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The Internationol Journol of Pericdontics S Resfcrofive Dentistry

451

The Edentuious Ridge Expansion


Technique: A Five-Year Study

Agosiino Sclpioni MD, DDS' Orofaoial widfh of bone thof is


Giovanni B. Bruschi, MD, DDS' too norrow to permit the totai
Gastano Calesini, MD, DDS' inciusion of an implant within
the bony housing is a common
problem in fhe placement of
dental implanfs. This is espe-
oiaiiy limifing in the maxillary
arch when postexfracfion col-
This study presents the clinical results of a surgical technique that expands lapse of the labial plate of
a rtarrow ridge when its orofacial width precludes the piacement of dentai bone necessifafes a palafaliy
implants, in 170 people, 329 implants were piaced in sites needing ridge displaced impiant. This gener-
enlargement using the edentulous ridge expansion procedure. This tech- oliy creates functional difficul-
nique involves a partial-thickness tiap, orestal and vertical intraosseous ties related fo opposing teeth.
incisions into the ridge, and bucoat displacement af the buccal cortical
plate, including a porfían of the underlying spongiosa. impiants were Esthetics olso suffer if fhe
piaced in the expanded ridge ond atiowed to heal tor 4 to 5 months. edenfuious ridge apiooi fo fhe
Wheh indicated, the impiants were exposed during d second-stage emergence profile of the
surgery to allow visualization ot the impiant site. Ocolusal hading was crown is concave. This is of par-
applied during the foiiowing 3 to 5 months by pravisionol prostheses. The ticuiar imporfance in the maxii-
final phase was the placement of the permanent prostheses. The results iary anterior region, Aiso. if fhe
yielded o success rate of 98.8%. (int J Peridont Rest Dent 1994;14:451-459) facioi porfion of a crown over-
laps fhe ridge in an attempt to
maintain proper alignment with
the adjacent teeth, then the'
patient's oral hygiene may be
severeiy compromised.
All of the above considera-
tions led to the deveiopment ot
a technique that, in effecf,
expands the edentulous ridge
* PI vate Practice. Rome, Italy.
buccally in a highiy pre-
tepint requests: Dr Agostino Scipioni, Via di Porto Pinciano 4. 00187 dicfable way. This study deais
Rome, italy.

Voiume 14. Numbers, 1994


452

F/g la A crestql ihoision i$ mode. Fig Ib Partiai-thickness buccal and tinguai flaps ate raised.
followed by fwo verileo! incisions defining the ¡urgicai area.

with situations in whioh the with an antibiotic (Ciproxin, grooves were formed by the
ridge is so narrow that implant Bayer), l g per day, and an penetration of the buccal oor-
placement using the traditionai anti-inflammatory agent ticai piate of the bone. The
technique is impossible. The (Naprosyn, Recordati), 1,5 g crestol incision was continued
present investigation wos per day. Two types of implants into the bone (Fig le) so thot
undertaken to assess the effec- were included in this study: an intraosseous groove was
tiveness of the technique AI2O3 impiants (Tübingen and formed with a #64 Beaver
called edentulous ridge expan- Monaco versions,Friatec) and blade. This groove was contin-
sion (ERE) for impiant place- iMZ impiants (Friateo). ued apicaiiy (Figs If and lg)
ment. Using the ERE technique, a and, when sufficient depth was
polotal incision in crestai direc- reoched, the buccai plate was
tion was mode, and portiai- slowiy dislocated in a taoial
Method and materials thickness buccal and linguai direction (Figs Ih and li). Care
fiaps were raised (Figs l a and must be taken to maintain a
In 170 individuáis, 329 implants lb), followed, when necessary, zone of spongiosa beneath the
were piaced in aiveoiar ridges by two verficoi reieasing inci- cortical piate so that there is a
that were tao narrow orofa- sions defining the surgical area. minimum overail thiokness ot
cialiy to permit traditionai After the fiaps were reflected, approximateiy 1.5 mm.' The
implant instailation. The ERE two transperiosteal incisicns biood supply on the facial
technique wos used in all cases. were made into the bone par- aspect of the displaced buc-
Ail patients were premed- aliel to the releasing incisions cal plate must aisa be main-
icated 1 hour before surgery (Figs l c ond Id); two vertioai tained by safeguarding the

The Infernationol Journol of Periodoniics & Restorotlve Dentistry


453

Figs le and Id Two transperiosfeat incisions are made in rhe bone poraiiel to the releas.

