If you lose all of your teeth, your jawbone and eventually your face will shrink. This cannot be stopped even with bone grafts. It naturally happens because of atrophy (lack of use) of both muscle and bone of the jaws. I have discussed this bone loss in many previous blog and web articles.
If you’re having an all on 4/6/8 etc dental implant Prettau bridge, this is an important consideration for facial aesthetics. Being able to support your face means that the lips, the base of the nose and cheeks can be positioned correctly so that you don’t have a caved in, wrinkled appearance.
Many dentists believe this cannot be done with fixed dental implant bridges and offer their patients snap-on overdentures. I have found there to be a lack of uniform knowledge of regular general dentists on this topic mostly because most dentists do not do this procedure routinely.
This issue is more substantial when discussing the upper jaw. A lack of facial/lip support also makes the nose appear much larger than it really is.
In the past (prior to 2005), I too treated some patients with upper overdentures to try to make facial esthetics the best possible but you still end up with a plastic denture! As of about 12 years ago I have developed a technique for predictably re-creating lip support and face aesthetics eliminating the need for upper overdentures. Lip and facial support are also determined by what we call vertical dimension of occlusion “VDO.”
This is best seen in side profile but can also be seen straight on. It is often measured from the tip of the nose to the tip of the chin. If you lose all of your teeth, that measurement from the tip of the nose to the tip of the chin becomes smaller giving you a premature aged appearance and many wrinkles.
Where many dentists believe this can’t be done is in the cleansability of the final Prettau dental implant restoration. I have been advocating and teaching a technique that levels the bone and gum to create a flat or convex surface UNDER the bridge so that the bridge can both be cleansable and aesthetic at the same time.
The fact that Prettau monolithic zirconia is nonporous also helps tremendously. It is not material of the bridge that makes the lip support but rather the surgical and prosthetic planning of the case from the very beginning.
Every single patient I treat has a very particular surgical modification of the gum or bone anatomy to be able to *create* this scenario right from day one. This is done by me at the first surgery. If it is not considered and created from the very first surgery/insertion of implants, it is very difficult to recover and correct later.
I also feel it is very important to “test” every patient with a fixed temporary PMMA bridge that allows them to test facial aesthetics, bite, lip support, color, tooth shape and size, etc. etc. I usually allow the patient to test the prototype bridges for somewhere between 3 weeks to 3 months. They look great too!
I often touchup this gum created contour with a carbon dioxide laser at the beginning of the tooth making process.
I also see that over time once I create a solid biting plane of occlusion, the atrophied, flabby muscles begin to come back over the first year or 2 tightening up the face.
There are some exceptions to creating ideal lip support and it almost always occurs in a patient that has either a severe overbite or severe underbite. When this occurs, sometimes a slight concavity needs to be created in a very certain position that can be digitally designed to be VERY cleansable with a water pick. This will lead to long term crestal bone and gum stability.
This patient that photographed has 6 implants on top and 5 implants on bottom and upper lower fixed Prettau bridges. It is my passion to deliver teeth that are long-lasting, cleansable, well engineered and beautiful. It really changes lives.
Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry
Hello, I read through this article, and although I am young and have all of my teeth, I resonate. My subnasal protrudes in a way that makes my nose look bigger, and it has really started to bother me. I have a deep bite that inhibits my jaw to sit in a comfortable place, so I’ve been dealing with a ton of TMJ issues. But every time I point out it to a person close to me or even an orthodontist/oral facial surgeon, they tell me I’m crazy and they don’t see it. It’s driving me nuts and I don’t know what to do. All I can do is hope this TMJ appliance (that I can barely afford) will get the othor to see that I do need braces to realign my midlines and fix the protrusion/deepbite. 🙁
Hi Dr. Amin – I recently had my perms put in – fixed full arch top and bottom with titanium bar reinforcements. I feel like the perms do not adequately support my lips because the teeth sit too high. Is it possible at this point to add pink gum to bring the teeth down lower and possibly offer better support? I know each case is different just wondering if perms can be adjusted or if I’d need to start over. FYI I’ve been expressing concerns about the short teeth since the temps but I was never offered other tooth sizes. Thank you.
