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Dental Traumatology 2003; 19: 1929 Printed in Denmark.

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Copyright # Blackwell Munksgaard 2003 DENTAL TRAUMATOLOGY ISSN 16004469

Augmentation of the narrow traumatized anterior alveolar ridge to facilitate dental implant placement
' Oikarinen KS, Sandor GKB, KainulainenVT, Salonen-Kemppi M. Augmentation of the narrow traumatized anterior alveolar ridge to facilitate dental implant placement. DentTraumatol 2003;19: 19^29. # Blackwell Munksgaard, 2003. Abstract ^ Traumatic tooth loss leads to alveolar resorption especially in sagittal direction. This can be due to avulsion of bone substance during the accident itself or due to resorption of the alveolar crest that takes place afterwards. Shortage of bone can prevent proper positioning of dental implants unless the volume of bone is increased before implantation. In the maxillary anterior area, this is also an esthetic problem. Several treatment modalities have been presented to augment the bone. This report reviews the latest literature on bone grafting, bone substitutes, guided bone regeneration, osteocompression and distraction which are potentially useful in the anterior maxilla. A special emphasis is paid to the versatility of using a crestal split osteotomy, by means of chisels and osteotomes to widen the narrow ridge. Three examples are illustrated showing onlay grafting, preservation of alveolar width with alloplastic coral material and lateral widening of a narrow maxillary alveolar ridge, using the crestal splitting technique. Kyosti S. Oikarinen1,2, George K. B. ' Sandor3, Vesa T. Kainulainen2,3, Maarit Salonen-Kemppi2
Faculty of Dentistry, Kuwait University, Kuwait; Institute of Dentistry, Oulu University, Oulu University Hospital, Yliopisto, Finland; 3The Hospital for Sick Children, Bloorview MacMillan Childrens Centre and Toronto General Hospital, University of Toronto, Toronto, Canada
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Key words: alveolar resorption; narrow alveolar crest; bone augmentation; splitting of alveolar bone Dr Kyosti Oikarinen, Institute of Dentistry, University of Oulu, PO Box 5281, FIN-90014 Oulun,Yliopisto, Finland Accepted 22 May, 2002

Dental implants are established alternatives for replacing missing teeth. In the anterior maxilla esthetic demands not only require well-anchored implants but also sucient soft and hard tissue in order to achieve natural looking result. Unfortunately, this is not always achieved with dental implants. Loss of incisors and canines is followed by a considerable loss of alveolar bone, especially in sagittal dimensions. Augmentation of both hard and soft tissues before implant therapy is, therefore, an essential part of the treatment. Localizedalveolar defects are also challenging from conventional prosthodontic treatment point of view (1) and bone augmentation is needed after alveolar bone is lost due to late complications of injured teeth (2). This is especially true if a tooth replanted during its growth becomes ankylosed and submerged, pre-

venting normal growth of the surrounding alveolar crest (3). Augmentation of the resorbed alveolar crest can be achieved, for example, with onlay bone grafts, membrane techniques, bone distraction and bone splitting. Maxillary sinus oor elevation and bone grafting increases the height of bone in the maxillary premolar and molar regions (4). Bone grafting and guided bone regeneration can increase the width and, to some extent, also the height of the alveolar bone (5, 6). Lateral widening, but not vertical augmentation, is possible with a crestal split technique (7^10). A feature common to all these treatments is that they are technique-sensitive. This is why the success rates dier in various follow-up studies and no prospective study on randomized material exists to estimate the benet of various bone augmentation procedures.

