What is All On 4
The term ‘ALL-ON-4’ refers to the replacement of ALL teeth ON FOUR dental implants, which support them. It is a modern technique where the back implants are tilted 45º to provide the required support for total rehabilitation. The tilting the back of implants helps overcome bone deficiencies often found in the back of the jaws and most often avoids the need for bone grafting.
Since less implants are used by comparison to older methods, there is less in the way of achieving optimal results. It also allows for simpler long-term maintenance and uncomplicated cleaning.
Dental implants themselves are small titanium fixtures that are inserted into the jawbone and have, for a long time, been used to support a tooth or a ‘Bridge’ of a segment of teeth. The fixtures form the foundation for the prosthetic replacement teeth. However, when we replace a full set of teeth, often referred to as full arch rehabilitation, whether in the upper or lower jaws or both, we do not need to place an implant under every tooth. We place 2 implants in the front of the arch and 2 in the back at an intended angle, and together these form the required foundation to support the prosthesis. By placing the implants at an angle, we are able to avoid the parts of the jawbone that are of a typically poor quality. This not only means that we can avoid the need for bone grafting, but we can also rely on these to reliably support a prosthesis fitted within days of the surgery.
By using fewer dental implants to support the prosthesis there is a smaller number of components, thus more versatility to design the most optimal function and aesthetics. Importantly there is also less in the way of cleaning, which helps simplify the hygiene and maintenance over time.
This procedure is the most common treatment in our clinic today for full arch rehabilitation and when appropriate it is often suitable for all lower jaws and most uppers. But even in Upper cases with extremely poor quality or quantity of bone, we can still offer reliable and streamlined immediate solutions using our All – On – 4 Plus.
Immediate Replacement Teeth
The All On Four concept involves the immediate fitting of the prosthesis to the fixtures, also known as Immediate Loading. It sounds simple, and this is exactly what we aim for our patients to experience …a process that appears to be simple and seamless. But this is not to be confused with it being a simple procedure. This is a highly advanced surgical procedure which offers many advantages to older methods of teeth replacement, and which has a remarkable success when performed by experts who have received special training.
But having a well-trained team is not sufficient on its own. To facilitate the immediate replacement of teeth there must also be a facility that can cater to immediate loading with a specially fitted operatory that is equipped for general anaesthetic or IV sedation, as well as an integrated dental implants laboratory.
Features of All On 4
- IMPROVED APPEARANCE
- IMMEDIATE TEETH
- EASY TO CLEAN
- CHEAPER TO MAINTAIN
- SHORTENED TREATMENT DURATION
- AVOIDS BONE GRAFTING
2 days process
Immediate Teeth All-On-4 techniques and streamlined process allow us to deliver immediate teeth that are FINAL and permanent.
HELPING YOU DECIDE
STEP 1 – Optional FREE Pre-consultation, Interview & Consultation with an Expert. Appointment Duration: 60 minutes.
STEP 2 – X-Rays
Special x-rays called cone-beam CT (CBCT) scans are needed to complete your diagnosis, determine your suitability for any sort of treatment, and plan the positioning of the fixtures. Appointment Duration: 30-60 minutes.
YOUR TREATMENT PLAN: After the dentist has assessed your health, x-rays and clinical situation, you will be given a treatment plan which outlines all the treatment stages as well as the costs involved. Appointment Duration: 30-60 minutes.
STEP 3 – Mock-up and pre-operative work-up
Once you decide to proceed with oral rehabilitation involving any of our treatments All On 4, All on 4 Plus you will need to attend the clinic for photos, models and other records as required, so as to enable the dentist to plan the optimal set-up of the replacement teeth in terms of both appearance and function.
Day 1 – All On 4 Dental Implants Surgery
After removing the teeth (if any), cleaning out any remnants of disease and preparing the jaw bone to accept the fixtures, these are inserted according to the work-up along with any repair or reconstructive work as may be required. The wounds are closed with dissolvable sutures that take 7-10 days to completely dissolve without the need for another appointment to remove them.
The surgery is typically done under General Anaesthetic or some form of sedation (I. V sedation)
Impressions are then taken of the implants through tiny opening in the gum, and this is sent to the laboratory.
The stents that the laboratory had prepared in advance are then used as a first try-in to help get very close to an optimal arrangement in the next stage.
