Case Study Of All On 4 Dental Implants - Performed At Brueggen's Dental Implant Center

By Author: Dr. Wayne. Brueggen
Total Articles: 130
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This has been a very typical week at The Brueggen Dental Implant Center - Houston. My primary case load centers around the All on 4 Dental Implant protocol and the ancillary procedures sometimes required to complete that type of case.
This week we did 2 full mouth All on 4 cases and 1 upper arch only case with individual implants to replace a few lower missing teeth and crowns to restore the remaining lower teeth. The rest of my time was filled with typical implant cases, ridge augmentations, and sinus lifts. I just finished the surgery on my last full mouth All on 4 dental implant case of the week today. This patient had Class IV periodontal disease with no missing teeth. There was Class IV mobility of the upper and lower central and lateral incisors, Class II mobility of all four cuspids, and Class III mobility of the bicuspids and molars. Pocket depth was 6 to 18 mm. The upper and lower centrals and laterals had no bone remaining at all. I mention this because these are particularly interesting cases on the ...
... upper. The lower is almost always routine. But when all of the upper teeth remain and especially when there is severe damage to the bone from periodontal disease, completing the uppers in one appointment can be challenging. Depending on the size and position of the maxillary sinuses the All on 4 Dental Implant protocol places the most posterior upper implants somewhere between the second bicuspid and the mesial root of the first molar. They will be angled to the anterior at 35 to 45%. When all three of these teeth exist and must be extracted at the time of implant placement finding enough bone to engage the implants at 35 to 45 ncm can be impossible especially if the apex of the first and second bicuspid roots are right at the floor of the sinus.
The complexity is compounded by severe periodontal disease which leaves no cortical plate and often several mm of very vascular, soft, membranous bone. Such was the case today. This case began 2 weeks ago when our patient arrived at the Brueggen Dental implant Center for their first visit. A cat-scan, consultation, examination, and treatment plan was completed. It was determined that with periodontal surgery, 5 maxillary and 4 mandibular teeth could be kept. After discussing these options it was clear that the All on 4 Dental Implant protocol was this patient's best option. The possibility that I might not be able to place the upper posterior implants with enough torque was discussed. If that happened I would place 2 to 4 mini transitional dental implants and the patient would need to wear an upper denture for 6 months before I uncovered the dental implants and attached the provisional fixed hybrid prosthesis. I actually warn every patient of that possibility. But on cases such as this I stress it. RX's were written and an appointed was reserved for this morning. Augmentin 500 mg bid, Metronidazole 250 mg qid were to be begun 3 dys before the appointment and continued for 7 dys after. A medrol dose pak was to be begun the morning after the surgery and 30# 600mg Ibuprofren were given for pain q6h prn. 10mgs of diazepam was given to take hrs the night before the appointment.
This patient arrived at 8 am this morning. Paper work was completed, post op instructions were reviewed with the patient and her spouse, the post op appointment was scheduled in 21 dys, and conscious sedation was begun with 10mg diazepam and .25 mg of triazolam. Approximately 1 hr later, 9:15 am, 50 - 50 N20 was begun as I scrubbed. At 9:30 I administered local anesthesia with 2% lidocaine and 1:100 epi and .5% bupivicaine HCL with 1:200 epi. All of the upper teeth were extracted, granulation tissues were removed, alveloplasty was completed, and implants were placed. Everything was uneventful until I placed the last implant. It was the upper right most posterior implant. I noted that the end of the osteotomy, which was prepared for a 4.0 X 18 Nobel Bio Care Speedy Goovey Dental Implant, was in a void. This is evidenced as an obvious lack of resistance and is never a good sign. If you are placing a 13 or 15 mm dental implant you can always go longer if there is room but once you have committed to an 18 mm dental implant you can only go larger which in the Speedy Groovey Dental Implant System is all the way to a 5mm wide platform dental implant. That implant has gotten me out of many jams in the past. When you lose resistance at the end of the osteotomy there are three possibilities. 1. You have penetrated a vacuole in the bone. 2. You have inadvertently entered the sinus, nasal cavity, or penetrated through one of the borders of the mandible or maxilla or 3. You have entered the socket of a tooth you have just extracted. In this case it was the later.
The Speedy Groovey Dental Implant is a straight wall design as opposed to a tapered implant so you have torque from the beginning to the end. In typical type II bone for a 4.0 X 18 dental implant I will prepare the last 3 mm to 2.8, the middle 9 mm to 3.0, and the first 6 mm to 3.2. This will usually give me 25 to 35 ncm of torque until I reach the terminal 3 mm where it rises to 45 ncm. As I placed this implant I noticed that the initial torque was only 15 to 20 ncm and as I approached the terminal 3 mm it was only 30 ncm but it was getting tighter. I screwed it in 2 mm deeper to reach 35 ncm and then did a little more alveloplasy to correct the ridge discrepancy. I considered removing the implant and placing a 5.0 diameter but this would have left me with less than 1mm of buccal bone and though I sometimes violate the 1 ½ mm rule I prefer not to. I was thinking how good I was until I placed the angled abutement on this implant and the implant turned slightly indicating that I had less than 35 ncm on the implant. 35 ncm is my absolute minimum for an immediate load fixed hybrid on 4 implants so something had to be done. I'll stretch a lot of things but not this. Fortunately there was room for a fifth implant so we placed it, achieved the desired torque, closed the case and where through with the first stage surgery at 10:40. Open tray impression pins were placed and luted together with spent surgical burs and Duralay and an impression was taken.
At 12:30 our lab had a screw down bite rim prepared, we took a bite registration, marked midline and other land marks, and began the surgical phase of the lower arch. As on the upper local anesthesia was administered, teeth were extracted, alveloplasty was performed, granulation tissue was removed, implants placed, tissues closed, and impressions taken. At 2:00 P.M. our lab picked up the impression. It is now 3:30 and I am seeing hygiene exams and catching up on my paper work while I wait on the lab to complete the fixed hybrids. Lab work is the most unpredictable part of the All on 4 dental implant protocol for me. Monday I was at home by 5:30 after completing an upper and lower case but sometimes its' almost 8:00. Accurate bite registrations can be a problem with sedated patients, I have never found manipulated retruded centric to be a good position, and we are very particular about the cosmetics. Thus it is not uncommon for us to do a bite registration and remount after the lower appliance is finished and we sometimes have to make an appliance over if we really don't like it.
Hopefully Alex will deliver these appliances in another hour or two, they will be perfect, and we'll get out early. But regardless, by 7 or 8 we will have provided a service for a 45 yr old woman that brings an excitement and joy to me that I wish every dentist could experience. In one day, only the second time this young lady has ever been in The Brueggen Dental Implant Center - Houston, we removed 32 terribly diseased teeth, placed 9 dental implants, and she will leave with upper and lower fixed teeth that she can eat with this evening and smile again with pride. She will require no analgesics stronger than Ibuprofren and will be able to return to work tomorrow if she wishes.
The All on 4 Dental Implant protocol is the closest thing to a miracle that I have ever been blessed to witness and I will be eternally grateful to Dr. Paulo Malo for his genius, wisdom, courage, and willingness to share this with me.