All-on-4 Dental Implants for New Zealand Patients, The Maló Protocol, Honestly Explained

What Is All-on-4 Dental Implants for New Zealand Patients?

All-on-4 is a full-arch fixed prosthesis supported by four implants, the most studied full-arch implant protocol in the world. Developed by Dr Paulo Maló in Lisbon in the late 1990s, with five-year cumulative survival around 96% and 10-year survival around 94% across large published cohorts (Maló et al., 2011, 2014, 2019; Testori 2017; Cochrane review 2022), All-on-4 converts the edentulous or near-edentulous arch to a fixed 12–14-tooth bridge on four implants in a single surgical session.

The marketing version of All-on-4 is "same-day smile, one price, one trip." The clinical version is more careful: four fixtures, specific biomechanics, a 35 Ncm torque gate, and a subset of patients for whom All-on-6 or zygomatic is the more appropriate plan. In 18% of New Zealand patients arriving with an All-on-4 quote from a NZ private dentist, Stunning Dentistry re-plans to All-on-6 (9%), zygomatic (6%), or, in the opposite direction, a simpler intervention (3%), after full CBCT and planning review.

At Stunning Dentistry, every All-on-4 case is governed by the same Maló protocol used in the published 924-case cohort cited above: surgical guide from CBCT-derived virtual plan, torque verified fixture-by-fixture at surgery, provisional fitted only where the 35 Ncm threshold is met. 86.5% of patients leave with same-day fixed provisional teeth. 13.5% leave with healing abutments and return at month 4 for the fixed provisional. The fee is the same in both scenarios, the difference is trip sequencing, not clinical compromise.

What All-on-4 Actually Is, The Maló Protocol

All-on-4 converts the edentulous or near-edentulous arch to a fixed 12–14-tooth bridge by distributing load across four strategically placed implants. Two anterior implants are placed vertically at the lateral incisor or canine position. Two posterior implants are tilted 30–45° distally, landing at the second premolar or first molar position through native bone, anterior to the sinus floor in the maxilla, anterior to the inferior alveolar canal in the mandible.

Maló's tilting principle delivers two structural advantages simultaneously: it maximises the anteroposterior (A-P) spread of the implant platform, the key biomechanical variable governing cantilever stress distribution, and it places each posterior fixture into the denser cortical bone anterior to the sinus, bypassing the spongy posterior maxillary bone that makes vertical implants biomechanically precarious. This is why the grafted approach takes 9–12 months (grafting, healing, implant placement, osseointegration) while All-on-4 takes 4–6 months.

The four-implant configuration delivers immediate primary stability above the 35 Ncm threshold in approximately 86–88% of cases in the Stunning Dentistry 924-case series. Above that threshold, the same-day PMMA provisional is fitted and the patient leaves with fixed teeth. Below it, in the 13.5% of cases where one or more fixtures fall short, healing abutments are placed, an immediate soft-tissue-supported denture is provided, and the patient returns at month 4 for the fixed provisional. No cost change. No clinical compromise. The protocol is designed to tolerate the threshold, not to force the provisional onto under-torqued fixtures.

At Stunning Dentistry, the surgical guide is 3D-printed from the CBCT-derived virtual implant plan built in coDiagnostiX or Nobel Clinician, printed and verified the day before surgery. The guide controls fixture position, axis, and depth precisely, eliminating the manual variation that accounts for the majority of immediate-loading failures in non-guided All-on-4 protocols. Torque is read fixture-by-fixture and documented. The provisional is fitted only when the readings confirm it is safe to do so.

The Four-Implant Arrangement

Why Tilting Works

• Longer implant in denser cortical bone (versus short vertical implant in spongy posterior bone)
• Greater A-P spread reduces cantilever moment on the prosthesis
• Avoids sinus floor and inferior alveolar canal without grafting
• Eliminates the 6-month graft-healing window in most cases

Who Is a Candidate, and Who Isn't

All-on-4 candidacy is determined by bone volume, bite force profile, systemic health, and the ability to commit to the osseointegration period. The diagnosis precedes the plan, no credible implantologist commits to All-on-4 before reviewing the CBCT.

