[Diagnostic / Planning]  Quad 3 Posterior Narrow ridge...?

Hello Everyone in Bites land!

I have a patient who would like to proceed with implant(s) in posterior quad 3.  The CBCT shows a very narrow ridge that will ultimately leave her with either;

1) exposed buccal threads of a mini Hiossen implant and need to use Titanium mesh to add buccal bone.  Due to it being in the posterior, I would stress need to add 2 implants and to double abutt them...


2) split the ridge?

The ridge measures about 3.7 to 4mm in width in the areas of the implants.

The more posterior implant runs into some debris in the bone since the previous exo was done (not by me!).  Looks like amalgam and I would want to clean that out if the implant goes into that area.  Moving the implant further back (as seen in the last picture) runs into a more prominent submandibular space and I'd have to use a 10mm length implant but don't run into debris or exposed threads.  This would then obviously be a implant supported bridge.

by Sokhi Sandhu at Tue, Sep 19, 2017 12:35 PM

951 Views | 3 Replies | Avg Rating : 5.00

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Mark Kwon Replied at Tue, Sep 26, 2017 10:21 PM

Nooooo 3.5mm et3 here !!!

ive had way too many fracture on me. 

Use 4.0minimum x2 and join later if needed be. 

If you must use narrower fixtures go w alloy implants such as Biohorzon 3.5 or 3.8mm simply for their sttength. 

Sometimes i onlay or sometimes i split. 

Which ever way , should be careful w :

1. Mental foramen

2. Adjacent teeth 

3. Post surgical Muscle pull from frenum

Slowly and carefully ❤️

Good luck!

Likes : 1

Bernard Jin Replied at Mon, Sep 25, 2017 4:16 PM

Hi Sokhi

PLEASE be very careful in this case.  Assuming the tracing of the mandibular nerve is correct, its proximity is very close.  Grafting around this is & can be trouble.  I would recommend that you consider staging it out & keeping away from the mental foramen altogether.


Lateral ridge augmentation of the molar area (and maybe the premolar area)

After healing - then take another CBCT to evaluate the site.  If there is still poor bone volume around the mental foramen, consider avoiding it.  Rather consider placing implants at the molar areas & then cantilevering the prosthetic to place a pontic at the bicuspid area.

Lastly - please consider using a 4mm diameter implant instead of the 3.5mm.  The 3.5mm diameter may not be sufficiently strong enough.  

Likes : 1

Ho-Young Chung Replied at Tue, Sep 19, 2017 3:36 PM

Hi Sokhi,

I would not use a 3.5 implant in the posterior ridge (unless it is a titanium alloy which HiOssen is not).  for premolar use 4.0 and for molar at least 4.5. both options are good but it might be difficult for you to get passivity on your bridge as it appears that the bone heights are different.  Also, I prefer to have the fixtures supporting an implant bridge to be at a similar height.  

doing a ti mesh especially around mental foramen will be difficult.  I do not use Ti mesh (don't like Smart builder either as it is prone to ingrowth and soft tissue responds poorly) and I don't split.  Splitting this ridge would be difficult at best in the best of hands due to remaining ridge anatomy.  

GBR w/ Biogide or a similar membrane tacked for stability (but with care as mental foramen needs to be respected) and using sticky bone would help.  

If you have a Panorex and intra-oral photos, these would help.  We need to assess 2D, 3D, and the mouth and look at both soft tissue and hard tissue deficiencies.  

any GBR case needs complete tension free closure.  Soft tissue manipulation is just as important as hard tissue manipulation.  

Thanks for posting Sokhi.  

Ho-Young Chung