CLINICAL CASE

All-on-4®
treatment
concept

Enrico Agliardi
ItalyEnrico Agliardi

Patient65, female, fully edentulous
in both jaws
Clinical situation
Wearing total removable dentures
Surgical solution
All-on-4® treatment concept,
NobelParallel™ CC TiUltra™ RP 4.3 x 13 mm,
Multi-unit Abutment Xeal™

“Thanks to the new Xeal surface,
I can get early soft tissue healing andsealing around the abutment. Xeal
abutments are a must-have productfor all clinicians performing immediateloading procedures.”

Restorative solution
NobelProcera® implant bar withcomposite teeth (planned)
Surgery date23 September 2019
Total treatment time
Approximately 7 months (April 2020)

Case courtesy of Dr. Enrico Agliardi

2/26

Initial clinicalsituation

Surgicalprocedure

Courtesy of Enrico Agliardi

Restorative
procedure

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

OutcomeCourtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Front, side and profile images of the fully edentulous patient.
Note the lack of lip support because of the bone resorption.
Case courtesy of Dr. Enrico Agliardi

3/26

Initial clinicalsituation

Surgicalprocedure

Restorative
procedure

OutcomeCourtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Intraoral view with removable dentures in both maxilla and mandible

Courtesy of Enrico Agliardi

Moderate ridge resorption with estimated bone quality of D3 to D4
in the maxilla and D2 to D3 in the mandible
Case courtesy of Dr. Enrico Agliardi

4/26

Initial clinicalsituation

Surgicalprocedure

Restorative
procedure

OutcomeCourtesy of Enrico Agliardi
Courtesy of Enrico AgliardiCourtesy of Enrico Agliardi
Courtesy of Enrico Agliardi

Occlusal view of the maxilla

Mandible showing unfavorable ridge form

Case courtesy of Dr. Enrico Agliardi

5/26

Initial clinicalsituation

Surgicalprocedure

Restorative
procedure

OutcomeMaxillaCourtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Making a palatal incision for flap elevation

Courtesy of Enrico Agliardi

Full-thickness flap elevation in the maxilla

Case courtesy of Dr. Enrico Agliardi

6/26

Initial clinicalsituation

Surgicalprocedure

Restorativeprocedure

OutcomeMaxillaCourtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Preparing the osteotomy in the midline
using a Ø 2 mm Twist Drill for insertionof the All-on-4® Guide

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Confirming angulation with the direction indicator

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Placing the All-on-4® Guide for predictable
positioning of implants
Case courtesy of Dr. Enrico Agliardi

7/26

Initial clinicalsituation

Surgicalprocedure

Restorative
procedure

OutcomeMaxillaCourtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Twist Drill in the posterior

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Placement of NobelParallel CCimplant with TiUltra™ surface

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Implant inserted until collar

Courtesy of Enrico Agliardi

Implant inserted in theposterior
Case courtesy of Dr. Enrico Agliardi

8/26

Initial clinicalsituation

Surgicalprocedure

Restorative
procedure

OutcomeMaxillaCourtesy of Enrico Agliardi

Courtesy of Enrico AgliardiCourtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Opposite side: posterior osteotomy preparationand implant placement

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Use of Multi-unit Aligning Instrument to find the suitable
Multi-unit Abutment angle
Case courtesy of Dr. Enrico Agliardi

9/26

Initial clinicalsituation

Surgicalprocedure

Restorative
procedure

Outcome

Drill protocol

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Anterior implants: Steps of the osteotomy preparation

Case courtesy of Dr. Enrico Agliardi

10/26

Initial clinicalsituation

Surgicalprocedure

Restorative
procedure

OutcomeMaxillaCourtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Multi-unit abutments Xeal™

Case courtesy of Dr. Enrico Agliardi

11/26

Initial clinicalsituation

Surgicalprocedure

Restorative
procedure

OutcomeMaxillaCourtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Flap closure and suturing

Case courtesy of Dr. Enrico Agliardi

12/26

Initial clinicalsituation

Surgicalprocedure

Restorative
procedure

Outcome

Mandible

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Raising the flap in the mandible

Courtesy of Enrico Agliardi

Isolation of alveolar nerveCase courtesy of Dr. Enrico Agliardi

13/26

Initial clinicalsituation

Surgicalprocedure

Restorative
procedure

Outcome

Mandible

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Making an osteotomy in the midline usinga Ø 2 mm Twist Drill for insertion of theAll-on-4® Guide

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Evaluating the direction of the osteotomies
using direction indicators

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Occlusal view of the osteotomies

Case courtesy of Dr. Enrico Agliardi

14/26Initial clinicalsituation

Surgicalprocedure

Restorative
procedure

Outcome

Mandible
Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Implant insertion in posterior positions

Case courtesy of Dr. Enrico Agliardi

15/26

Initial clinicalsituation

Surgicalprocedure

Restorative
procedure

Outcome

Mandible

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

All implants placed

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Closing and suturing the flap

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Healed soft tissue around Multi-unit
Abutments Xeal™
Case courtesy of Dr. Enrico Agliardi

16/26

Initial clinicalsituation

Surgicalprocedure

Courtesy of Enrico Agliardi

Restorative
procedure

OutcomeCourtesy of Enrico Agliardi
Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi
Courtesy of Enrico Agliardi

Immediate provisional prostheses, planned before surgery in articulator
after facebow registration

Courtesy of Enrico Agliardi

Prosthesis finalized after the surgery
before delivery to the patient
Case courtesy of Dr. Enrico Agliardi

17/26

Initial clinicalsituation

Surgicalprocedure

Restorative
procedure

Courtesy of Enrico Agliardi

OutcomeCourtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Healed maxilla and mandible.
Note the healthy soft tissue 2 weeks after surgery.
Case courtesy of Dr. Enrico Agliardi

18/26

Initial clinicalsituation

Surgicalprocedure

Restorative
procedure

OutcomeCourtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

2 months after implant insertion and placement of Temporary Snap Copingson Multi-unit Abutment Xeal™
Case courtesy of Dr. Enrico Agliardi

19/26

Initial clinicalsituation

Surgicalprocedure

Restorative
procedure

OutcomeCourtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Finalization of the temporary prosthetic.
Occlusal view shows Temporary Coping access holes blocked
Case courtesy of Dr. Enrico Agliardi

20/26Initial clinicalsituation

Surgicalprocedure

Restorative
procedure

OutcomeCourtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

13 months after implant insertion

Case courtesy of Dr. Enrico Agliardi

21/26

Initial clinicalsituation

Surgicalprocedure

Restorative
procedure

OutcomeCourtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

13 months after implant insertion with the final prostheses

Case courtesy of Dr. Enrico Agliardi

22/26

Initial clinicalsituation

SurgicalprocedureRestorative
procedure

OutcomeCourtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Final prostheses 13 months after implant surgery.

Case courtesy of Dr. Enrico Agliardi

23/26

Initial clinicalsituation

Surgicalprocedure

Restorative
procedure

OutcomeCourtesy of Enrico Agliardi
Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi
Courtesy of Enrico Agliardi

Before treatment

After rehabilitation with theAll-on-4® treatment concept

Smile close-up before (top) and after
rehabilitation of the patient with theAll-on-4® treatment concept (bottom)
Case courtesy of Dr. Enrico Agliardi

24/26

Initial clinicalsituation

Surgicalprocedure

Restorative
procedure

Courtesy of Enrico Agliardi

OutcomeCourtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

Courtesy of Enrico Agliardi

13 months after surgery

Case courtesy of Dr. Enrico Agliardi

25/26

Case courtesy of Dr. Enrico Agliardi

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