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 func- tion. 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 other- wise 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.
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.
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.
NOTE
A bone mill is intended for use only with Brånemark System and NobelSpeedy Groovy implants.
• A 30-degree multiunit abutment is placed and tightened to 15 Ncm with the Unigrip screwdriver machine and manual torque wrench prosthetic. The same procedure is performed on the opposite posterior site.
3. Anterior Site Preparation (Fig. 18-5)
• Two anterior sites are prepared as far apart as possible, allow- ing a safe distance from the apex of the posterior implants.
• A bone mill is used to seat the abutments correctly, if applicable.
NOTE
• A bone mill is intended for use only with Brånemark System and NobelSpeedy Groovy implants.
Straight or 17-degree multiunit abutments are placed, allow- ing for proper emergence of the prosthetic screw
• The 17-degree multiunit abutments are tightened to 15 Ncm using the Unigrip screwdriver machine and manual torque wrench prosthetic.
• Straight multiunit abutments are tightened to 35 Ncm using the screwdriver machine multiunit and manual torque wrench prosthetic.
4. Take an Impression (Fig. 18-6)
• After suturing, the multiunit impression copings open tray is connected to the multiunit abutments.
• An impression is taken using silicone soft putty material and a customized open tray.
5. Laboratory Procedure (Fig. 18-7)
• A model and a restoration are made in the laboratory.
6. Connect the Bridge (Fig. 18-8)
• Chlorhexidine gel is placed inside the copings, and the all-acrylic bridge is connected to the abutments.
• The abutments are tightened to 15 Ncm using a Unigrip screwdriver machine and manual torque wrench prosthetic.
• The occlusion is checked.
• After a sufficient healing period, established prosthetic procedures are followed for the final restoration, preferably a Procera implant bridge with individualized Procera ceramic crowns.
Edentulous Maxilla
When an All-on-4 treatment also is performed in the maxilla, the following steps are used for the posterior sites, in addition to those for the posterior sites in the mandible.
1. Posterior Site Preparation (Fig. 18-9)
• The anterior wall of the maxillary sinus is identified by drill- ing a small opening on the lateral wall of the maxilla where the anterior wall would be expected.
• The wall is explored with a probe, and the window is extended if necessary.
• The surgical marker is used to mark the position of the ante- rior wall (Fig. 18-10).
• The site preparation is started as posteriorly as possible, allow- ing approximately 4 mm from the sinus wall (Fig. 18-11).
• The drill is inclined as far back as possible (not more than 45 degrees) to minimize the cantilever, and the implants are then inserted (Fig. 18-12).
• A soft tissue model is fabricated using the abutment replicas multiunit (Fig. 18-13).
• Guide pins or laboratory screws are used to place the tempo- rary copings multiunit on the replica. The copings are adjusted if necessary.
• An all-acrylic bridge is fabricated from a high-density acrylic. The weak points of the prosthesis must be reinforced around the cylinders with more acrylic.
NOTE
If possible, a tooth setup should be tried in the patient’s mouth before the bridge is finalized.
FLAPLESS/NOBELGUIDE APPROACH (Fig. 18-14)
Preoperative Checklist
• All-on-4 with NobelGuide
• Correct implants, guided components (Fig. 18-15), and instru- ments
• Operation specification
• Surgical template
• Surgical index
• Prosthetic components and instruments
• Jig construction for placing 30-degree multiunit (Fig. 18-16)
• Nonengaging abutments
• Impression coping open tray multiunit
• Guide pin
• Abutment holder
• Jig stabilizer
• 30° multiunit nonengaging abutment
• Abutment screw
Edentulous Maxilla
The following step-by-step instructions outline the main procedures for using the NobelGuide with the All-on-4 treatment for totally edentulous jaws. (The images show NobelSpeedy Groovy RP implants.)
1. Four implants are placed according to the computer-based plan (Fig. 18-17).
• The surgical template is removed.
2. The multiunit abutments are connected.
• A bone mill is used to seat the abutments correctly, if applicable.
NOTE
A bone mill is intended for use only with Brånemark System and NobelSpeedy Groovy implants.
• The correct size and sterilized straight multiunit abutments are placed in the two anterior sites (Fig. 18-18).
• The abutments are tightened to 35 Ncm using the screwdriver machine multiunit and manual torque wrench prosthetic.
