A lot of decision-making goes into all phases of full-arch rehabilitation, especially when it comes to restorative treatment options. From the patient’s current dentition to his or her own preferences, clinicians have to juggle several factors to come up with the right full-arch restoration. Ultimately, the cascade of decisions taken stems from the mindset of wanting to restore missing teeth to normal function and esthetics in a predictable and efficient manner, which is the fundamental objective of modern implant dentistry.
Beginning with the end in mind, the first decision of the cascade should focus on the prosthetic component of the treatment. Indeed, it’s the design of the prosthesis that must dictate the implant placement and not the other way around. In the words of one of the founding fathers of implantology and original advocates for prosthetically-driven treatment plans, Dr. Carl E. Misch, “Patients are missing teeth, not implants”. Accordingly, clinicians must possess a solid grasp of the different types of prostheses and the demands of each.
Dr. Misch classified fixed prostheses into three types: FP-1, FP-2 and FP-3. All three options can be cemented or screw-retained. Choosing between them depends on the amount of residual bone and soft tissue as well as the esthetic characteristics of each. Now, let’s discuss each option in detail.
FP-1 prostheses mimic the appearance, size and contour of only the crowns of the patient’s missing teeth. They are typically indicated when the patient has minimal loss of bone and soft tissues.
Since an edentulous patient is lacking in the width and height of their crestal bone, clinicians often have to do bone augmentation before placing implants so the crowns appear natural in the cervical region. Also to avoid the presence of black triangular spaces in the place of interdental papillae as a patient smiles, clinicians often carry out soft tissue augmentation as well.
FP-2 restorations appear to replace the crowns and portions of the missing teeth’s roots. Because they are hyper-contoured and longer than healthy teeth, these restorations are used for edentulous patients with moderate bone loss to compensate for the increased clinical height.
With such an elongated design, the patient’s esthetic zone dictates whether they are eligible for FP-2 prostheses, provided that they’re also fully informed about how their restorations would eventually appear.
The esthetic zone is established by observing the patient’s maxillary arch while smiling and mandibular arch during speech of sibilant sounds. Ideally, an FP-2 case’s upper lip during smiling and lower lip line during speech should not expose any of the interdental papillary regions.
Even though FP-2 candidates would have to move their lips in unnatural positions to expose the restoration’s characteristically long crowns, some candidates still don’t feel comfortable donning FP-2 restorations and desire more natural-looking teeth. For this subset of patients, FP-3 restorations could prove more esthetically convenient.
FP-3 restorations replace the missing teeth’s crowns, roots and portions of the soft tissue. The top of FP-3 prostheses is made of pink-colored material to mimic the appearance of the gingiva and interdental papillae. Larger restorative space is required for FP-3 prostheses. This could be obtained naturally through moderate to severe bone resorption or through surgical bone reduction.
Unlike their FP-2 counterparts, FP-3 candidates may have high maxillary lip lines or low mandibular lip lines thanks to the presence of the prosthetic soft tissue. Smiles of ideal FP-3 candidates show the interdental papillae but not the tissue above the mid-cervical regions.
Available Guided Systems for Full-Arch Restoration
The Anatomic Guide®
3Sixty’s Anatomic Guide® has become the go-to guided surgery system in the industry for loading full-arch FP-3 prostheses containing pink-colored material. The system is fully customizable and stackable with its bone reduction guide, implant placement guide and PMMA provisional restoration; all easily attachable through latches.
Its bone reduction guide is 75% smaller and three times stronger than competing bone reduction guides. This allows for the highest anatomical accuracy and increased stability across the arch as well as a cutdown of overall surgery time by 50%. In addition, the Anatomic Guide® allows for minimally invasive bone reduction as only a buccal flap is required for guide placement. That leads to improved patient experience with reduced healing time, less postoperative pain and swelling.
The Scalloped Guide is a reliable system for loading full-arch FP-1 and FP-2 pink-free prostheses. Instead of considerably reducing bone and altering a patient’s anatomy to create sufficient restorative space, clinicians can use the Scalloped Guide for precise tissue removal. The guide creates satisfying gingival esthetics without pink-colored material because the scalloped shape of the guide helps the soft tissue adapt to the predetermined contour of the temporary restorations which supports the formation of interdental papillae in the long run.
3Sixty Digital Workflow
Regardless of the type of prostheses and guided surgery system clinicians opt for, 3Sixty’s cutting-edge digital workflow can help them reach favorable, predictable outcomes with every full-arch case. It all starts with treatment planning which is taken care of by our experienced 3Sixty Dentists who live for the intricacies of anatomy and implant surgery.
After the clinician reviews and greenlights their patient’s treatment plan, our CAD/CAM team takes over to design the guides needed for surgery. Finally, the guides are sent for 3D printing and delivery to the clinician’s practice complete with a precise drilling protocol, PMMA provisional restorations and everything that will be needed to make sure the patient’s new teeth end up exactly as planned in their mouth.
Dr. Misch’s words as mentioned earlier serve as a great reminder for clinicians to take a step back and remember that the benefits of implant dentistry can only be realized when treatment starts with an evaluation of the prosthetic outcome. Here’s a quick overview of the available fixed prosthetic options for full-arch cases:
|Prosthetic Option||Appearance||Amount of Bone||Guided Surgery System|
|FP-1||Mimics the crowns only||Minimal bone loss||Scalloped Guide|
|FP-2||Mimics the crowns and portions of the roots; appears elongated and hyper-contoured||Moderate bone loss||Scalloped Guide|
|FP-3||Mimics the crowns, roots and soft tissue with pink porcelain; looks most natural||Moderate-severe bone loss or bone reduction||Anatomic Guide|