Hmmmmmm Engel M4 Anyone?

Full arch implant dentistry is not becoming main stream, it is main stream. Being an alumni of M1 hopefully single implant placement is something that all alumni are doing in their practices. If you are an M1 and M2 graduate then your placing, extracting and grafting, doing membrane placement and deciding whether you will place at the time of extraction or just extract and graft. In addition, Dr. Engel goes over anterior implant placement and soft tissue connective tissue and free gingival grafts on pig  jaws. Then if you are an M3 grauduate you have an understanding of guided surgery and the placement of multiple implants for restoring multiple sites.

How many of the alumni have a knowledge of immediate load on full arch cases? Do you know the parameters for an immediate load case? Do you know what a transition line is and what is its importance? Do you know how much space is needed for a particular material that you are going to use for a final restoration? Do you know the benefits in flapping over punching in cases like this? I can keep on listing different questions for you to think about but what you need to know is that full arch planning is something you need to really think. Below are some pictures of botched cases that GP’s that had to be fixed by Oral Surgeons because these GP’s did not follow simple parameters such as minimum distance between implants, and the minimum width of bone for placing implants in these cases.


These above cases were all all done by GP’s Remember there is a lot of thought that needs to in the planning of cases like this. You cant just wing these cases. All cases need to be planned and you need to follow the principals of basic implant dentistry along with the guidelines of full arch implant dentistry.

Let me share another case with you. It was in 2014, My patient had a couple implants placed already on his upper right not restored. The rest of his teeth needed to come out do to rampant decay so I was going to do the case with my periodontist since I have not done and extraction and placement and immediate load case by myself.

The patient was not very diligent to keeping things clean and he smoked and we lost all the implants. The patient was placed in an upper denture for 6 months then when the CT was taken the only implants that could be placed were Zygoma. The periodontist refunded all the money back to the patient. Even though it was partly the patients fault in todays market, the periodontist felt it was in his best interest to give the patient his money back and the patient was happy. Here was the final hybrid Xray of his upper zygoma.

The patient had the same problem with his lower arch so I extracted, let heal then went back and did lower all over 4 and here was his final Xray.

Before M1 in October in Concord, Dr. Engel an I did a joint case along with 3DDX and Allure’s Frank Charles at my office. Here are the pre op photos.

Records were taken by me and new final denture was made. Fiduciary markers were placed on the denture and a wash was done with Kettenbach’s Silginat. Cone beam was taken of the patient wearing the denture, the denture itself, and I had a Cone beam of the patient. Data was sent to 3DDX for fabrication of the surgical stent. The patient had a low smile line so bone reduction would be done at a minimum if necessary.

Patient was numbed and new denture to be converted was placed and vertical was measured. Take a tongue depressor and a sharpie and mark it on the patient and the tongue depressor so when it time for conversion you have a guide. Surgery was performed by Dr. Engel. Stent was placed, pilots were drilled, punches were done to remove the connective tissue, stent was placed back on, implants were drilled and placed. You must have a combined torque value across the arch at 120ncm if you want to immediate load. After that multiunit abutments are placed on the implants and white caps on top of that to hold the tissue.


From here you take a wash in the final prosthesis and then drill holes so the denture will passively fit over the implant areas. Check vertical before you proceed. Temp Cylinders are placed on the multiunit abutments and then denture is rechecked over the cylinders. Once everything is where is needs to be you then you can do a pick up in the mouth using acrylic. Once that is done, you remove and can finish the modified temp hybrid out of the mouth.

Patient will heal for 4 months and I will then fabricate  her final hybrid.

Dr. Engel is putting together an M4 which will cover everything that we did during this surgery. From initial planning to actual surgery performed by attendees under mentors and conversion of All over X full arch case. Contact the Engel Institute for more information. Happy Holidays.






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