The Internotionai Journal cf Periodontics a Restorative Dentistry

2Ó9

Bone Regeneration in the

Edentulous Ridge Expansion
Tectinique: Histologie and
Uitrastructural Study of 20
Ciinical Cases

Agostino Scipioni. MD. DDS' An adequate voiume of heol-

Giovanni B. Bruschi. MD, DDS' fhy Pone tissue at reoipienf sifes
Gaetanc Caiesini. MD, DDS' is o fundomentol prerequisite
Ernesto Bruschi, DDS'
for a fovoroPle long-term prog-
Cesare De Martino, MD"
nosis of osseointegrated im-
plants,'-^ The edentulous ridge
expansion (ERE) technique was
The edentulous ridge expansion (FRE) technique is a partiai-thici<ness fiap
deveioped in 198Ó and first
procedure for impiant surgery that was developed in 1986. The ERE tech-
reported on 2 years later.^ The
nique permits the use of osseointegrated impionts at sites whase minimai
ERE technique is used to re-
orofdciai dimensions are insufficient tor traditionai impiant surgery. The pre-
sent work is a histoiogic and ultrastructurai study at hard tissue repair
establish adequate orofaoial
modaiitjes ot edentulous sites that were treated with the ERE technique in dimensions of defecfive oiveo-
20 humans. Biopsies were obtained frpm the tissue regenerating within the lar ridges during implant inser-
surgically created bpne gap between the mobile buccal and nonmobiie tion. The bone regenerotion
iinguai or paiafal bone-periosteum plates ("bane flaps") on days 40. 90. induced by the ERE technique
i20, 150, and 480 (day 0 = day of Implant insertion). The results suggest that is not memProne-guided and
osteabiasts differentiate from preexisting mesenchymai ceiis iocated on does not involve the implan-
the ariginai fissure walis. with cansequenf deposifion pf new bone in the tation of osteoinduotive or os-
surgically creafed intrabpny defect, (int J Periodontics Restorative Dent teooonduotive materials.
1999,-19:269-277.) The ERE technique wos Ini-
tially used in young odults to
correct alveolar bone detects
that resulted trom trauma or
agenesis of one or more teeth."
In such patients the buccal por-
tion ol the edentulous ridge
'Privóte Prootioe, Rome, Italy is generaliy deformed by
"Heod. Department ot Ceii Pothoiogy and Flectron Microscopy odvanoed Pone loss. The orofo-
Dermatologie o i institute St Mono and St Gollicono, Rome, Itoiy.
cial dimensions of the orest in
Reprint requests: Di Agostino Scipioni, Vio di Porta Pinciano 4, such areas are, therefore,
00187 Rome, Itoly, e-mail: bsc@exhibit,it trequently not sufücient to allow

