Int. J. Oral Maxillofac. Surg.

2017; 46: 116–128

http://dx.doi.org/10.1016/j.ijom.2016.08.017, available online at http://www.sciencedirect.com

Meta-Analysis
Dental Implants

The split crest technique and J. Waechter, F. R. Leite,

G. G. Nascimento, L. C. Carmo Filho,
F. Faot

dental implants: a systematic Graduate Program in Dentistry, School of

Dentistry, Federal University of Pelotas,
Pelotas, Rio Grande do Sul, Brazil

review and meta-analysis

J. Waechter, F. R. Leite, G. G. Nascimento, L. C. Carmo Filho, F. Faot: The split
crest technique and dental implants: a systematic review and meta-analysis. Int. J.
Oral Maxillofac. Surg. 2017; 46: 116–128. # 2016 International Association of Oral
and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. This systematic review aimed to determine: (1) the expected bone volume
gain with the split crest technique, and (2) how the use of surgical instruments
affects the performance of this technique. An electronic search was performed in the
Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Embase,
PubMed/MEDLINE, Scopus, and Web of Science databases. Twenty-seven articles
met the selection criteria and were subjected to meta-analysis of bone gain and
survival rate; 17 reported the use of conventional surgical instruments and nine the
use of surgical ultrasound. A total of 4115 implants were installed in 1732 patients
(average patient age 52 years). The overall implant survival rate was 97%. The
average bone gain in studies that used conventional surgical instruments was
3.61 mm, while this was 3.69 mm in those that used ultrasound. Only two studies
presented a low risk of bias. The greatest problems identified during the qualitative
analysis were related to random selection of the population and the absence of
Key words: split crest; piezoelectric surgery;
statistical analysis. The split crest technique appears to be a promising and effective
ridge expansions; edentulous ridge expansion;
technique to gain bone width, regardless of the surgical instruments used. dental implants.
Considering the diversity of the studies and implant types, no definitive
recommendations can be made, especially with regard to the best instruments and Accepted for publication 25 August 2016
implant design to be used. Available online 14 September 2016

Oral rehabilitation in areas where bone more severe. These factors might result in ridge bone volume include the use of
width is insufficient is a complex issue.1 insufficient vertical and horizontal support onlay grafts harvested from the iliac crest,
Insufficient bone width is common for to install dental implants and may impair, maxillary tuberosity, mandibular symphy-
edentulous patients, especially when alve- or even limit, the options for prosthetic sis, or external oblique line. However,
olar fracturing occurs during dental ex- rehabilitation. In such cases, bone volume these procedures demand a second surgi-
traction. When the bone loss results from a improvement has to be considered an ef- cal site, which results in additional post-
maxillofacial trauma, vertical dental root fective alternative treatment.2 operative morbidity. Also, the receptor
fracture, or from extensive periodontal/ Techniques that have been used suc- site often needs a healing time of 6–12
endodontic diseases, the effects are even cessfully for the reconstruction of alveolar months before implant placement, and the

0901-5027/010116 + 013 # 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
 The split crest technique and dental implants 117

risk of non-osseous integration of autoge- implant placement, taking into account and (2) discussing the influence of meth-
nous bone blocks is high.3 Guided bone the flap type (partial-thickness flap or odological aspects on the gain in bone
regeneration (GBR) and osteogenic dis- full-thickness flap).11 In addition, findings thickness. The latter was done specifically
traction are also adopted to improve the related to the role of the grafting material by investigating factors such as the type of
bone volume and enable fixed prosthetic and/or membrane, intraoperative and post- surgical instrument used to separate the
rehabilitation. These two techniques also operative biological complications, and alveolar ridge. It was hypothesized that
present potential disadvantages, such as the implant survival rate were also de- the use of surgical US instruments would
tissue dehiscence, displacement or col- scribed. Complementary to these, Gar- be beneficial in terms of bone thickness
lapse of the membrane, inappropriate dis- cez-Filho et al. briefly presented an gain and maintaining the peri-implant bone
traction vector, unpredictable bone overview of the main clinical studies eval- tissue compared to conventional instru-
resorption, and a delay prior to installation uating the SCT technique published from ments, because of the lower risk of surgical
of the implants. 1992 to 2007.12 These authors strongly trauma.
In 1986, Nentwig reported a bone crest believe that the SCT concept has raised
division technique that simultaneously great interest in recent years, especially
allowed the expansion of the alveolar crest due to the reduction in morbidity (no bone Materials and methods
and implant insertion.4 The surgical pro- harvesting from a second surgical site, no This systematic review followed the proto-
cedure divides the cortical bone crests, risk of membrane exposure, and low risk col for systematic reviews and meta-anal-
moving them to create an opening in the of graft loss).12 yses outlined in the PRISMA statement.
centre, which is then mainly occupied by The present systematic review further Two independent researchers (FF and JW)
simultaneously inserted implants. The examines the impact of the SCT on the conducted an electronic search in the fol-
remaining areas can be filled with bioma- bone volume obtained after separation of lowing databases: Cochrane Central Reg-
terials, autologous grafts, or autologous the cortical crests, and includes studies with ister of Controlled Trials (CENTRAL),
biological therapies such as plasma rich implant installation simultaneous and pos- ClinicalTrials.gov, Embase, PubMed/
in growth factors.5 The main benefit of the terior to the crest split. This review expands MEDLINE, Scopus, and Web of Science.
split crest technique (SCT) is the simple, on the previous systematic reviews by (1) The following medical subject heading
quick, and predictable way in which the providing the most extensive quantitative (MeSH) terms indexed by MEDLINE were
alveolar atrophic crest can be expanded. assessment of bone volume gain to date, used: ‘‘split crest’’ OR ‘‘split-crest’’ OR
This permits the use of bone grafts without
the need for a second surgical site, thereby
Records identified through Records identified
Identification

