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|Alveolar ridge split and expansion with simultaneous implant placement in mandibular posterior sites using motorized ridge expanders – modified treatment protocol
Varsha S Manekar1, SR Shenoi2, Sunil Manekar3, Janice Jhon4
1 Department of Oral and Maxillofacial Surgery (OMFS), Government Dental College and Hospital, Nagpur, Maharashtra, India
2 Department of OMFS, VSPM, Dental College and Research Centre, Nagpur, Maharashtra, India
3 Private Practice and Dental Laboratory, Manekar's Multispeciality Dental Clinic, Sidheshwar Dental and Ceramic Laboratory, Nagpur, Maharashtra, India
4 Department of OMFS, Yogita Dental College and Hospital, Ratnagiri, Maharashtra, India
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|Date of Submission||06-Oct-2021|
|Date of Acceptance||15-Sep-2021|
|Date of Web Publication||22-Jul-2022|
| Abstract|| |
Purpose: “The purpose of the study is to evaluate alveolar ridge split and expansion (ARSE) with simultaneous implant placement in mandibular posterior implant sites using motorized ridge expanders.”
Background: The ARSE is used in the management of horizontally deficient (narrow) alveolar ridge with optimum bone height available. The ARSE procedure in the posterior mandible has limited application as per literature. The successful cases reported are with extensive procedure of the osteo-mobilization with four corticotomies on buccal side. The authors presented the study of mandibular posterior implant sites using motorized ridge expanders. The ARSE performed here was by only crestal osteotomy simple osteo-condensation and immediate implant insertion.
Materials and Methods: The study was prospective type. The sample size was 15 patients and 31 implant sites. The study population included partially edentulous patients between 18 years and 60 years indicated for implant-supported prosthesis. The outcome variables studied included gain in ridge width, cervical bone loss, success of implant, and survival rate. Successful surgical outcome was evaluated by Buser's criteria. The data collected was evaluated by differential statistics.
Conclusion: The minimally invasive technique of one-stage ARSE performed with motorized ridge expander and insertion of implant in the same operative procedure decreases the morbidity, treatment time, number of surgical procedures, and the risk of complications, thereby, increasing patient acceptance. In this study, the authors have used this technique in the posterior mandible for narrow ridges (minimum 3 mm) and obtained promising results. The survival rate of the implants was 100% and the gain in ridge width was 3.2 mm. The author has also recommended the protocol according to bone density of mandible.
Keywords: Alveolar ridge split and expansion, bone density, horizontal ridge deficiency, immediate implant, mandible, motorized ridge expanders, narrow ridge, one stage ridge split, ridge width
|How to cite this URL:|
Manekar VS, Shenoi S R, Manekar S, Jhon J. Alveolar ridge split and expansion with simultaneous implant placement in mandibular posterior sites using motorized ridge expanders – modified treatment protocol. Natl J Maxillofac Surg [Epub ahead of print] [cited 2022 Dec 3]. Available from: https://www.njms.in/preprintarticle.asp?id=351760
| Introduction|| |
The horizontally deficient or narrow alveolar ridge is a common clinical finding. Various surgical procedures are performed to facilitate implant placement in these deficient sites, namely guided bone regeneration, onlay grafting, ridge split with expansion, and distraction osteogenesis. Each procedure has its own application with predictable results.
The alveolar ridge split and expansion (ARSE) technique is used in the management of horizontally deficient (narrow) alveolar ridge with optimum bone height. The alveolar ridge is split at the crest length wise, thereby, separating the buccal and lingual alveolar cortical plates using specialized instruments. It is a technique sensitive procedure. The instruments used for ridge split include surgical blade, thin bur, chisel/osteotomes, rotating/oscillating saw, and piezo tips. The split is followed by expansion using instruments such as osteotomes, chisels, or hand expanders.
The novel concept of ridge split was introduced by Tatum in 1986. Simion et al., and Scipioni et al., introduced the bone splitting technique using chisels for ridge expansion. Successful implant placement with ARSE can be achieved in alveolar bone with a width of 3 mm to 6 mm. At least 1 mm of trabecular bone should be present between the cortical plates for effective split. This will allow the bone to spread adequately on either side of the ridge without fracture and also maintain adequate blood supply.
