The ALL ON 4 PLUS concept is an outcome-based treatment planning philosophy for full arch rehabilitation with dental implants.
We Do It Differently!
1. All On 4 Clinic’s Individualised Final Custom Solution
Our innovative techniques with All On 4 Plus allow us to take impressions and records to start the fabrication process of the final prosthesis immediately after your surgery. We fit customised stents to the implants and these provide the necessary reference points and serve as a first try-in of the teeth in your mouth. From this immediate post-operative try-in, our technicians, using our special methods, are able to ascertain the required changes in terms of aesthetics, function and speech, and go on to then implement these changes into a brand new set up of teeth in wax, which we try in your mouth within 2 hours of your surgery for further fine-tuning.
As the teeth are set up in wax to your individual requirements and specifications, our clinicians are then able to make any further adjustments to attain the final aesthetic and functional result.
We use a High Impact Acrylic material, which is processed and fabricated after the aesthetics are finalised at the try-in stage, which often takes place on the very same day. Within the processed acrylic there is a stiffening bar to give the prosthesis additional support and rigidity. The connecting cylinders that are used to attach the prosthesis to the fixtures are processed within the prosthesis, which ensures a reliable connection and ultimate fit. Processing and finishing of high impact acrylic takes approximately 12 hours, so it would typically be inserted the very next day.
Alternative method: A Retro-fitted fixed denture
In a bid to save costs and make the process even quicker, an alternative method that we have seen involves the retrofitting of a pre-made denture onto the fixtures. The dentist would make a standard denture before the surgery, and would then fit metallic cylindrical collars to the fixtures and make holes in the denture where the cylinders emerge. The cylinders are then attached to the pre-fabricated denture through the openings with a plastic material. This makes the prosthesis rigidly attached to the implants, and albeit less than ideal, one other possible interpretation of an immediate fixed bridge. But there are numerous issues with this method, most concerning of which are the following:
- cleaning is extremely difficult because the denture cannot be adjusted to ideal contours as that would cause loosening and detachment from the metallic cylinders, which attach it to the implants. It often results in bad odours and taste in your mouth, which leads to inflammation and potential bone loss around the supporting fixtures
- The method of attaching the metallic cylinders to the denture is not reliable, and the bond is susceptible to brake down around one or more of the connections, resulting in the elimination of the advantageous cross-arch stabilisation when all the fixtures are reliably attached to the prosthesis. This may result in overloading and failure of the implants.
Those who adopt this method agree with the above, but often argue that the prosthesis which they fit immediately after surgery it is only for a temporary period of 3-4 months while the implants are healing, after which time they would convert it to something that is more reliable. At the All On 4 Clinic our philosophy is that we do not want to place the implant ‘ecosystem’ under strain, and especially not during the most critical period of initial healing. The problems with the fixtures otherwise may not be evident immediately, but this alternative and cheaper method may cause longer-term issues with peri-implant health, which cannot be reversed.
In addition, we also do not believe that a three to four months is an adequate period to allow us to diagnose the nature of the bite and direction of the forces in your mouth. It then follows that when using alternative methods that force you to have another prosthesis after that time, apart from those additional hidden costs, it might not be the right type of restoration for the long term. At the All On 4 Clinic, we generally advocate to wear our final bridge solution for 3-5 years before deciding on whether to replace it for the same type or to upgrade to other options. During this time the prosthesis may start to show signs of stress in certain cases, such as hairline cracks, which would provide us with key information about the magnitude and direction of forces in your mouth. When the forces are beyond the tolerance of the acrylic material a breakage may occur. When a breakage is a result of vertical forces, then upgrading the base material would be the treatment of choice, whereas if a tooth shears off due to excessive horizontal forces, then the only way to reliably fix the problem is upgrading the material of the teeth themselves.
2. Facilities for Immediate Teeth Replacement with Dental Implants
The rationale for fitting immediate teeth to the dental implants is well established and covered in under the section History of Dental Implants. However the set-up requirements are complex and cohesiveness of the entire team paramount in order to facilitate the fitting of an immediate final bridge in a streamlined approach. As such most methods still used today involve a 2-stage process. At the All On 4 Clinic our focus is streamlined immediate solutions, and our facilities are set up accordingly, supported by expert clinicians and experienced staff.
The Hospital Alternative
One of the important parts of the set up is incorporating an operating theatre together with a dental and laboratory set ups to allow our clinicians to produce the final bridge within one or two days. The alternative of doing this treatment in the hospital is not ideal, as the patient cannot sit up to allow the clinician to take records of the bite and assess speech, function and appearance. Using the hospital approach typically means that the impressions and records would be taken the following day. However in the following day the swelling sets in and it is difficult to adequately anaesthetise the area for impressions cause discomfort, and the swelling distorts the face which prevents us from making accurate assessment of the try-in, which means that we cannot be sure of the appearance and function until the swelling subsides. Our ability to undertake all the necessary procedures immediately after the surgery means not only better comfort, but also allows us to assess the various parameters before the swelling sets in and to construct the final bridge for insertion in the following day.
