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All-On-4 Treatment Concept REVIEW ARTICLE ISSN No 2230-7885 All-On-4 Treatment Concept - CODEN JPBSCT NLM Title J Pharm Biomed Sci A Review DOI https://doi.org/10.20936/JPBMS/170302 ABSTRACT Swati Sharma*, Being edentulous negatively impacts oral health related quality of life. There are several prosthetic options to rehabilitate such cases such as conventional complete dentures, Reena Luthra, implant supported removable and implant supported fixed prosthesis. Implant supported Monika Makkar, prosthesis may not be feasible in many conditions because of the vicinity of vital anatom- Preetinder Singh, ical structures, poor bone quality and quantity. Poonam Pathania “All-on-4” is a concept for completely edentulous maxilla and mandible, where patient can be taken care of in respect of vicinity of vital structures. The patient can also be Department of Prosthodontics, Crown & benefited with the immediate rehabilitation of edentulous arches which helps maintaining Bridge & Oral Implantology, Swami Devi Dyal selfconfidence and quality of life. Hospital and Dental College, Barwala KEYWORDS all-on-4, tilted implants, severe atrophy n Address reprint requests to: *Dr. Swati Sharma, Department of Prosthodontics, Crown & Bridge & Oral Implantology, Swami Devi Dyal Hospital and Dental College, Barwala INTRODUCTION E-mail: [email protected] In the 1980s, implant therapy for the edentulous arch was a major focus. n Article citation: Sharma S, Luthra R, Clinicians preferred either fixed prostheses supported by five to seven or Makkar M, Singh P, Pathania P. All-on-4 treatment concept - a review. more implants or the placement of two or four inter-foraminal implants 1 J Pharm Biomed Sci for the retention of removable dentures . Implant supported prosthesis 2017;07(3):53–56. may not be feasible in many conditions because of the vicinity of vital Available at www.jpbms.info anatomical structures like mandibular canal or maxillary sinus. Over the years, many techniques, procedures, and materials have been introduced Statement of originality of work: The manuscript has been read and approved by all to solve the complex problems associated with treatment of atrophic jaws the authors, the requirements for authorship have and avoid the vicinity of vital anatomical structures such as the use of short been met, and that each author believes that the implants, alveolar distraction osteogenesis, guided bone generation, use manuscript represents honest and original work. of intraoral and extraoral autogenous bone grafts, nerve repositioning etc. Source of funding: None. The high cost, time and morbidity associated with such approaches have 2 Competing interest / Conflict of interest: The limited their application . At the beginning of the millennium, distally author(s) have no competing interests for financial tilted implants were proposed, enabling the use of denser bone located in support, publication of this research, patents, the anterior mandible for improving bone anchorage, and replacement of and royalties through this collaborative research. posterior teeth without extended cantilevers and avoiding bone grafting All authors were equally involved in discussed procedures. research work. There is no financial conflict with the subject matter discussed in the manuscript. One of the early designs of the All-on-4 style concept can be traced back to Mattson and colleagues, in 1999 whereby they treated, patients Disclaimer: Any views expressed in this paper with severely resorbed edentulous maxilla by inserting 4 to 6 implants in are those of the authors and do not reflect the official policy or position of the Department of the premaxilla to avoid sinus augmentation and successfully restored them Defense. with fixed prosthesis with 12 teeth supported by superstructure3. In 2000, Krekmanov and colleagues were also able to demonstrate posterior tilted implant-supported prosthesis was possible4. The All-on-4 immediate load- ing concept was developed, institutionalized and systematically analyzed in the 2003 by a dentist Paulo Malo and colleagues3. This concept uses 2 verti- cal anterior implants in conjunction with 2 distally tilted inclined implants with their apices positioned anterior to the sinus wall or mental foramen. It involves the use of straight and angled multiunit abutments, which sup- port a provisional, fixed, and immediately loaded, full arch prosthesis. It has been developed to maximize the use of available bone and allows immediate function. In this technique, four implants are placed in the anterior region of the jaw between the two mental foramina in the mandible and between the mesial walls of the maxillary sinus in the maxilla. The two anterior implants follow the jaw anatomy and the two distal implants are tilted at 45° angulation. Many long-term studies and published data on the All-on-4 concept reported cumulative survival rates between 92.2% and 100%2. Copyright © 2017 Received Date: 15 January 2017 – Accepted Date: 02 March 2017 – Published Online: 10 March 2017 54 Swati Sharma Paul Malo did retrospective clinical studies and magnitude