Hard tissue ridge augmentation in Periodontology

1. RIDGE AUGMENTATION
DR. RINISHA SINHA
MDS III
DEPARTMENT OF PERIODONTOLOGY

2. TABLE OF CONTENTS
INTRODUCTION
01
HISTORY
02
OBJECTIVES
03
RIDGE
SPLITTING
05 06
AUTOGENOUS
BONE BLOCKS
RIDGE
PRESERVATION
04
TI MESH WITH
RHBMP2
07
DISTRACTION
OSTEOGENESIS
08
REFERENCES
09

3. INTRODUCTION
Teeth loss  Continuous
resorption
Diminished volume and
strength of residual bone
Impaired masticatory function
Loss of facial vertical
dimension
Speech difficulty
Facial soft tissue changes
Reference: Cordaro, L., H. Terheyden, D. Wismeijer, Stephen T. Chen, and
Daniel Buser. ITI Treatment Guide. A Staged Approach Vol. 7, Vol. 7. Berlin:
Quintessence Publishing Co. Ltd, 2014

4. SUCCESSFUL IMPLANT THERAPY depends upon “ADEQUATE VOLUME OF BONE”
To increase the
rate of bone
formation and to
augment bone
volume:
Osteoinduction Appropriate growth
factors
Osteoconduction
A grafting material
serving as a
scaffold for new
bone growth
Distraction
osteogenesis
A fracture is
surgically induced
and the two
fragments are then
slowly pulled apart
Guided Tissue
Regeneration
Allows spaces
maintained by
barrier membranes
to be filled with
new bone
Reference: Reddi 1981; Urist 1965
Reference: Buch et al. 1986; Reddi
et al. 1987
Reference: Ilizarov 1989a,b
Reference: Dahlin et al. 1988, 1991a; Kostopoulos
& Karring 1994; Nyman & Lang 1994

5. The use of autogenous bone
grafts with osseointegrated implants
was originally discussed by
Brånemark et al, who used the
iliac crest as a donor site.
This early Swedish study looked
at completely edentulous cases
and proposed the
autogenous
retransplantation of bone
from the iliac crest to add
bulk to thin cortex bone.
Naturally a learning curve
was expressed whereby the
authors attempted to
simultaneously graft and
place implants. However,
this resulted in low
implant survival.
HISTORY
Reference: Breine U, Brånemark PI. Reconstruction of alveolar
jaw bone. An experimental and clinical study of immediate
and preformed autologous bone grafts in combination with
osseointegrated implants. Scand J Plast Reconstr Surg
1980;14:23–48.
Brånemark PI, Lindström J, Hallén O, Breine U, Jeppson PH,
Öhman A. Reconstruction of the defective mandible. Scand J
Plast Reconstr Surg 1975;9:116–128.

6. Alveolar ridge augmentation has been one of the most widely performed surgical
procedures over the past three decades.
These
include
Ridge preservation Ridge
splitting/expansion
Horizontal bone
augmentation
Ridge augmentation
with block grafts and
with the use of
particulate grafts with
or without barrier
membranes
Vertical bone
augmentation
Guided bone
regeneration
Onlay bone
grafting
Distraction
osteogenesis
Reference: Cordaro, L., H. Terheyden, D. Wismeijer, Stephen T. Chen, and Daniel
Buser. ITI Treatment Guide. A Staged Approach Vol. 7, Vol. 7. Berlin: Quintessence
Publishing Co. Ltd, 2014

7. OBJECTIVES OF RIDGE AUGMENTATION
Function
Esthetics
Prognosis
Straight forward surgical technique
Minimal burden for the patient
Low morbidity
Reduced surgical sessions
Low cost,
High predictability
Lesser healing time
Reference: Cordaro, L., H. Terheyden, D. Wismeijer, Stephen T. Chen, and Daniel Buser. ITI Treatment Guide. A Staged Approach Vol. 7, Vol. 7. Berlin:
Quintessence Publishing Co. Ltd, 2014

8. BONE DEFECT CLASSIFICATION
In 1983, Seibert (1983a, 1983b)
classified the different types of
alveolar ridge defects that a
clinician may encounter.
Class I
Alveolar ridge defects
have a horizontal loss
of tissue with normal
ridge height.
Class II
Alveolar ridge defects
have a vertical loss of
tissue with normal ridge
width.
Class III
Alveolar ridge defects
have a combination
of class I and class II
resulting in loss of
normal height and width.

