Immediate Fixed Implant Supported Hybrid Prosthesis (all-on-4 technique) from start to finish, a complete case

Part 1 - Intro and Extraction

Instructors:

Mark Margolin, DDS

Mark Margolin, DDS

Currently in full time private practice at the Berland Bental Arts Center, which is a group practice providing comprehensive dental care in one location.  He provides the surgical and sedation aspect of the practice.

Lorin Berland, DDS

Lorin Berland, DDS

Dr. Berland is a Fellow of the American Academy of Cosmetic Dentistry (AACD), the co-creator of the Lorin Library Smile Style Guide, and the developer of the Web site , www.denturewearerscom.

Dr. Margolin and Dr. Berland describe the All-on-4 case that will be demonstrated in this video. Dr. Margolin will begin by extracting the maxillary teeth.

My motivation in putting together this video was not so much to promote this as a technique or make another how to video. There's lots of that out there. We want to create a video to more inform dentist about what's really involved in providing the service for your patients which we have an un-sponsored showing you really start to finish what's going to be involved in doing one of these cases. We have patients who are coming in, seeking the service from us all the time now and it's really a positive. There's a populations of patients who are out there denture patients who once they're edentulated and they have a denture that's working in their mouth is really kind of lost to the whole process of dentistry. They're really no longer dental patient cause they don't need to come in regularly for checkups and they may not return to a dentist for many years until they're no longer able to function comfortably with their prosthesis. This gentleman flew in from out of town. He had multiple dental issues but the bottom-line he was in pain, couldn't chew his food properly, and wanted to look better. He was an extreme dental phobic and had in fact been dismissed from several dental practices. For the past 30 years with the exception of his root canal and crown on his upper lateral incisor for appearance purposes his treatment of choice has been extractions with IV sedation. The lost of his posterior teeth as well as periodontal disease resulted in loss vertical dimension and splayed front teeth. Now due to severe carries his lower bicuspids and canine are giving him pain. And after much deliberation he felt he had no choice but to seek treatment. I couldn't eat right. I wasn't chewing my food well which was giving me indigestion and creating other health problems. So yes, I mean I had all kinds of trouble not to mention the cosmetic aspect. I haven't smiled and shown my teeth in over 25 years. Whenever I smile I'll smile like this because I was embarrassed. We begin with a series of digital radiographs and 3D scan as well as diagnostic study models and bite relation. He had seen other dentist before us and he had recommendations that range from orthodontic implants and prosthetics to full dentures. All possibilities. But he wanted a fixed more permanent immediate solution to his problems. After much discussion, Mark and I suggested immediate fixed hybrid prosthetics. And that is exactly why he made the trip to see us. We proceeded with cosmetic imaging. He chose smile design R2 [length 1] from my Smile Style guide. That's round cuspids, square round laterals, and square centrals with the centrals approximately as long as the cuspids. This reflected the shape and length of his natural teeth. I asked SmilePix, an online cosmetic imaging service, to give me two images; one with the space completely close and one with its slightly open. The choice was his. But he couldn't decide. He was afraid closing the gap completely would be too dramatic a change. I told him that's okay since this is a two-step procedure a transitional followed by final prosthetic, why don't we close this space a little bit with the transitional and decide when we do the final. I can even do a mock up with the transitional to close the space realistically so he gets a live preview. He thought that was a great idea. Because of the deep level of sedation necessary and his extreme dental phobia, we felt it would be best if we proceeded with one arch at the time. This case was a little unusual in that due to the pain from his lower teeth, he opted to begin with the lower arch. So the color discrepancy between the top and bottom teeth would have been too great, we chose A1. He didn't want to be two-one for too long. One month later, he returned to proceed with the top. So we left a little bit of a space and then Dr. Berland, it's some kind of magic. He pulled out some bond or something or whatever it is composite and filled the gap and showed me what I would like if there was no space. We took a couple of pictures of that before we took it out. So now I've got about two or three months to make up my mind if I want to close the gap completely or leave it slightly open. And I'm not sure which one I want to do yet and we'll see. Three months later, he returned for the final upper and lower prosthetics. Today, we're doing a procedure it's commonly referred to All on 4 technique. It's basically an implant retained immediate transitional denture. It's really nice procedure for patients especially our patient here today. He's had a large history of dentistry and he's not a big fan of dentistry. He's quite phobic actually. So every time he has to go to the dental office he needs to be sedated. By doing a technique like this it enables him to get his dentistry done in a single visit. And a very nice thing about this technique also is when you have a patient that you're transitioning from a natural dentition into a denture-type restoration there's that adjustment of going from a fixed natural dentition to removable appliance. And as anyone in dentistry knows that's a very hard transition from most patients. This will allow our patient today to leave without having to have removable appliance. Another issue is with sedation he takes benzodiazepines as part of a regular medication, so he has a very high tolerance to those type of medications. Meaning his respiratory window, the amount of medication you have to them to have them sedated, is quite a bit before it becomes a point where he might stop breathing. So the less number of visits that we have to sedate him the better and doing this technique we can get all this work done in a single visit and avoid all those extra sedation. Today, we'll be using Nobel Active Implants. It's a very nice implant for this technique because the internal