Irena Sailer | Vincent Fehmer | Bjarni Pjetursson

FIXED RESTORATIONS
Irena Sailer | Vincent Fehmer | Bjarni Pjetursson

FIXED RESTORATIONS
A CLINICAL GUIDE TO THE
SELECTION OF MATERIALS AND
FABRICATION TECHNOLOGY
A CIP record for this book is available from the British Library.
ISBN: 978-3-86867-563-4

Quintessenz Verlags-GmbH Quintessence Publishing Co Ltd

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Quintessenz Verlags-GmbH
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Editing: Anya Hastwell, Elizabeth Ducker, Quintessence Publishing Co

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Layout and Production: Ina Steinbrück Quintessenz Verlags-GmbH,
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Dedication
“To our families and mentors who inspired us”
Irena, Vincent, and Bjarni
Forewords

I must admit that the request from Irena Sailer, Vincent Fehmer, and
Bjarni Pjetursson to write a foreword for their new book entitled
“Fixed Restorations” surprised me. My first thought was: Do we need
a book about fixed restorations in this day and age?
On second thoughts, I rapidly changed my mind. They are right. It
is necessary and even urgent to publish such a book at this juncture.
In many discussions with colleagues, I have noticed how little we
know about the incredible product developments in fixed restorations
in recent years, and the controversies surrounding the issue. Many
protocols and elements have changed in this area of dentistry. It
seems essential that the dental community have an overview and
guidelines of the current state of the art. A multitude of different
materials is available in fixed restorations. Also, the manufacturing
techniques for fixed restorations have made fundamental
developmental changes, which need to be fully understood.
The practicing clinician should also have a strong foundational
knowledge of all the various materials and manufacturing techniques
in fixed restorations. But, hand on heart, is this requirement possible?
Only during their formal education years do clinicians learn the ability
to obtain profound knowledge of the composition and availability of
the different materials in fixed restorations; their advantages and
disadvantages; their various fields of application; and the various
manufacturing techniques. The combined elements of official tutoring,
available literature, communication, and controlled hands-on
experience allow the clinician to formulate opinions about the gold
standards of restorative treatment. Considering the last decades of
dentistry, it is apparent that a clinician will never be in the position of
always being up to date in the fields of new materials and new
manufacturing techniques of fixed restorations. During a clinician’s
entire professional life, development of these new techniques and
materials is too rapid and intensive to remain fully informed.
Therefore, nowadays, more than ever, the clinician must build a
team with his or her laboratory technician. The laboratory technician
is the individual who works with dental components daily, gaining a
deep understanding of the advantages and disadvantages of different
materials. Laboratory technicians hold casts in their hand or look at
models on the screen daily; they see the chipping, the fractures, and
the problems of the different materials used for fixed restorations as
they are utilized and produced. They can formulate opinions on
suitability and functionality better than anyone else. The wise and
ethically motivated dental clinician and researcher needs to lend an
ear to the incredible experience and understanding of laboratory
technicians.
Irena Sailer, Vincent Fehmer, and Bjarni Pjetursson choose this
innovative approach in their book by selecting authors with different
backgrounds. Irena Sailer and Bjarni Pjetursson are both incredible
clinicians and researchers. Still, they knew and understood that for
such a book project to succeed an exceptional laboratory technician’s
contribution and input would be required. They found it in Vincent
Fehmer. They together have the complete knowledge and experience
to create such a mammoth undertaking. I can see with my own eyes
what thorough and intense discussion they must have had during the
writing of this book. They knew that one of them would never be able
to finish such a project. The only way to succeed was to form a team
with three exceptional characters.
In the fall of 2019, I had the pleasure to be invited to the wedding
of Irena and Vincent. Bjarni was the chosen best man. At the
fantastic evening party, all attendees could feel the unique energy
between the three of them. They have more than just friendship.
There is energy, emotion, and pleasure between them. These
characteristics are necessary to build an incredible team to create a
unique project like this book.
Dear lovely readers, you now have this book in your hands. I am
convinced that you will feel the energy and the enthusiasm of the
team behind it while reading. The sparks of fixed restoration will also
fly in your mind.

Prof Dr Markus Hürzeler

Today’s progress in dentistry is extremely rapid regarding the
development of new materials and techniques for treating patients in
need of fixed restorations. It is easy for clinicians to lose oversight of
the myriad of materials available and the technical methods to
process them and thus to feel left behind this rapid but fascinating
progress. In addition, scientific journals in the field are filled with
articles on new material categories, new material compositions, and
new techniques and methods for material processing. It is becoming
increasingly difficult for clinicians to master the problem of which
material is best for which indication in clinical practice. With this book,
the authors Irena Sailer, Vincent Fehmer, and Bjarni Pjetursson have
compiled clinically relevant and useful recommendations on where
and how to apply the optimal dental materials in a given clinical
situation. It clearly represents the current best practice for decision
making regarding material selection in patients in need of fixed
restorations. I expect this book to help seasoned clinicians, trainees
in dental schools, as well as students in postgraduate programs to
provide better care for their patients.
Divided into four parts, the book covers basic information
regarding materials and the overall production processes in the first
part, and the clinical procedures step-by-step in the second part. The
broad illustration with excellent pictures helps the reader to
understand the connection between the initial diagnosis, the patient’s
needs, the careful identification of indications, and the optimal choice
of the best suitable materials, coupled with the state-of-the-art
manufacturing technique. The discussion of the clinical challenges
occurring around dental restorations would not be complete without
the third Part detailing the important issues of long-term outcomes,
and the final Part describing the management of complications.
Thanks to their years of experience in clinical dentistry and their
careers as clinical researchers, the authors excellently combine
clinical judgment with the scientific evidence for the recommendations
on best practice for fixed restorations. In the light of today’s important
role of dental implants to support and improve the desired clinical
outcomes, this book deals with materials to restore natural teeth as
well as dental implants.
In summary, the authors are to be congratulated for having
compiled a guide for the dental community to enable better health
care in this era of rapid technical and scientific development in the
field of dental restorative materials and their application in clinical
practice.

Prof Dr Dr h c Christoph Hämmerle

For decades, restorative dentistry has been dominated by
mechanistic therapeutic concepts and simple material sciences
aspects. However, in more recent years, these concepts were
severely challenged and replaced by biologically oriented treatment
concepts. “To maintain, rather than to extract a tooth” became the
paradigm for restorative dentistry. In this respect, the placement of
implants became a concept to replace missing teeth rather than to
replace teeth. The teeth experienced a renaissance in their
significance and priority in the concept of total patient care and
maintaining the dentition for a lifetime.
The periodontal aspects of abutment teeth and final restorations
receive great attention when restoring a mutilated dentition. It was
realized that oral diseases, with the exception of trauma and
malignancies, represent opportunistic infections that have to be
successfully treated before restorations can be incorporated. The
principle of “never building a house on sand, but rather on a solid
foundation” was introduced and consequently implemented in
restorative dentistry. This, in turn, meant that periodontal and
endodontic treatment had to be successfully completed prior to
prosthetic rehabilitation.
At the same time, tremendous progress was made in developing
dental materials that were able to mimic the natural dentition in terms
of esthetics and function. These techniques require highly skilled
laboratory technicians and profound knowledge of dental materials in
order to be applied in clinical work.
It is evident that a modern textbook on restorative dentistry has to
be based on the biologic principles discussed above. While a plethora
of texts address single aspects of prosthetic restorations, there are
only a few textbooks that present a comprehensive view on the entire
field of oral rehabilitation. Moreover, only occasionally do we
encounter a textbook with a clear biologic background. The present
text is such an exceptionally rare documentation of a biologically
based treatment philosophy. The numerous case documentations are
testament to the feasibility of individually optimal restorations
centering on the patient’s needs rather than on idealistic and hardly
affordable concepts.
Irena Sailer, Vincent Fehmer, and Bjarni Pjetursson are a trio that
has successfully established international recognition in the field of
oral rehabilitation. They have worked together for over 10 years and
are well known from their annual Icelandic Education Weeks. These
have been very successful 1-week events with an international
attendance of enthusiastic participants. Both Irena Sailer and Bjarni
Pjetursson are clinically highly competent and skilled clinicians. They
unite the fields of Periodontology and Restorative Dentistry in a
unique way. Vincent Fehmer is a well-known master dental technician
who completes the trio and contributes to the technical aspects of
restorative dentistry. It is fortunate indeed that this trio has taken the
time to provide the profession with such a unique textbook on all
modern aspects of restorative dentistry.

Prof Dr Dr Niklaus P Lang

Authors

Prof Dr Irena Sailer, Prof Dr med dent, Hon

Prof (U Aarhus)
Chair, Division of Fixed Prosthodontics and Biomaterials, University of
Geneva, Geneva, Switzerland
Honorary Skou Professor, University of Aarhus, Aarhus, Denmark
Adjunct Associate Professor, Department of Preventive and
Restorative Sciences, School of Dental Medicine, University of
Pennsylvania, PA, USA

MDT Vincent Fehmer

MDT, Division of Fixed Prosthodontics and Biomaterials, Clinic of
Dental Medicine, University of Geneva, Geneva, Switzerland

Prof Dr Bjarni E Pjetursson, Prof Dr med

dent, DDS, MAS Perio, PhD
Professor and Chairman, Department of Reconstructive Dentistry,
and Dean, Faculty of Odontology, University of Iceland, Reykjavík,
Iceland Invited Professor, Division of Fixed Prosthodontics and
Biomaterials, University of Geneva, Geneva, Switzerland

Co-author
Prof Dr Jens Fischer, Prof Dr med dent, Dr rer
nat
Division of Biomaterials and Technology, Clinic for Reconstructive
Dentistry, University Center for Dental Medicine UZB, University of
Basel, Basel, Switzerland

Prof Dr Irena Sailer, Hon Prof (U Aarhus)

Prof Dr Irena Sailer received her Dr med dent degree from the
University of Tübingen, Germany (1997/1998). She received an
Assistant Professorship at the Clinic of Fixed and Removable
Prosthodontics and Dental Material Sciences, Zurich, Switzerland
(2003), where from 2010 she was an Associate Professor. In 2007,
Prof Dr Sailer was a Visiting Scholar at the Department of
Biomaterials and Biomimetics, Dental College, New York University,
NY, USA. Since 2009 she has held an Adjunct Associate
Professorship at the Department of Preventive and Restorative
Sciences, Robert Schattner Center, University of Pennsylvania, PA,
USA (Head: Prof Dr MB Blatz).
Prof Dr Sailer is Head of the Division of Fixed Prosthodontics and
Biomaterials at the University of Geneva, Switzerland. In 2019, she
received an Honorary Skou Professorship at Aarhus University,
Denmark. She is a Specialist for Prosthodontics (Swiss Society for
Reconstructive Dentistry), and holds a Certificate of focused activities
in Dental Implantology (WBA) of the Swiss Society for Dentistry. She
is a member of the Board of Directors of the European Association of
Osseointegration (EAO), Vice President of the European Academy of
Esthetic Dentistry (EAED), member of the Swiss Society of
Reconstructive Dentistry, the Education Committee of the
International Team for Implantology (ITI), and the Greater New York
Academy of Prosthodontics (GNYAP), and Editor-in-Chief of the
International Journal of Prosthodontics. She is widely published and
holds several patents on esthetic coatings of dental/medical devices,
and on a digital dental splint.
MDT Vincent Fehmer
MDT Vincent Fehmer received his dental technical education and
degree in Stuttgart, Germany, in 2002. From 2002 to 2003 he
performed fellowships in the UK and the USA in Oral Design certified
dental technical laboratories. From 2003 to 2009 he worked at an
Oral Design certified laboratory in Berlin, Germany, at Zahntechnik
Mehrhof. In 2009 he received his MDT qualification in Germany. From
2009 to 2014 he was the chief dental technician at the Clinic for Fixed
and Removable Prosthodontics in Zurich, Switzerland. Since 2015 he
has been dental technician at the Clinic for Fixed Prothodontics and
Biomaterials in Geneva, Switzerland, and runs his own laboratory in
Lausanne, Switzerland.
MDT Fehmer is a Fellow of the International Team for
Implantology, an Active member of the European Academy of
Esthetic Dentistry (EAED), and a member of the Oral Design group,
the European Association of Dental Technology (EADT), and German
Society of Esthetic Dentistry (Deutsche Gesellschaft für Ästhetische
Zahnheilkunde, DGÄZ). He is active as a speaker at a national and
international Level. MDT Fehmer has received honors including the
prize for the Best Master Program of the Year (Berlin, Germany). He
has published numerous articles within the field of fixed prothodontics
and digital dental technology. He also serves as reviewer for several
international journals and is a section editor for the International
Journal of Prosthodontics.

Prof Dr Bjarni E Pjetursson, DDS, MAS Perio,

PhD
Prof Dr Bjarni Pjetursson received his DDS from the University of
Iceland in 1990. From 1990 to 2000 he worked as a general dentist
in his private clinic in Iceland. In 2000 he started his postgraduate
training in Periodontology and Implant Dentistry at the University of
Bern, Switzerland. He received his specialist certificate (EFP & SSP)
and Masters of Advanced Studies in Periodontology and Doctorate in
Dentistry from the Faculty of Medicine, University of Bern. From 2003
to 2005 he did his postgraduate training in Prosthodontics at the
University of Bern. From 2005 he was Assistant Professor and Senior
Lecturer at the Department of Periodontology and Fixed
Prosthodontics, University of Bern, and from 2009 to 2014 the Dean
of the Faculty of Odontology, University of Iceland.
Presently he is a Professor and Chairman of the Department of
Reconstructive Dentistry, University of Iceland, and a Titular
Professor at the Division of Fixed Prosthodontics and Biomaterials at
the University of Geneva, Switzerland. Prof Dr Pjetursson is a board
member of EAO, an ITI Fellow, Associate Editor of the International
Journal of Prosthodontics, and member of the editorial board of
Clinical Oral Implants Research. He has published extensively in and
given over 700 lectures in 50 countries around the world. His
research interests are clinical studies in implant dentistry and
evidenced-based evaluation of different treatment modalities in
implant and prosthetic dentistry.
Contributors

PD Dr G Benic
Lugano, Switzerland

PD Dr A Bindel
Zurich, Switzerland
Dr F Brandenberg
Lucerne, Switzerland

Dr D Büchi
Chur, Switzerland
Dr F Burkhardt
Geneva, Switzerland

Dr U Calderon
Geneva, Switzerland
Prof Dr Dr J Fischer
Basel, Switzerland

DT W Gebhard
Zurich, Switzerland
Dr P Grohmann
Berikon, Switzerland

Prof Dr R Jung
Zurich, Switzerland
Dr N Kalberer
Geneva, Switzerland

Dr D Karasan
Geneva, Switzerland
Prof Dr H Lee
Pusan, South Korea

Dr J Legaz Barrionuevo
Geneva, Switzerland
Dr L Marchand
Geneva, Switzerland

PD Dr S Mühlemann
Zurich, Switzerland
DT C Piskin
Lausanne, Switzerland

Dr J Pitta
Geneva, Switzerland
Dr C Riera
Geneva, Switzerland

Dr M Strasding
Geneva, Switzerland
DT B Thiévent
Zurich, Switzerland

Prof Dr D Thoma
Zurich, Switzerland
Dr E van Dooren
Antwerp, Belgium

PD Dr A Zembic
Winterthur, Switzerland
Contents

Forewords
Authors
Contributors

Part I Basics
1.1 Current restorative materials
Jens Fischer
1.1.1 Introduction
1.1.2 Requirements for restorative materials
1.1.3 Overview of current materials for fixed restorations
1.1.4 Conclusions
1.1.5 References

