All on 4 Protocol

I think that this is used in conjunction with the NobelGuide surgical protocol, which, I have heard ends up being very expensive for the patient as well as more invasive in some ways since you have to drill in order to stabilize the guide itself. Has anyone had experience with NobelGuide and/or All on 4? I, too, am curious!

I have, the thing nearly failed. I dont trust maxilla and over exposing bone, you can do alot of damage and perf sinus or vital anatomical structure. I rather do sinus augmentation place 6 implants do bar or fixed.

Four implants to end up in acrylic restorations does not seem to be logic.Also what is the need to change a 20 year-Acrylic Denture vs an immediate four-implant-supported acrylic Denture>? Because it is fixed? or because the patient is rich? Legally we can not induce patients to risk, and today we are risking too much....

I've fabricated close to ten all-on-four restorations, and just finished my first nobelguide. The all-on-fours were very well received by restorative dentists as well as patients. The cases were restored with denture teeth processed to substructures. As for the Nobelguide, I just witnessed (earlier this evening) a 70 year old patient receive 6 NobelReplace implants and a full max screw retained restoration in just under 2 hours. Same type of acrylic restoration as all-on-four. I was amazed at the results, and the patent was overjoyed to have this done in a quick and non-invasive procedure. I've been a lab tech for close to 30 years and I'm impressed with these new procedures.

Yes, all-on-four it's possible, but you should be aware of patient function, i.e. be sure she/he wasn't a clencher or a bruxer one. Then, you should check for bone quality, and be sure of implant primary stabilization and not to have put excessive torque (bone necrosis after a while on it. Then, you should be very comfortable about arranging teeth in a perfect position, avoiding any interference to ICP. In the maxilla, a bar-and-clip retained overdenture may be a safer way to solve the problem of your patient. In the mandible, provided that all the above requirements are satisfied, anything will work.

If you only want to earn money easy do it, it is possible. But if you want good results, whith retained esthetics and with durable prosthesis do it the right way. teech your pacients that its better to wait for the ealing of the gum and bone for better results and put more implants, spend more money in your pacients. The all on, we know that is possible like it is possible to be at 350 km/h in the new ferrary models but we don't do it. Do it the wright way for your pacients like they were your mom. sorry this is my opinion

Nobel Biocare recomends the multi-unit abutments with the 17 or 30 degree abutment to correct for the posterior implants being inclined off the vertical. Has anybody restored these cases with another technique?

Zigoma Implants? One of the recent consideration of Dental Praxis Certification was to pre-determine the possible risk any treatment could have....if you are placing Zigoma Implants what would you do in case of implant- or abutment(screw) fracture?How you retrieve the segment close to the sinus lift, what would be plan B for this instance? Do patients know about this possible complication?, Are they well informed about this?Which is the rationalle of the tretament when you compare the technique with sinus lift elevation procedures?

Zygoma implants are a good alternative to massive bone grafting, we use them whe their is only a possibility to place implants in the premaxilla ( very short implants) and practically no bone at the sinus level. weve done more than 70 cases, and the last 15 immediatley or early loaded, 100% percent zygoma and conventional implant survival. I´ve have yet to see any serious publication showing a zygoma implant failure,this is more than I can say about bone grafting. All this will be published in JOMI,CID&RR.

I have completed 4 arches on two patients. Both patients are doing well although the follow-up has been only 4 months. It is not necessary to use the NobelGuide for this proceedure. The technique is sound and as advertised, is not for the inexperienced surgeon.

It might not be recommended for an inexperienced surgeon but doesn't it seem like that's exactly who would want to use something like the NobelGuide or All-on-4? I agree with Cardoso - would I really want this used on my mother? on myself? No, I would want my surgeon to be absolutely confident that the procedure that they are performing will not fail in 5 years - I would want the surgeon to be confident that they are placing the best products available - documented and tested in a variety of clinical situations.

I would not even think of such approach, I dont even feel confortable with 6 implants, patiets develop parafunctional habits at some point in their lives and the dispersion of forces will play an issue on the longevity of the restorations. You would need to re think the issue of how long do you want your work to last.

I think that you are disscusing about you never see in practice! All on four is functioning for more than 25 years under the name of Nordic bridge , they have excellent results so the thing is functioning! Perforation of sinus?? i don"t see the problem it is important not to break membrane an working in aseptic condition! try it! Marko

Sorry Marko but you are completly wrong... The All-on-4 Concept and Nordic Bridge are diferent things. What makes you believe that they are the same?!! Are you talking about the surgical technique?! Prosthetics?!

