July 2022

C O N T I N U I N G
eBOOK
E D U C A T I O N • 2 C E U

IMPLANTOLOGY

Dental Rehabilitation
of the Atrophic Maxilla
Ankur Johri, DDS, MD, FACS

SUPPORTED BY AN UNRESTRICTED GRANT FROM NOBEL BIOCARE • Published by AEGIS Publications, LLC © 2022
 eBOOK
JULY 2022 | www.compendiumlive.com

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Atrophic Maxilla
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 C O N T I N U I N G E D U C A T I O N • 2 C E U

Dental Rehabilitation
of the Atrophic Maxilla
Ankur Johri, DDS, MD, FACS

ABSTRACT
Rehabilitation of the atrophic maxillary arch can present a number of challenges in clinical practice. Adequate implant insertional torque may be proble-
matic to achieve, and pneumatization of the sinuses may impede implant placement, among other clinical difficulties. All-on-X treatment concept has
been found to be a predictable approach with safe long-term outcomes in patients with edentulous maxilla. Treatment planning for the All-on-X treatment
approach in these patients involves special considerations—ie, bone quality, ensuring adequate bone reduction, the length of the implants, presence of
bone in the maxillary zones, and the length of the cantilever. This article presents important diagnostic and treatment planning principles of the All-on-4®
treatment concept (Nobel Biocare) for the rehabilitation of the atrophic maxillary arch, and includes a case report illustrating free-hand implant placement
using this treatment approach.

LEARNING OBJECTIVES
• Discuss the determination of adequate bone • Describe implant placement and immediate • Discuss the final prosthetic design and
reduction and evaluation of the maxillary loading of implants using the All-on-4 maintenance of the final prosthesis
zones for treatment planning of atrophic treatment concept
maxillary arch rehabilitation using the All-
on-4 treatment concept

D
ental rehabilitation of the atrophic maxilla poses sur- The All-on-X treatment concept, as pioneered by Dr. Paulo
gical and prosthetic challenges. Many patients can- Malo, has become a staple of single-stage rehabilitation of the
not tolerate an upper denture because of a sensitive atrophic maxillary arch.1 Further refinements, with the addition
gag reflex. Maxillary bone (especially in the poste- of zygomatic implants (Figure 1) have allowed the clinician to
rior maxilla) is softer (less dense) than its mandibu- bypass the maxillary sinuses and restore function and esthetics.
lar counterpart, presenting challenges for achieving adequate This article will discuss treatment using the All-on-4® modali-
implant insertional torque. Pneumatization of the maxillary si- ty (Nobel Biocare), and will present important diagnostic and
nuses creates obstacles for the placement of dental implants, treatment planning principles of this technique for the rehabil-
compromising available ridge height. Furthermore, the resorp- itation of the atrophic maxillary arch. Prosthetic concepts, in-
tive pattern of bone loss in the edentulous maxilla may result cluding implant stress distribution and anterior-posterior (A-P)
in severe knife-edged atrophy of alveolar bone, compromising spread, are covered, and an illustrative clinical case presenta-
available ridge width. tion is presented.

DISCLOSURE: Dr. Johri has received an honorarium from Nobel Biocare for writing this article.

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Fig 1. Zygoma All-on-4® treatment concept (Nobel Biocare), with zygomatic im-
plants. Fig 2. Digital planning software can be used to measure the amount of bone
reduction that is required: Panorex view (top panel): anterior-posterior spread and
right zygomatic implant. Left bottom panel: the thin knife-edged ridge and bicortical
engagement of the nasal floor and amount of vertical bone reduction required. Right 2
bottom panel: prosthetic screw axes after multi-unit correction.

