The ESTMJS (European Society of Temporomandibular Joint Surgeons) Consensus and Evidence-Based Recommendations on Management of Condylar Dislocation.

Although condylar dislocation is not uncommon, terminology, diagnostics, and treatment concepts vary considerably worldwide. This study aims to present a consensus recommendation based on systematically reviewed literature and approved by the European Society of TMJ Surgeons (ESTMJS). Based on the template of the evidence-based German guideline (register # 007-063) the ESTMJS members voted on 30 draft recommendations regarding terminology, diagnostics, and treatment initially via a blinded modified Delphi procedure. After unblinding, a discussion and voting followed, using a structured consensus process in 2019. An independent moderator documented and evaluated voting results and alterations from the original draft. Although the results of the preliminary voting were very heterogenous and differed significantly from the German S3 guideline (p < 0.0005), a strong consensus was achieved in the final voting on terminology, diagnostics, and treatment. In this voting, multiple alterations, including adding and discarding recommendations, led to 24 final recommendations on assessment and management of TMJ dislocation. To our knowledge, the ESTMJS condylar dislocation recommendations are the first both evidence and consensus-based international recommendations in the field of TMJ surgery. We recommend they form the basis for clinical practice guidelines for the management of dislocations of the mandibular condyle.

A randomized controlled preclinical trial on 3 interposal temporomandibular joint disc implants: TEMPOJIMS-Phase 2.

The effort to develop an effective and safe temporomandibular joint (TMJ) disc substitute has been one of the mainstreams of tissue engineering. Biodegradable customized scaffolds could approach safety and effectiveness to regenerate a new autologous disc, rather than using non-biodegradable materials. However, it is still technically challenging to mimic the biomechanical properties of the native disc with biodegradable polymers. In this study, new 3D tailored TMJ disc implants were developed: (1) Poly(glycerol sebacate) (PGS) scaffold reinforced with electrospun Poly(εcaprolactone) (PCL) fibers on the outer surface (PGS+PCL); (2) PCL and polyethylene glycol diacrylate (PEGDA) (PCL+PEGDA); and (3) PCL. The TMJ implants were tested in a randomized preclinical trial, conducted in 24 black Merino sheep TMJ, perfoming bilateral interventions. Histologic, imaging, and kinematics analysis was performed. No statistical changes were observed between the PGS+PCL disc and the control group. The PCL+PEGDA and PCL groups were associated with statistical changes in histology (p = 0.004 for articular cartilage mid-layer; p = 0.019 for structure changes and p = 0.017 for cell shape changes), imaging (p = 0.027 for global appreciation) and dangerous material fragmentation was observed. No biomaterial particles were observed in the multi-organ analysis in the different groups. The sheep confirmed to be a relevant animal model for TMJ disc surgery and regenerative approaches. The PCL and PCL+PEGDA discs presented a higher risk to increase degenerative changes, due to material fragmentation. None of the tested discs regenerate a new autologous disc, however, PGS+PCL was safe, demonstrated rapid resorption, and was capable to prevent condyle degenerative changes.

Defining a Standard Set of Health Outcomes for Patients With Squamous Cell Carcinoma of the Head and Neck in Spain.

PURPOSE: A systematic, standardized collection of health outcomes during patient treatment and follow-up, relevant from the perspective of all stakeholders, is a crucial step toward effective and efficient disease management. This project aimed to define a standard set of health outcomes for patients with squamous cell carcinoma of the head and neck (SCCHN). METHODS: The project was led and coordinated by a scientific committee (SC). It comprised: (1) a literature review (to identify variables used during SCCHN management); (2) 1st-SC meeting (to select the variables for presentation during nominal groups-NG); (3) five NG (n=42 experts) and four interviews with patients (to reach consensus on the variables for inclusion); and (4) final-SC meeting (to review the results of NG ensuring consensus on the variables where consensus was not reached). RESULTS: Experts agreed to include the following variables in the standard set: treatment-related (treatment intent and type, response to treatment, treatment toxicity/complication, treatment completion), degree of health (performance status, patient-reported health status, pain, dysphonia, feeding and speech limitations, body image alteration, tracheotomy), survival (overall and progression-free survival, cause of death), nutritional (weight, nutritional intervention), other variables (smoking status, alcohol consumption, patient satisfaction with aftermath care, employment status), and case-mix variables (demographic, tumor-related, clinical and nutritional factors). CONCLUSIONS: This project may pave the way to standardizing the collection of health outcomes in SCCHN and promote the incorporation of patients' perspective in its management. The information provided through the systematic compilation of this standard set may define strategies to achieve high-quality, patient-centered care.

