Beruflich Dokumente
Kultur Dokumente
available at www.sciencedirect.com
a r t i c l e i n f o a b s t r a c t
Article history: Objectives. The purpose of the present study was to evaluate the bending resistance of
Received 30 August 2006 implant-supported CAD/CAM-processed restorations made out of zirconia or manually
Accepted 31 May 2007 shaped made out of reinforced alumina.
Methods. Units of abutments and copies made of (i) a prefabricated hot isostatic pressed
(HIPed) yttrium oxide partially-stabilized zirconia (Y-TZP) (Denzir), (ii) a prefabricated
Keywords: densely-sintered magnesia partially stabilized zirconia (Mg-PSZ) (Denzir-M) or, copies made
CAD/CAM of (iii) a prefabricated partially-sintered, porous reinforced alumina ceramic (RN synOcta-
Dental ceramics In-Ceram) were subjected to static loading perpendicularly at the long axis. The abutments
Dental implants were attached to either stainless steel analogs or titanium implant fixtures. The Y-TZP and
Mg-PSZ Mg-PSZ copies were bonded onto the ceramic abutments with a dual-cured resin composite
Titanium (Rely-X Unicem). Units of titanium abutment attached to a titanium implant fixtures were
Y-TZP used as reference.
Results. The units comprising Denzir abutments as delivered (p < 0.05) and heat-treated Den-
zir copies bonded to the Denzir abutments as delivered (p < 0.01) and attached to stainless
steel analogs exhibited significantly higher bending resistance than the control. The heat-
treated Denzir copies bonded to the heat-treated Denzir M abutments attached to titanium
implant fixtures and the In-Ceram specimens attached to stainless steel analogs showed
significantly (p < 0.05) lower bending resistance than the heat-treated Denzir copies bonded
to the Denzir abutments as delivered and attached to stainless steel analogs. No statistically
significant (p > 0.05) differences were seen among the other groups studied.
Significance. All the ceramic abutments and copies exhibited values that were equal or supe-
rior to that of the control and exceeded the reported value, up to 300 N, for maximum incisal
bite forces. To assess the clinical behavior long-term clinical studies should be conducted.
© 2007 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.
∗
Corresponding author. Tel.: +46 90 785 61 32; fax: +46 90 77 56 17.
E-mail address: Goran.Sjogren@odont.umu.se (G. Sjögren).
0109-5641/$ – see front matter © 2007 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.dental.2007.05.021
612 d e n t a l m a t e r i a l s 2 4 ( 2 0 0 8 ) 611–617
among the public concerning allegedly adverse effects of den- resistant to low temperature aging than Y-TZP [14]. The high
tal metals and alloys have resulted in demands for esthetically fracture toughness of the Mg-PSZ prefabricated blanks seems
improved and biocompatible materials. to make it easier to mill dental ceramic restorations of reduced
One ceramic system used for implant-supported abut- thickness [11]. In an earlier paper it was reported that the hard-
ments is In-Ceram Zirconia (Vita Zahnfabrik, Bad Säckingen, ness of Mg-PSZ prefabricated blanks is less than that of the
Germany) [4]. The In-Ceram Zirconia core system is based HIPed Y-TZP and that the time needed to produce restorations
on a partially-sintered, porous alumina structure supple- from prefabricated Mg-PSZ blanks and the wear on the cutting
mented with 33 wt% ZrO2 partially stabilized zirconia, which tools were markedly reduced compared to when HIPed Y-TZP
is infiltrated with molten lanthanum glass [5]. When dental blanks were milled [11].
