journal of dentistry 36 (2008) 692696

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All-ceramic inlay-retained fixed partial dentures: Preliminary

results from a clinical study
Brigitte Ohlmann *, Peter Rammelsberg, Marc Schmitter, Stefanie Schwarz, Olaf Gabbert
Department of Prosthodontics, University of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany

article info

abstract

Article history:

Objectives: The objective of this study was to evaluate the clinical performance of zirconia-

Received 29 October 2007

based all-ceramic fixed partial dentures anchored by inlays.

Received in revised form

Methods: A total of thirty FPDs, manufactured using a zirconia frame and veneered with

28 April 2008

press ceramic, were anchored by use of inlay retainers. All FPDs were designed to replace

Accepted 30 April 2008

one missing molar and were adhesively luted by use of one of two different resin cements.
Documentation included failures and other complications, plaque accumulation, and
aesthetic and functional performance. Statistical analysis was performed using a cox-

Keywords:

regression model.

Ceramic

Results: During the 12 months observation period a total of thirteen clinically relevant

Bridge

complications occurredfour delaminations of the veneer and six decementations. Three

Inlay

FPDs had to be replaced because of a fracture of the framework. The cement chosen, the

In vivo

location, and the design of the retainer had no statistically significant effect on the
occurrence of complications.
During the observation period, accumulation of plaque on the abutment teeth was not
significantly greater than on reference teeth. Postoperative sensitivity did not differ significantly between the different luting cement groups. The aesthetic and functional performance of the FPDs was acceptable.
Conclusions: Improved adhesion between resin cement and inlay retainer is desirable before
general recommendation of all-ceramic inlay-retained FPDs.
Use of different luting cements seems to have no effect on the occurrence of complications.
# 2008 Elsevier Ltd. All rights reserved.

1.

Introduction

In recent decades the desire for inlay-retained fixed partial

dentures (FPDs), to minimize loss of dental hard tissue, has
increased. Although clinical results for metal inlay-retained
FPDs have been favourable,1 the visibility of the metal retainer
and the change in natural tooth translucency are aesthetically
unfavourable and have encouraged research on metal-free,
tooth-coloured materials for inlay-retained FPDs. Although
promising clinical results2 have been reported for fibre-

reinforced composites, these suffer from the disadvantages

of unstable aesthetics and problems with wear of the
veneering composite.3,4
All-ceramic materials may be another metal-free alternative. Although use of all-ceramic materials in dentistry has
become increasingly important, early generation all-ceramic
inlay-retained FPDs often failed to withstand posterior
mastication forces and their use was limited by the special
mechanical properties of the material.5 With the introduction
of dense sintered yttria-tetragonal zirconia polycrystal (Y-TZP)

* Corresponding author. Tel.: +49 6221 568799; fax: +49 6221 561775.
E-mail address: Brigitte_Ohlmann@med.uni-heidelberg.de (B. Ohlmann).
0300-5712/$ see front matter # 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jdent.2008.04.017

journal of dentistry 36 (2008) 692696

and the ability of Y-TZP to prevent crack propagation,6 the

production of stable inlay-anchored FPDs has become possible. Although in vitro results7 supporting this assumption are
available, clinical data on the performance of zirconia-based
inlay-retained FPDs are very limited.8,9
Loosening of one or both retainer adhesions seems to be
the crucial factor in the premature clinical failure of inlayretained FPDs made of heat-pressed lithium disilicate glass
ceramic.9 Starting from this point, and taking into consideration the bond strength of different luting cements to zirconia
oxide ceramics,10 the question arises whether the luting
cement may effect premature debonding and, as a result,
fracture and failure of the retainer.
The objectives of this prospective clinical study were,
therefore, assessment of the clinical performance of inlayretained zirconia-based fixed partial dentures and to test the
hypothesis that the luting material affected the failure rate of
inlay-retained FPDs.

2.

