Ridge Classification According to Ideal

Implant Esthetics:
Form Meeting Function
Implant Restorative Position
as Determined by CT Analysis with Radiographic Templates
Park, Young Sang; Lee, Cheng-Hsun; Jalbout, Ziad; Cho, Sang-Choon; Froum, Stuart; Elian, Nicolas; Tarnow, Dennis. Ashman Department of Periodontology and Implant Dentistry, New York University

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Depth: The implants were placed 3mm below the buccal cemento-enamel junction (CEJ) of the tooth posi- he ultimate goal of implant treatment is to surgically place implants in the most desirable posi- 55) of the cases studied were identified as requiring grafting procedures. This may be due to the pre-exist-
“...the results indicate that a tion outlined by the radiographic template. tion compatible with esthetics, phonetics, and function. Identification of the “optimal final tooth
position” allows the restorative dentist and surgeon to analyze the impact of pathologic alterations
ing anatomy and ridge resorption pattern in the maxillary anterior area (13, 14). However, deformities in
the anterior part of the maxilla may be related to the tooth biotype, genetic disorders, trauma, iatrogenic
Proposal of a new classification system of ridge deformities: and to determine if soft or hard tissues need to be reconstructed to maximize function and esthetics (9). damage of the bone, or other reasons independent of the maxillary resorption. The limited number of
high number of cases in the In the new proposed classification system ridges were categorized into seven different classes as follows: To achieve a long-lasting, ideal esthetic result with implants, in light of circumferential bone resorption that cases present in our study that did not require graft procedures with the 3.25 mm diameter template may
Class I: The implant is completely surrounded by bone; no dehiscence or fenestration present usually occurs as part of the healing response around the implant head, the thickness of the bone on the be of importance for clinicians placing implants in the maxillary anterior area. Moreover, the use of con -
maxillary anterior area would Class I-A : >= 2mm of facial plate of thickness
Class I-B : < 2mm of facial plate of thickness
buccal side of an implant should be at least 2mm (8). The new method of classification presented in the
current study can identify this parameter.
ventional diameter implants would have resulted in a greater number of ridge defects and complications
than that reported in the present study population. In addition this may have increased the number of
Class II: Dehiscences are detected but no fenestrations are present patients with more advanced classifications of deformities. Based on the number of ridge deformity com -
require augmentation procedures Class II-A: only buccal or palatal dehiscence is present Using the proposed new classification system, ridge classification of the bone defects may be identified and plications documented in the present study, a knowledge and training in procedures for ridge augmenta -
Class II-B: both buccal and palatal dehiscences are present complications avoided due to more accurate treatment planning of implant size and position. The rela - tion may be necessary for clinicians to obtain predictable results and manage surgical complications.
in order to achieve ideal implant Class III: Fenestrations are detected but no dehiscence is present
Class III-A: only buccal or palatal fenestration is present
tionship between the adjacent teeth and bone can also be observed by utilizing the radiographic template,
which was worn by the patient when taking the CAT-scan. CONCLUSION

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Class III-B: both buccal and palatal fenestrations are present he present report proposed a new classification system for maxillary alveolar ridge deformities based
placement and restoration...” Class IV: Both dehiscences and fenestrations are present The advantages of this new Implant Oriented Classification System (IOCS) include: 1) more accurate eval- on CAT-scan implant simulation as a useful concept in order to more precisely predict treatment out-
uation of the clinical situation prior to surgery to determine treatment options. 2) the ability to evaluate the comes and the necessity for ridge augmentation prior to implant placement. The results indicate that
RESULTS need for hard tissue augmentation and simulate the necessary augmentation prior to surgery. 3) allowing a high number of cases in the maxillary anterior area would require augmentation procedures in order to
selection of appropriate implant type and size before surgery. 4) using the radiographic template as a sur - achieve ideal implant placement and restoration.

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eformed partially edentulous ridges may compromise ideal implant placement and implant sur -
vival. Deformities of the alveolar ridge may be caused by traumatic extraction, facial trauma, clefts
from birth defects, endodontic surgeries, removal of teeth with advanced periodontal disease, or Classification Suggested Treatment Options
implant failures (1).
Class I-A Implant placement in ideal restorative position
Several published reports classified ridge defects to help plan the treatment regimen for clinical correction Class I
(2). Seibert classified ridge deformities into three broad categories which are buccolingual tissue loss, Class I-B Implant placement without dehiscence or fenestration
apicocoronal tissue loss, and a combination of both (3). Recently, Wang and Al-Shammari described a
new system, HVC classification, which is a modification of Seibert’s classification (4). These H (horizon - Class II-A
Staged GBR; Simultaneously GBR and implant placement; Ridge
expansion; Ridge splitting
tal), V (vertical), and C (combination) defects were subdivided into S (small), M (medium), and L (large) Class II
subcategories. They also described treatment options based on this HVC classification. The advent and Class II-B
Staged GBR; Simultaneously GBR and implant placement;
inlay/onlay block graft; distraction osteogenesis
widespread use of dental implants mandated careful evaluation of available bony ridge volume and
dimensions. Lekholm and Zarb’s classification includes five stages of bone resorption, from minimal to Class III
Staged GBR; Simultaneously GBR and implant placement;
inlay/onlay block graft, Taper implants; Shorter implants
severe (5). Misch and Judy’s classification describes four divisions of available bone with treatment
options based on the amount of available bone height, width, and angulation (6). Tinti and Parma-
Benfenati introduced a clinical classification of bone defects. They categorized “the envelope of bone” Class IV Distraction osteogenesis + Staged GBR or onlay graft; block graft