restorations are made using this system either the slip-cast or In previous papers, it has been suggested that machin-
dry-pressed technique can be used [4,5]. ing and other mechanical surface treatments can affect the
Another ceramic of special interest because of its superior generation of phase transformation of Y-TZP and Mg-PSZ and
mechanical properties compared to other dental ceramics is introduce residual compressive stresses on the surface, which
yttrium oxide partially-stabilized zirconia (Y-TZP) [6–8]. Dental influence the mechanical properties of zirconium ceramics
restorations using Y-TZP are made using recently developed [6–8,11]. In addition, it has been stated that subsequent heat-
CAD/CAM-systems and can be made either out of homo- treatment seems to induce relaxation of the tensile stresses
geneous ceramic green-body blanks of zirconia by milling generated during machining, which also influences the prop-
enlarged restorations, which are then sintered and shrunk erties of the ceramic [7,8,11]. This information has to be taken
to the desired final dimensions [9], or by milling the restora- into consideration when those materials are subjected to sur-
tions directly to the final dimensions out of highly dense face treatments or veneering.
sintered, hot isostatic pressed (HIPed) prefabricated Y-TZP Since there is an increasing demand for ceramic implants
blanks [7,8,10]. Yttrium oxide is added to zirconia as a phase the fracture resistance, among other things, of units compris-
stabilizer to maintain the high temperature tetragonal phase ing implant-supported ceramic abutments and copies are of
(t) and in that way reduces the spontaneous transformation interest. Ceramics are brittle and have a tendency to crack
into the monoclinc phase (m) at room temperature [6]. The but should withstand compressive stresses better than ten-
spontaneous transformation of t into m is known as ‘aging’ sile stresses [15]. Compressive loads to cantilever designed
and it has been stated that the t → m transformation causes implant-retained prostheses are, however, said to result in
mechanical property degradation of the material [6]. bending and tensile forces within certain regions of the pros-
Other oxide additives than yttria can be used as phase thesis [16,17]. The bending resistance of implant-supported
stabilizers and another zirconia ceramic for dental restora- ceramic abutments and copies is, thus, of particular interest.
tions has recently been presented, Denzir-M, a prefabricated According to a survey of the literature, no data were avail-
densely-sintered magnesia partially stabilized zirconia (Mg- able on the strength of implant-supported abutments and
PSZ) [11]. In Denzir-M, MgO is added as the ‘stabilising’ oxide. copies made of Mg-PSZ, HIPed Y-TZP or zirconia reinforced alu-
Mg-PSZ is known to be one of the most commonly used engi- mina ceramics. The aim of the present work, therefore, was to
neering ceramics based on zirconia [12] and to be one of determine the bending resistance of implant-supported abut-
the toughest zirconia-based ceramics in use [13] and more ments and copies made from prefabricated Mg-PSZ or HIPed
RelyX Unicem Resin composite cement 3M ESPE, St. Paul, MN, USA
Straumann solid screw implant, SLA. Ø Titanium Institut Straumann AG,
3.3 mm, 8.0 mm PLUS Waldenburg, Switzerland
Straumann SCS occlusal screw, long, L 7.6 Titanium Institut Straumann AG
mm
Straumann analog for RN synOcta, L 12.0 Stainless steel Institut Straumann AG
mm
Straumann RN synOcta abutment for Titanium Institut Straumann AG
cement-retained crowns/bridges,
height 5.5 mm
Straumann RN synOcta abutment, height Titanium Institut Straumann AG
2.5 mm
Denzir M Prefabricated densely-sintered magnesia partially Cad.esthetics AB,
stabilized zirconia (Mg-PSZ) Skellefteå, Sweden
Denzir Prefabricated hot isostatic pressed (HIPed) yttrium Cad.esthetics AB
oxide partially-stabilized zirconia (Y-TZP)
RN synOcta-In-Ceram Partially-sintered, porous alumina structure Vita Zahnfabrik, Bad
reinforced with 33 wt% ZrO2 partially stabilized Säckingen, Germany
zirconia and infiltrated with molten lanthanum
glass
d e n t a l m a t e r i a l s 2 4 ( 2 0 0 8 ) 611–617 613
3. Results
Table 3 – Location and mode of failure after load-to-fracture test. The letters in the head-line refer to the groups of units
listed in Table 2. (n = 5 in each group)
Fractured or deformed component(s) A B C D E F G H I J
The figures in the columns denote number of specimens. For some of the units more than 1 failure mode is given.
