Naval Postgraduate Dental School
Clinical Update
Vol. 39, No. 1
The Deficient Alveolar Ridge: Classification and Augmentation Considerations for Implant Placement
Lieutenant Michael Yang, DC, USN, and Commander Jeffrey Wessel, DC, USN
Introduction
Rehabilitation of the edentulous alveolar ridge with dental im-
plants is a common treatment modality. Successful esthetic
and functional implant rehabilitation relies on sufficient bone
volume in the vertical and horizontal dimensions, adequate
bone contours, ideal implant positioning and angulation, peri-
odontally healthy peri-implant soft tissue, adequate soft tissue
contours, and appropriate emergence profile.1 Following tooth
loss or trauma, however, both hard and soft tissue ridge defi-
ciencies can develop.2,3 Reduction in the alveolar ridge is
common following tooth extraction and it can occur rapidly.2
Additionally, the presence of anatomic structures including the
maxillary sinus, inferior alveolar nerve, and anterior loop of
the mental foramen can limit the osseous dimensions available
for implant placement.4,5
Hard tissue augmentation of a deficient ridge is a common
procedure employed to facilitate dental implant placement.
Ridge augmentation allows for use of longer and wider im-
plants and placement of implants in the ideal restorative posi-
tion. There are multiple treatment options available to correct
osseous ridge deficiencies. Prior to bone augmentation, the
alveolar ridge deficiency must be properly assessed to help
determine the best treatment option.
Alveolar Ridge Deficiency Classification
A variety of ridge deficiency classification schemes have been
described pertaining to both hard and soft tissue defects.
Lekholm and Zarb (1985) presented a classification scheme to
describe hard tissue deficiencies. The classification system
describes five groups of jaw shapes to include: intact ridge
(A), moderate ridge resorption (B), advanced ridge resorption
extending to the basal bone (C), initial resorption of the basal
bone (D), and extreme resorption of the basal bone (E).6
Misch and Judy (1985) presented a similar classification of
ridge resorption with suggested augmentation and prosthodon-
tic treatment modalities for each category. This classification
takes into account only hard tissue defects and was stratified
based on divisions that describe the natural bone resorption
pattern. The divisions represented abundant bone (A), margin-
ally sufficient bone (B), compromised bone (C), and deficient
bone (D). Furthermore, the authors suggest appropriate treat-
ments for each classification.7
Seibert (1983) presented a classification of ridge defects to
assess deficiencies in form, function and esthetics. The classi-
fication takes into account both hard and soft tissues. Seibert
Class I defects describe ridges deficient in the horizontal di-
mension. Seibert Class II defects describe ridges deficient in
the vertical dimension. Seibert Class III defects include ridges
deficient in both the horizontal and vertical dimensions. 8 The
Seibert classification does not provide any quantification of
the magnitude of ridge deficiencies.
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Allen et al. (1985) provided a modification to the original
Seibert classification by additionally describing the magnitude
of the ridge defect. Allen Type A classification represents ver-
tical ridge deficiency. Allen Type B classification represents
horizontal ridge deficiency. The Allen Type C classification
describes a combined horizontal and vertical ridge deficiency.
The severity of the ridge defect is further classified as mild
(<3mm), moderate (3-6mm), and severe (>6mm), as compared
to the contours of the adjacent ridge.9
When the Seibert (1985) and Allen (1985) classifications were
developed, they were meant to aid in the selection of appropri-
ate soft tissue augmentation modalities to improve upon the
esthetics in the pontic design. With the advent of guided bone
regeneration, further subdivisions of the Seibert classifications
were needed to assist in selection of appropriate hard tissue
augmentation techniques. Wang and Al-Shammari (2002) de-
veloped the HVC ridge deficiency classification to address
some of the shortcomings of the Seibert (1985) classification.
The classification utilizes three general categories to describe
horizontal (H), vertical (V), and combination (C) alveolar
ridge defects. These three categories can be further divided
into the subcategories of small (s, <3mm), medium (m, 4-
6mm), and large (l, >7mm). Based on the specific category,
subcategory and desired rehabilitation modality (fixed pros-
thesis or implant), different soft and hard tissue treatment op-
tions are presented. For example, an H-s defect can be ad-
dressed with ridge expansion, inlay/onlay monocortial grafts,
or particulate bone grafting; whereas a C-l defect would re-
quire large extraoral block grafts or multiple procedures to
correct.10
Bone Augmentation and Implant Placement
When dental implant placement is planned, the anatomy and
extent of a hard tissue ridge deficiency will determine the
amount of ridge augmentation needed and whether augmenta-
tion is needed horizontally, vertically or in both dimensions.
