The most difficult cases to treat are the moderate to advanced ones. The common question in these case is how much bone can be removed. Very little bone support is sacrificed if a rational choice of patients for osseous correction is made and the need for permanent splinting can be predicted before osseous surgery is performed.
Ostectomy actually removes little attachment. Loss of interdental bone is often negligible, except for some hemisepted defects. Ostectomy on buccal and lingual surfaces usually do not exceed 1-2 mm. Buccal and lingual areas are usually smaller and give less support to the teeth than the interproximal, situation that also makes ostectomy to get positive architecture less bad. Sometimes the visual effect of osseous surgery scares the clinician, but the actual amount of supporting bone removed is minimal.
The last part of crater are often left untreated and its total treatment would implicate in minimal ostectomy; this cases will also have a compromised result. In cases where extraction decision is not sure, the bone should be recontoured as if it was going to be retained and in many times, even if defect elimination is not possible an area of easier access was created for maintenance. Sequence for osseous reduction:
Vertical grooving between teeth and roots should be done first. Buccal and lingual thinning of the bone should be performed between the grooves. Craters should then be removed and ostectomy to achieve positive architecture performed.
We should be concerned about the amount of supporting bone left, it should be enough to avoid secondary occlusal trauma and tooth mobility.
Presence of plaque, inflammation and occlusal prematurities are more important than osseous surgery when well indicated in terms of tooth mobility. Mobility is something that tends to decrease once a healthy environment is established, although it is increased for up to a few months after surgery. The need for splints is basically based on patient's comfort, replacing of missing teeth, retention of teeth after orthodontic movement, prevention of extreme mobility related to severe parafunctional habits. There is no evidence that temporary splinting may help in decreasing tooth mobility and it has not been shown that looser teeth have worse prognosis than tighter teeth. The clinician should be concerned about increased mobility rather than mobility at a point in time.
The best therapy is the minimal therapy that will adequately preserve the oral structures in health, in function acceptable to the individual's patient biology, and in comfort and form acceptable to the patient.
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