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CLINICAL SCIENCE

A prospective evaluation of zirconia anterior partial fixed


dental prostheses: Clinical results after seven years
Maria Fernanda Solá-Ruíz, DMD, PhD, MD,a Rubén Agustin-Panadero, DMD, PhD,b
Antonio Fons-Font, DMD, PhD, MD,c and Carlos Labaig-Rueda, DMD, PhD, MDd

Since the end of the 20th ABSTRACT


century, high-strength ce- Statement of problem. Because of the high mechanical strength of zirconium dioxide, the metal in
ramics have come into use to fixed partial prostheses can now be replaced. However, the material is susceptible to aging or
replace the metal in fixed res- hydrothermal degradation and to chipping of the feldspathic veneer.
torations, a development that
Purpose. The purpose of this prospective study was to evaluate the survival (without failure) and
has led to high expectations.1 success (survival without any complication or failure) rate and clinical efficacy of anterior zirconia
Among the ceramics used in partial fixed dental prostheses.
these new systems, zirconium
Material and methods. Twenty-seven anterior partial fixed dental prostheses of 3 to 6 units were
dioxide (zirconia) has been the
fabricated. All participants were examined after 1 month and 6 months, then annually for 7 years.
main focus of research because
it offers a range of properties Results. Three partial fixed dental prostheses failed and had to be removed: 2 because of secondary
caries, which increased failure significantly (P=.001) and 1 because of severe chipping. Six partial
that make it suitable for use
fixed dental prostheses had complications: 2 debonded, 3 had chipping, and 1 had periapical
in dentistry: biocompatibility, pathology. All veneer porcelain fractures occurred in 6-unit fixed partial prostheses (P=.002). The
high fracture resistance, low clinical success rate was 88.8% after the 7-year follow-up.
thermal conductivity, resis-
Conclusions. The clinical behavior of partial fixed dental prostheses with a zirconium dioxide core
tance to corrosion, and a
in the anterior region provides an adequate medium-term survival rate. The main cause of failure
totally crystalline microstruc- was secondary caries. The most frequent complication was chipping, which was directly related to
ture.1,2 Yttrium-stabilized zir- the number of units of the prosthesis. (J Prosthet Dent 2015;-:---)
conium dioxide is suitable for
optical applications because of its high refraction index, inherent problem of the material is a phenomenon
its low absorption coefficient, and its high opacity in the known as spontaneous aging, hydrothermal degradation,
visible and infrared spectra.3 Its grain size and the dis- or low-temperature degradation.6,7 These factors change
tribution of different grain sizes, the pressure method its crystalline phase from tetragonal to monoclinic, which
and conditions, and different additives all determine the increases the volume (4% to 5%) of the crystals causing
translucency of a restoration.3 In spite of the material’s the loss of their mechanical properties and the appear-
high fracture resistance, chipping of the feldspathic por- ance of microcracks or macrocracks.6-9
celain veneer of zirconia fixed dental prostheses during In spite of these setbacks, the survival rates of zirconia
mastication is a frequent problem.4 This complication feldspathic fixed partial dental prostheses (FDPs) are
generates some uncertainty as to the long-term perfor- greater than those of lithium disilicate-based core ce-
mance of the material in dental restorations.5 An ramics10 and similar to those of metal ceramic prostheses,

a
Adjunct lecturer, Department of Buccofacial Prosthetics, Faculty of Medicine and Dentistry, University of Valencia, Valencia, Spain.
b
Associate lecturer, Department of Buccofacial Prosthetics, Faculty of Medicine and Dentistry, University of Valencia, Valencia, Spain.
c
Senior lecturer, Department of Buccofacial Prosthetics, Faculty of Medicine and Dentistry, University of Valencia, Valencia, Spain.
d
Senior lecturer, Department of Buccofacial Prosthetics, Faculty of Medicine and Dentistry, University of Valencia, Valencia, Spain.

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Clinical Implications
Zirconia fixed partial dental prostheses offer a
recommendable alternative for replacing teeth in
the esthetic zone.

