Saggital Split: What are the Criteria?

You have a good question, but I have one for you as well. This is a case that obviously needs some bone augmentation. Why not refer to a specialist that does this on a daily basis? Dentistry is losing its "team" approach as more and more general dentists want to do everything in an attempt to make more revenue. Very sad for our profession. I am going to answer this in a manner that will help you learn how to do this correctly. First of all, you have 3-4mm of ridge. From your description, it sounds like you are talking about the posterior mandible. So, the first question you need to answer is what size platform are you going to use? This is going to determine how much bone you need. If you want to place a 5mm diameter implant, you need Xmm of bone (I am not going to tell you how much...go look it up) Now that you know how much bone you need, you must determine which augmentation procedure is going to give you the width of bone that you desire. Should you simple GBR with a Ti-reinforced membrane? Maybe tenting screws? Ridge split? How about a ramus graft? Or what about a symphysis graft? Do you need some tibial, calvarial, or hip grafting? There is alot of good lit out there that will tell you how much bone you can expect to gain from these grafts. You will learn and retain much more if you look it up on your own than if I give you the answer.

In this cases i have used the technic by Dr. Shary Dager from Boston. It is an Split of the ridge with a very good results in 10 cases i did in this year and them placed implants 5.1mm width Type Endure by IMTEC

The master of all masters for splitting ridges is Dr. O'Hilt Tatum. Try to catch him on one of his lectures tours, or at the upcoming AAID annual meeting in San Diego end of October. Dr. Tatum is very approachable and he will be pleased to speak with you on a one to one basis.You will probably find him hanging out at the Tatum Surgical booth.... and he loves to talk and share his knowledge. Bare in mind, when a ridge is so thin, it is basiacally two cortical walls, one buccal and one lingual sealed together. It is very difficult for anyone, let alone a beginner, to be able to split this ridge without damaging the walls. Ordinary high speed surgical burs will chatter, and take away too much bone, chisels may fracture the bone, etc. There are specialized tools for this proceedure. Best advice, give it to an expert, with a lot of experience, and sit next to him/her when doing the procedure...... your patient will thank you. Gerald Rudick dds Montreal

Are you using CT imaging? Make sure that you have at least 3 mm of width or you'll have to do the augmentation on the fly with the materials and know-how you have on hand. If you are going to split the ridge use the Micro saw from Dentsply Friadent and get a Palti ridge splitting kit from STOMA (german instrument company). Make sure that you have a Plan B in the case that your saggital split splits up. What would your plan be if the ridge fractures. What other tricks do you have in your bag? RTKR suggests that specialists have the know how, but guess what, you see them in the same courses that you can and should take. No one does these techniques in residency, I saw it demonstrated by Ady Palti in a course I took in Germany. Get the necessary instrumentation and speak to someone who has done it.

IF you do block grafts in this case as another suggests, the preparation of the recipient site would be destroyed and you would loose even more height.

Dr. Morales' clinical comments are all well taken and he is clearly very knowledgeable, but his commentary in the first paragraph is an overgeneralization. Dentistry has not "lost its team approach as more and more generalists want to do everything in an attempt to make more revenue". This statement says that the only reason a general dentist is interested in doing more advanced surgical procedures is greed!!! Give me a break. This statement sounds like typical "turf protection" from a specialist. (By the way, I am a specialist). Yes, if not properly trained or inexperienced, this procedure is best done by a specialist or someone properly trained. But guess what, more and more generalists are getting properly trained. Additionally, while the team approach can often work very well, there are also many instances in which such an approach can be very inefficient and even disastrous.

I apologize, the above comments are regarding RTKR's comments, not Dr. Morales

Nice on RTKR. I wonder how much you really know! We could answer any question with, "Go look it up". If a colleague is sensible enough to ask advice, he is already deferring to those with more experience and should be advised accordingly (if you can see past your ego to do so). I have placed around 5,000 implants in a specialist practice, and now often employ very tapered implants which naturally expand the ridge as they insert. The chance of plate fracture is greatly reduced cf. the ridge split technique,and, if you employ a no-flap technique, the periosteum will still be on the bone to enhance healing of small fractures. A 3-4mm ridge should (in most cases) expand quite easily to accommodate a 4.5mm platform. Good luck!

Dr. Murray gives excellent advice. Yet I am still in the dark regarding the exact location of this thin ridge. Could Dr. A give us more details?

