Maxillary Posterior Multiple Teeth Replacement with Class I, II, and III CMI Fixations

Situation

Pre-operative panoramic radiograph

-The heights of residual alveolar bone in the areas of #16 & #27 were measured as 7-8mm.

Class III sinus bone graft using the SCA kit with simultaneous implant installation was planned.

Pre-operative intra-oral photograph. Bridge of four anterior teeth was removed. #16, #15, #12, #24, #25 & #27 were missing.

Occlusal view of right side pre-operative intra-oral photograph. Abundant keratinized gingiva was seen. Bony torus of buccal side could be seen.

Occlusal view of left side pre-operative intra-oral photograph. Abundant keratinized gingiva was seen.

Removed incised keratinized gingiva.

After serial drilling, 2.4mm diameter S-reamer of the SCA kit with 8mm stopper was used at the area of #16 due to 8mm residual alveolar bone height as measured with panoramic radiograph. After the 2.4 diameter S-reamer, the 2.8 diameter S-reamer was applied with caution to enlarge the hole of cortical bone at the maxillary sinus floor.

Allograft (RegenOss™) was inserted into the space of the elevated sinus membrane. Bone graft material was applied with the bone carrier of the SCA kit. The bone carrier was designed to hold 0.05cc at one time. A total of 0.3cc was placed.

Bone graft material of the apical side was dispersed with the bone spreader from the SCA kit using a handpiece with a speed of 50-80 rpm.

After bone graft, trans-mucosal IT type CMI implant (5.0X10.0) was ready for #16 area.

Fixture at #16 area was placed for optimal depth.

Another trans-mucosal IT type CMI implant (4.0X10.0) was planned for the area of #15.

Fixture was placed at the area of #15.

The initial torque of the #15 fixture was about 35 Ncm.

Two trans-mucosal (non-submerged) type implants were positioned at the place of #16 & #15 without an elevating flap.

Healing abutments were connected due to sufficient insertion torque.

Incised keratinized gingiva was removed with surgical curette. The site of #27 was prepared for the same way.

The site of #27 was prepared with the S-reamer from the SCA kit to perform a crestal sinus approach along 7-8mm residual alveolar bone height. After opening of cortical bone at the sinus floor area, Aqua tap of the Sinus All kit was connected to the drilling site for elevating the Schneiderian membrane with hydraulic pressure.

Aqua valve with saline syringe was linked to the access hole of the firmly fixed Aqua Tap.

The same amount of saline as planned for sinus membrane elevation was prepared in the syringe. The plunger of the syringe was moved forward and backward with attention not to cause the sinus membrane to tear. After elevation, bone graft material was inserted in the usual manner.

IT type wide neck CMI implant (5.0X10.0) was placed at the site of #27 with enough insertion torque.

Healing abutments were coupled with fixtures.

Post-operative panoramic radiograph after both side maxillary sinus bone graft and implants placement. Dome shaped bone graft material at the apex of #16 & #27 was observed.

Intra-oral photograph 3 weeks after surgery. Impression of #16, #15, #24 & #25 was taken. After controlling height of ready-made abutments, they were connected to the fixtures. Bite registration was made with silicone rubber material.

Periapical radiograph three weeks after operation. Abutments were placed in position, and alveolar bone around fixtures were well maintained

Final prostheses of right maxilla were delivered one and a half months later after surgery.

Lateral view of right maxilla after delivery of restorations.

Periapical radiograph of posterior maxilla five months after surgery. The alveolar bone around fixtures appeared firm and stable.

Panoramic radiograph after delivery of prostheses at both sides of the posterior maxilla.

Lateral view of left maxilla after treatment.

Panoramic radiograph five months after operation. All prostheses of implants were delivered. The bone graft material inserted with the SCA kit at the apical site of #16 & #27 was stable.