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CASE REPORT
242
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
vOLUME 5 º NUMBEP 3 º AUTUMN 2010
A Multi-faceted Treatment Approach
for Anterior Reconstructions Using
Current Ceramics, Implants, and
Adhesive Systems
Jan Hajtó, Dr Med Dent
Specialist in esthetic dentistry (DGÄZ), Munich, Germany
Uwe Gehringer, CDT
Private practice, Munich, Germany
Mutlu Özcan, Prof Dr Med Dent, PhD
University of Zurich Dental Materials Unit, Switzerland
Correspondence to: Jan Hajtó
Gomoinsonaítspraxis Ha|to & Caoaoi, Woinstr. 4, 80333 Munion, Gormany, tol: +49 89242 39910, o-mail: dr.|an.na|to@t-onlino.do
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vOLUME 5 º NUMBEP 3 º AUTUMN 2010
Abstract
Of all developments in dental technol-
ogy, fulfilling the esthetic and functional
demands of the patient, especially re-
garding anterior reconstructions, is still
a challenge for both dentists and dental
technicians. This becomes more diffi-
cult for patients with a previous treat-
ment history that is not ideal. This case
presentation demonstrates reconstruc-
tion oí an antorior ziroonia rosin-bondod
hxod dontal prostnosis (PBFDP) íor tno
mandible with a combined treatment ap-
proach utilizing veneers for harmonized
space distribution on the abutment teeth
and an implant-supportod ziroonia hxod
dental prosthesis in the anterior seg-
ment of the maxilla. Adhesive cementa-
tion of the restorations is also presented
in a stop-by-stop approaon basod on
the current state of the art.
(Eur J Esthet Dent 2010;5:242–259)
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vOLUME 5 º NUMBEP 3 º AUTUMN 2010
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vOLUME 5 º NUMBEP 3 º AUTUMN 2010
Introduction
Today, prosthetic and operative treat-
ment concepts could be categorized as
non-invasivo (rovorsiblo), minimally inva-
sive (partially reversible), and (more) in-
vasivo stratogios (non-rovorsiblo), using
various materials.
1
Dentistry, perhaps,
has the unique distinction of using the
widest variety of materials, ranging from
motals and motal alloys to rosin-basod
composites and ceramics. Develop-
ments, especially in the field of polymers
and ceramics, have largely eliminated
the use of metals in the mouth. In spite of
all the advances, clinicians should real-
ize the drawbacks before selecting the
most appropriate material for a particu-
lar situation. Concentrating only on the
matorial's proportios is not suíhoiont, oli-
nicians should be mindful of the best ap-
plication method. As the esthetic aspect
of dental care becomes increasingly im-
portant to patients, the dental practitioner
should be aware of the applications and
limitations oí tno various tootn- oolorod
restorative materials or systems and bal-
ance these with the ethical aspects of
the invasive applications.
1
Fortunately, the dental profession has
profited from remarkable technological
advances in the substitution of missing
dental tissues and teeth. However, we
are still faced with the challenge of rep-
licating the tooth tissues, mechanically,
physically, biologically, and optically.
With the increased options, the choice of
material is also becoming more difficult.
When a qualified ceramist is engaged,
pressed ceramics provide outstanding
results for a single anterior fixed dental
prosthesis (FDP), more so than almost
all other restorative options, with suitable
marginal fit, minimal abrasion, and con-
servative tooth preparation. Yet they are
not as effective as reinforced ceramics
in preventing premature failure. On the
otnor nand, a roiníorood all-ooramio FDP
can be achieved using milled aluminous
or zirconia copings.
2
However, the pres-
ence of the relatively opaque internal
ceramic core may provide an impedi-
ment to matching some tooth colors.
Although minimally invasive applica-
tions are possible using direct compos-
itos, sonsitivity oí toonniquo is an issuo,
the drawbacks of composites involve the
loss of surface lustre. This may require
repolishing, refinishing, or relayering.
3

This is commonly found to be the case
after several years of clinical function,
and therefore the maintenance of the
surface characteristics of composites,
even after finishing and polishing, is an
ongoing issue.
