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0278-2391/10/6810-0022$36.00/0 doi:10.1016/j.joms.2010.05.082
The use of angulated implants for short-span bridges or even long-span reconstructions to avoid bone grafts has now been used for 10 years, although many of these were not immediately loaded.13-16 However, with the advent of the All-on-4 immediate function, this became consistently possible using a graftless protocol. Immediate function is based on earlier studies, sometimes using up to 10 implants per arch until biomechanical analysis demonstrated that when 2 implants are placed sufciently close together, they function as if there were only 1 implant present (B. Rangert, personal communication, March 2007). This discovery rst became important in the mandible, where xed denture prosthetics using 5 implants had been (and still is) prescribed as optimal. However, when 5 implant distribution was studied biomechanically it was found that the middle implant took no measurable load in function and therefore could be eliminated. This same biomechanical nding was observed for the maxilla.17-21 Another important aspect of maxillary care is extraction of diseased teeth followed by simultaneous implant placement with immediate function.22-24 The surgeon is therefore faced with the challenge of removing failing teeth, trimming back bone stock, avoiding bone grafting procedures, inserting dental implants at angulations, and placing the patient into an immediately loaded provisional restoration; all of these procedures are counterintuitive to traditional surgical management, if not biomechanical understanding of maxillary treatment.25-27 Antemolar reduction in the number of implants, restricted to available bone anterior to the sinus cavities, further complicates the surgical difculty.28 Given this controversy, 3 questions must be asked in the face of reduced bone stock: 1) Can osseointegration occur without signicant grafting? 2) Can full arch prosthetic loading be obtained with only 4 implants placed at angulation? 3) Can imme-
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FIGURE 1. A, Bone leveling of the alveolus creates a new alveolar plane that functions as a shelf on which to place dental implants. The All-on-4 technique must take advantage of available bone, which is best observed using the All-on-4 shelf approach for which angled implants and compensating angled abutments are placed. B, The All-on-4 shelf provides several advantages for the surgical-prosthetic team, including determining optimal sites for implant placement and helping to avoid pneumatized structures to derive maximum anteriorposterior spread. Jensen et al. The All-on-4 Shelf: Maxilla. J Oral Maxillofac Surg 2010.
diate load biomechanics be established using the limited bone stock of the anterior maxilla? The somewhat oblique answer to these questions is found in the development of a simple surgical solution in which bone is leveled by prosthetic prescription creating a at surface termed the Allon-4 shelf (Fig 1A). Placed on this shelf are implants directed at angulations emerging from specic end points likely to gain primary xation (Fig 1B). The implant positions on the shelf are based in part on compensating angled abutments that must emerge through tissue at or lingual to the midocclusal axial plane.29 The shelf facilitates the anterior-posterior (A-P) spread maximum by identifying the anterior sinus wall and lateral nasal wall.14
There are numerous other advantages to using a shelf approach, which afrm that adequate osseointegration capacity of only 4 load-bearing implants can biomechanically sustain immediate provisionalization. Here, then, are 10 technical advantages for the surgical-prosthetic team to consider in the use of the maxillary All-on-4 shelf: 1. Creates prosthetic restorative space 2. Establishes the alveolar plane 3. Shelf width determines implant diameter selection 4. Shelf reduction proximates piriform bone xation
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FIGURE 2. A clear acrylic bone reduction guide ensures there is adequate restorative space for abutments and titanium bar housed within the prosthesis. Jensen et al. The All-on-4 Shelf: Maxilla. J Oral Maxillofac Surg 2010.
FIGURE 4. Bimaxillary All-on-4 surgery should have at least 22 mm of interarch space for the nal provisional restoration. The planes should be parallel front to back. Jensen et al. The All-on-4 Shelf: Maxilla. J Oral Maxillofac Surg 2010.
