Two of the most frequently discussed are also the most obvious:
- How many implants do you need?
- How quickly can you load them?
Having been encouraged to be cost effective and efficient from the outset I was an early adopter of the All-on-4 protocol. With now more than 10 years of experience of All-on-4, I am still bemused by the advocates of fixed implant bridgework, consisting of multiple fixed bridges, typically four three unit bridges.
This approach requires a minimum of 12 implants, very often sinus augmentation, and is restrictive with regard to implant placement. It is considerably more complicated from the outset, however it has many followers. I have seen the benefits of using fewer dental implants, and have not lost aprosthesis in this time.
I have, though, converted two patients from a fixed solution to a removable, to facilitate hygiene. I have met the pioneer of the All-on-4 approach on a number of occasions. He was met with a fairly hostile reception from the outset, to the point that he was suspended by his dental governing body for two years, on the grounds that four implants was insufficient to support a fixed bridge.
Times have changed. In the main the All-on-4 protocol has been accepted, though of course it is not a solution that fits all. In recent times I was in discussion with a practitioner who received a phone call from a lawyer on behalf of a patient who had seen a new dentist following the retirement of his practitioner.
The new dentist advised the patient, who had a perfectly satisfactory All-on-4 solution (for a number of years), that four implants was inadequate and that he should seek legal advice to pursue a claim. Suffice it to say four implants does the job very well and makes good use of advances in technology, notably CAD/CAM enabling the milling of very accurate frameworks from titanium.
The use of a milled framework avoids the issues of contraction on cooling as encountered with cast metal frameworks. That is the reason why short bridgework is simpler. Whilst it is not universally applicable, the All-on-4 does allow for a reasonably aesthetic prosthetic gingival tissue, and with that a very pleasing aesthetic result can be achieved every time.
So with improved aesthetics, more accurate framework (leading to reduced framework stresses – and greater framework longevity) a reduction in augmentation requirements and reduced number of implants, you can see the benefits.
When we consider that with good initial stability of four implants the process can reliably be loaded on the day of implant placement, you can appreciate the solution of choice for edentulism for the 21st century.
Cost effective, and reliable, the solution is really a patient centric option, and as we are advised in the best interest of our patients. Thank goodness for pioneers prepared to take on established protocols.