Dr. Enrico Agliardi

Immediate esthetic and functional rehabilitation of a complete mouth using the All-on-4® treatment concept

Dr. Enrico Agliardi


Patient: 59-year-old, female.

Clinical situation: Failing dentition in the upper and lower jaw due to severe periodontal disease, compromised function.

Surgical solution: Extraction of compromised residual teeth and placement of 4 Nobel Biocare N1™  implants in the maxilla and 4 intraoral implants in the mandible following the All-on-4 surgical protocol.

Restorative solution: Full zirconia implant bridge (Nacera).

Surgery date: March 2021.

Total treatment time: 6 months.

Tooth position: All.

Despite adequate bone volume, the case presents several challenges both surgically and prosthetically. From a surgical point of view, the management of an extensive gummy smile has been planned to be corrected through an osteotomy calibrated on extra and intraoral images prior to surgery. Prosthetically speaking the delivery of an immediate rehabilitation of both arches is another challenge faced during the case, due to the lack of reference points and severely compromised esthetics which has been managed through careful planning of the prosthesis manufactured prior to surgery. The key factor for the success was extensive presurgical planning using diagnostic records and photographs.




Case courtesy of Dr. Enrico Agliardi.

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Initial clinical situation

Case courtesy of Dr. Agliardi

Preoperative X-ray. Residual teeth present severe periodontal disease and compromised restorations.

Initial clinical situation

Case courtesy of Dr. Agliardi

Intraoral preoperative frontal view (left).

Intraoral preoperative upper jaw occlusal view (center).

Intraoral preoperative lower jaw occlusal view (right).

Initial clinical situation

Smile of the patient before the surgery (left).

Gummy smile analysis before the surgery (right).

Surgical procedure

Case courtesy of Dr. Agliardi

Flap raising and bone exposure (left).

Ridge regularization taking into consideration the amount of bone reduction needed to correct gummy smile appearance (center).

Final level of ridge regularization (right).

Surgical procedure

Case courtesy of Dr. Agliardi

Pilot osteotomy with OsseoDirector™ drill (left).

Final osteotomy with OsseoShaper™ 1 (center).

Placement of Nobel Biocare N1 Implant (right).

Surgical procedure

Case courtesy of Dr. Agliardi

Lower jaw surgical phases, OsseoDirector drill (left).

Final osteotomy with OsseoShaper 1 instrument (center).

Nobel Biocare N1 Implant placement (right).

Surgical procedure

Case courtesy of Dr. Agliardi

Upper jaw: Occlusal view after implant placement (left).

Lower jaw: Occlusal view after implant and Multi-unit Abutment Xeal placement (right).

Restorative procedure

Case courtesy of Dr. Agliardi

Provisional prosthesis delivered immediately after the surgery (left).

Smile with provisional prosthesis (center).

X-ray immediately after the surgery (right).

Restorative procedure

Try-in of monolithic zirconia structure (left).

Nacera pearl shaded zirconia (right).

Restorative procedure

Cut back of the structure in order to perform a ceramic stratification to improve the esthetic result (left).

Final rehabilitations ready to be delivered to the patient (right).

Restorative procedure

Final rehabilitation delivered to the patient 6 months after the surgery (left).

Upper jaw occlusal view (center).

Lower jaw occlusal view (right).


Final esthetic result (left).

Final smile result (center).

X-ray with final rehabilitations 8 months after the surgery (right).

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© Nobel Biocare USA, LLC, 2023. All rights reserved. Disclaimer: Nobel Biocare, the Nobel Biocare logotype and all other trademarks are, if nothing else is stated or is evident from the context in a certain case, trademarks of Nobel Biocare. Please refer to nobelbiocare.com/trademarks for more information. Product images are not necessarily to scale. All product images are for illustration purposes only and may not be an exact representation of the product. Some products may not be regulatory cleared/released for sale in all markets. Please contact the local Nobel Biocare sales office for current product assortment and availability. Caution: Federal (United States) law or the law in your jurisdiction may restrict this device to sale by or on the order of a dentist or a physician. See Instructions For Use for full prescribing information, including indications, contraindications, warnings and precautions. Not all medical devices used during surgery are Nobel Biocare devices. Nobel Biocare recommends that manufacturer‘s IFUs are followed. Full procedure is not shown. Certain sequences have been cut. Please refer to applicable IFUs for full instructions. Dr. Enrico Agliardi is a paid consultant for Nobel Biocare. The opinions expressed are those of the doctor. Nobel Biocare is a medical device manufacturer and does not dispense medical advice. Clinicians should use their own professional judgment in treating their patients. Individual patient results may vary.