98

O
ver the last fewyears, the evolution of restora-
tive materials has taken an important step.
1
The introduction of zirconia and pressed
ceramics has provided a new perspective on the
tooth-supported prosthesis.
2,3
However, the pre-
dictability of zirconia materials when used for im-
plant-supported prostheses is still undetermined.
This article aims to analyze when these new mate-
rials can be predictably implemented in implant-
supported restorations.
ZIRCONIA IN IMPLANT-
SUPPORTED RESTORATIONS
Based on clinical experience, there is no doubt
that zirconia is a viable material for restoring natu-
ral abutments. But what about implant-supported
abutments? The differences between implant
abutments and natural abutments are obvious.
However, in recent years it has been attempted to
convert implant-supported abutments into tooth-
like abutments.
4,5
In so doing, ceramic materials
have been applied to the attachments, thereby ap-
proaching the color and emergence profile of a
natural abutment.
Zirconia has been used to produce direct implant
abutments, thus taking advantage of the materials
fracture resistance. However, what clinical evidence
do we have that this is a viable solution? Direct
loading of an implant with a zirconia structure does
not guarantee durability. On the other hand, materi-
als such as gold-palladium, iridium, or titanium are
1
Barcelona, Spain.
2
Private Practice, Barcelona, Spain.
3
Private Practice, Valencia, Spain.
4
Sabadell, Spain.
Correspondence to: Mr August Bruguera, C/ Vilamari,
56 local 1, Barcelona 08015, Spain. E-mail:
bruguera.lab@infomed.es
QDT 2009
NEW MATERIALS IN IMPLANTOLOGY
Augusto Bruguera, CDT
1
Erika Tllez, DDS
2
Albert Vericat, DDS
3
Javier Moreno, CDT
4
Xavi Balmes, CDT
1
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QDT 2009 99
New Materials in Implantology
well documented to provide durability.
4
Therefore,
until clinical evidence is available to the contrary, it is
necessary to attach a transepithelial connector ele-
ment between the implant and zirconia. This will en-
sure that the restoration will not harm the implant. It
is important to remember that when a high-strength
material is used to load a material of lesser strength,
a superficial distortion will occur in the weaker mate-
rial. This means that if a load is applied to an im-
plant (which has a lesser flexural resistance) with a
zirconia superstructure (which has a greater flexural
resistance), the implant will always suffer the distor-
tion. Figure 1 shows the use of a zirconium abut-
ment with a titanium connector (Biomet 3i, Palm
Beach Gardens, Florida, USA) to restore a central in-
cisor. This type of abutment allows for the use of ce-
ramic, which is an effective material for restoring an
anterior tooth (Figs 2a and 2b). On the other hand,
the ceramic walls of the abutment allow for loading
with a pressed ceramic crown and cementing with
adhesive cement.
ZIRCONIA IN LONG-SPAN
RESTORATIONS
Although small anterior restorations still represent
an esthetic challenge, technically speaking such
restorations are not greatly complex. When con-
fronted with the challenge of an implant-sup-
ported rehabilitation with a metallic superstructure,
maintaining passive fit after firing the ceramic will
always be a challenge. In the authors experience,
this often leads to the need for adjustments. One
solution to this problem is the cemented prosthe-
sis. However, when fabricating long-span restora-
tions, screw-retained prostheses are often pre-
ferred due to thei r ease of removal and
modification. In this sense, zirconia is a reliable ma-
terial because the expansion and contraction that
occurs while in the oven is linear. Therefore, if
good passive fit is achieved prior to firing, it will
not be altered by the glazing process.
Fig 1 Abutment with a titanium connector and zirconia
superstructure.
Figs 2a and 2b Ceramic is placed on the abutment
(e.max Ceram, Ivoclar Vivadent).
1
2a 2b
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QDT 2009 100
BRUGUERA ET AL
CASE REPORT
The patient presented with periodontal problems
including the loss of more than two-thirds of the
bone support. For this reason, it was practical to
perform the extractions and immediately place and
load six implants at the same surgical appointment.