minimizing the risk of oedema, nerve

injury, and pain.6 database searching through hand searching
Several adaptations and modifications (n = 309) (n = 3)
of the SCT have been reported. Among
these is the adoption of rotary and oscil-
latory instruments and, more recently,
surgical ultrasound (US). The latter
allows precise, clean, and smooth cutting
of the bone tissue, with excellent visibili- Records after filtering duplicates
ty. It is also believed that the use of US (n=222)
Screening

could minimize the risk of complete frac-

ture of the crests, which ultimately results
in bone necrosis and implant loss.7 Com-
plete fracturing of the cortical crest is
more likely along the edges where the Records screened Records excluded
remaining bone is highly mineralized. (n =101) (n = 121)
The SCT is recommended in cases where
the height of the alveolar ridge is accept-
able, but its width is insufficient. Con-
versely, SCT should be contraindicated
Eligibility

in those with atrophic ridges that lack

Full-text articles Articles excluded
elasticity due to a reduced volume of
assessed with reasons
medullary bone tissue.8,9
(n = 27) (n = 74)
So far, two systematic reviews have
investigated this technique for surgical
division of the alveolar crest. Bassetti
et al. evaluated the clinical, radiographic,
and histological results of this technique in
Included

association with GBR.10 This review fo- Studies included in

cused mainly on the crest bone loss, mea-
sured on the mesial and distal surfaces of qualitative synthesis
the implant before or after loading. The (n = 27)
review by Elnayef et al. focused on esti-
mating the amount of horizontal bone gain
promoted by SCT, in conjunction with Fig. 1. Flowchart of the systematic review.
118 Waechter et al.

‘‘ridge expansions’’ OR ‘‘edentulous ridge the selected articles were read in full and Literature review articles were excluded, as
expansion’’ AND ‘‘dental implants’’. The included or excluded according to the cri- were case reports (n < 5), studies on cada-
search included articles published until teria previously determined by the two vers or animals, laboratory studies, and
October 2015. All articles were considered reviewers. Articles that did not fully de- articles that did not apply or evaluate the
for review, regardless of language or pub- scribe the inclusion criteria were retained conventional surgical division of the alve-
lication year. The identification of dupli- at this stage. In addition, the reference lists olar crest.
cate articles in the databases was performed of all manuscripts were hand-searched to The assessment of methodological qual-
using EndNote Web reference manager check for additional papers not found ity for risk of bias was applied in order to
software (Thomson Reuters, Philadelphia, through the database searches. Disagree- check the strength of the scientific evi-
PA, USA). An overview of the selection ments between the authors were resolved dence in clinical decision-making. The
procedure is shown in Fig. 1. by consensus in a joint session. The assess- classification of the polarization potential
A well-structured question in the PICO ment of the full-text articles retrieved after risk for each study was based on the criteria
format was formulated to direct the liter- the initial screening was performed inde- adopted by Clementini et al.,13 namely
ature search (P: population or problem of pendently by the same two reviewers. Pre- random sample selection, definition of in-
interest, I: intervention under investiga- defined data collection worksheets were clusion and exclusion criteria, reporting
tion, C: comparison of interest, O: out- used for the assessment of each selected and monitoring the implant loss, validated
comes considered most important to publication. measurements, and statistical analysis.
measure results). The PICO strategy for Inclusion criteria encompassed the fol- Studies that included all of these criteria
the construction of the research question lowing: accessible articles applying the were classified as having a low risk of bias,
and evidence search was structured as ‘split crest’ technique (surgical division those that did not include one of the criteria
follows: What is the expected increase of the alveolar ridge) in the maxilla, man- were classified as having a moderate risk of
in bone volume after the separation of dible, or both; study including at least five bias, and the remaining studies were
cortical bone with crests of low thickness, patients treated with the SCT; implant in- assigned a high risk of bias.
but with sufficient height for regular im- stallation simultaneous or subsequent to the The main characteristics of the studies
plant placement? Is this volume increase expansion of the alveolar crest. Outcome and populations included in the systematic
related to the surgical instruments used for variables including the success rate, surviv- review are reported in Table 1. The fol-
osteotomy? al rate, and gain and/or loss of bone lowing information was collected from
After an independent reading of all titles obtained after surgery (expressed as a per- each of the included studies: study design,
and abstracts by two authors (FF and JW), centage or in millimetres) were collected. follow-up period, city/country and sample

Fig. 2. Meta-analysis of the horizontal bone width gain for the studies that used conventional surgical instruments.
 The split crest technique and dental implants 119