Appointment Duration: 2 – 3 Hours
Day 1 (or 2) – Try-in of the new arrangement
While you are enjoying comfort in a recovery area, the laboratory works off the stents records obtained at surgery and prepares a new arrangement or set-up of teeth in wax. This is typically tried in your mouth a few hours later, but in some cases may need to be done the next day.
At this appointment all the necessary adjustments are implemented as required, and before you leave you get to see what the final teeth are going to look like.
Appointment Duration: 30-60 minutes
Day 2 (or 3)– Smile
After the try-in appointment you come back the very next day to have your replacement teeth fitted. There is no need for any sort of anesthetic at this appointment. The prosthesis is rigidly attached to the fixtures, and is aimed for optimal function, appearance, comfort and hygiene.
Appointment Duration: 30-60 minutes.
AFTER YOUR SURGERY
Hygiene and Diet
In the immediate period after your surgery you can expect to have swelling, bruising and maybe some pain or discomfort. Doctor will prescribe you medication, but it is not uncommon for patients not to feel the need to take the pain medication. As the teeth are not removable, brushing and cleaning follows the same principles as if they were your own healthy natural teeth, just a standard tooth brush 2 times per day.
Whilst it is common for patients to describe their teeth as feeling instantly solid and fully functional, it is important to stay on a softer diet (ﬁsh, pasta, eggs, stir-fry, etc.) for the initial 3 months of healing so as not to disturb the biological process of osseous-integration.
At 3 weeks after your surgery, once the swelling had subsided, and you have become more accustomed to your new teeth, our team will show you simple additional methods to effectively clean your new replacement teeth. These include water flosser, bridge floss, and brushes with specialized tips.
Review, Adjustments and Maintenance
At 4 months after your surgery your dentist will see you for review to verify that implants have integrated and to ﬁne tune your teeth as may be required. At this time, it is also possible to remove the bridge to re-line its surface, or to make adjustments that require processing in the laboratory. We always aim not to leave you without your teeth for longer than a few hours, depending on what (if anything) needs to be done. This review and any laboratory adjustments are part of the package and an extension of our clinic service to you.
Once we conﬁrm that the implants have integrated, at the 4 months review, you can start eating all types of food, even biting apples, nuts, crusty breads, chocolate and steak.
Future maintenance is often uncomplicated and involves regular attendance for scale and clean, as with natural teeth, x-rays every 2 years, and may at times require certain repairs. All repairs to your bridge are included for a period of 2 years.
Rose Dental clinic offers immediate teeth replacement solutions that are aesthetic, functional and comfortable, as well as various affordable upgrade options with Zirconia and Porcelain for the long term.
YOUR IMMEDIATE TEETH WITH HIGH IMPACT ACRYLIC
The teeth that are fitted immediately after surgery are constructed from a highly aesthetic and resilient acrylic material. The processing of this material makes it conducive to a quick turnaround using restorative protocols, and this is the only choice for immediate teeth. The bridge is reinforced internally with metal bar support, and is designed as the permanent restoration with optimal aesthetics and function, but this does not mean it will last a lifetime. Over time some wear occurs and this varies from patient to patient. On average, the acrylic teeth require replacement every 3-5 years.
This timeframe is only a guideline and it is not unusual for our patients to have worn their original restorations for 7 years or longer without requiring replacement. Replacing the acrylic bridge does not mean re-doing the entire All On 4 treatment from the start. The process of replacing the teeth is uncomplicated and does not require any additional surgery. However, the acrylic material, whilst intended as the permanent bridge, has a finite physical tolerance, and in certain patients, such as heavy grinders or those in whom the improvement to their biting force is beyond the tolerances of the acrylic material resulting is excessive wear or signs of stress, an upgrade to a stronger material such as Zirconia may be required at an earlier time, or at some time in the future.
TITANIUM & ZIRCONIA SOLUTIONS
All On 4 Plus® has changed the way we practice implant dentistry allowing us to offer fixed replacement teeth permanently anchored to dental implants, all within 2 or 3 days.
The immediacy of the process is facilitated by our innovative clinical procedures, an on-site laboratory and constructing the bridge from a high-impact acrylic material, which can be processed within one day. However, whilst our processes enable us to deliver the final aesthetics and function within such a short timeframe, the acrylic material naturally ages and wears and can lose its aesthetic appeal over time. As a guideline, it needs to be replaced within 5 years on average, unless signs of wear or fracture appear earlier, which often indicates that the improvements to the forces of the bite offered by the fixed replacement teeth are beyond the tolerance of the acrylic material in your mouth.
