PARIPEX - INDIAN JOURNAL OF RESEARCH | Volume-9 | Issue-3 | March - 2020 | PRINT ISSN No. 2250 - 1991 | DOI : 10.

36106/paripex

ORIGINAL RESEARCH PAPER Dental Science

ALVEOLAR RIDGE AUGMENTATION WITH

“SCREW TENT-POLE TECHNIQUE” : A STUDY OF KEY WORDS: Tent-pole,
ridge augmentation, PRF, DFDBA
10 CASES

(M.D.S.) (Oral & maxillofacial surgery), (Reader, College of dental sciences &
Dr. Setu P. Shah research centre, Manipur, A'bd
(M.D.S.) (Periodontist), Sr. Lecturer, College of dental sciences & research
Dr. Krishna Shah centre, Manipur, A'bd
Dr. Bhagyashree (M.D.S.) (Prosthodontist), Sr. Lecturer, College of dental sciences & research
Sutaria centre, Manipur, A'bd

Dr. Shreyansh
(M.D.S.) (O.M.R.)
Sutaria
Dr. Deep Shah (M.D.S.) (O.M.R.), Sr. Lecturer, Siddhpur Dental College
Purpose: The purpose of this study is to evaluate the 3-dimensional increase in bone volume using screw tent pole
technique with demineralized freeze dried bone allograft (DFDBA) in a tenting fashion for future prosthesis.
Materials and method: This prospective study evaluated augmentation in 10 consecutive patients with large 3-D
alveolar ridge defects. Alveolar ridge augmentation was performed using demineralized allograft placed around
ABSTRACT

titanium screws to tent out the soft tissue matrix. The alveolar ridges were clinically and radiographically evaluated 4
months after augmentation.
Results: 10 Patients with horizontal and/or vertical soft tissue defect as well as hard tissue defect had undergone the
procedure. 0.182 cc (52.9%) mean bone volume fill is noted after 4 months of the procedure. One patient had complete
dehiscence of the grafted site with screw & graft exposure requiring subsequent graft. Two patients had partial wound
dehiscence and one patient had screw head exposure only. Increase in bone volume was evaluated with special software.
Conclusion: It can be concluded that screw tent-pole technique is an effective treatment in patients with large vertical
alveolar defects. This technique involves expanding the soft tissue volume and prevents contraction of soft tissue matrix
around the graft, subsequently preventing graft from displacement or physiological resorption. Thus a stable increase in
alveolar bone height is achieved by this tent-pole technique.

INTRODUCTION : predictable bone regeneration in 2006 which outlines the four

Extraction of teeth can result in loss of alveolar ridge width major principles underlying successful GBR9:-
and height within first one to three years. This bone loss is Ÿ Primary wound closure,
exacerbated if the tooth is removed traumatically or if there Ÿ Angiogenesis,
are pre-existing endodontic or periodontal pathologies. Ÿ Space creation/maintenance and
These often require bone augmentation to create ideal Ÿ Stability of both the initial blood clot and implant fixture
gingival contour and aesthetics.(1) (PASS).

Following tooth removal varying amounts of bone resorption A major challenge to reconstructing large 3-dimensional
takes place due to qualitative and quantitative changes that bone defects is the contraction of the “soft tissue matrix”
occurs in the alveolar bone around the extraction site. leading to resorption and migration of the bone graft. Surgical
Alveolar ridge is a tooth dependent structure and therefore, control of the expanded soft tissue volume prevents
after a tooth is extracted, 3-dimensional bone resorption resorption of graft material(10) by maintaining a space between
takes place both, horizontally and vertically resulting in the periosteum and bone.
changes that may lead to esthetic and functional problems. A
deficient alveolar ridge fails to provide sufficient support and The hypothesis for this case study was whether 1.5-mm
retention for dentures. This will not only compromise the soft screws in combination with human demineralized bone could
tissue support and lower anterior facial height but also be used as an osteoconductive and osteoinductive scaffold to
preclude dental implants placement. Such deformities of the restore large horizontal and vertical defects. So this technique
alveolar ridge may compromise future implant placement2 as may result in sufficient bone quantity and quality after 4 to 5
well as esthetic results when a fixed partial denture is months to allow for subsequent osseointegration of
constructed in a visible area. endosseous implants.