Table 1. Characteristics of the studies included and their respective sample populations.
Location and country Number of Initial
Design Sample selection patients Average age Jaw thickness of
Study Follow-up period (M/F)/implants (range) (years) Region ridge (mm)
Crespi et al. 201521 Prospective Department of 36 (13/23)/93 57.1 (36–71) Max/Mnd 3.0  0.8
2 years Dentistry, San Raffaele Ant/Post (2.5–3.8)
Hospital, Italy
January 2010 to May
2011
Scarano et al. 201517 Prospective University of Chieti- 32 (9/23)/64 57 (53–68) Mnd 3.1  0.6
3 months Pescara, Italy Post (2.3–4.1)
Santagata et al. 201516 Prospective University Hospital 13 (6/7)/33 49.4 (32–68) Max 4.7 (3.5–7)
3 years (AOU), Second Ant/Post
University Naples,
Italy
January to November
2009
Tang et al. 201524 Retrospective Department of Oral 157 (92/65)/226 36.2 (17–74) Max/Mnd 2.0
3 years Implants, School of Ant/Post
Stomatology, Fourth
Military Medical
University, China
2004–2009
Garcez-Filho Retrospective Private practice, Brazil 21 (9/12)/40 55.5 (33–78) Max 3.0–5.0
et al. 201512 10 years 2000–2002 Post
Abu Tair 201425 Retrospective Oral and Maxillofacial 13/42 – Mnd 2.0–4.0
3 years Surgery Clinic, Israel Post
2007–2009
Shibuya et al. 201423 Retrospective Department of Oral and 6 (1/5)/14 58.7 (25–71) Mnd 3.4 (1.6–6.4)
2 years Maxillofacial Surgery, Ant/Post
Kobe University
Hospital, Japan
April 2004 to March
2013
Crespi et al. 201426 Prospective Department of 46 (13/33)/118 53.8 (31–73) Max/Mnd 2.0–3.5
2 years Dentistry, San Raffaele Ant/Post
Hospital, Italy
2007–2009
Bassetti et al. 201318 Prospective School of Dental 7 (2/5)/17 57.9 Max/Mnd 2.0
2 years Medicine, University Ant/Post
of Bern, Switzerland
Length: 30 months
Anitua et al. 201314 Retrospective Private practice, Spain 15 (–15)/37 53.6 (19–72) Max/Mnd 4.3 (1.8–6.2)
17 months September 2007 to Ant/Post
November 2008
Rahpeyma et al. 20138 Prospective Dental Research Centre 25 (13/12)/82 50.2 (16–78) Max/Mnd 3.0–4.0
6 months of Mashhad University Ant/Post
of Medical Science,
Iran
Anitua et al. 201219 Retrospective Private practice, Spain 6 (1/5)/9 61 (52–72) Max 4.0 apical
19 months March 2008 to June Ant/Post (1.5) and
2009 3.0 occlusal
(0.6)
Annibali et al. 201227 Retrospective University of Rome, 5/19 – Max/Mnd 4.6  1.3
1 year Italy Post (2.0–7.0)
May 2006 to January
2009
Scarano et al. 201122 Prospective University of Ferrara 22 (8/14)/44 59 (54–65) Mnd 1.5–3.0
3 months and University of Post
Chieti-Pescara, Italy
2007–2009
120 Waechter et al.

Table 1 (Continued )
Location and country Number of Initial
Design Sample selection patients Average age Jaw thickness of
Study Follow-up period (M/F)/implants (range) (years) Region ridge (mm)
González-Garcia Retrospective Centre of Implantology 8/33 53 (38–69) Max 3.0–4.0
et al. 20112 2 years and Oral and
Maxillofacial Surgery
CICOM, Spain
Demetriades Retrospective Tufts University 15 (10/5)/34 – Max/Mnd 3.0–5.0
et al. 201120 2 years School of Dental
Medicine, USA
Holtzclaw et al. 201036 Retrospective Private practice in 13 (7/6)/31 35.2 (22–43) Mnd 3.6  0.8
6 months Texas and Post
Pennsylvania, USA
2008–2009
Sohn et al. 201028 Prospective Korea 32 (5/27)/84 48 Mnd 2.0–4.0
3–4 months Post
Blus et al. 201029 Retrospective Italy 43 (20/23)/180 54.2 (26–82) Max/Mnd 3.3  0.7
3 years January 2003 to Ant/Post (1.5–5.0)
September 2004
Jensen et al. 200935 Retrospective Private practice, USA 40/81 – Max/Mnd –
1 year Duration: 2 years Ant/Post
Danza et al. 200930 Retrospective Italy 21/21 53 Max/Mnd –
1 year May 2004 to November Ant/Post
2007
Bravi et al. 200731 Retrospective Private practice, Italy 734 (233/501)/1715 48.6 (17–86) Max/Mnd –
10 years January 1992 to Ant/Post
December 2001
Blus and Prospective Italy 57 (28/29)/228 50.2 (23–82) Max/Mnd 3.2 (1.5–5.0)
Szmukler-Moncler 3 years January 2001 to May Ant/Post
200632 2004
Ferrigno and Prospective Private practice, Italy 40 (18/22)/82 47.1 (25–64) Max 3.0–5.0
Laureti 20051 2 years May 2002 to October
2003
Sethi and Kaus 200033 Prospective Centre for Implant and 150 (72/78)/449 – Max 2.0–4.0
5 years Reconstructive Ant/Post
Dentistry, England
1991–1996
Scipioni et al. 199434 Prospective Private practice, Italy 170/329 – Max –
5 years Ant
Simion et al. 199215 Prospective University of Milan, 5 (1/4)/10 53.2 (39–71) Max/Mnd 1.0–4.0
6 months Italy Ant/Post
M, male; F, female; Max, maxilla; Mnd, mandible; Ant, anterior; Post, posterior.

