Journal of Dentistry 43 (2015) 1411–1415

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Journal of Dentistry
journal homepage: www.intl.elsevierhealth.com/journals/jden

Five-year clinical outcome of posterior zirconia ceramic inlay-retained

FDPs with a modified design
M. Sad Chaar* , Matthias Kern
Department of Prosthodontics, Propaedeutics and Dental Materials, School of Dentistry, Christian-Albrechts University, Kiel, Germany

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: To evaluate the 5-year clinical outcome of posterior inlay-retained fixed dental prostheses
Received 24 July 2015 (IRFDPs) with a modified design made from zirconia ceramic (Vita In-Ceram YZ, Vita Zahnfabrik, Bad
Received in revised form 29 September 2015 Säckingen, Germany).
Accepted 5 November 2015
Methods: Thirty 3-unit IRFDPs were placed in 30 patients. Seven IRFDPs replaced the second premolars (4
in the maxilla, 3 in the mandible), and 23 replaced the first molars (15 in the maxilla, 8 in the mandible).
Keywords: Preparations were performed in accordance with general principles for ceramic inlay restorations and
Inlay-retained FDPs
modified with a short retainer-wing bevel preparation within the enamel at the buccal and oral sides. The
Minimal invasive preparation
Zirconia ceramic
frameworks were milled from zirconia ceramic, and the pontics were veneered with feldspathic ceramic.
Single missing tooth After air-abrasion of bonding surfaces, IRFDPs were bonded with an adhesive composite resin. The
Clinical trial patients were recalled 6–12 months after placement, and then annually. Kaplan–Meier analysis was used
to calculate the survival and complication rates of the IRFDPs.
Results: After a mean observation time of 64.4 (SD = 17.6) months (min 15, max 95.6), the 5-year
cumulative survival of IRFDPs was 95.8%. Debonding was reported for two IRFDPs (6.9%), one of them
failed finally after 49.4 months due to repeated debonding. Chipping of the veneering ceramic was
reported in three cases (10.5%). Secondary caries were reported in 2 patients (8.1%). Nevertheless, the
latter complications did not affect the clinical function of the involved IRFDPs.
Conclusion: The 5-year clinical outcome of zirconia-based IRFDPs fabricated in the modified design is
encouraging, so that they may represent a treatment alternative to replace posterior single missing teeth,
taking into consideration the appropriate case selection.
ã 2015 Elsevier Ltd. All rights reserved.

1. Introduction (IRFDPs) have been considered as a minimally invasive treatment

Implant-supported single crowns [1] as well as metal-based
fixed dental prostheses (FDPs) [2,3] have been considered the gold
standard for the replacement of single missing posterior teeth.
However, invasive full crown preparation may present a risk for
pulp reactions [4–6], as a large amount of the coronal tooth
structure, ranging from 67.5% to 75.6%, has to be removed [7]. On
the other hand, resin-bonded FDPs (RBFDPs) present a minimally
invasive option when replacing missing teeth, particularly in a
caries-resistant dentition, that require much less tooth preparation
compared to conventional FDPs [7]. Likewise, inlay-retained FDPs
* Corresponding author at: Department of Prosthodontics, Propaedeutics and
Dental Materials, School of Dentistry, Christian-Albrechts University, Arnold-
Heller-Str. 16, 24105 Kiel, Germany.
E-mail address: schaar@proth.uni-kiel.de (M. S. Chaar).
modality that use box-shaped preparation forms as retainers, or
often can make use of pre-existing fillings on teeth adjacent to the
edentulous space [8,9].
Originally, IRFDPs first reported in the 1960s [10], were made of
metal alloys and were cemented conventionally. These IRFDPs
failed commonly due to frequently secondary caries or loss of their
retention [11–13]. The first encouraging attempts to use inlays as
retainers for posterior metal-ceramic FDPs were reported by
Stokholm and Isidor in 1996, through bonding IRFDPs by
implementation of different metal treatment methods [14].
Despite the satisfactory results of metal-based IRFDPs the
display of the metal retainers, the alteration in natural tooth
translucency as well as the increased patients’ demands for
esthetic restorations have encouraged clinicians to use metal-free
materials for IRFPDs. Although promising initial clinical results
have been reported for IRFDPs made from fiber-reinforced
composites [15,16], they suffered over time from discoloration,

