A patient called Margaret — the name is changed — came in three years after having a full-arch monolithic zirconia bridge placed on four implants at an overseas clinic. The headline price had been a fraction of the domestic quote. The radiograph she handed me showed the implants in approximately the positions the procedure intended. The bridge had fractured at the posterior cantilever six months after delivery and had been repaired by her domestic dentist; the repair had failed; the screws on the two posterior implants had loosened twice in the intervening eighteen months; one of the implants was now showing 4 mm of marginal bone loss circumferentially. She wanted to know what came next. The honest answer, in her case, was that the prosthesis was at the end of its serviceable life and that the underlying implant configuration was not going to support a redesigned prosthesis without further surgery she had not budgeted for.
Margaret’s case is not common, but it is also not rare. It is the case the original All-on-4 protocol was designed to produce the opposite of, and the case the high-volume dental tourism version of the procedure produces with measurable frequency. The procedure is real. The procedure works. The procedure also has a small set of conditions that have to be met for the published five-year survival data to apply to the patient sitting in the chair, and the procedure is the largest single dental purchase most patients will ever make. This piece is the patient-side reference. It is intended to allow a patient considering All-on-4 — at home or overseas — to evaluate the plan being offered against the published evidence on what the procedure actually requires.
I will say what this piece is and is not. It is a reference. It is not a recommendation in any individual case. The decision is clinical, and the clinical decision belongs to the patient and a treating clinician who has examined them. The framework below is the patient-side filter that should sit in front of that decision.
What All-on-4 actually is
All-on-4 is a procedural concept: four implants per arch, placed in defined positions to allow a full-arch fixed prosthesis without the bone grafting that older protocols often required [2]. Two implants are placed vertically in the anterior region — typically in the lateral incisor or canine positions — where bone volume is most reliably adequate. Two implants are placed at a posterior angulation, usually around 30 to 45 degrees from the vertical, to engage available bone without requiring sinus lift in the maxilla or compromising the mandibular nerve in the mandible. The four implants are connected via multi-unit abutments to a single full-arch fixed bridge.
The procedural concept was developed and patented by Paulo Maló in the early 1990s and was associated with the Nobel Biocare implant system, although the same procedural geometry is now provided by most major implant brands and many smaller ones. The literature on the procedure has matured to the point where the survival data, the failure modes, and the case-selection criteria are documented in the published record [1] [2]. The marketing literature on the procedure has also matured to the point where the headline survival figures are widely quoted, often without the inclusion criteria the published trials enforced [3].
The procedure is performed in a single surgical visit, typically over four to eight hours, under intravenous sedation or general anaesthetic. Any remaining non-restorable teeth in the planned arch are extracted at the same visit. The implants are placed. Multi-unit abutments are seated. A provisional prosthesis — usually a milled acrylic bridge — is delivered the same day or within 48 hours, providing fixed teeth while osseointegration occurs. A definitive prosthesis is delivered at four to six months once the implants have integrated [3]. The patient leaves the same day with fixed teeth. They do not leave with a finished case.
The variants are All-on-6 (six implants instead of four, for patients with adequate bone for six positions and where the longer-term mechanical reliability of six is preferred), All-on-X (a generic marketing term covering both), and zygomatic-implant variants for patients with severely resorbed maxillae. The procedural concept is the same. The case-selection criteria are the same. The failure modes are the same.
Who is a candidate, and who is not
The procedure was designed for the fully edentulous adult, or the adult whose remaining teeth are independently assessed as non-restorable. The case-selection criteria the procedure presupposes are not, in my reading of the cases that arrive for retreatment, the criteria most high-volume clinics enforce.
The procedure assumes: a fully edentulous arch (or an arch in which the remaining teeth have been independently assessed as non-restorable on clinical and radiographic grounds by a clinician other than the one selling the procedure); adequate bone volume at the four planned implant positions, demonstrated on a CBCT scan reviewed in the patient’s presence [6]; no uncontrolled medical conditions that would compromise osseointegration (uncontrolled diabetes with HbA1c above 8%, immunosuppression, certain bone-affecting medications); no current smoking (or a documented cessation period before placement) [4]; no untreated periodontal disease; an occlusal scheme that has been worked out before the prosthesis is fabricated; absence of severe bruxism unless addressed with a documented prosthetic and occlusal-protection plan [7]; and a level of oral-hygiene self-care that allows the patient to maintain the prosthesis at home and to comply with the follow-up cadence.
