The Journal of Craniofacial Surgery  Volume 27, Number 2, March 2016
Options for reconstruction of bilateral total upper and lower
eyelid defects are more restricted because of limited availability of
locoregional flap tissue. Reconstruction in this setting will often
require multiple flaps and/or skin grafts increasing donor site
morbidity and risk of technical failure. The use of a swiveling
single expanded forehead flap to totally reconstruct bilateral upper
and lower eyelids in stages is novel and economical in application
requiring only a single donor site. The technique can be successfully
executed in a few stages with ease. By the same versatile concept,
the sufficiently expanded forehead flap may also be used for total
reconstruction of coexistent eyelid, canthal, and nasal defects on 1
or both sides of the face.
Tarsus reconstruction could have been done with cartilage but
was unnecessary because the reconstructed eyelids were suffi-
ciently rigid to support the prostheses. If desired, ancillary muscle
transfer and/or sling procedures might be done for eyelid articula-
tion in the future.
CONCLUSIONS
The novel approach of swiveling a single expanded forehead flap
effectively and economically provides adequate like for like auto-
logous well-vascularized tissue to totally recreate bilateral upper
and lower eyelids and help secure prosthesis containment.
REFERENCES
1. Levasoy MA, Kohan E. Total upper and lower lid reconstruction using an
expanded forehead flap. Ann Plast Surg 2011;67:502504
2. Yanaga H, Mori S. Eyelids and eye socket reconstruction using the
expanded forehead flap and scapha composite grafting. Plast Reconstr
Surg 2001;108:816
3. Altlindas M, Yucel A, Ozturk G, et al. The prefabricated temporal island
flap for eyelid and eye socket reconstruction in total orbital exenteration
patients. Ann Plast Surg 2010;65:177182
4. Atabay K, Atabay C, Yavuzer R, et al. One-stage reconstruction of eye
socket and eyelids in orbital exenteration patients. Plast Reconstr Surg
1998;101:14631470
5. Dortzbach RK, Hawes MJ. Midline forehead flap in reconstructive
procedures of the eyelids and exenterated socket. Ophthalmic Surg
1981;12:257268
6. Larsen J. Limits for the use of forehead flaps for small and extensive
midface reconstructions including septum/columella reconstructions.
Scand J Plast Reconstr Surg Hand Surg 1997;31:229237
7. Onaran Z, Yazici I, Karukaya E, et al. Simultaneous reconstruction of
medial canthus area and both eyelids with a single transverse split
forehead island flap. J Craniofac Surg 2011;22:363365
8. Margulis A, Amar D, Billig A, et al. Periorbital reconstruction with the
expanded pedicled forehead flap. Ann Plast Surg 2015;74:313317
Ridge Expansion by Flapless
Split Crest and Immediate
Implant Placement: Evolution of
the Technique
Antonio Cortese, MD, Giuseppe Pantaleo, DDS, PhD,y
Massimo Amato, MD,z and
Pier Paolo Claudio, MD, PhD
Abstract: Various treatment strategies and techniques have been
proposed to perform alveolar bone augmentation; most common are
# 2016 Mutaz B. Habal, MD
Copyright 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
guided bone regeneration, split crest, and autologous bone grafting.
All of these techniques are reported to possess bone regenerative
properties of osteoinduction and osteoconduction in relation to
regenerated bone survival. Split crest resulted to be one of the
most reliable bone augmentation techniques. In this study, we
describe a new flapless-modified split crest technique on 4 patients
to optimize the bone regeneration with bone augmentation implant
insertion in 1 single stage. The rationale of this technique is to
obtain a proper buccal cortex expansion preserving its vascular
supply and avoiding periosteal elevation for better cortical bone
preservation. The main advantages of this technique consist in a
single surgical stage without donor sites, vascular periosteal pres-
ervation of vestibular cortical walls, preservation of alveolar bone
height avoiding bone loss after implant kit drilling, and preservation
of proper cortical thickness on both sides, thereby saving periosteal
nourishment on the vestibular side. Indication for this technique
could be extended to almost every implant insertion for alveolar
height saving at drilling time for implant insertion, because of the
alveolar crest shape.
