All-on-4 Dental Implants in Turkey

The implementation of the All-on-4 treatment concept follows a specific protocol involving surgical and prosthetic procedures. The treatment involves the use of only four implants for full arch restoration.

All-on-4 treatment approach:

Conventional surgery (with flap removal):

This is surgery using conventional planning and a standardized All-on-4 Guide, in which an incision is made in the gingiva and the flap is lifted.

Guided surgery:

Correct positioning of the implants is achieved by using a customized surgical template with 3D diagnosis and treatment planning. This approach can be performed without flap removal (‘flapless’).

Diagnosis and treatment planning:

• The general health status of the patient is assessed. An intraoral examination is performed, and radiographic examinations (panoramic X-ray, tomography - CT scan) are performed to assess bone height, width, and quality.
• The appropriate All-on-4 approach is determined according to the available bone (standard, hybrid, or double zygoma).
• The positions and angulations of the implants are planned. The screw entry holes of the posterior implants are aimed to be in the occlusal plane of the first molar, second premolar, or first premolar.
• The patient's smile line and vertical occlusal dimension (VDO) are evaluated.
• If directed surgery is planned, 3D software is used.
• The patient's existing or immediate prosthesis can be used in planning.

Surgical procedure:

• If necessary, flap removal or a flapless approach is applied.
• Implant sites are prepared in the jawbone. If necessary, the correct position and angulation are ensured by using the All-on-4 Guide. Implant sites in the posterior regions can be drilled at an angle up to 45°.
• The most critical factor at this stage is to ensure sufficient primary implant stability for immediate loading. If stability cannot be achieved, the traditional healing process is awaited.
• If there are extraction sites, these are thoroughly cleaned, and, if possible, the implants are placed between the extraction sockets.

Multi-unit abutment connection:

After the implants are placed, straight or angled (17° and 30°) multi-unit abutments are attached to the implants to correct the angle of the implants and to position the screw access holes of the prosthesis in the appropriate positions.

Splinting may be required if the angle of the angled implants is 30° or more.

Application of a temporary denture (emergency loading):

• On the day of surgery, a temporary fixed prosthesis (usually acrylic) is prepared to be screwed to the implants; this is done immediately after the implants are placed.
• This temporary prosthesis can be prepared according to the measurements taken after surgery, or it can be created by making necessary modifications to the existing/immediate prosthesis. Abutment replicas, temporary caps (copings), guide pins/laboratory screws, and acrylic are used to prepare the prosthesis.
• The temporary prosthesis provides splinting by connecting the four implants together.
• This ‘immediate loading’ phase allows the patient to have a fixed prosthesis on the day of surgery, shortening the treatment time (‘time-to-teeth’).
• The temporary denture is adjusted according to the masticatory function. It is recommended that there be no occlusal contact at the distal (posterior) cantilever.

Healing process and follow-up:

The implants are expected to fuse with the bone (osseointegration). The patient is followed up with regularly. Postoperative complications are usually related to overloading of the temporary prosthesis (such as denture fracture or abutment loosening). These problems are quickly addressed.

Making the permanent (definitive) denture:

Once healing is complete, the patient receives a more durable and aesthetic permanent fixed denture, which is screwed to the implants via multi-unit abutments.

There are some important points that you should pay attention to after having the All-on-4 treatment concept.

Oral hygiene:

For the success of the treatment, it is important that you are in good general health and have acceptable oral hygiene. Effective home oral care should also be maintained in the post-treatment period. Your dentist will teach you specific cleaning methods that are suitable for your type of prosthesis (fixed or removable) and your oral structure. In general, implant-supported dentures are easier to maintain than conventional dentures.

Regular follow-up appointments:

It is important to attend regular follow-up appointments with your dentist to check the effectiveness of the treatment and your oral health. In particular, the effectiveness of home care will be assessed at these appointments.

Use of temporary prostheses and avoidance of overload:

After surgery, the patient is usually fitted with a temporary fixed prosthesis that is screwed to the implants on the day of surgery. Breakage of the temporary prosthesis or loosening of the abutments can be caused by overload or unstable occlusal contacts. For this reason, you should strictly follow the instructions given by your physician regarding chewing or biting with the temporary prosthesis and be especially careful not to exert excessive force on the posterior (distal) extensions of the prosthesis.

Signs of possible complications:

Excessive swelling or bruising may be normal in the first ten days after surgery. However, if you notice any fracture of the prosthesis or a feeling of loosening or discomfort in occlusion, you should contact your dentist as soon as possible, as these may be related to overloading of the prosthesis or occlusal imbalances.

Paying attention to general health:

As with any dental implant treatment, All-on-4 is a surgical procedure and may carry general surgical risks such as infection, nerve tissue damage, or excessive bleeding. To manage these risks and promote healing, it is essential that you take care of your general health and follow your dentist's recommendations.

You should consult your dentist about special care instructions and potential problems related to your treatment.

