Received: 23 May 2018 Accepted: 30 May 2018

DOI: 10.1111/jerd.12409

CLINICAL ARTICLE

A low cost minimally invasive adhesive alternative for maxillary

central incisor replacement
Wesley F Vasques DDS, MS1 | Felipe V Martins DDS, MS1 |
José Carlos Magalhães DDS, MS | Edgard M. Fonseca DDS, MS, PhD2
2

1
College of Dentistry, Federal Fluminense
University, Niterói, Rio de Janeiro, Brazil
2
Department of Dental Technique, College of
Dentistry, Federal Fluminense University,
Niterói, Rio de Janeiro, Brazil
Correspondence
Edgard M. Fonseca, Department of Dental
Technique, College of Dentistry, Federal
Fluminense University, Mario Santos Braga St.,
28 - Centro, Niterói, RJ 24020-140, Brazil.
Email: edgardfonseca@vm.uff.br
Abstract
Objective: The beneficial mechanical properties of zirconia, together with the adhesive tech-
niques, provide a wide range of clinical applications, including the construction of thin structures
and minimally invasive adhesive restorations.
Clinical Considerations: A periodontal disease-related missing maxillary central incisor, in a preg-
nant patient with chronic periodontal disease in the first trimester of pregnancy, and with type
II diabetes treated with resin-bonded fixed partial denture using the missing tooth cemented to
a zirconia framework and then bonded to the abutment teeth.
Conclusions: According to the systemic conditions presented in this case report, using a low-
cost technology and the missing tooth it was possible to obtain an easier and satisfactory
esthetic and functional result.

Clinical Significance
The mechanical properties of zirconia made it possible to treat a pregnant patient with chronic
periodontal disease in the first trimester of pregnancy, and with type II diabetes with a thin zir-
conia framework and minimally invasive adhesive restorations.

KEYWORDS

adhesive restoration, resin-bonded bridge, zirconia

1 | I N T RO D UC T I O N maxillary central incisor in a pregnant and diabetic patient, treated

with resin-bonded fixed partial denture (RBFDP) using the missing
The effectiveness of the bonding of the composite resin to the tooth cemented to a zirconia framework and then bonded to the abut-
enamel, the dentin and, also, the ceramic systems revolutionized the ment teeth.
practice of restorative dentistry. Since the beginning of the 1980s,
with the introduction of the acid conditioning technique, it is feasible
to perform adhesive ceramic restorations on teeth of the anterior 2 | CASE PRESENTATION
1
segment.
Blatz et al. emphasized that the longevity of adhesive bonding of A 35-year-old female patient presented spontaneous avulsion of the

zirconia and other high strength ceramics, lacks a combination of maxillary left central incisor as a result of the periodontal disease
2
chemical bonds, and micromechanical locking. This requires adequate (Figure 1). Anamnesis revealed that she was pregnant during the first

roughness and cleanness for surface activation. 3,4

However, according trimester of pregnancy and that she had type II diabetes, which
to another study by Blatz et al. the strength of chemical interaction is included clinical conditions in the severe risk group proposed by
limited and less predictable than the micromechanical influence. 5 Misch, contraindicating any surgical procedure for placement of an
The beneficial mechanical properties of zirconia, together with osseointegrated implant.8 Clinical and radiographic analyses revealed
the adhesive techniques, provide a wide range of clinical applications6, the presence of chronic periodontitis in the adult, according to Ameri-
including the construction of thin structures and minimally invasive can Academy of Periodontology classification of periodontal diseases
7
adhesive restorations. This article aims to report a case of a missing (1999),9 bleeding on probing, generalized bone loss, dental calculus,

J Esthet Restor Dent. 2018;1–5. wileyonlinelibrary.com/journal/jerd © 2018 Wiley Periodicals, Inc. 1

