All on 4: Possible in this Case?

This looks like a good start for all on 4 or all on 6. There are many good choices here. My advise is to take a course in this implant modality before jumping in and getting over your head before you know it. For example, you will have to remove bone from the arch you want to restore for adequate clearance for the multi unit abutments/bar/prosthetic. It also looks like your implant positioning for the distal implants can be more posterior for adequate AP spread. You can do this without sinus grafting. If you want to use crown and bridge abutments and cement the restoration it is a completely different protocol. This is also a good case for removables on locators or ball abutments. Again, you will have to remove bone for adequate clearance. There are many really good several day courses that will give you the tools to treat cases like this. Thanks for posting and for asking good questions.

some Questions: 1- Are you going to plan the guided surgery or the Lab technician? if you are going to do it, where is your design? If you are going to rely on the lab technician to do it, is it going to be the first time for you to do it a guided surgery? 2- is the patient going to wear a denture after surgery or you are thinking of loading it immediately? 3- Are you going to do all on 4 in the maxilla and a denture for the Mandible? 4- What is the restorative plan for the mandible? 5- Are you familiar with Osseodensification protocol? if you provide more information, i am sure you will get more accurate recommendations.

All-on-6 only. Need to do some ridge expansion. Prosthesis is up to you and patient.

Unrelated to your question but what is the measurement of that large incisive foramen. Greater than 6 mm is considered a cyst.

I believe the angle of the slices you are showing are making the ridge much wider than they actually are. Move the axis perpendicular to the ridge to measure or trace the arch.

What does your PG faculty recommend?

It can be done. Fabricate the dentures first. Then plan the surgery. The dentures will help determine the transition zone, esthetics and phonetics. You may or may not need to ramp down.

It can be done. Fabricate the dentures first. Then plan the surgery. The dentures will help determine the transition zone, esthetics and phonetics. You may or may not need to ramp down. You should be able to do this freehand.

Possible? There's tons of bone!!!

Yes , why not ? Plan a guided surgery and provisional bridge with the DSD planning centre and they will also give you a clic guide . Go to extranet.dsdplanningcenter.com

I bet you could plan case (denture first) 3d print case then try in. Extrapolate data, print guide, compress bone abit using ridge expanders, use as many implants as possible to spread load Blue sky bio would be a very reasonable and fantastic resource to plan this case

I have already given conventional dentures for this patient. There is a good interocclusal space and has a class 2 jaw relation.

You might check out the Bicon “Trinia” System which uses 4 implants on a wider spaced set of implants. You have plenty of bone for that. They’ll help make you a guide and make custom abutment with retentive sleeves which automatically swivel to parallel on device seating.

you should definitely consider immediate loading. Dentures will definitly compromise success!

malo initially placed sleeper implants in case the loaded ones failed. He found no need as the loaded did as well or better than the sleepers !

Are you doing the surgery? Or someone else in the department? If you are planning on doing the surgery, then, based on your comments so far, you need a lot more training and experience to do this case. There are a lot of ways to irreversibly foul up the surgery, a lot of ways to irreversibly foul up the pre-surgical prosthodontic planning, and a lot of ways to foul up the post-surgical treatment and prosthodontics (although these mistakes are mainly reversible if discovered in time). If you are planning to move forward anyway: 1. Get BlueSky planning software and training in how to use it, 2. Try to get help from someone who has done at least several dozen Ao4 cases, 3. Get a good inventory of implants, abutments, etc. from a reputable implant company that has an Ao4 protocol and preferably a rep on the ground to help you during the case, 4. Realize that this case may need bone grafting or ridge expansion, and may not have adequate implant stabilization for an immediate loading protocol (I can't really tell for sure from the windows provided). Good luck and I'm sure you'll do great with these cases sometime soon. This procedure is life changing for a lot of people, please make sure your treatment represents the procedure well so patients won't be afraid of it.

