Bone Regeneration after Loading: A Better Approach than All-on-4?

I don't get it. What does this have to do with all-on-4 or regeneration of bone? Anyway, I do agree with your philosophy. I see too many dentists jumping to implants these days for teeth which are treatable, dare I say, 'the old fashioned way'.

Me too i don't get it ?? All on 4 is for periodonatlly involved dentition typically with enough boen apically to support long 13mm plus length implants. Sorry to be critical but your crown is not fully seated on your abutment.

Hi Guys , as I said this is just a case to vindicate restoration of tissue and an ideal to restore not just hack of tissue and replace it with plastic which is I think a retrograde step which is becoming very fashionable at the moment. Agreed Tomo there was a re-cement ( Temp bond ) at 9 months but we will monitor although it has no effect on the tissues both hard and soft ( we will keep a look out for ant decay as well ) We have many full arches where some teeth have been retained and the periodontal situation dramatically improved over the longer period of time ( 5 years plus ) . So it is merely a statement of maybe looking forward with materials to a future of regeneration to a healthy state . Regads Peter

It was just that I had 2 cases in last week for a second opinion ( both in 50s )where they were told the needed a clearance and and all-on -four or Fast and Fixed type of solution. But both had some perfect stable teeth ( one 5 and the other 6 ) which were to be removed as they would be lost one day anyway to allow the protocol of teeth in a day to be employed. So John you are a younger Periodontist am I merely old fashioned ? Regads Peter

Fair point, i only do it where teh dentition is terminal i still routinely splint periodonally involved teeth, and focus very much on teh periodontal treatment and it seems to work. Also these patienst if stable can be candidates for implacement in edentulous areas!

It sounds similar to performing tonsillectomies in high numbers which was done in the 1920's, 30's and 40's to avoid problems in future.

Hi Peter! In a lot of your posts you´re using the term "bio-absorbable". Could you please explain what you mean? Is it different from a biomaterial being "regular" absorbable? Or completely absorbable? Or am I just a stupid...? Nice case though:-)

Hi OMS resident , it merely a more correct term indicating that the material ( BTcP ) is biologically ( by the body ) absorbed . Although Osteoclastic activity in this was initially thought not to have a large part in this I have photos from core samples showing Osteoclastic activity within particles of BTcP . The notion that you need some sort of HA to retain the bone and the buccal profile also seems to be dated . I have only used fully absorbable materials and the long term ( 7 year ) results have been very impressive ( on Scan and Micro CT ). Recent socket grafting research being done now also ahs show impressive facts that in as little as 8 weeks 85% of the material has been bio-absorbed and replaced with new bone. So Why are we putting foriegn materials in a site to slow the bodies ability to heal ? It is not done when you fracture a leg ! working with the bodies healing process is the key to the future. Woolfe knew that 160 years ago. We are currently working on some research to be shown later this year on the effects of improved angiogenesis in graft sites where no traditional membranes have been used something I have done in the last 8 years and in this case here. What we notice is that with time the bodies abiltiy to heal when we return it to its previuos state of health is remarkable which is seen in this case on the adjacent canine where the bone has regenerated even with the appearance of a restored PDL. This case is not the ideal but as it was live surgery at a big show ,exhibits the fact that although the techniques a radical as far a the teaching goes they are not as far as the bodies physiology is concerned. So all the debate is that YES we should be regenerating more in a manner that beneficail to our patients. As I say in my talks the body wants to heal lets help it ! Kind Regards Peter

We know teeth have the potential to last 100 years. I have practiced periodontics for 25 years and have never had a patient I treated become edentulous in an arch. I am willing to wager that the teeth removed because they would be lost in the future would have lasted longer than the all on four that was used to replace them. In addition when the all on fours are placed the premaxilla will resorb resulting in collapse of the upper lip profile with a significant compromise in the patients appearance. Greg Steiner Steiner Laboratories

Yes I must admit that even just a fullmouth 'Detox' regime by a good hygienist goes a long way to preserving teeth However one is often left with very poor aesthetics and teeth that may be stable but my indemnity insurers would be unhappy about me restoring extensively , I presume one problem with all on 4 is the continuing bone resorption in areas unsupported by implants which could restrict options later on , dave

is that a dio implant???

