Clinical performance of monolithic zirconia crowns on titanium-zirconium reduced-diameter implants in the molar area: Interim data at three years of a randomized controlled trial

AIM

The aim of the present study was (i) to evaluate the clinical performance of reduced-diameter implants placed in the molar area and (ii) to test whether monolithic zirconia implant-supported crowns lead to similar clinical outcomes compared to porcelain-fused-to-metal crowns.

MATERIALS AND METHODS

A total of 76 patients needing a single implant crown in the posterior region were recruited. All patients received a titanium-zirconium reduced-diameter implant (Straumann Roxolid, Tissue Level, Standard Plus, diameter 3.3 mm, regular neck) randomly allocated to receive either a (1) monolithic zirconia crown (test) or (2) porcelain-fused-to-metal crown (control). Implant survival, prosthetic outcomes, and patient-reported outcomes were assessed at crown delivery and after 3 years of follow-up. Marginal bone levels (MBL) as well as clinical parameters including probing depth (PD), bleeding on probing (BOP), and plaque levels (PCR) were also recorded.

RESULTS

A total of 59 patients were available at the 3-year follow-up; 32 patients with a monolithic zirconia crown (TEST) and 27 patients with a porcelain-fused-to-metal crown (CONTROL). 14 implants (11 implant fractures/3 aseptic losses) were lost leading to an estimated implant survival rate of 80% ± 5.1% (95% CI 70.8%-90.8%). Prosthetic complications were limited to the control group and involved minor chippings.

CONCLUSIONS

This type of reduced-diameter implant to support single implant molar crowns in the molar area cannot be recommended. Monolithic zirconia crowns appear to be a viable option in the posterior region showing similar prosthetic outcomes to porcelain-fused-to-metal crowns.

Ten-Year Performance of Posterior 6-mm Implants with Single-Tooth Restorations: A Randomized Controlled Trial

The aim of the study was to compare the clinical and radiographic outcomes of short dental implants (6-mm test group, TG) to longer implants (10-mm control group, CG) with single crown restorations after 10 y of loading. Patients requiring single-tooth replacement in the posterior jaws were randomly assigned to TG or CG. Implants were loaded with screw-retained single crowns after a healing period of 10 wk. Follow-up appointments were scheduled yearly and comprised patient-adapted oral hygiene reinstructions and polishing of all teeth and implants. After 10 y, clinical and radiographical parameters were assessed again. Out of initially 94 patients (47 in TG and CG, each), 70 (36 TG and 34 CG) could be reassessed. Survival rates accounted for 85.7% (TG) and 97.1% (CG), without significant intergroup difference (P = 0.072). All but 1 lost implant had been located in the lower jaw. These implants were not lost due to peri-implantitis but due to a late loss of osseointegration without signs of inflammation and with actually stable marginal bone levels (MBLs) over the investigation period. In general, MBLs were stable with medians (interquartile ranges) of 0.13 (0.78) mm and 0.08 (1.2) mm, for TG and CG, without significant intergroup differences. Crown-to-implant ratio showed a highly significant intergroup difference of 1.06 ± 0.18 mm and 0.73 ± 0.17 mm (P < 0.001). Few technical complications (i.e., screw loosening or chipping) were registered during the investigation period. In conclusion, given stringent professional maintenance, short dental implants with single-crown restorations show a slightly worse but statistically not different survival rate after 10 y, especially in the lower jaw, but can still be considered a valuable alternative, especially when vertical bone dimensions are limited (German Clinical Trials Registry: DRKS00006290).

Computer-assisted bone augmentation, implant planning and placement: An in vitro investigation

AIM

To assess in vitro the workflow for alveolar ridge augmentation with customised 3D printed block grafts and simultaneous computer-assisted implant planning and placement.