Var ious techniques have been descr ibed f or the MATERIALS AND METHODS:
reconstruction of these large 3-dimensional defects before This prospective study evaluated augmentation in 10
implant placement. These techniques have included consecutive patients presenting with vertical and horizontal
autogenous onlay block grafts(3-4), autogenous particulate alveolar ridge defect. Inclusion criteria for this study were
grafts(5-6), distraction osteogenesis(7), and porous titanium Patients aged between 20-60 years both male and female who
mesh tray, or a combination of these. Marx et al(8) reported on lost or got their teeth extracted (Mandibular Posterior teeth or
a novel surgical approach using dental implants as “tent- Maxillary Anterior teeth) due to severe periodontitis or who
poles” in combination with iliac crest bone grafting. The novel have undergone traumatic extraction. Preoperative
strategy of this surgery was to allow iliac bone grafts to examination and CBCT imaging were evaluated. Smokers,
consolidate and maintain their volume with dental implants diabetic patients, and any medically compromised patients
that create a tenting effect. were excluded from this series.

Wang and Boyapati proposed the PASS principles for Horizontal ridge augmentation was performed using human
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PARIPEX - INDIAN JOURNAL OF RESEARCH | Volume-9 | Issue-3 | March - 2020 | PRINT ISSN No. 2250 - 1991 | DOI : 10.36106/paripex
demineralized allograft placed around titanium screws to RESULTS:
tent out the soft tissue matrix and periosteum. The ridges were 10 patients (7 male/3 female) consecutive patients with
clinically evaluated 4 months after augmentation. Soft tissue localized vertical and horizontal alveolar ridge defects
dimensions with UNC probe and clinical ridge mapping was underwent surgery. (Table 1) The mean patient age was 50.06
done at baseline and at 4 months. Cone Beam computed years (range 20 to 60 yrs). Procedure was performed in the
tomography (CBCT) scans were taken to evaluate all grafted mandible in five patients and in five patients partially
segments. All the patients have undergone initial scaling and edentulous maxilla was augmented. Adequate tension-free
root planing with oral hygiene instructions.4 weeks following closure over the graft was achieved in all patients.
the phase I therapy, patients were re-evaluated.
There were no postoperative wound infections. Complete
SURGICAL TECHNIQUE: dehiscence of the grafted site with graft and screw exposure
All aseptic precautions were taken before the surgical was noted after 4 months in one patient which required
procedure. A preoperative 0.2 % chlorhexidine rinse was given subsequent grafting. Although there was complete exposure
for 2 minutes. Surgical area was anesthetized with local of the graft material, partial graft uptake was noted upon re-
infiltration, using 2% Lignocaine hydrochloride with 1:80000 entry after 4 months. Two patients had partial wound
adrenaline local anesthetic solution. A crestal incisions were dehiscence and one patient had screw head exposure only
made in all cases with vertical releasing incisions. Whenever after 10 days. Wound dehiscence and screw head exposure
possible, available keratinized tissue was identified and were treated with conservative care with oral hygiene
included in the flap. Aggressive tissue undermining was maintenance and oral rinse during the 4 months healing
performed before screw or graft placement to ensure tension- period. Partial graft loss was noted on re-entry in 3 patients
free closure. In the anterior maxilla, subperiosteal dissection with complete or partial wound dehiscence.
was carried up to the anterior nasal spine to obtain adequate
release for passive primary closure. In the posterior mandible, Clinically ridge mapping was done with the help of k-files and
this often involved split thickness dissection on the labial for acrylic stent for standardization. Gingiva mucosal thickness
supraperiosteal advancement.Titanium screws of 1.5 mm width was also evaluated for the soft tissue changes. Soft tissue
& 8 mm height were placed in the alveolar bone monocortically height and width were evaluated with the help of UNC-15
from buccal bone towards palatally so that approximately 5 to 7 probe. Radiographically, 3-D imaging was carried out for the
mm of screw threads was exposed. Particulate demineralized accurate pre operative and post operative results of bone
allograft (250 to 1,000 µm) was mixed with the PRF (Platelet rich height and width. Bone volume was also measured at baseline
fibrin). The composite graft was reconstituted with normal and 4 months with the help of EZ3Di software on C.B.C.T.
saline and covered with moist gauze dampened with saline for (Table 1) (Fig. 2)
15 minutes, to expand the DFDBA particles and placed to cover
the screw completely. (Fig. 1) Mean of soft tissue height at baseline 12.30 ± 1.636 mm and at
4 months 14.80 ± 1.751 mm, the difference is statistically
In order to obtain the PRF, we begin by taking a venous blood significant.(P < 0.05)
sample using a 21× 3 quarter gauge butterfly Vaccutte needle
and a vaccum-packed Vaccutte 9ml. Mean of soft tissue width at baseline 6.50 ± 1.080 mm and at 4
months 9.60 ± 1.075 mm, the difference is statistically
The defect was overcorrected with particulate material in significant.(P < 0.05)
anticipation of future graft resorption. A resorbable
membrane was placed over the grafted sites. Passive primary
closure over the entire graft was obtained with interrupted 5-0
Vicryl sutures. All the patients were recalled after 10 days.
Postoperatively, the patient prosthesis was adjusted to avoid
impingement on the grafted site and, when possible, to create
positive tissue architecture. All patients were prescribed,
postoperative antibiotic and analgesic for 7 days and a 0.2%
chlorhexidine gluconate mouth rinse for 2 weeks. Sutures Fig. 2 :-Clinical and radiographical measurement after 4
were removed 10 days post-operatively. After 4 months, the months of the procedure.
grafted sites were uncovered and the screws removed.
DISCUSSION:
Dealing with a resorbed edentulous maxilla or mandible
remains a major challenge in modern dentistry.(11,12) A
deficient alveolar ridge fails to provide sufficient support and
retention for dentures. That will not only compromise the soft
tissue support and the lower anterior facial height, but also
preclude dental implants placement, which may dramatically
reduce the quality of life for patients.(3,13)