Oh gosh. Once you get to the final they can’t be changed. This has to be worked out in the temp/prototype stage.
Here is another post on the topic.
Thank you very much. Not sure how you find the time to reply to all the questions but it’s very much appreciated! I went in and there was agreement regarding the need for more facial support and I will get new perms. They used a lot of lingo I’ve seen on your site – wouldn’t have known what they were talking about otherwise! So thank you for all of the education as well.
😉 Give more than you take.
Best of luck!
Is that option available? I have a full upper implant arch and I too feel like I need added lip support.
YES
Hello Dr., can you please show us a picture of the patient NOT smiling in her final permanent upper and lower All-on-4? The reason I ask is because it’s hard to tell how her face improved if she is smiling. Smiling lifts the cheeks. I would like to see her not smiling. Please!
Great question!!!!!!!!!! I will take me some time to update the post but thank you for the idea.
I can tell you she looks amazing at a rest position as well!
Dr Amin,
I have 4 narrow dental implants that are fully integrated, My original dentist was a prosthodontist but he had recommended a ivolcar vivodent over denture that is still basically plastic. I am very interested in getting a pretreau bridge or overdenture made with that material. ( I think it would still be an over denture though at the dentist I have been looking into it with). Now because my original oral surgeon doesn’t know this dentist or “work with him” he says he won’t honor 5 year guarantee on the implants if I go with zirconia through any other dentist but the original one who planned and sent me to him. I have four narrow implants and my teeth are fully integrated. I guess my question is do you think or would you trust (obviously with no guarantee from you) using the zirconia material on just the 4 implants. The guarantee is only for 5 years anyways so I will ultimately do what I feel most comfy with but trying to get all the “smart” in the know people opinions I can who may have an unbiased opinion. He says no financial motivation in pushing me to stick with original dentist I saw who is a prosthodontist. But I feel it is contradictory to say the guarantee is still honored “IF” this original dentist does the restoration with zirconia which I don’t know if he will make an option or not but that the lab is the one who actually makes the restoration and does the work anyways. Not a dentist. Anyways, any tidbits of advice I can get from you would be appreciated kindly. Also he says the zirconia has no give to it where the dentures do so this may affect the implant but this article and others I read seem contradictory to that – Christy
I know this is a few years ago but what did you end up doing?
Are you able to change out the implants to the ones you do?
Usually..but I would need to see you first.
Hi Dr. Amin – I recently had my perms put in – fixed full arch top and bottom with titanium bar reinforcements. I feel like the perms do not adequately support my lips because the teeth sit too high. Is it possible at this point to add pink gum to bring the teeth down lower and possibly offer better support? I know each case is different just wondering if perms can be adjusted or if I’d need to start over. FYI I’ve been expressing concerns about the short teeth since the temps but I was never offered other tooth sizes. Thank you.
Oh gosh. Once you get to the final they can’t be changed. This has to be worked out in the temp/prototype stage.
Here is another post on the topic.
Thank you very much. Not sure how you find the time to reply to all the questions but it’s very much appreciated! I went in and there was agreement regarding the need for more facial support and I will get new perms. They used a lot of lingo I’ve seen on your site – wouldn’t have known what they were talking about otherwise! So thank you for all of the education as well.
😉 Give more than you take.
Best of luck!
Hi I have just got my permanent teeth I always had naturally big teeth but when they made the teeth big u could see the lind of the teeth when I really smiled hard and I wasn’t happy they changed them to much smaller teeth as a result the area between my lip and nose it to long and my lip that was always narrow has disappeared. From reading your article there is not enough lip support I think . Should I go back I have spent crazy money and am only 48
Pls give me recommendations for huntsville alabama.i will surely call them as soon as i get it.i need a full mouth remodel.and i love your arti
Cles.i cant travel right now but very able to do it here.
Pls give me recommendations for huntsville alabama.i will surely call them as soon as i get it.i need a full mouth remodel.and i love your arti
Cles.i cant travel right now but very able to do it here.
Wow! What an amazing difference! I have been following you for year’s, and boy, you still blow me away with your before and after picture’s!!