Is the "Habsburg jaw" related to inbreeding?

Background: The "Habsburg jaw" has long been associated with inbreeding due to the high prevalence of consanguineous marriages in the Habsburg dynasty. However, it is thought that mandibular prognathism (MP) is under the influence of a dominant major gene.Aim: To investigate the relationship between the "Habsburg jaw" and the pedigree-based inbreeding coefficient (F) as a relative measure of genome homozygosity.Subjects and methods: The degree of MP and maxillary deficiency (MD) of 15 members of the Habsburg dynasty was quantified through the clinical analysis of 18 dysmorphic features diagnosed from 66 portraits.Results: A statistically significant correlation (r = 0.711, p = 0.003) between MP and MD was observed among individuals. Only MP showed a statistically significant positive regression on F as evidenced from univariate analysis (b = 6.36 ± 3.34, p = 0.040) and multivariate analysis (PCA) performed from single dysmorphic features (b = 14.10 ± 6.62, p = 0.027, for the first PC).Conclusion: Both MP and MD are generally involved in the "Habsburg jaw." The results showed a greater sensitivity to inbreeding for the lower third of the face and suggest a positive association between the "Habsburg jaw" and homozygosity and therefore a basically recessive inheritance pattern.

The Critical Peri-implant Buccal Bone Wall Thickness Revisited: An Experimental Study in the Beagle Dog.

PURPOSE: There is a lack of knowledge concerning the critical buccal bone thickness required for securing favorable functional and esthetic outcomes, conditioned to the dimensional changes after implant placement. A preclinical study was therefore carried out to identify the critical buccal bone wall thickness for minimizing bone resorption during physiologic and pathologic bone remodeling. MATERIALS AND METHODS: A randomized, two-arm in vivo study in healthy beagle dogs was carried out. The first group of dogs was sacrificed 8 weeks after implant placement for histomorphometric examination of postsurgical resorption of the buccal bone wall. The second group of dogs was monitored during three ligature-induced peri-implantitis episodes and a spontaneous progression episode. Morphometric and clinical variables were defined for the study of physiologic and pathologic buccal and lingual bone loss. RESULTS: Seventy-two implants were placed in healed mandibular ridges of 12 beagle dogs. Two groups were defined: 36 implants were placed in sites with a thin buccal bone wall (< 1.5 mm), and 36 were placed in sites with a thick buccal bone wall (≥ 1.5 mm). No implants failed during the study period. For the great majority of the histomorphometric parameters, a critical buccal bone wall thickness of at least 1.5 mm seemed to be essential for maintaining the buccal bone wall during physiologic and pathologic bone resorption. Suppuration (+) and mucosal recession (-) were more often associated with implants placed in sites with a thin buccal bone wall. CONCLUSION: A critical buccal bone wall thickness of 1.5 mm at implant placement is advised, since a thicker peri-implant buccal bone wall (> 1.5 mm) is exposed to significantly less physiologic and pathologic bone loss compared with a thinner buccal bone wall (< 1.5 mm).

Diagnostic accuracy of the implant stability quotient in monitoring progressive peri-implant bone loss: An experimental study in dogs.

OBJECTIVES: To investigate the impact of progressive bone loss in an experimental peri-implantitis model in the dog upon the implant stability quotient (ISQ) measured in the course of induced and spontaneous conditions of disease, and to evaluate the association between the clinical parameters and ISQ. MATERIALS AND METHODS: Seventy-two implants were placed in 12 Beagle dogs. Of these, 36 implants in six dogs were assessed during ligature-induced peri-implantitis (three timepoints) and at one timepoint following a period of spontaneous progression. The ISQ was recorded using resonance frequency analysis (RFA). Furthermore, the clinical peri-implant parameters were registered at four sites per implant at each timepoint. Marginal bone loss (MBL) was determined using computed tomography at four sites per implant and bone-to-implant contact (BIC) was assessed from histological samples. A linear regression model was estimated by generalized estimation equations (GEEs) in order to study the MBL-ISQ values at each measurement timepoint. Pearson's correlation test was applied. RESULTS: None of the implants failed during the study period. At implant level, a strong negative correlation was found for all timepoints between ISQ and MBL (r = -0.58; p < 0.001). Accordingly, as follow-up progressed, lower ISQ and higher MBL values were observed. A prediction of MBL depending on the ISQ values and timepoints showed a decrease in one ISQ unit to be related to ~1 mm of MBL. Likewise, a statistically significant correlation was found between BIC and ISQ evaluated after spontaneous chronification of peri-implantitis (r = 0.34; p = 0.04). Nevertheless, the ISQ values failed to correlate to any of the clinical parameters recorded. CONCLUSION: Resonance frequency analysis seems accurate in diagnosing progressive bone loss, as a statistically significant decrease in ISQ was recorded in the course of peri-implant disease. Nevertheless, the clinical relevance of this observation as a diagnostic tool is debatable, since implant stability remains high.

