CLINICAL

Classification of the Alveolar Ridge Width: Implant-Driven

Treatment Considerations for the Horizontally Deficient
Alveolar Ridges
Len Tolstunov, DDS, DMD1

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Among many techniques advocated for the horizontally deficient alveolar ridges, ridge-split has many
advantages. Here, treatment management strategies of the horizontally collapsed ridges, especially the ridge-
split approach, are discussed and a clinically relevant implant-driven classification of the alveolar ridge width is
proposed, with the goal to assist an operator in choosing the proper bone augmentation technique.
Comparison and advantages of two commonly used techniques, ridge-split and block bone graft, are presented.

Key Words: ridge-split, block bone graft, alveolar ridge

INTRODUCTION niques are designed to improve horizontal bone

loss before or simultaneously with dental implant

I
t has been shown that although bone collapse
after tooth loss is usually three dimensional placement.
(3D), the horizontal deficiency or width loss
develops to a larger extent.1,2 Alveolar width
DIAGNOSIS AND TREATMENT PLANNING
deficiency can represent loss of buccal (labial)
cortical or medullary bone, or both. Deficiency of It is important to establish a proper diagnosis based
the buccal cortex (cortical plate) after tooth on the alveolar ridge assessment before initiation of
extraction can present significant difficulty in the treatment plan. Initial clinical evaluation sup-
implant reconstruction.3,4 The buccal cortical plate plemented by radiographic images helps in most
with a thickness ,2 mm next to an implant appears cases to distinguish two-dimensional (2D) versus 3D
to have a higher risk of subsequent resorption.5 alveolar bone deficiency. Although minimal bone
A variety of implant-driven bone augmentation loss and patient’s lack of desire to go through
techniques for the deficient alveolar bone have grafting surgical procedure(s) can be circumvented
been proposed.6–8 Four of these techniques are with restorative means, extensive bone atrophy
frequently performed: (1) guided bone regeneration usually requires surgical correction for a proper
(GBR)/particulate bone grafting;9,10 (2) onlay (ve- implant placement.
neer) block bone grafting with intraoral sources,
Alveolar bone should be initially assessed
such as chin, ramus, posterior mandible, zygomatic
clinically (visually) for a rough width and height
buttress, and maxillary tuberosity;11–13 (3) ridge-
analysis and interarch-occlusal relationships. In
split/bone graft procedure;14–16 and (4) alveolar
some cases, although 7–8 mm of bone width is
distraction osteogenesis.17–19 Most of these tech-
present, it could be lingually (palatally) positioned
1
and therefore might require an additional buccal
Private practice, Oral and Maxillofacial Surgery, San Francisco,
Calif, and Departments of Oral and Maxillofacial Surgery, bone grafting for a proper restoratively driven
University of the Pacific, Arthur A. Dugoni School of Dentistry implant insertion.
and University of California San Francisco, San Francisco, Calif.
Corresponding author, e-mail: [email protected]
Alveolar width can be measured with different
DOI: 10.1563/AAID-JOI-D-14-00023 calipers on top of the thin mucosa or by ridge

Journal of Oral Implantology 365

Classification of the Alveolar Ridge Width

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FIGURES 1 AND 2. FIGURE 1. Cone beam computerized tomography scan of the horizontally deficient edentulous maxillary
alveolar ridge. Alveolar bone width and height, as well as thickness of the buccal and palatal cortical and medullary bone
are demonstrated. This alveolar ridge is a class III ridge according to the classification presented in the article. FIGURE 2. Axial
cone beam computerized tomography scan of the horizontally collapsed edentulous right maxillary alveolar ridge showing
varied thickness of the alveolar ridge.

TABLE 1
Classification of alveolar ridge width
Alveolar ridge width (mm), .10 8–10 6–8 4–6
based on CBCT* scan
Alveolar ridge deficiency No deficiency Minimal Mild Moderate

Class 0 I II III

Schematic diagram

Comments

Indications for surgery Hard tissue surgery is Hard tissue surgery is Particulate (GBR) An ideal width for the
not indicated. rarely indicated. grafting or ridge- ridge-split
Occasionally, Occasionally, split is often needed procedure that can
alveolar width alveolar width can to improve labial be done in a single-
(buccal convexity) be improved by bone projection and or two-stage
can be improved for particulate bone proper occlusal approach (see
esthetic reasons graft or palatal soft implant position. Figure 3). Block
with a soft tissue tissue graft for graft or GBR can
graft. esthetic and also be done.
prosthetic reasons.
Immediate insertion Yes Yes Yes/no, depends on Yes/no, depends on
presence of apical presence of apical
bone for primary bone for primary
implant stability implant stability (see
Figure 4)
Operator experience Basic Basic Basic Basic to advanced

*CBCT, cone beam computerized tomography.

ÀGBR, guided bone regeneration.

366 Vol. XL /Special Issue / 2014

 Tolstunov

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FIGURES 3 AND 4. FIGURE 3. Intraoperative photograph of the ridge-split procedure demonstrating the mobilization and
repositioning of the buccal muco-osteo-periosteal flap. FIGURE 4. Intraoperative photograph of the ridge-split procedure that
is done simultaneously with the implant insertion.

mapping (with local anesthesia) through it. Pano- beam computerized tomography (CBCT) scans.
ramic and other 2D radiographic images are often CBCT improves the ability for precise measurement
sufficient in some implant cases, although an of the ridge on all levels as well as evaluation of
implant-driven bone analysis often implies need both cortical and medullary portion of the bone for
for a 3D or volumetric bone evaluation with cone primary implant stability (Figures 1 and 2).

