For surgeons and clinicians all over the world, the All-On-4 concept has changed the way they look at not just full-arch restorations, but how they see the world of implant dentistry.

Russellville Dental Lab has been a frontrunner in the development of processes and methods in the design and restoration of All-On-4 cases all over the world.

All-On-4 is a surgical and restorative concept first developed and researched by Dr Paulo Malo. All-On-4 aims to:

  • Involve all parties in the treatment plan to ensure a quality outcome
  • Use a prosthetic driven method to improve the chances of a beautiful smile
  • Let the patient leave (in most cases) the day of surgery with implant retained teeth in the mouth
  • Reduce healing time for the patient
  • Provide a homogenized interface to reduce restorative complexity
  • develop a simplified restorative concept to reduce chair time
  • Increase patient acceptance by minimizing costs and payment complexity

In short, All-On-4 is a method for surgeons, restoring clinicians, and labs to work together to provide a lower cost alternative with a known prosthetic outcome as compared to more traditional full-arch implant protocols. All-On-4 achieves this method through a combination of surgical and restorative protocols that combine to give us the bigger picture – a complete final restoration that can be completed in fewer chairside visits and with more consistency and higher patient satisfaction.

The Surgical Approach

From the perspective of the surgeon, All-On-4 ties together some concepts that have years of research. The biggest concepts put to use are tilting implants, immediate load of placed implants, and cross-arch stabilization to promote implant integration.

Tilted Implants

The concept of tilting implants is one of the first things that throws most of us for a loop. We’ve all heard the quotes from such legends as Dr Branemark regarding the dangers of tilting implants – something that has been taught as gospel since the early days of implants telling us that titled implants cause bone loss. What is less likely to be known is the research done on thousands of tilted implants in a variety of studies sponsored by most every major company that contradict these beliefs showing that when done correctly, and when part of a larger process (linked to other implants with a structure) you can have long term results similar to those of axial implants.

Tilting of posterior mandibular and maxillary implants for improved prosthesis support. Krekmanov L, Kahn M, Rangert B, Lindström H. Int J Oral Maxillofac Implants. 2000 May-Jun;15(3):405-14.

Immediate Load


Most every major implant manufacturerer (Nobel Biocare, Straumann, Astra, etc) have at some point done long term studies on immediate load. In most all of these studies it has been found that bone quality is either equal to or superior to those of implants that have not been loaded.

Implant-Retained Mandibular Overdentures with Immediate Loading: A Prospective Study of ITI Implants (4 implants) Gatti et al IJOMI 2000

Five-year results with fixed complete-arch mandibular prostheses supported by 4 implants. Eliasson A, Palmqvist S, Svenson B, Sondell K. Int J Oral Maxillofac Implants. 2000 Jul-Aug;15(4):505-10.

Immediate mandibular rehabilitation with endosseous implants: simultaneous extraction, implant placement, and loading. Cooper LF, Rahman A, Moriarty J, Chaffee N, Sacco D . The International Journal of Oral & Maxillofacial Implants[2002, 17(4):517-25]

Cross-Arch Stabilization

Using the latest in CAD/CAM dentistry we have helped to restore thousands of these cases all across the United States by providing extremely accurate, passively-fitting milled Titanium sub-structures with acrylic wrap around.  Not only is this restoration cost-effective, it is easier and creates a more manageable restoration as compared to most any other option.  Easy to clean, easy to repair, and even easy to re-process should the patient decide to change their look or have more work done in the future, the NobelProcera Milled bar is the choice for the restoration for a healthy long-term solution to the full-arch implant case.

Russellville Dental Lab is proud of the influence that we have had in the continuing development of this process. The staff here have helped to train surgeons, clinicians, and technicians all over the United States and as far away as Great Britain on effective and efficient treatment of these surgical methods.  We’ve developed the 4 Stage Process for restorations, reduced chair time by grouping tasks on patient visits, and worked hard to help keep the surgical time to a minimum.

