Osseous Reduction

1. Periodontal Osseous Reduction (Resective Osseous Surgery)

Definition

Two Core Procedures (Friedman, 1955 classification)

Goals

• Elimination of osseous defects (intrabony pockets, craters, ledges)
• Reduction of periodontal pocket depth
• Creation of a bony contour that allows the patient to maintain adequate plaque control
• Establishment of physiologic gingival architecture

Indications

• Buccal and lingual bony ledges
• Shallow-to-medium intrabony defects (1-4 mm)
• Bony craters with thick walls
• Minimal furcation involvement
• Hemiseptal defects

Crater Classification (Ochsenbein & Bohannan, 1964)

• Class 1: 2-3 mm concavity, thick walls - treated with palatal ramping
• Class 2: 4-5 mm concavity, wide orifice, thinner walls - treated with buccal and palatal ramping
• Class 3: 6-7 mm concavity - treated with both palatal and buccal ramping
• Class 4: Variable depth, thin walls - requires both osteoplasty and ostectomy

Flap Design

• Apically positioned flap is used in conjunction with bone resection
• Buccal: split-thickness flap
• Palatal: thinned palatal flap
• Final flap position should be at the crest of bone
• Precise periosteal suturing ensures flap placement

Limitations and Criticisms

• Average 0.6 mm of supporting bone loss (Selipsky, 1976)
• Post-operative mobility increases, but typically returns to below presurgical levels at 1 year
• Requires sound clinical judgment to avoid excessive bone loss
• Not appropriate where deep angular defects are present (regenerative approaches preferred)

Outcomes

• In 4-6 mm pockets, osseous resective surgery achieves greater pocket depth reduction at 5 years compared to curettage
• Results are comparable to modified Widman flap surgery
• Stabilization or improvement of clinical attachment level (CAL) is a key endpoint

2. Orthopedic Osseous Reduction (Fracture Reduction)

Two Types

• Bone alignment achieved by external manipulation without opening the skin
• Not a surgical procedure
• Performed in the emergency department with local anesthetic or sedation
• A cast or splint is applied after to maintain position
• Best for minor, stable fractures that can be held with external immobilization

• Surgical procedure: skin is opened, bone fragments are directly visualized and manipulated
• Internal fixation devices (plates, screws, nails, wires) are used to hold the reduction
• Indicated when:
  • Closed reduction fails or is unstable
  • Open (compound) fracture
  • Intra-articular fractures requiring anatomic alignment
  • Multiple fractures
  • Severely comminuted fractures
  • When wound care requires surgical access

Principles of Osseous Reduction

1. Restore correct anatomical alignment
2. Achieve and maintain stable fixation
3. Allow early mobilization to prevent stiffness and promote healing
4. Prevent complications: malunion, nonunion, avascular necrosis (AVN)

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