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RIDGE EXPANSION IN DEFICIENT ALVEOLAR RIDGE WITH IMMEDIATE IMPLANT

Dr. Vrushali V. Bhoir,

DY Patil University School of Dentistry, DY Patil Vidyanagar, Sector

ARTICLE INFO ABSTRACT

With advancement in clinical dentistry, implant therapy is one of the most upcoming treatment option for fixed prosthesis with a predictable outcome. However, sometimes insufficient bone due to long standing edentulism may pose a challenge for implant plac

presentation in 1970s, ridge splitting or bone spreading procedure was introduced by

This technique has been used for esthetic rehabilitation and implant site preparation in cases of deficient alveolar ridges

report, we describe a case of horizontal ridge augmentation using ridge expansion technique which was performed using ridge expansion kit and simultaneous implant placement in esthet

anterior zone. Bone expansion resulted in correction of atrophic alveolar ridge (Labiolingual width > 3.5mm) without significant surgical risk and multiple surgeries. The degree of bone expansion obtained had remodelled the alveolar bone prov

significant increase was achieved in the bone dimension, which enabled the placement of endosseous dental implants successfully.

clinically and r

Copyright © 2016 Dr. Vrushali V. Bhoir et al. This

unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

INTRODUCTION

Rehabilitation of missing teeth using dental im

considered one of the most efficient treatment methods for edentulous patient. Patients often desire a “fixed” treatment rather than removable dentures, to feel normal and to overcome the psychological trauma they have been through. Insufficient bone thickness of an atrophic mandible ridge is a common problem for placement of dental implants. Narrow edentulous alveolar ridge of 4 mm or less requires horizontal

augmentation. Various surgical techniques have been

mentioned in the literature: Guided bone regeneration

et al., 1990), onlay block bone grafting (Pikos

split technique or ridge expansion (Scipioni and Kaus, 2000) and distraction osteogenesis

2005). Onlay grafting with biodegradable membranes and autografts is the most frequently used technique; however, this technique involves a long ossification period, and the tendency of the graft material to resorb can easily decrease bone quality and quantity (Ignatius et al., 2001).

*Corresponding author: Dr. Roshani Thakur,

DY Patil University School of Dentistry, DY Patil Vidyanagar, Sector- 7, Nerul (East), Navi Mumbai- 400706, Maharashtra, India.

ISSN: 0975-833X

Article History:

Received 27th December, 2015

Received in revised form 24th January, 2016

Accepted 17th February, 2016

Published online 16th March,2016

Key words:

Implant, ESSET Kit, Periosteum, Ridge Expansion.

Citation: Dr. Vrushali V. Bhoir, Dr. Roshani Thakur and Dr. Arvind shetty

placement: a case report”, International Journal of Current Research,

CASE REPORT

RIDGE EXPANSION IN DEFICIENT ALVEOLAR RIDGE WITH IMMEDIATE IMPLANT

PLACEMENT: A CASE REPORT

Vrushali V. Bhoir,

*

Dr. Roshani Thakur and Dr. Arvind shetty

DY Patil University School of Dentistry, DY Patil Vidyanagar, Sector- 7, Nerul (East), Navi Mumbai

Maharashtra, India

ABSTRACT

With advancement in clinical dentistry, implant therapy is one of the most upcoming treatment option for fixed prosthesis with a predictable outcome. However, sometimes insufficient bone due to long standing edentulism may pose a challenge for implant placement. To overcome such a clinical presentation in 1970s, ridge splitting or bone spreading procedure was introduced by

This technique has been used for esthetic rehabilitation and implant site preparation in cases of deficient alveolar ridges to satisfy the basic ideal need of hard tissue augmentation. In this case report, we describe a case of horizontal ridge augmentation using ridge expansion technique which was performed using ridge expansion kit and simultaneous implant placement in esthet

anterior zone. Bone expansion resulted in correction of atrophic alveolar ridge (Labiolingual width > 3.5mm) without significant surgical risk and multiple surgeries. The degree of bone expansion obtained had remodelled the alveolar bone providing adequate bone support for prosthesis. significant increase was achieved in the bone dimension, which enabled the placement of endosseous dental implants successfully. After 4-5 months of healing period both the implants were stable clinically and radiographically and hence were restored.

