Fixed partial denture supported by all-ceramic copings: A clinical report

Roberto Pellecchia, DDS,a Ki-Ho Kang, DDS, DMD, MS,b and Hiroshi Hirayama, DDS, DMD, MSc
School of Dental Medicine, Tufts University, Boston, Mass
This clinical report describes the prosthodontic treatment of a partially edentulous patient who had
a surgical closure of bilateral cleft of the lips, alveolar processes, and palate. The prosthodontic treatment
included the fabrication of a telescopic fixed partial denture supported by reinforced all-ceramic
primary copings. The use of all-ceramic primary copings, rather than gold copings, offers an alternative
fixed partial denture and improves the esthetic result in certain clinical situations. (J Prosthet Dent
2004;92:220-3.)

he concept of a primary gold coping was first introduced for the fabrication of a removable partial denture
retainer at the beginning of the 20th century.1 It was not
until the 1950s, however, when the concept of the
telescopic coping was reported to overcome the
problem of abutment parallelism during the fabrication
of fixed partial dentures (FPD).2 The telescopic or
primary coping concept was then successfully applied
in extensive prosthodontic treatments for periodontally
compromised patients for many years until the advent of
dental implants.3,4
The telescopic crown is defined as an artificial crown
fabricated to fit over a coping.5 Each primary coping is
usually fabricated parallel to the adjacent copings with
an average wall taper of a 6-degree angle of convergence.
The copings are definitively cemented to abutment
teeth, and then a fixed prosthesis as a secondary structure
is fabricated over the copings and placed with different
types of cements or medium. Modifying the height or
degree of taper of the copings may control the amount
of retention for the superstructure on the copings.6
Weaver7 outlined a series of advantages and
disadvantages of telescopic prostheses. The primary
advantages include aligning abutments for the
fabrication of a fixed partial denture without overreducing tooth structure. Excellent fit of copings to
the prepared teeth may reduce the possibility of recurrent caries on the abutment teeth when a long-span fixed
partial denture is fabricated, or when abutment teeth
have different degrees of mobility. An additional benefit
of telescopic prostheses is the retrievability of superstructure, which is usually placed on the copings with
provisional medium. This feature may allow removal
of the superstructure when there is a need for additional
periodontal or endodontic therapy, extraction of failed

Presented as a table clinic at the American Academy of Fixed

Prosthodontics Annual Meeting, February 2004, Chicago, Ill.
a
Visiting Clinical Instructor, Graduate & Postgraduate Prosthodontics,
Department of Prosthodontics and Operative Dentistry.
b
Assistant Professor, Graduate & Postgraduate Prosthodontics, Department of Prosthodontics and Operative Dentistry.
c
Professor, Department of Prosthodontics and Operative Dentistry;
Director, Graduate & Postgraduate Prosthodontics.

220 THE JOURNAL OF PROSTHETIC DENTISTRY

abutments, and/or implant placement after the completion of prosthodontic treatment.

Telescopic copings present some disadvantages that
limit their uses to specific clinical situations. The fabrication of copings and superstructure involves an increased
number of complex laboratory and clinical procedures,
such as additional casting and clinical remounting.
Laboratory costs and treatment fees are generally increased. The use of the conventional telescopic prosthesis may not be recommended when there is a high
esthetic demand. It may be difficult to place both the
gold collar of the coping and the metal margin of the superstructure subgingivally if a patient presents with high
lip line at smile and with thin, delicate gingival tissue
around anterior abutment teeth. This gingival tissue
biotype is more prone to recession, possibly caused by
prosthodontic procedures such as tooth preparation
and impression making.8,9 This clinical report describes
the use of a telescopic FPD supported by all-ceramic primary copings, as an alternative treatment with the aim
of overcoming the esthetic limitation resulting from
the presence of the metal collar of the traditional gold
copings.

CLINICAL REPORT
A 19-year-old man was referred to the postgraduate
prosthodontic clinic at the Tufts University School of
Dental Medicine for the completion of his dental treatment. The patient had a history of surgical closure of a bilateral cleft of the lip, alveolar process, and primary and
secondary palate (CLAP). The maxillary central, lateral
incisors, and first premolars were congenitally missing.
After bone grafting of the cleft areas and orthodontic
treatment of the maxillary teeth, a maxillary 10-unit interim acrylic resin FPD was inserted for the prevention
of postorthodontic relapse of the teeth and alveolar processes by his previous dentist (Fig. 1). During initial examination, the presence of a high lip line when smiling
and thin, high, scalloped gingival tissue over the facial
surfaces of the remaining abutment teeth were noted.
A computerized tomography (CT) assessment of the anterior maxilla exhibited lack of alveolar and basal bone
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PELLECCHIA, KANG, AND HIRAYAMA

Fig. 1. Pretreatment intraoral view of maxillary interim

acrylic FPD.

Fig. 3. In-Ceram Zirconia (ICZ) copings after 2 sintering

firings.

for implant placement, and the patient refused to

undergo another surgical bone grafting procedure.
After other alternative treatment options were discussed with the patient, including a combination of
maxillary FPDs and a removable partial denture, a maxillary 10-unit telescopic FPD supported by all-ceramic
primary copings was selected for improved esthetics as
a definitive restoration. A new maxillary 10-unit acrylic
provisional FPD was inserted. Surgical crown lengthening was performed for the maxillary first premolar and
first molars. After tissue healing, the definitive impression was made with a polyether impression material
(Impregum F; 3M ESPE, St. Paul, Minn). The impression was poured with Type V gypsum material (DieKeen; Heraeus Kulzer, Armonk, NY) and sent to a dental
laboratory (Fig. 2).
A glass-infiltrated, sintered zirconia-based ceramic
core (In-Ceram Zirconia (ICZ); Vita Zahnfabrik, Bad
Sackingen, Germany) was selected as a primary coping
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THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 2. Occlusal view of maxillary definitive cast.

