TRANSCRIPT:

All right, so this first thing I'm talking about is lip support. Very, very, very first thing, it determines if the patient's going to be a candidate for all in four or not. So let's get into it. So when a patient first gets their teeth taken out, they have what's called a, you know, I hate the terminology, but it's called a tooth only defect. That's the terminology that people have been using, tooth only defect. So for example, check this guy out. He just got his teeth taken out, and he's only missing the volume that was occupied by the teeth, right? So his ridge is still where it was at. The only thing he's missing now is the space occupied by the teeth. Now if you try to restore that patient with a tooth only defect, and you try to do an all in four, all in X kind of prosthesis for him, it's going to fail. There's just not enough space there, and it's just not going to work very well at all. So over time, a patient's ridge resorbs, right? So after a while of not having teeth, the ridge starts to resorb. In the maxilla, the ridge resorbs upwards and backwards. In the mandible, the ridge resorbs downwards and backwards. And this basal part of the bone right here, this part down here in the mandibular ridge kind of stays where it's at. Now as the patient loses some bone on their ridges, as their ridge resorbs, they start to lose some of the lip support. So I'm going to back up just a second over here. So remember right here, this is where the patient had their teeth, and then they just got them pulled. So the teeth are what supports the lip. So the incisal edges of the teeth are actually preventing your lip from collapsing, right? Everybody's seen the patient that is missing their teeth and has their dentures out, and their lips are all like that, right? They're kind of like caving in. And so without your teeth, you're missing that lip support. And as you have more resorption, that lack of lip support becomes more apparent. Your lips get more and more collapsed. So this is a patient right here. Sorry, let me back up for a second. That lack of lip support, that resorption of the bone, leads to what's called a composite defect. Remember at first you had a tooth -only defect, and then with some resorption you progress to a composite defect. Composite defect basically means that you're missing the space that was occupied by your teeth and the alveolar structure. So now you have a composite defect. And over time, your bone continues to resorb and you'll have a severe composite defect. So the little old lady that's been wearing dentures for 30, 40 years, she has a severe composite defect. And you can tell right here, so the lips, remember the lips are right here, the lips are outlined in blue, and the lips have no support. They're completely all shriveled up. And so she's got a severe composite defect. Alright, so I'm going to show you right here, this middle picture, you can see what happens as a person has a bigger and bigger composite defect, and you restore them with an all -on -four. Let's look back actually at this first picture. In this first picture, you can restore with an all -on -four, and it'll look pretty natural. I think it's a good treatment plan to follow. In this second picture, let's imagine this person's a little bit more resorbed. Can you see the difference? Can you see the difference between the two pictures? So in this picture, the prosthetic gums, they're not really sticking too far, they're not really bumped too far out from where the ridge is. The ridge is here, and the prosthetic gums are right here. But as the ridge resorbs more, so let's say the ridge is back here, and then the teeth kind of stick out further. You can see in this middle picture, the teeth are sticking out further, and where I circled right here, this is where you can imagine that the lips, so this is the lip, remember? The lip is going to dip in right here. I'm going to show you some real pictures of what this looks like, but I just want to show you these illustrations just to show you my point. This area right here is not supported by anything. That's why somebody with a severe composite defect, they might be better treated with a denture. Because a denture, as you can see right here, a denture's got a flange, and a flange can create a nice emergence, a nice lip plumping. I never promise that I'm going to have some sort of plastic surgery type result with my patients if they want. Lips plump, I'll send them to a plastic surgeon or somebody that does Botox, I don't know. But anyway, a flange, the fact of the matter is a flange bumps up the lips a little bit and provides lip support. Up high, where an all -on -four cannot. So an all -on -four, perfect candidate is somebody who has a moderate composite defect. Somebody who does not have a composite defect, who has a tooth -only defect, is not a great candidate yet, but you can turn them into a good candidate. Somebody who has a severe composite defect, a little tough to treat with an all -on -four, and you have to tell them ahead of time what might be the complication from that. So I'm going to show you right now, actually. This is a little old lady, this is her with her maxillary denture, this is her without her maxillary denture, and you can see what I'm talking about, the lip collapse. Now we'll do a side view. This lady has a, so same little old lady, she has an upper complete denture, and she has a lower all -on -four. In this part right here, that little dip that you see in between her chin and her lips, sometimes it's called like a witch's chin, that is called the mentolabial sulcus. So that's what I'm talking about, that there's not enough lip support there, so it dips in right there. If she had a flange, so if you had chosen a removable solution, so an overdenture that still snaps onto implants, that would plump up and potentially eliminate that little crease right there. This other patient over here, she has an upper all -on -X prosthesis, and you can see that she doesn't have adequate lip support right here. For some patients, this is a big deal, for other patients it's not a big deal. You just gotta know going into it that if the patient has a severe composite defect, they're likely to get this sort of outcome. This is another patient, she's got a composite defect, and there was just kind of like a stair step between her prosthesis and her gums, see, it's a stair step, it was a pretty severe stair step, and all I did actually was I just reset her teeth, I just kind of pushed her teeth, so I stripped her teeth off, I kept the bar, and I just had the teeth set a little bit more in, and I made the emergence of the gums a little bit more gradual, and I was able to remove that crease, so that crease just disappeared, right? So there it is, there's that crease, and there it's not there. All right, so that's the first thing that I ask, does the patient have adequate lip support without a flange? If they do, then I go ahead and proceed with the all on X treatment. If they don't, then they have a severe composite defect, I present a removable option as a potential plan for that patient, and I kind of put it in their court. If they want to proceed with an all on X, I tell them what could be the complication, and I generally recommend a removable for severe composite defects. Cool? All right, let's move on to the next thing, that's transition line.