A patient who has restorable natural teeth and is being recommended for All-on-4 has been advised against the procedure’s own indication. The honest plan in that scenario is to save the restorable teeth, and the patient is entitled to the alternative plan written out. A patient with uncontrolled diabetes, current heavy smoking, or untreated severe periodontal disease is not, on the published evidence, a patient at whom All-on-4 should be placed without addressing the underlying condition first. A patient with severe parafunction who has not had the parafunction screened, addressed, and incorporated into the prosthetic plan is at materially elevated risk of mechanical failure within the prosthesis’s expected lifespan [7]. None of these are theoretical concerns. They are the conditions that distinguish the cases that succeed at five years from the cases that arrive at my chair at three.
What the published survival data shows — and what it does not
Implant survival in well-selected All-on-4 cases at five years is reported in the published literature in the 94–98% range across multiple cohorts. This is the headline number that is widely cited in clinic marketing. It is, in the populations the trials enrolled, a real number. It is also a number that depends on the inclusion criteria the trials enforced — case selection, smoking exclusion, periodontal-disease exclusion, parafunction screening, defensible occlusal scheme, follow-up cadence. A high-volume clinic that does not enforce those inclusion criteria does not, by default, produce the trial populations the success figures came from [1] [3].
Prosthesis survival is a different question from implant survival. The implant survives — i.e., remains osseointegrated and functional — at the rates above. The prosthesis the implant supports is a separate mechanical object with its own failure modes: screw loosening, prosthesis fracture (especially at the cantilever), wear of the occlusal surface, debonding of the prosthesis from the multi-unit abutments, fracture of the milled framework. Published prosthesis-survival data is materially lower than implant-survival data at the same time point, and the gap is dominated by the high-load prostheses on cantilevers above the consensus length and on occlusal schemes that have not been worked out [2] [3].
The ten-year and longer data on All-on-4 is, in 2026, thinner than the five-year data. Specialist-led prosthodontic series report ten-year implant survival in the 87–93% range and prosthesis survival materially lower than that, with the leading failure modes being peri-implantitis on the implants and material fatigue on the prosthesis [4]. The published ten-year data is not yet available in volume from the high-volume dental-tourism cohorts, because those cohorts only began producing material patient volumes a decade ago and the follow-up tracking on returned patients is, by the structural design of cross-border treatment, limited.
The patient considering All-on-4 in 2026 is making a decision on five-year survival data from selected populations. The ten-year and twenty-year picture for the procedure is still being written. That is not an argument against the procedure. It is an argument for placing the procedure in patients who fit the inclusion criteria the trials enforced, and for placing it under a follow-up cadence that gives the patient a fighting chance of catching a developing problem before it becomes a prosthesis-replacement problem.
The seven elements of a defensible plan
A defensible All-on-4 treatment plan, in my reading of what the published evidence asks for and what my own retreatment caseload tells me distinguishes the cases that hold up from the cases that do not, contains the following seven elements. A plan missing any of them is not, on this framework, a plan at the standard the procedure requires.
A CBCT scan reviewed in the patient’s presence, in the planning consultation, with the planned implant positions and angulations marked on the scan. Panoramic radiographs alone are not adequate planning imaging for a full-arch implant case. The CBCT provides the bone volume, the relationship to the maxillary sinus, the mandibular nerve canal, the buccolingual width of the alveolus, and the anterior loop of the mental foramen [6]. A clinician planning All-on-4 without a CBCT is operating on imaging that is not adequate for the procedure they are recommending.
A written list of alternatives considered, and the reason each was excluded. The alternatives include retention of restorable teeth where present; an implant-retained overdenture on two to four implants (a different procedure with a different patient profile and a different cost); a conventional complete denture; a tooth-supported fixed bridge where remaining teeth allow it. A plan that does not list the alternatives considered is a plan that has not done the comparative work.
A staged timeline that respects osseointegration. The provisional prosthesis is delivered immediately. The definitive prosthesis is fabricated and delivered after four to six months of integration. A plan that delivers the definitive prosthesis on the same trip as the surgery is a plan that has subordinated the osseointegration timeline to the patient’s flight schedule. Osseointegration is biology; flights are scheduling. The biology does not negotiate.
A documented occlusal scheme. Centric relation registration. Anterior guidance. Posterior disclusion. The occlusal scheme is the difference between a prosthesis that survives parafunction and one that does not. A plan that does not describe the occlusal scheme has not done the occlusal work.
A cantilever length under the consensus upper limit of 10–15 mm, calculated from the most posterior implant. The calculation should be in the plan. A plan that does not specify the cantilever length is a plan in which the most predictive single variable for mechanical failure has not been engineered.
