Full Arch Rehabilitation – A Case Report From A to Z (Told in First Person)

“A clinical story told slowly, the same way I’d tell it to a student walking with me in the corridor.”

The Art of Implantology

Good morning to everyone, I hope you are OK. This is December… not really December, it’s more the end of November, and it’s cold in Lisbon, 10°. And it’s one day before we go to the United States, to New York, to present in the alumni. It’s gonna be a great week, but before we go, I just wanted to share a case with you.

It was a full-mouth upper and lower rehabilitation, and I had some students watching the surgery and doing the surgery.

when I have students, my brain goes immediately into “teaching mode.”

I talk more, I explain my choices, I open the curtains a little and show the logic behind each movement.

And maybe that’s why this case became a story — because every step could have been a lesson for someone watching.

They had a lot of questions, and I think it’s profitable for everyone if we go step by step on what I did, from the moment I sat the patient until I left him ready for the prosthetic work.

The Patient confrontation- “before the battle of the fist 👊 comes the battle of the mind !” - master shifu

The first thing I did was to see the patient and ask him about general health. I normally like to ask and review the medical history to see whether he has any allergies or if he has new medication—especially aspirin. Don’t forget to ask about aspirin, because sometimes they are taking aspirin and they don’t tell you. So I see the patient and I tell him to rinse with chlorhexidine so we can calm things down a little bit. Then I explain what I’m going to do and anesthetize a little bit, then wait a couple of minutes, go for the upper jaw, rest, take an x-ray, rest 10–15 minutes (I will explain why), and then go back and do the lower jaw at his own rhythm.

Spin-off #1 - Treatment Planning these cases the art of teatching your brain 🧠 - never underestimate a case - perform always your best - you are the water , be the water - Bruce Lee

After this, I set up the anesthesia. I always like to place some topical anesthesia so the patient feels that he’s being taken care of. It’s debatable—some people say this is more of a psychological thing. Yes, I believe that psychologically it helps, but it might also have some small impact on the first touch of the needle. Then I wait 30 seconds and start to anesthetize with local anesthesia.

The anesthesia - please go read Stanley Malamed anesthetic manuscript and our unpublished protocol for implant placement that I developed for University Study that was lost in time …….

I like to do the buccal anesthesia with Articaine 1:100,000 adrenaline. I use one cartridge on the posterior left side around the first molar area (always very gentle and slowly …..) , and the dental nurse has ready a second cartridge, and I repeat on the right side, again near the first molar. Then I have a third cartridge, and I divide it: half in the region of the lateral incisor on the second quadrant, and half on the first quadrant near the lateral incisor. So: three cartridges for the buccal area.

Then I tell the patient to rinse a little bit and then I apply Articaine 1:200,000 on the greater palatine nerve, the posterior palatal nerve ( near the anterior palatal foramen), and on the nasopalatine (this one you can gently, gently ….. inside the canal). I have one cartridge divided into these three areas. I start with a puncture on the anterior palatal canal, then the posterior area, then the nasopalatine. I always use the backside of the mirror to help me “punch” the area so the patient doesn’t feel the pressure.

Then I wait. At this point, I have four cartridges applied: three buccal, one palatal. Then I wait 5–6 minutes for the anesthesia to take effect. Time to go for the computer for a late recheck on the CBCT )

Spin-off #2 - Tai chi the Surgery - the art of mentally performing the future

When I enter again, I have one more 1:100,000 Articaine cartridge that I apply on the crest mainly to confirm the anesthesia.

So it’s four cartridges to start the immediate loading procedure.

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Incision Line

At this point, I’m ready to pick up my scalpel. I normally like to use a number 15 blade for these types of cases. I like a strong and long blade, not the 15C blade. You can use the 15C, it’s also a good blade for this type of procedure.

I normally tell the patient and the students that implant surgery always starts with Perio, then goes to Oral Surgery, then back to Perio again. What does this mean? You have to start gently with the tissues (Perio), then retract the tissues and work on bone (Oral Surgery), then close it and suture like a periodontist (Perio again). That is implant surgery.