9. INDICATION When the loss of gingiva or bone compromises the positive outcome of a
prosthetic restoration.
Easiest to treat : Class I > Class II > Class III
Prognosis: Horizontal > Vertical or Combination

10. The Cologne Classification of Alveolar Ridge Defects (CCARD) classifies volume
deficiencies of the alveolar process regardless of their etiology as vertical (V),
horizontal (H), or combined (C), possibly in conjunction with a sinus area defect (+S)
BONE GRAFT CLASSIFICATION

11. CCARD CRITERIA
• In general, intrabony defects are more easily
grafted and result in more predictable outcomes than
extrabony defects.
• It is easier to stabilize/immobilize and protect an
intrabony grafted defect.
• In addition, soft tissue coverage and inherent
generative capacity is optimized with these defects.
• Other considerations during bone grafting include
the osteogenic potential of the recipient site.
Reference: Wang HL, Boyapati L. “PASS” principles for
predictable bone regeneration. Implant Dent 2006;15:8–17

12. RIDGE PRESERVATION
Overview of the extraction site after 1, 2, 4, and 8
weeks of healing Reference: Araújo and Lindhe; 2005
• Ridge preservation is typically described as a socket or sinus augmentation using nonviable grafts
(ie, allografts, allogeneic bone, and xenogeneic bone).
The dimensional changes that occur following tooth extraction remain inevitable even if biomaterials are
utilized.

13. Healing process following tooth extraction Reference: Avila-Ortiz and Zadeh; 2019

14. MATRIX
VITRONECTIN
FIBRIN &
FIBRONECTIN
BIOLOGIC PERSPECTIVE OF AUGMENTATION
CELL
ADHESION
MOLECULES
SIGNALING
MOLECULES

15. CONVENTIONAL SOCKET GRAFTING AND RIDGE
PRESERVATION TECHNIQUES
1. Minimally Traumatic Tooth Extraction
USING PERIOTOME,
ROTARY BURS AND
EXTRACTION FORCEPS

16. 2.2. After tooth removal, the alveolar socket is debrided of all
granulation tissue.
3.3. Bleeding is stimulated from the osseous walls
through the use of rotary instruments or curettes.
To trigger the regional acceleratory phenomenon, which stimulates new bone formation and graft
incorporation. Reference: Frost HM; 1989
2.4. The extraction socket should be evaluated visually and tactilely with the help of a
periodontal probe.
Evaluation done with special attention to direct visualization of the labial plate’s integrity and
thisckness; identifying fenestration and dehiscence defects.

17. SINGLE-TOOTH
ALVEOLAR RIDGE
PRESERVATION IN THE
NON-ESTHETIC ZONE
• A HIGH-DENSITY PTFE (DPTFE)
MEMBRANE (CYTOPLAST,
OSTEOGENICS)
• FDBA (MINEROSS)
1ST SCENARIO

18. LEUKOCYTE PLATELET-RICH FIBRIN (L-PRF) AS A BARRIER MEMBRANE AS OPPOSED TO USING DPTFE
2ND SCENARIO Reference: Miron RJ, Zucchelli G, Pikos MA, et al; 2017

19. SINGLE-TOOTH ALVEOLAR RIDGE PRESERVATION IN THE
ESTHETIC ZONE
F
I
V
E
D
I
A
G
N
O
S
T
I
C
K
E
Y
S
F
I
V
E
D
I
A
G
N
O
S
T
I
C
K
E
Y
S
Reference: Kois JC; 2001
Management
guidelines
for
evaluating
tissue
degradation
Management
guidelines
for
evaluating
tissue
degradation

