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

Horizontal Bone Augmentation with Simultaneous Implant Placement Using Ridge Splitting with Sticky Bone Versus Onlay Sticky Bone Graft | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Horizontal Bone Augmentation with Simultaneous Implant Placement Using Ridge Splitting with Sticky Bone Versus Onlay Sticky Bone Graft Mohammad YA. Bolot, Sahar M. Ghoraba, Ahmed M. Badr This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4901038/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract 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 Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 INTRODUCTION 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. PATIENTS, MATERIALS AND METHODS 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 RESULTS (data are presented as mean ± SD) 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 DISCUSSION 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 CONCLUSIONS 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. Abbreviations 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 N Newton Declarations 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. References 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. 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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 Tables 1 to 5 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files Table01.docx Table02.docx Table03.docx Table04.docx Table05.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4901038","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":341244396,"identity":"aa7ac7aa-78ae-49ad-8c19-cb212a1ed8b8","order_by":0,"name":"Mohammad YA. 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placement\u003c/p\u003e","description":"","filename":"Figure01.png","url":"https://assets-eu.researchsquare.com/files/rs-4901038/v1/2784dc091730d0a6f8f2b379.png"},{"id":64569503,"identity":"998ac945-9828-4865-a353-1dc7a859488d","added_by":"auto","created_at":"2024-09-16 00:50:39","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2095933,"visible":true,"origin":"","legend":"\u003cp\u003esteps of ridge augmentation using Onlay sticky bone graft with simultaneous implant placement.\u003c/p\u003e","description":"","filename":"Figure02.png","url":"https://assets-eu.researchsquare.com/files/rs-4901038/v1/3fdf8e482e4c6bbe37ac9981.png"},{"id":64569508,"identity":"60780754-a623-4bb3-b76a-9ceb5b47fb3b","added_by":"auto","created_at":"2024-09-16 00:50:39","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2190475,"visible":true,"origin":"","legend":"\u003cp\u003ebone width measurement using bone caliper 6 months post-surgically.\u003c/p\u003e","description":"","filename":"Figure03.png","url":"https://assets-eu.researchsquare.com/files/rs-4901038/v1/7a2f406339a5d954814a87d1.png"},{"id":64569507,"identity":"b98e90c2-6707-4643-a1e9-e05a7b59d961","added_by":"auto","created_at":"2024-09-16 00:50:39","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1883754,"visible":true,"origin":"","legend":"\u003cp\u003ecomparing of bone width gain at base line, immediately postoperatively and 6-months post operatively.\u003c/p\u003e","description":"","filename":"Figure04.png","url":"https://assets-eu.researchsquare.com/files/rs-4901038/v1/a6c4d94376fdefab2e4f1d32.png"},{"id":64569510,"identity":"f19be17e-9903-47e8-9d98-ec45ca7d6f86","added_by":"auto","created_at":"2024-09-16 00:50:40","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":1745904,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"Figure05.png","url":"https://assets-eu.researchsquare.com/files/rs-4901038/v1/be6e4817a6cfb3215d497ffa.png"},{"id":64569511,"identity":"7c021c92-2765-4356-8d2a-57f46448f8e1","added_by":"auto","created_at":"2024-09-16 00:50:42","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":272259,"visible":true,"origin":"","legend":"\u003cp\u003eBone width gain at base line, immediately postoperatively and 6-months post operatively.\u003c/p\u003e","description":"","filename":"Figure06.png","url":"https://assets-eu.researchsquare.com/files/rs-4901038/v1/933fb1d35e059956464f0e3b.png"},{"id":64571046,"identity":"02459c4f-17cb-4b25-a22e-32aeb943aa7d","added_by":"auto","created_at":"2024-09-16 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00:50:39","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":20032,"visible":true,"origin":"","legend":"","description":"","filename":"Table04.docx","url":"https://assets-eu.researchsquare.com/files/rs-4901038/v1/6c7c2e4f7c5be08743e84819.docx"},{"id":64569506,"identity":"def4e7be-ec96-4699-8f33-cee28525384d","added_by":"auto","created_at":"2024-09-16 00:50:39","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":14657,"visible":true,"origin":"","legend":"","description":"","filename":"Table05.docx","url":"https://assets-eu.researchsquare.com/files/rs-4901038/v1/54b0ed784f7ed8baf79197ae.