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A Case Study:The All-on-4

Treatment Concept Using

Biohorizons Tapered Internal Implants

Patrick K. Chu, DDS

T
The All-on-4 treatment concept has been taught and done mainly with Noble (Nobel Biocare USA Yorba Linda,
California) Implant system.5 This study evaluated this concept using a Tapered Internal LaserLok Implant system from
BioHorizons (Biohorizons, Birmingham, Alabama). A tapered body implant with reverse buttress self-cutting threads
was used for increased initial stability. This study demonstrates that as long as the principles of ALL-ON-4 Treatment
Concept are observed, an alternative Implant System can be used with great success.

Introduction The All-on-4 concept therefore solves this problem of

The All-on-4 concept using two axially implants in the
anterior region and two tilted posterior implants has been
well documented and published by Malo P. et al with
cumulative survival rates well above 92.2%. This concept
using only four implants per arch is able to provide an
edentulous arch with an immediate function fixed esthetic
provisional prosthesis.4,5,6
Post extraction edentulous patients or long time full
denture patients often desire fixed prosthesis. However,
these patients often present with minimal posterior bone
support. Anatomical structures, namely, the maxillary sinuses
in the maxilla and mandibular nerves in the mandible prevent
implant placement in the posterior regions.
insufficient bone and presents anatomical structures in the
posterior regions by using implants just anterior to the
maxillary sinus in the maxilla and anterior to mental foramen in
the mandible by having them placed on a 30-45 degree angle.
This concept reduces the need for sinus and ridge
augmentation.
Keys to Success
1. Increasing the anterior-posterior distance (A-P Spread)
so that the cantilevers can be better supported.1
The two anterior axially oriented implants should
be placed at the most anterior position of the
dental arch.

Fig. 1: Preoperative view shows the severe protrusiveness of the anterior Fig. 2: Panoramic radiograph shows bilateral maxillary sinus pneumatization
ridges

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Fig. 3: Alveoplasty of maxillary anterior ridge Fig. 4: Angular placement of upper right posterior tilted implant

Fig.5: Angular placement of upper left posterior tilted implant Fig. 6: Instant overdenture abutments attached to angled abutments

The two posterior tilted implants should be placed Case History

at the most posterior position tilted to a maximum
of 45 degrees and be able to avoid the maxillary A healthy non-smoking 65 year-old male partially
sinus or the mental foramen. edentulous, presented with advanced periodontitis and
2. If possible, use wider and longer implants particularly in excessive mobility of his remaining maxillary and
the posterior. mandibular teeth. The upper and lower anterior ridges were
3. Using implants, which can achieve increased initial severely protrusive (Fig. 1). The upper posterior segments
stability. were severely resorbed and bilateral maxillary sinus
4. The counter arch splinting of the four implants with a pneumatization was present (Fig. 2).
fixed prosthesis contributes to the success of this Study models were taken and duplicated. The working
treatment concept. models were mounted and articulated. Facial photos were
5. Canine guided occlusion. taken with maximum smile line established.
6. Patient's smile line should not reveal the junction of the Intraoral photos were also taken. The teeth were removed
prosthesis with the tissue. on the casts and the anterior and posterior ridges were
leveled to the same height. Upper and lower complete
Objectives dentures were fabricated with minimal flange length and full
palatal coverage. The dentures were duplicated using clear
To evaluate the All -on- 4 concept using an alternative acrylic in order to be used as guides. These clear acrylic
Implant System: BioHorizons Tapered Internal Implant duplicates were troughed exposing the ridges and served
System. as surgical guides.

