You are the lucky ones you will be able to say yes to cases like these Within the grasp of every body here Invloves grinding bone, making a groove, But this is a two step procedure which will take about 5-6 months to accomplish On par with other augmentation procedures Without changing the distance between the crest and the nv bundle I can expand the ridge and do this case.
NOT EASY TO PERFORM RIDGE SPLITTING ON THE MANDIBLE. THE BONE IS NOT FLEXIBLE. IN THE MAXILLARY ARCH WE CAN SPLIT THE RIDGE IF WE HAVE SUFFICIENT WIDTH. FIRST SCORE THE CENTER OF THE RIDGE THIN BUR OR SCALPEL SECOND, USE ALVEOLAR EXPANDING CHISEL TO SEPARATE THE BUCCAL AND LINGUAL CORTICES THIRD INTRODUCE OSTEOTOMES OR SITE DILATORS TO EXPAND THE OSTEOTOMY TO AN APPROPRIATE SIZE AND INSERT FIXTURE ALL DONE IN ONE SURGERY.
WHO IS GOING TO BE A CANDIDATE FOR THIS PROCEDURE? ANATOMICALLY YOU NEED THE BUCCAL AND LINGUAL CORTICES TO BE SEPERATED BY CANCELLOUS BONE. IF THEY ARE FUSED THIS TECHNIQUE IS NOT INDICATED. THE ONLY WAY TO KNOW IS TO TAKE A CAT SCAN. THAT IS NOT TO SAY THAT EVERY CASE NEEDS A CAT SCAN. ON THE CONTRARY IT IS MY SUGGESTION THAT ONLY CASES SUCH AS THESE WITH VERY SPINY RIDGES RECEIVE A CAT SCAN. YOUR ONLY CHOICE IS OSTEOPLASTY OR AUGMENTATION WITH MY VOTE GOING TO BLOCK GRAFTING IN THIS AREA.
WHEN DO WE USE THIS PROCEDURE? THE AMOUNT OF BONE WE NEED TO RELIABLY EXPECT A STEADY STATE OF BONE TO IMPLANT INTERFACE FOR US TO RELIABLY EXPECT A STEADY STATE OF BONE TO REMAIN IN CONTACT WITH THE FIXTURE WE NEED ANY WHERE FROM 1-1.5 MM OF BONE TO BE ON THE STRAIGHT BUCCAL AND STRAIGHT LINGUAL. IT DEPENDS ON THE WIDTH OF THE IMPLANT FIXTURE WE WANT TO USE. FOR STD DIAMETER NEED 6-7 MM OF WIDTH FOR WIDE DIAMETER WE NEED 7-8.
IF I DO NOT HAVE 6 MM I CAN NOT PLACE A STANDARD DIAMETER IMPLANT AND I AM LOOKING FOR MORE BUCCAL LINGUAL WIDTH. FOR THIS CAN BE DIFFICULT TO COME BY
I ALSO DO THESE PROCEDURES TO GAIN A BIOMECHANICAL ADVANTAGE WE WANT TO MOVE THE CENTER OF THE IMPLANT TO THE BUCCAL TO PREVENT TIPPING FORCES ON THE FIXTURE AND ITS COMPONENTS AND WE WANT TO HELP AVOID THE NEED FOR A CROWN WHICH HAS TO BE FABRICATED WITH A LARGE BUCCAL CANTILEVER. PLUNGER CUSP OF THE MAXILLARY FIRST MOLAR COMMENT ON HOW THE LAB AND THE DENTIST WANT TO PLACE CROWN WE ALL KNOW THE CENTER OF THE RIDGE IS HERE
So let us use diagrams to illustrate how this is done then I will show a couple of videos demonstrating the technique. Orient people bone marrow cortex nv bundle Skinny ridge which is less than the desired 6-7 mm B and L plates need to be separate because we are going to purposely weaken the buccal cortex and out fracture in a buccal direction Remember still need sufficient height between the crest and mandibular canal
Channels corticotomies osteotomy grooves snap fracture , move it where we want it, push it, Make a FTF and identify the mental foramen – this technique will be blind when you come back meaning you will not visualize the mental foramen when you reenter so take your measurement now Inferior groove is wider because you do not want this edge to bind up or catch the portion of bone Narrow crestal osteotomy with a #2 bur or smaller bur Down into the cancellous or medullary bone Position very often is in the middle of the crest Inferior corticotomy is made with a larger bur #6 at least 3 mm above the canal
Channels corticotomies osteotomy grooves snap fracture , move it where we want it, push it, Make a FTF and identify the mental foramen – this technique will be blind when you come back meaning you will not visualize the mental foramen when you reenter so take your measurement now Inferior groove is wider because you do not want this edge to bind up or catch the portion of bone Narrow crestal osteotomy with a #2 bur or smaller bur Down into the cancellous or medullary bone Position very often is in the middle of the crest Inferior corticotomy is made with a larger bur #6 at least 3 mm above the canal You can pick a point more superior to the canal to improve your chances of gaining primary stability and to make it safer
