The All-on-4 treatment involves placing only four dental implants - two in the front of each jaw and two tilted posteriorly at a 45 degree angle. This technique allows for fixed teeth to be placed even in patients with minimal bone volume, as the tilted posterior implants make use of available bone. Studies show a 98% success rate for All-on-4, and it provides patients with a permanent set of teeth similar to natural teeth, avoiding the need for removable dentures. The procedure is typically completed in one or two appointments, with temporary teeth placed immediately and permanent teeth in a follow up visit 6-8 months later.

2. What is All-on-4 Treatment
All-on-4® is a revolutionary approach developed over a decade ago
by Paulo Malo and MALO CLINIC team, which allows the
rehabilitation of totally edentulous patients with the placement of only
4 titanium implants in each jaw, through a quick and minimally
invasive procedure. The Implants act as a foundation for MALO
CLINIC Bridge, which allows the placement of a fixed set of teeth, in
all similar to natural teeth. This technique stabilizes bone levels,
keeping the jaws healthy. By tilting 45° the two posterior implants, the
All-on-4® allows even those patients with virtually no bone to have
fixed teeth without need of bone transplant. The result is a fixed (non-
removable) natural looking dentition, indistinguishable from natural
teeth.

3. What is All-on-4 Treatment
The All-on-4 clinical solution has been developed to maximize the use
of available bone and to allow for Immediate Function™. Using only
four implants in edentulous jaws, the solution takes advantage of the
benefits of tilting the posterior.
Implants to provide a secure and optimal prosthetic support for a
prosthetic bridge, even with minimum bone volume.

4. Criteria for All-on-4
Patients treated with the technique and therefore included in the
retrospective analysis met the following criteria:
Jaw bone profile for the placement of at least 4 implants of at least 10
mm in length in either healed or immediate extraction sites.
Good general health with acceptable oral hygiene.
 Implants achieved stability at insertion.

5. All-on-4 Implant Procedure
Flap: All-on-4 using conventional
flap procedure with traditional
planning and a standardized All-on-4
Guide for predictable and optimal
positioning of the implants.
The All-on-4 clinical solution can be performed in two ways:
Flapless: All-on-4 with NobelGuide™
using flapless technique, computer-
based planning and a customized
Surgical Template to correctly drill
and position the implants.
1
2

6. Implants You Can Use For All-on-4
Parallel implants:
NobelSpeedy™ Groovy
NobelSpeedy™ Replace
Brånemark System® MkIII Groovy
NobelReplace™ Straight Groovy
Brånemark System® MkIII, TiUnite®
Brånemark System® MkIV, TiUnite®
Replace® Select Straight
Tapered Implants:
NobelReplace™ Tapered Groovy
Replace® Select Tapered

7. Implants You Can Use For All-on-4
Other Items You Will Need:
All-on-4 Guide
Products needed for the restorative
procedure are located in the Product Catalog
found at the back of this manual.
Manuals:
For a full description of the implant placement,
prosthetic procedures and all instruments
needed, please refer to the relevant manual for
the selected prosthetic components and/or
implant system.

8. Treatment Planning
General Considerations:
Ability to achieve primary implant
stability (35 – 45 Ncm insertion torque).
No severe parafunctions.
Indicated for totally edentulous maxilla
with a minimum bone width of 5 mm and
a minimum bone height of 10 mm from
canine to canine.
Indicated for totally edentulous
mandible with a minimum bone width of
5 mm and minimum bone height of 8 mm
in between the mental foramina.
To diminish the cantilever, tilt the
posterior implants to a maximum of 45°.
If the angulation is 30° or more, it is
necessary to splint the tilted implants.
The All-on-4 clinical solution has been developed to maximize the use of available bone
and to allow for Immediate Function™. When planning an All-on-4 treatment using a flap
technique, be sure to consider the following factors:

9. Treatment Planning
General Considerations (continued..)
For tilted posterior implants, plan the
distal screw access holes to be located at
the occlusal face of the 1st molar, 2nd pre-
molar or 1st pre-molar.
The All-on-4 treatment does not require
a wider opening of the mouth than a
normal straight position of the implants
due to the angulation of the posterior
implants.
If there are extraction sites, clean them
thoroughly. It is advisable to place
implants between extraction sockets.
Specific Considerations – Implants:
If possible, the posterior implants should
be 4.0 or 4.3 mm. Note: The 30° Multi-
unit Abutment is only available for
Regular Platform (RP). The 17° Multi-
unit.Abutment is available for Narrow
Platform (NP) and Regular Platform (RP)
When placing posterior implants with an
internal connection, make sure that one of
the tri-channel lobes on the implant is
pointing distal or slightly buccal.

10. Treatment Planning
Specific Considerations – Implants:
If possible, the posterior implants should
be 4.0 or 4.3 mm. Note: The 30° Multi-
unit Abutment is only available for Regular
Platform (RP). The 17° Multi-
unit.Abutment is available for Narrow
Platform (NP) and Regular Platform (RP)
When placing posterior implants with an
internal connection, make sure that one of
the tri-channel lobes on the implant is
pointing distal or slightly buccal.

