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HVC Ridge Deficiency Classification:

A Therapeutically Oriented
Classification

Hom-Lay Wang, DDS, MSD* Alveolar ridge defor mities or

Khalaf Al-Shammari, DDS, MS** defects may be present as a result
of several factors, including devel-
opmental defects/clefts, congeni-
Alveolar ridge defects resulting from tooth extraction, trauma, or periodontal dis- tally missing teeth, trauma, odon-
ease often require surgical correction prior to prosthodontic reconstruction. togenic cysts and tumors, tooth
Whether implants or conventional fixed prostheses are planned, without careful extractions, dehiscence or fenes-
consideration and proper treatment planning, hard and/or soft tissue defects may tration defects, and advanced peri-
lead to functional, structural, or esthetic compromises in the final prosthesis. This odontal disease.1–4 Defects result-
article reviews the etiology and treatment of alveolar ridge defects and introduces ing from tooth loss/extraction are
a therapeutically oriented classification system of such defects (horizontal, vertical,
considered to be the most com-
and combination—HVC—classification). In addition, a decision-making guide for
mon.5 Ninety-one percent of ante-
approaching each defect type will be discussed, and clinical examples of treated
rior ridge defects in that cross-sec-
cases will be presented. (Int J Periodontics Restorative Dent 2002;22:335–343.)
tional study were caused by tooth
loss. The stages of alveolar ridge
resorption after tooth loss have
been described by several au-
thors.6–10 Atwood8 described six
residual alveolar ridge stages after
tooth extraction, ranging from initial
to severe ridge resorption. Longi-
tudinal observations of residual
ridge volumes indicate that the
**Associate Professor and Director of Graduate Periodontics, Department greatest amount of bone loss oc-
of Periodontics/Prevention/Geriatrics, School of Dentistry, University of curs in the first year after tooth
Michigan, Ann Arbor.
**Adjunct Assistant Professor, Department of Periodontics/Prevention/
extraction.7,10 An estimated 25%
Geriatrics, School of Dentistry, University of Michigan, Ann Arbor. volume loss in the first year, increas-
ing to about 40% loss in 3 years, has
**Reprint requests: Dr Hom-Lay Wang, Department of Periodontics/
been reported. 6,11 Width defi-
Prevention/Geriatrics, University of Michigan School of Dentistry, 1011
North University Avenue, Ann Arbor, Michigan 48109-1078. e-mail: ciencies occur first because of the
homlay@umich.edu pattern of resorption, with height

Volume 22, Number 4, 2002

 336
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options based on the amount of

Table 1 Classification of ridge defects
available bone height, width, and
Study Classification angulation.
Soft/hard tissue defects Classification systems are gen-
Seibert12 Class I: buccolingual loss of tissue with normal apicocoronal ridge erally used to establish guidelines
height for treatment of a particular clinical
Class II: apicocoronal loss of tissue with normal buccolingual
situation. Viewed in this context,
ridge width
Class III: combination-type defects (loss of both height and width) such classifications should aid in
Allen et al14 A: apicocoronal loss of tissue defining the clinical problem, pre-
B: buccolingual loss of tissue dicting realistic treatment outcomes,
C: combination
and realizing proposed treatment
Mild: < 3 mm; medium: 3–6 mm; severe: > 6 mm
Hard tissue defects limitations. Ultimately, a better un-
Lekholm A: virtually intact alveolar ridge derstanding of a particular treatment
and Zarb13 B: minor resorption of alveolar ridge modality’s ability or inability to cor-
C: advanced resorption of alveolar ridge to base of dental arch
rect a clinical problem is possible.
D: initial resorption of base of dental arch
E: extreme resorption of base of dental arch This in turn should aid in proper
Misch A: abundant bone treatment planning and more effec-
and Judy15 B: barely sufficient bone tive communication among the sur-
C: compromised bone geon, other members of the dental
(C-h: compromised height; C-w: compromised width)
D: deficient bone team, and the patient.
The available classification sys-
tems of ridge volume represent valu-
able guidelines for evaluating alve-
olar ridge defects. However, certain
deficiencies resulting from longer and height deficiencies. Treatment limitations that restrict their applica-
periods of edentulism.8,10 options and predictability of out- bility in daily clinical practice can be
comes were based on the type of found. For example, Seibert’s12 clas-
defect present, with width deficien- sification represents the three broad
Classification of ridge cies having more predictable results, categories of ridge defects, but a
defects and height and combination defects division of those defects into sub-
being less predictable.12,16 categories is lacking. Each of the
Several classification systems of alve- The advent and widespread use three classifications can be further
olar ridge deformities have been of dental implants mandated careful subdivided into categories based on
proposed (Table 1). 12–15 Seibert evaluation of available bony ridge the size of the defect. Such division
introduced his widely used classifi- volume and dimensions. Conse- may prove useful in selecting treat-
cation of ridge defects in 1983. In quently, several classification sys- ment modalities and predicting
this classification, Class I defects rep- tems have been proposed to ad- treatment outcomes. As clinical
resent buccolingual loss of tissue dress ridge volume related to future experience has shown, treatment
and normal apicocoronal ridge di- implant placement. Lekholm and outcomes for large and small defects
mensions, Class II defects are those Zarb’s13 classification includes five cannot be expected to be similar.
with apicocoronal loss of tissue and stages of bone resorption, from min- As implied in the original classifi-
normal buccolingual ridge dimen- imal to severe. Misch and Judy’s15 cation system itself, height defects
sions, while Class III defects repre- classification describes four divisions may require additional surgical pro-
sent a combination of both width of available bone, with treatment cedures to achieve the desired