Sethi and Kaus, Kolerman, Bruschi et al., Strietzel et al. published successful use of osteotomes for ARSE by osteo-condensation whereas Blus et al., González-García et al., Mounir et al. published their successful results for ARSE using osteotome with osteo-mobilization technique. The dental implant was inserted immediately after ARSE, in their study. Vercellotti introduced piezoelectric surgery in dental implantology for ridge split technique.
Blus et al., Holtzclaw et al., Scarano et al., González-García et al. used piezoelectric tips for osteotomies and osteotome/chisels were used for alveolar expansion followed by dental implant insertion immediately. However, Mahmoud et al., and Zahran et al., used piezo kit for split as well as for expansion of alveolar bone. Holtzclaw et al., Sohn et al., Scarano et al., Agabiti and Botticelli, Gurler et al., Yao et al. also used piezoelectric tips for the ridge split and chisel/osteotome as expansion device. The technique of ARSE was based on the principle of osteo-mobilization and immediate implant insertion.
Anitua et al. published the study using motorized ridge expanders (MREs) for narrow alveolar ridge. Atraumatic bone expansion can be carried out with the MRE kits. Motorized ridge expansion kit is a newly introduced instrument. There are very few published studies that have evaluated the use of the MRE.
The mandibular alveolar ridge is dense. The edentulous mandibular ridges have thick cortices with decreased volume of vascular trabecular bone as compared to their maxillary counterparts. The lack of elasticity can be attributed to the mandibular posterior region having thicker cortical bone than the posterior maxilla., According to literature, ARSE has been done in these sites with osteo-mobilization technique. This type of ARSE needs extensive surgical intervention. The implant diameter indicated for prosthetically driven implants in mandibular posterior implant sites is more than 4 mm. The ideal buccolingual width indicated is more than 7 mm.
The purpose of this prospective case series was to evaluate the results of the use of MRE in mandible using only crestal osteotomy and osteo-condensation method of ARSE. The aim was “to evaluate ARSE with immediate implant in mandibular posterior implant sites using motorized ridge expanders.” The study population included partially edentulous patients between 18 years and 60 years indicated for implant-supported prosthesis reported between January 2018 and June 2019.
Method of selection of study subjects
This study included patients between 18 years and 60 years indicated for implant-supported prosthesis in posterior mandible with adequate alveolar height (8–13 mm) and width 3–6 mm at prospective implant site. The patients selected were fit for minor surgery and implant prosthesis.
Included patients unfit for minor oral surgery, implant sites not located in posterior mandible, insufficient vertical height of alveolar ridge, patients not consenting to participate in the study, alveolar ridge width <3 mm and more than 6 mm.
| Materials and Methods|| |
A total of 15 patients with 31 implant sites were enrolled for this study. The cases were selected after necessary clinical and cone beam computed tomography (CBCT) evaluation. This study was approved by the Institutional ethics committee of our institution as a part of an ongoing extensive research on ARSE. Written informed consent was taken from all the participants. ARSE and implant insertion were then performed. The surgical procedure for all implants was performed by one senior and trained surgeon according to standardized protocol. For Ethical Clearance was obtained from our Institutional Ethical Committee with Ref no GDCHN/ 9547 /18 dated 31.12.2018.
The three-cornered flap with crestal incision and releasing mesial and distal incisions was taken. The mucoperiosteal flap was reflected to expose the buccal bone. The procedure also required a small flap reflection on the lingual side. The bony surgery started with the use of a ridge reducer for reducing the crest of narrow ridge approximately by 2 mm, thus exposing both the buccal and lingual cortices and intervening thin cancellous bleeding bone. The Buccolingual width of the implant site was measured with a ridge mapper. A 1.8-mm drill was used as the pilot drill to decided initial depth. Crestal osteotomy (ridge split) was performed with rotating saw from RSE kit (ESSET Kit). The use of serial motorized expanders of ESSET kit [as shown in [Figure 1]] according to manufacturer's instructions resulted in the expansion of alveolus. If the bone did not yield to the expansion, alternate bone tapping was needed. This was followed by the insertion of the implant and cover screw fixation. The ridge mapper was used to again measure the buccolingual width immediately after implant insertion. In cases of buccal bone dehiscence, augmentation of the buccal bone was done using allograft/alloplast. The soft tissue was closed primarily, followed by digital intra oral periapical Xray (IOPA), thus completing the surgical phase. The patients were prescribed antibiotic amoxicillin and clavulanic acid 625 mg, analgesic and anti-inflammatory twice a day for 5 days. After 6 months, digital IOPA was taken and healing abutment placed. This was followed by impression taking, prosthesis (ceramometal crown) fabrication, and screw-retained fixation. The participants were recalled for follow-up and evaluated both clinically and with digital IOPA after 6 months.