3. Innovations that make a difference
Our All On 4 Plus treatment uses advanced procedures and methods that have been developed at the All On 4 Clinic, which are individualised to your needs and help improve the outcomes, click here to find out more.
Apples ain’t apples. All On 4 has become a popular treatment in recent years, but in may be done in various ways with hidden shortfalls. Learn how we do it differently to achieve our results.
Below are illustrations comparing our method against other methods used, which may also be referred to as “All-On-4”.
EXAMPLE 1: MINI-FLANGES & HAMPERED HYGIENE
Illustration of a fixed upper implant bridge done elsewhere.
All On 4 Clinic
Illustration of a similar implant supported bridge done at All on 4 Clinic
This gums and implants are covered with thin mini-flanges of the acrylic material. This makes cleaning difficult or impossible. Note it is impossible to tell how many dental implants there are, or where these are located.
There are no mini-flanges and the interface between the acrylic bridge and the natural gum is completely flat, which simplifies cleaning. It is also impossible to tell where the fixtures are, but with an All On 4 procedure at our clinics we know there are two fixtures in the front and two in the back.
The fixed prosthesis is removed to reveal that there are six implants (one is not visible here), and these are not evenly spread. There is a significant amount of infection and inflammation of the gums because it was not possible for the patient to clean.
The fixed prosthesis is removed to reveal four implants evenly spread, and a flat gum interface. The gums are pink and healthy because it was not complicated to clean.
Seeing the bridge out of the mouth reveals the extent of the mini-flanges, which hampered the cleaning, and the extent of plaque that accumulated as a result. It is also noteworthy that there is a broken tooth, which is the result of there being inadequate room to allow sufficient thickness of the acrylic material for strength and durability. The flanges make the prosthesis appear tall, but it is in–fact thin at its core.
This bridge out of the mouth is not as old, but it is possible to see the flat under-surface, which interfaces with the natural gums. It is also demonstrative of a typical construction design, which improves durability.
EXAMPLE 2: TEMPORARY IMMEDIATE RESTORATIONS
Upper and Lower fixed acrylic prosthesis by others inserted immediately after surgery. It was not a processed prosthesis, but a denture retro-fitted to the implants.
All On 4 Clinic
Upper and Lower fixed acrylic prosthesis at the All On 4 Clinic fitted within 24 hours from surgery as a fully processed final restoration.
Looking inside reveals the large flanges of the denture and repairs that were done in the process of attempting to retro-fit it to the implants. Because the under-surface is rugged, it is impossible to keep clean.
In our processing of the prostheses there are no flanges. The interfaces in the upper and lower are flat, which allows the patient to clean her teeth properly, as well as the gum interface.
A view of the upper teeth demonstrates the retro-fitting that was done. The denture that was made was cut back and holes were cut in it in the positions of the implants. After metallic cylinders were attached to the implants, the dentist connected the denture to those cylinders with a direct self-curing resin (this is visible as a lighter colour around the metallic cylinders.
Another issue here is that whilst an attempt was made to cut the denture back to free the palate, it could not be cut back sufficiently so as not to weaken the denture, and as such there is still partial coverage of the palate by the denture.
The positioning of the front two implants is not ideal causing bulkiness from the inside, discomfort and speech issues for the patient.
Our techniques feature the following visible advantages:
- Accurate positioning of the implants without creating unnecessary bulkiness on the inside
- No plastic covering any of the palate
- Fully processed durable restoration without cracks or defects
A similar problem is seen in the lower where the rugged under-surface makes it very difficult to clean.
Our techniques facilitate simple hygiene due to the flat and even interface.
The X-ray shows no connection between the implant cylinders. It is connected via the prosthesis, but the prosthesis does not show up on the x-ray.
This x-ray of our technique shows a rigid bar connection between the fixtures, this make the prosthesis more durable.
EXAMPLE 3: LACK OF ALVEOLECTOMY AND AESHETIC GUM REPLACEMENT
The picture above shows implant treatment by others, and demonstrates how gum recession around implants can affect the appearance. In addition the under-surface of the bridge is rugged making it more complicated to keep clean.
All On 4 Clinic
Our techniques using Aesthetic Gum Replacement mean that the transition line remains hidden under the lip, and this means that the appearance is more predictable and long term. Also the interface is flat making cleaning simple.
EXAMPLE 4: CANTILEVERS AND RUGGED INTERFACE
The above is another illustration of a rugged interface, which accumulates plaque.
All On 4 Clinic
A similar bridge using our techniques illustrating a flatter and more hygienic interface.