Clinical Cases

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Socket Grafting

Large Bone Reconstruction & Papilla Preservation In The Aesthetic Zone

Surgery David Baranes D.M.D /Amos Yahav D.M.D

  • The following case represent minimally invasive, simple, and most effective surgical  protocol to reconstruct a large bone deficiency in the aesthetic zone ,and at the same time  to preserve the papilla.

  • The patient came to our office complaining of mobility and discomfort of teeth 8,9 (11,21). Clinical and radiographic evaluation confirmed the patient’s complaint. The CBCT demonstrates a large bone deficiency at the apical level with absence of the buccal plate.
     
  • The augmentation was performed according to minimal invasive Bond Apatite Protocols. After the extractions, one vertical incision was performed distally at a distance of one tooth from the defect site of tooth 8(11). The vertical incision does not go beyond 3 mm in to the MGJ. The flap was reflected and complete debridement was done.
     
  • At this stage Bone Apatite bone cement was activated and injected directly into the site, followed by compaction of the cement in to place by using a sterile gauze and finger pressure for 3 seconds followed by a peritoneal elevator for additional pressure above the gauze for 2-3 seconds more on the buccal and occlusal (it is very important that the cement will be well compacted).
     
  • Immediately after stabilizing the cement in place soft tissue closure took place by stretching the mesial corner of the flap and Suturing it, then the distal ,then the middle portion. Due to the fact that there was one wall of bony frame in between the two incisors, a complete closure was not required and a large exposure gap can remain. However, the cement must be protected until secondary soft tissue healing takes place, therefore a simple collagen sponge was  secured above.
     
  • A temporary Maryland bridge was used during the healing period.
  • Reentry for implant placement took place at 3 months. Healing was uneventful. Keratinized  soft tissue bridged the exposed gap , the papilla was preserved in place.

  • Complete bone formation can be seen clinically and radiographically.
Augmentation post Extraction and cyst enucleation

Dr. Ganaiem Tamer

  • In the following case 50 years old female patient presented with a large maxillary radicular cyst in the  apical portion of 13,14 ( 25,26)and periapical lesion in 12(24).

  • After minimal flap reflection according to Bond Apatite ® protocols, the teeth  12,13,14 (24,25,26 )were extracted  and complete debridement was preformed by removing the granulation tissue and enucleating the cyst. Then followed augmentation with Bond Apatite® bone cement. Soft tissue closure was with tension and not tension free, as recommended by Bond Apatite ®  protocols.

  • Healing was uneventfully, and complete bone regeneration was achieved. Six months post op implants were placed.

Augmentation post implant failure
  • In the following case, a failed #29 (45) implant needed to be removed and the defect was to be augmented with Bone cement ( Bond Apatite ® Augma Biomaterials ltd.)
  • After sulcular incision and detachment of the soft tissue from the implant, a buccal flap was minimally raised. The implant was then removed.
  • After complete debridement and granulation tissue removal, BA cement was ejected directly into the defect. The graft was compacted by finger pressure over a dry sterile gauze pressing and molding the graft for 3 seconds. This is adequate time to achieve graft set and stability. The flap was then sutured. The flap was not dissected for release, since according to BA protocols the flap should be placed directly on the graft with tension and not tension free.
  • Healing was uneventful and 12 weeks post-op implant placement took place. The presence of higher bone peek levels mesially and distally enabled the placement of the implant above the buccal aspect of the alveolar crest and to augment over the exposed threads, of this newly placed implant, with additional BA cement at this stage .
Bone Augmentation in extracted site with buccal plate deficiency
  • Before the extraction, a 2mm vertical cut was performed into the mobile mucosa, followed by flap reflection and complete debridement. Bond Apatite cement was used to augment the site, and the flap was closed with tension directly above the cement for maximal closure.
  • Soft tissue healing sequence can be seen in the follow up while reentry took place 12 weeks post-op.
Minimal invasive surgical socket grafting and ridge contour preservation

Dr. David Baraness D.M.D

Minimal invasive surgical procedure for socket grafting and ridge contour preservation. The case was augmented with Bond Apatite bone cement. According to Dr. “Baraness  Technique” .

  • In the following case a hopeless tooth #28 (44) was removed. After extraction a missing buccal plate is evident. The site was augmented by using ”Bond Apatite ”bone cement (Augma Biomaterials) under Baraness surgical technique for BCS(biphasic calcium sulfate) bone cements  in  cases of socket grafting procedure  .
  • Baraness technique suggesting a minimally invasive flap manipulation and is based on the flap being closed under tension concept which can be implemented when BCS bone cements are used. 

Baraness technique

  • One short oblique mesial vertical incision is performed from the crest apically and towards the mesial aspect along the attached gingiva until 1-2 mm into the mobile mucosa.
  • Reflect the flap for clear vision of the defect. No flap dissection for flap release should be done .
  • Perform a Complete debridement of the site.
  • Place the cement according to Augma protocol-(PPC)
  • After placing the cement and pressing above for 3 seconds with a dry gauze, close the site by stretching the soft tissue for maximal closure. (During soft tissue closure and suturing 3 mm exposure is acceptable )
Upper left premolar. Mobile. No buccal plate. 2 Years follow up

Dr. David Baraness D.M.D

Minimal invasive surgical procedure for socket grafting and ridge contour preservation. The case was augmented with Bond Apatite bone cement. According to Dr. “Baraness  Technique” .

  • In the following case a hopeless tooth #28 (44) was removed. After extraction a missing buccal plate is evident. The site was augmented by using ”Bond Apatite ”bone cement (Augma Biomaterials) under Baraness surgical technique for BCS(biphasic calcium sulfate) bone cements  in  cases of socket grafting procedure  .
  • Baraness technique suggesting a minimally invasive flap manipulation and is based on the flap being closed under tension concept which can be implemented when BCS bone cements are used. 

Baraness technique

  • One short oblique mesial vertical incision is performed from the crest apically and towards the mesial aspect along the attached gingiva until 1-2 mm into the mobile mucosa.
  • Reflect the flap for clear vision of the defect. No flap dissection for flap release should be done .
  • Perform a Complete debridement of the site.
  • Place the cement according to Augma protocol-(PPC)
  • After placing the cement and pressing above for 3 seconds with a dry gauze, close the site by stretching the soft tissue for maximal closure. (During soft tissue closure and suturing 3 mm exposure is acceptable )

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Lateral Augmentation

Augmentation post implant failure

Dr. Mushayev Ilia, DDS PhD

  • After clinical and radiographic evaluation due to poor prognosis of the existing dentition. The treatment plan was to extract all the existing lower teeth and in addition to remove the 2 failed implants 45,46 (29,30) while keeping implant 33 (22) in place. Thereafter, to perform immediate implant placement of 3 implants and simultaneously augment and preserve the crest. The final prosthetic plan was to provide the patient removable over dentures on those implants.

  • After extraction and complete debridement, implants were placed with good primary stability and the crest was.

Atrophic ridge - scalloped gingiva

Dr. Snjezana Pohl 

** This case was published on Dental Xp on Nov 4, 2018

  • Layer by layer-as Salah Huwais described this case. Immediate loading was planned, for this reason, sinus elevation before implant placement. Unfortunately, two implants didn`t have enough primary stability. OD made it possible to place implants inside the bone envelope. Thin ridge was augmented with bond apatite (major objection: it doesn´t look good in images:). After three months implants were uncovered utilizing roll flap in lateral areas. In the anterior area collagen matrix and buccal sliding palatal pedicle flap. I am pleased with cleansable scalloped gingiva. 
    Occlusion line is not ideal – patient is saving money for the low jaw, it will take some time and prostho had to adjust the upper teeth to the low jaw situation.