Key Words: Immediate implant, platelet rich fibrin, ridge
expansion, split crest
T he presence of a thin edentulous ridge can be acquired or
congenital. Acquired alveolar defects may be caused by post-
extraction defects, traumatic tooth avulsion, periodontal disease,
and/or prolonged denture wear with subsequent atrophy. In the
largest part of the cases the most significant loss is in the horizontal
dimension.1
Because of the relationship between alveolar bone and basal
bone in the jaws (basal bone in the inner side of the maxilla and
basal bone in the external side of the mandible), and because of
the presence of a thicker cortical bone in the palatal and lingual
sides of both jaws, alveolar bone atrophy will result in a cen-
tripetal trend in the maxilla and a centrifugal trend in the
mandible.2 3 This regressive process that involves the alveolar
bone, furthermore, changes in the quality and quantity of the
coating soft tissue, with the reduction or total loss of fixed
keratinized gingiva collapsed in a crestal cord of residual fixed
gingiva and exuberance of mobile alveolar mucosa.4 Therefore, in
these patients, it is necessary to adopt bone regeneration tech-
niques to restore lost tissues, thus allowing adequate implant
positioning, particularly in more extensive implant cases needing
frontal teeth restoration.5 Most common techniques for alveolar
bone augmentation are guided bone regeneration (GBR)6 7 and
From the Department of Medicine and Surgery, Unit of Maxillofacial
Surgery, University of Salerno, Salerno; yDepartment of Neurosciences,
Reproductive and Odontostomatological Sciences, University of Naples
Federico II, Naples; zDepartment of Medicine and Surgery, University of
Salerno, Salerno, Italy; and Department of Surgery, Joan C. Edwards
School of Medicine, Marshall University, Huntington, WV.
Received July 10, 2015.
Accepted for publication November 9, 2015.
Address correspondence and reprint requests to Pier Paolo Claudio, MD,
PhD, Department of Surgery, Joan C. Edwards School of Medicine,
Marshall University, 1600 Medical Center Drive, Huntington, WV
25705; E-mail: claudiop@marshall.edu
The authors report no conflicts of interest.
Copyright # 2016 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000002367
e123
Brief Clinical Studies The Journal of Craniofacial Surgery
autologous bone grafting.8 Particularly, GBR retrospective stu-
dies recently demonstrated long-term resorption for regenerated
alveolar bone after GBR using heterologous bone.6,9
There is a hierarchy in bone regeneration related to long-term
stability that can be classified as follows: native bone, osteodis-
tracted bone, autologous bone grafts, homologous bone, heter-
ologous bone, and alloplastic bone substitute. The techniques that
use these kinds of bone or bone substitutes have different
regenerative properties of osteoinduction and osteoconduction.
Bone induction is typically associated with the use of fresh
autologous bone, whereas osteoconduction, is a property that
belongs to the homologous, heterologous bone, and alloplastic
materials.5,10
Considering different techniques for alveolar bone augmenta-
tion, relevant and better results for implant survival and stability
were reported in the literature for split crest technique. Chiapasco
et al11 reviewed publications related to augmentation procedures to
evaluate the success rate of different surgical techniques for the
reconstruction of the deficient alveolar bone and the survival/
success rates of implants placed in the reconstructed areas. Success
rates of surgical procedures ranged from 60% to 100% for GBR,
92% to 100% for onlay bone grafts, 98% to 100% for ridge
expansion techniques, 96.7% to 100% for distraction osteogenesis,
and 87.5% for revascularized flaps. Survival rates of implants
ranged from 92% to 100% for GBR, 60% to 100% for onlay bone
grafts, 91% to 97.3% for ridge expansion techniques, 90.4% to
100% for distraction osteogenesis, and finally 88.2% for
revascularized flaps.
