Complete arch site classification for

all-on-4 immediate function

Ole T. Jensen, DDS, MS
Complete arch immediate function of dental implants requires a treatment protocol that takes advantage of residual areas of
cortical bone for the apical xation of implants. A site and jaw bone classication is proposed that has been in use since 2006
for all stages of atrophy for both jaws. The use of the classication is strictly for immediate function based on specic cortical
bone sites in the facial skeleton to assist practitioners in diagnosis, treatment planning, and interdisciplinary communication,
as well as to reduce human error in patient management. A recent series of 100 consecutive arches that were treated according to this classication is presented. (J Prosthet Dent 2014;-:---)

The rst published site classication for osseointegrated implants was

based on vertical bone support for a
10-mm-long implant.1 The basis of the
classication was that only 10 mm of
osseointegration was needed for a
single-tooth implant restoration, a
theory since validated by several recent
studies showing that 10 mm or less can
be effective.2-8 However, a site classication for immediate function must be
entirely different from a site classication based on establishing osseointegration via staged implant placement.
The reason is that immediate function
is concerned primarily with mechanical
xation, not how much vertical bone is
present or how much bone graft
augmentation is needed to optimize
osseointgeration.1,9-12 Therefore, site
classication criteria based on the
implant length or millimeters of available bone are not as relevant. For
example, a jaw could have abundant
but low-quality bone incapable of
establishing primary stability for implants. In contrast, a patient with severe bone atrophy might still retain
small areas of cortical bone able to x
implants for immediate loading.
Therefore, an immediate loading site
classication is primarily concerned
with the presence of load bearing bone
that can mechanically x an implant
and is not merely descriptive of the
Private practice, Greenwood Village, Colo.

Jensen

presence or absence of bone. A second

divergence from previously described
classications is the near abandonment of vertical implant placement,
which is often problematic in late-stage
atrophy. The reason is that cortical
bone can usually be engaged apically
with the use of nonaxial implants
placed at a 30-degree angle from the
implant entry point.11 By placing implants in this way, the anteriorposterior spread is increased for
improved prosthesis stability. These 2
principles, the presence of cortical
bone and an angled implant placement
strategy, strongly suggest a need for
reinterpreting previously published site
classications of edentulous jaw bone
morphology. The overarching reason
for this is that a classication for immediate function must be based on
mechanical engineering principles
more than on biological (osseointegration) principles.13,14
A complete arch site classication
for immediate function implant placement with such strict parameters has
not been proposed previously. However, it is now important to address the
high level of interest in complete arch
dental implant reconstruction. The
purpose of this article is to propose and
report on the use of a site classication
for complete arch immediate function
using 4 implants.

The proposed edentulous jaw classication for immediate function

implant placement is as follows.

Class A mandible
The Class A mandible has sufcient
vertical bone in the posterior to place
implants above the inferior alveolar
nerve canal in rst molar positions, after vertical bone reduction to satisfy
prosthodontic requirements for interarch space.15 An anatomic variant of
the nerve deecting down toward the
inferior border of the mandible may
exist such that even if the mental foramen area is high, an implant can easily
be placed posterior to the foramen.
Anterior implants are usually placed
into canine extraction site locations.
The 4 vertically placed implants are
spaced 20 mm or more apart around
the arch (Fig. 1)16 so that the interimplant arch span exceeds 60 mm. A
cantilevered prosthesis is not necessary
when posterior implants are placed in
the rst molar locations.

Class B mandible
The Class B mandible has several
millimeters of bone above the inferior
alveolar nerve canal. This amount of
bone allows implant placement slightly
posterior to the foramen by angling the

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are adequate for immediate function

in the Class D mandible (Appendix
[available online]).

Class A maxilla

1 Class A: Implants placed in rst molar locations as well as

canine locations for favorable anterior posterior spread.
implant forward to miss the nerve, but
not enough for placement of vertical
implants posterior to the foramen.
Assuming a 1-mm anterior loop-the
most anterior projection of the inferior
alveolar nerve designated N point-the
implant entry point should be the
same distance as the bone height above
the foramen at N point extending posteriorly less than 1 to 2 mm to miss the
loop as the implant angles forward at a
30-degree angle (Fig. 2A).17-20 (The socalled anterior loop measures 0 to 1
mm more than 90% of the time.)20 This
usually allows for implant placement in
the second premolar zone for a planned
10-mm cantilever.20 The 2 anterior implants can be placed perpendicular to
the ridge spaced equidistant. The 4
implants are spaced up to 15 mm apart
with typical interimplant spans of between 40 and 45 mm (Fig. 2A). In some
patients, buccal to lingual transalveolar
implant placement at a 30-degree angle
will be successful posterior to the foramen in the rst molar location. However, at least 5 mm of vertical bone
should remain above the nerve, and
care should be taken not to perforate
the lingual wall (Fig. 2B).21

Class C mandible
The Class C mandible has little or no
vertical bone above the foramen, and the
angled implant entry point is forward of
the foramen in the rst premolar zone.21
This suggests a 10-mm cantilever
without an entire rst molar in the
denitive restoration.22 Anterior implants are spread at equal distances but
also angled at 30 degrees toward the

midline and extend apically just short of

the inferior border in a V formation,
termed the V-4 (Fig. 3).17 The anterior/
posterior (A/P) spread is typically
reduced to between 10 and 12 mm.17
The interimplant span of the 4 implants is typically between 30 and 40
mm. Because the bone is usually highly
dense, the use of all-on-3 placement
is an option that will slightly increase
the A/P spread.22,23