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Horizontal Bone Augmentation with Simultaneous Implant Placement Using Ridge Splitting with Sticky Bone Versus Onlay Sticky Bone Graft","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eSufficient 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\u003csup\u003e(1,2)\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eSubsequent 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\u003csup\u003e(3)\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSuch 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\u003csup\u003e(4,5)\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePreservation 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\u003csup\u003e(6,7)\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNanotechnology 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\u003csup\u003e(8,9)\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003ePlatelets contain a storage of different growth factors, which are unrestricted and get released on the tissues after injury. These include transforming growth factor \u0026beta; (TGF-\u0026beta;), platelet-derived growth factor, insulin-like growth factor, and fibroblast growth factors which proceed as differential factors on regenerating periodontal tissues\u003csup\u003e(10)\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn 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\u003csup\u003e(11)\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eDue 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. \u0026nbsp;\u003c/p\u003e"},{"header":"PATIENTS, MATERIALS AND METHODS ","content":"\u003cp\u003e\u003cstrong\u003eI.\u0026nbsp; \u0026nbsp;\u0026nbsp;PATIENTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 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.\u0026nbsp;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:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; \u0026nbsp;\u003cstrong\u003eRidge Splitting Technique with Sticky Bone Graft Group:\u003c/strong\u003e Seven implants (n=7 implants) were installed simultaneously utilizing crestal ridge splitting technique with sticky bone graft.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; \u0026nbsp;\u003cstrong\u003eOnlay Bone Grafting with Sticky Bone:\u003c/strong\u003e Seven implants (n=7 implants) were installed simultaneously utilizing Onlay bone grafting technique with sticky bone graft covered with collagen membrane.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSelection Criteria for Patients:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eInclusion criteria:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e-\u0026nbsp; \u0026nbsp; \u0026nbsp;Patients with absence of any relevant medical condition that contraindicate dental implant placement. (ASA I patient)\u003csup\u003e(12)\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e-\u0026nbsp; \u0026nbsp; \u0026nbsp;Optimal compliance as evidenced by no missed treatment appointments and a positive attitude toward performing oral hygiene measures.\u003c/p\u003e\n\u003cp\u003e-\u0026nbsp; \u0026nbsp; \u0026nbsp;Patients age ranged between 30 to 50 years of both genders.\u003c/p\u003e\n\u003cp\u003e-\u0026nbsp; \u0026nbsp; \u0026nbsp;Maxillary alveolar ridge with bone density (D3).\u003c/p\u003e\n\u003cp\u003e-\u0026nbsp; \u0026nbsp; \u0026nbsp;Alveolar bone ridge of minimum height of 10 mm and crestal bone width ranges from 3.5 mm to 5 mm.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eExclusion criteria:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e-\u0026nbsp; \u0026nbsp; \u0026nbsp;Insufficient vertical inter-arch space to accommodate the restorative component.\u003c/p\u003e\n\u003cp\u003e-\u0026nbsp; \u0026nbsp; \u0026nbsp;The presence of severe buccal undercut.\u003c/p\u003e\n\u003cp\u003e-\u0026nbsp; \u0026nbsp; \u0026nbsp;Thin gingival phenotype.\u003c/p\u003e\n\u003cp\u003e-\u0026nbsp; \u0026nbsp; \u0026nbsp;Patients with parafunctional occlusal habits.\u003c/p\u003e\n\u003cp\u003e-\u0026nbsp; \u0026nbsp; \u0026nbsp;Smokers and pregnant women.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eII . Materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; \u0026nbsp;\u0026nbsp;Implant System: \u0026nbsp;Imax NHSI implant system: Fixture macro and micro design - Implant surgical kit - Collagen membrane Nano hydroxyapatite bone graft - Piezo-electric device - Centrifuge apparatus: \u0026nbsp;iFuge D06 \u0026ndash; Neuation - Blood sample collection kit - Surgical kit.