1.2 Patient-related factors for material

selection
1.2.1 Introduction
1.2.2 Patient demands
1.2.3 Esthetic requirements
1.2.4 Amount and quality of tooth substance
1.2.5 Amount and quality of soft tissues
1.2.6 Occlusal and functional requirements
1.2.7 Conclusions
1.2.8 References

1.3 Technical factors

1.3.1 Introduction
1.3.2 Conventional vs computer-aided manufacturing techniques
1.3.3 Optical factors influencing the material selection
1.3.4 Monolithic and veneered restorations
1.3.5 Conclusions
1.3.6 References

1.4 Diagnostics
1.4.1 Introduction
1.4.2 Esthetic parameters to be evaluated: step-by-step checklist
1.4.3 Time points for diagnostics, diagnostic tools
1.4.4 Conventional procedures
1.4.5 Digital procedures
1.4.6 Augmented reality in dentistry
1.4.7 Diagnostics for fixed implant-supported restorations, surgical
stents
1.4.8 Conclusions
1.4.9 References

1.5 Decision-making criteria for replacing

the missing tooth
1.5.1 Introduction
1.5.2 An evidence-based approach to treatment planning
1.5.3 Factor 1 – The patient’s perception
1.5.4 Factor 2 – The estimated longevity of the restorations
1.5.5 Factor 3 – The neighboring teeth
1.5.6 Factor 4 – The evaluation of the tooth gap
1.5.7 Factor 5 – The complexity of implant placement
1.5.8 Factor 6 – Assessment of risk factors
1.5.9 Factor 7 – Multiple risk factors
1.5.10 Conclusions
1.5.11 References

1.6 Tooth preparation: current concepts for

material selection
1.6.1 Introduction
1.6.2 Minimally invasive preparation techniques
1.6.3 Defect-oriented preparation techniques for posterior teeth:
onlays, overlay-veneers, and partial crowns
1.6.4 Conventional crown and fixed dental prosthesis (FDP)
preparation technique: the universal tooth preparation
1.6.5 Virtual diagnostics and guided tooth preparation
1.6.6 Resin-bonded fixed dental prosthesis (RBFDP) preparation
1.6.7 Conclusions
1.6.8 References

1.7 Provisional restorations

1.7.1 Introduction
1.7.2 Direct provisionals
1.7.3 Eggshell provisionals
1.7.4 CAD/CAM provisionals
1.7.5 Conclusions
1.7.6 References

1.8 Impression techniques

1.8.1 Introduction
1.8.2 Biological width
1.8.3 Methods for temporary tissue retraction
1.8.4 Conventional impressions
1.8.5 Optical impressions
1.8.6 Conclusion
1.8.7 References

1.9 Material-related cementation procedu

res
1.9.1 Introduction
1.9.2 Adhesive cementation of silica-based ceramics (feldspathic
ceramics, glass-ceramics)
1.9.3 Adhesive cementation of oxide ceramics (zirconia)
1.9.4 Adhesive cementation of hybrid materials (resin-nano
ceramic, resin-infiltrated ceramic network)
1.9.5 Universal silanes/primers and universal resin cements
1.9.6 Conclusions
1.9.7 References

1.10 Fixation of implant-supported

restorations
1.10.1 Introduction
1.10.2 Cemented implant restorations
1.10.3 Screw-retained implant restorations
1.10.4 Screw-retained versus cemented
1.10.5 Conclusions
1.10.6 References

1.11 The titanium-base abutment concept

1.11.1 Introduction
1.11.2 Traditional implant restorations supported by
stock/customized abutments
1.11.3 Monolithic implant restorations supported by titanium-base
abutments
1.11.4 Factors for predictable outcomes: adhesive cementation of
monolithic ceramics to titanium-base abutments
1.11.5 Conclusions
1.11.6 References

1.12 Material selection flowcharts

Material selection for tooth-supported single-unit restorations
Material selection for tooth-supported multiple-unit
restorations
Material selection for implant-supported restorations

1.13 Cementation flowcharts

Cementation flowchart for metal-ceramic restorations
Cementation flowchart for zirconia restorations
Adhesive cementation flowchart for lithium disilicate
restorations
Adhesive cementation flowchart for feldspathic ceramic
veneers
Cementation flowchart for posts
Cementation flowchart for extraoral cementation (eg, in
laboratory)

Part II Clinical procedures step-by-step

2.1 Minimally invasive restorations
(veneers)
2.1.1 Anterior regions: Additional veneers after trauma (two
maxillary central incisors)
2.1.2 Anterior regions: Anterior veneer after trauma (single
maxillary central incisor)
2.1.3 Anterior regions: Traditional veneers for restoration of
amelogenesis imperfecta six maxillary anterior teeth)
2.1.4 Anterior & posterior regions: Traditional and palatal veneers
after deep bite and orthodontic pretreatment (six maxillary
anterior teeth)
2.1.5 Anterior & posterior regions: Traditional veneers after
undetected celiac disease (10 veneers – maxillary premolar
to premolar)
2.1.6 Anterior & posterior regions: Traditional veneers with the
application of augmented reality (10 veneers – maxillary
premolar to premolar)
2.1.7 Anterior & posterior regions: Traditional veneers with the
application of augmented reality and orthodontic
pretreatment (six maxillary anterior teeth)
2.1.8 Anterior & posterior regions: 360-degree and occlusal
veneers with a single implant restoration (seven mandibular
teeth and posterior implant)
2.1.9 Complex situations: Full-mouth rehabilitation with traditional
veneers and overlays
2.1.10 Complex situations: Additional veneers and implant
restorations (maxillary premolar to premolar)

2.2 Minimally invasive restorations (resin-

bonded fixed dental prostheses
[RBFDPs])
2.2.1 Anterior regions: Failing central incisor after many years of
periodontal treatment
2.2.2 Anterior regions: Congenitally missing lateral incisor (RBFDP
after orthodontic pretreatment)
2.2.3 Anterior regions: Congenitally missing lateral incisors
(RBFDP after orthodontic pretreatment)
2.2.4 Anterior regions: Full-mouth rehabilitation with congenitally
missing teeth (RBFDPs, veneers, and overlays after
orthodontic treatment)
2.2.5 Complex situations: RBFDP and additional veneer in
combination with orthodontic pretreatment

2.3 Defect-oriented restorations

2.3.1 Posterior regions: Defect-oriented partial crowns and overlay
in posterior regions
2.3.2 Posterior regions: Defect-oriented overlays in posterior
regions
2.3.3 Posterior regions: Defect-oriented restoration of
endodontically treated posterior tooth
2.3.4 Posterior regions: Defect-oriented restorations (direct
computer-aided composite build-up)

2.4 Conventional single crowns (SCs)

2.4.1 Anterior regions: Anterior SC with non-discolored abutment
tooth
2.4.2 Anterior regions: Anterior SCs with discolored abutment
teeth
2.4.3 Posterior regions: Posterior SC with non-discolored
abutment tooth
2.4.4 Posterior regions: Posterior SC with a discolored abutment
tooth
2.4.5 Complex situations: Conventional SCs and fixed dental
prostheses (FDPs)
2.4.6 Complex situations: SCs in combination with an implant
2.5 Tooth-supported all-ceramic single
crowns (SCs), fixed dental prostheses
(FDPs), and a removable telescopic
restoration
2.5.1 Anterior regions: Full-mouth rehabilitation
2.5.2 Posterior regions: Tooth-supported, all-ceramic three-unit
fixed dental prosthesis (FDP)
2.5.3 Posterior regions: The 3D-printed prototype

2.6 Implant-supported single crowns (SCs)

2.6.1 Anterior regions: Anterior implant- supported SC with GBR
2.6.2 Anterior regions: Anterior implant- supported SC with GBR
2.6.3 Anterior regions: Anterior implant- supported SC
2.6.4 Posterior regions: Posterior implant- supported SC with GBR
2.6.5 Posterior regions: Posterior implant- supported SC with GBR
2.6.6 Posterior regions: Posterior implant- supported SC and
optical impression
2.6.7 Complex situations: Tooth- and implant-supported all-ceramic
SCs and fixed dental prostheses (FDPs)

2.7 Implant-supported restorations

2.7.1 Anterior regions: Implant-supported four-unit fixed dental
prosthesis (FDP)
2.7.2 Posterior regions: Implant-supported three-unit fixed dental
prosthesis (FDP)
2.7.3 Posterior regions: Implant-supported fixed dental prosthesis
with mesial cantilever (FDP)
2.7.4 Posterior regions: Implant-supported fixed dental prostheses
(FDPs)
2.7.5 Complex situations: Full-arch implant-supported fixed
restoration with pink ceramics (FDP)

2.8 Maintenance
2.8.1 Intraoral direct repair of an existing restoration
2.8.2 Maintaining an existing restoration
2.8.3 CAD/CAM-fabricated Michigan splint

Part III Long-term outcomes of fixed

restorations
3.1 Introduction
3.2 Tooth-supported veneers
3.3 Tooth-supported inlays and onlays
3.4 Tooth-supported SCs
3.5 Endocrowns
3.6 Tooth-supported conventional multiple-unit FDPs
3.7 Tooth-supported cantilever FDPs
3.8 Resin-bonded fixed dental prostheses (RBFDPs)
3.9 Implant-supported SCs
3.10 Implant-supported FDPs
3.11 Implant-supported cantilever FDPs 693
3.12 Combined tooth-implant-supported FDPs
3.13 References

Part IV Avoiding and managing

complications
4.1 Introduction
4.2 Success of tooth- and implant-supported restorations
4.3 Tooth-supported restorations
4.4 Implant-supported restorations
4.5 References
PART I
BASICS
CHAPTER 1
Current restorative materials
Jens Fischer

1.1.1 Introduction
In this chapter:
■ Requirements for restorative materials
■ Overview of current materials for fixed restorations
■ Conclusions
In the past, material selection in fixed prosthodontics was mainly
based on metal-ceramics and on a few all-ceramic alternatives.
Metal-ceramic restorations were selected in clinical situations with
need for high stability (eg, in the posterior region or in the case of
multiple-unit fixed dental prostheses), whereas all-ceramic
restorations were recommended in single tooth replacement with high
esthetic demands, especially in the anterior region. These materials
were traditionally processed by manual fabrication technologies such
as casting, pressing, or layering1,2. Restorative dentistry with all-
ceramic restorations has suffered from a prolonged learning curve.
Several of the early systems disappeared shortly after being
introduced due to an unacceptable number of mechanical failures3.
Nowadays, clinicians and technicians can choose from a wide
range of reliable materials. Digital technologies such as intraoral
optical scans and computer-aided design/computer-aided
manufacturing (CAD/CAM) procedures have opened up new
treatment pathways in fixed prosthodontics. New digital fabrication
workflows were defined and in parallel advanced materials were
developed and adjusted to the specific requirements of numerically
controlled processing such as high-strength ceramics and
composites. In these digital workflows, the restorations are
fabricated by means of computer-aided milling from prefabricated
blanks, increasingly replacing conventional manual processing.
The different materials available today exhibit differences in
properties, influencing the esthetics and the long-term performance of
the restorations. As multiple alternatives exist for each clinical
situation, it is more difficult to select the most appropriate material for
the respective clinical situation today than in the past4–6. As a
consequence of the transformation in present technology, selection of
the restorative material requires understanding of the interaction
between material properties and clinical performance7.
After an introduction to the requirements for restorative materials
and the behavior of the different material classes used in dentistry,
this Chapter will provide an overview of the current material options
for fixed restorations and their clinically relevant properties,
indications, and limitations.

1.1.2 Requirements for restorative

materials
In the oral cavity, restorative materials have to meet three
requirements: biocompatibility, longevity, and esthetics.

Biocompatibility
The term biocompatibility implies that the material shall do no harm to
the living tissues, achieved through chemical and biological inertness8.
As every material potentially dilutes or degrades depending on the
environment, the extent of decomposition, and the quality and amount
of released substances determine the degree of biological
complications. A possible host response might be localized or
systemic toxicity, hypersensitivity, or genotoxicity9. The restriction to
biocompatible components strongly limits the room for the
development of new materials.
Due to the strict regulations for medical devices, manufacturers
have to prove biocompatibility of their materials. International
standards help the choosing of the appropriate tests and in
interpreting the results. Tests must be done with every novel material
prior to approval. Biological tests are employed in a sequence, ending
up with animal tests9. Furthermore, manufacturers of medical devices
are forced by law to perform a systematic post market surveillance of
the materials and devices. Measures have to be taken to minimize
risk and unexpected side effects must be notified to the authorities.
Fortunately, it can be concluded that biological and immunological
adverse reactions attributed to dental materials are rare and the
reported adverse effects are acceptable9.
On the other hand it is unrealistic to assume that absolute material
inertness is attainable and biological behavior is definitely predictable
by means of biological tests10. Hence, the biocompatibility of dental
materials must always be weighed against their benefit11. Controlled
clinical trials are currently still the best way to assess the clinical
response to materials. But even these tests have significant
limitations. Therefore, practice-based research networks and
practitioner databases are increasingly considered as a valuable
alternative10.

Longevity
The long-term success of a restoration mainly depends on its
mechanical performance. From the technical side the success of a
restoration can be controlled by the durability of the material, the
nature of the design, the quality of the processing, and the
effectiveness of the finishing.
Material
The mechanical behavior of dental materials is mainly characterized
by elasticity, flexural strength, fracture toughness, and hardness.
These properties are basically given by the type and strength of the
bondings between the atoms.
Elasticity is the ability of the material to resume its initial shape
after loading, measured in GPa (= 103 N/mm2). Stressing a material
beyond its limit of elasticity leads to plastic deformation, a permanent
distortion. Brittle materials such as ceramics only show minimal or no
plasticity, which means they fracture very soon after reaching the limit
of elasticity. The stress where fracture occurs is the flexural strength,
measured in MPa (= N/mm2). The resistance against crack growth is
called fracture toughness, measured in MPa√m.
Elasticity, flexural strength, and fracture toughness are bulk
properties. Hardness in contrast is a surface property, which is
defined as the resistance to localized deformation induced by
mechanical indentation or abrasion. Harder materials therefore show
less risk of surface damage. Flexural strength and hardness are
correlated to a certain extent.
The main risk for mechanical failure of restorations are flaws at
the surface, which might act as a starting point for microcracks. In
case of tensile loading, a microcrack opens and stress develops at
the tip of the crack. Stress which exceeds the strength of the material
leads to crack propagation. Under cyclic loading − such as
mastication − crack growth happens in a micrometer scale. But over
time the crack grows significantly. Finally, catastrophic failure occurs
when the residual cross-section is too small to withstand the load.
It is important to understand the fracture mechanisms of the
different materials. In metals the crack tip is rounded out by plastic
flow and thus the risk of fracture is significantly reduced (Fig 1-1-1).
In ceramics plastic flow is not possible due to the covalent bonds.
The crack tip remains sharp and crack growth is a significantly higher
risk than in metals. That is the reason for the well-known brittle
behavior of ceramics. To increase strength and in particular
toughness, strengthening mechanisms on the microscopic level to
impede crack propagation are employed. In brittle materials this
might be achieved by internal compression or by particles, which act
as obstacles against crack growth (Fig 1-1-2). The objective of such
strengthening mechanisms is to stop crack growth or at least to
hamper it, like a hurdler who is not as fast as a sprinter.

