Horizontal Bone Augmentation with Simultaneous Implant Placement Using Ridge Splitting with Sticky Bone Versus Onlay Sticky Bone Graft

doi:10.21203/rs.3.rs-4901038/v1

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Horizontal Bone Augmentation with Simultaneous Implant Placement Using Ridge Splitting with Sticky Bone Versus Onlay Sticky Bone Graft

https://doi.org/10.21203/rs.3.rs-4901038/v1

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Introduction: A variety of bone grafting techniques had been used to augment horizontally deficient alveolar bone ridges to provide a sufficient bone volume to achieve a correct prosthetic 3-dimensional placement of dental implants.

Objectives: to evaluate clinically and radiographically by cone beam computed tomography (CBCT) the amount of horizontal bone gain between two different augmentation techniques for horizontal ridge deficiency with simultaneous implant placement; using piezo-assisted ridge splitting technique with sticky bone graft versus Onlay sticky bone graft in patients who had bilateral posterior edentulous sites in the maxillary ridge.

Materials and methods: Seven patients including a total of 14 sites; 7 sites for each treatment modality. Each patient had bilateral posterior maxillary edentulous areas with horizontal ridge deficiency ranging from 3-5 mm. The augmentation sites were randomly divided into two groups; Piezo-assisted ridge splitting technique with simultaneous implant placement and Onlay sticky bone graft with simultaneous implant placement. Patients were evaluated for clinical parameters, including ridge width using a bone calliper, radiographic assessment of marginal bone width and alveolar bone density using CBCT, clinical attachment loss, plaque index, bleeding on probing and pocket depth. Results were obtained at surgery time, 6 months post-surgery, and 18 months post-surgery.

Results: there was a statistically significant increase in bone width in both groups, Also, bone density was slightly increased at implant and grafting sites at 6- and 18-months follow-ups. Furthermore, both groups showed a statistically significant increase in bone width measured by bone calliper at baseline and at 6 months post-surgically. There was no statistical difference between the two groups' bone gain measurements. No significant changes were observed in PI, BOP, or CAL.

Conclusion: Both surgical techniques provided promising clinical and radiographic outcomes with no statistically significant differences among them.

Implant Dentistry

Ridge Splitting

GBR

Nano HA

Sticky Bone

CBCT

Sufficient alveolar bone volume with favorable architecture of the alveolar ridge is mandatory for achieving proper three-dimensional prosthetic position of dental implants to obtain an ideal functional, esthetic and prosthetic outcome. Knowledge about the healing process at extraction sites, including contour changes caused by bone resorption and remodeling is essential^(1,2)

Subsequent to tooth extraction, the alveolar process will undergo remodeling process. The greatest amount of bone loss is in the horizontal dimension and occurs mainly on the facial aspect of the ridge. There is also, a loss of vertical ridge height, which has been described to be most pronounced on the buccal aspect⁽³⁾.

Such a remodeling process can result in a narrower and/or shorter ridge which is associated with the relocation of the ridge to be in a more palatal/lingual position. Moreover, the defect resulting from the loss of a tooth may be magnified by previous bone loss due to periodontal disease, endodontic lesions, or trauma. Such a situation becomes even more compromised when the alveolus has lost walls or height. Assessment of ridge contour at healing sites after bone resorption following teeth extraction is essential for proper treatment planning^(4,5)

Preservation or recontouring of the alveolar process is one of the keys to achieve optimal implant aesthetics and stable long-term results. Various augmentation techniques have been used successfully for the reconstruction of the volume of alveolar ridge including the use of Onlay grafts; either block or particulate, guided bone regeneration, distraction osteogenesis and ridge splitting^(6,7).

Nanotechnology has significantly improved bone graft material properties by stimulating bone cell growth to mimic the natural bone nano-composite architecture and overcoming limitations in bone regeneration. These nanostructured materials offer better performance properties such as close contact with tissues, quick resorption, and high number of molecules on its surface. Undisturbed osseous-integration and complete resorption of nano hydroxyapatite paste occur within 12 weeks of treatment^(8,9).

Platelets contain a storage of different growth factors, which are unrestricted and get released on the tissues after injury. These include transforming growth factor β (TGF-β), platelet-derived growth factor, insulin-like growth factor, and fibroblast growth factors which proceed as differential factors on regenerating periodontal tissues⁽¹⁰⁾.

In thin atrophic ridges, bony defects can be augmented by bone graft supported by autologous concentrated growth factors (CGF) enriched bone graft matrix (Sticky Bone). CGF can be used as alternative to traditional barrier membranes to cover bone graft with promising acceleration of tissue regeneration. CGF is theorized to produce much larger, denser and richer fibrin matrix containing more growth factors by the altered centrifugation speeds protocol⁽¹¹⁾.

Due to lack of studies comparing between the effects of horizontal ridge augmentation utilizing ridge splitting technique with sticky nano hydroxy apatite bone graft and Onlay bone grafting technique using sticky nano-hydroxyapatite bone graft with collagen membrane. So, the present study is conducted based on the null hypothesis to evaluate and compare clinically and radiographically between the two previously mentioned techniques with simultaneous dental implants placement.

I. PATIENTS

A split mouth randomized controlled clinical and radiographic study with allocation ratio 1:1. Seven patients with total number of 14 implant sites; 7 sites for each treatment modalities. Each patient had bilateral posterior maxillary edentulous areas with horizontal ridge deficiency ranged from 3-5 mm. The patients were recruited from the outpatient clinic of Oral Medicine, Periodontology, Oral Diagnosis and Radiology Department, Faculty of Dentistry, Tanta University. Sites either right or left in the same patient were randomly selected using sealed envelopes for each participant enrolled in the study and fulfilled the eligibility criteria as following:

· Ridge Splitting Technique with Sticky Bone Graft Group: Seven implants (n=7 implants) were installed simultaneously utilizing crestal ridge splitting technique with sticky bone graft.

