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The NobelGuideV All-on-4V Treatment Concept

for Rehabilitation of Edentulous Jaws:
A Retrospective Report on the 7-Years Clinical
and 5-Years Radiographic Outcomes
Armando Lopes, DDS, Msc;* Paulo Mal ujo Nobre, RDH, MSc;†
o, DDS, PhD;* Miguel de Ara
‡
Elena Sanchez-Fernandez, DDS, PhD; In^es Gravito, DDS*

ABSTRACT
Background: There is a necessity of studies documenting the long-term outcome of full-arch flapless rehabilitations.
Purpose: To evaluate the 7 years implant and prosthesis survival rate and 5-years marginal bone loss of full-arch fixed
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prosthetic rehabilitations supported by implants in immediate function with the All-on-4V treatment concept using a
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computer guided surgical protocol (NobelGuideV, Nobel Biocare).
Materials and Methods: This retrospective clinical study included 111 edentulous patients (n 5 53 bruxers; n 5 21
smokers; n 5 59 systemically compromised), rehabilitated between February 2005 and November 2010 with 532
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implants with the All-on-4V treatment concept using NobelGuideV. Outcome measures were implant and prosthesis
survival, marginal bone loss at 5-years and the incidence of mechanical and biological complications. Survival was
calculated using life-table analysis. Inferential analysis was performed to compare the difference in marginal bone loss
between axial and tilted implants.
Results: Sixteen patients were lost to follow-up. The implant cumulative survival rate was 94.5% at 7 years. Prosthetic
survival was 97.8% (n 5 3 prosthetic failures). The average (standard deviation) marginal bone loss at 5 years was
1.3 mm (1.06 mm) overall, 1.27 mm (1.02 mm) for tilted implants and 1.34 mm (1.1 mm) for axial implants (p < .001).
Ninety-one patients experienced complications in the provisional prostheses (n 5 47 patients who were bruxers; n 5 25
patients with implant-supported rehabilitation as opposing dentition) ranging from prosthetic fracture (n 5 66
patients) to abutment or prosthetic screw loosening (n 5 74 patients). Thirty-three patients experienced complications
in the definitive prostheses (all exclusive to patients who were bruxers or had implant-supported rehabilitations as
opposing dentition) ranging from acrylic-resin prosthetic/crown fracture (n 5 23 patients) to abutment or prosthetic
screw loosening (n 5 10 patients). Twenty-five patients (22%) registered peri-implant pathology.
Conclusions: Within the limitations of this study, it is possible to conclude that this treatment modality for completely
edentulous jaws is possible with high long-term survival outcomes. Bruxing and smoking habits had a negative impact
on implant failure, mechanical, and biological complications.
KEY WORDS: clinical research, computer assisted, edentulous mandible, edentulous maxilla, flapless implant
surgery, immediate function

INTRODUCTION
*Department of Oral Surgery, Mal o Clinic, Private practice, Lisbon, The rehabilitation of complete edentulism with a
Portugal; †Private practice, Research and Development, Mal o Clinic,
Lisbon, Portugal; ‡Oral Surgery and Implant Dentistry Department, fixed implant supported prosthesis immediately after
School of Dentistry, University of Granada, Spain implant placement allows the replacement of the mas-
Reprint requests: Miguel de Ara
ujo Nobre, RDH, MSc Epi, Mal o ticatory capability, phonetics, esthetics, and comfort
Clinic, Avenida dos Combatentes, 43, 11th floor, 1600-042 Lisbon, enabling the patients to return to their normal rou-
Portugal; e-mail: mnobre@maloclinics.com
tine within a short period of time.1,2
C 2016 Wiley Periodicals, Inc.
V Since the osseointegrated implant treatment
DOI 10.1111/cid.12456 was described in the 1960s by Brånemark3 that

