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5/19/2014

Adhesive Placement of a Zirconia FPD to Replace a Maxillary Central Incisor - - dentalAEGIS.com

AdhesivePlacementofaZirconiaFixedPartialDentureto
ReplaceaMaxillaryCentralIncisor:AClinicalReport
MariettaKalogirou,DDSRichardTrushkowsky,DDSJorjeAndrade,DDSand
StevenDavid,DMD

Abstract
Thereplacementofasinglemaxillaryincisorisanestheticchallenge.Manyoptionsprovidevarious
degreesoflongevityandeaseoffabrication.Theintroductionofzirconiasupportedfixedpartialdentures
(FPDs)hasseenincreaseduseinthelastseveralyears.However,abutmentpreparationguidelinesand
laboratoryfabricationhavetoadheretotheguidelinesestablishedbythemanufacturersandclinical
researchers.ZirconiaFPDscanprovidelongtermstrengthandestheticsiftheyaredesignedandfabricated
appropriately.
Theadvancementofadhesivetechniquesandmaterialshascreatednewrestorativepossibilities.Current
optionsforreplacementaretheconventionalthreeunitfixedpartialdenture(FPD),asingletoothimplant,
oraresinbondedFPD.ThethreeunitFPDcanbeatraditionalceramometaloranallceramicusingahigh
strengthcorematerial,suchaslithiumdisilicateorzirconia.TheuseoftraditionalFPDshasahighsuccess
ratebutrequiresasubstantialamountoftoothreductiontoachievethebestesthetics.Longterm
preservationofthepulpisalwaysuncertain.Lighttransmissionmayalsobereduceddespitetheuseofa
porcelainbuttjoint.AllceramicFPDsrequireasubstantialamountoftoothstructureremoval.Ifthe
adjacentabutmentshavenorestorations,animplantorresinbondedFPDmaybeabetteralternative.
Incasesinwhichspaceislimitedorhardandsofttissuesareinadequate,implantplacementisnotalways
feasible.Additionalsurgicalproceduresmayberequiredtoimprovebiomechanicalandestheticneeds.
However,thepatientmaynotwanttheadditionaltimeandexpenseforthesesurgicalprocedures.Another
viablealternativeistheresinbondedFPDmetal,ceramic,orfiberreinforcedcompositeforcariesfree
FPDs,designedassingleabutments.1 IthasbeendemonstratedthatFPDscreatedassingleretainer
restorationshavebettersurvivalratesthantraditionaltworetainerresinbondedFPDs.Thesingleretainer
resinbondedFPDmayallowlesstensilestressattheconnectorandadhesiveinterface.24 Recentadvances
inadhesivetechnologyandceramicmaterialsallowallceramic,singleretainerresinbondedFPDstobe
usedinadditiontometalretainers.Ceramicspossessdesirablecharacteristics:chemicalstability,
biocompatibility,highcompressivestrength,andacoefficientofthermalexpansionsimilartotooth
structure.5 Clinicianscanchoosefromawiderangeofceramicproducts,andzirconiahasbeenusedin
dentistryforabroadarrayofindications.
Zirconiahasfavorableesthetic,mechanical,andbiomechanicalproperties.Denselysinteredzirconia
possessesthehighestflexuralstrengthofapproximately1,000MPa.Zirconiacanbeusedforconventional
FPDsorresinbondedFPDsduetoitssuperiormechanicalpropertiesandhighfracturetoughness.