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Oikarinen et al. The aim of this article is to review the current literature concerning resorption and augmentation of the narrow alveolar crest prior to implantation. It is especially aimed to review the literature on various procedures and on their suitability in restoring the anterior alveolar crest after dental and alveolar bone trauma. As examples three cases, one treated with autogenous bone graft, one with granular coral allograft in the extraction socket and one widening of narrow alveolar ridge with crestal splitting method are more thoroughly reported. Resorption of alveolar bone after tooth loss Alveolar bone is a specialized part of mandibular and maxillary bone that forms the primary support for the teeth. Alveolar bone is composed of bundles of bonewhich isbuilt up in layers in aparallel orientation to the coronal^apical direction of the tooth.The anterior maxillary bone is less dense than mandibular bone but more dense than maxillary posterior bone (7,11). Alveolar ridge defects and deformities can be the results of trauma, periodontal disease, surgical treatment or congenital maldevelopment. Resorption after tooth loss has been shown to follow a certain pattern: the labial site of alveolar crest is primarily resorbed, which rst reduces its width and later the height (11^13). Alveolar bone is resorbed after tooth extraction or avulsion most rapidly during the rst years. Extraction of anterior maxillary teeth is associated with a progressive loss of bone mainly from the labial side (13).The loss is estimatedtobe 40^60% during therst 3 years and decreases to 0.25^0.5% annual loss thereafter (14,15).The cause for resorption of alveolar bone has been assumed to be due to disuse atrophy, decreased blood supply, localized inammation or prosthesis pressure (15). In order to preserve the form of alveolar crest after tooth loss, some root replicates have been introduced. These are made of, e.g. PLA (16) or bioglass (17) and are able to preserve the crestal width and height but may impair later implantation due to incomplete resorption. Also, autogenous grafts combined with allografts (18) and resorbable membranes (19) have been usedto llthe bone defects andto prevent resorption after tooth loss. Malmgren and co-workers (20, 21) and Filippi et al. (22) have introduced a method in which the alveolar ridge is preserved by removing the crown and lling the root of an ankylosed and infra-positioned tooth. The root is left in situ for slow resorption. The esthetic outcome of implantation in the anterior partof the jaws is oftena compromise. Careful soft tissue management may sometimes be helpful. Soft tissue augmentation has been achieved with sub-epithelial connective tissue grafts, which preserve gingival color and tissue characteristics (23, 24). Allogenic grafts and various plastics have also been used for esthetic reasonsto maintainthebone and softtissue level underneath the pontic area in xed bridges (25) and in improving appearance before prosthetic treatment in localized alveolar ridge defects (1). Methods to estimate bone quantity and quality Pre-operative estimation of the width and height of alveolar bone before implantation is important. Surprises occur especially in the maxillary anterior area where thick xed gingiva may give a misleading view of the bone volume underneath (26). The density of bone canbe conrmed atbest frombiopsiestaken during implantation (27). If the width of alveolar bone could be determined prior to operation, less invasive implant insertion using apless surgery would be possible (28). Panoramic radiographs are part of routine dental care and should be used in the pre-operative evaluation of an implant site as well as for the longitudinal assessment of the success of implants (29, 30). This examination is not expensive and radiation dose is rather low. The disadvantages are that the projection geometry may cause distortion and superimposion of anatomic structures (30).The height of the alveolar crest can be determined in conventional panoramic radiograph but estimation of transverse deciencies need more advanced methods (9, 29, 31, 32). Computed tomography (CT) scans have been used in estimating bone quality and quantity before implantation (9, 33) and the gain of new bone in sinus oor augmentations (34) as well as in integration of interpositional bone grafts (7). The analysis requires multiple thin axial CT slices through the jaws. The data obtained is reformatted with special software packages to produce cross-sectional and panoramic views (35). It is possible to scale the quality of bone objectively in CTscans using Houseld Units, which have been shown to correlate strongly with subjective evaluation of the scans (33). It is also possible to obtain three-dimensional view of the implanted area (36). The advantages and disadvantages of routine CT scanning before implantation, however, have been discussed recently (35, 37). Multimodal radiograph (Scanora) illustrate the volume of bone also in lateral direction (38) and has been used in pre-operative planning of dental implants as well as in pre-operative estimation of the risk for inferior alveolar nerve damage in third molar surgery (39) or in orthognathic surgery (40). A recent review by the American Academy or Oral and Maxillofacial Radiology concluded that tomographic radiographs are sucient in planning implantation with less than seven xtures. If more