http://dx.doi.org/10.1016/j.jdent.2015.11.001
0300-5712/ ã 2015 Elsevier Ltd. All rights reserved.
1412 M.S. Chaar, M. Kern / Journal of Dentistry 43 (2015) 1411–1415

severe wear of the veneering composite as well as degradation of

marginal integrity [17–19], so that the material could be only
recommended for provisional restorations [20]. Similarly, the
clinical outcome of IRFDPs made from lithium-disilicate ceramic
presented a high clinical failure rate and therefore they could not
be recommended for clinical applications [21–23].
Various laboratory studies revealed higher load-bearing capac-
ities for zirconia-based IRFDPs compared to IRFDPs made from
lithium-disilicate ceramic [24–26]. Nevertheless, one clinical study
reported excessive complication rate (20%) as well as high failure
rate in form of framework fracture (10%) for zirconia-based IRFDPs
during an observation period of only 12 months [27]. Thus, it has
been stated that to improve the outcome of all-ceramic IRFDPs,
both the tooth preparation as well as the framework design have to
be modified to minimize tensile and torsion forces applied to the
inlays-retainers [28]. Hence, different suggestions regarding Fig. 1. Occlusal view of the modified preparation for the zirconia-based IRFDP with
additional short retainer-wings at the buccal and oral sides of the abutment teeth.
framework design have been proposed [29–32]. Wolfart and Kern
[33] in 2006 suggested a new framework design for zirconia-based
IRFDPs using additional short retainer-wings at the buccal and oral
oral sides (Fig. 1). All preparations were finished so that no sharp
sides of both abutment teeth aiming to improve stress distribution
angles were left using 30–40 mm grain size diamond instruments.
as well as increase the adhesive bonding area to enamel. Initial
Provisional IRFDPs (Luxatemp, DMG, Hamburg Germany) were
results indicate no clinical failures within the first two years of
fabricated and cemented using provisional eugenol-free cement
clinical service [34]. Longer clinical data on this innovative
(Freegenol, GC EUROPE, Tokyo, Japan). Afterwards, full-arch
treatment modality have not been published yet. Therefore, the
impressions were made using a polyether material (Permadyne,
aim of the current study was to assess the medium-term clinical
3M Espe, Seefeld, Germany).
outcome of posterior zirconia-based IRFDPs manufactured with
The final impressions were poured using type IV stone (GC-Fuji
this new design after an observation period of 5 years.
Rock EP, Leuven, Belgium). The frameworks were modeled in resin
(Pattern Resin, GC Europe) so that the minimum proximal
2. Materials and methods
connector dimensions (height  width) were at least 3  3 mm,
the proximal wing-extensions were 3 mm in length and at least
The ethic committee of the Christian-Albrechts University at
0.6 mm thick. Subsequently, the frameworks were scanned and
Kiel approved the study protocol (Approval No. 119/06). According
milled out of zirconia ceramic (Vita In-Ceram YZ, Vita Zahnfabrik,
to the Declaration of Helsinki [35], all study participants were
Bad Säckingen, Germany) using the CEREC inLab System (Sirona
informed about risks and alternatives of the proposed therapy and
Dental Systems GmbH, Bensheim, Germany). The enlarged green-
an informed written consent was obtained from each participant.
stage-frameworks were then sintered at 1530  C using a special
Patients referred to the Department of Prosthodontics in need of
furnace (VITA ZYrcomat, Vita Zahnfabrik, Bad Säckingen, Germany)
FDPs in the posterior region were screened for the present study.
according to the manufacturer recommendation, then they were
The following inclusion criteria were used for the selection of the
checked for internal and marginal fit and adjusted if necessary
participants:
using water-cooled diamond burs under a light microscope
(magnification 20). Thereafter, all frameworks were veneered
- Each participant should receive a maximum of two IRFDPs
using the conventional layering technique with feldspathic
replacing either a second premolar or first molar without
porcelain (VITA VM 9, Vita Zahnfabrik, Bad Säckingen, Germany).
missing antagonistic teeth.
The final IRFDPs were checked intraorally for internal and
- Participants should be at least 18 years old with good oral
