Replacing a whole arch of teeth with a fixed bridge on four to six implants goes by a lot of names: All-on-4, All-on-6, All-on-X, teeth in a day. It is a genuinely good treatment for the right patient. It is also the most heavily advertised procedure in dentistry, and almost all of that advertising comes from the surgical side.
So here is the part the ads leave out. Two different clinicians do two different halves of this case, and the half you actually live with is the second one.
A full arch replaces twelve teeth and fourteen roots with one prosthesis carried on four implants. The back implants are tilted, commonly around thirty degrees although the angle is chosen per case rather than fixed, so the arch can be carried on bone that is already there instead of bone that has to be built. The teeth beyond the rearmost implant are the cantilever, and that span is what decides whether a titanium substructure is needed underneath the zirconia.
What we do, and what we do not
We do not place the implants. That is surgery, and it belongs with a surgeon who does it routinely, in a surgical setting, the same way we handle every other surgical procedure. The surgeon does the 3D imaging and the implant planning, and performs the surgery.
We plan the case with them from the restorative side, which is a different set of questions: where the teeth need to sit, what the bite has to do, how much vertical room the prosthesis needs, and what the finished arch has to look like. Those answers have to exist before anyone drills, because implant position is decided by where the teeth are going.
The surgeon places the foundation. We build what goes on top of it, and we look after it for as long as you have it. That is the arrangement, stated plainly, and we would rather you know it before the first appointment than after.
The provisional: same day, or the morning after
The fixed temporary bridge is ours, and when you receive it is a clinical decision rather than a marketing promise.
Sometimes we deliver it the same day. Often we deliver it the following day, once you have properly woken up from the surgery. Same-day delivery is what gets advertised, so the next-day version can sound like a compromise. In our experience it is usually the better appointment.
By the next morning you are alert, the anesthetic has worn off, and you are far more comfortable. You can also tell us how the bite feels and what you think of the teeth. Fitting a set of teeth you will wear for months to someone who is still coming out of sedation is not the way to get that right.
The other job of the provisional is the one nobody mentions: it is a working prototype. You wear it for months. How it looks, how you speak with it, where it catches food, how it feels when you chew, all of that is information, and all of it gets designed into the final prosthesis. A case where nobody uses the provisional that way is a case where the permanent teeth are a first attempt.
The final: monolithic zirconia
What we deliver as the definitive restoration is a monolithic zirconia bridge, screw-retained.
Both halves of that sentence are deliberate.
Zirconia, because the long-term data has now arrived. As recently as the 2018 ITI consensus, monolithic zirconia full-arch prostheses were described as a possible future option pending more evidence. That evidence has since been published: a series of 115 monolithic zirconia full-arch prostheses in 71 patients reported a 98.6% survival rate over a mean of about five years, with two fractures. The common problems were minor and fixable.
Papaspyridakos P et al. Zirconia full-arch implant prostheses: survival, complications, and prosthetic space dimensions with 115 edentulous jaws. J Prosthodont. 2025;34(3):271-280.
Screw-retained, because it can come off. A systematic review comparing screw-retained with cemented full-arch restorations found the trade-off is real in both directions: cemented cases had more biological complications, including implant loss and bone loss over 2 mm, while screw-retained cases had more technical ones, mostly screws loosening or fracturing. The reason the reviewers still preferred screw retention is retrievability. A loose screw on a screw-retained bridge is an appointment. The same problem under a cemented bridge can mean destroying the restoration to reach it.
Gaddale R, Mishra SK, Chowdhary R. Complications of screw- and cement-retained implant-supported full-arch restorations: a systematic review and meta-analysis. Int J Oral Implantol. 2020;13(1):11-40.
And occasionally, a titanium bar underneath. Most cases do not need one. Where the design calls for it, most often a long cantilever, we reinforce the zirconia with a titanium substructure. Zirconia is very strong, but it is still a ceramic, and long unsupported spans are exactly where ceramics are least forgiving. That is an engineering decision made case by case, not a house style we apply to everyone.
Design a full arch so that the predictable problems are serviceable, and the predictable problems stop being disasters. That is most of what separates a twenty-year restoration from a five-year one.
