Digital guides for precise U-shaped splitting and simultaneous implant placement with minimal surgical trauma: a clinical report

Digital guides for precise U-shaped splitting and simultaneous implant placement with minimal surgical trauma: a clinical report | 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 Case Report Digital guides for precise U-shaped splitting and simultaneous implant placement with minimal surgical trauma: a clinical report Xin Feng, Ziqianhong Wan, Xiaoxia Wang, Xiaoyue Wang, Jin Wang, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4593547/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 U-shaped splitting technology has been proven to be an effective horizontal bone augmentation technique for patients with insufficient bone width and labial concavity. However, obtaining a suitable U-shaped bone plate based on the ideal implant site by freehand remains difficult, especially without a sufficient surgical field. Case presentation A 25-year-old man came to restore his right canine teeth. Since a labial bone undercut was found in region 43, a surgical procedure involving U-shaped splitting in an envelope flap with simultaneous implant placement using two digital guides was performed. Conclusion With the assistance of two digital guides, precise U-shaped splitting in an envelope flap can minimize surgical trauma and has a significant effect on horizontal bone augmentation. U-shaped splitting Digital guide Envelope flap Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Background Bone width deficiency is often associated with various implant complications, such as implant failure and compromised final esthetics of the restoration 1 , 2 . To address this issue, ridge splitting technology (RST), which involves splitting the alveolar ridge into two parts and creating a greenstick fracture with simultaneous implant surgery, has been introduced. In previous studies, the extraordinary ability of the RST to increase bone width has been reported 3 , 4 . However, the RST carries the risk of labial bone plate fracture during bone expansion or implant placement 5 , 6 , especially for patients with labial concavity at the alveolar bone. Additionally, RST may also cause marginal bone loss due to the thin buccal bone plate and inevitable mechanical trauma during the splitting process 7 . For these patients, Yao et al. proposed a U-shaped splitting technique (UST) that involves splitting a U-shaped bone plate from below the crest of the alveolar ridge to reduce the risk of bone plate fracture and marginal bone loss 8 , 9 . However, for UST, it is crucial to obtain a suitable U-shaped bone plate and perform precise implant placement based on the ideal implant site for maintaining the final bone mass and eventual effect of restoration, which poses a great challenge for dentists. Therefore, surgeons usually resort to increasing the flap area and expanding the range of the U-shaped bone plate, resulting in greater surgical trauma 10 . Envelope flaps and digital guides can be used to address these problems. The envelope flap can preserve the integrity of blood vessels and cause less trauma; moreover, the surgical field of the envelope flap is sufficient for the UST. In addition, a digital guide, which is designed based on an ideal implant site, can help dentists precisely perform U-shaped splitting and minimize surgical trauma. Hence, the use of an envelope flap and a digital guide is highly advisable for UST 11 . Therefore, in this clinical case report, we present U-shaped splitting and simultaneous implant placement surgery with an envelope flap guided by customized digital guides, which precisely outlined the U-shaped bone plate and guided implant placement. This approach minimized surgical trauma, simplified the clinical operation procedure, and alleviated the financial burden on the patient. Case presentation A man aged 25 years who was healthy and nonsmoking asked to resolve the loss of two single teeth in regions 13 and 43 by implant restoration (Fig. 1 ). CBCT was performed in September 2023, when the residual upper right canine was present. Before he came, the canine fell off naturally. A dental scan was taken. CBCT revealed adequate bone mass in region 13 and a labial undercut in region 43 (Fig. 2 ). Analysis was carried out before treatment, and the mesiodistal width was 9.44 mm in region 13 and 9.61 mm in region 43 (Fig. 3 ), which are relatively larger than the normal width of the contralateral canine. CBCT images and dental scans were imported into the surgical design software 3Shape Implant Studio (3Shape, Copenhagen, Denmark) for treatment planning. The initial prosthetic plan was designed with surgical design software. If the missing teeth were restored according to the morphology of the contralateral homonymous teeth, gaps would exist between the prostheses and adjacent teeth. The second treatment plan was designed to close the gaps, which would result in overlarge prostheses, increasing the burden of the implant. As the patient had several natural gaps in the dental arch, after negotiating with him, the first treatment plan was adopted (Fig. 4 ). Then, according to the prosthesis design, the following implant types were chosen: a BLT straumann implant (3.3 mm in diameter and 10 mm in length) in area 13 and a BLT straumann implant (3.3 mm in diameter and 12 mm in length) in area 43 (Fig. 5 ). A lack of alveolar bone width was found in the undercut area of region 43 (Fig. 6 ). After discussing and comparing different bone augmentation technologies, the UST was chosen for region 43. For accurate implant placement and U-shaped splitting, two digital guides were designed in this case in the 3Shape implant studio, an implant surgical guide and an osteotomy guide (Fig. 7 ), both of which are tooth-supported. The osteotomy guide was used to guide the scope of the ostomy and avoid important anatomical structures, such as adjacent roots and mandibular nerves. Since it is necessary for the osteotomy guide to meet the surgical requirements, the designed osteotomy guide was exported from 3 shapes as a standard