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Fig. 7: Screw access holes are within the confines of denture teeth
Fig. 9: Bone dehiscences shows the implant threads and decortication holes
created for bone graft
Surgical Procedures
The patient was pre-medicated with amoxicillin (500mg,
tid) and chlorhexidine rinse one day before surgery. The
patient was anesthetized with 2% xylocaine (1:100,000
epinephrine).
Plasma Rich In Growth Factors (PRGF) (Biotechnology
Institute, Victora, Spain) was prepared from 40cc of blood
drawn from patient before surgery.2
Maxilla
Intra-sulcular incisions were performed around all
remaining upper teeth and a mid-crestal incision at the
anterior edentulous space. A full thickness flap was raised.
All teeth were then extracted atraumatically. The sockets
were curetted to remove any granulation tissue present. An
alveoplasty of the anterior ridge was completed using a
straight fissure bur based on the pre-op study models (Fig.
3). The bone from the alveoplasty was saved and mixed
with the PRGF and served for later uses.
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Fig. 8: Immediate postoperative panoramic radiograph
Fig. 10: Autogeneous bone graft with a layer of BioOss (Osteohealth,
Shirly, NY)
With the help of the surgical guide and the pre-op
panoramic radiograph the tilted implants of dia. 4.6 x 15mm
were inserted between the 1st and 2nd premolar sockets at
an angle of approximately 40 degree (Figs. 4,5). The two
axial implants of dia. 3.8 x 12mm were placed at the
canines positions. 25 degree angled abutments were used
on the posterior implants to correct the posterior angulation,
and 17 degree angled abutments were used on the anterior
implants to provided a lingual screw access. Instant fixed
overdenture abutments were then attached to the angulated
abutments (Fig. 6). The abutments were adjusted in such a
way so that the overdenture abutments were all protruding
through the trough of the surgical guide in order to prevent
buccal screw access in the prosthetic stage (Fig.7). A
panoramic radiograph was taken (Fig. 8).
Due to the severe protrusive nature of the pre-maxilla,
certain areas of the buccal plate around the implants were
very thin (Fig.9). Subsequently all the implants were grafted
on the buccal aspect with autogeneous bone saved from the
alveoplasty and covered with a layer of BioOss (Osteohealth,
Shirley, New York) (Fig. 10). Fibrin clot membrane prepared
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Fig.11: PRGF fibrin clot membrane Fig. 12: Primary wound closure

Fig. 13: Mid-crestal incision after all remaining mandibular teeth are extracted
Fig.14: Identification of right mental foramen and exiting nerve

from the PRGF was used to cover the grafts (Fig.11). The
flaps were closed with 4.0 PGA suture (Fig 12).

Mandible

All remaining teeth were extracted atraumatically. A

mid-crestel incision was made from first molar to first
molar (Fig. 13). A full thickness flap was raised to expose
the alveolar ridge, and the mental foramen and the exiting
mental nerves were identified (Figs. 14, 15).
An alveoplasty was performed with a fissure bur on the
anterior ridge in order to level it based on the pre-op study
models (Fig.16). The two anterior implants of dia. 3.8 x
15mm were first placed axially at the canines position.
The two posterior implants of dia. 4.6 x 15mm were
placed anterior to the foramen at an angle of Fig. 15: Identification of left mental foramen and exiting nerve
approximately 35 degree (Figs. 17, 18). Periapical x-rays
were taken to verify the positions of the implants (Figs.19,
20). 25 degree angled abutments were used on the
posterior implants. Straight abutments were used on the

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Fig. 16: Alveoplasty of anterior mandibular ridge Fig 17: Angular placement of lower right posterior tilted implant

Fig. 19: Peripical

radiograph confirms
the relative lower
right implant
positions

Fig. 18: Angular placement of lower left posterior tilted implant

anterior implants. The instant fixed overdenture abutments

were attached as in the maxilla (Fig. 21). The ridge was
Fig. 20: Periapical
grafted in the same manner as the maxilla. In addition, radiograph confirms
Alloderm membrane (Biohorizons, Birmingham, Alabama) the relative lower left
was also used to increase the thickness of attached implant position
gingiva at the labial side of the anterior mandible (Fig. 22).
The flaps were closed with 4.0 PGA sutures. Primary
closure was achieved (Fig. 23).

