All-on-4
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The term All-on-4, also known as All-on-Four and All-in-Four, refers to 'all'
teeth A tooth (: teeth) is a hard, calcified structure found in the jaws (or mouths) of many vertebrates and used to break down food. Some animals, particularly carnivores and omnivores, also use teeth to help with capturing or wounding prey, tear ...
being supported 'on four'
dental implant A dental implant (also known as an endosseous implant or fixture) is a prosthesis that interfaces with the bone of the jaw or skull to support a dental prosthesis such as a crown (dentistry), crown, bridge (dentistry), bridge, dentures, denture ...
s. The name All-on-4 is a registered trademark of Nobel Biocare, used globally for both dental products and services. The treatment concept is a
prosthodontics Prosthodontics, also known as dental prosthetics or prosthetic dentistry, is the area of dentistry that focuses on dental prostheses. It is one of 12 dental specialties recognized by the American Dental Association (ADA), Royal College of Sur ...
procedure for total rehabilitation of the
edentulous Toothlessness or edentulism is the condition of having no teeth. In organisms that naturally have teeth, it is the result of tooth loss. Organisms that never possessed teeth can also be described as edentulous. Examples are the members of the fo ...
(toothless) patient, or for patients with badly broken down teeth, decayed teeth, or compromised teeth due to
gum disease Periodontal disease, also known as gum disease, is a set of inflammatory conditions affecting the tissues surrounding the teeth. In its early stage, called gingivitis, the gums become swollen and red and may bleed. It is considered the main c ...
. It consists of the rehabilitation of either edentulous or dentate
maxilla In vertebrates, the maxilla (: maxillae ) is the upper fixed (not fixed in Neopterygii) bone of the jaw formed from the fusion of two maxillary bones. In humans, the upper jaw includes the hard palate in the front of the mouth. The two maxil ...
and / or
mandible In jawed vertebrates, the mandible (from the Latin ''mandibula'', 'for chewing'), lower jaw, or jawbone is a bone that makes up the lowerand typically more mobilecomponent of the mouth (the upper jaw being known as the maxilla). The jawbone i ...
with fixed
prosthesis In medicine, a prosthesis (: prostheses; from ), or a prosthetic implant, is an artificial device that replaces a missing body part, which may be lost through physical trauma, disease, or a condition present at birth (Congenital, congenital disord ...
by placing four implants in the anterior maxilla, where bone density is higher. The four implants support a fixed prosthesis with 10 to 14 teeth, and it is placed immediately, typically within 24 hours of surgery. The All-On-4 solution, with the latest technology in computer aid design/Mill (cad/cam) has evolved including the All-on-bar concept, which is adding a milled titanium bar structure to the dental implants, which helps them working together to protect the implants from failure, even after the hybrid bridge is broken. This concept helps the clinician provide a better long-lasting solution, instead of a conversion-denture which is a chair side repair and modified denture. The All-On-Bar reduces the appointments, eliminating the Denture Conversion technique, by replacing it with a long lasting hybrid. Some patients keep this option as their final due to a lower budget or because the space is limited for other final solutions. PMMA (polymethyl methacrylate AKA acrylic) or denture teeth over the titanium bar wears out over time and needs replacement, this is a controversial topic since the PMMA has the advantage of being shock absorbent. This helps the implants receive less stress during mastication forces but keeping a solid structure on the inside. Many professionals think this is a better solution, keeping in mind that the bridge can be switched to a new one a few years after. In recent years zirconium has become a highly researched material and has shown to be one of the best options for the prosthetic teeth (Manufactured by Zirkonzahn) used in the All-on-4 procedure. Implants created from zirconium have many benefits and are much more durable than your average, run of the mill ceramic or PMMA implants. Unlike dentures which can slip out of place or ceramic and PMMA veneers which are prone to chip, zirconium implants offer greater longevity. Thus, they are often seen as a lifelong investment rather than a temporary solution. Zirconia is also a natural compound, and its translucent material allows light to pass through, creating a more natural and whiter smile compared to more traditional materials that block the light making teeth appear false. Implant manufacturer Nobel Biocare AB of
Gothenburg Gothenburg ( ; ) is the List of urban areas in Sweden by population, second-largest city in Sweden, after the capital Stockholm, and the fifth-largest in the Nordic countries. Situated by the Kattegat on the west coast of Sweden, it is the gub ...
