BONE SPREADING TECHNIQUE – A CASE REPORT

AUTHORS: Renato Sussumu Nishioka, DDS, PhD*, João Carlos Paixão**

ABSTRACT: Bone spreading technique (BST) is horizontal augmentation with minimal trauma for

simultaneous implant placement and is an alternative Summer’s osteotome both clinical use as well as the

armamentarium. The foremost advantage of the crest dilation technique is a substantially less invasive

method; the buccal wall expands after the medular bone is compressed against the cortical bone. The lateral

dilation and compaction of medular bone improved primary stability. The vital difference is that the BST used

in this case report avoided discomfort of the patient, thus eliminating the need for malleting.

KEY WORDS: ridge expansion, deficient alveolar bone width, bone spreading, dental implant

* Professor, Department of Dental Materials and Prosthodontics, State University of São Paulo (UNESP) São

José dos Campos, São Paulo, Brazil.

** Private Practice, São Paulo, Brazil

Reprint requests and correspondence to: Renato Sussumu Nishioka, D.D.S., MSc, PhD. Department of

Dental Materials and Prosthodontics State University of São Paulo (UNESP) São José dos Campos, Av.

Francisco José Longo 777, São Dimas, São José dos Campos, São Paulo- Brazil Cep:12245-000

Phone: (55-012) 39479056 email: nishioka@fosjc.unesp.br

INTRODUCTION

One of the major problems encountered after the tooth extraction is the hard and soft tissue loss. Reduction of

the buccal alveolar bone caused by bone resorption in partially edentulous maxilla is a frequent problem1,2,.

Implants need an adequate volume of bone to stabilize the fixture. In partially edentulous patients often

maxilla atrophy requires to be augmented. Numerous augmentation techniques3-8 have been reported in dental

literature to facilitate implant placement in atrophic ridge using blocks grafts, which require several steps

before prosthetic restoration. In an effort to shorten the length of treatment, avoid an additional surgical

appointment, challenge to the patient a decrease patient morbidity. A technique which would both lessen the

trauma to patient and conserve the maximum amount of alveolar bone at precise site of anticipated implant

placement would offer clinical benefits. Spreaders of increasing diameters are gently introduced sequentially

to expand the implant site. With each insertion of a larger diameter spreader the bone is pushed laterally. The

implant should be slightly larger in diameter than the site created by the largest diameter spreader. BTS is an

alternative Summer’s osteotome9-13

both clinical use as well as the armamentarium.

This paper describes a technique for widening the maxillary cortical bone to improve the placement of

implant.

Surgical Technique

Patients were instructed to take 2.0g of amoxicillin or 600mg clindamycin 1 or 2 hours prior to surgery. After

administering 2 carpules of 2% mepivacaine this technique begins with a crestal incision. A full-thickness flap

is raised to expose the alveolar ridge. To secure a proper alignment of the implants, the surgical template was

used. The BTLock expanders kit ( BTLock s.r.l. Alte di Montecchio Maggiore-Vincenza) were used in this

case, as described next. The proposed implant site was cleared marked with a pilot drill used at 18,000 rpm

under copious irrigation with sterile saline, removing the cortical plate. The pilot drill (1.3 mm of diameter)

penetrated to the desired height. The pilot drill produced a sub-dimensional bone cavity. There is a successive

deployment of a series of smaller spreader in a progressive way (first 1.8mm, second 2.15mm, 2.5mm,

3.3mm-green code, then 3.75mm-yellow code). Care is taken to proceed as slowly as possible. With the help

of the appropriate carrier and, if necessary, with the help of the driver, the spreaders must be screwed in

cautiously. By having widened the implant cavity in this manner it is now possible to place the suitable

implant (BTLock s.r.l. Alte di Montecchio Maggiore-Vincenza). Furthermore, the clearly increased bone

rigidity achieved by bone condensation, results in optimized primary stability. Finally, the flaps are sutured in

their original positions. The patients were provided with home care; do not rinse their mouth vigorously and

use ice packs over the surgical area during the first 24 hours after the operation Patients were maintained on

preoperative antibiotics for additional 6 days and analgesic medications (600mg ibuprofen) and .02%

chlorhexidine-gluconate mouthwash twice a day, was prescribed. The sutures were removed at the seventh

postoperative day.

Case Report

A 43-year-old woman presented for replacement of a missing premolar in the maxilla. The premolar had been

extracted 7 years ago. Clinical exam revealed significant buccal bone loss in the premolar maxilla, although

adequate ridge height was present for implant placement (Fig. 1). The patient requested that we avoid any

bone-grafting procedure. With the use of a periapical radiograph, it was decided to place a 10mm length,

3.75mm diameter tapered screw implant. A full-thickness flap was raised and showed further bone concavity

on buccal aspect (Fig. 2). The following sequence was used to BST. When bone spreading the pilot drill used

was 1.8mm diameter bur. The pilot drill produces a sub-dimensional bone cavity. The pilot drill penetrated to

the desired height (Fig. 3). Following the osteotomy, widening was begun by the use of the primary spreader-

1.8mm of diameter (Fig 4). After placing the thinnest spreader, the following spreaders in ascending order can

be used without drilling (Fig 5-6-7). The successive deployment of a series of spreaders with increasing

diameters lead to bone spreading and horizontal condensing. The final lateral expansion prepared to receive a

3.75-mm diameter tapered screw implant (BTLock s.r.l. Alte di Montecchio Maggiore-Vincenza) (Fig. 8-9).

As can be seen, an increase was achieved in bone dimension. Primary stability was achieved by torquing the

implant to 35 Ncm. The flap was approximated and sutured.

