All-On-4 not for the faint-hearted

Take an increasingly aged population with ostensibly decades of stockpiled superannuation, who have had the value of investment and wealth creation rammed down their throats from their first days in the workforce, coupled with the inevitable decline of the dentition over time, and you have the perfect customer for All-On-4.

Famously developed by Paulo Malo in the 1990's and then patented by Nobel Biocare as part of its solution for the edentulous jaw, All-on-4 is a 'revolutionary approach' that allows the rehabilitation of totally edentulous patients with the placement of only 4 implants in each jaw through a quick and minimally invasive procedure. By tilting the two posterior implants to 45 degrees, All-on-4 allows even those patients with virtually no bone to have a fixed prosthesis without grafting.

"All-On-4 has been around for well over a decade, and there is a lot of published data including 10-year studies on its success, however, you could be forgiven for thinking that no one noticed it in Australia before the GFC," muses Robert Dulieu, principal of high-end dental laboratory, RWD Dental Image, based in the Sydney suburb of Bondi Junction. "And then, boom! All of a sudden, All-On-4 is the procedure du jour, and every time I turn the radio on, I hear adverts pushing it to the thousands of baby boomers out there who don't want to end up with dentures like their parents had."

Whilst All-On-4 is an expensive procedure at in excess of $25,000 a case, it is both affordable and justifiable to the generations of baby boomers who equally want to continue the 'good life' into old age. For many, All-On-4 can be a 'life changer', offering a fixed, stable option that allows patients to eat what they want and smile with impunity, boosting health and self-confidence.

"All-On-4 is an effective and affordable option for an increasing problem in need of a solution," said Mr Dulieu. "From a marketing perspective, there has been so much promotion of All-On-4, in Sydney at least, that it's getting up there with teeth whitening and Invisalign as far as patient awareness goes, particularly as it succinctly matches a major concern many patients have. Quite simply, if you have yellow teeth, get teeth whitening; if you have crooked teeth, get Invisalign; and if you have no teeth... or are losing them... then get All-On-4.

"From a clinicians perspective, it's very technically demanding, requiring advanced skills and experience, and because of that, it also means that All-On-4 is not for the faint-hearted. This in turn focuses demand on the limited number of clinicians who have trained in the technique, sought mentoring from the experienced, and put together a 'team' who can manage the case. Importantly, that includes managing the patient well through the sometimes arduous process of diagnosis, treatment planning, surgery and restoration choice over the long term."

Mr Dulieu's RWD Dental Image fulfils the laboratory requirements in that 'team' for several clinicians offering All-On-4. His focus on this treatment modality stemmed from a Mini Clinical Residency he completed at the Malo Clinic in Portugal in 2008 on the All-On-4 edentulous implant restorative technique.

"We work closely with half a dozen clinicians at present who are actively treating patients with All-On-4, and that's resulting in up to 20 cases a month going through the lab," Mr Dulieu said. "We've built up a lot of experience in this way and we translate that into protocols and procedures that help make cases more predictable and treatment more efficient.

"We actively participate in a team approach with our clients and because of that, all of us learn from each other. All our active All-On-4 clinicians started with us using vastly different approaches to treatment, however, through the active sharing and exchange of information based on practical experiences, there has been a gradual alignment in many ways.

"Our clients are all very individual and still approach treatment very individually, but equally, we're all committed to achieving optimal results aesthetically, clinically and technically, as well as minimising the impact of treatment on the generally elderly patient base.

"Having the proper systems and protocols in place reduces the stress of everyone involved and keeps 'surprises' to a minimum."

Mr Dulieu said that apart from training with Paulo Malo in Portugal and working with some of Sydney's most experienced All-On-4 clinicians, being a dental prosthetist gives RWD Dental Image a further edge.

"There are several factors that contribute to the success of an All-On-4 case and one of these is being efficient with the patient's time. Many All-On-4 candidates are elderly and All-On-4 is not a quick and simple process. It is complex and the 'to-do' list is extensive. If you don't manage the patient well, their commitment to treatment can quickly wane and they can start to question whether or not to proceed further.

"As a prosthetist, we can work with the patient directly, which streamlines the process for both the patient and the clinician. We've developed protocols in-house to deliver everything a clinician needs, from the initial consult where we typically duplicate their denture, set-up a new denture on a stable acrylic base (including radiopaque markers so it can be used as a scanning template) and send it back for the first try-in; through to subsequent try-ins, adjustments and consultations with the clinician face-to-face, or using tools like NobelConnect; to the issuing of the long-term provisional prosthesis and then ultimately the definitive restoration."

Apart from a growing base of candidates who both need and can afford All-On-4, Mr Dulieu credits the growing popularity of the procedure to the availability of high tech tools like 3D imaging, CAD/CAM and guided surgery.

"The clinicians we work with on All-On-4 cases are typically using cone beam 3D imaging and implant surgery planning software like NobelClinician for diagnosis and treatment planning; and some are also using NobelGuide for the surgical phase. In the lab, we're typically using NobelProcera CAD/CAM technology to produce the final prosthetics.

"All-On-4 is a multiple implant procedure using traditional 'flap' surgery that then requires a passively fitting prosthetic. Using high tech tools in diagnosis, treatment planning and delivery and the creation of the prosthetics all contribute to making All-On-4 more predictable."

Mr Dulieu said that developments in CAD/CAM have also increased the range of options for the definitive restoration.

"All-On-4 patients typically wear long term provisional bridges, sometimes for years and use these to retrain their bite. Come time for the definitive restoration, the condition of the provisional also gives us information on the occlusal forces at play as well as other factors and based on that, we can decide on the most appropriate final prosthesis.

"We're offering everything from NobelProcera Bars with a removable bridge or fixed NobelProcera Zirconia ceramic bridges or NobelProcera hybrid titanium designs. CAD/CAM offers myriad choice these days."

Mr Dulieu said that whilst participating in a team approach to All-On-4 is very fulfilling, equally, it requires skills, knowledge, mentoring and experience to deliver successful treatment.

"All-On-4 involves complex oral surgery and everyone involved in the pro cedure needs to be experienced. In my own field, I am grateful to have received the appropriate training and experience and my advice to clinicians would be to do the same and take advantage of the courses on offer and the mentoring opportunities that are available before attempting a case. In that way, the only lives you change will be the right ones!"