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Archived NewslettersExpert Analysis | Simple Options for Ridge Augmentation
Over my past 20 years of oral maxillofacial surgery practice, I have developed a special interest in osseous reconstruction. This article will focus on a simple, predictable and relatively an atraumatic approach for lateral alveolar ridge augmentation. Having sound osseous and soft tissue architecture for implant placement results in consistently aesthetic, predictable and long-lasting implants, thus saving patients from replacement implants over time. Future newsletters will highlight procedures for vertical ridge augmentation.
Although guided bone regeneration (GBR) and block grafting have been in use for well over two decades, clinical studies have shown that these procedures do have their deficiencies. Many alveolar ridges augmented with block grafts have shown significant resorption 10 years later in spite of implant placement in the site. GBR is excellent for small lateral defects, but does not provide predictable results in large defects especially with vertical gain.
A simple technique that can be applied frequently is the alveolar split graft known as the book flap described by Ole Jensen, DDS*. I utilize this procedure for most lateral augmentations for maxillary and mandibular alveolar ridges with deficiencies. This technique differs from a traditional ridge splitting technique in that the mucoperiosteum (soft tissue attachment) is not dissected free from the facial/buccal alveolar plate to widen the ridge. Once the soft tissue is dissected free from the facial aspect of the alveolus and the ridge split occurs, the osseous site then essentially becomes a non-vitalized graft physiologically similar to a block graft. The book flap is used to increase alveolar width 2-5 mm and up to 6 mm in certain cases. This procedure can be used with immediate implant placement (2 mm of facial alveolar plate is required) or delayed implant placement. The relatively soft bone in the maxilla is amenable to this technique especially in the aesthetic zone. In the mandible, this procedure is more difficult due to the thickness of the cortical bone. From experience, a two-stage procedure is preferable in the mandible.
In experienced surgical hands, the procedure is relatively simple. A crestal incision is created in the desired edentulous space. This incision is palatal to the crestal midline with minimal soft tissue reflection to visualize the alveolar crest. A sharp osteotome or a piezo electrical saw is used to create a crestal osteotomy extending to a depth of approximately 10 mm. This osteotomy must be 2 mm away from the adjacent periodontal ligament spaces of the adjacent teeth. Next, the vertical component of the osteotomy is completed within the alveolus and extended through the facial plate. The facial segment is then spread to the desired width. Allograft with or without the BMP (bone morphogenetic protein) can then be packed in the osteotomy site. A collagen membrane is then placed over the site with resorbable sutures. Physiologically, this will heal very similar to an extraction site with allograft placement. In a staged procedure, the implant placement can follow this initial procedure three to four months postoperatively. In the mandible, an inferior horizontal osteotomy is always necessary in order to be able to spread the bone to the desired thickness. This is due to the thickness of the cortical bone. From my experience, I believe the two-stage procedure is preferable. Stage one surgery requires a soft tissue dissection followed by the vertical and inferior horizontal osteotomies. Personally, I also make the crestal osteotomy to the desired depth. There is no mobilization of the osseous segment at this stage. The tissue is then primarily closed. Stage two surgery occurs at a minimum of 28 days following the initial procedure. This allows for revascularization of the surgical site. A minimally invasive second procedure is completed as described above in the maxilla. The bone segment with attached tissue and blood supply is easily spread to the desired width. The following is a case representing a 6 mm augmentation of the symphysis region of the mandible. To the left is an example of a two-staged procedure.
Maximize your hourly PROFIT! | Single Tooth Efficiency Model
Single Tooth Efficiency Model – What is the S.T.E.M?
It’s a business model for single unit implants, where the clinician delivers the best possible single unit restorative option for the patient. S.T.E.M. streamlines the variables involved with the case and creates a more predictable and profitable result for the restoring clinician.
While the surgeon has a predetermined surgical fee, the lab has a predetermined fee for the restorative work, and the general dentist bills according to their ideal rate for chair time. With S.T.E.M., the overall fee to the patient is similar to the fee for a 3 unit bridge.
According to the ADA, implant therapy is a better alternative due to predictability and longevity. The average life of a 3 unit bridge is estimated at 5 years. This, in combination with bone atrophy that takes place at the edentulous site, is more proof that implant therapy is a better option for patients.
How does it work?
