All On 4 Plus® Add-Ons

Next generation treatment and system unique to All-On-4 Plus® Centres

In highly compromised cases where the bone quality is poor or its structure/volume limited, one or more of the additional procedures below may be indicated to improve the prospects of success and longevity:

  1. 1Additional Implants
  2. 2Zygoma Implants
  3. 3Bone Grafting
  4. 4Nerve transposition
  5. 5Indication-Based Zirconia/Ceramic/Porcelain Upgrade

Additional Implants

Less is more in terms of cleanability and design, and four is ideal and symmetrical. However, in some cases, such as in poor quality bone, additional implants may be required to improve system’s ability to withstand the functional pressures. It may also be an option when wanting to increase the number of teeth beyond the typical arch of 12 teeth.

Irrespective of whether additional implants are required, we make every effort to position them correctly for enhanced comfort and spread them for simpler cleaning.

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All On 6

If your surgeon determines that more that four dental implants are necessary All On 4 Plus® system helps ensures high quality design.

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Idealised Spread of the Implants

When using additional implants it is even more critical to ensure that they are positioned correctly and spread evenly to maximise comfort.

Frequent
Questions about additional implants

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When should additional implants be considered?

All On 4 Plus® using only four implants is minimalistic and ideal for cleaning and maintenance. However, in order to be able to fit immediate teeth, the stability of those implants at surgery must be adequate. In cases where the stability cannot be achieved, an additional implant may be considered in order to improve the overall support for the immediately-fitted teeth. In most cases it is possible to tell the condition of the bone in advance from the x-rays during the planning stages, but in rare situations the bone condition at surgery may prove to be different to what is expected, and the surgeon would decide if an additional implant is required.

What percentage of people need additional implants with All on 4 Plus®?

The protocol and implants that we use at All On 4 Plus® Centres are such that additional implants are rarely required. Less than 10% of cases would require an additional implant.

What is the cost of additional implants when required?

When an additional implant is required, the cost is approximately $3,000 for the additional surgery and the components required to connect this to the new teeth.

Before and after two
Before and after five

Zygoma Implants

Zygomatic implants, also known as ‘Zygoma’, are longer than standard dental implants, which instead of relying on the jawbone, transverse the poor area of your upper jaw to anchor into the underside of the cheekbones from the inside through the sinus space.

This approach is used for severely resorbed upper jaws or when the structure and/or quality of the jawbone is extremely limited. It facilitates immediate rehabilitation with fixed replacement teeth. The zygoma implants are inserted from within the mouth, along with one or more additional regular implants in the front part of your jaw on each side.

In the most severe of cases two zygomatic implants may be used on each side, which is referred to as Quad Zygoma, which may sometimes also be combined with an additional midline implant when required.

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Our most asked Questions about Zygoma Implants

Are Zygomatic Implants painful?

The procedures is performed while you are asleep. Before the surgery commences the area is completely numbed with local anaesthetic to ensure that you are comfortable when you wake up. Compared to standard implants there is usually more swelling, but the pain aspect is no different and rarely do patients need to rely on the strong painkillers that the surgeon prescribes. Most patients can use standard over-the-counter medication, and some feel they don’t even need those.

When should Zygomatic implants be considered?

Zygomatic implants are used as supports in the upper jaw in patients who lack bone volume as a result of bone atrophy from wearing dentures, traumatic injuries, iatrogenic causes from prior failed dental implants or oncological resection.

These implants are also used in patients who still have teeth and have an adequate bone volume but where the bone density is low. In such cases of poor bone conventional implants may not reach the requisite stability in order to act as supports for the teeth, and Zygomatic implants is often a more predictable choice.

Other than the improved support, the use of zygomatic implants also allows positioning the back implants further towards the back which improves the spread and arch length.

How do I know if I have poor bone needing graft?

Your dentist will examine your mouth, medical history and 3-D x-rays and will advice you of the situation. The x-ray may show the bone to be of a poor density or deficient in volume, in which case the Zygomatic implants will be incorporated into your treatment plan at the start.

However, in some cases it may appear as though you might be suitable for standard implants, but the surgeon finds the bone to be poor during the surgery, in which case Zygomatic implants would be considered to improve the outcome and enable the subsequent fitting of immediate teeth.

Can I feel the Zygomatic Implants?

The surgery is done from within the mouth and typically it is not possible to tell that a patient has zygomatic implants unless you look at an x-ray. Done correctly, it is zygomatic implants should typically feel and function no different to conventional implants, however it is a more advanced surgery and on the rare occasions they can feel slightly bulkier within the mouth, though the appearance would still be the same as conventional implants.