Class D mandible
The Class D mandible is less than 10
mm in vertical height and corresponds
to Cawood Howell Class V-VI atrophy.24
Three well-spaced implants are used
with the posterior implants angled toward the midline. The inferior alveolar
nerve is commonly dehisced and is
usually on top of the ridge, where it can
easily be reected with a little manipulation.17 The implant site preparation
can then begin in the foramen concavity
itself to improve the A/P spread.17
Screw-tapped implants often perforate
the inferior border.17 A single central
implant placed vertically completes the
V-3 strategy (Fig. 4). The cantilever in
the denitive restoration should be
limited to 10 mm, as the A/P spread
will likely be between 8 and 12 mm.
The interimplant span varies between
25 and 35 mm. The surgeon and
prosthodontic team should understand that as arch length decreases in
the presence of decreased vertical bone
height, the risk of implant placement
increases, and a lower number of implants is required to satisfy load
biomechanics.16 Therefore, 3 implants

The Journal of Prosthetic Dentistry

The Class A maxilla, after bone

reduction, will have an anatomic variant
with a thick palatal wall of bone available
medial to the rst molar extraction site,
usually just anterior to the palatal root
socket. This entry point, angling forward
at 30 degrees, will enable implant
placement into the cortical bone of the
palatal wall, avoiding the immediately
adjacent sinus cavity (Fig. 5A,B).25,26
Anterior implants are placed 20 mm or
more forward in the arch but
angled back to create an M-shaped
pattern when viewed on a panographic
radiograph.27-29 This implant placement
pattern is designated M-4 with all 4 implants angled at 30 degrees and
establishes support for a restoration
requiring little or no cantilever and with
an anterior posterior spread approximating 20 mm and an interimplant arch
span greater than 60 mm. All implants
engage the M point, the location of
maximum bone mass at the lateral pyriform rim above the nasal fossa.2 When
the posterior implant entry point is near
the rst molar apical xation is often
found in the palatal wall itself as the
implant body can be placed in parallel
with the palatal wall. The anterior
implant then angles posteriopalatally
instead of buccally to x into this same
location within the palatal wall. The net
effect is that the M point is not engaged
as the maximum cortical bone mass but
is found palatally (designated M0 point)
such that implants do not need to traverse palatal to buccal to engage the
cortex of the pyriform rim (Fig. 5C). This
morphology is only found in robust individuals, usually men, but is also a
general nding of Class A and sometimes
Class B sites.7-29

Class B maxilla
The Class B maxilla has moderate
atrophy and prominent sinus cavities

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3
Class C maxilla

2 A, B, Class B: Posterior implants placed in second

premolar locations angled forward of foramen even though
entry point is behind foramen. C, Class B sites can sometimes
be treated with buccal to lingual transalveolar placement in
rst molar locations with implant angled 30 degrees to
buccal but engaging into lingual plate.
with a relatively thin palatal wall
requiring an entry point for the placement of the implants in front of the
sinus cavities. Posterior implants usually enter in the second premolar zone
before angling forward at a 30-degree
angle to gain primary stability at the
M point. The implants may pass
through a portion of the sinus, but if
there is secure bicortical xation, sinus

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grafting is not needed.30,31 Anterior

implant entry points are just anterior to
the canine extraction sockets. The
anterior implants then angle back to
the M point. The 4 implants are spaced
equidistant in an M-4 distribution, 15
mm or more apart with an A/P spread
approximating 15 mm (Fig. 6). The
interimplant arch span is between 45
and 55 mm.

The Class C maxilla is one in which

the alveolar process is absent, the sinuses project anteriorly and transsinus
implant placement is required to obtain
an adequate A/P spread.28,29 Sometimes implants can be placed at the
second premolar area, more often in
the rst premolar zone. Transsinus implants with minimal xation can be
dependably grafted within the sinus
with bone morphogenetic protein-2
delivered on absorbable collagen
sponge (BMP-2/ACS) for immediate
function (Fig. 7A,B).28 The M-point
bone mass is generally reduced in volume such that only the posterior implants can obtain xation there.
Therefore, anterior implants must
engage midline bone at what is designated the V point, which is the point of
maximum bone mass at the most superior aspect of the midline within the
nasal crest near the junction of the
vomer.29-32 The anterior implants are
angled 30 degrees forward from the
lateral or canine entry points into the
nasal crest and converge at the V
point.31 These are commonly called
vomer implants.29,30,32 Treatment for
the Class C maxilla is designated V-4
placement, as all implants converge
toward the midline in an upside down V
formation to include 2 transsinus grafted implants posterior and 2 vomer
implants anterior.33 Immediate function in this setting is highly reliant on
anterior implant xation.29 The A/P
spread can be up to 15 mm when
transsinus implants are well placed,
approximating the Class B A/P spread.
Sometimes, however, the A/P spread is
about 10 mm, suggesting a need for
sinus grafting for additional implants. A
typical interimplant arch span is between 40 and 45 mm.29

