Prosthodontics Themed Issue

Dental materials CLINICAL

Advances in materials and concepts in

fixed prosthodontics: a selection of possible
treatment modalities
Daniel Edelhoff,*1 Michael Stimmelmayr,2 Josef Schweiger,3 M. Oliver Ahlers4,5 and Jan-Frederik Güth6

Key points
Presents innovative pre-treatment Demonstrates less invasive preparation Identifies the potential and limitations Provides material selection criteria
options with CAD/CAM polymers in options for bonded all-ceramic veneers of all-ceramic restorations for the to ensure durable anterior cantilever
complex rehabilitations. and occlusal onlays. abraded dentition. resin-bonded FDPs and conventional
FDPs.

Abstract
The introduction of adhesive techniques in combination with translucent restorative materials has greatly influenced
treatment concepts in fixed prosthodontics. Modern production technologies offer access to new polymer materials that
provide innovative pre-treatment options for complex prosthetic rehabilitations. Additionally, computer-aided design and
manufacturing (CAD/CAM) provides access to new ceramic types and thus extends the range of indications for metal-free
restorative options. With these developments, important changes of treatment concepts in fixed prosthodontics have
occurred which affect the professional life of dental practitioners with a focus on prosthetic dentistry. This article gives an
overview of the advances in selected fields of fixed prosthodontics and provides support in material selection for different
kinds of indications, from single-tooth restorations to fixed dental prostheses.

Introduction a predominantly subtractive method, is This article demonstrates the advances in

gradually being superseded by a primarily materials and strategies in fixed prosthodontics
Treatment options in fixed prosthodontics defect-orientated additive approach. by discussing a selection of possible treatment
have changed significantly in recent decades. Second, modifications of conventional modalities and supports these concepts by
Three main developments have strongly treatment procedures have led to the citing the available scientific literature.
influenced these changes. First, minimally development of an economical approach to
invasive treatments have increasingly become the removal of healthy tooth structure, as Background
feasible in restorative dentistry, thanks to the the planned outcome is defined in a wax-up At present, conventional treatment with metal-
introduction of the adhesive technique in before the treatment itself is commenced. based crowns and fixed dental prostheses
combination with restorative materials with This wax-up is then used for reference (FDPs) are considered the gold standard
translucent properties comparable to those during tooth preparation. Third, digital for clinical success and survival.1 However,
of natural teeth. Mechanical anchorage of technology delivers important additional the extensive removal of tooth structure
restorations via conventional cementation, information including 3D data, for analysis, associated with full coverage crowns and
diagnostics, communication, restorative FDPs on prepared abutment teeth remains
designs and treatment planning, improving a major drawback. A retrospective clinical
1
Director and Chair, Department of Prosthetic Dentistry, reproducibility. Also, the computer-aided study has demonstrated that the 15-year
University Hospital, LMU, Munich, Germany; 2Associate
Professor, Department of Prosthetic Dentistry, University design/manufacturing (CAD/CAM) process survival probability of vital pulps was 81.2%
Hospital, LMU, Munich, Germany; 3Dental Technician, Head facilitates more standardised fabrication in metal-ceramic single crowns and only
of Dental Laboratory, Department of Prosthetic Dentistry,
University Hospital, LMU, Munich, Germany; 4Department processes and quality improvements in 66.2% in FDP abutments.2 Foster found an
of Prosthetic Dentistry, Centre for Dental and Oral Medicine, materials, and provides access to new endodontic complication rate of 21% for
University Medical Centre Hamburg-Eppendorf, University
of Hamburg, Hamburg, Germany; 5Director, CMD-Centre
materials offering favourable options during FDP abutments after six years.3.An initial
Hamburg-Eppendorf, Hamburg, Germany; 6Associate the pre-treatment period as well as for quantification of hard tissue removal with
Professor, Department of Prosthetic Dentistry, University
Hospital, LMU, Munich, Germany.
subsequent definitive restorations. Similarly, different preparation configurations revealed
Correspondence to: Daniel Edelhoff the introduction of cantilever resin-bonded that up to 72% of the clinical crown will be
Email: [email protected]
fixed dental prostheses and implants permits removed in full crown preparations in the
Refereed Paper. the preservation of tooth structure for teeth anterior and posterior regions.4,5 In contrast,
Accepted 7 January 2018 that would otherwise have had to be prepared all-ceramic anterior veneer preparations are
DOI:10.1038/s41415-019-0265-z
as abutment teeth. associated with removing tooth structure in