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIII. Methods:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA. Pre-surgical assessment:\u0026nbsp;\u003c/strong\u003eClinical assessment- Presurgical clinical evaluation modalities: Plaque control record\u003csup\u003e(13)\u003c/sup\u003e, Bleeding on probing and Radiographical assessment by\u0026nbsp;Cone beam computed tomography (CBCT)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.\u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ePhase І therapy.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.\u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eSurgical phase:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026bull;\u0026nbsp; \u0026nbsp;Ridge Splitting Technique with Sticky Bone Graft Group:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; \u0026nbsp;\u0026nbsp;Flap design and reflection,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; \u0026nbsp;\u0026nbsp;Alveolar ridge splitting and expansion,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; \u0026nbsp;\u0026nbsp;Implant bed preparation and installation\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; \u0026nbsp;\u0026nbsp;Application and stabilization of the graft material\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; \u0026nbsp;\u0026nbsp;Membrane stabilization and flap closure\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026bull; Onlay Bone Grafting with Sticky Bone Group:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; \u0026nbsp;\u0026nbsp;Flap design and reflection\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; \u0026nbsp;\u0026nbsp;Implant bed preparation and implant installation\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; \u0026nbsp;\u0026nbsp;Ridge augmentation\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; \u0026nbsp;\u0026nbsp;Membrane stabilization and flap closure\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.\u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ePost-surgical care and instructions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.\u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eProsthetic phase.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e5.\u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eMaintenance phase\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.\u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003cu\u003ePost-surgical evaluation\u003c/u\u003e\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003cstrong\u003eClinical evaluation:\u003c/strong\u003e Assessment of bone ridge width using bone calliper - Bleeding on probing (BOP) - Clinical attachment level around dental implants (CAL)\u003csup\u003e(14)\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; \u0026nbsp;\u0026nbsp;Radiographic evaluation post-surgically with fusion between CBCT views done at the interval periods\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"RESULTS (data are presented as mean ± SD)","content":"\u003cp\u003e\u003cstrong\u003eBiodata:\u0026nbsp;\u003c/strong\u003eThe study encompassed a total of seven patients;\u0026nbsp;2 males and 5 females. Their age ranged from 32 to 45 years old with a mean \u0026plusmn; SD of 36.28 \u0026plusmn; 4.42 years.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eI.\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003cu\u003eClinical evaluation\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMarginal Bone Level Bone Caliper (mm)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAt Base line:\u003c/em\u003e in the Ridge Splitting Group, the marginal bone level bone caliper (mm) ranged from 3.05 to 5.00 with a mean \u0026plusmn; S.D. of 4.05 \u0026plusmn; 0.68 (mm), while in the Onlay Sticky Bone Graft Group, it ranged from 3.35 to 4.26 with a mean \u0026plusmn; S.D. of 3.89 \u0026plusmn; 0.35 (mm), there was no statistically significant difference in the pre-surgically marginal bone level bone caliper between the two studied groups (\u003cem\u003ep\u003c/em\u003e =.474).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSix months post-surgically:\u003c/em\u003e In the Ridge Splitting Group, the marginal bone level bone caliper ranged from 6.25 to 9.56 with a mean \u0026plusmn; S.D. of 7.40 \u0026plusmn; 0.83 (mm), while in the Onlay Sticky Bone Graft Group, it ranged from 6.26 to 8.89 with a mean \u0026plusmn; S.D. of 7.51 \u0026plusmn; 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 (\u003cem\u003ep\u003c/em\u003e =.759)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn 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. (\u003cem\u003ep\u003c/em\u003e\u0026lt;.001 and \u003cem\u003ep\u003c/em\u003e\u0026lt;.001, respectively) table 1\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eII. \u003cu\u003eRadiographic evaluation\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMarginal Bone Level Bone Using CBCT\u003c/strong\u003e\u003cstrong\u003e: table 2\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePre-surgically,\u003c/em\u003e\u003c/strong\u003e In the Ridge Splitting Group, the marginal bone level CBCT (mm) ranged from 3.15 to 4.80 with a mean \u0026plusmn; S.D. of 3.98\u0026plusmn;0.61 (mm), while in the Onlay sticky bone Graft Group,\u0026nbsp;ranged from 3.25 to 4.25 with a mean \u0026plusmn; S.D. of 3.88 \u0026plusmn; 0.37 (mm). There was no statistically significant difference in the pre-surgical marginal bone level CBCT between the two studied groups (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e=.603).