Success With Screw-Retained Zirconia Bridges, Part One:

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Continuing Education

Success With Screw-RetainedZirconia Bridges, Part One:

Treatment Planning Concepts

Authored by Michael Tischler, DDS; Scott D. Ganz, DMD; and Claudia Patch, DMD

Upon successful completion of this CE activity 2 CE credit hours will be awarded

Volume 33 No. 9 Page 98

ABOUT THE AUTHORSDr. Tischler is a general dentist in privatepractice in Woodstock, NY. He is aDiplomate of the American Board of OralImplantology/ Implant Dentistry, aDiplomate and Fellow of the InternationalCongress of Oral Implantolo gists, a

Fellow of the American Academy of Implant Dentistry, anda Fellow and graduate of the Misch International Institute.He is on the continuing education editorial board forDentistry Today and on the editorial advisory board for theJournal of Implant and Advanced Clinical Dentistry. He haspublished many articles in various dental journals andlectures internationally on the principles of implant dentistryand bone grafting. He is the director of the dental implantdepartment for Tischler Dental Laboratory and is also onthe Bio Horizons educational speakers’ panel. He of fers in-office courses at his teaching facility in Woodstock manytimes during the year and has a popular instructional DVDavailable that covers the principles of implant dentistry andbone grafting. He can be reached at (845) 679-3706 or attischlerdental.com.

Disclosure: Dr. Tischler is the owner of Tischler DentalLaboratory, which produces the Prettau Implant Bridge. He isalso on the Biohorizons Implant System Educational panel.

Dr. Ganz graduated from the Universityof Medicine and Dentistry of New Jersey(UMDNJ) Dental School and thencompleted a 3-year specialty program inmaxillofacial prosthetics at MD AndersonCancer Center in Houston, Tex. He is a

Fellow of the Academy of Osseointegration, Diplomate andmember of the Board of Directors of the International

Congress of Oral Implantolo gists, on staff at HackensackUniversity Medical Center, and is on faculty at UMDNJDental School. He maintains a private practice forprosthodontics, maxillofacial prosthetics, and implantdentistry in Fort Lee, NJ. He currently serves as associateeditor for the peer-reviewed journal Implant Dentistry and ison the editorial staff of many other publications. He hasmore than 70 publications in various professional journalsand has contributed to numerous scientific textbookchapters. His book, An Illus trated Guide to UnderstandingDental Im plants, has been a classic for patient education formore than 19 years. He regularly presents internationallyon the prosthetic and surgical phases of implant dentistryand is considered one of the world’s leading experts in thefield of computer utilization for 3-D diagnostics andtreatment planning applications. He can be reached at(201) 592-8888, at [email protected], or at drganz.com.

Disclosure: Dr. Ganz has a financial interest in the PrettauImplant Bridge.

Dr. Patch is a general dental practitionerin Woodstock, NY. In 2009, she receivedher DMD degree from the University ofConnecti cut School of Dental Medicinewhere she received various awards,including the Ameri can Academy of

Esthetic Dentistry Merit Award. Together with Dr. Tischler,Dr. Patch is part of the Prettau Implant Bridge team,performing the restorative aspects of the process.Additionally, Dr. Patch is a continuing education lecturer onthe restorative components of the Prettau Implant Bridge. In2012, she was selected as one of Dental Products Report’sTop 25 Women in Dentistry. She can be reached [email protected].

Disclosure: Dr. Patch reports no disclsoures.

INTRODUCTIONWhen a patient presents with the need for full-arch toothreplacement supported by dental implants, it is important forall members of the team to understand the various fixed orremovable prosthetic alternatives. Factors that can affect the


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Success With Screw-RetainedZirconia Bridges, Part One:Treatment Planning Concepts Effective Date: 9/1/2014 Expiration Date: 9/1/2017

treatment plan include the available bone, type of bonequality, adjacent vital structures, pathology, the number ofpotential implants, smile-line, and aesthetic demands.

Once a patient has been informed about the choices, andit is determined that a fixed implant-supported option ispossible, the alternatives become more defined. One suchoption is the zirconia, implant-supported, screw-retainedbridge. This treatment choice offers advantages ofretrievability, ideal aesthetics, reduced susceptibility tochipping, strength, and more. Part one of this 2-part articleseries will review the background, justification, and treatmentplanning steps for a clinician to im plement a full-arch,zirconia, implant-supported, screw-retained bridge. Part 2 ofthis 2-part series will illustrate the recommended surgical andprosthetic steps for success with the zirconia, implant-supported, screw-retained bridge.

