ALL-ON-FOUR DENTAL IMPLANTS

PAVITHRA RATHINASWAMY
CRI
 SYNOPSIS
INTRODUCTION
HISTORY
GENERAL CONSIDERATIONS
SURGICAL PROTOCOL
LOADING CONCEPT
ANTEROPOSTERIOR SPREAD
OCCLUSAL SCHEME
ADVANTAGES
DISADVANTAGES
CONCLUSION
 INTRODUCTION
 Implant supported fixed prosthesis is impossible in some of the completely edentulous patients,
because of inadequate availability of residual alveolar bone, nerve proximation.

 In these compromised cases nerve transposition and grafting is required to overcome the problem.

 An alternative to above said problem is the all on four concept..

 The concept of “All on four” was given by Paulo Malo and his co-workers in the year 2003. In this
technique two implants placed vertically in the anterior region and two implants placed in the posterior
edentulous region up to an angle of 45 degrees.
 HISTORY OF ALL-ON-FOUR
CONCEPT
 Mattson and colleagues, in 1999
treated patients with severely
resorbed edentulous maxilla by
inserting 4 to 6 implants in the
premaxilla to avoid sinus
augmentation

 Successfully restored them with

fixed prosthesis with 12 teeth
 In 2000, Krekmanov and
supported by superstructure
colleagues were also able
to demonstrate posterior
tilted implant-supported
prosthesis was possible
ALL-ON-4 IMMEDIATE LOADING CONCEPT
(developed in 2003 by a dentist Paulo Malo and colleagues)

 This concept uses 2 vertical anterior implants

in conjunction with 2 distally tilted
inclined implants with their apices positioned anterior to the sinus wall or
mental foramen.

 It involves the use of straight and angled multiunit abutments, which support a provisional,
fixed, and immediately loaded, full arch prosthesis. It has been developed to maximize the use of available
bone and allows immediate function
 In this technique, four implants are placed in the anterior region of the jaw between
the two mental foramina in the mandible and between the mesial walls of the
maxillary sinus in the maxilla.

 The two anterior implants follow the jaw anatomy and the two distal implants are
tilted at 45° angulation.
 vital structure avoided in All
on 4 Concept

All on 4 concept design and

multi-unit abutment
 GENERAL CONSIDERATIONS

Ability to achieve primary implant stability (35 – 45 Ncm)

No severe parafunctions

To diminish the cantilever, tilt the posterior implants.

Does not require a wider opening of the mouth

 It is advisable to place implants between extraction sockets.

 Indicated with a minimum bone width of 5mm and minimum bone height of 10mm
from canine to canine in maxilla and 8mm in mandible.

If angulation is 300 or more, the tilted implants can be splinted.

For tilted posterior implants, the distal screw access holes should be located at the
occlusal face of the first molar, the second premolar, or the first premolar.
Treatment Protocol Consists of Two
Phases:

Surgical

Prosthetic
 SURGICAL PHASE:

Placement
Location of Maxillary of implant
Selection of case Planning implant
Antrum and Mental following
satisfying the placement using All-
Foramen with All-On- the
inclusion criteria On-4 Guide protocols
4 Guide
 The surgical guide is placed into a 2 mm osteotomy that is made in the midline position of
the maxilla or mandible.

 The titanium band is contoured to follow the arc of the opposing arch

 The vertical lines on the guide are used as a reference for drilling at the correct
angulation, which should not be greater than 45º.

 Angulated pins and denture can also be used as templates.

 The two most anterior implants follow jaw anatomy in direction (lingual tilting in cases of
severe mandibular resorption).

 The two posterior implants are inserted just anterior to the foramina or maxillary sinus

 They are tilted distally approximately 30°– 45° relative to the occlusal plane.

 Torque set to >35Ncm

 LOADING OVER RESIDUAL BONE
The bone which is surrounding the dental implant may undergo micro damage when occlusal loading
is done immediately after the implant placement.

 If the prosthesis is being loaded with the same loaded after the healing period No micro
damage occurs to the bone as adaptation of the bone around the dental implant occurred after the
initial healing phase.
 Splinting of all the four
implants placed in the
There should be no occlusal
edentulous arch along with
contact given in the distal
provisional prosthesis
most of the prosthesis
immediately after the
surgery HIGH
SUCCESS RATE
DUE TO

Bilateral occlusion is
provided in the canine and The antero posterior spread of
the first bicuspid area with the prosthesis should be
the help of occlusal maximized.
adjustment
 ANTEROPOSTERIOR SPREAD
According to Rangert, “ the antero posterior spread of the prosthesis (the distance between the
most anterior and most posterior implant) of 10 mm was proposed for a cantilever length of
20mm i.e. 2 x antero posterior spread.”

According to English, “ the antero posterior length of cantilever in case of mandibular implant
supported fixed prosthesis should be 1.5 time of the antero posterior spread.”

This will provide

 10 – 12mm of cantilever length in case of mandibular implant supported fixed prosthesis

 In case of maxillary implant supported fixed prosthesis the cantilever length should be reduced
to 6 – 8mm due to presence of low density bone in maxillary posterior region.
OCCLUSAL SCHEME:

 There should be presence of bilateral identical intercuspal contacts when the

jaws are stable.

