CLINICAL REPORT

Minimally invasive prosthetic restoration of posterior tooth

loss with resin-bonded, wing-retained, and inlay-retained xed
dental prostheses fabricated from monolithic zirconia: A
clinical report of two patients
Wolfgang Bmicke, Dr med dent, MSc,a Jochen Karl, ZTM,b and Peter Rammelsberg, Prof Dr med dentc

Metal ceramic resin-bonded ABSTRACT

xed dental prostheses
The esthetics and biocompatibility of ceramic resin-bonded xed dental prostheses (RBFDPs) are
(RBFDPs) retained by adhesive regarded as better than those of their metal ceramic counterparts. However, a high incidence of
wings (wing-retained RBFDPs, complications in the posterior arches of ceramic RBFDPs initiated a process of continuous and
WR-RBFDPs) or inlays (inlay- evolving design development. This clinical report describes 2 successful restorations of a missing
retained RBFDPs, IR-RBFDPs) posterior tooth with monolithic zirconia RBFDPs with 2 different retainer designs: retentively pre-
have been successfully used pared adhesive wings and inlays. (J Prosthet Dent 2016;-:---)
in the clinic to replace poste-
rior teeth with minimal tooth preparation.1-4 overcome by using monolithic translucent zirconia.12
Following the general trend toward restorations with Successful adhesion to the material, however, is greatly
better esthetics and increased biocompatibility, metal- dependent on the bonding method.13-15
free (ber-reinforced composite resin or ceramic) This clinical report describes the restoration of
RBFDPs were developed. Although initially successful,5,6 posterior edentulous areas with a WR-RBFDP and an
the low (73% to 78%) 5-year survival of posterior ber- IR-RBFDP, both fabricated from monolithic translucent
reinforced composite resin RBFDPs gave rise to doubts zirconia.
regarding the long-term success of the treatment.7,8 For
IR-RBFDPs fabricated from heat-pressed lithium dis-
CLINICAL REPORT
ilicate glass ceramic, a survival rate of 38% after 8 years
contraindicated their use.9 Results from in vivo testing of Patient 1
zirconia-based IR-RBFDPs are controversial.10,11 In 1 A 64-year-old nonsmoking woman with an uneventful
study, 28% of the restorations failed within the rst 12 medical history sought care in 2014 for a missing
months because of debonding or delamination of the maxillary right second premolar, which had been
veneering porcelain, ultimately leading to framework extracted approximately 1 year before after unsuccessful
fractures.11 In another study, an encouraging cumulative endodontic treatment. The adjacent teeth were vital and
5-year survival rate of 94.5% was observed for zirconia- periodontally stable, with no tooth mobility, and had
based IR-RBFDPs with a modied, more retentive buccal class V composite resin restorations; the rst
framework design with additional lingual and buccal premolar also had a class II and the rst molar a class I
retainer wings.10 Veneer chipping, however, still limited amalgam restoration. Radiographs of the prospective
the success of these restorations. Chipping can be abutments revealed healthy periapical conditions. Oral

a
Assistant Professor, Department of Prosthodontics, University Clinic Heidelberg, University of Heidelberg, Heidelberg, Germany.
b
Master dental technician, Department of Prosthodontics, University Clinic Heidelberg, University of Heidelberg, Heidelberg, Germany.
c
Director, Department of Prosthodontics, University Clinic Heidelberg, University of Heidelberg, Heidelberg, Germany.

THE JOURNAL OF PROSTHETIC DENTISTRY 1

2 Volume - Issue -

Figure 1. Treatment with monolithic zirconia wing-retained resin-bonded xed dental prosthesis (WR-RBFDP). A, Situation with unprepared abutment
teeth and existing amalgam restorations replaced by composite resin. B, Prepared abutment teeth. Planned extension marked with black permanent
marker. C, Occlusal view of adhesively cemented monolithic zirconia WR-RBFDP. D, Buccal view.