Channels corticotomies osteotomy grooves snap fracture , move it where we want it, push it, Make a FTF and identify the mental foramen – this technique will be blind when you come back meaning you will not visualize the mental foramen when you reenter so take your measurement now Inferior groove is wider because you do not want this edge to bind up or catch the portion of bone Narrow crestal osteotomy with a #2 bur or smaller bur Down into the cancellous or medullary bone Position very often is in the middle of the crest Inferior corticotomy is made with a larger bur #6 at least 3 mm above the canal
Vertical corticotomies or osteotomies made with 556 Connects the inferior and crestal osteotomys Again make sure you are down into the cortical bone Can come close to adjacent teeth as long as periodontium of adjacent teeth is respected
Use high speed or hall type drill
Close for 3-4 weeks to reestablish blood supply closer to 3 weeks to Buccal periosteum will reestablish itself Shoot for 3 weeks I had one case where I waited 5 weeks and I could not outfracrture
Orient the audience again Overlapped flap to expose the center of the crest Do not reflect the buccal flap need the buccal cortex to have a blood supply Keep the periosteal and endosteal interface intact Need the buccal cortex to have vascular supply because it is going to get fractured away from its previous blood supply from the cancellous bone. Reflect the lingual flap for better visualization if required A lot of times I do not do this A little more difficult to read the depth marks on the osteotomy drills Woodson curved chisel or straight chisel If it does not loosen go to your pilot drill there is probably some stiff dense bony trabecula present Then try to outfracture the buccal plate Go to your chosen depth which has to be inferior to the horizontal osteotomy Reintroduce the woodson, chisel and you will almost certainly be able to outfracture The only reason you will encounter difficultuy will be because the corticotomies are not into cancellous bone
There is an option to use larger burs just in case the trabecula is dense or stubborn But not highly recommended too much sacrifice of buccal bone
Insert fixture into the widened ridge Primary fixation is gained by the apical portion of the of the fixture as it engages bone which has not been modified except for normal drilling of the osteotomy. I would plan on this being a submerged implant with some countersinking as needed This particular implant is made to go subcrestal Loosely place whatever material you trust to turn into bone when placed beside an implant. Dr. Becker 2 things cannot occupy the same space Contain with small piece of surgicel it is sticky upon touching blood and will stay where you place it There to help with initial clot formation and containment of the material Works well for this and most of socket preservation procedures.
The artist took some license with this illustration as the flaps hardly ever reappose and that is where the surgicel comes in to contain Should allow at least 4 months for integration
If you are cheap lazy and a coward you can do this procedure You are all for a free lecture so I know I have somebody’s attention
FIRST START WITH FTF A LITTLE FAST BUT YOU GET THE IDEA Score or place holes in cortex the bone first Babe ruth performing this procedure I have to give credit where it is due Very difficult to get video of this procedure The Bicon learning instiute was kind enough to allow me this footage it was a little raw so I edited it for this presentation Here is the procedure in its pure form
Here is the case which I wanted to illustrate an improvement in Biomechanical advantage
Start with the corticotomies This is about as close as I usually come but I you can get a little closer
HERE IS THE OSTEOTOMY FOR A 5 MM FIXTURE THIS IS WHAT THE BUCCAL CORTEX LOOKS LIKE WHEN IT IS GETTING DISPLACED.
THE SLIDE ON THE LEFT IS PRE – OP AND THE RIGHT SIDE IS CLOSED AFTER FIXTURE PLACEMENT AND OUTFRACTURE. NOTE THE INCREASED WIDTH THAT IS PRESENT LACK OF PRIMARY CLOSURE NOT A CONCERN, JUST ADD YOUR BONE GRAFT MATERIAL AND SURGICEL TO CONTAIN AND ALLOW FOR HEALING BY SECONDARY INTENTION AT THE CREST
I WANTED TO SHOW THIS CASE BECAUSE IT ILLUSTRATES SO WELL HOW PERFECT THE HEALING CAN BE FOLLOWING THE CORTICOTOMIES. HERE IS A CASE WHERE THE I STARTED OUT WITH A REASONABLE WIDTH OF BONE FOLLOWING AN EXTRACTION. THE HEALING LIKE TO SHOPre-op first implant
A FIXTURE WAS PLACED BUT WAS MET WITH FAILURE. THE REASON FOR THE FAILURE COULD NOT BE DETERMINED.