steel blade, which should have aggravated the stress on the 110 GPa for the titanium abutments, respectively. The flex-
specimens. ural strength, according to the manufacturers’ information,
The bending resistance of the abutments and copies was was 500 MPa for Denzir-M, 1000 MPa for Denzir, 600 MPa for
determined for the units assembled either on stainless steel In-Ceram Zirconia, and 400 MPa for the titanium abutments,
analogs or titanium implant fixtures. This was because the respectively. In this context it is worth noting that the mean
modulus of elasticity of stainless steel is reported to be higher values obtained for the units comprising Mg-PSZ (Denzir-M) or
than that of unalloyed titanium, around 200 GPa and 100 GPa, HIPed Y-TZP (Denzir) abutments as delivered were superior,
respectively [21]. The rigidity of the stainless steel analogs was, but not to a statistically significant level, to those obtained
thus, considered to be higher than that of the implant fix- for the units comprising heat-treated abutments. This is in
tures and should therefore resist bending forces better. That agreement with the findings in previous studies, where it has
is, using stainless steel analogs was meant to provide fur- been shown that heat treatment of machined zirconia reduces
ther information about the bending resistance of the ceramic its fracture resistance [8,11]. Another interesting finding was
abutments and the copies studied. However, no statistically that in a preparatory study of four implant-supported units
significant differences were found between the bending resis- comprising titanium abutments assembled on stainless steel
tance determined with similar combinations of abutments analogs, minor fractures could be seen in the upper part of
and/or copies assembled on the titanium implant fixtures and the stainless steel analogs in close proximity to the titanium
those assembled on the stainless steel analogs. After fracture abutment interface after the bending test. This implies that
was registered all the titanium implant fixtures were, how- the stainless steel analogs and titanium abutments were sub-
ever, significantly more bent than the stainless steel analogs. jected to considerable stress concentration in this area. The
In addition, the range of variation in the values obtained for mean value of those specimens, 380 ± 189 N, was the lowest of
the bending resistance was considerably wider for the units all the unit combinations tested, and almost exactly the same
assembled on the stainless steel analogs. as the mean value of the titanium abutments assembled to the
After the load-to-fracture test no visible fracture of the titanium implant fixtures (380 ± 7 N). The theory that ceramic
copies was seen with the naked eye, with the exception abutments can strengthen the implant-supported units is to
of three copies. When the abutments were unscrewed and some extent similar to the theory presented in a previous
inspected after the test, fractures were however observed in all study of the protective effect from bending forces that the
the ceramic abutments in the proximity of the implant screw- coping-abutment interface has on the retaining screw [17]. In
abutment interface or of the stainless steel analog-abutment this earlier study, it was suggested that the configuration of the
interface, except for three of the abutments. This implies that coping-abutment interface would prevent rotation around the
this part of implant-supported restorations is an area of exces- axis of the bending moment and that long, vertical mating sur-
sive stress concentration. The finding is comparable to the faces would protect the retaining screw [17]. Thus, the design
results reported in previous studies of the fracture resistance of the head of the implant fixture and of the fixture/abutment
of alumina and zirconia implant-supported abutments [18,19]. interface seems to play an important role in reducing bending
In those in vitro studies, it was stated that the crack started forces on the abutments, copies and retaining screws. How-
from the cervical portion of the abutments close to the implant ever, more studies are needed to confirm such hypotheses.
