Immediate and Delayed Lateral Ridge Expansion …Numerous surgical techniques have been described for augmentation of the atrophic mandibular alveolar ridge. The strategies used to

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J Oral Maxillofac Surg68:2283-2290, 2010

Immediate and Delayed Lateral RidgeExpansion Technique in the Atrophic

Posterior Mandibular Ridge

Dong-Seok Sohn, DDS, PhD,* Hyun-Jin Lee, DDS,†

Jeung-Uk Heo, DDS, PhD,‡ Jee-Won Moon, DDS,§

In-Suk Park, DDS, PhD,� and

Georgios E. Romanos, DDS, Dr Med Dent, PhD¶

Purpose: The lateral ridge expansion technique is used to expand the narrow edentulous ridge forimplant placement. The staged approach can be used to split the mandibular ridge to decrease therisk of malfracture during osteotomy. The present study reports the clinical results of a surgicaltechnique that expands a narrow mandibular ridge using an immediate and a delayed lateralexpansion technique.

Materials and Methods: A total of 32 patients with a narrow edentulous posterior mandibular ridgeof 2 to 4 mm were included in the present study, and 84 implants were placed. Of the 32 patients, 23were treated with an immediate lateral expansion technique and 9 with a delayed lateral expansiontechnique.

Results: Of the 23 patients who underwent the immediate lateral expansion technique, a malfractureof the thin buccal cortical plate occurred during ridge splitting in 5 patients. All buccal segments of the9 patients who underwent the delayed lateral expansion technique fractured as planned at the inferiorhorizontal corticotomy line favorably. After 4 to 5 months, all implants were stable and surrounded bybone, and ossification of the osteotomy line was obvious.

Conclusions: The lateral ridge expansion technique is effective for horizontal augmentation in theseverely atrophic posterior mandibular ridge. The delayed lateral ridge expansion technique can be usedmore safely and predictably in patients with high bone quality and thick cortex and a narrower ridge inthe mandible.© 2010 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 68:2283-2290, 2010
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he management of the atrophic posterior mandibu-ar ridge is a common problem in implant dentistry.umerous surgical techniques have been described

or augmentation of the atrophic mandibular alveolaridge. The strategies used to overcome this have in-

*Chairman and Professor, Department of Dentistry and Oral and

axillofacial Surgery, Catholic University Hospital of Daegu,

aegu, Republic of Korea.

†Clinical Instructor, Department of Dentistry and Oral and Maxillofacial

urgery, Catholic University of Daegu, Daegu, Republic of Korea.

‡Private Practice, GoodWill Dental Clinic, Busan, Republic of

orea.

§Clinical Instructor, Department of Dentistry and Oral and Max-

llofacial Surgery, Catholic University of Daegu, Daegu, Republic of

orea.

�Clinical Instructor, Department of Dentistry and Oral and Max-

llofacial Surgery, Catholic University of Daegu, Daegu, Republic of

orea.

2283

luded onlay block bone grafting,1-3 guided bone re-eneration,4-6 ridge split technique/ridge expan-ion,7-10 and distraction osteogenesis.11,12

The lateral ridge expansion technique is aimed at thereation of a new implant bed by longitudinal osteot-

¶Professor, Division of Periodontology, Eastman Dental Center,

niversity of Rochester, Rochester, NY.

Address correspondence and reprint requests to Dr Sohn: De-

artment of Oral and Maxillofacial Surgery, Catholic University

ospital of Daegu, 3056-6 Daemyung-4 Dong, Namgu, Daegu, Re-

ublic of Korea; e-mail: [email protected]

2010 American Association of Oral and Maxillofacial Surgeons

278-2391/10/6809-0036$36.00/0

oi:10.1016/j.joms.2010.04.009

mailto:[email protected]

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2284 IMMEDIATE AND DELAYED LATERAL RIDGE EXPANSION TECHNIQUE

my of the alveolar bone.13 The buccal cortex is repo-itioned laterally using a greenstick fracture, and thepace between the buccal and lingual cortical plates islled with autologous,14 allogenic,15 or alloplastic15,16

raft material or without any graft material.8,17

The lateral ridge expansion technique is usuallyerformed simultaneously with implant placementnd significantly shortens the treatment time. Theateral ridge expansion technique is more suitable tohe maxilla than the mandible owing to the thinnerortical plates and softer medullary bone.18 In theandible, the risk of malfracture of the osteomized

uccal segment is greater because of the lower flexi-ility and thicker cortical plates.13,18 A staged ap-roach to avoid malfracture in the mandible can alsoe used.13