|Figure 1: The motorized ridge split kit consisting of rotating saw and set of sequential drills|
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In the case illustrated in the images, the patient had an edentulous posterior mandible with missing 35, 36, and 37 as seen in [Figure 2]. [Figure 3] and [Figure 4] show the CBCT cross section of 35 (B-L width 4 mm) and 36 (B-L width 6 mm) implant sites. [Figure 5] shows the reflected mucoperiosteal flap and the horizontal crestal osteotomy. The use of serial expanders according to manufacturer's instructions resulted in the formation of implant sites and expansion indicated by increase in buccolingual width after crestal osteotomy [Figure 6]. After immediate insertion of the implants in 35, 36, and 37 sites, increase in the width of crestal osteotomy is better appreciated in [Figure 7].
|Figure 3: Cone beam computed tomography cross section of Case no 3 at dental implant site 35|
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|Figure 4: Cone beam computed tomography cross section of Case no 3 implant site 36|
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|Figure 5: Implant site marking with pilot drill and crestal osteotomy in an intraoperative illustration of Case no 3|
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|Figure 6: Intra-operative illustration after use of sequential expanders showing widened crestal osteotomy and implant site osteotomy of Case no 3|
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|Figure 7: Intra-operative illustration showing the cover screw of implants inserted in implant osteotomy of Case no 3|
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One more case has been shown in [Figure 8] with clinical alveolar ridge of varying width in 45 and 46 sites. [Figure 8] also shows the inserted implant in which the widened alveolar split in inter-implant part was seen. Digital IOPA radiographs were taken at the time of implant insertion [Figure 9], at the time of healing abutment insertion, 6 months postoperative [Figure 10] and 6 months after loading of the implant [Figure 11]. Successful osseointegration of the implants and the level of cervical bone maintained on the mesial and distal side of the implants were noted (B-L width 4 mm). The first patient treated was recalled for follow-up and evaluated periodically for 2 years after loading of prosthesis. [Figure 12] shows the preoperative orthopantomogram (OPG) showing multiple missing teeth (43–48). The same surgical protocol was followed at 43, 44, and 46 sites, followed by an implant-supported bridge. The 2-year postoperative OPG [Figure 13] showed successful osseointegration of the implants. All the patients were evaluated for a minimum of 6 months after loading the prosthesis. Digital IOPA radiographs and Buser's criteria were used for evaluation of the success of the implant.
|Figure 8: Illustration of Case no 5 showing intraoral missing 45, 46 and intra operative crestal split and implant with cover screw|
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|Figure 9: The digital intra-oral periapical image of Case no 5 taken after implant insertion showing two implants in 45, 46 sites|
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|Figure 10: The digital intra-oral periapical image of Case no 5, 6-month postimplant insertion at the time of prosthetic loading showing good osseointegration and maintained cervical bone level|
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|Figure 11: The digital intraoral periapical image of Case no 5, 6 months after prosthesis that is 1-year postimplant insertion showing good osseointegration and maintained cervical bone level|
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|Figure 12: Orthopantomogram of Case no 1 showing missing teeth no 43 to 47|
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|Figure 13: Orthopantomogram 3-year postprosthesis of Case no 1 showing implant with prosthesis in 43, 44, and 46 sites with maintained cervical bone level and good osseointegration|
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The outcome variables (OV) studied included gain in ridge width, cervical bone loss, success of implant, and survival rate. Gain in ridge width (RWG) is equal to the difference in buccolingual width at cervical level measured after implant insertion (RW2) and the one measured by ridge mapper immediately after reflection (RW1) (RW2-RW1).
