Journal of Pharmaceutical Research International
33(60B): 3567-3574, 2021; Article [Link].79481
ISSN: 2456-9119
(Past name: British Journal of Pharmaceutical Research, Past ISSN: 2231-2919,
NLM ID: 101631759)
Prerequisite for Successful Implant Placement with
a Comparative Study on Novel Bone Ring
Technique: A Review
Saniya Sadaf Ali a†* and Anand N. Wankhede b#
a
Department of Prosthodontics, Sharad Pawar Dental College, Datta Meghe Institute of Medical
Sciences (Deemed to be University), Sawangi (Meghe), Wardha, Maharashtra, India.
b
Department of Periodontology, Sharad Pawar Dental College, Datta Meghe Institute of Medical
Sciences (Deemed to be University), Sawangi (Meghe), Wardha, Maharashtra, India.
Authors’ contributions
This work was carried out in collaboration between both authors. Both authors read and approved the
final manuscript.
Article Information
DOI: 10.9734/JPRI/2021/v33i60B35048
Open Peer Review History:
This journal follows the Advanced Open Peer Review policy. Identity of the Reviewers, Editor(s) and additional Reviewers,
peer review comments, different versions of the manuscript, comments of the editors, etc are available here:
[Link]
Received 22 October 2021
Review Article Accepted 26 December 2021
Published 28 December 2021
ABSTRACT
Implant placement is getting space day by day. However, in every case, we never get the ideal
condition of alveolar bone for implant placement. Alveolar bone loss is seen due to periodontitis,
tooth loss, tooth extraction, and periapical infection, etc.
Resorption of alveolar bone varies from person to person and side to side. It has been noted that
the size of the residual ridge shrinks more quickly within the first six months.
There is new demand for reconstruction of the alveolar ridge for implant placement. Various
techniques are available for increasing the ridge height and width by using bone graft, membrane,
etc., one of these is the vertical ring procedure.
Bone ring technique (BRT) has been described as a one-stage approach to restore vertical ridge
height defects, in which an autogenous or allogeneic bone block graft is used and the implant is
placed simultaneously.
This review aims to focus on the importance of the implant placement, consequences of complete
edentulism, the problem with removable partial denture (RPD) placement, as a result of bone loss
in fully edentulism patients, and the use of vertical ring technique for the implant placement.
_____________________________________________________________________________________________________
†
Intern;
#
Associate Professor;
*Corresponding author: E-mail: saniyaali5744@[Link];
Ali and Wankhede; JPRI, 33(60B): 3567-3574, 2021; Article [Link].79481
Keywords: Vertical ring; implant; periodontitis; allograft; implantology; bone grafts.
1. INTRODUCTION 12. Frontward elevation of the prosthesis from
normal inclination
A dental implant is a material made up of 13. Thinning of mucosa which leads to the
alloplastic, implanted into the oral tissues under sensitivity from abrasion
the mucosal or/and periosteal layer, and on/or 14. Paraesthesia in mandibular neurovascular
within the bony envelope to aid in retention and part
support to a fixed or removable dental prosthesis 15. Increased role of the tongue in the mouth
[1]. 16. Changes in the esthetics of the last third of
the face due to loss of bone
Types of Implant: 17. Maximum risk of mandible fracture of the
body from accelerated bone loss.
1) Endosseous Implants 18. Increased changes of a denture and sore
spots due to the reduction of the anterior
1) Bladelike ridge as well as nasal spine
2) Pins 19. Labiomental angle is loss
3) Cylindrical hollow and Cylindrical full 20. Skin of the lips and face are deepened.
