, irrespective of theirmorphological classification.

Contraindications for aesthetic osseous surgeryinclude deep buccal defects, deep craters, deepthree-wall defects and deep circumferential defects.

The significance of presurgicalplaque control

Prior to osseous surgery, excellent plaque control isindispensable for the restoration of interproximaltissue height. Yumet & Polson (41) reported loss ofconnective tissue attachment after surgery in theplaque-infected dentition. More mitotic epithelialactivity across the wound surface and into the in-

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cision is associated with the presence of chronic in-flammation in the underlying connective tissue (40,41). Mediators released from the inflammatory cellsin the connective tissue and production of variousbacterial toxins and enzymes contribute to furthertissue destruction.

The significance of postsurgicalplaque control

Following aesthetic osseous surgery, proper plaquecontrol is required to restore and preserve inter-proximal tissue height. Osseous surgery in patientspresenting poor plaque control could result not onlyin gingival inflammation but also a gradual recur-

Aesthetic osseous surgery

rence of pathologically deepened periodontalpockets (18, 22). Nyman et al. (22) reported an aver-age periodontal attachment loss of 1 mm per year inpatients treated by osseous surgery and presentingpoor postsurgical plaque control.

Aesthetic periodontal osseous surgery should notbe offered to patients who do not meet high stan-dards of oral hygiene (22). Weekly postsurgical recallfor 4 to 6 weeks and monthly thereafter for 1 yearmay be required to insure optimal conditions forperiodontal wound healing.

Histogenesis of osseous repair afterosteoplasty or ostectomy

At 2 to 3 weeks post-operatively, osseous resorptionoccurs on the periodontal surface if the osseousplate is thin, and on the osseous surfaces facing mar-row spaces and Haversian systems if the osseousplate is thick (40).

Osteoblastic repair activity reaches its peak at 3to 4 weeks post-surgery. Uncalcified osteoid tissueappears at 3 weeks and forms an immature osseoustissue at the alveolar crest and on the periosteal sur-face. Replacement by the intermediate type of oss-eous tissue takes place at 6 months and by matureosseous tissue at 18 months post-surgery. Preservingsufficient osseous thickness enhances osseous repairand anatomical restoration of the operated site (38–40). Loss of 0.5 mm to 1.0 mm of osseous crest maybe associated with a thin postoperative osseoustissue (40). Little or no permanent alteration of oss-eous height is usually associated with the interrad-icular area (39).

A definitive new periosteum would be evident at6 months (40). New collagen fiber bundles are em-bedded in osteoid tissue on the operated periostealsurface by the second month. In the area of the toothroot, the collagen fiber bundles are first parallel tothe long axis of the root until the fifth and sixmonths post-surgery when they angle from an apicaldirection into the root. A layer of cementoid, beingapposed for the first time on the root at 2 to 3months, provides for the angular attachment of thecollagen fiber bundles (38–40).

Conclusion

Modern medicine requires consistency in treatmentoutcomes. Aesthetic osseous surgery is a surgical

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treatment modality that may be used to effectivelyeliminate periodontal defects. Aesthetic osseoussurgery maintains the coronal aesthetic position ofthe buccal gingiva, reduces probing depths and sta-bilizes periodontal attachment levels.

Shallow post-treatment periodontal sites providereduced risk of future breakdown. Aesthetic osseoussurgery improves access to diseased radicular sur-faces for daily oral hygiene by the patient and main-tenance by the therapist. Post-treatment mechanicalaccess to causative factors by the patient is consist-ent with the goal of preventive medicine. Also, themain purpose of regular visits to the therapist wouldbe the preservation of the dentition in a state ofhealth, comfort and function, rather than the activetreatment of reinfection as a result of residual or re-current periodontal pockets.

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