Bone Regeneration after Loading: A Better Approach than All-on-4? Huh??? This contribution confirms that a tooth can be removed and successfully replaced by a dental endosseous implant. Whether it is performed in the privacy of one's office or "in front of a large audience in Live surgery during a big Dental Show", I am at a loss to see how the case presented in any way addresses the title question. It has not the slightest thing to do with the removal of all teeth in an arch and their replacement with four implants and a prosthesis. This case merely supports the commonly performed removal of a failed tooth and its replacement with an implant and some grafting material. While the note speaks about observing the buccal bone graft, there is no way to evaluate that statement given the images that have been presented. Deriving a conclusion that there is "improved bone situation" based on 2 dimensional radiographs which are not identical in angulation certainly does not follow good scientific or even quasi-scientific form. While the author states that "all the graft material [was] now long bio-absorbed", one must ask if this is just his assumption, or has there been a biopsy performed showing that to be accurate? I do believe that while there is room in this forum to discuss when and when not the "all on four" philosophy is appropriate, this particular communication does virtually nothing to contribute to it.

Very nice case. I follow this rule of thumb taught to me by a very wise endodontist. Root canals average lifespan is 15 years. It is wise to have an endodontist retreat under a microscope since many of these teeth have fractures, they can of course last longer. If you wait too long to remove "iffy" teeth the risk is vertical bone loss which is really hard to gain back, I still do apicoectomies in the case of pathology. It's an individual judgement call. There is a regular progression, a root canal treated tooth is always better than an implant it doesn't have to osteointegrate! But there is a reasonable lifespan on any dental work, RCT or crowns, make a judgement call nothing lasts forever!(even implants!)

Hi Tomobooth yes it is a Dio Bio-tite H Cap coated Implant . Sag a more thorough re-read of what I have said answers all your questions. The only Question I questioned was are savable being removed for the sake of a protocol ? Peter

LISTEN TO YOUR PATIENT! WHAT DOES HE/SHE WANT? Give options.

This is a nice case. I am not sure what all the confusion is about. Perhaps, I am wrong, but from my understanding the All on 4 is a graftless approach. All the poster is saying is that graftless approaches, like All on 4, are not necessarily the correct way to go about certain treatment plans. Obviously, his case is not the best example, especially at it pertains to all on 4, but the point, as I see it, is that, in general, we should not immediately rule out bone grafting procedures, in favor of a graftless solution, just because it's the latest trend.

Peter, point well taken and as dentist, it's a bit absurd that you would even have to re- iterate this philosophy, but apparently some one must say it. Did you get a chance to read Block's recent article in this months JOMS? We need to remember the implant is just a single tool of many in our arsenal. Restoring teeth should still be the primary focus of everyone, even the OMFS . Bv. Vinci o/ f surg. Baton Rouge, La.

Bravo Peter! At last some good old, old fashioned common sense. Wolff's law should alert us to the fact that bone will regenerate when you stimulate it. Your case shows how effective an implant stuck into a fresh socket can regenerate the alveolar bone back. This should give pause to all the all-on-4 practitioners who justify their sacrifice of many savable teeth based on the presumption that it is not worth saving periodontally involved teeth that already have bone loss.We should not also forget the other old fashioned, century old "principle of conservation of sound tooth structure" by GV Black which should also mean that we do not extract teeth as easily as we do now just because we can replace them with implants. The bone around the implant in your xrays not only grew up to the enamel cementum junction, but also showed a margin of healthy strong cortical bone. Tarnow in a recent lecture in Singapore showed a picture of an implant stuck in a socket with a 4mm gap between the implant and the socket margin..... a subsequent picture showed the bone grown back... and this happened without any bone graft, membrane or even closure of the wound!.... just a good old fashioned blood clot! He then said that it is a game changing paradigm shift in implant placement... and that we should trust the body's ability to heal intelligently more... sic.... methinks it is just common sense.Check out a similar case of mine: http://smalldentalimplants.blogspot.com/2011/12/minimized-dental-implant-replacement-of.html

Hi BV yes have read that , and Dr Chow thank you , nice case again on the link , althuogh not a mini fan they do have a place . It was also interesting hearing about Tarnow and paradigm change in regeneration philosophy something that is of great interest. I have a number of more relevant cases , one of which I could post showing massive regeneration of bone on adjacent teeth when Implants are placed and grafted. I did a talk earlier in the year and a Phd student asked why graft without Bovine HA as if the bone is lost through diesease the only way to keep it would be putting something non-resorbable in. After many cases or years that appears not to be the case ( again Wolffs law ), and this is the paradigm shift , the body in the right situation wants and will heal . Regards Peter