The cervical bone loss (second OV) was defined as the increase in distance between the upper-most point of the implant platform and the most coronal contact of bone and implant (the reference value was this distance measured at the time of implant insertion) evaluated from digital IOPA (mesial and distal side). Cervical bone level was measured 6 months after implant insertion, at the time of prosthesis (CBL1), and 6 months after prosthesis (CBL2). For this purpose, the cervical level of bone (CBL0) at the time of insertion of implant was considered as the baseline.
Successful surgical outcome was evaluated by Buser's criteria, 4 months after implant insertion and 6 months after placement of prosthesis.
This criteria include four parameters: (1) absence of clinically detectable implant mobility, (2) absence of pain or any subjective sensation, (3) absence of recurrent peri-implant infection, (4) absence of radiolucency around the implant. The survival rate was the number of successful implants 6 months after prosthesis fixation.
| Observations and Results|| |
The sample size was 31 implants in 15 participants. There were 3 male and 12 female participants. The mean age was 56.8 years. Twenty-two of osstem implants and 9 of myriad implant system. [Table 1] shows the data of observations for RW1, RW2, RWG, implant size, CBL1, CBL2 (as explained in previous section). The 7 implant sites of Class II and 24 implant sites were of Class III according to recent classification of the alveolar ridge width with implant-driven treatment considerations for the horizontally deficient alveolar ridges by Tolstunov. The data of alveolar ridge width and crestal bone level (mesial and distal side of all implants) of all implant sites are entered in [Table 2].
|Table 1: The demographics of the participants, implant sites, preoperative ridge width on CBCT cross section, and the type of ridge according to Tolstunov classification|
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|Table 2: Alveolar ridge width and crestal bone (mesial and distal side of all implants)|
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All 31 implants were successful as per Bruser's criteria and survival rate of implant was 100%. The differential statistics was used. Analysis of data as per differential statistics is shown in [Table 3]. Mean preoperative ridge width is 5.1 mm. Mean ridge width gain is 3.2 mm and standard deviation (SD) is 0.6 mm. The mean implant size used is 4.2 mm. [Table 3] shows that the mean crestal bone loss CBL1 on mesial side was 0.5 mm (SD 0.8). Mean CBL 2, on mesial and distal side was 0.5 (SD 0.6).
No intraoperative buccal wall fracture or dehiscence was observed. The postoperative recovery of the patients was uneventful and no exposure of the surgical area was occurred. All were screw-retained prosthesis. In the 6-month postloading prosthesis, loosening of screw occurred in one implant. No wound dehiscence and buccal bone fracture were observed.
| Discussion|| |
Cullum described two techniques of ARSE – “osteo-condensation” and “osteo-mobilization.” The principle of ARSE initially described by Tatum and later by summers was by “osteo-condensation”. This principle involved avoiding bone removal, lateral compression using osteotomes, and condensation of spongy maxillary bone. This results in increased periimplant bone density, increased bone to implant contact, and increased ridge width in osteotomy sites. Cullum described that rotary mechanical expanders use the modification of this “osteo-condensation” technique, thereby reducing surgical manipulation and patient awareness.
Osteo-mobilization as described by Cullum involves the use of precise osteotomies of the residual alveolus to allow progressive intraoperative manipulation and outward mobilization of buccal bone, thereby increasing the horizontal dimension. This technique of RSE comprises of green-stick fracture or out fracture of the osteotomized buccal cortical plate with osteotome, chisels, and/or rotary mechanical expanders. This technique is especially used in mandible where the bone is dense. However, in this study, the authors have used osteo-condensation technique with MRE in the mandible. The resultant average gain in width of 3.2 mm was satisfactory and all implant sites had intact buccal cortical plates.
As compared to maxillary bone, mandibular bone has greater density that results in greater resistance during expansion of the buccal cortical plate, thus increasing the risk of fracture. Goyal and Iyer stated that green-stick fracture during widening is not controllable in the mandible because of greater cortical thickness of the bone and the risk of mal-fracture during single-stage expansion is high in this region. Thus, the mandible represents a greater challenge that requires increased caution during the performance of single-stage ridge splitting since the bone tissue elasticity is not appropriate for mechanical expansion.
