Journal of Indian Society of Periodontology
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Year : 2018  |  Volume : 22  |  Issue : 6  |  Page : 555-558  

Hard- and soft-tissue augmentation around dental implant using ridge split and connective tissue graft for esthetic rehabilitation of atrophic anterior maxilla

Department of Periodontics, Dr. Ziauddin Ahmad Dental College, Faculty of Medicine, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Date of Submission06-Mar-2018
Date of Acceptance24-Jul-2018
Date of Web Publication1-Nov-2018

Correspondence Address:
Dr. Mahira Kirmani
Department of Periodontics, Dr. Ziauddin Ahmad Dental College, Aligarh Muslim University, Aligarh - 202 002, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jisp.jisp_152_18

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Esthetic rehabilitation of edentulous site with horizontal ridge deficiency presents as one of the most challenging situations in implant practice. With the increase in popularity of dental implants, augmentation of the alveolar ridge and soft tissue has also become a routine procedure in most of the cases. Although hard-tissue augmentation is performed by other specialists also, a periodontist needs to master the skills of soft-tissue management to deliver esthetic and functional results in implant-supported prostheses. This case report presents a single-staged ridge split approach using piezoelectric surgery with simultaneous implant placement followed by connective tissue grafting at second-stage surgery. Single-staged segmental ridge split technique not only reduces the total treatment duration but also the surgical morbidity for the patient. A subepithelial connective tissue graft is strongly advocated around implants as it is highly predictable while ensuring better esthetic results in terms of tissue color, texture, and long-term stability of the surrounding mucosa.

Keywords: Alveolar ridge augmentation, dental implant, piezoelectric bone surgery, tissue grafts

How to cite this article:
Kirmani M, Zia A, Ahad A, Bey A. Hard- and soft-tissue augmentation around dental implant using ridge split and connective tissue graft for esthetic rehabilitation of atrophic anterior maxilla. J Indian Soc Periodontol 2018;22:555-8

How to cite this URL:
Kirmani M, Zia A, Ahad A, Bey A. Hard- and soft-tissue augmentation around dental implant using ridge split and connective tissue graft for esthetic rehabilitation of atrophic anterior maxilla. J Indian Soc Periodontol [serial online] 2018 [cited 2020 May 27];22:555-8. Available from:

   Introduction Top

Implant placement in the esthetic zone is a challenging task, especially when the height and width of the alveolar ridge are inadequate. Atrophic ridges with horizontal, vertical, or combined defects are commonly encountered during treatment planning of endosseous implants. There are various treatment modalities that are advocated for treatment of ridge defects such as autogenous or allogeneic block bone grafting, alveolar distraction osteogenesis, guided bone regeneration (GBR), and segmental ridge-split procedure (RSP). Alveolar ridge split technique was first introduced by Tatum for bone augmentation in the maxilla.[1] Later, various authors have documented different modified techniques for RSP.[2] Conventionally, the segmental ridge-split technique consists of a single surgical stage in the maxilla and a two-stage approach in the mandible. There are various methods to accomplish the ridge split, involving the use of osteotomes, chisels, rotary instruments, and piezosurgery. Piezoelectric surgery is one of the recent techniques that is being used for osteotomy.

The osseointegration is one of the critical factors for successful implant therapy. However, for a stable, long-term, esthetic outcome, the importance of adequate soft tissue around the dental implant including an intact midbuccal soft-tissue profile and interproximal papilla cannot be ignored. Inadequate dimensions of soft tissue can result in esthetic and functional complications including challenges in oral hygiene maintenance, phonetic impediments, and susceptibility to mucosal recession.

This case report describes 1-year follow-up of piezosurgery-assisted segmental RSP and simultaneous implant placement in a 30-year-old female with an inadequate faciopalatal ridge dimension of 3.61 mm in maxillary central incisor region. In the second-stage surgery, subepithelial connective tissue grafting was also performed to achieve optimum pink esthetics.

