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A Three-Stage Split-Crest Technique:

Case Series of Horizontal Ridge Augmentation
in the Atrophic Posterior Mandible

Guei-Hua Hu, DDS, MS1 In patients with longstanding eden-

Stuart J. Froum, DDS2/Abdullah Alodadi, DDS1 tulism, extreme bone resorption (ver-
Fuyuki Nose, DDS, PhD1/Yung-Cheng Paul Yu, DDS3 tically, horizontally, or a combination
Takanori Suzuki, DDS, PhD4/Sang-Choon Cho, DDS5 of both) is frequently observed.1,2 The
use of augmentation techniques is
often necessary to create adequate
This paper introduces a three-stage split-crest (TSSC) technique for horizontal bone volume for implant place-
ridge augmentation in the atrophic posterior mandible. The first stage consists ment. The width of narrow posterior
of splitting the ridge. Following a 3- to 4-week healing interval, the second stage mandibular edentulous ridges can
consists of expansion of the cortical plate (without elevating the periosteum) and
be increased by four different hori-
placement of a bone replacement graft material. After 3 to 4 months of healing, the
implants are placed. The advantages of this three-stage technique are increased zontal augmentation procedures:
vascularization to the surgical area, a decrease in procedure complications, lateral augmentation using guided
and improved implant survival rates. An extended treatment time is the main bone regeneration,3 block grafting,4
disadvantage. The purpose of this retrospective case series is to review and discuss distraction osteogenesis,5 and inter-
a new step-by-step surgical procedure of a TSSC technique using a delayed implant positional augmentation.6 Guided
placement protocol. The results, advantages, and limitations are also presented.
bone regeneration is a predictable
Int J Periodontics Restorative Dent 2018;38:565–573. doi: 10.11607/prd.2907
procedure for horizontal ridge aug-
mentation, but its dependence on
the blood supply of the underlying
bone7 limits its use in an atrophic
mandible where there is limited mar-
row between the buccal and lingual
central plates. The same is true for
block grafting, which requires a sec-
ond surgery site if autogenous bone
1Resident, Advanced Program in Implant Dentistry, Department of Periodontology and
Implant Dentistry, New York University College of Dentistry, New York, New York, USA. is used.8 Distraction osteogenesis is
2Adjunct Clinical Professor and Director of Clinical Research, Department of Periodontology an effective technique for horizon-
and Implant Dentistry, New York University College of Dentistry, New York, New York, USA. tal ridge augmentation but requires
3Visiting Assistant Professor, Advanced Program in Implant Dentistry, Department of
precise execution; complications can
Periodontology and Implant Dentistry, New York University College of Dentistry,
New York, New York, USA. result in loss of large segments of
4Clinical Assistant Professor, Advanced Program in Implant Dentistry, Department of
bone.9 Interpositional augmentation
Periodontology and Implant Dentistry, New York University College of Dentistry, is a technique-sensitive procedure
New York, New York, USA.
5Director, Advanced Program in Implant Dentistry, Department of Periodontology and for ridge expansion using bone ex-
Implant Dentistry, New York University College of Dentistry, New York, New York, USA. panders or osteotomes with an ap-
proach known as the split-crest (SC)
Correspondence to: Dr Stuart J. Froum, 17 W 54th Street, Suite 1 C/D,
technique.10
New York, NY 10019, USA. Email: dr.froum@verizon.net
The SC technique consists of
©2018 by Quintessence Publishing Co Inc. segmenting the vestibular cortical

