Open Season for Japanese Visionaries …All-On-4 Style

August 5, 2016 | by Dr Alex Fibishenko
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If my first professional visit to Japan was synonymous with the famous Bullet Train, whilst similarly first class as a testament to my hosts and entourage, this one more closely resembled an overnight sleeper train …stopping all stations!

visited four cities in as many days, shuffling between airport, bullet trains stations and private cars, conducted three lectures in Tokyo, Nagoya and Osaka, and visited numerous high profile clinicians, …all that in humid 35 degree heat. But it was not as onerous as it sounds. I had the pleasure of meeting some very interesting people, and forged relationships that will likely be a basis to the establishment of a sub-economy in Oral Rehabilitation with Dental Implants. Let me explain …

You’ve Got To Be In It to Win It!

I have wanted to come back to Japan since my visit last December, so I gladly accepted the invitation from Nobel Biocare to come back and address some of the country’s most notable clinicians and implant study groups.

I planned to do this trip with my family, but it didn’t work out. I had to go alone …football always comes first. You see, my middle child had a game on …need I say more? As it turned out, it actually was a big game …a decider for the finals.

I was in Kyoto when the match was on. The back and forth texts with my wife during the game were a good distraction from the sizzling heat as I walked through the Geisha district with my concierge. The boys were losing badly after the first quarter. The coaches apparently yelled at them and told them that if they want to win, they have to play the game! They went into the second quarter 3 goals down, but they played the game …and they won 54-33.

This is not a blog about football, or my son, but what happened during my son’s game has a remarkable correlation to the motivational component of my lecture. You’ve got to be in it to win it. It applies to anything in life, like it applies to cutting edge surgery like All-On-4 dental implants treatment. Being in it does not mean being gung-ho and practising outside of depth of your knowledge or skill. But it does mean being aware of the possibilities to correctly advise your patients and to give them an opportunity to consider what is often a life-changing treatment with All-On-4.

We need to recognise that we don’t just treat teeth or jaws. We treat people who have jobs, social lives, families and hobbies, and whose entire lives can be affected by the state of their teeth.

Those patients are well aware that as dentists we are capable of dental treatment, what they want is a solution that gives them a freedom of life, not merely a never-ending cycle of drill-and-fill dentistry. They are often not aware of the possibilities, and rely on you as their dentist to consider those, regardless of your individual capacity to deliver any specific treatment. Those patients will do one of two things: they will either go on living their lives unhappy, in pain, embarrassed and/or introverted, or they will take their dental health into their own hand and will go from dentist to dentist until they find someone who gives them a solution. Both of those occasions are at a great loss to you as a caring and ethical clinician (and business owner).


When I got married, my mother said to my wife ‘please don’t try to change him’. My wife replied ‘Change is a very strong word, …improvement or progress might be more appropriate’.

People don’t like change …I get it. It pushes them out of their comfort zone and they fear the unknown. This is one of the reasons why the cutting edge treatment, All-On-4, is still not routine in every dental implants practice.

The All-On-4 market today still belongs to the visionaries, and it is still open season out there! This will continue to be the case until the mainstream gets over their fears and realises that dental implants are not new, that immediate loading is not new, and that what we do with All-On-4 is merely evolution. It’s “progress” not quite a change.

Nevertheless, from the vantage point of practicing in such a niche area of surgical dentistry, my bewilderment as to the slow pace of adopting progress by a broader spectrum of implant-dentists is admittedly quite possibly as ignorant as those dentists turning a blind-eye as to the actual progress to which I refer.

The Challenge

It’s been put to me that the regulations in Japan are such that dentists are not allowed to advertise their business. I have to say that this surprised me a little, because from what I have seen of Tokyo, it’s like New York Time Square on every second corner. Be it as it may, I am not looking to challenge the system or the culture, but there must be ways to make the public aware of treatments that could potentially help them. These might include the following:

  • Editorials and write-ups about the All-On-4 procedure to teach the public and stimulate them about exploring their options;
  • Running information evenings for patients;
  • Teaching more and more dentists about the efficacy and predictability of the All-On-4 treatment method;
  • Defining training paths for dentists to gradually build their knowledge and skills so as to be able to participate in one or another in the aesthetic, functional and social rehabilitation of their patient;
  • Internal marketing to an existing patient base.