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 CLINICAL Dental materials

the amount of between 7% (partial veneers)

and 30% (extended veneers).4 For occlusal
onlays with proximal extensions, 32% of the
tooth structure was removed.5 These findings
were confirmed in a study that used state-
of-the-art measuring techniques and are
increasingly affecting treatment decisions in
prosthodontics.6
Several in vitro studies on endodontically-
treated teeth have found that preserving greater
amounts of natural tooth structure has a
significant positive effect on fracture resistance
in all tooth types.7,8 Up to 45% more tooth
structure can be preserved by opting for partial
rather than complete coverage when restoring
endodontically-treated molars.9 Similar results
were found for retainer preparations for resin-
bonded FDPs and attachments.10,11
It is noteworthy that clinical studies on all-
ceramic partial coverage crowns have shown
no or very low endodontic complication Fig. 1 Industrial prefabricated CAD/CAM disc made of tooth-coloured polycarbonate (Temp
Premium Flexible; Zirkonzahn, Gais, Italy) after milling two fully-contoured removable splints
rates, at observation periods between seven
and 12.6  years, compared to studies on
metal-ceramic full coverage crowns.12 For Innovative pre-treatment with
veneer restorations, the rate of endodontic CAD/CAM polymers
complications was as low as 2.51% after an
observation period of 20 years.13 Hence, less Pre-treatment with occlusal splints is an
invasive preparation and restoration designs important step in a structured concept for
appear to have a favourable effect on the vitality complex prosthetic rehabilitations and serves
of restored teeth. Against this background, to determine and stabilise a physiological
Fig. 2 Fully-contoured CAD/CAM occlusal
fixed prosthodontics has been undergoing a condylar position. Furthermore, it permits splints for bimaxillary application (maxilla
paradigm shift towards less invasive methods evaluating acceptance of the intended vertical and mandible) after separation from the
in recent years. Prosthetic concepts have also dimension. Conventional positional splints are polycarbonate disc. The material exhibits an
become increasingly well-differentiated in a proven, established and relatively low cost extremely high degree of flexibility and, even
recent decades.10,14,15 pre-treatment. Their chemical composition when extremely thin (0.3 mm), has a high
Predominantly subtractive concepts, to allows the splints to be modified to follow fracture resistance
provide mechanical retention for traditionally adaptive changes in condylar position.
cemented restorations, are being replaced However, the willingness of patients to
by less invasive, primarily defect-orientated wear conventional splints during daytime is
procedures wherever feasible.16 In the case of limited, mostly due to aesthetic and phonetic
pronounced dental hard tissue loss, additive restrictions, limiting their efficiency.21 In
approaches offer innovative reversible addition, conventional positioning splints
pre-treatment options and functional are generally provided for only one jaw. In
restorations.17,18 In addition, modifications are bimaxillary restorative treatments, therefore,
being made to traditional procedures, such as they attempt to represent the entire change in Fig. 3 Preoperative frontal view of a female
defining the treatment goal in the lead-up to vertical dimension in a single appliance and patient with a right cleft lip and palate.
Tooth 12 is missing and the dentition exhibits
the treatment itself with the aid of a diagnostic cannot simulate the position of the occlusal
severe tooth wear that has led to a change
wax-up.19 The wax-up provides orientation plane of the subsequent restoration. Despite
in intercuspal position and a decrease in the
for tooth preparation and a more economical these limitations, conventional relaxation and vertical dimension of occlusion
approach when it comes to removing healthy positioning splints continue to be the method
dental hard tissue.20 of choice for initial pain relief and functional
This article intends to describe innovative rehabilitation. polycarbonate, these splints approximate the
pre-treatment options and methods that allow With the introduction of CAD/CAM- definitive restoration in terms of function and
the removal of hard tissues to be substantially milled polymers, novel alternatives to splints aesthetics (Fig. 1). Removable monomaxillary
reduced. Metal-free CAD/CAM materials have become available. Designed according or bimaxillary full contour splints provide the
will be presented and discussed, focusing on to a diagnostic wax-up and milled and option of conservative, surgical, periodontal
selected polymers and all-ceramic materials. finished to full contour from tooth-coloured and restorative interventions beneath them

