All-On-4 Technique: Any US Experts?

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Anon asks:
I am planning on taking the Nobel Biocare All-on-4 course. I read that Dr. Malo has done over a thousand of these kinds of dental implant cases successfully in Portugal. However, I have not been able to talk with anybody in the US who has been doing a significant number of these kinds of cases. Have any of the readers here done any cases using the Nobel Biocare system and what are your experiences?

53 thoughts on “All-On-4 Technique: Any US Experts?

  1. I am a lab manager in Southern Kentucky who has restored well over one hundred of these cases. I would be happy to refer you to numerous dentist who have done this procedure or you can contact Advanced Implants and Periodontics In Louisville Ky they do a two day training almost every month. feel free to contact me for more names, we work with about 10 docs now doing this on a regular basis.

  2. I have placed over 170 of these in just fewer than two years. My partner ken Parrish has placed many as well. We love this procedure and have found great success. We also have a weekend course that Joe Coursey mentioned above. To start performing this technique requires some training because it is different than what you have traditionally been taught. It has been a huge boost to our practice and I know many others who have incorporated this for their patients. They have all had similar success for their patients.

    Rob Schroering DMD

  3. I took the all on four course with Dr Shroering in NY and have done 3 cases so far. I have placed close to 200 implants prior to my first case and I will say that all on four is a great way to include more patients into your implant practice. The surgery can be quite difficult if you’re not used to significant flaps in your day to day practice. At the beginning, prepare for at least 3 hours of surgery and prosthetics. Also, if you plan to perform the significant alveoloplasty that many recommend be prepared for the extra time that will take. Overall I am impressed with the technique and my patients love it! The easiest sell in the world is to someone who just had the all on four on one arch and wants it on the other arch!

    As far as componentry goes, nobel groovy works quite well but I’ve done a case with astra and it worked fine. Good luck!

  4. Nice to read about the All-on-4 on this site. Majority of the implant dentist ridicule it where i practice. I am going to Lisbon, Portugal next month to train with Malo. I can’t wait!!

  5. I have done a couple of these cases. One consideration from my prosthodontist who restored them is that the distal implants require an intermediate abutment if they are to be used with a restoration such as a milled-bar overdenture. This can be a challenge in limited inter-arch space. Just a tidbit I picked up along the way.

