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I am sooo lucky. Like WOW lucky.(This may be graphic because it deals with seven syringe needles being inserted in my eye to try to save my vision after a workplace accident. Read no more if you get queasy. People shudder when I tell them in person.)I poked my eye from the inside and went legally blind in that eye.I was at work in a garden center one Mother’s Day four years ago when it started hailing and my manager asked me and a new employee to cover an exterior rack of petunias with a tarp, securing the tarp in place using 14″ industrial size zip ties (those plastic cable ties that have a little opening and you pull the end through to create a loop that does not loosen).Rain, hail and wind fought us. I held two zip ties in my left hand, the ends pointed upward, at the ready to secure the tarp. The new staff member lost his grip on the tarp as the wind picked up, and the tarp flew at me, sending my left hand toward my face.The zip ties went up my right nostril so perfectly, that I did not even get a scratch on the outside rim of my nose.Internally, they ripped through muscle and soft tissue and broke the small skull bone plate that holds the eye up, and ultimately poked my eyeball. (We did not know all the damage done until two months ago; I have been living with issues I did not realize could be attributed to this accident.)I saw stars so brilliant! A beautiful white firework display. No pain. It happened so fast.I heard a customer who had been asking me about petunias scream, “Pull it out!”All of my first aid training through the years echoed, “Never remove the embedded object.”I was so embarrassed. I just went for it. I pulled hard and fast, and the zip ties came out of my nose. There was no blood, so no big deal. (It was good I pulled them out because I could have ripped more eye muscles by looking around if I had left them in.) I should have gone to the hospital. I was a 47-year-old woman trying to keep up with young college students, so out of stupidity, I did not want to look weak. It was just a poke after all.My shift was over in 8 minutes, so I said good bye to everyone, and on my way out, I light-heartedly mentioned to a couple of colleagues and my manager what had happened. No blood. No big deal.Driving home, I saw two triangles in the vision of my right eye that looked like the ends of the zip ties (these were probably retinal tears - if you see a triangle in your eye or bright unexplained flashes, go to your doctor right away) and forest-green swirls that looked like a beautiful psychedelic ink-in-oil art concept. Each heartbeat produced more swirls. I enjoyed my Mother’s Day with my children and husband, telling them the crazy impossible story.The next morning, I woke up and saw no swirls. Hurray! The body is so amazing to heal itself. (Note, when it comes to the retina, no it won’t heal itself. Go get it checked out.) I went to work, lifted a few cement blocks, and the swirls came back with a vengeance. Yeah. Lovely. Maybe this was bad after all.I went to the emergency department. I became the doctors’ “ophthalmological mystery”. CT scans, X-rays, and an MRI (I know I am lucky that I live in my region of Canada where doctors have quick access to those tools in an emergency) showed that I had a severe sinus infection. (It turned out that all the sinuses were full of blood, that is why I had no external bleeding.) They spoke of how lucky I was. The zip ties could have taken out the eye. The zip ties could have gone in toward the center of my interior skull and poked something more important than my eye. It could have been so much worse. This was a one-in-a-million injury I was told.By the end of the day, they finally found an ophthalmologist who could look at me. I had to drive to his office across town. It was late and his office was officially closed, his last patient just leaving when I got there. He checked the eye and said, “This is bad” and to have my bags packed to head for morning surgery with one of the most renowned eye surgeons in the world. He would take care of the emergency surgery booking referral. I was to stay flat on my back until they called me, or else my retina would pull from the back of my eye.They did not call the next morning. I called his office, but my file had been lost. The receptionist had gone home before I had seen the doctor, and she had no idea I existed. She was not sure which “renowned” doctor her boss was referring to. The doctor never returned my call, despite all of my calls to him. I was not sure where to turn.I finally found another ophthalmologist and they gave me an appointment for the next day.I woke up that morning, and half the vision in my right eye was pure blackness. (The retina had begun to peel away and soon could totally fail and all would be black in that eye.)The new ophthalmologist used a special laser to cauterize the remaining part of the retina to the back of my eye. He said, “This will hurt quite a bit. Let me know when you need a break from the pain. Don’t move, and look only at the top of my ear to keep your eye steady.” Sitting, my chin resting on the chin cup of the laser machine, my forehead pressed against the headrest, he began. He had a dial that controlled the intensity and a computerized voice that told him the number of the intensity so he did not have to look down while he worked. He kept dialing it up and the pain was nearly intolerable, tears running down my face without my permission, my nose drippings running into my mouth. “Wow, you must practice yoga. This is the highest setting I have ever been able to use, are you sure you don’t need a break?”“Nope,” I calmly said, hoping I would not vomit from the pain, wanting to just sit back and pull away from the red light that hurt so bad inside my head. “Nope, no break,” I repeated. After all, how could I stop and then convince myself to go back to this? Keep it coming until it is done. Half vision is way better than no vision from that eye.When he was done, I asked what the next steps were to try to fix the failed part of the eye.He said, “Well, learn to live with it.”I was horrified and had a little screaming fit. There had to be something that could be done. I rehashed all of the helpless feelings I had, reminding him I had been patient with the system, and I could see perfectly fine right after the accident, other than the swirls. If only my file had not been lost, maybe I would still be able to see fully because they would have caught it in time and all he could say was to learn to live with it?He said, “Well, a colleague of mine will be visiting at the eye clinic tomorrow, second floor of the general hospital. Show up there at 5:30 am, and wait and maybe he will see you. He is a renowned eye surgeon.”Hope is a wonderful thing.“The renowned surgeon” was so learned. So easy-going. So calm.I told him my story. He said, “I hate zip ties and bungee cords. And bungee jumping. People don’t realize that their retina can be torn by bungee jumping.”He looked in the eye and asked when the retina peeled. I told him. He spoke to a nurse and told her to go to emerg and get a syringe full of something and to walk carefully bringing it back up the elevator and to him. When she returned, she held the huge syringe with the long needle so still, like it was a bomb about to explode. (From what I understand, it was just argon gas in a regular syringe.)Oh God. I think that needle is going to go in my eye. Give me strength.The doc had me sit on a stool. It was a simple stool with five castors and no back. It must have had superior ball bearings because it spun so twisty-smooth.He sat in front of me on a similar stool. He was so calm it helped me to stay calm.He told me to look at a spot on the wall behind him and “don’t move.” He raised his arms and blocked my view of the wall, my special spot hidden, so I just imagined a spot in the distance, concentrating hard on it, through his arm.He took a small syringe filled with something to numb