DOI: 10.7860/JCDR/2016/21286.

8452
Original Article

The Effect of Ridge Expansion on

Dentistry Section
Implant Stability in Narrow Partially
Edentulous Ridges - A Preliminary
Clinical Study

LATHEEF SAHEB SHAIK1, SRIDHAR MEKA2, VIVEKANAND SABANNA KATTIMANI3, SRINIVAS PANDI CHAKRAVARTHI4,
NAGA NEELIMA DEVI KOLLI5, KRISHNA PRASAD LINGAMANENI6, SUSMITA AVVARU7, RAHUL TIWARI8

ABSTRACT was performed using osteotomes and simultaneous implant

Introduction: Currently, dental treatments with better aesthetic placement was done. A total of 10 implants were placed.
results and less treatment time is more acceptable by the Stability, achieved ridge width and radiographic crestal bone
patients. Inadequate amount of bone for implant placement loss were assessed three months post-operatively.
at functionally and aesthetically most appropriate position is a Results: Three months follow-up revealed stable implants both
common problem. clinically and radiographically. All 10 implants were surrounded
Aim: To assess the effect of ridge expansion on implant stability by adequate amount of bone required for successful functional
in narrow partially edentulous ridges and to evaluate clinically rehabilitation.
and radiographically the success of dental implants, placed Conclusion: The study reveals that the technique of ridge
immediately following ridge expansion procedure. expansion using osteotomes is successful in horizontal
Material and Methods: Ten participants (nine males, one female, expansion, in cases of atrophic alveolar ridges thus, eliminating
average age - 28 years) with partial edentulism associated with the need for more complex treatment as well as reduces the
narrow atrophic alveolar ridges with adequate height and willing rehabilitation time along with improving the quality of bone
to participate in the study were included. The ridge expansion support.

Keywords: Atrophic ridge, Osteotome, Prosthesis, Rehabilitation, Technique

Introduction Various surgical widening techniques have been employed and

Ageing is a biological phenomenon resulting from changes at described for restoration of atrophic ridges, including block
cellular level to the changes at gross morphological level in grafting, lateral augmentation with or without Guided Bone
all aspects. Gradually, with ageing related, health problems Regeneration (GBR), onlay grafting and alveolar distraction
concomitantly accompany and further deteriorate the condition. osteogenesis [2]. These procedures are carried out before or after
These may include oral diseases which finally may lead to tooth implant placement to establish at least 1mm bony wall around
loss. Loss of teeth may require some form of aesthetics making screw type implants [2]. Although different techniques exist for
functional prosthetic treatment necessary for the patient. atrophic ridges, there are chances of need for multiple surgeries
Histological and morphological changes of the bony socket which carries surgical risk and postoperative morbidity. Expansion
and adjacent soft tissue may undergo a series of tissue repair of the existing residual ridge is another method and is referred as
processes after tooth loss. According to histological evidence Ridge Expansion Osteotomy (REO) [2].
active bone formation taking place at the bottom of the socket REO procedure was described by Summers [2]. The ridge
and bone resorption at the edge of the socket are observed
expansion technique is used to expand the edentulous ridge
around two weeks after tooth extraction; however, the complete
for implant placement [3]. Because of the problems of drilling in
fill of the socket with newly formed bone takes around six months
the maxilla for osteotomy, a technique is developed to place the
time. During this time rapid bone remodeling drops; however,
implant without removing the bone using an osteotome. It is called
continuous bone resorption may continue at the outer surface
the osteotome technique. This technique is to maintain, if possible,
of the crestal area of the residual alveolar bone. This results in
significant morphologic changes in the bone and its overlying soft all of the existing bone by pushing the bone aside with minimal
tissues over the years [1]. trauma while developing an accurately shaped osteotomy site.
The osteotome technique retains all of the bone and relocates the
Now-a-days, dental treatments with better aesthetic results and less
bone by taking the advantage of the softer bone quality.
treatment time are more acceptable by the patient. The prosthetic
treatment modalities like removable or fixed partial dentures have Conventional technique of implant placement includes drilling
risk of various complications including sacrifice of healthy tooth of the bone which always takes bone away from the site. Often
substance. Dental implants have overcome disadvantages of other there is a marginal quantity of bone to start with. During the drilling
procedures and emerged as an ideal replacement modality for process, there is no practical means to immediately improve
missing teeth. Inadequate amount of bone for implant placement adjacent bone quality. In addition, drilling creates heat, which is
at functionally and aesthetically most appropriate position is a the main obstacle for osseous integration. To overcome all these
common problem. Placement of endosseous implants in atrophic obstacles, osteotome technique is in practice which essentially
ridges is often accompanied by various challenges [1,2]. doesn’t produce any heat [2,3].
28 V. 1 Journal of Clinical and Diagnostic Research. 2016 Sep, Vol-10(9): ZC28-ZC33
www.jcdr.net Latheef Saheb Shaik et al., Osteotomy Ridge Expansion for Implant

