All-on-4® treatment concept clinical case: surgical procedure and denture conversion | Nobel Biocare

Product reviewed

Nobel Biocare All-on-4® treatment concept Clinical case demonstrating conversion of an upper denture to an immediately loaded provisional using four implants and guided surgery.

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Key information from the subtitles (features & workflow)

Patient context

• A patient (“Arno”) initially had the lower arch treated and was very happy.
• After that success, the patient requested upper denture fixation.

Pre-surgical planning

• A CT scan was used to evaluate:
  • Bone quantity
  • Ridge anatomy
• Reported finding: “very adequate ridge” with lots of bone in all dimensions (including width and other dimensions).

Implant placement plan

• Four implants were planned for the upper arch:
  • Positioned anterior to the sinus
  • Designed for immediate loading with a provisional restoration

Vertical dimension / occlusion orientation

• The team marks key reference points:
  • Total vertical dimension (described as a “dot on the nose” / forehead marking)
  • Incisal edge position taken from the current dentures to maintain correct prosthetic positioning
• Implant positioning is guided by those references, aiming to:
  • Stay within attached tissue
  • Follow guidance described as “staying to the buckle… midline… other side” (i.e., symmetric and properly located)

Bone shaping / reduction

• The case shows the amount of bone reduction required.
• A bone mill is used with the guide pin to create a concave crest surface (explicitly described as a “concave surface on the bone at the crest”).

Guided surgery

• An All-on-4® surgical guide is used to:
  • Ensure orientation
  • Control implant angulation

Drilling / soft bone protocol

• The bone is described as feeling soft, leading to a:
  • soft drill protocol
  • stepwise drilling sequence:
    • 2.4 → 2.8 mm step drilling referenced
    • depth target mentioned around ~13 mm, with later adjustments such as ~11.5 mm
    • near-final depth sequence referenced as 3.2 → 3.6

Implant specifics

• Implant system details mentioned:
  • Nobel Biocare parallel conical connection
  • Size referenced: 4.3 × 13 mm
  • A torque wrench with an implant driver (RP connection referenced)

Angulation control

• Implant angulation is controlled using the guide, stated as within 30 degrees.

Multi-unit abutments / screw-hole emergence correction

• Because implants are placed slightly facial, 17-degree multi-unit abutments are used to correct screw-hole emergence.
• 17° abutments referenced for the left front and right front implants.

Immediate provisional capture

• Multi-unit healing caps are placed; suturing is mentioned.
• The provisional is picked up using bite registration:
  • The patient is instructed to bite down (“Normally bite close… tight… stay close… open”)
  • Repeated open/close confirmations are described to verify fit and alignment.

Final prosthesis conversion

• The final prosthesis returns from the lab and is inserted.
• Screws are briefly mentioned as being removed shortly (“we’re going to have screws out in a second”), along with bite/occlusion checks.
• A likely adjustment is noted:
  • Heavy spot on the back molars to “take that down.”

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Pros highlighted (implied benefits)

• Adequate bone supports a confident All-on-4® approach.
• Guided surgery improves orientation and angulation control (stated within 30°).
• Immediate loading with a provisional restoration after implant placement.
• Prosthetic angle management (17° multi-unit abutments) helps correct screw-hole emergence, supporting better final fit/aesthetics.
• CT-based planning plus careful vertical dimension/incisal edge marking supports correct bite positioning during conversion.

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Cons / limitations mentioned

• Soft bone management is required:
  • Explicit need for a soft drill protocol
  • Depth adjustments during drilling
• Occlusion refinement may be needed:
  • A “heavy spot” is mentioned on the back molars, suggesting postoperative adjustment.

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Comparisons

• No explicit comparisons are stated (no “vs” mentioned).

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Unique points mentioned (complete list)

1. Patient (“Arno”) had lower arch done first; was very happy.
2. After success, decided to fix the upper denture in the mouth.
3. CT evaluation showed a “very adequate ridge” with lots of bone in all dimensions.
4. Plan: place four implants anterior to the sinus.
5. Immediate loading with a provisional restoration.
6. Ensure correct vertical dimension and orientation.
7. Marking techniques:
   • Dot on nose / marking for total vertical dimension
   • Incisal edge position marking for intraoral reference
8. Placement guidance: within attached tissue; stay properly located (buckle/crest guidance), midline and symmetric.
9. Visualization of required bone reduction amount.
10. Use of bone mill to create a concave crest surface.
11. Use of All-on-4® surgical guide for orientation.
12. Soft bone → soft drill protocol.
13. Drilling steps referenced with depths: 2.4/2.8, then ~13 mm, then ~11.5 mm, finishing near-final depth with 3.2/3.6.
14. Angulation controlled within 30 degrees.
15. Implant: Nobel Biocare parallel conical connection, 4.3 × 13 mm.
16. Torque wrench and implant driver used (RP connection referenced).
17. Implants slightly facial → 17° multi-unit abutments for screw-hole emergence correction.
18. Healing caps placed, suturing mentioned, then provisional pickup.
19. Bite registration used during provisional pickup (patient instructions repeated for alignment).
20. Final prosthesis inserted after lab return.
21. Possible occlusal issue: “heavy spot on back molars” may require reduction.

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Speaker-specific contributions

• Surgeon/clinical lead: Main procedural narration (CT/planning, guided drilling, bone milling, implant placement, abutments, provisional pickup, occlusion adjustment).
• Other staff/assistants (implicit): Support with markings/guide positioning and intra-op bite guidance (bite close/tight/stay close/open) plus confirmation checks (e.g., alignment/angulation).

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Concise verdict / recommendation

Strong demonstration of the Nobel Biocare All-on-4® concept for upper denture conversion, emphasizing:

• CT/planning + guided implant placement
• Immediate provisional loading
• Proper vertical/incisal orientation
• Use of 17° multi-unit abutments to correct emergence

The main downsides mentioned are soft-bone technique adjustments and a likely need for occlusal refinement (back molar heavy spot). Overall, the case supports All-on-4® as a workflow-driven option when adequate bone is confirmed.