My Version of All on Four Treatment

All on Four treatment is a treatment concept that aims to provide a fixed full arch treatment on the day of surgery.  It has been around for at least a decade and I must admit I am not a big fan of this treatment solution initially.  Don’t get me wrong.  It is a wonderful solution for many, and when indicated and done and planned properly, it offers enormous benefits to the patient’s experience when faced with the inevitable failing dentition.

But the truth is, the fun is in the surgery and the prosthetic conversion part is sometimes messy and depending on the state of the current prosthesis and dentition, it offers so many issues on my side. That’s why I was a very slow adapter to this solution.    One of my prosthodontic colleagues referred this solution as a very crude form of full mouth rehabilitation.

And because the denture conversion can get so messy, companies start to develop strategies to ease the conversion stage with better accuracy using digital technology and a series of fancy surgical templates to allow you to deliver the prosthesis with better precision.  That often comes with a heavy price tag and it really is indicated when someone has a good set of dentures or a set of dentition that is stable enough to be scanned and registered.

One of the condition in failing dentition is advanced periodontal disease.  These cases offer so many challenges because the remaining teeth have so much mobility.  Taking an accurate impression with proper extension may not be possible.  And these patients are often very anxious and may not allow you to take an impression.  With an unstable dentition, scanning such a case has been a challenge for me as the computer does not have consistent stable data to stitch together.  To be able to have a denture, accurate enough and ready for denture conversion is a challenge I see in these advanced periodontal cases.

In spite of the challenges, when it is the right case, I am prepared to offer this solution to my patients.  But I do modify the sequence of steps to improve the patients’ experience and counteract the “built in” errors in these cases.

I once took a course on terminal dentition at the Spear Institute and Dr. Ricardo Mitroni mentioned he does the conversion the next day instead of the day of surgery.  To me, that was enlightening.  It was because of his idea, I actually started reconsidering this treatment solution to my patient.

I don’t like the unpredictability of when I end up seeing the patients.  In my experience, if the denture conversion is planned on the day of surgery, couple of things may happen.  There may be a delay in transporting the patient to my office for the conversion.  Things like delayed start of the procedure or delayed recovery from sedation can happen to anyone.  But these things can have a domino effect on my part of the work.  The other possibility is that the implants may not be stable enough and conversion has to be postponed.  If that is a case, again my part of the schedule will be interrupted.

Again, I like to schedule the prosthetic conversion the next day in the morning.  So the patient has time to recover from the surgical appointment.    So if the conversion has to be postponed, I end up coming in at a later time and hopefully, it will not interrupt the rest of my schedule as much.

As an aside, I also perform my own implant surgery as well.  In theory, there is no need for patient transport and I should be able to perform the same day conversion.  Even with this arrangement, I arrange for the patient to come back for the conversion.

From the patient’s experience, I think it’s more comfortable as well.  The patient will be more rested, although still a bit sore.  The effects of sedation will be virtually gone by then.  Checking occlusion is also more accurate.  And most importantly, I don’t have to feel rushed to finish the prosthetic part of the procedures.

In this particular case, I planned to have a lot of adjustment on the immediate dentures only because of the challenge of getting an accurate impression and jaw relation record.   I also planned to take an abutment level impression the next day so I can have a model to work with.  The patient had surgery on Thursday.  I scheduled the patient for denture conversion on Friday morning as well as taking the abutment level impression.  Then I saw the patient on Monday again to do some fine tuning.  It gives the patient a chance to get used to the new teeth and me a chance to finalize some minor changes that I may not have had time after all the chair side procedures on Friday.  I share this set up here that perhaps other dentists may explore this for their own practice.

While this treatment offers many benefits, there are many variables that may affect the outcome of this treatment and patient’s experience.  So instead of teeth in a day, consider doing the denture conversion on a separate day.  You may get a better prosthetic outcome with less fractures and less stress!

Thanks for reading.

*Surgical treatment shown on this case by Dr. Kristopher Lee from Crescent Oral Surgery