C

o
pyr
i
g
h
t
b
y
N
o
t
f o
r
Q
u
i
n
t
e
s
s
en
c
e
N
o
t
f
o
r
P
u
b
l
i
c
a
t
i
o
n
155
Eur J Oral Implantol 2010;3(2):155163
CLINICAL ARTICLE
Carmen Pomares
Puig
Private practice,
Clnica Perio & Implant,
c/ Carratal, 24-26
Alicante 03007,
Spain
Tel: +34/965 12 47 15
Fax: +34/965 13 44 06
E-mail: perioimplant@
perioimplant.es
Carmen Pomares Puig
A retrospective study of edentulous patients
rehabilitated according to the all-on-four or
the all-on-six immediate function concept using
apless computer-guided implant surgery
Key words computerised tomographic scan, apless surgery, full edentulism, guided surgery,
immediate loading
Purpose: To report the outcome of an implant therapy protocol using 4 or 6 implants supporting
immediately loaded xed prostheses following 3D software planning and apless guided surgery.
Materials and methods: A total of 30 patients (24 women, 6 men), mean age of 53 years (range
3584 years) were treated with 195 immediately loaded implants (97 NobelSpeedy Groovy and 98
Brnemark MKIII Groovy) supporting 25 maxillary and 17 mandibular xed full-arch acrylic prosthe-
ses and followed for 1 year. The Procera Software v1.6 and v2.0 was used to plan implant position
and to obtain a surgical template for the guided apless implant placement. To perform immediate
loading, the implants had to be inserted with torque of at least 35 Ncm. Provisional prostheses were
made before surgery using software planning and were placed in the same session as the implants.
Denitive restorations were delivered 612 months after surgery. Outcome measures were failures
of the prosthesis and of the implants, marginal bone level changes, complications, clinical time and
patient satisfaction.
Results: Four patients with full edentulism and 26 with advanced periodontitis were enrolled in this
study. A total of 195 implants were immediately loaded (128 implants were placed in the maxilla and
67 implants were placed in the mandible). Four implants out of 195 failed in three patients during
the healing period: 2 in the maxilla (1 straight and 1 tilted), and 2 in the mandible (both of them
tilted). Three of them were successfully replaced. One year after loading there were no dropouts and
no failure of the denitive prosthesis occurred. In three cases, the surgical template fractured during
surgery. In one patient, a new impression had to be taken to t the provisional prosthesis onto the
implants. Three patients were subjected to surgery and systemic antibiotics to treat apically infected
implants.
Conclusions: The all-on-four and all-on-six treatment protocol combined with computer-guided
apless implant surgery could be a viable and predictable treatment. Some complications occurred
that were successfully treated. However, this technique could be sensitive to the experience of the
surgeon and a learning curve is required.
C
o
pyr
i
g
h
t
b
y
N
o
t
f o
r
Q
u
i
n
t
e
s
s
en
c
e
N
o
t
f
o
r
P
u
b
l
i
c
a
t
i
o
n
Puig All-on-four and all-on-six immediate function with flapless surgery 156
Eur J Oral Implantol 2010;3(2):155163
Introduction
For patients with severe periodontal disease or full
edentulism, it would be a great clinical advantage to
restore function and aesthetics in the same session
with a minimally invasive apless surgical approach,
and immediate placement of a provisional prosthesis,
thereby signicantly reducing morbidity, treatment
time and costs
1-3
. Immediate loading can be a viable
solution in cases of full edentulism and several studies
have demonstrated that immediately loaded full arch
xed prostheses represent a valid treatment option with
a high survival rate of both implants and prostheses
3-10
.
Different protocols have been developed for the
immediate rehabilitation of edentulous jaws. One
of these is the all-on-four concept. This concept
implies the placement of four strategically positioned
implants, two mesially and two distally placed and
tilted. By using this procedure, bone augmentation
procedures may be avoided in cases with reduced
residual bone volumes. As in any other immediate
function application when sufcient primary stability
is achieved, the probability of a successful treatment
outcome is high
11,12
. In some cases, when planning
a full arch ceramic rehabilitation in patients with poor
bone quality (type IV), it might be advisable to move
from the all-on-four protocol to the all-on-six pro-
tocol, thereby placing four anterior straight implants
and two tilted implants distally
13
.
