The Effect Of Single Versus Double Screws In Tenting Screw Technique For Horizontal Ridge Augmentation Before Dental Implant Placement (Randomized Clinical Trial)
Phase: NA
Conditions: Bone Defects
Sponsor: Omar Saad

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The Effect Of Single Versus Double Screws In 
Tenting Screw Technique For Horizontal Ridge 
Augmentation Before Dental Implant Placement 
(Randomized Clinical Trial) 
 
 
 
 
 
1/8/2022 
 
 
 

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Introduction and Review 
With increasing demands of the patient regarding aesthetics and function, the need 
for implant supported reconstructions has substantially increased. Extensive 
research is being done to improve the success of implant therapy. Numerous 
changes in the alveolus that follow tooth loss, frequently compromises dental 
implant placement in a prosthetically ideal position. The natural remodelling 
processes of alveolar socket begin immediately after extraction and may result in 
up to 50 % resorption of the alveolar ridge within 3 months (Deepika-Penmetsa, 
S. L et al., 2017). 
Dental implant has become an important treatment option for the treatment of 
partial and complete edentulism. High failure rates have been associated with 
implants placed in resorbed ridges with insufficient alveolar bone structure. 
Placement of implants in non-ideal positions as a result of bone deficiency may 
lead to the application of off-angle forces to the implant during function which 
significantly increases the force magnitude applied to the bone around the implant 
(Aeh, A. et al., 2017). 
Several classification systems of alveolar ridge deformities have been proposed. 
Seibert introduced his widely used classification of ridge defects in 1983. In this 
classification, Class I defects represent buccolingual loss of tissue and normal 
apicocoronal ridge dimensions, Class II defects are those with apicocoronal loss of 
tissue and normal buccolingual ridge dimensions, while Class III defects represent 
a combination of both width and height deficiencies. In 1988, Cawood and Howell 
suggested an anatomic classification of the edentulous jaws for the preprosthetic 
surgery. It proposed six classes and detailed the changes that the edentulous 
alveolar process in anterior and posterior maxilla and mandible undergo after teeth 
extraction (the pattern of resorption). In 1989, Jensen proposed an implant-driven 
site classification by bone quality and quantity and proximity to vital structures. In 
2002, Wang and Al-Shammari described a practical (therapeutically oriented) 
classification of alveolar ridge defects, that is, horizontal, vertical, and combination 
defects, proposing the edentulous ridge expansion approach (ridge-split) for the 
horizontal and combination defects of the alveolar Ridgel.  (Cawood, J. I. et al., 
1988) (Jensen O. 1989) (Wang, H. L. et al., 2002) 
 

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Bone regeneration and reconstruction in patients with severely atrophic ridges 
have been always controversial. Although several techniques can be used, it can be 
difficult to find an appropriate technique that provides bone with properties similar 
to those of the recipient site (Pourdanesh, F. et al., 2017). 
Various alveolar ridge augmentation procedures are available to gain enough bone 
volume and apply the ideal treatment plan afterwards. Guided bone regeneration, 
ridge splitting, distraction osteogenesis and autogenous block bone grafting are 
main techniques which have successful outcomes in reconstruction of bone defects. 
It’s difficult to demonstrate that one augmentation procedure offers better 
outcomes than another. Studies documenting augmentation techniques seem to be 
comparable and state favorable results for each procedure. (Aytekin, M. et al., 
2020) 
A number of grafting materials are available. The use of autogenous bone grafts 
for ridge repair has been considered as the gold standard for obvious biological 
reasons because of its inherent osteogenic, osteoinductive, and osteoconductive 
properties. However, the surgical morbidity associated with 
graft procurement procedures has triggered countless attempts to avoid a second 
surgical site for graft procurement by using allografts, xenografts, or synthetic 
material to replace the lost alveolar bone  (Troeltzsch, M. et al., 2016)  (Patel, A. 
et al., 2019) . 
Allografts are transferred from an individual to another within the same species. 
Since there is no need for a secondary surgical site to obtain allografts, reduced 
morbidity is one of the advantages brought by use of this graft. Unlimited source is 
another advantage over autografts. Although allografts have no osteogenic 
properties, they stimulate bone growth via osteoconduction and incorporation of 
osteoinductive growth factors. There are strict sterilization and decontamination 
protocols regarding these materials due to the risk of disease transmission and host 
immune response. Donors are carefully evaluated and graft materials are gradually 
processed to avoid any risks. Some studies reported that certain allografts are less 
osteoinductive than others because of the sterilization protocols and the variability 
of their content (Aytekin, M. et al., 2020). 
 