METHODS

Twenty resin mandible models with an edentulous area and horizontal ridge defect in the region 34-36 were scanned with cone beam computed tomography (CBCT). A block graft for horizontal ridge augmentation in the region 34-36 and an implant in the position 35 were digitally planned. Twenty block grafts were 3D printed out of resin and one template for guided implant placement were stereolithographically produced. The resin block grafts were positioned onto the ridge defects and stabilised with two fixation screws each. Subsequently, one implant was inserted in the position 35 through the corresponding template for guided implant placement. Optical scans of the study models together with the fixated block graft were performed prior to and after implant placement. The scans taken after block grafting were superimposed with the virtual block grafting plan through a best-fit algorithm, and the linear deviation between the planned and the achieved block positions was calculated. The precision of the block fixation was obtained by superimposing the 20 scans taken after grafting and calculating the deviation between the corresponding resin blocks. The superimposition between the scans taken after and prior to implant placement was performed to measure a possible displacement in the block position induced by guided implant placement. The (98-2%)/2 percentile value was determined as a parameter for surface deviation.

RESULTS

The mean deviation in the position of the block graft compared to the virtual plan amounted to 0.79 ± 0.13 mm. The mean deviation between the positions of the 20 block grafts measured 0.47 ± 0.2 mm, indicating a clinically acceptable precision. Guided implant placement induced a mean shift of 0.16 ± 0.06 mm in the position of the block graft.

CONCLUSIONS

Within the limitations of this in vitro study, it can be concluded that customised block grafts fabricated through CBCT, computer-assisted design and 3D printing allow alveolar ridge augmentation with clinically acceptable predictability and reproducibility. Computer-assisted implant planning and placement can be performed simultaneously with computer-assisted block grafting leading to clinically non-relevant dislocation of block grafts.

Zirconia implants restored with single crowns or fixed dental prostheses: 5-year results of a prospective cohort investigation

AIM

To evaluate the clinical and radiological outcomes of one-piece zirconia implants restored with single crowns (SCs) or fixed dental prostheses (FDPs) over an observation period of 5 years in function.

MATERIALS AND METHODS

In a prospective cohort investigation with two investigational centers, one-piece zirconia implants were placed in anterior and posterior sites. After a healing period of at least 2 months in the mandible and 4 months in the maxilla with immediate provisional reconstructions, the final all-ceramic SCs or three-unit FDPs were cemented. Patients were followed for 5 years. Clinical parameters and radiological measurements of the implants and the neighboring teeth were assessed. For the statistical analysis, linear mixed models were applied.

RESULTS

A total of 71 implants were placed in 60 patients. Sixty-three implants in 53 patients could be evaluated at the 5-year follow-up. Six patients with a total of seven implants were counted as dropouts. One implant did not achieve adequate osseointegration and had to be removed 5 weeks after implantation. The 5-year survival rate was calculated as 98.4% (95% CI 91.6, 99.9). The mean overall marginal bone loss from implant placement to the 5-year follow-up was 0.7 ± 0.6 mm. After an initial mean marginal loss before loading the implants (0.7 mm), no further statistically significant change in marginal bone level (p = .458) could be observed.

CONCLUSION

The investigated one-piece zirconia implant showed a high survival rate, very stable marginal bone, and mucosal margin levels after 5 years in function. Therefore, it can be considered safe and reliable for the reconstruction of implant-supported SCs or FDPs over a mid-term period.

Success of 6-mm Implants with Single-Tooth Restorations: A 3-year Randomized Controlled Clinical Trial

The aim of the study was to test whether implants of 6 mm in length perform equally well as 10-mm implants in terms of survival and marginal bone-level changes when supporting single crowns. Patients with a posterior single-tooth gap were randomly allocated to either the placement of a 6-mm (test) or 10-mm implant (control). The treatment protocol allowed for internal sinus lift but not for lateral bone augmentation. After a healing period of 10 wk, implants were loaded with screw-retained single crowns. Survival rates, number of pockets ≥5 mm, and bleeding-on-probing were assessed clinically. The change of marginal bone level and crown-to-implant ratios were analyzed by 2 examiners. Longitudinal intragroup analyses for marginal bone levels were performed applying the Wilcoxon signed rank test. Intergroup differences at baseline and at 3 y were compared using the Mann-Whitney U test. The effect of implant length and crown-to-implant ratio on changes of marginal bone level also was determined. Of 94 implants placed (47 test and 47 control), 78 implants (40 test and 38 control) were available for follow-up examination at 3 y of loading. One test implant was lost during the second year. Hence, implant survival was not significantly different between the 2 groups after 3 y (98% test; 100% control). We found no significant change in the crestal bone level from baseline to 3 y for test and control implants with -0.19 ± 0.62 mm and -0.33 ± 0.71 mm, respectively. The intergroup difference was not significant. Crown-to-implant ratios were not associated with a statistically significant difference in marginal bone loss. However, the number of sites with pockets ≥5 mm was significantly higher in the test group. Based on the 3-y assessment, the use of 6-mm implants can be considered a viable option when reconstructing posterior single tooth gaps (German Clinical Trials Registry: DRKS00006290).