Arthroscopy of the Inferior Compartment of the Temporomandibular Joint: A New Perspective.

OBJECTIVE: Arthroscopy of the temporomandibular joint (TMJ) has become a well-standardized non-invasive procedure for the treatment of TMJ internal derangement (ID). Since the last 1980s, no clinical application for arthroscopy of the inferior compartment has been established because of the intrinsic difficulty of the technique and the believing of the absence of clinical relevance for treatment of ID. METHODS: We report on a particular case in which arthroscopy of the inferior joint compartment together with the examination of the upper joint space was performed in a patient with ID of the TMJ. A 1.9 mm scope was used, while the technique for entering the inferior compartment is presented. RESULTS: The presence of intense synovitis, fibrous adhesion, and pseudowall were observed in the inferior joint compartment, thus leading to the hypothesis of the more than likely influence of the status of the synovial lining within this space in the persistence of symptoms in recalcitrant patients with ID. CONCLUSION: We believe that this new insight could lead surgeons to a more complete use of this non-invasive procedure for the treatment of this entity. LEVEL OF EVIDENCE: 4/5.

Bioengineered Temporomandibular Joint Disk Implants: Study Protocol for a Two-Phase Exploratory Randomized Preclinical Pilot Trial in 18 Black Merino Sheep (TEMPOJIMS).

BACKGROUND: Preclinical trials are essential to test efficacious options to substitute the temporomandibular joint (TMJ) disk. The contemporary absence of an ideal treatment for patients with severe TMJ disorders can be related to difficulties concerning the appropriate study design to conduct preclinical trials in the TMJ field. These difficulties can be associated with the use of heterogeneous animal models, the use of the contralateral TMJ as control, the absence of rigorous randomized controlled preclinical trials with blinded outcomes assessors, and difficulties involving multidisciplinary teams. OBJECTIVE: This study aims to develop a new, reproducible, and effective study design for preclinical research in the TMJ domain, obtaining rigorous data related to (1) identify the impact of bilateral discectomy in black Merino sheep, (2) identify the impact of bilateral discopexy in black Merino sheep, and (3) identify the impact of three different bioengineering TMJ discs in black Merino sheep. METHODS: A two-phase exploratory randomized controlled preclinical trial with blinded outcomes is proposed. In the first phase, nine sheep are randomized into three different surgical bilateral procedures: bilateral discectomy, bilateral discopexy, and sham surgery. In the second phase, nine sheep are randomized to bilaterally test three different TMJ bioengineering disk implants. The primary outcome is the histological gradation of TMJ. Secondary outcomes are imaging changes, absolute masticatory time, ruminant time per cycle, ruminant kinetics, ruminant area, and sheep weight. RESULTS: Previous preclinical studies in this field have used the contralateral unoperated side as a control, different animal models ranging from mice to a canine model, with nonrandomized, nonblinded and uncontrolled study designs and limited outcomes measures. The main goal of this exploratory preclinical protocol is to set a new standard for future preclinical trials in oromaxillofacial surgery, particularly in the TMJ field, by proposing a rigorous design in black Merino sheep. The authors also intend to test the feasibility of pilot outcomes. The authors expect to increase the quality of further studies in this field and to progress in future treatment options for patients undergoing surgery for TMJ disk replacement. CONCLUSIONS: The study has commenced, but it is too early to provide results or conclusions.

What is the role of elective neck dissection in patients with squamous cell carcinoma of the upper jaw? / ¿Cual es el papel de la disección cervical electiva en el carcinoma escamoso del maxilar superior?

