For total edentulous rehabilitation — safely, securely, affordably and fast

n this case of moderate bone resorption, the All-on-4 concept—with NobelGuide in the maxilla and the flap approach in mandible— provided complete rehabilitation with a minimally invasive solution.

By Dr. Paulo Maló and MALO Ceramics

The totally edentulous female patient depicted here was a removable denture wearer in her early 50s, and in good general health. At the time she approached our clinic for alternative treatment, she had had her dentures for 15 years and was complaining about poor retention and the general instability of her removable dentures.

In addition to the discomfort she experienced, the patient found it difficult to speak clearly and chew well, and she was unhappy with the overall appearance of her mouth. She was well-motivated for the fixed, implant supported rehabilitation that we subsequently proposed.

Our oral examination showed moderate bone resorption in the maxilla (at least 5 mm width and 10 mm bone height between the canines in the maxilla) and severe bone resorption in the mandible (at least 5 mm width and 8 mm bone height between the mental foramina in the mandible). The patient presented a low smile line.

We implemented fixed, implant supported, bimaxillary rehabilitation through the All-on-4 concept, following the NobelGuide protocol (flapless) in the maxilla, and the conventional flap approach with the All-on-4 Guide in the mandible.

Four NobelSpeedy Groovy Implants were placed in each of the jaws, followed by immediate placement of provisional, fixed, all-acrylic bridges, providing the patient with an immediate function solution.

In the maxilla, a NobelProcera Implant Bridge Titanium framework with individually designed and cemented zirconia crowns and pink acrylic was used. In the mandible, a NobelProcera Implant Bridge Titanium framework wrapped in pink acrylic and denture teeth was used. (Both placed six months after surgery according to the Malo Clinic protocol.)

 More to explore: More than a decade’s experience: www.nobelbiocare.com/all-on-4

1. Intra-oral view of the removable dentures. Since the patient’s denture did not meet the functional and esthetic requirements, a new removable upper denture was fabricated. After the intra-oral examination, special consideration was given to the low smile line and mouth opening capability of over 50 mm.

2. Pre-op radiograph together with the 3D radiographic analysis shows the moderate bone resorption in the maxilla and severe bone resorption in the mandible. Please note the lack of available bone for implant placement in the posterior maxilla and mandible.

3. All-on-4 treatment planning with the NobelClinician Software, for a detailed diagnostic process in both jaws. Prosthetic-driven planning based on the patient’s anatomy and prosthetic needs was chosen to ensure optimal implant support for an optimal restorative solution.

4. In the maxilla, a flapless procedure was chosen using the NobelGuide Surgical Template to optimally position the four implants and ensure minimally invasive treatment.

5. Post-op occlusal view immediately after the placement of the four implants and the multi-unit abutments. The straight multi-unit abutments were placed in the axial anterior implants. The 30° multiunit abutments non-engaging were placed using a custom jig for the correct positioning of the angulated abutments.

6. After the traditional treatment planning in the mandible, a conventional flap procedure was done. The All-on-4 Guide was positioned to assist implant placement. The purpose of the All-on-4 Guide is to assist in the correct angulations for posterior implant placement between 30° and 45°.

7. Jumping ahead 6 months, the immediately loaded temporary bridges were replaced with a Malo Clinic ceramic bridge in the maxilla and—following the same protocol— an acrylic arch built upon a NobelProcera Titanium framework on the mandibular implants below.

8. Radiograph at 6 months shows successful All-on-4 treatment with four NobelSpeedy Groovy implants in combination with precision manufactured NobelProcera frameworks in each jaw. They were milled from a solid monobloc of titanium to secure precision of fit and longevity, and designed to meet the patient’s esthetic and functional needs.

9. Extra-oral view of the patient showing the definitive rehabilitation with fixed bridges to fulfill the phonetic, masticatory and esthetic needs of the patient. The base of the definitive and provisional bridges are designed to be convex or flat, and polished for minimum plaque retention and easy cleaning.

The concept at a glance

Indications: Edentulous mandible or maxilla

Principle: Four implants—two straight implants in the anterior and two angled implants in the posterior—supporting a provisional, fixed and immediately loaded full-arch prosthesis.

Benefits:

• Helps prevent further bone loss
• Restores oral functionality, both in terms of chewing and speaking
• Minimal recovery time, ordinarily with very little discomfort or pain
• Angled posterior implants help avoid relevant anatomical structures, can be anchored in better quality bone, and offer improved support of the prosthesis by reducing cantilevers
• Angled posterior implants help eliminate the need for bone grafting by increasing bone-to-implant contact
• Efficient treatment flow results in shorter treatment times and improved patient satisfaction
• Increases the patient’s self-confidence and quality of life.

Surgical considerations:

• All-on-4 Guide is recommended for accurate placement of implants and abutments
• Can be combined with the computer-aided diagnostics and treatment concept NobelGuide
• Open flap, or with NobelGuide: flapless, mini-flap and flap.

Prosthetic flexibility:

• Final restoration after healing time is possible with fixed or fixed-removable prosthetic solutions
• Fixed provisional acrylic prosthesis is a good match
• Fixed final prosthesis—NobelProcera Implant Bridge in titanium with acrylic veneering, or individual NobelProcera Crowns cemented to the bridge framework
• Removable final prosthesis—overdenture on a NobelProcera Implant Bar Overdenture.

Available implant systems:

• NobelSpeedy, the widely documented implant for All-on-4 (see article to the right)
• All Nobel Biocare implant platforms and other major implant systems with multi-unit abutments.

NobelGuide:

• Prosthetic-driven diagnostics, treatment planning and guided surgery system
• Powered by NobelClinician Software, NobelGuide is a complete treatment concept for diagnostics, prosthetic-driven planning and guided implant surgery. NobelClinician functionalities work both individually or as part of a full planning and guided surgery process.

This article is a reprint from Nobel Biocare News Vol. 14, No.2, 2012. © Nobel Biocare Services AG, 2012. All rights reserved. Nobel Biocare, the Nobel Biocare logotype and all other trademarks are, if nothing else is stated or is evident from the context in a certain case, trademarks of Nobel Biocare. Product images are not necessarily to scale. Disclaimer: Some products may not be regulatory cleared/released for sale in all markets. Please contact the local Nobel Biocare sales office for current product assortment and availability.