Prospective Evaluation of Posterior Fixed Zirconia

Dental Prostheses: 10-Year Clinical Results

Sven Rinke, Priv-Doz, Dr Med Dent, MSc1/Jens Wehle, Dr Med Dent2/Xenia Schulz, MSc3/
Ralf Bürgers, Prof Dr Med Dent4/Matthias Rödiger, Priv-Doz, Dr Med Dent5

Purpose: To investigate the clinical survival and success rates of conventionally luted three- and
four-unit fixed dental prostheses (FDPs) with zirconia frameworks (Cercon Smart Ceramics,
DeguDent) after a mean observation period of 119 ± 36 months. Materials and Methods:
A total of 75 patients were treated in the Department of Prosthodontics at the University
of Goettingen, Germany, and a total of 99 posterior FDPs were inserted and luted with zinc
phosphate cement. Time-dependent survival and success rates were calculated using Kaplan-
Meier curves, and their relationships with the type of veneer (ceramic), location (maxilla vs
mandible), and span length (three-unit vs four-unit) were analyzed with a Cox regression model
(P < .05). Results: Of the 99 inserted FDPs, 24 were lost to follow-up, 51 remained functional
and passed the 10-year examination (overall survival rate: 75.0%; 95% confidence interval [CI]:
0.64, 0.85), and 13 were absolute failures caused by technical events (technical survival rate:
84%; 95% CI: 0.64, 0.85). In 50 FDPs, relative failure required a clinical intervention to maintain
function (overall success rate: 40%; 95% CI: 0.29, 0.52). For 35 of these FDPs, the relative
failure was caused by technical events (technical success rate: 61%; 95% CI: 0.49, 0.73). None
of the evaluated factors showed an association with overall or technical survival or success.
Conclusion: Zirconia-based posterior FDPs produced with a first-generation computer-assisted
manufacturing (CAM) system revealed high rates of absolute and relative failure, mainly due
to technical events, after a mean observational period of 10 years. Further clinical studies with
updated computer-assisted design (CAD)/CAM systems are needed to determine the long-term
performance of zirconia-based FDPs. Int J Prosthodont 2018;31:35–42. doi: 10.11607/ijp.5283

In previous decades, zirconia (ie, yttrium-containing

tetragonal zirconia polycrystalline [Y-TZP]) has been
well established in the field of fixed prosthodontics.
This process was promoted by advanced require-
ments regarding esthetics and biocompatibility in
dental therapies and was stimulated by the excellent
mechanical properties of zirconia.1,2 There have been
several clinical investigations evaluating the perfor-
mance of zirconia-based fixed dental prostheses
(FDPs). Nevertheless, studies documenting long-term
1PrivatePractice, Hanau, Germany; Adjunct Professor, Department of
Prosthodontics, Georg-August-University, Goettingen, Germany.
2Researcher, Department of Prosthodontics, Georg-August-University,
Goettingen, Germany.
3Researcher, Department of Medical Statistics, Georg-August-University,
Goettingen, Germany.
4Professor, Department of Prosthodontics, Georg-August-University,
Goettingen, Germany.
5Adjunct Professor, Department of Prosthodontics, Georg-August-University,
Goettingen, Germany.
Correspondence to: Dr Matthias Rödiger, Department of Prosthodontics,
Georg-August-University, Goettingen, Robert-Koch-Str. 40, 37075
Goettingen, Germany. Fax: +49 551 39 8118.
Email: mroedig@gwdg.de
©2018 by Quintessence Publishing Co Inc.
results with mean observation times of more than 5
years are still rare. Some studies with more extend-
ed follow-up periods were recently published that
showed survival rates for zirconia-reinforced, glass-
infiltrated alumina ceramic FDPs ranging from 83.4%
after 7 years to 94.7% after 6.9 years and to 84.6%
after 9.7 years.3–5 One study published in 2011 that
used a prototype computer-assisted manufactur-
ing (CAM) system (a precursor of the system used
in the present study) reported high complication and
failure rates after an observation time of 10.7 years,
with a 10-year overall survival rate of only 67% and
a significantly higher ceramic veneer fracture (CVF)
rate for four- and five-unit FDPs than for three-unit
FDPs.6 In general, the most common technical com-
plication associated with zirconia-based restorations
was CVFs, with a 5-year incidence of up to 30%.
These fractures led to significantly inferior stability of
the ceramic veneer in relation to porcelain-fused-to-
metal (PFM) restorations.7–12 Other crucial factors in
the survival and success rates of zirconia-based FDPs
have been reported in long-term clinical studies and
systematic reviews, including the minimum diameter
of the connectors, maximum span length, marginal
and internal precision, and secondary caries and loss
of retention.10,11

