{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,31]],"date-time":"2026-08-31T10:17:32Z","timestamp":1788171452578,"version":"build-2803163510"},"reference-count":46,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2026,8,31]],"date-time":"2026-08-31T00:00:00Z","timestamp":1788134400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Dent. J.","Dentistry Journal"],"abstract":"<jats:p>Background: Severe tooth loss affects approximately 267 million people worldwide and has a significant impact on quality of life and general health. Various prosthetic treatment concepts exist for oral rehabilitation. The All-on-Four concept, first described by Mal\u00f3 in 2003, is considered a modern approach for timely and patient-friendly restoration of oral function and esthetics. Methods: A systematic literature search was conducted in the electronic databases MEDLINE\/PubMed and EMBASE (Elsevier). Eligible studies were identified according to the framework, including investigations on the All-on-Four concept (PIO) and alternative implant-supported full-arch rehabilitation strategies (FDP4+, PCO). The methodological quality of the included studies was assessed using the Newcastle\u2013Ottawa Scale. Results: Following the selection process, eleven PIO studies and nine PCO studies were included for qualitative analysis. Reported prosthesis survival rates were comparable between All-on-Four (85.0\u2013100%) and concepts with more than four implants (88.2\u2013100%) over up to 20 years. Implant survival ranged from 89.7\u201397.9% for All-on-Four and 98.9\u201399.0% for alternative concepts. Marginal bone loss after 5 years reached up to 1.9 mm for All-on-Four and 2.9 mm for alternative concepts. Metal\u2013ceramic prostheses demonstrated lower fracture rates (7.27\u201318.2%) compared with metal\u2013acrylic restorations (7.3\u201336.7%). Discussion: The available evidence suggests that the All-on-Four concept represents a predictable treatment option for edentulous patients, with implant and prosthetic survival rates comparable to FDP4+ concepts. Immediate loading protocols may improve patient satisfaction and reduce treatment time when adequate primary stability is achieved. However, biological and technical complications remain clinically relevant. Interpretation of the findings is limited by heterogeneous study designs and predominantly retrospective evidence. Conclusions: The All-on-Four concept provides a reliable rehabilitation option for patients with advanced ridge atrophy who decline regenerative procedures or removable prostheses. Current evidence indicates no significant differences in survival or complication rates compared to other implant-supported treatment concepts.<\/jats:p>","DOI":"10.3390\/dj14090541","type":"journal-article","created":{"date-parts":[[2026,8,31]],"date-time":"2026-08-31T09:21:19Z","timestamp":1788168079000},"page":"541","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["All-on-Four Rehabilitation: A Systematic Review of Clinical Management, Workflow and Complications"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0009-0002-1122-3077","authenticated-orcid":false,"given":"Benjamin Reto","family":"Huber","sequence":"first","affiliation":[{"name":"Oral- and Cranio-Maxillofacial Surgery, Cantonal Hospital Aarau, Tellstrasse, 5001 Aarau, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-5499-3605","authenticated-orcid":false,"given":"Noah","family":"Walser","sequence":"additional","affiliation":[{"name":"Klinik f\u00fcr Zahnerhaltung und Pr\u00e4ventivzahnmedizin, Bereich f\u00fcr Parodontologie & Periimplant\u00e4re Erkrankungen, Zentrum f\u00fcr Zahnmedizin der Universit\u00e4t Z\u00fcrich, Plattenstrasse 11, 8032 Zurich, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thiemo","family":"Gamma","sequence":"additional","affiliation":[{"name":"Oral- and Cranio-Maxillofacial Surgery, Cantonal Hospital Aarau, Tellstrasse, 5001 