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eImmediately post-surgery:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eIn the Ridge Splitting Group, the marginal bone level CBCT ranged from 6.87 to 10.66 mm with a mean \u0026plusmn; S.D. of 8.55 \u0026plusmn; 1.13 mm while, in the Onlay Sticky Bone Graft Group it ranged from 7.05 to 9.94 with a mean \u0026plusmn; S.D. of 8.60 \u0026plusmn; 0.96 mm. There was no statistically significant difference in the marginal bone level CBCT between the two studied groups immediately post surgically (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e=.890)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSix months post-surgically:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eIn the Ridge Splitting Group, the marginal bone level CBCT (mm) ranged from 6.27 to 9.67 with a mean \u0026plusmn; S.D. of 7.60 \u0026plusmn; 0.84 mm) while\u0026nbsp;the Onlay Sticky Bone Graft Group it ranged from 6.14 to 8.98 (mm) with a mean \u0026plusmn; S.D. of 7.47 \u0026plusmn; 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 (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e=.728)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEighteen months post-surgically:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eIn the Ridge Splitting Group, the marginal bone level CBCT ranged from 6.20 to 9.40 with a mean \u0026plusmn; S.D. of 7.46 \u0026plusmn; 0.80 mm, while, in\u0026nbsp;the Onlay Sticky Bone Graft Group it ranged from 6.02 to 8.87 with a mean \u0026plusmn; S.D. of 7.39 \u0026plusmn; 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 (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e=.843).\u003c/p\u003e\n\u003cp\u003eIn 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 (\u003cem\u003ep\u003c/em\u003e\u0026lt;.001 and \u003cem\u003ep\u003c/em\u003e\u0026lt;.001, respectively).\u003c/p\u003e\n\u003cp\u003ePairwise 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 (\u003cem\u003ep\u003c/em\u003e \u0026lt; .001, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001, and \u003cem\u003ep\u003c/em\u003e \u0026lt; .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 (\u003cem\u003ep\u003c/em\u003e =.001, and \u003cem\u003ep\u003c/em\u003e =.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 (\u003cem\u003ep\u003c/em\u003e\u0026lt; .001).\u003c/p\u003e\n\u003cp\u003ePairwise 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 (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt; .001, \u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt; .001, and \u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt; .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 (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt; .001, \u003cem\u003ep \u0026lt;\u003c/em\u003e.001, respectively). The marginal bone level CBCT at eighteen months post-surgically showed a statistically significant increase compared with six months post-surgically (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt;.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eSecondary outcomes:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eI.\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003cu\u003eClinical evaluation\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e-\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003cstrong\u003eProbing Depth (mm):\u0026nbsp;\u003c/strong\u003eIn the Ridge Splitting Group, the probing depth (mm) ranged from 2.00 to 2.40 with a mean \u0026plusmn; S.D. of 2.24 \u0026plusmn; 0.16 mm, while in the Onlay Sticky Bone Graft Group, it ranged from 2.00 to 2.40 with a mean \u0026plusmn; S.D. of 2.19 \u0026plusmn; 0.13 mm. There was no statistically significant difference in the probing depth between the two studied groups (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e=.414) \u003cstrong\u003etable 3\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e-\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003cstrong\u003eBleeding on probing (mm) (at 18 months post-surgery):\u0026nbsp;\u003c/strong\u003eIn the Ridge Splitting Group, the bleeding on probing ranged from 0.00 to 0.40 with a mean \u0026plusmn; S.D. of 0.24 \u0026plusmn; 0.16 mm, while in the Onlay Sticky Bone Graft Group, it ranged from 0.00 to 0.40 with a mean \u0026plusmn; S.D. of 0.19 \u0026plusmn; 0.13 mm. There was non-statistically significant difference in the bleeding on probing between the two studied groups after eighteen months post-surgically (\u003cem\u003ep\u003c/em\u003e=.414) \u003cstrong\u003etable 3.