Ridge Augmentation

A Seminar
By
Girish Nagarale

 Introduction
Problems created by the smooth ridge contours
Rate of residual ridges resorption
Need for ridge augmentation
Causes of uneventful ridge resorption

Seibert classification of Ridge defects

 Orders of residual ridge forms

Examination of residual ridges
Evaluation of bone shape & quality
Prevention of soft tissue collapse following extrac.
Various factors to be determined prior to therapy

Flap Management for Ridge Augmentation

Hard tissue augmentation procedure

1. Guided Bone Regeneration
2. Barrier Membranes

3. Bone Graft Materials

4. Autogenous Bone Harvesting

5. Role of Growth Factors in Bone Augmentation

6. Platelet-Rich Plasma

Localized Ridge Augmentation

1. Horizontal Bone Augmentation:
a. Particulate Bone Graft
b. Monocortical Block Graft
c. Orthodontic Ridge Augmentation

d. Simultaneous Implant Placement & GBR.

2. Supracrestal / Vertical Bone Augmentation:
a. Distraction Osteogenesis

 Management of Extractions

1. Immediate Implant Placement

2. Delayed Implant Placement
3. Staged Implant Placement

Complications of Localized Ridge Augmentation

 Soft Tissue Augmentation Procedures

Pedicle graft procedure:

1. Roll flap procedure
Free graft procedures:
1. Pouch graft procedure
2. Interpositional graft procedure
3. Onlay graft procedure

Introduction:
Residual ridge

Residual ridge is not normal in many respects

Deformity in the ridge is directly related to
Ridge augmentation procedures

Problems created by the smooth

Ridge contours
1. FPD gives the impression that they rest on top...
2. Lack a root eminence.
3. Lack marginal gingiva and interdental papillae.

4. Dark triangles interfere with dento-facial esthetics...

Rate of residual ridges resorption:

RRR occurs at varying rates in diff. individuals
RRR is not a disease
Some pt. have little or no RRR over a period of time

Need for ridge augmentation

1. Normal function of bone to undergo constant
remodeling throughout life osteoporosis and PD...

2. Periodontal bone loss, tooth extraction, and long

term use of RPD result in advanced bone loss

3. RRR is a localized loss of bone that is not built back

by simply removing the causative factors

4. To place implant & FPD in a prosthetically driven

position to restore natural position & function
Causes of uneventful ridge resorption

Seibert classification of Ridge defects

Class I: Loss of buccolingual width but normal
apicocoronal height.

Class II: Loss of apicocoronal height but normal

buccolingual width
Class III: A combination of loss of both height and
width of the ridge.

Class I

Class II

Class III

Orders of residual ridge forms

Pre-extraction

IV

Knife-edge

II

Post-extraction

Low well rounded

III

High well rounded

VI

Depressed

Examination of Residual Ridges

1. Clinical examination.
Soft tissues overlying RR may range from
2. Radio graphical examination.

Evaluation of bone shape

A. Most of the alveolar ridge is present.
B. Moderate RRR has occurred.
C. Advanced RRR has occurred, only basal bone
remains.
D. Some resorption of the basal bone has started.
E. Extreme resorption of the basal bone.

Evaluation of bone quality

D1. Almost the entire jawbone is comprised of homogenous
compact bone.
D2. A thick layer of cortical bone surrounding dense
trabecular bone.
D3. A thin layer of cortical bone surrounding the core of dense
trabecular bone.
D4. A thin layer of cortical bone surrounding the core of low
density trabecular bone.

Prevention of soft tissue collapse following

extraction
Changes following extraction of a tooth
Soft tissue collapse can be prevented by immediate
placement of an ovate pontic
Insertion of ovate pontics may facilitate

Placement of an ovate pontic

Procedures for prevention of ridge collapse

1. Flap elevation for complete soft tissue closure of the
extraction sites. Borghetti & Glise 2000

2. Placement of connective tissue grafts over the

extraction sites. Nevins & Mellonig 1998
3. Placement of bone grafts. Becker et al. 1994
4. Utilization of barrier membranes.Lekovic 1997

Factors to be determined prior to therapy

1. Volume of tissue required to eliminate deformity.
2. Type of graft procedure to be used.
3. Timing of various treatment procedures.
4. Design of the provisional restoration

5. Potential problems with tissue discolorations.

Flap Management for Ridge Augmentation

Soft tissue management is a critical aspect
Design & management of flaps must consider the
increased dimensions of the ridge
Preserve the maximum vascularity to the flap
Prosthesis should not be inserted for 2 to 3 weeks
after surgery to avoid pressure over the wound

General concepts for flap management

1. It is desirable to make remote incisions relative to
the placement of membranes & ant. region
2. Full thickness flap elevation at least 5 mm beyond
the edge of the bone defect.