TABLE 1
Extended
2–4 ,2 6–10/2–4 2–4/6–10

Severe Extreme ‘‘Hourglass’’ (undercut) ‘‘Bottleneck’’

(buccal or lingual)
IV V VI VII

GBRÀ at the mid ridge Ridge reshaping or GBR

level can be done at the top of the ridge
can be done
Ridge-split or block bone Large extraoral block graft
graft is a graft of is a preferable surgical
choice (surgeon’s choice. Alternative is
experience). multiple and sequential
augmentation
procedures.

Not recommended No Yes/no, depends on the Usually yes, can depend

severity of the undercut on the morphology of
the top portion of the
ridge

Advanced Advanced Basic Basic

Journal of Oral Implantology 367

Classification of the Alveolar Ridge Width

TABLE 2
Ten-point comparison of ridge-split and monocortical block bone graft techniques
Comparison Monocortical Block Grafting (Intraoral) Ridge-split Procedure
1 Type of grafting Onlay: external, ‘‘cortex to cortex’’; Inlay: internal (like an ‘‘open book’’);
donor cortical graft is added to the cortical envelope is preserved and
collapsed recipient buccal cortical expanded and a particulate grafting
bone, resulting in the grafted bone is done ‘‘from within,’’ resulting in a
that has cortical environment on bilateral proximity of the grafted
one side and periosteum on the bone to both cortices (similar to a 4-
other side wall defect of extraction socket)
2 Graft resorption Free (devascularized) graft; the grafted Vascular bone flap (muco-osteo-
bone may contain a substantial periosteal flap) (see Figure 3),
amount of nonvital bone that did vascularization is preserved at all

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not survive detachment, times; ‘‘cancellous bone grafts are
devascularization, and transportation; more rapidly and completely
an increased risk of postoperative revascularize than cortical grafts’’29
graft resorption27; slow and Decreased risk of postoperative graft
incomplete neovascularization rate28 resorption16
3 Donor site morbidity Yes: pain, swelling, IAN* injury No
(posterior mandible, ramus),
‘‘wooden teeth sensation’’ (chin),
sinus perforation (zygomatic
buttress), others
4 Recipient site morbidity Soft tissue dehiscence and graft Soft tissue dehiscence and graft
exposure, loose fixation screws and exposure, buccal plate malfracture;
graft mobility; graft loss inadequate split
5 Wound closure Primary wound closure is mandatory Closure by secondary intention is
preferred
6 Buccal soft tissue flap Buccal flap is lifted and often Buccal flap is not compromised; it is
stretched; tension-free primary not lifted and left attached to the
closure is important, but can be buccal periosteum
challenging
7 Wound healing By plasmatic imbibition from the host Internal ‘‘coagulum’’ is easily converted
(recipient) tissue in the woven bone due to
protection and excellent
vascularization from both cortices
throughout the whole process
8 Immediate implant insertion Traditionally not done Can be done in some cases (see Figure
4)
9 Delayed implant insertion Implants are placed into the cortical Implants are placed into the cancellous
bone interface 4 to 6 months later bone interface 4 to 6 months later
10 Environmental factors and More subject to a postoperative injury Less subject to a postoperative injury
long-term stability of a (‘‘external’’ grafting); less long-term during mastication; it is more
graft stability and more long-term protected (‘‘internal’’ or
resorption28 interpositional grafting); less long-
term resorption and more long-term
stability30,31

*IAN, inferior alveolar nerve.

CLASSIFICATION OF THE ALVEOLAR RIDGE WIDTH an implant-driven site classification by bone quality
and quantity and proximity to vital structures. In
In 1988, Cawood and Howell20 suggested an
2002, Wang and Al-Shammari22 described a practi-
anatomic classification of the edentulous jaws for cal (therapeutically oriented) classification of alveo-
the preprosthetic surgery. It proposed six classes lar ridge defects, that is, horizontal, vertical, and
and detailed the changes that the edentulous combination defects, proposing the edentulous
alveolar process in anterior and posterior maxilla ridge expansion approach (ridge-split) for the
and mandible undergo after teeth extraction (the horizontal and combination defects of the alveolar
pattern of resorption). In 1989, Jensen21 proposed ridge.

368 Vol. XL /Special Issue / 2014

 Tolstunov

Here, a clinically relevant implant-driven classi- CONCLUSION

fication of the alveolar ridge width based on
Knowledge of 3D bone anatomy with CBCT scan
precise measurement of the alveolar width with
helps to establish a proper ridge diagnosis before
computerized tomography/CBCT scans is recom-
initiation of implant treatment. The recommended
mended; it is presented in the Table 1. The
ridge width classification for the horizontally
classification attempts to match the specific ridge
deficient alveolar ridges is designed to be a clinically
(its width and topography) with the appropriate
relevant implant-driven anatomic guide for choos-
surgical technique (GBR, ridge-split, or block graft)
ing an appropriate surgical modality for the specific
that can be used in the particular case of collapsed alveolar ridge. Operator experience and
horizontal bone atrophy. Although each opera- surgical comfort ultimately determines the choice of
tor’s experience ultimately determines the chosen the technique. The ridge-split approach tends to
surgical technique, it is important to compare

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have many advantages, including lack of donor site
benefits and drawbacks of different surgical morbidity and a graft stability over time.
procedures for certain ridges to improve the
selection process.
ABBREVIATIONS
COMPARISON OF THE RIDGE-SPLIT AND BLOCK BONE GRAFTING CBCT: cone beam computerized tomography
TECHNIQUES GBR: guided bone regeneration
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