, Sweden, was among the first to identify the evolution of the All-on-4 technique as a potential valid and cost-effective alternative to conventional implant techniques, and funded studies by
Portuguese Portuguese may refer to: * anything of, from, or related to the country and nation of Portugal ** Portuguese cuisine, traditional foods ** Portuguese language, a Romance language *** Portuguese dialects, variants of the Portuguese language ** Portu ...
dentist
Paulo Maló Paulo Maló is a Portuguese people, Portuguese dentist and businessman. Early life and career Paulo Maló was born in Portuguese Angola (an overseas territory of Portugal until 1975 in Portugal, 1975) and moved to mainland Portugal in the 1960 ...
to determine the efficacy of this approach. During this time, this technique was also used by various other clinicians around the world. All-on-4 is not an invention, but rather a treatment technique that has evolved over time, and has the following features: *four
dental implant A dental implant (also known as an endosseous implant or fixture) is a prosthesis that interfaces with the bone of the jaw or skull to support a dental prosthesis such as a crown (dentistry), crown, bridge (dentistry), bridge, dentures, denture ...
s to support a full fixed bridge (documented since 1977) *the use of angulated implants in the back to overcome bony deficiencies or anatomical structures (documented since 1990) *immediate loading (documented since 1990) The All-on-4 treatment concept is a
prosthodontic Prosthodontics, also known as dental prosthetics or prosthetic dentistry, is the area of dentistry that focuses on dental prostheses. It is one of 12 dental specialties recognized by the American Dental Association (ADA), Royal College of Surge ...
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 Dentures (also known as false teeth) are prosthetic devices constructed to replace missing teeth, supported by the surrounding soft and hard tissues of the oral cavity. Conventional dentures are removable (removable partial denture or complet ...
. 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 graft Bone grafting is a type of transplantation used to replace missing bone tissue or stimulate the healing of fractures. This surgical procedure is useful for repairing bone fractures that are extremely complex, pose a significant health risk to the ...
ing. The All-on-4 technique takes advantage of the dense bone that remains in the front part of the jaws, and by placing the two posterior implants on an angle to avoid the
sinus Sinus may refer to: History * a sac in front of body worn into a toga, in the typical style of wearing it Anatomy * Sinus (anatomy), a sac or cavity in any organ or tissue ** Paranasal sinuses, air cavities in the cranial bones, especially those ...
cavities in the upper jaw and the nerve canal in the lower jaw. The cost of the All on 4 procedure varies based on the final prosthetic material. Acrylic resin teeth over titanium bar is substantially cheaper resulting in a total cost of around $30K per arch/jaw in the United States. Premium prosthetic materials like Zirconium can result in a total treatment cost between $36K to $40k per arch/jaw in the United States. The cost of all on 4 dental implants are similar in Europe and in the UK but with the rising popularity of dental tourism the average costs are significantly lower (50%-70%) in countries such as Thailand, Mexico and Turkey. 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
cone beam computed tomography Cone beam computed tomography (or CBCT, also referred to as C-arm CT, cone beam volume CT, flat panel CT or Digital Volume Tomography (DVT)) is a medical imaging technique consisting of X-ray computed tomography where the X-rays are divergent, ...
(CBCT) scan. The All-on-4 protocol is for at least four implants to be placed in a jaw. The back implants are typically angled approximately 30 to 45 degrees from the occlusion (biting plane). The implant is placed in front of the
maxillary sinus The pyramid-shaped maxillary sinus (or antrum of Nathaniel Highmore (surgeon), Highmore) is the largest of the paranasal sinuses, located in the maxilla. It drains into the middle meatus of the noseHuman Anatomy, Jacobs, Elsevier, 2008, page 209- ...
in the upper jaw (
maxilla In vertebrates, the maxilla (: maxillae ) is the upper fixed (not fixed in Neopterygii) bone of the jaw formed from the fusion of two maxillary bones. In humans, the upper jaw includes the hard palate in the front of the mouth. The two maxil ...
), and in front of the menial nerve in the lower jaw (
mandible In jawed vertebrates, the mandible (from the Latin ''mandibula'', 'for chewing'), lower jaw, or jawbone is a bone that makes up the lowerand typically more mobilecomponent of the mouth (the upper jaw being known as the maxilla). The jawbone i ...
). The head of the implant emerges in approximately the second
premolar The premolars, also called premolar Tooth (human), teeth, or bicuspids, are transitional teeth located between the Canine tooth, canine and Molar (tooth), molar teeth. In humans, there are two premolars per dental terminology#Quadrant, quadrant in ...
position. This will allow a molar tooth to be cantilevered posterior, resulting in a denture or bridge with approximately twelve teeth.


References

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