TREATMENT PLANNING OF A MAXILLARY PROSTHESIS USING • Super-erupted anterior maxillary teeth.4 Ideally, the in-
THE ALL-ON-4 TREATMENT CONCEPT cisal edge of the maxillary teeth should be 1 to 2 mm from
The All-on-4 treatment concept has been found to be pre- the lower lip margin upon smiling. In a patient with a deep
dictable and safe with regard to long-term outcomes for the re- bite or attrition of the lower incisors, the anterior maxillary
habilitation of edentulous maxilla.1 The All-on-4 treatment ap- teeth will super-erupt an bring the alveolar housing infer-
proach was developed for the treatment of edentulous patients iorly, resulting in a “gummy smile.”
to provide an immediately loaded full-arch restoration requir- • Altered passive eruption.4 While the average normal max-
ing the placement of only four implants, using straight and an- illary incisor length is approximately 10 mm, in patients
gled multi-unit abutments and avoiding or minimizing the need with altered passive eruption, the clinical crown is shorter
for grafting.2 than 10 mm. In this condition, the free gingival margin does
Treatment planning for atrophic maxillary arch rehabilita- not recede apical to the cervical convexity of the clinical
tion cases in which the All-on-4 treatment approach will be crown, resulting in a shorter clinical crown.5-7 Consequently,
used involves special considerations—in particular, bone qual- there is excessive gingival display due to inadequate clin-
ity, ensuring adequate bone reduction, the length of the im- ical crown exposure. Patients with altered passive eruption
plants, presence of bone in the maxillary zones, and the length will require more vertical bone reduction to create ideal
of the cantilever.2 proportioned incisors in the final prosthesis.

Ensuring Adequate Bone Reduction The clinical examination dictates how many millimeters of
A fixed hybrid prosthesis, which includes both teeth and gin- vertical bone should be reduced. The minimum prosthetic space
giva, can be made with an underlying titanium bar with teeth recommended for a fixed hybrid with acrylic teeth and titani-
fabricated from acrylic or entirely from zirconia. At the time um bar is 16 mm,8 while for a ceramic (zirconia) prosthesis, the
of implant surgery, multi-unit abutments (MUA) are placed on minimum restorative space is 14 mm.8 This distance is mea-
the implants, allowing the clinician to change the angulation of sured from the incisal edge of the proposed restoration to the
the prosthetic screw axis to orient them in a more parallel re- shoulder of the implants.
lationship to each other. The fixed prosthesis is screwed onto Inadequate prosthetic space can result in complications such
the multi-unit abutments using prosthetic screws. The “transi- as screw loosening and prosthetic fractures. Furthermore, in-
tion zone” is the junction where the natural gingiva meets the adequate prosthetic space may force the clinician to open the
fixed prosthesis. This interface must not be visible when the bite by increasing the vertical dimension of occlusion (VDO),
patient smiles,3 otherwise the resulting esthetic outcomes can which may not be tolerated by the patient.
be disastrous. The following preoperative clinical measurements and clin-
To avoid this complication, the bone reduction must be ade- ical factors will help guide the clinician in determining how
quate to ensure that the transition zone is hidden within the up- much bone reduction is required3:
per lip. The clinician must therefore be wary of the following
types of clinical situations, as they will require more than the • Upper lip length
typical amount of vertical bone reduction: • Maxillary incisor length
• Gingival display upon maximal smile
• Short upper lip.4 The normal length of the female upper • Maxillary incisor tooth visibility at rest
lip is 20 mm, and the male upper lip is 22 mm. • Degree of overbite and overjet
• Vertical maxillary excess (VME).4 Vertical hypertrophy of • Maxillary incisal edge compared with lower lip margin
maxilla can result in a “gummy smile” with a normal inci- upon smiling
sor length and normal upper lip length and overbite relat- • Altered passive eruption, VME, highly active upper lip, or
ionship. super-eruption of maxillary anterior teeth

