The reason I love dental implants is, it has no rules. There are guidelines to it. Because every case is unique, the dentist must need to have good knowledge. He/She must know every case with details and hence should implement the treatment plan accordingly. The factors such as periodontal disease, occlusion, parafunction, and the budget of the patient can affect even the regular cases. A dentist should take all these factors into account and should listen to the patient’s wishes. These factors can also affect the patients who lack teeth. This article focuses on the patients who are not edentulous and ready to remove the teeth for implantation.
The recent most popular trend in implant dentistry is full-arched fixed implant bridges. These are also known as all on for implant. The dental implants, which are around four to six, support these bridges. They are made up of titanium, monolithic zirconia, and stacked porcelain to a chromium and cobalt frame. Some dentist practitioners promote all-on- 4 dental implants to their patients, who are on the verge of being toothless. It comes with package pricing to make an easy presentation of the case.
Six to ten years ago, patients were not so aware of all-on-four implants. But due to huge information available on the internet and promotions by the dentist industry, patients know the advantages of all-on-4 dental implants.
Nowadays, patients request this implant technique, but is it always beneficial? Can all-on-four implants be harmful? What are its consequences?
To answer this, it will take so long to write about all-on-four implants. But the following five factors can be considered to recommend these implants.
2.Difficulty of speech
4.Significant caries index
Now let’s see how these factors can affect all-on-four dental implants.
Some people have parafunctional habits. Habits such as clenching the teeth, bruxism, or chewing cycles that are not regular can affect the treatment. Teeth can detect these forces than the forces of the implant. To make the parafunction better, some natural teeth present in the mouth can help.
If parafunction is present, and there is a need to replace all the teeth, an overdenture that is bar supported can be helpful. This is still an all-on-four implant process but seems like a modification of fixed bridges through your patient’s vision. For the patients who have bruxism habit and do it often, bar overdentures are effective. Patients can remove the overdentures and use a night guard that fits on the bar for retention. This helps in the protection of prostheses. It also helps to reduce the strain on the bone and supporting implants. Even if the soft tissue volume and bone are healthy, we replace them. Some part of the bridge adjacent to the soft tissue gets bulkier than the previous soft tissue volume and bone.
The difficulty of speech:
Speech difficulty is a major issue for patients. For all-on-four implants, a minor speech issue can become a big concern. For strength, vertical and horizontal bulk is required for implant-supported bridges. Most bridges require 15 mm or more of height to fulfill the vertical needs of different restorative materials. To achieve these measurements, dentists have to replace more than the volume of a tooth that is missed. It also has an impact on speech sounds. To form the sounds, the tongue comes in contact with the hard palate lingual to the central incisors. Sounds such as ‘T,’ ‘N,’ ‘D,’ ‘G,’ ‘J,’ etc., are impacted by this. Similarly, the ‘S’ sound is affected by the horizontal bulk in the posterior area, which can result in slurring.
Patients with all-on-four dental implants should be aware of this situation. It is a compromise for them. Though they can get a habit of retraining their tongue by practicing, they can be anxious and tired by it. If the difficulty in speech is major, the dentist is recommended to offer alternative treatment options. He/She can make a plan to replace the missing teeth with individual implants or short-term bridges and save the healthy teeth. A bridge can be used to replace the missing tooth structure when the teeth are terminal. This process takes more effort. It often requires more implants and more bone grafting. It requires more prosthetics, and hence patients need to give more time and cost.
While recommending dual-arch treatments to a patient, the value of proprioception is often overlooked. The teeth become vulnerable to the lower forces by the periodontal mechanoreceptors, also known as (PMR). These are present in the periodontal ligament. A periodontal ligament is not present in a dental implant. That is why to make the same proprioception as a tooth takes 10x more force. The proprioception that is associated with dental implantation is almost similar to the tooth, which is affected by local anesthesia. It will be difficult to identify the excessive occlusal and premature contacts. Due to a lack of sensation and feedback, excessive biting forces may be generated. Patients having dual-arch all-on-four dental implants bite excessively than the patients with fewer teeth. This can cause a bone loss or fracture of the restoration. To improve chewing efficiency, Periodontal mechanoreceptors (PMRs) associate with motor movements when teeth are present. The poor efficiency of chewing and the stress on the restoration and implants can be caused due to fewer movements and dual-arch implants.
