All-On-4 Dental

Implant Treatment

What is All-on-4 Treatment

All-on-4 is a revolutionary approach developed over a
decade ago by Paulo Malo and MALO CLINIC team,
which allows the rehabilitation of totally edentulous
patients with the placement of only 4 titanium implants
in each jaw, through a quick and minimally invasive
procedure. The Implants act as a foundation for MALO
CLINIC Bridge, which allows the placement of a fixed set
of teeth, in all similar to natural teeth. This technique
stabilizes bone levels, keeping the jaws healthy. By tilting
45 the two posterior implants, the All-on-4 allows even
those patients with virtually no bone to have fixed teeth
without need of bone transplant. The result is a fixed
(non-removable) natural looking dentition,
indistinguishable from natural teeth.

What is All-on-4 Treatment

The All-on-4 clinical solution has been developed to
maximize the use of available bone and to allow for
Immediate Function. Using only four implants in
edentulous jaws, the solution takes advantage of the
benefits of tilting the posterior.
Implants to provide a secure and optimal prosthetic
support for a prosthetic bridge, even with minimum bone
volume.

Criteria for All-on-4

Patients treated with the technique and therefore
included in the retrospective analysis met the following
criteria:
Jaw bone profile for the placement of at least 4 implants
of at least 10 mm in length in either healed or immediate
extraction sites.
Good general health with acceptable oral hygiene.
Implants achieved stability at insertion.

All-on-4 Implant Procedure

The All-on-4 clinical solution can be performed in two ways:

Flap: All-on-4 using

conventional flap procedure
with traditional planning and
a standardized All-on-4 Guide
for predictable and optimal
positioning of the implants.

2Flapless: All-on-4 with

Flapless: All-on-4 with

NobelGuide using flapless
technique, computer-based
planning and a customized
Surgical Template to correctly
drill and position the
implants.

Implants You Can Use For All-on-4

Parallel implants:
NobelSpeedy Groovy
NobelSpeedy Replace
Brnemark System MkIII Groovy
NobelReplace Straight Groovy
Brnemark System MkIII, TiUnite
Brnemark System MkIV, TiUnite
Replace Select Straight
Tapered Implants:
NobelReplace Tapered Groovy
Replace Select Tapered

Implants You Can Use For All-on-4

Other Items You Will Need:
All-on-4 Guide
Products needed for the restorative
procedure are located in the Product
Catalog found at the back of this
manual.
Manuals:
For a full description of the implant
placement, prosthetic procedures and
all instruments needed, please refer to
the relevant manual for the selected
prosthetic components and/or implant
system.

Treatment Planning
The All-on-4 clinical solution has been developed to maximize the use of
available bone and to allow for Immediate Function. When planning an
All-on-4 treatment using a flap technique, be sure to consider the
following factors:

General Considerations:
Ability to achieve primary implant stability (35 45 Ncm insertion
torque).
No severe parafunctions.
Indicated for totally edentulous maxilla with a minimum bone width of 5
mm and a minimum bone height of 10 mm from canine to canine.
Indicated for totally edentulous mandible with a minimum bone width of 5
mm and minimum bone height of 8 mm in between the mental foramina.
To diminish the cantilever, tilt the posterior implants to a maximum of
45.
If the angulation is 30 or more, it is necessary to splint the tilted
implants.

Treatment Planning
General Considerations (continued..)
For tilted posterior implants, plan the distal screw access holes to be
located at the occlusal face of the 1st molar, 2nd pre-molar or 1st pre-molar.
The All-on-4 treatment does not require a wider opening of the mouth than
a normal straight position of the implants due to the angulation of the
posterior implants.
If there are extraction sites, clean them thoroughly. It is advisable to place
implants between extraction sockets.
Specific Considerations Implants:
If possible, the posterior implants should be 4.0 or 4.3 mm. Note: The 30
Multi-unit Abutment is only available for Regular Platform (RP). The 17
Multi-unit.Abutment is available for Narrow Platform (NP) and Regular
Platform (RP)
When placing posterior implants with an internal connection, make sure
that one of the tri-channel lobes on the implant is pointing distal or slightly
buccal.

Treatment Planning
Specific Considerations
Implants:
If possible, the posterior implants
should be 4.0 or 4.3 mm. Note: The
30 Multi-unit Abutment is only
available for Regular Platform (RP).
The 17 Multi-unit.Abutment is
available for Narrow Platform (NP)
and Regular Platform (RP)
When placing posterior implants
with an internal connection, make
sure that one of the tri-channel lobes
on the implant is pointing distal or
slightly buccal.

Treatment Planning
Specific Considerations Prosthetics:
No extensions over one-tooth on each side for the
immediate all-acrylic bridge, which should have a
maximum of 12 teeth.
If the patients removable prosthesis is in good
condition, it may be used to fabricate the immediate
all-acrylic bridge.
For proper esthetics and function, the final bridge
should have 12 teeth.

