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Maxillary and mandibular all-on-four implant designs: A review

Article  in  Nigerian Journal of Clinical Practice · August 2019

DOI: 10.4103/njcp.njcp_273_18

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Review Article
1 Maxillary and Mandibular All‑on‑Four Implant Designs: A Review 1
2 2
3 R Durkan, P Oyar1, G Deste 3
4 4
5 5
Department of Objective: The objective of this review is to evaluate maxillary and mandibular
6 6

Abstract
Prosthodontics, Faculty of
7 Dentistry, Afyon Kocatepe
all‑on‑four implant designs, their indications and contraindications, advantages 7
8 University, Afyonkarahisar, and disadvantages. Methods: By using Pubmed, Cochrane Library, and Google 8
9 1
Department of Dental Scholar, data from January 2003 to February 2018 were scanned electronically 9
10 Prostheses Technology, and manually as the title, abstract, and full text. The keywords specified were 10
11 Health Services Vocational determined to be the all‑on‑four concept, full‑arch implant prostheses, 4‑implant 11
12 High School, Hacettepe full‑arch, and tilted implants. The inclusion criteria consisted of the all‑on‑four 12
13 University, Ankara, Turkey 13
implant design, its use in completely edentulous maxillary and mandibular cases,
14 advantages and disadvantages of the technique, and changes observed in the 14
15 maxilla and mandible in completely edentulous cases. Clinical trials and laboratory 15
16 studies on the subject using the full text and English language were evaluated. 16
17 Results: A total of 176 articles were found as a result of Google Scholar, Pubmed, 17
18 and Cochrane Library. Thirty‑seven articles were selected according to inclusion 18
19 criteria; of these, 20 were related to the clinical trials. In addition, a total of 13 19
20 20
articles were found as a result of an additional hand search by screening the
21 21
reference list of all included publications; of these, 11 was related to the clinical
22 22
23
trials. Conclusions: It is necessary to carry out longer‑term clinical and laboratory 23
24 studies to determine long‑term success criteria in all‑on‑four implant designs and 24
25 to use new ceramic systems. 25
Date of Acceptance:
26 Keywords: All‑on‑four concept, mandible, maxilla, tilted implant 26
28-Feb-2019
27 27
28 28
29 Introduction temporary prostheses (in the postoperative 8‑‑48 h) and 29
permanent fixed prostheses after the 3‑month period.[2‑5]
30
31
32
I t is accepted that fixed prosthetic restorations with
full‑arch implants are better in terms of aesthetics,
function, and phonation than removable prostheses.[1]
The objective of the design is to make full‑arch fixed
restorations with fewer implants in cases when implants
30
31
32
33 33
The all‑on‑four implant design is an implant application cannot be placed in the posterior region because of
34 34
technique that is applied in severely resorbed anatomic limitations. Furthermore, it is also important
35 35
completely edentulous maxilla and mandible. Principles, that it is a design that minimizes or completely
36 36
37 specifications, and application procedures of all‑on‑four eliminates the posterior cantilever application. Implants 37
38 implant designs were first applied by Malo in 2003 to are placed in the premaxillary region in the maxilla 38
39 atrophic completely edentulous mandible and to maxilla and in the interforaminal region in the mandible. 39
40 in 2005. Although it is widely used in the mandible, this method 40
41 could not be fully evaluated in the maxilla. Because 41
42 The abutment of the all‑on‑four concept is defined as of the lower quality and quantity of the maxillary 42
43 full‑arch screw‑retained fixed prostheses made on a total bone compared with the mandibular bone and also 43
44 of four implants, being two implants placed orthogonally 44
Address for correspondence: Prof. P Oyar,
45 to the occlusal plane in the anterior region and two Department of Dental Prostheses Technology, 45
46 implants placed 15‑45° distal in the posterior region, Health Services Vocational High School, Hacettepe University, 46
47 in completely edentulous maxillary and/or mandibular D Block, 3. Floor, 06100 Sıhhıye, Ankara, Turkey.
47
E‑mail: poyar73@gmail.com
48 jaws. It includes immediate making and loading of 48
49 Access this article online
This is an open access journal, and articles are distributed under the terms of the 49
Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows
50 Quick Response Code: others to remix, tweak, and build upon the work non‑commercially, as long as
50
51 Website: www.njcponline.com appropriate credit is given and the new creations are licensed under the identical 51
52 terms. 52
53 DOI: 10.4103/njcp.njcp_273_18 For reprints contact: reprints@medknow.com 53
54 How to cite this article: Durkan R, Oyar P, Deste G. Maxillary and
54
55 PMID: ******* mandibular all‑on‑four implant designs: A  review. Niger J Clin Pract 55
56 2019;XX:XX-XX. 56