Background: Full-Arch Prosthetic Alternatives When treatment planning a screw-retained implant restoration,the material options are acrylic, ceramo-metal, or zirconia.

When monolithic (full contour) yttrium-stabilizedzirconia is used (Figure 1), there is a substantially reducedsusceptibility to chipping as compared to the other options.The literature shows that polished monolithic zirconia offersless occlusal wear to the opposing arch than feldspathicporcelain. The longevity of success for screw-retainedzirconia bridges for the prosthesis and implant survival hasproven success, as reported in the literature. With theadvancements in zirconia technology, full-contour zirconiacan rival the aesthetics of zirconia with porcelain on thefacial surface of the teeth (Figure 2).

Acrylic hybrid bridges have a substantial record ofchipping and prosthetic failure throughout time (Figure 3).1

This is due to the weak mechanical bond to a metal core,and the weak nature of acrylic as a material. By definition,a hybrid bridge is a metal bar with acrylic denture teeth.2

When a cast metal structure is used for a hybrid bridge,casting distortion could cause stress on implants, problemswith surrounding bone, and screw fatigue issues.2 If aCAD/CAM titanium metal core is used, there are issueswith the acrylic attaching to the titanium because of areduced chemical bond.3 It is often seen that entire teethde-bond from the prosthesis or pieces of acrylic teeth break

away with hybrid bridges (Figure 4). The screw-accessholes in hybrid bridges are notorious for acrylic chippingdue to occlusal forces. These screw-access holes are alsooften dark in color and unaesthetic due to shadow from themetal core of the hybrid bridge. Another disadvantage is theinherent porosity of acrylic that attracts plaque, which maylead to peri-implant issues.

PFM screw-retained bridges, due to the ceramic material,are difficult to repair. If a cast metal core has stress on it, theporcelain can de-bond from it. The same problems of castingdistortion are present as with any cast metal super-structure ofan implant-supported screw-retained bridge. Any hybrid bridgehas the inherent issues of stress on the implants and prosthetic


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Success With Screw-Retained Zirconia Bridges, Part One: Treatment Planning Concepts

Figure 1. The Prettaufull-contour zirconiaimplant bridge.

Figure 2. Closeupshowing facial aspect ofthe Prettau full-contourzirconia bridge.

Figure 3. Hybrid bridgefailure showing maxillary denture tooth de-bonding frommetal framework.

Figure 4. Hybrid bridgefailure showingmandibular denture tooth de-bonding frommetal framework.

abutments and screws. The long-term success of zirconia screw-retained implant

restorations has been proven in the dental literature sinceZirkon zahn (Zirkonzahn) originated the milled screw-retainedimplant-supported zirconia. Zirkonzahn was the first and onlycompany worldwide to create an entire dedicated system ofa specific zirconia material, milling machines, sinteringovens, and scanning machines (Figures 5 and 6). Thesystem also includes specific stains, glazes, porcelains, andlaboratory treatment for zirconia (Figure 7). While othercompanies have started to imitate Zirconzahn’s success,they do not have a proven long-term track record for full-archimplant-supported prostheses.

An implant-supported screw-retained zirconia implantrestoration is fabricated through CAD design and the CAMand milling. This CAD/CAM process negates castingdistortion and its resultant problems (Figure 8).4 Anotheradvantage of zirconia as an implant restorative material is itsability to splint dental implants in a very rigid manner due tozirconia’s high modulus of elasticity. The success of adjacentdental implants has been shown to be im proved throughrigid splinting.5 Zir conia has the advantage of offeringreduced plaque retention as compared to acrylicalternatives. The hygienic nature of zirconia can improvesuccess of the supporting dental implants.6