So, the aim of this study was to evaluate ridge-width gained for an average adult of 70kg, one day prior to implant placement
after ridge expansion procedure, effect of ridge expansion on and were maintained on it for the next five days), Tab. Aceclofenac
primary and secondary stability after implant placement by Radio 100mg with Paracetamol 500mg (thrice a day) was given to the
Frequency Analysis (RFA) test and to evaluate radiographic crestal patients an hour before implant placement and continued for next
bone loss using digital Intraoral Periapical Radiograph (IOPAR). five days along with Amoxicillin. The baseline clinical examination
consisted of a thorough medical and dental history, general and
MATERIALS AND METHODS oral health status, assessment of future implant site. The available
A preliminary prospective clinical study was conducted on patients vertical, mesio-distal and labio-lingual bone dimension was
who reported during year 2014-2015 to the Department of Oral and determined by measurements from CBCT and ridge mapping was
Maxillofacial Surgery, Sibar Institute of Dental Sciences, Guntur, used to assess labio-lingual ridge width using the ridge mapping
Andhra Pradesh, India. A total of 10 patients with inadequate calliper. Local anesthesia was administered (Lignocaine HCL + 2%
alveolar width and having sufficient alveolar height were included in Adrenaline 1:80000) following which an incision was made buccal
the study. Sample size was determined based on a previous study to the ridge crest to provide more attached tissue along the facial
[4]. Performance of the 10 implants placed in these 10 patients in aspect of the implant. During ridge expansion the micro-fracture of
the anterior maxilla was evaluated clinically and radiographically cortical plate possibility cannot be overlooked, as the cancellous
over a span of three months. bone will be compressed to both the buccal and palatal walls.
Ethical clearance was obtained from the Institutional Ethics The buccal cortical plate is considered to be more vulnerable for
Committee before the commencement of the study. The subjects expansion forces as it is not having adequate bone support like
for the study were selected on the basis of scientifically pre- palatal side, so it is better to have a good amount of soft tissue
defined inclusion and exclusion criteria. Patients who presented which makes the difference post operatively by providing adequate
with partial edentulous space in anterior maxilla, having a ridge coverage. Also, in undue cases of fracture it acts as pedicle for the
width of 2.0mm to 5.0mm, measured preoperatively, using Cone buccal cortical plate. Minimal mucoperiosteal flap reflection was
Beam Computed Tomography (CBCT, between 18 to 60 years performed to expose only the ridge crest. If necessary, the peak of
of age, co-operative, hygiene conscious, motivated and willing to the thin ridge was slightly reduced with a ronguer or osteoplasty
participate and gave written informed consent and those having bur. The mid-crestal osteotomy of the atrophied ridge was done
adequate vertical height (measured from crest of the ridge to the using round tungsten carbide bur. The ridge expansion began over
nasal floor using CBCT, having more than 12mm vertical height) the prepared initial osteotomy site such that it bisected the ridge
were included in the study. Patients with severely atrophic ridges, crest and expanded the cortical plates [Table/Fig-2-6].
those with co-existing vertical defect requiring additional corrective The handle of the osteotome was kept parallel to the palatal or
intervention, heavy tobacco users, uncontrolled diabetics, immuno- lingual cortex and advanced through the bone using a mallet. This
compromised patients and those who were poorly motivated and path resulted in a more facial angulation of the handle than the
unable to keep the follow-up were excluded from the study. ideal long axis of the teeth. After the osteotome was tapped to
Global Implants (two piece implants, endosseous, thread type) of depth, it was gently removed with a back and forth motion, parallel
pure titanium; length range 8mm to 16mm with diameter 3.8mm to the cut, to prevent alveolar bone fracture. The length of the
and 5mm were used for the present study. Ridge Expansion osteotomy was extended beyond the planned implant sites along
Osteotomes Kit and Mallet (Sirag Surgical Enterprises, Chennai, the edentulous area so as to allow the cortical plates to expand
India) [Table/Fig-1] was used for the expansion procedure. All during osteotomy preparation and implant insertion. Progressively,
surgical procedures were performed under strict aseptic conditions wider osteotomes were utilized to smoothly expand the atrophic
and following standard protocols. The patients were initiated on a maxillary ridge.
daily dose of antibiotic (Amoxicillin 20-25mg/kg/day i.e., 1.5gm/day

[Table/Fig-1]: Showing armamentarium. [Table/Fig-2]: Edentulous ridge. [Table/Fig-3]: Exposure of knife edge ridge.

