ORAL REHABILITATION

Cite this article:

Tartaglia G M, Sforza C.
Full-mouth Zirconia-based
FULL-MOUTH ZIRCONIA-BASED
IMPLANT-SUPPORTED FIXED DENTAL
Implant-supported Fixed
Dental Prostheses. Five
year - results of a Clinical

PROSTHESES. FIVE YEAR - RESULTS

Pilot Study.
Stoma Edu J. 2014; 1(2):
138-143.

OF A CLINICAL PILOT STUDY.

Gianluca Martino Tartagliaa,

Chiarella Sforzab* Abstract
LAFAS, Laboratorio di Anatomia Funzionale
dell’Apparato Stomatognatico, Dipartimento
di Scienze Biomediche per la Salute, Facoltà di Introduction: Full-mouth reconstruction using dental implants and CAD-CAM
Medicina e Chirurgia, Università degli Studi di prosthodontic procedure is a new option model in oral rehabilitation. One of the most
Milano, Milano, Italy
consolidated promising material is yttria-stabilized tetragonal zirconia polycrystals,
a. DDS, PhD, Assistant Professor and Consutant usually called “zirconia”. It is chemically derived from zirconium sand, partially stabilized
b. MD, PhD, Professor with yttrium, and then mechanically pressed into zirconia blocks that are used for
CAD-CAM technology. In this paper we provide the 5-year results from a pilot study on
full-mouth implant-supported zirconia-based fixed dental prostheses (FMIZBRs).
Methodology: Five women aged 55-75 years had received FMIZBRs from the same private
practice. At the 5-year follow up visit, restorations remained in situ and were still in use.
Results: There were no failures and no biological complications during the follow-up
period (100% survival rate). Eight FMIZBRs experienced some minor porcelain veneer
fractures that were easily polished. None of the fractures impaired function or aesthetics.
The patients were fully satisfied with the treatment.
Conclusion: Results from this pilot study suggest that FMIZBRs can be a treatment
option that is rapidly shaping the coming dental rehabilitation area on implants.

Keywords:
Oral rehabilitation, zirconia, full-mouth prostheses, implants, chipping

INTRODUCTION
Full-mouth reconstruction using dental implants and CAD-CAM prosthodontic procedure
is a new option model in oral rehabilitation. This clinical option could be used to overcome
vertical and horizontal bone resorptions and it could include the gingival area. In this case
it is possible to regenerate or, as an alternative, to replace lost tissue using prosthodontic
reconstruction that restores the function and the esthetics of the gingiva and teeth. Various
materials and techniques have been proposed to manufacture this type of restoration.
During the last years the consolidate extensive evidence of the excellent long-term
Received: 30 August 2014 results of traditional metal-ceramic prostheses (1) has started being compared with short-
Accepted: 11 September 2014 term clinical analysis of implant-retained fixed prosthodontics manufactured from materials
different from gold alloys. The rationale of using alternative materials to conventional
* Corresponding author: metals is based on both the potential adverse reaction against gold (2) and the market
Professor Chiarella Sforza, MD, PhD demand of materials with improved esthetics. One of the most consolidated promising
Dipartimento di Scienze,
Biomediche per la Salute, material is yttria-stabilized tetragonal zirconia polycrystals (Y-ZTP), usually called “zirconia”.
Facoltà di Medicina e Chirurgia, It is chemically derived from zirconium sand, partially stabilized with yttrium, and then
Università degli Studi di Milano,
Milano, Italy. mechanically (first axially and then isostatically) pressed into zirconia blocks that are used
via Luigi Mangiagalli 31, I-20133 Milano, Italy. for CAD-CAM technology.
Tel. +390250315385,
Fax +390250315387
Y-ZTP fixed dental prostheses have become popular for their biocompatibility, the limited
e-mail: [email protected] bacterial colonization and good aesthetic properties, and also for their predictable use with

138 STOMA.EDUJ (2014) 1 (2)

 FULL-MOUTH ZIRCONIA-BASED IMPLANT-SUPPORTED FIXED DENTAL PROSTHESES.
FIVE YEAR - RESULTS OF A CLINICAL PILOT STUDY.