Minimally invasive applications are
also possible using ceramic veneers.
According to the majority of studies, it
is clear that from the mechanical point
of view, retention of laminates is not
seen to be problematic.
4
Clinical stud-
ies rarely report debonding, indicating
that the adhesion of the luting cement,
not only to dental tissues but also to the
nydrohuorio- otonod and silanizod ooram-
ic, is very reliable. Therefore the choice
oí íull-oovorago FDPs ovor laminatos íor
mechanical retention reasons cannot be
justified.
1
Similarly, rosin-bondod FDPs
(PBFDPs), wnion aro all-ooramio, aro
preferable to metal ceramics due to be-
ing minimally invasive, and also for es-
thetic reasons. Nevertheless, teeth sur-
rounded by healthy periodontal tissues
generally have a very high longevity, up
to 99.5% ovor 50 yoars.
5
Therefore, the
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utmost care should be taken to preserve
the cementoenamel junction. This may
not always be achieved, however, due to
required tissue sacrifice for esthetic rea-
sons. ín addition, pationt-rolatod íaotors
will continue to dominate when choosing
one restoration type over another, or the
most suitable restorative materials for
the patient.
1

The situation becomes even more
complex when the patient has a history
of several treatment concepts that have
failed. This case presentation could be
considered an example of the most mini-
mally invasive and durable approach
being practiced, according to the cur-
rent state of the art and considering the
patient’s demands.
Materials and methods
A 30-yoar-old íomalo pationt prosontod
with an implant placed alio loco at tooth
21 by nor provious dontist and a tompo-
rarily rehabilitated situation in the max-
illa and mandiblo (Fig 1). Sno askod íor
a permanent rehabilitation in both the
maxilla and the mandible as quickly as
possible. Since she had already been
through extensive therapy, her explicit
wish was to limit therapy as much as
possible, but at the same time accom-
plish the best possible result. Among
others, the previous treatments involved
implantation and explantation in the re-
gion oí tootn 31 as woll as ropoatod soít
tissue augmentation in the region of teeth
11 and 21. Tno pationt dosoribod norsolí
as very sensible, nervous, critical, and
unsure about the treatment outcome.
Basolino situation
in the maxilla
In the maxilla, both bone loss and soft tis-
sue loss were observed. The implant was
positioned correctly. However, despite
the previously accomplished soft tissue
augmentation, the implant shoulder was
looatod labially, approximatoly 0.5 mm
bolow tno gingiva (Fig 2). For tnis roason,
an individualized zirconium oxide (ZrO
2
)
ooramio abutmont witn hrod-on ooramio
and a short external hex connector of
small diamotor (Brånomark Systom
®
NP) was made. The problem with this
approaon is unoortain long-torm rosist-
ance against loading of the connection.
During cyclic loading, vibrations and
osoillating mioro-movomonts or woar oí
the two participating materials occurs
with the consequence of material loss at
the surface. For the wear process, not
only the roughness but also the hard-
ness of the material plays a role. ZrO
2
Fig 1 Basolino situation witn an implant at 21, ro-
storod witn a tomporarily oomontod long-timo tom-
porary rosin-basod hxod dontal prostnosis (FDP)
(orown). Motal-basod rosin-bondod FDP on 31 and
21 witn 11 boing tno pontio.
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nas a Knoop nardnoss valuo oí 1200 kg/
mm
2
, being relatively harder than that of
titanium (250 kg/mm
2
).
6
For external hex
oonnootors, 1 to 4 dogroos oí rotational
loose fit between the implant body and
various tested abutments were deter-
mined.
7,8
Witn non-oonioal solí-blooking oon-
nootions, a mioro-movomont at tno in-
terface can never be avoided.
9
Also in
this case, wear of the titanium surface on
the ZrO
2
was notiood (Fig 3). Tno íood
debris and biofilm on the inner surface
of the abutment were indicators of the
presence of an insufficient connection.
The high rotational forces of the can-
tilever pontic are another unfavorable
factor in such a material combination.