· Onlay Bone Grafting with Sticky Bone: Seven implants (n=7 implants) were installed simultaneously utilizing Onlay bone grafting technique with sticky bone graft covered with collagen membrane.

Selection Criteria for Patients:

Inclusion criteria:

- Patients with absence of any relevant medical condition that contraindicate dental implant placement. (ASA I patient)⁽¹²⁾

- Optimal compliance as evidenced by no missed treatment appointments and a positive attitude toward performing oral hygiene measures.

- Patients age ranged between 30 to 50 years of both genders.

- Maxillary alveolar ridge with bone density (D3).

- Alveolar bone ridge of minimum height of 10 mm and crestal bone width ranges from 3.5 mm to 5 mm.

Exclusion criteria:

- Insufficient vertical inter-arch space to accommodate the restorative component.

- The presence of severe buccal undercut.

- Thin gingival phenotype.

- Patients with parafunctional occlusal habits.

- Smokers and pregnant women.

II . Materials:

· Implant System: Imax NHSI implant system: Fixture macro and micro design - Implant surgical kit - Collagen membrane Nano hydroxyapatite bone graft - Piezo-electric device - Centrifuge apparatus: iFuge D06 – Neuation - Blood sample collection kit - Surgical kit.

III. Methods:

A. Pre-surgical assessment: Clinical assessment- Presurgical clinical evaluation modalities: Plaque control record⁽¹³⁾, Bleeding on probing and Radiographical assessment by Cone beam computed tomography (CBCT)

1. Phase І therapy.

2. Surgical phase:

• Ridge Splitting Technique with Sticky Bone Graft Group:

· Flap design and reflection,

· Alveolar ridge splitting and expansion,

· Implant bed preparation and installation

· Application and stabilization of the graft material

· Membrane stabilization and flap closure

• Onlay Bone Grafting with Sticky Bone Group:

· Flap design and reflection

· Implant bed preparation and implant installation

· Ridge augmentation

· Membrane stabilization and flap closure

3. Post-surgical care and instructions

4. Prosthetic phase.

5. Maintenance phase

6. Post-surgical evaluation:

· Clinical evaluation: Assessment of bone ridge width using bone calliper - Bleeding on probing (BOP) - Clinical attachment level around dental implants (CAL)⁽¹⁴⁾

· Radiographic evaluation post-surgically with fusion between CBCT views done at the interval periods

Biodata: The study encompassed a total of seven patients; 2 males and 5 females. Their age ranged from 32 to 45 years old with a mean ± SD of 36.28 ± 4.42 years.

I. Clinical evaluation

Marginal Bone Level Bone Caliper (mm)

At Base line: in the Ridge Splitting Group, the marginal bone level bone caliper (mm) ranged from 3.05 to 5.00 with a mean ± S.D. of 4.05 ± 0.68 (mm), while in the Onlay Sticky Bone Graft Group, it ranged from 3.35 to 4.26 with a mean ± S.D. of 3.89 ± 0.35 (mm), there was no statistically significant difference in the pre-surgically marginal bone level bone caliper between the two studied groups (p =.474).

Six months post-surgically: In the Ridge Splitting Group, the marginal bone level bone caliper ranged from 6.25 to 9.56 with a mean ± S.D. of 7.40 ± 0.83 (mm), while in the Onlay Sticky Bone Graft Group, it ranged from 6.26 to 8.89 with a mean ± S.D. of 7.51 ± 0.95 (mm), There was no statistically significant difference in the marginal bone level bone caliper between the two studied groups after six months post-surgically (p =.759)

In each group, comparison of the marginal bone level bone caliper showed significant increase after six months compared with presurgical base line in the Ridge Splitting and Onlay Groups. (p<.001 and p<.001, respectively) table 1

II. Radiographic evaluation

Marginal Bone Level Bone Using CBCT: table 2

Pre-surgically, In the Ridge Splitting Group, the marginal bone level CBCT (mm) ranged from 3.15 to 4.80 with a mean ± S.D. of 3.98±0.61 (mm), while in the Onlay sticky bone Graft Group, ranged from 3.25 to 4.25 with a mean ± S.D. of 3.88 ± 0.37 (mm). There was no statistically significant difference in the pre-surgical marginal bone level CBCT between the two studied groups (p =.603).

Immediately post-surgery: In the Ridge Splitting Group, the marginal bone level CBCT ranged from 6.87 to 10.66 mm with a mean ± S.D. of 8.55 ± 1.13 mm while, in the Onlay Sticky Bone Graft Group it ranged from 7.05 to 9.94 with a mean ± S.D. of 8.60 ± 0.96 mm. There was no statistically significant difference in the marginal bone level CBCT between the two studied groups immediately post surgically (p =.890)

Six months post-surgically: In the Ridge Splitting Group, the marginal bone level CBCT (mm) ranged from 6.27 to 9.67 with a mean ± S.D. of 7.60 ± 0.84 mm) while the Onlay Sticky Bone Graft Group it ranged from 6.14 to 8.98 (mm) with a mean ± S.D. of 7.47 ± 1.00 mm. There was no statistically significant difference in the marginal bone level CBCT between the two studied groups after six months post surgically (p =.728)

Eighteen months post-surgically: In the Ridge Splitting Group, the marginal bone level CBCT ranged from 6.20 to 9.40 with a mean ± S.D. of 7.46 ± 0.80 mm, while, in the Onlay Sticky Bone Graft Group it ranged from 6.02 to 8.87 with a mean ± S.D. of 7.39 ± 0.99 mm. There was no statistically significant difference in the marginal bone level CBCT between the two studied groups after eighteen months post surgically (p =.843).

In each group, repeated measures analysis showed a statistically significant change in the marginal bone level CBCT between the different points of measurement in the Ridge Splitting and the Onlay Sticky Bone Graft Groups (p<.001 and p<.001, respectively).

