this presentation is the prosthodontic point of view described the importance of ridge augmentation procedures and the needs

1. RIDGE AUGMENTATION
PRESENTED BY- DR. NIKITA
CHHABARIYA

2. CONTENT
• Introduction
• Classification
• Ridge augmentation materials
• Ridge augmentation procedures in
• Mandible
• Maxilla
• Conclusion
• References

3. INTRODUCTION
Definition- Any procedure designed to enlarge or increase the size, extent, or
quality of a deformed alveolar ridge.( GPT-9)

4. RIDGE AUGMENTATION
• Onlay bone grafting –
Autogenous / allogenic grafts
• Interpositional / sandwich
grafts
• Sinus lift procedure
Maxillary
augmentation
• Superior border augmentation (Iliac crest,
rib graft, hydroxyapa tite)
• Inferior border augmentation (Autogenous
or allogenic freeze dried cadaveric
mandible)
• Interpositional / sandwich bone grafts
• Visor osteotomy
• Onlay grafting: Autogenous, allograft and
alloplastic
Mandibular
augmentatio

5. CLASSIFICATION OF ALVEOLAR RIDGES AND
TREATMENT PROTOCOL
Class I -Alveolar ridge
adequate in height
but inadequate in
width, usually with
lateral deficiency or
undercut areas:
Patients received
hydroxylapatite (HA)
alone.
Class II -Alveolar ridge
deficient in both
height and width
presents a knife-edge
appearance: Patients
received HA alone.
Class III- Alveolar ridge
resorbed to level of the
basilar bone, producing
concave form on
posterior areas of the
mandible and a sharp,
bony, ridge form with
bulbous, mobile soft
tissue in the maxilla:
Patients received HA
alone or HA mixed with
autogenous, cancellous
iliac bone.
Class IV- Resorption
of the basilar bone,
producing pencil-thin,
flat mandible or flat
maxilla: Patients
received HA mixed
with autogenous,
cancellous iliac bone
Kent, J. N., Quinn, J. H., Zide, M. F., Guerra, L. R., & Boyne, P. J. (1983). Alveolar ridge augmentation using nonresorb
hydroxylapatite with or without autogenous cancellous bone. Journal of Oral and Maxillofacial Surgery, 41(10), 629–
642. doi:10.1016/0278-2391(83)90016-2

6. • Loss of alveolar ridge height, width and decreased vestibular
depth and denture bearing area.
• Considerable basal bone resorption in the mandible, resulting in
neurosensory disturbances.
• Increased susceptibility to fracture of the atrophic jaws.
Replacement of necessary supportive bone.
• Progressive loss of denture stability and retention
Indications for Ridge Augmentation
Kent, J. N., Quinn, J. H., Zide, M. F., Guerra, L. R., & Boyne, P. J. (1983). Alveolar ridge augmentation using nonresor
hydroxylapatite with or without autogenous cancellous bone. Journal of Oral and Maxillofacial Surgery,

7. Graft:
Portion of a tissue or organ that after removal from its origin or
donor site is positioned or inserted at a different place with the
objective of reinforcing the existing tissues &/or correcting a
structural defect.

8. Classification
According to
structure
Cortical
Cancellous
Cortico-
cancellous
According to
source
Autograft
Allograft
Xenograft
Alloplast
According to
embryologic
origin
Membranous
Endochondral
Fonseca, R.J. and Davis, W.H. Reconstructive Preprosthetic Oral and Maxillofacial Surgery. W.B. Saunders Co., Philadelphia,

9. Mandibular
augmentation
procedure

10. SUPERIOR BORDER
AUGMENTATION
INDICATED
• when severe resorption of the mandible results in inadequate height and contour
and potential risk of fracture
• when the treatment plan calls for placement of implants in areas of insufficient bone height
or width.
• mental foramen is situated in the superior border
• Remaining bone < 10 mm
Davis in the year 1970
Fonseca, R.J. and Davis, W.H. Reconstructive Preprosthetic Oral and Maxillofacial Surgery. W.B. Saunders Co., Philadelphia, 1986

11. PROCEDURE
• Disadvantage
1. Morbidity of the donor site
2. Secondary surgical site
3. Necessity of the patient to withdraw denture till the
surgical wound heals for period of 6-8 months
autogenous bone graft is used.
• Two segments of the rib, about 15 cm long, are obtained
from the 5thand 9th ribs.
• The rib is contoured by vertical scoring in the inner surface.
• The second rib is made of corticocancellous paticles and
mould around first rib.
• Fixation is done by means of transosseous wiring or
circumferential wiring.
Fonseca, R.J. and Davis, W.H. Reconstructive Preprosthetic Oral and Maxillofacial Surgery. W.B.