1
2 Clinical Implant Dentistry and Related Research, Volume 00, Number 00, 2016

recommended two-stage techniques and healing peri- immediate loading in edentulous ridges, in follow-ups
ods of 3 to 6 months, a significant number of up to 3 years, and have generally reported predictable
research has focused on providing patients with a safe results with high survival rates.1,14,15,18–20 Nonetheless
but also simpler and faster treatment – the one-stage studies on clinical performance, prosthetic complica-
surgical procedure – while still maintaining the excel- tions and medium and long term follow-ups are still
lent results of previous methods.2,4–6 Since the begin- limited. Polizzi and Cantoni21 and Lopes and col-
ning of the century, the use of one-stage surgical leagues2 reported an implant survival rate of 97.3%
protocols with early and immediate implant function and 96.6%, respectively, at 5 years of follow-up using
has proven to be a valid approach in full-arch edentu- the NobelGuideTM system. Schneider and colleagues22
lous rehabilitations with high survival rates in both performed a systematic review on the accuracy and
maxilla and mandible.1,2,7–12 the clinical outcome of computer-guided implant
One of these immediate-function protocols is the dentistry presenting survival rates of 91 to 100%.
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All-on-4V treatment concept (Nobel Biocare, The aim of this study was to evaluate the 7-years
G€oteborg, Sweden), a valid surgical technique, which implant and prosthesis survival rate and 5-years mar-
involves the placement of four implants for the reha- ginal bone loss of full-arch fixed prosthetic rehabilita-
bilitation of completely edentulous jaws with a mini- tions supported by implants in immediate function
mum bone volume and avoiding bone augmentation with the All-on-4 treatment concept using a
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procedures. Provided the implants are placed strategi- computer-guided surgical protocol (NobelGuideV,
cally – two posterior implants tilted up to 458 and Nobel Biocare).
two anterior axial implants – and they are well
anchored (achieving a high primary stability of at MATERIAL AND METHODS
least 30 Ncm), the treatment success rate is high This retrospective clinical study was performed in a
(98% for the maxilla and 98.1% for the mandible private practice (Malo Clinic Lisbon, Portugal). The
after 5–10 years of follow-up).11,12 patients were rehabilitated between February 2005
In 2002, the concept of software planning and and November 2010. This study was approved by an
surgically guided techniques combined with immedi- independent ethical committee (Ethical Committee
ate loading was clinically introduced.13 These early for Health, authorization no. 001/2015). This manu-
treatments evolved to flapless computer-guided script was written according to the Strengthening the
implant surgery and one of these systems is the Nobel Reporting of Observational Studies in epidemiology
GuideTM concept (Nobel Biocare). guidelines).23 One-hundred-eleven full-arch edentu-
Using a surgical planning software (NobelGuide; lous patients (68 females and 43 males) with an aver-
Nobel Biocare) with DICOM files from computed age age (standard deviation) of 60.9 years (9.67) were
tomography (CT) scans or cone beam CT (CBCT), consecutively included and treated in a private prac-
data can be converted into three dimensional (3D) tice (Malo Clinic, Lisbon, Portugal). The patients
images allowing for the virtual accurate planning of who met the inclusion criteria were identified from
the exact position and direction of the implants. A sur- the medical records and the digital image software.
gical template and fixed acrylic prosthesis are fabricat-
ed, ensuring transfer precision from the virtual to the Inclusion and Exclusion Criteria
planned prostheses. Clinically the implants are placed Inclusion criteria were patients submitted to rehabili-
through the surgical template and immediately after tation with full-arch fixed prosthesis supported by
the flapless surgery, the immediate prosthesis is deliv- implants in immediate function inserted through the
ered achieving rehabilitation with the same level of All-on-4 concept with NobelGuide protocol. Patients
success as in flap surgery. These aspects of minimally were excluded from this study if they presented crite-
invasive, simplified, and more predictive surgery, along ria considered to be contraindicated for full-arch
with treatment time reduction and less postsurgical implant surgery such as insufficient bone volume,
discomfort are beneficial to the patient.14–17 active radiotherapy or active chemotherapy, or criteria
Several clinical reports have well documented that disallowed guided surgery such as remaining
computer-guided flapless implant surgery and teeth that could interfere with implant placement,
 Concept for Rehabilitation of Edentulous Jaws 3