Regarding who should be doing these more advanced surgical procedures, I suggest its someone with knowledge and experience whether its a general dentist or a specialist. Most of us can learn to do these treatments given the proper training which should include hands-on practice and if possible live surgeries with qualified colleagues. However in general, a surgical specialist will have a much better foundation of training and experience in various surgical modalities and the ability to react to the unexpected and to complications. Its because a surgeon is carrying out these procedures daily, not occasionally. And its not surprising you see specialists in the same courses you attend. It never hurts even the most seasoned and capable surgeon to see what's new and find out how others approach treatment planning and treatments. Even a good surgeon will occasionally refer certain cases to another practioner who may be better qualified. So suggesting that a general dentist should consider referring more advanced cases only makes sense and shouldn't be taken as belittling general dentists.

I will avoid any arguments about who should do this and just address the question. How much bone do you have vertically? Does the bone get wider apically rapidly or is it thin for a long ways? After these questions then I wounder if you have done ridge splits? I absolutely would not consider doing this site as my first. Secondly any time you do a split be prepared for a ridge fracture because that is the logical complication.

Dear all (even if you are a GP): Sagital Splitting come from Oral and Maxillofacial Surgery. The technique consist in splitting the mandible horizontal and vertical ramus in two sagitally (you open it like a book-Obwegeser-Dal Pont). By doing this you will obtain two free pieces of bone. If you want to do it in alveolar bone then you are talking more about rigid ridge expansion (you want to separate the upper part while having the bottom attached together or you wil have a free bone graft) There are several things to consider (and previously mentioned above) How much length of available bone you have( and will it be enough to anchor the apical part of a long implant wiyh enough stability to atempt a GBR technique over the expossed crestal part?) How much width? Do you have some espongious bone in between the two corticals or just one cortical plate that you need to cut in two. (literature says min 3mm). Is it in the front or in the back part of the mouth (more room to work in the anterior area). Do you have the apropriate tools (oscilating saws, sagital saws, diamond discs, Mectron piezosurgery device, chisels, retractors and periostotomes, screw expansors, osteotomes -only in the upper- or special kits like Palti from Stoma or the one from Messinger) and know how to use all of them? Do you know how much they cost and how many of this cases will you do in a 5 year period? Will the vascularization of the expanded bone be preserved by partial thickness flaps maintaining the periostium intact? If your answer is yes Then you can try to do it. No matter if you are a craniomaxillofacial surgeon or a general dentist only the ones who have the knowledge and ability should do it. Best regards to everybody P.P.

Dr. Rudick is correct-Learn from Dr. O. Hilt Tatum.

Lets try a different approach. Im a Oral surgeon, trained in oral surgery techniques and try to provide the very best care to my patient within that arena. Now what if I started doing veneers because I took a weekend course by Dr. Dorfman. Now sure Im a Dentist first, but I will be the first one to tell you I am not qualified to do what a very good cosmetic dentists does every day with restorations. I am not qualified because I dont have the training or the armamentarium to to cosmetic (this is but one example, I think any smart person can read between the lines). We all need to be held to a standard of care in order to elevate our profession. What RTKR is saying is that you can do implants but why not refer the case that your clearly not comfortable with(since you had to ask the question on how to treat) to a more qualified person ( that person can be a specialists or someone who had advanced implant training like at NYU or loma linda). I became a specialist in order to do what I feel I was most qualified to do and SUPPORT THE GENERAL DENTIST in the care of his patients. LET ME RESTATE "SUPPORT THE GENERAL DENTIST IN THE CARE OF HIS PATIENTS". This has nothing to do with a specialist protecting his tuff. This has to do with specialists and general dentists working togethor for the betterment of the patient. I agree with RTKR that dentistry is losing the team approach, and dentistry as a profession is going to suffer. OH to Dr.Jimenez you see surgeons at those CE course because our state board requires us to have continuing education and its important for us to be always on the cutting edge on the latests surgical techniques in our field. Ask yourself do you see many surgeons at courses on restorative?

Excuse me, but the last time I checked DDS did involve surgery.

I agree with the different techniques described especially Dr.P.P What I would like to state in this ongoing snarl between generalists n specialists is that sometimes there are cases equally well done by GPs but then there's always a 1% case that goes awry n thats when you feel you should have the specialised background to tackle the situation with plan B or C. No offence meant but I used to feel the same way as GPs do about specialists till I did my Maxfac. postgrads. The specialisation sometimes maynot help you do a case better but it may help you get out of a sticky situation in practice. All the best to all of us.