Another regeneration technique, that can be classified
between the onlay bone graft and the ridge expansion technique,
is the flapless sandwich graft method presented for the first time
by Schettler12, which increases the vertical ridge using the
insertion of a bone graft between the osteotomy stumps of the
alveolar bone. In this technique, bone regeneration is similar to
the osteodistraction procedure creating a regenerative chamber
with bone walls covered by native periosteum, which is not cut or
elevated during osteotomies, thereby preserving the blood supply
for the underlying bone. This procedure is comparable to recon-
structive procedures for treating periodontal intraosseous
defects.6,13
With the rapid advancement of dental implant therapeutics, the
current trend is more geared toward enhancing esthetics and max-
imizing patient comfort and satisfaction. Besides some advantages
of flapless implant surgery concerning patient acceptance include
decreased bleeding, less surgical trauma, decreased surgical time,
and accelerated healing.14
In this study, we propose a new flapless-modified split crest
technique to optimize the regenerative bone conditions in a bone
augmentation technique with implant insertion in 1 stage. Defi-
nition of flapless is related to a shifted mucosa incision from crestal
to palatal or lingual side with periosteal elevation up to the buccal
crest border leaving the periostium attached on the buccal
alveolar bone.
The development of this modified technique started approxi-
mately 10 years ago combining different surgical techniques with
new ones.
Surgical techniques rationales that are combined with this new
surgical procedure are: sandwich osteotomies; bone distraction;
flapless implant insertion; and autologous platelet rich fibrin
(PRF) use.
Sandwich osteotomies were first performed in the 1970s with
the aim of reducing morbidity and improving long-term results
after bone augmentation through the rationale of creating a bone
regenerative chamber between 2 expanded bone walls both nour-
ished by attached periostium. Osteotomies were performed with
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Copyright 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 27, Number 2, March 2016
tunnelization of the mucoperiosteal flap by leaving it attached on
most area of the mobilized bone fragment.12
Bone distraction techniques for maxillofacial skeleton in
humans were started by McCarthy et al in the 1990s by mandibular
lengthening, creating the concept of regenerative bone surgery.
After that time, bone distraction was also used for alveolar bone
augmentation.7
Flapless implant insertion technique was developed in 1970s by
Branemark but was largely adopted for implant surgery only at the
beginning of 2000. Rationale for this technique was the concept that
periosteal nourishment for alveolar bone walls was of paramount
importance in optimizing bone regeneration around implants by
leaving the periostium attached to the alveolar cortical plane.10,12
Autologous PRF use for improving bone regeneration in regen-
erative bone surgery was first prospected in oral surgery by Dohan
et al in 2006 showing improvement in alveolar bone augmentation
surgery.8
Based on these concepts and techniques, the authors devel-
oped a new split crest technique, which was further improved
during years through several steps and original modifications.
First step was the use of flapless concept adapted to split crest
technique, followed by elimination of proximal and distal osteo-
tomies at the expanded alveolar site. Then shift of the alveolar
gingiva incision from the mid crest to the palatal or lingual side
for better coverage of the osteotomy gap, followed by alveolar
gingiva elongation by scalpel release incision, and by double
level bone preparation for better primary stability. Finally, the
apposition of autologous PRF at the splitted bone gap concludes
the technique.
In the development of this technique some procedures were from
other authors, other ones, that is, preservation of periosteal attach-
ment on the buccal alveolar wall in splitting, double level implant
site preparation, and alveolar gingiva flap elongation by releasing
incision in alveolar gingiva are original.
Of course, before proceeding with the surgery, the general
health condition of the patient and the local situation should always
be fully assessed. We analyzed the alveolar bone anatomy in the
planned implant sites radiographically (panoramic x-ray, com-
puted tomography dentascan, cone beam, and lateral cephalo-
grams) and by meticulous specialist examination of the oral
cavity to assess vector (vertical or horizontal) and grade of the
ridge resorption.
