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Treatment Algorithm · Module
Full-arch immediate loading: All-on-4 / All-on-X candidacy
Selecting between immediate fixed full-arch, a staged protocol, or an overdenture alternative for the edentulous or terminal-dentition jaw. Insertion torque and cross-arch splinting are the gatekeepers for same-day loading.
Use: Full-arch case selection
Gatekeeper: Insertion torque
Framework: All-on-4 / ITI
01 — Concept
Candidacy, configuration, and provisional
The All-on-4 concept rehabilitates an edentulous jaw with four implants — two axial anterior and two tilted posterior — supporting an immediate cross-arch fixed provisional. Additional implants (All-on-X, 5–6) are used in larger or compromised arches.
Inputs
Candidacy factors
- Adequate inter-foraminal / pre-maxillary bone volume
- Opposing dentition and occlusal load
- Parafunction (bruxism) screening
- Oral hygiene and maintenance capacity
Configuration
Implant number & tilting
- 4 implants: 2 axial + 2 tilted (≈30–45°) posterior
- Tilting avoids sinus / nerve, lengthens A-P spread
- Reduces cantilever length
- All-on-X (5–6) for long arches / softer bone
Restoration
Immediate provisional
- Screw-retained cross-arch splinted fixed provisional
- Delivered within 24–48 h
- Limited / no cantilever; controlled occlusion
- Soft diet through osseointegration
02 — Decision Pathway
Immediate vs staged vs overdenture selector
Primary stability at placement drives the loading decision. Achieved insertion torque across the implants, the splintable configuration, and patient risk determine whether a same-day fixed prosthesis is appropriate.
Tap the scenario that best matches the case at surgery.
Step 1 — What stability and risk profile is present?
FAVORABLE
High torque, splintable, low risk
All implants ≥35 Ncm; good A-P spread; no severe parafunction.
GUARDED
Sub-threshold torque or risk
One or more implants below threshold, or bruxism/medical risk.
ALTERNATIVE
Limited bone / patient factors
Insufficient bone for fixed, or patient prefers removable.
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03 — Quick Reference
Requirements for immediate full-arch loading
Same-day fixed loading depends on multiple conditions being met together. A single unmet requirement should prompt stepping down to a staged protocol.
| Requirement | Target for immediate load | Defer / step down |
|---|
| Insertion torque | ≥35 Ncm (≥30 acceptable when splinted) | <30 Ncm on any key implant |
| Splinting | Rigid cross-arch splinted provisional | Non-splinted / inadequate rigidity |
| Cantilever | Minimal; ≤1.5× A-P spread, avoid overload | Long cantilever / heavy posterior load |
| Occlusion | Controlled, no parafunction | Bruxism / heavy opposing dentition |
| A-P spread | Wide; tilted posteriors maximize it | Narrow spread, poor distribution |
Reference
Sources & clinical disclaimer
For licensed clinicians — educational use only. This algorithm summarizes published concepts and consensus and is not a substitute for individual clinical judgment, examination, or the standard of care in your jurisdiction. Torque thresholds and prosthetic protocols vary by implant system — follow manufacturer instructions.
- Maló P, Rangert B, Nobre M. "All-on-Four" immediate-function concept with Brånemark System implants for completely edentulous mandibles: a retrospective clinical study. Clin Implant Dent Relat Res. 2003;5(Suppl 1):2–9.
- Gallucci GO, Hamilton A, Zhou W, et al. Implant placement and loading protocols in partially edentulous patients — ITI Consensus. Clin Oral Implants Res. 2018;29(Suppl 16):106–134.
- Soto-Penaloza D, Zaragozí-Alonso R, Penarrocha-Diago M, Penarrocha-Diago M. The all-on-four treatment concept: systematic review. J Clin Exp Dent. 2017;9(3):e474–e488.
Last reviewed: June 2026 · Next review due: June 2027 · Version 1.0