20. ALLOGRAFT; FREE GINGIVAL GRAFT AND DPTFE MEMBRANE
1ST SCENARIO

21. Two key parameters are noted:
1. To date, there are currently no available options to completely prevent
dimensional changes following tooth extraction. Resorption of bundle bone will
occur regardless of the alveolar ridge preservation technique utilized.
2. There is no ideal or favored method to preserve dimensional changes of the
alveolar ridge, including using GBR techniques, socket fillers, socket seals, or
combinations of these
Reference:
• Morjaria KR, Wilson R, Palmer RM. Bone healing after tooth extraction with or without an intervention: A systematic review of randomized controlled trials.
Clin Implant Dent Relat Res 2014;16:1.
• Lekovic V, Kenney EB, Weinlaender M, et al. A bone regenerative approach to alveolar ridge maintenance following tooth extraction. Report of 10 cases. J
Periodontol 1997;68:563–570.
• MacBeth N, Trullenque-Eriksson A, Donos N, Mardas N. Hard and soft tissue changes following alveolar ridge preservation: A systematic review. Clin Oral
Implants Res 2017;28:982–100

22. SYNONYMS: Socket Shield Technique; Partial Extraction Therapy; Root Submergence Technique
ALTHOUGH SOCKET PRESERVATION
METHODS HAVE BEEN SHOWN TO
LIMIT DIMENSIONAL CHANGES POST-
EXTRACTION AND REDUCE THE
UNPLEASANT ESTHETIC EFFECTS OF
PHYSIOLOGIC BONE RESORPTION IN
THE ESTHETIC ZONE, NONE
COMPLETELY PREVENT RESORPTION.
ROOT MEMBRANE TECHNIQUE
Reference: Chappuis V, Araujo J et al; 2017
For preserving the buccal bone with up to 10 -
year follow-up is the in-situ maintenance of the
buccal portion of the root in a procedure.
Hypothesis: By maintaining the buccal aspect of
the root and its associated periodontal ligament
(and hence the associated blood vessels), one may
be capable of preventing the physiologic bone
resorption of the buccal bone.
Reference: Hürzeler MB, Zuhr O, Schupbach P, Rebele SF, Emmanouilidis N, Fickl S. The
socket-shield technique: A proof-of-principle report. J Clin Periodontol 2010;37:855–862.

23. Based on current
evidence, there is
significant merit for
future research
attempts to investigate
in a controlled fashion
whether the benefit
from the use of this
technique can establish
it as the gold
standard for
immediate implant
placement in the
esthetic zone.

24. RIDGE SPLITTING
Hilt Tatum is given credit for working with ridge expansion protocols in the 1970s.
• The protocol at the time included tapered channel formers, D-shaped osteotomes, and
custom implants. Reference: Tatum H Jr. Maxillary and sinus implant reconstructions. Dent Clin North Am 1986;30:207–229.
Indications for ridge expansion
Narrow alveolar ridge (minimum 2+
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

25. Key points
• Ridge expansion and simultaneous implant placement in the maxilla
typically result in an exaggerated facial implant inclination because the implant
osteotome follows the denser palatal bone.
• Factors to consider include interocclusal space and biomechanical force factors
(especially parafunction).
• The advantages of the ridge splitting technique include faster healing.
• The treating clinician must always weigh the pros and cons because ridge split
failure can also occur and result in catastrophic bone loss.
• This technique is more suitable for the maxillary arch because of its more
cancellous nature (ie, lower bone density).
Reference: Lustmann J, Lewinstein I. 1995

26. RIDGE SPLIT TECHNIQUE
USING A
PIEZOSURGERY DEVICE

27. RIDGE SPLIT TECHNIQUE
USING OSTEOTOMES

28. MANDIBULAR RIDGE SPLIT TECHNIQUE USING
PIEZOSURGERY AND OSTEOTOMES

29. 1. Incision design/flap
management
2. Site preparation -
angiogenesis
3. Space
maintenance
4. Graft stability
5. Tension-free primary
closure
Reference: Wang HL, Boyapati L. “PASS” principles for
predictable bone regeneration. Implant Dent 2006;15:8–17
Keys for Predictable Bone Augmentation