The picture set below illustrates the visual appearance of the original high impact acrylic bridge on the left, and the way it looks on an x-ray on the right:
For improved durability and longevity of the restoration we offer various options depending on need. By wearing the immediately fitted high impact acrylic teeth our clinicians are able to monitor the performance over time and make better decisions when deciding when and what style of future restoration would work best for the longer term. In some cases, there is a need for stronger teeth, whereas in other situations it is the base structure needing strengthening.
Older methods of reinforcement or strengthening in dentistry involved the use of a cast gold substructure to support the teeth. Today’s technology allows the use of zirconia or titanium substructures instead. These materials are more biocompatible and are precision milled, leading to superior adaptation over the implants and improved tissue health. Titanium substructures may be used to support acrylic teeth or zirconia-ceramic teeth, whereas the zirconia substructure is designed especially for direct layering of ceramic teeth for improved light transmission and long-term natural aesthetics.
When it’s time to replace the original acrylic bridge, there are a number of options that can be considered. The frame or body of the new bridge construction can be either titanium or zirconia, and the teeth can be either acrylic or porcelain. However, whenever acrylic teeth are fitted, there is still the issue of wear and ageing over time.
The picture set below illustrates the visual appearance of a milled titanium frame with acrylic teeth on the right, and the way it looks on an x-ray on the left:
The picture set below illustrates the visual appearance of a milled titanium frame with porcelain (PFM) teeth on the left (note it is on a model before the gum material has been applied), and the way it looks on an x-ray on the right:
Zirconia, on the other hand, is a material with physical properties like steel, but a color which makes it conducive to creating highly aesthetic restorations. It is also a highly biocompatible material, and helps facilitate better hygiene because plaque does not adhere to zirconia to the same degree as acrylic. Acrylic is a more porous material, whereas zirconia is very dense. This means that the zirconia will not absorb the mouth fluids, resulting in a more hygienic, fresher smelling restoration.
For optimal aesthetics, unlike options with a titanium frame, porcelain can be layered directly onto the zirconia to individually characterize the aesthetics.
The picture set below illustrates the visual appearance of a milled ZIRCONIA bridge on the right, and the way it looks on an x-ray on the left:
By far the biggest advantage of zirconia is its likely performance over time, as well as the weight and texture feeling more like natural teeth. Zirconia is CAD-milled to duplicate a template of a wax set-up that has been tried in your mouth to fine-tune the aesthetics and arrangement of the teeth. Using new techniques where we can colour the zirconia after its milled, we can achieve high aesthetics from a monolithic block, even without layering of any other material, resulting in optimal durability.
– Improved Longevity
– Improved Comfort
– More Natural Feel
– Stable Aesthetics
– Improved Hygiene
Turning ‘Implant Survival’ into ‘Case Success’
We have long passed the development phase of implant therapy where restoring function and ensuring that the dental implants ‘survive’ were central. In today’s society, these criteria alone are no longer acceptable on their own. Function, aesthetics and long-term oral health parameters must all go hand in hand as implant ‘Survival’ is not necessarily synonymous with Implant ‘Success’, just as a cosmetic procedure is not necessarily an aesthetic one.
In the last decade the trend with the number of fixtures used to support a prosthesis replacing a full arch has been to use less and less dental implants. At the same time, the trend has also been to eliminate the healing phase and to immediately load them. In doing so, are we pushing the limits, or simply providing the product of evolution in this field? The answer is certainly evolution, and the various aspects pertaining to it are outlined in the paragraphs below:
1. Implant Number …Less is more!
In the past we used to place 6 to 12 fixtures to support the prosthesis. We did so because we were worried that if one or two fixtures failed, there would still be others left to support the prosthesis. However, over time we have come to realize that one of the major reasons for implant failures was inadequate hygiene, and it was not because the patient did not try to clean properly, just that they were unable to.
Dental Implants are placed in the jawbone, and when the prosthesis is attached to those fixtures they become submerged and it is difficult to locate their position. As such, the more fixtures present the more difficult it is for the patient to know how to clean around the gum interfaces. It follows that the less effective the cleaning the higher is the chance for infections of the implants or eventual failure.
When using only four fixtures, such as the case with the All-On-4 procedure, there are 2 fixtures in the front and 2 in the back of the jaw. This means that it is simpler to locate their positions, even though they are submerged, which makes the hygiene substantially more effective, and in turn leads to improved success.
