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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: [email protected]
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 spreader1.8mm 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.
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