© 2019 Nigerian Journal of Clinical Practice | Published by Wolters Kluwer ‑ Medknow 1

 Durkan, et al.: All-on-four implant designs

1 maxillary bones being more trabecular and less dense and jeopardize the effectiveness of the implant. Bone 1
2 than the mandibular bone, it is more disadvantageous resorption in the neck of the implant  (crater cratering) 2
3 compared with the mandibular interforaminal region.[3,6] becomes unavoidable.[11] 3
4 In maxillary all‑on‑four implants, posterior implants 4
5 In permanent prostheses in the all‑on‑four technique, a 5
are placed angularly to the premaxillary region, the
6 premature contact should not exist. Occlusal contacts are 6
anterior wall region of the maxillary sinus. Long‑angle
7 those that deflect the jaws from normal occlusal closure, 7
implants (≥13 mm) provide high primary stability.[7,8]
8 conflict with the normal, smooth, and compatible sliding 8
9 Misch  (2009)[9] emphasized that the part between the motion of mandibular movements, and/or disrupt the 9
10 mental foramina of the mandible is more stable to position of the condyle, tooth, or prosthesis.[11] There 10
11 bending and stress forces and that strains occurring should be a balanced occlusion around the canines and 11
12 along the opening phase and protrusive motion in the the first premolars. The occlusal contact distal to the 12
13 jaw occur on the distal of the mental foramina. The prosthesis should be reduced. Occlusal forces should be 13
14 researcher stated that mandibular motions in the distal of concentrated in the region between anterior and posterior 14
15 the mental foramen in fixed restorations negatively affect implants, and freedom should be ensured in the centric. 15
16 the prognosis of implants and that upon the placement The last tooth on the cantilever should be extracted 16
17 of implants between the mental foramina in full‑arch from occlusion. However, there are not enough studies 17
18 fixed restorations fixed to each other, less bending forces on occlusion in all‑on‑four restorations in the current 18
19 literature.[12,13] 19
occur in the mandible. In accordance with this opinion,
20 20
in the all‑on‑four treatment technique, implants are In all‑on‑four prostheses, cantilever extensions are either
21 21
placed between the mental foramina. absent or shortened. Thus, high prosthetic complications,
22 22
23 In all‑on‑four implant designs, screw‑retained prostheses abutment loosening, prosthetic fractures, or implant 23
24 are preferred. Mechanical and biological complication failures, which are the disadvantages of cantilever 24
25 rates decrease because of the easy removal of prostheses, are reduced.[14] 25
26 screw‑retained implant‑assisted prostheses. They can 26
27 The main objective of this study is to compile detailed 27
be used in cases when the abutment length is short. information on mandibular and maxillary all‑on‑four
28 The prosthesis can be removed for prosthetic hygiene. 28
29 implant designs and prosthetic restorations. 29
It can be easily removed when there is a problem with
30 30
the abutment and/or implants. It can be removed at the Materials and Methods
31 31
dentist’s control. Cementation problems are not observed.
32 Focused question 32
Moment forces are low. It is used when the interocular
33 What is the all‑on‑four implant design, what are 33
34 distance is insufficient.[10] However, clinical procedures 34
the advantages, disadvantages, indications, and
35 are difficult. They require precise work. Its cost is 35
contraindications of this technique?
36 high. Screw spaces on the occlusal surface should be 36
37 closed. Occlusion may be affected by the occlusal screw Search strategy 37
38 areas. The screw may loosen and break. There may be A computerized literature search was performed by 38
39 ceramic breaks in screw areas in the superstructure. three investigators using Google Scholar. Various 39
40 Bacterial invasion may occur in screw areas. keywords were used: all‑on‑four concept, full‑arch 40
41 A  temporary restoration is difficult to perform.[10] The implant prostheses, 4‑implant full‑arch, and tilted 41
42 European Association of Osseointegration recommends implants, using the search string ‘‘OR’’ and additional 42
43 screw‑retained substructures in implant‑assisted hand search was performed by screening the lists of all 43
44 prosthetic treatments. articles selected, and full texts of potentially interesting 44
45 studies were examined. The search was limited to the 45
46 It has been reported that bone resorption is low 46
English language. The search included scientific articles
47 in all‑on‑four implant designs. Overloads to the 47
published until February 2018.
48 bone‑‑implant interface in implant‑assisted prostheses 48
49 are activated by surgical trauma and bacterial invasion. Inclusion criteria 49
50 Inappropriate occlusion, improper prosthesis and/or The inclusion criteria consisted of the all‑on‑four 50
51 implant designs, and surgical implant placement failures implant design, its use in complete edentulous maxillary 51
52 lead to the inadequate load transfer mechanism of the and mandibular cases, advantages and disadvantages of 52
53 overloaded peri‑implant bone under functional forces. the technique, and changes observed in the maxilla and 53
54 Consequently, a high‑concentration stress accumulation mandible in complete edentulous cases. Clinical trials 54
55 occurs at the bone‑‑implant interface. Stress areas in and laboratory studies on the subject using the full text 55
56 the bone tissue stimulate biological bone resorption and English language were evaluated. 56