which have survival rates of 97% and 99% after 5 years,


respectively.11-14
Most published research has analyzed the behavior of
zirconia restorations in the posterior zone.15,16 Chipping
or delamination has been defined as the fracture of the
veneer ceramic, and a high rate varying between 6% and
28% has been confirmed over a period of 3 to 10 years.16- Figure 1. Chipping of veneer ceramic in maxillary central incisors of
33
These are high values compared to the 4% fracture rate fixed dental prosthesis with zirconia core.
demonstrated by conventional metal ceramic restorations
over 10 years.34
According to Heintze and Rousson,14 chipping, can
evaluation being on January 1, 2014. The ethical board for
be classified by severity and by the treatment required for
clinical trials of the University of Valencia approved the
repair, as follows: grade 1, small surface chipping, with
study protocol, and all participants gave their informed
treatment being polishing the restoration surface; grade
consent to take part.
2, moderate surface chipping, with treatment being using
Inclusion criteria were the need to replace 1 or 2
a resin composite repair system (Fig. 1); and grade 3,
anterior teeth (central or lateral incisors), indicating the
severe veneer ceramic chipping exposing the zirconium
placement of FDPs of between 3 and 6 units, periodon-
dioxide core, with treatment being replacing the
tally healthy abutment teeth, no signs of either resorption
damaged prosthesis. Literature reviews such as those by
or periapical pathology, stable occlusion, and natural
Heintze and Rousson,14 Anusavice,35 and Raigrodski,36
teeth in the antagonist arch.
show that the most frequent types of zirconia-based
Individuals requiring a fixed partial prosthesis of more
fixed dental prostheses chipping are grades 1 and 2,
than 2 pontics or with poor oral hygiene, a high incidence of
which do not involve restoration failure.
caries, active periodontal disease, or bruxism were excluded.
Several factors have been identified that can influence
the incidence of chipping, as follows: (1) residual tension
Prosthodontic procedures
due to differences in the thermal expansion coefficients
Three clinicians (S.R.M.F., A.P.R., F.F.A.) with experience
of the core and the veneer materials; (2) poor wettability
in fixed prosthodontics prepared the abutment teeth to
of the core by the veneer ceramic37; (3) compression
meet the following parameters: occlusal and/or incisal
resulting from firing the porcelain38,39; (4) the protocol for
reduction of 1.5 to 2 mm; axial reduction of 1 to 1.5 mm
heating and cooling the veneer and core37; (5) trans-
with a 10-degree included convergence angle, and a
formation of the zirconium dioxide crystal phase at the
circular chamfer or shoulder of 1 mm. Particular attention
core-porcelain veneer interface caused by thermal in-
was paid to rounded line angles (Figs. 2, 3). The color of
fluences or load forces40; (6) formation of inherent defects
each abutment tooth and adjacent teeth was identified
during processing41; (7) veneer ceramic application
with a shade guide (Vita shade guide, Vita Zahnfabrik).
technique (stratification/injection)41-43; (8) Inadequate
Interim restorations were fabricated from polymethyl
thickness of veneer ceramic44; and (9) occlusal trauma.45
methacrylate (AcryLux C&B; Ruthinium Group, Dental
The aim of this study was to evaluate the success and
Manufacturing Spa) and cemented with eugenol-free
survival rates and biological and/or mechanical compli-
interim cement (Temp Bond NE; Kerr Corp).
cations of zirconium dioxide FDPs in the anterior region
Definitive impressions were made with polyvinyl
over a 7-year follow-up.
siloxane impression material (Exaflex; GC America Inc) in
a stock perforated stainless steel tray (Zhermack; Badia
MATERIAL AND METHODS
Polesine). Impressions of the opposing arch were made
Twenty-seven participants (14 women and 13 men) aged with irreversible hydrocolloid impression material
between 30 and 65 years took part in the study, which (Orthoprint; Zhermack) and intermaxillary relations were
was carried out in the Prosthodontics and Occlusion registered in wax (X-hard; Miltex).
Department at the University of Valencia between The FDPs were fabricated with a computer-aided
January 1, 2005, and January 1, 2006, with latest design and computer-aided manufacturing (CAD/CAM)

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Figure 2. Patient before treatment with existing fixed dental prosthesis Figure 3. Abutment tooth preparation.
and tooth wear.

Figure 4. A, B, Zirconia framework evaluated intraorally to ensure adequate fit.

system (Lava; 3M ESPE). They had a connector surface


area of 7 mm2; a uniform coping thickness of 0.5 mm was
used for all prostheses to standardize the study protocol.
All internal frameworks were evaluated in the mouth to
ensure an adequate fit (Fig. 4). The veneer ceramic used
was Lava Ceram (3M ESPE). Before bonding, the internal
surfaces of the prosthetic framework were treated by
airborne-particle abrasion with a tribochemical silica
coating with 30 mm Al2O3 particles (CoJet; 3M ESPE). A
layer of silane (Monobond; Ivoclar Vivadent) was
applied. The teeth were also treated with 35% ortho-
phosphoric acid, followed by application of the dentin
adhesive (NT Prime Bond; 3M ESPE). All the FDPs were
bonded with a resin cement (Multilink; Ivoclar Vivadent)
(Fig. 5). Figure 5. Fixed dental prosthesis cemented.

