#19 – Dr. Larissa Steigmann – Socket Management for Predictable Implant Outcomes

00:00:00: Hi, it's so nice to be with you both as an expert.

00:00:03: I have a big honor here talk and have an expert talk with our dentist Larissa Steichmann And well...I need my colleague or more friend Larissa that I'm very proud of the topic which is quite interesting.

00:00:20: now.

00:00:23: We are exploring for years and trying to find the best solutions pretty much.

00:00:29: What is very interesting, our connection came also with your publication one beautiful publication about socket management.

00:00:39: And please if you can tell just how it was guide because You have such a style of decision tree For that type of the sockets.

00:00:48: So this decision trees what triggers us?

00:00:53: Pretty much.

00:00:54: So thank you very much, first of all for having me here for the interview.

00:00:59: I agree with you that socket management has become one Of the most crucial topics That we find around implant industry.

00:01:09: i think The reason is that socket Management Is really the prevention in a sense?

00:01:17: We see For long-term stability around implants So everything starts the time that we extract a tooth.

00:01:25: We can actually prepare and predict a lot in terms of the long-term stability, than what you see for our

00:01:32: implants.".

00:01:35: This is probably the background or idea that had to do with publication.

00:01:42: What we did was look into literature the most prominent and predictable factors in terms of bone loss after tooth extraction.

00:01:57: In this publication, we identified two factors that are extremely relevant.

00:02:03: These two factors first are the bone thickness which is a predictable factor for volume loss in terms heart tissue loss.

00:02:14: The second factor is bone dehesences.

00:02:18: So how much of the buckle plate is missing?

00:02:22: It's time for extraction.

00:02:25: We usually measure it in terms of length, so we have a crystal margin until the apex and see if that bone is lost after the extraction.

00:02:43: Okay?

00:02:43: Is it until two-third or more than two third, okay.

00:02:47: And according to that we then change our treatment approach.

00:02:52: so all of these factors were trying to bring into this classification and Then provide practical treatment options because at the end of day a lot of times We have classifications where we don't know how to actually treat right.

00:03:07: yeah So that's usually the problem that we find.

00:03:11: We divided them into three different types of sockets.

00:03:16: ST-one, socket type one... ...socket type two and socket type three.

00:03:23: A lot my participants always ask me is ST standing for Stygma?

00:03:29: We can use it!

00:03:31: We say you can I like it at the end But this supposed to be socket type but i liked that.

00:03:37: you said Stygman.

00:03:39: So then we said okay First of all we want to identify how thick our buckle bone is and we can do that with probing, visual assessment or a CBCT analysis before the extraction which in my opinion it's the most elegant way to approach it.

00:03:58: ST-II is looking into fenestrations because many times for extraction, if they're not periodontal reasons.

00:04:08: They are endodontic reasons.

00:04:10: so after we have an extraction We might find a perforation on the more apical aspect.

00:04:16: So we have a fenestration?

00:04:19: Yeah!

00:04:19: That's the second diagnosis.

00:04:21: and The third diagnosis is ST-III where which I just explained...we actually have three different types of severities of degrees of dehesences.

00:04:33: So until a third, one-third to two-thirds or more than two thirds.

00:04:38: Having walls compromised and not having almost like... Yes!

00:04:42: Not having walled.

00:04:43: Severity at mild moderate advance in terms of dehesences.

00:04:49: And so then we provided options on how to identify them?

00:04:55: There are subcategories that I just explained and then treatment options on how to treat these sockets.

00:05:02: And really, I would say why is this all important?

00:05:07: Because it gives you the possibility after the extraction to really say okay what is my socket diagnosis?

00:05:17: because we always talk about diagnosis of tissue diagnosis.

00:05:20: What's the reason for extraction?

00:05:26: really diagnose our sockets.

00:05:28: And I think we should start to diagnose our socket,

00:05:31: okay?

00:05:31: Who is the

00:05:32: identifier?

00:05:32: and if you compare this what will happen If You Don't Diagnose Properly?

