J Oral Maxillofac Surg

68:2520-2527, 2010

The All-on-4 Shelf: Maxilla

Ole 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, establish
maximum anterior posterior spread of implants, and to avoid pneumatized sites. Unlike a reduction
alveloplasty for denture placement, the All-on-4 shelf enables optimal surgical prosthetic management of
implant placement for the fixed hybrid prosthesis.
2010 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 68:2520-2527, 2010
All-on-4 treatment of the maxilla requires presurgical
prosthetic treatment planning for high smile line esthetics to be acceptable.1,2 This requires bone removal in the vast majority of dentate or edentulous
patients who undergo full arch treatment. This is
particularly important in the female population, who
have greater gingival display to avoid exposure of the
restoration margin during animation.3,4 Because of
this, the surgeon is faced with the dilemma of removal
of supporting bone for dental implant placement,
often to such an extent that axial implant placement
becomes impossible without significant bone grafting, especially sinus floor augmentation.5-7
Since the Sinus Consensus Conference of 1996,8
most treatment plans involving atrophic maxillae
have involved sinus bone grafting and placement of
multiple posterior implants. However, within the past
decade, a simple innovation, that of nonaxial implant
placement, with implant placement angulations of up
to 30, has led to a new concept, that of graftless
surgical management.9-13
Surgical care for the maxilla, therefore, stands at a
crossroads, that of subtraction of bone mass versus
addition of bone graft for osseointegration. Driving
this controversy is the desire for immediate function,
something nearly impossible to do when significant
bone 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:
Implant Dentistry Associates of Colorado, 8200 East Belleview
Avenue, Suite 520E, Greenwood Village, CO 80111; e-mail:
[email protected]
2010 American Association of Oral and Maxillofacial Surgeons

0278-2391/10/6810-0022$36.00/0
doi:10.1016/j.joms.2010.05.082

The use of angulated implants for short-span

bridges or even long-span reconstructions to avoid
bone grafts has now been used for 10 years, although
many of these were not immediately loaded.13-16
However, with the advent of the All-on-4 immediate
function, this became consistently possible using a
graftless protocol.
Immediate function is based on earlier studies, sometimes using up to 10 implants per arch until biomechanical analysis demonstrated that when 2 implants are
placed sufficiently close together, they function as if
there were only 1 implant present (B. Rangert, personal
communication, March 2007). This discovery first became important in the mandible, where fixed denture
prosthetics using 5 implants had been (and still is) prescribed as optimal. However, when 5 implant distribution was studied biomechanically it was found that the
middle implant took no measurable load in function
and therefore could be eliminated. This same biomechanical finding was observed for the maxilla.17-21
Another important aspect of maxillary care is extraction of diseased teeth followed by simultaneous
implant placement with immediate function.22-24 The
surgeon is therefore faced with the challenge of removing failing teeth, trimming back bone stock,
avoiding bone grafting procedures, inserting dental
implants at angulations, and placing the patient into
an immediately loaded provisional restoration; all of
these procedures are counterintuitive to traditional
surgical management, if not biomechanical understanding of maxillary treatment.25-27 Antemolar reduction in the number of implants, restricted to available
bone anterior to the sinus cavities, further complicates the surgical difficulty.28
Given this controversy, 3 questions must be
asked in the face of reduced bone stock: 1) Can
osseointegration occur without significant grafting?
2) Can full arch prosthetic loading be obtained with
only 4 implants placed at angulation? 3) Can imme-

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JENSEN ET AL

FIGURE 1. A, Bone leveling of the alveolus creates a new alveolar plane that functions as a shelf on which to place dental implants. The
All-on-4 technique must take advantage of available bone, which is best observed using the All-on-4 shelf approach for which angled implants
and compensating angled abutments are placed. B, The All-on-4 shelf provides several advantages for the surgical-prosthetic team,
including determining optimal sites for implant placement and helping to avoid pneumatized structures to derive maximum anteriorposterior spread.
Jensen et al. The All-on-4 Shelf: Maxilla. J Oral Maxillofac Surg 2010.

diate load biomechanics be established using the

limited bone stock of the anterior maxilla?
The somewhat oblique answer to these questions
is found in the development of a simple surgical
solution in which bone is leveled by prosthetic
prescription creating a flat surface termed the Allon-4 shelf (Fig 1A). Placed on this shelf are implants directed at angulations emerging from specific end points likely to gain primary fixation (Fig
1B). The implant positions on the shelf are based in
part on compensating angled abutments that must
emerge through tissue at or lingual to the midocclusal axial plane.29 The shelf facilitates the anterior-posterior (A-P) spread maximum by identifying
the anterior sinus wall and lateral nasal wall.14