tessellation language (STL) file and then imported into computer-aided design (CAD) software (Magics 24; Materialize, Belgium) to modify the structure (Fig. 8 A). Finally, the implant surgical guide and osteotomy guide were fabricated using a stereolithography three-dimensional printer (AccuFab-D1s; Shining 3D). Before surgery, the guides were seated on the patient’s teeth to examine their fitness and stability and determine the scope of the flap (Fig. 9 A). Then, the guides were sterilized. After administering local anesthesia, the implants were routinely placed in region 13 freehand. Next, a horizontal incision at the partial palatal side of the alveolar crest in region 43 and gingival sulcus incisions at adjacent teeth on both sides were made, and a full mucoperiosteal flap was lifted until the osteotomy guide was precisely positioned (Fig. 9 B, C). Then, according to the osteotomy guide, the U-shaped labial bone plate was outlined using ultrasonic osteotomy (Fig. 9 D, E). Next, the implant surgical guide was seated to guide the predrill of the implant bed with a 2.2 mm pilot drill (Fig. 9 F), and a 2.8 mm bone spreader kit was used to press the U-shaped labial plate to produce a greenstick fracture to increase the bone width (Fig. 9 G). Then, the implant was installed using a low-speed drilling procedure. A healing abutment was placed in position. An inorganic bovine bone substitute (Bio-Oss; Geistlich Pharma AG, Wolhusen, Switzerland) was subsequently placed to decrease labial alveolar bone absorption. Finally, the surgical site was closed with 5–0 Prolene sutures (Fig. 9 H). CBCT was performed after 3 months (Fig. 10 ). Discussion and Conclusions For patients with insufficient bone width accompanied by a labial concavity, several bone augmentation technologies have been introduced, including guided bone regeneration (GBR), onlay bone grafting, RST, and UST. 8 , 12 , 13 The instability of biodegradable membranes is responsible for compromised bone augmentation in GBR 14 . However, the elevated bone plate in the U-shaped splitting technique helps maintain the stability of the bone substitute and produces osteogenic factors to obtain a superior ridge width 15 . Studies have also shown that the UST can be used as an alternative method to the GBR 15 , 16 . Compared with onlay bone grafting, a second surgical site is not required for UST, and for patients with extremely narrow alevolar ridges, the UST can replace onlay bone grafting 8 . Finally, for the RST, the UST can decrease the risk of labial bone fracture, guarantee marginal bone stability, and cause less trauma. Thus, RST may be an effective technique for this specific case. As reported in the literature about the UST, a T-shaped flap is usually used because of its superior ability to provide full exposure of the surgical field 8 , 15 , 16 . However, the vertical incision of the T-shaped flap will destroy the integrity of the mucoperiosteal vessels. Studies have shown that the mucoperiosteum is a structure rich in osteoprogenitor cells and functions as a useful barrier with osteogenic properties 17 , 18 . Every incision and dissection of the mucoperiosteum will cause damage to the blood supply of the soft tissue and the alveolar bone 11 . In this clinical case, a horizontal incision and gingival sulcus incision were used to form an envelope flap, which has the advantage of only flipping the labial mucoperiosteal flap and is characterized by simpler operation compared to the angular or rectangular mucoperiosteal flap at the top of the alveolar ridge 19 . It is also easy to close the wound and ensure the integrity of the mucoperiosteum. Since whether the barrier membrane can reduce bone resorption has been debated and since the integrated mucoperiosteum is capable of ensuring osteogenic ability, the barrier membrane was not used in this case 18 , 20 . However, the envelope mucoperiosteal flap provides an inadequate surgical field compared with the T-shaped flap; thus, clinicians may face difficulties in forming a proper U-shaped bone plate, which may result in damage to important anatomical structures. Digital technology has brought convenience 21 . In this case, the range of the U-shaped bone plate was determined according to the final implant site and was then transferred to the digital osteotomy guide. The length of the horizontal osteotomy should be larger than the diameter of the planned implant, and the length of the vertical osteotomy should be equal to the length of insufficient bone mass. The guide not only ensures the ideal U-shaped bone plate but also reduces the range of bone splitting as much as possible. Moreover, the guide can be used for the envelope flap without blocking the surgical field, further reducing surgical trauma. At the same time, the digital implant guide can be used to transfer the ideal implant site to the mouth, reducing the labial deviation of the implant after splitting the bone mass, which is common in UST 22 . Digital guides can also help clinicians avoid damaging important anatomical structures and obtain better restorative effects. The limitation of this case is that the depth of the split was not controlled. Nickenig et al. used a narrow spiral mill (diameter 0.9 mm, Meisinger®, Neuss) with a guide to transfer the determined splitting depth when performing the RST 23 . However, the diameter of the pilot drill in Straumann® Guided Surgery instruments is 2.2 mm, and using this drill to determine the depth of U-shaped splitting may result in more bone mass loss. When the U-shaped bone plate is pressed in this case, bone plate fractures are more likely to occur. Therefore, the control of the splitting depth requires further consideration. Abbreviations RST Ridge splitting technology UST U-shaped splitting technique STL Standard tessellation language CAD Computer-aided design GBR Guided bone regeneration Declarations Ethics approval and consent to participate Not applicable Consent for publication Written informed consent was obtained from the patient for the publication of this case report and any accompanying images. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study did not receive any functional support from any funding organization. Authors' contributions Xin Feng and Zhuoli Zhu performed the clinical diagnosis, treatment and drafted the manuscript. Ziqianhong Wan and Xiaoxia Wang made the implant plan and drafted the manuscript. Xiaoyue Wang and Jin Wang managed the patient, participated in the operation, and drafted the manuscript. All the authors have read and approved the final manuscript. Acknowledgments Not applicable References Prati, C.; Zamparini, F.; Canullo, L.; Pirani, C.; Botticelli, D.; Gandolfi, M. G. Factors Affecting Soft and Hard Tissues Around Two-Piece Transmucosal Implants: A 3-Year Prospective Cohort Study. Int J Oral Maxillofac Implants 2020 , 35 (5), 1022–1036. Farronato, D.; Pasini, P. M.; Orsina, A. A.; Manfredini, M.; Azzi, L.; Farronato, M. Correlation between Buccal Bone Thickness at Implant Placement in Healed Sites and Buccal Soft Tissue Maturation Pattern: A Prospective Three-Year Study. Materials (Basel) 2020 , 13 (3), 511. Starch-Jensen, T.; Becktor, J. P. Maxillary Alveolar Ridge Expansion with Split-Crest Technique Compared with Lateral Ridge Augmentation with Autogenous Bone Block Graft: A Systematic Review. J Oral Maxillofac Res 2019 , 10 (4), e2. de Souza, C. S. V.; de Sá, B. C. M.; Goulart, D.; Guillen, G. A.; Macêdo, F. G. C.; Nóia, C. F. Split Crest Technique with Immediate Implant to Treat Horizontal Defects of the Alveolar Ridge: Analysis of Increased Thickness and Implant Survival. J Maxillofac Oral Surg 2020 , 19 (4), 498–505. Arnal, H. M.; Angioni, C. D.; Gaultier, F.; Urbinelli, R.; Urban, I. A. Horizontal Guided Bone Regeneration on Knife-Edge Ridges: A Retrospective Case‒Control Pilot Study Comparing Two Surgical Techniques. Clin Implant Dent Relat Res 2022 , 24 (2), 211–221. Bassetti, R.; Bassetti, M.; Mericske-Stern, R.; Enkling, N. Piezoelectric Alveolar Ridge-Splitting Technique with Simultaneous Implant Placement: A Cohort Study with 2-Year Radiographic Results. Int J Oral Maxillofac Implants 2013 , 28 (6), 1570–1580. Han, J.-Y.; Shin, S.-I.; Herr, Y.; Kwon, Y.-H.; Chung, J.-H. The Effects of Bone Grafting Material and a Collagen Membrane in the Ridge Splitting Technique: An Experimental Study in Dogs. Clin Oral Implants Res 2011 , 22 (12), 1391–1398. Yao, Y.; He, K.; Gong, P.; Tang, H. U-Shaped Bone Splitting and Osteotome Techniques for Narrow Alveolar Ridge in Implant Surgery. Implant Dent 2018 , 27 (4), 507–511. Bassetti, M. A.; Bassetti, R. G.; Bosshardt, D. D. The Alveolar Ridge Splitting/Expansion Technique: A Systematic Review. Clin Oral Implants Res 2016 , 27 (3), 310–324. Lin, X.; Zhou, Z.; Li, S.; Gao, Y.; Zheng, X. Digital Guides to Facilitate Retained Root Removal and Simultaneous Implant Placement. International Journal of Oral and Maxillofacial Surgery 2022 , 51 (7), 957–961. Gao, X.; Qin, S.; Cai, H.; Wan, Q. Comparison of General and Aesthetic Effects between Flapless and Flap Techniques in Dental Implantation: A Meta-Analysis of Randomized Controlled Trials. Int J Implant Dent 2021 , 7 (1), 100. de Azambuja Carvalho, P. H.; Dos Santos Trento, G.; Moura, L. B.; Cunha, G.; Gabrielli, M. A. C.; Pereira-Filho, V. A. Horizontal Ridge Augmentation Using Xenogenous Bone Graft-Systematic Review. Oral Maxillofac Surg 2019 , 23 (3), 271–279. Friberg, B. Bone Augmentation for Single Tooth Implants: A Review of the Literature. Eur J Oral Implantol 2016 , 9 Suppl 1 , S123-134. Hockers, T.; Abensur, D.; Valentini, P.; Legrand, R.; Hammerle, C. H. The Combined Use of Bioresorbable Membranes and Xenografts or Autografts in the Treatment of Bone Defects around Implants. A Study in Beagle Dogs. Clin Oral Implants Res 1999 , 10 (6), 487–498. Wu, Q.; Yang, B.; Gao, S.; Gong, P.; Xiang, L.; Man, Y.; Qu, Y. Apical U-Shape Splitting Technique for Undercut Areas of the Anterior Alveolar Ridge: A Prospective Non-Randomized Controlled Study. Int J Oral Maxillofac Surg 2019 , 48 (3), 388–394. Elboghdadi, I. A.; Elkenawy, M. H.; Abdelsameaa, S. E.; Ghoneim, N. I. U-Shaped Splitting Technique vs Conventional Bone Grafting in Maxillary Facial Undercut for Dental Implants Placement: A Preliminary Randomized Controlled Clinical Trial. J Contemp Dent Pract 2022 , 23 (12), 1245–1254. Gielkens, P. F. M.; Bos, R. R. M.; Raghoebar, G. M.; Stegenga, B. Is There Evidence That Barrier Membranes Prevent Bone Resorption in Autologous Bone Grafts during the Healing Period? A Systematic Review. Int J Oral Maxillofac Implants 2007 , 22 (3), 390–398. Saimbi, C. S.; Gautam, A.; Khan, M. A.; Nandlal, null. Periosteum as a Barrier Membrane in the Treatment of Intrabony Defect: A New Technique. J Indian Soc Periodontol 2014 , 18 (3), 331–335. Abed, P. F.; El Chaar, E.; Boltchi, F.; Bassir, S. H. The Novel Periosteal Flap Stretch Technique: A Predictable Method to Achieve and Maintain Primary Closure in Augmentative Procedures. J Int Acad Periodontol 2020 , 22 (1), 11–20. Kim, Y.-K.; Ku, J.-K. Guided Bone Regeneration. J Korean Assoc Oral Maxillofac Surg 2020 , 46 (5), 361–366. Stanley, M.; Paz, A. G.; Miguel, I.; Coachman, C. Fully Digital Workflow, Integrating Dental Scan, Smile Design and CAD-CAM: Case Report. BMC Oral Health 2018 , 18 , 134. Tallarico, M.; Meloni, S. M. Retrospective Analysis on Survival Rate, Template-Related Complications, and Prevalence of Peri-Implantitis of 694 Anodized Implants Placed Using Computer-Guided Surgery: Results Between 1 and 10 Years of Follow-Up. Int J Oral Maxillofac Implants 2017 , 32 (5), 1162–1171. Nickenig, H.-J.; Safi, A.-F.; Matta, R.-E.; Zöller, J. E.; Kreppel, M. 3D-Based Full-Guided Ridge Expansion Osteotomy – A Case Report about a New Method with Successive Use of Different Surgical Guides, Transfer of Splitting Vector and Simultaneous Implant Insertion. Journal of Cranio-Maxillofacial Surgery 2019 , 47 (11), 1787–1792. 