Figure 1. Patient M.A. (female, 68 y). Intraoral Figure 2. Patient M.A.

photograph before surgery, frontal view Immediately post-surgery X-ray

a b

Figure 3 a, b. Patient M.A. Figure 4. Patient M.A. Chipping

Frontal and lateral smile with the final prostheses complication at the two-years recall
visit. The chipped surface was
polished with patient’s satisfaction

the CAD-CAM manufacturing dental technique. MATERIALS AND METHODS

Nonetheless, some problems are still unsolved. In Patient selection
particular, technical complications like framework Between March and July 2014 five women aged
fracture and veneering porcelain chipping (3,4) 55-75 years were selected from dental hygiene
also in case of implant-supported zirconia-based clinical recall appointments in a private Milan
fixed dental restorations (5,6). Different methods dental clinic. They all had received FMIZBRs from
have been suggested to solve the problem of the same private practice between January 2008
chipping veneering porcelain. In brief they could and January 2009. Inclusion criteria were good
be summarized as follows: general health without severe general and local
- use of anatomically contoured framework medical or psychological conditions (as reported
design with respect to the veneering ceramic by the patients), and edentulous maxillary and
thickness necessity (between 1.5 to 2 mm) (7); mandibular dental arches for at least three months
- slow heating and cooling regimes when (Fig. 1).
porcelain is fired on zirconia (8); All subjects provided informed consent for
- the press-over veneering material technique the clinical procedures, in accordance with the
(9); Helsinki declaration and the Italian law. Five years
- the sintering technique where CAD-CAM extended warranty for the restorations was offered
lithium disilicate veneer is linked to a zirconia in case of failure. All subjects had confirmed their
framework (10). informed consent already provided to the clinical
The clinical necessity to collect data in order to procedures in conformity with current guidelines
understand, control and avoid the high percentage for good clinical practice (12).
of chipping (40%) that occur in full-mouth implant- An independent operator, who did not
supported zirconia-based fixed dental prostheses participate in the original prosthetic procedures,
(FMIZBRs) (11) is the objective of this clinical trial. performed all evaluations.
In this paper we provide the 5-year results of a The survival rate was defined as surviving fixed
pilot study on FMIZBRs. dental prostheses minus altered fixed dental

