DENTAL MEDICINE | CASE REPORT

Immediate loading all on 4 - all on 6 in total maxillary

edentulous
Cristian Adrian Ratiu∗ , Anca Porumb∗,1 and Gabriela Ciavoi∗
∗ Faculty of Medicine and Pharmacy, Department of Dentistry, Oradea, Bihor, Romania.

ABSTRACT Dental implantology is one of the areas that are growing lately. With the development of new materials,
new techniques and possibilities appear to ensure the integrity of the dentomaxillofacial apparatus from a functional and
physiognomic point of view in a short time. Immediate loading of the dental implant allows the restoration of function,
especially the physiognomic one in a very short time. Purpose: This study aims to report the management of immediate
loading in the frontal, maxillary area. The All-on-four concept allows an immediate loading and temporary prosthesis of
the patient, regardless of the jaw (upper or lower), on the same day that the implants were inserted. Immediate loading
all on 4 - all on six it is a viable and future solution in total edentulous.
KEYWORDS immediate loading, all-on-4, totally edentulous patient

stand the morphology of the maxillary bones, take into account

the alveolar mucosa, to determine together the ideal position of
the implant horizontally and vertically. [3]. It takes 3-6 months
Introduction
in which the implants are covered by the gums; this period may
Technological advances in the development of new materials and increase in areas where bone grafts have been performed (e.g.
new techniques in implant therapy allow us to obtain excellent sinus lift) [1,3].
results in prosthetic restoration on implants. The final aesthetic Thanks to the Swedish school we know that the long-term
result defines success or failure in implant therapy. On the other success of dental implants can only be achieved if they are os-
hand, even if the aesthetic aspect is a priority, we must not seointegrated, i.e. if they have direct contact with the bone;
neglect the functional aspect. [1].The doctor tends to go beyond as a result, the immediate loading was considered inappropri-
the subjective evaluation of the patient who besides aesthetics, ate because it led to the interposition of fibrous tissue between
is concerned with: phonation, social image, social inhibitions, the implant and the bone. Excessive micromovements at the
various disabilities. bone-implant interface threaten the stability of the implant and
The edentulous patient is a case that requires the restoration disrupt bone tissue formation, leading to stem cell differentiation
of functions as soon as possible. If the patient is partially dentate into fibroblasts rather than osteoblasts. [4]. With the evolution
or has inadequate prosthetic work and the therapeutic solution of implantology, the concept of "immediate loading" is gaining
includes extraction of all remaining teeth and removal of inade- ground, and the two surgical stages are replaced with a single
quate prosthetic work, the therapeutic solution must come in a surgical stage by using transmucosal components connected to
for as short a time as possible. [2] For these reasons, the all on 4 the implant.
/ all on 6 variant with immediate loading is from our point of
view a therapeutic solution to consider. In order to obtain good
results, however, both the doctor and the technician must under- Case report

Copyright © 2020 by the Bulgarian Association of Young Surgeons

The 65-year-old patient presents with a partially extended eden-
DOI:10.5455/IJMRCR.total-maxillary-edentulous tate in the upper jaw, wanting a fixed restoration of the im-
First Received: June 08, 2020 plant. Considering the precarious situation of the remaining
Accepted: June 15, 2020 teeth (Fig.1), it is decided to extract them and insert 4 implants.
Associate Editor: Ivan Inkov (BG); The radiological examination highlights a generous bone supply
1
Assoc. Prof. Anca Porumb, University Oradea, Faculty of Medicine and Pharmacy,
P-ta 1 Decembrie nr.10, Oradea, Bihor, Romania, Tel: 0040.726.286.237, e-mail:
so that the loading is decided immediately after the insertion
anca.porumb@yahoo.com of the 4 implants. Before extraction, the maxillary prosthesis is

Cristian Adrian Ratiu et al./ International Journal of Medical Reviews and Case Reports (2020) 4(7):50-54
 Figure 2: Application of direct impression abutments over multi-
unitabutments (MUA) immediately after suture completion.
Figure 1: Pre-operative Panoramic X-ray.