It looks like you have plenty of bone to do an All-on-4 fixed hybrid restoration. I have done over 180 All-on-4 restorations since 2007. If done properly (and I haven’t always done that), they are the most gratifying, successful things that I do in implant dentistry. I do almost all of my cases “free-hand” since I feel very competent surgically and I am not real computer savvy with digital restorations. Saying all that, here are 3 things that are important: 1. You have to follow Dr. Paulo Malo’s principals for All-on-4 restorations. Make sure you understand them thoroughly. If you deviate from them, you are inviting failure. 2. If you want to do Guided Surgery, which isn’t as accurate on fully edentulous patients, I HIGHLY recommend the Chrome System from Roe Dental Lab in Cleveland (Independence), Ohio. They are second to none. Call them at 216-663-2233 for information. Tell them I referred you. They will Walk you through the process and even be there on the day of your surgery. 3. There are so many ramifications to this process that are difficult to express here. I would be glad to help you. You can call me at(440) 655-6512 or email at dpcamm@aol.com. I would even be glad to come to your office to help you with this, but you said you are a grad student, and your school would not like my interference. I have been involved with the Midwest Implant Institute and the AIM (Advanced Implant Mentoring) since 1987. I would love to help you. Daniel P. Camm Dentalimplantsbrunswick.com Brunswick, Ohio Note to everyone else: The All-on-4 Technique was very controversial, and Dr. Malo has a lot of arrows in his back to prove that (and I have a few), but the technique has stood the test of time. I love open discussion about it, but I will NOT respond to nasty criticisms, remarks, etc. That has happened to me before on this site, and it causes me to shut down.

I would love to have this case to treat. We, as the surgeon and prosthodontist, see the case from the knowledge base we have. I see this case differently than someone relatively new to this full arch treatment and others with more experience see the case at a higher level than I do. Gather information on the pros and cons of full arch delivery. There is a surgical component and a prosthetic component. Each has its requirements. I would make very good impressions , wax rims and mount on a semi adjustable articulator. Then determine inter-arch space, bone reduction, implant emergence, tooth emergence for esthetics, lip support, envelope of function. You and the patient have to agree on the prosthetics at this point. Fixed, removable, type of substructure; AO4 denotes a Ti bar and acrylic teeth and gums. It also denotes angled posterior implants. If this is a locator attached denture, will you have a metal substructure; Locator abutments need parallelism and vertical implant placement. Locators on angled implants require a great amount of vertical space due to component adapters. Is this a six implant case, five? Will it be a zirconia one piece? Ti frame and procera individual teeth? Chrome Cobalt bar and PMMA? What can the patient afford; how long do they think the prosthetics will last. Regardless of a university case, these are critical issues. All these have different space requirements and failure points. All You will probably reduce 3mm bone maxilla and 3-5mm mandible. Conform to rules of average for prosthetics-implant support. 15mm from the implant platform to the incisal edge of 8,9 is a good start on the upper. 10mm minimum posterior space per arch. Another prosthetic principle is 21mm from vestibule to incisal edge maxilla and 18mm from vestibule to lower incisal edge. Is the current OVD RVD and FWS known and tested? It is well known that keeping too much bone leads to prosthetic failure due to lack of space, there is never enough space (NES). There are CAD/CAM and model based surgical guides. There needs to be a surgeon on the other end of either! In private practice, patients want success not excuses. Literature studies or Dr. Malo's comments are not you, there , doing the treatment. There is a steep learning curve. Read literature on protocols for all of these full arch treatments. The best way to hear the ins and outs of treatment is at seminar breaks, not from the podium. Of course my opinions only. Good Luck, the more detail in your homework, the less anxiety doing the case. Leonard

Thanks for all your valuable suggestions. Now that I have got a complete surgical report through thorough digital analysis for all on 4. But after bone reduction, I can place all on 4, with 2 implants of 3.3mm in anterior and 2 implants of 3.75mm in posterior. But Nobel biocare All on 4 guideline suggests a minimum of 5mm bone for all on 4, with 4.2mm implants in place. Am confused. But clinical experience may be different. So now what I can do. Can I proceed with 3.3mm and 3.75mm for this case. Experienced clinicians with all on 4, kindly give me your opinions

Most of my All-on-4 cases are done with 3.7mm implants, and occasionally I use a 4.7mm. I have done cases with all of the implants being 3.2mm, but when I do those, I try to place a 5th anterior implant. When you use less than 3.7, the weak link is the neck of the implant. I have had 2 cases in which the neck of the implant fractured in heavy bruxers. I always use Versah burs to densify the bone in the maxilla. You can also spread the bone with these burs (Osseodensification). That might enable you to place slightly larger posterior implants.

If there is room, I place one implant in the midline, one implant on each side as distal (posterior) as possible, angled 30 degrees posteriorally, and then one implant on each side between these three. I only do this if: 1. I have to use 3.2mm implants. 2. I cannot spread 4 implants enough because the anterior part of the sinus comes too far to the anterior. Please understand that I do an All-on-5 very rarely.