00:05:37: We know So many publications out saying about Resorption of The Bone Losing This Socket Losing The Volume Losing Possibility and Aesthetics In That Area...So If You don't diagnose it first then do next steps.

00:05:51: results can be very bad in

00:05:53: end Yes But people don't realize that at this point, the way you use your biomaterials and how to combine the right bone graft with the right membrane can have such long-term effects.

00:06:15: There are a lot of studies that now come up actually of implants that were placed after socket preservation and receive really, really good outcomes.

00:06:29: Because actually the main interest they look into these studies is implant success right?

00:06:36: It's implant success in stability on the marginal bone The concept people don't understand.

00:06:43: why should we use a bone graft at this time of extraction?

00:06:47: Why?

00:06:48: We need to rebuild and recreate the crystal bone Okay?

00:06:54: Because we diagnose peri-implantitis on how our crystal bone is being lost in the future, right.

00:07:03: So let me give you an example.

00:07:05: Aesthetic problems recessions why do we have them?

00:07:09: We see a loss of the crystal bone okay pocketing so we see bleeding around the implants.

00:07:15: Right!

00:07:16: We can have pus and bacteria that are actually accumulating because This is because we don't have a crystal bone around the implant.

00:07:26: So, we need to create this crystal bone before any implant is placed.

00:07:31: When

00:07:32: would be best time do that?

00:07:35: Pretty much at the beginning.

00:07:38: You start in the beginning Because when it's already lost We need follow-up surgeries.

00:07:44: Scarring Post trauma You know, patients need to come for multiple surgeries.

00:07:51: There are so many reasons that wish there's actually other way around... ...there is no reason why a patient should not have any of these grafting procedures done at the time of an extraction.

00:08:04: So that's why it's crucial.

00:08:05: But this is also reasons for you as a clinician To do treatment before.

00:08:10: but if we say and put ourselves in role or patient Isn't better for him?

00:08:15: The moment he has extraction?

00:08:17: Absolutely Also, because the concept that we see around socket preservation is not the same concept as the concept of guided bone regeneration.

00:08:30: What's the difference?

00:08:32: If you extract a tooth and do absolutely nothing... We will find bones!

00:08:39: We'll have a bone regeneration that is physiologically triggered genetically triggered by our body to rebuild this bone.

00:08:47: It's healing himself somehow.

00:08:49: It's rebuilding bone, it is less bone because we have a resorption but its re-building bone.

00:08:56: so you have the body actually helping us right?

00:08:59: In that moment I add bones and the bodies coming to help me build this socket... ...to build this bone everything necessary for an implant.

00:09:10: now what happening if already lost at bone and we want to do it in the future, let's say three months later four month later.

00:09:18: Now if I then add bone my body is not going to help me.

00:09:23: i need to create as a clinician ideal conditions.

00:09:28: okay which means primary intention closure stability maintenance gothic nervous

00:09:34: yeah

00:09:35: yeah yeah principle exactly.

00:09:38: so you have to have the past principal Perfectly done.

00:09:42: Otherwise, you will not have any bone.

00:09:45: So the body is no going to help you because at that moment it's... It's not something that comes naturally to the body.

00:09:53: I try to force my body To build a bone but actually My body isn't genetically triggered At this point in order for me to build this bone.

00:10:01: That another reason why we are so crucial.

00:10:06: Because the socket management means right now a potential genetic potential, physiologic potential of my body to help me to recreate this bone.

00:10:18: But why so many clinicians don't do socket preservations?

00:10:22: And it's still now after so many publications signed supporting all your words and in the end you research also support the same wording.

00:10:31: how is possible that they stick...still doesn't do preservation.

00:10:35: at that time

00:10:36: I think A lot of the concepts come from practical reality.

00:10:42: Okay?

00:10:43: What does it mean?

00:10:45: I cannot always guarantee an outcome and i can try to work with what is good enough.

00:10:52: in that moment if we find ourselves In a clinic, And We need To explain to our patients We're going to do a grafting and maybe you will Need to do grafting again and we don't really know how much We're going to lose, we are gonna get because we can't have these conversations really with the patients that we say.