All the above can be pursued, if not by the dentists themselves, then by relevant member-based organisations or study clubs, and can also be facilitated through the implant manufacturer Nobel Biocare;

A Sub-Economy

In business teaching your competition might not be a smart move. It may well be true that competition is good for business …the question is whose business? The advertising companies? The implant manufacturers? Is it good for “business”, or shall we say “good for the economy”? What about the dentists themselves?

From my personal experience, to change the perceptions and dogma in Australia, I couldn’t do it alone. I had to convince my counterparts about the validity and efficacy of All-On-4. I invited them to observe and trained many until they were convinced. 10 years later …they have become my competition.

I can certainly say that competition is good for the economy. But it’s also good for business. My business has not shrunk; it has grown and continues to grow.

Competition requires a higher financial commitment to ‘compete’, but it also creates more widespread and more frequent placement of information, which increases the chances for an individual to be exposed to the information multiple times, and which in turn increases the likelihood that an individual might go ahead and seek necessary treatment. It plainly and simply increases the pool of patients.

The other weird thing about implants is that they are not taught adequately or at all at university, and as such, dentists rely on private courses that are often sponsored by implant manufacturers and are primarily didactic in nature. But in a surgical discipline didactic training alone is not adequate. A high level of skill and dextrous ability is also required, which cannot be achieved without mentoring and supervision by more experienced mentors. But what incentive is there for mentors to teach their future competition?

The education of dentists and specialists, teaching them the required skills and the accumulation of experience takes time. Mentoring your less experienced counterparts is actually like another form of advertising, with only one difference: you don’t pay for it.

Through mentoring, the more clinicians become convinced by the efficacy of the All-On-4 procedure, the more they will speak to their existing and new patients about it, which again increases the pool of patients, and there will always be cases beyond the level of expertise of the less experienced clinicians, thereby creating a hierarchical referrals scheme …a sub-economy.

In my own practice I treat more and more complex cases that are often beyond the expertise of those who I previously trained …my competitors.


Speaking to a number of Japanese dentists during my visit, I came to realise that there are a number of common misconceptions in Japan:

1st Misconception: The Ti-unite surface is more prone to peri-implantitis compared to other implant systems and surfaces.

This is a myth and could not be further than the truth!

The Ti-unite surface is actually one of the important reasons that I use Nobel Biocare implants. It has been shown to lead to osseo-integration earlier than other implant surfaces, and maintains better stability throughout early healing (Glauser, Zechner, Ivanoff, etc.). Combined with a self-tapping implant design, such as that offered by the Nobel Active and Nobel Parallel systems, it is the most advanced surface available today for immediate loading and immediate function.

When also combined with a platform shift and Morse-taper micro-seal, such as that offered by a Conical Connection system, the bone levels are extremely stable over time. I have seen this phenomenon in my personal experience.

The misconception about the Ti-unite surface is a product of discredited bad publicity by competitors who highlighted one study in dogs where the Ti-Unite surface had a higher degree of peri-implantitis compared to other surfaces. The study did not relate to any kind of clinical situation because the inflammation around the implants was induced with ligature wires.

In real-life clinical situations, in the unlikely event that the Ti-unit surface is ever exposed for non-iatrogenic reasons, then in my personal experience it actually appears to repel plaque. This may be because a microbial bio-film may be less likely to adhere to the Ti-Unite surface due to its hydrophobic properties, and as such does it not appear to evoke a significant inflammatory response.

