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All-on-4 TM

TREATMENT CONCEPT FOR EDENTULOUS ARCHES


2 All-on-4

At a glance.

Principle Four implants two straight implants in the anterior and two
angled implants in the posterior supporting a provisional, fixed
and immediately loaded full-arch prosthesis

Benefits  Angled posterior implants help avoid relevant anatomical


structures, can be anchored in better quality anterior bone and
offer improved support of the prosthesis by reducing
cantilevers
Angled posterior implants help eliminate the need for bone
grafting by increasing bone-to-implant contact
Final restoration with fixed or removable prosthetic solutions
 Efficient treatment flow results in shorter treatment times and
improved patient satisfaction
 All-on-4 Guide for accurate placement of implants and
abutments
Can be combined with the computer-aided diagnostics and
treatment concept NobelGuide

Indications Edentulous mandible or maxilla

Surgical access Open flap; with NobelGuide: flapless, mini-flap and flap

Prosthetic flexibility Fixed provisional (metal-reinforced) acrylic prosthesis


 Fixed final prosthesis: NobelProcera Implant Bridge in Titanium
with acrylic veneering, or individual NobelProcera crowns
cemented to the bridge framework
Removable final prosthesis: overdenture on a NobelProcera
Implant Bar Overdenture

Available implant All Nobel Biocare implant systems with Multi-unit Abutments
systems NobelSpeedy: the widely documented implant for All-on-4

NobelGuide Prosthetic-driven diagnostics, treatment planning and guided


surgery system

Disclaimer: Some products may not be regulatory cleared/released for sale in all markets. Please contact the local Nobel Biocare
sales office for current product assortment and availability.
All-on-4 3

All-on-4 a proven and successful


TM

concept for edentulous patients.

The All-on-4 treatment concept was


developed to provide edentulous patients Full-arch restoration with only four implants
with an efficient and effective restoration
using only four implants to support an Reduced need for bone grafting
immediately loaded full-arch prosthesis.*
Immediately loaded for efficient and time-saving treatment
Angled posterior implants
For fixed and removable final prosthetic solutions
By tilting the two posterior implants, longer
implants can be used in minimum bone
Scientifically proven and documented
volume, thereby increasing bone-to-implant
contact and reducing the need for vertical
bone augmentation (bone grafting). In
addition, the angled posterior implants can
be anchored in better quality anterior
Planning with NobelGuide
bone and offer improved support of the
All-on-4 can be planned and performed
prosthesis by reducing cantilevers.
using the NobelGuide treatment
concept, ensuring accurate diagnostics,
Good clinical results
planning and implant placement. The
Biomechanical measurements show that
NobelGuide Software allows for detailed
tilted implants, when part of prosthetic
diagnostics such as the identification of Provisional prosthesis for immediate
support, do not have a negative effect on loading
available bone, virtual implant placement
the load distribution.1,2 The tilting of
according to the anatomical situation
implants has been used in clinical practice
and the prosthetic needs, and the ordering
for over a decade and has shown good
of the individualized surgical template.
results.319
NobelGuide supports minimally invasive
flapless techniques as well as surgical
Overall published data on the All-on-4
access through mini-flaps and full flaps,
concept shows cumulative survival rates
with the surgical template ensuring guided
between 92.2 and 100%.2026 The concept
and therefore exact implant placement.
is supported by good clinical outcomes
from studies using protocols in which four
Angled Multi-unit Straight
implants have been placed to support a
Abutment Multi-unit
full-arch prosthesis.21 (17 or 30) Abutment

* If one-stage surgery with immediate


loading is not indicated, cover screws
are used for submerged healing.
4 All-on-4

All-on-4 the efficient treatment


TM

concept with immediate loading.

High stability with only four Wide variety of prosthetic


implants options
Angled posterior implants can Fixed provisional prosthesis
be anchored in better quality for immediate loading.
anterior bone and offer Fixed and removable
improved support of the solutions for final restoration.
prosthesis by reducing
cantilevers.

