Dual Jaw Treatment of Edentulism Using Implant-Supported Monolithic Zirconia Fixed Prostheses

Evaluating the clinical behavior of veneered zirconia in comparison with monolithic zirconia complete arch implant-supported prostheses: A systematic review and meta-analysis

STATEMENT OF PROBLEM

Because the use of zirconia in dentistry is relatively new, the number of published studies on the subject is scarce, even though material selection is an important factor in clinical performance. Therefore, a systematic assessment of the impact of the prosthetic material, framework design, veneering material, and manufacturing process is required.

PURPOSE

The purpose of this systematic review and meta-analysis was to investigate the survival and success rates of feldspathic porcelain veneered zirconia (VZir) in comparison with monolithic zirconia (MZir) complete arch implant-supported prostheses (CAISPs). A secondary objective was to assess the influence of the type of loading, the presence or absence of a cantilever, the type of zirconia used, the location, and the opposing arch on complications rates and patient satisfaction.

MATERIAL AND METHODS

An electronic search of the MEDLINE database (via PubMed), Scopus, Science Direct, Cochrane Library, and OpenGrey was carried out. The criteria described in the preferred reporting items for systematic reviews and meta-analyses statement were used. The search was restricted from January 2000 to January 2022.

RESULTS

The systematic search resulted in 20 articles that met the established criteria. In total, 751 patients (VZir=302; MZir=449) with 3038 CAISPs (VZir=368; MZir=2670) were analyzed. Higher prosthetic survival and success rates were found in MZir compared with VZir CAISPs (100% and 95.45%, respectively). The meta-analysis found significantly fewer complications related to MZir (9.4% [4.8%-14.1%]) compared with VZir (33.7% [17.5%-49.9%]).

CONCLUSIONS

Based on the findings of this systematic review, MZir CAISPs had higher survival and success rates than VZir CAISPs, with significantly fewer prosthetic complications. The influence of factors such as the type of functional loading, the presence of a cantilever, the material used in the prosthodontic workflow, the location of the CAISP, and the type of antagonist arch on the performance of Zir CAISPs remains unclear.

A multi-center retrospective assessment of monolithic zirconia restorations on posterior teeth and implants

Objective: the purpose of this multicenter retrospective study was to report on survival, success, and complication rates in monolithic zirconia restorations on teeth and implants. Materials and Methods: data on 671 monolithic zirconia restorations was collected by five prosthodontists from three different specialty practice centers, including a dental school and two private practice centers. Restorations included single crowns and multiple-unit fixed dental prostheses on teeth and implants in the posterior area (premolar and molars). Follow-up time was up to 62 months. Results: mean follow-up time was 28.1±12.9 months. A total of 671 units, 534 single crowns, and 137 multi-unit restorations. Cumulative survival and success rates at 5 years were 97.4%, and 93.8% respectively. Complications presented in 11 restorations out of 671 and included: decementation, abutment screw loosening, restoration crack, restoration fracture, and tooth fracture. No significant differences were observed between tooth-supported and implant-supported restoration (p=0.42), single crowns and multiple-unit restorations (p=0.07), bruxers and non-bruxers (p=0.57). Patients with group function occlusal scheme had significantly less survival rates (p=0.001). Conclusion: the use of monolithic zirconia for restorations on the posterior teeth and implants seems to be promising as it provides a durable solution with a low rate of complications.

Randomized Controlled Clinical Trial to Compare Posterior Implant-Supported Modified Monolithic Zirconia and Metal-Ceramic Single Crowns: One-Year Results

PURPOSE

The purpose of this randomized controlled clinical trial was to investigate the prosthetic outcomes of posterior implant-supported single crowns (SCs) with a modified monolithic zirconia or metal-ceramic design at 1 year of loading.

MATERIALS AND METHODS

Forty participants with 73 dental implants in need of at least 1 maxillary or mandibular posterior implant-supported SC were consecutively selected for this study. The included participants were randomly divided into modified monolithic zirconia (MMZ) and metal-ceramic (MC) groups. The implant-supported SCs were examined after 1 year for survival and technical complications. Descriptive statistics were used to illustrate the data, and the association associated risks of complications were estimated using the logistic regression model with Firth's approach for rare outcome (α = 0.05).