Class D maxilla
The Class D maxilla typically has V
point bone but no M point bone mass
and corresponds to Cawood Howell
Class V-VI atrophy.24 There is often
capability for bilateral vomer implant

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3 Four Class C implants are placed in front of foramen

shortening anterior/posterior spread as 2 anterior implants
are placed near lateral incisor locations.

placement but little or no bone posterior

such that zygomatic implants are prescribed (Fig. 8A).30,33 If zygomatic implants are not elected, transsinus
placement with BMP-2 grafting can be
done as long as there is no conuence
between the sinus and nasal cavities and
vertical stability of the implant can be
obtained.29,33 Transsinus implants in
this setting have little or no insertion
torque, which means that anterior implants must have mechanical stability to
share the load.29 Occasionally, pterygoid
implants are used in a 6-implant scheme
(Fig. 8B; Appendix [available online]).30
In general, many Class D maxillary
situations can be treated with a V-4
approach by using transsinus implants
instead of zygomatic implants, but the
sum of the insertion torques must be at
least 120 Ncm to permit loading.29 This
means that the 2 anterior implants
must have high insertion torque values.
When this is not possible, zygomatic
implants should be used or a delayed
loading strategy.
When little or no bone mass is
available at either the V point or M
point, quad zygomatic implants are
indicated if immediate function is
absolutely necessary (Fig. 8C). In

contrast, lack of sufcient bone mass in

the paranasal zone of a at edentulous
maxilla is the best indication for bilateral sinus grafting and delayed implant
placement (Fig. 8D).34-37 Not every
implant should be immediately loaded,
particularly when opposing natural
dentition or parafunction occur.38

Classication data
From January 2, 2013, to April 9,
2013, 100 consecutive arches were
classied after bone reduction and
then treated with all-on-4 immediate
function. After bone reduction osteoplasty, each arch was classied by the
all-on-4 site classication. All patients
received 4 implants (Nobleactive;
Nobelbiocare Inc) with all implants
placed into function on the day of
surgery. Of the arches treated, 83.3%
were either Class A or B in the maxilla,
whereas in the mandible, 78.2% were
Class B or C treatment. Class D treatment was relatively infrequent in either
arch (3% in mandible and 2% in
maxilla).
The protocol suggested by this
classication led to infrequent need
for zygomatic implants in the maxilla

4 Class D mandible posterior implants placed through

foramen with nerve being retracted. In this setting, 3 implants
are placed angling toward midline in V formation,
termed V-3.

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(n2), suggesting an incidence of truly

severe maxillary atrophy of about 2%.
Every single arch was immediately
loaded on the basis of sufcient insertion torque of implants placed into
remnant cortical bone. The overarching
signicance of this short-term retrospective analysis was that all cases
could be immediately loaded as
implant insertion torque was obtained
by engaging cortical bone.
All patients were treated with rst
molar occlusion, but cantilevers were
variable. The longest cantilever was
10 mm, with the average cantilever
being 5.4 mm. Insertion torque values
were commonly over 150 Ncm with a
composite average of 166.2 Ncm.
There was a high frequency of 200
Ncm composite insertion torque
which occurred in 48% of patients.
On the other hand, there were 24
maxillas with 120 Ncm or less of
composite insertion torque. One- to
3-year data to determine osseointegration were not our subject, but
rather the ability to prosthetically
load an interim prosthesis using this
implant insertion techniques on the
basis of this classication. Data are
detailed in Table I.

DISCUSSION
Complete arch implant placement
patterns have come to be known by
common terms descriptive of the
number and angulations of the implants. The short form nomenclature of
M-4, V-4, and V-3 are meant to designate optimal apical xation sites as well
as simplify communication.23,27,32,34
The M-4 is the most commonly used
approach for the maxilla; these implants placed, in an M shape when
viewed with panoramic radiography,
can be done in the majority of maxillas
(Fig. 9).27 M-4 implants are xed into
the pyriform rim. The V-4 designation
indicates implants placed in a V formation in both the maxilla and
mandible, even though for the maxilla
the pattern is actually an upside-down
V, as the V-4 term also designates
vomer implant placement (Fig. 10A).

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5 A, Class A maxilla entry point for posterior implants angle

forward hugging palatal wall to engage cortical bone aimed
apically toward canine fossa but not extending to lateral
nasal rim. B, Class A maxilla after bone reduction maintains
cortical palatal wall, a favorable entry point angling forward
buccally toward M point. C, Implants can sometimes be
conned to palatal wall in robust individuals with thick
palatal walls to x into maximum available cortical bone
mass (designated M point) at palatal wall/palatal wall
junction.
V-4 situations are prescribed for severe
bone atrophy directing all 4 implants
toward the midline (Fig. 10B). For the
maxilla, the need for the V-4 may not
become evident until after alveolar
bone reduction, which can deplete