Figs 1-1-1 Schematic representation of crack propagation in

materials. (a) Plastic material (eg, metals). (b) Brittle material (eg,
ceramics).
Fig 1-1-2 Schematic representation of crack propagation in particle-
reinforced materials under tensile stress (red arrows). When the
crack tip strikes a particle, crack propagation is impeded, or at least
decelerated.

The term durability includes not only the mechanical

characteristics specified above but resistance to wear and aging as
well. The degradation of the materials by wear and aging depends on
the mechanical properties and also on the susceptibility to the oral
environment including humidity, temperature, and loading
characteristics. Water for instance may attack the material’s bonds
especially at phase boundaries or microcracks, thus promoting
degradation.

Design
Several mistakes can be made when designing a restoration.
Insufficient dimensioning in crown walls or connectors of fixed dental
prostheses is one reason for failures. Instructions of the
manufacturers have to be strictly followed. Further, sharp edges
increase the risk of failure due to an uncontrolled stress development
(Fig 1-1-3). And finally, restorations made by materials, which require
a thermal treatment should be designed with an even wall thickness
as far as possible to get a homogeneous stress distribution during
cooling. That applies especially for veneering ceramics, which must
be layered in a uniform thickness and adequately supported by the
framework both for metal-ceramic and all-ceramic bilayers.
Figs 1-1-3a to 1-1-3d Insufficient thickness of the crown and sharp
edges of the preparation caused fracture of the restoration. (a)
Restoration on tooth 47 after cementation. (b) Radiograph after
cementation. The insufficient occlusal thickness of the restoration and
the sharp edge of the distal preparation are obvious. (c) Fracture of
the restoration after 1 year in function. (d) Analysis of wall thickness
on the basis of the CAD design.
Processing
A shaping process always requires machining, a thermal treatment
such as sintering or pressing or a polymerization process. If not
processed properly, defects might be created in the material, thus
reducing the strength of the restoration (Fig 1-1-4). The
manufacturer’s instructions must be meticulously followed.
Figs 1-1-4a to 1-1-4c Fractured zirconia framework 42 x x 32. (a)
Framework after sintering, fracture occurred between 41 and 31. (b)
Light microscopy image of the fractured area. The area was cut in
the white state in order to separate the two pontics. Thus a crack
was initiated, which was not sealed during sintering. (c) Scanning
electron microscopy (SEM) of the fractured surface after sintering.
The formation of grains at the surface indicates that the fracture
occurred before sintering.

Finishing
Materials, if machined, sintered, pressed, or polymerized, must be
finished with material specific tools and appropriate speed, feed, and
pressure of the tools to avoid damage at the surface. For ceramics,
as an alternative a glaze firing (a heat treatment without additional
application of glaze) or glazing (a heat treatment with additional
application of glaze) can be performed (Fig 1-1-5). However, if the
restoration is not handled in a way appropriate to the material, it
might occur that subsurface damage is not sufficiently eliminated by
the finishing procedure and residual flaws potentially act as an origin
for microcracks.
Figs 1-1-5a to 1-1-5d Schematic representation of the effect of
polishing, glaze firing, or glazing on the surface quality. (a)
Microcracks at the surface after processing. (b) Surface after
polishing. (c) Surface after glaze firing. (d) Surface after glazing.

Esthetics
Materials for restoring teeth have to mimic the esthetic appearance of
the tooth itself. The tooth is a complex structure of a dentin core,
providing the color of the tooth, and a more translucent enamel layer.
The replacement of dental hard tissue by a dental material needs to
balance color, translucency, refraction and reflection, opalescence,
and fluorescence. Some materials show a blending quality, also
named the “chameleon effect.” These requirements strongly restrict
the choice of materials to ceramics and resins. As a compromise
metals may be used when covered by tooth-colored veneers.

Color
Coloring of resins and ceramics is obtained by using inorganic
pigments, mostly metal oxides (Fig 1-1-6).
Fig 1-1-6 Pigments used to produce the appropriate shades.

Translucency
When there is no light absorption and no optical obstacle in the
material, light passes through a material like a windowpane without
being scattered. This effect is called translucency (Fig 1-1-7).
Figs 1-1-7a and 1-1-7b Translucency of different ceramic shades.
(a) Dentin layer. (b) Enamel layer.

Refraction and reflection

When light passes through an interface and enters a different
material, eg, from air to glass, the direction of light propagation is
changed, which is called refraction. Depending on the incidence
angle, light might also be completely reflected as if hitting a mirror
(Fig 1-1-8). These effects lead to a scattering of the light. Interfaces
in a material (ie, particles incorporated for strengthening) add to the
optical properties by scattering the light as well (Fig 1-1-9).

Fig 1-1-8 Reflection of light at the ceramic surface. Depending on

the surface roughness and the incidence angle, reflection is more or
less pronounced.
Figs 1-1-9a to 1-1-9f Refraction of light in a glass-ceramic (Vita
Suprinity PC) before and after crystallization. (a and b) Schematic
representation of light refraction. In the glassy state (a) the material
is translucent. Light passes through the material without being
refracted. After crystallization (b) light is scattered at the interfaces
between glass matrix and crystals. The light is partially refracted and
the material thus appears whitish. The surface is slightly etched with
hydrofluoric acid to demonstrate the transition from the glassy state
to the typical microstructure of glass-ceramic characterized by a
glass matrix and incorporated crystals. (c and d) Microstructure
before (c) and after (d) crystallization. (e and f) Appearance before
(e) and after (f) crystallization.

Diffraction and opalescence

At obstacles smaller than the wavelength, the light will be refracted
and scattered in all directions. By diffraction white light is split into the
spectral colors. The short blue wavelength will be more deflected
than the long red one. If the light source is behind the observer,
mainly the blue light is seen; if the light source is behind the object
mainly yellow and red colors are seen (Fig 1-1-10). The effect is
visible in the sky: small water drops scatter the light. If the sun is in
front of us, we mainly see yellow and red light; if the sun is behind us,
we can see the azure blue sky.
Figs 1-1-10 Opalescence of a dental ceramic.

Fluorescence
The teeth glow when illuminated with ultraviolet light. Electrons are
stimulated by the ultraviolet light and give off the energy by emitting
visible light (Fig 1-1-11). Materials for esthetic restorations must
show a similar effect. The name originates from the mineral fluorite,
where this effect was first observed.
Fig 1-1-11 Fluorescence of a dental ceramic.

Blending quality
Blending quality (“chameleon effect”) is the perception that color
differences between esthetic dental materials and dental hard tissues
appear smaller when the materials are viewed side-by-side than
would be expected when viewed in isolation12.

1.1.3 Overview of current materials

for fixed restorations
Modern restorative systems may roughly be classified into
composites, silicate ceramics, and zirconia. The application of
metal-ceramics is still very common but decreasing.
Composites
A composition material – abbreviated to composite – is a material
composed of at least two constituent materials with differing physical
and/or chemical properties. In dentistry the term composite is − as a
general linguistic usage − restricted to materials composed of
polymers and ceramics. By coupling ceramic and resin the
advantageous properties of both materials are combined: the
elasticity of resin counteracts the brittleness of ceramic and the
tendency of resin to wear is counteracted by the wear-resistant
ceramic. Composites are provided in blanks either made out of a
polymer matrix reinforced with ceramic particles (particle-filled
polymer) or out of a ceramic network infiltrated with polymer
(polymer-infiltrated ceramic). They are both indicated for restoring
teeth or implants chairside in one session by CAD/CAM technology.
Of course, they may also be processed in a dental laboratory. Both
materials show an excellent milling accuracy and edge stability, as
well as a significantly reduced processing time compared to ceramic
materials.

Particle-filled polymer
The polymer of this material group is mainly composed of
dimethacrylates such as bisphenol A-glycidyl methacrylate (Bis-
GMA), urethane dimethacrylate (UDMA), and triethylene glycol
dimethacrylate (TEGDMA) (Fig 1-1-12). The resin matrix is filled with
ceramic particles (Fig 1-1-13). The basic structure is close to
composite filling material with a ceramic filler content of about 50%
by volume or 80% by mass13. Due to their low mechanical strength,
most materials are available in blanks for single-unit use only, yet in
different shades. The main indication for the particle-filled polymers
are posterior tooth-borne single-unit restorations like inlays, onlays,
overlays, and partial crowns. Some products are released for fixed
dental prostheses up to three units (eg, Ambarino High-Class,
creamed, Marburg, Germany) and even up to five units (eg,
LuxaCam, DMG, Hamburg, Germany) or for implant-supported full
arch fixed/removable prostheses (eg, Crystal Ultra/Trilor, digital
dental, Scottsdale, AZ). Some manufacturers also recommend the
fabrication of anterior tooth-borne restorations like veneers, however,
as the esthetic result does not reach the outcomes of silicate
ceramics, the particle-filled polymers cannot be recommended for
highly demanding esthetic situations. Esthetic improvement can be
achieved by “veneering” the particle-filled polymer restorations with
filling composites; however, their main application remains for the
fabrication of monolithic single-unit restorations.

Fig 1-1-12 Chemical structures of Bis-GMA, UDMA, and TEGDMA.

Fig 1-1-13 Microstructure of particle-filled polymer. The surface is
slightly etched with hydrofluoric acid to better illustrate the
microstructure composed of resin matrix and glass particles.

The fillers are mainly silica or quartz, as well as barium- or

strontium-containing silica glasses providing radiopacity, and
sometimes ytterbium fluoride, which shows a slight release of
fluoride. The particles are incorporated in order to reinforce the
material and to scatter the light, thus supporting a tooth-like
appearance of the restoration.
For Lava Ultimate (3M ESPE, Seefeld, Germany) the indication
“single crown” is excluded due to frequent problems with debonding.
In a clinical trial with this material on zirconia abutments an extreme
rate of debonding of 80% in the first year was observed14. It is
unclear whether the high debonding rate is transferable to other
composite materials. In any case the bonding procedure has to be
carefully observed and manufacturer recommendations should be
followed15. Particle-filled polymers need to be adhesively cemented
to the tooth substrate. To increase the surface area and thereby the
bond strength, the bonding area must be airborne-particle abraded
according to the manufacturer’s recommendations. Chemical bonding
is obtained by a primer containing methacrylates and silane, where
the methacrylates bond to the polymer matrix and the silane to the
ceramic fillers (Fig 1-1-14).

Fig 1-1-14 Chemical structure of silanes and their intermediate

bonding to polymer and ceramic surfaces.

Polymer-infiltrated ceramic
The main component of this type of composite is a sintered porous
ceramic network, which is infiltrated by polymer (Fig 1-1-15). There is
only one product available (Vita Enamic, Vita Zahnfabrik, Bad
Säckingen, Germany). The composition is 86% by mass of a fine-
grained ceramic and 14% by mass of a mixture from UDMA and
TEGDMA. The manufacturer recommends the material for all single
tooth restorations as well as implant-supported crowns. The
strengthening mechanism in this material is again the use of phase
boundaries between polymer and ceramic to stop or deviate cracks.
Furthermore, cracks are dissipated and thereby lose energy (Fig 1-1-
16).
Fig 1-1-15 Microstructure of a polymer-infiltrated ceramic.
Figs 1-1-16a and 1-1-16b Crack development originating from an
indentation. (a) In polymer-infiltrated ceramic the crack is dissipated
due to multiple phase boundaries. (b) In feldspar ceramic the crack
runs straight through the material.

Polymer-infiltrated ceramic restorations need to be adhesively

cemented to the underlying tooth substrate or abutment. The material
provides excellent bond strength similar to ceramics due to a micro-
retentive etch pattern when etched with hydrofluoric acid (Fig 1-1-17);
however, silane should be applied to the intaglio surface of the
restoration to improve bond strength16–18.

Fig 1-1-17 Etch pattern of polymer-infiltrated ceramic (60 sec with

5% hydrofluoric acid).

Silicate ceramics
The ceramic materials routinely used in restorative dentistry today
encompass feldspar ceramics and lithiumsilicate glass-ceramics.
Small crystalline particles are used to reinforce the material,
analogue to the particle reinforcement in composites. When the
particles are created by crystallization of a glass in a well-defined
temperature profile, the term glass-ceramic is used for these
materials. These particles support the optical properties of silicate
ceramics. The light may pass through the glassy phase and refraction
will occur at the phase boundaries between glass phase and
crystalline phase (cf. Fig 1-1-9). The more crystals are present the
more phase boundaries are effective and the material gets more and
more white and opaque, because the light is more and more
reflected.

Feldspar ceramics
Feldspars are a group of minerals composed of alkaline oxides,
alkaline earth oxides, alumina, and silicate. Feldspar-based ceramics
have the most tooth-resembling optical properties compared to other
dental materials and lead to high esthetic outcomes.
As the mechanical stability of these ceramics is rather low, their
indication is limited to single tooth restorations. For sufficient stability
during clinical function, feldspathic ceramic restorations have to be
adhesively cemented to enamel and, thereby, are reinforced.
Hydrofluoric acid etching provides a microretentive etch pattern,
which after silanization offers sufficient bond strength16. The main
application for the feldspathic CAD/CAM blanks is the chairside
fabrication of single-unit restorations like veneers, inlays, onlays, and
partial crowns.
The results of a systematic review showed that early feldspathic
single crowns exhibit significantly lower survival rates than other all-
ceramic crown types, especially when manually layered19. However,
in the beginning of the 1990s, a feldspathic CAD/CAM material
(VITABLOCS Mark II, Vita Zahnfabrik) was developed in line with the
CEREC system (Dentsply Sirona, York, PA, USA), which is still on the
market, successful, and unchanged over three decades.
Some of the current feldspathic materials are reinforced by
leucite, a feldspathoid (IPS Empress, Ivoclar Vivadent, Schaan
Liechtenstein; Paradigm C, 3M ESPE, Seefeld, Germany)20,21, others
(VITABLOCS Mark II, VITABLOCS Triluxe forte, VITABLOCS
RealLife, Vita Zahnfabrik) by sanidine and anorthoclase, minerals of
the feldspar group as well as nepheline, a feldspathoid22. These
particles develop during the production process. Feldspar ceramic is
also available for press technology.