my eyeball and slowly inserted it into the outside white part of my eye. I could feel it going in, the metal from the needle stopping my eye from moving around freely, my eye desperately wanting to move on its own accord, in some sort of self-defense mode.He said, “I really need you to stay still.”I smiled and looked at him with the greatest respect telling him, “I am so sorry, I think I need a more stable chair.” He found an open room with what seemed like a dental chair. I was so grateful.He stuck a needle from a second syringe in my eye (from what I understood, this was him gently taking some of the vitreous fluid out of the eye).The argon gas needle went in next. He put on what looked like a welding mask and looked in my eye through the attached scope. He said, “Oh no.” and he left the room saying, “Don’t move.”What did he mean by “don’t move”? Thoughts racing through my head, I figured I should breathe.My “seemingly calm renowned surgeon” came back in the room and I could sense his slight anxiety.After a total of seven insertions of needles in my eyeball, he said, “all right, in 24 hours, you should have light in that eye again, not blackness.” I was to stay totally upright for six weeks, sleeping sitting up, everything upright, to hold the argon bubble firmly in place so the not-yet-dead cells of my retina could heal against the live cells of my inner eyeball, at least that is what I interpreted from the conversation. (Most people healing from torn retinas need to stay face-down for six weeks. I am so lucky!)It worked. Exactly 24-hours later, nearly to the minute, I could make out undefined splotches of color and light, but no definition of form.Legally blind in the right eye. No depth perception. That’s okay. I had one good eye and partial something in the other.I had to see an Ear Nose Throat doctor to “scope” the path of the zip ties because the Workers Compensation Board accused me of claiming a pre-existing condition on the whole weird incident. The ENT said, “This will hurt terribly, not because of the camera that will go up your nose, but because of the heat from the light.” The cable was not long, perhaps, three feet. He positioned the end in my nostril and expertly began to insert it further up. Amazing tchnology. I felt the burning-feeling as the head of the cable found its way deeper into my head, but I also felt a strange tickle. Again, the eyes teared without permission from me, and the nose drained onto my upper lip as he drove the cable further in. The combination of sensations was extremely uncomfortable but not unbearable Ouch. Maybe he will say I am good at yoga, too.During the six weeks of balancing my argon bubble (which slowly absorbed over time getting smaller and smaller), I developed an epi-retinal membrane (this is like a clear sticker that holds the retina all wrinkled, irritated, and swollen), and cataracts in that eye.Basically, I was super happy with the outcome.I went back to work twelve weeks after the incident. It was not easy. Some key management bullied me. I received no monetary compensation for the injury. I eventually left there.I had to enjoy the painful laser three more times in the next two years.Two-and-a-half years after The Incident, during my annual check-up with my Renowned Eye Surgeon, he said to me, “We can fix this.” I had two weeks to get ready for surgery, including bloodwork, pre-op physical, X-ray, etc. During surgery, he gently pulled away the epi-retinal membrane, careful to leave no trace of it or it could grow back, gave me a vitrectomy, and put in a new corrective lens. I was half-awake for the surgery and I could hear them talking, the music playing, my heartbeat on the EKG machine, and the Surgeon acting as my personal Described Video Track… although I know it was for educational purposes for the students beside him. I was to say, “Ouch” if the pain got too intense. I thought, why? Would my perception of pain alert them to a problem? Would me keeping my mouth shut and enduring it cause the whole thing to mess up? This was too much responsibility. Plus, I thought, “I am under some sort of pain-relief or anesthesia of a sort, so maybe I am imagining the pain.” I did not want to insult this amazing doctor who has dedicated his life to eyeballs and sight. When the pain got really bad, like a hot poker in my eye, and I could feel the camera and the tool working away in my eye through the minute slices on either side of the whites, and I could feel him pulling the “transparent sticker” slowly and gently off the back of my eye like I peel off price tags from finds at my favorite kitchen store, I decided that was my cue. My mind raced. Ah ha! I ultimately decided the more gentle way to say “ouch” would be “ouch-y”. I heard my own voice and regretted it instantly.Four years later, I can see 20/20 from that eye. I am so lucky. What a journey.But, there are other complications. The zip ties ripped one of the muscles that controls my eye, so I am seeing a specialist to help me learn to control that eye so that I don’t have to go through surgery to repair it.And, after a routine appointment with my fabulous ENT, to figure out why I had started to smell cigarette smoke and skunk over the past few years, there was another issue. I was told it is typical in severe and chronic sinus infections for people to perceive incorrect interpretation of smells - I had to ask constantly to those around me, “What is that smell?” And they would tell me so I could re-teach my brain what different smells meant. As it turned out, the zip ties had also ripped through the right side sinuses and the latest CT scan showed they were basically flat now, other than a small “air sack” at the top that trapped bacteria. There were also bone shards that my body had not yet absorbed. Ah ha! That is the reason for the increasingly painful sinus infections I have had in the last four years! That is the reason I cannot smell properly. He confirmed his findings with another manual scoping. I feel I am an expert patient: I started practicing yoga. So, no problem, Mr. Scope.From the CT scan, he also saw that I had a cyst deep in the left nostril.My sinus surgery was a couple days ago. General anesthesia. No fun. But, I am excited to be able to smell again! I tasted a strawberry and was so overcome with the nuance of flavor that my eyes began to water without my permission (come on, again?)… and I heard a tiny couple of pops and then the blood started flowing out my nose… I guess it is all connected in there somehow. I am to resist the urge to blow my nose because my eye sockets will inflate with air. Yeah, I am not blowing my nose until I get clearance.And I am excited to not endure increasingly strong antibiotics every couple of months to treat these mystery infections along with corti-steroidal spray up my nose toward my brain. :)How amazing, that I could lose my sight but see again, and lose my sense of smell only to smell again.Life is good. I darn well know that life is not so good for others. I am so grateful. I have met so many wonderful people in the waiting rooms. Stories that blow mine away. This is my story. For whatever reason it happened, I have learned so much.I am a photographer by trade. I am listed on the volunteer board for the hospital of “My Renowned Eye Surgeon”. They need volunteers. I plan to give back in every way that I can, maybe even speaking about eye care and injury prevention. I plan to ask my ENT how I can help give back to his clinic, also.What's the most incredible coincidence that ever happened to you?

