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Ask UsAll On 4 Technique
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Peter, a dentist from the Netharlands, asks:
I trying to form my opinion on the ‘All On Four’ concept by Nobel Biocare. However, it is very difficult to find good data on the subject.
Everything looks fantastic, but my gut feeling tells me otherwise. I know gut feeling isn’t very scientific, so I’d appreciate some feedback from other dentists worldwide.
Some dentists have told me that the All-on-Four on the mandible avoids bone grafting of the posterior
mandible in many cases. Is this accurate?
In addition, can anyone please walk me thru exactly tell me how this works? Are impressions taken for
dentures (to address the out of line bite and sagging facial muscles),
with these then being incorporated into a bridge ready for fitting? I’m
finding it difficult to accept that aesthetics may well be lost for
stability. Can both be achieved? Thanks for any comments.
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38 Responses to “ All On 4 Technique ”
In my view it is biomechanically not very sound. Adding a fifth implant in the midline (which Nobel pioneered so why are they changing their tune) and making a hybrid prosthesis you have the most successful restoration we have for treating the edentulous mandible. It is a gimmick to lower the cost of the treatment by the cost of one implant. Why mess with a good thing?
Five implants on the mandible of which all implants are loaded vertically and the posterior implants share the load and cantilever makes more sense than putting a shear load on two angled posterior implants.
I will dance with the girl who brought me
Obviously the comments made here are not from Dr who have done this proceedure as for my self I have done 833 cases of all on 4. I did not attempt this until I went to portugol to review the technique with Palo Malo. He has done mor than 15,000 cases to date in his clinics and has less fail rate than I had doing traditional techniques. During the 800 cases I have done I have suffered a loss of 2 implants and this was on a patient who was a bruxer. I do hedge my bets. I choose patients wisely for immediate load which 99% of the all on 4 cases I do are.
That being said I appriciate the oppotunity to answer the question presented. As with all implant cases a good VDO occlusal scheme analysis, proper wax try-ins, ct scan to tell if the bone is of adequate volume and quality for the proceedure. If there is 5mm of width, 10mm height, the upper teeth don’t come forward of the ridge more than 5mm or greater than 45degres the case can be done with procera a guided proceedure though I don’t recomend the preplaned bridge for this type of case because of the nonenganging abutments, which rotate and give prosthetic night mares. If the case is lacking in any of those areas then an all on four guide should be used and because the distal implant is angled it can avoid the mental nerve or the maxillary sinus. If you wish you can usee an all on 5 technique if you feel the patient is a bruxer or is opposing other implants. As we all know no one methode is universally OK, but this technique saves quite a bit of grafting and shortens the wait to final prosthesis due to the minimal grafting that is necessary. donn’t discard this technique without looking more into it. This technique was not invented by nobel biocare: rather it was invented by Palo Malo
Sorry Randall, this technique was never invented by Paulo Malo. He told you he did 15.000 cases? Lets do some maths : 365 days per year, you will need 50 years to complete 15.000 cases doing one every day. Also notice that this guy is almost 50 % of the time out of his office lecturing for Nobelbiocare around the world. Then you will need 100 years to complete 15.000 cases.
This technique was developed by Branemark and cols (Ericsson and others) long time ago. The only thing that Malo did is advertising the technique as his intelectual property wich is a big lie.
But ansewering the question the technique works well for Hibrid prosthesis wich means no esthetic requirements and a certain amount of bone atrophy. In my hands it works better in the maxilla than in the mandible in wich I prefer 5 interforaminal implants. If there is enough bone behind the mental foramen I will add an extra short implant in the first molar area only in one side.With this treatment planing we obtain 99.6% of clinical success even with immediate loading.
The technique (treatment plan) works better in the maxilla than in the mandible. To obtain nice esthetics everything must be under the lip line (low smile line, no problem in the mandible). Final prosthesis will be a hibrid prosth. or procera implant bridge with ceramics.
Please take a look at youtube under bionic teeth, all these hybrid prosthesis are not very natural. Why can’t we have teeth!!
The Straumann approval from the FDA for all on four predates Nobel. K984104 is the approval for Straumann dated Mar. 13 1999 from the FDA. Nobel appears to have their approval under K022562 dated 10-11-2002. Nobel had another approval K992937 from the FDA which was likely approved in 2000-2001 but I could not find it on the FDA website as anything other than a reference number. Who blazed the trail again?
