Using zirconia-based prosthesis in a complete-mouth...
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CLINICAL REPORT Using zirconia-based prosthesis in a complete-mouth reconstruction treatment for worn dentition with the altered vertical dimension of occlusion Jung Nam, DMD, MS, MSD a and Hiro Tokutomi, RDT b Zirconia has been used clini- cally in restorative dentistry for more than a decade. 1-3 Because of the development of zirconia technology and methods, 4,5 zirconia has been used to restore both the anterior and posterior dentition and for fixed dental prostheses and implant prostheses. 1,6 Zirconia has become popular because of its high strength and toughness, 4,5 high biocompatibility, 7,8 low core thickness (0.3 mm anterior; 0.5 mm posterior), 9,10 mini- mal framework or marginal distortion during firing, 11 adequate marginal fit, 12 small connector sizes for fixed dental prostheses, 13 acceptable light transmission, 14 abil- ity to mask discolored teeth, 15,16 availability of different framework shades, and ease of fabrication by means of computer-aided design and computer aided man- ufacturing (CAD/CAM). 17 The most common problem in zirconia restorations has been veneer porcelain chipping. 18-20 The problem has been reduced by designing anatomic frameworks so as to minimize unsupported veneer porcelain, 21,22 choosing the appropriate veneering porcelain to match the thermal coefficient of the zirconia core, 18,20 process- ing with slower cooling rate temperatures, 18,22 and treating the zirconia core with a silica coating. 23 In restoring structurally compromised teeth with complete coverage restorations, achieving optimal re- tention and resistance form can be challenging. 24,25 Resin-based cements will enhance restoration reten- tion 26-28 ; however, the bond between the resin and zirconia is unpredictable. 29 Because zirconia is silica free, bonding cannot be enhanced by applying the traditional ceramic surface treatment of hydrofluoric acid and si- lane primer. 30 However, tribochemical treatments 31,32 (airborne-particle abrasion with silica-coated aluminum oxide) and the subsequent application of primers con- taining phosphate and/or carboxylic monomers 32-36 has led to improved zirconia-resin bonding. 37 Another challenge in restoring a worn dentition is increasing the vertical dimension of occlusion (VDO) to create restorative space. To determine the needed change in the VDO, clinicians should assess dentofacial esthetics, occlusion, choice of restorative material, and neuromus- cular adaptation. 38 The complete mouth treatment presented used bonded zirconia on structurally compromised teeth at an altered VDO. CLINICAL REPORT A 67-year-old white woman presented with defective interim complete mouth restorations. She reported dif- ficulty masticating and articulating. Generalized gingivitis was associated with the fractured, ill-fitting, and poorly fabricated interim restorations (Fig. 1). Diagnostic casts a Adjunct Assistant Professor, Department of Integrated Reconstructive Dental Sciences, University of the Pacific Arthur A. Dugoni School of Dentistry; Private practice, Saratoga, Calif. b Registered Dental Technician, Tewksbury, Mass. ABSTRACT This clinical report describes the complete mouth reconstruction of a patient with a worn dentition. Computer-aided design and computer-aided manufacturing processed porcelain fused-to-zirconia prostheses were used to achieve good esthetics, function, and biomechanics. (J Prosthet Dent 2015;113:81-85) THE JOURNAL OF PROSTHETIC DENTISTRY 81
Transcript of Using zirconia-based prosthesis in a complete-mouth...
CLINICAL REPORT
aAdjunct AssSaratoga, CabRegistered D
THE JOURNA
Using zirconia-based prosthesis in a complete-mouthreconstruction treatment for worn dentition with the altered
vertical dimension of occlusion
Jung Nam, DMD, MS, MSDa and Hiro Tokutomi, RDTbABSTRACTThis clinical report describes the complete mouth reconstruction of a patient with a worn dentition.Computer-aided design and computer-aided manufacturing processed porcelain fused-to-zirconiaprostheses were used to achieve good esthetics, function, and biomechanics. (J Prosthet Dent2015;113:81-85)
Zirconia has been used clini-cally in restorative dentistryfor more than a decade.1-3
Because of the developmentof zirconia technology andmethods,4,5 zirconia has been
used to restore both the anterior and posterior dentitionand for fixed dental prostheses and implant prostheses.1,6Zirconia has become popular because of its high strengthand toughness,4,5 high biocompatibility,7,8 low corethickness (0.3 mm anterior; 0.5 mm posterior),9,10 mini-mal framework or marginal distortion during firing,11
adequate marginal fit,12 small connector sizes for fixeddental prostheses,13 acceptable light transmission,14 abil-ity to mask discolored teeth,15,16 availability of differentframework shades, and ease of fabrication by means ofcomputer-aided design and computer aided man-ufacturing (CAD/CAM).17
The most common problem in zirconia restorationshas been veneer porcelain chipping.18-20 The problemhas been reduced by designing anatomic frameworksso as to minimize unsupported veneer porcelain,21,22
choosing the appropriate veneering porcelain to matchthe thermal coefficient of the zirconia core,18,20 process-ing with slower cooling rate temperatures,18,22 andtreating the zirconia core with a silica coating.23
In restoring structurally compromised teeth withcomplete coverage restorations, achieving optimal re-tention and resistance form can be challenging.24,25
Resin-based cements will enhance restoration reten-tion26-28; however, the bond between the resin and
istant Professor, Department of Integrated Reconstructive Dental Scienceslif.ental Technician, Tewksbury, Mass.