All-on-4 with NobelGuide

The All-on-4 with NobelGuide enables you to use CT
scan data as the basis for surgical planning in a 3D
computer environment. From your computer-based
planning, Nobel Biocare provides you with a Surgical
Template to guide you safely during flapless surgery.
To take advantage of Immediate Function and place a
highly esthetic prosthetic reconstruction at the time of
surgery, non-engaging 30 Multi-unit Abutments RP are
used for the posterior implants. The dental laboratory
fabricates an acrylic jig for transferring the ultimate
position of the angled abutment from the model to the
patient.

All-on-4 with NobelGuide

The All-on-4 with NobelGuide enables you to use CT
scan data as the basis for surgical planning in a 3D
computer environment. From your computer-based
planning, Nobel Biocare provides you with a Surgical
Template to guide you safely during flapless surgery.
To take advantage of Immediate Function and place a
highly esthetic prosthetic reconstruction at the time of
surgery, non-engaging 30 Multi-unit Abutments RP are
used for the posterior implants. The dental laboratory
fabricates an acrylic jig for transferring the ultimate
position of the angled abutment from the model to the
patient.

Implants You Can Use For All-on-4 With

Nobelguide:

Software you will need for All-on-4

with NobelGuide:
Procera Software for ComputerBased Planning
Parallel implants:
NobelSpeedy Groovy
NobelSpeedy Replace
Brnemark System Mk III Groovy
NobelReplace Straight Groovy
Tapered implants:
NobelReplace Tapered Groovy

Implants You Can Use For All-on-4 With

Nobelguide:
Other items you will need:
Surgical Template ordered in
Procera Software
Products needed for the restorative
procedure are located in the Product
Catalog found at the back of this
manual.
Manuals:
NobelGuide Concept Manual
For a full description of the implant
placement, prosthetic procedures and
all instruments needed,
Please refer to the relevant manual for
the selected prosthetic components
and/or implant system.

Treatment Planning
The All-on-4 clinical solution has been developed to maximize the use of
available bone and allow Immediate Function. When planning an All-on4 with NobelGuide treatment, be sure to consider the following factors:

General Considerations:

When using NobelGuide computer-based planning, a CT scan using a

Radiographic Guide is required. Please refer to the NobelGuide Concept
Manual
for details.
Ability to achieve primary implant stability (3545 Ncm insertion torque).
No severe parafunctions.
Indicated for totally edentulous maxilla with a minimum bone width of 5
mm and a minimum bone height of 10 mm from canine to canine.
Indicated for totally edentulous mandible with a minimum bone width of 5
mm and minimum bone height of 8 mm in between the mental foramina.
The sites must be fully healed.
To diminish the cantilever, tilt the posterior implants to a maximum of 45.

Treatment Planning

General Considerations (continued):

If the angulation is 30 or more, it is necessary to splint the tilted

implants.
For tilted posterior implants, plan the distal screw access holes to be
located at the occlusal face of the 1st molar, 2nd pre-molar or 1st premolar.
The All-on-4 treatment does not require a wider opening of the mouth
than a normal straight position of the implants due to the angulation of
the posterior implants. However, as with all Nobel- Guide treatments,
it is important to compensate for the extra height needed for
NobelGuide components and instruments

Treatment Planning
Specific Considerations Implants:

If possible, the posterior implants should be 4.0 or 4.3 mm.

Note: The 30 Multi-unit Abutment Non- Engaging is only
available for the Regular Platform (RP).

Specific Considerations Prosthetics:

No extensions over one-tooth on each side for the immediate

all-acrylic bridge, which should have a maximum of 12 teeth.
If the patients removable prosthesis is in good condition, it
may be used to fabricate the immediate all-acrylic bridge
For proper esthetics and function, the final bridge should have
12 teeth.

Checklist
Prior to and
Surgery
Correct Implants,
Guided Components
Instruments
Operation Specification
Surgical Template
Surgical Index
Prosthetic Components and Instruments

The jig construction for placing 30 Multi-unit Abutments

Non-Engaging, which includes:
1. Impression Coping Open Tray Multi-unit
2. Guide Pin
3. Abutment Holder
4. Jig Stabilizer
5. 30 Multi-unit Abutment Non-Engaging
6. Abutment Screw

How Are All-on-4 Dental Implants Different

From Dentures?

All-on-4 implants are a permanent set of teeth that look and feel like
natural teeth. All-on-4 dental implants:
Are permanent teeth that are brushed and cleaned like natural
teeth
Do not have to be taken out
Do not need adhesives
Are comfortable because they do not press down on your gums
Allow you to experience the hot and cold of your food, as well as
the taste
Allow you to bite with increased force (up to 70% more), so you
can eat all of your favorite foods again
Prevent bone deterioration
Restore your facial features

How Do All-on-4 Dental Implants Compare

To Traditional Implants?
The All-on-4 dental implant technique utilizes only four
implants per arch, whereas traditional implants utilize
anywhere from six to eight implants, or more, in each arch.
The implants of the All-on-4 procedure are also placed at an
angle, which allows for increased contact by using the
natural support of your bone. In addition, the All-on-4
procedure requires no bone grafting for most patients,
which is common in traditional implant procedures.
Therefore, All-on-4 dental implants save time, money, and
discomfort.