Patients can also sometimes feel the tips of the implants when specifically looking for it by pressing on the cheek bone, but again this is not visible otherwise.

Are Zygomatic Implants more invasive and what are the risks?

The implants are usually 30mm to 55mm in length and they are positioned from the jaw through the sinus space to anchor through the underside of the cheekbones. As such, whilst these implants can more reliably support a prosthesis when the jawbone is poor, the surgery is more invasive and should only be performed by highly experienced surgeons who do these procedures regularly.

There is more associated swelling and bruising but the risks for failure are generally comparable to conventional dental implants. As the implants traverse 3 anatomical structures, there are also additional risks such as sinusitis, dehiscence and exposure of the implants within the mouth, and potential effects on the nerves in the region.

The more significant risks are uncommon, and there are various implant choices and various techniques that your surgeon may use, such as incorporating bone grafting to separate and protect the implant from the sinus, in order to reduce the occurrence and/or impact of any potential complications.

What are the alternatives to Zygomatic implants?

Zygomatic implants are used in situations where the bone volume or quality is not adequate for conventional dental implants, so the only alternative (other than dentures) is to rebuild the bone with bone grafting.

Bone grafting can be performed together with the placement of dental implants in situations where there is adequate natural bone available to encase and stabilise the fixtures. In such situations the fixtures are not reliant on the bone graft. The graft is used only to patch defects around the fixtures or as a buffer when used with zygomatic implants separating it from the sinus space.

However, when there is not adequate natural bone and rebuilding of the bone is being considered (instead of Zygomatic implants) in order to enable placement of conventional implants, the graft needs to fully ossify before in can be a reliable structure to accept implants. The process of ossification of the graft can be anywhere from 6 to 18 months depending on the type and size of the graft. Whilst the graft consolidates, the patient can wear a denture, which can be loose and uncomfortable.

Grafted bone is often not as reliable as natural bone, and as such often more implants are often required to support a full arch of teeth. This means an increased complexity in the cleaning and maintenance of the implant-supported teeth over time, and a greater potential for complications. In other words, bone grafting can be a drawn out and costly process which may in the end lead to less ideal results.

Are the results with Zygomatic Implants different compared to standard All on 4 Plus® treatment?

Absolutely not, at least not at All On 4 Plus® Centres. The results are comparable to standard All-On-4 Plus® treatment both aesthetically and functionally. The implant surgeons who perform these procedures follow planning and surgical protocols to ensure that the implants are positioned for optimal aesthetics, function, cleanability and durability, just like with standard All On 4 Plus® treatment.

Bone Grafting

Typically considered in the upper only, bone grafting may be used simultaneously with All-On-4 surgery (when required) to rebuild the bone volume in the sinus areas (below left). This facilitates positioning and spreading of the implants, and it also improves contingency with more available bone in the future. Grafting may also be used with Zygoma Implants (below right) when the structure and/or quality of the jawbone is extremely limited.

Bone grafting diagram

Nerve Transposition

Repositioning of nerve bundles may be required in situations of extreme bone atrophy in the lower jaw, and allows improved placement and spread of lower implants for immediate fixed replacement teeth (below).

Nerve transposition

Indication-Based Zirconia/Ceramic/Porcelain Upgrade

All-On-4 Plus® Immediate Final TeethTM system is permanent by way of its titanium substructure (page 9). The teeth themselves are made from High Impact Acrylic and these are the working elements that are subject to wear and tear over time. Repairs or replacement of the teeth themselves using the original titanium substructure is reasonably straightforward with minimal downtime.

The average lifespan of the teeth is 8 years, and whilst it is not uncommon for us to see patients 10-15 years later still with their original teeth, we also see certain patients who need replacement after less than 5 years. This may be the case in the heaviest of bites where the improvements in functional forces are beyond the physical tolerance of the acrylic material. It is in those situations that there may be an indication for needing to upgrade to stronger teeth like Zirconia (also known as Ceramic or Porcelain teeth).

Zirconia would looks very similar to the acrylic teeth but it is far more durable. It is also heavier and has greater hardness. It is only used when appropriate and not as an immediate bridge because it transmits the impacts of the bite more readily through to the supporting implants and potentially disturbing their healing, unlike acrylic teeth which are more forgiving and better able to absorb functional impacts during the early stages.

Using All-On-4 Clinic’s sophisticated CAD-CAM production systems, we are able to convert the Immediate Final TeethTM to Zirconia at any stage at substantially reduced upgrade-only rates.

DSC 0090 Zirconia bridge with a titanium substructure
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