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available bone creating a relative state

of marked bone deciency and which is
especially evident in short-faced individuals.30 For the mandible, the V-4 is
used when bone loss occurs to such an
extent that implants are angled to the

midline to reduce the chance of implant

convergence with the risk of mandibular fracture. The V-4, although less
commonly used, is a critical technique
when immediate function is desirable in
the presence of severely reduced bone
stock.33
Implant angulation has many advantages, including increased implant
length, apical cortical xation, secondary stabilization from the sides of the
implants, and most importantly
increased A/P spread.16,29,38 Implants
placed in the maxilla without angulation but with good A/P spread can be
short and relatively unstable, usually
requiring a delayed placement strategy
as illustrated in Figure 11.30,36,37
Ideally, the M-4 and V-4 patterns will
lead to a 15 mm or greater A/P spread,
with posterior implant abutments
emerging at the second premolar or
molar locations, thereby minimizing the
need for cantilever. Normally, no great
advantage can be had in using vertical
implants unless substantial vertical
bone is available (10 mm or more after
bone reduction), as in a Class A
mandible (Fig. 12). Preoperative radiographic evaluation alone may be
misleading, as in patients with alveolar
hypertrophy. What may appear to be
abundant vertical bone stock usually
requires height reduction for prosthetic
reasons, once again suggesting implant
angulation to avoid nerve injury or
pneumatizations.15,30
After extensive surgical experience
treating patients with Cawood Class IVI edentulous situations, a system for
implant placement has been developed
that is most favorable for each stage of
atrophy. As bone is lost, the remaining
residual cortex bone becomes most
important and can be used for apical
xation for immediate loading. Even
when there is ample alveolar bone
available, these cortical areas remain
the best aiming point for consistent
implant xation. Essentially the same
surgical technique is used for all edentulous patients, no matter the severity
of bone loss, modied from the original
angled implant placement approach

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6 Class B maxilla has thin palatal wall and more prominent

sinus such that posterior implant entry point is second
premolar location angling forward to M point. Anterior
implants angle back to enter into M point bone mass,
creating M-shaped distribution pattern when viewed with
panography.

7 A, Class C maxilla very prominent sinus cavities can be

membrane reected for transsinus placement with entry
points rst or second premolar and apical xation at M
point. Anterior implants angle back to M point and often
touch posterior implants, but more often they angle forward
into midline bone at V point. B, Transsinus implant
placement should be grafted with BMP-2 if implant is
not well xed
rst described by Mattsson et al and
later Krekmanov and colleagues, then
standardized by Malo et al.39-43 The key
to immediate function treatment is
apical xation, not the amount of bone
remaining. Malo et al44 described a

classication of treatment similar to the

Cawood Howell description but based
on remaining bone, not on specifying
sites for apical xation for immediate
function. Other single-site or jaw bone
classications describe general atrophy

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Issue

either with regard to jaw bone reconstruction or for vertical implant placement generally without regard to
immediate function. This new classication applies specically to the potential for apical cortical xation for
immediate function. The classication,
used since 2006, has been applied
strictly for implants angled at specic
landmarks, no matter the extent of jaw
bone atrophy.
A new classication is needed is to
formally establish a treatment planning
protocol that encompasses all of the
various stages of atrophy when immediate function is specically intended.
This charge is signicantly different from
past classication schemes that most
often suggest alveolar reconstruction for
delayed implant placement or do not
specically describe how treatment
should proceed for immediate loading
stability. In addition, this effort to standardize optimal all-on-4 treatment according to available bone is needed
because the majority of clinicians remain
relatively inexperienced with complete
arch immediate function.
One way to consider this new classication is not to look at bone anatomy per se but at the 4 compartments
that affect implant placement potential. These are the sinus cavity, the nasal
fossa, the inferior alveolar nerve canal,
and inferior border of the mandible.
All of these locations can lead to
complications when transgressed, but
typically they only need to be addressed
directly in greater stages of atrophy. For
example, in Cawood Class V and VI
atrophy, nerve manipulation, penetration through the inferior border, transsinus placement including zygomatic
placement, and nasal oor entrance
may be needed in order for immediate
function to proceed.17,19,21,28,29 One
way to look at the classication is in
terms of managing these areas, with
complete avoidance of pneumatized
space in mild to moderate atrophy
to planned modication or spatial
manipulation in cases of severe to
extreme atrophy.
This jaw bone site classication is not
specically quantitative in that it only

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8 A, Class D maxilla is M point bone and V point bone mass

decient. Implant xation is zygoma, pterygoid plate, and
sometimes nasal crest. B, Use of pterygoid implants
requires 6-implant scheme, usually 2 pterygoids, 2 zygomatics,
and 2 vomers. C, Use of quad zygomatics, 2 zygomatic
implants on each side, is alternative for immediate function.
Sinus graft for delayed alveolar implant placement can be
considered.
generally conforms to the previously reported single-tooth 10-mm implant site
classication in terms of available
cortical bone for immediate loading. In
the single-implant classication, a Class
A site is described as having 10 mm or
more of periimplant bone anchorage, a
Class B site 7 to 9 mm, a Class C site 4 to
6 mm, and a Class D site 1 to 3 mm. This
single tooth site nomenclature is in fairly
close correlation with the immediate
function classication for the maxilla
and the posterior mandible, although
not for the anterior mandible. The direct

Table I.

