Int. J. Oral Maxillofac. Surg.

2011; 40: 57–64

doi:10.1016/j.ijom.2010.03.030, available online at http://www.sciencedirect.com

Clinical Paper
Pre-Implant Surgery

Alveolar split osteotomy for R. González-Garcı́a1,2, F. Monje1,2,

C. Moreno1,2
1
Department of Oral and Maxillofacial

the treatment of the severe Surgery, University Hospital Infanta Cristina,

Badajoz, Spain; 2CICOM, Centro de
Implantologı́a y Cirugı́a Oral y Maxilofacial,
Badajoz, Spain

narrow ridge maxillary atrophy:

a modified technique
R. González-Garcı́a, F. Monje, C. Moreno: Alveolar split osteotomy for the treatment
of the severe narrow ridge maxillary atrophy: a modified technique. Int. J. Oral
Maxillofac. Surg. 2011; 40: 57–64. # 2010 International Association of Oral and
Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. Alveolar bone splitting and immediate implant placement have been
proposed for patients with severe atrophy of the maxilla in the horizontal dimension.
A new modification of the classical alveolar bone splitting for the treatment of the
narrow ridge in the maxilla is provided. Thirty-three dental implants in eight
consecutive patients were evaluated retrospectively following the described
modified split-crest osteotomy. Inclusion criteria were: inadequate maxillary
buccolingual dimension, 3–4 mm of crestal width, and sufficient height from
alveolar ridge tip to maxillary sinus floor. Primary stability was calculated using
resonance frequency analysis (RFA). Alveolar bone height was measured in the
panorex pre- and postoperatively. Histological bone examination was assessed
following trephine bone harvesting during the second operation. Mean follow-up
was 28.33 months. Bone regeneration of the inter-cortical gap occurred in 98% of
implant sites (implant survival rate 100%). Mean implant stability quotient (ISQ)
Key words: alveolar split osteotomy; narrow
for the whole series of implants was 69.48. At the second operation, mean loss of the
ridge; maxillary atrophy; endosseous dental
alveolar bone height was 0.542 mm. Predictable results are obtained using the implants.
modified split-crest osteotomy. This technique provides an acceptable inter-cortical
gap, decreases the risk of necrosis of the outer cortex, and provides a firm-wall box Accepted for publication 16 March 2010
for the placement of particulate bone grafting. Available online 21 August 2010

Horizontal and vertical atrophy of the traction osteogenesis is mandatory pre- vector, bone resorption, absence of bone
alveolar ridge are usually present in severe vious to the placement of endosseous formation and prolonged time for implant
edentulism, corresponding to classes IV to implants. Specific disadvantages have placement, in alveolar distraction.
VI according to CAWOOD & HOWELL3. In been reported for each technique, such Alveolar bone splitting and immediate
these cases, vertical and horizontal aug- as: resorption, limited amount of bone, implant placement have been proposed for
mentation of the alveolar ridge is manda- damage to the adjacent teeth and sensory patients with severe atrophy of the maxilla
tory to allow adequate implant insertion. nerve disruption, in bone grafting; tissue in the horizontal dimension. OSBORN10
In the severely atrophied maxilla, alveolar dehiscence, membrane displacement and described the ‘extension plasty’, a two-
ridge augmentation by means of bone membrane collapse, in guided bone regen- staged method for splitting and extending
grafting, guided bone regeneration or dis- eration; and inadequacy of the distraction the alveolar crest and filling the expanded

0901-5027/01057 + 08 $36.00/0 # 2010 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
58 González-Garcı́a et al.

