I have a simple but not so straightforward answer.

I always advise people who can afford private health cover to definitely take out ‘Private Hospital Cover’ and ‘Ambulance Cover’ as these are covered well, up to 100% (less the excess) in some cases. But when it comes to ‘Extras Cover’ for dental treatment, its simply NOT worth it, this is why …

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Extras for dental and other ancillary services typically only cover a SMALL PORTION of the treatment. This means that you will still likely be quite substantially out of pocket;
There are many limits, and especially when it comes to expensive treatments such as Crowns, Bridges and Dental Implants, which fall under the category of “Major Dental”. The cap for Major Dental is typically sufficient for one or two crowns only, and once reached, you will not receive any more by way of a rebate;
The premium costs that you will pay for maintaining Dental Cover will end up being far more costly than the capped benefits that you will receive from the insurer in the one time that you need to do something more major on your teeth.
In some cases, the insurance company may entice patients to go to a “preferred provider” and receive FREE check ups and scale and clean per year. But these services collectively would not cost more that $250, whereas your annual premiums will be far more than this amount.

To be clear, a dental practitioner who is classified as a “Preferred Provider” by the insurer is typically NOT someone who has been selected by the insurer for any accolades or superlative care but rather someone who themselves ELECTS to enter into an agreement with the insurer to adhere to certain fees and charges when it comes to certain treatments, for the purpose of getting patients referred under the preferred provider scheme. This can becomes a problem when the dentist finds the need to compromise on quality or standards of care in order to maintain to the insurer’s recipe. But even then, for dental services other than check-ups and cleans, there is still a substantial out-of-pocket cost to the patient, and there are still the limits or “Caps” in place on Major Dental.

The Federal Government has just approved another premium increase for health cover, in some cases up to 10%, the average increase being above 6%.

“So that means that what I get back by way of rebates would also go up, right?”

No Way!!! How do I know? Because in the past 5 years there have been numerous premium increases approved (> 30% for some of the Private Health Insurers), the 30% government rebate has been eliminated and yet rebates have NOT increased by more than 5% in the same period of time, and in some instances, rebates have been reduced.

NOW THIS IS THE REAL KICKER!!!!!!!!!!!!!!

In Australia over the past 13 years, Private health Insurers have returned profits of over $8 BILLION!!

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So whether it’s “All on 4” treatment, a single tooth implant or a porcelain crown, don’t expect a significant rebate from your Private Health Insurer…… they are working for their shareholders and NOT for you.

Finally, the standard recommendation I give all my patients is, that if they have a big family in which everyone sees the dentist regularly, each child gets a new pair of optical glasses EVERY year, everyone sees a physiotherapist multiple times per year as well as the osteopath, chiropractor etc, then ancillary cover may be justified. Otherwise take out hospital and ambulance cover, don’t take out Extras Cover and with your yearly savings you can buy me a bottle of Penfolds Grange for Christmas, and still be way ahead!

Actually, the answer is quite the opposite. Staged, multi-implant systems have been around for many years, but the trend among experienced clinicians has been to use less implants and to undertake immediate loading with the ultimate aim of achieving a better outcome. So All-On-4 is actually a product of evolution (see History of All-On-4).

Nonetheless, All-On-4 is an advanced surgical and restorative oral rehabilitation system. It requires not only advanced skills and a great deal of experience, but also integrated dental, surgical and laboratory facilities. As such, not all dentists or specialists are, in fact, able to offer this treatment.

THE IDEAL NUMBER OF DENTAL IMPLANTS
The problem with full set implants is that the more implants we put in the more difficult it is for patients to clean around them because the implants are not actually visible. If you cannot clean them, then they will be smelly and will not last long.

More implants is also less comfortable for patients because of the increased number of screw access holes, which is additionally a known technical obstacle to achieving the best possible aesthetic result.

Four implants is ideal because there are two in the front and two in the back, and because of the way they are tilted not only do they provide the necessary support, but the spread also makes it more comfortable, more aesthetic, and much easier to know how to clean.

