Available Online at http://www.recentscientific.com International Journal of CODEN: IJRSFP (USA) Recent Scientific

International Journal of Recent Scientific Research Research Vol. 11, Issue, 08 (B), pp. 39498-39503, August, 2020 ISSN: 0976-3031 DOI: 10.24327/IJRSR Research Article

TISSUE EXPANDER IN PERIODONTICS

*Lakshana S., Esther Nalini H., Arun Kumar Prasad P., and Renuka Devi R

Department of Periodontology, K.S.R. Institute of Dental Science and Research, Tiruchengode, Tamilnadu, India

DOI: http://dx.doi.org/10.24327/ijrsr.2020.1108.5515

ARTICLE INFO ABSTRACT

Article History: Periodontitis is a multifactorial inflammatory disease which leads to the destruction of soft and hard tissues surrounding the teeth. in periodontics was introduced to correct the tissue Received 12th May, 2020 rd (soft and hard) defects, preserve and augment the dimensions of alveolar ridge. It overcomes the Received in revised form 23 complications like soft tissue dehiscence, poor tension free primary closure associated with the June, 2020 conventional augmentation procedures. Materials which are widely used as tissue expanders in Accepted 7th July, 2020 th dentistry are silicon expander, Hydrogel expander, Hydroxyapatite and Chitosan. Hydroxyapatite Published online 28 August, 2020 and chitosan are hard tissue expander, while Silicon and Hydrogel are soft tissue expanders. Hydrogel expander provides a greater advantage compared to silicon expander because of its hydrophilic Key Words: property which cause gradual expansion of the expander. In medicine it is mainly used for breast

periodontitis, ridge, augmentation, augmentation after , for renewing scar formation after , alopecia and to correct any expander, expansion facial deformities. In periodontics soft tissue expander is used in procedures like expansion of alveolar ridge, before augmentation procedure and implants dentistry so that it can provide a tension free flap closure and avoid dehiscence. Thus tissue expander is boon in regenerative periodontics since it provides adequate tissue coverage, good esthetics in defect area, with minimal hospital visit and discomfort.

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INTRODUCTION defect area. This new technique which is used for the construction of edentulous alveolar ridges also over comes the Periodontitis is a multifactorial disease infectious disease complications of all previously used techniques.4 resulting in inflammation within the supporting tissue of the teeth with progressive attachment loss and bone loss.1To History correct this defect, bone augmentation procedure is mandatory, The first tissue expander was introduced by NEWMANN in to achieve adequate dimension of alveolar ridge. To preserve the year 1957 for an ear defect which was made up of silicon the ridge many different types of techniques have been rubber. It was a conventional expander where an external port described, such as horizontal or vertical ridge augmentation, was visible and this external port was used for manual guided bone regeneration, onlay grafting, distraction 4 osteogenesis etc. The most common complication of all the inflations The self-inflating tissue expander was then above mentioned procedures is soft tissue dehiscence and poor introduced by AUSTAD and ROSE in 1982. It was semi tension free primary closure over the grafted area.2 To permeable silicon balloon filled with sodium chloride, without overcome this difficulty and unaesthetic failure procedure, soft an external port. The alveolar ridge tissue expander was then tissue expansion procedure was introduced. introduced by LEW ET AL (1989) with hydroxyapatite which was a hard tissue expander4. The novel self-inflating Tissue expansion is defined as, “The ability of at least some osmotically active soft tissue expander was introduced by living tissue such as , mucous membrane to accommodate a 3 WEISE in 1993, which was made up of co- polymers of slowly enlarging mass beneath it by increase in surface area”. hydrogel, where the inflation takes by the osmotic gradient.4 As a result tissue expansion procedure aids to achieve, tension and complete free soft tissue closure and thereby it decrease Characteristics of Ideal Expander5 soft tissue dehiscence, for a successful surgical procedure.  An ideal expander should be more comfortable and does not provide any damage to tissues and adjacent Soft tissue expander is mainly used for alveolar ridge 5 reconstruction, it aids in formation of new cell and its growth, area of expander placement . provide a good function and texture of skin or mucosa in the

*Corresponding author: Lakshana S Department of Periodontology, K.S.R. Institute of Dental Science and Research, Tiruchengode, Tamilnadu, India Lakshana S et al., Tissue Expander in Periodontics

