Plaque Accumulation Beneath Maxillary

All-on-4™ Implant-Supported Prostheses

Samer Abi Nader, DMD, MSc, FRCD (C);*†† Hazem Eimar, BDS, MSc;†,††
Moath Momani, BDS, MClinDent;‡ Ke Shang;§ Nach G. Daniel, DMD, BSc, MSc, FRCD(C);¶
Faleh Tamimi, BDS, MSc, PhD**

ABSTRACT
Background: Maxillary prostheses supported by four implants, following the All-on-4™ principles, have become an
accepted effective treatment for totally edentulous patients. Maintaining the hygiene of such fixed implant-supported
prostheses is challenging.
Purpose: The purpose of this clinical study was to evaluate the distribution of plaque on the fitting surface of All-on-4 fixed
prostheses in order to find new strategies for maintaining their hygiene.
Materials and Methods: Twenty All-on-4 maxillary fixed prostheses collected from 20 patients, 6 months after delivery, were
stained with methylene blue to disclose plaque accumulation at the fitting surfaces of the prostheses. Digital photographs
of the fitting surfaces of the prostheses were recorded and processed. The distribution of accumulated plaque was evaluated
statistically.
Results: The average percentage of area covered with plaque was 28 1 8% of the total area of the fitting surface of the
prostheses. The fitting surfaces of the prostheses had three times more plaque on the palatal area (52.5 1 7.33%) than on
the buccal area (17.3 1 7.33%, p < .05). The interimplant proximal areas of the fitting surface covered with plaque were high
when the distance between implants was short (r = −0.326, p = .014).
Conclusion: These findings suggest that the hygiene of the All-on-4 prostheses could be improved by maximizing the
distances between the inserted implants in the jaw, minimizing the prostheses’ palatal extension and guiding patients to
optimize their oral hygiene practices targeting the palatal area of their prostheses.
KEY WORDS: clinical study, fixed implant prosthesis, peri-implantitis, plaque accumulation, prosthesis hygiene

*Associate professor, Division of Restorative Dentistry, Faculty of
Dentistry, McGill University, Montreal, Quebec, Canada; †graduate
student, Division of Restorative Dentistry, Faculty of Dentistry,
McGill University, Montreal, Quebec, Canada; ‡prosthodontist at
Royal Medical Services, Jordanian Armed Forces, Amman, Jordan;
§
undergraduate DMD student, Faculty of Dentistry, McGill Univer-
sity, Montreal, Quebec, Canada; ¶oral and maxillofacial surgeon, East
Coast Oral Surgery Center (private practice), Moncton, New Bruns-
wick, Canada; **assistant professor, Division of Restorative Dentistry,
Faculty of Dentistry, McGill University, Montreal, Quebec, Canada
Corresponding Author: Faleh Tamimi, Faculty of Dentistry, McGill
University, 3640 University Street, Montreal, Quebec H3A 0C7,
Canada; e-mail: faleh.tamimimarino@mcgill.ca
††
Both authors contributed equally to this work.
© 2014 Wiley Periodicals, Inc.
DOI 10.1111/cid.12199
INTRODUCTION
The All-On-4™ fixed implant-supported prosthesis
(Nobel Biocare AB, Göteborg, Sweden) has been shown
to be an effective clinical treatment for totally eden-
tulous patients.1–6 This method of treatment aims to
restore adequate function and aesthetics with a fixed
prosthesis supported by four implants only.4,5 Clinical
studies report that this prosthesis has a good survival
and patient satisfaction rate and can be considered as an
alternative treatment for fixed prostheses over dentures
or conventional dentures.6,7 The success of any fixed
implant-supported prosthesis, such as All-on-4 pros-
theses, relies mainly on osseointegration of the dental
implants.8 Osseointegration can be compromised by
the presence of peri-implantitis,9–11 an inflammatory
process around the dental implant that leads to bone
loss and can cause loss of implants in the long term.12

