Alveolar ridge at that site is knife edged: Best solution for this case?

Last Updated: Aug 31, 2012

I have a patient who wants an implant installed in the #30 site [mandibular right first molar;46]. Â The alveolar ridge at that site is knife edged and very thin with most of the resorption creating a deficit primarily on the buccal wall. Â The CBVT scan shows that the wall is about 4.5mm thick buccolingually. Â The gingival biotype is very thin. Â There is a very narrow zone of keratinized tissue.

1. Place implant Ankylos A11 (3.5 x 11mm) with guided bone regeneration at the buccal wall (Bio-Oss and collagen membrane). It seems the easiest way but is technique sensitive and also I’m not sure about the long term result. Especially, the gingiva is thin and there is not much keratinized tissue at the site. Â Would you recommend that I do a connective tissue graft? Is it really neccessary? Is it predictable in this area? How can I do that?

2. Cut down the alveolar edge about 2mm, place implant Ankylos A9.5 (3.5 x 9.5mm) without guided bone regeneration and also connective tissue graft. Â Is this a safe and predictable procedure? Â Many studies from Frankfurt University show that we can use the A size Ankylos implants for molar teeth sites with high predictable success. Is that right? The thin ginigva and not so much the lack of keratinized gingiva is my worry for long term predictability. Â What are your experiences?

3. Enlarge the ridge by using a ridge- splitting technique and placing a wider implant (for example 4 or 4.5 mm diameter implant). Is this technique simple and predictable? With this technique, can I use the Ankylos implant instead of a tapered implant system to achieve a higher primary stability.

Do you think any of these approaches has a significant chance of success? Â Do you have other recommendations?

![]P30-07-2010-10](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2012/08/P30-07-2010-10.jpg)

![]P30-07-2010-11](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2012/08/P30-07-2010-11.jpg)

![]centric46](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2012/08/th-centric46.jpg)

40 Comments on Alveolar ridge at that site is knife edged: Best solution for this case?

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Leal

08/31/2012

I would go with 2 X ~3,3mm implants (that mesiodistal gap is huge), screw retained and a bit of xenograft in the buccal plate just to make some "osseous enlargement" and to make it a long term successful case. This is an easy case but not with one implant...

Baker k. Vinci

09/10/2012

I agree , but would go a bit wider. Bv

08/31/2012

No xenografts! Build bone! This method will produce fibrous tissue encapsulation of the material. The reason for fibrous tissue encapsulation is the bodyâ€™s defense mechanism, due to the materialsâ€™ negative mechanical and chemical properties; the body is trying to defend itself from this foreign material. The fibrous tissue results in a problem, as mentioned in a book by Ole T. Jensen, The Sinus Bone Graft, chapter 17 ( of Xenografts for Sinus Augmentation P. Tarnow).

Leal

09/01/2012

A xenograft in exposed threads I'm against. A xenograft in extraction sockets I'm against. Pure xenograft in sinus augm a bit against. But a xenograft for enlargment absolutely no problem. Come on.

Joseph Kim, DDS

09/04/2012

I routinely use xenograft for vertical and horizontal augmentation, as well as, in sinuses. I have dozens of documented gains of over 8 mm in width and 6 mm in height under dense PTFE membranes. It is technique sensitive, and I am moving away from it purely due to the longer healing time in these large grafts. I still prefer bovine xenograft for outer layer in a sandwich type graft over allograft, still under a teflon barrier membrane.

08/31/2012

Orthopedic surgeons do not use xenografts.

Tri Dung Nguyen La

08/31/2012

Dear my colleagues, Patient just wants to have 01 implant. It means I won't close the mesiodistal gap, just 01 implant at position tooth 30. The occlusion is acceptable with this treatment. If no xenograft, what material can I use to make bone? Thank you for your comments. Best regards, Tri Dung.

Leal

09/01/2012

If you're only going with 1 implant then use minimmum 4.5mm implant whatever you do to place it. I just think it's ridiculous to go with a ridge split in THAT mandibulae because of 1 implant. The price the patient will pay for that procedure is not worthy for the single implant he/she is going to get. Either place 2 small diam. implants or graft first and go back later with a 5mm implant between good bone. This is surely not a case for a single 3,5mm implant. By the way that is not what I call a knife edged ridge.

marc

08/31/2012

I would do a ridge split technic with piezo and bone spreaders and immediately place your A c/x 11mm. This way the patient will make it's own bone.

Bill Schaeffer

09/01/2012

To the original poster of this case - you have already outlined most of the ways of approaching this case. Any one of them would work just fine. What would I do if I was wanting to place an Ankylos implant here? I would place a 3.5 x 8mm Ankylos and relax. Lots of bone either side of the implant. Lots of bone above the nerve. There will be lots of people who will disagree with this approach and that's just fine. Any of the other approaches will work just fine too. As the largest user of Ankylos implants in the UK, I know that my approach will also work just fine. Kind Regards, Bill Schaeffer

Richard Hughes, DDS, FAAI

09/01/2012

Expanding the redge should work just fine.

