Fortschritte in der All-on-Four-Zahntechnologie

Hi everyone. In the last few weeks I have been asked about the material and what the best material for an all-on-four set of teeth is, probably about five times by five different patients thinking to go down this journey. So who better to tell us about this than the owner of one of the best dental labs in the UK. Now over the last 10 years there have been massive changes to the materials which are used. what we feel the best material is and the variations between all these different kinds of materials. I mean, when I was doing all on fours five, 10 years ago, we were predominantly using denture teeth. We've kind of moved away from that now. But in this video, we're going to explain to you all the different variations we've got and why you probably shouldn't believe all the marketing hype of some practices. Okay, so we've done the hard bit okay we've done the surgery and actually helped me with the case which we planned a couple of videos ago and now we're going to talk about the final set of teeth okay this is really really important and there's loads to talk about here in the first half an hour of me being here at the lab I've learned so much and we're going to share that with you okay so we're here this is Ashley Burns from Burns Dental and these guys do most of my full arch stuff okay so all the all-in-fours And we've changed things as we've been doing it over the years. And Ash has actually been restoring them far longer than I've been placing all of the implants. So I think we've got a lot to learn. Ash, would you be able to talk us through what are, in broad terms, what are our options in terms of we've got the implants in, what kind of materials and things are we going to use for the teeth? Yeah, I mean there are multiple ways to restore fell arches. A lot of it's down to cost, like most things. So, you know, our cheapest option is kind of denture teeth which is wrapped around a bar. Really nice aesthetics, works really well, it's a good restoration. The downside is that plastics, they are soft if you think about your own teeth and how hard they can be. If you're wearing against something plastic it can sort of wear out. I have seen that actually. Yeah, you also find things like toothpaste can scratch it and that gets stains on it. You then brush it a bit harder, gets more scratches, the stains don't really go away. And longevity wise, whilst we're seeing a good sort of say two to four, sometimes even five years of longevity here, they do wear out, they're plastic. So whilst it is a budget option, you would be expected to see a refurbishment about every sort of five years, I suppose. And that is we strip off all the plastic around the metal titanium bar and then we re-add the plastic again. It takes about a week to do and it's not too expensive, but it's a bit of an inconvenience. But that's the downside of that kind of level. I mean, that's what I've found as well. So seeing people, because I used to do a lot of these with acrylic teeth. And the thinking was that the acrylic being softer has the advantage of it being a little bit shock absorbing. And... It would wear to an extent. Now what we've found is with implants, because a lot of people, especially when they've got top and bottom implants, there's no sensation of pressure. Yes, correct. So they're grinding harder on these. Whereas when people just used to have dentures with no implants, it's a very different thing because the dentures move a little bit so there's less wear on the actual teeth. Yeah, you're squashing the gum, people can't bite as hard. Exactly. So with… implants it is slightly different and in the early days of implants I think people just thought well it stabilizes the denture yeah and that's why where this kind of thing came in but even like all of these things have a metal skeleton don't they? They do yes yes that's correct and again one of the things that I think we do very well here is that there are multiple types of metal bars now we only use a very high grade medical titanium and we we anodize our bars with a gold coating but actually we want to use some of the best smelling out there so all of our bars go to northern Spain to a company called Creotech and that is probably in my opinion sort of the highest standard of bar I can get a bar which is cheaper and more cost effective but here you know we're aiming for kind of the highest quality on the market so all of our bars go to northern Spain we tend to design some in-house some we get them to design But the quality of the machining is sort of aircraft grade standard and that's really important to us to have that high level of accuracy to make sure those implants are supported and the restoration fits accurately with no screw loosening or any other issues. Yeah and there's a difference in the scanners isn't there you're telling me downstairs. Yeah you've got scanners here so when I send you a temporary bridge We'll talk about this later, how we've designed this kind of workflow, but I'll send you a temporary bridge and say you'd have to copy that. And you could scan it here. We could. So what's the difference? Well we tend to, so for example from an aesthetic perspective, we'll scan your temporary bridging, but when we're talking about metal to implants, we're looking for the highest level of precision engineering. So with normal teeth there's a little bit of movement in the teeth, but with bone... You can get away with that. If