In any case the fixture was removed and this is what it looks like 5 months later. A loss of buccal lingual width observed. Preop ridgesplit after failure
SOMETIMES THAT BUR DANCES AROUND A LITTLE THAT IS WHY IT IS IMPORTANT TO MAKE THOSE SMALL PILOT OR STARTER HOLES AND THEN MAKE YOUR GROOVES WITH THE APPROPRIATE BUR The corticotomy is very wide on the distal Try to make a mental note in your photographic memory where the vertical corticotomies are so you can avoid them when you make the small buccal vertical releases.
Here we are outfracturing the buccal, drilling our osteotomy and placing a fixture. Notice the small vertical release which is not going to be over the corticotomy.
This is what it looks like when he presents for the stage II uncovering procedure. Notice the crest is perfectly healed with no divot, This is an implant that is made to go slightly subcrestal and the bone grew right over the top of the fixture. There are ways to prevent the bone from growing over the top so it is my fault that this happaened but what I wanted to show was the healing which helps to show how well the buccal cortex will heal along the periosteum
this is the center of the implant fixture. This is what I consider to be a good biomechanical position of the implant. The forces of occlusion will be directed down the center of the fixture as the big plunger cusp of the maxillary first molar makes contact with the central fossa of the implant supported first molar. This is a temporary abutment and you can get the feel that a crown of appropriate dimension no buccal cantilever which would have to occur if the implant was placed to the lingual
The last cases So those were examples of how things go as planned. But all does not go well all the time. Don’t you hate it when you go to a convention like this and you hear about a technique and on the way home you start developing questions or worse you do these procedures and things go wrong they don’t go well. I am going to try to share some mistakes I made and show some less than spectacular results in the hopes of having you obtain good results right away. I will try to quickly get you along the learning curve of this procedure. Here is a case where you can see how narrow the ridge is so I make my corticotomies and close it up. This ridge can not be more than 3.5-4 mm in width. That is a #1 bur pilot holes. What went wrong is I did not make the inferior corticotomy inferior enough. The mental foramen is looming down here somewhere I chose to be as far away as I could get. Unfortunately what happened the drill caused the outfractured buccal plate to separate from the periosteum.
So this is why I recommend the distance from the crest to where the inferior corticotomy be at least 6 mm especially if you are dealing with a single site. You need a sufficient amount of buccal cortex to be attached to the buccal periosteum.
Necessity is the mother of all inventions so I felt I only had one choice so I added bone and did not place the fixture. Norm did not teach me this
So I wait 4 months and come back and low and behold the bone is wide enough to place a 4 mm fixture. Difficult to tell but the buccal cortex heals fine. The same is true for the crestal osteotomy.
No longer do you see
Here you have a ridge which is almost respectable except for two things Undercut in the buccal cortex Proximity to mental foramen
Large enough but during the surgery the buccal plate was observed to separate For this patient perhaps 3 weeks was not enough for the periosteum to attach strongly to the buccal cortex 3 weeks good because bone will break away easy but perhaps periosteum-endosteum interface still a little fragile Need to respect the interface during the surgery careful with instruments and drills. By 5 weeks the callus is pretty strong as I observed in one case which I could not outfracture Wire jaws and broken arm 6-8 weeks I did not attempt to place the implant and grafted bone only and closed it I asked her to come back in 4 months and this is what I found
Do the same thing add bone
Absence of the undercut Total repair to the corticotomies
Slide to the left has a 2 mm pilot hole so you can see I have 2-3 mm to the buccal and lingual with a resulting BL width of at least 7 mm this is wide enough to get a short fat 5 mm diamete fixture superior to the mental foramen
Other complications I show you these complications for a couple of reasons to help you avoid the same surgical errors But also to show you why I think there are limits to what this procedure can offer you in its pure form that that is placing the implant at the same time the ridge is expanded or outfractured. I think it is important to send you home with some guidelines and the most predictable way to do this. I do not want you in the position to have to repair defects like this if it can be helped. By the way the way I treated these was with a combination of particulate bone and autogenous bone and resorbable tacks and membrane and crossing my fingers that bone would regenerate over the implant surface. So the complications I encountered at stage 2 took the form of dehisences and fenestrations So it has occurred to me that there may be a more predictable way to treat areas with minimal amounts of buccal lingual width say less than 4 mm.