Changing the implant geometry by
grinding must be considered a major
complication since, in the case of a re-
pair, the new restoration would require
a direct impression followed by manu-
facturing and inserting an individually
cast abutment. In the described case,
tno hrod-on ooramio was oloarly visiblo
beyond (cervically) the finishing line of
tno tomporary orown (Fig 1). Moroovor,
tno long-torm, tomporary FDP oxnibitod
an adoquato íorm, and tno ogg-snapod
pontic showed a correct contact surface
to the gingiva.
The therapy concept
Basod on tno abovo-montionod situa-
tion, it was decided to construct a new
all-ooramio ZrO
2
abutment bonded onto
a titanium base, and to thin the titanium
base on the labial side to the minimum
thickness possible. In such difficult cas-
es, the crown margin should be posi-
tioned labially and cervically, as much
as possible, in order to avoid any expo-
sure of the zirconium abutment. If fur-
ther recession occurs, the finishing line
between crown and abutment would be
visible.
Accomplishing a perfect harmony
from an esthetic standpoint is more diffi-
cult when fewer teeth are subject to treat-
ment in a given segment of the dental
arch. In the presented case, the baseline
situation exhibited asymmetric positions
Fig 3 The already existing individualized ZrO
2
abutment with traces of worn titanium and food de-
bris at the inner side.
Fig 2 Basolino situation wnoro tno implant snoul-
der is hardly covered with gingiva.
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Fig 4 The digital modeling of the new ZrO
2
abut-
ment. Note that due to the low implant depth, the
shoulder of the titanium adhesive base had to be
designed short. With this approach the metal mar-
gins were achieved almost invisibly.
Fig 5 The new finished individual ZrO
2
abutment
lutod on tno titanium baso (Modontika, Badon-
Badon, Gormany). Minimal proparation oí tootn 12.
Fig 6 Tno viow oí CAD/CAM ZrO
2
framework.
With ZrO
2
fixed dental prostheses, it is important
to navo not only 9 mm
2
oonnootor oross-sootions
but also a oonnootor noignt oí minimum 3 mm and
a rounded cervical transition shape from abutment
to the pontic.
of the lateral incisors due to soft tissue
loss and the rotation of the lateral inci-
sors. In order to fulfill the high esthetic
demands of the patient, it was decided
to involve these two teeth in the recon-
struotion. On tootn 22, a olassio labial
vonoor was mado. For tootn 12, a orown
as an abutment tooth was planned (Figs
4–8). This relatively invasive treatment
option was chosen for two reasons: (1)
tno long-torm stabilization oí tno oxton-
sion bridge seemed questionable, and
(2) a harmonious optimal closure of the
intordontal gaps botwoon 12 and 11 was
possible. In such a case, with several
extracted neighboring teeth, the papilla
loss botwoon 12 and 11 as woll as 11
and 21 prosontod a ma|or ostnotio prob-
lom. Booauso 12 was a sound tootn, tno
orown roduotion was kopt to 1 mm íor
preservation of the pulp. In the anterior
area, it is considered an appropriate
clinical practice to reduce the zirconium
oxido íramowork to 0.3 mm.
10,11
In so do-
ing, it is possible to achieve a good es-
thetic outcome even with minimal space
availablo. Witn FDPs, tno bisquo try-in
Fig 7 The labial position of the connector requires
precise planning. In this case, the waxup yielded a
palatal position of the connectors to obtain a maxi-
mum thickness strength also at the proximal areas.
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is one of the most important steps of the
treatment and should be practiced sev-
eral times if necessary. During bisque
try-in, tno íollowing aspoots snould bo
taken into consideration:
fit of the abutments n
proximal contacts n
basal shape and contact of the pon- n
tics with the gingiva
occlusion n
perception of the reconstruction with n
the tongue
phonetics n
esthetics. n
Fig 8 The labial surface of the ZrO
2
ooping oí 12 was roduood to 0.3 mm in ordor to aoniovo room íor tno
maximum thickness of the veneering ceramic.