00:11:12: So maybe we will have you know ten percent less of resorption but we still need to add twenty percent extra and then you need do it again and again if we try avoid this conversation.

00:11:25: so people said If I actually had a very wide range Why should I add bone?

00:11:31: Because at the end with what i will find,I'll manage and if it's not enough.

00:11:36: I would do What is necessary at that point.

00:11:38: It Is Not trying to think from a preventative Point of view.

00:11:42: yeah A lot Of people don't like prevention.

00:11:45: it's Like If i tell somebody if you go And eat healthy and work out every day today You Will be in a better position and People say no you know it will Be fine.

00:11:55: if i will have a problem I will go to the doctor, take a pill and deal with it then.

00:12:03: Tell people no if you do something today?

00:12:06: It would be better!

00:12:08: I cannot promise that everything is fine... You find this pattern everywhere in life right?

00:12:16: Prevention isn't what we love doing but it's very clear that its beneficial Of course.

00:12:23: There is no reason,

00:12:24: but with so many research that you did I think You find very nice solutions for each of these three sockets.

00:12:30: and in With this solution it comes quite science behind why you strictly chose the solutions?

00:12:37: So just slightly socket Stikeman type one stock at type One.

00:12:43: What did he choose as a perfect solution where you really have all intact walls Very thick walls like perfect solution that it's not so common, but if you have a perfect solution what is your go-to reason or result?

00:12:59: Okay.

00:12:59: So usually we have a subcategory —it depends—if We Have A Thick Or A Thin Bucklebone.

00:13:06: In the cases where there are thick buckles we have strong osteogenetic potential from our body and sometimes we can just have a calacone placed inside the socket which will help with homeostasis keep the blood clot in place.

00:13:21: Okay?

00:13:22: The moment we're having a thin buckle bone, We know that we have higher bone resorption In the future.

00:13:30: That's the moment when you need to start adding bones substitutes.

00:13:35: So don't add any sort of membranes at this point.

00:13:39: But we NEED TO COMBINE BONE SUBSTITUTES WITH A SEAL.

00:13:46: collagen product can be placed as a seal of the socket.

00:13:50: Okay, usually you want to actually fill this socket until one to two millimeter below the crystal bone because all the buckle bone is intact and then you just place a collagen cone on top to seal everything in suture the bone graft into place.

00:14:07: And what does your go-to bone?

00:14:10: So for me it is always what I love, love to work with now.

00:14:15: It's a bone graft that gives me basically good intrasurgical handling okay?

00:14:22: So what i love to do is the sticky bone especially for sockets.

00:14:27: Okay!

00:14:29: The bone graft you can have combined almost as the ball that you need to fit into the socket is giving me the least of a headache,

00:14:42: right?

00:14:42: Okay.

00:14:43: So what's amazing?

00:14:45: now I actually only work with all products with hyaluronic acid in combination because this hyaluranic acid will not give me healing potential a better outcome in terms of proliferation of the cells, healing potential for bone graft accumulating more attracting more cells and helping us with hardened soft tissue healing.

00:15:17: But actually what's really nice is that intra-surgically I can get this sticky bone perfectly prepared just to stick into my socket Because what I found myself feeling or having trouble with in the past is that the bone graft would be

00:15:35: all

00:15:36: over, okay?

00:15:37: And a patient would feel it.

00:15:39: I would feel like i'm not working very clean.

00:15:41: so The combination did we find now with the bone graphs?

00:15:45: Now if you talk about the types of bone grafts... ...I believe In one concept That Is extremely important.

00:15:53: If you have the availability for an Allocraft like MaxCraft, I think that a combination with MaxCrafed and Xenocraft is always the best solution.

00:16:08: Why?

00:16:10: Xerabon will give you volume stability over time.

00:16:17: It's maybe not going to be resorbed as much by the body and it's not going to have such an over turn, okay?

00:16:24: But... It will give us a stability.

00:16:27: If you add its together with MaxCraft You'll have best of both worlds

00:16:34: Okay?

00:16:34: Like combo or pretty much your perfect combo Exactly!

