All on 4 and all on 6

1. ALL ON FOUR
AND
ALL ON SIX CONCEPTS
BY,
PAAVANA
IIIMDS

2. CONTENTS
 INTRODUCTION
 CONVENTIONAL REHABILITATION WITH AXIAL
IMPLANTS
 TILTED IMPLANTS
 ALL ON FOUR AND ALL ON SIX CONCEPT
 PROSTHETIC REHABILITATION IN ALL ON 4 AND
ALL ON 6
 RELATED ARTICLES
 CONCLUSION
 REFERENCES

3. INTRODUCTION
 One of the greatest challenges in implant dentistry is
the treatment of patients with severely atrophic jaws.
ATROPHIC
EDENTULOUS
ARCHES
REMOVABLE
COMPLETE
DENTURES
IMPLANT
SUPPORTED
REMOVABLE
DENTURES
IMPLANT
SUPPORTED
FIXED
PROSTHESIS

Garg A.Full arch Implant Rehabilitation. Quintessence Publishing.1st

4. IMPLANT
SUPPORTED
FIXED
PROSTHESIS
CONVENTIONAL
APPROACH
WITH AXIAL
IMPLANTS
REHABILITATION
WITH TILTED
IMPLANTS
Garg A.Full arch Implant Rehabilitation. Quintessence Publishing.1st

5. CONVENTIONAL TREATMENT
APPROACH
 According to the original concept for the placement of Brånemark System
implants in atrophied completely edentulous arches, the implants were
placed in a fairly upright position.
 With such implant position it was often necessary to fabricate a bilateral
cantilever that was up to 20 mm in length so as to provide the patient with
good chewing capacity in molar regions, increasing the risk of implant
failure .
Wentaschek S, Hartmann S,
Walter C, Wagner W. Six-implant-
supported immediate fixed
rehabilitation of atrophic
edentulous maxillae with tilted
distal implants. International
Journal of Implant Dentistry. 2017

6.  Different procedures have been proposed to overcome these
anatomic limitations.
 The least invasive is the use of short implants ; however,
when bone height is insufficient even for short implants,
reconstructive alternatives, such as autogenous bone grafting
and sinus lift augmentation may be indicated.
 Other techniques may also be used, such as implants placed
in the pterygomaxillary region and zygomatic implants.
Nevertheless, each of these techniques presents
disadvantages, such as morbidity in graft donor sites,
postoperative discomfort, questionable predictability, and
surgical complexity .
Despite their wide-spread use, these techniques are clinically very
challenging, requires lengthy appoint procedures and display higher
levels of tissue and implant morbidity.
Wentaschek S, Hartmann S, Walter C, Wagner W. Six-implant-supported immediate fixed rehabilitation of atrophic edentulous maxillae with tilted distal implants. International Journal of Implant
Dentistry. 2017 Dec 1;3(1):35.

7. TILTED IMPLANTS
 First introduced in the early
1990’s.
 Implants were originally tilted in
a bodily fashion to bypass
certain anatomical structures.
 Increase the length of the
prosthetic table thereby allowing
better load distribution and
reducing the cantilever lengths
Vivek Choukse., et al. “Tilted Implants: A Review”. Acta Scientific Dental Sciences 2.12 (2018):

8. Rationale for tilted implants
To achieve primary implant stability (35 to 45 Ncm insertion torque) .
Indicated with a minimum bone width of 5mm and minimum bone height of 10mm from
canine to canine in maxilla and 8mm in mandible.
If angulation is 30º or more, the tilted implants can be splinted.
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.
Improved masticatory functions in terms of chewing efficiency and bite force
Vivek Choukse., et al. “Tilted
Implants: A Review”. Acta
Scientific Dental Sciences 2.12
(2018): 65-70.

