CLINICAL DATA
Raphaël Bettach, OD
Gretz-Armainvilliers, France

Ms M., aged 45 and in good general health, was referred for a permanent fixed prosthetic solution for her maxillary.
She presented with tooth loss concerning the right maxillary lateral incisor, as well as the three right maxillary molars.
On the left side, her tooth loss extended from the first to the third left maxillary molars.
Clinical examination of the teeth remaining on the maxillary revealed the presence of an implant in good condition at the level of the left lateral incisor.
The other teeth still present on the arch were all very mobile and all showed signs of terminal alveolysis.
The radiological examination (retroalveolar X-ray, panoramic X-ray and CT scan) confirmed the poor periodontal condition of the teeth on the maxillary, but also made it possible to visualize the very poor subsinusal height of the bone, both at the level of the right maxillary sinus and the left maxillary sinus.
After a full examination (clinical, radiographical and moulding study), the following treatment plan was chosen.

1. Complete depuration and encouragement of good oral hygiene.

2. Initial surgical stage:
a) Extraction of 13 and 14 and implantation of two so-called “post-extractional” implants with a ßTCP bone graft around the implants.

  
CAS CLINIQUE

b) Filler bone graft for the right maxillary sinus with Kasios ßTCP using a “Caldwell-Luc”-type bone window, with three subsinusal implants fitted on the same occasion.

3. Second surgical stage:
After a healing time of one month for the right maxillary sector, the left maxillary sinus was filled and 3 subsinusal implants fitted during the same operation.

4. Final surgical stage:
Extraction of teeth 11, 21, 24 and 25, then 5 so-called “post-extractional” implants fitted in these sites.
With regard to the implant in position 22, it was decided to remove the crown that was attached to it and to replace it with a cover screw on this implant for the integration period.
Given the number of implants placed in the maxillary, it was decided not to retain it as it was not compatible with the brand of implants chosen for this clinical case.

5. Implantation of a full, removable and temporary prosthesis on the maxillary.

6. After validation of the good osteo-integration of the implants on the maxillary, a ceramic and metal prosthesis will be screwed on to the implants.

 
 
1. Axial view of the buccal cavity before surgery.
  
2. Front view CT scan before surgery.
 
3. Reconstitution sections
Reconstitution sections at the level of the left maxillary sinus.
  
4. View of the left maxillary sinus window, as well as of the extraction sites after curettage of the granulous tissue.
 
5. Positioning of two implants at the level of extraction sites 14 and 15.
  
6. Filling the bone defects at the level of these two implants with ßTCP.
 
7. Implantation of a resorbable guided bone regeneration membrane.
  
8. Filling the left maxillary sinus with ßTCP and fitting three implants during the same operation.
 
9. Overall view of the surgery site with the five implants in position.
  
10. Hermetic sutures at the surgery site.
 
11. Post-operative panoramic X-ray.
  
12. Post-operative front view CT scan.
 
13. Post-operative reconstitution CT scan sections at the level of sites 16-17.
  
14. Gingival scarring on the right after four weeks and start of surgery on the right side.
 
15. Pre-surgery front view CT scan focussing on the right maxillary sector.
  
16. Right maxillary sinus approach window.
 
17. Positioning three implants during the same surgical procedure as the filling of the sinus.
  
18. View of the left maxillary site at the end of the procedure.
 
19. Sutures on the left maxillary site.
  
20. Post-operative panoramic dental X-ray.
 
21. Post-operative view CT scan of the left maxillary sector.
  
22. Reconstitution bone sections at the level of sector 26-27.
 
23. Front view CT scan of the entire maxillary after 3 months. Note the healing of Schneider’s membrane in each sinus.
  
24. Bone sample taken from sector 18 of the right maxillary sinus
 
25. Histological sections showing bone formation around the TCP particles.
  
26. Different staining showing bone apposition in close contact with the TCP particles. Note the degradation process in progress on the TCP particles.
 
27. Front view CT scan of the right maxillary sinus.
  
28. Reconstitution CT scan sections at the level of sector 16-17.
 
29. Front view CT scan of the left maxillary sinus.
  
30. Reconstitution CT scan sections at the level of sector 26-27.
 
31. CT scan of the entire maxillary, front view, before surgery positioning the implants in the anterior sector.
  
32. Reconstitution CT scan sections at the level of sector 21.
 
33. Reconstitution CT scan sections at the level of sector 22 and 23.
  
34. Reconstitution CT scan sections at the level of sector 24-25.
 
35. View of the buccal cavity before extraction of the anterior teeth.
  
36. Axial view of the maxillary bone after extraction of the anterior teeth and cleaning of the granulous tissue.
 
37. View of the osteo-integrated implants at the level of sectors 13-14. These implants were not totally buried in the bone on the day they were fitted. They were covered with Kasios TCP and were reopened after only 4 months to show the bone neoformation obtained around the implants by means of the TCP.
  
38. New image of the bone regenerated around the implants thanks to the Kasios ßTCP.
 
39. Positioning of the so-called “post-extraction” implants in the anterior sector
  
40. Filling the bone defects with Kasios ßTCP.
 
41. Gingival sutures.
  
42. Post-operative panoramic X-ray.
 

 
43. Positioning of full, removable, temporary and immediate prosthesis for the time needed for the osteo-integration of the implants.