Enhancement of Buccolingual Ridge Width Using Calcium Phosphosilicate Graft: A 10-Month Follow-Up Case Report

INTRODUCTION

The alveolar bone is a specialized structure whose integrity depends on the presence of teeth and functional loading transmitted through the periodontal ligament.^[1] Following tooth extraction, the alveolar ridge undergoes physiologic remodeling characterized by progressive resorption.^[2] Horizontal bone loss has been shown to exceed vertical bone loss, particularly affecting the buccal cortical plate, resulting in a narrow alveolar ridge.^[3,4]

Adequate alveolar ridge width is critical for successful prosthetic and implant rehabilitation.^[5] Insufficient buccolingual bone volume may compromise implant positioning and increase the risk of biological and mechanical complications.^[6] Consequently, ridge augmentation procedures are often required prior to implant placement.^[7]

Post-extraction resorption is the most common cause of horizontal ridge deficiency and is attributed to loss of periodontal ligament-mediated blood supply and remodeling of the bundle bone.^[3] Additional factors such as periodontal disease, traumatic extraction, periapical pathology, and long-standing edentulism further contribute to ridge resorption.^[8]

Several techniques have been proposed for horizontal ridge augmentation, including guided bone regeneration, ridge splitting, block grafts, and particulate grafting.^[9] The choice of graft material significantly influences regenerative outcomes.^[10] Synthetic alloplastic grafts offer advantages such as biocompatibility, unlimited availability, and elimination of donor-site morbidity.^[11]

Calcium phosphor silicate bioactive glass (Nova Bone®) is an alloplastic graft material with osteoconductive and osteostimulation properties.^[12] It forms a hydroxycarbonate apatite layer on contact with body fluids, promoting osteoblastic activity and new bone formation.^[13] Decortication of the recipient site further enhances regeneration by inducing the regional acceleratory phenomenon.^[14]

This case report describes horizontal ridge augmentation using calcium phosphor silicate bioactive glass putty with clinical and CBCT evaluation over a 10-month follow-up period.

CASE REPORT

Clinical examination

Intraoral examination revealed a partially edentulous space in relation to tooth 25 with a visibly narrow buccolingual ridge [Figure 1]. Ridge height was clinically adequate, and the overlying soft tissues were healthy. Adjacent teeth were periodontally stable.

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Figure 1: Pre-operative image showing reduced buccolingual ridge width.

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Radiographic evaluation (CBCT)

Preoperative CBCT evaluation revealed a buccolingual ridge width of ~3 mm at the crestal level [Figure 2], confirming the presence of a horizontal ridge deficiency and the need for augmentation prior to implant placement.

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Figure 2: Preoperative CBCT (Cone beam computed tomography) image showing reduced buccolingual ridge width of approximately 3 mm at the crestal level

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Surgical procedure

Following completion of the Phase I periodontal therapy, surgery was performed under aseptic conditions. Local anesthesia was administered, and a full-thickness mucoperiosteal flap was elevated to expose the alveolar ridge. Initial buccolingual ridge width was measured using a periodontal probe and confirmed to be ~3 mm.

Decortication of the recipient site was performed using a round bur under copious saline irrigation to induce bleeding points. Calcium phosphor silicate bioactive glass putty (Nova Bone®) was then placed over the decorticated ridge to achieve horizontal augmentation [Figures 3 and 4]. The flap was repositioned and sutured to obtain primary closure. Postoperative instructions and medications were prescribed.

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Figure 3: Flap elevation and decortication done

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Figure 4: Placement of calcium phosphosilicate bioactive glass (NOVA Bone)

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Follow-up and results

Postoperative healing was uneventful. The patient reported for review at 10 months due to the inability to attend intermediate follow-up visits. Clinical examination revealed healthy soft tissues and a well-contoured alveolar ridge.

Buccolingual ridge width was clinically measured and found to be ~5 mm, representing a net horizontal gain of 2 mm [Figure 5]. Follow-up CBCT imaging confirmed the increase in ridge width with satisfactory bone density and ridge stability, rendering the site suitable for mini-implant placement [Figure 6].

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Figure 5: Post-operative image showing increased buccolingual ridge width

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Figure 6: Post-operative cone-beam computed tomography after 10 months

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DISCUSSION

Resorption of the alveolar ridge following tooth extraction is a well-documented biological phenomenon and a major limitation in implant dentistry. Newman et al. emphasized that loss of the periodontal ligament eliminates functional stimulation to the alveolar bone, triggering physiologic remodeling.^[1] Araújo and Lindhe demonstrated that this remodeling results in significant dimensional alterations of the alveolar ridge, particularly during the early post-extraction period.^[2]

Several longitudinal studies have shown that horizontal ridge resorption is more pronounced than vertical resorption. Schropp et al. and Tan et al. reported horizontal bone loss ranging from 3–5 mm, predominantly affecting the buccal aspect of the ridge.^[3,4]

This is attributed to the thin buccal cortical plate, which is largely composed of bundle bone and is more susceptible to resorption following tooth loss.^[5]

Adequate buccolingual ridge width is essential for prosthetically driven implant placement. Benic and Hämmerle reported that insufficient ridge width compromises implant positioning and increases the risk of peri-implant complications.^[6] Buser et al. further emphasized that narrow ridges frequently require horizontal augmentation to achieve long-term implant success.^[5]

Recipient-site decortication was performed to enhance regenerative outcomes. Urban and Monje advocated decortication as a key step in horizontal guided bone regeneration due to its role in improving graft integration and vascularization.^[9] The biological rationale is based on the regional acceleratory phenomenon described by Frost, which involves increased bone turnover and remodeling following surgical insult.^[14] Retzepi and Donos reported that cortical perforations facilitate the migration of osteogenic cells and growth factors, thereby enhancing new bone formation.^[10]

Calcium phosphor silicate bioactive glass (Nova Bone®) was selected due to its osteoconductive and bioactive properties. Hench described its ability to form a hydroxycarbonate apatite layer that chemically bonds to bone.^[12] Xynos et al. demonstrated that ionic dissolution products of bioactive glass stimulate osteoblast activity and angiogenesis.^[13]

Compared to autogenous grafts, bioactive glass eliminates donor-site morbidity and reduces surgical time while maintaining satisfactory regenerative potential.^[15] Kolerman et al. reported predictable outcomes with alloplastic grafts in ridge augmentation procedures.^[11]

The putty formulation offers improved handling and graft stability, particularly advantageous in horizontal ridge augmentation.^[16]

In the present case, a 2 mm increase in ridge width was observed at 10 months. Although modest, Wang and Boyapati emphasized that even minimal horizontal augmentation may be clinically decisive in narrow ridges.^[7] The ridge width achieved was sufficient to allow implant planning without additional augmentation.

CONCLUSION

Calcium phosphor silicate bioactive glass putty, combined with recipient-site decortication, represents a predictable, minimally invasive approach for horizontal ridge augmentation. Clinical and CBCT findings at 10 months demonstrated satisfactory ridge width gain, supporting its use in the management of narrow alveolar ridges.