Case of upper jaw rehabilitation using post-extraction implants and immediate loading

All on four technique

Dr. Enrique Galán Ledesma


Oral Surgery and Implantology


  • Degree in Dentistry, Alfonso X El Sabio University, Madrid
  • Master in Oral Surgery, Implantology and Periodontology, Alfonso X El Sabio University, Madrid
  • Private practice as a specialist in Implantology and Oral Surgery. Cáceres y Badajoz

Medical history and antecedents

A 72-year-old female patient with no relevant medical history comes to the consultation with discomfort and general mobility in the parts of the first and second quadrant. Smoking patient with good oral hygiene but with chronic Periodontitis.

Due to mobility grade 3, it was decided to extract teeth 16-26 and the third and fourth quadrants were periodontally treated. Diagnostic and radiographic factors were considered and finally, under previous CBCT, fixed metal-ceramic rehabilitation was proposed using 4 implants with the all-on-four technique.

Definitive treatment plan: upper rehabilitation with immediate loading (Fig. 1)

(Figure 1)

Implant Extractions and Placement

The patient undergoes previous antibiotic and analgesic-anti-inflammatory treatment.

Under local anesthesia, the surgery was started with an intrasurcular incision of all the pieces and they were extracted conservatively to respect the entire bone anatomy. The idea is to maintain the same vertical dimension for the new restoration. After tooth extraction, curettage and cleaning of two post-extraction alveoli is performed.

To maintain the entire gingival contour, it was decided to do a full thickness mucoperiosteal detachment only at the crestal level, so that in this way there are no changes in volume and we can maintain the shape of the papillae and maintain the position of the mucogingival line.

The beds are healed and the implants are placed.

(Figure 2)

Rehabilitation implant placement

4 implants are placed in positions 15-13-23-25 ​​with apical anchorage slightly palatally. respecting the recommended drilling protocols.(Fig. 2)

The implant platform is located 1.5 mm infraosseous from the buccal and cervical aspects, in order to achieve an adequate emergence profile and the multiposition angled abutments are connected, all 3mm high, the anterior ones being 15 degrees of inclination and the rear 30 degrees.

The measurements of the implants were IPX3.5×12 the anterior ones and 3.5×14 the posterior ones. (Fig. 3)

(Figure 3)

Primary stability, suture and immediate loading

By performing conservative drilling, the primary stability of the implants is achieved and they are finally anchored with a dynamometric ratchet at 40ncm of torque. We sutured with 5-zero PGA absorbable suture. (Fig. 4 y 5)

Once the primary stability of the implants has been achieved, and according to the planning, the immediate loading process begins.

A drag measurement is taken through a test of teeth made of fenestrated PMMA at the level of the positions where the emergencies of the abutments were expected to emerge; and splints.

We take vertical dimension record to record and confirm height with heavy silicone.

(Figure 4)

(Figure 5)

Immediate provisional prosthesis

The immediate provisional screw-retained prosthesis is placed and the occlusion is adjusted. This provisional prosthesis is made keeping the gingival contours to gradually modify them for the definitive prosthesis. (Fig. 6 y 7)

(Figure 6)

(Figure 7)

Review after two weeks

During the two weeks the patient was recommended daily rinses with chlorhexidine. The patient went to the revision consultation for the removal of the stitches and a correct healing of the tissues can be observed, with the absence of pain and / or edema.

(Figure 8)

Final result of provisional maxillary rehabilitation

The degree of patient satisfaction with the implant treatment and its provisional rehabilitation is highly satisfactory.

At 4 months, the definitive prosthodontic protocol will begin.

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