During the healing period, tooth popping, and broken temporaries, the patients with the dual-arch all-on-four dental implants experience more implant loss. If both the arches need treatment, try to save at least some teeth. Use some restorative options for that. In some cases, this may not be possible. Then try treating the upper arch with staging treatment opposing natural teeth for a while, and you may modify the teeth at the occlusal plane level. For patients to avoid the extra biting force, the proprioception of the lower teeth helps. It also helps them to recognize the occlusal discrepancies. The dentist can treat the lower arch after some months. This will be helpful for a patient and give time to form mechanoreceptors in orofacial tissues. Orofacial tissues such as joints, muscles, periosteum, etc., will form the mechanoreceptors. To increase the osseointegration in the maxillary implant, the extra healing time can be helpful.
Significant caries index
Dentists can get this scenario often. Suppose a patient has a full upper denture, it can be an all-on-four, and his/her lower teeth are missing. He/She wanted to have an all-on-four lower fixed bridge. The patients like to eat chewy foods such as steak and have a square-shaped jaw. He/She seems to have a bruxism habit. The patient has crowns and root canals with some fractured teeth. Some of his/her teeth are filled with tartar and have periodontal pockets, and some teeth have lost the bone. In this situation, should a dentist save the teeth or not? What will be the risk factors? What will be the benefits?
If the canines and bicuspids are intact and less mobile, it will be the best option to save the teeth. There is a risk of developing periodontal disease. They will be a failure from decay. But these conditions have less chance than the prosthesis fracture or the damage to the implant due to parafunction.
Now again, if we consider the same situation but some canines and bicuspids have interproximal, and Class V decay. The teeth have plaque, and the cavities are not a problem. But now, how sure are you as a dentist to do future prognosis? You can diagnose the whole situation and ask a patient to take care of the teeth at home, have less sugar, and more visits to the dentist. But as you know, habits are easy to get and hard to change. The tooth decaying can increase the risk of prosthesis fracture, and a patient can lose these teeth. So the best treatment in such scenarios is all-on-four bar overdenture. Through this treatment, a patient can get a simple oral hygiene rule and reduce the stress of implantation. A dentist needs to give more time to patients with these conditions.
The bridge bulk can provide a different feeling in the mouth, and the patient needs to deal with it psychologically. It does affect not only the speech but also causes other difficulties. The all-on-four dental implant patients can feel the original soft tissue and later the fake soft tissue, and this may bother them. Unfortunately, they can suffer from this problem after surgery. The ridge got reduced after the surgery, and no steps can be taken to go back to have the feeling of natural tissues.
These surprises will never be appreciated by any patient. So the dentist should give advanced notice to them and have a conversation with the patient before the final treatment plan. The dentist can explain the natural structure and the structure after all-on-four implants to the patient. The replacement of the tooth volume can be done if the bulk is causing difficulty. The vertical and horizontal reduction of the bulk of these restorations needs more implants to support the bridge, and it can reduce the risk of fracture. There will be a need for grafting if the implants are placed posteriorly and the distal cantilevers are shortened. Because of the low cost and less treatment time, patients tend to choose the traditional all-on-four implants. Patients can accept the compromises and be secure when they receive all the information about the implant. They know about the limitations and can choose from the various treatment options.
Dentistry has a boon of implants to replace the lost tooth. In the old days, patients used to be happy even if they became able to chew again, and they were satisfied by that. The success rate of full-arch implants is high, but nowadays, the patient’s expectations are high too. Due to the widely available heap of information, patients are well-known about the implant techniques, and despite its long procedure and awkward feel, they demand all-on-four dental implants. But they must also know the side effects of all-on-four implants.
A dentist should always provide the best treatment to his/her patients. He/She can offer several full-arch options but should study deeply about the patient’s case and apply the best suitable technique. A dentist should tell the advantages as well as disadvantages of the treatment to the patient to get the best results. This way, the patients will be satisfied, and this is something a dentist will desire!
Center for implant dentistry- the best destination for the dental implants
The center for implant dentistry in San Francisco, California, provides the best implants to their patients by giving all the consultations before the treatment. With the highest level of training and qualified dentists, you can get everything under one roof. At the center of implant dentistry, we care about the patient’s oral health and are committed to providing satisfactory treatments to our patients. We care for your teeth. In our clinic, technology meets the dentistry to give only the best treatments to our patients. We have many happy patients smiling wide due to our high-level and pain-free implant techniques at reasonable prices. If you ever feel you need dental implants, just book an appointment with us, and we will be happy to help you.