hex affords us a variety of positions so our rotational direction with placement not as critical as with the prior system, the Replace system. And also because of the aggressive cutting threads on this Nobel Active, we're able to achieve a very high initial torque with the implant which will give us a better stability for immediate loading of the appliance. Even though this is known as the All on 4 technique, today we're actually planning on placing six implants in the maxillary bone. We have plenty of bone. We actually have to do a little bone reduction in order to make room for restorative components and four is safer than six if you have a non-integration problem we'll still be fine if we have four or five or six fixtures on the maxilla. Now in the past we've already done an All on 4 on his mandibular which you can see he's been wearing now probably about six weeks I would guess. And he's been very happy and comfortable with that. He made a smooth transition from his natural dentition. And today, we'll be removing the remaining maxillary teeth and placing our implants on the maxillary and he'll leave with a matching All on 4 type restoration on his maxilla. To start our extraction technique I'm going to be using microsurgery scalpel. I actually like this better than the standard Bard-Parker 15 or 15C's. They're a little bit more rigid and if you see the edge of it, it has kind of a rounded but almost flatter cutting edge on it. And I could use this both as a scalpel for the incision and I can apply pressure to get up through the periosteum and almost use it also like a periosteal elevator at the same time. And this works very nice for doing the intrasulcular incisions. It also helps minimize tissue damage to the gingiva as you're doing your intrasulcular incisions. We're ready to start the extraction now and for this part I'm going to use an instrument that's really changed the way I practice. It's put up by a company called Golden Dental Solutions and it's the Physic Forceps. And it's a little different concept in forceps. It actually uses leverage as opposed to force and enables us to get teeth out relatively easy with minimal bone removal and leaving the plates intact. It has the beak end which creates the leverage and then it has a bumper which will put pressure against the buccal plate and keeps that buccal plate safe while also helping apply a counterforce for that leverage. Now there is a little bit of a learning curve with using this. You don't want to apply to much force. There's a [proper reception] where you can kind of feel the tooth start to move in the socket. And you just want to apply a slow constant force with it. You don't want to squeeze the beaks too tight or you'll wind up breaking your tooth. But once you kind of get yourself through that learning curve and learn the nuances of it, it becomes a very very valuable instrument and it's almost always the first instrument I'll go to when I'm doing my extractions these days. These physics forces actually come in a variety of sizes. This is the original setup that I'm using right now. This is the upper anterior size and they come in a four sizes. The lower is a universal and then there's upper anterior, upper right and upper left. Now they also have a kit for third molars which I actually used often for second molars just because the access in somebody's mouth. It doesn't have a large vestibule. It's a little tight down there to fit your bumpers. So the third molar forceps is really a need supplement in order to do both second and third molars. And there's also a pedo set. I don't do a lot of pedo. So I haven't used the pedo ones but for adults really having both sets really change the way I practice. I must say. Here we go. We get our movement. Our sockets remain intact. Once you feel it moving the socket you just go to a traditional forceps just to take it out. So now we're done with that phase. The extractions are all completed. Buccal plate is intact. The next phase, now we're ready to start our implant portion. What we're going to do is we're going to lay flat so that we can see the bone. A very important thing that you don't normally think of when you're doing implant dentistry usually we'll worry that we have enough bone is we need to make sure that we have enough space for restorative components. So often we'll have to reduce bone in order to create that space. We need to have both enough space for the tooth and the acrylic of the restoration, and then also for your implant components being your multi-unit abutment and for your bar. So what we need to have is about 18mm from the top of our implant to the opposing dentition. You'll see we'll use a guide to make sure that we'll have actually appropriate bone reduction for this. We're just laying a full thickness flap. You want to make sure your full thickness so that you can evaluate your bone. You done want to leave any residual soft tissue. It might fool you in to thinking its bone when it's not. So you just want to make sure that you're taking your incision down to periosteum. A nice thing with All on 4 technique is you don't need to be as accurate with your implant positions because we don't have other teeth that you're going to run into. So unless there's a compromise in the bone quality we'll use the Nobel All on 4 guide which is a rather simple guide. You'll see that in a moment. But you don't actually need to use a CAD/CAM generated guide like we'll do when we're mixing implants with a natural dentition. Now, we'll start a reflection and we want to do like I said a full thickness reflection. So you want to have a nice clean view of your bone. We'll use a CT scan to do our initial treatment planning and we'll do a virtual surgery actually using a software. I'm using something called NVivo. And with that I can do a virtual procedure. Based on the CT scan I can actually place the implants in multiple positions, rotate around those implants 360 degrees. See where they come out in relation to the opposing dentition. Make sure that I avoid any anatomical structures. See the relationship between implant teeth from implant to implant. And if we're doing a guided surgery, from that we can upload that onto an internet site and a have a CAD/CAM stent made that would slip over the patient's teeth in order to guide our implant placement. But as I said with the All on 4 we're able to be a little bit more, we have a little more freedom in our implant positioning. And we can use more of standard implant guides to make sure that we're within the denture which we're going to be using as its restoration.