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Maxillary alveolar bone ridge width augmentation using the frame-shaped corticotomy expansion technique
G Model
JORMAS-744; No. of Pages 9 J Stomatol Oral Maxillofac Surg xxx (2019) xxx–xxx
Available online at
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Technical note
Maxillary alveolar bone ridge width augmentation using the frame-shaped corticotomy expansion technique J. Lalo a,*, H. Adouani b, S. Bouraoui b, N. Zaitri a, C. Teillaud a a
Department of Stomatology and Oral and Maxillofacial Surgery, Saint-Antoine Hospital, University of Paris 6, 184, rue du Faubourg Saint-Antoine 75012 Paris, France b Faculty of dental Medecine, University of Monastir, Monastir, Tunisia
A R T I C L E I N F O
A B S T R A C T
Article history: Received 14 May 2019 Accepted 10 September 2019
Maxillary alveolar ridge expansion performed by intercortical bone splitting is a seducing alternative surgical procedure for alveolar bone widening. The aim of this technique is to gain enough bone width to be able to place a dental implant simultaneously. This technique avoids a second surgical site for bone graft harvesting. However there are risks of surgical failure caused by unintended bone fracture during expansion and implant placement, or by insufficient bone widening for implant insertion. To limit these risks, we have published expansion techniques using various corticotomies. These corticotomies are achieved according to bone anatomy, most of them remote from implant position. Bone fractures are guided during the bone expansion and the implant placement, avoiding cortical bursting. Wider and safer bone movements can be achieved allowing to place the forecasted implant with adequate dimensions, axis, and cervical position on the bone ridge. Our technique increases the success rate of both the bone volume expansion and the dental implant placement, and improve the functional and aesthetic result of implant and prosthesis restoration. Four main types of bone expansion movement using corticotomies have been described: expansion with apical cortical hinge, cortical translation, bicortical osteotomy, and frame-shaped corticotomy. Our subject is the alveolar bone width augmentation with the frame- shaped corticotomy expansion technique, which allows to place an implant in a narrow and concave alveolar bone, with a straightened axis, without modifying its cervical position on the bone ridge arch. A series of 10 cases with a 1 to 5 year surgical follow-up is studied. Implants were all placed in the same stage and their supported prosthesis successfully made. Peculiarities and interest of this technique are discussed.
C 2019 Elsevier Masson SAS. All rights reserved.
Keywords: Dental implant Alveolar ridge augmentation Osteotomies
1. Introduction Inadequate sagittal maxillary alveolar bone dimensions are often pointed out during clinical and radiological assessment for prosthetic rehabilitation of edentulous ridge. This bone defect may be constitutional or due to alveolar bone remodeling after dental loss, dental agenesis, surgical sequels, bone infection, or preimplant spacing orthodontic treatment. In the maxilla, the bone width loss is caused by the collapse of the inter cortical space. This aveolar bone collapse is due to the weakness of the buccal cortical bone which structure is thinner and less resistant than the palatal cortical bone, and not supported by dental root.
* Corresponding author. E-mail address: [email protected] (J. Lalo ).
Transverse alveolar ridge expansion is defined as an immediate bone width augmentation performed by a bone splitting between the two cortical plates which are progressively separated and pushed back to their required or initial position. The main idea of the bone expansion is to achieve a reverse cortical movement, thus restoring the alveolar bone volume and anatomy. The first surgical splitting procedure was described by H. Tatum [1] in 1986, and performed with specially designed osteotomes. Shortly after, several surgical teams used this technique and published their cases or series [2–6]. The main aim was to gain enough intercortical bone width to place an implant in the same stage. However, during this procedure, and depending both on bone quality and operator’s skills, there are quite important risks of failure caused by cortical bursting, complete cortical coming apart, implant exposure during insertion, and insufficient bone widening. To make the result more reliable, we described expansion techniques [7,8] performing a bone width augmentation with
https://doi.org/10.1016/j.jormas.2019.09.001 C 2019 Elsevier Masson SAS. All rights reserved. 2468-7855/
Please cite this article in press as: Lalo J, et al. Maxillary alveolar bone ridge width augmentation using the frame-shaped corticotomy expansion technique. J Stomatol Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.jormas.2019.09.001
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various corticotomies, larger and more adapted to the anatomical bone situation. These corticotomies make possible the guiding of bone fractures away from the implant position during alveolar expansion. Wider and safer bone movements are achieved in order to place the forecasted implant. After a short overview of our four alveolar bone corticotomies, we will focus on frame-shaped cortical osteotomy. 2. Basic corticotomy expansion techniques for alveolar bone width augmentation Our four main techniques of expansion with corticotomies allow to widen the alveolar bone thickness sufficiently in order to place implants with adequate characteristics of dimension (length, diameter), axis (A), and cervical position (P) on the bone ridge [7,8] (Figs. 1–4): expansion with apical cortical hinge: allows an outer buccal (external) cortical bone movement (Fig. 1). Bone crest is widened externally. Cervical implant position is moved outwards (P), and implant axis is straightened (A);
expansion with cortical translation: performs an outer translation of the external (buccal) cortical bone (Fig. 2). It allows to insert in a second stage an implant with an outer crestal position (P) without modifying its axis (A); expansion with bi-cortical (internal and external) osteotomy (Fig. 3): achieves inner and outer bone ridge widening. Rare in the maxilla because of thickness and resistance of the palatal cortical bone, but more frequent in the anterior area of the mandibular bone (from right to left premolars). It allows implant placement without modifying its cervical ridge position and axis; expansion with frame-shaped corticotomy, which we shall now describe.
3. Alveolar bone expansion with frame-shaped corticotomy This expansion technique allows to widen a concave alveolar bone, and to restore its volume and structure (Fig. 4). It also makes possible the simultaneous placement of the implant with a straightened axis without modifying its cervical position on the bone ridge.