measure of cortical bone quantity is,

however, by necessity an intraoperative
nding for angled implant placement
and therefore somewhat impractical in
delineating a quantitative classication
preoperatively. In one sense, a classication designation is denitively established after completion of implant
surgery. Perhaps these 2 classications
are close enough not to confuse in that
an immediate function designation of 10
mm or more of bone for each implant
site is basically a Class A situation, and
so on down the line to a Class D

situation, where only a few millimeters of

vertical bone are available for all-on-4
treatment. Instead of millimeters,
though, it may be better to think in terms
of descriptive function, for example, M4, V-4, and zygoma placement, than
trying to predict a specify quantity of
periimplant bone in an angled implant
setting.
From an anatomic standpoint,
subtracting everything but cortical bone
in the maxilla reveals the dilemma for
the surgeon, that is, the expectation of
high function from limited load-bearing
bone stock. If the surgeon envisions
inserting the implants into cortical
bone, it quickly becomes obvious that
in late-stage atrophy, the paranasal
bone is often the only available cortex
for the maxilla other than the palate.29
Much of the strategy of immediate
function implant insertion for the
maxilla is based on engaging the palatal
wall, including angled palatal wall
placement (implant stays within the
palatal wall), transsinus placement
(palatal wall to nasal wall), and
bicortical transalveolar (palatal to
buccal) placement.27,28,31 If the palatal
wall is atrophic or thin from long-term
denture use, paranasal bone, which is
almost always present in all stages of
atrophy, may serve as the nal remnant
of maxillofacial cortex in the extremes
of maxillary atrophy.24,29
Although the alveolar crestal cortex
may be engaged, no matter how thin,
the alveolar crest is generally removed
to form the all-on-4 bone shelf in
Cawood Class I-III situations and is
largely absent in Cawood Class IV-VI
situations.15,18,24

Study data for 100 consecutive All-on-4 treatments

Class

Maxilla
(n[54)

Average No. of
Implants (4.00)

Mandible
(n[46)

Average No. of
Implants (3.96)

Immediate
Function

26

100%

19

23

100%

13

100%

100%

In maxilla, 83.3% were either Class A or Class B treatment, whereas in mandible, 78.2% were Class B or Class C treatment. Class D treatment was
relatively infrequent in either arch (3% in mandible and 2% in maxilla).

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9 Panoramic radiograph made on day of loading showing

M-4 implant placement pattern in Class A maxilla.
This all-on-4 jaw classication
implicitly establishes favorable biomechanics, including the use of longer
angled implants for intraosseous secondary stabilization (side loading of
implants), a greater interimplant arch
span resulting in a substantial increase
of A/P spread, and favorable prosthesis
support from cross-arch splinting
(extraosseous secondary stabilization).38 A desirable A/P spread is
generally 15 mm or more for each jaw
but is difcult to achieve in every patient. Potential A/P spread decreases as
vertical bone loss progresses, especially
in the lower jaw.24 This is illustrated in
Figure 13 A,B and is conrmed clinically. In 2-jaw all-on-4 treatments, there

is typically 5 mm or more less A/P

spread in the mandible than in the
maxilla primarily because of the position of the inferior alveolar nerve after
bone reduction.
Unlike other classications that
are based on available bone, this proposed taxonomy is derived from intraoperative ndings after bone reduction
to create the all-on-4 bone shelf.
The bone shelf is the basis for determining implant distribution, implant
platform level, abutment height, and
interarch space for the prosthesis.15,18
The bone shelf also establishes the
optimal trajectory of angled implants
into cortical anchorage and helps to
maximize anterior posterior spread.

Issue

This new jaw morphology classication

is not based on preoperative osteology
but on intraoperative ndings after surgical preparation. It is not only descriptive but also functional-descriptive, and
it takes loading capability into account,
ending the long heuristic development
of immediate function prosthodontics.
In highly atrophic patients, implant
support becomes more anterior,
resulting in diminished A/P spread and
excess posterior cantilever. Periimplant
bone support can tolerate long cantilevers, but despite a recommended 44
mm titanium bar, the prosthesis may
not because a linear relationship exists
between cantilever length and anterior
posterior spread related to screw loosening. Added stress to the prosthesis
leads to increased maintenance. Cantilevers, therefore, should be short (10
mm or less) to optimize support for the
prosthesis, particularly if the A/P spread
is 10 mm or less. This means shorter
restorations are likely in Cawood Class
V-VI situations. When this is not
acceptable in the maxilla, zygomatic
implants should be placed to establish
molar support for immediate function.33 However, for the atrophic
mandible, nerve transposition should

10 A, Postsurgical radiograph of V-4 placement in Class C maxilla. B, Postsurgical radiograph of V-4

placement in Class C maxilla and Class B treatment in mandible.

The Journal of Prosthetic Dentistry

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11 Angled implant placement as opposed to vertical

implant placement leads to increased implant length, better
implant xation, and secondary stabilization from angled
sides of implants for immediate function because of greater
implant resistance form within bone.