Volume 31, Number 1, 2018 35

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Posterior Fixed Zirconia Dental Prostheses Evalution
In addition, the processing technique for zirconia
cores might be an influential factor on the frequency
of core fractures. Zirconia can be milled in a presin-
tered state and subsequently sintered to final density.
Another fabrication process is based on the milling
of the restoration directly from hot isostatic pressed
(HIP) zirconia, which results in a higher fracture force
resistance. This process might be important for the
prevention of framework fractures; however, it is more
time consuming than milling from a presintered mate-
rial.6–14 Conventional luting for zirconia FDPs has been
reported to be a possible risk factor for retention loss
and secondary caries.3,15 Moreover, retention loss oc-
curred more frequently in FDPs luted with zinc phos-
phate or glass-ionomer cements than in restorations
fixed with resin cements.11
The aim of the current investigation was to determine
the time-dependent (10-year) overall and technical sur-
vival and success rates using Kaplan-Meier curves for
CAM-fabricated, conventionally luted posterior zirconia
FDPs. The 4- and 7-year results of this study popula-
tion have already been published.3,15 Furthermore,
possible risk factors for clinical absolute and relative
failures, such as span length (three-unit/four-unit), po-
sition (maxilla/mandible), and type of ceramic veneer
(experimental/Cercon Ceram S), were evaluated with a
multivariate Cox regression model. The null hypothesis
was that the 10-year clinical performance of posterior
zirconia-based FDPs is comparable to the overall sur-
vival and success rates documented in the literature for
fully veneered metal-ceramic FDPs.10,11
Materials and Methods
Patient Selection
In this study, 75 patients (36 female, 39 male) were
recruited from 2001 to 2005 in the Department of
Prosthodontics at the University Medical Center of
Goettingen, Germany. The subjects’ ages ranged from
26 to 76 years (mean age: 49.4 ± 12.4 years). Inclusion
criteria included a signed consent form, antagonistic
teeth in the area of the FDP, vital abutments or abut-
ments with sufficient endodontic treatment, and a
maximum of two missing neighboring teeth in the
posterior area. Patients with one or more of the fol-
lowing diagnoses were excluded from participation:
bruxism, severe periodontal disease, pulpitis, a hori-
zontal abutment tooth mobility of ≥ 1 mm, or preg-
nancy/lactation. The patients were informed of the
purpose of the investigation, clinical procedures, and
advantages/risks of the applied material. The Ethics
Committee of the University of Goettingen approved
the study (application no. 19/9/00). All subjects pro-
vided written informed consent.
36 The International Journal of Prosthodontics
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Clinical Approach
The clinical procedures were similar to those used
with metal-ceramic restorations. With the excep-
tion of two FDPs inserted by students under the su-
pervision of a dental clinician, the procedures were
performed by experienced dentists (full-time faculty
members). Detailed initial instructions and clinical
training were performed to ensure calibration of the
clinicians who treated the patients. All patients re-
ceived oral hygiene instructions and professional
prophylaxis prior to prosthetic treatment. Patients re-
ceived up to four FDPs. A total of 99 tooth-supported,
single-span FDPs supported by terminal abutments
(81 three-unit and 18 four-unit/two neighboring
pontics) were inserted (39 in the maxilla, 60 in the
mandible). A composite was used for the core build-
up for the majority of abutment teeth; however, the
preparation design was modified in accordance
with the guidelines for zirconia-based restorations.
Specifically, a chamfer design with a circular reduc-
tion of at least 0.8 mm was used. The occlusal reduc-
tion was 1.5 to 2 mm, and the taper angle ranged from
6 to 8 degrees (according to the manufacturer’s in-
structions). Impressions were made with a polyether
material (Impregum, 3M ESPE). The FDPs were finally
luted with zinc phosphate cement (Harvard, Richter
& Hoffmann Harvard Dental). The preferred occlusal
concepts were a canine-protected articulation or a
group function on canines and premolars.
Laboratory Techniques
All frameworks were produced using a CAM system
(Cercon smart ceramics, DeguDent) introduced to the
German market in 2001. For the frameworks, manually
fabricated wax patterns were digitized and enlarged
by about 30% to compensate for shrinkage during
sintering. Frameworks were milled from presintered
zirconia blanks (Cercon base, DeguDent). All FDPs
were produced with the same device (Cercon brain,
DeguDent) and then sintered to full density for 6
hours at 1,350°C (Cercon heat, DeguDent). The mill-
ing unit was calibrated every 6 months according to
the manufacturer’s instructions. The burs were cali-
brated with individual barcodes that were read by the
scanner of the milling device and were changed every
50 units. A total of 97 FDPs were fabricated from non-
colored blanks, and the remaining 2 were milled from
a dentin-colored presintered material (Cercon base-
colored, DeguDent). The minimum framework thick-
ness was 0.4 mm. To optimize the periodontal area
around the abutment teeth, the minimum connector
dimension was 9 mm2. The frameworks manufactured
in 2001 (51 units) were veneered with an experimental