All-On-4 Immediate dental Implants
There are situations where we might consider placing one or more additional implants. This is very rarely the case in the lower jaw, but may be necessary in a small percentage of upper jaws depending on individual bone situations, biting pressures, and other parameters that we must take into account in our planning. Though in doing so we must always remain focused on our quality standards to ensure simple cleaning, optimal function, ultimate aesthetics and longevity. In some instances we may still be able to revert to using only four supports with a special kind of implants know as Zygomas, even when the jaw bone quality is extremely poor, because these actually rely on the cheekbones for support.

THE IDEAL NUMBER OF STAGES
Traditionally, implants were done over a number of stages where after surgery the patients were committed either to a denture or an unreliable temporary restoration until the permanent teeth can be fitted. Over the years numerous studies have shown that apart from being poorly fitting and uncomfortable for patients, these may actually cause inadvertent issues with the healing of the implants because of individual concentrated pressures from movement of the dentures or temporary restorations.

Immediate loading is a concept that emerged in the late 90’s to avoid or reduce the undesirable impact of a temporary restoration on the healing of the implants. In full arch rehabilitation, when the teeth are immediately and reliably connected to the implants, the biting pressures are shared and distributed between all the implants, which reduces the impact on individual implants and allows them to more freely and more reliably be integrated within the host bone. When immediate loading is undertaken, we often require our patients to be on a soft diet for 4 months, eating foods the consistency of fish, pasta, soft chicken, and avoiding things like nuts, apples, bones, bread crusts, and steak.

At All-On-4 Clinic our immediate teeth replacement system enables us to complete total rehabilitation within 24 hours of surgery with teeth that are final and which do not require subsequent replacement. The teeth are made from a uniquely designed metal-reinforced high-impact acrylic. Although permanent, these teeth will wear over time, and may need to be replaced at some stage. The longevity varies from patient to patient depending on the strength of their bite, the types of food they eat, or if they grind their teeth. We indicate an average longevity of 5 years because even though in many of our patients these teeth last for 10 years and longer, we also have cases where they last less than 5 years.

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When its time to replace the All-On-4 implant teeth, the process is quite simple, non-costly and does not require any additional surgery or anaesthetic. At that time, the patient may elect to have the exact same kind of teeth, and thus expect similar longevity once again, or they might instead consider changing the teeth to a Zirconia material to improve durability and increase the expected longevity. The Zirconia is not going to look better than the original teeth, as we put a lot of effort to get it right in the first place, but they are just going to last much longer. As such it is unnecessary to upgrade to Zirconia before it is time to do so due to the wear and tear of the original teeth. Unfortunately it is not possible or desirable to fit the Zirconia teeth as an immediate restoration because of its weight and rigidity, which could have an impact on the integration of the implants during the initial four months of healing.

One of my first bosses as a graduate dentist was treating his friend for many years and recently faced this dilemma. Not knowing much about the all on 4 perth treatment, he gave her my email address for an opinion about her options. She wrote:

Dear Dr. Fibishenko,

I am a patient and friend of a colleague of yours who referred me to you.

I had trouble with an old bridge on the top right (my right) of my mouth and a (new replacement) bridge is no longer feasible (because the teeth are broken down). I went to see an oral surgeon, and together with my dentist they suggested two implants to support four teeth. I have to have two extractions and wait ten weeks, followed by implants and another period of ten weeks. But, I have the two front teeth on a bridge which I have had a lot of problems with. It was replaced over a year ago after many years, but broke TWICE, since then, but seems to be stable enough now. Given that the left hand side of my mouth has got another old bridge, and my teeth are generally VERY Not Great!, we were wondering whether All-On-4 would be a better option?

Firstly, my dentist does not think All-On-4 could be done in one day, like advertised. He thinks that is probably for people who have had false teeth or huge gaps that have long since healed, and he thinks that …I would probably need to wait at least ten weeks. Is this correct for a start?

I don’t expect you to say that all-on-four is not good, otherwise you would not be doing them, but I just wonder from what I have told you, if you think that for someone like me it is the correct solution?

I did have bisphosphonate (Alcasta) last December, but the blood test seems O.K.

I also wonder if the all on fours are plastic or porcelain, …and what the real price at the end of the day, taking everything into account, would roughly be? I realise that you can’t possibly quote me from an email, but just a roughly realistic idea would help me to decide whether to go ahead with the implants or try the all on four?

Thanking you in anticipation.