Nowadays, advancements in computer science
and technology allow a combination of the con-
ventional all-on-four treatment protocol with 3D
software planning after computerised tomography
(CT) examination, guided minimally invasive surgery,
and immediate provisional prosthesis delivery. The
purpose of the software program is to help dentists
when planning the implant position
14-17
. A custom-
ised surgical template allows transfer of the planned
implant position, and a prefabricated acrylic resin
prosthesis is made. Treatment time and post-surgical
discomfort are reduced since implants can be placed
without elevating a ap and a provisonal prosthesis
can be delivered in the same session
1,3,18
.
The purpose of the present study was to retro-
spectively evaluate the clinical outcome of the all-
on-four and all-on-six protocol in fully edentulous
jaws using 3D software planning, guided apless
surgery and immediate provisional delivery.
Materials and methods
The present study was reported according to the
transparent guidelines for observational (cohort) stud-
ies (STROBE: http://www.strobe-statment.org)
19
.
Thirty patients (24 women and 6 men) with
advanced periodontitis (26 patients) or who were
totally edentulous when enrolled in the study
(4 patients), a mean age of 52.9 years (range 35 to
84 years), were consecutively treated in a private
clinic. Ten patients were smokers and one patient
reported a history of non-insulin-dependent dia-
betes. A total of 195 implants (97 Speedy Groovy
implants: 74 in the maxilla and 23 in the mandible;
and 98 Brnemark MKIII Groovy implants: 54 in the
maxilla and 44 in the mandible; Nobel Biocare, Gte-
borg, Sweden) with an oxidised surface (Ti Unite)
were placed between December 2006 and Decem-
ber 2008. In the maxilla, 128 implants were placed
(14 patients received six implants and 11 patients
received four implants). Sixty-seven implants were
placed in the mandible (four implants in 16 patients,
and one patient received three implants because he
already had two implants placed in another clinic). In
total, 42 xed implant-supported cross-arch bridges
were inserted (28 all-on-four rehabilitations in
11 maxillae and 17 mandibles, and 14 all-on-six
rehabilitations in maxillae). Main selection criteria
were:
edentulous jaws, or arches with non-retainable
teeth in need of xed implant restorations
a residual bone volume allowing the placement
of implants with a diameter of at least 3.3 mm
and a length of at least 10 mm, as well as an
insertion torque of at least 35 Ncm.
Patients with a mouth opening of less than 4 cm,
poor oral hygiene, heavy smokers (>20 cigarettes
per day) and poorly controlled systemic diseases
were excluded. The implants used all had a diameter
of 3.34.0 mm and a length of 1018 mm.
Pre-treatment, surgical and
prosthetic procedures
Prior to implant treatment, all patients with teeth
with periodontitis received periodontal treatment
involving scaling and root planing to reduce the
C
o
pyr
i
g
h
t
b
y
N
o
t
f o
r
Q
u
i
n
t
e
s
s
en
c
e
N
o
t
f
o
r
P
u
b
l
i
c
a
t
i
o
n
Puig All-on-four and all-on-six immediate function with flapless surgery 157
Eur J Oral Implantol 2010;3(2):155163
bacterial contamination before implant surgery. All
periodontally involved teeth were extracted 3078
days prior to surgery. The pre-treatment recordings
consisted of anamnesis as well as clinical and radio-
logical evaluation (with initial CT scan); an impres-
sion with alginate was made and poured in a cast
to form the study model; and clinical pictures were
also taken. At a second pre-treatment, a silicon
impression was made in order to obtain the nal
cast and inter-arch relationships were recorded. For
the radiographic guide a removable prosthesis as
a radiographic template was made. Six buccal and
three palatal holes were made at different levels
of the removable prosthesis and lled with radio-
paque gutta-percha. A silicone interocclusal record
was made to serve as a radiographic index dur-
ing the rst CT scan (Dental CT scanner, Promax,
Planmeca, Helsinki, Finland) of the patient with the
removable prosthesis acting as radiographic guide.