Hydrofluoricacidisusedasapredictablebasisforrougheningthesurfaceoffeldspathicceramicfor
bondingcompositeresin.Highaluminacontentorzirconiacontentcannotbetreatedinthismannerbecause
theydonotcontainthesilicondioxide(silica)phase.6 Airabrasionwithsilicacontainingparticles(silica
coating),followedbysilanation,hasbeenusedonzirconiaceramicswithvariousresults.Silicacoatinghas
produceddurableresinbondingforsomezirconiaceramics.7 Severalbondingagentshavepreviouslybeen
investigated,andonlythosecontaininganorganophosphateestermonomerhavebeenproventobe
effective.Accordingtorecentstudies,thecombinationofairborneparticleabrasionanda10
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methacryloyloxydecyldihydrogenphosphate(MDP)monomeristherecommendedmethodforbonding
resincompositestozirconia.8

CaseReport
A29yearoldwomanwasseenattheAdvancedPrograminAestheticDentistryatNewYorkUniversity
CollegeofDentistrywantingtoreplacehermissingleftcentralincisorandimprovethecoloroftheright
centralincisor(Figure1andFigure2).Acomprehensiveexaminationwasconducted,includingafull
mouthradiographicseries,cariesdetection,periodontalprobing,andtemporomandibularexamination.Her
medicalhistorywasnoncontributory,andshehadnocontraindicationtodentaltreatment.Intraoraland
extraoralphotographsweretakeninordertoaidintheestheticevaluation.Studymodelswereobtained
withReprosil(DENTSPLYInternational,www.denstply.com).Abiteregistrationwastakenincentric
occlusion.Facialanalysisrevealedtheinterpupillarylinewasparalleltotheocclusalplane,themidline
relationship(centralincisortophiltrum)wassymmetric,andupperandlowerlipswerefullandprominent.
Atrest,thepatientdisplayed4mmto5mmofthemaxillarycentralincisorsandthemandibularincisors
werenotvisible.Shehadanormalnasolabialangleof90andtheRickettsEplaneof4mm.Shehada
highsmileline,anincisaledgetolowerlipparallelbutnottouching,exposureof12teethwhensmiling,a
straightmidline,andanincreasedbilateralnegativespace(Figure3).
Theoptionofaporcelainveneerontheupperrightcentralincisorandimplantandacrowntoreplacethe
upperleftcentralincisorwaspresentedfirst.OtheralternativespresentedwereatraditionalthreeunitFPD
oraresinbasedFPD.AnintraoralmockupusingaputtystentobtainedfromthewaxupandLuxatemp
(DMGAmerica,www.dmgdental.com)wasusedtodemonstratetothepatientthepotentialesthetic
benefitsoftherecommendedtreatment.Thepatientelectedtohavethetoothreplacedwithanallceramic
FPDcombiningfullcoverageonthemaxillaryrightcentralincisor(tomaskthedarkness)andabonded
wingontheleftlateralincisor(toconservethetoothstructure).Theshadeoftheunpreparedtoothwas
noted(Figure4).
Inthefollowingvisit,thesiteswereanesthetizedwith2%lidocainewith1:100000andthemaxillaryright
centralincisorwaspreparedforfullcoverage.Theleftlateralincisorwaspreparedtoprovide0.5mm
clearancewithagrooveatthepositionoftheconnectortoallowadequatebulkinthisarea.Afullmouth
impressionwasobtainedwithImpregumPentaSoftpolyetherimpressionmaterial(3MESPE,
www.3mespe.com)andBluBite(HenrySchein,www.henryschein.com)biteregistrationwasusedto
recordtherelationshipbetweenthemaxillaandmandibleincentricocclusion.Theshadeoftheprepared
centralincisorwasobtained(Figure5).Thelaboratoryfabricateddiemodels(Figure6)werescanned,and
thezirconiaframeworkwasdesignedandmilled(Figure7,Figure8,Figure9andFigure10)tosupportthe
overlyingporcelain(Figure11andFigure12).Thedimensionsoftheconnectorsarecriticaltothe
restorationslongevity(Figure13).Feldspathicporcelaincompatiblewiththeframeworkwasplaced
(Figure14).
Inthefollowingvisit,therestorationwastriedinandthemarginswereverified.TheFPDwasthenbonded
withPanaviaF2.0(KurarayAmerica,www.kuraraydental.com).Theprovisionalbridgewasremoved
andtheadherentsurfaceswerecleanedanddecontaminatedwithKEtchantGel(Kuraray)topreparefor
cementation.ClearfilCeramicprimer(Kuraray)wasplacedontheintagliosurfaceoftheFPD.EDPrimer
AandBwasmixedonedropeachinawellandappliedtotheabutmentteeth.Bothenamelanddentin
werecoatedusingadisposablebrushtip,andleftinplacefor60seconds.Theprimerwasthendriedwitha
gentleairflow.Poolinghastobeavoidedasthiswouldpreventseatingoftherestoration.PanaviaFpaste
wasthenmixedandappliedtotherestoration.Therestorationwasplacedinposition,andexcesscement
wasremovedfromthemargins.(WhentheadhesivecementcontactstheEDPrimer,thepolymerizationof
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theadhesivecementaccelerates.)Themarginswerelightcuredfor20secondsinseveralareas,and
OxyguardII(Kuraray)wasplacedwithadisposabletiptoensurecuring.After3minutes,OxyguardIIwas
removedwithacottonrollandwaterspray.Scalerswereusedtoremoveanyremainingexcesscement.
Occlusionwasconfirmedincentric,protrusive,andlateralexcursions.Thepatientwaspleasedwiththe
estheticresult(Figure15,Figure16andFigure17).

Discussion
AmissingcentralincisorisusuallyreplacedbyaconventionalthreeunitFPD,simpleimplant,resinbased
FPD,orremovablepartialdenture.9 Theselectionofthebestoptionrequirestheconsiderationofboth
functionandesthetics.Thegoalsshouldincludethelongevityoftherestoration,minimalinvasion,andcost
effectiveness.Theseconsiderationsmaybemodifiedbyinterdentalspacing,ridgecontour,orientationof
therootsorcrownsofadjacentteeth,anteriorguidance,potentialshadematchingproblems,parafunctional
habits,andthepatientsestheticconcerns.
Themostconservativetechniqueofrestoringthemissingcentralincisorforthispatientwouldhavebeen
implantplacementwithbleachingandaporcelainveneertomaskthedarkerrightcentralincisor.However,
thepatientrefusedimplantplacement,whichwouldhaverequiredridgeaugmentationonthelabialto
achieveacontoursimilartotheadjacentcentralincisor.ThiswouldhavebeenbeneficialforanyFPD
replacement.However,thepatientdidnotwantsurgeryandoptedfortoothreplacementasexpeditiouslyas
possible.ThelaboratorytechnicianthoughtmaskingthedarknessoftoothNo.8withonlyaporcelain
veneerwouldbedifficultandaceramicrestorationwithanopaquecorewouldprovidebetterresults.When
itwasdecidedtousefullcoveragewithahighstrengthceramic(zirconia)onthemaxillaryrightcentral
incisorwiththeleftcentralincisorasapontic,thedecisionhadtobemadewhethertousefullcoverageon
themaxillaryleftlateralincisor,cantilevertheupperleftcentralincisorofftheupperrightcentralincisor,or
placeabondedwingontheupperleftlateralincisor.
OneofthemaincausesoffailureofceramicresinbasedFPDsiswheretheponticconnectstothe
abutment.Thisfailuremaybeduetothedifferentialmovementoftheabutmentteethduringprotrusiveand
lateralexcursionswiththeteethincontact.Thestrengthofthisconnectordependsonitsdimensionsand
alsothephysicalpropertiesoftheframework.Therecommendationsforconnectordimensionsforyttria
stabilizedtetragonalzirconiapolycrystals(YTZP)FPDsvaryfrom2mmto4mminocclusalgingival
heightand2mmto4mminbuccolingualwidth.Toreducethefractureprobabilitywhendesigningall
ceramicFPDs,theshapeoftheconnectorisanimportantfactorthatalsohastobeconsidered.Theradius
ofcurvatureatthegingivalembrasurehasamajorroleintheloadbearingcapacity.YTZPFPDswith
smallgingivalembrasureradiiaresubjectedtohighstressconcentrationsintheconnectorareaduring
loading,comparedwithFPDswithlargeembrasureradii.10 Anotherpotentialproblemisthedebondingof
thewingtoeitherthelutingcementorthelutingcementtotoothstructure.Also,theveneeringporcelainto
thezirconiumframeworkmaychip.11,12
Severaloptionsforhighstrengthcorematerialscanbeusedintheanteriorregion.Thecorematerialcanbe
eitherglassinfiltratedaluminaceramic(VitaInCeramAlumina,Vident,www.vident.com),purealumina
ceramic(Procera,NobelBiocare,www.nobelbiocare.com),lithiumdisilicate(IPSe.maxPress,Ivoclar
Vivadent,www.ivoclarvicadent.com),orYTZP(Lava,3MESPE).Thebondstrengthofluting
cementstovariousceramicsurfacesiscriticalforresinbasedFPDstofunction.Varioustechniqueshave
beenintroducedtoprovideamechanicalattachmentbetweenresinandceramic.13 Hydrofluoricacidand
subsequentplacementofasilanecouplingagentwillincreasethebondingstrengthtofeldspathicceramic.
