Is a Screw Retained Bridge even Possible here?

We all know that a screw retained bridge is the gold standard for dental implant retained bridges. 

And with technologies like guided surgery, there is almost no reason not to have a screw retained bridge. 

Right? 

How about this case? 

We have a really deep bite here, this makes immediate load tricky (because the steep guidance and the wear increase the risk of occlusal contact on the temp bridge, especially if you have temp cylinders from the implants there, which are not fully cut down). 

But this is our biggest problem. 

There is no bone to even move the dental implant, so that screw retained is possible. Note, this is the shape of her maxillary bone, not after resorption. 

Also note, that what you see in the CBCT with the bite is not how it is in reality. Patients need to bite on something to separate their jaws, the real bite is imported into our planning software.

You can see that things are looking “tight” back there!

Okay, so what are our options? 

Really, I think we have 3, and all will work. 

  • We can use angled cement retained abutments.
    • This can solve the bite issue, as they can be made very thin, but the down side is retrievability. Taking a cement retained bridge off is often very difficult, if you need to do that in the future. 
  • Use an angled multi unit.
    • Isn’t this what they are designed for? We use them all the time for all on 4 treatments. Here is the new access hole, if we were to plan for a MUA. 
      Perfect, right? 
    • Derril Gillfeatherpng angled 2
  • Or we can use an angled screw channel and still stop at implant level. 

At this stage, I don’t actually know what we will do with the finals, but I hope we are not forced into cement retained. 

We should not be, as this case was fully guided, and planned to work with the second two options. 

The planned implants are Sweden and Martina Prama, these are trans mucosal implants, so taking temps on and off will not disrupt the soft tissue attachment. 

If we have an angled screw, the amount of angulation we need is less than that of the abutments, because we are attaching deeper. I have tried to explain this in this very artistic photo mark up. 

The blue lines are at implant level, and to have a palatal screw channel, you do not need as much angle correction as you have with the angled MUA (green cylinder). 

This would be my ideal solution as there are less components, and it simplifies everything. 

Multi units are also fatter, and in anterior cases, they can mess up the beautiful gingival aesthetics that we can achieve with thin components. 

But what about the immediate temps? 

Well, I warned the patient that we would have dark teeth, because the temp cylinders would show through. 

We removed the two roots, placed our implants, did our buccal bone grafting, and this is what the temps looked like. 

Not surprising. 

But with a little tidying up, we cut the cylinders short and filled with PTFE and more composite. 

You can see that the emergence on the UL2 is already a little wide, and we were just copying the natural root shape. 

We cut the teeth short, adjusted the occlusion and left the patient like this. 

Occasionally getting zero palatal contact will weaken the bridge too much, so I have placed bite raisers on the molars before, but this isn’t my favourite method. 

I will be seeing this patient for a review soon, so make sure you join me on Instagram or X to see the updated photos. 

If you would like to see cases like this in person, and spend more time going into the details of the planning, we can arrange day visits to the practice with short and intensive mentoring programs. 

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