A second CT scan of the removable prosthesis
alone with the same orientation as in the mouth
was also made. Once CT scan data were transferred
to a computer, the 3D software planning was per-
formed using the Procera Nobel Guide software
v1.6 and v2.0 (Figs 1 to 3) (Nobel Biocare). The
planning data were then sent to a manufacturing
plant (Nobel Biocare, Gteburg, Sweden), and a
surgical template with metallic cylinders guiding the
implants in the same position as in the virtual plan-
ning was fabricated
20
. At the laboratory a working
cast was made as derived from the surgical tem-
plate, and then mounted in an articulator to create
an all-acrylic resin xed complete denture.
One hour before surgery, patients received anti-
biotics (amoxicillin and calvulanic acid 500/125
or 875/125 mg, or diacetylmidecamycin 900 mg
[Momicine, Inibsa, Barcelona, Spain] for patients
allergic to penicillin), ibuprofen 600 mg (Zambon,
Barcelona, Spain) and were sedated with diazepam
510 mg (Roche, Madrid, Spain) if needed. Mouth
rinses with 0.2% chlorhexidine were performed
for 1 min prior to surgery. Local anaesthesia was
administered using articaine 40 mg with epinephrine
0.01 mg/ml (Scandinibsa; Inibsa Laboratorios, Bar-
celona, Spain). The surgical template was placed
using a surgical index and stabilised with three
anchor pins. The implant surgery was performed fol-
lowing the manufacturers instructions (Figs 4 to 8).
Fig 3 Image of the
surgical template.
Fig 2b Occlusal view
of the prosthesis show-
ing prosthetic emer-
gence of the posterior
abutments at the level
of second premolars.
Fig 2a Anterior view
of the prosthesis with
virtual position of the
implants according
to the all-on-four
protocol.
Fig 1 A 2D image showing an edentulous maxilla with the all-on-four virtual design.
C
o
pyr
i
g
h
t
b
y
N
o
t
f o
r
Q
u
i
n
t
e
s
s
en
c
e
N
o
t
f
o
r
P
u
b
l
i
c
a
t
i
o
n
Puig All-on-four and all-on-six immediate function with flapless surgery 158
Eur J Oral Implantol 2010;3(2):155163
In cases of insufcient keratinised mucosa, a 2-mm
drill was used to indicate preparation of the implant
site, the surgical template was removed and a small
ap was elevated to secure at least 1 mm of kerat-
inised mucosa around the implant. The surgical tem-
plate was then xed again, taking care not to injure
the small aps during the drilling procedure.
The all-on-four protocol was used in both jaws
except when ceramic rehabilitations were planned
in maxillae with medium or poor bone quality (type
III and IV)
21
. In these cases, two additional implants
were placed. Two tilted implants were placed distally
with prosthetic emergence at the second premolar or
rst molar for minimum distal extension. The other
Fig 4 View of a maxillary edentulous ridge. Fig 5 Surgical template with the surgical index
in place.
Fig 6 Surgical template xed with three
anchor pins.
Fig 7 Start of the drilling sequence. Fig 8 Drill guides and guided abutments. Fig 9 View of the implant heads placed
according to the all-on-four concept.
Fig 10 Placement of the posterior tilted multi-
unit abutments.
Fig 11 Occlusal view of the xed provisional
prosthesis.
C
o
pyr
i
g
h
t
b
y
N
o
t
f o
r
Q
u
i
n
t
e
s
s
en
c
e
N
o
t
f
o
r
P
u
b
l
i
c
a
t
i
o
n
Puig All-on-four and all-on-six immediate function with flapless surgery 159
Eur J Oral Implantol 2010;3(2):155163
four implants were placed in the anterior part of the
jaw. The implant necks were positioned at the bone
level crest.
After implant placement, to facilitate abutment
seating, excess soft tissues were removed (Fig 9)
with a punch (guided soft tissue punch 32Z2007.00,
MDL, Delebio, Italy) or a round blade scalpel for
microsurgery (mini scalpel blade 69 ref MB 69 Hu-
Friedy microblades, Hu-Friedy, Leimen, Germany).
