# Full-Arch Oral Rehabilitation in All-on-4 “M” Configuration Using Surgical Guides with Internal Cooling: A Clinical Case Report

## TL;DR

A new surgical guide with cooling was used to safely and accurately place dental implants in a patient with bone resorption.

## Contribution

A personalized surgical guide with internal cooling was applied in flapless All-on-4 'M' configuration implant surgery.

## Key findings

- Implant positioning was accurate with no intraoperative complications.
- All implants achieved primary stability above 35 N·cm.
- Radiographic follow-up confirmed correct 3D positioning and bone-implant contact.

## Abstract

Background/Objectives: The All-on-4 technique is a minimally invasive approach for full-arch oral rehabilitation. In cases of anterior bone resorption, the classic All-on-4 configuration may be limited by insufficient bone for axial implant insertion. An effective alternative is the “M” configuration, where all four implants are inserted at approximately 30°. This report presents a clinical case of full-arch rehabilitation using personalized surgical guides with internal cooling, designed to optimize irrigation and prevent thermal bone damage. Methods: A 57-year-old female patient underwent digital planning and flapless guided implant surgery. At the maxilla, four DENTIS SQ implants were inserted in an “M”-shaped configuration (4 × 10 mm anterior, 4 × 14 mm posterior). Before insertion, implant beds were prepared using surgical templates with internal irrigation channels. At the mandible, four posterior implants (4 × 8 mm) were placed using dentally supported guides with internal cooling. The surgical guides were designed using Implastation and Blue Sky Plan, 3D-printed in biocompatible resin and sterilized before use. We performed the osteotomies under controlled irrigation with continuous saline flow through the integrated cooling channels. Results: The guides ensured accurate implant positioning. We did not observe intraoperative complications, and all implants achieved primary stability above 35 N·cm. Postoperative healing was uneventful, with minimal edema and no mucosal dehiscence. These indirect clinical indicators suggest that the guide also ensured effective cooling. Radiographic follow-up confirmed correct 3D positioning and intimate bone-implant contact. Conclusions: This case study shows that personalized surgical guides with integrated coolant channels may provide a safe and precise solution for flapless All-on-4 “M” rehabilitations, reducing thermal risks and enhancing surgical accuracy.