Category Archives: Full Arch Implants/ All On 4, 5, 6, 7, 8…

Broken All On 4 Dental Implant Bridges

 
I have been seeing a rise in complications on patients who have had the ALL ON 4 dental implant procedure.  Many patients end up in my office for redo treatment after things have gone very wrong.  I'm seeing a lot of broken bridges and bone loss recall peri-implantitis.  In this video I will discuss what to do to prevent and deal with this complication. Below are some pictures of broken bridges. Your comments and questions are welcome.
Ramsey A. Amin, D.D.S. Diplomate of the American Board of Oral Implantology /Implant Dentistry Fellow-American Academy of Implant Dentistry

Patient Review: Full Upper Dental Implants with a Fixed Prettau Bridge

Are you interested in dental implants? See what one patient (who traveled all the way from Michigan to California for her procedure) has to say after receiving full mouth upper and lower dental implants with a fixed Prettau bridges from Dr. Ramsey Amin.

If you are looking to replace all of your teeth with dental implants, please hear with this patient has to say about her experience with Ramsey Amin DDS.

Converting Bad Dental Implant Overdentures To Fixed Full Arch Bridges -Review Of Complex Case

Here is an interesting full double arch dental implant case that I took over from another dentist.  This patient desired full mouth dental implants.  When he presented to my office he already had 10 implants but could not use his teeth.  He paid a lot of money only to be disappointed with the removable over dentures that were made for him.

initial x-ray when I first met the patient--10 implants that would not work for over dentures

initial x-ray when I first met the patient–10 implants that would not work for over dentures

initial presentation when I first met the patient with his existing 10 dental implants and over dentures that would not work.

initial presentation when I first met the patient with his existing 10 dental implants and over dentures that would not work.

pre-existing condition when I met the patient-upper jaw

pre-existing condition when I met the patient-upper jaw

pre-existing condition when I met the patient-lower jaw

pre-existing condition when I met the patient-lower jaw

bulky, huge dental implant over dentures...poorly done

bulky, huge dental implant over dentures…poorly done

poorly made overdenture attachment connection

poorly made overdenture attachment connection

poorly made overdenture attachment connection

poorly made overdenture attachment connection

 after healing on the lower arch dental implants

after healing on the lower arch dental implants

after healing on the upper arch dental implants

after healing on the upper arch dental implants

after healing on the 17 dental implants--the Gold abutments aren't locators used by the previous dentist attempt at making teeth.

after healing on the 17 dental implants–the Gold abutments aren’t locators used by the previous dentist attempt at making teeth.

impression transfer on the upper 10 implants

impression transfer on the upper 10 implants

impression transfer on the lower 7 implants

impression transfer on the lower 7 implants

screw retained full arch temporary dental implant bridge

screw retained full arch temporary dental implant bridge

screw retained full arch temporary dental implant bridge

screw retained full arch temporary dental implant bridge

narrow gum the sulcus channelson the existing implants towards the front of the mouth

narrow gum the sulcus channels on the existing implants towards the front of the mouth

fully biting into full mouth fixed temporary implant Fp1 teeth

fully biting into full mouth fixed temporary implant Fp1 teeth

PMMA double arch full mouth dental implant fixed temporaries--other side

PMMA double arch full mouth dental implant fixed temporaries–other side

PMMA double arch full mouth dental implant fixed temporaries--side view

PMMA double arch full mouth dental implant fixed temporaries–side view

PMMA double arch full mouth dental implant fixed temporaries

PMMA double arch full mouth dental implant fixed temporaries

x-ray of the 17 implants during the process. Some of the implants were placed by me in some by previous dentist.

x-ray of the 17 implants during the process. Some of the implants were placed by me in some by previous dentist.

Handsome smile with temporary upper and lower full arch teeth.

Handsome smile with temporary upper and lower full arch teeth.

You can see on the preoperative x-ray that he had 6 upper dental implants and only all on 4 lower dental implants.

The implants were mostly well placed from a spacing standpoint and might have been able to be used for fixed dental implants such as a Prettau zirconia full mouth dental implant bridge.  Rather than having a fixed bridge or an all on 4 fixed bridge, the dentist chose to make an overdenture!! 

The overdentures never worked for him.

