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



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

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


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A. Berzaghi et al.


  A                                                             B




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 Ger-
                                                                                   mano 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 ce-
ramic pastes (Dentaurum s.p.a).



10.59987/ads/2023.1.17-22                                                                                                   19
     Modern concepts in Implant-Supported Fixed Complete Dental Prostheses (IFCDPs)...

     The metal bar gives stiffness, excellent tensile strength,      Conclusions
     high fracture strength, passive fit and allows you to man-
                                                                     The introduction of monolithic zirconia for its charac-
     age long spans between adjacent implants and extend
                                                                     teristics of reliability and practicality has led to a down-
     cantilevers. It also allows versatile use on different im-
                                                                     sizing in prosthetic design in implant prosthesis. The
     plant platforms, compensates for problems of unfavor-
                                                                     monolithic screw-retained design has encouraging
     able angles and offers the possibility, if necessary, to be
                                                                     success rates in the medium term but requires further
     segmented. The metal frameworks obtained by laser
                                                                     in vitro and clinical studies for a more scientific analy-
     sintering/melting procedures have improved the “fit”,
                                                                     sis of the design criteria. Recent hybrid metal-zirconia
     the “bonding” and the corrosion resistance compared
                                                                     solutions combine the advantages of two different
     to the bars obtained by casting47. Titanium is a suit-          materials such as monolithic zirconia and metal (Ti or
     able material due to its high tensile strength, fracture        Co-Cr as indicated) and appear to solve the limitations
     resistance, biocompatibility and low weight. The alter-         of screw-retained solutions. This innovative prosthetic
     native is Cr-Co which has recently been re-evaluated            implant design looks very promising. However, the
     in the implant-prosthetic field: it boasts a long experi-       long-term outcome of these implant-supported rehabil-
     ence of exposure in the oral cavity in removable partial        itations remains unknown due to the lack of sufficient
     prostheses, it is considered the first choice in the case       clinical data.
     of cantilevers or long spans, it is harder than titanium
     with improved scratch resistance and has great resis-
     tance to oxidation over time. Furthermore, in case of           Acknowledgments
     laser welding it guarantees excellent mechanical re-
     sistance47,48. The monolithic zirconia in this prosthetic       The authors would like to thank Dentaurum Italia S.p.a.
                                                                     for supporting this article. We thank for the clinical case:
     design represents the first choice solution for reasons
                                                                     Dr. Biagio Di Giuseppe, Roseto Degli Abruzzi (Te); Dr.
     related to the intrinsic characteristics of the material
                                                                     Roberto Secchiaroli, Senigalia (An); Mdt Germano Ros-
     and to the prosthetic technologies. From an aesthetic
                                                                     si, Alba Adriatica (Te).
     point of view, the metal framework gives the possibility
     to take full advantage of the new generations of trans-
     lucent zirconia without risk of structural failure: only
     minimal ceramization of the gingival areas is neces-
     sary without resorting to vestibular cut-backs on the           References
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