you're doing a full set of veneers, you don't need... that level of accuracy but when you're screwing a titanium bar with no flex to titanium implants in the mouth where there is no flex you want a perfect fit so we actually send ours over to to northern spain they design them but actually what they do is it's they scan the model but they actually use a contact scanner an incredibly expensive i think it's over a million euros or something ridiculous they actually contact scan those so they take our scan They take their own scan, plus they do the contact scan, and they fuse them all together to give us this incredibly accurate result. And what that does is that eliminates these bridges coming loose, screws coming undone, risk of screw fracture drops. So it's just another way of eliminating problems. Also, what it does is when I tighten these down to between 20 and 30 newton centimeters, that's very specific. And you don't want any pressure, long-term pressure on the implants. Yeah. So by having something that fits really well, you've reduced all this long-term pressure. Correct. Yeah, exactly that. But it's not as solid as that, is it? We're going to discuss that in a second. No, it's not, sadly. So you've got this other thing. So we talk about dentures, but you've got this other material, which we've been using, this PMMA. Yes. So what's this? Again, it's an entry-level option, isn't it? It is, yeah, it is, yeah. Again, it's still a plastic. We do two types. We do a standard, what we call a PMMA, polymethyl amethacrylate. It's an acrylic material which is multi-layered. So it goes from a dentine to an enamel. And the multi-layer just adds aesthetics. It does, yeah, very much so. That's the beauty of it. That's it. But the downside of PMMA is it's not a particularly strong material. So we do have a slightly higher failure rate. What I say by failure, it's not everything failing, it's chipping. And we get a little bit pinging off, that kind of thing. The alternative material we're just using at the moment is a material called GCAM, which is a polymethan bethacrylate, which has graphene fibres in it. Really interesting material. So graphene adds strength? Strength, yeah, massively, yeah. So it creates, it allows the material to flex more before it cracks. Okay. So if you're really biting hard on it, it is slightly harder, so we're seeing it last longer, but also the graphene in there stops the micro cracks, much, much less chance of The downside of that though is that the graphene is not multi-layered. So you don't have quite the aesthetics but still looks pretty amazing. I mean a lot of the people who I see who need these all on four, it's got to a point where teeth are really bad. So number one, if you just get a dramatic improvement, a lot of our patients are happy. But they're not looking for a Hollywood smile. No. Yeah, but it's more, we want a dramatic improvement, something that looks natural. Yes, that's right. And normal teeth, normal smiles are not perfectly symmetrical. There is a little bit of variance in there. And the nice thing, okay, we spoke about the bar with the denture teeth versus this new material, PMMA. It's digital dentistry now. It is. When it comes to the refurb, what's the difference? So when we use denture teeth it's a handmade process. We buy stock teeth, teeth that are pre-formed, we set them in wax and then we post with acrylic but it's all set by hand. So it's very artistic. The advantage of digital is that we're still using artistry but we're using CAD, we're using computer-aided design. So we will take the same tooth libraries but we digitally place them, we mock them all up by hand, we have some really some of the most UK's and in fact Europe's talented dental technicians here and they position that all there and then we have what's called an STL file. So that generates a file that we can then machine. So that's essentially a 3D model on a computer. Correct, exactly that. So once the patient is happy, what they're going to get is stored in a little file. Forever, yeah. I mean they can keep it with them, they can do whatever they want. A little 10 megabyte file, that's all it is. It is, they can shrink it down and make a keyring if they wanted to. But we keep that forever. The advantage of this is that it's always reproducible. So when it comes to a refurbishment, if we refurbish the denture teeth, there's still a hand... crafted aspect to it. So that particular dental technician might no longer be working here, or they might have forgotten this is five years down the line and things have changed. With a digital process, what we can do is that we put that back into the CNC machines, we call it milling, and we mill a 90% 99.9% exact accurate copy and that's what gives us that the wonderful advantage of digital is that everything is always reproducible. It's reproducible and what I'm also learning is you know you were telling me about different materials which are almost here in the UK. They've been used in the department because of licensing or whatever. We can't use those. Yeah, CE marking. You know say a patient has an all-on-four and they have one of these PMMA bridges. They've got the design there. Yes, but in five ten years whenever it needs to be refurbed we could use potentially a better material we can yeah exactly materials are always improving and I think one of the nice things digital is that let's say for example that a patient went for a budget option in acrylic we can actually