A fixed solution for an edentulous or almost edentulous jaw, with temporary teeth on the same day. An open, professional account of how the method works, what it realistically delivers and where its limits lie.
General information, not personal advice. This article explains the method in general terms and is neither an individual treatment plan nor a substitute for a clinical examination. Whether All-on-4, All-on-6 or some other variant is right for you can only be assessed after a clinical examination and complete digital X-ray diagnostics, including a 2D orthopantomogram and a 3D CBCT scan.
All-on-4 is a well documented method in which an entire dental arch is supported by four strategically positioned implants, and the patient as a rule receives fixed temporary teeth on the same day. For many people who have worn removable dentures for years or who are losing their teeth one after another, this is the difference between a denture that comes out and fixed teeth that stay in the mouth. The method is not for everyone, but when it is correctly indicated the results are predictable in the long term and well supported by the literature.
In this text we explain how we carry out the method in practice, how All-on-4, All-on-6 and All-on-X differ, what you can realistically expect and, just as importantly, where the limits are. We write in the first person because we are describing how we work at Ortoimplant DENTAL SPA in Zagreb.
The basics
What All-on-4, All-on-6 and All-on-X are
The idea shared by all of these solutions is the same: instead of replacing teeth one by one, a whole arch of fixed teeth is supported by a smaller number of implants strategically positioned in the jaw. The difference lies in the number and position of the implants and in the quantity, quality and three dimensional anatomy of the bone that is available.
Standard
All-on-4
The entire arch is carried by four strategically positioned implants. Most often the two front implants are placed straight and the two rear implants are tilted, which makes better use of the existing bone and frequently avoids the need for bone augmentation.
More points of support
All-on-6
The same principle, but with six implants. We choose it when the anatomy and the quality of the bone allow additional implants to be placed strategically and when those implants can contribute to a better distribution of forces, to relieving individual points of support and to additional biomechanical stability.
Adaptable
All-on-X
The name for an approach in which we adapt the number, type and position of the implants to the individual anatomy of the patient, including advanced implantology techniques when the available bone does not allow the standard approach. We do not adapt the patient to the All-on-4 concept. We adapt All-on-X to the anatomy of the patient.
The letter X in All-on-X means that the number of implants is not fixed in advance. All-on-X rests on the basic All-on-4 concept but extends it, so that we adapt the number, type and position of the implants to the individual anatomy of the patient and to the biomechanical demands of the future fixed restoration.
In patients who have been told that they do not have enough bone, this approach may also include rare advanced techniques such as zygomatic, pterygoid, transnasal and transsinus implants, with which we look for secure bone anchorage outside the area of pronounced bone loss. More about this in a separate text. implants without bone, zygomatic and pterygoid implants
An important distinction: All-on-4 is not a brand of implant but a placement concept. The aim of every variant is the same, fixed teeth that are not removed, and the difference lies in how many points of support, of which type and in which positions the individual anatomy of the patient requires.
Origin of the method
Where the method comes from and how long we have been using it
The All-on-4 concept was developed by the Portuguese dentist Dr Paulo Malo. The first patient was included in a clinical study in 1998, and the first scientific papers describing the surgical and prosthetic protocol were published in the early 2000s, first for the lower jaw and then for the upper jaw. Since then the method has been used in a large number of patients and belongs among the well researched solutions in implantology.
At Ortoimplant DENTAL SPA we have been using the All-on-4 concept and its variants for more than 15 years. Dr Zdenko Trampuš, DDS, completed his training in the All-on-4 implantology concept at the Malo Clinic in Lisbon in 2009, with the originator of the method, Dr Paulo Malo. He continued his professional development in 2011 with a clinical course in Zygoma All-on-4 at the Malo Clinic in Lisbon and with Dr Luc Vrielinck in Brussels. Today we build on that experience with the All-on-X approach and with advanced implantology techniques for demanding cases of pronounced bone loss.
Correcting a common misconception: All-on-4 is not a concept that originated at Ortoimplant DENTAL SPA. It was developed by Dr Paulo Malo, and our contribution is many years of experience in applying it, training with the originator of the method, and continuous professional development together with an individualised approach to demanding implantology cases.