This woman look’s like she got a lower face lift as well as a chin implant, that’s how well you transformed her face using your technique developed in 2005! I’ll go one step further in saying she look’s like a completely different woman!!
I would have loved to have been there when this woman was given the mirror! You truly are a miracle from God! Total Heaven sent!
😉 Thank you
IS THERE ANY RECOMENDATIONS IN HUNTSVILLE ALABAMA?I WOULD LOVE TO GET THIS PROCEDURE DONE.MY EMAIL IS [email protected]..Dr.Amin ?s get back with me.
I am sorry. I do not know anyone there. ;-(
Greetings,
My face looked very similar to this patient a couple of years ago. The bone loss, facial collapse is more severe now. Can this help me at this stage?
I have seen two top rated maxillofacial practices in Texas and both have told me that they could make my lower teeth stable with implants but did not offer any hope for my upper. They could only promise lower jaw stability not that my face would look more normal. Both practices said my facial collapse was the worst that they had ever seen in such a short time. I’ve had complete dentures for 8 years now. They repair birth defects and major trauma injuries but had nothing to offer me. Needless to say that was depressing. I have been apprehensive about asking this question because I honestly feel that you are my last hope.
There is no way I can open my mouth nearly as wide as the patient featured. Could the collapse have progressed to the point that nothing will be of help to me?
I hear that story every day. And every day I am able to provide solutions to patients that were told it was impossible. Your case is likely extremely difficult and you may need zygomatic implants. I would be happy to see you. I have had many patients travel from Texas to my office
Best thing to do would be to call the office at 818-846-3203
Go ahead and see this link to learn a bit more about what might work for you
https://www.burbankdentalimplants.com/?s=Zygomatic&submit=Search
How much for the Zygomatic implants?? Roughly for 4 ?? Top of mouth no teeth now..no bone for implants..told I need sinus lifts..thank you
Zygomatic implants can get costly. Most people do not need for of them. On average they need to but sometimes only one. At the same time you would not need sinus lifts as well which would reduce the cost. Please see this article on sinus lifting versus zygomatic implants so you can be more well-informed.
Are you saying that this bridge is not removableand is a permanent fixture in the mouth?
correct!
Are you able to fix a procedure that was done by another Dentist? I had both top and lower All on 4 done, but my face is sunk in now, and I look so much older!!. It breaks my heart that so much money was spent on my teeth, and have been back several times for adjustments, and they are nothing like they should be. 🙁
Sadly. 30% of my practice is redo’s and revisions. Click the link to learn more. Happy to help you!
Dear dr Amin lovely to come accross
one of your fabulous articles and associated links, I have loved all your work from the first time i saw your first info video, all of which showed your genuine care,passion,honesty and obvious outstanding ability .I still can not find anyone here that even compares to you/ i am sick of wasting money on consults and getting nothing in return, and a lot do not even give me a treatment plan
/ this mentality just breaks my spirit as this is my health.I truly believe that do not like the knowlege i have along with what i have learnt from you /also i think it is beyond their capability ,yet they never say that/ i would prefer them to tell me that from the begining(al la then i would not open my mouth or my wallet🤐😉.) Anyway it is still my dream to come and see you one day as i need help to get out of this quick sand that i am sinking in /i truly trust you and trust is paramount…
Kindest Regards..
Julie
sigh, I hate my life, all about the Benjamin’s. wish I cold afford you, beautiful work. I must admit to envy those who have money to take care of themselves
Hi,
I am considering the full arch upper and would like to know if you can refer me to someone in the central Florida area? I am using due diligence but depending on reviews from patients is not the way I want to choose my dentist. Do you have any suggestions?
Hello,
Where are you located?
Respectfully,
Elizabethe Carlisle
Burbank California
Hi! I have been reading some of the information here and I’m so confused as to what I should do. I am a 37 year old mom of 5 and my teeth are a mess. When I was younger I had a ton of cavities that were filled, the dentist I had seen in childhood was eventually sued. I did not find this out until adulthood, he was over drilling teeth prior to filling. Now as an adult I have a mouth full of teeth that are falling apart. Every tooth I had filled as a child has either lost its filling with no tooth left to fill or had a filling still in but is decaying. I currently need 3 of my top left teeth pulled and 3 on my top right pulled…leaving me with only my front top teeth. what are my options? do I need to have everything pulled on top and put in permanent on 4 or 6? I don’t know what options I have at this point.
