Severe Mandibular Edentulism? All on Four? Part 1

350 Rating(s).


Posted on By Maurice Salama In Full Arch & Dentures

Patient completely edentulous with severe atrophy of posterior with nerve exposure over the ridge.
Thoughts on our plan? Minimal Bone Grafting, Nerve management including anterior loop and extension, possible nerve issues post placement, incision designs, prosthetic approach ALL on FOUR etc. etc. Just completed this case yesterday with Guided Surgery from CBCT 3D plan immediate loading ALL on Four. Will post updated images next week. Dr. Salama

Surgiguide Horizontal Screw
Lateral View 3D

Lateral View as Implant going into bone
Parallel Pins Multi-Unit Abutment


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38 Comments

Dr. Salama; Very challenging case. Many questions here. How far back can you cantilever the All on Four Prosthesis? What incisions do you make to access? If you did this with a overdenture removable prosthesis what would the long term issues be regarding pressure on the distal ridges where the nerve is exposed? Is this even an option here? What about nerve repositioning? Doess the case require Soft tissue grafting or Vestibulplasty? When will it be performed?
thanks as always Band


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Maurice. This is timely and helpful post. I am currently treatment planning a similar case and have the same concerns as Band. Guided surgery is the way go. I hope you can update case progress. Thanks for posting. Chuck.


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Maurice, thank you for posting this interesting case. Following all the discussion very keenly! Was just wondering whether you have much Attached Mucosa? Do post clinical/surgical pics if possible. Thanks.


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In fact the proposed concept is the gold standard from surgical as well as prosthetic perspective. I don´t see a point in nerve lateralisation in these cases. Good luck Dr. Salama.


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I assume upper arch is also edentulous?
I have many of these type cases with successful tripod subperiosteal implant and removable snap-on prosthesis.
Many are 20+ years in function. Very grateful patients. Low morbidity. Low maintenance. And can be done in one stage.
PK


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Paul; Can you share one of those cases on the Forum? The Maxilla is NOT yet edentulous but will be shortly. I am DEFINITELY doing this case GUIDED and will post follow up soon. Incision the be crestal in anterior and lingual to crest in posterior to avoid nerve on crest. Dr. Salama


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2 cases posted. I would today do one-stage technique with implant made from CBCT generated model.
PKDDS


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Paul; All on Four Today or Subperiosteal? Maurice


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I haven't done enough All on 4 to pick. But I would feel very comfortable doing Sub.
PK


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This would be an excellent case to do a Ramus Frame.


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Looking at the anterior ridge and the lack of bone in the posterior the choices are:

1) Ramus Frame - this can now be prepared on a 3D model from CBCT.

2) Subperiosteal - again can be prepared on a 3D model

3) Nerve lateralisation, tunnel grafting OR block grafting with bone builder and then implant placement.

Please note that all these cases will work as long as the soft tissue is in good condition.


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Kish; excellent review of treatment options. Which would you prefer here? Your thoughts on All on Four approach and Hybrid fixed prosthesis? Is it a better option and less complicated then the other options? This creates great discussion. Thanks Dr. Salama


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Hi Maurice,
my immediate thoughts are on the patients desire. Firstly, how is the patient managing with the discomfort from the dehisced state of the ID nerve. Secondly, looking at the volume of bone in the anterior region: is limited and the angulation of the implants for All-on-4 would limit the distal cantilever and not forgetting the crown-root ratio of the reconstruction. So, if the upper arch is edentulous the forces will be limited and be able to withstand the forces. My thoughts would be on the Ramus frame as it is relatively straight forward using the 3D Model to get all the right lengths and curves. Also during the placement some augmentation material can be placed to cover up the dehiscence.


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Just completed this case yesterday with Guided Surgery from CBCT 3D plan immediate loading ALL on Four. The patient returned today without any nerve issues in mandible!! Yeah. Very critical how the flap was managed. Thanks to all for the discussion. Dr. Salama


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Tricky but Nice!!


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Will add more clinical photos and radiographs in the coming weeks. Hit the Star button to save this Forum discussion to your favorites so you can easily return to it. Dr. Salama


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Mo,

Nice case-
couple questions-
what is length and diameter of implants (Zimmer?) and what was degree of posterior abutments- expected length of cantilever?