Fig Ie (right) The orestot incision is oontinued info the bane

Figs If and Ig The groove is continued apioolly.

Volume 14, Number 5, 1994


454

figs í/) and li The buocal piate is slowiy dislocated m a facial direction.

integrity of the periosteum that is the more significant fac-


(Odrich RB, personal communi- tor in this study. Implants were
cation, 1992).2-' included in the study from the
Implants were ploced doy of insertion ond were con-
within the confines of the newly sidered successful offer 5
created space (Figs Ij to 1 i) months of final prosthetic re-
and the fiaps were ciosed (Fig construction and acclusai
lm). Antibiotic and anti-infiam- ioading, it should be noted
matory medication was contin- that, prior to the final prosthetic
ued for a totai of 3 days. After insertion, e a c h impiont re-
4 to 5 months, the second ported here had been in place
phase of surgical exposure was at least 1 year before being
corried out in oil cases except included in this anaiysis.
those using the Tübingen im- The AijOj implonts ore most
plants, A provisianal partial suited for use in the maxiliary
denture was kept in place for 3 anterior region as single eie-
to 5 months, at which time the ments and were used accord-
final prosthesis was placed. ingly. The iMZ impiants were
The standard of success for used for the reconstruction of
impiant function as estabiished iarge edentulous surfaces. In
by Albrektsson et ai' was cho- all, 96 AI2O3 implants and 233
sen because it is the ultimate IMZ implants were inserted
fate of the "loaded" implant using the ERE technique.
rather than the ridge expansion

The Internationai Journal of Periodcntics & Restorative Dentistry


455

Fig Ik

Figs Ijto li impiants are piaced within the confines of the


newly created space.

Fig II

Fig Im The flaps are dosed.

Voiume 14, Number 5, 1994


45ó

Table 1 Success rate tor Tubingen implants Results


Year IMo. of implants No, o t patients No. of failures
Results of this study are shown
198Ó 9 8 0 in Tables 1 and 2. There was an
1987 13 12 2* 88,5% success rate for the
1988 11 8 0
1989 38 35 3" Tübingen implonts (see Tabie 1)
1990 25 22 1"* using the ERE technique. All
except nine implants were
Total 9Ó 85 6'"*
ploced in the region of the
'Fraclured implant ploced in 1987. maxillary incisors. The IMZ
"FraclureO ImpJanIs placed in 1987 and 1989.
"•'Fractured imolont placed inlQ89 implants yielded a 99,0% suc-
""Two lost implonts, four froclureö implonls.
cess rate (see Table 2). The
total success rate for both
types of implonts using the ERE
technique was 98,5%, discount-
ing the four fractured fixtures
(see Table 1),

Table 2 Success rate for IMZ implants Discussion


Year No, of implants No, of patients No, of failures
The ERE technique permits
1988 26 11 0 placement of implants in sites
1989 68 26 0 that otherwise do not provide
1990 139 48 2-
enough bone to permit
Total 233 85 2 osseointegration. By expanding
the buccai cortical plate, the
'Failsd implant placed in l
buccal concavity generally
encountered in postextraction
ridges is greatly reduced, thus
permitting implant placement,
proper emergence profiie, ond
effective oral hygiene.
An essentiai teature of the
ERE technique is the partioi-
thickness flap, in such proce-
dures, the blood suppiy must
be kept intact on the focioi
aspects of radiouiar bone to
ensure optimai healing and
preservotion of the very thin
bone thot covers root promi-
nences (Odrich RB, personol
communicofion, 1992). The

The international Journal ot Period o ntics & Restorative Dentistry


457

Fig 2a Edentuious ridge at oreo of Fig 2b Probe moihfoining displace- Fig 2c Two probes placed ih implont
teethBto W. which were lost 20 years ment of labial plate of bone whiie fur- sites.
previously in an automobile occident. ther ridge expansion is effected with
Note tack of dimension to arch form. elevator.

partiai-thickness fiap also aids sented a variety of surgicai Cne fracfure was due to a
in immobilization of the dis- solutions to the probiem of nor- motorcycle accident; the
placed buccal corticai plate. row alveolar ridges and implanf remoining three were attribuf-
When using fhe ERF tech- piacemenf, Sfreckbein ond abie to occiusal overioad.
nique, fhe integrity of the Woifge,"* and Koury'^ used The two toiled liVlZ implanfs
periosfeum must be main- bone graffs fo increase bone are sfiii in funcfion, but are con-
tained so thdt fenestratians, subport. Osborn,'* and Nenfwig sidered foilures because fhey
dehiscences, or necrosis of the and Kniha^' suggesied the use hove iosf subsfanfioi bony sup-
buccal piate are avoided dur- of hydroxyapafife. A recent port: one has losf cresfai bone
ing the placement and heaiing investigation by Nyman et aP^ for 10% to 15% of its iengfh, the
phase of osseointegrafed used guided tissue regenera- other for approximateiy 40% of
impiants. It is thus necessary to tion materiais and techniques ifs iength. it is interesting fo
maintain buccai cartical bone to attempt a soiution. note thaf fhese faiiing impianfs
and spongiosa at a minimum In this study, fhe fwo failures occurred in fhe same patient
thickness of nof iess than 1.5 of AI2O3 impionfs occurred in aged 43 years, who was heav-
mm. The rafes of revascuiariza- fhe same pafienf, an 18-year- iiy medicafed with anticoogu-
tion of cortioai bone (0.D05 mm ianf fherapy for pre-exisfing
oid woman who had losf aii
per day) and meduiiory bone cardiac pathosis.
four maxiiiary incisors in an
(0.500 mm per day) are aufomobiie accidenf. This was The heaiing period for
thereby assured.'°'^"'^ one of the firsf cases treafed impiants inserted with the ERE
In fhis sfudy, the ccnsistent wifh fhe ERE fechnique in 198Ó. technique appears to be the
fotai bone fiii achieved in each The faiiure was due to a fenes- same as for other impionts,
case was remarkable. It should fration of the palafdl bone sur- although it is recommended
be nofed fhat fhis was accom- face, probabiy fhe resuif of an that fhe provisional prcsthetic
plished wifhcuf the use of a erroneous evaiuation of fhe phase be extended for more
membrane and, thus, without bone fhickness. fhan fhe usuoi 2 months.
ifs inherent risk of postoperative Four of the foilures nofed in Figures 2o to 2j are represenfa-
five of a case using fhe ERE
infection. Over the years, other Tabie 1 were the resuif of
fechnique.
invesfigators'''"'^ have pre- impiant fraoture, as indicdfed.

Volume 14, Number 5, 1994


458

F/g 2tí (left) Radiograph of both


implants ot time at insertion.

Fig 20 (right) Hop closure with


subperlosteal sutures.

Fig 2f (right) Ridge at 5 months


postinsertion pecond stage)

Fig2g (left) fiealing abutments


in piace ot second stage. Note
total bone fiil and expansion ot
ridge Idbiolty.

Fig2h (lighf) Healing I month offer


second stage procedure Labldifldpis
positioned apically: nofe iabiat expan-
sion of ridge profile.

Fig 2i (left) Radiograph of impiants


i 1 months atfer ooclusol load with
porceiain crowns.

Fig2i (right) Aspecf of fhe aiveatar


crest reconstructed with its physiologic
curvature and with distinct radicular
prominences around the implonts after
11 months of occiusat laad.