  6. All on 4 is a wonderful technique, but it is very difficult to perform due to access either under GA or even under local, where the posterior abutments must be fitted in a very limited space. A head light is essential, as is a pressure free clinical environment free from patient expectations of “a same day technique”. As with all implant planning, a fall back position is required: 3 stable implants and one “failed” is always a possibility, so that reality must be planned…… the taking of VD, centric, mid-line, smile line, anterior ‘setup’ must also be prepared at one or 2 postop sessions and really, to tout All on 4 as a “one day technique” is falsely
    applying an operator derivative and driven pressure… the time line and delivery does not have to be so tight.. I prefer to place the implants on say a Monday, then try-in on a Wednesday and then provisional insertion on a Friday. Some of my cardiac learning experiences are to remove the handle from the delicate thread of the angulated abutments once immediately removed from the packet for 2 reasons: firstly the handle can bend the threads for the set screw during manipulation to seat the abutment and secondly, the handle can obstruct the passage of the abutment screw, as it needs to be half unscrewed prior to the seating of the abutment screw into the fixture, thus exposing it or the protective cap to possible cross threading. I always apply some Silicone lubricant, yet it is a vexing problem if the patient swallows at that delicate moment or one’s glove twirls around the driver! All on 4 is a demanding yet wonderful technique not for the beginner and not for the less than nimble fingered! An additional problem is torquing the abutment screw to 20 Ncm: such a pressure can move the new fixture out of occlusal alignment, a fortuitous 1/4 turn can place the access hole to the more easily accessible buccal, yet if it is more than that, one is faced with either backing out the fixture 3/4 turn or tightening further… but with what? – the abutment screw to more than 20 Ncm? Sometimes a long driver of 12 inches would be grand to deflect the lip and allow more access to one’s large hand rather than the saliva coated (little) fingers, fighting the Lock Ness tongue in the shadow of a dim ceiling light? I applaud All on 4, yet it is a VERY demanding technique and best not matched with a simultaneous maxillary and mandibular syn: if one landmark is removed, two implants loose, the dentures to modify, a fall back solution delayed.. yuk.. one at a time for less stomach lining and heart muscle loss.. self inflicted due only to marketing and the patient’s expectation based upon a guilt harbored over 30 years of cognoscente neglect! One jaw at a time.. be warned that the patient’s neglect has taken 30 years and it is only the Jungian “nurse archetype” of the operator that capitulates to their “abracadabra” desire for an instantaneous solution.
    Take your time and don’t offer a quick solution because All on 4 is grand, difficult and demanding when the fall back position is demanded by the oseeo-biology. My experience with Novum was wonderful in that the failed implant could be replaced EXACTLY where the structure required: All on 4 often requires a new improved, or better position for a failed fixture, thus a new impression and new super structure AT THE PROVIDER’S COST. “Teeth in an Hour”, “Teeth in a Day” is marketing hype designed to sell product and ungenerously bite the COMPLIANT AND CONSUMER DRIVEN provider in “the bum”. We all enjoy the immediate rewards of instant dental restitution, yet who needs the stress and the hassle of a broken promise for a sudden release from infected /broken/loose /neglected/over-erupted/
    endodontically
    questionable sites? Tranquillo and experience will give All on 4 its just position as a difficult, yet wonderful technique in the hands of the gifted,hesitant and cautious practitioner. All on 4 sets the benchmark for all dentistry: why spend more than the fee for All on 4 on multiple crowns or even multiple implants when a simple acrylic renewable structure can be hung off not 12, not 8, not the reliable 6, but a simple 4 fixtures? If I had a stroke and was languishing in a terminal facility, incubating bacteria, give me All on 4, but slowly. A shorten dental arch.. Yes. A lower fee … Yes, but don’t compress the time, for I can create that dimension.

  7. This most recent post by JULIAN O’BRIEN PERTH seems right on the money. It has taken many of these patients many many many years to edentulate themselves. Proper diagnostics and careful planning results in success with most techniques. However, if the only tool you have is a hammer, everything looks likes a nail.

    It seems to me that All-on-4 is mostly marketing and probably not the solution I would do for my mother or close friend. There may be appropriate applications but trying to stick every patient into this category is foolish and I believe inappropriate.

    While the All on 4 practices are now booming, the All on 3 restorative practices are likely to be booming in about 7 years.

  8. I use the All on 4 system as one of my many different treatment options. Many people are sceptical about this system but it works brilliantly as long as has been said previously your planning is very detailed. I can only feel sorry for those dentists, or more importantly their patients, whose use a system that does not allow them to do this type of treatment, they are missing out on an invaluable treatment option.

  9. The only thing new about all-on-4 is that the distal implants are angulated to reduce the cantilever, but if there is bone below the sinus, you can place the distal implants more distal, avoid the angle and the special handling needed with angulated abutments. We started out in the 1980’s trying to do cases on a minimum number of implants but soon learned that all-on-5, 6,7 or 8 was more predictable.

  10. Dr. Niznick is correct, the idea of all on four violates every engineering principle we have every used in dentisty. Angulation of the implants has always been equated with off axis loading and has been considered less than ideal.

    I watched the doctor from Lisbon present on this and his presentations were absolutely scary. He even recommended cutting away a ton of bone to make his system work. :(

    You now have the opinion of two prosthodontists.

  11. Remember don’t let the guys saying it CAN”T be done get in the way of the ones alraedy doing it.I went to lisbon I watched a master perform his magic and now i am (trying) to do it. In the early 80’s i heard a great lecture from a british dentist Cullen on blade implants 4 heads placed in the 6-3-3-6 position, proper vertical proper centric ( not bruxers) and he showed 20 yr plus of success. Off angled loading obviously works. malo has thousands of cases with 98% success! There is less cantilevering there is cross arch stabilization and the cases are immedietly loaded. Read his reasearch the immedietrely loaded implants did better than the not loaded sleeper implants he placed just in case ;to the point that he eventually stopped placing sleeper implants. Go to the nobel web site search for all on 4 and watch the video, it’s worth just seeing him work with both hands equally.