Figure 1 Preoperative orthopantomogram.

insufficient mouth opening to accommodate surgical

instruments (at least 50 mm), or whenever bone Figure 3 Patient CBCT scan with removable prosthesis (radio-
graphic guide) stabilized with radiographic index in maximum
reduction was needed due to high smile line in the intercuspidation.
maxilla, irregular bone crest, or thin bone crest.14
A removable prosthesis was prepared to be used
Surgical, Prosthetic and Maintenance Protocols as radiographic guide before CT/CBCT scan. Whenev-
The implants positions were similar (using the flap er adequate the previously existing removable pros-
procedure as reference)11,12 and the immediate pros- thesis was used or, if not, a newly removable
theses were manufactured prior to implant surgery prosthesis was fabricated. Three palatal and 6 buccal
(NobelGuideV, Nobel Biocare).13
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holes 1 mm deep and 1.5 mm wide were made at dif-
Presurgical intraoral clinical observations, pano- ferent levels and filled with a radiopaque marker
ramic radiographs, and CT/CBCT scan were per- (gutta-percha; SDI, Bayswater, Victoria, Australia). A
formed for all cases (Figures 1 and 2). The anatomical silicone (Zhermack Spa) interocclusal record was
inclusion criterion were: residual ridge crest of at made to stabilize the bite (radiographic index).
least 4 mm wide, buccolingually and greater than The patients were scanned first with the remov-
8 mm high in the interforamina area for the man- able prosthesis (radiographic guide) in the mouth sta-
dible and residual ridge crest with enough width to bilized with the radiographic index in maximum
insert a 4.0 mm diameter implant, and greater than intercuspidation (Figure 3) and a second scan was
10 mm high from canine to canine in the edentu- performed on the prosthesis alone with the same ori-
lous maxilla. In situations of a residual crest with entation as in the mouth – double scan technique.14
4 mm of width, a bone expansion was performed in The CT/CBCT scan DICOM files were inserted in a
order to insert the 4.0 mm diameter implants, tak- software planning program (NobelGuide; Nobel Bio-
ing advantage of the characteristics of the implants care) (Figure 4), and converted into 3D computer
used (NobelSpeedy, Nobel Biocare AB, Gothenburg, images that allowed to plan virtually the exact
Sweden).

Figure 2 Maxillary intraoral pre-operative view. Figure 4 Three-dimensional computer planning.

4 Clinical Implant Dentistry and Related Research, Volume 00, Number 00, 2016

Figure 5 Maxillary surgical template. Figure 7 Maxillary surgical template stabilized with anchor
pins.
implants positions. A surgical template was then fab-
ricated through this virtual planning14 (Figure 5). prefabricated fixed prosthesis immediately and when
The surgical template was used in the laboratory needed occlusion adjustments were performed (Fig-
process to create a working cast. The cast was articulat- ures 10 and 11).
ed with the radiographic guide and radiographic index The patients were enrolled in an implant mainte-
and the removable prosthesis was converted into an nance program and instructed to stay on a soft diet
all-acrylic resin fixed complete bridge (Figure 6). for 2 months. After 4 months, if the implants were
The surgical procedures for both jaws were per- judged stable, the patient had the option of replacing
formed under local anesthesia and a specific medica- the fixed acrylic resin prosthesis with a metal-acrylic
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tion protocol previously described14 was given to all resin with a titanium framework (ProceraV frame-
patients. The surgical template was stabilized in the work, Nobel Biocare) and acrylic resin prosthetic
patient’s mouth with anchor pins (Nobel Biocare) teeth (Heraeus-Kulzer GmbH); or metal-ceramic
(Figure 7) after using a surgical index fitting to the prosthesis with titanium framework and all-ceramic
opposing arch and flapless implant surgery was per- Zirconia crowns (Procera titanium framework, Pro-
formed, following the manufacturer’s instructions cera crowns, and NobelRondo Ceramics; Nobel Bio-
(NobelGuide) (Figure 8). Anterior abutments care AB).
(straight or 178 Multiunit Abutments; Nobel Biocare)
Primary and Secondary Outcome Measures
were placed after the surgical template was removed,
followed by the posterior abutments (308 Multiunit Primary outcome measures were implant and pros-
Abutment Non-Engaging, Nobel Biocare), using a thetic survival. Implant survival was based on func-
custom jig manufactured in the laboratory (Figure 9). tion and determined by fulfillment of the following
Immediate function was achieved by delivering the criteria: clinical stability, patient reported function
without any discomfort; absence of radiolucent areas