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 Dental materials CLINICAL

rehabilitations. They can serve to identify the

most adequate occlusion concept, especially
in patients sensitive to occlusal changes. In
complex prosthetic rehabilitations, they permit
a conversion to the definitive restoration, a
segment at a time (Fig. 9). However, relevant
clinical studies are still absent.
Fig. 4 After a successful clinical evaluation
of aesthetics and function over at least Fig. 7 Preoperative situation of a patient
three months, the transition to the definitive seeking treatment for bite correction because Conversion to definitive all-ceramic
restoration can proceed segment by segment, of severe pain in function as a consequence restorations
using the reciprocal transfer method for the of a generalised malocclusion
evaluated jaw relation. The right quadrant
All-ceramic anterior veneers
was prepared and the maxillary splint Encouraged by positive long-term clinical
separated in half with a separating disk results, there has been a steady expansion of
the range of indications for all-ceramic veneers,
even going so far as to re-evaluate previous
contraindications to open up possible new
fields of application.24,25,26,27,28,29 Against this
background, ceramic veneers have shed their
reputation of being purely aesthetic adjuncts,
Fig. 8 Occlusal PMMA veneers bonded
turning into a serious treatment alternative,
to existing restorations. Before adhesive in addition to conventional, far more invasive
placement with a low viscosity resin cement, types of restorations.30,31,32 Today, veneers are
the existing metal ceramic restoration with also used to restore the biomechanics of the
Fig. 5 With the left half of the splint inserted gold margins were tribochemically air- dentition, establish adequate function, mask
in the still unprepared left quadrant, the jaw abraded (CoJet; 3M, Seefeld, Germany), then highly discoloured endodontically-treated
relation was registered using a high precision cleaned and coated with a primer
teeth, and for other purposes.33 Silicate ceramic
bisacrylate registration material (LuxaBite; materials are the material of choice to replace
DMG, Hamburg, Germany), which can be
An additional pre-treatment option is lost natural enamel thanks to their enamel-like
corrected with Aluwax (American Dental
the application of polymethyl methacrylate optical and mechanical properties.34,35 However,
Systems, Vaterstetten, Germany). Limitations
of this technique exist in patients who suffer (PMMA) repositioning onlays and veneers, veneer preparation, provisionalisation and
from instable temporomandibular joints or bonded to the compromised tooth or existing adhesive bonding place greater demands on the
who are occlusion-sensitive. In these cases, restorations (Figs 6, 7 and 8). They can be made operator’s skills than complete-coverage crown
the techniques featured in the subsequent conventionally or by CAD/CAM.22,23 Given the preparation and conventional cementation.
illustrations should be used higher edge stability compared to ceramics, Enamel preservation represents a determining
polymer-based materials can be milled to factor for the success of a veneer restoration.36,37
very thin layers of up to 0.3 mm and can thus Therefore, veneers should be designed using a
serve as pure additive restorations without mainly additive approach.
any tooth preparation.23 However, this pre- Veneer preparations are subject to stringent
treatment option is more complicated because principles, but they still offer a high degree of
the bonded PMMA restorations are difficult flexibility in terms of the restorative design,
to modify intraorally, their reversibility is depending on the clinical situation (tooth
limited, and they are relatively expensive. position, degree of destruction, occlusal
Fig. 6 CAD/CAM repositioning onlays made Nevertheless, because the contours of these conditions, periodontal surroundings etc).38,39
of PMMA (TelioCAD; Ivoclar Vivadent, Schaan, temporary restorations are identical to the This is true for both the incisal design and
Liechtenstein). These extra thin additive intended restored situation and because they for its interproximal extension.38,24 Preparing
PMMA restorations can be bonded to existing are inserted permanently, patients can even eat a palatal chamfer offers the highest degree of
restorations for occlusal correction as a fixed
with them, which makes the evaluation period freedom in positioning the incisal edge, which
pre-treatment and simultaneously for a ‘test
drive’ of the new occlusion as realistic and effective as possible. is particularly important if a large amount of
According to the authors’ experience, both hard tissue has been lost.38,39,40
monomaxillary and bimaxillary full contour Similar considerations apply to the
without adverse effects on the newly defined simulation splints, as well as repositioning interproximal extension of the preparation
aesthetic and functional situation (Figs 2 onlays and repositioning veneers, enjoy (Fig.  10).35,24 If the popular medium wrap
and 3). At the end of the ‘test drive’ period, substantially better patient acceptance than design is used, the contact area, and thus the
a segmented transfer to the final restoration conventional positional splints and provide width of the existing tooth, are maintained
can be performed, facilitating the treatment of new ‘test drive’ options to explore the aesthetics, and, consequently, the height is determined
complex rehabilitations (Figs 4 and 5).17 phonetics and function of complex prosthetic by the defined width to height ratio (Fig. 11).