  12. You can contact any one of the Clear Choice Dental Implant Centers around the country. Chicago, Denver, Dallas, Cleveland, Las Vegas, Austin, ……….they have been and are doing the All-On-4.

  13. Mark Adams, DDS at Clearchoice in Denver is the most experienced All On Four provider in the United States. He has been trained by Dr. Malo and does at least 3 cases a week, often more.

  14. All-on-4 will be all-on-nothing when even 1 implant fails, and then the dentist will be all-in-court when the patient sues the dentist.
    I recently met a dentist in Jerusalem with more than 25-years of experience who puts 8-12 implants in each jaw and sleeps well, because he does not bother with 1 or 2 or some implants failing.
    There is no science to back any of Nobel’s current claims including NobelActive.
    All-on-4 and Teeth-in-an-hour are gimmicks that Nobel will pay dearly for. Sad.

  15. tell me dr rumi what happens when a single tooth implant fails is it an automatic law suit? how abuout a three unit bridge when 1 or even two abutments fail is it automatic lawsuit? This Jerusalem dentist does he ever have gross failures where all implants placed fail? I bet he does .All on 4 works read the published articles by Malo. nobel are no worse then any other profit seeking implant company. Ther speedy groovy happens to be the implant i use when i do the all on 4. ,however i’ve used the principles i’ve learnt from my visit to the malo clinic in Lison with my alpha bio and mis implants. Please don’t take out your personal dislike for nobel on a beautiful technique.

  16. we do near 50 cases in iran with All-On-4 treatment concept in tehran university and all cases is success. Patients like this treatment because after surgery they have fixed implant, I suggest all dentists use this technique after spend for course in palo malo clinic.

  17. I just had the 4 on 1 procedure done. The top was on 5/14/08 and the bottom on 5/26/08. I am currently in totally disabling pain on the bottom and extreme pain on the top. It feels like the bridges are either screwed on too tight and the swelling from the bone grinding and gum cutting trauma has nowhere to go or there is some type of infection in the gums. I’ve gone to my dentist twice for follow-ups and she told me to be patient and gave me vicodin. This is the kind of pain in which 2 500mg. vic, 6 advil, and 3 extra strength excedrin will give me enough relief to be able to talk for about 3 hours tops. I had all my teeth pulled in 2005 and had two implants installed with snap-on dentures and suffered throught that for about 4-5 days on just advil and tylenol, so I can handle pain. I don’t smoke or drink alchohol and took the cortosteroids and anti-biotics exactly as directed. This is horrible, I am going in early monday morning and demanding the bottoms be removed immediately. Does anyone have any thoughts?

  18. Hi Bryan
    Give it more time
    This is big stuff you had done
    Every case and every person is a little different
    I am sure you will have an improvement for every day you wait

  19. I am 40 years old and have periodonal disease. I have found some comfort in learning about the 4 on 1 procedure. I presently have a beautiful teeth top and bottom, my smile looks great, you would never think that I would need dentures, however I have lost to-date 5 upper molars, 3 on one side and 2 on the other. My pockets are at 7 and 8, so not sure if constant hygenic dental cleaning will shrink my pockets enough so that I don’t have to go to this option. Any answers for me?????