12. INFERIOR BORDER AUGMENTATION OF MANDIBLE
Indications:
• severely atrophic edentulous mandible are a
need for augmentation
• prevention of pathologic fracture.
• reduction and fixation (management) of
nonunion or malunion in cases of fractures.
Sanders and cox
Sanders, B. (1982). Augmentation rib grafting to the inferior border of the mandible. Head & Neck

13. ADVANTAGES
No dehiscence
Less pain
Better # stabilization
2o sulculoplasty not required
Less bone resorption
Indicated for pencil thin ridges
Easier to perform skin graft vestibuloplasty
DISADVANTAGES
Scarring
Presence of loose submandibular tissue Does
not correct superior irregularities
Sanders, B. (1982). Augmentation rib grafting to the inferior border of the mandible. Head & Neck

14. CASE REPORT- SANDERS, B. (1982). AUGMENTATION RIB
GRAFTING TO THE INFERIOR BORDER OF THE
MANDIBLE. HEAD & NECK SURGERY,
• 31 patients have undergone inferior border rib grafting.
Sanders, B. (1982). Augmentation rib grafting to the inferior border of the mandible. Head & Neck
Article-
Patient unable to wear satisfactory lower denture because of severely atrophic
edentulous mandible.
Preoperative appearance of alveolar ridge.
lack of denture-bearing surface.

15. Alveolar ridge after skin-graft vestibuloplasty performed
six months after rib grafting.
Mandibular denture with extended flanges for excellent
stability and retention.
Results
Two patients did not require vestibuloplasty.
In one other patient, in whom the graft was used to support a
mandible with a subperiosteal implant, no further treatment was
deemed necessary.
To date, all patients who had vestibuloplasty and those that did not
require vestibuloplasty are wearing dentures satisfactorily
Bone resorption rates to date have been minimal to moderate.

16. HORIZONTALOSTEOTOMY (DANIELSON AND
NEMARICH)/SANDWICH TECHNIQUE
Splitting of maxilla and mandible bone is grafted into osteotomy gap
Can be used with osteointegrated implant
Tucker, R.M. Ambulatory Preprosthetic Reconstructive Surgery

17. SEGMENTAL SANDWICH OSTEOTOMY AND TUNNEL
TECHNIQUE FOR THREE-DIMENSIONAL RECONSTRUCTION OF
THE JAW ATROPHY: A CASE REPORT
• Case report - A 59-year-old woman with a
severely atrophied right mandible was treated with
the sandwich osteotomy technique filled with
autologous bone graft harvested by a cortical
bone collector from the ramus.
International Journal of Implant Dentistry
Mario Santagata et.al
Article
Clinical examination revealed that the
mandible was edentulous bilaterally from
the first molar to the second molar region.
Radiographically, atrophy of the mandibular alveolar ridge in
the same teeth site was observed- began to treat the right side.

18. • The entire bone fragment was displaced cranially, and the
desirable position was obtained.
• The gap was filled completely with autologous bone chips
harvested from the mandibular ramus through a cortical
bone collector.
• No barrier membranes were used to protect the grafts.
• The vertical incisions were closing with interruptive
suturing of the flaps with a resorbable material.

19. VERTICAL OSTEOTOMY (HARLE,1975)/VISOR
OSTEOTOMY
1. Was originated by Harle and modified by Peterson
and Slade.
2. It is used where insufficient vertical mandibular
bone height is present for the horizontal osteotomy
technique but adequate bone width (approximately
10mm) is present.
Tucker, R.M. Ambulatory Preprosthetic Reconstructive Surgery

20. 1.The mandible is split vertically and the lingual
section is elevated to increase the mandibular height.
2. Cancellous bone or particulate bone and marrow is
placed to correct the contours and fill in the gaps on the
facial side of the elevated segment.
3.Transosteal wires hold the segments in place for a
period of 3-4 months before vestibuloplasties are
performed.
The disadvantage is
unavoidable nerve trauma
and the resultant
parasthesia.
Tucker, R.M. Ambulatory Preprosthetic Reconstructive Surgery

21. COMBINED VERTICALAND HORIZONTAL OSTEOTOMY
(KOOMEN ET AL)
The combination of the ‘visor’ and ‘sandwich’ techniques
was designed to over come the disadvantages in bone grafting.
A modification of the visor osteotomy has been recommended
for patients with at least 8 mm of bone height as measured at
mental nerve region.
the viability of the bone will be greater and the resorption
decreased
Stoelinga, P.J.W. Preprosthetic Reconstructive Surgery.

