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 Table of Contents  
Year : 2015  |  Volume : 5  |  Issue : 1  |  Page : 49-52

Ultrasonic bone surgery assisted ridge split in posterior mandible

1 Department of Periodontics, Bapuji Dental College and Hospital, Davangere, Karnataka, India
2 Department of Prosthodontics, Bapuji Dental College and Hospital, Davangere, Karnataka, India

Date of Web Publication7-Dec-2015

Correspondence Address:
J Jishnu Pannicker
Department of Periodontics, Bapuji Dental College and Hospital, Davangere - 577 004, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2231-6027.171164

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Narrow dentoalveolar ridges remain to be a major challenge for the successful placement of endosseous implants. Traditionally, these areas have been treated with autogenous grafts, but the significant resorption of these grafts, in combination with patient morbidity at the secondary donor site, has led clinicians to seek alternatives for augmenting the edentulous posterior mandible. The ridge-split procedure provides a quicker method wherein an atrophic ridge can be predictably expanded and grafted with synthetic bone substitutes, eliminating the need for the second surgical site. This case report describes one such case in which narrow mandibular ridge splitting was carried out by means of ultrasonic bone surgery unit with immediate placement of implant followed by prosthetic rehabilitation.

Keywords: Calcium phosphosilicate, posterior mandible, ridge split, ultrasonic bone surgery

How to cite this article:
Pannicker J J, Tarun Kumar A B, Dhanya Kumar B H, Mehta DS. Ultrasonic bone surgery assisted ridge split in posterior mandible. Int J Oral Health Sci 2015;5:49-52

How to cite this URL:
Pannicker J J, Tarun Kumar A B, Dhanya Kumar B H, Mehta DS. Ultrasonic bone surgery assisted ridge split in posterior mandible. Int J Oral Health Sci [serial online] 2015 [cited 2022 Aug 18];5:49-52. Available from: https://www.ijohsjournal.org/text.asp?2015/5/1/49/171164

  Introduction Top

Dental implants have become an integral part of the comprehensive management of dental patients. Successful implant therapy often requires sound osseous support. Scipioni et al., suggests that wherever dental implants are placed, a minimum thickness of 1–1.5 mm of bone should remain all around the implant to ensure a long-term, predictable outcome.[1] For most standard implants, a minimum of 7 mm ridge width is necessary for a favorable outcome. A major limitation for successful implant placement remains the problem of inadequate ridge width. To achieve such bony dimensions, a variety of augmentation techniques have been successfully used including guided bone regeneration, block grafts, and ridge splitting/expansion.

Ridge splitting technique causes lateral ridge expansion which creates new implant bed by longitudinal osteotomy, positioning buccal cortex laterally.[2] The buccal cortex is positioned laterally to create space between buccal and lingual cortical plates, which is filled by an endosseous implant with or without any graft material.[3],[4]

Ridge splitting is more applicable to the maxilla than the mandible. The thinner cortical plates and softer medullary bone make the maxillary ridge easier to expand. The posterior mandible has been referred as the most difficult region for reconstruction and early implant placement in cases of severe alveolar resorption in the maxillomandibular complex.[3] In addition to complicating anatomic features, such as the inferior alveolar nerve, mental foramen, oblique ridge, and lingual undercut of the mylohyoid ridge, edentulous mandibular ridges have thicker cortices and decreased volumes of vascular trabecular bone than their maxillary counterparts.[5],[6] Furthermore, the mandibular bone lacks the elasticity as compared to the maxillary because of the predominance of cortical bone.

This clinical report describes the art of ridge splitting for the gradual expansion of narrow mandibular ridge with simultaneous implant placement.

  Case Report Top

A 35-year-old female patient reported to our clinic with a chief complaint of missing teeth in the lower left region of the jaw [Figure 1]a and [Figure 1]b. She requested fixed prosthesis, preferably an implant supported. Her expectations were reasonable. Patient's medical history was noncontributory. Extra- and intra-oral examinations had normal findings, and her dentition was in a good state of repair. Dental history revealed missing mandibular left first and second molar which had been extracted 5 years ago. Radiographic examination revealed no related pathology and also good bone trabeculation pattern. During clinical examination, a ridge defect with a reduction in the thickness of bone, which appeared to be thin, was diagnosed. Hence, a treatment plan of ridge split followed by simultaneous implant placement was decided.
Figure 1: (a) Preoperative radiograph. (b) Preoperative occlusal view