3. The jig is placed to connect the 30-degree multiunit abutments (Fig. 18-19).
• The disinfected jig is placed on the corresponding anterior abutment and posterior implant.
• Correct seating of the jig is verified, and the guide pin is tightened to the anterior abutment.
4. The 30-degree multiunit abutment is connected (Fig. 18-20).
• The 30-degree multiunit abutment is connected using a Unigrip screwdriver and tightened manually.
5. The Jig is disconnected (Fig. 18-21).
• The jig is disconnected by unscrewing first the abutment holder and then the guide pin.
• The entire procedure is repeated for the opposite side.
CAVEAT
The abutment holder connected to the 30-degree multiunit abutment is never unscrewed before the posterior angulated abutment is tightened completely.
6. Final tightening of the 30-degree multiunit abutments is performed (Fig. 18-22).
• The 30-degree multiunit abutment is tightened to 15 Ncm using the Unigrip screwdriver machine and manual torque wrench prosthetic.
All-Acrylic Bridge (Fig. 18-23)
The all-acrylic bridge is delivered with the temporary copings mul- tiunit in three implant positions. An extended hole is located in one of the posterior positions.
1. The temporary coping is connected.
• The bridge is connected with three prosthetic screws and manually tightened with a Unigrip screwdriver.
• A temporary coping multiunit is placed in the extended hole and manually tightened with a Unigrip screwdriver.
• All the screws are tightened to 15 Ncm with a Unigrip screw- driver machine and manual torque wrench prosthetic.
• Tooth color flow composite or acrylic is used to secure the temporary coping to the bridge, with care taken to keep the screw access hole free of composite.
2. The temporary coping multiunit is reinforced (Fig. 18-24).
• The bridge is disconnected.
• The gap between the temporary coping and the bridge is filled with self-curing acrylic.
• The bridge is adjusted and polished.
3. The bridge is connected (Fig. 18-25).
• Chlorhexidine gel is placed inside the copings, and the all-acrylic bridge is connected to the abutments.
• The abutments are tightened to 15 Ncm with the Unigrip screwdriver machine and manual torque wrench prosthetic.
• The occlusion is checked. After a sufficient healing period, established prosthetic procedures are followed for the final restoration, preferably with a Procera implant bridge with individualized Procera ceramic crowns.
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.
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.
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.
NOTE
A bone mill is intended for use only with Brånemark System and NobelSpeedy Groovy implants.
• A 30-degree multiunit abutment is placed and tightened to 15 Ncm with the Unigrip screwdriver machine and manual torque wrench prosthetic. The same procedure is performed on the opposite posterior site.
3. Anterior Site Preparation (Fig. 18-5)
• Two anterior sites are prepared as far apart as possible, allow- ing a safe distance from the apex of the posterior implants.
• A bone mill is used to seat the abutments correctly, if applicable.
NOTE
• A bone mill is intended for use only with Brånemark System and NobelSpeedy Groovy implants.
Straight or 17-degree multiunit abutments are placed, allow- ing for proper emergence of the prosthetic screw
• The 17-degree multiunit abutments are tightened to 15 Ncm using the Unigrip screwdriver machine and manual torque wrench prosthetic.
• Straight multiunit abutments are tightened to 35 Ncm using the screwdriver machine multiunit and manual torque wrench prosthetic.
4. Take an Impression (Fig. 18-6)
• After suturing, the multiunit impression copings open tray is connected to the multiunit abutments.
• An impression is taken using silicone soft putty material and a customized open tray.
5. Laboratory Procedure (Fig. 18-7)
• A model and a restoration are made in the laboratory.
6. Connect the Bridge (Fig. 18-8)
• Chlorhexidine gel is placed inside the copings, and the all-acrylic bridge is connected to the abutments.
• The abutments are tightened to 15 Ncm using a Unigrip screwdriver machine and manual torque wrench prosthetic.
• The occlusion is checked.
• After a sufficient healing period, established prosthetic procedures are followed for the final restoration, preferably a Procera implant bridge with individualized Procera ceramic crowns.
Edentulous Maxilla
When an All-on-4 treatment also is performed in the maxilla, the following steps are used for the posterior sites, in addition to those for the posterior sites in the mandible.
1. Posterior Site Preparation (Fig. 18-9)
• The anterior wall of the maxillary sinus is identified by drill- ing a small opening on the lateral wall of the maxilla where the anterior wall would be expected.
• The wall is explored with a probe, and the window is extended if necessary.