Adhesion of veneering resins to polymethylmethacrylate-based CAD/CAM polymers after various surface conditioning methods

OBJECTIVES

The aims of this study were to test whether the bond strength of a hybrid composite and a PMMA-based veneer to CAD/CAM polymers would improve after pre-treatment and to evaluate the failure types after debonding.

MATERIALS AND METHODS

Three types of PMMA-based (CAD-Temp, artBloc Temp and TelioCAD) CAD/CAM blocks were obtained (N = 360, n = 15 per test group). They were divided into four groups to be conditioned with the following methods: (a) no-treatment, (b) air-abrasion (50 μm Al2O3), (c) air-abrasion (50 μm Al2O3) + MPS-Silane (Monobond S) + Adhesive resin (StickResin) (for Gradia)/MMA (for Integral Esthetic Press) application, (d) Silica coating and silanization (CoJet-System). The conditioned surfaces were veneered with a hybrid composite (Gradia) or a PMMA-based resin (Integral esthetic press). After water storage (1 week, 37°C), the bond strength was measured. Data were analyzed using 3-way ANOVA and post-hoc Scheffé test (α = 0.05).

RESULTS

Surface-conditioning method, veneer type and CAD/CAM polymers significantly affected the results. Hybrid composite did not bond to non-conditioned CAD/CAM polymers. Regardless of the conditioning method, PMMA-based resin showed significantly higher bond strength to all CAD/CAM polymers compared to hybrid composite. Air-abrasion increased the bond strength in all tested groups. Additional silane application after air-abrasion did not significantly increase the bond strength of hybrid composite. While exclusively adhesive failures were observed between the hybrid composite and the CAD/CAM polymers, PMMA veneer demonstrated cohesive failures in the CAD/CAM polymers.

CONCLUSION

CAD/CAM polymers could be veneered with only a PMMA-based veneer with and without air-abrasion.

The effect of dentin desensitizer on shear bond strength of conventional and self-adhesive resin luting cements after aging

This study tested the impact of Gluma Desensitizer on the shear bond strength (SBS) of two conventional (RelyX ARC, Panavia 21) and two self-adhesive (RelyX Unicem, G-Cem) resin luting cements after water storage and thermocycling. Human third molars (N=880) were embedded in acrylic resin. The buccal dentin was exposed. Teeth were randomly divided into four main groups, and the following cements were adhered: 1) RelyX ARC, 2) Panavia 21, 3) RelyX Unicem, and 4) G-Cem. In half of the teeth in each group, dentin was treated with Gluma Desensitizer. In the conventional cement groups, the corresponding etchant and adhesive systems were applied. SBS of the cements was tested after 1 hour (initial); at 1, 4, 9, 16, and 25 days of water storage; and at 1, 4, 9, 16, and 25 days of thermocycling. SBS data were analyzed by one-way analysis of variance (ANOVA); this was followed by the post hoc Scheffé test and a t-test. Overall, the highest mean SBS (MPa) was obtained by RelyX ARC (ranging from 14.6 ± 3.9 to 17.6 ± 5.2) and the lowest by Panavia 21 in combination with Gluma Desensitizer (ranging from 0.0 to 2.9 ± 1.0). All tested groups with and without desensitizer showed no significant decrease after aging conditions compared with baseline values (p>0.05). Only the Panavia 21/Gluma Desensitizer combination showed a significant decrease after 4 days of thermocyling compared with initial values and 1 day thermocycling. Self-adhesive cements with Gluma Desensitizer showed increased SBS after aging conditions (ranging from 7.4 ± 1.4 to 15.2 ± 3) compared with groups without desensitizer (ranging from 2.6 ± 1.2 to 8.8 ± 2.9). No cohesive failures in dentin were observed in any of the test groups. Although self-adhesive cements with and without desensitizer presented mainly adhesive failures after water storage (95.8%) and thermocyling (100%), conventional cement (RelyX ARC) showed mainly mixed failures (90.8% and 89.2%, after water storage and thermocyling, respectively). Application of the Gluma Desensitizer to dentin before cementation had a positive effect on the SBS of self-adhesive cements.

