Clinical protocol for intraoral repair of a chipped all-ceramic crown: a case report.

Ceramic chipping occurs frequently in veneered all-ceramic crowns, and the decision to repair or replace them depends on many factors. The least invasive method is the intraoral repair. This case report describes a conservative restorative treatment performed on a chipped dental crown. A 59-year-old patient fractured her all-ceramic crown, revealing chipping and debonding of the feldspathic ceramic veneer and exposure of the zirconia framework. The fractured fragment was brought to the dental office. Due to the patient's esthetic concerns about prolonged treatment, it was decided to use the fragment to repair the crown intraorally. The result exceeded the patient's expectations. The intraoral repair of a chipped all-ceramic crown is a conservative and low-cost alternative that allows for immediate restoration of the function and esthetics. It is essential to establish protocols that can support clinician decision-making about the most appropriate clinical treatment, seeking the longevity of the restoration and the dental structure.

Framework Fracture of Zirconia Supported Full Arch Implant Rehabilitation: A Retrospective Evaluation of Cantilever Length and Distal Cross-Sectional Connection Area in 140 Patients Over an Up-To-7 Year Follow-Up Period.

PURPOSE: To evaluate the relationship between different dimensional parameters in implant-supported monolithic zirconia fixed complete dental prostheses (IFCDPs) and the incidence of framework fracture in a large sample of cases in vivo. MATERIALS AND METHODS: This retrospective observational study evaluated all patients rehabilitated with screw-retained zirconia IFCDPs between January 2013 and April 2019 at a private practice. The minimum follow-up period was 1 year after occlusal loading. Fractures were classified as: type I-fractures that happened between but not involving the two most posterior screw-access openings (SAOs) and type II-fractures of the distal cantilever. Cantilever length, distal connector cross-sectional area, and screw access opening length were measured using data obtained from digital scans. Logistic regression was performed to evaluate the relationship between types I and II fractures and the independent variables (dimensional parameters). Using the receiver operating characteristic curves, two parameters were identified to be useful for establishing a cut-off and predicting type II fractures. RESULTS: A total of 180 prostheses delivered to 140 patients were analyzed. Five implants failed in three patients: three before delivery of the definitive prostheses and two after. Ten prostheses failed (5.6% prosthetic failure rate): 2 because of implant failures, and 8 because of framework fractures. Five fractures were classified as type I and three as type II. Significant associations were found between cantilever length and type I fractures (Wald = 5.772, df = 1, p = 0.016), distal connector cross-sectional area and type II fractures (Wald = 3.806, df = 1, p = 0.051), and cantilever length and the total number of fractures (Wald = 6.117, df = 1, p = 0.013). CONCLUSION: Zirconia IFCDPs may be reliable medium-term solutions if some dimensional parameters are followed. The ratios between the cantilever length and cross-sectional connector area should be <0.51, while the ratio between the cantilever length and screw access opening length should be <1.48.

A systematic review and meta-analysis evaluating the survival, the failure, and the complication rates of veneered and monolithic all-ceramic implant-supported single crowns.

OBJECTIVE: To assess the survival, failure, and complication rates of veneered and monolithic all-ceramic implant-supported single crowns (SCs). METHODS: Literature search was conducted in Medline (PubMed), Embase, and Cochrane Central Register of Controlled Trials until September 2020 for randomized, prospective, and retrospective clinical trials with follow-up time of at least 1 year, evaluating the outcome of veneered and/or monolithic all-ceramic SCs supported by titanium dental implants. Survival and complication rates were analyzed using robust Poisson's regression models. RESULTS: Forty-nine RCTs and prospective studies reporting on 57 material cohorts were included. Meta-analysis of the included studies indicated an estimated 3-year survival rate of veneered-reinforced glass-ceramic implant-supported SCs of 97.6% (95% CI: 87.0%-99.6%). The estimated 3-year survival rates were 97.0% (95% CI: 94.0%-98.5%) for monolithic-reinforced glass-ceramic implant SCs, 96.9% (95% CI: 93.4%-98.6%) for veneered densely sintered alumina SCs, 96.3% (95% CI: 93.9%-97.7%) for veneered zirconia SCs, 96.1% (95% CI: 93.4%-97.8%) for monolithic zirconia SCs and only 36.3% (95% CI: 0.04%-87.7%) for resin-matrix-ceramic (RMC) SCs. With the exception of RMC SCs (p < 0.0001), the differences in survival rates between the materials did not reach statistical significance. Veneered SCs showed significantly (p = 0.017) higher annual ceramic chipping rates (1.65%) compared with monolithic SCs (0.39%). The location of the SCs, anterior vs. posterior, did not influence survival and chipping rates. CONCLUSIONS: With the exception of RMC SCs, veneered and monolithic implant-supported ceramic SCs showed favorable short-term survival and complication rates. Significantly higher rates for ceramic chipping, however, were reported for veneered compared with monolithic ceramic SCs.

