Advanced Bone Grafting: Case Study 1

Diagnosis: Extreme bone atrophy of both upper and lower jaw due to early tooth loss.

Treatment timeframe: 2008-2009

Bone grafting can restore the jawbone to where there is enough bone to retain dental implants, thus restoring full mouth function. It also helps restore facial collapse, filling out the face and making the patient look younger.

These advanced bone grafting procedures are for patients who are looking to restore and rejuvenate their jaws, teeth, and face. Patients who are concerned about long term outcomes and quality of life issue will find these cases appealing. They are time consuming, expensive, and technically challenging. If you do not expect to live for a decade or longer, there are many cheaper, faster, and easier options advertised by many dentist on TV, magazines, billboard, radio, and newspapers daily. They will all tell you “you can get your new smile in just a day”. Remember, life is full of choices and each patient must decide what is best for them based on their goals, priorities, and budget.

Below is an example. Dina is a patient who came to Dr. Chal as what could only be called a dental cripple. She said she was using “a pound of glue a day” to try to hold her denture in, and it wasn’t working. She presented with 100% bone atrophy of the upper jaw. Since the time that all her teeth were extracted decades ago, her body had been re-absorbing her jawbone. (See our page on facial collapse for more information on this process.)

In cases like these of severe facial collapse, many implant dentists will say that nothing can be done. But Dr. Chal and his team of specialists have done many cases like this. They take bone from the hip and graft it into the jaw to provide a foundation for the dental implants.

Here are before-and-after photographs of Dina:

Before - Dina is very reluctant to smile, and her face is tense and looks strained.

Before – Dina is very reluctant to smile, and her face is tense and looks strained.

After - Notice that her normal chin-to-nose dimension has been restored. And of course, her smile is relaxed and happy.

After – Notice that her normal chin-to-nose dimension has been restored. And of course, her smile is relaxed and happy.

This is Dina's denture. The teeth look artificial. Notice that the back teeth drop down, creating what is called a reverse smile line. But the worst part isn't apparent, and that is that she has to rely on glue to hold it in, and has the constant worry that her teeth may come out at the wrong time. Plus, she can't eat normally.

This is Dina’s denture. The teeth look artificial. Notice that the back teeth drop down, creating what is called a reverse smile line. But the worst part isn’t apparent, and that is that she has to rely on glue to hold it in, and has the constant worry that her teeth may come out at the wrong time. Plus, she can’t eat normally.

After her bone grafting, Dina was fitted with a fixed hybrid restoration. Not only are the esthetics perfectly natural, but she has the secure feeling of teeth that are anchored to her jaw. She can eat normally, can forget about the adhesive, and can smile naturally without fear of embarrassment.

After her bone grafting, Dina was fitted with a fixed hybrid restoration. Not only are the esthetics perfectly natural, but she has the secure feeling of teeth that are anchored to her jaw. She can eat normally, can forget about the adhesive, and can smile naturally without fear of embarrassment.

Dina is so thrilled with her results that she has provided the following testimonial for this website, you can read Dina’s testimonial below. And Dr. Chal has been asked to lecture at an upcoming scientific meeting on the techniques that produced this result.

From the onset, my husband Leon and I wanted an implant dentist who could offer us experience, proven superior results, and commitment. We found these qualities and more in Dr. Arthur Chal.

Nearly all my teeth were extracted when I was in my early twenties, and I have worn dentures ever since. Now in my mid sixties, Dr. Chal has given me the comfort and self-confidence I have longed for. The improvement in the quality of my life is tremendous.

Dr. Chal doesn’t claim to perform miracles, but I am living proof that he can.

When you demand the best possible outcome for your mouth and appearance, select Dr. Chal for all your dental needs.” – Dina


Now that you’ve seen Dina’s incredible transformation, we will show you the diagnosis and treatment plan required to achieve this result.

Dr. Arthur Chal works closely with an extensively trained team of dental specialists, including oral facial radiologists David Hatcher, DDS, MSc, and S. Thomas Deahl, D.M.D., Ph.D. Oral and maxillofacial surgeon Reed Day, MD, DMD, FACS collaborates to individualize and customize each treatment plan.

Dental Implant Bone Grafting img1

In the above image you can see the initial CAT scan with panoramic view. Our patient for Case Study 1, Dina, has been wearing dentures for over 40 years. She is currently wearing a denture with porcelain teeth. These porcelain teeth have metal anchors holding them into the denture base, which present as eight white dots on the image. Her lower eight anterior natural teeth have been present her entire life.

You may notice in the “before” picture Dina has a reverse curve on her back teeth. You can see that her smile appears to tip down as opposed to up inside her mouth. The panoramic view reveals the reason for this condition, which we have highlighted with green arrows located at the base of the maxillary sinus cavity. The yellow lines indicate the tissue supporting her current denture base. This entire area shows a tissue overgrowth that has occurred over 40 years. Medically referred to as tuberosity tissue hyperplasia, the overgrowth is analogous to having a great callus form in your mouth as a result of friction, similar to what happens to your foot after wearing a bad shoe.

The first step of treatment is to have the surgeon remove the overgrowth of tissue. Then a Prototype Denture can be created that allows for the correct placement of the teeth.

Following extensive review of Dina’s CAT scan and in consultation with the treating surgeon, Dr. Chal then begins to do the model preparation phase that is outlined below. Guides have been developed for the surgeon to perform the initial tissue surgery, which you can see in the photographs below.