Case discussions, even where indications for a specific surgical technique is referred to discussion, should be accompanied by all data available like radiographies and intraoral views. Evaluating the patient and debating on the indicated surgical method would be more sounding, not?

All this bickering over specialist vs GP just gives some predatory lawyers or sue happy patients more ammo to go after us with. You guys are going to have to eventually sleep in the bed you've made. Dentists are just a bad bunch especially to each other!!! Now would you high powered pontificating specialists and other assorted blowhards just answer Dr A's question on the criterion on ridge splits!.......... or don't you know the answer??

ManOSteel, If you keep talking like that, you will get the king of the answers! Do not pock your nose into bussiness you do not know. Be clever! If anything happens to your patient, specialists that you do not like will collect your ass.

Cos Turk : Evidently you didn't read my response thoutoughly or you are not capable of comprehension. Your response just TOTALLY reinforces what I said!!!! in illogical English!! And your specialist "friends" will can your ass just as easily as mine! If you're so smart then why dont you just answer Dr A's original question??...... probably because you can't!! And by the way business is spelled "business".

Take a good course ...then take another one ...then another one...review the literature...try to forsee the possible pitfalls and complications...then do it as many times with a friendly mentor who has the necessary skills and knowledge as you need to give you the confidence to fly on your own...then do it! "'Nuf Said?"

Way less than 50% useful answers to the question. As an assistant, I appreciate answers FAR more than flames. So... RKTR & MainOSman, do you know the answer? ps: I think most of the questions from A and Anon, et al, are rhetorical and intended to generate action, not answers. Raising the BP of RKTR & MainOSman is just an added benefit!

dear A, u already have 3-4mm of bone . 1. if it is anterior u can use 3.3 mm ( provide 4.3mm is min. width of bone ) of implant. or u can split the ridge , provided lot of amount of cancellous bone is present. 2. if it is in post. area, if lot of amount of cancellous bone is present THEN ridge split can be used, taking care of inferior alveolar nerve.( 1-1.5 mm can be gained.) or u can use onlay grafting with membrane.( preferred & can gain 2-3mm) 2.If any time of ridge split , the split ridge breaks then forget about placing implant, go for bone augmentation ( can use alloplast) & membrane placement & do the implant after 6-8 months. goodluck

Mike Stanley I really like your no-nosense approach.I really admire your knowledge and kin interest,which may be hard to find in an asistant. Keep it up.

Dr. Joshi, Thank You. I haven't progressed far into Misch's book yet, but I love studying this stuff. I wish more doctors shared our interest in progress and learning. James, yet another cogent answer. Since we arent' doing splits yet, I can guide conversation with our patients in the right direction before we do a referral.

Let me draw another analogy. I've been doing endo and post cementation for a couple of decades. I'm familiar with the procedures. I have a vast majority of successes and a small minority of failures. Before I knew what implant surgery was all about, I'd assumed that I would need a postgraduate degree to do it. But then, I started doing it under supervision and discovered a secret. It's not rocket science. One morning, my implant patient came late. An endo patient was scheduled after her. I had only 30 mins to place an implant. Upper molar, 10mm wide ridge and 10mm from the sinus floor. I prepared the osteotomy, placed a 5x8.5mm Osstem GS2 and closed up in 30mins. My endo patient didn't have to wait. But finding all the canals in that molar took me 1 hour. And I charged less for the endo (more visits to follow) than for the implant placement. When it was time to restore the implant, I just screwed in an impression coping, took a silicone impression ... all in less than 30mins. With the endo-treated tooth, I had to carefully remove gutta percha to avoid perforation before I cemented the posts, built up the core and then took the impression. Took me more than 1 hour. There are simple and straightforward cases, there are complex cases in every specialty. The secret about implant surgery, is that it's much easier to get that twist drill (or bone reamer in the case of Bicon) going in the right place and direction for a straightforward case than to get a gates glidden bur to go in the right place and direction even in a most straighforward case. It may hit many people's ego, but I think it's far harder to replace good dental technicians than to replace good dentists. Good, aesthetic lab work is an ART. I would go as far to say that it requires some rare talent to produce really good ceramics. The most simple, straightforward implant surgery is very fast and easy. In fact, it can be quite mechanical and definitely far more lucrative, hour for hour than many other complex procedures like endo. If I were an oral surgeon, it certainly benefits me if I only do simple implant surgery and avoid the messy stuff. Having said all that, ridge splitting is not for the newbie. Even I would want to do it under supervision.