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566
plate and displacing it buccally in
the maxilla or mandible to create a
gap to contain the placed implants.
The space around the implants can
be filled with bone graft or bone
substitute materials such as autog-
enous,11 allogenic,12 or xenogeneic
graft materials.13
The use of an ultrasonic cutting
device makes the SC procedure less
traumatic when compared to con-
ventional surgery using disks, burs,
and chisels.14 Ultrasonic devices
have the ability to cut mineralized
hard tissues in a safe and precise
way, with minor soft tissue dam-
age. Clinical studies evaluating the
potential of ultrasonic bone surgery
with a split-crest expansion tech-
nique have reported satisfactory
results.15
The SC technique may be per-
formed simultaneously with implant
placement,6,12,15–19 resulting in a short-
ened treatment time. However, this
approach has the potential for seri-
ous complications, including buccal
bone fracture, prolonged pain or par-
esthesia, and loss of bone height.16
A minimum of 3 mm of bone width,
including at least 1 mm of cancellous
bone, is indicated for this approach.17
Implants placed in maxillary bone in
which the width was increased by
means of interpositional augmenta-
tion have demonstrated 5-year cu-
mulative success rates between 86%
and 99%.6,12,16,18 Attempts to use this
procedure in denser bone, such as is
present in the mandible, have shown
limited success to date.12,19
A staged approach presents a
solution to the problems inherent in
the use of the SC technique in the
mandible. Consequently, a staged
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approach has been proposed with
splitting and expansion performed
followed by implant placement after
a 3-week healing interval.13,20 This al-
lows re-establishment of the blood
supply to the surgical site. However,
this staged technique was reported
to have potential complications such
as infection and separation of bony
segments.20 To reduce the potential
for complications, this study intro-
duces a modified three-stage SC
(TSSC) technique. The purpose of
this retrospective case series was to
describe this novel TSSC technique
and report on patient outcomes
when TSSC was used in the atro-
phic posterior mandible. The step-
by-step surgical procedure using
delayed implant placement is pre-
sented, along with the advantages
and limitations of this technique.
Materials and Methods
Clinical data used in this study was
obtained from the Implant Data-
base (ID) of the Ashman Depart-
ment of Periodontology and Implant
Dentistry at New York University
College of Dentistry (NYUCD). This
data set was extracted as deidenti-
fied information from the routine
treatment of patients in the de-
partment. The ID was certified by
the Office of Quality Assurance at
NYUCD. This study is in compliance
with the Health Insurance Portability
and Accountability Act (HIPAA).
A total of 10 patients were con-
secutively selected from the ID for
this case series based on the inclu-
sion and exclusion criteria. Inclusion
criteria were as follows:
• All patients received implants
placed using the modified
TSSC technique.
• Preoperative periapical
radiographs and cone beam
computed tomography (CBCT)
scan images of the posterior
mandible were available
prior to surgery for case
assessment.
• Patients required single
or multiple implants in the
posterior mandible.
• A ridge width of < 4 mm was
present in CBCT images as
measured 2 mm apical to the
crest of the ridge.
• A ridge height of > 10 mm
was present as measured from
the superior border of the
mandibular canal to the crest of
ridge.
• The ridge had healed for at
least 3 months following tooth
extraction.
Exclusion criteria were as follows:
• Presence of uncontrolled
diabetes, immunologic
diseases, or other systemic
conditions that contraindicated
surgery.
• Radiation therapy to the head
and neck region in the 12
months prior to the proposed
therapy.
• Chemotherapy within a
12-month period prior to the
proposed therapy.
• Patients currently on or with
a history of bisphosphonate
therapy.
• Presence of periodontal
disease, or unwillingness to

Fig 1 Clinical intraoral view before
treatment showing a severely atrophic
posterior mandible.
undergo needed periodontal
therapy, around the remaining
teeth.
• Pregnancy or wish to become
pregnant within 1 year of
therapy.
• Smoking habit of one pack or
more per day and unwillingness
to enter a smoking cessation
protocol.
• Psychologic problems that, in
the opinion of the surgeons,
would have rendered the
delivery of comprehensive
therapy untenable.
• Unwillingness to commit to
a long-term posttherapy
maintenance program.
To be included for evaluation, im-
plants and prostheses were re-
quired to survive and function for a
minimum of 6 months from time of
completion of the final restoration.
A lack of neurosensory problems
or other complications was also re-
quired for evaluation.
Following screening and ex-
amination, an institutional review
board–approved written and oral
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Fig 2 Preoperative CBCT scan and
periapical radiographic images of right
posterior mandible. Note the 2-mm-thick
alveolar ridge.
informed consent was obtained
from each patient. All necessary
periodontal and caries treatments
were performed prior to surgery.
Prior to surgery, a CBCT scan of
the surgical site was taken for each
patient (Figs 1 and 2).
Surgical Procedure
The surgical procedures were stan-
dardized and were performed in
three stages.
First Stage
Patients were prescribed 2 g of
amoxicillin or, if allergic, 600 mg of
clindamycin 1 hour prior to surgery
and told to continue them (three
times a day if amoxicillin 500 mg
and four times a day if clindamycin
150 mg) for 10 days postsurgery.
Local infiltration anesthesia of xylo-
caine (Lidocaine HCl, Henry Schein)
2% containing epinephrine at a con-
centration of 1:100,000 was admin-
istered, or carbocaine (Mepivacaine
HCl, Carestream Health) 3% in cas-
es where a vasoconstrictor was con-
567
Fig 3 Clinically very narrow alveolar width
was observed after flap reflection.
traindicated. A midcrestal incision
was made along the ridge crest
slightly lingual to the midline, and
two vertical incisions were made at
the termination of the crestal inci-
sion (Fig 3). Alveolar ridge width
was measured at the time of sur-
gery at the crest of the planned im-
plant position from buccal to lingual
with an electronic caliper (Absolute
700-113-10, Mitutoyo) to the nearest
0.5 mm. A full-thickness mucoperi-
osteal flap was elevated to expose
the buccal aspect of the mandibular
alveolar ridge. Rectangular corti-
cotomies were made using a piezo-
electric saw (Mectron). A crestal
horizontal corticotomy was started
2 mm mesial or distal to the adja-
cent teeth. The length of the hori-
zontal cut was determined based
on the number of implants and the
space between the existing teeth or
implants. The depth of the horizon-
tal inferior cut was 2 mm coronal to
the inferior alveolar canal as mea-
sured on the CBCT scan. This apical
cut averaged 10 mm in depth. Ver-
tical osteotomies were deepened
1 to 2 mm using the piezoelectric
Volume 38, Number 4, 2018
568

