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Q U I N T E S S E N C E I N T E R N AT I O N A L

Novel ceria-stabilized tetragonal zirconia/


alumina nanocomposite as framework material
for posterior fixed dental prostheses:
Preliminary results of a prospective case series
at 1 year of function
Alexander Philipp, Dr Med Dent1/
Jens Fischer, PD Dr Med Dent Dr Rer Nat2/
Christoph Hans Franz Hmmerle, Prof Dr Med Dent3/
Irena Sailer, Dr Med Dent4

Objective: To examine the clinical performance of veneered ceria-stabilized tetragonal


zirconia/aluminananocomposite (Ce-TZP/Ananocomposite) frameworks for three-unit
fixed dental prostheses (FDPs). Method and Materials: Eight patients in need of one FDP
replacing one premolar or molar were included in this case series. Eight Ce-TZP/A
nanocomposite FDP frameworks were fabricated with a CAD/CAM system (Hint-Els) and
veneered with a zirconia veneering ceramic (Vintage ZR, Shofu). The FDPs were cemented with resin cement (baseline) and were evaluated at baseline; 2 weeks; and 3, 6, and 12
months after cementation. For the technical evaluation, the USPHS criteria were used. The
biologic outcome was judged by comparing the plaque control record (PCR), bleeding on
probing (BOP), and probing pocket depth (PPD) of the abutment teeth (test) and untreated contralateral teeth (control). Radiographs were made at baseline and at 6 and 12
months of follow-up. The data were descriptively analyzed. Results: The mean observation period of the eight examined FDPs was 12.8 1.1 months. The survival rate of the
FDPs was 100%. Furthermore, no technical or biologic complications were found. No differences of the mean (m) PCR (test: 0.1 0.1, control: 0.2 0.2), mBOP (test: 0.2 0.2,
control: 0.1 0.1), and mPPD (test: 2.6 0.8, control: 2.6 0.6) were found between test
and control teeth. Conclusions: Ce-TZP/A nanocomposite was found to be a reliable
framework material at 1 year of function. Longer observation periods and randomized
controlled clinical trials including more patients are needed to validate these findings.
(Quintessence Int 2010;41:313319)

Key words: CAD/CAM, ceria-stabilized, fixed dental prosthesis, framework, zirconia,


zirconia/alumina nanocomposite

Postgraduate Student, Clinic for Fixed and Removable

Prosthodontics and Dental Material Science, Center for Dental


and Oral Medicine, University of Zurich, Zurich, Switzerland.
2

Associate

Professor,

Clinic

for

Fixed

and

Removable

Prosthodontics and Dental Material Science, Center for Dental


and Oral Medicine, University of Zurich, Zurich, Switzerland.
3

Professor

and

Chair, Clinic

for

Fixed

and

Removable

Prosthodontics and Dental Material Science, Center for Dental


and Oral Medicine, University of Zurich, Zurich, Switzerland.
4

Assistant

Professor,

Clinic

for

Fixed

and

Removable

Prosthodontics and Dental Material Science, Center for Dental


and Oral Medicine, University of Zurich, Zurich, Switzerland.

In recent years, there has been an increasing


demand for the replacement of missing teeth
with all-ceramic fixed dental prostheses
(FDPs).1,2 However, when posterior teeth were
replaced, high failure rates of the all-ceramic
FDPs were reported.1,2 To date, four clinical
studies are available presenting 5-year results
of all-ceramic FDPs.36 Two of these studies
analyzed glass-infiltrated alumina as framework material.4 In these investigations, FDP
failure rates of 10%4 and 12%5 were reported.

Correspondence: Dr Irena Sailer, Clinic for Fixed and Removable


Prosthodontics and Dental Material Science, Center for Dental and

This study was presented at the Pan European Federation

Oral Medicine, University of Zurich, Plattenstrasse 11, 8032 Zurich,

(PEF)International Assocation for Dental Research Congress,

Switzerland. Fax: 41 44 634 43 05. Email: irena.sailer@zzmk.uzh.ch

London, September 1012, 2008.

