Novel Double Expansion Technique Versus Ridge Splitting for Immediate Implant Placement in Narrow Ridges: A Randomized Trial

Novel Double Expansion Technique Versus Ridge Splitting for Immediate Implant Placement in Narrow Ridges: A Randomized Trial | 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 Novel Double Expansion Technique Versus Ridge Splitting for Immediate Implant Placement in Narrow Ridges: A Randomized Trial Mosaad Khalifah This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6235010/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 Background Horizontal deficiency of the alveolar ridge is a challenging condition for dental implant (DI) placement. Although the ridge splitting technique (RST) is very successful, the associated marginal bone loss (MBL) is a critical drawback. The current study aimed to present and compare a novel technique, the double expansion technique (DET), with the RST. Methods A total of 40 patients (57 DI) with narrow ridges were randomly allocated to the control group employing RST, and to the study group employing DET. DI was then immediately placed. Primary stability was measured at the time of implant placement. Secondary stability, marginal bone loss (MBL), keratinized mucosa width (KMW), the plaque index (PI), the bleeding index (BI), and probing depth (PD) were assessed at baseline (time of definitive abutment and temporary crown placement) and then at 3, 6, and 12 months. Pain and the number of analgesic tablets consumed were assessed daily during the first postoperative week. Results The study group had lower pain levels during the first two postoperative days. The study group presented greater primary and secondary stability at baseline and at 3 months. Moreover, it had less MBL at all time points and more KMW at the sixth and twelfth months. Otherwise, both groups showed comparable results regarding the PI, BI, and BD. Conclusion The study group had superior performance, which may be attributed to the lower degree of trauma. Clinical trial registration number: Thai Clinical Trials RegistryTCTR20250226005 at 26/2/2025 (Retrospectively registered) Horizontal deficiency Immediate implant placement Double expansion technique Ridge splitting technique Expansion Marginal bone loss Keratinized mucosal width Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Successful endosseous dental implants (DIs) require sufficient bone volume and dimensions. Deficient horizontal dimension is a typically challenging condition. Some authors consider a width of 5 mm width (faciolingual dimension) as the minimum width for dental implant placement 1 . Others believe that 6 mm is the minimum ridge width for successful DI placement. In either circumstance, a minimum of 1 mm bone thickness should be present at both the facial and the lingual aspects of the DI 2 . Therefore, many techniques have been developed for horizontal ridge augmentation, including guided bone regeneration 3,4 , onlay bone block grafting 5 , alveolar ridge expansion 6–8 , distraction osteogenesis 9 , and ridge splitting 10 . The ridge splitting technique (RST) was first described by Tatum in 1986. It requires a minimum of 3 mm of bone width with at least 1 mm of cancellous bone, to allow the insertion of a chisel between cortical plates to expand the cortical bone while maintaining an adequate blood supply 11 . RST involves the utilization of a chisel, osteotome, and/or peizotome to create a midcrestal horizontal osteotomy, followed by the creation of two vertical release osteotomies on the buccal surface. Thereafter, osteotomes of increasing diameter are inserted in the horizontal osteotomy to expand the ridge to create a gap that is large enough to accommodate DI. Ultimately, a specialized osteotomy for the DI is created using drills in the conventional manner 2,10,12,13 . Another technique that has gained popularity is the conventional ridge expansion technique (CRET). This technique was first introduced in the 1990s. It comprises the creation of a drill-made longitudinal hole, followed by the insertion of screw-type expanders of successively increasing diameters to expand bone. A disc of 4 mm diameter is usually included in the kit to create a midcrestal groove of 2 mm depth. However, you may proceed without creating that groove. This technique is less traumatic than the RST and has the advantages of facilitating bone condensation while expanding the bone laterally, thereby improving bone quality, enhancing DI primary stability, and facilitating wound healing 14,15 . Moreover, this technique is more comfortable for the patient and eliminates the need to use a mallet 28,29 . Nevertheless, Chan et. al. reported that the screw-expansion technique has a modest effect on ridge expansion, therefore, its application is limited to those cases where the ridge width is 4.5 mm or greater; otherwise, dehiscence is highly inevitable 16 . Therefore, RST is commonly indicated for ridges narrower than 4.5 mm. The present study presents a novel technique, the “double expansion technique (DET),” which may be less traumatic than the conventional RST, but more versatile than the conventional expansion technique, and can be employed for narrow ridges as narrow as 3 mm. DET comprises the creation of a horizontal midcrestal osteotomy, which was then expanded on two steps. In the first step, the ridge is expanded along the total osteotomy length via a hand osteotome, but only for approximately 1.5 mm. In the second step, the ridge is expanded only at the site of the DI to the total required expansion, using screw expanders of increasing diameter. Moreover, the current study aimed to compare the DET with the conventional RST. Patients and methods Study design The current study was a single-center, parallel-group, single-blinded, randomized clinical trial with balanced randomization (1:1). The study was conducted at the Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Kafrelsheikh University, from January 2020 through December 2023 in compliance with the Declaration of Helsinki (revised in 1975) and with the 2010 CONSORT (Consolidated Standards of Reporting Trials) prin­ciples 17 and was approved by the regional ethical review board. All patients provided informed consent. The null hypothesis was that the percentage of bone loss around the DI placed by the RST not significantly different from that around the DI placed by the DET. Sample size The sample size was calculated to determine a 0.5 mm difference in marginal bone loss (MBL) with a standard deviation (SD) of 0.03 (at 85% power, with a 5%, two-sided, significance level). This was based on a previous study 18 . Accordingly, the minimum required number of patients in each group was 18, and with an extra 10% of the dropout ratio, the final number was 20 participants for each group. Participants: The inclusion criterion was patients aged 18 years or older with missing single or multiple maxillary teeth with a ridge of a 3-4 mm wide. The exclusion criteria were smoking, the presence of an endocrine disease, hematologic disease, healing problems, immune disease, bone disease, the presence of inflammation, or a history of any grafting procedure at the proposed edentulous ridge. Randomization The participants were assigned in ascending order at the enrollment visit and were randomly assigned at a 1:1 ratio to both the control group (ridge splitting group) and the test group (double expansion group) via an online randomization tool ( https://www.randomizer.org/ ). Allocation was concealed within opaque envelopes to be opened intraoperatively by the surgeon. A noninvolved researcher created the sequence of the envelopes. Blinding The participants, the statistician, and the clinical surgeon who examined and recorded the clinical outcomes of interest and postsurgical complications were all blinded to the allocated arm. Interventions All patients underwent preoperative cone beam computed tomography (CBCT) (Cybermed, Korea). Local anesthesia was administered via the use 4% articaine HCl with epinephrine (1:100,000) (ArtPharmaDent TM , Artpharma, Egypt). The flap design was a three-line pyramidal full-thickness mucoperiosteal flap. The crestal incision over the edentulous area was slightly lingual to accommodate the expected increase in ridge width. The two buccal vertical release incisions were papilla preservation incisions, and were placed 2 mm mesial and distal to the proposed buccal relief osteotomies. The buccal flap was reflected exceeding the mucogingival junction, while the lingual flap was minimally reflected. For the control group, a midcrestal osteotomy was performed via piezosurgery (Piezotome® Cube, Acteon, Satelec, France) using the BS1S tip down to a depth 2-3 mm short to the length of the planned DI. The buccal relief osteotomy(ies) was performed using the CS3 tip. Then, conical tips CS4, CS5, and CS6 were used to gradually increase the resulting osteotomy gap from 1 to 4 mm. Thereafter, the usual drilling protocol provided by the DI manufacturer was followed to allow the insertion of DI(s) (Biohorizons tapered Pro, Alabama, USA) to the level of the crestal bone via a torque wrench. Finally, a periosteal releasing incision was placed at the base of the inner aspect of the buccal flap to obtain tension-free closure of the wound using 3–0 polyglactin 910 sutures (Vicryl Plus, Ethicon, USA) 19 . For the study group, a mid-crestal osteotomy was performed via piezosurgery (Piezotome® Cube, Acteon, Satelec, France) using the BS1S tip down to 9 mm, which is the full cutting depth of the tip BS1S. This horizontal osteotomy exceeds the area of the proposed DI to involve 5 mm mesial and distal to that area (if possible). No vertical osteotomies were performed. Then, a hand osteotome was inserted into the created horizontal bone groove to expand the groove, along its total length, buccally and lingually by gentle hand pressure. This expands the ridge by approximately 1-1.5 mm. Thus, the total gap width can reach 2-2.5 mm (Figure 1). This was the first expansion step, which was a generalized, partial, expansion step. Thereafter, localized expansion was performed only at the proposed DI site(s) via successively increasing-diameter root-form screw-type expanders (Dental Bone Expander Kit, Star Edge Tools, Pakistan) without the use of discs or drills (Figure 2). This localized expansion was performed to the full desired expansion width. This was the second expansion step, which was a localized full-width expansion step. If the planned DI length was more than 9 mm, the piezotome was inserted once again through the expanded gap until the full length of the planned DI was reached, and the generalized expansion process was attempted once again. This was followed by the repetition of the localized expansion step to the full length of the DI. A DI (Biohorizons Tapered Pro, Alabama, USA) was then placed at the level of the