Augmentation Post Implant Failure

In the following case, a failed #29 (45) implant needed to be removed and the defect was to be augmented with Bond Apatite bone cement.

After sulcular incision and detachment of the soft tissue from the implant, a buccal flap was minimally raised. The implant was then removed.
After complete debridement and granulation tissue removal, Bond Apatite cement was injected directly into the defect. The graft was compacted by finger pressure over a dry sterile gauze pressing and molding the graft for 3 seconds. This is adequate time to achieve graft set and stability.

The flap was then sutured.The flap was not dissected for release since according to Bond Apatite protocols the flap should be placed directly on the graft with tension and not tension free.

Healing was uneventful and 12 weeks post-op implant placement took place. The presence of higher bone peak levels mesially and distally enabled the placement of the implant above the buccal aspect of the alveolar crest and to augment over the exposed threads, of this newly placed implant, additional Bond Apatite cement was delivered at this stage.

Surgery by: Dr. Amos Yahav











34 Comments on Augmentation Post Implant Failure

New comments are currently closed for this post.
Can Bayrak
1/17/2018
Would you prefer titanium mesh if bone hight was the first concern?
Dr.Amos Yahav
1/17/2018
if there is at least one bony wall support no need for any kind of support ,all you need is flap under tension .which mean you reflect the flap minimally as required to see the defect place the graft do not dissect the flap for release and stretch it for maximal closure (3 mm exposure is acceptable .not more. for vertical, there is another technique with printed titanium foil shield ,which is left uncovered. not mash. it is completely defferent technique in the near future we will publish this technique .
Greg Kammeyer, DDS, MS
1/17/2018
Nice documentation. I wonder if you scaled the adjacent teeth. The bicuspid appears to have calculus that would/did limit the height of proximal bone growth. I would use TiMesh on a case like this. The resulting bone height you will have as a result will likely yield proximal PPD's that are deeper, propagating peri-implantits.
Dr.Amos Yahav
1/17/2018
of coures i scaled it , the bone in such cases can reach until the maximum hight of the proximal bone . there are also different techniques in which we can treat this case .i choose that technique with bone cement because its enable me to perform this case in the most less invasive protocol and fast and predictable procedure .we need to remember it looks easy ,it is easy , but it is completely deferent than conventional method and the key success factor is the application and the flap with tension (not tension free as we used to )
Rand
1/17/2018
Nice! Thanks for sharing!
Dr.Amos Yahav
1/17/2018
thank you
Paul
1/17/2018
It would be nice to know the outcome of the implant placement as well as the periodontal condition of the adjacent teeth.
Timothy C Carter
1/17/2018
Bone height is not a concern. There is bone on the lingual so this is simply a lateral augmentation at the time of implant placement. All of this talk about titanium mesh is unnecessary and assuming the implant was placed with decent stability even the additional graft at placement is just a "feel good" in order to cover the threads.
Dr.Amos Yahav
1/17/2018
i agree
Julian
1/17/2018
Was the molar connected to the failing implant? The first picture shows a cut of the mesial of the 6 perhaps indicating that the 2 were connected? Submersion of the natural tooth can occur when connected to an implant nes pas?
Dr.Amos Yahav
1/17/2018
i do believe that there was a connection between the implant failure and the connection to the molar even so ,i saw many implants which are connected to natural tooth that function well as well ,but I thing that it might be related to the periodontal situation ,personally i don't like to connect implants to natural tooth .defferent mechanism of stability
Dr SANJAY JAMDADE
1/18/2018
The type of bony crater around the Alphbio SPI failed implant suggests overtorquing of implant in dense mandibular bone. This is typical pressure necrosis seen in spiral implants placed in dense bone. This kind of defect doesn't arise due to splinting implant to natural teeth. If you see apical thread are integrated. a tapered deep thread spiral implants has specific indications and they should be followed for best results.
Matt helm DDS
1/19/2018
Very nice! Thanks for sharing. Why Bond-apatite cement and not Bio-Oss granules instead. Just curious as to your reasoning.
