Full Arch Hybrids – All On X

Full arch dentistry is the process of replacing all of the teeth on one arch with implants, and prosthetic teeth and/or gums. For many patients, either all of the teeth they have on one or both arches are failing, have gross decay, or are already missing. When we see an arch like that, we determine that the dentition is terminal, and that the process of attempting to replace single teeth is complex. We have a few options, we can either try to replace individual teeth with implants and implant brides, or go with a fixed full arch bridge, or ‘hybrid’. For a hybrid, typically, between 4 and 6 implants are placed in these cases. Technology and procedural designs have come a long way since implants were developed and is still an ever-evolving part of our industry.

Implants were originally developed as a full mouth/full arch solution to support dentures. It was through these discoveries that we found out how strong implants are, and that they can support bridged teeth together, and that as few as 4 implants can be used to support an entire arch of teeth, and that those teeth can be rigidly fixed together, for a fixed bridge not just dentures.

The typical hybrid procedure today involves ‘immediate placement/immediate load’. What that means is that on the same day as the terminal dentition or remaining teeth are removed, the implants are immediately placed, and immediately loaded or put into function. So the implants are placed, and a prosthetic is either converted or fabricated to rigidly splint the implants together. It is vital we get cross arch stability, and high insertion torques on the implants to keep them stable against each other. The temporary teeth are then worn for 3 months while the bone heals, then final prosthetics are fabricated and inserted.

Without a doubt, full arch hybrids are the single coolest thing we can do for patients. The ability to deliver a brand new smile, function, bite, all in as little as one visit is just amazing. We love getting to know our patients through the process, and the increase in their confidence is huge! Full arch implants are an investment in patients future, and so much easier than going through the process of single tooth implants or implant dentures.

What makes full arch hybrids so different is that it all happens at once. We can completely transform an entire arch in just one visit, but because you do not have nerves in your bone, it is not sore to chew after the procedure! The new teeth can be put to limited (soft food) use immediately, and you get a new smile that is fixed and not removable. This is in contrast to overdentures or single tooth implants. Implant dentures can not be snapped in for 3 months until the implants heal, and the dentures rest on the gum tissue which is very sore after surgery. Single tooth implants or implant bridges can almost never be immediately loaded, so you are forced to either miss the teeth for 3+ months, or wear a removable appliance such as a flipper while the implants heal. Hybrids however, are not only are the most natural tooth replacement option, but the ability to use the implants and teeth during that 3 month healing time is just remarkable. I always tell patients, I recommend hybrids to anyone who is interested in a full arch solution.

Hybrids are without a doubt the best treatment modality out there for patients missing multiple teeth — especially posterior teeth — or patients with a terminal dentition.

Hybrid Restoration Types

I wrote a blog post discussing some differences, you can check that out here. As with many other procedures, there are options for what types of materials are used. I will go over some of the most common ones below.

Monolithic Zirconia – A full arch bridge is made out of Zirconia, a hard ceramic materials. The prosthetic gums, if necessary, are added to this prosthetic, which screws directly to the implants. These hybrids are strong, natural looking, and do not wear. The downsides to them is that if they do break, they need to be removed to be fixed or replaced.

Acrylic over a Bar – A titanium bar is fabricated to go over the implants and fit passively over them. Denture teeth are then set in their ideal position, and acrylic is flowed and then processed over that bar to make a full arch bridge. Acrylic hybrids used to be very popular, and can look VERY natural, however they have some downsides. Acrylic is pores, so it can hold onto moisture and bacteria in the mouth. Additionally, denture teeth (which are also acrylic) wear out over time, and are significantly softer than natural teeth. Finally, it is not uncommon for a denture tooth to ‘pop out’ of the acrylic. For those reasons, I do not do acrylic hybrids.

PMMA – PMMA is a fancy acronym for a type of acrylic. Unlike processed acrylic over a bar, this is a solid block of material, and the hybrids are milled out of them. Because they are monolithic, they are less prone to having something pop off, but they are not particularly strong. These are very common temporaries, and we use them during the healing period, as well as for try-ins for esthetic or functional changes.

Zirconia Superstructure over a Bar – Similar to the acrylic over bar option, but in this case the superstructure over the bar is made of the ceramic Zirconia, which is then characterized to look like natural teeth. These can be very natural looking restorations, and have the added strength of the titanium bar under them.

Individual Crowns – What we call an ‘esthetic hybrid’ or titanium hybrid. This is by far, in my opinion, the best restorative option. This restoration involves a milled titanium bar that has individual tooth ‘crown preps’ on it. Individual zirconia crowns are milled, and cemented on this structure. This restoration is flossable between the teeth, very strong, the most life-like restoration, and does not need as much room for optimal strength. Additionally, if something breaks, an individual crown can be replaced without removing the entire hybrid – making it the easiest to maintain. The primary downside is that this option is more expensive, but it is worth it!