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e- \u0026nbsp; \u0026nbsp; \u003cstrong\u003ePlaque index (PI) (pre-surgically, 6 months and 18 months post surgically):\u0026nbsp;\u003c/strong\u003eThere was no statistically difference in mean values of plaque indices pre-surgically, 6 months and 18 months post-surgically).\u003c/p\u003e\n\u003cp\u003e- \u0026nbsp; \u0026nbsp; \u003cstrong\u003eClinical Attachment Loss (mm) (at 18 months post surgically):\u0026nbsp;\u003c/strong\u003eIn the Ridge Splitting Group, the clinical attachment loss ranged from 0.00 to 0.40 with a mean \u0026plusmn; S.D. of 0.24 \u0026plusmn; 0.16 mm while in the Onlay Sticky Bone Graft Group, it ranged from 0.00 to 0.40 with a mean \u0026plusmn; S.D. of 0.19\u0026plusmn;0.13 mm. There was no statistically significant difference in the clinical attachment loss between the two studied groups after eighteen months post-surgically (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e=.414).\u003cstrong\u003e\u0026nbsp;table 3\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eII. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003cu\u003eRadiographic outcomes\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBone Density Before implant placement (HU) (Table 4)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAt Base line:\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eIn the Ridge Splitting Group, the bone density ranged from 370.00 to 450.00 with a mean \u0026plusmn; S.D. of 406.92 \u0026plusmn; 24.63 HU, while in the Onlay Sticky Bone Graft Group, it ranged from 370.00 to 450.00 with a mean \u0026plusmn; S.D. of 405.38\u0026nbsp;\u0026plusmn; 24.36 HU. There was no statistically significant difference in the before implant bone density between the two studied groups (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e=.874)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSix months post-surgically:\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eIn the Ridge Splitting Group, the bone density ranged from 420.00 to 520.00 with a mean \u0026plusmn; S.D. of 469.23 \u0026plusmn; 32.78 HU, while in the Onlay Sticky Bone Graft Group, it ranged from 420.00 to 500.00 with a mean \u0026plusmn; S.D. of 457.69 \u0026plusmn; 25.55 HU. There was no statistically significant difference in the bone density between the two studied groups after six months post-surgically (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e=.327).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEighteen months post-surgically:\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eIn the Ridge Splitting Group, the bone density ranged from 600.00 to 750.00 with a mean \u0026plusmn; S.D. of 660.00 \u0026plusmn; 52.12 HU, while in the Onlay Sticky Bone Graft Group, it ranged from 600.00 to 750.00 with a mean \u0026plusmn; S.D. of 660.77 \u0026plusmn; 48.56 HU. There was no statistically significant difference in the bone density between the two studied groups after twelve months post-surgically (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e=.969)\u003c/p\u003e\n\u003cp\u003eIn 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 (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt; .001), and in the Onlay Sticky Bone Graft Group (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt; .001).\u003c/p\u003e\n\u003cp\u003ePairwise 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 (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt; .001 and \u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt; .001, respectively). The bone density at twelve months post-surgically showed a statistically significant increase compared with bone density at six months (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt;.001)\u003c/p\u003e\n\u003cp\u003ePairwise 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 (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt;.001 and \u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt;.001, respectively). The bone density at 18 months post-surgically showed a statistically significant increase compared with bone density at six months (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt;.001). \u003cstrong\u003etable 5a and 5b\u003c/strong\u003e\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eMany bone augmentation procedures are performed to achieve the concept of prosthetically driven implant placement concept to restore both esthetic and function\u003csup\u003e(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/sup\u003e. 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.