Placement of Implants in Maxillae and Mandible

Thought I might share a recent case. Patient is a healthy adult male, non-smoker.  He is fed up with mobile broken down dentition.  Three weeks prior to surgery, I injected Dysport [abobotulinumtoxin A] into his Temporalis and Masseter muscles. Alginates were taken to create full immediate dentures which would be converted to screw-retained temps on the day of surgery. I have an in-house lab technician to help with the conversion.
Day 1 maxillae: To help with Pterygoids I used a pilot drill guide made by MIS Implants in their implant center here in Israel . Patient does not receive teeth at end of day 1 .
Day 2 mandible:  Extractions and implant placement. Impression for creating model used by technician to retrofit the immediate denture to a screw retained acrylic temp. At end of day 2 deliver both screw retained temps.

Update: Here is another case. 9-yr old classic All on 4.



25 thoughts on: Placement of Implants in Maxillae and Mandible

  1. Dr. David Morales says:

    Hello Doctor, very nice placement of implants. How long have you been using this technique and what is your oldest case? Since you place and restore your cases, what is your life expectancy on a case like this one?
    I have been placing and restoring implants since 1998. I place and wait 3 to 6 months depending on the torque I am able to obtain at time of placement. I have read and seen different techniques such as yours and the all on 4. I have yet to see an article on how long these cases last. Thanks for sharing this case!

  2. Ex Prof Dr Phulphagar S S , Pune says:

    Good ! Continue to update, follow ups I think a follow up of minimum 5-6 years is required to assess a technique! Thanks for presenting the case!

  3. yosef k says:

    Thanks for your comments. I have been doing All on for about 10 years. Most work well. Even though the cases are screw retained perimplantitis is a factor in about 10 % .

  4. yosef k says:

    In full arch cases immediate loading is a nobrainer . Out of hundreds of cases only once was the maxillary bone so soft that I did not load for 6 months . All other case a are immediate load . With single Implants I am more hesitant to immediately load . But if 3 or more are connected most cases I immediately load with great success

  5. Matt Helm DDS says:

    Very VERY nice case, and superb placement. I especially like the mesially angulated implants in the tuberosities. Ingenious. Done that myself on a couple of cases some years ago. It’s a nice way to avoid the sinuses. I thought it was crazy at the time, but desperate times call for desperate measures. I never thought anyone else would think of it, LOL. I was skeptical at the time, but they’re still gong strong with no problems.
    I also like that instead of sticking to a strict all-on-4 protocol you extended it to an all-on-6 in the mandible as well.
    Beautiful case! Congrats. Would’ve been nice to see the clinical photos of the finished result, and of course, follow up x-rays and photos at 2-3, and 5-6 years.

  6. Yosef Kowalsky

    I’m not great with the clinical photos I”ll try to send some in a couple of days . I’m also uploading a 9 year old case of classic All on 4 . Its going strong and he’s very happy . The only issues are with Acrylic breakage . These days I try to avoid Acrylic permanent bridges unless the opposing arch is a full denture.

    • Matt Helm DDS says:

      Nicely done. However, this isn’t a classic all-on-4. I don’t know if you uploaded anything else, because there seems to be a post of yours that showed up in my e-mail but doesn’t show up on here. The post says: “9yr old classic A O 4”, but when I opened the link all I got was this one with the lower incisors still present. I am assuming that you uploaded another x-ray of a classic all-on-4 which isn’t showing up on this comments page.
      But I do agree with you that many problems on the classic all-on-4 are caused by acrylic deterioration and breakage. It is one of the many reasons that I’m not really an adept of the classic all-on-4 design, except for the smallest mandibles, where I don’t have to extend too far distally and can therefore still fabricate a classic fixed bridge. My take on the issue, in the greater scheme and principle of things, is that if we’re already placing implants in a completely edentulous patient and, if that patient is already investing so much money, why not give that patient the best possible prosthetic restoration, which is a classic, standard, fixed bridge instead of giving him what is, essentially, a fancy and complicated denture? I’m sure many will debate that view and come out screaming against it. Call me a traditionalist, but I, for one, prefer to give the patient the best and highest level of comfort that I can, from all points of view. And of course I could go on with my many reasons for being against the all-on-4 type dentures, but I would have to fill a few pages, so I’ll stop here. 🙂
      Anyway, the one you posted here is commendable for your ingenious placement of the angled distal lower right implant. It shows that you have the kind of imagination and vision that few do! Congrats. (Oh, and I do hope those lower restorations are porcelain bridges, since the upper affords it.)

      • OsseoNews says:

        The other case uploaded was added at the top of page along with the original post. Please refresh your page, scroll up the page to the original 4 case photos, and you will see 2 new ones added, plus a PDF download.

