The Cardinal Rule of All-On-X Surgery

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 Poker in Las Vegas. 

During his journey, he finds himself at an intense, high stakes table. Caught up in the moment, he foolishly bets his entire bankroll on one hand…and loses it all…down to the felt. 

As he reflects on his loss, he cannot believe that he bet everything on one potential outcome. On one set of cards. No back up plan, no secondary way to win. The cards had to fall just right. How could he put himself in such a position!

As he walked away from the table he could not believe he had lost his discipline, let his emotions get the best of him, and subsequently broke The Cardinal Rule of Poker: 

Always leave yourself outs.

He frustratingly reiterates to himself that the great players always leave themselves outs. They always have more than one way to win. 

I have also learned over my career that this mantra could not be more true for All-On-X surgery. 

In order to consistently, immediately load AOX surgeries, it is imperative to always leave yourself outs. 

So what exactly does this mean in the context of All-On-X surgery?

When I treatment plan a case, my goal is to develop at least three possible treatment pathways.

These are three surgical “paths” that all get me from point A (the patient’s pre-op state) to point B (a prosthetically driven, immediately loaded, fixed full arch). 

I always plan…that things won’t go according to plan. I want to ensure that I have always left myself outs.

And if on occasion things in fact don’t go according to plan…I know that I can seamlessly transition to “my next move”.  

Here’s how I envision the 3 treatment pathways playing out in my mind: 

Treatment Pathway A

The ideal scenario. Everything goes according to plan.

Treatment Pathway B

Not ideal…but manageable with a slight shift in the game plan. 

Treatment Pathway C

Things are far more difficult than anticipated and we need to salvage this case so we can still immediately load. 

Below I will outline an example of the three treatment pathways I mentally walk through for an AOX patient. Keep in mind that these scenarios change with each patient presentation and that the example provided below is specific to this patient and the provided pre-op imaging. 

Learn to leave yourself outs…this is how you consistently load AOX cases. 

Treatment Plan Scenarios

Treatment Pathway A

When I look at the pre-op pano I am first assessing the ideal treatment plan scenario. In my mind, this includes an A-P spread that extends to at least the 2nd bicuspid and is accomplished with a traditional 4 implant configuration. 

This particular maxillary AOX patient presents with pneumatized sinuses, as well as an anterior extension of the sinus cavities. This type of anatomy can make achieving adequate A-P spread difficult. 

With this presentation, however, I am confident that I can achieve a 2nd bicuspid spread with a 45 degree angulation of implants #4 and #13 and an “Inverted V” configuration of implants #7 and #10.

This would be Treatment Pathway A. This is the “simplest” surgical plan, utilizes a traditional 4 implant configuration, and achieves adequate A-P spread.

Treatment Pathway B

I know, that despite my confidence in Treatment Pathway A, this surgery can be very, very humbling. Therefore,  I never stop at just “one” treatment plan. 

When I look at this case I see 5 or 6 possible treatment scenarios. However, my goal as mentioned above, is to always have at least 3 possible treatment scenarios. 

In this example, Treatment Pathway B would occur if I am unable to access the second bicuspid site following bone reduction. Increased reduction requirements will move the posterior implant anteriorly and decrease A-P spread. If I feel A-P spread would be inadequate, even with a 45 degree angulation, its time to move to Treatment Pathway B. 

In this scenario, I would move my traditional posterior implants forward to the first bicuspid sites and place them at an angle of ~30 degrees. I would also add additional implants posteriorly, at the palatal socket sites of the existing maxillary molars. This would eliminate any cantilever created by the sinus anatomy and reduction requirements, as well as improve composite torque. 

Treatment Pathway C

Continuing to mentally walk down the treatment pathways, I am now assuming for whatever reason, that I was unable to place a palatal root implant. Maybe there was a fracture of the tooth upon removal and bone in this area had to be removed to access the remaining root. Or maybe bone reduction requirements did not leave enough of a socket to utilize. 

In either case, I would move on to Treatment Pathway C and place a traditional 4 implant configuration anteriorly, with a first bicuspid A-P spread. I would then proceed to utilize bilateral pterygoid implants to eliminate the otherwise two tooth cantilever, as well as improve composite torque. 

And there you have it! This treatment pathway mental exercise takes all of 30-60 seconds, but allows me to know prior to walking into the surgical operatory what my options are if something does not go as planned. I always want to leave myself outs…

Why do I do this? 

While a combination of burying implants and/or grafting and delayed loading is technically always an option, this is not what patients come to see me for and not the service for which they are truly paying. So, while this is always a possibility, I do everything in my power to avoid a delayed loading scenario, unless immediate loading is truly not beneficial to the patient.

Learning to leave myself outs with every AOX surgery has ensured that I am able to consistently load my AOX cases and has provided better surgical outcomes for my patients. 

Remember that while you cannot predict every AOX surgical difficulty you may encounter, you can predict most of them. 

Therefore, it isn’t wise to wait until you have a problem to try to figure out what you are going to do. You should have already ran through that scenario in your head. 

Great AOX surgeons have already anticipated problem scenarios mentally and know what to do when things don’t go right. They know that if they cut enough arches, that unexpectedly difficult cases will come… and come again…and again – trust me.

I guess in the end…All-On-X surgery isn’t that different than high stakes poker.

Sometimes, deep in a surgery, your surgeon’s cap filled with sweat and your cortisol levels spiking, you feel like you have it all on the line. 

In these situations, just remember The Cardinal Rule…of All-On-X surgery: 

The great surgeons always leave themselves outs. They always have more than one way to win. 

Matthew Krieger DMD 

P.S.

This case was able to be completed with Treatment Pathway A as shown in the post-op images below.