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• Measurement of lower facial height from soft tissue subna- sites Nos. 4 and 13. However, owing to anterior pneumatization
sale to menton (VDO) of the sinuses in some patients, zygomatic implants are placed
• Preoperative photographs of exaggerated smile and video at teeth sites Nos. 4 and 13 to bypass the maxillary sinuses and
of the patient talking give adequate anterior-posterior spread to restore function from
first molar to first molar.
All the above clinical parameters and measurements will im-
pact how much vertical bone reduction needs to be performed Digital Software for Implant Planning
for the case. Inadequate bone reduction is the most common When the All-on-4 treatment concept is used, a CBCT is the
reason for poor outcomes with cases using the All-on-4 treat- current standard of care for treatment planning of a maxil-
ment concept. The clinician should err on the side of deeper im- lary prosthesis. An intraoral scanner can be used to generate
plant placement, as this will leave the proper restorative space stereolithographic (STL) files instead of traditional impressions
(“running room”) for the final prosthesis. and bite registrations. Importing these data into digital plan-
The amount of bone reduction required can easily be mea- ning software allows the clinician to plan the implant place-
sured using the ruler tool provided by the digital planning soft- ment with the final prosthesis in mind.11 If the clinician desires,
ware from the preoperative CBCT (Figure 2). An analog method they can use this plan to fabricate surgical guides for “guided”
for determining how much bone reduction is necessary involves implant placement or perform mock-surgery for free-handed
placing an ideal upper denture in the patient’s mouth and hav- placement. Digital planning can be used as a case presentation
ing the patient bite down in their proper VDO. Using a sterile or be sent to other clinicians or laboratories for communication.
marker, a line can then be marked on the bone 16 mm apical to If a patient is edentulous and has a complete denture, pros-
the incisal edge to indicate the level to which the bone needs to thetic planning can be carried out using the “double-scan tech-
be reduced. nique” (Figure 4). This technique entails the placement of ap-
proximately six to eight radiographic markers using gutta-percha
Evaluating the Maxillary Zones placed in small holes in the denture (or commercially available
The concept behind basal implantology is that implants are small radio-opaque stickers placed on the denture). The denture
placed in the dense “facial buttresses” where the bone is cur- is then scanned in the CBCT scanner to generate the first set of
rently present and are typically resistant to the effects of perio- DICOM files. Next, the patient wears the modified denture and
dontal disease and the resorption patterns of the maxilla.9 The a second CBCT scan is performed to generate the second DI-
basal bone is highly resistant to resorption. Even in a patient COM file set. In the digital planning software, the two DICOM
with long-standing edentulism or chronic periodontal disease, sets are matched, and the denture can be seen superimposed over
the basal bone is maintained despite compromise of the alveolar the bone.12 This allows the surgeon to plan the placement of the
bone. The “facial buttresses” (zygomaticomaxillary, nasomax- implants with the best anterior-posterior spread and angulations,
illary, and pyriform rims and pterygoid regions) are the same keeping the final prosthesis in mind.
areas of bone that are used by maxillofacial surgeons to place A good rule of thumb is to use implants that are at least 10
titanium plates and screws to reduce and fixate facial fractures. mm in length. The distal-most implants should be prosthetical-
The dense nature of the basal bone allows cortical engage- ly in the second premolar / first molar locations. Engagement of
ment of the implants and increases insertional torque values, basal buttresses such as the nasal floor and pyriform rim and zy-
enabling immediate loading to be possible in most cases. The gomatic bone is planned to achieve as much insertional torque as
maxilla is typically classified based on the Zones of Bedrossian possible to enable immediate loading. Soft tissue thickness is im-
Classification (Figure 3): anterior maxilla (zone I), premolar portant, and it can be measured with a periodontal probe during
regions (zone II), and molar/tuberosity/pterygoid regions (zone surgery. To be adequate for implant placement, vertical soft tis-
III).10 The zygoma bone (zone IV) provides an additional zone sue thickness should be at least 3 to 4 mm. This is typically easi-
for implant anchorage to increase the anterior-posterior implant ly achieved after the vertical bone reduction is performed, allow-
spread and allow full-arch rehabilitation. For a traditional All- ing adequate biologic width and helping maintain vertical bone
on-4 case, bone in zones I and II will allow placement of two levels on the implants. Internal conical hex implants are used to
anterior implants at teeth sites Nos. 7 and 10 and of two pos- allow 6° of rotation of the multi-unit screw axis and prosthetic
terior tilted implants with angled multi-unit abutments at teeth flexibility. Platform-switched implant systems are beneficial for

3 4

Fig 3. Basal bone zones in the maxilla. Left panel: anterior maxilla (zone I). Right panel: premolar regions (zone II), molar/tuberosity/pterygoid regions (zone III), and the zy-
goma bone (zone IV). Fig 4. Double-scan technique. Denture preparation: the denture has gutta percha markers placed within it and scanning is performed with this denture
in the patient’s mouth to generate the first set of DICOM files. A second scan of the denture itself in the CBCT scan (not shown) is used to generate the second DICOM set.
Then both sets of DICOM files are superimposed in the implant planning software to superimpose the denture onto the 3D-rendered model.