3. Limit the use of vertical incisions

4. Use periosteal releasing incision
5. Avoid postoperative trauma to the surgical site
6. Combination of sutures

Hard tissue augmentation procedure

1. Guided Bone Regeneration
2. Barrier Membranes

3. Bone Graft Materials

4. Autogenous Bone Harvesting

5. Role of Growth Factors In Bone Augmentation

6. Platelet-Rich Plasma

Guided Bone Regeneration

Healing without the intervention of regenerative
procedures
GTR concept is based on the principle

Guided bone regeneration

Objective of GBR is to regenerate a single tissue

 Murray and Roschlau demonstrated that when a

cavity with a source of osteoblasts and a blood
supply was isolated from adjacent soft tissues
They suggested not to use bone graft

Bone is a unique tissue that has the capacity to

completely regenerate itself

Requirements for Bone Regeneration

Biologic Requirements

Surgical Procedure

Blood supply

Stabilization
Osteoblasts
Confined space
Space maintenance
Wound coverage

Cortical perforations
Fixation screws
Membrane tacks
Autogenous bone graft
Barrier membrane
Tenting screws
Bone graft materials
Flap management
Tension-free suturing

Barrier Membranes (BM)

BM are bio-inert materials that serve to protect the blood
clot & prevent soft tissue cells
BM have been manufactured from
BM used in ridge augmentation procedures are made of
e-PTFE: (Gore-Tex, W.L. Gore Ass., Flagstaff & AZ)
Titanium reinforced variety of the e-PTFE membrane is
used to obtain optimal stability of the wound.

 Adjustment of titanium reinforced e-PTFE memb

Mini-screws: made of stainless steel or titanium are
often used to support the membrane

As an alternative a block of autogenous bone can be

placed to stabilize the membrane.
Ideal properties of a barrier membrane:
Biocompatibility, space maintenance, cell-occlusive
ness, good handling properties, and resorbability.

Nonresorbable Barrier Membranes

Various materials used as BM are latex & teflon

Variety of shapes and sizes have been designed

Advantages:

Disadvantage:

Space maintanance below the membrane:

Resorbable Barrier Membranes:

Copolymers of polylactide and polyglycolide
(PLA/PGA) or collagen have been used to construct
biodegradable membranes.

Advantages:
Disadvantage:

Bone Graft Materials

1. Bone formation within a given space by
2. Ingrowth of neovascularization.

3. Osteoconductive...
4. Size of graft particles ranges from 100 to 1000 m
5. Bone forms in cones called osteons with a central
blood supply.

Biologic Properties of Various Bone Grafts

Osteoconductive Osteoinductive Osteogenic
Alloplast

Yes

No

No

Xenograft

Yes

No

No

Allograft

Yes

Yes/ No

No

Autograft

Yes

Yes

Yes

 At a minimum bone graft materials should be

osteoconductive
DFDBA is thought to have osteoinductive effects
because it retains some of the original BMPs

Schwartz et al reported that variations in the amount

of bone formation induced by DFDBA might be
related to the source and processing of the bone

Autogenous Bone Harvesting

Autogenous bone is thought to be the best

Extraoral sources:
Iliac crest, tibia and calvaria.
Intraoral sources:
Edentulous spaces, maxillary tuberosity, mandibular
ramus, mandibular symphysis, and extraction sites.

 Bone from a recent extraction site have the

advantage of increased osteogenic activity
Maxillary tuberosity provides a more cellular source
of autogenous bone as compared with other sites

For greater amounts of bone it is desirable to harvest

bone from the mandibular ramus or symphysis

Surgical procedure in the region of symphysis

Incision, full thickness flap

To prepare a particulate bone graft

To prepare a block of bone
Hunt & Jovanovic 1999 stated the limits of bone
harvesting5mm

 Positioning of the bone graft in the recipient site:

When the recipient site is located close to a natural tooth

Closure of the recipient site:

1. Releasing incision
2. Suturing

a. Resorbable suture - horizontal mattress

b Non-resorbable interrupted

Postoperative care:

Risks of surgery in mandibular

symphysis region

Postoperative bleeding Damage to lower Inci

Bruising

Disfigurement

Wound dehiscence

Injury to nerves

 Nerve injury is perhaps the most significant concern

More serious risk is alteration of facial appearance..

witch's chin can occur when the facial muscles and

overlying skin of the chin fall.
Hunt and Jovanovic emphasized maintaining a 5mm margin of safety between

Following basic principles minimize the risk of

postoperative morbidity:
1. Comprehensive

clinical

and

radiographic

examination of the intraoral donor site

2. Use extreme care in making incisions laterally
3. Dissect the area with blunt instrument
4. Do not elevate and reflect muscle attachments
beyond inferior border of mandible.

