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REVIEW ARTICLE Table of Contents  
Ahead of print publication
The effect of modern devices of alveolar ridge split and expansion in the management of horizontally deficient alveolar ridge for dental Implant: A systematic review


1 Oral and Maxillofacial Surgery, Government Dental College and Hospital, Nagpur, Maharashtra, India
2 VSPM Dental College and Research Centre, Nagpur, Maharashtra, India
3 Private Practice, Manekar's Multispeciality Dental Hospital, Nagpur, Maharashtra, India
4 Department of Public Social Medicine, Government Medical College and Hospital, Nagpur, Maharashtra, India

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Date of Submission17-Jun-2021
Date of Acceptance31-Oct-2021
Date of Web Publication22-Jul-2022
 

   Abstract 


The alveolar ridge split and expansion (ARSE) can be performed using conventional devices (osteotome/chisel) or modern devices (ultrasonographic [USG], motorized ridge expansion [MRE], etc.). The aim of this systematic review was to evaluate the effect of modern devices for ARSE. This review has been registered at PROSPERO under the number CRD42020213264. A systematic search was conducted by two reviewers independently in databases PubMed, MEDLINE, Cochrane Central Register of Controlled Trials, Grey Open, Hand search of reference lists of relevant studies, and previously published systematic reviews. The article published until September 2020 were searched for this review. The searches identified 24 eligible studies, twenty-two cohort and two randomized control trial studies. A total of 1287 dental implants were installed in 634 patients with the age range of 17–70 years and a minimum of 3 months of follow-up. Ten articles of USG device and seven of MRE device were finally evaluated for metanalysis. The mean ridge width gain was 3.40 mm (USG device) and 2.83 mm (MRE device). The overall implant survival rate was 98.07%. Mean width gain between USG and MRE devices was significantly different (P < 0.0001, HS). Test of heterogeneity was significant (Q = 88.3877, P < 0.0001, HS) and there was no publication bias (Intercept = 6.6634, P = 0.6142, NS) by Egger's test. The most commonly used devices were USG and MRE. USG is more effective for osteo-mobilization type and MRE device for minimally invasive osteo-condensation.

Keywords: Edentulous ridge expansion, motorized ridge split, ridge augmentation, ridge split devices, the alveolar ridge expanders


How to cite this URL:
Manekar VS, Shenoi RS, Manekar SM, Morey S. The effect of modern devices of alveolar ridge split and expansion in the management of horizontally deficient alveolar ridge for dental Implant: A systematic review. Natl J Maxillofac Surg [Epub ahead of print] [cited 2022 Dec 10]. Available from: https://www.njms.in/preprintarticle.asp?id=351761





   Introduction Top


Rationale

The horizontally deficient alveolar ridge is a frequently encountered clinical scenario. Various procedures are performed by clinicians for increasing the horizontal width namely guided bone regeneration (GBR), alveolar ridge split and expansion (ARSE), block bone grafting, etc., The novel concept of ridge split was introduced by Tatum in 1986. ARSE as described by Simion[1] in 1992 utilized the split crest technique. He had split the alveolar ridge longitudinally into two parts by positioning a small chisel (Beaver blade No 62) and gently tapping it with a hammer, using this as an ARSE device, to create a space making defect. Scipion[2],[3] later published the clinical results obtained by using the No. 64 beaver blade for creating an intra-osseous groove for edentulous ridge expansion in 1994 and 1999.

Summers[4] proposed the use of customized cylindrical and tapered osteotomes to perform ridge expansion osteotomy.

The ARSE is now routinely used for the gain in ridge width. The conventional instruments used for osteotomies are surgical blade, thin bur, chisel/osteotomes. This is followed by expansion with osteotomes or chisels. The development in technology introduced new devices for the ARSE. Vercellotti T[5] (2000) introduced piezo-electric (ultrasonic bone cutting device) surgery in dental implantology for ridge split technique.

Hand expansion screws, motorized expansion kits are the new devices specifically designed for ARSE. These technically advanced devices improve surgical skills, the convenience of the procedure and provide a better experience for both the patient and dental implant surgeon. This refined surgical procedure results in lesser surgical trauma, reduces the surgical time and is easy to use with better results. The purpose of this study was to review the results of the use of modern devices for ARSE. This review has been registered at PROSPERO under the number CRD42020213264.

Section 1.1: The rationale for the review in the context of available published systematic review

There are no reviews on the use of modern devices for ARSE. In their systematic review Jha et al.[6] studied the devices for the alveolar ridge expansion technique. They have listed chisel (hand mallet/electric mallet), osteotomes, surgical blade, micro-saw blade as traditional devices.