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The patient was premedicated with augmentin (1.2 g) 1 h prior to surgery. Surgery was carried out under local anesthesia, using lignocaine with 1:80,000 epinephrine. A full thickness mucoperiosteal flaps was reflected on the buccal and lingual aspects to get sufficient access [Figure 2]a. Horizontal bone osteotomy was then performed in the middle of the ridge using an ultrasonic bone surgery unit, to a depth of 8 mm, starting 2 mm distal to the premolar, and extending 10 mm posterior to the planned distal implant site, after which two vertical relaxing osteotomies in the buccal bone plate was given which extended from the cortical into the cancellous bone. The two vertical cuts were then joined at the base by another horizontal cut called the "hinge cut" which does not breach the labial cortical plate [Figure 2]b. A horizontal split expander (Komet, USA) device was then inserted into the split, which was created to horizontally distract off the buccal cortical plate [Figure 3]a. Once the expansion was sufficient, the implant sites were prepared by starting with the pilot drill followed by screw expanders to obtain an apical implant preparation of about 3 mm to get primary stability for the implants. Two implants (Corte × 3.8 × 11.5 mm) were placed within the split ridge [Figure 3]b. The space surrounding the implants was filled with calcium phosphosilicate (CPS) graft (Nova Bone Putty, USA). In order to preserve the buccal cortical plate, bioactive glass morsels (Nova Bone Morsels, USA) were then packed buccally [Figure 4]. Platelet-rich fibrin was then placed over the graft, and the flap was sutured without tension using 4–0 ethilon suture (Johnson and Johnson, USA) [Figure 5]. The patient was put on antibiotic (augmentin 625 mg) and analgesic (keterol DT) for 5 days The site was allowed to heal for a period of 4 months after which, the second stage surgery was performed to place the healing caps [Figure 6] followed by recording of the final impression using polyether impression material (3 M monophase, USA). One week later, final restorations with implant-supported porcelain-fused-to-metal crowns were cemented [Figure 7]a. The patient was on regular recall visits. One year postloading radiograph revealed stable crestal bone level around the implants [Figure 7]b.
Figure 2: (a) Full thickness mucoperiosteal flap reflected. (b) Ultrasonic bone surgery unit assisted ridge split done

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Figure 3: (a) Horizontal split expander inserted into the split. (b) Implants placed into the osteotomies created

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Figure 4: Split ridge packed with calcium phosphosilicate putty and morsels

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Figure 5: Tension-free primary closure

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Figure 6: Healing caps placed at 4 months

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Figure 7:(a) Crowns cemented, (b) 1 year postloading radiograph

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  Discussion Top

The alveolar ridge split augmentation procedure was introduced nearly 20 years ago and since then it has undergone a variety of modifications.[7] In their original description of the procedure, Simion et al. noted that the aim of the ridge split technique was to create a "self-space making" defect, that would allow for better graft containment and produce additional bony walls adjacent to the graft.[7] The expanded defect heals in a similar manner to an extraction socket and simultaneous implant placement, in the space formed after the dislocation of the buccal plate in a labial direction, can be achieved.[8] The ridge-split technique should be delineated as a bone expansion procedure, which potentially eliminates the overall disadvantages of onlay grafting for esthetic and functional demands. Other advantages include lesser overall cost, no need of barrier membranes and no morbidity related to the second donor site.[9] The limitation of this technique lies in its inability to create bone vertically. Therefore, it is not indicated for the correction of vertical defects. The evidence of medullary bone between the labial and palatal cortical plates is an indication for the ridge expansion in the maxillary arch. The presence of only cortical bone represents a contraindication of the technique.[8] The surgical technique for implant placement with an inadequate buccolingual thickness of bone was first described by Tatum [10] and then modified by other authors.[7] Tatum described a split thickness flap with a palatal incision to move keratinized tissue to the labial surface, which is particularly indicated when there is uncertainty regarding whether the ridge can be expanded without a risk of fracture of the labial wall. The periosteum was not reflected, and its integrity was maintained for bone blood supply. The chisel was very lightly tapped into the medullary space parallel to the palatal wall, to avoid the perforation of the concavity that normally exists on the labial surface of the anterior maxilla. The palatal wall was intact and immobile, and then the facial wall was expanded after the medullary bone was compressed against the cortical wall.