turn that into another material much harder material that we're going to talk about shortly and we can actually almost upgrade those bridges in years to come but the nice thing is is that as every year we do see PMMAs getting better getting more aesthetic they're getting stronger and that that file remains the same So as those new materials come out, when it comes to refurbishment, I would be 90% sure we'd have seen a 10, 20, 30% increase in the quality of that material. That's fantastic. Yeah. That's going to bring us neatly into probably our most popular, it's the bridge that I do recommend to most patients now. Okay. It is a jump up in cost. It is. Right. But I recommend if it is within the patient's budget, go for... A zirconia bridge. Zirconia bridge, yeah. I mean if it was my mouth that would be the restoration I would have. Why's that? So what I find with zirconia, zirconia is a glass-based material. We buy it in a sort of white puck form, we machine that and then we actually, we sinter this material at about 1500 degrees and it creates an incredibly strong glass ceramic. I mean it's unbelievably strong. We actually use a German brand of zirconia here. So whilst it's incredibly strong, it's also soft. So it's not aggressive against the opposing team. So this is the thing. There are different levels of strength and abrasiveness in zirconia. Completely. So zirconia is a broad term to a lot of people. It is, yeah. Exactly that. It's a type of material, but you can have very cheap, quite dense material that is quite abrasive. It's quite white and opaque. Right. and you can have really nice translucent, really high quality material, which is also softer against the opposing dentition, vastly more aesthetic. It is a cost issue, and again, the lab that we are, we're always working to the highest standards. So you told me the cost of these pucks. Yes, they range massively. How much? I can get a puck for probably around £25. Our pucks here cost us about £300. It's more than a 10x difference. It is. in costs yeah but literally the input material only very much and we would refuse to use the cheap parks yeah so unfortunately there are people out there using that but you know they claim it to be zirconia is zirconia but you need to understand there are really strong different standards of zirconia out there and we use you know probably the best on the market yeah and if you're using a harsh abrasive one it's going to wear down the opposing teeth it is yeah much more quickly yeah very much so yeah because you do want this so we were talking about this before I used to recommend the acrylics all the time because of the wear, because they are softer, but now I'm actually changing my mind and going more to the zirconia. Yeah, and I think it's again, it's you know that we've seen big zirconia advancements. The downside of modern developments is they've become at a higher price, but we really are seeing a great, great, great improvement in this material. Absolutely fantastic. And also the latest version we're using is multi-layered. So the bottom part of that puck is actually about 1200 to 1400 megapascals. The top part is actually 800. So this is strength? Strength, yeah. So the base, yeah. A single zirconia bridge has different strengths? Correct, yeah. So right against the bar when we need that real strength and rigidity to stop it from breaking is there. And that the incisal edge, the sort of the occlusal surface, the top of your teeth, it's softer, more translucent, more natural. But a good thing is as you're biting on that, the strength is being taken at the bottom. But again, having multi-layered, multi-strength zirconias comes at a cost. But it's definitely the way forward, when I'm down. That's crazy. So even when we talk zirconia, there's two kind of types of zirconia, isn't there? There is. So there's the bar and what we call Thai bases. Correct, yeah. Okay. So the bar... Yeah, tell me the difference. Yeah, so we used to do with the Thai base. So what the Thai base is, is a small little metal cap that fits on the implant. And then we have a big titanium bar and we glue it to those little caps. It generally worked pretty well. But we started seeing some failures after a few years. And the last thing I want anything... Any patient to have is an actual failure of the bridge and that actually means the bridge was effectively breaking in half. It wasn't a major problem. So there's no metal bar with this one? No, this would just be little titanium like tubes that connect the zirconia to the top of the implant head. Yes, yeah. It was cost effective, but actually we found we have problems. And the lab that we are, we are very reflective when we have problems. So we looked at an alternative solution. And now what we do is we have a little, almost like an iron girder. It's like a little... sleeve that goes around machined in titanium and that links all the implants perfectly the same concept that we had again sending to northern spain for the level of accuracy and then we do our zirconia sleeve and we bond it on top of the titanium so we get the strength of the metal we get the super strength of the the strongest zirconia at the top and then we have the beautiful soft translucent zirconia at the top the whole combination of bridge just gives us the most outstanding result absolutely beautiful Yeah, it works really well. So I mean I've had a full zirconia break on me out of it and yeah, I've had to remake it. Disappointment all