 Sudden rapid expansion should be avoided since it “xerogel”11The hydrogel has 2 component, the polymer and leads to perforation of the tissues. aqueous component. The polymer component remains constant  Henceslow and gradual expansion is advisable5. and the aqueous component varies and the expanders self-  The expander should be soft and easy to insert, the inflate through osmotic process.8 size of the soft tissue expander must be comparatively 4 smaller than that of the defect area.5 Phases in Hydrogen Expander

 T he expander should be able to withstand the external There are 3 phase in hydrogel expander, stimuli, it should not dislocate from its position.5 PHASE 1(“Time switch”): In this phase there is usually a 5  C osteffective,easy to handle for surgeons. delay in the expansion of the expander, immediately after the  Itshould be easy to adaptand easy to rem ove before and after placement. This phase last up to 2 weeks of implantation4. 5 surgicalprocedure. PHASE 2: It is the expansion phase, the expander gradually

Materials used in tissue Expander starts to expand, which is carefully controlled by the polymer reaction and also helps to prevent the inhibition of unwanted Materials which are widely used as tissue expanders in swelling4. dentistry are silicon expander, Hydrogel expander,

6 Hydroxyapatite and Chitosan. Hydroxyapatite and chitosan PHASE 3: In this phase, completion of swelling is significant, are hard tissue the hydrogel turns inert &removed4. expander, while Silicon and Hydrogel are soft tissue 6 Comparison of silicone balloon expander and hydrogel expanders .

7 Expander Hydroxyapatite Silicone Balloon 9 9 Hydrogel Expander It is a hard tissue expander used for alveolar ridge Expander augmentation. Its characteristics include,

It is soft and easy to Hard in consistency, not adaptable to the . Easily carved and molded7. adapt to the 9 9 . Adequate mechanical properties to support a denture7. underlying tissues underlying tissues Soft, sometimes hard to 9 7 9 Hard, easy to push into its pocket . Biocompatible and stable . place in tissue pocket . Bond firmly with bone and soft tissue7. Delayed expansion can 7 sometimes take place Immediate expansion, starts as soon as body . Soft tissue healing after implant exposure . after placement of the 9 fluids touch the hydrogel 9 . Resistance to infection7. expander 9 9 . No adverse effect on the adjacent bone7 Presence of Filling port No filling port Periodic filling moments . Hydroxyapatite is extremely biocompatible in bone and in 9 9 No periodic filling moment soft tissue, and it does not initiate any foreign body needed for expansion 7 Expansion speed can be reaction in the host . handled at the filling Expansion speed cannot be influenced by the moments by the surgeon 9 surgeon 4 9 Hydrogel Expander as its manual inflation More gradual expansion provided it is 9 Before hydrogel expander, conventional expander were used Expansion peaks 9 which was introduced by NEUMAN in 1957, the expander body Enveloped End volume can be 9 is covered with a silicone elastomer and an injection port was 9 End volume pre-defined attached to the body for serial injection, though the convention handled by the filling Leakageof the expander exhibited some positive results, it was always expander can 9 accompanied with some discomfort to the patients like increase Leakage of the expander impossible damage in frequency of hospital visit, expander perforation and cost of 4 the treatment4. Classification of Expanders

The above mentioned disadvantage of conventional expander Standard Expanders4 lead to the rise of novel self-inflating expander by WEISE in The expanding volume ranges from, 50cc to 1000cc these the year 1993, which was made up of copolymer of expanders are manufactured in predetermined shapes which methylmetacrylate and n-vinyl-pyrrol this polymeric 4 4 include the shapes like , component, made the expander insoluble in aqueous solution . It is named as “hydrogel” as it has good affinity towards water 1. Cylindrical4. and gels with it and the name is not related to any chemical 4 formulation. It is made up of cross linked hydrogel co polymers 2. Rectangular . of methylmethacrylate and n-vinyl pyrroli, which makes it 3. Crescent4. hydrophilic, before implantation and the expander is referred as 39499 | P a g e International Journal of Recent Scientific Research Vol. 11, Issue, 08 (B), pp. 39498-39503, August, 2020

4. Cupola4.

Cupola and cylindrical shape tissue expander are used for soft tissue expansion in dentistry, while circle and rectangular are used in breast and scar reconstruction procedures4.