RESULTS

During the observation period, 2 participants in the MC group were lost to follow-up. A total of 38 participants with 70 posterior implant-supported SCs (36 and 34 SCs in the MMZ and MC groups respectively) completed the 1-year follow-up examination. One implant failed in the MMZ group. The 1-year survival rates for implants and crowns were both 97.2% in the MMZ group. The survival rates for implants and crowns were both 100% in the MC group. One screw loosening event was observed in one screw-retained SC in the MMZ group; however, 8 complication events occurred in 7 SCs in the MC group. Therefore, the complication-free rates were 97.1% and 79.4% in the MMZ and MC SCs respectively. The most common complication in the MC group was screw loosening (14.7%), followed by loss of retention (5.9%), and ceramic fracture (2.9%). Significantly more technical complications were observed in the MC SCs than MMZ SCs (p = 0.0432).

CONCLUSION

The modified monolithic zirconia design applied to the posterior implant-supported SCs had a significantly lower technical complication rate than did the metal-ceramic one.

Clinical Results and Technical Complications of Posterior Implant-Supported Modified Monolithic Zirconia Single Crowns and Short-Span Fixed Dental Prostheses: A 2-Year Pilot Study

PURPOSE

The purpose of this clinical trial was to investigate the clinical outcomes of implant-supported modified monolithic zirconia single crowns (SCs) and short-span fixed dental prostheses (FDPs) after a follow-up of 2 years.

MATERIALS AND METHODS

Twenty-seven patients in need of implant-supported SCs or 3-unit FDPs in the posterior maxilla or mandible were consecutively selected for this study. A total of 56 modified monolithic zirconia prostheses including 44 SCs (8 screw-retained, 36 cement-retained) and twelve 3-unit FDPs (5 screw-retained, 7 cement-retained) were included in this study. All patients were followed at 6 months, 12 months, 18 months, and 2 years after placement of the modified monolithic zirconia prostheses. During the follow-up period, all prostheses were evaluated with clinical and radiographic examinations. The following technical parameters were assessed: framework fracture, fracture of veneering porcelain, screw loosening, loss of retention because of prosthesis de-cementation and opposing tooth fracture.

RESULTS

No implant was lost during the follow-up period, yielding a 2-year implant survival of 100%. One FDP failed because of framework fracture. The overall prosthesis survival rate was 98.2% after 2 years of clinical service. During the study, 5 complication events were observed in 3 SCs and one FDP, including one fracture of veneering porcelain and 2 screw loosenings in 3 SCs, and loss of retention and opposing tooth fracture in the same FDP. Therefore, the complication-free rate of prostheses was 91.1%.

CONCLUSION

According to the results of this study, the modified monolithic zirconia design used in this study resulted in a favorable short-term outcome for posterior implant-supported SCs and 3-unit FDPs.

Evaluation of Fracture Resistance of Varying Thicknesses of Zirconia Around Implant Abutment Cylinders

Zirconia is becoming increasingly used as a restorative material for implant-supported restorations; however, information is lacking with respect to the minimum thickness of zirconia surrounding the implant components. The purpose of this study is to evaluate the resistance to fracture of different thicknesses of zirconia luted to implant components. Thirty cylinders of zirconia (Prettau, Zirkonzahn) with 13-mm height, designed with indented occlusal surface for loading, and varying wall thicknesses (0.5 mm, 1 mm, 1.5 mm; n = 10/group) were milled using a computer-aided design/computer-aided manufacturing system (Modellier, Zirkonzahn), after which they were sintered. Titanium temporary cylinders (ITCS41, Biomet3i) were attached to 30 implant analogs (ILA20, Biomet3i) that were embedded into polymethylmethacrylate blocks (Palapress Vario, Heraeus Kulzer) with dimensions of 4.5 × 1.8 × 2 cm. Zirconia specimens were cemented to the titanium cylinders using a self-adhesive, dual-cure resin cement (Panavia SA, Kuraray). Load to failure test was performed under compression until fracture using a universal testing machine (Instron5965, Instron) at a crosshead speed of 0.5 mm/min and measured in N (Newton). Statistical analysis was performed using 1-way analysis of variance and Tukey B test at α = .05 (SPSS19, IBM). Mean load to failure was 1059.94 N, 2019.46 N, and 4074.79 N for groups 0.5 mm, 1 mm, and 1.5 mm, respectively. Values were significantly different between the groups (P < .05). Study limitations are that it is in vitro, specimens do not replicate tooth dimensions, and forces are static and directed toward the occlusal portion of each specimen. Within these limitations and considering the average human bite force, a thickness of 0.5 mm to 1 mm of this particular type of zirconia around this type of implant component can avoid fracture with these dimensions.

