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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.”

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

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

  1. 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…😁 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 suffering🙁😖 (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.

  2. 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.

  3. 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 fiancé 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 🙁

      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.