[Table/Fig-4]: Ridge width measurement before expansion using bone calliper. [Table/Fig-5]: Osteotome in place for expansion. [Table/Fig-6]: Ridge width measurement
after expansion.

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 Latheef Saheb Shaik et al., Osteotomy Ridge Expansion for Implant www.jcdr.net

[Table/Fig-7]: Measurement of primary implant stability. [Table/Fig-8]: Placement of healing cap. [Table/Fig-9]: Measurement of secondary implant stability.

[Table/Fig-10]: Final prosthesis. [Table/Fig-11]: Pre operative CBCT showing ridge width. [Table/Fig-12]: Post operative ridge width showing ridge width.

After sufficient expansion (which should be larger than the size The results were scientifically recorded, data collected, collated,
of the implant; as a thumb rule the implant should have minimum entered and analyzed using paired t-test.
1.5mm of surrounding bone, so required implant size plays an
important role in the ridge expansion) of the ridge was achieved, RESULTS
the endosteal implants were introduced into the prepared site The implant stability gradually increased over the study period on
and evaluated for primary stability using the resonance frequency all the aspects. [Table/Fig-13] shows the data of patient, stability
analyzer and torque wrench, a minimum Implant Stability Quotient in ISQ and ridge expansion pre, postoperative measurements.
(ISQ) of 50 was considered to include in the study implants with Pre-operative ridge width mean was 3.94 ± 0.33 and after ridge
torque more than 25 Ncm. The reflected mucoperiosteal flaps expansion ridge width was 7.39 ± 0.66. The difference of mean
were sutured using black braided silk suture material. The patient value was 3.45 which was highly significant (p-value <0.001)
was advised Chlorhexidine (0.12%) mouth rinse twice daily for [Table/Fig-13]. [Table/Fig-14] reveals crestal bone loss at different
two weeks post-operatively. Suture removal was done seven days time intervals during the study. In comparison of crestal bone loss
post-operatively. on the mesial and distal aspect in a time period of three weeks and
The patients were followed-up at the 7th post-operative day, 3rd three months after implant placement, mesial bone loss after three
week and 3rd month. The patients were evaluated for implant weeks was 0.26 and after three months it was 0.50 which was
stability and crestal bone loss at 3rd week and 3rd month post- significant (p-value=0.033). Also, on the distal aspect crestal bone
operatively using CBCT [Table/Fig-7-12]. Functional rehabilitation loss after three weeks was 0.34 and after three months mean it
of the implants were done after three months post-operatively. was 0.58 which was significant (p-value=0.008) [Table/Fig-14].

Implant stability (ISQ) values on different aspects Ridge width

Age
Patient Sex Labial Labial Palatal Palatal Mesial Mesial Distal Distal Occlusal Occlusal
(years) Pre-op Post-op
Pre-op Post-op Pre-op Post-op Pre-op Post-op Pre-op Post-op Preop Post-op
1 26 M 70.00 79.00 72.00 80.00 73.00 78.00 72.00 80.00 73.00 81.00 4.00 7.90
2 23 M 68.00 80.00 72.00 79.00 65.00 70.00 60.00 75.00 70.00 79.00 4.40 7.80
3 23 M 71.00 80.00 70.00 81.00 70.00 81.00 68.00 79.00 72.00 75.00 3.90 8.00
4 20 F 70.00 72.00 63.00 74.00 65.00 76.00 64.00 71.00 66.00 70.00 3.50 6.70
5 23 M 65.00 71.00 68.00 71.00 69.00 73.00 70.00 70.00 67.00 70.00 3.30 6.00
6 19 M 71.00 78.00 72.00 78.00 76.00 76.00 75.00 74.00 76.00 76.00 4.20 7.80
7 25 M 71.00 78.00 72.00 76.00 74.00 80.00 76.00 72.00 69.00 80.00 4.00 7.00
8 25 M 72.00 76.00 72.00 78.00 69.00 78.00 70.00 79.00 76.00 78.00 4.10 7.20
9 38 M 68.00 79.00 71.00 78.00 76.00 81.00 78.00 78.00 71.00 81.00 4.20 8.00
10 24 M 71.00 72.00 68.00 76.00 76.00 78.00 72.00 78.00 76.00 76.00 3.80 7.50
MEAN 24.60 69.70 76.50 70.00 77.10 71.30 77.10 70.50 75.60 71.60 76.60 3.94 7.39
SD 1.641 0.667 1.118 0.93 0.93 1.36 1.11 1.73 1.16 1.16 1.28 0.105 0.209
RANGE 19-38 65-72 71-80 63-72 71-81 65-76 70-81 60-78 70-80 66-76 70-81 3.30-4.40 6-8
p-value <0.001 (HS) <0.001 (HS) <0.001 (HS) <0.001 (HS) <0.001 (HS) <0.001 (HS)