There are numerous other advantages to using a

shelf approach, which affirm that adequate osseointegration capacity of only 4 load-bearing implants can biomechanically sustain immediate provisionalization.
Here, then, are 10 technical advantages for the
surgical-prosthetic team to consider in the use of the
maxillary All-on-4 shelf:
1. Creates prosthetic restorative space
2. Establishes the alveolar plane
3. Shelf width determines implant diameter selection
4. Shelf reduction proximates piriform bone fixation

2522

FIGURE 2. A clear acrylic bone reduction guide ensures there is

adequate restorative space for abutments and titanium bar housed
within the prosthesis.
Jensen et al. The All-on-4 Shelf: Maxilla. J Oral Maxillofac Surg
2010.

THE ALL-ON-4 SHELF: MAXILLA

FIGURE 4. Bimaxillary All-on-4 surgery should have at least

22 mm of interarch space for the final provisional restoration. The
planes should be parallel front to back.
Jensen et al. The All-on-4 Shelf: Maxilla. J Oral Maxillofac Surg
2010.

5. Shelf findings suggest convergent or divergent

implant placement strategy
6. Establishes optimal osseous sites for implant
placement
7. Defines secondary fallback sites for implant
placement
8. Exposes palatal plate cortical anatomy for implant fixation
9. Facilitates posterior implant placement (A-P
spread) in relation to anterior sinus wall
10. Provides bone stock for bone grafting

Prosthetic Restoration Space

One of the most difficult surgical prosthetic errors
to manage is insufficient interocclusal space, that is,
inadequate interrestorative space between opposing
arches.27,30,31 This can be due to inadequate bone
removal in full arch cases. Therefore, the most important function of the All-on-4 shelf is adequate bone

FIGURE 3. The provisional appliance can be windowed to

determine adequate bone removal and used to determine appropriate abutment angulation.
Jensen et al. The All-on-4 Shelf: Maxilla. J Oral Maxillofac Surg
2010.

reduction, especially in dual-arch cases which require

22 mm of interarch prosthetic space. The use of bone
reduction guides (Fig 2) or windowed denture guides
(Fig 3) helps facilitate adequate bone removal.
When the junction of the prosthesis and tissue is
visible, there is esthetic failure. A flange is required to
hide the junction. Use of a flange on a fixed prosthesis
creates an oral hygiene access problem. By locating
the prosthesis tissue junction a minimum of 3 mm
beyond the visible gingiva, the surgeon and restorative dentist are assured of hiding the prosthesistissue junction. This is perhaps the greatest advantage
of using the All-on-4 shelf. Although not yet published, alveolar reduction to this extent has not led to
bone-level instability, greater tendency for bone loss,
or gingival hyperplasia around implants.

Alveolar Plane
Using the interpupillary plane as a guide, a new
alveolar plane is established, which avoids a cant in
the positioning of implants and creates level placement of implant platforms; this is difficult to do without creating the All-on-4 shelf.16,32 When upper and
lower jaw shelves parallel each other (Fig 4), there is
less likely to be prosthetic problems with implant
positioning.
The alveolar plane must also be level front to back.
A common error in making the shelf is to taper the
shelf too much toward the alveolar crest posteriorly,
leaving the prosthodontist with inadequate interarch
space. This leads to an alligator bite effect and can
result in a thin prosthesis in the bicuspid-molar region. Therefore, the All-on-4 shelf must not only create an alveolar plane parallel to the interpullary line

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JENSEN ET AL

FIGURE 5. A thin residual maxillary alveolar process will split

unless small-diameter implants are used as shown. The shelf width
helps determine implant diameter selection.
Jensen et al. The All-on-4 Shelf: Maxilla. J Oral Maxillofac Surg
2010.

but a plane, when viewed laterally, that is parallel to

Frankfort horizontal.

FIGURE 7. M-Point, the area of maximum lateral pyriform rim

bone mass above the nasal fossa, enables using the M-shaped
(when viewed on Panorex) placement strategy, including fixation of
longer implants placed at a favorable distribution for anteriorposterior spread.
Jensen et al. The All-on-4 Shelf: Maxilla. J Oral Maxillofac Surg
2010.

Piriform Rim Proximation

Shelf Width
After bone reduction, the width of the shelf becomes defined at the level of the desired implant
platform vertical dimension. Alveolar concavities become evident, and optimal diameter of implants can be
assessed.33 When the ridge is thin (Fig 5), small-diameter
implants are placed; if it is wide and osteoporotic, a
wide-diameter implant may be prescribed.34
Midalveolar constriction, the so-called hourglass effect, seen on cross-sectional computed tomography in
the anterior maxilla can sometimes be pronounced. If
the alveolar plane is established at the constriction, a
narrow implant is needed to avoid fracturing the alveolus. The width of the shelf is another factor that
can be addressed at the time the shelf is made by
sometimes removing more bone than necessary to
optimize the width of implants used.