Materials and methods

Participants in this study were recruited from patients visiting

the Department of Prosthodontics. All patients in the study
group gave informed consent and the universitys review
board approved the study.
All patients had good oral hygiene and no signs of
periodontal or periapical pathology. Maximum tooth mobility
of grade 1 was accepted. Criteria for excluding patients from
the study were being under the age of 18 or being incapable of
taking out a contract, pregnancy or lactation, unacceptable
oral hygiene status, bruxism, or known allergic reaction to the
materials used.
The study group consisted of 27 patients (16 females and 11
males) between 24 and 67 yrs of age (mean 42.9, S.D. 11.7 yrs).

693

All restorations were constructed as three-unit end-to-end

FPDs. At least one of the abutment teeth was provided with an
inlay retainer, and the combination of one crown or partial
crown and one inlay retainer was allowed [Fig. 1ad]. The
edentulous space between the abutments had to be the width
of a molar, but not more than 16 mm. Depending on the extent
of caries removal, an inlay, a partial crown, or a complete
crown was prepared for the abutment teeth.
Clinical treatment (by three dentists) and laboratory
procedures were standardized. After removal of old restorative
materials and excavation of caries the teeth were built up with
Rebilda SC1 (Voco GmbH, Cuxhaven, Germany), in accordance
with the manufacturers instructions. The minimum occlusal
reduction for an inlay retainer was 2.0 mm and the convergence
angle was added up to 68. The minimum occlusal reduction for a
crown retainer was 1.5 mm, axial reduction (chamfer design)
was set at 1.0 mm, and the convergence preparation angle was
added up to 68. Impressions were made using polyether
material (Impregum1, 3 M Espe, Seefeld, Germany). Stone casts
(Fujirock1, GC Europe, Leuven, Belgium) were poured and
mounted in an articulator and the FPDs were then fabricated by
three trained dental technicians.
The frameworks were prepared from prefabricated ceramic
blanks made of yttria-stabilized zirconia (IPS e.maxZirCAD,
Ivoclar Vivadent, Ellwangen, Germany) using a Cerec InLab
milling machine (Cerec, Sirona Dental Company, Bensheim,
Germany).
The TZP frames were veneered with one type of a pressable
fluorapatite glass ceramic (IPS e.max ZirPress, Ivoclar Vivadent) after application and firing of the appropriate liner
0.1 mm thick. The temperature and pressure gradient used
were in accordance with the manufacturers recommendations (Ivoclar Vivadent).
Before cementation, the inner surface of the framework
was tribochemically pretreated (Rocatec1, 3 M Espe, Seefeld,

Fig. 1 (a and b) FPD retained by crown and dihedral inlay: preparation and FPD in situ; (c and d) FPD retained by two
dihedral inlays: preparation and FPD in situ.

694

journal of dentistry 36 (2008) 692696

Table 1 Clinically relevant complications

Type of failure

Relative failure

Delamination
Chipping
Debonding of both retainers
Debonding of one retainer
Framework fracture (after debonding of one retainer)

2.1.

3.





Fifteen FPDs replaced a missing mandibular molar and

fifteen FPDs replaced a missing maxillar molar.
During the 12 months observation period a total of
thirteen clinically relevant complications occurred
[Table 1]. Chipping (n = 1) or delamination (n = 3) of the
veneer, without frame fracture, was observed for four FPDs
[Fig. 2]. All delamination and chipping could be repaired
intraorally by use of a composite material and were regarded
as relative failures.
Loss of retention was observed for dihedral inlays only. A
total of six FPDs debonded (n = 6). Three of these six FPDs
suffered from loss of retention of both retainers and could be
re-cemented, whereas for three FPDs loss of one retainer only
occurred and these FPDs had to be replaced.
A fracture of the framework could be observed in three
FPDs (n = 3). According to patient information, the fracture of
the framework occurred after debonding in two cases, and for
one of the fractured FPD loss of retention by dentine and by the
veneering material was observed [Fig. 3]. Adhesive failure
between the framework and the luting cement was observed
for all debonded FPDs.

Statistics

Statistical analysis was performed by use of SPSS (Version

14.0; Chicago, IL, USA). To determine the effect of different
clinical factors on the occurrence of complications, a coxregression model was used. The MannWhitney U-test and the
t-test, respectively, were used to assess the significance of
differences between postoperative sensitivity and plaque
index for the test groups. Statistical significance was accepted
at p < 0.05.