ceramic veneer. This material was designed for the
veneering of titanium and zirconia frameworks and
therefore had an intermediate thermal expansion co-
efficient (TEC) of 8.5 µm/m*K. Since the beginning of
2002, a ready-to-market veneering material (Cercon
Ceram-S, DeguDent) with a TEC optimized for the
veneering of zirconia frameworks (9.5 µm/m*K) was
used for the remaining 48 FDPs. The internal parts of
the reconstructions were sandblasted with aluminum
oxide (110 μm, 2.0 bar) before the FDPs were cement-
ed. After the final adjustment of the occlusion, the
surface was meticulously polished.
Evaluation Procedures
The examinations started at the point of final cemen-
tation (baseline). To determine the points of potential
complications as precisely as possible, the patients
were continuously re-evaluated at 6-month follow-
up intervals for the first 5 years and annually there-
after. The dentist who placed the restoration did not
perform the follow-up examination. The following
parameters were assessed: decementation (mobil-
ity); loss of vitality of the abutment teeth (cold spray
test); need for endodontic treatment; marginal integ-
rity; secondary caries; fracture of the framework; and
CVFs. Radiographic images were used to verify the
clinical diagnosis of secondary caries and endodon-
tic complications. All patients were asked to visit the
Department of Prosthodontics exclusively if any prob-
lems occurred.
Statistical Analyses
In the statistical analyses, information was used on
the survival and success rates of the reconstructions.
Overall survival was defined as a reconstruction that
remained in situ at the follow-up examination without
meeting an absolute failure criterion (in situ criteri-
on).3,7,10,11,15 Absolute failure was defined as a techni-
cal event (eg, ceramic fracture, loss of retention) or a
biologic event (eg, caries, tooth fracture, periodontal
reason) that required replacement of the entire FDP
or the extraction of an abutment tooth. Technical sur-
vival was defined as a reconstruction that remained in
situ without an absolute failure caused by a technical
event. Overall success was defined as a reconstruc-
tion that remained unchanged and free of a relative
failure. A relative failure was defined as a technical or
biologic event that required a clinical intervention to
maintain function.3,7,10,11,15 Technical success was de-
fined as a reconstruction that remained in situ without
a relative failure caused by a technical event.
Necessary interventions to maintain function due
to relative failure were divided into technical events
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Rinke et al
Table 1   Reasons for Absolute Failures
No. of restorations
Type of absolute failure (N = 99)
Technical events 13
  Core fracture 4
  Extensive ceramic veneer fracture 4
  Retention loss 5
Biologic events 10
  Marginal secondary caries 6
  Periodontal lesion 2
  Root fracture 2
Unknown 1
Total 24
(eg, minor CVF, recementation of an intact FDP) and
biologic events (eg, caries, endodontic treatments,
periodontal interventions). The survival time of an FDP
was defined as the period between the day of cemen-
tation and the last follow-up appointment or, in the
case of a failure/event, the appointment scheduled to
address the failure/event as documented in the pa-
tient’s file.3,7,10,11,15 Data were classified as censored
observations if patients were lost to follow-up or de-
clined further participation in the study.
Time-dependent technical survival and success
rates of FDPs were calculated for span length (three-
unit vs four-unit), position (maxilla vs mandible), and
ceramic veneer (experimental ceramic vs Cercon
Ceram-S) using Kaplan-Meier survival analysis. The
influences of span length, position, and ceramic ve-
neer on technical survival and success rates were
examined using a multivariate Cox regression model.
Different observations from the same patient were
considered to be dependent on the adjusted variance
estimation in the Cox regression model.16