1
2 Clinical Implant Dentistry and Related Research, Volume *, Number *, 2014
Fixed implant-supported prostheses, such as All-
on-4, are difficult to clean, and thus high levels of plaque
tend to accumulate on the surfaces of these pros-
theses.13,14 Consequently, the possibility of peri-implant
infection significantly increases with fixed implant-
supported prostheses, and this in return could limit
the survival rate of the provided dental treatment.15,16
Accordingly, we have conducted a clinical study to assess
plaque accumulation and topographical distribution on
the fitting surfaces of All-on-4 prostheses. The results of
this study can be adapted to develop new strategies for
better hygiene of fixed implant-supported prostheses,
including All-on-4 prostheses.
MATERIALS AND METHODS
The study was carried out in accordance with Decla-
ration of Helsinki guidelines and was approved by
the Research Ethics Committee of McGill University
Health Center. This study included dental records of
20 patients (9 males and 11 females), 50–77 years old
(mean = 61.8 1 7.6), treated by maxillary fixed implant-
supported prostheses following the All-on-4 concept. All
patients included in our study were medically fit and free
of any systemic or local diseases that might contraindi-
cate the placement of an implant. No patients were
excluded or lost to follow-up over the course of the
study.
The surgical procedure was done as described pre-
viously by Malo et al.4,5 Briefly, a mucoperiosteal flap
was raised at the ridge crest, with a relieving incision on
the buccal aspect in the molar area. An antrostomy
defect was created using a round bur for identification of
the exact position of the sinus antrum. Implant place-
ment sites were assessed using the All-on-4 surgical
guide. All patients received four dental implants (Nobel
Biocare AB) in their maxilla; two distally tilted implants
in the posterior region were positioned just anterior to
the maxillary sinus antrum, followed by two straight
anterior implants in the anterior maxilla. The length of
the immediately loaded implants ranged from 11.5
to 15 mm. The diameter of the inserted implants was
4 mm. All surgeries were done by the same surgeon.
Immediately following surgery, straight 17-degree-
angled multiunit abutments and internal. 30-degree-
angled multiunit abutments (Nobel Biocare AB) were
used to achieve relative parallelism of the implants
so that a rigid prosthesis would be seated in a
passive manner. An impression was taken with
polyvinylsiloxane impression materials (Express, 3M
ESPE, St. Paul, MN, USA), and a model was poured.
Implant-supported prostheses were then fabricated on
the model following the profile prosthesis concept
design, in which the prosthesis fitting surfaces are kept
in intimate contact with the alveolar ridge.17 Fitting of
each prosthesis on the alveolar ridge was evaluated
by visual inspection. The biting (occlusal) surface of
the prosthesis was fabricated following the opposing
mandibular teeth (n = 12) or prosthesis (n = 8). All
prostheses were fabricated and seated by the same
prosthodontist 3 to 4 hours after completion of the
surgery.
Upon completion of the surgical and prosthodontic
treatments, verbal and written oral hygiene instructions
were provided to all patients. Patients were notified to
avoid brushing and warm-water rinses for the first
postoperative week. A cold or room-temperature soft
diet was recommended for the first 24 hours follow-
ing surgery, followed by a semisolid diet for the
next 3 months. Patients were also instructed to use
chlorhexidine 0.12% mouthwash (Peridex, 3 M ESPE)
three times a day for the first 10 days after the treatment.
After day 10, patients were instructed to floss their
prostheses and alveolar ridge once a day using a dental
floss threader (GUM Eez-Thru Floss, Sunstar Americas,
Chicago, IL, USA) and an unwaxed dental floss (Johnson
& Johnson, New Brunswick, NJ, USA). Also, patients
were instructed to brush both the prosthesis and the
alveolar ridge with a soft toothbrush (Gum Delicate
Post-Surgical Toothbrush, Oral B–Gillette, Redwood,
CA, USA) using a low-abrasive toothpaste (Dentu-
Cream, Block Drug Co., Jersey City, NJ, USA) and
mouth rinse (Crest Pro-Health Multi-Protection,
Procter & Gamble Co., Cincinnati, OH, USA) three
times a day. Patients were recalled six weeks after surgery
and instructed to use an oral irrigator (WaterPik®,
Teledyne Hanau, Buffalo, NY, USA) once a day to clean
beneath the prosthesis. These irrigators are water pumps
that gently flush out food, debris, and bacterial toxins
from the surfaces of teeth, prostheses, and implants in a
highly efficient way.18–20
Following 6 months of function, the cleanliness of
the All-on-4 prostheses was examined as part of the
routine follow-up. Briefly, the prostheses were removed
and washed with tap water for 60 seconds before being
stained with a plaque-disclosing agent (methylene blue;
Henry Schine Company, Melville, NY, USA). Digital
 Fixed Implant Prostheses and Plaque Accumulation 3