The most common risks in implant surgery are postoperative
bleeding, possible pain, swelling, hematoma, infection, and if the
implant is inserted close to the lower alveolar nerve, tingling,
hypoesthesia, or hyperesthesia that may last for a long time
(612 months).
MATERIALS AND METHODS
Four patients were referred for evaluation for moderately edentu-
lous ridge reabsorption secondary to several previous extractions
(Figs. 1-3).
The treatment plan included rehabilitation with an implant-
supported restoration.
The patients past medical and social history were noncontrib-
utory, and they all had good oral hygiene. All the patients had no
contraindications to implant placement.
In this new modified technique, we performed palatal or lingual
incision double implant site preparation: split crest in the alveolar
bone followed by bone drilling for the basal bone by a flapless
technique with palatally or lingually shifted incisions, which
included partial thickness incision releases to elongate the gingival
flap for primary closure. The rationale of this technique is to obtain
a primary closure following the buccal cortex expansion technique
# 2016 Mutaz B. Habal, MD
The Journal of Craniofacial Surgery  Volume 27, Number 2, March 2016
FIGURE 1. Case 2 A, Panoramic x-ray and computed tomography dentascan of
case 2 selected for flapless split crest. A thin edentulous ridge is shown; B.
diagram on computed tomography slice of case 2 showing the split osteotomy
design (arrow) at the alveolar crest level and the implant site preparation by
drilling at basal bone level (cylinder); and C, sharp and smooth chisels for split
crest osteotomy cut and expansion, respectively.
by preserving its vascular supply and avoiding periosteal elevation
for increased cortical bone preservation.
Patient 1 was a 65-year-old man with alveolar bone resorption at
the level of 11 who was subjected to alveolar split crest with flapless
technique on the buccal side. Implant insertion was performed at the
same time of alveolar expansion performing a double level implant
site preparation following our technique. Primary closure was
possible after alveolar mucosa release incision.
FIGURE 2. Case 2 Flapless split crest technique: A, palatal shifted incision; B,
split crest with smooth chisel expansion; C, implant insertion with double level
site preparation; D, adherent gingiva elongation by scalpel incision; E, primary
closure; and F, temporary prosthesis positioning after refinements in both
transversal and vertical dimension.
# 2016 Mutaz B. Habal, MD
Copyright 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
FIGURE 3. Case 3 A, Preoperative panoramic x-ray; B, computed tomography
dentascan slices; C, palatal incision with alveolar gingiva elevation without
buccal flap elevation; D, split crest osteotomy; E, implant insertion after
expansion; F, autologous platelet rich fibrin gel positioning; G, alveolar gingiva
incision for elongation; and H, primary closure.
Patient 2 was a 40-year-old woman with alveolar ridge atrophy
at the upper left side (Fig. 1). Implant insertion was performed at 22,
23, and 24 position after palatal incision, flap elevation up to the
buccal crestal level without periosteal elevation on the buccal
alveolar wall, split crest flapless without proximal and distal bone
cuts, and double level implant site preparation following our
procedure (split crest at the alveolar level and current implant kit
drilling at basal bone level after alveolar crest expansion).
Attached mucosa elongation was achieved by performing
release incision by scalpel. Temporary prosthesis was positioned
after refinements in both vertical and transversal dimension after
alveolar ridge transversal expansion (Fig. 2).
Patient 3 was a 60-year-old woman showing alveolar bone
atrophy at the level of 11 and 12 after extractions. Same implant
surgical procedure as in case 2 was performed. Autologous PRF gel
was applied at the osteotomy site to promote bone healing (Fig. 3)
Patient 4 was a 35-year-old woman showing alveolar bone
atrophy of the upper left side after extraction of 14, 15, and 16.
Implant insertion was performed following the aforementioned
technique with implant insertion at 14 and 15 positions with
autologous PRF application, flap elongation, and primary closure.
Surgical Technique
After administration of local anesthesia, a palatally (maxilla) or
lingually (mandibular) shifted incision was made to gain access to
the underlying bone ridge: periosteum elevation was performed
only on the alveolar ridge up to the vestibular cortical wall.