[Originally drafted on December 23, but I just got around to finishing this answer.]"Everybody has a plan until they get punched in the face....He's going to do this, do that. Everybody has a plan until they get hit. Then, like a rat, they stop in fear and freeze.”—Former Heavyweight Champ Mike Tyson“The practice of readiness is more about recreation than preparation.”— Former Navy SEAL Eric DavisWhile I do love zombie movies and TV shows, I have never walked through Home Depot taking note of what could be used as weapons if the zombies arrive and suddenly I’m in the stronghold for the last of the uninfected. I don't have a zombie gun or an INCH bag or a SHTF cabin. I doubt I've given them any thought.As it so happens, however, I’m reading this question while actually parked at a Walmart — just down the highway from a middle-of-nowhere prison town, halfway through a cross-country trip — which makes the idea of a dry run (a Supermarket Survival Sweep, if you will[1]) suddenly intriguing. I'm curious to see how this would actually play out. I mean, this place is huge — at least 230,000 square feet by the looks of it— and I haven't been to a Walmart in years. Plus, it can't be that they all stock the same things in the same way (firearms in particular). Nevertheless, I have a plan. It's probably a terrible plan. Still, it’s a plan.Here are the rules:I’m not diving into the weeds. Let's just say it's zero-hour and I have free-range inside for 10 minutes. I'll assume that what's here now would be here, stored as is. Also, the zombies and outbreak will be the Romero/Kirkman standard (rather than one of the other 300-some varieties).I'm not making a list, checking inventory, or other pre-planning. I'll also proceed as if I have none of the assets in my truck, just what I'm carrying on my person at this exact moment — my clothes, wallet, watch, phone and wireless drive, and the shoes on my feet — plus, of course, the dog.The countdown starts once I enter Walmart, and the timer stops once I return to that entrance. And there will be no time-outs. I'll also use a walk-tracking app to record time, distance, path, and speed.Since an actual looting spree would result in my arrest or homicide, I’ll instead briskly walk through the store pawing whatever I would be looting, taking close-up pictures. For things that are secured (i.e., guns, controlled substances, and pricey electronics), I'll pause a reasonable time to simulate a smash and grab.Finally, I’ll limit myself to items and an overall volume that I imagine would fit in my cart(s), or which I could otherwise transport.Let’s begin.OUTSIDE(1) Display by Garden/Plants:Two 96-Gallon Trash Cans.Stock carts with: A Chopping Axe, a Small Sledge (I don’t think they even sell the latter; both useful for “liberating” secured loot), Trimmer Cord (useful for opening doors with slam latches), Nylon Outdoor Couch and Ottoman Covers (waterproof, durable fabric), and a rusty Extendable Branch Trimmer (not pictured).A pallet with Heavy-Duty Webbing.A telescoping pole like the trimmer (and hiking poles) with a hook, plus some FAST rope, tubular webbing, or escape ladder makes for an improvised way to place breaching or rescue gear.The trash cans will hold more than the shopping carts. (In fact, some community response agencies use them to store and distribute kit during disasters. Also, they make for decent rain collection barrels.) The plan is to fill one, then return to some point for the other.FOYER (10:00-9:44 left)(2) Entrance/Shopping Cart:An Extension Cord, Fish Tape, and a Cordless Drill; a Tool Bag containing: a 50-Bit Set, a Multi-Bit Screwdriver, a Folding Hex Key, Pliers and Vise Grips, a File, Utility and Hawkbill Knives, a Multi-Tool, a Jab Saw, a Wire Cutter/Stripper, Aviation Snips, a Tape Measure, a Framing Hammer, and a Stanley FuBar.A handful of Walmart Shopping Bags.Whether intentional or just a matter of sloppiness, I saw at least 8 places where tools and other goodies were left lying around. (This one seems to part of an actual project, however, not just a surreptitious display item.)HEALTH AND BEAUTY SECTION (9:42-8:20 REMAINING)(3) Supplements and Adult/Performance Nutrition Aisles:Salmon/Fish/Krill/Omega-3 Oil (you can't have too much fish oil) and Chia Seeds, a Greens Supplement, Emergen-C (all in a row), and a Multi-Vitamin.Mass Gainer, Protein Powder, and BCAAs (all by less-distinguished brands), 3 flavors of Atkins Shakes, and Ensure; and Boxes of Met-Rx, Atkins, Cliff and Cliff Builders, Kind, and Lara-Brand Bars, plus Power Bar Energy Gels and Cubes.Prune Juice.The variety in protein supplements here is intentional, as mass consumption of the same brand, particularly if it's low quality, can result in "unpleasant" developments. Also, after looking at my food stash, I may be needing the prune juice.(4) Pharmacy/Counter and Adjacent Displays:(Planning for gold in the) Pharmacy Pick-up Orders.First Aid Kits, Wound Care Kits (which, happily, contain Celox, a hemostatic agent), Blister Kit, Rubber Gloves.Antiseptic and Hydrogen Peroixide; and (from a return cart) Pedialyte (an oral electrolyte great for athletes), Benadryl (for the dog especially), and Gold Bond Friction Defense and Moisturizer.And a blood pressure cuff, which (along with a door stop) can be used for an impromptu Air Wedge should you lock your keys in the car and find AAA to be … unresponsive.I estimated it would take 22 seconds to open the half-door and rip the prescriptions off the clips by the armful. The results will be very much a "box of chocolates”; but, out of the 300+ prescription orders, at least 10% minimum should be useful.[2](5) Travel-Size and Soap Aisle:Personal Wipes on the end caps (all the wipes are mine; except the painful antibacterial ones).Travel sizes items (i.e., Toothpaste, Toothbrushes, and Floss (now is not the time to skimp on dental hygiene); Bar Soap; Cotton Pads; Gold Bond Powder, Lip Balm, Vaseline, and Moisturizer (seriously); and Lysol Spray and Clorox Wipes.Pantyhose and Nylons (to, uh, reduce skin chafing).I will hypothetically literally run out of food before I do wipes and toilet paper — and not by accident.DIY SECTIONS (8:18 -7:32 REMAINING)(6) End Caps of Outdoor Improvement Aisle:Assorted Solar-Powered Accent Lights (basically solar powered battery chargers) and boxes of AA, AAA, and 3.7v Li-ion and NiMH Batteries.(7) Tool Aisle:Leather and Mechanix Wear M-Pact Gloves, Large and Small Cans of WD-40, a Gerber Micro-Tool, Leatherman, Hearing and Eye Protection, C-Clamps, Hand Riviter, 18” Bolt Cutters, a Stanley 252-Piece Tool Set, and Nylon Mechanic’s Bags and Carpenter’s Belts.Cordless Dremel Rotary Tool and Kit, B&D 20V Cordless Drill and Project Kit, and a Hyper Tough Corded Angle Grinder and Kit.(On the end cap or back wall) Mini-Duraflame Log, (mislaid) Heavy Duty Plastic Wrap, Long Stick Matches, Auto/Marine Fire Extinguisher, Rubber Door Wedges (a fast way to jam a door), and a Kidde Emergency 2-Story Escape Ladder (it’s easy enough to make your own Etrier, but this is ready-made; though parts certainly could be trimmed to cut weight (ounces = pounds, pounds = pain, etc.)).The mechanic’s bags are some of the most durable yet flexible fabric in the store: Tough enough that I've used them to reinforce old pants when clearing very thorny brush, and made of thicker material than what’s used to make Kong chew toys. The door stoppers can be used for vehicle entry and (duh!) can stop doors from being opened.Also: Why do survivors always stumble right into a moaning hoard? They’re all deaf. “Mawp ...mawp...mawp…MAWP….”AUTO CARE (7:30-6:03 REMAINING)(8) Tire And Lube Shop:● Spare Tire; Car Batteries from the assorted groups; Powermate Portable Inverter Generator.(9) Body, Engine Repair, and RV Aisle:(All in a row) 5W-20/30 Motor Oil, Antifreeze/Coolant, ATS and Drivertrain Fluids, Stop-Leak Products, Silicone and Graphite Lubricants, Refrigerant, Compressed Air, and an Air Filter.Fix-a-Flat, and a Slime Flat Tire Repair Kit.Grey Primer, Spray Tint/Kit, Plastidip, Flex Seal (good for adding grip and eliminating metal-on-metal noise), and Bed Liner Coating.Various Tapes (Duct/Gorilla in assorted colors, plus Rubber and Silicone Tapes), Glues/Epoxies, etc (i.e., Goop; Loctitie Sumo, Quick-Dry, and Epoxy; Rubber Cement; J-B Weld and Stix), and FiberFix.A Camco Marine/RV Water Filter and an Auto/Marine Fire Extinguisher.Bed liner (rubberized polyurethane) is pretty versatile stuff, from protecting fuel cans to lining ponds, to (so it appears) some ... less traditional uses.