Saturday, January 13, 2018

All on 4 broke

Is your All on 4 broke?

All on 4 broke and you need a repair or replacement? If so check out some of the issues and options to fix the problem. You may also find out find out why your all on 4 broke and what if anything you can do to prevent it from occurring again. The term all on 4, hybrid denture, AO4 are interchangeable. The issues on this page occur with many implant supported dentures.

Well what specifically about the all on 4 broke?

There are many things that can break or fail on an all on 4. Starting at the very base a denatl implant can fail and need removal. Implants or the abutments attaching the implant to the all on 4 denture part can break. Screws of the all on 4 can break or come loose. The metal support can break. Finally the teeth or acrylic can break of fall off. Each problem has a specific solution to fix and also should possibly change how your dentist and you maintain your all on 4 going forward. I will discuss each type of breakage individually with tips on how to fix and how to avoid in the future.

Teeth and acrylic of the all on 4 can break

This is by far the most common issue we see. Studies show that half of acrylic all on 4 prosthesis will have a tooth or acrylic fracture @ the 10 year mark. In my personal experience once a patient has this occur once it seems to be a recurring theme for them.

The simplest fracture is when an individual tooth comes out. This is fairly easy to fix and we often just fix it in the office. A more sever fracture of acrylic may require the whole thing be sent to the lab. This is a pretty big inconvenience for a patient.


Image all on 4 broke tooth

Solution – The dentist or the dental lab can replace the tooth, teeth, or acrylic at a cost of several hundred to maybe a thousand or so depending on severity.

Prevention – Wear a night-guard to protect your investment and be careful what you are eating.

The teeth on an all on 4 can wear down.

It is my belief that the percentages we see of wear correlate directly with the percentage of patients that suffer from sleep bruxism. The exact percentage of the population that suffer from sleep bruxism is not well known.  A questionnaire study from 1981 shows the number of sleep bruxers to be 13% but I personally don’t trust a questionnaire study on bruxism at all. About 1/3 of prosthesis will show signs of wear at the 10 year mark.

Solution – Replace the teeth at a cost of perhaps a thousand or two.

Prevention – Wear a night-guard to protect your investment.

Failure of a dental implant on the all on 4.

This is pretty rare but it does happen. Typically if the dental implant survives the first year it’s chances of long term survival are very high. When a dental implant fails, it needs removal. However, if we catch a dental implant that is just failing, there are things we can do to help ensure that you keep the implant. There are procedures such as LANIP that can sometimes save a failing dental implant but that is the exception not the rule.

If the dental implant fails and needs removal this can be a major issue. However, if your mouth was over-engineered and you have extra implant then we can remove the implant and it will not impact the prosthesis on top. If you have only 4 implants and one fails your prosthesis can be in serious trouble of complete failure. I have seen an individuals take off the prosthesis, place a new dental implant, and laser weld to the existing prosthesis to save the day. That is a fantastic save and is something that most labs can accomplish these days.

Below is this case about 1 year after delivery. The area had an infection that would not go away and we could place the probe into the infection site. After awhile the infection ate up enough bone to cause the loss of a dental implant. Fortunately we we over-engineered the aces and had 6 total implants so the loss of one middle one didn’t impact the case at all.

Solution – If have enough implants do nothing. If not add an implant at a cost of around 2k plus costs to attach to prosthesis, which can be hefty.

Prevention – Not much one can do other than maintain excellent hygiene, however many failures happen for unknown reasons.

Implant or the abutments attaching the implant to the all on 4 breaking is pretty rare.

I am sure this can occur but I have not ever seen it personally or heard about it happening. However, I have seen individual implants break and we must remove them. This seems less likely when we attach 4 or more dental implants together because we can distribute the forces out more.  I have never seen a metal abutment break, but the zirconia ones are notorious for this. I do not think anyone uses zirconia for their all on 4 dentures and I have never seen or heard of an all on 4 abutment breaking ever. Depending on how many implants you have this type of breakage could be irrelevant or very damaging.

Since I have not seen this type of breakage I will include a photo of what a single abutment breakage looks like.

