Background
Navigation with virtual implant placement provides accurate spacing and angulation of the implants compared with the use of free-hand approaches. The use of virtual implant planning and subsequent navigation also allows for prosthetic and surgical collaboration with precise planning and accurate orchestration of the plan to achieve a high level of patient-specific results. More research is needed to evaluate the outcome of implant-supported surgical procedures assisted by dynamic navigation.

Aim/Hypothesis
To describe the workflow of a maxillary full-arch rehabilitation through the All-on-4® concept assisted by dynamic navigation. 

Material and Methods
A female healthy patient with 57 years of age presented with need of maxillary full-arch rehabilitation. Orthopantomography and Cone Beam Computerized Tomography (CBCT) scan were taken and the DTX Studio Implant Software was used to evaluate the baseline clinical situation.The surgery was performed under local anesthesia. After incision, flap raising and bone reduction 5 tri-screws were fixated in the maxilla. A CBCT scan was made and in the DTX Studio Implant Software the position and size of implants were selected. After the fixation of the X-Guide® receptor the navigation surgery was initiated. The  drills used to prepare the implant bed were calibrated before the osteotomy. Four implants (All-on-4® Maxilla MALOCLINIC protocol; Nobel Parallel CC implants) were inserted achieving 35 N/cm of primary stability; Multi-Unit Plus abutments were attached and a provisional pre-made prosthesis was connected achieving immediate function.

Results
The X-Guide Navigation® provided the precise position and orientation of the drills and implants in every step of the surgery. This tool enabled the placement of the implants in the most favorable prosthetic and surgical positions, avoiding important anatomic structures such as the maxillary sinus and the nasal cavities. All the implants were placed with an insertion torque of 35 N/cm which allowed the connection of the prosthesis on the same day of surgery, achieving immediate function. The main advantages of the dynamic navigation assisted surgery include its accuracy, time- and cost-effectiveness, and the ability to change the implant size, system and location during the surgical procedure. Nevertheless, the clinician must understand that a learning curve is required to gain proficiency using a dynamic navigation system. This system could benefit from the following improvements. For total edentulous cases, simpler fiducial markers could make the surgery faster and less complicated once the tri-screws fixation costs time and could limit the implants position.

Conclusion and Clinical implications
The surgical procedure assisted by dynamic navigation for the full-arch rehabilitation of the maxilla was safe and predictable, allowing an accurate insertion of the implants in depth, angulation and crestal position. The system could benefit from improvements in order to make the management of full-arch cases simpler.

Dynamic Navigation with X-Guide- Total edentulous workflow - Maxilla All-on-4