Beruflich Dokumente
Kultur Dokumente
on Steyern
ISBN 91-628-6444-0
Swedish Dental Journal Supplement 173, 2005
ISBN 91-628-6444-0
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CONTENTS
Preface 7
Abstract 9
Introduction 13
Aims 25
Results 41
Discussion 51
Conclusions 61
Acknowledgements 63
References 65
Appendix:
Paper I
Paper II
Paper III
Paper IV
Paper V
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PREFACE
The papers have been reproduced with the kind permission of the publishers.
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You blow, fresh wind of the ocean
from the southwest
and sweetly caress the sailor's cheek
best of all the winds
8
ABSTRACT
Background: The development of refined, tougher, and stronger ceramic core
materials in recent years has led to the wider use of new, strong all-ceramic systems
based on oxide ceramics. Results from in-vitro studies investigating the use of oxide
ceramics in shorter all-ceramic fixed partial dentures (FPDs) have been positive, but
clinical studies and additional in-vitro studies are needed to confirm the advisability of
such procedures. Aims: One aim of this thesis was to investigate whether alumina-
based and zirconia-based material systems are adequate for use in shorter (d five-
unit) FPDs and to evaluate the clinical results. Additional aims were to investigate how
to achieve optimal fracture strength in an all-ceramic FPD by varying the try-in
procedure, the cervical shape of the abutments, and the support of the FPD (abutment
teeth or dental implants). The final aim was to compare the strength of a zirconia
material system with that of an alumina equivalent with known long-term clinical
performance. Materials and Methods: Two clinical studies investigating one alumina-
based and one zirconia-based material system were performed. Twenty posterior,
three-unit FPDs (glass-infiltrated alumina) were followed for 5 years and 20 three–five-
unit FPDs (HIP zirconia) for 2 years. Long-term follow-ups were made after 11±1
(glass-infiltrated alumina) and 3 years (HIP zirconia). In three in-vitro studies, the
following variables were investigated: 1a) the flexural strength of porcelain specimens
depending on whether they were exposed to saliva before the glaze firing (n=20) or
first after the glaze firing (n=20), 1b) the fracture strength of three-unit all-ceramic
FPDs (glass-infiltrated alumina) supported by abutments prepared with cervical
shoulder preparations (n=9) and abutments with cervical chamfer preparations (n=9),
2) the fracture strength of crowns (n=30) made of a zirconia material system (densely
sintered zirconia) and of crowns (n=30) of an alumina material system (densely
sintered alumina) that had undergone three different pre-treatment modalities (water
storage only; water storage and cyclic pre-loading; water storage, cyclic pre-loading,
and thermocycling), 3) the fracture strength of all-ceramic FPDs (densely sintered
alumina) supported by simulated teeth (n=12) or by dental implants (n=12). Results:
The success rate of the clinical alumina study was 90% after 5 years. Six (±1) years
later (after a total of 11 ± 1 years), the success/survival rate was 65%. In the second
9
clinical study, the success rates of the 2- and 3-year follow-ups were 100%. In the
three in-vitro studies, the following results were found: 1a) the mean flexural strength
of the specimens in the group that was exposed to saliva first after glazing was
significantly higher (P < 0.001) than that of the specimens in the group that was
exposed to saliva before glazing, 1b) the FPDs luted on shoulder preparations resisted
higher loads than the FPDs luted on chamfer preparations (P = 0.051), 2) total
fractures were more frequent in the alumina than in the zirconia group (P < 0.001), 3)
FPDs loaded on implants resisted higher loads (mean = 604 N, SD=184 N ) than
FPDs loaded on abutment teeth (mean= 378 N, SD=152 N, P = 0.003).
Conclusions: This thesis justifies the use of shorter alumina- (d three-unit) and
zirconia-based (d five-unit) FPDs as the clinical results are acceptable. The clinical
performance of alumina is, however, not as good as that of comparable high-gold alloy
based porcelain-fused-to-metal FPDs concerning fracture resistance. Within the
limitations of the in-vitro studies: Saliva exposure of porcelain before glaze firing
should be avoided to optimize the strength of the porcelain. Shoulder preparations can
be beneficial for the strength of all-ceramic FPDs compared to chamfer preparations,
as can support by dental implants compared to abutment teeth. The fracture mode of
alumina crowns (total fractures) differs from that of zirconia crowns (veneer fractures),
suggesting that the zirconia core is stronger than the alumina core.
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HELKERAMISKA TANDBROAR
Keramiska material har länge använts inom tandvården för framställning av
tandersättningar. Keramer har många goda egenskaper som gör dem särskilt lämpliga
att använda i munnen. Viktigast är kanske att de är biokompatibla, det vill säga att de
inte skadar omgivande vävnader, att de inte ger upphov till allergier eller utgör någon
risk för förgiftning och att de inte bryts ner i den miljö i vilken de är tänkta att fungera.
Särskilt intressanta bland keramerna är porslin som förutom nämnda fördelar har
optiska egenskaper som liknar tandemaljens. Detta har bidragit till att dentalt porslin
sedan många år används för att ge olika typer av tandersättningar ett ytskikt med
tandliknade utseende.
Broar är fastsittande tandersättningar som används när man behöver ersätta förlorade
tänder. Det idag mest använda materialet för framställning av tandbroar är så kallad
"metallkeramik", en kombination av en metallegering, ofta högädel, och ett porslin.
Den viktigaste rollen som metallegeringen spelar är att förstärka porslinet så att det
motstår de belastningar som förekommer i munnen.
Metallegeringar har emellertid flera nackdelar. Dels finns det en risk att patienten är
allergisk mot någon av legeringsmetallerna om de läcker ut. Metallers optiska
egenskaper begränsar dessutom möjligheterna att få tandersättningarna så tandlika
som man många gånger önskar, vilket försvårar förutsättningarna att framställa
tandersättningar med gott estetiskt resultat.