2 Nigerian Journal of Clinical Practice  ¦  Volume XX  ¦  Issue XX  ¦  Month 2019
 Durkan, et al.: All-on-four implant designs

1 Exclusion criteria from the searches based on the inclusion criteria. 1

2 Studies not meeting all inclusion criteria were excluded On the basis of the selection of articles were then 2
3 from the review. Publications dealing with the following obtained in full text. The final selection based on 3
4 inclusion/exclusion criteria was made for the full‑text 4
topics were also excluded: all‑on‑six implant design.
5 articles. Three authors evaluated together the reference 5
6 Selection of studies lists of all articles selected, and full texts of these 6
7 Three authors independently screened the titles derived studies were examined. 7
8 8
9 9
10 Table 1: Indications of all‑on‑four implant design 10
11 Indications References/year 11
12 Patients the implant made with a good oral hygiene and to prevent the absence of systemic disease 15/2007 12
13 In the region of interforaminal, bone length is at least 10 mm of cases 7/2012 13
14 Interforaminal bone width is at least 5 mm of cases 16/2013 14
15 Maxillary anterior region, bone length is at least 10 mm in cases 17/2015 15
16 Anterior maxillary sinus bone length is at least 10 mm in cases 17/2015 16
17 Maxillary region of bone width at least 5 mm in cases 17/2015 17
18 Conditions provided in the primary stability 7/2012 18
19 Cases in which the implant is placed immobile for immediate loading 7/2012 19
20 Arches distance at least 20 mm in cases 7/2012 20
21 21
22 Table 2: Contraindication of all‑on‑four implant design 22
23 Contraindication References/year 23
24 Cases with contraindications to conventional implant placement 7/2012 24
25 Systemic conditions of patients do not allow to the surgical implant placement 15/2007, 17/2015 25
26 Bone reduction needed due to a high smile line in the maxilla 7/2012, 7/2012 26
27 Irregular bone crest, or thin bone crest. 7/2012 27
28 Insufficient bone volume 7/2012, 7/2012 28
29 Remaining teeth or root that interfere with the planning for implant placement 7/2012 29
30 Insufficient mouth opening to accommodate surgical instrumentation of at least 50 mm 7/2012 30
31 31
32 32
33 Table 3: Advantages of all‑on‑four implant design 33
34 Advantages References/year 34
35 The low cost 18/2013 35
36 In particular achieving higher of posterior primary stability 7/2012 36
37 Temporary acrylic prosthesis make functions to start immediately (immediate loading) 19/2000, 20/2016 37
38 The decrease in the sinus lifting surgery, grafting, and does not need to be mandibular nerve 3/2013 38
39 repositioning and minimally invasive surgery 39
40 To ensure a natural aesthetic and be sufficient masticatory forces 3/2013 40
41 The use of longer implants for posterior (≥13 mm) and an increase in bone anchorage and 3/2013, 4/2014, 19/2000, 21/2007, 41
42 consequently provide high primary stability with the right to be placed of biomechanical position 7/2012, 22/2004, 14/2014, 42
43 Planning and implant surgery computer‑assisted method (CAM) and computer assisted surgery (CAS) 3/2013, 7/2012, 22/2004 43
are used, surgical planning and guidance to increase the success rate of implants made of digital plates
44 44
Being regular occlusal forces distribution 3/2013
45 45
Cantilever in the maxilla is less of 9.3 mm and 6.6 m extension to be mandible 19/2000
46 46
Post‑surgical period is comfortable for the patient and the less complications 3/2013
47 47
The implementation of atrophic edentulous maxilla and/or mandible 3/2013
48 48
A 5‑year success rate of tilted implants is 95.2‑98.9% and in axial implant 91.3‑93%. The overall 12/2011
49 success rate is given as 92.2‑100%.
49
50 This increases the use of angled implants. Between vertical and angled implants is no difference 19/2000
50
51 between marginal bone loss and success rates 51
52 Jaw type, gender and place of implant does not affect the treatment plan 23/2014 52
53 Crestal bone loss at the end of 1 year of use: it is 0:34 to 1:14 to 0:43 to 1:13 mm axial and angled 24/2014 53
54 implants 54
55 Quickly and effective treatment option 6/2010 55
56 56