How long is the All-on-4 dental implant surgery?

The surgery takes approximately 2.5 hours per arch.
What is the success rate with All-on-4 Dental Implants?
Published studies show a 98% success rate using All-on-4 dental implants.
Who is the ideal candidate for All-on-4 Dental Implants?
The ideal candidate for the All-on-4 dental implant procedure from The
Implant Center at Dental Associates is someone who is currently wearing
dentures or who will need dentures in the future. Age doesnt matter but
dental implant candidates should be in good health.

Where will my replacement teeth be made?

The Implant Center at Dental Associates does everything inhouse. Your new teeth will be crafted by certified lab technicians
on-site. In fact, every part of your procedure, from consultation to
follow-up care happens under one roof.
Will my results look natural?
Absolutely. The All-on-4 dental implant technique gives you
permanent teeth that look, feel and function just like real teeth.
No one will know you have implants unless you tell them.
Why don't I get my permanent set of teeth the day my implants
are placed?
As with any surgery, you need time to heal. However, you will not
leave our office without teeth! A temporary set of teeth will be
placed on your implants. Once the healing process is complete,
your permanent teeth will be placed at a follow up visit
approximately six to eight months after surgery.

What if I just need implants on my bottom arch? What if I

someday need All-on-4 dental implants on both arches?
All-on-4 implants can be placed on just the upper or lower arch.
Your implant specialists will evaluate your circumstance and if he
or she feels you might eventually need replacement teeth on both
the upper and lower arches, he or she might suggest performing
the procedure on both arches at the same time. This provides
better results while also saving time and money. Your doctor will
work with you to determine what best meets your needs both
health wise and cost wise.
What type of cleaning is required after an implant is placed?
Dental implants should be treated like your natural teeth, daily
brushing and flossing is recommended. Our team of specialists and
dental hygienists will review oral hygiene instructions with you
and will recommend the most appropriate oral hygiene treatment
plan to fit your needs.
Are there any additional costs/fees to expect?
All fees will be discussed prior to surgery during the consultation
appointment.

Benefits of All-on-4 Implant

Stability Even In Minimum Bone Volume
By tilting the two posterior implants, longer implants can
be used in minimum bone volume, increasing bone-toimplant contact and reducing the need for vertical bone
augmentation. The tilted posterior implants can be
anchored in better quality anterior bone, reducing
cantilevers and thus improving support of the prosthesis.
Good clinical results
Biomechanical measurements show that tilted implants,
when part of prosthetic support, do not have a negative
effect on the load distribution. The tilting of implants has
been used in clinical practice for over a decade and has
shown good results.

Benefits of All-on-4 Implant

Planning With Nobelguide Treatment Concept
All-on-4 treatmentscan be planned and performed using
the NobelGuide treatment concept, ensuring accurate
diagnostics, planning and implant placement. The
NobelGuide Software allows for detailed diagnostics such
as identification of available bone, virtual implant
placement according to the anatomical situation and
prosthetic needs, and ordering of an individualized
surgical template. NobelGuide supports minimally
invasive flapless techniques as well as surgical access
through mini-flaps and full flaps, while the surgical
template ensures guided and therefore exact implant
placement.

Benefits of All-on-4 Implant

Prosthetic flexibility
With an All-on-4 treatment, patients benefit from an
immediate implant-supported restoration, as a provisional
prosthesis is screwed onto the implants right after surgery.
Final solutions for All-on-4 treatments include both fixed
prostheses, such as NobelProcera Implant Bridge Titanium
with acrylic veneering, or individual NobelProcera crowns
cemented to the bridge framework, and removable solutions,
such as acrylic overdentures on a NobelProcera Implant Bar
Overdenture.
Increased efficiency
Efficient treatment flow results in shorter treatment times
and improved patient satisfaction.

Price of the Treatment

The price may vary for each country or region, and normally it is
divided in two phases
The first phase involves removing any remaining teeth, and
placing the four dental implants along with an immediate
temporary bridge secured to the four implants. This phase may
cost between $10000 to $15000, dependent on the above factors.
Few months after the above phase, once complete healing and
bonding of the implants to the bone has taken place, a final bridge
is usually fabricated. This bridge typically consists of a metal
framework, which strengthens the system, and often has a few
more posterior teeth. This phase may cost between $10000 to
$17500, dependent on the materials used and the type of teeth
(porcelain or acrylic) developed.
The total price (if both superior and inferior arches are
considered) could possibly reach $57000. (Source-Wikipedia)