    * For the full case discussion: Click here 

Bone ridge reconstruction after failed implants removal

David Baraness DMD

  • 67 years old female came to the office her main complain was being unsatisfied with the aesthetic appearance of the lower anterior prosthetic bridge due to the exposed implant threads. Those implants were placed 8 years earlier . During clinical and radiographic examination, all implants were stable, with large buccal bone deficiency, exposed threads and loss of the attached keratinized gingiva.
  • The treatment decision was to remove all involved implants, augment and reconstruct the deficient bone ridge and soft tissue, and to place a new implants.
  • Flap was reflected according to recommended Bone cements envelope technique by preforming midcrestal incision continued with intrasulcular involving the medial and distal teeth. Then a full thickness flap was elevated, and an envelope was created .It is important to emphasize that during flap reflection the periosteal elevator should not pass the mucogingival junction with more than 2-3 mm. In that way we prevent the involvement of the muscles’ insertion and eliminate muscles movements and thus pull on the flap. At this stage implants were removed and complete debridement was preformed .
  • Prior to Bond apatite placement a stretching was preform by grasping mesial corner of the flap with a needle holder and stretching ,than the distal part of the flap and than the middle. If we want to release the flap a bit more we insert the periosteal elevator into the mesial apical corner of the pouch with 45 degree angle and than distally and stretch the flap . The Bond Apatite cement was ejected into the site, a dry sterile gauze was placed and pressed above the material for 3 seconds ,and flap closure took place by stretching the mesial corner of the flap and suturing than the distal ,than the middle. After 3 points of suturing a predictability test was preformed by placing a finger in the vestibule and vibrating the flap; if the sutures do not move at all it means that the muscles movements will not influence the stability of the graft during the healing phase, which can indicate that high success rate will be guaranteed.
  • Healing occurred uneventfully and reentry and new implants placement took place 3 months post op .
Augmentation post implant failure - buccal deficiency

David Baraness DMD

  • 72 years old patient presents to the clinic for treatment. Exam reveal implants 8,9, and 7 were failing. It was decided to remove the implants.
  • Intraoperatively it was determined that #7 can be immediately replaced. Area 8 and 9 had a large defect that extended to the medial aspect of #7 where several threads were expose. The entire area, including the exposed threads of implant #7, was grafted with Bond Apatite bone graft cement ( Augma Biomaterials)
  • Three months following an uneventful healing period, at the opening of the site, one can appreciate the quantity and quality of the reformed bone in the entire previously deficient area, especially above the implant threads that were exposed during the implantation. Due to this complete regeneration, placement of implant #9 was possible.
  • The procedure was done with a minimally invasive surgery according to the recommended protocols when augmentation is planned with Bond Apatite
  • The gingival envelope flap is performed without vertical releasing incisions utilizing a crestal flap elevation no more then 3mm in to the mobile mucosa.
  • After removal of the granulomatous tissue, augmentation is performed by injection of Bond Apatite and allowing it to fully set in the host site.
  • Flap closure is done with tension by stretching the flap without any releasing incision, which makes this protocol unique and specific when Bond Apatite is used.

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Sinus Lift

Vertical sinus lift autograft and implant placement

Dr. Michael Katzap

  • 52-year-old female presented to treat two upper left failing molars. There was a buccal defect on the mesial buccal root of tooth number 14 and missing buccal bone. The teeth were extracted, the infection removed, the area was grafted with biphasic calcium sulfate cement ( Bond Apatite). After four months of healing the area was reopened. A vertical sinus lift was performed using densah burs using vertical lift protocol and autographed to allow placement of two implants.

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Endo

Augmentation post implant failure

Dr. Damian Dudek

  • Male patient, healthy, age 30 years. In position of teeth no. 19,20, and 21 (34,35,and 36) the patient reported inflammation, swelling and pain on occasion consistent with Vincent’s symptom. Surgery was performed under general anesthesia. We removed a radicular cyst (with histopathology), root resection of tooth 20 (35) with retrograde MTA filling and extraction of tooth 19 (36). The bone defect was grafted with Bond Apatite (6 cc). The patient reported minimum pain and discomfort in the first three days after surgery. Adequate bone remodeling was observed after 3 and 8 months, but on the panoramic x- ray a slight radiolucency has developed in the area of the resurrected tooth #20 (35), but until now patient reported no clinical symptoms
Large cyst enucleation , apicoectomy with MTA retrograde filling and Augmentation

Dr. Damian Dudek

  • Healthy woman, age 35, cyst in the right maxilla. We did an enucleation and resection of roots 11(8) and 12(7) with retrograde fillings(MTA) and augmentation with Bond Apatite® bone cement.

  • The x rays was taken 7 days before the treatment and 7 days, 3 and 6 months after the operation. Healing was uneventfully and after six months post op the place was asymptomatic and bone was formed.