When a small ap was raised, it was repositioned with
a polyglycolide resorbable suture (Perma Sharp
TM

Hu-Friedy Fast Absorbable Synthetic Sutures, suture
C-3, 5-0, Hu-Friedy). The anterior straight abut-
ments were then placed rst (Multi-Unit; Nobel
Biocare) followed by the posterior 30-degree angu-
lated abutments, using a repositioning jig (Fig 10).
Abutments were placed after the application of a
chlorexidine 0.2% spray.
The prefabricated prosthesis was inserted imme-
diately after surgery (Figs 11 to 13). In the case of
the all-on-four, a posterior cylinder was not placed,
to allow for adjustments to be made and a primary
tting to be obtained. For the all-on-six, when
more than two cylinders were placed and stability
could be observed, adjustments were performed in
mouth. In case of lack of stability, an impression
with multi-unit abutments with a duplicate of the
transparent resin radiological template and copings
for indirect impression were taken (impression cop-
ing bar closed tray multi-unit 29093, Nobel Biocare),
using Impregum Soft (3M ESPE, Seefeld, Germany).
The laboratory performed the required adjustments
in the same session. In some cases, an anterior cyl-
inder was released to change a straight multi-unit
abutment to a 17-degree angulated abutment to
obtain a better prosthetic emergence (this cannot be
done by the virtual design of the software), followed
by the adjustments of the pre-fabricated prosthesis.
For anterior implants, angulated and straight
multi-unit abutments were set at 17 degrees and
those for posterior implants at 30 degrees, and
tightened to 10 Ncm. These abutment angulations
were chosen to avoid vestibular emergence of the
prosthetic screw access holes. Periapical radiographs
were taken to check the correct seating of the abut-
ments. The emergence positions of the screw access
holes for posterior implants were normally at the
level of the second premolar. Provisional prosthe-
ses were designed to hold a minimum of 10 teeth.
In every case, soft splints were fabricated to avoid
overloading. Occlusion was checked. Patients were
recommended a soft diet regimen, and given oral
hygiene instructions.
Post-surgery antibiotics (amoxicillin and cal-
vulanic acid 500/125 or 875/125 mg, augmentin
[GlaxoSmithKline, Madrid, Spain] or diacetylmideca-
mycin 900 mg [Inibsa], for patients allergic to peni-
cillin) and analgesics (ibuprofen 600 mg once every
12 h and paracetamol 650 mg, [Gelocatil, Gelos,
Barcelona, Spain] or metamizole 650 mg [Nolotil,
Boehringer Ingelheim, Barcelona, Spain] once every
8 h) were prescribed for 1 week.
Follow-up visits were scheduled each week for
the rst month after surgery, and once a month
thereafter up to the sixth month. Final prostheses
were delivered between 6 and 12 months after sur-
gery. Most nal prosthesis frameworks were made
in milled titanium prosthetic frameworks (Procera
Implant Bridge, Nobel Biocare) and included 12
teeth, with a maximum of a one-unit cantilever.
Fig 12 Anterior view of the provisional prosthesis placed
just after surgery.
Fig 13 Patient smiling with the provisional prosthesis.
C
o
pyr
i
g
h
t
b
y
N
o
t
f o
r
Q
u
i
n
t
e
s
s
en
c
e
N
o
t
f
o
r
P
u
b
l
i
c
a
t
i
o
n
Puig All-on-four and all-on-six immediate function with flapless surgery 160
Eur J Oral Implantol 2010;3(2):155163
A hard splint was delivered 2 weeks after the deni-
tive prosthesis placement.
A strict maintenance protocol was adopted.
The rst follow-up visit was 1 week after the inser-
tion of the nal prosthesis and then after 1, 3 and
6 months: oral hygiene, occlusion, and soft tissues
were checked and the hard splints were reviewed.
After that period, follow-up visits were made every
6 months. Panoramic and periapical radiographs
were taken at provisional delivery the same day as
the surgery, when inserting the nal prosthesis, and
at a minimum of 1 year of function of the nal pros-
thesis (Fig 14).
The following outcome measures were assessed.
Success of the prosthesis: the prosthetic recon-
structions are stable and in good function and
without complication in fabrication or removal.
Implant success measured as individual implant
stability in absence of pain, infection and radi-
olucency
22
. A lack of mobility was recorded
clinically when the straight and angulated multi-
unit abutments were inserted with a torque of
35 Ncm and 15 Ncm, respectively, to make the
nal prosthesis.