space with hydroxyapatite or autogenous the complex bone/implant. The frequency ventional two-step procedure, and a sec-
bone, while insertion of the implant was of the resonance (in Hz) in a transducer is ond stage surgical procedure to place the
performed 8–12 weeks later. NENTWIG & established by means of the implant sta- abutments was performed following the
KNIHA9 reported the bone splitting techni- bility quotient (ISQ), and typically ranges healing process 4 months later. Patients
que in 1986, as a one-staged method that between 45 and 85. Although the use of were selected using the following inclu-
allowed extension of the alveolar crest and RFA was primarily introduced to help in sion criteria: inadequate maxillary bucco-
insertion of the implant at the same time. the decision of when to use implants with lingual dimension, 3–4 mm of crestal
These classical approaches for the split- the immediate load technique, its use in width; and sufficient height from the tip
ting technique were generalized with the other scenarios makes it possible to eval- of the alveolar ridge to the floor of the
use of osteotomes. Since then, several uate the primary stability of implants maxillary sinus, to allow immediate
modifications have been reported for the placed on atrophic crests undergoing pre- implant placement without the need for
classical technique, such as the use of vious augmentation procedures. an associated sinus lift procedure. Panora-
ultrasonic surgery2 or the staged ridge The authors describe a modification of mic radiography and dental CT scans were
splitting technique6. CHIAPASCO et al.5 the classical alveolar bone splitting tech- used to assess the preoperative conditions.
cited the technique of sagittal osteotomy nique for the treatment of the narrow ridge Implant stability was measured using the
of the anterior maxilla with preservation in the maxilla, bearing in mind the degree RFA with the OstellTM Mentor (Integra-
of the buccal cortex periosteum and vas- of implant primary stability measured by tions Diagnostics AB, Savedalen, Swe-
cularization with a half-thickness flap, RFA. den) in ISQ units. The pre- and
stating that this technique results in a postoperative alveolar height measure-
better outcome than other techniques. ments were made in relation to implant
Otherwise, it is thought that implant Patients and methods sites. Height of the maxillary bone was
primary stability plays a major role in 33 dental implants in 8 consecutive measured from the head of the implant
successful osseointegration. It depends patients (mean age 53 years; range 38– (postoperatively) or from the tip of the
on the quality and quantity of the bone, 69 years) with severe atrophy of the alveo- alveolar ridge at implant site (preopera-
the implant geometry and the technique lar maxillary ridge were evaluated in this tively) to the cortical bone corresponding
for preparation of the implant site12. retrospective study (Fig. 1). The study was to the floor of the maxillary sinus or the
Volume and quality of bone are important carried out at the Centro de Implantologı́a nasal cavity. The loss or increase of alveo-
factors in determining the surgical process y Cirugı́a Oral y Maxilofacial CICOM, lar height was expressed as the difference
and the type of implant to be used, and are Badajoz, Spain. The study was approved between pre- and post-operative heights.
related to the success of implant surgery. by the Ethical Committee. All the patients Adequate bone formation was assessed
The technique of resonance frequency underwent a modified split-crest technique by histological examination of specimens
analysis (RFA) measures the stability of with immediate implant insertion. Implant obtained with a trephine drill during the
the implant as a function of the rigidity of placement was conducted through a con- second operation. The biopsy was taken
[(Fig._1)TD$IG] with a 2.0 mm diameter trephine intro-
duced within the grafted bone in the vici-
nity of the implant. Special care was taken
not to disturb the architecture of the bone
around the implant. Specimens were
washed and immediately fixed in 10%
formalin following biopsy. Conventional
histological examination with haematox-
ylin–eosin was performed once the bone
was completely decalcified with a freshly
prepared aqueous solution of CH2O 4%
and HCl 10%. A physical method (needle
prick) was used to confirm adequate dec-
alcification of the specimen, taking care to
use it away from the site of interest to
avoid artifacts. The specimens were rinsed
to wash away the acid. The sections were
processed and embedded in paraffin
blocks.
All patients were clinically followed
for at least 24 months postoperatively
(Fig. 2), although mean postoperative
follow-up for the whole series was
28.33 months. Panorex radiography was
performed for each patient to assess post-
operative alveolar bone height in the site
of implant placement. Panorex radiogra-
phy obtained at month 24 was compared
with that for preoperative evaluation in
terms of alveolar bone height at the
Fig. 1. Cone-beam CT showing severe horizontal resorption of the atrophic maxilla. implant site.
[(Fig._2)TD$IG] Alveolar split osteotomy for severe narrow ridge maxillary atrophy 59

a bone scraper and the allogenic bovine

particulated bone graft Laddec1 (Trans-
phyto, France). A re-absorbable mem-
brane Gore Resolute1 (W.L. Gore &
Associates, Inc, Newark, Delaware,
USA) was used to cover the graft. Finally,
the mucoperiosteal flap was repositioned
and fixed with a 4/0 Gore-tex1 suture (W.
L. Gore & Associates, Inc, Newark, Dela-
ware, USA) (Figs 3D and 7C). The degree
of ossification in the inter-cortical gap
was assessed by histological analysis of
bone biopsies adjacent to implants
obtained during the second operation
(Fig. 8).