hygiene was good, with only minimal plaque visible,
predominantly located in the interdental spaces. Func-
tional evaluation revealed no signs or symptoms of
temporomandibular disorders. Absence of cheek and
tongue biting, absence of heavy wear facets (attrition
score 2),16 negative self-reporting of grinding and
clenching in a questionnaire (bruxing scale),17 and results
from a portable electromyographic device (Bite Strip,
up2dent.com pixeltown OHG)18 warranted a negative
diagnosis of bruxism. Subsequently, the patient was
treated with a WR-RBFDP.
After professional tooth cleaning and oral hygiene
instruction, the treatment was started by replacing the
amalgam restorations in the abutment teeth with
anatomic restorations with a dual-polymerizing com-
posite resin foundation material (Rebilda DC white;
VOCO GmbH) (Fig. 1A). Diagnostic casts were obtained
from irreversible hydrocolloid impressions and analyzed
for planning of the direction of insertion of the RBFDP
and the extent of the adhesive retainers. A waxing of the
missing tooth, after duplication of the cast, enabled
fabrication of a vacuum-formed thermoplastic template
for the fabrication of an interim restoration. During the
next visit, tooth color was determined, and, after local
anesthesia, the abutment teeth were prepared with a
taper of 4 degrees with ne grit (30 mm) diamond rotary
instruments (all from Gebr Brasseler GmbH & Co KG) in
a manner similar to that used for posterior metal ceramic
RBFDPs (Fig. 1B).3 This included proximal and oral axial
reduction of 0.5 mm with a chamfer-shaped rotary in-
strument (no. 8879.314.014), occlusal reduction of 0.6
mm with an egg-shaped rotary instrument (no.
8379.314.018), and, as retentive elements, the prepara-
tion of a proximal seating groove (approximately 4 mm
long) with a tapered shoulder-shaped rotary instrument
(no. 8847.314.012) and of an occlusal box (1 mm deep
and 1 mm wide, following the ssure pattern) with a
tapered shoulder, rounded edge-shaped rotary instru-
ment (no. 8847KR.314.014). An interim restoration was
fabricated chairside from dual-polymerizing composite
resin (Luxatemp Automix Solar; DMG GmbH) and, after
a polyether (Impregum Penta Soft; 3M ESPE) denitive
impression had been made, was seated with eugenol-
free interim cement (RelyX Temp NE; 3M ESPE). Scan-
nable Type IV dental gypsum (GC Fujirock EP; GC
Europe NV) was used to fabricate the denitive cast,