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 CLINICAL Dental materials

implementation of this technique is difficult.

Circular preparation designs (360° veneers),
also known as ‘full wrap’ veneer designs, are
particularly recommended for complex cases
that require increasing the vertical dimension
of occlusion to close the resultant free space on
the palatal aspect of the maxillary anterior teeth
(Fig.  13). Essentially, a diagnostic template
or silicone mould should be manufactured
from the wax-up and used as a guide during
Fig. 9 Overview of the pre-treatment options for complex prosthetic rehabilitations with major tooth preparation, reducing the amount
changes in aesthetics and function, and the transition to definitive restorations
of tissue removed, by taking into account
the previously defined external contour of
the future veneer (Fig.  14).35,37,43 If severe
discolouration is present, the preparation may
be slightly deeper to provide sufficient scope
for masking the tooth.33 Luting composites
can also be used to slightly modify the final
colour of ceramic veneers.44 In a retrospective
ten-year cohort study, these veneers have been
shown to offer a 93.5% survival probability.13
First interim results of a prospective clinical
study on veneers with a long wrap design
have been promising; however, no sufficient
data are as yet available on either long wrap
Fig. 10 Design options for the interproximal extension. Left to right, with increasing levels of or full wrap veneers.45 The survival rates of
invasiveness. Short wrap design: easy to implement, but with a visible adhesive joint. Medium
ceramic veneers are also influenced by other
wrap design: retains the contact point, with the adhesive joint not visible. Long wrap design:
parameters, including the amount of available
removes the contact point and requires a deeper (approximately two thirds) interproximal
preparation enamel, the optical and mechanical properties
of the material used, the preparation design,
tooth function and occlusion, the degree of
By contrast, a long wrap design eliminates the preparation can be conveniently accomplished destruction and the vitality of the tooth to be
contact areas due to their deep interproximal with oscillating preparation instruments treated (vital or endodontically-treated), as
extension, offering considerably more scope (for example, Sonic Line; Komet Dental, well as the level of experience of the restorative
for variation regarding the shape and position Lemgo, Germany) and Soflex discs (2382 M; team.13,31,36,37
of the restoration (Fig.  12). The long wrap 3M, Seefeld, Germany).41 In periodontally
design is therefore advantageous in severe compromised situations, the long wrap design All-ceramic occlusal onlays
discolouration, diastemas, extensive shape may be combined with a horizontal insertion Adhesively connected all-ceramic occlusal
modifications, slide midline corrections, black axis,42 eliminating the need for an extensive onlays are a reliable treatment option for the
triangles and large fillings. Furthermore, the reduction of the coronal tooth structure. The posterior region.46,47 In this context, it should
long wrap design is recommended for veneers width can be smaller cervically than incisally. be borne in mind that most clinical long-term
in the immediate vicinity of crowns, as it allows Substantial amounts of hard tissue can be studies are based on leucite-reinforced glass
the contact area between the two restorations preserved with this configuration. On the ceramics, whereas considerably stronger
to be executed in ceramics. Interproximal downside, however, the clinical and technical ceramic materials based on lithium disilicate

Fig. 12 Veneer preparation in long wrap Fig. 13 Veneer preparation in full wrap
Fig. 11 Veneer preparation in medium wrap design, opening the contact points, and try-in design (360° veneers) and try-in of the
design, preserving the contact points, and try-in of the definitive veneers made of feldspathic definitive monolithic bichromatic veneers
of definitive feldspathic veneers, sintered on ceramics using the sintering technique on made of lithium disilicate ceramic (IPS e.max
refractory dies (laboratory procedures: Otto refractory dies (laboratory procedures: Otto Press Multi; Ivoclar Vivadent; Otto Prandtner,
Prandtner, MDT, Munich, Germany) Prandtner, MDT, Munich, Germany) MDT, Munich, Germany)