I assume you did immediate pick up in mouth or stone model?
did prosthesis have 12 teeth?
Did you have full denture in maxilla?
As always incredible cases- thank you for your commitment to education and creating a platform to thrive


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Richard; Glad you are watching. Zimmer implants were 13mm lenght 3.7 wide. 10 teeth immediate loading on lower arch. Will canitlever 10mm in final restoration. Used Smile bridge from Materilaise and Sterolithographic model for set up. Upper arch is full acrylic temp on implants. Will keep posting. Maurice


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Mo,

thanks for info- will post soon!


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Dr.Maurice, very challenging case and wonderful management.
It looks on the radiograph that the posterior implant is angulated more than what planned in the CBCT. Is it due to the orientation of the film/cone during taking the radiograph ? I think OPG will be a better record for this case.


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Omar; The PA films are never accurate with angulation etc. etc. What is OPG? Dr. Salama


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OPG is a panoramic radiograph, as we name it in this part of the world.


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Wow, impressive. Planning was key, along with the skill set you bring. Looking forward to see how it progresses.
Please post photos of the conversion prosthesis.


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Thanks John, this is PRECISELY the kind of case where ALL on Four fits!! Patient walked out with teeth after 30 years with a denture. regards and thanks for the post. Dr. S


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Maurice, Fabulous! I am meeting with my Zimmer rep next week to review their available "Revitalize" (all on 4) components. Please keep posting your progress. Did you make a video? Chuck


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Dr. Salama, are you concerned at all with the visible threads of the posterior implants? Did you overgraft these areas? It's been my experience that there is bone available from the drills to use in this way. Also is there a slight difference in the depth of the implants clinically than what was visualized in the pre-op plan. If so, is this a shortcoming with guided surgeries? Thanks Terry


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Robert; Very good evaluation of the photos. I took this photo prior to completely seating the implant to allow you to better visualize the angulation. I then continued to completely seat the implant. Any threads that were exposed were minimal and covered with bone and PRGF. Dr. Salama


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Depth control not precise yet but very close. Remarkably no parasthesia or dysthesia. Will continue to updat case. Took Final impressions today!! Dr. Salama


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Maurice, You've got my attention. Looking back in retrospect would you still have chosen these positions and length of implants? Thanks for the update. Chuck.


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Maurice,

I think the impression procedure is a critical step to understanding the full treatment- Did you by chance photo and can you also tell us what imp material you prefer? Aquasil- impergum- genie? etc- do you do heavy and light?

Also did you have any fracture of immead smile bridge during healing?

Thx,

Richard


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Richard; No Fracture of smile bridge during immediate loading. We index and test impression accuracy with pattern resin. Use a combination of heavy and light body poly vinyl siloxane impression material. Maurice


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Dr Salama, in your opinion. In thes cases where the mental foraman is over the ridge, is a fixed prostheses the only option? Especially when the patient complains of pain related to pressure of their removable denture in this area.


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Naresh; not the only option but a reasonable one that avoids loading of the posterior edentulous area over the nerve. Dr. Salama


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thanks


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Nicely done. Huge planning. Clean procedure. Predictable, safe, comfortable, fast... & all this despite the tough bone condition we're facing here. Thx Maurice. Filipe Lopes.


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My concern for these cases are hardware fatigue long term.
Fracture of screws, implants, prosthesis. Then bone loss.
Greater the loads (muscle and rigidity of opposing arch) greater the risk. Anxious to see these at 5, 10, 15 years.


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Hi there Maurice:
In this kind of situations, i always try to place an extra short implant on each side, distal to the 4 anterior ones, to avoid cantilever effect, and long term fatigue at the prostodontic structure...
Although i can see the ct scan cuts, it looks like in the region of 2nd molar we have enough length until the alveolar nerve, Bti has extra-short implant as short as 4mm.... splinted with the anterior 4 implants we can have a 6 implant supported structure without cantilever, and
with no need to angle de anterior distal implants.
What do you think about this approach?
Best regards Bernardo


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Thank Mo, really interesting. As always perfect.
I am going to consider this option.
Best regards


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