 They were way too bulky and had a tremendous thick pink area we call a flange.  The crazy thing is that there is no way overdentures could have ever worked because all the implants were placed way too shallow!  In order to have overdentures, you must have enough room from top to bottom (inter-arch space) to fit the dentures and plastic abutment attachments that make them snap into place.  The gold attachments are called locator abutments which typically work well on the lower jaw only.

He never wanted to have removable teeth but that is NOT what he got.  He was not able to wear the overdentures at all and came to me for a better solution.  He had gone 3 years like this.  The teeth were even made twice and then he gave up.  He told me I was his last hope. 

After evaluating him carefully I determined that the implants were placed in a shallow position more ideal for “regular implants.”  We refer to this in dentistry as an “Fp1” prosthesis.  That means there is no reason or room for the pink portion which most patients need because they are missing bone and gum.  This patient actually had excessive bone which is very rare and in retrospect if he really wanted an overdenture should’ve had a bone leveling alveoloplasty procedure.

This very well could have been a communication problem between the restorative, tooth making dentist,  and the implant surgeon.  In this case, there were 2 different people who started the procedure.  I am a strong believer that these complex dental implant procedures should be done from start to finish with a *single* skilled provider or a very tightly connected and experienced partnership duo.

The upper implants unfortunately were all squished in the front, without any dental implants in the molar back tooth positions with minimal inter-arch space.  On the lower jaw they were well spaced but there was too much space between implants for the regular/crown and bridge/Fp1 type teeth. 

The solution was to add four additional implants into the molar regions on the upper with some simple internal sinus lifting.  On the lower jaw I added 3 implants in strategic locations to shorten the spans of the bridges.  If the span is too long, and the zirconia material is not thick enough, the teeth will break…yikes!!!!   The additional implants will support the material.  This will allow him to have basically regular teeth back again without any of the pink porcelain or pink plastic.

In a single appointment, I added these additional 7 implants with minor sinus grafting under IV sedation at my office in Burbank, California.  The implants were allowed to heal for approximately 4 months prior to starting the restorative process.

Fabricating his teeth was very complex because of 2 different implant systems and at least 4 different proprietary screwdrivers and parts.  The locator abutments also had a very narrow “sulcus” which would be too small at the tooth neck for regular size teeth.  I actually had to custom alter make all of the special titanium implant impression transfers to fit into the overly narrow gum channels.

A verification jig was 3D print milled to be certain that all 17 implants had a very accurate impression so that there is no misfit of the new teeth.  I also created a screw retained wax rim teeth in order to  select tooth size, color, position, bite level and a host of other factors.

In these photographs what you are seeing is a temporary PMMA double arch bridge.  This is not the final although it may look like a final bridge! 

All teeth were designed using 3-D  3shape software.  I had my very skilled lab technician digitally create wider gum channels so the teeth at the neck appeared more of a normal size so they would not have mushroomed stalks.  At the delivery appointment for the temporaries I had to surgically open his gums to fit the teeth.  This will allow any papilla or gum triangles to fill in as needed and “groom the gum tissue” to fit the new teeth.  The PMMA is a milled plastic/acrylic material so the bite can be adjusted and refined.  I will then take all of this information and translate that to the final restoration.

I usually allow my patients to wear the screw retained PMMA full fixed implant temporary bridge for a few weeks to a few months depending on how much testing and adapting the patient needs.  Some people adapt very quickly with speech while others need a bit more time to learn where there teeth are in space.  This testing duration also allows the TMJ jaw joints an adaptation period.  Also the bone can progressively be given bite strength with this softer material and gradually get to the solid monolithic zirconia restorations.

Sorry for the blood in some of the photos as they were taken on the day of surgical delivery of these temporary restorations.  The finals will look very similar to this except even better 🙂

I hope this explain some of the highly complex procedures that go into recovering such a difficult situation.  Unfortunately a lot of what I do nowadays is correcting and redoing bad situations which could’ve been done right the first time with better planning.

Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry

Full Arch All on 4, 5, 6, 7, 8 Implants – 3D Lab Teeth Design Video

 
This is a great video explanation of full arch zirconia Prettau style dental implant bridges made for the All on 4, 5, 6, 7, 8 etc. procedures.  These are full jaw situations.  In this video I narrate the actual lab design of how the teeth are made.  Buyer beware!  Not all teeth are created equal!  Experience is everything when it comes to designing the teeth.  In this case the upper is an “All on 6” while the lower is an “All on 5” totaling eleven dental implants.
Every single day I get comments, calls and patients in my office that have had these procedures done.  Although the implants have integrated the bridges have failed, broken or they are so ugly and bulky that the patient hates them.  Fabrication of the teeth is controlled by me and a very skillful lab technician.  Everything I do is done in 3-D planning so that we can make the teeth as precise and naturally cosmetic as possible.  There are so many factors to consider…..watch the video to find out! Ramsey A. Amin, D.D.S. Diplomate of the American Board of Oral Implantology /Implant Dentistry Fellow-American Academy of Implant Dentistry

All On Dental Implants With Prettau Solid Zirconia Dental Implant Bridges ~A Case Explained

In this post I will try to detail the start to finish of full upper and lower dental implants with Prettau solid zirconia dental implant bridges.  This gives a general outline for what to expect if you were to have to lose all of your teeth and replace them with full arch zirconia implant bridges.

I will describe the rationale for treatment which may help those of you in similar situations.  Sometimes you have to have bone graft and sometimes you do not.  Sometimes the dental implants can be placed simultaneously with extractions and other times the extractions, implants and bone grafts need to be or should be done in phases.


before treatment x-ray showing failing teeth

before treatment x-ray showing failing teeth

IMG_0680
before treatment open retracted photograph

before treatment open retracted photograph

upper jaw

upper jaw

lower jaw

lower jaw

flipper stayplate for lower front teeth

flipper stayplate for lower front teeth

LEFT
RIGHT
1 week after upper jaw dental implants and extraction of all remaining teeth

1 week after upper jaw dental implants and extraction of all remaining teeth

lower jaw dental implants after one week

lower jaw dental implants after one week

upper jaw dental implant impressions

upper jaw dental implant impressions

lower jaw dental implant impression

lower jaw dental implant impression

conventional open tray impressions

conventional open tray impressions

wax pattern of teeth for try-in purposes

wax pattern of teeth for try-in purposes

verification jigs

verification jigs

PMMA temporaries.

PMMA temporaries.

IMG_4852
IMG_4856
IMG_4858
IMG_4866
Final x-ray with upper and lower solid zirconia Bridges on 12 implants. There are 24 teeth supported by these 12 implants.

Final x-ray with upper and lower solid zirconia Bridges on 12 implants. There are 24 teeth supported by these 12 implants.


What is unique about my approach is often procedure can be done in a single visit surgery without the need for “major” bone grafting such as lateral window sinus procedures or block grafting(although I routinely do these major grafts for other reasons).

he plan is to harness this patient’s existing good bone and avoid the areas where the bone is deficient, thin, risky and doesn’t have a lot of density.

Final x-ray with upper and lower solid zirconia Bridges on 12 implants. There are 24 teeth supported by these 12 implants.

Final x-ray with upper and lower solid zirconia Bridges on 12 implants. There are 24 teeth supported by these 12 implants.

ThisIMG_4858 patient is about 55 years old and as you can see has quite a substantial dental problem.  His upper teeth have a temporary bridge that is not well fabricated and was just put in so he could have “something there.”  The lower front teeth are missing.  The upper jaw is very small and narrow in comparison to the lower jaw which is wide.  This places the patient into a reverse cross bite which must be taken into account for both the surgery and the long-term with the teeth.  The mechanics of the bite can often destroy the fragile bone at the top of an implant.

I cannot emphasize enough that replacing all of your teeth with dental implants is a highly complex procedure that should be unique to your situation and not just the same recipe “all on 4” for every single patient.  I also believe that one implant dentist completing your treatment from start to finish has the most control of your result.  It also helps to save cost as compared to this procedure being done by 2 different dentist….A surgeon and a restorative dentist.

Your treatment plan and diagnosis is the most critical element which is done early in the planning phase.  For this patient I need to engineer his full mouth dental implants and solid zirconia bridges to be strong at the level of the teeth and strong in the bone so that he does not get bone loss or broken teeth.  This happens very commonly when these procedures are not well planned or discount parts and techniques are used.