Definition of flapless is related to the shifted mucosa incision from
crestal to palatal or lingual side with periosteal elevation just up to
the buccal border of the alveolar crest, leaving in this way the
periostium attached on the buccal alveolar bone. Split crest was
performed making a thin milling at alveolar crest edge, and then
combining first sharp and then smooth osteotomes insertion for
expansion (Fig. 2).
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Brief Clinical Studies The Journal of Craniofacial Surgery
Chisel insertion is performed only at the alveolar ridge level to
obtain alveolar crest expansion by smooth chisel insertion. After
sufficient alveolar crest expansion is obtained, basal bone drilling is
performed by traditional implant kit drilling to obtain firm primary
stability at implant insertion (Fig. 3). The rationale of this technique
is related to the common observation of sufficient bone wideness
usually available at the basal bone level even in alveolar crest
atrophy. With this double level implant site preparation advantages
of alveolar bone expansion are combined with firm primary implant
stability, frequently difficult to obtain with traditional split crest
techniques.
Rotating drills of the implant kits are used in the basal bone
preserving an adequate bone thickness for buccal and medial bone
walls. With this method, there is preservation of the vascular supply
of the vestibular cortical wall leaving the periostium attached on the
vestibular side, without any vestibular, mesial, and distal osteo-
tomies. In case of difficulties, to expand short alveolar arch sectors
between adjacent teeth, additional osteotomies at the mid crest
cortex alveolaris of adjacent teeth can be performed.
To obtain an optimal implant insertion, stabilization, and bone
contact, a 2 levels implant site preparation was performed: split
crest flapless technique for alveolar bone and small amount of basal
bone and additional and traditional drilling preparation by implant
kit at the basal bone level (usually showing sufficient thickness).
In this way, optimal implant stability was obtained simul-
taneously to adequate alveolar expansion, bone stability over time
for adequate cortical walls thickness, and optimal nourishment from
native periosteum with attached gingiva covering. Expansion with
smooth chisel continued until appropriate site preparation for the
selected implant was obtained before performing the second step of
surgical preparation with traditional implant kit drilling. Final
expansion was maintained by the implants itself insertion. The
implants (Exacone Leone, In-Kone Tekka, Straumann Bone level)
were positioned at the same time of surgery; bone level implants
were preferred for the patients (Fig. 3).
A Vicryl polyglactin (91, 3/0) absorbable suture was used to
close the flap.
To obtain a primary closure of the flap, essential for proper
healing of the osteotomy site, partial releasing incisions technique
by scalpel at the mid-crest fibromucosa was performed for flap
elongation. This aspect is particularly important because of the
impossibility to apply a traditional membrane on the split crest
osteotomy at the time of this flapless technique.
Platelet rich fibrin application was used at the osteotomy site. In
this way all the bone deficiency at the osteotomy site was covered
by fibromucosa after PRF application at the osteotomy site for
best healing.
Postoperative therapy required good oral hygiene, rinsing with
mouthwash containing 0.2% chlorhexidine solution twice a day to
enhance plaque control, and an evening application of the same
product in gel form, as well as the administration of a nonsteroidal
anti-inflammatory aid (ketoprofen 80 mg) for 3 consecutive days in
association with oral antibiotic (amoxicillin 1 g  2) administration
for 5 days.
In 2 of these patients, metronidazole powder 1000 mg was also
used in the bone gap to prevent postsurgical infections.
Particular attention must be paid to temporary prosthesis adap-
tation in immediate postoperative period.
Inappropriate early clinical loading by direct contact between
head implant, expanded bone surface, and prosthesis surface
must be mandatorily avoided to prevent implant bone-integration
failure.15
To obtain this goal temporary prosthesis were accurately trimmed
in vertical and horizontal dimension because of the alveolar ridge
transversal expansion after split crest surgical procedure.
