All On Dental Implants With Prettau Solid Zirconia Dental Implant Bridges ~A Case Explained

In this post I will try to detail the start to finish of full upper and lower dental implants with Prettau solid zirconia dental implant bridges.  This gives a general outline for what to expect if you were to have to lose all of your teeth and replace them with full arch zirconia implant bridges.

I will describe the rationale for treatment which may help those of you in similar situations.  Sometimes you have to have bone graft and sometimes you do not.  Sometimes the dental implants can be placed simultaneously with extractions and other times the extractions, implants and bone grafts need to be or should be done in phases.


before treatment x-ray showing failing teeth
before treatment x-ray showing failing teeth
before treatment open retracted photograph
before treatment open retracted photograph
upper jaw
upper jaw
lower jaw
lower jaw
flipper stayplate for lower front teeth
flipper stayplate for lower front teeth
1 week after upper jaw dental implants and extraction of all remaining teeth
1 week after upper jaw dental implants and extraction of all remaining teeth
lower jaw dental implants after one week
lower jaw dental implants after one week
upper jaw dental implant impressions
upper jaw dental implant impressions
lower jaw dental implant impression
lower jaw dental implant impression
conventional open tray impressions
conventional open tray impressions
wax pattern of teeth for try-in purposes
wax pattern of teeth for try-in purposes
verification jigs
verification jigs
PMMA temporaries.
PMMA temporaries.
Final x-ray with upper and lower solid zirconia Bridges on 12 implants. There are 24 teeth supported by these 12 implants.
Final x-ray with upper and lower solid zirconia Bridges on 12 implants. There are 24 teeth supported by these 12 implants.

What is unique about my approach is often procedure can be done in a single visit surgery without the need for “major” bone grafting such as lateral window sinus procedures or block grafting(although I routinely do these major grafts for other reasons).

he plan is to harness this patient’s existing good bone and avoid the areas where the bone is deficient, thin, risky and doesn’t have a lot of density.

Final x-ray with upper and lower solid zirconia Bridges on 12 implants. There are 24 teeth supported by these 12 implants.
Final x-ray with upper and lower solid zirconia Bridges on 12 implants. There are 24 teeth supported by these 12 implants.

IMG_4858 This patient is about 55 years old and as you can see has quite a substantial dental problem.  His upper teeth have a temporary bridge that is not well fabricated and was just put in so he could have “something there.”  The lower front teeth are missing.  The upper jaw is very small and narrow in comparison to the lower jaw which is wide.  This places the patient into a reverse cross bite which must be taken into account for both the surgery and the long-term with the teeth.  The mechanics of the bite can often destroy the fragile bone at the top of an implant.

I cannot emphasize enough that replacing all of your teeth with dental implants is a highly complex procedure that should be unique to your situation and not just the same recipe “all on 4” for every single patient.  I also believe that one implant dentist completing your treatment from start to finish has the most control of your result.  It also helps to save cost as compared to this procedure being done by 2 different dentist….A surgeon and a restorative dentist.

Your treatment plan and diagnosis is the most critical element which is done early in the planning phase.  For this patient I need to engineer his full mouth dental implants and solid zirconia bridges to be strong at the level of the teeth and strong in the bone so that he does not get bone loss or broken teeth.  This happens very commonly when these procedures are not well planned or discount parts and techniques are used.

On the preoperative panoramic x-ray we can see that the patient has had a substantial amount of dental work.  There is bone loss and decay on most of the remaining teeth. This patient was tired of investing thousands of dollars over the years into procedures that all failed and he did not feel that his smile was attractive.

In his case, while he slept under IV moderate sedation, I extracted all of the remaining teeth and placed all the implants simultaneously.  The procedure was planned by 3-D CBCT analysis which is essentially virtual computer surgery.  The bone had to be leveled in some areas so that all of the implants were approximately on an even plane leaving plenty of thickness for teeth.

These types of full arch solid zirconia bridges not only replace teeth but in his case were also replacing bone and gum.  This is why these types of restorations look different because without replacing the bone and gum on the bridge the patient’s face would look sunken in and his speech would be improper.

Prior to the surgery, upper and lower impressions were made to fabricate temporary upper and lower dentures.  These dentures will be used for several months while the implants heal and give us some idea of the patient’s facial aesthetics and bite needs.  Connecting the teeth to the dental implants on the same day in his case was not appropriate.  Immediate teeth can be made in some cases but should not be made in all cases.  Many dental clinics market this as being a solution for all patients but the reality is it is not safe and predictable for all patients but it is for ‘some.’

At no point will this patient ever be without teeth.  In my practice in Burbank, California, this is unacceptable for patient to walk around without teeth although I have had a few patients that preferred to do that.