The restorative doctor simply removes the healing abutment, takes a simple implant level impression and reinserts the healing abutment. From that fixture level impression, the laboratory creates the custom abutment and final crown, or a screw retained crown, thus taking cement out of the equation. Upon the final seating appointment, the restorative doctor removes the healing abutment, places the custom abutment, and then cements the crown. The average combined chair time for both appointments is 20 minutes.
With the laboratory creating a “custom” implant abutment, a more accurate and controlled abutment margin is fabricated. Proper abutment margins are critical to help prevent excess crown cement traveling down to the implant bone interface, causing future bone loss and potential implant failure.
Compare 20 minutes of chair time with the average of 120 minutes involved with the preparation, temporization, and seating of a 3 unit bridge. This time-savings allows the restorative doctor to increase productivity and provide patients with better care. Example:
Industry Resources | Links of Interest
The following websites are provided as a resource for our referring doctors. This page contains hyperlinks to World Wide Web sites that are created and maintained by other organizations. We have included these links because we think that our referring doctors may find them of interest. Keep in mind that the Center for Oral & Reconstructive Surgery does not necessarily endorse the views expressed on these websites. Also, we do not guarantee the accuracy or completeness of any information presented on these sites, they are provided as reference resources.
- British Dental Association
- List of International Dental School Website
- WebDental – American based dental database
- Cambridge University Medical Library
- Medical Library University of Manchester
- MedicineNet – Content-rich commercial site includes interactive groups, ask-the-doctor feature, medical dictionary, comprehensive drug information, medical news, disease-specific information, and links.
- Medscape – Searchable commercial collection of full-text articles from such useful sources as the National Institutes of Health and the Centers for Disease Control and Prevention.
- Oncolink – Huge collection of cancer information and links based at the University of Pennsylvania. The best starting place found for cancer information.
- ParentsPlace.com – Not health-only, but this commercial site contains many pages of sophisticated, reader friendly information on children’s health issues.
- Medical Matrix – Physician maintained commercial database of annotated health links. Oriented toward medical professionals, but accessible to an educated lay person. A keyword search gets you to a subject index, from which you navigate to the links you want.
- American Journal of Oral and Maxillofacial Surgery
- British Medical Journal
- Journal of Cranio-Maxillofacial Surgery
- Nature – International weekly journal of science
- New England Journal of Medicine
- Academy of Osteointegration
- American Academy of Dermatology
- American Academy of Implant Dentistry
- American Academy of Restorative Dentistry
- American Association of Endodontists – national organization representing the specialty of endodontics or root canal treatment.
- American Academy of Periodontology – mission is to advance the periodontal health of the public and represent and serve the members of the academy.
- American Association of Oral & Maxillofacial Surgeons – find information about oral and maxillofacial surgery including cancer, dental implants, sports safety, jaw surgery, and more.
- American Association of Women Dentists – dedicated to enhancing and promoting participation and leadership for women in organized dentistry.
- American College of Oral and Maxillofacial Surgeons
- American College of Prosthodontics
- American Dental Association – ADA Online – access to news, publications, and products and services related to dental health.
- American Endodontic Society, Inc. – endorses and teaches the Sargenti or N2 technique of root canal therapy.
- American Independent Dentist’s Association – dedicated to the survival of the concept of optimal care in dentistry. Working to re-engineer organized dentistry and bring new tools to the education of patients.
- American Medical Association – another useful site with links to consumer health information, vast AIDS information center, searchable database of more than 650,000 physicians
- American Society for Dental Aesthetics
- American Society of Dentist Anesthesiologists
- Association of Managed Care Dentists – a non-profit organization dedicated to the education of dentists and related professionals about the emerging managed care delivery systems.
- Center for Reconstructive Jaw Surgery
- Craniomaxillofacial Surgery Database Membership
- Craniomaxillofacial Surgery Related Sites
- Crown Council – dental professionals dedicated to continual improvement of their clinical and management skills.
- International Association of Dental Research
- International Association for Disability and Oral Health – general informational brochure and quarterly newsletter information.
- International Association of Dento-Maxillo-Facial Radiology
- International Congress of Oral Implantologists (ICOI) – professional organization of dental implantology specialists.
- Medical Protection Society
- National Association of Dental Laboratories (NADL) – contains news, general and membership information, links, and a forum.
- National Association of Dental Plans – NADP representative and recognized resource of the dental HMO/PPO industry with news, meetings, statistics and other resources.
- Oral Cancer Information Center – US based web-site