  20. All-on-4 is for the more advanced surgeon,the ones that knock ,it may not be ready for it! Case selction is paramount,once you know how to do that,know your treatment limitations then All-on-4 will solve many a problem case.If a chair is stable on 4 legs with a certain load sitting on it,will it be any more stable with same load on 5 legs,no… So long as selection criteria is well chosen,All-on-4 is a great success,as for a failure on 1 side,as a short term fix,all-on-3, so long as original selction criteria was correct then wait a 6 month period,then replace another implant,using screw retained,take off,Implant in,bob’s your uncle…. It is normally competitive companies that knock this concept,but come on really,dentists are intelligant guys,surely you can see this is a sales tactic half the time,Knock Nobel Biocare,the one that takes the risks to evolve modern day Implantology,as for the person that says they have no research on it,if you care to look,there is plenty and more on it!!!! Dont knock what you have not tried,its normally fear that makes one do that…

  21. can an upper all on 4 be done on a bruxer that has all his lowers? my patieng ground down 75% of his maxillary anteriors his posteriors are still there;
    has all his lower anteriors yet nowhere near as badly attritioned as uppers, maybe 10% gone not even. has a history of doing coke, said it all started after that….

    any advice?

  22. Dear YK
    I did not read this blog for quite some time till I got an alert today. I read the response of a “YK” to me on 8 May and so I must respond.
    First of all i don’t know why some people want to hide their identity when they put a response. I would say such responses should NOT be posted on the blog.
    Anyway YK, I see everywhere I travel that Nobel is now definitely losing its shine and name. There is near unanimous decision within the dental fraternity that Nobel is on the wrong path and that they are taking dentists for granted.
    I will welcome any new technique that helps to alleviate suffering of patients and one that is simpler or resolves a complex problem in a simple manner.
    In case of Nobel, they have taken their own right away to introduce such products and be trusted because they have in the past introduced products that have been harmful. Nobel Direct is a case in point.
    Now about whether a single tooth replacement failure qualifies for automatic court case. My point was misunderstood by you. In All-on-4 it is very important that all the 4 implants succeed. If even 1 is not in function, then the procedure is a failure. If one implant fails, it would be difficult to get the same position of implant back to use the same prosthesis. In this case, a new implant has to be placed and a new prosthesis done. This was my point.
    I have heard good things about this technique and I am sure it works well. Can you please enlighten me how you use Alpha Bio and MIS for this technique? Do they have abutments for this?
    I would like to clarify I am not against Nobel Biocare. I am only against some of their policies that are detrimental to their own survival. The continual drop in their profits, sales and overall performance is proof enough that they should listen to good sense and good words. I do not wish Nobel destroyed. I wish them to use their resources in a positive way that will enhance them as a company and will make dentists once again respect them.

  23. Rumi- nice hearing from you again. Check out the three cases of all on 4 i posted on osseonews website under the “CASES” section.I am not as aware as you of all the Nobel issues. I use Speedy groovy for all on4 and they work nicely. Others have tried the Nobel active and told me they get better initial torque values especilly in soft maxillary bone . I haven’t tried them yet.I have had two implants fail in the past year / in one case it was the upper distal implant i removed the implant shotened the temporary prosthesis and left the patient with an allon 3 . After 4 months i replaced the implant and stretched the temporary acrylic prosthesis back to all on4.In the second case an anterior implant failed probably due to a residual infection from a tooth. Again i removed the implant and after 4 months replaced it with a new implant. pt managed on an all on 3 for the 4 months only needing repair twice of the temporary during the 4 months. two Israeli companies are making angled abutments for internal hex implants. I have not used them yet. I just returned from my second trip to Lisbon i was at the Malo clinic i highly recomend it .

  24. Dear Rumi,

    Whilst I may agree with some of your sentiments posted above, I disagree with your comments about what happens when one of the implants fail. “All-on-4″ does NOT mean “none-on-3″.

    I was sceptical about the technique too (and also believed the none-on-3 “myth”) until I spent some time with Dr Malo in Lisbon.

    This is a technique he is doing day-in, day-out. He’s an “implant factory” in all the best ways that the term might imply.

    He presented his figures and although he had lost the very occasional implant, he had never lost a case – i.e. he was always able to maintain the temporary fixed bridge and replace the failed implant WITHOUT any patient returning to a denture (and he was taking on some “Challenging” cases!!)

    I have absolutely no reason to disbelieve his figures and indeed he appeared to be completely open and honest about both his technique (the good and bad bits) and about Nobel Biocare (the good and bad bits).

