All-on-4 versus all-on-6 ved fuldkæberehabilitering hos tandløse patienter og patienter med stadium IV-parodontitis
Evidensen understøtter, at all-on-4 giver sammenlignelige korttids- og mellemlange resultater hos standardrisikopatienter, men all-on-6 kan være relevant ved specifikke risikofaktorer og biomekanisk udfordrende forhold.
Baggrund og formål
Tandløse patienter som følge af omfattende caries, frakturerede tænder og restaureringer og stadium IV-parodontitis udgør en betydelig klinisk udfordring. Implantatunderstøttet fuldkæbeprotetik baseret på all-on-4- og all-on-6 tilbyder faste protetiske løsninger uden eller med minimal knogleopbygning. Formålet med denne oversigtsartikel er at sammenligne resultater for allon-4 vs. all-on-6 med fokus på implantatoverlevelse, marginalt knogletab, komplikationer, mundhygiejne og periimplantær sundhed hos tandløse patienter og patienter med parodontitis, stadium IV.
Materiale og metoder
Der blev udført en struktureret litteratursøgning i PubMed, Cochrane Library og Google Scholar. Artikler fra 2003-2025 blev inkluderet med fokus på randomiserede kontrollerede studier (RCT), prospektive kohorteundersøgelser, systematiske reviews og metaanalyser.
Resultater
To direkte sammenlignelige RCT´ere med 5-års og 3-års opfølgning samt flere retrospektive kohorteundersøgelser og systematiske oversigter viste ingen signifikant forskel i implantatoverlevelse (all-on-4: 98,75-100 %; all-on-6: 95-99,4 %). Marginalt knogletab var sammenligneligt, enkelte metaanalyser har antydet en tendens til mindre marginalt knogletab og færre tekniske komplikationer ved 6 implantater.
Biomekaniske studier viste lavere spændinger ved 6 implantater uden klinisk relevante forskelle. Patienter med parodontitis havde markant øget risiko for periimplantitis. Færre implantater faciliterede mulighed for sufficient mundhygiejne.
Konklusion
Evidensen understøtter, at all-on-4 giver sammenlignelige korttids- og mellemlange resultater hos standardrisikopatienter, men all-on-6 kan være relevant ved specifikke risikofaktorer og biomekanisk udfordrende forhold. Evidensen for parodontitispatienter og langtidsresultater er fortsat begrænset. Oral rehabilitering uden knogleopbygning reducerer den samlede behandlingstid samt morbiditet og økonomiske omkostninger. Parodontitispatienter kræver intensiveret støttebehandling før og efter implantatbehandling.
Klinisk relevans:
For den almenpraktiserende tandlæge giver oversigten et opdateret grundlag for visitation og patientinformation. All-on-4 er et rimeligt førstevalg hos standardrisikopatienter med atrofisk maksil eller mandibel, hvis man vil undgå knogleopbygning, og hvor der kan opnås tilstrækkelig anterior-posterior spredning af fire fiksturer. All-on-6 bør overvejes ved specifikke risikofaktorer som rygning, bruksisme, lav knogletæthed, behov for lange distale ekstensioner, eller hvor den kliniske situation tillader seks veldistribuerede fiksturer uden behov for omfattende augmentation. Hos patienter med stadium IV-parodontitis er parodontal forberedelse, fokussanering, hygiejnevenligt protetisk design og livslang understøttende parodontal- og periimplantær behandling med individuelt tilpassede intervaller afgørende, uanset om der vælges fire eller seks implantater.
All-on-4 versus all-on-6 in full-mouth rehabilitation in edentulous patients and patients with stage IV periodontitis
Background and aim
Edentulous patients resulting from extensive caries, fractured teeth and restorations, and stage IV periodontitis represent a significant clinical challenge in Danish dental practice. According to data from Danish dental clinics, patients with nine teeth or fewer constitute 2.6% of all individuals who consulted a dentist at least once during the period 2000-2022. Implant-supported full-arch prosthetic rehabilitation based on the all-on-4 and all-on-6 concepts offer fixed prosthetic solutions without or with minimal bone augmentation, respectively, for patients with a terminal dentition.
The aim of this narrative review with a structured literature search was to compare clinical outcomes of the all-on-4 and all-on-6 concepts with emphasis on implant survival, marginal bone loss, biological and technical complications, oral hygiene access, and peri-implant health in edentulous patients and patients with stage IV periodontitis.
Material and methods
A structured literature search was conducted in PubMed, the Cochrane Library, and Google Scholar using search terms related to all-on-4, all-on-6, ”full-mouth rehabilitation, ”tilted implants,” ”graftless rehabilitation,” and ”stage IV periodontitis.” Articles published between 2003 and 2025 were included, with a focus on randomized controlled trials (RCTs), prospective cohort studies, systematic reviews, and meta-analyses.
Results
Two head-to-head RCTs (Tallarico et al. 2016, 5-year follow-up; Toia et al. 2021, 3-year multicentre follow up), together with several retrospective cohort studies and systematic reviews, demonstrated no statistically significant difference in implant survival between all-on-4 (98.75–100%) and all-on-6 (95–99.4%). Marginal bone loss was comparable between the two concepts, although individual meta-analyses have suggested a tendency towards less marginal bone loss and fewer technical complications with six implants.
Biomechanical (finite element) studies consistently indicated lower peak stress distribution with six implants; however, this did not translate into clinically relevant differences in available clinical studies. Patients with a history of periodontitis exhibited a markedly increased risk of peri-implantitis. Fewer implants facilitated the patient’s ability to achieve adequate oral hygiene around the prosthesis. Implant survival, the most consistently reported outcome, is acknowledged as a crude proxy for treatment success.
Conclusion
The available short- and medium-term evidence indicates that the all-on-4 concept yields clinical outcomes comparable to those of all-on-6 in standard-risk patients, and does not demonstrate a clear clinical advantage of six over four implants in this population. All-on-6 may be considered when specific risk factors are present (smoking, bruxism, low bone density, long distal cantilevers) or in biomechanically demanding situations. Evidence in patients with stage IV periodontitis and on long-term outcomes (>10 years) remains limited.
Rehabilitation without prior or concurrent bone augmentation reduces the overall treatment time before functional loading and substantially reduces morbidity and financial costs. Patients with periodontitis require intensified supportive periodontal and peri-implant therapy both before and after implant treatment.