crestal bone without any previous drilling and by using a torque wrench (Figure 3). Finally, the wound was closed as was in the control group. For both groups, amoxicillin 800 mg with clavulanic acid 200 mg tablets (Augmentin, GSK, Egypt) were prescribed every 12 hours for 7 days. Ibuprofen 600 mg tablets (Brufen, Abbott, Egypt) were prescribed every 12 hours for 5 days and then taken, when necessary, after these five days. All patients were instructed to preserve proper oral hygiene and to use a chlorhexidine HCl mouthwash 125 mg/100 mL (Hexitol, Adco, Egypt) three times a day. After three months, the DI was exposed, and a healing abutment was placed for two weeks to allow for the definitive abutments and temporary crowns to be placed. The placement of the definitive restorations was deferred to the end of the follow-up period to determine about the need for grafting to provide an adequate environment for an acceptable emergence profile and to decrease the vertical cantilever as much as possible. Outcomes Clinical outcomes The primary implant stability (at implant placement time) was assessed via a resonance frequency analyzer (Osstell IDx Mentor, Osstell AB, Goteborg, Sweden) as the average of the buccolingual and mesiodistal measurements of the implant stability quotient (ISQ). For seven consecutive postoperative days, pain was assessed daily via the 0 – 10 score visual analog scale (VAS) with 0 indicating “no pain” and 10 indicating “worst pain”. During the same follow-up period, the number of analgesic tablets consumed daily by the patient was also recorded. Peri-implant mucositis and peri-implantitis were assessed according to the 2017 World Workshop Case Definitions and Diagnostic Consideration 20,21 . The baseline was the time point of placement of the definitive abutments and temporary crowns. The secondary implant stability, keratinized mucosa width (KMW), Lindquist plaque index (PI), bleeding index (BI), and pocket probing depth (PD) were measured at baseline and then at three, six, and 12 months. Secondary implant stability was assessed via a resonance frequency analyzer (Osstell IDx Mentor, Osstell AB, Goteborg, Sweden) as the average of the buccolingual and mesiodistal measures (ISQs). The KMW was measured as the distance between the gingival margin and mucogingival junction at the mid-labial area 22 . The PI was assessed at the mesial and distal angles and at the center of the labial and lingual aspects of the DI, and the mean of the scores was taken. A score of 0 was assigned if there was no visible plaque detected; a score of 1 was assigned for local plaque accumulation (<25); and a score of 3 was assigned for general plaque accumulation (greater than 25%) 23 . The BI was measured as the mean of measurements at the same points. The score was assessed after 30 seconds of gentle application of a periodontal probe (11 Colorvue® Probe Kit; Hu-Friedy, Chicago, IL, USA) by one blinded trained resident with a gentle probing force (0.15 N) calibrated via a precision scale. A score of 0 was assigned if there was no bleeding when the probe was passed along the gingival margin adjacent to the implant; a score of 1 was assigned if there were isolated bleeding spots visible; a score of 2 was assigned if blood formed a confluent red line on the margin, whereas; a score of 3 was assigned for heavy or profuse bleeding 24 . The PD was measured as the mean of probing depths at the same points mentioned for BI (as the distance from the gingival margin to the bottom of the pocket in 1 mm increments) and using the same periodontal probe under the same standardized force while maintaining the probe parallel to the long axis of the implant 25 . Radiographic analysis Immediate postoperative panoramic radiographs (Cranex TM D, Sredex, Finland) were taken (Figure 4: which shows dental implants on the right side, which were placed as a control case, and the left side dental implants as a study case). Also, Standardized immediate postoperative periapical radiographs were taken via an imaging plate (i-Scan Imaging Plate Scanner, Guilin Woodpecker, China) via the long-cone paralleling technique with a customized condensation silicone bite record made with Orthogum (Zhermack, Badia Polesine, Italy) on a Rinn XCO Ring positioner (Dentsply, Constanz, Germany). Thereafter, standardized periapical radiographs were taken at baseline and after three, six, and 12 months. A panoramic radiograph was taken at the 12 th postoperative month (Figure 5, which shows the DI on the right side, which was used as a control case, and the left side DI, which was as a study case). Marginal bone loss (MBL) at a given time point was measured via the standardized periapical radiographs as the means of the differences between the marginal bone level at that time point and that measured immediately postoperatively at the mesial and distal aspects of the implant. The marginal bone level was measured as the vertical distance from the implant platform (the horizontal interface between the implant and the abutment) to the most coronal level of bone-to-implant contact. The known implant length and diameter were used to calibrate each individual measurement 26 . Statistical analysis Statistical analysis was performed with SPSS software (version 19, IBM Co., USA). The data were not normally distributed. Thus, group means were tested via the Mann-Whitney test for numerical data, and Fisher’s exact test was used for categorical data. Moreover, a mixed linear model was employed to test the clinical outcomes measured at multiple time points. Results Among a total of 207 patients who attended the department, 40 patients (who received 57 DIs) met the inclusion criteria and were enrolled in the study. The demographic data are shown in Table 1, which reveals a statistically nonsignificant difference between the groups. Table 1: Demographic data of the patients. parameter Control group Study group Significance of the difference at P≤0.5 Age mean±SD 45.81±5.33 47.51±5.64 Nonsignificant (P=0.361) Age range 39-65 39-59 NA Gender (male: female) 11:9 8:12 Nonsignificant (P*= 0. 342178) SD: standard deviation, NA: not applicable; P: P of the Mann–Whitney U test; P*: P of the Chi square test. Clinically, uneventful healing was observed without postoperative infection or wound dehiscence in both groups (Fisher’s exact test value = 1; nonsignificant difference at p<0.05). No patients in either group presented with peri-implant mucositis or peri-implantitis (Fisher’s exact test value = 1; nonsignificant difference at p<0.05). The preoperative ridge width was 3.5±0.8 mm in the control group and 3.3±0.64 mm in the study group (the P value of the Mann-Whitney U test was 0.4281, indicating a nonsignificant difference). As Table 2 shows, the patients in the study group presented lower pain levels than did those in the control group did during the first two postoperative days, and a lower number of analgesic tablets were taken for the first three postoperative days. Thereafter, there were no significant differences between the groups with respect to postoperative pain or the number of analgesic tablets consumed daily. Table 2: VAS score and analgesic tablets used during the first postoperative week. Day VAS, mean (SD) Analgesic tablets, Mean (SD) Control gr Study gr P value Control gr Study gr P value 1 6.71 (0.64) 5.89 (0.37) <0.01 3.9 (0.56) 3.1 (0.12) <0.01 2 5.35 (0.76) 4.25 (0.25) <0.01 3.6 (0.23) 2.7 (0.31) <0.01 3 3.17 (0.38) 3.01 (0.12) 0.0752 3.0 (0.15) 2.1 (0.09) <0.01 4 1.56 (0.31) 1.32 (0.64) 0.1168 1.6 (0.72) 1.4 (0.66) 0.3816 5 0.83 (0.41) 0.59 (0.39) 0.06471 0.77 (0.22) 0.73 (0.19) 0.6944 6 0.15 (0.36) 0.1 (0.3) 0.80258 0.05 (0.22) 0 (0) 0.3262 7 0.00 (0.00) 0.00 (0.00) 1.0 0 (0) 0 (0) 1.0 VAS: Visual analog scale; P value was calculated using Mann–Whitney U test; gr: group. As shown in Table 3, the study group had significantly greater primary stability and secondary stability at baseline and after three months; nevertheless, this difference was nonsignificant thereafter. For the control group, intragroup comparisons over time revealed that secondary stability increased over time but was statistically significant only at the sixth and twelfth months. Nevertheless, for the study group, the increase in secondary stability was statistically significant at all time points. Table 3: Implant stability in the control and study groups (groups 1 and 2). parameter Control gr Study gr P value and significance Primary implant stability 40.07±7.7 58.6±6.9 Significant (P<0.01) Secondary implant stability (at baseline) 71.4±5.5 75.8±3.8 Significant (P=0.007) Secondary implant stability (at 3 months after baseline) 74.2±3.6 78.2±1.4 Significant (0<0.01) P value of the intragroup change from the baseline value 0.0724, Nonsignificant 0.0236, significant Secondary implant stability (at 6 months after baseline) 78.4±2.38 79.7±2.01 Nonsignificant (0.0749) P value of the change from the 3 months value <0.01, significant <0.01, significant Secondary implant stability (at 12 months after baseline) 82.2±0.6 82.57±0.11 Nonsignificant (P=0.012) P value of the change from the 6 months value <0.01, significant <0.01, significant *P value was calculated using Mann-Whitney U test; the significance of the difference was considered at P≤0.5; gr: group. Table 4 shows that the marginal bone loss in the study group was significantly lower than that in the control group at every time point. Over time, MBL significantly increased in both groups, with the highest values occurring at the twelfth month. With respect to the KMW, the study group presented a significantly greater KMW than did the control group at the sixth and twelfth months; otherwise, the differences were statistically nonsignificant. With respect to intragroup comparisons, the control group presented a statistically significant reduction in the KMW over time, with the lowest value occurring at the twelfth month. However, for the study group, there were no statistically significant differences in the KMW over time. Nevertheless, all these values were within the normal, clinically acceptable ranges. With respect to the PI, BI, and PD, the differences between the two groups at every time point were statistically nonsignificant. Although the intragroup comparisons for these parameters showed fluctuations over time; these differences were statistically nonsignificant, and all the values were within the normal, clinically acceptable ranges. Table 4: Marginal bone loss, keratinized mucosa width, plaque index, bleeding index, and probing depth for the control and study groups at different time points. Parameter The value at the different time points P value * Baseline 3 months 6 months 12 months MBL control 0.42±0.07 1.2±0.44 1.47±0.63 1.63±0..91 <0.01 MBL study 0.13±0.02 0.56±0.11 0.68±0.05 0.68±0.08 <0.01 P value ‡ <0.01 <0.01 <0.01 <0.01 KMW control 4.32±1.55 4.21±1.36 3.15±0.98 