(10) Travel and Interior Aisle:Recovery Snatch Strap and Recovery Strap, Utility Chain, SmartStraps, Cambuckle and Ratchet Tie Downs, Nite Ize Gear Ties, Bungee Cargo Nets, Shackles, Waterproof Roof Top Cargo Bag, a Grey Tarp, and a 6x4 Rubber Cargo Mat.Here are just a few of the many ways flat webbing and ratchets can be used to lock, secure, hoist, carry, tow, anchor, and self-rescue.(11) Towing and Electronics Aisle:Cobra CB Radio (behind an easily-smashed glass display).Torin Off-Road Jack. (Almost literally a jack of all trades, serving as a jack, winch, spreader, clamper, locker, crusher, and puller. Useful for garage and door entry, as well for as barring doors.)Reese Electric Winch, Deep Socket Set, Maxsa Foldable Traction Mats.Fuse/Repair Kit; Schumacher Multi-Functional Power Station, 500 Watt Power Inverter, Battery Cables, and an Emergency Kit Travel Kit with Extended Jumper Cables.Siphon, 2-Gallon Gas Cans; Big and Small U-locks, and Cable/Receiver Locks; Zip-Ties (note: automotive plastic ties are usually stronger and more useful than the regular ones); and a Half-Shell Motorcycle Helmet and Goggles, and Motorcycle Batteries.SPORTING GOODS (6:00-3:44 REMAINING)(12) Fishing Aisle:(On end cap) 80-Test Fishing Line, Nylon Tackle Bag, and a Casting Net.Fishing Knife, Line Cutter (basically, a seatbelt cutter), Flare Gun, Ray Guard/Walk-N-Wade Guards, L/R Lindy Fish Gloves(!).12-Gallon Plastic Fuel Tank; Large carabiners, S/9 Biners, Snap Hooks/Links, Cam Jams, Metal O-Rings, Cleats, Lashing Tabs, U-Bolts, Marine Waterproofer, and Dock/Anchor/Utility/Rigging Line and 550 (all of which which can be braided into something more useful — see this under-appreciated masterpiece for more fun).What are Lindy fish gloves? Well, they're made with SuperFabric®, which is a multi-layered fabric covered with tiny plasticized resin guard plates, designed to protect against barbed-wire, cuts and stabs, and even snake bites and needle puncture. You’ll also see it on tactical gear and motorcycle apparel, and find it wherever people handle sharp and pointy things.[3](13) Hunting and Shooting Aisle:A Remington 870 shotgun, a .308, a Ruger 10/22 (in the main firearms cabinet).Ammunition for current selection of firearms, plus other popular calibers, 9mm and .223/.556 especially (in a secondary cabinet).1-6x24 Scope and 3-9x32 Scope, CenterPoint 1x25mm and Aimpoint Holographic Optics, Sightmark Night Raider 2.5x50 Night Vision Scope, 60x Spotting Scope, GSM IR-Capable Trail Cam (all in the flat display cabinet), and a Workplace Employee’s First-Aid Cabinet (underneath the cash register).Mounting Accesories, Batteries for Optics, Truglo Shotgun Front Sights, Weapon Light, SOG EOD Multi-Tool, Gerber Hunting Knive, Bowie Knife, and Ammunition Pouches and Cans.The firearms in this Walmart were left in a vertical display cabinet (not secured in a cage and/or with a cable) which is quite smashable. The glass on the counter displays will, to varying degrees, be stronger. The drawer behind the counter, fortunately, is generally much less so. (Estimated time spent smashing the glass and grabbing the loot: 35 seconds. Right now is why I brought along the axe and FUBAR and grabbed those leather gloves.) Each gun did have a tubular trigger lock. While the same brand of locks are sold in-store, and thus might provide a twin key, drilling/cutting the locks will be just as efficient.Side note: I walked right past a Smith’s sharpening kit and a hand-held GPS. It should go without saying that I indeed missed many things: like a collapsable ladder, a flexible inspection camera/endoscope, a pink “Brave” compound bow, a sling case for rifles, a compass, a Nikon Camera with 55–300 mm lenses, the entire hardware aisle….(14) Camping Aisle:8 or 9 Flashlights and Headlamps of varying battery platforms; a Micro-Light (always good to keep a micro on your zipper/chest strap), and Glow Sticks (which can be dropped from distance to illuminate the ground, work underwater, and won't set things on fire).PVC/Nylon Rain Suit, Poncho, Waterproof Pack Cover, and a Ozark Trail 2–1 Hammock/Sleeping Bag15/25/45L Backpacks, a Camelbak-Type Pack and extra Bladder, and a Coleman Rolling Duffle.Bear Grylls/Gerber Parang, Machete, Hand Axe, Fixed-Blade, and Multi-Tool; and an Ozark Trail Folding Shovel.Propane and Butane Fuel, Pocket Survival Stove, Combustible Cubes, and Waterproof Matches.Purifying tablets; Lifestraw-type filter, Cobra 2-Way Radio, Fire Starter, Emergency Blankets (for heat and signaling), “Commando” Saw, Tenacious Tape Repair Patch, and 2 pair of Cascade Mountain telescoping Carbon Fiber Trekking Poles.Mountain House Camping Meals and UST Emergency Rations (50 and 70 total, respectively).Stainless Steel Water Bottles, and collapsible 5-Gallon Water Bag, and as many 7-Gallon Plastic Jerry Cans will fit.The lights cover all battery platforms — AA, AAA, CR2, CR123, CR2032, C and D — particularly since camera (CR) batteries are more likely to be overlooked by looters. Was it hard to find the CR-powered lights among the wall of choices? Nope, just grabbed the most expensive compact models.Incidentally, anyone hoping for a “high-quality” machete will have to settle for what will basically be a giant spatula after more than a few wacks to a human head. Also, the only bats in the store were for t-ball — really just fish bats with delusions of grandeur.(15) Fitness Aisle End Cap:● Gold’s Gym 40-Pound Training Vest (snatched from an already open box; no need for the weights), and a Yoga Mat.I may die wearing a fitness vest for a chest rig, using a yoga mat as a bed roll. :((16) Bike Aisle End Cap:● Inner Tubes (with a 1000 uses).RETURN TO STARTING POINT (3:44-3:35 REMAINING)(17) End Caps and Displays on the Way Back:● FoodSaver Heat Seal Vacuum Rolls; Tea Candles; Dish Soap and Clorox Wipes; and a bag of Dog Food.ELECTRONICS, HOME GOODS, AND CLOTHING (3:33-2:14 REMAINING)(18) Craft Aisle:● A Lockstitch Sewing Awl, Upholstery/Size 18 Hand Needles.(19) Clearance Electronics/Camera Section:● Pocket Juice 20,000 mAh Portable Charger; Parrot Camera Drone, plus Extra Battery; a Compact 50” Pocket Tripod and a Gorillapod (since most of your post-apocalypse long-gun shooting will likely involve non-standard positions).(20) Men’s Wear:● Assorted Clothing in a return cart: Jeans (which, amazingly, might fit), Underwear, Polyblend and Marino Wool Socks, T-shirts, Sweaters, and Performance Pullovers. Also, a nearby Dickie’s Canvas Work Jacket.I'm struck by the range of clothing sizes. It later took me 3 minutes just to find pants remotely in my size. No amount of hemming will make a pair of 48x32 pants wearable for me.(21) Footwear:Interceptor “Tactical” Boots, Rubber Muck Boots, and OP Men’s Water Shoes.Saddle Soap/Leather Lotion (helps condition shoes to be sneaky Pete), and Freesole and Aquaseal (great not just for shoe repair, but also adding a flexible, tear-resistant coating to clothing, nylon especially).Quality boots may be, without exaggeration, the second or third most important bit of kit. What goes on your feet will determine whether blisters, hotspots, athlete’s foot, and/or peripheral neuropathy slow you down. These, however, are not quality — they merely happened to be on the clearance racks, in roughly my size. Of course, there’s no time to try anything on (in which case maybe go a size up).GROCERY (2:03-1:10 REMAINING)(22) End of Kitchen Aisle:Toilet paper (on the end cap), Press-and-Seal, Zip-Lock and Snap Lock Bags, and 3 Mil Contractor Bags.(23) Stock Cart:Peanut Butter and PBfit Powdered Peanut Butter, Iberia and Goya Beans, Goya Cooking Paste, Kraft Mac and Cheese Cups, Quaker Oatmeal, Great Value Chunk Light Tuna, White Rice, and five flavors of Earth’s Best Baby Food.This Walmart was filled with these ready-made, pot-luck emergency pantries. Let's hope the Zompocalypse starts after 7:00 pm.