\u003c/p\u003e \u003cp\u003eIn 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 \u003cb\u003eJuodablalys et al\u003c/b\u003e.,\u003csup\u003e(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/sup\u003e 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.\u003c/p\u003e \u003cp\u003eCrestal 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.\u003c/p\u003e \u003cp\u003eThis is in accordance with \u003cb\u003eMoro et al\u003c/b\u003e.,\u003csup\u003e(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/sup\u003e 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 \u003cb\u003eJha et al.\u003c/b\u003e, \u003csup\u003e(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/sup\u003e \u003cb\u003e.\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe maximum insertion torque of implants ranged between 20N-CM and 50N-Cm. As \u003cb\u003eP\u0026eacute;rez-Pevida et al.\u003c/b\u003e, \u003csup\u003e(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/sup\u003e 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.\u003c/p\u003e \u003cp\u003eThe 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 \u003cb\u003eElla et al\u003c/b\u003e., \u003csup\u003e(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/sup\u003e 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\u0026ndash;group increase in bone width gain, while there was no statistically significant difference of bone width gain at the follow up periods.\u003c/p\u003e \u003cp\u003eIn 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.\u003c/p\u003e \u003cp\u003eThis is in consistent with \u003cb\u003eHommos AMA et al\u003c/b\u003e.,\u003csup\u003e(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/sup\u003e 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 \u003cb\u003eAbd El-Fattah et al\u003c/b\u003e.,\u003csup\u003e(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/sup\u003e 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\u003csup\u003e(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOn 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.\u003c/p\u003e \u003cp\u003eThis is in accordance with \u003cb\u003eSoni et al.\u003c/b\u003e,\u003csup\u003e(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/sup\u003e 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, \u003cb\u003eSohn et al.\u003c/b\u003e, \u003csup\u003e(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/sup\u003e 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.\u003c/p\u003e \u003cp\u003eIn 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 \u003cb\u003eAboelela et al.\u003c/b\u003e, \u003csup\u003e(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/sup\u003e 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 \u003cb\u003eTony et al.\u003c/b\u003e, \u003csup\u003e(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/sup\u003e; 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.\u003c/p\u003e \u003cp\u003eCollagen membrane was used in the current study based on the results of the study reported by \u003cb\u003eFriedmann et al.\u003c/b\u003e, \u003csup\u003e(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e)\u003c/sup\u003e 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. \u003csup\u003e(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/sup\u003e. 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.\u003c/p\u003e \u003cp\u003eIn Ridge Splitting Technique with Sticky Bone Graft Group, PRF membrane was used as a barrier membrane over the sticky bone as recommend by \u003cb\u003eK\u0026ouml;kdere et al.\u003c/b\u003e, \u003csup\u003e(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e)\u003c/sup\u003e 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 \u003cb\u003eVerdugo et al.\u003c/b\u003e,\u003csup\u003e(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/sup\u003e 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 \u003cb\u003elutz et al\u003c/b\u003e.,\u003csup\u003e(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e)\u003c/sup\u003e who reported that there is no significant benefit of using collagen membrane with bone grafting in ridge augmentation procedures.\u003c/p\u003e \u003cp\u003eAlso, the results of bone gain obtained in Ridge Splitting Technique with Sticky Bone Graft Group are in parallel line with the study conducted by \u003cb\u003eFolkman et al\u003c/b\u003e.,\u003csup\u003e(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e)\u003c/sup\u003e who stated that \u0026ldquo;bone regeneration and osseointegration may occur around implants placed in surgically-created bone defects\u0026rdquo;, i.e., the bone is able to \u0026ldquo;jump a gap\u0026rdquo; 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\u003csup\u003e(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe 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 \u003cb\u003eElian et al.