However,thistechniqueisnotapplicabletothehighaluminaorzirconiaceramicmaterialsbecausethese
donotcontainsilicondioxide.
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Formostrestorations,highstrengthceramicsdonotrequireadhesivebondingtotoothstructureand
conventionalcementationcanbeused.14 Adhesioncanreducemicroleakage,increaseretention,and
increasefractureandfatigueresistance.15 Usually,silanesareusedtocoattheinorganicfillerparticlesto
allowtheadhesivebondingofresinlutingmaterialstoporcelain.Asilanecouplingagenthastwotypesof
reactivityinthesamemolecule.Asilanecouplingagentwillactasalinkbetweenaninorganicsubstrate
andanorganicmaterialtobondorcouplethetwodissimilarmaterials.Themetalhydroxylgroupsonthe
surfaceofmineralsareusuallyhydrophobicandincompatiblewithorganicpolymers.Silanesareaddedto
treatthesurfaceofthemineraltomakethemineralmorecompatiblewiththepolymerandallowtheparticle
tobedispersedinthepolymer(eg,composites).Highstrengthceramics(aluminaandzirconia)aremore
chemicallystablethansilicaglassesandceramicsthatcontainsilica.Thisstabilityandglassfreeaspect
doesnotallowthezirconiatobetreatedwithhydrofluoricacidetchingandsilanizationtocreateastable
bond.16
Theincreaseduseofzirconiahasresultedingreaterinterestinadhesionbetweenthezirconiarestoration
andtoothstructure.Someclinicianshavesuggestedtheuseofsurfaceabrasionwithaluminaandthe
subsequentplacementofatribochemicalsilicacoating(Rocatec,3MESPE)toallowthecreationof
chemicalbondsbetweensilaneandaresincement.13 Thebondedsilicaparticlereactswiththe
organosilanemonomerhowever,thebondisstillweakerthanthebondtoconventionalporcelain.17 Itis
thoughtthatairparticleabrasionmaycausemicrofracturesthatwouldultimatelyresultinfailureofthe
restoration.18
Anothertechniqueistheapplicationofmolecularvapordepositionofgasphasechlorosilane(SiCl4)
pretreatmenttoplaceanultrathinsilicaseedlayer.Thisisachievedbycombiningchlorosilanewithwater
vaportoformamorereactivesurface.This2nmto3nmlayerallowsthecreationofbondstrength
statisticallyequivalenttotraditionalbondedporcelainmaterials.19
Amodifiedroughsurfacezirconia,tentativelynamedtheMarylandSurface(NobelBiocare),hasbecome
available.ItiscompletelydifferentfromthecompanysZiUnitesurface."Themodifiedsurfaceis
producedbycoatingapresinteredorafullysinteredandmilledzirconiaframeworkwithslurrycontaining
zirconiaceramicpowderandaporeformer.Then,theslurrycoatedceramicissinteredwhilethepore
formerburnsoff,leavingaporoussurface.Theporositiesofthesurfacecanbemodifiedbyusingdifferent
sizesofporeformersorrepeatingthecoatingprocess."20Thecoatingisabout20mto40m.However,
itseffectonstrengthremainsunknown.21,22
Aboushelibetal22foundthatstructuralchangescanoccuronthegrainleveltoYTZP.Graingrowthand
cubicgrainformationcanoccurwhenzirconiaisheatedto1,450Cfor2hours.Heatingatlower
temperatures(700Cto900C)causesthermalagingofthesurfaceofthezirconia.Thethermalaging
Resultsintheformationofsurfaceelevations,grainpullout,anddetachmentwithincreasedgrainboundary
thickness.Thermaletchingofzirconiaat1,350Cfor12minutesresultedinsurfaceelevations,rippled
grainsurfaces,andverticalgroovesatgrainmargins.Thesechangescorrespondtothetetragonal
monoclinictransformationofthezirconiacrystals.Heatinducedmaturationcreatesstressesinthegrain
boundaryregionusingtwoshortthermalcyclesthatdonotcreateenoughenergyforgraingrowthorcubic
grainformation.Initially,thezirconiaisheatedto750Cfor2minutes,cooledto650Cfor1minute,and
reheatedto750Cfor1minute,causingthegrainboundariestobecomeprestressed.Thisallowsother
materialstoinfiltratetheseareas.
