Ridge

Augmentation

k. Shiva Teja
CONTENTS
• INTRODUCTION
• HISTORY
• ETIOLOGY
• CLASSIFICATION OF RIDGE DEFECTS
• RATIONALE FOR RIDGE AUGMENTATION
• GRAFTING MATERIALS
• AUGMENTATION TECHNIQUES
• VERTICAL & HORIZONTAL RIDGE AUGMENTATION
• CONCLUSION
• REFERENCES
 INTRODUCTI
ON
• It has now become common practice to restore maxillary and mandibular
edentulous areas with implants.
• To obtain ideal osseointegration and a favourable restoration, the maintenance of
at least 1 mm of alveolar bone width in the buccal and palatal plane is required.
• Due to trauma, atrophy, or surgeries, there is often a lack of supporting alveolar
bone, and in such cases bone augmentation represents an effective treatment
option.
• In today’s practice, patients with normal skeletal pattern who have lost a
substantial degree of their original osseous dimensions due to tooth loss or
trauma are much more prevalent.
• Alveolar ridge defects are common and poise a significant problem in dental
treatment and rehabilitation.
• A thorough knowledge of ridge augmentation is required for successful
interdisciplinary approaches.
 HISTORY OF RIDGE
AUGMENTATION
• The use of bone grafts in can be traced to the work of Hegedus.
• He reported success in six cases by transplanting autogenous bone from the tibia.
• The evaluation of xenografts of various types became the main focus of attention.
• Beube and Silvers used boiled cow bone powder to successfully repair intrabony
defects in humans.
• Studies in dogs suggested that surgically created periodontal defects had an
accelerated rate of healing after placement of boiled cow bone powder, with
bone and cementum being deposited more rapidly in grafted defects.
 ETIOLOGY FOR RIDGE
DEFECTS
The loss of teeth and alveolar structures can result from many causes:
 Improper tooth extractions
 Advanced periodontal disease
 Abscess formations
 Tumor
 Trauma
 Congenital disease
 Implant failures and
 Long standing periapical infections.
• The anatomic factors include such things as the size and shape of the
ridge, the type of bone, and the type of mucoperiosteum.
• The metabolic factors include such things as age, sex, hormonal balance, osteo-
porosis etc.
• The functional factors include the frequency, direction, and amount of force
applied to the ridge.
• The prosthetic factors include the type of denture base, the form and type of
teeth, the interocclusal distance.
• For further convenience, since the functional factors must function through the
prosthetic factors, they may be grouped together as - anatomic, biologic and
mechanical.
Reduction of residual ridges: A major oral disease entity- Atwood D.A
• Seibert (1983) presented a classification of ridge defects to assess deficiencies in
form, function and esthetics.
• The classification takes into account both hard and soft tissues.
• Seibert Class I defects describe ridges deficient in the horizontal dimension.
• Seibert Class II defects describe ridges deficient in the vertical dimension.
• Seibert Class III defects include ridges deficient in both the horizontal and vertical
dimensions.
• The Seibert classification does not provide any quantification of the magnitude of
ridge deficiencies.

The Deficient Alveolar Ridge: Classification and Augmentation Considerations for Implant Placement.
Lieutenant Michael Yang, DC, USN, Vol. 39, No. 1
Lekholm and Zarb (1985) presented a classification scheme to describe hard
tissue deficiencies. The classification system describes five groups of jaw
shapes to include:
A. Intact ridge
B. Moderate ridge resorption
C. Advanced ridge resorption extending to the basal bone
D. Initial resorption of the basal bone
E. Extreme resorption of the basal bone
Misch and Judy (1985) presented a similar classification of ridge resorption
with suggested augmentation and prosthodontic treatment modalites for each
category.

This classification takes into account only hard tissue defects and was stratified
based on divisions that describe the natural bone resorption pattern.