4) Disclike
21. Chin moves forward and then face have a
5) Screw shaped
prognathic view
6) Tapered shaped
22. Horizontal angle of the lip is decreased
2) Subperiosteal frame like implants changing the rest expression of patient
23. Loss of tonicity in muscles responsible for
3) Trans-mandibular implants [2] facial expression
24. Advance columella-philtrum angle
Why Implant Placement Is Important? [3,4,5,6] 25. Thinning of the vermillion border as a
result of loss of muscle tone
The implant placement is important to preserve 26. Nasolabial groove appears deep
the alveolar bone, maintain the vertical 27. Dimension of the maxillary lip is increased,
dimension, occlusion, improve mastication.
However, if early tooth loss occurs, partially or However, if some teeth are retained by doing the
complete edentulism can lead to the periodontal therapy or conservatively therapy
consequences that are: and had a partial edentulism. For these, we
generally use removable partial denture (RPD) in
1. Continue loss of bone of jaws those conditions where fixed partial denture
2. Undesirable changes in the soft tissues of (FPD) cannot be given. However, there are
the jaws several problems related to RPD, they are as
3. Undesirable facial feature changes followed: [6]
4. Reduced masticatory process
5. Issues related to psychology
1. Low rate of survival of more than 60% in 4
6. Decreased width and height of the
years.
supportive bone
2. 35% rate of survival in 10 years
7. Protruding mylohyoid as well as internal
oblique ridges and amplified sore spots 3. Rate of restoration of abutment of at least
8. Advanced loss of keratinized mucosa area 60% in 5 years as well as 80% in 10 years
9. Protruding superior genial tubercles with 4. Advance mobility as well as plaque
sore spots and augmented denture accumulation, bleeding on probing, and
movement caries in underlying supporting abutment
10. Muscle attachment neighboring crest near teeth
the ridge 5. 44% loss of underlying supporting abutment
11. Raise of the prosthesis as well as the teeth in 10 years
reduction of mylohyoid as well as 6. Faster loss of bones in the edentulous area if
buccinator helping in the latter provision the patient wears RPD
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Advantages of Single Tooth Implant periapical radiograph is of sufficient use to
[7]: estimate the available alveolar bone height.
1. Increased success rate (above 97% in the 10 Generally, the anterior part of the mandible has
years) the highest bone height. The bone is dense in
2. Reduced chances of caries to the next teeth the mandible anterior area. Even when the
3. Increased capability to clean the proximal resorption of the bone takes place after the loss
areas of the adjacent tooth of a tooth there is enough bone to have the
4. Increased esthetics of next tooth implant. The areas with greater forces and where
5. Increased lifespan of alveolar bone in the naturally wider teeth were present with 2 or 3
area where teeth are absent roots, also some shorter size implants, are
6. Decreased cold as well as contact sensitivity generally used and are usually lesser in number
to the adjacent tooth because of the limited anatomy.
7. Psychologically healthy patient
8. Decreased risk of loss of next tooth Oikarinen et al. had said that if there is more than
6mm of the height of bone is seen in as less as
Alveolar Bone Height: 50% of the posterior mandible and 40% in the
posterior maxilla in partial edentulism patients.
The height available is calculated by evaluating The available bone height is the most critical
the radiograph in an ideal edentulous area where criterion for implant placement because it has an
the placement of the implant is intended. When impact on both implant length and also the height
one or a couple of teeth is missing then a of the crown [8].