 

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One of the most popular techniques is guided bone regeneration (GBR), which 
entails placing a membrane over the defect to create a secluded space into which 
osteogenic cells can migrate and remain undisturbed over the exposed part of the 
implant. Guided bone regeneration (GBR) is frequently used in combination with 
the installment of titanium implants. The application of a membrane to debar non-
osteogenic tissues from interfering with bone regeneration is a key principle of 
GBR (Elgali I et al., 2017) (Vijayalakshmi R et al., 2012). 
The tenting technique, which originated from the principles of guided bone 
regeneration, involves raising the periosteum like a tent to allow osteoblasts to 
migrate into the gap to start osteogenesis. The gap that is made is then filled with 
osteoconductive or osteoinductive materials, and in some cases, both. The 
migration of epithelial cells can be prevented by the application of a barrier-like 
collagen membrane or other component. The technique is divided into three 
categories that depend on the method that is used to keep the periosteum up. the 
first of which was the tent-pole technique. The two other modifications, cortical 
autogenous tenting, and screw tenting, are usually used for smaller oral defects. 
Studies have shown that they can all be used to augment bone effectively 
(Khojasteh, A. et al., 2012) (Takata, T. et al., 2001) (Marx, R. E etl al., 2002). 
To avoid shrinkage resulting from pressure after flap closure, several space 
maintenance modalities were used to facilitate reconstruct ridge formation such as 
tenting screws, titanium (Ti) meshes, and Ti-reinforced polytetrafluoroethylene 
(PTFE) membranes. Nonresorbable membranes have a high risk of exposure, 
necessitating removal in the re-entry stage. Resorbable membranes have shown 
better biocompatibility and support of underneath bone growth. However, their 
lack of stiffness can lead to decreased bone volume gain. Therefore, the tent-pole 
technique, which combines resorbable collagen membrane and tenting screws, 
represents an effective approach, offering easy manipulation and low complication 
rates (Doan, Tu et al., 2020). 
 
 
 
 

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Aim of the study 
 
-First aim: Evaluate the effectiveness of screw tent technique in horizontal ridge 
augmentation  
-Second aim: Compare the effect of using single screw versus double screws on 
obtaining maximum bone gain. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Patients and Methods 
 
Patient selection 
 
this study will be conducted on 16 patients indicated for horizontal ridge 
augmentation in premolar and molar area. After approval from the ethical 
committee, the entire patients will be recruited from the outpatients' clinic of the 
Oral Medicine, Oral Diagnosis, and Periodontology Department Faculty of 
Dentistry, Minia University. 
Inclusion criteria: 
1. Selected patients of both genders are 20-55 years old. 
 2. Patients are systemically healthy based on questionnaire dental modification of 
Cornell index (Bolender, C. L. et al., 1969). 
 3. Gingival health according to the new classification system (Caton, J. G. et al., 
2018).  
4. The recipient site of the augmentation is free from any pathological conditions. 
5. At least 1 tooth area with a ridge defect and planned to receive a dental implant. 
The site must be bordered by at least 1 tooth. 
 6. Class I ridge defect according to Seibert’s classification. 
 7. Adequate interocclusal space to accommodate the available restorative 
components. 
Exclusion criteria:  
1. Pregnant female. 
2. Parafunctional habits such as bruxism and clenching. 
3. Smokers. 
 
