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Dental implant treatment has guidelines, and they are not rules. So, this is the main reason why I love dental implants. The clinician or the dentist must have a broad understanding of their patient’s unique factors and then start the best treatment plan for that individual patient. The most appearing implant case can be impacted by factors such as parafunction, occlusion, periodontal disease, the space size to be restored, and the patient’s budget.

It is much more important for them to analyze these factors and listen to their patients, and work for their priority by offering the treatment plans. Although these treatments must be considered for the patients who fully lack the teeth as well, for purposes of this article, I would like to address the cases only for patients who have most of their teeth and those who are seriously considering removal of the teeth for implant treatment.

So, whom all do you think need All-on-4 dental implants? A dental implant is a tooth replacement, which is permanently attached to the patient’s jawbone, which is never removed. In this process, a small titanium post is surgically placed in the bone, and they are allowed to heal on their own. During the recovery of this process, this orthodontic anchor fuses with the bone. An abutment, which is called a connector, is then attached to the anchor, and an artificial tooth or crown is then placed on the top. This prosthetic tooth is made up of porcelain, ceramic, or metal alloy. The dental implant includes single-tooth implant, multiple-tooth implant, All-on-4 dental implants, implant-supported dentures.    

A full-arch fixed bridge is also known as All-on-4, which takes the dental field by storm. And these bridges are supported by four to six implants, which are fabricated from the materials such as monolithic zirconia, acrylic fused to titanium, and porcelain stacked to a cobalt-chromium frame. Usually presented with package pricing, and some practices promote All-on-4 as the best treatment for their soon-to-be-edentulous patients.

I would like to thank the aggressive marketing by the companies such as ClearChoice and the extensive information present on the internet. The patients are more aware than ever of the benefits of All-on-4 bridges. The truth is that five to ten years before, the people weren’t aware that All-on-4 bridges existed. But, today, it is a very common practice for patient’s to specifically request this treatment. It is always in the patient’s best interests, right?

These are the five factors that are regular dental implant practice:

  • Speech issues
  • Difficulty adapting to bridge thickness
  • Proprioception
  • Parafunction
  • High caries index

And now, let us see these factors in detail, one by one, and see how much the treatment affects.


           This is regarded as the major concern for the patients. However a minor speech flaw can become an overwhelming concern. Both vertical and horizontal bulks are required for the implant-supported bridges for their strength. Vertical bulk needs a variety of different restorative materials, but bridges only require 15 mm or more height. So, the clinicians are forced to replace just the volume of the missing teeth to achieve these measurements. We must replace the bone and soft tissue even if they are healthy. The reason is that the portion of the bridge adjacent to the soft tissue is bulkier than the original bone and soft tissue volume that is being replaced. This can have an impact on speech sounds such as “D,” “T,” and “N”. As to pronounce these the tongue contacts the hard palate lingual to the central incisors to form the sound. As same as, the posterior can affect the “S” sound, where the lateral borders of the tongue flare upon making the sound, which may result in slurring. 

The patients must be made aware of this compromise. They can retrain their tongues with time and practice. If speech is the major concern for the patients for the treatment, then the clinician must be prepared with another kind of treatment, such as saving the healthier teeth and replacing the missing teeth with very short-span bridges or individual dental implants if the tooth is found to be terminal, a bridge that only replaces the missing tooth structure and is the only option. This will require more implants, bone grafting, and expensive prosthetics, so the patients are prepared for the additional treatment time and cost. 


           In addition to bridge bulk affecting speech, there is another downside for it. It is very difficult for patients to adopt psychology. They are used to feel the transition from their soft tissue to their teeth. In this, the patients can feel the real soft tissue and duplicate soft tissue (the tissue of the bridge). This can be a big problem for some of the patients, and they think that it is all because of the surgery done, when the ridge has been reduced. The patients cannot be brought back to that natural-feeling transition. 