2. TYPES OF BONE DENSITY IN MAXILLA AND MANDIBLE
A) Misch’s bone density classification scheme [9]
The density of the Description Physical Standard Anatomical Site
bone Equivalent
D1 Densely corticated Oak, Maple wood Anterior area of mandible
D2 Porous cortical and White pine as well Anterior area of mandible
coarse trabecular as spruce wood Posterior area of the
mandible
Anterior maxilla
D3 Porous cortical and Balsa wood Anterior area of maxilla
fine trabecular area of
D4 Finely trabecular Styrofoam Posterior area of the maxilla
B) Generalized bone density location [10]
Anterior area of Mandible D2
Posterior area of Mandible D3
Anterior area of Maxilla D3
Posterior area of Maxilla D4
C) Computed tomography determination of bone density [11]
D1 >1250 Hounsfield units
D2 850-1250 Hounsfield units
D3 350-850 Hounsfield units
D4 150-350 Hounsfield units
D5 <150 Hounsfield units
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Ali and Wankhede; JPRI, 33(60B): 3567-3574, 2021; Article [Link].79481
D) Initial bone-in relation to implant contact percent (BIC%) [12,13]
Density BIC %
D1 85%
D2 65-75%
D3 40-50%
D4 30%
*: Bone to Implant Contact0
3. BONE GRAFT
a) Types of bone graft [14]
Various Graft Material
1) Autogenous Bone Grafts
a) Bone - Intraoral Sites. b) Bone - Extraoral Sites
1) Osseous coagulum 1) Iliac Autografts
2) Bone Blend
3) Cancellous Bone Marrow Transplants
4) Bone Swagging
2) Allografts 3)Xenografts
Freeze-Dried Bone Allograft (FDBA) Calf bone
Demineralized Freeze-Dried bone Allograft Bio-Oss
(DFDBA) Bio-Guide
Nonbone Graft Materials
Sclera from the eye
Cartilages
Plaster of Paris (pop)
Plastic Materials
Calcium Phosphate Biomaterials- Hydroxyapatite (HA) and Tricalcium phosphate (TCP)
Bioactive Glass
Coral- Derived Materials
b) Biologic requirement for bone regeneration [15]
Requirement Surgical Procedures
Blood supply Cortical perforations
Wound coverage Flap management, tension-free suturing
Stabilization Fixation screws membrane tacks
Osteoblasts Autogenous
Space maintenance bone graft materials
Confined space Barrier membrane
c) Biologic properties of various bone graft materials [16]
Sources Osteoinductive Osteoconductive Osteogenic
Alloplast No Yes No
Xenograft No Yes No
Autograft Yes Yes Yes
Allograft Yes/No Yes No
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Ali and Wankhede; JPRI, 33(60B): 3567-3574, 2021; Article [Link].79481
4. BONE REGENERATION Osteogenesis- development of new bone with
the help of cells in the graft.
With the increasing pace of development in
dentistry, there is increased demand for the Osteoinduction- the chemical procedure by
reconstruction of bone before or during implant which the molecules present inside graft also
therapy in partially or fully edentulous patients known as bone morphogenetic proteins change
with deficient jawbone, especially when the main the surrounding cells in osteoblasts which leads
concern is aesthetics. to the form of the bone.
Advanced loss of alveolar bone prevents the Osteoconduction- It is a physical effect
proper placement of the implant in a prosthetic in which the matrix molecules of the graft
position can be due to tooth extraction, lead to the formation of a scaffold that aids the
periodontal bone loss, tooth, and also long term outside cells to enter the graft and form new
use of removable and fixed appliances. bone [17].
Recent advances in implantology sometimes
5. BONE RING TECHNIQUE
contradict the original standard procedures by
the placement of implants in such areas where
Various treatment modalities are available to
the adequate volume of bone is absent,
increase the vertical height and horizontal width
simultaneously augmentation of bone and
for the alveolar ridge defect. Successful implant
placing and loading the implants after the short
placement has been seen in the ridge defect
healing period.
having the vertical height and horizontal width
Restoration of periodontal osseous defects can defect by using ridge augmentation methods.
be done by various therapeutic grafting One of the recent techniques which are used to
modalities. Materials that can be used for grafting increase the vertical height is the Bone ring
can be obtained from the same individual that is technique (BRT).
called an autograft, materials that are derived
from a different individual of the same class are BRT has been described as a one-stage
known as allografts and the ones derived from a approach to restore vertical ridge height defects,
different class are called xenografts. in which an autogenous or allogeneic bone block
graft is used and the implant is placed
Bone graft materials are usually graded simultaneously. Various studies about the
according to their osteogenic, osteoconductive, vertical bone ring technique have been
or osteoinductive properties. performed.
