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Implant-supported fixed complete dental prostheses (IFCDPs) can be made with different prosthetic designs in a wide range of material combinations. The choice of materials and the implant-prosthetic design are closely linked. In the recent past, the combinations of materials used for full-arch fixed prosthetic restorations were exclusively: metal-acrylic resin, metal-composite resin and metal-ceramic. In the last two decades, zirconia frameworks have become increasingly popular in the implant prosthetic field and the introduction of CAD/CAM technology has made it possible to approach full-arch restorations in a different way. The most advanced implant-prosthetic designs exploit the aesthetic and mechanical strength qualities of the latest generation monolithic zirconia. These solutions looks very promising. However, the long-term outcome of these implant-supported rehabilitations remains still unknown due to the lack of sufficient clinical data.
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Sergio  Bortolini
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Annali di stomatologia
Implant-supported fixed complete dental prostheses
Modern concepts in Implant-Supported Fixed Complete Dental Prostheses (IFCDPs): from traditional solutions to current monolithic zirconia restorations. Concise review
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Sergio  Bortolini
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Department of Surgery, Medicine, Dentistry and Morphological Sciences with Interest in Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia (UNIMORE), Via del Pozzo 71, 41125 Modena, Italy.
1971-1441
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Implant-supported fixed complete dental prostheses
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Modern concepts in Implant-Supported Fixed Complete Dental Prostheses (IFCDPs): from traditional solutions to current monolithic zirconia restorations. Concise review
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                                                                                                     Original Article


Modern concepts in Implant-Supported Fixed
Complete Dental Prostheses (IFCDPs): from
traditional solutions to current monolithic zirconia
restorations. Concise review



Andrea Berzaghi1 DDS, MSc, PhD                                rial combinations chosen based on clinical and economic
Sergio Bortolini1 DDS, Associate Professor                    factors. Therapeutic options differ on the basis of reten-
                                                              tion methods, framework design, combination of pros-
1
    Department of Surgery, Medicine, Dentistry and Mor-       thetic materials, gingiva construction methods3. In all
    phological Sciences with Interest in Transplant, Oncol-   implant-prosthetic designs we can find advantages and
    ogy and Regenerative Medicine, University of Modena       disadvantages related to aesthetics, strength, simplici-
    and Reggio Emilia (UNIMORE), Via del Pozzo 71,            ty, manufacturing method, complications and cost. The
    41125 Modena, Italy.                                      choice of materials and the implant-prosthetic design are
                                                              closely linked. In order to select the most advantageous
                                                              therapeutic option, in the decision-making process it is
Corresponding author:
                                                              essential to know the strengths and weaknesses of the
Andrea Berzaghi
                                                              available solutions. The most current solutions make it
andrea.berzaghi@unimore.it
                                                              possible to exploit the translucency potential of the new
                                                              generations of zirconia which, however, require ade-
                                                              quate knowledge of the materials and a correct design
Abstract
                                                              evaluation. In this article we expose current knowledge
Implant-supported fixed complete dental prostheses            on modern full-arch implant prosthetic solutions in the
(IFCDPs) can be made with different prosthetic de-            light of the recent zirconia-based materials offered by the
signs in a wide range of material combinations. The           product sector.
choice of materials and the implant-prosthetic design
are closely linked. In the recent past, the combina-
tions of materials used for full-arch fixed prosthetic
                                                              Traditional solutions
restorations were exclusively: metal-acrylic resin,           Historically, resin occlusal surfaces have been used in
metal-composite resin and metal-ceramic. In the last          implant prosthetics to provide a “cushioning effect” to the
two decades, zirconia frameworks have become in-              implants in order to compensate for the resilience of the
creasingly popular in the implant prosthetic field and        periodontium and allow the occlusal surface to be the
the introduction of CAD/CAM technology has made it            weakest link in the implant prosthetic restoration5. With
possible to approach full-arch restorations in a differ-      the deepening of knowledge on osseointegration and a
ent way. The most advanced implant-prosthetic de-             greater diffusion of implant prosthesis, the use of metal
signs exploit the aesthetic and mechanical strength           alloy and ceramic for occlusal surfaces has spread. Cur-
qualities of the latest generation monolithic zirconia.       rently, there is no scientific evidence showing a link be-
These solutions looks very promising. However, the            tween osseointegration and the type of occlusal surface
long-term outcome of these implant-supported reha-            material. Furthermore, there does not appear to be any
bilitations remains still unknown due to the lack of          differences in terms of stresses transmitted to the bone
sufficient clinical data.                                     based on the fabrication material of the occlusal surfac-
                                                              es of the restoration6. Nonetheless, fracture of the occlu-
Keywords: Zirconia, monolithic zirconia, metal bar,           sal material is one of the most common complications
Implant-supported fixed complete dental prostheses.           reported in the literature7,8. In the recent past, the com-
                                                              binations of materials used for full-arch fixed prosthetic
                                                              restorations were exclusively: metal-acrylic resin, met-
Introduction
                                                              al-composite resin and metal-ceramic. The metal-acryl-
Implant-supported fixed complete dental prostheses (IF-       ic resin combination (Metal framework-prefabricated
CDPs) represent the therapeutic solution of excellence        acrylic artificial teeth) has shown high success rates9
for total edentulism and demonstrate high clinical suc-       and remains a popular choice due to its long tradition in
cess rates in the literature1,2,3. IFCDPs have 95% clinical   literature, simplicity, low cost, simple repair management
success at 5 years in the maxilla and 97% at 10 years         and a “clinicians comfort level” acquired over the years10.
in the mandibular arch4 .These restorations can be made       The metal-composite resin and metal-ceramic alterna-
with different prosthetic designs in a wide range of mate-    tives are both expensive, more laborious to manufac-


