5 Reasons Practitioners Get Frustrated with Full-Arch Surgery

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 also be a fun and rewarding surgery for practitioners to perform. And, it just has that cool factor. 

As a result, many doctors want to learn and take part in full-arch surgery. Unfortunately, there are many practitioners that jump on board the AOX train without proper training and/or without proper expectations. This can all too often lead to frustration and eventually a dislike of, or even a complete aversion to full-arch surgery. 

In my experience, the five reasons listed below are the most common points of frustration for new (and even experienced) doctors in AOX. If you are new to full-arch surgery (or are experienced but feeling burned out), take a look below to see if one of these key areas might be your frustration trigger point. 

5 Reasons Practitioners Get Frustrated with Full-Arch Surgery

1. Full-Arch surgery takes too long.

This is the most common complaint that I hear. For those in private practice, doing a double jaw full-arch case often means shutting down the entire office for the day and even having the team work over-time if performing both the surgery and the pick-up. 

It goes without saying that the more you do something the better you are going to get. However, getting over this initial hurdle of feeling like each AOX case is a marathon for you, your referral, and your staff can be overwhelming and has turned many a provider away from this surgery. 

Take heart. Efficiency can be learned and improved.

The truly good news is that this is an aspect of surgery for which you are completely in control. But – you must practice efficiency, be aware of it, and analyze each surgical step both before and after surgery to see where you can get better. 

If you pay attention to this aspect of your surgical technique – you will be rewarded. Efficiency will improve and an AOX case will simply be a part of your morning, and/or you will soon schedule multiple cases in one day. 

For those interested in more on this topic please see the previously posted articles below related to efficiency: 

5 AOX Efficiency Tips for You and Your Surgical Team 

Breaking Down the Math: Why AOX Efficiency is More Important than You Think

The Rule of 10’s: An AOX Mental Timeline for Success

What is Your Hourly Rate?

And for those with access to the AAOMS 2024 national meeting you may also access my on demand lecture using the search tab accessed via the link below:

“The Efficient Arch: How to Consistently Cut a Quality Full-Arch Case in Under 60 Minutes”.

2. Surgeons don’t leave outs or plan for failures.

I have heard the following two statements expressed with resentment and frustration… 

Statement 1: 

“I don’t like full-arch surgery because it never goes as planned and immediately loading is too stressful”.

This is absolutely true. Full-arch cases rarely go exactly as planned. 

This is a valid point of frustration and dismay for new practitioners. This is worsened by the fact that many have spent 2 hours treatment planning, carved out time for a 1 hour digital planning phone call, paid $1000 plus for reduction and implant guides… and then something does not go as planned and they are unable to load.

The first step to overcoming this frustration is acknowledging that AOX surgery rarely goes as planned.

Therefore, rather than one “set treatment plan”, it is far more important to have 2, 3 or 4 treatment “plans” or “possibilities” with multiple outs. 

In order to begin to truly enjoy this surgery and not stress about every little thing intra-operatively, you have to learn to adapt and be flexible, while maintaining your focus on the end goal (immediately loading a quality full-arch).

You have to think outside of a rigid treatment plan.

This, in my opinion, is one reason traditional guides are so harmful to the training of young AOX surgeons and why they do not provide much value in this surgery (not in all surgeries – but in this surgery). 

Statement 2: 

“I don’t like full-arch surgery because when they fail – they are a nightmare to manage”.

This is also a valid, and at times, a very true statement. Believe me, I’ve been there. 

However, yet again, the key to overcoming this frustration and moving past it is acknowledging that some of these cases will absolutely fail. This is true even if you do everything perfectly on your end. Sometimes the end result is simply out of your control. 

Once you come to grips with this reality, you can shift your mindset from: 

Beginner: 

“Here is where I can put four implants for this case. I’m good to go.”

Intermediate: 

“Here is where I can put four implants for this case. I’m good to go.”

“If plan A doesn’t work I also have the following outs to provide plan B and C.”

Advanced: 

“Here is where I can put four implants for this case. I’m good to go.”

“If plan A doesn’t work I also have the following outs to provide plan B and C.”

“While difficult, I can use advanced techniques to also provide an immediate load with the following outs and plans D and E.”

*** “If something fails in the future I have the following “future” outs… and/or I will build in the following outs during my surgery today”. 

Once you learn to think with a failure mindset… the stress and frustration of failure will begin to have less control over you and your enjoyment of this surgery. 

3. Surgeons undervalue the importance of the prosthetic side.

There is a false notion out there in the AOX world that the surgery aspect of this procedure is far more important than the prosthetic aspect. I will admit that the surgical aspect has some higher stakes attributes such as anesthesia, bleeding, vital structures etc. 

However, over my full-arch career I have learned the following: 

1. A “high quality” surgical result can fail if the prosthetic end is not completed with care and accuracy (just like a perfectly made and adjusted prosthetic can fail with a poorly carried out surgery). 
2. A “less than ideal” surgery can be improved by a talented restorative doctor that is able to manipulate the prosthetic size, shape, position, bite, jaw relationship, etc. – in favor of the surgeon. I am not ashamed to admit that I know the value in this firsthand.
3. A talented restorative doctor can take an unhappy full-arch patient and improve not only their prosthetic, but the patient’s mental and emotional state, their understanding of the prosthetic function, their prosthetic expectations, and their ability to adapt to the new prosthetic. This is incredibly important and, in my experience, is a distinguishing factor in an expert full-arch restorative practitioner.
4. An experienced full-arch restorative doctor can help diagnose why implants are failing – even when the surgeon is uncertain as to why. I have been in this scenario more than once – and it has been my skilled restorative colleague who has solved the mystery.

