This is a 42-year-old male with aggressive periodontal disease, without any other relevant pathology.
The intervention followed the following sequence:
- Supracrestal incision with posterior and medial discharges to avoid tension of the flap and properly locate the menton
- Severe post-extraction alveoli cure if any.
- Menton identification.
- Regulation of the crest, ensuring that all implants remain at the same height or gingival.
- 2 mm strawberry central osteotomy at a depth of 10; this is confirmed by direction indicator that the osteotomy is perpendicular to the bipupilary line.
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- All-on-4 position: this is a guide (Nobelbiocare ®) which, thanks to its marks and references, allows placement of implants away from the surgical field (restorative attachment of the tongue) a
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Distal implants with a 30o inclination were placed.
Observe the presence of the right distal molar that served the patient for retention of the removable prosthesis and that we will extract in the same session.
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- Also note the presence on the left side of an anti-aesthetic diapneusia in the lower lip commissure that will subsequently be removed by conventional surgical excision.
- We also see that the bed of preparation of the right distal implant is in the vertical position of the chin exit.
- Perform the corresponding drilling and insert the right distal implant (Brånemark implant of Nobelbiocare®, Ti-Unite Groovy of 3.75 x 15), of the same dimensions used.
- Care must be taken not to use an excessive number of milling required for a minimum insertion torque of 35 N cm.
- We always use a hazelnut raft in distal implants, so that they are submerged (infrared) so as not to fix the mesial incline due to these fixations.
- Once the first distal implant was placed, the corresponding 30o multiunit abutment was inserted.
As shown in Figure 4, the 30o inclination of the implant, corrected with a pillar with the same fixation, results in a perpendicular to the crest and, as we intend, to the line.
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- We repeated the procedure with left distal implant/pilar.
- Next, we prepare for mesial implants to maintain parallelism and equidistant between them and with the distal ones.
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- We placed in already inserted mesial implants with straight multi-unit abutments.
- Then, we applied the appropriate torque (15 N cm in the posterior implants and 35 in the anterior ones) as these abutments will never be deinsert again (the provisional and definitive prostheses will be manufactured on them).
- Then screw provisional titanium cylinders which will later be embedded in the provisional prosthesis and sutured around them with absorbable suture.
- Once the entire incision was sutured, the cylinders were unscrewed and a circular scalpel was used around the multi-unit pillars so that, in the tornillated minutes, the tapes were not turned around.
- We tested the passive side of the prosthesis, lowering it if necessary.
Let's remove the stent with silicone and send the patient a bite.
Once set, the marks of the multi-unit abutments on it will mark the points where we must pierce the prosthesis, a maneuver we then do.
- Return to the titanium cylinders.
- We tested the passive seat of the perforated prosthesis and checked whether the cylinders allowed the maximum intercuspation; if not, we removed the cylinders until this allowed.
- We placed a rubber tip to isolate the surgical field during subsequent maneuvers.
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- We put cotton balls on the chimneys of the cylinders and close the perforations of the stent with soft wax.
- Dry the stent well and pass through it with self-curing resin and send the patient a bite in position.
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- We removed waxtapons and filled them with more resin by occlusal, leaving only the access to condoms.
- Let's let the whole set, unscrew and check stability of cylinders already embedded in the stent.
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- We fill the holes (pores) with more resin and cut the cylinders at the edge of the stent.
- Removal of the distal loops of the prosthesis (in the provisional prosthesis we do not leave practically cantilever); we remove the rubber tip.
- We also remove any resin in contact with the ridge. To this end, we used GC Fit-checker® as a base, which indicates the area which exerts pressure on the ridge.
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- We place the stent, we screw it firmly at 15 N cm and adjust occlusion.
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- At 15 days the patient comes for review and we remove the suture we have access to; the rest, being resorbable, do not worry us
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- We have trained the patient in the management of Superfloss® so that hygiene is optimal (it is quite simple in the case of only four implants).
- Periodic revisions were carried out until the final prosthesis was manufactured after 5-6 months.
During this period, it is not necessary to unblock the provisional prosthesis.