photographs of the fitting surfaces of the prostheses

before and after staining were recorded and shown to
patients (as an educational tool for the patients) to iden-
tify plaque accumulation areas at the fitting surfaces that
needed special attention during the cleaning process.
The photos were processed with ImageJ 1.45s software
(National Institutes of Health, Bethesda, MD, USA). The
photographs were converted to monochromatic binary
images (Figure 1). Specific standardized thresholds were
established in order to distinguish the pixels that con-
tained plaque (blue) from those that did not (pink).
Average percentage of plaque covering the fitting
surface of the prostheses was calculated. Topographical
plaque distribution on the fitting surface of the prosthe-
ses was examined by measuring plaque covering the
following specific areas of the prosthesis fitting surface:
buccal, palatal, anterior, posterior, and interimplant Figure 2 A, Monochrome image of the fitting surface of the
proximal areas. The buccal and palatal areas of the pros- prosthesis, delineating buccal and palatal areas. B, Negative
image of A, showing plaque in black. C, Box-plot graph
thesis fitting surface were identified by drawing a curved comparing percentage area of plaque covering the buccal semi-
line that crossed the center of all implants and bisected arch of the prosthesis to that covering the palatal semi-arch.
the fitting surface (Figure 2, A and B). Anterior and pos-
erior interimplant proximal areas; the anterior inter-
terior areas of the prosthesis fitting surface were identi-
implant proximal area was the area between the most
fied as areas mesial and distal, respectively, to the centers
anterior implants (blue area, Figure 4, A and B), and the
of the most posterior implants (Figure 3, A and B). The
posterior interimplant proximal areas were the areas
interimplant proximal area was defined as the area of
the fitting surface within two curved tangent lines that
intersected all implants at the most buccal and palatal
points, respectively. The interimplant proximal area of
the fitting surface was divided into anterior and post-

Figure 3 A, Monochrome image of the fitting surface of the

Figure 1 A, Original dental digital image of the fitting surface
of an All-on-4 fixed implant-supported prosthesis. B, Cropped
image of A. C, Colorized image of B to facilitate thresholding.
D, Establishing the threshold for plaque recognition. E, Binary
image of D, showing plaque in black.
prosthesis indicating the anterior areas (distal to the posterior
implants) and posterior areas (mesial to the posterior
implants). B, Negative image of A, showing plaque in black. C,
Box-plot graph comparing percentage area of plaque covering
the anterior and posterior areas of the prosthesis fitting surface.
4 Clinical Implant Dentistry and Related Research, Volume *, Number *, 2014
Figure 4 A, Monochrome image of the fitting surface of the
prosthesis indicating anterior interimplant proximal area and
posterior interimplant proximal areas. B, Negative image of A,
showing plaque in black. C, Box-plot graph comparing
percentage of plaque area covering anterior interimplant
proximal area and posterior interimplant proximal areas of the
prosthesis fitting surface.
between anterior and posterior implants (red areas,
Figure 4, A and B).
The average percentage of plaque covering the
examined areas was calculated. Differences between
examined areas were conducted by paired Student’s
two-tailed t-test: the buccal area of the prosthesis fitting
surface versus the palatal area of the prosthesis fitting
surface (Figure 2, A and B); the anterior area of the
prosthesis fitting surface versus posterior areas of the
prosthesis fitting surface (Figure 3, A and B); and, finally,
the anterior interimplant proximal area of the prosth-
esis fitting surface versus the posterior interimplant
proximal area of the prosthesis fitting surface (Figure 4,
A and B).
The relationship between the percentages of plaque
coverage and the interimplant distance (shortest
distance between adjacent implants) was tested for
Pearson correlation. The correlation coefficient (r) and
the significance of the correlation (P) were calculated.
The statistical significance was set at p < .05. All the
statistical analyses were done with Origin 7.0 software
(Origin Lab Co; Northampton, MA, USA).
RESULTS
The average percentage of area covered with plaque
was 28.3 1 8.4% of the total area of the prosthesis fitting
surface. Plaque accumulation at the fitting surface of
the prostheses was not correlated with participants’ age
(r = 0.211, p = .488) or gender (p = 0.597, power = 0.075).
Plaque accumulation was significantly different on
the buccal and palatal areas of the prosthesis fitting
surface (p < 0.001, Figure 2C). The fitting surface area
covered with plaque was three times higher on the
palatal half of the prostheses (41.3 1 17.7%) than on the
buccal half (22.3 1 8.3%, power = 0.994, Figure 2C). No
significant differences were observed between the per-
centage of plaque on the posterior area of the prosthesis
fitting surface (33.4 1 17.1%) and that on the rest of
the prosthesis (28.4 1 11.8%, power = 0.167; Figure 3C).
The results also showed no significant differences
between the accumulated plaque on the anterior
(33.8 1 12.2%) and posterior (31.2 1 9.9%) inter-
implant proximal areas of the prosthesis fitting surface
(power = 0.212, Figure 4C).
The percentages of plaque accumulated inter-
proximally to the implants were significantly associated
with the distance between implants (Figure 5). This
association indicated that the shorter the distance
between implants, the more plaque accumulation
(r = 0.3345, p < .05).
DISCUSSION
In this study we provide the first clinical evidence for
plaque distribution on the fitting surface of All-on-4
fixed implant-supported prostheses. Based on our
Figure 5 Linear regression analysis that illustrates the relation
between the interimplant distance and the accumulated plaque
on the fitting surface of All-on-4 prostheses.

