Full-arch surgical techniques, theory, and clinical expertise.
Operate. Adapt. Load. Adaptability is the single greatest trait of an effective full-arch surgeon. Early in my career, when a difficult case was encountered (low-density bone, inadequate bone, poor AP spread, etc.),…
Read Article →A common belief in the full-arch community is that it is wise to place a “backup” implant. Many practitioners place five or six implants every case with the idea that they are…
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Four implants per arch, or six? This is a hotly debated topic, with strong supporters on both sides. My opinion is quite simple. Based on literature and my own anecdotal experience, I…
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There are countless aspects of full-arch surgery that are crucial to understand and perfect in order to perform this procedure at a high level. That being said, there are four critical AOX…
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AOX surgery will test us as practitioners. It will shape and mold each of us. We can either choose to be blown by the surgical winds of chance, or take control and…
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Navigating the private practice world of referrals can be a significant challenge for the full-arch surgeon. From speaking with OMFS colleagues, I know that there can be a lot of frustration and…
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My alveolar reduction consists of two principle steps: First, removal of bulk bone with a double action rongeur – which I affectionately call the “Monster Rongeur”. And second, removal of any additional…
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Full-Arch surgery aims to avoid anatomic structures via strategic planning and implant angulation. That being said, there are cases where increased proximity to the neurovascular bundle is necessary to create an implant…
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In AOX surgery, treatment planning emphasis is normally placed upon the CT image. The 3-dimensional information provided is paramount to assessing and treatment planning a full-arch case. This is without a doubt…
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I have seen a lot of different techniques over the years on how to approach the edentulous maxilla with regard to incision design. I’m often asked about a “palatal incision” design and…
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In today’s newsletter, I am going to take a break from clinical content and share a recent experience that I had as a full-arch educator. This particular situation was one that was…
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Existing integrated implants in a planned arch are never ideal. That being said, they are almost never as big an issue as many practitioners worry they will be. When I come across…
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A while back, I wrote a blog article titled “The Piriform Rim: Pearls and Pitfalls“. This article highlights the technique of engaging the piriform rim during AOX surgery and some of the…
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The dreaded preoperative X-ray that includes existing integrated implants… Many a full-arch surgeon has been known to let out a stressful sigh or mutter a few choice words after seeing their full-arch…
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Confirming osseointegration of full-arch implants is typically done by most providers at the 4 month mark. I also adhere to this standard. There are many different techniques, as well as some fancy…
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At the heart of any hospital based procedure is a pre-operative protocol that includes a “surgical time-out”. This is a brief but important time where everyone in the OR stops and confirms…
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No fluff. Just the good stuff. 1. Resist the temptation to offset less AOX experience by placing more implants per case. Four well placed implants with good torque and A-P spread are…
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One of the many benefits of All-On-X surgery is that it is typically a graftless procedure. That being said, there are no absolute rules regarding when to graft and when not to…
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A debate as old as time… Ok, not really. But it’s a logical question. Should we start with the maxilla or the mandible first when performing AOX surgery?? Or, should it vary…
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I’m a huge fan of Graphite-Guided Surgery. This technique, however, relies heavily on being able to utilize anatomical references or bony irregularities to demarcate where to apply our graphite-guide. When delineating our…
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The vast majority of the time I place my anterior implants in an “Inverted V” configuration at lateral incisor sites #7/10. The rationale behind placing the anterior implants at these anatomical locations…
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I remember residency well 👆. Countless surgeries, endless learning opportunities, and little sleep. These were some of the most difficult, yet also some of the best years of my life. While OMFS…
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The atrophic jaw often presents significant challenges for All-On-X surgeons. This is especially true in the setting of immediately loaded prosthetics. Not only can these cases be difficult clinically, but they can…
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AOX Surgery seems to be the sought-after procedure in dentistry right now. With proper patient selection, it can have a profoundly positive and life changing effect for patients in need. It can…
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Those of you who have read my articles for some time, know that I am a huge fan of palatal root implants in full-arch surgery. When a palatal root implant is indicated,…
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Mandibular full-arch surgery can, at times, be simple and straightforward. And yet at other times, it can present the most difficult of surgical scenarios. The reason as to why this significant variance…
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I absolutely love Platelet Rich Fibrin. I have found it to be incredibly beneficial in All-On-X surgery. Furthermore, PRF comes at almost no cost to the practice and requires no additional surgical…
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First of all, I’d like to say that it is rare that I am doing any significant grafting during All-On-X surgery. However, in about 10-15% of cases, I will do low volume…
