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Oral Maxillofac Surg8:2520-2527, 2010

The All-on-4 Shelf: MaxillaOle T. Jensen, DDS, MSc,* Mark W. Adams, DDS, MSc,†

Jared R. Cottam, DDS, MD,‡ Stephen M. Parel, DDS, MSc,§ and

William R. Phillips III, DDS, MD�

All-on-4 treatment is facilitated by bone reduction to create prosthetic restorative space, establishmaximum anterior posterior spread of implants, and to avoid pneumatized sites. Unlike a reductionalveloplasty for denture placement, the All-on-4 shelf enables optimal surgical prosthetic management ofimplant placement for the fixed hybrid prosthesis.© 2010 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 68:2520-2527, 2010
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ll-on-4 treatment of the maxilla requires presurgicalrosthetic treatment planning for high smile line es-hetics to be acceptable.1,2 This requires bone re-oval in the vast majority of dentate or edentulousatients who undergo full arch treatment. This isarticularly important in the female population, whoave greater gingival display to avoid exposure of theestoration margin during animation.3,4 Because ofhis, the surgeon is faced with the dilemma of removalf supporting bone for dental implant placement,ften to such an extent that axial implant placementecomes impossible without significant bone graft-

ng, especially sinus floor augmentation.5-7

Since the Sinus Consensus Conference of 1996,8

ost treatment plans involving atrophic maxillaeave involved sinus bone grafting and placement ofultiple posterior implants. However, within the past

ecade, a simple innovation, that of nonaxial implantlacement, with implant placement angulations of upo 30°, has led to a new concept, that of “graftless”urgical management.9-13

Surgical care for the maxilla, therefore, stands at arossroads, that of subtraction of bone mass versusddition of bone graft for osseointegration. Drivinghis controversy is the desire for immediate function,omething nearly impossible to do when significantone grafting is performed.

*Director, Colorado Tissue Engineering Institute, Denver, CO.

†Private Practice, Denver, CO.

‡Fellow, Colorado Tissue Engineering Institute, Denver, CO.

§Private Practice, Dallas, TX.

�Private Practice, Dallas, TX.

Address correspondence and reprint requests to Dr Jensen:

mplant Dentistry Associates of Colorado, 8200 East Belleview

venue, Suite 520E, Greenwood Village, CO 80111; e-mail:

[email protected]

2010 American Association of Oral and Maxillofacial Surgeons

278-2391/10/6810-0022$36.00/0

ooi:10.1016/j.joms.2010.05.082

2520

The use of angulated implants for short-spanridges or even long-span reconstructions to avoidone grafts has now been used for 10 years, althoughany of these were not immediately loaded.13-16

owever, with the advent of the All-on-4 immediateunction, this became consistently possible using araftless protocol.Immediate function is based on earlier studies, some-

imes using up to 10 implants per arch until biomechani-al analysis demonstrated that when 2 implants arelaced sufficiently close together, they function as ifhere were only 1 implant present (B. Rangert, personalommunication, March 2007). This discovery first be-ame important in the mandible, where fixed denturerosthetics using 5 implants had been (and still is) pre-cribed as optimal. However, when 5 implant distribu-ion was studied biomechanically it was found that the

iddle implant took no measurable load in functionnd therefore could be eliminated. This same biome-hanical finding was observed for the maxilla.17-21

Another important aspect of maxillary care is ex-raction of diseased teeth followed by simultaneousmplant placement with immediate function.22-24 Theurgeon is therefore faced with the challenge of re-oving failing teeth, trimming back bone stock,

voiding bone grafting procedures, inserting dentalmplants at angulations, and placing the patient inton immediately loaded provisional restoration; all ofhese procedures are counterintuitive to traditionalurgical management, if not biomechanical under-tanding of maxillary treatment.25-27 Antemolar reduc-ion in the number of implants, restricted to availableone anterior to the sinus cavities, further compli-ates the surgical difficulty.28

Given this controversy, 3 questions must besked in the face of reduced bone stock: 1) Cansseointegration occur without significant grafting?) Can full arch prosthetic loading be obtained with
nly 4 implants placed at angulation? 3) Can imme-
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JENSEN ET AL 2521

iate load biomechanics be established using theimited bone stock of the anterior maxilla?