5. Limit bone cuts to an area of at least 5 mm away

6. Do not extend cuts deeper than 6 mm, do not
include both labial and lingual cortical plates.
7. Suture the wound in layers...

8. Use techniques that prevent overheating and

maintain viability of the bone cells

Surgical procedure in region of ramus of mandible

Indication:
When the third molar is missing and when only a
limited amount of bone is required.
Surgical technique:

Amount of bone harvested is dependent on:

1. The bucco-lingual dimension of the ramus.
2. The position of the inferior alveolar nerve.

Role of Growth Factors In Bone Augmentation

Another adjunct to regenerative therapy is
osteogenic stimulating substrates to enhance bone
formation.
BMPs belonging to the transforming growth factor
(TGF-) super family.
Of this family (rhBMP-2) has shown significant
signs of bone enhancing potential.

 Recently studies showed rapid new bone formation

using rhBMP-2 in critical size defects.
The potential of combining barrier membranes and
rhBMP-2 for osteogenesis is evident.
Platelet-Rich Plasma: Growth Factor
Enhancement for Bone Grafts

Localized Ridge Augmentation

Depending on size and morphology of the defect,

various augmentation procedures can be used
Methods used to augment horizontal as well as
vertical bone deficiencies include
Principles of GBR and flap management must be
followed to achieve good results

Horizontal Bone Augmentation

Deficiency in the horizontal dimension of bone may
be minimal, such as a dehiscence or fenestration of
an implant surface
Buser investigated the lateral ridge augmentation
procedure using an autograft from the retro molar or
symphysis area covered by a membrane

Nevins and Doblin demonstrated that use of FDBA

with membranes increased the amount of new
bone, even in the presence of a membrane
exposure.
1. Particulate Bone Graft (or bone chips):
Advantages:

1. More rapid ingrowth of blood vessels

2. Larger osteoconduction surface.
3. More exposure of osteoinductive GF.

4. Easier biologic remodeling when compared

Disadvantages:

Lack rigid structure

Harvested in smaller or in larger block size

Indications:
1. Indicated in defects with multiple osseous walls or

single bone walls.

2. When implants are placed simultaneously with the

bone augmentation procedure.

2. Monocortical Block Graft:

Horizontal alveolar deficiencies can easily be
reconstructed with a monocortical block graft.
Cortical block of bone harvested from
Fixated to the recipient site with screws
Graft separated from overlying tissue by

Disadvantage:
Biologic limitation of revascularizing

Orthodontic Ridge Augmentation

Simultaneous Implant Placement & GBR

Large alveolar bone defects need to be augmented
prior to implant placement

Indications:
1. Implant dehiscence or fenestration defect
Fenestration and dehiscence defects can be managed
with barrier membranes or simply with flap closure.
Bone grafts have also been used.

Dehiscence

Fenestration

Supracrestal/Vertical Bone Augmentation

Supracrestal or vertical bone augmentation presents
the greatest challenge in terms of regenerating bone.
Studies showed that supracrestal bone formation up
to 3 mm is predictable using the GBR technique
with a membrane & blood clot combination.

 Simion and Jovanovic used a TR-membrane for

vertical bone regeneration.

No supportive bone substrates were used, except a

careful fill of space with blood clot by perforating
the bone surface.

Distraction Osteogenesis
Ilizarov introduced the process of generating new
bone by stretching

Indications:
Advantages:
Limitations:

Management of Extractions
Tooth extraction or tooth loss often results in ridge
resorption or collapse, preservation of bone volume
at the time of extraction is a desirable goal.
A majority of the bone loss after extraction occurs
within the first 6 to 24 months.
Conservative approach to the management of
extraction sites can eliminate or significantly reduce
the necessity of bone augmentation procedures.

 Studies have shown that use of a BM enhances the

predictability of bone fill in the extraction site
Recent studies concluded that complete wound
closure over the BM might be associated with
greater bone fill.
Placement of implants after tooth extraction can be
immediate, delayed, or staged., depending on

1. Immediate Implant Placement:

Advantages:

1. Reduction of the healing time

2. Bone-to-implant healing begins immediately
3. Normal bone healing which generally occurs
within extraction site, takes effect around implant.

Disadvantages:
1. Need for mucogingival surgeries and bone grafting
around the implant.
2. When a two-stage implant is placed at the time of
extraction, mucogingival flap must be advanced to
completely cover the implant.
3. It may also be necessary to graft bone into the
extraction site in areas that do not contact implant to
avoid soft tissue invasion around the implant.