Course of the procedure
What the day looks like: fixed teeth in 24 hours
The phrase “fixed teeth in 24 hours” means that within one day of implant placement you receive a fixed temporary bridge, so you do not go home without teeth. The fixed temporary teeth are worn during the period of osseointegration, after which the definitive fixed restoration is made. Here is how it looks at our clinic:
1First examination and 3D CBCT analysis
Through a clinical examination and complete digital X-ray diagnostics, including a 2D orthopantomogram and a 3D CBCT scan, we obtain a detailed insight into the three dimensional anatomy of the jaw, into the quantity and characteristics of the available bone and into the position of important anatomical structures such as nerves and sinuses. We also analyse the bite and the relationship between the jaws so that we can plan the implants according to the future fixed restoration. On the basis of all this data we decide which variant is optimal for the patient: All-on-4, All-on-6 or All-on-X.
2Planning and guided surgery
We plan the procedure digitally, and in indicated cases we use guided (navigated) implantology. We also prepare the fixed temporary teeth in advance.
3Surgery under analgosedation
In patients with remaining teeth that cannot be saved, we first extract them and then place the implants during the same operation. The procedure is performed under local anaesthesia and potentiated intravenous analgosedation supervised by an anaesthetist, so that the patient feels no pain, fear or discomfort during the procedure. Our patients generally sleep through these more extensive procedures completely and afterwards remember very little of them or nothing at all.
4Fixed temporary teeth the same day
After the implants have been placed we as a rule fit the fixed temporary teeth the same day, so you leave the practice with fixed teeth. That is our standard immediate loading protocol. Only in exceptionally rare, specific and clinically complex situations may we judge that, for the safety of the patient and the long term success of the treatment, it is better not to fit the fixed temporary teeth straight away.
5Healing and the definitive bridge
After the procedure the soft tissues heal relatively quickly, and about two weeks after surgery there is a check-up and the removal of the sutures. At the same time osseointegration takes place, that is the biological union of the implant with the bone, which as a rule takes around three months. Once osseointegration is complete we make the definitive fixed teeth, adapted to the function, bite and aesthetics of the patient.
The immediate loading protocol, meaning the fitting of fixed temporary teeth immediately after implant placement, is based on the primary stability achieved and on the overall clinical assessment. At Ortoimplant DENTAL SPA we as a rule fit the fixed temporary teeth on the same day. Only in exceptionally rare, specific and clinically complex situations may we judge that, for the safety of the patient and the long term success of the treatment, it is better to wait before fitting them, and we will tell you that honestly.
At our clinic these procedures are carried out as a matter of protocol under potentiated intravenous analgosedation. You can read more about analgosedation and about what to expect during the procedure in a separate text. analgosedation, treatment without fear and pain
Realistic expectations
What the method realistically delivers
The advantages of All-on-4 are real, but we prefer to state them without exaggeration, together with what each one realistically means. This is what an honest balance sheet looks like:
Success in figures. The method is among the better documented ones in implantology. Early studies of immediate loading in the upper jaw reported implant survival of around 97.6 per cent after one year,[1] while ten year follow-up in the lower jaw showed implant survival close to 95 per cent with bridge durability above 99 per cent.[2] A systematic review of immediately loaded implants gave an average survival of around 97.4 per cent.[3] These are encouraging results, but they are not perfect ones. A small proportion of implants can still fail, and the outcome also depends on the patient.
One claim, without any sugar coating. You sometimes hear that with teeth like these there is “no more decay and no more gum disease”. Half of that is true: crowns and implants cannot develop decay. But the tissues around the implants can become inflamed, and with peri-implantitis the bone around the implant can also be lost, so hygiene and regular check-ups remain compulsory. Teeth on implants are not teeth without maintenance.
Choosing the variant
All-on-4 or All-on-6: how we choose
A common question is whether six implants are “better” than four. The answer is that this is not a matter of better and worse, but of what suits your bone and your bite. In a large comparative study, four and six implants showed very similar and high survival rates over five years of follow-up.[4] In other words, we do not choose the higher number for the sake of the number. The optimal number of implants is the one that the specific anatomy of the patient requires, whether that is four or six.
When All-on-4
Four implants
When there is enough bone for four stable points of support with tilted rear implants. Less surgery, a well documented outcome.
When All-on-6
Six implants
When the bone and the clinical picture allow additional points of support and when we want a more even distribution of load, especially in the upper jaw.