Fig 4 A crestal horizontal corticotomy was
made using a piezoelectric saw, followed
by two vertical osteotomies that were
deepened 1 to 2 mm through the cortical
bone along with a horizontal inferior cut.
Fig 5 The mucoperiosteal flap was sutured Fig 6 The healing ridge, 3 to 4 weeks after
using 4-0 chromic gut resorbable material. the primary surgery, prior to performing
ridge expansion and placing grafting
material during the second-stage surgery.

greenstick fractured buccal seg-

ment was readapted with finger
pressure, and the mucoperiosteal
flap was sutured using 4-0 chromic
gut resorbable material (635-CG,
Henry Schein). Tension-free soft
tissue closure was achieved in all
a b cases (Fig 5).
Fig 7 (a) A 3.3-mm diameter split crest chisel (SCC33, EBI) was used during the second-
stage surgery. (b) A crestal incision to expose the initial crestal cut without elevation of a
buccal flap. This allowed conservation of the blood supply on the buccal aspect of the
Second Stage
displaced buccal plate. The displacement of the buccal plate to expand the ridge was Following a 3- to 4-week healing
achieved by using a 3.3-mm-diameter split crest chisel and a 15c blade. period, ridge expansion and place-
ment of the grafting material was
performed as part of the second-
stage surgery (Fig 6). A crestal in-
cision to expose the initial crestal
cut was performed without eleva-
tion of a buccal flap. A 3.3-mm-
diameter split crest chisel (SCC33,
EBI) and 15c blade were used to
carefully separate and mobilize the
Fig 8 A xenograft material (small particle Fig 9 Tension-free soft tissue closure was segmented bone, creating a green-
Bio-Oss, Geistlich) was packed in the achieved with 4-0 chromic gut.
created space.
stick fracture (Fig 7). This allowed
preservation of the blood supply on
the buccal aspect of the displaced
buccal plate. Small-particle (0.25 to
saw through the cortical bone to elevator (E301, Hu-Friedy) was used 1 mm) xenograft material (Bio-Oss,
intersect with the horizontal inferior to expand the buccal segmented Geistlich) was packed in the created
cut (Fig 4). These cuts were made bone approximately 3 mm, provok- space (Fig 8). The mucoperiosteal
through the cortical bone leaving ing a greenstick fracture. This seg- flap was sutured with 4-0 chromic
only the cancellous bone to be part ment remained stable due to the gut. Tension-free soft tissue closure
of the greenstick fracture. A #301 underlying cancellous bone. The was achieved in all cases (Fig 9).