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-4593547","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":319373838,"identity":"b4c2ed08-0416-447d-ad45-4d304bf5f0bc","order_by":0,"name":"Xin Feng","email":"","orcid":"","institution":"Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Xin","middleName":"","lastName":"Feng","suffix":""},{"id":319373839,"identity":"a11b3844-7ee2-4add-b2c3-d3734f731da0","order_by":1,"name":"Ziqianhong Wan","email":"","orcid":"","institution":"Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Ziqianhong","middleName":"","lastName":"Wan","suffix":""},{"id":319373840,"identity":"9ef85e3b-6cbb-4594-af23-17706abb0c73","order_by":2,"name":"Xiaoxia Wang","email":"","orcid":"","institution":"Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Xiaoxia","middleName":"","lastName":"Wang","suffix":""},{"id":319373841,"identity":"98df21fb-31ad-4ecf-9f29-7540080fa40b","order_by":3,"name":"Xiaoyue Wang","email":"","orcid":"","institution":"Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Xiaoyue","middleName":"","lastName":"Wang","suffix":""},{"id":319373842,"identity":"969f2648-d3a6-48be-aa50-d947bebf8d58","order_by":4,"name":"Jin Wang","email":"","orcid":"","institution":"Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Jin","middleName":"","lastName":"Wang","suffix":""},{"id":319373843,"identity":"b95da679-6372-4e41-b616-07cbfedad3af","order_by":5,"name":"Zhuoli Zhu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2ElEQVRIiWNgGAWjYDACCQYGZiAlw8beAOYzNhCrhYeN5wCpWhgkEojUIj+7x/hzYZsND5/k84efeRhsZDccYH72AJ8WxjlnDIxntqXxsEnnGEvzMKQZbzjAZm6ATwuzRI5BMm/bYZAWNmYehsOJGw7wsEng08IG1HIYrEXy+DOglv+EtfBI5Bg2g7VIMJgBtRwgrEVCIq2Ymecc0C88OcaScwySjWceZjPDq0V+RvLmzzxlNnLy7ccffnhTYSfbd7z5GV4taAAUVMwkqB8Fo2AUjIJRgB0AAAaDOe8HA3NdAAAAAElFTkSuQmCC","orcid":"","institution":"Sichuan University","correspondingAuthor":true,"prefix":"","firstName":"Zhuoli","middleName":"","lastName":"Zhu","suffix":""}],"badges":[],"createdAt":"2024-06-17 10:31:46","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4593547/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4593547/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60444443,"identity":"95c5c6ce-bc28-49d5-b171-29a92e18c10e","added_by":"auto","created_at":"2024-07-16 20:30:39","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1152628,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative image\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4593547/v1/85d66b69c8c497d908e8a6e2.png"},{"id":60443821,"identity":"db25d0f4-1f86-4b58-b66e-c185b1de4665","added_by":"auto","created_at":"2024-07-16 20:22:39","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":206141,"visible":true,"origin":"","legend":"\u003cp\u003eCBCT images of regions 13 and 43\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4593547/v1/2c618295680ff4dd10ba964d.png"},{"id":60444823,"identity":"b61dfe8b-a1f9-42f1-b22c-7e1f36762854","added_by":"auto","created_at":"2024-07-16 20:38:39","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":358398,"visible":true,"origin":"","legend":"\u003cp\u003eThe mesiodistal width in region 13 and region 43\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4593547/v1/1d60925da4acab37a663644d.png"},{"id":60444445,"identity":"6f02179a-a2e3-43ba-a455-521f1d4654af","added_by":"auto","created_at":"2024-07-16 20:30:39","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":392011,"visible":true,"origin":"","legend":"\u003cp\u003eThe final prosthetic design\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-4593547/v1/33499937ee14aeeb830d979a.png"},{"id":60443827,"identity":"31654d4c-fcc4-4c07-9265-4a1a6733bd1b","added_by":"auto","created_at":"2024-07-16 20:22:40","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":622654,"visible":true,"origin":"","legend":"\u003cp\u003eIdeal implant position based on the final prosthetic design\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-4593547/v1/4f8004b9a90bbcde94d73964.png"},{"id":60443829,"identity":"19b2a57e-dc38-49a2-a195-6693d80381a7","added_by":"auto","created_at":"2024-07-16 20:22:40","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":585829,"visible":true,"origin":"","legend":"\u003cp\u003e(A) A lack of alveolar bone width was found in the undercut area; (B) the osteotomy range was determined based on the implant.\u003c/p\u003e","description":"","filename":"Figure6.png","url":"https://assets-eu.researchsquare.com/files/rs-4593547/v1/9df8a6d14b2c4d3e374d6c23.png"},{"id":60443824,"identity":"6331ebcb-a3cf-4c47-9170-777c82a636ea","added_by":"auto","created_at":"2024-07-16 20:22:39","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":616483,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Implant surgical guide; (B) initial osteotomy guide\u003c/p\u003e","description":"","filename":"Figure7.png","url":"https://assets-eu.researchsquare.com/files/rs-4593547/v1/01223fd908c4f1d2060d5d45.png"},{"id":60444446,"identity":"48d50207-6738-42a4-b99b-1a9bfc645f32","added_by":"auto","created_at":"2024-07-16 20:30:40","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":258982,"visible":true,"origin":"","legend":"\u003cp\u003eFinal osteotomy guide\u003c/p\u003e","description":"","filename":"Figure8.png","url":"https://assets-eu.researchsquare.com/files/rs-4593547/v1/6e81e5d927004d0345d60d19.png"},{"id":60443828,"identity":"837b0967-b095-4e3e-88fe-3254897ae97d","added_by":"auto","created_at":"2024-07-16 20:22:40","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":1358555,"visible":true,"origin":"","legend":"\u003cp\u003eSurgical procedure: (A) The stability of the guide was examined; (B) an envelope flap was formed; (C) the osteotomy guide was fully seated in place; (D) a U-shaped bone plate was made with an ultrasonic osteotome (Surgybone; Silfradent) following the osteotomy guide; (E) a U-shaped bone plate was formed; (F) the implant bed was prepared with an implant guide; (G) the U-shaped bone plate was pressed with a spreader kit; (H) postoperative image.\u003c/p\u003e","description":"","filename":"Figure9.png","url":"https://assets-eu.researchsquare.com/files/rs-4593547/v1/b224f2cb3cbc763b05b0a0e3.png"},{"id":60443830,"identity":"adc9f24d-fc64-44da-aefa-ef244e5a7b67","added_by":"auto","created_at":"2024-07-16 20:22:40","extension":"png","order_by":10,"title":"Figure 10","display":"","copyAsset":false,"role":"figure","size":428936,"visible":true,"origin":"","legend":"\u003cp\u003eCBCT images obtained (A) at baseline, (B) immediately after the final restoration, and (C) 1 year after surgery.