split the ridge for augmentation

1. Ridge Split
Techniques
DR. RINISHA SINHA
MDS PART III
DEPARTMENT OF PERIODONTOLOGY

2. Table of contents
01
02
03
04
Introduction
Ridge Split
Technique
Cross-References
Article

3. Following tooth loss….
● Thin buccal cortex of the maxillary alveolus
resorbs to a greater degree than the thicker
palatal socket wall
● Resorption  decrease in bone width and more
medial position of the residual ridge
● Narrower ridge in anterior maxilla and
premolar area  ideal for placement of
standard – diameter dental implants (4 mm)
● When considering ridge split
● DO NOT COMPROMISE on the desired
implants diameter simply for implant
placement
● Goal = EXPAND the ridge to allow placement
of appropriate size implant for proper
prosthetic or biomechanical support
Reference: Chiapasco M, Zaniboni M, Boisco M. 2006

4. Introduction
Reference: Demetriades N, Park JI, Alternative bone expansion
technique for implant placement in atrophic edentulous maxilla and
mandible. J Oral Implantol. 2011 Aug;37(4):463-71
Reference: Turker et al. 2004
• Implants : desirable for replacement
of missing teeth
• Bone width > 5mm required to
facilitate osseointergration and avoid
bone resorption
• Need to establish a bony wall
thickness of atleast 1mm around the
screw-type implants.

5. Five main
methods
to augment the
local bone
volume of
deficient sites
Osteoinduction by the use of appropriate growth factors
Osteoconduction where a grafting material serves as a scaffold for
new bone formation
Distraction osteogenesis (DO), by which a fracture is surgically
induced and the two bone fragments are then slowly pulled apart
Guided bone regeneration (GBR), which allows spaces maintained by
barrier membranes to be filled with bone
Revascularized bone grafts, where a vital bone segment is transferred
to its recipient bed with its vascular pedicle, thus permitting immediate
survival of the bone and no need of remodeling/substitution process
Reference: Urist 1965; Reddi et al. 1987
Reference: Burchardt 1983; Reddi et al. 1987
Reference: Ilizarov 1989a; 1989b
Reference: Dahlin et al. 1989, 1991; Kostopoulos & Karring 1994; Nyman & Lang 1994; Hammerle et al. 1996, 2002
Reference: Taylor 1982; Soutar & McGregor 1986; Swartz et al. 1986; Hidalgo 1989

6. Cowell and Howell classification

7. Crestal Bone Ridge Augmentation
● First introduced by Dr Hilt Tatum in the 1970s.
● Commonly referred to as
○ Ridge Splitting,
○ Bone Spreading, or
○ Ridge Expansion Technique.
● This method aims at the generation of bone around the implant sites by bone
osteotomies that enable buccal cortex repositioning (lateral repositioning) after greenstick
fracture of the buccal bony wall.
● Sometimes, simultaneous graft placement in the space created by the buccal-lingual
cortical plate separation.
Reference: Tatum H; 1986
Reference: Ewers et al. 2006

8. History
● RIDGE EXPANSION TECHNIQUE: Introduced by TATUM in 1986;
modified by SUMMERS in 1994
○ By the means of Hand Osteotomes with gradually increasing dimensions
○ Designed an implant system (Omni R system; Fluorida) for this technique
● RIDGE SPLITTING TECHNIQUE: by SIMION et al. 1992
A longitudinal ridge splitting in two parts, provoking a GREENSTICK fracture
○ By the means of small Chisels
PRE-REQUISITES:
1. A minimum ride width of 3-4 mm
2. Only in soft bone quality (Type III or IV)
Reference: Vercelotti. 2000; Suh et al. 2005

9. Indications for ridge expansion
For implant placement or interpositional
bone graft placement
Narrow alveolar ridge (minimum 3 mm,
marrow component)
Primarily maxillary sites greater than
one tooth
If in the mandible, only posterior distal-
extension edentulous sites with a
marrow component
Adequate alveolar bone height
(approximately 10 mm minimum)
Contraindications for ridge expansion
Inadequate alveolar bone
height
Concavities or undercuts of
ridge
Fused cortices (no marrow)
Less than 2-mm ridge width
Single-tooth sites
Reference: Agabiti I, Botticelli D (2017)