A. Abundant bone
B. Marginally sufficient bone
C. Compromised bone
D. Deficient bone
• Allen et al. (1985) provided a modification to the original Seibert classification by
additionally describing the magnitude of the ridge defect.
• Allen Type A classification represents vertical ridge deficiency.
• Allen Type B classification represents horizontal ridge deficiency.
• Allen Type C classification describes a combined horizontal and vertical ridge
deficiency.
• The severity of the ridge defect is further classified as
• Mild (<3mm)
• Moderate (3-6mm) and
• Severe (>6mm) as compared to the contours of the adjacent ridge.
In 1988 Cawood and Howell published a classification of the general dimensional changes after
tooth loss Here, maxilla and mandible show different absorption patterns.
• Hammerle and Jung have classified crest defects in fresh extraction sockets:
• Class I extraction socket that has intact bone walls after tooth extraction
• Class II extraction socket that has a marginal dehiscence fenestration of the
buccal bone wall after tooth extraction
• Class III extraction socket that has a large dehiscence of the buccal bone wall after
tooth extraction.
• Wang and Al-Shammari (2002) developed the HVC ridge deficiency classification
to address some of the shortcomings of the Seibert (1985) classification.
• The classification utilizes three general categories to describe horizontal (H),
vertical (V), and combination (C) alveolar ridge defects.
• These three categories can be further divided into the subcategories of
• Small (s, <3mm)
• Medium (m, 4-6mm) and
• Large (l, >7mm).
• Based on the specific category, subcategory and desired rehabilitation modality
(fixed pros-thesis or implant), different soft and hard tissue treatment options are
presented.
 COLOGNE CLASSIFICATION OF
ALVEOLAR RIDGE DEFECT (CCARD)
• The Cologne Classification of Alveolar Ridge Defects uses three part codes to
describe the effect of the alveolar ridge as comprehensively as possible with a
view to existing therapeutic options:

Cologne Classification of Alveolar Ridge Defects (CCARD),8th European Consensus Conference of BDIZ EDI, February 2013.
Tolstunov. L J of Oral Implantol, 2015
R
PRESERVATION reduces bone loss after tooth extraction to preserve the
I dental alveolus in the alveolar bone.

D AUGMENTATION Predictable procedure to recreate and regenerate

hard and soft tissues lost due to extraction or any other reason.

G CORRECTION Any procedure designed to establish the best hard and

soft tissue contour over the alveolar bone.

E
RATIONALE OF RIDGE
AUGMENTATION
• It can be concluded that ridge/socket augmentation is an efficient procedure for
augmenting atrophic/deficient bone.
• Statistically significant alveolar volume gains in preserved/ augmented versus
nonpreserved sites have been reported, i.e., +1.89 mm in terms of buccolingual
width, +2.07 mm for midbuccal height, +1.18 mm for midlingual height, +0.48
mm for mesial height, and +0.24 mm for distal height.
• Even greater alveolar bone volume gain has been reported with use of Ti-mesh as
barrier in combination with autogenous/ allogenic/xenogenic bone grafts, i.e.,
≈4.91 mm of vertical regeneration and ≈4.36 mm of horizontal regeneration.
• On the other hand, it is quite interesting as well as contrasting to note that similar
rates of implant success and survival have been reported for implant placement
in augmented versus naive bone.
• This seriously questions the rationale of ridge augmentation.
EVIDENCE ON RIDGE/SOCKET PRESERVATION
Decision pathway for ridge augmentation- Ridge augmentation in the maxilla
 Decision pathway for ridge augmentation- Ridge augmentation in the mandible

Goyal et al., Ridge augmentation in implant dentistry. J Int Clin Dent Res Organ 2015;7:94-112.
MATERIALS THAT CAN BE USED
 INTRAORAL BONE GRAFTS

Site Indication
Chin 0.5 X 1.5 X 6 cm corticocancellous bone block
Mandibular ramus 0.4 X 3 X 5 cm mostly cortical bone block, J graft (thin)
Maxillary tuberosity 1 -3 mL cancellous marrow
Bone blocks can be processed in a bone mill to obtain particulate grafts