…If something is going to break, let it be the cement! An individual crown can be recemented or replaced without remaking the entire prosthetic, eliminating the need for the patient to be ‘toothless’ while repairs are made.

FP1 Prosthetics – The above mentioned hybrids all involved artificial gums as well as teeth. While I do like the individual crowns, this is another amazing restoration option. We fabricate a restoration to fit up against the natural gums. This restoration is the most conservative as we do not have to contour the bone or gum in this case to make room for artificial gums. These prosthetics can look ‘unnatural’ as the real gums heal. Since the roots are not there, the papilla (or pink tissue between your teeth) isn’t supported by the roots and bone the same way. Most of the time, this is hidden by your lips. And because of how much more conservative we can be during surgery, this can be a phenomenal option for many patients. This option works best if most of the teeth are still present and we are not significantly augmenting the bone/teeth/smile/bite.

The FantaskiSmiles Hybrid Process

Step 1 – Consultation

Our team will see you, take CBCT 3D xrays, and determine if you are a candidate for full arch implants or hybrids. Thankfully most patients are, if we get creative enough about where the implants go!

Step 2 – Records

We take 3D scans or impressions of your teeth, and tons of photos of your current smile and face to help us design your new teeth. Since your next visit will be surgery, you have a chance to ask questions during this visit.

Step 3 – Digital Design (the two weeks before the procedure)

Your doctor will work with a dental laboratory to figure out where the implants and teeth are going to go, what we want the final teeth to look like, and how to reconstruct your smile and your bite. Some surgical guides are designed and 3D printed, and all implants and components are ordered. This process takes about 2 weeks.

Step 4- Surgery and Temporaries

On surgery day, you are sedated. This is really 3 visits that happen at once.

Your surgeon will get you numb, and remove any existing teeth
We contour the bone, do bone grafting, and place the implants and stitches. We then get scans of your implants. We design and print the temporary teeth.
We seat your temporary teeth!

Temporary Prosthetic Fabrication/Delivery

If the implants are all stable, we can make temporary teeth that are fixed and go on the implants while they heal. This happens about 95% of the time, thankfully! In cases where the implants are not stable, a denture must be fabricated to be worn while the implants heal [BUT again, this almost never happens!]. The lab and your dentist will combine the scans taken on surgery day with the pre-opp designs and fabricate a set of temporary teeth.

If everything goes well, a set of provisional teeth is 3D printed in our office, with a super strong ceramic material. We add the gums and glaze it, and delivered it the same day!

It is IMPERATIVE that patients follow the post-opp instructions while wearing provisional teeth. Because the implants are still healing, the bone will become weaker during the 3 months that you have the provisional teeth. Despite the fact that they feel rock solid, you can not eat everything you want while the implants are healing and weak. We require all patients to only chew soft foods, not bite or rip food/packaging/nails/other items, and keep the teeth clean.

Step 5 – Post Op Visits

After the temporaries are seated, we want to see you to ensure the surgery sites are healing well! These are quick and easy visits. We may talk about the esthetics, or anything you want to change with your provisional teeth going into the finals. We typically see you after 1 week and maybe again once more if we want to make cosmetic changes.

During the time you are healing, we recommend water picks 2 weeks after the surgery to clean around the gums, and normal brushing with an electric toothbrush (we love Sonicares). Soft foods are easily defined as anything you can mash up with a fork. Failure to follow these instructions can result in complications with the temporary prosthetic, or the implants, and are not covered under warranty – so please be careful!

Step 6 – Verification and Final Impressions

After you have healed for 3 months, your doctor will take new impressions of your tissue, and will verify the implant positions to make sure they are stable and accurate. The final prosthetic is harder than the temporaries, so it is important it fits perfectly passively! Any esthetic changes are addressed here, and try-ins can be done if necessary.

Step 7 – Teeth Day – Delivery of the Final Prosthetic

On this visit, the temporary teeth are removed, your gums are cleaned, and the new teeth are delivered! This is our favorite part!! We will review homecare routines, get you scheduled for your first cleaning (usually 6 months after delivery), and make sure the teeth and bite are perfect for you!

Step 8 – Bite Adjustment and Verification

We usually like to see you again after about a week to make sure we do not need to adjust your bite and take final photos! We can discuss hygiene or any questions you have about maintaining your new smile then.

Step 9+ – Cleanings

The final steps on your implant journey is just your normal recare visits with our hygienists. If you usually get your teeth cleaned at 3 months, we will do that, if its usually 6 months we will do that. For our patients with severe periodontal disease, we insist on 3 month recare visits. The teeth only come out if necessary, we do not get in the habit of removing them unless there is a hygiene problem, or we need to check on the implants. If you keep them clean with your water pik and toothbrush, we usually do not need to take them out. If they have to come out due to bad homecare, we sadly have to charge to replace the screws since they can only be tightened a few times.

Check out our gallery below to see some smile transformations, and send us a DM @FantaskiSmiles on Instagram for implant questions or a consultation!