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zirconia is unpredictable.29 Because zirconia is silica free,bonding cannot be enhanced by applying the traditionalceramic surface treatment of hydrofluoric acid and si-lane primer.30 However, tribochemical treatments31,32
(airborne-particle abrasion with silica-coated aluminumoxide) and the subsequent application of primers con-taining phosphate and/or carboxylic monomers32-36 hasled to improved zirconia-resin bonding.37
Another challenge in restoring a worn dentition isincreasing the vertical dimension of occlusion (VDO) tocreate restorative space. To determine the needed changein the VDO, clinicians should assess dentofacial esthetics,occlusion, choice of restorative material, and neuromus-cular adaptation.38
The complete mouth treatment presented usedbonded zirconia on structurally compromised teeth at analtered VDO.
CLINICAL REPORT
A 67-year-old white woman presented with defectiveinterim complete mouth restorations. She reported dif-ficulty masticating and articulating. Generalized gingivitiswas associated with the fractured, ill-fitting, and poorlyfabricated interim restorations (Fig. 1). Diagnostic casts
, University of the Pacific Arthur A. Dugoni School of Dentistry; Private practice,
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Figure 1. Preoperative intraoral view. Patient initially presented withexisting complete-mouth interim restorations.
Figure 2. Initial diagnostic casts (brought by patient at initial appoint-ment). Note general wear of maxillary and mandibular teeth.
Figure 3. Preoperative panoramic radiograph.
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revealed short teeth (maxillary central incisor heightswere 7.5 mm and mandibular central incisor heightswere 4 mm), wear of the anterior teeth, several missingteeth, and multiple defective restorations (Fig. 2). Bothhorizontal and vertical overlaps were 3 mm. A panoramicradiograph (Fig. 3) revealed existing implants on the sitesof the maxillary right canine, right lateral incisor, left firstpremolar, and left first molar (Nobel Replace; NobelBiocare).
An increase in the height of the maxillary central in-cisors to 10.5 mm and that of the mandibular centralincisors to 7.5 mm was planned based on a dentofacialanalysis. From a diagnostic waxing, it was determinedthat a 4 mm increase in VDO at the incisor area couldaccommodate 3 mm of vertical and 3.5 mm of horizontaloverlap with the new length of teeth as well as a shal-lower angle of anterior guidance (Fig. 4).38
After the removal of the existing interim restorations,new complete mouth interim restorations based on thediagnostic waxing were made. Subsequent periodontaltreatments, foundation restorations on multiple teeth,and endodontic treatments followed by prefabricatedfoundation restorations on the maxillary right first molarand maxillary right second premolar were provided.
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To offset the compromised retention and resistanceform (Fig. 2), the margins were redefined and parallelaxial walls created on the prepared teeth (Fig. 5). Theautopolymerized acrylic resin external forms (NewOutline; Anaxdent) were relined clinically to fabricateinterim restorations.39 The interim restorations weremaintained for 3 months to allow the patient to adapt toa new VDO, clinical crown lengths, phonetics, esthetics,and masticatory function (Fig. 6).2 After the adaptationperiod, definitive impressions were made with polyvinylsiloxane (Aquasil Ultra; Dentsply Caulk) impressionmaterial. A face bow transfer record of the maxillaryinterim restorations and a centric relation record wasmade with the anterior interim restorations as an anteriorreference point and a silicone interocclusal record (JetBite; Coltène/Whaledent).
Definitive casts were poured and fabricated, and thecasts of the interim restorations and the definitive castswere articulated with a cross-mounting technique.40
Zirconia copings (Katana; Noritake) were fabricated byCAD/CAM and evaluated clinically for marginal and in-ternal adaptation. After veneer porcelain (CZR; Noritake)was applied, the esthetics, marginal and internal fitinterproximal contacts, and occlusion were evaluated atthe bisque bake stage. Minimal occlusal adjustmentswere required.
