Sequential Ridge Augmentation Protocol for Hard and Soft Tissue Grafting in Alveolar Ridge Deficiencies: A Proposed Evidence-Based Algorithm

Implants demonstrating inadequate keratinized tissue, strong frenal pull, and plaque accumulation.

Sequential ridge augmentation protocol. Figures in parentheses refer to citations, which justify each step in this evidence-based protocol.

Site nos. 20 and 21 assessed prior to implant placement using the sequential ridge augmentation (SRA) protocol revealed inadequate keratinized tissue (less than 2 mm); howeverm, the soft tissue defect was minor. The alveolar width was adequate for planned implant diameter and did not require augmentation. The applied SRA protocol is described in detail in Figures 4 and 5.

Sequential ridge augmentation protocol applied to sites 20 and 21.

(a) Implant placement was performed first. (b, c) After 3 months at the time of implant uncovery (second stage), soft tissue augmentation with a free gingival graft was done. (d) Final restorations placed 10 weeks after second-stage surgery, showing adequate keratinized tissue around final restorations.

Sites 18 and 19 assessed using the sequential ridge augmentation (SRA) protocol revealed inadequate keratinized tissue (less than 2 mm) and strong frenal pull at the planned implant site. The available alveolar width was inadequate for a restoratively driven implant placement as seen on cone-beam computerized tomography (range, 3.8–4.6 mm). The applied SRA protocol can be seen in detail in Figures 7 and 8.

Sequential ridge augmentation protocol applied to sites 20 and 21.

After application of the sequential ridge augmentation protocol, (a) free gingival graft was done first to get adequate keratinized tissue at the implant site. (b) After 6 weeks, guided bone regeneration was performed to increase the buccal-lingual dimension of the ridge to allow implant placement in the resotratively determined implant position. (c) Implant placement was done 3 months after guided bone regeneration using a surgical stent. (d) Excellent soft and hard tissue profiles were seen at 3 months after implant surgery at the time of recording implant-level impressions.