A written aftercare protocol. Hygiene technique. Interdental brush size. Water flosser use. The peri-implant maintenance schedule and what it costs in the destination country and at home. A plan that does not address aftercare assumes the patient will work it out, and patients who work it out unaided are the patients whose prostheses arrive at my chair three years later with peri-implantitis. See the dental tourism trust gap for the structural argument behind why this aftercare gap recurs in cross-border treatment.
A named prosthodontic-trained colleague reviewing the case at the planning stage, where the placing surgeon is not themselves prosthodontically trained. Full-arch prosthetic planning is its own clinical discipline. The clinician who places the implants may or may not be the clinician with the prosthodontic depth to plan the prosthesis they will support. A plan that does not name a prosthodontically trained second clinician is a plan in which the prosthetic side has been treated as a downstream consequence of the surgical decision, when it is — in the cases that succeed — the upstream constraint on it.
Cost in Q2 2026, across ten countries
The cost numbers below are quoted prices collected in Q2 2026 from published clinic price lists and from quoted treatment plans the publication has reviewed. They cover a single arch of four implants, with multi-unit abutments, provisional prosthesis at delivery, and definitive monolithic zirconia prosthesis at the four-to-six-month review. They include the standard implant and prosthesis fees and the follow-up visits within the first twelve months. They do not include the CBCT scan, the diagnostic workup, the extraction fees if extractions are required at the same visit, parafunction-related night-guard fabrication, or domestic remediation if complications arise after return from an international clinic.
| Country | Range (local currency) | What the price typically excludes |
|---|---|---|
| Australia | $22,000–$35,000 AUD per arch | CBCT often separate ($250–$400); zygomatic alternatives extra |
| New Zealand | $22,000–$32,000 NZD per arch | CBCT often separate; specialist-led pricing higher |
| United Kingdom | £14,000–£25,000 GBP per arch | Premium clinics higher; CBCT sometimes included |
| United States | $20,000–$35,000 USD per arch | Wide regional variation; specialist-led pricing higher |
| Canada | $20,000–$30,000 CAD per arch | Provincial variation; CBCT often separate |
| Hungary | €6,500–€11,000 EUR per arch | Inclusive of basic monolithic zirconia |
| Turkey | $5,500–$12,000 USD per arch (Antalya high-volume); $9,000–$16,000 (İstanbul premium) | Wide variation by clinic tier; aftercare often not included |
| Thailand | $9,000–$17,000 USD per arch | Bangkok premium tier toward higher end |
| Mexico | $9,000–$18,000 USD per arch | Border-clinic tier lower; Mexico City premium higher |
| Vietnam | $5,500–$13,000 USD per arch | Wide range; what’s included varies materially |
Cost figures are quoted Q2 2026 prices. Currency drift, fee-schedule revision, and clinic-tier shifts will change these figures over time. The publication updates this reference quarterly.
For the underlying domestic cost-coverage picture in Australia and New Zealand — the reason the offshore arithmetic looks attractive — see the dental care costs in Australia reference and the New Zealand reference. For the procedure-level critique of the high-volume version of the procedure, see zirconia full-arch when it’s the wrong answer. For the cost of a single implant rather than a full arch, see the implant cost-by-country reference. For the long-read on the four-country source-market coverage failure that produces the demand for this procedure, see the dental care access crisis.
The eight questions to ask before signing
A patient evaluating an All-on-4 plan — at home or overseas — can ask the questions below by email before paying any deposit. The quality of the answers, in my experience reviewing returned cases, distinguishes the clinics that produce the trial-population outcomes from the clinics that produce the cases I retreat.
What implant brand and fixture system are you placing, and what is your survival data at five and ten years on that system in the All-on-4 configuration in your own caseload? Named brand. Documented in the plan. A clinic that cannot answer is not in a position to defend the choice.
What is the CBCT-derived cantilever length you have planned, and what is the calculation that produced it? Numerical answer. Under 15 mm.
What is the occlusal scheme — centric relation registration, anterior guidance, posterior disclusion — and how was it derived? Specific terms. A plan that hand-waves on this has not done the occlusal work.
Have I been screened for bruxism, and if so what is the management plan in the prosthesis design and the aftercare? Documented screening. Documented management plan.
What is the timeline between fixture placement and definitive prosthesis delivery, and where will each step take place? The biology requires four to six months between integration and definitive prosthesis. A plan that does not allow that time has subordinated biology to scheduling.