And also fenestrations
The reason I pick 4 mm is that at that width even if you had to use the pilot drill you will at least have 1 mm of bone on either So you may not want to promise that you can place the implant at the second stage when you are treatment planning this. You will know more when the corticotomies are done. I agree with Brunski and believe that if you do not have at least 1-1.5 mm of bone buccal or lingual to the implant surface , that fixture is in danger of dehising or fenestrating. Even if you hit it dead center you only have 1 mm on each side and that is the minimum Basically how did these complications occur.How did this happen? The bone could not stand the trauma of the procedure or it was whittled away beyond the threshold to repair itself and regenerate bone between the periosteum and fixture surface The red line represents the narrow crestal osteotomy so you are going to lose too much here The yellow represents the diameter of the 2 mm pilot drill You can see at least there will be some about a millimeters worth of bone on the buccal and lingual bone I think if you insult the buccal and lingual bone more than that and wind up with less than 1 mm you risk dehisence and fenestration So I agree with Dr. Brunski when he says ……………..and so care must be taken when placing the implant fixture at the second stage.
Less than 4mm then do not use procedure in its pure form do not place the implant I think it is possible for the bone to devitalize on the buccal and not have the capacity to regenerate from the trauma of the drilling procedures Even at 4 mm you will have to successfully outfracture and do your best not to whittle away too much bone Unless you want to live with these defects or feel confident to regenerate at the time of uncovering then better to be safe and predictable and instead of placing the fixture I am suggesting that you graft in some particulate bone
Here is the first case I did after the light bulb went off in my head that said placing the implant is a bad idea in this out fractured bone and knew that if I grafted in bone I could confidently come back and there would be bone of sufficient quality to enable fixture placement. Vertical release in the vertical corticotomy I wanted to avoid the possibility of a dehisence The distance seemed too great to expect bone to grow
Not in its pure form but this is more predictable
3 months later
4.5 mm osteotomies 3 months later a little soft I waited 3 months because that is what I normally wait for extraction site and we get about 1 mm of bone growth per month so I thought that would close the gap reasonably well 1mm from the buccal per month 1mm per month from the lingual cortex
Woodson to elevate
Introduced into the crestal osteotomy you can feel it ant very often see the opening in the crest Hand pressure or gentle malleting can out fracture for awhile I was using a buck knife to separate the trabecula. I would not advise using this instrument to torque it as you risk breakage but it can be helpful if it is difficult to introduce a chisel. Try not to place too much pressure on the lingual cortex in order to reduce the risk of fracturing the lingual cortex.
Here is my alveolar crest in the lower right. As you can see I am starting out with approximately 3 mm and I no chance to do osteoplasty in this area as the nv bundle is staring me in the face. The distance between the crest and the bundle is very limited. So the osteotomies were cut in the manner I have described. 3-4 weeks later the buccal cortex is outfractured and graft material placed. #1 round bur used at crest
We wait 4 weeks and perform grafting.This is immediately post-op closed with surgicel in place.
I waited 3 months and performed the implant osteotomies as you see them here. That means within 4 months I have gone from a knife edge spiny ridge of about 3 mm in width to placing standard and wide diameter implant osteotomies.
THIS IS WHAT IT LOOKS LIKE AT STAGE II THIS BONE STOOD UP WELL TO THE DRILLING PROCEDURES AT STAGE I , THIS IS A 4.5 MM IMPLANT WITH A 3 MM WELL SO YOUO CAN SEE I WAS ABLE TO DEVELOP ENOUGH BONE TO THE BUCCAL AND LINGUAL WHICH SHOULD ALLOW FOR A STABLE IMPLANT BONE INTERFACE. AND THIS IS A 4 MM IMPLANT WITH A 2 MM WELL
Here is the case that I showed you in the beginning. This ridge was so spiny that I thought for sure the buccal and lingual cortices were fused which in my mind would require her to fly to florida and have michael pikos to a block graft in this area because I was not going to be the one incising the periosteum and blunt dissecting around the contents coming out of the mental foramen after a block graft is done here. I will do block grafts but not in this area and I do not think you have to because even if you do not get what you want the first time you can outfracture again and add more graft material or outfracture and place implant if the conditions are right.
I thought I developed enough bone here and placed 3 standard diameter implant fixtures.
Less than 6-7 mm use this 4-6-7 you have a chance to place the implant if you are just starting out you might want to split ridge and graft If less than 4 mm strongly consider grafting and come back
IF YOU FALL OFF A BIKE YOU DO NOT HAVE A CHOICE PEOPLE DO NOT LIKE THESE PROCEDURES BLUNT DISSECTION NEEDED RISK OF NO PRIMARY CLOSURE AND PARESTHESIA IN DONOR AND REC SITE
Swelling in a location similar to what we see in periodontal surgery and third molar removal The more swelling the more pain consider steroids to reduce swelling beginning a day before the surgery. Bruising which usually resolves within one week Pain usually a liittle worse than periodontal and implant surgery consistent with swelling More release of inflammatory factors really wake up these inflammatory pathways