The more of your website I review, the more I think I should travel from the east coast for an All on 5 or 6 lower arch.
I have 3 failing/cupping left lower quadrant implants and 3 right lower quadrant implants (all placed about 9 years ago) which might/ might not last another decade. I would consider myself lucky if a full arch were to last another decade, since I am a very senior citizen.
I am just asking for ballpark estimates now. Please tell me the approximate number of visits over, say, a year would be necessary–can any of the steps be done within a few days or each other? The trips, especially if they require a lot of hotel time, are probably prohibitive, but your videos and your website make me hope this is possible.
And, of course, the approximate costs of a lower All on 5 or 6. I have a current CT, am in good health.
Hi Win,
I have many patients that travel. Please call the office on Tuesday and speak to my front desk staff. They can help you with these questions in more detail. Most of these procedures are done in very few visits due to advanced technique and digital technologies.
😉
Is it possible to build the upper gum area using a gum graft/augmentation of some sort for lip support so that the zirconia implant bridge would consist of teeth only and no upper pink material?
Please advise further
Yes it is possible to have full upper that has no sort of pink material. Here is a case that I recovered for another dentist that may help you understand. Typically the cases that do not involve gum tissue are much more difficult, costly and require a very skilled practitioner.
Hi I have had upper dentures for 35 yrs I had a calcium deficiency I had lost a lot of my bottom back teeth to years ago I am now to the point of the rest of my bottom have to be pulled they are acting like I don’t have enough ridge left on bottom to hold a denture is this fixable?
If you don’t have enough gum and Bone then implants are the solution to either hold the Denture in or more ideally convert to a fully fixed bridge that you never need to remove
I have bone loss from having several teeth removed on the bottom and having all on 4’s on the top. It’s changed my appearance so much that I no longer socialize and friends I run into look shocked at how much it appears I’ve aged. I’ll eventually need to have my lower teeth replaced with implants but I’m afraid to have any more pulled due to the bone loss. Is there anyone like you on the East coast that is willing to do 8 – 14 implants on the bottom? I live in the Pittsburgh area and I haven’t found anyone that doesn’t promote all on 4’s which, in my opinion, is a waste of money. I wish I lived in California!
great article and very informative. If only I read all of this 8 days ago prior to having my work done. I am sitting here doing the research I thought I had already done before electing to get the all on 6 .
I just had 8 top teeth removed and 6 dental implants installed and now I have the transitional teeth in which are in my opinion dentures. I assumed that these were just the temporary and my final product would be the beautiful teeth I wanted that feel like real teeth. I now find that my permanent teeth will be pretty much the same with the large flange under my lip and the acrylic covering my entire gum. Like I said I think this is basically just a denture that is screwed in minus the large palatte. I already spent 30k on this and am almost in tears thinking I made a huge mistake. I have called back and am waiting to hear if what they did can be changed to a fixed bridge which would feel more like teeth than this denture. The more I read the more I am scraed that they will tell me I need to have different type of implants and more of them, plus grafting, etc. in order to change the type of teeth. Is it possible to retain the implants I already have in and healing and change this to a fixed bridge such as the prettau zirconia. I am going to be sick to my stomach if they tell me its going to be another 10k or more. I may just tell them to stop everything and head to Mexico to have this done correctly.
Oh gosh…. The transitional teeth are often converted dentures or PMMA so they do feel a bit like plastic. This is not uncommon at all.
please see this article on temporary full arch/full mouth implant bridges.
If the bridges made in zirconia it may be able to be thinned out a bit but zirconia has a certain minimal thickness that it needs to be to prevent fracture of the entire bridge. The thinnest material but you can use it is actually porcelain fused to metal. The problem with porcelain fused to metal (PFM) is it can chip or break more easily but it can be made thinner. The reality is without that flange your lip may caved in. Sometimes the shape of the palate or the shape of the lips require more of the pink to be done for proper support. I’m not sure that you would be able to go backwards to have individual crown and bridge type restorations done. That would be a major task.
