All-on-4 – Facts and Misbeliefs

A very poular solution to the situation of complete edentulousness with a fixed bridge on 4 implants is the All-on-4 method. It is certainly a method that provides the optimal solution for many, but there is also a lot of misconception around the All-on-4 concept. In our article you will learn everything about the All-on-4 method.

The All-on-4 concept is a fixed prosthesis or bridge on 4 implants, which can be used in complete edentulousness of a jaw. For the All-on-4 solution, the implants are always placed on the left and right in positions 2 and 5 (second incisor and premolar). The posterior implants are placed at a usually 45-degree angle. So one escapes the maxillary sinus and a related further treatment, the sinus lift, so an increase of the maxillary antrum with bone replacement, which is always associated with additional costs and effort. On the 4 implants, either prosthesis or a bridge is screwed down. The 4 implants can be connected with a titanium bar for a more stable hold.

All-on-4 is copyrighted by implant manufacturer Nobel Biocare. Nobel Biocare is the best selling implant system in the world. Nobel Biocare has developed the All-on-4 concept together with the inventor of the method, Dr. med. prof. Paulo Maló from Portugal. Meanwhile, the so-called Procera technology is used in the manufacture of Nobel Biocare prosthetics. The bridge is planned digitally in the Procera CAD / CAM system and both the implant abutments (the connecting elements between the implant screw and the dental prosthesis) and the teeth are manufactured individually in the production facility of Nobel Biocare in the USA. This is the most advanced solution of its kind, providing perfect tilt and irresistible aesthetics. With this solution, zirconium crowns can be made on only 4 implants. Nobel Biocare offers a 5-year full warranty with worldwide support for this solution. This means that in case of a problem Nobel Biocare not only takes care of the new production, but organizes the treatment with a local partner near the patient’s place of residence. Since the impressions can be stored on data carriers thanks to the digital planning, a new production of the dentures is possible at the touch of a button. Strictly speaking, only the solution with Nobel Biocare implants and a Procera solution must be called All-on-4.

Although the original All-on-4 designation was copyrighted and co-developed by Nobel Biocare, other implant manufacturers have of course also copied and offered this solution. Thus, the term All-on-4 has loosened up and is used in the vernacular on all solutions in which a fixed prosthesis or bridge is screwed on 4 implants. This often leads to irritation and huge price differences, because a fixed composite prosthesis on a standard implant system is just as All-on-4 called as the most technologically advanced All-on-4 solution with Nobel Biocare implants, custom-made elements, a titanium bar and a zirconium bridge, where qualitatively, functionally and aesthetically two solutions of different can hardly be.

The All-on-4 method is used for complete edentulousness of a jaw. Four implants are placed, two at the front and two at the back. The two posterior implants are inserted at a 45-degree angle and later corrected to an overall vertical position for the prosthetic restoration with angled abutments. The construction elements are therefore not standard construction elements, but special construction elements with angle correction and screw-retain, so structural elements that allow a bolted solution. Either prosthesis or a bridge is screwed onto the implants.

The Procera is the CAD / CAM system of the company Nobel Biocare, which, among other things, is used for the producing of all-on-4 solutions. CAD / CAM (computer-aided-design / computer-aided-manufacture) stands for digital planning and digitally controlled manufacturing. This innovative technology guarantees a perfect, custom-made and top-aesthetic solution. Planning takes place in a Procera lab, a dental laboratory that has the Procera system, and is manufactured in Nobel Biocare’s US manufacturing facility. With Procera, crowns, bridges, bars and implants can be made to individual dimensions. The impression is either digitally recorded or digitized so that all necessary parameters can be stored on data carriers. This allows any time a repair or new production at the touch of a button, which is granted by Nobel Biocare also worldwide as part of a 5-year full warranty worldwide.

The All-on-4 solution with standard implants and a fixed bridge costs 7.180 €/jaw at Evergreen Dental. The price includes 4 standard implants, the final bridge, all CT and X-ray images as well as surgery package.

The All-on-4 solution with Nobel Biocare implants and the fixed bridge costs 8.020 €/jaw at Evergreen Dental. The price includes 4 Nobel Biocare Implants, the final bridge, all CT and X-ray images as well as the surgical package.

The Nobel Biocare All-on-4 Procera solution costs 11.580 €/jaw at Evergreen Dental. The price includes 4 Nobel Biocare implants with custom built components, titanium bar, the final bridge of zirconium, all CT and X-ray images as well as surgery package.

*Evergreen Dental reserves the right of price changing.

It is true that the All-on-4 method was designed so that the implants can be loaded immediately, if only with a therapeutic, so temporary bridge. Later, after the healing period, this must be replaced by a definitive bridge. In practice, the immediate loading of the implants is always associated with a risk, because in principle, implants should first integrate with the bone before they are loaded, since the chewing force can move the implants from the original position, as long as the tissue around the implants is soft. Therefore, the immediate load in theory is possible, but in reality always very much depending on the individual anatomical conditions, primarily dependent on the bone situation. Immediately loaded implants should always be checked regularly in the early days and weeks after treatment.

As already mentioned, there are different all-on-4 solutions. The simplest solution is also called hybrid solution. A plastic prosthesis is screwed onto the 4 implants. For additional support, the implants can be connected with a titanium bar. Teeth can either be made of plastic, of porcelain fused to metal or of full ceramic (zirconium). In addition to the longevity of this solution, a unique aesthetic result can be achieved.