selection period, number of patients and SCT. The random-effects model was used (n = 10); conference abstract (n = 1); tech-
implants, average age, type of implant, in the presence of heterogeneity and the nical note (n = 3); case report or case series
region in which they were installed, and fixed-effects model was employed in all including fewer than five cases (n = 34);
the initial thickness of the alveolar ridge. other cases. Analyses were performed outcome variables not related to the study
The methodological characteristics of the using Stata 13.0 software (StataCorp, Col- (n = 5); division of the alveolar crest was
surgical techniques used are presented in lege Station, TX, USA). not performed by fracture (n = 21). Finally,
Table 2; these cover the intervention per- 27 studies published between 1992
formed, instruments used to perform the and 2015 were selected for analysis
Results
osteotomy, associated biomaterials, eval- (Tables 1 and 2).1,2,8,12,14–36 Among these
uation methods, success criteria, bone The initial electronic search retrieved 309 studies, 13 were prospective and 14 were
width and height variation (millimetres), studies. After checking for duplicated retrospective. This systematic review in-
success rate, and implant survival rate. references, 222 remained for title and ab- cluded studies that analyzed a total of
Meta-analyses were employed to esti- stract reading. Following this, 121 studies 1732 patients and 4115 implants associated
mate the survival rates of dental implants were excluded. Of the 101 papers included with SCT. Only 122 implants were lost,
and the horizontal bone width gain accord- for full-text reading, 74 were excluded for resulting in an overall survival rate of 97%.
ing to the surgical instruments used for the the following reasons: literature review The average age of patients was 52 years.
Table 2. Methodological specifications of the surgical techniques described in the selected studies.
Bone graft/
Instruments biomaterial/ Evaluation Bone expansion
Study Intervention for osteotomy membrane methods Bone loss (mm) (mm) Success rate Survival rate Observations
Crespi SPC + II + IL Chisel and – Periodontal 0.78  0.26 Initial: 3.0  0.8 – 99% 1 implant failed
et al. 201521 magnetic probe, peri-apical (2.5–3.8)
mallet radiographs Final: 6.6  1.6
(5.4–8.5)
Scarano SPC + DI Chisel Xenograft Calliper, – 5.2  0.9 (4.1– 97% 97% 2 implants had
et al. 201517 panoramic and 6.8) not
peri-apical osseointegrated
radiographs
Santagata SPC + II Chisel and Xenograft and Peri-apical – 3.5 (1.5–4.9) – 97% 1 implant lost
et al. 201516 mallet connective tissue radiographs, CT before loading
Tang SPC + II Chisel Xenograft and Clinical and G1: 2.60  0.75 – 93.2% G1 100% 11 patients with
et al. 201524 G1: without GBR resorbable collagen radiological G2: 2.37  1.72 95.6% G2 cortical fracture
G2: <4 mm with membrane criteria were omitted
GBR from the study
Garcez-Filho SPC + II Drills and Xenograft: small Calliper 1.93  0.93 – 95% 95% 2 implants failed
et al. 201512 chisel granules (0.25–
1 mm)
Abu Tair 201425 SPC (2 Drills Autologous bone CT or panoramic 2.47 3.2  1.0 (2.0– 100% 100% –
stages) + DI (3–5 radiographs 5.0)
months)
Shibuya SPC + II or CL Saw or US Autologous bone CT – Apical: 5.0 100% 100% –
et al. 201423 and biomaterial Occlusal: 2.2

The split crest technique and dental implants

Crespi SPC + II Osteotomes Collagen membrane Periodontal – Initial: 2.8  0.7 – 98% –
et al. 201426 and electrical probe (2.0–3.5) CG: 97% TG:
or hand mallet Final: 7.2  1.7 100%
(5–8)
Bassetti SPC + II US Xenograft: small Calliper,
et al. 201318 granules (0.25– periodontal
1 mm) and probe, and
resorbable collagen radiographs
membrane
SCT = 1.66  1.08 4.7  0.8 100% – –
Non-
CT = 1.35  0.75
Anitua SPC + II US Autologous bone, CT, panoramic – 3.35  0.34 100% – Implants were
et al. 201314 xenograft, and radiographs not loaded in 2
PRGF (Endoret) patients and were
removed from the
sample

121
 122
Table 2 (Continued )
Bone graft/
Instruments biomaterial/ Evaluation Bone expansion

Waechter et al.
Study Intervention for osteotomy membrane methods Bone loss (mm) (mm) Success rate Survival rate Observations
Rahpeyma SPC + II Drills and Beta tricalcium Radiographs – 2  0.3 100% – Cortical fracture
et al. 20138 chisel phosphate in 3 patients and
they were
omitted from the
study
Anitua SPC + II US Autologous bone, CT, panoramic – Apical: 100% – –
et al. 201219 xenograft, and radiographs 5.60  1.9
PRGF Occlusal:
7.33  1.73
Annibali SPC (2 Drills Resorbable Periodontal M = 0.49  0.44 4.45  1.19 (2– – 100% –
et al. 201227 stages) + II membrane probe, CT, and D = 0.34  0.39 6.7)
panoramic and
peri-apical
radiographs
Scarano SPC + DI (4 US Xenograft Panoramic and – 53 97.5% 97.5% 1 implant did not
et al. 201122 weeks) peri-apical reach
radiographs osseointegration
González-Garcia SPC + II Reciprocating Autologous bone, CT, panoramic 0.542 – – 100% –
et al. 20112 saw or xenograft, and radiographs, ISQ
diamond disc resorbable
membrane
Demetriades SPC + II or DI (3 Drills Xenograft CT, ISQ, hand – – 97% – 1 implant was
et al. 201120 weeks) wrench device, removed
peri-apical
radiographs
Holtzclaw SPC + DI (3–4 US Allograft, xenograft, Periodontal – 4.03  0.67 – 100% –
et al. 201036 months) and collagen probe
membrane
Sohn SPC + II or DI Piezoelectric Bone grafts and Panoramic and – – – 98.8% –
et al. 201028 (3–4 weeks) and/or laser resorbable peri-apical
device membrane radiographs
Blus SPC + II US Xenografts and Periodontal – Initial 3.3  0.7 – 97.2% 5 internal
et al. 201029 membrane of PRGF probe Final: 6.0  0.4 hexagon implants
did not integrate
at second surgery
Jensen SPC + DI Sagittal saw Bone graft Periodontal 1.1  1.4 3.4  0.4 (2.7– 95% – 4 implants failed
et al. 200935 probe 4.2)
Danza SPC + II US None CT, panoramic – – 100% – –
et al. 200930 and peri-apical
radiographs
Bravi SPC + II or DI Chisel and Collagen membrane Intraoral – – 96% – 73 implants
et al. 200731 (40 days) drills radiograph failed
Blus and SPC + II US Xenograft and Periodontal – Initial 3.2 (1.5– 96.5% 96.5% 8 implants failed
Szmukler- membrane of PRGF, probe 5.0) (94.7% Max and
Moncler if ridge <3.5 mm Final: 6.0 (4.0– 100% Mnd)
200632 9.0)
Ferrigno and SPC + II Drills Autologous bone, CT, peri-apical – Cylindrical: 5.0 Cylindrical: 95% – 2 implants were
Laureti 20051 xenograft, radiographs Conical: 3.5 Conical: 100% lost
resorbable
membrane
Sethi and Kaus SPC + II Osteotomes Autologous bone Calliper, – – – 97% 12 implants
200033 and drills and hydroxyapatite cephalometric failed;
radiographs, and 24 patients (78
CT implants) were
lost to follow-up
Scipioni SPC + II Osteotomes None – – – 98.5% – 8 implants were
et al. 199434 lost (6 fractures
in the IMZ
implants)
Simion SPC + II Chisel e-PTFE membranes Calliper, clinical – 2.6  1.3 100% – –
et al. 199215 exams,
panoramic and
peri-apical
radiographs
Edentulous
patients: CT
CG, control group; CL, conventional loading; CT, computed tomography; D, distal; DI, delayed implants; e-PTFE, expanded polytetrafluoroethylene; GBR, guided bone regeneration; II, immediate