Results
The postoperative period was uneventful.
The mean follow-up for the whole series
was 28.33 months. Thirty-three endoss-
eous implants were placed following the
modified split-crest osteotomy. Twenty
implants were placed in the anterior max-
illa (intersinus), and 11 in the posterior
maxilla. The implant diameters were:
3.3 mm (9%); 3.75 mm (31%); and
4 mm (60%). Bone regeneration of the
inter-cortical gap occurred in 98% of the
implant sites, with an implant survival
rate of 100%. Mean ISQ for the whole
series was 69.48. At the end of the fol-
low-up period, mean loss of the alveolar
Fig. 2. Patient no. 1. (A) Preoperative clinical view. (B) Postoperative clinical view. (C) bone height was 0.542 mm. Twenty-two
Panoramic radiography showing the placement of implants in the upper maxilla for prosthetic implants underwent bone resorption ran-
rehabilitation following the modified alveolar split osteotomy. ging from 0.1 mm to 2.8 mm, while nine
implants underwent increases of alveolar
bone height from 0.1 mm to 1.1 mm
Surgical technique order to create a green-stick fracture and (Table 1). Two other cases did not experi-
avoid a complete fracture of the buccal enced any change in alveolar bone height
A buccal mucoperiosteal flap was ele- plate. The other osteotomies required dee- pre- and postoperatively. Neither dehis-
vated following mid-crestal and intracre- per cuts, and a diamond disc (Fig. 3A) or cence of the suture nor wound infection
vicular incisions. No palatal flap was a reciprocating saw was used. was observed in any of the patients. No
harvested in order to maintain adequate A green-stick fracture of the cephalad total fracture of the buccal plate was
irrigation of the alveolar ridge. First, a horizontal corticotomy was performed observed, probably due to the careful
mid-crestal osteotomy with a reciprocat- carefully with the introduction of a thin insertion of the osteotomes within the
ing saw or a diamond disc was performed chisel (Fig. 4). Following this manoeuvre, bone cut followed by the green-stick
into the alveolar ridge (Fig. 3A). This progressive introduction of thin osteo- fracture of the horizontal cephalad
osteotomy was extended as far as the tomes between buccal and palatal cortical osteotomy. For eventual cases with total
narrow alveolar crest was present. Two plates was performed in order to obtain fracture of the buccal bone segment, the
vertical cuts were then performed on the the desired widening of the inter-cortical authors believe that careful fixation of the
proximal and distal ends of the mid-cres- gap (Figs 3B,4 and 5). The sequential buccal cortex to the underlying palatal
tal osteotomy (Fig. 4). The cephalad ends introduction of the osteotomes from a bone cortex with two bicortical micro-
of the vertical cuts were connected with a minor to a major diameter allowed safer screws may be enough to stabilize the
horizontal corticotomy by means of a and more controlled splitting. Following bone segment, while allowing the preser-
piezosurgical device (Fig. 5). Vertical splitting of the outer cortex, implants vation of a neo-gap that should be filled
osteotomies were deepened 3 mm were placed in the cancellous bone with- with autogenous or allogenic bone graft.
through the cortical bone, with preserva- out saline irrigation (Figs 6 and 7A). The histological specimens showed a
tion of intact cancellous bone. The Primary implant stabilization was mixture of autogenous bone graft and
authors only used the piezosurgical assessed with the ISQ values. Subsequent allogenic bovine particulated bone graft,
device to make the corticotomy that con- filling of the gap with particulated bone together with de novo formation of
nected both vertical osteotomies. This graft was carried out (Figs 3C and 7B). It mature bone connecting previous isolated
was because a careful cut to cortical bone was composed of a mixture of autogenous bone islands between the allogenic mate-
was selectively required at this point, in bone graft obtained from the vicinity with rial (Fig.8).
[(Fig._3)TD$IG]
60 González-Garcı́a et al.