Background. Surgical treatment of clinically negative neck in maxillary squamous cell carcinoma (SCC) of the upper jaw is controversial. The purpose of this study was to define the incidence of cervical metastasis and to assess if elective neck dissection is justified when the neck is not primarily affected. Methods. We retrospectively reviewed 20 patients treated of SCC of the maxillary alveolus and hard palate between 2005 and 2012. Results. Six (30%) patients presented with cervical lymph metastasis at initial diagnosis. Two of the14 patients who initially had no signs of metastasis in the neck developed cervical metastasis during follow-up and another patient with cervical metastasis at diagnosis developed contralateral cervical metastasis. All the patients with cervical metastasis (45%) were pT3/T4 SCC. Cervical metastasis developed at a mean of 11.6 months. Conclusions. Despite this study being limited by its retrospective nature and the sample size, based on our findings and on an extensive review of the literature, we may conclude that cervical metastasis from maxillary alveolus and hard palate SCC appears most frequently in pT3/T4 tumors. Therefore, we find elective neck dissection appropriate for patients with pT3/T4 SCC of the upper jaw (AU)

Introducción. El tratamiento quirúrgico del cuello clínicamente negativo en el carcinoma de células escamosas (CCE) del maxilar superior es controvertido. El objetivo de este estudio es mostrar la incidencia de metástasis cervical y analizar si la disección cervical electiva está justificada cuando el cuello no está afectado de inicio. Métodos. Revisamos retrospectivamente 20 pacientes tratados por CCE de paladar duro y reborde alveolar superior entre 2005 y 2012. Resultados. Seis (30%) pacientes presentaron metástasis cervical de inicio. Dos de los 14 pacientes que inicialmente no tuvieron signos de metástasis cervical la desarrollaron durante el seguimiento, y otro paciente con metástasis cervical al inicio desarrolló una metástasis cervical contralateral. Todos los pacientes con metástasis cervical (45%) fueron pT3/T4 CCE. El tiempo medio de aparición de metástasis cervical fue de 11,6 meses. Conclusiones. A pesar de las limitaciones de este estudio (naturaleza retrospectiva, limitado número de pacientes), y tras analizar los resultados obtenidos y revisar la literatura, podemos concluir que la metástasis cervical de CCE de maxilar superior aparece con mayor incidencia en tumores pT3/T4. Por lo tanto, creemos conveniente realizar disección cervical electiva en pacientes con CCE T3/T4 de maxilar superior (AU)

A Modified Single-Step Method to Repair a Central Defect of the Upper Lip.

INTRODUCTION: Defects in the central region of the upper lip are difficult to repair. DISCUSSION: Several techniques have been described, many of them requiring a second surgical procedure to obtain acceptable aesthetic results. CASE REPORT: A patient with a soft defect in the central region of the upper lip following aggression by human bite is presented. To repair the defect, the principles described by Goldstein for lateral lip defects were used (Goldstein in Plast Reconstr Surg 85(3):446-452, 1990; Robotti et al. in J Plast Reconstr Aesthet Surg 63:431-439, 2010). CONCLUSION: In this particular case, two full-thickness advancing miomucosal flaps from the vermilion of the upper lip were used with predictable aesthetic results.

Endoscopically-Assisted Zygomatic Implant Placement: A Novel Approach.

BACKGROUND: Zygomatic implants (ZIs) have been proposed as a valid alternative to advance bone-grafting procedures in the rehabilitation of the severe atrophied upper maxilla, with a reported overall success rate of more than 95 %. Otherwise, the use of the endoscope has been described for the treatment of maxillofacial trauma, orthognatic surgical procedures, sinonasal pathology, salivary gland disease, and TMJ internal derangement. A careful identification of anatomical landmarks is of utmost importance while trying to avoid potential complications during the insertion of ZIs. Several approaches for ZI insertion have been reported, such as the classical approach; the sinus slot technique; and the exteriorized approach. MATERIALS AND METHODS: The authors first introduce in the literature the endoscopically-assisted approach for the insertion of ZIs in the extremely severe atrophic maxilla. RESULTS: Optimal results in terms of ZIs positioning with no damage to surrounding structures were obtained. CONCLUSIONS: By means of this new technique the surgeon may minimize the risk of complications related to the damage of neighbouring anatomic structures, such as orbital disruption or infraorbitary nerve damage, while ensuring an adequate drill positioning and angulation for the placement of one or two implants into the zygomatic bone.

