The treatment of patients with atrophic ridges, who need functional and esthetic rehabilitation, is a common problem encountered in our daily practice as oral surgeons, which prevents ideal implant placement. Alveolar ridge splitting is a minimally invasive surgical technique that expands the alveolar bone, particularly in the maxilla, which has inherent flexibility properties, to create an optimal site for dental implant placement. This technique improves the quantity and quality of bone around the implant in both crestal and apical directions. It is indicated for the alveolar ridge with adequate height and minimal width, enabling direct implant placement with reduced morbidity and overall treatment time compared to other augmentation techniques. The technique was introduced in the 1970s by Dr. Hilt Tatum, with later refinement in 1994 by Summers, who advocated the use of osteotomes. This case report describes a maxillary ridge splitting procedure for a missing left central incisor, involving simultaneous implant placement and a 24-month follow-up.

Dental implants are now the treatment of choice for edentulous ridges; however, insufficient bone width can compromise this outcome. Several surgical techniques for horizontal augmentation have been described in the literature, including guided bone regeneration, block bone grafting, the ridge split technique, ridge expansion, and distraction osteogenesis.[1-13] These techniques are used with some limitations to enhance the bone volume in the case of a narrow alveolar ridge.[14,15] While the GBR procedure can be performed with simultaneous implant placement, only grafting implies a reconsolidation time of at least three months to enable implant placement in a staged procedure.[16-19] Many studies have demonstrated the success of these well-documented surgical approaches. Still, donor site morbidity, unexpected bone resorption, block consolidation at the site of grafting, and infection are among the drawbacks of these conventional techniques.[20,21]

The technique of ridge split, or ridge expansion, was introduced in the early 1970s for horizontal ridge augmentation while maintaining periosteal attachment by carefully expanding the cortical plates. This approach was further developed by Summers (1994), who advocated the use of osteotomes to progressively increase the diameter and create an osteotomy bed for implant placement. This technique had the added advantage of augmentation and implant placement in a single sitting. Ridge-splitting techniques are useful for managing narrow edentulous ridges (˂3.5 mm) for implant placement, yielding a predictable outcome in the maxilla more often than in the mandible.[22]

Proper case selection and evaluation are important to achieving a successful surgical and prosthetic outcome. Another advantage in our case was the use of a piezoelectric device to ensure atraumatic bone separation, thereby decreasing the risk of bone fracture due to expansion; this makes the bone more elastic.[23-26]

A 19-year-old female patient presented with a missing maxillary left central incisor (tooth number 21); the medical history was noncontributory. The width of the alveolar crest was 3.1mm, which could not allow for any implant insertion (Figure 1 and 2).

Figure 1 and 2: Photo showing the volume loss in the buccal side and cross-sectional image measuring the bucco-lingual thickening of residual bone

The split technique was employed to facilitate the suitable positioning of the osseous implant. A crestal and intra-sulcular incision was performed extending from the distal aspect of the maxillary right canine to the maxillary left canine, with an additional releasing incision on the distal aspect of the left canine.

A mucoperiosteal flap was raised, then crestal osteotomy preparation was performed with an ultrasonic piezo device using an insert that cuts the bone into two parts, buccal 2.1mm and 1mm palatal. Supplementary mesial and distal osteotomies were added to ensure easy bone separation. Immediate implant site preparation, aimed at maintaining the expanded space, was performed using a Lindemann burr and bone expander kit (Figure 3-6).

Figure 3-6: Buccal osteotomy using piezo surgery- Lindemann burr preparing implant bed- Bone expander creating more space- Implant placement

A Straumann bone level tapered (BLT) implant with a 3.3 mm diameter and 11 mm length, classified as a rock-solid type of dental implant, was then placed (Figure 7 and 8).

Figure 7 and 8: Final implant position and CBCT control image two years later

Generally, after tooth extraction, an average 40–60% decrease of horizontal as well as vertical dimensions of the alveolar ridge occurs during the first 2 years.[27] Bone resorption and three-dimensional changes of the crest are predominantly more pronounced at the buccal than on the lingual aspect of the extraction socket.[28] The aim of this case report was to demonstrate a successful clinical implant installation in a patient with a 3.1 mm alveolar width, utilizing the splitting technique.

Different splitting modifications have been documented in the literature, such as the two-stage technique specifically designed for the mandible, or how to address the gap created between the two cortices. In our case, a simultaneous implant installation was the solution to preserve the space created in only one intervention and avoid bone graft harvesting from secondary donor sites.[29,30]

However, ridge expansion also discloses certain technical and physiological limitations. One major drawback of alveolar bone splitting is the requirement of a trabecular bone compartment between the buccal and lingual plates to allow separation.

Jensen et al. indirectly demonstrate the rare usage of the ridge splitting technique in the lower jaw compared to the upper, mainly due to the rigidity of the mandibular cortical bone.[31]

Another disadvantage of the alveolar bone splitting technique, which can be quite severe, is the risk of bone resorption due to malnutrition of the laterally displaced buccal bone wall.[27] Although some approaches have been proposed to reduce bone resorption, evidence for their efficacy remains lacking.[32,33]

In conclusion, the most important factors for successful ridge split cases are careful patient selection and thorough bone evaluation. Although this surgical approach can be used in both jaws, it is more suitable for the maxilla. Thus, to achieve the ideal goals of implant dentistry, augmentation of deficient alveolar ridges is a crucial aspect of dental implant therapy, with the ultimate goal of providing a functional restoration that is in harmony with the adjacent natural dentition, as in this case report.

My first gratitude goes to the surgery department and the faculty of dental medicine at the Lebanese University for providing me with this opportunity. I would also like to thank Dr. Charbel Choubaya and Dr. Jean Nassar for their valuable contributions. Finally, I am deeply grateful to my wife for her continuous support and love.

No funding was received to conduct this case report.

Corresponding Author:
Jean Saade
Department of Surgery
Faculty of Dental Medicine, Lebanese University
Email: jean.saadeh1@hotmail.com

Co-Authors:
Jean Nassar
Department of Periodontology
Faculty of Dental Medecine, Lebanese University

Charbel Choubaya
Department of Surgery
Faculty of Dental Medicine, Lebanese University

All authors worked collaboratively to complete the manuscript. Photographs used in the paper were sourced from clinical cases provided by Dr. Charbel Choubaya. The accompanying case descriptions were written by Dr. Jean Saade and were subsequently revised and referenced by Dr. Jean Nassar.

Informed consent was received from the patient.

The authors declare no conflicts of interest.

This article received no specific grant from any funding agency in the public, commercial, or profit sectors.

https://doi.org/10.63096/medtigo30623223

Saade J, Nassar J, Choubaya C. Alveolar Split Procedure: Advancing Precision in Dental Surgery. medtigo J Med. 2025;3(2):e30623223. doi:10.63096/medtigo30623223 Crossref