around. Yeah, it's really annoying when your patient's gone through all of this and literally the last step something breaks. Yeah, right. So disappointing for everybody. Now for those people who have won the lottery, there is a more expensive solution isn't there there is actually yeah there is and i don't think i've ever recommended this to any of our patients but tell me about this it is i mean it's quite a unique restoration uh we call it individual crowns on a titanium bar it has multiple names but literally for example when we've done the zirconia that's machined in one piece okay so all the teeth are joined together still it's incredibly natural and looks like individual teeth but there is actually an individual teeth option And we machine a bar with little posts on it. And each post is one tooth. We then hand make one individual tooth for each post. And then we wrap the gum in a pink composite with multiple colours. It is a stunning looking restoration and probably the highest aesthetic out there. But being individual teeth, you have to look after them much more. There's much more maintenance. If a tooth was to chip or crack, it's easily replaceable. But we don't really get that these days. And the pink... composite material again that can wear a little bit but it can be refurbished so without a doubt it's the highest aesthetic it really does look like individual teeth so you really would never know you've had any work done but it does come at an eye-watering cost because the labour time and the artistic skill it can be done by so few people so we don't do many it's crazy just thinking about it there is one person who I have done this for so I've got photos of that and I'll stick them in the video so people know what we're talking about there. Tell me about that material which isn't licensed in the UK. Yeah, got ya. So machining is, the way we manufacture a little in dental technology is done in two forms of digital process. There is subtractive manufacturing which is machining. You have a block and you machine away the outside. So when you say a puck, it's literally like an ice hockey puck, isn't it? Literally a disc that big. It's actually 98mm wide. They're always that size. And they range from 16, 18, 20, 25 thickness. And that puck is what we machine those bridges out of. The other way of manufacturing is additive manufacturing. And that is 3D printing, predominantly. And we can 3D print multiple materials, but one of the interesting materials for us is a resin-based material. It's like a polymethylmethacrylate, but it's an incredible-So like an acrylic. It is like an acrylic. Yeah, again, it would be more of the budget option. But what we're finding is that in America, they've had the license. It's literally a medical grade approval. So we have the material, it's amazing, but unfortunately there's no medical grade yet. It's due any day. And we actually print the pink, we print the white, we fuse the two together. and then we loop that onto the same titanium bar. It's a really great way of doing a restoration. What's fascinating about this material is that when it was designed and discovered, it was an amazingly strong material. When they put it actually into testing, they found that at around 35 degrees, it over-doubled in strength. Yeah, by accident, just by accident. So we've seen this great material. I've tried it. It's wonderful. The colors and the aesthetics are incredible. But we're waiting for the CE marking. I imagine we will have this May, June and again we will add that to your portfolio of options for your patients. Pretty cool stuff. Yeah, so that's exciting. I'm actually amazed at how quick things are moving in the dental technology side. Clinically, we've been putting implants in, things haven't really changed. The design of implants does change over time. You get minor improvements, but I think implants stick. Our industry, yeah, they just have such good evidence in plants, but why sort of change something that's not right? But certainly in our industry, we're seeing incredible developments. I don't think there's been a more exciting time to be making teeth as we do now. It's a pretty cool time. Amazing. So I don't know about you, but when I sat down with Ash, I learned a lot. And visualizing, seeing all the different stages in the labs is really great from a clinical point of view because you understand. different aspects of the materials which we're using for our final prosthetics, the final set of teeth. I mean especially that zirconia with the different strengths depending on the different thickness of the material. This is crazy that we're getting this kind of technology in dental prosthetics. So if you found this video useful please give it a thumbs up. consider subscribing but also if you want to find out about the different stages in an all-on-4 treatment there are two other videos before this one which kind of detail the planning the treatment on the day and then obviously this is a few months afterwards once the gums have all healed we'll make the final set of teeth I've also got another video which details how I do it because I do it slightly different to a lot of practices But this is just because I'm really coming at it from a cosmetics first approach, whereas a lot of practices are just there to give a dramatic improvement and good is good enough. Okay, so I've got that video coming up soon. So stick around if you subscribe, you will get notifications for that one. Take care.