The split crest technique and dental implants

implants; IL, immediate loading; ISQ, implant stability quotient; M, mesial; Max, maxilla; Mnd, mandible; PRGF, plasma rich in growth factors; SCT, split crest technique; SPC, split crest ridge
expansion; TG, test group; US, surgical ultrasound.

123
124 Waechter et al.

The follow-up period was heterogeneous, average bone gain of 3.69 mm (Fig. 3, excluding reciprocating saws and
ranging from 3 months to 10 years, with an 95% CI 3.32–4.05 mm).14,18,19,22,29,32,36 diamond discs, was 98% (95% CI 97–
average of 31 months. SCT was applied in Most studies opted for implant place- 99%), while it was 99% (95% CI 99–
the maxilla in seven studies,1,2,12,16,19,33,34 ment simultaneously with the SCT; 100%) for those installed using US
mandible in six,17,22,23,25,28,36 and in both implants were installed after crest division (Figs. 4 and 5). Great heterogeneity
jaws in 14.8,14,15,18,20,21,24,26,27,29–32,35 in only six studies.17,22,25,27,35,36 Biomate- in success criteria was observed, with
Studies included rehabilitated alveolar rial was used between the cortical walls in 14 different criteria adopted in the studies
ridges with diverse bone thickness, ranging 20 studies1,2,8,12,14,16–20,22–25,28,29,32,33, analyzed. The success criteria described
35,36
from 1.0 mm to 7.0 mm. In all cases, the ; however it was associated with a by Buser et al. (1997)37 and Albrektsson
alveolar crest division resulted in a bone resorbable membrane in only 14 cases. et al. (1986)38 were the most frequently
site with dimensions that allowed the an- Four studies used only resorbable mem- adopted. Fourteen different brands of
choring of dental implants. Eighteen stud- branes.15,26,27,31 Two studies did not use implants were used; eight articles did
ies reported the bone expansion in the any graft or membrane, but nonetheless not report any information on the dental
alveolar ridge thickness, with results rang- achieved a high success rate.30,34 All 15 implant brands.2,8,20,28,30,33,35,36 Only
ing between 2.0 mm and 7.33 mm in the studies recommending postoperative med- three studies did not provide any informa-
apical region for all types of surgical instru- ication reported the prescription of antibio- tion on the dental implant dimen-
ments used.1,8,14–19,21–23,25–27,29,32,35,36 tics.1,12,14–19,21,22,24–26,31,36 In addition, sions,2,8,20 and overall the diameter of
Eight studies evaluated the marginal bone non-steroidal anti-inflammatory drugs the implants used ranged from 2.5 mm
loss of implants installed simultaneously were prescribed in five of these stud- to 6.7 mm.
with the SCT, with an average bone loss of ies,12,15,17,22,31 non-opioid analgesics in Regarding the estimated risk of bias,
1.44 mm.2,12,18,21,24, 25,27,35 four,1,14,15,19 and chlorhexidine mouthwash only two studies were classified as having
A total of nine studies using convention- in eight.1,12,15,17,18,22,24,36 a low risk of bias1,26; a moderate risk was
al surgical instruments, in which 542 Among the studies reviewed, there was detected in 17 studies8,12,14,16–
19,21,22,24,27,29–33,35
implants were installed, showed an average consensus that the surgical division of the and a high risk in
bone gain of 3.61 mm (Fig. 2; 95% confi- alveolar crest in both jaws showed posi- eight.2,15,20,23,25,28,34,36 The major prob-
dence interval (CI) 2.84–4.37 mm).8,15– tive results, with success rates close to lem identified in this qualitative analysis
17,21,25–27,35
The osteotomy was performed 100%. On meta-analysis, the overall sur- was the absence of a random sample se-
using US in seven studies in which 546 vival rate of the dental implants installed lection method, followed by the absence
implants were installed, resulting in an using conventional surgical instruments, of statistical analysis (Fig. 6).