The All-on-4 treatment, like any implant treatment, requires two arrivals. On the first arrival, the implants are placed and, if necessary, the provisional teeth are created. Patients who have a full denture may continue to wear it after the implant insertion during the healing period. The prosthesis only needs to be relined. The healing time is normally 3 months. The first visit usually takes 5 days, the second visit 10 working days. On the first visit, the implants are placed, impression is taken, the temporary prosthesis or bridge is fitted, finalized and checked. In the second treatment, a total of 3-4 samples are taken.

Based on a panoramic x-ray, it is likely that an All-on-4 treatment as an option can be determined but as with any implant treatment the final wisdom is always provided by the 3D image. Based on this, the treatment can be finally planned and the implant position determined.

If teeth removal is still pending, they can usually be done in one session with implantation. The implant treatment usually takes between 1-2 hours per jaw and can also be done under general anaesthesia.

After the implants have been inserted, an impression is taken directly for the temporary restoration, which will be completed at the earliest the next day by the dental laboratory.

After the healing period, treatment usually takes 10 days. During this time various fittings of the new bridge will be made. This is done at every manufacturing stage of the denture, to check everything with regard to bite, shape, colour, statics, etc. During this phase any number of adjustments can be done.

Therefore, we take a lot of time during the probes so that a perfect result can be guaranteed at the end.

Since no bone graft is necessary with the All-on-4 treatment, the complete healing of the implants usually takes place within 3 months.

The immediate loading of the implants enormously increases the risk of implant loss, which you have to be aware of, if you want to have “fix teeth in a day”. Nevertheless, this is very often offered, as it sounds indeed very tempting to immediately have fixed teeth after implantation. It should be remembered that dentistry is subject to the laws of physics. Freshly inserted implants in soft bone tissue cannot logically offer the stability, such as implants that are already firmly integrated into the bone, meaning the bone cells have grown into the pores of the implants and build together a solid unit. The human chewing power is extremely strong, in the front area it corresponds to an average of 50, in the rear area 180 pounds weight. This is the weight that can be applied to the newly inserted implant, and thus there is a possibility that the implant will move away from the original position under the pressure of this chewing force and jeopardize the success of the complete treatment.

The result can be inflammation or even implant loss. Because all-on-4 treatment involves the minimum number of implants for a fixed solution, losing one single implant means failing the entire treatment. The following can happen:

• Removal of the implant from the inflamed site,
• Waiting for a healing time or antibiotics treatment against the inflammation
• Renewed implantation including extended healing time
• Possibly necessary bone rehabilitation measures (bone graft)

One should always choose the safe variant with an implant treatment because in case the worst case happens, one loses much more time and money and have to endure much more effort and treatment.

Yes, absolutely, all-on-4 treatment is definitely the most minimally invasive method for a fixed solution on implants, as it usually does not require bone augmentation. For anxiety patients we recommend to have the first step (implantation and possibly tooth removal) under general anaesthesia.

Thorough planning must be made prior to treatment so that the bone situation can be checked and the implant positions planned. The patient should, of course, before having the treatment extensively eat food and after receiving the provisional teeth first chew carefully and only gradually increase the load on the teeth. It should be avoided to bite on hard stuff at all.

Our patients are always informed in advance and after the treatment about the procedure, risks, advantages and disadvantages and afterwards informed about the handling of the new teeth.

The treatment is always done under local anaesthesia, so the patient does not feel any pain. After the treatment, we give painkillers and antibiotics in order to alleviate any pain and prevent possible postoperative inflammation.

The biggest risk is too early loading of the implants if the bone situation is not optimal. Providing implants with the healing time needed and the patient following the clinician’s prescriptions reduces the risk of implant loss.

• Fixed teeth on only 4 implants
• Well applicable even in bad conditions in the rear area
• No bone structure necessary
• Quick solution
• Easily removable thanks to the screw-retain solution which is a great advantage in annual cleaning or repairs
• The most minimally invasive method among fixed solutions on implants
• Cost effective

• Less stable, because only 4 implants
• A compromise both functionally and aesthetically compared to the porcelain bridge on six implants, as the teeth in the standard solution are made of plastic and only 4 implants provide the stability.
• When losing a single implant, everything has to be completely redone

Yes, the All-on-4 method has been developed especially for patients who lost a lot of bone mass in the back area and cannot get any implants there. The prerequisite is that the patient still has enough bone in the front area. If a fixed solution is possible for the patient, then the all-on-4 solution is always an alternative.

We recommend the All-on-4 method for patients who no longer have teeth, but who prefer low-priced teeth, or for patients who do not have enough bone substance in the posterior region because of long-term edentulousness.

The All-on-4 method uses a special implant technique that can only be accurately performed by a few implantologists, so we recommend a very experienced surgeon who has a lot of experience with this technique. In addition, the cooperation between the surgeon and the prosthetic specialist is of particular importance, so one should visit a dental clinic where oral surgeons and dentists work hand in hand to achieve the best possible solution in the team.

Evergreen Dental is one of the few dental clinics in Budapest that has a great deal of experience with the All-on-4 concept, so be sure to contact us and get full consultation on the All-on-4 solution and any alternatives. Get in touch with us today and learn more.