interface and the abutment screw [18,19]. The mean values determined for the bending resistance in
Among the 10 unit combinations tested, the only com- the present study ranged from 380 N to 649 N. The titanium
ponent that was included in all the combinations was the abutment assembled on titanium implant fixtures showed
titanium abutment screw. Since statistically significant differ- the lowest mean value (380 ± 7 N), whereas the Denzir heat-
ences were only found between a small number of groups one treated copies bonded to the Denzir abutments as delivered,
can speculate that the titanium abutment screw was the com- and assembled on the stainless steel analogs showed the high-
ponent that largely determined the bending resistance of the est (649 ± 130 N). Reported mean value for the physiological
assembled units. Thirty-five of the titanium abutment screws maximal bite force for men in the anterior region in a study
were markedly bent, deformed, and/or fractured. This is con- by Waltimo and Könönen [22] was up to around 300 N and
sistent with the findings in a study by Tripodakis et al. [2] of up to around 850 N in the molar region. However, since the
the fracture strength and the failure mode of all-ceramic In- stresses and strains of dental restorations in vivo are complex,
Ceram Alumina abutments under static load, in which it was it is difficult to extrapolate in vitro values to clinical situa-
concluded that the weakest link was the abutment screw. tions. Values reported in previous in vitro studies addressing
Even though only two groups showed statistically signifi- the bending resistance of implant-supported all-ceramic abut-
cantly higher values compared to the control, the mean values ments and/or crowns range from 170 N to 738 N [2,18–20,23]. In
of the bending resistance of the units comprising ceramic all those studies, the load was applied at 30 or 45◦ to the long
abutments, irrespective of type of ceramic, pretreatment or axis of the implant and in some of the studies the specimens
combination, were superior to those of the units comprising were subjected to dynamic loading and thermal cycling, and,
titanium abutments. One possible explanation for this may in addition, the size and type of implant fixtures and the sur-
be that the ceramic abutments, with a higher modulus of rounding materials varied, making direct comparison between
elasticity and flexural strength than the titanium abutments, the results difficult [2,18–20]. For example, in the study by
stabilized the implant-supported units and, thus, reduced the Gehrke et al. [20] the specimens that were subjected to static
stress on the titanium abutment screws. Values for the mod- loading exhibited a maximum fracture load of 672 N, whereas
ulus of elasticity provided by the manufacturers were 200 GPa only 269 N was recorded for those subjected to 800,000
for Denzir-M and Denzir, 258 GPa for In-Ceram Zirconia, and cycles. Thus, the experimental set up significantly affected the
d e n t a l m a t e r i a l s 2 4 ( 2 0 0 8 ) 611–617 617
outcome. In the study by Att et al. [18], the mean value of the [6] Piconi C, Maccauro G. Zirconia as a ceramic biomaterial. Rev
fracture resistance of titanium abutment/Al2 O3 crown units Biomater 1999;20:1–25.
subjected to vertical loading was 1344 N, which was around [7] Sundh A, Sjögren G. A comparison of fracture strength of
yttrium-oxide-partially-stabilized zirconia ceramic crowns
three times that determined for the units in the same study
with varying core thickness, shapes and veneer ceramics. J
that comprised Al2 O3 crowns bonded to ZrO2 or to Al2 O3 abut- Oral Rehabil 2004;31:682–8.
ments. This contrasts with the outcome in the present study, [8] Sundh A, Molin M, Sjögren G. Fracture resistance of yttrium
in which the titanium abutment exhibited inferior or almost oxide partially-stabilized zirconia all-ceramic bridges after
equal mean values compared to the ceramic units. However, veneering and mechanical fatigue testing. Dent Mater
in another study it was shown that the loading direction could 2005;21:476–82.
influence the results [23]. In that study, under vertical loading [9] Filser F, Kocher P, Weibel F, Luthy H, Scharer P, Gauckler LJ.
Reliability and strength of all-ceramic dental restorations
the fracture resistance of restorations that comprised tita-
fabricated by direct ceramic machining (DCM). Int J Comput
nium abutments was almost twice that of those comprising Dent 2001;4:89–106.
ceramic abutments, whereas under oblique loading (45◦ ) no [10] Sjölin R, Sundh A, Bergman M. The Decim system for the
statistically significant differences in fracture resistance were production of dental restorations. Int J Comput Dent
seen between the restorations with ceramic abutments and 1999;2:197–207.
those with titanium abutments [23]. All the mean values were [11] Sundh A, Sjögren G. Fracture resistance of all-ceramic
zirconia bridges with differing phase stabilizers and quality
also significantly reduced when the specimens were subjected
of sintering. Dent Mater 2006;22:778–84.
