A New Design For All-Ceramic Inlay-Retained Fixed Partial Dentures: A Report of 2 Cases
A New Design For All-Ceramic Inlay-Retained Fixed Partial Dentures: A Report of 2 Cases
A New Design For All-Ceramic Inlay-Retained Fixed Partial Dentures: A Report of 2 Cases
In a previous clinical study, all-ceramic resin-bonded 3-unit inlay-retained fixed partial den-
tures (IRFPDs) had a significantly worse outcome in the posterior region than did crown-
retained 3-unit FPDs made from the same material. Debonding or fractures were causes
of failure. To improve the clinical outcome of IRFPDs, a new framework design was devel-
oped: (1) The inlay retainers were made out of CAD/CAM-manufactured zirconia ceramic
to improve fracture resistance, and additional veneering of the inlays was omitted. (2) The
inlay retainers were completed with a shallow occlusal inlay (1-mm minimum thickness)
and an oral retainer wing (0.6-mm minimum thickness). The wings were designed to
reduce stress on the inlay retainer caused by torsion forces when the FPD is loaded non-
axially and to increase the enamel adhesive surface area. The pontic was circumferentially
veneered with feldspathic porcelain. The clinical and laboratory procedures of this new
treatment modality are described, and 2 exemplary clinical cases are presented. This new
preparation and framework design might improve the clinical outcome of all-ceramic resin-
bonded IRFPDs. However, adequate evidence of long-term safety and efficacy is required
before this new design can be recommended for general clinical practice. (Quintessence
Int 2006;37:27–33)
The use of all-ceramic materials for fixed progress in material technology and manu-
restorations in dentistry has become more facturing procedures has extended the indi-
and more important for patients and clini- cations for these materials. In 19902 the IPS
cians in the last decades. Since the first felds- Empress system (Ivoclar Vivadent) was intro-
pathic crown was inserted in 1886,1 recent duced to the dental community and became
a popular all-ceramic system for pressed
glass-ceramic inlay, onlay, and veneer
restorations. To increase the mechanical
1
Assistant Professor, Department of Prosthodontics, strength of all-ceramic restorations, different
Propaedeutics and Dental Materials, School of Dentistry,
Christian-Albrechts University at Kiel, Kiel, Germany.
core materials were used. They were made
2
either from glass-infiltrated alumina ceramic
Professor and Chair, Department of Prosthodontics,
Propaedeutics and Dental Materials, School of Dentistry, (In-Ceram Alumina, Vita Zahnfabrik),3 pure
Christian-Albrechts University at Kiel, Kiel, Germany. alumina ceramic (Procera, Nobel Biocare),4
Reprint requests: Dr Stefan Wolfart, Department of or lithium disilicate-based glass-ceramic (IPS
Prosthodontics, Propaedeutics and Dental Materials, School
Empress 2). However, the highest fatigue
of Dentistry, Christian-Albrechts University, Arnold-Heller-
Strasse 16 D-24105 Kiel, Germany. Fax: + 49-431-597-2860. fracture strength so far is achieved by the
E-mail: [email protected] core material zirconia ceramic.5
Irrespective of which type of ceramic clini- resistance, and on the other hand, the design
cians use, a crown preparation is always a of the IRFPDs has to be reconsidered to min-
risk to pulp vitality and may lead to pulpal imize the risk of debonding.
reactions in the long term.6 About 63% to The aim of this article is to describe a new
73% of the coronal tooth structure is design of inlay-retained FPDs that will (1)
removed when teeth are prepared for all- increase the adhesive strength by maximiz-
ceramic crowns.7 Given these facts, it ing the bonding area and (2) minimize tor-
seemed desirable to adapt the type of abut- sion forces on the inlay retainers when the
ment preparation to the extent of sound tooth FPDs are loaded nonaxially. Because of its
structure after caries removal, not only for a very high static and fatigue fracture strength,
single-tooth restoration but also for fixed par- the use of a zirconia ceramic material
tial denture (FPD) abutment preparations. seemed reasonable.
Therefore, if a patient rejects an implant treat-
ment and if enough sound tooth structure is
available, it would be desirable to restore a
missing tooth with an inlay-retained FPD METHODS AND MATERIALS
(IRFPD) instead of a crown-retained FPD.
However, clinical evaluations showed a fail- Patients
ure rate of 10% after 9 months (Empress 2)8 Two patients referred to the Department of
and 13% after 37 months (IPS e.max Press, Prosthodontics of Christian-Albrechts Univer-
Ivoclar Vivadent)9 for inlay-retained 3-unit sity at Kiel, Germany, with the indication for 3-
FPDs. In both studies, the failure was evoked unit FPDs, were selected for this new type of
by debonding or a combination of both restoration. Patient A was a 33-year-old man
debonding and fracture. Compared to missing the maxillary right first molar. The
crown-retained FPDs, these failure rates tooth gap corresponded to the typical size of
appear to be much too high to recommend a maxillary molar and had already been treat-
this treatment strategy. To improve the out- ed 22 months earlier with an all-ceramic resin-
come of IRFPDs, 2 strategies look promising. bonded IRFPD (experimental ceramic).
On the one hand, the core material has to be Because of debonding of the inlay retainer at
improved to demonstrate a higher fracture the second molar after 22 months, the FPD
*
Fig 1c (left) Resin framework and the
enlarged milled framework (patient A).
had to be removed. The inlay retainer of the tooth gap corresponded to the typical size of
second premolar was still in situ. The patient a maxillary premolar. The maxillary right first
rejected implant treatment and again chose premolar had a small carious lesion distally,
an all-ceramic IRFPD. Figures 1a to 1g show and the first molar had an insufficient mesial-
the treatment procedures step-by-step. occlusal-palatal-buccal restoration. Figures
Patient B was a 46-year-old man missing 2a to 2g show the treatment procedures
the maxillary right second premolar. The step-by-step.
Fig 2a (left) The maxillary right first premolar and first molar before treatment (patient B).
Fig 2b (center) Epoxy cast showing the final preparation (patient B).
Both patients were healthy and had an resorption or periapical pathology. Oral
almost complete dentition. All abutment hygiene was very good, and caries activity
teeth were vital. The bone level of the abut- was low. All abutment teeth showed no
ment teeth corresponded to the upper third mobility, and probing depths ranged from 2
of the root length with no signs of active bone to 3 mm. Extreme bruxism or a conspicuous
ed as acceptable for general clinical practice. 15. Kanca J. Improving bond strength through acid
etching of dentin and bonding to wet dentin sur-
faces. J Am Dent Assoc 1992;123:35–43.
16. Yoshida K, Funaki K, Tanagawa M, Matsumura H,
Tanaka T, Atsuta M. Mechanical properties and
ACKNOWLEDGMENTS bond strength of commercially available adhesive
resin cements to tooth substrates and precious
The authors are grateful to the patients for their kind dental alloys. J Jpn Dent Mater 1994;13:529–536.
cooperation and to the dental technicians B. Schlueter 17. Wegner S, Kern M. Long-term resin bond strength
and R. Gerhardt (Department of Prosthodontics, to zirconia ceramic. J Adhes Dent 2000;2:139–145.
Propaedeutics, and Dental Materials, School of
18. Blatz MB, Sadan A, Kern M. Resin-ceramic bonding:
Dentistry, Christian-Albrechts University at Kiel).
A review of the literature. J Prosthet Dent 2003;
89:268–274.