Volume 19, Number 3,1999

270
the insertion of denfoi implants.
The ERE fechnique was subse-
quenfly used in patienfs who
had muifipie foofh loss and
associated bone atrophy.^
Several fypes ef esseoinfe-
grafed implanfs have been
used for fhe ERE fechnique.
Bofh press-fif (Tübingen [Fria-
teo), IMZ (Friatec}, and Frioiit-2
sfepped cyiinder [Friafec)) ond
screw-fit (Brânemark System
(Nobei Biecare) and Friaiif-2
sfepped screw) implanfs have
been used successfully, in oddi-
fien, fhe ERE fechnique has aiso
been used successfuiiy for sin-
gie-phase implants (Tübingen).
Impianf selecfion fcr fhe ERE
technique, therefore, should
be guided primarily by fhe
morphoicgic demands of fhe
edenfuious area te be treoted.
The Ei?E feohnique permits
the insertion of implants with
ideoi dimensions—cicseiy ap-
proximating these ot the dentai
roots they are repiocing—in
sifes that are normaily consid-
ered fo be inapprepriafe for
impiant fherapy
Expérimentai resuifs from a
beagle dog modei confirmed
fhaf bone regenerafion occurs
wifhin fhe infrobony fissure fhaf
is creafed in fhe ERE technique
and that esseointegration oc-
curred to the same degree in
the regenerated area as in cen-
troi sites where traditienai im-
plant surgery was appiied.*
iVloreever, the ERE technique is
highiy reliabie. Frem 198Ó te
1993 a tetai cf 1,078 impianfs
The Internofionai Journal of Periodonfics & Restorafive Dentisfry
were inserfed wifh fhis tech-
nique; the success rate, col-
culafed on the basis of the
parameters suggested by Ai-
brektsson et ai.^ was 97%.
The aim of fhe presenf werk
was te desoribe fhe hisfoiogic
events that lead to fhe oom-
piefe bene fili ever time of fhe
space wifhin the infrabony fis-
sure created by the ERE tech-
nique between the mobile fa-
ciai and nonmobile iinguai or
paiatai bene-periosteum plates
of the expanded aiveoiar ridge.
The study was carried out in 20
humans.
Methiod and materials
A tetai of 20 patients who re-
ceived befween 2 and 4 im-
pianfs in a single ERE surgery
were randomiy seiecfed fcr
biopsy. All 20 patients were
informed abeuf the nature ef
the sfudy and granfed fheir
censent. The bicpsy procedure
did not oause any additienai
discomfcrt to the patienfs.
The basic steps of the ERE
technique are:
1. A partiai-fhickness flap is eie-
vated fo expose the impiant
site.
2. A # 64 Beaver biade (Becton
Dickinson Acute Care) is
used fe creafe a verticai
infrabony fissure extending
frem fhe margin ef fhe resid-
uai alveelar crest tcwerd the
basai bone.
3. The buccai bcne-peries-
feum piate is mobilized and
displaced focialiy. The dis-
piacemenf, which is observ-
ed at marginal level, corre-
sponds fe a small hinge-like
rofation of fhe buccai piafe
at basai bone ievei. The size
ef the resuifing infrabony fis-
sure is befween 4 ond 8 mm
at the marginai level. Larger
dispiacemenfs can be ob-
toined at sites where a
higher propcrticn ef cancel-
ieus bene granfs elasficity to
fhe displaced bcne-perics-
feum pidte.
4. Appropriateiy sized impiants
are inserfed and sfabiiized
within the surgically created
fissure. The displaced "bone
ficp" hcs strong elasticity
and thus cioses back on the
impianfs.
5. The flaps are sutured.
Every patienf was recaiied
only once fer biopsy. A smail
frephine (exfernai diameter 1.8
mm, internal diamefer 1.3 mm)
was fobricafed by serrating a
needie for epidural anesthesia:
it was used te harvest a sampie
ot the hard tissue that fiiied fhe
originai space between the 2
separated bone-pericsteum
plates. The biopsies were col-
lected after intervals ot 40. 90,
120, 150, and 480 days (day 0 =
doy cf impiant inserfion).The laf-
esf biopsies ccrresponded to
3óO days of impianf ioading. In
every patient, the approximate
minimum and maximum width
 271

of the marginal bone gap that

existed immediately after
implant insertion wos measured
m 1 Summary of biopsies tai<en
Interval between Bone gap at
with a periadontai probe and Patient/ Age Smoker implant insertion Site of margina level (mm]
recorded (Tabie 1). gender (y) (Y/N) and biopsy (days) biopsy' Min Max
The rod-shaped specimens 1/M 41 N 40 25(13) 4.5 6.0
of mineralized tissue were 2/M 58 Y 40 25(14] 5.5 6.5
3/F 35 Y 40 35(19] 4.5 S.O
ropidly fixed in a picric acid-
4/M 45 Y 90 15(4] 4.5 6.0
poratormaidehyde solution^ 5/F 42 Y 90 24(12] 4.0 5.0
with 2% glutaraldehyde. The 6/M 42 N 90 25(13] 4.5 4.5
undecaioified tissues were moin- 7/F 5Ö N 90 36(19] 4.0 4.0

tained in blocks in the same fixo- 8/F 38 N 120 15(4] 4.0 5.0
9/F 53 Y 120 16(3] 5.S 5,0
tive. Subsequently the blocks 10/M 44 N 120 21 (9] 4.5 4.5
were postfixed in unbuffered 11/F 41 N 120 2S(13) 5,5 5,5
OsOj ond embedded in Epon 12/F 42 Y 120 25(13) 5.5 6.5

812 (Serva Feinbiochemica). 13/M 37 Y 120 46 (30) 4.5 5.5

14/F 45 Y 150 15(4) 4.0 S.O
Plastic sections 1 [jm thick were 15/F 48 N 150 15(4) 4.0 6.0
cut trom the undecaicified 16/IVl 47 N 150 2S(13) 4.0 6.0
bloci<s. sfained with 1% toiuidine 17/F 42 Y 150 26(14) 4.0 4.0

blue, and abserved with a iight 18/IVl 56 Y 150 36(19) 5.5 6.5
19/M S3 N 480 2S(13) 4.5 6.0
microscope. Additional, thinner 20/F 55 Y 480 46 (30) 5.5 6.0
sections 130 to 150 nm thici<
"Fédáralion Dentaire Internatiünaie tooth numbering system (Universal System number; in paren-
were stoined with uronil ocetate
theses).
ond leod citrate and studied
with the H7000 Eiectron Micro-
scope (Hitachi).