Fig 11 Temporarily cemented fixed dental pros-
thesis (bridge) for several days with the veneer on
tootn 22. viow oí tno tomporary rostoration in tno
mandible.
Fig 10 The finished individualized ZrO
2
abutment
lutod on a titanium baso (Modontika, Badon-Badon,
Gormany). Proparation oí 12, as minimally as pos-
siblo, and vonoor on tootn 22.
Fig 9 During bisquo try-in oí tno 3-unit hxod don-
tal prostnosis, it was notiood tnat loaving tootn 22
unchanged, which is too narrow and tilted distally,
is an esthetic compromise. With the consent of the
patient, a labial veneer was placed to improve the
esthetics.
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The control of the position of the pon-
tics in relation to the gingiva is especially
important. Corrections can be made by
removing ceramic or by adding material,
and the correct relationship should be
communicated to the dental technician.
ín tnis oaso, tno try-in snowod tnat tno vo-
noor option íor 22 signihoantly improvod
tno gonoral ostnotios (Figs 9 and 10).
The veneers had to be made twice since
the form did not suit the clinical require-
ment at the first attempt and the color
was too light. (With veneers, the color
of the ceramic should be correct right
away, a lator oorrootion witn tno luting
composite gives only very limited scope
for change.
12
For this reason, it is pre-
ferred to remake a veneer if the color is in
doubt.) Booauso tno pationt did not íool
sure about the final treatment outcome,
despite great care and individual adjust-
ments, the finished work was cemented
tomporarily (Fig 11). Suon a proooduro
is rarely performed due to possible dam-
age occurring during the temporarization
period or during removal of the restora-
tion. It is, however, sometimes necessary
if the patient specifically requests it.
Basolino situation
in the mandible
The missing tooth could be replaced
witn an all-ooramio PBFDP witn lingual
wings using a tissuo-saving approaon.
The question was which design would be
best. Extension of the wings over more
than one abutment tooth has yielded
clinically unfavorable outcomes, the dis-
tally connected tooth showing delamina-
tion over time. The question of whether
a two-wing dosign would bo bottor tnan
a ono-wing dosign nas boon answorod
by Kern.
13
Clinical data have clearly
snown tno suporior longovity oí ono-
wingod PBFDPs. ín tno maxilla, ono-unit
oxtonsion PBFDPs aro oloarly proíorrod.
However, it is the present authors’ expe-
rionoo tnat in tno mandiblo, tno two-wing
design functions very well. For this rea-
son a two-wing dosign was onoson. ín
the mandible, the gap was significantly
larger than the usual width of the man-
dibular inoisors (Fig 12). ín suon oasos,
the best esthetics are achieved when
the width is distributed equally to each
tooth. As to how this can be realized, the
theoretical possibilities are as follows:
enlarge the abutment teeth with n
composite
enlarge the abutment teeth with n
ceramic as an integrated part of the
bridge
make separate additional veneers. n
The therapy concept
In order to close the proximal gap as
much as possible towards the cervical,
the authors’ preference was the last op-
tion (Figs 1321). Tno sooond option
would have required firing on veneer-
ing ceramic without an adequate sup-
porting substructure, which seemed
questionable from a technical point of
view. Furthermore, the required inser-
tion path would have created problems
cervically. The possible aging of the
composite was the reason for rejecting
the first option. The contact points of the
vonoors to tno PBFDP woro prooisoly
determined using a laboratory paralel-
lometer. Additional veneers are virtually
invisible on teeth as long as the finishing
lino is oriontod oorvioo-inoisally (Fig 18).
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However, finishing lines perpendicular
to the tooth’s long axis may be visible in
some cases. After adhesive cementa-
tion of the veneers, a new impression
was made. The construction of the ZrO
2

framework was achieved using an es-
tablisnod CAD/CAM systom (Fig 19).
The surface treatment of the ZrO
2
for
adhesive cementation can be achieved
using air abrasion witn 50 µm alumina
partiolos at 2.5 bar íor 15 s togotnor witn
a pnospnato monomor (MDP)-oontain-
ing primer and the corresponding ce-
ment.