Solution – Dentist replaces the screw which should cost hundreds to maybe a thousand or so.

Prevention – Nothing you can do to prevent.

All on 4 screws can break or come loose.

This is also rare. Typically if this happens it is not that difficult to remove them and replace. Around 10% of prosthesis have a screw come loose by the 10 year mark and about half that number have a screw break.

Pushing the limits on what is possible is a sure way to increase the chances of this happening. We have one patient with an all on 2 and both screws have broken.

Solution – Replace the screws at a cost of a few hundred dollars.

Prevention – Not much. Have dentist check design of the bite, in other words how the teeth come together.


The all on 4 framework can break

This is also rare but if it happens it can be a major issue, perhaps even ruining the entire prosthesis. A fracture of a zirconia framework requires a remake. A fracture of a metal framework can have a laser weld to repair it. Under 10% of frames will fracture by the 15 year mark.

Solution – Big issue if breaks somewhere that you need a repair. If you have a metal framework we can laser weld it back together but that is not cheap, couple thousand at least. If zirconia you are out of luck and are going to have to get a new one.

Prevention – Not much you can do. Dentist can limit cantilevers or in layman’s terms not add so many teeth to the the back.


All on 4 broke and you need help?

If your all on 4 broke, we can help you with any issue dealing with your dental implant prosthesis. Whether it is a surgical dental implant issue or a prosthesis complication, just give us a call and we can try to find a solution for you.

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Tuesday, January 9, 2018

White kids crown

Are you looking for a white kids crown alternative?

White kids crown alternative to the metal kids crown is available and our Board Certified Pediatric Dentist, Dr. Briney is providing this service to kids across the Midwest.

What are the benefits of the white kids crown?

The only real benefit is the esthetic benefit. One complaint we hear is that a child is socially aware of the black metal crown. Kids picking on each other is a part of life and a metal crown sometimes makes a child a target. Few parents are aware that there is a even a choice for a white kids crown, which is a shame.

What does a white kids crown look like?

There is no way to explain it other than to show it, so below you will see a photo of 4 white pediatric crowns.

Image of a white kids crown alternative

Why aren’t all kids crowns white?

Well they cost more for one. The cost is that much more in terms of the actual material cost but it takes more skill to do the white kids crown well. Basically it is harder to do and thus it costs more to do. We can bend metal kids crowns to fit a tooth whereas a white kids crown has to have the tooth fit it perfectly. It takes some skill and experience to prepare the tooth so that it is a perfect fit for the preformed white crown.

Why wasn’t I made aware of the option for a white pediatric crown?

The stainless steel crown alternative is not available everywhere and it is very likely your dentist does not provide this service or they do it very rarely. It’s simply not possible to always let everyone know every possible alternative available in the whole world. We provide the options for the services we are aware of and feel are appropriate for a given situation. The is also the fact that stainless steel crowns have a long history and thus lots of research behind them. Whereas, the stainless steel crown alternative white crown is too new to have that data.

What do I do if I would like to have these white crowns for my child?

Give our office a call and we will happily review your insurance and answer any questions that you have. We see patient from across the Midwest so our staff can accommodate your family no matter where you live.

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Sunday, December 31, 2017

Tooth material options

What are your tooth material options for an all on 4?

Tooth material options vary depending on your particular situation. Typically if doing an all on 4 or any implant prosthesis There are many options available for tooth material section for the all on 4 or other types implant prosthesis. The options will certainly continue to increase. We are probably to a point where the lab technicians preference and experience is more important than the differences in material to some extent.

Tooth material options for your all on 4 or implant prosthesis.

There are several many categories for you to choose from when picking your teeth out for your prosthesis. Factors that you can use to help you deiced are found below. The most important decision is actually whether or not you want individual teeth or a single unit or block of teeth.

  1. Traditional acrylic denture teeth
  2. Modern nano composite denture teeth
  3. Porcelain teeth not including zirconia.
  4. Zirconia teeth.

Traditional acrylic denture teeth for the all on 4 or implant prosthesis.