In my practice placing in excess of 1,000 Ti-Unite implants per year, peri-implantitis occurs in less than 0.5% of situations. Whereas having recently attended a European forum on peri-implantitis, it appeared to me that there are practitioners who see peri-implantitis on an almost daily basis with other surfaces. Unless they are considering creating a speciality dedicated to the treatment of peri-implantitis …perhaps it is time for them to switch implant systems.

2nd Misconception: Using multiple Implant Systems leads to better results because different kinds of implants are better suited to different kinds of clinical situations.

I have a real issue with this. Firstly, the more different kinds of implant systems that you use, the less opportunity you have to master any specific type of implant. Therefore you become a Jack-of-All and Master-of-None. This will inevitably lead to poorer results with every one of the systems that you are using. It will also lead to confusion and inefficiencies by staff.

If at all possible, I would always recommend to choose the one implant system, and to master it. When choosing an implant system, I would look for the following parameters:

  • nano-surface technology
  • self-tapping design that is suitable for immediate loading
  • available in lengths from 7mm to 18mm
  • available in widths from 3.5mm to 6.0mm
  • simple drilling protocol
  • coronal micro-threads that make it suitable for placement at or below bone level
  • versatility and suitability for all kinds of bone quality
  • universal restorative interface that is interchangeable between various models or sizes of the implant body
  • a biologic restorative interface incorporating morse taper connection to minimise micro-movement and seal the interface, and platform shift to avoid biologic infringement on the tissues
  • availability of straight and angulated abutments that have interchangeable components at the abutment level
  • versatile restorative options

Unfortunately there is not one implant on the market that fulfills all the above parameters, but there is a pair of models that together can indeed fulfill all of the requirements: Nobel Active and Nobel Parallel CC.

The Nobel Active is ideal for dense and medium bone, as well as for soft bone that is narrow. The Nobel Parallel is ideal for soft bone that is wide. Together they make the perfect pair because of a universal conical connection. Choosing either one or the other (based on the quality of the bone) provide versatility for all kinds of restorations, from a single tooth in the aesthetic zone to All-On-4, and enables me to master my surgical skills without having to consider logistics and compatibility issues.

3rd Misconception: Nobel Active is the best implant for soft bone.

This misconception is only partly so. The Nobel Active is hands down definitely the best and most versatile implant available today. But whether it is best specifically in soft bone is altogether different.

The design of the active is such that it has a tapering conical design and wide aggressive threads. It can also withstand torques above 200Ncm (RP and WP) when required, such as in reversing of a stuck implant. However the aggressive threads can cause it to mush the bone when it has a poor density, so it should NOT be used in situations when the bone is soft, unless it is also narrow. When the bone is narrow, then the wider threads can engage the cortical plates on either side and stabilise the implant.

The people

It was nice to see again some of the people who previously attended my residency programs in Australia. I had lunch with Dr Goro Hashimura who shared with me his plans for a new centre for dental implants in the upmarket Ginza district in Tokyo.

I was honoured with enormous efforts, a gift and a special reception organised for me by Dr Ando and his entire team at his Oral Rehabilitation Centre. I spoke to the team and gave them some motivation in relation to treatment planning and communication with their patients. I couldn’t possibly motivate Dr Ando any more, he is already an experienced and motivated individual who I respect and admire. I was particularly humbled by Dr Ando’s drawing a parallel to historic timelines BC and AD with his concept of BA and AA in reference to his visit to my clinic, and the importance of changes that he implemented in his own clinic ever since.

I was invited to dinner on my first night with Dr Senichi Suzuki and Dr Masafumi Wakita, both chairmen of ISO Study Club, Dr Masaaki IWAKI, chairman of JADE Study Club, and some of their colleagues and associates. Mike Thompson, head of Nobel Biocare APAC also joined us. It turned out to be a night that I could not easily forget.

After Mike, Senichi and I polished a bottle of Dassai Sake, each shot followed by KIRIN mug chaser, it was after midnight …but something told us we had to keep going. Along with Masafumi and Masaaki we decided to go to a karaoke bar …I mean out of all the possibilities in the world on a Thursday night, what better way is there for 5 blokes to spend the night? I have never done Karaoke before, so I thought why not give it a go? At worse we can just have a few more beers.