Maybe you should refer this case out and ask to walk through all the steps with the Doctor or Doctors, who you are comfortable working with, while they plan and complete the treatment. This will give you first hand experience which beats the heck out of great marketing. Although great marketing appears to bestow the title of pioneer, deserved or otherwise.
Nobel Biocare offers a course on the all-on-4 concept. Has anybody taken the course?
I use All-on-4 concept in the maxilla only as a temporary solution with a hybrid (reinforced acrilic) bridge and add 2 more implants after 6 months in the grafted sinus site. In the mandible it could work depending on the implant size, oposing dentition and chewing forces.
Why not doing a simple computer simulation of the bridge/implant ONLY. (Forget the bone at this time!)
If the calculation shows that it is doomed under fail under load, who will want to put that at work in real patients?….
To the mandible:I use the All-on-4 concept since 2002. Let’s start to saying that the All-on-4 concept is a surgical and prosthetic solution. In the surgical field we avoid bone graft or nerve transposition. In the Prosthetic field we can deliver a provisional fixed prosthesis with 10 teeth and with no cantilever (in the day of the surgery) and a final prosthesis with only 1 molar each side of cantilever. I have had a classical European formation and this “revolution” was very hard for me to digest. But, after I rethink some of the myths and brake away with some concepts and fundamentally see the results in Clinica Maló, I engaged this method and my practice suffered a total change.
If we make a comparative analysis, this technique is a vigorous rupture with the classical concepts. Let’s look at the different clinical situations. In the mandible we have benefits and risks; by the risks we surely have the “one shoot opportunity” after measure the loop with a probe and making the anterior mark tilting back the 2mm drill at the maximum of 45º in relation of the All-on-4 Guide (Maló Guide)-normally corresponding to the third mark of the guide, 21mm of the midline. This procedure is in order to not to damage the inferior alveolar dental nerve in the most anterior loop position. By Tilting back this implant we achieve normally the second premolar, making the provisional prosthesis with 10 teeth and no cantilevers. This implant is placed in three-dimensional aspects: from posterior to anterior and from vestibular to lingual. This final consideration of the implant is very important: if we place in very straight way from posterior to anterior it will appear with the apex on the vestibular cortical (not very dangerous but can compromise the surgery) if we place a very lingual way from vestibular to anterior-lingual way we may perforate the lingual cortical and damage the submenthal arteria (very dangerous with a blind bleeding trough the mouth floor to the respiratory ways, leaving the patient with a strong probability to suffocate).
I alert not to change the protocol and to see every movies of this technique.
Please read more of this technique in Implant Dentistry and related research and in other magazines.
For the next post I well write about All-on-4 in the Maxilla (what a breakthrough!)
Miguel Guimarães
Porto
PORTUGAL
How do you correct for the angled position of the implants? Are you using stock angled abutments? Are you using screw retention for the provisional or final bridge?
We use Anguleted MultiUnit abutments from Nobel Biocare in order to correct the angled position of the implants.
We use screw retention for both the provionel and final bridge.
just how necessary is it to use the all-on-4 guide during this surgery? what surgical errors does it help prevent?
Angulated abutments:
For the posterior abutments is essential to use a 30º angulated abutment with a final 15N/Cm torque. To the anterior ones is recommended to use a 0º with 1mm, 2mm, 3mm, or higher with a 20 N/Cm torque. You can use Nobel Biocare Abutments or Conexâo or Neodent abutments if you replace the screw by an torquetite screw (self experienced and much better market). The advantages of the Maló Guide are a better control angulations of the tilted back implants, a truly aid to the position of the angulated abutment (just look at the guide) and a security barrier between the tongue and the drills. The guide should only be used to perforate to posterior implants and to mark the anterior ones. After marking the anterior implants with a round drill (first mark, 7mmm from the midline), its better to remove the guide and replace by a guide pin. The most important step is a correct position of the guide in the mideline. After a accurate placement of this 2mm diameter pin, the surgery may have a good beginning.