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Success rates of immediate loading are similar to those of

delayed conventional loading if proper protocols are followed

bone maintenance around the implants.13 Platform switching is Micromotion of soft tissue–borne stents can result in place-
a technique in which the cervical size of the abutment placed is ment of implants in the wrong positions. Soft tissue–borne
smaller than the implant platform. This connection shifts the im- stents are the most inaccurate of the stents, responsible for lin-
plant-abutment junction inward towards the central axis of the ear errors and angular errors much more often than bone- or
implant. Thus, any bacteria at the micro-gap will be away from tooth-borne stents,18 although they are nevertheless consid-
the crestal bone surrounding the implant, resulting in less bone ered acceptable for full-arch procedures. Furthermore, implants
loss after remodeling and implant osseointegration.13 placed fully guided via a soft tissue stent are often placed us-
ing a tissue punch, which may result in tissue punching away
IMPLANT PLACEMENT the keratinized tissue around the implant site. Lack of adequate
The four implants should ideally be placed in the lateral in- keratinized tissue around the multi-unit abutments has been
cisor regions and the second premolar / first molar region to shown to be risk factor leading to peri-implantitis over time.19
maximize anterior-posterior spread.14 Anterior-posterior spread Guides are not perfect. Errors in CBCT (motion artifact), er-
is determined by measuring the distance from the most anterior rors in matching STL to DICOM files, errors in bone segmenta-
implant to the most posterior implant in the arch. Finite element tion during CT rendering, and errors in 3D printing fabrication,
analysis shows that placing the two anterior implants too close flexion, or inadequate seating of the stent can all result in incor-
to each other (at central incisors) increases the strain pattern rect placement of the implants.17 Also, guided systems add fur-
upon loading of the posterior two implants.15 ther costs to the patient. Ultimately, it is the clinician’s decision
Placing the posterior two implants as posteriorly as possible whether to perform the surgery fully guided or free-handed.
(to increase anterior-posterior spread) allows better load dis- At the end of this article, we present a case study of a free-hand
tribution.16 If the maxillary sinuses are too anteriorly pneuma- implant placement (“brain-guided”). The implants are placed free-
tized and the posterior two implants, despite angling, cannot be hand, using a duplicate of an upper denture to verify the prosthet-
placed in the second premolar / first molar region, then place- ic screw axes of the multi-unit abutments to ascertain that they are
ment of zygomatic implants to bypass the sinuses should be within the dentoalveolar envelope for screw-retained prosthetics.
included in the All-on-4 treatment plan. Because the bone in
the maxilla is softer than that of its mandibular counterpart, Autogenous Grafts and Products
over-engineering of the maxillary prosthesis with six implants An All-on-4 treatment is typically a “graft-less” solution. How-
(especially against a fixed opposing arch) is beneficial for bet- ever, in cases of severe atrophy, bone augmentation will pro-
ter load distribution in the less dense maxillary bone. Angled duce good long-term results and may be needed to achieve the
implants must be bone profiled to prevent binding of bone to desired clinical results. Autogenous bone is the “gold standard”
allow seating of the multi-unit abutment on the implant. All of bone grafting. It offers the osteoinductive, osteoconductive,
multi-unit abutments must seat passively and be seated fully on and osteogenic properties that are desirable for bone augmen-
the implant before an impression or chairside conversion of the tation. Autogenous bone can be obtained from the vertical bone
denture can be taken. If the clinician is in doubt as to whether reduction, where it can be removed with a surgical unit or ron-
a multi-unit is seated, a periapical radiograph should be taken, geurs and then crunched into smaller pieces manually or in a
and it is recommended that a radiograph be taken to confirm bone mill. Safe scrapers in the lateral maxillary posterior walls
complete mating of the part to the implant. can also be used, as well as bone trap suctions. These are both
Finally, it is important to follow proper manufacturer proto- useful tools to collect the precious autogenous bone. This bone
cols to avoid over-tightening and fracture of the multi-unit or can be repurposed back on the buccal aspect of the ridge, which
prosthetic screws during placement. is generally deficient (Figure 5, left panel).
The bone may be mixed with platelet rich plasma (PRP),
Guided vs Freehand Surgery which can be made with any of the many commercially available
Various guided systems exist in the market for implant place- systems using autologous blood. PRP is prepared as per manufac-
ment. If the patient has stable existing teeth, then a guided stent turer recommendations using an anticoagulant so that the platelet
that is tooth-borne will yield good accuracy for placing the im- concentrate is in liquid form.20 The bone graft is mixed with PRP
plants in their correct positions. If the patient has loose teeth, placed into the recipient site. PRP releases several growth factors
has an inadequate number of teeth, or is edentulous, then a quickly (within 1 hour) into the surgical wound.21
bone-borne stent that fits intimately with bone will be the most Platelet rich fibrin (PRF) membranes are also made and can
accurate stent.17 A bone-borne stent will require extensive flap be placed on top of the autogenous bone graft. Several PRF
elevation on the buccal and palatal aspect to allow passive seat- membrane protocols are reviewed in the literature.22 The pro-
ing of the stent without soft tissue impingement. tocol that the author uses is 1,300 RPM x 8 minutes using Red