Stern and Barzani 2015. Autogenous Bone Harvest for Implant Reconstruction. Dent Clin N Am
 EXTRAORAL BONE GRAFTS
Site Indication
Tibia 5 – 40 mL uncompressed cancellous marrow
Anterior ilium 30 – 50 mL of corticocancellous marrow
1- 5 cm corticocancellous bone block
Posterior ilium 40 – 120 mL uncompressed cancellous marrow
4 – 12 cm corticocancellous bone block
Cranial bone Corticocancellous bone block (onlay graft) for midface,orbital,
zygomatic and nasal reconstructions

Bone blocks can be processed in a bone mill to obtain particulate grafts. Tibia grafts can be performed
in an outpatient setting

Marx & Stevens 2010. Atlas of Oral and Extraoral Bone Harvesting. Quintessence Pub
 COMPARISON OF DIFFERENT
GRAFTING MATERIALS

Jambhekar et al 2015. Clinical and histologic outcomes of socket grafting after flapless tooth extraction: A
systematic review of randomized controlled clinical trials. J Prosth Dent.
 Sequential Bhatavadekar. B J of Oral
ridge augmentation Implantol· Jan 2018
protocol.
 ALVEOLAR RIDGE AUGMENTATION
TECHNIQUES
GUIDED BONE REGENERATION (GBR)
• GBR is a surgical procedure that uses barrier membranes with or without
particulate bone grafts or/and bone substitutes for ridge augmentation.
Regeneration at the deficient site depends on the exclusion of soft tissue
(epithelial cells and fibroblasts) from osteogenic tissue (osteoblasts) during
organization of the bone.
• Osteoblasts are mainly responsible for increasing the amount of regenerated
alveolar ridge. However, osteoblasts do not regenerate the alveolar ridge as
quickly as epithelial and connective tissue cells grow. The success of the GBR
approach mainly depends on the exclusion of soft tissue cells during bone
remodeling by slowly working osteoblasts.
CONCLUSIONS:

The maxillary sinus augmentation procedure has been well documented, and the long-term clinical
success/survival (> 5 years) of implants placed, regardless of graft material(s) used, compares
favorably to implants placed conventionally, with no grafting procedure, as reported in other
systematic reviews. Alveolar ridge augmentation techniques do not have detailed documentation or
long-term follow-up studies, with the exception of GBR.
• The GBR technique can be applied in two stages (delayed approach) or in one
stage (simultaneous approach with implant placement). If the bone deficiency is
low and implant stability can be achieved, the one-stage approach can be
applied.
• However, if a greater amount of bone must be regenerated, then the two-stage
approach is preferable and the complication risk will be reduced.
• The predictability of GBR is based on several principles, such as space
maintenance, stability, nutrition, and primary closure
 Grafting biomaterials
• Currently, the use of a bone substitute material in GBR applications is the
standard of care. The primary types of bone substitutes are autogenous bone,
xenografts, allografts, and alloplasts.
• An ideal biomaterial for bone regeneration should have the ability to form new
bone, and bone formation must be balanced with the speed of resorption.
Autogenous bone is the gold standard for augmentation because of its osteogenic
potential. It has the ability to regenerate bone through the mechanisms of
osteogenesis, osteoinduction, and osteoconduction.
• Xenografts are bone grafts obtained from animals such as cows, horses, or
species other than human. Deproteinized bovine bone (DBB) is a xenograft
material that is frequently used in GBR applications.
• DBB is osteoconductive and has an interconnecting pore system that serves as a
scaffold for the migration of osteogenic cells; the inorganic bone substance has a
microscopic structure similar to that of natural cancellous bone.
• DBB particles are incorporated over time within the living bone, and DBB resorbs
very slowly and has low substitution rates. Therefore, it can provide space
maintenance over a very long term.
Conclusion: Both sizes of BBM granules preformed equally and achieved the aim of the sinus floor
augmentation procedure clinically and histologically.
• Allografts are bone grafts obtained from the same species but are genetically
dissimilar from the recipient. Allograft donors are meticulously screened, and
specimens are carefully processed to reduce the possibility of disease
transmission.
• Freeze drying is a commonly used process. Mineralized allografts (MAs) provide
stability and space by maintaining their physical properties during the bone
remodeling phase. Osteoconductive scaffolds provide volume enhancement and
effective site management for successful dental implant placement after
augmentation.
• MAs can be composed of cortical and cancellous particles. Mineralized cortical
particles with slow resorption rates offer a scaffold, whereas cancellous particles
that have faster resorption rates and are prone to resorption may provide a space
for the ingrowth of bone cells and angiogenesis.
• Therefore, if the amount of cortical graft particles is increased in the composite,
less resorption can be expected.
Conclusion:
Both putty and powder forms of de-mineralised Bone Matrix showed satisfactory
results and there was no significant difference in marginal bone loss around
dental implants and survival rates.
• Various synthetic graft materials have been developed for crestal ridge
augmentations, such as synthetic hydroxyapatite (HA), beta-tricalcium phosphate
(β-TCP), and calcium sulfate (CS) .
• HA has a low or very limited resorption rate. β-TCP and CS are highly
biodegradable and have less compressive strength than synthetic HA and DBB. CS
can be completely resorbed within 1 month.
• Therefore, according to the defect properties, these materials can be mixed with
slow resorbable materials in different ratios to maintain space during healing.
• Freeze-dried bone allografts and demineralized freeze- dried bone allografts have
been widely used in periodontal therapy in the past and continue to be used in
contemporary clinical practice. They have been demonstrated to be safe and
capable of supporting new bone formation and, in the case of DFDBA, have
been shown to induce new bone formation and periodontal regeneration.
 Space maintenance

