One of the common dilemmas in dentistry is knowing when to “pull the plug” on conservative treatment and re-think how to address an ongoing cycle of dental problems.

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One of my first bosses as a graduate dentist was treating his friend for many years and recently faced this dilemma. Not knowing much about the All-On-4 treatment, he gave her my email address for an opinion about her options. She wrote:

Dear Dr. Fibishenko,

I am a patient and friend of a colleague of yours who referred me to you.

I had trouble with an old bridge on the top right (my right) of my mouth and a (new replacement) bridge is no longer feasible (because the teeth are broken down). I went to see an oral surgeon, and together with my dentist they suggested two implants to support four teeth. I have to have two extractions and wait ten weeks, followed by implants and another period of ten weeks. But, I have the two front teeth on a bridge which I have had a lot of problems with. It was replaced over a year ago after many years, but broke TWICE, since then, but seems to be stable enough now. Given that the left hand side of my mouth has got another old bridge, and my teeth are generally VERY Not Great!, we were wondering whether All-On-4 would be a better option?

Firstly, my dentist does not think All-On-4 could be done in one day, like advertised. He thinks that is probably for people who have had false teeth or huge gaps that have long since healed, and he thinks that …I would probably need to wait at least ten weeks. Is this correct for a start?

I don’t expect you to say that all-on-four is not good, otherwise you would not be doing them, but I just wonder from what I have told you, if you think that for someone like me it is the correct solution?

I did have bisphosphonate (Alcasta) last December, but the blood test seems O.K.

I also wonder if the all on fours are plastic or porcelain, …and what the real price at the end of the day, taking everything into account, would roughly be? I realise that you can’t possibly quote me from an email, but just a roughly realistic idea would help me to decide whether to go ahead with the implants or try the all on four?

Thanking you in anticipation.

In the above there are some very common questions, and a dilemma not just for patients, but quite often also for their dentists, so I decided to post my reply:

Dear Mrs J,

Whilst I am unable to offer you advice via email, being Dr S’s patient/friend I am happy to reply and to try to answer some of your questions in general terms.

Even tough I am known for my work in the area of All-On-4, I have no blind bias towards it and receive referrals for many other kinds of implant surgical procedures. The focus and priority always is to offer our patients solutions that work, not merely “dental treatment”.

An implant bridge is ideal when the other teeth are completely healthy, look good and function well. However when there are also problems with the other teeth, we always need to consider the long term prospects, as well as our patients cosmetic desires.

One of the problems with placing a couple of implants in a dentition that is deteriorating is that once the other teeth fail, you may be committed to further individual or segmental implants with the following potential issues:
– poor aesthetics: when doing implants in segments the gums recede and the gumline often appears dull/grey and with black triangles between the teeth. Also the connections between the different segments are often a cosmetic problem and may also be a food trap;
– inability to re-design the bite: often when other teeth are compromised the bite chages over time, and doing treatment in segments does not give us the opportunity to re-establish the correct bite;
– potentially ongoing cycle of dental treatments
– cost over time;

One of the advantages of an All-On-4 style bridge, in suitable patients, is that the entire arch is being treated at once, which gives us the flexibility to design the bridge to the most ideal aesthetics, bite, function and hygiene. The gum-line is formed as part of the bridge with our Aesthetic Gum Replacement techniques, so grey margins are not an issue.

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Perhaps one of the main problems of doing implants in segments is that it can not be readily converted to an All-On-4 style bridge, and so the cycle of dental problems and treatments may continue. This is because the way implants are positioned for a segmental bridge is very different to how they are positioned for All-On-4.