Sedan mer än 40 år har forskning pågått för att utveckla helkeramiska material som
har egenskaper som tillåter framställning av broar utan metallunderstöd. Olika metoder
och material har testats, men resultaten har många gånger varit nedslående; broar har
spruckit efter en allt för kort tid i funktion. Inte förrän 1985 kom ett material som
verkade kunna fungera och som hade teoretiska hållfasthetsvärden långt över de
traditionella keramernas. Nittonhundranittiotvå presenterades flera laboratoriestudier
med samma slutsats - nu fanns ett material som verkade vara tillräckligt starkt för att
kunna användas till broframställning; glasinfiltrerad aluminiumoxid. Man betonade
dock att kliniska långtidsstudier behövdes innan materialet kunde rekommenderas för
allmänt bruk.
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Föreliggande arbete består av 5 delarbeten, samtliga rörande helkeramiska broar eller
material som används i broarna. Delarbete 1, 3 och 5 är laboratoriestudier medan
delarbete 2 och 4 är kliniska studier. I delarbete 1 undersöktes dels vilken
inprovningsmetod som ger högst hållfasthet hos porslin (göra bron helt färdig på
laboratoriet alternativt att prova den i munnen som halvfabrikat innan bron färdigställs),
dels vilken typ av tillslipning man bör göra av tänderna som skall bära bron för att få
högst brohållfasthet ( s.k. skulderpreparation alternativt chamferpreparation
[hålkälsprofil] ). Delarbete 2 är en klinisk 5-årsuppföljning av broar framställda i
glasinfiltrerad aluminiumoxid och delarbete 3 jämför hållfastheten hos 2 olika
bromaterial (aluminiumoxid och zirkoniumdioxid). Delarbete 4 är en klinisk 2-
årsuppföljning av broar framställda i zirkoniumdioxid och slutligen delarbete 5 jämför
helkeramiska broars hållfasthet beroende på om de är förankrade med tänder eller
tandimplantat. Utöver dessa delarbeten finns en sammanställning av kliniska resultat
från delarbete 2 och 4 efter 11±1 år (glasinfiltrerad aluminiumoxid) respektive 3 år
(zirkoniumdioxid).
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INTRODUCTION
Ceramics in dentistry
The word “ceramics” is derived from keramikos, which is the ancient Greek word for
"earthen", and most commonly used for inorganic materials consisting of one or more
metals combined with a non-metallic element, usually oxygen20. The present high
interest in the use of dental ceramics is illustrated by the rising demand for ceramic
crowns: an increase of 50% every 4 years in recent years61. The optical properties of
dental ceramics in general are considered to be similar to those of the natural tooth;
this makes them suitable for reconstructions designed to fulfill high esthetic demands.
There are, however, dental ceramics that do not possess such optical properties but
are used for other reasons—strength being the main one. Hence, in discussions on
which material produces the most pleasing result esthetically and gives the best
impression of vitality, the qualities of dental porcelains are not matched by those of
any other material. The expression dental ceramics is more a general description of a
large group of materials within which the dental porcelains are but one subgroup.
Dental porcelain
The word porcelain is derived from porcellana, which is the Italian name for a small
continuous glass matrix in which different fractions of crystals and particles are
units and a matrix consisting of potassium and/or soda feldspar (potassium feldspar;
K2O-Al2O3-6SiO2)65.
13
Porcelain has been used in dentistry for more than 200 years and was first introduced
the 1960s, made it possible to use porcelain restorations in the anterior regions with
acceptable success. Today, however, the inherently low tensile strength of dental
porcelains still does not allow their use in high stress-bearing applications without the
The primary reason for using porcelains in dentistry is their superior esthetic
appearance, which is a result of the light absorbing and light scattering behavior of the
material and its potential to reproduce the depth of translucence, the color, and the
texture of natural teeth. Porcelain is chemically stable, has good wear resistance and
color stability in the oral environment, and is relatively affordable compared to precious
alloys. Thermal expansion and conductivity are similar to those of enamel and dentine,
as has been described for metal alloys6. Glazed porcelain is, moreover, the only
There are, however, drawbacks to the use of dental porcelains. Despite high bonding
forces between the atoms, the material cannot withstand deformations of more than
0.1% without fracturing. This brittleness is due to the nature of the strong covalent
bonds that do not allow plastic deformation when subjected to tensile or shear forces.
14
The atoms in ceramics cannot, in contrast to metal, which has relatively low atomic
bond forces, slide along the atomic planes when the applied load exceeds the elastic
capacity of the material. Such loads result in a brittle fracture originating from the point
flaw37.
Porcelain components and specimens have a large variation in types and sizes of pre-
existing flaws that act as starting points in the formation of cracks. Such flaws could be
areas of porosity, agglomerates, inclusions, and large-grained zones, which can all be
processing related. Machining and grinding determine the size and number of surface
flaws. Finally, during firing, formation of weak, secondary grain boundary phases can
Under continuous loading, cracks propagate and insidiously weaken the porcelain
the mechanical capacity of the remaining sound portion of the material, catastrophic
failure will occur56. Thus, the major problem in designing porcelain restorations resides
in the unpredictable strength of the material itself. Differences in the shape, size, and
distribution of flaws and cracks in dental porcelain make it difficult to predict the
failure33,47,48,49.
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Glaze and polishing
Different kinds of surface treatments have been investigated to find the optimal
procedure for reducing surface flaws. A glaze layer can be used to fill in the flaws; or
polishing can be used to reduce their depth. Studies have reported that highly polished
porcelain can be even stronger than glazed equivalents. The improved strength might
preferably avoid—the size and number of cracks and flaws33. Hence, it is essential to
optimize the production techniques and thereby improve control of the quality of the
ceramic restorations.
The problem of improving the strength of porcelain restorations so that they will be
able to withstand the loads they will be subjected to during service can be solved in
two ways. One is to make the porcelain itself stronger and tougher; the other is to
provide the porcelain with a stronger substructure that supports the porcelain. At the
present time, the mechanical strength of porcelain ( 120 MPa) and glass ceramics
(~180 MPa) is too low for use in high stress applications without some kind of
16
In the first case above, etching the cementation surface and coating it with a polymer
can substantially improve the strength of porcelain and glass ceramics. The
reduced stress corrosion through a reduction in the transport of water to the crack tips
by the polymer coatings37. Another possible explanation is that the bond between
In the second case above, the strengthening mechanism of high strength ceramic
compatible with that of porcelain. In all-ceramic, high strength (oxide) core materials,
the shape of the substructures serves to support the weaker veneering porcelain.