00:16:38: Yeah You've got osteo-inductive potential.

00:16:41: So there is cell differentiation Great bone turnover but also volume stability.

00:16:48: So you actually combine both of them together.

00:16:52: In my opinion, You will always have the best outcomes.

00:16:55: when is it extremely important?

00:16:57: If you're working in the aesthetic zone now.

00:16:59: Okay if you find yourself extracting a premolar or even a molar I think if you just use one type of bone graft okay It's sufficient.

00:17:10: but the moment that actually switch into the aesthetic zone, this combination to have volume stability together with an osteoductive potential.

00:17:22: It's the best combination

00:17:23: because pretty much bone resolves and remodelates through your whole life.

00:17:28: so it is like a organ we say.

00:17:31: So having something that will still have these bones in the bones which are not resolving gives stability Is what you're then searching for?

00:17:40: I

00:17:43: always say, you place an implant.

00:17:45: You have the prosthetic rehabilitation of the side and then that's when the problem starts.

00:17:54: The patient goes home.

00:17:55: After one year a patient comes back And says hmmm...I already see something.

00:17:59: You said no don't worry it will be fine.

00:18:02: Then their patients come after three years.

00:18:05: We as dentists we do not move.

00:18:08: It's not like I'm moving countries or offices over here.

00:18:11: You will find your previous view, the patient would find you and say... ...you did this!

00:18:17: And now i start to see something gray.

00:18:20: Yeah..and

00:18:21: you know that you can control this from the beginning by placing a volume stable bone graft-like terabone in that socket.

00:18:31: Like I said ideally in combination.

00:18:33: I want to ask you also when we have... So, were talking about ideal situations.

00:18:40: But if go further and some compromised walls or even not having walls We had problems there because don't has potential from biological point of view like said endost will build up the bone.

00:18:53: but what is then goes your reasons?

00:18:59: more compromised sockets.

00:19:00: So we're entering in the classification, the ST-III direction where we have three subcategories A B and C depending on the severity.

00:19:12: Now these cases start to become More challenging because We need to rebuild The missing wall.

00:19:22: Okay?

00:19:23: Completely

00:19:24: Yes Because usually we have a very strong osteogenic potential.

00:19:28: If you've got four walls, then know that cells come from all sides helping us to rebuild the bone.

00:19:36: The moment it's missing is exactly where needed Exactly on the buckle aspect when there are always aesthetic problems We need to actually build this wall.

00:19:48: This is the moment When entering the era.

00:19:51: or use of membranes.

00:19:54: Okay, we have different type of membranes and depending on the type of severity.

00:20:00: So you can use collagen membrane for less severe sockets where you just a missing part of the socket okay?

00:20:12: And if not... You need to start using non-resolvable membranes!

00:20:16: This is what I love about working with panamem.

00:20:21: Why?

00:20:24: is extremely moldable.

00:20:26: It's when you try to hold the permanent membrane, I feel like you have a paper that... You can move like this right?

00:20:36: And and i can exactly adjust it to the socket that I want covering up all the sockets tunneling it nangoli and advancing in all the way covering my buckle aspect okay and it's not going to accumulate a lot of bacteria over time, which is usually all the problems that we're seeing.

00:20:57: And because we are working around sockets... ...we don't need primary closure like when you needed with any other type of bone grafts.

00:21:04: So with this soft tissue or with the closure We have already exactly the anatomy for future and we also have the Pema Membrane keeping everything in place.

00:21:18: Now, let's think one step further.

00:21:22: What else could I want that is extremely volume stable?

00:21:26: That stays exactly in the place where i wanted and it not gonna need to be covered right?

00:21:33: So

00:21:35: this is what a

00:21:38: socket management.

00:21:41: This would be my goal, right?

00:21:42: Yeah of course!

00:21:44: To have something that's extremely volumestable and stays exactly in place but now it will also be resorbed.

00:21:54: Perfect because then to not open or cut soft tissue to remove something because permanent is non-resorbible

00:22:02: But

00:22:02: still...

