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458 Volume 37, Number 7COMPENDIUM July/August 2016
Since its introduction to dental literature in 2003,1 the
All-on-4® (Nobel Biocare, www.nobelbiocare.com)
treatment concept has proven to be a predictable
2,3
and cost-eective4 method used for full-arch dental im-
plant rehabilitation. True adherence to this manner of
treatment involves restoring an arch with at least 4 dental implants,
the distal of which are tilted up to 45 degrees, and immediately
loading a screw-retained provisional prosthesis.5 Various articles
have documented both short- and long-term success rates for All-
on-4–style treatment, with dental implant and prosthetic survival
rates consistently exceeding 98%.
1-12
While these studies document
the success rates for this treatment concept and others discuss
variations on surgical design to accommodate specific anatomic
situations,13-16 few studies examine complications associated with
the procedure beyond standard infections or mechanical fracture
of the prosthesis.1-20
Accordingly, the purpose of this article is to present obstacles and
complications that may be encountered before, during, and after
All-on-4–style treatment and how to manage them. The author
draws on his experiences with treating more than 500 arches and
more than 2000 dental implants using All-on-4–style treatment.
Presurgical Complications
Teeth Exfoliating With Initial Impressions
Many patients requiring All-on-4–style treatment have extremely
compromised teeth that may be unintentionally removed during
the initial impression process. This is typically due to severely
decayed teeth or extremely mobile teeth secondary to advanced
periodontal disease (Figure 1). Such situations must be recognized
and these patients advised of the potential for tooth loss during
the impression process.
When encountering teeth that have been exfoliated with impres-
sions, the author typically cleans the exfoliated tooth and adjusts
the length of the root so that the tooth may be temporarily bonded
back into place using composite resin in a Maryland-bridge fash-
ion. Occlusion is adjusted on the bonded tooth so that it makes no
contact with opposing teeth.
On some occasions, the author has bonded patients’ natural
exfoliated teeth to their existing removable partial prostheses. In
select cases in which no adjacent teeth or removable prostheses
are available for bonding of an exfoliated tooth, the author has
used a transitional mini dental implant with a chairside-fabricated
temporary crown as in interim restoration prior to the patient’s
surgical procedure.
Intrasurgical Complications
Arterial Disruptions During Mucogingival Flap Reflection
Following the administration of local anesthesia, the first step in
All-on-4–style treatment is full-thickness mucogingival flap reflec-
tion. Depending on anatomic variability, vasculature such as the
All-on-4® Implant Treatment: Common Pitfalls
and Methods to Overcome Them
Dan Holtzclaw, DDS, MS
CONTINUING EDUCATION 4
COMMON IMPLANT OBSTACLES
Abstract: Although highly successful in terms of both short- and long-term
survival rates, All-on-4®–style dental implant treatment is a multistep process
with many potential complications. Beyond reports of survival rates for dental
implants and the final prostheses, the dental literature is relatively devoid of
information regarding obstacles and pitfalls associated with All-on-4–style
dental implant treatment. In the current article, the author describes common
issues that he has encountered before, during, and after All-on-4–style dental
implant treatment of more than 500 arches and discusses methods for over-
coming these obstacles.
• discuss complications that
may be encountered with
the All-on-4 implant
concept before, during,
and after treatment
• describe intrasurgical
obstacles associated with
the All-on-4–style approach
and how to alleviate them
• explain why fracturing of
provisional restorations
may occur following All-
on-4–style implant surgery
LEARNING OBJECTIVES
greater palatine artery or sublingual artery, or various branches
thereof, may be disrupted. Should this occur, excessive hemor-
rhaging may obscure visibility of the surgical field in addition to
becoming a hazard for the patient.
Initial treatment in these situations involves administration
of local anesthetic with at least 1:100,000 epinephrine.21 In most
cases, the vasoconstrictor eect of epinephrine is enough to stop
the hemorrhaging. Should the vasoconstrictor fail to alleviate the
problem, an electrosurgical generator or laser with a coagulation
setting may be applied to the source of hemorrhage. A third option
Fig 1.