10. Site-Specific Indications
≥ + 2 mm of
horizontal
bone
thickness at
crest
≥ + 10 mm of
vertical bone
height to vital
structures
Non-concave
cross-
sectional
anatomy
Corticotomies
must remain
1mm away
from adjacent
teeth
Single tooth
sites difficult
(only molars if
single tooth)
Reference: Holtz-claw et al. 2010; Bassetti et al. 2013

11. Types of
Devices Used
???

12. Traditional Devices
Chisel and Hand mallet;
• Modified to Chisel and
Electrical Mallet
Osteotomes
Surgical Burs; Microsaw blade
Modern Devices
Motorized Ridge Expander
Threaded Bone Expanders
Expansion Crest Device
Laser
Ultrasonic / Piezoelectric devices

13. What
happens after
the ridge split
procedure?

14. Reference: Ewers et al. 2006
Reference: Misch CM; 2004
Reference: Berglundh T; Lindhe J 1997
• SPONTANEOUS OSSIFICATION
• Perfusion of the buccal segment remains intact;
• However, it shifts from an internal supply from the spongy
bone to an external perfusion from the periosteum.
• Blood supply from the periosteum allows for osseous tissue to
develop, which eventually leads to the formation of lamellar
bone.
• Even though some studies have placed graft material between
the separated plates, most studies have shown this placement
to be unnecessary.

15. Advantages
• It provides a shorter treatment period in
comparison to conventional bone graft
techniques.
• Since it does not require a waiting
period of 4–6 months for bone
consolidation prior to implant
placement.
• It decreases the morbidity and
complication rates since it avoids a second
surgical donor site for bone harvesting.
• Also allows the installation of implants in
the same surgery.
• Repositions cortical bone around implants.
• Decreased cost.
Disadvantages
• Can only increase the bucco-lingual
bony dimension.
• Is not applicable if there is insufficient
bone height for implant placement.
• If implemented on atrophic ridges less
than 3.0 mm wide  may result in
unfavorable bone fractures that lead to
bone resorption.
• Can be applied only when the buccal
and palatal/lingual plates are separated
by spongy bone.
• Unfavorable buccal inclination of
implants placed in expanded areas.
Reference: Chiapasco M, Zaniboni M, Boisco M. 2006
Reference: Figliuzzi MM, Giudice A, Pileggi S, Pacifico D,
Marrelli M, Tatullo M et al (2016)

16. Reference: Tolstunov L. Classification of the alveolar ridge width: implant-driven treatment considerations for the horizontally deficient alveolar
ridges. J Oral Implantol. 2014 Jul;40 Spec No:365-70.

17. Reference: Tolstunov L. Classification of the alveolar ridge width: implant-driven treatment considerations for the horizontally deficient alveolar
ridges. J Oral Implantol. 2014 Jul;40 Spec No:365-70.

18. Alveolar Ridge Expansion:
Comparison of Osseodensification and
Conventional
Osteotome Techniques
Name of the Authors: Jimmy H. Tian; Andrea Torroni et al.
Name of the Journal: The Journal of Craniofacial Surgery
Year of Publication: 2019
Type of study: In-vivo Animal research

19. AIM:
To evaluate the potential of combining Alveolar Ridge Expansion Technique
(ARET) and Osseodensification drilling as a predictable ridge expansion
method, a combination not yet described in the literature, in a highly translational
porcine model.
Two hypotheses are tested:
• If the osseodensification expansion method achieves the same degree of ridge
expansion relative to manual osteotomes
• Whether implants placed via ARET with osseodensification ridge expansion
would yield a statistically significant higher levels of primary stability and
osseointegration indicators at bone-implant interface than those placed
with manual osteotome expansion

20. METHOD:
A total of 12 Ti-6Al-4V implants with internal connection, 4 mm in diameter
and 13 mm in length were utilized in this study between two groups:
Group I: Osseodensification (n = 6 osseodensification implant placement)
Group II: Osteotome expansion groups (n = 6 conventional implant
placement).
The thread design was identical between the 2 groups.
The only difference being the ridge expansion method, whether it was with
osteotome or osseodensification

