Eur J Oral Sci 2009; 117: 741–749  2009 The Authors.

Printed in Singapore. All rights reserved Journal compilation  2009 Eur J Oral Sci
European Journal of
Oral Sciences

Stefan Wolfart1, Sçnke Harder2,

Four-year clinical results of fixed dental Stefanie Eschbach2, Frank
Lehmann2, Matthias Kern2
prostheses with zirconia substructures 1
Department of Prosthodontics and Dental
Materials, Medical Faculty, RWTH Aachen

(Cercon): end abutments vs. cantilever University, Aachen, Germany;

2
Department of Prosthodontics, Propaedeutics
and Dental Materials, School of Dentistry,

design Christian-Albrechts University at Kiel, Kiel,

Germany

Wolfart S, Harder S, Eschbach S, Lehmann F, Kern M. Four-year clinical results of

fixed dental prostheses with zirconia substructures (Cercon): end abutments vs.
cantilever design. Eur J Oral Sci 2009; 117: 741–749.  2009 The Authors. Journal
compilation  2009 Eur J Oral Sci

The purpose of this prospective study was to evaluate the clinical outcome of three- to
four-unit posterior all-ceramic fixed dental prostheses (FDPs) made of yttria-stabilized
tetragonal zirconia-polycrystal ceramic frameworks (CerconBase; Degudent). Fifty-
eight restorations were placed in 48 patients. Twenty-four FDPs had an end abutment
design (EAD) replacing 3 premolars and 21 molars. Thirty-four FDPs had a cantilever
design (CD) replacing 11 premolars and 23 molars. The frameworks had a minimum
proximal connector dimension of 3 · 3 mm. The fixed dental prostheses were Prof. Dr Matthias Kern, Department of
cemented with glass-ionomer cement after air-abrading the inner crown surfaces. Three Prosthodontics, Propaedeutics and Dental
Materials, School of Dentistry, Christian-
FDPs were defined as drop-outs. The mean observation period was 48 ± 7 months
Albrechts University at Kiel, Arnold-Heller-
for the EAD (21 patients/24 FDPs) and 50 ± 14 months for the CD (25 patients/31 Street 1624105 Kiel, Germany
FDPs). The 4-yr survival rate, according to the Kaplan–Meier analyses, was 96% for
the EAD and 92% for the CD. The technical complication rate was 13% for the EAD Telefax: +49–431–5972860
E-mail: mkern@proth.uni-kiel.de
and 12% for the CD, and the biological complication rate was 21% for the EAD and
15% for the CD. For none of the analyses were significant differences found between Key words: all-ceramic; clinical outcome; fixed
dental prosthesis; survival rate; zirconia
both groups. After 4 yr the clinical outcome of three- to four-unit posterior FDPs with
EAD and CD was promising. Accepted for publication September 2009

In recent years, the favorable mechanical properties of
new all-ceramic core materials, such as alumina and
zirconia, have made treatment with more extensive all-
ceramic fixed dental prostheses (FDPs) possible. The
increased strength of zirconia makes it a favorable
choice as a core material. Yttria-stabilized tetragonal
zirconia polycrystals (Y-TZP) have been made
available to dentistry by the computer-aided design
(CAD)/computer-aided manufacturing (CAM) tech-
nique (1). By using this core material for all-ceramic
frameworks, excellent mechanical performance, supe-
rior strength, and fracture resistance have been
shown when compared with other ceramic materials
(2–5).
However, such restorative all-ceramic systems should
fulfil biomechanical requirements and provide longevity
similar to that of metal-ceramic restorations (6), while
providing enhanced aesthetics (7). For FDPs made from
Y-TZP, a variety of concerns are still being discussed.
One concern about zirconia is its aging over time (4, 8),
and another is the quality and longevity of the bond
between the framework and the covering feldspar cera-
mic (9, 10). Different study groups have tried to address
these issues. They showed, in 3–5 yr results, that zirconia
offers sufficient stability as a framework material
(10–13). Even in the high-stress molar region, three- to
four-unit FDPs made of Y-TZP with anatomically
designed frameworks seem to be promising prosthetic
alternatives to metal-ceramic FDPs (11–13). Most of the
all-ceramic FDPs had an end-abutment design (EAD).
All-ceramic FDPs with a cantilever design (CD)
were used only in few cases [2 out of 65 (13); 1 out of
21 (12)].
Currently, little clinical evidence is available for FDPs
made from Y-TZP with a CD. However, some data
regarding the in vitro performance of cantilever FDPs
with a zirconia framework have been published (14, 15).
The authors concluded that the use of zirconia ceramics
for cantilever FDPs cannot be recommended without
reservations. However, FDPs with a CD are a promising
treatment option, particularly in the shortened dental
arch, if implant therapy is rejected. Clinical data
regarding the use of Y-TZP ceramic for these type of
restorations are still missing.
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742 Wolfart et al.