Nigerian Journal of Clinical Practice  ¦  Volume XX  ¦  Issue XX  ¦  Month 2019 3
 Durkan, et al.: All-on-four implant designs

1 Results included peer‑reviewed publications only in English 1

2 Study selection language. 2
3 3
All recent publications on the all‑on‑four implant General characteristics of included studies
4 4
5 design, advantages, disadvantages, indications, and Thirty nine articles were selected according to inclusion 5
6 contraindications of this technique were selected 6
criteria; of these, 20 were related to the clinical trials.
7 [Tables 1-4],[3,4,6-9,12,14-27] as this was the primary aim of 7
this review. A total of 176 articles were found as a result A  total of 13 articles were found as a result of an
8 8
of Google Scholar, Pubmed, and Cochrane Library. additional hand search by screening the reference list of
9 9
10 Thirty‑nine articles were selected according to inclusion all included publications. Thirteen articles were selected 10
11 criteria. In addition, 13 studies were found by screening according to inclusion criteria; of these, 11 were related 11
12 the reference list of all included publications. The search to the clinical trials. 12
13 13
14 Table 4: Disadvantages of all‑on‑four implant design 14
15 Disadvantages References/year 15
16 Due to the angled posterior implants; cantilever extension increases tension in the curved posterior 21/2007 16
17 peri‑implant, phonetic disorders 17
18 The lack of long‑term clinical follow‑up studies, in particular data on long‑term success of the maxillary 3/2013, 8/2014 18
19 implant angle are insufficient 19
20 Language contraction of the room, 21/2007 20
21 Making the excessive volume of the posterior tooth bridge and 21/2007 21
22 Hygiene problems 21/2007 22
23 Data on the biomechanical advantages of fixed dentures cantilever extension is inadequate 8/2014 23
24 Especially extreme resorbed crest and in the distal inclined implants to provide adequate anchorage implants 12/2011, 25/2012, 26/2011 24
25 should be at least 4.0 mm. 25
26 Not recommended in patients with high parafunctional activity 7/2012 26
27 Narrow diameter 3.5 mm implant use is not widespread 12/2011, 25/2012, 26/2011 27
28 Especially with poor mouth opening in patients is difficult to placement of posterior implants 7/2012, 24/2014 28
29 Especially in the follow‑up of 12 months 92% success rate in the maxilla 27/2011 29
30 30
31 31
32 Table 5: Atrophic edentulous maxilla transactions to be made in the implementation of the implant 32
33 Procedures of surgery References/year 33
Le Fort I osteotomy 21/2007
34 34
Sinus grafting with block grafts, autografts (from an intraoral location or the iliac crest), and xenografts 21/2007
35 35
(usually of bovine origin)
36 36
Bypassing the maxillary sinus 21/2007
37 37
Split‑crest technique for lateral bone expansion 21/2007
38 38
Tuber, or ptergo‑maxillary zygomatic implant applications 21/2007, 7/2012,
39 23/2014 39
40 Short implants (<10 mm) and/or angled implant applications 8/2014, 28/2005,
40
41 7/2012 41
42 42
43 43
44 Table 6: The drawbacks of the atrophic edentulous maxilla in the implementation process 44
45 Disadvantages of the procedures of surgery References/year 45
46 To be higher failure rates when procedures such as sinus floor elevation and sinus complications 21/2007 46
47 Increased site morbidity 21/2007 47
48 Postoperative discomfort after harvesting autogenous bone grafts 21/2007 48
49 The consent of the patient 21/2007 49
50 Delayed resorption of various grafts prevents 21/2007 50
51 New bone formation 51
52 Be boundary of neurovascular bundle in the zygomatic implant site, requiring detailed anatomical 21/2007 52
53 knowledge and long and delicate surgical procedures 53
54 Challenges to be resolved when the prosthetic complications 8/2014, 29/2009 54
55 For anterior maxilla; it is more difficult to achieve high levels of implant stability at implant placement 27/2011 55
56 (primary stability) 56

