Tilting Implants, Shifting Perspectives: A Mixed Methods Study of All-On-4 Among Postgraduate Dental Trainees.

Abstract

Background: Edentulism remains common in resource-constrained settings, where conventional dentures often fail to meet patient needs. The 'All-On-4' concept offers immediate loading and reduced treatment duration for atrophic jaws, although its integration into clinical practice remains inconsistent. This study aimed to quantify postgraduate dental trainees' knowledge, attitudes and practices (KAP) regarding All-On-4 in Karachi and explore their lived experiences with this technique.

Methods: A mixed-methods design involved a cross-sectional KAP survey (n = 296) and in-depth interviews (n = 20), analysed using Interpretative Phenomenological Analysis. The survey examined associations between demographic variables and KAP, while interviews provided insight into participants' personal and professional perspectives.

Results: Of the 296 trainees, 71.8% had heard of All-On-4, 44.5% demonstrated adequate knowledge, and 16.4% reported consistent clinical implementation. Knowledge correlated with age (p = 0.001) and department (p = 0.039), whereas attitudes were associated with gender (p = 0.010), age (p = 0.036) and training level (p = 0.022). Frequently cited barriers included cost (65.2%), limited specialised kits (52.8%) and inadequate mentoring (59.4%). Four qualitative themes emerged: (1) Resource Constraints, (2) Complexity and Learning Curves, (3) Evolving Professional Identity and (4) Strategies for Resilience. Although trainees acknowledged the benefits of All-On-4, they perceived insufficient institutional support and high patient expenses as major impediments. Proposed solutions included peer-led groups, interdisciplinary collaboration and enhanced funding.

Conclusions: Despite moderate awareness, All-On-4 adoption among postgraduate dental trainees remains limited, primarily due to cost, resource shortages and insufficient supervisory training. Focused institutional measures comprising of subsidised implant kits, structured mentorship, and cost-sharing could promote broader application of All-On-4 in low-resource environments.