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Copyright 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 27, Number 2, March 2016
Attention must also be paid to the stability of the temporary
prosthesis under masticatory pressure to avoid any contact between
implant and buccal alveolar crest surfaces.
This aspect is one of the most frequent reasons for implant
failure, particularly when bone augmentation surgical procedure is
performed.15
RESULTS
All of the 4 patients had good results: there were no problems at
surgery time, postoperatively, and during the period of osteointe-
gration. All implants achieved osteointegration with a good degree
of primary stability.
All patients underwent an uneventful 1-stage implant surgery.
All implants were placed according to the manufacturers instruc-
tions, achieving primary stability (35 Ncm). No intraoperative
surgical complications were recorded.
The clinical healing was optimal in the short-term and no
dehiscence was reported.
These results were obtained by accurately managing immediate
and late postoperative period in all of the operated patients.
Particular attention was paid to oral hygiene, and to inappropri-
ate early clinical loading at immediate and late postoperative time.
DISCUSSION
From a recent literature analysis, 2 rules are mandatory in implant
surgery associated with alveolar bone augmentation for long-term
results: alveolar cortical bone preservation (2 mm for each side),
bone vascular preservation. To achieve these 2 goals a new split
crest flapless-modified technique was performed obtaining ade-
quate buccal and lingual cortical thickness: this is a rare condition in
implant surgery, fundamental for implant long-term survival.5,16
The first step was the use of a flapless concept adapted to the split
crest technique, followed by elimination of proximal and distal osteo-
tomies at the expanded alveolar site. Second step was the shift of the
alveolar gingiva incision from the mid crest to the palatal or lingual side
for better coverage of the osteotomy gap, followed by alveolar gingiva
elongation by scalpel release incision; and by double level bone
preparation for better primary stability. Finally, the apposition of
autologous PRF at the splitted bone gap concludes the technique.
In the development of this surgical procedure, some techniques
were used from other authors, other ones, that is, preservation of
periosteal attachment on the buccal alveolar wall in bone splitting,
double level implant site preparation, and alveolar gingiva flap
elongation by releasing incision at the alveolar mucosa are original
to this group.
Because of the development of this technique through several
modifications during the past 10 years, we presented here 4
homogeneous and consecutive cases that were operated with the
latest development of the surgical technique.
This technique is important for the choice of the implant length:
because of the alveolar ridge nonflat conformation, a 4 mm
diameter cutter use will result in a vertical ridge decrease of at
least 2 mm.17 Because of the presence of the mandibular canal and
maxillary sinus anatomy, meticulous measurements in case of
relevant vertical bone loss have to be taken.
With the split crest flapless technique we developed, vertical
bone loss is negligible, because minimal is the crest drilling impact.
There is a height ridge saving during implant site preparation
because of the double level technique: flapless split crest at the
alveolar and basal bone level without implant cutter kit use,
subsequently performed at the basal bone level only for optimal
primary stability after alveolar bone expansion.18
In the traditional split crest techniques the sectioned cortical
walls of the expanded segments are subjected to periosteal elevation
# 2016 Mutaz B. Habal, MD
The Journal of Craniofacial Surgery  Volume 27, Number 2, March 2016
and will undergo resorption because of lack of nourishment,
particularly for the thin buccal cortex, followed by implant thread
exposure. The advantages of the aforementioned double preparation
in split crest technique consist of: preservation of cortical wall
without proximal, basal, and distal cortical cuts and without peri-
osteal elevation; better stability and larger contact surface between
implant and bony site.17,19
The use of piezosurgery was avoided, because we have
increased sensitivity during surgical preparation with osteotomies.