4 Nigerian Journal of Clinical Practice  ¦  Volume XX  ¦  Issue XX  ¦  Month 2019
 Durkan, et al.: All-on-four implant designs

1 Table 7: Atrophic edentulous mandibula transactions to Immediate loading is preferred for all‑on‑four 1
2 be made in the implementation of the implant implant‑assisted fixed prostheses.[6,7,12,16] Following the 2
3 Procedures of surgery References/year implant application, temporary prosthetic restorations are 3
4 Mandibular nerve repositioning 21/2007 made and start to function immediately. Thus, patients 4
5 Different bone augmentation procedures, 21/2007 do not remain edentulous, and they use prostheses 5
6 lateral or vertical direction phonetically, aesthetically, and functionally. 6
7 Split‑crest technique for lateral bone 21/2007 7
8 expansion Within 1  week following the placement of implants in 8
9 Short implants (<10 mm) and/or angled 8/2014, 28/2005, the all‑on‑four mandibular implant design, a temporary 9
10 implant applications 7/2012 prosthesis consisting of an acrylic resin base and teeth 10
11 is made, and implants are loaded immediately and start 11
12 to function. The permanent prosthesis is made as a 12
13 Table 8: The drawbacks of the atrophic edentulous 13
metal‑‑ceramic full‑arch fixed prosthesis approximately
14 mandibula in the implementation process 14
Disadvantages of procedures of surgery References/year
3 months later.[16,32]
15 15
16 Increased site morbidity 21/2007 Prosthetic materials used in all‑on‑four implant‑assisted 16
17 Postoperative discomfort after mandibular 21/2007 prostheses are an important factor affecting stress/ 17
nervous reposition
18 strains observed in implants and peri‑implant bone. In 18
The consent of the patient 21/2007
19 this regard, while some researchers suggest[27,33] a metal 19
20 substructure due to its rigid structure, others suggest 20
21 Discussion full‑acrylic resin prostheses and state that this structure 21
22 is used for a longer period.[34,35] 22
23 All‑on‑four implant designs were developed especially 23
24 for the application in severely resorbed mandibular The tensile strength limit values of materials are 24
25 completely edentulous cases, but later, they were also 552‑‑1034 MPa for Co‑‑Cr, 860‑‑965 MPa for Ti, and 25
26 applied in maxillary completely edentulous cases. In 900‑‑1200 MPa for Zr. Stress is higher in prosthetic 26
27 cases when resorption is severe in the mandibular materials with high hardness and durability. However, 27
28 posterior region, full‑arch fixed prostheses can be made because of the high elastic modulus values of such 28
29 with four implants placed in the interforaminal region.[28] materials, breakage or mechanical complications against 29
30 In cases when sinus‑dependent implant applications in bending and deformations are lower.[36] 30
31 the maxilla are limited, the application is performed so 31
32 Full‑arch all‑on‑four implant‑assisted fixed dental 32
that it will not cross the mesial wall of sinuses. It has prostheses are metal‑reinforced ceramic restorations,
33 33
many advantages compared with conventional complete metal‑reinforced hybrid fixed prostheses, and
34 34
35 edentulism implant applications. In all‑on‑four implant zirconia‑reinforced ceramic fixed prostheses.[34,35] The 35
36 designs, digital, diagnostic, CAD/CAM‑assisted surgical increased rigidity associated with the metal frameworks in 36
37 procedures are used. Moreover, dental ceramics or prostheses had an important role in the survival rates seen 37
38 metal‑reinforced ceramics with the CAD/CAM system with this design, although the literature is not conclusive 38
39 are used in making full‑arch fixed prosthetic restoration. in this matter. Grunder[37] found that implant failures were 39
40 found in patients with nonmetal‑reinforced restorations. 40
Factors affecting the construction of maxillary and
41 Others[38] who have used acrylic resin prostheses have 41
42
mandibular full‑arch all‑on‑four implant‑assisted fixed 42
prosthesis are the triangle, square, or U‑shape of the reported high survival rates. Although the literature is
43 conflicting on this point,[39-41] several authors maintain 43
44 arch, the position of mental foramina in the mandible, 44
the position and resorption degree of maxillary sinuses that the use of acrylic resin (shock absorbing occlusal
45 45
in the maxilla, the value of the anteroposterior  (AP) surface) results in reduced stresses transmitted to the
46 46
bone‑‑implant interface.[42,43] Patients who were treated
47 distance, the cantilever length, parafunctional status, 47
48 with bar‑retained implant supported overdentures 48
crown heights, the status and prosthetics type of the
49 experienced difficulties in maintaining good oral hygiene 49
opposite arch, the activity of the chewing muscles, the
50 and have high plaque indexes. Mechanical problems 50
number, type, shape of implants, the quality and quantity
51 occurred to the bar‑retained acrylic superstructures 51
of the bone, and the patient’s systemic status.[19,29-31]
52 could be resolved more cheaply than those occurred to 52
53 Implant loading protocols for completely edentulous the ceramic superstructures.[44-49] With the development 53
54 mandible and maxilla include different protocols such of restorations made with zirconia substructure ceramic 54
55 as conventional loading, early loading, and immediate systems using computer‑aided design and computer‑aided 55
56 loading for full‑arch fixed prostheses. manufacturing (CAD/CAM) and performing zirconia core 56