This is an open access article distributed under the Creative Commons Att use, distribution, and reproduction in any medium, provided the original work is properly cited.

Rehabilitation of missing teeth using dental implants is considered one of the most efficient treatment methods for atients often desire a “fixed” treatment rather than removable dentures, to feel normal and to overcome the psychological trauma they have been through. Insufficient bone thickness of an atrophic mandible ridge is a common problem for placement of dental implants. Narrow edentulous alveolar ridge of 4 mm or less requires horizontal

Various surgical techniques have been

bone regeneration (Buser Pikos, 2000), ridge Scipioni et al., 1994; Sethi and distraction osteogenesis (Laster et al., grafting with biodegradable membranes and autografts is the most frequently used technique; however, this technique involves a long ossification period, and the tendency of the graft material to resorb can easily decrease bone quality

DY Patil University School of Dentistry, DY Patil Vidyanagar, 400706, Maharashtra, India.

Time lost and donor-site morbidity are the main disadvantages of this reconstructive approach. The split

should be delineated as a bone expansion procedure, which potentially eliminates the overall disadvantages of Onlay grafting for esthetic and functional demands.

report describes the ridge expansion technique using ridge expansion kit (ESSET kit) for expansion of atophic anterior mandibular ridge with immediate implant placement.

Case report

A 48 years female patient repor

Periodontics and Oral Implantology, D.Y.

School of Dentistry, Navi Mumbai with a chief complaint of missing teeth in lower front region of the jaw (Figure 1). She underwent extraction of mandibular incisors one y

they were mobile. Extraction was done under Local anesthesia with no complications. Patient was systemically healthy. Intraoral examination revealed missing mandibular incisors (Teeth no. 32, 31, 41, 42) with atrophic alveolar ridge covered with thin, healthy, and un-inflamed mucosa. Various treatment options were discussed with the patient. As the patient was concerned about her appearance she wanted a fixed prosthesis replacing missing teeth.

Available online at http://www.journalcra.com

International Journal of Current Research

Vol. 8, Issue, 03, pp. 27667-27671, March, 2016

INTERNATIONAL

V. Bhoir, Dr. Roshani Thakur and Dr. Arvind shetty, 2016. “Ridge expansion in deficient alveolar ridge with immediate implant

International Journal of Current Research, 8, (03), 27667-27671.

z

RIDGE EXPANSION IN DEFICIENT ALVEOLAR RIDGE WITH IMMEDIATE IMPLANT

Dr. Arvind shetty

7, Nerul (East), Navi Mumbai- 400706,

With advancement in clinical dentistry, implant therapy is one of the most upcoming treatment option for fixed prosthesis with a predictable outcome. However, sometimes insufficient bone due to ement. To overcome such a clinical presentation in 1970s, ridge splitting or bone spreading procedure was introduced by Hilt Tatum. This technique has been used for esthetic rehabilitation and implant site preparation in cases of to satisfy the basic ideal need of hard tissue augmentation. In this case report, we describe a case of horizontal ridge augmentation using ridge expansion technique which was performed using ridge expansion kit and simultaneous implant placement in esthetic mandibular anterior zone. Bone expansion resulted in correction of atrophic alveolar ridge (Labiolingual width > 3.5mm) without significant surgical risk and multiple surgeries. The degree of bone expansion iding adequate bone support for prosthesis. A significant increase was achieved in the bone dimension, which enabled the placement of endosseous 5 months of healing period both the implants were stable

is an open access article distributed under the Creative Commons Attribution License, which permits

site morbidity are the main disadvantages of this reconstructive approach. The split-crest technique should be delineated as a bone expansion procedure, which potentially eliminates the overall disadvantages of Onlay ic and functional demands. This clinical report describes the ridge expansion technique using ridge expansion kit (ESSET kit) for expansion of atophic anterior mandibular ridge with immediate implant placement.