This was once our only choice and works ok for people if they are not clenchers, grinders, or hard on their teeth in general.


  • Cheapest materiel available
  • Easy to replace and fix
  • Standardized shapes and sizes to choice from
  • In use for decades so we know a lot about them, which means people have experience with them and we know their weaknesses and strengths


  • Don’t look as nice
  • Don’t last as long (wear down faster)
  • Break out easier

Image of teeth material options acrylic teeth

Modern nano composite denture teeth for the all on four or implant prosthesis

These are the modern line of denture teeth and there is little reason not to be switching to these except cost. Phonares are one popular brand.


  • Reasonably priced
  • Easy to replace and fix
  • Esthetically they are very nice in my opinion.
  • Standardized sizes
  • Can bond to it and fix in the mouth


  • Break out easier

Image for tooth material options nano composite.

Porcelain teeth for all on four implant prosthesis

This is basically traditional crown and bridge dental work that happens to be on dental implants.


  • Holds up extremely well
  • Can look beautiful
  • Can customize however want.


  • Difficult and expensive to do well
  • If breaks, expensive and difficult to repair (unless do individual teeth)

Image for tooth material options porcelain

Zirconia teeth for your all on 4 implant prosthesis.

The newest porcelain in dentistry that is extremely strong.


  • Strongest material we have that is tooth color.
  • Holds up extremely well
  • Can look beautiful but takes some skill
  • Can customize however want.


  • If breaks, expensive and difficult to repair (unless do individual teeth)
  • Makes a loud clicking sound when you have top and bottom teeth same (this is the only reason that zirconia against zirconia may not be the absolute best)
  • Is the mode of failure now with the implants?

Images of tooth material options zirconia.

Factors in choosing tooth material for your all on 4

How hard you are on your teeth, what the opposite teeth are, how esthetic you want it to be and how much money you are willing to spend on the teeth are the main options I consider.

  • Cost – porcelain and zirconia cost more
  • Esthetics – most are pretty good, but porcelain can be amazing
  • Longevity – porcelain and zirconia probably last the longest
  • Experience of dentist and lab technician
  • What the opposing jaw is
  • Dental habits
  • Type or prosthesis

My preference for teeth selection for an all on 4

My person preference for restoring an all on 4 or any implant prosthesis changes depending on several factors but a prosthesis with individual teeth is most ideal in my mind. Tooth material selection for me would be zirconia on top and nano-composite denture teeth on the bottom. The nano-composite act as our fail safe system and act as shock absorbers to a minor extent.

Tooth material options – Individual teeth vs single unit for your implant prosthesis

Individual teeth are much more expensive but better long term because if something ever happens to a tooth we can simply change it out and give you a new one without having you give up all your teeth for several weeks. This option is not given very often because it is more difficult. I actually prefer it and try to make the cost not that much more than a prosthesis that is one unit.


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Wednesday, December 6, 2017

Silver diamine fluoride SDF

What is silver diamine fluoride SDF?

Silver diamine fluoride (SDF) is a product dentists use to treat dental caries. It is new to the US but has been in use elsewhere for decades. SDF application is around 80% effective but teeth with “holes” still need to have a filling and we often use the SMART. It is a great new treatment tool for pediatric dentists.

What does silver diamine fluoride staining on back molars look like?

SDF staining looks black. It is not pretty but it does work. On back teeth it is not a big deal for most patients, however this depends on big of an area is black.

Photo of silver diamine fluoride staining on back molars

What does SDF staining on front teeth look like?

SDF staining on front teeth looks pretty bad IMHO. It looks worse than decay does to me but there may be few options until the child is old enough or mentally ready enough to fix properly.

Photo of silver diamine fluoride staining on front teeth

Silver diamine fluoride cost is usually very cheap in comparison to other dentistry.

Our fee for SDF application is $80 per visit. Some offices charge per tooth and some charge per tooth surface. The silver diamine fluoride ada code description is not specific on this, therefore how offices charge is hard to compare office to office. I image offices also charge on how difficult it is to place the SDF, which I think is the most fair.

What is silver diamine fluoride ADA code?