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I love pterygoid implants. And, I place them often. That being said, if available, I will almost always opt for a palatal root implant in place of a pterygoid implant. Why? 1.…
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We’ve all seen it. And if you’ve done enough All-On-X cases, you’ve done it too. I know I have. Despite my best efforts, I cannot argue with that post op scan. Those…
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I know, I know, it’s embarrassing right? Your assistants are watching you struggle. You’re trying to keep your cool. But despite your best efforts, you cannot get the $#$%!# torque wrench driver…
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Failure. We all want to avoid it. We all hope that it doesn’t happen to our full-arch cases. We all want to believe that everything is going to work out wonderfully. While…
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A previous blog post titled, Abutment Placement: A Strategic Sequence, discussed the order in which I place my abutments for both optimal prosthetic flexibility and patient centered prosthetic design. Following the article,…
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It never fails. Ever. I’m in the middle of an extremely difficult case and all the torque I can muster up on a particular implant is 25 N-cm. My composite torque is…
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If you aren’t fracturing some roots, you aren’t taking out enough teeth. It happens. Here’s how I manage a fractured root and/or root tip during AOX surgery: First of all, I don’t…
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In a recent article titled Breaking Down The Math: Why AOX Efficiency Is More Important Than You Think, I highlighted the math behind the ways in which efficiency directly impacts our patients,…
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My target torque value for all of my implants is 45-60 N-cm. You can read more about why here. In order to fully seat my implants and to confirm the torque value,…
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The anterior mandible is an anatomic region well known for its dense bone and predictable implant torque. But… The lower anterior jaw has its own unique challenges and is great at…
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One of the most difficult aspects of treatment planning I encountered when I began doing full-arch surgery, was assessing the edentulous maxilla. Without teeth in place, it was difficult to identify reference…
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Today’s post is a continuation of the most recent article titled, Your AOX Questions Answered (Part 1). This article, in similar fashion, will answer additional full-arch surgery questions that were submitted by…
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Crestal or Subcrestal? There are many different opinions when it comes to crestal versus subcrestal implant placement. I don’t technically fall into either camp. My preference for AOX implants is…
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For those of you working in, and/or considering working in a full-arch style practice, it is no secret that the working relationship between the restorative doctor and the surgeon is paramount to…
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A recent @aoxsurgery post on Instagram asked what questions you may have regarding full-arch surgery that you would like answered here on the blog. I received a lot of great questions and…
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It is said that experience breeds both greatness and humility. This could not be more true than in the world of AOX surgery. While confidence is important, the more experience I…
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While the mandibular arch often presents with more predictable bone volume and density, it comes with its own headaches. Most notably, the tongue and the floor of the mouth. Working around these…
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The lone standing maxillary molar. A prized possession for the AOX surgeon – yet also a formidable adversary. In atrophic, partially dentate patients, a lone standing maxillary molar is one of my…
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It happens. Sometimes implants fail. Ironically, whether you work in a DSO style full-arch practice or a traditional private practice, it is often the restorative provider who first notices a potential failed…
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Whether you’re just starting out in AOX surgery, or are a seasoned veteran, I want to share with you a quick look at 5 surgical instruments I feel are of vital importance…
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“Why don’t you run your own full-arch practice?” I wanted to address this frequent question today in somewhat of a philosophical, AOX opinion piece. This article is not meant to…
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AOX surgery is a team sport. There is simply no way around it. For those of us in a referral relationship, one of the most important aspects of the full-arch team culture…
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The dreaded total arch failure. An uncommon occurrence, but a devastating one nonetheless for both patient and practitioner. In my clinical experience, there are 3 key suspects in a total arch failure.…
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We all like to show cool x-rays on social media. I’m no different. And in my opinion, pterygoid implants are the coolest looking titanium on a post-op scan. They just sort…
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Ahhh bruxism… The irony. Patients who frequently require a procedure like AOX, yet a group who we are often hesitant or unwilling to treat. Should we or should we not treat bruxers?…
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We’ve all been there. Feeling confident. Implant #4 in – Torque 45 N-cm. Implant #7 in – Torque 50 N-cm. Implant #10 in – Torque 50 N-cm. Implant #13…in…? Torque…
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Last week’s newsletter discussed how I manage mandibular third molars in the setting of full-arch surgery. The take home being, that I have gotten more conservative the more arches I have cut.…
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One of my biggest pet peeves as an AOX surgeon is when someone tells me, Oh so and so is such a great surgeon. They never turn anyone away. They treat every…