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5 6

Fig 5. Autogenous grafting. Left panel: Autogenous bone grafting. Right panel: buccal
fat pad grafting. Fig 6. Platelet rich fibrin membranes (left panel) and platelet rich
plasma infused bone graft (right panel). Fig 7. Implant placement. Fig 8. Chairside
conversion of the denture into a temporary prosthesis. 8

Cap, BD glass tubes23 (Figure 6). The difference between PRP torque and good anterior-posterior spread to restore with an im-
and PRF is that during PRF processing, a fibrin clot (scaffold/ mediate fixed temporary restoration (Figure 7). If the distal-most
matrix) is allowed to form. Therefore in the “membrane” form, implants do not meet adequate insertional torque, then a deci-
growth factors are released slowly into the surgical site (typi- sion must be made to either shorten the temporary prosthesis or
cally factors are released for up to 7 days).21,24 not load immediately or to place another implant as a distal stop
PRP and PRF both release several growth factors, such as plate- (pterygoid or zygomatic) to allow immediate loading.
let-derived growth factor (PDGF), transforming growth factor-beta Techniques such as underprepping, having a “bail out” wid-
(TGF-β), and vascular endothelial growth factor (VEGF).25 These er implant, osseodensification using either counterclockwise
growth factors help with angiogenesis, enhanced wound healing, burs or condensing osteotomes and engaging bicortically (nasal
and improved bone grafting results.21 floor/sinus floor) can help achieve adequate insertional torque
A buccal fat pad graft is often utilized when zygomatic im- for the majority of cases.
plants are placed. The buccal fat can be taken from the ipsilater- Osseodensification using counterclockwise burs has shown
al aspect and draped over the midbody of the zygomatic implant benefit in compacting the alveolar bone and improving the bone
(Figure 5, right panel), thus providing an extra barrier of pro- density during implant site preparation.29
tection to prevent mucosal dehiscence and peri-implantitis and The temporary prosthesis must be screw-retained and all im-
helping to form a seal to prevent the development of any sinus plants must be cross-arch splinted. The temporary prosthesis
fistulae around the zygomatic implant.26 should also be cleansable, highly polished, and have a convex in-
taglio surface to avoid trapping food. The prosthesis should not
Criteria for Immediate Loading Using the All-on-4 have any distal cantilevers, and it also should not have any buc-
Treatment Concept cal flanges that will exert pressure on the buccal plate (Figure 8).
Loading of the implants within the first 48 hours of placement Occlusion must be carefully checked to ascertain that there are
is known as “immediate loading.” Patient satisfaction is higher no interferences upon excursive movements. For patients with a
when implants are immediately loaded and temporized. temporary prosthesis, compliance with a mechanical soft diet and
Success rates of immediate loading are similar to those of de- good oral hygiene are important success factors.
layed conventional loading if proper protocols are followed.27
Implants can be immediately loaded if their insertional torque FINAL PROSTHETIC DESIGN AND MAINTENANCE OF THE
is greater than 45 Ncm.28 In clinical practice, some implants in a FINAL PROSTHESIS
particular patient may achieve this minimum torque, while oth- Like the temporary prosthesis, the final prosthesis must be pol-
ers may not. It is recommended that a cover screw be placed on ished and smooth and have a convex intaglio surface to prevent
the implants that do not meet this minimum torque value, and food trapping and chronic inflammation around the implants.3
that they be bypassed to have at least four implants with adequate Also, occlusion must be tightly controlled, with no prematurity

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in occlusion and no interferences in lateral excursions. A postop-

erative nightguard on the opposing arch is recommended for pa-
tients with bruxism. In the final restoration, the posterior canti-
lever must not extend more than 10 mm past the distal-most
implant.30 Increasing this distal cantilever will have deleterious
effects on the terminal-most implant, resulting in bone loss and
eventual failure of the implant.
The patient must be educated on meticulous oral hygiene.
A water flosser used on a low setting to clean under the fixed
bridge is recommended,31 as is the use of an electric toothbrush.
Monitoring of the prosthesis annually with panoramic radio-
graphy and an occlusion check twice per year are recommend-
ed at a dental office.32