Working with a talented and experienced restorative doctor is important, should not be undervalued, and will make your surgical life much less stressful. 

The area I see this frustration most commonly surface in, is in private practice oral surgery. In this setting, there are often referrals from restorative doctors that do not have full-arch experience and/or do not want to take part in the surgery or treatment planning. Yet, it is not uncommon for them to want to provide the restorative aspect by “tightening the final prosthetic screws”. 

I understand that the private practice world is a different ball game. However, operating with referrals who feel the responsibility all falls on the surgeon and the restorative doctor only needs to “tighten the screws” – is dangerous in my opinion to say the least. I know from speaking with colleagues the frustration that this situation creates and it has driven more than one surgeon away from the AOX world.

In this less than ideal scenario, you will have a higher incidence of prosthetic complications that will ultimately turn into surgical complications. It is wise to either prepare for this, or to find a way in which the necessary prosthetic expertise can be provided to the patient – no different than the requirement of surgical expertise. 

4. Surgeons and restorative providers underestimate potential complications.

Full-arch surgery has complications. Period. It’s a part of the game. 

It’s important to understand this if you want to pursue AOX surgery. And, this is not just important for the surgeon to understand. Many restorative doctors have become burned out on full-arch surgery due to surgical complications. While they are not necessarily the provider directly managing the surgical complication, it is their mutual patient dealing with the complications nonetheless.  

Having a plan (as discussed above) to deal with failures is paramount to being able to consistently enjoy this surgery. But more importantly, it is critical to understand that you do not need to treat every patient that walks in your door – especially starting out. 

There are patients that will present to your practice that are either a higher surgical complexity, medical risk, or both. It is not wise to jump into full-arch surgery with the most difficult cases and/or patients. 

Selecting straightforward cases, and fundamental techniques is where a new surgeon should begin.

I quite honestly feel that far too many providers try to “jump ahead” much too quickly.

This typically does not lead to a surge of skills.

It more often leads to frustration and surgical situations that are not ideal for either the patient or the surgeon. I have known more than one highly trained OMFS colleague (including myself early in my career) that has jumped into complicated AOX cases too quickly and had second thoughts as to if they wanted to continue to pursue full-arch cases at all. 

We can never eliminate complications. What we can do is grow slow and steady as an AOX surgeon to minimize the risk of complications and maximize the chance that we have the training to manage them when they do occur. 

For those interested in how I would outline my first 1000 arches for maximum training and experience, click here to read more. 

5. Practitioners underestimate the importance of a prosthetically driven surgery and/or a prosthetically driven surgeon (a rare breed).

This goes for both restorative and surgical providers. 

I have found that while restorative providers conceptually understand the value in a prosthetically driven surgery (more so than surgeons) – they can often underestimate the importance of it in the setting of AOX. This underestimation can become a huge frustration down the road – souring many practitioners to AOX.

What exactly do I mean by this? 

When implants are not placed in a prosthetically driven position – it is often assumed that this is the surgeon’s responsibility and “problem”. While it is true that implant position and placement are ultimately the surgeon’s responsibility – they are not necessarily the surgeon’s problem. While it may not be fair, they are unfortunately the restorative doctor’s problem from that day forward.

Working with poorly positioned implants can be frustrating for restorative providers during the pick-up and fabrication of the prosthetic. However, the most frustrating aspect that has turned many a restorative provider away from AOX – is the countless prosthetic follow ups (over the following years) of a patient unhappy with a lingual or palatal flange that is too thick due to less than ideal implant placement. 

This never-ending management and the intimate relationship between implant position and prosthetic outcome is all too often overlooked in the excitement to get on the AOX train.

A surgeon new to AOX should not assume that they have mastered the surgery simply because they can place four implants “in the bone”. Nor should a restorative doctor new to AOX (or working with a new surgical referral) assume that they will be provided an optimal product for restoration. And, more importantly, a restorative doctor should not assume that poorly positioned implants will be “the surgeon’s problem”. 

AOX is, and always has been, a team sport. Remember this when selecting your teammates and do not underestimate the importance of a prosthetically driven surgery.

AOX surgery is one of the most groundbreaking surgical procedures of our time. It is also a large surgery as far as office based procedures go and demands its own unique skillset and knowledge. Couple this with the fact that it often requires a “team” or referral based approach and you have a procedure poised to either be extremely rewarding… or extremely frustrating. 

The 5 points above are the most common areas of frustration that I see (and know firsthand) in the full-arch world. My hope is that this article can help shed some light on an area that may have you discouraged or that you may be overlooking (and may soon have you discouraged), so that you can regain and experience the joy that this rewarding procedure should bring to you and your patients. 

Sincerely, 

Matthew Krieger DMD