Horizontal ridge expansion and implant placement using ...€¦ · 233 Horizontal ridge expansion...
Transcript of Horizontal ridge expansion and implant placement using ...€¦ · 233 Horizontal ridge expansion...
233
Horizontal ridge expansion and implant placement using screws: a report of two cases
Young-Kyun Kim1,2, Su-Gwan Kim3
1Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital, Seongnam, 2Department of Dentistry and Dental Research Institute, School of Dentistry, Seoul National University, Seoul,
3Department of Oral and Maxillofacial Surgery, School of Dentistry, Chosun University, Gwangju, Korea
Abstract (J Korean Assoc Oral Maxillofac Surg 2014;40:233-239)
Implants are typically placed after performing ridge expansion by inserting screws of gradually increasing thickness and good clinical outcomes are often obtained. We placed 11 implants in 6 patients, and one implant failed during osseointegration but it was replaced immediately after removal and successful prosthetic treatments were completed. During these surgeries, buccal cortical plate complete fractures do not occur. Inserting screws for ridge expansion is a successful and predictable technique for implant placement in narrow alveolar bone.
Key words: Dental implants, Alveolar ridge augmentation, Bone screws[paper submitted 2014. 7. 3 / revised 2014. 8. 7 / accepted 2014. 8. 14]
separationofthebuccolingualboneduringsurgeryarepo-
tentialrisks,soitiscrucialtominimizethesecomplications.
Methodsaugmentingthealveolarbonetothebuccolingual
sideareoftendonebecauseridgesplittinginvolvingtheuse
ofanosteotomeandmalletcaninducegreenstickfractures
ofthebuccalcorticalbone.Intheridgesplittingprocedure,
discomforttopatientsisoftensubstantialbecauseofmallet-
ing,andthereisariskofbuccolingualbonefracturewhen
excessiveforceisdelivered.Therefore, thepresentreport
introducesandevaluatestheclinicalresultsofaprocedure
thatexpandstheridgeinastepwisetechniqueusingscrews
ofgraduallyincreasingwidth.
II. Cases Report
Thisstudywasperformedafterobtainingapprovalfrom
theinstitutionalreviewboardoftheSeoulNationalUniver-
sityBundangHospital(No.B-1007-105-106).Inthedepart-
mentoforalandmaxillofacialsurgery,oneoralandmaxil-
lofacialsurgeonperformedridgeexpansionsfromMay2008
toSeptember2009.Theprocedurewasperformedusingex-
pandingscrews(SplitMaster;Mr.Curette,Seoul,Korea),and
implantswereplacedsequentiallyorsimultaneouslyin6pa-
tients(1maleand5females).Theageofthepatientsranged
from31 to69yearswithameanageof55.1years.One
I. Introduction
Manycasesofimplantplacementinvolveinsufficientbuc-
colingualwidthoftheedentulousridge.Themethodsused
toresolvethisissuearethefollowing:narrowimplantplace-
ment,horizontalveneerblockbonegraft,horizontalguided
boneregeneration(GBR),andtheridgesplittingprocedure1-3.
Ridgesplittingisappliedprimarilyincaseswherethebone
heightissufficient,butthewidthisnarrow.Thepurposeof
ridgesplittingistowidenthealveolarridgebytakingadvan-
tageoftheelasticityofbones,anditisfrequentlyperformed
intheanteriormaxillomandibulararea.Thissurgeryrestores
themorphologyofthelingualsideofthealveolarboneand
obtainsnotonlyaestheticresults,butalsoahousingeffect
exertedbythecorticalboneofthebuccolingualside,which
improvestheosseointegrationofimplantsbyprovidingan
amplesupplyofbloodcirculation4.Nevertheless,fractureand
CASE REPORT
Su-Gwan KimDepartment of Oral and Maxillofacial Surgery, School of Dentistry, Chosun University, 309 Pilmun-daero, Dong-gu, Gwangju 501-759, Korea TEL: +82-62-220-3815 FAX: +82-62-228-7316E-mail: [email protected]
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
CC
Copyright Ⓒ 2014 The Korean Association of Oral and Maxillofacial Surgeons. All rights reserved.
http://dx.doi.org/10.5125/jkaoms.2014.40.5.233pISSN 2234-7550·eISSN 2234-5930
J Korean Assoc Oral Maxillofac Surg 2014;40:233-239
234
sions,amaxillaryliftsurgerywasperformedsimultaneously.
Atotalof11implantswereplaced:5inthemaxillaryante-
riorand3inthemaxillarypremolararea.(Table1)Complica-
tionsduringsurgery,suchasbuccalcorticalplatecomplete
fracture,didnotdevelopwiththeexceptionofsevereedema
andpost-surgicalecchymosisinonecase.Inthatcase,osseo-
integrationfailurewasobserved4monthsafterthefirstsur-
gery,sotheimplantwasremovedandwasreplacedimmedi-
ately.Wounddehiscencedevelopedafterimplantplacement,
andtheimplantwasconsideredapossibleetiologicfactor.
Afterapproximately8weeksafterreplacement,afixedpar-
tialprosthesiswasinstalled.Duringthefollow-upobserva-
tionperiod,averaging44.7months,all6patientsmaintained
normalfunctionwithoutanyspecificproblems.(Table2)
1. Case 1
A31-year-oldmalepatientwithahistoryofrightunilateral
cleftlipandpalatepresentedtoourclinicwithamissingright
maxillary lateral incisorandalveolarbone loss.Together
withorthodontictherapy,atreatmentplanwasdevelopedthat
includedasymphysisbonegraft,oronasalfistulaclosuresur-
gery,andimplantplacement.Thefirstimplantsurgerywas
performedaftera6-monthhealingperiodfollowingthebone
graft.Tosecureanadequateview,afullthicknessflapwas
created.Theboneheightwassufficientforimplantplacement
andthebuccolingualwidthwasapproximately3mm.Us-
ingSplitMasterexpandingscrews,a4-mmridgeexpansion
wasperformed;subsequently,animplantthatwas3.5mmin
diameterand11mminlengthwasplaced.Topreventbuccal
bonefracture,expandingscrewswerecarefullyhandledwith
patienthadosteoporosis,andtherestweregenerallyhealthy.
Thepostsurgicalfollow-upobservationperiodrangedfrom
24to63monthswithanaverageof44.7months.
Thesurgerywasperformedunderlocalanesthesia.Amid-
crestalincisionwasmadeinthemaxillaryandmandibular
alveolarbone,andthebonewasexposedthroughthecreation
ofafullthicknessflap.Initialdrillingswereperformedinthe
areaofimplantplacement,andtheimplantwasplacedatthe
properplacementdepthusingaSplitMasterNo.1expanding
screw.Gradually, thickerscrewswereusedrelativetothe
finalwidthandlengthoftheimplants.Simultaneousimplants
wereplacedwithself-tappingandsequentialimplantswere
placedwithanapproximately3-to4-monthhealingperiodin
between.Intwocases,agroovewascreatedinthealveolar
ridgewithFriossaws(DentsplyImplants,Mannheim,Germa-
ny)or#15blades,andalveolarridgesplittingwasperformed
usinganosteotome.Then,theimplantplacementsitewasex-
pandedtothewidthoftheimplantbyusingexpandingscrews.
Insomecases,additionalbonegraftwasperformedtoprevent
resorptionofthethinbuccalcorticalplate.Thespacebetween
theimplantsandthebonewasfilledwithgraftmaterialsand,
ifneeded,blockingmembranes.Inoneoftheridgeexpan-
Table 1. Location of implant
Location Number
MaxillaryanteriorMaxillarybicuspidMaxillarymolarMandibularmolarTotal
531211
Young-Kyun Kim et al: Horizontal ridge expansion and implant placement using screws: a report of two cases. J Korean Assoc Oral Maxillofac Surg 2014
Table 2. Overview of cases
PatientsNo.
Age(yr)/sex
SiteAccompanied
surgeryImplant
diameter(mm)Implant
length(mm)Ridgesplitting
methodProsthesis
typeComplications
12
3
4
5
6
31/male60/female
69/female
61/female
65/female
45/female
#12#13#23#35#37#14
#16#11
#12#24
#25
GBRGBRGBRGBRGBRGBR
GBRGBR
GBRSinuselevation,GBRSinuselevation,GBR
3.53.44.3454
53.5
3.54.3
4.3
11121211.511.513
1313
11.58.5
8.5
BoneexpanderBoneexpanderBoneexpanderBoneexpanderBoneexpanderFriossaw,blade,chisel,boneexpander
Friossaw,blade,chisel,boneexpanderBoneexpander
Boneexpander
SinglePFPPFPPFPPFPPFP
PFPPFP
PFPPFP
PFP
NoneSwelling,ecchymosisNoneNoneNoneNone
NoneOsseointegrationfailureNoneNone
None
(GBR:guidedbonyregeneration,PFP:partialfixedprosthesis)Young-Kyun Kim et al: Horizontal ridge expansion and implant placement using screws: a report of two cases. J Korean Assoc Oral Maxillofac Surg 2014
Horizontal ridge expansion and implant placement using screws
235
restorationarea.Boneheightwassufficient for implant
placement;thebuccolingualwidthwasasnarrowas3to4
mm,bonequalitywasD3,andosteoporosiswassuspected.
ahandratchet.Onthebuccalside,a2-mmimplantthread
wasexposed,soGBRwithxenogeneicbones(Biocera;Os-
scotec,Cheonan,Korea)andbarriermembranes(Bioarm;
ACESurgicalSupply,Brockton,MA,USA)wasperformed
intheexposedarea.Aftera4-monthhealingperiod,thesec-
ondsurgerytomaintainthebuccalvolumewasperformed
throughcreatingalabialpouchandgraftingtheBiocera.After
3monthsoforthodontictreatmentforregainingthespaceof
implantprosthesis,aprovisionalrestorationwasplaced.After
theorthodontictreatmentwasfinished(ninemonthsafterthe
implantsurgery),theimplantwasrestoredwithanall-ceramic
crownsupportedbyzirconiaabutmentpost.(Figs.1-6)
2. Case 2
A69-year-oldfemalepatientwithoutanyhistoryofsys-
temicdiseasespresentedtoourclinicwithachiefcomplaint
ofmissingseveralteeth.Underlocalanesthesia,afullthick-
nessflapliftwasperformedintheleftmandibularimplant
Fig. 2. Expansion of buccal plate achieved by splitting the ridge with bone expander in SplitMaster (Mr. Curette).Young-Kyun Kim et al: Horizontal ridge expansion and implant placement using screws: a report of two cases. J Korean Assoc Oral Maxillofac Surg 2014
A B
Fig. 1. Clinical view before implant placement. A. Preoperative intraoral photograph. B. Mucoperiosteal flap was elevated. Narrow alveolar ridge is observed.Young-Kyun Kim et al: Horizontal ridge expansion and implant placement using screws: a report of two cases. J Korean Assoc Oral Maxillofac Surg 2014
A B
Fig. 3. A. Implant was placed at the ex-panded ridge. B. Periapical radiograph after implant placement.Young-Kyun Kim et al: Horizontal ridge expansion and implant placement using screws: a report of two cases. J Korean Assoc Oral Maxillofac Surg 2014
J Korean Assoc Oral Maxillofac Surg 2014;40:233-239
236
Afterinitialdrilling,expansionwasperformedusingSplit-
Masterexpandingscrewsattheleftmandibular2ndpremolar
and2ndmolararea;theareaswereexpandedto3.8mmand