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    Modern concepts in Implant-Supported Fixed Complete Dental Prostheses (IFCDPs...

    ture, difficult to repair and susceptible to the manufac-       tilevers must be sized with large occlusocervical thick-
    turing technique11. All traditional rehabilitation typologies   nesses and limited extension in order to withstand high
    present various complications in the short and long term        occlusal loads40. It is also important to ensure adequate
    including: fracture or detachment of resin teeth, wear of       thicknesses of the framework in correspondence with
    occlusal surfaces, ceramic chipping, difficulty in color        the access chimneys to the connection screws adjacent
    matching related to gingival pink, lack of passive adap-        to the cantilevers33. The same attentions in the design
    tation, expensive prosthetic repairs10,12-21.                   phase are valid in the case of anterior cantilevers, a
                                                                    potential cause of catastrophic fracture often underes-
                                                                    timated and which require a safety dimensioning of the
    Zirconia
                                                                    areas with the greatest risk of failure. The advantages
    The recent evolution of ceramic materials in prosthet-          of the monolithic screw-retained prosthesis are many.
    ic dentistry is aimed at increasing the mechanical and          The screw-retained prosthesis traditionally represents
    aesthetic properties and simplifying the manufacturing          the first choice in full-arch implant-prosthetic rehabilita-
    and decision-making processes for clinicians and tech-          tion for fewer biological complications and easier man-
    nicians. The interest in zirconia as a framework material       agement of complications41,42. Zirconia guarantees ad-
    derives from the possibility of advantageously exploit-         vanced mechanical properties with a low complication
    ing the phase transition (PTT, Phase Transformation             rate; excellent biocompatibility; favorable wear charac-
    Toughening), obtaining a ceramic material with high             teristics; reduced accumulation of plaque and biofilm;
    resistance and fracture toughness. Until a few years            satisfactory gingival and dental aesthetics associated
    ago, it was universally recognized in the literature that       with minimal ceramization of non-functional areas; re-
    the most mechanically resistant ceramics offered less           duced pigmentation compared to acrylic resin. The
    advanced aesthetic characteristics, most of the time re-        CAD-CAM design and production of zirconia has led to
    sulting more opaque, therefore less translucent and at-         further advantages: better precision of the prosthesis
    tractive. Thus, in recent years zirconia has undergone          thanks to modern manufacturing systems; availability of
    changes in microstructural composition to improve               a permanent digital file with the possibility of duplicating
    translucency while maintaining adequate mechanical              the prosthetic restoration; possibility of making tempo-
    properties: with the third generation of zirconia, born in      rary posts in PMMA. However, the monolithic zirconia
    2015, and the subsequent fourth generation, structural          screw-retained design remains a complex prosthetic
    changes have been made starting from the increase               solution, in which clinical success is linked to the knowl-
    of the yttrium oxide content22,23,24. Furthermore, the in-      edge of the materials and the high precision required
    troduction of monolithic zirconia for its characteristics       by 3Y-TZP32,33,43. The need to guarantee the framework
    of reliability and practicality has led to a downsizing in      suitable dimensions in areas at risk of fracture, the im-
    prosthetic design with indisputable advantages for cli-         possibility of recovery of the structure in the event of
    nicians and technicians25,26. In the last two decades, zir-     failure, the low tolerance to imprecisions and the opacity
    conia frameworks have become increasingly popular in            of the high-strength material represent the current limits
    the implant prosthetic field and the introduction of CAD/       of this prosthesis2,33. The monolithic screw-retained de-
    CAM technology has made it possible to approach full-           sign is not able to take advantage of the progress of the
    arch restorations in a different way and with promising         material because it requires high-strength but opaque
    success rates27-30.                                             zirconia, which needs digital cut-back procedures and
                                                                    ceramization of the aesthetic area34,44. Even the latest
    Screw-retained IFCDPs: monolithic zirconia                      generation multitranslucent materials do not seem to
                                                                    be the adequate answer to the problem as the com-
    restorations                                                    plex design of the screwed monoblock places too many
    Monolithic zirconia has recently found an indication in         unknowns on the strength of the structure. However,
    screw-retained full-arch implant prosthetic restorations.       the new generations of 4Y-TZP and multi-translucent
    In this prosthetic design, the reference material remains       monolithic zirconia materials, incorporating 3Y, 4Y and
    the second generation 3Y-TZP for mechanical strength            5Y-TZP with varying translucency levels, appear to be
    and high success rates: recent studies have shown a             promising in these designs as well. In particular, some
    survival rate of 99.3% with minimal technical complica-         types of 4Y-TZP with high mechanical performance can
    tions in the medium term31. These restorations can pro-         represent promising materials in this sense.
    vide in the CAD phase a digital “cut back” of the struc-
    ture in the non-functional areas in which the minimum           Metal-Zirconia Implant Fixed Hybrid Full-Arch
    ceramicization is required limited to the aesthetic areas
                                                                    Prosthesis: monolithic zirconia on metal bar
    including the gingival part32,33,34. The elimination of the
    zirconia/ceramic interface from the functional surfaces         To overcome these limitations, recent studies have pro-
    solved the clinical complications related to the delami-        posed an innovative prosthetic solution that has been
    nation or chipping of the veneering layer3,29,35. The key       defined as a metal-zirconia hybrid for the combination
    to the clinical success of the screw-retained monolith-         of a metal framework supporting a monolithic structure
    ic prosthesis lies in the extreme precision and correct         in zirconia45,46. This prosthetic design features a bar,
    design of the monolithic monoblock, particularly in the         usually in titanium or Cr-Co, to support a latest gener-
    areas potentially most exposed to fracture. The distal          ation monolithic zirconia superstructure. By exploiting
    cantilever, which has a long history of clinical success        advanced CAD-CAM digital technologies, it is possible
    in full-arch implant prosthetics36,37, in the case of limit-    to combine the advantages of the two materials, offer-
    ed prosthetic space (less than 15mm) or parafunctional          ing aesthetic and reliable restorations (Figg.1-3). The
    habits of prosthetic components at higher risk of me-           metal bar gives stiffness, excellent tensile strength, high
    chanical complications38,39. In zirconia restorations, can-     fracture strength, passive fit and allows you to manage