COMPLICATIONS OF FIXED ALL-ON-4 CASES

Fortunately, with the benefit of cross-arch splinting, proper an-
terior-posterior spread, appropriate hygiene, and occlusal con- 9

trol and restorative space, complications with the full-arch

fixed hybrid prosthesis are uncommon. If the above principles
are adhered to and proper maintenance protocols are in place,
then a compliant, nonsmoking, nonimmunocompromised pa-
tient with good oral hygiene will benefit from a long-standing,
trouble-free restoration.
Peri-implantitis can occur as a result of occlusal overload-
ing, poor oral hygiene, lack of keratinized tissue, and lack of
regular implant maintenance and may progress to the eventual
loss of the implant.33 Peri-implantitis is a difficult problem to
treat, and therefore prevention is ideal. Some treatments dis- 10

cussed in the literature are improvement in oral hygiene/plaque

control, local debridement using plastic curettes, and occlusal Fig 9. Vertical bone reduction. Fig 10. Angulated screw channel.
control.34
Sinusitis may occur, often caused by chronic oral-antral fistu-
la, and can be treated with amoxicillin/clavulanate (Augmentin) Prosthetic-level planning was carried out, and the surgery
nasal steroids/decongestants, and closure of oroantral fistulas.35,36 was performed free-hand. The plan was to place five endosse-
The patient may require endoscopic sinus surgery to create a new ous implants and one zygomatic implant and immediately load
path for drainage of a blocked sinus by an ENT colleague. the case if criteria were met (insertional torque values of each
Loss of implant is another possible complication. The failed implant greater than 45 Ncm each) (Figure 2).
implant will need to be removed and the case managed by either In this patient, a significant vertical bone reduction of about
bypassing the failed implant or placing another future implant at 10 mm had to be performed to allow adequate bone width for
a different site. The prosthesis will need to be remade or short- implant placement (Figure 9). Two of the six implants (Nos. 6
ened because of the failed implant. The benefit of the use of more and 11) did not achieve adequate insertional torque and were
than four implants is that if one is lost, the prosthesis may not buried with cover screws and multi-unit abutments placed 3
be compromised, allowing its use while a new implant is added. months later (Figure 7). Because adequate anterior-posterior
spread and insertional torque were achieved for the remaining
CASE REPORT four implants, it was decided to load the case immediately. A
A healthy nonsmoking 65-year-old female patient with no con- zygomatic implant with a built-in 45° correction was placed on
traindications to implant therapy presented with an edentulous the right side to increase anterior-posterior spread and bypass
maxilla. She had worn a maxillary complete denture for many the maxillary sinus.
years and wished to have fixed teeth. Autogenous bone mixed with PRP was used to graft the defi-
A CBCT showed an extremely thin knife-edged ridge with cient sites. Then, PRF membranes (Figure 6) were used to cov-
preservation of the basal bone. She had an adequate amount of er over the autologous bone graft and a buccal fat pad graft was
bone in the left posterior aspect (zone II) to allow implant place- overlaid on the right zygomatic implant to prevent mucosal de-
ment with a 30° multi-unit abutment. The anterior aspect of the hiscence and mucosa complications (Figure 5, right panel). The
bone was thin and would require bone augmentation laterally at patient’s existing denture was converted chairside into a tempo-
the time of implant placement. Owing to the anterior pneumatiza- rary hybrid screw-retained prosthesis (Figure 8). Approximate-
tion of the right maxillary sinus (no bone in zone II), a zygomatic ly 3 months after the provisional hybrid was placed, the buried
implant was planned on the right side (Figure 2). A “double-scan implant Nos. 6 and 11 were uncovered and multi-units were
technique” using her maxillary denture with gutta-percha points placed on them. The prosthodontist was able to incorporate all
was utilized to match her CBCT to her denture (Figure 4). six implants into the final fixed hybrid zirconia prosthesis.

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11 12

13 14

Fig 11. Digital planning of final prosthesis. Fig 12. Screw axis of tooth No. 11 has been “hidden” into the distofacial line angle using the angulated screw channel.
Fig 13. Final zirconia prosthesis, intraoral view. Fig 14. Final zirconia prosthesis, facial view.