   Case Report Top

A 30-year-old female reported with the chief complaint of a missing front tooth for the past 8 months. According to her past treatment records, the tooth was lost to a traumatic injury involving upper lip and anterior maxilla. She was systemically healthy. Her lip was found to be normal without any sign of injury. On intraoral examination, maxillary left central incisor was missing and horizontal atrophy of edentulous area was noticed [Figure 1]a and [Figure 1]b. Incisal edge of adjacent lateral incisor was also fractured; however, the patient was not concerned about it. Angle's Class II malocclusion with anterior deep bite was present. Oral hygiene was fair, but teeth had generalized intrinsic staining, suggestive of hypomineralized enamel. A comprehensive case history was recorded, followed by investigations including routine blood screening, periapical radiograph, and cone beam computed tomography (CBCT) of the anterior maxilla [Figure 2]a and [Figure 2]b. CBCT image showed ridge width as 3.61 mm, while ridge height was adequate [Figure 2]b. Segmental RSP was planned along with implant placement. Scaling and polishing was done and the patient was instructed to follow strict oral hygiene protocol.
Figure 1: (a) Preoperative frontal view. (b) Preoperative occlusal view

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Figure 2: (a) Preoperative radiograph. (b) CBCT image of the edentulous site showing inadequate width of the alveolar ridge

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Presurgical considerations

Preoperatively, the alveolar ridge was carefully inspected and palpated with fingers sliding along the alveolar crest providing a tactile sense of the ridge contour, thickness, and the presence of tissue defect. RSP requires a minimum of 3.5 mm bucco-palatal width and 7 mm of mesiodistal width for a single-tooth edentulous area.[1] The vertical extent of the split needs to approximate the length of implant to be placed which was 11.5 mm in this case.

Surgical technique

After administration of local anesthesia (2% lignocaine with 1:200,000 adrenaline), a crestal incision and two vertical incisions were given; on the mesiolabial line angles of adjacent right central incisor and left lateral incisor. A mucoperiosteal flap was elevated [Figure 3]a and [Figure 3]b. For segmental ridge split, three cuts were made in the cortical bone. A crestal osteotomy was followed by two vertical cuts on the labial aspect with saw tips and diamond coated tips of the piezosurgery unit [Figure 3]c. The depth of crestal osteotomy was 10 mm. The length of two vertical cuts was 10 mm and depth was 2 mm at coronal ends and 3 mm at apical ends. The buccal plate of the edentulous ridge was separated from the lingual plate and expanded up to 4.3 mm with the help of a wide periosteal elevator [Figure 3]d. Extent of expansion (in mm) was measured using the bone gauge (for outer width) and osteotomy drills (for inner width), intermittently during the procedure. In the expanded available space, an implant of 3 mm diameter and 11.5 mm length was placed under slow speed and high torque, which further expanded the bone width to 6.7 mm [Figure 3]e and [Figure 3]f. The leftover space between two cortical plates was filled with alloplastic particulate bone graft material; β-tricalcium phosphate and the ridge was covered with a collagen membrane. The flap was coronally advanced to compensate for ridge expansion, and primary closure was achieved with interrupted 4–0 silk sutures. The patient was instructed to avoid brushing in maxillary anterior teeth and to use 0.2% chlorhexidine mouth rinse twice daily for next 15 days. Antibiotics (amoxicillin 500 mg and metronidazole 400 mg) were prescribed three times daily for 7 days along with analgesics (Aceclofenac 100 mg and Paracetamol 325 mg) twice daily for 5 days. Healing was uneventful. Sutures were removed 2 weeks after surgery.
Figure 3: (a) A crestal and two vertical incisions were given in the edentulous area. (b) Flap elevation. (c) Osteotomy for ridge-split procedure using piezosurgical unit. (d) Expansion of bone with the help of a periosteal elevator. (e) An implant of 3 mm diameter was placed between two cortical plates. (f) Periapical radiograph after implant placement

