|Year : 2011 | Volume
| Issue : 2 | Page : 97-100
Narrow ridge augmentation technique for improved immediate oral implant placement
S Elanchezhiyan1, K Vennila2
1 Department of Periodontia, KSR Institute of Dental Sciences and Research, KSR Kalvinagar, Tiruchengode, India
2 PG Student, Department of Periodontia, JKK Nataraja Dental College, Komarapalayam, Tamil Nadu, India
|Date of Web Publication||30-Dec-2011|
65-A, IYANKADU, Devasthanampudur, Namagiripet, Namakkal, Tamil Nadu - 637 406
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Resorption ridges often pose hindrance in oral implant placement. Inadequate width of ridge requires some more innovative techniques in placing implants. One of such techniques is ridge splitting technique, which helps expansion of narrow ridge with or without fracture of cortical plates. This technique has the advantage of immediate implant loading, in comparison with other ridge widening techniques. This article deals a case study using the ridge splitting technique with the conclusion of, it could be consider as novel technique for implant placement in narrow ridges.
Keywords: Immediate loading, implant placement, narrow ridge, ridge splitting
|How to cite this article:|
Elanchezhiyan S, Vennila K. Narrow ridge augmentation technique for improved immediate oral implant placement. J Dent Implant 2011;1:97-100
|How to cite this URL:|
Elanchezhiyan S, Vennila K. Narrow ridge augmentation technique for improved immediate oral implant placement. J Dent Implant [serial online] 2011 [cited 2020 Sep 22];1:97-100. Available from: http://www.jdionline.org/text.asp?2011/1/2/97/91290
| Introduction|| |
Sufficient bone quantity will be an essential pre-requisite for implant placement in oral implant therapy.  Many etiologies as extraction, trauma, periodontal disease resulting in decreasing the bone quantity, ended with both vertical and horizontal bone loss. Inadequate horizontal bone volume often results in an implant surface exposure and consequent decrease bone-implant interface and potential implant failure.
To enhance the bone volume in implant therapy, several techniques are used. They are like bone grafting, guided bone regeneration (GBR), distraction osteogenesis. Residual ridge widening is another novel method to prepare atrophic jaw bones for implant placing.
The ridge splitting technique also called as widening technique first done by Hilt Tatum and further developed by Summers  followed by greenstick fracture technique with membrane closure for root form ceramic implants by Bruschi and Scipioni. This technique is useful in widening the narrow ridge for implant placement. Suitable for only increasing the width of the ridge, 3-5 mm width will be ideal corresponding to the implant diameter with available adequate bone height.
The ridge splitting technique having the advantage over ridge augmentation techniques as bone grafting may be the simultaneous implant placement. The simultaneous implant placement shortens the treatment period in comparison with other techniques. 
The patient evaluation and preparation for implant placement is similar to preparing for other implant procedures. Started with the bone height calculation by conventional radiograph, advanced CT scanning may also be advocated.  Starting the procedure with crestal incision along the ridge crest and minimum mucoperiosteal flap reflection is performed to expose only the crest ridge. The lateral cortices periosteum should remain intact to ensure blood supply to the underlying bone. A round-handed scalpel with a #15 or round tip Beaver blade is used to begin the osteotomy. The osteotomy should bisect the ridge crest and separate the cortical plates. A mallet may be used to advance the scalpel blade through the bone. The handle of the scalpel blade through the bone should be parallel to the cortex. The length of the osteotomy along the edentulous span should extend well beyond the planned implant sites. After crestal osteotomy is completed, thin chisels, osteotomes, tapered fissure burs, or saws may be used to separate the cortices and begin the ridge expansion. If possible, the depth of the osteotomy should be extended beyond the planned length of the implant, which will allow a hinging of bony plates at the base of the ridge split osteotomy. Gradual expanding of the ridge will be done by wider chisels or osteotomes. Bone grafts included may be with platelet rich plasma in implant placement. The graft is covered with bio-resorbable membrane followed by flap approximation.  For primary wound closure, the split thickness is flap dissected from facial part. Adequate implant healing time (minimum 3 months) is needed to allow regeneration of the bone between the separate plates.
| Case Report|| |
A 41-year-old woman was referred for prosthetic treatment associated with implant placement in the anterior edentulous maxilla in relation to upper central incisors [Figure 1] Clinical examination revealed an edentulous margin with obvious labial and palatal bone resorption. Clinical and radiographic examination showed that the ideal vertical bone height and inter arch space both favor implant placement. The ridge width of 5 mm was not adequate for implant placement; it was decided to augment the alveolar crest horizontally.
With 2% lidocaine local anesthesia, a full thickness flap was raised to expose the defect, and surface of the bone was freed from the remaining muscle and periosteal fibers. The initial osteotomy was performed on mid-crestal bone using a #15 blade [Figure 2]. Chisels of increasing width and a mallet were used to further enlarge the osteotomy to a point 3 mm shorter than the final length of the implants placed [Figure 3]. Approximately 2-3 mm of expansion was achieved without performing vertical incisions in the bone [Figure 4]. Sequential surgical burs according to standard implant placement protocol were used to prepare the osteotomy site for implant placement up to the final length of the implants. The implants were placed [Figure 5] and presented with initial primary stability, the cover screws were placed and implants were submerged for a healing period of 4 months. The widened space between cortical plates were densely filled with a mix of bone filler (Bio-OSS) and surfaced with bioresorbable collagen membrane [Figure 6]. The flaps were approximated and patient was instructed not to give any pressure on the healing site.
Second surgery was performed 4 months later, healing abutments were placed and the soft tissue was allowed to heal for an additional 5 weeks. Splinted porcelain fused-to-metal crowns then were delivered [Figure 7]. Post operative X-ray was taken for recheck the implant condition before placing prosthetic components [Figure 8].
| Discussion|| |
The ridge splitting technique allows single procedure implant placement in a narrow crestal ridge. The surgical success and implant survival rate are high, with the advantage of shorter treatment period.  Though partial thickness flaps also advocated by many authors, full thickness flaps were used to avoid excessive bleeding, resulting in better visualization of the operating sites and better handling of the surgical steps. The partial thickness flap procedure becomes difficult, if there is thin connective tissue, and remaining tissue over the alveolar bone is too thin to protect the bone adequately.  The unexpected cortical plate factures may be retained with bone fixation screws.  If the primary stability of the implants is compromised, placement of implants should be done only after the healing of the augmented site.
The dense mandibular bone requires different approach in ridge splitting in comparison with the maxilla.  Maxillary crestal osteotomy may be done with chisels and without the assistance of the surgical burs. Plate expansion may be done with a mallet without vertical osteotomy. In mandible, however, surgical burs are used in initial osteotomy along with two vertical osteotomies.
The possibility of treating only horizontal defects and necessity of spongy bone are the limitations of the technique. The following are the benefits of ridge splitting technique in comparison to other techniques. 
- It allows less invasive manner implant placement and avoids donor-site morbidity caused by bone grafting and
- It allows primary implant placement and short treatment time.
It allows treatment of narrow ridge location within the context of a routine dental office procedure.
| Conclusion|| |
This article gives a brief view on implant placement in narrow ridge crests using the ridge-splitting technique. The correct indication associated with careful clinical maneuvers of the ridge-splitting technique allows predictable placement of implants even in narrow alveolar ridges.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]