Discussion Topic All on 4: Rescue Protocols If Some Implants Fail?

There has been a lot of publicity over the Nobel Biocare All-on-4 concept. There are training programs all over the world for this. The concepts are simple to understand and the protocols are all clear and precise. But my question is what happens if 1 (one) of the 4 (four) implants fails? Does that mean you have to extract the failed implant and redo the entire bridge? Are there rescue protocols to replace the implant and save the bridge? I am concerned that some implants fail for no apparent reason, even when you have done everything right. I would like to feel that I have a fallback position if I commit to an All-on-4 protocol. Or should I be more cautious with treatment planning and go to All-on-6?

25 thoughts on: Discussion Topic All on 4: Rescue Protocols If Some Implants Fail?

  1. CRS says:

    Very good question, a bridge is burned since so much bone is removed to allow room for the prosthesis. There is no rescue that I’m aware of possibly the zygomatic implant. There are however patients that initially present with this type of bone loss pattern and are reasonable candidates for an all on four. I feel an all on six gives more “wiggle room” if an implant fails to integrate. .

  2. Richard Hughws DDS, FAAID, FAAIP, DABOI says:

    It is as Dr. Carl Misch states, “All on 4 and None on 3”. In these cases you may have to punt and place another implant and or use a different attachment system and abandon the all on four for a conventional bar over denture etc. I f you are going to do a fixed case, consider Ante”s law. I use a modified concept of Ante’s Law. I take the number of teeth that need replacing, divide by two and add one. That gives the number of implants to use. This applies to root forms, not plate forms, subs etc. This, when it can be applied, has never let me down.

  3. Khoury Dental Clinic says:

    In fact the big problem is if one of the tilted implants is lost , otherwise you can always replace the straight one by placing another implant next to it. You can also do an immediate loading on this implant if you are still in the temporary phase.
    But if you lose the tilted one , you will have to think again about doing a bone graft more distaly if there is not enough bone to place an implant, if you wish to give your patient an occlusion that arrive to his molar.

  4. advance dental says:

    ‘all on 6’ isn’t usually possible with patients with sinus enlargement, hence the development of the all on 4 technique to avoid a sinus lift, the tilted posterior implants usually take out any other potential sites in the canine 1st premolar region. loss of the distal implant can be an issue but with correct patient selection and accurate placement failure seems rare

  5. Leonard Sinclair says:

    “All on four” is a risk, but I believe the advice given is to explain that risk to the patient before treatment. The problem is that the doctor would like to rescue and somehow retain the original bridge. Suggestions have been given that you may be able to put in another implant, but how do you design it so that it will connect to a bridge that was not designed to accept another fixture in a positive and helpful way. I believe that is the main problem of rescue and the one to scupper the idea of using the original bridge. I believe this means a new bridge.

  6. Baker k. Vinci says:

    There is no absolute answer to your question . Every case is different and as you probably know ” all on 4″, could mean 5,6 or even 7 implants. To suggest you are immediate loading them, is inappropriate. If you are loading these implants the succes rate, or lack there of prohibits the prudent surgeon from proceeding as such. Why not place the implants, bury them and give them a relieved prosthesis for cosmetics only. “It” is a small sacrifice (3 months ), for a far superior product. I just reviewed a case where one of Nobel’s biggest lecture circuit boys edentulated a mans maxilla and did an all on 6, to have every fixture fail. ( immediate load, 8 healthy maxillary teeth ). Now the patient is edentulous, with severe atrophy . Pretty devastating, in my opinion. Bvinci

  7. Don Rothenberg says:

    This is an interesting problem that will come up for all of us possibly in the future. Treatment planning is most important…we will not do the procedure on smokers….or for that matter, any compromised health situatuons but as we all know life happens. So it is important to discuss all opinions with our patienst. I think all dentists who do implants would like as many implants as the number of teeth we are going to replace …but for many reasons this is not always/ever possible. The all on 4 technique is just another tool and should be used as such. With the technique that we use in my practice…Bicon implants and TRINIA bridgework….it would be possible to fit a new implant to the existing bridge…not easy but possible. Also mentioned was the chance of non- integration of an implant…since we do not do immediate load cases…we can stop and correct that situation before the bridge is fabricated. I would be know interested to hear if people are experiencing this problem yet…since the procedure is relatively new.

  8. Jean Paul Demajo says:

    I have just seen a patient of mine who lost all of his 6 implants using all-on-6 technique with Nobel speedy. They were immediately loaded too. The patient is a heavy smoker,2pkt a day. I warned him but he still went for it. Now we’re both in a jam. Shouldn’t have started in the first place. Other cases on non or mild smokers worked very well. I wonder if the smoking is the sole reason???