On the preoperative panoramic x-ray we can see that the patient has had a substantial amount of dental work.  There is bone loss and decay on most of the remaining teeth. This patient was tired of investing thousands of dollars over the years into procedures that all failed and he did not feel that his smile was attractive.

In his case, while he slept under IV moderate sedation, I extracted all of the remaining teeth and placed all the implants simultaneously.  The procedure was planned by 3-D CBCT analysis which is essentially virtual computer surgery.  The bone had to be leveled in some areas so that all of the implants were approximately on an even plane leaving plenty of thickness for teeth.

These types of full arch solid zirconia bridges not only replace teeth but in his case were also replacing bone and gum.  This is why these types of restorations look different because without replacing the bone and gum on the bridge the patient’s face would look sunken in and his speech would be improper.

Prior to the surgery, upper and lower impressions were made to fabricate temporary upper and lower dentures.  These dentures will be used for several months while the implants heal and give us some idea of the patient’s facial aesthetics and bite needs.  Connecting the teeth to the dental implants on the same day in his case was not appropriate.  Immediate teeth can be made in some cases but should not be made in all cases.  Many dental clinics market this as being a solution for all patients but the reality is it is not safe and predictable for all patients but it is for ‘some.’

At no point will this patient ever be without teeth.  In my practice in Burbank,California, this is unacceptable for patient to walk around without teeth although I have had a few patients that preferred to do that.

On the upper jaw  6 dental implants were placed into the best possible bone.  The rear most dental implants were placed at a tilt facing backwards on purpose.  This will alleviate the need in this patient for right and left maxillary sinus bone grafts.  The teeth can be cantilevered about 1-1/2 teeth beyond where the implants end to give this patient teeth all the way to the first molar position.  This means that the 6 dental implants will support 12 teeth on the bridge.  This tilted concept is not always possible and depends on where God made your sinuses and nerves.  Sometimes the sinuses are too far forward for this to work.  Especially on the upper jaw you want implants going as far back as possible and as many implants as possible because the bone is soft.  The number of implants is critical and should never be compromised as this is the main structure that will hopefully make things last as long as possible because dental implants are not permanent!!

On the lower jaw, the 6 dental implants are scattered more evenly around the jaw because this particular patient had room above the nerve on the rear molar areas.  This places dental implants underneath all of the bridge without a cantilever which is a great approach.  In a patient that does not have bone in the rear molar area, the implants can be more centralized towards the front middle and teeth cantilevered towards the back.  In the latter scenario, you want to make sure that the implants are good and long and you have at least 5 of them.

It takes 3-6 months for the implants to integrate.  During that phase, I  begin to prototype the patient’s mouth so that they can see feel and test drive what their new smile will look like.  Adjustments will be made to the teeth and a wax pattern is fabricated.

In this patient, I made  conventional open tray impressions of his upper and lower jaw using a putty type of material.  Sometimes the impressions can be made digitally also using the 3Shape Trios 3 scanner that I have.  The impressions are then scanned in a physical and digital model is made.  I then fabricate what is called a verification jig.  This device verifies that your impression is accurate and your bridge *will* fit…no guesses or maybes.  This is not a step that should be skipped although I find many dentists that do.  This is the equivalent of the framing of a house… It needs to be perfect from the structural standpoint so that everything last a long time.  Panoramic x-rays are generally taken along the way in order to verify that the custom abutments are flush to the implants.

After the verification jig comes another try in to verify you like the look of everything and then we switched over to PMMA fixed temporaries.  The fixed temporaries are the closest prototype to the real one.  The purpose is for you to be able to test drive the real ones.  It also allows me to test  speech, facial aesthetics, dental aesthetics, bite, TMJ, hygeine and so much more.  You will go home wearing these great looking, stong temporaries and wear them for 1-2 months generally.  During this time life is good and transitioning to the final is really easy because it feels even better than the digitally fabricated and milled PMMA temporaries.

The final solid zirconia Prettau dental implant bridges are delivered and generally screwed into place.  The screw access holes were closed with a composite material after all of the abutments screws are tightened.