The somewhat oblique answer to these questionss found in the development of a simple surgicalolution in which bone is leveled by prostheticrescription creating a flat surface termed the All-n-4 shelf (Fig 1A). Placed “on” this shelf are im-lants directed at angulations emerging from spe-ific end points likely to gain primary fixation (FigB). The implant positions on the shelf are based inart on compensating angled abutments that mustmerge through tissue at or lingual to the midoc-lusal axial plane.29 The shelf facilitates the anteri-r-posterior (A-P) spread maximum by identifying

IGURE 1. A, Bone leveling of the alveolus creates a new alveolall-on-4 technique must take advantage of available bone, which isnd compensating angled abutments are placed. B, The All-on-ncluding determining optimal sites for implant placement andosterior spread.

ensen et al. The All-on-4 Shelf: Maxilla. J Oral Maxillofac Sur

he anterior sinus wall and lateral nasal wall.14

here are numerous other advantages to using ahelf approach, which affirm that adequate os-eointegration capacity of only 4 load-bearing im-lants can biomechanically sustain immediate pro-isionalization.Here, then, are 10 technical advantages for the

urgical-prosthetic team to consider in the use of theaxillary All-on-4 shelf:

1. Creates prosthetic restorative space2. Establishes the alveolar plane3. Shelf width determines implant diameter selec-

tion4. Shelf reduction proximates piriform bone fixa-

that functions as a “shelf” on which to place dental implants. Theserved using the All-on-4 shelf approach for which angled implantsprovides several advantages for the surgical-prosthetic team,to avoid pneumatized structures to derive maximum anterior-

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2522 THE ALL-ON-4 SHELF: MAXILLA

5. Shelf findings suggest convergent or divergentimplant placement strategy

6. Establishes optimal osseous sites for implantplacement

7. Defines secondary fallback sites for implantplacement

8. Exposes palatal plate cortical anatomy for im-plant fixation

9. Facilitates posterior implant placement (A-Pspread) in relation to anterior sinus wall

10. Provides bone stock for bone grafting

rosthetic Restoration Space

One of the most difficult surgical prosthetic errorso manage is insufficient interocclusal space, that is,nadequate interrestorative space between opposingrches.27,30,31 This can be due to inadequate boneemoval in full arch cases. Therefore, the most impor-ant function of the All-on-4 shelf is adequate bone

IGURE 2. A clear acrylic bone reduction guide ensures there isdequate restorative space for abutments and titanium bar housedithin the prosthesis.

ensen et al. The All-on-4 Shelf: Maxilla. J Oral Maxillofac Surg010.

IGURE 3. The provisional appliance can be “windowed” toetermine adequate bone removal and used to determine appro-riate abutment angulation.

aensen et al. The All-on-4 Shelf: Maxilla. J Oral Maxillofac Surg010.

eduction, especially in dual-arch cases which require2 mm of interarch prosthetic space. The use of boneeduction guides (Fig 2) or windowed denture guidesFig 3) helps facilitate adequate bone removal.

When the junction of the prosthesis and tissue isisible, there is esthetic failure. A flange is required toide the junction. Use of a flange on a fixed prosthesisreates an oral hygiene access problem. By locatinghe prosthesis tissue junction a minimum of 3 mmeyond the visible gingiva, the surgeon and restor-tive dentist are assured of hiding the prosthesis-issue junction. This is perhaps the greatest advantagef using the All-on-4 shelf. Although not yet pub-

ished, alveolar reduction to this extent has not led toone-level instability, greater tendency for bone loss,r gingival hyperplasia around implants.

lveolar Plane

Using the interpupillary plane as a guide, a newalveolar plane” is established, which avoids a cant inhe positioning of implants and creates level place-ent of implant platforms; this is difficult to do with-

ut creating the All-on-4 shelf.16,32 When upper andower jaw shelves parallel each other (Fig 4), there isess likely to be prosthetic problems with implantositioning.The alveolar plane must also be level front to back.common error in making the shelf is to taper the

helf too much toward the alveolar crest posteriorly,eaving the prosthodontist with inadequate interarchpace. This leads to an “alligator bite” effect and canesult in a thin prosthesis in the bicuspid-molar re-ion. Therefore, the All-on-4 shelf must not only cre-

IGURE 4. Bimaxillary All-on-4 surgery should have at least2 mm of interarch space for the final provisional restoration. Thelanes should be parallel front to back.


te an alveolar plane parallel to the interpullary line

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ut a plane, when viewed laterally, that is parallel torankfort horizontal.

helf Width

After bone reduction, the width of the shelf be-omes defined at the level of the desired implantlatform vertical dimension. Alveolar concavities be-ome evident, and optimal diameter of implants can bessessed.33 When the ridge is thin (Fig 5), small-diametermplants are placed; if it is wide and osteoporotic, a

ide-diameter implant may be prescribed.34

Midalveolar constriction, the so-called hourglass ef-ect, seen on cross-sectional computed tomography inhe anterior maxilla can sometimes be pronounced. Ifhe alveolar plane is established at the constriction, aarrow implant is needed to avoid fracturing the al-eolus. The width of the shelf is another factor thatan be addressed at the time the shelf is made byometimes removing more bone than necessary toptimize the width of implants used.

