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All on four - the basics

Article in Biomedical and Pharmacology Journal · October 2015

DOI: 10.13005/bpj/756


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Samson Jimson
Tagore Dental College & Hospital,


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Biomedical & Pharmacology Journal Vol. 8(Spl. Edn.), 609-612 (Oct. 2015)

All on four - the basics


Corresponding author E-mail: dr.b.anandh@gmail.com

Department of Oral and Maxillofacial Surgery,Tagore Dental College and Hospital,

Rathinamangalam, Melakottaiyur Post, Chennai – 600127, India.

DOI: http://dx.doi.org/10.13005/bpj/756

(Received: August 15, 2015; accepted: September 20, 2015)

INTRODUCTION to avoid these unfavourable posterior areas is the

use of tilted implants to allow for a better anterior-
Advances in implant dentistry have allowed posterior spread of dental implants. This in turn
a shift from the early paradigms established by the favors a better load distribution. This concept, known
pioneer work of Branemark and his coworkers. as “All-on-Four,” was described by Paulo Malo and
While initial healing of 6 months in the maxilla and coworkers in 2003. In brief, four (or more) implants
3 months in the mandible was recommended, are placed in the anterior part of the fully edentulous
progress in the understanding of biology and jaw. The two most anterior implants are placed
technical developments have allowed immediate axially, and the posterior implants are placed in an
loading of implants in specific clinical situations. angled position to maximize implant length and
One such situation is represented in the fully avoid anatomic structures (ie, mental nerve and
edentulous jaw.1 The All-on-4 concept is one such anterior border of the maxillary sinus). These
treatment procedure which enlightens us for its use implants are loaded immediately with a provisional
in the completely edentulous patients, which also fixed dental prosthesis.1
leaves behind the routine treatment alternative of
conventional dentures with successful outcome in General considerations
the short term, long term and the retrospective ´ To achieve primary implant stability (35 to
studies that have been done in the past2. 45 Ncm insertion torque).
´ Indicated with a minimum bone width of
The concept of All on four 5mm and minimum bone height of 10mm
Alveolar atrophy in the posterior regions from canine to canine in maxilla and 8mm in
of fully edentulous patients often hinders with the mandible.
placement of dental implants without being ´ If angulation is 30 0 or more, the tilted
augmented to increase the height and width of implants can be splinted.
available alveolus. The technique-sensitive ´ For tilted posterior implants, the distal screw
augmentation surgery for the atrophied alveolus access holes should be located at the
also has the potential for increased patient morbidity occlusal face of the first molar, the second
and complications. One suggested treatment option premolar, or the first premolar.
610 ANANDH et al., Biomed. & Pharmacol. J., Vol. 8(Spl. Edn.), 609-612 (Oct. 2015)

Surgical Procedure
Implants in the maxilla are placed with two
distal implants in the posterior region which are
tilted anterior to the maxillary antrum while in the
mandible implants are positioned anterior to the
mental foramen. They should be inserted at an
angulation of 300-450. The use of All-on-4 surgical
guide assists in ensuring the placement of implants
with correct positioning, angulation and emergence.
The guide is placed into a 2mm osteotomy that is
made in the midline position of the maxilla or
mandible and the titanium band is contoured to
follow the arc of the opposing arch. The guide also
Advantages of the All-on-4 concept assists in retracting the tongue in mandibular cases.
´ Angled posterior implants avoid anatomical The vertical lines on the guide are used as a
structures reference for drilling at the correct angulation, which
´ Angled posterior implants allow longer should not be greater than 450.
implants anchored in better quality bone
´ Reduces posterior cantilever Bevilacqua et al., demonstrated that tilting
´ Eliminates bone grafts in the edentulous of the distal implant by 300 in a FFP decreased the
maxilla and mandible in majority of cases. level of stress by 52% and 47.6% in compact bone
´ High success rates and cancellous bone respectively, when compared
´ Implants well-spaced, good biomechanics, to vertical implants supporting FFP with longer
easier to clean, immediate function and cantilevers3. The use of angled abutments on two
aesthetics tilted implants placed in a curved arch and with
´ Final restoration can be fixed or removable cross-arch splinting might help decrease the
´ Reduced cost due to less number of implants stresses around the distal implants4.
and avoidance of grafting in the majority of
cases. There are three phases in All on Four
Limitations • Surgical phase
• Good general health and acceptable oral • A-P spread
hygience. • Prosthetic phase
• Sufficient bone for 4 implants of at least
10mm in length. Surgical phase
• Implants attain sufficient stability for ´ Step 1 -Selection of case satisfying the
immediate function. inclusion criteria
´ Step 2-Planning implant placement using
Disadvantages All-On-4 Guide(Prefered)
• Free hand arbitrary surgical placement of ´ Step 3-Location of Maxillary Antrum and
implant is not always possible as implant Mental Foramen with All-On-4 Guide
placement is completely prosthetically ´ Step 4-Implant placement done following the
driven. protocols
• Length of cantilever in the prosthesis cannot
be extended beyond the limit.
• It is very technique sensitive and requires
elaborate pre-surgical preparation such as
CAD/CAM, surgical splint.