Depending on the amount of ridge augmentation required, im-
plants can either be placed simultaneously with the grafting
procedure (one-stage procedure) or after bone augmentation
procedures have been completed (two-stage procedure).11
Simultaneous vs. delayed implant placement
A delayed two-staged procedure can be indicated when there
are horizontal, vertical or combination defects that result in
insufficient bone to achieve primary implant stability or when
implant placement would result in a peri-implant osseous de-
fect not amenable to grafting. According to Milinkovic and
Cordaro (2014), when the horizontal dimension of the residual
ridge is <3.5mm a delayed two-stage procedure is recom-
mended.12 A two-stage approach is also suggested when the
residual bone height is < 4mm.13 When the pre-operative ver-
tical defect is >4.7mm, a delayed two-stage procedure is rec-
ommended with expected linear vertical bone gain of
4.3mm.12
A simultaneous one-stage procedure is utilized when adequate
bone volume and alveolar crest height allow for primary sta-
bility of the implant.13 The amount of bone needed to achieve
primary stability can vary based on bone quality, but an alveo-
lar crest height of >5mm has been reported as the minimum
vertical dimension needed. 13 A systematic review on indica-
tions for different alveolar bone augmentation procedures by
Milinkovic and Cordaro (2014) suggests that if the horizontal
ridge dimension exceeds 4mm then a simultaneous one-stage
procedure can be recommended. In addition, when the pre-
operative vertical defect is <4.1mm, a simultaneous one-stage
procedure is recommended with expected vertical bone gain of
3.04mm.12
One rationale for the simultaneous one-stage procedure is that
both block grafts and particulate grafts with a membrane can
experience graft resorption, with reported mean volume reduc-
tions in guided bone regeneration and ramus block bone graft-
ing sites of 12.5% and 7.2%, respectively.14 Placing the im-
plant simultaneously with bone augmentation in a one-stage
procedure shortens the time between ridge augmentation and
prosthodontic rehabilitation, and thus potentially reduces the
risk of bone resorption.13 In contrast, those who advocate the
delayed two-stage procedure maintain that it allows the im-
plant to be placed in vascularized vital bone and thus poten-
tially increases the osseointegration of implants as measured
by bone-implant contact and implant stability.15, 16
While there remains controversy regarding the preferred sur-
gical protocol, the simultaneous one-stage procedure is often
the preferred technique by both clinicians and patients because
it reduces surgical time, treatment cost and patient morbidity.17
In addition, survival rates of implants placed with single and
two stage procedures have been shown to be comparable, with
single-stage implant survival rates ranging 61-100% and two-
stage implant survival rates ranging 73-100%.13 Thus where
possible, it is preferable to perform bone augmentation with
simultaneous implant placement.
A Novel Bone Augmentation Technique with Simultaneous
Implant Placement
Advances in guided bone regeneration using computer-aided
design (CAD) and electron beam melting have resulted in the
creation of a novel bone augmentation technique using a cus-
tom titanium ridge augmentation matrix (CTRAM).18 Recent-
ly, in conjunction with the 3D Medical Applications Center,
NPDS clinicians have applied the use of CAD technology to
produce customized matrices using a zirconia material. The
newly developed custom zirconium ridge augmentation matrix
(CZRAM) is fabricated using a 5-axis milling machine. In a
novel treatment modality, CZRAM scaffolds have been de-
signed for use as a surgical guide to facilitate simultaneous
ridge augmentation and guided implant placement.
The combination of CBCT imaging and CAD technology to
create a CZRAM from virtual 3D models of the jaw allows for
precise pre-surgical planning of the ideal ridge augmentation
as well as ideal placement of the implant. This novel tech-
nique further reduces intraoperative time through the dual
functionality of the matrix as both an augmentation matrix and
surgical implant guide.
A B
The photos above display the CZRAM functioning as both an augmen-
tation matrix and implant placement guide at placement (A) and provi-
sional restoration in place 6 months after implant placement (B).
Summary
Prior to ridge augmentation procedures, the ridge deficiency
must be classified to allow for proper assessment of defect
type and appropriate reconstructive techniques. If the condi-
tions allow, bone augmentation with simultaneous implant
placement presents the preferred method of addressing defects
with horizontal and or vertical deficiencies.
References
1. Jovanovic SA. Bone rehabilitation to achieve optimal aesthetics. Pract Periodontics Aesthet
2.
Dent. 1997 Jan-Feb;9(1):41-51; quiz 52.
Schropp L, Wenzel A, et al. Bone healing and soft tissue contour changes following sin-gle-
tooth extraction: A clinical and radiographic 12-month prospective study. Int J Peri-odontics Re-
storative Dent. 2003; 23:313-323.
3. Seibert JS, Salama H. Alveolar ridge preservation and reconstruction. Periodontol 2000. 1996
4.
Jun;11:69-84.
Jivraj S, Chee W, Corrado P. Treatment planning of the edentulous maxilla. Br Dent J. 2006 Sep
9;201(5):261-79; quiz 304.
5. Greenstein G, Tarnow D. The mental foramen and nerve: clinical and anatomical factors related
to dental implant placement: a literature review. J Periodontol. 2006 Dec;77(12):1933-43.
6. Lekholm U, Zarb G. Patient selection and preparation. In: Brånemark P-I (ed). Tissue-Integrated
Pros-theses: Osseointegration in Clinical Dentistry. Chicago: Quintessence, 1985:199–209.
7. Misch CE, Judy KW. Classification of partially edentulous arches for implant dentistry. Int J
Oral Implantol 1987;4:7–13.
8. Seibert JS. Reconstruction of deformed, partially edentulous ridges, using full thickness onlay
grafts. Part I. Technique and wound healing. Compend Contin Educ Dent. 1983 Sep-
Oct;4(5):437-53.
9. Allen EP, Gainza CS, Farthing GG, Newbold DA. Improved technique for localized ridge aug-
mentation. A report of 21 cases. J Periodontol. 1985 Apr;56(4):195-9.
10. Wang HL, Al-Shammari K. HVC ridge deficiency classification: a therapeutically oriented
classification. Int J Periodontics Restorative Dent. 2002 Aug;22(4):335-43.
11. Esposito M, Grusovin MG, Felice P, Karatzopoulos G, Worthington HV, Coulthard P. Interven-
tions for replacing missing teeth: horizontal and vertical bone augmentation techniques for dental
implant treatment. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD003607.
12. Milinkovic I, Cordaro L. Are there specific indications for the different alveolar bone augmenta-
tion procedures for implant placement? A systematic review. Int J Oral Maxillofac Surg. 2014
May;43(5):606-25.
13. Chiapasco M, Zaniboni M, Boisco M. Augmentation procedures for the rehabilitation of defi-
cient edentulous ridges with oral implants. Clin Oral Implants Res. 2006 Oct;17 Suppl 2:136-59.
14. Gultekin BA, Bedeloglu E, Kose TE, Mijiritsky E. Comparison of Bone Resorption Rates after
Intraoral Block Bone and Guided Bone Regeneration Augmentation for the Reconstruction of
Horizontally Deficient Maxillary Alveolar Ridges. Biomed Res Int. 2016;2016:4987437. Epub
2016 Oct 26.
15. Lundgren S, Rasmusson L, Sjöström M, Sennerby L. Simultaneous or delayed placement of
titanium implants in free autogenous iliac bone grafts. Histological analysis of the bone graft-
titanium interface in 10 consecutive patients. Int J Oral Maxillofac Surg. 1999 Feb;28(1):31-7.
16. Rasmusson L, Meredith N, Cho IH, Sennerby L. The influence of simultaneous versus delayed
placement on the stability of titanium implants in onlay bone grafts. A histologic and biomechan-
ic study in the rabbit. Int J Oral Maxillofac Surg. 1999 Jun;28(3):224-31.
17. Kuchler U, von Arx T. Horizontal ridge augmentation in conjunction with or prior to implant
placement in the anterior maxilla: a systematic review. Int J Oral Maxillofac Implants. 2014;29
Suppl:14-24.
18. Connors CA, Liacouras PC, Grant GT. Custom Titanium Ridge Augmentation Matrix
(CTRAM): A Case Report. Int J Periodontics Restorative Dent. 2016 Sep-Oct;36(5):707-14.
Lieutenant Yang is a third year resident in the Periodontics Department. Commander
Wessel is a faculty member in the Periodontics Department.
The opinions and assertions contained in this article are the private ones of the authors
and are not to be construed as reflecting the views of the Department of the Navy.
The Naval Postgraduate Dental School is affiliated with the
Uniformed Services University of the Health Sciences’
Postgraduate Dental College.