Any complications that occurred during the
entire follow-up period (1 year after implant
placement): mechanical complications (fracture
or loosening of mechanical and prosthetic com-
ponents), biological factors (such as pain or infec-
tion) and bone resorption, were assessed through
both periapical and panoramic radiographs.
Absence of functional (phonetics and chewing
ability) and aesthetic complication factors.
Radiographic evaluation, based on periapical
radiographs obtained using the parallel tech-
nique with a lm holder (Planmeca Oy, Helsinki,
Finland) after abutment placement during sur-
gery, and panoramic radiographs after the provi-
sional prosthesis placement. The same procedure
was carried out at the time of nal prosthesis
placement, and 1 year after loading. The ref-
erence point for reading the radiographs was
the implant platform (the horizontal interface
between the implant and the abutment). Mar-
ginal bone remodelling was dened as the differ-
ence in marginal bone level observed at delivery
of the denitive prosthesis relative to the bone
level at the time of surgery.
Fig 14a Preoperative panoramic radiograph of a patient presenting advanced peri-
odontitis prior to extractions.
Fig 14b Post-surgery panoramic radiograph with implants and provisional prosthesis
placed in the same session according to the all on four protocol.
Fig 14c Panoramic radiograph 1 year after insertion of the nal prosthesis.
C
o
pyr
i
g
h
t
b
y
N
o
t
f o
r
Q
u
i
n
t
e
s
s
en
c
e
N
o
t
f
o
r
P
u
b
l
i
c
a
t
i
o
n
Puig All-on-four and all-on-six immediate function with flapless surgery 161
Eur J Oral Implantol 2010;3(2):155163
Clinical time to place implants and provisional
prostheses were assessed.
Patient satisfaction with the treatment, and
whether the new technique was considered
worthwhile.
Results
All 30 patients were followed up to 1 year after load-
ing. Regarding immediate loading, a total of 195
implants were placed in 30 patients. In total, four
out of 195 immediately loaded implants (two Speedy
Groovy in the maxilla and two MKIII Groovy in the
mandible) failed in three patients before placement
of the nal prosthesis. Out of three patients, only one
patient was a smoker (although she reduced con-
sumption 20 days prior to the surgery); the patient
lost a tilted implant in the maxilla (position 25) after
4 months and it was replaced in position 26 after
4 days with an implant of the same length and width.
The second patient lost a tilted implant in the mandi-
ble (position 45) after 4 months, and a replacement
implant was placed in position 46 after 8 days. In the
same patient, another implant failed in the maxilla
(position 23) after 12 months, before placing the
nal prosthesis. This was an all-on-six case, and at
the patients request the implant was not replaced.
The third patient lost a tilted implant in position 45
after 5 months. A new implant of the same length
and a larger diameter was placed, and left unloaded.
The replaced implants were left unloaded until the
denitive prostheses were placed. The cumulative
implant survival rate was 98% (98.5% in the maxilla
and 97% in the mandible).
All implants were inserted with a torque of
35 Ncm. The majority of implants were engaged
bicortically. Four small aps had to be elevated in
four patients because of insufcient keratinised
mucosa width. In three patients, the surgical tem-
plate fractured during surgery due to an implant that
was inserted with a torque > 50 Ncm, or because
there was insufcient acrylic around the metallic
cylinders. This might explain the poor t between
the prosthesis and the implants when they were
inserted, requiring some adjustment by releasing
some cylinders when the provisional prosthesis did
not t onto the implants.
A total of 195 implants were loaded immediately,
supporting 42 xed provisional prostheses. In some
cases, more cylinders than those recommended by
the manufacturer were released to obtain an inser-
tion and a passive adjustment without changing the
maxillo-mandibular relationship. One cylinder was
released because of fracture of the surgical tem-
plate, and the others by changing from straight to
17-degree angulated abutments either for aesthetics
or because abutments were too short. The cylinders
were splinted in the mouth and the work was com-
pleted in the laboratory. In only one patient was an
impression made because the prosthesis was unsta-
ble in the mouth after releasing three cylinders, and
the prosthesis was adjusted in the laboratory.