Clinical follow-up vitality or infection of the abutment teeth (cold test and
The 27 participants were examined by 2 clinicians who periapical radiographs), secondary caries, debonding,
had not been involved in treating them, at 1 month after fracture of the prosthesis core, and chipping of the veneer
restoration, after 6 months, and thereafter annually for 7 ceramic. Both clinicians evaluated the prostheses inde-
years. The clinical parameters analyzed were loss of pendently. The parameters were such that assessment

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Figure 6. A, Incisal edge chipping level 1. Maxillary right canine. B, Chipping corrected with intraoral polishing.

Table 1. Complication details in prospective evaluation after 7 years 1.0


Complication Complication Present n Incidence (%)
Chipping No 23 85.2
0.8
Yes 4 14.8
Core fracture No 27 100

Survival
0.6
Yes 0 0
Debonding No 25 92.6
0.4
Yes 2 7.4
Secondary caries No 25 92.6
Yes 2 7.4
0.2
Survival Function
Endodontic No 26 96.3 0

Yes 1 3.7 0.0


0.00 2.00 4.00 6.00 8.00 10.00
Complication time
was objective in all prostheses, so reliability testing was
Figure 7. Probability of survival without complications until end of
not thought to be necessary. Nevertheless, if divergences
follow-up period.
did occur between their findings, the lower value was
used for analysis.
Statistical analysis was performed with software
4 unit) with secondary caries (7.4%) in the abutment
(Statistical Package for the Social Sciences; IBM SPSS
teeth, requiring replacement of the prosthesis at the 3-
Statistics) applying initial descriptive and bivariate ana-
year follow-up and one 4-unit FDP (3.7%) with an
lyses, the Kruskal-Wallis test, the Mann-Whitney test,
endodontic problem with periapical lesions after 2.5
and Kaplan-Meier survival analysis (a=.05).
years; however, after periapical surgery, there was no
need to replace the prosthesis. Mechanical complications
RESULTS
involved 4 FDPs with chipping (14.8%), all of them 6-
The 27 participants received 27 FDPs: ten 3-unit, ten 4- unit FDPs: one was replaced after 3 years and the
unit, two 5-unit, and five 6-unit FDPs. All participants others were corrected by polishing and intraoral repair
completed the 7-year follow-up, and no appointments (Fig. 6). Two FDPs (one 4 unit and one 6 unit) debonded
were missed. After 7 years of monitoring, 3 complete after 7 and 6 months, respectively. None of the FDPs had
restoration failures had occurred requiring removal (one fracture of the internal zirconia cores (Table 1). When the
3-unit and one 4-unit FDP failure because of secondary type of complication was related to the FDP’s number of
caries and one 6-unit FDP failure because of irreparable units (applying the Kruskal-Wallis test), a statistically
chipping). The survival rate of the zirconia core restora- significant relation was identified involving chipping
tions was 88.8% after the 84-month follow-up (95% (P=.002). Five 6-unit FDPs showed a higher incidence of
confidence interval [CI] 70.8 to 97.7). chipping than those with shorter spans (P<.001, Mann-
The complications observed were classified as bio- Whitney). No identified differences were found be-
logical (secondary caries, pulp affectation) or mechanical tween 3-unit and 4-unit spans (P=1.000, MW), with null
(fracture of the core or veneer ceramic, debonding). incidence of chipping. When the causes of restoration
Biological complications involved 2 FDPs (one 3 unit, one failure were analyzed, the only statistically significant

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1.0 tetragonal to monoclinic phase associated with the


degradation of the material’s mechanical properties. This
0.8 phenomenon is promoted by the presence of water or
vapor and by the temperature caused by the reactions of
water and the crystalline lattice. The susceptibility of
Survival