22. Procedure:
• Vertical osteotomy cut is made in the posterior region to divide
the segments buccolingually.
• A horizontal osteotomy is performed in the anterior mandible
to divide the anterior segment superiorly and inferiorly, and
bone grafting was done into the osteotomised gap.
• Two osteotomised segments are fixed with wires.
Stoelinga, P.J.W. Preprosthetic Reconstructive Surgery.

23. ONLAY GRAFTING-
• This procedure helps in increasing width of the ridge.
Here graft material is placed on the buccal cortex either in putty form by mixing with
saline/blood or in the form of blocks or split thickness rib/illiac crest graft.
Tunnel is created via midline.
Advantages:
Improves width and to some extent height too.
Can be used in anterior and posterior region.
Stoelinga, P.J.W. Preprosthetic Reconstructive Surgery.

24. MAXILLARY
AUGMENTATION
Gross, B. D., James, R. B., & Fister, J. (1980). Use of pocket inlay grafts and tuberoplasty in maxillary prosthetic
construction. The Journal of Prosthetic Dentistry, 43(6), 649–653. doi:10.1016/0022-3913(80)90381-9

25. • Advantages
Development of increased height and form of the alveolar
ridge and the palatal vault area.
The anteroposterior position of the maxilla can be corrected.
Disadvantages
Need for a secondary donor site.
Extensive post operative resorption.
Postoperative secondary soft tissue procedures.
Delay in wearing dentures for 6-8 months

26. Inter positional bone grafts
Indications
•In a bony deficient maxilla where there is adequate form to the
palatal vault but insufficient ridge height, particularly in the
zygomatic buttress and posterior tuberosity areas.
Advantages
•Stable and predictable results by changing maxillary
position in the vertical, anteroposterior and transverse
directions.
Disadvantages
•Need to harvest bone from the iliac bone crest
•Possible secondary soft tissue surgery
This technique effectively increases the ridge height
from the lateral maxillary area to the crest of the ridge.
lateral maxillary and lateral nasal walls and
pterygoid maxillary suture area

27. Procedure
• The lateral maxillary and lateral nasal walls and pterygoid maxillary suture area
separated using surgical saws and osteotome and the maxilla is down fractured.
• Bone grafts obtained from the iliac crest are shaped and wired in place in the lateral
maxillary areas.

28. SINUS LIFT PROCEDURES -
Riben C, Thor A. The Maxillary Sinus Membrane Elevation Procedure: Augmentation of Bone around Dental Implants without Grafts-A Review of a Surgical Technique.
During long-term edentulism, resorption of the alveolar process occurs. Since the
maxillary sinus also pneumatises during these circumstances
the remaining bone volume can become very small and therefore clinicians and
researchers have continuously developed techniques to overcome this problem.
Increased bone volume in
the maxillary sinus floor in
order to enable
installation of fixtures in
the region

29. SUBANTRAL CLASSIFICATION AND TREATMENT
OPTIONS
Misch organized treatment options depending on available bone height
Vlassis JM, Fugazzotto PA. A classification system for sinus membrane perforations during augmentation procedures with options for repair. J

30. INDIRECT SINUS AUGMENTATION TECHNIQUE
sinus floor is lifted carefully by fracture
of floor, separated from the
Schneiderian membrane without
damage to the membrane using a
surgical mallet with controlled force. If
required, autogenous graft material is
inserted within the socket.
The material is gradually displaced apically with
the help of larger-diameter instruments.
Riben C, Thor A. The Maxillary Sinus Membrane Elevation Procedure: Augmentation of Bone around Dental Implants without Grafts-A Review of a
Surgical Technique. Int J Dent 2012;2012:105483.

31. DIRECT SINUS AUGMENTATION TECHNIQUE
Autogenous bone grafts are harvested by shaving the
mandibular bone from external oblique ridge area or
parasymphysis region.
Buccal window
The implant can be placed on same sitting with the help of
a stent for appropriate faciolingual and mesiodistal
positioning.
Vlassis JM, Fugazzotto PA. A classification system for sinus membrane perforations during
augmentation procedures with options for repair. J Periodontol 1999;70:692-9

32. ONLAY AND INLAY AUGMENTATION
• Indications:
Severe resorption of the maxillary alveolar resulting in
the absence of a clinical alveolar ridge and loss of
adequate palatal vault form.

