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ePaper created 2017-05-12, 09:42:21 | version 1.38.0
case report | implants 2 2017 15 Fig. 9 Fig. 10 Fig. 11 Fig. 12 Fig. 13 Fig. 14 Fig. 9: Isolation and highlighting of the right foramen and mandib- ular nerve. – Fig. 10: Isolation and highlighting of the left foramen and mandibular nerve. – Fig. 11: Preparation of the distal right im- plant site, tilted by 30°. – Fig. 12: Insertion of distal left implant (CAMLOG SCREW-LINE®). – Fig. 13: Checking the correct posi- tion using the "Vario SR Aligning". – Fig. 14: Addition of two mesial implants. – Fig. 15: Installation of Vario conical abutments. The in- ternal connection camshafts improve the stability of the abutments. of the maxilla, to give support to the soft tissue it is necessary to build the vestibular flanges, which of- ten complicates the correct manoeuvres of oral hy- giene, since it is impossible for the patient to remove the prosthesis. There we have to keep in mind that oftentimes edentulous patients are elderly and thus their manual ability may not be sufficient to maintain a correct hygiene that ensures a positive long-term outcome.27 Therefore, the "All-on-4" protocol has to be evaluated with regard to function, aesthetics and the patient's ability to properly maintain the hygiene of the prosthesis. Clinical case The patient, 56 years old, has no systemic diseases but has been smoking for the last 30 years (more than 20 cigarettes per day). She reports to have a TMJ pain, tooth mobility with toothache and halito- sis for several months now. The patient has a poor oral hygiene, compounded by fear of further dis- Fig. 15 location of the teeth while brushing, having already suffered the spontaneous loss of three molars in the months prior to her visit (Figs. 5–8). For professional reasons, the patient has close contact with the public. She thus requests for a solution in a reason- ably short time, a less invasive surgery due to her phobia and less time between teeth extraction and prosthesis replacement so that she can continue her job without serious disruption. Considering the vast bone atrophy of the maxilla, the loss of vertical dimension and the already weak lip support, I proposed an upper overdenture preceded by a removable prosthesis during the months needed for the implants to osseointegrate and a fixed prosthesis in the mandible prepared for immediate loading according to the "All-on-4" con-