Another thing... The All-on-4 maxilla... does not uses implants in the zygoma. The technique is the same as the All-on-4 mandible. And is the best option to avoid bone graft procedures profiting from the quality of anterior bone. And believe me... they both (upper and lower) result perfectly. The All-on-4 with Nobel Guide turns the technique quite more easier... and as the great advantage of doing a flapless surgery.

The original All on 4 Protocol is for screw retention. Has anybody adapted the original protocol for cement retention?

The All on 4 protocol is only one design for full arch restoration. What about cement retention for any full arch case? I think this would be easier to fit than a full arch screw retained case. What is the experience with cement retention in full arch cases?

The All on 4 system works quite well for the parameters it was designed with. But, knowing our mindset as I do, some will push the envelope beyond the limits. They will ask for 33 degree posteriors and extend the cantilever back to the 2nd molar. The case will fail and they will blame everyone but themselves. How do I know this? 35 years of scratching my head wondering why the lab wasn't consulted first. All ideas are good ideas but not all ideas are workable.

There are a range of questions and comments arising from this initial question. I have been involved with Nobel's guided surgery concept since beta testing. NobelGuide is the only way I place implants in our practice today (unless there is an immediate ext/implant). The ability to plan extraorally and proceed intraorally with precision and minimally invasive techniques is incredible. Furthermore, this procedure is diagnostic...we can determine if grafting will be needed prior to proceeding. Regarding the All on 4 concept, I have done many. The concept of getting the fixture top distal to the implant body is unique. I have provided this concept to many patients with excellent success. We have combine NobelGuide technoques with All on 4, but immediate loading is not possible with the Teeth in an Hour concept (no adjustable abutments...must use the multi-unit abutment which requires an impression) it gets down to ability, understanding, and patient selection. In the wrong patient or with non-ideal occlusal factors, this and other implant techniques are likely to have problems.

I used it on my father-in-law, and he is still my father-in-law and I am still married to his daughter. All-on-four on the mandible avoids bone grafting of the posterior mandible in many cases. Given many cases of severely resorpted mandible, I am providing a good alternative that is less invasive, less costly, and less time consuming than other techniques.

Has anybody adapted the All on 4 protocol for cement retained fixed partial dentures instead of the classic screw retained fixed partial denture?

I use 6 to 8 implants in the maxila, impression open tecnique and after i use a "free" that i adapt and after a take a impression with impregnum. The Gold suprastructure never failed with this procedure. After that it is like a total denture procedure. I did my first cad-cam with simplant 3 years ago and the precision is hi but only to make suprastructures that have to be breaked and glued with patern resin and in the lab put in place with laser. that takes more than 2 hours to make but it is more acurate. I put the hybrid strutures generaly in 4 weeks i wait to the gum to be in place, the results and periodontic stability is great.

We have done close to 40 All on4 with 100% success so far. We also have excellent results with zygoma and Teeth in an hour. Overall success with new techniques using Nobelguide has increased significantly. Gary Wadhwa

Hello, 1. I did some (more than 30)of all-on-4 and about 10 procedures with guide. First thing is very nice, till You don't loose the first implant... then this is the time to explain the patient why he had to pay so much and has to wear regular denture instead of bridge... That happens, also to the inventor of this technique... 2.With guide I'm not satisfied, although had no bigger problems (if not to count breaking of surgical tray...), but it's too early for telling anything.

I don't understan why Stef use the all-on-four technique if he doesn't like. You are wrong about the autor because he has 100% sucess in the bridge. From the theoretical point of view is possible to do an all-on-three bridge. Few implants are better because much bone is available to share.

how do I find an experienced surgeon for the all-on-4 system? all-on-4 sounds very good to me. any help is very much appreciated.

just want to know the exact price of implantation ? please give numbers

Even with the high success rate of the all on four, if you do enough of anything you will experience a failure. The beauty of doing any implant with the guide, especially all on four or all on six etc., is if an implant does fail all you have to do is unscrew the denture,graft the socket and after healing get out the patients guide redrill the osteotomy and you are able to replace the implant exactly in the same position. Then simply replace the bridge. This is a huge benefit cost wise and the ultimate plan B. The all on four is cost saving treatment plan that makes it available to those who cannot afford 6-8 implants and this enables me to help a great deal more patients. I have to give Nobel props for their pushing of the research and idea of placing, and therefore selling less implants. Theoretically!