14,15
Of all possible alternatives,
grit blasting nas tno bost suríaoo-oloan-
ing effect.
16-18
Booauso ziroonium oxido
is not etchable, a clean and rough sur-
face is obtained that ensures wetting of
the surface, which is a prerequisite for
adnosion. Anotnor possibility is to silioa-
Fig 13 Waxup of the required enlargement of the
neighboring teeth.
Fig 12 The wax setup on the prepared tooth
serves as a quick impression of the width discrep-
ancy and the gap between the abutment teeth (set-
up system: Anteriores Set, Wichnalek, Augsburg,
Germany).
Fig 15 Additional ceramic veneers (Creation
Classic) on the plaster model.
Fig 14 For a better visualization of the width distri-
bution, gold powder was used on the waxup.
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Fig 19 Digital dosign oí tno rosin-bondod hxod
dental prosthesis.
Fig 18 Adnosivoly oomontod vonoors on 32 and
41. As a rulo, vortioal transitions aro inoorporatod
quite invisibly.
coat the cementation surfaces with Co-
Jot¹ or Pooatoo¹ (3M ESPE, Sooíold,
Germany) silanization and then use
a Bis-GMA-basod oomont
19
(Figs 22
to 24). Currontly, tnoro is no long-torm
clinical study available on the effect of
suríaoo oonditioning oí non-otonablo
ceramics on clinical behavior.
20
Aging
was reported to have a detrimental ef-
íoot on long-torm adnosion.
14,20

In the case presented, the whole lin-
gual surfaces of the teeth and the proxi-
mal cementation surfaces of the veneers
woro oloanod using mioro-abrasion witn
25 µm alumina slurry undor wator (Prop
K1 Max, EMS, Nyon, Switzorland) and
tno suríaoos woro rougnonod (Fig 24).
Finally, tno tootn woro otonod witn 35%
pnospnorio aoid (Ultra-Eton
®
, Ultradent
Products, South Jordan, UT, USA) and
Fig 17 Proximal veneers. Fig 16 The already accomplished lingual prep-
aration is completed with additional veneers. The
sharp finishing line is placed backwards behind
the middle in order to enable a smooth adaptation
between the etched feldspathic ceramic and the
ZrO
2
framework. Central positioning grooves in the
preparation make cementation easier.
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Fig 21 Posin-bondod hxod dontal prostnosis witn
two wings (two bonded retainers). ZrO
2
framework
was vonoorod witn Croation Zí-F ooramio but tno
retainers were not veneered.
Fig 20 Finisnod all-ooramio rosin-bondod hxod
dental prosthesis on the model.
Fig 23 Application of the silane coupling agent
(Monobond S, Ivoclar Vivadent, Schaan, Liechten-
stoin). ít takos 1 minuto to ovaporato tno solvont.
Fig 25 Cloaning tno suríaoo witn airhow (Prop K1
Max, EMS).
Fig 22 Silica coating of the cementation surfac-
os oí tno wings witn tno CoJot systom (3M ESPE,
Seefeld, Germany).
Fig 24 Applioation oí tno dual-ourod luting oom-
posite (Variolink II, Ivoclar Vivadent, Schaan, Liech-
tonstoin) on tno oomontation suríaoos oí tno rosin-
bonded fixed dental prosthesis.
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Fig 27 Posin-bondod hxod dontal prostnosis aí-
ter the adhesive cementation in situ.
Fig 26 Cementation of the ZrO
2
rosin-bondod
fixed dental prosthesis and photopolymerization.
Fig 28 The final treatment result.
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254
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
vOLUME 5 º NUMBEP 3 º AUTUMN 2010
conditioned, followed by the application
oí a olassio oton-and-rinso adnosivo sys-
tem (Syntac, Ivoclar Vivadent, Schaan,
Liechtenstein). The cementation was
aoniovod using dual-ourod adnosivo
cement (Variolink
®
II, Ivoclar Vivadent)
(Figs 24 to 26). Figs 27 and 28 snow tno
final treatment result.