  9. CRS says:

    With an all on six yes you need a small sinus lift, I did not think about the short Bicon implants, could be a new application. The problem is that these patients become prostodontic cases even in the best hands they are very tricky, the prosto has to be very accurate! Jean Paul how about burying the implants and allow them to osteointegrate and have the patient enrolled in a medically based smoking cessation program while the implants are integrating!

  10. MAC says:

    To defy the science of implantology is to abuse the patient in your hands!!!!!
    This is exactly the same question I asked the Nobel representative, His answer…. I will replace the implant…….Where should I place the new implant?……..His answer …It won’t fail……… All on 4 screw retained prosthesis …yes, all on 4 fixed prosthesis….NO!!

  11. Kevin Neshat says:

    I’ve been using the “All on 4” protocol for over 5 years now with over 200 successful cases. I too am still hesitant on placing only 4 in the maxilla, but have always placed 4 in the mandible. I use 5 or 6 in the maxilla. Occasionally, you may find it difficult to fit all 6 implants but usually you can. I too had the same concern with the fear of losing a distal implant, etc. and honestly, still do. However, as odd as it sounds, it just doesn’t seem to happen often. However, as you can see, I’m still cautious and place 6 in the maxilla, just in case I get one. Now, I have to say that I have had a couple of my distal implants fail during the temporary phase, but that’s easy to fix. Simply remove, graft, and replace. I strongly disagree with the comment of not loading these implants immediately. That’s the beauty of this system and concept, the immediate load. I also believe that the immediate load adds to the healing process rather than retarding it. I make sure that I have the appropriate torque for all of my cases (over 35), if not, I will place healing abut on that particular implant and either load the rest or not load the case at all if it’s in a critical position. I have NEVER (without exaduration) had an implant fail post final prosthesis since I’ve been placing these implants. I do get bone loss around a few cervical threads from time to time, but this does not effect the prosthesis. Also, I practice in North Carolina so you know most of my patients are smokers. I tell them all to quit but half will never listen. By the way, I use a combination of the Nobel Speedy and Active implants. I load it all in the office myself to be certain my vertical and occlusion are dead on. This is another key to success. Anyways, I don’t often comment on these sites but I thought it would be nice to share the info.

    • OMSDan says:

      All-on-4 is a tool, that can be used on many edentulous patients or those with failing dentitions. There are studies out there with 20 years of follow-up. There is science behind it.

      It is technique-sensitive and like any implant treatment, is dependent on patient selection. Immediate temporization is most often used and does provide benefits to the patient. It also allows the implants to be loaded for 6 months before the expensive final restoration goes on. Most implant that fail in an all-on-4 technique fail before the final prosthesis is made. They can be placed in new positions or grafted and then replaced. The temporary prosthesis can then be adapted to the new implant and a longer waiting period is prescribed before the final prosthesis.

      Heavy smokers are more likely to lose implants, but it also depends on the density of the bone, making sure your implants are completely surrounded by bone, etc. Basically the same tenets as any other implant treatment.

      I would put forward that there is at least as much science behind all-on-4 as there is on short implants, and the published survival rates are higher than for short implants.

  12. Baker k. Vinci says:

    Because success rates reach 99% in the experienced surgeons hands, when “rules” are followed. I have seen studies that show 70%-85% success rates in ” immediate load fixtures”. Loosing 30 out of 100 implants is not acceptable, in my practice! Bvinci. Vinci Oral and Facial surgery. Baton Rouge, La.

  13. Baker k. Vinci says:

    I doubt that the suggestion of some implants fail, “for no reason at all”, has any merit. Remember first; why were all of the teeth lost and secondly, what is the likelihood of the patient changing their habits? Next, everyone and his mother is placing implants and I would say a large majority of them are learning on sites such as this one, in a non controlled setting.
    These patients neglected their teeth and lost them all, over a long period of time. Why do we feel that we have to immediately replace the missing body parts, knowing all along that relative to two stage implant treatment, ” it ” is a compromised plan.
    I have done some of these cases and have been very lucky, in that I have reserved the treatment for ” ideal ” patients, if there is such a thing. I can assure you, that when one of the fixtures fails, we will either be making an entirely new prosthesis, or cutting and soldering the metal. Bvinci

    • Richard Hughes, DDS, FAAID, FAAIP, DABOI says:

      Baker, I agree with you 100% as per the success rates vs failures. Implants fail for a reason(s). I have a very active implant/restorative practice. Through the years I have noticed that the ideal patient is the exception and not the rule. People lose teeth for a reason and old habits die hard. Many times patients are not honest with their doctor(s). Patients are commonly taking medications (long term) that have adverse effects on bone ( steroids, opioids, HRT, anticoagulants, antineoplastics, immunosuppressants, antiretrovirals, proton pump inhibitors and BPs etc). Bariatric surgery patients and those with bulimia nervosa are also at risk. The age group that commonly seeks dental implant treatment is compromised due to age. Those over 50 have a diminished metabolic rate thus bone metabolism slowes down. As per habits, bruxing, smoking, substance abuse and the lack of oral hygiene are significant issues. As per immediate loading, I have backed off this in most cases with root forms. Blades and subperiosteal and (custom endosteal) implants are the exception. As Misch stated all on 4 or none on 3.

