Prosthodontic Perspective to All

On – 4 Concept
Taruna M, Chittaranjan B, Sudheer N, Tella S, Abusaad M. Prosthodontic
perspective to All-On-4® concept for dental implants. Journal of clinical
and diagnostic research: JCDR. 2014 Oct;8(10):ZE16.

Presented by – Guided by-

Dr. Krupali Jain Dr. Jyoti Karani
IInd Year MDS, Dept. of Prosthodontics Dr. Saloni Mistry
• Described by Paulo Malo along with co – workers in 2003.

• Involves surgical and prosthetic procedures –

Total rehabilitation of edentulous patients

Patients with compromised dentition – periodontal / carious reasons

• Based on immediate loading concept of implants in specific clinical situations.

• The All-on-Four treatment concept provides edentulous arches and immediate / post

extraction subjects with an immediately loaded, fixed prosthesis using 4 implants:

2 axially oriented implants in anterior region

2 tilted posterior implants (upto 45)

 Principle – use of 4 implants restored with straight and angled
multiunit abutments, supporting a provisional, fixed, immediately
loaded, full arched prosthesis placed on same day of surgery
An attempt :
• avoid anatomical limitations
typically seen in posterior
regions of upper and lower jaws.
• Nerve transposition, grafting
procedures and bone
augmentation techniques.
• Maximum use of available bone
• Immediate function
 General considerations
• Primary implant stability – 35 – 45Ncm torque.

• Minimum bone width – 5mm.

• Minimum bone height – maxilla – 10mm.

mandible – 8mm.

• 30 angulation – splinting of tilted implants.

• Distal screw access holes – occlusal surface of 1st/ 2nd premolars/ 1st molar.
 Tilted implants
Enables : longer implants

improved prosthetic support

with short cantilever arm

improved inter implant

distance
• Increased prosthetic base –
inclination of implants –
improved bone anchorage reduces cantilever length –
reduced forces
• Bevilacqua et al., - tilted distal implants by 30 in fixed prosthesis

sed stresses by 52% & 47.6% in compact bone

& cancellous bone respectively

compared to vertical implants with long cantilevers

 Applied vertical load

Splinted tilted implants

Load shared between two neighboring implants through prosthesis

No overloading or bending

Lower stresses than axial implants

 Immediate loading

• This concept advocates immediate loading

Slight load on healing bone shortens healing time rather than

prolonging, provided forces are controlled
Surgical perspective : careful implant site
preparation.

low – torque producing implants.

osseous shelf to level alveolar ridge.

provision of adequate interocclusal

space.
• Prosthodontic perspective : stable splinting of all 4 implants.

provisionalization immediately after

surgery.

maximize A-P spread.

avoid occlusal contact at the distal end

of

the prosthesis.
 A – P Spread & Cantilever Values

• By Rangert – 2 x A – P Spread
• By English – 1.5 x A – P Spread

An A – P Spread which minimizes the distal cantilever an establishes well distributed

4 – point stability contributes to both implant and prosthetic success, following

immediate implant loading protocol.

• A long term study showed - No significant difference in implants survival rates
compared in prosthesis supported by 4 / 6 implants. Stress location and
distribution patterns were very similar in both cases.

• A study analyzing strain patterns around distal implants placed at 0,

15,30,45 found increase in strain patterns only for 45 angled implants

• A study by Krekmanov showed no significant differences between use of

tilted and non-tilted implants
 Multi-unit Angled Abutments
• Simplifies prosthetic access for diverging implant angles.
• Facilitates implants with greater height and width.
• Reduces treatment time.
• Non-surgical management in compromised patients.