Miguel Guimarães
Porto
PORTUGAL
Regarding the debate that the technique is not Malo’s. Well, he is one of the very few “Nobelians” that have actually succeeded in publishing their results (see Clin Impl Dent Rel Res 2003; 5(Suppl 1): 37-46; Clin Impl Dent Rel Res 2000; 3: 138-46; Clin Impl Dent Rel Res 2005; 7(Suppl 1): S88-S94 - I have the full text articles if you are interested). It was him who first advocated and described the immediate function “for patients where an immediate prosthesis placement was important to the patient”. So, he must be given credit for that.
I think we can expect longer observation times from his team - and that will give us a real information on how successful the “All-on-4″ really is.
Publishing results? Why would anyone need to do that, just release the product and throw out some marketing and voila you too can be the market leader in implant dentistry!
If ITI Straumann had FDA approval for all on 4 in 1999, meaning they had research which demonstrated to the FDA that this was a viable procedure, then a Nobel approval that followed with research done by by whoever does not make Nobel or that researcher a pioneer of this technique. Good quality research that is published in peer reviewed journals and not newsletters for implantologists should be commended even if it is not the first study to be published on a topic. The fact that ITI may not have had the podium power in 1999 or 2000 to appear as the first to discuss this technique does not change the date of FDA approvals. Nor does Dr. Malo being the first “Nobelian” to publish and promote this technique change the reality that ITI was first with this approval although I can not name who did the research for ITI.
The marketing language taking by Nobel is the real issue, Not the researchers or speakers who promote applications for implants that they practice everyday. Published articles for NobelDirect turned out to be non-peer reviewed journals described as Newsletters in Europe for Dental Implantologists. The issue is the message - this is not Nobels technique. While Dr. Malo’s technique using Nobel implants most certainly is his technique.
I completely agree with you. What I have read and seen in the articles written by Malo and his co-workers is only information I have on his technique. His articles are published in peer-reviewed journals (otherwise I would not cite them), so there is no discussion about his NobelBiocare/Branemark-all-on-4 technique.
What I really think we need is some independent research, not some mercenaries or fake journals.
Still, the best experience is practice.
What do all of you think about CAD/CAM ceramic bridge over (troubled water)all-on-four > http://www.cmceramics.com/bridge.htm
Remember, NB is to sell implants and that is all–Watch out. Know the biological principles and stick to them.
The only way to beat commerce in dentistry in NOT beeing heroic about our achievments BUT share our failures. On fora like this as clinicians and in long term studies as scientists.
Peter,
You could ask Han van Dijk in Amersfoort. He is an experience Nobel Biocare user and I know he did some all-on four concept treatments and have promoted it for Nobel Biocare in the Netherlands.
T. horneman
I was wondering if anyone has torqued implants in beyond the recommended 35Ncm? Is there any data out there to show failure/success rates with implants placed at higher torques. I have seen some dentists torquing them in at 50Ncm, while others stop at 35Ncm. The ones who torque them in at higher Ncm state that they are trying to achieve primary stability which sometimes is attained at 40 to 50Ncm. Any comments? Palo Malo I know goes way beyond 35Ncm very frequently when doing All on 4.
is it true that nobel faces a lawsuit & some kind of ban for having copied some pre-existing company software for planning dental implants
I just came back from the malo clinic in portrugal. The mini surgery residency was very intersting. They have the all on 4 technique mastered. Implants are placed at 50 to 70 ncm torque. same day loaeded prosthesis are placed. don’t let the guy telling you it can’t be done get in the way of the guy already doing it.
To Y Kowalsky:
to insert at 50-70 Ncm they must underprepare the site; to what extent? if they place a 4 mm diameter what is the last bur they use?
Also can u forward me a contact to check out the malo clinic residencies please. Their website seems not to be working properly.
Yes they do under prepare if the bone is soft. the first drill is 2.o it goes to length. then depending on bone type they procede. I saw him place a 4mm implant after only using the 2 drill. many times he would go to length with 2 then use 2.4 and then 3.4 only a few mm in the cortical bone.If implant could not go down he recomends removing implant redrilling a litlle more and then trying to place again. But yes underprepare especially in soft bone so that initial torque is high.He only uses the NB speedy groovy implant, apical taper but aggresive threads with external hex.
As far as malo clinic they have changed website adrres try through your nobel biocare rep if not successful try professionals-clinicamalo.com
How do you treat a fixture loss in the All-on-4 system after the prosthesis has been placed? We all get non-integrations in our practices, but a case of non-integration with All-on-4 seems to be somewhat of a catastrophe? Could those with all the All-on-4 experienc please comment.