Aarau, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Philipp","family":"Metzler","sequence":"additional","affiliation":[{"name":"Oral- and Cranio-Maxillofacial Surgery, Cantonal Hospital Aarau, Tellstrasse, 5001 Aarau, Switzerland"},{"name":"Clinic of Cranio-Maxillofacial and Oral Surgery, Center of Dental Medicine, University of Zurich, Plattenstrasse 11, 8032 Zurich, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,8,31]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1789","DOI":"10.1016\/S0140-6736(18)32279-7","article-title":"Global, Regional, and National Incidence, Prevalence, and Years Lived with Disability for 354 Diseases and Injuries for 195 Countries and Territories, 1990\u20132017: A Systematic Analysis for the Global Burden of Disease Study 2017","volume":"392","author":"James","year":"2018","journal-title":"Lancet"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"358","DOI":"10.1111\/cdoe.12466","article-title":"Is Tooth Loss Important When Evaluating Perceived General Health? Findings from a Nationally Representative Study of Costa Rican Adults","volume":"47","author":"Fantin","year":"2019","journal-title":"Community Dent. Oral Epidemiol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"937","DOI":"10.3109\/00016357.2012.734421","article-title":"Qualitative Studies of Patients\u2019 Perceptions of Loss of Teeth, the Edentulous State and Prosthetic Rehabilitation: A Systematic Review with Meta-Synthesis","volume":"71","author":"Nordenram","year":"2013","journal-title":"Acta Odontol. Scand."},{"key":"ref_4","first-page":"503","article-title":"Oral Health-Related Quality of Life in Patients Treated with Fixed, Removable, and Complete Dentures 1 Month and 6 to 12 Months after Treatment","volume":"17","author":"John","year":"2004","journal-title":"Int. J. Prosthodont."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"s63","DOI":"10.11607\/ijp.7162","article-title":"Different Interventions for Rehabilitation of the Edentulous Maxilla with Implant-Supported Prostheses: An Overview of Systematic Reviews","volume":"34","author":"Messias","year":"2021","journal-title":"Int. J. Prosthodont."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"2","DOI":"10.1111\/j.1708-8208.2003.tb00010.x","article-title":"\u201cAll-on-Four\u201d Immediate-Function Concept with Br\u00e5nemark System Implants for Completely Edentulous Mandibles: A Retrospective Clinical Study","volume":"5","author":"Rangert","year":"2003","journal-title":"Clin. Implant Dent. Relat. Res."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"6285620","DOI":"10.1155\/2016\/6285620","article-title":"Impact of Dental Implant Surface Modifications on Osseointegration","volume":"2016","author":"Smeets","year":"2016","journal-title":"BioMed Res. Int."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"434","DOI":"10.1111\/j.1708-8208.2009.00265.x","article-title":"Immediate Rehabilitation of the Extremely Atrophic Mandible with Fixed Full-Prosthesis Supported by Four Implants","volume":"14","author":"Weinstein","year":"2012","journal-title":"Clin. Implant Dent. Relat. Res."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"538","DOI":"10.1111\/cid.12771","article-title":"The All-on-4 Concept for Full-Arch Rehabilitation of the Edentulous Maxillae: A Longitudinal Study with 5-13 Years of Follow-Up","volume":"21","author":"Lopes","year":"2019","journal-title":"Clin. Implant Dent. Relat. Res."},{"key":"ref_10","unstructured":"DGI, and DGZMK (2020). Implantatprothetische Versorgung Des Zahnlosen Oberkiefers, AWMF. Available online: https:\/\/register.awmf.org\/assets\/guidelines\/083-010l_S3_Implantatprothetische-Versorgung-zahnloser-Oberkiefer_2021-03.pdf."