Dr.Amos Yahav
1/19/2018
Thank you, doctor Matt, for your compliment and for your question there are few main reason to work with BA , such as : 1. surgical protocol, 2. handling, and surgical procedure length 3. membrane, 4 outcome, 5.costs. 1-surgical protocol with BA is the most less invasive because you must have tension on the flap and not tension free as with other grafts among them also Bio- Oss .therfor no need for flap dissection for release, less pain, less swelling to our patient and less complication due to exposure. 2-handling and the surgical procedure length -the entire graft placement and stabilization with BA is in less than one minute, instead of 15-25 minutes in conventional grafts. 3- membrane -with BA you don't use a membrane, therefore, you don't block the periost , you don't disturb the healing, you save time and unnecessary additional expenses 4- outcome -with all existing grafts including of course Bio Oss the outcome is integration which means that the patient is not going to have its own bone back with BA due to the biphasic calcium sulfate within it. regeneration of the bone take place ,instead of integration. therefore in 3 months most of the site is already new vital bone of the patient himself -you can see very nicely the replacement in the consecutive radiographic images where it appears radioopaque during placement after 2-3 weeks it disappear and then in 3 months it becomes again radioopaque with the same trabecular form of the native bone. the entire healing period is only 3 months at this stage you can place or load your implant. 5- costs -no membrane, and saving an average of 50 minutes from every working hour, make the calculation ,you will save thousands of dollars and at least 10 entire working day every year .and as many procedures that you will do more ,you will earn more. nevertheless, it is important to be aware IT LOOKS EASY -IT IS EASY -BUT IT IS DIFFERENT. and you need to work acording to its protocols
Matt Helm D.D.S.
1/20/2018
Thank you for your detailed, EXCELLENT, and well-documented reply, Dr. Amos! Indeed you are right: the difference in bone regeneration with BA as opposed to integration of Bio-Oss is palpable. The x-ray tells the whole story! Personally I've never seen an x-ray with this high quality, dense bone trabeculation after Bio-Oss augmentation. Additionally, with Bio-Oss, upon re-entering the site and doing the osteotomy for the implant, one can actually feel that the density of the bone is just not the same as real bone. Needless to say that your point nr. 5 is quite true and invaluable. As for it being different and having to work according to its own protocol should be no big deal to any one. If the differences discourage them so much, they probably shouldn't be doing implants anyway. Adaptability and evolution should be in the tool-box of any dentist/surgeon worth his mettle. Don't you think? :) Thank you again for taking the time, and I wish you many more happy cases! KUDOS!!! PS: Do you have a Facebook page or a website?
Paul
1/20/2018
Dr. Amos Yahav Where is the scientific support of everything you say? Yes, there are some studies that show biphasic calcium sulfate to cause bone regeneration but is that what we need to call it a treatment protocol? Where do all these cooking recipes start and end? Are we practicing or doing procedures according to some accepted therapeutics. Dentistry never seas to amuse me. No wonder medical schools don't want anything to do with dentistry in the US.
Dr.Amos Yahav
1/20/2018
Thank you, Paul for your comment, more than 120 years of in-depth scientific research from all field including the orthopedic and maxillofacial field with thousands of articles that back up the abilities of calcium sulfate. in any quick search in Pubmed, the virtues of the material can be found.among them the ability to completely transform into the patient own bone, regeneration identical to autogenous bone graft, the ability to provide the soft tissue to proliferate above its surface without retraction .the ability to encourage angiogenesis, to encourage the differentiation of osteoblast etc, all of those characteristics together with the existing knowledge enables me to use those cooking recipes. which works wonderfully and predictably in my cases and for many other clinicians around the world who do the same.so i am sharing my cases and other clinician cases with the healing sequence flow and the outcome .and each one can decide whether it is interesting or not.