what we feel the best material is and the variations between all these different kinds of materials. I mean, when I was doing all on fours five, 10 years ago, we were predominantly using denture teeth. We've kind of moved away from that now. But in this video, we're going to explain to you all the different variations we've got and why you probably shouldn't believe all the marketing hype of some practices. Okay, so we've done the hard bit okay we've done the surgery and actually helped me with the case which we planned a couple of videos ago and now we're going to talk about the final set of teeth okay this is really really important and there's loads to talk about here in the first half an hour of me being here at the lab I've learned so much and we're going to share that with you okay so we're here this is Ashley Burns from Burns Dental and these guys do most of my full arch stuff okay so all the all-in-fours And we've changed things as we've been doing it over the years.

And Ash has actually been restoring them far longer than I've been placing all of the implants. So I think we've got a lot to learn. Ash, would you be able to talk us through what are, in broad terms, what are our options in terms of we've got the implants in, what kind of materials and things are we going to use for the teeth?

Yeah, I mean there are multiple ways to restore fell arches. A lot of it's down to cost, like most things. So, you know, our cheapest option is kind of denture teeth which is wrapped around a bar.

Really nice aesthetics, works really well, it's a good restoration. The downside is that plastics, they are soft if you think about your own teeth and how hard they can be. If you're wearing against something plastic it can sort of wear out.

I have seen that actually. Yeah, you also find things like toothpaste can scratch it and that gets stains on it. You then brush it a bit harder, gets more scratches, the stains don't really go away.

And longevity wise, whilst we're seeing a good sort of say two to four, sometimes even five years of longevity here, they do wear out, they're plastic. So whilst it is a budget option, you would be expected to see a refurbishment about every sort of five years, I suppose. And that is we strip off all the plastic around the metal titanium bar and then we re-add the plastic again. It takes about a week to do and it's not too expensive, but it's a bit of an inconvenience.

But that's the downside of that kind of level. I mean, that's what I've found as well. So seeing people, because I used to do a lot of these with acrylic teeth. And the thinking was that the acrylic being softer has the advantage of it being a little bit shock absorbing. And...

It would wear to an extent. Now what we've found is with implants, because a lot of people, especially when they've got top and bottom implants, there's no sensation of pressure. Yes, correct. So they're grinding harder on these. Whereas when people just used to have dentures with no implants, it's a very different thing because the dentures move a little bit so there's less wear on the actual teeth.

Yeah, you're squashing the gum, people can't bite as hard. Exactly. So with… implants it is slightly different and in the early days of implants I think people just thought well it stabilizes the denture yeah and that's why where this kind of thing came in but even like all of these things have a metal skeleton don't they? They do yes yes that's correct and again one of the things that I think we do very well here is that there are multiple types of metal bars now we only use a very high grade medical titanium and we we anodize our bars with a gold coating but actually we want to use some of the best smelling out there so all of our bars go to northern Spain to a company called Creotech and that is probably in my opinion sort of the highest standard of bar I can get a bar which is cheaper and more cost effective but here you know we're aiming for kind of the highest quality on the market so all of our bars go to northern Spain we tend to design some in-house some we get them to design But the quality of the machining is sort of aircraft grade standard and that's really important to us to have that high level of accuracy to make sure those implants are supported and the restoration fits accurately with no screw loosening or any other issues. Yeah and there's a difference in the scanners isn't there you're telling me downstairs.

Yeah you've got scanners here so when I send you a temporary bridge We'll talk about this later, how we've designed this kind of workflow, but I'll send you a temporary bridge and say you'd have to copy that. And you could scan it here. We could. So what's the difference? Well we tend to, so for example from an aesthetic perspective, we'll scan your temporary bridging, but when we're talking about metal to implants, we're looking for the highest level of precision engineering.

So with normal teeth there's a little bit of movement in the teeth, but with bone... You can get away with that. If you're doing a full set of veneers, you don't need... that level of accuracy but when you're screwing a titanium bar with no flex to titanium implants in the mouth where there is no flex you want a perfect fit so we actually send ours over to to northern spain they design them but actually what they do is it's they scan the model but they actually use a contact scanner an incredibly expensive i think it's over a million euros or something ridiculous they actually contact scan those so they take our scan They take their own scan, plus they do the contact scan, and they fuse them all together to give us this incredibly accurate result. And what that does is that eliminates these bridges coming loose, screws coming undone, risk of screw fracture drops.

