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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 14  |  Issue : 4  |  Page : 422-426

Modified approach for alveolar ridge augmentation in narrow maxillary anterior region by using screw-shaped bone expanders: A case report


Unit of Periodontics, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Date of Submission15-Feb-2022
Date of Decision13-Jun-2022
Date of Acceptance16-Jun-2022
Date of Web Publication29-Aug-2022

Correspondence Address:
Dr. Monika Bansal
Unit of Periodontics, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JIOH.JIOH_45_22

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  Abstract 

The objective of the present case report is to discuss the ridge expansion by using screw-shaped bone expanders in the narrow maxillary anterior region. A 24-year-old male subject was subjected to rehabilitate the #12 edentulous site with an implant-retained fixed prosthesis. Initially, a point drill of 1.5 mm diameter was used to initiate the osteotomy preparation to the depth of the implant length. After that, sequential screw-shaped bone expanders were used to expand the osteotomy progressively rather than cutting to the desired width of the implant. Finally, an implant was placed with an insertion torque of 35–40 N-cm. At the third month, a final prosthesis was placed and excellent esthetic was achieved. Conclusively, ridge split and expansion technique is a simple, less-invasive, and viable alternative to modify the ridge to make the prosthetic-driven implant placement rather than bone-driven and screw-shaped bone expanders to avoid the bone augmentation procedure and to reduce the overall treatment time.

Keywords: Bone Expanders, Dental Implant, Narrow Maxillary Region, Ridge Expansion Technique


How to cite this article:
Bansal M, Nahid R, Pandey S. Modified approach for alveolar ridge augmentation in narrow maxillary anterior region by using screw-shaped bone expanders: A case report. J Int Oral Health 2022;14:422-6

How to cite this URL:
Bansal M, Nahid R, Pandey S. Modified approach for alveolar ridge augmentation in narrow maxillary anterior region by using screw-shaped bone expanders: A case report. J Int Oral Health [serial online] 2022 [cited 2022 Oct 5];14:422-6. Available from: https://www.jioh.org/text.asp?2022/14/4/422/355022


  Introduction Top


Edentulism either partial or complete is a major health concern that needs rehabilitation to prevent physiological, psychological, and esthetic problems. The extraction of a tooth in the maxilla results into more deficiency in the horizontal dimensions than the vertical because of alveolar bone resorption mainly from the facial side. A minimum 1 mm of bone is required to remain buccally and lingually/palatally after implant insertion.[1] Onlay graft, guided bone regeneration (GBR), ridge split and ridge expansion, and osteogenesis distraction are the procedures used to modify the ridge to make the prosthetic-driven implant placement rather than the bone-driven.

Ridge split and expansion technique is a simple, less-invasive, and viable alternative in which a screw-shaped bone expander can be used to expand the alveolar bone in a lateral direction that improve the quality of bone by the condensation of soft bone without removing the bone.[2] The present case report discusses the placement of dental implant in a narrow maxillary anterior region by using screw-shaped bone expanders.


  Case Report Top


A 24-year-old male patient presented to the department with the chief complaint of missing tooth in the right upper anterior region since 2 years. The patient had a history of trauma in which he had lost his tooth. On extraoral examination, no significant finding was present. Intraoral examination showed missing #12 tooth along with the horizontal deficiency on the facial side [Figure 1]A. An implant-retained fixed prosthesis was planned to rehabilitate the edentulous site. The patient was systemically healthy. Phase-1 therapy including the scaling and root planning was done. The diagnostic cast was prepared for further reference and to evaluate the edentulous site. The implant site was evaluated clinically and radiographically by intraoral periapical x-ray, orthopantomogram x-ray [Figure 1]B, and dentascan. Dentascan showed a faciolingual and mesiodistal width of the edentulous site was approximately 3.5 mm and 6.5 mm at the crest of the edentulous site [Figure 2].
Figure 1: Preoperative (A) photograph showing missing #12 tooth along with the horizontal deficiency on the facial side; (B) orthopantomogram x-ray

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Figure 2: Dentascan showing 3.5 mm faciolingual width and 6.5 mm mesiodistal width at the crest of the edentulous site

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Before implant surgery, routine blood investigations were done, and written informed consent was obtained after explaining the procedure. Implant surgery was performed under local anesthesia using 2% lignocaine with adrenaline in the ratio of 1:80,000. A crestal incision slightly palatal was given and extended at least one tooth beyond in both mesial and distal directions, and a vertical incision to the mucogingival junction distal to the #13 was also given. Full-thickness flap was elevated to expose the site of implant placement having narrow ridge [Figure 3]. The faciolingual width was 3.5 mm, and the mesiodistal width was 6.5 mm. Thus, 3.0 mm diameter implant with 11.5 mm length (TauregTM-S Adin dental implant system LTD, Israel) was decided to be placed. The point drill of 1.5 mm diameter was used at 1200 rpm to penetrate the cortical bone and to initiate the osteotomy preparation at the site of implant placement. After that, a point drill was inserted to the depth of the implant length [Figure 4]. After that, 2.6 mm and 3.0 mm screw-shaped bone expanders were used [Figure 5] to expand the osteotomy progressively rather than cutting to the desired width of implant being slightly shorter to achieve the primary initial stability and to preserve the bone at the facial and palatal cortical side. The screw-shaped bone expanders were used at the site of osteotomy with the help of finger initially, and then a ratchet was used to the depth of implant length. During the insertion of expanders, slow clockwise direction was used along with 20–30 s waiting time between each half turn that will allow the bone to expand without the fracture of facial cortical plate. After that, 3.0 mm diameter implant was placed with the help of a ratchet with an insertion torque of 35–40 N-cm, and the cover screw was placed [Figure 6]A, B. The flap was approximated using 3-0 black silk suture. Postoperative instructions were given along with the prescription of antibiotics and analgesic for 5 days. Chlorhexidine mouth wash was prescribed at least for 15 days. The patient was re-called after 24 h for follow-up. Sutures were removed after 7–8 days. The patient was re-called at the first month and third month for the follow-up examination. At the third month, the second-stage surgery was performed and healing abutment was placed. After that, a final prosthesis was placed [[Figure 7]A, B] and excellent esthetic was achieved in the anterior maxillary region, and the patient was happy after the replacement of his missing tooth.
Figure 3: Photograph showing the exposed narrow ridge site after the flap reflection

