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3. Ferri J, Dujoncquoy J-P, Carneiro JM, et al. Maxillary reconstruction to
enable implant insertion: a retrospective study of 181 patients. Head
Face Med 2008;4:31
4. Lee H-G, Kim Y-D. Volumetric stability of autogenous bone graft with
mandibular body bone: cone-beam computed tomography and three-
dimensional reconstruction analysis. J Korean Assoc Oral Maxillofac
Surg 2015;41:232–239
5. Restoy-Lozano A, Dominguez-Mompell JL, Infante-Cossio P, et al.
Reconstruction of mandibular vertical defects for dental implants with
autogenous bone block grafts using a tunnel approach: clinical study of
50 cases. Int J Oral Maxillofac Surg 2015;44:1416–1422
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evaluation of graft morphology, orientation, and embryonic origin. Plast
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7. Oikarinen KS, Sàndor GKB, Kainulainen VT, et al. Augmentation of the
narrow traumatized anterior alveolar ridge to facilitate dental implant
placement. Dent Traumatol 2003;19:19–29
8. Andersson L. Patient self-evaluation of intra-oral bone grafting
treatment to the maxillary frontal region. Dent Traumatol
2008;24:164–169
9. Chung VH-Y, Chen AY-L, Jeng L-B, et al. Engineered autologous bone
marrow mesenchymal stem cells: alternative to cleft alveolar bone graft
surgery. J Craniofac Surg 2012;23:1558–1563
10. Schliephake H. Clinical efficacy of growth factors to enhance tissue
repair in oral and maxillofacial reconstruction: a systematic review. Clin
Implant Dent Relat Res 2015;17:247–273
11. Mendez BM, Chiodo MV, Patel PA. Customized «in-office» three-
dimensional printing for virtual surgical planning in craniofacial
surgery. J Craniofac Surg 2015;26:1584–1586
Coronal Split Corpus Osteotomy
of the Mandible: A Modified
Visor Osteotomy Technique for
Bone Volume Enhancement
Mustafa Sancar Ataç, DMD, PhD and Yeliz Kilinç, DMD, PhD
Abstract: The bony augmentation of severely atrophied mandible
is generally required for the purposes of prosthetic rehabilitations.
The treatment strategies have been well defined in the literature
ranging from osteotomy techniques to distraction osteogenesis.
Visor osteotomy is the milestone of the reconstructive surgery
for the atrophied mandible which has received some modifications.
In the present study, the authors describe a new modification of
visor osteotomy in which a complete coronal split osteotomy down
to the inferior border at the mental region has been performed. The
main advantage of this modification is to preserve the lingual cortex
From the Department of Oral and Maxillofacial Surgery, Faculty of
Dentistry, Gazi University, Ankara, Turkey.
Received December 16, 2015.
Accepted for publication July 28, 2016.
Address correspondence and reprint requests to Yeliz Kilinç, DMD, PhD,
Specialist of Oral and Maxillofacial Surgery, Research Assistant,
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry,
Gazi University, Bişkek Cd.(8. Cd) 82. Sk. No: 4, 06510 Emek, Ankara,
Turkey; E-mail: dtykilinc@hotmail.com
The authors report no conflicts of interest.
Copyright # 2016 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000003134
# 2017 Mutaz B. Habal, MD
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
from the inferior border of the mandible up to the alveolar region
without disturbance of the suprahyoid muscle attachments. The
procedure is thought to be a ‘‘highly sensitive’’ one and undesired
fractures may occur during splitting of the bony segments.
Key Words: Mandibular augmentation, preprosthetic
rehabilitation, visor osteotomy
A favorable 3-dimensional bone volume of mandibular ridge
must exist for implant placement to fullfill the prosthodontic
and esthetic criteria of rehabilitation. Several surgical procedures
have been advocated for bone augmentation of the atrophic mand-
ible.1,2 Current techniques include onlay bone grafts, ridge splitting,
subperiosteal membrane-guided regeneration, alveolar osteo-
tomies/sandwich grafts, interpositional grafts, mandibular inferior
border grafting, distraction osteogenesis, and the use of growth
factors.3,4
One important alternative in the reconstruction of atrophic
mandible is preprosthetic reconstructive surgery using autogenous
bone graft prior to the placement of osseointegrated dental
implants.5
The visor osteotomy, first described in 1975 by Harle, was
initially performed for the reconstruction of severely resorbed
edentulous mandibles.6 The procedure involved a parasagittal
osteotomy of the mandible from body to body, with the lingual
plate of bone raised superiorly and pedicled to the lingual soft
tissue.7 The classic osteotomy was further modified by Stoelinga
et al8,9 to include a horizontal osteotomy in the anterior mandible
with autogenous bone placed within the interpositional gap. Peter-
son10 described a similar technique to the anterior mandible and
suggested a horizontal osteotomy extending between mental fora-
mens, allowing the insertion of autogenous bone blocks between
segments.
In the present article, the authors propose a combination of
previously described techniques of Harle and Stoelinga in the
mental region. The authors have focused on 3-dimensional man-
dibular osseous volume enhancement for preprosthetic purposes
prior to dental implant installations and for denture applications
as well.
METHODS
Ten patients (7 women, 3 men) with severely atrophied mandibles
underwent augmentation surgery with autogenous bone harvested
from anterior ilium. Panoramic radiographs and cone beam com-
puted tomography scans were used preoperatively to assess bone
height and shape. The age of the patients ranged from 30 to 56-year
old. Informed consent was obtained from all patients prior to
surgery. All operations were performed under general anesthesia
via nasotracheal intubation. Cephazoline sodium was administered
before surgery. The patients were treated with the modified osteot-
omy technique as follows.
A mucosal incision at the cheek and labial sides of vestibular
fornix was performed from 1 retromolar region to contralateral side
(Fig. 1A). After elevation of the mucosal flap an incision on the
periosteum over the alveolar crest was initiated and periosteal flap
was raised to reach to the bone (Fig. 1B). Mucosal and periosteal
dissections were continued in all directions to identify the mental
nerves. The crestal osteotomy was initiated close to the lingual side
at the premolar and molar region beginning from the alveolar crest
to the mylohyoid ridge (Fig. 2A and B). Further at the anterior
aspect of the mandibular body, 2 parallel vertical osteotomies just
mesial to the mental foramen were performed at the lateral cortex
without touching the lingual cortex and these vertical osteotomies
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Brief Clinical Studies The Journal of Craniofacial Surgery  Volume 28, Number 2, March 2017

