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All-on-4: Why Nuffield Dental for this Dental Implant Procedure?

Millions of people globally have missing or have broken down teeth. One of the many different implant treatment options they may have includes the “All-On-4”. Before returning to Singapore in 2013, this was not a common procedure.


Currently in 2018, we are seeing patients having this procedure done by their dentists. Dr Paulo Malo invented the All-on-4 procedure in the 1990s in Portugal.


What is an All-on-4?

Four to six implants are placed in the jaw bone to support an acrylic or zirconia dental bridge which predictably restores patient’s chewing function and smile. As per the MALO Protocol, the posterior implants are tilted to avoid anatomical features and may not need lengthy bone grafting or sinus lift procedures. The safety profile published in the literature of a 98.2% success rate is largly accepted as the pinnacle for full mouth implants.

The “All-On-4” or “All-On-6” is an implant-based full mouth reconstruction, which requires teamwork and coordination with a high-quality dental laboratory that makes the patient’s final set of teeth.

The original MALO Protocol has been published in the literature and is free domain knowledge. However, this implant treatment is technique sensitive. The treatment’s success depends on proper initial treatment planning, the treating dentists’ expertise, and cooperation between the surgeon, restoring dentist, and the dental laboratory.

Along with the increasing popularity of the All-on-4 dental implant, patient complaints also have similarly increased.

Recently I examined a patient who came to me with an All-on-4 bridge that had completely broken loose inside his mouth. A detailed examination showed that all the gold screws connecting the prosthesis to the denture had broken. Worse, one dental implant was failing based on the x-ray.

The All-on-4 bridge was of low quality and it lacked key design features as originally described by Dr Paulo Malo. As Director for MALO DENTAL Singapore, I have come across many similar patient complaints like lack of aesthetics, unpleasant smile, chewing problems, bridge fracture and poor hygiene designs for All-on-4 bridges to failures and patient dissatisfaction.



Problems with Poor Treatment Planning

Poor treatment planning before the surgery is a recipe for failure. Additionally, if the restorative dentist is not involved in the treatment plan or fails to spend the time needed for proper treatment planning or fail to communicate with the surgeon, implant placement can be compromised.

These problems will negatively impact the restorative phase of the treatment and they are not easy to correct later in the treatment phase. Simply put, it is challenging to treat a case after another dentist has partially treated the matter. I remember another case of an elderly gentleman who had been to another country for treatment and was told he would get the All-on-4 treatment done.

When he woke after the local anaesthesia, he was told that the treatment could not be done but instead dental implants and bone grafts had been done. He rushed to MALO DENTAL in Singapore for an urgent opinion and was rehabilitated with a fixed bridge within three days of seeing me. This would have been avoided by proper treatment planning with CT scans and adequate analysis.

The position of dental implants in this All-on-4 procedure has a significant role on the All-on-4temporary bridge and final bridge durability. Cantilevers or unsupported teeth beyond the implants can break off due to excessive stress. Too much stress on the implants due to inadequate treatment planning can lead to bone loss and implant failures.

These problems are worse in patients with a history of teeth grinding or bruxism. Proper treatment planning must be done to overcome the grinding forces, which is challenging for any dentist to handle.

Problems with the All-On-4 restorative Procedure

Transitioning from a temporary All-on-4 implant treatment to a final bridge is a highly technically demanding process with numerous stages. The restorative dentist must pay close attention to all the steps involved in this process and work with the dental lab at every stage. Should these steps not be followed through or insufficient patient trials are not completed, the final bridge may not be aesthetically and functionally adequate for the patient.

Poor bridge design will lead to poor chewing, poor smile aesthetics and on many occasions, a bridge that is too thick and makes it difficult to speak. At MALO DENTAL, we frequently make another temporary bridge for the final bridge - this time with all the correct desired measurements and expectations. This transitional bridge is called the MALO DENTAL All Acrylic Bridge and the final bridge will be a replica of this should the patient be happy with this.



Poor Construction of All-on-4 bridges

Every dentist knows that not all dental laboratories are the same, and the final All-on-4 bridge’s quality is directly related to this. The restoring dentist must ensure that the bridge is constructed correctly with high-quality materials selected for the bridge. The design of the All-on-4 bridge must avoid food collecting inside. Sharp edges and ledges must be avoided with the bridge being silky smooth to the touch of the tongue.

Also, original implant parts and screws must be used to prevent mechanical failures of the bridge. Your all-on-4dentists must advise you to use a Waterpik daily. In addition to toothbrushing, the WaterPik is the secret of how the All-on-4bridge can be kept clean. The all-on-4 bridge design - regardless of whether it is temporary or not, must allow easy everyday cleaning. If it cannot be kept clean easily, the design of the bridge has to be altered.

Type of Materials Used for the Construction of the All-on-4 Bridge

All patients must be aware of the limitations of materials and the implant cost related to All-on-4 bridge construction. The final MALO All-on-4 bridges are made with Acrylic or Zirconia, the option may be made based on cost or clinical limitations. The Acrylic bridge tends to wear faster. However, the Zirconia or MALO Ceramic Bridge is a much harder wearing material and aesthetically high-ranking.

The Ceramic Bridges are stunningly thin compared to the Acrylic Bridge. However, the ceramic layer may chip or fracture, especially if the biting forces (occlusion) is not analysed and adjusted.

At MALO DENTAL Singapore, we avoid using PMMA for the temporary bridge as PMMA is a porous material prone to stains. Stains can hoard bacteria.



Patient Expectations

Most of the All-on-4 patients would not have had full teeth for a long time. With the All-on-4 procedure is done in a single day, this suddenly introduces a foreign object into the mouth that patient must get slowly adjusted to. There are some inherent problems with the implant-supported full arch denture that patient must be aware of.

Natural teeth have nerves and it has proprioception which allows teeth to protect themselves from pressure and excessive forces. Dental implants do not have proprioception and thus, they lack this protective mechanism. Hence any bite problems may be exacerbated, causing bridges chipping or failing. Patients are advised to eat slowly and carefully and thus develop a safe chewing pattern and chewing muscle memory with their novel All-on-4 teeth.

Remember that All-on-4 bridge teeth do not come out of the gum-like natural teeth. The patient may feel that the novel All-on-4 bridge is bulky and always touches the cheek and tongue. There is an adjustment period and the patient must slowly get used to the prosthesis in the mouth.

Caring for Your All-on-4 Teeth

Routine care includes water flossing with a Waterpik and super floss to avoid food accumulation under the bridge. We stress that 4-6 month oral hygiene appointments to clean the gum around the implant areas prevent dental implant failure. Some patients will be advised to wear a soft night guard to protect the bridge at night.

The gold screws supporting the bridge on the implants will work harden and fatigue over time. Patients are advised to go to the restoring dentist, remove the small gold screws and replace them with original novel screws every few years.

At Malo Dental Clinics, the All-on-4 bridges are done on the same day as the dental implant surgeries. Same Day Teeth is what Dr Paulo Malo sought to achieve. 




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Nuffield Dental is a one-stop, multi-disciplinary dental care centre. Here at Nuffield Dental, we pride ourselves of our personalised oral care for each and every one of our patients. We need to make sure you get all the help you need to make your dental procedures comfortable, accessible and seamless.

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