All-on-X dental implants are becoming increasingly popular in the dental field. The procedure allows dentists to replace multiple teeth or entire arches with just a few implants. All-on-4^® is the Nobel Biocare-trademarked name for the treatment, but all-on-X is the commonly accepted generic term. The “X” refers to the number of implants, which can be four or more, all the way up to eight. 

The treatment approach was developed by Portuguese dentist Paulo Maló,¹ and it has become widely recognized by patients and dental providers in the United States. With information widely available on this treatment and some patients even requesting it, many dentists are wondering if all-on-X implants could be a good fit for their practices and their patients. 

Is the All-on-X Procedure Right for Your Practice? 

The all-on-X implant treatment can be a useful and lucrative addition to a dental practice, but it is important to understand the investment in time and money it takes to successfully introduce it. “It’s not a simple protocol by any stretch of the imagination,” said Timothy F. Kosinski, DDS, MAGD, AGD editor, dental educator and implant dentist practicing in Bingham Farms, Michigan. 

Practice Fit 

First, dentists who are interested in potentially adding all-on-X procedures should evaluate their current practice to determine how this treatment could fit. All-on-X implants are within the purview of general dentists, but they may be a better fit for practices that already have a surgical emphasis. “You can’t be doing fillings, cleanings, checkups, crowns and root canals back and forth all day and just pop in real quick for an all-on-X procedure,” said Todd B. Engel, DDS, founder and owner of Engel Institute in Charlotte, North Carolina. “This needs a dedicated nurturing and strategic focus to get acceptable results.” 

Training and Equipment 

The procedure requires an initial surgical skill set, ongoing education and equipment, as well as careful, appropriate patient selection. And, with any new technique, it will take dentists time to hone their skill sets. Engel, who teaches dentists how to perform the all-on-X procedure, recommends anyone who wants to learn this technique be fully committed, patient and critical of their own abilities and limitations. 

There are a number of programs that train dentists on this technique, including those at the Engel Institute. Once they find the right course, dentists will need to consider the costs associated with their chosen program as well as travel expenses. “The initial investment to do these high-end procedures could be in the $20,000 range. However, you’re making all of that up in one or two cases,” said Kosinski. 

The investment in education may also include a dental practice’s staff, not just the dentist who will be performing the treatment. “This is something that’s truly a four- to six-handed procedure,” said Engel. Bringing staff members to the educational courses can be invaluable to smoothly integrating all-on-X into a practice. Naturally, different educational courses will have different approaches. Some will offer didactic courses and hands-on training with models, while others will pair didactic training with live patients. “We all learned in dental school on live patients,” said Engel. He stressed the importance of doing the same when learning how to perform all-on-X. 

Dental implants have an element of art in addition to the science of planning and placement. Educational courses teach dentists the guidelines for the procedure, but each patient will be different and require an individualized approach. The learning curve does not end when a dentist completes a training course. The ability to perform the all-on-X technique develops and improves over time. “To become proficient in this surgery, it will take time and repetition in your practice in order to feel like it’s a routine type of procedure,” said Engel. 

Whether or not a dentist brings team members to the training course, they will be a part of the learning process in the practice. “It is important to have that strong team behind you as you develop your skills,” said Kosinski. 

Education is the first part of the investment necessary to bring all-on-X to a dental practice. Dentists will also need to invest in equipment and materials. All-on-X implants require handpieces, motors, surgical instruments, prosthetic instrumentation and more.² Cone-beam computed tomography (CBCT), the largest piece of equipment needed, is an essential element of implant planning for all-on-X cases. “The advent of CBCT analysis really changed the way we can diagnose and plan our implant cases,” Kosinski explained. “We can now virtually design not only the ideal placement of the implants in the available hard tissue — we can also virtually design the final teeth.” 

Introducing All-on-X Implants to a Practice 

Performing all-on-X cases is a team effort that extends beyond the practice team. Dental labs are important elements in successfully completing cases. Many labs today regularly work with practices on implant procedures, but finding a lab that meets the practice’s needs for all-on-X procedures is important. “You have to have a lab that has the acumen to bring your case to life,” said Engel. “Labs are important not only for the long-term prosthetic fit and function but also for the beauty. Get them involved early on, and strategize the selected case before starting in order to minimize or eliminate problems later.” 