0.6
zirconia to aging depends on factors such as grain size,
0.4 presence of residual stress, or the quantity, type, and
Type FPD distribution of the stabilizing element; the larger the
0.2 3 units
4 units
3 units-censored
4 units-censored
grain size or the greater the residual stress or the lower
5 to 6 units 5 to 6 units-censored the quantity of stabilizing element, the greater the ag-
0.0 ing.46 This is also a phenomenon that is accelerated by
0.00 2.00 4.00 6.00 8.00 10.00 the presence of water vapor.47 Of particular relevance
Complication time was the news reported in various American orthopedic
journals of the fracture-after only a short time-of 400
Figure 8. Survival (without failure) according to FDP number of units.
Zircone Prozyr (3Y TZP) femoral prostheses made from
zirconia in 2001 to 2002. These had to be removed and
led to a marked reduction in the use of the material and
factor (Mann-Whitney test) was secondary caries
the closure of the supplier of the prosthesis.1 Numerous
(P=.001). All FDPs that presented with secondary caries
research articles have shown how the kinetics of the
in the abutment teeth had to be removed.
tetragonal-monoclinic transformation, which generally
The Kaplan-Meier survival test estimated an accu-
appears to be linked to chemical composition, is accel-
mulated survival rate of 8 years and 5 months (95% CI
erated as temperature rises.38-40 The activation energies
7.6 to 9.0). The critical moment for survival was around
measured vary between 70 and 110 kcal/mol. This evi-
the 3-year mark, given that a restoration that had sur-
dence has important technological consequences because
vived 3 years maintained a constant probability of sur-
of zirconia’s low thermal conductivity (2.5 W/mK),
viving the follow-up period (with a value of 0.9). The
whereby the surface treatment of zirconium dioxide lines
mean survival time without any incidence of complica-
by abrasion can cause notable temperature rises locally
tions (success) was 6.83 years (95% CI 5.6 to 8.1). If by 3
that can initiate phase transformation.46
years no complication had occurred, there was a high
Crisp et al17 analyzed the behavior of 13 FDPs (3- and
probability that none would appear thereafter (Fig. 7).
4-unit prostheses), but they did not observe any com-
When success was related to the FDP (Kaplan-Meier
plications after a 12-month follow-up, nor did Tinschert
test), the probability of some complication occurring
et al18 in an analysis of 15 anterior FDPs (3- to 10-unit
increased in relation to the number of units of the FDP
prostheses) over 38 months. These results are not com-
(Fig. 8). For 6-unit FDPs, complications occurred both
parable with the present study given the small numbers
soon and frequently. For these restorations, the time
of FDPs and the shorter follow-up periods.
taken to stabilize survival probability was 2 years, but
Schmitter et al19 monitored 30 FDPs (4- to 7-unit
thereafter the probability of survival was only 0.42.
prostheses) over 25 months, distributed in both the
anterior and posterior regions; among the anterior FDPs, 1
DISCUSSION
had endodontic problems and 2 debonded among the
Little research has been published on the clinical posterior FDPs, 1 had a fracture of the internal core, and 1
behavior of anterior FDPs with zirconia cores. For this had veneer chipping. Edelhoff et al20 analyzed the
type of restoration, the most frequent complication is behavior of 21 FDPs (3- to 6-unit prostheses) over 39
chipping of the veneer porcelain.15-34 Factors that influ- months, of which only 4 were placed in the anterior re-
ence chipping are related to a series of variables, which gion, with 1 incidence of a loss of pulpal vitality in 1
range from the varying thermal behavior after firing and abutment tooth.
cooling the substrate and the overlay ceramic to insuffi- Almost all published research of FDP behavior deals
cient wettability of the substrate in relation to the veneer with restorations placed in the posterior region.21-33 The
porcelain during construction, which can produce insuf- most common mechanical complication was chipping of
ficient homogeneity at the veneer/core interface.3,4,37 the veneer ceramic, although there is controversy be-
One of the most widely studied ceramic veneer tween researchers as to its incidence. Some authors
phenomena that might be related to ceramic veneer report that chipping occurs in 3% to 6% of posterior
chipping, is aging or low-temperature degradation. FDPs,17-19,22,23 whereas others state that it is 9% to
Zirconium dioxide’s hydrothermal transformation was 15%,8,13,20,24-29 and some report that it is as high as 19%
discovered by Kobayashi et al,46 who observed a to 28%.21,29-31 However, several other authors have
slow, progressive, spontaneous transformation of the found no mechanical complications among the FDPs

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monitored.32,33 The present study found that 14.8% of CONCLUSIONS


the restorations had chipping, all of them longer, 6-unit
Within the limitations of this study (in particular the
FDPs. None of the FDPs in the present study had frac-
small sample size), the conclusions are as follows:
ture of the zirconia cores.
As for biological complications, the present study 1. Anterior FDPs with zirconium dioxide frameworks
found an incidence of 11.1% (2 participants [7.4%] showed a success rate of 88.8% within the 7-year
with secondary caries, and 1 [3.7%] endodontic prob- follow-up.
lem) over the 84-month follow-up period. Again, there 2. The most frequent cause of failure was secondary
is controversy between authors over the incidence of caries (P=.001), which was related to the number of
these complications, which range between 1.5% to units of the FDP.
5.5% 36,18-20,21,23,27,28,30 and 10.1% to 20% 26,31,29 over 3. The most frequent complication was chipping of the
clinical observation periods of between 50 and 84 veneer ceramic.
months. The latter studies concur more closely with 4. All chipping occurred in longer, 5- or 6-unit FDPs
the present one, both in the number of biological (P=.002).
complications and in the follow-up period. 5. The critical period for the occurrence of mechanical
When the causes of mechanical restoration failure are and biological complications was between the first
analyzed, according to studies with 3- to 5-year follow- and the third year.
up, success rates vary between 88.8% and 6. More long-term longitudinal studies are required to
100%,6,12,17,18,20,22,25,30,32,33 while for failure due to bio- confirm the behavior of this type of restoration in
logical complications, the success rate decreases to the oral environment.
73.9%,11,21,23,27,29,31 findings that agree with the present
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