Regarding metal ceramic restorations, the incidence
of failure for the CD is higher than for the EAD. The
most frequent biological problem was caries (8%) and
the most frequent technical complication was loss of
retention (8%). These complications made up more
than half of all problems reported (16). The question
arises of whether these complications might even
increase when Y-TZP material is used, because it was
found that for Y-TZP material, decementation (11, 13),
secondary caries (10), and chipping of the veneering
material (9, 10) were frequently observed complications.
Therefore, the main concerns for all-ceramic FDPs with
a CD, besides fracture of the core material, might be
chipping of the veneering material, loss of retention,
and caries.
The hypothesis of our investigation was that three-
to four-unit Y-TPZ-based posterior FDPs with a
CD show more complications than FDPs with end
abutments.
range 34–69 yr) were included in the study and gave their
informed consent to participate (Fig. S1).
Inclusion and exclusion criteria
All restorations were constructed as three- to four-unit
FDPs. For the control group (EAD), the edentulous space
had to be equal to or smaller than the width of a molar. For
the test group (CD), the cantilever had to be equal to the
width of a premolar. The bone level of the vital abutment
teeth had to correspond to at least two-thirds of the root
length, with no signs of active bone resorption or peri-apical
pathology. Oral hygiene had to be good and caries activity
low. A maximum tooth mobility of grade 1 (17) was ac-
cepted. Furthermore, patients with probing depths greater
than 4 mm, vertical bone pockets around the abutment
teeth, extreme bruxism or a conspicuous medical or psy-
chological history, were not accepted. Patients were in-
formed about the risks of, and alternatives to, the proposed
therapy.

Material and methods
Patients referred to the Department of Prosthodontics of
the University at Kiel, Germany, with the indication for
three- to four-unit FDPs, were selected for the study. All
participants were healthy and had an almost complete
dentition. Informed consent to take part in the study was
obtained from all subjects on a written form approved by
the Ethical Committee of the Medical Faculty of the
University at Kiel. Forty-eight patients (24 women, mean
age 55.7 yr, range 23–75 yr; and 24 men, mean age 54.3 yr,
Restorations
Table 1 gives an overview over the distribution and dif-
ferent designs of the FDPs: in the control group, 24 three-
unit FDPs with an EAD were incorporated. Altogether 21
molars and 3 premolars were replaced. The test group
(n = 34) was divided into 29 three-unit FDPs and 5 four-
unit FDPs with a CD. Of these, six FDPs had a mesial
pontic and 28 FDPs had a distal pontic. As cantilever, 23
molars and 11 premolars were replaced. Thirty-eight
patients received one restoration. Ten patients received two
restorations.