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Fig 13 (a) Clinical occlusal view of the
mandibular right second premolar and first
molar porcelain-fused-to-metal bridge.
(b) Clinical buccal view of the mandibular
right second premolar and first molar
porcelain-fused-to-metal bridge.
Third Stage
After 3 to 4 months, a CBCT scan
was taken prior to implant placement
(Fig 10). A full-thickness flap was re-
flected, and landmarks such as the
mental foramen and inferior alveolar
nerve were identified (Fig 11). Alveo-
lar ridge width was measured to the
nearest 0.5 mm and recorded again
at the crest of the ridge using the
same method described in the first-
stage procedure. A round bur was
used to mark the initial osteotomy,
and a Lindemann drill (EBI) was used
to achieve a depth of 6 mm into the
bone. Depending on the width of
the bone, standard-width implants
(3.3 to 4.1 mm) were inserted in the
area, achieving primary stability, and
the surgical site was sutured with
4-0 chromic gut and allowed to heal
(Fig 12).
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569
Fig 10 (left) A CBCT scan was taken prior Fig 12 (below) Two Straumann bone-level
to implant placement. implants (3.3 × 10 mm, mandibular right
second premolar and first molar) were
Fig 11 (below) Reentry after 4 months of placed.
healing showing an enhanced bone width
of 4 mm.
a b
Fig 14 CBCT
scan images
taken before
treatment,
after the
second stage,
and 4 months
after delivery
of the final
restoration,
showing the
desirable result.
Restorative Procedure metal crowns, which were splinted,
cemented, or screw retained ac-
The implants were allowed to inte- cording to the restorative dentist’s
grate for 3 to 4 months. Impressions preference (Fig 13). A CBCT scan
were then taken using polyether was taken after prosthesis delivery
material and sent to the lab for and compared to the presurgical
fabrication of porcelain-fused-to- scan (Fig 14).
Volume 38, Number 4, 2018
570

a b c

d e f
Fig 15 The three-stage split-crest technique. (a) Presurgical atrophic posterior mandibular ridge. (b) Rectangular osteotomies are made
using the piezoelectric saw, provoking a greenstick fracture. (c) Second surgery, using a 3.3-mm-diameter chisel to separate the buccal
fractured segment. (d) Suturing following placement of the bone substitute graft. (e) Placement of implants in the augmented ridge.
(f) Flap suturing following implant placement.

The technique as performed is allowed successful implant place- Discussion

illustrated in Fig 15.
Results
In this retrospective study, a total
of 10 subjects received 20 implants
placed using the TSSC technique.
All patients showed substantial re-
construction of alveolar crest defi-
ciencies with an average increase in
ridge width of 2.5 to 4 mm, which
ment. All implants were loaded
for a minimum of 6 months, and all
implants and prostheses survived.
No implant failure or neurosensory
impairment was reported. There
were no complications with the
surgery or the restorations (such as
broken, fractured, or chipped res-
torations) during the follow-up pe-
riod (6 to 24 months) during which
the final restorations were in func-
tion (Table 1).
The TSSC technique as described
was applied in severely buccolin-
gually atrophied posterior man-
dibular edentulous regions as a
three-stage procedure. The out-
comes of the 20 implants in 10 pa-
tients presented were all positive,
with a 100% implant survival rate
and no reported complications.
The lateral ridge expan-
sion technique with simultaneous

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 571

Table 1 Summary of the Study Sample and Outcomes of the TSSC Techniques
Bone width (mm) Implants
Surgical (SC) or
Location Diameter Length Follow-up prosthetic (PC)
Subject Sex Age (y) Pre Post Gain (FDI) (mm) (mm) (mo) complications
1 F 34 3 6.5 3.5 45 3.3 10 34 None
3 6 3 46 3.3 10 None
2 M 55 2 6 4 45 3.3 10 38 None
3 6 3 46 3.3 10 None
3 F 46 3.5 6.5 3 37 4.1 10 31 None
3.5 6.5 3 36 4.1 10 None
4 M 52 4 7 3 36 4.1 10 29 None
5 F 45 3 6 3 45 4.1 10 28 None
3 6 3 46 4.1 10 None
6 F 42 3 6 3 37 4.1 10 22 None
3.5 6 2.5 36 4.1 10 None
7 F 70 2.5 5.5 3 45 3.3 10 21 None
3 6.5 3.5 46 4.1 10 None
8 F 58 3 6 3 36 4.1 10 20 None
3 5.5 2.5 35 4.1 10 None
3.5 6 2.5 34 3.3 10 None
9 M 45 3 6.5 3.5 36 4.1 10 20 None
3.5 6.5 3 35 4.1 10 None
10 F 50 3 6 3 37 4.1 10 20 None
3 6 3 36 4.1 10 None
Mean ± SD 49.7 ± 9.88 3.1 ± 0.42 6.15 ± 0.37 3 ± 0.36 26.3 ± 6.62