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result.4,16,17 Knowledge of the pos-
sible need for additional surgical
procedures to correct height defects
or large width defects prior to initi-
ating treatment should help improve
patient awareness and avoid poten-
tial misunderstandings.
In addition, Seibert’s classifica-
tion was originally used to address
treatment of ridge defects in prepa-
ration for receiving a pontic. As such,
presented treatment options were
all soft tissue augmentation proce-
dures used to enhance the esthetic
appearance of fixed partial den-
tures.4,12 The use of guided bone
regeneration (GBR) to augment the
osseous structures was incorporated
into later publications.16,17 However,
division of defect types into different
size categories may again prove
valuable for predicting the degree of
success of the various treatment
modalities available for the treat-
ment of both soft and hard tissue
defects.
A modified system:
HVC classification
A new classification scheme is out-
lined in Fig 1. This system is a mod-
ification of Seibert’s classification that
attempts to address some of its lim-
itations. The three broad categories
are still present, with the use of sim-
pler terminology, referring to Class I,
II, and III defects as horizontal (H),
vertical (V), and combination (C)
defects, respectively. Each category
is further subdivided into small (s, ≤
3 mm), medium (m, 4 to 6 mm), and
large (l, ≥ 7 mm) subcategories (Fig
1). Both soft and hard tissue defects
are considered in this classification
scheme, with treatment options sug-
gested based on the type and size of
the defect and the planned restora-
tive treatment plan. Table 2 lists the
treatment options for ridge aug-
mentation procedures in prepara-
tion for the edentulous ridge to
receive a pontic or an implant. The
treatment options presented for
implants are for hard tissue aug-
mentation and assume that similar
soft tissue augmentation procedures
as presented for fixed prosthesis
preparation may be undertaken if
needed for proper emergence pro-
file and esthetics. In addition, for all
types of defects, medium and large
deficiencies may require multiple
surgical interventions before the
desired outcome is reached.
Horizontal defects
Small and medium soft tissue defects
may be treated by the “roll”
technique, or various connective
tissue pouch and/or inlay
grafts.12,14,18,19 Large defects may be
treated with a combination of con-
nective tissue inlay and/or interposi-
tional grafts.16 Hard tissue augmen-
tation for future implant placement in
small defects may be accomplished
using ridge expansion procedures
with osteotomes, ridge splitting,
GBR, monocortical inlay/onlay graft-
ing, or piezoelectric surgery.20–29
Medium and large defects may
require monocortical inlay/onlay
grafting from intraoral or extraoral
sources or GBR procedures.26–29
337
g
Classification H (horizontal defects)
H
H
s = ≤ 3mm, m = 4-6mm, l = ≥ 7mm
Classification V (vertical defects)
V
V
s = ≤ 3mm, m = 4-6mm, l = ≥ 7mm
Classification C (combination defects)
H
H
V
V
Fig 1 HVC ridge classification. Subclas-
sification: small (s) ≤ 3 mm; medium (m)
4–6 mm; large (l) ≥ 7 mm.
Vertical defects
Vertical ridge deficiencies present
greater challenges in treatment plan-
ning. Interpositional and onlay con-
nective tissue grafts are indicated
for the treatment of small and
medium vertical soft tissue defects;
for large defects, multiple onlay
grafting procedures may be
needed.16,17 Orthodontic extrusion
prior to tooth extraction may be
attempted for the correction of small
vertical ridge defects.30,31 Hard tis-
sue augmentation for medium and
large defects may be attempted with
onlay osseous grafts and/or GBR
procedures.32–38 More recently, dis-
traction osteogenesis techniques
have been described for intraoral
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distraction osteogenesis). Large