139
 ORAL REHABILITATION
prostheses according to grades 2 and 3 of the three files (Geomagic, Research Triangle Park, NC, USA)
grade scale of chipping fractures (13). Both grades and modified by using a CAD system (Rhinoceros,
indicate that the alteration of the veneer surface Seattle, WA, USA).
cannot be polished without altering the original For all prostheses, the zirconia core was devised
anatomic form. In contrast, grade 1 of chipping also considering the veneering ceramic. The core
fractures is used if the altered surface does not was covered by a uniform thickness of veneering
involve a functional area and with polishing it is ceramic, and a maximum of 2 mm of unsupported
possible to maintain the original anatomy. porcelain was allowed. The connectors within the
Clinical procedures for FMIZBRs crowns were designed with a 10 mm2 area at least,
Four to six dental implants (Titanmed, Milde as measured by the software used for the CAD
Implants, Bergamo, Italy) were placed in each of technique. A Computer Aided Manufacturing
the jaws of each patient in a one-stage surgical (CAM) system was used to mill the zirconia
procedure with the aid of a surgical guide (Fig. 2). core in the pre-sintered state (Zirite, Keramo,
Primary stability, with an implant stability quotient Tavernerio, Como, Italia). The cores were then
(ISQ) (14) of 65 at least, was obtained for all sintered (3dObjects, Taverne, Switzerland), and
the implants. With the use of a rubber dam for covered by feldspathic porcelain (CZR Noritake
isolation, autopolymerized acrylic resin (Takilon BB, Kizai Co. Ldt, Nagoya, Japan). Porcelain fusion was
Salmoiraghi srl, Melegnano, Lodi, Italy) was used made with zirconium oxide margins by a single
to isolate the gingiva and to record the location of master ceramist (SST Dental Clinic, Milano, Italia),
the titanium temporary abutments (Cylinder, Milde following a slow cooling protocol (16, 17).
Implants, Bergamo, Italy). All the implants were The passive fit of the fixed detachable
immediately loaded with an acrylic screw-retained prostheses on the abutments was evaluated in
interim prosthesis. The patients were instructed three ways. First, pressure was applied first on
to remain on a soft diet for the subsequent two one end abutment and then on the other one (18)
weeks. After two months, all implants showed good to look for movement of the prostheses. A visual
osseointegration at clinical, instrumental (resonance check was then carried out, and fit was evaluated
frequency analysis) and radiographic tests. with an explorer (19). Passivity was verified with
Using a pick-up technique, polyether complete- an individual screw (20) in both sides of the end
arch impression (Impregum/Permadyne, 3M ESPE abutments. No movement of the restoration was
AG,Seefeld,Germany) was performed in a customized noticed at finger sensibility, and the restoration
open tray (Apex trays, Megadenta Dentalprodukte remained in its position at the opposite unscrewed
Radeberg, Germany). A plaster model (Esthetic-base end abutment. The fit between the prostheses
gold, Dentona AG, Dormund, Germany) was made and all abutments was clinically verified in three
and used to obtain an anatomical contour wax-up. dimensions (21). By using 8-mm-wide, 8-mm-thick
Soft tissue was reproduced in the impression using shim stock foils (Hanel, Roeko, D-89122 Langenau,
vinylpolysiloxane (Gingifast Rigid; Zhermack, Rovigo, Germany), occlusal contacts were tested in
Italy). The maxillary relation was taken with a postural maximum intercuspation without interferences in
facebow (15). The occlusal vertical dimension and an lateral excursions, and adjusted as necessary.
interocclusal centric relation were transferred to the All prostheses were polished and lustered
articulator using occlusal rims. before final insertion by using a pearl surface paste
Afterward, a verification device was fabricated (Noritake Kizai Co. Ldt, Nagoya, Japan). According
intraorally to evaluate the accuracy of the definitive to a previously standardized protocol (22), all
cast. Impression copings were connected to the patients were submitted to functional analysis of
abutments and splinted to each other with acrylic their masticatory muscles after the detachable
resin (Duralay, Reliance, Dental Mfg. Co. Worth, IL). prostheses were hand screwed in the mouth
The verification jig was sectioned and reconnected, (Fig. 3). At the achievement of a good neuromuscular
unscrewed, and transferred to the definitive cast. equilibrium (23, 24), the screw access holes were
Passive fit of the index on the definitive cast was filled with gutta percha (Temporary stopping, GC)
confirmed, and the accuracy of the definitive cast followed by light-cured composite resin (Filtek Z250,
was verified. The wax contour was then impressed 3M ESPE).
on the plaster model.
The plaster model, the silicone mask, and then Follow-up evaluation
both components together were scanned with Clinical events were recorded as irreversible
a laser scanner (Dental Wings series 3, Dental events (failures) or as reversible/ adjustable
Wings Inc., Montreal, Canada). The zirconia core events (complications) (25). Failures require the
was designed with respect to the ceramic support replacement or removal of the prosthesis; the
and directly screwed on 1 to 4 mm shoulder multi- causes could be fractures, loss of retention of the
unit abutments implant connection (3dObjects, prosthesis, loss of osseointegration of the implant,
Taverne, Switzerland). Using a reverse engineering persistent pain. Technical (loss of retention,
technique, the STL files were transformed in JGESS crown fractures) and biological (periodontal/

140 STOMA.EDUJ (2014) 1 (2)

 FULL-MOUTH ZIRCONIA-BASED IMPLANT-SUPPORTED FIXED DENTAL PROSTHESES.
FIVE YEAR - RESULTS OF A CLINICAL PILOT STUDY.