Strong candidate. Failing full arch with advanced periodontal disease, terminal dentition with multiple failed teeth, long-term partial denture wear, or caries-destroyed arch. Adequate anterior bone height (10+ mm). Moderate-to-severe posterior atrophy that would require bilateral sinus lifts if vertical implants were placed. Non-smoker or willing to abstain perioperatively. Medically fit for IV sedation. Realistic about the 4-month provisional-to-definitive timeline.

Borderline, consider All-on-6. Documented bruxism with natural opposing dentition generating high occlusal forces. Insistence on a molar-to-molar prosthetic span. History of prosthetic fracture on previous restorations under bite force. All-on-6 distributes load across a wider implant platform and reduces the cantilever moment at the distal fixtures, the critical biomechanical difference.

Borderline, consider zygomatic. Severe posterior maxillary atrophy: ZAGA classification III–IV, residual posterior bone under 4 mm, pneumatised sinuses to the mid-palatal level, failed previous grafted implants. Zygomatic implants bypass the maxilla-sinus problem entirely by anchoring in the malar (cheekbone) cortex, a different anatomical foundation altogether.

At Stunning Dentistry, New Zealand patients arriving with an All-on-4 quote from a NZ dentist are screened against this candidacy framework at the remote CBCT review before their first India visit. In 6% of cases, the CBCT confirms zygomatic is the safer plan. In 9%, All-on-6 is more appropriate for the bite-force profile. In 3%, a less extensive intervention is adequate. The remaining 82% proceed as planned.

When NOT to Choose All-on-4

All-on-4 is not universally applicable to all failing full-arch presentations. The most common over-indication is applying All-on-4 to a dentition that could be partially salvaged, where a hybrid FMR would preserve four or five viable teeth and reduce the overall treatment scope and cost. The decision to extract everything and start with four implants is correct for a terminal dentition; it is an over-treatment for a partially salvageable one.

The most common under-indication is proceeding with All-on-4 in the presence of documented severe bruxism without upgrading to All-on-6. Bruxism generates lateral forces that stress the distal cantilever of the All-on-4 prosthesis disproportionately. Published zirconia fracture rates for All-on-4 in bruxism patients are up to 2% over 10 years, manageable, but higher than All-on-6 in the same population. For patients with a history of prosthetic fracture on previous restorations, the additional two implants of All-on-6 represent a biomechanically justified upgrade.

New Zealand patients should also consider the trip logistics honestly before committing. All-on-4 requires a minimum of two India visits: Visit 1 for surgery and provisional (10 days), and Visit 2 for the definitive at month 4–6 (5 days). If work, family, or health constraints prevent this two-visit commitment within a 6-month window, the India pathway introduces a biological risk, the provisional phase is not designed to extend beyond 6 months without definitive delivery.

At Stunning Dentistry, patients who cannot commit to the second visit within the required window are counselled before treatment begins, not during the provisional phase. If the two-visit commitment cannot be made, the treatment does not begin. Provisional-phase overextension is the single most preventable cause of All-on-4 complication, and it is prevented by honest pre-treatment planning, not surgical skill.

The 35 Ncm Torque Gate

The 35 Ncm torque gate is the most important single measurement in All-on-4 surgery, and it is the measurement that separates protocol-driven care from outcome-driven shortcuts. Insertion torque reflects the friction between the implant threads and the bone walls at the moment of full seating, it is the closest measurable proxy for primary stability in theatre, and primary stability is the prerequisite for immediate loading.

Below 35 Ncm, the implant-bone interface is mechanically insufficient to withstand the micromotion generated by a loaded provisional prosthesis. That micromotion disrupts the contact osteogenesis that initiates osseointegration, producing fibrous encapsulation instead of bone-implant contact. The immediate result is a provisionally stable prosthesis that feels secure; the 3-month result is an implant that has not integrated. This is the most preventable cause of All-on-4 failure, and it is prevented entirely by respecting the gate.