[Table/Fig-13]: Showing data of patient, stability in ISQ (Implant stability quotient) and ridge expansion pre, post-op measurements.

30 Journal of Clinical and Diagnostic Research. 2016 Sep, Vol-10(9): ZC28-ZC33

www.jcdr.net Latheef Saheb Shaik et al., Osteotomy Ridge Expansion for Implant

Bone loss on Mesial side Bone loss on Distal side is mandatory. Various techniques have been mentioned in the
Patient published literature for reconstruction of the atrophic ridges so as
At 3 Weeks At 3 Months At 3 Weeks At 3 Months
to increase the existing bone volume like bone grafting, guided
1 0.0 0.5 0.0 0.5
bone regeneration and distraction osteogenesis, however, these
2 0.4 0.5 0.6 0.7 techniques suffer from limitations like being invasive and increase
3 0.3 0.5 0.5 0.7 morbidity, moreover resorption of grafting materials, membrane
4 0.5 0.6 0.5 0.7 collapse, exposure to infection and delaying of implant installation
5 0.5 1.5 0.8 1.5 for grafting maturation are few other constraints associated with
these techniques [1,2].
6 0.0 0.2 0.0 0.3
7 0.0 0.0 0.0 0.0
Ridge expansion of the remaining residual ridge is an additional
method to prepare the atrophic ridges for implant placement.
8 0.0 0.0 0.0 0.0
This approach has been referred to as ridge expansion, ridge
9 0.4 0.5 0.5 0.6
splitting, bone spreading and was developed by Tatum in 1986
10 0.5 0.7 0.5 0.8 [12], but was then reintroduced in 1990 by Bruschi and Scipioni
MEAN 0.26 0.50 0.34 0.58 [13]. The method involves the splitting of the vestibular and buccal
SD 0.073 0.134 0.096 1.137 cortical plates [2,3] and further expanding the gap with Summers’s
Range 0-0.5 0.0-1.50 0.0-0.8 0.0-1.5
osteotomes [2,3]. A minimum of 3mm of bone width, including at
least 1mm of cancellous bone is required to place an osteotome
p-value 0.033 (S) 0.008 (S)
between cortical plates and accordingly expand the cortical bony
[Table/Fig-14]: Showing crestal bone loss at the mesial and distal aspects at
different time intervals.
plates.
Summers, Scipioni et al., Hahn J [2,3,13,14] and many others
got successful results following this technique for narrow ridges.
DISCUSSION They showed ridge expansion technique having advantages of
Dental implants have now become an integral part of various simultaneous implant placement, lesser overall cost, no need
treatment modalities. Availability of adequate amount of bone of barrier membranes or bone graft materials and no morbidity
in terms of vertical as well as horizontal dimension is the first related to second site. So in the present study, ridge expansion
requirement for a successful implant therapy, but it becomes was carried out using the osteotome technique owing to its
difficult to place the implant when there is inadequate amount of advantages documented in literature.
bone [5].
In the present study effect of ridge expansion of narrow partially
Morphological and histological changes in the alveolar process are edentulous ridges on ridge width, implant stability and crestal bone
teeth-dependent processes that develops in conjunction with the loss was evaluated. The first parameter assessed was the gain
eruption of the teeth. Previous clinical and cephalometric studies in the ridge width which was measured using the ridge mapping
have revealed atrophy and dimensional reduction of the alveolar caliper. The use of ridge mapping caliper to assess bone levels for
ridges in both the horizontal and vertical axis after all teeth are implant placement in anterior maxilla, avoids some of the problems
removed [6,7]. The greatest reduction occurs in the first 6-12 associated with CT scanning [15,16].
months [7]. Bone loss occurs in the anterior mandible and the
In present study ridge expansion using osteotomes resulted in
maxilla mainly at the labial side.
significant gain in ridge width after three post operative months