Vertical ridge augmentation remains a challenge in the

reconstruction of the atrophic maxilla and mandible. The main
problem arises from the need to expand the soft-tissue
envelope and achieve the proper bony architecture.
Techniques that have been developed to solve or circumvent
this problem include onlay bone grafting with particulate
bone graft, block bone graft, barrier techniques with
permanent or resorbable membranes, distraction
osteogenesis, vascularised ridge splitting techniques, sinus
lifts, nerve repositioning techniques, short implants, and
angled implants.

The choice of technique depends on the size of defect,

horizontal or vertical defect, anatomical structures, and the
Fig. 1 :- Stepwise procedure of “tent-pole technique”. size of area to be augmented.
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PARIPEX - INDIAN JOURNAL OF RESEARCH | Volume-9 | Issue-3 | March - 2020 | PRINT ISSN No. 2250 - 1991 | DOI : 10.36106/paripex
Distraction osteogenesis is mainly used for vertical ridge performed ideally as outpatient surgery, thereby decreasing
deficiencies. More than 12mm of bone height can be achieved the overall costs of the procedure. Le and Burstein reported
by this method. The main disadvantages are patient the successful use of mineralized allograft for the
compliance and cost factor. Various soft tissue changes also reconstruction in patients with severely atrophic maxilla for
occur during distraction and consolidation periods. So, when implant placement. Le et al reported the use of mineralized
a large amount of bone is to be obtained, better results are allograft as a particulate onlay graft to augment atrophic
seen if total amount of distraction is divided into several time alveolar ridge for single implant site development.
periods rather than distracting the bone at once.(19)
Various studies through their result have shown regenerative
Onlay bone grafting (Le et al. and Le and Burstein) is the action of PRF and hence has proved efficacy of PRF in bone
positioning and securing of bone grafts on the surface of regeneration. Recently, Shah M et al. in 2015 in a randomized
alveolar ridge. It can be either block or particulate onlay bone clinical trial compared the regenerative capacity of PRF as
grafts. Titanium mesh (Louis et al.) for localized alveolar sole bone substitute and DFDBA for infrabony defects. They
ridge augmentation can also be used. Complications with concluded that PRF group showed significant improvement in
traditional grafting include : infection, soft tissue defects, graft clinical parameters at 6 months post-operatively.
exposure due to soft tissue dehiscence, loss of grafting
material, in adequate bone volume.(14,15,16) Barrier membranes should create secluded space over the
area to be augmented, in order to stabilize the blood clot and
Guided Bone Regeneration (GBR) is a predictable to exclude the soft tissue penetration. The protected space is
therapeutic technique that can be used separately in a staged then colonized by osteogenic cell populations resulting in
approach to first augment the ridge or in conjunction with new bone formation. Various resorbable or non-resorbable
implant placement when primary stability of the implant is membranes can be used in increasing the bone volume in
desirable. This technique is based on filling the defect with both horizontal and vertical augmentations.(17) Collagen
bone grafts and/or bone substitutes and covering the membranes, as all resorbable membranes, do not normally
material with a membrane to prevent ingrowth of epithelial require a second surgery for retrieval. Patients appreciate the
and gingival connective tissue cells. Possible complications elimination of a second surgery, in addition to less morbidity.
are : exposure of the membrane or early breakdown of the Collagen is the principal component of connective tissue and
membrane. It is mostly restricted to defects where vertical provides structural support for tissues throughout the body.
bone augmentation of about 2-7 mm is needed.
The main cause of wound dehiscence is failure to provide
So the present study was planned by placing 1.5 mm screws in tensionless closure. Other reasons for a dehiscence are
combination with human demineralized bone that could be infection, trauma from opposing dentition, irritation from a
used as an osteoconductive scaffold to restore large ridge removable prosthesis, and hematoma development. Flap
defects resulting in sufficient bone quantity and quality after 4 advancement is a required part of ridge augmentation
months to allow for subsequent osseointegration of procedure to attain tension-free primary closure along the
endosseous implants. Autogenous bone graft has long been incision line. Primary closure results in decreased
considered the gold standard for grafting severe hard tissue discomfort, faster healing and is critically important in
defects. Louis et al reported on the use of titanium mesh for attaining desired objectives (e.g., bone regeneration). Failure
reconstruction of severely atrophic maxilla or mandible using to attain tensionless closure may result in a soft tissue
iliac crest bone graft with a 97% overall graft success rate, dehiscence along the incision line that can cause a poor
although exposure of the titanium mesh was reported to be outcome and/or postoperative complications.(18)
high (52%). The obstacles to using iliac crest bone are
obvious. In addition to the higher resorption rate of iliac crest
CONCLUSION:
grafts, other disadvantages include the high costs of It can be concluded that tentpole procedure is an effective
hospitalization, risk of general anesthesia, and morbidity of
technique for treatment in patients with large alveolar ridge
the procedure. defects. This technique involves expanding the soft tissue
volume and prevents contraction of soft tissue matrix around
Conversely, the use of mineralized allograft offers many the graft, subsequently preventing graft from displacement or
advantages, including an unlimited amount of donor bone, physiological resorption. Thus a stable increase in bone
reduced anesthesia and operative time. The procedure can be volume can be achieved by this tentpole procedure.
Table 1 :- Comparative evaluation of alveolar augmentation using screw tent-pole technique,
CLINICAL PARAMETERS RADIOGRAPHIC PARAMETERS
% OF VOLUME FILL
BONE VOLUME FILL
PHENOTYPE