The present study reports the clinical results of anmmediate and a delayed lateral expansion techniquesed to expand a narrow mandibular ridge.

aterials and Methods

A total of 32 patients (5 men and 27 women, withmean age of 48 years) with an edentulous atrophicosterior mandibular ridge were included in theresent study, and 84 tapered screw type implantsere placed. Of the 32 patients, 23 were treated with

he immediate lateral expansion technique and 9ere treated with the delayed lateral expansion tech-ique. These patients had a buccolingual ridge dimen-ion ranging from 2 to 4 mm that was inadequate tollow the placement of dental implants but had ade-uate bone height.

IMMEDIATE LATERAL EXPANSION TECHNIQUE

After administration of local anesthesia, 1 incisionas made along the ridge crest slightly toward the

ingual side and 2 vertical incisions were made (FigsA-F). A full-thickness mucoperiosteal flap was ele-ated to expose the buccal aspect of mandibular al-eolar ridge. The lingual flap was minimally raised toaintain the blood supply to the bone. Rectangular

orticotomies were made using the piezoelectric sawSurgyBone, Silfradent, Sofia, Italy) or erbium:yttrium-luminum-garnet laser (Dual Laser; Lambda Scienti-ca, Altavilla Vicentina, Italy). The laser parametersere set at a power of 6 W, with a frequency of 20z. A crestal horizontal corticotomy was started 1 tomm away from the adjacent tooth. The length of theorizontal cut was determined, considering the num-er of implants and the space between the implants.wo vertical corticotomies were created on the buc-al cortical plate, and the height of the vertical corti-otomies was approximately one half length com-ared with the length of the implant to be placed. All
orticotomies were performed to reach the lingual p
late in depth. A small chisel was used to expand theuccal segmented bone, provoking a greenstick frac-ure.

The chisel was carefully tapped with a mallet,nd the buccal segmented plate was slowly dislo-ated in a buccal direction. After the preparation ofhe implant sites using twist drills, the implantsere placed. Care was taken to avoid penetrationf the sublingual plate. Each split area received 2 orimplants. Varying size bone grafts were grafted

nto the gap between the expanded plate and theingual plate and varying resorbable barriers cov-red the augmented areas. They were used to coathe implants and fill the residual space created aftereplacement of the split window. Adjunctive mate-ial was not used in all cases. Tension-free softissue closure was performed over the implantssing 4-0 or 5-0 nonresorbable sutures in all cases.fter 4 to 5 months of healing, the implants werexposed.

DELAYED LATERAL EXPANSION TECHNIQUE

The delayed lateral expansion technique was ap-lied to the ridges with a dense and thick cortexecause the expansion could be caused by fracture ofhe expanded buccal segment.

After administration of local anesthesia, an incisionas made along the ridge crest slightly toward the

ingual side, and 2 vertical incisions were made (FigsA-F). A full-thickness mucoperiosteal flap was ele-ated to expose the buccal aspect of the mandibularlveolar ridge. After completing the rectangular corti-otomies with a piezoelectric saw or erbium:yttrium-luminum-garnet laser, greenstick fractures were cre-ted in the buccal segments.

The greenstick fractured buccal segments were re-ositioned, and the mucoperiosteal flap was sutured.fter the primary surgery, a 3- to 4-week healingeriod was allowed before performing delayed ridgexpansion and implant placement as second-stage sur-ery. A crestal incision to expose the crestal cut waserformed. The buccal flap had to be minimally re-ected to preserve the blood supply for the buccalortical plate. Also, a small chisel was used to care-ully separate and mobilize the segmented bone, pro-oking a greenstick fracture. The blood supply on theuccal aspect of the displaced buccal plate was main-ained. After preparation of the implant sites usingwist drills and osteotomes, the implants were placednd bone graft augmentation was performed. Adjunc-ive material was not used in all cases. Tension-freeoft tissue closure was achieved in all cases. After 3 to

months, the third phase of surgical exposure tohange the cover screw to a healing abutment was
erformed.