immediate implant placement is
often performed because it short-
ens the total treatment time.15–19,21–23
However, the risk of fracture of the
osteomized segment is increased
in the mandible because the man-
dibular bone has a more rigid cor-
tical bone and a thicker cortical
plate. Several complications have
been reported for ridge expansion
with simultaneous implant place-
ment, such as a lack of initial stabil-
ity for the implants, fracture of the
buccal segmented bone, and com-
promised implant placement in the
buccolingual and/or apicocoronal
direction.12,16,18 Some studies recom-
mend a staged approach to avoid
postoperative complications such
as bone sequestrum of the buccal
segment.24,25 Although a two-stage
approach increases treatment time,
it also allows for subsequent evalu-
ation of the expanded ridge and
avoidance of other complications.
With this approach, the location
of the greenstick fracture is pre-
determined, and blood supply for
the buccal segment remains intact.
However, buccal bone resorption
was reported using a two-stage
procedure20 and Scarano et al13 re-
ported an early implant failure rate
of 3.12% at 3 months using the two-
stage procedure in the posterior
mandible. Moreover, there is uncer-
tainty as to the amount of bone the
clinician can expect prior to stage 2
of two-stage technique.
The TSSC technique described
in this case series provides a sub-
stantial improvement in diagnosing
and planning implant positioning,
reducing potential implant com-
plications and failures. Enhanced

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572
bone volume during implant place-
ment provides a greater potential
for implant stability and long-term
results. In addition, a more robust
blood supply is expected within 3
weeks to achieve revascularization.
Some studies described revascular-
ization at 9 days with normal histo-
logic and microvascular appearance
at 14 days.26 This is the rationale
for the 3-week waiting period used
in this protocol to ensure sufficient
blood supply to the mucogingival
flap and underlying bone. The use
of a crestal incision only, avoiding
flap reflection and preserving the
periosteum during the second sur-
gical procedure, when the bone
substitute graft is performed, avoids
scar tissue formation and improves
the healing response. This tech-
nique differs from the piezoelectric
hinge-assisted ridge split technique
in that it adds an additional surgical
step but avoids the use of a mem-
brane barrier, which eliminates pos-
sible complications. Moreover, in
the TSSC technique, grafting and
further widening of the ridge are
performed during stage 2 surgery
without flap reflection. This allows
the healing of the graft and ridge
to take place under an intact perios-
teum, connective tissue, and epithe-
lium cover, providing an improved
blood supply during this critical step
in healing.27
The use of ultrasonic cutting
devices is advocated with the TSSC
procedure due to their ability to cut
mineralized hard tissues with minor
soft tissue damage.14,28 Vital soft tis-
sue structures such as nerves and
blood vessels are not damaged by
the cutting tip because of their abil-
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ity to oscillate at the same speed
and amplitude as the cutting tip of
the instrument.29 Successful results
have been reported using these
cutting instruments with a split-
ridge technique.14,15
However, the TSSC technique
increases the time until final prosthe-
ses delivery and surgical exposure.
Additionally, the clinical cases in this
report were treated by surgeons
experienced in implant placement
and ridge-splitting techniques. It is
unclear whether these results can
be obtained by less experienced
operators. In the present study, the
TSSC technique was proven to be
safe and merits further studies. Ran-
domized clinical trials are needed
to validate the effectiveness of this
procedure.
The preliminary results of this in-
vestigation indicated that the modi-
fied staged split-crest technique can
be a safe and successful procedure
and may reduce the reported com-
plications associated with single- or
two-stage spilt crest procedures
without causing significant delay in
treatment.
Conclusions
The TSSC technique used in this
study in 10 patients with 20 implants
proved to be an effective method
for horizontal augmentation in se-
verely atrophic posterior mandibu-
lar ridges. The TSSC technique can
be used safely and predictably in
patients with dense and thick cor-
tical bone and narrower ridges in
the posterior mandible. However,
this technique requires planning,
knowledge, skill, and experience
on the part of the operator. Further
studies are recommended to deter-
mine whether these results can be
achieved in additional cases.
Acknowledgments
The authors reported no conflicts of interest
related to this study.
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Volume 38, Number 4, 2018