All on 4: Is laboratory involvement necessary?

I treatment planned a patient for an All-on-4 and referred the patient to an oral surgeon for placement of the implants.  I have not worked with this oral surgeon before.  The oral surgeon declined to place the implants and wrote back to me that “without the benefit of a dental laboratory involvement which contradicts multiple years of literature protocol I am declining to take part in the intended surgical treatment plan for this patient”.  My question: Is this truly the standard of care?  Is it necessary for me to involve the dental laboratory?  I have been in practice over 40 years please my own implants and do my own restorations.  Your feedback would be appreciated.

9 thoughts on “All on 4: Is laboratory involvement necessary?

  1. Mark Huels, CDT, MICOI says:

    In my lab I do almost exclusively the type of restorations you treatment planned. I applaud the surgeon for knowing his limitations without the proper planning and guides for bone reduction, implant placement, and abutment angle. Just placing four implants without these guides will almost always result in a compromised prostheses.

  2. David says:

    Sounds like a communication problem. Treatment planning complicated cases and then simply referring to a specialist without prior communication is a good way to add uncertainty in your case. Typically you should have a discussion with your oral surgeon about the case and treatment plan the case together with a lab. That way every aspect of the case will go smooth.

  3. Greg Kammeyer, DDS, MS says:

    I agree with Lee. Since you referred out the case, it is beyond your comfort zone. Yes, anyone can do conversions yet I like having them done by someone that doesn’t them ALL DAY EVERY DAY. They are an invaluable adjunct to my team. Call your labs and see who does the conversions. You do want to keep your relationship with your OMFS as you WILL need help with a case in the future and 3 heads are better than 1!!!!

    A word to a seasoned practioner: I used to place and restore all my own cases (16 years + 3 years implant training). The last 17 years I focused on surgery only …no prosth. A much better result for my patients and I am still challenged to do top notch care.

  4. yosef k says:

    He did you a favor . After doing hundreds of these cases he is correct . There is a steep learning curve > get some intense proper training . Only do the conversion with an experienced lab technician preferably on site at time of surgery

  5. FRANK says:

    You should be able to plan the case yourself . CT Scan with barrium radiological guide if necessary. Surgical guide. Immediate prosthesis.
    Naturally a lab can help you with manufacturing guides and prosthesis. The conversion of the immediate prosrhesis can be done at the lab the same day in collaboration with you and the surgeon.
    But you are the contractor with biological and medical knowledge.
    A dental lab will not replace comprehensive prostho training.

    Your surgeon , if adequate, should be able to help you in the planning and telle you what he needs.
    Good luck!

    • Ed Dergosits says:

      Frank it has been many years since I have used a Barium radiographic guide for a patient to have in place when they have a CBCT. A much better way to treatment plan is to merge a 3D optical scan (Itero and others) with the CBCT images. Treatment planning can then be done on the computer and surgical guides sent for printing.

      • Frank says:

        Hi Ed. Good comment!
        How do you merge a full upper denture with the cbct?
        I have not done that yet.

  6. Lee Coursey, MICOI says:

    This sounds like a surgeon who has been there, done that. Our laboratory has been heavily involved in All-On-4 from the North American launch. We don’t believe that our skills supersede those of professionally trained surgeons and clinicians, but I believe there is a strong case to be made that they are a serious addition to those skills. Our lab has restored several thousand of these cases and been involved in the chairside conversion process for hundreds of cases with dozens of surgeons with varying degrees of skills and training. As such, a good, well-trained lab can spot things in the process that the surgeon and/or clinician may not know to look for.

    You say you place your own implants, but you knowingly sent this more complex case to a surgeon. You acknowledge that it’s outside of your skill-set, but I don’t understand the hesitation to involve a lab that has parallel skills.

  7. Sajjad A.Khan DDS,BDS,MICOI says:

    Any implant placement should be guided by a prosthetic design or treatment plan needs so you have two choices . If want t to do it yourself meaning the prosthetic design then get trained in CBCT assisted surgical guide design fabrication .Then contact the OMFS with the surgical guide prosthetic blue print so he can create a surgical plan to execute.
    To expedite or may be the few first few cases contact the lab they will be amazing resource for you and make this prosthetic planning very easy and simple .You will have less stress and headache .


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Posted in Clinical Questions, Restorative, Surgical.
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