For all Nobel Biocare


implant systems
Multi-unit Abutments are
Reduced need for vertical
available for all Nobel Biocare
bone augmentation
implant systems.
Angled posterior implants
allow for the use of longer
implants, increasing
bone-to-implant contact and
reducing the need for bone
grafting.
NobelSpeedy
Widely documented implant
Preservation of vital structures
for All-on-4.
Angled posterior implants help
Slightly tapered with a more
avoid the mandibular nerve and
pronounced apical
the maxillary sinus.
taper allowing for under-
preparation.
Designed to achieve high
primary stability in soft to
With or without NobelGuide medium bone and to
Safe and minimally invasive shorten drilling protocols.
surgery with full 3D diagnostics
and planning using NobelGuide.
Traditional open flap surgery
using the All-on-4 Guide for
accurate placement of implants.
All-on-4 5

All-on-4 for fixed and removable


TM

prosthetic solutions.

Only four implants needed Fixed and removable prosthetic All-on-4 step by step

The All-on-4 treatment concept, with its use solutions


of straight and angled Multi-unit Abutments, With All-on-4, patients benefit from an
allows for a firmly-seated restoration on immediate implant-supported restoration,
only four implants two placed vertically in as a provisional prosthesis is screwed
the anterior, two placed at an angle of up to onto the implants right after surgery.*
45 in the posterior region.
Final solutions include both fixed and
By tilting the two posterior implants, the removable prostheses: Insertion of implants
bone-to-implant contact is enhanced, F ixed solutions include NobelProcera
providing optimal bone support even with Implant Bridge Titanium with acrylic
minimum bone volume.21 Additionally, veneering, or individual NobelProcera
tilting of implants in the maxilla allows for crowns cemented to the bridge
improved anchorage in better quality framework.
anterior bone and bicortical anchorage in R emovable solutions include acrylic
the cortical bone of the sinus wall and overdentures on a NobelProcera
the nasal fossa.21 Implant Bar Overdenture, attached by
means of a variety of attachment
Tilting of the posterior implants also helps Securing of Multi-unit Abutments
systems.
avoid vital structures, such as the
mandibular nerve or the maxillary sinus, NobelProcera Implant Bridge and Implant
and results in a better distribution of Bar Overdenture are milled from a
implants along the alveolar crest, which biocompatible titanium monobloc using
optimizes load distribution and allows state-of-the-art CAD/CAM technology,
for a prosthesis with up to 12 teeth and resulting in consistent precision of fit,
minimal cantilevers.20 individualized design and optimal esthetics.

Multi-unit Abutments
Nobel Biocare offers straight, as well as
17 and 30 angled Multi-unit Abutments Securing of provisional prosthesis with
prosthetic screws
for all Nobel Biocare implant systems.
The abutments are available with various
collar heights to match the thickness of
the soft tissue.

* If one-stage surgery with immediate


loading is not indicated, cover screws
are used for submerged healing.
6 All-on-4

All-on-4 digital treatment


TM

planning and guided


surgery with NobelGuide . TM

NobelGuide is the ideal treatment concept Safe and predictable implant


for All-on-4, because it optimizes implant placement
placement by means of 3D diagnostics, After planning the case in NobelGuide
digital treatment planning and guided Software, a ready-to-use surgical template,
surgery with a surgical template. together with all necessary implants,
abutments and surgical instruments, can
Existing prosthesis can be modified
Accurate diagnostics and prosthetic- be ordered online in a single order. The
directly into a radiographic guide
driven planning surgical template enables guided implant
Based on 3D (CB) CT diagnostic imaging of site preparation and precise and efficient
the patient and a radiographic guide, virtual implant insertion, which minimizes patient
implant placement following prosthetic- pain and swelling.
driven planning can be performed within
the NobelGuide Software, ensuring Prefabrication of provisional
high diagnostic accuracy and safe and prosthesis before surgery
predictable implant placement. The surgical template can be used to create
a stone model with implant replicas already
Digital prosthetic-driven planning in
With the combination of the 3D radiological in place before surgery. This enables the
NobelGuide Software
dataset and 3D models of bone and dental technician to produce the provisional
radiographic guide, dental professionals prosthesis and the abutment placement
can evaluate bone quantity and quality, jig in advance, so that the clinician can
mark vital anatomical structures such as finalize the prosthesis and mount it on the
the alveolar nerve and the maxillary sinus, implants right after surgery.
and position the implants according to
prosthetic needs. Through controlled
and customizable angulation of the dental
Guided implant insertion with
reslice planes in the split-screen view of the
ready-to-use surgical template software, the tilted posterior implants are
also ideally positioned.
All-on-4 7

All-on-4 achieving TM

predictable results
with NobelGuide . TM

63-year old edentulous female patient requests a fixed restoration. All-on-4 using
NobelGuide is chosen to avoid bone grafting.