into five categories: extraction wounds, fenestrations, dehiscences, horizontal ridge deficiencies, and ver-
tical ridge deficiencies (2). They also proposed treatment based on this classification.
Fig 1. Vertical and horizontal defects Fig 2. Edentulous ridge Table 3. New classification and treatment options Fig 3. Metal exposure due to insufficient facial bone Fig 6. Class II-A Fig 7. Class II-B
To date, no published report has classified ridge deformities according to the position of the projected
implant restoration. Currently, 3-dimensional radiographic images are available to evaluate hard tissue
Author Year Classification
and to plan implant placement prior to surgery. Clinicians must focus on the 3-D bone-to-implant rela - Class I: buccolingual loss of tissue with normal apicocoronal ridge height
Defect Type Classification Detailed Description

tionship to establish the basis for an ideal and harmonic soft tissue situation that is stable over a long peri- Siebert 1983 Class II: apicocoronal loss of tissue with normal buccolingual ridge width
Extraction Class I the envelope of bone is intact

od. Furthermore, many authors discussed the importance of at least 2mm of facial plate thickness (7, 8). Class III: combination-type defects (loss of both height and width)
wounds Class II the envelope of bone is not intact
When the facial plate is less than this critical thickness, the clinician may expect frequent and greater loss A: Apicocornal loss of tissue

of vertical height of the facial plate.

B: Buccolingual loss of tissue the implant surface penetrates the wall of bone by an insignificant
Allen et al 1985 Class I amount and located within the envelope of bone
C: Combination
Mild: <3mm; Medium:3-6mm; Severe:>6mm
Fenestrations
there is a convexity and a significant portion of the implant is exposed
The purpose of present study was to classify ridge deformities utilizing Computerized Axial Tomographic virtually intact alveolar ridge Class II outside the envelope of bone for reasons of restorability

(CAT) scan images based on the ideal implant restorative position as determined by implant simulation. Lekholm
minor resorption of alveolar ridge
Class I the implant surface resides within the envelope of bone
1985 advanced resorption of alveolar ridge to base of dental arch
Dehiscence
MATERIALS AND METHODS
and Zarb initial resorption of base of dental arch
Class II the implant surface resides outside the envelope of bone

C
extreme resorption to base of dental arch
linical and CAT-scan data in this study were obtained from the Implant Dentistry Database (IDD) abundant bone Horizontal ridge Class I the exposed implant surface resides within the envelope of bone

established at the Department of Periodontology and Implant Dentistry at New York University barely sufficient bone deficiencies
Class II the exposed implant surface resides outside the envelope of bone
(HRD)
College of Dentistry (NYUCD) Kriser Dental Center. This data set was extracted as de-identified Misch and
1987
compromised bone

information from the routine treatment of patients. The IDD was certified by the Office of Quality Judy C-h: compromised height;
C-w: compromised width
Vertical ridge
deficiencies
Class I the vertical insufficiency is < 3 mm

Assurance at NYUCD. This study is in compliance with the Health Insurance Portability and deficient width (VRD) Class II the vertical insufficiency is > 3 mm

Accountability Act (HIPAA) requirements and was approved by the IRBA.

Table 1. Classifications of ridge defects Table 2. Tinti’s clinical classification Fig 4. Class I-A Fig 5. Class I-B Fig 8. Class III Fig 9. Class IV
CAT-scans were selected with the following criteria:

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-Only maxillary anterior missing teeth were included. he following represents the findings in our study utilizing 144 CAT-scan images to classify maxillary gical guide. 5) ability to communicate with restorative dentists and patients concerning treatment proce -
-At least two consecutive missing teeth were required. anterior ridge deformities: dures and the expected outcomes.
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endosteal implants: Organized alternative
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tion. tially edentulous patients. J Prosthet Dent
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-Radiographic templates used during taking of the CAT-scan were a prerequisite for this study. 19.4% (28) of our locations were classified as Class I-A ridge deformities; 10.4% (15) were Class I-B; ature, this is the smallest permanent implant with a high success rate (10, 11). The ideal implant position 2. Tinti C, Benfenati SP. Clinical Classification
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al bone response stage 1 placement through ly edentulous jaws: A 10-year prospective
-Unclear CAT-scan images were excluded from this study 20.8% (30) were Class II-A alveolar defects; Class II-B were present on 12.5% (18) of our samples; 6.3% in this study was based on the radiographic template. The simulated implants were placed 3mm below the of Bone Defects Concerning the Placement of stage 2 uncovering. Ann Periodontolgy multicenter study. Int J Oral Maxillofac
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(9) of sites were fenestrations without dehiscences (Class III), and all were in the Class III-A category (buc- ideal CEJ as a determined from the wax-up and radiographic template in order to provide enough apico- 2003;23:147-155.
2000;5:119-128. Implants 1999;14:639-645.
8. Grunder U, Gracis S, Capelli M. Influence of 12. Buser D, Martin W, Belser U. Optimizing
One thousand and five hundred CAT-scans were screened from the NYUCD Department of cal or palatal fenestration). Finally, 30.6% (44) of the potential implant site showed both dehiscences and coronal room for esthetic prosthetic replacement (12). 3. Seibert JS. Reconstruction of deformed, par- the 3-D bone-to-implant relationship on Esthetics for Implant Restorations in the
tially edentulous ridges, using full thickness
Periodontology and Implant Dentistry IDD. Fifty five cases satisfied the selection criteria. In these 55 sub- fenestrations(Class IV). Class IV ridge deformities had the highest incidence followed by Class II- A, Class onlay grafts. Part I. Technique and wound
esthetics+. Int J Peri Resto Dent Anterior Maxilla: Anatomic and Surgical
2005;25:113-119. Considerations. Int J Oral Maxillofac Implants
jects, 144 implant sites were evaluated. I-A, II-B, I-B, and Class III. The results reported in the present study revealed that 29.8% of the deformities were classified as Class I. healing. Compend Contin Educ Dent 9. Mecall RA, Rosenfeld AL. Influence of 2004;19:43-61.
1983;4:437-453.
Characteristics of the measurements: Almost 66% of Class I deformities were classified as Class I-A. The remaining 34% of the Class I defects 4. Wang HL, Shammari KA.. HVC Ridge
Residual Ridge Resorption Patterns on 13. Atwood DA. Reduction of residual ridges:
-All the measurements were performed and documented using CAT-scan software(SimPlant 8.0, Other findings showed that 28 Class I-A deformities were in 17 cases; 15 Class I-B deformities were in 14 would require some form of bone augmentation procedure for a successful long term prognosis. On the Deficiency Classification: A Therapeutically
Fixture Placement and Tooth Position, Part3: A major oral disease entity. J Prosthet Dent
Presurgical Assessment of Ridge 1971;26:266-279.
Materialize, Glen Burnie, MD, USA) in a IDD by two independent investigators cases; 30 Class II-A deformities presented in 21 cases; 18 Class II-B deformities were found in 9 cases; 9 other hand 30% of the deformities were classified as Class IV according to the CAT-scan simulation. This
Oriented Classfication. Int J Peri Resto Dent Augmentation Requirements. Int J Peri Resto 14. Atwood DA, Coy W. Clinical, cephalomet-
2002;22:335-343.
-In all CAT-scan images, one 3.25x10mm parallel side simulated implant was positioned for every Class III deformities were observed in 5 cases, and 44 Class IV deformities were noted in 18 cases. Class high number of Class IV deformities may be due to the fact that when these patients were evaluated at the 5. Lekholm U, Zarb GA. Patient selection and
Dent 1996;16:323-337. ric, and densitometric study of reduction of
10. Andersen E, Saxegaard E, Knutsen BM, residual ridges. J Prosthet Dent 1971;26:280-
single edentulous area. II-A was the most common ridge deformities followed by Class IV, Class I-A, Class I-B, Class II-B and Class time of intra-oral examination the treating clinician, noting the ridge defect, subsequently sent the patient preparation. Tissue Integrated Prosthesis Haanæs HR. A Prospective Clinical Study 295.
1985;1:199-209.
-Every simulated implant was placed in the ideal tooth position according to following protocol: III. for CAT-scan evaluation. Nevertheless, these findings indicate that a significant number of implant cases
Evaluating the Safety and Effectiveness of

Position: The implants were placed according to the tooth position outlined by the radiographic tem-
plate.
Angulation: The implants were placed according to the angulation of the adjacent existing tooth.
Inclination: The implants were placed using the adjacent existing tooth/teeth and the tooth position
outlined by the radiographic template as guides.
would require ridge augmentation for implant placement or a modification in the treatment plan which
There were 34 patients (61.8%) with more than one class of ridge deformities present and the remaining
may preclude the use of an implant in these sites.
21 patients (38.2%) showed only one class of deformity.
This Presentation was Sponsored by New York University Department of Implant Dentistry
DISCUSSION According to our IDD CAT-scan data, 81% (116 of the total 144) of the implant sites and 92.7% (51 of
Alumni Association (NYUDIDAA) and the Office for International Program