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Narrow alveolar ridge and implantation implants are inserted and especially if autogenous or allogenous grafting is used or implantation is performed due to trauma, additional CTscanning should be performed (29). Bone quality in conventional radiographs is not easy to estimate. The classication by Lekholm & Zarb divided the quality of adult jaw bone into four categories (41). T ype I bone is composed entirely of compact bone and is, fo example, the result of advanced resorption in edentulous mandible. T ype II bone has thick cortical layer and well-trabeculated spongious part while type III bone is typically composed of thin cortex and highly trabeculated spongious bone. T ype IV bone, which is the least suitable for implantation, is composed of thin cortical layer and sparse trabeculated spongious bone (41). The types II and III are found more frequently than types Iand IV ype III is most common type in the maxilla .T while type IIdominates in the mandible.The anterior mandible is the site for the densest bone followed by posterior mandible, anterior maxilla and posterior maxilla (11). Thick gingiva of upper anterior edentulous crest often gives false information about the bone availability underneath (26).The form and width of the alveolar crest can be estimated and measured from a split dental cast after the soft tissue hasbeen measuredwith endodontic needles or other instruments facilitating the measurement of the thickness of the soft tissues (42). Soft tissue should be measured in several locations in order to illustrate the form of the bone on the split cast. In a recent study, however, it was shown that accuracy of pre-operative ridge-mapping inanterior maxilla is not sucient alone to provide reliable information about the bone level (43). Methods to increase bone quantity or quality Augmentation with bone grafts At the present time, autogenous bone is the golden standard by which all techniques of osseous reconstruction of the maxillofacial skeleton must be judged. Bone grafting studies have shown, that autogenous cancellous bone produces successful and predictable results (44). Autogeous bone grafts have been in use for many years, but free grafts resorb and may cause long-term failures of implants. Freebone grafts act mostlyas scaffolds and are thus more osteoconductive than osteoinductive even though osteogenic activity may have remained in the spongious part of the graft (45). The other disadvantage of autogenous grafts is the need for a second surgical site and its associated morbidity (46). Autogenous grafts can be taken from the maxillofacial area or from distant sites such as iliac crest, tibia, bula and even scapula. Intra-oral bone grafting is sucient in treating narrow maxillary alveolar crest. It has been shown that bone grafts taken from the jaws resorb more slowly than other grafts (47^49). This might be due to the origin of jaw bones, which is membranous while other long bones mainly are endochondral (47). Membraneous bone has been shown to form vascularization of the graft more rapidly than does endochondralbone graft (50). Autogenous bone grafts are either cortical blocks, corticocancellous blocks, bone chips or compressed cancellous bone cakes. The amount of bone needed can be pre-determined using a surgical template to illustrate the amount of bone needed for implant placement. Suitable intra-oral donor sites are symphysis, maxillary tuberosity, mandibular retromolar area, and zygoma. The bone slurry produced during preparation of implant bed can be harvested using suction-connected bone collector (51^53) and the bone chips achieved can be compressed in order to increase the volume and the amount of viable cells (53). Contamination with oral bacteria is possible during harvesting procedure but this risk is decreased if harvesting is performed as aseptic as possible (54). One application of autogenous bone grafting is the transpositioning of a thin alveolar crest. The knifeedged ridge is cut with a saw preserving the soft tissue attachment. The tip is rotated downwards and xed with screws on the alveolar crest increasing the width (55). Autogenous bone grafts can be combined with allogenic materials to increase the volume. According to Rosen, the recommended relation of the total volume is 20% allogenic and 80% autogenous material (56). A meta-analysis of available bone grafting literature was performed by T ong et al. (57). Autogenous bone graft in combination with bovine-derived HA has been mixed with brin glue to improve handling of the graft and helping to maintain its position after surgery (58). Figure1(a)^(d) show the treatment of a young man, who at the age of 12 had traumatically avulsed the maxillary central incisors and the right lateral incisor. He wore a partial denture for 6 years and sustained a remarkable amount of alveolar resorption of the anterior maxilla in the sagittal direction. Once growth had ceased a bone graft was harvested to treat this decient maxillary ridge. Six months later, three dental implants were placed into the successfully incorporated bone graft. Augmentation with allogenic grafts Extensive research has been focused on the development of bone substitutes. Many of these products are

