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.

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