By Danny Chan
On January 16, 2023, in Zurich, Switzerland, Dr Paulo Malo received the Quarter Century Award from Nobel Biocare, marking 25 years of the revolutionary All-on-4® treatment concept.
Few dental innovations have made a more profound impact than the All-on-4® technique. Dr Malo’s visionary implant concept has singularly transformed the lives of over 350 million edentulous individuals worldwide. Yet like a rose that grows from the concrete, it first had to contend with harsh resistance.
Road less travelled
Dr Paulo Malo's journey with the All-on-4® treatment concept began in the early 1990s, at a time when few believed in the feasibility of his technique. In fact, Dr Malo once remarked that he and his teammates were called “cheaters and cowboys” in the early days, despite garnering huge praise from the patients themselves.
“People said we couldn’t place just four implants or incline implants. I remember once we did a live surgery, and someone said that we must have cheated on the video because it was not possible to do it in 35 minutes,” he recalls.
“But it was not the opinions of dentists that I cared about; I kept going because I knew this changed the lives of patients.”
Prior to Dr Malo's innovative work, dental implants were often not a viable solution for patients with compromised bone structures. The All-on-4® treatment concept, developed with crucial support from the late Dr Bo Rangert of Nobel Biocare, fundamentally reshaped implant dentistry by offering a cost-efficient, graftless solution for full-arch prostheses.
Today, the Founder of the world-famous Malo Dental imparts his sought-after wisdom at prestigious universities, traversing six continents, addressing audiences ranging from 300 to 10,000 individuals.
Just four will do
The All-on-4® technique is essentially a restorative dental implant solution that enables the replacement of an entire arch of teeth with just four dental implants. Two of these implants, strategically placed at the back of the mouth, are inserted at a 45° angle using purpose-made Speedy Groovy dental implants, designed to navigate areas of low bone density.
As well as eliminating the need for complex bone grafting procedures, this approach offers a permanent and fixed alternative to traditional dentures and is known for its high success rate of 98%, as validated by extensive clinical data over the years.
Nobel Biocare's Speedy Groovy Implants, exclusively designed by Dr Paulo Malo for All-on-4® treatments, are instrumental in achieving implant stability and supporting the immediate loading protocol. Nobel Biocare's decades-long commitment to science-backed technology has played a pivotal role in advancing All-on-4® treatments globally.
25 years on, the All-on-4® treatment concept remains one of the most vaunted milestones of modern dentistry. This well-documented, evidence-based solution has been credited with treating over 250,000 patients since its commercial launch in 2004.
All-on-4® arrives Down Under
From an Australasian standpoint, contemplating a quarter-century of the All-on-4® concept would be remiss without acknowledging the incredible metamorphosis it has ignited within the realm of one of Australia's foremost practitioners in the implant technique.
Synonymous with the All-on-4® brand Down Under, Dr Larry Benge is the Lead All–on–4® Dental Surgeon and owner of Next Smile Australia (Sydney/ Melbourne), an establishment where all the dental surgeons and their dedicated staff have been trained and mentored in the Malo Protocol by Dr Malo himself.
Dr Larry Benge specialises in reconstructive, aesthetic, and implant dentistry, with a specific focus on the innovative All-on-4® treatment approach for comprehensive full-arch restoration. He earned his first-class honours degree in Dental Science from The University of Melbourne in 1980, following his earlier completion of a Bachelor of Science with Honours at Monash University.
The experienced dental surgeon’s voyage into All-on-4® dentistry commenced back in 2004 at a conference in Perth, run by Dr Patrick Henry. Little did he know that this would be the spark that ignited a transformational detour in his career.
Yet, it wasn't until the year 2007 when Nobel Biocare invited him to a five-day residency program in the city of Lisbon, Portugal, that Dr Benge's perspective underwent a profound shift.
“It opened my eyes to the possibilities of full-arch rehabilitation,” says Dr Benge. “This marked a significant departure from our previous approaches involving bone grafting and multiple implants. I was truly amazed by the potential.”
However, this pioneering era wasn't without its challenges. Echoing Dr Malo’s experience, Dr Benge faced his fair share of criticism and skepticism from peers.
“Upon returning to Australia in 2007, I decided to take a cautious approach,” Dr Benge recounts.
“I collaborated with Dr Kevin Spencer and completed 20 supervised cases to ensure that the concept was appropriately taught and mastered. The shift in my practice completely altered the way I approached dentistry. I recall that my initial marketing efforts for 'All-on-4®' focused on informing people about the benefits rather than trying to convince them to get the procedure.”
Taking the low-profile approach resulted in a fourfold expansion of Dr Benge’s practice during that time. The clinician realised that he had only scratched the surface of what All-on-4® had to offer. This epiphany led to multiple trips to Portugal and one-on-one training with Dr Malo, where he tackled complex cases and explored the limitations of 'All-on-4®' and zygoma implants.
Dr Benge has, to date, completed thousands of cases which places the clinician in a privileged position of teaching the advanced technique to many dentists across the country. As a matter of fact, at the time of this interview, Dr Benge was conducting a second cadaver course on the technique in Sydney.
“The 25th anniversary of 'All-on-4®' is truly remarkable. In its early days, it challenged the dental community, and many were skeptical. While some still hold reservations, the profession has largely embraced it,” Dr Benge says, with a deserved sense of validation.
In 2019, Dr Benge’s practice group, Next Smile Australia (Melbourne and Sydney), made a significant move to their new, purpose-built location in Hawthorn, Melbourne.
Their All-on-4® Super Centre is thoughtfully designed to strike a balance between a warm, inviting atmosphere and clinical efficiency. The clinic is equipped with onsite CBCT scanners to expedite precise diagnosis and is custom-built to accommodate a wide range of dental procedures, including All-on-4® full-arch treatment, as well as single and multiple dental implant surgeries.
The practice group has also been certified as Nobel Biocare Centre of Excellence by the world-famous Malo Dental.
“As the All-on-4® treatment concept becomes more mainstream, there is a downside – everyone is marketing and providing All-on-4® often without a full understanding of its complexities.
“This is why it's essential that Nobel Biocare has established Centres of Excellence. To earn this designation, one must invest time, complete cases, and undergo essential education.”
Dr Benge's efficiency in performing All-on-4® cases, taking only 45 minutes to an hour, sets the benchmark, as compared to the four to five hours that others may require for the same procedure.
A key element of their formula for consistency, Dr Benge notes, is adhering to Nobel Biocare’s protocol.
“Centres of Excellence ensure the use of the correct implant, the Nobel Speedy External Hex, specifically designed for All-on-4®. This choice of implant significantly contributes to achieving the necessary primary stability, a vital aspect of the procedure's success.”
On the horizon
Looking ahead to the future, Dr Benge believes the dental implant community face fresh challenges, along which the All-on-4® treatment concept continues to evolve and adapt.
“Patients are aging, their bones are becoming softer, and there are more medical conditions to contend with,” he predicts.
“We're working on new implants, including zygoma and Speedy implants, designed to offer stability even in very soft bone. While we had hoped to launch these innovations for the 25th anniversary, we're slightly behind schedule.
“Nonetheless, we're excited about what the future holds, including advancements in digital dentistry.”