\u003c/b\u003e, \u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e, 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, \u003cb\u003eDemetriades et al.\u003c/b\u003e, \u003csup\u003e(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e)\u003c/sup\u003e 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\u003csup\u003e(\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn the current study, secondary stage surgery was planned at time of 6 months follow up as recommended by \u003cb\u003eAnitua et el.\u003c/b\u003e\u003csup\u003e(\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e)\u003c/sup\u003e, 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.\u003c/p\u003e \u003cp\u003eIn 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\u0026ndash;1.6 mm during the first year and 0.05\u0026ndash;0.13 mm annually thereafter\u003csup\u003e(\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e)\u003c/sup\u003e. 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.\u003c/p\u003e \u003cp\u003eIn 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 \u003cb\u003eChugh et al.\u003c/b\u003e\u003csup\u003e(\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e)\u003c/sup\u003e 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\u003csup\u003e(\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn 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\u003csup\u003e(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eRadiographic 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.\u003c/p\u003e \u003cp\u003eNon-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 \u003cb\u003eBarbu et al.\u003c/b\u003e, \u003csup\u003e(\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e)\u003c/sup\u003e 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.\u003c/p\u003e \u003cp\u003eOn the other hand, the results reported by \u003cb\u003eKeith et al.\u003c/b\u003e, \u003csup\u003e(\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e)\u003c/sup\u003e; 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.\u003c/p\u003e \u003cp\u003eSame 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 \u003cb\u003eRamal et al\u003c/b\u003e., \u003csup\u003e(\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e)\u003c/sup\u003e showed 2.29 mm mean gain in bucco-lingual width of the ridge is in well accordance with the current study which resulted in \u0026asymp;\u0026thinsp;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.\u003c/p\u003e \u003cp\u003eIn 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\u003csup\u003e(\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e)\u003c/sup\u003e and this coincide with the studies reported by \u003cb\u003eAl-Nakib L.\u003c/b\u003e,\u003csup\u003e(\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e)\u003c/sup\u003e 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.\u003c/p\u003e \u003cp\u003e 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 \u003cb\u003eFarina et al\u003c/b\u003e,\u003csup\u003e\u003cb\u003e(\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e)\u003c/b\u003e\u003c/sup\u003e 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\u0026thinsp;\u0026le;\u0026thinsp;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\u003c/p\u003e \u003cp\u003eConclusively, 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\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003ePiezo-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.\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eRECOMMENDATIONS\u003c/h2\u003e \u003cp\u003eFurther 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.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eLIMITATIONS\u003c/h2\u003e \u003cp\u003eThe 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.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLDS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLithium Disilicate Glass\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMOD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMesio-Occluso-Distal\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCAD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputer-Aided Design\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCAD-CAM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecomputer-aided design (CAD) and computer-aided manufacturing (CAM)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMOD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMesial Occlusal Distal\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUSPHS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUnited States Public Health Service\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNewton\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u0026nbsp;\u003c/strong\u003eThe authors declare no conflicts