One important caveat that must be appreciated whenplanning for a zirconia implant-supported restoration is thethickness of the material. If the CAD/CAM zirconiaframework is too thin, it will be susceptible to potentialfracture. The authors have found that a minimum of 12.0mm of prosthetic thickness measured from the occlu saltable to the implant platform is adequate.4 In order toensure that 12.0 mm of prosthetic height is achieved, it maybe necessary to reduce the alveolar crestal bone throughadequate alveoloplasty at the time of surgery (Figure 9).Ade quate vertical space can also be accomplished throughan increase in vertical dimension of occlusion (VDO), or viamodification of the opposing arch. Reducing alveolar crestalbone allows an FP3 prosthesis based on the MischClassification.2 An FP3 prosthetic design has in creasedprosthetic space, which requires an area of “pink” artificialgingiva to close the vertical space. An advantage of the FP3prosthesis is that the pink gingival area can be controlled

based upon the patient’s smile-line, and can result in a veryaesthetic appearance, and will maintain itself without thepossibility for recession (Figure 10).

Treatment Planning a Full-Arch Implant ProsthesisThe decision whether or not to save a tooth (or teeth), with


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Figure 5. Zirkonzahn’sspecific 5-axis zirconia milling machinefor Prettau zirconia.

Figure 6. Zirkonzahn’sspecific sintering oven forPrettau zirconia.

Figure 7. Zirkonzahn’sspecific stains for Prettauzirconia.

Figure 8. CAD/CAMzirconia framework withtitanium interfaces thatconnects it to theimplants.

respect to long-term prognosis, is multifactorial. It requirescareful clinical and radiological evaluation of the remainingteeth, periodontal condition, caries risk assessment, andsurrounding bone (Figure 11).7 It is understood that patientsmay not immediately accept the loss of teeth throughextraction; a subjective factor that is part of the patient’s desireto save his or her existing teeth, or not. Many clinicians makeheroic efforts to save teeth, despite their limited or hopelesslong-term prognosis, leaving patients frustrated (Figure 12).Some patients, after being informed of the option to save teethby different treatment modalities (such as periodontal therapy),now choose to extract teeth and have them replaced by dentalimplants. Therefore, the treatment alternatives presented to thepatient must now include implant-supported restorations whichmay require the extraction of all remaining teeth in an arch tohelp preserve their remaining bone and to restore function andaesthetics. Comparing the financial cost of preserving keyteeth and placing strategic implants, or extracting all remainingproblematic teeth with an implant-supported restoration, is asubjective factor that requires an analysis of long-term riskversus benefits of treatment. A patient may not want to spendmoney to save teeth when full-arch dental implants maypresent with a better long-term and less problematicprognosis. Even if it costs less financially to save someremaining teeth, a patient may decide not to risk the chance ofthose teeth needing future dental services that might includeboth additional financial and time commitments.

Additionally, patients who pre sent with xerostomiarepresent a multi factorial etiology, with causa tive factorsrelated to pharmaceutical, aging, autoimmune, or radiationbased causes.8 Once xerostomia is a consideration intreatment planning for a patient, teeth become a morevulnerable option compared to im plants with respect todecay (Figure 13). Thus, implants may be the treatmentplan of choice.

Often, treatment plans that in volve maintaining certainteeth may also require ancillary procedures such as sinusgrafting, bone grafting, and soft-tissue procedures. Theseadjunctive procedures can add considerable cost andadditional healing time to the treatment plan.

Another scenario when trying to save teeth and placeimplants might involve restoring natural teeth with full-coverage restorations for aesthetic and/or functional

improvement. This cost and result can be directly compared tothe aesthetic and functional results that can be achieved witha full-arch, implant-supported restoration.

Another consideration for the patient is the number ofappointments needed for each proposed treatmentscenario. A patient may opt for a shorter treatment scenarioif it is a possibility, especially if one has a busy lifestyle.Patients need to be informed of the risks and benefits, long-term prognosis, and quality of life improvements that can beexpected from each treatment modality.

When a full-arch reconstruction is required, all fixed orremovable treatment options should be given to the patient.Once a patient indicates that he or she does not want aremovable prosthetic option, the fixed implant options of eitherscrew- or cement-retained im plant prostheses can be furtherex plored and ex plained. When comparing available materialalternatives for a full-arch, screw-retained, implant-supportedrestoration, the advantages of zirconia are: retrievability, theability to cantilever, great aesthetics, low susceptibility tochipping when full-contour zirconia is utilized, improved plaquecontrol, and a decreased risk of peri-implantitis secondary tocement remnants around implants.

