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Original. Proven. Life changing: The All-on-4® treatment concept

by: Michael Stuart

Rehabilitate an entire jaw with just four well-placed implants.

A revolution when it was first introduced, the multiple benefits of the All-on-4® treatment concept are now well proven.1-6 The concept was developed to efficiently provide edentulous patients and those with a failing dentition with an immediately loaded, fixed full-arch prosthesis.* Today, Nobel Biocare continues to develop the concept, with innovations designed to further enhance treatment results.

All-on-4 treatment concept

There are now more implant options for the All-on-4® treatment concept than ever before, including NobelParallel Conical Connection (pictured), NobelActive and an extended range of NobelSpeedy implants.

The All-on-4® treatment concept makes the rehabilitation of fully edentulous mandibular or maxillary arches possible using just four implants. By tilting the two posterior implants, anatomical structures such as nerves and the sinus are avoided and the need for bone augmentation is reduced. Tilting the posterior implants also moves the implant abutment connection to the back of the mouth. Cantilevers are therefore reduced, improving support for the prosthesis.7,8

It’s an approach that is less invasive and cost-­intensive for the patient than bone grafting, more efficient for the clinician and—most importantly—is clinically validated to work.1-6

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Introduced more than 20 years ago, the All-­on-­4® treatment concept offers a reliable solution for patients looking to escape the discomfort that so often comes from wearing a removable denture, or those with a failing dentition who do not want to spend even a day without teeth. Long-­term success has been shown in both the edentulous maxilla and mandible. More than 30 clinical trials provide evidence of cumulative survival rates of 94.8–98.0%.9,10

These results go hand-­in-­hand with patient satisfaction. In one study, 95% of 250 patients said that they were satisfied with their new teeth, while 88% said they would definitely recommend similar treatment to friends and colleagues.11

Patients

The All-on-4® treatment concept is the original, proven and cost-efficient graftless solution that provides patients with a fixed full-arch prosthesis on the day of surgery.

Immediate Function

Today, Nobel Biocare offers more implant options than ever before for the All-­on-­4® treatment concept, helping clinicians choose the right implant for each case.

When Nobel Biocare implants are used, a unique combination of implant design, surgical protocol and the proven TiUnite surface help to ensure primary stability and maintain it during the healing phase.

This stability means that Nobel Biocare implants make it possible for a fixed provisional restoration to be loaded on the day of surgery—a key benefit of the All­-on-­4® treatment concept and an important consideration when trying to meet patient demands.

For increased flexibility

NobelSpeedy, the original and widely documented implant for the All-­on-­4® treatment concept, is now available in more lengths and diameters for increased surgical flexibility.

Shorter, longer and wider versions have been added to an expanded NobelSpeedy range designed to further help clinicians utilize a graftless approach and achieve cortical or bicortical anchorage where bone quality and quantity are limited, thus allowing more patients to benefit from the proven advantages of the All­-on-­4® treatment concept.12,13

NobelActive and NobelParallel Conical Connection are other well­-established implant systems that have proven effective for the All­-on-­4® treatment concept.14

NobelGuide

Precision during implant placement for the All-on-4® treatment concept can be maximized with 3D digital diagnostics and guided surgery. Using the NobelClinician software, clinicians can make the most of digital treatment information and conduct prosthetic-driven implant planning for their All-on-4® treatment concept patients.

Precision during implant placement for the All­-on-­4® treatment concept can be maximized with 3D digital diagnostics and guided surgery. Using the NobelClinician software, clinicians can make the most of the digital treatment information they have acquired and conduct prosthetic-­driven implant planning for their All-­on-­4® treatment concept patients.

NobelClinician also facilitates collaboration between members of the treatment team and allows easy ordering of all surgical components required for the planned treatment.

Once finalized in NobelClinician, the plan can be predictably transferred to clinical reality using the NobelGuide guided surgery concept, which provides the clinician with ready-­to-­use patient­-specific surgical templates and instruments tailored for the surgery.