3.08±1.04 0.0172 KMW study 4.37±1.42 4.29±1.17 4.25±1.23 4.24±1.08 0.8631 P value ‡ 1.1304 0.9312 0.0048 0.0023 PI control 0.75±0.12 0.75±0.08 0.68±0.18 0.72±0.23 0.6739 PI study 0.74±0.06 0.79±0.11 0.75±0.14 0.71±0.09 0.2289 P value ‡ 0.8127 0.2364 0.2193 0.8924 BI control 0.16±0.11 0.15±0.08 0.1±0.19 0.11±0.12 0.1872 BI study 0.18±0.16 0.13±0.07 0.08±0.12 0.12±0.14 0.1462 P value ‡ 0.6637 0.5518 0.7343 0.8292 PD control 3.25±0.66 2.93±0.71 2.82±0.98 3.36±0.26 0.5213 PD study 2.86±0.98 3.11±0.26 3.05±0.41 3.11±0.78 0.4106 P value ‡ 0.1578 0.3014 0.4311 0.2317 P value *: P value for the Mann–Whitney U test; P value ‡: the P value for the Kruskal-Wallis test; MBL control: Marginal bone loss for the control group (in mm); MBL study: Marginal bone loss for the study group (in mm); PI control: Plaque index for the control group; PI study: Plaque index for the study group; BI control: Bleeding index for the control group; BI study: Bleeding index for the study group; PD control: Probing depth for the control group (in mm); PD study: Probing depth for the study group (in mm); KMW control: Keratinized mucosa width for the control group (in mm); KMW study: Keratinized mucosa width for the study group (in mm). Discussion In the current study, there were Nonsignificant differences regarding age, gender distribution, and preoperative ridge width; therefore, both groups can be considered comparable. The study group presented lower pain levels than did the control group during the first and second postoperative days. This may be attributed to the lower degree of trauma associated with DET. With respect to primary implant stability and early secondary implant stability, the study group presented superior results to those of the control group. This may be the result of the variance in the nature of the two techniques. In contrast with the RST, which depends on ridge splitting and subsequent mobilization of the semi-detached buccal plate of bone, the DET involves the buccal plate being lateralized without being detached. Moreover, the second step of localized ridge expansion leads to bone condensation, improving bone quality and offering some resistance to DI placement, allowing firmer DI holding aided by bone rebound due to its resiliency. When bone healing reached advanced stages in both groups, DI stability was comparable. With respect to MBL, the MBL levels in the control group were comparable to those reported in various previous studies 18,19,27 . Compared with those in the control group, the MBL levels in the study group were lower at all time points. This may be the result of the nature of the DET, which comprises a two-stage expansion. The first aimed to achieve approximately half the required expansion distance, therefore, less load was placed on the bone plates. Moreover, no vertical osteotomies were placed on the buccal plate of bone, providing richer blood supply than that present in the RST. The remainder of the required expansion was performed through localized progressive expansion only at the planned DI site, which was essentially an expansion of the already expanded bone plates; therefore, this expansion was easier and less traumatic than expanding the bone to the total required expansion in one step. For the same reasons, the amount of KMW was greater in the study group than in the control group at the sixth and twelfth months, when the MBL was high enough to reduce the KMW in the control group. The other clinical parameters, the PI, BI, and PD were comparable between the two groups at all time points. This may be the result of the uneventful healing in both groups. To conclude, the difference in strategy between the DET, RST, and CRET is that the DET comprises ridge expansion over two steps, whereas both RST and CRET expands the ridge to the full required expansion length in one stage. Although buccal plate lateralization is needed only at the DI site, RST leads to lateralization of the entire buccal plate. This was avoided in DET, and thereby, there is no need to perform the vertical osteotomies. The second step in DET is devoted to expanding the already expanded bone plates and only at the DI site. Therefore, the least forces, the least potential for dehiscence, richer blood supply, better healing and less MBL may be expected while achieving the maximum possible expansion. Limitations of the current study: The results of the current study needs to be furtherly assessed through multi-center studies. Conclusion The DET involves a two-step expansion; generalized partial-extent expansion, which is followed with a localized full-extent expansion. The first-step expansion is intended to decrease bone resistance to further expansion, thereby substituting the buccal release osteotomies performed during RST. The DET group had a more comfortable early postoperative period, and higher primary and early secondary stabilities. Moreover, the DET group had a lower MBL and a wider KMW. This superior performance may be attributed to the lower degree of trauma, fewer stresses on the bone, and lack of need for vertical osteotomies. According to the results of the current study, the null hypothesis can be rejected. Abbreviations RST: Ridge splitting technique MBL: Marginal bone loss CRET: Conventional ridge expansion technique DET: Double expansion technique ISQ: Implant stability quotient (ISQ) VAS: visual analog scale KMW: keratinized mucosa width PI: Lindquist plaque index BI: bleeding index PD: pocket probing depth (PD) Declarations Human Ethics and Consent to Participate declaration The study was conducted in compliance with the Declaration of Helsinki (revised in 1975) and was approved by the regional ethical review board of Kafrelsheikh University. All participants provided informed consent. Consent for publication No individual person’s data was included in the current study. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The author declares no conflict of interest and no funding. Funding No funding to declare. Authors' contributions Mosaad Khalifah is the sole author. Acknowledgements The author deeply acknowledges Dr Ahmad Kamel for his efforts in collecting data of the clinical parameters. Clinical trial registration number: TCTR20250226005. References Misch CM, Misch CE, Resnik RR, Ismail YH. Reconstruction of maxillary alveolar defects with mandibular symphysis grafts for dental implants: a preliminary procedural report. Int J Oral Maxillofac Implants . 1992;7(3):360-366. Scipioni A, Bruschi GB, Calesini G. The edentulous ridge expansion technique: a five-year study. Int J Periodontics Restorative Dent . 1994;14(5):451-459. Melcher AH. On the Repair Potential of Periodontal Tissues. J Periodontol . 1976;47(5):256-260. doi:10.1902/jop.1976.47.5.256 Wang HL, Boyapati L. “PASS” Principles for Predictable Bone Regeneration. Implant Dent . 2006;15(1):8-17. doi:10.1097/01.id.0000204762.39826.0f Cordaro L, Amadè DS, Cordaro M. Clinical results of alveolar ridge augmentation with mandibular block bone grafts in partially edentulous patients prior to implant placement. Clin Oral Implants Res . 2002;13(1):103-111. doi:10.1034/j.1600-0501.2002.130113.x Chiapasco M, Ferrini F, Casentini P, Accardi S, Zaniboni M. Dental implants placed in expanded narrow edentulous ridges with the Extension Crest ® device. Clin Oral Implants Res . 2006;17(3):265-272. doi:10.1111/j.1600-0501.2005.01196.x Siddiqui AA, Sosovicka M. Lateral Bone Condensing and Expansion for Placement of Endosseous Dental Implants: A New Technique. Journal of Oral Implantology . 2006;32(2):87-94. doi:10.1563/786.1 Summers RB. The osteotome technique: Part 2--The ridge expansion osteotomy (REO) procedure. Compendium . 1994;15(4):422, 424, 426, passim; quiz 436. Chin M, Toth BA. Distraction osteogenesis in maxillofacial surgery using internal devices: Review of five cases. Journal of Oral and Maxillofacial Surgery . 1996;54(1):45-53. doi:10.1016/S0278-2391(96)90303-1 Tatum H. Maxillary and sinus implant reconstructions. Dent Clin North Am . 1986;30(2):207-229. Demarosi F, Leghissa GC, Sardella A, Lodi G, Carrassi A. Localised maxillary ridge expansion with simultaneous implant placement: A case series. British Journal of Oral and Maxillofacial Surgery . 2009;47(7):535-540. doi:10.1016/j.bjoms.2008.11.012 Mestas G, Alarcón M, Chambrone L. Long-Term Survival Rates of Titanium Implants Placed in Expanded Alveolar Ridges Using Split Crest Procedures: A Systematic Review. Int J Oral Maxillofac Implants . 2016;31(3):591-599. doi:10.11607/jomi.4453 Simion M, Baldoni M, Zaffe D. Jawbone enlargement using immediate implant placement associated with a split-crest technique and guided tissue regeneration. Int J Periodontics Restorative Dent . 1992;12(6):462-473. Coatoam GW, Mariotti A. The segmental ridge-split procedure. J Periodontol . 2003;74(5):757-770. doi:10.1902/jop.2003.74.5.757 González-García R, Monje F, Moreno C. Alveolar split osteotomy for the treatment of the severe narrow ridge maxillary atrophy: a modified technique. Int J Oral Maxillofac Surg . 2011;40(1):57-64. doi:10.1016/j.ijom.2010.03.030 Chan HL, Fu JH, Koticha T, Benavides E, Wang HL. Ridge width gain with screw spreaders: a cadaver study. Implant Dent . 2013;22(5):552-558. doi:10.1097/ID.0b013e3182a3333c Schulz KF, Altman DG, Moher D. CONSORT 2010 Statement: Updated guidelines for reporting parallel group randomised trials. BMC Med . 2010;8(1):1-9. doi:10.1186/1741-7015-8-18/FIGURES/1 Mounir M, Beheiri G, El-Beialy W. Assessment of marginal bone loss using full thickness versus partial thickness flaps for alveolar ridge splitting and immediate implant placement in the anterior maxilla. Int J Oral Maxillofac Surg . 2014;43(11):1373-1380. doi:10.1016/j.ijom.2014.05.021 Mahmoud ZT, El-Dibany MM, El-Ghamrawy SM, Osman SM, Troedhan AC. MUCOSAL FLAP VERSUS MUCOPERIOSTEAL FLAP IN RIDGE SPLITTING AND SIMULTANEOUS IMPLANT PLACEMENT USING PIEZOSURGERY (A RANDOMIZED CONTROLLED CLINICAL TRIAL). Alexandria Dental Journal . 2017;42(1):67-72. doi:10.21608/adjalexu.2017.57859 Renvert S, Persson GR, Pirih FQ, Camargo PM. Peri-implant health, peri-implant mucositis, and peri-implantitis: Case definitions and diagnostic considerations. J Clin Periodontol . 2018;45 Suppl 20:S278-S285. doi:10.1111/JCPE.12956 Berglundh T, Armitage G, Araujo MG, Avila-Ortiz G, Blanco J, Camargo PM, et al. Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Periodontol . 2018;89 Suppl 1:S313-S318. doi:10.1002/JPER.17-0739 Newman M, Takei H, Klokkevold P, Carranza F. Carranza’s Clinical Periodontology. Elsevier Health Sciences . Vol 11th edition. Elsevier; 2012. Lindquist LW, Rockler B, Carlsson GE. Bone resorption around fixtures in edentulous patients treated with mandibular fixed tissue-integrated prostheses. J Prosthet Dent . 1988;59(1):59-63. doi:10.1016/0022-3913(88)90109-6 Mombelli A, van Oosten MAC, Schürch E, Lang NP. The microbiota associated with successful or failing osseointegrated titanium implants. Oral Microbiol Immunol . 