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Intraoral Tissue Expander: Tissue Augmentation for Deficient Alveolar

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Intraoral Tissue Expander: Tissue Augmentation for Deficient Alveolar ISSN: 2469-5734 Medikeri et al. Int J Oral Dent Health 2020, 6:123 DOI: 10.23937/2469-5734/1510123 Volume 6 | Issue 4 International Journal of Open Access Oral and Dental Health SYSTEMATIC REVIEW Intraoral Tissue Expander: Tissue Augmentation for Deficient Alveolar Ridge by Mechanotransduction - A Systematic Review of Literature Raghavendra S Medikeri1* , Marisca A Pereira2 and Manjushri Waingade3 1 Check for Professor, Department of Periodontology, Sinhgad Dental College and Hospital, India updates 2Post-graduate student, Department of Periodontology, Sinhgad Dental College and Hospital, India 3Associate Professor, Department of Oral Medicine & Radiology, Sinhgad Dental College and Hospital, India *Corresponding author: Dr. Raghavendra S Medikeri, Professor, Department of Periodontology, Sinhgad Dental College and Hospital, Vadgaon (Bk), Pune-411041, Maharashtra, India, Tel: +91-9766337620 closure [1]. Similarly, Proussaefs & Lozada reported Abstract 25% wound dehiscence in patients with vertical bone Background: Rehabilitation of edentulous ridges with im- augmentation with autogenous bone blocks [2]. Inad- plants is becoming so popular. However, it becomes oner- ous for a dentist to place implants in severely resorbed equate tension free primary closure is due to insuffi- ridges which requires tension free primary wound closure. cient amount of overlying soft tissue. One way to avoid Instead of using invasive and extremely tedious methods to wound dehiscence after guided bone regeneration tech- augment soft tissue, an intra-oral soft tissue expander is an nique is by using vertical releasing incisions and perios- ideal option. teal releasing incision for flap advancement. However Purpose: This review aims to pool all the data available on these two incisions greatly compromises vascularisa- the intra-oral soft tissue expander and all the recent advanc- tion of the surgical area since it disrupts the continuity es of the concept of soft tissue expansion. of the flap and the periosteum [3,4]. Decreased vascu- Material & methods: The electronic data bases search on larisation and wound dehiscence negatively affect the pubmed, google scholar and cochrane database for articles searched until June 2020. outcome of ridge augmentation [3]. For primary wound closure and to prevent post-operative complications, a Results & discussion: Soft tissue expander can be used as a very effective treatment option for increasing the soft very successful soft tissue management is mandatory. tissue volume before ridge augmentation. There are insuffi- Free fibula flaps [5], distraction osteogenesis [6], peri- cient human intra-oral studies validating this method. How- osteal distraction [7] and tissue engineered periosteum ever, there is a need for more well-designed human trials to [8] are some available methods for soft tissue augmen- comprehend its use. tation but their use for long length edentulous ridges is Keywords very difficult. In plastic and reconstructive surgery the Tissue expanders, Soft tissue expander, Osmed® expand- soft tissue augmentation is done with the use of tissue ers, Hydrogel expanders, Intra-oral soft tissue expander expanders [9]. This idea was mimicked with the use of intra-oral soft tissue expanders to improve the overlying Introduction mucosal volume before ridge augmentation. Intra-oral soft tissue expander is a device that is placed in the sub/ Soft tissue complications like wound dehiscence af- supra-periosteal pouch that expands gradually leading ter ridge augmentation is around 16.8% which occurs to increase in the soft tissue volume and thickness by mostly due to inadequate tension free primary would mechano-transduction. This literature review primarily Citation: Medikeri RS, Pereira MA, Waingade M (2020) Intraoral Tissue Expander: Tissue Augmenta- tion for Deficient Alveolar Ridge by Mechanotransduction- A Systematic Review of Literature. Int J Oral Dent Health 6:123. doi.org/10.23937/2469-5734/1510123 Accepted: December 29, 2020: Published: December 31, 2020 Copyright: © 2020 Medikeri RS, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Medikeri et al. Int J Oral Dent Health 2020, 6:123 • Page 1 of 14 • DOI: 10.23937/2469-5734/1510123 ISSN: 2469-5734 focusses on the use of intra-oral soft tissue expanders C (comparison): Soft tissue volume with and without for soft tissue expansion in ridge augmentation. placement of expander Methods O (outcome): Soft tissue expansion The electronic data bases, pubmed, google scholar All the studies were assessed separately by both the and cochrane library were searched