In cases where maxillary bone is severely resorbed, zygomatic implant placement may nevertheless allow graftless restoration of the full arch on four implants.

Building further on 25 years of success with Nobel Biocare’s zygomatic implants, the new NobelZygoma implants provide greater surgical and prosthetic flexibility than previous options, while a new tapered apex is designed to support high primary stability for Immediate Function.

Create an accurate prosthesis in a snap

At the restorative stage of the All-on-4® treatment concept procedure, clinicians using conical connection implants can now take advantage of the new Multi­-unit Abutment Plus**— an enhancement of the successful Nobel Biocare Multi­-unit Abutment. It is designed to significantly reduce the chair time required to perform provisionalization processes such as a denture conversion—a procedure commonly used for the All­-on-­4® treatment concept.

Multi-unit Abutment Plus

The new snap-fit function of the Multi-unit Abutment Plus can save valuable time during the conversion of a denture into a fixed provisional restoration—a common procedure in the All-on-4® treatment concept.

By introducing a snap-­fit function between the temporary cylinders and the abutment, screws are no longer required during the try-­in process. This means the common practice of removing the temporary cylinders and the denture several times during the conversion process can be done in a few snaps, with no need to tighten and loosen four screws each time.

This new way to work provides a significant time­-saving opportunity for the clinician. It can also dramatically increase patient comfort and eliminates worry about the screws potentially dropping out.

When it comes to the final restoration, NobelProcera offers a wide variety of precision-­milled fixed and fixed-­removable restorations for All­-on­-4® treatment concept patients.

Patients looking for maximum esthetics can opt for individualized crowns on a zirconia implant bridge, while those requiring a cost­-effective restoration can select a removable overdenture in acrylic on an implant bar. Regardless of the option they choose, NobelProcera offers easy handling for the clinician and excellent esthetics and function for the patient.15,16

Restoring more than a smile

The All­-on-­4® treatment concept puts dental professionals at the forefront of their profession. In fact, 24% of those that attended a Nobel Biocare All-­on-­4® treatment concept course grew the number of implants they placed by 50% the following year.17

Such success is largely thanks to the popularity of the All­-on­-4® treatment concept among patients.11 Reduced cost, less trauma, Immediate Function and excellent esthetic results are all clear patient benefits, as is the prospect of a solution that feels like natural teeth.

Greater chewing ability, improved speech, increased comfort, less bone resorption—the list of attributes that can help drive patient acceptance goes on and on. Above all, in combination these benefits lead to a potentially life­-changing result: the return of a patient’s self-­confidence.

Prof. Paulo Malo

A few well­-chosen words from the pioneer, Professor Paulo Malo, who successfully treated the first patient with the All-on-4® treatment concept in 1998:

“The use of four implants reduces treatment complexity, which yields many benefits. Costs for both the doctor and the patient are reduced because less surgical time and fewer products are used.

The lab technician can profit from reduced intricacy in the fabrication of the prosthesis—leading directly to more predictable workflow patterns. And simplified hygiene bodes well for improved long­-term oral health.” 

References

1 Patzelt SB, Bahat O, Reynolds MA, Strub JR (2014) The all-on-four treatment concept: a systematic review. Clin Implant Dent Relat Res 16(6):836-55.

2 Lopes A, Maló P, de Araújo Nobre M, Sanchez-Fernández  E(2015) The NobelGuide® All-on-4® Treatment Concept for Rehabilitation of Edentulous Jaws: A Prospective Report on Medium- and Long-Term Outcomes. Clin Implant Dent Relat Res. doi: 10.1111/cid.12260.

3 Maló P, de Araújo Nobre M, Lopes A, Ferro A, Gravito I (2016) All-on-4® Treatment Concept for the Rehabilitation of the Completely Edentulous Mandible: A 7-Year Clinical and 5-Year Radiographic Retrospective Case Series with Risk Assessment for Implant Failure and Marginal Bone Level. Clin Implant Dent Relat Res. doi: 10.1111/cid.12282.