2 VASQUES ET AL.
FIGURE 1 Preoperative view of the periodontal disease-related
missing maxillary central incisor
and an alveolar ridge defect class III (Seibert)10 at the edentulous
space (Figure 2).
Initially, the patient was submitted to nonsurgical periodontal
therapy and full-arch impressions of the maxillary and mandibular
arches were made with Speedex putty and light body c-silicone
(Coltene/Whaladent—Cuyahoga Falls, Ohio). The impressions were
poured with type IV gypsum (GC Fujirock EP, GC America, Alsip, Illi-
nois). The analyses of stone casts revealing sufficient occlusal clear-
ance for the production of a RBFDP without tooth preparation. The
tooth was cleaned with ultrasonic instrumentation (Figure 3), and the
root was sectioned to adapt to alveolar ridge defect. Later, retroin-
strumentation and retrofilling with Empress Direct light curing resin
were made (Ivoclar vivadent—Schaan, Liechtenstein).
In the working cast, a Pattern Resin framework (GC America) was
builded-up (Figure 4) and then tried-in, revealing a similar appearance
to the model (Figure 5). The option of not extending the prosthesis
beyond the first abutment teeth took into account the need for
removal in the medium term, as well as the elimination of possible
interferences in the mandibular excursion movements.
Through a manual zirconia milling system (Zirconzahn—Atlanta,
Georgia), the framework was milled in zirconia (Figure 6). After milling
FIGURE 3 Maxillary left central incisor after cleaning with ultrasonic
instrumentation
FIGURE 2 Occlusal view showing the alveolar ridge defect
and sintering, the tooth was bonded to the framework with resin
cement (Multilink—Ivoclar Vivadent; Figure 7). The framework pontic
area was cleaning with 9% buffered hydrofluoric acid (Porcelain Etch,
Ultradent Products, Inc.—South Jordan, Utah) for 20 seconds, washed
and dried. A silane coupling agent (Metal/Zirconia Primer—Ivoclar
Vivadent) was applied with the aid of a microbrush (Coltene/Whala-
dent) in the intaglio surface of framework and allowed to evaporate
for 3 minutes. Primer A and Primer B, already mixed, were applied for
15 seconds to the lingual surface of the tooth. The adhesive cement
was dispensed and applied directly to the intaglio surface of the zirco-
nia framework. The excess of resin cement was removed from the
margins with a microbrush, and the surface was polymerized for
1 minute (Valo Led Curing Light, Ultradent) with 395-480 nm light
output.
The framework cementation to the abutment teeth used the
same protocol described for bonding the tooth into the framework
(Figure 8).
3 | DI SCU SSION
For restorative treatments of missing anterior teeth, new technologies
and materials offer the following options: implant-supported prosthe-
sis, conventional fixed dental prosthesis, and RBFDP.8,9 However, for
patients with systemic diseases such as uncontrolled diabetes,
implants can not be used.9–11
Diabetes is considered a contraindication in dental implant thera-
pies when plasma glucose levels are elevated.11 This pathology is
associated with slow healing and impaired defense systems, such as:
FIGURE 4 Pattern resin framework
VASQUES ET AL. 3

FIGURE 6 Maxillary left incisor cemented to the framework

FIGURE 5 Pattern resin framework try-in

from ZrO2 ceramics. The choice of two retainers provided greater
contact with the surface of the enamel, contributing to the union of
defective migration of polymorphonuclear leukocytes; impaired
the structure to the abutment teeth.8,19,21,22 In addition, studies have
phagocytosis and excessive inflammatory response to microbial
shown higher fracture resistance for RBFPD from two retainers than
products.11–13 In the short term, these variables may influence the
for cantilever RBFPDs.23,24
prognosis of bone graft and implant therapies.11–17
Traditional RBFDP made with metal frame, present esthetic dis-
Implant treatment may be contraindicated for a given period in
advantage with grayish discoloration through the enamel of the teeth
the case of pregnancy.8,15 Clinical studies show that local anesthesia
of the pillar caused by the shadow effect of the structure.8,19,25
during pregnancy is safe. After the first trimester, patients are released
RBFPD made entirely in ceramic, can minimize this disadvantage.8
for dental treatments.8,15 However, dental implants require, in addi-
Both ceramic glass and high-strength oxide ceramics can be used to
tion to local anesthesia, a Cone-beam CT scan for surgical planning
produce optical properties similar to those observed in natural
and x-ray during surgery.16 Pregnant women are advised to avoid
teeth.8,9,19
stress during pregnancy, since anxiety can lead to high blood pressure.
One of the main causes of all ceramic RBFDP failure is the frac-
Any type of surgery can cause feelings of fear and worry.15,17,18 To
ture in the connector area.26,27 The use of a zirconia-based ceramic
avoid this additional stress, a RBFDP can be considered as a solution.
was approved for its excellent mechanical properties.28 When the zir-
The RBFDP can be used as a conservative treatment to replace
conia is submitted to thermomechanical factors, the transformation of
missing teeth, especially if the patient presents vital and noncarious
its tetragonal phase to monoclinic occurs and an increase of approxi-
abutments and a minimal occlusal contact on the retainer and the
mately 4% in the volume of its grains can be observed.29,30 This phe-
pontic.8,9,19 In relation to the restorations supported by the teeth,
nomenon is called tenacification and is responsible for its high
RBFDP is a minimally invasive option and serves as a definitive or pro-
fracture resistance when compared to other ceramics.29,30 Because of
visional prosthesis until implant rehabilitation is possible.8,9,19 Studies
the high strength of the zirconia material, it is possible to reduce the
have shown that RBFPD show successful results. Pjetursson et al.
size of the proximal connector.23,31 The clinical result of the RBFDP
showed that in a period of 5 years, RBFPD had a success rate
made of zirconia ceramics was studied in a randomized controlled trial
between 81.6% and 91.9%.23
for a period of 5 years and had a success rate of 93.3%.32
This clinical report describes the treatment option for replace-
ment of a missing central incisor, using two retainer RBFDP made

