Ridge split or height reduction for this implant case: Recommendations?

I intend to install a 4.2 x 10mm implant.  Do you think it is necessary to do ridge split or vertical ridge height reduction to achieve adequate bone width volume in this case?  The buccal bone thickness is 1mm, and the lingual thickness is nearly 1.5mm at 1.5mm below the ridge. Also there is a bone vacuum.  Do you think that this case will be compromised for the osseointegration and later for the implant loading?

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29 thoughts on “Ridge split or height reduction for this implant case: Recommendations?

  1. Looks OK but you are a bit tight to the IAN and the lingual plate , so check with pilot bur , this requires a bit of caution .
    Peter

    • I don’t think IA is too close. I’m not a fan of single tooth ridge splitting. Be sure to use a bone level implant if you intend to place sub crestally as you depicted in you 3D placement.

  2. I would place the implant at the crest of the bone and graft above it and onlay it on the buccal. I would also use a motorized expander to get a 4.7 in there but a 4.1 is okay also. Look at the bone height in regard to the adjacent teeth if the implant is placed that deep it will be in a hole and will be difficult to restore and maintain. What is lacking is height and that can be helped by placing at the crest or a mm above and grafting over and placing a membrane. Burying an implant in a deficient mandible for a crown makes the restorative much less favorable, the bone needs to be put back, you will also avoid much of th vacuole. I don’t know what a vacuole is marrow space or a blood vessel? A ridge split in this area may compromise the adjacent teeth especially the premolar with over 50% bone loss already. I would onlay the superior surface of the bone to get some augmentation on the adjacent teeth a Teflon membrane would be nice.

  3. I was only stressing caution as may be a relative novice and have seen a number cases like this with poor bone density internally where the implant was placed sub crestally using and handpiece and agressive cutting type implant.
    And before they knew it , they had damaged the IAN .
    Peter

  4. Thank you for the answers.
    I allready have notice the poor bone quality.
    Another issue is the long intratooth space almost 11mm and the distance from ridge to occlusal plane 11,5mm so the crown height/implant ratio is<1.
    This is not a long term compromise for implant stability?

    For these reasons i'm thinking to place two 3,75*10mm implants and splinted them with a screw retained crown.
    Any advise-recommendation?

    • Absolutely DO NOT Place two implants in this mesio distal concave anatomy.
      Just think about it what’s gonna happen if u place u implants in this area. Let’s all think together.

      • Actually I agree with Sam on this one build up the bone first due to the level lost on the adjacent teeth, my next comment is predicated on bone grafting and keeping at least 3 mm of bone between implants. A lab wax up and surgical stent would also be helpful. The adjacent teeth may need to go in the future, plan for it in the implant restoration.

  5. There is no harm in creating mini molars or premolars keepin the occlusal table in proportion to the narrower implants I would not splint due to the hygiene issue, I still think a 4.1 width with grafting would be fine. Use a surgical stent this is not a case fo a novice thanks for reading

  6. The mid
    The Mid facial of the implant should be at the deepest point of concave profile of the bone so that you have less of a open gingival embrauusre problem.

    If you place two implants with the deepest part of bone in b/w the two implants, you would have ugly big gaping hole… open enbrassure…..giving you reverse anatomy.

    So just place a 4.2 or 4.7 fixture and finish the case.

    In my office, osteotomy would be made by trephine and harvested cyclinder screwed to the facial of the implant with prf membrane held by neck of tissue level screw plus implant and 5mm healing collar and no periosteal release needed. The flaring neck of the implant acts as a tenting aid.

  7. I think you can use 3,5mm implant with height between 9 and 10mm with cone-Morse, perform surgical procedure in local anesthesia not in block IAN, make some spread of bone with lateral bone augmentation,. You can use membrane but for me periostium is the best membrane. Go sub-crestaly.

  8. Since you have indicated that the bone is not of the best quality, why not think about a shorter…8mm implant……gently prepare the site for a 4.2 mm diameter, but in fact screw in a 5mm diameter implant which will gently engage the buccal and lingual cortical plates, and will give you sufficient clearance of the IAN.

    Adin Dental Implants ( manufactured in Israel and licenced and sold all over the world) make a very nice self taping 5 x 8 implant called the Touareg – S
    ISP-S 0850. It is very similar to the Nobel Active, which was also designed in Israel, but is more reasonably priced.