Sr. no Author (Year) Title of study Conclusion
1 Kerri Thomas Simpson Computer -Guided The method of
et al. [18] Surgery using the computer-guided
Allograft Ring technology for
Technique” with planning and placing of
Simultaneous Implant an allograft bone block
Placement: a case and simultaneous
report insertion of implant
aides for a
prosthetically headed
group approach to
conciliated grafting at
the site in addition to
improving precision as
well as accuracy as a
comparison with no
guided techniques.
2. Robert J Miller et al. Indications for The Allograft Ring
[19] Simultaneous Technique is utilized
Implantation and Bone successfully to
Augmentation Using regenerate both the
the Allograft Bone vertical and horizontal
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Ali and Wankhede; JPRI, 33(60B): 3567-3574, 2021; Article [Link].79481
Sr. no Author (Year) Title of study Conclusion
Ring Technique defects in the ridge
following placement of
the implant. Many
clinical situations occur
that can get the benefit
from this technique;
however, case
assessment is the key
factor. The optimal
three-dimensional
placing of the implant
is the ultimate guide to
surgical success and
must be prior
analyzed. The defect
in the bone should be
considered as the
placement of the
implant within the bone
increases the chances
of surgical success. An
alternative that has a
two-stage procedure
should be considered
when there is no
possibility for
restoratively driven
placement. The
standard factors that
influence surgical
success, including a
selection of the patient
and the surgical
judgment of the dentist
should not be
overlooked.19
3. El Chaar E et al. [20] Bone Ring Allograft: This case study shows
Digitally Guided a one-stage process in
Placement in the which a bone ring
Anterior Esthetic Area. allograft, as well as
A Retrospective Case implant, are placed for
Series treating a severe
damage ridge in the
anterior region of the
maxilla. The technique
is reliable to use in the
esthetic zone, with
minimal first-year loss
of peri-implant bone
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Ali and Wankhede; JPRI, 33(60B): 3567-3574, 2021; Article [Link].79481
6. CONCLUSION 8. Available Bone And Dental Implant
Treatment Plans, Carl E. Misch, Dental
Reconstruction of deficiencies in the alveolar Implant Prosthetics, Second Edition,
bone, preservation of dimensions of alveolar Elsevier, 318.
bone, and replacement of lost teeth with dental 9. Bone Density: A Key Determinant For
implants in an aesthetic position with a natural Treatment Planning, Carl E. Misch, Dental
appearance, the form can be achieved by bone Implant Prosthetics, Second Edition,
augmentation and simultaneous implant surgery Elsevier, 242.
procedures. The desired outcome of this 10. Bone Density: A Key Determinant For
procedure also depends on various biologic Treatment Planning, Carl E. Misch, Dental
principles that should be taken into Implant Prosthetics, Second Edition,
consideration. Diagnosis, treatment planning, Elsevier, 244.
clinical approach and treatment and also 11. Bone Density: A Key Determinant For
postoperative follow-up, and appropriate implant Treatment Planning, Carl E. Misch, Dental
loading are all deciding factors in achieving Implant Prosthetics, Second Edition,
success. Elsevier, 245.
12. Bone Density: A Key Determinant For
CONSENT Treatment Planning, Carl E. Misch, Dental
Implant Prosthetics, Second Edition,
It is not applicable. Elsevier, 247.
13. Ghoshal PK, Kamble RH, Shrivastav SS,
Daigavane PS, Jadhav VV, Tiwari MM.
ETHICAL APPROVAL Radiographic Evaluation of Alveolar Bone
Dimensions in the Inter-Radicular Area
It is not applicable. between Maxillary Central Incisors as
“Safe Zone” for the Placement of
COMPETING INTERESTS Miniscrew Implants in Different Growth
Patterns-A Digital Volume Tomographical
Authors have declared that no competing Study. Journal of Evolution of Medical and
interests exist. Dental Sciences-Jemds .2019;8:3836–
3840.
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