},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Grandi, T., and Signorini, L. (2022). Rehabilitation of the Completely Edentulous Mandible by All-on-Four Treatment Concept: A Retrospective Cohort Study with Up to 10 Years Follow-Up. Medicina, 58.","DOI":"10.3390\/medicina58010010"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"559","DOI":"10.1111\/cid.12483","article-title":"Immediate Implant and Rehabilitation Based on All-on-4 Concept in Patients with Generalized Aggressive Periodontitis: A Medium-Term Prospective Study","volume":"19","author":"Li","year":"2017","journal-title":"Clin. Implant Dent. Relat. Res."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"n71","DOI":"10.1136\/bmj.n71","article-title":"The PRISMA 2020 Statement: An Updated Guideline for Reporting Systematic Reviews","volume":"372","author":"Page","year":"2021","journal-title":"BMJ"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"387","DOI":"10.1136\/emermed-2020-209567","article-title":"Population, Intervention, Comparison, Outcomes and Study (PICOS) Design as a Framework to Formulate Eligibility Criteria in Systematic Reviews","volume":"37","author":"Janati","year":"2020","journal-title":"Emerg. Med. J."},{"key":"ref_15","unstructured":"Wells, G.A., Shea, B., O\u2019Connell, D., Peterson, J., Welch, V., Losos, M., and Tugwell, P. (2026, March 31). The Newcastle-Ottawa Scale (NOS) for Assessing the Quality of Nonrandomised Studies in Meta-Analyses. Available online: http:\/\/www.ohri.ca\/programs\/clinical_epidemiology\/oxford.asp."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"265","DOI":"10.1563\/aaid-joi-D-15-00098","article-title":"An up to 7-Year Retrospective Analysis of Biologic and Technical Complication with the All-on-4 Concept","volume":"42","author":"Tallarico","year":"2016","journal-title":"J. Oral Implantol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"849","DOI":"10.1111\/cid.12526","article-title":"Comparison of Marginal Bone Loss and Implant Success between Axial and Tilted Implants in Maxillary All-on-4 Treatment Concept Rehabilitations after 5 Years of Follow-Up","volume":"19","author":"Hopp","year":"2017","journal-title":"Clin. Implant Dent. Relat. Res."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"298","DOI":"10.1111\/clr.14383","article-title":"Fixed Full-Arch Maxillary Prostheses Supported by Four Versus Six Implants: 5-Year Results of a Multicenter Randomized Clinical Trial","volume":"36","author":"Toia","year":"2025","journal-title":"Clin. Oral Implant. Res."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"831","DOI":"10.1111\/cid.13134","article-title":"Immediate Flapless Full-Arch Rehabilitation of Edentulous Jaws on 4 or 6 Implants According to the Prosthetic-Driven Planning and Guided Implant Surgery: A Retrospective Study on Clinical and Radiographic Outcomes up to 10 Years of Follow-Up","volume":"24","author":"Pranno","year":"2022","journal-title":"Clin. Implant Dent. Relat. Res."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"565","DOI":"10.1111\/cid.12769","article-title":"The All-on-4 Treatment Concept for the Rehabilitation of the Completely Edentulous Mandible: A Longitudinal Study with 10 to 18 Years of Follow-Up","volume":"21","author":"Lopes","year":"2019","journal-title":"Clin. Implant Dent. Relat. Res."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"106286","DOI":"10.1016\/j.jdent.2025.106286","article-title":"Immediate Full-Arch Mandibular Rehabilitation Supported by Four Implants: A Retrospective Study with 20 to 25 Years of Follow-Up","volume":"165","author":"Lopes","year":"2026","journal-title":"J. Dent."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"233","DOI":"10.1111\/cid.12456","article-title":"The NobelGuide\u00ae All-on-4\u00ae Treatment Concept for Rehabilitation of Edentulous Jaws: A Retrospective Report on the 7-Years Clinical and 5-Years Radiographic Outcomes","volume":"19","author":"Lopes","year":"2017","journal-title":"Clin. Implant Dent. Relat. Res."