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All on 4/6 Prettau Fixed Implant Bridge Lip and Facial Support Considerations

If you lose all of your teeth, your jawbone and eventually your face will shrink. This cannot be stopped even with bone grafts. It naturally happens because of atrophy (lack of use) of both muscle and bone of the jaws. I have discussed this bone loss in many previous blog and web articles.

If you’re having an all on 4/6/8 etc dental implant Prettau style bridge, this is an important consideration for facial aesthetics. Being able to support your face means that the lips, the base of the nose and cheeks can be positioned correctly so that you don’t have a caved in, wrinkled appearance.

Many dentists believe this cannot be done with fixed dental implant bridges and offer their patients snap-on overdentures. I have found there to be a lack of uniform knowledge of regular general dentists on this topic mostly because most dentists do not do this procedure routinely.

This issue is more substantial when discussing the upper jaw. A lack of facial/lip support also makes the nose appear much larger than it really is.

In the past (prior to 2005), I too treated some patients with upper overdentures to try to make facial esthetics the best possible but you still end up with a plastic denture! As of about 12 years ago I have developed a technique for predictably re-creating lip support and face aesthetics eliminating the need for upper overdentures. Lip and facial support are also determined by what we call vertical dimension of occlusion “VDO.โ€

This is best seen in side profile but can also be seen straight on. It is often measured from the tip of the nose to the tip of the chin. If you lose all of your teeth, that measurement from the tip of the nose to the tip of the chin becomes smaller giving you a premature aged appearance and many wrinkles.



Where many dentists believe this can’t be done is in the cleansability of the final Prettau dental implant restoration. I have been advocating and teaching a technique that levels the bone and gum to create a flat or convex surface UNDER the bridge so that the bridge can both be cleansable and aesthetic at the same time.

The fact that Prettau monolithic zirconia is nonporous also helps tremendously. It is not material of the bridge that makes the lip support but rather the surgical and prosthetic planning of the case from the very beginning.

Every single patient I treat has a very particular surgical modification of the gum or bone anatomy to be able to *create* this scenario right from day one. This is done by me at the first surgery. If it is not considered and created from the very first surgery/insertion of implants, it is very difficult to recover and correct later.

I also feel it is very important to “test” every patient with a fixed temporary PMMA bridge that allows them to test facial aesthetics, bite, lip support, color, tooth shape and size, etc. etc. I usually allow the patient to test the prototype bridges for somewhere between 3 weeks to 3 months. They look great too!

I often touchup this gum created contour with a carbon dioxide laser at the beginning of the tooth making process.

I also see that over time once I create a solid biting plane of occlusion, the atrophied, flabby muscles begin to come back over the first year or 2 tightening up the face.

There are some exceptions to creating ideal lip support and it almost always occurs in a patient that has either a severe overbite or severe underbite. When this occurs, sometimes a slight concavity needs to be created in a very certain position that can be digitally designed to be VERY cleansable with a water pick. This will lead to long term crestal bone and gum stability.

This patient that photographed has 6 implants on top and 5 implants on bottom and upper lower fixed Prettau bridges. It is my passion to deliver teeth that are long-lasting, cleansable, well engineered and beautiful. It really changes lives.

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

17 thoughts on “All on 4/6 Prettau Fixed Implant Bridge Lip and Facial Support Considerations

  1. The more of your website I review, the more I think I should travel from the east coast for an All on 5 or 6 lower arch.

    I have 3 failing/cupping left lower quadrant implants and 3 right lower quadrant implants (all placed about 9 years ago) which might/ might not last another decade. I would consider myself lucky if a full arch were to last another decade, since I am a very senior citizen.

    I am just asking for ballpark estimates now. Please tell me the approximate number of visits over, say, a year would be necessary–can any of the steps be done within a few days or each other? The trips, especially if they require a lot of hotel time, are probably prohibitive, but your videos and your website make me hope this is possible.

    And, of course, the approximate costs of a lower All on 5 or 6. I have a current CT, am in good health.