11. Treatment Planning
Specific Considerations – Prosthetics:
No extensions over one-tooth on each side for the immediate all-
acrylic bridge, which should have a maximum of 12 teeth.
If the patient’s removable prosthesis is in good condition, it may
be used to fabricate the immediate all-acrylic bridge.
For proper esthetics and function, the final bridge should have
12 teeth.

12. All-on-4 with NobelGuide™
The All-on-4 with NobelGuide™ enables you to use CT scan data as
the basis for surgical planning in a 3D computer environment. From
your computer-based planning, Nobel Biocare provides you with a
Surgical Template to guide you safely during flapless surgery.
To take advantage of Immediate Function™ and place a highly
esthetic prosthetic reconstruction at the time of surgery, non-engaging
30° Multi-unit Abutments RP are used for the posterior implants. The
dental laboratory fabricates an acrylic jig for transferring the
ultimate position of the angled abutment from the model to the
patient.

13. All-on-4 with NobelGuide™
The All-on-4 with NobelGuide™ enables you to use CT scan data as
the basis for surgical planning in a 3D computer environment. From
your computer-based planning, Nobel Biocare provides you with a
Surgical Template to guide you safely during flapless surgery.
To take advantage of Immediate Function™ and place a highly
esthetic prosthetic reconstruction at the time of surgery, non-engaging
30° Multi-unit Abutments RP are used for the posterior implants. The
dental laboratory fabricates an acrylic jig for transferring the
ultimate position of the angled abutment from the model to the
patient.

14. Implants You Can Use For All-on-4 With
Nobelguide™:
Software you will need for All-on-4 with
NobelGuide™:
Procera® Software for Computer-Based
Planning
Parallel implants:
NobelSpeedy™ Groovy
NobelSpeedy™ Replace
Brånemark System® Mk III Groovy
NobelReplace™ Straight Groovy
Tapered implants:
NobelReplace™ Tapered Groovy

15. Implants You Can Use For All-on-4 With
Nobelguide™:
Other items you will need:
Surgical Template ordered in Procera®
Software
Products needed for the restorative
procedure are located in the Product Catalog
found at the back of this manual.
Manuals:
NobelGuide™ Concept Manual
For a full description of the implant placement,
prosthetic procedures and all instruments
needed,
Please refer to the relevant manual for the
selected prosthetic components and/or implant
system.

16. Treatment Planning
General Considerations:
When using NobelGuide™ computer-
based planning, a CT scan using a
Radiographic Guide is required. Please
refer to the NobelGuide™ Concept
Manual
for details.
Ability to achieve primary implant
stability (35–45 Ncm insertion torque).
No severe parafunctions.
Indicated for totally edentulous maxilla
with a minimum bone width of 5 mm and
a minimum bone height of 10 mm from
canine to canine.
Indicated for totally edentulous
mandible with a minimum bone width of 5
mm and minimum bone height of 8 mm in
between the mental foramina.
The sites must be fully healed.
To diminish the cantilever, tilt the
posterior implants to a maximum of 45°.
The All-on-4 clinical solution has been developed to maximize the use of available bone
and allow Immediate Function™. When planning an All-on-4 with NobelGuide™
treatment, be sure to consider the following factors:

17. Treatment Planning
General Considerations
(continued):
If the angulation is 30° or more, it is
necessary to splint the tilted implants.
For tilted posterior implants, plan the
distal screw access holes to be located
at the occlusal face of the 1st molar,
2nd pre-molar or 1st pre-molar.
The All-on-4 treatment does not
require a wider opening of the mouth
than a normal straight position of the
implants due to the angulation of the
posterior implants. However, as with all
Nobel- Guide™ treatments, it is
important to compensate for the extra
height needed for NobelGuide™
components and instruments

18. Treatment Planning
Specific Considerations –
Implants:
If possible, the posterior implants
should be 4.0 or 4.3 mm.
Note: The 30° Multi-unit Abutment
Non- Engaging is only available for
the Regular Platform (RP).
Specific Considerations –
Prosthetics:
No extensions over one-tooth on
each side for the immediate all-acrylic
bridge, which should have a
maximum of 12 teeth.
If the patient’s removable prosthesis
is in good condition, it may be used to
fabricate the immediate all-acrylic
bridge
For proper esthetics and function,
the final bridge should have 12 teeth.

19. Checklist Prior to Surgery
Correct Implants, Guided
Components and Instruments
Operation Specification
Surgical Template
Surgical Index
Prosthetic Components and
Instruments
The jig construction for placing 30°
Multi-unit Abutments Non-Engaging,
which includes:
1. Impression Coping Open Tray
Multi-unit
2. Guide Pin
3. Abutment Holder
4. Jig Stabilizer
5. 30° Multi-unit Abutment Non-
Engaging
6. Abutment Screw

20. How Are All-on-4 Dental Implants Different
From Dentures?
Are permanent teeth that are
brushed and cleaned like natural teeth
Do not have to be taken out
Do not need adhesives
Are comfortable because they do not
press down on your gums
Allow you to experience the hot and
cold of your food, as well as the taste
Allow you to bite with increased force
(up to 70% more), so you can eat all of
your favorite foods again
Prevent bone deterioration
Restore your facial features
All-on-4 implants are a permanent set of teeth that look and feel like natural teeth.
All-on-4 dental implants:

21. How Do All-on-4 Dental Implants Compare
To Traditional Implants?
The All-on-4 dental implant technique utilizes only four implants per
arch, whereas traditional implants utilize anywhere from six to eight
implants, or more, in each arch. The implants of the All-on-4 procedure
are also placed at an angle, which allows for increased contact by using
the natural support of your bone. In addition, the All-on-4 procedure
requires no bone grafting for most patients, which is common in
traditional implant procedures. Therefore, All-on-4 dental implants save
time, money, and discomfort.