},{"key":"ref_23","first-page":"164","article-title":"Retrospective Analysis of the Prevalence of Peri-Implant Diseases in Non-Smoking Patients Rehabilitated with a Fixed Full-Arch Restoration, Supported by Two Mesial Axial and Two Distal Tilted Implants","volume":"65","author":"Cavalli","year":"2016","journal-title":"Minerva Stomatol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"e406","DOI":"10.1111\/cid.12260","article-title":"The NobelGuide\u00ae All-on-4\u00ae Treatment Concept for Rehabilitation of Edentulous Jaws: A Prospective Report on Medium- and Long-Term Outcomes","volume":"17","author":"Lopes","year":"2015","journal-title":"Clin. Implant Dent. Relat. Res."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"284","DOI":"10.1111\/j.1600-0501.2009.01843.x","article-title":"Early Loading of Implants with Fixed Dental Prostheses in Edentulous Mandibles: 4.5-Year Clinical Results from a Prospective Study","volume":"21","author":"Schwarz","year":"2010","journal-title":"Clin. Oral Implant. Res."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"433","DOI":"10.1111\/j.1600-0501.2007.01510.x","article-title":"Five-Year Results from a Randomized, Controlled Trial on Early and Delayed Loading of Implants Supporting Full-Arch Prosthesis in the Edentulous Maxilla","volume":"19","author":"Fischer","year":"2008","journal-title":"Clin. Oral Implant. Res."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"256","DOI":"10.1111\/j.1532-849X.2011.00824.x","article-title":"Retrievable Metal Ceramic Implant-Supported Fixed Prostheses with Milled Titanium Frameworks and All-Ceramic Crowns: Retrospective Clinical Study with up to 10 Years of Follow-Up","volume":"21","author":"Borges","year":"2012","journal-title":"J. Prosthodont."},{"key":"ref_28","first-page":"227","article-title":"The Rehabilitation of Completely Edentulous with Different Degrees of resorption with Four or More Immediately Loaded Implants: A 5-Year Retrospective Study and a New","volume":"4","author":"Nobre","year":"2011","journal-title":"Eur. J. Oral Implantol."},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Velasco-Ortega, E., Jim\u00e9nez-Guerra, A., Ortiz-Garcia, I., Moreno-Mu\u00f1oz, J., N\u00fa\u00f1ez-M\u00e1rquez, E., Cabanillas-Balsera, D., L\u00f3pez-L\u00f3pez, J., and Monsalve-Guil, L. (2021). Immediate Loading of Implants Placed by Guided Surgery in Geriatric Edentulous Mandible Patients. Int. J. Environ. Res. Public Health, 18.","DOI":"10.3390\/ijerph18084125"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"189","DOI":"10.11607\/prd.1938","article-title":"Peri-Implant Outcome of Immediately Loaded Implants with a Full-Arch Implant Fixed Denture: A 5-Year Prospective Case Series","volume":"34","author":"Martens","year":"2014","journal-title":"Int. J. Periodontics Restor. Dent."},{"key":"ref_31","first-page":"602","article-title":"Implant Treatment in the Edentulous Mandible: A Prospective Study on Br\u00e5nemark System Implants over More than 20 Years","volume":"16","author":"Ekelund","year":"2003","journal-title":"Int. J. Prosthodont."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"612","DOI":"10.1111\/cid.13017","article-title":"Clinical Outcomes and Biological and Mechanical Complications of Immediate Fixed Prostheses Supported by Zygomatic Implants: A Retrospective Analysis from a Prospective Clinical Study with up to 11 Years of Follow-Up","volume":"23","author":"Agliardi","year":"2021","journal-title":"Clin. Implant Dent. Relat. Res."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"173","DOI":"10.1034\/j.1600-0501.2003.140206.x","article-title":"A Longitudinal Study of Quality of Life Outcomes in Older Adults Requesting Implant Prostheses and Complete Removable Dentures","volume":"14","author":"Allen","year":"2003","journal-title":"Clin. Oral Implant. Res."},{"key":"ref_34","first-page":"351","article-title":"The Use of Intraorally Harvested Autogenous Block Grafts for Vertical Alveolar Ridge Augmentation: A Human Study","volume":"25","author":"Proussaefs","year":"2005","journal-title":"Int. J. Periodontics Restor. Dent."