Discussion
Unfortunately, there is rarely a single so-
lution for all problems in dentistry and
dental technology. In most cases, den-
tists find solutions for individual situa-
tions and individual complications. The
presented case involved several such
challenges and indicates that esthetics
in reconstructive dentistry is an extremely
demanding discipline requiring experi-
ence and knowledge, and the poten-
tial to apply both. The esthetic aspect
of treatment always adds an additional
requirement to the medical basics, and
sometimes competes with them, mak-
ing the whole treatment more difficult.
Good esthetics do not happen neces-
sarily as a consequence of correct den-
tal and medical treatment. Often there
is a need to do more. Furthermore, the
individual patient’s wishes need to be
taken into consideration. Patients with
high esthetic demands require good
management, which can create chal-
lenging situations.
The present case illustrates, from dif-
ferent angles, the demanding daily task
of the practicing dentist to apply modern
and advanced methods and at the same
time assess their benefits and risks. With
the increasing complexity of cases, the
responsibility of the clinician is increas-
ing. The solutions demonstrated should
not be considered the most correct
troatmont, instoad tnoy illustrato tno
thought process during the planning of
such complex cases. Whilst almost two
decades ago the missing teeth in such
oasos woro rostorod witn motal-ooramio
FDPs, with the preparation of at least four
abutment teeth, today there is the pos-
sibility of using implants and zirconium
oxide frameworks, but these also require
moro oxporionoo and know-now. ín oon-
sidering hard and soft tissue augmen-
tation and the indications for implants,
their number, position, system, design,
and the dental material itself need to be
considered in the treatment planning, as
well as time management on the part of
the dental professional.
Tno statomont "Hign-toon dontistry
is nign-risk dontistry" was an aoooptod
saying a decade ago but it is not true
anymoro. CAD/CAM millod ZrO
2
frame-
works and glass ceramic restorations
(eg, lithium disilicate) are more reliable
íull-ooramio matorials tnan manually
produced ceramics. Today, the follow-
ing statement is more valid: “High es-
tnotios dontistry is nign-risk dontistry."
The more esthetic the material is, or the
more translucent the ceramic, the weak-
er it is. Moreover, the higher the esthetic
demands, the more difficult it is to es-
tablish static and mechanically strong
restorations. Today, ZrO
2
implants and
ZrO
2
abutments that are screwed direct-
ly onto the titanium implants are still an
experimental solution.
The pressure from the market is trig-
gering sales of such untested medical
products, and every practitioner needs
to dooido íor nim/norsolí now and wnon
such progressive alternatives should be
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THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
vOLUME 5 º NUMBEP 3 º AUTUMN 2010
applied in their own practice. With the
presented adhesive abutment solution
in the maxilla, it is clearly shown that
even in such challenging situations it is
possible to offer, in borderline cases, a
relatively safe and clinically proven so-
lution. The most probable risk here is
the debonding of the ZrO
2
restorations.
ín suon a situation, a non-problomatio
intra- or oxtraoral robonding would bo
an easy solution. Adhesion of ZrO
2
abut-
ments to titanium bases is successful
in vitro
21
and has become successful
clinical practice for years in the authors’
office as well as in many others.
Regarding the mechanical stability of
the components, the alternative titanium
abutment in combination with metal
frameworks is considered the most reli-
able option with the longest track record.
The chosen material combination in the
presented case must still prove its lon-
gevity in the clinic. However, experience
with several such cases is promising.
The most difficult decision in this case
was wnotnor to oonsidor a íull-oovorago
singlo-unit FDP on tootn 12 or not. Tnis
issue was discussed intensively with the
patient. A series of review articles tried to
answor tno quostion oí wnotnor implant-
supported FDPs or combined implant–
tootn-supportod FDPs aro prognostioally
in íavor oí tno sololy implant-supportod
restorations.
22-25
Tno analysis oí 21
studies that met the inclusion criteria
indicated an estimated survival rate for
implant-supportod FDPs oí 95% aítor 5
yoars and 86.7% aítor 10 yoars oí íuno-
tion.