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SOHN ET AL 2285

IGURE 1. Immediate lateral expansion technique (from patient 19). A, B, Rectangular corticotomies were made using a piezoelectric saw., D, After expanding buccal segmented bone using a small chisel, 2 implants were placed on the split ridge, and the intercortical space waslled with mixed bone of allograft and xenograft. E(a), Preoperative cone-beam computed tomography scans. E(b), Postoperative cone-beamomputed tomography scans. E(c), Follow-up cone-beam computed tomography scans after the 5-month healing period (implant correspond-ng to the left mandibular first molar). F(a), Preoperative cone-beam computed tomography scans. F(b), Postoperative cone-beam computedomography scans. F(c), Follow-up cone-beam computed tomography scans after the 5-month healing period (implant corresponding to theeft mandibular second premolar). G(a), Postoperative panoramic view. G(b), Follow-up panoramic view after 3 months of prosthetic loading.(c), Follow-up panoramic view after 6 months of prosthetic loading.

ohn et al. Immediate and Delayed Lateral Ridge Expansion Technique. J Oral Maxillofac Surg 2010.

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IGURE 2. Delayed lateral expansion technique (from patient 7). A, After reflecting buccal mucoperiosteal flap, rectangular corticotomiesere made using a piezoelectric saw. The mucoperiosteal flap was repositioned and closed with nonresorbable sutures. B, Delayed lateralxpansion was performed 3 weeks after corticotomies. The buccal flap was minimally reflected to preserve blood supply for buccal corticallates. C, D, Two implants were placed, and the intercortical space was filled with particulate bone grafting material. E(a), Preoperativeone-beam computed tomography scans. E(b), Postoperative cone-beam computed tomography scans. E(c), Follow-up cone-beam computedomography scans after 6-month healing period (implant corresponding to the right mandibular first molar). F(a), Preoperative cone-beamomputed tomography scans. F(b), Postoperative cone-beam computed tomography scans. F(c), Follow-up cone-beam computed tomographycans after 6-month healing period (implant corresponding to the right mandibular second molar). G(a), Postoperative panoramic view. G(b),ollow-up panoramic view after 3 months of prosthetic loading. G(c), Follow-up panoramic view after 8 months of prosthetic loading.

ohn et al. Immediate and Delayed Lateral Ridge Expansion Technique. J Oral Maxillofac Surg 2010.

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SOHN ET AL 2287

esults

A total of 32 patients with a narrow edentulousosterior mandibular ridge of 2 to 4 mm were in-luded in the present study, and 84 implants werelaced. Of the 84 implants, 63 were placed using the

mmediate lateral expansion technique and 21 werelaced using the delayed lateral expansion technique.Of the 23 patients who underwent the immediate

ateral expansion technique, malfracture of the thinuccal cortical plate occurred during ridge splitting inpatients. Of the 5 malfractured buccal plates, 1 wasxed with a microscrew and 4 were repositioned inlace after placing the implants. All buccal segmentsf the 9 patients who underwent the delayed lateralxpansion technique fractured as planned at the infe-ior horizontal corticotomy line favorably, leaving theuccal periosteum attached to the buccal segmentedone.The soft tissue healing was uneventful. None of the

atients complained of paresthesia. The criteria ofuser et al19 were used to evaluate the osseointegra-ion of the implants. The postoperative results weressessed using panoramic and periapical radiographs.fter 4 to 5 months, all implants, except for 1 case,ere stable and were surrounded by bone, and ossi-cation of the osteotomy line was obvious. In 1 pa-ient (patient 23) who underwent the immediate lat-ral ridge expansion technique, buccal bone resorptionas found at the second procedure (Fig 3). The sec-

IGURE 3. Buccal bone resorption found at second procedure inatient 23.

yohn et al. Immediate and Delayed Lateral Ridge Expansionechnique. J Oral Maxillofac Surg 2010.

ndary bone graft was performed. Fixed partial pros-heses were successful in all cases. The adjacent im-lants were splinted. The average time to prosthetic

oading was 17 months (Tables 1, 2).

iscussion

The lateral ridge expansion technique is useful foranaging the narrow edentulous ridge for implantlacement. Careful expansion of the buccal plate isssential when the lateral expansion technique issed because abnormal bone healing can result fromndue trauma to the plate.In 1992, Simion et al7 introduced a split-crest tech-

ique. The surgical technique involved splitting thelveolar ridge longitudinally in 2 parts, provoking aongitudinal greenstick fracture at the top of the boneo create a space-making defect. The created self-pacing anatomy prevented the membrane from col-apsing into the defect and augmented the surfacerom which the osteogenic cells could be recruited.his technique was indicated when a standard osteot-my could not be created because of a crest width ofmm or less.7