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Fig. 16 Occlusal onlay preparations are

associated with a gentle removal of tooth
structure, especially if the preparation does
not extend beyond the equator into the
infrabulge (red marked area)
Fig. 14 Template-guided veneer preparation.
The silicon index was made on the wax-up and
then seated on the prepared teeth to control
Fig. 15 Preparation of an occlusal plateau
the removal of hard tissue against to the
for a lithium disilicate ceramic occlusal onlay.
planned contour of the definitive restoration
The specific geometry of the abrasive body
using a special probe featuring a millimetre
(here: OccluShaper as finisher, Komet Dental,
scale (CP-15UNC, University of North Carolina;
Lemgo, Germany) creates anatomically-
Hu-Friedy, Tuttlingen, Germany)
shaped convex cusp support for the future
occlusal onlay while leaving enough space
in the central fissure to implement an
are available today.12,48 With the decreasing Fig. 17 Monolithic occlusal onlays made of
immediate side shift (ISS) during dynamic
incidence of caries, accompanied by an occlusion IPS e.max Press (degree of turbidity: HT) with
increasing incidence of biocorrosive defects, an occlusal thickness of 1 mm and a 0.5 mm
including in generalised form, changed circular border (laboratory procedures: Otto
defect morphologies of the dental hard tissue restorations (staining technique) (Figs  17 Prandtner, MDT, Munich, Germany)
are gaining in importance. 49,50 Thus, the and 18). Discussions are currently underway
requirement profile for minimally invasive, about further reductions in layer thickness if
defect-orientated, adhesively-cemented single- appropriate enamel support is present.14,48
tooth restorations has changed. Restorative Glass ceramic onlays appear to be ideally
treatment in the posterior region now focuses suited for rebuilding abraded and eroded
increasingly on occlusal defects, seeking to posterior teeth because they offer enamel-
restore adequate function, aesthetics and like properties and a favourable interface
biomechanics, and to help prevent further behaviour.51 They allow particularly gentle
pathological wear. preparation of the tooth structure, as long
In view of the sometimes extreme changes in as the preparation does not extend beyond Fig. 18 Try-in of the lithium disilicate ceramic
occlusal contour due to tooth wear, adhesively- the equator into the infrabulge (Fig.  16). occlusal onlays (IPS e.max Press, degree of
cemented occlusal onlays made of high-strength Consequently, these onlays can help avoid turbidity: HT) with a colour-keyed dyed try-in
glass ceramics are a more desirable type of conventional, much more invasive prosthetic paste (Variolink Esthetic, Try-in, colour: warm;
restoration than conventional full crowns, which procedures. It is essential for the preparation Ivoclar Vivadent)
are twice as invasive.5 As they permit a defect- margins to be located predominantly in
orientated preparation and eliminate the need enamel. Extensive silicate ceramic onlays have period of 12.6 years revealed failure rates of
for a retentive preparation design, all-ceramic displayed a favourable stress response pattern 20.9% in vital teeth and 39% in endodontically-
onlays are a sensible treatment option and and with almost exclusively compressive forces treated teeth.47
avoid conventional invasive methods.14,51 The at the interface in in vitro studies.51 However,
supragingival preparation margins of occlusal all transitions should be rounded and soft to Resin-bonded anterior all-ceramic FDPs
onlays offer numerous advantages in terms prevent stress peaks within the restoration Resin-bonded fixed dental prostheses
of better control during preparation, reduced (Fig. 15).52 (RBFDPs) in the anterior region were first
loss of dental hard tissue, less or no traumatic It is generally useful to distinguish between described in the 1970s.54 In a literature review,
interference with the marginal gingiva, easier pure onlays, involving only occlusal surfaces, RBFDPs comprising two retainers showed a
conventional and digital impression-taking, and onlay veneers, involving the vestibular significantly lower probability of survival than
more available enamel for bonding and well- surface. The latter are indicated if a major full crown abutments over a period of ten
controlled adhesive cementation, possibly shade modification in the aesthetic region years.1 However, it should be borne in mind
under rubber dam (Figs 15 and 16). (premolar) is required (Fig.  15). 23 In a that anterior maxillary teeth are considered to
Since the introduction of lithium disilicate, controlled prospective clinical study, silicate be particularly vulnerable to vitality loss when
the recommended preparation depths for glass ceramic onlays showed satisfactory long-term used as full crown abutments in conventional
ceramic onlays have been reduced significantly. results after 12  years. They are also suited FDPs.2 The tooth structure removal on anterior
Today, a minimum occlusal thickness of for use in extensive tooth structure defects.53 maxillary central incisors was measured to be
1  mm is recommended for monolithic Another clinical study with an observation up to 72.1% for full crown abutments and only