THE JOURNAL OF PROSTHETIC DENTISTRY Bmicke et al

- 2016
Figure 2. Treatment with monolithic zirconia inlay-retained resin-bonded xed dental prosthesis (IR-RBFDP). A, Initial situation with defect-free anterior
abutment tooth and previously restored posterior abutment tooth. B, Prepared abutment teeth. C, Occlusal view of IR-RBFDP. D, Buccal view of
IR-RBFDP.
which was mounted by using an arbitrary facebow
(AXIOQUICK III; SAM Przisionstechnik GmbH) in a
semi-adjustable articulator (SAM 2PX; SAM Przision-
stechnik GmbH) with the opposing diagnostic cast in
maximum intercuspal position, using a polyvinyl siloxane
(Futar D Fast; Kettenbach GmbH & Co KG) interocclusal
record. The situation was digitized with a dental labo-
ratory scanner (D800 3-D Scanner; 3Shape A/S). The
RBFDP was designed virtually (Dental Designer; 3Shape
A/S), milled (Cercon brain XPERT/Cercon brain CAM
Pro; DeguDent GmbH) from presintered, translucent Y-
TZP (Cercon ht light; DeguDent GmbH), colored (Colour
Liquid Prettau; Zirkonzahn GmbH), and sintered at
1500 C (Cercon heat plus; DeguDent GmbH). After
tting in the articulator, the RBFDP was characterized
and glazed (Cercon stain/Cercon glaze; DeguDent
GmbH).
In the ofce, the interim restoration was removed, the
abutment teeth were cleaned with zirconium silicate
prophylaxis paste (Zircate Prophy Paste; Dentsply
DeTrey), and the RBFDP was adjusted for t and occlu-
sion (eccentric contacts on the pontic were avoided). A
rubber dam was placed. The internal surfaces of the
Bmicke et al
3
RBFDP were silica-coated using the Rocatec (RC) method
(RC Pre and RC Plus; 3M ESPE) and treated with a silane
and 10-methacryloyloxydecyl diphosphate (MDP)-con-
taining primer (Clearl Ceramic Primer; Kuraray Inc) for
60 seconds. Enamel bonding surfaces were selectively
etched (10 seconds, 37% phosphoric acid) before the
RBFDP was seated with self-etch MDP-containing resin
cement (ED Primer + Panavia 21; Kuraray Inc). After 2
years, the RBFDP remained in place without complica-
tions and the patient was satised with the esthetics and
function of the RBFDP (Fig. 1C, D).
Patient 2
A 75-year-old nonsmoking woman with an uneventful
medical history had the rst maxillary left molar
extracted after endodontic failure approximately 1 year
before her presentation in 2014. Clinical and radio-
graphic examination revealed no further treatment was
needed, and oral hygiene was good. Bruxism screening
was negative. Defects of the vital abutment teeth were
limited to a class II composite resin restoration of the
second molar (Fig. 2A), and no tooth mobility was
recorded. Subsequently, the patient was treated with a
THE JOURNAL OF PROSTHETIC DENTISTRY
4 Volume
monolithic zirconia IR-RBFDP. With the exception of
abutment tooth preparation, treatment of the patient
followed the steps already described for patient 1.
Occlusal boxes were prepared with a minimum vertical
reduction of 1.5 mm, measured from the deepest point
of the central ssure. The minimum width was 2.5 mm,
and the preparation followed the anatomy of the ssure
pattern. The proximal boxes were 2 mm deeper than the
occlusal boxes, with axial reduction of 1 mm, and a
width of at least 3 mm, with tapers of 4 degrees. Me-
dium (100 mm, no. 959KRD.314.018; Gebr Brasseler
GmbH & Co KG) and ne-grain (30 mm, no.
8847KR.314.014; Gebr Brasseler GmbH & Co KG)
tapered shoulder, rounded edge-shaped diamond rotary
instruments (Fig. 2B) were used for the preparations.
Again, after 2 years, no complications had occurred and
the patient expressed satisfaction with the esthetics and
function of the IR-RBFDP (Fig. 2C, D).
DISCUSSION
In this clinical report, RBFDPs were fabricated from
monolithic zirconia to avoid veneer chipping and
framework fracture, both of which have limited the
prognosis of ceramic RBFDPs in the past,9-11 yet still
achieve reasonable esthetics.12 The bonding procedure
used here performed well in in vitro testing.13 After
37 500 thermocycles and 150 days of water storage, the
bond strength was above 10 MPa. In a clinical study, the
use of the MDP-containing resin cement enabled suc-
cessful bonding of anterior single-retainer zirconia
RBFDPs over a period of 5 years.15 Nevertheless,
particular emphasis was given to the use of a retentive
preparation which included a near parallel preparation of
