Watanabe et al.

Int Chin J Dent 2004; 4: 93-96.

Functional and esthetic reconstruction using implant systems andmaxillary sinus grafting: A clinical report
Ikuya Watanabe, DDS, PhD,a Catherene Pham, BDSc, BSc, MS,b and Uwe Frohberg, MD,DMDc
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Department of Biomaterials Science, Post-Graduate Prosthodontics, and Department of Oral &Maxillofacial Surgery/Pharmacology, Baylor College of Dentistry, Texas A&M University System Health
Science Center, Dallas, Texas, USA
This clinical report describes a functional and esthetic reconstruction using the Brånemark Novum system for themandible and ITI implants for the maxilla after maxillary sinus grafting. After the extraction of mandibular teeth,
the Novum system and a prosthesis were placed in the patient’s mouth. Autologous bone transplantation fromthe mandible was also performed in the maxillary sinus at the same time. After the implant placement
subsequent to the maxillary sinus grafting, the maxillary teeth and implants were restored with ceramic
prostheses. These functional and esthetic prostheses have performed favorably without any problems for twoyears. (Int Chin J Dent 2004; 4: 93-96.)
Key Words: esthetics, function, implant, maxillary sinus graft.

Introduction
Implant-supported prostheses are frequently applied restorations for patients with functional and esthetic
demands. A unique alternative in the realm of immediate loading of osseointegrated implants is the Brånemark
Novum system for the edentulous mandible. Experience to date with over 200 Novum patients treated indicatesa success rate of fixtures and fixed prostheses comparable to that of conventional fixed partial dentures.1-3 In
addition, bone loss patterns seem to indicate that the same kind of steady-state bone resolution occurs with theNovum that has been the benchmark of the original Brånemark fixed implant bridgework in the anterior
mandible.
Maxillary sinus grafting is occasionally necessary to complement insufficient bone volume to support
maxillary implants, especially for posterior regions. There are several techniques to increase the bone volume
such as guided bone regeneration (GBR) with autogenous bone graft,4,5 and sinus floor elevation.6 This clinicalreport describes the functional and esthetic reconstruction using the Novum system for the mandible and ITI
implants for the maxilla after maxillary sinus autologous bone transplantation from the mandible.

Clinical Report
A 56-year-old female patient had multiple missing and stump teeth, fracture and attrition of porcelain in PFM
restorations (Figs. 1-3). All of the mandibular teeth, left molars and the first right premolar in the maxilla had
type 2-3 mobility and resorption of alveolar bone, as evident in the radiographs (Fig. 4). Anterior mandibular
teeth also indicated an apical lesion. The patient was classified as having bone quality of 2-3 and bone type ofB-C (Lekholm and Zarb)7 after examination of the lateral radiographic cephalogram and occlusal radiograph,and was considered appropriate for treatment in the Novum system (Nobel Biocare USA Inc., Yorba Linda, CA,USA). After several possible treatment plans were outlined to the patient, the definitive plan that the patient
accepted was the application of the Novum system with a fixed detachable prosthesis after the extraction of all
mandibular teeth. For the maxilla, the selected plan was the grafting of maxillary sinus (left posterior and right93

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Int Chin J Dent 2004; 4: 93-96.

Fig. 1

Fig. 2

Fig. 3Fig. 5

Fig. 6
Fig. 4

Fig. 7

Fig. 8Fig. 10

Fig. 11Fig. 12

Fig. 9Fig. 13

Fig. 14

Fig. 1. Frontal view of the patient referred for prosthetic evaluation.
Fig. 2. Occlusal view (maxillary) of the patient referred for prosthetic evaluation.
Fig. 3. Occlusal view (mandibular) of the patient referred for prosthetic evaluation.

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Int Chin J Dent 2004; 4: 93-96.

Fig. 4. Dental X-ray radiograph of the patient before treatment.
Fig. 5. Surgical splint: anterior residual ridge of the mandible was ground flat.
Fig. 6. Titanium (lower and upper) bars placed on mandible to confirm adequate space.
Fig. 7. Placement of two lateral implant fixtures using V-template.
Fig. 8. Titanium (upper and lower) bars installed on the Novum implants.
Fig. 9. Autogolous bone (from mandible) transplantation in maxillary sinus.
Fig. 10. Definitive mandibular prosthesis installed on the Novum system.
Fig. 11. Panoramic radiograph after placement of maxillary implants.
Fig. 12. Master cast for fabrication of Procera and custom copings.
Fig. 13. All-ceramic crowns (top) with Procera copings for anterior and PFM prostheses (bottom) forposterior.
Fig. 14. Frontal view of the patient after final restorations.
premolar regions) from the mandible and the placement of four implants and ceramic restorations. Although theNovum system and a definitive prosthesis can be installed in the same day as the tooth extraction, the systeminstallation was conducted after the tooth sockets of the extracted teeth had healed. The vertical dimension ofocclusion (VDO) was maintained using a mandibular temporary complete denture and maxillary provisionalrestorations. Before the installation of the Novum system, a surgical guide was fabricated on the master castmounted on the semi-adjustable articulator (Fig. 5). The alveolar ridge of the mandibular cast was ground flat byremoving amounts equivalent to actual surgical bone reduction. There was enough space to place two titanium(lower and upper) bars and artificial teeth between the maxillary teeth and mandibular residual ridge (Fig. 6).
According to the instructions, the Novum system (4 mm diameter) was installed using four templates after thereduction of the mandibular alveolar bone crest.