Preparation Case courtesy of Dr. Armando Lopes,


DDS, MALO CLINIC Lisbon, Portugal
The existing removable denture represents
the intended teeth setup and is transformed
into a radiographic guide (gutta percha
markers). A bite index is created to ensure
correct anatomical positioning of the guide
during CT scanning.

Treatment planning
Based on 3D CT diagnostic imaging of
patient and radiographic guide, the four
implants are placed virtually in the
NobelGuide Software, optimizing position,
angulation and distribution.

Implant insertion
The ready-to-use surgical template is used
for site preparation and insertion
of four NobelSpeedy Groovy implants. It is
secured by guided anchor pins.

Minimally invasive surgery


If a flapless procedure is chosen, trauma to
tissue is minimized. This image shows
the maxillary arch immediately after implant
insertion.

Provisional prosthesis
Immediate loading of the implants is
achieved by using a prepared
fixed prosthesis, which is finalized by the
clinician on the day of surgery.
8 All-on-4

All-on-4 efficient TM

treatment
with NobelSpeedy . TM

44-year old edentulous female patient requests a fixed restoration due to inadequate
function, comfort and esthetics of the existing removable denture.

Case courtesy of Dr. Paulo Mal, DDS, Diagnosis


MALO CLINIC Lisbon, Portugal
Limited bone volume in the posterior and
a need for bone crest level optimization.

Preparation
A conventional flap procedure is performed,
the bone crest level optimized and the
All-on-4 Guide anchored.

Implant site preparation


Implant site preparation according to the
drilling protocol for straight implants using
the All-on-4 Guide. The vertical lines on
the guide are used as reference for drilling
at an angle of 45.

Implant insertion
Insertion of NobelSpeedy Groovy implants
with external hex connection.

Provisional prosthesis
Immediate loading of the implants can
be achieved by using a fixed provisional
prosthesisbased on an impression taken
straight after surgery.
All-on-4 9

References.