Cupola Expander: Used for completely edentulous region4.

Cylindrical Expander: Used when one or two teeth missing in a quadrant, edentulous arch and front region of the jaw4.

Custom Built Tissue Expander4 Fig 1 Layers of skin As the name indicates it is made with specific measurements of the defect for an individual patient usually indicated in patients When the therapeutic tissue expander is placed in the defect with congenital abnormalities, trauma, alopecia, burns and area the changes observed are more similar to the normal vascular deformities4. physiological expansion as evident during pregnancy. After the expander is being placed, a thick fibrous capsule is found on the Differential Expander4 outer surfaces of tissue expanders within a short span of days. The fiber capsule become more thick within 2 to 2.5 months of The differential expander is mainly used for esthetic reasons, expansion and it is composed of elongated fibroblasts and a few where the expander is used for expansion of one area of the myofibroblasts. The newly formed fibroblasts are made up of body compared to other area of the body. The main advantage very active rough endoplasmic reticulum with prominent of the expander is that the thickness and the elasticity of the cisternae, and many of these cells have numerous vesicles filled expander can be adjusted and it is indicated in plastic with electron-dense material14. like ear, breast and nose reconstruction surgeries4. Indications of tissue expander 4 Anatomical Expander

Anatomical expanders are mainly used in the field of breast In medicine reconstructions to produce a mimicking breast shape and  Reconstruction of Traumatic scar in aesthetic region of proportions. After the expansion of the skin, envelope is 10 expanded to desired size, the expander is replaced by the face .  Reconstruction in head and neck area defects10. implant. It is indicated for cases like hypoplasia and tissue 10 4  procedure after mastectomy . defects, scar revision and reconstruction of breast.  Burns10.

 Congenital anophthalmos10. Commerical Names of Tissue Expander4  Immunotherapy and vaccination10  Cardiac application10 4 Osmed Self Inflating Tissue Expander  healing applications10

6  Mentor tissue expander4 In Dentistry

4  Cui brand tissue expander  Bone regeneration procedures6.

10 Physiology of Tissue Expasion  Onlay grafting procedure6.

 Augmentation of resorbed edentulous ridges6. Tissue expansion was initially performed by orthopedic 6 surgeons in the year 1900s. Tissue expansion is a combination  In craniofacial clefts correction procedures of Creep and Biological stretch. In “Creep”, when a constant  Correction of Alveolar ridge deficiencies6. force is applied to stretch the skin, it continues to extend. In 6 “Biological stretch”, the skin or any other tissue enlarges,  For placement of dental Implant . whenever a force is applied. In tissue expansion, the tissue is Contraindications6 stretched without affecting the quality of the original tissue. Basically the skin consist of 3 layers namely:  Systemic disease6.

6 The epidermis  Psychological problems . The dermis  Active infections6. 6 The subcutaneous layer  Clinically persistent malignancy

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When And Why A Tissue Expander In Periodontics?2 swelling is caused by absorption of water and diffusion across the hydrogel4 Tissue expander is mainly advised for reconstructive surgical procedures, which are used to restore or improve defective, Use of Soft Tissue Expander for Alveolar Ridge damaged or missing structures. During an implant surgery, when Augmentation12 there is no sufficient bone present to place an implant, bone The tissue expander for alveolar ridge augmentation is usually augmentation procedure is advised, but one main disadvantage available in arch shape and in two designs one with the external in bone augmentation procedure is, difficult to provide a port and another without the port17.The inflatable tissue tension free tissue closure which leads to dehiscence. But for expander is not suitable to maxilla when compared to mandible predictable bone regeneration primary wound closure is a must because of the inelastic property of the palatal mucosa. So when in those type of cases, tissue expansion with tissue expander tissue expander is placed in the palatal mucosa it leads to the along with bone augmentation procedure can be an option rolling of the mucogingival junction, usually submucosal which can be considered in the treatment planning1. vestibuloplasty is done for maxillary ridge augmentation which Surgical Guidelines for Placement of an Expander11 is mainly indicated for edentulous maxillary arch.12