Dr. Alex Zavyalov

09/01/2012

Lealâ€™s advice about two implants is a prosthetically driven approach and is beneficial for the patient. Otherwise, the patient will waste the money and get complications with a worse clinical prognosis.

Tri Dung Nguyen La

09/01/2012

Thank you for your all comments. I appreciate all of them. Tri Dung.

ttmillerjr

09/03/2012

Okay, so it sounds like you and the patient have agreed that all the work will be done at your office. It also sounds like these procedures may not be done regularly in your office. That being the case I strongly recommend that one procedure is done at a time. There is a learning curve with each procedure. If the patient is in a rush, refer and observe the surgeries, if not explain that you want to proceed the most predictable way, not the fastest. One miracle at a time. I say graft the ridge first. My favorite approach in a situation like this is tent grafting. Google tent pole grafting. I recommend re-opening the flap then evaluate the result and place the implant(s). While the implant is integrating you can do the FGG. Later on you can combine steps.

CRS

09/04/2012

On the Cone beam it looks like good bone, just onlay graft the bone defect with a membrane and allograft. I like to use expanders and graft within the expanded socket and onlay allograft with prgf. You need to lay a flap and get primary closure wait 14wks and place a 4.1 self tapping implant. You could also place the implant and onlay the defect primarliy close with a flat healing screw the bone will grow over it. Allow enough time to heal! The trick to these is primary closure and allow enough time for osteointegration and add bone or membrane. The Biotype classification is for the esthetic area not post mandible.

Dr Anshuman

09/04/2012

dear could be 2 ways- 1.crestal split,vertical releasing incision on bone mesial and distal,ridge expansion and place 4/4.5 mm implant.on the exposed threads,mix b-TCP with PRGF and place. 2.Rapid Prototyping Bone block for the deficiency,screw and leave.implant placement in next stage.

John Manuel, DDS

09/04/2012

Go with a two-stage ridge split wherein a window in the cortical plate is cut at appt. #1, and that window popped out like a rumble seat 3 weeks later. Best to place two small, short implants, e.g. Bicon 4.5 x 6.0 or 4.0 x 5.0. Watch "Webcast Replays" on Bicon.com Done correctly, you will get a broad, square ridge with a broad band of new keratinized tissue atop it. John

Don Rothenberg

09/04/2012

I agree with John Manuel...I saw this technique done last spring by Dr.Shadi Daher at Bicon..we have since used it with nice results. I also agree with placing 2 implants...the space, mesio-distally is too large for 1 implant. If the patient only wants 1 implant; then I would make that VERY AWARE that there will be a space distal to the implant and that they accepted this treatment....and sign off on it!!!

Baker k. Vinci

09/04/2012

That is correct, because there are two teeth missing. Some people are ok with the food trapping diastema. Listen to the advice above and either place a single implant or two, to replace both missing teeth. Nothing bugs a decent surgeon more, than seeing the " globbed" tooth, leaving the inferior most embrasures way too big. Bv

Baker k. Vinci

09/04/2012

I have never seen a knife with a 4+ mm ridge. Why would you ridge split this? Because it sounds good! For goodness sakes, place a 4.1 or 4.3 mm implant. Can we try to do away with the embellished anatomical adjectives. B Vinci

Leal

09/05/2012

Thank you one more time Vinci

Dr. Gerald Rudick

09/04/2012

From the photos,and the scan image, it appears that splitting the ridge with a Piezo blade to a depth of 8-10 mm, followed by using 2 tapered implants with a diameter anywhere between 3.75 - 4.2, the buccal and lingual plates will be gently moved apart and will hold the implants securely.Particulate grafting material mixed with PRP and covered with the platelet rich fibrin harvested from the procedure will fill the void......do not uncover or load for six months.... it should work well, as the implants are supported by autogenous cortical walls. The Touareg style implants from Adin have nice aggressive threads that would help the implants get well integrated. Gerald Rudick dds Montreal, Canada

S.Lin

09/05/2012

Ridge split as decribed above and by Bicon website is not without merit in this case. If you are going to place an implant of 4+mm,ridge split and expansion is the preffered choice. Sure, you can go ahead and place a 4.3 or 4.1 mm implant, but you are running a great risk of thining out the bacal plate to less than 1 mm, and thus icrease the risk of bucal bone dehiscence. A .75mm piezo ultrasonic saw will leave a buccal plate of more than 1.5mm for comfort. It's a well documented procedure.

S.Lin

09/05/2012

............but one must be proficient at it !

Baker k. Vinci

09/05/2012

And there needs to be an indication for "it"!!! Bv

Tri Dung Nguyen La

09/05/2012

Dear All my colleagues, Thank you very much for your comments. I'll study from "Webcast replay" about the technique Dr. John Manuel mentioned. With me, I prefer to split the ridge but patient doesn't want. She hopes I place implant and onlay graft at buccal wall with bioss and collagen membrane. I'll see patient maybe in next week. Best regards, Dr. Tri Dung.

Dr. Smith

09/05/2012

You will study a video before your surgery ? I sure hope you will refer this patient to someone who is proficient to perform the surgery rather than reviewing a video...this is just my humble opinion. It's only fair to the patient...you would not want any of your loved ones to undergo surgery from a clinician who is learning how to do it on a video. Please think of the patient's best interest before yours.

