All on 4 implants for full mouth rehabilitation

14. Composite defect :pateitn’s missing teeth ,
soft tissue and hard tissue mass
Vertical dimension in occlusion (VDO)

15. Visible transition line during
animation results in unaesthetic
exposure of the prosthesis and the
edentulous ridge .

17. Cross sectional view allows for the inspection
of the alveolus process in relation to the
proposed tooth position

18. Lang duplicator used to reproduce and existing denture Reseat the clear stent on the cast or the patient
mouth , note the moderate composite defect
between the teeth and the alveolus ridge

20. All on four treatment can be performed in two Ways:

24. An incision is made from first molar to first molar with
bilateral buccal releasing incisions distally. A full-thickness
mucoperiosteal flap reflection is performed.
an All-on-4 GuiDE is placed in the midline after an
osteotomy is made with a 2-mm twist drill going to 10-mm
depth
Starting with the posterior implant sites, the drill should be
angulated distally with 30to 45with respect to the guide
Using the same precision drill for the anterior sites,
place the osteotomy in either the central or the lateral
position with 0 tilt.

25. Insertion of the posterior implants
at 45degree
intraoperative radiograph to verify the depth and
angulation of these 4 drills.
Next, sequentially enlarge it to 2.0 mm twist drill, then
Narrow Platform (NP) tapered drill 13 mm drill, and finally,
RP tapered drill 13 mm drill.
When inserting these implants, do not exceed greater
than 45Ncm because bone necrosis and implant fracture
can occur
A measure of 4.3 mm is the smallest diameter
recommended
for the posterior sites and 3.5 mm for the anterior sites
Immediate
load protocol requires implant stabilization at 35 to 45

26. Placement of four maxillary implant :introral view Post operative panaromic radiograph of all on four maxilla

28. A bilateral oblique releasing incision is made at the
second molar positions; this is then connected to the
crestal incision.
A full-thickness mucoperiosteal reflection is
created with attention to locate and avoid damaging the
mental nerve
start with the posterior implant site, angle the precision
drill distally at a 30to 45angle with respect to the guide
and drill to a planned depth
The precision drill is also used in the anterior implant site
and is usually placed along the solid vertical lines at 0next
to the midline
verify the angulation of these precision drills
with an intraoperative radiograph

29. Placement of four twist drills
Intraoperative panaromic radiograph for four twist drills

30. Enlarge the osteotomy and adjust the
angulation to the desired implant size.
posterior and anterior Implants are placed in to
its desired position
Close up of post operative panoramic radiograph of
four mandibular implants in all on four treatment plan

32. Implant torque is confirmed to greater than 35Ncm
Placement of multiunit abutments onto posterior and anterior implants.
Note the emergence of abutment toward the occlusal surface.

34. Lute the tissue-baring surface of the denture to the
temporary coping (multiunit) with self cure acrylic

42. • Fixed removable restoration is an acrylic prosthesis that can
accommodate the following type of bars:
Dolder, Hader, Round, Paris, and or Free Form Milled Bar to
the final prosthesis as an overdenture option
• ADVANTAGES :
1. provide routine fixed solutions for the completely
edentulous upper jaw
2. to provide esthetic anatomic contours when restoring
hard- and soft-tissue deficits
3.there is no need for the bone grafting procedure .
• The Marius bridge is a complete-arch, double-structure
prosthesis that is removable by the patient for oral
hygiene

43. Dolder type of bridge
Hader type of bridge

46. A putty index is performed on the prosthesis
that provides information to the laboratory
technician the length of the future resin pattern
framework
This resin pattern is fabricated
in the laboratory in multiple
sections that are transferred to
the patient’s mouth and luted
with more autopolymerizing
resin to ensure an accurate fit.

47. The completed pattern gets transferred back onto the
cast and a framework is fabricated with CAD/CAM
technology and returned to the patient’s mouth for
try-in.
A passive fit is paramount to ensure accuracy
and not to translate undue strain onto the
implants.

48. A Soft tissue index is performed and
sent back to the laboratory for a set up
Wax try-in is
performed with
framework, and the
final prosthesis is
seated in the
patient’s mouth

49. • The ability to select
between the straight
and
the multiunit
abutments
Allow for the great
flexibility in prosthetic
reconstruction.
• Angled abutments helps
in optimally positioning
of the screw access
holes
• Also provides a good
path of insertion an
withdrawal of the
framework as well
providing a pssive fit of
the framework used in
partial and full arch

52. • helps to identify the angulation of the most suitable Multi-unit Abutment as well as the implant
rotational position, that defines the abutment screw access hole
• Available for three different angulations identification (0°, 17°, 30°)

53. Secure the Multi-unit Aligning Instrument
with dental floss
Assemble the Multi-unit Aligning Instrument on
the implant driver . If a Tri-Channel implant driver
is used, then the laser marking on the implant
driver (red arrow) has to be aligned with the
Multi-unit Aligning Instrument
Insert the implant driver Multi-unit Aligning
Instrument assembly
into the implant
The angulation indicator of the Multi-unit Aligning
Instrument indicates the position of the prosthetic
screw hole when selecting a 17° or 30° Multi-unit
Abutment. Position the Multi-unit Aligning Instrument
so that the angulation indicator is perpendicular to
the bone. The arm of the Multi-unit Aligning
Instrument perpendicular to the bone, indicates the
recommended Multi-unit Abutment to use.
Adjust the rotational position of the implant if necessary
with the Manual Torque wrench
Remove the implant driver and Multi-
unit Aligning Instrument assembly
and insert the appropriate Multi-unit
Abutment

59. All-on-4 “V-4” (FOR ATROPHIC MANDIBLE )
Placement of 2 anterior implants angled at 30 to midline created
a
V shape for “all on- 4” placement, designated V-4.

60. They are single piece implants in which the implant and
the abutment are fused in to one single piece . This
minimizes the failure of the implants due to interface
problems