Discussion

The ultimate objective of implant treatment is to provide support for the replacement of missing teeth. As with

any treatment, presurgical planning is decisive to the success.

In response to changing treatment concepts, different surgical approaches implant placement has been

developed, including immediate implant placement following the cortical plate dilation in maxilla. The

edentulous ridge expansion (ERE) technique was development by Scipioni et al.14 to slowly dislocated the

buccal plate in a facial direction. An aspect of ERE technique is the partial thickness flap; the integrity of

periosteum is maintained. The healing period for implant insert with ERE technique seems to be the same as

other implant14-16

. Elian et al. have17 used the split ridge expansion technique in fully edentulous maxilla. The

BST is an immediate bone dilation and implant placement is preferred than ERE two-stage approach. The

BST is essentially dissimilar than ERE and Summers’osteotome both in pattern of design as well the

technique of use. The BST utilizes a “screw type” design are smoothly introduced in increasing diameter for

lateral bone dilation and condensing the medular bone for simultaneous placement of dental implants. With

each insertion of a larger spreader the bone is pushed laterally. Patient acceptance of this technique has been

very high. The ERE technique and Summer’s osteotome are based on “palm-held” design and the mallet.

Sethi and Kaus18 have used D shaped in cross section osteotome and mallet to progressively separate the

cortical plate. Such force application and repeated malleting could be disconcerting the patient. The chances

of achieving a sufficiently lateral dilation with the BST are excellent19.

CONCLUSION

BST for ridge horizontal augmentation with immediate implant placement has been shown to be predictable

and successful in treating the maxilla with deficient alveolar bone width. BST is superior to drilling technique

for application in soft maxillary bone. The BST offers a number of advantages over both the Summer’s

osteotome and ERE technique. The BST has proven to be highly advantageous for the comfort of patients,

increasing their acceptance and overall satisfaction. This surgery technique is a predictable procedure when

patient selection and surgical technique are appropriate.

DISCLOSURE

The authors claim to have no financial interest, directly or indirectly, in any entity that is commercially related

to the products mentioned in this article.

References

1. Bernhart T, Weber R, Mailath G et al. Use of crestal bone for augmentation of ridges prior to of extremely

knife-edge alveolar ridges prior to implant placement: report of 3 cases. Int J Oral Maxillofac Implants,

1999;14: 424-427.

2. Tinti C, Parma-Benfenati S. Clinical classification of bone defects concerning the placement of dental

implants. Int J Periodontics Restorative Dent. 2003; 23:147-155.

3. Collins TA, Onlay bone grafting in combination with Branemark implants. Oral Maxillofac Surg Clin

North Am 1991;3:893-902.

4. Jensen J, Sindet- Pedersen S. Autogenous mandibular bone grafts and osseointegrated implants for

reconstruction of the severely atrophied maxilla: A preliminary report. J Oral Maxillofac Surg 1991;

49:1277-1287.

5. Misch CM, Misch CE. The repair of localized severe ridge defects for implant placement using

mandibular bone grafts. Implant Dent 1995;4:261-267.

6. Misch CM. Comparison of intraoral donor sites for onlay grafting prior to implant placement. Int J Oral

Maxillofac Implants 1997;12:767-776.

7. Montazem A, Valauri DV, St-Hilaire H, Buchbinder D. The mandibular symphysis as a donor site in

maxillofacial bone grafting: a quantitative anatomic study. Int J Oral Maxillofac Implants 2000;58:1368-

1371.

8. Triplett RG, Schow S. Autologous bone grafts endosseous implants: Complementary techniques. J Oral

Maxillofac Surg 1996;54:486-494.

9. Shulman LB: Surgical considerations in implant dentistry. J Dent Educ 1988;52:712-720. a. Summers RB.

Maxillary implant surgery. The osteotome technique. Part 1. Compend Contin Educ Dent 1994;15:152-

162.

10. Summers RB. The osteotome technique. Part 2. The ridge expansion osteotomy (REO) Compend Contin

Educ Dent 1994;15:422-436.

11. Summers RB. The osteotome technique. Part 3. Less invasive methods of elevating the sinus floor.

Compend Contin Educ Dent 1994;15:698-708.

12. Summers RB. The osteotome technique. Part 4. The future site development Compend Contin Educ Dent

1995;11:1090-1025.

13. Davarpanah M, Martinez H, Tecucianu J F, Hage G, Lazzara R. The modified osteotome technique. Int J

Periodontics Restorative Dent 2001;21:559-607.

14. Scipioni A, Bruschi GB, Calesini G. The edentulous ridge expansion technique: a five-year study. Int J

Periodontics Restorative Dent 1994; 14: 415-459.

15. Scipiono A, Bruschi GB, Giargia M, Berglundh T, Lindle J. Healing at implants with and without primary

bone contact: An experimental study in dogs. Clin Oral Implants Res 1997;8:39-47.

16. Scipioni A, Bruschi GB, Calesini G, Bruschi E, De Martino C. Bone regeration in the edentulous ridge

expansion technique: histologic and ultrastructural study of 20 clinical cases. Int J Periodontics

Restorative Dent 1999; 19: 269-277.

17. Elian N, Jalbout Z, Ehrlich B, et al. A two-stage full-arch ridge expansion technique: review of the

literature and clinical guidelines. Impl Dent 2008; 17: 16-23.

18. 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: 491-499.

19. Nishioka RS, Kojima AN. Souza, F.A. Screw spreading technical considerations and case report. Int J

Periodontics Restorative Dent (in press).

FIGURE 1 FIGURE 2

FIGURE 3 FIGURE 4

FIGURE 5 FIGURE 6

FIGURE 6 FIGURE 8

FIGURE 9