1 Bellini CM, Romeo D, Galbusera F, 8 Hirsch JM, Ohrnell LO, Henry PJ, 16 Khatami AH, Smith CR.All-on-Four 23 Mal P, de Arajo Nobre M, Lopes
Taschieri S, Raimondi MT, Zampelis A, Andreasson L, Brnemark PI, immediate function concept and clinical A. The use of computer-guided flapless
Francetti L. Comparison of tilted versus Chiapasco M, Gynther G, Finne K, report of treatment of an edentulous implant surgery and 4 implants placed
non-tilted implant-supported prosthetic Higuchi KW, Isaksson S, Kahnberg KE, mandible with a fixed complete denture in immediate function to support a fixed
designs for the restoration of the Malevez C, Neukam FW, Sevetz E, and milled titanium framework. J denture: preliminary results after
edentulous mandible : a biomechanical Urgell JP, Widmark G, Bolind P. A Prosthodontics 2008;17(1):47-51. a mean follow-up period of 13 months.
study. Int J Oral Maxillofac Implants clinical evaluation of the zygoma J Prosthet Dent 2007; 97(Suppl):26-34.
2009 May-June; 24 (3):511-7. fixture. One-year follow-up at 16 clinics. 17 Francetti L, Agliardi E, Testori T,
J Oral Maxillofac Surg 2004; 62 (9 Romeo D, Taschieri S, Fabbro MD. 24 Pomares C. A retrospective clinical
2 Bellini CM, Romeo D, Galbusera F, Suppl 2):22-9. Immediate rehabilitation of the study of edentulous patient
Agliardi E, Pietrabissa R, Zampelis A, mandible with fixed full prosthesis rehabilitated according to the
Francetti L. A finite element analysis of 9 Krekmanov L, Kahn M, Rangert B, supported by axial and tilted implants: all-on-four or the all-on-six immediate
tilted versus non-tilted implant Lindstrm H. Tilting of posterior interim results of a single cohort function concept Eur J Oral Implantol
configurations in edentulous maxilla. mandibular and maxillary implants of prospective study. Clin Implant Dent 2009; 2 (1):55-60.
Int J Prosthodont 2009 Mar-Apr; improved prosthesis support. Int J Oral Relat Res 2008; 10(4):255-263.
22 (2):155-7. Maxillofac Implants 2000; 15:405-14. 25 Agliardi E, Panigatti S, Cleric M,
18 Davo R, Malavez C, Rojas J, Villa C, Mal P. Immediate rehabilitation
3 Davo Rodriguez R, Malevez C,Rojas 10 Aparicio C, Perales P, Rangert B. Rodriguez J, Regolf J. Clinical outcome of the edentulous jaws with full fixed
J. Immediate function in atrophic upper Tilted implants as an alternative of 42 patients treated with 81 prostheses supported by four implants.
jaw using Zygoma implants: A to maxillary sinus grafting: a clinical, immediately loaded zygomatic Interim results of a 5-year single
preliminary study. J Prosthet Dent 2007; radiologic, and periotest study. implants: a 12 to 42 month cohort prospective study. Accepted for
97(suppl):44-51. Clin Implant Dent Relat Res 2001; retrospective study. Eur J Oral Implantol publication in Clin Oral Implants Res.
3 (1):39-49. 2008;1 (2):141-150.
4 Tulasne J F. Osseointegrated fixtures 26 Testori T, Del Fabbro M, Capelli M,
in the pterygoid region. In: Advanced 11 Fortin Y, Sullivan R, Rangert BR. The 19 Mal P, de Araujo Nobre M, Rangert Zuffetti F, Francetti L, Weinstein RL.
osseointegration surgery. Applications Marius implant bridge: surgical and B. Implants placed in immediate Immediate occlusal loading of tilted
in the maxillofacial region. Worthington prosthetic rehabilitation for the function in periodontally compromised implants for the rehabilitation of the
P; Brnemark PI. Chicago, USA: completely edentulous upper jaw with sites: a five-year and one-year atrophic edentulous maxilla: 1-year
Quintessence Publ. Co, Inc. 1992: moderate to severe resorption: a 5-year prospective study. J Prosthet Dent interim results of a multicenter
182-8. retrospective clinical study. Clin Implant 2007; 97:86-95. prospective study. Clin Oral Implants
Dent Relat Res 2002; 4 (2):69-77. Res 2008 Mar; 19 (3):227-32.
5 Graves SL. The pterygoid plate 20 Mal P, Rangert B, de Arajo Nobre
implant: a solution for restoring the 12 Aparicio C, Arevalo X, Ouzzani W, M. "All-on-Four" immediate-function
posterior maxilla. Int J Periodontics Granados C. A retrospective clinical and concept with Brnemark System
Restorative Dent 1994; 4:512-23. radiographic evaluation of tilted implants for completely edentulous
implants used in the treatment of mandibles: A retrospective clinical
6 Parel SM, Brnemark PI, Ohrnell LO, severely resorbed edentulous maxilla. study. Clin Implant Dent Relat Res
Svensson B. Remote implant Appl Osseointegrat Res 2003; 1:17-21. 2003; 5 (Suppl 1):2-9.
anchorage for the rehabilitation of
maxillary defects. J Prosthet Dent 2001; 13 Calandriello R, Tomatis M, Rangert 21 Mal P, Rangert B, de Arajo Nobre
86 (4):377-81. N, Gottlow J. Immediate function of M. All-on-4 immediate-function concept
tilted implants in the atrophic posterior with Brnemark System implants for
7 Vrielinck L, Politis C, Schepers S, maxilla. Clin Oral Impl Res 2004; 15: completely edentulous maxillae: A
Pauwels M, Naert I. Image-based abstract 159. 1-year retrospective clinical study. Clin
planning and clinical validation of Implant Dent Relat Res 2005; 7 (Suppl
zygoma and pterygoid implant 14 Calandriello R, Tomatis M. Simplified 1):88-94.
placement in patients with severe bone treatment of the atrophic posterior
atrophy using customized drill guides. maxilla via immediate/early function 22 Mal P, de Arajo Nobre M,
Preliminary results from a prospective and tilted implants: a prospective 1-year Petersson U, Wigren S. A pilot study of
clinical follow-up study. Int J Oral clinical study. Clin Implant Dent Relat complete edentulous rehabilitation with
Maxillofac Surg 2003; 32 (1):7-14. Res 2005;7 (Suppl 1):1-12. immediate function using a new
implant design: case series. Clin
15 Agliardi E, Francetti L, Romeo D, Implant Dent Relat Res 2006; 8
Taschieri S, Del Fabbro M. Immediate (4):223-32.
loading in the fully edentulous maxilla
without bone grafting: the V-II-V
technique. Minerva Stomatol 2008
May; 57(5):251-9.
10 All-on-4

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All-on-4 11

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