Fig. 1. Schemas of cortical bone expansion with apical cortical hinge, allowing a modification of implant cervical position (from P0 to P1) and axis (from A0 to A1).
Please cite this article in press as: Lalo J, et al. Maxillary alveolar bone ridge width augmentation using the frame-shaped corticotomy expansion technique. J Stomatol Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.jormas.2019.09.001
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Fig. 2. Schemas of alveolar bone expansion with external cortical translation. Modification of cervical implant position (from P0 to P1) but no change of its axis placement (A0 = A1).
3.1. Indications
3.3. Surgical technique
We use this technique in case of narrow alveolar bone width with significant vestibular cortical concavity. This clinical situation is mainly found in the anterior maxillary area and for single tooth restoration, in case of dental agenesis, and also after dental loss, apical root surgery, and pre-implant spacing orthodontic treatment.
We present a typical surgical procedure for a lateral incisor restoration (Fig. 5).
3.2. Preoperative investigation The intra-oral clinical examination evaluates the external alveolar bone and mucosa concavity. Radiological investigation with CT dentascan provides more information about alveolar bone anatomy: bone height and thickness, shape, axis, cortical and cancellous bone structure, and dental alignment curve position. It shows the bone width defect, the external cortical bone concavity, the excessive obliquity of the inter-cortical axis, and the satisfying thickness and position of the bone crest. Clinical and radiological study allows to decide where to shape the frame of the corticotomy and how to perform the bone expansion, in order to widen the intercortical space and to introduce simultaneously an implant with suitable dimension and axis.
3.4. Surgical equipment No specific instrumentation is needed except for a few corticotomy and expansion tools: straight and curved osteotomes with double beveled blade (2 to 4 mm width) and scaled conical and cylindrical osteotomes (2 to 4 mm in diameter). Osteosynthesis kit with screws from 1.2 to 1.8 mm in diameter and bone harvesting instrumentation must be available in case of failure. Homologous or heterologous powder bank bone and resorbable-collagen membrane might become necessary if an additionnal bone graft is decided. 3.5. Surgical procedure This surgery is performed under local anesthesia, sedation or general anesthesia, according to the planned procedure and the patient’s choice. A short medication with antibiotics, such as amoxicillin or clindamycin, is combined with mild analgesic and corticosteroid.
Please cite this article in press as: Lalo J, et al. Maxillary alveolar bone ridge width augmentation using the frame-shaped corticotomy expansion technique. J Stomatol Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.jormas.2019.09.001
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Fig. 3. Schemas of bi-cortical bone expansion without noticeable modification of the axis (A0 = A1) and cervical position (P0 = P1). a–b: maxillary alveolar expansion; c: mandibular alveolar expansion with immediate implant placement.
The frame-shaped corticotomy expansion technique begins with mucosal incisions (crestal, sulcular, and remote vestibular incisions), subperiosteal stripping, and exposure of the surgical area up to the adjacent dental root bone bulges. The palatal cortical bone is exposed on a few millimeters to visualize the bone axis and ultimately to place the covering membrane. The corticotomy cutlines around the bone concavity to be expanded are marked with a dermographic pencil. The bone surgery begins with the two vertical corticotomies, performed by gently tapping with a mallet on the flat osteotomes up to the cancellous bone. This stage allows to assess the resistance of the cortical bone layer and its thickness (between 0.5 and 2 mm). Then the two horizontal corticotomies are achieved: the lower corticotomy at the lower part of the concavity, a few millimeters above the crestal bone, and the superior corticotomy at the upper part of the concavity where the cortical bone is thicker which may require the use of a thin bur or a circular saw (radius 3 mm). Next step is the bone splitting, between palatal and vestibular (buccal) cortical bone: drilling in the alveolar bone crest at the planned implant position, with pilot drill and drills 2 to 3 mm in diameter, up to the lower horizontal corticotomy; inter-cortical splitting with a 3 mm straight osteotome which is introduced through the drilled crestal bone hole, into the cancellous bone, and beneath the concave cortical plate to free it from its cancellous bone ties; achieving bone expansion and well sized implant bed, gradually, using alternately osteotomes (conical and cylindrical) and drills. Conical osteotomes perform a gradual expansion of the concave cortical plate which is released from its depth and compact the cancellous bone into the intercortical space improving thereby the implant stability. Drills create a concave shape on the inner side of the cortical plate thus preventing it from excessive outer moving during the implant placement. During this step the bone flap progressively lifts out, and a counter-pressure with an instrument or with the finger may be applied to stabilize it in the meantime.
The expansion movement is carried on until sufficient alveolar bone width is obtained to place an implant with suitable diameter and axis. The depth of the implant hole, and therefore the length of the implant, should ideally reach above the upper horizontal osteotomy. The stability of the implant is then strongly ensured by its intraosseous apical and cervical parts, screwed above and below the cortical bone expansion area. A counter pressure is also useful to stabilize the bone flap during the implant insertion. Implants with sharp threads are avoided in order not to weaken or perforate the cortical flap. After expansion, two additional steps help to improve the bone volume and shape aesthetic result: leveling of an osseous surplus, and grafting both the bone concavity and the corticotomy cutlines. For bone grafting, we use homologous tissue bank bone mixed with the patient’s blood sample. We generally cover the bone splitting with a resorbable collagen membrane, which protects and maintains the bone flap and the additional graft during the wound healing process. No osteosynthesis device is needed. An intraperiosteal incision allows to slip down the mucosal flap and to suture easily. Sutures are made with silk wire stitches, which are more flexible and reduce inflammation. Intraoral hygiene care and feeding advices are given to the patient. During the first postoperative month, anything that could injure the operated area or press on it should be avoided, in order to limit the risk of bone resorption and implant exposure. Wearing a removable partial denture is not recommended during the first two weeks, and resine excavation is often provided. A clinical control is scheduled 10 to 15 days after surgery to check the healing process and to remove the nonabsorbable sutures, healing cap placement is planned 4 to 6 months after. 4. Clinical cases and results We have studied our last 10 patients, with a minimum followup of 1 year after implant placement (interval of 1 to 5 years). The mean age was 32 years (range 19–55 years), 14 frame-shaped corticotomies (single site for 6 patients, double site for 4 patients)
Please cite this article in press as: Lalo J, et al. Maxillary alveolar bone ridge width augmentation using the frame-shaped corticotomy expansion technique. J Stomatol Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.jormas.2019.09.001
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Fig. 4. Schemas of alveolar bone expansion with frame-shaped corticotomy. Restoration of bone volume and structure. Modification of the axis (from A0 to A1), thus preserving the cervical ridge postion of the implant (PO = P1).
