Tibbetts, LS, Ochsenbein, C, and Loughlin, DM. The rationale for the lingual approach to mandibular osseous surgery. Dent Clin North Am, 20:61, 1976.

This paper discusses the anatomical patterns of the mandible and alveolar bone as well as tooth inclinations, suggests how periodontitis and the elimination of its effects relate to its basic formation, and introduces the rationale for the lingual approach to mandibular osseous surgery as a further refinement in achieving and maintaining pocket elimination in the mandibular posterior segments.

Size and anatomical thickness, as well as depressions and prominences are presence and vary to a great extent from mandible to mandible.

Anatomical considerations:

• (a) external surface of the mandible: external oblique ridge - if it is heavy and the buccal vestibule shallow, osseous recontouring is limited. A depression called retromolar area is located between the internal lateral border of the retromolar triangle and the external oblique ridge.
• (b) internal surface of the mandible: the mylohyoid ridge can be blunt and slightly elevated to marked elevated and spiked and therefore create different degrees of thickening of the mandible in the molar/second bicuspid region. Bone prominences or exostoses are found in different locations of the mandible.

Axial root inclinations:

• Distal inclination of the root apex increases from canine back. The root apices of canine and first bicuspid are inclined lingually, while the posterior teeth are inclined buccally.
• The buccal bony plate is higher than the lingual plate.
• Normal relationship of alveolar bone to gingiva: the normal alveolar bone parallels the CEJ. Alveolar crest is convex in the bicuspid area and flat in the molar area.
• Locations and types of bony defects: the most common lesion is the interdental crater, followed by thickened alveolar margin and bone loss. Lower molars and premolars are the teeth most affected by osseous defects in the mouth.
• Reverse architecture is a common finding in the mandible after interproximal craters are eliminated and can be easily eliminated without furcation compromise if ostectomy is performed.
• Rationale for the management of mandibular defects:
• Due to the lingual inclination of mandibular molars (± 20°) the base of the crater in that area is located lingually. One common mistake is to ignore this situation and over treat the buccal and under treat the lingual (fig. 8). It should be remembered that bone should be conserved in the buccal because it is supporting bone. The lingual approach therefore removes the lingual wall of the crater and corrects bone thickness on the buccal by osteoplasty that should go apical to the mylohyoid ridge; buccal bone should be preserved. The fact that the buccal furca is situated further coronal than the lingual one is another reason to do osseous from the lingual.

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