opposing surfaces following the anatomy of the ssure
pattern for the IR-RBFDPs and the placement of seating
grooves and occlusal boxes for the WR-RBFDPs. For WR-
RBFDPs, such a retentive preparation reduced the risk of
failure by a factor of almost 4.2 Finally, eccentric contacts
on the pontics were avoided. The choice of prosthesis
design should be dependent on the defects present in the
abutment teeth.
SUMMARY
A conservative approach to replacing posterior teeth with
monolithic zirconia has been described in this clinical
report. After only minor tooth preparation, 1 wing-
retained and 1 inlay-retained RBFDP manufactured
from the material were placed in 2 patients, and high
patient satisfaction with esthetics and function was
THE JOURNAL OF PROSTHETIC DENTISTRY
- Issue -
achieved. Although no complications occurred within a
2-year period, a clinical trial must precede a general
recommendation for the use of monolithic zirconia
RBFDPs.
REFERENCES
1. Aggstaller H, Beuer F, Edelhoff D, Rammelsberg P, Gernet W. Long-term
clinical performance of resin-bonded xed partial dentures with retentive
preparation geometry in anterior and posterior areas. J Adhes Dent 2008;10:
301-6.
2. Behr M, Leibrock A, Stich W, Rammelsberg P, Rosentritt M, Handel G.
Adhesive-xed partial dentures in anterior and posterior areas. Results of an
on-going prospective study begun in 1985. Clin Oral Investig 1998;2:31-5.
3. Boemicke W, Kappel S, Stober T, Rammelsberg P. Clinical comparison of
metal ceramic resin-bonded xed dental prostheses with a conventional and
a mixed retainer design. J Prosthet Dent 2014;112:472-80.
4. Isidor F, Stokholm R. Resin-bonded prostheses for posterior teeth. J Prosthet
Dent 1992;68:239-43.
5. Ayna E, Celenk S. Polyethylene ber-reinforced composite inlay xed partial
dentures: two-year preliminary results. J Adhes Dent 2005;7:337-42.
6. Monaco C, Ferrari M, Caldari M, Baldissara P, Scotti R. Comparison of 2
bonding systems and survival of ber-reinforced composite inlay xed partial
dentures. Int J Prosthodont 2006;19:577-85.
7. Ghring TN, Roos M. Inlay-xed partial dentures adhesively retained and
reinforced by glass bers: clinical and scanning electron microscopy analysis
after ve years. Eur J Oral Sci 2005;113:60-9.
8. van Heumen CC, Kreulen CM, Creugers NH. Clinical studies of ber-
reinforced resin-bonded xed partial dentures: a systematic review. Eur J Oral
Sci 2009;117:1-6.
9. Harder S, Wolfart S, Eschbach S, Kern M. Eight-year outcome of
posterior inlay-retained all-ceramic xed dental prostheses. J Dent
2010;38:875-81.
10. Chaar MS, Kern M. Five-year clinical outcome of posterior zirconia ceramic
inlay-retained FDPs with a modied design. J Dent 2015;43:1411-5.
11. Ohlmann B, Rammelsberg P, Schmitter M, Schwarz S, Gabbert O. All-
ceramic inlay-retained xed partial dentures: preliminary results from a
clinical study. J Dent 2008;36:692-6.
12. Rinke S, Fischer C. Range of indications for translucent zirconia modica-
tions: clinical and technical aspects. Quintessence Int 2013;44:557-66.
13. Bmicke W, Schrz A, Krisam J, Rammelsberg P, Rues S. Durability of resin-
zirconia bonds produced using methods available in dental practice. J Adhes
Dent 2016;18:17-27.
14. Kern M. Bonding to oxide ceramics-laboratory testing versus clinical
outcome. Dent Mater 2015;31:8-14.
15. Sasse M, Kern M. CAD/CAM single retainer zirconia-ceramic resin-bonded
xed dental prostheses: clinical outcome after 5 years. Int J Comput Dent
2013;16:109-18.
16. Pullinger AG, Seligman DA. The degree to which attrition characterizes
differentiated patient groups of temporomandibular disorders. J Orofac Pain
1993;7:196-208.
17. van der Meulen MJ, Lobbezoo F, Aartman IH, Naeije M. Self-reported oral
parafunctions and pain intensity in temporomandibular disorder patients.
J Orofac Pain 2006;20:31-5.
18. Shochat T, Gavish A, Arons E, Hadas N, Molotsky A, Lavie P, et al. Vali-
dation of the BiteStrip screener for sleep bruxism. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2007;104:e32-9.
Corresponding author:
Dr Wolfgang Bmicke
Department of Prosthodontics
University Clinic Heidelberg
Im Neuenheimer Feld 400
69120 Heidelberg
GERMANY
Email: Wolfgang.Boemicke@med.uni-heidelberg.de
Acknowledgments
The authors thank Ian Davies for editorial work.
Copyright 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.
Bmicke et al