were performed, and 14 implants placed immediately (100%) allowing the restoration of 9 lateral incisors (64%), 4 central incisors (29%) and 1 canine (7%) (Figs. 6–8). This technique makes possible in each case instantaneous implant insertion with adequate dimensions, superior to 3,5 mm in diameter and from 12 to 16 mm length, with a straightened suitable axis. Aesthetic shape of gingival mucosa has been improved by bone volume augmentation. No failure of the implant and its supportedprosthetis, has been reported during the follow-up. 5. Discussion The maxillary alveolar ridge expansion procedure helps to widen the alveolar bone, without the need for a second surgical bone harvesting site, in order to place dental implants simultaneously [1–6]. The expansion technique is based both on the osseous plasticity and on the postoperative healing of the created bone expansion fractures [2].
Its reliability has been demonstrated by clinical series [4,6,9– 12], some of which had over 8 years follow-up [9,12]. The success rate was 88 to 98%, after ‘‘immediate inserted implants’’ [6,9– 12]. Authors recommend this technique for maxillary crest width ranging from 1.5 to 3 mm [3,11,13–15], with enough cancellous bone between buccal and palatal cortical plates. The alveolar ridge widening, which may reach 4 to 5.5 mm [10,11], allows adequate implant placement with lasting prosthetic restoration. The improvement of the volume and shape of the alveolar bone, overlaid by the attached and free mucosa, contributes to a better aesthetic prosthetic result. Alveolar expansion is an alternative procedure to bone widening apposition techniques, such as guided bone regeneration (GBR) [5,15] and osteo-synthesized bone graft (OSBG). But these techniques may require a second surgical stage for implant placement 4 to 6 months later, to make sure bone graft healing is achieved or to wait for osteosynthesis screw removal. Bone harvesting also implies more morbidity, and two stage surgical procedure induces an additional cost [16]. Furthermore, alveolar expansion allows anatomical bone reconstruction, producing a
Please cite this article in press as: Lalo J, et al. Maxillary alveolar bone ridge width augmentation using the frame-shaped corticotomy expansion technique. J Stomatol Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.jormas.2019.09.001
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Fig. 5. Frame-shaped coticotomy expansion technique. Clinical case: a 47-year-old patient with a missing maxillary lateral incisor (12); a-b-c: X-ray investigations: a: panoramic dental; b: CT dentascan with horizontal sections showing the dental alignment curves; c: sagittal sections showing excessive inter-cortical bone obliquity, buccal cortical concavity, alveolar bone thinness, and suitable thickness and position of bone crest; d: concave clinical aspect of the mucosa; e: frame-shaped corticotomy; f: expansion step using conical osteotome; g: digital counter-pressure during implant placement; h: dental implant cervical position; i: bone graft apposition filling the remaining bone volume defect; j: collagen membrane placement; k: post-operative panoramic dental X-ray; l: prosthetic result after 2 years.
reverse cortical plate movement after alveolar cortical collapse. It also helps to preserve cortical bone integrity during drillings and implant placement. However these expansion techniques also risk failure caused by a lack of bone resistance and elasticity during bone splitting procedure or implant placement [1]. Unintended fractures, coming apart and bursting of the buccal cortical plate, or implant exposure may occur. Bone width gain can also be smaller than expected, due to limited expansion movements, preventing the placement of the forecasted implant.
To make the surgical procedure more reliable, Lalo and al. [7,8] described 4 main techniques of bone expansion: expansion with apical cortical hinge, cortical translation, bi-cortical osteotomy, and frame-shaped corticotomy. The type of the corticotomy to be performed is decided according to the anatomical bone defect and the selected implant parameters The corticotomies performed are larger than those previously described [1,6,13], most of them remote from the implant position. This way, bone fractures occur mostly at distance from the implant placement site during bone expansion, to limit risks of failure. It also allows wider bone
Please cite this article in press as: Lalo J, et al. Maxillary alveolar bone ridge width augmentation using the frame-shaped corticotomy expansion technique. J Stomatol Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.jormas.2019.09.001
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Fig. 6. Clinical case of a 28-year-old patient: upper lateral incisor missing (12) with a prior apical resection; a: preoperative CT dentascan with sagittal sections: deep vestibular bone concavity; b: preoperative clinical aspect; c: performing the frame-shaped corticotomy; d: dental implant placement; e: peri implant tissue restoration; f: prosthetic result.