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Q U I N T E S S E N C E I N T E R N AT I O N A L
Philipp et al

The third and the fourth studies, however, analyzed the high-strength ceramic zirconia as
framework material.3,6 With frameworks made
of zirconia, the failure rate of the FDPs was significantly lower than for frameworks with glassinfiltrated alumina. In the clinical studies, failure
rates of those FDPs ranged from 0%3 to 2.2%.6
The most frequent reason for failure of
FDPs made of glass-infiltrated alumina
was fracture of the ceramic framework.5
Interestingly, after the same observation period for zirconia-based FDPs, fracture of
framework was a rare clinical complication.3,6

crowns, in most cases, solely chippings of the


veneering ceramic occurred, without involvement of the ceramic framework.15
To date, no clinical studies of FDPs with
Ce-TZP/A nanocomposite frameworks are
available to validate these promising laboratory findings. The aim of the present case series
was therefore to assess the clinical performance of veneered Ce-TZP/A nanocomposite
frameworks for posterior three-unit FDPs.

Recently, a new type of zirconia ceramic


was developed as framework material, the
ceria-stabilized tetragonal zirconia/alumina
(Ce-TZP/A) nanocomposite. This new zirconia
ceramic variation offers superior mechanical properties compared to conventional
yttrium-stabilized (Y) TZP.712 Although the flex-

METHOD AND MATERIALS

ural strength of this new ceramic is in the same


range as that of conventional Y-TZP, its fracture
toughness is significantly higher.12,13 The
homogenous dispersion of an alumina phase
in the TZP matrix of this new nanocomposite
suppresses the grain growth and increases
the hardness, elastic modulus, and hydrothermal stability of the tetragonal zirconia.14
One critical factor that had to be considered before the clinical introduction of CeTZP/A nanocomposite was that new veneering ceramics would possibly be needed for
this new type of zirconia. Therefore, the compatibility of the available zirconia veneering
ceramics to the new Ce-TZP/A nanocomposite was analyzed in recent laboratory studies.15,16 In one study, the fracture strength and
crazing resistance of Ce-TZP/A nano composite frameworks, veneered with a commercially available ceramic, was compared to
veneered sintered and hot isostatically
pressed (HIP) Y-TZP.15 The results showed
that the fracture load of veneered Ce-TZP/A
nanocomposite single crowns was similar to
that of veneered Y-TZP crowns. Furthermore,
the study showed even beneficial fracture patterns of the veneered Ce-TZP/A nanocomposite crowns compared to the Y-TZP
crowns. While the Y-TZP crowns failed
because of fracture of the veneering ceramic,
including the ceramic framework (catastrophic failure), at Ce-TZP/A nanocomposite

314

Study design and patient selection


All procedures and materials of this prospective case series were approved by the local
ethical committee, and the included patients
provided informed consent.
Eight generally healthy patients fulfilling the
following criteria were included: one missing
mandibular or maxillary premolar or molar , a
healthy periodontium before the restorative
treatment phase, a plaque control record
(PCR)17 below 30%, and probing pocket
depths (PPDs) of the abutment teeth of 4 mm
or less.
Periodontal or endodontic treatment was
performed when necessary.
All patients underwent comprehensive
dental care and were instructed to maintain a
high level of oral hygiene. Patients with parafunctional habits such as bruxing or clenching were excluded.

Prosthodontic procedures
Four patients were treated by experienced clinicians and four patients by undergraduate
students under strict guidance by experienced
clinicians. Treatment was performed according to standard techniques applied for metalceramic reconstructions. The procedures
were published in detail elsewhere18 and will
therefore be briefly summarized with respect
to the abutment tooth preparation.
The abutment teeth were prepared as follows (Fig 1): margin with a circumferentially
rounded shoulder (width 1.0 mm), tapering
angle of 6 to 10 degrees for both premolars
and molars, and occlusal reduction of 1.5 to
2.0 mm.

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Q U I N T E S S E N C E I N T E R N AT I O N A L
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Fig 1 Occlusal view of the abutment teeth prepared


for a replacing FDP. Pontic site modified to receive an
ovate pontic.