gap following the split osteotomy, as

proved with alveolar palatal cleft grafting,
sinus floor augmentation and interposi-
tional bone grafts in the maxilla. Cor-
tico-cancellous block grafts as ‘onlay’
grafts are used to augment areas where
an important horizontal decrease of the
alveolar process is present. Using the tech-
nique described, the use of barrier mem-
branes to contain the particulated graft is
unnecessary. SIMION et al.14 and SCIPIONI
et al.11 first described the split-crest tech-
nique. The obvious advantage of this tech-
nique is the absence of donor site
morbidity associated to autologous bone
harvesting. This condition is usually
observed when harvesting bone from the
hip, maxillary tuberosity, chin or mandib-
ular ramus for onlay grafting. Another
advantage is the possibility of immediate
implant insertion without the need for a
second surgical procedure. This is espe-
cially true with lateral augmentation graft-
ing, in which a healing phase before
implant placement is usually required.
The degree of lateral onlay bone graft
resorption varies between 20% and 50% in
the reported series6,8. The authors have not
observed any degree of bone resorption
following the modified split-crest techni-
que. This condition is extremely important
when severe limitation of the alveolar
width is present. Several authors have
reported an implant 5-year cumulative
success rate between 86% and 99% for
maxillary interpositional augmenta-
tion7,13. The main limitation of the present
study was the relatively short follow-up
period in comparison with other previous
studies2,14. No implant failure was
observed for more than 24 months for
the whole series, and maintained adequate
bone expansion was assessed by means of
postoperative CT scans during the 28.33-
month mean follow-up period. These
results are probably not extendable to
the mandible, since attempts to use inter-
positional augmentation in this bone have
shown less predictable results15. Care
must be taken in extrapolating these data
to the mandible, since they have been
exclusively obtained from the maxilla.
Fig. 3. Patient no. 2. Split osteotomy on the anterior maxillary bone. (A) Use of a diamond disc Despite the need for a buccal subper-
to perform a longitudinal mid-crestal osteotomy. (B) Use of an osteotome to expand the outer iosteal flap elevation, the authors did not
cortex. (C) Placement of two implants and particulated demineralized bovine bone graft. (D)
observe any alteration to the general bone
Placement of allogenic membrane over the particulated bone graft.
perfusion. This may be attributable to the
preservation of a complete intact palatal
Discussion and difficulty with the harvesting proce- periostium and the design of the green-
dure, selected cases with maxilla Class IV stick fracture of the basal horizontal cor-
In relation to the atrophic maxilla, most may benefit from the modified split osteot- ticotomy. The development of a green-
authors recommend some type of bone omy for the immediate insertion of stick osteotomy avoids the presence of a
augmentation procedure for anterior and endosseous implants4. full free cortical bone block, which is more
posterior Class IV and V cases. Owing to Predictable results are obtained using prone to show any perfusion problem. The
potential complications at the donor site particulated cancellous bone within the authors strongly recommend the use of a
[(Fig._4)TD$IG] Alveolar split osteotomy for severe narrow ridge maxillary atrophy 61