Fig. 7. Clinical case: A 21-year-old patient with congenital absence of the 2 upper lateral incisors. a: preoperative clinical aspect; b: drawing of the 2 buccal cortical frames; c: corticotomies and immediate implant placement; d: postope´rative dental panoramic result; e: healing screws placement; f: prosthetic result.
movements, improving the parameters (dimensions and axis) of the inserted implant. The expanded cortical bone plate is moved to its new lateral position with a preserved cortical structure, protecting implant from exposure. The alveolar bone expansion using the frame-shaped corticotomy technique is one of our four techniques. The aim is to place the adequate implant behind an expanded concave vestibular cortical bone into the bone expansion, with a straightened axis, without moving its cervical position on the bone crest. The main surgical indication is the alveolar bone width defect with a deep buccal cortical concavity, an excessive obliquity of the intercortical axis, with a sufficient thickness of the cervical bone arch. This situation is found after congenital or acquired dental loss, and after orthodontic treatment so to recover the space for an implant. In our statistics, this technique is mainly used for single dental implant restoration, mostly to replace missing lateral incisors. The surgical steps are similar to the 3 other expansions we have described [7,8]. For cortical incisions, we rather use osteotomes than burs or piezosurgical instrumentation because they are more bone-saving [7,8,11,14]. Osteotomes incise the thin cortical bone without damaging the adjacent dental roots. However, if the cortical bone is thicker, or depending on the operator’s habits, the corticotomies may be performed with a thin bur or a bone saw. If surgery is performed under local anesthesia, informing the patient
of gently performed osteotome tappings, will reduce stress and agitation [7,8,17]. We also use screwed implants rather than cylinder implants [4,5,7,8]. In the frame shaped corticotomy technique, the stability of the implant is ensured by its double apical and cervical attachment. Thus in our series, all the implants have been placed immediately. This option is also possible with GBR, but not with OSBG technique using a transversal bone screw. If a complementary appositional bone graft is needed, we use only a little amount of bone powder, because the main alveolar volume gain is due both to the bone expansion and the intercortical inserted implant itself. We have never needed osteosynthetis material to fix the cortical plate. We never observed soft tissues and bone healing disorders. In our opinion, the postoperative bone healing is probably facilitated by the thinness of the cortical bone flap and its cancellous bone ties, making its revascularization easier. The anatomical cortical bone structure restoration improves its physiological resistance to transverse dental forces. The alveolar volume restoring achieves a better support for attached and free mucosa around the implant prosthesis. The improvement of bone volume and structure, and the optimized parameters of the inserted implant (dimension, axis, cervical position), enhance the final aesthetic and mechanical quality of the implant and prosthetis restoration [5–8,17–19].
Please cite this article in press as: Lalo J, et al. Maxillary alveolar bone ridge width augmentation using the frame-shaped corticotomy expansion technique. J Stomatol Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.jormas.2019.09.001
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Fig. 8. Clinical case: A 49-year-old patient with a missing upper canine (23); a: preoperative dental panoramic; b: CT dentascan: sagittal sections; c: cortical flap lift and implant placement; d: healing screw placement step showing (and) the cortical bone flap healing.
This one stage surgery shortens the time span leading to implant prosthesis. This technique can be used from the age of 16, often for dental agenesis; in adulthood, the cortical bone becomes thicker and less flexible, which increases the risk of failure. The risks of cortical bursting or coming apart, and of primary implant instability, are not frequent in this technique; in this case, we just proceed to a bone width augmentation without placing the implant. We then fill the splitting area with a powder bone graft and place upon it the free vestibular cortical bone, in order to restore the alveolar volume and anatomy. The implant will be placed in a second stage, 4 to 6 months later, after clinical and X-ray checking. In our series, in the immediate and long-term postoperative follow-up, no cortical bone loss, no implant exposure and no failure of the implant and its supported- prosthetis have been observed. Our experience has shown stable long-term outcomes which must be confirmed by further studies. In our team a staff, gathering surgeon periodontist and prosthodontist, assesses all the parameters for the implant and prosthetic project, and plan the protocol in order to reach the best functional and aesthetic results. This staff also informs the patient of the procedure steps, the treatment time span, the cost, the risks and aleas. In conclusion this frame-shaped corticotomy expansion technique has been practiced in our team for over 15 years. It is a seducing and reliable alternative procedure for bone thickness restoration in narrow alveolar ridge with concave vestibular cortical bone. It allows an anatomical bone volume and structure reconstruction and makes immediate implant placement possible. It improves the functional and aesthetic result of the implantprosthetic restoration. A trained surgeon, also able to deal with the unexpected situations we have described, will perfoms it easily.
In our opinion, this technique should be learned and practiced by every implantologist and should become the first surgical choice for narrow and concave alveolar bone widening. Further studies will compare and confirm the interest and reliability of this technique. Disclosure of interest The authors declare that they have no competing interest.
Re´fe´rences [1] Tatum Jr H. Maxillary and sinus implant reconstruction. Dent Clin North Am 1986;30:207–29. [2] Alveolar augmentation: new application for implants. Bruschi GB, Scipioni A, Heimke G, editors. Osseo-integrated implants, Vol 1 (2). Boca Raton, FL: CRC Press; 1990. p. 35–61. [3] Simion M, Baldoni M, Zaffe D. Jawbone enlargement using immediate implant placement associated with a split-crest technique and guided tissue regeneration. Int J Periodontics Restorative Dent 1992;12:462–73. [4] Summers RB. A new concept in maxillary implant surgery: the osteotome technique. Compendium 1994;15:152–62. [5] Summers RB. The osteotome technique: part 2–The ridge expansion osteotomy (REO) procedure. Compendium 1994;15:422–36. [6] Scipioni A, Bruschi GB, Calestini G. The edentulous ridge expansion technique: a five-year study. Int J Periodontics Restorative Dent 1994;14(5):451–9. [7] Lalo J, Chassignolle V, Beleh M, Djemil M. Maxillary ridge expansion for dental implant placement with alveolar corticotomy osteotomy. Rev Stomatol Chir Maxillofac 2008;109(5):316–22. [8] Lalo J, Verrons AS, Lezy JP. M Alve´olar ridge augmentation with cortical osteotomies for dental implantation Rev Stomatol Chir Maxillofac 2012;113:276–90. [9] Sethi A, Kaus T. Maxillary ridge expansion with simultaneous implant placement: 5-year results of an ongoing clinical study. Int J Oral Maxillofac Implants 2000;15:491–9. [10] Huang Y, Ou Y, Song G. Clinical application of maxillary endosseous implant with edentulous ridge expansion technique. Hua Xi Kou Qiang Yi Xue Za Zhi 2003;21:374–6 [388]. [11] Blus C, Szmukler-Moncler S. Split-crest and immediate implant with ultrasonic bone surgery: a 3-year life-table analysis with 230 treated sites. Clin Oral Implants Res 2006;17:700–7.