 There should be establishment of “freedom in centric” in the occlusal scheme.

 There should be no interference present between the maximal intercuspal

position and the retruded position.

 Slight of tooth contact with free mandibular movements, during lateral and
protrusive movement.
Immediately loading All on four, occlusal scheme
The length of the cantilever should always be minimal.

There should be bilateral, simultaneous contact present over all the teeth, except the teeth which is
present distal to the emergence of the implant.

In lateral movement, group function can be given or guidance that too with flat linear pathways
with minimal superimposition in vertical, excluding the teeth present in the cantilever.

In protrusive movements, guidance should be given in all the anterior teeth i.e. from canine to
canine, with flat linear pathways along with minimal vertical superimposition.

There should be no balancing contacts given when implant supported fixed prosthesis is occluding
with a removable prosthesis
Occlusal scheme for definitive prosthesis
for All on Four:

Simultaneous bilateral contact

present over cuspids and the posterior
teeth with slight grazing contacts over
the incisors.

If in case implant supported fixed prosthesis is occluding with removable partial denture,
complete denture, cast partial denture or with implant supported over denture, the
distal most tooth should remain slightly out of occlusion and in excursive
movement, one or more balancing contact should be given.
• In lateral movements, canine
The inclination of the cuspal planes
guidance should be given
must be lesser than the condylar
when opposing natural
dentition is present. path inclinations

Group function occlusion should be given

when opposing implant supported bridge is
preent in posterior, flat linear pathways with
minimum vertical imposition should be given.
 PROSTHETIC PHASE

17º multiunit abutments and 30º angulated, Straight Abutments with different collar heights are
placed onto the implants to achieve to achieve the correct access allowing relative parallelism.

For provisional prosthesis fabrication on the day of surgery (2–3 hours after surgery), the impression
copings are placed onto the multiunit abutments which are then splinted with autopolymerising resin
and wire bars.

Protective healing caps are placed on the abutments while provisional is being made
Acrylic provisional screw retained prosthesis is torqued to 15 Ncm. Only soft diet is
recommended

For final prosthesis (4–6 months after initial implant placement), if the implants are judged
stable, provisional restoration is removed and bite is registered

Multiunit laboratory analogs are attached to the provisional and then it is mounted on an
articulator against a counter model

The prosthesis is indexed with putty. Resin pattern is fabricated in sections and the sections are
joined in the patient’s mouth
This resin pattern gets scanned and framework is made by CAD/CAM technology.

After try-in Final prosthesis made of metal-acrylic resin with a titanium framework and
acrylic resin prosthetic teeth, or a metal ceramic prosthesis with titanium framework and all
ceramic zirconia crowns is delivered.
 ADVANTAGES
Anatomical structure can be avoided by the use of angled implants in the posterior region.

Implants with longer dimensions can be anchored in the bone for better stability.

Span of the posterior cantilever is reduced.

Bone augmentation procedure can be avoided.

Immediate function.

Better esthetics.

Success rate is relatively higher.

Economical, as number of implants are reduced.

DISADVANTAGES
 Length of the cantilever being given is limited and can not be extended beyond the limits.

 Very much technique sensitive, and requires presurgical splint for the proper placement of implant at
desired position and angulation.

 Free hand arbitrary surgical placement of implant is not always possible as implant placement is completely
prosthetically driven.
 ALL ON FOUR
Secure confident smile
Maintains jaw bone
Creates normal bite force
Aids normal healthy digestion
CONVENTIONAL CD
Confidence in smiling is slightly
lesser
Causes loss (thinning) of jaw
bone
Reduces bite force
Reduces normal healthy
digestion

Maintains normal B12, folic Reduces normal B12, folic acid

acid and albumin levels and albumin levels
Provides long term stability Increased mobility over time
No denture adhesive is required Denture adhesive is required
No acrylic on the roof of mouth Acrylic on the roof of the moulh
Fixed, secure with no
movement Loose and mobile
Enjoy favorite foods again Limited food choices
CONCLUSION:
The “All-on-4” treatment concept seems to be an alternative option for rehabilitating edentulous
jaws compared with advanced surgical approaches without using removable prostheses.

 It is a cost-effective procedure, decreasing the treatment times, the morbidity and allowing a higher
patient quality of life.

Placement of dental implants previously in attempts to treat the severely resorbed maxilla and
mandible has had only limited success.

 But the rehabilitation of completely edentulous, 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
patients.
REFERENCE:

 Rosa, (2018) All-on-four Protocol in an Atrophic Mandible. The Open Dentistry Journal 12:
1004-1010.

 Thumati P, Reddy M, Mahantshetty M, Manwani R (2015) “All-On-4/ DIEM 2” A concept to

rehabilitate completely resorbed edentulous arches. J Dent Implant 5(1): 76-81.

 Malo P, Rangert B, Dvarsater L (2000) Immediate function of Branemark implants in the

esthetic zone: a retrospective clinical study with 6 months to 4 years of follow-up. Clin
Implant Dent Relat Res 2(3): 138- 146.
THANK YOU