Dental case: maxillary modification of an all-on-4 Dr. Virgilio Mongalo DMD

Dental
Case:

Maxillary
Modifica-on
of
an
“all-‐on-‐4”
by

placing
Pterygoid
implants
and
intra-‐crestal

sinus
li=s
::
Dr.
Virgilio
Mongalo
DMD,
DICOI,
MAAIP

•  It’s
impossible
to
argue
with
the
clinical
efficacy
of
Dr.
Paolo
Malo’s
“all-‐on-‐4”.

He
has
truly
had
an
enormous
effect
on
implant
den-stry,
many
other

clinicians
have
modified
His
technique
according
to
clinical
situa-ons.

•  The
following
case
demonstrates
two
surgical
modifica-ons
since
we
plan
to

reconstruct
the
maxillary
arch
with
14
units
and
want
to
avoid
using

can-levering.

•  This
is
achieved
by
eleva-on
the
maxillary
sinuses
in
the
1st
molar
site
using

intra-‐crestal
li=
technique
since
we
have
more
than
4mm
of
residual
bone
and

also
by
placing
implants
in
the
Pterygo
maxillary
region
which
are
commonly

referred
to
as
Pterygoids.

•  WEB
VERSION:
liveimplan@raining.com

47
year
old
healthy
female
presents
to
LIT
Ins-tute
with
failing
maxillary
ﬁxed

bridges
cemented
20
years
ago.

www.Liveimplan@raining.com


Clinical
view
shows
that
the
existent
prosthesis
was
well
designed
fabricated

following
Antle’s
law


Digital
panoramic
view
reveals
broken
abutments


Upon
removal
of
the
8
unit
segment,
we
observe
complete
destruc-on
of
the

natural
abutments.
At
this
conjecture
is
clear
that
we
must
remove
all
maxillary
teeth

and
place
suﬃcient
implants
to
support
a
14
unit
ﬁxed
prosthesis


Using
a
CBCT
(Carestream
8100,
USA)
we
are
able
to
obtain
2D
images
that

are
converted
into
a
3D
working
model
via
conversion
of
advanced

algorithms.


In
this
frontal
3D
image
we
are
able
to
conﬁrm
what
we
observed
clinically,

the
poor
condi-on
of
natural
abutments
and
need
for
full
arch
extrac-ons.


Lateral
le=
3D
image
reveals
periapical
pathology
on
several
teeth
as
well
as

site
were
implants
can
be
placed
in
the
anterior
and
posterior
region.


3D
plan
will
consist
of:

A…

B…
implants
in
the
pterygo
maxillary
region

C…and
implants
in
the
1st
molar
region
by
means
of
intracrestal
sinus
li=s.


Full
muco-‐periosteal
ﬂap
from
2nd
molar
to
2nd
molar,
autrauma-c
surgical

extrac-ons
is
achieved
and
care
to
preserve
the
thin
buccal
bone.


A
large
bone
acrylic
bur
is
used
at
35,000
RPM
under
copious
irriga-on
to
plasty
the

en-re
ridge
and
achieve
a
ﬂat
working
plaaorm
which
is
essen-al
for
placement
of
RP

implants
and
also
creates
height
for
prosthe-c
components.


Maxillary
sinus
is
iden-ﬁed
and
outlined
with
a
sterile
#2
pencil.


A
bone
caliper
is
used
to
draw
a
line
that
will
be
parallel
to
the
anterior-‐
ascending
part
of
antrum.

This
line
will
guide
the
placement
of
the
most
posterior
implant
as
indicated

by
Dr.
Paolo
Malo.


The
sinus
is
outlined
posteriorly
and
a
second
line
is
drawn
to
indicate
the

placement
of
a
Pterygoid
implant.

Orienta-on
of
Pterygoids:
start
at
site
of
ML
of
the
2nd
molar,
at
30=45*

drilling
through
the
tuberosity
and
engaging
the
Lateral
Pterygoid
plate.
This

is
strictly
reserved
for
advanced
doctors
that
have
placed
300+
ﬁxtures.


3D
rendering
of
“all-‐on-‐4”,
placement
in
1st
molar
via
crestal
li=
and
Pterygoid

implants.


Six
guides
pins
conﬁrm
that
the
orienta-on

and
spacing
for
the
and

for
the
Pterygoid
ﬁxtures
are
correct.


X-‐ray
veriﬁca-on
demonstrate
how
we
have
avoided
to
perforate
the

maxillary
sinuses
in
an
anterior
and
posterior
rela-on.


Pterygoid
implants
are
inserted
manually.
This
site
is
always
D3-‐D4
and
as

such
allows
for
under-‐prepara-on
of
the
site
by
1-‐2
drills.

Implant
anterior
to
the
maxillary
sinus
(TUFF
series
by
Noris
Medical
System,

Israel).
This
self-‐tapping,
aggressive
thread
design
is
selected
due
to
its
bio-‐
mechanical
characteris-cs.



Ini-a-on
of
intra-‐crestal
sinus
eleva-on:
start
with
stopper
1mm
less
than
the

height
of
the
sinus
from
the
ridge.


Use
sinus
probe
with
stopper.
Look
for
one
of
3
signs
to
conﬁrm
reaching
the
sinus

membrane.

A…Tac-le
sense
will
feel
smooth,
rubbery
or
spongy

B…while
drilling
you
might
feel
a
drop

C…pa-ent
might
feel
pain

Once
you
have
conﬁrmed
reaching
the
sinus
membrane,
begin
adding
bone

par-cles
un-l
site
is
ﬁlled
to
the
crest,
proceed
to
condense
site
using
the

instrument
and
stopper,
repeat
this
step
3-‐5
-mes.


What
appeared
to
be
an
atrophic
ridge
resulted
in
a
modiﬁed
“all-‐
on-‐4”
with
4
addi-onal
posterior
ﬁxtures.


Lets
compare
our
3D
planning
with
actual
free-‐handed
surgery.

Post-‐op
ct-‐scan
demonstra-ng
the
clinical
advantages
from
planning
a
case

using
3D
models.

The
would
had
yield
a
10
unit
prosthesis
to
occlude
with
2nd
pre-‐
molars,
the
addi-on
of
Pterygoids
allows
for
incorpora-ng
4
extra
molars

with



Post-‐op
scan
of
ﬁnal
surgery,
note
how
every
mm
of
available
residual
bone

has
been
u-lized.

While
this
might
appear
to
be
a
“restora-ve
nightmare”
due
to
crazy
angula-ons,

is

not
!

Noris
Medical
System
has
0*,
!7*,
30*,
45*
and
60
*
mul--‐unit
abutments
that
will

allow
a
screw
retained
prosthesis
with
less
than
10*
divergency.


So=
-ssue
management
cannot
be
overlooked,
mastering
suturing

techniques
is
paramount
in
the
healing
process.


Dental case: maxillary modification of an all-on-4 Dr. Virgilio Mongalo DMD

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