Paul
1/20/2018
I am fully aware of the various studies, research that show the outcomes of many bone substitutes. There are lectures going on every week costing thousands of dollars to the participants, there is a thriving market of recipes and ingredients for socket augmentation, sinus lift augmentations, etc. not to mention elaborate instrumentation. It is hard to believe that educated professionals support these endeavors and pay the extraordinary sums for something that can be accomplished with something that can be cooked up at a much lower cost with identical results if not better. Is that a serious sign of many weaknesses of our industry that is full of experts but masters of nothing.
Dr.Amos Yahav
1/20/2018
I completely agree with you Paul, definitely many procedures can be accomplished less traumatic, less complicated and less expansive.and there is an entire industry out there that might become irrelevant if it will be so. therefore they will do everything in their power to prevent it.
Paul
1/20/2018
A good example is a company by the name Augma who sells biphasic calcium sulfate for the price of platinum. Materials like these should be purchased from a compounding pharmacy for much less than an aspirin. Dentistry was and remains an industry out of the spotlight or if it was truly in the core the healthcare industry it would behave differently. Organized dentistry is a circus of incompetence and ignorance. Dental schools are a an embarrassment to those graduates whose ambition was to become an educated professional in the area of healthcare. American dental schools are far from being in the forefront of research and development. Anyone with two left hands seeks refuge in dental schools not to mention their scholastic achievement.
Matt Helm DDS
1/20/2018
@Paul: You are right Paul: organized dentistry is indeed a circus of incompetence and ignorance. In my many years of practice doing it all, I’ve seen it “all”. It is up to US, THE PROFESSIONALS, to decidedly shun companies like Augma and send a clear signal that we are not stupid. It is up to us to not spend thousands of dollars on every new expensive kit or toy with all kinds of claims, some more dubious than others, and then have to increase our fees to cover our increased costs. Experience has clearly shown that one or two simpler but sound instruments and/or methods are worth much more than a thousand fancy and expensive toys, and it keeps costs down, thereby often granting patients access to treatment that they ordinarily could not reach. We ARE Dr’s and we do have a body of knowledge, so it is up to us to use that knowledge and our imagination to find newer and better ways of doing things. As in this example, it is up to us to use cross-sectionality, and adapt proven techniques and materials from other medical fields, like Dr Amos did with Bond Apatite. Calcium sulfate has indeed been used in orthopedic surgery for a very long time. I’ve used it myself a lot (probably before Dr Amos) with great success, but with slanted looks from colleagues who were too rigid to allow a new concept to penetrate despite the evidence – it is what motivated me to ask him the questions that I did out of pure curiosity to see his reasoning. It is sound! We are being inundated by big-name companies pushing their “magical” and expensive wares, and it is the patients who suffer due to decreasing access caused by ever-increasing costs. No doubt, some of these companies do, and did, have their role in dental material and techniques advancements, and we have come a very long way indeed. We have made great strides and have access to wonderful technologies not even dreamed of a mere half century ago. Yet somehow I feel that we are lagging, that with all this wonderful technology and research we should be further along in our scientific and clinical progress. For while some ideas that should be within our grasp have been ignored, other things of lesser value are over hyped. The endodontic microscope is a perfect example of over-hype. How does anyone think they'll do a root canal any better with a microscope, if they can't do it well without one? Everyone is singing "the microscope virtues" but EVERYONE FORGETS that the microscope's line of sight stops at the first canal curvature. Past that curvature lies only one thing: the dentist's knowledge, talent, feel, and clinical experience. And no two-left-handed dentist will ever comprehend that or do a proper root canal, not with a thousand microscopes. Don’t get me wrong here: the microscope is a great tool and I use it myself, but it’s not what we would call indispensible, really. And how much did dentists have to raise their fees, and how much additional pressure and stress did they have to put on themselves to "produce" more to cover the cost of that microscope? Wouldn’t it have been much better to invest all that research, instead of in a microscope, into ways that we can actually eliminate the need for root canals? I really do believe that