Comprehensive Patient Examination Treatment planning for a full-arch, implant-supportedreconstruction re quires a comprehensive patient evaluation,documentation of the patient’s condition, and informed


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Figure 9. Alveoloplastybeing performed to obtain a 12.0-mmprosthetic space.

Figure 10. Example of zirconia FP3 prosthesis showingaesthetic artificial gingiva.

consents, and any necessary prescriptions. Good extra- andintraoral photographs allow for an objective assessment of thepatient’s lip-line, occlusal scheme, and the condition ofexisting restorations. This also offers sound medical-legaldocumentation.9

Charting the patient’s existing restorations and periodontalcondition is also an imperative step in the treatment planningprocess. This information allows the clinician to formulatealternative plans for treatment and decide with the patient theappropriate long-term solution. Charting information also helpsthe clinician have a discussion with the patient, with respect tothe financial considerations of various treatment options. Other

information—including temporomandibular joint (TMJ) status,oral cancer status, and medical history—is also critical toformulating a treatment plan. Infor mation on the patient’spsychological status as well as general expectations providespertinent information in formulation of a treatment plan.

Once the information from a CBCT scan has beenreviewed and all other charting and medical historyinformation is obtained, the clinician can then presenttreatment plan options to the patient. This is part of theinformed consent process, and as each option is presented,the pros and cons of each are reviewed. The advantages anddisadvantages of the alternative implant-supported options


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Figure 11. Panoramic radiograph showingteeth with a questionable long-term prognosis.

Figure 12. Image of a patient who was frustrated with trying to save teeth via conventional dental treatment.

Figure 13. Xerostomia patients could begood candidates for a full-arch zirconiaimplant bridge.

Figure 14. CBCT axial view showing proposed implant positions.

Figure 15. Examples of 17° multiunit abutments to redirect a screw hole.

Figure 16. CBCT cross-sectional view showing how a CT scan can help orient thescrew hole toward the cingulum.

Figure 17. Panoramic radiograph of immediate screw-retained acrylic provisionalat the time of implant placement.

Figure 18. Immediate loaded maxillaryscrew-retained provisional delivered at thetime of surgery.

need to also be presented and documented as part of thepatient chart.10

A CT/CBCT scan is recommended to plan for the correctimplant positions, to diagnose existing pathology, and to avoidiatrogenic damage to vital anatomy (Figure 14).11 CBCT scansoffer low radiation and interactive 3-D planning through manyavail able software programs. Third-party diagnostic imagingservices are now available for any clinician to gain access andassistance in treatment planning for an implant case;eliminating the need to purchase costly software or to havespecific knowledge on how to use these programs.12 ACT/CBCT scan can offer information for the clinician to achieveideal implant positions to support the implant prosthesis. Thesurgical procedure can then be executed according to the planwith or without using a surgical guide according to theclinician’s preference and experience. The correct restorativelydriven planning objective for an implant-supported zirconiascrew-retained restoration is to have the screw-access holesproject from the im plants through the envelope of the tooth ineither the cingulum area for the anterior region, or the midocclusal, or lingual aspect of the posterior teeth beingreplaced. If the screw-access hole is directed toward the facialof the anterior teeth, its emergence through the facial aspect ofthe tooth will be an aesthetic issue. An alternative is to redirectthe screw-access hole lingually with a multiunit abutment(Figure 15). A CBCT scan and proper 3-D planning can offerthe clinician significant guidance with regards to the correctimplant position (Fig ure 16). Placing im plants with interactivetreatment planning software can help assess the bony receptorsite in an attempt to place the implant in a lingual or palatalposition. If the CBCT shows the need for bone reduction, thiscan be easily accomplished during the surgical intervention toallow for sufficient prosthetic space.

Presenting the Options and Treatment Sequence Presenting the treatment options, the sequencing oftreatment, needed documentation, and financial options arean integral part of the treatment planning process. For apatient to accept treatment, the clinician or staff membermust present these necessary steps in a confident andorganized manner. The more organized and confidentlydelivered the presentation is, the more likely a patient will beto accept treatment. Many patients are overwhelmed with

the process of having major oral reconstruction, and arereliant on the treatment facility to simplify the process whileproviding a level of comfort. It is recommended that anorganized protocol be utilized when presenting treatmentoptions, treatment sequences, financial op tions, anddocumentation. This or ganized protocol can consist of team(staff) roles for each presentation step, specific books orvideos to explain options, and organized folders for theneeded paperwork.13 It is recommended to systemize andsimplify the process as much as possible. This will beindividualized for each office’s situation, but should berepeatable, smoothly executed.