between models of implants placed at 0º, found that long-term outcomes ( upto 10 yeras ) of 15º, 30º, but increase in strain pattern for 45º angled 245 patients with completely edentulous mandibles implants10. Angulated abutments less than 45° have rehabilitated with the All-on-4 treatment concept and found to increase the bone mass and mineralization. reported cumulative implant survival rates of 93.8% and Greater angulation can increase the strain and result in 94.8% using the patient and implant as units of analysis, crystal brown breakdown. respectively5. In general, the magnitude of stress and strain for Kan et al. said that combining these 2 concepts, the angled abutments was within or slightly above the phys- All-on-4 immediate-function concept is a simple, safe, iologic limits. The use of angled abutments on two tilted and effective surgical and prosthetic protocol for imme- implants placed in a curved arch and with cross-arch diate function (within 2 h) of four implants supporting splinting might help decrease the stresses around the a fixed prosthesis in a completely edentulous mandible. distal implants. The treatment can be predictable with a high implant Parel and Phillips conducted a retrospective analy- survival rate6. sis of implant performance to determine the efficacy Babbush et al. described a protocol of combining of maxillary complete arch reconstructions when only the 3.5-mm-diameter NobelActive implants with the 4 implants are used. They identified several factors in All-on-4 concept and reported on the results of 227 maxillary implant failure and concluded that planning implants after 1 to 3 years of follow-up. The cumulative process may also help determine if more than 4 implants survival rate was 98.7% at the end of 3 years, with a or an implant variation such as zygoma or pterygoid 100% prosthetic survival rate7. implants might be needed to help avoid failure3. Lopes et al. did a prospective study to evaluate the The All-on-4 concept advocates immediate loading. medium- and long-term outcomes of the rehabili- A slight load on healing bone shortens healing time rather tation of completely edentulous jaws in immediate than prolonging. Immediately loaded implants osseointe- function with the All-on-4 treatment concept using a grate provided that forces and implant micromotion are computer-guided surgical protocol and reported an controlled. Thus, immediate-function protocols help to overall 96.6% cumulative survival rate after 5 years of rehabilitate the completely edentulous maxilla or mandi- follow-up8. ble with a full-arch fixed acrylic prosthesis connected on Zampelis et al. did a study using two dimensional the day of surgery10. finite element analysis, to evaluate if the tilting of splinted implants affects the stress distribution in the General considerations bone surrounding the implant cervix, and to investi- gate if the use of tilted implants as distal abutments is The procedure is indicated if there is a minimum bone biomechanically superior to the use of distal cantilevers. width of 5 mm and minimum bone height of 10 mm They said that distal tilting of implants splinted by fixed from canine to canine in the maxilla and 8 mm in man- restorations does not increase bone stress compared to dible10. An implant diameter of at least 4.0 mm, espe- normally placed, vertical implants. There is a biome- cially for the two distal tilted implants, has been thought chanical advantage in using tilted distal implants rather necessary to ensure adequate anchorage. The patient than distal cantilever units9. The spread of the implants should have no severe parafunctional habits and a stan- and stiffness of the prosthesis will reduce the bending dard mouth opening (40 mm). It cannot be carried out of the implant. The more distal position of the posterior satisfactorily if there are remaining teeth that interfere implant and the resulting shorter cantilever may have a with the planning of implant placement or in patients role in the reduction of stress values in the implant10. with insufficient mouth opening as it is difficult to Strain gauge measurements performed by Krekmanov accommodate surgical instrumentation for tilted place- showed no significant differences in forces and bending ment of implants3. moments between titled and non tilted implants. From a surgical perspective, careful implant site Theoretical models show that an increased pros- preparation (including tapping), use of relatively low thetic base, due to the inclination of implants can reduce torque producing implants, the preparation of an osse- the force acting over the implants. Therefore, from a ous shelf to level the alveolar ridge and the provision of biological point of view, the position of the neck of the adequate interocclusal space are important. implant can be more important than the inclination of While designing for the location of the implant the implants themselves4. Bevilacqua et al. demonstrated placement, the prosthodontist must consider the A-P that tilting of the distal implant by 30º decreased the spread of the implants.
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