Fig 2 View of the intaglio surface of a veneered Ce-TZP/Ananocomposite FDP with marginal area in zirconia.

In case of a lack of dentin for an adequate


preparation, a composite resin core buildup
(Syntac Classic/Tetric Classic, Ivoclar Vivadent)
was fabricated. Upon completion of tooth
preparation, vital tooth abutment surfaces
were sealed by means of a bonding system
(Syntac, Ivoclar Vivadent). Impression of the
jaw with the abutment teeth was made by
means of a polyether impression material
(Permadyne, 3M ESPE). Provisional restorations were fabricated using a provisional composite resin material (Pro Temp, 3M ESPE)
and cemented with a eugenol-free temporary
cement (Freegenol, GC America).

Fabrication of the restorations and


cementation
The working casts were scanned (HiScan,
Hint-Els), and an appropriate framework was
designed (Fig 2). Presintered Ce-TZP/A
nanocomposite blanks were used (Nanozir,
Hint-Els). The frameworks were machined by
means of a computer-aided design/computerassisted manufacture (CAD/CAM) milling
machine (hiCut, Hint-Els) and subsequently
sintered to full density in a specialized furnace
(hiTherm, Hint-Els). The frameworks were
veneered (Vintage ZR, Shofu) by one dental
technician. For the sintering of the veneering
ceramic the technician used a conventional
furnace (D4, Dekema). The firing schedule
was performed following the instructions of
the veneering ceramic manufacturer. The

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Fig 3 Postoperative view of an FDP adhesively cemented with resin


cement.

FDPs were veneered onto the zirconia crown


margins (see Figs 2 and 3).
Before cementation, the abutment teeth
were cleaned (Clean Polish, Kerr Hawe). The
internal surfaces of the FDPs were cleaned
with ethanol and subsequently silanized
(Clearfil Porcelain Activator, Kuraray). The
FDPs were adhesively cemented with one
resin cement (Panavia TC, Kuraray) according to the manufacturers instructions (Fig 3).
In situations in which the occlusion
required adjustment, the reshaped surfaces
were meticulously polished with polishing
disks (Sof-Lex Pop-on Discs, 3M ESPE).

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Q U I N T E S S E N C E I N T E R N AT I O N A L
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Ta b l e 1

Distribution of USPHS ratings of the eight FDPs


Baseline

Integrity of framework
Integrity of veneering ceramic
Occlusal wear
Marginal adaptation
Anatomical shape

6 mo

12 mo

8
8
8
5
5

0
0
0
3
3

0
0
0
0
0

0
0
0
0
0

8
8
7
3
5

0
0
1
5
3

0
0
0
0
0

0
0
0
0
0

8
8
5
2
5

0
0
2
6
3

0
0
1
0
0

0
0
0
0
0

Baseline and follow-up


examinations

RESULTS

At baseline and at 2 weeks, 3, 6, and 12


months after insertion, the technical and biologic outcome of the reconstructions was
evaluated.
Technical evaluation. The technical outcome of the FDPs was assessed by means of
the US Public Health Service (USPHS) criteria.19 For the analysis of the surface of the
veneering ceramic over time, impressions of
the FDPs were made at each follow-up visit
using a highly viscous A-silicone impression
material (President Jet, Coltne).20 These
impressions were poured with epoxy resin,
resulting in highly accurate replicas of the
FDPs. The surface of the replicas was analyzed by means of scanning electron
microscopy (SEM) with a magnification of
5,000 (SEM CS4, CamScan).20
Biologic examination. Biologic parameters
were assessed at the abutment (test) teeth
and at contralateral control teeth immediately
following cementation of the reconstructions.
The plaque control record (PCR), bleeding
on probing (BOP), and probing pocket
depths (PPD) were assessed at six sites per
tooth. Pulp vitality of the abutment and control teeth was tested using carbon dioxide.
Radiographs of the FDPs were made at baseline, and at the 6- and 12-month visits.
Postoperative data collection forms, radiographs, and clinical photographs were used
as documentation tools.
Finally, patients were asked whether they
were satisfied with the esthetic and functional outcome of their reconstructions by means
of polar questions (yes/no).