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Oikarinen et al.

Fig. 1. (a) Resorbed alveolar crest of an 18-year-old young man. T eeth were lost in an accident 6 years previously. (b) Bone graft harvested from iliac crest was used as an onlay graft. (c) Six months later, three dental implants were placed into the successfully incorporated bone graft. (d) Part of panoramic radiograph showing good incorporation of implants in bone.

based on minerals, which are found in bone (58). Hydoxylapatite (HA) is the major bone mineral. It can be also manufactured industrially. HA is nonresorbable while other coral-derived materials are gradually resorbed (59, 60). Coral granules obtained from natural coral skeletons will be completely resorbed and replaced by host bone (61) and have been used in bone augmentation procedures (59). Resorption of Bio-Oss has been observed in animal studies (62) but not in clinical trials (58, 63, 64). Bioactive glass is supposed to have osteoinductive capacity and has been tested in animal trials (65). Its clinical use has been sparse, so far. Allogenic materials have limited indications in bone augmentations. Only few of them are osteoinductive and many do not resorb but can become foreign bodies. Some animal-derived bone products might be abandoned in the future due to the risk of transmitting diseases. Allogenenic materials can be mixed with bone chips and thus decrease the amount

of bone graft needed, which in this case can be harvested from intra-oral sites (58). A case of a 14-year-old girl losing her maxillary right central incisor due to trauma is presented in Fig.2(a)^(d). An alveolar sparing procedure wasused by placing coral granules into the extraction socket when the tooth was removed due to ankylosis. Three years later, once growth had ceased a dental implant was placed into the alveolus and the missing tooth was restored. Guided bone regeneration Guidedbone regeneration (GBR) hasbeenused inthe treatment of vertical periodontal pocketsbut has been also introduced for minor augmentation procedures prior to dental implant placement (66^68). GBR is a technique in which bone growth is enhanced by preventing soft tissue ingrowth into the area and utilizes either resorbable or non-resorbable membranes.

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Narrow alveolar ridge and implantation

Fig. 2. (a) Lateral view of narrow alveolar crest of a 14-year-old girl who lost her maxillary right central incisor due to trauma. (b) Occlusal view of the incisor area. (c) The alveolar width was spared by placing coral granules into the extraction socket when the tooth was removed due to ankylosis. (d) Occlusal radiograph 3 years later. Dental implant was placed at this stage after the growth had ceased.

Metallic membranes (69) or membranes supported by titanium frame (6, 68,70) have been tested. Acellular dermal matrix has been used as a barrier membrane with demineralized freeze-dried bone allograft (71). Membranes in general are a controversial issue in implantology and their use is at least very technique sensitive (72). Non-resorbable membranes need a second operation for their removal (69) and resorbable membranes can give rise to inammation (73). Intact periosteum or a split palatal gingival ap are regarded by some authors as natural membranes (17). Still, however, good results with augmentation procedures using membranes have been presented (5,7, 66, 68,70).Vertical increase of a narrow alveolar crest has been shown to be possible with membranes (68, 69). Membranes are often accompanied with bone grafts beneath them (74). Also, here autogenous bone chips are superior to demineralized allogenic grafts (70).

Osteoinduction, osteopromotion, and osteoconduction Osteoinduction denes a process whereby new bone is produced in an area where there was no bone before. This process requires the participation of tissue factors. Osteoconduction describes the facilitation of bone growth along a scaolding of autogenous or allogenic materials. Osteopromotion enhances the growth of bone and is possible with some allogenic materials. Most allografts are osteoconductive even though mixing them with bone-inductive factors might change this pattern into a more osteoinductive type (58,75). Bone morphogenic protein (BMP) is most available from bovine bone. BMP has been tested in animal trials (76) but have also been used clinically (77). Concern regarding the immunogenicity of interspecies BMP has been raised in the literature. Moose-derived BMP showed, however, strong osteoinductive capacity and weak immunogenicity in a sheep study (78).

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Oikarinen et al. Demineralized bone matrix (DBM) has been shown to contain BMP and may be used as a bone substitute with predictable healing in critical-sized rabbit calvarial defects (79). Platelet-rich plasma (PRP) containing bone growth factors such as platelet-derived growth factor (PDGF) is separated from the patientss own blood and is, therefore, better acceptedthan animal-derived products. This is possible with an equipment, which separates platelets from serum. The inventors of the technique have shown excellent healing capacity and growth potential in cases where autologous bone chips are mixed with PRP (80, 81). Centrifuged PRP contains platelet-derived growth factors, which in combination with autogenous bone increase the maturation of graft up to two-fold and also increase the bone density of the graft (81). Osteocondensation Osteocondensation physically reshapes the bone of the maxilla to optimally receive a dental implant, resulting in better primary stability and increases cone density in areas of poor bone quality. Osteocondensation is best performed in the maxilla in which type III is the dominant type of bone. Osteogenic cells are maintained at the implant site. Osteocondensation is performed with osteotomes, which compress the bone but osteocompression can also be achieved in either jaw with dental implants (82^84). An implant bed is created without drilling or with minimal removal of bone. This is possible in maxilla but less so in mandible and is especially benecial in type III and IV bone. Implants producing osteocondensation can be press-t xtures (82).The major benet of osseocondensation is that the bone, which otherwise would be removed by drilling, is preserved (10). The major author of osteocondensation in oral and maxillofacial surgery is Robert B. Summers. In 1994 and 1995, he published methods to increase the width of alveolar bone and to facilitate sinus oor elevation without opening the lateral sinus wall (83^87). T atum further developed the technique and used D-shaped osteotomes as well as Crestosplit chisels ( J van Straten Medische T echniek, Nieuwegein, the Netherlands) (88). In addition to lateral widening, both sets of instruments are able to produce osteocompression and increase the density of cancellous bone (10). Ridge expansion osteotomy (REO) is achieved with osteotomes which have concave tips and sharpened edges. The instruments are shaped in such a way that the next larger osteotome tip ts into the opening created by the previous one. Instruments are sensitive to changes in bone texture and density and allow excellent tactile sensation for the surgeon. REO can even be used without drilling although initial opening of the cortical surface allows better access to the spongious part. Patience by the operator is needed between tapping new chisels in order to allow the previous instrument to adjust in the bone and to decrease heating caused by friction (85). REO can be used in all parts of the maxilla even in cases where alveolar crest has undercuts which can be reduced by bulging out the base of the buccal bone. Straight-in osteotomes have access also to the posterior parts of the maxilla (83, 84). The minimum alveolar width for alveolar splitting needed is 3 mm assuming that spongiousbone isfound betweencortical layers (85). As narrowas 2 mmalveolar crest have been shown to be suitable for alveolar splitting (9). Distraction of low and narrow alveolar crests Osteodistraction of long bones in growing children has been used for decades and is based on secondary wound healing. The resulting distraction gap is initially lled with callus and later with bone (89). Osteodistraction has also been adopted into maxillofacial area and special devices and implants undergoing development for that purpose (90^92). One application of distraction is orthodontic extrusion of the root tip of a periodontally injured tooth. Slow extrusion brings the surrounding alveolar bone higher, thus decreasing and eliminating the defect caused by vertical periodontal pockets (93). The distraction technique has also been adapted for limited augmentations of the alveolar crest prior to implantation. Some of the systems use equipments, which are removed in conjunctionwith implant placement (92) and some utilize the implant itself as the distraction device (90, 91, 94). The benets of distraction are that donor site problems of grafts and dehiscences of grafted bone are avoided (94). However, a second surgery is needed if implant-based distraction is not used. The daily rate of alveolar crest distraction is approximately 0.25^0.5 mm and is initiated in 1week after the primary osteotomy. Distraction is continued up to 30 days and the nal gain will be between 4 and 7 mm (91, 95). In some cases overcorrection is recommended (91). However, some limitations due to the lack of stretching of the palatal tissues, may not allow the distracted segment to move exactly as planned. Appliances allowing three-dimensional distraction have been presented (17, 92). Implants are placed in the best available bone and later moved into a prosthetically desirable position following segmental osteotomy (92). The three-dimensional distraction can be adapted to any implant system.