In the present study, there was no dehiscence or fracture of buccal bone. Inability to split and expand due to high density of the alveolar bone (Type 4) in 1 case was managed by bone tapping along with ARSE. This procedure creates stresses at cervical bone, resulting in cervical bone loss. Anitua et al.,, published two studies of ARSE in the mandible based on the technique of sagittal osteotomy (crestal osteotomy) performed with ultrasonic scalpel followed by expansion with motorized expanders and immediate implant insertion in patients with ridge width of more than 3 mm. The gain in width was 3.35 mm in the 1st case while it was 2.3 mm in the 2nd case. The implant survival rate was 100%.
The ARSE technique used in our study is similar to the one described by Anitua with the only difference that a rotating saw was used instead of ultrasonic scalpel for the crestal osteotomy. The mean width gain was 3.2 mm.
Jamil and Al-Adili in their study used the technique of osteo-mobilization with piezo-cutting device and motorized expanders for expansion of the ridge. They also used synthetic bone substitute as fillers in the sagittal split region and guided bone regeneration. The implants were inserted immediately. The mean bone width gained in the mandible was 4.38 mm. In their study, complications were noted in 8 cases, of which 7 were in the mandible. They attributed this to the presence of highly dense cortical bone and sparse cancellous bone in this arch.
Many authors have recommended treatment with two-stage approach in the mandible. Sohn et al., concluded that delayed (2-stage) approach assures greater safety and predictability in patients having narrow ridge with denser and thicker cortices in the mandible. The strength of our study lies in “the success of implant insertion using single-stage ARSE with the minimally invasive approach of osteo-condensation,” performed by sequential noncutting drills of MREs and immediate implant insertion, significantly reducing the treatment duration in the horizontally deficient mandibular posterior region. The response of bone to MREs depends on the thickness of the cortical bone, especially on the buccal aspect and the thickness and quality of cancellous bone. As mentioned by Mazzocco F et al., a limited amount of cancellous bone might increase the amount of expansion, hence reducing the amount of possible bone condensation. Motorized expanders carry out the condensation of the cancellous bone as a result of absorbed part of the centripetal pressure generated by the expander. Simultaneously, the cortical plates are expanded to some extent. Thus, crestal osteotomy with the use of MRE leads to osteo-condensation and ridge expansion. The quality of bone is the deciding factor here. In this study, the authors have highlighted the response of the five different bone quality types to MRE noncutting drills, as mentioned in [Table 4].
|Table 4: Response of different alveolar bone types, with width of 3.6 mm on cone beam computed tomography to motorized alveolar ridge split and expansion, categorized by the authors|
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Holtzclaw et al., in the retrospective case series used piezo-electric hinge assisted ridge split procedure in the posterior mandible. The surgical procedure used here is osteo-mobilization and delayed implant insertion after 4 months. Although the ridge width gain was 4.1 mm and piezo-electric surgery is a good option for osteotomies, the two-stage approach and osteo-mobilization procedure involves extensive surgery and prolonged treatment duration. Bravi et al., in a multicentric retrospective clinical study of 1715 implants placed with edentulous ridge expansion observed that 44% of the implants placed in the mandibular sites required a two-stage procedure. They have described the mandibular bone as an “inelastic bone.”
From the authors' experience, implant sites of Type 4 [Table 4] are difficult to split and do not respond to osteo-condensation. MREs along with tapping or osteo-mobilization are recommended in Type 4 alveolar bone. Other types of alveolar bone in the mandible respond well to the MRE. The mean cervical bone loss of only 0.5 mm shows that the cervical bone level is well preserved.
| Conclusion|| |
The minimally invasive technique of one-stage ARSE performed with MRE and insertion of implant in the same operative procedure decreases the morbidity, treatment time, number of surgical procedures, and the risk of complications, thereby, increasing the patient acceptance. In this study, the authors have used this technique in the posterior mandible for narrow ridges (minimum 3 mm) and obtained promising results. The survival rate of the implants was 100% and the gain in ridge width was 3.2 mm. However, clinical trials with bigger sample size and long-term follow-up are recommended. The author has also recommended the protocol according to bone density of mandible.
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Conflicts of interest
There are no conflicts of interest.
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Varsha S Manekar,
Department of Oral and Maxillofacial Surgery, Government Dental College and Hospital, Nagpur - 441 401, Maharashtra
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]
[Table 1], [Table 2], [Table 3], [Table 4]
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