Fig 4.
Fig 2.
Fig 1. Presurgical panoramic radiograph of a patient with severe peri-
odontal disease and who is an All-on-4–style treatment candidate.
Fig 2. Sublingual arterial branch tied o with 4-0 chromic gut suture.
Fig 3. Presurgical cross-sectional CBCT scan slice of an All-on-4–style
dental implant patient with crestal location of the inferior alveolar
nerve (yellow crosshairs on nerve) secondary to bone resorption.
Bone reduction in this location risks exposure and damage to the
nerve. Fig 4. Presurgical panoramic radiograph of an All-on-4–style
patient with pneumatized maxillary sinuses that extend beyond the
planned horizontal plane of bone reduction (yellow line).
for containing the bleed is to use a resorbable suture to tie o the
vessel posterior to the site of hemorrhage (Figure 2).
Exposed Nerves
In cases of severe mandibular atrophy, supracrestal exposure of
the mental foramen or inferior alveolar nerve (Figure 3) may be
possible.
8,22
When encountered, these situations require special
consideration for incision design, mucogingival flap reflection,
bone reduction, dental implant placement, soft-tissue reduction,
and suturing. With exposed nerve tissue, each of these steps has
the potential for causing damage.
When faced with an exposed inferior alveolar nerve, the au-
thor has placed dehydrated human amnion-chorion membrane
(DHACM) directly onto the nerve fibers based on the positive
outcomes that have been reported with DHACM nerve wraps
around the prostatic neurovascular bundle in prostatectomy
surgeries.23 In 4 cases of DHACM that the author used inferior
alveolar nerve wraps, patients reported no adverse outcomes,
such as permanent or transient anesthesia, paresthesia, hypo-
esthesia, or dysesthesia.
Pneumatized Maxillary Sinus Extending Below Bone
Reduction Plane
It is well established that maxillary sinus pneumatization may
occur following posterior maxillary tooth loss.24 In select cases,
pneumatization of the maxillary sinus may extend beyond the
anticipated horizontal plane of bone reduction required for All-
on-4–style treatment (Figure 4). Failure to adequately reduce
bone in these areas may lead to restorations of inadequate thick-
ness that are at increased risk for fracture.25 Conversely, standard
bone reduction in these areas may lead to significant damage to
the Schneiderian membrane.
To overcome this complication, the author carefully reduces
the residual maxillary crestal bone until crestal exposure of the
Schneiderian membrane is achieved (Figure 5). On crestal visu-
alization of the Schneiderian membrane, the author uses curettes
to lift the membrane apically from the anticipated plane of bone
reduction (Figure 6). The maxillary bone is then reduced apically,
and the process is repeated until the desired amount of bone reduc-
tion is achieved. When performed in this manner, the Schneiderian
membrane remains intact while crestal areas of reduced maxil-
lary bone will have openings of varying degrees depending on the
amount of bone reduction (Figure 7). The author does not augment
these openings with bone graft and simply closes the surgical site
with primary closures of thick mucogingival flaps. To date, patients
receiving treatment from the author in this fashion have had no
adverse outcomes (Figure 8).
Hemorrhage From Osseous Nutrient Canals
All-on-4–style treatment typically involves reduction of alveolar
and/or basal bone (Figure 9) to achieve adequate restorative space
for both the interim and final prostheses.25-27 During reduction of
this bone, exposure of intraosseous nutrient canals
28,29
may lead to
hemorrhaging that may obscure visualization of the surgical field. If
left uncontrolled, hemorrhaging from nutrient canals can become
460 Volume 37, Number 7COMPENDIUM July/August 2016
CONTINUING EDUCATION 4 | COMMON IMPLANT OBSTACLES
Fig 3.
ing the anterior-posterior spread of the All-on-4–style prosthesis.
Furthermore, in cases in which accessory mental foramina are
located superior to the main mental foramen,
30
the amount of bone
reduction may be compromised, increasing the risk for prosthetic
fracture.