On the upper jaw  6 dental implants were placed into the best possible bone.  The rear most dental implants were placed at a tilt facing backwards on purpose.  This will alleviate the need in this patient for right and left maxillary sinus bone grafts.  The teeth can be cantilevered about 1-1/2 teeth beyond where the implants end to give this patient teeth all the way to the first molar position.  This means that the 6 dental implants will support 12 teeth on the bridge.  This tilted concept is not always possible and depends on where God made your sinuses and nerves.  Sometimes the sinuses are too far forward for this to work.  Especially on the upper jaw you want implants going as far back as possible and as many implants as possible because the bone is soft.  The number of implants is critical and should never be compromised as this is the main structure that will hopefully make things last as long as possible because dental implants are not permanent!!

On the lower jaw, the 6 dental implants are scattered more evenly around the jaw because this particular patient had room above the nerve on the rear molar areas.  This places dental implants underneath all of the bridge without a cantilever which is a great approach.  In a patient that does not have bone in the rear molar area, the implants can be more centralized towards the front middle and teeth cantilevered towards the back.  In the latter scenario, you want to make sure that the implants are good and long and you have at least 5 of them.

It takes 3-6 months for the implants to integrate.  During that phase, I  begin to prototype the patient’s mouth so that they can see feel and test drive what their new smile will look like.  Adjustments will be made to the teeth and a wax pattern is fabricated.

In this patient, I made  conventional open tray impressions of his upper and lower jaw using a putty type of material.  Sometimes the impressions can be made digitally also using the 3Shape Trios 3 scanner that I have.  The impressions are then scanned in a physical and digital model is made.  I then fabricate what is called a verification jig.  This device verifies that your impression is accurate and your bridge *will* fit…no guesses or maybes.  This is not a step that should be skipped although I find many dentists that do.  This is the equivalent of the framing of a house… It needs to be perfect from the structural standpoint so that everything last a long time.  Panoramic x-rays are generally taken along the way in order to verify that the custom abutments are flush to the implants.

After the verification jig comes another try in to verify you like the look of everything and then we switched over to PMMA fixed temporaries.  The fixed temporaries are the closest prototype to the real one.  The purpose is for you to be able to test drive the real ones.  It also allows me to test  speech, facial aesthetics, dental aesthetics, bite, TMJ, hygeine and so much more.  You will go home wearing these great looking, stong temporaries and wear them for 1-2 months generally.  During this time life is good and transitioning to the final is really easy because it feels even better than the digitally fabricated and milled PMMA temporaries.

The final solid zirconia Prettau dental implant bridges are delivered and generally screwed into place.  The screw access holes were closed with a composite material after all of the abutments screws are tightened.

It is quite the process to replace all teeth with fixed solid zirconia dental implant bridges but it is so worth it.  I’m certain this is the best that dentistry has to offer as of 2016.  There are many clinics that advertised discounted procedures and techniques but you need to be very careful what you may end up with.  Sometimes people have problems and no dentist wants to fix them because treatment was so bad to begin with.  Sadly, I see this every single week.

This patient can chew whatever he wants an should not have any problem for a long time.  Total treatment time for this patient was approximately 9 months from start to finish.

Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry

21 thoughts on “All On Dental Implants With Prettau Solid Zirconia Dental Implant Bridges ~A Case Explained”

  1. What is the difference between this implant bridge and an implant denture? Does this implant bridge just get billed to my insurance as one thing, or is it billed as bridges w/ retainer crowns and pontics? I want to make sure my DDS bills my insurance for the right thing.

    Reply
    • Removable Implant Dentures: These are also known as “overdentures” and are supported by implants. They can be snapped onto the implants but can be removed for cleaning and while sleeping.

      Fixed Implant Bridges: Sometimes referred to as “all-on-4” or “all-on-6,” these types of dentures are permanently attached to the implants. They offer more stability but are not removable by the patient.
      How it Works: Implant dentures use a few strategically placed implants in the jaw to support a full arch of teeth. The denture then attaches to these implants, providing a secure fit and natural function.
      In summary, the main difference in terms of removability is that implant bridges are usually fixed and can only be removed by a dentist, while implant dentures can be designed to be either removable by the patient or fixed.

      Billing: Your insurance is only go to pay $1500 toward the whole treatment regardless of codes ;-(

      Reply
  2. Dr. Amin-
    I read many of your articles and find them fascinating. I see that there are quite a few implant dentists who have seriously developed systems for installing a Pretteau Bridge on perhaps 10 mini implants. They seem to be doing alveoloplasty procedures though perhaps with more flexibility due to the narrow implants . . . it seems as if with 10-12 mini implants, and different lengths, there could also be greater flexibility in the ridge height. What do you think of this ?
    e

    Reply
    • It’s a terrible idea to use mini implants for full arch dental implants.

      Mini implants Break and Bend. They should be thought of as temporary Implants! They do not allow the dentist to get ideal contours of the bridge. It’s really a bad idea 👎🏻

      Reply
  3. Hi Dr. Amin:

    Wasn’t sure where to post my question for this matter after you helped me with the zygomatic implants that I thought I might need. Woke up from that surgery to be told I didn’t need to do it on the maxillary (6) that I had because the healing had surpassed his expectations! Lots of prayer by many people for me :). Now I am starting the lower mandible and was wondering if it is best to go with opposing materials for top and bottom, than both being zirconia. Maxillary All-on-Six is zirconia. Any problems with that combo, or should I select Zirconia for the bottom too?