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12.4% after preparation of wing retainers for

an RBFDP.4 With the introduction of metal-
based cantilever RBFDPs (cRBFDPs) in the
1980s, invasiveness levels were further reduced
and the need for unphysiological splinting
of abutment teeth was eliminated.55,56 In the
anterior region, cRBFDPs were identified
Fig. 19 CAD/CAM zirconia-based cantilever Fig. 20 Post-orthodontic palatal view of the
to have a lower clinical failure rate than resin-bonded fixed dental prosthesis anterior tooth display of a young female
two retainer RBFDPs.57,58 The principles of (cRBFDPs) for the replacement of two missing patient with bilateral agenesis of the
minimally invasive treatment also favour maxillary lateral incisors (left and right) in a maxillary lateral incisors. The recipient site
cRBFPDs.58 In the 1990s, glass-infiltrated young female patient (laboratory procedures: of the pontic had been pre-treated for an
aluminium oxide ceramics were used for the Otto Prandtner, MDT, Munich, Germany) improved emergence profile
first time in a clinical study to manufacture all
ceramic RBFDPs with two retainers.59 With
greater popularity and better access to CAD/
CAM technology, zirconia-based cRBFDPs
became the therapy of choice where metal-free
cRBFDPs are indicated.60,61
Today, most cRBFDPs are made with
frameworks made of materials with a high
modulus of elasticity, such as base-metal
alloys or zirconia ceramics (Fig. 19). They are
used in the anterior region as an alternative
to implant-supported restorations for single
teeth if implant treatment is contraindicated, Fig. 21 For zirconia-based cantilevered RBFDPs, a flat proximal box 0.5 mm in depth and
extensive surgical interventions should be 2×2 mm in width is recommended at the connector side for the pontic
avoided, the space available is insufficient for
implant treatment, the patient is too young
or too old, or if an implant is simply not
wanted.55,61 In a clinical trial investigating the
impact of complications of anterior single-
tooth restorations, the oral health-related
quality of life was similar irrespective of
whether implant-supported single crowns or
cRBFDPs were used.62
One of the most important indications is
in the anterior region of the maxilla, as the
highest incidence of dental agenesis is reported Fig. 22 For a reliable bond to the zirconia wing, the internal surface was air-abraded with
to affect maxillary lateral incisors, with a higher carborundum (50 μm grain) at 1 bar of pressure. For better control of the air abrasion
prevalence in female than male patients.63 process, a black marker was applied to the internal surface of the wing. In a second step,
In the same meta-analysis, bilateral agenesis the air-abraded zirconia was cleaned and a MDP primer was applied ahead of the luting
of maxillary lateral incisors was found more composite
frequently than unilateral agenesis (Fig. 20).
If a maxillary lateral incisor is missing, central abutment teeth that are primarily free of
incisors will be the abutments of choice for both caries and fillings, enough interocclusal
cRBFDPs due to their larger proximal contact space (approximately 0.8 mm) and sufficient
area (PCA) (Figs  20 and 21).64 Removing amounts of enamel.61 Where central incisors
between 0.5 mm and 0.7 mm of tooth structure show major carious lesions, extended fillings,
is recommended in preparation for the wing- endodontic treatment or similar, the canine
shaped retainer, with either a slight chamfer can be selected as the abutment tooth for
or slight rounded shoulder as a finishing cRBFDPs. Fig. 23 Postoperative palatal view after
line. Instead of retentive grooves associated One of the most frequent minor the adhesive placement of two zirconia
with metal-based RBFDPs, a flat proximal complications is debonding. A reliable cRBFDPs with an ovate pontic design.
box 0.5 mm in depth and 2 × 2 mm in width procedure for binding to either tooth hard Since the distal contact area of the pontics
is recommended at the connector side for tissue or zirconia is considered the most can be accessed by dental floss, hygiene
procedures are simplified compared to two
pontics of all-ceramic cRBFDPs (Fig. 21).60,65 important prerequisite for the long-term
retainer RBFDPs
Additional requirements include healthy clinical success of zirconia-based cRBFDPs.66

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Fig. 26 Palatal view of a four-unit FDP with a

CAD/CAM zirconia framework and a manually
Fig. 24 Post-orthodontic frontal view of sintered ceramic veneer (IPS e.max ZirCAD LT
Fig. 25 Postoperative frontal view after
a young female patient with congenitally [3Y-TZP]/IPS e.max Ceram; Ivoclar Vivadent). The
adhesive insertion of the zirconia cRBFDPs
missing maxillary lateral incisors (orthodontic ceramic gingiva replica was also sintered onto
restorations. Both canines and centrals
procedures: Professor A. Wichelhaus, LMU the zirconia framework (laboratory procedures:
received bonded no-prep feldspathic veneer
Munich, Germany) Oliver Brix, CDT, Bad Homburg, Germany)
restorations made using the refractory-die
technique (laboratory procedures: Otto
Prandtner, MDT, Munich, Germany)