Lithium-silicate glass-ceramics
It is well known from household items that glass-ceramic is a very
strong and durable material. The idea was to adapt the material for
dental application21. The glass-ceramic is based on a lithium-silicate
glass, which is rather weak and therefore machinable. Via thermal
treatment the glass partially crystallizes. The crystals act as particle
reinforcement and increase strength while mimicking the optical
properties of tooth substance (reflection, scattering of light)21.
Two types of glass-ceramics were developed over the years. In
the first material (IPS e.max, Ivoclar Vivadent, Schaan, Liechtenstein)
lithium-disilicate (Li2[Si2O5]) is the main crystalline phase. In a further
development, the main crystalline phase was changed to lithium-
metasilicate (Li2[SiO3]) and zirconia was added in an amount of 10
weight%, solved in the glass phase23 for the purpose of strengthening
it (Celtra Duo, Dentsply Sirona; Vita Suprinity PC, Vita Zahnfabrik).
The crystals are much smaller compared to lithium-disilicate (Fig 1-1-
18), resulting in better wear properties when opposing human
enamel24.
Figs 1-1-18a and 1-1-18b Microstructure of glass-ceramics. (a)
Lithium-disilicate (IPS e.max CAD). (b) Lithium-metasilicate (Suprinity
PC).

In general, glass-ceramics may be milled in the fully crystallized

state (eg, Celtra Duo) or in the glass state and crystallized
subsequently (eg, IPS e.max CAD, Vita Suprinity PC). As the
crystallization process does not influence the dimension of the work
piece, the fit of the restoration is not affected by the thermal process.
Lithium-silicate glass-ceramic is also offered for the fabrication of
restorations by press technology (eg, IPS e.max Press, Ivoclar
Vivadent; Celtra Press, Dentsply Sirona; Vita Ambria, Vita
Zahnfabrik). The respective composition is adjusted to the press
process and therefore slightly different from the machinable variant.
Today, the lithium-silicate glass-ceramics are mostly applied in the
monolithic state, without additional veneering ceramic or with only a
very small amount of veneering ceramic in facial areas. With this, the
risk for chipping of the veneering ceramic is reduced. Recent
investigations have demonstrated very favorable clinical outcomes of
the monolithic lithium-disilicate tooth- and implant-supported single-
unit restorations, and also of lithium-disilicate resin-bonded
prostheses19,25,26. However, multiple-unit lithium-silicate fixed dental
prostheses exhibited pronounced failure rates due to catastrophic
fracture. Therefore, the indication for fixed dental prostheses is
limited27.

Zirconia
Zirconia, the strongest tooth-colored ceramic, was adapted to the
requirements of dental application in line with the evolution of the
28
CAD/CAM technology . Zirconia is the oxide of zirconium (ZrO2). Zr
and O form a strong chemical bond, resulting in a high flexural
strength, exceeding the strength of any other tooth-colored ceramic.
Zirconia cannot be processed with conventional procedures like
layering or pressing. Zirconia was processed in the densely sintered
stage in the beginning, yet, the milling of this hard, tough ceramic was
very time-consuming and associated with excessive tool wear. The
development of the zirconia white-stage milling out of pre-sintered
blanks with subsequent sintering to full density using the direct
ceramic machining (DCM) procedure29 enabled its large-scale
application in dentistry. To compensate the sintering shrinkage,
restorations must be milled so as to be considerably oversized, in the
range of 20%.
Zirconia shows three different crystal modifications. At room
temperature zirconia has a monoclinic structure. Heating zirconia
leads to a phase transition from monoclinic to tetragonal structure at
1170°C. And finally, above 2370°C a cubic structure is stable (Fig 1-
1-19). Replacing 3 mol% of ZrO2 by Y 2O3 stabilizes the tetragonal
phase down to room temperature due to oxygen voids in the crystal
lattice and the larger atomic radius of Y compared to Zr. The
abbreviation of this material is 3Y-TZP (TZP stands for “tetragonal
zirconia polycrystals”). The tetragonal phase of this material is
metastable and only occurs when the grain size of zirconia is less
than 1 µm30. When energy is brought into the material the phase
transition to the monoclinic structure is triggered, even at room
temperature. This phenomenon is used to reinforce zirconia: the
phase transition from tetragonal to monoclinic (t 🡢 m) is associated
with a volume increase of about 4–5%. Microcracks under tensile
stress lead to stress concentration at the crack tip. In this area, the
mechanical energy is sufficient to provoke the t 🡢 m phase transition.
For the phase transition only a slight movement of the atoms in the
crystal lattice is necessary (Fig 1-1-19). The increase in volume
associated with the phase transition leads to an intrinsic compressive
stress at the crack tip, opposing the external tensile stress and thus
increasing the materials strength. This effect is not reversible. When
the monoclinic phase is established, the strengthening mechanism in
this area is consumed; like a match, once lit it cannot be lit again.
Figs 1-1-19a to 1-1-19c Crystal structures of zirconia. (a) Cubic. (b)
Tetragonal. (c) Monoclinic.

As zirconia is a polycrystalline ceramic without a noteworthy

glassy phase, multiple phase boundaries are present. Further, the
refractive indices of the tetragonal and the monoclinic phase differ as
a function of the direction of the light incidence. That is the reason
why 3Y-TZP has an opaque whitish appearance. 3Y-TZP, therefore,
is solely used either as abutment material for implants or framework
material for fixed restorations, which for esthetic reasons has to be
masked with veneering ceramic.
Most veneering ceramics are based on feldspathic ceramics. For
the veneering procedure, the feldspathic ceramic powders have to be
mixed with modeling liquid by the dental technician in order to become
ceramic slurries. Differently colored slurries are then manually applied
to the restoration framework according to the desired shade and the
respective optical properties, 20–40% oversized. Subsequently, the
veneering ceramics are sintered onto the framework in a furnace,
thereby shrinking to the desired dimension. The sintering procedure is
performed under vacuum to remove the air captured in the ceramic
slurry. Despite the vacuum the air cannot be fully eliminated. Smaller
voids of some micrometers in diameter do not equal any risk but may
contribute to the optical properties of the ceramic by reflection and
scattering of light.
However, numerous studies have reported problems with the
zirconia veneering ceramic, ranging from superficial chipping to
31 33
fractures of larger pieces like, eg, entire cusp tips31–33. Despite all
scientific efforts to further improve the strength of the veneering
ceramics, their bond to the zirconia substrate and the firing regime
during the veneering process, chipping remains to be the major
technical complication of veneered zirconia restorations33.
More recently, new variations of zirconia were developed
exhibiting tooth-like color and more translucency, allowing for the
monolithic application of zirconia for single- and multiple-unit
restorations28. These new types of zirconia have a higher amount of
yttria. An increasing yttria content leads to the stabilization of the
cubic phase. The cubic structure is isotropic, which means that
whatever the light’s angle of incidence, the refractive angle is always
the same. Therefore, the higher the amount of yttria, the higher the
translucency (Fig 1-1-20). These recently developed zirconia types
can be applied almost without veneering ceramic or just monolithic,
even in esthetically demanding situations. However, with an increasing
amount of cubic crystals the strengthening mechanism by phase
transition under stress is increasingly lessened and the flexural
strength is reduced (Fig 1-1-21).
Fig 1-1-20a to 1-1-20c Translucency of 3Y-, 4Y-, and 5Y-TZP.

Fig 1-1-21 Flexural strength and corresponding translucency of 3Y-,

4Y-, and 5Y-TZP.
Typically, the zirconia qualities are classified by their yttria content
of 3, 4, or 5 mol%, termed as 3Y-TZP, 4Y-TZP, or 5Y-TZP.
The same shade and translucency of the zirconia offered by
different manufacturers may exhibit different mechanical stability.
Hence, the indications and dimensions of the monolithic zirconia
restorations must be carefully considered, and manufacturer
recommendations should be followed when selecting a material for a
specific indication and designing the appropriate restoration.
Furthermore, the details on the applied zirconia type, its shade, and
manufacturer should be documented in the patient’s record.
Clinical studies on monolithic zirconia restorations are scarce, and
the observation periods rather short. More research with longer
observation periods is needed to elaborate the indications and
limitations and the effect on the stomatognathic system of this recent
type of all-ceramic restorations.
As a side note, it may be hypothesized that the clinical success of
zirconia has stimulated the rapid development of the digital
technologies and CAD/CAM procedures.

Metal-ceramics
Metal frameworks veneered with feldspathic ceramics are a long
existing, well-documented material combination for single- and
multiple-unit fixed dental prostheses on teeth and implants19,32,33. The
composition of the veneering ceramics is very near to the veneering
ceramics for zirconia, based on natural or synthetic feldspathic raw
materials. However, the coefficient of thermal expansion has to match
that of the underlying metal. It has been evaluated empirically that the
coefficient of thermal expansion of the veneering ceramic should be
one unit below that of the metal. In that case the metal is shrinking a
little more during cooling and puts the ceramic under pressure.
Thereby, detrimental tensile stress is avoided in the ceramic area.
Metals provide elasticity. Thus, the layered veneer is protected
against tensile stress from underneath during mastication. The
success story of metal-ceramic restorations is based on this
phenomenon. In the beginning of the 1960s it was the first time that
esthetic fixed restorations were achievable by veneering a metal
framework with a tailored ceramic. From then on metal-ceramics
were the gold standard for fixed restorations. However, the
importance of this technique significantly decreased with the progress
in all-ceramic restorations using zirconia instead of alloys as
framework material. Due to the increasing demand for esthetic,
biocompatible, and metal-free restorations by patients, all-ceramic
and composite materials are increasingly used and will replace metal-
ceramic restorations in the near future.
The metal substructures of metal-ceramic restorations are
fabricated from different alloys by casting, milling, or selective laser
melting. While casting is possible with all types of alloys, milling and
laser melting is only economical with base metal alloys. The
advantage of metals is their plastic behavior under stress. While in
high-strength composite and ceramics cracks might grow under
tensile load due to stress concentration at the crack tip, in metals a
crack tip is rounded under stress due to plastic deformation (cf. Fig
1-1-1). Thus the stress intensity is reduced. This is why metals have
a much higher fracture toughness compared to ceramics or high-
strength resins.
The starting point for the metal-ceramic technique was a high-gold
alloy, based on the binary system gold-platinum with a gold content of
approximately 70–80% by weight. Over the years, as gold and
platinum prices rose, different types of precious metal alloys were
developed for economic reasons. These were precious metal alloys
mainly based on a considerable amount of palladium, replacing gold
as well as alloys based on the binary systems palladium-copper or
palladium-silver with only low or even no gold and no platinum
content. Further, base metal alloys such as cobalt-chromium alloys
and chromium-nickel alloys were developed.
The traditional way to process precious and base metal alloys is
casting, applying the lost-wax technique. A wax model of the
framework is modeled manually, embedded in a refractory
embedding compound, and burnt out, resulting in a hollow shape
according to the desired framework. Molten alloy is cast into the
hollow. After solidifying of the alloy, the casting object is divested,
cleaned, and further processed.
Base metal alloys, such as cobalt-chromium alloys, have recently
become a valid alternative to the gold-reduced and palladium-based
varieties. They suffered from some technical disadvantages in the
past, as casting of these metals is difficult. Their indications in daily
clinical practice were very limited for this reason. Yet, CAD/CAM
technology enabled the processing of the base metal alloys by
allowing for computer-aided milling of industrially fabricated blanks,
as well as additive manufacturing by selective laser melting
technology.
With all types of metal-ceramics, the dark color of the metals has
to be esthetically improved with veneering ceramics, adapted to the
material properties of the respective metal alloy. Until today, the
veneering procedure for the metal-based types of restorations is
mostly performed by manual layering of veneering ceramic34,35. Some
veneering ceramics can also be applied by the pressing technique, a
veneering process that is not widely used, however.
It may be very challenging to achieve perfect esthetics with metal-
ceramics, since the underlying framework is dark and the space for
transforming its color into a natural tooth-resembling appearance with
veneering ceramic is limited. Dental technicians need to develop
pronounced skills and high experience levels for excellent esthetics
with metal-ceramics.

1.1.4 Conclusions
Material properties determine the indications for the respective
materials. Metal-ceramics will increasingly be replaced by
composites and all-ceramic solutions. Composites play a certain role
in single tooth restorations. The trend today is toward all-ceramic
restorations due to their high esthetics and biocompatibility. For
multiple-unit restorations, the material selection portfolio is rather
limited. Of all-ceramic options, only zirconia demonstrates sufficient
mechanical stability for this indication.
For the practitioner it is important to choose the right material.
Table 1-1-1 gives an overview of selected non-metallic material
options, their indications, and recommended cementation protocols to
facilitate the choice.