Can anyone please 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?

My partner and I have been doing the all-on-4 with great success. It is extremely well received by our restoring doctors and patients. The science is published, the data are there, and in our hands it has worked as advertised. Patients appreciate getting an immediate load full arch restoration the same day as the implants are placed and it eliminates the cost and extended time required for sinus augmentations (during which the patient has to wear a complete denture. Patients who have some teeth also appreciate being able to transition to a full arch restoration the same day as extractions and implants are done, no need to ever wear a complete denture. Just one perspective from Louisville, KY.

I am doing all on four in the maxilla with the aid of computer guide surgery and it is fantastic. With the computer we are able to do the planification and perform a straight forward surgery through the gingiva and finish the case with an immediate loaded prosthesis. In the mandible I don´t find any advantage and on the contrary there are several surgical risks that I don´t want to accept. No advantages in all on four in the mandible (except using 1 implant less) increased surgical risks and increased prosthetic risks (failling of one implant means that all the treatment fails) It is our opinion of course. Pedro.

This technique has been used for cement retained prostheses for years but just not in a final restoration fabricated ahead of time. With Biotemps or Duratemps that use metal in the framework you can extract, place and load immediately and not be committed to 100% prosthesis success hinging on everything going perfectly. Humans don't heal perfectly and those boasting thirty or so "all on four" cases with 100% success have my eyebrow raised. I just can't comprehend a thirty year prosthesis hinging upon zero percent error in the maxilla. Many of us wouldn't take that gamble. Congrats to those it works well for but I'll keep placing a couple extra so the odds stay in my favor. I'd love to see some of the materials used on these prostheses and the spans they reach without flexure. And how can you tell the degree of parafunction in some of the edentulous cases? Four uppers on a good clencher? No chance. Jackson

I can see from the many post that the "All on 4" is certainly misunderstood. I had the same apprehension as well. I went to a Palo Malo course, looked at the science and found that this is a great procedure for patients and very successful. In just 9 months I have performed over 65 cases. All with total success. Their is less cost to the patient and less time involved since this is an immediate load. I do not place the posterior implants as zygomatic implants. I angle these anterior to the wall of the sinus. I am now teaching a hands-on course for Nobel for this procedure. My partner has performed over 25 of these and we expect to about double the number this year.

If you have performed 65 cases in just 9 months, all with "total success," I question your definition of success. Can "total success" be determined in 9 months or less?

Is the all-on-4 technique recommended mainly to avoid a sinus lift and bone grafting? If a pt doesn't require either, is it still a viable course of tx? (Ignoring the fact that the conventional tx takes months to complete).

With the "all-on-4" you not only avoid a sinusgraft or the mental nerf. If you go back in time you will see it was developed for the lower yaw and the problems we had with the mental nerf and the limitations of the extentions of the bridges to the first molars. By putting the two implants under an angel we can have more extension of the brigde to the rear without putting to much off-load strain on the implants. It is developed from the same principels we used for partial protheses.

I had the "all on four" procedure done recently. Everthing went smoothly and I am very satisfied except for the blood and mucus from one side of the nose. Is this a sign of the sinus perforation that I read about? The Nobel Bio-Care procedure was used and the implants were placed at an angle.

AS I understand from what I have heard, there is a 25% failure rate with the all on four. Remember Anti's Law. I have not done any myself.

Dear R highes. Wher do get your rumors from ? the published research shows 97-98% success. all on o4 is one of the most innovative techniques in implant dentistry in the last 20m years.i invite any skeptics to be in touch with me or better yet visit Malo in Lisbon. my email is Yosrebco@netvision.net.il

Who published the papers with the data. Are they in Nobelpharma's hip pochet or was this an independent long term study?

We performed all on 4 on a patient before 15 days in mandible .Everything is fine.But as we cud not get enough torque in one of the distal implant we didn't give immediate denture.Pt has been given healing caps over the multiunit abutments except on the distal implant where we placed a cover screw so that there is no additional pressure over it.Shall I wait for few more weeks & then give him the denture.Another thing is it always necessary to give a titanium framework & then a bridge or some cheaper option can work.Can some body guide me .

you can see my cases on the osseo news website listed under "implant cases". all cases are given an acrylic denture i.e. hybrid bridge for the first 4-6 months.In your case I would wait 3 months before loading . every4-6 weeks soft reline the denture.I had a case where the distal implant on one side did not have sufficient torque but i placed a fifth implant distal to it not angled got torque and loaded the bridge.

