Implants
Fig 4 Positioning of implants for all-on-4
Fig 5
Fit surface of All-on-4 bridge showing titanium framework
Fig 6
All-on-4 bridge showing titanium reinforcement on cantilever
Fig 7 Visible gingival margins prior to treatment
Fig 8
After All-on-4 transition zone moved under lip
which began in the mandible5, where success rates were already high and treatment time was the shortest. Single teeth immediate restoration in the upper arch came next and finally immediate full arch restoration. Initially, the number of implants remained the same, often with researchers placing “sleeper implants” in case of failure6, 7. With so much at risk, biologi-
cally and fiscally, it is essential that general practice adopts protocols only after there is a body of evidence to suggest efficacy. The evidence for management of
the edentulous maxillae with four implants is now over 10 years. The concept of All-on-4 was created by Portuguese dentist Paulo Malo and development was carried out in the 1990s funded by Nobel Biocare, initially for the mandible and then the
maxillae8,9 (figure 4). The protocol is specific for Nobel Biocare implants and the term has been trademarked. Given the dramatic impact this treatment protocol has had, many other implant companies are now marketing that their systems are also suitable. Clinicians should be cautious as, in many instances, there is limited evidence to validate the claims. The significant features with the
All-on-4 concept are: 1. Four, or more, Nobel Biocare implants to support a full arch maxillary or mandibular hybrid bridge (hybrid bridge = a fixed bar, usually of CAD/CAM titanium and veneered with acrylic resins and denture teeth [figures 5 and 6]) 2. The two most distal implants are angled in order to avoid anatomical structures (mental foramen and
Fig 9 Compromised aesthetics
ID canal in the mandible, maxil- lary sinus in the maxilla), to allow implants of optimum dimensions in more dense bone and reduce canti- levering 3. In the maxilla, the residual alveolar ridge is, in most instances, resected to increase the restorative space and hide the transition from restoration to patient under the upper lip (transition zone) (figures 7 and 8) 4. Following insertion of the implants, a provisional bridge is immediately fabricated on site, and fitted, which acts to splint the implants together 5. The bridge and implants are under functional immediate load 6. The definitive hybrid bridge is fabricated following the required integration and healing period (usually not less than three months). Successful application of this tech-
Fig 10
Improvement of aesthetics with provisional bridge fitted same day as extractions and implant placement
Fig 11
Need for an anterior bite plane may cause speech dysfunction
nique requires full understanding of many advanced and challenging principles, among which are: 1. The fundamentals of compre- hensive rehabilitation and aesthetic smile design 2. Experience in managing the psychological aspects of providing full arch implant restorations 3. Occlusal concepts including management of a patients occluso- vertical dimension in centric relation
Continued » Scottish Dental magazine 39
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