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A. Berzaghi et al.




Figure 1. Based on CAD information, we can design and fabricate temporary and definitive prosthetic restorations on a
metal bar.




                     Figure 2. Zirconia superstructure coupled to the titanium bar (Mdt Germano Rossi). In
                     this case, the bar was made of grade 5 titanium Rematitan 5 (Dentaurum s.p.a) while
                     zirconia Ceramotion Z Hybrid 1300/1020 Mpa (Dentaurum s.p.a) was chosen for the
                     superstructure.




                     Figure 3. Case concluded: gingival and dental aesthetic ceramization with Ceramotion
                     One Touch ceramic pastes (Dentaurum s.p.a).



10.59987/ads/2023.2.7-11                                                                                                9
     Modern concepts in Implant-Supported Fixed Complete Dental Prostheses (IFCDPs...

     long spans between adjacent implants and extend can-            monolithic screw-retained design has encouraging
     tilevers. It also allows versatile use on different implant     success rates in the medium term but requires further
     platforms, compensates for problems of unfavorable              in vitro and clinical studies for a more scientific anal-
     angles and offers the possibility, if necessary, to be          ysis of the design criteria. Recent hybrid metal-zirco-
     segmented. The metal frameworks obtained by laser               nia solutions combine the advantages of two different
     sintering/melting procedures have improved the “fit”,           materials such as monolithic zirconia and metal (Ti or
     the “bonding” and the corrosion resistance compared             Co-Cr as indicated) and appear to solve the limitations
     to the bars obtained by casting47. Titanium is a suitable       of screw-retained solutions. This innovative prosthet-
     material due to its high tensile strength, fracture resis-      ic implant design looks very promising. However, the
     tance, biocompatibility and low weight. The alternative         long-term outcome of these implant-supported rehabil-
     is Cr-Co which has recently been re-evaluated in the            itations remains unknown due to the lack of sufficient
     implant-prosthetic field: it boasts a long experience of        clinical data.
     exposure in the oral cavity in removable partial prosthe-
     ses, it is considered the first choice in the case of can-
                                                                     Acknowledgments
     tilevers or long spans, it is harder than titanium with im-
     proved scratch resistance and has great resistance to           The authors would like to thank Dentaurum Italia S.p.a.
     oxidation over time. Furthermore, in case of laser weld-        for supporting this article. We thank for the clinical case:
     ing it guarantees excellent mechanical resistance47,48.         Dr. Biagio Di Giuseppe, Roseto Degli Abruzzi (Te); Dr.
     The monolithic zirconia in this prosthetic design rep-          Roberto Secchiaroli, Senigalia (An); Mdt Germano Ros-
     resents the first choice solution for reasons related to        si, Alba Adriatica (Te).
     the intrinsic characteristics of the material and to the
     prosthetic technologies. From an aesthetic point of
     view, the metal framework gives the possibility to take
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10.59987/ads/2023.2.7-11                                                                                                                      11