Figure 6 Provisional acrylic resin fixed prosthesis in the artic-

ulator before surgery. Figure 8 Anterior implant placement.
 Concept for Rehabilitation of Edentulous Jaws 5

Figure 11 Postoperative orthopantomogram.

the implant and the abutment), and marginal bone

Figure 9 Nonengaging abutment jig (308). loss was defined as the difference in marginal bone
level relative to the time of surgery. The radiographs
around the implants. To assess implant stability, pros-
were accepted or rejected for evaluation based on the
theses were removed and implants individually and
clarity of the implant threads; a clear thread guaran-
manually evaluated at each maintenance appointment
tees both sharpness and an orthogonal direction of
every 6 months. Prosthetic survival was based on
the radiographic beam towards the implant axis.
function, with prosthesis removal classified as failure.
The biological complications evaluated were sup-
Secondary outcome measures were marginal bone
puration, fistulae formation, peri-implant pathology
loss for axial and tilted implants, and the incidence of
(including local bone defects around the implant,
biological and mechanical complications.
pocket formation, bleeding on probing, and mucosal
Periapical radiographs were made at implant
insertion and 5-years of follow-up. All patients were inflammation); while the mechanical complications
evaluated clinically and radiographically per protocol evaluated were fracture or loosening of any prosthetic
at the specific time points. A conventional radiograph components.
holder (Super-bite; Hawe Neos, Bioggio, Switzerland) Statistical Analysis
was used, and its position was manually adjusted for
Survival was calculated using life table analysis (actu-
an estimated orthognathic position of the film. An
arial method) and using the implant and prosthesis
outcome assessor examined all implant radiographs.
Each periapical radiograph was scanned at 300 dpi as unit of analysis. Descriptive statistics were comput-
with a scanner (HP Scanjet 4890, HP Portugal, Paço ed for the variables of interest (marginal bone loss
de Arcos, Portugal), and the marginal bone level was and incidence of biological and mechanical complica-
assessed with image analysis software (Image J version tions). Inferential analysis (Wilcoxon Signed Ranks
1.40g for Windows, National Institutes of Health, test) was used to evaluate the difference in marginal
USA). The reference point for reading was the bone loss between axial and tilted implants. The level
implant platform (the horizontal interface between of significance was set at 5%. The data were analyzed
using the software SPSS for Windows (IBM SPSS,
New York, USA) version 17.

RESULTS
Patients and Implants
A total of 111 patients treated with 133 full-arch fixed
dental prosthesis supported by 532 implants
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(NobelSpeedyV groovy; Nobel Biocare) were included
and evaluated during the follow-up of this study.
A total of 16 patients (14.5%) with 64 implants
(12%) were lost to follow-up. One patient (with
Figure 10 Maxillary intraoral postoperative view. 8 implants) deceased after 9 months due to unrelated
6 Clinical Implant Dentistry and Related Research, Volume 00, Number 00, 2016

