Study by: Dr. Ana Ferro

A 23-year-old patient with a severely degraded dentition came to the MALO CLINIC in Portugal, under its pro bono program. He had no oral hygiene habits and poor oral health. He had severe deterioration in the upper jaw, and in the lower jaw both quadrants’ molar teeth required extraction. His remaining teeth showed no sign of periodontal loss and/or mobility.

Full-arch rehabilitation of young patients is always demanding, not so much anatomically (e.g. reduced bone availability) but rather functionally and esthetically. Given the irreversible damage to most of his teeth and large apical lesions, we decided to perform full extractions, clean all granuloma lesions and treat the patient with implant surgery and Immediate Function.

We selected the All-on-4® treatment concept for this case since it is proven to be a predictable surgical option in the long-term1,2 and in demanding clinical situations.3 Use of the NobelParallel Conical Connection (CC) implants and the new Multi-unit Abutment Plus allowed us to deliver immediate, fixed rehabilitation even in the post-extraction sites – thus restoring the complete function of the upper jaw in one surgery.


Surgery was performed under local anesthesia. The procedure started with the extraction of the remaining teeth. A full-thickness flap was opened and elevated following a crestal incision and two releasing incisions in the first molar area. Through a photo showing the maximum smile line bone was reduced in order to hide the prosthetic transition, allowing for a more regular bone platform and a smooth gingival profile, making it easier for the patient to maintain after the surgery.

Implant surgery started with a mid-line osteotomy perpendicular to the bipupillary line, enabling the placement of the All-on-4® Guide.

Once the guide was in position and adapted to the maxilla’s size, the anterior wall of the sinus was identified in order to start placing the posterior implants as close to the cortical bone as possible, with an angulation of 45°. An under-preparation drilling protocol was used with the intention to achieve sufficient primary stability to allow for Immediate Function.

With the posterior implants stabilized and in position, the new Multi-unit Aligning Instrument was used to choose the most appropriate abutment angulation and prosthetic setting.


Anterior implant placement followed, also achieving adequate primary stability.

Suture and splinted impressions were then executed and the pre-made, all-acrylic bridge was then relined in the mouth and finalized in the lab. The patient returned to the clinic 10 days after the operation to remove the sutures and control the healing.


Despite the advanced deterioration of the upper jaw, the final result was very satisfactory for both the patient and myself.

The patient was able to immediately recover function and esthetics – which can be life-changing given the patient’s age – without having to go through additional, time-consuming and costly surgeries, instead benefiting immediately from this long-term predictable solution.

Top 5 tips

  1. Accurately extract the teeth and clean all the infections and granuloma tissue in order to make sure that your implants are placed in the best bone available.
  2. Use an underpreparation drilling sequence according to the bone density in order to achieve good primary stability.
  3. Use an implant that allows for bone condensation.
  4. Try to get bicortical anchorage in low-quality bone for better primary stability.
  5. Avoid delivering long cantilevers in the provisional all-acrylic prosthesis.


In this case the All-on-4® treatment concept allowed for immediate rehabilitation of function and esthetics. This patient had no need for additional surgeries such as bone grafting or sinus lifting. The All-on-4®treatment concept is time saving and cost efficient,4 while increasing patient satisfaction by providing immediate high esthetics5 and easy hygiene maintenance.6

This evidence-based treatment concept allows clinicians to effectively treat different types of patients and provide fast and predictable outcomes.7 The high implant and prosthetic survival rates of the All-on-4® treatment concept make it a predictable procedure for clinicians.1,2,7 I highly recommend that clinicians adopt this treatment concept in their daily practice, and avoid other demanding and time-consuming approaches.

The All-on-4® treatment concept is a team approach and I would like to thank all my MALO CLINIC colleagues involved in treating this patient: Ana Abadia (Oral Hygiene Department), Dr. João Botto (Oral Surgery Department), Dr. Raquel Lucas (Prosthodontic Department), Dr. Rodrigo Gonzalez (Prosthodontic Department) and Helena Alexandre (MALO CLINIC Ceramics Laboratory).

Why I use Nobel Biocare products

The manufacturer matters: the likelihood of predictable, long-term results is increased with the use of high-quality, original products from Nobel Biocare.8-11 All the products used in the present case were designed to work together as part of the All-on-4® treatment concept. In particular, by using the Multi-unit Aligning Instrument it was easier to identify the correct angulation for the abutment and adjust the implant position for the final Multi-unit Abutment placement. This reduces the need to make changes and substantially decreases chair time and discomfort for the patient. Together with appropriate training, these new products can help surgeons make the most out of the All-on-4® treatment concept.

