The technique for total rehabilitation of the edentulous patient or for patients with badly broken down teeth, decayed teeth or compromised teeth due to gum disease, known as the All-on-4 treatment concept, is a prosthodontics procedure. The All-on-4 or simply All on 4 or All on Four concept was developed, institutionalized and systematically analyzed in the 1990s through studies funded by Nobel Biocare in collaboration with a Portuguese dentist Paulo Maló. It consists of the rehabilitation of the edentulous maxilla and mandible with fixed prosthesis by placing four implants in the anterior maxilla, where bone density is higher. The four implants support a fixed prosthesis with 12 to 14 teeth and it is placed immediately on the day of surgery. All-on-4 is a registered trademark of Nobel Biocare.
Description of the procedure
The All-on-4 treatment concept is a prosthodontic procedure (i.e replacement of missing teeth) that provides a permanent, screw-retained, same-day replacement for the entire upper and / or lower set of teeth with a bridge or denture. The procedure is best for patients with significant tooth loss or decay and for people whose bone loss in the jaw area prevents them from getting conventionally oriented (vertical) dental implants. Often, tooth loss is accompanied by loss of the jaw bone which poses the problem of reconstruction of the jaw bone requiring bone grafting. The All-On-4 protocol is considered to be a graftless solution thereby avoiding the long and costly road of rebuilding bone when conventionally oriented implants are used. For the implementation to be successful a careful analysis of the bone structure needs to be made. The most ideal way to evaluate the bone is by a CBCT scan. The All-On-4 protocol is for at least 4 implants to be placed in a jaw. The back implants are typically angled approximately 30 to 45 degrees from the biting plane. The implant is placed in front of the maxillary sinus in the upper jaw (maxilla) and in front of the mental nerve in the lower jaw (mandible). The head of the implant emerges in approximately the second premolar position. This will allow a molar tooth to be cantilevered posterior resulting in a denture or bridge with approximately 12 teeth.
The All-on-4 treatment concept owes its name to the very nature of the method, which consists of applying a dental prosthesis with at least twelve teeth (bridge) fixed in the jaw, based only on four titanium implants.
The specific implants or pillars used by Malo are protected by international patenting.
Patent claims for the dental implant fixation
According to the first claim accepted under the European patenting process, the implant is characterized by having a form that allows an effective anchoring even in a jaw bone with a combination of soft and hard bone portions or inlays, which fixture can be applied in holes with diameters which are substantially smaller than a main diameter of the fixture so as to produce a clamping effect on the fixture from the soft bone portion or portions, said fixture comprising an outer surface, the main diameter, an end surface and a front portion, which from the point of view of diameter grows very much narrower towards the end surface and which is arranged with both a cutting function and a threading function and is thus able, upon contact with a hard bone portion or portions, to penetrate through these hard bone portions without causing any substantial tendency for displacement of the respective hard bone portion, and a thread which has one, two or more thread turns and extends along the greater part of the outer surface and also down along the front portion while substantially maintaining its thread profile, wherein the main diameter is 4 mm, the diameter of the end surface is 2 mm, and the front portion has a Height which is substantially equal to the diameter of the end surface.
Price of the treatment
The price may vary for each country or region, and normally it is divided in two phases. The usual price in the United States is described below:
- The first phase involves removing any compromised 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 per jaw, dependent on the above factors.
- Few months (3 to 4 months) after the first 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 stronger and durable materials. This phase may cost between $5000 to $7000 per jaw, dependent on the materials used and the type of teeth (porcelain or acrylic).
The total price (if both upper jaw and lower jaw are considered) could possibly reach $57000. It is important to note that when this treatment is completed by a single doctor, the treatment fees is much lower when compared to a team approach with 2 doctors, where both doctors would charge separate fees, potentially increasing the cost of the treatment.
It should also be noted that a single doctor is usually a general dentist or a Diplomate of the American Board of Oral Implantology/Implant Dentistry. It is important to note that general dentists are not specialists in Dental Implants. Also to be considered All-on-4 it should be the trademarked protocol with Nobel Speedy implants and genuine parts.
- Patzelt SB, Bahat O, Reynolds MA, Strub JR (April 2013). "The All-on-Four Treatment Concept: A Systematic Review". PubMed.
- Zhao X1, DI P, Lin Y, Li JH, Qiu LX, Luo J, Cui HY (October 2014). "Implanting the edentulous jaws with "All-on-4" immediate reconstruction: a preliminary clinical observation". PubMed.
- Maló, Paulo; Rangert, Bo; Nobre, Miguel (2003). "'All-on-Four' Immediate-Function Concept with Brånemark System Implants for Completely Edentulous Mandibles: A Retrospective Clinical Study". Clinical Implant Dentistry and Related Research 5: 2–9. doi:10.1111/j.1708-8208.2003.tb00010.x. PMID 12691645.
- Malo, Paulo; Rangert, Bo; Nobre, Miguel (2005). "All-on-4 Immediate-Function Concept with Brånemark System Implants for Completely Edentulous Maxillae: A 1-Year Retrospective Clinical Study". Clinical Implant Dentistry and Related Research 7: S88–94. doi:10.1111/j.1708-8208.2005.tb00080.x. PMID 16137093.
- "Trademarks". Nobel Biocare. May 25, 2011.
- Maló, P; Nobre, M; Lopes, A (2011). "Short implants in posterior jaws. A prospective 1-year study". European journal of oral implantology 4 (1): 47–53. PMID 21594219.
- Maló, Paulo; De Araújo Nobre, Miguel (2011). "Implants (3.3 mm Diameter) for the Rehabilitation of Edentulous Posterior Regions: A Retrospective Clinical Study with Up to 11 Years of Follow-Up". Clinical Implant Dentistry and Related Research 13 (2): 95–103. doi:10.1111/j.1708-8208.2009.00188.x. PMID 19681926.
- Malo, Paulo; de Araújo Nobre, Miguel; Lopes, Armando; Moss, Steve M.; Molina, Guillermo J. (2011). "A longitudinal study of the survival of All-on-4 implants in the mandible with up to 10 years of follow-up". Journal of the American Dental Association 142 (3): 310–20. doi:10.14219/jada.archive.2011.0170. PMID 21357865.
- WO patent 2004091424, Carvalho, Paulo Malo, "Fixture for anchoring in jaw bone", issued October 28, 2004