It is noteworthy that on implant No. 11, even with the cor- ACKNOWLEDGMENTS
rection of a 30° multi-unit abutment, the screw axis was too fa- The author would like to thank Dr. Joseph Kelly (Prosthodontist,
cial. This is where the angulated screw channel (ASC) becomes Private Practice, Clarks Summit, Pennsylvania) who performed
highly useful (Figure 10), by allowing the prosthodontist a fur- the restorative work in the case study presented in this article.
ther 25° of rotation so that the screw axis can be “hidden” in
the distofacial line angle of tooth No. 11, making it nearly im- REFERENCES
perceptible when the patient smiles (Figure 11 and Figure 12). 1. Maló P. The All-on-4® concept for full-arch rehabilitation of the
edentulous maxillae: a longitudinal study with 5-13 years of fol-
The zirconia bridge as seen in the final prosthesis is an excel- low-up. Clin Implant Dent Relat Res. 2019;21(4):538-549.
lent material that offers superior strength and esthetics (Figure 2. Taruna M, Chittaranjan B, Sudher, N, Tella S, Abusaad Md.
13 and Figure 14). This restorative case exemplifies the incredi- Prosthodontic perspective to All-on-4® concept for dental im-
ble results that can be achieved using a fixed zirconia prosthesis. plants. J Clin Diagn Res. 2014;8(10):ZE16-ZE19.
3. Jivraj S, Zarrinkelk H. Diagnosis and treatment planning: a
restorative perspective. In: Jivraj S, ed. Graftless Solutions for the
CONCLUSION Edentulous Patient. BDJ Clinician’s Guides. Springer; 2018:1-14.
The All-on-4 treatment concept has become a staple in the re- 4. Robbins JW. Differential diagnosis and treatment of excess gin-
habilitation of the atrophic maxillary arch, as it enables imme- gival display. Pract Periodontics Aesthet Dent. 1999;11(2):265-272.
diate loading of implants and thus greater patient satisfaction. 5. Binirja KR, Jnardhanan M, Sunil MM, et al. A combined peri-
While All-on-4 treatment generally obviates the need for graft- odontal – prosthetic treatment approach to manage unusual gin-
gival visibility in resting lip position and inversely inclined upper
ing of the edentulous ridges that would otherwise be required anterior teeth: a case report with discussion. J Int Oral Health.
for these cases, severe atrophy may warrant bone augmentation 2015;7(3):64-67.
with autogenous bone. Careful treatment planning involves de- 6. Padhye NM, Pdhye AM, Pathak TS. Clinical short crowns: a
termining adequate bone reduction, since inadequate bone re- report on perioplastic management of altered passive eruption of
duction is the most common reason for poor outcomes when the three cases. Indian J Dent Sci. 2019;11(1):56-60.
7. Alpiste-Illueca F. Morphology and dimensions of the dentogin-
All-on-4 treatment approach is used. Implant stress distribu- gival unit in the altered passive eruption. Med Oral Patol Oral Cir
tion and placement to maximize anterior-posterior spread must Bucal. 2012;17(5):e814-e820.
also be considered. Finally, the individual clinician should de- 8. Jivraj S, Chee W, Corrado P. Treatment planning for the edentu-
termine whether to perform guided or free-hand surgery. As the lous maxilla. Br Dent J. 2006;201(5):261-279.
case study presented in this article demonstrates, after consci- 9. Ghalaut P, Shekhawat H, Meena B. Full-mouth rehabilitation with
immediate loading basal implants: a case report. Natl J Maxillofac
entious prosthetic-level planning was completed, free-hand sur- Surg. 2019;10(1):91-94.
gery using the All-on-4 approach yielded excellent results in a 10. Bedrossian E. Implant Treatment Planning in the Edentulous
patient requiring rehabilitation of an atrophic maxilla. Patient:, A Graft Less Approach. St. Louis: Mosby; 2011.

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 C O N T I N U I N G E D U C A T I O N • 2 C E U