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Narrow alveolar ridge and implantation Widening of alveolar crest with chisels Alveolar reconstruction or alveolar widening with osteotomes and chisels produces a greenstick fracture leaving the remaining periosteum attached to the bone.This periosteally pedicled buccal cortex is repositioned and a new implant bed is created without even drilling. Lateral widening completely exposing the labial cortex has been introduced (96). The major benet ofcrestalwidening is that the thin alveolarbone canbe utilized for implantationwithout grafting. Esthetics and implant positioning is improved and wider implants can be used. Grafting between the fractured cortical lamellae is better integrated and opening of marrow space improves vascularization and healing (8). The direction of forces by chisels should be aimed palatally to decrease the damage exerted on fragile andthin labial plate andthe surgeon should be patient and appreciate the time needed for manipulation of bone. The bone can be molded to some extent due to its viscosity (10). Bone compression is also achieved as well as an increase in the density of trabeculocity in the adjacent site (34). The resulting gap can be covered by nonresorbable membrane (5, 8) and lled with allogenic material (8). Interpositional autogenous bone grafts have been used to improve bony healing in the gap (7). Membranes do not necessarily improve the prognosis (10). Lamellar cortical splitting can be initiated with a diamond disc or burs and nalized with osteotomes (8, 96). The nourishment to the buccal lamella is maintained through unattached periosteum. The method by Engelke had additional vertical cuts distal to the site of implantation and xed the fractured lamella with a microplate to achieve good implant stability (8). Implants inserted in alveolar bone in which the width hasbeen increasedby means of lateralwidening have been shown to give success rate between 86 and 97% (8, 9).This should be regarded as a very acceptable result and is comparable with implantation without bone augmentation. A case is presented in Figs.3(a^d) and 4(a^d). The patient is a 40-year-old woman who had lost all her upper incisors,10 years previously. Resorption due to misuse and pressure caused by a removable partial

Fig. 3. (a) Narrowing of anterior alveolar crest had occurred on a 40-year-old woman, who had lost all her upper incisors, 10 years previously. (b) Intraoperative view of alveolar splitting using chisels. (c) Four implants were inserted in the split gap without additional bone grafting. (d) Clinical view after second operation, which took place 6 months after the first one.Widening of the alveolar crest is obvious.

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Fig. 4. (a) Periapical radiograph 6 months after widening operation and implant placement showing acceptable osseous healing around implants. (b) Abutments inserted. (c) Clinical view of the area immediately after bridge fixation. (d) Smile view of the area illustrating that some adjustment of the color of the bridge is necessary.

denture has narrowed the crest especially in the labial side.Vertical loss was less which is why splitting technique was possible. Four implants each 13 mm in length and 3.5 in diameter were inserted. The treatment was successfully completed approximately 6 months after the rst operation. Acknowledgements ^ Supported by Grant Kuwait University, DS 01/01. References
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