**2.5 The augmentation procedure**

Try-in of the bone wedges into the grooves at the recipient bed was performed in order to adapt one bone wedge to each groove. Thereafter, one wedge was inserted and taped into one groove using a flat edge cylindrical instrument and hummer (**Figure 4a**). It was extremely important to check the stability of each wedge by trying to extract it out from its groove; an unstable wedge should be removed and replaced by a stable one. This procedure is the fixation method of the bone wedge to the recipient site. The next step was the trimming and rounding of the sharp edges of each wedge in order to prevent trauma to the soft tissue overlying the augmentation (**Figure 4b** and **c**), consequently, multiple bone compartments were achieved (**Figure 4d**). The next step was packing those compartments with allograft particulate bone substitutes (**Figure 4e** and **f**), the desired bone volume was achieved

#### **Figure 3.**

*The recipient site. (a) Grooves are created by height speed, low speed or piezoelectric. (b) Three grooves were created at the recipient site.*

*The Use of Cortical Bone Wedges from the Mandibular Ramus "Wedge Technique"… DOI: http://dx.doi.org/10.5772/intechopen.100099*

#### **Figure 4.**

*The bone augmentation procedure. (a) Insertion and tapping of the bone wedges inside the grooves. (b) Trimming of the sharp edges of bone wedge. (c) Stability checking of the bone wedge inside the groove. (d) Bone compartments at the recipient site. (e) The bone filler, allograft particulate bone. (f) The filling of the bone compartments with the allograft particles. (g) The obtained final bone volume. (h) The resorbable membrane covering the bone graft. (i) Tension free closure of the augmented site. (j–o) Bone grafting of the patient's right side with the WT.*

(**Figure 4g**), subsequently the bone graft was covered with a resorbable membrane (**Figure 4h**). A tension-free closure of the flap was performed (**Figure 4i**), utilizing a free buccal fat pad graft was used to enhance flap closure. The right side of the mandible was augmented using 4 bone wedges, with the same sequence that was performed to augment the left side (**Figure 4j**–**o**).

The follow-up was performed every two weeks for the first six weeks, and once a month later on (**Figure 5a**). After 4 months the patient underwent a dental CT scan (CBCT) to evaluate the amount of bone gain that was achieved from the augmentation procedure (**Figure 5b**–**d**), then dental implants were inserted under local anesthesia (**Figure 6**). Three to four months later the patient was referred for prosthetic rehabilitation (**Figure 7a** and **b**). This case has been followed up for 120 months (**Figure 7c**–**e**).

#### **2.6 Case presentations**

#### *2.6.1 Case 1*

A 45-year-old woman was referred to our department to augment atrophic ridges at the anterior and left posterior mandible. On examination, partial edentulism of the mandible with missing anterior and left posterior teeth (43–33 and 35, 36), moreover, the left and right first premolar were with poor prognosis (**Figure 8a**–**c**). Computed

#### **Figure 5.**

*Follow-up after two weeks. (a) The post-op panoramic view demonstrates one donor site and two recipient sites. (b–d) Computed tomographic views demonstrate the new bone that was obtained.*

tomography was performed and demonstrated the bone deficit at the anterior and left mandible (**Figure 8d** and **e**). The patient had been treated in two stages; at the first stage, WT was performed to augment the anterior and left mandibular regions. Under general anesthesia the bone block was harvested from the left retromolar area (the same surgical site), then was split to obtain the bone wedges (**Figure 8f**–**i**). The recipient sites were prepared by creating grooves, consequently, 7 bone wedges were inserted into the grooves in a stable position and several bone compartments were achieved (**Figure 8j**–**l**). Then, the compartments were filled with particulate allograft bone substitute, obtaining the desired bone volume (**Figure 8m**), which was covered with a resorbable membrane (**Figure 8n**), and tension free closure of the recipient site was performed

(**Figure 8o**). A temporary bridge based on left and right first premolars was placed. The healing process was uneventful during the follow-up period, after 4 months a Computed dental tomography was performed and demonstrated the bone gain which was 4–6 mm horizontally and vertically (**Figure 8p**–**r**). At the second stage, the reentry to the augmented sites revealed new bone volume, and integration of the bone wedges into the new bone mass (**Figure 8s**), thereafter, 6 implants were inserted with immediate loading (**Figure 8t**–**v**). All implants were successfully osseointegrated (**Figure 8w** and **x**) and the final rehabilitation was performed after 3 months (**Figure 8y**). This case is followed for 72 months (**Figure 8y**).