• Maintenance of space at the augmented site is one of the fundamental principles

of the GBR technique. A protected space is needed for hard-tissue cells to
regenerate bone that excludes soft-tissue cells during healing and maturation.
• Bone substitutes, membranes, tenting screws, titanium, and bone plates are
suggested for the maintenance of space.
• Jovanovic et al. evaluated the treatment groups in a pre-clinical study on GBR.
They found that significant bone gain could be achieved when membrane and
graft material were used than when no membrane was used .
• Space maintenance can be challenging depending on the properties of the defect
site. When significant bone augmentation is required in a severely resorbed
alveolar ridge, creating space is more critical for the success of GBR.
• Barrier membranes- Barrier membranes are routinely used to maintain space.
There are two kinds of barrier membranes: resorbable and non-resorbable.
• Resorbable membranes
• The most important advantages of resorbable membranes are the elimination of
membrane removal after healing, resulting in decreased morbidity, easy
manipulation, and lower rate of complications.
• However, resorbable membranes are not very successful in comparison with non-
resorbable membranes with regard to space maintenance. These membranes
must be used with bone graft substitutes and additional tools, such as tenting
screws or plates for space maintenance.
• These membranes may lose their barrier function early due to rapid
biodegradation. The resorption time depends on the membrane’s properties, the
cellular activity of the native bone, and exposure.
• One of the most important benefits of non-crosslinked collagen membranes is
the spontaneous closure of membrane exposure during the healing period.
• Epithelization of the exposed membrane occurs within weeks after mucosal
dehiscence. Although spontaneous healing of the exposure occurs, the grafting
volume may be negatively affected during healing, and some bone loss may be
expected.
 Non-resorbable membranes
• When a higher amount of bone augmentation is required, reinforced non-
resorbable membranes are used.
• Reinforced membranes withstand the pressure from the surrounding tissues,
resulting in the prevention of membrane collapse and allowing the bone to be
regenerated during healing.
• Titanium mesh, titanium-reinforced expanded polytetrafluoroethylene (e-PTFE),
and dense polytetrafluoroethylene (d-PTFE) membranes are most commonly
used, and their benefits have been demonstrated in published studies.
Conclusions:
(1) Vertical augmentation with e-PTFE membranes and particulated autografts is a safe and
predictable treatment.
(2) success and survival rates of implants placed in vertically augmented bone with the
GBR technique appear similar to implants placed in native bone under loading conditions.
(3) Success and failure rates of implants placed into bone regenerated simultaneously with sinus
and vertical augmentation techniques compare favorably to those requiring only vertical
augmentation.
• Currently, e-PTFE membranes are not used in surgery due to high rates of
complications related to membrane exposure. d-PTFE membranes are novel
titanium-reinforced nonresorbable membranes that have replaced e-PTFE
membranes.
• Novel d-PTFE membranes are manufactured in a dense micro-porous form that
prevents oral bacteria from entering the grafted site when exposed. These
membranes are also easy to mechanically and chemically clean.
Conclusions:
Based on the data from this study, both d-PTFE and e-PTFE membranes showed identical clinical
results in the treatment of vertical bone defects around implants, using the GBR technique. The
membrane removal procedure was easier to perform in the d-PTFE group than in the e-PTFE
group
• Titanium mesh is another alternative to non-resorbable membranes, and this
type of mesh has a good space maintenance advantage. It can be easily trimmed
and bent according to the defect site.
• Another advantage, and also a disadvantage, of mesh over a PTFE membrane is
that the holes within the membrane allow vascularization and nutrition from the
periosteum to the grafting site.
• However, bone can also grow from inside these holes over the mesh. After
healing, the mesh can integrate with newly formed bone and complicate removal
during surgery at the second stage.
Bone tacks Bone screws Tenting screws
VERTICAL RIDGE AUGMENTATION HORIZONTAL AUGMENTATION
Conventional techniques (3 main groups)
• Onlay bone block grafting • GBR
• Guided bone regeneration • Sandwich technique
• Distraction osteogenesis • Split Ridge technique
Other techniques • Distraction Osteogenesis
• Khoury's protocol • Sonic Weld
• Tenting screws
• Orthodontic bone regeneration
• Fence technique
• I Gen
• 3D printed bone
• Box technique
• Interpositional grafting
Complex surgical procedures
• Le Fort 1 osteotomy
• Nerve transposition (technically not an augmentation)
 Chin grafts
1. Chin grafts
2. Ramus grafts
3. Tuberosity Grafts