In the Stunning Dentistry 924-case series: 86.5% of patients receive a same-day fixed provisional. The 13.5% who fall below the threshold on one or more fixtures receive healing abutments, an immediate soft-tissue-supported denture (not a bare-gum discharge), and return at month 4 for the fixed provisional after confirmed osseointegration. The delayed-load group has the same 10-year implant survival as the immediate-load group, the only difference is trip sequencing.

At Stunning Dentistry, the torque reading is shared with the patient on the day of surgery, not retrospectively in a clinical note. If the reading is 32 Ncm rather than 38, the patient knows, the clinical team knows, and the provisional is not fitted. No same-day provisional is fitted at Stunning Dentistry to meet a patient's schedule expectation rather than to meet the biomechanical threshold.

Pain and Sedation

All-on-4 surgery is performed under local anaesthesia. IV sedation (Midazolam + Propofol, monitored by an anaesthetist throughout) is available to every patient who requests it and is the standard at Stunning Dentistry for international patients undergoing implant surgery, it eliminates awareness of the procedure without the risks of general anaesthesia. Nitrous oxide inhalation sedation is available as an adjunct for anxious patients who prefer not to be IV-sedated.

The post-surgical experience involves 2–5 days of mild-to-moderate swelling and soreness. Swelling typically peaks at 48–72 hours and resolves within 5–7 days. Paracetamol plus ibuprofen per the NZ Formulary manages this effectively for most patients. The written post-operative protocol provided at discharge includes the escalation threshold: persistent pain unresponsive to standard analgesia, or acute swelling beyond day 5, requires same-day contact with the clinical team.

The soft-diet calendar during the provisional phase (weeks 1–12) is the most sustained adjustment New Zealand patients report. Kiwi-kitchen-friendly options: pumpkin soup, mashed kūmara, soft-poached eggs, scrambled eggs, flaked terakihi or snapper, natural yoghurt, hokey pokey ice cream (softened), mashed banana, avocado, soft-steamed broccoli. Avoid: crunchy bread, hot steak, raw apples and carrots, pineapple, nuts, and anything requiring incisor force for weeks 1–12.

At Stunning Dentistry, the pre-surgical protocol includes written sedation consent specifying the anaesthetic agent, monitoring protocol, and discharge criteria. The anxiolysis pathway, Zoom consultation the week before surgery to walk through the day-of-surgery sequence minute-by-minute, is available to any patient who requests it. Surgical anxiety is a clinical reality, not a personal weakness, and the protocol accounts for it explicitly.

Risk Transparency

Escalation pathway (New Zealand patients):

Non-clinical: Ella Watson → Kiran Madhav → Clinical Director

Clinical: Ravi Sharma → Clinical Warranty Committee → Australasian prosthodontist consultant (Auckland/Sydney/Melbourne rotating)

Claim Boundaries

All-on-4 outcomes are among the best-documented in implant dentistry. The evidence base spans 25 years and multiple independent institutions. The survival numbers above are from the largest published series. Individual outcomes, however, depend on factors that are measurable before surgery (bone density, HbA1c, smoking status) and on factors that are managed after surgery (maintenance compliance, night-guard use, oral hygiene).

Lifetime implant warranty at Stunning Dentistry: covers implant failure to integrate (primary failure) and premature implant loss (secondary failure), excluding documented neglect or trauma. The warranty is exercised through the written warranty document issued at definitive delivery, it specifies coverage, exclusions, the claim process, and the escalation pathway. There is no verbal warranty at Stunning Dentistry. If it is not in the written document, it does not exist.

Clinical Success Determinants

Healing Timeline

Retreatment and Alternative Options

The most common All-on-4 retreatment scenarios are: a failed primary implant replaced after 3-month healing (occurs in 2.1% of the SD series; Category A warranty covers re-trip and replacement); a peri-implantitis case requiring debridement and possibly one implant removal and replacement (occurs in ~8% at 10 years, conditional Category B coverage); and a definitive prosthesis fracture requiring replacement (under 0.5%, Category A).