Motorized ridge expanders (MRE), threaded bone expanders, expansion crest devices, lasers, ultrasonic/piezoelectric devices have been classified as Modern devices. This article did not study the width gain and implant survival rate using modern devices.

The increasing use of modern equipment indicates the need of review of the clinical results and possible complications and limitations of the modern devices used for ARSE. Hence this systematic review is carried out.

The aim of this systematic review was to evaluate the effect of modern devices of ARSE for ridge width gain (RWG) and implant survival.

Research question-What is the gain in ridge width and implant survival rate of the ARSE technique for dental implants insertion using modern devices? P-horizontally deficient (2–6 mm) edentulous dental arches indicated for dental implant in partially/completely edentulous mandible/maxilla;

I-the ARSE technique for dental implants insertion using modern devices; C-ARSE with conventional technique or GBR;

O-RWG; Survival rate;


   Methods Top


The studies of modern ARSE devices were included with the Inclusion criteria:

  1. Study design used: Randomized control trial (RCT), CCT, Cohort studies, Case-control studies
  2. Sample size of at least ten and more number of implants
  3. Use of the modern devices for ridge split and expansion
  4. Minimum 3 months follow-up period after prosthesis
  5. Literature in the English language
  6. Abstract and full text available
  7. Mention of the ARSE device used.


Exclusion criteria

  1. Case reports
  2. In-vitro studies
  3. Sample size <10 implants.


The data were collected in an excel sheet after manual search for the outcome variables. Two reviewers extracted the data through extensive search of abstracts followed by a complete article reading. The discrepancies were resolved by a third reviewer. Information sources reviewed included PubMed, MEDLINE, Cochrane Central Register of Controlled Trials, Grey Open, Hand search of reference lists of relevant studies, and previously published systematic reviews.

Search strategy

Keywords used were devices for ridge split, motorized ridge split, hand expanders, the alveolar ridge expanders, piezo split; narrow alveolar ridge, split crest, ridge expansion, ridge augmentation. The article published until September 2020 were searched for review. The PRISMA flow diagram[7] of the screening and selection process is presented in [Table 1]. The records identified after initial search thorough database searching 1020 nos, and 10 were from other searches. After removal of duplicates 110 articles. These were screened through abstracts and 79 searches were excluded according to inclusion and exclusion criteria. The remaining 31 were assessed for eligibility as the complete articles were screened for eligibility criteria. The total seven searches were excluded for <10 number of implants sample size and case reports. The total number of studies which matched the eligibility criteria, included in the systematic review were twenty-four (n = 24) were subsequently analyzed.
Table 1: Flow diagram of selection process of research papers

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Risk of bias assessment

For observational studies (22 no), the adapted version of Newcastle-Ottawa[8] (modified) was used. The criteria adapted for quality assessment for selection of the study (Defined inclusion and exclusion criteria); Representation of cases; Selection of controls type of modern devices for ridge split), comparability (of cases and control); for the outcome (Report of losses to follow-up; Validated measurements for outcome measures; Primary outcome mentioned; Statistical analysis; Sample size calculation; Follow-up duration; Success rate of implants). Appendix A gives details of the quality assessment of articles. Quality Assessment of the observational studies is represented in [Figure 1].
Figure 1: Quality assessment of the observational studies

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Randomized control trial

Assessment of RCT (2 no) for risk of bias was performed according to Cochrane Collaboration modified tool[9] for assessing the risk of bias for RCT's, to assess the risk of bias for randomized controlled trial. And Use this form to assess the risk of bias for randomized controlled trials. Only two RCT were included in this study. The Randomisation was done in both. Only one study did computerized allocation. Controlled group present in both, very small sample size, no sample size calculation, the outcome variables were clear in both. Statistical calculations mentioned [Appendix A].


   Results Top


Demographic data

The selected studies included a total of 634 patients [Table 2]. As per studies which mentioned gender; there were 200 males and 286 females. Few studies did not mention gender. The age range was 17-70 years. Mean follow-up duration of 13.23 months. Eligible studies included 1287 implants. The distribution of the location of cases is shown in [Figure 2].
Table 2: Demogrphics details

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Figure 2: Location distribution of alveolar ridge split and expansion in maxilla/mandible

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The modern devices and type of alveolar ridge split and expansion data