FIGURE 7 Postoperative occlusal view FIGURE 8 Immediate postoperative view

4 VASQUES ET AL.
Despite the scientific acceptance of the RBFDP, many clinicians
are afraid of the framework debonding. 8,33
However, preliminary clini-
cal observations show that the most common and simple bonding
methods to be reliable. Goodacre et al. showed that the debonding
rate varies from 10% to 24%.36 Moreover, the debonding rate for
RBFPDs with more than 1 pontic (52%) was doubles that the frame-
work supporting a single pontic. In this clinical report, RBFPD sup-
ported a single pontic.33 Long-term resin bond strength can be
achieved through a ceramic bonding system containing special adhe-
sive phosphate monomers.34–37 To minimize the possible debond risk,
or failure to restore, the RBFPD must be checked for maximum inter-
cuspation (MIP) and dynamic excursions. The retainer and pontic
should have slight contact in the MIP, even if the tooth in question
was not occlusive before the placement of the RBFPD.34–36
4 | CO NC LUSIO N
For restorative treatments of missing anterior teeth, implant-
supported prostheses are ultimately the best solution. However, in
this case report, because the first trimester of pregnancy and the sys-
temic conditions it was not possible. The two retainer RBFDP, made
from zirconium ceramics, can be used as a conservative treatment to
replace missing teeth. It is a low-cost technology, minimally invasive,
capable of produce optical properties similar to those observed in nat-
ural teeth and serves as a definitive or provisional prosthesis until
implant rehabilitation is possible.
DISCLOSURE
The authors do not have any financial interest in the companies
whose materials are included in this article.
ORCID
Felipe V Martins http://orcid.org/0000-0002-1843-7206
RE FE R ENC E S
1. Horn HR. Porcelain laminate veneers bonded to etched enamel. Dent
Clin North Am. 1983;27:671-684.
2. Blatz MB, Sadan A, Kern M. Bonding to silica-based ceramics: clinical
and laboratory guidelines. Quintessence Dent Technol. 2002;25:54-62.
3. Wolf DM, Powers JM, O'Keefe KL. Bond strength of composite to
porcelain treated with new porcelain repair agents. Dent Mater. 1992;
8:158-161.
4. Chen JH, Matsumura H, Atsuta M. Effect of different etching periods
on the bond strength of a composite resin to a machinable porcelain. J
Dent. 1998;26:53-58.
5. Blatz MB, Sadan A, Kern M. Resin-ceramic bonding: a review of the lit-
erature. J Prosthet Dent. 2003;89:268-274.
6. Burke FJT, Fleming GJP, Nathanson D, Marquis PM. Are adhesive
technologies needed to support ceramics? An assessment of the cur-
rent evidence. J Adhes Dent. 2002;4:7-22.
7. Júnior SD, Phark JH, Tada T, et al. Conservative adhesive application
of a new modified zirconia surface QDT 2009;24–36
8. Misch CE. Contemporary Implant Dentistry. 3rd ed. São Paulo, Brazil:
Santos; 2006:443-444.
9. Armitage GC. Development of a classification system for periodontal
diseases and conditions. Ann. Periodontol 1999;4:1-6.
10. Seibert JS. Reconstruction of deformed, partially edentulous ridges,
using full thickness onlay grafts. Part II. Prosthetic/periodontal interre-
lationships. Compend Contin Educ Dent. 1983;4:549-562.
11. Kammoun R, Hadyaoui D, Ghoul MS, et al. Replacement of Missing
Lateral Incisor Using A Zirconium Resin-Bonded Fixed Partial Denture:
A Clinical Report. J Dent Oral Care Med 2016;2:1-6.
12. Duarte S, Phark J-H, Tada T, et al. Resin-bonded fixed partial dentures
with a new modified zirconia surface: a clinical report. J Prosthet Dent.
2009;102:68-73.
13. Marchand F, Raskin A, Dionnes-Hornes A, et al. Dental implants and
diabetes: conditions for success. Diabetes Metab. 2012;38:14-19.
14. Annibali S, Pranno N, Cristalli MP, la Monaca G, Polimeni A. Survival
analysis of implant in patients with diabetes mellitus: a systematic
review. Implant Dent. 2016;25:663-674.
15. Naujokat H, Kunzendorf B, Wiltfang J. Dental implants and diabetes
mellitus—a systematic review. Int J Implant Dent. 2016;2:5.
16. Jardini MA, Tera TM, Meyer AA, Moretto C, do Prado R,
Santamaria M. Guided bone regeneration with or without a collagen