The Restorative Approach

From the restoring clinicians perspective, All-On-4 provides several unique features:

  • The patient almost always has a temporary prosthesis for reference, and frequently patients want the final to be “just like” the temporary, making the job of communicating esthetic requirements to the laboratory easier
  • A detailed 4-Stage or simplified 1-Stage method for creating the final prosthesis, thereby reducing chairside time for a complex case
  • A higher number of fee-for-service patients who have their expectations exceeded.

Scientific References

  • Malo P, Rangert B, de Araujo, Nobre M. “All-on-Four” immediate-function concept with Branemark System® implants for completely edentulous mandibles: A retrospective clinical study. Clin Implant Dent relate Res 2003; 5 (Suppl 1): 2-9
  • Malo P, Rangert B, de Araujo, Nobre M. All-on-4 immediate function concept with Branemark System implants for completely edentulous maxillae: A 1 year retrospective clinical study. Clin Implant Dent Relat Res 2005; 7 (suppl 1): 88-94.
  • Malo P, de Araujo, Nobre M, Peterson U, Wigren S. A pilot study of complete edentulous rehabilitation with immediate function using a new implant design: Case series. Clin Implant Dent Relat Res 2006; 8:223-232
  • Malo P, de Araujo, Nobre M, Lopes A. The use of computer-guided flapless implant surgery and 4 implants placed in immediate function to support a fixed denture: Preliminary results after a mean follow up period of 13 months. J Prosthet Dent 2007; 97 (suppl): 44-51.
  • Dave Rodriguez, Malevez C and Rojas J. Immediate Function™ in atrophic upper jaw using zygoma implants. J Prosthet Dent 2007; 97 (suppl): 44-51
  • Tulasne J F. Osseointegrated fixtures in the pterygoid region. In: Advanced osseointegration surgery. Applications in the maxillofac region. Worthington P; Branemark PI. – Chicago, USA: Quintessence Publ. Co, Inc. 1992.- p.182-188
  • Graves SL. The pterygoid plate implant: a solution for restoring the posterior maxilla. Int J Periodontics Restorative Dent, 1994; 4: 512-523.
  • Parel S, Branemark PI, Ohrnell LO, Svensson B. Remote implant anchorage for the rehabilitation of maxillary defects. J Prosthet Dent 2001; 86: 377-381
  • Vrielinck L, Politis C, Schepers S, Pauwels M, Naert I. Image-based planning and clinical validation of zygoma and pterygoid implant placement in patients with severe bone atrophy using customized drill guides. Preliminary results from a prospective clinical follow up study. Int. J Oral Maxillofac Surg 2003; 32:7-14.
  • Hirsch J-M, Henry P, Andreasson L et al. A clinical evaluation of the Zygoma fixture. One year follow up at 16 clinics. J Oral Maxillofac Surg 2004; 9 (Suppl): 22-29.
  • Krekmanov L, Kahn M, Rangert B, Lindstrom H. Tilting of posterior mandibular and maxillary implants of improved prosthesis support. Int J Oral Maxillofac Implants 2000; 15: 405-414
  • Aparicio C, Perakes P, Rangert B. Tilted implants as an alternative to maxillary sinus grafting: A clinical, radiologic, and periotest study. Clin Implant Dent Relat Res 2001; 3: 39-49.
  • Fortin Y, Sullivan R, Rangert B. The Marius implant bridge: surgical and prosthetic rehabilitation for the completely edentulous upper jaw with moderate to severe resorption: A 5 year retrospective clinical study. Clin Implant Dent Relat Res 2002; 4: 69-77.
  • Aparicio C, Arevalo X, Ouzzani W, Granados C. A retrospective clinical and radiographic evaluation of tilted implants used in the treatment of severely resorbed edentulous maxilla. Appl Osseointegration Res 2003; 1: 17-21.
  • Calandriello R, Tomatis M, Rangert N, Gottlow J. Immediate function of tilted implants in the atrophic posterior maxilla. Clin Oral Impl Res 2004; 15: 1xxi
  • Calandriello R, Tomatis M. Simplified Treatment of the Atrophic Posterior Maxilla via Immediate/Early function and tilted implants: A prospective 1 year clinical study. Clin Implant Dent Relat Res. 2005; 7 Suppl 1:S1-12

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