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The healing abutment was removed 4 months after implant placement, and a prosthetic abutment was placed to check the height and width of abutment collar. However, a soft-tissue deficiency and the presence of thin biotype were noted over the labial surface of the abutment [Figure 4]a. Connective tissue grafting with pouch technique was performed to enhance soft-tissue bulk and contour around the abutment [Figure 4]b. Esthetic crown lengthening was also performed on adjacent central incisor. Impressions were made after the healing period of 4 weeks when the soft tissue around the abutment was found adequate [Figure 4]c.
Figure 4: (a) Abutment placed before soft-tissue augmentation. Note the soft-tissue deficiency over prosthetic abutment. (b) Connective tissue grafting with pouch technique. (c) Four-weeks postoperative view after connective tissue grafting. (d) Final prosthesis

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Implant restoration

An implant level indirect impression was made with closed tray technique after placing a transfer coping. A combination of putty and light body addition silicone material was used for the impression. A zirconia crown with E-max layering was cemented over the titanium abutment. The patient was satisfied with functional and esthetic results [Figure 4]d. Oral hygiene instructions were reinforced, and the patient was instructed about the need of regular follow-up.


After placement of the prosthesis, patient-reported twice in the last 1 year. In the meantime, she also got her fractured lateral incisor restored. On 1-year follow-up, she reported with mild inflammation of gingival margins around her left maxillary lateral incisor [Figure 5]a. Probing depth around the prosthesis was 3 mm on all four aspects. On a periapical radiograph, mild crestal bone loss was obvious around the implant-supported prosthesis [Figure 5]b. Scaling and polishing were performed, and oral hygiene instructions were reinforced.
Figure 5: (a) Clinical view one year after loading (b) Periapical radiograph 1 year after loading

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   Discussion Top

Severe resorption of alveolar bone can make implant insertion challenging due to inadequate bone volume and/or abnormal morphology. For the placement of implants, there should be at least 1.5 mm of bone on the facial aspect and 0.5 mm on the palatal aspect.[3] This indicates that, for placing an implant of 3 mm diameter, the width of alveolar ridge should be at least 5 mm. In this case, initially, the width of alveolar ridge was 3.61 mm at maximum convexity in the edentulous area which was inadequate for placing a successful implant. For accomplishing worthy results, ridge augmentation was needed in this case.

Augmentation of bone volume can be done by various methods including onlay/inlay bone grafting procedures, GBR, segmental ridge-split technique, and distraction osteogenesis. The present case of collapsed alveolar ridge of 3.61 mm width with adequate vertical height was suitable for segmental RSP. Requirement of the additional donor site, invasiveness of the procedure, resorption of grafting materials, membrane exposure or collapse, and increased duration of overall treatment were some of the factors considered before choosing segmental RSP over other regenerative procedures in this case.

Different modifications of RSP with or without inlay bone grafting have been documented.[2],[4] The technique we have used has been reported to be a highly successful procedure with implant success rate of 98%–100%.[5] Usually, 3–4 mm of alveolar width and more than 10 mm of alveolar height should be present for a single-tooth edentulous ridge to undergo RSP.[6] In this case, 3.61 mm faciopalatal width of the ridge was present with an adequate layer of cancellous bone facilitating the elasticity while separating the two cortical plates.

Alveolar ridge splitting can be performed by various instruments such as chisels and mallet and rotary instruments such as the diamond disc, burs, rotating saw, or the piezoelectric surgery unit.[2] With the advent of piezosurgery, this procedure has become easy, simpler, reliable, and more predictable.[7],[8] Piezoelectric bone surgery is superior to other devices as it makes a precise cut on the bone surface and causes minimal damage to soft tissues.[8] It also maintains osteogenic potential by rapid cutting and preventing rise in temperature at the surgical site.[9] Advantages of piezoelectric surgery also include good tactile sensitivity compared to the surgical burs or saws. Although the periosteal elevators have rarely been reported to be used for such purpose, we found it (particularly the wider one) to be more efficient in the controlled separation of cortical plates after splitting by a piezosurgical unit.