with present day technology and the state of the art in research we can find ways to preserve the dental pulp in at least 40-50% of cases and avoid that RCT. We have forgotten that a root canal is, by its very nature, a brutal amputation of a part of one’s body. N’est pas? We have stem cells available, and they are finally being clinically used successfully to treat recalcitrant bone fractures that don’t heal. Why isn’t anyone researching a way to preserve the dental pulp with stem cells? Or to REGROW teeth with stem cells? I bet that maybe 200 years from now we will have forgotten all about implants because we’re regrowing teeth. Implants are great but let’s face it: we are putting metal screws into maxillaries, and these screws are not all that different than a simple wood screw! Yet they cost inffinitely more than a box of wooden screws. I’m joking and exagerating, of course, but I’m sure you (and everyone else here) get the point. It is up to us to demand that government stop over-regulating and allow the local pharmacies to compound biphasic calcium sulfate the old-fashioned way. Unfortunately compounding the old fashioned way has un-necessarily long been eliminated. And it falls to us to find ways to make proper dental care more affordable to the general population. But in a world where the tools and materials we need to provide proper care are increasingly more expensive, and the dentists' bottom lines are getting increasingly squeezed from every direction (and I say this without ANY greed here) our job as true health-care providers has been forced to morph into one of more business and less dental care. That is the reason dentistry has NOT behaved like mainstream medicine, and unfortunately the results show: world-wide dental health and patient education are down, while other fields are advancing and providing the general population with better technology and an improved standard of life. There are civlized countries in Europe where dental standards are behind by at least 50 years, and patients’ attitudes toward dental care are lagging by 100 years. What do you say to the patient who says “I have no money for implants or expensive dental work, I’ll eat with my gums”? There are way more people with this kind of attitude than you can possibley imagine! How can we correct this downward trend? Only by being vocal at all levels, by educating, and by being innovative and imaginative in our own right. So all those recipes really do start and end with us. It is our job!
Dr SANJAY JAMDADE
1/20/2018
Yes Dental materials should be cheaper to make dentistry available to the poorest segment of society. But why do think stem cell would be economical and make dentistry available to the poorest?
Matt Helm DDS
1/21/2018
@Dr Sanjay: I wasn’t trying to say that stem-cells would be affordable to the poorest. Of course they would not be at first. That was on the topic of advancement that I was referring to, a completely separate topic from that of the current cost of dental materials. Sorry if my writing style didn’t clarify that.
Dr.Amos Yahav
1/20/2018
Since i am the inventor of the biphasic calcium sulfate, i will take this opportunity to explain the difference between the regular calcium sulfate that you can find in the pharmacy and the biphasic calcium sulfate. chemically they are completely the same the development of the BCS took 15 years in order to enable the regular calcium sulfate to set and harden in the presence of blood and saliva.without changing its chemical structure.the BCS enable fast and complete crystallinity of the material also in the harsh oral cavity environment instantly with neutral PH and low exothermic reaction. that gives the material a predictable resorption pattern and not just to be washed out rapidly with too fast and unpredictable resorption pattern as with the hemihydrate calcium sulfate.as well due to its fast and immediate setting it's provide your patient and to you less morbidity and a quick procedure. the other issue is that CS from the pharmacy is unregulated and unsterile and you can not sterilize it in an autoclave or dry heat sterilization it must be gamma irradiated because if you will try to sterilize it in your clinic you will destroy its crystallization by turning it to anhydride form. which is completely forbidden to be used as an implantable material .also the purity of pharmacy CS is not controlled and not validated you might have some unwanted metals and toxins .and if something will happen to the patient I can assure you that you will have no legal back up since there is no lot traceability. and then to try to protect yourself will cost you much more than what you are trying to save. there where and are a huge of investment to provide you safe and a better composition, therefore, the price is very fair
Julian O'Brien
1/20/2018
What is the liquid used in the syringe prior to application please?
Dr Yahav Amos
1/20/2018
Sterile saline
Dr SANJAY JAMDADE
1/20/2018
Very well written refutation!