Range - 0,15,25,30,35
Stresses are exerted within physiological tolerance of bone
17 Multi-unit abutment 30 Multi-unit abutment
Treatment Planning Considerations
PIS-35Ncm
Existing
denture can No Severe
be used as Parafunction
provisional

Maximum of
Bone Width
12 teeth on
– 5mm
each side

45–
posterior Bone Height
implant, –
reduction of >30 10mm/8mm
cantilever splinting of
tilted
implants
 Position All-on-4 Guide Prepare Posterior Site

Placements of implants ahead of

Prepare anterior site
mental foramen
Making of Impression Connect Straight Multi-unit
Abutments

Placement of jig to connect 30 Multi-unit Abutments

Placement of temporary copings Connect the bridge using 3 prosthetic Secure temporary coping with
which is not connected to the screws composite
prostheses

Tighten all the prosthetic screws and

Reinforce temporary copings check the occlusion
The jig construction for placing 30 Multi-
unit Abutment:
1. Impression Coping Open Tray Multi-unit
2. Guide Pin
3. 30 Multi-unit Abutment
4. Abutment Holder
5. Jig Stabilizer
6. Abutment Screw
 Surgical Guides

Existing
Prostheses
Minimally Invasive Flappy
Technique.
Efficient Implant Insertion.
Enables fabrication of provisional
prostheses and multi-unit
abutment placement jig in
advance.
Fabrication of Definitive Prostheses
• Options :
Zirconia /
Zirconia /
Titanium
Titanium
framework with
framework with
individual
acrylic
crowns
veneering
cemented

Cast metal
Removable
framework with
prostheses,
porcelain
over-denture
veneering
Titanium /
Zirconia
Frameworks
Minimally Invasive Flapless Approach due to Existing denture transform
adequate mouth opening into radiographic guide

CBCT Imaging of the patient Implant site preparation

Implant Post implant
insertion placement Provisional prostheses

Immediate function Final Restoration

 Occlusal scheme
Implant
protected
30 – 40% occlusion: by
Carl.E.Misch Shallow
reduction in anterior
occlusal guidance.
table.
Bilateral
Reduced
stability in
cuspal
centric
inclination,wid
occlusion.
e grooves.
Lateral Elimination of
excursive interferences
movements between
without retruded
interferences. position and
MIP.
 Occlusion on full-arch fixed prostheses

• Mutually protected occlusion with shallow anterior guidance

• Infra-occlusion on a cantilever unit

Mandible < 15mm cantilever

Maxilla < 10-12mm

• Lateral movements : avoid balancing contacts

 Advantages
• Immediate function and
esthetics.
• High success rates.
• Reduced posterior cantilever.
• Elimination of bone grafts.
• Longer implants .
• Preserves vital structures.
• Reduced cost (less number of
implants).
Disadvantages
• Technique sensitive.
• Cantilever length cannot be
extended.
• Requires elaborate pre-surgical
preparation like surgical splints
etc.
• Limitations –
Good general health, acceptable oral hygiene.
Sufficient bone of minimum 10mm.
Sufficient primary stability for immediate function.
 Conclusion

• High success rates of this technique have been seen as a conclusion of

various studies. However, factors such as bone quality, length of
implants, immediate loading concept, patient satisfaction levels, cost
concern as well as the oral hygiene status should be evaluated when
All-on-4 treatment option is to be considered.
 References
• Christopher, et al, Implant rehabilitation in the edentulous jaw: The “All-on-4®
concept” immediate function. Australian dental practice. 2012, 138-48.
• Pankaj P singh. A Norman Cranin. Atlas of oral implantology.275-81.
• Paulo Malo, et al. All-on-4® immediate function concept for completely
edentulous maxillae. A clinical report on the medium and long term 5 years
outcome, Journal of Oral Implantology.2011.
• Dallenback K, et al. Biomechanics of in-line vs offset implants supporting a
partial prosthesis. J Dent Res. 1996;75:183.
• Chiara M Bellini, et al. Comparison of tilted versus non-tilted Implant –
supported prosthetic designs for the restoration of the edentulous mandible. A
biomechanical study. Int J oral Maxillofacial implants. 2009;24:511-12.
• Krekmanov L, et al. Tilting of posterior mandibular and maxillary implants of
prosthesis support. Int J Oral maxillofacial implants. 2000;15:405-14.