series of consecutive thin osteotomes

between the buccal and palatal cortical
plates, in order to avoid undesired lines
of fracture.
The assessment of alveolar height by
panorex pre- and postoperatively at month
24 led to the conclusion that a mean loss of
0.542 mm was present for the whole series
at the second stage surgical procedure,
following insertion of implants. Although
almost one-third of the implants under-
went a process of alveolar height increase
of 0.6 mm (range: 0.1–1.1 mm) at the
second stage surgical procedure, the other
Fig. 4. Patient no. 4. Right upper maxilla. Use of a chisel and progressive osteotomes for two-thirds underwent resorption of the
gradual expansion of the outer cortex in maxillary bone. Note both vertical osteotomies alveolar bone height of 1.06 mm (range:
performed with a reciprocating saw or a diamond disc in a previous step. 0.1–2.8 mm). These results show that
[(Fig._5)TD$IG] despite the aggressive approach to the
alveolar bone, the cortical bone is ade-
quately perfused following vertical osteo-
tomies and horizontal corticotomies. The
mainstay of width preservation together
with a very slight loss of alveolar bone
height makes this technique predictable,
although controlled studies with dental CT
scans or cone-beam CT pre- and post-
operatively may be necessary to further
assess these observations, more specifi-
cally in terms of alveolar width dimen-
sions.
In relation to the osteotomy design,
ENISLIDIS et al.8 have described a staged
ridge splitting technique that may alleviate
the poor success rate of the splitting tech-
nique. It consists of dividing the surgery in
two steps: the first to mark the corticotomy
sites via the buccal flap without mobiliz-
ing the bone segment; the second to com-
plete the osteotomies apically leaving the
periosteum attached to the buccal surface
of the bone segment, and generating a
green-stick fracture. This technique
reduces overall treatment time in compar-
ison with onlay grafting procedures and
Fig. 5. Patient no. 4. Left upper maxilla. The cephalad ends of the vertical cuts were connected
avoids the need for a donor site. The
with a horizontal corticotomy (white arrow) by means of a piezosurgical device.
technique requires a longer treatment per-
[(Fig._6)TD$IG] iod in relation to the above single-step
technique. The presence of a better vas-
cularized bone makes the modified split-
crest technique a predictable method for
the maxilla. For these cases, the authors
believe that the staged ridge splitting tech-
nique is unnecessary.
Some authors1 have analysed the out-
come of implants placed in a gap gener-
ated between a completely separated
osteotomized bony window and the inner
mandibular cortex. The inter-cortical
space was filled with platelet rich plasma
(PRP) and b-tricalcium phosphate (b-
TCP) allograft, and the separated bony
fragment was stabilized with bicortical
Fig. 6. Patient no. 5. Longitudinal mid-crestal osteotomy involving the entire upper maxilla. bone screws, which allowed a tight adap-
Immediate implant placement. tation for adequate pressure on the
[(Fig._7)TD$IG]
62 González-Garcı́a et al. [(Fig._8)TD$IG]

Fig. 7. Patient no. 7. (A) Gap following osteotomy and

expansion of the maxillary outer cortex. (B) Filling the gap
with particulated demineralized bovine bone graft. (C) Place-
ment of a membrane covering the reconstructed narrow
alveolar ridge.
Fig. 8. Histological examination (haematoxylin–eosin) of the specimen. (A)
Mixture of autogenous bone graft (arrows) and allogenic bovine particulated
bone graft (asterisks) (20). (B) Note the new bone formation as a bridge
(arrows) between the interpositioned material (asterisks) (40). (asterisk, new
bone). (C) De novo formation of mature bone (arrow) connecting previous
isolated bone islands between the allogenic material (20) (asterisks).

implants and the grafted material. By By means of the green-stick fracture consider that the split-crest technique
means of the split-crest technique predict- no additional fixation procedures such as creates a self-space-making structure.
able results in terms of bone regeneration bicortical screws were necessary for ade- This seems to be important for the reten-
of the osteotomy lines and implant overall quate implant stabilization. This was also tion of the heterologous bone graft. In
survival were obtained. Other authors2 demonstrated by the high ISQ values for relation to the so-called ‘guided bone
have reported expanding edentulous the primary implant stabilization in the regeneration’, the use of barrier mem-
ridges without filling bone gaps, and authors’ series. The absence of any fixa- branes has been reported to cover
described the inter-cortical bony gap as tion hardware also reduces the incidence implants following a split-crest techni-
an extraction site that should be left at rest of suture dehiscence or wound infection que11. PRP and membranes were used for
without bone grafting. In the present and may lead to a better outcome in terms selected cases in order to stabilize the
study, the use of a mixture of autogenous of implant survival. In the authors’ opi- particulated bone graft and to avoid the
bone graft and allogenic bovine particu- nion, the green-stick fracture provides a internalization of soft tissue fibers from
lated bone graft showed predictable results firm self-space-making structure that the vicinity. The PRP seems to be espe-
in terms of generation of new bone within may be able to keep the bone graft fol- cially effective as a carrier for the parti-
the inter-cortical space. lowing the osteotomy. Other authors also culated bone graft.
 Alveolar split osteotomy for severe narrow ridge maxillary atrophy 63

