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The Functionally Fixed Restoration

The Functionally Fixed Restoration

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03/18/2014

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The Functionally Fixed Restoration: A Third Modality of Treatment
Compendium / Feb. 2002
By Paul J. Berson, DDS
Private PracticePhiladelphia, PA
Abstract:
Most dental practitioners as well as their patients prefer to have fixed rather than removable restorations.However, there are many clinical situations that prohibit the use of the fixed modality. These clinical cases can varyfrom simply not having the proper number of healthy teeth and/or implants to the esthetically challenging cases of high smile lines and severe loss of alveolar support. The approach of using a traditional removable prosthesis in thesesituations has always been met with severe compromises. The functionally fixed restoration is a third modality of treatment that can solve many of the problems of the removable restoration and at the same time provide the samecomfort and success of the fixed prosthesis.Currently, most restorative dentists use two modalities of treatment (ie, restorations involving implants and/or naturalteeth are either fixed or removable). In some cases, a combination of both types of treatment are used. In the past,these modalities provided a restoration that fulfilled the expectations of the patients. However, patients' expectationshave now risen. Patients want their teeth to look whiter and feel healthier at all times. They also want theirrestorations to last a lifetime and, at the same time, be financially within their budgets.Using natural teeth and/or implants as abutments, the fixed restoration will most often satisfy the expectations of patients! However, there are a few clinical situations where this modality of treatment falls short. The fixed modalitywill not provide the proper anterior esthetics for individuals who have lost substantial amounts of anterior alveolarsupport. Oftentimes, the patient is unwilling to undergo periodontal reconstructive procedures to restore his or herlost attachment.
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Consequently, the fixed restoration must replace the loss of periodontium and teeth with onlytooth-colored prosthesis. This leaves the patient with teeth that appear overly large with an unnatural appearance.Furthermore, many times when there has been a tremendous loss of the periodontium, the restorations need tosupport the patient's lip. Figure 1 shows an individual who has lost a severe amount of alveolar support and has beenrestored with a fixed implant-supported prosthesis. Note how the maxillary lip is inverted and a concavity is formed.The individual has taken on a class III profile, which leads to an older appearance. A fixed prosthesis cannot providethis profile enhancement. Conversely, Figure 2 shows the same type of case restored with a restoration that supportsthe maxillary lip. The individual looks more youthful by maintaining a more natural profile.Traditionally, the removable prosthesis is used when there are not enough teeth and/or implants to support a fixedprosthesis or there are financial limitations precluding the use of the fixed modality.
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Most dentists and patients areunhappy with the removable restoration because of the compromises in stabilty, retention, esthetics, andmaintenance. The most severe deficiencies in these restorations are most likely the need for palatal coverage in themaxillary arch or a lingual bar on the mandibular.
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 The functionally fixed restoration can meet the needs of patients in many clinical situations in which the fixed and/orremovable modalities cannot be used. The functionally fixed restoration can provide the proper esthetics and comfortfor a patient with a lack of severe alveolar support coupled with a high smile line.
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If needed, it can provide profileenhancement. It can also create palateless restorations when there is not enough natural tooth and/or implantsupport for a fixed restoration. The functionally fixed restoration is the ultimate unilateral or bilateral distal extensionprosthesis. With the functionally fixed restoration, there is no need for palatal coverage or a lingual bar and it isextremely effective in combining implants and natural teeth into one restoration.The functionally fixed restoration is the perfect solution to salvaging a prosthetic restoration where implants werepreviously placed in unrestorable positions. Furthermore, this restoration can mediate the problem of poor implant-to-crown ratios.The functionally fixed tooth and tissue replacement restoration with removable ponis bar retained, yet tissuesupported.
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The restoration has a fixed as well as a functionally fixed component (Figure 3). The pontics areabsolutely immobile, and do not rise from tissue resilience, nor depress from the forces of occlusion (Figure 4). Theforces from occlusion are directed perpendicularly and equally to all ridge areas. Only a direct, deliberate, preciseaction removes the pontics from the fixed permanent section containing the specialized bar. For all intent andpurposes, the removable section is functionally fixed.
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It acts as a fixed restoration from a phonetic, esthetic, andmasticatory prospective. The only difference between a fixed and a functionally fixed restoration is that with the latter,the pontics can be removed by the patient for hygienic reasons.The functionally fixed restoration incorporates the use of Andrews bars and sleeves.
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These attachments can be usedas a single bar and sleeve, as well as a double bar with a corresponding sleeve (Figure 5). The bar is attached to thefixed fixed prosthesis. These curved bars and sleeves are made of a special stainless-steel material that is mated totolerances of 1:2,000 of an inch. They are cut from three different sized concentric rings. The curvature of the barsand sleeves allows the covered ridge to be under constant pressure from occlusion, as well as provide the retention. Amolecular "stickiness" is created when the two pieces move against each other. Small grooves along the length of thebar prevents full metal contact, which prohibits the creation of too much retention.The attachments also allow for a quick increase in retention by crimping the bar very slightly with three-prongedpliers. The key point is that these restorations are bar-retained, yet tissue-supported.The sleeve should be set 1 mm above the bar as the acrylic comes into contact with the tissue. The attachment doesnot bottom out. The saddle and flange areas aid with the retention of the restoration, as well as help distribute theocclusal forces over the entire edentulous area. This protects the abutments from undue occlusal pressure.
 
 
Case 1
Case 1 is a 58-year-old woman who lost teeth Nos. 11 through 16. Figure 6A shows an x-ray of the edentulousmaxillary left quadrant with the placement of two implants in the positions of teeth Nos. 11 and 12. Additionalimplants were not possible. Note the tremendous loss of alveolar attachment apparatus and, consequently, the largeamount of interarch room between the arches on the working model (Figure 6B). A fixed provisional shows howunesthetic this restoration would be as a permanent option. All of the areas above the black markings (Figure 6B)need to be restored with a tissue?colored replacement instead of a tooth-colored material. If not, the teeth wouldappear too large in a mesial/distal as well as a gingival/incisal dimension. Pink porcelain will not provide an estheticsubstitute for the gingiva. There is a very compromised crown-to-implant ratio and the angle of the implants wasdecidedly buccal (Figure 6C). Teeth Nos. 9 and 10 required full crown coverage for restorative reasons.The functionally fixed restoration (Figures 6D and 6E) provided the patient with the proper esthetics. Not only are theteeth in the correct proportions as they relate to other natural dentition, but the restoration allows for cheek support.Also, the restoration allowed three more teeth to be added, which enhanced the patient's smile.This restoration has many other functional advantages. For example, a cantilever is no longer required. The prosthesisis restored with soft acrylic teeth, which will be kinder to the transfer of occlusal forces to the implants. The poorcrown-to-implant ratio is mitigated by the support the restoration gains by intimate contact with the ridge and palate.Lastly, the patient has easy access to the daily hygienic maintenance of the implant abutments (Figure 6F).

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