Table 2 Treatment options based on HVC classification
Defect
class* Fixed prosthesis
H-s “Roll”procedure
Pouch procedure
Inlay soft tissue graft
H-m Pouch procedure
Inlay soft tissue graft
H-l Inlay soft tissue graft
Interpositional graft
V-s Interpositional graft
V-m Interpositional graft
Onlay soft tissue graft
V-l Interpositional graft
Onlay soft tissue graft (low
predictability)
C-s Combination of soft tissue
grafting procedures
C-m Combination of soft tissue
grafting procedures (low
predictability)
C-l Difficult to correct
May be improved to smaller
defect with combination of
soft tissue grafting procedures
*Multiple procedures may be required for medium and large defects.
†In addition to the soft tissue procedures, hard tissue procedures needed for fixed prosthesis prepa-
ration.
use, with promising results. 39,40
However, the long-term success of
these techniques remains to be
determined.
Combination defects
Combination defects present even
greater challenges for the treating
clinician. A combination of horizon-
Implant†
Ridge expansion procedures
Inlay/onlay monocortical grafts
GBR
Inlay/onlay monocortical grafts
GBR
Inlay/onlay monocortical grafts
GBR
Orthodontic extrusion
GBR
Orthodontic extrusion
GBR
Onlay osseous grafts
Distraction osteogenesis
GBR
Onlay osseous grafts
Distraction osteogenesis
Inlay/onlay monocortical grafts
GBR
Combination of GBR, monocorti-
cal inlay/onlay grafts, and dis-
traction osteogenesis
Difficult to correct
Large extraoral block grafts (tibia,
rib, calvaria)
Multiple procedures needed
tal and vertical soft and hard tissue
augmentation procedures is often
required for the correction of such
defects. Small and medium defects
may be treated with a combination
of various soft tissue grafting tech-
niques in multiple procedures (in-
lay/onlay grafts, pouch procedures,
and interpositional grafts) and hard
tissue procedures (GBR with inlay/
onlay block grafts, with or without
combination defects are the most
difficult to treat. Complete resolu-
tion of such defects may not always
be a realistic objective. Improvement
of such defects to smaller defect
types can be attempted with multi-
ple grafting procedures. Extraoral
sources of block grafts (tibia, rib,
calvaria) are often needed for hard
tissue augmentation of these de-
fects.36,41–43 Figures 2 to 4 demon-
strate clinical illustrations of each of
the three defect types and describe
the treatment procedures per-
formed in each case.
Discussion
Ridge augmentation procedures
prior to conventional fixed prostho-
dontic or implant therapy are indi-
cated when an adequate width or
height of the alveolar ridge is not
present. Soft tissue augmentation
procedures are used to correct
esthetic defects, such as loss of the
interdental papilla and improper
emergence profile, and hard tissue
augmentation procedures are used
to allow for placement of dental
implants of sufficient length and
width. The definition of adequate
width and height requirements for
implant placement is based mainly
on clinical experience and on phys-
ical and mechanical requirements
for the actual implant placement
process. A minimum width of 5 mm
and a height of 7 to 10 mm of bone
are suggested by most clinicians.13,43
The minimum height requirement of
10 mm is also supported by several