Pairwise comparison revealed that in Ridge Splitting Group, the marginal bone level CBCT showed a statistically significant increase immediately post-surgically, six months post-surgically and eighteen months post-surgically compared with pre-surgical marginal bone level CBCT (p < .001, p < .001, and p < .001, respectively). The marginal bone level CBCT at six months post-surgically and eighteen months post-surgically showed a statistically significant decrease compared with immediate post-surgically marginal bone level CBCT (p =.001, and p =.001, respectively). The marginal bone level CBCT at eighteen months post-surgically showed a statistically significant decrease compared with six months post-surgically marginal bone level CBCT (p< .001).

Pairwise comparison revealed that in Onlay Sticky Bone Graft Group, the marginal bone level CBCT showed a statistically significant increase immediately post-surgically, six months post-surgically and eighteen months post-surgically compared with pre-surgically marginal bone level CBCT (p < .001, p < .001, and p < .001, respectively). The marginal bone level CBCT at six months post-surgically and eighteen months post-surgically showed a statistically significant decrease compared with immediate post-surgically (p < .001, p <.001, respectively). The marginal bone level CBCT at eighteen months post-surgically showed a statistically significant increase compared with six months post-surgically (p <.001).

Secondary outcomes:

I. Clinical evaluation

- Probing Depth (mm): In the Ridge Splitting Group, the probing depth (mm) ranged from 2.00 to 2.40 with a mean ± S.D. of 2.24 ± 0.16 mm, while in the Onlay Sticky Bone Graft Group, it ranged from 2.00 to 2.40 with a mean ± S.D. of 2.19 ± 0.13 mm. There was no statistically significant difference in the probing depth between the two studied groups (p =.414) table 3

- Bleeding on probing (mm) (at 18 months post-surgery): In the Ridge Splitting Group, the bleeding on probing ranged from 0.00 to 0.40 with a mean ± S.D. of 0.24 ± 0.16 mm, while in the Onlay Sticky Bone Graft Group, it ranged from 0.00 to 0.40 with a mean ± S.D. of 0.19 ± 0.13 mm. There was non-statistically significant difference in the bleeding on probing between the two studied groups after eighteen months post-surgically (p=.414) table 3.

- Plaque index (PI) (pre-surgically, 6 months and 18 months post surgically): There was no statistically difference in mean values of plaque indices pre-surgically, 6 months and 18 months post-surgically).

- Clinical Attachment Loss (mm) (at 18 months post surgically): In the Ridge Splitting Group, the clinical attachment loss ranged from 0.00 to 0.40 with a mean ± S.D. of 0.24 ± 0.16 mm while in the Onlay Sticky Bone Graft Group, it ranged from 0.00 to 0.40 with a mean ± S.D. of 0.19±0.13 mm. There was no statistically significant difference in the clinical attachment loss between the two studied groups after eighteen months post-surgically (p =.414). table 3

II. Radiographic outcomes

Bone Density Before implant placement (HU) (Table 4)

At Base line: In the Ridge Splitting Group, the bone density ranged from 370.00 to 450.00 with a mean ± S.D. of 406.92 ± 24.63 HU, while in the Onlay Sticky Bone Graft Group, it ranged from 370.00 to 450.00 with a mean ± S.D. of 405.38 ± 24.36 HU. There was no statistically significant difference in the before implant bone density between the two studied groups (p =.874)

Six months post-surgically: In the Ridge Splitting Group, the bone density ranged from 420.00 to 520.00 with a mean ± S.D. of 469.23 ± 32.78 HU, while in the Onlay Sticky Bone Graft Group, it ranged from 420.00 to 500.00 with a mean ± S.D. of 457.69 ± 25.55 HU. There was no statistically significant difference in the bone density between the two studied groups after six months post-surgically (p =.327).

Eighteen months post-surgically: In the Ridge Splitting Group, the bone density ranged from 600.00 to 750.00 with a mean ± S.D. of 660.00 ± 52.12 HU, while in the Onlay Sticky Bone Graft Group, it ranged from 600.00 to 750.00 with a mean ± S.D. of 660.77 ± 48.56 HU. There was no statistically significant difference in the bone density between the two studied groups after twelve months post-surgically (p =.969)

In each group, repeated measures analysis showed a statistically significant increase in the bone density among the different points of measurement in the Ridge Splitting Group (p < .001), and in the Onlay Sticky Bone Graft Group (p < .001).

Pairwise comparison revealed that in the Ridge Splitting Group, the bone density showed a statistically significant increase at six months post-surgically and at 18 months post-surgically compared with before implant bone density (p < .001 and p < .001, respectively). The bone density at twelve months post-surgically showed a statistically significant increase compared with bone density at six months (p <.001)

Pairwise comparison revealed that in the Onlay Sticky Bone Graft Group, the bone density showed a statistically significant increase at six months post-surgically and at twelve months post-surgically compared with before implant bone density (p <.001 and p <.001, respectively). The bone density at 18 months post-surgically showed a statistically significant increase compared with bone density at six months (p <.001). table 5a and 5b

Many bone augmentation procedures are performed to achieve the concept of prosthetically driven implant placement concept to restore both esthetic and function^{(15, 16)}. The aim of current study was to compare two different bone augmentation techniques with simultaneous implant placement using ridge splitting technique with sticky bone graft versus guided bone regeneration using Onlay sticky bone graft with collagen membrane.

In the current study, regarding selection of the implant system, iMAX dental implant system was selected for many reasons specially the rough surface of implant body which was roughened by sandblasting and acid etching which facilitated the adherence and deposition of osteoid tissue matrix on the roughened implant surface, this is in accordance with Juodablalys et al.,⁽¹⁷⁾ who stated that the surface roughness increases implant surface area, widens the implant-bone surface area, produces firmer mechanical interlock and allowing easily attachment, proliferation, and differentiation of osteoblasts on the implant surface.

Crestal ridge splitting was done using piezo-electric device with a sequence of piezoelectric tips at operating frequency ranging from 22 to 35 kHz. The piezo-electric tips were used progressively in order of size starting from B1 to B4. Using, tips in sequence and adhering to this method allowed for a bone sparing osteotomy and minimize mechanical stress on the alveolar ridge which avoided undesired fractures being caused in the bone segments.