We should always have a detailed explanation and conversation about this compromise they will experience before finalizing the treatment plan to prevent surprises and showing your patients with an All-on-4 model and then a model of a traditional bridge. If the bulk is the problem for them, then they should consider options that only replace tooth volume. 

Because of the reduced bulk restorations, in both vertical and horizontal, more implants likely will be required to support the bridge to reduce pontic spans and the risk of fracture. Distal cantilevers may need to be shortened. The implants were placed more posteriorly, which could result in the need for grating. Due to lower cost and reduced treatment time, patients may choose the traditional All-on-4 bridge after consultation. In more cases, patients are more likely to agree with any compromises when they have options to choose from and know about any limitations before the treatment. 


           Its value is overlooked when recommending dual-arch treatments. Periodontal mechanoreceptors (PMRs), which are present in the periodontal ligament, make your teeth sensitive to low forces. A dental ligament does not have any periodontal ligament, and it takes 10 times more force to register the same proprioception as a tooth. It is associated with a dental implant that is similar to the tooth affected by local anesthesia. Patients feel difficulty in recognizing premature or excessive occlusal contacts. Because of the lack of feedback, they generate excessive biting forces. Patients with dual-arch are more likely to bite excessively than patients with the remaining teeth. Results in the fractures of the restoration or bone loss. With refined motor movements, chewing efficiency is well increased. With dual-arch implants, less refined movements result in poorer chewing efficiency, and great stress, and implants due to angled forces. 


           Parafunctional habits-such as bruxism, clenching, and irregular chewing cycles, impact your treatment decision. Teeth can detect forces, readily than implants. In the treatment, naturally saved teeth may enable patients to sense the parafunction better. This will increase the chances of them by modifying the negative behavior. 

Suppose it is necessary to replace all of your teeth when parafunction is present; you just want to consider recommending a bar-supported overdenture. This is a technical procedure, but it may be modified from your patient’s visions of fixed bridges. The overdenture can be removed in the night and can be replaced with a flat-planed night guard, protects the final prosthesis, and reduces strain on the supporting implants and bone. 


           All-too-common scenario, in which a patient presents with a full upper denture, maybe even an upper All-on-4, and decayed and missing lower teeth. If the bicuspids and canines have minimal mobility and are mostly intact, then I would consider saving the tooth. The risk of developing further periodontal disease is likely less than the risk of fracturing the prosthesis or damaging the implant or bone complex due to overly aggressive chewing or parafunction. 

Let us take another scenario, except five of the six bicuspids and canines have class V decay, four have interproximal decay, and the teeth are covered in plaque. The cavities present aren’t that big, which can be fixed, but how do you feel about the future prognosis? The patients are said to increase their home care, visit the dentist more frequently, and significantly reduce their sugar intake. The Risk of losing the teeth to decay in the no-too-distant future likely exceeds the risk of prosthesis fracture or loss of bone. So, here the best treatment for this patient is an All-on-4 bar overdenture. Apart from the ability to reduce stress, this treatment will accommodate a simplified oral hygiene protocol. You just want to enquire more of time with this kind of patient before the final treatment decision. 


  • “Look better, feel better.” Missing teeth replaced and having a smile on your face, and able to speak properly. When you look and feel better, you increase your level of confidence in yourself. 
  • “Convenience.” These dental implants are permanent in your lifetime. They don’t require any removal for cleaning like dentures, and there are non-messy adhesives to deal with.
  • “Improving your oral health.” Missing teeth are bad for gums and bones, but implants can keep them healthy. 
  • “Eat better.” With the restored chewing ability, you can eat whatever you love to eat.
  • “They last a long time.” Most of them are made up of titanium and are quite durable, and most of the implants last a lifetime with proper care. 

We really feel blessed to have these implants in our armamentarium as options for replacing the missing teeth. In the past days, the patients seemed to be very happy, just able to chew again, and they were appreciative. Nowadays, patients seem less stressed by the awkward feel of All-on-4 bridges and of the amount of time the procedure takes. I suspect this trend will continue as they become even more educated about their options.