22. How long is the All-on-4 dental implant surgery?
The surgery takes approximately 2.5 hours per arch.
What is the success rate with All-on-4 Dental Implants?
Published studies show a 98% success rate using All-on-4 dental implants.
Who is the ideal candidate for All-on-4 Dental Implants?
The ideal candidate for the All-on-4 dental implant procedure from The Implant Center
at Dental Associates is someone who is currently wearing dentures or who will need
dentures in the future. Age doesn’t matter but dental implant candidates should be in
good health.

23. Where will my replacement teeth be made?
The Implant Center at Dental Associates does everything in-house. Your new
teeth will be crafted by certified lab technicians on-site. In fact, every part of
your procedure, from consultation to follow-up care happens under one roof.
Will my results look natural?
Absolutely. The All-on-4 dental implant technique gives you permanent teeth
that look, feel and function just like real teeth. No one will know you have
implants unless you tell them.
Why don't I get my permanent set of teeth the day my implants are placed?
As with any surgery, you need time to heal. However, you will not leave our
office without teeth! A temporary set of teeth will be placed on your implants.
Once the healing process is complete, your permanent teeth will be placed at a
follow up visit approximately six to eight months after surgery.

24. What if I just need implants on my bottom arch? What if I someday need All-
on-4 dental implants on both arches?
All-on-4 implants can be placed on just the upper or lower arch. Your implant
specialists will evaluate your circumstance and if he or she feels you might
eventually need replacement teeth on both the upper and lower arches, he or she
might suggest performing the procedure on both arches at the same time. This
provides better results while also saving time and money. Your doctor will work
with you to determine what best meets your needs both health wise and cost wise.
What type of cleaning is required after an implant is placed?
Dental implants should be treated like your natural teeth, daily brushing and
flossing is recommended. Our team of specialists and dental hygienists will review
oral hygiene instructions with you and will recommend the most appropriate oral
hygiene treatment plan to fit your needs.
Are there any additional costs/fees to expect?
All fees will be discussed prior to surgery during the consultation appointment.

25. Benefits of All-on-4 Implant
Stability Even In Minimum Bone Volume
By tilting the two posterior implants, longer implants can be used in
minimum bone volume, increasing bone-to-implant contact and
reducing the need for vertical bone augmentation. The tilted posterior
implants can be anchored in better quality anterior bone, reducing
cantilevers and thus improving support of the prosthesis.
Good clinical results
Biomechanical measurements show that tilted implants, when part of
prosthetic support, do not have a negative effect on the load
distribution. The tilting of implants has been used in clinical practice
for over a decade and has shown good results.

26. Benefits of All-on-4 Implant
Planning With Nobelguide Treatment Concept
All-on-4 treatments can be planned and performed using the
NobelGuide treatment concept, ensuring accurate diagnostics,
planning and implant placement. The NobelGuide Software allows for
detailed diagnostics such as identification of available bone, virtual
implant placement according to the anatomical situation and prosthetic
needs, and ordering of an individualized surgical template. NobelGuide
supports minimally invasive flapless techniques as well as surgical
access through mini-flaps and full flaps, while the surgical template
ensures guided and therefore exact implant placement.

27. Benefits of All-on-4 Implant
Prosthetic flexibility
With an All-on-4 treatment, patients benefit from an immediate implant-
supported restoration, as a provisional prosthesis is screwed onto the
implants right after surgery. Final solutions for All-on-4 treatments
include both fixed prostheses, such as NobelProcera Implant Bridge
Titanium with acrylic veneering, or individual NobelProcera crowns
cemented to the bridge framework, and removable solutions, such as
acrylic overdentures on a NobelProcera Implant Bar Overdenture.
Increased efficiency
Efficient treatment flow results in shorter treatment times and improved
patient satisfaction.

28. Price of the Treatment
The price may vary for each country or region, and normally it is divided in two
phases
The first phase involves removing any remaining teeth, and placing the four
dental implants along with an immediate temporary bridge secured to the four
implants. This phase may cost between $10000 to $15000, dependent on the above
factors.
Few months after the above phase, once complete healing and bonding of the
implants to the bone has taken place, a final bridge is usually fabricated. This
bridge typically consists of a metal framework, which strengthens the system, and
often has a few more posterior teeth. This phase may cost between $10000 to
$17500, dependent on the materials used and the type of teeth (porcelain or
acrylic) developed.
The total price (if both superior and inferior arches are considered) could
possibly reach $57000. (Source-Wikipedia)