33. USE OF POCKET INLAY GRAFTS AND
TUBEROPLASTY IN MAXILLARY PROSTHETIC
CONSTRUCTION. THE JOURNAL OF PROSTHETIC
DENTISTRY.
• A white man, 59 years of age, was referred to the oral/maxillofacial surgery clinic
for evaluation of his deficient maxilla.
Gross, B. D., James, R. B., & Fister, J. (1980).
Article
Past medical history- had sustained a war injury to his face in 1944 which
resulted in the avulsion of most of the maxillary alveolus and the entire
hard palate
Physical examination was unremarkable,
except for the intraoral findings.
Bilaterally, there was no clinically discernable
alveolar ridge or tuberosity.
Palpation revealed only a rim of bone in the
area of the lateral wall of the maxillary sinus.

34. Pocket inlay skin grafts would be developed bilaterally in the region of the anterior
lateral sinus walls, and bilateral tuberoplasties would be accomplished in the
pterygoid region.
PROCEDURE-
Preoperatively, an overextended impression was
made of the maxilla. The diagnostic cast was then
marked to delineate the proposed surgical sites.
With the patient present, the angulation and dimensions
of the pockets and tuberoplasty were carved into the
diagnostic cast. Acrylic resin was added to the patient’s
dentures in these regions. Modeling compound was added
at surgery for the final contour.

35. The original denture was modified using
autopolymerizing acrylic resin and
modeling compound to fit into the
previously created pockets and the space
created behind the tuberosity . The
splitthickness skin graft was then draped
over the prepared denture, and the
denture was inserted into the prepared
surgical sites. Stabilization was achieved
with bilateral circumzygomatic wires.
Ten’ days later the
denture was removed,
and the surgical sites
were cleaned. At this
time, a cast was made
using the modified
denture. The compound
was replaced with acrylic
resin. An impression tray
was constructed from the
cast. The denture was
immediately reinserted,

37. TITANIUM MESH FOR BONE
AUGMENTATION
When the alveolar bone has severe vertical or
horizontal bone defects, many clinical studies
suggest that titanium mesh shows superior
mechanical properties and great osteogenic
performance during application
Use of titanium mesh for staged 3D localized alveolar ridge augmentation Sajith 2015 int joral health
The use of Ti-mesh allows the regeneration of sufficient bone volume for
ideal implant placement. The clinical advantages related to this technique
include the possibility of correcting severe vertical atrophies associated with
considerable reductions in width and the lack of major complications if soft-
tissue dehiscence and mesh exposures do occur.

38. CONCLUSION
• Prosthetic-driven augmentation is recommended for a better
outcome. If the clinician focuses only on ridge augmentation
techniques to solve bone deficiency problems, he or she may
overlook other treatment options that may have lower risks and less
morbidity, such as using short, narrow, or tilted implants. After all,
ridge augmentation is being performed for the ideal placement of
dental implant.

39. REFERENCES
• Peterson, L. J. Principles of Oral and Maxillofacial Surgery. Vol. II. J. B. Lippincott Co., Philadelphia, 1992.
• Zarb, G. Prosthodontic View of Traditional and Contemporary Preprosthetic Surgery. Chapter 42,
• Tucker, R.M. Ambulatory Preprosthetic Reconstructive Surgery. Chapter 43,
• Stoelinga, P.J.W. Preprosthetic Reconstructive Surgery.
• Fonseca, R.J. and Davis, W.H. Reconstructive Preprosthetic Oral and Maxillofacial Surgery. W.B. Saunders Co., Philadelphia, 1986.
• Kent, J. N., Quinn, J. H., Zide, M. F., Guerra, L. R., & Boyne, P. J. (1983). Alveolar ridge augmentation using nonresorbable hydroxylapatite
with or without autogenous cancellous bone. Journal of Oral and Maxillofacial Surgery, 41(10), 629–642. doi:10.1016/0278-2391(83)90016-
2
• Proussaefs, P., & Lozada, J. (2003). The use of resorbable collagen membrane in conjunction with autogenous bone graft and inorganic
bovine mineral for buccal/labial alveolar ridge augmentation: A pilot study. The Journal of Prosthetic Dentistry, 90(6), 530–
538. doi:10.1016/s0022-3913(03)00521-3
• J Pharm Bioallied Sci. 2012 Aug; 4(Suppl 2): S414–S416.
• dPre-prosthetic surgery: Mandible 10.4103/0975-7406.100312 PMCID: PMC3467894 jpd
• Sandwich bone graft for vertical augmentation of the posterior maxillary region: a case report with 9-year follow-up Kenko Tanaka
j.international implant
• Riben, C., & Thor, A. (2012). The Maxillary Sinus Membrane Elevation Procedure: Augmentation of Bone around Dental Implants without
Grafts—A Review of a Surgical Technique. International Journal of Dentistry, 2012, 1–9.

40. THANK YOU
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