Prosthetic

Holes were drilled through the pre-made immediate

dentures using the surgical guide as an aid to identify the
positions of the overdenture abutments. The holes were
enlarged so that the denture can be properly positioned in
the mouth. All undercuts around the implants and screw
holes were blocked out with liquid dam (Discuss Dental,
Culver City, California). The maxillary denture was first
relined and fitted through the overdenture abutments with
the mid-line aligned and the palate fully seated. After the
reline acrylic was fully cured, the denture was removed by

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Fig. 21: Screw access holes are within the confines of denture teeth Fig. 22: Alloderm (BioHorizons, Birmingham,Alabama) is used to thicken
the attached gingiva

Fig.23: Primary wound closure Fig.24: Intercuspation of finished prosthesis

unscrewing the overdenture abutments. These abutments

were then cut back and the palate of the denture was
removed to transform the denture into an acrylic bridge.
The tissue side of the bridge was made convex and
polished. The bridge was then reattached back to the
implant abutments in the mouth.
The mandibular process followed the same steps as
the maxilla except that the overdenture abutments had to
be cut back first so that when the patient was closed into
occlusion, there would not be any obstructions. The
denture was first fitted, relined, and the patient was
instructed to bite and was held in proper occlusion. The
vertical height was determined by patients intercuspation
with the dentures, therefore the predetermined vertical
height was first recorded by making two dots at the
midline of the upper lip and the chin. The patient was
Fig. 25: Open bite view of finished prosthesis
then instructed to stop at this predetermined height and
held until the reline acrylic was cured (Figs. 24, 25).
The occlusion was adjusted to canine-guided
occlusion (Fig. 26). A final panoramic radiograph was
taken (Fig. 27).

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Fig 26: Buccal view shows canine guided occlusion
Fig.28: Pre-treatment view
The transformation was quite remarkable as evident with
the before and after photos (Figs. 28, 29). The patient
returned after six week, where the bridges were removed in
order to review the soft tissue healing (Figs. 30, 31).
Discussion
The All-on-4 or Tilted Implant treatment concept may
not be considered or adopted as a conventional treatment
modality by many clinicians. However, this treatment concept
using four implants to support a fixed prosthesis without
sinus grafting and posterior bone augmentation is extremely
attractive to certain patients and clinicians.4,6
Originally, this concept of using a minimum number of
implants and the conversion of a inexpensive denture into
an immediate function fixed bridge was thought to benefit a
great number of patients who can not afford conventional
implant rehabilitation. However, with this case study, the
author realized this concept requires very detailed pre-
treatment planning and demands a high level of surgical and
prosthetic expertise. The treatment fee is therefore much
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Fig.27: Final panoramic radiograph
Fig. 29: Post-treatment smile view
higher than placing four conventional single tooth implants.
Dr. Carl Misch in a recent article7 mentioned that the All-
on-4 treatment of placing only four implants in the maxilla,
which has softer bone relative to the mandible, will have a
higher risk of implant failure, therefore, the fee should be
higher to compensate any retreatment necessary.
In Canada, the average treatment fees are $20,000 to
$25,000 per arch. With these high fees, the attractiveness of
this treatment concept may quickly fade for some patients
and clinicans.
Conclusion
In this study, author demonstrated that as long as the
principles of All-on-4 Treatment Concept are observed,
an alternative Implant System can be used with good
success.
Acknowledgements
All the implants and related parts used in this study were donated by BioHorizons.All
the laboratory works were sponsored by ADL Dental Laboratories Inc. Special thanks
to Dr. Gitte Frederiksen for her assisting in the surgery and her valuable opinions.
 tapered internal

Overdenture treatment using

Tapered Internal implants
optimal esthetics
crestal bone attachment
maximum bone maintenance
excellent primary stability
inhibit epithelial cell downgrowth
compressive bone loading

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