Once dentists have the necessary skills and equipment, trained staff and an established dental lab relationship, they can begin to offer all-on-X procedures in their practices. But, integrating this treatment into a practice takes careful planning and time. “It’s very important that doctors take the time to diagnose and plan, meaning utilizing CBCT, working with laboratory technicians and visualizing the finished case before they ever start,” according to Kosinski. 

Dentists who have been performing all-on-X for years can complete the initial surgical procedure in one or two hours, but a dentist’s first case might take up to seven hours, according to Engel. “Make your first three cases your only cases for those days, and schedule them when you’re at your best,” he suggested. 

It is important to recognize that skills will improve over time with such a complex procedure. “I tell doctors to be realistic. Whether this is your first, second, third, eighth or 12th time doing it, you are not going to have the same results you would have if you have done 200,” said Engel. “It is critical that you learn from your mistakes each and every time to understand the ‘whys’ and become more proficient case by case.” 

The all-on-X procedure can significantly increase a practice’s revenue. “The ROI on the treatment itself is probably bigger than anything we do,” said Engel. 

“Implant dentistry in general is certainly one of the most financially rewarding therapies we offer,” said Kosinski, “and breaking down the dentist’s cost helps us better prepare our patients to budget themselves properly. Average fees for surgical and prosthetic construction for implants vary depending on several factors: overhead, clinician competency, time needed to perform the procedures, implant cost, prosthetic component cost and laboratory charges.” 

As far as setting up the practice to perform all-on-X procedures, assuming the practice already owns a CBCT machine, Kosinski says the investment in purchasing the surgical supplies as well as an inventory of implants often totals in the $10,000 range, “but this initial investment is paid off after only a few cases.” According to Kosinski, the costs to the dentist per case are as follows: 

• Dental implants: $160–$385 each. 
• Impression copings: $40–$50. 
• Lab charges for custom abutments in titanium or zirconia: $200–$300 each. 
• Zirconia crowns: $120–$155 each.  
• Soft-tissue model work and articulation: $90. 
• Full-arch impressions: $40 each. 
• Extractions, grafting, membranes, CBCT scans and surgical guide fabrication: $550–$600. 
• Overhead cost: Approximately $400 for a single implant, although this cost will be greater for all-on-X treatment given the complexity of the planning and surgical time involved. 

While these costs will multiply based on factors such as the number of implants used for an all-on-X case as well as the prosthetic materials used for a full-arch prosthesis versus a single crown, they should be useful in helping calculate the dentist’s costs versus the profit generated by the procedure. (For information on purchasing a CBCT machine for your practice, see “CBCT Purchasing Guide: How to Choose the Perfect Machine” in the February 2020 AGD Impact.) 

Because all-on-X is such a high-ticket treatment, dentists should also consider any credit responsibilities they may take on per case when the patient decides to take on a loan to pay for treatment. “If the patient elects to get credit to pay for procedures, the dentist is paid up front but is charged 5.9%–14.9% of the contract amount depending on the length of the contract offered/selected,” said Kosinski. “This is a significant cut in percentage of profit, but it’s worth it if the case is accepted.” 

“Even with the time scheduled for surgery and prosthetics, the hourly production for the dentist may increase by incorporating dental implant therapy,” said Kosinski. “The dentist can work less hours to achieve the same financial goals or increase revenue by maintaining the same volume of patient treatment hours.” 

But, the higher ROI comes with a risk. All-on-X is a complex surgical endeavor. Dentists must have an intimate understanding of patients’ bone quality, periodontal habits and overall health. The complexity of the procedure means that there is potential to cause significant harm to patients. Choose cases carefully, particularly when first introducing all-on-X to a practice. “If you’re doing your first implant, we advise you start in the back of the mouth, where you can make little mistakes and not affect the patients’ esthetics,” Kosinski advised. 

Recognizing the risk that comes with this procedure means dentists not only need to be comfortable and confident with their skill levels, but they also need to be prepared to make proper patient selection and to handle case management for a procedure that ultimately takes months to complete. 