The average surgical time ranged from 15 to
45 min. Adjustment time to insert these prostheses
ranged from 60 to 150 min. The prostheses were
placed a maximum of 3 h after surgery.
No post-surgery complications such as pain,
inammation or haematoma occurred. There were
no phonetic, aesthetic or chewing ability problems.
Eight patients experienced fractures in their
xed provisional acrylic prostheses during the heal-
ing period, which were repaired in the clinic; these
patients disregarded instructions to stay on a soft
diet during the rst months. The prostheses were
repaired and instructions were given to the patients
to minimise the overloading of their prostheses,
insisting on the use of the soft splint. No other
mechanical complications occurred.
Three patients had to be surgically debrided for
peri-implant apical infection and received both topi-
cal (Perio Film

, Italmed, Florence, Italy) and systemic

antibiotics (amoxicillin and calvulanic acid 500/125
or 875/125 mg, or augmentin or diacetylmide-
camycin 900 mg for patients allergic to penicillin)
and bone substitute (Bone bank, Transplant Serv-
ices Foundation, Mejia Lequerica, Barcelona, Spain).
The problems were successfully solved and it was
observed radiographically that the periapical radi-
olucency at the apex of the implant disappeared.
At 1 year, radiographic examination showed stable
bone levels for all implants except for two implants
that had bone loss up to the second thread. In some
cases, the base of the tilted multi-unit abutment was
left infrabony, and remodelled bone was observed
up to the shoulder of the implant.
C
o
pyr
i
g
h
t
b
y
N
o
t
f o
r
Q
u
i
n
t
e
s
s
en
c
e
N
o
t
f
o
r
P
u
b
l
i
c
a
t
i
o
n
Puig All-on-four and all-on-six immediate function with flapless surgery 162
Eur J Oral Implantol 2010;3(2):155163
All prostheses were successful 1 year after load-
ing. The new protocol described involved additional
costs compared to conventional placement (such as
new provisional prosthesis and double scanning). All
patients were very satised with this technique, and
said that it was worthwhile and they would undergo
the same treatment again.
Discussion
No prosthesis failed. A 98% success rate for the
implants is comparable to results of other studies for
immediate loading protocols with computer-guided
apless surgery, which reported survival rates of
95%
23
and 97.8%
24
. In a previous study, the all-
on-four and all-on-six protocol with conventional
ap surgery was performed: the survival rate was
96.7%
13
. Four loaded implants were lost in three
patients, possibly for overloading because they did
not follow the soft diet recommendations and were
not careful with the use of the prosthesis. All patients
were treated with a similar protocol despite the dif-
ferent degrees of bone resorption and bone quality.
It is possible that implants were inserted with an
apparent torque of 35 Ncm but that owing to friction
between the components (Guided Implant Mount
Bmk SystRP with Guided Sleeve of the surgical tem-
plate) the actual torque at the implant was lower. All
prostheses survived on the remaining three implants
until the replacement implants were loaded.
The present computer-guided treatment protocol
allowed the implant rehabilitation procedures to be
simplied and shortened for both the patient and the
clinical team. Immediate loading of apless placed
implants delivers benets to the patients, especially
when it comes to their social life and professional
activities. The post-surgical period is more comfort-
able since patients have their xed provisional pros-
theses from the rst day. Post-surgical discomforts
such as pain and swelling were minimal.
All implants were placed with apless surgery
(although in four cases small aps had to be elevated
to preserve the keratinised mucosa) and all prostheses
could be successfully loaded immediately. The most
common complication was that the provisional pros-
thesis did not t and was adapted in the clinic. The
explanation is that some implant placement deviated
from the original plan, possibly because the surgical
template was incorrectly positioned due to a minor
rotation or due to fracture of the surgical template. In
these cases, the surgical template should have been
reinforced. Several patients also experienced fractures
of their xed provisional acrylic prostheses during the
healing period. In some cases, the maxillo-mandibular
space was limited and the prostheses needed to be
reinforced. For these possible imprecisions, it might
be wise to place a provisional prosthesis immediately
after the implant surgery prior to placing the denitive
prosthesis.