The eight patients (four men, four women)


with the eight FDPs were followed for a mean
observation period of 12.8 1.1 months. The
mean age of the patients was 58.5 5.6 years
(range 49 to 69 years). The eight FDPs were
all in the mandible. Three FDPs replaced premolars and five replaced molars.
No failure of an FDP occurred, and
the survival rate was therefore 100%. Interestingly, in addition to the good clinical stability of the frameworks, the performance of
the veneering ceramic was good. No chippings or fractures of the veneering ceramic
were observed.
The technical evaluation revealed very
good initial USPHS ratings for all FDPs, which
remained almost unchanged during the
follow-up period (Table 1). Only two parameters, marginal integrity and occlusal wear,
exhibited slight changes over time, and the
number of FDPs with lower ratings increased
over time (see Table 1).
One FDP exhibited clinically relevant
occlusal wear of the veneering ceramic (C
rating) at the 12-month visit (see Table 1 and
Figs 4 and 5a). The resin replica of this FDP
was thoroughly analyzed by means of the
SEM (Figs 5b and 5c) to differentiate
between clinically visible roughness and a
potential ceramic chipping. The analysis
revealed that pronounced occlusal wear, not
chipping, was the reason for the roughness
(see Figs 5b and 5c).
Another technical parameter that exhibited changes during the 12 months of followup was marginal adaptation. At the clinical

316

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Q U I N T E S S E N C E I N T E R N AT I O N A L
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Fig 4 Occlusal view of the FDP after 1 year of clinical


service. In the region of the mesiobuccal cusp an occlusal
wear facet is visible (arrow).

Fig 5b Overall SEM view of the occlusal region of


the FDP in Fig 5a. A distinct wear facet is visible after
1 year of clinical service (original magnification 100).

service at six of the eight FDPs, the margins


were detectable with a probe at a clinically
acceptable level (B rating).
The biologic evaluation of the FDPs
showed no differences between test and
control teeth regarding the mean (m) PCR,
mBOP, and mPPD at baseline, and at the follow-up examinations (Table 2). No secondary
caries was found.
Only very few biologic problems were
observed. One patient presented with postoperative sensitivity after cementation; however, the sensitivity subsided after 6 months.
Furthermore, at 12 months of observation,
periodontal problems were found at an abutment tooth of one patient. A second molar
abutment tooth exhibited a PPD of 11 mm.

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Fig 5a Buccal view of the FDP after 1 year of clinical service showing
the occlusal wear facet (box).

Fig 5c Detailed SEM aspect of Fig 5b. Rough surface of the veneering ceramic is visible (original
magnification 5,000).

Ta b l e 2

Mean values and SDs of the biologic


parameters at baseline and 12 months
of clinical service
Test sites

PPD (mm)
BOP
PCR

Control sites

Baseline

12 mo

Baseline

12 mo

2.5 0.8
0.1 0.1
0.2 0.3

2.6 0.8
0.2 0.2
0.1 0.1

2.4 0.4
0.1 0.1
0.2 0.4

2.6 0.6
0.1 0.1
0.2 0.2

Units for BOP and PCR are +/- (+ = 1, - = 0).

This molar received a root canal treatment


through the reconstruction to treat the combined periodontal-endodontic lesion.