\u003c/p\u003e","description":"","filename":"Figure10.png","url":"https://assets-eu.researchsquare.com/files/rs-4593547/v1/1583a75b8a6979bdfcf3d15f.png"},{"id":63785351,"identity":"de8d99c8-291f-425e-931d-0c8529bd47cb","added_by":"auto","created_at":"2024-09-02 10:28:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":10101419,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4593547/v1/10f675b3-ef5c-4882-90b5-551a43df63c7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Digital guides for precise U-shaped splitting and simultaneous implant placement with minimal surgical trauma: a clinical report","fulltext":[{"header":"Background","content":"\u003cp\u003eBone width deficiency is often associated with various implant complications, such as implant failure and compromised final esthetics of the restoration\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. To address this issue, ridge splitting technology (RST), which involves splitting the alveolar ridge into two parts and creating a greenstick fracture with simultaneous implant surgery, has been introduced. In previous studies, the extraordinary ability of the RST to increase bone width has been reported \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. However, the RST carries the risk of labial bone plate fracture during bone expansion or implant placement\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e, especially for patients with labial concavity at the alveolar bone. Additionally, RST may also cause marginal bone loss due to the thin buccal bone plate and inevitable mechanical trauma during the splitting process\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFor these patients, Yao et al. proposed a U-shaped splitting technique (UST) that involves splitting a U-shaped bone plate from below the crest of the alveolar ridge to reduce the risk of bone plate fracture and marginal bone loss\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. However, for UST, it is crucial to obtain a suitable U-shaped bone plate and perform precise implant placement based on the ideal implant site for maintaining the final bone mass and eventual effect of restoration, which poses a great challenge for dentists. Therefore, surgeons usually resort to increasing the flap area and expanding the range of the U-shaped bone plate, resulting in greater surgical trauma\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eEnvelope flaps and digital guides can be used to address these problems. The envelope flap can preserve the integrity of blood vessels and cause less trauma; moreover, the surgical field of the envelope flap is sufficient for the UST. In addition, a digital guide, which is designed based on an ideal implant site, can help dentists precisely perform U-shaped splitting and minimize surgical trauma. Hence, the use of an envelope flap and a digital guide is highly advisable for UST\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTherefore, in this clinical case report, we present U-shaped splitting and simultaneous implant placement surgery with an envelope flap guided by customized digital guides, which precisely outlined the U-shaped bone plate and guided implant placement. This approach minimized surgical trauma, simplified the clinical operation procedure, and alleviated the financial burden on the patient.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA man aged 25 years who was healthy and nonsmoking asked to resolve the loss of two single teeth in regions 13 and 43 by implant restoration (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). CBCT was performed in September 2023, when the residual upper right canine was present. Before he came, the canine fell off naturally. A dental scan was taken. CBCT revealed adequate bone mass in region 13 and a labial undercut in region 43 (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Analysis was carried out before treatment, and the mesiodistal width was 9.44 mm in region 13 and 9.61 mm in region 43 (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), which are relatively larger than the normal width of the contralateral canine. CBCT images and dental scans were imported into the surgical design software 3Shape Implant Studio (3Shape, Copenhagen, Denmark) for treatment planning. The initial prosthetic plan was designed with surgical design software. If the missing teeth were restored according to the morphology of the contralateral homonymous teeth, gaps would exist between the prostheses and adjacent teeth. The second treatment plan was designed to close the gaps, which would result in overlarge prostheses, increasing the burden of the implant. As the patient had several natural gaps in the dental arch, after negotiating with him, the first treatment plan was adopted (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Then, according to the prosthesis design, the following implant types were chosen: a BLT straumann implant (3.3 mm in diameter and 10 mm in length) in area 13 and a BLT straumann implant (3.3 mm in diameter and 12 mm in length) in area 43 (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). A lack of alveolar bone width was found in the undercut area of region 43 (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). After discussing and comparing different bone augmentation technologies, the UST was chosen for region 43. For accurate implant placement and U-shaped splitting, two digital guides were designed in this case in the 3Shape implant studio, an implant surgical guide and an osteotomy guide (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e), both of which are tooth-supported. The osteotomy guide was used to guide the scope of the ostomy and avoid important anatomical structures, such as adjacent roots and mandibular nerves. Since it is necessary for the osteotomy guide to meet the surgical requirements, the designed osteotomy guide was exported from 3 shapes as a standard tessellation language (STL) file and then imported into computer-aided design (CAD) software (Magics 24; Materialize, Belgium) to modify the structure (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003eA). Finally, the implant surgical guide and osteotomy guide were fabricated using a stereolithography three-dimensional printer (AccuFab-D1s; Shining 3D).