It is quite the process to replace all teeth with fixed solid zirconia dental implant bridges but it is so worth it.  I’m certain this is the best that dentistry has to offer as of 2016.  There are many clinics that advertised discounted procedures and techniques but you need to be very careful what you may end up with.  Sometimes people have problems and no dentist wants to fix them because treatment was so bad to begin with.  Sadly, I see this every single week.

This patient can chew whatever he wants an should not have any problem for a long time.  Total treatment time for this patient was approximately 9 months from start to finish.

Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry

 

 

 

 

 

Bone Reduction Leveling For Dental Implants to Avoid a Bone Graft

Bone leveling is a procedure called “alveoloplasty.” Bone leveling is extremely beneficial in cases where a bone graft can be avoided altogether. Especially in the lower jaw when the bone atrophies, (melts away) what’s left of the bone is just a skinny spine knife edge type of ridge where the teeth used to be. That skinny knife edge ridge will not allow a normal size implant to fit inside of it.

stimulation of bone reduction leveling to take off the skinny part of the jawbone.  This is the jawbone in cross section.

stimulation of bone reduction leveling to take off the skinny part of the jawbone. This is the jawbone in cross section.

What’s interesting about our jawbone especially in the lower jaw and even in the upper jaw is it is shaped like a triangle if you look at it in cross section. The top of the bone is the apex of the triangle which is skinniest and the bottom of the bone is the base of the triangle which is the widest. So if your bone is really skinny at the tip and is wider at the base, a bone leveling alveoloplasty reduction procedure can take top of the triangle off leaving a wide base of bone to place the implants.  The procedure has minimal risks.

I do this very commonly when replacing implants in the lower jaw when all teeth are missing. This serves many purposes. One purpose for leveling bone is to avoid bone grafting. A second purpose would be to provide bone around the entire head platform of the implant. Finally, bone leveling for dental implants reduces cost to the patient and decreases the time until you get your final teeth… A win-win situation!

Bone reduction alveoloplasty example (1)

Before —note uneven bone that is higher in the front of the mouth where some broken roots remain

Bone reduction alveoloplasty example (2)

Before —note uneven bone that is higher in the front of the mouth where some broken roots remain

sample real case bone reduction for dental implants (1)

Before —note uneven bone that is higher in the front of the mouth where some broken roots remain

sample real case bone reduction for dental implants (2)

After –simultaneous extraction, bone leveling and placement of four dental implants….this is healing at one month

Bone reduction alveoloplasty example (3)

After -Bone reduction alveoloplasty example


Why don’t we just do this for all implants?

Why is this only limited to full arch replacement such as a Prettau dental implant bridge or when replacing large segments of teeth?

The reason is that it makes the teeth longer from the gum line to the top of the tooth. If you are missing all of your teeth bone leveling (as opposed to bone grafting ) can be extremely beneficial because it provides thickness to the overdenture or fixed dental implant bridge such as the Prettau.

Having significant thickness of your bridge will prevent problems that you may not think about such as breaking your bridge or breaking your implant overdenture. This happens so commonly when the depth of the implant is too shallow and a full arch zirconia, hybrid all on 4 bridge or overdenture case is made and the material was so thin that it just breaks in half or the teeth chip or fracture off.

Bone leveling reduction alveoloplasty can be very important for replacing all upper teeth also especially if you are missing gum tissue. Sometimes we have to use pink tissue ceramic colored porcelain to mimic lost gums. You never want this transition between the prosthetic pink gum and your natural gum to show when you smile. Although the pink gum tissue looks very natural, it does not look natural if you see the line between the two in full smile. So sometimes a bone leveling reduction alveoloplasty is done in order to hide the transition. I have been doing this procedure for at least 15 years as of 2015.

Other Benefits

Another other benefit is the bone shavings can be used to graft another area of the mouth that may need bone! This can be combined with L PRF/PRP (made from your own blood)  and other bone grafting materials to as your own bone and make a composite bone graft that is extremely successful.

Bone leveling is also important to make sure that the heads of all the implants are all relatively on the same plane. It is extremely common for the lower jaw to be missing more bone in the back and the bone to be sticking up in the front. This bone that is sticking up in the front is usually reduced for thickness purposes and to make sure the implants are at a good level with the rest of the bone and the other implants. Typically I do this procedure when I am placing anywhere between 3-10 implants in the jaw. It also allows for the gum to be closed very well and stitch in such a way that the gums almost always touch each other. This is called primary closure and leads to fast healing from surgery.