In the above there are some very common questions, and a dilemma not just for patients, but quite often also for their dentists, so I decided to post my reply:

Dear Mrs J,

Whilst I am unable to offer you advice via email, being Dr S’s patient/friend I am happy to reply and to try to answer some of your questions in general terms.

Even tough I am known for my work in the area of All-On-4, I have no blind bias towards it and receive referrals for many other kinds of implant surgical procedures. The focus and priority always is to offer our patients solutions that work, not merely “dental treatment”.

An implant bridge is ideal when the other teeth are completely healthy, look good and function well. However when there are also problems with the other teeth, we always need to consider the long term prospects, as well as our patients cosmetic desires.

One of the problems with placing a couple of implants in a dentition that is deteriorating is that once the other teeth fail, you may be committed to further individual or segmental implants with the following potential issues:
– poor aesthetics: when doing implants in segments the gums recede and the gumline often appears dull/grey and with black triangles between the teeth. Also the connections between the different segments are often a cosmetic problem and may also be a food trap;
– inability to re-design the bite: often when other teeth are compromised the bite chages over time, and doing treatment in segments does not give us the opportunity to re-establish the correct bite;
– potentially ongoing cycle of dental treatments
– cost over time;

One of the advantages of an All-On-4 style bridge, in suitable patients, is that the entire arch is being treated at once, which gives us the flexibility to design the bridge to the most ideal aesthetics, bite, function and hygiene. The gum-line is formed as part of the bridge with our Aesthetic Gum Replacement techniques, so grey margins are not an issue.

Perhaps one of the main problems of doing implants in segments is that it can not be readily converted to an All-On-4 style bridge, and so the cycle of dental problems and treatments may continue. This is because the way implants are positioned for a segmental bridge is very different to how they are positioned for All-On-4.

Regarding your specific questions about the All-On-4 procedure:

after some preliminary planning and work-up steps, it can absolutely be done within 24 hours! There is no need to wait for sockets to heal, in fact there is an advantage of doing this treatment simultaneously with the extractions as it affords me the opportunity to scavenge some of the bone and reuse it in deficient areas of the jawbone or extraction sockets;
the teeth that we fit within 24 hours of surgery are the final teeth. They do not need to be detached again (unless for a specific indication);
the teeth are metal-reinforced High Impact acrylic, they look realistic and natural, and have an average lifespan of 5 years, however we do have patients who still have the original bridge for over 10 years;
when it comes time to replace the original bridge, this is typically an elective procedure and costs approx. $4,000 per arch. However, at that time we also give our patients an opportunity to upgrade to a zirconia/porcelain bridge, which is far more durable over the long term, for a discounted upgrade fee of $8,800 (instead of 4K). The porcelain teeth cannot be fitted to the implants in the early healing period because they are heavier/denser and could affect the ossepintegration process. They can electively be fitted at any time after 4 months, but the acrylic teeth look fantastic and its usually best and more cost-effective to upgrade when the need actually arises in the future. The upgrade fee is guaranteed against price rises for a period of 5 years.
typical cost of All-On-4 for suitable patients:
Consultation $130
3-D X-Rays $150 (I assume you already have this, as long as its no more than 6 months old and you have not had extractions since)
All-On-4 surgery and fitting of immediate teeth $25,000
Anaesthetic costs $4,000, of which patients get a substantial rebate from Medicare
Anaesthetic facility fee $750
Surgical reviews, x-rays and adjustments are included for a period of 2 years.
osteoporosis: patients like you who receive bisphosphonates for osteoporosis may be more susceptible to risks. The longer you have received the treatment, the higher the risk, whether implant bridges or All-On-4. Blood tests are often of not much benefit. We need to assess your history, frequency and dosages and advise you accordingly. If the 2 teeth that need extracting are infected or painful then the extractions should be done ASAP. The healing of the extraction sockets would be a good indication of your healing capacity whilst on the bisphosphonate medication. Would be good to keep track of the healing over a period of 2-4 weeks, and to see it at 4 weeks.

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I cannot say whether All-On-4 will be my absolute recommendation for your circumstances, but should you wish to explore your options further and receive advice specific to your situation, please call the clinic on 8845 5400 to make an appointment for a consultation.