    Adin implants have internal hex connections and I have a more than 20 year experience of using them when the original company was called Medigma Technologies.

    This is a straight forward case, and is not necessary to be complicated with ridge spitting, grafting,etc…….good luck.

    Gerald Rudick dds Montreal

  9. The KISS rule applies here. This would be a straightforward placement for me. No grafting, no ridge split, no trephines. A single implant is all that’s required. I also wouldn’t place the implant that deep and would watch the lingual plate as Peter says. If you are concerned about leaving some threads exposed buccally, you could consider using a Profile Astra implant with a sloping head but I doubt this would be needed here. Hope that helps.

  10. Hi! Answers to both your questions is NO!
    Just a few questions- why has the implant been planned a) in the thinnest portions of the available bone? B) have you considered putting 2 thinner implants representing the 2 roots of the 46.c) with the present planning what kind of a prosthesis been planned?-d) have you considered the direction & amount of stresses the current planned position would put on the implant?

    • The answer is

      a/ because this is the center point of the intrateeth space
      b/ yes, this is my second plan,2 implants 3,75*10mm with 3mm dinstance between them (there is almost 15mm space) bone grafting between them at the major concave space,and one screw retained crown.
      i think with this plan is better for implant longevity.
      c/ one huge screw retained crown
      d/ yes ,and with plan A (1 implant) i have too match stresses

      • More explanations related to the previous questions,
        A) Is the anterior-posterior insertion angulalation adequate to transfer the stresses along the long axis of the implant? Check the angulalation of the 47 &the 45.
        B)yes 2 implants make better sense especially when you have a 15 mm space.
        C) & D)making one huge crown on 1 implant would create vertical ,mesial & distal cantilevers + the bone being the weakest could lead to detrimental stresses. 2 implants with 2 premolars crowns in sufficient bone with sufficient surface area to distribute the stresses could be a win-win situation.

  11. I would use a tissue level implant (like Straumann 4.1S RN x10) and place the rough-smooth border 1-1.5 mm subcrestally. The polished colar moves up the restorative platform for 2.8 mm so implant shoulder will be sitting 1.3-1.8 mm above the crest. This makes the crown-root ratio more favorable and improves cleansibility. Also prevents a need for grafting and unnecessary extra costs.

  12. I think some the colleagues make this straight forward implant placement a complicate case! I would use a tissue level implant (like Straumann 4.1S RN x10) and place the rough-smooth border 1-1.5 mm subcrestally. The polished colar moves up the restorative platform for 2.8 mm so implant shoulder will be sitting 1.3-1.8 mm above the crest. This makes the crown-root ratio more favorable and improves cleansibility. Also prevents a need for grafting and unnecessary extra costs.

    • I may be missing something looking at the x-ray images. I would have placed 2 narrow body implants, even 3.2 mm if needed, with plenty of bone arround them and restored with narrow teeth to control forces. This would be easy to keep clean and function well. The aesthetics in this area of the mouth are not all that critical, and a novice would not have a difficult or complicated procedure to do. If this would cause a problem please comment.

  13. I would insert a 4mm tissue-level implant, placing the polished collar slightly below the crest, as someone has already said. This would help manage the uneven bone height around the implant platform, keeping the rough surface in the bone. A wide platform (4.7mm / 5mm) would be helpful to build the molar.

  14. A few words of caution.
    During some of my training we installed Bicon implants in S.A. and one fell into a laguna. It was in a Latino and I have since encountered these vacuums in other Latino patients. It couldn’t be retrieved so it was put to sleep as it ended up being horizontal in the laguna. The Straumann tissue level will prevent this as it has the flared neck and it won’t just drop out of sight. The other word of caution is to watch out for a lingual perforation during the preparation of the osteotomy. Use your finger as a guide to feel the lingual as you are drilling and you can feel the bur chatter on the inner lingual wall if you are getting to close.

  15. Trust ur scan and if the implant can be restored with an angled abutement, place it. Don’t ridge split this case! Bvinci

  16. Gents – there is evidence in the literature indicating that short implants (8.5mm) are just as successful as longer fixtures. Crown to root ratio concerns do not apply in implantology – they are a myth. We all must strive to practice evidence based dentistry. Good luck with the case.

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