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eBefore surgery, the guides were seated on the patient\u0026rsquo;s teeth to examine their fitness and stability and determine the scope of the flap (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e9\u003c/span\u003eA). Then, the guides were sterilized. After administering local anesthesia, the implants were routinely placed in region 13 freehand. Next, a horizontal incision at the partial palatal side of the alveolar crest in region 43 and gingival sulcus incisions at adjacent teeth on both sides were made, and a full mucoperiosteal flap was lifted until the osteotomy guide was precisely positioned (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e9\u003c/span\u003eB, C). Then, according to the osteotomy guide, the U-shaped labial bone plate was outlined using ultrasonic osteotomy (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e9\u003c/span\u003eD, E). Next, the implant surgical guide was seated to guide the predrill of the implant bed with a 2.2 mm pilot drill (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e9\u003c/span\u003eF), and a 2.8 mm bone spreader kit was used to press the U-shaped labial plate to produce a greenstick fracture to increase the bone width (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e9\u003c/span\u003eG). Then, the implant was installed using a low-speed drilling procedure. A healing abutment was placed in position. An inorganic bovine bone substitute (Bio-Oss; Geistlich Pharma AG, Wolhusen, Switzerland) was subsequently placed to decrease labial alveolar bone absorption. Finally, the surgical site was closed with 5\u0026ndash;0 Prolene sutures (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e9\u003c/span\u003eH). CBCT was performed after 3 months (Fig.\u0026nbsp;\u003cspan refid=\"Fig10\" class=\"InternalRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion and Conclusions","content":"\u003cp\u003eFor patients with insufficient bone width accompanied by a labial concavity, several bone augmentation technologies have been introduced, including guided bone regeneration (GBR), onlay bone grafting, RST, and UST.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e The instability of biodegradable membranes is responsible for compromised bone augmentation in GBR\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. However, the elevated bone plate in the U-shaped splitting technique helps maintain the stability of the bone substitute and produces osteogenic factors to obtain a superior ridge width\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Studies have also shown that the UST can be used as an alternative method to the GBR\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Compared with onlay bone grafting, a second surgical site is not required for UST, and for patients with extremely narrow alevolar ridges, the UST can replace onlay bone grafting\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Finally, for the RST, the UST can decrease the risk of labial bone fracture, guarantee marginal bone stability, and cause less trauma. Thus, RST may be an effective technique for this specific case.\u003c/p\u003e\n\u003cp\u003eAs reported in the literature about the UST, a T-shaped flap is usually used because of its superior ability to provide full exposure of the surgical field\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. However, the vertical incision of the T-shaped flap will destroy the integrity of the mucoperiosteal vessels. Studies have shown that the mucoperiosteum is a structure rich in osteoprogenitor cells and functions as a useful barrier with osteogenic properties\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Every incision and dissection of the mucoperiosteum will cause damage to the blood supply of the soft tissue and the alveolar bone\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. In this clinical case, a horizontal incision and gingival sulcus incision were used to form an envelope flap, which has the advantage of only flipping the labial mucoperiosteal flap and is characterized by simpler operation compared to the angular or rectangular mucoperiosteal flap at the top of the alveolar ridge\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. It is also easy to close the wound and ensure the integrity of the mucoperiosteum. Since whether the barrier membrane can reduce bone resorption has been debated and since the integrated mucoperiosteum is capable of ensuring osteogenic ability, the barrier membrane was not used in this case\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. However, the envelope mucoperiosteal flap provides an inadequate surgical field compared with the T-shaped flap; thus, clinicians may face difficulties in forming a proper U-shaped bone plate, which may result in damage to important anatomical structures.\u003c/p\u003e\n\u003cp\u003eDigital technology has brought convenience\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. In this case, the range of the U-shaped bone plate was determined according to the final implant site and was then transferred to the digital osteotomy guide. The length of the horizontal osteotomy should be larger than the diameter of the planned implant, and the length of the vertical osteotomy should be equal to the length of insufficient bone mass. The guide not only ensures the ideal U-shaped bone plate but also reduces the range of bone splitting as much as possible. Moreover, the guide can be used for the envelope flap without blocking the surgical field, further reducing surgical trauma. At the same time, the digital implant guide can be used to transfer the ideal implant site to the mouth, reducing the labial deviation of the implant after splitting the bone mass, which is common in UST\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Digital guides can also help clinicians avoid damaging important anatomical structures and obtain better restorative effects.