The use of a zirconia custom implant-supported fixed partial denture prosthesis to treat implant failure in the anterior maxilla: A clinical report

Anterior Esthetic Rehabilitation with Computer-Aided Design/Computer-Aided Manufacturing Zirconia: A Case Report

In layered zirconia prosthesis, the choice of zirconia composition, framework design, and shade is closely related to the properties of the abutments. This interdependence emphasizes how crucial it is to take a deliberate and tailored approach to meet the unique needs of every therapeutic circumstance. To successfully treat anterior teeth and achieve restorations that look natural, challenges such as incorrect size and shape, atypical gingival contour, and unsightly hues need to be resolved. Ceramodetal restorations have occasionally allowed for the most appealing, authentic replication of natural teeth, despite its proven strength, endurance, and improved aesthetics. Due to their superior cosmetic results, metal-free materials have been used for anterior rehabilitation. Materials like dental zirconia, which offers excellent aesthetics and desired mechanical characteristics, have emerged in response to the increased need for visually appealing and metal-free alternatives. In this case study context, experiences in the clinic using multilayer zirconia prostheses intended exclusively for anterior teeth are discussed.

Mechanical behavior of titanium and zirconia abutments at the implant-abutment interface: A systematic review

STATEMENT OF PROBLEM

Zirconia has become popular for dental implant abutments in the esthetic zone but can damage the implant connection interface. Studies have been conducted to compare zirconia abutments with conventional titanium abutments; however, a consensus or systematic review is lacking.

PURPOSE

The purpose of this systematic review was to evaluate the performance of abutments made of zirconia and titanium in relation to wear and misfit at the implant-abutment interface.

MATERIAL AND METHODS

Electronic databases (PubMed/MEDLINE, Embase, Web of Science) were independently searched by 2 researchers for relevant studies published up to June 2021. The population, intervention, comparison, outcome (PICO) question was "Do zirconia abutments cause greater wear at the implant-abutment interface than titanium abutments under occlusal forces?" Eligible studies included in vitro studies that evaluated changes in the surface of external and/or internal connections and single and/or multiple, screwed and/or cemented prostheses rehabilitated with titanium and zirconia abutments submitted to mechanical cycling.

RESULTS

Nine studies were included for qualitative analysis. A total of 172 specimens were analyzed, 86 zirconia and 86 titanium abutments. In terms of wear on the implant connection surface, zirconia abutments caused more severe wear, more scratches, and more rounding of the hexagonal angles at the implant connection interface than titanium abutments. In terms of misfit at the connection interface, zirconia abutments showed greater misfit than titanium abutments.

CONCLUSIONS

Zirconia abutments produce more wear at the titanium implant connection interface, titanium abutments showed better fit to the implant connection interface, and the fit can be influenced by the abutment manufacturing method.

Using Genipin to Immobilize Bone Morphogenetic Protein-2 on Zirconia Surface for Enhancing Cell Adhesion and Mineralization in Dental Implant Applications

Our objective in this study was to promote cell responses through the immobilization of bone morphogenetic protein-2 (BMP-2) on roughened zirconia (ZrO₂) through using the natural cross-linker genipin in dental implant applications. Field emission scanning electron microscope, X-ray photoelectron spectroscopy, and attenuated total reflection-Fourier transform infrared spectroscopy were used to analyze the surface characterizations, including the topography, chemistry, and functional groups, respectively, of the test specimens. Human bone marrow mesenchymal stem cells (hMSCs) were used to detect cell responses (adhesion, proliferation, and mineralization). The surface characterizations analysis results revealed that genipin was effective in immobilizing BMP-2 on roughened zirconia surfaces. BMP-2 proved effective in promoting the adhesion and mineralization of hMSCs on roughened zirconia. The surface modification proposed has potential in zirconia dental implant applications.