During loading of a laminate crown where the porcelain is supported by a strong core,
the resulting forces in the veneer will be compressive rather than shearing or tension
shearing and tension ones, this will be beneficial for the load-bearing capacity of the
crowns.
The dense core blunts flaws and cracks in the critical inner surface of the crown,
hence preventing time-dependent slow crack growth emanating from this area.
Another mechanism could be that ceramic substructures prevent water from getting
access to the crack tip and thus indirectly decrease the risk of stress corrosion in this
surface area. The stiff, strong inner construction resists radial expansion of the dentine
core and wedging of the crown during loading and prevents tension on the inner
17
Oxide ceramics
The quest for all-ceramic materials with properties that would enable their use in fixed
partial dentures (FPDs) led to the development of many new materials and processing
techniques in the last decade. Whereas traditional dental ceramics primarily comprised
a glass matrix with a crystalline phase as filler, newly developed ceramic materials are
fabricate FPD frameworks with a flexural strength and fracture toughness that are
considerably higher than those of the ceramics that have been previously used, thus
toughest oxide ceramics used today are based on aluminum oxide (alumina), and on
Alumina
Alumina has been used to increase the strength of dental porcelains for more than 4
1 - As slip powder, used dispersed in water to build up crown copings and FPD
cores.
2 - As dry pressed material processed for milling FPD frameworks and crown
In both instances, lanthanum glass is used after the final shaping of the frameworks
and copings to infiltrate the porous alumina structure. Finally, the substructures are
18
veneered with dental porcelain to create the appearance of a natural tooth. Studies
have shown that glass-infiltrated alumina has a flexural strength up to four times
greater than that of conventional ceramics. The authors concluded that it seemed
possible to make restorations with all-ceramic FPDs in cases not only of anterior but
also posterior tooth loss. They emphasized, however, that long-term follow-up studies
Another all-ceramic system based on alumina employs a technique where high purity
the alumina substructures are densely sintered and veneered with dental porcelain.
Clinical studies have indicated that such alumina-based crowns may be used for
crowns in all locations of the oral cavity41,42. The system includes a technique for
alumina pontic that is joined to the copings using a specially formulated connecting
Zirconia
The dental ceramic with the best mechanical properties is yttrium-stabilized zirconium
dioxide17,59. Zirconia is well known as an orthopedic implant material and has been
used in hip surgery for many years9. By adding a small amount of Y2O3 to ZrO2, it is
room temperature. The energy that arises around crack tips and sharp corners when
grains into monoclinic ones that are larger, thus sealing the cracks and stopping
19
found in steel, giving the material a beneficial toughening property that could not be
found in any other dental ceramic19. Several studies have indicated that flexural
strength values of 1200 MPa and fracture toughness values of 9 MPa m½, which are
possible with zirconia and substantially higher than for other ceramics makes this
material useful for highly loaded, all-ceramic restorations. Hence, suggestions have
been made that zirconia could also be a viable alternative to metal in reconstructive
dentistry, especially for crowns in the molar region and FPDs 17,19.
Stress corrosion
Even though dental ceramics are chemically stable, they are still susceptible to
transition of damage mode and strength degradation after multi-cyclic loads compared
to static loading tests26. When water is present, stress corrosion enhances further
crack propagation62. When tension periodically occurs at the crack tip as a result of
load cycles, the damage is increased in the presence of water. Oxygen atoms that are
debonded when the interatomic distance increases during tension in the crack tip area
are blocked as a result of hydration and are then unable to re-establish the previous
bond when expansion ceases during the unloaded phase. A 27% decrease in fracture
strength has been reported for aluminous and feldspathic porcelains tested in water
mastication. Water in the saliva plays an important role as a catalyst for this fatiguing
mechanism31,49,56.
20
Moisture plays a vital part in the time-dependent reduction of the strength of dental
porcelain38. The presence of water and organic molecules in the oral cavity are, of
course inevitable, as they are always present in the saliva. A frequently used
in raw porcelain, before the glaze firing. This try-in is made in the mouth. Whether
saliva molecules, if present in the subsequent firing process, could react with the
porcelain has, however, not been investigated. If so, and if these reactions affect the
porcelain, it would be advisable to postpone the try-in stage in the mouth until after the
Cervical shaping
The brittle nature of ceramics makes the fracture resistance of all-ceramic fixed partial
dentures highly dependent on a solid support and on reduced strain in the beam of the
prosthesis. Several authors have discussed the influence of cervical shaping on the
fracture resistance of all-ceramic crowns. Today’s knowledge thus indicates that all-
ceramic crowns luted with non-adhesive luting techniques should be designed with a
cervical shoulder preparation to resist high loads18,55. Whether this is applicable to all-
Abutments
As teeth are lost due to caries or periodontal disease, implants can be used to replace
the natural abutments. The biomechanical support gained from implants differs,
however, from the support provided by natural teeth because the implants are directly
connected to the bone without any other intermediate tissue, a biomechanical situation
21
similar to the one of tooth ankylosis where no periodontal ligaments exists. The
periodontal membrane of a tooth acts as a shock absorber, has sensory functions, and
If supporting bone has been lost due to periodontal disease, the capacity of the
increases when loaded54. The direction and magnitude of these movements varies
considerably depending on among other things the anatomy of the root, remaining
bone height, bone density and other periodontal conditions, and it has been concluded
that the tensile stress in an FPD can reach critical values when abutment teeth with
excessive loss of bone support are loaded4,34. Because ceramics are brittle as
mentioned above, they cannot withstand deformations. Hence, when planning an all-
ceramic FPD, it is essential to evaluate abutment support since the resistance of all-
strain in the beam of the prosthesis. One question that remains to be answered is
whether all-ceramic FPDs benefit from implant support when the prosthesis is loaded
Hypotheses
Dental porcelain that is glazed prior to saliva exposure will resist higher loads
than equivalents that have been subjected to saliva prior to the final firing.
will resist higher loads than equivalents that are supported by abutments cut
22
Oxide ceramics veneered with dental porcelain can be used for FPDs with
alumina.
equivalents.