In three patients, three implants presented peri-
implant pathology, inlcuding bone defects in the
apex of the implant with inammation and bleeding,
possibly due to secondary osteonecrosis caused by a
drill overheating and insufcient irrigation reaching
the apex at that moment; irrigation with refrigerated
saline was successfully introduced in the protocol.
Some of these complications can be explained
by the learning curve because most of them were
observed in the rst cases and very few in the last
ones.
Clinical data about the application of the soft-
ware planning program are limited
14,16
. One study
14

reported that both surgery and prosthetic placement
were performed within approximately 1 h; how-
ever, in the present study the average time to com-
plete the procedure (adding surgery and placement
of the provisional prosthesis time) was between
75 and 195 min, which is similar to that reported
elsewhere
16
. In one case, the procedure time was
approximately 3 h because a new impression had
to be taken to t the provisional prosthesis onto the
implants.
The limitations of the present study include its
retrospective design, the short follow-up period, the
lack of an independent assessment, and the radio-
graphic evaluation of marginal bone loss, which was
very approximate. Prospective studies are needed
to further evaluate the immediate function concept
using apless computer-guided implant surgery.
This protocol involves additional costs compared
with conventional placement (such as a new pro-
visional prosthesis and double scan). However, all
patients said that the treatment had been worth-
while and that they would undergo the same treat-
ment again.
C
o
pyr
i
g
h
t
b
y
N
o
t
f o
r
Q
u
i
n
t
e
s
s
en
c
e
N
o
t
f
o
r
P
u
b
l
i
c
a
t
i
o
n
Puig All-on-four and all-on-six immediate function with flapless surgery 163
Eur J Oral Implantol 2010;3(2):155163
Conclusions
The all on four and all on six protocols for rehabilita-
tion of completely edentulous jaws with placement of
immediate xed prostheses through computer-guided
apless surgery could be an effective and predictable
treatment, with the potential for great acceptance
among patients, the clinical team and the laboratory.
However, this technique could be sensitive to the expe-
rience of the surgeon and a learning curve is required.
Acknowledgements
The author acknowledges the Clnica Perio &
Implant team for their assistance during the clinical
procedures and data recording. This study was not
nancially supported by Nobel Biocare; however, I
would like to thank Franco Biondi, Clinical Research
Manager of Nobel Biocare, for his assistance.
References
1. Esposito M, Grusovin MG, Maghaireh H, Coulthard P,
Worthington HV. Interventions for replacing missing teeth:
management of soft tissues for dental implants. Cochrane
Database Syst Rev 2007;3:CD006697.
2. Fortin T, Bosson JL, Isidori M, Blanchet E. Effect of apless
surgery on pain experienced in implant placement using
an image-guided system. Int J Oral Maxillofac Implants
2006;21:298-304.
3. Esposito M, Grusovin MG, Achille H, Coulthard P, Worthing-
ton HV. Interventions for replacing missing teeth: different
times for loading dental implants. Cochrane Database Syst
Rev 2008;1:CD003878.
4. Cannizzaro G, Torchio C, Leone M, Esposito M. Immediate
versus early loading of apless-placed implants supporting
maxillary full-arch prostheses: a randomized controlled clini-
cal trial. Eur J Oral Implantol 2008;1:127-139.
5. Cannizzaro G, Leone M, Esposito M. Immediate versus
early loading of two implants placed with a apless tech-
nique supporting mandibular bar-retained overdentures: a
single-blinded, randomized controlled clinical trial. Eur J Oral
Implantol 2008;1:33-43.
6. Engquist B, Astrand P, Anzen B, Dalhgren S, Engquist E,
Feldmann H et al. Simplied methods of implant treatment
in the edentulous lower jaw: a 3-year follow-up report of a
controlled prospective study of one-stage versus two-stage
surgery and early loading. Clin Implant Dent Relat Res
2005;7:95-104.
7. Randow K, Ericsson I, Nilner K, Peterson A. Early functional
loading of Brnemark dental implants: 5-year clinical follow-
up study. Clin Implant Dent Relat Res 2000;2:70-77.
