One-Staged Ridge Split with Surgical Bur

Pre-op examination shows the narrow ridge at #30 (Fig.1) and residual roots at #31 (Fig.2).  The narrow ridge is split with a thin surgical fissural bur (Fig.3), followed by insertion of bone expander 1 (1/1.6 mm, Fig.4 (E1)).  By the time expander 3 (1.7/3.1 mm, Fig.5 (E3)) is being placed, the buccal plate starts to be greenstick fracturing.  After the expander is removed, Lindamann bur is used to enlarge lingual osteotomy.  Still a 4x13 mm bone-level implant is placed with high torque and bulging buccal plate.  The implant is removed.  The drill for the implant is used, pressure being exerted lingually.  Then the implant is placed without grossly fracturing the buccal plate (Fig.6).

With infiltration anesthesia, extraction of the residual roots at #31 is without difficulty, but removal of granulation tissue in the mesial socket and osteotomy are associated with pain.  After a 5x17 mm tap is placed with stability (Fig.6 T) , block anesthesia is administered.  Placement of a 5x17 mm tissue-level implant is finished without discomfort (Fig7); abutments (A) and bone graft (*) are placed.  Periodontal dressing is applied.  Then the patient complains of chewing pain in the upper left quadrant. 

Two months postop, the provisional is loose at #30 because of loosening abutment screw.  It seems that the abutment at Fig.7 was not fully seated.  A PA is taken (Fig.8) after tightening the screw, cleaning the abutments and the provisional with diluted bleach (.25%) and Q-tip and recementation.  It appears that there is bone resorption at #30 (*) and #31 (v).  It appears that 1-staged ridge split is associated with more bone resorption than 2-staged one.

There is bone fill in the mesial socket at #31 and no further bone loss at #30 5 months postop (Fig.9).  The distal surface of #29 is trimmed and the abutment is changed to 5.5x5.5(2) at #30 before impression (Fig.10 (taken after impression)).  Ask the lab to make a smaller crown for #30, since the implant is small (4 mm). 

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Xin Wei, DDS, PhD, MS 1st edition 07/22/2016, last revision 04/10/2021