The significance level was set at α = 5% for all
statistical tests. All analyses were performed using
R statistical software (version 3.0.2, www.r-project.org)
with the R-package ‘prodlim’ for the survival analyses.
Results
Of the 99 FDPs, 51 passed the 10-year examination.
The mean observation time was 119 ± 36 months
(minimum = 100, maximum = 165). A total of 24 FDPs
had to be coded as dropouts (recall rate of 75.8%), and
their data were censored. Another 24 FDPs were con-
sidered absolute failures following replacement of the
FDP: 13 were caused by technical events and 10 by bi-
ologic events. Moreover, one FDP was lost in alio loco
for unknown reasons (Table 1). Therefore, the overall
10-year survival rate was 75.0% (95% confidence in-
terval [CI]: 0.64, 0.85) according to the Kaplan-Meier
analysis (Fig 1). The corresponding 10‑year technical
Volume 31, Number 1, 2018 37
Posterior Fixed Zirconia Dental Prostheses Evalution
100
75
Overall survival (%)
50
25
0 0
0 20 40 60 80 100 120 140 160
Time (mo)
Fig 1  Time-dependent overall survival rate and 95% confidence
interval.
a b
Fig 3   Catastrophic failure of a Cercon FDP 35–37 after 9 years of
clinical function. (a) Massive cohesive fracture of the ceramic veneer
(white arrow) and a core fracture at the distal connector (arrow head).
(b) FDP after removal of the pontic fragment.
survival rate (free of absolute failure caused by tech-
nical events) was 84% (CI: 0.75, 0.94) (Fig 2). Of the 13
absolute failures caused by technical events, 4 were
related to core fractures (Fig 3). Additionally, four
FDPs failed due to extensive CVFs, and five failures
were related to loss of retention (recementation not
possible) (Table 1).
Only 24 of the 99 FDPs remained functional
without any clinical intervention; thus, the overall
success rate (free of any events) after a mean ob-
servation time of 10 years was 40.0% (CI: 0.29, 0.52)
(Fig 4). Relative failures occurred in 50 FDPs. Eleven
biologic events required a clinical intervention to
maintain function: Six FDPs with secondary caries
required marginal composite filling, and endodontic
treatment of an abutment tooth was needed for five
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100
75
Technical survival (%)
50
25
0 20 40 60 80 100 120 140 160
Time (mo)
Fig 2   Time-dependent technical survival rate and 95% confidence
interval.
(Table 2). A total of 39 relative failures were caused
by technical events (1 marginal core fracture/31
CVFs/7 loss of retention) (Table 2). Thus, the techni-
cal success rate (free of technical events) after an
observation period of 10 years was 57% (CI: 0.45,
0.69) (Fig 5).
For 35 FDPs, relative or absolute failure of the ce-
ramic veneer was recorded. In four FDPs, extended
fractures led to replacement of the FDP. The functions
of all other FDPs could be maintained by polishing (Fig
4). The 10-year ceramic veneer success rate based on
Kaplan-Meier analysis was 61% (CI: 0.49, 0.73).
A Cox regression model was used to identify risk
factors for absolute and relative failures in the zir-
conia FDPs. Factors considered were span length
(three-unit/four-unit), position (maxilla/mandible),
and type of ceramic veneer (experimental/Cercon
Ceram S). None of these factors had significant ef-
fects on overall or technical survival and success
rates (Table 3). However, the overall survival rate
showed a tendency for a possible association with
FDP position (Hazard Ratio [HR]: 0.46/P = .0686).
The survival probability for FDPs in the mandible
was 69% (CI: 0.56, 0.82); for those in the maxilla, it
was 83% (CI: 0.7, 0.95) (Table 3).
Discussion
This study revealed that, after a mean observation
time of 10 years, CAM-fabricated, zirconia-based
FDPs in the posterior region had an overall survival
rate of 75.0% (CI: 0.64, 0.85) and an overall success
rate (free of any intervention) of 40% (CI: 0.29, 0.52).
The overall survival rates reported in systematic re-
views for metal-ceramic FDPs range from 94.4% after
5 years to 89.2% after 10 years.7,8,11
 Rinke et al