The first reply said they have heard it is more invasive because of the extra drilling to secure the guide. The guide is secured with guide pins that are 1.5 mm in diameter. They cause little to no discomfort. It is the least invasive way to do implants. The procedure is flapless. You can do the All on 4 with guided stint or guided with a flap. the unguided procedure has you flap the ridge and use a metal guide that helps you visually align the burs. It is a very successful procedure that has been done in Europe for over 15 years.

Can the all on 4 technique be done with a removable acrylic denture as the prosthesis, using ball, locators etc.

DEFINITELY NO. you need rigid non removable fixation..

Where on the web can I find independent research of success/failure rate of maxilla "all-on-four" immediate function procedure with fixed implant bridge?

Dear Amit S., THIS CAN BE DONE, BUT ONLY IF THE IMPLANTS ARE SPLINTED WITH A BAR! THUS THE OD IS ATTACHED TO SAID BAR WITH "O" RINGS, LOCATORS, HADER CLIPS OR LEW ATTACHMENTS. Immediate load is nothing new. Check out the work of Linkow and others. You can use "O" RINGS singly but not with an immediate load. A bar case in the mand can be immediate loaded (within 4-5 days) just enough time to have the bar fabricated after the implants have been placed.

Here's what I know. I researched many sites including this one before I underwent the "all-on-4" procedure. It has been six months now. I just had the permenant teeth put in place. At no point have I been dissatisfied. I don't know if it was the Nobel Bio-Care procedure or maybe the DMD facility that I chose. At any rate, I am a satisfied patient.

I've been doing all-on-four cases for roughly 18 months, and probably have the second or third most experience in our company. In over 200 cases, we have had a failure rate of 3-4% for all implants; that is similar to any other published success rates - certainly taking into account all areas of the mouth. If anyone has questions, I am happy to offer insight.

Dr E - if you could re do the failed cases, would you do anything differently?

i have 4 upper and 2 lower cement based implants done over 20 years ago (4 failed in the upper and 2 in the lower during bone healing time . i have weak lower bone density and same on top and wonder if i could add more implants with the all on 4 method or put a fixed bridge on the existing implants. i have no natural teeth.

I t is possable but a removable overdenture and bar may be better.

Skepticism is healthy regarding All on 4 or any other "new" product or procedure. But All on 4 is not new. Though I am unsure, I believe Paulo Maulo began publishing on this protocol in 1984. I began following everything he published , in disbelief, in 1990, and ended my investigation with an intensive week with Dr. Maulo and his team in Lisbon in 2000. During the yrs between 1976 and 2000 I placed hundreds of implants and restored them with all of the conventional metods that were available mostly with great success. Upon returning from Portugal I immediately began using the All of 4 protocol. I do these cases almost daily. I completed an upper and lower a couple of hours ago and will do a case every day next week so I do alot of them. I'm just like most of you. I love what I do but I find complications devistating. So obviously if it didn't produce a very high rate of professional and patient satisfaction I wouldn't do it. There just AIN'T enough money. Of course just because it works in my hands doesn't mean it will work in yours. That being said however time for debating whether on not it works is past; it does. Now we should concentrate on further perfecting the technique and teaching others.I would be happy to relate my experiences with anyone who asks and if you are interested in how I present this to prospective patients you can check out nodentures.com

I am amazed at the low level of research standards in this discussion. Everything seems to be based on personal experience or what people have heard. Some of you have rightly asked for references, but nobody seems to supply them. This level of "science" wouldn't pass in medicine or nursing. Why should it pass in dentistry? Where is the serious epidemiology? Where are the controlled clinical trials? I mean large-population studies of all-on-4 as compared to older methods with proper statistical analysis. Can anyone provide a bibliography of articles in peer reviewed journals? I am not a medical or dental professional but a philosopher. I have, however, just retired after having taught medical ethics (including research ethics) and philosophy of science to medical, nursing, microbiology, etc, students for close to twenty years. So I know how clinical research should be carried out. I certainly cannot make an intelligent decision about implants on the basis of your discussion.

Hi Frank, Before you start bashing the serious practitioners on this board, I would suggest you do a little more research on your topic. There is tons of research and papers supporting All On 4. I suggest you go to Nobel Biocare's website and read thru the 90 plus articles there and then come back here with intelligent comments.