marginal fit using a silicone indicator paste (Fit Checker, GC
hygiene and low caries activity.
Corporation, Tokyo, Japan) and a dental explorer. Before bonding,
- No conspicuous medical or psychological history. Female
all IRFDPs were finally approved and inspected by two specialized
participants should not be pregnant or breastfeeding mothers.
supervisors (approved by the German Society for Prosthodontics
- Periodontally healthy abutment teeth, with bone level of at least
and Biomaterials (DGPro)). Rubber dam was applied always during
two-third of the root length, a maximum probing depth of 4 mm,
bonding procedures, which were performed using the total-etch
no signs of active bone resorption or periapical pathology, and a
technique with 37% phosphoric acid (Total Etch, Ivoclar-Vivadent,
maximum tooth mobility of grade 1.
Schaan, Liechtenstein) and a dentine adhesive (Clearfil New Bond,
- Balanced occlusal forces without any signs of extreme bruxism
Kuraray, Japan). Moreover, the inner retention surfaces for all
or parafunction.
IRFDPs were airborne-particle abraded with 50 mm alumina
particles at a pressure of 2.5 bar followed by ultrasonically
Consequently, between 2007 and 2010 30 IRFDPs were placed
cleaning in 96% isopropyl alcohol, and then luted with a composite
in 30 patients (18 females, 12 males, mean age 41.9 years). IRFDPs
resin (Panavia 21 TC, Kuraray, Osaka, Japan). Excess cement was
replaced 7 s premolars (4 in the maxilla, 3 in the mandible) and 23
removed gently by means of sponge pellets, and margins were
first molars (12 in the maxilla, 6 in the mandible). Twelve clinicians
covered with air-inhibiting gel (OXYGUARD II, Kuraray). After
(assistant professors) performed the treatment for the 30 involved
setting, the occlusion was checked and adjusted as needed using
IRFDPs. Tooth preparations were performed in accordance with
diamond burs with 30–40 mm grain sizes, and reshaped surfaces
general principles for ceramic inlay restorations [36], with a box-
were polished using ceramic polishing instruments in three steps
shaped inlay cavities (size 3  3 mm, minimum thickness 1.2 mm),
(Tanaka polishing wheels nos. 10172-10174, Tanaka, Friedrichsdorf,
taking into consideration the adaptation to the specific abutment
Germany).
tooth defect. Preparations were modified with a retainer-wing
A baseline evaluation for all IRFDPs was conducted one to three
bevel preparation within the enamel (thickness 0.2–0.5 mm),
weeks after cementation, followed by recall visits after 6 and 12
parallel to the insertion line of the boxes, at both the buccal and
 M.S. Chaar, M. Kern / Journal of Dentistry 43 (2015) 1411–1415
Fig. 2. (a) Occlusal view of IRFDP one month after placement. (b) Occlusal view of
the same IRFDP after 6 years.
months and then annually (Fig. 2a and b). At each recall visit
technical complications in terms of fracture of the framework,
chipping of the veneering ceramic, occlusal wear, degradation of
marginal adaptation and loss of retention were recorded. Biological
complications in terms of secondary caries, loss of vitality,
endodontic complications as well as tooth fracture were evaluated.
Moreover, periodontal parameters including probing depth, plaque
index, bleeding on probing and tooth mobility were reported at
four sites of the abutment teeth and their contra laterals.
Furthermore, all patients were asked to indicate their satisfaction
with their restorations in terms of function and esthetics according
to the visual analog scale.
Statistical analysis was performed using descriptive statistics
and Kaplan–Meier survival nonparametric analysis. The analytical
software used in the current study was Statistix 10.0 (Analytical
Software, Tallahassee, Florida, USA) with confidence intervals of
95%.
3. Results
Over a mean observation period of 64.4 (SD = 17.6) months (min
15, max 95.6), one patient was regarded as dropout because he did
not attend the recall program for more than two years. Another
four patients, who were relocated and could not attend the last
recall visit, were contacted via telephone and confirmed their
regular visits to their dentists. Their dentists were also contacted
and they informed us about the current status of the involved
IRFDPs.
Only one IRFDP that replaced a first upper molar failed during
the observation period due to repeated debonding. This failure
