Extractions and augmentation for ridge preservation

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Posted on By David Baranes In Implants

The case demonstrates extractions and augmentation for ridge preservation followed by implants placement three months following the extractions
In order to perform extractions and ridge preservation a diagonal vertical incision was performed from the neck of the tooth and carried inferiorly up to 2mm in to the movable mucosa. Full thickness flap was elevated in order to expose the site and clearly appreciate the defect dimensions in the area.
Immediately following the extractions, site and sockets debridement was accomplished. Augmentation was performed using Bond Apatite bone graft cement.
Placement of the cement in to the graft site is relatively easy due to the ability to inject the cement in to the site, placement of a sterile gauze pad on top and adaptation of the graft by pressing ( with finger pressure or instrument handle – if space is narrow) over the pad for three seconds. Flap closure immediately follows directly over the graft without any membranes, by stretching the flap to achieve maximal closure.
It is important to note that use of this material does not require excessive releasing incisions. The flap does not need to be tension free and in primary closure. The opposite is what is needed. The flap has to be under tension and maximal closure is enough. Up to 3mm of incision line opening is adequate, for graft volume preservation and appropriate wound healing, but not more than that.
Three months following the initial surgery, the deficient bone in the area was rebuilt and regenerated and the ridge was optimal for placement of dental implants.

Vertical incision up to 2mm in to the movable mucosa and flap elevation for defect exposure in the area of the extractions
Placement of Bond Apatite cement in to the graft site

Immediately following flap closure, the tension and the sutures
Clinical view of soft tissue healing three months from the day of grafting


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5 Comments

Nice result!
Have you veneer grafted in premolar area after implant placement?
In my experience, Augma is really easy to handle. The pics don´t look good with this material (lol) but I do have some good experience if applied for socket preservation. But the lateral ridge augmentation looks better on CBCT than clinically.
What is your experience with Bond Apatite cement for the lateral ridge augmentation?
thank you for sharing
Snjezana


Reply

Thank you Dr. Snjezana.
Yes I do have quite many cases with lateral augmentation and around implant .from my experience from the day that I adapted the new protocols my success rate improved significantly above 95% ,in which from day one i can predict almost for sure the outcome .
The key success factor is working exactly according to this type of bone cement protocols ,which is completely different than what we used to do up until now .it was difficult for me as well to change my habits because we use to do tension free, to release large flaps, to dissect them for getting primary closure ,and to use membrane ,and PRF .here instead is completely opposite , the flap must be with tension and no membrane or PRF should be used .while during closure it can be left exposed as the company instruct not more than 3 mm .
for lateral augmentation we can do it in two easy ways.
1.with vertical cut
2.Envelop technique
tunneling is also an option but it dose not gives me any added value than those techniques , it is not less invasive ,more difficult to preform properly ,and time consuming .and probably a question can be raised how come it is not less invasive? .the answer is that this specific surgical protocol for bone cement are minimal invasive due to flaps with tension , with no disections for rlease .
OPTION ONE -with vertical cut –we can preform one or two vertical cuts those should be mesial or distal in a distance from the required augmentation site. the cut should not exceed more than 2-3 mm into the mobile mucosa .then I reflect the flap to expose the entire site for grafting .at this stage I take a forceps and stretch the flap to get feeling how much it can be stretched .normally 2 mm into the mobile will provide me 4 mm of stretching while 3 mm -6 mm of stretching together with the ability to live it exposed up to 3 mm I can gain 7-9 mm width which is sufficient for almost any case .than after preparing the site ,I make sure to hold aside the flap before ejecting the Bond Apatite (only Bond apatite can be used for lateral augmentation not the 3D bond ).i am ejecting the BA to place and press strongly above with a dry gauze for about 2-3 seconds .Than I hold the mesial buccal corner of the flap and stretch it to the palatal or lingual mesial corner and make my first suture ,than the distal ,and than in between them . if during closure the material accidently get cracked this is not an issue I take the gauze and press again for a second and continues suturing .
the way for me to predict if I will gain success or not is after suturing I place my finger on the vestibule and start vibrating it .if the sutures dose not move at all I am sure that the flap will be stable during the healing and will not be influence by the mussels movement at all.
THE SECOND OPTION –Envelop technique .here I don’t do any vertical cuts ,I do a mid crestal incision that can continue with intra sulcular to half of the adjacent tooth, than with periosteal elevator I reflect the flap to create a pocket (envelop ) I go all way down into 2-3 mm into the mobile mucosa . After creating the envelop I take a forceps and stretch the tissue it will gives me by stretching about 4 mm due to the elasticity of the mobile if I want more I push my periosteal elevator mesial and distally into the mobile and stretch it gives me additional 4 mm of release. Now I ask my assistance to hold aside the soft tissue to exposed the bone and I eject inside the Bond Apatite, place above a dry gauze and instead my finger I use the periosteal elevator to press and condense the material into the site and slightly overfill thereafter I can shape a little bit ,press again for a seconds and close the soft tissue above starting with the mesial corner ,than distal and than in between .

In case when I have exposed new placed implant if I do a vertical cut it must be in a distance of at least one tooth from the augmented site ,the implant should be placed 1 mm below the crest and with good primary stability .flap reflection and closure should be done similarly as with lateral augmentation


Reply

Thank you very much for your detailed answer.
Protocols are very important, you are right.
We should be familiar with instructions for any product before we use it.
I watched Amos Yahav and Ziv Mazor’s webinars and lectures.
So far, my procedure was in accordance with their guidelines and you have described it very nice here.
I have already reopened some cases, I must go throught foto documentation.
I still don’t understand why not primary closure-flap advancement?
Best regards
Snjezana


Reply

Nice post...any histology on these cases? regards Dr. S


Reply

Thank you Dr. Salama
for this case i didint took histology


Reply


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