1987;2(4):145-151. doi:10.1111/J.1399-302X.1987.TB00298.X Buser D, Weber H ‐P, Lang NP. Tissue integration of non-submerged implants. 1-year results of a prospective study with 100 ITI hollow-cylinder and hollow-screw implants. Clin Oral Implants Res . 1990;1(1):33-40. doi:10.1034/J.1600-0501.1990.010105.X Zhang XX, Shi JY, Gu YX, Lai HC. Long-Term Outcomes of Early Loading of Straumann Implant-Supported Fixed Segmented Bridgeworks in Edentulous Maxillae: A 10-Year Prospective Study. Clin Implant Dent Relat Res . 2016;18(6):1227-1237. doi:10.1111/CID.12420 Jensen OT, Cullum DR, Baer D. Marginal Bone Stability Using 3 Different Flap Approaches for Alveolar Split Expansion for Dental Implants—A 1-Year Clinical Study. Journal of Oral and Maxillofacial Surgery . 2009;67(9):1921-1930. doi:10.1016/j.joms.2009.04.017 Nishioka RS, Souza FA. Bone Spreader Technique: A Preliminary 3-Year Study. Journal of Oral Implantology . 2009;35(6):289-294. doi:10.1563/1548-1336-35.6.289 Nishioka RS, Souza FÁ. Bone Spreading and Standardized Dilation of Horizontally Resorbed Bone: Technical Considerations. Implant Dent . 2009;18(2):119-125. doi:10.1097/ID.0b013e318198e517 Additional Declarations No competing interests reported. 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-6235010","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":462639468,"identity":"638f69b9-d83c-4ec3-944d-4fa1c795bb54","order_by":0,"name":"Mosaad Khalifah","email":"data:image/png;base64,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","orcid":"","institution":"Kafrelsheikh University","correspondingAuthor":true,"prefix":"","firstName":"Mosaad","middleName":"","lastName":"Khalifah","suffix":""}],"badges":[],"createdAt":"2025-03-15 23:23:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6235010/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6235010/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83681738,"identity":"706ac9b6-c6cd-4994-9c4b-6a72d7587b94","added_by":"auto","created_at":"2025-05-30 16:21:06","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1046919,"visible":true,"origin":"","legend":"\u003cp\u003eThe generalized expansion step of the mid-crestal osteotomy (study group).\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6235010/v1/98acd5065766569666028dd5.jpg"},{"id":83681739,"identity":"de81218a-4fa5-4d50-b62a-7a1a9ef12096","added_by":"auto","created_at":"2025-05-30 16:21:06","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1028946,"visible":true,"origin":"","legend":"\u003cp\u003eRoot-form screw-type expanders were used for the localized expansion step (study group).\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6235010/v1/779c4d3bac3d993fa815cd4b.jpg"},{"id":83681345,"identity":"6ae9bef2-e104-4f02-82db-67ba6f95b020","added_by":"auto","created_at":"2025-05-30 16:13:06","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1140367,"visible":true,"origin":"","legend":"\u003cp\u003eDental implants were immediately placed (study group).\u003c/p\u003e","description":"","filename":"figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6235010/v1/e24d1233429e840e1a704107.jpg"},{"id":83681347,"identity":"fcc68243-f73d-4baa-89f1-650a80f94bf9","added_by":"auto","created_at":"2025-05-30 16:13:06","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":143311,"visible":true,"origin":"","legend":"\u003cp\u003eImmediate postoperative panoramic radiograph (which shows dental implants on the right side that were placed as a control case, and the left side dental implants as a study case).\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6235010/v1/5a248f7e150cbe699718bb1f.jpg"},{"id":83681349,"identity":"cee8b51e-9de1-4a8f-b1f0-9bb88a516d1d","added_by":"auto","created_at":"2025-05-30 16:13:06","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":1068234,"visible":true,"origin":"","legend":"\u003cp\u003eA panoramic radiograph taken at the twelfth postoperative month (which shows the dental implants on the right side that were placed as a control case, and the left side dental implants as a study case).\u003c/p\u003e","description":"","filename":"Figure5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6235010/v1/d41eb6786fe8de79cedf734b.jpg"},{"id":85721982,"identity":"9c05c2a0-ae89-4627-b9a6-7877f824dea8","added_by":"auto","created_at":"2025-07-01 05:46:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5110835,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6235010/v1/c2041771-a7a6-49d2-b12c-270fce46356b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Novel Double Expansion Technique Versus Ridge Splitting for Immediate Implant Placement in Narrow Ridges: A Randomized Trial","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSuccessful endosseous dental implants (DIs) require sufficient bone volume and dimensions. Deficient horizontal dimension is a typically challenging condition. Some authors consider a width of 5 mm width (faciolingual dimension) as the minimum width for dental implant placement \u003csup\u003e1\u003c/sup\u003e. Others believe that 6 mm is the minimum ridge width for successful DI placement. In either circumstance, a minimum of 1 mm bone thickness should be present at both the facial and the lingual aspects of the DI \u003csup\u003e2\u003c/sup\u003e. Therefore, many techniques have been developed for horizontal ridge augmentation, including guided bone regeneration \u003csup\u003e3,4\u003c/sup\u003e, onlay bone block grafting \u003csup\u003e5\u003c/sup\u003e, alveolar ridge expansion \u003csup\u003e6\u0026ndash;8\u003c/sup\u003e, distraction osteogenesis \u003csup\u003e9\u003c/sup\u003e, and ridge splitting \u003csup\u003e10\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe ridge splitting technique (RST) was first described by Tatum in 1986. It requires a minimum of 3 mm of bone width with at least 1 mm of cancellous bone, to allow the insertion of a chisel between cortical plates to expand the cortical bone while maintaining an adequate blood supply \u0026nbsp;\u003csup\u003e11\u003c/sup\u003e. RST involves the utilization of a chisel, osteotome, and/or peizotome to create a midcrestal horizontal osteotomy, followed by the creation of two vertical release osteotomies on the buccal surface. Thereafter, osteotomes of increasing diameter are inserted in the horizontal osteotomy to expand the ridge to create a gap that is large enough to accommodate DI. Ultimately, a specialized osteotomy for the DI is created using drills in the conventional manner \u003csup\u003e2,10,12,13\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother technique that has gained popularity is the conventional ridge expansion technique (CRET). This technique was first introduced in the 1990s. It comprises the creation of a drill-made longitudinal hole, followed by the insertion of screw-type expanders of successively increasing diameters to expand bone. A disc of 4 mm diameter is usually included in the kit to create a midcrestal groove of 2 mm depth. However, you may proceed without creating that groove. This technique is less traumatic than the RST and has the advantages of facilitating bone condensation while expanding the bone laterally, thereby improving bone quality, enhancing DI primary stability, and facilitating wound healing \u003csup\u003e14,15\u003c/sup\u003e. Moreover, this technique is more comfortable for the patient and eliminates the need to use a mallet \u003csup\u003e28,29\u003c/sup\u003e. Nevertheless, Chan et. al. reported that the screw-expansion technique has a modest effect on ridge expansion, therefore, its application is limited to those cases where the ridge width is 4.5 mm or greater; otherwise, dehiscence is highly inevitable \u003csup\u003e16\u003c/sup\u003e. Therefore, RST is commonly indicated for ridges narrower than 4.5 mm.\u003c/p\u003e\n\u003cp\u003eThe present study presents a novel technique, the \u0026ldquo;double expansion technique (DET),\u0026rdquo; which may be less traumatic than the conventional RST, but more versatile than the conventional expansion technique, and can be employed for narrow ridges as narrow as 3 mm. DET comprises the creation of a horizontal midcrestal osteotomy, which was then expanded on two steps. In the first step, the ridge is expanded along the total osteotomy length via a hand osteotome, but only for approximately 1.5 mm. In the second step, the ridge is expanded only at the site of the DI to the total required expansion, using screw expanders of increasing diameter. Moreover, the current study aimed to compare the DET with the conventional RST.\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003ch2\u003eStudy design\u003c/h2\u003e\n\u003cp\u003eThe current study was a single-center, parallel-group, single-blinded, randomized clinical trial with balanced randomization (1:1). The study was conducted at the Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Kafrelsheikh University, from January 2020 through December 2023 in compliance with\u0026nbsp;the Declaration of Helsinki (revised in 1975) and with the 2010 CONSORT (Consolidated Standards of Reporting Trials) prin\u0026shy;ciples \u003csup\u003e17\u003c/sup\u003e and was approved by the regional ethical review board. All patients provided informed consent.\u003c/p\u003e\n\u003cp\u003eThe null hypothesis was that the percentage of bone loss around the DI placed by the RST not significantly different from that around the DI placed by the DET.\u003c/p\u003e\n\u003ch2\u003eSample size\u003c/h2\u003e\n\u003cp\u003eThe sample size was calculated to determine a 0.5 mm difference in marginal bone loss (MBL) with a standard deviation (SD) of 0.03 (at 85% power, with a 5%, two-sided, significance level). This was based on a previous study \u003csup\u003e18\u003c/sup\u003e. Accordingly, the minimum required number of patients in each group was 18, and with an extra 10% of the dropout ratio, the final number was 20 participants for each group.\u003c/p\u003e\n\u003ch2\u003eParticipants:\u003c/h2\u003e\n\u003cp\u003eThe inclusion criterion was patients aged 18 years or older with missing single or multiple maxillary teeth with a ridge of a 3-4 mm wide. The exclusion criteria were smoking, the presence of an endocrine disease, hematologic disease, healing problems, immune disease, bone disease, the presence of inflammation, or a history of any grafting procedure at the proposed edentulous ridge.\u003c/p\u003e\n\u003ch2\u003eRandomization\u003c/h2\u003e\n\u003cp\u003eThe participants were assigned in ascending order at the enrollment visit and were randomly assigned at a 1:1 ratio to both the control group (ridge splitting group) and the test group (double expansion group) via an online randomization tool (\u003cstrong\u003ehttps://www.randomizer.org/\u003c/strong\u003e). Allocation was concealed within opaque envelopes to be opened intraoperatively by the surgeon. A noninvolved researcher created the sequence of the envelopes.