occurred after eight repeated debondings and ended with partial
enamel fracture of one abutment tooth after 49 months of
placement, which disabled a recementation of the involved IRFDP.
1413
Visual examination showed a mixed failure, i.e. resin cement
remained partially on the bonding surface of the restoration and
partially on the abutment teeth. Chipping of the veneering
porcelain was also reported on the same failed IRFDP previously.
In this case the patient was a bruxer with a deep bite and without a
canine-protected occlusion. Hence, the cumulative 5-year survival
rate of IRFDPs using the Kaplan–Meier analysis was 95.8% (95% CI:
80.2–99.2%) (Fig. 3). Furthermore, a one-time debonding was
observed after 37 months of placement for an IRFDP that replaced a
first lower molar. The involved IRFDP was re-bonded again and was
still in function until the last recall visit. Accordingly, the 5-year
reported cumulative debonding rate was 6.9%.
No framework fracture was reported in this study resulting in a
5-years survival rate of 100% for the zirconia frameworks.
Biological complications were demonstrated as secondary caries,
which were reported in two cases, one of them involved the lingual
margin of a wing retainer, and the other one at the gingival margin
of an inlay retainer. Consequently, the 5-year biological complica-
tion rate was 8.1%. Furthermore, loss of vitality was not reported for
any of the involved abutment teeth, and no significant changes of
the periodontal parameters were stated.
Nevertheless, the most common reported complication was
chipping of the veneering ceramic at the pontic area, which was
reported in 3 IRFDPs that replaced first molars, two of them needed
repair as the core material of the pontic was exposed (major
chipping). Accordingly, the 5-years estimated cumulative chipping
rate was 10.5%. However, the latter complications did not affect the
clinical function of the involved IRFDPs. Moreover, 25 IRFDPs were
free of any kind of complications (83.3%). The descriptive analysis
of complications that were reported for the 30 IRFDPs is shown in
Table 1.
Finally, the average estimation of the patients’ satisfaction in
regards to function and esthetics was very positive and reported to
be 95% and 84.5%, respectively.
4. Discussion
The present prospective clinical trial was conducted to evaluate
the medium-term outcome of zirconia-based IRFDPs with a
modified design. The 5-year cumulative survival rate reported
for IRFDPs in the current study was 95.8%, which is comparable
with that reported for conventional FDPs as stated in a systematic
review with meta-analysis (93.8%) [37].
Fig. 3. Kaplan–Meier’s curve demonstrating the 5-years cumulative survival rate of
the IRFDPs (95.8%).
1414 M.S. Chaar, M. Kern / Journal of Dentistry 43 (2015) 1411–1415
Table 1
Descriptive analysis of the complications that occurred in the 30 IRFDPs with their distribution (location of the replaced teeth according to the FDI tooth numbering system).
Replaced teeth n Complication form
Debonding
Maxilla 15 1 0
25 3 0
16 6 0
26 7 1
Mandible 35 2 0
45 1 0
36 6 1
46 4 0
Total 30 2 3
IRFDPs made from lithium-disilicate ceramic failed clinically to
withstand posterior masticatory forces [23]. The main complica-
tions were ceramic fractures, debonding or a combination of
debonding and fracture at the isthmus of one of the inlay retainers.
The authors related the excessive failure rate to the high stresses at
the adhesive interfaces when loading the pontics during chewing
eccentrically. Furthermore, the relatively small area bonded to
enamel and the large portion bonded to dentin might be
responsible for losing the retention of the retainers. Consequently,
after losing retention in the proximal inlay, the stability of the inlay
retainer was limited to its fracture strength in the small isthmus
area of the inlay, which could not withstand the chewing forces
leading finally to fracture of the restoration.
On the other hand, one short-term clinical study reported
excessive failure rate (20%) as well as a high framework fracture
rate (10%) for zirconia-based IRFDPs during an observation period
of only 12 months [27]. The failures were mainly related to
debonding, major chipping and framework fracture. The last study
used two dihedral inlays as retainers and all IRFDPs were bonded