All-on-4, All-on-6, All-on-X: what the number means
The number is simply how many implants carry the arch. All-on-X is the generic way of saying the number is decided per patient rather than fixed in advance.
More implants is not automatically better. The ITI consensus on this is that the literature supports a range of implant numbers for supporting a full-arch fixed prosthesis, and that deliberately tilting implants is appropriate when the conditions call for it. How many, and at what angle, is a surgical judgment driven by how much bone is there and where it is. It is not a package you should be choosing off a price list.
What we would say about survival, since the numbers get quoted at people constantly: reported implant survival for this approach is very high, commonly cited around 99% in the short term, and reviews of the literature are candid that follow-up is often short, samples get lost along the way, and peri-implant disease is common enough that survival alone is a thin measure of success. A tooth that is still attached is not the same as a result that is working.
When a full arch needs redoing
This is a real and growing part of what we see, and it splits into two situations that deserve to be told apart.
Some of them are ours
We are now redoing full arches that we restored fifteen and twenty years ago. In most of those cases nothing went wrong in the sense of a mistake. That is what the end of a service life looks like.
Most of them were built the way the whole profession built them at the time: a titanium bar wrapped in acrylic, with denture teeth set into it. That construction works, and it wears. The acrylic abrades, teeth wear flat or break away from the bar, and after two decades of chewing there is often not enough left to repair. Watching that happen over twenty years is a large part of why we deliver monolithic zirconia now.
Sometimes the prosthesis is not the only thing that needs replacing. Where implants have been lost, new ones have to be placed before anything can be rebuilt on top, and that part of the case goes back to a surgeon exactly as it did the first time.
This is the part the survival figures above cannot tell you, because very little of that research follows anyone for twenty years. We can tell you because we are still seeing the same patients. A full arch is a restoration with a service life, not a permanent fixture, and that is worth planning for rather than being surprised by.
And some of them are not
The rest arrive from somewhere else, and they tend to look like one of these:
- The prosthesis has fractured or the teeth have worn, often on an older acrylic bridge that has been in service a long time.
- Screws keep loosening, which is usually telling you something about the bite rather than about the screws.
- It cannot be cleaned. The arch traps food, the tissue underneath is inflamed, and nobody ever showed the patient how the underside is supposed to be maintained.
- The bite is wrong, and everything from soreness to fracture traces back to it.
- Nobody is taking responsibility. The surgical center points at the lab, the lab points at the dentist, the practice has closed, or the whole case was done in another country.
What we can usually do is assess the whole thing properly, and in many cases design and deliver a new prosthesis onto the implants that are already there. What we cannot do is fix implants that were placed in positions the teeth cannot work around. That is a surgical problem, it needs a surgeon, and we will tell you that on the day rather than after you have paid for a restorative plan that was never going to work.
One patient came to us after having crowns and bridges done abroad, unhappy with how they looked. The exam found the real problem was deeper: none of it fit, which had already caused gum disease and cost him several back teeth. See how we solved S.V.’s case →
The part nobody sells you
A full arch is not a set of teeth you stop thinking about. It is a prosthesis bolted to bone, and it needs maintaining.
That means professional cleaning of a surface you cannot reach at home, periodic checks on screws and on the fit, monitoring the bite as it changes, and watching the tissue around every implant for the inflammation that precedes bone loss. Peri-implant disease is the single most common reason a case that looked perfect at delivery is in trouble years later, and it is largely preventable if somebody is actually looking.
Being the practice that restores rather than the one that placed them, this is the half of the case we are built around.
Is this even the right option?
Sometimes the honest answer is no. Going to a full arch means committing to removing whatever teeth are left, and that is not a decision to make quickly because a seminar made it sound easy. If some of your own teeth are strong enough to build around, that is usually worth knowing before anything is extracted.
We will walk you through how this compares to individual implants, a bridge, or an implant-supported denture for your specific mouth, your bone and your budget, before anyone recommends anything.
Talk it through first
Whether you are considering this, already scheduled for it somewhere else, or living with one that is not working, a conversation costs you nothing. Call 702-734-0776 or tell us what is going on.