Biomechanically we know that 4 implants is certainly enough in the vast majority of clinical situations, but there are cases where there is an imbalance between the forces at play during function, and the resistance of the implant system to withstand them. An example is when the bite is very strong, such as in those who grind their teeth heavily, leading to increased forces at play (loading of the fixtures), and/or when the bone is of a very poor quality leading to a reduced stability or capacity of the implants to withstand the functional loads. In such situations there may be a need to increase the number of dental implants for long term support.
- Implant Angulation and Evolution of All-On-4-Plus
A feature of All-On-Four treatment is the placement of the back implants at an intended angle.
Numerous clinicians at about the same time in the 80’s and 90’s in an attempt to avoid certain anatomical limitations typically seen in the back of the upper and lower jaws have successfully avoided bone-deficient areas with the use of angulated implants. Anatomical limitations are more prevalent in patients with full dentures, and once the back implants are placed at an angle there is often only enough room left for two more implants in the front. This has led to the use of only four fixtures to support a full set of teeth
- The space that makes the case
In the past we used to try and preserve or build up the bone that had been lost through trauma or natural bone atrophy which occurs following the loss of teeth in preparation for the placement of dental implants. However, whilst these procedures are quite predictable in terms of creating a bed into which to place fixture, they are far less predictable in actually achieving a natural choreography of the gums, leading more often than not to poor appearance by our standards.
In addition, building up the bone caused a reduction in the space available for the teeth themselves, which were to be replaced, and apart from poor aesthetics, the strength of the bridge that was fitted to the implants was compromised.
To attain a high level of aesthetics, one of the important steps included in our All-On-4 Plus treatment is the re-shaping of the jawbone by flattening the uneven parts of the residual bone once the teeth are removed. This procedure has a number of important benefits:
- It allows for a flatter interface under the bridge which, when compared to a rugged interface of older methods, further simplifies the cleaning process
- It allows for Aesthetic Gum Replacement, where in essence that the gum section becomes part of the prosthesis. As such the final appearance and choreography of the gums can be designed and controlled by our technicians leading to a more predictable aesthetic outcome
- The additional space created allows for an improved design of the restoration aimed for better aesthetics, improved comfort and more durable restorations
- Immediate teeth replacement
In the past we used to do the dental implant procedure in two stages. We started by placing the fixtures in the bone, we would then allowed them to heal for 4-6 months, after which time we would commence the process of making the prosthesis that would ultimately attach to those fixtures.
However, the problem was that during the healing period the patient would wear a denture as an interim prosthesis. This denture, as we have come to learn over time, would impart pressures on the implants in an uncontrolled manner, thus disturbing their adaptation with the bone.
Today the teeth are attached to the dental implants within days of their placement, such as the case with All-On-4 Plus treatment. The reason this works is because the implants are attached to each other through the prosthesis, and they share the load through cross-arch stabilization, rather than individually being subjected to loading from a loose denture. However, in all such treatments the patients are asked to maintain a softer diet for the initial period of healing so as to avoid excessive pressures or disturbance in the adaptation of the implants.
All – On – 4 Plus
What is All-On-4 Plus
The All On 4 Plus® concept was introduced by Dr Alex Fibishenko, borrowing from some of the most basic and minimalist elements of All On 4 as well as other proven techniques with full set teeth replacement on dental implants, whilst additionally incorporating methods and procedures that can make a difference in terms of function, comfort, and appearance as well as durability of the restoration.
With All-On-4 Plus approach each treatment is planned on an individual basis, and whilst certain patients may need additional implants or procedures for long term results, we aim to avoid prolonged treatment duration with further advanced techniques that afford minimal disruption to our patients’ day-to-day life and function. Whether it’s with four or more implants, with or without grafting, All-On-4 Plus® encompasses indication-specific treatment planning incorporating our innovative techniques that have a built-in contingency and facilitate the delivery of an immediate final restoration in the most streamlined process.
All-On-4 Plus incorporates:
- RESHAPING OF THE JAWBONE AND GUM SURGERY
When teeth are lost the gums shrink because the underlying bone undergoes natural atrophy and resorbs. Prior infections, gum disease, trauma or other conditions of the teeth that have led to their necessary removal also results in defects in the jaw bone and an uneven surface.