Please cite this article in press as: Lalo J, et al. Maxillary alveolar bone ridge width augmentation using the frame-shaped corticotomy expansion technique. J Stomatol Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.jormas.2019.09.001
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JORMAS-744; No. of Pages 9 J. Lalo et al. / J Stomatol Oral Maxillofac Surg xxx (2019) xxx–xxx [12] Bravi F, Bruschi GB, Ferrini F. A 10-year multicenter retrospective clinical study of 1715 implants placed with the edentulous ridge expansion technique. Int J Periodontics Restorative Dent 2007;27(6):557–65. [13] Coatam GW, Mariotti A. The segmental ridge-split procedure. J Periodontol 2003;74:757–70. [14] Vercellotti T. Piezoelectric surgery in implantology: a case report–a new piezoelectric ridge expansion technique. Int J Periodontics Restorative Dent 2000;20:358–65. [15] Flanagan D. Flapless dental implant placement. J Oral Implantol 2007;33:75–83.
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[16] SIiddiqui AA, Sosovicka M. Lateral bone condensing and expansion for placement of endosseous dental implants: a new technique. J Oral Implantol 2006;32:87–94. [17] Lee EA, Anitua E. Atraumatic ridge expansion and implant site preparation with motorized bone expanders. Pract Proced Aesthet Dent 2006;18:17–22. [18] Silverstein LH, Hahn J, Kurtzman D, Harden S, Shatz PC. Aesthetic enhancement of pontic sites for fixed partial dentures. Dent Today 1998;17:80–5. [19] Commissionat Y: Expansion de la creˆte maxillaire et distraction alve´olaire. Princ G, Piral T, editors. Chirurgie osseuse pre´-prothe´thique. Chirurgie osseuse preprothe´tique. Paris: C.D.P; 2008. p. 111–7.
Please cite this article in press as: Lalo J, et al. Maxillary alveolar bone ridge width augmentation using the frame-shaped corticotomy expansion technique. J Stomatol Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.jormas.2019.09.001
JORMAS-744; No. of Pages 9 J Stomatol Oral Maxillofac Surg xxx (2019) xxx–xxx
Available online at
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Technical note
Maxillary alveolar bone ridge width augmentation using the frame-shaped corticotomy expansion technique J. Lalo a,*, H. Adouani b, S. Bouraoui b, N. Zaitri a, C. Teillaud a a
Department of Stomatology and Oral and Maxillofacial Surgery, Saint-Antoine Hospital, University of Paris 6, 184, rue du Faubourg Saint-Antoine 75012 Paris, France b Faculty of dental Medecine, University of Monastir, Monastir, Tunisia
A R T I C L E I N F O
A B S T R A C T
Article history: Received 14 May 2019 Accepted 10 September 2019
Maxillary alveolar ridge expansion performed by intercortical bone splitting is a seducing alternative surgical procedure for alveolar bone widening. The aim of this technique is to gain enough bone width to be able to place a dental implant simultaneously. This technique avoids a second surgical site for bone graft harvesting. However there are risks of surgical failure caused by unintended bone fracture during expansion and implant placement, or by insufficient bone widening for implant insertion. To limit these risks, we have published expansion techniques using various corticotomies. These corticotomies are achieved according to bone anatomy, most of them remote from implant position. Bone fractures are guided during the bone expansion and the implant placement, avoiding cortical bursting. Wider and safer bone movements can be achieved allowing to place the forecasted implant with adequate dimensions, axis, and cervical position on the bone ridge. Our technique increases the success rate of both the bone volume expansion and the dental implant placement, and improve the functional and aesthetic result of implant and prosthesis restoration. Four main types of bone expansion movement using corticotomies have been described: expansion with apical cortical hinge, cortical translation, bicortical osteotomy, and frame-shaped corticotomy. Our subject is the alveolar bone width augmentation with the frame- shaped corticotomy expansion technique, which allows to place an implant in a narrow and concave alveolar bone, with a straightened axis, without modifying its cervical position on the bone ridge arch. A series of 10 cases with a 1 to 5 year surgical follow-up is studied. Implants were all placed in the same stage and their supported prosthesis successfully made. Peculiarities and interest of this technique are discussed.
C 2019 Elsevier Masson SAS. All rights reserved.
Keywords: Dental implant Alveolar ridge augmentation Osteotomies
1. Introduction Inadequate sagittal maxillary alveolar bone dimensions are often pointed out during clinical and radiological assessment for prosthetic rehabilitation of edentulous ridge. This bone defect may be constitutional or due to alveolar bone remodeling after dental loss, dental agenesis, surgical sequels, bone infection, or preimplant spacing orthodontic treatment. In the maxilla, the bone width loss is caused by the collapse of the inter cortical space. This aveolar bone collapse is due to the weakness of the buccal cortical bone which structure is thinner and less resistant than the palatal cortical bone, and not supported by dental root.
* Corresponding author. E-mail address: [email protected] (J. Lalo ).
Transverse alveolar ridge expansion is defined as an immediate bone width augmentation performed by a bone splitting between the two cortical plates which are progressively separated and pushed back to their required or initial position. The main idea of the bone expansion is to achieve a reverse cortical movement, thus restoring the alveolar bone volume and anatomy. The first surgical splitting procedure was described by H. Tatum [1] in 1986, and performed with specially designed osteotomes. Shortly after, several surgical teams used this technique and published their cases or series [2–6]. The main aim was to gain enough intercortical bone width to place an implant in the same stage. However, during this procedure, and depending both on bone quality and operator’s skills, there are quite important risks of failure caused by cortical bursting, complete cortical coming apart, implant exposure during insertion, and insufficient bone widening. To make the result more reliable, we described expansion techniques [7,8] performing a bone width augmentation with
https://doi.org/10.1016/j.jormas.2019.09.001 C 2019 Elsevier Masson SAS. All rights reserved. 2468-7855/
Please cite this article in press as: Lalo J, et al. Maxillary alveolar bone ridge width augmentation using the frame-shaped corticotomy expansion technique. J Stomatol Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.jormas.2019.09.001
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JORMAS-744; No. of Pages 9 2
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various corticotomies, larger and more adapted to the anatomical bone situation. These corticotomies make possible the guiding of bone fractures away from the implant position during alveolar expansion. Wider and safer bone movements are achieved in order to place the forecasted implant. After a short overview of our four alveolar bone corticotomies, we will focus on frame-shaped cortical osteotomy. 2. Basic corticotomy expansion techniques for alveolar bone width augmentation Our four main techniques of expansion with corticotomies allow to widen the alveolar bone thickness sufficiently in order to place implants with adequate characteristics of dimension (length, diameter), axis (A), and cervical position (P) on the bone ridge [7,8] (Figs. 1–4): expansion with apical cortical hinge: allows an outer buccal (external) cortical bone movement (Fig. 1). Bone crest is widened externally. Cervical implant position is moved outwards (P), and implant axis is straightened (A);
expansion with cortical translation: performs an outer translation of the external (buccal) cortical bone (Fig. 2). It allows to insert in a second stage an implant with an outer crestal position (P) without modifying its axis (A); expansion with bi-cortical (internal and external) osteotomy (Fig. 3): achieves inner and outer bone ridge widening. Rare in the maxilla because of thickness and resistance of the palatal cortical bone, but more frequent in the anterior area of the mandibular bone (from right to left premolars). It allows implant placement without modifying its cervical ridge position and axis; expansion with frame-shaped corticotomy, which we shall now describe.
3. Alveolar bone expansion with frame-shaped corticotomy This expansion technique allows to widen a concave alveolar bone, and to restore its volume and structure (Fig. 4). It also makes possible the simultaneous placement of the implant with a straightened axis without modifying its cervical position on the bone ridge.
Fig. 1. Schemas of cortical bone expansion with apical cortical hinge, allowing a modification of implant cervical position (from P0 to P1) and axis (from A0 to A1).
Please cite this article in press as: Lalo J, et al. Maxillary alveolar bone ridge width augmentation using the frame-shaped corticotomy expansion technique. J Stomatol Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.jormas.2019.09.001
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Fig. 2. Schemas of alveolar bone expansion with external cortical translation. Modification of cervical implant position (from P0 to P1) but no change of its axis placement (A0 = A1).
3.1. Indications
3.3. Surgical technique
We use this technique in case of narrow alveolar bone width with significant vestibular cortical concavity. This clinical situation is mainly found in the anterior maxillary area and for single tooth restoration, in case of dental agenesis, and also after dental loss, apical root surgery, and pre-implant spacing orthodontic treatment.
We present a typical surgical procedure for a lateral incisor restoration (Fig. 5).
3.2. Preoperative investigation The intra-oral clinical examination evaluates the external alveolar bone and mucosa concavity. Radiological investigation with CT dentascan provides more information about alveolar bone anatomy: bone height and thickness, shape, axis, cortical and cancellous bone structure, and dental alignment curve position. It shows the bone width defect, the external cortical bone concavity, the excessive obliquity of the inter-cortical axis, and the satisfying thickness and position of the bone crest. Clinical and radiological study allows to decide where to shape the frame of the corticotomy and how to perform the bone expansion, in order to widen the intercortical space and to introduce simultaneously an implant with suitable dimension and axis.
3.4. Surgical equipment No specific instrumentation is needed except for a few corticotomy and expansion tools: straight and curved osteotomes with double beveled blade (2 to 4 mm width) and scaled conical and cylindrical osteotomes (2 to 4 mm in diameter). Osteosynthesis kit with screws from 1.2 to 1.8 mm in diameter and bone harvesting instrumentation must be available in case of failure. Homologous or heterologous powder bank bone and resorbable-collagen membrane might become necessary if an additionnal bone graft is decided. 3.5. Surgical procedure This surgery is performed under local anesthesia, sedation or general anesthesia, according to the planned procedure and the patient’s choice. A short medication with antibiotics, such as amoxicillin or clindamycin, is combined with mild analgesic and corticosteroid.
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Fig. 3. Schemas of bi-cortical bone expansion without noticeable modification of the axis (A0 = A1) and cervical position (P0 = P1). a–b: maxillary alveolar expansion; c: mandibular alveolar expansion with immediate implant placement.
The frame-shaped corticotomy expansion technique begins with mucosal incisions (crestal, sulcular, and remote vestibular incisions), subperiosteal stripping, and exposure of the surgical area up to the adjacent dental root bone bulges. The palatal cortical bone is exposed on a few millimeters to visualize the bone axis and ultimately to place the covering membrane. The corticotomy cutlines around the bone concavity to be expanded are marked with a dermographic pencil. The bone surgery begins with the two vertical corticotomies, performed by gently tapping with a mallet on the flat osteotomes up to the cancellous bone. This stage allows to assess the resistance of the cortical bone layer and its thickness (between 0.5 and 2 mm). Then the two horizontal corticotomies are achieved: the lower corticotomy at the lower part of the concavity, a few millimeters above the crestal bone, and the superior corticotomy at the upper part of the concavity where the cortical bone is thicker which may require the use of a thin bur or a circular saw (radius 3 mm). Next step is the bone splitting, between palatal and vestibular (buccal) cortical bone: drilling in the alveolar bone crest at the planned implant position, with pilot drill and drills 2 to 3 mm in diameter, up to the lower horizontal corticotomy; inter-cortical splitting with a 3 mm straight osteotome which is introduced through the drilled crestal bone hole, into the cancellous bone, and beneath the concave cortical plate to free it from its cancellous bone ties; achieving bone expansion and well sized implant bed, gradually, using alternately osteotomes (conical and cylindrical) and drills. Conical osteotomes perform a gradual expansion of the concave cortical plate which is released from its depth and compact the cancellous bone into the intercortical space improving thereby the implant stability. Drills create a concave shape on the inner side of the cortical plate thus preventing it from excessive outer moving during the implant placement. During this step the bone flap progressively lifts out, and a counter-pressure with an instrument or with the finger may be applied to stabilize it in the meantime.
The expansion movement is carried on until sufficient alveolar bone width is obtained to place an implant with suitable diameter and axis. The depth of the implant hole, and therefore the length of the implant, should ideally reach above the upper horizontal osteotomy. The stability of the implant is then strongly ensured by its intraosseous apical and cervical parts, screwed above and below the cortical bone expansion area. A counter pressure is also useful to stabilize the bone flap during the implant insertion. Implants with sharp threads are avoided in order not to weaken or perforate the cortical flap. After expansion, two additional steps help to improve the bone volume and shape aesthetic result: leveling of an osseous surplus, and grafting both the bone concavity and the corticotomy cutlines. For bone grafting, we use homologous tissue bank bone mixed with the patient’s blood sample. We generally cover the bone splitting with a resorbable collagen membrane, which protects and maintains the bone flap and the additional graft during the wound healing process. No osteosynthesis device is needed. An intraperiosteal incision allows to slip down the mucosal flap and to suture easily. Sutures are made with silk wire stitches, which are more flexible and reduce inflammation. Intraoral hygiene care and feeding advices are given to the patient. During the first postoperative month, anything that could injure the operated area or press on it should be avoided, in order to limit the risk of bone resorption and implant exposure. Wearing a removable partial denture is not recommended during the first two weeks, and resine excavation is often provided. A clinical control is scheduled 10 to 15 days after surgery to check the healing process and to remove the nonabsorbable sutures, healing cap placement is planned 4 to 6 months after. 4. Clinical cases and results We have studied our last 10 patients, with a minimum followup of 1 year after implant placement (interval of 1 to 5 years). The mean age was 32 years (range 19–55 years), 14 frame-shaped corticotomies (single site for 6 patients, double site for 4 patients)
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Fig. 4. Schemas of alveolar bone expansion with frame-shaped corticotomy. Restoration of bone volume and structure. Modification of the axis (from A0 to A1), thus preserving the cervical ridge postion of the implant (PO = P1).
were performed, and 14 implants placed immediately (100%) allowing the restoration of 9 lateral incisors (64%), 4 central incisors (29%) and 1 canine (7%) (Figs. 6–8). This technique makes possible in each case instantaneous implant insertion with adequate dimensions, superior to 3,5 mm in diameter and from 12 to 16 mm length, with a straightened suitable axis. Aesthetic shape of gingival mucosa has been improved by bone volume augmentation. No failure of the implant and its supportedprosthetis, has been reported during the follow-up. 5. Discussion The maxillary alveolar ridge expansion procedure helps to widen the alveolar bone, without the need for a second surgical bone harvesting site, in order to place dental implants simultaneously [1–6]. The expansion technique is based both on the osseous plasticity and on the postoperative healing of the created bone expansion fractures [2].
Its reliability has been demonstrated by clinical series [4,6,9– 12], some of which had over 8 years follow-up [9,12]. The success rate was 88 to 98%, after ‘‘immediate inserted implants’’ [6,9– 12]. Authors recommend this technique for maxillary crest width ranging from 1.5 to 3 mm [3,11,13–15], with enough cancellous bone between buccal and palatal cortical plates. The alveolar ridge widening, which may reach 4 to 5.5 mm [10,11], allows adequate implant placement with lasting prosthetic restoration. The improvement of the volume and shape of the alveolar bone, overlaid by the attached and free mucosa, contributes to a better aesthetic prosthetic result. Alveolar expansion is an alternative procedure to bone widening apposition techniques, such as guided bone regeneration (GBR) [5,15] and osteo-synthesized bone graft (OSBG). But these techniques may require a second surgical stage for implant placement 4 to 6 months later, to make sure bone graft healing is achieved or to wait for osteosynthesis screw removal. Bone harvesting also implies more morbidity, and two stage surgical procedure induces an additional cost [16]. Furthermore, alveolar expansion allows anatomical bone reconstruction, producing a
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Fig. 5. Frame-shaped coticotomy expansion technique. Clinical case: a 47-year-old patient with a missing maxillary lateral incisor (12); a-b-c: X-ray investigations: a: panoramic dental; b: CT dentascan with horizontal sections showing the dental alignment curves; c: sagittal sections showing excessive inter-cortical bone obliquity, buccal cortical concavity, alveolar bone thinness, and suitable thickness and position of bone crest; d: concave clinical aspect of the mucosa; e: frame-shaped corticotomy; f: expansion step using conical osteotome; g: digital counter-pressure during implant placement; h: dental implant cervical position; i: bone graft apposition filling the remaining bone volume defect; j: collagen membrane placement; k: post-operative panoramic dental X-ray; l: prosthetic result after 2 years.
reverse cortical plate movement after alveolar cortical collapse. It also helps to preserve cortical bone integrity during drillings and implant placement. However these expansion techniques also risk failure caused by a lack of bone resistance and elasticity during bone splitting procedure or implant placement [1]. Unintended fractures, coming apart and bursting of the buccal cortical plate, or implant exposure may occur. Bone width gain can also be smaller than expected, due to limited expansion movements, preventing the placement of the forecasted implant.