Table 1
Distribution of the 61 fixed dental prostheses (FDPs)

Type n Distribution of FDPs

CD-d 2 P A P A
2 P A A
2+ A A P
3 A A P
1 A A P
CD-m 1 A P A P
1 A A P
1 A A P
1 P A A
1 P A A
EAD 2 A P A
1 A P A
3 A P A
2 A P A
Tooth 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27
Tooth 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37
EAD 11 A P A
5 A P A
CD-m 1 A P A P
CD-d 5 P A A
2 P A A
1 A A P
1 A P A P
9+ A A P

Tooth, numbering system according to FDI World Dental Federation; A, Abutment; CD-d, cantilever design with distal pontic
(n = 28); CD-m, cantilever design with mesial pontic (n = 6); EAD, end abutment design, n = 24; P, Pontic.
+
Three drop-outs during the observation time: 1 · CD-d with pontic 25 and 2 · CD-d with pontic 46.

A B C A
D E
Fig. 1. (A) Typical preparation with rounded angles for the end
abutment design (EAD). (B) The final restoration with a Yttria-
stabilized tetragonal zirconia polycrystals (Y-TZP) framework.
(C) Restoration in situ 6 months after cementation. (D) Typical
preparation for the cantilever design (CD). (E) Restoration
in situ 6 months after cementation.
Intervention
The following prosthetic procedures were performed: For
the abutments, a full-crown preparation with an occlusal
reduction of at least 1.5 mm, followed by a circular 0.8-mm-
wide rounded shoulder preparation was performed. The
abutment height varied between 3 and 6 mm. All prepara-
tions were finished by rounding sharp angles (Fig. 1A,D).
After abutment preparation, impressions were made with a
simultaneous, dual-mix technique using the polyether
material, Permadyne (3M Espe, Seefeld, Germany).
After an anatomically designed wax-up of the frame-
work, the framework was scanned, milled, and sintered
according to the manufacturerÕs instructions. For the
proximal connector, the minimum dimensions were 3 mm
in height and 3 mm in width. The minimum framework
thickness was 0.5 mm occlusal and 0.4 mm cervical. In the
control group the zirconia framework did not reach to the
preparation margin (1 mm distance to the preparation
margin), so the shoulder area was covered with the
veneering material (Fig. 1B). However, in the test group,
the frameworkÕs marginal rim was extended up to the
preparation margin to enhance the support of the veneer-
ing material in the CD design with higher stresses
(Fig. 2D).
For the veneering process, the conventional porcelain
build-up technique was used (CerconCeramS; Degudent,
Hanau, Germany) for the test group, and the overpressing
technique (Cercon Ceram Express; Degudent) was used for
the control group. Therefore, an anatomical wax-up was
made on the zirconia framework, invested, and overpressed
following the manufacturerÕs instructions (18). The thick-
ness of the veneering material ranged from 0.4 to 1.0 mm.
The marginal fit of the abutments was checked intra-
orally with a silicone indicator paste (Fit Checker; GC,
Tokyo, Japan). Adjustments – if necessary – were per-
