Clinical protocol

All-on-4 step by step

The full-arch fixed rehabilitation protocol on four implants, explained phase by phase with operated cases and radiographs from our São Paulo editions.

Why All-on-4 changed full-arch rehabilitation

Four implants — two axial and two tilted distal — anchor a fixed arch in residual bone without major grafting. Less surgical time, less morbidity, and a fixed provisional the same day. This is the protocol we perform and teach on real patients during the residency.

The protocol in 8 phases

Each phase is performed by participants under direct faculty supervision.

01
Diagnosis and digital planning
CBCT, available bone volume assessment, maxillary sinus and inferior alveolar nerve position, and reverse prosthetic planning from the desired final result.
02
Extractions and ridge reduction
Atraumatic extractions, thorough socket curettage and bone reduction until there is enough prosthetic space for the bar and gingival aesthetics.
03
Axial anterior implants
Progressive drilling and placement of the two anterior implants seeking high insertion torque — primary stability is the criterion that allows immediate loading.
04
Tilted posterior implants
Distal implants tilted 30–45° to bypass the sinus or nerve, reduce the cantilever and anchor in better-quality bone.
05
Multi-unit abutments and parallelism
Angled abutments (17° or 30°) to correct the axes, torque verification and a common insertion path for the whole arch.
06
PRF and soft-tissue management
PRF membranes prepared from the patient's own blood, applied to the sockets, with tension-free suturing to speed up healing.
07
Same-day fixed provisional
Registration, prosthesis conversion, occlusal adjustment and delivery of the fixed provisional — the patient leaves rehabilitated.
08
Follow-up and definitive prosthesis
Radiographic follow-up of osseointegration, hygiene and maintenance, and transition to the definitive prosthesis after a few months.