to oblique loading [23]. For example, the fracture resistance of
[12] Liu Z, Spargo AE. Identification of various phases in HRTEM
In-Ceram Alumina crowns bonded to alumina abutments was images of MgO-PSZ. J Electron Microsc 2001;50:443–6.
reduced from 858 ± 91 N at vertical loading to 182 ± 55 N at [13] Hannink RHJ, Howard CJ, Kisi EH, Swain MV. Relationship
oblique loading [23]. between fracture toughness and phase assemblage in
To summarize, all the combinations of ceramic abutments Mg-PSZ. J Am Ceram Soc 1994;77:571–9.
and copies in the present study exceeded the reported value of [14] Masaki T. Mechanical properties of Y-TZP after aging at low
temperatures. Int J High Tech Ceram 1986;2:85–98.
up to 300 N for the physiological maximal incisal bite force. In
[15] Lüthy H, Filser F, Loeffel O, Schumacher M, Gauckler LJ,
addition, the bending resistance of the ceramic specimens was Hammerle CH. Strength and reliability of four-unit
equal or superior to the titanium control. The combinations of all-ceramic posterior bridges. Dent Mater 2005;21:
ceramic abutments and copies studied thus showed promis- 930–7.
ing bending resistance under the tested conditions. However, [16] Rangert B, Jemt T, Jörneus L. Forces and moments on
long-term clinical studies should be conducted to assess the Brånemark implants. Int J Oral Maxillofac Implants
clinical behavior of the ceramic abutments and copies under 1989;4:241–7.
[17] Jaarda MJ, Razzoog ME, Gratton DG. Effect of preload torque
clinical conditions.
on the ultimate tensile strength of implant prosthetic
retaining screws. Implant Dent 1994;3:17–21.
references [18] Att W, Kurun S, Gerds T, Strub JR. Fracture resistance of
single-tooth implant-supported all-ceramic restorations: an
in vitro study. J Prosthet Dent 2006;95:111–6.
[19] Yildirim M, Fischer H, Marx R, Edelhoff D. In vivo fracture
[1] Adell R, Lekholm U, Rockler B, Brånemark PI. A 15-year study
resistance of implant-supported all-ceramic restorations. J
of osseointegrated implants in the treatment of the
Prosthet Dent 2003;90:325–31.
edentulous jaw. Int J Oral Surg 1981;10:387–416.
[20] Gehrke P, Dhom G, Brunner J, Wolf D, Degidi M, Piattelli A.
[2] Tripodakis AP, Strub JR, Kappert HF, Witkowski S. Strength
Zirconium implant abutments: fracture strength and
and mode of failure of single implant all-ceramic abutment
influence of cyclic loading on retaining-screw loosening.
restorations under static load. Int J Prosthodont
Quintessence Int 2006;37:19–26.
1995;8:265–72.
[21] Anusavice KJ. Phillip’s science of dental materials. 11th ed.
[3] Yildirim M, Edelhoff D, Hanisch O, Spiekermann H. Ceramic
St. Louis: Saunders; 2003. p. 765.
abutments—a new era in achieving optimal esthetics in
[22] Waltimo A, Könönen M. A novel bite force recorder and
implant dentistry. Int J Periodontics Restor Dent
maximal isometric bite force values for healthy young
2000;20:81–91.
adults. Scand J Dent Res 1993;101:171–5.
[4] Jackson MC. Posterior implants using a new ceramic
[23] Cho HW, Dong JK, Jin TH, Oh SC, Lee HH, Lee JW. A study on
material. J Dent Technol 1999;16:19–22.
the fracture strength of implant-supported restorations
[5] Apholt W, Bindl A, Lüthy H, Mörmann WH. Flexural strength
using milled ceramic abutments and all-ceramic crowns. Int
of Cerec 2 machined and jointed InCeram-Alumina and
J Prosthodont 2002;15:9–13.
InCeram-Zirconia bars. Dent Mater 2001;17:260–7.