Is the All-on-X Procedure Right for Your Patients? 

How do dentists determine if a patient is a candidate for all-on-X implants? The answer is not always simple, but edentulous patients are natural starting points. Age is a common reason that patients become edentulous. “People are outliving their teeth,” said Engel. More than 36 million people in the United States are living without teeth, and 120 million are missing at least one of their teeth, according to the American College of Prosthodontists.³ 

Candidate Evaluation 

While age is a major cause of edentulism, people can also lose their teeth due to factors like neglect, addiction, trauma or genetics. All-on-X is designed to be a less invasive, more cost-effective treatment option for patients missing multiple teeth because it requires fewer implants. 

Dental practices located in areas with large geriatric populations, such as Arizona or Florida, have access to significant patient pools. Many older patients have the financial means to afford all-on-X implants, but geriatric patients also come with other health concerns that can impact their candidacy. Many older patients are likely on some kind of stabilization medication for conditions like high blood pressure, chronic obstructive pulmonary disease, diabetes, osteoporosis or cancer, according to Engel. These conditions and medications affect a patient’s risk profile. “I don’t think you should start with patients who have compromised situations that are going to stretch your ability,” said Kosinski. 

Taking a comprehensive health history is essential before accepting a patient for an all-on-X procedure. “Everything that they check on that health history is another strike against your success because it all has to do with how they bleed,” said Engel. Carefully considering each patient’s comorbidities and the provider’s comfort level can help dentists during the patient selection process. 

Some younger patients may be candidates for all-on-X. While these patients will likely be healthier than elderly candidates, they may also be more demanding, according to Engel. Older patients may simply want a functional set of teeth and an alternative to dentures, while the cosmetic aspects of the treatment may be more important to younger patients, who will likely live with the implants for a longer period of time. 

Edentulous patients may want all-on-X implants and specifically seek out dentists who perform the procedure, but that does not mean they are automatically candidates for this treatment. “Not everyone who wants permanent, fixed prostheses is a candidate for this procedure,” said Kosinski. “Our treatment decisions cannot be dictated by what the patient wants. They have to be dictated by what we can provide the patient.” 

Patient desire is an important aspect, particularly because the procedure requires a lengthy healing process, but it is not the only determining factor. Certain physical limitations should be considered beyond a patient’s overall health. “First and foremost, there has to be enough interocclusal distance. There has to be enough space to allow for the implant and the final prosthesis,” said Kosinski. Vertical interocclusal space for dental implants should be 12–16 millimeters, according to Kosinski. Additionally, if the patient does not have adequate bone volume vertically and horizontally, all-on-X implants are not the right solution. The use of CBCT can help with this aspect of case planning. 

If neglect or damage has rendered a patient’s mouth beyond the scope of all-on-X implants, general dentists may not be able to treat the patient, but they can refer that patient to another provider, such as an oral and maxillofacial surgeon. 

Patient Communication and Case Management 

The all-on-X treatment process is not completed in a day. During the initial procedure, a dentist will remove any damaged teeth remaining in the arch being prepared for the all-on-X implant screws.⁴ The implants are placed, and temporary teeth are then screwed in, which the patient will use for three or more months while healing after the procedure. Once integration takes place, the dentist can begin the process of designing the permanent teeth. During the healing process, patients will need to follow strict instructions to maximize the chances of a successful outcome. “There’s a healing period, and it’s uncomfortable. Patients need that explained to them very clearly before you start,” said Kosinski. 

Planning an all-on-X implant case requires open and honest communication with the patient. The work dentists will be doing in the mouth is only part of the process. “I already see the finished case when they first come in. For me, the most important part is interviewing the patient,” said Engel. “The mouth is where I work; the person is what I treat.” 