for articles pub- authors and divergent opinions and assessments with lished from January 1950 until 1st June 2020. regards to the assignment of strengths and weaknesses, consensus was reached by discussion. The terms “Tissue expander”, “Soft-tissue expand- er”, “dental expander”, “oral expander”, “dental soft History tissue expanders”, “oral soft tissue expanders”, “Hydro- The idea of using a tissue expander stems in 1957 gel expanders”, “Osmed® expanders” and “Osmed® soft when Charles Neumann was successful in reconstruct- tissue expanders” were used. Only human studies that ing an external ear by placing an inflatable silicon rub- have used intra-oral expanders for soft tissue expansion ber balloon beneath the skin and inflating it by multi- in ridge augmentation was included in the study. Exclud- ed studies include the use of intra-oral expanders used ple injections manually several times via an external in cranio-facial reconstruction and cleft lip and palate. port [10]. However due to presence of the port close Animal studies, literature and systematic reviews, in-vi- to the reservoir, chances of infections and difficulty in tro studies were excluded. The methodology of study tracing the port for injection made the procedure stren- selection is illustrated in Figure 1. uous for the clinician. Chedomir Radovan constructed a conventional expander with inflatable reservoir but Systematic assessment of papers with self-sealing valve and external port for breast re- The methodological characteristics of the selected construction [11,12]. The following year, Argenta used papers were assessed according to the PICO format i.e. this technique for treatment of burns [13]. In 1992, Van Damme used a conventional expander in craniofacial P (patient/population): Patients requiring alveolar defect [14]. Eric Austad and Rose developed a self-in- ridge augmentation flating hydrogen expander covered with semi-perme- I (intervention): Placement of soft tissue expander able silicon cover filled with hypertonic NaCl which did PubMed (2236), Google scholar (6490), Cochrane database (18) n = 8744 No of articles excluded (n = 8706) (Uses other than the oral cavity, Reviews, in vitro studies, duplicates, animal studies) Abstract screening n = 33 No of articles excluded (n = 18) Articles on cleft lip and palate n =7 Articles on use of expanders in craniofacial reconstruction = 9 Others n = 2 Full text screening n = 15 Figure 1: The methodology of study selection. Medikeri et al. Int J Oral Dent Health 2020, 6:123 • Page 2 of 14 • DOI: 10.23937/2469-5734/1510123 ISSN: 2469-5734 Table 1: Classification of commercially available soft tissue expanders. Standard tissue expanders Differential tissue expanders Anatomic tissue Custom built expanders tissue expanders Available in different shapes and sizes The stiffness or thickness of Used specially in breast These expander such as circular, rectangular or crescentic the silicon envelope is altered reconstruction. Becker are customised (croissant) with different volumes. These differentially in different areas expander is a variation according to the expanders are made commercially available of the expander. of this type. length, width and by various manufacturing companies. volume required. not require external port and multiple injections for in- ration and treatment failures [16]. flation which overcame most of the trouble and cost of 2) Self-inflating soft tissue expander: the treatment for the patient [15]. It was based on the principle that the expander would gradually swell due Self-inflating soft tissue expander consists of hy- to the osmotic forces of the surrounding fluid into the drogel encompassed with semipermeable silicon hypertonic sodium chloride filled expander [15]. Hyper- membrane without an external port [15]. Hydrogel is tonic sodium chloride solution was used since the solute a three-dimensional (3D) network of hydrophilic poly- had to be a highly water-soluble, low-molecular weight, mers that swells in aqueous media but does not dis- non-toxic compound that produces two ions in solution solve in it due to the presence of cross-links and exhibits that double the effect of a single, non-ionised species anisotropic expansion [16,17,20,21]. The rationale for (e.g.: Glucose) [15]. These expanders were custom fab- using semi-permeable coating over the hydrogel was to ricated by Dow-Corning Medical products in 1976. Later prevent the rapid expansion of the expander [22]. in 1981, it was used in clinical trials in two patients after Soft tissue expanders can also be classified based on multiple experimental studies [15]. However, it was ob- the commercially available forms. (Table 1) [23]. Osmed served that the hypertonic NaCl solution in the expand- self-inflating tissue
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