30. INCISION
DESIGNS

31. FINGER
SWEEP
PROTOCOL
FOR
MANDIBULAR
LINGUAL
FLAP
RELEASE

32. WORKFLOW
DEMONSTRATING
KEY
PRINCIPLES
FOR
BONE
AUGMENTATION

34. AUTOGENOUS BONE BLOCK GRAFTING
• INCISIONS AT THE DONOR SITE
• INCISIONS AT THE RECEIPIENT SITE

35. INDICATIONS, ADVANTAGES, AND DISADVANTAGES FOR
EACH INCISION METHOD

36. Several possible origins for autogenic bone include
the calvarium, tibia, and the iliac crest.
Reference: Harsha BC, Turvey TA, Powers SK. 1986. Reference: Breine U, Bränemark PI. 1980. Reference:
• Keller EE, van Roekel NB, Desjardins RP, Tolman DE.
1987.
• Listrom RD, Symington JM. 1988.
• Schwartz-Arad D, Dori S. 2002.
• Although the iliac crest is most often used in major jaw reconstruction, it is not always
recommended due to its morbidity, altered ambulation, and
the need for hospitalization.
• There is also significant resorption associated with cortico-cancellous block
grafts from endochondral donor sites.
• These disadvantages, together with the fact that dental implants
do not demand large amounts of bone, led to the growing use of intraoral block bone grafts
from intraoral sources, especially from the
mandibular symphysis and ramus. Reference: Misch CM; 1996, 1997.
Reference:
• Misch CM; 1992, 1995, 1997.
• Kleinman A et al. 2002

37. ADVANTAGES OF INTRAORAL BONE GRAFT SOURCES
Conventional surgical access
and the proximity of donor
and recipient sites
Reduce operative and
anesthesia time
Making it ideal for outpatient implant surgery
• There is no cutaneous scar
• Patients report minimal discomfort and
less morbidity compared with extraoral
locations

38. SYMPHYSIS HARVESTING
• THREE PRIMARY INCISION DESIGNS CAN
BE USED FOR HARVESTING BLOCK BONE
FROM THE SYMPHYSIS: SULCULAR,
MARGINAL, AND ALVEOLAR MUCOSAL.
• SULCULAR INCISION PREFERRED MORE
OVER CONVENTIONAL VESTIBULAR
APPROACH.
• FOLLOWED BY AN OBLIQUE SURFACE
RELEASING INCISION.
• FULL THICKNESS MUCOPERIOSTEAL FLAP
Reference: Linkow LI. Bone transplants using the
symphysis, the iliac crest and synthetic bone
materials. J Oral Implantol 1983;11:211-247.
THE 5-MM RULE

39. SULCULAR V/S VESTIBULAR APPROACH
SULCULAR
• EASIER ACCESS
• BETTER VISUALISATION OF THE MENTAL
NEUROVASCULAR BUNDLES
• EASIER SUPERIOR AND INFERIOR RETRACTION OF
THE FLAP MARGINS
• NO WOUND DEHISCENCE NOTED
• POSTOPERATIVE PAIN IS REDUCED, AND NO
ASSOCIATED PTOSIS
VESTIBULAR
• LIMITED ACCESS
• INCOMPLETE VISUALIZATION OF THE MENTAL
NEUROVASCULAR BUNDLES
• MORE DIFFICULTY IN SUPERIOR AND INFERIOR
RETRACTION OF THE FLAP MARGINS
• BLEEDING IS SECONDARY TO THE MENTALIS
MUSCLE INCISION AND RESULTS IN THE NEED
FOR HEMOSTASIS
• CAN RESULT IN WOUND DEHISCENCE AND SCAR
BAND FORMATION