Patient selection11 Proper patient selection and treatment plan Surgical Technique in Maxilla13 should be made before the placement of a tissue expander, After administration of local anesthesia, Z –plasty incision is patient should be psychologically stable for tissue expander made, this aids in the surgical access, then a dissection is made, application, to which the results are highly appreciated. the depth of the dissection should be superior to the outward Selecting the right and suitable shape of the expander5: The curvature of the maxilla, the zygoma buttress and inferior to the defect to be corrected should be completely evaluated before the dissection site to the mucogingival junction. All these incision surgery, like its exact dimension, location, presence of any and dissection leads to submucosal tunnel formation, after the important nerves or glands adjacent to the defect area.12 completion of the submucosal tunnel preparation. The muscle Depending upon the defect site, anatomical boundaries, the and the connective tissue overlying the periosteum is removed, shape of the expander is selected. sutures are given, then a customized interim surgical splint is prepared, and placed over the sutured area, where it is left for Implantation of the Expander5 first 48 hours, later it is removed and irrigated, the splint should be worn nearly for 8 to 10 weeks until the prosthesis is fabricated.

Fig 2 Implantation of tissue expander

Under local anesthetic solution a small incision is made from the defect site, the depth of the incision should be of 3mm wide, a tunnel preparation is made to insert the expander in the defect area (where the incision is made from attached gingival margin 4 Fig 3 Surgical technique in maxilla to the distal to the level of the bone . In order to form a passage on the lateral part of the defect site a smaller incision is usually Surgical Technique in Mandible advised so that it reduces the risk of failure and dehiscence. So A 8mm bilateral vertical cuspid incision given buccal to the after the initial incision and tunnel being prepared without residual keratinized mucosa or a single transverse incision can elevation of the periodontium the expander is placed inside the be given in the labial sulcus, by a sub periosteal dissection, the pouch with a bone fixation screw to further provide a good mucoperiosteium of the mandible is elevated from left 3rd stability to the expander ,wound is then sutured using rd 4 molar to the right 3 molar, transversely from the mylohyoid monofilament suture . 17 ridge to the buccal aspects of labiolingual sulcus . Expansion of the Expander4

Depending upon the defect, the tissue expander is selected, different shapes of tissue expander have different initial volume of swelling, so the duration being primarily dependent on the expander usually take total of 40 to 60 days to inflate, the Placement of the Expander inflation of the expander is by kinetic action, where the 39501 | P a g e International Journal of Recent Scientific Research Vol. 11, Issue, 08 (B), pp. 39498-39503, August, 2020

damage4. d. Low risk of infection4. e. Short surgical time4. f. Reduced post-operative complications4.

Disadvantages of Tissue Expander

1. Frequent visit to the hospital10. 2. Possibilities of infections like tissue necrosis in case of overexpansion10 3. In case of quick expansion it leads to hypoxia10

DISCUSSION

Tissue expander was introduced into the field of medicine in

the year 1982 by AUSTAD and ROSE, which was made up of Fig 4 Surgical technique in mandible silicon, in which sodium chloride is used to inflate the expander

The expander should be carefully placed in the center and in but due to certain disadvantages like tissue perfusion and buccolingual direction on the residual portion of the jaw, and hypoxia of the area exposed to expander and risk of rupture, the expander is carefully sutured in the retromolar pad region certain modifications are made by K.G WEISE in the year with the resorbable suture, so that it helps the expander to stay 1993. He introduced a hydrogel expander, to overcome the in position19 In case of expander with port, the expander is drawbacks of silicon expander. This hydrogel expander cautiously placed in center across the midline in buccolingual provides a greater advantage compared to silicon expander. The direction on the residual bone of the jaw and sutured. A small main advantage of hydrogel is its hydrophilic property which cause gradual expansion of the expander.4 vertical incision is made in the midline so that the port can be placed outside. Later expander is removed after 40 to 60 days, In the flied of medicine it used mainly for breast augmentation the saline is aspirated through the port, after the removal of the after masectomy, for renewing scar, alopecia, to correct soft tissue expander. A wide fibrous tissue is formed around the any facial deformities thus STE is boon in the flied of cosmetic expander above the residual ridge, the fibrous ring should not surgery26 be removed as it helps in development of blood supply and formation of new periosteum, then the hydroxyl crystals are In periodontics soft tissue expander is used in procedures like injected and sutured with a resorbable sutures. A resilient lining expansion of alveolar ridge, before bone augmentation procedure and implants dentistry so that it can provide a of temporary prosthesis is placed in the ridge after 3 weeks, 2. 14 tension free flap closure and avoid dehiscence after removal of soft tissue expander .