Clinical Application of the PES/WES Index on Natural Teeth: Case Report and Literature Review

The use of reliable indices to evaluate the aesthetic outcomes in the aesthetic area is an important and objective clinical aid to monitor the results over time. According to the literature various indices were proposed to evaluate aesthetic outcomes of implant-prosthetic rehabilitation of the anterior area like Peri-Implant and Crown Index [PICI], Implant Crown Aesthetic Index [ICAI], Pink Esthetic Score/White Esthetic Score [PES/WES], and Pink Esthetic Score [PES] but none of them was related to prosthetic rehabilitation on natural teeth. The aim of this study is to verify the validity of PES/WES index for natural tooth-prosthetic rehabilitation of the anterior area. As secondary objective, we proposed to evaluate the long-term predictability of this clinical application, one of which is presented below, following the analysis of the most currently accepted literature.

Effect of geometry on deformation of anterior implant-supported zirconia frameworks: An in vitro study using digital image correlation

PURPOSE

To evaluate the effect of geometry on the displacement and the strain distribution of anterior implant-supported zirconia frameworks under static load using the 3D digital image correlation method.

METHODS

Two groups (n=5) of 4-unit zirconia frameworks were produced by CAD/CAM for the implant-abutment assembly. Group 1 comprised five straight configuration frameworks and group 2 consisted of five curved configuration frameworks. Specimens were cemented and submitted to static load up to 200N. Displacements were captured with two high-speed photographic cameras and analyzed with video correlation system in three spacial axes U, V, W. Statistical analysis was made using the nonparametric Mann-Whitney test.

RESULTS

Up to 150N loads, the vertical displacements (V axis) were statistically higher for curved frameworks (-267.83±23.76μm), when compared to the straight frameworks (-120.73±36.17μm) (p=0.008), as well as anterior displacements in the W transformed axis (589.55±64.51μm vs 224.29±50.38μm for the curved and straight frameworks), respectively (p=0.008). The mean von Mises strains over the surface frameworks were statistically higher for the curved frameworks under any load.

CONCLUSION

Within the limitations of this in vitro study, it is possible to conclude that the geometric configuration influences the deformation of 4-unit anterior frameworks under static load. The higher strain distribution and micro-movements of the curved frameworks reflect less rigidity and increased risk of fractures associated to FPDs.

Osteoblast integration of dental implant materials after challenge by sub-gingival pathogens: a co-culture study in vitro

Sub-gingival anaerobic pathogens can colonize an implant surface to compromise osseointegration of dental implants once the soft tissue seal around the neck of an implant is broken. In vitro evaluations of implant materials are usually done in monoculture studies involving either tissue integration or bacterial colonization. Co-culture models, in which tissue cells and bacteria battle simultaneously for estate on an implant surface, have been demonstrated to provide a better in vitro mimic of the clinical situation. Here we aim to compare the surface coverage by U2OS osteoblasts cells prior to and after challenge by two anaerobic sub-gingival pathogens in a co-culture model on differently modified titanium (Ti), titanium-zirconium (TiZr) alloys and zirconia surfaces. Monoculture studies with either U2OS osteoblasts or bacteria were also carried out and indicated significant differences in biofilm formation between the implant materials, but interactions with U2OS osteoblasts were favourable on all materials. Adhering U2OS osteoblasts cells, however, were significantly more displaced from differently modified Ti surfaces by challenging sub-gingival pathogens than from TiZr alloys and zirconia variants. Combined with previous work employing a co-culture model consisting of human gingival fibroblasts and supra-gingival oral bacteria, results point to a different material selection to stimulate the formation of a soft tissue seal as compared to preservation of osseointegration under the unsterile conditions of the oral cavity.