either by use of the use of dual-curing resin cement Panavia F
(Panavia F, Kuraray Europe GmbH, Frankfurt, Germany) or by use of
the automixing self-curing resin cement Multilink (Multilink
Automix, Ivoclar Vivadent), with the inner surface being tribo-
chemically pretreated and silanised before cementation. The
authors concluded that it is imperative to improve the adhesion
between resin cement and inlay retainer is desirable before
zirconia-based IRFDPs can be recommended for clinical applica-
tion.
Hence, the favorable survival rate in the current study could not
only be related to the fracture resistant framework material used
(zirconia), which was also used in the above study, but it probably
can be linked to the modified preparation and framework design,
which seems to be of high relevance [29]. In fact, the modified
design has been suggested to minimize torsion forces at the inlay-
retainers when the pontics are loaded non-axially and to extend
the bonding surface in enamel [24,33]. Moreover, an adhesive resin
cement was employed that contains a phosphate monomer (MDP),
which seems to play an essential role to achieve a durable bonding
to zirconia [38]. A recent review of the clinical literature on
bonding to zirconia ceramic revealed that air-abrasion at a
moderate pressure and using phosphate monomer containing
primers (MDP) and/or luting resins provide long-term durable
bonding to zirconia ceramic under the humid and stressful oral
conditions [39].
In terms of biological complications (secondary caries), which
were reported to be 8.1% after 5-years, the current results are
comparable to the data reported for metal-based IRFDPs [14] and
to the data reported for conventional FDPs [37]. This might be due
to the minimal invasive preparation with the margins being placed
always in enamel and to the adequate bonding technique used. The
Chipping Caries Complication free
0 0 1
0 0 3
0 0 6
2 1 4
0 0 2
0 1 0
1 0 5
0 0 4
2 25
most common reported complication was chipping of the
veneering ceramic at the pontic area (11.1%), which is a well-
known problem for zirconia-based restorations. Currently, through
the introduction of much translucent zirconia materials it might be
possible to eliminate the chipping problem as well as to improve
the esthetic outcome of IRFDPs made from monolithic zirconia.
Nevertheless, it should be emphasized that this clinical study
has some limitations in regards to the relative small number of
participant (n = 30), which was chosen for ethical reasons as a
previous study on IRFDPs with a different design and material at
our department showed an unacceptable outcome [22]. In order
not to put too many patients at risk with the new design, this study
aimed to prove first the clinical validity of the new design on a
small number of patients, before a larger clinical trial might be
considered.
Another limitation of the current study was the strict inclusion
criteria of the participants, as it is essential to consider carefully all
relevant factors that influence the longevity of IRFDPs, particularly
the appropriate case selection with proper indications [9].
Moreover, the present study did not include a control group
reconstructed with conventional FDPs. Therefore, the clinical
outcome and complication rates of the involved IRFDPs can only be
compared to data found in the literature.
5. Conclusion
Within the limitations of this clinical study, the 5-year clinical
outcome of zirconia-based IRFDPs fabricated in the modified
design is encouraging, so that they may be recommended as a
treatment modality to replace a missing tooth in the posterior
region. However, further long-term randomized controlled clinical
trials should be performed to establish clear clinical and technical
guidelines for different IRFDPs, before they can be recommended
for general clinical implications without restrictions.
Acknowledgements
This study was financially supported by Vita Zahnfabrik, Bad
Säckingen, Germany.
The authors are grateful to the patients for their kind
cooperation and want to thank the dental technicians B. Schlueter
and R. Gerhardt for their work (Department of Prosthodontics,
Propaedeutics and Dental Materials, School of Dentistry, Christian-
Albrechts University at Kiel).
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