    1. Hi Win,
      I have many patients that travel. Please call the office on Tuesday and speak to my front desk staff. They can help you with these questions in more detail. Most of these procedures are done in very few visits due to advanced technique and digital technologies.
      ๐Ÿ˜‰

  2. Is it possible to build the upper gum area using a gum graft/augmentation of some sort for lip support so that the zirconia implant bridge would consist of teeth only and no upper pink material?

    Please advise further

  3. great article and very informative. If only I read all of this 8 days ago prior to having my work done. I am sitting here doing the research I thought I had already done before electing to get the all on 6 .
    I just had 8 top teeth removed and 6 dental implants installed and now I have the transitional teeth in which are in my opinion dentures. I assumed that these were just the temporary and my final product would be the beautiful teeth I wanted that feel like real teeth. I now find that my permanent teeth will be pretty much the same with the large flange under my lip and the acrylic covering my entire gum. Like I said I think this is basically just a denture that is screwed in minus the large palatte. I already spent 30k on this and am almost in tears thinking I made a huge mistake. I have called back and am waiting to hear if what they did can be changed to a fixed bridge which would feel more like teeth than this denture. The more I read the more I am scraed that they will tell me I need to have different type of implants and more of them, plus grafting, etc. in order to change the type of teeth. Is it possible to retain the implants I already have in and healing and change this to a fixed bridge such as the prettau zirconia. I am going to be sick to my stomach if they tell me its going to be another 10k or more. I may just tell them to stop everything and head to Mexico to have this done correctly.

    1. Oh gosh…. The transitional teeth are often converted dentures or PMMA so they do feel a bit like plastic. This is not uncommon at all.

      please see this article on temporary full arch/full mouth implant bridges.

      If the bridges made in zirconia it may be able to be thinned out a bit but zirconia has a certain minimal thickness that it needs to be to prevent fracture of the entire bridge. The thinnest material but you can use it is actually porcelain fused to metal. The problem with porcelain fused to metal (PFM) is it can chip or break more easily but it can be made thinner. The reality is without that flange your lip may caved in. Sometimes the shape of the palate or the shape of the lips require more of the pink to be done for proper support. I’m not sure that you would be able to go backwards to have individual crown and bridge type restorations done. That would be a major task.

      Prettau zirconia is simply a material. It will not magically replaced the need for the pink part of the bridge. Some people need a lot of pink and some people need very little in some not at all. Typically this is known in advance of ever removing the teeth during the consultation visit.

      I hope I have helped you in understanding your situation better.

  4. Hi Dr Ramsay Amin….lovely to see your great work again along with your genuine informative explanations…..I still have not found a tone in australia that I really trust…so many do the all on 4 but it is plastic denture teeth…and they do not like it when I mention prettau zirconia 6 on top 5 on bottom……this work is so complex and should only be done by truly experienced professional people…..a lot of people that do it should not……I did find a top ceramist with decades of experience who has a large licensed lab to use prettau zirconia..I have not met him yet..his name is Wauner Sauer.i was talking to his wife the other day and mentioned great guy in Burbank she said he knows someone in Burbank must be you …a guy from what his wife told me he does work with some all on 4 mob but they only use 4 foundations??and a metal bar?..anyway that did not sound enough for foundations….I hope this email finds you well and happy…๐Ÿ˜ I have never forgotten your saying “it has to be done right not right now ” l LOVE THAT SAYING BECAUSE ITSAYS IT ALL AND IT IS TRUE!!……I am still suffering๐Ÿ™๐Ÿ˜– (lower getting worse) this is crazy as it is such an important health issue ….I think some people think I am in the top hard basket…I think they just want the 4 foundations and plastic denture teeth. It would be funny if you knew the ceramist I mentioned earlier. Kindest Regards Julie …

    1. I do not know the ceramist that you are mentioning. I’m sure you can find somebody close to your home that can help you!! You are a wonderful human being. Thank you for your kind words. I truly hope that you can get your mouth back to 100% health, function and beauty.