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Fig 2a Treatment of H-m (horizontal
medium size) defect with monocortical
inlay graft. Preoperative view shows a hori-
zontal ridge defect.
Fig 3a Treatment of V-m (vertical medi-
um size) defect with a free soft tissue graft.
Preoperative view of a vertical ridge defect
(lack of interdental papillae).
Fig 3d Graft secured in place with 4.0
Gore-Tex sutures (3i/WL Gore).
Fig 2b Two monocortical symphysis inlay
grafts are placed horizontally and secured
with fixation pins. Demineralized freeze-
dried bone allograft is also added around
the blocks to enhance the volume.
Fig 3b Recipient bed preparation.
Fig 3e Three-month postoperative view
demonstrates the amount of vertical aug-
mentation achieved.
339
Fig 2c Six-month postoperative view
demonstrates graft incorporation and ade-
quate ridge width.
Fig 3c Free gingival graft harvested from
the palate.
Fig 3f Postoperative view of the new tem-
porary prosthesis illustrates the improved
height of the interdental papillae.
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implant survival studies in which
higher failure rates were consistently
reported for shorter implants.44,45
Various ridge augmentation proce-
dures have been described for the
enhancement of both height and
width requirements, including block
grafts, particulate grafts, GBR, ridge
expansion techniques, and distrac-
tion osteogenesis.26–29,40
The use of corticocancellous
bone grafts for ridge augmentation
in implant dentistry was first reported
by Breine and Brånemark.46 Extra-
oral sources were primarily used for
the reconstruction of atrophic
arches, with immediate or delayed
implant placement.42,47,48 Although
still indicated for large alveolar ridge
defects, extraoral graft sources have
the obvious disadvantages of
greater morbidity and expense.
The International Journal of Periodontics & Restorative Dentistry
Fig 4a (left) Treatment of C-m (combined
horizontal and vertical medium size) defect
with a monocortical onlay graft. Preopera-
tive view of the combined horizontal and
vertical ridge defect.
Fig 4b (right) J-shaped monocortical sym-
physis graft is secured with fixation pins.
Fig 4c (left) Implant placement 6 months
after the onlay graft ridge augmentation
procedure.
Fig 4d (right) Final restoration.
Intraoral graft sites have therefore
been suggested and used for ridge
augmentation procedures in smaller
defects.49–53 Intraoral sources of
block grafts include the mandibular
symphysis, body, and ramus. Advan-
tages of intraoral graft sources
include decreased morbidity, con-
venient surgical access, lack of cu-
taneous scar formation, and favor-
able bone quality.29
GBR is a technique based on
the principles of guided tissue
regeneration, in which barrier tech-
niques are used in the hope of
regenerating lost periodontal struc-
tures.54,55 The objective of GBR is
the formation of new bone to recon-
struct a deficient ridge prior to or in
conjunction with implant place-
ment. Cell-occlusive barrier mem-
branes have been used for horizon-
tal or vertical ridge augmentation
with or without bone grafts, with
varying degrees of success.26,56–60
The principle of GBR is based on
the creation and maintenance of
space and the exclusion of soft tis-
sue cells from adjacent bone to
allow preference for bone-forming
cells to populate and regenerate
the defects. GBR procedures have
been shown to provide a fairly pre-
dictable outcome if strict adherence
to proper surgical technique and
compliance with its principles are
used. Membrane exposure is one of
the complicating factors associated
with reduced success outcomes.61
Several modifications for barrier
reinforcement have therefore been
reported, especially for vertical
ridge augmentation, with variable
degrees of success.62–66

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An alternative to ridge aug-
mentation procedures is the use of
expansion techniques to increase
the width of available bone. Several
techniques have been described,
including the osteotome technique,
the edentulous ridge expansion
technique, and the piezoelectric
scalpel expansion technique.20–25
Expansion techniques are proposed
to reduce surgical morbidity and
complications associated with graft-
ing procedures, and similar success
rates have been reported.22,23
Distraction osteogenesis is a
concept first established and used
in the orthopedic literature as a
method for the reconstruction and
elongation of long bones.67–69 The
principle of distraction osteogenesis
relies on the response of bone to
tension forces by new bone forma-
tion. Distraction osteogenesis has
been used in the correction of cran-
iofacial deformities and in mandibu-
lar lengthening procedures.70–73 The
use of this technique for alveolar
ridge augmentation prior to implant
therapy has also been evalu-
ated.40,74–78 Results of these investi-
gations offer promising outcomes,
but long-term evaluations and re-
finements in device design and
methodology are needed before
fully establishing the value of this
technique for alveolar ridge aug-
mentation.
Conclusion
Several treatment modalities for the
correction of alveolar ridge defects
are available. Soft and hard tissue
augmentation procedures for the
correction of such defects are used
with varying degrees of success. The
size and type of defect are two of the
main factors to consider when
selecting the appropriate treatment
modality. The HVC classification
scheme introduced in this article
takes both factors into considera-
tion. Defect types are divided into
horizontal, vertical, or combination-
type defects. Each defect type is fur-
ther divided into small, medium, or
large defects. This scheme is
intended to aid in organizing the
thought process involved in the
treatment planning and prediction of
treatment outcomes.
Acknowledgments
This study was partially supported by the
University of Michigan, Periodontal Graduate
Student Research Fund. The authors would
also like to thank Drs Kenneth Kimble and
Pintippa Bunyaratavej for their contribution
in Figs 2 and 3.
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