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I love seeing my full-arch patients present with third molars intact (cue the sarcasm)… Least favorite of all, are those pesky mandibular third molars. Partially impacted. Kind of in the way.…
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Why are we all in such a hurry?? I am often perplexed by the need so many of us feel to progress from full-arch beginner to full-arch expert…somehow, miraculously, overnight. …
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In a previous article titled Benefits of Performing Reduction on Both Jaws Prior to Implant Placement, I discussed 5 key advantages as to why I prefer to perform my bone reduction on…
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I am shocked at how many times I’ve been asked: “Do you place your own abutments?” My response is always, Since I began writing ArchGhost.com, I have encountered the following two recurring…
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AOX surgery is a different animal. There is an unparalleled reward and an unmatched sense of fulfillment for the surgeon upon completion of an AOX case. However, there can also be a…
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All-On-X surgery is about as big a procedure as is consistently done in the outpatient oral surgery setting. Given the magnitude and transformative nature of the procedure, there is a lot at…
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If you haven’t performed a “remove & replace”, you haven’t cut enough arches. Removing a failed implant, and replacing a new implant to maintain a loaded prosthetic, is simply part of full-arch…
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“What are you doing?!? Do NOT change those drill settings!!?” I may or may not have said those words with passion a few times in the operating room. I am very protective…
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Many surgeons are naturally interested in full-arch surgery. Most, however, are hesitant about looking at a “full-time” career in All-On-X surgery. As a surgeon that focuses solely on full-arch surgery, I am…
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I have yet to bury a pterygoid implant at the time of surgical placement. I want to admit that in writing this, I will probably have to bury a pterygoid implant within…
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I always attempt, with a fervent passion, to avoid removing a full arch prosthetic during the first four months of osseointegration. During this time, the implants have not yet integrated. Furthermore, the…
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Retracting the palatal tissue via “stay sutures” is a popular technique for providing improved visual access to the maxillary arch during AOX surgery. While this is a completely valid and arguably beneficial…
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There are many different surgical styles when it comes to where a surgeon positions themselves relative to the patient in order to complete different aspects of the AOX procedure. I have been…
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Last week’s newsletter discussed the AOX Surgical Time-Out. This is the checklist that I perform before every single All-On-X surgery. In similar fashion, I also utilize an “End of Surgery Checklist” that…
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I do not routinely perform bone grafting during All-On-X surgery. While opinions on grafting during full arch surgery vary widely, in my experience, one of the more profound benefits of the AOX…
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I always attempt to perform both the maxillary and the mandibular bone reductions, prior to beginning my implant placement. Ok, full disclosure: There are a few select instances where I will not…
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I am fortunate to have the luxury of practicing alongside a prosthodontist. Therefore, in my practice I do not do the prosthetic work-up for our All-On-X cases. And quite frankly, that’s how…
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Ok – I know this isn’t an action packed clinical technique article. But hold on just a minute before you skip to the next post… As a surgeon, this may very well…
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Closure says more about who a surgeon is than any other aspect of AOX surgery. It separates those surgeons who are meticulous, from those who just want to be done. Closure not…
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The periodontal probe is not the surgical instrument most commonly associated with All-On-X Surgery. In fact, I’m not even sure you can classify it as a “surgical instrument”. I avoided the perio…
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The infamous, anxiety-ridden, dreaded high smile line. This is the patient that has kept many an All-On-X provider up at night, tossing and turning restlessly. Some lay awake wondering if that transition…
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Ahhh… the amazing maxillary molar palatal root socket. So frequently overlooked. And yet it keeps showing up, waiting patiently to be noticed. Hoping to help make our lives easier. A built in…
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I almost always load all of the AOX implants in my arch at the time of initial surgery. In the vast majority of cases, I am confident in achieving adequate and…
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Teeth are out. Bone reduction is complete. And, implants have all torqued well. Smooth sailing now. But what the…?! Why can’t I get that freaking abutment to fully seat in the implant…
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I exclusively use a tapered implant for All-On-X surgery. And by exclusively, I mean 100% of the time. While most implant options today are tapered, there are still parallel walled (and/or very…
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I have had the opportunity to work with many exceptional All-On-X assistants over the years. I have learned a great deal from these assistants that has shaped how I perform surgery today.…
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An All-On-X surgeon should not look at an incision as a way to create access to their surgical field. This is merely a byproduct of the incision. An All-On-X surgeon should see…
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I am not a fan of traditional surgical guides in the setting of All-On-X surgery. Not even a little bit. To be fair, while I have seen traditional AOX reduction and implant…