surgical guide & template

ANANDH et al., Biomed. & Pharmacol. J., Vol. 8(Spl. Edn.), 609-612 (Oct. 2015) 611

Anterio-posterior spread ´ Step 2-Final impressions after integration is

Rangert-10 mm for a cantilever of 20 mm verified, being splinted with GC resin and
(2xA-P-spread)for mandibular ISFPs metal.
´ Step 3-All ceramic Zirconia bridge being
English-ISFPs should be 1.5 times A-P- designed with CAD/CAM technology
spread for mandible maxillary ISFP posterior ´ Step 4-Use of CAD/CAM zirconia bridge or
cantilever should be reduced to 6-8mm due low Titanium framework milled for crown
bone density cementation
´ Step 5-Crowns luted to zirconia framework
Prosthetic phase ´ Step 6-Implant-supported zirconia bridge
´ Step 1-Open tray impression made with wire framework with individual crowns luted.
and GC resin splinting for improved accuracy

Fig. Prosthetic phase – a resin splinting and final prosthesis

Loading the healing bone and bone reduction followed by immediate function
The All-on-4 concept advocates is believed to be as a result of
immediate loading. A slight load on healing bone • Stable splinting of all four implants with the
shortens healing time rather than prolonging 4. provisional immediately after surgery
Immediately loaded implants osseointegrate early • Careful occulsal adjustment to provide
with adequate strength provided that the forces and bilateral occulsion in the canine and first
implant micromotion are controlled. premolar areas
• Avoid occlusal contact toward the distal of
Immediate extraction socket placement: the prosthesis and maximizing the
The connection of implants may provide a anteroposterior spread.
safer transfer of load on each implant, so the
placement of implants in healed or fresh extraction An Anteroposterior spread that minimizes
socket region may not influence implant survival the distal cantilevers and establishes well
when rehabilitating patients with totally edentulous distributed four-point stability was probably
maxilla and mandible4. contributary to both implant and prosthetic success.
The immediate implant loading and function in the
From a surgical perspective, the most dental extraction setting can be performed with a
notable are careful implant site preparation high degree of confidence.
(including tapping), use of relatively low – torque
producing implants , the preparation of an osseous DISCUSSION
shelf to level the alveolar ridge and establish
optimum implant sites and the provision of Published studies on the All on-Four
adequate interocclusal space. concept have shown cumulative survival rates to
range between 92.2% and l00%.7-9 Owing to the
From a prosthetic perspective, the high freedom of tilting, the implants can be anchored in
success rate obtained with this protocol, including dense bone structures (anterior bone with higher
minimal bone loss even with multiple extractions density) and well spread anteriorly-posteriorly,
612 ANANDH et al., Biomed. & Pharmacol. J., Vol. 8(Spl. Edn.), 609-612 (Oct. 2015)

giving an effective prosthetic base. By reducing the CONCLUSION

number of implants to four, each implant can be
placed without coming into conflict with adjacent Placement of dental implants previously
implants. This treatment approach, using tilting and in attempts to treat the severely resorbed maxilla
few implants rather than inserting several implants and mandible has had only limited success. But
competing for space, has demonstrated good the rehabilitation of completely edentulous,
results. atrophied maxilla and mandible by the placement
of implants using the AII-on-Four protocol gives new
hope for a perceivable success, while becoming a
promising treatment method of choice and
standard in the care for severely compromised


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on 4 concept for dental implants. Journal of Oral Implantol 5(3): 277–285 (2012).
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ZE16-ZE19 (2014). Function Concept with Branemark System®
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Finite Element Analysis of Load Maxillae:A 1-Year Retrospective Clinical
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Concept Configuration, The International Clinical Implant Dentistry and Related
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