\u003c/p\u003e\n\u003ch2\u003eBlinding\u003c/h2\u003e\n\u003cp\u003eThe participants, the statistician, and the clinical surgeon who examined and recorded the clinical outcomes of interest and postsurgical complications were all blinded to the allocated arm.\u003c/p\u003e\n\u003ch2\u003eInterventions\u003c/h2\u003e\n\u003cp\u003eAll patients underwent preoperative cone beam computed tomography (CBCT) (Cybermed, Korea). Local anesthesia was administered via the use 4% articaine HCl with epinephrine (1:100,000) (ArtPharmaDent\u003csup\u003eTM\u003c/sup\u003e, Artpharma, Egypt). The flap design was a three-line pyramidal full-thickness mucoperiosteal flap. The crestal incision over the edentulous area was slightly lingual to accommodate the expected increase in ridge width. The two buccal vertical release incisions were papilla preservation incisions, and were placed 2 mm mesial and distal to the proposed buccal relief osteotomies. The buccal flap was reflected exceeding the mucogingival junction, while the lingual flap was minimally reflected.\u003c/p\u003e\n\u003cp\u003eFor the control group, a midcrestal osteotomy was performed via piezosurgery (Piezotome\u0026reg; Cube, Acteon, Satelec, France) using the BS1S tip down to a depth 2-3 mm short to the length of the planned DI. The buccal relief osteotomy(ies) was performed using the CS3 tip. Then, conical tips CS4, CS5, and CS6 were used to gradually increase the resulting osteotomy gap from 1 to 4 mm. Thereafter, the usual drilling protocol provided by the DI manufacturer was followed to allow the insertion of DI(s) (Biohorizons tapered Pro, Alabama, USA) to the level of the crestal bone via a torque wrench. Finally, a periosteal releasing incision was placed at the base of the inner aspect of the buccal flap to obtain tension-free closure of the wound using 3\u0026ndash;0 polyglactin 910\u0026nbsp;sutures\u0026nbsp;(Vicryl Plus, Ethicon, USA) \u003csup\u003e19\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eFor the study group, a mid-crestal osteotomy was performed via piezosurgery (Piezotome\u0026reg; Cube, Acteon, Satelec, France) using the BS1S tip down to 9 mm, which is the full cutting depth of the tip BS1S. This horizontal osteotomy exceeds the area of the proposed DI to involve 5 mm mesial and distal to that area (if possible). No vertical osteotomies were performed. Then, a hand osteotome was inserted into the created horizontal bone groove to expand the groove, along its total length, buccally and lingually by gentle hand pressure. This expands the ridge by approximately 1-1.5 mm. Thus, the total gap width can reach 2-2.5 mm (Figure 1). This was the first expansion step, which was a generalized, partial, expansion step. Thereafter, localized expansion was performed only at the proposed DI site(s) via successively increasing-diameter root-form screw-type expanders (Dental Bone Expander Kit, Star Edge Tools, Pakistan) without the use of discs or drills (Figure 2). This localized expansion was performed to the full desired expansion width. This was the second expansion step, which was a localized full-width expansion step. If the planned DI length was more than 9 mm, the piezotome was inserted once again through the expanded gap until the full length of the planned DI was reached, and the generalized expansion process was attempted once again. This was followed by the repetition of the localized expansion step to the full length of the DI. A DI (Biohorizons Tapered Pro, Alabama, USA) was then placed at the level of the crestal bone without any previous drilling and by using a torque wrench (Figure 3). Finally, the wound was closed as was in the control group.\u003c/p\u003e\n\u003cp\u003eFor both groups, amoxicillin 800 mg with clavulanic acid 200 mg tablets (Augmentin, GSK, Egypt) were prescribed every 12 hours for 7 days. Ibuprofen 600 mg tablets (Brufen, Abbott, Egypt) were prescribed every 12 hours for 5 days\u0026nbsp;and then taken, when necessary, after these five days. All patients were instructed to preserve proper oral hygiene and to use a chlorhexidine HCl mouthwash 125 mg/100 mL (Hexitol, Adco, Egypt) three times a day. After three months, the DI was exposed, and a healing abutment was placed for two weeks to allow for the definitive abutments and temporary crowns to be placed. The placement of the definitive restorations was deferred to the end of the follow-up period to determine about the need for grafting to provide an adequate environment for an acceptable emergence profile and to decrease the vertical cantilever as much as possible.\u003c/p\u003e\n\u003ch2\u003eOutcomes\u003c/h2\u003e\n\u003ch3\u003eClinical outcomes\u003c/h3\u003e\n\u003cp\u003eThe primary implant stability (at implant placement time) was assessed via a resonance frequency analyzer (Osstell IDx Mentor, Osstell AB, Goteborg, Sweden) as the average of the buccolingual and mesiodistal measurements of the implant stability quotient (ISQ). For seven consecutive postoperative days, pain was assessed daily via the 0 \u0026ndash; 10 score visual analog scale (VAS) with 0 indicating \u0026ldquo;no pain\u0026rdquo; and 10 indicating \u0026ldquo;worst pain\u0026rdquo;. During the same follow-up period, the number of analgesic tablets consumed daily by the patient was also recorded. Peri-implant mucositis and peri-implantitis were assessed according to the 2017 World Workshop Case Definitions and Diagnostic Consideration \u003csup\u003e20,21\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe baseline was the time point of placement of \u0026nbsp;the definitive abutments and temporary crowns. The secondary implant stability, keratinized mucosa width (KMW), Lindquist plaque index (PI), bleeding index (BI), and pocket probing depth (PD) were measured at baseline and then at three, six, and 12 months.\u003c/p\u003e\n\u003cp\u003eSecondary implant stability was assessed via a resonance frequency analyzer (Osstell IDx Mentor, Osstell AB, Goteborg, Sweden) as the average of the buccolingual and mesiodistal measures (ISQs). The KMW was measured as the distance between the gingival margin and mucogingival junction at the mid-labial area \u003csup\u003e22\u003c/sup\u003e. The PI was assessed at the mesial and distal angles and at the center of the labial and lingual aspects of the DI, and the mean of the scores was taken. A score of 0 was assigned if there was no visible plaque detected; a score of 1 was assigned for local plaque accumulation (\u0026lt;25); and a score of 3 was assigned for general plaque accumulation (greater than 25%) \u003csup\u003e23\u003c/sup\u003e. The BI was measured as the mean of measurements at the same points. The score was assessed after 30 seconds of gentle application of a periodontal probe (11 Colorvue\u0026reg; Probe Kit; Hu-Friedy, Chicago, IL, USA) by one blinded trained resident with a gentle probing force (0.15 N) calibrated via a precision scale. A score of 0 was assigned if there was no bleeding when the probe was passed along the gingival margin adjacent to the implant; a score of 1 was assigned if there were isolated bleeding spots visible; a score of 2 was assigned if blood formed a confluent red line on the margin, whereas; a score of 3 was assigned for heavy or profuse bleeding \u003csup\u003e24\u003c/sup\u003e. The PD was measured as the mean of probing depths at the same points mentioned for BI (as the distance from the gingival margin to the bottom of the pocket in 1 mm increments) and using the same periodontal probe under the same standardized force while maintaining the probe parallel to the long axis of the implant \u003csup\u003e25\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eRadiographic analysis\u003c/h3\u003e\n\u003cp\u003eImmediate postoperative panoramic radiographs (Cranex\u003csup\u003eTM\u003c/sup\u003e D, Sredex, Finland) were taken (Figure 4: which shows dental implants on the right side, which were placed as a control case, and the left side dental implants as a study case). Also, Standardized immediate postoperative periapical radiographs were taken via an imaging plate (i-Scan Imaging Plate Scanner, Guilin Woodpecker, China) via\u0026nbsp;the long-cone paralleling technique\u0026nbsp;with a customized condensation silicone bite record made with Orthogum (Zhermack, Badia Polesine, Italy) on a Rinn XCO Ring positioner (Dentsply, Constanz, Germany).\u003c/p\u003e\n\u003cp\u003eThereafter, standardized periapical radiographs were taken at baseline and after three, six, and 12 months. A panoramic radiograph was taken at the 12\u003csup\u003eth\u003c/sup\u003e postoperative month (Figure 5, which shows the DI on the right side, which was used as a control case, and the left side DI, which was as a study case).\u003c/p\u003e\n\u003cp\u003eMarginal bone loss (MBL) at a given time point was measured via the standardized periapical radiographs as the means of the differences between the marginal bone level at that time point and that measured immediately postoperatively at the mesial and distal aspects of the implant. The marginal bone level was measured as the vertical distance from the implant platform (the horizontal interface between the implant and the abutment) to the most coronal level of bone-to-implant contact. The known implant length and diameter were used to calibrate each individual measurement \u003csup\u003e26\u003c/sup\u003e.\u003c/p\u003e\n\u003ch2\u003eStatistical analysis\u003c/h2\u003e\n\u003cp\u003eStatistical analysis was performed with SPSS software (version 19, IBM Co., USA). The data were not normally distributed. Thus, group means were tested via the Mann-Whitney test for numerical data, and Fisher\u0026rsquo;s exact test was used for categorical data. Moreover, a mixed linear model was employed to test the clinical outcomes measured at multiple time points.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAmong a total of 207 patients who attended the department, 40 patients (who received 57 DIs) met the inclusion criteria and were enrolled in the study. The demographic data are shown in Table 1, which reveals a statistically nonsignificant difference between the groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1: Demographic data of the patients.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eparameter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eStudy group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eSignificance of the difference at P\u0026le;0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eAge mean\u0026plusmn;SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e45.81\u0026plusmn;5.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e47.51\u0026plusmn;5.