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Ask UsAll-On-4 Technique: Any US Experts?
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Monday, February 25th, 2008 | in
Nobel Biocare, en, All On 4
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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?
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18 Responses to “ All-On-4 Technique: Any US Experts? ”
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.
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
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!
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!!
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.
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.
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.
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.
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.
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.
Have you read the research and been trained in the all-on-4?
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.
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.
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.
Does anyone have a link to the literature on the all on 4 technique??
go to nobel web site go to search bar enter all on 4 and watch the live surgery done by malo. you can contact me at yosrebco@netvision.net.il i have two cases next week. have a good weekend.
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.
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.
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