Conversion from All-on-4 to All-on-6 mid-treatment is uncommon but available where initial bone density was underestimated at CBCT review and cantilever stress distribution requires the additional posterior implants. This is documented at the pre-surgery planning review and does not represent a failure of the original plan, it represents honest intraoperative assessment.

Cost Logic, NZD Out-of-Pocket Reality

All-on-4 Both Arches, Total NZD Out-of-Pocket

Single arch: Clinical fee NZD 14,500–19,800 at Stunning Dentistry vs NZD 38,000–52,000 in New Zealand.

Insurance and funding:

• ACC: not applicable unless dental damage is accident-related. If tooth loss resulted from a covered accident, lodge an ACC45 claim before planning.
• Southern Cross, nib NZ, Accuro, UniMed, Partners Life: Most dental implant procedures are excluded from standard policies. Higher-tier Major Dental benefit caps (NZD 1,000–2,500/year) may partially offset costs. Itemised invoices with NZDA item descriptors issued for all claims.

Post-Treatment Biological Reality

The All-on-4 prosthesis functions as a biological prosthesis after delivery, it loads the bone through the four fixtures, it is cleaned around the gingival margins daily, and it is monitored annually for bone-level stability. Three things keep it working for 15+ years: night-guard use every night, professional hygiene every 6 months, and annual radiographic bone-level review.

The prosthetic care pathway for New Zealand patients uses the Stunning Dentistry NZ hygienist network: vetted hygienists in Auckland, Wellington, Christchurch, Hamilton, Tauranga, Dunedin, Palmerston North, and Queenstown who are familiar with implant-supported prostheses on Straumann and Nobel Biocare platforms. The hygienist roster contact is provided at definitive delivery. The annual radiographic review is conducted via upload to the clinical portal and reviewed by the assigned prosthodontist at the Zoom annual check-in.

The home-dentist handover document, full CBCT (DICOM), intraoral scan (STL), operative record, prosthesis design file, and manufacturer warranty documentation, is prepared and transferred to the patient's New Zealand dentist with consent at definitive delivery. Any NZ dentist or implantologist familiar with Straumann or Nobel Biocare components can service the prosthesis indefinitely through Australasian dental laboratories.

At Stunning Dentistry, the biological reality of year 8 is as well-documented in the patient file as the reality of day 4. The 924-case cohort includes patients at year 12 and year 15 of follow-up. What is observed at those timepoints is what the post-treatment protocol is designed to produce: bone levels within the Albrektsson threshold, screw integrity maintained by annual re-torque, and prosthetic surfaces showing measurable but clinically insignificant wear. The protocol produces the outcome. The outcome requires the protocol.

Common Mistakes

The most consequential mistake in the All-on-4 market is choosing a clinic based on price without verifying the implant brand, the surgical guide protocol, and the written warranty. An All-on-4 at 50% of the standard cost typically means unlisted implants (no 10-year published data), freehand surgery (±5 mm placement error vs ±0.3 mm guided), and a verbal warranty. The patient will not know the difference on day 4 in India. They will know the difference at month 24 in Auckland.

The most common patient-side mistake is not respecting the 12-week soft-diet protocol. The provisional phase is the osseointegration period, the four fixtures are accruing bone-implant contact from approximately 25% on day 4 to over 70% by month 3. Hard foods during this period create micromotion that disrupts contact osteogenesis. The fracture is not the problem; the micromotion is. It takes 3 months to regain what a single hard carrot can compromise in a moment.

The third mistake, specific to the NZ context, is treating the India pathway as a one-off event rather than a long-term clinical relationship. The post-operative protocol, the annual review, the maintenance hygienist visits, the night-guard renewal at year 5, these are not optional follow-ons; they are the second half of the treatment. Patients who engage the maintenance pathway show complication rates that track the published Maló and Pjetursson data. Patients who do not, do not.

At Stunning Dentistry, every NZ patient leaves with a written 10-year maintenance calendar, annual review dates, hygienist visit schedule, night-guard replacement milestone, screw re-torque protocol, and the radiographic upload instructions for the annual Zoom review. The calendar is not aspirational; it is part of the clinical record.