Getting to know patients helps dentists understand how their mouths have reached their current conditions and what they expect following all-on-X implants. Establishing this line of communication is foundational to creating an individualized treatment plan and managing patient satisfaction and outcomes. “The bigger the check that they write, the higher the expectations are going to be,” Engel explained. A practice’s staff members also need to be prepared to communicate with all-on-X patients. For example, front office staff should be comfortable and have the knowledge to answer financial questions about the procedure, which can cost $15,000 to $34,000 for one arch, depending on the materials used, the number of implants placed and the practice location.⁵ 

Patient Concerns 

Patients are increasingly familiar with the all-on-X procedure, educated by the plethora of information available online. But, familiarity with the procedure does not mean they understand the full ramifications of these long-term prostheses. “Our job is to educate and instruct and make people aware of what we can do,” said Kosinski. “We have to get away from the marketing that everybody has to have teeth right away.” 

Form, function and esthetics are likely the main goals for any patient seeking all-on-X implants. Dentists can achieve these goals, but patients must understand that these teeth are still replacements that cannot exactly replicate the feel and experience of having natural teeth. All-on-X implants can affect speech and proprioception,⁶ which may or may not be issues that patients have thought about prior to getting into the dentist’s chair. Explaining these issues can help patients determine whether or not to move forward and accurately shape their expectations if they do want to proceed. 

Recovery Process 

Patients will need to be on a completely liquid diet for seven days and a soft diet for three months following the procedure, according to Kosinski. They will leave the dentist’s office after the initial surgical procedure with prefabricated, temporary teeth fixed to the implants. After healing is completed, the fixed implant bridge or bridges can be placed. 

Once the patient leaves the practice with permanent teeth, they will need to know how to care for the bridge and maximize its lifespan. As a part of all-on-X patient education, a dental practice can help patients develop an oral hygiene routine that includes regular flossing and Waterpik^® use.⁷ 

Many patients have the misconception that dentistry will last forever, according to Kosinski. It is important to emphasize that implants still need regular checkups, just like natural teeth. Recommend recall visits at least twice a year for all-on-X patients.⁷ 

All-on-X implants are not for every dental practice or for every patient. Dentists, whether they have just started to practice or have been practicing for years, need to be committed to learning and honing a very challenging skill set if they want to introduce the procedure to their practices. They also need the communication skills to evaluate and find patients who meet the physical requirements and have the commitment to go through the procedure. While the financial benefit to dental practices is clear, the clinical challenge and procedure outcome can be another incentive. “It could be really rewarding for the clinician, and it could be life-changing [for the patient],” said Engel. 

Carrie Pallardy is a freelance writer and editor based in Chicago. To comment on this article, email impact@agd.org. 

References 
1. Taruna, M., et al. “Prosthodontic Perspective to All-on-4^® Concept for Dental Implants.” Journal of Clinical and Diagnostic Research, vol. 8, no. 10, Oct. 2014, pp. ZE16-ZE19. 
2. “Full Arch Rehabilitation: All-on-4™ Restorative Steps Roadmap for Success.” Nobel Biocare, iddentallab.com/wp-content/uploads/2017/02/Nobel-Biocare-All-on-4-quick-reference-guide.pdf. 
3. “Facts & Figures.” American College of Prosthodontists, gotoapro.org/facts-figures/. 
4. Gould, Ethan. “Why the All on X Treatment Concept Is a Win for Everyone.” Ripe Global, 24 March 2021, ripeglobal.com/blog/why-the-all-on-x-treatment-concept-is-a-win-for-everyone-w/-dr-pedro-rodrigues. Accessed 5 Jan. 2022. 
5. A., Alison. “New Teeth in One Day (All on 4 or 6) – Cost & Procedure.” Dental Implant Cost Guide, 16 May 2020, dentalimplantcostguide.com/all-on-4/. Accessed 5 Jan. 2022. 
6. Hodges, John. “When Is All-on-4 the Best Option? 5 Factors to Consider When Creating Your Dental Treatment Plan.” Dentistry IQ, 11 Nov. 2021, dentistryiq.com/dentistry/implantology/article/16365915/when-is-allon4-the-best-option-5-factors-to-consider-when-creating-your-dental-treatment-plan. Accessed 5 Jan. 2022. 
7. Hodges, John. “Hygiene Protocol for Full-Arch All-on-4 Fixed Bridges.” Dentistry IQ, 27 June 2018, dentistryiq.com/dentistry/implantology/article/16367646/hygiene-protocol-for-full-arch-allon4-fixed-bridges. Accessed 5 Jan. 2022.