25
Presurgical cone-beam computed tomography (CBCT)
scans and radiographs for proposed All-on-4–style surgeries should
be scrutinized for accessory mental foramina (Figure 13). Notably,
dental literature has shown that even with careful evaluation of
CBCT scans, it is not possible to identify 100% of accessory mental
foramina cases.
31
As such, care should be taken during mucogingival
flap reflection to search for this anatomic anomaly.
When encountering accessory mental foramina, the author has
performed modifications to bone reduction and/or more mesial
placement of posterior dental implants; on a few occasions, he
has carefully dissected the nerve from the accessory mental fora-
men and relocated it to a more distal position. To date, the author
has had no adverse outcomes in patients, such as permanent or
transient anesthesia, paresthesia, hypoesthesia, or dysesthesia,
resulting from this technique.
Fig 5. Fig 7.
Fig 8.
Fig 6.
Fig 5. Crestal exposure of the Schneiderian membrane at the initiation of horizontal plane bone reduction. Fig 6. Curette used to elevate
Schneiderian membrane from residual crest to allow for additional horizontal plane bone reduction. Fig 7. Maxillary arch from Figure 5 and Figure 6
following crestal Schneiderian membrane elevation, horizontal plane bone reduction, and dental implant placement. Fig 8. Postsurgical panoramic
radiograph of patient shown in Figure 5 through Figure 7. Fig 9. Alveolar bone reduction prior to dental implant placement in a mandibular All-on-4–
style dental implant surgery. Fig 10. Woodson hand instrument used to condense bone at the site of an intraosseous nutrient canal hemorrhage.
significant, resulting in excessive blood loss. It is not uncommon
to encounter multiple concurrently hemorrhaging intraosseous
nutrient canals, especially during mandibular bone reduction.
When faced with this situation, the author uses the blunt end
of a handheld instrument, such as a Woodson instrument (Figure
10), to put heavy pressure on bone directly adjacent to the bleeding
nutrient canal. This pressure typically deforms the adjacent bone to
a point at which it occludes the hemorrhaging. The author has en-
countered hundreds of hemorrhaging intraosseous nutrient canals
and has never had this technique fail to achieve the desired results.
Accessory Mental Foramina
The prevalence of accessory mental foramina is well documented
in dental literature with findings from 2.7% to 13% (Figure 11).30-
32
Accessory mental foramina pose a particular obstacle for All-
on-4–style treatment because the mental foramen is the landmark
used to determine the posterior limits of tilted implant placement
(Figure 12).
9
The presence of accessory mental foramina often
requires more mesial placement of dental implants, thus limit-
Fig 9. Fig 10.
461
www.compendiumlive.com July/August 2016 COMPENDIUM
Sublingual Artery Insertion in the Anterior Mandible
Because All-on-4–style treatment in the mandible requires dental
implant placement anterior to the mental foramina, special consid-
eration should be given to the vasculature in this region. A number
of articles have reported potentially life-threatening complications
when dental implant placement has damaged vasculature in the ante-
rior mandible. A 2015 literature review
33
on immediate or immediate
postoperative bleeding complications in implant dentistry noted that
the most common cause of bleeding complications was damage to
the sublingual artery. Although this literature review noted an ab-
sence of fatalities, advanced airway management by intubation was
needed in 41% of patients and tracheostomy was required in 47% of
patients. Certainly, avoidance of the sublingual artery during implant
placement in the anterior mandible is paramount.
Cadaveric34,35 and CBCT36 assessments of vascular supply to the
anterior mandible have found that lingual foramina for insertion of
the sublingual artery most commonly occurs in the midline of the
mandible. While the location of sublingual artery insertion in the
anterior mandible is typically beyond the depth of bone reduction
required for most All-on-4–style surgeries, it may be encountered
in cases of severely resorbed mandibles. Furthermore, while den-
tal implant placement is typically not required in the mandibular
midline for All-on-4–style treatment, it is occasionally necessary to
place a dental implant in this location. When faced with this situation,
the author has modified the total amount of bone reduction in the
anterior mandible to allow for safe placement of a dental implant
that avoids vascular impingement while still enabling adequate
prosthesis thickness.