23
The survival rates for the implants
tnomsolvos woro 95.4% and 92.8% aítor
5 and 10 yoars, rospootivoly. Aooording
to Pröbster a prosthetic restoration sys-
tem can be regarded as successful if it
snows a olinioal survival rato oí 95% aítor
5 yoars and 85% aítor 10 yoars oí íuno-
tion.
26
Against the high survival rates for
implant-supportod FDPs, íroquont oom-
plioations (38.7%) woro roportod witnin
the first 5 years in the same study.
23

These included chippings and loosen-
ing or fracture of screws. The term “suc-
ooss" is usod wnon an FDP romainod
unchanged and free of all complications
over the entire observation period. The
reported complication rates indicate that
implant-supportod rostorations gonor-
ally carry a high risk of retreatment and
require maintenance services.
24
In a
oomparablo mota-analysis oí 13 studios
that met the inclusion criteria, combined
tootnimplant-supportod FDPs snowod
a significantly lower estimated survival
rato oí 94.1% aítor 5 yoars and 77.8%
aítor 10 yoars. Tno suoooss ratos íor tno
implants woro also lowor witn 90.1% and
82.1% aítor 5 and 10 yoars, rospootivoly.
However, the complication rates related
to the implants alone ranged between
0.7% and 11.7%, doponding on tno typo
that presented a figure considerably low-
or tnan tnoso oí tno implant- supportod
restorations.
22
In the present case, the issue in ques-
tion was wnotnor a tnroo-unit oombinod
tootnimplant-supportod FDP would
have a higher survival and lower com-
plioation rato tnan a two-unit oantilovor
FDP supported by a single implant.
Thus the decision made for this case
deviates from the situations analyzed
in the dental literature. Although trends
can be observed, the literature does not
provido an answor. Nonotnoloss, tootn-
supported cantilever FDPs show lower
survival rates and higher complication
rates than those of conventional FDPs
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CASE REPORT
supported by at least two abutments.
25

This indicates that the leverage forces
created by a cantilever should, in gen-
eral, be regarded as mechanically prob-
lematic.
Due to the fact that the diameter of
the implant and of the external hex was
small and that the vertical dimension of
the prosthesis was high, and that there-
fore strong leverage forces were to be
expected, the conventional bridge solu-
tion was oonsidorod saíor tnan a íroo-ond
pontic. This assessment was confirmed
by the fact that the temporary restora-
tions showed multiple debondings. The
implant situation was given and, accord-
ing to today’s possibilities, correct as
well. The presence of two neighboring
implants in the anterior region is a de-
manding esthetic challenge for the pros-
thodontist, due to the soft tissue (ie, pa-
pillae) problems. In fact, an implant can
only provont a íull-oovorago orown on
the abutment tooth and at the same time
replace the missing tooth. Therefore the
decision to incorporate a crown on tooth
12 in tno prosont oaso oould bo |ustihod
from an ethical standpoint as well.
The situation in the mandible is a clas-
sio indioation íor an PBFDP. Tnis is ospo-
cially true after an already failed implant
attompt. A oonvontional íull- oovorago
FDP would require much hard tissue
loss. In cases where there are soft tissue
recessions in combination with small root
diameters at the gingival level, a correct
crown preparation is almost impossible.
Suon PBFDPs oould bo mado witn ono or
two wings on ono or two abutmonts. Ono-
wing PBFDPs mado ontiroly oí ooram-
ics have been shown to be a successful
treatment option.
27,28
The disadvantage
oí tno two-wing typo is tnat, in a oaso
where an unnoticed fracture, debond-
ing, or delamination occurs, second-
ary caries on the abutment tooth could
occur.
23,29
Knowing tnat tno ono-wing
PBFDP nas an oxoollont olinioal longov-
ity record,
30
other options are not justi-
fied in such a situation. The most com-
mon indioation íor PBFDPs is missing
lateral incisors in the maxilla. Splinting
the central incisor with the canine of the
samo sido using an PBFDP nas provon
to be not physiologic. The experience of
tno autnors rogarding suon PBFDPs in
the maxilla has shown unilateral debond-
ings in many cases. A possible reason
for these debondings could be stress at
the adhesive interfaces due to uneven
tooth mobility of the anterior maxillary
teeth under physiologic functional load.