So it's just another way of eliminating problems. Also, what it does is when I tighten these down to between 20 and 30 newton centimeters, that's very specific. And you don't want any pressure, long-term pressure on the implants. Yeah.

So by having something that fits really well, you've reduced all this long-term pressure. Correct. Yeah, exactly that. But it's not as solid as that, is it?

We're going to discuss that in a second. No, it's not, sadly. So you've got this other thing. So we talk about dentures, but you've got this other material, which we've been using, this PMMA.

Yes. So what's this? Again, it's an entry-level option, isn't it?

It is, yeah, it is, yeah. Again, it's still a plastic. We do two types. We do a standard, what we call a PMMA, polymethyl amethacrylate.

It's an acrylic material which is multi-layered. So it goes from a dentine to an enamel. And the multi-layer just adds aesthetics. It does, yeah, very much so. That's the beauty of it.

That's it. But the downside of PMMA is it's not a particularly strong material. So we do have a slightly higher failure rate.

What I say by failure, it's not everything failing, it's chipping. And we get a little bit pinging off, that kind of thing. The alternative material we're just using at the moment is a material called GCAM, which is a polymethan bethacrylate, which has graphene fibres in it.

Really interesting material. So graphene adds strength? Strength, yeah, massively, yeah.

So it creates, it allows the material to flex more before it cracks. Okay. So if you're really biting hard on it, it is slightly harder, so we're seeing it last longer, but also the graphene in there stops the micro cracks, much, much less chance of The downside of that though is that the graphene is not multi-layered. So you don't have quite the aesthetics but still looks pretty amazing. I mean a lot of the people who I see who need these all on four, it's got to a point where teeth are really bad.

So number one, if you just get a dramatic improvement, a lot of our patients are happy. But they're not looking for a Hollywood smile. No. Yeah, but it's more, we want a dramatic improvement, something that looks natural. Yes, that's right.

And normal teeth, normal smiles are not perfectly symmetrical. There is a little bit of variance in there. And the nice thing, okay, we spoke about the bar with the denture teeth versus this new material, PMMA.

It's digital dentistry now. It is. When it comes to the refurb, what's the difference?

So when we use denture teeth it's a handmade process. We buy stock teeth, teeth that are pre-formed, we set them in wax and then we post with acrylic but it's all set by hand. So it's very artistic. The advantage of digital is that we're still using artistry but we're using CAD, we're using computer-aided design. So we will take the same tooth libraries but we digitally place them, we mock them all up by hand, we have some really some of the most UK's and in fact Europe's talented dental technicians here and they position that all there and then we have what's called an STL file.

So that generates a file that we can then machine. So that's essentially a 3D model on a computer. Correct, exactly that.

So once the patient is happy, what they're going to get is stored in a little file. Forever, yeah. I mean they can keep it with them, they can do whatever they want. A little 10 megabyte file, that's all it is.

It is, they can shrink it down and make a keyring if they wanted to. But we keep that forever. The advantage of this is that it's always reproducible.

So when it comes to a refurbishment, if we refurbish the denture teeth, there's still a hand... crafted aspect to it. So that particular dental technician might no longer be working here, or they might have forgotten this is five years down the line and things have changed. With a digital process, what we can do is that we put that back into the CNC machines, we call it milling, and we mill a 90% 99.9% exact accurate copy and that's what gives us that the wonderful advantage of digital is that everything is always reproducible. It's reproducible and what I'm also learning is you know you were telling me about different materials which are almost here in the UK.

They've been used in the department because of licensing or whatever. We can't use those. Yeah, CE marking.

You know say a patient has an all-on-four and they have one of these PMMA bridges. They've got the design there. Yes, but in five ten years whenever it needs to be refurbed we could use potentially a better material we can yeah exactly materials are always improving and I think one of the nice things digital is that let's say for example that a patient went for a budget option in acrylic we can actually turn that into another material much harder material that we're going to talk about shortly and we can actually almost upgrade those bridges in years to come but the nice thing is is that as every year we do see PMMAs getting better getting more aesthetic they're getting stronger and that that file remains the same So as those new materials come out, when it comes to refurbishment, I would be 90% sure we'd have seen a 10, 20, 30% increase in the quality of that material. That's fantastic.