formed using a turbine (250,000 rpm with a 1.2 mm dia-
meter diamond burr; water cooling: 50 ml min)1) and
diamond burs with 30–40 lm grain size. The marginal fit of
the restorations was accepted when the silicon indicator
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Clinical results of zirconia FDPs 743
B
C D
Fig. 2. (A) Example of a technical complication of a three-unit
fixed dental prosthesis (FDP) with an end abutment design
(EAD). The minor chipping occurred within the veneering
ceramic (size 2 · 2 mm). In the chipping area a small bubble
within the veneering material (size 1 · 0.2 mm) is visible. The
chipping occurred 7 months after insertion (complication no. 8,
Table 3). (B) Example of a technical complication of a three-
unit FDP with an EAD. The major chipping occurred at the
margin of tooth 26. In the chipping area, veneering material
and core material is exposed. The chipping occurred 23 months
after insertion (complication no. 10, Table 3). (C,D) Example
of a biological failure of a four-unit FDP with cantilever design
(CD). The failure occurred 13 months after insertion. Both vital
abutment teeth (upper right canine and second premolar)
fractured. Part C shows the fractured abutment teeth in situ,
and part D shows the FDP with the fractured parts of the
abutments. (failure no. 4, Table 2).
paste showed a thin and homogeneous thickness. The FDPs
were cemented with glass-ionomer cement (Ketac Cem
maxicap; 3M Espe) following the manufacturerÕs instruc-
tions. Before cementation, the internal walls of the crowns
were air-abraded with 50 lm alumina particles at 0.25 MPa
for approximately 10 s each. If occlusal adjustments were
necessary after cementation, diamond burs with 30–40 lm
grain size were used (contra-angle-handpiece; 100,000 rpm
with a 1.2 mm diameter diamond burr; water cooling:
50 ml min)1). Finally the occlusal surfaces were polished
with ceramic polishing instruments in three steps (Tanaka
polishing wheels no. 10172-10174; Tanaka, Friedrichsdorf,
Germany). After cementation, a radiograph of the restora-
tion and its abutment teeth was taken to ensure complete
removal of excess cement. The patients were scheduled for a
final evaluation (baseline) 1–3 wk after cementation.
Clinical examination during the follow-up
appointments
Follow-up examinations were performed after 6 and
12 months, and then annually (Fig. 1C,E). The follow-up
examinations were performed between 2004 and 2009.
Follow-up assessments were not performed by the clinician
who had placed the restorations. The restorations were
visually inspected using a dental mirror and a probe. Each
restoration was examined for framework fractures, veneer-
ing material chipping, and debonding (loss of retention).
The chipping was assigned to two groups: minor (the
chipping was smaller than or equal to 2 · 2 mm and no
core material was visible); and major (the chipping
was larger than 2 · 2 mm or core material was visible).