Well said!!

Dear drcalif, Finally, a reference! I thank you for sending it. Others on this thread asked for references before I did. But they got no results. I guess a bit of what you call "bashing" (which isn't what I intended) is the best way to get results. Incidentally, although I have begun to check out the site you referred to, and although I certainly have nothing personal against Nobel Biocare, I will put as much faith in a bibliography supplied by a dental supplies manugacturer or marketer as I would put into a bibliography supplied by a pharmaceutical company. I will have to find independent sources before making a decision. Very best wishes to all.

You can do the All-on-4 with guided stent or guided with a flap. The unguided procedure has you flap the ridge and use a metal guide that helps you visually align the burs. It is a very successful procedure that has been doing for 5 years now.

Would anyone care to share the names of their dental labs who are fabricating the prosthetics for these all-on-4 cases? This includes any technicians out there doing this type of work.

Dear Dr Schweizer, We specialize in the Malo technique restoring AO4 Hybrids in ceramic and acrylic. I would be happy to address any questions you may have about the Malo Clinic Ceramic Bridge. This is a state of the art AO4 Hybrid which reduces maintenance issues and chair time, while at the same time giving your patient the finest restorative prosthesis in the industry today. Please contact me directly with any questions you may have about the restorative process and laboratory cost estimates. Our lab follows strict protocols (not easily replicated) to guaranty a high quality prosthesis for your patient. We have a complete staff of surgeons, prosthodontists and technicians that will assist in any restorative questions you need answered. Sincerely, Robert L Donahue CDT,MAAIP Chief Operating Officer CM Ceramics USA LLC 201-672-0077 rdona84905@aol.com

clearly, aa-on-4 is the state of the art in dentistry today as a patient and a dentist i see this. i myself am tired of paying for failed dental work, bridges that last 5 years. and i'm tired of my patients having to go through that. i don't do all-on-4 but i surely refer my patients to experience dentists who do when appropriate. to say we do this procedure because are patients are rich and all other naysayers here, it's because YOU don't know how to do it. do your patients like dentures? i don't think so. no one would. i see patients who have spent $18,000 on a few implants and over denture and are still in dentures and still miserable. all-on-4 gives patients real teeth at a fraction of the cost, time, constant pain and dental issues, failures and everything you've all seen and performed. how much money does a patient throw away on failed procedures before they resign themselves to dentures. that'where you're making myour money. do you think people have $5,000 a pop to keep replacing the same failing bridgework just to have their teeth in a glass at night?????? let me say this, if you can't embrace new technology, if you're so threatened because you're being left behind, don't stand in the way of it. just move aside. and yes i'd recommend this to anyone i love who could benefit from it. it is the state of the art. i'd cry if i had to resign my mother or children or anyone else to a life of constant failing work in their mouths, thousands and thousands of dollars, a lifetime of the misery of dentures. get real. i could almost guarantee you're the same naysayers who held on to installing godawful toxic mercury fillings for as long as possible. look inside yourselves and see what you're so afraid of. without all-on-4, i also guarantee that your "rich" patients have lined your pockets with much more than the cost of all on 4 and have over the course of their treatment AND, they still have garbage for teeth. again, if you can't help, step aside and make way for modern dentistry. all-on-4 is the best thing that has happened to dentistry in the history.

Hello, Recently, I visited two dentists. One recommended that I get ridge augmentation alone to deal with my maxilla which has been without teeth since I was eighteen, I am now 62. After visiting the first dentist, my denturist introduced me to the all on 4 concept. I have since visited a second dentist/perodontist who, after a CT Scan and full consultation, recommended an all on 5 scenario and voiced strong optimism for success. The first dentist, who recommended ridge augmentation, provided me with a four implant and bar denture over implant solution for my lower jaw. He speaks very strongly against the all on 4 methodology, citing a high failure rate and lack of long-term clinical proof. Now that the second dentist has told me of his successes with the procedure and his optimism for its success given my case, I am now quite confused and somewhat apprehensive. When I read of the disagreements in the field over the all on 4 practice, I tend to become more undecided in what to do. Consequently, I am looking for advice. Can anyone help. John

hello, just read everyones comments....I'm 49 yrs old and losing all of my top teeth due to hereditary bone loss. I'm getting the All on 4 in 2 weeks. I truly hope I'm not making a mistake...I prefer having teeth in my mouth than in a glass of water when I go to sleep.