AOX Protocol

The All-on-X procedure demands precise planning and the evaluation of multiple critical parameters. Dentists who take these factors into account can guarantee their patients get the most favorable outcome from the surgery. It is highly advisable for dentists to pursue additional full arch training before initiating these types of cases. This will improve their competency and confidence in carrying out the All-on-X procedure.

1. Patient selection: When considering a patient for the All-On-X procedure, the first parameter to consider is the patient's overall health and suitability for the treatment. Patients with significant medical conditions or those with high smiles may not be the best candidates for All-On-X. Additionally, it's crucial to understand the patient's expectations before beginning the case. Ask yourself whether you can meet all their expectations. If you're not certain, it's best not to take on the case, as the cost of not meeting their expectations can outweigh any financial gain.

2. Bone reduction: The purpose of bone reduction is to create a precise and adequate bone architecture for implant placement and establish adequate inter-arch space for the planned prosthesis (15mm from incisal edge to MUA platform, from first molar to first molar), while considering the patient's occlusion, tooth position, and functional needs. Reduction may also be necessary to improve aesthetic outcomes in patients with high smile lines or excessive gingival display. Bone reduction can be accomplished free-hand, with a surgical guide generated CAD/CAM or with robotic, with the main advantage of using a guide or robotic being the ability to virtually pre-plan exactly how much bone needs to be removed. Careful planning is necessary to reduce surgical and prosthetic complications, and both under-reduction and over-reduction can lead to poor outcomes. 

3. Transition line: The transition line is by definition the junction of the prosthesis with the soft tissue over the residual ridge and thereby predicting the transition line is critically important in planning for the final prosthesis. The transition line is established by recognizing the transition line between the prosthesis and the crestal soft tissues of the edentulous ridge. If the transition line is epical to the smile line, the outcome will be positive and predictable. However, if the smile line is apical to the transition line, further evaluation must be made as the final esthetic outcome will be compromised. Too often this step is neglected, which creates huge esthetic and hygiene problems.

4. Implant position: The position of the implants is critical to the success of the procedure. Proper placement of the implants will ensure proper AP spread (anterior/posterior spread) which will translate into a strong, stable, functional, and aesthetically pleasing prosthesis. Make sure that you have an array of implant sizes and lengths to best meet the need of each patient.

5. Angulation of the implants: The angle of the implants is also important. Proper angulation will allow for a better AP spread and restorative space. Make sure that you have an array of MUA/SRA to correct the angulation of the implants and meet the unique needs of each patient. MUA/SRA options generally include straight, 17, and 30-degree angulations while a few implant companies do provide more angulations.

6. Number of implants: The number of implants needed will depend on the size and shape of the arch, as well as the forces that will be applied to the prosthesis. Plan the case well by placing the incisal edges in the proper position first, then planning the surgery and number of implants. Ensure you always have a variety of implant lengths and sizes readily available to address any potential complications that may arise during the procedure.

7. Bone quantity: The quantity and quality of the bone are important factors to consider when planning an All-on-X procedure. The dentist must ensure that there is enough bone present to support the implants and prosthesis.

8. Prosthesis design: The design of the prosthesis is another important consideration. The dentist must ensure that the prosthesis is properly designed to provide adequate support and stability to the implants. This can only happen when an adequate amount of bone reduction has been provided with the appropriate AP spread. (anterior/posterior spread)

9. Occlusion: Proper occlusion is CRITICAL for the prosthesis to function well and last long as well as planning correctly for bone reduction or teeth positioning. Unfortunately, too often, dentists plan the case based on the patient's existing dentition, which may be over-closed or even too open. Therefore, it's essential to carefully consider the occlusion to avoid these issues. 

10. Post-operative care: Finally, postoperative care is critical to the success of the procedure. Patients must be carefully monitored to ensure proper healing and function of the prosthesis.