We make the decision on the basis of the 3D scan, the quantity and quality of the bone, the position of the sinuses and nerves and your bite. The goal is the most stable and most predictable solution for your case, not a number fixed in advance.
An honest picture
Limitations, and who the method is not right for
Few people write this part, and we write it deliberately. All-on-4 solves a great deal, but it is not a guarantee of the outcome and it is not the right solution for absolutely everyone. In these situations the method may not be the first choice or may call for additional steps:
- Active infection or untreated inflammation: the inflammation has to be resolved first, because it affects healing and the safety of the procedure.
- Insufficient implant stability at placement: in exceptionally rare situations, when the primary stability achieved does not allow safe immediate loading, we wait before fitting the fixed temporary teeth.
- Active smoking and poor oral hygiene: smoking increases the risk of complications and of treatment failure, so depending on the individual assessment we may recommend stopping smoking temporarily or permanently. Good oral hygiene is essential for the long term health of the tissues around the implants.
- Certain general health conditions and medicines: some systemic diseases (for example osteoporosis, diabetes, blood clotting disorders or more serious cardiovascular disease), certain medicines (for example blood thinners, bisphosphonates and other antiresorptive drugs, and some biological or immunosuppressive drugs) or recent oncological treatment may require coordination with your doctor, additional preparation for the procedure or postponement of the procedure.
- Unrealistic expectations: anyone expecting teeth that need no care and no check-ups at all will probably be disappointed, whatever the method.
Our principle: if we judge that All-on-4 is not the right solution for you, or that additional preparation is needed before the procedure, we will tell you so. Even then, however, we do not give up on looking for the best solution. At Ortoimplant DENTAL SPA we always take into account the patient’s complete medical history, general health and any comorbidities, and we adapt the treatment further where necessary, including working together with the doctors who look after the patient. In this way, even in more complex health situations, we can often create the conditions for the appropriate implantology treatment to be carried out safely. An honest assessment matters more than any procedure, and the goal is to find the best, safest and most durable solution for every patient.
Recovery
Recovery: the DENTAL SPA approach
Placing implants that carry an entire dental arch is a bigger procedure than placing a single implant, so we take recovery seriously. Alongside analgosedation during the procedure, we apply a holistic, medically supported DENTAL SPA approach that includes DENTAL SPA treatments before, during and after surgery, with the aim of preparing the body for the procedure, reducing swelling and discomfort and supporting healing and the most comfortable recovery possible.
Against swelling
Lymphatic drainage before the procedure
Lymphatic drainage precedes the surgical procedure in order to stimulate lymphatic circulation, prepare the body for recovery in advance and act preventively against the development of postoperative swelling.
During the procedure
Ozone therapy and intravenous supplementation
Ozone therapy and intravenous supplementation with vitamins, minerals and amino acids are applied during surgery as additional support for the body and the tissues throughout the procedure.
Healing and recovery
Hyperbaric oxygen therapy and torsion field magnetotherapy
After the procedure we apply torsion field magnetotherapy and, when it is indicated, hyperbaric oxygen therapy (HBOT) as well, as additional support for healing and postoperative recovery.
Clear instructions
Guidance after the procedure
Check-ups, instructions on diet and hygiene, and the availability of the team throughout the healing period.
We adapt the DENTAL SPA treatments individually to the patient and to the type and extent of the procedure. Their purpose is to prepare the body for the procedure, to provide additional support during surgery, to support healing and postoperative recovery and to contribute to the general wellbeing and comfort of the patient throughout the whole course of treatment. You can read more about our DENTAL SPA approach in a separate text. DENTAL SPA recovery after the procedure
Frequently asked questions
Can I really get fixed teeth in 24 hours?
As a rule, yes. After the implants are placed you receive fixed temporary teeth the same day, while the definitive fixed restoration is made once osseointegration is complete, which as a rule takes around three months. Whether immediate loading is possible in your case is something we assess on the basis of a clinical examination and complete digital X-ray diagnostics, including a 3D CBCT scan, and the final decision also depends on the primary stability achieved when the implants are placed. Only in exceptionally rare, specific and clinically complex situations may we judge that it is safer to wait before fitting the fixed temporary teeth.
What is the difference between All-on-4, All-on-6 and All-on-X?