From a financial and communication perspective, there aremany advantages to presenting an overall fee for a compleximplant case. This adds simplicity for both the patient and for theprovider presenting treatment. When one overall fee includesthe extractions, bone grafting, and the comprehensive surgicaland prosthetic steps, the entire process is more scripted, andthe authors have found an increased ac ceptance of full-archtreatment plans. Organized presentation steps are alsoimportant from a medical/legal standpoint and allow for a stronginformed consent as part of the medical legal record oftreatment and should be documented as carefully as possible.

Concepts for the Provisionalization StepAn important aspect of treatment is how the case will beprovisionalized. The choices to provisionalize a full arch during


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Figure 19. Panoramicradiograph of a final full-arch, zirconia, screw-retained bridge afterimmediate loading.

Figure 20. Example of a finished full-arch,maxillary Prettau zirconia,screw-retained bridgeafter immediate loading.

implant treatment will affect a patient’s lifestyle in many ways.Speech, eating, and confidence levels will all be affected,depending on the choice of how an implant restoration case isprovisionalized. When a full arch is being reconstructed, it canbe provisionalized either by immediately loading the implants,submerging the implants in a 2-stage manner with a transitionalremovable prosthesis, or utilizing certain stable teeth in atemporary manner to support a provisional restoration until theimplants integrate.

Using teeth to support a provisional while implantsintegrate in a 2-stage manner offers advantages anddisadvantages. The advantage of utilizing teeth for supportis that the implants can integrate without pressure frommasticatory load, especially in softer bone. Thedisadvantages are that utilizing teeth to support aprovisional restoration can interfere with the amount ofalveoloplasty that can be done during surgery. Anotherdisadvantage in saving teeth for provisional support is thatoften the teeth being saved are problematic, or periodontallycompromised, and might not last for support during implantintegration, or the transitional prosthesis may fracture. A 2-stage procedure mandates an additional surgery withuncovering of the underlying implants, and that a patientmust wear a removable denture during healing.14

Immediate loading is the authors’ preferred option.15 Animmediate-load protocol can provide patients with atransitional restoration the same day, or within 48 hours of thetime of surgery when adequate implant stability is achieved.An immediate-load protocol negates a second surgicalprocedure for im plant uncovering. When immediate loading isperformed, the authors recommend an acrylic, screw-retainedprovisional to be utilized while the implants heal for a periodof 3 to 5 months (Figures 17 to 20).

IN SUMMARYThere are unique advantages of a screw-retained,CAD/CAM zirconia implant bridge as compared to otherfixed options. The inherent strength of yttrium-stabilizedzirconia allows for rigged implant fixation with a lowsusceptibility to chipping. This is especially true when theprosthesis is monolithic zirconia (no porcelain on thefacial/occlusal areas).

Treatment planning for a screw-retained, CAD/CAM

zirconia implant bridge requires an assessment of theprognosis of any remaining teeth. Many factors have to beconsidered before completely edentulating a patient versussaving certain teeth. These factors include an assessment ofthe prognosis of remaining teeth, quantity and quality ofavailable bone, aesthetic advantages of each plan, the timefactors involved related to a patient’s lifestyle, and thefinancial ramifications of various plans.

A comprehensive patient assessment is needed before afinal plan can be presented—this includes a CBCT scan, aphotographic series, charting existing restorations, anassessment of TMJ status, and additional diagnostics, ifrequired. Presenting the ideal determined options to a patient,including the financial aspects, is an important part of thetreatment planning process. A presentation that is organizedand simplified will im prove doctor-patient communication,aiding the patient to make an educated and informed decision.In formed consent must be given to the patient that outlines therisks and benefits of each treatment option.

Lastly, a treatment plan for a full-arch, CAD/CAMzirconia implant restoration must include a plan forprovisionalization during implant in tegration. Depending onmany factors, implants can either be immediately loaded,done in a 2-stage protocol, or staged using residual naturalteeth to support a transitional restoration.