  14. Lori says:

    I am a female non smoker 52 years old. As of now I have all crowns and a bridge upper and 7 teeth on bottom with a partial. I have some decay under every single croen and they have been done twice and and I always have issues.
    They want to do upper & lower all on four at the same time. I will do it but I am afraid of alll the trauma and asked them if I should do lower and then at a later date do the upper,,or vise versa. They insist on doing them both at once stating that my bite will be better and I’ll only have to do it once and be done. Now that I have read of some failing…I am totally afraid. I have teeth now.. So I could if things didn’t go as planned end up with dentures?
    I just want to have a good outcome and be an informed patient with a good solid plan.
    ANY comments or advice would be so appreciated.

  15. Des says:

    If your doctors have done a fair amount of all-on4, then you are in good hands. A failing implant can happen with 4 implants or 8. We don’t put 6 wheels on cars, only 4. Scientific studies have showed that 4 implants supporti g a fixed bridge where the back 2 implants are tilted is a sound and successful treatment option. Remember, nothing is fool-proof, but all-on-4 is a good, reliable treatment.

    • LORI says:

      THANK YOU DES,,,Do you think extracting all upper and 7 on bottom is reasonable? Not too much trauma?
      I asked what kind of pain that I would be in and they said they would give only Lortab,
      Now…I have had planty of surgeries… cosmetic, etc…and Lortab to me doesn’t seem reasonable. They said I need to get anything stronger from my MD. Huh?
      They are charging 38,000 dollars and they can’t take care of me if needed. I don’t get it.
      I am just trying to get the best care for a major procedure…
      I have to have this done soon and I am afraid that I am not going to get the best.
      I did have 3 consults and 2 were dentists and I would have to go from office to office…this place has everything in one location.
      Geez…I hate to ask but as I said I need this work done asap :((
      Any insight would be greatly appreciated!

      • Des says:

        Usually Lortab will work well. They shouldn’t be afraid to give you something stronger. It is more convenient to have it all done in one office, but the other places may be just fine. We often will take out multiple teeth on the upper and lower and do the implants the same day. You should be fine with this, some pain, swelling and maybe bruising.

        • Lori says:

          Thank you Thnak Thank you Des.
          At least I know it isn’t so out of the ordinary to have all those teeth out, It’s just seems weird because when you look at me my teeth look great. They are just failing root canals…decay because of the open margins. That is what happens when you go from dentist to dentist all your life and everyone is doing a little of this & that. Due to insurance you always had to go with who was accepting yours at that particular time….ugh
          I will keep ypu updated on here just so I can share my experience. Hopefully others can learn from reading our posts,
          One other thing…I am going to tell them to use more than 4 if they can becuase of what I read about all on four ..none on 3.
          They also said I can’t chew for 2 months…all soft. After 2 months you can eat whatever you can eat with fork. It sounds tough…but somehow you seem to always get through with God’s grace.
          Thanks again…

  16. Des says:

    You may no have room for more than 4 implants. Do we put 6 wheels on a car? There is a documented 95%succes rate in the literature with all on 4. Sometimes, we put six in the upper jaw if there is room. If your surgeon is experienced with all on 4, they will tell you if it can be done. Good luck!

    • Lori says:

      I will probably have it done the 1st or second week in december. They said no chew for 2 months 🙁 Thank you for all the input. Beleive me I am going to keep you updated! I want to help as many people as possible just as you have helped me. Stay in touch!

  17. mohammed shakeel

    It’s funny how people comment on the all on four technique with out any experience with the procedure or have done any cases. I have atleast a hundred documented cases and my surgeon friend with 400 cases documented cases with 98 percent success and 100 percent success with final prosthesis . The key to success is immediate load , immediate load helps with remodeling by stimulating bone vs loading with denture which causes bone resorption by pressing on the bone and pain by pushing on the soft tissues .
    This is my 2 cents take it or leave it

    Dr S

    • Lori says:

      Thanks Dr S.
      I’ll take your 2 cents!
      I am just afraid because I have to have aprox 20 teeth removed and getting all on 4 upper and lower. I feel that it is just a lot of trauma and I do fear that 🙁

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