Nigerian Journal of Clinical Practice  ¦  Volume XX  ¦  Issue XX  ¦  Month 2019 5
 Durkan, et al.: All-on-four implant designs

1 ceramic systems with these methods for the last 20 years, many studies were encountered on the use of different 1
2 more rapid, aesthetic, and durable prostheses have been implant systems. No standard length and diameter could 2
3 made. It has been emphasized that implant‑assisted be determined for implant lengths. More studies are 3
4 full‑arch fixed prosthetic restorations made according to needed to be conducted on all‑on‑four implant‑assisted 4
5 the all‑on‑four concept are biomechanically adequate. prosthetic restorations which have many advantages. 5
6 Studies continue to make longer‑lasting and advantageous 6
7 Because of the fact that an increase in comfort and 7
treatments with fewer implants.[30] All‑on‑four aesthetic expectations of both the mandible and maxilla
8 8
protocol indications [Table 1],[7,15-17] contraindications has been observed during prosthetic dental treatment
9 9
[Table 2],[7,15,17] advantages [Table 3],[3,4,6,7,12,14,18,19,21-24] in all‑on‑four protocols, it is possible to use them
10 10
and disadvantages [Table 4][3,7,8,12,21,24-27] are given in the successfully. Nevertheless, it is necessary to increase
11 11
12 following section. long‑term reliability limit as a result of conducting 12
13 There are generally macroscopic and microscopic further clinical‑based studies. It is required to apply 13
14 differences between edentulous maxillae and edentulous all‑on‑four protocols, full‑arch implant osseointegration 14
15 mandibles. There should be an adequate amount of in conventional restoration, biological and mechanical 15
16 the alveolar bone for implants in the anterior of the concepts and rules by taking them into account 16
17 edentulous maxilla. The maxillary bone is significantly since the overall treatment plan in implantology, 17
18 surgical stage, the precision of technique, the rules 18
more trabecular, and thus it is determined to be less
19 of the temporary prosthesis, appropriate prosthetic 19
dense. Posterior maxilla bone resorption, the current
20 superstructures, cantilever length, usage of materials 20
bone quality, and quantity are insufficient. The
21 21
maxillary sinus leads to difficulties in the implant produced with developed technology, and adequate
22 22
presence.[8,21,27,28,50] Tables 5[7,8,38,40,46] and 6[8,21,27,29] contain know‑how are necessary. It is a well‑known fact that
23 23
information on atrophic edentulous maxilla implants to the all‑on‑four protocol performed by considering all
24 24
25 be performed in the process of implementation and the of the above‑mentioned increases the success rate of 25
26 disadvantages of the mentioned process. complying with the rules of prosthetic restoration that 26
27 are specific to the system. 27
There should be an adequate amount of bone for the
28 Financial support and sponsorship 28
placement of implants in the anterior alveolar crest for
29 Nil. 29
