Clinical case of an edentulous maxilla

Using the All-on-4® treatment concept


Edentulous Patient Clinical Case | Nobel Biocare


Situation: Edentulous maxilla
: Full-arch reconstruction with immediate provisionalization using the All-on-4® treatment concept and NobelParallel Conical Connection implants.
Oral surgeon: Dr. Armando Lopes, DDS, MSc, Malo Clinic
Prosthodontist: Dr. Carlos Moura Guedes, DDS, Malo Clinic
Laboratory: Maloceramics

Treatment planning

Patient: 37-year-old female, edentulous in the upper jaw, rehabilitated with a denture 22 years ago.

Chief complaint: Patient complained about poor retention of the prosthesis and recurrent fractures. Her main concern was related to the esthetic requirements that restrained her from getting employment. The patient’s main goal was to obtain a fixed implant-supported rehabilitation that fulfilled the functional and esthetic demands.

Overall health: History of previous epilepsy. Non-smoker.

Oral examination: After evaluating the radiological exams (OPG and CBCT scan) it was assessed there was moderate resorption in the maxilla (residual bone at least 5 mm width and 10 mm bone height between the canines), a high smile line (visible gingival tissue between 2-5 mm in maximum smile) and mouth opening capability of over 50 mm.

Decision: It was proposed to perform a full-arch fixed rehabilitation with an immediate provisional prosthesis. A 3D treatment plan was previously obtained using the NobelClinician software. The surgery combined guided and freehand approaches, using a NobelGuide pilot drill surgical template to prepare the initial osteotomy of the four NobelParallel Conical Connection implants.

Total treatment time: Six months to final prosthesis. Immediate temporary prosthesis just after surgery.

Highlighted products used:

Treatment summary

Since the patient’s removable prosthesis did not meet the functional and esthetic requirements, a new upper prosthesis was fabricated. This presented optimal design with a correct representation of the teeth position and a perfect fit with the soft tissue, while keeping in mind that the radiographic guide will be converted exactly into a surgical template.

Registration of smile line
Frontal intraoral view without prosthesis
Frontal intraoral view with old prosthesis
Intraoral view of the radiographic guide
Radiographic guide with markers
NobelGuide pilot drill surgical template in NobelClinician software

Reference points: Gutta-percha markers were incorporated into the radiographic guide in order to facilitate the subsequent matching of the two CBCT scans in the NobelClinician software. The patient with the radiographic guide and the radiographic guide alone were scanned following the double-scan protocol and by using the calibration object.

The two CBCT scans were matched and correct 3D treatment planning was achieved using the NobelClinician software. Four NobelParallel Conical Connection implants were selected for this rehabilitation: two tilted regular platform (4.3x11.5 mm) posterior implants and two narrow platform (3.75x10 mm) anterior implants. 

A mucoperiosteal flap (full thickness flap) was raised along the top of the ridge with vertical incisions on the buccal aspect in the molar area. The surgical template was used as a guide to prepare the initial osteotomy for four NobelParallel Conical Connection implants.

Intraoral view of the edentulous ridge
Initial preparation of osteotomy using NobelGuide Pilot Drill surgical template
Estimation of necessary bone reduction
Alveolar crest after bone reduction
Occlusal view after insertion of Multi-unit Abutments
Placement and fixation of open tray impression copings
Final adjustment of the prosthesis
Finalized provisional prosthesis
Frontal intraoral view with provisional prosthesis


Patient before the surgery

With the old prosthesis

Patient after the surgery

With the provisional prosthesis

"Thanks to this treatment I had the chance to restore not only my teeth but also my life. Now I’m much more positive, confident and happy because I can smile, kiss and eat properly. I was feeling older than my years but now I feel young again. Thank you to the entire team for this incredible result!"

Lilia Tavares, Portugal

"The All-on-4® treatment concept enables us to treat edentulous patients better, faster and easier. Fixed provisional teeth can be delivered on the same day of surgery1 with a predictable protocol offering high success rates. In this challenging case we were able to successfully deliver fixed new teeth to this young patient."

Dr. Armando Lopes, Portugal

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1 For patients meeting the criteria for immediate loading of implants.