100 100

75 75

Technical success (%)

Overall success (%)

50 50

25 25

0 0
0 20 40 60 80 100 120 140 160 0 20 40 60 80 100 120 140 160
Time (mo) Time (mo)

Fig 4  Time-dependent overall success rate and 95% confidence Fig 5   Time-dependent technical success rate and 95% confidence
interval. interval.

Table 2   Relative Failures and Corresponding Clinical Intervention to Maintain Function
Type of relative failure No. of restorations (N = 99) Management
Marginal core fracture 1 Sealing with composite
Ceramic veneer fracture 31 Polishing
Loss of retention 7 Adhesive recementation
Secondary caries 6 Sealing with composite
Loss of vitality 5 Endodontic treatment
Total 50

In the present study, an annual overall failure rate Table 3   M

 ultivariate Cox Regression Results
of 2.5% was calculated. This rate is in the range of Reflecting Model Coefficient,
Hazard Ratio (HR), and 95% Confidence
the annual failure rates calculated for FDPs made Interval (CI) and Significance of Span Length,
from densely sintered zirconia in a systematic review Position, and Ceramic Veneer on Overall and
(2.02%) based on studies published between 1998 Technical Survival and Success Rates
and 2013.10 In the same review, based on 15 studies Parameter Coefficient HR HR 95% CI P
published between 1989 and 2013, the annual failure Overall survival
rate for metal-ceramic FDPs was estimated at 1.15%.10   Span length –0.23 0.8 0.35, 1.8 .5866
The date of publication is highly relevant for the  Position –0.77 0.46 0.2, 1.04 .0636
comparison of the overall survival rates between   Ceramic veneer –0.43 0.65 0.26, 1.63 .358
zirconia and metal-ceramic FDPs. To reduce poten- Overall success
tial sources of bias, all restorations should be fully   Span length 0.05 1.05 0.59, 1.88 .8570
veneered using the same type of material in the oc-  Position –0.39 0.68 0.37, 1.22 .1906
clusal area. This precondition is fulfilled in the above-   Ceramic veneer 0.25 1.29 0.70, 2.39 .4197
mentioned systematic review10 because only recently Technical survival
published studies for metal-ceramic FDPs were in-   Span length –0.57 0.57 0.15, 2.17 .4071
cluded. This eliminates potential bias introduced by  Position –0.38 0.68 0.25, 1.84 .4529
partially veneered or gold-acrylic restorations includ-   Ceramic veneer –0.36 0.7 0.18, 2.68 .6001
ed in earlier published reviews.10 Therefore, it must be Technical success
stated that the overall survival rates for zirconia-based   Span length 0.18 1.2 0.52, 2.77 .677
FDPs fabricated with an early-stage CAM system are  Position –0.01 0.99 0.49, 1.99 .9743
inferior to those of metal-ceramic FDPs fabricated   Ceramic veneer 0.53 1.7 0.83, 3.48 .1464
with various framework materials (eg, titanium, gold
alloys, or cobalt-chromium).

