Extensive 3D bone deficiency in the aesthetic zone upper jaw

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Posted on By David Baranes In Bone Grafting

The following case describes an augmentation procedure using Bond apatite Bone graft cement (Augma Biomaterials Ltd.) in most extensive three-dimensional bone deficiency lesion in the esthetic segment of the upper jaw.

Soft tissue and site preparation was performed according to the recommended protocols for biphasic calcium sulfate bone cements, in which a minimally invasive surgery is indicated.
A buccal flap was lifted, with minimal reflection, in order to expose the lesion and at the same time avoid any excessive release in order to keep the flap under tension during closure.

This is done to avoids muscle movements in the area and not affect the stability of the graft during the healing period (vertical cuts do not extend more than 2-3 mm beyond the MGJ, and no horizontal releasing incision was performed).

After removal of granulation tissue and preparation of the site, augmentation was completed by injecting the Bond-Apatite cement directly into the site followed by applying firm pressure for 3 seconds above using a sterile gauze pad to compact the cement in place. Soft tissue closure was accomplished by stretching the flap tacking it down on the mesial then distal and then in between thereafter continued for maximal closure(3 mm exposure is acceptable).

3 months post op complete regeneration was achieved and implant was placed.

Clinical appearance before graft placement
Bond Apatite in place

Flap maximal closure under tension According to Bond Apatite bone cements recommended protocols
Pre op CBCT

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It is good to see that utilizing such a minimal invasive procedure sufficient hard tissue volume could be achieved to place an implant. If the patient doesn`t have aesthetic demand and if the volume of the grafted area stays stabile it seems to be a nice, simple solution.
Thank you for sharing


do you think this result is reproducible between practitioners?


i think that yes as long as the protocols are strictly respected .becouse as you can see here the surgical procedure is very simple there is no sophisticated surgery .however we need to respect few things not to move the palatal flap at all .to reflect minimal buccal flap (3 mm into the mobile mucosa ) in order to engage the muscles .and to close the flap under tension(not tension free) by stretching .and no removable provisional .


The CCT post op looks interesting but I would be a bit concerned about 3 month re-entry for such a vast lesion. Also, the clinical post op does not look like complete bone fill. Perhaps a biopsy or histologial section would shed more light on what we are seeing here? Thanks for sharing. Dr. Salama


thank you Dr. Maurice
in such cases in 3 months the bone can be class 3 however since this type of cement is made of mainly biphasic calcium sulfate and resorbeble HA in 3 months it mostly transform already into vital bone that with the time continue to maturate.


Would a flapless approach here work? Flapless debridement of lesion and fill void with bondapetite? Just curious as I have noticed incision and flap designs like this tend to lead to midfacial and interproximal recession on the adjacent teeth that are virtually impossible to correct and a less aesthetic result of the final restoration. How are protocols different to handle this graft material in the aesthetic zone?


Tunneling technique can not be applied to this particular case since the granulation tissue and complete debridement require flap reflection which indeed can lead to some recession.
Normally recession start with soft tissue retraction due to any incision . however here to the minimal flap reflection with no tension free dissection releasing incisions and the ability of the soft tissue to proliferate above this specific graft reduce the retraction to minimum .depend as well on your vertical incisions that must be on the bone .


Daid; Keep us posted on this case. Truly not sure about the type of tissue you are finding here? warm regards Dr. Salama


sure i will


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