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ABSTRACT
Objective: This clinical report describes an alternative treatment modality for the replacement of congenitally missing
maxillary lateral incisors in a 17-year-old patient.
Clinical Considerations: Zirconia-based resin-bonded fixed partial dentures (RBFPDs) were selected as a viable and
conservative treatment option in a young individual with highly aesthetic expectations. Fabrication of all-ceramic
RBFPDs followed specific preparation design and features to accommodate two retainers. The zirconia frameworks
with bilateral wings were digitally designed and then milled by a computer-aided design and computer-aided
manufacturing (CAD/CAM)-controlled milling machine. Zirconia surface was treated with a two-step chairside
tribochemical silica-coating/silane coupling surface treatment protocol, and adhesive resin luting cement was used to
achieve micromechanical and chemical bonding. Completion of the treatment resulted in a functional and aesthetic
successful outcome and a 17-month follow-up presented uneventful.
Conclusion: Contemporary adhesive techniques involving resin-bonded zirconia-based prostheses can be utilized
successfully and predictably in young patients with single missing teeth when implant therapy is currently not a
treatment of choice and a less invasive approach is desired.
CLINICAL SIGNIFICANCE
The zirconia-based resin-bonded prosthesis constitutes a viable and conservative treatment modality for the
replacement of missing teeth either congenitally or from another etiology in young patients in which implant therapy
and a fixed partial denture are currently contraindicated.
(J Esthet
(J Esthet Restor
Restor Dent
Dent 28:8^17,2015)
:, 2016)
*Prosthodontist, Former Prosthodontics Resident, Department of Restorative Sciences, Graduate Prosthodontics, University of Alabama at Birmingham School of
Dentistry, Birmingham, AL, USA
Professor and Chair, Department of Restorative Sciences, Graduate Prosthodontics, University of Alabama at Birmingham School of Dentistry, Birmingham, AL, USA
Professor Emeritus, Department of Restorative Sciences, School of Dentistry, University of Alabama at Birmingham, Birmingham, AL, USA
8 2015
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of Esthetic and Restorative Dentistry Journal of Esthetic and Restorative
DOI 10.Dentistry Vol
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MAXILLARY LATERAL INCISORS RESTORATION MAXILLARY LATERAL INCISORS RESTORATION Stylianou et al
Stylianou et al
have been developed at two-thirds to three-fourths of the Maryland bridge,17 a non-perforated, nonprecious
the nal root length.6 Despite the biologic approach of metal alloy framework with micromechanical retention
this technique, it can be considered surgically technique by electrolytic etching, these advancements have led to
sensitive with age limitation requirements and possible the evolvement of resin cements, ber-reinforced resin,
needed additional orthodontic treatment.7 In the and ceramic materials. In regards to the ber-reinforced
majority of the cases, adjunctive orthodontic treatment composite as an alternative to metal retainers, the
is required before nal restorative and implant therapy adhesion, reparability, and aesthetics are improved;7
for redistribution or establishment of properly and however, the composite material is subject to wear and
adequately aligned space. discoloration through time when compared to ceramic.
Nonetheless, the retentive capabilities of previous
The successful outcome of single-tooth implant RBFDPs could frequently result in the loss of additional
restorations, as reported in various studies,8,9 has rendered tooth structure, beyond the enamel boundaries, in
this treatment alternative a predictable option for the order to achieve mechanical resistance for the
replacement of missing teeth including maxillary lateral prevention of debonding. With the introduction of
incisors.10 Implant restorative treatment is commonly all-ceramic RBFDPs in the early to mid-1990s, superior
perceived as the most conservative approach, since it does and more predictable bonding to the tooth structure
not involve any modication or utilization of the adjacent could be obtained along with an enhanced aesthetic
teeth. However, endosseous implant placement in appearance18 that also addressed the main problem of
growing patients is indicated until after the completion of gray coloration of teeth abutments of the traditional
craniofacial/skeletal growth unless severely partial or resin-bonded metal restorations.4
complete edentulism require an earlier intervention.11
Several studies have suggested the continuation of Specic criteria in respect to the position and mobility
craniofacial growth on average until the age 17 and 21 for of adjacent teeth as well as the anterior teeth
females and males, correspondingly.5,12 The impact of relationship must be fullled to ensure a predictable
facial growth on implant timing and position can be restorative outcome. Ideal patient conditions are stable
explained by the amount of implant submergence and and upright abutment teeth with translucency in the