All-ceramic FPDs supported by dental implants will resist higher loads than
23
24
AIMS
before the final firing with an equivalent exposed first after the final firing.
To determine how the cervical shape of the preparations influences the fracture
To evaluate and compare the strength of a zirconia material system for crowns
and FPDs with an alumina material system with known long-term clinical
performance.
adequate for use in three–five-unit FPDs and to evaluate the clinical results.
implants.
25
26
MATERIALS AND METHODS
Paper
Study Ia Ib II III IV V
design
Type of study In-vitro In-vitro In-vivo In-vitro In-vivo In-vitro
Core material - Alumina Alumina Alumina/zirconia Zirconia Alumina
Veneer Porcelain Porcelain Porcelain Porcelain Porcelain Porcelain
material
Glaze firing / Before / - After - After -
saliva after
exposure
FPD units - 3 3 1 3-5 3
Abutments - Duralay® Teeth Duralay® Teeth Duralay®/implants
Abutment - End End End End End
position
Connector Ø - 3 mm 3 mm - 3 / 4 mm 2 x 3 mm**
FPD position - Posterior Posterior - All mouth Posterior
Follow-up - - 5 years - 2 years -
Extended - - 11 years - 3 years -
follow-up ±1
Type of Porcelain Three-unit FPDs - Norm crowns - Three-unit FPDs
specimen rectangular
bars
Cervical - Shoulder/chamfer Shoulder Chamfer Shoulder Chamfer
shape
Preloading - Yes - Yes / no - Yes*
300 N
10.000 cycles
Water Human Yes Human Yes Human Yes
exposure saliva saliva saliva
Thermocycling No No - Yes / no - No
*100 N
** According to the manufacturer’s instruction
The different materials and methods used in this thesis are summarized in this section.
For details (including manufacturers´ details), please see the Materials and Methods
sections in the individual papers.
27
Fracture strength of a veneering porcelain in relation to try-in
procedure. (I a)
In the first part of the first in-vitro study (I a) in this thesis, 40 rectangular bar porcelain
specimens with standardized dimensions and a small projection on one side were
fabricated (Fig. 1). After firing, the luster of the specimens was removed using a white
stone. The specimens were subsequently randomly divided into two groups of 20 and
fracture resistance of the specimen. For this purpose, a test rig was used with the
porcelain specimen resting on two metal stainless steel rods with a diameter of 1.5
mm and a span length of 7 mm. The unground surface of the specimen was loaded
with another 1.5-mm stainless steel rod, centered between the other two rods, until
fracture occurred. The crosshead speed of the load was 0.255 mm min-1 (Fig. 2).
Finally, flexural strength in the two groups was compared. Statistical differences were
The load was registered and the flexural strength was defined as:
3 F l
Vfs 2b h 2
where Vfs is the flexural strength; F the load in Newtons; and l the length, b the
breadth, and h the height in mm.
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Figure 1. The porcelain specimens.
A = 1.7 mm
B = 15.3 mm
C = 3.2 mm
D = The projection
E = After removal of the projection
Try-in stage
The specimens The projection The specimens The specimens The specimens
Group 1 were stored in was removed to were stored in were cleaned were
n=20 human saliva simulate human saliva with autoglazed in
for 15 minutes occlusal for 30 minutes Elma®clean** the final firing
adjustments*
Table 2. *The projection was removed with a fine diamond burr. **The specimens were
utrasonically cleaned in the Elma Transonic T310 ultrasonic bath using Elma clean 10'
cleaning detergent. ***The specimens were polished using a diamond-impregnated wheel.
Figure 2.
29
Fracture strength of all-ceramic (alumina) FPDs in relation to cervical
shape. (I b)
were fabricated. Nine of the FPDs were made on the preparations with 1.0-mm wide
90° shoulders with a rounded inner angle and the other nine on the preparations with
120q chamfers. The angles of convergence of the preparations were 15q (Figs. 3–4).
The FPDs were luted on dies made of inlay pattern resin with zinc phosphate luting
cement. The surface of the root section of the dies was covered with anti-slip varnish
to simulate a periodontal ligament. The dies were fixed in holes in acrylic blocks using
All FPDs were subjected to preloading in a cyclic preloading procedure. This cyclic
preload was applied to the FPDs for 10,000 cycles at loads between 30 and 300 N
with a load profile in the form of a sine wave at 1 Hz. All FPDs were stored in distilled
water during preloading and mounted with a 10-degree inclination relative to the
After preloading, the FPDs were mounted in a testing jig, still inclined 10 degrees as
described above, and subjected to a load applied by a universal testing machine. The
crosshead speed was 0.255 mm min-1 and the load was applied with a 2.5-mm
stainless steel ball placed in the mesial fossa of the FPD pontic. The FPDs were
loaded until fracture occurred, and the required loads were registered. Differences
30
Figure 3.
The two different preparation modes.
A = Shoulder preparation
B = Chamfer preparation
A B
Figure 4.
Design and dimensions of the FPDs: A) The core rests on the entire extension of the shoulders/chamfers. B)
1.0-mm core material in the area adjacent to the connectors. C) U-shaped interproximal grooves. D) 8.0-mm
length of the pontic. E – Depth of the cervical preparation = 1.0 mm. F) t 0.7-mm core and 1.0-mm veneer
porcelain. G) Diameter in the connector in the marked plane t 3.0 mm. H) Total length 26 mm.
Figure 5.
The test models. A = Inlay pattern resin, B = Anti-slip varnish, C = Die stone plaster, D = Acrylic block
Figure 6.
Jig and application of the load in
the preloading and loading tests.
A = Brass foundation
B = Acrylic block
C = The FPD pontic
31
Five-year evaluation of posterior all-ceramic (alumina) three-unit
FPDs. (II)
The first clinical study in this thesis involved 18 patients who were treated with a total
technique. The FPDs were constructed with bilateral support and one pontic and all
replaced one premolar (n=11) or molar (n=9). Four dentists performed the treatment.