4.3mm,respectively.TwoGSIIimplants(Osstem,Busan,
Korea)whichwere4mmindiameter,11.5mmin length
and5mmindiameter,11.5mminlengthwereplaced.As
measuredbytheOsstellMentor(IntegrationDiagnostics,
Savedalen,Sweden),theprimarystabilityoftheimplantsin
theleftmandibular2ndpremolarand2ndmolarwas76and
77implantstabilityquotient(ISQ),respectively.Thesewere
relativelygoodvalues.Subsequently,axenogeneicbonegraft
(Biocera)wasperformedinthespacebetweenthebonesand
thethinareaofthebuccalside.Thesurgerywasperformed
usingtheone-stagemethod,andafterahealingperiodof
approximately2months,theimplantswererestoredwitha
fixedpartialprosthesis.(Figs.7-11)
Fig. 4. Clinical view of 2nd surgery.Young-Kyun Kim et al: Horizontal ridge expansion and implant placement using screws: a report of two cases. J Korean Assoc Oral Maxillofac Surg 2014
Fig. 5. Delivery of the final implant-supported all-ceramic restora-tion. Young-Kyun Kim et al: Horizontal ridge expansion and implant placement using screws: a report of two cases. J Korean Assoc Oral Maxillofac Surg 2014
Fig. 6. Periapical view 24 months after the placement of implant.Young-Kyun Kim et al: Horizontal ridge expansion and implant placement using screws: a report of two cases. J Korean Assoc Oral Maxillofac Surg 2014
Fig. 7. Clinical aspect before implant placement.Young-Kyun Kim et al: Horizontal ridge expansion and implant placement using screws: a report of two cases. J Korean Assoc Oral Maxillofac Surg 2014
Fig. 8. Expansion of buccal plate achieved by splitting the ridge using the bone expander in SplitMaster (Mr. Curette).Young-Kyun Kim et al: Horizontal ridge expansion and implant placement using screws: a report of two cases. J Korean Assoc Oral Maxillofac Surg 2014
Horizontal ridge expansion and implant placement using screws
237
stillcontroversialastowhetherabonegraftisrequiredfor
thespacegeneratedaftersplitting.Insimultaneousimplant
placements,itiscontroversialwhetherbonegraftmaterials
improveosseointegration6.Ithasbeenreportedthatincases
withbonygapssmaller than3mm,bonegraftmaterials
otherthancollagenspongesarenotrequired7.Also,implants
placedinthespacebetweenexpandedbonesareprotected
frombiodynamicexternalloading.Furthermore,bonycom-
pactioneffectscanoccurasaresultofthecompressionof
bonytrabeculae.Nonetheless,thissurgeryisamethodthat
usesboneelasticity,soitcanonlybeperformedincaseswith
cancellousbonewithinthecorticalboneonbothsides.There-
foretheindicationsofthisproceduremightbelimitedwhen
comparedwithGBRoronlaygraftthatcouldbeappliedin
acancellousbone-deficientarea.Incaseswherethewidthof
thebasalboneistoonarrow,theprimarystabilityortheslope
III. Discussion
Since1990,itwaswidelyusedandreferredtointhelit-
eraturewithvarioustermssuchasridgewidening,thesplit
crestprocedure,andstagedridgesplitting5.Generally,this
surgeryinducesagreenstickfractureinthenarrowalveolar
ridgewithanosteotome.Theprocedureformsanimplantbed
andfacilitatestheplacementofimplantswithwidediameter.