Prettau zirconia is simply a material. It will not magically replaced the need for the pink part of the bridge. Some people need a lot of pink and some people need very little in some not at all. Typically this is known in advance of ever removing the teeth during the consultation visit.
I hope I have helped you in understanding your situation better.
Hi Dr Ramsay Amin….lovely to see your great work again along with your genuine informative explanations…..I still have not found a tone in australia that I really trust…so many do the all on 4 but it is plastic denture teeth…and they do not like it when I mention prettau zirconia 6 on top 5 on bottom……this work is so complex and should only be done by truly experienced professional people…..a lot of people that do it should not……I did find a top ceramist with decades of experience who has a large licensed lab to use prettau zirconia..I have not met him yet..his name is Wauner Sauer.i was talking to his wife the other day and mentioned great guy in Burbank she said he knows someone in Burbank must be you …a guy from what his wife told me he does work with some all on 4 mob but they only use 4 foundations??and a metal bar?..anyway that did not sound enough for foundations….I hope this email finds you well and happy…😁 I have never forgotten your saying “it has to be done right not right now ” l LOVE THAT SAYING BECAUSE ITSAYS IT ALL AND IT IS TRUE!!……I am still suffering🙁😖 (lower getting worse) this is crazy as it is such an important health issue ….I think some people think I am in the top hard basket…I think they just want the 4 foundations and plastic denture teeth. It would be funny if you knew the ceramist I mentioned earlier. Kindest Regards Julie …
I do not know the ceramist that you are mentioning. I’m sure you can find somebody close to your home that can help you!! You are a wonderful human being. Thank you for your kind words. I truly hope that you can get your mouth back to 100% health, function and beauty.
Thank you for your kind reply as I know you are a very busy man. I am seeing a dr philip tan at bayside dental he is a prosthodontist I saw him last year but did not have time to see his oral surgeon dr Sam Verco I have appt to see both in early may as they are both in Melbourne,I think philip does his own milling if so doubt if prettau zirconia would be an option as last year I got in contact with the overseas manufacturers and they gave me their austalia rep. and I got the name of licensed labs on the east coast of australia,but still can not find a team of prosthodontist , surgeon,and prettau lab that work together that do more. than 4 foundations/ I know how important the plan/the foundations/occlusion/tmj/ work load forces in the mouth/the protective canine rise are as without it all being correct, the domino effect kicks in,and boom crash opera the house falls down/I only know this as I have lived it and learnt it years ago…. that is why I understand the Importance of your explanations..I just get you./dentistry can be such a cover up industry/I do not mean to be disrespectful to the industry but a lot of bad work is done and there is no accountability 😕 that is why you make people feel safe as you are honest and open and capable such rare qualities am sure you know . where I am coming from…..that is why people feel safe putting their lives in your hands…kindest regards julie… you never know we could still meet…meanwhile stay safe in this volitile world we live in …….
Hi dr Amin .I would like to send you an email I received from Macquarie st centre NSW, there is a link to their free e- book on all on 4 I was able to download it to pdf l will try and send email to you whether u can download to pdf re their e-book ,I would like to try if that is ok ,I apologize in advance if I am annoying you….kindest regards ..julie
Hi dr Ramsey Amin,I just watched short video on Bruxir full arch bridge….?it seems to be for people who grind their teeth/I know if your bite is not correct that alone can make people grind their teeth / just wonder is that Bruxir just for the plastic denture type teeth with only 4 implants to give it to more strength? or is it required with prettau zirconia all 0n5/6 full upper and lower bridges ..my first thought was if the bite was spot on it would not be required in the final restoration/but then I thought don’t over think it just ask dr Amin, no urgency to reply just curious as I am very concerned/ that if things are not done properly here how would I know..only when is too late..sorry to disturb you . I have never seen that before.and I trust you and value your opinion… kindest regards…julie
In the article you state that the bone loss cannot be stopped even with bone grafts. I have been suffering from bone loss and facial atrophy to the point that Ive been a recluse for a numberbof years. Does this mean that even if I was able to afford the surgery, I would still have bone loss and a sunken mouth? Now Im feeling hopeless.