Chin grafts Incision

1. Sulcular
2. Vestibular , 10mm below the MGJ
3. Submarginal on attached gingiva
DISTRACTION OSTEOGENESIS

KHOURY TECHNIQUE
MICRO-SAW®

Khoury and Hanser. Mandibular Bone Block

Harvesting from the Retromolar Region: A
10-Year Prospective Clinical Study. Int J Oral
Maxillofac Implants 2015.
 ORTHODONTIC BONE REGENERATION

Molon et al 2013. Forced orthodontic eruption for augmentation of soft and hard tissue prior to implant placement
FENCE TECHNIQUE
I GEN- TITANIUM MEMBRANE FROM MEGAGEN BOX TECHNIQUE
INTERPOSITIONAL GRAFTING WITH XENOGRAFT BLOCK
 3D PRINTED BONE

3D Printed membrane

3D PRINTED MEMBRANE
SPLIT RIDGE TECHNIQUE
• Edentulous Ridge expansion (ERE) technique for implant placement.
• 98.5% success rate.
PIEZOELECTRIC RIDGE EXPANSION
• New technique that permits simultaneous expansion and placement of dental
implants in edentulous ridges 2-3 mm thick
• Successfully used in type 1 and 2 bone.
 SONICWELD
SonicWeld system
• Pins made of poly D-lactide (50%) and L-lactide (50%) acid are inserted with the
aid of ultrasound following conventional drilling and melted to weld with the
bone in order to fix plate or mesh (1mm thick).
• Horizontal bone augmentation traditionally used mini titanium alloy screws.
• Resorbable ultrasound activated pins and resorb able foil panels are an
alternative.
 Technique
• 1.6mm diameter adjustable drill to prepare sites for pins.
• Pins placed at least 2-3mm into bone .
• Resorb-X foil panels 0.1mm heated insterile bath 60-70 Celsius for 30seconds
before adapting to the bone.
• Foils cut to desire shape.
• Fixation of pins and grafting material added. Final shape with heated Q-tip.
 AUGMENTATION
R
I
D
G
E
CONCLUSION
 REFERENCE
S
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