Closure of the Radial Forearm Free Flap Donor Site Using the Combined Local Triangular Full-Thickness Skin Graft.

PURPOSE: Traditional donor-site closure has been associated with serious esthetic and functional morbidity. The purpose of this study was to assess morbidity in esthetics and function and measure the postoperative complications of the radial forearm free flap (RFFF) donor site after using combined local triangular full-thickness skin grafting. MATERIALS AND METHODS: This prospective study of patients who underwent reconstruction of head and neck defects using an RFFF was conducted from July 2008 through December 2014. The donor site was repaired with a combined local triangular full-thickness skin graft. Quality of the scar, color match, tendon exposure, presence of necrosis, dehiscence of the suture, and presence of dysesthesia were recorded and analyzed using SPSS 21.0 software. RESULTS: One hundred consecutive patients (71 male and 29 female) underwent RFFF harvesting. RFFF donor-site defects ranged from 15 to 70 cm2; partial skin graft loss occurred in 7% of patients. Five patients (5%) had small dehiscences of the forearm skin graft, and 2 cases (2%) presented tendon exposure. In all cases, these sites healed secondarily by conservative management, with no final impairment of function. Esthetic results were considered excellent in 87%, good in 11%, and suboptimal in 2% of the cases. CONCLUSIONS: The combined local triangular full-thickness skin graft is a reliable method for closing RFFF donor-site defects because it obviates a second surgical site, it provides excellent color match and pliability, and it can be used for covering large defects of the donor site.

Surface Topographical Changes of a Failing Acid-Etched Long-Term in Function Retrieved Dental Implant.

The aim of the present study was to report the main topographical and chemical changes of a failing 18-year in function retrieved acid-etching implant in the micro- and nanoscales. A partially edentulous 45 year old rehabilitated with a dental implant at 18 years of age exhibited mobility. After careful examination, a 3.25 × 13-mm press-fit dental implant was retrieved. Scanning electron microscope (SEM) analysis was carried out to study topographical changes of the retrieved implant compared with an unused implant with similar topographical characteristics. Moreover, X-ray photoelectron spectroscopy (XPS) analysis was used to study the surface composition of the retrieved failing implant. Clear changes related to the dual dioxide layer are present as visible in ≥×500 magnification. In addition, it was found that, for the retrieved implant, the surface composition consisted mainly of Ti2p, O1s, C1s, and Al2p. Also, a meaningful decrease of N and C was noticed, whereas the peaks of Ti2p, Al2p, and O1s increased when analyzing deeper (up to ×2000s) in the sample. It was shown that the superficial surface of a retrieved press-fit dual acid-etched implant 18 years after placement is impaired. However, the causes and consequences for these changes cannot be determined.

Vagus Nerve Paraganglioma: Radiological Features We Should Be Aware of.

INTRODUCTION: A rare case of vagal paraganglioma is reported. MATERIAL AND METHODS: The specific radiological features of this tumor are presented to the clinician in order to make presumptive diagnosis. CONCLUSION: By CT-scan and/or MRI it must be suspected when a hypervascular tumor in relation to the major cervical vessels displaces the internal and external carotid arteries forward, does not open the carotid bifurcation, and displaces the internal jugular vein backwards.

Reliability of four zygomatic implant-supported prostheses for the rehabilitation of the atrophic maxilla: a systematic review.

PURPOSE: The reliability of oral rehabilitation by four zygomatic implants with no anterior support remains to be determined. The aim of this systematic review was to assess the predictability of this approach in regard to implant survival, technical and biologic complications, and quality of life. MATERIALS AND METHODS: An electronic literature search was conducted from September 2000 to November 2013. Human clinical trials in which oral rehabilitation was achieved by the use of four zygomatic implants with no additional placement of standard implants were included. The primary outcome was the survival rate of the zygomatic implants. In addition, random effects meta-analyses of the selected studies were applied to avoid potential bias caused by methodologic differences among studies. RESULTS: Zygomatic implant survival rate weighted mean (WM) was 96.7% (range, 95.8% to 99.9%), with a 95% confidence interval (CI) of 92.5% to 98.5%. Only a limited number of surgical complications were reported, with orbital perforation the most significant. Similar results were obtained for prosthetic complications (few occurrences). Additionally, patient satisfaction levels were shown to be high, approaching that of the general population. CONCLUSION: Data from the present systematic review suggest that maxillary rehabilitation by four zygomatic implants with no anterior support is a reliable approach.