Dina’s case planning illustrate the care and attention to detail of Dr. Chal, and how he is able to obtain such outstanding, predictable results. The below photograph are of a pre-operative model of an upper jaw. In the anterior, the patient has only a small amount of bone remaining — not enough to hold a removable denture. The posterior has no bone remaining and only a thick hyperplastic tissue overgrowth (marked with red diagonal lines) which will need to be surgically excised.

ABG workup

Based on his esthetic and functional analysis, Dr. Chal adds a pink acrylic material to the model. This acrylic will help show the surgeon exactly where he needs to add bone, and how much and what shape the bone needs to be. While many dentists simply give verbal instructions to the surgeon, remember that this work is taking place in three dimensions. But no verbal communication, no matter how clear, could be as effective as actually illustrating in three dimensions on an actual model of the patient’s jaw what needs to be done.

The clear acrylic surgical splint, shown here, is then created. This splint is sterilized and then used during the surgery as a guide to the surgeon. This leaves no room for error.


Dental Implant Bone Grafting img2

The above radiographic image shows the lower jaw with extreme bone atrophy. The yellow arrows indicate the nerve canal, and the vertical red arrows clearly reveal where there is no bone, which is the foundational tissue needed to place dental implants. The green lines running alongside the lower teeth show where the bones used to be. Below the nose you will see to white lines. The short vertical white line in the nasal spine, the longer horizontal white line is the roof of the mouth.

Note that where Dina’s eight teeth are still present there is no atrophy. However, where the teeth are missing the bone has completely disappeared. This is due to the lack of the piezoelectric effect.

The green lines show where little natural bone remains, as well as where advanced vertical bone grafting will be placed. The yellow arrows identify the nerve canals in the lower jaw. If the nerve is violated during surgery or due to the dental implant, the result will be permanent numb lip. The red arrows clearly identify that there is no room available for dental implants without complex bone grafting.


ABG Case 1c catscan image3

The above radiograph image provides a detailed view of the atrophy of Dina’s upper jaw bone. The areas marked in green show where bone will be grafted into both sinus cavities and into the area below the nose. The yellow X’s indicate where the tissue overgrowth, or callus, will be excised as discussed previously.


AVB Case1 b1 catscan image 4

The above image shows the innovative Chal-Hatcher™ guide in place. It was designed from the Prototype Denture made for the patient. The guide places the teeth in the functionally correct position. The Prototype Denture, i.e. “an ideal denture,” is a step that’s often neglected or never done, but it forms the foundation for ALL bone grafting surgery and dental implant surgery to follow !

The green arrows show that the chewing surfaces of the teeth are now precisely level. They are no longer reversed or hanging down as seen in the “before” photograph of Dina and in her initial CAT scan image. The yellow arrows are pointing to black void air tubes, of which there are eight in the upper jaw and eight in the lower jaw-imaging guide. They indicate possible positions for future implants. Multiple cross sections will be taken to verify each future position.


ABG Case1 catscan image 5

In the above image you can see the sinus bone graft in place and the tissue tuberosity reduction/excision completed. The yellow X’s show where the “large tissue callus” has been removed and where the implant-planning guide is now in place.


ABG Case 1 catscan image 6

The above radiographic image offers a panoramic view of the upper and lower jaw, revealing the sinus grafts, upper jaw grafts, and lower jaw grafts in place. The long green arrows point to the placement of titanium mesh, which supports a bone graft. The small white dots indicated on the upper and lower jaw are retention screws holding the mesh and bone in place.

Note: The bone utilized for these grafts was harvested from the patient’s hip. This type of bone graft in an autogenous graft. This mean that the bone was harvested from one site and transplanted to another site in the same individual. This type of bone is more successful than synthetic, inorganic bone substitute material.


ABG Case 1 catscan image 7

This next radiograph shows a panoramic view of both the upper and lower jaw with eight upper and six lower implants in place. Note that more than adequate bone volume has been placed to support all of these dental implants.


ABG Case 1 catscan image 8

Our final CAT scan image was taken approximately six months after the previous image. At this point, the surgeon has uncovered the dental implants, and the bone healing, dental implant integration, and tissue healing is complete. There are cover screws placed on all the implants. Dr. Chal will now utilize individual custom-made gold abutments with zirconium crown restorations on the lower teeth. He will also proceed to restore the upper hybrid restoration.

The green lines in this film indicate a critically important feature for long-term stability of the bone and teeth. All types of dental implants are similar to a railroad system. When the tracks are parallel, the train can run smoothly forever. If they’re not parallel, you end up with a train wreck. Dr. Chal ensures that the implants are placed in such a way as to optimize bite alignment for long-lasting results.

You can see as you scroll through these images and descriptions that the quality and thoroughness of the treatment plan is essential. Dr. Chal emphasizes that “it’s not the scan, but the plan.” He feels strongly that it is in the patients best interest to have a dual-degree surgeon (i.e., medical and dental degree) on their case. Dr. Chal and the treating surgeon Reed Day, MD, DMD, FACS, (pictured below) have worked together as an effective dentist and surgeon, detail-oriented team for over 25 years.


drday1

Reed Day, MD, DMD, FACS

Harvard Medical School
Harvard Dental School
Massachusetts General Hospital
(5 year surgical residency)
Fellow American College of Surgeons


For more information about Dina’s case and advanced bone grafting, contact us today and we can answer your questions or schedule an appointment with Dr. Chal.

The end result? A successful treatment outcome, and an enthusiastic patient like Dina.

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