Table 1. Surgical data. ISQ, implant stability quotient. AH, alveolar bone height.
Implant Implant Implant
Patient position width length ISQ Preop AH Postop AH AH difference
1. 1 22 4 mm 10 mm 67 10.4 mm 11.2 mm 0.8 mm
2. 1 24 4 mm 10 mm 68 11.2 mm 12.0 mm 0.8 mm
3. 2 12 4 mm 8.5 mm 70 7.7 mm 7.8 mm 0.1 mm
4. 2 14 4 mm 8.5 mm 75 6.5 mm 5.6 mm 0.9 mm
5. 2 22 4 mm 8.5 mm 69 7.7 mm 7.8 mm 0.1 mm
6. 2 24 4 mm 8.5 mm 57 6.5 mm 6.4 mm 0.1 mm
7. 3 15 4 mm 10 mm – 25.0 mm 23.5 mm 1.5 mm
8. 3 16 4 mm 10 mm – 22.1 mm 21.4 mm 0.7 mm
9. 4 12 3.3 mm 13 mm 83 15.7 mm 13.7 mm 2.0 mm
10. 4 13 3.75 mm 13 mm 78 16.4 mm 15.7 mm 0.7 mm
11. 4 21 3.75 mm 13 mm 73 17.1 mm 15.7 mm 1.4 mm
12. 4 26 4 mm 10 mm 85 9.5 mm 9.5 mm 0.0 mm
13. 4 15 3.75 mm 13 mm 77 26.7 mm 26.0 mm 0.7 mm
14. 4 16 4 mm 8.5 mm 68 21.2 mm 18.4 mm 2.8 mm
15. 5 11 4 mm 13 mm 72 19.5 mm 18.7 mm 0.8 mm
16. 5 13 4 mm 13 mm 65 18.7 mm 17.3 mm 1.4 mm
17. 5 14 4 mm 13 mm 70 15.8 mm 14.4 mm 1.4 mm
18. 5 16 4 mm 13 mm 75 10.1 mm 10.8 mm 0.7 mm
19. 5 21 4 mm 13 mm 78 18.7 mm 18.1 mm 0.6 mm
20. 5 23 4 mm 13 mm 66 19.5 mm 18.1 mm 1.4 mm
21. 5 25 4 mm 13 mm 77 15.1 mm 14.4 mm 0.7 mm
22. 5 27 4 mm 11.5 mm 49 10.1 mm 10.1 mm 0.0 mm
23. 6 12 4 mm 8.5 mm 76 11.0 mm 9.8 mm 1.2 mm
24. 6 14 4 mm 8.5 mm 79 6.1 mm 7.2 mm 1.1 mm
25. 6 22 4 mm 8.5 mm 77 11.6 mm 12.4 mm 0.8 mm
26. 6 24 3.3 mm 13 mm 83 11.0 mm 11.7 mm 0.7 mm
27. 7 13 4 mm 13 mm 81 17.3 mm 15.9 mm 1.4 mm
28. 7 14 4 mm 13 mm 77 18.0 mm 15.9 mm 2.1 mm
29. 7 16 4 mm 13 mm 80 15.1 mm 14.4 mm 0.7 mm
30. 8 14 4 mm 10 mm 82 8.2 mm 8.0 mm 0.2 mm
31. 8 16 4 mm 11.5 mm 77 10.4 mm 10.0 mm 0.4 mm
32. 8 24 3.3 mm 13 mm 77 8.8 mm 8.6 mm 0.2 mm
33. 8 25 3.75 mm 11.5 mm 82 7.0 mm 7.3 mm 0.3 mm
Pre- and postoperative ISQ values in relation to implant width and length. Pre- and postoperative alveolar height measurements in relation to
implant sites. Height in maxillary bone was measured from the head of the implant (postoperatively) or from the tip of the alveolar ridge at the
implant site to the cortical bone corresponding to the floor of the maxillary sinus or the nasal cavity. Loss or augmentation of alveolar height was
expressed as the difference between pre- and post-operative heights.

The modified split-crest osteotomy for Ethical approval onlay grafts, and sagital osteotomy of the
the maxillary narrow alveolar ridge pro- anterior maxilla: preliminary surgical and
Not required. prosthetic results. Int J Oral Maxillofac
vides predictable results in relation to
primary stability and implant surveillance. Implants 1998: 13: 394–399.
6. Cordaro L, Amade DS, Cordaro M.
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