18: All-on-4 Implants

CHAPTER 18 All-on-4 Implants

ARMAMENTARIUM

All-on-four guide
Cold-cure acrylic and GC Pattern resin
Dental floss, orthodontic ligature wire, and wire cutter
Final or intermediate prosthesis
Impression and bite registration material
Impression trays
Necessary abutments and retaining screws
Necessary impression copings
Prosthetic kit
Surgical kit for the system used
Implants selected

The All-on-4 and All-on-4 with NobelGuide clinical solutions were developed by Dr. Paulo Maló at CM Clinica Maló in Lisbon, Portugal. The All-on-4 clinical solution was developed to maximize the use of available bone and allow immediate function. Using only four implants in edentulous jaws, this technique takes advantage of the benefits of tilting the posterior implants (which are longer than the vertically placed implants that otherwise could be accommodated in the available space) to provide secure, optimum prosthetic support for a prosthetic bridge, even with minimum bone volume.

TECHINIQUE FOR THE ALL-ON-4 CLINICAL SOLUTION

Implants That Can Be Used for All-on-4

Parallel Implants

• NobelSpeedy Groovy
• NobelSpeedy Replace
• Brånemark System Mk III Groovy
• NobelReplace Straight Groovy
• Brånemark System Mk III, TiUnite
• Brånemark System Mk IV, TiUnite
• Replace Select Straight

Tapered Implants

• NobelReplace Tapered Groovy
• Replace Select Tapered

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 All-on-4 treatment is planned using a flap technique, both general and specific considerations must be taken into account.

General Considerations

1. The surgeon must be sure of the ability to achieve primary implant stability (35 to 45 Ncm insertion torque).
2. The patient must have no severe parafunctions.
3. The procedure is indicated for a totally edentulous maxilla with a minimum bone width of 5 mm and a minimum bone height of 10 mm from canine to canine.
4. The procedure is indicated for a totally edentulous mandible with a minimum bone width of 5 mm and a minimum bone height of 8 mm between the mental foramina.
5. To reduce the cantilever, the posterior implants can be tilted to a maximum of 45 degrees.
6. If the angulation is 30 degrees or more, the tilted implants must be splinted.
7. For tilted posterior implants, the distal screw access holes should be located at the occlusal face of the first molar, the second premolar, or the first premolar (depending on the location of the mental foramen).
8. The All-on-4 treatment does not require wider opening of the mouth than normal straight-positioned implants because of the angulation of the posterior implants.
9. If any remaining teeth require removal, the sockets should be cleaned and debrided thoroughly after extraction, and the implants should be placed between the extraction sockets into the interdental bone.

Specific Consideration: Implants

1. If possible, the posterior implants should be 4 or 4.3 mm in diameter.

NOTE

The 30-degree multiunit abutment is available only for regular platform (RP) implants. The 17-degree multiunit abutment is available both for RP and for narrow platform (NP) implants.

2. When posterior implants with an internal connection are placed (Fig. 18-1), one of the trichannel lobes on the implant must be pointing distally or slightly buccally.
image

FIGURE 18-1. One lobe of the anterior implants is positioned midbuccal, and one lobe of the posterior implants is positioned at the distal line angle.

(Courtesy Nobel Biocare, Yorba Linda, Calif.)

Specific Considerations: Prosthetics

1. No extensions over one tooth on each side should be made for the immediate all-acrylic bridge, which should have a maximum of 12 teeth.
2. If the patient’s removable prosthesis is in good condition, it can be used to fabricate the immediate all-acrylic bridge.
3. For proper esthetics and function, the final bridge should have 12 teeth.

FLAP SURGICAL APPROACH

Edentulous Mandible

The following step-by-step instructions outline the main procedures for All-on-4 treatment of a totally edentulous mandible. (The images show NobelSpeedy Groovy RP implants.)

1. Positioning of the All-on-4 Guide (Fig. 18-2)

• An incision is made for flap elevation. A 2-mm twist drill is then used to make a 10-mm osteotomy in the midline.
• The All-on-4 guide is placed in the osteotomy.
2. Posterior Site Preparation (Fig. 18-3)

• A 2-mm twist drill tilted to a maximum of 45 degrees is used to drill to appropriate depth.
image

FIGURE 18-2. Proper identification of the midline is critical.

(Courtesy Nobel Biocare, Yorba Linda, Calif.)

image

FIGURE 18-3. Visual identification of the mental foramen and the anterior nerve loop is very important.

(Courtesy Nobel Biocare, Yorba Linda, Calif.)

NOTE

It is important to identify the mental foramen and exiting inferior dental nerve. The final position of the implant should be at least 6 mm in front of the foramen to avoid the nerve loop.

• Correct angulation is checked with the All-on-4 guide.
• The site is enlarged according to the type of implant used and the density of the bone.
• An implant is installed (Fig. 18-4).
• A bone mill is used to correctly seat the abutment, if applicable.
image

FIGURE 18-4. The use of angulation pins to verify 30-degree preparation is helpful for the placement of a 30-degree abutment in the posterior implants.

(Courtesy Nobel Biocare, Yorba Linda, Calif.)

NOTE

A bone mill is intended for use only with Brånemark System and />

Related posts:

  1. Suggested Readings
  2. Postoperative Instructions for the Patient
  3. 28: Principles of Occlusion in Implantology
  4. 23: Root Form Implant Prosthodontics: Abutments
  5. 3: Evaluation and Selection of the Implant Patient
  6. 6: Preparations for Implant Surgery

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Jan 5, 2015 | Posted by in Implantology | Comments Off on 18: All-on-4 Implants

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