10-year clinical outcomes of fixed dental prostheses with zirconia frameworks

OBJECTIVES

The aim of this prospective clinical study was to assess the long-term clinical survival rate and the technical and biological complication rates of zirconia-based posterior FDPs.

MATERIALS AND METHODS

Forty-five patients in need of one or more posterior FDPs received 57 three- to five-unit zirconia-based FDPs. The frameworks were fabricated by means of a prototype computer-aided manufacturing (CAM) system (direct ceramic machining, DCM), first processing zirconia in the white stage. The frameworks were veneered with a prototype veneering ceramic.The FDPs were adhesively placed. At baseline, 6 months, and 1,2, 3, 5, 8 and 10 years of function, the FDPs were examined for technical and/or biological complications. Furthermore, the periodontal health of the abutment teeth (test) and untreated control teeth was analyzed. Statistical analysis was performed applying descriptive statistics, Kaplan-Meier survival and multiple mixed effects regression tests.

RESULTS

Twenty-one patients with 26 FDPs were examined at a mean observation time of 10.7 +/- 1.3 years. A total of 16 FDPs were lost to follow-up. Fifteen FDPs had to be replaced due to technical/biological complications; hence, the 10-year survival rate of the FDPs was 67%. Three framework fractures occurred, resulting in a 10-year survival rate for the zirconia frameworks of 91.5%. Chipping/fracture of the veneering ceramic was detected in 16 FDPs over 10 years (complication rate 32%). A significant correlation of the span of the FDPs and the incidence of chipping was observed: 4- and 5-unit FDPs had a 4.9 times higher probability for chipping than 3-unit FDPs. Marginal discrepancy/degradation was found in 90.7% of the FDPs over 10 years. At 11 of the FDPs (complication rate 27%), secondary caries occurred. No difference of the periodontal health was found around test and control teeth.

CONCLUSION

The zirconia frameworks exhibited very good long-term stability. However, the zirconia-based FDPs frequently exhibited problems such as marginal deficiency or chipping of the veneering ceramic. Both problems may be associated with the prototype status of the system.

Misfit of suprastructures on implants processed by electrical discharge machining or the Cresco method

OBJECTIVE

To assess the accuracy of fit of frameworks on implants processed with electrical discharge machining (EDM) or the Cresco technique (Astra Tech).

METHOD AND MATERIALS

On 12 identical master casts with implants at positions 9(21), 11(23), and 13(25), high-gold alloy frameworks were produced by standard casting procedure. Six frameworks were used for the Cresco technique (group CRE) by employing specific fixed partial denture supports. The remaining 6 frameworks were cast with prefabricated gold copings and served as control. The finished frameworks were screwed onto implant 25 of the corresponding master cast. Dimensions of the marginal gaps were measured at 4 locations on each implant under the scanning electron microscope, applying the replica technique. Subsequently, the control group was processed by EDM (SAE EDM 2000) (group EDM) and analyzed alike. Statistical analysis of the results was performed with Kruskal-Wallis and Mann-Whitney U tests.

RESULTS

The mean marginal gaps were measured as follows (CRE/EDM/control): position 25: 0.0 microm/1.0 +/- 1.6 microm/1.5 +/- 2.1 microm; position 23: 5.2 +/- 5.6 microm/18.7 +/- 29.3 microm/23.6 +/- 30.7 microm; and position 21: 36.0 +/- 21.6 microm/40.7 +/- 31.0 microm/46.0 +/- 41.1 microm. The only statistically significant difference was found at location 23 between group CRE on one side and both group EDM and control on the other side. The strong increase of misfit for group CRE from location 23 to location 21 indicates that laser welding is the crucial parameter in this technique.

CONCLUSION

The Cresco technique has a potential to reduce the marginal gap between implants and suprastructures.