      • Matt Helm DDS says:

        Yosef, found your other posting thanks to the moderator, as you can see from his post.
        Thanks for taking the time and trouble to upload the PDF! Interesting! Had no clue that someone else had also done the same thing I did and also wrote about it. It never dawned on me to write about it, LOL.
        Thanks again!
        As for the case you posted, very very nicely done, again!

    • Matt Helm DDS says:

      I know all about it. Yes, stronger, but it’s still a denture with flanges. I know we dentists are used to the concept, but patients are not. Denture flanges are unnatural, both esthetically and especially functionally, not to mention in terms of patient perception and “feel”. Ask a patient, any patient (and especially one who has already worn dentures). if they prefer the final restoration with, or without, denture flanges.
      Don’t get me wrong: dentures do have their place in dentistry and will continue to for the foreseeable future. But I feel that if i’m going to place a bunch of implants, that the patient will spend a small fortune on, I owe that patient the most comfortable and natural type of restoration possible, whenever possible. And that means no denture flanges. )

    • Matt Helm DDS says:

      I omitted to add in my last post that I’ve used the standard all-on-4 implant placement scheme on which I placed classic porcelain fused to metal fixed bridges (no flanges). Worked like a charm. What’s the difference between a titanium base reinforced denture and a Cr-Ni alloy PFM bridge? From a structural standpoint, none my friend! NONE! But from a patient patient comfort, ease of patient hygiene, and especially from a patient satisfaction standpoint, it’s a whole world of difference! A WHOLE WORLD! No contest!

  7. Yosef Kowalsky

    I really appreciate the posts thank you. I humbly disagree about the full zirconia . It has no flanges , is not a denture( my acrylic screwed in bridges do not have flanges either) . the zirconia is just like your Cr- C0 (No nickel) pfm bridges I use to do but broke more .

    • Matt Helm DDS says:

      I really appreciate your posts too. I like inventive guys like you because I’m the same way. You say your PFM’s broke more? Wonder why. Poorly made (porous) porcelain perhaps? In any case, nice that you can do the zirconias with no flanges. I would love to see it. Can you upload a couple of photos of one from a couple of different angles? Any photos, they don’t have to be great, as long as they show the labial, lingual, and gingival. Or even of an acrylic one will do. Many thanks!

  8. Lois Mendenhall says:

    I have no bottom teeth on either side, tried implant one lasted 10 years but it broke off at the threads and canot be fix. Would you remove the rest or the screw? 2 that are missing, on each side molers. but rest of teeth are pretty good I am 80 years old, What would you do. if anything? Thank You, Lois Mendenhall

    • Matt Helm DDS says:

      Dear Lois, unfortunately you do not provide enough details for truly accurate and complete advice. (how many implants you have on each side, their positions, precisely which of your own teeth you still have, which implants broke and exactly how, etc., and of course some x-rays would help greatly) But, in principle, broken screws inside implants can be removed with special tools that a restorative implant dentist should have. If the implant itself is broken it should be removed and another one can be placed in its place. Perhaps not immediately, depending on the situation, but another implant can be placed at the same site, nevertheless. If you are in reasonable good general health and have no contra-indications there is no reason not to place another implant there. I hope this helps. WIth a more accurate, detailed description I’m sure we can come up with more pertinent and practical advice.

  9. Greg Kammeyer, DDS, MS says:

    Very nice use of available bone. A key paper to read is Goodacre’s paper on implant and prosthetic outcomes: JPD 1999. This paper will show how the plastic wears out much too fast, esp when it isn’t thick enough.

    I’ve been doing full arch immediate loading since 2000. Even then, with less technology the literature showed simular implant success rates vs 1 stage or 2 stage implant placement.

    I’ve seen the least prosthetic problems with segmented metal ceramic bridges (a refined technology) and certainly this prosthesis is the closest in shape, size & cleanzibility to natural teeth. This must be segmented as master technicians will tell you, rather than a roundhouse prosthesis. Today most the the restorative dentists I work with favor Zirconia (either monolythic or on a titanium bar) The lab bill is the primary difference and the chair time not much difference. I STRONGLY favor 6 implants in the maxilla. When converting the prosthetic, my lab techs don’t put a cantilever on the provisional. The provisional FCD also gives the patient a good sense of prosthetic bulk and oral hygiene challenge. I avoid one staging or two staging whenever feasible (too much pain on the wound and the immediate loading road tests the implants before the final) . I have had some osteoporotic bone that I couldn’t immediately load. My patient base is 65-95 yr/o.

    I also have used a distal angled implant for a 3 unit FPD successfully. It is a challenge to get an accurate implant level impression with this design and I don’t like using the angled multiunit abutments on these cases due to the small screw.

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