The supporting teeth were cut for cervical shaping according to study I (I b) with a 90°
shoulder and a slightly rounded inner angle. The aim was to cut the cervical shoulder
The try-in procedure was performed after the firing as described in study I (I a, group
2), without any saliva exposure prior to the final firing. Subsequent to try-in, the FPDs
were permanently cemented with zinc phosphate cement in one sitting. No temporary
cementation of the finished FPD was allowed, to avoid creating microcracks or flaws in
The FPDs were evaluated in clinical and radiographic examinations after 6 months
and then once yearly for 5 years. Fisher’s exact probability test was used to assess
statistical differences between the FPDs replacing the premolars and molars.
32
8.
7.
Figure 7-12
7). Shoulderpreparation with rounded
9. inner-angle
11. 12.
33
Fracture strength comparison between two oxide ceramic systems
(alumina and zirconia). (III)
(Fig.13). Each group of 30 was randomly divided into three groups of ten crowns that
fabrication, the crowns were cemented to dies made from inlay pattern resin using zinc
phosphate cement. Excess cement was removed, and the crowns were stored in
distilled water with a temperature of 37˚C until they were subjected to different
underwent preloading with 10,000 cyclic loads between 30 and 300 N at 1 Hz. In
baths—5˚C and 55˚C—20 seconds in each bath before loading (Table 3). Subsequent
to pre-treatment, all 60 crowns were subjected to load until fracture. Load was applied
with a 2.5-mm stainless steel ball placed on the occlusal surface of the crowns and a
crosshead speed of 0.255 mm min-1. The loads at fracture were registered, and
differences between the groups were calculated using Student’s t-test. Any differences
34
Porcelain Core
Table 3. Test protocol with a description of the test groups and number of crowns in each group.
Pre-treatment
Core material Group 1 (control) Group 2 Group 3
Water storage only Preloading* Thermocycling**
+
Preloading*
Alumina 10 10 10
Zirconia 10 10 10
* Force was applied with a 2.5-mm stainless steel ball placed on the occlusal
surface of the crowns. All crowns were stored in distilled water during preload and
mounted at a 10-degree inclination relative to the long axis of the crowns. The
crowns underwent 10,000 cycles at 30–300 N and 1 Hz.
35
All-ceramic (zirconia) CAD/CAM-produced FPDs. A 2-year clinical
study. (IV)
Eighteen patients—nine women and nine men—were selected and accepted for
participation in the study. The FPDs were to replace one missing tooth or two missing
teeth with a total gap not exceeding a length equal to the width of one premolar and
one molar and constructed with end abutments. In total, 20 DC-Zirkon® FPDs were
The overall design is described in Figure 4. Differences between this study and study
l b, however, were that the aim for the interdental connectors in cases of molar
the cervical shoulder was 1.2 mm. The cores were subsequently veneered with
compatible veneering porcelain (Fig. 14). The patients were examined 1 and 2 years
after cementation and the FPDs were evaluated regarding secondary caries,
fractures. Any structural flaws were described. The margins were rated as excellent,
Score Criteria
Alpha (excellent) No visible evidence of crevice along margin into which the explorer can
penetrate.
No discoloration on the margin between restoration and tooth structure.
Bravo (acceptable) Visible evidence of slight marginal discrepancy with no evidence of decay;
repair can be made or is unnecessary.
Discoloration between restoration and tooth structure.
Charlie Faulty margins that cannot be repaired.
(unacceptable) Penetrating discoloration along the margin of restoration in the pulpal direction.
Retained excess cement.
Mobile reconstruction.
Fractured reconstruction.
Caries continuous with margin of restoration.
Fractured tooth structure.
Table 4 Marginal integrity according to modified CDA criteria
36
A
37
Fracture resistance of all-ceramic (alumina) FPDs supported by
simulated teeth vs dental implants. (V)
Two titanium implant abutments—one for position 24 and one for position 26—were
cut to preparations representing one premolar and one molar. By scanning those
abutments and by using the CAD/CAM technique, 24 alumina all-ceramic FPDs were
made. Subsequent to fabrication they were randomly divided into two groups—12 to
be supported by dental implants (Fig. 15) and 12 by simulated teeth (Fig. 16).
parts. Finally, they were copied and 24 simulated abutment teeth were made from the
The FPDs were subsequently luted on the implants and the simulated teeth using zinc-
phosphate cement. Finally all the FPDs, both those supported by implants and those
by simulated teeth, were fixated in holes in acrylic blocks using die stone as described
All FPDs were subjected to preloading as described in study I (l b). The cyclic preload
was between 30 and 100 N with a load profile in the form of a sine wave at 1 Hz.
Finally, the FPDs were loaded until fracture occurred, and the required loads were
Differences between the two groups were tested with Student’s t-test.
38
A
Figure 15
B Implant abutment (10 mm, wide
platform with a connected PROCERA®
titanium abutment, cut with a 120°
chamfer and 15° angle of convergence)
Figure 16
A simulated abutment tooth, cut with a
D 120° chamfer and a 15° angle of
convergence. The root section is
covered with an anti-slip varnish to
simulate the periodontal ligament.
Figure 17
A= The two type of abutments
B=View of a completed FPD
C=FPD supported by implants and simulated teeth
D=Test model (implant supported)
E=Settings for preload and load until fracture
39
Long-term follow-ups. (II and IV)
The patients in studies ll and lV were re-examined after 11±1 years (II) and 3 years
(IV) respectively. During the re-examinations, the patients were interviewed regarding
their experience with the FPDs. One dentist made all clinical examinations, and the
FPDs were evaluated regarding secondary caries, clinical wear, and presence of
cracks or fractures. The FPD was considered “successful” if it was in service and
flaws. If, on the other hand, the FPD was still in use but showed signs of secondary
"survivor". An FPD that had been removed was considered a “failure”. If an FPD had
been removed, we checked whether the abutment teeth were still in place and we
interviewed the patients regarding their opinion of the underlying reasons for removal
of the FPD.
40
RESULTS
The results from the different studies in the thesis are briefly described in this section.
41
I In the first part of study I (I a), the mean flexural strength of the specimens in the
group that was exposed to saliva after glazing (group 1) was significantly higher
(P < 0.001) than that of the specimens in the group that was exposed to saliva before
glazing (group 2). The mean flexural strength of the specimens in group 1 was 81 MPa
r 13 (SD) and the strength of the specimens in group 2 was 116MPa r 15 (SD). The
results indicate that saliva exposure before glaze firing can decrease the flexural
Force (MPa)
Group 1 Group 2
Mean 81 P < 0.0001 116
SD 13 15
Table 6.