Many of recent investigations have inspected the resorption pattern (3.94 ± 0.33 pre-operatively to 7.39 ± 0.66 post-operatively)
and evaluated the changes that occur in the alveolar processes (p-value <0.001) [Table/Fig-13]. Similar to the present study,
following tooth extractions by various means including study cast Roni Kolerman, et al., conducted a study on long-term outcome
measurements, subtraction radiography and direct measurements of ridge expansion using the osteotome procedure followed by
of the ridge at surgical re-entry [8-10]. It was reported that in the implant placement in combination with guided bone regeneration
first three months after tooth extraction around two thirds of bone in patients with atrophic maxillary alveolar ridges and reported
loss occurs, signifying that maximum alteration in dimension significant increase in the ridge width over the study period (pre-
of alveolar ridge takes place within the first three months post op ridge width values increased significantly from 3.73±0.67 to
extraction and the reported corresponding vertical bone loss is 7.19 ± 0.80) [4].
around 0.9mm to 3.25mm. [8-10].
Demarosi F et al., conducted a study on localized maxillary ridge
Loss of alveolar bone may also occur prior to tooth extraction expansion with simultaneous implant placement in adult patients
because of advanced periodontal disease, periapical pathology, with atrophy of the upper maxilla, 26 ridge expansion surgeries
or trauma to teeth and bone or during tooth extraction procedure, were carried out and 36 implants were placed. The ridge width
periodontal health of the neighboring teeth and periodontal increased from an initial range of 2.5mm-4.5mm to 6mm-7.5mm
biotype (shape and thickness of soft tissue) the width of the labial at the end of the procedure [17]. That is the gain in alveolar ridge
cortical plate may also result in bone loss and affect the resorption width ranged from 3mm to 5 mm. Measuring primary stability and
process [11]. Osteoporosis, renal disease and endocrine disorders secondary stability was the second parameter assessed in this
are some of the systemic conditions that may speed up bone loss study. Stability of the implant was measured in ISQ using RFA
by varying normal bone physiology and metabolism [6] Moreover, device. Primary stability of an implant comes from mechanical
habits, including smoking and bruxism have been considered as engagement with cortical bone. It is affected by the quantity and
contributing factors in increased bone loss. All the above stated quality of bone that the implant is inserted into, surgical procedure,
reasons may result in resorption over a wide area of labial surface length, diameter, and form of the implant [18]. Secondary stability
leading to marked narrowing of the labio-lingual diameter of the is a biological phenomenon, that is the result of healing that takes
crest of the ridge, thus, forming a knife edge ridge, which is place around the implant, (osseointegration) [18].
particularly problematic for implant placement owing to insufficient
There is no consensus regarding which method to use when
ridge width. Alveolar bone width should be sufficient to provide
measuring implant stability. One commonly used, non-invasive
a minimum 1mm bone width around the implant [2]. When the
method is resonance frequency analysis, which evaluates the
alveolar ridge is narrower than the optimally planned implant
stiffness of the bone-implant complex. The result is given as implant
diameter, reconstruction of the ridge before implant placement
stability quotient, ISQ [Table/Fig-13]. A dip in ISQ is usually seen
Journal of Clinical and Diagnostic Research. 2016 Sep, Vol-10(9): ZC28-ZC33 31
 Latheef Saheb Shaik et al., Osteotomy Ridge Expansion for Implant www.jcdr.net