This is in accordance with Moro et al.,⁽¹⁸⁾ who stated that the advantages offered by using piezo-electric device are the protection of the delicate anatomical structures, the ability to modulate the depth of the cut, and the precision of the incision, which permitted their usage even for the expansion of very thick alveolar ridge. These tips have made alveolar ridge split technique simple, safe, and effective for the treatment of horizontal and vertical bone defect. On the contrary, using rotary devices other than piezoelectric device such as carbide tungsten bur, air driven rotary hand pieces and oscillating saws, micro saw and rotary discs are associated with a risk of uncontrolled traumatic cutting, and this is in consistent with the systematic review conducted by Jha et al., ⁽¹⁹⁾ .

The maximum insertion torque of implants ranged between 20N-CM and 50N-Cm. As Pérez-Pevida et al., ⁽²⁰⁾ showed that if insertion torque was below 20N-CM, this would cause micromotion and affect proper osseointegration, while if insertion torque was greater than 50N-Cm., this would cause marginal bone loss.

The gap created after ridge splitting was grafted with nano bone graft material mixed with concentrated growth factors to achieve the form of sticky bone graft; this allowed to achieve less horizontal bone loss due to the unavoidable sequalae of the bone bounce effect combined with ridge splitting technique, this is in accordance with Ella et al., ⁽²¹⁾ who stated that the application of bone substitutes into the gap between the bone plates after surgical ridge splitting resulted in significantly less horizontal bone resorption compared to the application of alveolar ridge splitting without application of a bone augmentation material. And this was reflected in the results with less marginal bone loss noted at 6 and 18 months follow ups where there was a statically significant intra–group increase in bone width gain, while there was no statistically significant difference of bone width gain at the follow up periods.

In the current study, nano bone graft was selected as it has highly porous silica gel matrix where the molecular silica particles were released by decomposition of the carrier leading to speeding up vascularization of the defect and thus promoting wound healing. This was followed by decomposition of the granulate by osteoclasts, then the granulate was permeated by tissue paths, this was followed by formation of woven bone around it, finally the woven bone was replaced by lamellar bone.

This is in consistent with Hommos AMA et al.,⁽²²⁾ who used nano bone graft material in the gap created after ridge splitting procedure and reported that; placement of bone graft materials showed very good prognosis regarding bone formation rather than leaving a gap without placement of any bone graft. Moreover, this was supported by Abd El-Fattah et al.,⁽²³⁾ who reported that nano bone graft shows more benefits as its shape, structure, and composition are similar to those of hydroxyapatite in human bone. And also, similar in size to natural inorganic minerals in bone, facilitating its identification by the cells and molecules in the human body. Also, it has good osteoconductive properties, and its mechanical properties, especially compressive strength, flexural strength, and modulus of elasticity, are similar to those of human cortical bone. Therefore, nano graft materials have better biological performance and are becoming a preferable choice as a replacement material for treatment of bone defects⁽²⁴⁾.

On the contrary, nano bone is alloplastic material lacking the osteogenic and osteo-inductive properties which is a critical factor in bone regeneration. So, in the current study it was mixed with concentrated growth factors prepared from platelet concentrates in the form of sticky bone, this added increased ability for regeneration and bone gain. Sticky bone was used in the two surgical techniques to standardize the effect of the graft material. The results showed that there was a statistically significant intra-group bone width gain at 6 and 18 months follow ups as if compared to bone width pre-surgically. And upon inter-group comparison, there were no statistically significant differences between the two studied groups.

This is in accordance with Soni et al.,⁽²⁵⁾ who stated that; filling the defect area and exposed implant threads with sticky bone and covering it with autologous PRF membrane accelerates the bone formation and wound healing. Moreover, Sohn et al., ⁽²⁶⁾ mentioned that obtaining the sticky form of bone graft would prevent micro and macro movement of grafted particles, so the volume of bone augmentation is maintained during healing period. Therefore, the need for block bone and titanium mesh is minimized. Also, fibrin network entraps platelets and leukocytes to release growth factors, so bone regeneration and soft tissue healing was accelerated; and this was shown in our results where no dehiscence happened post surgically. Fibrin interconnection also minimizes soft tissue ingrowth into sticky bone graft, so this would enhance the outcomes of bone augmentation surgeries and minimizes the shrinkage during bone healing.

In the current study, cross-linked collagen membrane was used in Onlay Bone Grafting with Sticky Bone Group to fulfill the concept of GBR. The result of the current study showed that there was a statistically significant intra-group improvement in all the clinical parameters including the horizontal ridge width (HRW) gain, with mean gain achieved was 2,7 mm, and this is comparable with the results of Aboelela et al., ⁽²⁷⁾ who evaluated the efficacy of GBR using bone graft in combination with CGF and a native collagen membrane and showed that there was a mean gain of bone of about 2.4 mm. And this also goes in accordance with a study conducted by Tony et al., ⁽²⁸⁾; aimed at evaluating the outcomes of using sticky bone with and without a collagen membrane during horizontal alveolar ridge augmentation procedures, where the study showed that there was also a significant increase in horizontal ridge width.

Collagen membrane was used in the current study based on the results of the study reported by Friedmann et al., ⁽²⁹⁾ related to the advantages of the early generations of bio-absorbable membranes including their manageability, processability, tuned biodegradation. However, they have major disadvantages including ; lack of rigidity and stability, their degradation might elicit a strong inflammatory response, leading to resorption of the regenerated bone and reduces the available function time of the barrier membrane and its space making ability, which may affect the outcome of bone regeneration. ⁽³⁰⁾. By preparing bone graft in the form of sticky bone in the current study, it gained the ability to overcome the limitations of collagen membrane collapse in the defect site and as a result, it maintained and created a space for bone regeneration.