5. Shelf ndings suggest convergent or divergent implant placement strategy 6. Establishes optimal osseous sites for implant placement 7. Denes secondary fallback sites for implant placement 8. Exposes palatal plate cortical anatomy for implant xation 9. Facilitates posterior implant placement (A-P spread) in relation to anterior sinus wall 10. Provides bone stock for bone grafting
reduction, especially in dual-arch cases which require 22 mm of interarch prosthetic space. The use of bone reduction guides (Fig 2) or windowed denture guides (Fig 3) helps facilitate adequate bone removal. When the junction of the prosthesis and tissue is visible, there is esthetic failure. A ange is required to hide the junction. Use of a ange on a xed prosthesis creates an oral hygiene access problem. By locating the prosthesis tissue junction a minimum of 3 mm beyond the visible gingiva, the surgeon and restorative dentist are assured of hiding the prosthesistissue junction. This is perhaps the greatest advantage of using the All-on-4 shelf. Although not yet published, alveolar reduction to this extent has not led to bone-level instability, greater tendency for bone loss, or gingival hyperplasia around implants.
Alveolar Plane
Using the interpupillary plane as a guide, a new alveolar plane is established, which avoids a cant in the positioning of implants and creates level placement of implant platforms; this is difcult to do without creating the All-on-4 shelf.16,32 When upper and lower jaw shelves parallel each other (Fig 4), there is less likely to be prosthetic problems with implant positioning. The alveolar plane must also be level front to back. A common error in making the shelf is to taper the shelf too much toward the alveolar crest posteriorly, leaving the prosthodontist with inadequate interarch space. This leads to an alligator bite effect and can result in a thin prosthesis in the bicuspid-molar region. Therefore, the All-on-4 shelf must not only create an alveolar plane parallel to the interpullary line
FIGURE 3. The provisional appliance can be windowed to determine adequate bone removal and used to determine appropriate abutment angulation. Jensen et al. The All-on-4 Shelf: Maxilla. J Oral Maxillofac Surg 2010.
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FIGURE 5. A thin residual maxillary alveolar process will split unless small-diameter implants are used as shown. The shelf width helps determine implant diameter selection. Jensen et al. The All-on-4 Shelf: Maxilla. J Oral Maxillofac Surg 2010.
FIGURE 7. M-Point, the area of maximum lateral pyriform rim bone mass above the nasal fossa, enables using the M-shaped (when viewed on Panorex) placement strategy, including xation of longer implants placed at a favorable distribution for anteriorposterior spread. Jensen et al. The All-on-4 Shelf: Maxilla. J Oral Maxillofac Surg 2010.
FIGURE 6. Using an angulated placement strategy, paranasal cortical bone is able to anchor an implant placed at some distance away. When subnasal bone is reduced in height, anterior implants are angled posteriorally to engage bone in this same area. Jensen et al. The All-on-4 Shelf: Maxilla. J Oral Maxillofac Surg 2010.
2524 into marrow space, often a difcult task to do and still obtain insertion torque values adequate for immediate load. Therefore, computer guidance systems are inadequate to the task, having no ability to assess bone reduction or implant torque.34,38 Alternatively, the shelf provides the surgeon with an opportunity to specically select optimal sites for placement without the constraint of computer generated guides.39 This applies especially to dental extraction cases in which there are often multiple defects present or created during the course of extraction. Following bone reduction, the surgeon is able to identify either visually or tactically the best load bearing sites possible for implant placement.
FIGURE 9. The All-on-4 shelf frequently exposes the sinus cavity or brings it into close approximation such that the exact visual location of the anterior sinus wall (S-point) can be identied to place the posterior implant as far back in the arch as possible without subjecting the patient to sinus oor bone grafting. Jensen et al. The All-on-4 Shelf: Maxilla. J Oral Maxillofac Surg 2010.