FIGURE 1. (A) Mucosal incision. (B) Periosteal flap.

FIGURE 3. (A) Inferior border osteotomy. (B) Intraoral view of the inferior
border osteotomy.

FIGURE 2. (A) Design of the coronal split corpus osteotomy. (B) Intraoperative view FIGURE 4. The bone grafts are stabilized with miniplates and screws.
of the coronal split corpus osteotomy after mobilizing the osteotomized segment.

were connected with a horizontal lateral cortex osteotomy above the
inferior border leaving the lingual cortex intact (Fig. 2A and B). The
osteotomy continued with the inferior border osteotomy (Fig. 3A
and B). By using the angled tip of the piezosurgery instrument, the
osteotomy was carried out from the inferior border upward at the
mental region (Fig. 3A and B).
Once the osteotomies were completed, the splitting procedure
was achieved by using a thin spatula osteotome. The segmented
lingual cortex including the osteotomized anterior segment was
slided coronally. The corticocancellous bone that has been obtained
from the anterior ilium simultaneously was used to augment the
bony gaps (Fig. 4). The harvesting technique was described pre-
viously by the authors.11,12 All bony segments and grafts were
stabilized by means of titanium mini plates and screws. The edge of
mucosal flap was sutured to the edge of the periosteal flap with
resorbable sutures to enhance the soft tissue volume. Intravenous
antibiotic therapy was continued twice a day for 7 days
postoperatively.
After 4 months of healing, dental implants (Straumann Dental
Implant System, Basel, Switzerland) were replaced in a standard
fashion. Bone plates and screws were removed at the time of
surgery. Conventional prosthetic rehabilitation proceeded with
fixed bridges 4 months after implant placement.
RESULTS
Table 1 shows the data of patients treated by the coronal split corpus
osteotomy (CSCO) combined with interpositional bone graft. Ten
patients with severely atrophied mandibles were treated and fol-
lowed from 12 to 36 months. Interpositional grafting was performed
by autogenous bone blocks harvested from the anterior ilium.
Dental implants were placed in all patients.
Postoperative wound healing was uneventful in all patients.
All patients had some transient paresthesia in the postoperative
period. None of these patients complained of permanent anesthe-
sia. The maximum duration of paresthesia lasted 8 weeks.
Paresthesia was likely related to flap retraction of the mental
nerve. A bilateral fracture of the lingual cortex occurred in patient
1 and unilateral lingual cortex fracture occurred in patient
3 intraoperatively.
Remodeling of the vestibular sulcus was needed in 3 patients.
Patients 1 and 3 underwent sulcoplasty before dental implant