This article reviewed concepts related to treatmentplanning for a CAD/CAM, screw-retained, implant-supported zirconia restoration as multifactorial, as is thepresentation of the treatment plan to the patient.

REFERENCES1. Fischer K, Stenberg T. Prospective 10-year cohort

study based on a randomized, controlled trial (RCT)on implant-supported full-arch maxillary prostheses.Part II: prosthetic outcomes and maintenance. ClinImplant Dent Relat Res. 2013;15:498-508.

2. Misch CE. Contemporary Implant Dentistry. 2nd ed.St. Louis, MO: Mosby; 1999:69, 595-607.

3. Tischler M, Ganz SD, Patch C. An ideal full-arch toothreplacement option: CAD/CAM zirconia screw-retainedimplant bridge. Dent Today. 2013;32:98-102.

4. Reich S, Wichmann M, Nkenke E, et al. Clinical fit ofall-ceramic three-unit fixed partial dentures, generatedwith three different CAD/CAM systems. Eur J Oral Sci.2005;113:174-179.


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5. Bergkvist G, Simonson K, Rydberg K, et al. A finiteelement analysis of stress distribution in bone tissuesurrounding uncoupled or splinted dental implants.Clin Implant Dent Relat Res. 2008;10:40-46.

6. van Brakel R, Cune MS, van Winkelhoff AJ, et al. Earlybacterial colonization and soft tissue health aroundzirconia and titanium abutments: an in vivo study in man.Clin Oral Implants Res. 2011;22:571-577.

7. Tischler M. Treatment planning implant dentistry: anoverview for the general dentist. Gen Dent.2010;58:368-376.

8. Singh M, Tonk RS. Xerostomia: etiology, diagnosis, andmanagement. Dent Today. 2012;31:80-85.

9. Wander P. Dental photography in record keeping andlitigation. Br Dent J. 2014;216:207-208.

10. Rees J. Medicolegal implications of dental implanttherapy. Prim Dent J. 2013;2:34-38.

11. Benavides E, Rios HF, Ganz SD, et al. Use of conebeam computed tomography in implant dentistry: theInternational Congress of Oral Implantologistsconsensus report. Implant Dent. 2012;21:78-86.

12. Tischler M, Ganz SD. The CT/CBCT-based teamapproach to care: Part 2: communication with thesurgeon to support the final prosthesis. Dent Today.2012;31:108-115.

13. Ganz SD. An Illustrated Guide to UnderstandingDental Implants: Root Form Implants. Fort Lee, NJ:SDG Publications; 1993.

14. Esposito M, Grusovin MG, Chew YS, et al. One-stageversus two-stage implant placement. A Cochranesystematic review of randomized controlled clinicaltrials. Eur J Oral Implantol. 2009;2:91-99.

15. Dierens M, Collaert B, Deschepper E, et al. Patient-centered outcome of immediately loaded implants inthe rehabilitation of fully edentulous jaws. Clin OralImplants Res. 2009;20:1070-1077.


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POST EXAMINATION QUESTIONS

1. The longevity of success for screw-retained zirconiabridges, for the prosthesis and implant survival hasproven success, as reported in the literature.

a. True b. False

2. Acrylic hybrid bridges have a substantial record ofchipping and prosthetic failure throughout time.

a. True b. False

3. When a CAD/CAM titanium metal core is used, thereare no issues with the acrylic attaching to thetitanium because of an increased chemical bond.

a. True b. False

4. The success of adjacent dental implants has beenshown to be improved through rigid splinting.

a. True b. False

5. The authors have found that a minimum of 10.0 mmof prosthetic thickness measured from the occlusaltable to the implant platform is adequate.

a. True b. False

6. Patients who present with xerostomia represent amultifactorial etiology, with causative factors relatedto pharmaceutical, aging, autoimmune, or radiationbased causes.

a. True b. False

7. The advantages and disadvantages of the alternativeimplant-supported options need to also be presentedand documented as part of the patient chart.

a. True b. False

8. Using teeth to support a provisional, while implantsintegrate in a 2-stage manner, offers advantages anddisadvantages. The advantage to utilizing teeth forsupport is that the implants can integrate withoutpressure from masticatory load—especially in softerbone.

a. True b. False


9


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Success With Screw-Retained Zirconia Bridges, Part One: