Implant Options for Narrow Ridge on #11?

This 52 yo female lost #9, #10, #11 and #12 in a MVA trauma. I am planning a 3 unit implant bridge to replace #9-#11 and a single Implant to replace #12. Please enclosed photos. #9, #12 have adequate alveolar width for a 4 mm implant. The alveolus for #11 is narrow. I was thinking about using the Versah drill protocol to widen the ridge to allow a 4 mm implant. I have not used the Versah technique yet.
Advice about the #11 site?

Fernando Álvarez comments:

F. Álvarez. Have you tried the Magnetic Mallet? This will be a good case for that technique.

Mahendra Bagur comments:

Good case for Basal-Cortical Implant as well

Omar comments:

What I'd that implant?

Omar comments:

Sorry typo. What is that implant

Russell Ollerton comments:

In your photos and screen shots I did not notice a diagnostic wax up, be it an imported model or a digital wax up done against the opposing dentition. Doesn’t matter how much bone there is if the implants are not placed in an ideal position for restoration.

Having said that there are many approaches you can take. You can augment the ridge before placement. You can also graft at the time of placement. Densah burs are nice but if the thickness of the buccal bone is not ideal, you should still graft at the time of placement.

Good luck in your treatment. You can do great things for this patient and you will be her hero from then on.

Tim Carter comments:

Just place the fixture and augment at the time of placement using conventional techniques

Greg Kammeyer, DDS, MS comments:

A great question: remember the cuspid is subject to anterior and lateral forces so bone volume is paramount. Versah drill protocol or traditional osteotomes will give you the 2+ mm of buccal bone, that I would want. This tooth is prone to recession too, so check the phenotype and consider a CTG if thin or marginal. "Over engineer the case!"

John Townend comments:

Your CBCT views indicate that the palato-buccal dimension of the ridge is wide enough to accept 4mm diameter implants with adequate cortical bone coverage at all three sites. I would advise against attempts to expand the ridge with osteotomes or Densah drills as there is a risk of fracturing the buccal cortical plate. I would also advise against putting in a Basal-Cortical implant: there's simply no need as the bone quality is good and the ridge height is excellent and will accept an orthodox design of parallel-walled shoulderless fixture at all three sites. Your CBCT scans appear to show Astra Tech implants which would be ideal. If you're really worried about the ridge width at #11 perhaps the implant brand you use has a narrower (say 3.5-3.7mm) version. It would be perfectly safe and stable with this length of fixture. However, this is an aesthetically highly sensitive zone and I agree with Russell Ollerton that a diagnostic wax up would be a wise precaution. Your digitally generated bridge work is no doubt helpful to you but from the patient's point of view there is really no substitute for a laboratory generated wax up for showing her the final appearance (e.g. slightly longer crowns and compromised interdental papilla morphology) and making sure she is happy with this before you start the treatment.

Timothy Carter comments:

About 8-10 years ago I was attending a lecture by Dr. Michael Block and he addressed the issue of CBCT always (100%) showing less B-L bone width than what is present clinically. Based on my experience over the past 15 years and utilizing various different image capturing devices I will concur with his assessment. With that I think it is true that we as clinicians place entirely too much emphasis on our digital images and AI means of treatment planning. In my own perio practice I have a Carestream 9600 CBCT, iTero introral scanner, 3D printer and AG milling machine with Exocad design software... Despite all of this fancy stuff I still do traditional impressions and mount cases on a Denar Mark 320 articulator. All of the fancy AI devices in the world can not replace good old fashion analog models and I think it would benefit you and this patient if you took a step back and relied more on traditional clinical skills/techniques rather than AI that is rarely, if ever,100% accurate!!!