    Reply
    • Zirconia top and bottom is best. Some people mix and match but I have not found any need to do that. It just creates more expense for the future that way

      Reply
  4. Hi dr Amin..amazing complex information again from you..I was going to ask you about a Macquarie Street Centre in Sydney NSW..30years established a Dr David Dunn owns the set up ,but the more I come across such intelligent complex information on different sites of yours the more I think you are the best and so willing to pass on your wealth of Information to help others, such amazing generosity! ..I have to be honest here and admit I am scared of not getting the best experienced person to do my upper and lower prettau zirconia implant based bridges in austalia/as you know trust is so important and that is a true comment as I have been burnt before by specialists??? I honestly do not know what to do/i just want it done right,regards julie

    Reply
    • Thank you for your kind words once again. Complications can and do occur. Remember that dental implants are a replacement for teeth. They are not natural teeth. I wish we could make things like nature made them but we are left making prosthetic versions of nature.

      Reply
      • Thanks I do realise our own natural teeth are amazing….but that ship has sailed and as mentioned before this is complex work…and if done by the wrong person /disaster 😖😟..you would understand as you have seen many disasters and have had to do many re dos/what a nightmare those cases must be for you and the patients 😟..thanks for your response I appreciate your time and imput …just wish I did not have to address this situation /but I do / with whom in this country??that is the big question ..time will tell who when and where kindest regards julie….😁
        …..

        Reply
      • Hi Dr Amin .I meant to add you are very diplomatic and kind when you reply as that is your true nature and as a professional you also have to acutely aware to respond in a professional way..😉you know what I mean……but I would like to add as a patient (without mentioning names of certain dentists) that the reason I am wary and scared of whom I chose is because I was butchered in the past(not just burnt as I previously mentioned)i suffered through 18 months and a full mouth reconstruction..at an enormous cost both physically, psychologically and financially ..I still can not comprehend how people can do this/that is how I have learnt a lot.. I am sure I am not the only one who has suffered …but dentists should realise that they have to earn the patients trust…and realise they have a duty of care…. in a perfect world that would happen….but we do not live in a perfect world.. money seems to be their ultimate goal and a lot of patients are just left to suffer I often wonder what happened to that saying “”first do no harm””..I will never understand that mentality of not caring ….I will sign off now as the thought of enduring more with the wrong person sickens me.. not my fault but my problem. I will sort this one way or another….regards julie

        Reply
        • Hi dr Amin yet again you never cease to amaze me with your intricate work both visual / and such detailed explanations..no one else does this ..you should feel very proud of your high standards and accomplishments…I feel privileged just to have found your sites😊..I have 2 appointments for tomorrow..I just have not found the open verbal and visual explanations that I have found with you.. and knowledge to make an informed decision is paramount ..so once again congratulations on all your devotion ..I know I would feel confident with you ..kindest regards julie 😊oh well see how I go tomorrow this situation has to be resolved as my oral health is paramount and I need to move forward with the right person/ you must know you are unique in this field..regards julie

          Reply
  5. I am in desperate need of some intervention in the mouth. I have 3 working teeth and have multiple health problems and on disability.

    I can’t chew much and I am in need of help.

    Reply
    • Try a local dental school…they can provide basic treatment. They would not do a fixed implant bridge in most situations.

      Reply
  6. I bet this chap is over the moon!! How many years would implants like these need taking out and replacing? Also how do you clean the implants if the front is covered by artificial gum?

    Reply
    • Implants are easily cleaned with a water pick device , floss, toothbrush and little brushes that are computer designed to fit in the tiny hygiene space. The material was so smooth that it is very plaque resistant but it is important to practice excellent oral hygiene. Typically I do not remove these unless something is wrong which is very infrequent.

      Ramsey A. Amin, D.D.S.
      Diplomate of the American Board of Oral Implantology /Implant Dentistry
      Fellow-American Academy of Implant Dentistry

      Reply
      • Thank you!! If I ever need anything like this doing in years to come I’m flying from the uk to see you. I have family in marina del rey. I don’t care how much it costs. Your work speaks for itself! :0!

        Reply
  7. I note that in this case there was quite a bit of false gum. This is understandable if the patient had gum loss. However, it does seem to make them more like a fixed over denture instead of a bridge.

    Reply
    • Hi Lynne,

      This is an excellent observation.

      Keep in mind that some people are missing just teeth. Some people are missing teeth and gum and some people are missing teeth, gum and bone… The trifecta.

      Each situation is unique. Most people have lost a significant amount of bone and require a pink portion of replacement so that the face does not cave-in in the teeth do not look overly elongated likely horse teeth.

      Some people need bone leveling in order to put all the implants in properly while others do not. The goal is to make the solid zirconia dental implant bridges has natural feeling as possible but of course they are different than your original teeth.

      Ramsey A. Amin, D.D.S.
      Diplomate of the American Board of Oral Implantology /Implant Dentistry
      Fellow-American Academy of Implant Dentistry

      Reply

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