Advanced Bone Grafting: Case Study 2

Diagnosis: Advanced chronic periodontal disease with multiple failing root canals causing large draining abscesses in upper jaw. This pathology resulted in the loss of all healthy bone needed to support a proper dental implant restoration. Lower teeth were all saved with periodontal surgery and custom Zeno-zirconium crowns.

Treatment timeframe: 2014-2015

These types of bone grafting procedures are done either in a hospital environment or an in-patient surgical center where the patients have the ability to stay overnight. These operations need to be performed in a sterile environment.

For more information about Advanced Bone Grafting or to learn more about Dr. Arthur Chal, our experienced dentist, please contact us today.
Case 2 CS image 1

The image above clearly indicates that there is no bone in the upper jaw to place dental implants. The three red arrows on the right clearly show the destruction done by the multiple periodontal abscesses. Utilizing this 3D cat scan image, the decision was made to have oral and maxillofacial surgeon Reed Day, MD, DMD, FACS move this patient’s upper jaw down and forward, and then place bone grafts into that entire area to receive future dental implants.


Here in this film, as well as the 3D images to follow, you can see the Chal-Hatcher™ imaging guide in place. The 3D radiographs were done after the major surgery was complete, and they will be used in the virtual planning of the dental implant placement. During the surgery, the upper jaw (maxilla) underwent a down fracture and was advanced seven millimeters. The upper jaw is then held in position with Stryker® plates and screws. The upper jaw was down grafted about two millimeters as well. Following this fixation, bone was grafted from the posterior hip. The bone marrow was packed into both sinus cavities and the floor of the nose.

Case 2 Image 3

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case 2 image 3b

We utilize these three images to illustrate our 3D virtual implant planning. Dr. Chal will work with oral and maxillofacial specialist Dr. S. Thomas Deahl, and he will verify that there are no problems with the bone graft, that it has completely healed, and there are no hidden pockets of infection or bony non-union.

Dr. Chal will then work with Dr. Douglas Chenin via computer tele-conference, and they will go through all of the complex scans in great deal to identify where implants can and cannot be placed safely. The Chal-Hatcher™ guiding system always plans for eight implants. In this particular case, though, only six could be used, because fixation screws and plates would have interfered with additional placement. Nonetheless, when we can do six full size and appropriately placed implants we can typically offer the same level of restoration as if eight had been utilized.

Dr. Chal and Dr. Chenin will work out the position of each implant site. The x, y, and z-axis (i.e. horizontal, vertical, and sagittal plane) of each implant fixture must be identified. The black and white images to the left of the 3D skeletal image show how they manipulate each potential implant site. The Chal-Hatcher™ imaging guide is then converted to a surgical guide that can be sterilized and used by the surgeon in the operating room. He will use it to accurately place each dental implant. You can see pictures of the conversion of the models from imaging guide to surgical guide below. In this particular case, the bone graft on the patient’s left side was overly large, meaning large enough that bone had to be removed to place implants in the position that would achieve the correct plane of occlusion (i.e. ability to chew correctly, or to have the “railroad tracks” work in parallel). An additional guide was made for the surgeon to reduce three to four millimeters of bone on the patient’s upper left. Again, all of these guides were sterilized for the surgeon to use in the operating room during surgery.


case 2 model image 2

The above photos display how Dr. Chal and Dr. Chenin communicate the position of each implant to be utilized. They also show how the Chal-Hatcher™ imaging guide will be converted into the surgical guide that will be sterilized by the surgeon and used in the operating room.

Case 2 model image 2a

In these photos you can see the addition of a bone reduction guide, which the surgeon must make in this case. You only have to make a bone reduction guide in the event there’s too much bone.


case 2 CS image 5

This image will appear somewhat blurry compared to the previous images, because it was taken the day of surgery at the surgi-center. As a result, you will see some motion artifact. This effect occurs when the patient moves while the photo is taken, which can make for a hazy image.


Below are the final images of this case. The first image is a Panoramic X-ray with the implants in place. The last two images are of our happy patient with his stunning new smile.
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Dr. Chal is currently working with his radiologists and surgical colleagues to add cases of the treatment of cancerous tumors, benign tumors, and total facial atrophy.

If you have additional questions about this case study or on advanced bone grafting, please contact us today.

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