Effect of various surface preparations on bond strength of a gingiva-colored indirect composite to zirconia framework for implant-supported prostheses

To evaluate the effects of various surface preparations on shear bond strength of a gingiva-colored indirect composite material and zirconia framework. Zirconia disks were prepared with one of nine surface treatments: hydrofluoric acid etching (HF), heating at 1,000°C for 10 min (HT), wet-grinding with 600- and 1500-grit SiC paper (SiC 600 and 1500), alumina-blasting at 0.1, 0.2, 0.4 and 0.6 MPa (AB 0.1, 0.2, 0.4, and 0.6), and no treatment (NT). An indirect composite material was bonded to zirconia. Shear bond strengths were measured. Bond strength was significantly higher in AB 0.2, 0.4, and 0.6 groups than in other groups at 0 and 20,000 thermocycles. Post-thermocycling bond strength was lower in NT, HF, and HT groups than in other groups. Alumina-blasting with 0.2 MPa or higher yielded sufficient durable bond strength between gingiva-colored indirect composite and zirconia frameworks. Hydrofluoric acid etching and heat treatment did not achieve durable bond strengths.

Torque loss under mechanical cycling of long-span zirconia and titanium-cemented and screw-retained implant-supported CAD/CAM frameworks

OBJECTIVES

This study evaluated the screw joint stability after cyclic loading of implant-supported titanium and zirconia CAD/CAM frameworks for fixed dental prostheses (FDPs) with different retention methods.

MATERIAL AND METHODS

Twenty four one-piece frameworks supported by six threaded implants placed in the maxilla were fabricated using a CAD/CAM technique (NeoShape). Dry-pressed porcelain crowns were luted to the frameworks to standardize the specimens. The specimens were then divided into four groups (n = 6) according to framework material (titanium or zirconia) and retention method for the prosthesis (cement- or screw-retained): G1, Ti-cemented; G2, Ti-screw-retained; G3, Zr-cemented; and G4, Zr-screw-retained. A digital torque ratchet was used to assess the initial preload removal torque. Torque was then reapplied and the specimens were submitted to a 200 N cyclic load, at a frequency of 2 Hz, underwater in controlled temperature of 37°, and for 1 × 106 cycles. An opposing lower dental arch was fabricated using bis-acrylic resin to simulate occlusal contacts in centric. After cyclic loading, postload removal torque was measured. Preload and postload torque loss was expressed as a percentage of the initial load. Data were submitted to a linear mixed-effects model for statistical significance (α = 0.05) to evaluate the effect of cyclic loading in the screw torque loss used with frameworks of different materials and retention methods.

RESULTS

Significant screw torque loss (%) was found for the tested groups (before/after cyclic loading, respectively): G1 (39.77/61.83), G2 (37.57/50.96), G3 (34.87/54.10), and G4 (47.56/73.50) (P < 0.05).

CONCLUSIONS

The screw removal torque was significantly reduced for all groups in this study after cyclic loading the specimens. Screw-retained zirconia specimens presented the highest torque loss before and after the cyclic loadings compared with the other specimens that were tested.

A new testing protocol for zirconia dental implants

OBJECTIVES

Based on the current lack of standards concerning zirconia dental implants, we aim at developing a protocol to validate their functionality and safety prior their clinical use. The protocol is designed to account for the specific brittle nature of ceramics and the specific behavior of zirconia in terms of phase transformation.

METHODS

Several types of zirconia dental implants with different surface textures (porous, alveolar, rough) were assessed. The implants were first characterized in their as-received state by Scanning Electron Microscopy (SEM), Focused Ion Beam (FIB), X-Ray Diffraction (XRD). Fracture tests following a method adapted from ISO 14801 were conducted to evaluate their initial mechanical properties. Accelerated aging was performed on the implants, and XRD monoclinic content measured directly at their surface instead of using polished samples as in ISO 13356. The implants were then characterized again after aging.

RESULTS

Implants with an alveolar surface presented large defects. The protocol shows that such defects compromise the long-term mechanical properties. Implants with a porous surface exhibited sufficient strength but a significant sensitivity to aging. Even if associated to micro cracking clearly observed by FIB, aging did not decrease mechanical strength of the implants.

SIGNIFICANCE

As each dental implant company has its own process, all zirconia implants may behave differently, even if the starting powder is the same. Especially, surface modifications have a large influence on strength and aging resistance, which is not taken into account by the current standards. Protocols adapted from this work could be useful.

