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31 Jan 2019 | Australasian Dental Practice

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Online All-on-4® treatment concept training course from Nobel Biocare

Dr Saj Jivraj, an experienced prosthodontist, and Dr Hooman Zarrinkelk, a board-certified maxillofacial surgeon, have been educating clinicians and delivering full-arch rehabilitations to their patients using the All-on-4 treatment concept for more than a decade.


Now, in partnership with Nobel Biocare, the two clinicians have developed a free, three-hour online training course that explains the protocol and essential principles that support this proven approach.

We caught up with them to find out more about the training and how it can benefit dental professionals.

How has the All-on-4 treatment concept impacted your practice?

Dr Saj Jivraj: I finished my prosthodontic residency program in 2002 and I was well-trained in all the principles and practice of treating compromised patients with dental implants. For my patients without bone, we'd talk about bone grafting. This usually involved harvesting bone from the hip.

Today, my team and I treat 98% of the edentulous patients using graftless procedures. Obviously, this is a huge advantage for the patients. With the All-on-4 treatment concept - and zygomatic implants - we're able to provide patients with fixed, functioning teeth the same day.

Dr Hooman Zarrinkelk: Bone grafting was core to my surgical education. I've seen patients from all over the world who have undergone bone grafting. I have first-hand experience of the results and the cost to the patients' lifestyle and pocket. By eliminating those things and treating patients with the All-on-4 treatment concept, I see a dramatic increase in the number of patients I treat.

It's night and day. The important thing is that the net outcome for the patient is the same, even though one approach is much more complicated and involved, so why not do the simpler procedure? That is the paradigm shift in my thinking and approach.

What motivated you to develop an online course for the All-on-4 treatment concept?

Dr Jivraj: The reason for doing something online is to enhance education in general. Hooman and I had been running All-on-4 treatment concept hands-on courses where doctors would come in, listen to lectures and see a live surgery. Unfortunately, we were only able to reach a very small segment of the population, because of the travel involved.

The online platform allows us to have a wider reach. It allows convenience for the end user and it's a very nice way to convey a lot of practical information quickly.

Dr Zarrinkelk: As we've travelled and spoken to many clinicians, I sense there is still a tremendous amount of uncertainty and confusion when it comes to treatment planning for the terminal dentition and the edentulous and atrophic edentulous patient.

That was certainly the case for me in the past, but I overcame this by changing the way I think and plan through a simplification of the thought process. Our primary motivation was to show the audience this simplified process and to share our experiences.

What were your key objectives when developing this online course?

Dr Jivraj: The key objectives were to try and present the subject matter in a very simple way that clinicians could relate to. Having gone through the experience ourselves, we wanted to deliver something that is practical, usable and inspires the person watching to go to the next level.

Dr Zarrinkelk: Our key objective has always been to share and educate. The online course is a perfect medium for the interested clinician to learn, at their convenience, all the things that we sometimes had to learn the hard way. The objective was to really share the key parameters that clinicians need to know and satisfy in order to successfully treat patients with the All-on-4 treatment concept.

Obviously there are variations on how you accomplish things, but we wanted to show that you can't skip or miss these key points. We're not holding anything back; we've put everything out there. If these details aren't understood or taken into account, clinicians may have difficulties when they perform their own procedures. And nobody wants that.

Can you describe what the online course covers?

Dr Jivraj: The content is step-by-step: from initial diagnosis, which is critical, to delivering the final restoration to the patient. Every step requires attention to detail and what we tried to do in this course is provide these details, ensuring clinicians master one step before going to the next one.

Dr Zarrinkelk: We designed this course to be all-encompassing. We wanted to show our approach to treating edentulous patients or those with a terminal dentition. We also wanted to simplify treatment planning for this class of patients.

The course outlines the critical elements that make the All-on-4 treatment concept work, which clinicians must follow. If they don't, they might create problems that are going to be hard to deal with. After watching this online course, clinicians will have a solid understanding of the points that they should be aware of for patient treatment.

What can clinicians expect to gain by completing the course?

Dr Zarrinkelk: In one word, "simplification." We hope that after watching this course video from start to finish, clinicians pick up some very important points that they would never get from a book or a manual. With this online program, clinicians can learn not only what the literature says about the protocol, but also all the little details that make the protocol work. Ultimately, clinicians will gain insight into our simplified approach to treating complex patient situations.

Dr Jivraj: The course gives clinicians a good theoretical background in the All-on-4 treatment concept: all the necessary steps for rehabilitating a patient. Once again it's theoretical information. People watching this course should seek out hands-on experiences before implementing the concept in their practice.

What obstacles can this course help clinicians to avoid?

Dr Jivraj: The online course will educate clinicians to identify the patients that they can diagnose, plan and treat using the All-on-4 treatment concept. The diagnosis must be "spot on" for this procedure to be successful.

Dr Zarrinkelk: We really want this to be an essential tool for the entire team. We want them to see beyond the obstacles of treatment planning and execution. They should see that by changing their thinking process, as we did, they can also overcome the obstacles and treat more patients.

We simplify the approach and walk them through the complete procedure, from start to finish, giving them those key points to avoid problems. There's always going to be variations in patient anatomy and medical conditions that the team will have to deal with, there isn't a book that covers everyone.

Why is the All-on-4 treatment concept needed in modern clinical practices?

Dr Jivraj: My feeling is that the All-on-4 treatment concept will become more and more commonplace, because it's a great way to treat patients in the simplest way possible, with the fewest implants possible, providing a long-lasting, high-quality end result.

Dr Zarrinkelk: There's an increasing demand for it. We have a lot more patients that are living longer and they don't want to live with dentures. It's an important concept because it helps many patients that were previously considered untreatable or refused treatment because of the complexity of traditional approaches for the treatment of edentulous, atrophic or terminal dentition patient classifications.

Why is collaboration between the entire treatment team critical when working with the All-on-4 treatment concept?

Dr Zarrinkelk: The way I look at it, it's really difficult to be good at everything involved in the treatment of these patients. That doesn't mean there are not those that can do it all, but for the typical clinician it may be difficult to achieve competence in all aspects.

This is a clinically demanding procedure. It is simple in the sense that patients are treated quickly and simply, but it's a very demanding procedure both in the prosthetic and surgical phases. Our goal should always be to provide the patient with the best possible outcome our individual skill set offers - whatever that may be - and involving a team is the best way to do that in my opinion.

Dr Jivraj: Teamwork is crucial: the patient must receive the best of everyone's skills in order to complete the treatment efficiently, predictably and quickly. Surgeons do surgery best. Prosthodontists and restorative dentists are trained at providing aesthetic, functional teeth. My recommendation to the novice is to assemble a very strong team that includes a surgeon, a prosthodontist or restorative dentist and a very capable laboratory technician.

What advice do you have for clinicians just starting out with the All-on-4 concept?

Dr Jivraj: My single piece of advice is they get adequately trained. This is not a single tooth, it's a full mouth. Patient expectations, as well as fears, are high. Having adequately trained individuals, in my opinion, is key to the success of the procedure. They have to seek out the appropriate learning pathway. When they do, they'll have happier patients.

Dr Zarrinkelk: My biggest piece of advice is they have to get it into their minds that this is a three-dimensional concept, not just four implants placed next to each other. Details and fine points must be known that can be easily missed, ruining the whole process if not followed.

They should read as much as they can. And practice as much as they can with people who have done it, learning all the little details and tricks.

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