In 1994, Scipioni et al8 presented the clinical resultsf an edentulous ridge expansion technique. Theylaced 329 implants in 170 patients. They had a suc-ess rate of 98.8%. Scipioni et al8 suggested that wher-ver dental implants are placed, a minimal thicknessf 1 to 1.5 mm of bone should remain on both theuccal and the lingual/palatal aspects of the implantso ensure a successful outcome. This technique re-uires at least 3 to 4 mm of ridge width and can bextremely difficult or impossible to perform if theemaining bone is primarily cortical because of theisk of fracturing the expanding plates of bone and ofeing unable to stabilize the implant sufficiently tonsure predictable osseointegration.8,9

Sethi and Kaus10 reported the technique of maxil-ary expansion with simultaneous implant placement.hey placed 449 implants in 150 patients in thinaxillary ridges of adequate height and comprising 2

eparate cortical plates with intervening cancellousone and observed them for a period of up to 93onths. A 97% implant survival rate after a 5-year

bservation period was found.In the ridge splitting procedure, the corticotomies

an be performed using a No. 15 blade, Beaver blade,azor-sharp chisel, round bur, fissure bur, diamondisk, reciprocal saw, or piezoelectric device. On low-ensity bone such as the maxilla, the blade or razor-harp chisel can be efficient; however, on high-den-ity bone such as the mandible, the rotary bur,iamond disk, piezoelectric device, or laser (erbium:ttrium-aluminum-garnet, erbium, chromium-doped:
ttrium-scandium-gallium-garnet) is recommended.

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The piezoelectric saw is safer and more precisehan the conventional rotary bur or reciprocal sawhen performing osteotomies. In the present clinical

eport, a piezoelectric surgery system or erbium:ttrium-aluminum-garnet laser was used to create theertical and horizontal corticotomies. Piezoelectricevices use ultrasonic microvibrations to create an

Table 1. IMMEDIATE LATERAL EXPANSION

Pt No.Gender/Age

(yr) Site

1 F/71 Left mandibular second premolar and fimolar

2 F/53 Left mandibular first premolar, secondpremolar, and first molar

3 F/60 Left mandibular second premolar, firstmolar, and second molar

4 F/35 Right mandibular first molar5 M/49 Left mandibular first molar and second

molar6 F/62 Left mandibular first molar and second

molar, right mandibular first premolafirst molar, and second molar

7 F/42 Right mandibular first molar and seconmolar

8 F/53 Left second premolar and first molar9 F/52 Left mandibular first premolar, first mo

and second molar, right mandibularfirst molar, and second molar

10 F/38 Left mandibular first molar and secondmolar

11 F/34 Left mandibular second premolar and fimolar, right mandibular first molar asecond molar

12 M/54 Right mandibular first molar and seconmolar

13 F/59 Right mandibular second premolar, firsmolar, and second molar

14 F/30 Right mandibular second premolar andfirst molar

15 F/32 Right mandibular second premolar, firsmolar, and second molar

16 F/27 Right mandibular first molar17 F/55 Left mandibular second premolar, first

molar, and second molar18 F/66 Left mandibular second premolar and fi

molar19 F/46 Left mandibular second premolar and fi

molar20 F/55 Left mandibular first molar and second

molar21 F/60 Left mandibular first premolar, first mo

and second molar, right mandibularsecond premolar, first molar, andsecond molar

22 M/26 Left mandibular first molar23 F/50 Left mandibular first molar and second

molar

bbreviations: Pt No., patient number; F, female; M, male;

ohn et al. Immediate and Delayed Lateral Ridge Expansion Tec

steotomy, and these microvibrations make selective p

one cuts possible without soft tissue damage.20-22

oreover, more precise cuts can be performed and aeverely narrow ridge of 2 to 3 mm can be osteoto-ized.22 The erbium:yttrium-aluminum-garnet laser

llows increased hemostasis, improved visibility dur-ng surgery, a reduced incidence of infection, andeduced patient discomfort postoperatively when ap-

ean ImplantDiameter Osteotomy Device

ProstheticLoading (mo)

4.2 Piezoelectric saw 44



3.9 Piezoelectric saw 344.3 Piezoelectric saw 26


4.3 Er:YAG laser 24

4.4 Er:YAG laser 224.1 Piezoelectric saw 22




3.7 Er:YAG laser 15

4.8 Er:YAG laser 12

4.57 Er:YAG laser and piezoelectricsaw

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The lateral ridge expansion technique with simul-aneous immediate implant placement is usually per-ormed because it shortens the total treatmentime.7,10,24-26 However, in the mandible, the risk ofalfracture of the osteomized segment is great be-

ause the mandibular bone has less flexibility and ahicker cortical plate. Ridge expansion with simulta-eous implant placement has resulted in several com-lications such as a lack of initial stability for the

mplants, fracture of the buccal segmented bone, andompromised implant placement in the buccolingualnd apicocoronal direction. Enislidis et al13 and Eliant al27 recommended a staged approach to avoid post-perative complications from malfracture of the buc-al segment. Although a 2-stage approach increaseshe time, it also allows for subsequent evaluation ofhe expanded ridge and the avoidance of complica-ions. With this approach, the location of the green-tick fracture is predetermined, and perfusion for theuccal segment remains intact.In the present study, bone grafts in the intercortical

rea were performed and resorbable collagen mem-ranes were used to cover the graft, preventing softissue ingrowth into the graft site. Although somelinicians prefer to place particulate bone graftingaterials around the implants and in the intercortical

pace,16,25-28 Scipioni et al8,17 have found that a boneraft is usually unnecessary. However, they used toreate a partial thickness flap initially to preventrestal bone resorption. Simion et al,7 when theyntroduced the split-crest technique in 1992, useduided tissue regeneration with expanded polytetra-uoroethylene membrane to cover the defect and

Table 2. DELAYED LATERAL EXPANSION

Pt No.Gender/Age

(yr) Site

1 F/52 Left mandibular second premolar, firsmolar, and second molar

2 F/443 F/25 Right mandibular first molar and

second molar4 M/40 Left mandibular second premolar, firs

molar, and second molar5 F/57 Left mandibular first molar and

second molar6 F/44 Right mandibular first molar7 F/48 Right mandibular and second molar

8 M/57 Left mandibular second premolar, firsmolar, and second molar

9 F/53 Left mandibular second premolar, firsmolar, and second molar

bbreviations as in Table 1.

ohn et al. Immediate and Delayed Lateral Ridge Expansion Tec

reate a space to allow bone tissue regeneration. In

ontrast, Calvo Guirado et al25 believed that the peri-steum is the best possible biologic membrane be-ause it contains a rich supply of osteogenic cells. Inhe present clinical study, we used a tapered screw-ype implant to increase the initial stability and pre-ent buccal bone segment fracture. Brunski29 re-orted that screw-shaped implants provided thetrongest retention immediately after implant place-ent. Kan et al30 reported a notably greater implant

urvival rate for threaded implants (titanium 94.9%;A-coated 96.0%) than for nonthreaded implants (HA-oated 75.4%).The lateral ridge expansion technique is very effec-

ive for horizontal augmentations in severely atrophicosterior mandibular ridges. In the mandibular ridge,hich has low bone quality and a thin cortex, imme-iate lateral ridge expansion can be a useful proce-ure. Delayed lateral ridge expansion can be usedore safely and predictably in patients with high

one quality and a thick cortex and narrower ridge inhe mandible to avoid complete fracture of the buccalegments. In addition, delayed ridge expansion is rec-mmended when the initial stability of the implants isoor.

eferences1. Vermeeren JI, Wismeijer D, van Waas MA: One-step reconstruc-

tion of the severely resorbed mandible with onlay bone graftsand endosteal implants. A 5-year follow-up. Int J Oral Maxillo-fac Surg 25:112, 1996

2. Pikos MA: Block autografts for localized ridge augmentation.part II. The posterior mandible. Implant Dent 9:67, 2000

3. Cordaro L, Amade DS, Cordaro M: Clinical results of alveolar

an Implantiameter Osteotomy Device

ProstheticLoading (mo)


3.8 Piezoelectric saw 365.0 Laser 11


10

4.0 Er:YAG laser 10

4.0 Piezoelectric saw 84.5 Er:YAG laser and piezoelectric

saw8


7


3

. J Oral Maxillofac Surg 2010.

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ridge augmentation with mandibular block bone grafts in par-

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Documents

Immediate and Delayed Lateral Ridge Expansion …Numerous surgical techniques have been described for augmentation of the atrophic mandibular alveolar ridge. The strategies used to