the edentulous mandible. Higher posterior mandible bone
30 30
resorption, the current bone quality, and quantity are Conflicts of interest
31 31
32 inadequate. When posterior mandibular bone resorption There are no conflicts of interest. 32
33 is excessive, bone quality and quantity are observed to 33
34 be inadequate. In this case, when the implant is placed, References 34
35 the implant may damage the nerve of the mandible.[6‑10] 1. Bellini  CM, Romeo  D, Galbusera  F, Taschieri  S, Raimondi  MT, 35
36 Tables  7[7,8,21,28] and 8[21] contain information on the Zampelis  A, et al. Comparison of tilted versus nontilted 36
37 atrophic edentulous mandible implant to be performed in implant‑supported prosthetic designs for the restoration of 37
the process of implementation and disadvantages of the the edentuous mandible: A  biomechanical study. Int J Oral
38 38
Maxillofac Implants 2009;24:511‑7.
39 mentioned process. 39
2. Lierde  KM, Browaeys  H, Corthals  P, Matthys  C, Mussche  P,
40 Van Kerckhove  E, et al. Impact of fixed implant prosthetics 40
41 Conclusions using the ‘all‑onfour’ treatment concept on speech intelligibility, 41
42 Although there are many articles on mandibular articulation and oromyofunctional behaviour. Int J Oral 42
43 Maxillofac Surg 2012;41:1550‑7. 43
all‑on‑four implant restorations, short‑ and medium‑term
44 3. Spinelli  D, Ottria  L, De Vico  G, Bollero  R, Barlattani  A, 44
clinical trials are available but no long‑term clinical trials Bollero  P. Full rehabilitation with Nobel clinician ® and
45 45
covering 10  years and above have been encountered. procera implant bridge ®: Case report. Oral Implantol  (Rome)
46 2013;6:25‑36.
46
More studies and information are found on maxillary
47 4. Ehsani  S, Siadat  H, Alikhasi  M. Comparative evaluation of 47
48 all‑on‑four implant designs. Furthermore, not much data 48
impression accuracy of tilted and straight implants in All‑on‑Four
49 were found on the use of different ceramic systems in technique. Implant Dent 2014;23:225‑30. 49
50 implant‑assisted prosthetic restorations. Although the 5. Dellavia  C, Francetti  L, Rosati  R, Corbella  S, Ferrario  VF, 50
51 vertical placement is standard for anterior implants, Sforza  C. Electromyographic assessment of jaw muscles in 51
52 the application of posterior implant angles at different patients with All‑on‑Four fixed implant‑supported prostheses. 52
angles suggests that there is no standard for this situation J Oral Rehabil 2012;39:896‑904.
53 53
6. Ferreira EJ, Kuabara MR, Gulinelli JL. All‑on‑four” concept and
54 and that it can vary according to the characteristics immediate loading for simultaneous rehabilitation of the atrophic
54
55 of the case. Moreover, despite being the implant maxilla and mandible with conventional and zygomatic implants. 55
56 recommended to be used in terms of implant types, not Brit J Oral Maxillofac Surg 2010;48:218‑20. 56

6 Nigerian Journal of Clinical Practice  ¦  Volume XX  ¦  Issue XX  ¦  Month 2019
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