00:22:03: great in terms of bacteria adhesion over time.

00:22:06: If you give the correct patient instruction, patient management.

00:22:10: it's very important.

00:22:12: We did even a study comparing sitoplasm and perma-man, we figured out that we were calculating diversity in bacteria.

00:22:19: We have such less of the diversity of bacteria and accumulation... Of course you know one bacterium comes from another and then they spread like pieces.

00:22:28: It's really on perma man.

00:22:29: it is blue and it stays like this.

00:22:33: You see all your patients come back

00:22:35: without plug on it And doesn't stick to the bone or soft tissue

00:22:41: Even if I need to remove it after six weeks.

00:22:43: when you have osteoid formation, It's perfect.

00:22:48: That is why saying that i love because any support, I don't need any titanium reinforcement.

00:22:55: That's not what we're looking for when working around sockets.

00:22:59: We are working to rebuild and just keep that area of the buckle dehesants or the buckled wall like to re-build this missing part that we have lost... ...we do not want it to be rebuilt everything as we did in guided bomber generation!

00:23:12: We have different requests for the membrane.

00:23:17: This is why, my opinion, the PMMA MSO ideal.

00:23:21: But what I try to tell you is that now, What i love so much Is That Now We Have The Availability Of The Socket Shield Okay?

00:23:34: of the Magnesium Shield.

00:23:35: okay To build this socket shield for me was a game changer.

00:23:40: This is where our journey came because we try to listen clinicians all the time and this how you learn.

00:23:46: We listened your needs, tried to juice them from scientific point of view of biomaterials And that's when the journey with magnesium started.

00:23:54: It was a long journey But then it comes in focus on sockets.

00:24:00: So we figured out that we changed technique outcome results and possibility just Because we have something completely different.

00:24:09: And this is where our connection will start to be better best friends because we wrote so many, well you wrote so much publication on the topic of it.

00:24:17: Because... You fell in love

00:24:19: somehow!

00:24:20: So can you tell me a little bit about this shield that we have now?

00:24:24: Yes

00:24:25: It's exactly what I was describing.

00:24:28: What did we need?

00:24:31: We needed something That we could place inside or tunnel under our soft tissue.

00:24:38: that is extremely volume stable, so it keeps all the bone graft in place.

00:24:44: That basically replaces my bucklebone right?

00:24:47: I just replace... In terms of build new

00:24:52: you make a

00:24:52: new one!

00:24:53: I put something inside and looks like my buckle bone And then i don't have to remove because when we work with non-resorbable membranes We have monitor patients very closely.

00:25:05: It's not that we don't sleep good, but it's... We know.

00:25:09: Oh I have this patient who is coming into my office and hopefully nothing happens!

00:25:12: Hopefully nothing will happen if i have a membrane which is resorbable Okay?

00:25:19: That is volume stable My body recognizes in a way because at the end of our day..

00:25:26: We are

00:25:28: talking about magnesium.

00:25:31: So its something our body is familiar with, I feel better.

00:25:37: It's from a surgical point of view fulfilling all my requirements and it's giving me peace-of mind... ...and it's resorbable!

00:25:47: All these years we were looking for something that was volume stable but was resorbible.

00:25:53: We never actually could combine this because the college members were compromising on their stability And with the non-resolvable membranes we were compromising on, you know.

00:26:04: second intervention.

00:26:06: You know being a bit hesitant in terms of patient management and now this is the ideal situation.

00:26:14: so In terms of socket The magnesium shield Is exactly in perfect size.

00:26:20: just inserted to where I need it My bone graft can be placed.

00:26:24: I don't have to do any soft tissue management, so i don't need to be concerned about closing the flap because we're talking about sockets.

00:26:32: there's no need for primary closure Because were working in a field

00:26:36: of

00:26:36: socket management or alveolar rich preservation and not in the field of guided bone regeneration.

00:26:42: So No Need of Primary Closure Just To Fit It!

00:26:46: Put my Bone Graft In The Right Combination That I just mentioned how you like it And Switch it aside.