Fig. 2 Chipping of the ceramic veneer.

Results

The most frequent designs of the FPDs in the study group were
retention by use of two dihedral inlays (n = 13) and retention by
use of one dihedral inlay and one crown (n = 8). Seven FPDs
were retained by means of one dihedral inlay and one
trihedral/partial crown and two FPDs were retained by use
of one trihedral inlay and one crown.

N
3
1
3
3
2





Framework fracture (after loss of retention by dentin and by the veneering)

Germany), with protection of the veneering material, and

silanised with Monobond S1 (Ivoclar Vivadent). For patients
with supragingival margins the FPDs were cemented under a
rubber dam (n = 7). If fixation of a rubber dam was impossible,
cotton rolls and retraction cords were placed, to prevent
contamination with saliva or sulcus fluid. After computerized
randomization the FPDs were cemented either by use of the
dual-curing resin cement Panavia F (Panavia F, Kuraray Europe
GmbH, Frankfurt, Germany), after manual mixing, or by use of
the automixing self-curing resin cement Multilink (Multilink
Automix, Ivoclar Vivadent), both in accordance with the
manufacturers recommendations including the corresponding
etching and bonding procedure. Each surface was light-cured
for 40 s after seating the FPD. The liquid strip (glycerine) was
then applied and each retainer was light-cured for another 40 s.
Recalls were scheduled after 2 wks (recorded as baseline)
and after 12 months. Clinical evaluation was performed by one
dentist who was not involved in treatment of the patient.
Documentation included sensitivity and percussion tests, and
plaque index (PI).11
Complications, for example caries, endodontic treatment,
fractures of the facing or core material, and loss of retention,
were recorded. The aesthetic and functional performance of
the FPDs was subjectively evaluated by dentists and patients
by use of visual analog scales (VAS), from 0 (completely
inadequate) to 10 (perfect). To assess postoperative sensitivity,
subjects were asked to grade sensitivity by use of a VAS on
which 0 = no pain and 10 = extreme pain. No tactile, cold, or
evaporative air stimuli were used.

Absolute failure

Fig. 3 Decementation of the premolar inlay retainer,

followed by framework fracture.

journal of dentistry 36 (2008) 692696

Fig. 4 Aesthetic and functional performance, evaluated by

patients and dentists.

Cement ( p = 0.310), preparation design ( p = 0.305), dynamic

contacts ( p  0.268), and arch localization ( p = 0.947) had no
significant effect on failure rate.
Gingival conditions after 12 months in service were
generally sound. The mean values (S.D.) for PI, 0.62 (0.6) and
0.92 (0.6) for the two retainers, were comparable with those for
reference teeth (0.46 (0.5); 0.77 (0.5)), without statistically
significant differences ( p  0.462).
A mean value of 9.3 was obtained for patients subjective
rating of aesthetic performance; dentists subjective ratings
(7.1) were lower than those of the patients.
The mean value of patients subjective ratings of functional
performance was 7.1; again the dentists subjective ratings
(6.7) were lower [Fig. 4].
There were no significant differences between patients
subjective ratings of postoperative sensitivity after use of
different cements ( p  0.275).

4.

Discussion

During the short period of observation in this study thirteen

clinically relevant complications were encountered. This high
clinical failure rate is surprising because promising in vitro
results have been obtained for inlay-retained all-ceramic
FPDs.7,12 Complications for inlay-retained zirconia-based FPDs
in this study were delamination and chipping of the veneer
and debonding of at least one inlay retainer. These observations indicate the weak points of the FPDs are between the
framework and the veneer and between the framework and
the resin composite. Comparable results were obtained in a
recent study,9 although it must be remarked that this study
was of glass ceramic restorations without a zirconia framework. Those authors, however, regarded loosening of retainer
adhesion as a crucial factor in the failures.
One possible explanation of the high occurrence of
debonding in the current study may be the reduced area of
adhesion, either because of the small retainer surface
(dihedral inlays) or because of the presence of voids or
bubbles in the cementation material.13 If the reduced area of
adhesion was because of voids or bubbles, one would expect