12 Class A mandible can be treated with vertical implants

when sufcient bone height is available, as shown in
panoramic image.

not be done except at the foramen to

avoid dysesthesia and increased potential for jaw fracture at the corpus.19
Parafunction leads to a high incidence of implant loss from immediate
function.38 Should the clinical setting
be compounded by bruxism, a wide

A/P spread may not be enough and

additional implants should be placed
to increasing the total number to 6 or
more; sometimes a delayed placement
strategy is necessary.
The decision to delay loading or increase the implant number is based on

the sum of the implant insertion torque of

the 4 implants and the anterior posterior
spread, with the latter being the more
important. The minimum suggested sum
of the insertion torque values is 120 Ncm,
allowing a maximum of 50 Ncm for any 1
implant.29,38 It is more important for
anterior xtures to be stable than posterior xtures, especially in the maxilla.29,38
The minimum A/P spread acceptable for
immediate loading has not been established, but 10 mm is recommended,
assuming the implant spacing is
optimal.15,18,29,38
In the mandible, the A/P spread is
locked into place because of nerve position, so unless nerve manipulation is
done, the A/P spread diminishes greatly
with atrophy. With profound atrophy,
the necessity for a fourth implant is
much reduced because the distance
around the arch from mental foramen
to mental foramen is diminished and
fewer implants are needed to span the
available arch length. Also, because the
2 implants are close, they are interpreted biomechanically as a single
implant support. By using an all-on-3
approach, the A/P spread is usually
increased slightly while still satisfying
the necessary load bearing capacity.13
The use of a rational classication
system helps not only to establish a
treatment plan but also implies treatment difculty to help prepare for surgical workow, such as the need for
zygomatic implants. This classication

13 A, B, Mandibular and maxillary color-schematic showing Class A through Class C bone

loss levels with associated implants. As vertical bone loss progresses, implant length decreases
and interimplant arch span and anterior posterior spread decrease.

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Volume
can help to reduce human error when
implant surgeons use all-on-4 surgery
without a clear understanding of the
underlying consequences.

SUMMARY
This functional-descriptive complete
arch edentulous jaw bone classication
is a departure from single tooth implant
site classications, which essentially
impose a requirement for osseous
modication, as in the 10-mm implant
formula.1 Hundreds of different operative procedures are used to recover
missing bone based on classications
of axial implant placement. However,
hard tissue loss need not be recovered
at all when an angled implant strategy
is used.33 The surgeon must therefore
visualize xation points for cortical
bone as described by this classication
for angled implant placement, which,
although contrary to the common
practice of axial implant placement, are
much more favorable for immediate
loading. This new classication shows
not only that grafting can be mostly
avoided but that enough cortical
implant xation can be obtained in the
majority of patients to proceed with
immediate function.

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7. Felice P, Checchi V. Bone augmentation

versus 5-mm dental implants in posterior
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8. Mal P, de Arajo Nobre M. Short implants
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Coelho PG. Inuence of implant shape, surface morphology, surgical technique and
bone quality on the primary stability of
dental implants. J Mech Behav Biomed Mater
2012;16:169-80.
10. Makary C, Rebaudi A, Sammartino G,
Naaman N. Implant primary stability
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21:474-80.
11. Romanos GE, Cionei G, Jucan A,
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12. Norton MR. The inuence of insertion torque
on the survival of immediately placed and
restored single tooth implants. Int J Oral
Maxillofac Implants 2011;26:1333-43.
13. Brunski JB. In vivo bone response to
biomechanical loading at the bone/dental
implant interface. Adv Dent Res 1999;13:
99-119.
14. Thaliji G, Cooper LF. Molecular assessment
of osseointegration in vitro: a review of current literature. Oral Craniofac Tissue Eng
2012:221-50.
15. Jensen OT, Adams MW, Cottam JR,
Parel S, Phillips W. The All-on-four shelf:
maxilla. J Oral Maxillofac Surg 2010;68:
2520-7.
16. Brunski J. Biomechanics in Osseointegration
in Dentistry: An Overview. 2nd ed.Chicago:
Quintessence; 2003. p. 49-83.
17. Jensen OT, Adams MW. All on four treatment of highly atrophic mandible with
mandibular V-4; report of 2 cases. J Oral
Maxillofac Surg 2009;657:1503-9.
18. Jensen OT, Adams MW, Cottam JR,
Parel SM, Phillips WR. The all on four shelf
mandible. J Oral Maxillofac Surg 2011;69:
175.
19. Jensen OT, Cottam JR, Ringeman JL. Avoidance of the mandibular nerve with implant
placement: a new mental loop. J Oral Maxillofac Surg 2011;69:1540-3.
20. Benninger B, Miller D, Maharathi A,
Carter W. Dental implant placement investigation: is the anterior loop of the mental
nerve clinically relevant? J Oral Maxillofac
Surg 2011;69:182-5.
21. Jensen OT, Cottam JR, Adams MW,
Adams S. Buccal to lingual transalveolar
implant placement for all on four immediate
function in posterior mandible: report of 10
cases. J Oral Maxillofac Surg 2011;69:
1919-22.