In Ridge Splitting Technique with Sticky Bone Graft Group, PRF membrane was used as a barrier membrane over the sticky bone as recommend by Kökdere et al., ⁽³¹⁾ who found that PRF membranes enriched with growth factors enhanced tissue healing ability without hindering blood supply from the surrounding periosteum. And this goes in accordance with Verdugo et al.,⁽³²⁾ who assisted bone healing in large maxillary defects with bone graft and stated that periosteal membrane preservation seems to be sufficient as a barrier membrane to protect the grafting material provided that primary closure could be achieved, with no need for another barrier membrane. Also, this coincide with the systematic review by lutz et al.,⁽³³⁾ who reported that there is no significant benefit of using collagen membrane with bone grafting in ridge augmentation procedures.

Also, the results of bone gain obtained in Ridge Splitting Technique with Sticky Bone Graft Group are in parallel line with the study conducted by Folkman et al.,⁽³⁴⁾ who stated that “bone regeneration and osseointegration may occur around implants placed in surgically-created bone defects”, i.e., the bone is able to “jump a gap” and heal on top of implants even without the initial bone contact. And same results were proven true by Scipioni who has shown that the average ridge width increased from 2.4 to 6.0 mm by using this technique. Where in our study, the presurgical mean value measurement of ridge with was 3,98 and changed to a mean value of 7,93 with average mean increase in bone width equal to 3,9 mm which reflects a statistically significant intra-group increase in bone width gain. Also, the amount of direct bone contact to the implants along the mesial and distal surfaces was similar to the buccal and lingual surfaces in the previous mentioned studies^{(35, 36)}.

The two selected bone augmentation techniques were performed with simultaneous implant placement in only one step surgery instead of two surgical staged approach. This depended on combination of three factors to take the decision of simultaneous implants placement with grafting, which are; achieving implant placement in a correct 3D dimensional prosthetic position, achieving sufficient primary stability and contained defect morphology. On the other hand Elian et al., ⁽³⁷⁾, in their study stated that although two-stage ridge split approach increases the time required until case completion but it provides the patient with more predictable and stable results. It also helps to better address the potential esthetic and functional concerns of the patient. Use of a two-stage delayed technique will optimize the esthetics and function that can be successfully achieved. However, Demetriades et al., ⁽³⁸⁾ reported that there were no difference between immediate and late implant placement and the established split crest through the crestal bone during augmentation is a valid procedure used to augment the horizontal alveolar defect simultaneously with implant placement, when implants are placed simultaneously with the ridge split, implants gain stability by engaging the apical (basal) bone. Primary implant stability is one of the most important factors in the success of immediate implantation⁽³⁹⁾.

In the current study, secondary stage surgery was planned at time of 6 months follow up as recommended by Anitua et el.⁽⁴⁰⁾, at this follow up period of surgical re-entry, a standardized measurement of the ridge was done at fixed points using the conventional surgical guide that was used at time of implant placement, and upon comparing the results obtained by bone caliper, they were in parallel line with the measurements obtained by CBCT.

In our current study, selection of 18 months follow up was to figure out any bony changes that might happen after prosthetic loading as many studies revealed that changes happen in the bone surrounding dental implants and in the marginal bone when implants were being in function during masticatory forces; marginal bone loss may result in the failure of osseointegration. During the first year after loading, a typical pattern of bone loss called "saucerization" occurs. Studies have reported a marginal bone loss of 0.9–1.6 mm during the first year and 0.05–0.13 mm annually thereafter⁽⁴¹⁾. And this coincides with the current results of Ridge Splitting Technique with Sticky Bone Graft Group) as mean value of marginal bone loss at 6 months was 0.02 mm changed to 0.89 mm at 18 months with average mean of marginal bone loss equals to 0.87 mm. Also, Onlay Bone Grafting with Sticky Bone Group showed changed of mean value of marginal bone level from 0.03 mm at 6 months follow up to 0.9 mm at 18 months post- surgically with average mean of marginal bone loss equals to 0.87 mm., and this shows that there is no statistically significant inter-group difference between the two groups.

In current study, bucco-lingual dimension of the ridge was directly measured with bone caliper during surgery before augmentation after flap reflection and 6 months post-surgically only. However, using CBCT was found to be very accurate in predicting bone volume in the posterior maxilla and this is in agreement with Chugh et al.⁽⁴²⁾ who found that the CBCT method for the evaluation of alveolar ridge width measurements is indicated in areas where the ridges are resorbed, maxillary anterior ridge concavities, and yields more accurate results than ridge mapping⁽⁴³⁾.

In the current study, analysis of CBCT scans before and after surgeries were conducted in OnDemand3D software, with automated superimposition on the cranial base. Three reference points were established, based on reliably identifiable anatomical landmarks, anterior nasal spine (ANS), posterior nasal spine (PNS) and maxillary palatal bone. Transverse linear measurements at the resulting cross-points between the overlapping sections of CBCT resulted in 4 different linear measurements in either sagittal, axial and coronal sections at each surgical site representing pre-surgical, immediately post-surgical, 6 and 18 months post-surgically^{(44, 45)}.

Radiographic results using CBCT immediately post surgically showed a significant increase in bone width at implant sites from baseline (immediately pre-surgically) moreover, at follow up periods at 6 and 18 months, it showed that bone mostly maintains its width around successfully integrated dental implants. The result of current study showed that in (Ridge Splitting Technique with Sticky Bone Graft Group) there was statistically non-significant bone resorption at 6 and 18 months post-surgically when compared to bone width immediately post-surgically (baseline); this might be explained by atraumatic piezoelectric assisted ridge splitting, submerged implant placement, using bone graft in sticky form, overcorrecting the graft site by incorporating a vertical incision in the flap design so that the flap could be coronally advanced to achieve primary wound closure.

Non-significant bone resorption during remodeling occurred in (Onlay Bone Grafting with Sticky Bone Group) which reflects reliable outcomes of bone augmentation using sticky bone technique as reported by Barbu et al., ⁽⁴⁶⁾ who compared between guided bone regeneration in a sticky bone and bone-shell technique in horizontal ridge augmentation and reported comparable clinical outcomes in horizontal ridge augmentation, resulting in sufficient crestal width increase to allow implant placement in an adequate bone envelope.