Fig. 27 Try-in of the four-unit zirconia-based

FDP on two implants (Screw-line, 3.8/13 mm;
Fig. 28 Basal view of a posterior three-unit FDP Fig. 29 Abutment teeth 35 and 37 prepared for
Camlog, Wimsheim, Germany) in the lateral
with a CAD/CAM zirconia framework (3Y-TZP, a three-unit zirconia FDP with ceramic veneer
incisor positions 12 and 22, with zirconia
Lava Plus; 3M) and manually-sintered ceramic
hybrid abutments
veneer (IPS e.max Ceram; Ivoclar Vivadent) to
replace tooth 36 (laboratory procedures: Otto
Prandtner, MDT, Munich, Germany)
Where bonding to enamel represents a
predictable and well-established procedure,
different methods to generate a reliable
adhesion to zirconia surfaces are described.67 loss were recorded; all debonded zirconia
Based on the results of a systematic review, the cRBFDPs could be rebonded.10 In carefully
physico-chemical conditioning of zirconia, selected cases, lithium disilicate ceramics
Fig. 30 Postoperative situation after
including moderate airborne particle abrasion might be suitable as a framework material for
adhesive placement of the three-unit zirconia
and the use of MDP-based resin cements, were cRBFDPs.70 FDP with sintered ceramic veneer
found to produce reliable adhesion (Figs 22 and
23).68 Following these protocols, this type of Conventional FDPs made of zirconia
minimally invasive restoration can satisfy high Lithium disilicate ceramics was introduced of their high opacity, the first generation of
aesthetic demands while requiring relatively in 1998 as a reliable metal-free material for zirconia was used predominantly as a framework
little treatment time (Figs 24 and 25). Since different types of single-tooth restorations. For material that was manually veneered by a
the preparation takes place almost exclusively single crowns, long-term clinical survival rates sintering ceramic for aesthetic reasons. Specific
within the enamel, local anaesthetics are comparable to metal ceramic crowns have been material properties of zirconia in contrast to
usually not required. reported.71,72,73 In contrast, conventional three- metal alloys, such as a different coefficient of
Data from clinical studies on zirconia unit FDPs made of lithium disilicate ceramics thermal expansion and extreme low thermal
cRBFDPs show excellent clinical results. In are recommended for only limited indications conductivity, required new veneering materials
a four-year clinical study, with 15 zirconia (anterior dentition with second premolar as and new firing parameters.78 The combination
cRBFDPs, a survival rate of 100% was distalmost abutment), and survival rates were of the optical properties of both the dentin-like
reported.69 Two early debondings could be strongly correlated with the framework design, zirconia framework and the enamel-like ceramic
successfully reattached. In a clinical long-term veneered or monolithic.74,75,76 The introduction veneer greatly raised the aesthetic standards for
study of a total of 108 anterior zirconia of CAD/CAM technology gave rise to the first metal-free FDPs in the anterior and posterior
cRBFDPs, 75  in the maxilla and 33  in the generation of yttrium-stabilised polycrystalline jaw (Figs  26, 27, 28, 29 and 30).79 In clinical
mandible, a ten-year survival rate of 98.2% tetragonal zirconia (3Y-TZP), with significant studies, the first generation of zirconia ceramics
and a corresponding success rate of 92.0% were higher flexural strengths than all dental glass or rarely exhibited framework fractures, but many
reported. Six debondings and one restoration oxide ceramics available at this time.77 Because cases of minor and major chipping of the veneer