Post-thermocycling shear bond strength of a gingiva-colored indirect composite layering material to three implant framework materials

OBJECTIVE

To evaluate shear bond strength of a gingiva-colored indirect composite to three implant framework materials, before and after thermocycling, and verify the effect of surface pre-treatment for each framework.

MATERIALS AND METHODS

Commercially pure titanium (CP-Ti), American Dental Association (ADA) type 4 casting gold alloy (Type IV) and zirconia ceramics (Zirconia) were assessed. For each substrate, 96 disks were divided into six groups and primed with one of the following primers: Alloy Primer (ALP), Clearfil Photo Bond (CPB), Clearfil Photo Bond with Clearfil Porcelain Bond Activator (CPB+Activator), Estenia Opaque Primer (EOP), Metal Link (MLP) and V-Primer (VPR). The specimens were then bonded to a gingiva-colored indirect composite (Ceramage Concentrate GUM-D). Shear bond strengths were measured at 0 and 20 000 thermocycles and data were analyzed with the Steel-Dwass test and Mann-Whitney U-test.

RESULTS

Shear bond strengths were significantly lower after thermocycling, with the exception of Type IV specimens primed with CPB (p = 0.092) or MLP (p = 0.112). For CP-Ti and Zirconia specimens, priming with CPB or CPB+Activator produced significantly higher bond strengths at 0 and 20 000 thermocycles, as compared with the other groups. For Type IV specimens, priming with ALP or MLP produced higher bond strengths at 0 and 20 000 thermocycles.

CONCLUSIONS

Shear bond strength of a gingiva-colored indirect composite to CP-Ti, gold alloy and zirconia ceramics was generally lower after thermocycling. Application of a hydrophobic phosphate monomer and polymerization initiator was effective in maintaining bond strength of CP-Ti and zirconia ceramics. Combined use of a thione monomer and phosphoric monomer enhanced the durable bond strength of gold alloy.

The effect of different surface treatments on the bond strength of a gingiva-colored indirect composite veneering material to three implant framework materials

OBJECTIVES

To evaluate and compare the shear-bond strength of a gingiva-colored indirect composite material to three different implant framework materials (zirconia ceramics, gold alloy, and titanium), and to investigate the effect of surface pretreatment by air-particle abrasion and four priming agents.

MATERIAL AND METHODS

A gingiva-colored indirect composite (Ceramage) was bonded to three framework materials (n = 80): commercially pure titanium (CP- Ti ), ADA (American Dental Association)-type 4 casting gold alloy (Type IV), and zirconia ceramics (Zirconia) with or without airborne-particle abrasion. Before bonding, the surface of the specimens was treated using no (control) or one of four priming agents: Alloy Primer (ALP), Estenia Opaque Primer (EOP), Metal Link Primer (MLP), and V-Primer (VPR). Shear-bond strength was determined after 24-h wet storage. Data were analyzed using Steel-Dwass for multiple comparisons, and Mann-Whitney U-test (P = 0.05).

RESULTS

For both CP- Ti and Zirconia substrates, three groups, ALP, EOP, and MLP, showed significantly higher bond strengths (P < 0.05) than the other groups with or without airborne-particle abrasion. For Type IV substrates, significantly higher bond strengths were obtained in ALP and MLP groups (P < 0.01) compared with the other groups with airborne-particle abrasion.

CONCLUSIONS

Application of priming agents containing specific phosphoric ester groups significantly enhances the bond strength of a gingiva-colored composite material to commercially pure titanium and zirconia frameworks. Combined use of a thione monomer with a phosphoric monomer enhances the bond strengths to airborne-particle abraded type IV gold alloy.

An overview of immediate root analogue zirconia implants

Owing to its excellent biomechanical characteristics, biocompatibility, and bright tooth-like color, zirconia has the potential to become a substitute for titanium as dental implant material and to be successfully used as root-analogue implants by reproducing the contours of the extracted tooth. This article presents an overview of the technique of using root analogue zirconia dental implants as an immediate implantation material. These implants are replicas of the extracted tooth and therefore truly anatomically correct and socket friendly.