RIDGE MAPPING SOFT TISSUE 3D IMAGING BONE

GINGIVAL
EDENTULOUS SITE

CLASSIFICATION

(Acrylic Stent) (mm) DIMENSIONS VOLUME

(mm)
SIEBERTS

(mm) (cc)
AGE (Yrs.)
Pt. No.

SEX

Buccal Palatal/ Occlusal Buccal Height Width Height Width

Lingual

B 4 B 4 B 4 B 4 B 4 B 4 B 4 B 4 B 4 4 4
1 50 M 23 Class I 1.5 3 2 3 5 4 1.5 3 11 11 7 12 7.5 8 4.1 6 0.26 0.42 0.16 61
2 45 M 36 Class II 1.5 2 1 2 3.5 2 1.5 2 13 15 6.5 9 9.5 13 4.5 5.2 0.2 0.32 0.12 60
3 49 F 14 Class II 1 2 1.5 2 1.5 2 1 2 9.5 13 7.5 10 8 11 5 6 0.33 0.48 0.15 45
4 51 M 23 Class I 1.2 2.1 1 2 1 2 1.2 2.1 13 15 7.4 9.3 12 14 5.2 6.3 0.46 0.66 0.26 56
5 45 M 46 Class II 1.3 2.2 1.2 2.3 1.5 1.5 1.3 2.2 10.5 15.5 5 8 9 14 3.5 4.5 0.3 0.46 0.16 51
6 54 F 13 Class I 1.5 2.5 1 2 1.5 1.5 1.5 2.5 13 15 6.5 10.5 11.5 13.5 4 6.5 0.37 0.52 0.15 41
7 48 F 46 Class II 2 2 1 2 2 2 2 2 11.5 16 7.2 10 9.5 14.5 4.2 6 0.29 0.48 0.19 65
8 40 M 24 Class I 1 2 2 2 3 3 1 2 14 16 6.2 9 11 13 3.2 5 0.41 0.67 0.26 56
9 55 M 36 Class II 1.6 1.8 1.7 1.8 2.5 2 1.6 1.8 12 14 8 9 10.5 12 4.7 5.4 0.31 0.49 0.18 58
10 52 M 44 Class I 1 2.5 1 1.5 2 2 1 2.5 15 17 5 9.5 13 15 3 5.5 0.51 0.76 0.25 49
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PARIPEX - INDIAN JOURNAL OF RESEARCH | Volume-9 | Issue-3 | March - 2020 | PRINT ISSN No. 2250 - 1991 | DOI : 10.36106/paripex
B = Baseline (pre-operative), 4 = After 4 months (post-
operative).

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