membrane in rats with induced diabetes mellitus: histomorphometric
and immunolocalization analysis of angiogenesis and bone turnover
markers. Int J Oral Maxillofac Implants. 2016;31:918-927.
17. Esquivel-Upshaw J, Mehler A, Clark A, Neal D, Gonzaga L,
Anusavice K. Peri-implant complications for posterior endosteal
implants. Clin Oral Implants Res. 2015;26:1390-1396.
18. Steinberg BJ, Hilton IV, Iida H, Samelson R. Oral health and dental care
during pregnancy. Dent Clin North Am. 2013;57:195-210.
19. Rios HF, Borgnakke WS, Benavides E. The use of cone-beam com-
puted tomography in management of patients requiring dental
implants: an American academy of periodontology best evidence
review. J Periodontol. 2017;88:946-959.
20. Hagai A, Diav-Citrin O, Shechtman S, et al. Pregnancy outcome after
in utero exposure to local anesthetics as part of dental treatment: a
prospective comparative cohort study. J Am Dent Assoc. 2015;146:
572-580.
21. Rocha JS, Arima LY, Werneck RI, Moysés SJ, Baldani MH. Determi-
nants of dental care attendance during pregnancy: a systematic
review. Caries Res. 2018;52:139-152.
22. Stylianou A, Liu P-R, O'Neal SJ, Essig ME. Restoring congenitally miss-
ing maxillary lateral incisors using zirconia-based resin bonded pros-
theses. J Esthet Restor Dent. 2016;28:8-17.
23. Pjetursson BE, Tan WC, Tan K, Brägger U, Zwahlen M, Lang NP. A
systematic review of the survival and complication rates of
resin-bonded bridges after an observation period of at least 5 years.
Clin Oral Implants Res. 2008;19:131-141.
24. Thammajaruk P, Inokoshi M, Chong S, Guazzato M. Bonding of com-
posite cements to zirconia: a systematic review and meta-analysis of
in vitro studies. J Mech Behav Biomed Mater. 2018;80:258-268.
25. Tzanakakis E-GC, Tzoutzas IG, Koidis PT. Is there a potential for dura-
ble adhesion to zirconia restorations? A systematic review. J Prosthet
Dent. 2016;115:9-19.
26. Rosentritt M, Kolbeck C, Ries S, et al. Zirconia resin-bonded fixed partial
dentures in the anterior maxilla. Quintessence Int. 2008;39:313-319.
27. Rosentritt M, Ries S, Kolbeck C, Westphal M, Richter EJ, Handel G.
Fracture characteristics of anterior resin-bonded zirconia-fixed partial
dentures. Clin Oral Investig. 2009;13:453-457.
28. Kinzer GA, Kokich VO. Managing congenitally missing lateral incisors. Part
II: tooth-supported restorations. J Esthet Restor Dent. 2005;17:76-84.
29. Tanoue N, Nagano K, Sawase T, Matsumura H. A nine-year clinical
case study of a resin-bonded fixed partial denture seated on the maxil-
lary anterior teeth. J Prosthodont Res. 2010;54:143-146.
30. Ketabi A-R, Kaus T, Herdach F, et al. Thirteen-year follow-up study of
resin-bonded fixed partial dentures. Quintessence Int. 2004;35:
407-410.
31. Gautam C, Joyner J, Gautam A, et al. Zirconia based dental ceramics:
structure, mechanical properties, biocompatibility and applications.
Dalton Trans Camb Engl. 2016;45:19194-19215.
32. Shahmiri R, Standard OC, Hart JN, Sorrell CC. Optical properties of
zirconia ceramics for esthetic dental restorations: a systematic review.
J Prosthet Dent. 2018;119:36-46.
VASQUES ET AL. 5

33. Blatz MB, Vonderheide M, Conejo J. The effect of resin bonding on 37. Lally U. Resin-bonded fixed partial dentures past and present—an
long-term success of high-strength ceramics. J Dent Res. 2018;97: overview. J Ir Dent Assoc. 2012;58:294-300.
132-139.
34. Nemoto R, Nozaki K, Fukui Y, et al. Effect of framework design on the
surface strain of zirconia fixed partial dentures. Dent Mater J. 2013;32:
289-295. How to cite this article: Vasques WF, Martins FV,
35. Sasse M, Kern M. CAD/CAM single retainer zirconia-ceramic Magalhães JC, Fonseca EM. A low cost minimally invasive
resin-bonded fixed dental prostheses: clinical outcome after 5 years. adhesive alternative for maxillary central incisor replacement.
Int J Comput Dent. 2013;16:109-118.
J Esthet Restor Dent. 2018;1–5. https://doi.org/10.1111/jerd.
36. Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JYK. Clinical
complications in fixed prosthodontics. J Prosthet Dent. 2003;90: 12409
31-41.