(24) Grocery Aisle End Caps and Displays.Applesauce, Canned Fruits, Instant Soup, and Canned Pumpkin.EVOO, Nut, Sesame, Avocado, and Blended Oils (i.e., liquid fat).Tea, Coco, and Coffee (don't underestimate the value of creature comforts).CHECKOUT (1:08-:38 REMAINING)(25) Impulse Displays:Red Bull and 5-Hour Energy Drinks, 36-Packs of Bottled Water, so-so much Krave Jerky and Summer Sausage, Bulk Mixed Nuts (the delux, peanut-free kind!), Pretzels, M&M's, Bananas, and Doritos.That the cheesy dust of powdered fat is both yummy and really flammable. And bananas can make a gastric-friendly energy paste and treat burns, while the peels can, among other things, be used to filter water.(26) Battery Display:● Batteries of all the various sizes.(27) Checkout Aisle:● Pens; Bic Lighters, Butane Lighters, and Zippos; and a Cartoon of Cigarettes, a Phone Charger, 50 State Atlas, and Trail Mix.I don't smoke; but I've heard enough stories of WWII POWs trading smokes for boots that I'm banking on them making for good currency.FINISH (28 SECONDS REMAINING)(28) Display:● A KayakIt’s here, so why not? It’s potentially useful in my current AO. I’ll drag it with me on the way out.THE PLANThis is not a SHTF shopping list. This was a hyperactive kid on an Easter egg hunt glomming whatever looked pertinent for (1) being not-eaten, and (2) a month-long overland expedition in a developing country. It’s also an example, for better and worse, of how much stuff you can grab in 10 minutes when your eyes lead your brain (and not the other way around) and you limit yourself to 15 or so seconds for the non-priority sections.[4]When traveling in the middle of nowhere, you’ll definitely need food and water (especially where chemically contaminated sources can't be treated just with boiling). You need tools to do basic repairs and the ability to get your vehicle out of most sticky situations. That means the ability to carry extra fuel, a quality air compressor, a puncture repair kit, at least one full-sized spare, a quality jack, a shovel, comms, analog and digital navigation tools, auxiliary power sources for your gadgets, and vehicle recovery gear. You'll also want spare oil and drivetrain fluids, fan belts, filters, bulbs, fuses and a sensible tool kit.It also safer and more enjoyable to drive a vehicle that is free of rattling, shifting, or bouncing gear. Everything has to be lashed, locked, and/or bolted down once you leave pavement least it move around dangerously. You also have to balance the impact of all the extra weight on performance (say, while driving down a hill) with both the flexibility for carrying extra passengers/supplies and overall organization.[5]Depending on your location, hygiene may be particularly pressing. Any disruption in the natural barriers of the body left untreated can become infected by tiny amounts of water, dirt, or even germs and particulates already on the skin.[6] Given how quickly many areas can, in the absence of human intervention, become rat-infested, disease-ridden literal cesspools of waste-water, some level of hazmat protection (i.e., rubber boots, gloves, and clothing) and disinfecting supplies may also be necessary. Similarly, depending on the environment, plastic bags, sheeting, and the like may be essential to keep dirt, dust, sand, smoke, and/or rain from choking and corroding you gear, food, and vehicle.Also, depending on the political or social climate, you might upgrade your vehicle's security. Very dark-tinted windows or screens will prevent anyone from seeing what, or who, is inside. Security cages on the windows and deadbolts on the doors may also be considered. (The drawback to all three: increased conspicuity.) Locks on fuel caps, water, and car batteries may also be handy. Finally, in the absence of a kill-switch, removing something like the fuel pump relay (or replacing it with an inert duplicate), or putting some sort of lock on the steering wheel, may be advisable.[7]Of course, there are other concerns apart from traveling. Always plan your exfil and for Murphy's law first. If, for example, you are traveling and your destination is compromised, the weather takes a turn for the worse — dust storms, fires, blizzards, etc. — or your vehicle breaks down, you'll need tools and materials to turn a place like this into shelter, find a way to breach Walls, or be able to transport/drag your assets to safety.______________________________________________________________________________________________________________[1] I so want this to be a real game show now.[2] ‘Useful’ meaning Analgesics — NSAIDs, corticosteroid anti-inflammatories, and opioids — Psychotherapeutics (e.g., amphetamines, Ambien, and Modafinal), Anti-Infectives, Respiratory Aids (e.g., Albuterol and Epinephrine), and Gastrointestinal Aids. (Pro-Tip: Veterinarians and ambulances aren’t the only “alternate” sources of meds, as most professional and major-collegiate sports teams will store medications on-site.)[3] I'm also awaiting the day the first screen writer realizes there are low-profile literal (anti-)bite suits among the myriad protective garments ( see Miguel Caballero’s Online Store, for example) that exist.[4] And I do mean grabbing, if not shoveling things. Why those exact backpacks? Because they were in a pile. The various optics and firearms? That's what was in the display case. The casting net, helmet, and dog hammock? Because they were on top of other things. Lots of stuff was just … there. Of course, change the store, season, time of day, or even the entrance, and the result no doubt would be somewhat different. (The optimal approach, incidentally, would have been to enter exit through the tire and lube shop, thus nabbing one or two full-size spares and whatever is in the shop on the way out.)[5] When it comes to inventory, it's ideal that all that food, gear, materials, etc. should by stored in way that allows you to, at a glance, visually identify everything and see what's missing (kinda like having an outline of a tool on pegboard). You'll never leave something behind, and restocking becomes almost subconscious. The more you can customize your storage and use available space, the easier that becomes.[6] Similarly, is having a shirt with a high-collar really a big deal? Well — if after a week of rucking in a t-shirt the chafing on your neck from a camelbak or a sling gets infected — yes.[7] In less permissive environments, you also want to tape or use dirt to dun up any shiny or reflective surfaces and other notable features. In some cases, you might want to completely tape over unnecessary light units — dome lights, brake lights, the radio, etc. — if not remove the fuses altogether, to ensure nothing can be accidentally operated. Tinting or diffusing headlights is another possibility, as would be covering those lights and relying on night vision should you have it.

ABSTRACTIntroduction: Currently, dental treatments with better aesthetic results and less treatment time is more acceptable by the patients. Inadequate amount of bone for implant placement at functionally and aesthetically most appropriate position is a common problem.Aim: To assess the effect of ridge expansion on implant stability in narrow partially edentulous ridges and to evaluate clinically and radiographically the success of dental implants, placed immediately following ridge expansion procedure.Material and Methods: Ten participants (nine males, one female, average age - 28 years) with partial edentulism associated with narrow atrophic alveolar ridges with adequate height and willing to participate in the study were included. The ridge expansion was performed using osteotomes and simultaneous implant placement was done. A total of 10 implants were placed. Stability, achieved ridge width and radiographic crestal bone loss were assessed three months post-operatively.Results: Three months follow-up revealed stable implants both clinically and radiographically. All 10 implants were surrounded by adequate amount of bone required for successful functional rehabilitation.Conclusion: The study reveals that the technique