Apart from several advantages of ridge split, there are some shortcomings of this technique as well. RSP cannot be used for vertical augmentation and is highly dependent on the operator's skills. Although this technique is difficult to perform in an edentulous space for a single tooth, we have successfully performed this procedure for a single implant placement in the anterior maxilla.

Subepithelial connective tissue graft was used to cover the deficient gingiva around the implant. It has various advantages over free gingival grafts including greater soft-tissue volume and relatively fewer chances of postoperative necrosis, as they receive more vascular nourishment.[10] Long-term (7–12 years) stability has been demonstrated in periodontal-prosthetic procedures with subepithelial connective tissue grafts.[11]

   Conclusion Top

Ridge Split Procedure is an established technique for augmentation of deficient alveolar bone before implant placement. However, its precise application in the edentulous area of a single tooth requires comprehensive treatment planning and very good surgical skills. Use of subepithelial connective tissue graft is a reliable option to achieve pink esthetics around implant-supported prostheses. Nevertheless, patient motivation about excellent plaque control and regular follow-up will help in the long-term maintenance of the successful outcome of this case.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Mechery R, Thiruvalluvan N, Sreehari AK. Ridge split and implant placement in deficient alveolar ridge: Case report and an update. Contemp Clin Dent 2015;6:94-7.  Back to cited text no. 1
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González-García R, Monje F, Moreno C. Alveolar split osteotomy for the treatment of the severe narrow ridge maxillary atrophy: A modified technique. Int J Oral Maxillofac Surg 2011;40:57-64.  Back to cited text no. 2
Misch CE. Single tooth implant restoration: Maxillary anterior and posterior regions. In: Misch CE, editor. Dental Implant Prosthetics. 2nd ed. Missouri: Elsevier Mosby; 2015. p. 499-552.  Back to cited text no. 3
Shimoyama T, Kaneko T, Shimizu S, Kasai D, Tojo T, Horie N, et al. Ridge widening and immediate implant placement: A case report. Implant Dent 2001;10:108-12.  Back to cited text no. 4
Moro A, Gasparini G, Foresta E, Saponaro G, Falchi M, Cardarelli L, et al. Alveolar ridge split technique using piezosurgery with specially designed tips. Biomed Res Int 2017;2017:4530378.  Back to cited text no. 5
Parthiban PS, Lakshmi RV, Mahendra J, Sreekumar K, Namasivayam A. A contemporary approach for treatment planning of horizontally resorbed alveolar ridge: Ridge split technique with simultaneous implant placement using platelet rich fibrin membrane application in mandibular anterior region. Indian J Dent Res 2017;28:109-13.  Back to cited text no. 6
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Vercellotti T. Technological characteristics and clinical indications of piezoelectric bone surgery. Minerva Stomatol 2004;53:207-14.  Back to cited text no. 7
Pavlíková G, Foltán R, Horká M, Hanzelka T, Borunská H, Sedý J, et al. Piezosurgery in oral and maxillofacial surgery. Int J Oral Maxillofac Surg 2011;40:451-7.  Back to cited text no. 8
Arora S, Lamba AK, Faraz F, Tandon S, Ahad A. Role of cone beam computed tomography in rehabilitation of a traumatised deficient maxillary alveolar ridge using symphyseal block graft placement. Case Rep Dent 2013;2013:748405.  Back to cited text no. 9
Thoma DS, Benić GI, Zwahlen M, Hämmerle CH, Jung RE. A systematic review assessing soft tissue augmentation techniques. Clin Oral Implants Res 2009;20 Suppl 4:146-65.  Back to cited text no. 10
Mesimeris V, Davis G. Use of subepithelial connective tissue grafts in combined periodontal prosthetic procedures. Periodontal Clin Investig 1996;18:12-5.  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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