Yeah. That's going to bring us neatly into probably our most popular, it's the bridge that I do recommend to most patients now. Okay.

It is a jump up in cost. It is. Right.

But I recommend if it is within the patient's budget, go for... A zirconia bridge. Zirconia bridge, yeah.

I mean if it was my mouth that would be the restoration I would have. Why's that? So what I find with zirconia, zirconia is a glass-based material. We buy it in a sort of white puck form, we machine that and then we actually, we sinter this material at about 1500 degrees and it creates an incredibly strong glass ceramic.

I mean it's unbelievably strong. We actually use a German brand of zirconia here. So whilst it's incredibly strong, it's also soft.

So it's not aggressive against the opposing team. So this is the thing. There are different levels of strength and abrasiveness in zirconia. Completely.

So zirconia is a broad term to a lot of people. It is, yeah. Exactly that.

It's a type of material, but you can have very cheap, quite dense material that is quite abrasive. It's quite white and opaque. Right. and you can have really nice translucent, really high quality material, which is also softer against the opposing dentition, vastly more aesthetic. It is a cost issue, and again, the lab that we are, we're always working to the highest standards.

So you told me the cost of these pucks. Yes, they range massively. How much?

I can get a puck for probably around £25. Our pucks here cost us about £300. It's more than a 10x difference.

It is. in costs yeah but literally the input material only very much and we would refuse to use the cheap parks yeah so unfortunately there are people out there using that but you know they claim it to be zirconia is zirconia but you need to understand there are really strong different standards of zirconia out there and we use you know probably the best on the market yeah and if you're using a harsh abrasive one it's going to wear down the opposing teeth it is yeah much more quickly yeah very much so yeah because you do want this so we were talking about this before I used to recommend the acrylics all the time because of the wear, because they are softer, but now I'm actually changing my mind and going more to the zirconia. Yeah, and I think it's again, it's you know that we've seen big zirconia advancements. The downside of modern developments is they've become at a higher price, but we really are seeing a great, great, great improvement in this material. Absolutely fantastic.

And also the latest version we're using is multi-layered. So the bottom part of that puck is actually about 1200 to 1400 megapascals. The top part is actually 800. So this is strength? Strength, yeah. So the base, yeah.

A single zirconia bridge has different strengths? Correct, yeah. So right against the bar when we need that real strength and rigidity to stop it from breaking is there.

And that the incisal edge, the sort of the occlusal surface, the top of your teeth, it's softer, more translucent, more natural. But a good thing is as you're biting on that, the strength is being taken at the bottom. But again, having multi-layered, multi-strength zirconias comes at a cost. But it's definitely the way forward, when I'm down.

That's crazy. So even when we talk zirconia, there's two kind of types of zirconia, isn't there? There is.

So there's the bar and what we call Thai bases. Correct, yeah. Okay.

So the bar... Yeah, tell me the difference. Yeah, so we used to do with the Thai base.

So what the Thai base is, is a small little metal cap that fits on the implant. And then we have a big titanium bar and we glue it to those little caps. It generally worked pretty well.

But we started seeing some failures after a few years. And the last thing I want anything... Any patient to have is an actual failure of the bridge and that actually means the bridge was effectively breaking in half. It wasn't a major problem.

So there's no metal bar with this one? No, this would just be little titanium like tubes that connect the zirconia to the top of the implant head. Yes, yeah.

It was cost effective, but actually we found we have problems. And the lab that we are, we are very reflective when we have problems. So we looked at an alternative solution.

And now what we do is we have a little, almost like an iron girder. It's like a little... sleeve that goes around machined in titanium and that links all the implants perfectly the same concept that we had again sending to northern spain for the level of accuracy and then we do our zirconia sleeve and we bond it on top of the titanium so we get the strength of the metal we get the super strength of the the strongest zirconia at the top and then we have the beautiful soft translucent zirconia at the top the whole combination of bridge just gives us the most outstanding result absolutely beautiful Yeah, it works really well.

So I mean I've had a full zirconia break on me out of it and yeah, I've had to remake it. Disappointment all around. Yeah, it's really annoying when your patient's gone through all of this and literally the last step something breaks. Yeah, right. So disappointing for everybody.