To make the surgical procedure more reliable, Lalo and al. [7,8] described 4 main techniques of bone expansion: expansion with apical cortical hinge, cortical translation, bi-cortical osteotomy, and frame-shaped corticotomy. The type of the corticotomy to be performed is decided according to the anatomical bone defect and the selected implant parameters The corticotomies performed are larger than those previously described [1,6,13], most of them remote from the implant position. This way, bone fractures occur mostly at distance from the implant placement site during bone expansion, to limit risks of failure. It also allows wider bone
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Fig. 6. Clinical case of a 28-year-old patient: upper lateral incisor missing (12) with a prior apical resection; a: preoperative CT dentascan with sagittal sections: deep vestibular bone concavity; b: preoperative clinical aspect; c: performing the frame-shaped corticotomy; d: dental implant placement; e: peri implant tissue restoration; f: prosthetic result.
Fig. 7. Clinical case: A 21-year-old patient with congenital absence of the 2 upper lateral incisors. a: preoperative clinical aspect; b: drawing of the 2 buccal cortical frames; c: corticotomies and immediate implant placement; d: postope´rative dental panoramic result; e: healing screws placement; f: prosthetic result.
movements, improving the parameters (dimensions and axis) of the inserted implant. The expanded cortical bone plate is moved to its new lateral position with a preserved cortical structure, protecting implant from exposure. The alveolar bone expansion using the frame-shaped corticotomy technique is one of our four techniques. The aim is to place the adequate implant behind an expanded concave vestibular cortical bone into the bone expansion, with a straightened axis, without moving its cervical position on the bone crest. The main surgical indication is the alveolar bone width defect with a deep buccal cortical concavity, an excessive obliquity of the intercortical axis, with a sufficient thickness of the cervical bone arch. This situation is found after congenital or acquired dental loss, and after orthodontic treatment so to recover the space for an implant. In our statistics, this technique is mainly used for single dental implant restoration, mostly to replace missing lateral incisors. The surgical steps are similar to the 3 other expansions we have described [7,8]. For cortical incisions, we rather use osteotomes than burs or piezosurgical instrumentation because they are more bone-saving [7,8,11,14]. Osteotomes incise the thin cortical bone without damaging the adjacent dental roots. However, if the cortical bone is thicker, or depending on the operator’s habits, the corticotomies may be performed with a thin bur or a bone saw. If surgery is performed under local anesthesia, informing the patient
of gently performed osteotome tappings, will reduce stress and agitation [7,8,17]. We also use screwed implants rather than cylinder implants [4,5,7,8]. In the frame shaped corticotomy technique, the stability of the implant is ensured by its double apical and cervical attachment. Thus in our series, all the implants have been placed immediately. This option is also possible with GBR, but not with OSBG technique using a transversal bone screw. If a complementary appositional bone graft is needed, we use only a little amount of bone powder, because the main alveolar volume gain is due both to the bone expansion and the intercortical inserted implant itself. We have never needed osteosynthetis material to fix the cortical plate. We never observed soft tissues and bone healing disorders. In our opinion, the postoperative bone healing is probably facilitated by the thinness of the cortical bone flap and its cancellous bone ties, making its revascularization easier. The anatomical cortical bone structure restoration improves its physiological resistance to transverse dental forces. The alveolar volume restoring achieves a better support for attached and free mucosa around the implant prosthesis. The improvement of bone volume and structure, and the optimized parameters of the inserted implant (dimension, axis, cervical position), enhance the final aesthetic and mechanical quality of the implant and prosthetis restoration [5–8,17–19].
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Fig. 8. Clinical case: A 49-year-old patient with a missing upper canine (23); a: preoperative dental panoramic; b: CT dentascan: sagittal sections; c: cortical flap lift and implant placement; d: healing screw placement step showing (and) the cortical bone flap healing.
This one stage surgery shortens the time span leading to implant prosthesis. This technique can be used from the age of 16, often for dental agenesis; in adulthood, the cortical bone becomes thicker and less flexible, which increases the risk of failure. The risks of cortical bursting or coming apart, and of primary implant instability, are not frequent in this technique; in this case, we just proceed to a bone width augmentation without placing the implant. We then fill the splitting area with a powder bone graft and place upon it the free vestibular cortical bone, in order to restore the alveolar volume and anatomy. The implant will be placed in a second stage, 4 to 6 months later, after clinical and X-ray checking. In our series, in the immediate and long-term postoperative follow-up, no cortical bone loss, no implant exposure and no failure of the implant and its supported- prosthetis have been observed. Our experience has shown stable long-term outcomes which must be confirmed by further studies. In our team a staff, gathering surgeon periodontist and prosthodontist, assesses all the parameters for the implant and prosthetic project, and plan the protocol in order to reach the best functional and aesthetic results. This staff also informs the patient of the procedure steps, the treatment time span, the cost, the risks and aleas. In conclusion this frame-shaped corticotomy expansion technique has been practiced in our team for over 15 years. It is a seducing and reliable alternative procedure for bone thickness restoration in narrow alveolar ridge with concave vestibular cortical bone. It allows an anatomical bone volume and structure reconstruction and makes immediate implant placement possible. It improves the functional and aesthetic result of the implantprosthetic restoration. A trained surgeon, also able to deal with the unexpected situations we have described, will perfoms it easily.
In our opinion, this technique should be learned and practiced by every implantologist and should become the first surgical choice for narrow and concave alveolar bone widening. Further studies will compare and confirm the interest and reliability of this technique. Disclosure of interest The authors declare that they have no competing interest.
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Please cite this article in press as: Lalo J, et al. Maxillary alveolar bone ridge width augmentation using the frame-shaped corticotomy expansion technique. J Stomatol Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.jormas.2019.09.001