of ridge expansion using osteotomes is successful in horizontal expansion, in cases of atrophic alveolar ridges thus, eliminating the need for more complex treatment as well as reduces the rehabilitation time along with improving the quality of bone support.IntroductionAgeing is a biological phenomenon resulting from changes at cellular level to the changes at gross morphological level in all aspects. Gradually, with ageing related, health problems concomitantly accompany and further deteriorate the condition. These may include oral diseases which finally may lead to tooth loss. Loss of teeth may require some form of aesthetics making functional prosthetic treatment necessary for the patient.Histological and morphological changes of the bony socket and adjacent soft tissue may undergo a series of tissue repair processes after tooth loss. According to histological evidence active bone formation taking place at the bottom of the socket and bone resorption at the edge of the socket are observed around two weeks after tooth extraction; however, the complete fill of the socket with newly formed bone takes around six months time. During this time rapid bone remodeling drops; however, continuous bone resorption may continue at the outer surface of the crestal area of the residual alveolar bone. This results in significant morphologic changes in the bone and its overlying soft tissues over the years [1].Now-a-days, dental treatments with better aesthetic results and less treatment time are more acceptable by the patient. The prosthetic treatment modalities like removable or fixed partial dentures have risk of various complications including sacrifice of healthy tooth substance. Dental implants have overcome disadvantages of other procedures and emerged as an ideal replacement modality for missing teeth. Inadequate amount of bone for implant placement at functionally and aesthetically most appropriate position is a common problem. Placement of endosseous implants in atrophic ridges is often accompanied by various challenges [1,2].surgical widening techniques have been employed and described for restoration of atrophic ridges, including block grafting, lateral augmentation with or without Guided Bone Regeneration (GBR), onlay grafting and alveolar distraction osteogenesis [2]. These procedures are carried out before or after implant placement to establish at least 1mm bony wall around screw type implants [2]. Although different techniques exist for atrophic ridges, there are chances of need for multiple surgeries which carries surgical risk and postoperative morbidity. Expansion of the existing residual ridge is another method and is referred as Ridge Expansion Osteotomy (REO) [2].REO procedure was described by Summers [2]. The ridge expansion technique is used to expand the edentulous ridge for implant placement [3]. Because of the problems of drilling in the maxilla for osteotomy, a technique is developed to place the implant without removing the bone using an osteotome. It is called the osteotome technique. This technique is to maintain, if possible, all of the existing bone by pushing the bone aside with minimal trauma while developing an accurately shaped osteotomy site. The osteotome technique retains all of the bone and relocates the bone by taking the advantage of the softer bone quality.Conventional technique of implant placement includes drilling of the bone which always takes bone away from the site. Often there is a marginal quantity of bone to start with. During the drilling process, there is no practical means to immediately improve adjacent bone quality. In addition, drilling creates heat, which is the main obstacle for osseous integration. To overcome all these obstacles, osteotome technique is in practice which essentially doesn’t produce any heat [2,3].So, the aim of this study was to evaluate ridge-width gained after ridge expansion procedure, effect of ridge expansion on primary and secondary stability after implant placement by Radio Frequency Analysis (RFA) test and to evaluate radiographic crestal bone loss using digital Intraoral Periapical Radiograph (IOPAR).MATERIALS AND METHODSA preliminary prospective clinical study was conducted on patients who reported during year 2014-2015 to the Department of Oral and Maxillofacial Surgery, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India. A total of 10 patients with inadequate alveolar width and having sufficient alveolar height were included in the study. Sample size was determined based on a previous study [4]. Performance of the 10 implants placed in these 10 patients in the anterior maxilla was evaluated clinically and radiographically over a span of three months.Ethical clearance was obtained from the Institutional Ethics Committee before the commencement of the study. The subjects for the study were selected on the basis of scientifically pre-defined inclusion and exclusion criteria. Patients who presented with partial edentulous space in anterior maxilla, having a ridge width of 2.0mm to 5.0mm, measured preoperatively, using Cone Beam Computed Tomography (CBCT, between 18 to 60 years of age, co-operative, hygiene conscious, motivated and willing to participate and gave written informed consent and those having adequate vertical height (measured from crest of the ridge to the nasal floor using CBCT, having more than 12mm vertical height) were included in the study. Patients with severely atrophic ridges, those with co-existing vertical defect requiring additional corrective intervention, heavy tobacco users, uncontrolled diabetics, immuno-compromised patients and those who were poorly motivated and unable to keep the follow-up were excluded from the study.Global Implants (two piece implants, endosseous, thread type) of pure titanium; length range 8mm to 16mm with diameter 3.8mm and 5mm were used for the present study. Ridge Expansion Osteotomes Kit and Mallet (Sirag Surgical Enterprises, Chennai, India) [Table/Fig-1] was used for the expansion procedure. All surgical procedures were performed under strict aseptic conditions and following standard protocols. The patients were initiated on a daily dose of antibiotic (Amoxicillin 20-25mg/kg/day i.e., 1.5gm/day for an average adult of 70kg, one day prior to implant placement and were maintained on it for the next five days), Tab. Aceclofenac 100mg with Paracetamol 500mg (thrice a day) was given to the patients an hour before implant placement and continued for next five days along with Amoxicillin. The baseline clinical examination consisted of a thorough medical and dental history, general and oral health status, assessment of future implant site. The available vertical, mesio-distal and labio-lingual bone dimension was determined by measurements from CBCT and ridge mapping was used to assess labio-lingual ridge width using the ridge mapping calliper. Local anesthesia was administered (Lignocaine HCL + 2% Adrenaline 1:80000) following which an incision was made buccal to the ridge crest to provide more attached tissue along the facial aspect of the implant. During ridge expansion the micro-fracture of cortical plate possibility cannot be overlooked, as the cancellous bone will be compressed to both the buccal and palatal walls. The buccal cortical plate is considered to be more vulnerable for expansion forces as it is not having adequate bone support like palatal side, so it is better to have a good amount of soft tissue which makes the difference post operatively by providing adequate coverage. Also, in undue cases of fracture it acts as pedicle for the buccal cortical plate. Minimal mucoperiosteal flap reflection was performed to expose only the ridge crest. If necessary, the peak of the thin ridge was slightly reduced with a ronguer or osteoplasty bur. The mid-crestal osteotomy of the atrophied ridge was done using round tungsten carbide bur. The ridge expansion began over the prepared initial osteotomy site such that it bisected the ridge crest and expanded the cortical plates [Table/Fig-2-6].The handle of the osteotome was kept parallel to the palatal or lingual cortex and advanced through the bone using a mallet. This path resulted in a more facial angulation of the handle than the ideal long axis of the teeth. After the osteotome was tapped to depth, it was gently removed with a back and forth motion, parallel to the cut, to prevent alveolar bone fracture. The length of the osteotomy was extended beyond the planned implant sites along the edentulous area so as to allow the cortical plates to expand during osteotomy preparation and implant insertion. Progressively, wider osteotomes were utilized to smoothly expand the atrophic maxillary ridge.