9. ADVANTAGES
 Stability in minimum bone volume: Longer implants can be used in
minimum bone volume with advantage of in creasing bone-to-implant
contact and reducing the need for vertical bone augmentation.
 Clinical results are better.
 Need for bone grafting is eliminated.
 Can be performed in patients with systemic diseases which are
contraindicated for bone grafting.
 The angulations avoids impingement of anatomical structures.
 Biomechanical advantage in using tilted distal implants rather than distal
cantilever units.
 Reduce the length of cantilevers without performing bone grafting or sinus
lifting.
 Distally tilted implants induced better loading transmission than vertical
implant
Vivek Choukse., et al. “Tilted Implants: A Review”. Acta Scientific Dental Sciences 2.12 (2018): 65-70.

10. DISADVANTAGES
 Technique sensitive procedure.
 Surgeon need to be very skillful.
 Computer guided surgical stent required for implant to be placed in desired
angulation.
 Not even slight change in angulation can be done.
 Long term studies are not available
Vivek Choukse., et al. “Tilted Implants: A Review”. Acta Scientific Dental Sciences 2.12 (2018): 65-70.

11. Vivek Choukse., et al. “Tilted
Implants: A Review”. Acta
Scientific Dental Sciences 2.12
(2018): 65-70.

12. Tilted Implants as an Alternative to Maxillary Sinus Grafting: A
Clinical, Radiologic, and Periotest Study
Aparicio C, Perales P, Rangert B. Clinical implant dentistry and related research. 2001
Jan;3(1):39-49.
In this study, a combination of tilted and axial implants was used in patients with
severely resorbed posterior maxillae as an alternative to sinus grafting

13.  After 5 years, the implant cumulative success rate was 95.2%
(survival: rate 100%) for the tilted implants and 91.3% (survival rate:
96.5%) for the axial implants, and the prosthesis survival rate was
100%.
 At the fifth year, the average marginal bone loss was 1.21 mm for
the tilted implants and 0.92 mm for the axial ones.
 The mean Periotest values (PTV) at loading time were -2.62 and -
3.57, and after 5 years the PTVs were -4.73 and -5.00 for the tilted
and the axial implants, respectively.
 During the follow-up, all prostheses but two were mechanically
stable, retightening of 18 abutment screws and of 5 gold screws in
14 prostheses was done, and fracture of two abutment screws and
two occlusal surfaces was experienced.

14. ALL ON 4 AND ALL ON 6
 The posterior bone reabsorption restricts the use
of dental implants and often results in the use of
long cantilevered prostheses or sinus-grafting
procedures.
 The all-on-four and all-on -six concept was
introduced to address these problems.
 This treatment concept enables the rehabilitation
of a fully edentulous jaw with minimal bone
volume, short treatment intervals, lower cost,
lower patient morbidity and a better quality of life.

16. DIAGNOSTIC CRITERIA
Nobel Biocare.
All on 4
Treatment

17. TREATMENT PLANNING
 Reviewing the presence or lack of hard and soft
tissue can help to determine the type of final
prosthesis needed.
 Identification of a transition line can help to
determine potential esthetic considerations and
needs.
 Evaluating maxillary zones can help you to select a
particular surgical and restorative treatment protocol.
 Considering the use of 3D software is also
recommended for evaluating the potential sites for
Nobel Biocare. All on 4 Treatment concept.2020

18. REVIEWING THE PRESENCE OR
LACK OF HARD AND SOFT
TISSUE
Nobel Biocare.
All on 4
Treatment
concept.2020

20. IDENTIFICATION OF A TRANSITION
LINE
Bidra AS. Three‐dimensional esthetic analysis in treatment planning for implant‐supported fixed prosthesis in the edentulous maxilla: review of the
esthetics literature. Journal of esthetic and restorative dentistry. 2011 Aug;23(4):219-36.

21. Bidra AS. Three‐dimensional esthetic analysis in treatment planning for implant‐supported fixed prosthesis in the edentulous maxilla: review of the
esthetics literature. Journal of esthetic and restorative dentistry. 2011 Aug;23(4):219-36.