744 Wolfart et al.
Retention and secondary caries were evaluated using
modified California Dental Association’s (CDA) criteria
(19). Pulp vitality was verified using a CO2 test.
The periodontal parameters (probing depth) were
recorded at four sites of the abutment teeth and the corre-
sponding contralateral teeth. Bleeding on probing was
diagnosed as present (1) or absent (0) by gently moving a
blunt periodontal probe in the marginal part of the gingival
sulcus. Tooth mobility was classified into three grades (17):
grade 1, 0.2–1 mm horizontally; grade 2, more than 1 mm
horizontally; and grade 3, as for grade 2 but with additional
movement vertically.
In addition, during the follow-up examinations the
patients were interviewed regarding their satisfaction with
the ceramic FDPs using a visual analogue scale (VAS) of
100 mm, with the end points being extremely satisfied (0) or
extremely dissatisfied (100).
Fractographic analysis of the chipping cases
Descriptive fractography (20, 21) for fracture analysis of
chipping was performed according to a recent National
Institute of Standards and Technology recommended
practice guide for fractography of glasses and ceramics
(22). Thereafter, the fracture surface of the recovered
failed parts of the FDPs were analyzed using both stere-
omicroscopy and scanning electron microscopy (SEM),
searching for key fracture features providing evidence as
to the crack propagation direction and sequence of the
crack travel history (20–22). In this context, wake hackle
and twist hackle indicate where a crack runs. The iden-
tification of a compression curl indicates the end point of
the fracture. With this information, the location of the
origin of fracture can be estimated.
Statistical methods
Randomization was not applicable because of the different
abutment configurations necessary for FDPs with EAD or
CD, respectively. Blinding was not performed because of the
visible discrepancy of the two treatments.
Kaplan–Meier survival analyses (23) were used to
demonstrate cumulative survival rates and cumulative
complication rates. For the survival analysis only the
event Ôremake of the FDPÕ was considered as a failure.
For the complication analysis the event Ôendodontically
treatedÕ, ÔrecementationÕ, ÔapicoectomyÕ, and Ôsecondary
Table 2
Descriptive analysis of the failures
Type of Age Replaced
No failure Design Gender (yr) tooth
1 bio EAD F 47 36
2 bio CD-d F 65 46
3 bio CD-d M 60 36
4 bio CD-d F 75 14, 16
Age, age (in years) at time of cementation; bio, biological failure; CD-m, cantilever design with mesial pontic; CD-d, cantilever design
with distal pontic; EAD, end abutment design; Event, time of event (month); F, female; M, male.
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cariesÕ were considered as biological problems. The event
ÔchippingÕ was identified as a technical problem. These
analyses were calculated from the cementation date to the
end of the latest follow-up visit (April 2009) and to the
latest date of the status known of participants who
dropped out of the study as a result of relocation or
death. All hypothesis testing was conducted at a 95%
level of confidence.
As the data were not normally distributed (Kolmogorov–
Smirnov test), statistical analyses were performed using the
Wilcoxon rank sum test to determine differences regarding
the periodontal parameter (EAD vs. CD).
Results
Patients
Of the original 48 patients, one died during the observa-
tion period and one relocated. A total of three FDPs
(CD-d) were present in these patients. The FDPs were
successful until death or until the last follow-up before
relocation. These FDPs were defined as drop-outs. All other
patients attended the annual follow-up sessions regularly.
For the EAD, the 3-yr follow-up was attended by 21
patients (mean age 48.3 yr) in whom 24 FDPs were
incorporated, and the 4-yr follow-up was attended by 15
patients (mean age 48.9 yr) in whom 17 FDPs were
incorporated. For the CD, the 3-yr and 4-yr follow-ups
were attended by 25 patients (mean age 61.7 yr, range
45–75 yr) in whom 31 FDPs were incorporated, and the
5-yr follow-up was attended by six patients (mean age
61.6 yr) in whom eight FDPs were incorporated.
The mean observation times were 48 months for the
EAD (range 34–59 months) and 50 months for the CD
(range 1–68 months).
Failures and complications
No framework fractures occurred in the given follow-up
periods. For the marginal adaptation, no visible evidence
of crevice and no penetration of explorer were observed
for any restoration. Regarding periodontal parameters,
no significant differences (P > 0.05, Wilcoxon rank sum
test) were found concerning pocket depth, bleeding on
Event Still in situ
(month) (month) Details of failure
33 no Secondary caries on tooth 35
1 no Fracture of the pontic after trepanation
of tooth 45
18 no Decementation on tooth 35; tooth 35 was
already treated with a post and core
13 no Both abutment teeth (13,15) fractured.
Both teeth were vital. (Fig. 3 C,D

Fig. 3. Kaplan–Meier curve demonstrates the 4-yr survival rate
of all fixed dental prostheses (FDPs). The analysis for the end
abutment design (EAD) (unbroken line) shows 96% survival
with one failure (biological problem) for a total of 24 FDPs,
whereas the analysis for the cantilever design (CD) (broken
line) shows 91% survival with three failures (biological prob-
lems) for a total of 34 FDPs. The different failure episodes
between both designs were not statistically significant
(P = 0.463, log rank test).
probing, and tooth mobility between abutment teeth and
contralateral teeth.
Table 2 shows all failures that occurred during the
observation time. For the control group (EAD), one fai-
lure, and for the test group (CD), three failures, occurred
as a result of biological problems (see Fig. 2C,D). The 4-yr
survival rate, according to Kaplan–Meier analyses, was
96% for EAD and 91% for CD (Fig. 3).
Table 3 shows all biological and technical complica-
tions. All restorations with complications are still in situ.
In the control group (EAD), three complications
occurred as a result of biological problems and three
complications occurred as a result of technical problems
(Fig. 2A,B). The technical problems were minor chip-
ping in one case and major chipping in two cases.
According to Kaplan–Meier analyses, the 4-yr compli-
cation rate was 21% as a result of biological problems
and 13% as a result of technical problems (Fig. 4). In the
test group (CD), four complications occurred as a result
of biological problems and three as a result of technical
problems (Figs 5 and 6). The technical problems were, in
all three cases, major chipping. According to Kaplan–
Meier analyses, the 4-yr complication rate was 15% as a
result of biological problems and 12% as a result of
technical problems.
No significant differences between test and control
groups were detected in any of the Kaplan–Meier anal-
yses (P > 0.05, log rank test).
Fractographic analysis of the chipping cases
Figures 5 and 6 show chipping of the mesio-buccal cusp
of a lower right first molar (complication no. 12, Table 3)
after 21 months of clinical use. The patient was not able
to provide any information about how the chipping
occurred. No important wear or impact was present on
the occlusal surface. Figure 5 shows the restoration after
chipping. For better orientation, the recovered failed
part, and its position in relation to the restoration, is
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Clinical results of zirconia FDPs 745
indicated by white arrows. The SEM image (Fig. 6) of
the recovered fractured part from the abutment shows
wake hackle and twist hackle, indicating that the crack
ran outwards towards the disto-buccal and cervical areas
in the direction of the black arrows. The identification of
a compression curl was possible. The origin of the frac-
ture was assumed in the opposite direction of the black
arrows. However, no conclusive origin was found.
Fractographic analysis of the other teeth in which
chipping occurred (complication nos 8–11, 13) showed,
similarly to Ôcomplication no. 12Õ, wake hackle, indicat-
ing the direction in which the crack ran. It was possible
to identify a compression curl; however, no conclusive
origin was found.
PatientsÕ satisfaction
The means (± standard deviations) of patientsÕ satis-
faction regarding chewing comfort (EAD, 12 ± 29; CD,
3 ± 7), color (EAD, 7 ± 10; CD, 2.9 ± 7), and will-
ingness to try the same technique again (EAD, 5 ± 11;
CD, 6 ± 13) were high. Furthermore, the patients did
not notice any color changes in the FDPs. No significant
differences between the groups were found for any of the
parameters (P > 0.05).
Discussion
The two groups did not start simultaneously in this
study. The test group started in June 2003 and the con-
trol group started in February 2004. In June 2003 only
the conventional porcelain build-up technique was
available and was followed by the overpressing technique
in January 2004. At that time, the first results of high
chipping rates with similar materials were reported
(personal communication with I. Sailer, Zürich Uni-
versity) and later published (9).
Clinical studies that used the conventional porcelain
build-up technique reported chipping rates of 15% (10)
and 25% (9) after 3 and 5 yr, respectively. One of the
reasons for these high numbers of chipping might be the
high variability of this process as a result of the individual
building and firing procedures. Thus, it might be expected
that overpressing has a higher density and introduces
fewer flaws than layering, resulting in better strength
properties (24, 25). For ethical reasons the type of
veneering procedure was changed for the control group to
the overpressing technique. This is a clear limitation of
the study. However, this limitation is relative, as two
in vitro studies (25, 26) showed that no significant differ-
ences in the fatigue and fracture properties following
overpressing or conventional build-up technique could be
found. These results were confirmed by our study, which
also did not show any significant differences in the tech-
nical complications concerning the different FDP designs,
in combination with the different veneering techniques.
The observation time of this study ranged from 3 to
5 yr and exhibited a relatively high variation. Because of
this variation, the statistical comparison of mean values
or mean follow-up periods was not reasonable. To
 16000722, 2009, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1600-0722.2009.00693.x by University Of Rochester, Wiley Online Library on [11/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
746 Wolfart et al.