The effects of repetitive firing processes on the optical, thermal, and phase formation changes of zirconia.

PURPOSE: The aim of this study was to investigate the effect of different numbers of heat treatments applied to superstructure porcelain on optical, thermal, and phase formation properties of zirconia. MATERIALS AND METHODS: Forty zirconia specimens were prepared in the form of rectangular prism. Specimens were divided into four groups (n = 10) according to the number of firing at heating values of porcelain. Color differences and translucency parameter were measured, and X-ray diffraction (XRD) analysis and differential scanning calorimetry (DSC) were performed. Data were analyzed with analysis of variance (ANOVA). RESULTS: There were no statistically significant differences in ΔE, TP, L, a, and b value changes of the zirconia specimens as a result of repetitive firing processes (P>.05). CONCLUSION: Although additional firing processes up to 4 increase peak density in thermal analysis, additional firing processes up to 4 times can be applied safely as they do not result in a change in color and phase character of zircon frameworks.

A systematic review of the survival and complication rates of zirconia-ceramic and metal-ceramic multiple-unit fixed dental prostheses.

OBJECTIVES: The aim of the present review was to compare the outcomes, that is, survival and complication rates of zirconia-ceramic and/or monolithic zirconia implant-supported fixed dental prostheses (FDPs) with metal-ceramic FDPs. MATERIALS AND METHODS: An electronic MEDLINE search complemented by manual searching was conducted to identify randomized controlled clinical trials, prospective cohort studies and retrospective case series on implant-supported FDPs with a mean follow-up of at least 3 years. Patients had to have been examined clinically at the follow-up visit. Assessment of the identified studies and data extraction was performed independently by two reviewers. Failure and complication rates were analyzed using robust Poisson regression models to obtain summary estimates of 5-year proportions. RESULTS: The search provided 5,263 titles and 455 abstracts. Full-text analysis was performed for 240 articles resulting in 19 studies on implant FDPs that met the inclusion criteria. The studies reported on 932 metal-ceramic and 175 zirconia-ceramic FDPs. Meta-analysis revealed an estimated 5-year survival rate of 98.7% (95% CI: 96.8%-99.5%) for metal-ceramic implant-supported FDPs, and of 93.0% (95% CI: 90.6%-94.8%) for zirconia-ceramic implant-supported FDPs (p < 0.001). Thirteen studies including 781 metal-ceramic implant-supported FDPs estimated a 5-year rate of ceramic fractures and chippings to be 11.6% compared with a significantly higher (p < 0.001) complication rate for zirconia implant-supported FDPs of 50%, reported in a small study with 13 zirconia implant-supported FDPs. Significantly (p = 0.001) more, that is, 4.1%, of the zirconia-ceramic implant-supported FDPs were lost due to ceramic fractures compared to only 0.2% of the metal-ceramic implant-supported FDPs. Detailed analysis of factors like number of units of the FDPs or location in the jaws was not possible due to heterogeneity of reporting. No studies on monolithic zirconia implant-supported FDPs fulfilled the inclusion criteria of the present review. Furthermore, no conclusive results were found for the aesthetic outcomes of both FDP-types. CONCLUSION: For implant-supported FDPs, conventionally veneered zirconia should not be considered as material selection of first priority, as pronounced risk for framework fractures and chipping of the zirconia veneering ceramic was observed. Monolithic zirconia may be an interesting alternative, but its clinical medium- to long-term outcomes have not been evaluated yet. Hence, metal ceramics seems to stay the golden standard for implant-supported multiple-unit FDPs.

A systematic review of the survival and complication rates of zirconia-ceramic and metal-ceramic single crowns.

OBJECTIVES: The aim of the present systematic review was to analyze the survival and complication rates of zirconia-based and metal-ceramic implant-supported single crowns (SCs). MATERIALS AND METHODS: An electronic MEDLINE search complemented by manual searching was conducted to identify randomized controlled clinical trials, prospective cohort and retrospective case series on implant-supported SCs with a mean follow-up time of at least 3 years. Patients had to have been clinically examined at the follow-up visit. Assessment of the identified studies and data extraction was performed independently by two reviewers. Failure and complication rates were analyzed using robust Poisson's regression models to obtain summary estimates of 5-year proportions. RESULTS: The search provided 5,263 titles and 455 abstracts, full-text analysis was performed for 240 articles, resulting in 35 included studies on implant-supported crowns. Meta-analysis revealed an estimated 5-year survival rate of 98.3% (95% CI: 96.8-99.1) for metal-ceramic implant supported SCs (n = 4,363) compared to 97.6% (95% CI: 94.3-99.0) for zirconia implant supported SCs (n = 912). About 86.7% (95% CI: 80.7-91.0) of the metal-ceramic SCs (n = 1,300) experienced no biological/technical complications over the entire observation period. The corresponding rate for zirconia SCs (n = 76) was 83.8% (95% CI: 61.6-93.8). The biologic outcomes of the two types of crowns were similar; yet, zirconia SCs exhibited less aesthetic complications than metal-ceramics. The 5-year incidence of chipping of the veneering ceramic was similar between the material groups (2.9% metal-ceramic, 2.8% zirconia-ceramic). Significantly (p = 0.001), more zirconia-ceramic implant SCs failed due to material fractures (2.1% vs. 0.2% metal-ceramic implant SCs). No studies on newer types of monolithic zirconia SCs fulfilled the simple inclusion criteria of 3 years follow-up time and clinical examination of the present systematic review. CONCLUSION: Zirconia-ceramic implant-supported SCs are a valid treatment alternative to metal-ceramic SCs, with similar incidence of biological complications and less aesthetic problems. The amount of ceramic chipping was similar between the material groups; yet, significantly more zirconia crowns failed due to material fractures.

An in vitro evaluation of fracture load of implant-supported zirconia-based prostheses fabricated with different veneer materials.

OBJECTIVES: The purpose of this in vitro study was to evaluate fracture loads of implant-supported zirconia-based prostheses fabricated with different veneer materials (resin-based material and lithium disilicate ceramics). MATERIAL AND METHODS: Forty-four zirconia-based molar prostheses were fabricated on dental implants and divided into four groups (n = 11): zirconia-based prostheses veneered with feldspathic porcelain (ZVF), zirconia-based prostheses bonded with the lithium disilicate glass-ceramic veneer (ZBD), zirconia-based prostheses veneered with indirect composite resin (ZVC), and zirconia-based prostheses bonded with composite materials fabricated from a CAD/CAM resin block (ZBC). The zirconia-based prostheses and abutments were adhesively bonded with a dual-polymerized resin-based luting material. Fracture load was determined using compression load to the prostheses with a universal testing machine. The data were analyzed with one-way analysis of variance (ANOVA) and Tukey's HSD test (α = .05). RESULTS: The mean fracture load was significantly higher in the ZBC group (3.95 kN) than in the ZVC group (3.28 kN). No significant difference in fracture load was found among the ZVF (3.52 kN), ZBD (3.48 kN), and ZVC groups. CONCLUSIONS: The adhesively bonded veneering technique enhances fracture resistance of implant-supported zirconia-based prostheses fabricated with a resin-based material. All implant-supported zirconia-based restorations tested should resist physiologic masticatory forces in the oral environment.

A Contemporary Framework and Suprastructure Ceramic Design for Posterior Implant Fixed Partial Denture.

Bone and soft tissue deformities in long-standing partial edentulism are commonly treated with implant therapy. The various ceramic restorative systems available and digital technology allow for customization of design and material selection. A substructure design that mimics tooth preparation in a custom zirconia framework with a lithium disilicate suprastructure is presented as an effort to address the functional and esthetic challenges posed by long-standing posterior partial edentulism. The aim is to present several contemporary elements of design to address the functional, esthetic, and maintenance needs.

Effect of round curvature of anterior implant-supported zirconia frameworks: finite element analysis and in vitro study using digital image correlation.

Two groups of 4-unit zirconia frameworks were produced by CAD/CAM to simulate the restoration of an anterior edentulous gap supported by 2 implant-abutment assemblies. Group 1 comprised straight configuration frameworks and group 2 consisted of arched frameworks. Specimens were made with the same connector cross-section area and were cemented and submitted to static loads. Displacements were captured with two high-speed photographic cameras and analysed with video correlation system. Frameworks and the implant-abutment assembly were scanned and converted to 3DCAD objects by reverse engineering process. A specimen of each group was veneered and the corresponding 3D geometry was similarly obtained after scanning. Numerical models were created from the CAD objects and the FE analysis was performed on the zirconia frameworks and on the FPDs bi-layered with porcelain (veneered frameworks). Displacements were higher for the curved frameworks group, under any load. The predicted displacements correlated well with the experimental values of the two framework groups, but on the straight framework the experimental vertical displacements were superior to those predicted by the FEA. The results showed that the round curvature of zirconia anterior implant-supported FPDs plays a significant role on the deformation/stress of FPDs that cannot be neglected neither in testing nor in simulation and should be considered in the clinical setting.

Fracture resistance of implant-supported screw-retained zirconia-based molar restorations.

OBJECTIVES: The objective of this in vitro study was to investigate fracture loads of screw-retained zirconia-based molar restorations (hybrid abutment crown) fabricated with different restorative materials and designs. MATERIAL AND METHODS: Forty-four screw-retained zirconia-based molar restorations were fabricated on dental implants and divided into four groups (n = 11): porcelain-layered zirconia-based restorations (PLZ), indirect composite-layered zirconia-based restorations (ILZ), metal-ceramic restorations (MC), and monolithic zirconia restorations (MONO). The zirconia-based restorations in the PLZ, ILZ, and MONO groups were adhesively bonded on implant abutments with a dual-polymerized resin material. All restorations were tightened on implant bodies with titanium screws and were tested for fracture resistance. The Kruskal-Wallis test and Steel-Dwass test were used to evaluate differences in fracture loads (α = 0.05). RESULTS: As compared with the other groups, the MONO specimens had a significantly higher mean fracture resistance (7.54 kN); no significant differences were found among the PLZ (1.96 kN), ILZ (1.80 kN), and MC (1.45 kN) groups (P > 0.05). For the PLZ, ILZ, and MC groups, all specimens fractured within the layering materials. In contrast, the fracture mode for the MONO group was complete fracture of the restorations. CONCLUSIONS: All restorations withstood the masticatory forces. Fracture loads were significantly higher for screw-retained implant-supported monolithic zirconia restorations than for screw-retained bilayered restorations. For the screw-retained bilayered zirconia-based restorations, the fracture resistance of ILZ restorations was comparable to that of PLZ restorations and MC restorations.

Microtensile bond strength of lithium disilicate to zirconia with the CAD-on technique.

PURPOSE: Recently, a novel technique was introduced to combine lithium disilicate and zirconia into one restoration. The purpose of this study was to compare the microtensile bond strength of veneering ceramic to a zirconia core in two techniques: the e.max® CAD-on technique and the Press-on technique. MATERIALS AND METHODS: Group A was prepared by veneering sintered zirconia blocks (e.max® ZirCAD) with lithium disilicate blocks (e.max® CAD) using the CAD-on technique according to manufacturer's instructions. Group B was prepared by taking sintered e.max® ZirCAD blocks and veneering them with fluorapatite glass-ceramic (e.max® ZirPress) using the Press-on technique according to manufacturer's instructions. Each block was loaded in a dynamic cyclic loading machine. The blocks were then sectioned into 1 × 1 mm(2) beams (n = 43) using a precision saw, thermocycled, and loaded in tension until failure on a universal testing machine. A mean and standard deviation were determined per group. Data were analyzed using an unpaired t-test (α = 0.05). RESULTS: The mean microtensile bond strengths were 44.0 ± 13.8 MPa for the CAD-on technique and 14.9 ± 8.8 MPa for the Press-on technique. Significant differences were found between the two groups (p = 2.7E-19). CONCLUSIONS: The CAD-on technique (lithium disilicate/zirconia) resulted in greater microtensile bond strength than the Press-on technique (fluorapatite glass-ceramic/zirconia).

Implant-supported fixed dental prostheses with CAD/CAM-fabricated porcelain crown and zirconia-based framework.

Recently, fixed dental prostheses (FDPs) with a hybrid structure of CAD/CAM porcelain crowns adhered to a CAD/CAM zirconia framework (PAZ) have been developed. The aim of this report was to describe the clinical application of a newly developed implant-supported FDP fabrication system, which uses PAZ, and to evaluate the outcome after a maximum application period of 36 months. Implants were placed in three patients with edentulous areas in either the maxilla or mandible. After the implant fixtures had successfully integrated with bone, gold-platinum alloy or zirconia custom abutments were first fabricated. Zirconia framework wax-up was performed on the custom abutments, and the CAD/CAM zirconia framework was prepared using the CAD/CAM system. Next, wax-up was performed on working models for porcelain crown fabrication, and CAD/CAM porcelain crowns were fabricated. The CAD/CAM zirconia frameworks and CAD/CAM porcelain crowns were bonded using adhesive resin cement, and the PAZ was cemented. Cementation of the implant superstructure improved the esthetics and masticatory efficiency in all patients. No undesirable outcomes, such as superstructure chipping, stomatognathic dysfunction, or periimplant bone resorption, were observed in any of the patients. PAZ may be a potential solution for ceramic-related clinical problems such as chipping and fracture and associated complicated repair procedures in implant-supported FDPs.

Stress distribution on a three-unit implant-supported zirconia framework. A 3D finite element analysis and fatigue test.

PURPOSE: The purpose of this study was to investigate, by finite element analysis (FEA) and fatigue analysis, the influence of different loading conditions on the stress distribution in a 3-unit implant-supported Y-TZP fixed partial denture (FPD). MATERIAL AND METHODS: A three-dimensional FEM model was developed. The materials used in this study were assumed to be linearly elastic, homogeneous and isotropic. 100 N and 300 N loads over a 0,5 mm(2) areas with different angles (0°, 15° and 35°) and locations were applied on the prosthesis and the distribution of equivalent von Mises stress was investigated. A fatigue analysis was carried out too. RESULTS: Maximum stresses were found at the connector region of the framework when the intermediate element is loaded (100 N load pattern: 32,9 MPa, 33 MPa and 51,8 MPa; 300 N load pattern: 98,6 MPa, 102,8 MPa and 155,7 MPa, respectively with 0°, 15° and 35° of inclination). Results confirmed the vulnerability of both connector areas even if just one pillar was loaded with an increase in stress when angle of load inclination is larger. The cyclic fatigue evaluation indicates a strong propensity for fatigue behavior, presenting a considerable range of loading conditions. No fracture fatigue occurred with a 100 N force. A 300 N force applied to the pontic produces no fatigue problems because the load is equally shared by whole system. A 300 N force applied to one of the two pillars, or to both implants generates fatigue problems. CONCLUSION: F.E.M. analysis of a 3-unit implant-supported Y-TZPFPD, give accurate information about loading conditions for clinical success over time. Fatigue analysis results show structural reliability of the Y-TZP as framework material for 3-unit posterior FPDs.