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While it should not be common, a complication that you will see on more than one occasion in All-On-X surgery, is incision line dehiscence. A dehiscence can be troublesome as it can…
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Ahhh, abutment placement. The end of the surgery is near. You can relax a little. Your mind might start to wander a bit. Your team may even begin to remove a few…
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There are many benefits to All-On-X surgical efficiency. However, providers often assume that it takes hundreds of arches to reach a predictable, smooth AOX workflow. While there is some truth to this,…
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One of the best pieces of All-On-X advice I ever received had nothing to do with surgical technique. Before completing my very first arch, I was told by a friend and mentor, …
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In a recent blog post, I addressed a question I received from a colleague regarding what to do if you cannot get primary closure during your surgery. I wanted to piggyback on…
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The blog post Why I Converted to an Inverted V Configuration is one of the most frequently read articles on ArchGhost.com. It is also one of the posts I receive the most…
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All-On-X Surgery has a lot of moving parts, pieces and skill sets. It’s easy to get lost in the surgery and before we know it we are 2 hours, or more, into our…
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We’ve all been there. Some, more frequently than others. We’re proud of the All-On-X case we just completed. Another one in the books. While closing our surgical site, we are deep in…
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I think we can all agree that being more efficient is better than being less efficient. And to clarify, I am never trying to be “fast”. My goal, first and foremost, is…
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Achieving clinically acceptable torque is critical to the consistent success of immediately loaded All-On-X surgeries. In my experience achieving great torque… more than just the minimum clinically acceptable values, leads to a…
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“It takes 100 arches to know what the heck you’re doing and 1000 arches to become an expert”. My clinical director told me this when I first began my All-On-X journey, and…
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In honor of the New Year and all the goal setting that surrounds it, I wanted to post a motivational article specific to All-On-X surgeons. It is my hope that this article…
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I recently received an intra-op phone call from a colleague, a twinge of stress in their voice, asking what to do if they couldn’t get primary tissue closure for their All-On-X case. …
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I love efficiency! But there is one time during my All-On-X surgery where I slow down significantly. During the drilling of my implant osteotomies I drill at a speed well below what…
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When I look back on how my All-On-X career started, I realize that I was very fortunate in the clinical scenario in which I was placed. The surgical opportunities and experiences I…
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The beloved Midline Implant. A favorite of many a practitioner and part of the 5 Implant Configuration used frequently in All-On-X surgery. As someone who almost never…ever…places a midline implant, I…
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All-On-X surgery draws on many different aspects of oral & maxillofacial surgery. This is one reason the procedure is so challenging, yet fun and rewarding at the same time. Because this procedure…
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The piriform rim is a thin, cortical layer of bone that outlines the nasal aperture. In laymen’s terms, it’s a rim of dense bone around the nose. The maxilla, often having more…
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There are many things that make a great All-On-X surgeon. That being said, the one most likely to make you restorative friends, keep your referrals flowing, and make you enjoyable to work…
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The acclaimed movie Rounders, tells the story of a professional poker player (Matt Damon) grinding it out to make a living, ultimately trying to make it big at the World Series of…
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Most practitioners who routinely perform All-On-X surgery have some preference toward a certain implant size. Sure, depending on the case, we adjust as necessary. But there tends to be a certain implant…
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I extract all teeth in the arch before I make my surgical incision. Cue the “Gasp”?! I realize that I am in a very small minority, if not a loner when it…
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While often overlooked, I feel that closure is one of the single most important aspects of All-On-X surgery. I believe that the quality of surgical closure directly impacts both soft and hard…
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Inadequate alveolar reduction is one of the worst, but most avoidable, All-On-X complications. Insufficient reduction of the alveolar ridge can lead to a thin prosthesis prone to fracture, having to unnecessarily open…
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There are three primary ways to place anterior maxillary implants (#7/#10) in an All-On-X configuration. 1. Vertical Orientation 2. “M” or “M-4″ Configuration 3. “Inverted V” or “V-4” Configuration All…
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We’ve all been there… 45 minutes into an All-On-X “digital” treatment planning session with [insert your implant company of choice], wondering why this process takes sooo long… For those of us that…
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If you’ve done enough All-On-X cases you know that quite possibly the worst, gut wrenching feeling you can get is realizing post operatively that reduction was inadequate. This leads to a host…
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I started my All-On-X journey as inexperienced as you can get. Four years out of OMFS residency, I had yet to do a single fixed arch. On top of that I was…
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