This has been an interesting week bringing unique opportunities and challenges for my all on 4 dental implant
cases. Though I didn’t start any All on
4 cases this week but I saw many that were in their healing and restorative
stages. My time was consumed with orthopedic dentistry [bone regeneration] of
almost every type and routine dental implant placement at my dental implant
clinic in Houston.
The All On 4 Dental Implant Case
Wednesday I was a guest on Great Day Houston hosted by Debra Duncan and I took a 23 yr old nurse with me. She
required full mouth extractions because of rampant dental decay, 4 upper and 4
lower dental implants, and new set of upper and lower teeth; typical All on 4
dental implant. Debra Duncan has been a great friend of my practice and has
been very helpful in getting the word out about All on 4 dental implant in
Houston. Our intention was to make people aware that not everyone who needs All
on 4 is 40 yrs old or more. Many of my patients who need All on 4 dental
implant are younger and some are even in their early 20’s.
Based on the calls my office has received I believe our mission was accomplished. In the field of dental implants surgery seems
to get all of the “glory”. I don’t know why but even I tend to study and report
on it more. But the surgery is really the easiest part of the procedure and of
course has nothing to do with what the patient wants. People want beautiful
teeth that look and function naturally and are dependable. Ideally they’ll
never know a dental implant is even there. With single unit dental implants
this isn’t very difficult but with full arch cases it certainly can be.
Complications With All On 4 Dental Implant
I find the most common complication by far, with the All on 4 dental implant system, to be breakage of
the transitional and even the final appliances. With natural teeth when we
close our mouths a proprioceptive signal lets us know how hard and in what
position our mouths are closing. With full mouth dental implants most of this
awareness is lost. Consequently we can bite very hard or in odd positions
without knowing it and that can lead to broken appliances. I expect that for
the rest of my career I will be exploring opportunities to mediate this.
Solutions for Complications With All On 4 dental Implants
If a patient is a severe grinder of their teeth at night or has shown signs of extreme clenching during their
sleep it is probably best to restore at least one of the archs with a removable
appliance that is tissue supported but implant retained such as a “locator”
attached overdenture. This would be a
better choice than a bar supported overdenture because proprioception is improved and when the appliance is removed
at night there is nothing to grind or clinch against the opposing appliance.
But what do you do to compensate for when then patients parafunctional habits
are miscalculated and opposing fixed appliances are fabricated or a fixed
appliance is made to function against an arch of natural teeth?
Many things help but none of them are good enough. Occlusion needs to be designed with ½ mm of overbite in the
anterior with traditional anterior guidance in protrusive. Flat plane teeth with balanced lateral
movements rather than cuspid rise is preferable. All of that sounds great but for many reasons
it is rarely achievable in full so almost every case has at least a few
compromises. When constructed against natural teeth many compromises are the
rule. All patients with fixed dentistry should wear a night guard. Simple soft
guards are fine if the patients TMJ will tolerate them but NTI’s work very well
also. This would solve most of the problems if only patients would wear them
consistently. Though intuitively I would expect a high quality acrylic tooth to
be superior to a porcelain tooth experience has not shown a difference in
breakage.
However, since the porcelain teeth wear longer I normally prefer them. Of course all final All on 4 dental implant appliances have milled
titanium frameworks and this prevents breakage of the appliance. Though if the
framework is not extended adequately beyond the most posterior abutement that
portion of the appliance may break off. Unfortunetly, even when everything
seems perfect teeth will still sometimes debond or break. Meticulous lab work
and occlusal equilibration helps but to date our greatest opportunity to
improve this service for our patients remains in developing more satisfactory
appliances. For now the traditional All on
4 dental implant with a fixed hybrid prosthesis is the most extraordinary
service dentistry has ever been able to provide for those who have lost all of
their teeth or who are going to lose all of their teeth.