Richard Hughes, DDS, FAAI

09/05/2012

One could expand te ridge if they wanted to use wide body implants. However, narrow body implants will work, without any need for augentation.

Richard Hughes, DDS, FAAI

09/05/2012

That is augmentation

K. F. Chow BDS., FDSRCS

09/06/2012

Place in minimized diameter implants and obviate bonegrafts and bone splitting. You have a bounded saddle. We have done free end saddles with minimized. Do not flatten the ridge if you can help it. Conserve sound oral tissues as far as possible. Add to it only when necessary. http://smalldentalimplants.blogspot.com/2012/09/a-knife-edged-ridge-case.html

Tri Dung Nguyen La

09/06/2012

Thank you Dr.Smith to remind me about patient.However, in my country, it's difficult to refer patient to other doctors. I'll try my best for best result. Thank you Dr. Chow and Dr. Richard about small diameter implant suggestion. My patient also hope the simple protocol with less surgery, less pain and cost. I just worry about the long term success of small diameter implant for molar. I use Ankylos implant system. It is maybe the best choice for small diameter implant, isn't it? Best regards, Dr. Tri Dung.

Dr Abhishek N Z, MDS Peri

09/07/2012

Dear Doctor, I suggest a wider implant (either 4 or 4.5mm) since it is the maximal load bearing area and is difficult to get away with a 3.5mm The options could be 1. Ridge split followed by bone grafting around the implant. 2. Osteotomy with implant placement, followed by bonegrafting and a collagen membrane to cover the exposed implant. Im not sure, but some degree of crestotomy at the site could also help

MICHAEL VO

09/07/2012

I had a similar case 6 months ago. I did 2 implant placement with simultaneous Puros and SonicWeld. The result was amazing. However, if you are not familiar with GBR,I would recommend to : 1 - Refer this case out for bone grafting with allograft or block graft. Then place your implant(s). My preferred option for you. Why take all the problems on your shoulder when there are excellent dentists/specialists out there. 2 - Or keep it simple, and place you 3.5mm Ankylos implant. Good luck.

PhD. BOJI SAAD

09/07/2012

put 4,5 implant and put the bone particles(autograft) that you can select by special filters inside special surgical sucker, over the exposed threads of the implant buccaly and close. wait for about 2,5 months then open for crown positioning ,that's it .

Tri Dung Nguyen La

09/07/2012

Thank you for your comments. I heard that GBR with collagen membrane in mandibular area is not predictable. How many cases you've done, Dr. Micheal Vo? All are OK? How to control the flap to get primary closure, especially with Asia patient, thin biotype and usually, not so much keratinized tissue? Thank you very much. Dr. Tri Dung.

MICHAEL VO

09/07/2012

To answer your question regarding GBR with collagen, lots. The lower posterior mandible is the area where I can release the flap the most with the least amount of swelling. You can release a lot from the buccal flap and even more ifq you know how to release the lingual flap. Thin biotype will allow you to release the flap more than a thick biotype. However, in my hands, GBR with allograft and collagen membrane is the most technique sensitive among all bone grafts. Therefore, I would not recommend this technique at this stage. There is a learning curve that can bring a lot of complications whenever you fail. If you really want to do this case, go the simple way. But don't forget, this patient will be yours for a very long time... And don't worry, 3.5mm Ankylos won't fail because it's small, only if there is insufficient bone or occlusal overload.

K. F. Chow BDS., FDSRCS

09/07/2012

Dear Dr Tri Dung. You wrote,"My patient also hope the simple protocol with less surgery, less pain and cost." I am glad that you mentioned the most important criteria in treatment planning... which is the patient's hope and expectations. The other two criteria are the patient's oral and general medical condition, followed by the dentist's expertise and materials available. With these in mind, and if the patient wants to replace just one tooth, then use one 3.5mm diameter and 9 mm long Ankylos and do it flapless. It will mean less surgery and less pain. I assure you that it will carry a single tooth very well. The alternative is minimized dental implants which mean using one piece dental implants of diameters 2.5mm or less. See my earlier link. The patient's hope of less surgery, less pain and cost can then be met even more. I will most likely be speaking in Vietnam in November this year on "Treatment of Simple and Complex Cases in Implant Dentistry: Striking a Happy Balance". Hope to see you then. If not, come to Malaysia in January 2013. http://www.mda.org.my/90-20130112-01.html Cheers.

Tri Dung Nguyen La

09/08/2012

Thank you very much for your comments, Dr. Micheal and Dr. Chow. I'm very happy to study with all of you. Hope to see Dr. Chow in VN. Let me know exactly your schedule in VN. Best regards, Dr. Tri Dung.

Alberto Miselli

09/11/2012

Dear Coleague: I saw the picture and I think that is more than 10 mm M-D 8 maybe two bicuspid is necessary. And why donÂ´t try with two 4mm did x 8mm Bicon, 2 mm under the ridge and we donÂ´t need any augmentation?.

Sok Chea

09/27/2012

If you want to be a hero, let do the graft, ridge split.......... If you want to make it simple, just put two narrow implants

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