Resorbed ridges: recommended protocol?

What do you want to do? Treatment plan? X-ray? The treatment plan will dictate the treatment protocol.

Patient is not interested in implant supported dentures, but the ridges are literally knife edge in upper & lower jaws felt upon probing.In pictures what you see is just thick soft tissue.

Well there are two choices, to augment the ridges horizontally with a closed tunneling technique using a non resorb able material such as hydroxyapatite. A careful wax up adding thickness to the ridge to make a surgical guide which is fixated to the arch with a bone screw for six weeks, mandible has circummandibular wires or prolene sutures. I would do one arch at a time. This is the original technique prior to implants. It works very well and is permanent. The other way which I would suggest is place a few key implants in the canine and molar regions for locators along with the hydroxyapatite augmentation to thicken the ridges long term. I am really glad you posted this since in the excitement of implants I have forgotten the value of ridge augmentation in the posterior with or without implants and the mandibular stent could also be retained with TADS or mini implants. Since the patient is so young I would push for a few implants for retention. The key to making this work is very simple a good model and wax up adding the width for stents and making a really well balanced denture. We all learned this in dental school and I learned how to make the surgical stents in residency. Work with a trusted OMS and you will have control of the case and be very happy,happy with the results. This is very similar to the skills used for gunning splints, orthognathic surgery or major bone grafting. We try not to use rib or hip since they resorb and I think he protocol I suggested should be adequate. Thanks for reading your surgeon can really help you as a team.

Considering a distraction or augmentation can be a choice. In any scenario prosthetic rehab will require a balanced occlusion later.

Never put particulate HA in a load bearing edentulous ridge. It migrates under denture pressure. I have had experience with this when the mandibular ridge was augmented by a well meaning surgeon and the particles migrated forward into the mental foramina causing paresthesia. Don’t do it! If the patient is not interested in implants don’t do any surgery. There is no such thing as a permanent ridge augmentation. Check the literature. I am a prosthodontist and see too many unnecessary surgeries. Save the patient pain, time and money and make a good set of dentures. If you haven’t made dentures in a while refer to a prosthodontist, we do them every day. As you know, the mandible shrinks 4 times faster than the maxilla so will go away the quickest. That’s no big deal since you simply trim off the knife edga between the foramina and place four implants for a hybrid; no bone graft needed, ever! Do I sound jaded? you bet! I am constantly fixing improper surgeries,grafting, implant placements etc when good old fashioned quality removable pros was the treatment of choice.

HA as a bone Graft resorbs completely in 2years. By that time patient had already lost the Bone height

Also thick soft tissue makes for a nice pocket for the non resorbable HA. We used to remove mobile , unsupported soft tissue like this in preprosthetic surgery for a stable denture base. Even reasonably non inflamed epuli can be used after a period of tissue conditioning. My point being this preimplant techniques have fallen by the wayside but are still valid in select cases. It is funny, the techniques may resurface under a new author. I find it all goes back to good prosthetic lab work, waxing in the thicker ridges and making a well fitting balanced denture. The patient needs to come in periodically for adjustments to keep the system stable with wear vs just showing up when there is a problem like any other dental procedure. So before criticizing check your facts perhaps ask a clarifying question vs stating a perceived "fact". Thanks for the feedback.

I am still of the belief that no surgery is better than HA ridge augmentation. If the patient can't afford implants why spend money on a graft procedure that doesn't appreciably make a difference with a removable prosthesis? Maybe firming up a flabby anterior maxilla would be an indication, where the primary denture bearing area is the palate so no pressure is placed on the graft but in no way should a mandibular ridge be built up with HA. Even though the buccal shelf is the primary denture bearing foundation quickly the ridge begins to bear some load. This will put pressure on the particulate HA and it will migrate under pressure. Therefore, if the patient can afford HA ridge augmentation surgery they can afford two implants and locators which is a much better use of their money. In my mind implants are considered preprosthetic surgery! No other form of preprosthetic surgery is as succesful as impants so do what is proven to be dependable over the longest period of time... implants. If the patient can't afford implants, don't do surgery.

Just haven't seen the complications described, still remove epuli and flabby tissue from dentures sitting on resorbed ridges. These clinical scenarios still exist the principles are the same. Two locators will provide retention only, if the posterior ridges are atrophic they don't supply much support. I disagree that an implant is preprosthetic surgery, they fail if expected to support a denture if not planned appropriately. I start to see problems 5-8years out. Each case is an individual treatment. The only absolute in my mind is that there are no absolutes in medicine or dentistry. It's my humble opinion.