\u003c/p\u003e\n\u003cp\u003eThe limitation of this case is that the depth of the split was not controlled. Nickenig et al. used a narrow spiral mill (diameter 0.9 mm, Meisinger\u0026reg;, Neuss) with a guide to transfer the determined splitting depth when performing the RST\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. However, the diameter of the pilot drill in Straumann\u0026reg; Guided Surgery instruments is 2.2 mm, and using this drill to determine the depth of U-shaped splitting may result in more bone mass loss. When the U-shaped bone plate is pressed in this case, bone plate fractures are more likely to occur. Therefore, the control of the splitting depth requires further consideration.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eRST Ridge splitting technology\u003c/p\u003e\n\u003cp\u003eUST U-shaped splitting technique\u003c/p\u003e\n\u003cp\u003eSTL Standard tessellation language\u003c/p\u003e\n\u003cp\u003eCAD Computer-aided design\u003c/p\u003e\n\u003cp\u003eGBR Guided bone regeneration\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for the publication of this case report and any accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author\u0026nbsp;upon\u0026nbsp;reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not receive any functional support from any funding\u0026nbsp;organization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eXin Feng and Zhuoli Zhu performed the clinical diagnosis, treatment and drafted the manuscript.\u0026nbsp;Ziqianhong Wan and Xiaoxia Wang made the implant plan and\u0026nbsp;drafted the manuscript.\u0026nbsp;Xiaoyue\u0026nbsp;Wang and\u0026nbsp;Jin\u0026nbsp;Wang\u0026nbsp;managed the patient, participated in the operation, and drafted the manuscript. All the authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePrati, C.; Zamparini, F.; Canullo, L.; Pirani, C.; Botticelli, D.; Gandolfi, M. G. Factors Affecting Soft and Hard Tissues Around Two-Piece Transmucosal Implants: A 3-Year Prospective Cohort Study. \u003cem\u003eInt J Oral Maxillofac Implants\u003c/em\u003e \u003cstrong\u003e2020\u003c/strong\u003e, \u003cem\u003e35\u003c/em\u003e (5), 1022\u0026ndash;1036.\u003c/li\u003e\n\u003cli\u003eFarronato, D.; Pasini, P. M.; Orsina, A. A.; Manfredini, M.; Azzi, L.; Farronato, M. Correlation between Buccal Bone Thickness at Implant Placement in Healed Sites and Buccal Soft Tissue Maturation Pattern: A Prospective Three-Year Study. \u003cem\u003eMaterials (Basel)\u003c/em\u003e \u003cstrong\u003e2020\u003c/strong\u003e, \u003cem\u003e13\u003c/em\u003e (3), 511.\u003c/li\u003e\n\u003cli\u003eStarch-Jensen, T.; Becktor, J. P. Maxillary Alveolar Ridge Expansion with Split-Crest Technique Compared with Lateral Ridge Augmentation with Autogenous Bone Block Graft: A Systematic Review. \u003cem\u003eJ Oral Maxillofac Res\u003c/em\u003e \u003cstrong\u003e2019\u003c/strong\u003e, \u003cem\u003e10\u003c/em\u003e (4), e2.\u003c/li\u003e\n\u003cli\u003ede Souza, C. S. V.; de S\u0026aacute;, B. C. M.; Goulart, D.; Guillen, G. A.; Mac\u0026ecirc;do, F. G. C.; N\u0026oacute;ia, C. F. Split Crest Technique with Immediate Implant to Treat Horizontal Defects of the Alveolar Ridge: Analysis of Increased Thickness and Implant Survival. \u003cem\u003eJ Maxillofac Oral Surg\u003c/em\u003e \u003cstrong\u003e2020\u003c/strong\u003e, \u003cem\u003e19\u003c/em\u003e (4), 498\u0026ndash;505.\u003c/li\u003e\n\u003cli\u003eArnal, H. M.; Angioni, C. D.; Gaultier, F.; Urbinelli, R.; Urban, I. A. Horizontal Guided Bone Regeneration on Knife-Edge Ridges: A Retrospective Case‒Control Pilot Study Comparing Two Surgical Techniques. \u003cem\u003eClin Implant Dent Relat Res\u003c/em\u003e \u003cstrong\u003e2022\u003c/strong\u003e, \u003cem\u003e24\u003c/em\u003e (2), 211\u0026ndash;221.\u003c/li\u003e\n\u003cli\u003eBassetti, R.; Bassetti, M.; Mericske-Stern, R.; Enkling, N. Piezoelectric Alveolar Ridge-Splitting Technique with Simultaneous Implant Placement: A Cohort Study with 2-Year Radiographic Results. \u003cem\u003eInt J Oral Maxillofac Implants\u003c/em\u003e \u003cstrong\u003e2013\u003c/strong\u003e, \u003cem\u003e28\u003c/em\u003e (6), 1570\u0026ndash;1580.\u003c/li\u003e\n\u003cli\u003eHan, J.-Y.; Shin, S.-I.; Herr, Y.; Kwon, Y.-H.; Chung, J.-H. The Effects of Bone Grafting Material and a Collagen Membrane in the Ridge Splitting Technique: An Experimental Study in Dogs. \u003cem\u003eClin Oral Implants Res\u003c/em\u003e \u003cstrong\u003e2011\u003c/strong\u003e, \u003cem\u003e22\u003c/em\u003e (12), 1391\u0026ndash;1398.\u003c/li\u003e\n\u003cli\u003eYao, Y.; He, K.; Gong, P.; Tang, H. U-Shaped Bone Splitting and Osteotome Techniques for Narrow Alveolar Ridge in Implant Surgery. \u003cem\u003eImplant Dent\u003c/em\u003e \u003cstrong\u003e2018\u003c/strong\u003e, \u003cem\u003e27\u003c/em\u003e (4), 507\u0026ndash;511.\u003c/li\u003e\n\u003cli\u003eBassetti, M. A.; Bassetti, R. G.; Bosshardt, D. D. The Alveolar Ridge Splitting/Expansion Technique: A Systematic Review. \u003cem\u003eClin Oral Implants Res\u003c/em\u003e \u003cstrong\u003e2016\u003c/strong\u003e, \u003cem\u003e27\u003c/em\u003e (3), 310\u0026ndash;324.\u003c/li\u003e\n\u003cli\u003eLin, X.; Zhou, Z.; Li, S.; Gao, Y.; Zheng, X. Digital Guides to Facilitate Retained Root Removal and Simultaneous Implant Placement. \u003cem\u003eInternational Journal of Oral and Maxillofacial Surgery\u003c/em\u003e \u003cstrong\u003e2022\u003c/strong\u003e, \u003cem\u003e51\u003c/em\u003e (7), 957\u0026ndash;961.\u003c/li\u003e\n\u003cli\u003eGao, X.; Qin, S.; Cai, H.; Wan, Q. Comparison of General and Aesthetic Effects between Flapless and Flap Techniques in Dental Implantation: A Meta-Analysis of Randomized Controlled Trials. \u003cem\u003eInt J Implant Dent\u003c/em\u003e \u003cstrong\u003e2021\u003c/strong\u003e, \u003cem\u003e7\u003c/em\u003e (1), 100.