The force (MPa) required to fracture the specimens in group
1 (exposed to saliva before glazing) and group 2 (glazed
before exposure to saliva).
In part I b, the FPDs luted on shoulder preparations resisted higher loads than the
FPDs luted on chamfer preparations. This result was significant at the P = 0.051 level.
In four of the FPDs luted on chamfer preparations, the porcelain veneer fractured
before the core. In contrast, all the FPDs on shoulder preparations fractured instantly
through all the layers (Table 7). The orientation of the fracture was from the inferior
42
Loads at fracture (N)
Chamfer Shoulder
FPD no. Veneer fracture Total fracture Total fracture
1 325 375 537
2 300 412 537
3 - 426 537
4 - 438 537
5 - 450 555
6 387 537 575
7 - 575 600
8 - 588 762
9 413 787 812
Mean 434 510 606
SD 98 128 106
Table 7. The loads (N) at fracture and the type of fracture in the two groups
of fixed partial dentures (FPDs): chamfer preparations and shoulder
preparations.
II In the second study (II) all FPDs were found to be functioning at the
A second FPD was found to be fractured after 35 months (Table 8). Of the
remaining 18 FPDs, none had any defects. No caries and no signs of gingivitis or
periodontitis exceeding those found in the rest of the dentition were registered.
On closer examination of the fractured FPDs, the following observations were made:
x The FPD that was lost after 24 months was the last one in the series
of 20. It replaced the upper right first molar in a man who was 50
years old. The fracture was located at the connection between the
pontic and the distal abutment tooth. The operator responsible for the
43
x The second fractured FPD replaced the lower left first molar and, like
the first one, fractured at the connection between the pontic and the
distal abutment tooth. This FPD had the longest pontic of the 20
FPDs. The patient was a man who was 50 years old, and he was
It could thus be established that all the FPDs that replaced premolars were in function
at the end of the observation period. Two of the nine FPDs that replaced molars were
fractured. There was, however, no significant difference in the success rate between
FPDs replacing molars and the FPDs replacing premolars (Fisher’s exact probability
test P = 0.190). 95 09 25
96 10 15*
95 04 03
93 05 07
94 02 24
Table 8. 94 05 06
95 01 27
Date of cementation (year, month,
93 12 21
day) and position in the mouth
94 02 07
*Date when failure was dicovered 93 02 17
93 06 04
93 06 15
93 06 11
93 12 18
93 04 02
93 04 28
93 02 19
92 12 11
96 01 30*
7 6 5 4 3 3 4 5 6 7
R i g h t L e f t
44
III In the third study (III) two types of fractures occurred: total fracture, through
both core and veneer, and partial fracture, through the veneer only. Total
fractures were more frequent in the alumina group compared to the zirconia group,
and this difference was statistically significant (P < 0.001). In all instances of partial
retention. The other 13 crowns in the group experienced no such loss (Table 9).
IV For the 18 patients in the second clinical part of the thesis (IV), 20 three–
DCS® Precident System. For details of FPD placements and dimensions of the inter-
45
Table 10.
46
All FPDs were in use and none had fractured at the 12-month follow-up. No chip-off
fractures or clinical wear could be observed. Marginal integrity was rated Alpha at 46
abutments and Bravo at 10 abutments. No margins were rated Charlie. All patients
were fully satisfied with their FPDs. Initial inter-examiner agreement was 91%.
At the 24-month follow-up, all FPDs were still in use and none had fractured or showed
any clinical wear. In three cases, however, minor chip-off fractures were observed on
FPD #2, #9, and #12. These units were opposed by a natural tooth with an occlusal
amalgam filling in one case, a PFM crown in the second case, and a gold crown in the
third case. Marginal integrity was rated Alpha at 45 abutments and Bravo at 11
abutments. No margins were rated Charlie. All patients were fully satisfied with their
FPDs, and none of the three patients where chip-off fractures had occurred had
Complications
During the fabrication period, one patient (FPD #5) developed symptoms of pulpitis on
the second molar. The tooth was subsequently treated endodontically with sufficient
remaining tooth substance to allow reconstruction without a post and core. The same
patient developed symptomatic acute apical periodontitis during the first 6 months after
FPD cementation on the mesial abutment tooth (first premolar). Endodontic treatment
was performed subsequent to trepanation through the occlusal surface of the FPD. No
further symptoms were registered at the 12- or 24-month follow-up. Also during the
47
V In this study (V) the FPDs loaded on implants resisted 60% higher loads
(mean = 604 N, SD=184 N) than the FPDs loaded on simulated teeth (mean
= 378 N, SD=152 N). The result was significant at the P = 0.003 level. All fractures
were total fractures (through both the core in the area of the fuse and the veneer) that
occurred in one of the connector areas (in the fuses between an abutment crown and
48
Results from the long-term follow-up examinations (II, IV).
The outcomes of the 2- and 3-year follow-ups of the zirconia FPDs were similar. All
FPDs were still in service and showed no signs of fractures other than the minor chip-
The survival rate of the alumina FPDs, however, decreased dramatically. The last
follow-up was made when the FPDs had been in service for 11±1 years (mean 11). Of
the original 20 patients, 3 dropped out: 2 died and 1 was untraceable. At this follow-up,
11 (65%) of the remaining 17 FPDs were still in service. The surface condition of 10 of
these 11 was excellent. The one that was not excellent had an excessively rough
occlusal surface. Ten (59%) of the FPDs were considered successful (no signs of
In the patient interview, all patients with FPDs still in service stated that they were
satisfied with their prostheses. The patients who had their FPDs removed were unable
49
50
DISCUSSION
Several different material systems intended for all-ceramic FPDs are available in
dentistry; some of them since more than 15 years. Despite this length of time, few
results from clinical studies are available to support (or refute) the use of all-ceramic
FPDs. Although in-vitro studies are reporting promising results concerning the flexural
such procedures 22,25,40,43,52,59,60,64. In-vitro studies can, on the other hand, give useful
information, and together with data from actual in-vivo measurements, they can be
reconstructions, basic information that is valuable for other researchers in the design
of clinical trials16,25. The second (II) and the fourth (IV) studies in this thesis are clinical
(in-vivo) trials of all-ceramic FPDs. The others (I, III, V) are in-vitro studies that focus
designing an FPD.