Considerations when eating after surgery:

• After the placement of ALL-on-4, it is recommended that you follow your dentist's advice to manage the healing process well and prevent swelling and bleeding.
• For the first 2 weeks, liquid or pureed food should be eaten, neither too hot nor too cold.
• First 15-30 days: pasta, rice, cereals, eggs, fish, finely chopped vegetables, and soft fruits should be eaten.
• 2nd month and onwards: A normal diet should be observed, and hard foods should be avoided.

Advantages and benefits:

• One of the most important advantages of All-on-4 is that it allows you to avoid or reduce the need for bone grafting procedures, which can be time-consuming and costly.
• Since only 4 implants per jawbone are used in the All-on-4 method, this helps to reduce pain, accelerate wound healing, and reduce the risk of infection complications.
• The angled placement of the posterior implants up to 45° helps to maximize the available bone and avoid vital anatomical formations such as sinuses or nerves.
• The angled placement of the posterior implants and the ability for immediate loading reduce treatment complexity and the number of surgical procedures required. Furthermore, a ‘flapless’ approach may be possible when using guided surgery, making surgery less invasive.
• Time-to-teeth: It is usually possible to apply a fixed temporary denture (emergency loading) to patients on the day of surgery. This allows the patient to have fixed teeth immediately after surgery, shortening the treatment time.
• Compared to traditional full-jaw implant treatments, All-on-4 is a more cost-effective solution as it uses fewer implants and generally eliminates or reduces the need for bone grafting.
• Providing a fixed denture on the day of surgery allows patients to achieve rapid improvement in function, aesthetics, sensation, speech, and self-confidence. This is an attractive and potentially life-changing treatment option for patients.
• Functional and aesthetically satisfying results are achieved. All-on-4 gives you a brand new, bright smile immediately after surgery
• The prosthesis can last for decades or a lifetime.

Disadvantages:

Although the All-on-4 treatment concept has many advantages and benefits, there are also some potential disadvantages, limitations, and challenges:

• The length of the posterior extensions of the denture, called cantilevers, is limited and cannot be extended beyond certain limits. Cantilever loading can greatly affect the stress and strain on the bone around the dental implants. Higher bone stress and strain can increase the risk of bone overload loss. Prostheses with long wingspans can lead to more complications.
• The All-on-4 procedure requires considerable technical precision. Preoperative templates or guidance may be required for implant placement in the desired position and angle.
• Most postoperative complications are associated with overloading of the provisional denture, which is usually placed on the day of surgery.
• Fracture of the temporary or even final denture can occur as a result of overloading or unbalanced occlusal contacts. Abutment loosening is usually associated with occlusion instability and can be caused by contacts, especially during lateral movements of the jaw.
• In very low-density (Type IV) jaws, especially in the maxilla, there may be difficulty in achieving the primary stability required for immediate function. It may be necessary to use extra-maxillary implants (e.g., zygoma implants) instead of the All-on-4 protocol.

Prices may vary depending on the clinic, city, materials used, and extent of treatment, so average ranges are given:

Country	Price Range (Euro)
Turkey	€4,000 – €7,000
UK	€15,000 – €25,000
USA	€20,000 – €30,000
Germany	€12,000 – €20,000

Is the All-on-4 procedure painful?

Since the procedure is performed under local anesthesia, no pain is felt during the procedure. There may be mild pain and swelling during the recovery period; these are normal.

How long is the All-on-4 treatment time?

Implant placement usually takes 1-2 hours. Temporary prostheses can be worn the same day, but it may be necessary to wait 3-6 months for a permanent prosthesis.

How long does All-on-4 last?

With proper care and regular checkups, it can be used for 20 years or more without any problems.

Why is the All-on-4 price different from other implants?

The use of fewer implants, shorter operation time, and less need for bone grafts reduces the price. However, the quality of the material used and the clinic location affect the price.

Can the dentures be removed?

All-on-4 dentures are usually fixed, i.e., not removable. However, cleaning is easy, and oral health is maintained with professional care.

When can I return to my normal life after All-on-4?

Most patients can return to their daily activities within 1-2 days after the procedure. As the pain and swelling decrease, eating and speaking return to normal.

What materials are used for All-on-4?

Implants are made of titanium or titanium alloys; prosthetic teeth are made of durable materials such as acrylic, porcelain, or zirconium.

Are aesthetic results achieved with All-on-4 treatment?

The shape, color, and alignment of the teeth are planned individually. Natural and aesthetic results are achieved with smile design.

Is there any difference between All-on-4 implants and normal teeth?

Visually and functionally, it gives results very close to natural teeth. However, it is necessary to pay more attention to oral hygiene.

Is jawbone resorption prevented with All-on-4?

Yes, since the implants are fixed to the jawbone, it significantly prevents bone resorption.

Are there other options if the standard All-on-4 bone criteria cannot be met?

Yes, the standard All-on-4 criteria (required bone height and width) may not be met, especially in patients with severe bone resorption. In such cases, alternative All-on-4 approaches may be considered:

• All-on-4 Hybrid: This is the concept of using standard implants in combination with extra-maxillary implants extending to the zygomatic bone in the maxilla.
• All-on-4 Double Zygoma: It is the concept in which four extra-maxillary implants extending only to the zygomatic bone in the maxilla are used. Zygoma implants provide posterior support without the need for bone grafting.