The pink part will support your face is designed correctly! https://burbankdentalimplants.com/all-on-4-full-mouth-dental-implants/
Ten years ago I had a sinus infection that was treated with an antibiotic. I had a severe reaction and ended up in a hospital in CCU for three days. For some reason the doctors there told my wife that it wasn’t my sinuses it was my teeth. It was not. They told her I could die with such bad teeth and they all needed to be extracted. They pulled 22 healthy teeth. I suffered from PTSD since childhood and this sent me into a tailspin for 8 years. Now ten years later I’m finally emotionally ready for implants. I’ve tried regular dentures now for 2 years and I can’t get used to them. I’ve been told by prosthodontist that implants would cost around 50,000 dollars. I’m disabled on a fixed income. How will I ever be able to afford that? I can barely eat. Ive gone from 195 lbs. down to 125 lbs. I’m 6ft. 3. I’m beginning to think I’ll probably die from this. Any suggestions?
Yikes…have you considered treatment in a dental school graduate program? They may be able to help you at a reduced cost.
You should’ve gotten regular dentures street your mouth healed from having your teeth pulled. You can’t get used to the dentures because you’re used to not having any teeth now, I spills make myself wear the dentures no matter what and if they rub the inside of your mouth then go back and get them readjusted
Dr Amin: Have you or do you teach other doctors the method you invented for rebuilding a resorbed upper arch with lip and facial support considerations? Would you take a patient who lives in Fallbrook, Ca.? There is no one else like you, anywhere. You are a genius and an Artist. I want so much to be your patient.
Your work is beautiful.
Thank you 🙂
I live in L.I., N.Y. I just turned 65 and after having tens of thousands of dental work done I am now being told I will probably lose all my teeth. I am more than hysterical-after my fifth bridge in upper front teeth(stemming from being in accident-a passenger at age 14 and lost a front tooth-probably swallowed) At any rate I received a whopping $2,000 because my lawyer said I was much too pretty to receive any sympathy! Unfortunately my fiancé died leaving me without funds-I became an RN and re-couped my losses-I had to go on disability due to a severe back injury;then went off a ladder at my daughter’s home and was life-flighted to repair the compound fractures with ORIF-I’ve been paying off those bills and face more surgery. A dentist said I was getting decay under last front bridge-pulled out all my upper teeth and placed bonded together temps. I could waste your time with more traumas but since I cannot get to you I’m praying for anyone nearly as competent as you to be found closer to home.Please excuse this poorly written tale-I am in excruciating pain as I write. I cannot bear dentures. (small bite) I briefly had a temp plate which was intolerable. I have a small home I will sell not to have dentures. Please help if possible. I’m still pretty but it’s not simply vanity-it’s the intolerance of all the effects of dentures. Thank You.
So sorry about what you are dealing with 🙁
Fortunately you live in NY which is full of great dental opportunity. Just do your due diligence and find a provider who is skilled, experienced and compassionate.
Since your case is complex make sure you understand what you are getting into.
Your story sounds so close to mine that’s it’s eery. Just curious. Did you ever get your teeth fixed?
Hi Raechel-unfortunately, no. Haven’t had the funds. On tiny fixed income and everytime I try to save something comes up-I realize that happens to everyone(well-not everyone!) but when you are just making your monthly bills, it is just about impossible. How are you making out? I had never read that with bone grafting your face still sinks in. All that $$$ and you end up with one of the big problems you want to avoid? At my age that is a hell of a concern. I’m in limbo. My fractured leg had the metal screws break 2 mon. after-metal fragments digging into your bones make it hard to socialize; so I haven’t even thought about looking for a man who might possibly help with finances. I realize that sounds terrible-should have added a man I love; not just someone with a healthy bank acc’t.
I’m still in the same place. Like you… I live month to month barely making ends meet and something always comes up. I’m so sorry that you have to go through all you go through. Seems like there is very little help for those who have limited incomes and need Medical or Dental care. It gets depressing. I have given up on a guy. My fiancé passed away suddenly at the end of 2017. I’m not looking anymore. 😢