By using osteotomes it is possible to detect the difference in
consistency between the trabecular and cortical bone, which is
not always easy with piezosurgery, with risk of fenestration for the
vestibular cortex. Osteotomy use is anyway necessary to obtain
crest enlargement after the split osteotomy. Furthermore, piezo-
surgery may be useful only for superficial osteotomies. For deeper
osteotomies with larger bone friction there is the risk of damaging
the cortical wall by heating it with the piezo-insert particularly for
buccal cortex, where the bone wall is very thin and prone to
resorption after periosteal elevation.2021 For this reason it is
essential to preserve the periosteal supply as reported in periodontal
literature.13
With this flapless technique with lingual or palatal mucosa
incision, buccal alveolar cortex is preserved by shifting incision
and periosteal elevation on palatal or lingual sides where cortical
wall are thicker and more resistant to resorption. Periosteal
elevation is performed up to the buccal border of the alveolar crest,
thus leaving the periostium attached on the buccal alveolar bone
wall. In this way nourishment of the buccal alveolar wall is
preserved preventing alveolar bone fenestration and periimplantitis.
For these reasons, this type of technique will prevent implant-
prosthesis failure and subsequent medicolegal consequences by
reducing the possibility of vestibular bone fenestration and related
periimplantitis.22
Recent literature suggests it is essential to leave unchanged the
vascularity of the site, as evidenced by Schwartz-Arad.10,23 To
allow proper osteointegration with good healing of the surgical sites
and to assure primary closure of the surgical site, releasing incisions
by scalpel at the mid crest collapsed fibromucosa were performed
obtaining sufficient flap elongation.
To promote bone healing at the osteotomy sites PRF was also
used. Platelet rich fibrin seemed to assure a better soft tissue healing,
making wound healing faster.24 Even in case of PRF membrane
exposure, there is no risk of membrane infection or bone loss, as PRF
can assure also a second intention healing of the soft tissues. More-
over, several clinical articles have demonstrated the effectiveness of
PRF in promoting the healing of surgical wounds; the PRF has, in fact,
platelet growth factors that can improve the vascularization of
surgical sites, promoting neoangiogenesis.25
Platelet rich fibrin, if used in a regenerative chamber of native
bone fed by periosteum may help obtaining regeneration while not
having osteoinductive properties. The osteoinductive and osteo-
conductive power of PRF and the acceleration of wound healing
process have been already demonstrated by Schwarz-Arad et al.26
Following predictors criteria for implant success or failure15
great care was taken to oral hygiene, temporary prosthesis stability,
and trimming to avoid inappropriate early clinical loading of the
inserted implants and expanded bone by the surgical splitting
technique.
CONCLUSIONS
This new modified technique might find application as a standard
method for implant placement because of alveolar bone height
preservation after drilling of the curved alveolar crest and for the
ability to preserve a double nourished alveolar bone wall. It is a
# 2016 Mutaz B. Habal, MD
Copyright 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
predictable and safe technique compared with other alveolar bone
expansive techniques, without significant risk for hard and soft
tissue injury and also well accepted by patients. This method may
expand and create sufficient osseous width to appropriately support
implants by respecting 2 surgical rules from recent literature:
cortical bone walls and vestibular blood supply preservation with
better aesthetic outcome. This technique should be a good alterna-
tive to other surgical techniques. The rationale of this technique lies
in creating the conditions for an optimal regenerating bone chamber
for better long-term implant site bone stability by using nourished
native bone expansion and avoiding periosteal elevation on the
buccal cortical bone. Indication for this technique might reasonably
be extended to every implant insertion not only in cases with limited
alveolar bone thinness. In fact, conditions with 2 mm cortical bone
on both sides after implant insertion are very rare in implant surgery
without bone augmentation techniques.
In conclusion, the main advantages of this technique are: single
surgical stage, no donor sites, vascular preservation of vestibular
cortical walls, and preservation of alveolar crest bone height
avoiding vertical bone loss after implant kit drilling, preservation
of proper cortical thickness on both sides with native vascular
supply saving on vestibular side.
