Narrow Ridge: Best Treatment Plan?

In my hands the best treatment would be to do a autogenous block graft to increase width. This allows development of the emergence profile for the correct placement of the implant for maximum aesthetics and function. Long term it seems as though I have less problems with resorption of the ridge. Your other options will cause aesthetic problems and or placement of the implant in poor functional postion, which will cause facial/buccal resorption. The partitulate graft is unpredictable, good luck Ed Kusek

Dr. C, I think all of your proposed solutions have merit. What is left out of your question is what does the patient want? In terms of financial commitment, time commitment, potential pain and discomfort, the ability to accept that proposed surgical intervention may not have a positive outcome, their current prosthesis may not be suitable to wear during the healing phase etc...... While it is admirable to consider replacing what nature gave your patient; it comes with a multitude of costs. I am a bit dismayed that you consider a small diameter implant the last plan. I think that this is a great area to consider a narrow body implant. Best of luck with your case. Paresh B Patel

How narrow is it? If the ridge is as narrow as less than 2 mm, in my opionion, bone graft would be in doubt as the cortical bone alone would not provide enough physiological activity to promote osteogenesis. The first plan: not bad, but prothetic part would be a problem. The second plan: I would suggest to use non-resorbable membrane and to be fixed by bone pins. Sometimes, the fibrous tissue may penetrate the resorbable and disturb osteogenesis. Furthermore, xenograft should be mixed with autograft. The third plan: Forget about it, unless you are an expert to manage soft tissue surgery. Once the bone block is exposed, the graft must result in failure. Moreover, bone screws (not pins) must be used. Are you dare to perform such kind of operation??

Consider blade implants!

Please mention the area concerned and exact ridge width and height. Because the treatment plan varies a great deal accordig to the density of the bone and residual ridge width available. Width available is 3mm or 5 mm can make all the difference! Similarly cancellous bone can be expanded but cortical bone can only be split. I'll be able to contribute with a greater precision only after knowing these facts.

Please identify the site that you're talking about. It's difficult to determine what the best treatment should be otherwise. Also if you're using particulate bone for width augmentation, a rigid non resorbable barrier is best, it will guarantee shape retention.

Dr. C: You don't mention the area of the mouth in question or how many teeth or implants are involved. If it is the anterior mandible, you can probably reduce the ridge until the width is sufficient. In other areas, this is not a good treatment, and either particulate grafts such as lateral ridge augmentation with reinforced nonresorbable membranes or block grafts, or membranes supported by "tent poles" would work well. The membrane should be tacked down along its periphery to insure containment of the graft. A ridge-split can also work well either as a preliminary separate procedure or as a combined procedure with implant placement. The use of a narrower implant can also be feasible if their length and width will give sufficient support to the prosthesis. Any of the bone augmentation techniques can work if you are proficient in performing them. The critical components of bone grafting is flap design and graft coverage. In order for the grafts, using any technique to yield predicable results, requires 100% coverage of the graft 100% of the time.

Titanium mesh

Dear Dr. C I wonder why you never considered a Ridge Splitting Procedure as one of your options.I have had good results with this method,especially at the posterior mandible.C'est possible,je vous promets.

I would first allow 2mm of bone adjacent to the implant in planning (Tatum). This gives an average of 1mm viable bone in case of some crestal bone loss. If you can do a ridge split go for it. Ace surgical. Messinger and BTI make tapered threaded rotary bone expanders that self thread and work well for the splits. If you cant to the split then the block graft gives a good hard dense recipient site when matured

Delayed (staged) lateral expansion technique The delayed lateral expansion technique is applied to the ridge with a dense and thick cortex because the expansion could be caused by fracture of the expanded buccal segment. After administration of local anesthesia, an incision should be made along the ridge crest slightly toward the lingual side, and 2 vertical incisions also are made. A full-thickness mucoperiostal flap is elevated to expose the buccal aspect of the mandibular alveolar ridge. The authors emphasize that limited flap reflection should be performed to expose only the ridge crest, with no attempt made to expose the buccal cortical plate.. Such exposure might compromise blood supply and also allow for further unnecessary resorption of bone. The nourishment to the buccal lamella is maintained through unattached periosteum. After completing the rectangular corticotomies with a piezoelectric saw or erbium: yttrium-aluminum-garnet laser, greenstick fractures are created in the buccal segments. To prevent a fracture of the buccal plate during the expansion process, an apical osteotomy is performed connecting the apical ends of the two “bony verticals”. The horizontal and vertical corticotomies might be done through a small fissure carbide tungsten bur with a straight handpiece. The crestal bone cut can be made to within a millimeter of an adjacent tooth. The length of osteotomy along the edentulous span should be extending well beyond the planned implant sites. This extended length will allow the plates toexpand or bow during preparation of the osteotomy. An alternative to simultaneous implant placement is the placement of an inlay or an interpositinal bone graft such as particulate allograft material or anorganic bovine bone between the expanded cortices and self-space making defect. Autogenous bone grafts can be combined with allogernic materials to increase the volume According to Rosen, the recommended relation of the total volume is 20% allogenic and 80% autogenous material.After the primary surgery, a 3- to 4- week healing period should be allowed before performing delayed ridge expansion and implant placement as second-stage surgery. A crestal incision to expose the crestal cut should be performed. The buccal flap should be minimally reflected to preserve the blood supply for the buccal cortical plate. Also, a small chisel might be used to carefully separate and mobilize the segmented bone, provoking a greenstick fracture. The blood supply on the buccal aspect of the displaced buccal plate should be maintained. After preparation of the implant sites using twist drills and osteotomes, the implants should be placed and bone graft augmentation might be performed. Adjunctive material is not necessary in all cases. A Tension-free soft tissue closure must be achieved. After 3 to 4 months, the third phase of surgical exposure to change the cover screw to a healing abutment could be performed.