DevelopedbyAboushelibetal16andothers,asurfacetreatmentcalledselectiveinfiltrationetchingmakes
useoftheheatinducedmaturationconceptandgrainboundarydiffusiontoformahighlyretentivesurface
onYTZP.Initially,heatinducedmaturationcreatesprestressesintheboundaryregion,andthenthese
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areasarewidenedbytheapplicationofathinlayerofaninfiltrationglassonatreatedzirconiasurface.This
Resultsina3dimensionalnetworkofintergrainporosityonlyatthesitewherethesurfacegrainscontact
theinfiltrationglass.Theinfiltrationagenthasathermalexpansioncoefficientthatissimilartothatof
zirconia.Thisisimportantasnodetrimentalprestressorsoccurduringroomtemperaturecooling.This
infiltrationglasscanthenbedissolvedwithhydrofluoricacidtocreateareasofnanomechanicalretention
toalutingresin.Thiswouldbepreferredtocreatingchemicalbonds(MDPmonomer)orcreatingsurface
roughnesswithairborneparticleabrasivesbecausethiswastheonlywaythatbondstrengthvalueswere
maintainedwhenstoredinwater.23 Otherzirconiamaterialswithdifferentstabilizingagentsmayneed
differentheatinducedmaturationprotocolsandinfiltrationagents.Inaddition,becauseselectiveinfiltration
etchingisonlyasurfacetreatment,themechanicalpropertiesofYTZParenotdetrimentallyaffected.This
isbecauseonananoscale,zirconiacrystalscantransformfromtetragonaltomonoclinicphaseswhen
suitablystimulated.However,onamicrolevel,thegrainsofzirconiacanrearrangebymoving,splitting,
andslidinginthepresenceofthedopantphasesandtheappropriateamountoftemperatureincrease.24
Lasertreatmenthasalsobeenshowntocreatetocreateacidetchtypeeffects.
Severalphosphate/phosphonatemonomerbasedprimerscanalsobeusedwithzirconiathathavenotbeen
treatedorsandblasted.TheseincludeMonobondPlus(IvoclarVivadent),ClearfilCeramicprimer
(Kuraray),AZPrimer(ShofuDental,www.shofu.com),andZPrimePlus(Bisco,www.bisco.com).
Mostofthesematerialshaveaphosphatemonomerwithsolventsonly(eg,ethanol,acetone).Thenew
Biscoproductcontainsphosphoric,carboxylicacid,andothermonomersthatcanbeusedwithdifferent
surfacetreatments(ie,sandblastedorpolished)andiscompatiblewithselfcuredorlightcuredcements.

Conclusion
TheuseofzirconiaforFPDshasincreasedthepotentialforprovidinglonglastingestheticrestorations.
Saileretalconcludedthatzirconiawillprovidesufficientstabilityasaframeworkforthreeandfourunit
posteriorFPDsbuttheveneeringceramicneedsimprovement.Thisstudywasforonly5yearsandideally
durabilitycomparedwithporcelainfusedtometalshould,intheauthorsopinion,bethestandard.8 The
useofceramicresinbasedFPDshasresultedinrestorationsthatprovideestheticsandconservationoftooth
structure.Replacingasinglemissingtoothwithanimplantisusuallyoneofthebesttreatmentoptions.
Sometimesanimplantplacementisnotfeasiblebecauseofmedicalreasons,habits,inadequatebonenot
amenabletografting,andpatientdesires.Theuseofadhesivelyplacedceramicrestorationsprovidesa
viablealternativethatneedstobeconsideredintherestorativepractice.Theadhesiontozirconianeeds
furtherresearchandclinicalstudiestoascertainlongtermbenefitsofthevarioustechniquescurrently
promoted.

Acknowledgment
ThelaboratoryphotographsandlaboratoryworkwereprovidedbyAdrianJurim,MDT,JurimDental
Studio,GreatNeck,NewYork.

AbouttheAuthors
MariettaKalogirou,DDS
Resident,InternationalPrograminAdvancedEstheticDentistry,
NewYorkUniversityCollegeofDentistry,NewYork,NewYork
RichardTrushkowsky,DDS
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