Zirconia in fixed implant prosthodontics

BACKGROUND

CAD/CAM technology in combination with zirconia ceramic has increasingly gained popularity in implant dentistry.

PURPOSE

This narrative review presents the current knowledge on zirconia utilized as framework material for implant-borne restorations and implant abutments, laboratory tests and developments, clinical performance, and possible future trends for implant dentistry are addressed.

MATERIAL AND METHODS

A review of available literature from 1990 through 2010 was conducted with search terms zirconia,""implants,""abutment,""crown," and "fixed dental prosthesis" using electronic databases (PubMed) and manual searching.

RESULTS

Latest applications of zirconia in implant dentistry include implant abutments, multiple unit and full-arch frameworks as well as custom-made bars to support fixed and removable prostheses. High biocompatibility, low bacterial surface adhesion as well as favorable chemical properties of zirconia ceramics are reported. Zirconia stabilized with yttrium oxide exhibits high flexural strength and fracture toughness due to a transformation toughening mechanism. Preliminary clinical data confirmed the high stability of zirconia for abutments and as a framework material for implant borne crowns and fixed dental prostheses. Zirconia abutment or framework damage has rarely been encountered. However, veneering porcelain fractures are the most common technical complication in implant-supported zirconia restorations. These porcelain veneer failures have led to concerns regarding differences in coefficient of thermal expansions between core and veneering porcelain and their respective processing techniques.

CONCLUSION

As presently evidence of clinical long-term data is missing, caution with regard to especially extensive implant-borne zirconia frameworks is recommended.

Immediate loading of the maxilla with prefabricated interim prosthesis using interactive planning software, and CAD/CAM rehabilitation with definitive zirconia prosthesis: 2-year clinical follow-up

Immediate loading in implant dentistry has provided several advantages for both patients and clinicians. Recent advances in computer-aided design/computer-aided manufacturing (CAD/CAM) technology, medical imaging and rapid prototyping have added to the armamentarium of implant dentistry in terms of efficiency, accuracy and predictability. Rapid prototyping and CAD/CAM technology are used to fabricate stereolithographic surgical templates for flapless implant placement. In addition to that, this technology is also used for the fabrication of zirconia frameworks. The zirconia-based implant restorations are gaining popularity in implant prosthodontics combining esthetic properties with strength and biocompatibility. The purpose of this article is to illustrate the steps for implant rehabilitation of the edentulous maxilla with zirconia prosthesis and report the 2-year clinical follow-up of novel technological advances in surgical placement, provisionalization and fabrication of a definitive restoration.

CLINICAL SIGNIFICANCE

A comprehensive approach to full mouth implant rehabilitation using cutting edge technology is illustrated in a simplified manner.

Clinical trials in zirconia: a systematic review

Zirconia is unique in its polymorphic crystalline makeup, reported to be sensitive to manufacturing and handling processes, and there is debate about which processing method is least harmful to the final product. Currently, zirconia restorations are manufactured by either soft or hard-milling processes, with the manufacturer of each claiming advantages over the other. Chipping of the veneering porcelain is reported as a common problem and has been labelled as its main clinical setback. The objective of this systematic review is to report on the clinical success of zirconia-based restorations fabricated by both milling processes, in regard to framework fractures and veneering porcelain chipping. A comprehensive review of the literature was completed for in vivo trials on zirconia restorations in MEDLINE and PubMed between 1950 and 2009. A manual hand search of relevant dental journals was also completed. Seventeen clinical trials involving zirconia-based restorations were found, 13 were conducted on fixed partial dentures, two on single crowns and two on zirconia implant abutments, of which 11 were based on soft-milled zirconia and six on hard-milled zirconia. Chipping of the veneering porcelain was a common occurrence, and framework fracture was only observed in soft-milled zirconia. Based on the limited number of short-term in vivo studies, zirconia appears to be suitable for the fabrication of single crowns, and fixed partial dentures and implant abutments providing strict protocols during the manufacturing and delivery process are adhered to. Further long-term prospective studies are necessary to establish the best manufacturing process for zirconia-based restorations.