Influence of atrophic posterior maxilla ridge height on bone density and microarchitecture.

PURPOSE: There is limited evidence available on the influence of residual ridge height (RH) on bone density. Therefore, this study aimed to investigate the correlation between the atrophic posterior RH in the maxilla and its bone density as determined by microcomputed tomography (µ-CT). MATERIAL AND METHODS: Thirty-two subjects with atrophic posterior maxilla of residual RH <8 mm were included in this study. A preoperative cone beam CT scan with a radiographic stent was taken for each patient. A bone core biopsy was thus obtained from the predetermined surgical site. Out of 32 biopsies, 27 were intact and sent for µ-CT analysis. RESULTS: A statistically significant positive correlation between bone volumetric fraction (BV/TV) and RH was identified (r = 0.417, p = .03). A statistically significant negative correlation between trabecular pattern factor and RH was also found (r = -0.415, p = .03). The rest of the morphometric parameters analyzed did not have any significant correlation to RH. CONCLUSION: BV/TV is potentially influenced by the residual bone height at the posterior maxilla. The lesser the RH, the lower the bone quantity and quality present.

Microarchitectural pattern of pristine maxillary bone.

PURPOSE: There is limited evidence available on the influence of location on bone density in the maxilla. Therefore, this study was aimed at comparing the microarchitecture of bone harvested from different nonatrophic maxillary locations. MATERIALS AND METHODS: A total of 37 partially edentulous subjects (aged 48.15 ± 15.85 years) were included in the study. A bone core biopsy specimen was obtained from one site per patient at the planned implant surgery location. Thirty-four specimens were used for microcomputed tomography (micro-CT) analysis. Mann-Whitney U tests (independent samples) were performed to determine whether the distributions of the six bone-related parameters showed significant differences between sexes and site locations. Study sites were categorized as either anterior (incisors and canines) or posterior (premolars and molars). The possible associations among variables (bone volume fraction [BV/TV], age, and five bone-related parameters) were examined using the Spearman rank correlation test. RESULTS: The mean BV/TV values showed no significant difference between the maxillary anterior (46.93 ± 26.2) and posterior (51.90 ± 28.42) locations. Statistically significant positive correlations were identified between BV/TV and trabecular thickness (Tb.Th) (r = 0.6, P < .001) and between BV/TV and trabecular number (Tb.N) (r = 0.49, P = .006). Statistically significant negative correlations were found between BV/TV and trabecular spacing (Tb.Sp) (r = -0.65, P < .001), between BV/TV and trabecular pattern factor (Tb.Pf) (r = -0.7, P <.001), and between BV/TV and the structural model index (SMI) (r = -0.68, P <.001). However, no correlations between BV/TV and age or sex were found. CONCLUSION: Bone density was independent of the anatomical location, assessed by micro-CT in the pristine nonatrophic maxillary bone. Studies with a larger sample size and different population should be conducted to validate the findings of the current project.

Horizontal Bone Augmentation Using Autogenous Block Grafts and Particulate Xenograft in the Severe Atrophic Maxillary Anterior Ridges: A Cone-Beam Computerized Tomography Case Series.

The aim of the present study was to use cone-beam computerized tomography (CBCT) to assess horizontal bone augmentation using block grafts, harvested from either the iliac crest (IC) or mandibular ramus (MR) combined with particulate xenograft and a collagen membrane for in the severe maxillary anterior ridge defects (cases Class III-IV according to Cadwood and Howell's classification). Fourteen healthy partially edentulous patients requiring extensive horizontal bone reconstruction in the anterior maxilla were selected for the study. Nineteen onlay block grafts (from IC or MR) were placed. The amount of horizontal bone gain was recorded by CBCT at 3 levels (5, 7, and 11 mm from the residual ridge) and at the time of bone grafting as well as the time of implant placement (≈5 months). Both block donor sites provided enough ridge width for proper implant placement. Nonetheless, IC had significantly greater ridge width gain than MR (Student t test) (4.93 mm vs 3.23 mm). This was further confirmed by nonparametric Mann-Whitney test (P = .007). Moreover, mean pristine ridge and grafted ridge values showed a direct association (Spearman coefficient of correlation = .336). A combination of block graft, obtained from the IC or MR, combined with particulate xenograft then covered with an absorbable collagen membrane is a predictable technique for augmenting anterior maxillary horizontal ridge deficiency.