When the Ridge is a Knife Edge… and We Still Achieve a Perfect Implant

Andre Chen
4 days ago
4 min read

Updated: 9 hours ago

Yesterday I had one of those cases that reminds us why implant dentistry is never just “placing a screw into bone.”

It was tooth 36.

It had been a hard week. Rainy. Heavy. Always moving… moving… moving… never stopping.

And then a patient shows up and says:

“I’m ready for you, Dr. Chen.”

Perfect, I thought…

Until I looked at the implant site.

Bone That Looked Like a Blade

At first glance, the residual bone was literally a blade: a true knife-edge ridge, with a horizontal defect and almost no keratinized tissue.

Initial Situation - Horizontal deficiency and lack of suficient keratinized Mucosa

Everything there was saying — even Margarida:

“This is going to be difficult.”

But when we opened the CBCT… the case became even more extreme.

A marked lingual concavity, dense lingual and buccal cortices, almost impenetrable, and a ridge so thin that placing an implant safely seemed impossible.

During planning, the problem became obvious:

Even a 3.75 mm implant would end up with the buccal aspect completely outside the ridge, except at the apical zone.

And this is where modern implantology truly begins:

It’s not only about choosing an implant…it’s about choosing the right architecture for that bone.

In this case, we selected a TLX implant with an aggressive apical thread design to secure primary stability, and an RT tulip-shaped platform, specifically designed for crestal anchorage.

A supracrestal implant with a polished collar, meant to interact with keratinized tissue in the best possible way.

“So… how are we going to do this?”

Margarida asked:

“So how are we going to do this?”

And I answered:

Preparation, Margarida. Implant bed preparation is everything.

I know many clinicians who, faced with a case like this, would immediately start down the classic path:

first regenerate the bone with non-resorbable membranes, metallic or not
Then complain about a lack of keratinized mucosa
Then harvest bone from another part of the body
and only then… place the implant

The result?

6 or 7 months of treatment.Thousands of euros.Three major surgical traumas for the patient.

And in the end… the patient still has no tooth....

"Modern implantology does not forgive overtreatment."

Do that protocol, and the number of patients you treat will drop dramatically.

The morbidity becomes so high that, if you truly think about it…

You wouldn’t do it that way if it were your own mouth ?

Preparation: When the Angle Is Everything

Here, a correctly executed surgery — with biological principles respected and the right instrumentation — changes everything.

We began with a full-thickness mucoperiosteal incision, carefully splitting the keratinized tissue and mobilizing part of it toward the buccal side.

Because here, every millimeter matters.Every fiber matters.

The entry was performed almost horizontally, about 3 mm below the bone crest, with an angle of approximately 45 degrees toward the buccal.

With the spear drill, we penetrated until reaching the trabecular bone.Then we repeated the osteotomy with the 2.2 mm drill.

But the critical moment came next:

Using a large spherical turbine bur — note: a tungsten handpiece bur may work, but vibration for the patient is higher — we reshaped the coronal cortical entry point.

We literally created the pathway for the 2.8 mm drill to enter in the prosthetically correct position.

The osteotomy was then followed by the lingual wall until the desired depth.

We wanted the tulip platform to remain crestal. So we advanced to 10 mm.

Then we widened with the 3.5 mm drill.

And finally, we returned to the spherical bur to open the medial and distal ridge, accommodating the implant platform as if sculpting a new crest.