IGURE 5. A thin residual maxillary alveolar process will splitnless small-diameter implants are used as shown. The shelf widthelps determine implant diameter selection.


IGURE 6. Using an angulated placement strategy, paranasalortical bone is able to anchor an implant placed at some distanceway. When subnasal bone is reduced in height, anterior implantsre angled posteriorally to engage bone in this same area.

tensen et al. The All-on-4 Shelf: Maxilla. J Oral Maxillofac Surg010.

iriform Rim Proximation

When there is alveolar crest atrophy, vertical di-ension may still be present but at reduced width

uch that reduction of height will not only widen thehelf but bring the created alveolar plane in closerpproximation to the piriform rim, the most desirableite for implant fixation using an M-4 placement strat-gy (Fig 6).35 Shelf reduction then determines theosition and length of posterior implant placementith a maximum available implant length of 18 mm

Nobel Biocare, Zurich, Switzerland). Inadequateone reduction may force the clinician to anteriorizehe placement of the posterior implant or even pre-ent adequate fixation. Optimal implant fixation for thetrophic maxilla is frequently obtained using an M-4lacement strategy fixing implants at what has beenalled M-point (Fig 7), the point of maximum bone masst the lateral piriform rim just above the nasal fossa.35

ven in highly atrophic cases, the posterior implant canften be placed 10 mm or more posterior to this point.

mplant Angulation Strategy

More than any surgical procedure, the All-on-4helf helps determine the angulation strategy em-loyed for implant placement. Long face syndromeatients, after shelf reduction, may still have ade-uate bone for axial placement of implants,36

hereas short face patients after bone reductionequire all implants to be angled, usually using the-4 strategy.35,37

ptimal Osseous Implant Sites

After alveolar crest reduction, the surgeon is of-

IGURE 7. M-Point, the area of maximum lateral pyriform rimone mass above the nasal fossa, enables using the “M”-shapedwhen viewed on Panorex) placement strategy, including fixation ofonger implants placed at a favorable distribution for anterior-osterior spread.


en faced with the prospect of implant placement

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nto marrow space, often a difficult task to do andtill obtain insertion torque values adequate formmediate load. Therefore, computer guidance sys-ems are inadequate to the task, having no ability tossess bone reduction or implant torque.34,38 Alter-atively, the shelf provides the surgeon with anpportunity to specifically select optimal sites forlacement without the constraint of computer gen-rated guides.39 This applies especially to dentalxtraction cases in which there are often multipleefects present or created during the course ofxtraction. Following bone reduction, the surgeons able to identify either visually or tactically theest load bearing sites possible for implant place-ent.

etermine Fallback Implant Sites

Before preparation of final implant sites, secondary,r fallback, sites are assessed. Oftentimes, there are a

imited number of sites available, and therefore, it ismportant for the surgeon to address this ahead ofime. In the process of creating 4 receptor sites, oner more sites may need to be abandoned because of a

ack of bone quality or quantity for fixation. A sequen-ial (and careful) preplanned placement strategy withecondary fallback sites can salvage treatment for anmmediate-load strategy best facilitated by use of thell-on-4 shelf.This process of selecting sites is important lest the

urgeon paint himself or herself into a corner. Therst site selected is the posterior site, not the anteriorite. If that site does not work, moving slightly for-ard is the secondary site. After posterior implants

re placed, anterior sites are selected in a distributedashion.

IGURE 8. The All-on-4 shelf established a visual cue by exposinghe palatal cortical bone thickness for optimal placement for highnsertion torque implants.

qensen et al. The All-on-4 Shelf: Maxilla. J Oral Maxillofac Surg010.

alatal Cortical Plate

Although a computed tomographic scan can delin-ate width of the palatal plate,39,40 after bone reduc-ion, the specific site of placement is more easilyssessed for cortical thickness because implants willikely need to engage the palatal plate because of theomplete loss of facial bone that is often seen ineriodontally involved dental extraction cases.40 Gen-rally, the palatal plate can be difficult to engage, butith shelf reduction, it usually is clear to the surgeonow best to gain access through the alveolus andngage at least a portion of the palatal cortex. Thehicker the plate, the more likely adequate insertionorque will be obtained (Fig 8).41

osterior Implant Placement andnterior-Posterior Spread

The All-on-4 shelf clearly shows the maximum al-owable posterior position where the posterior im-lant can be placed because shelf reduction fre-