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eNonsignificant\u003c/p\u003e\n \u003cp\u003e(P=0.361)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eAge range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e39-65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e39-59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eGender (male: female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e11:9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e8:12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eNonsignificant\u003c/p\u003e\n \u003cp\u003e(P*= 0. 342178)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 638px;\"\u003e\n \u003cp\u003eSD: standard deviation, NA: not applicable; P: P of the Mann\u0026ndash;Whitney U test; P*: P of the Chi square test.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eClinically, uneventful healing was observed without postoperative infection or wound dehiscence in both groups (Fisher\u0026rsquo;s exact test value = 1; nonsignificant difference at p\u0026lt;0.05). No patients in either group presented with \u0026nbsp;peri-implant mucositis or peri-implantitis (Fisher\u0026rsquo;s exact test value = 1; nonsignificant difference at p\u0026lt;0.05). The preoperative ridge width was 3.5\u0026plusmn;0.8 mm in the control group and 3.3\u0026plusmn;0.64 mm in the study group (the P value of the Mann-Whitney U test was 0.4281, indicating a nonsignificant difference).\u003c/p\u003e\n\u003cp\u003eAs Table 2 shows, the patients in the study group presented lower pain levels than did those in the control group did during the first two postoperative days, and a lower number of analgesic tablets were taken for the first three postoperative days. Thereafter, there were no significant differences between the groups with respect to postoperative pain or the number of analgesic tablets consumed daily.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2: VAS score and analgesic tablets used during the first postoperative week.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003eDay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eVAS, mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003eAnalgesic tablets, Mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eControl gr\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eStudy gr\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eControl gr\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eStudy gr\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e6.71 (0.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e5.89 (0.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e3.9 (0.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e3.1 (0.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e5.35 (0.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.25 (0.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e3.6 (0.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e2.7\u0026nbsp;(0.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3.17 (0.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3.01 (0.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.0752\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e3.0 (0.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e2.1 (0.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1.56 (0.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1.32 (0.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.1168\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1.6 (0.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1.4 (0.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.3816\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.83 (0.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.59 (0.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.06471\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.77 (0.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.73 (0.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.6944\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.15 (0.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.1 (0.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.80258\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.05 (0.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.3262\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.00 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.00 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 623px;\"\u003e\n \u003cp\u003eVAS: Visual analog scale; P value was calculated using Mann\u0026ndash;Whitney U test; gr: group.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAs shown in Table 3, the study group had significantly greater primary stability and secondary stability at baseline and after three months; nevertheless, this difference was nonsignificant thereafter.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor the control group, intragroup comparisons over time revealed that secondary stability increased over time but was statistically significant only at the sixth and twelfth months. Nevertheless, for the study group, the increase in secondary stability was statistically significant at all time points.\u003c/p\u003e\n\u003cp\u003eTable 3: Implant stability in the control and study groups (groups 1 and 2).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eparameter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eControl gr\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eStudy gr\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eP value and significance\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003ePrimary implant stability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e40.07\u0026plusmn;7.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e58.6\u0026plusmn;6.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eSignificant\u003c/p\u003e\n \u003cp\u003e(P\u0026lt;0.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eSecondary implant stability (at baseline)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e71.4\u0026plusmn;5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e75.8\u0026plusmn;3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eSignificant\u003c/p\u003e\n \u003cp\u003e(P=0.007)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eSecondary implant stability (at 3 months after baseline)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e74.2\u0026plusmn;3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e78.2\u0026plusmn;1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eSignificant\u003c/p\u003e\n \u003cp\u003e(0\u0026lt;0.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eP value of the intragroup change from the baseline value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.0724, Nonsignificant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e0.0236, significant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eSecondary implant stability (at 6 months after baseline)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e78.4\u0026plusmn;2.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e79.7\u0026plusmn;2.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eNonsignificant\u003c/p\u003e\n \u003cp\u003e(0.0749)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eP value of the change from the 3 months value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026lt;0.01, significant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026lt;0.01, significant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eSecondary implant stability (at 12 months after baseline)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e82.2\u0026plusmn;0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e82.57\u0026plusmn;0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eNonsignificant\u003c/p\u003e\n \u003cp\u003e(P=0.012)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eP value of the change from the 6 months value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026lt;0.01, significant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026lt;0.01,\u003c/p\u003e\n \u003cp\u003esignificant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 623px;\"\u003e\n \u003cp\u003e*P value was calculated using Mann-Whitney U test; the significance of the difference was considered at P\u0026le;0.5; gr: group.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 4 shows that the marginal bone loss in the study group was significantly lower than that in the control group at every time point. Over time, MBL significantly increased in both groups, with the highest values occurring at the twelfth month. With respect to the KMW, the study group presented a significantly greater KMW than did the control group at the sixth and twelfth months; otherwise, the differences were statistically nonsignificant. With respect to intragroup comparisons, the control group presented a statistically significant reduction in the KMW over time, with the lowest value occurring at the twelfth month. However, for the study group, there were no statistically significant differences in the KMW over time. Nevertheless, all these values were within the normal, clinically acceptable ranges.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWith respect to the PI, BI, and PD, the differences between the two groups at every time point were statistically nonsignificant. Although the intragroup comparisons for these parameters showed fluctuations over time; these differences were statistically nonsignificant, and all the values were within the normal, clinically acceptable ranges.\u003c/p\u003e\n\u003cp\u003eTable 4: Marginal bone loss, keratinized mucosa width, plaque index, bleeding index, and probing depth for the control and study groups at different time points.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eParameter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 347px;\"\u003e\n \u003cp\u003eThe value at the different time points\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eP value *\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eMBL control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.42\u0026plusmn;0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1.2\u0026plusmn;0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1.47\u0026plusmn;0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e1.63\u0026plusmn;0..91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eMBL study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.13\u0026plusmn;0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.56\u0026plusmn;0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.68\u0026plusmn;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e0.68\u0026plusmn;0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eP value \u0026Dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eKMW control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.32\u0026plusmn;1.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.21\u0026plusmn;1.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3.15\u0026plusmn;0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e3.08\u0026plusmn;1.