of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Statement:\u0026nbsp;\u003c/strong\u003eThe authors received no specific funding for the conduction of this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis 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\u003c/p\u003e\n\u003cp\u003eEach patient agreed and signed Arabic and English informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot Applicable (extracted teeth)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eData available on request from the authors\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u0026nbsp;\u003c/strong\u003eThe 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Statement:\u0026nbsp;\u003c/strong\u003eThe authors received no specific funding for the conduction of this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eM.A. and I.M. conceived of the presented idea. A.E. developed the theory.\u003c/p\u003e\n\u003cp\u003eM.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.\u003c/p\u003e\n\u003cp\u003eAll authors discussed the results and contributed to the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003eThe authors acknowledge the statistical analysis team.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eSingh M, Kumar L, Anwar M, Chand P. Immediate dental implant placement with immediate loading following extraction of natural teeth. \u003cem\u003eNational journal of maxillofacial surgery\u003c/em\u003e\u003cstrong\u003e\u0026nbsp;2015\u003c/strong\u003e;6(2):252.\u003c/li\u003e\n \u003cli\u003eSchneider R. Prosthetic concerns about atrophic alveolar ridges. \u003cem\u003ePostgrad Dent\u003c/em\u003e\u003cstrong\u003e\u0026nbsp;1999\u003c/strong\u003e;6(2):3-7.\u003c/li\u003e\n \u003cli\u003eAra\u0026uacute;jo MG, Lindhe J. Dimensional ridge alterations following tooth extraction. 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Guided Bone Regeneration with Concentrated Growth Factor Enriched Bone Graft Matrix (Sticky Bone) vs. Bone-Shell Technique in Horizontal Ridge Augmentation: A Retrospective Study. \u003cstrong\u003e\u0026nbsp;2021\u003c/strong\u003e;10(17):3953.\u003c/li\u003e\n \u003cli\u003eKeith Jr JDJIJoP, Dentistry R. Localized ridge augmentation with a block allograft followed by secondary implant placement: a case report. \u003cstrong\u003e\u0026nbsp;2004\u003c/strong\u003e;24(1).\u003c/li\u003e\n \u003cli\u003eRamal A, Mohammed S, Nahed AJASDS. Modified staged ridge splitting technique versus conventional technique for horizontal expansion of narrow posterior mandible (randomized controlled clinical trial). \u003cstrong\u003e\u0026nbsp;2018\u003c/strong\u003e;2(7):101-9.\u003c/li\u003e\n \u003cli\u003eAl-Zubaidi SM, Madfa AA, Mufadhal AA, Aldawla MA, Hameed OS, Yue X-GJFiM. Improvements in clinical durability from functional biomimetic metallic dental implants. \u003cstrong\u003e\u0026nbsp;2020\u003c/strong\u003e;7:106.\u003c/li\u003e\n \u003cli\u003eAl-Nakib LHJJobcod. Computed tomography bone density in Hounsfield units at dental implant receiving sites in different regions of the jaw bone. \u003cstrong\u003e2014\u003c/strong\u003e;26(1):92-7. doi,\u003c/li\u003e\n \u003cli\u003eFarina R, Filippi M, Brazzioli J, Tomasi C, Trombelli LJJocp. Bleeding on probing around dental implants: a retrospective study of associated factors. \u003cstrong\u003e\u0026nbsp;2017\u003c/strong\u003e;44(1):115-22.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 5 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Implant Dentistry, Ridge Splitting, GBR, Nano HA, Sticky Bone, CBCT","lastPublishedDoi":"10.21203/rs.3.rs-4901038/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4901038/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction: \u003c/strong\u003eA 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives: \u003c/strong\u003eto 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and methods:\u003c/strong\u003e 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Both surgical techniques provided promising clinical and radiographic outcomes with no statistically significant differences among them.\u003c/p\u003e","manuscriptTitle":"Horizontal Bone Augmentation with Simultaneous Implant Placement Using Ridge Splitting with Sticky Bone Versus Onlay Sticky Bone Graft","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-16 00:50:34","doi":"10.21203/rs.3.rs-4901038/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"73547ea3-5164-4c42-8eaf-597354836959","owner":[],"postedDate":"September 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-16T00:50:37+00:00","versionOfRecord":[],"versionCreatedAt":"2024-09-16 00:50:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4901038","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4901038","identity":"rs-4901038","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}