40. • ONE OF THE MOST FREQUENTLY USED SITES
FOR INTRAORAL HARVESTING OF
AUTOGENOUS BLOCK GRAFTS.
• FULL-THICKNESS MUCOPERIOSTEAL INCISION
• OBLIQUE RELEASING INCISION
• FULL-THICKNESS MUCOPERIOSTEAL FLAP
• “THREE COMPLETE OSTEOTOMIES AND ONE
BONE GROOVE”
RAMUS BUCCAL SHELF BLOCK
GRAFT HARVESTING

41. 1. USING ROTARY FISSURE BURS 2. USING PIEZOSURGERY DEVICE

42. RAMUS BUCCAL SHELF BLOCK GRAFT TECHNIQUE

43. TIMING FROM BLOCK GRAFTING TO IMPLANT PLACEMENT
HORIZONTAL
AUGMENTATION
VERTICAL
AUGMENTATION
MAXILLA 4 MONTHS 5 MONTHS
MANDIBLE 5 MONTHS 5 MONTHS
ADVANTAGES AND DISADVANTAGES
OF AUTOGENOUS BONE GRAFTING
Native bone qualities Increased surgical time
Optimal bone volume and density Minimal donor bone Volume
Predictable volume enhancement More surgical training required
Increased patient acceptance Donor site morbidity
Lower cost

44. TITANIUM MESH PARTICULATE GRAFT WITH RHBMP-2

45. ADVANTAGES OF COLLAGEN MEMBRANES AND
TITANIUM-REINFORCED MEMBRANES AND MESH
COLLAGEN MEMBRANES
• LACK OF NEED FOR STAGE-TWO SURGERY
• PHYSIOLOGICALLY FAVORABLE PROPERTIES
• IMPROVES HEMOSTATIC FUNCTION BY PLATELET
AGGREGATION, WHICH FACILITATES EARLY CLOT
FORMATION AND WOUND STABILIZATION
• CHEMOTACTIC FUNCTION FOR FIBROBLASTS THAT
ASSISTS IN CELL MIGRATION TO PROMOTE
PRIMARY WOUND CLOSURE
• EFFECTIVE IN INHIBITING EPITHELIAL MIGRATION
AND PROMOTING NEW CONNECTIVE TISSUE
ATTACHMENT
TITANIUM-REINFORCED MEMBRANES AND MESHES
• FATIGUE STRENGTH IS NOT AN ISSUE; IT CAN BE
USED AT A THICKNESS OF 0.2 MM WITH VERY
LITTLE POSSIBILITY OF FRACTURE
• HIGH TENSILE STRENGTH ALLOWS IT TO ADAPT
NICELY AND BE PHYSIOLOGIC WITH BONE
• THICKNESS RANGES FROM 0.1 TO 0.6 MM
• HIGH DUCTILITY AND STRENGTH

46. STEP-BY-STEP GUIDE TO ALVEOLAR BONE AUGMENTATION WITH
TITANIUM MESH (MEGAGEN; I-GEN)

47. • Distraction osteogenesis (DO) was first described by CODIVILLA in1905 and later popularized via
the extensive research performed by ILIZAROV in orthopedic literature in 1989.
DISTRACTION OSTEOGENESIS
Reference:
• Codivilla A: On the means of lengthening in the lower limbs, the muscles and tissues which are shortened through deformity. Am J Orthop Surg 1905;2:353–369.
• Ilizarov GA: The tension stress effect on the genesis and growth of tissues. Part I. The influence of stability of fixation and soft tissue preservation. Clin Orthop
1989;238:249–281.
• Ilizarov GA: The tension stress effect on the genesis and growth of tissues. Part II. The influence of the rate and frequency of distraction. Clin Orthop 1989;239:263–
285.
• Craniofacial DO was first done by SNYDER in 1973 in a canine model and later reported in
humans by GUERRERO (1990), MCCARTHY ET AL. (1992), KABANET AL. (1993).
Reference:
• Snyder CC, Levine GA, Swanson HM, Browne EZ Jr: Mandibular lengthening by gradual distraction. Preliminary report. Plast Reconstr Surg 1973;51:506–508.
• Guerrero CA: Expansion rapida mandibular. Rev Venez Ortod 1990;12:48.
• McCarthy JG, Schreiber J, Karp N, Thorne CH, Grayson BH: Lengthening the human mandible by gradual distraction. Plast Reconstr Surg 1992;89:1–8.
• Perrott DH, Berger R, Vargervik K, Kaban LB: Use of a skeletal distraction device to widen the mandible: a case report. J Oral Maxillofac Surg 1993;51(4):e435–439.
• Alveolar distraction was initially reported via animal studies conducted by BLOCK ET AL. and
later described via a clinical report by CHIN ET AL. in 1996.
Reference:
• Troulis MJ, Glowacki J, Perrott DH, et al: Effects of latency and rate on bone formation in a porcine mandibular distraction model. J Oral Maxillofac Surg
• 2000;58:507.
• Kaban LB, Thurmüller P, Troulis MJ, et al: Correlation of biomechanical stiffness with plain radiographic and ultrasound data in an experimental mandibular distraction
wound. Int J Oral Maxillofac Surg 2003;32:296.