used to mark the size of the lower third of the face on the skin.
Remove the remaining teeth, insert 4 implants in positions 15,
1.2, 2.2 and 2.5. Apply multi-unit-abutments angled over the
implants in order for the orifice through which the prosthetic
work will be screwed to be located palatine. With a standard
tray, an impression is taken by the closed tray method, and an in-
dividual tray is made. Position the direct impression abutments
(Fig.2) with which the screwing direction of the future pros-
thetic restoration is checked. The gypsum impression is taken
with an open tray (Fig.3), and implant analogues are applied
(Fig.4). Apply on the front implants two titanium abutments
(Fig.5) which will adapt (Fig.6) so that the patient can close his Figure 3: Impression in the individual tray using gypsum as
mouth in a centric relationship; the size of the lower floor of the impression material.
face was previously recorded. The prosthesis made preopera-
tively by erasing the remaining teeth from the gypsum model
is perforated at the level of the frontal implants; the prosthesis
is applied on the prosthetic field and then in the created holes
self-curing acrylate is applied. The respect of the vertical di-
mension of the face is verified, the patient closes in maximum
intercuspation, and after taking the acrylate, the intermaxillary
relations are registered. Then the prosthesis is unscrewed from
the 2 front implants (Fig. 71.1 7.2) and fixed in the moulded
model based on the gypsum appliance with an open tray. The
two titanium abutments are applied in the prosthesis for the dis-
tal implants (Fig.8), and then the prosthesis is reinforced with a
thin metal band (Fig.9). The final prosthesis is applied in the oral
cavity (Fig.10), and a control radiograph is performed (Fig.11)
to verify the correct screwing of the titanium abutments in the
Figure 4: Application of implant analogues in impression abut-
multi-unit-abutments. The occlusion is checked both in maxi-
ments.
mum intercuspation and in lateral movements to eliminate any
premature and interfering contact (Fig.12). The patient comes
for a daily check-up for a week to check for occlusion.

Discussion
The All-on-four concept allows an immediate loading and tem-
porary prosthesis of the patient, regardless of the jaw (upper
or lower), on the same day that the implants were inserted.
Implants may or may not be post-extraction. The All-on-four
concept involves the insertion of 2 anterior vertical implants and
two inclined implants in the distal area, a concept developed by
Paulo Malo. Moreover, at the jaw, they will allow the use of long
implants, 13-15 mm, which through the bicortical support will
ensure a torque of minimum 40 N / cm necessary in immediate
Figure 5: Application of titanium abutments on frontal implants.
loading[3].

Cristian Adrian Ratiu et al./ International Journal of Medical Reviews and Case Reports (2020) 4(7):50-54
Figure 6: Adaptation of titanium abutments to allow the patient
to close in a centric relationship.

Figure 9: Temporary acrylic prosthesis reinforced with a thin

metal strip.

Figure 10: Application of the acrylate prosthesis and fixing by

screwing in the 4 implants.

Figure 7.1 and 7.2 Fixing titanium abutments with self-curing

acrylate and recording intermaxillary relationships.

Figure 11: The panoramic control radiograph shows the correct

adaptation of the titanium abutments from the prosthesis into
the multi-unit-abutments.
Figure 8: Completion of the temporary acrylate prosthesis.