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1135","DOI":"10.1053\/joms.2002.34986","article-title":"Staged Reconstruction of the Severely Atrophic Mandible with Autogenous Bone Graft and Endosteal Implants","volume":"60","author":"Bell","year":"2002","journal-title":"J. Oral Maxillofac. Surg."},{"key":"ref_36","unstructured":"DGI, and DGZMK (2022). Implantationszeitpunkte, AWMF. Available online: https:\/\/www.awmf.org\/leitlinien\/detail\/II\/083-040.html."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"311","DOI":"10.1111\/clr.13288","article-title":"Effect of Advanced Age and\/or Systemic Medical Conditions on Dental Implant Survival: A Systematic Review and Meta-analysis","volume":"29","author":"Schimmel","year":"2018","journal-title":"Clin. Oral Implant. Res."},{"key":"ref_38","unstructured":"DGI, and DGZMK (2022). Zahnimplantate Bei Diabetes Melitus, AWMF. Available online: https:\/\/www.awmf.org\/leitlinien\/detail\/II083-025.html."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"207","DOI":"10.11607\/ijp.3569","article-title":"Immediate Versus Delayed Loading of Dental Implants in Edentulous Patients\u2019 Maxillae: A 6-Year Prospective Study","volume":"27","author":"Tealdo","year":"2014","journal-title":"Int. J. Prosthodont."},{"key":"ref_40","unstructured":"DGI, and DGZMK (2020). Knochenersatzmaterialien Zur Verwendung Bei Kieferkammdefiziten Und -Defekten, AWMF. Available online: https:\/\/www.awmf.org\/leitlinien\/detail\/II\/083-009.html."},{"key":"ref_41","first-page":"1359","article-title":"Systematic Assessment of Clinical Outcomes in Bone-Level and Tissue-Level Endosseous Dental Implants","volume":"27","author":"Vouros","year":"2012","journal-title":"Int. J. Oral Maxillofac. Implant."},{"key":"ref_42","doi-asserted-by":"crossref","unstructured":"Esposito, M., Worthington, H., Thomsen, P., and Coulthard, P. (2003). Interventions for Replacing Missing Teeth: Different Types of Dental Implants. Cochrane Database of Systematic Reviews, John Wiley & Sons, Ltd.","DOI":"10.1002\/14651858.CD003815"},{"key":"ref_43","doi-asserted-by":"crossref","unstructured":"Sun, F., Lv, L.-T., Cheng, W., Zhang, J.-L., Ba, D.-C., Song, G.-Q., and Lin, Z. (2021). Effect of Loading Angles and Implant Lengths on the Static and Fatigue Fractures of Dental Implants. Materials, 14.","DOI":"10.3390\/ma14195542"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"560","DOI":"10.11607\/ijp.8131","article-title":"EAO Position Paper: Current Level of Evidence Regarding Zirconia Implants in Clinical Trials","volume":"35","author":"Balmer","year":"2022","journal-title":"Int. J. Prosthodont."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"493","DOI":"10.1002\/JPER.18-0338","article-title":"Outcome of Early Dental Implant Placement versus Other Dental Implant Placement Protocols: A Systematic Review and Meta-analysis","volume":"90","author":"Bassir","year":"2019","journal-title":"J. Periodontol."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"222","DOI":"10.11607\/jomi.2014suppl.g4.1","article-title":"Loading Protocols for Single-Implant Crowns: A Systematic Review and Meta-Analysis","volume":"29","author":"Benic","year":"2014","journal-title":"Int. J. Oral Maxillofac. Implant."}],"container-title":["Dentistry Journal"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2304-6767\/14\/9\/541\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,31]],"date-time":"2026-08-31T09:44:47Z","timestamp":1788169487000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2304-6767\/14\/9\/541"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,31]]},"references-count":46,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2026,9]]}},"alternative-id":["dj14090541"],"URL":"https:\/\/doi.org\/10.3390\/dj14090541","relation":{},"ISSN":["2304-6767"],"issn-type":[{"value":"2304-6767","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,31]]}}}