The time, complexity, and expense that are entailed in fixed prosthetic treatment are
justified only if the lifetime of a restoration is lengthy23. It is not evident, however, how
“a long time” or “failure” should be defined. The failure criteria used to evaluate FPDs
differ substantially between published studies. The clinical definitions vary from
while for the individual patient the criterion of failure may be extremely subjective10.
51
Scurria et al.51 describe three categories of FPD failure: 1) the prosthesis had been
removed, 2) the prosthesis had been removed or had technically failed, necessitating
replacement, and 3) one or more abutments were lost. The failures in the present
thesis are technical failures if the follow-ups are restricted to 5 years (II). Meta-
analyses of the outcome of treatment with conventional FPDs show survival rates of
comparisons become more uncertain because the reasons for FPD replacement were
unknown. In comparisons with results after 10 years or longer on PFM FPDs, the
failure rate of the alumina FPDs in this thesis is higher than published failure rates for
Studies on conventional FPDs report survival rates of 90%–92% after 10 years and
67.5% after 15 years10,23,51. It has been stated that half-life close to or slightly more
restorative treatment and a sound economic investment for the patient23. Based on the
assumption of a linear relationship, a 65% survival rate after 11 ± 1 years (II) is close
cannot always be assumed, especially in the case of ceramics that are susceptible to
good as that of comparable high-gold alloy based PFM FPDs. This conclusion,
Zirconia, on the other hand is more than 3 times stronger and tougher than alumina.
The fracture strength of glass-infiltrated alumina is approximately 400 MPa and the
52
fracture toughness approximately 3 MPa m½. The corresponding values for zirconia
are 1200 MPa and 9 MPa m½, which are substantially higher than for alumina17,19,50.
Furthermore, CAD-CAM is being used in many new material systems to produce the
FPD cores under optimized industrial conditions by milling a substructure from a blank.
In this way, it can be assumed that the population of intrinsic flaws in the new
materials is reduced in both number and size compared to traditional ceramics. Thus,
The results of the 3-year zirconia study (IV) are promising when compared with results
anterior and posterior In-Ceram® FPDs were still in use after a clinical trial period of 2–
35 months. The cumulative survival rate was calculated to be 93.3% for a 12-month
success rate.
Another study reported an 82.5% success rate for posterior alumina FPDs after 3
years of service57; the success rate in our alumina study was 95% after 3 years (II). In
our study on zirconia (IV), the success rate after 3 years was 100%. Other authors
have had similar success with zirconia. Molin reported a 100% survival rate for 18 all-
ceramic zirconia-based FPDs after 2 years in service39. Thus, it might be assumed that
in this short term perspective, clinical results for zirconia-based all-ceramic FPDs are
53
The minor occlusal chip-off fractures experienced in study IV were not a cause for
replacing any of the reconstructions, especially since the patients were unaware of
them until the clinical examination. That the chip-off fractures occurred is important to
discuss since a fracture is always undesirable and in one way a failure, even though
such fractures are insignificant. The fracture pattern is similar to that found in another
study (III) in this thesis where two types of fractures occurred: total fractures, through
both the core and the veneer, and partial fractures, through the veneer only. Veneer
fractures were more frequent in the zirconia group in this in-vitro study.
One reason for chip-off fractures could be that the strength of the veneering porcelains
is insufficient, as was the case with the early veneer porcelains used in titanium-PFM
FPDs and crowns that were susceptible to chip-off fractures. The survival probability of
ceramic-veneered titanium FPDs in a 3-year follow-up study was only 59% after 30
months28. One of the criteria for failure in that study was the presence of cracks or
chipping of the veneering porcelain, failures which did not result in the replacement of
Other reasons for chip-off fractures can be flaws emanating from the fabrication of the
laminate will always form a constant strain system because of the mismatch of elastic
source of structural flaws29 due to wettability factors and difficulties to build up the
green porcelain prior to firing densely and homogenously over the core surface without
trapping air bubbles. All chip-off fractures in the present clinical study, however, were
superficial. The shape of the high strength inner construction normally serves to
support the less strong veneer material. In study IV, where the design of the
54
framework was processed in the computer by "true" CAD/CAM, there is an inherent
risk that the occlusal shape is insufficient regarding veneer support. Mechanically
agglomerates, inclusions, and large-grained zones, are other possible reasons for
veneer fractures31,33.
There are several possible mechanisms that, after try-in in the mouth and subsequent
glaze firing, could decrease the strength of the veneering porcelain. One is that the
strength of the ceramics is directly related to the number of firings; additional firings
have been shown to decrease ceramic strength. The advantages of glaze firing with
respect to flaw-healing are not achieved if the glaze firing itself weakens the material14.
The specimens in the first part of study I (I a) were all fired twice, irrespective of which
group they represented, to avoid any influence that different numbers of firings might
have had. Polishing, on the other hand, can strengthen a material by eliminating
surface flaws and the development of residual compressive stresses in the porcelain
surface14,21,30.
Other explanations for the differences found in the first part of study I (I a) can be
saliva molecule residues on the surface or in cracks and porosities of the specimens
as well as inadequate cleaning procedures that leave behind saliva molecules which
could react with the porcelain during firing and thus decrease strength. Finally, residual
moisture after clinical and cleaning procedures may expand during firing and act to
decrease the strength. The results in the first part of study I (I a) lead to the conclusion
that short-term exposure to saliva prior to the final firing could have a negative effect
55
on the strength of porcelain. With respect to the limitations of an in-vitro study,
the oral cavity during service is still unclear. Insufficient clinical data often led
manufacturers and dentists to place great emphasis on the data for the strength of a
material to define clinical indications. Hence, data from laboratory studies are used to
extrapolate strength and toughness values to promote novel materials and processing
technologies25. Survival probability analyses assume that the maximum biting forces
on anterior crowns rarely exceed 900 N and the maximum force on posterior crowns
rarely exceeds 2200 N whereas most patients generate typical bite forces between
400 N and 800 N3. To withstand such loads, it is important not only to select materials
with suitable material properties, but to design the prosthesis to reduce stresses in the
The cervical shape of a supporting abutment can be critical to the strength of all-
ceramic crowns. It has been shown that fracture resistance is related to cervical shape
since chamfer preparations induce higher levels of stresses in crowns when loaded
than do shoulder preparations. Thus, it has been emphasized that all-ceramic crowns
However, no studies have been conducted on whether the stress that occurs when
loading an FPD supported by chamfer preparations also affects the connector areas.