21. Animal Model and Surgical Procedures
• Inclusion of 6 minipig; age of 24 months and average weight of 30 kg.
• The study conducted according to the ethical approval from the Institutional Animal Care and Use
Committee of the Ecole Veterinaire d’Alfort under Animal Research: Reporting of In Vivo
Experiments guidelines.
• Endosseous root-form implants placed on horizontally deficient mandibular ridges (12 weeks post
healing of extraction of maxillary premolars).
• Standardized Surgery performed.
• Bone-implant contact (BIC) and bone area fraction occupancy (BAFO) were quantified to evaluate
the “osteogenic parameters around the peri-implant surface”
• The BIC determines the degree of osseointegration by tabulating the bone percentage of bone contact
over the entire relevant implant surface perimeter.
• The BAFO measures the quantity of bone (newly formed and nonvital autografted/native bone
due to instrumentation) as a percentage of the space occupied within the implant threads.

22. RESULTS:
• The MEAN RIDGE EXPANSION DIMENSION CHANGE
Approximately 80% in the O group and 63% in the R group; with no statistical
difference in the degree of ridge expansion between the 2 groups.
• The MEAN IMPLANT INSERTION TORQUE
56.7 Ncm in the O group - significantly higher than the 32.5 Ncm insertion torque
in the regular osteotome group.
• The MEAN BIC% VALUE
Approximately 62.5% in the O group, which decreased to 31.4% in the R group; a
significant effect of the surgical preparation technique
• The MEAN BAFO% VALUE
The substantial difference between the O group at 56.6% relative to 31.7% in the R
group; No statistical difference in BAFO as a function of surgical preparation
technique

23. HISTOLOGICAL EVALUATION: Osseointegration of all implants
• Both O and R groups showed integration with the newly formed bone in contact to
the implant surface.
• For both drilling groups, the pattern of osseointegration showed similar features.
• Regardless of the surgical instrumentation method, the bone surrounding the
implants in either groups showed extensive remodeling that included both sites of
bone apposition and bone resorption in close proximity to the implant surface.
• Higher amount of bone was observed along the surface and within threads of the O
group relative to its R counterparts.
• Extensive bone remodeling was occurring along the implant surface for all
groups.
• New bone growth around clearly demarcated bone chip surfaces was observed for the
O group; in contrast, the bone surrounding the R group showed less bone chips
with less discernable borders for such particulates

24. CONCLUSION
The results of the present study show that
• osseodensification was compatible with ARET with observation of
osseointegration without adverse effects on bone healing and provided
histologic and biomechanical evidence of increases in osseointegration and
implant primary stability, respectively.
CRITICAL ANALYSIS
• Further temporal investigation (short follow-up period of 4 weeks) for long-
term prognosis of implant osseointegration following ARET through
osseodensification.
• Only animal study.
• Smaller sample size.

25. Cross-References

26. REHABILITATION OF NARROW RIDGE WITH RIDGE SPLIT
USING PIEZOTOME V/S ROTARY ALONG WITH BONE GRAFT -
A CLINICAL COMPARATIVE STUDY
G. Abirami et al. 2019
The Tamil Nadu Dr. M.G.R Medical University Journal; UGC approved
• AIM
To compare the implant stability, bucco-lingual width of the alveolar ridge and marginal bone loss around
implants, after ridge split technique and implant placement using piezoelectric bone surgery and
rotary instruments.
• MATERIALS AND METHODS
A split mouth study design was done among 5 patients with bilateral partially edentulous sites with
horizontal ridge deficiency in posterior mandibular arch.
Control sites - traditional rotary instruments
Experimental sites - piezoelectric device.
Clinical parameters such as implant stability, bucco-lingual ridge width and marginal bone loss
around implants were recorded.
• RESULTS
o There was an increase in implant stability in both piezo and rotary treated sites, but
comparatively more in piezoelectric device site when compared to control site.
o There was also statistically significant increase in bucco-lingual width of the ridge in test sites in 3
months.
o There was no significant change in marginal bone level on both sites.
• CONCLUSION
The implant stability and bucco-lingual ridge width were comparatively more in test site than
in control site which shows the efficiency of piezoelectric device.
• Overall, the test sites showed desirable results when compared to control sites.