 A 1-year study of 49 immediate extraction site

implants treated by a membrane alone demonstrated
a 93.6% bone fill.
Studies have shown good results with use of auto &
allografts alone or in combination with BM.
Contraindications:
1. If inadequate bone exists to stabilize the implant.
2. Acute or subacute infection

2. Delayed Implant Placement:

Advantages:
1. It shares some of the advant. afforded by immediate
implant placement, i.e extraction site preservation.

2. Allows time for soft tissue healing, mucogingival

flap advancement is not necessary.

3. It reduces treatment time by several months as it is

not necessary to wait for complete bone healing.
4. Allows time for resolution of infections.

3. Staged Implant Placement:

Advantages:
1. Allows adequate time for osseous healing.
2. Eliminates the necessity of flap advancement.
3. Allows time for the resolution of infections.
4. By using an extended healing period, the grafted
bone also become vascularized.
Disadvantage:

Surgical Technique:
To decide which implant placement method to use,
the quantity & location of bone surrounding the
tooth should be assessedprobe the area
If the tooth to be extracted has sufficient bone
support on all surfaces:
If little or no bone exists on the labial surface:
Surgical Technique: A traumatic extraction

Complications of Localized Ridge Augmentation

1. Subsequent corrective surgeries
2. Use of bone grafts from the hipexposure

3. Membrane exposure

Recent review of literature (published from 1976

to 1994) included 2315 implants, which includes:

Autogenous blocks, particulate, and various other

bone graft materials.

Complications reported
Bleeding
Postoperative infection

Loss of a portion of the

bone graft
Pain

Bone fracture

Decubital ulcers

Nerve dysfunction

Sinusitis

Perforation of the mucosa

Wound dehiscence

Soft Tissue Augmentation Procedures

Pedicle graft procedure:
Studer et al. (1997) proposed its use for the correction of a
single tooth ridge defect with minor horizontal and vertical
loss.
Abrams 1980: Roll flap involves the preparation of a deepithelialized connective tissue pedicle graft, which is
subsequently placed in a subepithelial pouch.
It is used in the treatment of small to moderate Class I ridge
defects, primarily in cases with a single tooth space.

 A buccolingual ridge concavity can be converted

into a ridge convexity resembling the eminence
1. The roll flap procedure:
Surgical technique:

Adjustment of pontic contours:

Postoperative care:

Roll flap procedure

Free graft procedures:

1. Pouch graft procedures:
A subepithelial pouch is prepared in the area of the

ridge deformity, into which a free graft is placed and

molded to create the desired contour of the ridge.
Indication:
To correct Class I defects.

Pouch graft procedures

 The entrance incision and the plane of dissection

may be made in different ways

Kaldahl et al. 1982, Seibert 1983, Miller 1986,

Cohen 1994
1. Corono-apically:
2. Apicop-coronally:
3. Laterally:

2. Interpositional graft procedure:

Surgical concept:

Interpositional grafts are not completely submerged

and covered in the manner that a subepithelial
connective tissue graft is placed.
No need to remove the epithelium from the donor
tissue.

 If augmentation is also required in the apico-coronal

direction, a portion of the graft must be positioned
above the surface of the tissue surrounding the
recipient site.
Indications:
Used to correct Class I and Class II defects.
Surgical technique:

Interpositional graft procedure

Interpositional graft procedure

3. Onlay graft procedures:

Surgical concept:
The onlay procedure was designed to augment ridge
defects in the apicocoronal plane, i.e. to gain ridge
height Meltzer 1979, Seibert 1983.
Onlay grafts are epithelialized free grafts which
receive their nutrition from the de-epithelialized
connective tissue of the recipient site.
If necessary the grafting procedure be repeated at 2month intervals to gradually increase ridge height.

Indications:
1. Used in treatment of large Class II and III defects.
2. Also indicated for ridge augmentation primarily in
the presence of additional mucogingival problems
Studer et al. 2000.

3. They are not suitable in areas where the blood

supply at the recipient site has been compromised

Onlay graft procedures

 Selection of donor site:

Dissection of donor tissue:

Preventive measures:

Treatment of donor site:

Planning in graft
preparation:

Try in & graft stabilization:

Selection of donor site

Combined onlay & interpositional

graft procedures:
Advantages:
1. The submerged connective tissue section of the
interpositional graft aids in the revascularization of
the onlay section of the graft.
2. Smaller postoperative wound in palate donor site.
3. Faster healing in the palate donor site with less
patient discomfort.

4. Greater ability to control the degree of buccolingual and apicocoronal augmentation within a
single procedure.
5. Vestibular depth is not decreased and the
mucogingival junction is not moved coronally,
thereby eliminating the need for follow-up
corrective procedures.
Gingivoplasty procedures

Combined onlay & interpositional graft

procedures

Summary & Conclusion

Thank You!!!