Fig. 3. Meta-analysis of the horizontal bone width gain for the studies that used surgical ultrasound.
 The split crest technique and dental implants 125

Fig. 4. Meta-analysis of the implant survival rate for the studies that used conventional surgical instruments.

Discussion after implant placement in order to estab- the maxillary bone crest is obtained with
lish a bony wall of at least 1 mm around relative ease due to bone characteristics
The rehabilitation of missing teeth can be them.14 Taking this recommendation into (types III and IV) and due to the higher
problematic in cases where bone thickness account during SCT is essential to suc- vascularization of the maxilla. Lower arch
is reduced. In such cases, the alveolar SCT cessfully predict the aesthetic result and expansion is rarely achieved, also because
might increase bone width and the possi- long-term functioning. In this review, of the bone site quality (types I and II).
bility of implant installation. However, studies included ridges with a thickness Furthermore, the presence of the external
it is difficult to predict the total thickness of between 1 mm and 7 mm for the alveo- oblique line in the posterior region of the
of bone gain after using the SCT in lar ridge division; however the amount of mandible makes the displacement and ex-
horizontally resorbed jaws, because any bone tissue achieved after the surgical pansion of the cortical crests difficult,
thickening of the alveolar ridge has been procedure was not described by bone site. unless the cortical bone is completely
considered successful. Furthermore, the In this sense, any results that described fractured. According to Scarano et al.,
interference of instruments with the clini- bone gain were considered as successful the posterior mandible is the most difficult
cal outcome is unknown, and consequent- treatment. Of note, the gain in thickness region for reconstruction and early im-
ly there are no references to support the was not always fully described and differ- plant placement, especially in cases of
selection of a specific surgical instrument ent methodologies were employed to mea- severe alveolar resorption.17 However,
for osteotomy. This review sought to ad- sure it, which has implications for Bassetti et al. showed a 100% success rate
dress these gaps by systematically analyz- reproducibility. in their study that included implants
ing the published literature. The SCT was The smallest change in bone thickness placed immediately after the SCT using
effective regardless of the surgical instru- was found in a study that included only US instruments in the anterior mandible.18
ments used. Furthermore, an average gain data from the mandible.16 In contrast, the In that study, the authors achieved an
of 3.8 mm in thickness of the alveolar study with the greatest increase in the average 4.7 mm of bone gain, in spite of
ridge can be expected. alveolar ridge thickness only manipulated the aforementioned difficulties.
Anitua et al. consider that an edentulous maxillae.19 These data corroborate the Different surgical instruments have
ridge with a thickness of <5 mm requires results of Simion et al.,15 and more recent- been used successfully for the creation
bone augmentation procedures before or ly Rahpeyma et al.,8 that the division of of space between cortical crests. With
126 Waechter et al.

Fig. 5. Meta-analysis of the implant survival rate for the studies that used surgical ultrasound.

respect to this criterion, the highest aver- suggested a modification of the procedure, diameter implants (3–4.5 mm) in the sec-
age gain in thickness of the alveolar ridge with the installation of narrow dental ond surgical stage. The average interval
was 5.6 mm,19 using a piezoelectric sur- implants (2.5–3 mm) in the first stage, time between the two stages was 5.78
gery device (US instrument). The authors which are further substituted with regular months.

Fig. 6. Assessment of the methodological risk of bias for the 27 articles included in this review, according to the criteria adopted by Clementini
et al.13
 The split crest technique and dental implants 127