So we start with Perio. I grab my 15 blade and I do a full incision from first molar to first molar, from one quadrant to the other. A continuous incision line always supported by bone, in one shot. I always say it’s like the song: “the first cut is the deepest.”

If your rehabilitation goes from 6 to 6, then beyond number 6 (mesial of 7) I always do a releasing incision—vertical, oblique, toward the posterior region—so I have a triangular type of flap from tooth 17 to tooth 27. Then I start to retract.

This was a fully edentulous case. The patient was wearing a removable denture, so at this point you have very attached keratinized mucosa on the crest, and it is very hard to start releasing those fibers. So you want to use three instruments: the backside of the scalpel (as a dissector), a dissector instrument with a small tip that goes left and right through the incision, and then your Molt or Prichard elevator plus a plier to hold the flap while you retract.

You always start with the releasing incision. With the triangle of the releasing area, you put the plier and fold the flap toward the buccal, releasing the flap from the crest. This part must be slow but precise. The best way is to use your finger to support the releasing incision: place your finger on the buccal part to counter-pressure while you release from palatal to buccal.

As you move to the midline, you will feel stronger fibers because of the papilla and nasopalatine vessels, so you slow down until you jump to the other side around the region of tooth 22. Then you repeat the process from distal to midline.

Once you pass those crestal fibers, you enter mucosa and the flap becomes easier to release. Be sure you release the muscles from the maxilla—especially the orbicularis oris—so you have a clear bony view.

Now gently release the palatal flap, but only to the point where you can see the crest. Don’t elevate the entire palatal flap—it increases morbidity and complicates the prosthetic part of immediate loading.

Once you have your field of vision, clean the debris created when opening the flap. You can do this with a rongeur (“pinça goiva”) or with a low-speed bur at around 20,000 RPM to level the bone on the crest.

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Implant Placement

Drilling – The Conversation With the Bone

The first thing is to drill a hole in the midline with your 2 mm bur. Drill more or less 5 mm deep and place a central pin. This pin must align with the patient’s midline and show you the buccal-palatal inclination of the implants. Ideally, use a surgical guide or template. In this case, we used the patient’s prosthesis as a guide.

This central pin will guide the entire case.

From this central pin, you do your left and right anterior implants, normally in the lateral incisor regions—teeth 12 and 22. Just follow the parallelism of the central pin.

I do my 2.2 mm drill first, check it, then the 2.8 mm yellow conical drill (BLT) to full depth. Then you have two parallel anterior osteotomies.

After this set, you go to the posterior region. In this case we placed only four implants because the AP spread was more than enough. The posterior implant must be anterior to the sinus wall. You look for where the sinus ends: after sinus elevation, the convexity drops and forms a concavity toward the posterior nasal wall. When the concavity finishes, measure about 2 mm anteriorly and start drilling.

This is an angulated implant. Use the spear drill slowly, parallel to the sinus wall. You must feel if you enter the sinus. If you do, redirect the osteotomy more anteriorly. After the spear drill, go to the 2.2 mm drill, repeat, and check again. Then use the 2.8 mm drill to full depth.

Place your indicator pins, repeat on the other side, and now you have your posterior osteotomies.

One small tip: do not begin drilling exactly on the crest. Start slightly on the palatal side at a 45° angle and then redirect occlusally once you enter bone—similar to anterior immediate sockets. If you start too buccal, you can perforate the buccal plate.

Implant insertion

My last drill was 2.8 mm and I’m placing a 3.5 BLX implant. In the anterior area, I drilled to 14 mm to place a 12 mm implant 2 mm subcrestal. To avoid over-compression of the cortical, if I feel a strong cortical, I gently open the crestal part with the 3.5 drill, only at the crestal 2 mm. This allows the implant to enter smoothly at 35–50 Ncm without excessive pressure.

I did this in the anterior region, but not in the posterior region because the bone was softer.

