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Bone reconstruction in the aesthetic zone using Lateral Augmentation approach
Posted on 08.27.2017 01:49 AM By David Baranes In Bone Grafting
The following video describes the technique when using Bond Apatite bone graft cement for bone reconstruction in the aesthetic zone by lateral augmentation approach.
Bone graft cement is a different concept compared to all of the existing augmentation solutions such as granules /putties, or blocks. therefore it requires a different attitude.
Such as :
• The augmented site should be completely prepared before the activation of the cement.
• Soft tissue Release should be minimal in order to have it in a moderate tension during closure (not tension free as we use to when working with granules and membrane. )exposure of 2-3 mm is not an issue, soft tissue will migrate rapidly above the graft to close this gap. however, if it will be exposed more than that we might lose volume.
After activation of the cement within its syringe, 3 consecutive steps should be followed
Place - The cement should be ejected directly into the site, Press- place a dry sterile gauze on the cement and press firmly for 3 seconds, Close – close directly the flap above the graft.
The healing period is 3-4 months.
Maurice Salama says on 08.28.2017 02:11 PM
Nice video and well described. A few questions.
1. No bone graft mixed into the calcium sulfate as a binder?
2. No occlusive membrane? If not why?
3. Resorption period of this material?
4. Was Ridge Expansion or Ridge Split a consideration?
At 3 months bone would not have been able to resorb and replace the material....how can you explain the biology.
Nice material and good handling properties but I would utilize somewhat differently here. Thanks for sharing Dr. Salama
David Baranes says on 08.29.2017 03:07 AM
Thank you Dr.Salama
1.in this case Bond Apatite cement was used ,Bond apatite is already made composite graft that has a mixture of 2/3 biphasic calcium sulphate and 1/3 HA particles to slow the overall resorption .so there is no need to add additional materials to slow the resorption .of course in such cases calcium sulphate alone can not be use because it will resorb too fast ,therefor Bond Apatite was used and not 3D bond .
2.with this type of cement there is no need for membrane due to the graft nature and it stability . using a membrane is a obligatory with other grafts but on the same time its block the periosteum which is a very potent osteoprogenitor . so we inhibit the healing .
here with Bond Apatite we don't use a membrane and the the protocol for flap release and closure is different that the conventional protocols .here during flap release and closure it should be with moderate tension and not tension free as we used to ,this is extremely important to obtain a good result.
3. the material is a composite graft with 2 matrices BCS+HA with two resorption pattern behaviours .the
BCS matrix resorbe in 4-10 weeks and elaborate space and induce the bone to be form while the HA particles are in different size and shapes from 90 micron to 1 mm size and remain longer .
normally we are not expecting HA to resorb unless it has the condition to do so, therefore in 3-6 month most of the small to medium size particles resorb as well and the larger ones which are less than 10% last longer .
4.deffeneatly ring expansion and ride split can be an good option .but i chooses this technique because it is so easy and very predictable when the protocols is respected .
the mechanism of bone formation is deferent than other graft materials .with others we expect to have at first integration and for those that has the possibility to resorb gradually the bone will form in between the granules .
and because that the quantity of bone is limited we suppose to wait 5-6 months until we can place or loads an implant .
Here the mechanism of bone formation with the CS or BCS is completely deferent .There is never integration between the graft and the bone .immediately after it's placement start a dissolution of the material and release of calcium ions which start to precipitate in a biological prosess into HA calcium phosphate lattice work or the bone (there is a very nice articles of Ricci at el about this .)as well the presence of calcium ions provide a favorable environment for the differentiation of the osteoblast .
the HA particles are just a space maintainer that helps to preserve the scaffolding 3 D until the bone will be formed .