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.0172\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eKMW study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.37\u0026plusmn;1.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.29\u0026plusmn;1.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.25\u0026plusmn;1.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e4.24\u0026plusmn;1.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.8631\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eP value \u0026Dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1.1304\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.9312\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.0048\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e0.0023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003ePI control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.75\u0026plusmn;0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.75\u0026plusmn;0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.68\u0026plusmn;0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e0.72\u0026plusmn;0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.6739\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003ePI study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.74\u0026plusmn;0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.79\u0026plusmn;0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.75\u0026plusmn;0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e0.71\u0026plusmn;0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.2289\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eP value \u0026Dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.8127\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.2364\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.2193\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e0.8924\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eBI control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.16\u0026plusmn;0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.15\u0026plusmn;0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.1\u0026plusmn;0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e0.11\u0026plusmn;0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.1872\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eBI study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.18\u0026plusmn;0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.13\u0026plusmn;0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.08\u0026plusmn;0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e0.12\u0026plusmn;0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.1462\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eP value \u0026Dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.6637\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.5518\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.7343\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e0.8292\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003ePD control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3.25\u0026plusmn;0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2.93\u0026plusmn;0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2.82\u0026plusmn;0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e3.36\u0026plusmn;0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.5213\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003ePD study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2.86\u0026plusmn;0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3.11\u0026plusmn;0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3.05\u0026plusmn;0.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e3.11\u0026plusmn;0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.4106\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eP value \u0026Dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.1578\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.3014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.4311\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e0.2317\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 564px;\"\u003e\n \u003cp\u003eP value *: P value for the Mann\u0026ndash;Whitney U test; P value \u0026Dagger;: the P value for the Kruskal-Wallis test; MBL control: Marginal bone loss for the control group (in mm); MBL study: Marginal bone loss for the study group (in mm); PI control: Plaque index for the control group; PI study: Plaque index for the study group; BI control: Bleeding index for the control group; BI study: Bleeding index for the study group; PD control: Probing depth for the control group (in mm); PD study: Probing depth for the study group (in mm); KMW control: Keratinized mucosa width for the control group (in mm); KMW study: Keratinized mucosa width for the study group (in mm).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the current study, there were Nonsignificant differences regarding age, gender distribution, and preoperative ridge width; therefore, both groups can be considered comparable. The study group presented lower pain levels than did the control group during the first and second postoperative days. This may be attributed to the lower degree of trauma associated with DET. With respect to primary implant stability and early secondary implant stability, the study group presented superior results to those of the control group. This may be the result of the variance in the nature of the two techniques. In contrast with the RST, which depends on ridge splitting and subsequent mobilization of the semi-detached buccal plate of bone, the DET involves the buccal plate being lateralized without being detached. Moreover, the second step of localized ridge expansion leads to bone condensation, improving bone quality and offering some resistance to DI placement, allowing firmer DI holding aided by bone rebound due to its resiliency. When bone healing reached advanced stages in both groups, DI stability was comparable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWith respect to MBL, the MBL levels in the control group were comparable to those reported in various previous studies \u003csup\u003e18,19,27\u003c/sup\u003e. Compared with those in the control group, the MBL levels in the study group were lower at all time points. This may be the result of the nature of the DET, which comprises a two-stage expansion. The first aimed to achieve approximately half the required expansion distance, therefore, less load was placed on the bone plates. Moreover, no vertical osteotomies were placed on the buccal plate of bone, providing richer blood supply than that present in the RST. \u0026nbsp;The remainder of the required expansion was performed through \u0026nbsp;localized progressive expansion only at the planned DI site, which was essentially an expansion of the already expanded bone plates; therefore, this expansion was easier and less traumatic than expanding the bone to the total required expansion in one step.\u003c/p\u003e\n\u003cp\u003eFor the same reasons, the amount of KMW was greater in the study group than in the control group at the sixth and twelfth months, when the MBL was high enough to reduce the KMW in the control group.\u003c/p\u003e\n\u003cp\u003eThe other clinical parameters, the PI, BI, and PD were comparable between the two groups at all time points. This may be the result of the uneventful healing in both groups.\u003c/p\u003e\n\u003cp\u003eTo conclude, the difference in strategy between the DET, RST, and CRET is that the DET comprises ridge expansion over two steps, whereas both RST and CRET expands the ridge to the full required expansion length in one stage. Although buccal plate lateralization is needed only at the DI site, RST leads to lateralization of the entire buccal plate. This was avoided in DET, and thereby, there is no need to perform the vertical osteotomies. The second step in DET is devoted to expanding the already expanded bone plates and only at the DI site. Therefore, the least forces, the least potential for dehiscence, \u0026nbsp;richer blood supply, better healing and less MBL may be expected while achieving the maximum possible expansion.\u003c/p\u003e\n\u003cp\u003eLimitations of the current study:\u003c/p\u003e\n\u003cp\u003eThe results of the current study needs to be furtherly assessed through multi-center studies.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe DET involves a two-step expansion; generalized partial-extent expansion, which is followed with a localized full-extent expansion. The first-step expansion is intended to decrease bone resistance to further expansion, thereby substituting the buccal release osteotomies performed during RST. The DET group had a more comfortable early postoperative period, and higher primary and early secondary stabilities. Moreover, the DET group had a lower MBL and a wider KMW. This superior performance may be attributed to the lower degree of trauma, fewer stresses on the bone, and lack of need for vertical osteotomies. According to the results of the current study, the null hypothesis can be rejected.\u003c/p\u003e\n"},{"header":"Abbreviations","content":"\u003cp\u003eRST: Ridge splitting technique\u003c/p\u003e\n\u003cp\u003eMBL: Marginal bone loss\u003c/p\u003e\n\u003cp\u003eCRET: Conventional ridge expansion technique\u003c/p\u003e\n\u003cp\u003eDET: Double expansion technique\u003c/p\u003e\n\u003cp\u003eISQ: Implant stability quotient (ISQ)\u003c/p\u003e\n\u003cp\u003eVAS: visual analog scale\u003c/p\u003e\n\u003cp\u003eKMW: keratinized mucosa width\u003c/p\u003e\n\u003cp\u003ePI: Lindquist plaque index\u003c/p\u003e\n\u003cp\u003eBI: bleeding index\u003c/p\u003e\n\u003cp\u003ePD: pocket probing depth (PD)\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003ch4\u003eHuman Ethics and Consent to Participate declaration\u003c/h4\u003e\n\u003cp\u003eThe study was conducted in compliance with\u0026nbsp;the Declaration of Helsinki (revised in 1975) and was approved by the regional ethical review board of\u0026nbsp;Kafrelsheikh University. All participants provided informed consent.\u003c/p\u003e\n\u003ch4\u003eConsent for publication\u003c/h4\u003e\n\u003cp\u003eNo individual person\u0026rsquo;s data was included in the current study.\u003c/p\u003e\n\u003ch4\u003eAvailability of data and materials\u003c/h4\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available\u0026nbsp;from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch4\u003eCompeting interests\u003c/h4\u003e\n\u003cp\u003eThe\u0026nbsp;author\u0026nbsp;declares no conflict of interest and no funding.\u003c/p\u003e\n\u003ch4\u003eFunding\u003c/h4\u003e\n\u003cp\u003eNo funding to declare.\u003c/p\u003e\n\u003ch4\u003eAuthors\u0026apos; contributions\u003c/h4\u003e\n\u003cp\u003eMosaad Khalifah is the sole author.