Be careful: when BLX implants reach the subcortical areas of the nose or nasopalatine canal, they sometimes want to “slip” buccally. Keep a tight hand and keep them parallel to the central pin.

Posterior implants: on the right side I had 14 mm so I drilled to 16 mm and placed a 12 mm implant (2 mm subcrestal). On the left I had only 14 mm of bone so I placed a 12 mm implant at 17°.

Before implant placement, always check that you have not perforated the sinus floor with a gauge.

Then select the intermediate abutments: usually if you are 2 mm subcrestal you use an SRA abutment about 3.5 mm in the anterior and also 3.5 mm, 17° in the posterior. Place the white caps to protect them and suture everything.

I normally use Gore-Tex, but here I used Vicryl because the patient was not from Lisbon and was flying out, so I needed resorbable sutures.

First stitch in the midline, then the posterior releasing incisions, and then simple interrupted sutures.

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Panoramic X-ray

After implant placement, we go for the panoramic x-ray. Sit the patient up, wait a couple of minutes, otherwise he may feel dizzy. When the pano machine rotates, some patients may faint, so always keep visual contact.

After the pano, let the patient rest 10–15 minutes. Two reasons:

1. He can recover after a long surgery.

2. You allow the Articaine to clear a bit before starting the lower arch.

This is also a good moment for you to take a break with the team before round two.

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Lower Full-Arch Rehabilitation

For the mandible I use Articaine 1:100,000. One cartridge near each mental foramen (left and right): two cartridges. Then a third cartridge divided: half in the left lateral incisor region, half on the right. So again three cartridges buccal. Then one 1:200,000 cartridge on the lingual floor of the mouth. Wait five minutes.

This was a very resorbed mandible. The mental foramen was near the crest, especially on the right. When this happens, the floor of the mouth and vestibule look like one tissue—no defined crest. So we do a lingual incision, not a crestal incision, to avoid cutting the mental nerve.

Severe Mandibular Resorption: Modified Flap Design

Normally I avoid midline releasing incisions because of bleeding and morbidity, but here I needed one to elevate the flap and clearly see the mental foramina. So I did a midline incision plus posterior releasing incisions just beyond tooth 36/46. A triangular flap slightly lingual.

Expect bleeding and a more difficult postop.

The incision should be as posterior as possible—around tooth 37 or 47—to stay far from the mental foramen.

Then raise the flap using the same instruments as in the maxilla. Lingual muscles retract easily, but crestal periosteal fibers can be very attached. I start on the left because I’m right-handed. Raise from the midline toward lingual, then from the posterior releasing incision toward the mental foramen, gently finding the concavity of the mental foramen and the neurovascular bundle. Repeat on the right.

Once everything is open, clean debris with a bur or rongeur.

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Mandibular Drilling Protocol

Again, start with the spear drill in the midline, aligned with the facial midline. Use a guide or the patient’s prosthesis.

Drill 5 mm, place the 2 mm pin.

Then do the two lateral incisor-area implants. Spear drill → 2.2 mm drill → parallel pins → 2.8 mm drill to final depth (14 mm for 12 mm implants).

Place the 2.8 pins and go to the posterior sites: drill 3 mm anterior to the mental foramen, with about 17° distal angulation, so the implant apex runs away from the nerve and any anterior loop.

Avoid falling lingually. Check the osteotomy floor.

Repeat left and right.

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Implant Insertion – Mandible

Place the two anterior implants first (3.5 BLX x 12 mm, placed 2 mm subcrestal). If needed, open the crestal bone slightly with the BLT 3.5 flute to avoid over-compression—enter at 35–50 Ncm.

Then place the posterior implants once you achieve primary stability.

Use 3.5 × 17° SRA abutments posteriorly and 2.5 mm straight abutments anteriorly. Place the white caps.

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Suturing – Mandible

You must close the midline first, bringing the lingual flap forward. Because you have a midline releasing incision, it’s like closing a triangle.

First stitch in the triangle apex, then the midline, then posterior releasing incisions, then the remaining simple sutures.