When there is alveolar crest atrophy, vertical dimension may still be present but at reduced width
such that reduction of height will not only widen the
shelf but bring the created alveolar plane in closer
approximation to the piriform rim, the most desirable
site for implant fixation using an M-4 placement strategy (Fig 6).35 Shelf reduction then determines the
position and length of posterior implant placement
with a maximum available implant length of 18 mm
(Nobel Biocare, Zurich, Switzerland). Inadequate
bone reduction may force the clinician to anteriorize
the placement of the posterior implant or even prevent adequate fixation. Optimal implant fixation for the
atrophic maxilla is frequently obtained using an M-4
placement strategy fixing implants at what has been
called M-point (Fig 7), the point of maximum bone mass
at the lateral piriform rim just above the nasal fossa.35
Even in highly atrophic cases, the posterior implant can
often be placed 10 mm or more posterior to this point.

Implant Angulation Strategy

FIGURE 6. Using an angulated placement strategy, paranasal

cortical bone is able to anchor an implant placed at some distance
away. When subnasal bone is reduced in height, anterior implants
are angled posteriorally to engage bone in this same area.
Jensen et al. The All-on-4 Shelf: Maxilla. J Oral Maxillofac Surg
2010.

More than any surgical procedure, the All-on-4

shelf helps determine the angulation strategy employed for implant placement. Long face syndrome
patients, after shelf reduction, may still have adequate bone for axial placement of implants,36
whereas short face patients after bone reduction
require all implants to be angled, usually using the
M-4 strategy.35,37

Optimal Osseous Implant Sites

After alveolar crest reduction, the surgeon is often faced with the prospect of implant placement

2524

THE ALL-ON-4 SHELF: MAXILLA

into marrow space, often a difficult task to do and

still obtain insertion torque values adequate for
immediate load. Therefore, computer guidance systems are inadequate to the task, having no ability to
assess bone reduction or implant torque.34,38 Alternatively, the shelf provides the surgeon with an
opportunity to specifically select optimal sites for
placement without the constraint of computer generated guides.39 This applies especially to dental
extraction cases in which there are often multiple
defects present or created during the course of
extraction. Following bone reduction, the surgeon
is able to identify either visually or tactically the
best load bearing sites possible for implant placement.

Determine Fallback Implant Sites

Before preparation of final implant sites, secondary,
or fallback, sites are assessed. Oftentimes, there are a
limited number of sites available, and therefore, it is
important for the surgeon to address this ahead of
time. In the process of creating 4 receptor sites, one
or more sites may need to be abandoned because of a
lack of bone quality or quantity for fixation. A sequential (and careful) preplanned placement strategy with
secondary fallback sites can salvage treatment for an
immediate-load strategy best facilitated by use of the
All-on-4 shelf.
This process of selecting sites is important lest the
surgeon paint himself or herself into a corner. The
first site selected is the posterior site, not the anterior
site. If that site does not work, moving slightly forward is the secondary site. After posterior implants
are placed, anterior sites are selected in a distributed
fashion.

FIGURE 9. The All-on-4 shelf frequently exposes the sinus cavity or

brings it into close approximation such that the exact visual location
of the anterior sinus wall (S-point) can be identified to place the
posterior implant as far back in the arch as possible without subjecting the patient to sinus floor bone grafting.
Jensen et al. The All-on-4 Shelf: Maxilla. J Oral Maxillofac Surg
2010.

Palatal Cortical Plate

Although a computed tomographic scan can delineate width of the palatal plate,39,40 after bone reduction, the specific site of placement is more easily
assessed for cortical thickness because implants will
likely need to engage the palatal plate because of the
complete loss of facial bone that is often seen in
periodontally involved dental extraction cases.40 Generally, the palatal plate can be difficult to engage, but
with shelf reduction, it usually is clear to the surgeon
how best to gain access through the alveolus and
engage at least a portion of the palatal cortex. The
thicker the plate, the more likely adequate insertion
torque will be obtained (Fig 8).41

Posterior Implant Placement and

Anterior-Posterior Spread
FIGURE 8. The All-on-4 shelf established a visual cue by exposing
the palatal cortical bone thickness for optimal placement for high
insertion torque implants.
Jensen et al. The All-on-4 Shelf: Maxilla. J Oral Maxillofac Surg
2010.