Cristian Adrian Ratiu et al./ International Journal of Medical Reviews and Case Reports (2020) 4(7):50-54
 and so is hygiene[1,3]. In this case, because of bone availability
only for implants were implants: all the implants were 4mm
diameter, the length was 13 mm for frontal implants and 15 mm
for distal implants (Nobel Biocare®).
The distribution of the implants forms a prosthetic polygon
enlarged by the distal inclination; A relative parallelism is re-
quired for to obtain a passive adaptation of the prosthetic work:
this is achieved by applying on implants multi-unit-abutments
of 0 °, 17 ° and 30 ° angles with different threshold heights de-
pending on the thickness of the gum. [4,5]. Identical to this
concept with the success rate of other oral rehabilitation on im-
plants, 98%. In order to obtain such a success rate, in the oral
rehabilitation with four implants of the total edentulous, it is im-
Figure 12: Adaptation of the occlusion, the very important stage portant to take into account: bone quality, length implants, the
in the osseointegration of the implants. thickness of the implants. It is very important that the prosthetic
work is inserted in the first 48-72 hours and the abutments are
tightened with the necessary torq (approx. 15 N / cm) [8]. No
Research has shown that if implants have characteristics that intervention is performed on the abutment-implant assembly
ensure good primary stability, limiting micromovements to 50- during the osseointegration period of 6-8 weeks [2,4].
150 µm, called tolerated movements, in implants, loaded earlier The degree of bone atrophy will dictate the fixed / mobile
than 3-6 months, as required by the classical protocol, no fibrous work. The prostheses used in the immediate loading can be
tissue appears. However, tissues appear if micromovements made entirely of acrylate or acrylate and a metal structure, with-
occur above the value of 100-150 µm, due to insufficient primary out requiring scientific data to determine which is better. The
stability or excessive load, causing the interposition of fibrous prosthesis must rigidly and firmly join the implants and dis-
tissue. [3,5]. To obtain primary stability that allows immediate tribute the forces evenly.
loading, the torque required to remove the implants should be 40 Implant failure in immediate loading is caused by prosthetic
- 45N / cm. The torque decreases from day 15 to day 21, which causes such as: Lack of precision / passive adaptation, occlusal
corresponds histologically to a maximum of bone resorption causes, decimation of prosthetic work, prosthesis fracture, longin
[1,2,3]. [2].
Stability gradually recovers from day 30 to 45, which histo-
logically corresponds to an increase in bone apposition. His-
tological and biomechanical evidence shows that peri-implant Conclusion
bone undergoes rapid and intense resorption between 2-4 weeks Immediate loading allows the patient to restore in a very short
of functional loading when primary stability decreases until it time both masticatory and physiognomic and phonetic function.
reaches a critical value. [6]. Performing prosthetic work during In the case of all on 4 - all on 6, we may consider therapeutic
this period endangers the stability of the implant and may cause solution to think the first time when we have a total edentate.
failure. If an immediate prosthetic load is made it should be done
in the first 2-3 days after implant insertion when the primary sta-
Acknowledgements
bility of the implant is sufficient to oppose the forces that seem to
screw/unscrew the prosthetic abutments/prostheses. Stability Not applicable
gradually recovers from day 30 to 45, which from a histological
point of view corresponds to an increase in bone apposition. Conflict of interest
Performing prosthetic work between days 3-30 endangers the
stability of the implant and can cause failure[6,7]. There are no conflicts of interest to declare by any of the authors
Experimental studies have shown that the application of axial of this study.
forces / of different angles on inclined implants causes bend-
ing forces and pressure on the bone but which are annihilated References
by binding to other axially inserted implants. It is inserted in
1. Kodama T., Implant-supported full mouth reconstruction
front of the mentonier hole/maxillary sinus, and the implant
Malo Implant Bridge retrieved no results, J Calif Dent As-
protrudes from the bone in position PM2. It requires the bone
soc.2012 Jun; 40(6):497-508;
thickness to be 5-6 mm so that the implants have a diameter of
4mm. If we do not have this thickness, it must be evaluated 2. Babbush C.A.,Posttreatment quantification of patient expe-
whether the reduction in crest height will ensure the desired riences with full-arch implant treatment using a modifica-
thickness and bone height between canines: minimum 10 mm at tion of the OHIP-14 questionnaire, J Oral Implantol., 2012
max. and 8 mm at the mandible [5,6]. Jun; 38(3):251-60;
At the level of the jaw, they can be inserted with/without
sinus lift. Achieving a sinus lift is beneficial because the in- 3. Testori F, Galli M, del Fabro M., Immediate loading -A New
sertion is done under visual control, and the passage through Era in Oral Implantology, Quintessence Publishing 2011,
the sinus cortices will significantly increase the stability of the 9-51;
implant. The inclination towards the occlusal plane is 30-45
degrees. However, no higher than 45°. 4 implants are inserted in 4. Ahmed M.E., Evaluation of Early Loading Versus Immedi-
the jaw, and 6 in the maxillary, with a small number of implants ate Loading of Dental Implants: A Comparative Study, EC
obtaining a passive adaptation of the metal structure, is easier, Dental Science 2020, 19(1):01-12;

Cristian Adrian Ratiu et al./ International Journal of Medical Reviews and Case Reports (2020) 4(7):50-54
5. Lefkove M.D., Beals R.P., Immediate loading of cylinder
implants with overdentures in the mandibular symphysis:
the titanium plasma-sprayed screw technique, Journal of
Oral Implantology.1990;16:265-271.32.

6. Rae T et all., The toxicity of metals used in orthopedic pros-

theses. An experimental study using cultured human syn-
ovial fibroblasts,The Journal of Bone and Joint Surgery. 1981,
63(3):435-440;

7. Sul Y.T., Oxidized bioactive implants are rapidly and

strongly integrated in bone. Part 1-experimental implants,
Clinical Oral Implants Research, 2006, 17(5):521-526;

8. Ellingsen J.E. et all., .Improved retention and bone-to im-

plant contact with fluoride-modified titanium implants,
The International Journal of Oral and Maxillofacial Im-
plants.2004, 19(5):659-666.

Cristian Adrian Ratiu et al./ International Journal of Medical Reviews and Case Reports (2020) 4(7):50-54