The All-on-4 shelf clearly shows the maximum allowable posterior position where the posterior implant can be placed because shelf reduction frequently exposes the sinus membrane, which can then
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2525 where implants must bypass to not traverse the sinus cavity and where posteriorly, no load-bearing bone is present36 (Fig 10A). The vertical alveolar bone available from S-Point to the alveolar plane of the All-on-4 shelf often determines how far posteriorly the implant can be inserted. For example, if there is 5 mm of bone from S-Point to the All-on-4 shelf, implant insertion can usually be accomplished about 5 mm posterior to S-Point when the implant is angled 30 (Fig 10B). When S-Point and M-point converge, A-P spread is reduced proportionately; when there is conuence between the nasal fossa and maxillary sinus (1 cavity), no xation points are available and the alveolar Allon-4 procedure may be contraindicated in favor of a zygomatic All-on-4 strategy.42,43
FIGURE 10. A, When the shelf is well away from the sinus, the most anterior sinus deection (S-point) is identied using a lateral antrostomy burr hole. The space from this point to the shelf is measured. This same distance posterior of the S-point perpendicular should be the entrance location of the posterior implant site (when placed at 30) to avoid the sinus. B, The vertical alveolar bone available from S-Point to the alveolar plane of the All-on-4 shelf often determines how far posteriorally the implant can be inserted. Jensen et al. The All-on-4 Shelf: Maxilla. J Oral Maxillofac Surg 2010.
be directly visualized (or reected) for placing the implant just anterior to the anterior sinus wall (Fig 9). When the sinus is not exposed, a lateral punch hole into the sinus is made at the most anterior inferior extent of pneumatization to serve as a guide for implant placement and angulation.14 This point is called S-Point, for sinus point, in All-on-4 nomenclature. This is the most anterior inferior projection of the sinus
FIGURE 11. Variants of the natural orice of the nasolacrimal duct that may occur intraossesously below the inferior turbinate and can be close to piriform rim bone used to place M-shaped distribution implants. Care should be taken not to cause nasolacrimal damage inadvertently when the duct is near M-point for All-on-4 implant placement. Jensen et al. The All-on-4 Shelf: Maxilla. J Oral Maxillofac Surg 2010.
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likely to be answered afrmatively by use of the All-on-4 shelf. In summary, the All-on-4 shelf is a surgical prosthetic tool not unlike reduction alveoplasty for denture placement that aids in optimal surgical-prosthetic management of the All-on-4 restoration (Figs 12A,B). After the surgeon can accept the idea of nonaxial implant placement as well as a reduced number of implants, the All-on-4 shelf becomes a necessary tool to optimize what is a highly efcient, although counterintuitive, maxillary implant placement scheme.
References
1. Garber DA, Belser UC: Restoration-driven implant placement with restoration-generated site development. Compend Contin Educ Dent 16:796, 798, 804, 1995 2. McFadden DD, Australas AR: Pre-prosthetic surgery options for xed dental implant reconstruction of the atrophic maxilla. Coll Dent Surg 15:61, 2000 3. Jivraj S, Chee W: Treatment planning of implants in the aesthetic zone. Br Dent J 201:77, 2006 4. Berson PJ: The functionally xed restoration: A third modality of treatment. Compend Contin Educ Dent 23:157, 164, 166, 2002 5. Kahnberg KE, Wallstrm M, Rasmusson L: Local sinus lift for single-tooth implant. I. Clinical and radiographic follow-up. Clin Implant Dent Relat Res, 2009 6. Raja SV: Management of the posterior maxilla with sinus lift: Review of techniques. J Oral Maxillofac Surg 67:1730, 2009 7. Huang HL, Fuh LJ, Ko CC, et al: Biomechanical effects of a maxillary implant in the augmented sinus: A three-dimensional nite element analysis. Int J Oral Maxillofac Implants 24:455, 2009 8. Jensen OT, Shulman L, Block M, et al: Report of the Sinus