Inaddition,boneregenerationisachievedonbothsides,so
thebonehealingcapacityisgood;therefore,sufficientos-
seointegrationcanbeachievedwithrelativelysmallvolumes
ofbone.Furthermore,a3-monthwaitingperiodisrequired
atminimumfordistractionosteogenesisand6months is
requiredforGBRinimplantplacement.Ontheotherhand,
afterperformingridgesplitting,thefirstplacementsurgery
canbeperformedonthesamedayorwithinthemonth.Itis
Fig. 11. Periapical radiograph 63 months after implant placement.Young-Kyun Kim et al: Horizontal ridge expansion and implant placement using screws: a report of two cases. J Korean Assoc Oral Maxillofac Surg 2014
Fig. 10. Intraoral view after delivery of final implant-supported por-celain fused to metal restoration.Young-Kyun Kim et al: Horizontal ridge expansion and implant placement using screws: a report of two cases. J Korean Assoc Oral Maxillofac Surg 2014
A B
Fig. 9. A. Implants were placed at the expanded ridge. B. Periapical radiograph after implant placement.Young-Kyun Kim et al: Horizontal ridge expansion and implant placement using screws: a report of two cases. J Korean Assoc Oral Maxillofac Surg 2014
J Korean Assoc Oral Maxillofac Surg 2014;40:233-239
238
partialthicknessflapsshowgoodresults.Inthisstudy,and
incasesinvolvingthemaxillaryanteriorareawhereesthetics
arerequired,full-thicknessflapelevationswereperformedin
thealveolarridgeandslightlybelowit.Afterwards,apartial
flapwaselevated.Intheposteriorareas,afull-thicknessflap
waselevatedinmostcases.
The ridgeexpansion techniquementioned in thiscase
report isslightlydifferentfromtheexistingridgesplitting
technique.Theridgesplittingtechniqueisamethodology
toincreasetheridgewidthbyperformingtheridgesplitting
usingachiselaftertheformationofagrooveatthecenter
ofridgecrestusingasaworsurgicalburandismainlyused
inthemaxilla.Iftheridgesplittingtechniqueisperformed
inthemandiblecomposedofmainlycorticalbone,thenit
runstheriskofcorticalbonefractures.Whereas,theridge
expansiontechniqueisastepwisetechniqueusingscrewsof
graduallyincreasingwidth,soithasalowerriskofcortical
bonefracturethantheridgesplittingtechnique.Therefore,
ridgeexpansiontechniqueisconsideredtobeanacceptable
methodtouseonthemandible.
Inthisstudy,onecaseinvolvingimplantplacementinthe
maxillaryanteriorareadevelopedacomplicationoffailed
osseointegration.However, implantreplacementwasper-
formedimmediatelyafterremoval,andsuccessfulprosthesis
treatmentswerecompleted.Buccalcorticalbonefracturedid
notoccurinanyofthecases.Evenaftertheprosthesiswere
functioning,alladjacentalveolarbonesandsofttissuesre-
mainedstable.
Conflict of Interest
Nopotentialconflictofinterestrelevanttothisarticlewas
reported.
References
1. BuserD,BräggerU,LangNP,NymanS.Regenerationanden-largementofjawboneusingguidedtissueregeneration.ClinOralImplantsRes1990;1:22-32.
2. JovanovicSA,SpiekermannH,RichterEJ.Boneregenerationaroundtitaniumdentalimplantsindehisceddefectsites:aclinicalstudy.IntJOralMaxillofacImplants1992;7:233-45.
3. MischCM.Maxillofacialdonorsitesforsinusfloorandalveolarreconstruction.In:JensenOT,ed.Thesinusbonegraft.2nded.Chicago:QuintessencePublishing;2006:129-43.
4. JensenJ,Sindet-PedersenS.Autogenousmandibularbonegraftsandosseointegratedimplantsforreconstructionof theseverelyatrophiedmaxilla:apreliminaryreport.JOralMaxillofacSurg1991;49:1277-87.
5. KimYK,KimSG,LeeBG.Bonegraftandimplant.1sted.Seoul:NaraePublishing;2007:435-67.
6. JensenOT,CullumDR,BaerD.Marginalbonestabilityusing3
ofedentulousalveolarbonecanbeworsenedandanestheti-
callypoormaxillaryprosthesismaybeproduced.Thus,itis
bettertoselectalternateprocedures.Ithasbeenreportedthat
caseswitharesidualwidthofmorethan4mmareidealfor
theprocedure;incaseswithawidthof3mmorless,other
bonegraftproceduresshouldbeadditionallyperformed,and
theimplantshouldbeplacedafteracertainhealingperiod6.