Inadequate Bone Density
Multiple studies indicate that a high degree of primary implant
stability is a prerequisite for the successful immediate loading
of dental implants37,38 and that high insertion torque values are
correlated to high primary implant stability.39-42 Insertion torque
and primary implant stability have proven to be substantially
dependent on bone density with denser bone producing a more
favorable situation.
42
In cases of inadequate bone density, or
“soft bone,” some authors have recommended underpreparing
dental implant osteotomies to achieve improved implant stabil-
ity.7,9 Although this technique is effective in many cases, select
instances arise in which underpreparing the bone still results in
low initial torque values.
When such instances occur, whether in the mandible or maxilla,
the author first attempts to place a larger-diameter implant of
the same length as the implant that failed to achieve high initial
torque value. Should this adjustment prove ineective, a longer
implant of a larger diameter is then used. In the maxilla, the lon-
ger implant may engage the vomer or lateral piriform rims to
achieve apical stability.
13
In the mandible, the author achieves
primary implant stability by engaging the cortical bone at the
inferior border of the mandible with the apical portion of the
dental implant (Figure 14 and Figure 15).
Removal of Dental Implants
All-on-4–style treatment sometimes requires the removal of previ-
ously placed dental implants (Figure 16 and Figure 17). Although
some of these implants may have biologic complications such as
peri-implantitis that may ease the removal process, most previ-
ously placed implants requiring explantation by the author have
been firmly osseointegrated. Previously placed dental implants are
not typically suitable for All-on-4–style surgeries because the plat-
forms were placed to a level in accordance with the natural teeth.
462 Volume 37, Number 7COMPENDIUM July/August 2016
CONTINUING EDUCATION 4 | COMMON IMPLANT OBSTACLES
Fig 11. Accessory mental foramina (arrows)
encountered during mandibular All-on-4–
style dental implant surgery. Fig 12. CBCT
imaging of accessory mental foramina from
Figure 11. Fig 13. Mental foramen used to
determine the posterior extent of tilted
dental implant placement in a mandibular
All-on-4–style dental implant surgery. Fig
14. Postsurgical panoramic radiograph of
All-on-4–style dental implant surgery with
dental implants engaging cortical bone at
the inferior border of the mandible. Fig 15.
Cross-sectional CBCT scan slice from Figure
14 showing apical engagement of the dental
implant with the dense cortical bone at the
inferior border of the mandible.
Fig 11.
Fig 14.
Fig 12.
Fig 15.
Fig 13.
Although this is perfectly suitable when natural teeth are present,
these platform positions are too coronal for All-on-4–style treat-
ment. Furthermore, previously placed dental implants preclude
the ability for adequate bone reduction. In the author’s experi-
ence, using previously placed dental implants for All-on-4–style
treatment often results in restorations of inadequate thickness
that have a propensity for fracture due to the coronal position of
the platforms and the lack of bone reduction. As such, the author
routinely removes previously placed dental implants when per-
forming All-on-4–style treatment.
Dental implant removal for All-on-4–style surgery is particu-
larly concerning because of the need for immediately loading a
prosthesis. Dental implants requiring removal are typically the
same diameter as the implants intended for use in the All-on-4–
style surgery. If the implants can be removed with a high-torque
dental implant retrieval tool (Figure 18), bone is preserved and a
dental implant of at least the same diameter and length can be used
for the All-on-4–style treatment. Should the implant retrieval tool
fail to explant the previously placed dental implant, trephination
is required. The bone loss subsequent to trephination of a dental
implant may eliminate the possibility of placing a new implant and
thus compromise immediate loading of a transitional prosthesis.
As has been reported by others,
43-45
the author has had a high degree
of success in removing previously placed dental implants with
high-torque retrieval tools. In cases in which trephination was
required, the author has replaced the previously existing implants
with new implants of both wider and longer dimensions.