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The Coexistence of Rathke Cleft
Cyst and Pituitary Adenoma
Mingtong Gao, MD, Yanyan An, MD,y Zhihong Huang, MD,z
Jianyi Niu, MD, Xunhui Yuan, MD,z Yunan Bai, MD,z and
Liemei Guo, MD, PhDjj
Abstract: Both of Pituitary adenoma (PA) and Rathke cleft cyst
(RCC) are the most common and benign sellar lesions. Generally,
the origin of RCC is considered to be derived from remnants of
Rathke punch, while PA is formed by proliferation of the anterior
wall of Rathke pouch. Although they have a possibility to share a
common embryological origin, the coexistence of PA and RCC is
extremely rare. Here, the authors report a 50-year-old male patient
who was found to have a large cystic sellar lesion, and surgical
resection revealed components of a RCC coexisting with a PA. This
collision reminded us of the possibility of RCC coexisting with PA.
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Copyright 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 27, Number 2, March 2016
Furthermore, a clinicopathologic relation of them were reviewed
and investigated.
Key Words: Coexistence, pituitary adenoma, Rathke cleft cyst
P ituitary adenoma (PA) is the third most common primary brain
tumor, with an average frequency of approximately 14.4% in
the general population at autopsy,1 while Rathke cleft cyst (RCC) is
reported to be found incidentally in 11% to 33% of postmortem
examinations.2 Generally, the origin of RCC is considered to be
derived from remnants of Rathke punch, while PA is formed by
proliferation of the anterior wall of Rathke pouch.2 Thus, they have
a possibility to share a common embryological origin.2 The coex-
istence of PA and RCC, however, are extremely rare, and only a few
cases have been reported.2,3 Here, we report a rare RCC with
concomitant PA, to remind the rare possibility of collisions.
CLINICAL REPORT
A 62-year-old woman presented to the department with severe
headache and visual field defect for 1 month. Her medical history
was unremarkable. Physical examinations showed biotemporal
visual field defect. Laboratory examinations including of endocri-
nological levels were within normal limits. Cranial magnetic reson-
ance imaging (MRI) demonstrated a large cystic mass in the sellar
region, and enhanced MRI with contrast showed peripheral
enhancement (Fig. 1A-B). The patient underwent minimally inva-
sive endoscopic transnasal transphenoidal pituitary resection. Once
the sellar floor was exposed (Fig. 1C), an incision was made in the
dura, releasing a large amount of cream white fluid from the cyst
(Fig. 1D). After removal of fluid, a mass was demonstrated located
at the cyst cavity (Fig. 1E). The mass was resected carefully and
completely (Fig. 1F, Fig. 2A-B), and pathologic analysis confirmed
the diagnosis of RCC consistent with PA (Fig. 2C-D). The patient
had an uneventful postoperative course and was discharged in a
stable condition.
DISCUSSION
Till now, a number of RCC coexising with PA have been reported,
and most of the PAs are prolactinomas, followed by GH-secreting,
corticotrophic, and nonfunctioning PAs.2,3 The coexistence of RCC
and PA has been described in up to 2.1% of patients with sellar
region.3 In another study involving 464 patients, RCCs have been
found to be associated with 1.7% of the PA cases.2
Generally, RCCs are believed to arise from remnants of Rathke
pouch, a structure apparent during the third or fourth week of
gestation and formed by the infolding of the roof of the stomo-
deum.2,4 Between the anterior and the posterior walls that form the
From the Department of Emergency, Affiliated Hospital of Weifang
Medical University; yDepartment of Ultrasound Imaging, Maternal and
Child Care Service Centre of Weifang, Weifang; zDepartment of
Neurosurgery; Department of Neurology, Yidu Central Hospital of
Weifang, Qingzhou; and jjDepartment of Neurosurgery, Renji Hospital,
Shanghai Jiao Tong University School of Medicine, Shanghai, China.
Received September 13, 2015.
Accepted for publication November 6, 2015.
Address correspondence and reprint requests to Liemei Guo, MD, PhD,
Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong
University School of Medicine, No. 160, Pujian Road, Pudong District,
Shanghai 200127, China; E-mail: guolm001@126.com
The authors report no conflicts of interest.
Copyright # 2016 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000002371
# 2016 Mutaz B. Habal, MD