Placement of soft tissue expander for dental implants15 D. Lew et al (1986)17 reviewed 10 patients with a posterior sub periosteal filling port for past 2 years as traditional The need for dental implant arises, when there is loss of tooth, method of expander caused damage to the inferior alveolar the most common reason for the loss of tooth is either nerve. He concluded that the use of subperiosteal soft tissue periodontal or endodontical problem, loss of tooth usually leads expander with bilateral incision eliminated the dehiscence to esthetically unappealing to the patient, the average bone loss and minimize the trauma to the inferior alveolar nerve. after tooth extraction ranges to a minimum of 1.5–2 mm (vertical) and 40%–50% (horizontal) which take place after a Dogankaner et al (2011)18 conducted a study, to evaluate span of 6months of extraction or tooth loss. the combined effect of STE and vertical ridge augmentation Use of soft tissue expander in dental implant9 procedure in 12 patients at 24 sites which were implanted with STE. The result states that there was high vertical bone gain and good primary wound healing.

Christian mertens et al (2013)19 conducted a study which evaluated the use of soft tissue expander, prior to bone augmentation of atrophied alveolar ridge in 8 patients, where 11 intra oral implants were placed. The result of this study stated that only 2 patient had perforation. And they concluded that the use of STE before bone augmentation reduces the risk of soft tissue dehiscence and its overallcomplication.

Fig 5 Decision tree – implant placement 20 Cvon ce et al (2013) conducted a case study, where a 24 Advantages of Tissue Expander year old patient, who underwent a mandibular 1st molar extraction followed by a mandibular osteoectomy. So prior 4 a. Allows complete wound closure . to bone augmentation procedure, under local anesthesia a b. The recipient site resembles same texture color and soft tissue expander was placed in defect area, after 21 days 4 consistency that of adjacent tissue . when the expander reached it maximum expanding capacity, c. Short and sharp incision which leads to minimal tissue the expander was removed, a retromolar autogenuous bone 39502 | P a g e Lakshana S et al., Tissue Expander in Periodontics was grafted and placed in the defect site. He also concluded 9. Uijlenbroek HJ, Liu Y, Wismeijer D. Soft tissue that, soft tissue under constant tension leads to formation of expansion: principles and inferred intraoral hydrogel new cells and also in helps in tension free closure of the tissue expanders. Dent Oral Craniofac Res. 2015 Dec wound. 6;1:178-85. Manohar laxmanoro et al (2014)21 reviewed , the use of 2 10. Agrawal K, Agrawal S. Tissue regeneration during distinct expander that is inflatable silicon balloon over or tissue expansion and choosing an expander. Indian self-inflating osmotic tissue expander before vertical ridge journal of : official publication of the augmentation, and he concluded that, STE is highly Association of Plastic Surgeons of India. 2012 advantageous as the gain of more tissue is more and it aids Jan;45(1):7. in easy augmentation of ridge when compared to inflatable 11. Wagh MS, Dixit V. Tissue expansion: Concepts, silicon balloon. techniques and unfavourable results.Indian journal of plastic surgery: official publication of the Association CONCLUSION of Plastic Surgeons of India. 2013 May;46(2):333. 12. Quayle Alan A. PhD FDS RCS LDS; McCord, J Tissue expansion is the future of dentistry, since it helps the Frazer BDS, DDS, FDS, DRD,: current status status patient to come out with adequate tissue coverage and good in alveolar ridge agumentation RCS Implant esthetics in defect area, with minimal hospital visit and Dentistry: October 1992. discomfort. Wide knowledge about tissue regeneration is 13. Wessberg GA, Schendel SA, Epker BN. Modified necessary for intra oral clinical application of tissue maxillary submucosal vestibuloplasty. International expander. A good surgeon can achieve increased surface area journal of oral surgery. 1980 Feb 1;9(1):74-8. of the tissue by mechanical creep and biological stretch, 14. Lew D, Hinkle RM, Collins SF. Use of subperiosteal which are used for resurfacing the defect. It improves the implants with distal filling ports in the correction of quality and quantity of soft tissue and facilitates primary the atrophic alveolar ridge. International journal of wound closure & reduces the incidence of wound oral and maxillofacial surgery. 1991 Feb 1;20(1):15- dehiscence and exposure of bone grafts5. 7. The only thing should be kept in surgeon mind is proper 15. Sheikh Z, Sima C, Glogauer M. Bone replacement placement and control of degree of inflation of the expander, materials and techniques used for achieving vertical there is also study going on the use of “smart hydrogel”, alveolar bone augmentation. Materials. this smart hydrogel is used in drug delivery, tissue 2015;8(6):2953-93. engineering and possess a very good biocompatible 16. Bellini E, Pesce M, Santi P, Raposio E. Two-Stage property22.Thus tissue expander is going to play an Tissue-Expander Breast Reconstruction: A Focus on important role in future dentistry. the Surgical Technique. BioMed research international. 2017. References 17. Lew D, Clark R, Shahbazian T. Use of a soft tissue