Table 1-1-1 Classification, indications, and cementation protocols for

selected metal-free restorative materials according to the
manufacturers’ instructions

1.1.5 References
1. Zhang Y, Kelly JR. Dental ceramics for restoration and metal
veneering. Dent Clin North Am 2017;4:797–819.
2. Guess PC, Vagkopoulou T, Zhang Y, Wolkewitz M, Strub JR.
Marginal and internal fit of heat pressed versus CAD/CAM
fabricated all-ceramic onlays after exposure to thermo-
mechanical fatigue. J Dent 2014;42:199–209.
Pollington S, van Noort R. An update of ceramics in dentistry.
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Int J Clin Dent 2011;2:3–27.
4. Rödiger M, Schneider L, Rinke S. Influence of material selection
on the marginal accuracy of CAD/CAM-fabricated metal- and
all-ceramic single crown copings. Biomed Res Int
2018:2143906; eCollection 2018.
5. Edelhoff D, Schweiger J, Prandtner O, Stimmelmayr M, Güth
JF. Metal-free implant-supported single-tooth restorations. Part
I: abutments and cemented crowns. Quintessence Int
2019;50:176–184.
6. Edelhoff D, Schweiger J, Prandtner O, Stimmelmayr M, Güth F.
Metal-free implant-supported single-tooth restorations. Part II:
hybrid abutment crowns and material selection. Quintessence
Int 2019;50:260–269.
7. Trost L, Stines S, Burt L. Making informed decisions about
incorporating a CAD/CAM system into dental practice. J Am
Dent Assoc 2006;137(supplement):32S–36S.
8. Williams D. On the mechanisms of biocompatibility. Biomaterials
2008;29:2941–2953.
9. Shahi S, Özcan M, Maleki Dizaj S, et al. A review on potential
toxicity of dental material and screening their biocompatibility.
Toxicol Mech Methods 2019;29:368–377.
10. Wataha JC. Predicting clinical biological responses to dental
materials. Dent Mater 2012;28:23–40.
11. Schmalz G, Galler KM. Biocompatibility of biomaterials –
lessons learned and considerations for the design of novel
materials. Dent Mater 2017;33:382–393.
12. Paravina RD, Kimura M, Powers JM. Blending effect of
composites related to restoration size. Dent Mater
2006;22:299–301.
13. Han JM, Zhang H, Choe HS, Lin H, Zheng G, Hong G. Abrasive
wear and surface roughness of contemporary dental composite
resin. Dent Mater J 2014;33:725–732.
14. Schepke U, Meijer HJ, Vermeulen KM, Raghoebar GM, Cune
MS. Clinical bonding of resin nano ceramic restorations to
zirconia abutments: a case series within a randomized clinical
trial. Clin Implant Dent Relat Res 2016;18:984–992.
15. Zimmermann M, Koller C, Reymus M, Mehl A, Hickel R. Clinical
evaluation of indirect particle-filled composite resin CAD/CAM
partial crowns after 24 months. J Prosthodont 2018;27:694–
699.
16. Hu M, Weiger R, Fischer J. Comparison of two test designs for
evaluating the shear bond strength of resin composite cements.
Dent Mater 2016;32:223–232.
17. Schwenter J, Schmidli F, Weiger R, Fischer J. Adhesive
bonding to polymer infiltrated ceramic. Dent Mater J
2016;35:796–802.
18. Rohr N, Flury A, Fischer J. Efficacy of a universal adhesive on
the bond strength of resin composite cements to polymer-
infiltrated ceramic. J Adhes Dent 2017;19:417–424.
19. Sailer I, Makarov NA, Thoma DS, Zwahlen M, Pjetursson BE.
All-ceramic or metal-ceramic tooth-supported fixed dental
prostheses (FDPs)? A systematic review of the survival and
complication rates. Part I: single crowns (SCs). Dent Mater
2015;31:603–623. Erratum in: Dent Mater 2016 Dec; 32:e389–
e390.
20. Della Bona A. Bonding to Ceramics: Scientific Evidences for
Clinical Dentistry. São Paulo, Brazil: Artes Medicas; 2009.
21. Höland W, Schweiger M, Frank M, Rheinberger V. A
comparison of the microstructure and properties of the IPS
Empress 2 and the IPS Empress glass-ceramics. Biomed
Mater Res 2000;53:297–303.
22. Yin L, Song XF, Qu SF, Han YG, Wang H. Surface integrity and
removal mechanism in simulated dental finishing of a feldspathic
porcelain. Biomed Mater Res B Appl Biomater 2006;79:365–
378.
23. Barchetta NF, Amaral M, Prochnow C, et al. Strength of
zirconia-reinforced lithium silicate ceramic: acid-etching time and
resin cement application effects. Int J Periodontics Restorative
Dent 2019;39:431–437.
24. D’Arcangelo C, Vanini L, Rondoni GD, De Angelis FJ. Wear
properties of dental ceramics and porcelains compared with
human enamel. Prosthet Dent 2016;115:350–355.
25. Sun Q, Chen L, Tian L, Xu B. Single-tooth replacement in the
anterior arch by means of a cantilevered IPS e.max Press
veneer-retained fixed partial denture: case series of 35
patients. Int J Prosthodont 2013;26:181–187.
26. Rabel K, Spies BC, Pieralli S, Vach K, Kohal RJ. The clinical
performance of all-ceramic implant-supported single crowns: a
systematic review and meta-analysis. Clin Oral Implants Res
2018;29 Suppl 18:196–223.
27. Pjetursson BE, Valente NA, Strasding M, Zwahlen M, Liu S,
Sailer I. A systematic review of the survival and complication
rates of zirconia-ceramic and metal-ceramic single crowns. Clin
Oral Implants Res 2018;29 Suppl 16:199–214.
28. Zhang Y, Lawn BR. Novel zirconia materials in dentistry. J Dent
Res 2018;97:140–147.
29. Filser F, Lüthy H, Schärer P, Gauckler L. All-ceramic
restorations by new direct ceramic machining process (DCM). J
Dent Res 1998;77:762 (spec. issue B, abstract no. 1046).
30. Maziero Volpato CA, D’Altoé Garbelotto LG, Fredel MC,
Bondioli F. Application of zirconia in dentistry: biological,
mechanical and optical considerations. In: Sikalidis C (ed).
Advances in Ceramics – Electric and Magnetic Ceramics,
Bioceramics, Ceramics and Environment. Rijeka, Croatia:
InTech, 2011;397–420.
31. Heintze SD, Rousson V. Survival of zirconia- and
metalsupported fixed dental prostheses: a systematic review.
Int J Prosthodont 2010;23:493–502.
32. Sailer I, Strasding M, Valente NA, Zwahlen M, Liu S, Pjetursson
BE. A systematic review of the survival and complication rates
of zirconia-ceramic and metal-ceramic multiple-unit fixed dental
prostheses. Clin Oral Implants Res 2018;29 Suppl 16:184–198.
33. Pjetursson BE, Sailer I, Makarov NA, Zwahlen M, Thoma DS.
All-ceramic or metal-ceramic tooth-supported fixed dental
prostheses (FDPs)? A systematic review of the survival and
complication rates. Part II: multiple-unit FDPs. Dent Mater
2015;31:624–639. Erratum in: Dent Mater 2017;33: e48–e51.
34. O’Keefe KL, Strickler ER, Kerrin HK. Color and shade
matching: the weak link in esthetic dentistry. Compendium
1990;11:116–120.
35. Sproull RC. Color matching in dentistry. Part III. Color control. J
Prosthet Dent 1974;31:146–154.
CHAPTER 2
Patient-related factors for
material selection

1.2.1 Introduction
In this chapter:
■ Patient demands
■ Esthetic requirements – prerequisites
■ Amount and quality of tooth substance
■ Amount and quality of soft tissues
■ Occlusal and functional requirements
The selection of the restorative material is a crucial step within the
rehabilitation of patients with fixed restorations, as the material is of
high importance for the esthetics and the long-term performance of
the fixed tooth- and implant-supported restorations. The restorative
team, ie, the dentist and dental technician, need to be aware of the
indications, advantages and limitations of all restorative materials in
order to select the most appropriate alternative for the specific
patient situation (Part I, Chapter 1).
Today, the selection of the material also includes the selection of
the fabrication technology and, consequently, the efficiency (time,
costs) and efficacy (predictability of outcomes) of the treatment.
In this chapter, the clinically relevant patient-based factors for the
material selection will be discussed.
1.2.2 Patient demands
The thorough evaluation and definition of the patient expectations at
the beginning of the treatment is possibly the most important Part of
a prosthetic rehabilitation.The patient demands for dental
improvement can focus on the following factors:
■ esthetics
■ occlusion and function
■ intraoral health.
A patient may have only one priority or may desire to improve several
or all of these factors with the proposed treatment. Esthetics is
probably the most complex patient demand for a prosthetic
rehabilitation when considering the material selection. Some esthetic
prosthetic materials exhibit low stability (see Part I, Chapter 1),
feldspathic ceramics being a good example. Besides good esthetics,
the restoration has to withstand the conditions of the oral environment
for long-term periods. With this in mind, the selection of material for
esthetic rehabilitation needs to include such parameters as the
position in the jaws (anterior, posterior), occlusal and functional
scheme, expected occlusal forces, and quality of substrate for
adhesive cementation (abutment tooth, implant abutment).
Dental esthetics has generally become a very important Part of
well-being today1,2. Patients research social media and the internet
on methods of self-improvement.3 It has been shown that the
improvement of dental esthetics contributes to self-improvement
independent of culture or gender1,2. Frequently, patients approach the
dental office with a clear treatment goal in mind after having
researched the internet. They won’t hesitate changing dentist to
receive the desired treatment, if their current dentist is not willing to
perform it due to medical/dental or other reasons. This can
complicate the professional relationship with the patients today. A
thesis, focusing on factors that influence the demands of patients for
restorative treatment, demonstrated the importance of the
relationship of confidence and competence between clinicians and
dental technicians and patients4.
Communication of the treatment goal and the individual treatment
steps is crucial for the establishment of confidence between the
restorative team and the patients. The discussion and the decision-
making process between patients and the restorative team is
simplified if the foreseen treatment goal has been visualized in the
diagnostic phase, either by a conventional, manually made wax-up
and set-up, or by virtual wax-ups and set-ups using CAD5.
Hence, prior to any prosthetic treatment the patient-oriented
treatment goal needs to be defined through comprehensive pre-
treatment diagnostics (see also Part I, Chapter 4). Diagnostics is the
key element to the execution of the treatment, the selection of the
restorative material, and shared decision-making.

1.2.3 Esthetic requirements

From an esthetic point of view, the material selection depends on the
color of the substrate, ie, the abutment tooth or the implant abutment,
and the optical properties of the remaining dentition (technical factor,
see Part I, Chapter 3).
In situations with no or only slight discoloration, all restorative
materials can be used. The selection of the respective material
depends more on factors like the available space and the region of
the jaw (see decision trees, Part I, Chapter 12).
In situations with discoloration, however, the selection of the
restorative material becomes more complex (Fig 1-2-1). Dental
ceramics are translucent materials, and depending on the type of
microstructure their translucency varies. Glass-ceramics are rather
translucent and have low masking ability. In order to improve their
masking ability, the thickness of the ceramic needs to be increased.
Oxide ceramics have more opaque properties and, therefore, better
masking quality (Fig 1-2-2).
Fig 1-2-1a to 1-2-1e Overview of different abutment teeth in the
esthetic area displaying the potential differences in color of the
substrate, that have to be considered at the restorative material
selection.

Fig 1-2-2 Translucency of different ceramic materials. From left to

right; the leucite-reinforced glass-ceramic, feldspathic ceramic,
zirconia, In-Ceram alumina, and In-Ceram zirconia samples have the
same thickness (0.5 mm), and show obvious differences in
translucency.
To mask the same discoloration different amounts of space may
be required depending on the ceramic. It has been shown that a
thickness of at least 1.2–1.5 mm of glass-ceramic is needed to cover
dark discolorations6. To mask discolorations with this type of ceramic
induces a need for more invasive preparations. The same applies
also to oxide ceramics like zirconia; however, this ceramic is also
influenced by the color of the substrate and the cement used for the
fixation of the restorations at thicknesses below 1 mm7,8. In situations
with intense dark discoloration, metal-ceramics may be the most
appropriate material combination for the masking.

1.2.4 Amount and quality of tooth

substance
The amount and the quality of the abutment tooth substance influence
the selection of the restoration type (eg, overlay or crown), and of the
respective restorative material. The conventional prosthetic treatment
concepts are in transition today, shifting from full fixed/removable
partial prostheses to less invasive, defect-oriented restoration types
like veneers, overlays, partial crowns, or resin-bonded prostheses,
where applicable.
One reason for this change of concepts is, that conventional tooth
preparation for full crowns has been shown to lead to the of loss of
abutment tooth vitality at rates between 2% to 4% after 5 years up to
10% at 10 years of restoration function9–12 (for further details see
Part III). Hence, on the one hand biologic limitations exist at the tooth
preparation and the amount of the tooth substance needs to be
considered. On the other hand, the minimal material thickness values
recommended for the respective restorative materials have to be
taken into consideration. Table 1-1-1 in Chapter 1 summarizes the
indications of the different types of restorative materials for
conventional fixed partial dentures. Another reason for the change of
concepts is, that significant improvements of the adhesive
cementation means and methods have been made, widening the
indications for esthetic materials that need adhesive cementation for
good long-term stability13.
The amount and the quality of the tooth substance have to be
evaluated during treatment planning as Part of the decision-making
process, influencing the type of restoration and the restorative
material (including its fixation).

Amount of tooth substance

The mean thickness of the enamel and dentin, eg, at sound central
incisors, varies between 1.8 mm for 10–19-year-old patients to 3.1
14
mm for 60-year-old patients (Fig 1-2-3).
Fig 1-2-3a to 1-2-3c Cross-sections of anterior and posterior teeth,
displaying the differences of the amounts of dentin and enamel
surrounding the pulpal chambers.

A histologic investigation has examined the minimal thickness of

dentin needed to avoid pulpal damage at different amounts of
abutment tooth preparations15. The researchers included vital teeth
with poor prognosis in this investigation foreseen for extraction, and
full-crown preparations were performed. Thereafter, the teeth were
extracted and the pulpal tissues histologically examined. A correlation
between the degradation of the pulpal tissues and the remaining
thickness of the dentin after tooth preparation was performed. The
study showed that a minimum remaining amount of dentin of 1 mm
was crucial in order to avoid pulpal damage at tooth preparation. As
a consequence, to avoid damage to the pulp a maximum of 0.7 mm
(young patients) and up to 2.1 mm (elders) of (sound) tooth
substance may be removed for restorative purposes. These values
apply for sound healthy teeth which under normal conditions would
not need to be restored. Still, the biologic limitations need to be
considered when performing tooth preparations for restorative
purposes.
It was assumed that for esthetic all-ceramic crowns less invasive
tooth preparations were needed than for conventional metal-ceramic
crowns, as the color of the ceramics already resembles the color of
the tooth substance. Consequently, less loss of vitality of abutment
teeth supporting all-ceramic crowns would be expected. This,
however, does not apply for all dental ceramics. A recent review of
the literature has shown that with weaker ceramics, like glass-
ceramic, the incidence of loss of abutment tooth vitality was even
higher than with metal-ceramics9,10. Indeed, a laboratory study
demonstrated that the amount of removed tooth substance for all-
ceramic and metal-ceramic anterior and posterior crowns is rather
similar. Both are the most invasive types of fixed restorations16.
An overview of the different types of preparations for the different
restorations is given in detail in Part I, Chapter 6.
Quality of tooth substance
The quality of the tooth substance influences the predictability of
adhesive fixation of the restoration material to the abutment tooth
substance. Materials for minimally invasive restorations like
composites and ceramics depend on the adhesive fixation to the
enamel and/or dentin in order to obtain sufficient stability for good
clinical performance17. Numerous studies have demonstrated that
adhesively cemented ceramic crowns exhibited better clinical survival
rates than conventionally cemented ceramic crowns13. Veneers,
onlays, and resin-bonded fixed/removable dental prostheses rely
entirely on the adhesive fixation, as they have no or only little
geometric retention to the abutment teeth. For good adhesion, the
amount and the quality of enamel and/or dentin are crucial18. In case
of lack of enamel/dentin for predictable adhesive cementation, the
conventional treatment protocols with conventionally cemented
restorations shall still be considered.

