Abstract
Alveolar crest-splitting and horizontal distraction is an established surgical technique to enable implant insertion into the narrow, lateral atrophic alveolar crest. This surgical technique is challenging for the oral surgeon and restricted to crest-widths of 3 - 5 mm: significant procedural bone loss at osteotomy, the need to prepare a full thickness mucoperiostal flap and milling a baseline-osteotomy to weaken the bone for distraction inhere significant risks of accidental fractures. Aim of the study was to investigate if the recently developed novel Flapless Piezotome enhanced Crest-Splitting and Widening Technique (FPeCSWT) could safely narrow down the indication for this procedure to narrow alveolar crests of widths of even less than 2 mm in a three-year survey-period. 239 patients underwent 261 FPeCSWT-surgeries and 488 implants were inserted simultaneously in the upper and the lower jaw and clinical parameters such as intrasurgical complications, patient morbidity, implant loss and vertical bone loss (VBL) in the first three years after surgeries were recorded comparing sites with less than 2 mm width with sites of more than 2 mm. After three years a significant difference (p = 0.24) of VBL could be observed between the group with less than 2 mm crest-width (mean: 0.97 mm, max: 2.0 mm/min: 0.0 mm; SD: 0.41) compared with the group with more than 2 mm crest-width (mean: 0.69 mm, max: 1.5 mm/min: 0.0 mm; SD: 0.36) but was still significant lower when compared with the results of similar studies published with a mucoperiostal-flap approach and baseline bone-cut. The cumulative 3-year-implant-survival-rate was 98.8%, no accidental fracture of the distracted buccal bone-plate occurred. The re-sults of the study suggest that the FPeCSWT narrows safely down the indication for crest-splitting to also crest-widths of only 1 mm. The procedure is highly predictable and significantly reduces the challenge of surgical skills and leads to negligible patient-morbidity. The higher VBL in crest-widths of less than 2 mm can easily be compensated by subcrestal placement of implants.
Highlights
The alveolar crest in the upper and lower jaw is the result of growth of the permanent dentition and loses its biological function when teeth are removed, resulting in a typical atrophy pattern [1] [2]: in a first phase of 5 - 12 months a significant centripetal reduction of crest-width up to 50% but only little loss of crest-height can be observed (Figure 1) with a concomitant reduction of vascularization and is only later followed by vertical atrophy
A total of 239 patients aged from 29 yrs to 82 yrs fulfilling the inclusion criteria underwent 261 Flapless Piezotome-enhanced Crest-Split and Widening-Technique (FPeCSWT)-surgeries and 488 dental implants were inserted simultaneously (Table 1) in the upper and the lower jaw (Table 2)
All surgeries were performed uneventful mainly in the Upper Jaw anterior canine-to-canine and the Lower Jow lateral premolar-to-molar region (Figure 22) and no complications such as unintentional vertical or baseline fractures of the distracted buccal bone-plate had to be recorded, all planned implants were inserted with an average Insertion Torque Value (ITV) of 40 Ncm both in the Upper and Lower Jaw (Table 3) and no adverse events or complications occurred in the immediate postsurgical phase and within the first year after surgery in both patient-groups
Summary
The alveolar crest in the upper and lower jaw is the result of growth of the permanent dentition and loses its biological function when teeth are removed, resulting in a typical atrophy pattern [1] [2]: in a first phase of 5 - 12 months a significant centripetal reduction of crest-width up to 50% but only little loss of crest-height can be observed (Figure 1) with a concomitant reduction of vascularization and is only later followed by vertical atrophy. With the introduction of ultrasonic surgical instruments (“Piezotomes”) the applicability of the crest-split technique was narrowed down to crest-widths of 2 mm by the more bone-conserving primary osteotomy but still demanded the highly invasive preparation of a full-thickness mucoperiostal flap and comprised the significant risk of accidental iatrogenic vertical fractures or total baseline-fractures of the distracted buccal cortical boneplate by osteotomes, chisels, widening screws or mechanical distractors [15] [16] due to the need of weakening the buccal bone-plate by milling bone-cuts into the distraction-baseline which might lead to a complete failure of the surgical procedure or at least to devitalization of the distracted buccal bone-plate and highly challenges the experience and skills or the oral surgeon [12]
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