4 Mozzati M, Arata V, Gallesio G, Mussano F, Carossa S. Immediate postextractive dental implant placement with immediate loading on four implants for mandibular full-arch rehabilitation: a retrospective analysis. Clin Implant Dent Relat Res 2013;15:332-40.

5 Weinstein R, Agliardi E, Fabbro MD, Romeo D, Francetti L. Immediate rehabilitation of the extremely atrophic mandible with fixed full-prosthesis supported by four implants. Clin Implant Dent Relat Res 2012;14:434-41.

6 Maló P, de Araújo Nobre M, Lopes A, Ferro A, Gravito I (2016) Complete Edentulous Rehabilitation Using an Immediate Function Protocol and an Implant Design Featuring a Straight Body, Anodically Oxidized Surface, and Narrow Tip with Engaging Threads Extending to the Apex of the Implant: A 5-year Retrospective Clinical Study. Int J Oral Maxillofac Implants 31 (1) 153-61.

7 Malo P, de Araujo Nobre M, Lopes A. The use of computer-guided flapless implant surgery and four implants placed in immediate function to support a fixed denture: preliminary results after a mean follow-up period of thirteen months. J Prosthet Dent. 2007 Jun; 97(6 Suppl): S26-34. Erratum in: J Prosthet Dent. 2008 Mar; 99(3): 167.

8 Aparicio, C., Perales, P. & Rangert, B. (2001) Tilted implants as an alternative to maxillary sinus grafting: a clinical, radiologic, and periotest study. Clinical Implant Dentistry & Related Research 3: 39–49.

9 Maló P, de Araújo Nobre M, Lopes A, Francischone C, Rigolizzo M. "All-on-4" immediate-function concept for completely edentulous maxillae: a clinical report  on the medium (3 years) and long-term (5 years) outcomes. Clin Implant Dent Relat Res. 2012 May;14 Suppl 1:e139-50. doi: 10.1111/j.1708-8208.2011.00395.x. Epub 2011 Oct 18. PubMed PMID: 22008153.

10 Malo P, de Araújo Nobre M, Lopes A, Moss SM, Molina GJ. A longitudinal study of the survival of All-on-4 implants in the mandible with up to 10 years of follow-up. J Am Dent Assoc. 2011 Mar;142(3):310-20. PubMed PMID: 21357865

11 Babbush CA, Posttreatment quantification of patient experiences with full-arch implant treatment using a modification of the OHIP-14 questionnaire. J Oral Implantol 2012; 38:251-60.

12 Malo P, de Araujo Nobre MA, Lopes AV, Rodrigues R. Immediate loading short implants inserted on low bone quantity for the rehabilitation of the edentulous maxilla using an All-on-4 design. J Oral Rehabil epub ahead 2015.

13 Vicent et al. (2016), Clinical outcome of extra-long tilted for the rehabilitation of complete edentulous atrophic maxilla using the all-on-four concept. Implant Therapy Outcomes, Surgical Aspects. Clin. Oral Impl. Res., 27: 269. doi:10.1111/clr.267_12958.

14 Babbush CA, Kanawati A, Brokloff J. A new approach to the All-on-Four treatment concept using narrow platform NobelActive implants.J. Oral Implantol 2013; 39(3):314-25.

15 Katsoulis J, Mericske-Stern R, Rotkina L, Zbären C, Enkling N, Blatz MB. Precision of fit of implant-supported screw-retained 10-unit computer-aided-designed and computer-aided-manufactured frameworks made from zirconium dioxide and titanium: an in vitro study. Clin Oral Implants Res. 2014 Feb;25(2):165-74.

16 Katsoulis J, Mericske-Stern R, Yates DM, Izutani N, Enkling N, Blatz MB. In vitro precision of fit of computer-aided design and computer-aided manufacturing titanium and zirconium dioxide bars. Dent Mater. 2013 Sep;29(9):945-53.

17 Data on file: Comparing annual increase in customer net sales (2013-2014).