1.2.5 Amount and quality of soft

tissues
With tooth- and implant-supported restorations, the initial examination
should include the evaluation of the patient- and site-specific soft
tissues in addition to the previously discussed tooth-related factors.
The amount and the quality of the soft tissues play an important
role for the selection of the restorative material. The thickness and
the type of the soft tissues vary between patients. At approximately
80% of the population thin, delicate, and rather translucent soft
tissues can be found, whereas at 20% of the population thick and
resistant soft tissues are observed19. This difference plays an
important role at treatment planning as it influences the selection of
the restorative material. The soft tissue color may be positively or
negatively influenced by the restorative material, most specifically in
the marginal area of tooth- or implant-supported restorations20–22.
A recent study demonstrated that soft tissue color changes are
perceived by dental professionals (dentist, dental technician) and
laypeople to similar extent23. This study tested the threshold value for
the visibility of soft tissue color changes using photographs of ideal
anterior dentitions with non-discolored soft tissues as test objects.
The photographs were introduced into a specific software (Adobe
Photoshop), and by means of this software the gingiva and the teeth
were separated into two layers. Thereafter, the color parameters
(Lab values) of the gingival layer were gradually changed to a 1–6%
range of higher and lower Lab values, increasing or reducing the
brightness and shifting the soft tissue color within the color spectrum
(either to more red and yellow, or to more green and blue). The
modified gingival layers were merged back with the tooth layers,
resulting in 12 color-changed pictures of the respective clinical case
and one original picture. In another software (Keynote), the changed
and the unchanged pictures of each of the clinical cases were
combined in the presentations in a way that half of each image was
of original color and the other half was color-modified. These
presentations were then separately examined by 3 groups of 10
observers each – 2 professional groups (dentists, technicians) and 1
group of laypeople. The observers had to determine whether or not
they perceived a difference in soft tissue color between the
unmodified and the modified sides at the 13 images per patient, and if
yes, whether the color change was lighter or darker. With the aid of
the color difference ∆E, calculated between the modified and
unmodified soft tissues for each picture, and the evaluations of the
different groups of observers, the respective threshold values for the
perception of soft tissue color changes were assessed23. The study
showed that our human eyes are sensitive to soft color differences,
and soft tissue discolorations are equally perceived by professionals
and laypeople23. Consequently, soft tissue discoloration caused by
the restorative material can lead to the esthetic failure of the
restoration and the restorative material has to be selected carefully.
The soft tissue color can be a critical factor for the esthetic
outcome of a restoration both at non-vital discolored abutment teeth
and at implant-supported restorations. In some situations, the
restorative material is not capable of improving pre-existing
discolorations. It has been shown that at non-vital abutment teeth, the
soft tissue color was not related to the restoration material, ie, the
post-and-core material or the prosthesis24. The soft tissue color could
not be influenced, neither positively by white root post nor negatively
by dark root posts24. Hence, in clinical situations with discolored non-
vital abutment teeth, existing soft tissue discolorations have to be
accepted to some extent as an esthetic compromise of the new
restorations (Fig 1-2-4). An alternative solution is to augment the
thickness of the buccal soft tissues with connective tissue grafts.

Fig 1-2-4 Clinical case example showing the different outcomes of

two zirconia-ceramic crowns on the vital abutment of the maxillary
right central incisor, and the non-vital, discolored abutment of the left
central incisor (note the grayish shadowing at the gingiva).

With implant-supported restorations, the selection of the material

of the prosthetic components exhibits an influence on the soft tissue
color. Titanium implant abutments and metal-ceramic implant
restorations can lead to dark, grayish peri-implant soft tissue
discoloration, as has been shown in several clinical studies21,22 (Fig
1-2-5). The thickness of the soft tissues was identified as crucial
parameter for the presence or absence of the soft tissue
discoloration. A minimal soft tissue thickness of 2 mm was defined as
the threshold value for the color influence22.

Fig 1-2-5 Grayish discoloration of metal-ceramic implant crown of

the maxillary left first premolar, supported by a titanium abutment.

At a soft tissue thickness of >2 mm the material selection and,

hence, color of the implant restoration is less critical for the esthetic
outcome. Still, in patient cases with thin soft tissues and anterior
implant-supported restorations, the use of ceramic abutments and all-
ceramic restorations is recommended (Fig 1-2-6).
Fig 1-2-6a to 1-2-6e All-ceramic implant single crown supported by
a veneered customized zirconia abutment for the replacement of the
maxillary left lateral incisor.

1.2.6 Occlusal and functional

requirements
Prior to restoring compromised teeth or replacing missing teeth with
fixed or removable dental prostheses, a thorough occlusal analysis
has to be performed, as Part of the initial clinical examination.
Occlusion and function play a significant role for the long-term
behavior of all-ceramic restorations.
The basic principle of occlusion is to distribute the occlusal load as
much as possible on all teeth and/or restorations. Premature occlusal
contacts have been shown to increase the muscular activity during
mastication25–28. Hence, any contact or restoration that causes
elevate muscular activity can cause muscle tenderness and even lead
to TMD25,29. On restorations, premature contacts increase the risk
for technical complications. The occlusal load should preferably follow
the long axis of teeth and implants and horizontal load should be

30 33
avoided as much as possible30–33. The height of the cusps should be
enough to break up the food.
Occlusal concepts and their focus have changed over the years.
They can broadly be classified into three categories: bilateral
balanced occlusion, unilateral balanced occlusion (group function),
and mutually protected occlusion (canine guidance).
The concept of bilateral balanced occlusion is to have as many
teeth as possible in contact, both in maximal intercuspal position
(MIP) and in all excursive positions. This is very difficult to achieve in
the natural dentition and can cause additional tooth wear on the
balance side. Bilateral balanced occlusion has been propagated for
removable prostheses to maintain better denture stability. More
recent studies on edentulous patients with conventional dentures
have, however, not been able to show that bilateral balanced
occlusion significantly increases the chewing capacity compared with
patients wearing dentures with unilateral balance occlusion34–36.
In the concept of unilateral balanced occlusion, multiple teeth in
the maxilla and mandible, both anterior and posterior, on the working
side are in contacts during lateral movements. The idea is that
simultaneous contact of several teeth acts as a group to distribute
occlusal load and by that may reduce the risk of trauma from
occlusion and fracture or chipping of the restoration. No teeth on the
balanced side should be in contact and during protrusive movements
there should also be no posterior contacts. Long-centric or freedom
in centric has been propagated as a Part of unilateral balanced
occlusion, especially by patients in whom MIP and centric occlusion
(CO) are not identical37–39. This allows for a certain freedom of
movement (0.5–1.5 mm) in the anterior-posterior direction.
The concept of mutually protected occlusion assumes that MIP =
CO and that the six anterior teeth in the maxilla and mandible guide
the excursive movements of the mandible, and that the posterior teeth
only come into contact in CO.

Evaluation
The following factors have to be evaluated and registered.

Centric relation
Centric relation (CR) should be evaluated. CR is defined as the
maxillo-mandibular relationship, independent of tooth contact, in which
the condyles articulate in the anterior-superior position against the
posterior slopes of the articular eminences. In CR, the mandible is
restricted to a purely rotary movement, so this is a repeatable
reference position.

Centric occlusion
Centric occlusion (CO) should be registered with a wax plate in the
conventional workflow (Fig 1-2-7). CO is traditionally defined as the
occlusion of opposing teeth when the mandible is in CR position.
Fig 1-2-7a and 1-2-7b Centric occlusion (CO) is registered by
putting a double layer wax plate with additional aluminum wax dots on
the occlusal surface of the maxillary teeth; the patient is asked to
close their jaws in the centric relation (CR) position until touching the
wax dots.

Maximal intercuspal position

Maximal intercuspal position (MIP) should be registered with a wax or
a bite paste (Fig 1-2-8). MIP is defined as the complete
intercuspation of the opposing teeth independent of condylar position,
sometimes referred to as the best fit of the teeth regardless of the
condylar position (CR).

Fig 1-2-8 Maximal intercuspal position (MIP) can be registered with

a double layer wax plate.

Occlusal position
The occlusal position or the Angle classification should be registered
(Fig 1-2-9). This represents the relationship of the mandible and
maxilla when the jaw is closed and the teeth are in MIP.
Fig 1-2-9a to 1-2-9c Schematic drawing showing (a) Angle Class I,
(b) Angle Class II, and (c) Angle Class III occlusal relationship of the
first molars, canines, and anterior teeth.

Premature contacts and sliding

Premature contacts and sliding in MIP should be registered and a
decision should be made whether it is reasonable to reduce the
premature contacts to make MIP = CO prior to the insertion of a new
restoration. This is simply done to stabilize the occlusion, not to treat
or prevent temporomandibular disorders40,41. According to studies
evaluating the location of CO and MIP, the incidence of patients was
MIP = CO and ranged from 10% to 43%42–44. The position of the
premature contacts can be evaluated intraorally, or on articulated
study casts mounted according to a CO registration.

Occlusal contacts
The occlusal contacts on the working side during laterotrusion should
be analyzed and recorded. According to these contacts the patients
are classified using canine guidance (Fig 1-2-10), in which the vertical
and horizontal overlap of the canine teeth discludes the posterior
teeth in the excursive movements of the mandible. In patients with
group function (Fig 1-2-11), multiple contact relations between the
maxillary and mandibular teeth exist on the working side at lateral
movements, whereby simultaneous contact of several teeth as a
group distributes the occlusal forces.

Fig 1-2-10 Canine guidance on the working side in lateral

movements.
Fig 1-2-11 Group function on the working side in lateral movements.

The absence or presence of occlusal contacts on the non-working

balance side should be evaluated and registered.
The absence or presence of posterior occlusal contacts in the
protrusive movement of the mandible should be evaluated and
registered.

Vertical overlap
The vertical overlap is registered in millimeters. If a deep bite (Fig 1-
2-12) is present it must be analyzed, whether it is a primary deep bite
with a skeletal basis, or a secondary deep bite caused by a vertical
collapse due to a loss of posterior teeth or significant tooth wear.
Fig 1-2-12 Partially edentulous patient with a combination of primary
and secondary deep bite due to loss of molar support and significant
tooth wear.

Horizontal overlap
The horizontal overlap is registered in millimeters (Fig 1-2-13).
Fig 1-2-13a to 1-2-13d Horizontal overbite can be registered by
placing a finger on the buccal surface of the mandibular front teeth at
the level of the incisal edge of the maxillary front teeth. The distance
from the incisal edge of the mandibular teeth to the finger position,
representing the overbite, can then be measured in millimeters with a
periodontal probe.

Interocclusal rest space

The interocclusal rest space is evaluated. The normal distance
between the occluding surfaces of the maxillary and mandibular teeth
in resting position should be around 3 mm.

Crowding
Crowding of teeth and teeth that are in a reverse articulation (cross-
bite) or out of occlusion (scissor bite) should be noted (Fig 1-2-14).

Fig 1-2-14 Patient with deep bite and premolars that are out of
occlusion or in so-called scissor bite. A significant increase of the
vertical dimension of the occlusion (VOD) is needed to restore this
sextant.

Parafunctions
Any signs of bruxism or parafunctions should be evaluated and
registered (Fig 1-2-15). Furthermore, signs of trauma from occlusion
and the possible etiology should be evaluated. The manifestation of
trauma from occlusion can be diagnosed through functional
disturbances, through changes in the hard structure of teeth or
through periodontal changes. Embodiment of trauma from occlusion
on tooth structure can be excessive mechanical tooth wear, both
attrition and abfraction, or even tooth fractures. The periodontal
changes can be progressive tooth mobility due to widening of the
periodontal ligament, dull percussion sound, soreness of teeth, tipping
of teeth, root resorption, or hypercementosis.

Fig 1-2-15 Patient suffering from significant tooth wear due to

bruxism and parafunctions.

Tooth mobility
The etiology of increased tooth mobility has to be addressed. The
most frequent reason for increased tooth mobility is reduced bone
support due to periodontal disease. Other factors that can cause
increased mobility are: occlusal trauma with widening of the
periodontal ligament; overload due to poorly designed restorations
(Fig 1-2-16); trauma, periodontal abscesses; orthodontic treatment;
tumors; or combination of different factors.
Fig 1-2-16a to 1-2-16c Overload due to extensive cantilever units,
causing widening of the periodontal ligament of tooth 45 and
increased mobility of the restoration. The problem disappeared after
redesigning the restoration with a smaller cantilever unit that only had
occlusal contact in MIP and without contact in lateral movements.

Temporomandibular disorders
The diagnosis of temporomandibular disorder (TMD) is based largely
on history and physical examination findings. The symptoms of TMD
are often associated with jaw movement (eg, opening and closing the
mouth, chewing) and pain in the pre-auricular, masseter, or
temporalis regions. Another source of orofacial pain should be
suspected if the pain is not affected by jaw movement. Adventitious
sounds of the jaw such as clicking or crepitus may occur with TMD,
but do also occur in asymptomatic patients. The most common
presenting signs and symptoms of TMD were facial pain, ear
discomfort, headache, and jaw discomfort or dysfunction. Chronic
TMD is defined by pain of more than 3 months’ duration.
Clinical examination that may support the diagnosis of TMD should
be performed and registered. Such examinations are: abnormal or
deviation in the mandibular movement; decreased range of motion
measured in millimeters or by applying the three-finger rule;
tenderness of masticatory, neck or shoulder muscles; pain with
dynamic loading. A clicking, crepitus, or locking of the
temporomandibular joint (TMJ) may accompany joint dysfunction. A
single click during opening of the mouth may be associated with an
anterior disc displacement. A second click during closure of the mouth
results in recapture of the displaced disc; this condition is referred to
as disc displacement with reduction. When disc displacement
progresses and the patient is unable to fully open the mouth (ie, the
disc is blocking translation of the condyle), this condition is referred to
as closed lock. Crepitus is related to articular surface disruption,
which often occurs in patients with osteoarthritis.

Design
Designing the occlusal scheme is a crucial Part of the treatment plan.
The decision whether or not to apply a unilateral balanced occlusion
(group function) or a mutually protected occlusion (canine guidance)
depends on the initial occlusal situation of the natural dentition, the
presence or absence of TMD, the position and extension of the
planned restoration, the planned restoration material, and if the
restoration is tooth- or implant-supported. There are some principal
differences between tooth- and implant-supported restorations. The
proprioception of an implant is 8.8 times lower than that of a
tooth45,46. Hence, almost nine times more load must be applied to an
implant until the patient feels the load. Teeth under occlusal load
move approximately 50 µm downwards within the alveola supported
by the periodontal ligament. If the same load is applied to an
osseointegrated implant it does not move due to the ankylosis. Due to
this, some clinicians have fabricated implant-supported restorations in
slight infraocclusion. This might make sense if a partially dentate
patient is restored with occluding implant-supported restorations in
both jaws. However, if an implant-supported restoration that
articulates with natural teeth is made in infraocclusion, the antagonist
teeth will tend to extrude into contact and the implant-supported
restoration will end up in contact.
In designing the occlusal scheme, the following steps have to be
taken:
■ During the occlusal analysis, it has to be registered whether the
natural dentition is in unilateral balanced occlusion (group function)
or in mutually protected occlusion (canine guidance). The basic
principle is that a patient who has been functioning well without
any signs of TMD in unilateral, balanced, or mutually protected
occlusion should be restored utilizing the same occlusal scheme
as present in the natural dentition.
■ During the occlusal analysis, it must be evaluated whether MIP
and CO are in the same position or whether there is a slide
between the two positions (MIP ≠ CO). If MIP and CO are not in
the same position, the premature contacts have to be located and
a decision has to be made whether occlusal adjustment should be
initiated to reduce or eliminate the premature contacts creating
MIP = CO, or whether the restoration should be made long-
centric, allowing for a certain freedom in the occlusion.
■ To evaluate the dental arch and decide whether additional
treatment steps such as orthodontic treatment are needed for
better position of abutment teeth, to correct malpositioned teeth
or crowding (Fig 1-2-17).
Fig 1-2-17a to 1-2-17c Patient with a mediastema and an old
ceramic crown in position 11. The teeth were orthodontically aligned
for even distribution of the diastemas before redoing the crown on
tooth 21 and placing two ceramic veneers on teeth 12 and 22.