Consensus Conference of 1996. Int J Oral Maxillofac Implants 139(Suppl.):11, 1998 9. Aparicio C, Perales P, Rangert B: Tilted implants as an alternative to maxillary sinus grafting: A clinical, radiologic, and periotest study. Clin Implant Dent Relat Res 3:39, 2001 10. Capelli M, Zuffetti F, Del Fabbro M, et al: Immediate rehabilitation of the completely edentulous jaw with xed prostheses supported by either upright or tilted implants: A multicenter clinical study. Int J Oral Maxillofac Implants 22:639, 2007 11. Testori T, Del Fabbro M, Capelli M, et al: Immediate occlusal loading and tilted implants for the rehabilitation of the atrophic edentulous maxilla: 1-year interim results of a multicenter prospective study. Clin Oral Implants Res 19:227, 2008 12. Francetti L, Agliardi E, Testori T, et al: Immediate rehabilitation of the mandible with xed full prosthesis supported by axial and tilted implants: Interim results of a single cohort prospective study. Clin Implant Dent Relat Res 10:255, 2008 13. Krekmanov L, Kahn M, Rangert B, et al: Tilting of posterior mandibular and maxillary implants for improved prosthesis support. Int J Oral Maxillofac Implants 15:405, 2000 14. Calandriello R, Tomatis M: Simplied treatment of the atrophic posterior maxilla via immediate/early function and tilted implants: A prospective 1-year clinical study. Clin Implant Dent Relat Res 7(Suppl. 1):S1, 2005 15. Aparicio C, Rangert B, Sennerby L: Immediate/early loading of dental implants: A report from the Sociedad Espanola de Implantes World Congress consensus meeting in Barcelona, Spain. Clin Implant Dent Relat Res:5:57-60, 2003 16. Naylor CK: Esthetic treatment planning: The grid analysis system; J Esthet Restor Dent 14:76-84, 2002 17. Jemt T: Fixed implant-supported prostheses in the edentulous maxilla. A ve-year follow-up report. Clin Oral Implants Res 5:142, 1994
FIGURE 12. A, Reduction alveoloplasty of the All-on-4 shelf provides enough interarch space for the esthetic prosthetic reconstruction. B, The use of M-4 placement, as shown in the panographic x-ray, was facilitated by the All-on-4 shelf. Jensen et al. The All-on-4 Shelf: Maxilla. J Oral Maxillofac Surg 2010.
Nasolacrimal Duct
One nal anatomic structure to be aware of is the nasolacrimal duct, which exits below the inferior turbinate sometimes anatomically near where M-point implant xation is desirable in the piriform (Fig 11).4-9 Implants that penetrate the piriform and enter into the nasal fossa can on rare occasions disturb nasolacrimal drainage.47
Discussion
The overall benet of the All-on-4 shelf is one of technical, biological, and biomechanical advantage to the surgical prosthetic team.13 The use of the shelf ensures that implants are placed at the right level, at the most optimal angles, at maximum A-P spread, and with the most favorable insertion torque obtainable for immediate load restorations. Recall the three questions of controversy: 1) Can osseointegration occur in the maxilla without bone grafting? 2) Can full arch prosthetic loading be accomplished with only 4 implants placed at angulation? 3) Can full arch immediate load biomechanics be satised by the often limited bone stock of the anterior maxilla? All of these questions are more
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18. Palmqvist S, Sondell K, Swartz B: Implant-supported maxillary overdentures: Outcome in planned and emergency cases. Int J Oral Maxillofac Implants 9:184, 1994 19. Marshall JA, Hansen CA, Kreitman BJ: Achieving a passive t for a screw-retained implant-supported maxillary complete arch ceramometal prosthesis: Clinical report. Implant Dent 3:31, 1994 20. Simons AM, Campbell Z: The implant-supported overdenture prosthesis for the edentulous maxilla. J Oral Implantol 19:39, 1993 21. Mijiritsky E, Mardinger O, Mazor Z, et al: Immediate provisionalization of single-tooth implants in fresh-extraction sites at the maxillary esthetic zone: Up to 6 years of follow-up. Implant Dent 18:326, 2009 22. Younis L, Taher A, Abu-Hassan MI, et al: Evaluation of bone healing following immediate and delayed dental implant placement. J