Postsurgical Complications
Fracture of Provisional Restorations
Postsurgical biologic complications following All-on-4–style den-
tal implant surgery are rare.
1-12
The most common postsurgical
complication following this surgery noted in the dental literature
is fracture of the provisional restoration, with rates from 4.17%
to 41%.
46-48
Fractures of provisional All-on-4–style restorations
during healing are concerning, because they eliminate cross-arch
stabilization and disrupt stress distribution patterns. Furthermore,
fractures of these prostheses are unsettling to patients because
they impair masticatory function and marginalize esthetics. The
most common causes of fractured All-on-4–style provisional res-
torations are prostheses of inadequate thickness due to under-re-
duced bone, processing errors, or improper occlusal adjustment.
46
In some cases, however, fractures may occur because acrylic and
polymethyl methacrylate materials are inadequate for extended
periods of heavy occlusal use.
To reduce the incidence of postsurgical fracture of All-on-4–
style provisional restorations, the author reinforces transitional
prostheses with 1-mm-diameter interplaited steel wire (Figure 19
and Figure 20) based on the findings of research by Yamaguchi et
al,49 Li et al,50 and others.51-53 Upon incorporating this reinforce-
ment technique for All-on-4–style provisional restorations, the
rates of fracture for the author’s provisional restorations decreased
from 16.14% to 4.17%.46
Conclusion
Although All-on-4–style full-arch dental implant procedures
have one of the highest success rates of any treatment in dental
literature, the technique is also among the most dicult and can
be fraught with obstacles. With careful planning and knowledge
of potential pitfalls associated with performing the procedure, cli-
nicians can incorporate All-on-4–style dental implant treatment
into their practices with a high degree of confidence and less stress.
463
www.compendiumlive.com July/August 2016 COMPENDIUM
Fig 16. Presurgical panoramic radiograph
of a patient receiving All-on-4–style treat-
ment with multiple dental implants requir-
ing explantation. Note the dental implants
in the mandibular right quadrant that are
compromising the inferior alveolar nerve.
Fig 17. Postsurgical panoramic radiograph
of the patient from Figure 16 following All-
on-4–style dental implant treatment. Fig
18. High-torque retrieval tool being used
to remove dental implant during All-on-4–
style treatment. Fig 19. All-on-4–style tran-
sitional restoration being fabricated with
interplaited steel wire for reinforcement.
Fig 20. Finished All-on-4–style transitional
restoration from Figure 19.
Fig 16. Fig 17. Fig 18.
Fig 19. Fig 20.
DISCLOSURE
The author had no disclosures to report.
ABOUT THE AUTHOR
Dan Holtzclaw, DDS, MS
Consultant Faculty, US Navy Postgraduate Dental School, Department of
Periodontics, Bethesda, Maryland; Private Practice, Austin, Texas
Queries to the author regarding this course may be submitted to
authorqueries@aegiscomm.com.
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CONTINUING EDUCATION 4 | COMMON IMPLANT OBSTACLES
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465
www.compendiumlive.com July/August 2016 COMPENDIUM
easy-graft® CLASSIC
alloplastic bone grafting system
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Designed
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Placement
Once the coated granules of GUIDOR® easy-graft ® are syringed
into the bone defect and come in contact with blood, they change
in approximately one minute from a moldable material to a rigid,
porous scaffold.
• Designed for ease of use and predictability
• 100% synthetic and fully resorbable
• Ideal for ridge preservation and filling voids around
immediate implant placements
This product should not be used in pregnant or nursing women.
rated it excellent or good and worthy
of trial by colleagues.* Full-report is available
at http://us.guidor.com/cliniciansreport/
*Source: Gordon J. Christensen Clinicians Report
®
, September 2015.
Published by CR Foundation, an independent, non-profit, dental
education and product testing foundation.
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or call 1-877-484-3671. Instructions for Use (IFU), including indications,
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