Moreover,ithasbeenreportedthatridgesplittingisapro-
cedurethatshouldbeappliedprimarilytothemaxilla,asthe
outcomesarepoorinthemandibleduetotheabundanceof
corticalbone7.However,ithasalsobeenreportedthatifthe
characteristicsofthemandiblearewellunderstoodandslow
expansionisperformedmanuallyratherthanwithamallet,
thensuccessfulresultscanbeobtained7.Chiapascoetal.8
demonstratedgradualboneexpansionof1mmperdayfor
4-5daysusingscrew-typetoolsinthemandible.Recently,
minimalinvasiveridgeexpansionandscrewspreadingtech-
niqueswerereported9.Chanetal.10reportedthatthemean
increasedridgewidthwas0.79mminacadaverstudyonthe
ridgewidthgainthroughtheuseofscrews.Inthisstudy,even
inthemandibularmolararea,thebonewidthwasexpanded
toamaximumof4.3mmusingexpandingscrewsandsimul-
taneouslyplacingimplants.Eventhoughsomeofcasereports
reportedtheoccurrenceofcorticalbonegreenstickfracture
aftersurgery,theseparationofbonefragmentcausedbythe
occurrenceofcompletefracturewasnotreported.Oneyear
afterfunctional loading,goodresultswithout thegingival
recessionoralveolarboneresorptionwereobtained.Inacase
withpoorD4bonequality,thecompactioneffectofthebony
trabeculaeusingscrew-typetoolswasobservedandresulted
ineffectiveprimarystabilityoftheimplants.
Inseveralreports,a97.0%-97.6%successrateofridge
splittingwasreported;however,corticalbonefracture,re-
sorptionofthealveolarridge,nerveinjury,andothercom-
plicationsmayoccur11,12.Buccalcorticalbonesarefractured
inmanycases,particularlywhenridgesplittingisperformed
inthemandiblewithhardbonequality,andthiswillinduce
resorptionofthealveolarridgeduringtheboneremodeling
process.Thescrew-typetoolsusedinthisstudydeliverrela-
tivelylowamountsofforce.Thebonewasalsoexpandedse-
quentiallyinthedeeparea,anditwasconsideredtobemore
effectiveinpreventingcorticalbonefracture.Inaddition,the
conventionalmalletingprocesswasminimized,therebymini-
mizingheadechoandtheresultingheadaches,injurytothe
temporomandibularjoint,andothers.
Jensenetal.6reportedthatmucoperiostealelevationshould
beperformedminimallyinridgesplitting,andthattheuseof
Horizontal ridge expansion and implant placement using screws
239
erationsandcase report. Int JPeriodonticsRestorativeDent2011;31:141-7.
10. ChanHL,FuJH,KotichaT,BenavidesE,WangHL.Ridgewidthgainwithscrewspreaders:acadaverstudy.ImplantDent2013;22:552-8.
11. SethiA,KausT.Maxillaryridgeexpansionwithsimultaneousimplantplacement:5-yearresultsofanongoingclinicalstudy.IntJOralMaxillofacImplants2000;15:491-9.
12. FerrignoN,LauretiM.SurgicaladvantageswithITITEimplantsplacement inconjunctionwithsplitcrest technique.18-monthresultsofanongoingprospectivestudy.ClinOralImplantsRes2005;16:147-55.
different flapapproachesforalveolarsplitexpansionforden-tal implants: a1-yearclinical study. JOralMaxillofacSurg2009;67:1921-30.
7. JensenOT,CullumDR,BaerD.Marginalbonestabilityusing3different flapapproachesforalveolarsplitexpansionforden-tal implants: a1-yearclinical study. JOralMaxillofacSurg2009;67:1921-30.
8. ChiapascoM,FerriniF,CasentiniP,AccardiS,ZaniboniM.Den-talimplantsplacedinexpandednarrowedentulousridgeswiththeExtensionCrestdevice.A1-3-yearmulticenterfollow-upstudy.ClinOralImplantsRes2006;17:265-72.
9. NishiokaRS,KojimaAN.Screwspreading: technicalconsid-