 
 
 
 

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Ethical regulation and Informed consents 
All patients will undergo a delayed implant placement and the complete treatment 
plan will be explained to all patients including detailed steps, risks, and expected 
results. Verbal and written informed consent will be obtained from all patients 
before the commencement of the study. All steps will be examined and approved 
by the appropriate ethics committee and have therefore been performed following 
the ethical standards laid down in the Declaration of Helsinki and the research 
ethics committee of the Faculty of Dentistry, Minia University. 
Pre-surgical phase 
- At the initial visit, each patient will receive a diagnostic work-up that included a 
full periodontal examination, standardized periapical radiographs and diagnostic 
study casts. 
- Horizontal ridge width will be measured with a bone caliper to the nearest 
millimeter at the midridge crestal level and then 5 mm apically. Stent will be used 
for the standardization of the measurements.  
- A preoperative cone-beam computed tomography (CBCT) will be performed for 
each patient who met the inclusion criteria before the surgery to determine bone 
height and width and to evaluate the underlying bone condition. 
- These clinical and radiographic measurements will be repeated at reentry after 6 
months of healing. 
Randomization 
All cases will be randomly allocated according to flip coin test into 2 groups each 
group will include 8 patients. 
Group A: 
: 8 patients indicated for lateral ridge augmentation in premolar-molar area (class I 
Seibert’s classification) will be candidates to screw tent technique using single 
screw at crest position 
 
Group B:  
8 patients indicated for lateral ridge augmentation in premolar-molar area (class I 
Seibert's classification) will be candidates to screw tent technique using double 
screws, one at a crestal position and the other one 5 mm apical to the first one. 

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Surgical Phase 
- All patients will receive prophylactic antibiotic (1 gm. Amoxicillin-clavulanate, 
Augmentin ®, GlaxoSmithKline, UK) one hour preoperatively and then every 
twelve hours for four days and will be instructed to rinse with 0.12% 
Chlorhexidine (Orovex ®, MACRO, Egypt) for one minute prior to surgery and 
twice daily for 2 weeks postoperatively. 
- All procedures will be performed under local anesthesia utilizing articaine 
hydrocholoride 4% with 1:100000 epinephrine (Septanest®, Septodont, USA). 
- Sulcular incisions around teeth with mesial and distal vertical releasing incisions. 
A full thickness flap will be reflected on the buccal, and a full thickness flap will 
be reflected on the lingual/palatal to expose the residual alveolar ridge.  
- Multiple cortical perforations will be performed with a 1/2 round bur to increase 
angiogenesis and supply of growth factors in all defect areas. 
- In group A: single titanium bone screw will be placed in a crestal position to aid 
in graft stability. In group B: double titanium bone screws will be placed, one at a 
crestal position and the other one will be places 5mm apical to the first one. 
- In both groups the defect will be filled with allograft, the graft will be extended at 
least 10 to 12 mm in the apicocoronal direction. 
- The grafted site will be covered with Bovine pericardium membrane  
- Tension-free primary flap closure will be achieved and sutured using a 5-0  
Polypropylene suture. 
- 6 months later at the reentry, the bone screws will be removed and dental implant 
will be placed at the augmented site. 
 
 
 
 
 
 

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Postoperative instructions 
1. Routine verbal and written postoperative instructions for periodontal surgery 
will be given to all patients including ice compression on the surgical site during 
the first 4 h, a liquid and/or soft food diet for 3 days. 
2. As with all surgical procedures, patients will be informed to contact our clinic if 
any problems will be developed during the postoperative period. 
3. 1 gm. Amoxicillin-clavulanate (Augmentin ®, GlaxoSmithKline, UK) to be 
taken regularly every 12 hours for 4 days. Diclofenac Sodium 75 mg intramuscular 
injection (Voltaren, Novartis, Switzerland) was given every 12 hours for the first 
48 hours and then was replaced with 50 mg enteric coated tablets taken only when 
needed. Patients were instructed to rinse with 0.12% Chlorohexidine 2 times per 
day for two weeks 
 4. The sutures will be removed after 2 weeks. 
5. Patients were followed up for signs and symptoms of pain, inflammation, 
infection, wound dehiscence or membrane exposure 24 hours postoperatively, then 
day after day for the first week, and then monthly for 6 months. 
 
Clinical assessment:  
At reentry 6 months later, 
Keratinized mucosa will be measured using periodontal probe to the nearest 
millimeter   
horizontal ridge width will be measured with a bone caliper to the nearest 
millimeter m at the midridge crestal level and then 5 mm apically. Same stent will 
be used for the standardization of the measurements 
Radiographic evaluation 
After 6 months CBCT imaging will be used to measure ridge width and bone 
density. 
 
Statistical analysis: 
-All data will be tabulated and analyzed by statistical method. 
 

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