Hi, This may help a little. I have an old video on YouTube which shows a ridge split procedure. Now this was recorded when I was still a resident at Loma Linda University in 1994, but it shows the TATUM method with his D-shaped expanders and utilizing his D-shaped, finned implants. The doctor attending the surgery is Dr. Richard Borgner, who is working with Dr. Tatum at his Florida office. http://www.youtube.com/watch?v=3FE-YZ8221g Hope this helps, Robert

Insufficient data on which to make reasonable suggestions. Good grief, I can't believe the posts here.

I whole heartily agree with Dr Chan Joon Yee. With every comma full stop and semicolon. I would like to add that every dentist should make a realistic assessment of his skills, his love for reading scientific literature and his own track record. We just have to "know" what we are doing. Soul searching is one of the ways. I don't agree with "one track minds" who keep on saying keep some work for specialists. If you "know" you "know". Period. I know that a specialist conservative dentist could do a better GV Black's class One than a GP. Should I then refer it out to a specialist? Todays GPs are better informed than before because they are from wealthy homes and buy textbooks and visit a billion websites, and attend hundreds of courses.They are a motivated lot. The interest shown by GPs is really a good sign. I remember having been told one day, years ago, that composites and endodontics should only be handled by Specialists. See what's happening today. See the radical improvement in GP's Endo and composites. Specialists will always be needed by society but how and where their role comes in will change with time. There are millions of kids with war wounds, cleft palates, severe jaw anomalies, serious accidents, Cancerous tumours, etc. where the OSMFS can put their skills to good use. You can't argue that there isn't a "market" there, can you? How many GP's are going to attempt mandibular repositioning? How many will do surgical reduction of mandible by sagittal split osteotomy with a gigli saw? And what percentage of GPs are ever going to try distraction osteogenesis? It's the OSMFs who will have to try the adventurous surgeries and learn and master them. Such "turf defending" shows that the OSMFs don't know and don't go beyond a few simple surgical procedures like wisdom Molar surgery.( and make it sound like open heart surgery!) In life every one has to move up and grow up. Today 16 year old kids drive high speed cars, are you going to argue that this job is only for a specialist race drivers? As the GP is mutating into a specialist GP, I guess the need of a specialist goes up, not down. Just because cars have accidents, GM and Ford weren't forced to stop making them. Rather people trained doctors to treat vehicular accidents and build Hospitals. Why don't you guys create an "Implant complication Management Centre" and charge sky high fees for the same? You'll make your money any ways! Release the simpler and easier parts of Implantology to the GP and you move up the ladder. Why attempt to push us down the ladder? Why do you specialists try to make a mumbo-jumbo abraca-dabra over every little implant question? Ignorance of the answer could be a reason, isn't it? Be the Tough guy and take real challenges and don't mess with kids. For Kids will be kids. Is ridge splitting, Sinus lifting, implant placement, Lateral overlay grafting more difficult than a kidney transplant? Ask you conscience? You guys want to make your money on the easy predictable stuff and then who will operate those cleft palates, the GP? It's you specialists who are invading the turf that should right fully belong to the GP and not the other way around. Don't steal toys from kids. And it's your job to enlighten us if we stumble, you guys are sworn into it. So if any specialist has any illusion that he/she is doling out favors to the GPs is highly mistaken. You guys are only doing your sworn duty as a specialist. So grow up, you specialists! Mankind still needs you!

A note to our specialist peers, let me remind you that Hilt Tatum is a GENERAL DENTIST who told me personally that he originally shared the idea of sinus lift with oral surgeons and they told him it couldn't be done. The following year they invited him to California to teach them how to do it. Also, you have no right to attribute motivation to that person who wanted to do more surgery. Why do you think that it was money motivation??? Couldn't it just be the passion for surgery and treating the patient. I have a good relationship with my oral surgeon because he respects my GPR training/anesthesia, etc. He's always encouraged me to do what I am trained to do and he gets all my referrals of things I elect not to do.

Exactly Dr Tony D I couldn't agree more. There are a billion examples of very smart GPs who could give the specialists a run for their money. This turf defending is an acquired archaic trait specialists would do well to refrain from. I know that some of the leading lights in Dentistry globally are GPs. Dr Hilt Tatum Junior is one of them. There are any similar example in every Town.