The internal surfaces of the zirconia restorationswere airborne-particle abraded with tribochemical sil-ica coated 30 mm Al2O3 (CoJet; 3M ESPE). A zirconiaprimer was then applied for 5 seconds (Z Prime Plus;Bisco) and air dried. The teeth were also treatedwith 30 mm Al2O3 (CoJet; 3M ESPE), followed by a30-second application of desensitizer (Gluma; HeraeusKulzer). Customized zirconia/titanium implant abut-ments (Procera; Nobel Biocare) were tightened to 35Ncm, and their seating was verified with periapicalradiographs.
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Figure 4. Diagnostic waxing. Figure 5. Frontal view of prepared teeth.
Figure 6. Smile with interim restorations. Figure 7. Two-year postoperative frontal view.
Figure 8. Postoperative maxillary occlusal view. Figure 9. Postoperative mandibular occlusal view.
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The zirconia crowns were cemented with self-etchingdual-polymerized adhesive (All-bond SE; Bisco), followedby dual-polymerized resin cements (Duo-Link; Bisco)that were light polymerized. The cemented implant-
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supported crowns and FDPs were cemented withinterim resin cements (Premier Implant Cement; Pre-mier Products Co) for future retrievability. The patientwas instructed on oral hygiene, care of the new
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Figure 10. Postoperative smile.
Figure 11. Postoperative panoramic radiograph.
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prostheses, and the wearing of a heat-polymerized clearocclusal device.
SUMMARY
This treatment of a worn dentition was successfulin gaining restorative space by an alteration of theVDO. The treatment demonstrated that the retentionand resistance of zirconia-based restorations can beimproved by using an appropriate primer and lutingagent (Figs. 7-11).
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Noteworthy Abstracts of
Surface characteristics and corrosion propertidental alloy after porcelain firing
Xin XZ, Chen J, Xiang N, Gong Y, Wei BDent Mater 2014;30:263-70
Objective. We examined the surface characteristics and corrchromium (Co-Cr) dental alloys before and after porcelain-f
Methods. Samples were manufactured utilizing SLM technitional casting methods. The microstructure and surface compX-ray diffraction (XRD), and X-ray photoelectron spectroscoelectrochemical impedance spectroscopy. Student’s t-test waelectrochemical corrosion tests between SLM and cast specimchemical corrosion tests of the SLM and cast samples before
Results. Although PFM firing altered the microstructure of thomogeneous structure, and XPS analysis indicated that thesition of the specimens after firing. In artificial saliva at pH 5before firing and 2.84MUcm(-2) after firing, suggesting thereproperties (P>0.05). In artificial saliva at pH 2.5, the Rp valu2.88MUcm(-2) after firing, again indicating no significant diffepH 2.5, there was a significant difference in corrosion behaviothe cast group being 0.78MUcm(-2) vs. 2.88MUcm(-2) for th
Significance. The improved post-firing corrosion resistance oprosthodontic applications, as the oral environment may bec
Reprinted with permission of the Academy of Dental Materi
Nam and Tokutomi
Corresponding author:Dr Jung Nam1848 Saratoga Ave, Ste 6BSaratoga, CA 95070Email: [email protected]
AcknowledgmentsThe authors thank Dr Prasit Aranyarachkul (Saratoga, Calif) for periodonticsadvice, Dr Linda Lee (Foster City, Calif) for the implant surgeries, and Dr VictoriaMoore (San Mateo, Calif) for the endodontic treatments presented.
Copyright © 2015 by the Editorial Council for The Journal of Prosthetic Dentistry.
the Current Literature
es of selective laser melted Co-Cr
osion properties of selective laser melted (SLM) cobalt-used-to-metal (PFM) firing.
ques and control specimens were fabricated using tradi-osition were examined using metallographic microscopy,py (XPS). Corrosion properties were evaluated usings used to evaluate differences in numerical results ofens before or after PFM firing. The results of electro-and after firing were analyzed using one-way ANOVA.
he SLM specimens, they still exhibited a compact andre were no significant differences in the surface compo-, the Rp value of the SLM specimens was 6.21MUcm(-2)was no significant difference in electrochemical corrosione of the SLM group was 4.80MUcm(-2) before firing andrence in electrochemical corrosion properties (P>0.05). Atr between the cast and SLM groups, with the Rp value ofe SLM group.
f SLM specimens provides further support for their use inome temporarily acidic following meals.
als.
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