00:26:52: Because when we are

00:26:52: talking,

00:26:53: when we're talking about comparison with any kind of collagen in it and you were talk-talking About tunneling perma man everything.

00:27:01: I think Tunneling something rigid.

00:27:03: You always know where you come?

00:27:04: You come to the root To the apex so that you know which shield That you came for it And in the end It gives this convexity.

00:27:12: like he said He provides stability and provides space for this bone to be grown.

00:27:17: Exactly!

00:27:19: But also there are quite lots of signs behind magnesium, it's already present in cardiovascular and orthopedics so... It is very well known I think especially how it influences on bone growth.

00:27:35: So you have something like synthetic as an option with magnesium.

00:27:40: Do you think that the magnesium has some effect really?

00:27:45: Definitely.

00:27:46: I mean, like you said there are so many supportive effects that we're seeing not only this but also having antibacterial effect in the degradation of the membrane.

00:27:58: So it's something to keep in mind because we have an open socket We work with a open environment where we have a bacterial infiltration.

00:28:09: So not only from everything that you just mentioned, also from that aspect of having an antibacterial effect in the degradation process.

00:28:18: I think this is extremely important and how would we not prefer something inherent compared to artificial?

00:28:32: Always!

00:28:33: There will be choice right, so it's supporting its antibacterial and it's um supporting the bone growth.

00:28:40: So I think all effects of it are.

00:28:46: there is nothing that i don't feel comfortable with.

00:28:50: but really from a clinical point-of view like from a scientific point of view it's very clear.

00:28:58: But from a handling point of view, is really what I always try to explain that it makes such difference because you have something prepared in size.

00:29:10: That's exactly doing the job for your needs and just placing everything else on top right?

00:29:17: So this makes life easier!

00:29:21: Because magnesium comes after everything else... It does by itself, right?

00:29:26: I don't need to control the environment.

00:29:28: And this is what i mean with a non-resorbable membrane.

00:29:31: you need to controlled the environment.

00:29:33: What suture material that are used?

00:29:35: How's the patient cleaning decide?

00:29:37: Is it moving ?

00:29:38: The membrane staying in place?

00:29:44: All of these aspects.

00:29:45: So from with the magnesium shield...I have everything in place and I don't have to worry about everything that comes after.

00:29:52: So we are talking about flatless, no fixation solution.

00:29:56: you're not fixate shield.

00:29:58: so the procedure goes that you extract the tooth clean the area?

00:30:03: yes And how do then perform?

00:30:05: Just detach soft tissue?

00:30:10: Yes

00:30:12: exactly just Just basically tunnel the soft tissue and then insert it in between your mucoperiostal flap, end of bone.

00:30:23: And you just want to make sure that with any type of membrane going two millimeter past the defect That's the rule for any membrane that you're using okay?

00:30:34: You want to be on native bone...you don't stop directly there but Automatically, with the membrane if you know the size that the heathens are having.

00:30:44: You're measuring it in your probe and you do two millimeter plus.

00:30:48: It usually already comes to the right size but just tunneling inside is a practical point of view.

00:30:57: I think this is what we were looking for at the end today because let's say the science has been approved We're proofed already, we know what's working.

00:31:10: And now the clinicians usually ask how fast?

00:31:15: How can I do it and just stick to inside?

00:31:18: perfect!

00:31:18: Can i go home after?

00:31:19: yes you have very little headache amazing thank.

00:31:24: I

00:31:26: also want to ask you about the question, immediacy now starts to be such a boom and i'm not so familiar with this as a clinical view.

00:31:37: So immediacy is not possible in every case isn't it?

00:31:41: How then shield comes into that area of immediacy.

00:31:45: when do you do immediacy or do you use immediacy?

00:31:47: Yes

00:31:48: Of course I am using immediacy.

00:31:53: Let's call it tool.

00:31:55: Okay, let's call it a tool for now.

00:31:57: It is an amazing tool something to have in your toolbox

00:32:01: okay?

00:32:02: Something that you Have in the back of your mind.

00:32:06: That is possible To do at the time Of extraction usually requires very meticulous planning and there should never ever be any prosthetic compromise.

