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In the following case, the implant has failed and there is no option but to remove it. On an ailing implant, once the implant is detoxified and the defect is grafted Bond Apatite can be used as a final graft layer/membrane. This will allow a more conservative flap reflection, and a quicker conclusion to the procedure. The bond apatite should not be used as the sole graft material against detoxified implant threads, since complete implant sterility cannot be guaranteed and thus results will be unpredictable.

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 a 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).

When working with Augmabio bone cements the Key factor is keeping the workflow as simple as we recommend.

  • In case of flap reflection, it should be minimal without release dissections (the flap should be placed directly above the cement and sutured in place with tension).
  •  The grafted site should be fully prepared prior to activating the cement.
  • Cement application to the defect, after activation in the syringe,  should be in 3 consecutive steps –Place, Press and Close- ejecting the material into the site, press above with dry sterile gauze for 3 seconds, and immediately close the flap

 

THE LESS YOU DO – THE MORE YOU GET”

Socket Preservation Tip 

There are two options when performing socket preservation :
1- Without reflecting a flap when there are four bony walls – the clinician can use a collagen sponge to protect the graft.

2- With a flap reflection when there are four bony walls or less
(this can also be implemented when the buccal plate is missing) –

a. Extract the tooth and remove all granulomatous tissue.

b. Create a short mesial vertical incision 1 mm into the non-keratinized (mobile)    mucosa (Take notice of vital anatomical structures), and reflect the flap partially until the defect is exposed.

c. Apply the cement into the socket from its syringe, place a dry STERILE gauze and press above, thereafter press firmly for 3 seconds.

d. Hold the flap, with tissue forceps, in its mesial crestal (Superior) corner and stretch/mobilize the flap to close the crestal gap by placing your first suture into the lingual aspect of the socket. Make a distal suture trying to approximate the buccal flap into the lingual aspect.
Thereafter, in the middle between the mesial and the distal suture to close the border of the flap. The middle suture, however, should be loose.

Please remember that crestal primary closure is not mandatory at the crest. 1-2mm opening is ok. However, the flap has to be properly secured on its mesial and distal aspects.

Working with Augma Biomaterial’s biphasic calcium sulfate cement
(3D Bond and Bone Apatite):

Socket grafting with 4 bony walls
•  No need to raise a flap
•  Eject the cement into the socket.
•  Press firmly over the cement for 3 seconds using dry sterile gauze
and finger pressure. Do not use an instrument to push and
compact the cement into the bottom of the socket.

• If the interdental space is too narrow to accommodate direct finger
pressure on the sterile gauze, then a mirror handle or similar
instrument can be applied to the top of the gauze.

• Protect the cement by covering it with a collagen sponge and
secure the sponge in place to the surrounding soft tissue by an
initial suture thereafter with a cross stitch above – During the
initial stage of healing the cement should not be left exposed.

During immediate implant placement when 4 bony walls socket exists do not use an instrument to push down the cement between the socket walls and the implant

Eject the cement above –press firmly with dry gauze pad above for 3 seconds and close the flap with a moderate tension

In cases after flap reflection, it should be slightly and minimally released.

The release cut should be at the base of the flap and minimal as possible, so during the closure itself, the flap should be placed directly above the graft without using any membrane while there should be maximal closure with moderate tension. (shouldn’t  be tension free as we are used to with granules and membranes).

It will provide less pain to the patient, less swallowing, stability to the graft during healing and higher predictability.

Exposure of maximum 1-3mm is not an issue. The soft tissue will proliferate rapidly above the cement and bridge the gap. Do not leave it exposed more than this as you may lose volume.

Socket Preservation Procedures

Press firmly with a dry gauze for 3 seconds to stabilize the material
Do not use a tool to push the cement to the bottom of the socketIn case that you didn’t reflect a flap, protect the cement with a simple collagen sponge that must be sutured and secured to the surrounding soft tissue.Due to the conversion of the grafting material into the patient’s own bone, The radiographic appearance will show the following:
  • During day one after graft placement – it appears radiopaque.
  • Gradually, radiolucency appearance takes place (reflecting the graft transformation into the newly formed osteoid before its calcification).
  • 2-4 weeks after graft placement, the majority of the grafted site will appear radiolucent while few radiopaque spots remain, reflecting the presence of the HA particles.
  • Within 12 weeks, radiopacity takes place with the appearance of the native trabecular form. That is the time when the new osteoid has already calcified.