Journal of Dental Health Oral Disorders & TherapyCase ReportOpen AccessHorizontal alveolar ridge expansion in anterioratrophic maxila using rotatory instruments (boneexpander ): a case reportAbstractVolume 10 Issue 6 - 2019Some conditions are necessary when placing an dental implant, good bone density, heightand weight must be available in the alveolar process. Tooth decay, trauma, periodontaldisease and other causes can lead to tooth loss and subsequently bone loss. Therefore,many sites where dental implants are needed have also lack of bone support. The mainof this present study is to report a case where a implant surgery was performed usingrotatory instruments Bone Expander , for volume gain in atrophic alveolar ridge and lowbone density, due to the absence of the four upper incisors. Guided Bone Regenerationwas associated in order to gain vestibular bone volume in the alveolar ridge. The resultsshowned that the use of Bone Expander is able to expand the alveolar ridge horizontallyand at the same time compacting bone in the inner walls of the prepared site increasing bonedensity in this area and allowing to the implant greater primary stability.Elisa Mazzotti Schmitz,1 Carlos EduardoGazola Zanettini,2 Leonardo Matos SantolimZanettini,3 Irani Zanettini,3 LeonardoDeCesaro,4 Daniel Galafassi5Keywords: dental implant, ridge augmentation, anterior atrophic maxila, boneregeneration, osseodensification, bone expanderGraduate Student, FSG University Center, BrazilDepartment of Dental Implantology, FSG University Center,Brazil3Department of Bucomaxilofacial Sugery, FSG University Center,Brazil4Department of Prosthesis, FSG University Center, Brazil5Department of Restorative Dentistry, FSG University Center,Brazil12Correspondence: Daniel Galafassi, Rua Dezoito do Forte2366, Caxias do Sul, Rio Grande do Sul, Brazil, Tel 55 54981655099, EmailReceived: October 01, 2019 Published: November 21, 2019IntroductionMost of the sites that need an implant are alveolar ridges thatdon’t configure good conditions to receive one. Atrophic alveolarridges don’t have sufficient volume, thickness and height to receivean implant, and if done will violate it’s functionals and aestheticsprincipals. The atrophic ridges can be caused by trauma; periodontaldisease, and tooth loss.1,2 Mostly, alveolar ridges with 4mm thicknessor less need an augmentation.3Narrow-diameter dental implants between 3mm and 3.5mmdecreased the need for surgeries on which purpose was ridgeaugmentation. Although, the 1mm thickness of bone surroundingthe implant must be respected, and in cases of very narrow ridges asurgery for augmentation still is a necessary intervention. 4 Therefore,for implant placement, several techniques allow gaining bone volume,increasing the size of the alveolar ridge.2 Some of the most frequentlyused methods that make possible vertical or horizontal augmentationsare osteotome technique, distraction osteogenesis, block bone graft,guided bone regeneration (GBR), and split crest.1Alveolar ridge expansion using rotatory instruments has beendocumented in osseodensification technique, lateral bone condensingand expansion, and bone spreader technique, these techniques showto be relatively simple to implement and also does not require lots ofadditional material. They have demonstrated good primary stability inatrophic and low bone density alveolar ridge.5–7 Horizontal alveolarridge expansion with Bone Expander (Maximus, Contagem, Brazil)performed in this article is a relatively new technique and there is noscientific study published about this subject until this present moment.The Bone Expander is a rotatory instruments kit consistingof a sequence of reamers of differents diameters, when used in thethin trabecular bone of an atrophic ridge is capable of its horizontalSubmit Manuscript http://medcraveonline.comexpansion. After the initial perforation made with a needle drill tocut and remove bone, and also guide the site preparation, the reamersare inserted with “in and out” movement and clock-wise rotationin order to expand and condense the bone, instead of removing it.Following the manufacturer instructions, the site preparation shouldbe done between 800 to 1200 rpm and an insertion torque value of20N when done in the maxillary bone. This preparation must be doneunder irrigation with a saline solution to prevent Osseo tissue fromoverheating and subsequently healing complications. The reamerssequence must be used increasing its diameter until it reaches adiameter compatible with the diameter of the chosen implant. Theaim of the study is to report a case where Bone Expander was used inatrophic ridge. For being a new technique, no case report was foundabout it.Case reportFemale patient, 50 years old, systemically healthy, attended theclinic complaining of the lack of four upper incisors. Clinically, thelack of bone support was evident, and in the absence of the four upperincisors the patient had a fixed bridge prosthesis supported by theupper canines (Figure 1&2). This prosthesis was poorly adapted andaesthetics compromised.Computed Tomography was requested, which showed an atrophicanterior maxilla with thin width thickness and presented differencesin thickness when observing the transverse sections, varying between3.40mm and 4.28mm. Regarding the height of the alveolar ridge, thevariation was between 13.08mm and 16.54mm, which demonstratedto be satisfactory to receive an implant treatment (Figure 3).The treatment of choice was idealized by reverse planning, startingwith prosthetic planning so it could serve as a guide, and from that, itwas possible to determine the best implant position (Figure 4). It wasJ Dent Health Oral Disord Ther. 2019;10(6):317‒322.317 2019 Schmitz et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, whichpermits unrestricted use, distribution, and build upon your work non-commercially.