00:32:20: This is the two rules in terms of immediacy, and my opinion.

00:32:24: Okay?

00:32:25: Meticulous planning.

00:32:26: understand what you're doing.

00:32:28: so it means that You know exactly where you need to position your implant.

00:32:32: And number two It needs to be prosthetic In the course correct position if you feel did you need To prosthetically compromise your positioning.

00:32:40: So for example not placing it in The correct single imposition you Need to abort mission and go with socket grafting.

00:32:49: now Patients like immediate.

00:32:51: I think they come in office with a tooth to extract and immediately go out With the two teeth will be perfect saying

00:32:57: then come to you saying, I heard it's possible Can You do?

00:33:02: It so already the pressure is on right.

00:33:05: They expect you dates they expect you to provide immediacy now And you should.

00:33:09: you should but you should also explain that it has to be an ideal indication to do it, and if I see that i am able to do you should be doing.

00:33:20: Now in terms of understanding the biological principle what's very important is when we talk about immediacy we're placing an implant into a extraction socket right?

00:33:33: So... We are dealing here with this same biological principles which we did with alveolar rich preservation.

00:33:44: Everything is exactly the same.

00:33:45: Our body's gonna rig it to exactly the Same.

00:33:48: Sometimes people think oh if I'm going to place an implant, am i not Gonna have bone resorption?

00:33:53: No you're gonna Have Exactly The Same Biological Cascade That You Would Have.

00:33:58: so the Principles that we just talked about for rich preservation They also apply for immediacy okay.

00:34:05: So If I see, then i can place my implant in the correct prosthetic position.

00:34:11: I planned everything correctly and was able to remove all of the granulation tissue right?

00:34:16: So I don't feel like there is any infectious tissue left.

00:34:20: you Can go ahead with immediacy And Then You continue With The Same Protocol That You Would Find Before.

00:34:29: and Exactly that Like Because You Just Asked About The Soccer Shield.

00:34:33: Even Better just To Place A Membrane on the buckle aspect that is missing, filling the remaining space with bone and just covering this side with a suture or if you want even with a collagen color cone on top.

00:34:47: Just to kind of have a seal on the side but nothing more than that.

00:34:51: so your combining everything together.

00:34:53: there's no contra indication.

00:34:56: uh...to do it.

00:34:57: combine all the barrier materials together in conjunction with the implant except for you don't have to write indication.

00:35:07: So it all goes back, I always would say that socket preservation or alveolar rich preservation which is more the correct term... ...is a more biological principle we need to understand.

00:35:22: We have a reduction of heart tissue and an increase in soft tissue so we want counteracted.

00:35:27: so use combination of biomaterials to maintain my socket.

00:35:33: If we move to the field of immediacy, it's more for a prosthetic question.

00:35:37: Okay?

00:35:38: Can I place my implant in the correct prosthetic position?

00:35:42: can i actually plan correctly from the beginning have good digital workflow?

00:35:48: go Have A Good Flow In Terms Of Placing My Implants.

00:35:51: Did I remove all of my granulation tissue?

00:35:54: okay so I can place my implant in combination with my biological principles.

00:35:59: But this is usually what i would always give as a guideline, that rich preservation has more biological principle we're trying to preserve and immediacy it's more of a prosthetic principal.

00:36:14: will have my implant the correct position plus primary stability the okay at the end, check that you placed everything correctly and then say oh!

00:36:31: And it's stable.

00:36:33: And go to bone?

00:36:34: You said you fulfill always a gap.

00:36:36: what is the go-to bone in fulfilling your gaps?

00:36:39: with the situation of immediate signal case

00:36:41: I would probably go for a volume stable.

00:36:44: so for CeraBone I would probably go for Cerebon in these areas, because we want to maintain the space which is usually a more compromised space or smaller space in this area.

00:36:57: And that idea should be something that stays in place and it's volume stable over time.

00:37:02: so Cerebone will be my goal... Go too!

00:37:04: In this case.

00:37:06: Thank you very much You're

00:37:07: welcome.