Theoretical knowledge in implant dentistry for undergraduate students

Implant therapy has evolved into an important part of daily dental practice. Appropriate knowledge of diagnostic and therapeutic options with dental implant therapy is, therefore, mandatory for dental students. The present consensus paper describes the theoretical knowledge as a foundation to the teaching of implant dentistry at the undergraduate level. Students need a solid basic knowledge about biological prerequisites and clinical procedures leading to successful implant treatment and, in particular, an understanding of the importance of embedding implants into the overall treatment concept. Among others this includes aspects of bone and soft tissue integration of dental implants, as well as aspects of materials that are used in implant dentistry. The students should also be able to differentiate between low, medium and high-risk situations, which assumes that they have knowledge about a proper clinical examination. Furthermore, the students need to be able to inform the patient about the different treatment options and their advantages and disadvantages. Frequently, a choice has to be made between an FDP anchored on teeth and an implant-borne reconstruction. This is highly influenced by the long-term prognosis of the different treatment options. In order to perform implant placement in uncomplicated cases and to give appropriate patient information, adequate knowledge of surgical procedure and surgical complications is mandatory. Furthermore, the dentist needs to be competent in evaluating clinical situations and in advising patients about the suitability of the different options, e.g. removable or fixed reconstructions. It is possible that peri-implant tissue destruction may be a more common finding during long-term service of implant-borne reconstructions than was previously believed. The dentist needs knowledge about etiology and pathogenesis of peri-implantitis and should know how to provide an effective maintenance care programme. In cases of peri-implantitis the student should be knowledgeable regarding suitable interventions.

Flexural strength of veneering ceramics for zirconia

OBJECTIVES

The flexural strengths of veneering ceramics for zirconia were compared.

METHODS

With 10 different veneering ceramics for zirconia (test group) and three different veneering ceramics for the metal-ceramic technique (control group) three-point flexural strength and biaxial flexural strength according to ISO 6872: 1995 as well as four-point flexural strength according to EN 843-1: 2005 were measured (n=10). Statistical analysis was performed with one-way ANOVA and post hoc Scheffé test (SPSS, p<0.05).

RESULTS

For the test group, three-point flexural strength ranged between 77.8+/-8.7 and 106.6+/-12.5MPa without any statistically significant differences, biaxial flexural strength between 69.1+/-4.8 and 101.4+/-10.5MPa with three homogeneous groups and four-point flexural strength between 59.5+/-6.2 and 89.2+/-9.5MPa with five homogeneous groups. The control group showed three-point flexural strength values ranging from 93.3+/-13.5 to 149.4+/-20.5MPa, biaxial flexural strength values from 93.4+/-10.0 to 141.2+/-11.6MPa, and four-point flexural strength values from 82.7+/-8.5 to 116.9+/-9.8MPa. In every case, the results of the four-point flexure test were significantly lower than those obtained in the three-point flexure test. The three-point flexural strengths of the test group are similar to those of two ceramics of the control group. The flexural strength of one ceramic of the control group significantly exceeded the strengths of all other ceramics investigated.

CONCLUSION

Three-point flexural strength values of veneering ceramics for zirconia are similar to those of veneering ceramics for the metal-ceramic technique. The four-point flexure test among all three tests showed highest discrimination between the different ceramic materials.

Visual and spectrophotometric shade analysis of human teeth

Due to interhuman differences in the perception of color, visual shade assessment of human teeth is lacking standardization that may be improved by the use of a spectrophotometer. In this study, we tested the hypothesis that spectrophotometric assessment of tooth color is comparable with human visual determination. On 30 patients, three operators with unreported visual color deficiency independently selected the best match to the middle third of unrestored maxillary central incisors, using a Vita Classical Shade Guide. The same teeth were measured by means of a reflectance spectrophotometer. In the human group, all 3 visual shade selections matched in only 26.6%. In the spectrophotometric group, all 3 shade selections matched in 83.3%. In 93.3%, Delta E values of visually assessed tooth shades were higher than spectrophotometrically assessed Delta E values (p < 0.0001). The results suggest that spectrophotometric shade analysis is more accurate and more reproducible compared with human shade assessment.