Horizontal alveolar ridge expansion in anterior atrophic maxila using rotatory instruments (boneexpander ): a case reportdecided that two implants in the lateral uppers incisors regions wouldbe sufficient to rehabilitate the area. Bone ridge preparation would bedone with Bone Expander rotary instruments followed by implantplacement, associating the GBR technique. For aesthetic reasons, thepatient would use a temporary canine-supported prosthesis until thecomplete alveolar healing process.Copyright: 2019 Schmitz et al.318sites preparated with Bone expander . As the anterior ridge was toonarrow, there was a need for ridge augmentation, which would beassociate to some bone grafting; the grafting of choice was guidedbone regeneration (GBR), with xenogen bone graft and resorbablemembranes.Figure 1 Lack of four lateral upper incisors.Figure 4 Guide made from reverse planning to provide the best position ofthe implants.Figure 2 Alveolar bone defect.Under local anesthesia using articaine hydrochloride 4%with epinephrine 1:100.000 (Nova DFL, Rio de Janeiro, Brazil),an incision was made on the alveolar crest, two relaxing incisionswere made in first premolars and took to beyond the mucogingivaljunction. A full-thickness mucoperiosteal flap was elevated on bothsides, buccal and palatal (Figure 5). After the Osseos tissue wasexposed, with the guide assistance initial perforations were made withthe 1.3 diameter needle drill in 12mm depth. In this first perforation,a clockwise rotation was used on purpose to cut and remove bone(Figure 6). Further, the Bone Expander (Maximus, Contagem,Brazil) reamers sequence was used until a reamer which had a2.8mm diameter and reached 12mm depth in the bone site (Figure7). As manufacturer instructions, reamers were acting with “in andout” movement, clockwise rotation, at a speed of 800 rpm and underirrigation.Figure 3 Computed tomography, transverse sections of anterior maxilla.After the pacient signed the whritten informed consent formtreatment has began. Treatment included two implant placements,one in the region of element 12, and the other in the 22 region, bothFigure 5 Full-thickness mucoperiosteal flap exposing alveolar bone.Citation: Schmitz EM, Zanettini CEG, Zanettini LMS, et al. Horizontal alveolar ridge expansion in anterior atrophic maxila using rotatory instruments (boneexpander ): a case report. J Dent Health Oral Disord Ther. 2019;10(6):317‒322. DOI: 10.15406/jdhodt.2019.10.00505
Horizontal alveolar ridge expansion in anterior atrophic maxila using rotatory instruments (boneexpander ): a case reportCopyright: 2019 Schmitz et al.319hours for 3 days, Chlorhexidine digluconate 0.12% every 12 hoursfor 7 days. The patient returned within 7 days for reassessment andsuture removal (Figures 17&18). Clinically presented asymptomaticand with good healing pattern.Figure 6 Alignment pin showing future implant position.Figure 8 Implant placement.Figure 7 Horizontal alveolar expansion using bone expander.After the sites were prepared, two BLT Ø3.3 mm X 10mm(Straumann Basel, Switzerland) implants were placed, the implantwhich was replacing the region of element 12 reached a torque valueof 30N, while the implant who took place of 22 element achieved atorque of 35N (Figure 8). Implants positions were verified by placingthe guide (Figure 9). Afterward, healing abutments 3.3 mm x 2mm(Straumann Basel, Switzerland) were placed (Figure 10). Observingthe buccal side, the alveolar bone showed to be really thin, allowing usto see the implant by translucence, but no fenestration has occurred.GBR was performed, the bone was prepared with smallperforation using 1.3mm diameter spherical burr (Straumann Basel,Switzerland) in order to provide blood nutrition from the bone to thexenogen bone graft Cerabone (Straumann Basel, Switzerland)(Figure 11), the graft was covered with a colagen resorbable membrane15mm x 12mm Jason (Straumann Basel, Switzerland) that hasbeen cutted in two separeted pieces, so each piece of the membranecould cover