Contemp Dent Pract 10:35, 2009 23. Kahnberg KE: Immediate implant placement in fresh extraction sockets: A clinical report. Int J Oral Maxillofac Implants 24:282, 2009 24. Balshi TJ, Wolnger GJ: Teeth in a day for the maxilla and mandible: Case report. Clin Implant Dent Relat Res 5:11, 2003 25. Kinsel RP, Lamb RE: Development of gingival esthetics in the terminal dentition patient prior to dental implant placement using a full-arch transitional xed prosthesis: A case report. Int J Oral Maxillofac Implants 16:583, 2001 26. Kosinski TE, Skowronski R Jr: Immediate implant loading: A case report. J Oral Implantol 28:87, 2002 27. Lin CL, Wang JC, Ramp LC, et al: Biomechanical response of implant systems placed in the maxillary posterior region under various conditions of angulation, bone density, and loading. Int J Oral Maxillofac Implants 23:57, 2008 28. Kao HC, Gung YW, Chung TF, et al: The inuence of abutment angulation on micromotion level for immediately loaded dental implants: A 3-D nite element analysis. Int J Oral Maxillofac Implants 23:623, 2008 29. Park C, Raigrodski AJ, Rosen J, et al: Accuracy of implant placement using precision surgical guides with varying occlusogingival heights: An in vitro study. J Prosthet Dent 101:372, 2009 30. Aboul-Ela LM: The evaluation of the inter-occlusal distance in complete dentures. Egypt Dent J 13:56, 1967 31. Owen WD, Douglas JR: Near or full occlusal vertical dimension increase of severely reduced interarch distance in complete dentures. J Prosthet Dent 26:134, 1971 32. Eskelsen E, Fernandes CB, Pelogia F, et al: Concurrence between the maxillary midline and bisector to the interpupillary line. J Esthet Restor Dent 21:37; discussion: 42, 2009
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33. Ding X, Liao SH, Zhu XH, et al: Effect of diameter and length on stress distribution of the alveolar crest around immediate loading implants. Clin Implant Dent Relat Res 11:279, 2008 34. Aguilar-Meimban CO: Available bone is the foremost criterion in the insertion of endosteal implants. J Philipp Dent Assoc 47:3, 1996 35. Jensen OT, Adams MW: The maxillary M-4: A technical and biomechanical note for all-on-4 management of severe maxillary atrophyReport of 3 cases. J Oral Maxillofac Surg 67: 1739, 2009 36. Schendel SA, Eisenfeld J, Bell WH, et al: The long face syndrome: Vertical maxillary excess. Am J Orthod 70:398, 1976 37. Freihofer HP: Surgical treatment of the short face syndrome. J Oral Surg 39:907, 1981 38. Dreiseidler T, Neugebauer J, Ritter L, et al: Accuracy of a newly developed integrated system for dental implant planning. Clin Oral Implants Res 20:1191, 2009 39. Horwitz J, Zuabi O, Machtei EE: Accuracy of a computerized tomography-guided template-assisted implant placement system: An in vitro study. Clin Oral Implants Res 20:1156, 2009 40. Valente F, Schiroli G, Sbrenna A: Accuracy of computer-aided oral implant surgery: A clinical and radiographic study. Int J Oral Maxillofac Implants 24:234, 2009 41. Roze J, Babu S, Saffarzadeh A, et al: Correlating implant stability to bone structure. Clin Oral Implants Res 20:1140, 2009 42. Arajo MG, Wennstrm JL, Lindhe J: Modeling of the buccal and lingual bone walls of fresh extraction sites following implant installation. Clin Oral Implants Res 17:606, 2006 43. Misch KA, Yi ES, Sarment DP: Accuracy of cone beam computed tomography for periodontal defect measurements. J Periodontol 77:1261, 2006 44. Thor A, Wannfors K, Sennerby L, et al: Reconstruction of the severely resorbed maxilla with autogenous bone, platelet-rich plasma, and implants: 1-year results of a controlled prospective 5-year study. Clin Implant Dent Relat Res 7:209, 2005 45. Cordaro L: Bilateral simultaneous augmentation of the maxillary sinus oor with particulated mandible. Report of a technique and preliminary results. Clin Oral Implants Res 14:201, 2003 46. McAllister BS, Haghighat K: Bone augmentation techniques [review]. J Periodontal 78:377, 2007 47. You ZH, Bell WH, Finn RA: Location of the nasolacrimal canal in relation to the high Le Fort I osteotomy. J Oral Maxillofac Surg 50:1075, 1992