8. Schnitman PA, Whrle PS, Rubenstein JE, DaSilva JD, Wang
NH. Ten-year results for Brnemark implants immediately
loaded with xed prostheses at implant placement. Int J Oral
Maxillofac Implants 1997;12:495-503.
9. Wolnger GJ Balshi Tj, Rangert B. Immediate functional
loading of Brnemark System implants in edentulous man-
dibles: clinical simplied protocols. Int J Oral Maxillofac
Implants 2003;18:250-257.
10. Chee W, Jivraj S. Efciency of immediately loaded mandibu-
lar full-arch implant restorations. Clin Implant Dent Relat Res
2003;5:52-56.
11. Malo P, Rangert B, Nobre M. All-on-Four immediate
function concept with Brnemark System Implants for com-
pletely edentulous mandibles: a retrospective clinical study.
Clin Implant Dent Relat Res 2003;5(suppl 1):2-9.
12. Malo P, Ragert B, Nobre M. All-on-4 immediate function
concept with Brnemark System implants for completely
edentulous maxillae: a 1-year retrospective clinical study.
Clin Implant Dent Relat Res 2005;7(suppl 1):S88-S94.
13. Pomares C. A retrospective clinical study of edentulous
patients rehabilitated according to the all on four or the
all on six immediate fuction concept. Eur J Oral Implantol
2009;2:55-60.
14. van Steenberghe D, Glauser R, Blomback U, Andersson M,
Schutyser F, Petterson A et al. A computed tomograph-
ic scan-derived customized surgical template and xed
prosthesis for apless surgery and immediate loading of
implants in fully edentulous maxillae: a prospective multi-
center study. Clin Implant Dent Relat Res 2005;7(suppl
1):S111-S120.
15. Verstreken K, Van Cleynenbreugel J, Marchal G, Naert I,
Suetens P, van Steenberghe D. Computer-assisted planning
of oral implant surgery: a three-dimensional approach. Int
J Oral Maxillofac Implants 1996;11:806-810.
16. Merli M, Bernardelli F, Esposito M. Computer-guided ap-
less placement of immediately loaded dental implants in the
edentulous maxilla. A pilot prospective case series. Eur J Oral
Implantol 2008;1:61-70.
17. Hoffman J, Westendorff C, Gomez-Roman G, Reinert
S. Accuracy of naviagation-guided socket drilling before
implant installation compared to the conventional free-hand
method in a synthetic edentulous lower jaw model. Clin Oral
Implant Res 2005;16:609-614.
18. Kupeyan HK, Shaffner M, Armstrong J. Denitive CAD/
CAM- guided prosthesis for immediate loading of bone-
grafted maxilla: a case report. Clin Implant Dent Relat Res
2006;8:161-167.
19. STROBE statement. Available at: http://www.strobe-
statement.org/index.php?id=checklist. Accessed 20 May
2009.
20. van Steenberghe D, Molly L, Jacobs R, Vandekerckhove B,
Quirynen M, Naert I. The immediate rehabilitation by means
of a ready-made nal xed prosthesis in the edentulous
mandible: a 1-year follow-up study on 50 consecutive
patients. Clin Oral Implants Res 2004;15:360-365.
21. Lekholm U, Zarb GA. Patient selection and preparation.
In: Brnemark P-I, Zarb GA, Albrektsson Y (eds). Tissue-
integrated Prostheses: Osseointegration in Clinical Dentistry.
Chicago: Quintessence Publishing, 1985:201-209.
22. Van Steenberghe D. Outcomes and their measurement in
clinical trials of endosseous oral implants. Ann Periodontol
1997;2:291-298.
23. Sanna AM, Molly L, van Steenberghe D. Immediately
loaded CAD-CAM manufactured xed complete den-
tures using apless implant placement procedures: a
cohort study of consecutive patients. J Prosthet Dent
2007;97:331-339.
24. Malo P, Nobre M, Lopes A. The use of computer-guided
apless implant surgery and four implants placed in immedi-
ate function to support a xed denture: preliminary results
alter a mean follow-up period of thirteen months. J Prosthet
Dent 2007;97:S26-S34.
Copyright of European Journal of Oral Implantology is the property of Quintessence Publishing Company Inc.
and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright
holder's express written permission. However, users may print, download, or email articles for individual use.