ín oontrast, during moro tnan 10 yoars
of observation, no unilateral debonding
was obsorvod in tno mandiblo witn all-
ooramio PBFDPs mado oí litnium disili-
cate.
31
Furtnormoro, tnoso PBFDPs woro
made specially with proximal grooves
but no wings. This indicates that in the
mandible, the load is directed axially
rather than lingually, which may explain
wny two-wing PBFDPs woro moro suo-
cessful. Similarly, Kern et al found all
ono-sidod dobondings oxolusivoly in tno
maxilla.
13
The question remains whether,
under the assumption that in the mandi-
ble both options could function clinically,
a second wing is necessary. Even if the
potential danger of a connector fracture
is present, in the present authors’ opinion
tno two-wing dosign is íavorod, booauso
it allows for thinner connectors.
The discussion above clearly un-
derlines the difficulty of the practicing
dentist to make the right decisions to
guarantoo long-torm olinioal suoooss.
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Also, the question regarding durabil-
ity of the adhesive cementation with a
non-otonablo ooramio ziroonium ox-
ide ceramic remains unanswered. The
longest clinical experience exists with
glass-inhltratod aluminum oxido ooram-
ics. The results with this material indi-
oato tnat suríaoo oonditioning witn air-
abrasion using alumina, and the use of
a primer and adhesive with bifunctional
(MDP) monomers, yields a good clinical
survival rate.
13
However, in vitro micro-
tensile tests showed unfavorable results
íor tno adnosion oí rosin oomonts to ín-
Ceram
®
Alumina and ín-Coram Ziroonia
after artificial aging conditions.
20,32
For
pure zirconium oxide, such information
is limited in the literature.
33-35
In general,
it oan bo antioipatod tnat all kinds oí non-
etchable ceramics would behave simi-
larly. Basod on tno iníormation dorivod
from in vitro studies, the aging effect on
the adhesive interfaces and thereby the
durability of the adhesion is the Achilles’
heel of such therapies.
19,33-35

A possible structural change through
air abrasion in the stabilized zirconium
oxide could be a concern. Limited in-
formation is available on the possible
negative effects of air abrasion on zir-
conium oxide.
36
The opinions on this
aspect are controversial.
36,37
Neverthe-
less, chairside application of silicatiza-
tion was claimed to be less hazardous
on the material properties of zirconium
oxide than laboratory air abrasion utiliz-
ing alumina.
37
Air abrasion could be expected to
create damage in the form of delamina-
tion or total fracture according to cur-
rent knowledge.
36
However, it depends
on several other parameters.
37
It was,
however, claimed that the cleaning of
cementation surfaces is best achieved
with air abrasion.
17
Since oxide ceram-
ics do not contain silica, as an alternative
to tno adnosivo oomontation witn MDP-
containing cements, chairside silica
coating and silanization could be con-
sidered in combination with dual polym-
orizod Bis-GMA oomont.
19,33,34
Which
method for the cementation of zirconium
oxide would be clinically more success-
ful needs to be determined. Therefore,
such cases are currently under review
in the present authors’ practice.
Conclusions
Missing teeth can be restored both func-
tionally and esthetically utilizing treat-
ment modalities such as veneers and
suríaoo-rotainod PBFDPs oouplod witn
implants and zirconia suprastructures.
The durability of such restorations can
be achieved through adhesive cementa-
tion, based on the current state of the art
derived from both clinical and laboratory
studies. This clinical example illustrates
the particular challenge for any clini-
cian when confronted with exceptional
situations, where former experience or
scientific evidence may not followed. It
is important to learn from previous unfa-
vorable applications and inappropriate
assessments or decisions affecting the
individual and to keep an open mind re-
garding treatment concepts in the light
of new findings and experiences.
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vOLUME 5 º NUMBEP 2 º SUMMEP 2010
258
CASE REPORT
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