Retrospective 2- to 7-Year Follow-Up Study of 20 Double Full-Arch Implant-Supported Monolithic Zirconia Fixed Prostheses: Measurements and Recommendations for Optimal Design

PURPOSE

To measure the extension of cantilever lengths, thicknesses, and heights of zirconia prostheses in the lingual and facial areas of the distal screw access openings, and to evaluate the clinical performance regarding chipping or fracture of the distal cantilevered sections of double full-arch CAD/CAM screw-retained, stained, monolithic zirconia, gingival-colored ceramic implant-supported fixed prostheses (MZ-FPs).

MATERIALS AND METHODS

Ten edentulous patients were provided with a total of 20 CAD/CAM double full-arch MZ-FPs. The zirconia thicknesses around distal screw access openings at three different levels (crown height space, screw access opening lengths, and dimensions of the cantilevered segments) were measured in the resin prototypes. Patients were evaluated clinically (visually) without magnification, with intraoral digital photography, and radiologically by the author, approximately every 6 months. Ten patients with 20 MZ-FPs were evaluated. Twenty resin prototypes with 35 cantilevered segments (15 maxillary, 20 mandibular) were measured. The lingual and facial thicknesses of the resin frameworks and the crown height spaces of 35 distal access openings were measured.

RESULTS

The average extension of the maxillary cantilever segments was 7.72 mm; the mandibular cantilever average was 13.72 mm. The average crown height space for maxillary prostheses was 13.27 mm, for the mandibular prostheses it was 11.89 mm. Zirconia thickness around distal screw access openings at the middle of the crowns, margins and middle of the gingival areas (buccal side of maxillary prostheses) was 4.29, 3.79, and 3.87 mm, respectively. On the lingual sides the thicknesses were 3.13, 2.85, and 3.15 mm, respectively. For mandibular prostheses the thicknesses were 3.56, 3.08, and 3.15 mm, respectively, on the buccal sides, and 2.07, 2.00, and 2.99 mm, respectively, on the lingual sides. No implant failure or changes in the occlusal surface, chipping of the cuspid or incisal edges, or prosthesis distal extension fractures were observed during follow-up periods ranging from 2 to 7 years. The survival rate was 100% for implants and prostheses. In one of the patients, chipping of the pink ceramic was noted in the maxillary prosthesis 36 months after placement.

CONCLUSIONS

The results of this study indicated that full-arch MZ-FPs without cutback, or with partial digital cutback and veneering ceramic, were a therapeutic option. Recommendations regarding the thickness of zirconia at the level of the distal screw access openings, the crown height spaces, and the lengths of the cantilever segments were recorded. Additional in vitro and clinical studies will be required for more scientific analysis of the criteria for design of this type of prosthesis to minimize prosthetic complications. Long-term and multicenter studies are needed to corroborate the findings discussed in this report.

Complete-arch implant-supported monolithic zirconia fixed dental prostheses: A systematic review

STATEMENT OF PROBLEM

Monolithic zirconia prostheses are emerging as a promising option in the implant-based rehabilitations of edentulous patients, yet their clinical performance is not fully documented.

PURPOSE

The purpose of this systematic review was to assess the clinical performance of complete-arch implant-supported monolithic zirconia fixed dental prostheses.

MATERIAL AND METHODS

The electronic databases PubMed, Science Direct, and Cochrane Library were searched for clinical studies on complete-arch implant-supported monolithic zirconia fixed dental prostheses. Human studies with a mean follow-up of at least 1 year and published in an English-language peer-reviewed journal up to June 2015 were included. Two independent examiners conducted the search and the review process.

RESULTS

The search generated 903 titles. Eighteen qualifying studies were retrieved for full-text evaluation. Nine studies were included on the basis of preestablished criteria. Eight studies reported satisfactory clinical and esthetic outcomes. One study demonstrated prosthesis failure. Clinical studies are lacking on the long-term outcome of complete-arch implant-supported monolithic zirconia prostheses.

CONCLUSIONS

Complete-arch dental implant restoration with monolithic zirconia is associated with high short-term success. Despite the many advantages and short-term favorable reports, studies of longer duration are necessary to validate the broad application of this therapy.