Results
Figure 1 shows 3 titonium im-
pionts piaced within an ex-
panded aiveolar ridge that was
prepared according to the pro-
tocoi of fhe ERE technique.
Figures 2 and 3 illusfrate the pro-
cedure that was used to collect
the somples of hard fissue that
formed within the surgicaiiy cre-
oted bone defecf.
The surgically created intra-
bony fssure was initiaiiy fiiied by
a coagulum. and ciinicaiiy one
could observe that its repair
resuited in the formation of new
hord tissue wifh an ompie gain
in buccoi ridge volume. Examin-
ation of fhe 40-day biopsies
with the light microscope
demonstrated the presence of
highly ceiiuiar and actively pro-
iiferating young bone (Fig 4). A
iayer of osteoid covered the
frabeculae. The osteoid iayer
was often in ciose contact with
osteoblasfs, tibroblasfs (proba-
biy precursors of osteobiosts),
and interstitioi fissue containing
several blood vessels (Fig 4).
Scattered erythrocyfes of the
primitive biood clot were found
in the interstitioi tissue. There
were also fragments of matute
bone frabeculoe in the superfi-
cial region (Fig 5). iHowever,
these were probably microfrao-
ture frogments resulting from
the surgicai procedure or por-
tions of mature bone that were
pici<ed up by the trephine on
the peripheral waiis of the intra-
bony tissure. Numerous flat-
tened fibroblasts and parallel
bands ot connective tissue
fibers were visible between the
young and the mature bone.

Voiume 19, Number 3,1999

272
Fig 1 Implant site is exposed with a
superimposed partiai-thickness flap
Three identicai iMZ impianfs (diameter 4
mm, iength I5mm)areplqcedwitiiin
the bone fissure. Note the surgicaiiy cre-
afed crestai bone gap, with a minimum
width at 4 mm, as weli as the mesiai and
distai bone-releasing incisians.
Fig 4 i\ :.' .'I 'I •' .• .'• •^,(.•1 j ; •,' I il h 'U'i .1 lew bone
numerous osieobiasf-containing iacuhae. The interstitial tissue
contains numerous fattened celis (fibroblasfs) dnd btood ves-
sels. Some flattened ceils are embedded in ond/or are in
clase relationship with the peripheral osleoid. (Originai magni-
fication y. 400: toluidine blue stain.)
The Internotionol Journal of Periodontics & Restorative Dentistry
Fig 2 After exposure of the tissues dur- Fig 3 Hollow created by the trephine.
ing stage 2 surgery, smaii trephine Comparison with Figs I and 2 shows
(exterhai diameter 1.3 mm, internai thot the biopfic sampie has been gath-
diameter 1,3 mm) is used to seiectiveiy ered setecfiveiy, wifhih the boundaries
gather a biaptic sampie of the newly of fhe original intrabony fissure that was
farmed hard tissue. fiiled ohiy by a caaguium during stage
I surgery.
trabeculae with Fig 5 ivliciophotogrnph ol thr -.ir^pp i^ortirn o' o 4n-iiny
undecaiclfied preparation shaws connective tissue with tiat-
tened fibroblasts oriented in parailei iines and portions of fhe
preexisting iaterat bone walis fhat were picked up by the
trephine on the margin of the originat intrabony fissure.
(Originai magniñcofion x 200; foiuidine biue sfain.)
 273

fig 6 Transmission electron micrograph fig 7 Transmission electron micro-

of osteoid tissue shows an osfeoblast-like graph shows progressive mineralization
ceii and smaii bodies of crysfai (arrow- af the osteoid matrix. An osteocyte can
heads). (Originai magnification y. 4,0a0.) be seen on the right. (Originai magnifi-
cation X 3.500.)

fig 8 (right) Transmission eiecfron

micrograph demonstrates 2 types of
ossificatian. A portion of a deveioping
trabecuia contains minerai deposifs in
ciose reldtionship with large caildgen
fibers (boffom). while smail hydroxyap-
afife crystals lie free in the matrix (tap).
A dark iine. probabiy a result of mineral
condensation, separates the deveiop-
ing trabecuia from the matrix. (Original
magnification x 20.000.)

Electron microgrophs made
ot on eariy stage of ossificofion
showed thaf the intercellular
motrix contoined coliogen fi-
bers thot were mostly of smoli
diameter; the fibers were either
isoiated or o g g r e g o t e d in
bonds, with mony smoll de-
posifs of oaioium soit. Mossive
mineralization of matrix ond
collogen fibers wos present
within the frabecuioe, whiie on
occumuiotion of scattered
hydroxyapatite crystals oo-
ourred in the osteoid seoms.
These 2 ditterenf ossification
layers were separoted by o
dark front fhot wos probobiy o
result of highiy compoct mi-
neraiization. in the 40-day biop-
sies the new bone, oontoining
osteocyfes wifhin iocunoe. wos
surrounded by an osteoid ioyer
with osteoblosts ond by o
matrix in vorious stages of min-
eraiizotion (Figs ó to 8).
The successive biopsies of
doys 90 and 120 showed motu-
rotion of the regeneroted bone;
there wos a progressive increase
of the coicified mafrix, in which
numerous osteocytes were
iocoiized (Figs 9 ond 10). A dis-
continuous Ioyer ot osteobiosts
wos presenf ot the periphery of
new bone frobecuioe.
in fhe 150-doy specimens
fhe primory frabecuioe of
woven bone hod been reploo-
ed by more moture conceilous
bone, Celi-rich bony trobecuioe
were surrounded by o thin ioyer
of osteoid tissue thot wos cov-
ered by eiongoted celis, which
were probobiy osfeobiosf pre-
cursors. The fine sfrucfure of the
periphery ot a bone trobeouia
is iilusfrated in Fig 11.
Atter 480 doys the trobecu-
iae hod the chorocteristics of
moture bone, with osteobiasts.

Volume 19. Number 3.1W9

274
Fig 9 Transmission eieciron mcrograptt äiow-, slago of Im-
becular mineraiizaiion subsequent fo fig 8. Three osteocytes
are localized in iarge iacunae. Note that one of the osteo-
cytes projects a ciiium toward the mineraiized matrix (arrow-
head). fOfigina/magn/Rcaton X 2.500.)
Fig 11 Transmission eiectron micrograph of newiy formed
bone collected i50 days after the edentulous ridge expan-
sion shows the periphery of a caidfied trabecuia. A weil-
deveioped osteobiast. right projects numerous micravilii
(orrowheads) toward and within the mineraiized tissue: this
asteoblast is probaÈ:)iy iocated in the asteoid. Left, a typicai
asteocyte in a iacuna Note that the caicified tissue is highly
mineralized and compact. (Originoi magnification x 2.500.)
The internatianol Journoi ot pgnodontics & Restorative Dentistry
FgiO i f i j t « . J If
tion of the motrix 150 days after the edentulous ridge expan-
sion technigue.Visibie Ofe:{l) isiets of mature bone surround-
ed by different layers of progressively less mature tissues that
are continuous with one another, and (2) newiy formed bone
rich in osteocyfe iocunae. osteoid. and a iayer of flattened
ceiis (fibrobiasts). (Originoi magnification x JDD, toiuidine blue
stain.)
Fig 12 Microphofograph of a specimen collected on the
bone eres' that deveioped in the intrabony fissure of the eden-
tulous ridge expansion befween 2 neighboring impiants 480
days after the edentuious ridge expansion (360 days from
impiant ioading) shows fully mature hard and soft tissues. Left
to right: connective tissue, the 2 celiuior layers of the perios-
teum, and Iameiiar bone (b) thai contains rare asteocytic
iacunae. The arrowheods indicate some afthe numerous
canallcuii carrying osteocytic ceii processes. (Original magnifi-
cation X 400: taluidine blue stain.)
 275

Fig 13 Microphotograph of a mafure Haversian canal found
in a deeper segment of fhe specimen shown in Fig 12 con-
fains a biood vessei (v) and fiaftened, peripheraiiy iocafed
osteoblasfs (arrowfieod). The arrow depicfs a ceil of the
endosfeai iayer (Originai mognlUcotion x 400: foiuidine biue
stain )
Fig 14 Transmission eleofron micrograph shows a portion of
fhe Hoversion canal of Fig 13 in a successive (thin) secfion
with endofheiial ceiis and on osfeocyte fhot projects o ceii
process toward fhe lumen. (Originai magnification x 2.500.)