TABLE 1 Cumulative Implant Survival Rate for Patients Rehabilitated Through the All-on-4 Treatment Concept
Using Computer Guided Flapless Surgical Approach
Total number Total Number Implant Lost to Not Yet Survival
Time of Patients Implants Losses Follow-Up Due Rate CSR %

Loading 11 532 19 28 0 96.3 96.3

1 year 106 485 3 0 0 99.4 95.7
2 years 105 482 2 8 0 99.6 95.3
3 years 103 472 4 8 0 99.1 94.5
4 years 101 460 0 4 13 100 94.5
5 years 96 443 0 16 53 100 94.5
6 years 87 374 0 16 42 100 94.5
7 years 74 316 0 0 0 100 94.5

CSR%: Cumulative Survival Rate.

causes to the implant treatment and 15 patients became with Diabetes, 5 patients with Rheumatologic condi-
unreachable: 4 patients with 20 implants (4 implants tions, 3 patients with Hepatitis, 1 patient with neuro-
each patient and 1 patient with 8 implants) in the first logical condition, 1 patient HIV positive taking
year of follow-up, 2 patients and 8 implants (4 implants medication. Fourteen patients presented more than
each patient) between the second and third year of fol- one co-morbidity. Twenty-one patients (18.9%) were
low-up), 2 patients and 8 implants (4 implants each smokers. Fifty-three patients (47.7%) were bruxers.
patient) between the third and fourth year of follow-up,
1 patient with 4 implants between the fourth and fifth Primary Outcome Measures
year of follow-up, 4 patients and 20 implants (3 patients A total of 28 implants failed in 14 patients (17 in the
with 4 implants each and 1 patient with 8 implants) maxillae, 11 in the mandible) giving a cumulative
between the fifth and sixth year of follow-up, and 3 implant survival rate of 94.5% at 7 years of follow-up
patients and 12 implants (4 implants each patient) (Table 1, Figure 12). The patients’ characteristics,
between the sixth and seventh year of follow-up. The potential risk indicators for implant failure, remedies
patients were included in the implant and prosthetic and outcomes are displayed in Table 2. Patients that
survival analysis. registered implant failures (14/111) presented a higher
Fifty-nine patients presented with co-morbidities prevalence of bruxing (n 5 8/14 patients) or smoking
including the following medical conditions: 44 habits (6/14 patients).
patients with cardiovascular condition, 11 patients Prosthetic failure was observed in three patients
with history of oncological condition, 10 patients (one prosthesis in each patient), rendering a 97.8%
survival rate at prosthetic level.

Secondary Outcome Measures

The frequencies and distribution of marginal bone
loss at 5 years is illustrated on Table 3 and Figure 13.
The average (standard deviation) marginal bone loss
was 1.30 mm (1.06 mm) at 5 years, with 1.27 mm
(1.02 mm) for tilted implants and 1.33 mm (1.10
mm) for axial implants (p < .001).
Ninety-one patients (81.9%) experienced
mechanical complications in the provisional prosthe-
ses: Sixty-six patients (59.4%) experienced a fracture
of the provisional prosthesis, 67 patients (60.3%) pre-
Figure 12 Implant survival function. sented abutment loosening, 7 patients (6.3%)
 Concept for Rehabilitation of Edentulous Jaws 7

TABLE 2 Patients’ Characteristics with Failed Implants and Corresponding Outcomes

Implant Follow-Up
Patient Age Gender Position (Months) Comorbidities Outcome*

1 55 Male 15 45 None Prosthesis was kept in function with three implants

for 6 months and a new implant was inserted.
2 50 Female 32,42 6 Smoker Implants failed to integrate. Prosthesis was kept in
function with two implants for 6 months and two
new implants were inserted. One of the new
implants failed and final prosthesis was supported
by three implants.
3 60 Male 22 4 Bruxer Implant failed to integrate. Prosthesis was kept in
function with three implants for 6 months and a
new implant was inserted.
4 76 Male 25 5 Cardiovascular Implant failed to integrate. Prosthesis was kept in
condition function with three implants for 6 months and a
new implant was inserted.
5 63 Male 32,35,45 4,6,4 Bruxer Implants failed to integrate. Prosthesis was removed
from function and three new implants were
inserted 6 months later. Two of the new implants
failed and a fourth implant was inserted. Final
prosthesis was supported by three implants.
6 48 Female 32,42,45 32,32,38 Bruxer, smoker Implants presenting severe bone loss and suppura-
tion were removed. A new implant was inserted
(position 31), the prosthesis was kept in function
supported by three implants (positions 31,35,45)
and after 6 months implant was removed and a
new implant inserted and loaded. Final prosthesis
supported by three implants.
7 64 Female 16 13 Bruxer Implant removed due to parafunctional habit after
an episode of prosthetic fracture. Prosthesis was
kept in function for 6 months supported by three
implants. A new implant was inserted after 6
months.
8 73 Female 15 8 Bruxer Implant failed to integrate. Prosthesis was kept in
function for 6 months supported by three
implants. A new implant (zygomatic) was inserted.
Final prosthesis was supported by three standard
implants and one zygomatic implant.
9 67 Female 45 1 Bruxer, history Implant failed to integrate. Prosthesis was kept in
of oncological function for 6 months supported by three
condition implants. A new implant was inserted after 6
months.
10 50 Male 32,42 45,45 Smoker Implants presenting severe bone loss and suppura-
tion were removed. A new implant was inserted on
the same day (position 41). A second implant was
inserted after 6 months (position 43). Prosthesis
was kept in function supported by three implants
for 10 months. Final prosthesis was supported by
four implants.
8 Clinical Implant Dentistry and Related Research, Volume 00, Number 00, 2016

Table 2. cont.
Implant Follow-Up
Patient Age Gender Position (Months) Comorbidities Outcome*
11 70 Female 12,15,22,25 9,7,7,21 Smoker, Implants 12,15,25 failed to integrate. New implants
cardiovascular were inserted and also failed to integrate. Implant
condition 25 was lost at the time of the new inserted
implants failed. Patient was rehabilitated with a
removable denture.
12 70 Male 12,15,22,25 4,3,14,8 Smoker, bruxer, Implants failed to integrate. Two standard and two
cardiovascular zygomatic implants were inserted. Prosthesis was
condition kept in function on the remaining implants. Final
prosthesis was supported by four implants.
13 44 Female 12,15,25 10,6,5 Smoker Implants failed to integrate. One standard and two
zygomatic implants were inserted. Prosthesis was
kept in function on the remaining implants. Final
prosthesis was supported by four implants.
14 58 Female 25 6 Bruxer Implant failed to integrate. Prosthesis was kept in
function with three implants for 6 months and a
new implant was inserted. Final prosthesis was
supported by four implants.

*None of the newly inserted implants were accounted for the study.

presented prosthetic screw loosening; 49 patients pre- adjusting the occlusion, and reinforcing the impor-
sented more than one mechanical complication. tance for the use of an occlusal nightguard (n 5 43
Forty-seven of these patients (52%) were bruxers patients previously diagnosed as heavy bruxers). No
diagnosed previously to the rehabilitation and 25 further mechanical complications occurred.
(28%) patients (non-bruxers) had an implant- Thirty-three patients (29.7%) presented mechani-
supported rehabilitation as opposing dentition. These cal complications in the definitive prostheses: Twenty-
problems were resolved by repairing the prostheses, three patients (20.7%) experienced a fracture of the
retightening the abutments and prosthetic screws,

TABLE 3 Marginal Bone Loss at 5-Years for

Patients Rehabilitated Through the All-on-4 Treat-
ment Concept Using Computer Guided Flapless
Surgical Approach
Axial Tilted
Overall Implants Implants

Average (mm) 1.30 1.34 1.27

Standard deviation (mm) 1.06 1.10 1.02

Number of implants 367 177 190
Frequencies N % N % N %
0 mm 37 7.0 21 11.9 16 8.4
0.1 to 1.0 mm 122 22.9 51 28.8 71 37.4
1.1 to 2.0 mm 138 25.9 71 40.1 67 35.3
2.1 to 3.0 mm 44 8.3 20 11.3 24 12.6 Figure 13 Boxplot representing the descriptive analysis of the
marginal bone loss at 5 years according to the type of implant
>3.0 mm 26 4.9 14 7.9 12 6.3
orientation. Box edges represent first and third quartiles of data
(25% and 75% of all data); the black line represents the median
Overall, axial implant specific and tilted implant specific descriptive (50% of data); whiskers represent all data not suspected of AQ10
and frequency values are reported. being outlier; dots and asterisk represents outlier value.
 Concept for Rehabilitation of Edentulous Jaws 9

definitive prosthesis (acrylic resin teeth/prosthesis), using computer guided surgery is effective in the
eight patients (7.2%) presented abutment loosening, long-term outcome in a sample with a high percent-
one patient (0.9%) presented abutment fracture, one age of patients who were bruxers or present systemic
patient presented prosthetic screw fracture and pros- conditions. The number of studies reporting the
thetic screw loosening (0.9%). Eighteen of these long-term outcome of full-arch rehabilitations sup-
patients (55%) were bruxers diagnosed previously to ported by immediate function implants inserted
the rehabilitation and the remaining 15 (45%) through flapless surgical protocols is scarce. The cur-
patients (non-bruxers) had an implant-supported rent study, with an overall 94.5% implant cumulative
rehabilitation as opposing dentition. These problems survival rate achieved after 7 years of follow-up,
were resolved by repairing the prostheses, replacing together with the 1.30 mm average marginal bone
the fractured abutments and prosthetic screws, loss at 5 years compares favorably with another study
retightening the abutments and prosthetic screws, using a flapless surgical approach: Polizzi and Can-
adjusting the occlusion, manufacturing (n 5 15 toni,21 in a study evaluating the outcome of 27
patients) and reinforcing the importance for the use patients treated (n 5 19 patients with full-arch reha-
of an occlusal nightguard (n 5 18 patients previously bilitations) with immediate fixed restorations of max-
diagnosed as heavy bruxers). No further mechanical illary implants inserted in both fresh extraction
complications occurred. sockets and healed sites using the NobelGuide system
Thirty-four patients (30.6%) with 64 implants reported a 97.3% survival rate and an average mar-
(12%) registered biological complications: Five ginal bone loss of 1.39 mm at 4 to 5 years.
Taking into consideration the marginal bone loss
patients (4.5%) and 9 implants (1.7%) presented soft
after 5 years of follow-up, the present study registered
tissue inflammation; 7 patients (6.3%) and 10
a significant difference between axial and tilted
implants (1.8%) presented implant infections. From
implants. Despite the statistical significant difference,
these patients, all situations were resolved through
the 0.07 mm difference during 5 years was considered
nonsurgical interventions (scaling, antibacterial appli-
negligible from a clinical significance point of view.
cation, and reinforcing the importance of an efficient
The descriptive analysis of the present study
oral hygiene) except for one patient with two
pointed to a possible deleterious influence of bruxing
implants that lost both implants. Twenty five patients
habits and smoking habits on the long term outcome,
(22.5%) registered peri-implant pathology, including
with patients that registered implant failures present-
local bone defects around the implant, pocket forma-
ing a high prevalence of bruxing or smoking habits.
tion, bleeding on probing, and mucosa inflammation.
Despite the real effect of bruxing habits on the
These episodes occurred in 19 bruxers (76%) and 11
osseointegration and survival of dental implants is
smokers (44%). The incidences were solved through judged to be still not well established, a risk ratio of
nonsurgical intervention (n 5 13 patients; 21 2.9324 and an odds ratio of 2.7125 were previously
implants), through surgical intervention consisting of reported for bruxing patients. Furthermore, patients
flap reflection, mechanical cleansing and decontami- with bruxing habits registered a high incidence of
nation of the implant surface with 0.2% chlorhexi- mechanical complications in both the provisional and
dine, removal of granulation tissue (n 5 3 patients, 4 definitive restorations and in the incidence of biologi-
implants) and was not resolved for 11 patients (19 cal complications. This trend was registered in previ-
implants) with 2 patients loosing 4 implants and 15 ous studies: a recent meta-analysis suggested bruxism
implants remaining in function. Three patients with as a contributing factor causing the occurrence of
eight implants experienced both outcomes (n 5 4 dental implant technical/biological complications
implants resolved versus four implants nonresolved). while playing a role in dental implant failure.26 Brux-
No further biological complications occurred. ing habits impact implant-supported rehabilitations
far beyond implant failure rates, as mechanical com-
DISCUSSION plications constitute a source of frustration demand-
The results of the present study indicate that full-arch ing a significant investment in terms of service,
prosthetic rehabilitation through the All-on-4 concept maintenance, costs, and time for both patients and
10 Clinical Implant Dentistry and Related Research, Volume 00, Number 00, 2016

clinicians. Additionally, the treatment of bruxism practice, with all measured maximum deviations
should be taken in consideration, as the nightguard within the safety margins recommended by the plan-
that is usually indicated as primary option, may not ning software.31 This may imply a dependence of the
be enough to prevent mechanical complications. This technique from the clinical experience of the rehabili-
premise is based on the etiology of bruxism that is tation team, with a corresponding learning curve
considered to be multifactorial.27 A previous review effect.31
reported that bruxism is mainly regulated centrally, The limitations of this study include the involve-
with factors such as smoking, alcohol, drugs, diseases, ment of a single center, the lack of a control group,
and trauma as possible aetiological agents of brux- and the lack of multivariable analysis; while the
ism,27 deeming a much more in depth and multidis- strengths rely on the low lost to follow-up date.
ciplinary approach for the treatment of bruxism. Future studies should investigate the impact of poten-
Conversely, smoking habits constitute a risk factor for tial risk factors such as bruxing and smoking habits
implant failure with a high impact on implant failure on long term survival and marginal bone loss con-
rates: A recent meta-analysis28 reported a risk ratio of trolling for the presence of other potential risk factors
2.01 in dental implant failure rates for smokers, or confounders.
together with a higher risk of postoperative infections
as well as marginal bone loss. Given the descriptive CONCLUSION
nature of the statistical analysis in the present study, Within the limitations of this study, it is possible to
these associations should be further investigated using conclude that full-arch prosthetic rehabilitation
multivariable analysis. through the All-on-4 concept using computer guided
The present report describes the long term out- surgery (NobelGuide) is viable with high long-term
come of a protocol implementing combination of survival outcomes.
computer guided surgery (minimally invasive, less
chair time, reduced post-surgical period), and the CONFLICTS OF INTEREST
All-on-4 treatment concept (total edentulous graftless Armando Lopes: previous grant support and educa-
solution in immediate function). The benefits of flap- tional fees by Nobel Biocare Services AG; Paulo Mal o
less surgery include a lower pain perceived by the is currently a consultant for Nobel Biocare; previous
patients as reported previously, with patients under- grant support and educational fees by Nobel Biocare
going flapless surgery registering lower pain scores Services AG; Miguel de Ara ujo Nobre: previous grant
and less painkillers intake when compared to the flap
support by Nobel Biocare Services AG; Elena Sanchez-
approach.29
Fernandez: No conflict of interest; In^es Gravito: previ-
Nevertheless, there are limitations to consider
ous grant support by Nobel Biocare Services AG.
when implementing this flapless implant protocol:
Anatomically, insufficient bone volume, presence of REFERENCES
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