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Posterior Fixed Zirconia Dental Prostheses Evalution
In the present study, an overall complication rate
(both biologic and technical events) of 60% after a
mean observation period of 10 years was calculated.
This finding supports the findings of a systematic re-
view reporting a 5-year overall complication rate of
27.6% for zirconia FDPs.11 The majority of complica-
tions in the present study were caused by technical
events, and the most common technical complica-
tions were CVFs and loss of retention. This finding is
also in agreement with the findings of two more re-
cently published systematic reviews that reported the
incidence of CVFs and loss of retention were signifi-
cantly higher for zirconia FDPs than for metal-ceramic
FDPs.10,11 The most frequent biologic complication
was secondary caries. This finding supports the find-
ings of a systematic review that reported a significant-
ly higher rate of secondary caries with zirconia FDPs
than with metal-ceramic FDPs.10
When interpreting the results of the present study,
the fact that the study was started in 2001 with an
early-stage CAM system must be considered. The
present results led to the suggestion that the increased
event rates for secondary caries and loss of retention
are directly related to semi-optimal fit of the FDPs fab-
ricated at this stage of development.10,11 The effect of
the fabrication technique on clinical performance can
be demonstrated in the results of the present study,
which used a first-generation CAM system (Cercon
Smart Ceramics, DeguDent) rather than its precur-
sor prototype CAM system (DCM-system, University
of Zürich). The 10-year overall survival rate for the
FDPs fabricated with the CAM prototype system was
67% (present study: 75%), the framework fracture
rates were 8.5% for the prototype system (6.2% in the
present study), and the complication rates caused by
secondary caries were 27% for the prototype system
(8% in the present study). This effect might be attrib-
uted to an improved quality of fit for the restoration
due to improved scanning technology and new mill-
ing strategies. Nevertheless, for the first-generation
CAM system used in the present study, reduced inter-
nal fit accuracy compared with that of metal-ceramic
crowns has been demonstrated.3,10,15 This reduced
internal fit quality might explain the increased risk for
loss of retention, especially if conventional cementa-
tion methods are used.3,10,11 Since the starting point of
the present study, various improvements in scanning
and milling technology have been introduced to im-
prove fit accuracy, thus reducing at least two types of
failures observed in the present study: loss of reten-
tion and secondary caries.3,6,15
Moreover, technical improvements, such as pro-
longed cooling periods during the veneering firing
process and a pronounced anatomical design of the
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zirconia cores, offer reduced chipping rates and are
not included in the present study.17–19
Furthermore, it must be considered that the pres-
ent study was conducted in a university setting.
Additionally, the FDPs were fabricated by experienced
dentists. This issue can bias the outcome measure-
ments; therefore, more data generated under typical
conditions in a private practice are needed to deter-
mine the clinical performance more comprehensively.
Additionally, it must be noted that 21 subjects (24
FDPs) did not attend the 10-year follow-up examina-
tion. Consequently, they could not be reassessed, re-
sulting in a dropout rate of 24%.
Even given the limitations of the present study, the
findings make a valuable contribution to the literature
on the clinical performance of all-ceramic FDPs, as
they provide 10-year data from a prospective clinical
study, which is still rare for this type of restoration.3–6,11
There is only one study with a mean observation
time of more than 10 years that evaluated a proto-
type CAM system for zirconia-based FDPs.6 Further
studies with at least 10-year results only exist for
other all-ceramic materials—such as glass-infiltrated
alumina ceramic and lithium disilicate—or for implant-
based FDPs,5,20–24 and in other studies, 10-year rates
were only estimated.4 The estimation of survival and
success is based on the assumption of a constant
annual event rate throughout the follow-up period.
However, if the annual failure rates change for longer
evaluation periods, estimation of survival and success
rates could be difficult and carries a risk of under- or
overestimation.10 To avoid the possible bias of estimat-
ed survival rates based on studies with limited evalu-
ation periods, clinical trials with prolonged evaluation
periods, such as in the present study, are useful.5,6,21,24
In the present study, 4 out of 24 absolute failures
were caused by framework fractures. This finding
supports observations from other clinical investiga-
tions demonstrating an improved framework stability
of three- and four-unit posterior zirconia FDPs com-
pared with veneered reinforced glass-ceramic FDPs
and glass-infiltrated alumina FDPs.10,11
Apart from material selection, the core fracture
rate is influenced by the framework design. In vitro
and in vivo results support the hypothesis that core
fractures of all-ceramic FDPs are more dependent on
connector size than on the material itself.5,15,20,21,25
A promising approach to further reduce the risks of
technical failures and complications might be the use
of monolithic zirconia FDPs.25,26 As these FDPs are
fabricated without any ceramic veneer, the risk of CVF
is eliminated. Furthermore, the lack of ceramic veneer
offers more space for enlarged connector areas and
increased material thickness, thus improving fracture