during the early healing phase after osseointegration and is related the removal of osteotome is inadvertent or more buccal, then the
to the shift between primary and secondary stability. The results chances of buccal cortical plate fracture are increased. In our two
of the present study revealed that the implant stability increased of the cases wrong direction while pulling the osteotome lead to the
gradually over the study period and the results were statistically fracture in which the placement of implant was considered in the
significant over 3 months [Table/Fig-13]. later stage. Only single patient complained about the pain during
Padmanabhan TV et al., conducted a study to evaluate the the procedure due to inadequate local anesthesia given to patient.
crestal bone loss and effect on primary stability exhibited by the Also, one patient complained about redness and pain at implant
bone around early non-functionally loaded implants placed with site after one month due to gingival inflammation. Three patients
conventional implant placement technique and with Summer’s were not able to come in time for follow-up. These patient data
osteotome technique and demonstrated a significantly higher were not considered for the statistical analysis because they were
stability of implants in the conventional group than in osteotome lost to follow-up. To overcome all these problems further studies
group on the day of surgery [19]. However, after six months of with larger sample size and comparative control groups must be
implant placement, no statistically significant difference in stability carried out with an extended follow up period to substantiate the
was found between both groups (p = 0.076). A significantly less results of the present preliminary study.
crestal bone loss was reported with conventional group. Thus,
the authors concluded that this technique can be utilized for knife Limitation
edge ridges and should not be substituted for the conventional The study sample size was smaller. The duration of follow-up is
procedure for implant placement. Kreissel P, in a similar study less. The single operator did all procedures. The study warrants
assessing the implant stability in expanded ridges, reported that long term follow-up with multi center and multi-operators. The
bony micro-architecture had no consequence on implant stability, fracture of buccal plate is one of the limitation. It requires training to
initial bone density, presence of a cortical layer. They also reported handle the osteotome. The study warrants long term multi-center
that the application of the screw-shaped spreaders significantly blind studies. The case selection is critical factor for the success of
increased ISQ values over the study period [20]. implant . The inadvertent force during removal of osteotome may
lead to fracture of buccal cortical plate.
Mesial and distal crestal bone loss in a time period of three weeks
and three months after implant placement was the 3rd parameter
assessed in present study for which Digital IOPAR and DIGORA CONCLUSION
was utilized similar to Padmanabhan TV et al., [19]. Kolerman R Horizontal expansion in atrophic alveolar ridge without any complex
et al., conducted a similar study to evaluate the outcome of a treatment can be performed using Ridge expansion technique.
ridge expansion osteotome procedure and implant placement This technique is helpful and patient friendly as it decreases the
combined with guided bone regeneration in patients with narrow rehabilitation time and improves quality of overall bone support
maxillary alveolar ridges and reported that over a mean follow- with adequate implant stability achieved at three months post
up period of 52.4 months the survival rate of 116 implants was operative period.
found to be 100% with statistically significant gain in ridge width
of 3.5 ± 0.93 (p < 0.0001) and significant enlargement of the buccal Acknowledgements
bone was about 1.91 ± 0.6 (p < 0.0001) [4]. The vertical mesial Authors acknowledge authorities of Dr.NTR University of health
and distal bone loss reported ranged from 0.3mm to 4.2 mm, sciences, Vijayawada, Andhra Pradesh, India and Faculty
and 0.4mm to 4.5 mm respectively. Padmanabhan TV et al., department of oral and maxillofacial surgery and Department of
conducted a study on crestal bone loss in implant placement done Prosthodontics, Crown and Bridge for their help in completing the
by using osteotome technique and reported a mean bone loss study protocol.
of 1.19 after placement of 10 implants in the maxillary anterior
region of five patients [19]. Comparison of marginal bone loss References
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PARTICULARS OF CONTRIBUTORS:
1. Postgraduate student, Department of Oral and Maxillofacial Surgery, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India.
2. Professor, Department of Oral and Maxillofacial Surgery, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India.
3. Reader, Department of Oral and Maxillofacial Surgery, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India.
4. Professor, Department of Oral and Maxillofacial Surgery, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India.
5. Professor, Department of Oral and Maxillofacial Surgery, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India.
6. Professor, Department of Oral and Maxillofacial Surgery, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India.
7. Post graduate student, Department of Oral and Maxillofacial Surgery, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India.
8. Post graduate student, Department of Oral and Maxillofacial Surgery, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Vivekanand Sabanna Kattimani,
Reader, Department of Oral and Maxillofacial Surgery, Sibar Institute of Dental Sciences, Guntur-522509, Andhra Pradesh, India. Date of Submission: May 12, 2016
E-mail: [email protected] Date of Peer Review: Jul 19, 2016
Date of Acceptance: Jul 31, 2016
Financial OR OTHER COMPETING INTERESTS: None. Date of Publishing: Sep 01, 2016

Journal of Clinical and Diagnostic Research. 2016 Sep, Vol-10(9): ZC28-ZC33 33