Who is the named prosthodontically-trained clinician reviewing this plan, and may I see their credentials? Named clinician. Real credentials. A plan in which the surgical placement and the prosthetic design are both done by a single non-prosthodontically-trained clinician without external review is a plan with no second set of eyes on the prosthetic side.
What is the documented follow-up cadence, and where do I do the follow-up? Written cadence (one-week, three-month, six-month, twelve-month, then annual). Named domestic clinic for follow-up if the placement is overseas, or a defensible plan for return visits to the destination clinic.
What is the warranty, what entity warrants it, and what is required of me to claim under it? Named warrantor entity. Jurisdiction of incorporation. The continuity-of-care obligations of the returning Australian dentist are documented in the cross-border dental liability review for Australian patients; a warranty that requires return travel to a country where the patient cannot reasonably return is a warranty of limited practical value.
A clinic that answers all eight clearly is a clinic operating to the standard the procedure asks for. A clinic that deflects, that responds with marketing language, or that does not respond is providing information of a different kind.
Follow-up — the procedure does not end at the prosthesis delivery
The most common pattern I see in the failed All-on-4 cases that arrive in my chair is not a surgical failure. It is a follow-up failure. The implants integrated. The prosthesis was delivered. The patient returned home. The follow-up cadence was either not specified or not maintained. By the time the patient presented with a symptom, the underlying problem had progressed past the point where it could be managed without major intervention.
The follow-up cadence the procedure presupposes is not optional. One-week soft-tissue check. Three-month review with imaging. Six-month review with periodontal/peri-implant probing and bite check. Twelve-month review with full-mouth radiographs, peri-implant probing, screw torque check, and prosthesis assessment. Annual review thereafter, with full-mouth radiographs every two to three years. Peri-implant maintenance hygiene visits at three to six monthly intervals depending on individual risk. Night-guard wear if parafunction has been identified.
For a patient who has had the procedure performed overseas, the follow-up cadence has to be built before the trip. An identified domestic clinic that has agreed to see the patient at the cadence above, in writing, at a defined fee. Not “I will find someone when I get home.” The general dental capacity in the Australian primary-care market is running at sustained utilisation; the recall appointment is not available on short notice. The follow-up arrangement is part of the procedure, not a downstream administrative task.
What this reference is for, and what it is not
This is a reference. It is not a recommendation. The decision to undergo All-on-4 is a clinical decision that belongs to the patient and a treating clinician who has examined them, reviewed their imaging, taken their history, and assessed their alternatives. The reference above sets out what the procedure is, who the trials say it is for, what a defensible plan contains, what it costs, and what to ask. The patient who has read it and is considering the procedure is in a better position to evaluate the plan in front of them than the patient who has not. That is what a reference is for.
For the trial-level companion on implant-related evidence and the external-validity question the procedure presupposes, see the Scandinavian implant registry trial review. For the procedure-level critique of the high-volume international version of the procedure, see the zirconia full-arch review and the Antalya sinus implant case review. For the upstream procedure decision on whether the natural teeth being recommended for extraction in order to enable All-on-4 should in fact be saved, see when to save a tooth and when to replace it and vital pulp therapy vs root canal. For the upstream procedure decision on whether bone grafting recommended as part of an All-on-4 plan is actually indicated, see why most dental implants do not need bone grafting. For the cross-border policy companion, see the cross-border dental liability review for Australian patients. For the structural account of why the patient cannot, from a clinic’s website, evaluate any of the elements of a defensible plan, see the dental tourism trust gap. For the technical companion on the infection-control axis a defensible plan presupposes, see the dental sterilization standards long read.
Sources
- Wikipedia. Dental implant. https://en.wikipedia.org/wiki/Dental_implant
- Wikipedia. All-on-4. https://en.wikipedia.org/wiki/All-on-4
- Wikipedia. Osseointegration. https://en.wikipedia.org/wiki/Osseointegration
- Wikipedia. Peri-implantitis. https://en.wikipedia.org/wiki/Peri-implantitis
- Wikipedia. Edentulism. https://en.wikipedia.org/wiki/Edentulism
- Wikipedia. Cone beam computed tomography. https://en.wikipedia.org/wiki/Cone_beam_computed_tomography
- Wikipedia. Bruxism. https://en.wikipedia.org/wiki/Bruxism
- Australian Institute of Health and Welfare. Oral health and dental care in Australia. https://www.aihw.gov.au/reports/dental-oral-health/oral-health-and-dental-care-in-australia
- Therapeutic Goods Administration. https://www.tga.gov.au/