The re-shaping of the jawbone with a procedure called alveolectomy, or alveoplasty, removes the rugged areas of the jawbone to leave a flatter surface and more favourable surroundings for dental implants. By removing the rugged areas, we also eliminate the parts of the jaw that are most susceptible to resorption, and can rely on the deeper bone that is of a better quality for improved heath of the dental implants over time.
Apart from improving the conditions for the placement of the fixtures, the re-shaping of the bone also improves the amount of space that is available for the construction of the teeth, which improves our ability to design a restoration that is more durable and aesthetic, and helps ensure that the transition between the prosthesis and natural gums remains hidden.
The re-contouring of the jawbone also creates a flat interface of the prosthesis where it contacts the natural gums, which helps patients in cleaning and maintaining good hygiene.
- BONE AUGMENTATION (WHEN REQUIRED)
Every case is different, and the bone anatomy can even vary in the same patient between the left and the right sides. In some cases, particularly in the upper jaw, there may simply not enough bone for as standard All On 4 approach because the anatomy of the sinuses is such that they do not allow for implants to be placed sufficiently towards the back and they would be placed closer together instead of being more ideally spread out. This may result in a shortened arch situation with less than a full complement of teeth in the prosthesis.
Whether it is at all required is assessed on an individual basis, but bone augmentation, particularly of the sinus spaces, using traditional or some of our own newer methods, may offer a number of benefits both short and long term as described under sinus grafting.
MAIN BENEFITS: Improved surgeon’s visualisation of the bone anatomy, wider spread of the implants with potentially more teeth in the arch-space, and improved contingency by having newly formed bone.
- CRITICAL IMPLANT POSTIONING USING ALL ON 4 CLINIC’S PROTOCOLS
We use unique methods to ensure the dental implants are positioned in a way that makes them not only simpler to restore from an engineering perspective, but also reduces the bulkiness in the mouth for improved comfort, speech and hygiene.
- ADDITIONAL FIXTURES (ONLY WHEN INDICATED)
We strongly believe in a minimalistic approach to the number of implants that we place to support a full set of replacement teeth for one primary reason: to improve your ability to clean. However, every case is different, and sometimes there are conditions that require us to place additional implants for improved support. These conditions can be divided into two main categories: the forces that are applied on the implants through the prosthesis during function VERSUS the resistance of the system of the supporting fixtures and the bone to withstand those forces.
For long-term health we need to ensure that the foundations of the system are able to withstand the insults from function. In situations where the insults are significant, such as in patients who are heavy grinders, or where the foundations are inadequate, such as the case in very poor quality bone, there may be a tipping point disturbing the healthy equilibrium, leading to potential problems. The placement of additional implants improves the support and the biomechanical resistance, and is only used when deemed required, or when a significant increase in the size of the arch and the number of teeth is desired.
- DELIVERY OF FINAL PROSTHESIS WITHIN 2-3 DAYS USING INNOVATIVE TECHNIQUES
The techniques developed by Dr Alex Fibishenko allow for the delivery of a final restoration within days of the surgery. The teeth are completely individualized and are tried in the mouth for fine-tuning, typically on the same day as the surgery when the swelling has not set in and we are able to accurately assess the new teeth before finalizing and processing the final prosthesis. Not only does this improve our patients overall experience, but it also improves reliability of the implant connections, because the connections are processed not retro-fitted, and is one of the reasons that we enjoy a high rate of success of our dental implants.
- INDICATION-SPECIFIC RESTORATIVE UPGRADES (WHEN REQUIRED)
The replacement teeth that are fitted within days of the surgery are designed with the final aesthetics and function, and as the permanent restoration. However, in certain cases the improvements in the forces of the bite may be beyond the tolerance of the material used to make the immediate bridge. However, when that is the case, before deciding on any course of action, it is important to diagnose the weak areas of the bridge and the direction of the forces so as to have a better understanding of what type of treatment or restorative upgrades would be required for longer term function.
The bridge, or prosthesis, is designed to unique specifications with metal reinforcement, and provides a rigid fixation and stabilization of the implants, thus allowing it to be fitted both immediately and as the permanent restoration.
Patient has large sinus spaces and not enough bone to spread the implants sufficiently for a full complement of teeth.
All-On-4 Plus® treatment with sinus grafting and insertion of a FINAL prosthesis that functions until the patient decides she wants more teeth or upgrade.
FUTURE EXTENTION & UPGRADE
Additional implants are inserted in the grafted bone and the fitting of a Zirconia bridge extending further back for a full complement of teeth.
(Source from Dr Alex Fibishenko. Melbourne)