The SDF ADA dental code is D1354. Other dental codes that you can also use are D1999, D9910, and D1208. Those are not the most accurate and my guess is the only people using them are those that are trying to get more money out of the insurance plan.

What is silver diamine fluoride FDA approval status?

The FDA clearance is for hypersensitivity only. However, dentist in the US typically use it off label for caries treatment. This is exactly how dentists use fluoride varnish.

Where can one purchase silver diamine fluoride?

Most dental vendors sell Advantage Arrest which treats around 250 teeth if you are using one drop per tooth. One drop can theoretically treat up to 5 teeth.

Silver diamine fluoride staining will occur on most surfaces.

Keep it off clothing and all clinic surfaces since it will stain almost everything. However, if SDF touches anything quickly wash with water, ammonia, and or ethanol. It will stain permanently. It will stain skin for few days without harm.

Do we use a silver diamine fluoride staining consent form?

No, rather than more paperwork we simply tell parents the issues of staining and what it is and why we use it. That is good enough in my opinion, but you do need to find if there is a silver allergy. The most likely “bad” thing to occur would be black staining of the skin of the face for a few days, therefore try to be careful with it around skin! It may also sting intraoral tissue and may leave a metallic taste for awhile.

Silver diamine fluoride application steps

  1. Protect patient lips and cheeks with vaseline to help prevent staining
  2. Dry and apply SDF with a mircobrush, however be very careful what it touches!
  3. Should be for 1-3 minutes but in my experience will work in even shorter amount of time.
  4. Wash with water.
  5. Repeat twice a year
  6. Apply glass ionomer over if can or want to. This is the known SMART, which is simple addition to ART.
ART = Alternative restorative treatment, formerly known as atraumatic restorative treatment, is “a dental caries treatment procedure involving the removal of soft, demineralized tooth tissue using hand instrument alone, followed by restoration of the tooth with an adhesive restorative material, routinely glass ionomer”
SMART simply adds the SDF application into the ART.

More information on SDF

AAPD guidelines for SDF to treat cavities in pediatric and special needs patients. AACDP presentation on SDF

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Monday, December 4, 2017

Teeth cleaning before braces?

Do I need a teeth cleaning before braces?

Do you need a teeth cleaning before braces? The short answer is YES!

Why do orthodontists and dentists make you get a teeth cleaning before braces?

There are many reasons that an orthodontist will want you to get a professional teeth cleaning before starting braces. Not least of which is just to ensure you have a dental home in case there is some dental emergency that they do not treat. We also want you starting off with clean teeth and the knowledge that your gums and bone are healthy enough to get braces.

Additionally, we want to know if there is decay present, prior to placing braces on the teeth. If there is decay we really want to treat it before you get braces. Braces get in the way of the dentist’s ability to properly fix your teeth. Not to mention it can be challenging to clean your teeth properly with braces on and we do not want to make a bad situation like decay worse with braces.

What is the cost of a teeth cleaning before braces?

The cost of a teeth cleaning before braces is the same as the cost of a teeth cleaning at any time. Nothing is special or different about this one. It is arguably a more important cleaning though.

The cost for your cleaning will depend on the severity of any conditions you may have. If you have not been going to the dentist regularly then you may need a debridement or a scaling and root planing if your gums are in bad shape. This is also known as a deep cleaning. If you need either of those you will need to ensure your orthodontist and dentist are working closely together to monitor any potential negative issues.

A normal cleaning cost can be found on fair health consumer. Fees vary from practice to practice and from area to area.

What things are we looking for at the teeth cleaning before braces?

There are several important things that we want to check when getting a cleaning before braces. The first is to ensure that your bone support for your teeth is proper. If it is not, braces can cause you to lose your teeth! Secondly, we want to ensure you are decay free. Next, we want to ensure there is no faulty dental work. Finally, we want your gums to be in excellent health so that when we bond the brackets to the teeth we do not run into excessive bleeding that will cause the brackets to fail.

Th x-rays below show someone that is starting braces but did not get the cleaning before. In red you can see calculus build up in between many of the teeth. This is a sign of poor gum health.