each implant (Figure 12). The flap was repositioned andsutured with Mononylon 5.0 Ethilon (Ehicon , São Paulo, Brazil)(Figure 13&14). A provisory prosthesis was cemented because of theaesthetic demand of the region (Figure 15&16). Postoperative careinstructions were given to the patient, and following medications wereprescribed: Amoxicillin 875mg every 12 hours for 7 days, Ibuprofen600mg every 12 hours for 3 days, Acetaminophen 750mg every 6Figure 9 Verifying implants position using the guide as a reference.Figure10 Healing abutments.Citation: Schmitz EM, Zanettini CEG, Zanettini LMS, et al. Horizontal alveolar ridge expansion in anterior atrophic maxila using rotatory instruments (boneexpander ): a case report. J Dent Health Oral Disord Ther. 2019;10(6):317‒322. DOI: 10.15406/jdhodt.2019.10.00505
Horizontal alveolar ridge expansion in anterior atrophic maxila using rotatory instruments (boneexpander ): a case reportCopyright: 2019 Schmitz et al.320Figure 11 Particulate bone graft cerabone .Figure14 Suture.Figure 12 Bone graft covered with resorbable mambrane jason .Figure 15 Pos-operative with temporary prothesis cemented.Figure 16 Temporary prothesis.Figure 13 Suture.Citation: Schmitz EM, Zanettini CEG, Zanettini LMS, et al. Horizontal alveolar ridge expansion in anterior atrophic maxila using rotatory instruments (boneexpander ): a case report. J Dent Health Oral Disord Ther. 2019;10(6):317‒322. DOI: 10.15406/jdhodt.2019.10.00505
Horizontal alveolar ridge expansion in anterior atrophic maxila using rotatory instruments (boneexpander ): a case reportCopyright: 2019 Schmitz et al.321provided by a large amount of collagen in the trabecular bone. Bonedeformation is directly related to the stress applied to it by the drillin vertical movements and the pressurization of irrigation.5–10 In bothtechniques, it is possible to visualize increase the ridge width and thebone density.Figure 17 Healing pattern 7 days after the surgery.A histological analysis comparing bone remodeling of implantsplaced with the standard technique and implants placed after the useof osseodensification drills clockwise and counterclockwise promoteddifferent patterns. Counter-clockwise osseodensification showeda faster regeneration in which there was no bone resorption of thecervical third,5 an important characteristic for the maintenance ofgingival tissue. There are no studies showing histological analyses ofbone tissue prepared with Bone Expander, but with this study, we cansee that there is a significant increase in the ridge width and that therewas no implant fenestration, which would be common when using theconventional technique. Taking the hypothesis that Bone Expanderwould bring less bone resorption by preserving the integrity of thealveolar walls.The osteotome technique is performed using osteotomes(cylindrical instruments), sequentially increasing the diameters untilthe desired implant size is obtained.11 The use of osteotomes in lowdensity bone works with bone viscoelasticity, induces small fracturesof the bone trabecular bone then compressing them.12 This techniqueshows better results in the vertical increase of the ridge, and someauthors disagree on the ability of osteotomes to increase primarystability and accelerate the healing process.11–13Figure 18 Healing pattern 7 days after the surgery.DiscussionDue to the physical characteristics of the reamers kit, use andresults obtained with Bone Expander , the technique developedwhen using these instruments is similar to osseodensification. Thistechnique allows you to expand ridge volume and increase bonedensity in contact with the implant without removing bone.8 Whilethe conventional technique uses drills to excavate and remove bonefor later implant placement, osseodensification drills increase bonedensity by compacting the bone in the socket walls, which could becompared to an autogenous graft. They increase bone density at thebone-implant interface and primary stability.9 Features, again, verysimilar to thos