On the other hand, the results reported by Keith et al., ⁽⁴⁷⁾; who mentioned that, following grafting procedures, resorption and remodelling is a natural process in graft healing and often results in graft shrinkage as the pattern, rate, and quality of new bone formation depend on complex reactions between the structure of a graft material and the healing processes of the biological host. Successful graft incorporation requires simultaneous revascularization and resorption as it is replaced with new bone that maintains the strength and volume of the graft.

Same findings were reported in (Ridge Splitting Technique with Sticky Bone Graft Group) where little bone resorption occurred in the split sites around integrated dental implants, same findings were reported by Ramal et al., ⁽⁴⁸⁾ showed 2.29 mm mean gain in bucco-lingual width of the ridge is in well accordance with the current study which resulted in ≈ 3.9 mm mean gain in clinical bucco-lingual width of the ridge after ridge expansion using piezo surgery. Results revealed that there are no statistically significant differences in bone gain at different times of follow up; starting at pre-surgically (baseline) and immediately post-surgically, 6 months and 18 months follow ups.

In the current study there is a significant increase in bone density at 6 and 18 months follow up after simultaneous implant placement with grafting; continuous functional loading on osseo-integrated dental implants would result in increasing bone density⁽⁴⁹⁾ and this coincide with the studies reported by Al-Nakib L.,⁽⁵⁰⁾ who measured bone density around dental implants by using CBCT scan in terms of Hounsfield unite (HU) and found that, the mean HU of jaw bone increased significantly after 6 months after implant placement than immediately after implant placement.

Upon evaluation of BoP as a secondary clinical outcome, there was no statistically significant difference among the different follow up periods regarding the two groups; this is explained by the meticulous selection of patients that were included in the current study with maintenance of oral hygiene instruction during the follow up periods. Because BoP is a risk indicator for peri-implant mucosal health as the presence of peri-implant mucositis can be associated by a degree of BoP with possibility of progression into peri-implantitis. Moreover, studies reported by Farina et al,⁽⁵¹⁾ showed that BoP has shown to have a high negative predictive value for future disease progression. In particular, a high probability of stable periodontal conditions was observed over time for BoP. Moreover, patients under maintenance care showing a full -mouth BoP score ≤ 20% were found at a lower risk for progressive attachment loss. Therefore, BoP is one of the parameters included in different methods for periodontal risk assessment

Conclusively, the findings of present study revealed a comparative outcome of two bone augmentations techniques; piezo-assisted ridge splitting technique with simultaneous implant placement versus Onlay sticky bone grafting technique with simultaneous implant placement. Both of the two techniques showed promising results of bone gain around simultaneous implant placement without any statistically significant differences among them

Piezo-assisted ridge splitting technique and guided bone regeneration using Onlay sticky bone graft with simultaneous implant placement showed comparable surgical results for horizontal bone augmentation regarding horizontal ridge deficiency ranged from 3 to 5 mm. Applying sticky bone graft enriched with CGF in the surgically created gap by ridge split resulted in bone formation mesially and distally comparable to buccal and palatal aspects of the osseointegrated implant. Bone grafts applied in sticky form can be relatively easily prepared and showed better physical handling properties, less movement and less shrinkage on follow up visits. Simultaneous augmentation combined with implant placement is a case-dependent selection depending on achieving correct 3-dimensional prosthetic position. CBCT superimposition is a reliable technique to achieve standardized 3-dimentional measurements of the alveolar bone changes after the two different treatment modalities in axial, coronal and sagittal slices, providing real measurements with no magnification.

RECOMMENDATIONS

Further studies with different modalities applying other types of bone graft materials and barrier membranes are needed to compare between the two grafting techniques. The satisfactory results achieved by using Piezo surgery suggest that piezo-assisted ridge splitting can be a feasible approach for treating alveolar bone with deficient width. However, high quality randomized control traits are required with long term follow up to investigate the resultant outcomes. The preference between both techniques of horizontal alveolar ridge augmentation would be determined by other factors like the skills of the oral surgeon, easiness of surgical steps, acceptance of the patient.

LIMITATIONS

The number of patients available for the analysis was limited to 7 patients due to restriction during pandemic covid-19 attack which was overcome by using split mouth RCT for evaluation. Newly formed bone and its close relation to the host bone was difficult to be assessed histologically. As, implants were placed simultaneously with grafting.Artifacts induced by metal objects during radiographic assessment using CBCT, image resolution of CBCT machine, image segmentation, field of view and type of tissue. CBCT devices need to have a well-established unite of caliperation, to make sure all data obtained from CBCT devices can be used in daily clinical surgeries with highest degree of accuracy and efficacy.

LDS

Lithium Disilicate Glass

MOD

Mesio-Occluso-Distal

CAD

Computer-Aided Design

CAD-CAM

computer-aided design (CAD) and computer-aided manufacturing (CAM)

MOD

Mesial Occlusal Distal

USPHS

United States Public Health Service

Newton

Conflict of Interest: The authors declare no conflicts of interest.

Funding Statement: The authors received no specific funding for the conduction of this study.

Ethics approval and consent to participate:

This research got ethics and research committee approval from The Scientific Research Ethics Committee at the Faculty of Dentistry, Alexandria University, Egypt at 19 June 2022

Each patient agreed and signed Arabic and English informed consent.

Consent for publication: Not Applicable (extracted teeth)

Availability of data and materials: Data available on request from the authors

Competing Interests: The authors declare no conflicts of interest. The authors declare that they have no significant competing financial, professional, or personal interest that might have influenced the performance or presentation of the work described in this manuscript.

Funding Statement: The authors received no specific funding for the conduction of this study.

Authors' contributions

M.A. and I.M. conceived of the presented idea. A.E. developed the theory.

M.A. and I.M. verified the analytical methods. M.H. encouraged I.M. to and supervised the findings of this work. All authors discussed the results and contributed to the final manuscript.