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22. Oliva J, Oliva X, Oliva JD. All on three

delayed implant loading concept for the
completely edentulous maxilla and mandible: a
retrospective 5 year follow-up study. Int J Oral
Maxillofac Implants 2012;27:1584-92.
23. Dekok IJ, Chang KH, Lu TS, Cooper LF.
Comparison of three-implant-supported
xed dentures and two-implant-retained over
dentures in the edentulous mandible: a pilot
study of treatment efcacy and patient
satisfaction. Int J Oral Maxillofac Implants
2011;26:415-26.
24. Cawood JI, Howell RA. A classication of the
edentulous jaws. Int J Oral Maxillofac Surg
1988;17:232-6.
25. Peterson J, Wang Q, Dechow PC. Material
properties of the dentate maxilla. Anat
Rec A Discov Mol Evol Biol 2006;288:962-72.
26. Suresh S, Sumathy G, Banu MR, Kamakshi K,
Prakash S. Morphological analysis of the
maxillary arch and hard palate in edentulous
maxilla of South Indian dry skulls. Surg
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27. Jensen OT, Adams MW. The maxillary M-4: a
technical and biomechanical note for all on
four management of severe atrophy-report of
three cases. J Oral Maxillofac Surg 2009;67:
1739-44.
28. Jensen OT, Cottam J, Ringeman J,
Adams M. Transsinus dental implants,
bone morphogenetic protein 2 and immediate function for all on four treatment of
severe maxillary atrophy. J Oral Maxillofac
Surg 2012;70:141-8.
29. Jensen OT, Adams MW, Smith E. Paranasal
bone: the prime factor affecting the decision to
use transsinus vs. zygomatic implants for
biomechanical support for immediate function
in maxillary dental implant reconstruction. Oral
and Craniofac Tissue Eng 2012;2:198-206.
30. Graves S, Mahler BA, Javid B, Armellini D,
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angled implants: a 16 month clinical study of
1110 implants in 276 jaws. Dent Clin North
Am 2011;55:779-9.
31. Jensen OT, Cottam JR, Ringeman JL,
Graves S, Beatty L, Adams MW. Angled
dental implant placement into the vomer/
nasal crest of atrophic maxillae for all on four
immediate function: a 2 year clinical study of
100 consecutive patients. Oral Craniofac
Tissue Eng 2012;2:66-71.
32. Bedrossian E, Rangert B, Stumped L,
Indresano T. Immediate function with the
zygomatic implant: a graft less solution for the
patient with mild to advanced atrophy of the
maxilla. In J Oral Maxillofac Implants
2006;21:937-42.
33. Jensen OT, Adams MW. Secondary stabilization of maxillary M-4 treatment with
unstable implants for immediate function:
biomechanical considerations and
report of 10 cases one year in function.
Oral Craniofacial Tissue Eng 2013;2:
294-302.
34. Tail G, Marla M. Sinus oor elevation using a
bovine bone mineral with or without the
concomitant use of a bilayered collagen
barrier: a clinical report of immediate and
delayed implant placement. Int J Oral Maxillofac Implants 2001;16:713-21.

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35. Williamson RA. Rehabilitation of the resorbed maxilla and mandible using autogenous
bone grafts and osseointegrated implants. Int
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476-88.
36. Cricchio G, Sennerby L, Lundgren S. Sinus
bone formation and implant survival after
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37. Esposito M, Pellegrino G, Pistilli R, Felice P.
Rehabilitation of posterior edentulous jaws:
prostheses supported by 5 mm short implants or by longer implants in augmented
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2011;4:21-30.
38. Parel SM, Phillips WR. A risk assessment
treatment planning protocol for the four
implant immediately loaded maxilla: preliminary ndings. J Prosthet Dent 2011;
106:359-66.

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39. Mattsson T, Kndell PA, Gynther GW,
Fredholm U, Bolin A. Implant treatment
without grafting in severely resorbed maxillae.
J Oral Maxillofac Surg 1999;57:281-7.
40. Krekmanov L, Kahn M, Rangert B,
Lindstrom H. Tilting of posterior mandibular
and maxillary implants for improved prosthesis support. In J Oral Maxillofac Implants
2000;15:405-14.
41. Krekmanov L. Placement of posterior
mandibular and maxillary implants in patients with severe bone deciency: a clinical
report of procedure. Int J Oral Maxillofac
Implants 2000;15:722-30.
42. Malo P, Rangert B, Nobre M. All on 4 immediate function concept with Branemark
system implants for completely edentulous
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Clin Implant Dent Relat Res 2005;7(suppl 1):
S88-94.

43. Malo P, de Araujo Nobre M, Lopes A,

Francischone C, Rigolizzo M. All on four
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medium (3 years) and long term (5 years)
outcomes. Clin Implant Dent Relat Res
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44. Malo P, Nobre M, Lopes A. The rehabilitation of completely edentulous maxillae with
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227-43.
Corresponding author:
Dr Ole T. Jensen
8200 E Belleview Avenue
Suite 520/ East Tower
Greenwood Village, CO 80111
E-mail: oletjensen13@gmail.com
Copyright 2014 by the Editorial Council for
The Journal of Prosthetic Dentistry.