695

use of automix luting cement, reducing the risk of air bubbles

compared with the manual mixing procedure, to have an
effect on the occurrence of debonding. No significant
differences were detected in this study, however, in accordance with the results of Palacios.14
Irrespective of the cementation material, another explanation of the large occurrence of adhesive failure may be a poor
zirconia-resin compound. Although use of resin cement and
the pretreatment chosen tribochemical silica coating and
silanisation seems to be the most effective cementation
procedure,15 it could be shown that resin bonding to a zirconia
surface is not always predictable. Recent discussion of
pretreatment of zirconia by use of silane coupling has
furnished no consistent results. Whereas some authors
demonstrated that some silane agents improve bond
strength,16,17 others challenged whether the surface of
silica-coated zirconia is coarse enough to enable durable
bonding,18 or reported reduced strength.19 It could also be
shown that the bond strength decreased over time.20
Apart from these possible explanations, five of the six
debonded fixed partial dentures in this study occurred in the
mandibular position and it must be remembered there is
always torsion of the mandible. Although no conclusive trend
in maxillary or mandibulary debonding could be observed for
different arches,21 it must be recognised that during clinical
function of FPDs with rigid connectors, and thus low bending
behaviour, interabutment forces will stress the retainer
framework and luting interface, causing possible debonding.22
Another frequent failure in this study was delamination of
the veneer. Although it has been stated that adhesive failure
between veneer and core ceramic does not occur in the
presence of a good bond between a compatible ceramic core
and the veneer material,23 and a recently published study has
shown that pressable ceramics had excellent surface contact
with the zirconia,24 delamination occurred in this study. In
this study a liner material was used, which may be responsible
for reduced microtensile bond strength of the pressable
ceramic,24 increasing the risk of delamination.25
It must, however, be considered that the term delamination indicates adhesive failure and no microscopic examination was performed in this study because these FPDs remained
in situ, so the assumption of purely adhesive failure in this
study could not be verified.
Several factors are associated with chipping or delaminationthe thickness of the veneer material and its mechanical
properties, the direction, magnitude, and frequency of applied
load, the size and location of occlusal contact areas, residual
stresses in the veneer material,26 the presence of internal
defects and damage, and the strength of the veneer ceramic
must also be take into account.
The framework fractures which occurred in this study were
observed after premature loss of retention of one inlay
retainer. This loss of retention would result in mobility of
the retainer followed by unfavourable stresses and strains,
and thus framework fracture.
When assessing the clinical performance of these inlayretained FPDs, however, some critical aspects must be
considered. First, these results are from a short period of
observation only. To make valid predictions of the mode of
failure of inlay-retained FPDs a longer period of observation is

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journal of dentistry 36 (2008) 692696

needed. Second, it must be noted that the results, in particular

those from statistical analysis, were limited by the size of the
groups.
Despite the limitations of this study it seems that the
strength of the bond between the veneer and the core material
and between the resin cement and the core material must be
improved27 before clinical use of inlay-retained fixed partial
dentures can be recommended without reservation. Etching of
the press ceramic instead of silanisation of the zirconia frame
might be a promising alternative means of improving the
retention of the resin cement.
Furthermore, a recently published case report demonstrated another promising approach to improve clinical
outcome of these FPDs8: by preparation of oral wings, the
effect of torsion forces during nonaxially loading might be
reduced and thus the stress at the adhesive interfaces. Further
investigations are required regarding the alternatives means
of improving the retention of inlay-retained FPDs.
Within the limitations of this study stable bonding between
zirconia and pressable ceramic and between zirconia and
resin composite was not observed for zirconia-based inlayretained fixed partial dentures. Furthermore, the hypothesis of
the influence of different luting cements on the occurrence of
decementation has to be rejected.
Further research on bonding behaviour or the effect and
different preparation are needed to enable valid prediction of
the failure behaviour of inlay-retained FPDs, and before they
can be recommended, without restrictions, for general clinical
use.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

Acknowledgment
We are grateful to Ivoclar/Vivadent, Schaan, Liechtenstein for
supporting this study.

18.

19.

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