All authors discussed the results and contributed to the final manuscript.

Acknowledgements The authors acknowledge the statistical analysis team.

Singh M, Kumar L, Anwar M, Chand P. Immediate dental implant placement with immediate loading following extraction of natural teeth. National journal of maxillofacial surgery 2015;6(2):252.
Schneider R. Prosthetic concerns about atrophic alveolar ridges. Postgrad Dent 1999;6(2):3-7.
Araújo MG, Lindhe J. Dimensional ridge alterations following tooth extraction. An experimental study in the dog. Journal of clinical periodontology 2005;32(2):212-8. doi,
Faria-Almeida R, Astramskaite-Januseviciene I, Puisys A, Correia F. Extraction socket preservation with or without membranes, soft tissue influence on post extraction alveolar ridge preservation: A systematic review. Journal of oral & maxillofacial research 2019;10(3).
Bassir SH, Alhareky M, Wangsrimongkol B, Jia Y, Karimbux N. Systematic Review and Meta-Analysis of Hard Tissue Outcomes of Alveolar Ridge Preservation. Int J Oral Maxillofac Implants 2018;33(5):979-94. doi: 10.11607/jomi.6399.
González-García R, Monje F, Moreno C. Alveolar split osteotomy for the treatment of the severe narrow ridge maxillary atrophy: a modified technique. Int J Oral Maxillofac Surg 2011;40(1):57-64. doi: 10.1016/j.ijom.2010.03.030.
Waechter J, Leite FR, Nascimento GG, Carmo Filho LC, Faot F. The split crest technique and dental implants: a systematic review and meta-analysis. Int J Oral Maxillofac Surg 2017;46(1):116-28. doi: 10.1016/j.ijom.2016.08.017.
Alpaslan E, Webster TJ. Nanotechnology and picotechnology to increase tissue growth: a summary of in vivo studies. Int J Nanomedicine 2014;9 Suppl 1(Suppl 1):7-12. doi: 10.2147/ijn.S58384.
Thorwarth M, Schultze-Mosgau S, Kessler P, Wiltfang J, Schlegel KA. Bone regeneration in osseous defects using a resorbable nanoparticular hydroxyapatite. J Oral Maxillofac Surg 2005;63(11):1626-33. doi: 10.1016/j.joms.2005.06.010.
Landesberg R, Moses M, Karpatkin M. Risks of using platelet rich plasma gel. Journal of Oral and Maxillofacial Surgery 1998;9(56):1116-7.
Atia WM, Khalil AAF, Melek LN. Sticky bone in dehiscence defect around dental implant. Alexandria Dental Journal 2018;43(1):35-40.
Doyle DJ, Hendrix JM, Garmon EH. American society of anesthesiologists classification. 2017.
Silness J, Löe H. Periodontal disease in pregnancy II. Correlation between oral hygiene and periodontal condition. Acta odontologica scandinavica 1964;22(1):121-35. doi,
Abreu MH, Bianchini MA, Magini RS, Rösing CK. Clinical and radiographic evaluation of periodontal and peri-implant conditions in patients with implant-supported prosthesis. Acta Odontol Latinoam 2007;20(2):87-95.
Bassir SH, Alhareky M, Wangsrimongkol B, Jia Y, Karimbux NJIJOMI. Systematic review and meta-analysis of hard tissue outcomes of alveolar ridge preservation. 2018;33(5):979-94.
Villa R, Polimeni G, Wikesjö UMJTJoPD. Implant osseointegration in the absence of primary bone anchorage: A clinical report. 2010;104(5):282-7. doi,
Juodzbalys G, Sapragoniene M, Wennerberg A, Baltrukonis TJJoOI. Titanium dental implant surface micromorphology optimization. 2007;33(4):177-85. doi,
Moro A, Gasparini G, Foresta E, Saponaro G, Falchi M, Cardarelli L, et al. Alveolar ridge split technique using piezosurgery with specially designed tips. 2017;2017.
Jha N, Choi EH, Kaushik NK, Ryu JJJPo. Types of devices used in ridge split procedure for alveolar bone expansion: A systematic review. 2017;12(7):e0180342.
Pérez-Pevida E, Cherro R, Camps O, Piqué NJIJoO, Implants M. Effects of Drilling Protocol and Bone Density on the Stability of Implants According to Different Macrogeometries of the Implant Used: Results of an In Vitro Study. 2020;35(5).
Ella B, Laurentjoye M, Sedarat C, Coutant J-C, Masson E, Rouas AJIJoO, et al. Mandibular ridge expansion using a horizontal bone-splitting technique and synthetic bone substitute: an alternative to bone block grafting? 2014;29(1).
Hommos AM, Abd Elmoneam A, El Mohandes WA, Helmy YN. Evaluation Of Ridge Splitting For Immediate Implant Placement With Nano-Hydroxyapatite Bone Graft. doi:
Helmy Y, El-Kholy B, Marie MJJotENCI. In vivo animal histomorphometric study for evaluating biocompatibility and osteointegration of nano-hydroxyapatite as biomaterials in tissue engineering. 2010;22(4):241-50.
Nandi SK, Kundu B, Ghosh SK, De DK, Basu DJJovs. Efficacy of nano-hydroxyapatite prepared by an aqueous solution combustion technique in healing bone defects of goat. 2008;9(2):183-91.
Soni R, Priya A, Yadav H, Mishra N, Kumar LJNjoms. Bone augmentation with sticky bone and platelet-rich fibrin by ridge-split technique and nasal floor engagement for immediate loading of dental implant after extracting impacted canine. 2019;10(1):98.
Sohn D-S, Huang B, Kim J, Park WE, Park CCJJIACD. Utilization of autologous concentrated growth factors (CGF) enriched bone graft matrix (sticky bone) and CGF-enriched fibrin membrane in implant dentistry. 2015;7(10):11-8.
Aboelela S, Fattouh H, Abdel Rasoul MJEDJ. Ridge Augmentation using Autologous Concentrated Growth Factors (CGF) Enriched Bone Graft Matrix (sticky bone) versus Guided Bone Regeneration using Native Collagen Membrane in Horizontally Deficient Maxilla. 2021;67(4):3061-70.