Once the implants had osseointegrated, the final
impression was made to fabricate the diagnostic
waxup and provisional restorations, with the goal of
obtaining a proper emergence profile (Fig 3). The
diagnostic waxup is always more useful when it can
be tried in the patients mouth, because while func-
tion is easily evaluated using an articulator, it is
often difficult to evaluate esthetics without observ-
ing the impact of the waxup within the facial ex-
pressions of the patient (Fig 4). The objective of the
try-in is to locate the incisal contours as they relate
to the lips. Thanks to the waxup, any modifications
can be carried out quickly and easily.
Initially, the intention was to obtain a second
provisional restoration from the diagnostic waxup.
6,7
However, because this provisional would have to
be removed repeatedly from the patients mouth to
make modifications and mold the emergence pro-
file, it was decided to sacrifice esthetics and use an-
gled abutments (Fig 5), despite being unable to
obtain proper incisal contours (Figs 6 and 7).
5
6 7
Fig 5 Angled transepithelial attachments were
placed to correct the facial emergence of the abut-
ments.
Fig 6 Screw-retained provisional restoration.
Fig 7 The provisional restoration was placed even
though the correct incisal contours had not been ob-
tained.
Fig 4 Diagnostic waxup in the patients mouth. Fig 3 A final impression was made once the six im-
plants had osseointegrated.
CASE REPORT
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QDT 2009 101
New Materials in Implantology
Once the gingival contours are molded, the
definitive framework can be fabricated. In this
case, it was decided to use cemented restorations
in the anterior region and screw-retained restora-
tions in the posterior region to better ensure an
acceptable emergence profile.
For the preparation of the anterior abutments, a
pressed ceramic technique was used. Loading the
abutment with pressed ceramic is not a novel con-
cept; however, manufacturing these abutments from
pressed ceramic is a new technique. Pressed ce-
ramic does not have sufficient fractural resistance to
be used as an abutment; therefore, a metallic inter-
nal structure is necessary. Pressed ceramic provides
a tooth-colored restoration with translucency and
light refraction very similar to that of a natural tooth
(Figs 8 and 9).
8,9
Further, pressed ceramics fractural
resistance of 440 MPa and reduced costs make it a
material that should be strongly considered.
To restore an anterior tooth with a pressed ce-
ramic abutment, titanium or gold-palladium must
be added to provide additional support. The abut-
ment will have to be opacified as if it were going
to be baked (Fig 10a). One of the advantages of
pressed ceramic is the precision of the lost-wax
technique. If care has been taken to produce a
provisional restoration with an emergence profile
that maintains healthy tissue, that same emer-
gence profile should be replicated by the defini-
tive abutment. To ensure the replication of the
8 9
Fig 8 Ceramic restorations must imitate the opales-
cence and translucence of natural teeth.
Fig 9 The translucency and light reflection of e.max
Press (Ivoclar Vivadent) emulates those of the natural
tooth.
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QDT 2009 102
BRUGUERA ET AL
emergence profile, a soft tissue cast must be fabri-
cated with the provisional in place.
Once the opaque gold-palladium posts are
placed, the profile of the planned abutments must
be checked. This way, all the technician will have
to do is correct the emergence profile and mold
each of the abutments with wax using the silicone
matrix as a guide (Fig 10b). The provisional
restorations and ring attachments in the posterior
region will mark the path of insertion. The place-
ment of these gold rings is necessary to obtain a
good passive fit while acting as a connector be-
tween the implant and the restoration. When the
profile is well defined, the wax pattern is prepared
for replacement with pressed ceramic (Fig 11), in
this case with medium opacity e.max Press MO1
(Ivoclar Vivadent, Schaan, Lichtenstein) (Fig 12).
Once injected with ceramic, the fit is verified, acid
Fig 10a Gold-palladium abutment.
Fig 10b Waxup of the abutments after obtaining a proper emergence profile.
Fig 11 The wax pattern is prepared for replacement with pressed ceramic.
Fig 12 Ceramic abutment cover after pressing with e.max Press MO1.
10a 10b
11
12
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QDT 2009 103
New Materials in Implantology
etching is carried out, and the adhesive cement is
applied (Multilink, Ivoclar Vivadent) (Figs 13 to 15).
After the abutments have been cemented and the
path of insertion is identified, the abutment sur-
faces can be polished (Figs 16 and 17).
With the abutments finished, the gold rings are
attached to the two posterior implants (Figs 18
and 19). The coping is then molded in composite
resin and processed in zirconia (Figs 20 to 23). This
way, the zirconia coping will already have the cav-
ity needed to house the gold rings. Once the ce-
ramic has been pressed, the gold rings can be ce-
mented, ensuring an acceptable passive fit.
The ceramic is applied to the zirconia in a con-
ventional manner based on standard shades (A1 to
A2) (Fig 24). At this point, it is up to the ceramist to
choose which stains will be applied to achieve a
vital color.
Fig 13 The abutment was etched with hydrofluoric
acid and silanated. Note that the screw was pro-
tected with blue wax.
Fig 14 In a second stage, the pressed ceramic abut-
ment cover was also etched and silanated.
Fig 15 The pressed ceramic cover was cemented
over the metal structure.
Fig 16 Final abutments after being finished and polished, respecting the path of insertion.
Fig 17 The cast is ready for the fabrication of zirconia copings, which will be cemented in the an-
terior region and screw retained in the posterior region.
13 14
15
17 16
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QDT 2009 104
BRUGUERA ET AL
23
24
Figs 18 and 19 In the posterior
region, a gold ring is used as a
connector between the implant
and the zirconia coping.
Fig 20 The copings were
molded in composite resin and
then processed in zirconia.
Fig 21 Framework after pro-
cessing in zirconia.
Fig 22 Zirconia framework
try-in.
Fig 23 Repositioning the gold
ring, which will then be ce-
mented in the coping.
Fig 24 Ceramic is convention-
ally applied using standard
shades (A1 to A2).
18
19
20 22 21
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QDT 2009 105
New Materials in Implantology
One of the problems with metallic structures is
the lack of control of passive fit after the ceramic
has been processed. Zirconia is much more stable
in this regard, even though the better choice is still
to use a cemented prosthesis if a good passive fit
is desired. For this reason, once the glazed ce-
ramic is ready, it should be cemented to the gold
rings that were previously screwed into the two
posterior implants (Fig 25). At this stage (Fig 26),
the site is ready to be torqued down and the
restoration can be cemented in the patients
mouth (Figs 27 to 30).
Fig 25 The glazed ceramic structure is cemented to the screw-retained at-
tachments at the posterior implants.
Fig 26 Passive fit is achieved once the attachments have been cemented.
Figs 27 to 30 Final result.
25
26
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QDT 2009 106
BRUGUERA ET AL
27
28
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QDT 2009 107
New Materials in Implantology
30
29
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QDT 2009 108
BRUGUERA ET AL
CONCLUSIONS
Implementation of new materials such as zirconia
and pressed ceramic in implantology has made it
much easier to obtain satisfactory results. The fact
that these materials are both highly esthetic and
functional is a great advancement. Until recently,
only metallic structures were available when
strength was of primary concern; however, these
promising new materials offer excellent outcomes
and great patient satisfaction.
ACKNOWLEDGMENTS
The authors thank all of the patients that have trusted in us
and all of the professionals that, with much effort, have made
this paper possible.
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the fabrication of an implant-supported, full-mouth, fixed
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plant-supported reconstruction utilizing CAD/CAM tech-
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Quintessence Dent Technol 2008;31:4960.
8. Kina S, Bruguera A. Invisible, Restauraes Estticas em
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work Media, 2003.
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holder's express written permission. However, users may print, download, or email articles for individual use.