A 48 years female patient reported to the Department of Periodontics and Oral Implantology, D.Y. Patil University School of Dentistry, Navi Mumbai with a chief complaint of missing teeth in lower front region of the jaw (Figure 1). She underwent extraction of mandibular incisors one year back as they were mobile. Extraction was done under Local anesthesia with no complications. Patient was systemically healthy. Intraoral examination revealed missing mandibular incisors (Teeth no. 32, 31, 41, 42) with atrophic alveolar ridge covered inflamed mucosa. Various treatment options were discussed with the patient. As the patient was concerned about her appearance she wanted a fixed prosthesis

INTERNATIONAL JOURNAL OF CURRENT RESEARCH

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[image:2.595.51.271.56.196.2] [image:2.595.318.545.227.372.2]

Figure 1. Intraoral pre-operative view

Figure 2. Cone Beam Computed Tomography of mandibular anterior region

Cone beam computed tomography was performed to evaluate the bone quality and quantity. CT scan (Figure 2) revealed inadequate labio-lingual dimension of bone at the crest for implant placement. In the lateral incisor region width of bone was more than 3.5 mm (Figure 3). There was adequate cortical and cancellous bone to allow ridge expansion.

decision was made to place immediate implants, with ridge expansion technique using the ESSET Kit.

Figure 3: CBCT showing width 3.9mm and height 15mm

Clinical Procedure

Prophylactic antibiotic was given to the patient an hour before the procedure. Local anesthesia lignocaine 2% containing 1:80,000 Adrenaline was injected in the area of surgery as an

27668 Dr. Vrushali V. Bhoir et al. Ridge expansion in deficient alveolar ridge with immediate implant placement: a case report

operative view

Cone Beam Computed Tomography of mandibular

Cone beam computed tomography was performed to evaluate the bone quality and quantity. CT scan (Figure 2) revealed lingual dimension of bone at the crest for acement. In the lateral incisor region width of bone was more than 3.5 mm (Figure 3). There was adequate cortical and cancellous bone to allow ridge expansion. Hence the to place immediate implants, with ridge

Figure 3: CBCT showing width 3.9mm and height 15mm

Prophylactic antibiotic was given to the patient an hour before Local anesthesia lignocaine 2% containing was injected in the area of surgery as an

infiltration. After administration of local anesthesia, incision was made along the ridge crest (Figure 4) and extended atleast one tooth adjacent on both the sides of the edentulous region. A full thickness muco-periosteal flap (Figure 5) was elevated on the labial and lingual aspect of mandibular alveolar ridge. A decision was made to place two immediate implants in the lateral incisors region (teeth no. 32, 42). For ridge expansion procedure Easy Safe Stable Exp

was used (Figure 6). Narrow irregular bone (width>3.5 mm) was modified using Crest remover (Ø7.0) with a speed of 1,200-1,500 rpm (Figure 7). Twist drill (Ø1.8 mm) was used to locate the placement of implant. After this full

[image:2.595.44.276.232.377.2]

cut was given using the saw (Ø 7mm, Ø 10mm, Ø 13 mm in this sequence) with a speed of 1,200

Figure 4. Crestal incision given

(a)

(b)

Figure 5 (a, b). Full thickness mucoperiosteal ridge width between 3

Ridge expansion in deficient alveolar ridge with immediate implant placement: a case report

infiltration. After administration of local anesthesia, incision was made along the ridge crest (Figure 4) and extended atleast one tooth adjacent on both the sides of the edentulous region. periosteal flap (Figure 5) was elevated on the labial and lingual aspect of mandibular alveolar ridge. A decision was made to place two immediate implants in the lateral incisors region (teeth no. 32, 42). For ridge expansion procedure Easy Safe Stable Expanding & Tapping (ESSET) kit was used (Figure 6). Narrow irregular bone (width>3.5 mm) was modified using Crest remover (Ø7.0) with a speed of Twist drill (Ø1.8 mm) was used to locate the placement of implant. After this full depth vertical cut was given using the saw (Ø 7mm, Ø 10mm, Ø 13 mm in this sequence) with a speed of 1,200-1,500 rpm.