• The surgical marker is used to mark the position of the ante- rior wall (Fig. 18-10).
• The site preparation is started as posteriorly as possible, allow- ing approximately 4 mm from the sinus wall (Fig. 18-11).
• The drill is inclined as far back as possible (not more than 45 degrees) to minimize the cantilever, and the implants are then inserted (Fig. 18-12).
• A soft tissue model is fabricated using the abutment replicas multiunit (Fig. 18-13).
• Guide pins or laboratory screws are used to place the tempo- rary copings multiunit on the replica. The copings are adjusted if necessary.
• An all-acrylic bridge is fabricated from a high-density acrylic. The weak points of the prosthesis must be reinforced around the cylinders with more acrylic.
NOTE
If possible, a tooth setup should be tried in the patient’s mouth before the bridge is finalized.
FLAPLESS/NOBELGUIDE APPROACH (Fig. 18-14)
Preoperative Checklist
• All-on-4 with NobelGuide
• Correct implants, guided components (Fig. 18-15), and instru- ments
• Operation specification
• Surgical template
• Surgical index
• Prosthetic components and instruments
• Jig construction for placing 30-degree multiunit (Fig. 18-16)
• Nonengaging abutments
• Impression coping open tray multiunit
• Guide pin
• Abutment holder
• Jig stabilizer
• 30° multiunit nonengaging abutment
• Abutment screw
Edentulous Maxilla
The following step-by-step instructions outline the main procedures for using the NobelGuide with the All-on-4 treatment for totally edentulous jaws. (The images show NobelSpeedy Groovy RP implants.)
1. Four implants are placed according to the computer-based plan (Fig. 18-17).
• The surgical template is removed.
2. The multiunit abutments are connected.
• A bone mill is used to seat the abutments correctly, if applicable.
NOTE
A bone mill is intended for use only with Brånemark System and NobelSpeedy Groovy implants.
• The correct size and sterilized straight multiunit abutments are placed in the two anterior sites (Fig. 18-18).
• The abutments are tightened to 35 Ncm using the screwdriver machine multiunit and manual torque wrench prosthetic.
3. The jig is placed to connect the 30-degree multiunit abutments (Fig. 18-19).
• The disinfected jig is placed on the corresponding anterior abutment and posterior implant.
• Correct seating of the jig is verified, and the guide pin is tightened to the anterior abutment.
4. The 30-degree multiunit abutment is connected (Fig. 18-20).
• The 30-degree multiunit abutment is connected using a Unigrip screwdriver and tightened manually.
5. The Jig is disconnected (Fig. 18-21).
• The jig is disconnected by unscrewing first the abutment holder and then the guide pin.
• The entire procedure is repeated for the opposite side.
CAVEAT
The abutment holder connected to the 30-degree multiunit abutment is never unscrewed before the posterior angulated abutment is tightened completely.
6. Final tightening of the 30-degree multiunit abutments is performed (Fig. 18-22).
• The 30-degree multiunit abutment is tightened to 15 Ncm using the Unigrip screwdriver machine and manual torque wrench prosthetic.
All-Acrylic Bridge (Fig. 18-23)
The all-acrylic bridge is delivered with the temporary copings mul- tiunit in three implant positions. An extended hole is located in one of the posterior positions.
1. The temporary coping is connected.
• The bridge is connected with three prosthetic screws and manually tightened with a Unigrip screwdriver.
• A temporary coping multiunit is placed in the extended hole and manually tightened with a Unigrip screwdriver.
• All the screws are tightened to 15 Ncm with a Unigrip screw- driver machine and manual torque wrench prosthetic.
• Tooth color flow composite or acrylic is used to secure the temporary coping to the bridge, with care taken to keep the screw access hole free of composite.
2. The temporary coping multiunit is reinforced (Fig. 18-24).
• The bridge is disconnected.
• The gap between the temporary coping and the bridge is filled with self-curing acrylic.
• The bridge is adjusted and polished.
3. The bridge is connected (Fig. 18-25).
• Chlorhexidine gel is placed inside the copings, and the all-acrylic bridge is connected to the abutments.
• The abutments are tightened to 15 Ncm with the Unigrip screwdriver machine and manual torque wrench prosthetic.
• The occlusion is checked. After a sufficient healing period, established prosthetic procedures are followed for the final restoration, preferably with a Procera implant bridge with individualized Procera ceramic crowns.
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