The only one who sees no failures is the one who isn’t doing it.If the failure is one of the distal implants the temporary acrylic prosthesis is shortened to an all on3 untill a 4th implant can be replaced. Its the same if only 3 could be placed due to a severly infected site initially. If the failure is one of the anterior implants then the implant is removed and the prsthesis sits on 3 or if bone and space is available the implant is replaced and the abutment position changed and your back to all on 4. By the way there is a free movie download of the whole surgery by malo on the nobel biocare web site just search for it.
How can I contact the Malo Clinic for treatment.
Has anyone performed the All on four after immediate full extractions in the maxilla? How safe is this to actually do immediately, with severe periodontal disease?
What is the most one could pay in the U.S. for ALl ON 4 procedure? I just mean, I know I want this procedure done. I need to know how much to save before I even consult.Because I don’t want to finance this, I’m skipping the initial consult until I have atleast 75% of the average cost for the procedure. I don’t want to tempt myself on financing it. So can someone give me the average price so no what to expect in my future?
Back to the late 80s, when I began to place implants, we were always told that there are two very strict rules in implant dentistry; avoid any off-axis force in surgical planning and avoid any cantilevers in prosthetic planning(of course, both of them as much as possible).I am not very well familiar with the philosophy and concept of ALL ON 4 technique, but I guess both of those rules have been totally overlooked.Will somebody please help me out of this nasty paradoxical puzzle and let me know how wrong I have ever been? Thank you.
Ken,
You can plan on spending 22,000 - 25,000 for one arch.
I think it would be interesting to superimpose 20 random panorex films of maxillary and mandibular hybrid cases from the 1980’s & these Nobel gimmicks. In a bllind study, I bet that even theses self-promoting nobel gurus (certainly not classically trained surgeons) could not differentiate which case is which.
Everything we learned about biomechanics, in terms of bone augmentation to facilitate implant placement intended to facilitate vertical, rather than horizontal or oblique forces is appparently no longer pertinent. As long as we can slam fixtures into bone, there is no need to considered the importance of an intact buccal plate, healthy keratinize mucosa, ORAL HYGIENE, or directional forces best suited for the componentry or surrounding bone.
I stayed away from this website for a while because the lack of telling who was providing opinions was making a bottomless pit of misinformation and good information. Anyone approached by a Nobel, Zimmer, Bicon, Dentsply, etc rep, and told that a 2-. 3-, or 4-day miniresidency can be a competent surgeon is blinded by money. Ethical clinicians want what is best for their patients and make plenty of money working in the team concept, using well-researched implant materials, techniques, and treatment plans.
It is shameful that we have come to the point that doctors who sacrificed to complete lengthy, challenging residencies are now forced to compete with these “mini-residencies” for the opportunity to provide patient care. The public is blinded by flashy advertisements in airline magazines, glossy city rags, radio and television marketing. If the dental field is not careful, we will quickly follow the medical profession, where there is an outcry for oversight. this means malpractice lawyers, insurance companies and public oversight boards. The whole profession will lose the autonomy we have enjoyed.
I would hate to have implant therapy become the next erectile dysfunction drug adverstised on television with toothless people in outdoor bathtubs. I don’t think the companies would mind so much. They have no craving for integrity, only profits.
I don’t know if you guys answer this sort of question. But here goes. I am seriously considering implants, quite possibly the all on 4 method.I practice martial arts on a regular basis. If I take a hard punch or kick to the jaw, while wearing a proper boxer’s teeth protector, should the implants withstand the force?
On 28th January, almost a month ago, I submitted a query, but have not yet seen a reply. I am seriously considering getting dental implants, perhaps “All on 4″. But I practice martial arts seriously. If I wear a proper boxer’s teeth protector, and if I receive a punch or kick to the mouth, will implants stand any more chance of being broken than natural teeth? I hope someone who can advise me will see this and respond.
There is never really an indication for a fixed four implant prosthesis. A conventional 5-8 implant fixed prosthesis is a much better clinical decision. Teeth in an hour is marketing hype, as faculty at a major university dental implant center in Southern California, we have done many four implant teeth in a hour cases and many of the prosthesis have come back and the do not fit to be clinically acceptable. If you lose one implant the whole case can be lost. Be wise in choosing the technique and the Doctors performing the surgery and the prosthetics.
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