Why you need a teeth cleaning before braces.

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Saturday, December 2, 2017

Replacement dental veneers

Can you replace dental veneers?

Replacement of dental veneers is a common procedure that we perform. Technology and the ability of both the cosmetic dentist and lab tech determine how well the dental veneers actually match.

Why would someone want to replace dental veneers?

There are two major reasons that we see for why people want to replace dental veneers. The first reason is that they do not like the look of the dental veneers. Usually the patient lost faith in the previous dentist or has come to realize better esthetics are available. The other reason is that a dental veneer has broke.

Below is a before and after dental veneer replacement photo showing two veneers that were no longer esthetically pleasing.

Before and after photo of replacement dental veneers

Can you replace dental veneers?

Yes, of course you can replace dental dental veneers! One can theoretically even remove dental veneer with a laser without having to cut into more tooth structure. In my hands that does not work well for a variety of reasons that are not worth discussing here. However, removing old dental veneers is easier than preparing them the first time. That does not mean that the entire process of replacing dental veneers is easier than doing the first time. Actually, I think it is likely more difficult. It is more difficult for several reasons. First of all, almost everything is more difficult when fixing or changing someone else’s work. Secondly, it is highly likely that the esthetics that you are looking for a second time around are much higher or more specific.

Below is the smile of a young man who recently had 10 denatl veneers placed in Texas. He was unhappy with the results and wanted something that looked more natural, as if nothing had been done. The first veneers in the top photo are fake looking.  They are flat, square, monochromatic, and lacking life. We were able to remove all ten denatl veneers and replace just four to give him a more natural look. We also did some minor bonding as well.

Can you replace dental veneers?

What does it cost to replace dental veneers?

The fee will vary greatly from office to office. Some dentists add a fee for the removal of old dental veneers. I do not do that but think it is very reasonable and fair if a dentists does charge. The fee for a dental veneer in your zip code can be found at fair health consumer by typing in code D2962 or just type in veneer.

The replacement dental veneer fee should be the same or very similar to whatever the dentist’s original fee for a porcelain veneer is. However, shopping for dental veneers by fees alone is not very smart. Asking what is the fee for a dental veneer is like asking what is the price of a car. The range of esthetic results and abilities of the dentist to provide those results varies enormously. You can get a cheap veneer that looks like crap but resembles a tooth or a work of art that looks gorgeous AND looks like a real tooth.

The dental veneer replacement cost in our office is $1500 in 2017.

This fee is per tooth, however, the fee does go down if you do a lot of teeth.

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Thursday, November 30, 2017

Blood blister on lip

Blood blister on lip that won’t go away?

Blood blister on lip that won’t go away is probably not a blood blister at all but a venous lake. Venous lakes are common venous malformations that look like blood blisters but they do not go away and actually slowly grow over the years.

Blood blister on lip that won’t go away – well maybe not a blood blister!

We are all familiar with blood blisters. Often we will get one on a finger that gets an injury but does not get cut into. We also know how they heal, the blood blister gets hard, crusts up, and falls off. The whole process is usually done in a couple weeks. However, what about those blood blisters that do not go away? Maybe it is not a blood blister at all, but a venous lake. If it is on one of your lips then the chances are very good that the thing you believe is a blood blister is actually a venous lake.

How do we treat a blood blister on lip that won’t go away?

The procedure is actually very quick and effective. We use a laser that targets the blood that is inside the lesion. The energy of the laser cauterizes the blood vessel, destroying it.

What is the healing time for this treatment?

Healing time is typically 2-3 weeks, during which a scab will form and then fall off. The images below are the pre treatment photo and a 2 week follow up sent in by the patient.  The last bit of scab has not fallen off yet at this point but is only a few days away from total healing. The image quality for the followup is poor because patients just send me cell phones shots as they usually live far away.

Image of blood blister on lip that won't go away.

Want to see more before and after photos and learn more about venous lakes? Then click here!

Blood blister on lip? NO! It’s a venous lake and we can treat it; just give us a call!

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