The ARSE for management of horizontally deficient alveolar ridge was performed with modern devices. These devices include (ultrasonographic [USG] bone cutting instrument, also called as piezo device), hand screw expanders, motorized ridge split kit (MRE), crest control bone splitting device, osteodensifiers. The ARSE procedure includes an initial alveolar ridge split followed by the expansion. These devices are used for the types of ARSE,[10] namely osteo-condensation (OC) and osteo-mobilization (OM). OC refers to lateral condensation of cancellous bone resulting in an increase in peri-implant density. OM refers to the use of precise bone osteotomies of the residual alveolus. Two vertical and one/two horizontal osteotomies were carried out to increase horizontal dimension. The types of ARSE technique used in the included studies were: OC-osteo-condensation; CO-OC-Crestal osteotomy and osteo-condensation; OM-osteo-mobilization; delayed osteo mobilisation (DOM); SOM-Staged osteo-mobilization.

DOM refers to two-stage OM wherein wide exposure is obtained, the vertical and horizontal osteotomies were followed by soft tissue closure. The surgical site is re-entered with limited incision and expansion carried out. Staged OM, SOM refers to the addition of graft in the osteotomised site and expansion of the alveolar bone. The implant is inserted after 6 months. The OC and CO-OC were simple, minimally invasive type. The implants were inserted at the same surgical procedure itself whereas in OM, DOM types of ARSE the Implants were delayed and inserted in the second stage. In SOM the implants are inserted at the third stage. [Figure 3] shows the distribution of the number of articles, type of ARSE and devices used for ARSE. The total 1287 implants installed in the eligible studies were categorized according to the time of implant insertion. These included implant insertions Immediately after ARSE in the same surgery (III). Implant insertion in the second stage is the delayed implant insertion (DII); In cases of staged ARSE, the implants were inserted in the third stage (TSII). [Figure 4] shows the distribution of time of implant insertion according to the type of device used. For the sake of comparison, two main groups were used as USG devices and MRE. The grafting was done in 15 studies only.
Figure 3: Distribution of the number of articles, type of ARSE and devices used for ARSE. Types of devices used: HSE: Hand Screw expander, USG1: USG for osteotomies and chisel mallet for expansion, USG 2: USG for osteotomies and osteotome for expansion, USG 3: USG for crestal osteotomy and implant as expander, MRE 1: Disk or split and motorized expansion drills for expansion, MRE 2: USG Split and motorized expansion drills for expansion, CCBS: Crest control bone splitting system, OD: Osteodensification. Colored bars – type of ARSE: OC: Osteocondensaion, CO-OC: Crestal osteotomy and osteocondensation, OM: Osteomobilization. DOM: Delayed osteomobilization, SOM: Staged osteomobilization

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Figure 4: Distribution of time of implant insertion according to the type of device used. Horizontal bar- Categories of time of implant insertion- III: Immediate implant insertion, DII: Delayed implant insertion, TSII: Third-stage implant insertion - Delayed Implant insertion. Colored bars: Types of devices used – HSE: Hand screw expander, USG: USG1 - USG for osteotomies and chisel mallet for expansion, USG 2: USG for osteotomies and osteotome for expansion, USG 3: USG for crestal osteotomy and implant as expander, MRE: MRE 1-, Disk or split and motorized expansion drills for expansion, MRE 2: USG Split and motorized expansion drills for expansion, CCBS: Crest control bone splitting system, OD: Osteodensification

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Outcome variables

The outcome variables for which data were sought include demographic data, site, device used, type of ARSE, time of implant insertion, and complications encountered. The main outcome variables were RWG, implant survival, cervical bone loss, stability torque. These were to decide the success of the procedure.

The quantitative outcome variables of metanalysis were RWG and survival rate of implants. The ten articles of USG device and seven articles of MRE device qualified for the inclusion of these outcome variables. The data are included in [Table 3] in detail. This data were analyzed for metanalysis. The mean initial ridge width (IRW) of the included ten articles of USG device was 3.76 mm, the mean final ridge width (FRW) was 7.13 mm. The mean RWG was 3.40 mm. Similarly, the mean IRW of the selected seven articles of MRE was 3.78 mm, FRW was 5.92 mm and RWG was 2.83 mm. The WG is little higher in the USG group. The mean success rate of the selected articles of USG studies was 98.42% and of MRE studies were 98.97%. The forest plot for the articles evaluated for the USG group [as per [Table 3]] evaluated the RWG is as shown in [Figure 5]. The results are statistically significant (P < 0.01, 95% of confidence interval) significance level by Egger's and Begg's test. Similarly, [Figure 6] shows the forest plot for the articles of MRE of seven articles included in metanalysis. The result is significant (P < 0.01, 95% confidence interval), significance level by Egger's and Begg's test. [Figure 7] and [Figure 8] show the asymmetrical funnel plot for the effect size for the survival rate of implants in USG and MRE groups, respectively.
Table 3: Data of the two devices namely ultrasonographic and motorised ridge expander for width gain and implant success rate for metanalysis