TABLE 1. Patient Clinical Features and Complications

Number of Complications Complications After

Patient Gender/Age (yr) Follow-Up (mo) Dental Implants (n) of the Procedure Dental Implant Placement

1 Female/56 18 8 Transient paresthesia, bilateral lingual cortex fracture Peri-implantitis (2 implants)

2 Female/30 36 4 Transient paresthesia None
3 Female/30 15 6 Transient paresthesia, unilateral lingual cortex fracture None
4 Female/49 12 5 Transient paresthesia None
5 Female/36 12 6 Transient paresthesia None
6 Male/50 16 6 Transient paresthesia None
7 Female/34 12 6 Transient paresthesia None
8 Female/54 20 7 Transient paresthesia None
9 Male/55 12 6 Transient paresthesia None
10 Male/56 36 8 Transient paresthesia Failure of the implant (1 implant)

e176 # 2017 Mutaz B. Habal, MD

Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery  Volume 28, Number 2, March 2017
FIGURE 5. (A) Lateral view of the patient before surgery. (B) Lateral view of the
patient after surgery. (C) Lateral radiographic view of the patient before surgery.
(D) Lateral radiographic view of the patient after surgery.
placement. Patient 2 received tissue expanders to enhance soft
tissue volume before CSCO.
One implant was lost due to the lack of osseointegration in
patient 10. Patient 1 experienced peri-implantitis around 2 implants
which responded to conventional therapy.
DISCUSSION
In the authors’ experience the modified visor osteotomy technique
is a useful method for establishing the anatomical morphology of
the mandible. The technique also restored the intermaxillary
relationship and it was possible to place dental implants in the
molar, premolar, and anterior areas.
In order to preserve the blood supply it is of fundamental
importance that the lingual pedicle of the soft tissue is not
damaged.13,14 In an experimental study by Frame et al15 it was
confirmed that the lingual pedicle was able to maintain the viability
of the coronal bone segment, allowing for rapid remodeling of the
interpositional autogenous bone graft. Due to the osteotomy design
on the inferior margin of the symphysis the risk of harming the
lingual flap and muscle attachments is minimized. The elevated
segment remains dimensionally stable because of the maintained
periosteal blood supply and the bone graft incorporates endosteally
from the adjacent bone marrow.6
The technique used in the present study allows 3-dimensional
reconstruction of the symphysis area. The osteotomy is extended
farther to the inferior margin of the symphysis, thereby increasing
the size of the lingual segment. Due to the reverse L-shaped design
of the osteotomy in the anterior mandible, the segmented bone is
easily manipulated and repositioned on the desired position. The
stable bone contact is maintained between the mandible and the
segmented bone. Then it is possible to obtain a bony reconstruction
both vertically and horizontally.
This modified technique also changed the lower lip protrusion
(Fig. 5A–D). This can be attributed to the coronal split design of the
osteotomized segment. When the segment is lifted upward, the
segment naturally moves toward the anterior side, thereby causing
protrusion of the lip. This effect has greatly improved the facial
aesthetics in the patients.
# 2017 Mutaz B. Habal, MD
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
The double-layered flap approach in which the mucosa was
raised separately over the periosteum contributed a tension-free
closure, thus avoiding wound dehiscence.
Coronal split corpus osteotomy is a reliable technique to recreate
the anatomical morphology of mandible. However, the procedure is
highly sensitive and there is a risk for lingual cortex fracture. The
experience of the surgeon would be enough to manage the possible
complications that might occur regarding this technique. A bilateral
and unilateral fracture of the lingual cortex occurred in patient 1 and
patient 3 respectively. The occurrence of the fractures may be
attributed to the long extension of the crestal osteotomy. Therefore,
crestal osteotomy should not exceed too far to the posterior of the
first molar region.
In conclusion, although CSCO is a sensitive technique itself,
it provides an intraoral lingual genial cortex with muscles
remained intact with good blood supply. In combination with
iliac bone grafting, the enhanced bone volume meets the ana-
tomic, esthetic, and preprosthetic requirements of severely
atrophied mandible.
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