IGURE 9. The All-on-4 shelf frequently exposes the sinus cavity orrings it into close approximation such that the exact visual locationf the anterior sinus wall (S-point) can be identified to place theosterior implant as far back in the arch as possible without sub-

ecting the patient to sinus floor bone grafting.


uently exposes the sinus membrane, which can then

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e directly visualized (or reflected) for placing themplant just anterior to the anterior sinus wall (Fig 9).

hen the sinus is not exposed, a lateral punch holento the sinus is made at the most anterior inferiorxtent of pneumatization to serve as a guide for im-lant placement and angulation.14 This point is called-Point, for sinus point, in All-on-4 nomenclature. This

IGURE 10. A, When the shelf is well away from the sinus, theost anterior sinus deflection (S-point) is identified using a lateralntrostomy burr hole. The space from this point to the shelf iseasured. This same distance posterior of the S-point perpendicu-

ar should be the entrance location of the posterior implant sitewhen placed at 30°) to avoid the sinus. B, The vertical alveolarone available from S-Point to the alveolar plane of the All-on-4helf often determines how far posteriorally the implant can benserted.


s the most anterior inferior projection of the sinusJ2

here implants must bypass to not traverse the sinusavity and where posteriorly, no load-bearing bone isresent36 (Fig 10A).The vertical alveolar bone available from S-Point to

he alveolar plane of the All-on-4 shelf often deter-ines how far posteriorly the implant can be in-

erted. For example, if there is 5 mm of bone from-Point to the All-on-4 shelf, implant insertion cansually be accomplished about 5 mm posterior to-Point when the implant is angled 30° (Fig 10B).

When S-Point and M-point converge, A-P spread iseduced proportionately; when there is confluenceetween the nasal fossa and maxillary sinus (1 cavity),o fixation points are available and the alveolar All-n-4 procedure may be contraindicated in favor of aygomatic All-on-4 strategy.42,43

one Stock Source

Although the All-on-4 procedure is considered agraftless” procedure, it often is not.13 Bone removaln creation of the All-on-4 shelf is ground up for usen grafting fenestrations, extraction wall defects,ystic cavities, exposed implant threads in narrowlveolar placements, and sometimes even for sinusrafting.44-46

IGURE 11. Variants of the natural orifice of the nasolacrimal ducthat may occur intraossesously below the inferior turbinate and cane close to piriform rim bone used to place “M”-shaped distribution

mplants. Care should be taken not to cause nasolacrimal damagenadvertently when the duct is near M-point for All-on-4 implantlacement.


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asolacrimal Duct

One final anatomic structure to be aware of is theasolacrimal duct, which exits below the inferior tur-inate sometimes anatomically near where M-point

mplant fixation is desirable in the piriform (Fig 11).4-9

mplants that penetrate the piriform and enter intohe nasal fossa can on rare occasions disturb nasolac-imal drainage.47

iscussion

The overall benefit of the All-on-4 shelf is one ofechnical, biological, and biomechanical advantageo the surgical prosthetic team.13 The use of thehelf ensures that implants are placed at the rightevel, at the most optimal angles, at maximum A-Ppread, and with the most favorable insertionorque obtainable for immediate load restorations.ecall the three questions of controversy: 1) Cansseointegration occur in the maxilla without bonerafting? 2) Can full arch prosthetic loading beccomplished with only 4 implants placed at angu-ation? 3) Can full arch immediate load biomechan-cs be satisfied by the often limited bone stock of

IGURE 12. A, Reduction alveoloplasty of the All-on-4 shelf pro-ides enough interarch space for the esthetic prosthetic reconstruc-ion. B, The use of M-4 placement, as shown in the panographic-ray, was facilitated by the All-on-4 shelf.


he anterior maxilla? All of these questions are more

ikely to be answered affirmatively by use of thell-on-4 shelf.In summary, the All-on-4 shelf is a surgical pros-

hetic tool not unlike reduction alveoplasty for den-ure placement that aids in optimal surgical-pros-hetic management of the All-on-4 restoration (Figs2A,B). After the surgeon can accept the idea ofonaxial implant placement as well as a reducedumber of implants, the All-on-4 shelf becomes aecessary tool to optimize what is a highly efficient,lthough counterintuitive, maxillary implant place-ent scheme.

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