What is the disadvantage of this procedure?

If bone leveling reduction alveoloplasty is used in the wrong location, such as a single missing tooth, you will end up with a huge, open black triangles between your teeth. It is not meant to be used in cosmetic areas of the mouth such as upper front teeth. These areas are better served with bone grafting than bone reduction leveling. It is meant to treat long span missing teeth or when you are missing all teeth. Bone reduction alveoloplasty needs to be carefully planned from a full set of photographs and a 3-D scan. The point is to take away just enough bone but not too much.

Please feel free to comment and ask questions.  Please use the proper area of the blog to do so

Prettau Full Mouth Dental Implants ~3D planning by Ramsey Amin DDS

This is a case being planned for upper and lower Prettau dental implant Bridges. The patient just lost her lower front teeth extracted and now has no teeth at all. She can no longer wear a lower denture and desires dental implants that are nonremovable.

This video walks you through some of the clinical photographs involved in planning the case and then moves into 3-dimensional planning from a 3-D CBCT scan. I will show you how the implants should be spread out and placed into the best bone possible. The video also shows how a surgical guide is made from the 3-D scan planning that I personally do for every single case. I do not believe in outsourcing surgical planning to other dentists and technicians from companies that do not understand anatomy…. Yes this is very common!

The video highlights some of the powerful software that I use every day to plan surgeries for safety and predictability. The surgeries are performed in one of four surgical suite in my Burbank, California office

Thank you for watching!

All On Four Dental Implant Procedure Review: Is It The Best? –Ramsey Amin DDS

The All on 4 dental implant procedure has become quite popular. You probably even hear about it on radio and TV advertising. Even many dentists don’t really understand it. It is sometimes advertised as the “smile and a day” procedure.   All on four is simply a treatment option for replacing all of your teeth on the upper or the lower with just four dental implants. It is possible to replace all of your teeth in just 1 day. In fact I have been doing this for the last 15 years.

You just have to be very selective that you are the right patient for this type of procedure. I don’t suggest that the final teeth are made on the same day because you will not be able to test the teeth for how they look, feel or bite.  There are many steps to achieve a really good result and a full mouth reconstruction.

The All on 4 Dental Implant Procedure Video Review

There is a lot of hype about all on four. What is perceived is not always the reality. In this video I will review several things you should know about total teeth replacement with “ALL ON FOUR”.

Some advantages are:

Some disadvantages are:

  • Under engineered–only four implants are supporting what 14 upper natural teeth would do.
  • Cost is reduced by making a “fixed hybrid.” These are essentially fixed dentures which have high maintenance and break very often.
  • No implants are placed in the molar areas of your mouth where the bite force is the highest

Here is a patient a decade ago:

 

Generally speaking, 6 dental implants on the upper and 5 dental implants on the lower are minimum number for stable long-term bone.

This should be combined with an all zirconia or metal ceramic bridge rather than a hybrid, which are plastic denture teeth fused to a base metal. Depending on the size your jaw and bite force, you may need up to 8 dental implants on your upper jaw and 6-8 on your lower jaw.

Sometimes bone grafting cannot be avoided and is necessary to obtain good long-term results for you. You may require sinus bone graft if your sinuses are farther forward in your mouth.

I would strongly suggest all porcelain teeth, preferably CAD milled Prettau, if you have enough space from top to bottom. Porcelain teeth don’t stain, chip and break like plastic hybrid denture teeth do. I would also suggest that all on four or all on 6 or 8 are held in by screws rather than cement, if at all possible, based on dental implant angulation. This video should clarify a lot of questions you may have.

The all on four dental procedure is really heavily marketed and is rarely the best option but **can work for some**.

Remember your teeth are your body parts. I truly believe a customized solution for your particular situation is best. Some dentists just plan all on 4 dental implants for all patients regardless of their unique situations.

It is the equivalent of trying to make your mouth fit the prefabricated teeth, rather than making teeth to fit your mouth.

If my mom or dad were to ever need to replace all of their teeth, this is not the way I would do it.

Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry