Board Certified Periodontist, Dr. Scott O. Kissel

Guided Surgery – Case Report

Table of Contents

Guided surgery has been a part of oral surgery for at least 15 years. I can remember being thrilled with the software used in Simplant 1; they are now up to at least version 17 or 18! My New York City practice now uses multiple software solutions to create my surgical guides because they each have their own advantages. The literature supports the fact that there is greater accuracy in placement of implants when guides are used. I have used guides for over 15 years, and in my experience, they are absolutely fantastic. Recently I have treated several patients who required “All-on-4 or more” using the nSequence guided surgery technique. The nSequence technique uses a special 3D solution for implant-supported full arch restorations.

All-on-4 treatment is a concept of cost-efficient, graft-free surgery for full arch prostheses. All-on-4 is so named because it relies entirely on four implants tilted in various ways, “all teeth” are supported “on four” dental implants. This tilt utilizes available bone to remove the necessity of grafting. This dense bone on the front part of the jaws is strong enough to support these implants and makes the process possible. There are two advantages to the all-on-4 nSequence process: The position of the prosthesis in space is predetermined with photos, scans, and models; and the transition of the prosthesis is extremely simple, while not necessitating an in-house lab technician. This guided system uses a series of stackable guides and gaskets to achieve this goal.

Below you will see photos of a young woman who had to lose all her teeth due to Generalized Aggressive Periodontal disease. You will note that connecting the temporary abutments to the prosthesis only requires syringing acrylic through the small holes in the buccal flange of the prosthesis. This is followed by typical finishing and polishing.

<pre-op photo>

Here is a 3D printed maxilla on a platform, on top of which is a series of guides. There is a bone level guide which is secured to the jaw with 3 pins. On top of this, a bone reduction guide, an implant guide, a rubber gasket (which is visible under the prosthesis) and the prosthesis with predetermined cutouts for the implant components.


Here are the small holes where acrylic is syringed to secure the denture to the temporary abutments. The temporary abutments are connected to straight or angulated multiunit abutments.


At my New York City practice, I work in conjunction with an Anesthesiologist for this type of all-on-4 treatment. The guide is pinned in place, and you can see the implant abutments emerging through the predetermined holes in the denture. Next, another rubber gasket is placed over the occlusal surface to form a contained space and acrylic is syringed through the buccal holes in the denture.


Please feel free to call my New York City office with any questions or if you would like to discuss a patient needing this type of treatment.

For patients, the all-on-4 prosthesis is a well-tested and proven technique. It has evolved over time and is a very important and effective technique to provide same-day replacement for the entire upper and/or lower sets of teeth. If you are a New York City local with significant tooth loss or decay or perhaps have significant bone loss in the jaw area, the all-on-4 technique might be right for you.

I provide only the highest quality of care in prosthodontic procedures. Prosthodontics procedures are significant undertakings, and I can help you through the process while helping you find the correct procedures.

Prospective patients are encouraged to call (212) 702- 9088 or come in for a consultation so we can discuss what treatment is correct for you.

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