Fig. 7 presents the final template (V-template) for theplacement of two lateral implant fixtures positioned in relation to a central fixture. After the titanium bars wereplaced in position (Fig. 8), the interocclusal record was registered with a polyvinylsiloxane putty to fabricate thedefinitive prosthesis. The maxillary sinus grafting was performed during the fabrication of the mandibular
prosthesis (Fig. 9). The alveolar bones removed from the mandible were transplanted beneath the maxillarysinus mucous membrane. After the wax denture was tried in the patient’s mouth to confirm the occlusion andesthetics, the denture resin was finally polymerized according to conventional methods. The definitive fixeddetachable prosthesis was then installed in the patient’s mouth on the same day (Fig. 10).
Four ITI solid screw implants (4.1 mm diameter, 12.0 mm long, Institut Straumann AG, Waldenburg,Switzerland) were placed in the grafting area 6 months after the maxillary sinus grafting (Fig. 11). Five months
after implant placement, custom gold alloy copings for implants and Procera alumina copings (Nobel Biocare,Fair Lawn, NJ, USA) for the anterior teeth were made from the master cast (Fig. 12). The final maxillary
restorations were all-ceramic crowns with Procera copings for the anterior teeth, and PFM single crowns andfixed partial dentures for the posterior implants and teeth (Fig. 13). The maxillary prostheses were finallycemented with a resin luting cement (Rely X; 3M ESPE, St. Paul, MN, USA). The definitive prostheses had thegroup function occlusal scheme (Fig. 14). The patient was satisfied with these functional and esthetic prostheses,
which have performed favorably without any fracture or bone resorption for two years.

Discussion
It is sometime difficult to place implants establishing functional and esthetic superstructures due to insufficientbone volume or bone loss (resorption) of the implant placement area. In the present clinical case, the patient’s
maxillary sinus floor in the posterior area was low, and the level of the sinus floor had to be elevated to place the95Watanabe et al.

Int Chin J Dent 2004; 4: 93-96.

implants. Since the number of patients having difficulty with implant placement is increasing, the collaboration ofprosthodontists, periodontists and oral surgeons is very important to achieve satisfactory results for these patients.
With the appropriate informed consent from the patient, the mandibular teeth suffering from periodontal andendodontic disease were extracted, and the Novum system was installed to produce good functional and estheticresults. Another reason for choosing this treatment plan was that the appropriate function may not be achieved
even if the fixed anterior teeth are reserved on the anterior residual ridge that is much higher than that of theposterior residual ridge due to severe bone resorption (Fig. 1). The bone debris removed from the mandible for theNovum installation was used as autologous bone for the maxillary sinus floor elevation to increase the support forthe maxillary implant placement.

As a result, sufficient bone support was achieved for the functional

superstructures on the implants. The all-ceramic restorations with Procera copings used for the maxillary anterior
teeth are also likely to contribute to the achievement of good esthetic results. Follow-up appointments to monitor
the prostheses’ function will continue.
Acknowledgment
Supported in part by BOHF Y2001-Z. Editorial assistance by Mrs. Jeanne Santa Cruz is appreciated.

References
1. Brånemark PI, Engstrand P, Öhrnell LO, et al. Brånemark NovumTM.: A new treatment concept for rehabilitation of theedentulous mandible. Preliminary results from a prospective clinical follow-up study. Clin Implant Dent & Rel Res 1999; 1:2-16.
2. Brånemark PI. The Brånemark Novum protocol for same-day teeth. A global perspective. Berlin: Quintessence Publishing
Co.; 2000. p. 31-166.
3. Engstrand P, Gröndahl K, Öhrnell LO, Nilsson P, Nannmark U, Brånemark PI. Perspective follow-up study of 95 patients withedentulous mandibles treated according to the Brånemark Novum concept. Clin Implant Dent & Rel Res 2003; 5: 3-10.
4. Schenk RK, Buser D, Dahlin C. Healing pattern of bone regeneration in membrane-protected defects: a histologic study in thecanine mandible. Int J Oral Maxillofac Implants 1994; 9: 13-29.
5. Buser D, Lang NP, Nyman S. Regeneration and enlargement of jaw bone using guided tissue regeneration. Clin Oral Impl
Res 1990; 1: 22-32.
6. Summers RB. Maxillary implant surgery: The osteotome technique; Part 1. Compend Contin Educ Dent 1994; 15: 152-162.
7. Lekholm U, Zarb GA: Patient selection and preparation. In: Brånemark PI, Zarb GA, Albrektsson T (eds): Tissue-integrated
prostheses: Osseointegration in clinical dentistry. Chicago: Quintessence; 1985. p. 199-209.

Reprint request to:
Dr. Ikuya Watanabe
Department of Biomaterials Science, Baylor College of Dentistry
Texas A&M University System Health Science Center
3302 Gaston Ave., Dallas, TX 75246, USAFax: +1-214-828-8458 E-mail: iwatanabe@bcd.tamhsc.edu
Received October 8, 2004. Revised October 27, 2004. Accepted November 3, 2004.
Copyright ©2004 by the Editorial Council of the International Chinese Journal of Dentistry.

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