displacement which in turn depends on the patients incisal third and moderate thickness, with minimal
skeletal and dental age and growth pattern as well as the anterior vertical overlap without signs and symptoms of
maxillary or mandibular positional placement.13 Taking occlusal parafunction.10 In essence, when the teeth
into consideration that chronologic age is not sucient in abutments have dierent grades of mobility, they will
estimating growth, due to the signicant variability within move in dierent vectors resulting in debonding of the
one gender, other methods such as superimposing least mobile retainer and thus, failure of the overall
tracings of serial cephalometric radiographs taken at least prosthetic restoration.10 The interincisal angle between
6 months apart, and analysis of a radiograph of the wrist maxillary and mandibular incisors denes the upright
of the least used hand must be considered before any position of the teeth and the type of forces at the bond
implant treatment attempt in young individuals.14 interface. Particularly, with a larger interincisal angle
and thus, a more upright position of the incisors, a
Regarding tooth-supported restorations, resin-bonded more shear type force can be generated at the bond
xed dental prostheses (RBFDPs) constitute a relatively interface. This will be 40% more tolerated by the loaded
minimal invasive approach and can serve either as a objects than a tensile type of force.4,19 In cases where
denitive or interim prosthesis until implant deep vertical overlap exist between the anterior teeth,
rehabilitation is permitted. Since its development in an inadequate surface for bonding will increase stress
1973, RBFDP has undergone signicant alterations in on the bond interface thereby rendering the RBFDP
design, materials, and tooth preparation.15 From the treatment less favorable.19 In addition to a thorough
early technique of direct macromechanical bonding preprosthetic evaluation, a precise preparation of the
using a Rochette bridge,16 a perforated gold casting, to abutment teeth coupled with patient follow-up on a
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The main goal of the nal treatment was to provide a with epinephrine 1:100.000), the palatal surfaces were
xed restorative solution for the missing lateral incisors reduced axially by 0.6 mm with the marginal nish line
that could preserve the properly established mesiodistal being 1 mm distant from the incisal edge and gingival
space for future implant treatment with the least tissue, respectively, using a round-end taper diamond
amount of tooth structure removal. Based upon all the bur (Brasseler, USA # 850-016), maintaining the axial
diagnostic ndings, zirconia-made resin-bonded FDPs preparation into the enamel. The supragingival margin
utilizing two retainers were proposed as a denitive was created as a 0.5 mm light chamfer nish line in the
xed-prosthetic treatment plan. The rationale of the enamel. Then, interproximal retentive grooves were
use of two retainers instead of cantilever prosthesis is prepared parallel to the planned path of insertion with
based on the absence of dierential mobility between the use of a round-end taper diamond bur (Brasseler,
the retainers and the existing occlusal scheme. USA #850-012) at 1 mm depth and with length that
varied from 2.5 mm for the central incisors and 3.5 mm
Clinical Treatment Procedures for the canines. The preparation design was completed
with a horizontal central groove in the form of a
The nal preparation of teeth abutments which cingulum ledge at the height of the lingual fossa
included the maxillary central incisors and canines extending from the vertical groove to 1 mm from the
followed a three-step procedure. The occlusal corresponding proximal surface. To provide a smooth
evaluation revealed that this patient has no vertical transition within the preparation design for better stress
overjet, therefore, the preparation objectives are to distribution of the zirconia-based restoration, all sharp
reduce minimal amount of tooth structure for line angles were rounded with a round-end taper
structural durability of the prosthesis and to maintain a diamond bur (Figure 4).
normal anatomical contour at the palatal surface. The
utilization of two retainers is justied by the absence of Prior to the nal impression, a maxillary alginate
dierential mobility between the teeth abutments as impression was made and a study cast of the tooth
well as by the relatively short clinical crowns of the preparations was fabricated and surveyed to verify if the
canines that did not allow for sucient bondable proper path of insertion was obtained. For the nal
surface for cantilever prosthesis. After successful local impression, a double-cord retraction technique was
anesthesia of the teeth (two carpules of carbocaine 3% applied and a vinyl polysiloxane (VPS) medium body
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FIGURE 10. Intraoral view of definitive restorations. FIGURE 11. Lingual view of bonded zirconia-based RBFPDs.
RBFPDs = zirconia-based resin-bonded fixed partial dentures.
