Large Bone Defect as a Consequence of Roots Fracture

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Posted on By dr Amos yahav In Bone Grafting

I would like to share with you a case of Dr. Luis Amar,
In this case, a large bone defect as a consequence of fractured roots of the first molar was augmented by
Bond Apatite bone graft cement.
The molar was extracted and a complete debridement of the granulation tissue was performed, followed by
bone grafting with Bond Apatite bone graft cement.
During the augmentation procedure, the flap was minimally reflected and minimally released. Thereafter, the cement was activated within its syringe and ejected directly into the site.
After cement placement, a firm pressure was applied on a dry sterile gauze above the cement for 3 seconds to induce its hardening in place.
The flap was placed directly above the cement without a membrane and was maximally closed with moderate tension.

Pre op radiographic appearance
14 weeks post op Soft tissue appearance before reentry

At reentry hard tissue appearance. Newly formed bone can be seen
CBCT image 14 weeks post op

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It looks really good!
It would be nice to see the clinical situation before bone augmentation.
How long between augmentation and re entery?
And: in his recent post David Baranes stressed that a minimal flap release is required. For all other bone augmentation procedures we need tension free closure, why is it different with Bond Apatite?
Thank you for sharing


Thank you doctor
i placed now the pre op radiography
the time frame is 3 months from day one to reentry .
indeed the protocol for flap release and flap closure is completely deferent when we work with bone graft cements here membrane should not be used ,and the flap should be placed directly on the graft with moderate tension .this is less invasive procedure with less post operative pain and less swelling to the patient, because our release cuts are minimal if at all.on contrary when you use a membrane and granules if you will not have a tension free there is a risk of exposure and graft failure .with Bond Apatite cement this risk just don't exsist .since there is not presence of a membrane and the nature of the biphasic calcium sulphate that enable the proliferation of soft tissue above it surface .
The flap should be placed directly on the cement and maximally closed ,2-3 mm exposure is not an issue ,but not more than that .

please see the protocol below:

1. Socket grafting with 4 bony walls .

No need to reflect a flap
Do not use an instrument to push the cement into the bottom of the socket
Protect the cement by collagen sponge secured to the surrounding soft tissue

2. Socket grafting when the buccal plate is missing .

Reflect a flap –Augment –Reposition–Collagen sponge

3. Defects with bony walls frame.

Reflect a flap –Augment –Reposition–Collagen sponge

4. Defects with no bony walls frame. (lateral augmentation)
Minimal flap release –Moderate tension – Maximum closure



Would LOVE to see histology and core biopsy of area to evalute type of bone fill %? Thanks Dr. Salama


In the following similar case histology was taken 3 months post op ,the biphasic calcium sulphate transform simultaniosly into the patient own bone .the HA particles within the graft are about 33% and they are from 90micron to 1 mm in size .they do not integrate instead they resorb while the small to medium size particles resorb in 3-6 months the larger particles which are less than 10% remain longer and during reentry already after 3 months their appearance is like pebbles due to their resorption process .



In this case cement placement is the best option which applied greatly.