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Figure 5: Forest plot for gain in width of ultrasonographic articles

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Figure 6: Forest plot for gain in width by MRE

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Figure 7: Funnel plot for implant survival rate by ultrasonographic

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Figure 8: Funnel plot for implant survival rate by MRE

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   Discussion Top


ARSE is the routinely used preprosthetic procedure for the management of narrow alveolar ridge before insertion of the dental implant. Jha et al.[6] in their systematic review analyzed the devices used for ARSE. They concluded that the motorized expanders and ultrasonic surgery systems are easier to use and cause less trauma to the bone compared to the traditional/conventional instruments like mallets and osteotomes. However, their cost was a limiting factor; hence, osteotomes remain a popular mode of instrumentation.









In this study, we systematically reviewed the 22 observational studies and two randomized controlled studies using modern devices. The document of PRISMA [Appendix A] explains the methodology. We carried out this study to find evidence in the literature for the effect of modern devices for ARSE.

We evaluated two parameters namely RWG and survival rate mentioned in the selected articles. The effect size of the selected studies for these parameters was 10 studies. These 10 studies using USG device and seven studies using MRE device were analyzed as per these parameters. A total of 360 implants inserted by USG and 202 by MRE were studied. The mean RWG by USG (3.40 mm) and MRE (2.83 mm) devices were comparable. OM type of ARSE was used with the USG device. OM was extensive and technique sensitive with more chances of buccal fracture. USG was a precise bone-cutting tool causing minimal trauma to the bone. This was used for horizontal and vertical osteotomies for OM type of ARSE, followed by expansion using chisel or osteotome.

CO-OC type was used using the MRE device. CO-OC was minimally invasive, only crestal osteotomy followed by OC with noncutting drill-like expanders with low speed resulted in the expansion of ridge. Considering the time of implant insertion, all studies of MRE used immediate implant insertion whereas, studies of USG devices used time-consuming DII. Thus, the MRE device reduced the number of surgical procedures and total treatment duration.









The most common complication mentioned was implant failure followed by buccal plate fracture or bad split, peri-implantitis. Few studies mentioned the possibility of buccal plate dehiscence in using MRE expanders. Mahmoud et al.[33] studied mucosal verses mucoperiosteal flap in ridge split using USG. The sample size was small and the results focused on the peri-implant health of the patient. Kheur et al.[34] (2017) compared the graft particle type and size in ARSE. Although the study design was RCT, these studies could not contribute to the objectives of this systematic review. The other studies were observational studies. There was inconsistent data for important parameters like buccal wall dehiscence, bad split, cervical bone loss, stability of implants among these studies. Hence could not be evaluated for metanalysis. There was no study in the literature comparing the conventional and modern devices of ARSE. The effect size for each outcome from the observational studies was small. The analysis of the strength of the body of evidence, GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) rating is “very Low.” This manuscript has followed the PRISMA-P 2015 checklist [Appendix B].

We conclude that the USG unit and MRE are the most commonly used modern ARSE devices. USG being a precise osteotomy tool is more effective for OM type. Using the MRE device the ARSE procedure is minimally invasive and implants inserted immediately. However, for literature evidence the randomized controlled trial with a sufficiently large sample and long follow-up duration is needed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


   Appendix A: Quality assessment of the included studies (Tables A to E) Top


For cohort studies

For the observational studies, the adapted version of Newcastle-Ottawa (modified) was used. The following topics were evaluated for quality assessment for selection of study group (criteria 1, 2, 3,4), compariabilty (criteria no 5); for outcome (criteria no 6, 7, 8, 9, 10, 11, 12)





The study was analyzed based on stars given to each parameter. A total of 12 stars were given, of which studies with 9–12 stars (more than 80% domain fulfilled) were high-quality studies, 5–8 were medium quality, and less than 5 were considered low-quality studies





For randomized control trial (RCT):

Only two RCT were included in this study.

The Randomization was done. Only one study did computerized allocation. Controlled group present in both, very small sample size, no sample size calculation the outcome variables were clear in both. Statistical calculations mentioned









 
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Correspondence Address:
Varsha Sunil Manekar,
Government Dental College and Hospital, Nagpur - 441 401, Maharashtra
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njms.njms_423_21



    Figures

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