Narrow Ridge with Versah drills and Ritter Implants

351 Rating(s).


Posted on By Maurice Salama In Bone Grafting

A Patient presents with need for Implant in mandibular right 1st molar. The Ridge is narrow with only 2.8mm of width. 3rd molar also requires extraction. Many options here. We decided to harvest Autogenous Bone from area of extraction with ACM drills and Bone scraper. Ridge Expansion accomplished with OD protocol from Versah and placement of a Ritter Implant 5.0mm X 10mm. Impressively the entire implant was surrounded by bone and the stability was 45 NCm. LAbial Contour grafting still performed with autologus bone, PRGF, Fibrin, Collagen membrane and tacks from Salvin Regen. Dr. Salama

Narrow Ridge Occlusal View
Versah OD protocols

4.5mm OD site prep
Ritter 5.0mm Spiral Implant


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35 Comments

Sx GBR Steps 1

Intramarrow penetration
Autogenous Bone placed


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Sx GBR Steps 2

Fibrin membrane placed
Ora mem sustain collagen membrane and tacks


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Stunning case Mo. Love the protocol


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Maurice:

Just Perfect...
It is Site Optimization at its best... enhancing bone plasticity by preservation is the way of the future.

Thank you! for sharing.


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In the future...perhaps utilize 3rd molar for bone grafting material?? Tooth Grinder would have allowed for us to avoid harvesting. Thoughts on that as well? Things are changing in our field so rapidly. Got to stay involved with XP Forum. Dr. Salama


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Maurice, beautiful case and extremely well managed. Amazing the results of the densah drills. I like the flap as well with the extension that gives a good flexibility for the complete coverage.


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Agreed Mo. out of interest why a 5mm. why not the narrowest one necessary for that area thereby increasing the amount of natural bone around the implant.
Thanks H


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Mo. Nice case! Much better than bone extraction drilling. Yes things are moving fast on Dentalxp. All aboard! Thank you for sharing. Warm regards. Chuck

5mm ridge
Megagen AnyRidge4.5 (widest thread 4.9mm0


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Howard; Great question. As I did not expect the amount of expansion I got with the OD Densah burs and was prepared actually to place a 4mm but since I already harvested a lot of autogenous bone chips from the 3rd Molar site and ramus buccal shelf, I decided to go with the 5mm diameter for a large molar replacement and perform the contour graft regardless. I was surprised not to have a dehiscence or fenestration....regards Mo


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Nice case! When the implant stopped 2mm above the crest at 40N/cm, I assume you hand ratcheted to fully seat the implant? Any concerns about over torqueing and placing too much pressure at the crest?


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Steven; Yes, correct. I have a torque ratchet so I can continue to measure my torque. I do not feel that implants have an issue of over torque at insertion as long as it does not damage the internal aspects of the implant. Typically with ritter Implants I am between 40-55NCm which is ideal for immediate and or early loading protocols.
Dr. Salama


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Great case Mo...no doubt this is the way to go . The amazing densah drills changed the way I practice..i hardly use the conventional drills.


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Beautifully managed case Dr Salama !! It is amazing that you did not have any dehiscence, ridge looks NARROW
Would you have still utilized autogenous if you did not have harvest site within same flap?
How long would you wait to uncover ?

Thank you for sharing :)

Ehab


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Great case Dr. Salama,
Its amazing that Versah is able to expand the bone from 2.8mm ridge to over 7mm (5mm diameter implant and possibly 1mm on both B and L) without any fracture or deheiscence. My experience on the posterior mandible usually bone fractures at the last drill. Do you think your patient may had softer site or recently extracted site?


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Hui,
I find this is routine to expand even in the mandible. If you are having fractures in dense bone consider utilizing piezo crestal cut to allow the expansion. They work very well together at high speeds with Densah drills.
Dr S
Great case. I agree using the 3rd molar as graft is another great option. I've been very impressed with the results.


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Hui:
Osseodensification is an applied science of Bone Plasticity. We need more trabecular bone and less cortical bone to achieve it.

In other words, the amount of expansion is related to bone plasticity and it is directly related to trabecular bone. Two factors will influence the expansion rate and minimize the fracture risk:

1-The thickness of the cortical plate plays a negative role because cortical bone is stiffer and less dynamic than trabecular bone. Maurice's case has more factors and "finesse" than it shows. The buccal cortical layer in the case appears to be thin so it did allow more plasticity and as a result more expansion with no fracture or dehiscence.

2-The bounsing operation of the burs and the need to introduce small increments of expansion to allow the bone a rate dependant stress to produce a rate dependant strain (ie expansion).

In cases with thick cortical plate and <3mm ridge width, I, personally, create a horizontal groove to enhance elasticity and produce more plasticity.

I hope this helps.

Salah


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Mo, great case to show a fact: bone plasticity. Versah drills use perfectly well this principle and makes the "miracle" of expanding.
I love the control that assures the use of the drills at 1200 rpm on CCW direction.
Regards.
Jorge


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Mou, very nice application of Versah concept! I believe we should spend some words about bone plasticity concept: -how does it work biologically? -what structures are modified and how? Thanks for sharing. Armando


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Armando:

My lecture at the JTI in Madrid, next week, will cover Bone Plasticity and osseodensification biomachanics. See you then.

Salah


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Salah, great opportunity to partecipate to your lecture and meet you. See you in Madrid. Armando


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An important partof the Dentalxp family is gathering NEXTweekend at JTI Madrid.
I'm very excited about the consequences...
Jorge


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Best regard dear colleagues.

Why not think about of #Piezosurgery procedure? I think it might be less invasive and very good prognosis.

Big hug. Thanks again. Sergio Tobón.


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Sergio; Could have used piezo too but this was much easier....IMO regards Dr. S


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Great case Mo,
Perfect and solid protocol
I believe most people would be terrified to speak about EXPANSION in that area.
You showed a very friendly and non invasive way to look this procedure in a complex area like that for many surgeons. And i think that´s the way it should be, clean, simple, perfect...


I´m using a lot of dentin now and the histological findings are amazing and for sure it will became one more tool in regenerative procedures. Thanks Ziv for sharing that concept also.

Warm regards and Thanks for sharing.

by the way, need those drills

Marcelo


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The Ritter Spiral Implant fits perfectly into the sites prepared with Versah...almost seems that these drills were made for this implant system. great combination. Dr. Salama


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Dr Salama, very nice execution. Do you have a pre operative CBCT to share?I just want to see bone density and thickness of the cortical bone.


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Masoud; Bone quality was Type 3....
Dr. S


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The Versah protocol is very elegant and technique sensitive. I have been using the drills for over a year and I'm amazed every time; ridge expansion, in socket sinus lift...Also, L-PRF will make this case heal quickly and be very stable. Much better and quicker than bone block protocols.
Dr. Salah will be presenting at the Alabama Implant Study Group meeting, August 4-6.


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Do you feel grafting is always beneficial following the Versah expansion?


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Chris; Not always but when expansion leaves a THIN labial plate over the threads DEFINITELY BG.
regards Maurice


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beautiful Dr. Salama... I think I need to get the Versah!


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Thanks Thanos...let us know your thoughts? Dr. S


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Anyone use the new G2 burs? Thoughts?


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Maurice,

I have been using G2 for a couple weeks - IMO- they seem to "hold" the osteotomy a bit more in immed cases - and in thin ridges "grip" the pilot hole especially in dense bone and lastly seem to spread the slurry against the walls of extraction site more uniformly.......

great teaching experiencing this weekend!

Cheers,

Richard



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Ritter
Versah
Salvin