#### *2.6.2 Case 2*

A 28-year-old woman was referred complaining of severe atrophy of the anterior maxillary region; after a failed bone augmentation procedure which was done by her surgeon. Clinical and radiographic examinations revealed severe atrophy of the anterior maxillary ridge and pneumatization of the right maxillary sinus (**Figure 9a**–**e**). She was treated in three stages; bone augmentation of the anterior maxilla with the wedge technique, extraction and socket augmentation of the right second premolar, and right maxillary sinus augmentation. The right mandibular retromolar area was the donor site for the bone block, after splitting the bone block, 7 bone wedges were

*The Use of Cortical Bone Wedges from the Mandibular Ramus "Wedge Technique"… DOI: http://dx.doi.org/10.5772/intechopen.100099*

#### **Figure 6.**

*Reentry after 4 months and implant placement. (a) Shows good bone regeneration after 4 months at the right side. (b) Shows good new bone volume at the left side. (c and d) Implants placement.*

#### **Figure 7.**

*Rehabilitation and follow up. (a and b) Implant abutments. (c–e) Panoramic radiograph and clinical view 60 months after the surgery.*

obtained. Four cortical bone wedges were inserted at the grooves that were prepared at the recipient site (**Figure 9f**). Then, particulate allograft bone substitute was used as the bone filler between the bone wedges (**Figure 9g**). The right maxillary first premolar, and the left maxillary canine were temporarily preserved to hold an acrylic bridge during the healing phase. Follow-up examinations at months showed excellent

#### **Figure 8.**

*Case 2. (a–e) Clinical and radiographic view of the mandible. (f–i) Bone block harvest and the preparation of the bone wedges. (j–o) WT bone augmentation at the anterior and the left mandibular ridges. (p–r) Computed tomography 4 months after bone grafting. (s–u) Reentry and implant insertions 4 months after the augmentation surgery. (v) Radiographic view-follow up of the implants. (w and x) Crowns rehabilitation. (y) 72 months follow-up.*

recovery (**Figure 9h**) and CBCT showed the new bone gain and the available bone (width; 6 to 10 mm) for implant insertion (**Figure 9i**–**k**). At the stage-two surgery, the intraoperative views showed a good regeneration, and the bone wedges had excellent integration in the new bone volume (**Figure 9l**). **Figure 9(m)** and **(n)** demonstrate the drilling through those wedges indicating their stability and viability.

*The Use of Cortical Bone Wedges from the Mandibular Ramus "Wedge Technique"… DOI: http://dx.doi.org/10.5772/intechopen.100099*

#### **Figure 9.**

*Case 2. (a and b) Clinical view-anterior maxilla. (c–e) Computed tomography of the anterior maxilla demonstrates the severe atrophy of the residual ridge. (f–g) The WT bone augmentation, intraoperative views. (h–k) Clinical and radiographic views at four months after the surgery. (l) Reentry 4 months after the surgery demonstrates nice bone regeneration. (m and n) Show the drilling for the implants that was performed through the bone wedges. (o) 4 implants were placed at the recipient site. (p and q) Clinical and radiographic view at 4 months after implant placement. (r and s) Temporary rehabilitation follow up 5 months after implants insertion. (t) 60 months follow-up after the surgery, fixed prosthesis supported by dental implants with excellent outcomes.*

At the same stage, the right maxillary first premolar, and the left maxillary canine were extracted with socket augmentation. In addition, 4 implants were placed at the anterior augmented region (**Figure 9o**) with immediate loading. **Figure 9(p)** and **(q)** show clinical and radiographic view one month after implant placement. At stage-three surgery, additional 4 implants were placed; 3 at the right maxilla and one implant at the left maxillary canine. Four months later the patient was referred to her dentist for a fixed prosthesis over the implants (**Figure 9r** and **s**). This patient had been followed for 60 months (**Figure 9t**).