The Internotional Jcurnal ct Periodontics & Restorative Dentistry


459

Conclusion References to. Pfeiffer JS. The reaction of ttie alve-


ciar bone to flap procedures in
man. Periodcntics 1965:3:135-140.
The 98.5% total success rate 1. Albrektsson T. Zarb G, Wcrthington P.
Eriksson AR. Ttie iong-tefm efficacy t l . Schulte W. Kleineikenscheidt H,
and the rapidity of total bone
of currentiy used dentai implant: A Schareyka R. tHeimke G. Konzept
fill are encouraging signs fhaf review and proposed criterio of suc- und Prüfung des Tübinger Sofcrt-
fhe ERF technique offers a cess, int J Oroi Maxiliofac impiants impiantates. Dfscti Zannärzfl Z
1966,i:ll-27.
patentiai solution to the prob- 1986;2:80-a5.
lem of piacing implants in nar- 2. Suliivan DY, Langer B. 12. Aibrektsscn T. Repair of bone grafts.
Ossecintegration: its impact on the Scand J Piast Reconstr Surg 1980;
row ridge sites.
interreiationship of periodontics and 14:1.
restorotive dentistry. Part I. int J 13. Rhineionder FW. The normai circulo-
Periodont Rest Dent 1989;9:S5-105, tion of bone and ifs response to sur-
Acknowledgments 3. Wrigtit WH. Healing of periodontoi gical intervention. J Biomed Mater
surgicoi wounds. In: Goidman Mi-i. Res t974:8:87.
Ihe authors wlst^ fa thank Dr Ronold 8. Catien WD (eds). Periodontoi 14. Streckbein RG. Woitge E.
Odrich for tils translation of ttie materiai Therapy, St Louis: tvlosby, 1968,29:
Augmentationspiasfik mit tiefge-
and Dr Jotianna Odrioti for her edito ri a i 857-941.
frorener homologer Spcngiosa ais
assistance. 4. Pfeiffer JS. The growfh of gingiuai tis- praimpiantogishe Mossnanme bein
sue ever d e n u d e d bone. J Peric- Einzelzahnersatz. Z Zohnörztliche
danfai 1903:34:10-10. Impiantoiogie 1987: 3'83-94,
5. Corn H, Pericsteai separotion — its 15. Koury F. Die modifizierte aiveclar-
ciinicai significance. J Periodcntoi exfensionpiastik. I Zohnärztiiche
1962;33:t40-152, impiantoiogie 1987; 3:17d-l 78.
6. Wliderman MN. Wentz Fivl. Orban BJ. 16. Osborn JF. Die aiveclar-extensions
Histogenesis of repair öfter mucogin- piastik. Quintessenz 1985:36:
glvai surgery. J Periodontoi 239-246.
1960:31:283-299. 17 Nentwig GH. Kniha H. Die
7. Staffiieno H. Levy S. Gargiulc A. Rekonstruktion iokaler Aiveolar-
Histologie study of ceiiuiar mobiiiza- fortsatzrezessionen im Fronzohn-
tlon a n d repair faliowing a bereich mit Kalziumphcsphatker-
periosteol via spiit ttiickness amik. Z Zahnärztliche impiantoiogie
m u c o g i n g i v a l f i a p surgery. J 1986;2'8O-85.
Periodontoi 1906:37:117-t31.
la. Nyman S. Long NP. Buser D.
8. Stoffileno H, Wentz FM, Orbon BJ. Bragger LJ. Bone regeneration adja-
i-iistoiogic study of hediing of spiit cent to titanium dental impiant
fhickness flap surgery in dogs. J using guided tissue regeneration: A
Periodontoi 1902:33:56-69. report af t w o cases. Int J Oral
Maxiilofac Implants 1990:5:9-14.
9. Wildermon MN. Repair atfer a
periosteol retention procedure, J 19. Bruschi GB. Scipicni A. Aiveoiar
Periadontol 1963; 34:487-^503. augmentation: New application tor
impianfs In' Heimke G (ed). Ossea-
Integrated Implonfs. vol 1. Boca
Raton. FL' CRC Press, 1990:2:35-61.
20. Longer B. Langer L. il lembo sovrap-
posto: tvlcdifica chirurgica per
I'inserimento d i impionti. Int J
Periodont Rest Dent 1990:10(3):
208-215.

Volume 14. Number 5, 199d

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