Matt Helm DDS
1/21/2018
Out of pure curiosity I looked up the Augma company Paul mentioned and imagine my surprise when, lo-and-behold, it’s our illustrious Dr. Amos’s company. Gee, Dr. Amos, why didn't you just say so outright? You're obviously here to promote your product so why hide behind a veil of secrecy? Dr Amos, at almost $140 PER 1 CC, your Bond Apatite is THREE AND A QUARTER TIMES more expensive than A GRAM OF 24K GOLD at today’s price (which is $46 per gram! And since 1cc=1g, we are comparing apples to apples weight-wise! You may have done 15 years of research, but there are medications out there that were 20 or more years in research which cost much greater fortunes (BILLIONS), and they don’t cost nearly as much. One can hardly call yours “a fair price”. If we are to use the usual rule of thumb that the fee=3x the cost, it would add a whopping MINIMUM of $420 -- and possibly as much as $840 -- PER IMPLANT SITE! That can make it or break it for many patients with implantology costs being as they are today, specially if one has to use it in multiple implant sites in the same patient. When the bone additive alone costs as much as the implant itself, I would imagine that the cost would become prohibitive for many patients. Also, with the internet available, these days most patients seeking dental implants do come in with some education on the subject, including about costs; and I would not want to be the dentist on the receiving end of an angry patient's -- justified -- rant, gripe, complaint, or accusation of price-gouging. That can open up a dastardly Pandora's box I wish no dentist to ever have to deal with, specially in the US! Dr Amos, what clinical studies do you present? Sure we’ll see your prettiest cases here, but what is the failure rate? Any limitations, contra-indications, adverse reactions? Do you provide objective clinical studies? Was your Bond Apatite reviewed by any university or by CRA (Clinical Reseach Associates)? Any objective third-party reviews or studies available? And out of those 15 years how many years has your product effectively been in FDA-approved SUCCESSFUL use?
Matt Helm DDS
1/21/2018
Dr Amos, the last photo of the case you posted here is on the patient's post-healing visit (after the initial intervention) when you inserted the implant and, lacking sufficient bone depth available to sink it to the alveolar crest you had to add yet more Bond Apatite around the implant to fully cover it. Leaving aside for one moment the fact that this alone added the aforementioned $840 to the total cost (having now used at least 2 cc's), do you have any 3-month or 6-month post-op follow-up x-rays? It would be nice to see them.
Michael katzap DDS
1/21/2018
Dr. You need to calm down a bit. Did you know there were no clinical studies of parachutes when they were developed and still they were used hundreds of thousands of times? Amazing. You don’t like the cost of the material then don’t use it. Do you realize the material has been used in orthopedics for hundreds of years? It’s 1cc of graft that can be used with out a membrane. Do your cost analysis and you will come close to the cost of a 1cc of allograft and collagen. The material doesn’t fail. It’s the doctor or the patient that fails. I have been using the material for three years and love it and love the results.
Matt Helm DDS
1/21/2018
Michael, Michael , Michael, since when does asking for post-op follow up pa's qualify as not being calm? Are we living in different universes with different values, perchance? I know I am from Terra. And you? Methinks you might be the one who needs to calm down a tad. I'm glad you're satisfied with the material, and you should continue to use it, no doubt. There were no clinical studies for disc brakes either, but that doesn't make them -- or parachutes, for that matter -- fail-safe. N'est pas? Don't like my comment? Don't read it! Or don't tire yourself replying. My -- very reasonable -- request for follow up x-rays stands!
Matt Helm DDS
1/21/2018
Oh, and by the way Dr Katzap, do the cost analysis yourself and you'll see that there is no combination of graft material/collagen or /membrane that reaches almost $1000 per ONE implant site. Additionally, Dr Amos himself clearly stated in his post that he is "sharing my cases and other clinician cases with the healing sequence flow and the outcome". I hardly call the lack of long term post-op evaluation radiographs a complete healing sequence with the final outcome! My request for long term post-op pa's STANDS! And while we're at it, let's see some 2 and 3 year follow up pa's, to make the picture truly complete.
