When All-on-Four Goes Wrong: A Real Patient Case Study

Today we're walking through a real case that highlights some of the most common, and most often overlooked, pitfalls in All-on-Four treatment. It's a story about a patient who trusted an experienced surgeon at his own implant center, where everything looked great on paper. But the outcome told a different story.

How She Found Us

The patient's treatment went ahead as planned, but something felt off to her — both in how her new teeth looked and how they felt in her mouth. She didn't say anything about it at first. She kept her smile makeover to herself.

That changed when she ran into a close friend whose smile looked noticeably better than her own. As it turned out, they had both gone through All-on-Four treatment around the same time — her friend at our practice, and she at a different office.

That chance comparison is what finally brought her in for a second opinion, hoping to get the confident smile she'd been promised the first time.

What We Found When We Reviewed Her Case

As soon as we reviewed her records, one issue jumped out immediately: the two lower front implants had been placed too far toward the outer edge of the jaw — what's known clinically as being positioned too "facially."

Here's what made this especially puzzling. This patient had a wide jaw ridge, meaning she had plenty of bone to work with.

During All-on-Four surgery, the surgical team has direct access to the underlying bone, allowing the anatomy to be evaluated along with the patient's CBCT scan and surgical plan.

That raised some important questions:

• Was the CBCT scan — the 3D X-ray used to plan implant placement — reviewed carefully?
• Was the available bone fully evaluated during surgery?
• Was the implant size and position selected specifically for this patient's individual anatomy?

We don't have definitive answers to those questions. What we do know is that the final implant positions created significant challenges. In areas where bone coverage would ideally be present, portions of the implant threads were visible.

The Fallout: Grafting, Bulk, and Limited Options

Because of the exposed implant threads, we referred her for soft tissue grafting to try to improve and protect the area. One side responded well to treatment. The other side, unfortunately, remains compromised.

On top of that, she felt that her prosthesis — the new set of teeth attached to the implants — was too bulky and uncomfortable.

One factor that can influence prosthesis bulk is abutment selection. An abutment is the connector between the dental implant and the prosthetic teeth.

In many cases, appropriately selected angled abutments can help improve the restorative position of the prosthesis and create a more natural contour.

This is where collaboration between the surgeon and prosthodontist becomes especially important.

Prosthodontists focus heavily on the design, bite, function, aesthetics, contours, and long-term performance of the final teeth. Surgical and restorative decisions made together can help reduce compromises later.

Patients Don't Really Want Implants

Patients don't walk into an implant practice because they dream about titanium implants. They want teeth they can smile with, chew with, speak with, and feel proud of.

In this patient's original treatment, the prosthesis had been fabricated through the dental laboratory. Dental technicians can be incredibly skilled at creating restorations, but the restorative treatment plan still benefits from clinical oversight.

That's why having a prosthodontist involved in the treatment team can be so valuable. The surgeon and prosthodontist can evaluate implant positioning, abutment selection, tooth position, tissue contours, bite, speech, and aesthetics together.

Instead of trying to solve restorative problems after surgery, those decisions can be incorporated into the surgical plan from the beginning.

Trying to Fix What Can't Fully Be Undone

Our prosthodontist is now working to change the abutment angles in an effort to reduce the thickness of the prosthesis and improve both its fit and appearance.

But there is a major limitation.

More than six months had already passed since the original surgery. Once dental implants have integrated with the surrounding bone, changing their physical position is no longer a simple adjustment.

Correcting a severely unfavorable implant position may require removing the implant and placing another one in a different position — a major procedure that this patient understandably did not want to undergo.

So our team is doing everything possible to work around a foundation that isn't ideal rather than being able to completely redesign that foundation.

The 3 Biggest Takeaways

Final Thoughts

This case is a powerful reminder of just how much goes into a successful All-on-Four outcome.

A great result depends on thoughtful treatment planning, appropriate implant positioning, restorative planning, tissue management, and close collaboration between the surgical and prosthetic sides of treatment.

If you're considering All-on-Four treatment, take the time to ask the right questions before surgery. Decisions made during the initial planning and surgical phases can significantly influence what is possible with your final smile.

Considering All-on-Four Dental Implants?

A successful full-arch restoration starts with the right diagnosis, surgical plan, implant position, and restorative team. Schedule a consultation with North Texas Dental Surgery to discuss your options.

Call 214-592-0692