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Rapid improvement in quality of life

A fixed full-arch prosthesis on the day of
surgery quickly leads to improved patient satisfaction – with regards to function,
esthetics, sense, speech and self-esteem.2,3

Shorter treatment times

Tilting of the posterior implants avoids the
need for time-consuming bone grafting procedures, while immediate loading
shortens time-to-teeth.4

Lower costs

The concept is the least costly in comparison with conventional implant treatment modalities of the edentulous and soon-to-be edentulous jaw.4

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Drinking too many drinks that are acidic can be damaging to your teeth. With so many drink choices it can be hard to determine which ones are good for you. You may be saying, “I’m ok I drink flavored water”. The truth is flavored water can be just as harmful as drinking soda or juices. To determine the acidity, we need to look at the pH, the lower the pH, the more acidic, and the likelier to cause harm and tooth erosion. The American Dental Association recommends minimizing the amount of these drinks we consume, instead the best drink would be plain water. When that thirst kicks in, think healthy teeth and reach for some refreshing water!

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What is the All-on-4® treatment concept?

In 1998 Dr. Paulo Malo successfully treated the first patient with the All-on-4® treatment concept. Since then hundreds of thousands of patients have been treated with this concept using Nobel Biocare implants.

The All-on-4® treatment concept is the best solution for full-arch treatment using tilted implants. But only when Nobel Biocare products are combined. Many have tried to mirror this groundbreaking concept, but only we have the scientifically documented success to back it up.

The All-on-4® treatment concept is a cost-efficient, graftless solution that provides patients with a fixed full-arch prosthesis on the day of surgery.

Characteristics include:

  • Full-arch rehabilitation with only four implants
    Two straight anterior implants and two implants tilted up to 45º in the posterior
  • Immediate Function (fixed provisional bridge)
    For patients meeting criteria for immediate loading of implants
  • Graftless procedure
    Bone grafting is avoided by tilting the posterior implants, utilizing available bone
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Are you an ice cube chewer? If so we encourage you to quit this bad habit! You may think there is no harm in this but because ice is a crystal as is your tooth enamel, when they rub against each other one is going to break. Yes, most of the time it will be the ice, but sometimes it will be your tooth or a filling that will break. To help you break this habit we suggest you drink your beverages with no ice as well as use a straw.


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Experts are warning that woman who loose teeth after menopause are at a higher risk of an early death. Major studies done are suggesting gum disease and the loss of teeth are a red flag indicator of severe health problems. For seven years scientists tracked 57,000 post-menopausal women. They found those women with gum disease were 12 percent more likely to die during that study period. The chance of dying increased to 17 percent for those who lost their teeth. Researchers are warning that gum disease may be an indicator of other problems in the body such as type II diabetes and heart disease. These researchers are encouraging women to go and have a dental screening to try to ward off any future problems. Dr. Nichols and her experienced team can screen you for periodontal disease and put you on the right path to maintain healthy teeth and gums! Keep your teeth and body healthy, schedule your dental check-up today!


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Your Teeth are not Tools!

by on February 21, 2018 | Posted in Blog

Stop go get those scissors! Don’t open that bag up with your teeth! Your teeth were made for eating, not to be used as a pair of scissors or as an extra set of hands when your hands are full. Using your teeth as tools puts you at greater risk for cracking your teeth, injuring your jaw or the possibility of accidentally swallowing something you shouldn’t. So do your teeth a favor and ask for help before using them as tools.


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 According to reports the FDA will be issuing a new proposal for regulating homeopathic medicines. The focus will be on products that pose the biggest safety risks, including those that are used for children with serious diseases. Understandably there are some that prefer to use alternative methods, but it is the FDA’s responsibility to protect you from products that have no real benefit, especially those that may cause harm! The FDA will focus on those homeopathic products that are being marketed for the use of serious diseases and illnesses that have been proven to offer no clinical benefit. Unfortunately many have placed their trust and money into these homeopathic medicines only to receive no benefit or even worse, irreparable harm ! In 2016 the FDA alerted the ADA of homeopathic tablets and gels being used for teething that had the potential to cause harm! We recommend looking for the ADA seal of approval when purchasing products to treat your mouth.


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So many of you are putting off scheduling your routine dental check-up. Many think skipping there dental visit will help save them money. Putting off your dental treatment is not only bad for your health, but it will wind up costing you more in the end! Would you skip doing an oil change on your car? I’m sure the answer would be no! Skipping routine maintenance may save you a little money but eventually neglecting these upkeep costs will lead to a breakdown that will become a major expense for you. Similarly keeping up with your routine dental check-ups will help prevent bigger, more expensive problems from occurring. Do not delay call today and schedule your cleaning and check-up!


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Snack Much?

by on November 16, 2017 | Posted in Blog

For those of you who like to snack or graze throughout the day, you are at a greater risk for tooth decay. Cavity causing bacteria feed off the leftover food on your teeth producing an acid that attacks the outer layer of your tooth causing cavities. The more you eat during the day the greater the risk for tooth decay. Eating well balanced meals will help you feel fuller longer and will help reduce snacking. If you do snack try to make it low in sugar. When eating sugary snack’s, you should drink a glass of water to help wash away any left overs. We recommend brushing and flossing daily as well as routine dental check- ups to ensure a healthy mouth!


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