48. Alveolar augmentation for placement
of dental implants
In treating moderate to severe
maxillary and mandibular alveolar
ridge atrophy, mostly in the anterior
region.
For correcting vertical alveolar ridge
defects but can be used for
increasing the width as well
Some degree simultaneous correction
of an alveolar bone horizontally
due to often observed pyramidally
shaped morphology of the alveolar
bone
“To increase soft tissue as well
as bone”
In cases where the bone loss
is so severe that the device
cannot be placed
If the transport segment is
not at least 5 mm in size.
Patients unable to follow the
distractor activation protocol
INDICATIONS
CONTRAINDICATIONS
Reference:
• Zimmermann CE, Thurmüller P, Troulis MJ, et al: Histology of the porcine mandibular distraction wound. Int J Oral Maxillofac Surg 2005;34:411.

49. • Jensen and block presented an alveolar site classification system that could be applied in making treatment
decisions:
• Class I – mild alveolar deficiency with up to 5 mm of vertical bone loss;
• Class II – moderate deficiency with 6–10 mm of vertical bone loss;
• Class III – severe deficiency with greater than 10 mm of vertical bone loss;
• Class IV – severe bone loss at the edentulous alveolar ridge as well as significant bone loss on adjacent
teeth
 Class I defects : smaller; hence, treated with traditional sandwich osteotomy or with conventional bone
grafting techniques.
 Class II defects : more amenable to be reconstructed with Alveolar Distraction Osteogenesis.
 Treatment of Class III defects depends on the availability of bone stock in the defect.
 If there is enough bone, distraction can be performed but may have to be supplemented by bone grafts
later or else will need bone grafting first with secondary Alveolar Distraction Osteogenesis.
 Class IV defects : complicated by adjacent teeth that have a poor prognosis. These teeth can be extracted to
convert the defect into a Class III type defect and continue treatment as above.
Reference: Chiapasco M, Zaniboni M, Rimondini L: Autogenous onlay bone grafts vs. alveolar distraction osteogenesis for the correction
of vertically deficient edentulous ridges: a 2–4-year prospective study on humans. Clin. Oral Impl. Res. 2007;18:432–440

50. ADVANTAGES
• Avoids donor site morbidity and
surgical risks associated with
autogenous bone graft harvest.
• Simultaneous distraction of bone and
soft tissues decreases or eliminates
the need for soft tissue grafting in
contrast to other bone augmentation
techniques.
• The distraction device is maintained
and activated by patients
themselves at home.
DISADVANTAGES
• Additional cost of the device
• Patient compliance
• Difficulty in controlling the
vector of distraction

51. ALVEOLAR DISTRACTION OSTEOGENESIS DEVICES
EXTRAOSSEOUS DISTRACTORS
Synthes®, distractor track;
KLS/Martin®, Tuttlingen, Germany
Used in severe alveolar defects
Can provide both vertical and horizontal
vectors depending on the placement technique
Not a great amount of horizontal augmentation
achieved
Easier to place, as the plates are flexible to be
adapted over the remaining bone.
The plates can be contoured to control the vector
of distraction.
The distraction rod of the device extends through
the mucosa into the oral cavity
INTRAOSSEOUS DISTRACTORS
LEAD® System, Leibinger, Kalamazoo,
MI; DIS-SIS distraction implant; SIS
Systems Trade GmbH, Klagenfurt, Austria
Work best in smaller segments
The threaded rod is rotated to obtain
distraction