Tony JB, Parthasarathy H, Tadepalli A, Ponnaiyan D, Alamoudi A, Kamil MA, et al. CBCT Evaluation of Sticky Bone in Horizontal Ridge Augmentation with and without Collagen Membrane—A Randomized Parallel Arm Clinical Trial. 2022;13(4):194.
Friedmann A, Strietzel FP, Maretzki B, Pitaru S, Bernimoulin JPJCOIR. Histological assessment of augmented jaw bone utilizing a new collagen barrier membrane compared to a standard barrier membrane to protect a granular bone substitute material: a randomized clinical trial. 2002;13(6):587-94.
Stoecklin-Wasmer C, Rutjes A, Da Costa B, Salvi GE, Jüni P, Sculean AJJodr. Absorbable collagen membranes for periodontal regeneration: a systematic review. 2013;92(9):773-81.
Kökdere NN, Baykul T, Findik YJDrj. The use of platelet-rich fibrin (PRF) and PRF-mixed particulated autogenous bone graft in the treatment of bone defects: An experimental and histomorphometrical study. 2015;12(5):418.
Verdugo F, Uribarri A, D'Addona AJCID, Research R. Autogenous bone block grafting provides facial implant tissue stability long‐term. 2017;19(3):478-85.
Lutz R, Neukam FW, Simion M, Schmitt CMJCoir. Long‐term outcomes of bone augmentation on soft and hard‐tissue stability: a systematic review. 2015;26:103-22.
Folkman M, Becker A, Meinster I, Masri M, Ormianer ZJSR. Comparison of bone-to-implant contact and bone volume around implants placed with or without site preparation: A histomorphometric study in rabbits. 2020;10(1):12446.
Sivolella S, Bressan E, Salata LA, Urrutia ZA, Lang NP, Botticelli DJCoir. Osteogenesis at implants without primary bone contact–An experimental study in dogs. 2012;23(5):542-9.
Scipioni A, Bruschi G, Giargia M, Berglundh T, Lindhe JJCOIR. Healing at implants with and without primary bone contact: an experimental study in dogs. 1997;8(1):39-47.
Elian N, Jalbout Z, Ehrlich B, Classi A, Cho S-C, Al-Kahtani F, et al. A two-stage full-arch ridge expansion technique: review of the literature and clinical guidelines. 2008;17(1):16-23.
Demetriades N, Park Ji, Laskarides CJJoOI. Alternative bone expansion technique for implant placement in atrophic edentulous maxilla and mandible. 2011;37(4):463-71. doi,
Javed F, Romanos GEJJod. The role of primary stability for successful immediate loading of dental implants. A literature review. 2010;38(8):612-20.
Anitua E, Alkhraisat MH. Is alveolar ridge split a risk factor for implant survival? J Journal of Oral Maxillofacial Surgery 2016;74(11):2182-91.
Kihara H, Hatakeyama W, Kondo H, Yamamori T, Baba KJJoOS. Current complications and issues of implant superstructure. 2022;64(4):257-62.
Chugh A, Bhisnoi P, Kalra D, Maggu S, Singh VJJodi. Comparative evaluation of three different methods for evaluating alveolar ridge dimension prior to implant placement: An in vivo study. 2013;3(2):101.
Rezallah NN, Dahaba MM, Ahmed EAE, Mahmoud EAJJoIOH. Radiographic evaluation of bone and mucosa using low-dose CBCT with radiopaque X-resin stent versus CT and ridge mapping: A Validity study. 2020;12(6):586.
Elamrousy wAha, nassar m, alnoamany f, marzouk m, ragheb a. Radiographic Bone Changes around Immediately Placed Immediately Restored Dental Implants in Periodontally Compromised Sites Treated With Duo-Teck Membrane. 2014 2014;1(2):12. doi, http://www.journals.wsrpublishing.com/index.php/tjasr/article/view/26
Yatabe M, Prieto JC, Styner M, Zhu H, Ruellas AC, Paniagua B, et al. 3D superimposition of craniofacial imaging—The utility of multicentre collaborations. Orthodontics & craniofacial research 2019;22:213-20.
Barbu HM, Iancu SA, Rapani A, Stacchi CJJoCM. Guided Bone Regeneration with Concentrated Growth Factor Enriched Bone Graft Matrix (Sticky Bone) vs. Bone-Shell Technique in Horizontal Ridge Augmentation: A Retrospective Study. 2021;10(17):3953.
Keith Jr JDJIJoP, Dentistry R. Localized ridge augmentation with a block allograft followed by secondary implant placement: a case report. 2004;24(1).
Ramal A, Mohammed S, Nahed AJASDS. Modified staged ridge splitting technique versus conventional technique for horizontal expansion of narrow posterior mandible (randomized controlled clinical trial). 2018;2(7):101-9.
Al-Zubaidi SM, Madfa AA, Mufadhal AA, Aldawla MA, Hameed OS, Yue X-GJFiM. Improvements in clinical durability from functional biomimetic metallic dental implants. 2020;7:106.
Al-Nakib LHJJobcod. Computed tomography bone density in Hounsfield units at dental implant receiving sites in different regions of the jaw bone. 2014;26(1):92-7. doi,
Farina R, Filippi M, Brazzioli J, Tomasi C, Trombelli LJJocp. Bleeding on probing around dental implants: a retrospective study of associated factors. 2017;44(1):115-22.

Tables 1 to 5 are available in the Supplementary Files section

No competing interests reported.

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Horizontal Bone Augmentation with Simultaneous Implant Placement Using Ridge Splitting with Sticky Bone Versus Onlay Sticky Bone Graft

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INTRODUCTION

PATIENTS, MATERIALS AND METHODS

RESULTS (data are presented as mean ± SD)

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RECOMMENDATIONS

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