■ If unilateral balanced occlusion (group function) is planned for

multiple-unit restorations, care should the taken to have at least
two occlusal contacts simultaneously on the restoration on the
working side in lateral movements.
■ If mutually protected occlusion (canine guidance) is planned, steep
latero-protrusion facets on the canines causing resistance on the
working side in lateral movements should be avoided (Fig 1-2-18).
Fig 1-2-18 If canine guidance is planned, steep latero-protrusion
facets on restored canines should be avoided.

■ Avoid making balancing mediotrusion contacts in the new

restoration.
■ Avoid having posterior contacts in the new restoration during
protrusion.
■ To avoid losing the occlusal relationship when full-arch restorations
are made, it usually makes sense to restore the occlusion in
segments. That is, first restore the posterior area to gain a stable
occlusion and then as a second step the anterior area. If the
primary goal of treatment is to change the length, shape, and
position of the anterior teeth, comprehensive pretreatment
diagnostics are crucial to determine the prospective
incisal/occlusal plane prior to the restoration of the posterior
segments. In conclusion, the basic principle is not to restore
everything simultaneously, but to first stabilize the posterior
support before restoring the anterior segments.

Vertical dimension of occlusion

Recent minimally invasive treatment concepts include an increase of
the vertical dimension of occlusion (VDO) in order to gain
interocclusal space for the restorations.
There are several indications for raising the VDO:
■ Restoring missing tooth substance by patients with significant
attrition or erosion.
■ For esthetic reasons, that is to increase the anterior intraocclusal
space to be able to increase the length of anterior teeth.
■ To eliminate traumatic deep bite.
■ To increase the vertical dimension of the lower face.
■ In selected cases with TMD after thorough diagnosis with occlusal
stents and provisional restorations.

Different approaches have been proposed for raising the VDO. As it

is usually not recommended to do both maxilla and mandible
simultaneously for patients that need extensive restorations in both
jaws, the first decision to make is with which jaw to begin. If the VDO
has to be increased in both jaws, it is highly recommended to begin
with the maxilla in order to harmonize the esthetically relevant
occlusal and incisal maxillary planes with the smile line and the bi-
pupillary line. The mandibular occlusal plane is then adapted
accordingly.
In selected situations only minor augmentation of the VDO may be
needed. In these cases, the decision has to be made in which jaw the
VDO shall be augmented. The crucial parameter for this choice again
is the relationship of the maxillary occlusal/incisal plane and the smile
and bi-pupillary lines, and the dental situation.
Finally, if the plan is to restore both jaws extensively it is
recommended to finish one jaw, having the final restorations
articulating against provisional restorations in the antagonist jaw. To
find out whether the patient can adapt to the new vertical dimension,
it is advised to use provisional restorations for at least 4 weeks. If the
patient is not experiencing any muscle tenderness or other TMD after
that time, then the final restorations can be inserted.
1.2.7 Conclusions
Consideration of the discussed patient-related factors is crucial for
the clinical success and longevity of the restorations, and influences
the material selection. Less invasive restorations made out of
ceramics or hybrid materials are increasingly replacing conventional
restorations. Due to their better esthetics, yet lower material stability,
the presented factors have to be evaluated for good clinical
outcomes.

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CHAPTER 3
Technical factors

1.3.1 Introduction
In this chapter:
■ Conventional vs computer-aided manufacturing techniques
■ Optical factors influencing the material selection
■ Monolithic and veneered restorations
Digital technologies offer significant new opportunities in many dental
and medical fields. Restorative dentistry has been one of the
disciplines that has profited the most from these technological
advancements in the last decade1. Among these innovations,
computer-assisted design and computer-assisted manufacturing
(CAD/CAM) technologies have greatly influenced the production of
provisional and definitive restorative components1–3. As the
technology establishes and further develops (intraoral optical
scanners, cast optical scanners, virtual design software, 3D printers),
new indications arise in other treatment phases of the restorative
workflow. APart from the previously discussed clinical decision-
making criteria, the following technical considerations play an
important role for the material selection: the fabrication technology;
the optical properties of the tooth/implant substrate; and the selection
between purely monolithic or veneered types of restorations.
1.3.2 Conventional vs computer-aided
manufacturing techniques
Computer technology is increasingly changing the way dentistry is
being performed. CAD/CAM processes are transforming what were
previously manual tasks into easier, faster, cheaper, and more
predictable mechanized methods3. Current industrial product
development would be impossible without CAD technologies. No
engineer would consider designing a prototype layering or carving a
structure manually; instead a virtual environment is used, where
different versions can be tried-in without increasing significantly the
time invested and with no impact in the costs. Carving shapes
manually has evolved into designing volumes virtually by means of
dedicated software. In restorative dentistry, the wax and modeling
are evolving into software and mouse-clicks. The restorative team
can profit from virtual libraries from where different tooth
morphologies can be selected (Exocad, Darmstadt, Germany;
3Shape; Copenhagen, Denmark; Dental Wings, Montreal, Canada;
Sirona Dental, Wals, Austria). These software tools offer numerous
different tooth shapes categorized according to parameters such as
size, age, or patient’s phenotype. Moreover, real teeth can be used
as a reference to generate tooth morphology proposals4. These
standard shapes can later be modified and adapted to individual
patient situations. Working time is substantially reduced by eliminating
the mechanical handwork needed for conventional waxing techniques.
This allows the technician to focus solely on shapes and tooth
arrangements.
To date, subtractive CAM processes dominate the dental
manufacturing routines. Restorations are obtained by trimming a solid
block of material into the desired three-dimensional object, by means
of a computer-controlled milling machine2. However, these
procedures present several shortcomings such as waste of
considerable amounts of material, impossibility to create geometries
that lie below the milling bur diameter, or the impossibility to allow for
mass production of components1,3. These restrictions can be
overcome by the introduction of additive processing routes of layered
fabrication5. An example of these technologies is three-dimensional
(3D) printers, which allow the manufacturing of several objects at the
same time in a precise and cost-efficient manner. The 3D printers
work by jetting photopolymerizable materials in ultrathin layers. Each
layer is cured by ultraviolet light immediately after it is deposited,
producing fully cured objects6. The dual jetting printing procedure
requires two materials: a hard fundament material and a gel-like
support material. The support material is necessary to sustain
complex geometries of the fundamental material during fabrication
and it is easily removed by water jetting after printing. Micron-
accurate shapes can be printed in different combinations of
photopolymers, producing materials with specific mechanical and
visual properties. Products with different levels of strength, rigidity,
color, transparency, heat resistance, or texture can be obtained. This
production modality has widened the indication spectrum of
restorative computer-assisted dentistry. It may be assumed that
dental restorations can be printed one day, mimicking all optical (and
possibly mechanical) properties of natural teeth.

1.3.3 Optical factors influencing the

material selection
The evaluation of the clinical site for the selection of the restorative
material for a tooth- or implant-borne restoration encompasses the
analysis of the translucency and the lightness/brightness of the
neighboring reference teeth, together with the available restorative
space and the degree of discoloration of the abutment tooth/teeth.

Translucency of the neighboring reference

teeth
The first step in the systematic evaluation of the reference teeth for
material selection is the assessment of light transmission in the
reference teeth. The amount of translucency or opacity in the
reference teeth has to be defined. The first assessment is therefore
based on optical criteria of both the teeth and the ceramics (Fig 1-3-
1; see also Chapter 2, Part I).

Fig 1-3-1a Highly translucent tooth 21 serves as reference to restore

missing tooth 11.

Fig 1-3-1b Tooth 11 was restored with a glass-ceramic implant and

crown.
Fig 1-3-1c Highly opaque tooth 11 serves as reference to restore
missing tooth 21.

Fig 1-3-1d Tooth 21 was restored with a veneered zirconia crown.

If the teeth exhibit high translucency (high amount of light

transmission; see Figs 1-3-1a and b), glass-ceramics shall be the
preferred restorative material. It ensures a maximum of light flow and
glass-ceramic crowns per se exhibit a translucent effect7–10. In the
case of other core materials, this effect may be amplified by the use
of translucent veneering ceramics.
In contrast, in case of a deeply opaque reference tooth (with low
amount of light transmission), often a monochrome color effect is
associated. Thus, zirconia may be recommended as core material
due to its material properties, the uniform tooth-colored appearance,
and adapted translucency9. By the use of highly translucent veneering
ceramics in combination with opaque zirconia cores a predictable
esthetic outcome may be achieved (Figs 1-3-1c and d). More
recently, new zirconia types are available with increased
translucencies and different shades. These more esthetic types of
zirconia can be used without veneering ceramic (ie, monolithic), or
with a buccal microveneering.

Brightness/value of the neighboring teeth

The second step in the evaluation of the material selection is the
assessment of the brightness value of the reference teeth. Thus, the
second assessment also focuses on visual criteria. Basically, the
brightness value can be subdivided into the color “White,” the color
with the highest brightness value, and into the color “Black,” the color
with the lowest brightness value. By transferring this information to
the clinical setting, the color “White” represents a very bright and
opaque tooth. In contrast, the color “Black” is associated with a
rather grayish, and translucent tooth (see Fig 1-3-2a).
Fig 1-3-2a Tooth 11 with a high value represents pronounced
brightness and serves as reference to restore missing tooth 21.

Fig 1-3-2b Tooth 11 was restored with a veneered zirconia implant

crown.
Fig 1-3-2c Tooth 11 with a medium value of brightness and a highly
chromatic value serves as reference to restore missing tooth 21.

Fig 1-3-2d Tooth 21 was restored with a glass-ceramic implant

crown.
Fig 1-3-2e Tooth 21 with a low value of brightness and a high amount
of gray color serves as reference to restore missing tooth 11.

Fig 1-3-2f Tooth 11 was restored with a porcelain-fused-to-metal

implant crown.

In case the framework material is selected based on the

brightness value of the reference teeth, the most predictable result
may be achieved, if “White” teeth are restored with zirconia crowns
(Figs 1-3-2a and b) and “Black” teeth with increasing intensity of the
gray and translucent appearance are restored with glass-ceramic
(Figs 1-3-2c and d) or metal-ceramic crowns (Fig 1-3-2e and f).
Amount of space in the facial area
The third step in the evaluation is based on technical aspects and
includes the assessment of the available buccal space. The available
space is divided into “minimal” or “sufficient.” Considering the clinical
and technical requirements of restoration materials such as the
opacity level or the minimum wall thickness, the material of choice in
minimal or less invasive areas (with an available space of ≤1 mm) is
exclusively glass-ceramic. These ceramics (feldspathic or glass-
ceramic) are the only materials that allow unimpeded light
transmission to the supporting tooth surface (Figs 1-3-3a to f). If the
available space is greater than 1.2 mm, zirconia may be a valuable
alternative to glass-ceramics (Figs 1-3-3g to l). In clinical situations
with an available space of ≥1.5 mm, the selection of the most
appropriate framework material is less crucial (Figs 1-3-3m to o).

Fig 1-3-3a Initial situation of a fractured incisor 11 after the removal

of the composite restoration and prior to minimally invasive
preparation.
Fig 1-3-3b Minimal buccal reduction.

Fig 1-3-3c Feldspathic restoration (veneer) 11 after adhesive

cementation.
Fig 1-3-3d Minimally invasive preparation of 43–31 and 33 affected
by odontogenesis imperfecta.

Fig 1-3-3e Circumferential preparation with a reduction of tooth

substance less than 0.8 mm
Fig 1-3-3f 360° Veneers based on glass-ceramic in regions 43–31 &
33.

Fig 1-3-3g Universal, classic crown preparation tooth 11.

Fig 1-3-3h Circumferential preparation with a reduction of tooth
substance of ca.1 mm.

Fig 1-3-3i Veneered zirconia crown 11. (DT: Walter Gebhard, Zürich)
Fig 1-3-3j Classic crown preparation after removal of an old
insufficient crown 21.

Fig 1-3-3k Circumferential preparation with a reduction of tooth

substance of 1.2 mm on discolored abutment tooth.
Fig 1-3-3l Microveneered zirconia crown 21.

Fig 1-3-3m Rather invasive crown preparation of non-vital abutment

tooth 11.
Fig 1-3-3n Circumferential preparation with buccal reduction of tooth
substance of 1.5 mm.

Fig 1-3-3o Porcelain-fused-to-metal crown 11. (DT: Belinda Sapina,

ZZM Zürich)

Degree of discoloration of the abutment tooth

The fourth and final step in the evaluation for material selection is also
based on technical aspects and involves the assessment of the
abutment tooth color and its effect on the restorative material. The
abutment tooth may be subdivided into three categories: (1) normal
color with a homogenous appearance; (2) slightly to moderately
discolored; and (3) severely discolored with metal build-ups.
The choice of material is specifically critical in the latter group. On
one hand, the dark color has to be masked. On the other hand, the
dark color of the abutment tooth and its roots may negatively affect
the appearance of the surrounding gingiva. Since all-ceramic
materials including zirconia allow the transmission of light at the
material-specific wall thickness, it is recommended to use glass-
ceramic as framework material only for an uncolored or slightly
discolored abutment tooth (Fig 1-3-4)10.

Fig 1-3-4a Normal-colored homogenous abutment tooth: no need to

mask. Glass-ceramic allows the ideal transmission of light.
Fig 1-3-4b Slightly discolored abutment tooth. Minimal need to mask.
Similarly, glass-ceramic allows the ideal transmission of light.

Fig 1-3-4c Moderately to severely discolored abutment tooth with

slight grayish discoloration of gingival margin: minimal need to mask.
To be restored with slightly increased value of opacity in the glass-
ceramic or a translucent zirconia core.

When restoring moderately to severely discolored abutment teeth,

the material selection also depends on the available space. If, for
example, zirconia was selected as the material of choice based on
the brightness value and the translucency of the reference teeth (Fig
1-3-5a), a higher minimum thickness for the core material has to be
respected for moderately to severely discolored abutment teeth. In
clinical situations with severely discolored abutment teeth an esthetic
outcome may only be achieved by the use of high-noble alloy as
framework material. Metal-ceramic restorations with a core thickness
of 0.3 mm may offer sufficient firing stability and completely mask the
underlying staining (Figs 1-3-5b and c).