Together with the complexity of the stress pattern that occurs during loading of
56
FPDs24,27, regardless of the cervical shape, the type of preparation could influence
The other results in study I (I b) show that there are dissimilarities between the fracture
patterns in FPDs supported by chamfer preparations and the fracture patterns in FPDs
supported by shoulder preparations. All fractures in the latter were fractures through
both core and veneer—total fractures—while the former exhibited two modes of
failures: total fracture or partial fracture through the veneer only. This might be
The characteristic strength and elasticity modulus of the alumina core is much higher
than that of the veneer porcelain. Kelly et al. described an interfacial mismatch in
properties between the core and the veneer material29. This could imply that when
FPDs supported by chamfer preparations are loaded, tensile and shearing stresses
reach critical levels in the veneer before they do in the core ceramic, resulting in
different kinds of failures depending on the cervical shape of the preparation. This,
together with our finding that FPDs on shoulder preparations resisted higher loads
than FPDs on chamfer preparations, supports earlier findings concerning crowns, that
the different abutments of a prosthesis. An FPD will splint the abutment teeth, but
resultant bending forces will be absorbed in the beam of the prosthesis, especially in
57
the connector areas58,66. The biomechanical support provided by implants differs,
however, and the biomechanical situation is similar to that of tooth ankylosis where no
The results of study V suggest that the support provided by implants might be
favorable compared to that provided by natural teeth since implants give a more solid
support than teeth. Because all-ceramic FPDs are more susceptible to bending forces,
on the other hand, if well integrated, do not allow for sensory response or movements.
loads that exceed the load bearing capacity of the veneer. This could more easily
different. A more resilient attachment, such as the periodontal ligament, may respond
to loadings with different amounts of movement occurring at each end of the FPD7.
The resultant bending forces absorbed in the beam of the FPD might then be
favorable compared to a more resilient one. Conclusively, these results (V) suggest
When analyzing results obtained from in-vitro studies, it is important to keep in mind
that masticatory system are highly complex and that the actual clinical situation is
impossible to mimic to more than a limited extent. It has been concluded that only
simple surveys should be carried out and that rigid die stone models can provide
experimental data of the same quality as more complex ones15,45. Less complicated
models than those used in this thesis (I, V) could have been used, but the approach
58
chosen was considered valid since a more rigid model could have been resulting in
techniques under study. The fatigue tests used in the thesis (I,III, V) are recognized as
valid for ceramic testing and have been used in previous studies8,67. Finally, the clinical
parts of the study could preferably have included control groups. Clinical studies are,
however, complicated for several reasons. One reason is that it is very difficult to find
patients with indications for the reconstructions that are to be studied. If patients only
with indications for both the studied reconstruction and an intra-individually control
should be included, this would result in few patients or an unacceptable time gap
between the first and the last patient in the study. The approach chosen was therefore
59
60
CONCLUSIONS
Within the limitations of the in-vitro parts of this thesis, the following
conclusions can be drawn:
Short-term exposure to saliva, before the final firing, could have a negative
effect on the strength of dental porcelain. The mechanisms behind this
phenomenon are, however, not fully known and further studies are needed to
confirm this finding. The hypothesis that dental porcelain which is glazed prior
to saliva exposure will resist higher loads than equivalents that are subjected to
saliva prior to the final firing, is thus confirmed.
Crowns made with zirconia cores have significantly higher fracture strengths
after preloading compared with crowns made with alumina cores. The
hypothesis that zirconia-based reconstructions veneered with dental porcelain
and subjected to fatiguing and stress-corrosion can resist higher loads than
alumina-based equivalents is thus confirmed.
The hypothesis that all-ceramic FPDs supported by dental implants will resist
higher loads than equivalents that are supported by natural teeth is confirmed.
61
Hence, all-ceramic FPDs might be used in combination with dental implants.
Clinical studies, however, are needed to confirm these findings because other
factors also influence the final clinical outcome.
The results of the clinical (in-vivo) parts of this thesis justify the following
conclusions:
The hypothesis that oxide ceramics veneered with dental porcelain can be used
for FPDs with extensions of up to five units if based on zirconia and three units
if based on alumina can not be rejected.
62
ACKNOWLEDGEMENTS
To the many people who made this thesis possible I wish to extend my sincere
gratitude. They include:
Professor Krister Nilner for his advice, invaluable support and personal involvement in
this work.
Professor Per-Olof Glantz for his valuable advice and comments on this thesis.
Professor Tore Dérand for his valuable advice and comments on the first part of the
study.
Associate professor Erik Strandman for many valuable hints and stimulating
discussions and for always giving a helping hand.
Dr Yuji Kokubo, Tsurumi University, Japan, for fruitful collaboration and stimulating
discussions.
Mr Stig A Svensson for his most skilful technical assistance and help with technical
illustrations.
Mrs Gail Conrod-List for valuable linguistic advice and revision of the text.
Mr Bertil Rohlin for the financial support that initiated this work.
My coauthors (if not mentioned above) for making this thesis possible; in order of
appearance:
Dr Ola Jönsson
Dr Asim Al-Ansari
Mrs Katarina White
Miss Sandra Ebbesson
Miss Jenny Holmgren
Dr Per Haag
Dr Per Carlsson
The staff of the Department of Prosthetic Dentistry and Dental Technology, Faculty of
Odontology, Malmö University.
63
The staff of the faculty library for their valuable help
Last and most profoundly I extend my gratitude and love to my wife and my family for
their love and never ending patience and support.
64
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