implants problems, tenderness, temporary pain) fractures recorded in the present group of patients
complications were resolved without changing the did not affect function or aesthetics. They all could
prosthesis. In addition to the clinical examination, be adjusted by polishing, without replacement of
the patients were interviewed, and their satisfaction the prostheses. The patients were very satisfied
with the prosthetic treatment was rated from 0 with the treatment, and the presence of this minor
(‘not satisfied at all’) to 3 (‘completely satisfied’). complication should not be over-estimated.
They were also asked about recommending or not To put it briefly the type of veneering material and
the treatment to someone else. technique used do not fully explain the veneering
material fractures. Instead there is increasing
RESULTS evidence that the design of the core/framework
At the 5-year follow up visit, all restorations supporting the veneering material seems to be
remained in situ and were still in use. critical to avoid fractures. If the veneering material
There were no failures recorded during the follow- is unsupported the risk of fracture is significantly
up period. All the ten FMIZBRs that were followed up increased (12, 17, 18). This is associated with
for 5 years experienced no biological complications. another important factor—the thickness of the
Eight FMIZBRs experienced some type of technical veneering material. The authors started more
complications. Among complications there were than 10 years ago to manage zirconia for dental
minor porcelain veneer fractures that were easily restoration and they have never forgotten what
polished (Fig. 4). The fractures occurred on different they learned from metal framework where the
surfaces and were randomly distributed. None of customized thickness of support is the success key
the fractures impaired function or aesthetics. All for the veneering material (7). Moreover, there is
complications were independent from the number increasing evidence that the design of the core/
of implants present in the mouth. No framework framework supporting the veneering material is
fractures were noted and none of the restorations crucial to avoid fractures (11).
were in need of repair or replacement—indicating a It has to be mentioned that for the last two
100% survival rate. years a novel technique has been approaching
The patients were fully satisfied with the the Zirconia based restorations (ZBRs). It uses
treatment. All patients answered that they would zirconia monoblocks and the entire restoration is
recommend this treatment to another patient. machined with CAD-CAM technology (31). This
approach seems to increase fracture resistance
DISCUSSION and reduce veneering chipping (32). Moreover it
Different materials (metal, acrylic-metal, ceramic- may reduce the occlusal wear of an antagonistic
zirconia, ceramic) were studied to offer different tooth in comparison to feldspathic dental porcelain
options to patients and dentists to choose from. restoration (33). In vitro studies demonstrate that
With different percentages, all of them have shown it can prevent chipping (34). The dark side of this
complications that could be summarized with: approach is that light transmission is reduced, and
- Fractures of the resin facing or teeth (26, 27); this can compromise the esthetic outcome of the
- Fractures of titanium (more frequent) or gold prosthesis. Indeed, the lack of medium-long term
framework (28); clinical studies reduces the actual significance of
- Excessive wear of the resin teeth (29, 30); this novel approach. At the moment, the use of
- Inflammation of soft tissues (28); pre-sinterized zirconia frameworks seems to be
- Veneering material chipping (5-7). the best solution for complex oral rehabilitations.
The final choice for the single patient has to be Obviously, long-term studies involving a larger
addressed considering clinical necessity linked with number of patients than those analyzed in this
biological and technical difficulties. Consequently, preliminary report must be carried out using
prognosis and economic patient cost have to be zirconia/ ceramic implant-supported, full-arch
related to mid-long term results. The results in this fixed restorations.
preliminary report, where no framework fractures
were noted and all restorations were still in function CONCLUSION
after 5 years, are in accordance with the absence Results from this pilot study suggest that
of complete failure risk for implant supported FMIZBRs can be a treatment option that is rapidly
restorations (5, 6). shaping the coming dental rehabilitation area on
The veneering porcelain, however, is subjected, implants. The survival rate of the restorations as
we believe, to loads that exceed its load-bearing well as patient satisfaction are very good, despite
capacity when the restoration is supported by the occurrence of veneering material chipping.
implants, resulting more frequently in chip-off Further studies, including a larger number of
fractures (11,31, 32). The good results of the patients, are necessary to better understand the
implant support (no zirconia fractures) seem to be interlink between the technical characteristics of
counterbalanced by the negative effects on the the prostheses, clinical necessities, and biological
chipping. After all, the veneering material chipping responses.

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