The All-on-4 shelf clearly shows the maximum allowable posterior position where the posterior implant can be placed because shelf reduction frequently exposes the sinus membrane, which can then

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JENSEN ET AL

where implants must bypass to not traverse the sinus

cavity and where posteriorly, no load-bearing bone is
present36 (Fig 10A).
The vertical alveolar bone available from S-Point to
the alveolar plane of the All-on-4 shelf often determines how far posteriorly the implant can be inserted. For example, if there is 5 mm of bone from
S-Point to the All-on-4 shelf, implant insertion can
usually be accomplished about 5 mm posterior to
S-Point when the implant is angled 30 (Fig 10B).
When S-Point and M-point converge, A-P spread is
reduced proportionately; when there is confluence
between the nasal fossa and maxillary sinus (1 cavity),
no fixation points are available and the alveolar Allon-4 procedure may be contraindicated in favor of a
zygomatic All-on-4 strategy.42,43

Bone Stock Source

Although the All-on-4 procedure is considered a
graftless procedure, it often is not.13 Bone removal
in creation of the All-on-4 shelf is ground up for use
in grafting fenestrations, extraction wall defects,
cystic cavities, exposed implant threads in narrow
alveolar placements, and sometimes even for sinus
grafting.44-46

FIGURE 10. A, When the shelf is well away from the sinus, the
most anterior sinus deflection (S-point) is identified using a lateral
antrostomy burr hole. The space from this point to the shelf is
measured. This same distance posterior of the S-point perpendicular should be the entrance location of the posterior implant site
(when placed at 30) to avoid the sinus. B, The vertical alveolar
bone available from S-Point to the alveolar plane of the All-on-4
shelf often determines how far posteriorally the implant can be
inserted.
Jensen et al. The All-on-4 Shelf: Maxilla. J Oral Maxillofac Surg
2010.

be directly visualized (or reflected) for placing the

implant just anterior to the anterior sinus wall (Fig 9).
When the sinus is not exposed, a lateral punch hole
into the sinus is made at the most anterior inferior
extent of pneumatization to serve as a guide for implant placement and angulation.14 This point is called
S-Point, for sinus point, in All-on-4 nomenclature. This
is the most anterior inferior projection of the sinus

FIGURE 11. Variants of the natural orifice of the nasolacrimal duct

that may occur intraossesously below the inferior turbinate and can
be close to piriform rim bone used to place M-shaped distribution
implants. Care should be taken not to cause nasolacrimal damage
inadvertently when the duct is near M-point for All-on-4 implant
placement.
Jensen et al. The All-on-4 Shelf: Maxilla. J Oral Maxillofac Surg
2010.

2526

THE ALL-ON-4 SHELF: MAXILLA

likely to be answered affirmatively by use of the

All-on-4 shelf.
In summary, the All-on-4 shelf is a surgical prosthetic tool not unlike reduction alveoplasty for denture placement that aids in optimal surgical-prosthetic management of the All-on-4 restoration (Figs
12A,B). After the surgeon can accept the idea of
nonaxial implant placement as well as a reduced
number of implants, the All-on-4 shelf becomes a
necessary tool to optimize what is a highly efficient,
although counterintuitive, maxillary implant placement scheme.

References

FIGURE 12. A, Reduction alveoloplasty of the All-on-4 shelf provides enough interarch space for the esthetic prosthetic reconstruction. B, The use of M-4 placement, as shown in the panographic
x-ray, was facilitated by the All-on-4 shelf.
Jensen et al. The All-on-4 Shelf: Maxilla. J Oral Maxillofac Surg
2010.

Nasolacrimal Duct
One final anatomic structure to be aware of is the
nasolacrimal duct, which exits below the inferior turbinate sometimes anatomically near where M-point
implant fixation is desirable in the piriform (Fig 11).4-9
Implants that penetrate the piriform and enter into
the nasal fossa can on rare occasions disturb nasolacrimal drainage.47

Discussion
The overall benefit of the All-on-4 shelf is one of
technical, biological, and biomechanical advantage
to the surgical prosthetic team.13 The use of the
shelf ensures that implants are placed at the right
level, at the most optimal angles, at maximum A-P
spread, and with the most favorable insertion
torque obtainable for immediate load restorations.
Recall the three questions of controversy: 1) Can
osseointegration occur in the maxilla without bone
grafting? 2) Can full arch prosthetic loading be
accomplished with only 4 implants placed at angulation? 3) Can full arch immediate load biomechanics be satisfied by the often limited bone stock of
the anterior maxilla? All of these questions are more

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