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 CLINICAL Dental materials

available that can be differentiated by their adhesive fixation, and less interference with
admixture of aluminium and yttrium oxides. the marginal gingiva. While these possibilities
Not only their optical characteristics but also inspire a great deal of excitement, we should
the mechanical properties are influenced as bear in mind that the methods described above
a result of a matter of changes in refractive involve a high degree of technique sensitivity
index, grain size, and crystalline composition regarding preparations (mainly enamel),
(Figs 31, 32 and 33).86,87 Recently innovative adhesive bonding and fine-tuning of the static
CAD/CAM-materials were introduced, which and dynamic occlusion.24,52,61,90,91
Fig. 31 Occlusal view of a CAD/CAM combine two different zirconia compositions While clinical long-term studies10,13,46,47,91
posterior three-unit FDP made of monolithic in one disc (gradient technology). New exist on minimally invasive restorative
multilayer zirconia (3Y-TZP zirconia; Katana generations of zirconia ceramics promise new methods using ceramic materials, valid clinical
HT/ML, Kuraray Noritake, Tokyo, Japan). indications. All relevant long-term clinical data on the long-term behaviour of minimally
Surface staining was applied, without trials refer to restorations made of 3Y-TZP invasive definitive restorations made of CAD/
sintered ceramic veneer
zirconia. Many open questions remain, related CAM composite resins are still lacking.92,93 The
especially to the third and fourth zirconia intermediate three-year results of a five-year
generations. Long-term clinical stability, wear prospective clinical study with 45 inlays and
behaviour and bonding options have not yet 58 partial-coverage restorations made of
been fully verified.88 Initial  in  vitro studies CAD/CAM polymer-infiltrated ceramics have
have demonstrated a significant increase of demonstrated good performance.94 However,
translucency in novel zirconia materials, but a significant decrease in marginal adaption
associated with a significant reduction in and an increase in marginal discolouration
flexural strength.89 and surface roughness were observed over
For 5Y-TZP zirconia, flexural strength and time. 94 A randomised clinical trial with
translucency parameters between those of indirect composite resin and glass ceramic
Fig. 32 Intraoral view of the prepared
3Y-TZP and lithium disilicate ceramic are veneers showed similar survival rates of 87%
abutment teeth 14 and 16
reported. Both the short-term and long-term and 93.5%, respectively. However, changes in
bond strengths of 5Y-TZP and 3Y-TZP were surface characteristics were more frequent in
shown to be similar to lithium disilicate. the composite material.95
5Y-TZP demonstrated no measurable material The clinical results with direct composites
wear, and antagonist enamel wear was as a definitive restorative material were
comparable to other materials tested.88 initially good, especially in the anterior
region. 96,97 However, clinical follow-ups
Discussion showed that in more complex cases, direct
posterior composite restorations discernibly
With the introduction of digital technologies deteriorated after five and a half years and
Fig. 33 Try-in of the three-unit FDP made and access to new restorative materials, more, in terms of surface texture, anatomical
of monolithic multilayer zirconia (3Y-TZP clinicians are facing a continuously shape and marginal fit.98 The survival rates of
zirconia, Katana HT/ML; Kuraray Noritake)
increasing range of treatment options in fixed composite resin as a restorative material in
prosthodontics. These options allow strategies complex direct rehabilitations depend on the
as the most frequent complication.80,81,82 In a and materials to be selected specifically for the tooth position, being most unfavourable in the
randomised clinical trial (RCT), zirconia FDPs individual patient’s needs. However, clinicians case of molars.99
with up to five units demonstrated satisfying and technicians need well-developed skills, Numerous in vitro studies on CAD/CAM
long-term results comparable to those of the experiences and knowledge to select the right composite resins and polymer-infiltrated
metal ceramic control group.83 Nevertheless, a therapy based on scientific data. ceramics have examined their optical and
higher rate of framework fractures, debonding, A paradigm shift towards less invasive mechanical properties, surface and wear
chipping and inferior marginal adaption was treatment options is obvious; the overall aim is behaviour, as well as bonding options. In
reported. to reach the treatment goal while removing the one of these in  vitro studies, CAD/CAM
The use of monolithic zirconia would reduce least possible amount of natural tissue. Reliable composite resins showed higher flexural
the risk of chipping and improve the stability bonding to natural enamel and tooth-coloured strengths than leucite ceramics and polymer-
of the restoration while simplifying the CAD/ materials have ushered in a shift towards much infiltrated ceramics, but lower strengths than
CAM procedure.84 One important prerequisite more conservative preparation designs than lithium disilicate ceramics.100 Glass ceramics
for using zirconia in monolithic restorations was previously thought possible.4,5 showed lower discolouration rates than
was improved aesthetics through reduced Minimally invasive restorations are CAD/CAM composites and less two-body
opacity and the option of individual staining. considered beneficial because of the low wear.100 In multiple in vitro studies, ceramics
New formulas resulted in new types of zirconia risk of damaging the pulp, better hard tissue showed superior gloss retention compared
ceramics with greater translucency.85 Four protection, easier impression-taking, a better to hybrid ceramics, composites and acrylic
generations of zirconia ceramics are now view of the site during preparation and polymers.101,102,103

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 Dental materials CLINICAL

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748 BRITISH DENTAL JOURNAL | VOLUME 226 NO. 10 | May 24 2019

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