All three variants carry a fixed bridge for the whole dental arch, and they differ in the number, type and position of the implants. All-on-4 uses four implants, All-on-6 uses six, and All-on-X is an approach in which we adapt the number, type and position of the implants to the individual anatomy of the patient. Where there is pronounced bone deficiency, All-on-X may also include advanced techniques such as zygomatic, pterygoid, transnasal or transsinus implants. Which variant is right for you is something we assess on the basis of the quantity, quality and three dimensional anatomy of the bone, the position of important anatomical structures and the bite.
How long do teeth on All-on-4 last?
All-on-4 implants and the fixed teeth are intended as a long term solution. Peer reviewed studies report high implant survival rates over periods of ten years and more, and our experience shows that with proper oral hygiene, regular check-ups and professional maintenance they can last for many years, and for many patients for life.
The fixed restoration may over time require maintenance, repair or renewal. That is precisely why, once treatment is finished, our patients enter a programme of lifelong monitoring and professional maintenance of the implant supported restoration, so that we can regularly follow the condition of the implants, the restoration and the surrounding tissues and help their new teeth serve them for many years.
Is the placement painful?
The procedure is performed under local anaesthesia and potentiated intravenous analgosedation supervised by an anaesthetist, so that the patient feels no pain, fear or discomfort during the procedure. Our patients generally sleep through these procedures completely and afterwards remember very little of them or nothing at all. After the procedure, swelling and sensitivity are to be expected in the first few days, and we control them with appropriate medication and clear postoperative instructions. Our holistic, medically supported DENTAL SPA approach gives further support to healing and recovery and helps to reduce swelling and to improve the general wellbeing and comfort of the patient.
Can I have All-on-4 if I have been told I do not have enough bone?
Often, yes. The tilted implants used in All-on-4 make more effective use of the available bone and in many cases make it possible to avoid bone augmentation or a sinus lift. Where bone loss is pronounced, advanced implantology techniques come into consideration within the All-on-X approach, such as zygomatic, pterygoid, transnasal or transsinus implants. Which solution is possible and best for you specifically can only be assessed after a clinical examination and complete digital X-ray diagnostics, including a 3D CBCT scan.
Can implants develop decay or gum disease?
Implants and crowns cannot develop decay because they are not made of natural tooth tissue. The tissues around the implants can, however, become inflamed. Inflammation limited to the soft tissues around the implant is called peri-implant mucositis, while peri-implantitis also affects the supporting bone and can lead to its loss.
That is precisely why correct planning, preparation and execution of implantology treatment, along with proper oral hygiene, professional maintenance of the implant supported restoration and regular check-ups with the dentist after treatment is finished, play an important part in preserving the health of the implants and the surrounding tissues over the long term. Regular check-ups make it possible to notice changes in good time, to prevent problems and to intervene early, before more serious problems develop.
Teeth on implants are not without risk and they do require maintenance, but with properly conducted treatment and long term professional monitoring they can be a durable and stable solution.
Sources and references
- Maló P, Rangert B, Nobre M. All-on-4 immediate-function concept with Brånemark System implants for completely edentulous maxillae: a 1-year retrospective clinical study. Clinical Implant Dentistry and Related Research. 2005;7(Suppl 1):S88-94. pubmed.ncbi.nlm.nih.gov/16137093
- Maló P, de Araújo Nobre M, Lopes A, Moss SM, Molina GJ. A longitudinal study of the survival of All-on-4 implants in the mandible with up to 10 years of follow-up. Journal of the American Dental Association. 2011;142(3):310-320. pubmed.ncbi.nlm.nih.gov/21357865
- Del Fabbro M, Testori T, Kekovic V, Goker F, Tumedei M, Wang HL. A Systematic Review of Survival Rates of Osseointegrated Implants in Fully and Partially Edentulous Patients Following Immediate Loading. Journal of Clinical Medicine. 2019;8(12):2142. pmc.ncbi.nlm.nih.gov/articles/PMC6947536
- Caramês JMM, Francisco HCO, Vieira FA, Caramês GB, Martins JNR, Marques DNS. Four vs. Six Implant Full-Arch Restorations: A Direct Comparative Retrospective Analysis in a Large Controlled Treatment Cohort. Journal of Clinical Medicine. 2025. pubmed.ncbi.nlm.nih.gov/40565982
Content undergoes professional review before publication. This text is general information and does not replace a clinical examination. Book a free consultation