Myth Deconstruction

People Also Ask

Will I leave India with fixed teeth?

86–88% of patients do. 12–14% leave with a soft-tissue-supported immediate denture (healing abutments in place) and return at month 4 for the fixed provisional. No cost difference between the two groups. The provisional decision is made in theatre based on the torque reading.

Is All-on-4 reversible?

No. Extraction of existing natural teeth, where part of the All-on-4 plan, is irreversible. Implant placement is reversible only in the sense that implants can be removed; the bone and soft tissue changes from extractions are permanent. This is why the diagnostic phase, the CBCT review, and the candidacy assessment are non-negotiable before committing.

How does All-on-4 compare to All-on-6 in cost at Stunning Dentistry?

All-on-4 (both arches): NZD 27,500–37,000 clinical fee. All-on-6 (both arches): NZD 32,000–44,000 clinical fee. The additional cost reflects two more fixtures per arch. For most patients, All-on-4 is the clinically and financially appropriate choice. For bruxism or high bite-force profiles, the All-on-6 premium is justified biomechanically.

Can my New Zealand dentist maintain All-on-4 after I return?

Yes. Straumann and Nobel Biocare platforms are standard in every Australasian implant practice. Records, CBCT (DICOM), STL scan, operative notes, component specifications, are transferred to the patient's NZ dentist with consent. Any NZ implantologist can service the prosthesis through Australasian dental laboratories.

Does ACC cover All-on-4?

Only if tooth loss is demonstrably caused by a covered accident (sporting injury, fall, motor vehicle crash). Generalised caries, periodontal disease, and natural tooth loss are not accident-related. If you have a documented accident component, lodge an ACC45 claim before planning.

How long does All-on-4 last?

The Maló Clinic's 18-year data shows 93% cumulative implant survival and 99% prosthetic survival. Individual outcomes depend on bone quality, maintenance adherence, smoking status, and systemic health. With nightly night-guard use, 6-monthly hygiene, and annual review, most All-on-4 restorations function well beyond 15 years.

Related Treatments

• All-on-6 Dental Implants, Six-implant variant; better load distribution for bruxism and high bite force
• Zygomatic Implants, For severe posterior maxillary atrophy where All-on-4/6 cannot be placed
• Teeth in a Day, The immediate-loading provisional component of All-on-4/6, fixed teeth placed the same day as surgery
• Full Mouth Rehabilitation, For partially salvageable dentitions where hybrid tooth-and-implant reconstruction is appropriate
• CBCT Planning, Cone beam CT; foundational imaging for any All-on-4 surgical guide
• Guided Implant Surgery, Printed surgical guide from CBCT plan; reduces placement error from ±5 mm to ±0.3 mm
• Bone Grafting, Alternative to tilting in patients with moderate bone loss who prefer a grafted vertical approach
• Sinus Lift, For patients with posterior maxillary atrophy who prefer vertical implants over the tilted All-on-4 arrangement

Book a Consultation

If you are unsure whether All-on-4 is the right treatment, or whether the India pathway makes sense for your case, request a remote CBCT review.

The review is free. If All-on-6, zygomatic, or a simpler intervention is more appropriate for your bone volume and bite-force profile, we will say so in writing.

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Diagnosis precedes decision.

Clinical Review and Authority Block

Reviewed by: Dr. Priyank Sethi, MDS Prosthodontics, Ph.D. in Dentistry

Clinical Board: Dr. Ravi Sharma (Oral & Maxillofacial Surgeon), Dr. Kiran Madhav (Director, Implant Prosthodontics)

Last Updated: May 2026

Protocols aligned with the Maló All-on-4 clinical protocol and DCNZ implantology standards. Data referenced from Maló et al. (CIDRR 2019), Pjetursson et al. (COIR 2012), and the Stunning Dentistry 924-case series. NZD costs current as of May 2026.

Stunning Dentistry | Forbes #1 Dental Clinic in India, 4 Consecutive Years | AAID, AACD, BACD Accredited