stability. Although monolithic zirconia restorations
could potentially yield better long-term stability, clini-
cal data on this type of restoration are still rare and
limited by short observational periods and low num-
bers of included restorations and patients.25,26
Another attempted avoidance of long-term failures
of zirconia cores is the use of HIP zirconia27,28; how-
ever, at this time, clinical data on long-term perfor-
mance are scant.7–12 Thus, the clinical advantages of
this material remain unclear.
In the present study, the factors of ceramic veneer,
span length, and location were evaluated for their po-
tential impact on overall and technical survival and
success rates. In accordance with the equivalent anal-
ysis during the 7-year evaluation of this study, neither
ceramic veneer nor span length had a statistically sig-
nificant influence.3 Only location showed a tendency
for a correlation with the overall survival rate of FDPs,
with those in the mandible having a lower survival rate
than those in the maxilla (HR = 0.46/P  =  .0636). In
the maxilla, a 10-year survival rate of 83% (95% CI: 0.7,
0.97) was measured. In contrast to that finding, FDPs
in the mandible showed a survival rate of 69% (95%
CI: 0.56, 0.82). The HR of 0.46 indicates a 2.1-fold
higher risk for an absolute failure of FDPs placed in
the mandible compared to FDPs placed in the max-
illa. An obvious explanation for this difference could
be that decementation causing loss of the restoration
occurred more frequently in the mandible than in the
maxilla.
A possible explanation for an increased risk for loss
of retention can be seen in the cementation method
used in the present study (conventional luting with
zinc phosphate cement). Based on the findings of a
systematic review including 27 studies, zinc phosphate
and glass-ionomer cements were over-represented in
cases of retention loss, whereas only a few incidents
of retention loss have been reported in restorations
using resin-based luting agents.10 Therefore, the rec-
ommendation to critically reconsider conventional lut-
ing of zirconia FDPs was supported by the findings of
the present study.3,10,11
Based on the findings of the present study, over-
all and technical survival and success rates for
zirconia-based FDPs are still inferior to those of
metal-ceramic FDPs with different framework materi-
als, particularly in terms of technical events (eg, CVF,
framework fracture, loss of retention).7,11,29–32
The null hypothesis of the present study must be
rejected. Based on the available clinical data, metal-
ceramic FDPs should be considered the gold standard
for veneered FDPs in the posterior region.
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Rinke et al
Conclusions
Considering the limitations of the present study, af-
ter a mean observation time of 10 years, the following
conclusions can be drawn:
•• The 10-year overall and technical survival and
success rates of conventionally luted zirconia-
based FDPs in the posterior region fabricated
using an early-stage CAM system confirmed their
inferiority to the published survival rates of metal-
ceramic FDPs.
•• Most absolute and relative failures were caused
by technical events (eg, framework fractures and
extensive CVFs).
•• Conventional luting led to a significantly increased
rate of decementation, particularly in the mandible;
therefore, the use of this type of luting in the
mandible should be critically considered.
•• Span length, type of ceramic veneer, and position
of the FDP had no significant impacts on overall or
technical survival and success rates.
Acknowledgments
The authors would like to thank Stephan Kerl and Ulrich Wenzel for
their technical assistance and DeguDent for its financial support of
the study. The authors report no conflicts of interest.
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Literature Abstract

Engineering a Highly Elastic Human Protein-Based Sealant for Surgical Applications

Surgical sealants have been used for sealing or reconnecting ruptured tissues, but often have low adhesion, inappropriate mechanical
strength, cytotoxicity concerns, and poor performance in biologic environments. To address these challenges, the authors engineered a
biocompatible and highly elastic hydrogel sealant with tunable adhesion properties by photocrosslinking the recombinant human protein
tropoelastin. The subcutaneous implantation of the methacryloyl-substituted tropoelastin (MeTro) sealant in rodents demonstrated low
toxicity and controlled degradation. All animals survived surgical procedures with adequate blood circulation by using MeTro in an
incisional model of artery sealing in rats, and animals showed normal breathing and lung function in a model of surgically induced rat lung
leakage. In vivo experiments in a porcine model demonstrated complete sealing of severely leaking lung tissue in the absence of sutures
or staples, with no clinical or sonographic signs of pneumothorax during 14 days of follow-up. The engineered MeTro sealant has high
potential for clinical applications because of its superior adhesion and mechanical properties compared to commercially available sealants,
as well as the opportunity for further optimization of the degradation rate to fit desired surgical applications on different tissues.

Annabi N, Zhang YN, Assmann A, et al. Sci Transl Med 2017;9(410), pii: eaai7466. References: 64. Reprints: Nasim Annabi, nannabi@neu.edu
—David Ojcius, USA

42 The International Journal of Prosthodontics

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Copyright of International Journal of Prosthodontics is the property of Quintessence
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