Oftentimes, procedures do not go quite as expected and quick intraoperative thinking is required to remedy the situation.  This featured case demonstrates how a ridge split procedure was used to salvage a site with a failed ramus graft.

 Intraoperative Recovery from Failed Ramus Graft

Dan Holtzclaw, DDS, MS - Diplomate American Board of Periodontology

A few days ago, I received a referral patient from a prosthodontist to place dental implants at sites 8 and 9.  In September 2008, this particular patient was augmented with a ramus graft to sites 8 and 9 by a local provider.  Under normal circumstances, this same provider would have placed the dental implants, but he was out of town for an extended period...hence, I enter the picture.

  Upon flap relfection I noticed significant resorption of the ramus graft.  During removal of the fixation screws, movement of the graft was noted.  

  Following removal of the failed ramus graft and elimination of all residual granulation tissue, the patient was informed of his treatment options.  The patient wanted the site re-augmented as he had a strong desire for dental implants.  The patient did, however, note that he did not want another "onlay" type of graft.  As such, treatment with a ridge split was agreed upon.

As you can see from the pictures above, the patient had a significant resorption defect at sites 8 and 9.  Residual fixation screw sites are visible.

For the ridge split, an initial crestal cut was performed with a piezoelectric unit.

  The piezoelectric unit was also used to make vertical cuts for the ridge split.  The location of the vertical cuts is dictated by the roots of the teeth adjacent of the edentulous site. 

After making the ridge split cuts, an apical scoring line was created with the piezoelectric unit.  The scoring line is different than the prior cuts in the fact that it is not a full depth cut.  The concept behind the scoring cut is to provide a level of control during the outfracture of the ridge.

Following establishment of the ridge split, the intrabony aspect of the ridge split was grafted with a combination of Bio-Oss and LifeNet Health freeze dried bone allograft.

The extraosseous aspect of the ridge split was grafted with the same combination.

The grafts were covered with Ace resorbable collagen membranes.  Periosteal releasing incisions were necessary to attain primary closure of the grafted site.  A combination of Vicryl and Cytoplast PTFE sutures were utilized for flap closure.

I found this to be an interesting case and wanted to share it with everyone. 

Now it's your turn!  JIACD wants to feature your interesting cases!  If you have an interesting case with photodocumentation, send it to us at editors@jiacd.com.  Please provide a very simple description of the case and let us know the order of your photos.  If accepted, your case will be displayed in the "Features" section of the JIACD homepage and may even be considered for a "Case of the Month" in a future issue of the journal.