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include mechanical pretreatment.32 Alternatively, a which underlies the importance of the preparation
recent and promising technique of zirconia surface relative to the survival of the restoration.39,40 It has been
conditioning through the application of a low-fusing demonstrated that both the framework thickness and
porcelain glaze on the intaglio surface of Y-TZP has retainer preparation design aect framework
been introduced in an attempt to create an etchable deformation with dierent mechanisms.43 The thickness
hydrouoric acid layer.33,34 of the retainer is determined by the available
interocclusal space and the lingual enamel thickness. A
With regard to the number of retainers of an all-ceramic recent in vitro study23 found that a combination of
RBFDP, there are strict criteria for the cantilevered zirconia framework thickness of as low as 0.5 mm with
prosthesis in respect to the patients existing occlusal a retentive retainer preparation resulted in a
scheme and the amount of vertical space. In other words, signicantly lower magnitude of principal strain.
favorable factors for the more conservative cantilevered Moreover, with the preparation of proximal grooves as
prosthesis are a mutually protected occlusion including part of the retainer design, both the bonding surface
canine or group function as well as minimal anterior area and mechanical interlock are increased, leading to
vertical overlap of the teeth.35 In a recent study of Sasse enhanced retention of RBFDPs.44 Likewise, this
and colleagues,36 the 5-year survival rate for the preparation feature can provide resistance to dislodging
CAD/CAM single retainer zirconia-ceramic RBFDPs in forces and reinforce the framework design through the
the anterior region was found to be 100% and signicantly increase of the framework rigidity. Also, it serves for
greater than the survival rate results of similar studies that aesthetic purposes as it compensates for the absence of
used glass-inltrated alumina ceramic.37 On the other proximal wraparound. Aside from that, a
hand, the uneven distribution of forces during well-developed or prepared cingulum rest can improve
mastication directed to the cantilever RBFDP prosthesis the resistance form of the framework23 and facilitate
can cause multiple bending and torqueing forces; thus, accurate seating of the RBFDP.45
increasing the risk for debonding, fracture of the
connector or even fracture or loss of the abutment
tooth.38 In the event of an overload of the pontic of the CONCLUSIONS
cantilever RBFDPs, abutment tooth rotation can occur
thereby compromising the long-term prognosis of the When treatment planning for replacement of missing
prosthesis.39 An in vitro study of Rosentritt and maxillary lateral incisors, aesthetic expectations, and
colleagues40 revealed a signicantly higher fracture potential ongoing growth of the patient as well as the
resistance to thermocycling and mechanical loading for interdisciplinary management must be thoroughly
the two-retainer RBFDPs when compared to the considered and evaluated in the denitive restorative
cantilever RBFDPs. In considering the use of a cantilever treatment. In regards to the most suitable combination
design, the rationale is based on the dierential mobility of surface treatment and adhesive cementation system
that might exist between the two abutments and for zirconia-based RBFDPs, there is currently not a
potentially lead to the debonding of one retainer and its standardized protocol suggesting a more sucient
increased susceptibility to caries.41,42 Therefore, it can be bonding eect. With further advances in adhesive
assumed that when there is no signicant dierence in clinical dentistry, alternative tooth preparation designs
the mobility of the two retainers, a three-unit RBFDP can must be developed to accommodate the new minimally
be proposed and utilized predictably. invasive restorative treatments.
8 Vol Wiley
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2015
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No 1Periodicals, Inc.
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DOI 10.Dentistry Vol
1111/jerd.12179 No
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MAXILLARY LATERAL INCISORS RESTORATION MAXILLARY LATERAL INCISORS RESTORATION Stylianou et al
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33. Cura C, Ozcan M, Isik G, Saracoglu A. Comparison of 40. Rosentritt M, Ries S, Kolbeck C, et al. Fracture
alternative adhesive cementation concepts substructures characteristics of anterior resin-bonded zirconia-xed
to resin using a glaze-on technique. J Dent partial dentures. Clin Oral Investig 2009;13:4537.
2012;40:34751. 41. Botelho MG, Leung KC, Ng H, Chan K. A retrospective
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bonding of zirconia substructures to resin using a xed partial dentures. J Am Dent Assoc 2006;137:
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35. Barwacz CA, Hernandez M, Husemann RH. Minimally 42. Sterzenbach G, Tunjan R, Rosentritt M, Naumann M.
invasive preparation and design of a cantilevered, Increased tooth mobility because of loss of alveolar bone
all-ceramic, resin-bonded, xed partial denture in the support: a hazard for zirconia two-unit cantilever
esthetic zone: a case report and descriptive review. J resin-bonded FDPs in vitro? J Biomed Mater Res B Appl
Esthet Restor Dent 2014;26:31423. Biomater 2014;102:2449.
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2013;16:10918. 44. Saad AA, Claey N, Byrne D, Hussey D. Eects of groove
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on single retainer all-ceramic resin-bonded xed partial
dentures characteristics of anterior resin-bonded Reprint requests: Antigoni Stylianou, University of Alabama at
zirconia-xed partial dentures. Clin Oral Investig Birmingham School of Dentistry, Birmingham, AL, USA. Tel:
2009;13:4537. 205-223-5271; 205-934-6898; Fax: 205-975-4747; email: astylian@uab.edu
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