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Figure 4: Intraoral periapical x-ray showing the point drill to the depth of the implant length

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Figure 5: Photograph showing the screw-shaped expanders to prepare the osteotomy

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Figure 6: (A) Photograph and (B) intraoral periapical showing the placement of dental implant

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Figure 7: Postoperative (A) photograph and (B) orthopantomogram x-ray showing the rehabilitation of the edentulous site

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  Discussion and Conclusion Top


The placement of dental implants in atrophic sites with an insufficient horizontal ridge width is a challenging task. After the extraction of a tooth or trauma in an anterior maxilla, the alveolar bone resorption generally takes place on the facial side and results into the ridge deficiency in the horizontal direction along with depression. If the remaining facial or lingual bone is less than 1 mm after the osteotomy preparation, there is an increased risk of bone dehiscence or fenestration.

Various methods such as block graft, GBR, ridge split and expansion technique, and osteogenesis distraction are indicated for the augmentation of the bone laterally so that a sufficient volume of bone can be present for the osseointegration of the dental implant. Block graft is an invasive procedure, and the main disadvantage of the block graft is morbidity because of a second surgical site created during the harvesting of autograft.[3 In GBR],[ barrier membrane and bone graft are used specially on the facial side to remove the ridge deficiency],[ which is also associated with certain disadvantages such as redness],[ swelling],[ pain],[ soft-tissue dehiscence],[ membrane exposure],[ bone loss],[ the collapse of membrane],[ treatment cost],[ and the duration of treatment.[4]

To avoid the second surgical site and to overcome the problem associated with GBR technique, ridge split and expansion technique is a simple, less-invasive, and viable alternative over the GBR and block bone graft in which the space is created between the facial and lingual/palatal cortices and implant is inserted. It eliminates morbidity and overall treatment time.[5],[6] There should be at least 1 mm of cancellous bone between both cortical plates to spread the bone adequately on the facial and lingual or palatal side of the ridge that maintains sufficient blood supply. Traditionally, osteotome techniques were introduced by Summers to expand the ridge by using the round osteotomes in an increasing order.[7] The osteotome technique is associated with usually buccal cortical bone fractures, discomfort, headaches, and temporomandibular joint injuries to the patient due to repeating malleting that can be minimized in the bone spreader technique (BST) in which a relatively less amount of force is used and malleting is avoided.[8] In the BST of the ridge expansion, screw-shaped bone expanders in an increasing diameter are used.[9] In conclusion, BST is a highly predictable, noninvasive, and a relatively complication-free procedure that expands the external facial and palatal cortical plates of the maxilla to allow the insertion of implants.

Acknowledgement

Not applicable.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Authors’ contributions

MB: Concept, design, definition of intellectual content, manuscript preparation; MB, RN, SP: Literature search, clinical study, data acquisition, manuscript editing, manuscript review.

Ethical policy and Institutional Review board statement

Not applicable.

Patient declaration of consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initial will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Data availability statement

Not applicable.

 
  References Top

1.
Schropp L, Wenzel A, Kostopoulos L, Karring T Bone healing and soft tissue contour changes following single tooth extraction: A clinical and radiographic 12-month prosthetic study. Int J Periodont Restor Dent 2003;23:313e-23.  Back to cited text no. 1
    
2.
Nishioka RS, Souza FA Bone spreader technique: A preliminary 3-year study. J Oral Implantol 2009;35:289-94.  Back to cited text no. 2
    
3.
Zijderveld SA, ten Bruggenkate CM, van Den Bergh JP, Schulten EA Fractures of the iliac crest after split-thickness bone grafting for preprosthetic surgery: Report of 3 cases and review of the literature. J Oral Maxillofac Surg 2004;62:781-6.  Back to cited text no. 3
    
4.
Tolstunov L, Hicke B Horizontal augmentation through the ridge-split procedure: A predictable surgical modality in implant reconstruction. J Oral Implantol 2013;39:59-68.  Back to cited text no. 4
    
5.
Kumar I, Singh H, Arora SS, Singh A, Kumar N Implant placement in conjunction with ridge split and expansion technique. Oral Surg 2019;12:214-23.  Back to cited text no. 5
    
6.
Monteiro AS, Macedo LG, Macedo NL, Balducci I Polyurethane and PTFE membranes for guided bone regeneration: Histopathological and ultrastructural evaluation. Med Oral Patol Oral Cir Bucal 2010;15:e401-6.  Back to cited text no. 6
    
7.
Summers RB The osteotome technique: Part 2—The ridge expansion osteotomy (REO) procedure. Compendium 1994;15:422, 424, 426, passim; quiz 436.  Back to cited text no. 7
    
8.
Kim YK, Kim SG Horizontal ridge expansion and implant placement using screws: A report of two cases. J Korean Assoc Oral Maxillofac Surg 2014;40:233-9.  Back to cited text no. 8
    
9.
Jha N, Choi EH, Kaushik NK, Ryu JJ Types of devices used in ridge split procedure for alveolar bone expansion: A systematic review. Plos One 2017;12:e0180342.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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