From the results of the studies with favourable conditions with a bone bed carefully selected patient populations,
implant installation during the SCT, this of sufficient thickness and hence SCT control groups, and well-documented
one-stage surgery is almost always possi- effectively increases the volume of the methodologies are required to adequately
ble, since primary stability is achieved atrophic ridge, allowing successful im- assess the performance of the SCT, since
mainly from the apical bone division. plant installation. the high implant success rates may repre-
Additional advantages of simultaneous Despite the fact that this systematic sent a bias related to patient pre-screening.
implant placement include a shortened review showed SCT to be effective regard- Therefore, it is strongly recommended that
time between the first surgery and pros- less of the surgical instruments used, some the number of patients excluded, the num-
thetic treatment. Furthermore, immediate clinical clarifications need to be addressed ber of implants lost, the inclusion and
implant installation requires lower to better understand the positive and neg- exclusion criteria, and statistical data re-
amounts of biomaterials, reduces costs, ative aspects of US and conventional sur- garding the success rate of the procedure
and also prevents the collapse of the ex- gical instruments. When hand instruments are reported. Even though bone gain using
panded cortical walls. Finally, it also are used, they are pressed against the bone the SCT seems promising, taking into
results in less discomfort for the patient, with precise and gentle hammer blows. consideration the diversity of the studies
who will undergo only one surgical pro- The use of conventional surgical instru- and implant types, no definitive recom-
cedure. ments is more time-consuming than the mendations can be made, especially with
Demetriades et al. found no differences use of US instruments and requires greater regard to the best instruments and implant
between osseointegration applied in one or technical skill. By comparison, rotational design to be used.
two stages.20 These authors installed instruments are faster, but the soft tissues
implants 3 weeks after expansion in cases such as the tongue, cheek, and lips may be
with very low bone density, with the buc- injured.14,29 In addition, these instruments Funding
colingual dimension around 3 mm and are difficult to handle when adjacent teeth This research was carried out without
primary stability below 35 N. Crespi are present, due to the angle required. In funding.
et al. reported that implants placed after comparison to rotary instruments, US
the SCT with immediate loading can be devices show practical clinical benefits
expected to display the same biological such as (1) reduced noise and vibration, Competing interests
behaviour as implants in fresh extraction (2) reduced psychological stress, (3) no
The authors declare that they have no
sockets.21 In both cases, the lower half of risk of soft tissue injury, and (4) ease of
conflicts of interest.
the implant is placed in native bone with horizontal and vertical bone incisions
recommended insertion torque, while the without damage to the adjacent structures.
coronal portion is only in contact with the In addition, these instruments offer better Ethical approval
bone walls. For implants installed in re- visibility during the procedure since they
cent extraction sockets, the distance be- keep the work area clean.18,30 Not applicable.
tween the coronal bone surface and the It is noteworthy that the biological via-
implant walls is critical, since this is the bility of bone tissue treated with US is Patient consent
point of greatest bone–implant contact in comparable to that of bone that has been
the apical direction. subjected to cutting by other surgical tech- Not applicable.
Scarano et al. recommended the two- niques. Osteotomy with US devices seems
stage technique with conventional loading to be beneficial during the early stages of
of the implants, since this might prevent bone healing. Larger amounts of bone References
unplanned fracturing of the vestibular morphogenetic proteins seem to be intro- 1. Ferrigno N, Laureti M. Surgical advantages
wall, reducing complications and obsta- duced at the beginning of the healing with ITI TE implants placement in conjunc-
cles to treatment.22 In contrast, Shibuya process, reducing inflammation and stim- tion with split crest technique. 18-month
et al. stated that even if a malfracture ulating bone remodelling.14 The use of results of an ongoing prospective study. Clin
occurs, a sufficient volume of alveolar bone grafts between cortical walls did Oral Implants Res 2005;16:147–55.
bone can be obtained using a free bone not significantly influence the bone vol- 2. González-Garcia R, Monje F, Moreno C.
segment without rigid fixation.23 The ume gain. However, more studies are nec- Alveolar split osteotomy for the treatment
authors also mentioned that dental essary to confirm this finding. of the severe narrow ridge maxillary atrophy:
implants placed within the malfracture The bone loss around implants after a modified technique. Int J Oral Maxillofac
area show a good prognosis. separation of the cortical bone walls seems Surg 2011;40:57–64.
This systematic review provides the to be similar to that expected when 3. Coatoam GW, Mariotti A. The segmental
ridge-split procedure. J Periodontol
most comprehensive quantitative assess- implants are installed under ideal condi-
2003;74:757–70.
ment of the SCT to date, demonstrating tions. The benefits of adopting the SCT are
4. Nentwig GH. Technic of bone splitting for
that this technique is effective at increas- related to its speed, the predictable expan-
alveolar recession in anterior maxillary re-
ing bone thickness in the buccal-palatal sion of the atrophic alveolar ridge, and the gion. Quintessenz 1986;37:1825–34.
and buccal-lingual cross-sections when greater patient comfort. 5. Anitua E, Begona L, Orive G. Two-stage
performed on ridges without sufficient The alveolar crest division technique split-crest technique with ultrasonic bone
bone thickness. An average bone gain of allows the predictable treatment of surgery for controlled ridge expansion: a
3.8 mm is expected independent of the clinical conditions that would otherwise novel modified technique. Oral Surg Oral
surgical instruments used to cut bone, be impossible without implementing bone Med Oral Pathol Oral Radiol Endod
i.e., piezoelectric instruments (US) have augmentation techniques. In addition, 2011;112:708–10.
no advantages with respect to convention- prosthetically oriented implant treatment 6. Tolstunov L, Hicke B. Horizontal augmen-
al instruments for bone gain. These results planning is critical to the success of oral tation through the ridge-split procedure:
are comparable to those achieved in rehabilitation. Future clinical studies with a predictable surgical modality in implant
128 Waechter et al.