In the present clinical report, an ultrasonic bone surgery system was used to create the vertical and horizontal corticotomies. The ultrasonic bone surgery device operates with modulated ultrasonic micromovements and with an oscillating frequency of 29 and 32 kHz, making it specifically suitable for bone surgeries but not soft tissue cutting. Holtzclaw stated that with piezoelectric hinge-assisted ridge split technique, substantial gains in horizontal ridge width could be achieved in the posterior mandible without associated morbidity.[11] The split ridge was filled with CPS putty, which has a higher conversion rate into vital bone compared to any other xenograft turnover rate.[12] Grafting was done on the buccal aspect to fill and diffusely cover the vertical corticotomies and apical hinge cut. This is to compensate for the crestal bone loss of the split ridge which may occur due to the compromised vascularity.[11]

Chiapasco et al., evaluated the efficiency of different surgical techniques for ridge reconstruction and success rates of implants placed in the augmented areas. The surgical success and the implant survival rates were as high as the guided bone regeneration and onlay graft procedure, with the advantage of a shorter treatment time.[13] Wound healing in these cases is similar to the fracture repair of bone. The gap that is packed with bone graft is filled with a blood clot, which is organized and replaced with woven bone and further matures into the load-bearing lamellar bone at the implant interface.[14]

In the present case report, with the help of ultrasonic bone surgery assisted ridge split, we were able to gain a substantial horizontal ridge width nearing to around 4 mm which helped us to place two 3.8 mm diameter implant in a three-dimensionally oriented position and at the same time achieving a sound primary stability. This technique has greater predictability, since the grafted area is essentially a five-wall bony defect, with excellent blood supply. However, at the same time, the disadvantage of this procedure is that, if the complication arises, and bone loss occurs, the patient is left with a larger bone defect than before. Therefore, appropriate case selection and surgical technique is of great importance when considering the application of this technique.

  Conclusion Top

The ultrasonic bone surgery assisted ridge split technique is a very predictable procedure that can achieve substantial gains in horizontal ridge width of the edentulous posterior mandible without associated morbidity. This technique allows the clinician to augment the site and do the implant insertion in a single stage surgery, shortening the healing period drastically.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Scipioni A, Bruschi GB, Calesini G. The edentulous ridge expansion technique: A five-year study. Int J Periodontics Restorative Dent 1994;14:451-9.  Back to cited text no. 1
Enislidis G, Wittwer G, Ewers R. Preliminary report on a staged ridge splitting technique for implant placement in the mandible: A technical note. Int J Oral Maxillofac Implants 2006;21:445-9.  Back to cited text no. 2
Basa S, Varol A, Turker N. Alternative bone expansion technique for immediate placement of implants in the edentulous posterior mandibular ridge: A clinical report. Int J Oral Maxillofac Implants 2004;19:554-8.  Back to cited text no. 3
Misch CM. Implant site development using ridge splitting techniques. Oral Maxillofac Surg Clin North Am 2004;16:65-74.  Back to cited text no. 4
Neiva RF, Gapski R, Wang HL. Morphometric analysis of implant-related anatomy in Caucasian skulls. J Periodontol 2004;75:1061-7.  Back to cited text no. 5
Flanagan D. A comparison of facial and lingual cortical thicknesses in edentulous maxillary and mandibular sites measured on computerized tomograms. J Oral Implantol 2008;34:256-8.  Back to cited text no. 6
Simion M, Baldoni M, Zaffe D. Jawbone enlargement using immediate implant placement associated with a split-crest technique and guided tissue regeneration. Int J Periodontics Restorative Dent 1992;12:462-73.  Back to cited text no. 7
Belleggia F, Pozzi A, Rocci M, Barlattani A, Gargari M. Piezoelectric surgery in mandibular split crest technique with immediate implant placement: A case report. Oral Implantol (Rome) 2008;1:116-23.  Back to cited text no. 8
Basa S, Varol A, Turker N. Mandibular ridge splitting and gradual bone expansion technique for immediate placement of implant in the posterior thin region: A clinical report. Int J Oral Maxillofac Implants 2004;19:554-8.  Back to cited text no. 9
Tatum H Jr. Maxillary and sinus implant reconstructions. Dent Clin North Am 1986;30:207-29.  Back to cited text no. 10
Holtzclaw DJ, Toscano NJ, Rosen PS. Reconstruction of posterior mandibular alveolar ridge deficiencies with the piezoelectric hinge-assisted ridge split technique: A retrospective observational report. J Periodontol 2010;81:1580-6.  Back to cited text no. 11
Mahesh L, Narayan TV, Bali P, Shukla S. Socket preservation with alloplast: Discussion and a descriptive case. J Contemp Dent Pract 2012;13:934-7.  Back to cited text no. 12
Chiapasco M, Abati S, Romeo E, Vogel G. Clinical outcome of autogenous bone blocks or guided bone regeneration with e-PTFE membranes for the reconstruction of narrow edentulous ridges. Clin Oral Implants Res 1999;10:278-88.  Back to cited text no. 13
Ignatius AA, Ohnmacht M, Claes LE, Kreidler J, Palm F. A composite polymer/tricalcium phosphate membrane for guided bone regeneration in maxillofacial surgery. J Biomed Mater Res 2001;58:564-9.  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]


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