Table 3
Descriptive analysis of the biological and technical complications

Type of Age Replaced Event Still in situ

No failure Design Gender (yr) tooth (month) (month) Details of complication

1 bio EAD M 50 46 41 53 Endo: 45

2 bio EAD F 25 46 1 50 Decementation on tooth 45FDP was recemented
3 bio EAD M 63 36 24 43 Endo: 37
4 bio CD-d F 52 26 19 45 Endo: 24, 25
5 bio CD-m F 52 14 26 45 Tooth 15 was already treated with a post and core,
apicoectomy was performed
6 bio CD-d M 68 16 35 52 Secondary caries on tooth 15 adhesive composite
resin filling was performed
7 bio CD-d F 55 36 50 53 Secondary caries on tooth 35 adhesive composite
resin filling was performed
8 tech EAD F 43 36 7 39 Minor chipping on pontic 36 within the veneering
ceramic. (see Fig. 3A Size of chipping: height:
2 mm; width: 2 mm repair with a composite resin
filling
9 tech EAD M 39 46 20 37 Minor chipping on tooth 47 within the veneering
ceramic (disto lingual cuspid). Size of chipping:
height: 0.5 mm; width: 1 mm no repair. Only
polishing of the ceramic
10 tech EAD F 23 25 23 36 Major chipping on tooth 26 at the bukkal margin.
Aspects of the core material are visible. (see Fig. 3B
Size of chipping: height: 2 mm; width: 8 mm no
repair. Only polishing of the ceramic
11 tech CD-d F 75 36 6 46 Major chipping on tooth 35 within the veneering
ceramic and core material (bukkal cuspid). Size of
chipping: height: 7 mm; width: 5.5 mm Repair with
a composite resin filling
12 tech CD-m M 43 45, 47 21 52 Abutment teeth: 48, 46. Major chipping on tooth 46
(mesio-buccal) within the veneering and core
material. (Fig. 6) Size of chipping: height: 7.5 mm;
width: 5 mm Repair with a composite resin filling
13 tech CD-m M 54 24 50 52 Major chipping on tooth 25 within the veneering and
core material (palatinal). Size of chipping: height:
7.5 mm; width: 5.5 mm repair with a composite
resin filling

Age, age (in years) at time of cementation; bio, biological complication; CD-m, cantilever design with mesial pontic; CD-d, cantilever
design with distal pontic; EAD, end abutment design; Event, time of event (month); F, female; M, male; tech, technical complication.

compensate for this limitation, statistical analyses were

Fig. 4. Kaplan–Meier curves demonstrate the cumulative
complication rate for the biological complications (endodontic
treatment, apicoectomy, recementation, and secondary caries)
in the left chart and for the technical complications (chipping)
in the right chart. The 4-yr biological complication rate was
21% for the end abutment design (EAD) (unbroken line) and
15% for the cantilever design (CD) (broken line), respectively.
The 4-yr technical complication rate was 13% for the EAD and
12% for the CD. No significant differences between designs
were found for any of the analyses (P > 0.05, log rank test).
performed using Kaplan–Meier testing followed by the
log rank test to determine the statistical differences
between test and control groups. However, it can be
considered a further limitation that the 5-yr follow-up
has not been reached for all restorations.
Technical outcomes of this study were not reported
using United States Public Health Service (USPHS) and
CDA criteria (19, 27), as those were not developed to
differentiate between framework fractures and minor and
major chipping of the veneering material, which are the
major criteria for the success of all-ceramic FDPs.
However, regarding retention of FDPs and secondary
caries, standardized modified CDA criteria were used for
evaluation.
The success rate of the zirconia frameworks was 100%
for both groups. These results were similar to findings
described in the international literature where survival
rates between 100% (9, 11–13) and 98% (10), after
an observation time of 3–5 yr, were reported for
frameworks made from Y-TZP. In our investigation, the
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Clinical results of zirconia FDPs 747

