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 »  Home  »  Dental Implant 2  »  Ridge Widening and Immediate Implant Placement
Ridge Widening and Immediate Implant Placement
A Case Report

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Tetsuo Shimoyama, DDS, PhD, Takahiro Kaneko, DDS, Shinjirou Shimizu, DDS, Daigo Kasai, DDS, Takahiro Tojo, DDS, Norio Horie, DDS, PhD
Department of Oral and Maxillofacial Surgery, Saitama Medical Center, Medical School, Saitama, Japan.


Alveolar atrophy is a major problem that has limited the use of endosseous implants since their introduction. When an anterior tooth in the maxilla is lost, often as a result of trauma or endodontic complications, the labial wall of the alveolar socket resorbs rapidly and the residual ridge actually consists of the previous palatal wall. Therefore, the alveolar ridge is predominantly reduced in the horizontal dimension, and immediate implant placement with routine techniques is not possible because of the discrepancy between the thickness of the ridge and the diameter of the implant. Although numerous procedures have been devised to augment the alveolar crest with autogenous bone grafting, such as the ribs and iliac crest, sometimes in conjunction with a barrier membrane, a risk of dehiscence and infections of the mucosa may jeopardize the graft. Furthermore, a two-stage approach to implant placement is generally advocated, lengthening treatment time and increasing cost. In 1992, Simion et al introduced a split-crest-bone manipulation technique. The purpose of this technique was to create self-spacemaking defects by splitting the atrophic crests into two parts with a longitudinal greenstick fracture and placing the implant between them, which is also an effective technique for severely thin alveolar bone. This is advocated when a standard osteotomy technique in which a crest width .4 mm is recommended cannot be applied. Various types of implants have been used within the ridge widening procedure. Because the taper-shaped implants (Endopore implant system, Innova, Toronto, ON) are tapped into position similarly to the driving of a wedge, it is considered to be appropriate for this procedure. The present study reports a case of severe maxillary alveolar atrophy during placement of an immediate taper-shaped implant associated with a ridge widening procedure (RWP) in accordance with Simion et al.

MATERIALS AND METHODS.
57-year-old woman was referred for prosthetic treatment associated with implant placement. Clinical examination showed an edentulous margin with obvious labial and buccal bone resorption (Lekholm and Zarb’s class D atrophy). The radiographic appearance indicated an adequate bone height for implant placement, except that the tomogram view of the anterior maxilla region revealed a knife-edge morphology. For the purpose of placing the implant with an overdenture abutment that assists denture support, two Endopore (Innova) implant placements in the bilateral premolar regions were scheduled.

Surgical Procedure.
For the prosthetic treatment associated with the implant placement, an Endopore (Innova) implant system was prepared.
After appropriate sedation (diazepam, 5 mg; intravenous injection), an incision was made on the crest of the ridge of the bilateral premolar regions slightly toward the palate. In addition, mesial and distal vertical incisions were extended in the buccal direction for the purpose of flap relief. Using a periosteal elevator, mucoperiosteal flaps were buccally elevated sufficient to visualize the alveolar ridge anatomy. After this, the bone crests revealed that the ridge width was approximately 2 mm in diameter and the buccal aspect had a concave form. A surgi chisel was carefully tapped with a mallet to create a channel along the crest of the bone. The channels were extended to a depth of 8 to 10 mm to reduce the occurrence of cortical plate fracture in the subsequent procedures. After cortical plate separation, the punch tip (Endopore [Innova] implant system) was used, starting with the punch tip starter. Using a rotating motion of the two-sized punch tip pilots, the cortical plates were further widened to approximately 4 mm. The final depth and orientation of the prepared sites were then checked by inserting the appropriate trial-fit gauge. After saline irrigation, the Endopore (Innova) implant fixtures (length, 7 mm; diameter, 4.1 mm) were placed and driven into their final fully seated positions with several firm taps using a Teflon-tipped punch and mallet. Releasing incisions in the periosteum at the base of the flap were made to enhance the elasticity of the flap. Closure was carried out by using vertical mattress sutures.
Stage II surgery was scheduled six months after the implantation. Complete healing of the defects had taken place, and the fixtures were covered by regenerated bone. After the soft tissue was restored by placement of a healing abutment, an overdenture abutment was attached to the implant fixture. For the final prosthesis, the overdenture was seated and no functional disorders were observed during five months of follow-up.