Crestal incision given

(a)

(b)

Full thickness mucoperiosteal flap raised showing ridge width between 3-4mm

[image:2.595.322.544.402.730.2] [image:2.595.39.290.522.665.2]
(3)
[image:3.595.325.534.54.392.2]

Figure 6. Ridge expansion kit (ESSET Kit)

(a)

(b)

Figure 7(a, b). Crestotomy done using crest removal

Horizontal splitting along the crestal bone was performed from distal to mesial direction 2 mm away from the adjecent teeth. Bone expansion was carried out using sequential set of drills (Ø1.6, Ø 2.2, Ø 2.7) at full depth (length 11.5mm) (Figure 8) simultaneously on both the implant sites with

speed. A significant increase was achieved in the bone dimen sion, which enabled the placement of endosseous dental implants successfully. After preparation of the im

implants were placed in both the lateral incisors region (size 3.5mm × 11.5mm) (Figure 9). Tension free mucoperiosteal tis sue closure was performed over the implants using 3 resorbable suture (Figure 10).

27669 International Journal of Current Research,

Ridge expansion kit (ESSET Kit)

Crestotomy done using crest removal

[image:3.595.41.284.54.231.2]

bone was performed from distal to mesial direction 2 mm away from the adjecent teeth. Bone expansion was carried out using sequential set of drills (Ø1.6, Ø 2.2, Ø 2.7) at full depth (length 11.5mm) (Figure 8) simultaneously on both the implant sites with 25-35 rpm A significant increase was achieved in the bone dimen-sion, which enabled the placement of endosseous dental implants successfully. After preparation of the implant sites, implants were placed in both the lateral incisors region (size (Figure 9). Tension free mucoperiosteal tis-sue closure was performed over the implants using 3-0

non-(a)

(b)

[image:3.595.64.258.270.588.2]

Figure 8 (a, b). Ridge expansion done

Figure 9. Implant placed after ridge expansion

Figure 10. Interrupted sutures placed

International Journal of Current Research, Vol. 08, Issue, 03, pp. 27667-27671, March,

(a)

(b)

Ridge expansion done

Implant placed after ridge expansion

Interrupted sutures placed

[image:3.595.313.552.425.546.2] [image:3.595.314.548.578.726.2]
(4)

(a)

(b)

Figure 11(a, b). Post-operative view after 3

(a)

(b)

Figure 12(a, b). Healing abutments placed

27670 Dr. Vrushali V. Bhoir et al. Ridge expansion in deficient alveolar ridge with immediate implant placement: a case report

operative view after 3-4 months

[image:4.595.338.520.52.250.2]

Healing abutments placed

[image:4.595.56.267.53.396.2]

Figure 13. Impression made (using Rubber based impression material)

Figure 14. Final prosthesis

Nonsteroidal analgesics Tablet Enzoflam thrice daily for 7 days and Antibiotics combination of Amoxicillin 500 mg and Clavulanate potassium 125mg thrice daily for 7 days and 0.2% chlorhexidine mouth rinse for 2weeks twice daily was the postoperative protocol administered to the patient. Patient was recalled after 14 days and Suture removal was done as healing was uneventful. This report demonstrated the successful use of expanding the anterior mandibular

showed that this technique allows for immediate implant placement. After 3-4 months of healing period both the implants were stable clinically and radiographically (Figure 11) and well osseointegrated. Hence, second stage surgery w planned for both the implants.

