Computer-guided surgery to restore function and esthetics in partially and fully edentulous patients: the FAIR protocol

Dr. Arun K. Garg discusses an alternative treatment for edentulous patients

The introduction of digital imaging and planning tools in dentistry has dramatically changed the traditional workflow and expanded the range of treatment options available for patients with total or near-total edentulism. Studies have shown that wearing removable dentures can reduce patients’ quality of life, causing pain and areas of discomfort, chewing and speaking difficulties, slippage, reduced occlusal force, and poor oral sensation. The full-arch implant rehabilitation (FAIR) protocol provides a step-by-step procedure for restoring the edentulous (and nearly edentulous) maxilla and mandible to nearly natural function and esthetics. Modeled on the four-implant full-arch restoration concept pioneered by Malo, et al.,^1–5 FAIR was developed using less costly materials and processes to offer an alternative treatment for edentulous patients with limited options. In contrast to conventional removable dentures, full-arch implant rehabilitation utilizing a digital workflow is a predictable treatment with less morbidity, less laboratory and clinical chair time, and a substantial increase in patient satisfaction.

The FAIR treatment protocol has two parts: (1) a surgical procedure that concludes with placement of a provisional restoration accomplished within a single visit; and (2) following a short healing period, delivery of the definitive fixed prosthesis. The provisional prosthesis that is delivered on the day of surgery allows patients to consume soft foods during healing. The definitive prosthesis, which has a 95% success rate over 30 years, gives patients a natural esthetic appearance while imposing virtually no food restrictions.

The ideal candidate for the FAIR protocol has ≤8 teeth per arch, moderate to advanced periodontal disease, limited finances, and the desire for a same-day fixed provisional restoration. The standard surgical protocol involves the placement of two or three implants in the traditional axial positions with no or minimal angulation, and two tilted posterior implants angled approximately 30 degrees distally to avoid anatomical barriers such as the maxillary sinus floor in the maxilla and the mental nerve in the mandible. In the edentulous maxilla, the tilted implants closely parallel the maxillary anterior sinus wall.

For novice and expert surgeons alike, avoiding vital anatomy, particularly in patients with limited bone volume, is the primary rationale for using guided surgery when planning and placing implants. A computer-designed implant guide system allows the surgeon to plan implant placement while visualizing the surrounding anatomy. In the FAIR protocol, cone beam computed tomography (CBCT) scans are used to design each case. A three-dimensional stereolithographic (3D STL) model is then made based on the patient’s CBCT scan. Once the treatment plan has been finalized, a surgical guide is fabricated.

In the maxilla, the implant surgeon must be thoroughly acquainted with the lateral piriform rim, the nasal floor, the incisive nerve and foramen, the anterior wall of the sinus, the crestal width, and the midline. The implants for mandibular rehabilitation follow the anterior loop of the mental nerve (Figures 1A-1D). The clinician should take great care not only to identify the mental foramen but also to have an idea of the path of the anterior loop of the inferior alveolar nerve. The improved accuracy of CT-guided surgery has been well documented in the literature; in the FAIR protocol, it allows the clinician to feel confident that the treatment plan has been followed, and the implants are in the most appropriate locations.

Fully edentulous cases may or may not require bone removal or a blood draw for applying platelet-rich plasma (PRP) therapies, but partially edentulous cases will involve both bone removal and a blood draw as well as bone grafting and the use of special socket-debriding burs. All implants are restored with straight and angled multiunit abutments to support a provisional, fixed, immediately loaded, full-arch prosthesis with survival rates between 92% and 100%.

The FAIR protocol represents 30 years of clinical evolution, enabling skilled clinicians to provide edentulous or near-edentulous patients with the dental appearance and function they increasingly demand. Through this approach, fixed rehabilitation of the total arch is achieved without the complex surgeries, high-morbidity rates, high costs, and lengthy perioperative treatments traditionally associated with bone regeneration and grafting procedures. Interested readers can find more information about the FAIR protocol in the author’s step-by-step book, Full-Arch Implant Rehabilitation, published by Quintessence (quintpub.com).