We have developed a method of full arch regeneration with the goal of regenerating a complete ridge with vital bone. In addition the method allows the patient to function as if they had a natural dentition within weeks of surgery. We have not yet published the method but if anyone is interested you can contact us and we will be happy to share this with you. Greg Steiner Stiener Laboratories

If the patient is not interested in implants, then the options are very limited. While we used to do split thickness skin graft vestibuloplasties, I have had really good success with laser vestibular lengthening. I use a broad tip, in a defocused mode. Attempting to augment the ridges without the added benefit of implants is a disaster. Is perma-ridge still around? I placed several of those and took several out as well, regardless of how conservative my tunnel was. Every autogenous graft, used without implants, was a "bust". If they are refractory to implants, I would make a "hard sale" for the soft tissue surgery and two implants at 22 and 27. B Vinci

If the patient is refusing implants the grafting of any type is a mute point. prosthodontically speaking even a well made lower denture will move up to 10mm in all directions. Youe best and only option is provide well extended denture overing all available load bearing surfaces and try to get a peripheral seal (even in this case) - the upper jaw (with a properly border moulded impression) will be retentive the lower will have movement but using zero degree teeth with balancing ramps should get you the most stable dentures. all graft will resorb and remodel so whats the pooint if you're not placing implants

Who said that the patient is refusing for implants. Rather she wants implants supported bridges.

Unfortunately the person who posted these photos only gave us one clue...that the patient is 30 years old........this is not enough information to suggest a treatment plan. Growing up and living in Montreal, the largest city in the Province of Quebec, in Canada.... it was not unusual to see many young people ending up in this situation...... there were many French Canadian families who felt the best gift a bride could give her future husband was that she show up at the wedding with dentures....therefore saving him the future expense of repairing carious teeth. I distinctly remember some of my affluent French Canadian neighbours ,walking around with visibly rotted out teeth, bleeding gums,etc .......who went to dentists who would not repair carious teeth....their only method of treatment to relieve pain was extraction....oral hygiene was not practiced, home care did not exist, and these young people grew up on sugary Mae Wests and Pepsi Cola.....is it any wonder why they had such problems? I see some of these victims of gross dental incompetence today and what has happened to them over the last 50 years......many have shriviled up faces because they can no longer support dentures, and their general health is suffering. I have seen some of these people have HA injected under the soft tissue as described above.......sometimes it works, other times they are worse off with the problems described above. Today, our advances in bone regeneration, implantology and prosthodontics has given us the tools to try to help these people....but first we must know all the elements involved in order to help solve the problem...... it would be great if the poster of this case can resubmit it with radiographs and a scan...then we can all offer our suggestions based on good scientific experience and knowledge. Gerald Rudick DDS a Montreal Dentist who believes in saving teeth, good diet and a vigorous oral hygiene regiment.

this case has many treatment options but no one has mentioned mini implants evidence supporting their use is there. this would avoid any issues with grafting and would help stabilize her dentures

If the patient is interested in implants and if the ridges are greatly resorbed, then subperiosteal implants are a consideration. Even a RAMUS frame for treating the mandible is a quick and efficient treatment, but then keep the patient in a maxillary denture with mucosal inserts. I know some of you scoff at this. However, if properly performed they work very well. My question is just why is a 30 yr old edentulous? Dr Johnson is correct about dense HA. Don't place it in load bearing areas. If there is more bone vertically then blade implants will work nicely, if done correctly. When I state done correctly, this is inclusive of surgery and prosthetics.

Patient don't want Ny over dentures. She wants implants supported fixed prosthesis. Bone height is adequate but width is negligible.

Manisk , then scan the patient and you can make a treatment plan , then ask the good surgeons above a question two photos only with no plan is wasting all their time. Regards Peter

Dear Peter, All I wanted to know is how to proceed with the grafting,graft type, time, membrane or without? I actually recieve too many of these cases & want to start up doing them. Reason asking all of respectable dentist including you was to seek help & advise overall not specifically about this case.Hope you understand my scenario. Thanks & regards

Because you want to " start doing them ", is no reason to do "it". Most "all on cases "need ridge reduction, so grafting is rarely indicated. We are seeing this trend of doctors doing things outside of their envelope and the patients are not getting the best available care. Bvinci

Great that is what this good web site is for but maybe more information would be helpful to all concerned so as to eliminate the variables Peter

After CBCT things can be planned. But any vertical ridge augmentation can be very difficult. How about angulated implant with Trans mucosal abutments. I have done few cases with severe resorbed ridges with all on four for mandible and all on six for maxilla. Using Narrow platform - at some places where thickness is less, 3 mm implants can be useful . I have used Adin TMA with pterigopalatine implants posterior to sinus. For mandible angulated implant above mental foramen distmesially. Hybrid fixed prosthesis. Immediate loading on same day can also be good option for young patient.

A Sept. 3rd, 2013, video on the Bicon.com website shows, in the latter half, amazing fixed "Trinia" (composite frames) fixtures cantilevered on 3, 4, and 5 4.0 X5.0mm Bicon short implants. Some use two 3.0 wide by 8.0 long, angles Bicon implants to dip inside to the Lingual of the Inferior Alveolar Nerve channel. The key speaker, Rolf Ewers, MD, DMD, Ph.D., compares the historic solutions to these extreme ridge loss and even mandible loss cases to the newer use of about four of these tiny implants to support an entire arch. Relating to this question in particular are some photos showing four 4x5 Bicon short implants in the basal bone, "chin button" area sitting completely anterior to the supported full arch Trinia Prosthetic. This is a long video - it starts slowly... Also to be noted is the increase in posterior mandibular ridge height as a result of loading entirely from this mental basal bone area alone over several years. John