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Volume
APPENDIX
Denition of terms and acronyms
All-on-4: A 4-implant scheme used in
either arch, usually for immediate
function. The complete arch is edentulous or edentulated in conjunction
with implant placement. Typically implants are placed at 30 degree angles in
the posterior to avoid the sinus in the
maxilla or the nerve in the mandible.
Anterior implants are placed variably
but most often angled at 30 degrees.
All-on-4 treatment can be used for the
vast majority of patients, except those
with gross parafunction and partial
maxillary or mandibulectomy.
All-on-3: A 3-implant scheme used in
the highly atrophic mandible. The
technique includes placement of 2
posterior implants inserted into the
mental nerve fossa after nerve reection
posteriorly. Because of reduced arch
length, a single vertical implant is
placed in the midline. This will usually
allow for a 10-12 mm anterior posterior spread. The all-on-3 mandible is
usually 10 mm or less in vertical height
with a much reduced arch length.
All-on-4 Bone Shelf: All-on-4 bone
reduction should be done by prosthetic
prescription by using a denture-guide
in such a way that a new alveolar
plane is established, optimal implant
sites can be identied, and vital structures more easily avoided. The bone
shelf should parallel the inter-pupillary
line. Implant bodies should be placed
ush to the bone shelf, allowing the
abutments and the prosthesis to be
placed on top of the shelf. The bone
shelf is made for both arches with
a recommended 1- mm space from
the incisal edge of the prosthesis
to the bone shelf to allow for a 4 x
4 mm titanium bar-supported nal
prosthesis.
A/P spread: An acronym for anterior
posterior spread: The distance between
the front 2 implants and the back 2
implants is measured by drawing lines

between the front 2 and back 2 implants, then a midline perpendicular

measure is made going posterior off
the front line to intersect the back line.
This distance is the anterior posterior
spread. For the maxilla, 15 mm or
more is desirable.
M-4: The designation of M-4 is based
on the use of 4 implants in the maxilla,
all placed at 30 degree angles and with
the front 2 implants tilting back to miss
the nasal fossa and the back 2 implants
tilting forward to miss the sinus cavities. The implants are aimed toward
the maximum available bone mass
lateral and superior to the base of the
nasal fossa. When viewed with panoramic radiography, the 4-implant
pattern has an M shape, thus the
designation M-4. M-4 treatment can be
done in more than 80% of all maxillary
cases treated and takes advantage of
cortical bone for anchorage for immediate function.
M Point: M point is the surgical aiming point for implant placement in the
maxilla when the treatment involves a
4 implant scheme. M point is the point
of maximum bone mass above the
nasal fossa at the lateral pyriform rim.
More than 80% of the time, enough
bone mass is available for both
the anterior and posterior implants
to gain xation into cortical bone.
When only enough bone for 1 implant
is available, the posterior implant
is anchored there, and the anterior
implant is anchored into midline
bone.
M Point: M point is the surgical aiming point for implant placement in the
maxilla when treatment involves a four
implant scheme and there is robust
bone available usually in a dentate patient undergoing complete dental extractions for all-on -our treatment. M
point differs from M point in that due to
a wide palatal wall and abundance of
cortical bone the posterior implant
placement aiming point is palatal with
apical xation usually found at the
palatal wall/palatal vault junction

The Journal of Prosthetic Dentistry

Issue

superior to the rst bicuspid medial root

extraction site. Anterior implants then
insert in about the lateral incisor position, angle towards the palatal bone
and converge at M point as well. The
pattern is still an M shape when viewed
on panoramic x-ray. This approach
usually allows for rst molar placement
of the posterior implants which eliminates cantilevers and can often avoid
the sinus cavity even when present in
the molar second premolar zone. The
technique can be used more than half
the time for fully dentate patients
undergoing edentulation for all-on-four
therapy.
V-4: The designation of V-4 is based on
the use of 4 implants in the maxilla, all
placed at 30 degree angles with all 4
implants angled forward in an upside
down V formation when viewed with
panoramic radiography. Posterior implants are aimed at the maximum
available bone mass at the lateral pyriform rim above the nasal fossa, while
the anterior 2 implants are directed
from about the lateral incisor positions
forward into the nasal crest at the
midline of the maxilla. V-4 treatment
can be done in almost any patient but
is required in cases of severe maxillary
atrophy when lateral nasal bone sock is
reduced or a conuence of the maxillary sinus and nasal fossa occurs. V-4 is
used about 20% of the time to facilitate
cortical anchorage for immediate
function.
V Point: V point is the surgical aiming
point for implant placement in the
maxilla when the treatment plan involves a 4-implant scheme in the presence of reduced bone stock at the
lateral pyriform rim. V point is the
point of maximum bone mass in the
midline of the maxilla, typically above
the base of the nasal fossa within the
nasal crest near the junction of the
vomer. The nasal crest is present in the
vast majority of patients even in late
stage atrophy. The 2 implants are
directed at 30 degree angles from the
lateral incisor positions toward the
midline with the implants anchoring

Jensen

2014

apically into the cortical bone of the

nasal crest above the nasal oor and
sometimes extending to the nasal crestvomer junction.
N Point: Most anterior deection of
the inferior alveolar nerve within the
bone as the nerve emerges from the
mental foramen. Based on human
cadaver studies, little or no anterior
loop can be found within bone (1mm

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11.e2
or less). N point is a radiographicbased location used as an aiming
point, usually 2 mm anterior to the
N point when placing 30 degree
angled posterior xtures in a 4- implant
scheme used for immediate function.
Pterygoid Implant: An implant placed
into the pterygomaxillary suture at the
posterior maxilla and angled forward
about 30 degrees to provide for

posterior implant support when bone

is not available in the molar and
sometimes premolar sites.
Vomer Implant: Angled implants that
pass into the nasal crest of the anterior
midline maxilla, sometimes extending
superiorly into the vomer junction. The
term vomer implants is a misnomer as
the implants are actually apically
anchored to nasal crest.