11. Rosenfeld AL, Mandelaris GA, Tardieu PB. Prosthetically direct- advances patients’ own inflammatory cells, platelets and growth
ed implant placement using computer software to ensure precise factors: the first introduction to the low speed centrifugation con-
placement and predictable prosthetic outcomes. Part 1: diagnos- cept. Eur J Trauma Emerg Surg. 2018;44(1):87-95.
tics, imaging, and collaborative accountability. Int J Periodontics 24. Miron RJ, Zucchelli G, Pikos MA, et al. Use of platelet-rich fibrin
Restorative Dent. 2006;26(3):215-221. in regenerative dentistry: a systematic review. Clin Oral Invest.
12. Ritter L, Reiz SD, Rothamel D, et al. Registration accuracy of 2017;21(6):1913-1927.
three-dimensional surface and cone-beam computed tomo- 25. Marx RE. Platelet-rich plasma (PRP): what is PRP and what is
graphy data for virtual implant planning. Clin Oral Implants Res. not PRP? Implant Dent. 2001;10(4):225-228.
2012;23(4):447-452. 26. Guennal P, Guiol J. Use of buccal fat pads to prevent vestibular
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S. Platform switching technique and crestal bone loss around the fac Surg. 2018;119(2):161-163.
dental implants: a systematic review. Ann Afr Med. 2019;18(1):1-6. 27. Papaspyridakos P, Chen C-J, Chuang S-K, Weber H-P. Implant
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force within injectable platelet-rich-fibrin (PRF) concentrates

10 COMPENDIUM EBOOK JULY 2022

 CONTINUING EDUCATION QUIZ 2 Hours CE Credit

Dental Rehabilitation of the Atrophic Maxilla

Ankur Johri, DDS, MD, FACS

TAKE THIS FREE CE QUIZ BY CLICKING HERE: COMPENDIUMLIVE.COM/GO/CCEDDENTREHABAT

ENTER PROMO CODE: CCCEDDR1

1. The fixed prosthesis is screwed onto the multi-unit 6. For a traditional All-on-4 case, bone in which zones
abutments using prosthetic screws. The “transition will allow placement of two anterior implants at teeth
zone” is: sites Nos. 7 and 10?
A. where the multi-unit abutments are joined to the A. Zones I and II
prosthetic screws. B. Zones II and III
B. where the multi-unit abutments are placed on the C. Zones III and IV
implants. D. Zones I, II, and III
C. the junction where the natural gingiva meets the
fixed prosthesis. 7. Owing to anterior pneumatization of the sinuses in
D. None of the above some patients, to bypass the maxillary sinuses,
zygomatic implants are placed at which teeth sites?
2. For atrophic maxillary arch rehabilitations, which A. Nos. 7 and 10
of the following types of clinical situations will B. Nos. 7 and 4
require more than the typical amount of vertical C. Nos. 4 and 13
bone reduction? D. Nos. 10 and 13
A. Short upper lip
B. Altered passive eruption 8. With the All-on-4 treatment concept, a good rule of
C. Active eruption thumb is to use implants that are what length?
D. A and B A. At least 10 mm
B. At least 12 mm
3. The minimum prosthetic space recommended for C. At least 14 mm
a fixed hybrid with acrylic teeth and titanium bar is: D. At least 16 mm
A. 10 mm.
B. 12 mm. 9. In the final restoration, what must not extend more
C. 14 mm. than 10 mm past the distal-most implant?
D. 16 mm. A. The zygomatic implant
B. The two anterior implants
4. Which of the following is the most common reason C. The two posterior implants
for poor outcomes with cases using the All-on-4 D. The posterior cantilever
treatment concept?
A. Inadequate bone reduction 10. Which of the following are complications of fixed
B. Inadequate length of implants All-on-4 cases?
C. Incorrect use of digital software for implant A. Peri-implantitis
planning B. Sinusitis
D. Inadequate length of the cantilever C. Loss of implant
D. All of the above
5. Which of the following Zones of Bedrossian
Classification provides an additional zone for implant
anchorage to increase the anterior-posterior implant
spread?
A. Anterior maxilla (zone I)
B. Premolar regions (zone II)
C. Molar/tuberosity/pterygoid regions (zone III)
D. Zygoma bone (zone IV)

Course is valid from 7/1/2022 to 7/31/2025. Participants must attain

a score of 70% on each quiz to receive credit. Participants receiving
a failing grade on any exam will be notified and permitted to take one AEGIS Publications, LLC, is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in
identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance
re-examination. Participants will receive an annual report documenting of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at https://www.ada.org/cerp/.
their accumulated credits, and are urged to contact their own state
AEGIS Publications, LLC, is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of
registry boards for special CE requirements. this program provider are accepted by the AGD for Fellowship/Mastership and membership maintenance credit. Approval does not imply acceptance by a state or
provincial board of dentistry or AGD endorsement. The current term of approval extends from 1/1/17 to 12/31/22. Provider ID# 209722.

11 COMPENDIUM EBOOK JULY 2022

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