3-Year follow-up Mandibular Ridge Expansion utilizing Osseodensification

58 Rating(s).


Posted on By Salah Huwais In Bone Grafting

The patient is a 62-year-old male presented with missing teeth #'s 19, 20, and 21. Clinical and radiographic examination revealed a significant alveolar ridge resorption. Initial alveolar ridge measurement was 2.5 mm in areas of # 19, and # 21. Alveolar bone was preserved and plastically expanded to allow for implant placement utilizing Osseodensification with Densah Burs. 3.7/11.5 mm implants were placed with good stability. Full flap coverage was done over a veneer graft (Bone Putty) and collagen membrane. Minimal uncover was done at 10 weeks. The restoration was delivered at 14 wks. A yearly follow-up is provided up to 39 months.

Initial Ridge pre surgery
Osseodensification Ridge Expansion

Implant Placement with Veneer bone graft
10 wks Healing


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15 Comments

IMO, this case is another example of "Site Optimization" achieved by bone preservation. Please note area of #21.

Salah

3-year follow-up


Reply

Salah. Nice case and follow up. IMO Soft tissue management is also important. We need to protect what we preserve. Do you have guidelines for osseodensification when in close proximity to the mandibular canal? Always a pleasure my friend. Chuck.


Reply

Chuck:
I totally agree with you. Soft tissue thickness is key in maintaining bone level around implants.
There is no special protocol for mandibular canal proximity. I always recommend following the already established surgical protocols. For that instance, we must allow at least 2 mm safe zone over the canal. Osseodensification will not deposit bone into the mandibular canal as long as the surgery did not penetrate it and it should not.
Happy new year :)
Salah


Reply

Nice Case Salah!
Very well managed with the osseodensification process.
Canine root also improved coverage with time? Did you graft the zone?
Tissues around implant seems to improve over time.
Regards
Jorge


Reply

"Site Optimization" a good description of this cases

The beauty of the Densah Burs can be fully appreciated here!

Great Job Salah


Emil


Reply

Emil:
Thank you!!. Happy new year, my good friend.


Reply

Jorge:

At the uncovered stage, I used the "Modified Roll" technique to increase soft tissue thickness in the buccal of the implants as well as #22 area. I also think that we have some "creeping attachment phenomenon" as well.
Salah


Reply

Salah, Can you tell us something of your camera selection and settings. The photography, along with the surgical technique is exceptional. I was interested in the fact that there were no vertical bone cuts in this expansion. Would they help in this case? Or are you finding the Densah burs to be totally effective in expansion? Thank you.


Reply

Terry:

Thank you for your kind words. I use a Macro lens (Canon 1:1) with Canon 7D camera and a ring flash, nothing significant. The lens is the key. Cameras these days are all good and affordable.

I tend not to use vertical cuts beyond the bony walls in ridge expansion surgeries due to fracture risk. With osseodensification, I only do the trough (vertical cut within the bony walls) to 10 mm depth, in mandibular cases with an initial ridge width less than 3 mm, to create elasticity during expansion.

As you know, I am biased, I use Densah Burs and osseodensification for all my implants surgeries especially in ridge expansion procedures.

Salah


Reply

Hi Salah,
first of all thanks for showing such a great long term result. I would like to ask you
-is initial bone configuration as D1 or D2 modulating your technique on densification and you never take into consideration the bone release incision?
And often there is a long term bone resorbtion on split crest that you don't seem to have with densah, do you have any explanation for that?
Warm regards and Happy new year.
Armando


Reply

Armando:
Osseodensification works well wherever there is a trabecular bone. Mandibular ridges with a width of 3 mm or less have minimal trabecular bone structure left and more cortical structure exist. As you know, Cortical bone, biomechanically, is slow deforming bone with little plasticity. So I utilize the split in these ridges to create more elasticity during expansion. More elasticity leads to better plasticity.

Cortical bone is a coward tissue. It runs away quickly from insult or infection. IMO, the buccal plate resorption that we have seen historically with the ridge split techniques is related to over-insulting the cortical bone beyond its mechanical ability to plastically deform.

Happy new year to you and yours.

Salah


Reply

Armando:

Here is an example of "What can Wrong" when buccal cortical bone is pushed beyond its ability to plastically deform. In this Maxillary case even with Osseodensification, Implant #4 has failed due to the inability of the remaining buccal bony structure to regenerate. Looking back at this case, I should have delayed #4 implant placement and grafted the osteotomy. Allow the osteotomy socket to heal as a "Guided Expansion Graft" site for three months, and then place #4 implant

It is all about Bone Plasticity my friend. Even further, it is all about Collagen Plasticity.

Salah


Reply

Salah,
I know exactly what you mean by elasticity although now it is rather in my mind then in my hand, but I guess it is a matter of time and case experience. :)
Another question I wanted to ask: what is the behavior of regenerated bone? too soft, consumed by the drill, ossedensify at lower speed. ..?
Thanks for reply, I believe it is an invaluable knowledge how to work that out clinically.
Armando


Reply

Armando:
According to bone biomaterial literature, collagen gives bone its plasticity and its ability to dissipate energy. So collagen integrity is an important determinant of fracture risk (see references below) When surgery extracts enough bone bulk (mineral and collagen), it will deteriorate its plasticity and its ability to resist fracturing, and the site will need longer time to heal. With osseodensification, We optimize the site by preserving its minerals as well as its collagen.
I do not know about the bone graft materials. We have been noticing that healed Xenografts might provide the bulk, but it behaves biomechanically differently than bone tissue. I use mainly allograft (FDBA) 70/30 Cancellous/cortical. In my hands, the allograft when healed well tends to behave similarly to the autogenous bone when Osseodensified. More research is in the planning stage to determine graft materials behavior with osseodensification.

I use 1200 RPM in CCW OD mode.
Salah


Reply

The published Case Report:

http://versah.com/wp-content/uploads/2015/02/Enahncing_Implant_Stability_Osseodensification.pdf


Reply


Hu-Friedy
Salvin