27. COMPARISON OF RIDGE EXPANSION AND RIDGE SPLITTING
TECHNIQUES FOR NARROW ALVEOLAR RIDGE IN A SWINE
CADAVER MODEL
Daniel W.K. Kao et al. 2015
The International Journal of Periodontics and Restorative Dentistry
• AIM
To evaluate the efficacy of ridge gain by ridge expansion or ridge splitting.
• MATERIALS AND METHODS
Eighteen (36 ramus) swine cadaver jaws were divided into two groups:
Group I – Ridge expansion with a motor-driven expander
Group II – Ridge splitting with a piezosurgical system
Then, either an active-tapping implant or non active-tapping cylinder-type implant was inserted.
The crestal ridge diameter change was measured with a Boley gauge. The area of bony
perforation, which includes fenestrations and dehiscences, was measured by a prefabricated
reference grid.
• RESULTS
o The difference in crestal width gain was not statistically significant between the two groups.
o More perforation of the alveolar ridges was observed in the ridge split with piezosurgery group.
o Lower perforation in the active tapping implant group.
o 77.8% of cases had perforations in the area within 3 mm of the crestal site. The occurrence
of perforation gradually decreased apically. It decreased to 5.6% at 10 mm apical from the
crest.
• CONCLUSION
o There was no statistically significant difference in crestal width gain between groups.
o However, the combination of motor-driven ridge expansion technique and the active-
tapping implant could be beneficial in significantly decreasing the bony perforation area.

28. PUBLICATION DEVICE USED
FOR BONE
EXPANSION
WIDTH OF BONE PATIENT
DISCOMFORT
COMPLICATIONS
Shaik et al.
(2016)
Osteotome kit and
mallet
3.94 mm 7.39 mm - 2 (Buccal)
Crespi et al.
(2014)
Osteotome;
electrical and hand
mallet
2.5 mm 7.26 mm 1 patient
showed BPPV
-
Teng et al.
(2014)
Chisel, mallet and
manual reamers (2,
2.5, 3mm)
Mean increase = 2.8 mm - -
Scarano et al.
(2011)
Scalpel, chisel,
Osteotomes
1, 3, 5 mm
Mean increase= 3 mm
- -
Holtzclaw et al.
(2010)
Chisel 3.72 mm 7.09 mm - -
Blus et al.
(2010)
Osteotomes,
Conical screws
3.3 mm 6 mm - -
Demarosi et al.
(2009)
Osteotomes 2.5 – 4.5
mm
6 – 7.5 mm - -

29. Newman, Takei, Klokkevold, Carranza:
Carrazanza’s Clinical Periodontology, Saunders,
10th edition.
Altiparmak N, Akdeniz SS, Bayram B, Gulsever S,
Uckan S. Alveolar Ridge Splitting Versus
Autogenous Onlay Bone Grafting: Complications
and Implant Survival Rates. Implant Dent. 2017
Apr;26(2):284-287.
Lindhe, Lang, Karring: Clinical Periodontology
and Implant Dentistry. Blackwell Munksgaard, 5th
edition.
Tian JH, Neiva R, Coelho PG, Witek L, Tovar NM,
Lo IC, Gil LF, Torroni A. Alveolar Ridge
Expansion: Comparison of Osseodensification
and Conventional Osteotome Techniques. J
Craniofac Surg. 2019 Mar/Apr;30(2):607-610. doi:
10.1097/SCS.0000000000004956. PMID: 30507887.
Goyal M, Mittal N, Gupta GK, Singhal M. Ridge
augmentation in implant dentistry. J Int Clin Dent
Res Organ 2015;7:94-112.
Kao DW, Fiorellini JP. Comparison of ridge
expansion and ridge splitting techniques for
narrow alveolar ridge in a Swine cadaver model.
Int J Periodontics Restorative Dent. 2015 May-
Jun;35(3):e44-9. doi: 10.11607/prd.2269. PMID:
25909532.
Jha N, Choi EH, Kaushik NK, Ryu JJ (2017) Types
of devices used in ridge split procedure for
alveolar bone expansion: A systematic review.
PLoS ONE 12(7): e0180342.
https://doi.org/10.1371/journal.pone.0180342
Khairnar MS, Khairnar D, Bakshi K. Modified ridge
splitting and bone expansion osteotomy for
placement of dental implant in esthetic zone.
Contemp Clin Dent. 2014 Jan;5(1):110-4. doi:
10.4103/0976-237X.128684. PMID: 24808709;
PMCID: PMC4012101.