    I use the all-on-4 technique and have been very impressed by it.

    Kind Regards,

    Bill Schaeffer

  25. RE: bruxism

    As a lab which has restored hundreds of All-On-4 cases, we see the best results from, and recommend the use of, hard acrylic night guards in patients who you may suspect of even light bruxism when placing the final restoration. In fact, many of our restorative doctors choose this option with every case as a preventative option, since this is most likely the first time the patient has had any major appliance in the mouth. The tendency to grind seems much higher.

  26. Dear Ruumi,

    No other system at present can offer All-on-4,again at present Nobel Biocare are the only ones that supply us with the 30 Degree Angulated Abutment and have FDA approval. As for Nobel Direct,it has its place,have you read the court decision?

    Regards

  27. I am glad to hear such positive news on this technique. Any technique that offers so many advantages must be recommended widely. I will have a close look at Yossi’s cases and perhaps also visit Dr Malo in Lisbon. I anyway am planning a holiday in Spain soon.

  28. all on four: I have done over 30 cases of all on four and i am in Charlotte, 2nd city that started with the all on four technique and with a blinded study.any more questions

  29. Can anyone tell me where I can get this procedure done that won’t cost me a fortune? I’m being told here in Canada that it will cost over $60,000 for the upper and lower. Are there dental colleges that offer this procedure for less?

  30. To: jota Feb.8 2009
    Hi ,

    where are you located in Charlotte?
    I am looking to have this procudre done!
    Please e-mail at: ady1160@yahoo.com
    I hope will hear from you soon!
    Thank you,

    Respectfully,
    Adam Farkas

  31. I realize that every case is different and therefore costs for each case will be different but can anyone tell me the approximate cost of these? I am from the Chicago area. I am just looking for a ballpark “guesstimate” to get an idea if I should pursue these or go with dentures. My upper consists of only teeth 7-11. The bottom is teeth 21-28 however, I have a full lower denture. It’s fits over these teeth as they were ground down for crowns about 6 years ago. As I had lost my insurance I could not have them done. I am back on my feet again and what to get my teeth back in order. I have been doing implant research into the various options and the all-on-4 sounds like something I might be able to afford.
    I have called several dentists but they want a couple hundred just to look at them. Any feedback is appreciated and if anyone can give me a guesstimate with the little info I have provided I would appreciate it. THANK YOU!

  32. I had this proceedure done on March 09, 2009 – I had all extractions done at the same time. I had two days that I thought I would die – or wished I would. I have the most beautiful smile in the world- no pain from the actual implant sites (top and bottom) but do have discomfort from the material around my gums – I actually hate the extra material in my mouth and cannot wait for it to be gone. I know that this was the correct way for me to go – to do this much work over 2 l/2 years would hsve been impossible for me – and if I can hardly tolerate the small amount of material around the teeth how would I hsve worn a denture (upper and lower) for over 6 months? I would rather get hit once – I lived through it and I can’t stop smiling. The only other problem I am having is slight pain/numb sensation in my nose.. Beyond that I hsve received the finest of csre and instructions from Clesr Choice in Las Vegas. They didn’t save my life but they gsve me mine bsck. Bsring any accident or? I see no downside to this proceedure. I am so very happy…

  33. I have had a number of patients where I performed all-on-4 and they have all been successful. I have however had one or two who find there to be too much material in their mouth. One especially has made me redo the prosthesis several times and still complains about the bulk and difficulty in cleaning down by gum on lower jaw.

    I was very happy using the technique before this. Any other users have the same issues and how did they address them?

  34. What is the average cost for the denture for the all-on-4 procedure to be created for a patient for the upper and lower jaw? I was told that they run between $15,000-$20,000. Is that true?

  35. JLaverne…

    The All-on-4 procedure typically costs between $19,000 and $25,000 an arch. This would include the temporary fixed denture and then the final fixed prosthesis. If you hear of a higher price, it may include a higher-end final prosthesis.