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DISCUSSION
At 12 months of observation, the new CeTZP/A nanocomposite FDPs exhibited a survival rate of 100%. Within the limitations of
the present case series, the new framework
material was found to be clinically reliable.
Furthermore, the performance of the veneering ceramic was very good at this new type
of zirconia ceramic. No chipping or fracture
of the veneering ceramic occurred.
The performance of the zirconia frameworks in the present case series is in accordance with the findings of various other
studies analyzing zirconia as framework
material in posterior regions of the
jaws.46,21,22 In these studies, survival rates of
98.8% to 100% of zirconia-based FDPs were
reported, however, after longer observation
periods of up to 5 years.46,21,22 Hence, a
longer observation time of the FDPs in the
present case series, and additional studies
of Ce-TZP/A nanocompositebased reconstructions with a higher sample size, are
needed to verify the positive primary findings. Furthermore, comparison of the present results with the ones of metal-ceramic
FDPs (golden standard) is needed in the
future. As an example, two meta-analyses
observed failure rates of only 8%23 and
10%24 of FDPs with metallic frameworks after
10 years. These results are considered to be
the benchmark for new types of FDP.
Besides good mechanical strength of the
framework, the stability of the veneering
ceramics is one further prerequisite for the
clinical success. The fact that no chippings
occurred in the present case series is very
promising. Problems such as chipping or
fracturing of the veneering ceramic were the
main technical complication in previous
studies analyzing Y-TZP.3,6,18 Metal-ceramic
or alumina-ceramic FDPs exhibited lower
complication rates of the veneering ceramic
than zirconia-based FDPs.46,2224 Clinical
studies reported chipping or fracture rates of
the metal veneering ceramic of only 2.5%.25
Even more, with veneered glass-infiltrated
alumina FPDs no failures of the veneering
ceramic were observed at all after 5 years of
clinical function.4,5 Veneered Y-TZP frameworks, however, showed varying chipping

318

rates. One study reported 15.2% of chipping


after 5 years.6 Another study reported a chipping rate of 15% after 2 years.26 In a third study
using a prototype ceramic, however, chipping
of the veneering ceramic occurred at only
4.3% of the FDPs 18 months after insertion.27
In contrast to the previously mentioned findings with zirconia veneering ceramic, in the
present case series, no chippings or fractures
of the veneering ceramic were observed at all.
Again, it has to be considered that the number of observed reconstructions was small.
The results of previous laboratory studies
show that the veneering ceramic for Ce-TZP/A
nanocomposite has to be chosen carefully.16,28
Based on a recent laboratory study,15 the
veneering ceramic Vintage ZR was chosen as
veneering material in combination with the CeTZP/A nanocomposite in the present study. At
the 12-month examination, moderate occlusal
wear of the veneering ceramic was visible at
three FDPs, of which one reached a clinically
unacceptable level. This finding is in accordance with previously published results.3,22,26,29
Before final conclusions on the compatibility of
the veneering ceramic used in the present
case series and the new framework material
can be drawn, however, longer observation
periods and studies with a higher sample size
are needed similar to those of studies with YTZP frameworks.4,6,18,21,22
Finally, the biologic outcome of the FDPs in
the present case series was good and corresponded to findings of previous studies.4,1719
Therefore, it can be summarized that
veneered Ce-TZP/A nanocomposite frameworks for posterior three-unit FDPs exhibited
similar clinical performance as those with YTZP frameworks at 1 year of function.

CONCLUSIONS
At 12 months of clinical service, Ce-TZP/A
nanocomposite proved to be a promising and
reliable framework material for posterior FDPs.
Yet, before final conclusions can be drawn,
longer observation periods, studies with more
patients, and randomized clinical long-term trials are needed to validate the clinical performance of this first preliminary case series.

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ACKNOWLEDGMENTS

14. Hirano M, Inada H. Fracture toughness, strength and


Vickers hardness of yttria-ceria doped tetragonal

The authors would like to gratefully acknowledge


Panasonic Electric Works, Panasonic Dental, and Shofu
for supporting the study. Furthermore, they would like
to thank master dental technician Mr Dieter Lingweiler
for fabricating the frameworks and Mrs Beatrice Sener
for the help with the SEM analyses of the replicas.

zirconia/alumina composites fabricated by hot isostatic pressing. J Mater Sci 1992;27:35113518.


15. Fischer J, Stawarczyk B. Compatibility of machined
Ce-TZP/AL2O3 nanocomposite and a veneering
ceramic. Dent Mater 2007;23:15001505.
16. Fischer J, Stawarczyk B, Trottmann A, Hmmerle
CHF. Impact of thermal properties of veneering
ceramics on the fracture load of layered Ce-TZP/A
nanocomposite frameworks. Dent Mater 2009;25:
326330.

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