1. Newman MG, Takei H, Klokkevold PR, Carranza FA. expander in alveolar ridge augmentation: a preliminary Carranza's clinical periodontology. Elsevier health report. Journal of Oral and Maxillofacial Surgery. 1986 sciences; 2011 Feb 14. Jul 1;44(7):516-9. 18. Kaner D, Friedmann A. Soft tissue expansion with 2. Asa'ad F, Rasperini G, Pagni G, Rios HF, Giannì AB. self‐filling osmotic tissue expanders before vertical ridge Pre-augmentation soft tissue expansion: an overview. augmentation: a proof of principle study. Journal of Clinical Oral Implants Research. 2016 clinical periodontology. 2011 Jan;38(1):95-101. May;27(5):505-22. 19. Mertens C, Thiele O, Engel M, Seeberger R, Hoffmann J, 3. Austad ED, inventor; Austad Eric D, assignee. Self- Freier K. The use of self‐ inflating soft tissue expanders inflating tissueexpander. United States patent US prior to bone augmentation of atrophied alveolar ridges. 5,005,591. 1991 Apr 9. Clinical implant dentistry and related research. 2015 4. Nurhyana,hannan Binti,Izham akam.Tissue expander a Feb;17(1):44-51. Review ISSN2320- 540,volume4,issue 6 (2016) 20. Sakkas A, Ioannis K, Winter K, Schramm A, Wilde F. 5. Uijlenbroek HJ, Liu Y, Wismeijer D. Soft tissue Clinical results of autologous bone augmentation expansion: principles and inferred intraoral hydrogel harvested from the mandibular ramus prior to implant tissue expanders. Dent Oral Craniofac Res. 2015 Dec placement. An analysis of 104 cases. GMS 6;1:178-85. Interdisciplinary plastic and reconstructive surgery 6. Harini G, Kaarthikeyan G. Periodontal soft tissue DGPW. 2016;5. expanders-a review. IOSR J. Dent.Med. Sci. 21. Dhadse PV, Yeltiwar RK, Bhongade ML, Pendor SD. 2014;13(1):31-5. Soft tissue expansion before vertical ridge 7. Frame JW. Hydroxyapatite as a biomaterial for augmentation: Inflatable silicone balloons or self- alveolar ridgeaugmentation.International journal of filling osmotic tissue expanders?. Journal of Indian oral and maxillofacial surgery. 1987 Dec Society of Periodontology. 2014 Jul;18(4):433. 1;16(6):642-55. 22. Ashish garg:History and applications of hydrogel 8. Swan MC, Bucknall DG, Goodacre TE, Czernuszka hydrogel classification properties and technical JT. Synthesis and properties of a novel anisotropic features Department of Pharmaceutical Science, Guru self-inflating hydrogel tissue expander. Acta Ramdas Khalsa Institute of Science and Technology biomaterialia. 2011 Mar 1;7(3):1126-32. 2011 June. 39503 | P a g e