Paul
1/21/2018
There is a lot to be said about dentistry as a whole. We do some very invasive procedures after some training on weekends for big bucks and think nothing of it. Even universities like UCLA get involved in week courses for over 15,000 dollars tuition training people in the placement of implants. This is unheard of in medicine. Looking from dentistry point of view at our country, I would not surprise if someone would have an opinion of our dental industry reminiscent of a third world country. With the scope of our services going beyond the traditional it is time to rethink dental education and dental educators. Dentistry needs to become a specialty of medicine like in many European countries. Enough of the trade school approach, enough of faculty that has no place in an institution aspiring to be called a university. The enormous glut of seminars training dentists in placing implants is sickening, to say the least. There is no business for entrepreneurship in dental education unsupervised, uncredentialed and under no auspices of a legitimate educational entity. Organized dentistry is to be blamed together with the system of cranking out so-called doctors of dental surgeries. In time our legal system will eventually catch up and the media will find it interesting to the amusement to all of us.
docphil
1/21/2018
These attacks on Dr. Yahav are completely inappropriate and baseless. He is an excellent clinician who has developed a product that is useful to many who use calcium sulfate (CS) and hydroxyapatite (HA) in their practices. These type of nonsensical comments about calcium sulfate (CS) always come up here whenever anyone mentions the material. If you don't like the product, and want to use other grafting materials, that's fine, don't buy it. Everyone can use what they want. But don't besmirch the name of a highly qualified and honest professional for ridiculous reasons. Personally, I use many types of grafting materials, and ocassionally will use bond apatite for specific cases, because I have seen the benefits of CS. Honestly, all of these materials work, including allograft and xenograft. And in the long run all the costs are pretty much the same, because of certain variables. It really all depends on the case. The fact of the matter is that calcium sulfate (CS) and hydroxyapatite (HA), the two ingredients in bond apatite, have been used successfully in grafting procedures for decades already (actually I think CS has a century of use), in many medical disciplines, including spinal surgery, orthopedics and dentistry. There are hundreds of studies backing up the use of these materials, which anyone can easily find at Pubmed. There is nothing innovative or new about these types of grafting materials. They are clinically proven. You may not want or use CS or HA for grafting, but to question the efficacy of CS for grafting procedures shows complete ignorance. What Dr. Yahav has done with Bond Apatite is simply provide a simpler, and faster mechanism for delivering CS and HA for dental procedures. If you use these materials, you will understand the benefits of bond apatite. If you haven't then you probably won't understand the benefits. But, I suggest you try them, and you will see that CS is an excellent material to use in certain cases. As for the cost, if you have the time, and think you can buy CS and HA yourself cheaper, and mix it up appropriately yourself, then by all means do so. Others who have tried just this method, and who value their time, will appreciate a better delivery mechanism and pay for it. By the way, you can also buy CS, as Dentogen. It's cheaper than Bond Apatite, but it is not mixed up with HA, and doesn't have a delivery mechanism. I've bought both, and don't recommend one of the other. It depends on what you are doing. Some people like to mix CS with allograft, in which case, Dentogen is probably the better solution. Others want to use only synthetic materials, in which case, you will want to consider Bond Apatite. Of course, you can also buy plaster of paris (CS) at Walmart, mix it up, and apply it for your patients. You will certainly save alot of money doing this, but you also probably lose your dental license. Presumably, those who recommend this way of doing things, are also buying a wrench at Home Depot to extract teeth. I think these types of arguments are silly, of course. One interesting thing about CS, by the way, is that because CS functions like a membrane, you may not need a membrane when using CS or bond apatite for certain cases, which factors into the cost equation.

Featured Products

OsteoGen Bone Grafting Plug
Combines bone graft with a collagen plug to yield the easiest and most affordable way to clinically deliver bone graft for socket preservation.
CevOss Bovine Bone Graft
Make the switch to a better xenograft! High volume of interconnected pores promotes new bone. Substantially equivalent to BioOss and NuOss.