  36. Hello everyone. I am a dentist in Portugal, so as you can imagine I know some things about Dr. Paulo Malo’s work. First of all and as said in most comments, this procedure is NOT for begginers. You must be used to large flaps and more complicated bone management procedures. Second it must be said that making an edentulous jaw can be far different from a jaw in wich say the patient still has 6 or 7 teeth. Is these cases, specially in the maxilla, achieving enough primary stability even with modified preparation techiques can be a challenge. In these cases conical or paralell with conical end implants is mandatory. About the tilted implant issue wich is a long discussion, the current literature is showing fine performance of these implants. Furthermore, as you know the gold standard for years in the mandible was 6 implants. Prof. Rudolf Slavicek work on the deflection rate of the mandible shows that the full arch splinting of 6 implants is wrong as it produces lateral forces to the most posterior implant during clenching. To this regard the All-on-Four techique solves this issue, as no implant is placed behind the deflection area of the mandible (around the second premolar). One issue posted by some colleages in other forums can be a problem to the mandible though: when you place an implant you have the piezoelectric effect, wich prevents bone resorption (theoretically of course). In the All-onFour tecnique if you are not placing an implant behind the first/second premolar you will keep on having further bone resorption to the posterior mandible. This, combined with the forces used by the mastigatory organ during its function can, many years later cause mandible green stick fractures. This is still not clear because we have had all-on-four cases for about 10 or 15 years. Let’s see what happens with the 30 year follow ups. My personal experience is very good and although it has some limitation and marketing around it this procedure is safe, problem solving and good for your well planned, careful selected case rotine.

    Best regards to all

  37. I have been doing all on 4 proceedures for about 2 years now and have done about 50 arches so far. The patient response has been very good. The cases however are next to impossible without CT scans to determine bone quality and availability for Maximum implant length. I have used three different systems for these cases all with good success and distinct advantages with each system. Implant Direct Tri-Lobes with Multi Unit angle correcting abutments on the distals. Nobel Active 4.3’s, and Straumann Bone Level Implants 4.1 SLA.

    I like the Implant Direct for ease of ordering and price. I like the Nobel Active for when bone quantity and density is a concern. And I like the Straumann Bone Levels in diabetics or other compromised patients. I also particularly like the Straumann Angled Multi Unit abutments which are taller than the other two systems and are easier to manage when it comes time to retrofit the immediate denture.

    We also platform the bone in all cases and make the implant / alveolar crest interface flat and level around all implants even when we use surgical guides to improve the adaptation of the soft tissue and the seal of the coronal implant threads around the bone. We do this on edentulous cases also so don’t be fooled into thinking that you dont have to flap these type cases…..

    Very well tolerated and a great service to patients who often times are thrilled with the results.

  38. Hello. I am a patient that has just had all my maxillary teeth (I only had 6 left so three had to be surgically removed)which were removed 9 months ago. I am planning on having a “all on 4 implants” in my maxillary bone structure. My CAT scan looks good for this procedure. Two vertical and two at 20 degree angles, thus avoiding a sinus lift/bone graft. The Dr doing the implants is top notch, intelligent, exacting and extremely detail oriented. He is having a company that makes a mold for this procedure that will somehow help guide his drill (apparently a new procedure). Anyway, he has done many, many, implants and has a great reputation. However, (and this is my major concern)this will be his first “all on 4″. Given his rep and how much studying he is doing for this operation, it makes me feel confident that he is going to do his very best at being successful in this surgery. Given all of that information, should I be concerned? Thank you in advance for any thoughts people have and anything that will help me feel more confident.

  39. Eric – In my opinion the fact that he is doing the computer scan stent for guidance is a tip-off that he will do a great job. I use these stents even for difficult mini dental implant placements designed for permanent cemented bridges, and they result in a very precise placement in the very best available bone. Your dentist can do a “virtual” placement via a computer hook-up with the lab so he has the last word on where he wants the implants, and the angle’s can be very precise. I hope all goes well for you and your dentist.

  40. all on 4 is not an easy procedure . how did this dentist learn the procedure? ideally if its his first case he shoulkd be mentored or coached by someone with good experience.

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