53. COMPLICATIONS
The complication
rates have been
reported to be
anywhere
between 30%
and 100% but
the majority of
them are reported
to be minor.
1. Thinning of the transport segment or the basal bone and excessive force during osteotomy make
the transport segment or the mandible more vulnerable to fracture.
If small fractured fragment of the transport segment  discarded and treatment continued as planned.
If it is significantly large  reduced and stabilized along with abortion of the planned procedure.
This complication can be prevented by meticulous case selection with an adequate amount of available
bone and appropriate execution of the osteotomy.
Avoiding sharp angles in the osteotomy is reported to reduce the incidence of fractures
2. Excessive length of the threaded rod of the distractor can cause occlusal interference,
discomfort to the patient, and limit distraction.
This can be prevented by appropriate selection or modification of the length of the threaded rod by
fitting and/or trimming with application on mounted dental models.
3. Damage to adjacent soft and hard tissue structures occurs usually due to an improper technique or
use of excessive force during osteotomy.
Using an osteotome for completion of the lingual part of the osteotomy or using a piezoelectric saw blade
may help reduce this complication.
4. Dehiscence or perforation of the mucosa by the transport segment/distractor is secondary to
poor soft tissue coverage over the osteotomy and sharp edges of bone or excessive tension at
closure over the distractor.
Reducing the rate of distraction and reduction of the sharp bony edges may be required.
Reference: Chin M, Toth BA:
Distraction osteogenesis in
maxillofacial surgery:
using internal devices. J
Oral Maxillofac Surg
1996;54:45–53.

54. 1. SANDWICH TECHNIQUE
2. SHELL TECHNIQUE
3. SWINGING INTERPOSITIONAL GRAFT FOR
VERTICAL AND HORIZONTAL AUGMENTATION
4. INTERPOSITIONAL GRAFT FOR VERTICAL
AUGMENTATION IN THE MAXILLA (LE FORT I
LEVEL)
5. TRANSOSSEOUS ANCHOR SUTURE TECHNIQUE
6. KHOURY’S PROTOCOL
7. FENCE TECHNIQUE
8. BOX TECHNIQUE
9. INTERPOSITIONAL GRAFTING
10. FUTURE DEVELOPMEMTS

55. 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.
Urban IA, Montero E, Monje A, Sanz-Sánchez
I. Effectiveness of vertical ridge augmentation
interventions: A systematic review and meta-
analysis. J Clin Periodontol. 2019 Jun;46
Suppl 21:319-339.
Goyal M, Mittal N, Gupta GK, Singhal M.
Ridge augmentation in implant dentistry. J Int
Clin Dent Res Organ 2015;7:94-112.
Kakar A, Kakar K, Sripathi Rao BH, Lindner A,
Nagursky H, Jain G, Patney A. Lateral
alveolar ridge augmentation procedure using
subperiosteal tunneling technique: a pilot
study. Maxillofac Plast Reconstr Surg. 2018
Feb 25;40(1):3.
Kloss FR, Offermanns V, Kloss-Brandstätter
A. Comparison of allogeneic and autogenous
bone grafts for augmentation of alveolar
ridge defects-A 12-month retrospective
radiographic evaluation. Clin Oral Implants
Res. 2018 Nov;29(11):1163-1175.
Ciocca L, Lizio G, Baldissara P, Sambuco A,
Scotti R, Corinaldesi G. Prosthetically CAD-
CAM-Guided Bone Augmentation of Atrophic
Jaws Using Customized Titanium Mesh:
Preliminary Results of an Open Prospective
Study. J Oral Implantol. 2018 Apr;44(2):131-
137.