      1. Thank you for your kind reply as I know you are a very busy man. I am seeing a dr philip tan at bayside dental he is a prosthodontist I saw him last year but did not have time to see his oral surgeon dr Sam Verco I have appt to see both in early may as they are both in Melbourne,I think philip does his own milling if so doubt if prettau zirconia would be an option as last year I got in contact with the overseas manufacturers and they gave me their austalia rep. and I got the name of licensed labs on the east coast of australia,but still can not find a team of prosthodontist , surgeon,and prettau lab that work together that do more. than 4 foundations/ I know how important the plan/the foundations/occlusion/tmj/ work load forces in the mouth/the protective canine rise are as without it all being correct, the domino effect kicks in,and boom crash opera the house falls down/I only know this as I have lived it and learnt it years ago…. that is why I understand the Importance of your explanations..I just get you./dentistry can be such a cover up industry/I do not mean to be disrespectful to the industry but a lot of bad work is done and there is no accountability ๐Ÿ˜• that is why you make people feel safe as you are honest and open and capable such rare qualities am sure you know . where I am coming from…..that is why people feel safe putting their lives in your hands…kindest regards julie… you never know we could still meet…meanwhile stay safe in this volitile world we live in …….

  5. Ten years ago I had a sinus infection that was treated with an antibiotic. I had a severe reaction and ended up in a hospital in CCU for three days. For some reason the doctors there told my wife that it wasn’t my sinuses it was my teeth. It was not. They told her I could die with such bad teeth and they all needed to be extracted. They pulled 22 healthy teeth. I suffered from PTSD since childhood and this sent me into a tailspin for 8 years. Now ten years later I’m finally emotionally ready for implants. I’ve tried regular dentures now for 2 years and I can’t get used to them. I’ve been told by prosthodontist that implants would cost around 50,000 dollars. I’m disabled on a fixed income. How will I ever be able to afford that? I can barely eat. Ive gone from 195 lbs. down to 125 lbs. I’m 6ft. 3. I’m beginning to think I’ll probably die from this. Any suggestions?

    1. Yikes…have you considered treatment in a dental school graduate program? They may be able to help you at a reduced cost.

  6. I live in L.I., N.Y. I just turned 65 and after having tens of thousands of dental work done I am now being told I will probably lose all my teeth. I am more than hysterical-after my fifth bridge in upper front teeth(stemming from being in accident-a passenger at age 14 and lost a front tooth-probably swallowed) At any rate I received a whopping $2,000 because my lawyer said I was much too pretty to receive any sympathy! Unfortunately my fiancรฉ died leaving me without funds-I became an RN and re-couped my losses-I had to go on disability due to a severe back injury;then went off a ladder at my daughter’s home and was life-flighted to repair the compound fractures with ORIF-I’ve been paying off those bills and face more surgery. A dentist said I was getting decay under last front bridge-pulled out all my upper teeth and placed bonded together temps. I could waste your time with more traumas but since I cannot get to you I’m praying for anyone nearly as competent as you to be found closer to home.Please excuse this poorly written tale-I am in excruciating pain as I write. I cannot bear dentures. (small bite) I briefly had a temp plate which was intolerable. I have a small home I will sell not to have dentures. Please help if possible. I’m still pretty but it’s not simply vanity-it’s the intolerance of all the effects of dentures. Thank You.

    1. So sorry about what you are dealing with ๐Ÿ™

      Fortunately you live in NY which is full of great dental opportunity. Just do your due diligence and find a provider who is skilled, experienced and compassionate.
      Since your case is complex make sure you understand what you are getting into.

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About Ramsey A. Amin, DDS

Dr. Ramsey Amin has extensive experience in surgical and restorative implant dentistry. As one of only less than 400 Diplomates of the American Board of Oral Implantology/ Implant Dentistry (ABOI/ID) he is considered an expert, and board-certified in dental implants. He is a former instructor at the UCLA School of Dentistry.