22. EVALUATING MAXILLARY
ZONES
Nobel Biocare. All on 4 Treatment concept.2020

23. EVALUATING MAXILLARY
ZONES
Nobel Biocare. All on 4
Treatment concept.2020

24. 3D- PLANNING

25. ALL ON FOUR CONCEPT
 The All-on-4 immediate loading concept was developed,
institutionalized and systematically analyzed in the 2003 by a
dentist Paulo Malo and colleagues
Nobel Biocare. All on 4 Treatment concept.20

27. ADVANTAGES
 Avoids complex surgery,
 Less invasive procedure for the patient.
 Graft less procedure.
 Implants well-spaced, good biomechanics, easier to clean, immediate function and
aesthetics
 Simplified surgical & prosthetic procedure.
 Reduced cost due to less number of implants.
 High success rates.
 Angled posterior implants:-
a. Avoid anatomical structures
b. Allow longer implants anchored in better quality bone
c. Reduces posterior cantilever
Shakhawan M. A, Zanyar M. A, Rebwar A H, Hawbash O M, Rozhyna P K, PaymanKh M. All-On-Four Treatment Concept in Dental Implants: A Review Articles.
Sur Cas Stud Op Acc J. 2(4)- 2019.

28. DISADVANTAGES
 Length of cantilever in the prosthesis cannot be
extended beyond the limit.
 Free hand arbitrary surgical placement of implant
is not always possible as implant placement is
completely prosthetically driven.
 It is very technique sensitive and requires
elaborate pre-surgical preparation such as
CAD/CAM, surgical splint
Shakhawan M. A, Zanyar M. A, Rebwar A H, Hawbash O M, Rozhyna P K, PaymanKh M. All-On-Four Treatment Concept in Dental Implants: A
Review Articles. Sur Cas Stud Op Acc J. 2(4)- 2019.

29. GENERAL CONSIDERATIONS
 Ability to achieve primary implant stability (35 – 45 Ncm)
 No severe parafunctions
 To diminish the cantilever, tilt the posterior implants.
 Does not require a wider opening of the mouth
 It is advisable to place implants between extraction sockets.
 Indicated with a minimum bone width of 5mm and minimum bone
height of 10mm from canine to canine in maxilla and 8mm in
mandible.
 If angulation is 300 or more, the tilted implants can be splinted. 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.
Shakhawan M. A, Zanyar M. A, Rebwar A H, Hawbash O M, Rozhyna P K, PaymanKh M. All-On-Four Treatment Concept in Dental Implants: A Review
Articles. Sur Cas Stud Op Acc J. 2(4)- 2019.

30. TREATMENT
PROTOCOL
SURGICAL
PHASE
PROSTHETIC
PHASE
Shakhawan M. A, Zanyar M. A, Rebwar A H, Hawbash O M, Rozhyna P K, PaymanKh M. All-On-Four Treatment Concept in Dental Implants: A
Review Articles. Sur Cas Stud Op Acc J. 2(4)- 2019.

31. SURGICAL PROCEDURE
Guided pilot drill surgical template
for the All-on-4® treatment concept
Fully guided surgical template for the
All-on-4® NobelGuide treatment concept
Nobel Biocare. All on 4 Treatment concept.2020

32. Nobel Biocare. All
on 4 Treatment
concept.2020

33. Nobel Biocare. All on 4 Treatment concept.2020

35. SURGICAL PROCEDURE AND
PROVISIONALIZATION

36. ALL ON 6

37. ADVANTAGES
 Avoids complex surgery,
 Less invasive procedure for the patient.
 Graft less procedure.
 Implants well-spaced, good biomechanics, easier to clean, immediate function and
aesthetics
 Simplified surgical & prosthetic procedure.
 Reduced cost due to less number of implants.
 High success rates.
 Angled posterior implants:-
a. Avoid anatomical structures
b. Allow longer implants anchored in better quality bone
c. Reduces posterior cantilever
Shakhawan M. A, Zanyar M. A, Rebwar A H, Hawbash O M, Rozhyna P K, PaymanKh M. All-On-Four Treatment Concept in Dental Implants: A Review
Articles. Sur Cas Stud Op Acc J. 2(4)- 2019.

38. DISADVANTAGES
 Increased cost
 Need of a highly skilled approach to correctly place implants in
pterygoid process
 Difficult approach for the insertion and restoration of posterior
implants
 Need of a skilled technician to fabricate the prosthesis
 Problems in oral hygiene maintenance in the back region
Shakhawan M. A, Zanyar M. A, Rebwar A H, Hawbash O M, Rozhyna P K, PaymanKh M. All-On-Four Treatment Concept in Dental Implants: A Review
Articles. Sur Cas Stud Op Acc J. 2(4)- 2019.

39. SURGICAL PROCEDURE
Signorini L, Faustini F, Samarani R, Grandi T.
Immediate fixed rehabilitation supported by
pterygoid implants for participants with severe
maxillary atrophy: 1-Year postloading results from a
prospective cohort study. The Journal of Prosthetic
Dentistry. 2020 Jul 3.

40. PROSTHETIC REHABILITATION
IN ALL ON 4 AND ALL ON6
CUSTOM
MADE
IMPRESSIONS
FINAL
IMPRESSIONS
VERIFICATION
OF MASTER
CAST AND
FINAL
RECORDS
WAX TRY-IN
IMPLANT
BRIDGE
FRAMEWORK
TRY-IN
IMPLANT
BRIDGE -
FINAL
PROSTHESIS
Nobel Biocare: Full Arch Rehabilitation - All-on-4™ Restorative Steps - Roadmap for Success

41. ANGULATED ABUTMENTS
 Angulated abutments are used when a change to the axis of the
implant is required.
 First developed by Nobel Biocare in 2000, and a first in the industry
at the time, the technology continues to evolve.
Kendall C. Taking the All-on-4® treatment concept to the next level. 2017

42. Hsu ML, Chung TF, Kao HC. Clinical applications of angled abutments-a literature review. Chinese Dental Journal. 2005 Mar 1;24(1):15.

43. Nobel Biocare: Full Arch Rehabilitation - All-on-4™ Restorative Steps - Roadmap for Success

44. IMPRESSIONS
CLOSED TRAY OPEN TRAY
Nobel Biocare: Full Arch Rehabilitation - All-on-4™ Restorative Steps - Roadmap for Success

45. Nobel Biocare: Full Arch Rehabilitation - All-on-4™ Restorative Steps - Roadmap for Success

46. Nobel Biocare: Full Arch Rehabilitation - All-on-4™ Restorative Steps - Roadmap for
Success

47. Nobel Biocare: Full Arch Rehabilitation - All-on-4™ Restorative Steps - Roadmap for
Success

48. Verification of Master Cast and Final
Records
 Un-screw the provisional implant
bridge with Unigrip Driver
 Take a Bite Registration
 Mark Midline, High Lip Line, Incisal
Edge and Shade.
 Verification Jig Try-in - The Jig must
sit passively to each
implant/abutment.
Take an X-ray to verify seated properly.
If the jig does not fit passively, section
the jig and retake final impression with
the custom tray over the jig.
Nobel Biocare: Full Arch Rehabilitation - All-on-4™ Restorative Steps - Roadmap for

49. Wax Try-in
 Un-screw the provisional
implant bridge with Unigrip
Driver
 Wax Try-in - If esthetics,
phonetics, function, and lip
support are acceptable,
send to lab for the Implant
Bridge framework to be
fabricated.
 Try in Jig (if didn’t fit
passively the first time)
Nobel Biocare: Full Arch Rehabilitation - All-on-4™ Restorative Steps - Roadmap for Success

50. Implant Bridge framework Try-in
CAD/CAM designed fixed prosthesis with
Zirconia or Titanium framework.
Individual crowns are cemented to the
final bridge framework.
Fixed prosthesis with CAD/CAM
designed Titanium or Zirconia framework
with acrylic veneering.
Fixed prosthesis with cast metal and
veneering porcelain.
Removable final prosthesis: e.g. milled
bar overdenture, MK1 attachment
overdenture.
Nobel Biocare: Full Arch
Rehabilitation - All-on-4™
Restorative Steps - Roadmap
for Success

51.  Un-screw the provisional implant bridge with
Unigrip Driver
 Try-in the Implant Bridge framework, verify
passive fit with each implant/abutment
Nobel Biocare: Full Arch
Rehabilitation - All-on-4™
Restorative Steps - Roadmap
for Success

52. Implant Bridge - Final Prosthesis
 Un-screw the provisional implant bridge with Unigrip
Driver
 Seat the final prosthesis - Take X-ray to verify
seated properly. The final prosthesis should seat
firmly against the soft tissue, like an ovate pontic.
The design of the tissue interface should be such
that it causes the tissue to roll over the prosthesis on
the buccal and lingual aspects.
 Torque the Prosthetic Screws with Torque Wrench to
15 Ncm when attaching to MultiUnit Abutments.
Always use new prosthetic screws to seat the final
prosthesis.
 Block out screw access holes to protect screw head
with Teflon Tape, Foam, etc. Seal screw access
areas with Acrylic .
 A night guard is provided
Nobel Biocare: Full Arch Rehabilitation - All-on-4™ Restorative Steps - Roadmap for Success

53. Occlusal Schemes
Establishment of stable jaw relationships with maximum
intercuspal contacts that are bilaterally identical
Establishment of “ freedom in centric” within the overall
occlusal scheme
Elimination of any interference between the maximum
intercuspal and retruded contact positions
Provision of harmonic, free mandibular movements with light
tooth contacts during both lateral and protrusive maneuvers.
Taruna M, Chittaranjan B, Sudheer N, Tella S, Abusaad M. Prosthodontic perspective to all-on-4® concept for dental implants. Journal of clinical and diagnostic research: JCDR. 2014

54.  Simultaneous bilateral point contacts on canine and posterior teeth
and grazing contacts on incisors. In lateral movements, canine
guidance opposing natural dentition, group function opposing
posterior implant supported bridge with flat linear pathways and
minimum vertical super imposition.
 If the implant supported prosthesis is opposed to removal, complete
denture or implant supported over denture or a distal extension cast
partial denture leave the most distal tooth slightly out of occlusion
and in excursive movements seek one or more balancing contacts,
planning greater anteroposterior space at the anterior teeth.
 The occlusal pattern should have relatively flat cusps i.e. the
inclination of the cuspal planes should be less than the inclinations
of the condylar path
Taruna M, Chittaranjan B, Sudheer N, Tella S, Abusaad M. Prosthodontic perspective to all-on-4® concept for dental implants. Journal of clinical and diagnostic research: JCDR.
2014 Oct;8(10):ZE16.

55. RELATED ARTICLES
Six-implant-supported immediate fixed rehabilitation of
atrophic edentulous maxillae with tilted distal implants.
Wentaschek S, Hartmann S, Walter C, Wagner W. Int J Implant Dent. 2017 Dec 1;3(1):35.
 The aim of this retrospective study was to evaluate the treatment outcome
of six Bredent blueSky™ implants (Bredent GmbH, Senden, Germany)
immediately loaded with a fixed full-arch prosthesis (two tilted posterior and
four axial frontal and premolar implants).

56. METHODS
 In a retrospective study, all patients with immediately
loaded implants in an edentulous maxillae with limited
posterior ridge dimensions that received an equal
concept were included if they had a follow-up of at
least 3 years.
 The concept contained immediate loading with distal
tilted implants and six implants per edentulous
maxillae of a single implant system (blueSky™
implants, Bredent GmbH, Senden, Germany), and it
includes an equal lab-side-prepared provisional fixed
prosthesis

57.  Sixty implants were placed to support 10 screwed
prostheses.
 Twenty-one of them were inserted in fresh extraction
sockets.
 Lab-side-prepared provisional fixed prostheses were
placed at the day of implantation.
 Periotest (PT) values and implant stability quotient
(ISQ) were measured after implant surgery and after 3
months of healing in all patients.

58. RESULTS
 The analyzed implants were in function in
mean 64 ± 13 months (range 42 to 84
months).
 One axial and two tilted implants failed in three
patients. The mean PT values decreased, and
ISQ increased significantly after the first 3
months at the osseointegrated tilted and axial
implants.

59. CONCLUSION
 Within the limits of this small group (n = 10
patients/60 implants), the failure rate of the
analyzed implant system (n = 3 respective 5%
implant loss) seems to be comparable with other
immediate-loading protocols.
 The failure rate of tilted implants in the atrophic
upper jaw was quite high, but the aimed treatment
concept could be achieved in every patient.
 The rehabilitation of the posterior region in
edentulous maxilla remains a challenge

60. Straight and tilted implants for supporting screw-retained
full-arch dental prostheses in atrophic maxillae: A 2-year
prospective study
Menéndez-Collar, M., Serrera-Figallo, M.A., Hita-Iglesias, P., Castillo-Oyagüe, R., Casar-Espinosa, J.C., Gutiérrez-
Corrales, A., Gutiérrez-Perez, J.L. and Torres-Lagares, D., 2018. Med Oral Patol Oral Cir Bucal. , 23(6), p.e733.
To evaluate, over a 2-year period, the treatment outcomes for maxillary full-
arch fixed dental prostheses (FDPs) supported by a combination of both tilted
and axially-placed implants and to compare the marginal bone loss (MBL) and
implant survival rates (SR) between tilted and axial implants.

61. METHODS
32 PATIENTS
(187
IMPLANTS)
T GROUP
(n-68)
A GROUP
(n-119)

62.  From the total, 28% of the implants (n=53) were immediately loaded
with screw-retained provisional acrylic restorations, whereas 72%
underwent conventional delayed prosthetic loading 6 months post-
operatively.
 Definitive restorations were hybrid implant prostheses (metal
framework covered with high-density acrylic resin) and metal-
ceramic screw-retained implant prostheses, and were placed 6
months after surgery.
 Such definitive restorations were checked for proper function and
aesthetics every three months for two years.
 Peri-implant marginal bone levels were assessed by digital
radiographs immediately after surgery and MBL was assessed at
definitive implant loading (baseline) and 2 years afterwards.

63. RESULTS

64. CONCLUSION
 Based on the results of this retrospective
clinical study, full-arch fixed prostheses
supported by a combination of both tilted and
axially placed implants may be considered a
predictable and viable treatment modality for
the prosthetic rehabilitation of the completely
edentulous maxilla.

65. The all-on-four treatment concept: Systematic
review
Soto-Peñaloza D, Zaragozí-Alonso R, Peñarrocha-Diago M, Peñarrocha-Diago M. J Clin Exp Dent. 2017
Mar;9(3):e474.
To systematically review the literature on the “all-on-four” treatment
concept regarding its indications, surgical procedures, prosthetic
protocols and technical and biological complications after at least three
years in function.

66. STUDY DESIGN

67. CONCLUSION
 The all-on-four treatment concept offers a predictable way to treat the
atrophic jaw in patients that do not prefer regenerative procedures, which
increase morbidity and the treatment fees.
 The results obtained indicate a survival rate for more than 24 months of
99.8%.
 However, current evidence is limited due the scarcity of information referred
to methodological quality, a lack of adequate follow-up, and sample
attrition.
 Biological complications (e.g., peri-implantitis) are reported in few patients
after a mean follow-up of two years.
 Adequate definition of the success / survival criteria is thus necessary, due
the high prevalence of peri-implant diseases.

68. Hybrid Polyetheretherketone (PEEK)–Acrylic Resin Prostheses
and the All-on-4 Concept: A Full-Arch Implant-Supported Fixed
Solution with 3 Years of Follow-Up
de Araújo Nobre M, Moura Guedes C, Almeida R, Silva A, Sereno N. J. Clin. Med. 2020 Jul;9(7):2187.
The aim of this three-year prospective study was to examine the
outcome of a solution for full-arch rehabilitation through a fixed
implant-supported hybrid prosthesis (polyetheretherketone
(PEEK)-acrylic resin) used in conjunction with the All-on-4
concept.

69. METHODS
The primary outcome measure was prosthetic survival.
Secondary outcome measures were marginal bone loss, plaque and
bleeding scores, veneer adhesion issues, biological complications,
mechanical complications, and the patients’ subjective evaluation
Thirty-seven patients (29 females, 8 males), with an age range of 38 to
78 years (average: 59.8 years) were rehabilitated with 49 full-arch
implant-supported prostheses (12 maxillary rehabilitations, 13
mandibular rehabilitations and 12 bimaxillary rehabilitations).

71. RESULTS
PRIMARY OUTCOME
MEASURE
SECONDARY OUTCOME
MEASURE

72. CONCLUSION
 Based on the results, the three-year outcome
suggests the proposed rehabilitation solution
as a legitimate treatment option, providing a
potential shock-absorbing alternative that
could benefit the implant biological outcome.

73. TO CONCLUDE…

74. REFERENCES
 Garg A.Full arch Implant Rehabilitation. Quintessence Publishing.1st Edition
 Wentaschek S, Hartmann S, Walter C, Wagner W. Six-implant-supported immediate fixed
rehabilitation of atrophic edentulous maxillae with tilted distal implants. International Journal of
Implant Dentistry. 2017 Dec 1;3(1):35.
 Vivek Choukse., et al. “Tilted Implants: A Review”. Acta Scientific Dental Sciences 2.12 (2018):
65-70.
 Aparicio C, Perales P, Rangert B. Tilted implants as an alternative to maxillary sinus grafting: a
clinical, radiologic, and periotest study. Clinical implant dentistry and related research. 2001
Jan;3(1):39-49.
 Signorini L, Faustini F, Samarani R, Grandi T. Immediate fixed rehabilitation supported by
pterygoid implants for participants with severe maxillary atrophy: 1-Year postloading results from
a prospective cohort study. The Journal of Prosthetic Dentistry. 2020 Jul 3.
 Nobel Biocare. All on 4 Treatment concept.2020
 Shakhawan M. A, Zanyar M. A, Rebwar A H, Hawbash O M, Rozhyna P K, PaymanKh M. All-On-
Four Treatment Concept in Dental Implants: A Review Articles. Sur Cas Stud Op Acc J. 2(4)-
2019.
 Kendall C. Taking the All-on-4® treatment concept to the next level. 2017
 Nobel Biocare: Full Arch Rehabilitation - All-on-4™ Restorative Steps - Roadmap for Success

75.  Bidra AS. Three‐dimensional esthetic analysis in treatment planning for implant‐supported fixed
prosthesis in the edentulous maxilla: review of the esthetics literature. Journal of esthetic and
restorative dentistry. 2011 Aug;23(4):219-36.
 Brunski JB. Biomechanical aspects of the optimal number of implants to carry a cross-arch full
restoration. Eur J Oral Implantol. 2014 Jan 1;7(Suppl 2):S111-31.
 Hsu ML, Chung TF, Kao HC. Clinical applications of angled abutments-a literature review. Chinese
Dental Journal. 2005 Mar 1;24(1):15.
 Menéndez-Collar, M., Serrera-Figallo, M.A., Hita-Iglesias, P., Castillo-Oyagüe, R., Casar-
Espinosa, J.C., Gutiérrez-Corrales, A., Gutiérrez-Perez, J.L. and Torres-Lagares, D. Straight and
tilted implants for supporting screw-retained full-arch dental prostheses in atrophic maxillae: A 2-
year prospective study 2018. Med Oral Patol Oral Cir Bucal. , 23(6), p.e733.
 Wentaschek S, Hartmann S, Walter C, Wagner W. Six-implant-supported immediate fixed
rehabilitation of atrophic edentulous maxillae with tilted distal implants. Int J Implant Dent. 2017
Dec 1;3(1):35.
 Soto-Peñaloza D, Zaragozí-Alonso R, Peñarrocha-Diago M, Peñarrocha-Diago M. The all-on-four
treatment concept: Systematic review. J Clin Exp Dent. 2017 Mar;9(3):e474.
 de Araújo Nobre M, Moura Guedes C, Almeida R, Silva A, Sereno N. Hybrid Polyetheretherketone
(PEEK)–Acrylic Resin Prostheses and the All-on-4 Concept: A Full-Arch Implant-Supported Fixed
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