\u003c/p\u003e\n\u003ch4\u003eAcknowledgements\u003c/h4\u003e\n\u003cp\u003eThe author deeply acknowledges Dr Ahmad Kamel for his efforts in collecting data of the clinical parameters.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial registration number: TCTR20250226005.\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMisch CM, Misch CE, Resnik RR, Ismail YH. Reconstruction of maxillary alveolar defects with mandibular symphysis grafts for dental implants: a preliminary procedural report. \u003cem\u003eInt J Oral Maxillofac Implants\u003c/em\u003e. 1992;7(3):360-366.\u003c/li\u003e\n\u003cli\u003eScipioni A, Bruschi GB, Calesini G. The edentulous ridge expansion technique: a five-year study. \u003cem\u003eInt J Periodontics Restorative Dent\u003c/em\u003e. 1994;14(5):451-459.\u003c/li\u003e\n\u003cli\u003eMelcher AH. On the Repair Potential of Periodontal Tissues. \u003cem\u003eJ Periodontol\u003c/em\u003e. 1976;47(5):256-260. doi:10.1902/jop.1976.47.5.256\u003c/li\u003e\n\u003cli\u003eWang HL, Boyapati L. \u0026ldquo;PASS\u0026rdquo; Principles for Predictable Bone Regeneration. \u003cem\u003eImplant Dent\u003c/em\u003e. 2006;15(1):8-17. doi:10.1097/01.id.0000204762.39826.0f\u003c/li\u003e\n\u003cli\u003eCordaro L, Amad\u0026egrave; DS, Cordaro M. Clinical results of alveolar ridge augmentation with mandibular block bone grafts in partially edentulous patients prior to implant placement. \u003cem\u003eClin Oral Implants Res\u003c/em\u003e. 2002;13(1):103-111. doi:10.1034/j.1600-0501.2002.130113.x\u003c/li\u003e\n\u003cli\u003eChiapasco M, Ferrini F, Casentini P, Accardi S, Zaniboni M. Dental implants placed in expanded narrow edentulous ridges with the Extension Crest \u003csup\u003e\u0026reg;\u003c/sup\u003e device. \u003cem\u003eClin Oral Implants Res\u003c/em\u003e. 2006;17(3):265-272. doi:10.1111/j.1600-0501.2005.01196.x\u003c/li\u003e\n\u003cli\u003eSiddiqui AA, Sosovicka M. Lateral Bone Condensing and Expansion for Placement of Endosseous Dental Implants: A New Technique. \u003cem\u003eJournal of Oral Implantology\u003c/em\u003e. 2006;32(2):87-94. doi:10.1563/786.1\u003c/li\u003e\n\u003cli\u003eSummers RB. The osteotome technique: Part 2--The ridge expansion osteotomy (REO) procedure. \u003cem\u003eCompendium\u003c/em\u003e. 1994;15(4):422, 424, 426, passim; quiz 436.\u003c/li\u003e\n\u003cli\u003eChin M, Toth BA. Distraction osteogenesis in maxillofacial surgery using internal devices: Review of five cases. \u003cem\u003eJournal of Oral and Maxillofacial Surgery\u003c/em\u003e. 1996;54(1):45-53. doi:10.1016/S0278-2391(96)90303-1\u003c/li\u003e\n\u003cli\u003eTatum H. Maxillary and sinus implant reconstructions. \u003cem\u003eDent Clin North Am\u003c/em\u003e. 1986;30(2):207-229.\u003c/li\u003e\n\u003cli\u003eDemarosi F, Leghissa GC, Sardella A, Lodi G, Carrassi A. Localised maxillary ridge expansion with simultaneous implant placement: A case series. \u003cem\u003eBritish Journal of Oral and Maxillofacial Surgery\u003c/em\u003e. 2009;47(7):535-540. doi:10.1016/j.bjoms.2008.11.012\u003c/li\u003e\n\u003cli\u003eMestas G, Alarc\u0026oacute;n M, Chambrone L. Long-Term Survival Rates of Titanium Implants Placed in Expanded Alveolar Ridges Using Split Crest Procedures: A Systematic Review. \u003cem\u003eInt J Oral Maxillofac Implants\u003c/em\u003e. 2016;31(3):591-599. doi:10.11607/jomi.4453\u003c/li\u003e\n\u003cli\u003eSimion M, Baldoni M, Zaffe D. Jawbone enlargement using immediate implant placement associated with a split-crest technique and guided tissue regeneration. \u003cem\u003eInt J Periodontics Restorative Dent\u003c/em\u003e. 1992;12(6):462-473.\u003c/li\u003e\n\u003cli\u003eCoatoam GW, Mariotti A. The segmental ridge-split procedure. \u003cem\u003eJ Periodontol\u003c/em\u003e. 2003;74(5):757-770. doi:10.1902/jop.2003.74.5.757\u003c/li\u003e\n\u003cli\u003eGonz\u0026aacute;lez-Garc\u0026iacute;a R, Monje F, Moreno C. Alveolar split osteotomy for the treatment of the severe narrow ridge maxillary atrophy: a modified technique. \u003cem\u003eInt J Oral Maxillofac Surg\u003c/em\u003e. 2011;40(1):57-64. doi:10.1016/j.ijom.2010.03.030\u003c/li\u003e\n\u003cli\u003eChan HL, Fu JH, Koticha T, Benavides E, Wang HL. Ridge width gain with screw spreaders: a cadaver study. \u003cem\u003eImplant Dent\u003c/em\u003e. 2013;22(5):552-558. doi:10.1097/ID.0b013e3182a3333c\u003c/li\u003e\n\u003cli\u003eSchulz KF, Altman DG, Moher D. CONSORT 2010 Statement: Updated guidelines for reporting parallel group randomised trials. \u003cem\u003eBMC Med\u003c/em\u003e. 2010;8(1):1-9. doi:10.1186/1741-7015-8-18/FIGURES/1\u003c/li\u003e\n\u003cli\u003eMounir M, Beheiri G, El-Beialy W. Assessment of marginal bone loss using full thickness versus partial thickness flaps for alveolar ridge splitting and immediate implant placement in the anterior maxilla. \u003cem\u003eInt J Oral Maxillofac Surg\u003c/em\u003e. 2014;43(11):1373-1380. doi:10.1016/j.ijom.2014.05.021\u003c/li\u003e\n\u003cli\u003eMahmoud ZT, El-Dibany MM, El-Ghamrawy SM, Osman SM, Troedhan AC. MUCOSAL FLAP VERSUS MUCOPERIOSTEAL FLAP IN RIDGE SPLITTING AND SIMULTANEOUS IMPLANT PLACEMENT USING PIEZOSURGERY (A RANDOMIZED CONTROLLED CLINICAL TRIAL). \u003cem\u003eAlexandria Dental Journal\u003c/em\u003e. 2017;42(1):67-72. doi:10.21608/adjalexu.2017.57859\u003c/li\u003e\n\u003cli\u003eRenvert S, Persson GR, Pirih FQ, Camargo PM. Peri-implant health, peri-implant mucositis, and peri-implantitis: Case definitions and diagnostic considerations. \u003cem\u003eJ Clin Periodontol\u003c/em\u003e. 2018;45 Suppl 20:S278-S285. doi:10.1111/JCPE.12956\u003c/li\u003e\n\u003cli\u003eBerglundh T, Armitage G, Araujo MG, Avila-Ortiz G, Blanco J, Camargo PM, et al. Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. \u003cem\u003eJ Periodontol\u003c/em\u003e. 2018;89 Suppl 1:S313-S318. doi:10.1002/JPER.17-0739\u003c/li\u003e\n\u003cli\u003eNewman M, Takei H, Klokkevold P, Carranza F. \u003cem\u003eCarranza\u0026rsquo;s Clinical Periodontology. Elsevier Health Sciences\u003c/em\u003e. Vol 11th edition. Elsevier; 2012.\u003c/li\u003e\n\u003cli\u003eLindquist LW, Rockler B, Carlsson GE. Bone resorption around fixtures in edentulous patients treated with mandibular fixed tissue-integrated prostheses. \u003cem\u003eJ Prosthet Dent\u003c/em\u003e. 1988;59(1):59-63. doi:10.1016/0022-3913(88)90109-6\u003c/li\u003e\n\u003cli\u003eMombelli A, van Oosten MAC, Sch\u0026uuml;rch E, Lang NP. The microbiota associated with successful or failing osseointegrated titanium implants. \u003cem\u003eOral Microbiol Immunol\u003c/em\u003e. 1987;2(4):145-151. doi:10.1111/J.1399-302X.1987.TB00298.X\u003c/li\u003e\n\u003cli\u003eBuser D, Weber H ‐P, Lang NP. Tissue integration of non-submerged implants. 1-year results of a prospective study with 100 ITI hollow-cylinder and hollow-screw implants. \u003cem\u003eClin Oral Implants Res\u003c/em\u003e. 1990;1(1):33-40. doi:10.1034/J.1600-0501.1990.010105.X\u003c/li\u003e\n\u003cli\u003eZhang XX, Shi JY, Gu YX, Lai HC. Long-Term Outcomes of Early Loading of Straumann Implant-Supported Fixed Segmented Bridgeworks in Edentulous Maxillae: A 10-Year Prospective Study. \u003cem\u003eClin Implant Dent Relat Res\u003c/em\u003e. 2016;18(6):1227-1237. doi:10.1111/CID.12420\u003c/li\u003e\n\u003cli\u003eJensen OT, Cullum DR, Baer D. Marginal Bone Stability Using 3 Different Flap Approaches for Alveolar Split Expansion for Dental Implants\u0026mdash;A 1-Year Clinical Study. \u003cem\u003eJournal of Oral and Maxillofacial Surgery\u003c/em\u003e. 2009;67(9):1921-1930. doi:10.1016/j.joms.2009.04.017\u003c/li\u003e\n\u003cli\u003eNishioka RS, Souza FA. Bone Spreader Technique: A Preliminary 3-Year Study. \u003cem\u003eJournal of Oral Implantology\u003c/em\u003e. 2009;35(6):289-294. doi:10.1563/1548-1336-35.6.289\u003c/li\u003e\n\u003cli\u003eNishioka RS, Souza F\u0026Aacute;. Bone Spreading and Standardized Dilation of Horizontally Resorbed Bone: Technical Considerations. \u003cem\u003eImplant Dent\u003c/em\u003e. 2009;18(2):119-125. doi:10.1097/ID.0b013e318198e517\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"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":"Horizontal deficiency, Immediate implant placement, Double expansion technique, Ridge splitting technique, Expansion, Marginal bone loss, Keratinized mucosal width","lastPublishedDoi":"10.21203/rs.3.rs-6235010/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6235010/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground Horizontal deficiency of the alveolar ridge is a challenging condition for dental implant (DI) placement. Although the ridge splitting technique (RST) is very successful, the associated marginal bone loss (MBL) is a critical drawback. The current study aimed to present and compare a novel technique, the double expansion technique (DET), with the RST.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMethods A total of 40 patients (57 DI) with narrow ridges were randomly allocated to the control group employing RST, and to the study group employing DET. DI was then immediately placed. Primary stability was measured at the time of implant placement. Secondary stability, marginal bone loss (MBL), keratinized mucosa width (KMW), the plaque index (PI), the bleeding index (BI), and probing depth (PD) were assessed at baseline (time of definitive abutment and temporary crown placement) and then at 3, 6, and 12 months. Pain and the number of analgesic tablets consumed were assessed daily during the first postoperative week.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResults The study group had lower pain levels during the first two postoperative days. The study group presented greater primary and secondary stability at baseline and at 3 months. Moreover, it had less MBL at all time points and more KMW at the sixth and twelfth months. Otherwise, both groups showed comparable results regarding the PI, BI, and BD.\u003c/p\u003e\n\u003cp\u003eConclusion The study group had superior performance, which may be attributed to the lower degree of trauma.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eClinical trial registration number: Thai Clinical Trials RegistryTCTR20250226005 at 26/2/2025 (Retrospectively registered)\u003c/p\u003e","manuscriptTitle":"Novel Double Expansion Technique Versus Ridge Splitting for Immediate Implant Placement in Narrow Ridges: A Randomized Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-30 16:13:01","doi":"10.21203/rs.3.rs-6235010/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":"018b165c-0cec-4dbf-afec-e4f3b57aaf1c","owner":[],"postedDate":"May 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-01T05:38:35+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-30 16:13:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6235010","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6235010","identity":"rs-6235010","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}