Fig. 4. ICZ copings after glass infiltration firing.

because of its good flexural strength,10-14 fracture

toughness,11,14,15 and marginal adaptation.16-19 The
ICZ core is fabricated by a slip-casting, the process
of preparing stable suspensions and fabricating
structures by adding a solid layer on the surface of a porous mold that absorbs the liquid phase by means of capillary forces.20 The fabrication process also involves the
creation of an aluminum oxide (55%)/zirconium oxide
(25%) mixture as framework material during 2 sintering
firings (first firing at 1000C for 2 hours; second firing at
1180C for 2 hours) (Fig. 3). The sintered structure is
infiltrated by the glass phase (20%) during the glass-infiltration firing (1140C for 2 1/2 hours) (Fig. 4). This
strengthening mechanism of the ICZ all-ceramic system
is called transformation toughening.18
Six In-Ceram Zirconia (ICZ) cores were fabricated
with a uniform thickness of 0.7 mm and evaluated on
the abutment teeth for fit (Figs. 3 and 4). The core margins were cut back 360 degrees, and shoulder porcelain
(Cerabien; Noritake, Nagoya, Japan) was applied. The
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PELLECCHIA, KANG, AND HIRAYAMA

Fig. 6. Frontal view of cemented ICZ copings.

Fig. 5. Occlusal view of cemented ICZ copings.

Fig. 7. Occlusal view of completed maxillary telescopic

FPD supported by ICZ copings.

Fig. 8. Frontal view of completed maxillary telescopic FPD

supported by ICZ copings.

DISCUSSION
ICZ cores were modified to be parallel to each other and
then a definitive 10-unit metal ceramic FPD was fabricated on the copings using ceramometal casting alloy
(V-Deltaloy; Metalor Technologies USA, Attleboro,
Mass) and porcelain (Super Porcelain EX-3 and
Cerabien; Noritake). The ICZ copings were airborneparticle abraded internally with 120-mm Al2O3/ZrO2
at a maximum pressure of 2.5 to 3 bar. The intaglio surfaces of the copings were then acid-etched with 10% hydrofluoric acid (Bisco, Schaumburg, Ill) and silanized
(Monobond-S; Ivoclar Vivadent, Amherst, NY). The
copings were cemented on the abutments with a resin
cement (Variolink II; Ivoclar Vivadent) (Figs. 5 and
6). The superstructure was luted with a provisional cement (TempBond; Kerr Corp, Orange, Calif) mixed
with petroleum jelly (Figs. 7 and 8). The patient was recalled at 1 week, 1 month, 2 months, and 6 months. No
further occlusal adjustment or recementation of the superstructure was needed.
222

The primary concerns of treating CLAP patients include providing definitive retention of the tooth position and alveolar/basal bone segmental relationship
after surgical and orthodontic treatment. The use of
a multiple-abutment FPD is recommended as the treatment of choice because it prevents postorthodontic relapse and provides an optimal functional and esthetic
outcome.21-25 The bone and tooth movement may result in loosening of the cement bond with a long-span
fixed prosthesis, resulting in failure of the fixed prosthesis due to recurrent caries. The use of primary copings
may be indicated for maintaining the integrity of the
abutment-coping interface.
The main disadvantage of using any all-ceramic core
as a primary coping is its opaque nature when the
achievement of an esthetic outcome is important. InCeram Zirconia consists of dispersed particles of zirconium oxide, slightly greater in size than the wavelength
of light. This feature determines its opaque appearance.26 In this clinical report, ICZ core margins were
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PELLECCHIA, KANG, AND HIRAYAMA

cut back and replaced with shoulder porcelain

(Cerabien; Noritake) to increase translucency in the cervical areas. Future studies should include strength of
bonding between feldspathic porcelain and ICZ core
material. Other concerns regarding the use of all-ceramic
cores relate to technique-sensitive clinical and laboratory
procedures. Tooth preparation should also be considered (Fig. 2). Abutment teeth should be prepared as parallel to each other as possible because thin all-ceramic
copings may not provide as much flexibility as gold copings for the correction of angulation problems.

SUMMARY
Reinforced all-ceramic cores supporting a telescopic fixed partial denture may be an alternative approach to the conventional telescopic prostheses
using gold copings when the esthetic outcome is the primary concern, especially for patients with a high lip line
at smile.
The authors thank Yukio Oishi, CDT, a chief technician and
laboratory instructor in postgraduate prosthodontics, Tufts University
School of Dental Medicine, who provided the laboratory work
presented in this clinical report.

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Reprint requests to:
DR KI-HO KANG
GRADUATE & POSTGRADUATE PROSTHODONTICS (DHS-248)
DEPARTMENT OF PROSTHODONTICS AND OPERATIVE DENTISTRY
TUFTS UNIVERSITY SCHOOL OF DENTAL MEDICINE
ONE KNEELAND STREET
BOSTON, MA 02111
FAX: 617-636-0469
E-MAIL: kiho.kang@tufts.edu
0022-3913/$30.00
Copyright 2004 by The Editorial Council of The Journal of Prosthetic
Dentistry

doi:10.1016/j.prosdent.2004.06.006

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