Kaplan–Meier analysis showed 4-yr chipping rates

Fig. 5. Example of a technical complication of a four-unit fixed
dental prosthesis (FDP) with a cantilever design (CD-m:
abutment teeth are lower right first and third molars). The
major chipping occurred at the mesio-buccal cusp of the first
molar. In the chipping area, veneering material and core
material is exposed. The chipping occurred 21 months after
insertion (complication no. 12, Table 3). No important wear or
impact can be seen on the occlusal surface. For better orien-
tation, the recovered failed part from Fig. 6, and its relation to
the restoration, is shown by white arrows. The identification of
a compression curl (Co) was possible (broken line) and the
origin of fracture is assumed at O1 or O2, respectively.
calculated 4-yr survival rate of the FDPs was 96% for
EAD and 91% for CD, as a result of biological failures.
Additionally, these results are comparable with those
described in the literature, where FDPs made from
Y-TZP achieved survival rates between 100% (9, 11–13)
and 74% (10).
(technical failure) of 13% (for EAD) and 12% (for CD).
These results were also in accordance with the literature,
where chipping of the veneering material varied, with
results of 6% (13), 9% (12), 15% (10), and 25% (9) being
reported. The 4-yr biological complication rate, accord-
ing to Kaplan–Meier analysis, was 21% for EAD and
15% for CD. Concerning this parameter (including
endodontic treatment, apicoectomy, decementation, and
secondary caries) our results showed a higher complica-
tion rate than presented in the majority of similar stud-
ies. In other studies, biological complications varied
between 0–3% (9, 11–13) and 21% (10). However, this
comparison must be made with caution because often it
had not been reported whether all complications (for
example apicoectomy), or only ceramic-related compli-
cations, had been included.
Recementation of restorations was necessary in one
case (4%) for EAD and in one case (6%) for CD. These
results were within the range published in the interna-
tional literature, where, for the complication Ôrecemen-
tationÕ, values of 0% (9), 3% (10, 12, 13), and 5% (11)
are reported. In this context it is interesting that,
according to the publications, air-abrasion of the
internal parts of FDPs directly before cementation was
performed only in one study (10). In another study (12),
FDP abutments were air-abraded before the final try in
and then cleaned again with alcohol directly before
cementation. Other studies did not perform any air-
abrasion at all (9, 11, 13). Considering these results, no
direct correlation between air-abrasion and the compli-
cation ÔrecementationÕ seems to exist.

Fig. 6. Scanning electron microscopy view of the recovered fractured surface of Ôcomplication no. 12Õ from the abutment (see also
Fig. 5). Wake hackle (WH) and twist hackle (TH) indicate that the crack ran outwards towards disto-buccal (DB) and cervical (C)
areas in the direction of the black arrows. It was possible to identify a compression curl (broken line), and the origin of fracture (O1 or
O2, respectively) on this recovered part must be located on the opposite mesio-occlusal (MO) side of the restoration. However, no
conclusive origin was found. (*) Core material is exposed. DO, disto-occlusal; MB, mesio-buccal.

748 Wolfart et al.
Additionally, it might be interesting to compare these
promising findings with the available in vitro results (14,
15). Gabbert et al. (14) compared the fracture resistance
of three different framework designs (inlay-retainers and
crown-retainers) of cantilever FDPs replacing one distal
premolar. Mean fracture values ranged from 172 to
792 N. For inlay–crown and crown–crown-retained
cantilever FDPs, further clinical investigations were
encouraged. Another investigation of the same working
group compared five different framework designs (only
crown retainers) for cantilever FDPs (15). The mean
fracture-load values ranged from 346 to 548 N. Their
results indicate that all-ceramic cantilever FPDs cannot
yet be recommended without reservations for clinical
replacement of a missing molar with a reduced span. In
this context, our clinical investigation is promising and
justifies further clinical investigations.
Because of the small numbers of events, for other
factors, such as gender, age, upper or lower jaw, molar or
premolar region, mesial or distal cantilevers, data were
evaluated only descriptively (Tables 2–3). Under the
limitation of the study the hypotheses can be rejected
because no significant differences were shown concerning
survival rate, or biological or technical complications,
between the control group (FDPs with EAD) and the test
group (FDPs with CD). A 4-yr cumulative survival rate
of 96% for the control group and of 91% for the test
group was shown. These preliminary results indicate that
both FDP designs with anatomically designed frame-
works are promising prosthetic alternatives, even in the
premolar and molar regions. On the other hand, these
findings are limited because different veneering systems
and framework designs were used in the control and test
groups.
Acknowledgements – This study was supported by Degudent,
Hanau, Germany. The authors are grateful to the participating
dentists and patients for their kind cooperation. They also
gratefully acknowledge the laboratory assistance provided by
the dental technicians B. Schlueter and R. Gerhardt and to the
linguistic revision of J. Oberli.
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Supporting Information
Additional Supporting Information may be found in the online
version of this article:
Figure S1. The Consort E-Flowchart of the 51 enrolled patients.
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