reconstruction. J Oral Implantol 2013;39: a clinical and histologic case series. Int J Oral surgery (Piezosurgery): 3-year follow-up
59–68. Maxillofac Implants 2015;30:144–9. of 180 treated implant sites. Quintessence
7. Happe A. Use of a piezoelectric surgical 18. Bassetti R, Bassetti M, Mericske-stern R, Int 2010;41:463–9.
device to harvest bone grafts from the man- Enkling N. Piezoelectric alveolar ridge-split- 30. Danza M, Guidi R, Carinci F. Comparison
dibular ramus: report of 40 cases. Int J ting technique with simultaneous implant between implants inserted into piezo split
Periodontics Restorative Dent 2007;27: placement: a cohort study with 2-year radio- and unsplit alveolar crests. J Oral Maxillofac
241–9. graphic results. Int J Oral Maxillofac Surg 2009;67:2460–5.
8. Rahpeyma A, Khajehahmadi S, Hosseini Implants 2013;28(6):1570–80. 31. Bravi F, Bruschi GB, Ferrini F. A 10-year
VR. Lateral ridge split and immediate 19. Anitua E, Begona L, Orive G. Controlled multicenter retrospective clinical study of
implant placement in moderately resorbed ridge expansion using a two-stage split-crest 1715 implants placed with the edentulous
alveolar ridges: how much is the added technique with ultrasonic bone surgery. Im- ridge expansion technique. Int J Periodon-
width. Dent Res J 2013;10:602–8. plant Dent 2012;21:163–70. tics Restorative Dent 2007;27:557–65.
9. Sakamoto Y, Takasu R, Hongo T, Harada N, 20. Demetriades N, Park JL, Laskarides C. Al- 32. Blus C, Szmukler-Moncler S. Split-crest and
Hasegawa Y, Tsuyama Y. The conservative ternative bone expansion technique for im- immediate implant placement with ultra-
surgical strategy for insufficient alveolar plant placement in atrophic edentulous sonic bone surgery: a 3-year life-table anal-
ridge employing split crest and socket lift maxilla and mandible. J Oral Implantol ysis with 230 treated sites. Clin Oral
procedure. Int J Oral Maxillofac Surg 2011;37:463–71. Implants Res 2006;17:700–7.
2011;40:1047. 21. Crespi R, Bruschi GB, Gastaldi G, Cappare 33. Sethi A, Kaus T. Maxillary ridge expansion
10. Bassetti MA, Bassetti RG, Bosshardt DD. P, Gherlone EF. Immediate loaded implants with simultaneous implant placement: 5-
The alveolar ridge splitting/expansion tech- in split-crest procedure. Clin Implant Dent year results of an ongoing clinical study.
nique: a systematic review. Clin Oral Relat Res 2015;17:692–8. Int J Oral Maxillofac Implants
Implants Res 2015;27:310–24. 22. Scarano A, Murmura G, Sinjiari B, Assenza 2000;15:491–9.
11. Elnayef B, Monje A, Lin GH, Gargallo- B, Sollazzo V, Spinelli G, et al. Expansion of 34. Scipioni A, Bruschi GB, Calesini G. The
Albiol J, Chan HL, Wang HL, et al. Alveolar the alveolar bone crest with ultrasonic sur- edentulous ridge expansion technique: a
ridge split on horizontal bone augmentation: gery device: clinical study in mandible. Int J five-year study. Int J Periodontics Restor-
a systematic review. Int J Oral Maxillofac Immunopathol Pharmacol 2011;24(2):71–5. ative Dent 1994;14:451–9.
Implants 2015;30:596–606. 23. Shibuya Y, Yabase A, Ishida S, Kobayashi 35. Jensen OT, Cullum DR, Baer D. Marginal
12. Garcez-Filho J, Tolentino L, Sukekava F, M, Komori T. Outcomes and treatments of bone stability using 3 different flap
Seabra M, Cesar-Neto JB, Araujo MG. malfractures caused by the split-crest tech- approaches for alveolar split expansion for
Long-term outcomes from implants installed nique in the mandible. Kobe J Med Sci dental implants: a 1-year clinical study. J
by using split-crest technique in posterior 2014;60:E37–42. Oral Maxillofac Surg 2009;67:1921–30.
maxillae: 10 years of follow-up. Clin Oral 24. Tang YL, Yuan J, Song YL, Ma W, Chao X, 36. Holtzclaw DJ, Toscano NJ, Rosen PS. Re-
Implants Res 2015;26:326–31. Li DH. Ridge expansion alone or in combi- construction of posterior mandibular alveo-
13. Clementini M, Morlupi A, Canullo L, Agres- nation with guided bone regeneration to lar ridge deficiencies with the piezoelectric
tini C, Barlattani A. Success rate of dental facilitate implant placement in narrow alve- hinge assisted ridge split technique: a retro-
implants inserted in horizontal and vertical olar ridges: a retrospective study. Clin Oral spective observational report. J Periodontol
guided bone regenerated areas: a systematic Implants Res 2015;26:204–11. 2010;81:1580–6.
review. Int J Oral Maxillofac Surg 25. Abu Tair JA. Modification of mandibular 37. Buser D, Mericske-Stern R, Dula K, Lang
2012;41:847–52. ridge splitting technique for horizontal aug- NP. Clinical experience with one-stage, non-
14. Anitua E, Begona L, Orive G. Clinical eval- mentation of atrophic ridges. Ann Maxillofac submerged dental implants. Adv Dent Res
uation of split-crest technique with ultrason- Surg 2014;4:19–23. 1999;13:153–61.
ic bone surgery for narrow ridge expansion: 26. Crespi R, Cappare P, Gherlone EF. Electrical 38. Albrektsson T, Zarb G, Worthington P, Eriks-
status of soft and hard tissues and implant mallet provides essential advantages in split- son AR. The long-term efficacy of currently
success. Clin Implant Dent Relat Res crest and immediate implant placement. used dental implants: a review and proposed
2013;15:176–87. Oral Maxillofac Surg 2014;18(1):59–64. criteria of success. Int J Oral Maxillofac
15. Simion M, Baldoni M, Zaffe D. Jawbone 27. Annibali S, Bignozzi I, Sammartino G, La Implants 1986;1:11–25.
enlargement using immediate implant Monaca G, Cristalli MP. Horizontal and
placement associated with a split-crest tech- vertical ridge augmentation in localized al- Address:
nique and guided tissue regeneration. Int J veolar deficient sites: a retrospective case Fernanda Faot
Periodontics Restorative Dent series. Implant Dent 2012;21:175–85. Department of Restorative Dentistry
1992;12:462–73. 28. Sohn DS, Lee HJ, Heo JU, Moon JW, Park School of Dentistry
16. Santagata M, Guariniello L, Tartaro G. Mod- IS, Romanos GE. Immediate and delayed Federal University of Pelotas
ified edentulous ridge expansion technique lateral ridge expansion technique in the atro- Gonçalves Chaves Street 457
and immediate implant placement: a 3-year phic posterior mandibular ridge. J Oral Max- 96015-560 Pelotas
RS
follow-up. J Oral Implantol 2015;41:184–7. illofac Surg 2010;68:2283–90.
Brazil
17. Scarano A, Piattelli A, Murmura G, Iezzi G, 29. Blus C, Szmukler-Moncler S, Vozza I, Ris-
Tel: +55 53 3222-6690
Assenza B, Mancino C. Delayed expansion of poli L, Polastri C. Split-crest and immediate
E-mail: [email protected]
the atrophic mandible by ultrasonic surgery: implant placement with ultrasonic bone