results, we discuss new strategies to improve the hygiene
level of these prostheses. In this study, plaque accumu-
lation on the fitting surfaces of All-on-4 prostheses was
identified using a disclosing solution. This method has
previously been used to evaluate and monitor hygiene
level of removable complete prostheses21–23; however,
this study is the first one to use this method in fixed
implant-supported prostheses.
We found that around one-third of the fitting
surface area of the prostheses was covered by plaque.
This high percentage of plaque accumulation on the
fitting surfaces of the prostheses might badly affect
the condition of the nearby soft tissues, promoting
their infection.24–26 Soft tissue infection might reach
tissues surrounding the implants, causing peri-implant
mucositis, which could subsequently develop into
peri-implantitis.27 Accordingly, keeping prostheses at
the optimum hygiene level is an essential preventative
procedure in order to minimize the probability of
peri-implant tissue infection.
Our study revealed that more plaque accumulates
on the palatal areas of the prosthesis fitting surface than
on the buccal areas (Figure 2C). This difference might be
related to the anatomy of the maxilla, in which the cur-
vatures of the upper jaw and the palate produce hidden
areas that are difficult to clean and consequently favor
plaque accumulation.22,23 Another problem that might
exacerbate the observed poor hygiene at the palatal area
of the fitting surface is the substantial difficulty in reach-
ing the palatal semi-arch when cleaning the maxillary
prosthesis.23 Another factor that might increase plaque
accumulation in palatal areas of the fitting surface is the
use of oral irrigators. Oral irrigators are usually used
from the buccal side during the cleaning process, and
this might force the plaque to accumulate on the palatal
area of the prosthesis fitting surface. However, future
research will have to be performed in order to confirm
these hypotheses.
Comparing results for plaque accumulation
between the other examined areas of the fitting surface
did not reveal significant differences within the 20
samples analyzed (Figure 3 and 4). Although this might
indicate that wearers of All-on-4 prostheses have good
cleaning access to these areas of the fitting surface,
further studies with a greater pool of fixed implant-
supported prosthesis samples are required to confirm
the results of this study. This study illustrated that
plaque accumulation on the interimplant proximal areas
Fixed Implant Prostheses and Plaque Accumulation 5
of the prosthesis fitting surface was influenced by the
distance between the inserted implants. These results are
aligned with previous clinical studies, in which it has
been shown that the wider the distance between inserted
implants, the less plaque accumulates on the surfaces of
these implants.28–30
These findings are of great relevance in dentistry, as
they have surgical, prosthetic, and hygienic implications.
Surgically, the results of this study highlight the im-
portance of wide distances between the implants that
support fixed implant-supported prostheses in order to
facilitate oral hygiene. Prosthetically, our findings on
plaque emphasize the importance of minimizing the
palatal extension of fixed implant-supported prostheses
in order to facilitate the cleaning process. Hygienically,
our results can be adapted as an educational tool to
guide patients in order to optimize their oral hygiene
practices targeting the palatal area of their prostheses.
CONCLUSION
One-third of the fitting surface in All-on-4 implant-
supported prostheses was covered with plaque. Plaque
accumulates more on the palatal areas of the fitting
surface of the prostheses than on the buccal areas.
Plaque accumulation was influenced by the distance
between implants. These findings suggest that the
hygiene of the All-on-4 prostheses could be improved by
maximizing the distances between implants, minimizing
prostheses’ palatal extension, and guiding patients to
optimize their oral hygiene practices targeting the
palatal area of the prostheses.
ACKNOWLEDGMENTS
The authors would like to acknowledge the McGill
Faculty of Dentistry’s Summer Research Scholarship
(KS), Le Réseau de recherche en santé buccodentaire et
osseuse (FT, HE), the Jordanian Armed Forces (MM),
Fondation de l’Ordre des dentistes du Québec (FT),
the Faculty of Dentistry of McGill University and the
Natural Sciences and Engineering Research Council
of Canada (FT), and Ministère du Développement
Économique, Innovation et Exportation (FT) for their
financial support.
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