\u003c/li\u003e\n\u003cli\u003ede Azambuja Carvalho, P. H.; Dos Santos Trento, G.; Moura, L. B.; Cunha, G.; Gabrielli, M. A. C.; Pereira-Filho, V. A. Horizontal Ridge Augmentation Using Xenogenous Bone Graft-Systematic Review. \u003cem\u003eOral Maxillofac Surg\u003c/em\u003e \u003cstrong\u003e2019\u003c/strong\u003e, \u003cem\u003e23\u003c/em\u003e (3), 271\u0026ndash;279.\u003c/li\u003e\n\u003cli\u003eFriberg, B. Bone Augmentation for Single Tooth Implants: A Review of the Literature. \u003cem\u003eEur J Oral Implantol\u003c/em\u003e \u003cstrong\u003e2016\u003c/strong\u003e, \u003cem\u003e9 Suppl 1\u003c/em\u003e, S123-134.\u003c/li\u003e\n\u003cli\u003eHockers, T.; Abensur, D.; Valentini, P.; Legrand, R.; Hammerle, C. H. The Combined Use of Bioresorbable Membranes and Xenografts or Autografts in the Treatment of Bone Defects around Implants. A Study in Beagle Dogs. \u003cem\u003eClin Oral Implants Res\u003c/em\u003e \u003cstrong\u003e1999\u003c/strong\u003e, \u003cem\u003e10\u003c/em\u003e (6), 487\u0026ndash;498.\u003c/li\u003e\n\u003cli\u003eWu, Q.; Yang, B.; Gao, S.; Gong, P.; Xiang, L.; Man, Y.; Qu, Y. Apical U-Shape Splitting Technique for Undercut Areas of the Anterior Alveolar Ridge: A Prospective Non-Randomized Controlled Study. \u003cem\u003eInt J Oral Maxillofac Surg\u003c/em\u003e \u003cstrong\u003e2019\u003c/strong\u003e, \u003cem\u003e48\u003c/em\u003e (3), 388\u0026ndash;394.\u003c/li\u003e\n\u003cli\u003eElboghdadi, I. A.; Elkenawy, M. H.; Abdelsameaa, S. E.; Ghoneim, N. I. U-Shaped Splitting Technique vs Conventional Bone Grafting in Maxillary Facial Undercut for Dental Implants Placement: A Preliminary Randomized Controlled Clinical Trial. \u003cem\u003eJ Contemp Dent Pract\u003c/em\u003e \u003cstrong\u003e2022\u003c/strong\u003e, \u003cem\u003e23\u003c/em\u003e (12), 1245\u0026ndash;1254.\u003c/li\u003e\n\u003cli\u003eGielkens, P. F. M.; Bos, R. R. M.; Raghoebar, G. M.; Stegenga, B. Is There Evidence That Barrier Membranes Prevent Bone Resorption in Autologous Bone Grafts during the Healing Period? A Systematic Review. \u003cem\u003eInt J Oral Maxillofac Implants\u003c/em\u003e \u003cstrong\u003e2007\u003c/strong\u003e, \u003cem\u003e22\u003c/em\u003e (3), 390\u0026ndash;398.\u003c/li\u003e\n\u003cli\u003eSaimbi, C. S.; Gautam, A.; Khan, M. A.; Nandlal, null. Periosteum as a Barrier Membrane in the Treatment of Intrabony Defect: A New Technique. \u003cem\u003eJ Indian Soc Periodontol\u003c/em\u003e \u003cstrong\u003e2014\u003c/strong\u003e, \u003cem\u003e18\u003c/em\u003e (3), 331\u0026ndash;335.\u003c/li\u003e\n\u003cli\u003eAbed, P. F.; El Chaar, E.; Boltchi, F.; Bassir, S. H. The Novel Periosteal Flap Stretch Technique: A Predictable Method to Achieve and Maintain Primary Closure in Augmentative Procedures. \u003cem\u003eJ Int Acad Periodontol\u003c/em\u003e \u003cstrong\u003e2020\u003c/strong\u003e, \u003cem\u003e22\u003c/em\u003e (1), 11\u0026ndash;20.\u003c/li\u003e\n\u003cli\u003eKim, Y.-K.; Ku, J.-K. Guided Bone Regeneration. \u003cem\u003eJ Korean Assoc Oral Maxillofac Surg\u003c/em\u003e \u003cstrong\u003e2020\u003c/strong\u003e, \u003cem\u003e46\u003c/em\u003e (5), 361\u0026ndash;366.\u003c/li\u003e\n\u003cli\u003eStanley, M.; Paz, A. G.; Miguel, I.; Coachman, C. Fully Digital Workflow, Integrating Dental Scan, Smile Design and CAD-CAM: Case Report. \u003cem\u003eBMC Oral Health\u003c/em\u003e \u003cstrong\u003e2018\u003c/strong\u003e, \u003cem\u003e18\u003c/em\u003e, 134.\u003c/li\u003e\n\u003cli\u003eTallarico, M.; Meloni, S. M. Retrospective Analysis on Survival Rate, Template-Related Complications, and Prevalence of Peri-Implantitis of 694 Anodized Implants Placed Using Computer-Guided Surgery: Results Between 1 and 10 Years of Follow-Up. \u003cem\u003eInt J Oral Maxillofac Implants\u003c/em\u003e \u003cstrong\u003e2017\u003c/strong\u003e, \u003cem\u003e32\u003c/em\u003e (5), 1162\u0026ndash;1171.\u003c/li\u003e\n\u003cli\u003eNickenig, H.-J.; Safi, A.-F.; Matta, R.-E.; Z\u0026ouml;ller, J. E.; Kreppel, M. 3D-Based Full-Guided Ridge Expansion Osteotomy \u0026ndash; A Case Report about a New Method with Successive Use of Different Surgical Guides, Transfer of Splitting Vector and Simultaneous Implant Insertion. \u003cem\u003eJournal of Cranio-Maxillofacial Surgery\u003c/em\u003e \u003cstrong\u003e2019\u003c/strong\u003e, \u003cem\u003e47\u003c/em\u003e (11), 1787\u0026ndash;1792.\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":"U-shaped splitting, Digital guide, Envelope flap","lastPublishedDoi":"10.21203/rs.3.rs-4593547/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4593547/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eU-shaped splitting technology has been proven to be an effective horizontal bone augmentation technique for patients with insufficient bone width and labial concavity. However, obtaining a suitable U-shaped bone plate based on the ideal implant site by freehand remains difficult, especially without a sufficient surgical field.\u003c/p\u003e\u003ch2\u003eCase presentation\u003c/h2\u003e \u003cp\u003eA 25-year-old man came to restore his right canine teeth. Since a labial bone undercut was found in region 43, a surgical procedure involving U-shaped splitting in an envelope flap with simultaneous implant placement using two digital guides was performed.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eWith the assistance of two digital guides, precise U-shaped splitting in an envelope flap can minimize surgical trauma and has a significant effect on horizontal bone augmentation.\u003c/p\u003e","manuscriptTitle":"Digital guides for precise U-shaped splitting and simultaneous implant placement with minimal surgical trauma: a clinical report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-16 20:22:34","doi":"10.21203/rs.3.rs-4593547/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":"92b3553e-1032-4167-a12a-8c0b08cec178","owner":[],"postedDate":"July 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-02T10:20:40+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-16 20:22:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4593547","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4593547","identity":"rs-4593547","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}