Now for those people who have won the lottery, there is a more expensive solution isn't there there is actually yeah there is and i don't think i've ever recommended this to any of our patients but tell me about this it is i mean it's quite a unique restoration uh we call it individual crowns on a titanium bar it has multiple names but literally for example when we've done the zirconia that's machined in one piece okay so all the teeth are joined together still it's incredibly natural and looks like individual teeth but there is actually an individual teeth option And we machine a bar with little posts on it. And each post is one tooth. We then hand make one individual tooth for each post.

And then we wrap the gum in a pink composite with multiple colours. It is a stunning looking restoration and probably the highest aesthetic out there. But being individual teeth, you have to look after them much more.

There's much more maintenance. If a tooth was to chip or crack, it's easily replaceable. But we don't really get that these days.

And the pink... composite material again that can wear a little bit but it can be refurbished so without a doubt it's the highest aesthetic it really does look like individual teeth so you really would never know you've had any work done but it does come at an eye-watering cost because the labour time and the artistic skill it can be done by so few people so we don't do many it's crazy just thinking about it there is one person who I have done this for so I've got photos of that and I'll stick them in the video so people know what we're talking about there. Tell me about that material which isn't licensed in the UK. Yeah, got ya. So machining is, the way we manufacture a little in dental technology is done in two forms of digital process.

There is subtractive manufacturing which is machining. You have a block and you machine away the outside. So when you say a puck, it's literally like an ice hockey puck, isn't it?

Literally a disc that big. It's actually 98mm wide. They're always that size. And they range from 16, 18, 20, 25 thickness.

And that puck is what we machine those bridges out of. The other way of manufacturing is additive manufacturing. And that is 3D printing, predominantly. And we can 3D print multiple materials, but one of the interesting materials for us is a resin-based material.

It's like a polymethylmethacrylate, but it's an incredible-So like an acrylic. It is like an acrylic. Yeah, again, it would be more of the budget option.

But what we're finding is that in America, they've had the license. It's literally a medical grade approval. So we have the material, it's amazing, but unfortunately there's no medical grade yet. It's due any day.

And we actually print the pink, we print the white, we fuse the two together. and then we loop that onto the same titanium bar. It's a really great way of doing a restoration. What's fascinating about this material is that when it was designed and discovered, it was an amazingly strong material. When they put it actually into testing, they found that at around 35 degrees, it over-doubled in strength.

Yeah, by accident, just by accident. So we've seen this great material. I've tried it.

It's wonderful. The colors and the aesthetics are incredible. But we're waiting for the CE marking. I imagine we will have this May, June and again we will add that to your portfolio of options for your patients. Pretty cool stuff.

Yeah, so that's exciting. I'm actually amazed at how quick things are moving in the dental technology side. Clinically, we've been putting implants in, things haven't really changed.

The design of implants does change over time. You get minor improvements, but I think implants stick. Our industry, yeah, they just have such good evidence in plants, but why sort of change something that's not right?

But certainly in our industry, we're seeing incredible developments. I don't think there's been a more exciting time to be making teeth as we do now. It's a pretty cool time.

Amazing. So I don't know about you, but when I sat down with Ash, I learned a lot. And visualizing, seeing all the different stages in the labs is really great from a clinical point of view because you understand. different aspects of the materials which we're using for our final prosthetics, the final set of teeth. I mean especially that zirconia with the different strengths depending on the different thickness of the material.

This is crazy that we're getting this kind of technology in dental prosthetics. So if you found this video useful please give it a thumbs up. consider subscribing but also if you want to find out about the different stages in an all-on-4 treatment there are two other videos before this one which kind of detail the planning the treatment on the day and then obviously this is a few months afterwards once the gums have all healed we'll make the final set of teeth I've also got another video which details how I do it because I do it slightly different to a lot of practices But this is just because I'm really coming at it from a cosmetics first approach, whereas a lot of practices are just there to give a dramatic improvement and good is good enough.

Okay, so I've got that video coming up soon. So stick around if you subscribe, you will get notifications for that one. Take care.

Transcript for:Fortschritte in der All-on-Four-Zahntechnologie

Transcript for:
Fortschritte in der All-on-Four-Zahntechnologie