Full-thickness mucoperiosteal flap was reflected from 32 region, healing abutments were placed (size: 4mm x 5mm) (Figure 12) and flap sutured using interrupted sutures. patient was recalled after 14 days. On remova

abutments healthy gingival collar was seen hence using elastomer putty and light body impression material (Figure 13), impression was made and sent to the laboratory for fabrication of prosthesis. Due to longer crown height and space below the restoration margins, a FP3 type of prosthesis with pink colored porcelain to replace a portion of the soft tissue was given (Figure 14).

Ridge expansion in deficient alveolar ridge with immediate implant placement: a case report

Impression made (using Rubber based impression material)

Final prosthesis

Nonsteroidal analgesics Tablet Enzoflam thrice daily for 7 days and Antibiotics combination of Amoxicillin 500 mg and Clavulanate potassium 125mg thrice daily for 7 days and 0.2% chlorhexidine mouth rinse for 2weeks twice daily was the ostoperative protocol administered to the patient. Patient was recalled after 14 days and Suture removal was done as healing This report demonstrated the successful use rior mandibular alveolar ridge. It also showed that this technique allows for immediate implant 4 months of healing period both the implants were stable clinically and radiographically (Figure 11) and well osseointegrated. Hence, second stage surgery was

thickness mucoperiosteal flap was reflected from 32-42 region, healing abutments were placed (size: 4mm x 5mm) (Figure 12) and flap sutured using interrupted sutures. The patient was recalled after 14 days. On removal of the healing abutments healthy gingival collar was seen hence using elastomer putty and light body impression material (Figure 13), impression was made and sent to the laboratory for fabrication of prosthesis. Due to longer crown height and space the restoration margins, a FP3 type of prosthesis with pink colored porcelain to replace a portion of the soft tissue

[image:4.595.311.552.291.437.2] [image:4.595.65.259.428.732.2]
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DISCUSSION

The technique of ridge split or ridge expansion was introduced in early 1970s by Hilt Tatum for horizontal ridge augmentation while maintaining the periosteal attachment by carefully expanding the cortical plates to improve atrophic alveolar ridge for implant placement. This technique has an added advantage of augmentation and implant placement in a single sitting. Ridge splitting techniques are useful for managing narrow edentulous ridge (>3.5 mm) for implant placement with a predictable outcome (Summers, 1995). Tantum inserted >5000 maxillary anterior implants using ridge splitting before 1985 wherein, he expanded atrophic ridges >3 mm for simultaneous implant placement and augmentation keeping the periosteum intact. Later, Summers and Scipioni et al. in 1994 revived and published articles on edentulous ridge expansion with 98.8% implant survival rate for over 5 years (Scipioni et al., 1997).

The ridge deficiencies can be horizontal, vertical or combination of both as described by Siberts classes A, B and C, respectively. Dental implant devices are placed into edentulous ridges where an appropriate bone width is available to support removable or fixed type dental restorations. A minimum of 1.0 – 1.5 mm of bone width/thickness on the facial and lingual aspects of the implants is necessary making an average of 6 mm buccal/lingual ridge thickness necessary for a commonly desired 4 mm diameter implant. This creates a major challenge in implant dentistry since alveolar atrophy always occurs subsequent to tooth extraction which limits the use of endosseous implants to restore oral function. With the emergence of implant dentistry and introduction of microsaws, piezosaws, and specific ridge split osteotomes this technique has become an integral part of implant dentistry, wherein primarily bone expansion techniques were indicated in regions of division B bone volume and density of D3 or D4. Bone due to its dynamic viscoelastic nature, thinner ridges (<3.5 mm) can be expanded with better controlled instrumentation with less risk of fracture, trauma and bone perforations. The softer the trabacular bone quality, the lower the elastic modulus and greater the viscoelastic nature of the ridge. Therefore, less dense the bone, the easier and more predictable is the bone expansion (Misch, 1999).