csteocyfes wifhin lacunae, and

i-iaversian canals wifh pariefai
elongated asfeabiasts (Figs 12
fo 14). In the lacunae ef the tra-
beculae the osteocytes ap-
peared in differenf morphcicgic
sfages: healthy cells, cells show-
ing regressive iesicns, and com-
pletely degenerated cells.
Table 2 summarizes fhe
changes in primary oell fypes
fhaf were observed ever fime.
Ne differenoes in the healing
process were noticed between
smokers and nonsmekers. ner
between males and femaies.
Changes in primary cell types over time
Day Primary ceil type and location
40 Osteoblasts and fibroblasfs in ciose contact with the osteoid
iayerof the young trabecular bone
Scattered erythrocytes within blood vessels and flattened fibro-
blasts (probably precursors of osteobiasts] among paraiiel
bands of connective tissue fibers in the interstitial tissue
90-120 Numerous osteocytes within tiie progressively increasing
calcified matrix
Osteoblasts at the periphery of the new trabecuiae
150 Elongated cells representing O5teoblasts line fhe thin osteoid
layer of osteocyte-rich bone trabeculae
480 Osteocytes in different morphologic stages in the lacunae of
mature bone trabeculae
Parietal elongated osteobiasts within i-iaversian canals

Voiume 19. Number 3,1999

 276
Discussion
The resuits indicóte that the sur-
gicol distraction of the alveoiar
crest tor the creation ot an im-
piant housing within 2 walls of
spongiosa promotes bone for-
mation ond ossecintegration of
the implont(s) within a period
thot does not exceed 4 months.
it is i<nown that strong iocal
metabolic activity follows any
mechanical trauma to bone,
such as o frocture. In ERE the
new bone is conceivably syn-
thesized by osteocytes and
osteobiosts that differentiate
from preexisting cells located
along the walis of the original
surgicaiiy produced alveoiar fis-
sure. The osteoblost precursor
ceiis situated in fhe periosteai,
endosteal, and bone marrow tis-
sues are probobiy octivated.
The 2 basic prerequisites tor
bone regeneration are: (1) a
solid nutritionai base provided
by a minimum 1- to 1.5-mm
thici<ness of the bone fiaps;
and (2) on ampie periosteai
blood supply ieoding to fhe
neoangiogenesis' necessory
for the newiy formed bone tro-
beculae. The periosteum oon-
tains many capillaries, arteri-
ales, and venuies trom which
newiy formed vessels are
spread to the new bone tra-
becuiae ond iHoversion canals.
Bone formation within the intra-
bony fissure of the ERE tech-
nique is demonstrated by: (J)
the presence of woven bone
and numerous osteocytes; (2) 2
Tine International Journal of Periodonlics & Restorative Denlisiry
modes of calcification; (3) dif-
ferent stages of osteocyte
deveiopmenf; and (4) progres-
sive bone maturation.
The present results showed
teatures of intramembronous
ossification and the formation
of a spongiosa of woven bone.
Concurrentiy, an occumuiation
of scatfered hydroxyapotite
crysfais occurred in the coila-
gen matrix of the osfeoid.
These 2 different modes of
bone formafion were observed
in adjocent tissue loyers that
were separated by an eiec-
tron-dense mineraiization fronf.
This front was previously de-
scribed by Sennerby'° who in-
terpreted if as a iamina limi-
fqns-iike sfruoture.
The funcfionai ioading thof
follows the integrafion period
probabiy has an important roie
in the mofurotion of the regen-
erated bone. Considering the
bone ciassificafion suggesfed
by Lekhoim and Zarb," the
structures of the earlier biopsies
were consistent with bone of
Types 3 ond 4, whiie the speci-
mens coiiected after 1 year
(360 doys) ot functional iooding
contained lameiiar bone with
osteons and a reiativeiy sparse
osteocyte population.

Acknowledgments
The authors wish to ooknowledge the
editoridi assisfonce of Dr Dovid R,
Leidner in the various stages of prepdro-
tion of the manuscript. They also extend
their thani<s to Sergio Di Pizio for his con-
tribution in the preparotion af the light
and eiectron microscope sections.
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Voiume 19, Number 3,1999