I was invited to dinner on my first night with Dr Senichi Suzuki and Dr Masafumi Wakita, both chairmen of ISO Study Club, Dr Masaaki IWAKI, chairman of JADE Study Club, and some of their colleagues and associates. Mike Thompson, head of Nobel Biocare APAC also joined us. It turned out to be a night that I could not easily forget.

After Mike, Senichi and I polished a bottle of Dassai Sake, each shot followed by KIRIN mug chaser, it was after midnight …but something told us we had to keep going. Along with Masafumi and Masaaki we decided to go to a karaoke bar …I mean out of all the possibilities in the world on a Thursday night, what better way is there for 5 blokes to spend the night? I have never done Karaoke before, so I thought why not give it a go? At worse we can just have a few more beers.

Imagine 5 blokes doing Karaoke to the tunes of Hotel California, Bohemian Rhapsody, and The Show Must Go On …the Celine Dion version, look it up.

That night became a night of a few firsts for me: It was the first time in many years that I ate past 3am; for the first time I discovered that I can actually hold my alcohol like a true Russian; I first discovered that Kirin Beer goes down real easy; and most surprisingly I discovered that I have a hidden talent …a great voice.

The next morning was also a morning of a few firsts: It was the first time in many years that I missed breakfast. It was when I realised that I actually can not hold my alcohol, and that Kirin Beer comes back up just as easily as it goes down. And after watching the Karaoke video I realised that my voice, amazing as it seemed at the time, was far from a talent I would ever wish to embrace again.

I managed to recover not one minute too early for my next lectures in Nagoya.

That same night I had dinner with Dr. Kenji Imai, who heads the IPPC Study Group, Dr Tanaka, Mr Segawa, the area manager from Nobel Biocare, and Hideki Sakurada, my attaché for the duration of my trip. I took it easy on the Kirin this time, but had fun exploring interesting cultural themes with those guys.

The next day in Kyoto I had lunch with Dr Chihiro Morioka, who comes from an orthodontic background, yet he does implants. I surprised him when I highlighted that he has something in common with my friend Ophir Fromovich, the designer of Noble Active …the world’s most popular implant system, who was also an orthodontist. After 3 days of Waygu it was a medical necessity to unblock my arteries with an alternative …we had clam pasta in olive oil and chilli.

Osaka was my last lecture for the trip. The venue was great, and I think would be the ideal place for a future hands-on program that was sought by the participants across the country. I had dinner overlooking Osaka’s gorgeous skyline, in great company yet again, Dr Hajime Igarashi, second chairman of ISO, and his associates.

The Future

At the end of my trip I visited Jishu-Jinja Shrine.

It was symbolic of my experience as it is the oldest shrine in Kyoto for gods of love and relationships, and is especially popular with those seeking fulfillment through new or renewed relationships. I managed to forge some strong bonds during my visit, and I look forward to the next phase of developing the All-On-4 market, and sub-economy, in Japan.

One interesting things that I learnt visiting at the Shrine was that if you want to make a wish for wealth, it’s not enough just to wish to be wealthy. For your wish to come true, before you ring the bell, you must have a target amount in your mind. I love this concept. With an actual amount in mind, there is a psychological target that will be a drive for you to reach your goal. For Japan …don’t just wish for it to happen, set a target and make it happen!

Thank you Mike Thompson, Hideki Sakurada, Sonomi Higuchi and all the other people that I met from Nobel Biocare, who looked after all my needs and made my trip as professionally rewarding as it was fun.

Dr. Alex Fibishenko


Oral Implantology & Reconstructive Dento-facial Surgery
Dental Surgeon in Self-Restricted Practice
Innovator of All-On-4 Plus ® & founder of All-On-4 Clinic

Dr Alex Fibishenko practices exclusively in Oral Implantology, Dento-Facial Surgery and Facial Aesthetics.

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