The ESSET Kit was developed over the course of 10 years. Initially developed in 2002 by Dr. B.H. Suh, Dr. Suh tried to resolve the issue of insufficient horizontal bone volume without using bone grafts by focusing on the visco-elastic properities of bone tissue and the elasticity coefficient of the alveolar bone. Using the ESSET (Easy Safe Stable Expanding & Tapping) Kit for narrow ridge cases can shorten the healing time by not using bone grafts but utilizing natural stem cells from the expanded bone. Dental implants are placed with high degree of stability. Ridge expansion technique using ESSET kit was simple, predictable, and safe. Using a mallet and chisel to split the ridge may cause patient discomfort and is associated with high risk of buccal plate fracture The procedure is unpredictable and implant initial stability is unknown. In GBR cases, bone cells are supplied from a limited direction. Bone generation requires significant time to go through the multiple stages of healing; incorporation replacement, modeling and RAP. In ridge split cases, the

dental implant was enveloped by the patient’s natural bone. Sufficient blood supply surrounding the implant allows for bone regeneration to occur quicker. This shortens the bone healing process and integration of the implant. Demetriades

et al. (2011) in this study ridge split technique, splits and

expands the buccal-lingual bone to create space that allows for new bone to form. In other words, blood supply through the periosteum of the buccal cortical bone is maintained to form the osseous tissue and the lamellar bone. The treatment period is relatively shorter compared to GBR procedures (4 to 6 months) (Neophytos Demetriades, 2011).

Conclusion

Ridge split technique is effective for horizontal expansion in atrophic alveolar ridge without the need for more complex treatment. It also decreases the rehabilitation time and improves bone support quality. This procedure can be implemented in patient with good bone quality and narrow ridge with thick cortex and some cancellous bone in mandible. Owing to the various advantages of ESSET kit over other conventional procedures it is one of the most predictable and easy to use technique implant placement in narrow ridges.

REFERENCES

Buser, D., Brägger, U., Lang, N.P., Nyman, S. 1990. Regeneration and enlargement of jaw bone using guided tissue regeneration. Clin Oral Implants Res.,1:22–32 Ignatius, A.A., Ohnmacht, M., Claes, L.E., Kreidler, J. and

Palm, F. 2001. A composite polymer/tricalcium phosphate membrane for guided bone regeneration in maxillofacial surgery. J Biomed Mater Res., 58(5):564-9.

Laster, Z., Rachmiel, A. and Jensen, O.T. 2005. Alveolar width distraction osteogenesis for early implant placement. J Oral

Maxillofac Surg., 63:1724–30.

Misch, C.E. 1999. 2nd ed. St. Louis: The CV Mosby Company; Contemporary Implant Dentistry; pp. 3–11.

Neophytos Demetriades, Jong il Park, Constantinos

Laskarides, 2011. Alternative Bone Expansion Technique for Implant Placement in Atrophic Edentulous Maxilla and Mandible. Journal of Oral Implantology: August 2011, Vol. 37, No. 4, pp. 463-471.

Pikos, M.A. 2000. Block autografts for localized ridge augmentation: Part II. The posterior mandible. Implant

Dent., 9:67–75

Scipioni, A., Bruschi, G.B. and Calesini, G. 1994. The edentulous ridge expansion technique: A five-year study. Int J Periodontics Restorative Dent., 14:451–9. Scipioni, A., Bruschi, G.B., Giargia, M., Berglundh. T. and

Lindhe, J. Healing at implants with and without primary bone contact. An experimental study in dogs. Clin Oral

Implants Res., 1997;8:39–47.

Sethi, A. and Kaus, T. 2000. Maxillary ridge expansion with simultaneous implant placement: 5-year results of an

ongoing clinical study. Int J Oral Maxillofac

Implants. 5:491–9.

Summers, R.B. 1995. The osteotome technique: Part 4 – Future site development. Compend Contin Educ Dent.,

16:1090–1092.

*******

Figure

Figure 1. Intraoral pre-operative view operative view
Figure 9. Implant placed after ridge expansionImplant placed after ridge expansion
Figure 13. Impression made (using Rubber based Impression made (using Rubber based  impression material)impression material)

References

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