[Table/Fig-1]: Showing armamentarium.[Table/Fig-2]: Edentulous ridge.[Table/Fig-3]: Exposure of knife edge ridge.[Table/Fig-4]: Ridge width measurement before expansion using bone calliper.[Table/Fig-5]: Osteotome in place for expansion.[Table/Fig-6]: Ridge width measurement after expansion.Dental Implants - Partha Dental HospitalAfter sufficient expansion (which should be larger than the size of the implant; as a thumb rule the implant should have minimum 1.5mm of surrounding bone, so required implant size plays an important role in the ridge expansion) of the ridge was achieved, the endosteal implants were introduced into the prepared site and evaluated for primary stability using the resonance frequency analyzer and torque wrench, a minimum Implant Stability Quotient (ISQ) of 50 was considered to include in the study implants with torque more than 25 Ncm. The reflected mucoperiosteal flaps were sutured using black braided silk suture material. The patient was advised Chlorhexidine (0.12%) mouth rinse twice daily for two weeks post-operatively. Suture removal was done seven days post-operatively.The patients were followed-up at the 7th post-operative day, 3rd week and 3rd month. The patients were evaluated for implant stability and crestal bone loss at 3rd week and 3rd month post-operatively using CBCT [Table/Fig-7-12]. Functional rehabilitation of the implants were done after three months post-operatively. The results were scientifically recorded, data collected, collated, entered and analyzed using paired t-test.RESULTSThe implant stability gradually increased over the study period on all the aspects. [Table/Fig-13] shows the data of patient, stability in ISQ and ridge expansion pre, postoperative measurements. Pre-operative ridge width mean was 3.94 ± 0.33 and after ridge expansion ridge width was 7.39 ± 0.66. The difference of mean value was 3.45 which was highly significant (p-value <0.001) [Table/Fig-13]. [Table/Fig-14] reveals crestal bone loss at different time intervals during the study. In comparison of crestal bone loss on the mesial and distal aspect in a time period of three weeks and three months after implant placement, mesial bone loss after three weeks was 0.26 and after three months it was 0.50 which was significant (p-value=0.033). Also, on the distal aspect crestal bone loss after three weeks was 0.34 and after three months mean it was 0.58 which was significant (p-value=0.008) [Table/Fig-14].DiscussionDental implants have now become an integral part of various treatment modalities. Availability of adequate amount of bone in terms of vertical as well as horizontal dimension is the first requirement for a successful implant therapy, but it becomes difficult to place the implant when there is inadequate amount of bone [5].Morphological and histological changes in the alveolar process are teeth-dependent processes that develops in conjunction with the eruption of the teeth. Previous clinical and cephalometric studies have revealed atrophy and dimensional reduction of the alveolar ridges in both the horizontal and vertical axis after all teeth are removed [6,7]. The greatest reduction occurs in the first 6-12 months [7]. Bone loss occurs in the anterior mandible and the maxilla mainly at the labial side.Many of recent investigations have inspected the resorption pattern and evaluated the changes that occur in the alveolar processes following tooth extractions by various means including study cast measurements, subtraction radiography and direct measurements of the ridge at surgical re-entry [8-10]. It was reported that in the first three months after tooth extraction around two thirds of bone loss occurs, signifying that maximum alteration in dimension of alveolar ridge takes place within the first three months post extraction and the reported corresponding vertical bone loss is around 0.9mm to 3.25mm. [8-10].Loss of alveolar bone may also occur prior to tooth extraction because of advanced periodontal disease, periapical pathology, or trauma to teeth and bone or during tooth extraction procedure, periodontal health of the neighboring teeth and periodontal biotype (shape and thickness of soft tissue) the width of the labial cortical plate may also result in bone loss and affect the resorption process [11]. Osteoporosis, renal disease and endocrine disorders are some of the systemic conditions that may speed up bone loss by varying normal bone physiology and metabolism [6] Moreover, habits, including smoking and bruxism have been considered as contributing factors in increased bone loss. All the above stated reasons may result in resorption over a wide area of labial surface leading to marked narrowing of the labio-lingual diameter of the crest of the ridge, thus, forming a knife edge ridge, which is particularly problematic for implant placement owing to insufficient ridge width. Alveolar bone width should be sufficient to provide a minimum 1mm bone width around the implant [2]. When the alveolar ridge is narrower than the optimally planned implant diameter, reconstruction of the ridge before implant placementis mandatory. Various techniques have been mentioned in the published literature for reconstruction of the atrophic ridges so as to increase the existing bone volume like bone grafting, guided bone regeneration and distraction osteogenesis, however, these techniques suffer from limitations like being invasive and increase morbidity, moreover resorption of grafting materials, membrane collapse, exposure to infection and delaying of implant installation for grafting maturation are few other constraints associated with these techniques [1,2].Ridge expansion of the remaining residual ridge is an additional method to prepare the atrophic ridges for implant placement. This approach has been referred to as ridge expansion, ridge splitting, bone spreading and was developed by Tatum in 1986 [12], but was then reintroduced in 1990 by Bruschi and Scipioni [13]. The method involves the splitting of the vestibular and buccal cortical plates [2,3] and further expanding the gap with Summers’s osteotomes [2,3]. A minimum of 3mm of bone width, including at least 1mm of cancellous bone is required to place an osteotome between cortical plates and accordingly expand the cortical bony plates.Summers, Scipioni et al., Hahn J [2,3,13,14] and many others got successful results following this technique for narrow ridges. They showed ridge expansion technique having advantages of simultaneous implant placement, lesser overall cost, no need of barrier membranes or bone graft materials and no morbidity related to second site. So in the present study, ridge expansion was carried out using the osteotome technique owing to its advantages documented in literature.In the present study effect of ridge expansion of narrow partially edentulous ridges on ridge width, implant stability and crestal bone loss was evaluated. The first parameter assessed was the gain in the ridge width which was measured using the ridge mapping caliper. The use of ridge mapping caliper to assess bone levels for implant placement in anterior maxilla, avoids some of the problems associated with CT scanning [15,16].In present study ridge expansion using osteotomes resulted in significant gain in ridge width after three post operative months (3.94 ± 0.33 pre-operatively to 7.39 ± 0.66 post-operatively) (p-value <0.001) [Table/Fig-13]. Similar to the present study, Roni Kolerman, et al., conducted a study on long-term outcome of ridge expansion using the osteotome procedure followed by implant placement in combination with guided bone regeneration in patients with atrophic maxillary alveolar ridges and reported significant increase in the ridge width over the study period (pre- op ridge width values increased significantly from 3.73±0.67 to7.19 ± 0.80) [4].Demarosi F et al., conducted a study on localized maxillary ridge expansion with simultaneous implant placement in adult patients with atrophy of the upper maxilla, 26 ridge expansion surgeries were carried out and 36 implants were placed. The ridge width increased from an initial range of 2.5mm-4.5mm to 6mm-7.5mm at the end of the procedure [17]. That is the gain in alveolar ridge width ranged from 3mm to 5 mm. Measuring primary stability and secondary stability was the second parameter assessed in this study. Stability of the implant was measured in ISQ using RFA device. Primary stability of an implant comes from mechanical engagement with cortical bone. It is affected by the quantity and quality of bone that the implant is inserted into, surgical procedure, length, diameter, and form of the implant [18]. Secondary stability is a biological phenomenon, that is the result of healing that takes place around the implant, (osseointegration) [18].There is no consensus regarding which method to use when measuring implant stability. One commonly used, non-invasive method is resonance frequency analysis, which evaluates the stiffness of the bone-implant complex. The result is given as implant stability quotient, ISQ [Table/Fig-13]. A dip in ISQ is usually seen during the early healing phase after osseointegration and is related to the shift between primary and secondary stability. The results of the present study revealed that the implant stability increased gradually over the study period and the results were statistically significant over 3 months [Table/Fig-13].Padmanabhan TV et al., conducted a study to evaluate the crestal bone loss and effect on primary stability exhibited by the bone around early non-functionally loaded implants placed with conventional implant placement technique and with Summer’s osteotome technique and demonstrated a significantly higher stability of implants in the conventional group than in osteotome group on the day of surgery [19]. However, after six months of implant placement, no statistically significant difference in stability was found between both groups (p = 0.076). A significantly less crestal bone loss was reported with conventional group. Thus, the authors concluded that this technique can be utilized for knife edge ridges and should not be substituted for the conventional procedure for implant placement. Kreissel P, in a similar study assessing the implant stability in expanded ridges, reported that bony micro-architecture had no consequence on implant stability, initial bone density, presence of a cortical layer. They also reported that the application of the screw-shaped spreaders significantly increased ISQ values over the study period [20].Mesial and distal crestal bone loss in a time period of three weeks and three months after implant placement was the 3rd parameter assessed in present study for which Digital IOPAR and DIGORA was utilized similar to Padmanabhan TV et al., [19]. Kolerman R et al., conducted a similar study to evaluate the outcome of a ridge expansion osteotome procedure and implant placement combined with guided bone regeneration in patients with narrow maxillary alveolar ridges and reported that over a mean follow- up period of 52.4 months the survival rate of 116 implants was found to be 100% with statistically significant gain in ridge width of 3.5 ± 0.93 (p < 0.0001) and significant enlargement of the buccal bone was about 1.91 ± 0.6 (p < 0.0001) [4]. The vertical mesial and distal bone loss reported ranged from 0.3mm to 4.2 mm, and 0.4mm to 4.5 mm respectively. Padmanabhan TV et al., conducted a study on crestal bone loss in implant placement done by using osteotome technique and reported a mean bone loss of 1.19 after placement of 10 implants in the maxillary anterior region of five patients [19]. Comparison of marginal bone lossthe removal of osteotome is inadvertent or more buccal, then the chances of buccal cortical plate fracture are increased. In our two of the cases wrong direction while pulling the osteotome lead to the fracture in which the placement of implant was considered in the later stage. Only single patient complained about the pain during the procedure due to inadequate local anesthesia given to patient. Also, one patient complained about redness and pain at implant site after one month due to gingival inflammation. Three patients were not able to come in time for follow-up. These patient data were not considered for the statistical analysis because they were lost to follow-up. To overcome all these problems further studies with larger sample size and comparative control groups must be carried out with an extended follow up period to substantiate the results of the present preliminary study.LimitationThe study sample size was smaller. The duration of follow-up is less. The single operator did all procedures. The study warrants long term follow-up with multi center and multi-operators. The fracture of buccal plate is one of the limitation. It requires training to handle the osteotome. The study warrants long term multi-center blind studies. The case selection is critical factor for the success of implant . The inadvertent force during removal of osteotome may lead to fracture of buccal cortical plate.ConclusionHorizontal expansion in atrophic alveolar ridge without any complex treatment can be performed using Ridge expansion technique. This technique is helpful and patient friendly as it decreases the rehabilitation time and improves quality of overall bone support with adequate implant stability achieved at three months post operative period.AcknowledgementsAuthors acknowledge authorities of Dr.NTR University of health sciences, Vijayawada, Andhra Pradesh, India and Faculty department of oral and maxillofacial surgery and Department of Prosthodontics, Crown and Bridge for their help in completing the study protocol.Referenceson two aspects, i.e., mesial and distal in a time period of three weeks and three months after implant placement revealed that the distal aspect bone loss after three weeks was 0.34±0.31 and after three months was 0.58±0.43 which was significant for distal bone loss. The lowest ridge expansion width found to be was 2.70mm because it was a narrow ridge and with poor bone quality and the highest ridge width gain was 4.10mm. Least primary stability value was 60 ISQ because of buccal bone fracture. Secondary stability achieved was 70 ISQ with maximum of 81 ISQ which is indication of success of an implant. In comparison of vertical bone loss in mesial and distal side, greater than 1.5 mm bone loss was observed in one case, whereas, the bone loss in the remaining cases was below 0.8mm.Kolerman R reported an average gain in ridge width of about3.5±0.93 and bone loss 1.81±1.07 on the mesial side, whereas it was 1.74±1.12 on the distal side [4]. Similarly, in present study average ridge width gain was 3.45±0.33 which was significant and bone loss on mesial side was 0.24 ±0.20, whereas, on the distal side it was 0.24±0.12 and the results were significant. According to Padmanadhan TV et al., primary stability mean value was 59.60ISQ and secondary stability was 61.50 ISQ which is similar to the results of the present study [19]. In the present study, complications included buccal bone fracture in two of the patients and were not considered in the study protocol. The fractures might have attributed to the technique of removal osteotome after tapping.Dr.Latheef Saheb Shaikh(MDS)Oral Maxillofacial Surgeon & Implantologistwww.Parthadental.com