Fig 1-3-5a Severely discolored abutment tooth with gold build-up and
apparent discoloration of marginal gingiva: need to mask. To be
restored with a zirconia core with minimal thickness of 0.4 mm.
Fig 1-3-5b Severely discolored abutment tooth with gold build-up and
obvious discoloration of marginal gingiva: need to mask. To be
restored with a zirconia core with minimal thickness of 0.6 mm or a
classic porcelain-fused-to-metal crown.

Fig 1-3-5c Extremely discolored abutment tooth with dark gold build-
up and strong discoloration of marginal gingiva: maximal need to
mask. To be restored with a classic porcelain-fused-to-metal crown
to achieve predictable esthetic outcome.
1.3.4 Monolithic and veneered
restorations
Lithium-disilicate and zirconia ceramics are available in different
shades and levels of translucency today, allowing for a monolithic
application of both ceramics in most clinical situations (for more
details, see Part I, Chapter 1). Lithium-disilicate is solely indicated for
the restoration of single teeth (overlay, crowns) or single implants,
while zirconia can be used for the fabrication of tooth- and implant-
supported single- and multiple-unit fixed dental prostheses. These
indications result out of the differences in mechanical stability of the
different ceramics (see Part I, Chapter 1).
Until recently, zirconia was only available as yttria-stabilized
tetragonal zirconia polycrystals – a non-esthetic, rather opaque
whitish framework material which had to be veneered. As presented
in Parts III and IV of this book, very high rates of chipping of the
veneering ceramic were reported in the scientific literature leading to
rising doubts with respect to this restorative material. Due to
modifications of the crystalline structure of zirconia (tetragonal –>
cubic zirconia) increased translucency of the ceramic was achieved.
Furthermore, color modifications improved its esthetic appearance.
Therefore, a monolithic or microveneered application of zirconia is
possible today. However, as the mechanical stability of the
translucent and shaded zirconia types differ significantly between the
grades of translucency/shade and, even more, between the
manufacturers. This leads to indications and limitations for the clinical
application11. To avoid complications like catastrophic fracture,
clinicians and technicians need to be aware of the recommendations
by the respective manufacturers.
Five factors need to be considered for the selection between
monolithic and veneered restorations:
■ Esthetic factors
■ Position in the dental arch
■ Material-specific limitations
■ Options for surface modification
■ Abrasion/wear properties.

Esthetic factors
The individual characteristics of the remaining dentition used as a
reference play an important role for the selection between monolithic
and veneered restorations. The more complex the optical properties
of the reference teeth, eg, the more internal and superficial structure
and staining they have, the more difficult (or even impossible) will be
their mimicking with monolithic materials. Multilayer ingots may
improve the esthetic appearance to a certain extent12. With very
translucent reference teeth, a buccal cut-back of the monolithic
restorative material and microveneering needs to be planned13.
With discolored teeth, it has to be considered that all ceramic
materials including zirconia may be unable to mask strong
discolorations14, if not certain thicknesses of the ceramic can be
provided. Monolithic ceramics are, hence, mostly indicated for non-
discolored or slightly discolored situations15.
With very discolored abutment teeth, either a more invasive
preparation needs to be provided, or a masking of the discoloration
with opaque composite materials needs to be performed. This,
however, implies a more invasive reduction of the tooth substance to
gain space. Alternatively, metal-ceramic restorations may be
preferred.

Position in the dental arch

The second factor to be evaluated is the position of the restoration in
the dental arch. In posterior regions, highly esthetic results can be
achieved with monolithic materials, even more with aid of multilayer
ingots. In the posterior area, the application of veneering ceramic can
be avoided and the risk for chipping of the ceramic during occlusion
and function may be reduced (Fig 1-3-6).
Fig 1-3-6a Occlusal view of the initial situation of a non-preservable
second premolar due to a fracture.
Fig 1-3-6b Occlusal view after extraction of the fractured premolar.
Fig 1-3-6c Occlusal view before final impression.
Fig 1-3-6d Buccal view of the initial situation of a non-preservable
second premolar due to a fracture.

Fig 1-3-6e Buccal view before implantation of the BLT 4.1 mm

implant (Straumann, Basel, Switzerland).
Fig 1-3-6f Final buccal view of the direct screw-retained, monolithic
lithium-disilicate restoration based on a titaniumbase abutment (Vario-
Base, Straumann) after 3 years of clinical function.

Fig 1-3-6g Radiographic control after 3 years of clinical function.

Fig 1-3-6h and 1-3-6i Final buccal and occlusal view of the directly
screw-retained, monolithic lithium-disilicate restoration on the master
cast.
Figs 1-3-6j and 1-3-6k Final view of the monolithic lithium-disilicate
restoration cemented to the titanium-base abutment with Multilink
Hybrid Abutment HO-0 (Ivoclar Vivadent).
Fig 1-3-6l Occlusal view before placement of the direct screw-
retained implant restoration.
Fig 1-3-6m Final occlusal view of the direct screw-retained,
monolithic lithium-disilicate restoration on a titanium-base abutment
(Vario-Base, Straumann), after 3 years of clinical function.
Individualized only by the application of ceramic stains and glaze
(Ivocolor, Ivoclar Vivadent, Schaan, Liechtenstein).
In patient situations with high smile line and exposure of the
posterior maxillary teeth, facial microveneering may be needed for
good esthetic integration.
In anterior regions, the current monolithic ceramics do not allow
for perfect esthetic outcomes, not even when multilayer materials are
used. The facial application of veneering ceramics (microveneering)
and stains is, hence, needed for good esthetic results including a cut-
back design of the monolithic restoration (Fig 1-3-7).

Fig 1-3-7a Buccal view of the initial situation of a non-preservable

central incisor (tooth 11) due to a fracture.
Figs 1-3-7b and 1-3-7c Buccal and occlusal views during implant
placement of a regular diameter bone level implant (BLT 4.1 mm,
Straumann) guided by a conventional surgical guide.
Figs 1-3-7d and 1-3-7e Buccal and occlusal view before final
impression.
Figs 1-3-7f and 1-3-7g Adjustment of the connector in the blue pre-
sintered phase.
Fig 1-3-7h Sintered lithium-disilicate crown on the master model
before buccal microveneering.

Fig 1-3-7i Application of about 0.4 mm of dentin in the cervical area

(Power Dentin A2, IPS e.max Ceram, Ivoclar Vivadent).
Fig 1-3-7j After finalization of the microveneering by the application
of Enamal (IPS e.max Ceram, Power Incisal, Ivoclar Vivadent).
Fig 1-3-7k to 1-3-7n Final view of the microveneered lithium-
disilicate restoration cemented to the titanium-base abutment with
Multilink Hybrid Abutment HO-0 (Ivoclar Vivadent).

Material-specific limitations
Technicians and clinicians need to be aware of the material-specific
strength and indications of the materials indicated for monolithic
application. Hybrid materials like, for example, the polymer-infiltrated
ceramic network (PICN) (Vita Enamic, Vita Zahnfabrik, Bad
Säckingen, Germany), lithiumdisilicate glass-ceramic, and highly
translucent zirconia exhibit strength values ranging from 250 up to 800
MPa (see Part I, Chapter 1). Compared to this, the yttria-stabilized
zirconia polycrystals, used for framework fabrication, exhibit strength
values of approximately 1500 MPa. Due to this reduced material
stability, the indication of the latter materials is limited to single-unit
application (Fig 1-3-8).

Fig 1-3-8a Initial situation of a missing first molar and the application
of a spectrophotometer (Vita Easyshade, Vita Zahnfabrik) to transfer
the reference tooth shade.
Fig 1-3-8b Final individualized monolithic PICN (Vita Enamic, Vita
Zahnfabrik) restoration before cementation to the titanium-base
abutment.

Fig 1-3-8c Final buccal view of the directly screw-retained,

monolithic PICN restoration on a titanium-base abutment (Vario-Base
for Cerec, Straumann).
Figs 1-3-8d to 1-3-8h Superficial individualization of the monolithic
PICN restoration by the application of light-curing stain and glaze
(Vita Enamic Stains, Vita Zahnfabrik).

Some manufacturers of translucent zirconia allow its use for short-

span fixed dental prostheses with one pontic. In this case, the
minimum dimensions of the cross-sections, as recommended by the
respective manufacturer, need to be applied for sufficient clinical
stability (Fig 1-3-9).
Fig 1-3-9a Initial situation after optical impression using intraoral
camera (Trios3, 3Shape) for the fabrication of a four-unit monolithic
zirconium oxide fixed dental prostheses (FDP) with mesial cantilever.
Fig 1-3-9b Digital design of the four-unit FDP using a CAD software
(Exocad).
Fig 1-3-9c Try-in of the monolithic zirconium oxide FDP (Lava Plus,
3M, Seefeld, Germany) with super glue, temporarily cemented to the
titanium-base abutments (Vario-Base, Straumann).
Fig 1-3-9d Final view of the superficial individualization (Ivocolor,
Ivoclar Vivadent) of the monolithic zirconium oxide prior to
cementation to the titanium-base abutments.
Fig 1-3-9e Final occlusal view of the direct screw-retained,
monolithic zirconium oxide FDP on titanium-base abutments (Vario-
Base, Straumann).

Options for surface modification

If the reference teeth exhibit pronounced surface microtexture (eg,
perikymata), the mimicking may be technically difficult with monolithic
ceramics. Reinforced glassceramics and zirconia exhibit high surface
hardness and can only be surface-individualized with diamond-coated
instruments; the texture may then be smoothened by the application
of glaze ceramic. The facial application of softer veneering ceramic is
recommended in these situations.

Abrasion/wear properties
The monolithic materials are industrially fabricated and exhibit optimal
quality and integrity, with no pores16,17. Yet, their hardness has been
questioned and a higher risk for abrasion and wear of the antagonists
was assumed for the monolithic restorations (Fig 1-3-10).
Fig 1-3-10a Detailed microscopic image of a conventionally veneered
zirconium oxide restoration after a simulated 5 years of aging. The
traces of abrasion and the exposure of individual porosities can
already be seen very clearly.

Fig 1-3-10b Detailed microscopic image of a monolithic zirconium

oxide restoration after a simulated 5 years of aging.
Fig 1-3-10c Detailed microscopic image of a monolithic lithium-
disilicate restoration after a simulated 5 years of aging.

Fig 1-3-10d Detailed microscopic image of a monolithic PICN

restoration after a simulated 5 years of aging.

It has been shown, indeed, that these technical processing steps

are crucial for the abrasiveness of monolithic restorations. High-gloss
polished lithium-disilicate and zirconia lead to very low abrasions with
the antagonistic teeth or restorative materials18,19. Yet, intaglio,
rough, and stained and glazed monolithic ceramics induce pronounced
wear of the antagonists, as studies have shown.

1.3.5 Conclusions
Hence, monolithic restorations should always only be high gloss
polished in the occlusal and functional areas, and may be veneered,
colored, and/or glazed on the buccal and oral parts.

1.3.6 References
1. Beuer F, Schweiger J, Edelhoff D. Digital dentistry: an overview
of recent developments for CAD/CAM generated restorations.
Br Dent J 2008;204:505–511.
2. Miyazaki T, Hotta Y, Kunii J, Kuriyama S, Tamaki Y. A review of
dental CAD/CAM: current status and future perspectives from
20 years of experience. Dent Mater J 2009;28:44–56.
3. van Noort R. The future of dental devices is digital. Dent Mater
2012;28:3–12.
4. Schenk R. Biogeneric – another step closer to nature. Int J
Comput Dent 2010;13:169–174.
5. Rengier F, Mehndiratta A, von Tengg-Kobligk H, et al. 3D
printing based on imaging data: review of medical applications.
Int J Comput Assist Radiol Surg 2010;5:335–341.
6. Cohen A, Laviv A, Berman P, Nashef R, Abu-Tair J. Mandibular
reconstruction using stereolithographic 3-dimensional printing
modeling technology. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2009;108:661–666.
7. Fehmer V, Muhlemann S, Hammerle CH, Sailer I. Criteria for
the selection of restoration materials. Quintessence Int
2014;45:723–730.
8. Pjetursson BE, Sailer I, Zwahlen M, Hammerle CH. A
systematic review of the survival and complication rates of all-
ceramic and metal-ceramic reconstructions after an observation
period of at least 3 years. Part I: single crowns. Clin Oral
Implants Res 2007;18 Suppl 3:73–85.
9. Sailer I, Pjetursson BE, Zwahlen M, Hammerle CH. A
systematic review of the survival and complication rates of all-
ceramic and metal-ceramic reconstructions after an observation
period of at least 3 years. Part II: fixed dental prostheses. Clin
Oral Implants Res 2007;18 Suppl 3:86–96.
10. Vichi A, Ferrari M, Davidson CL. Influence of ceramic and
cement thickness on the masking of various types of opaque
posts. J Prosthet Dent 2000;83:412–417.
11. Kolakarnprasert N, Kaizer MR, Kim DK, Zhang Y. New multi-
layered zirconias: composition, microstructure and translucency.
Dent Mater 2019;35:797–806.
12. Elsaka SE. Optical and mechanical properties of newly
developed monolithic multilayer zirconia. J Prosthodont
2019;28: e279–e284.
13. Kurbad A. Microveneering technique for esthetic enhancement
of monolithic zirconia restorations. Int J Comput Dent
2016;19:165–178.
14. Tabatabaian F, Shabani S, Namdari M, Sadeghpour K. Masking
ability of a zirconia ceramic on composite resin substrate
shades. Dent Res J (Isfahan) 2017;14:389–394.
15. Bacchi A, Boccardi S, Alessandretti R, Pereira GKR. Substrate
masking ability of bilayer and monolithic ceramics used for
complete crowns and the effect of association with an opaque
resin-based luting agent. J Prosthodont Res 2019;63:321–326.
16. Gwon B, Bae EB, Lee JJ, et al. Wear characteristics of dental
ceramic CAD/CAM materials opposing various dental composite
resins. Materials (Basel) 2019;12.
17. Zhang F, Spies BC, Vleugels J, et al. High-translucent yttria-
stabilized zirconia ceramics are wear-resistant and antagonist-
friendly. Dent Mater 2019;35:1776–1790.
18. Kontonasaki E, Rigos AE, Ilia C, Istantsos T. Monolithic
zirconia: an update to current knowledge. Optical properties,
wear, and clinical performance. Dent J (Basel) 2019;7: pii: E90.
19. Zarone F, Di Mauro MI, Ausiello P, Ruggiero G, Sorrentino R.
Current status on lithium disilicate and zirconia: a narrative
review. BMC Oral Health 2019;19:134.
CHAPTER 4
Diagnostics

1.4.1 Introduction
In this chapter:
■ Esthetic parameters to be evaluated: step-by-step checklist
■ Time points for diagnostics, diagnostic tools
■ Conventional procedures
■ Digital procedures
■ Augmented reality in dentistry
■ Diagnostics for fixed implant-supported restorations, surgical
stents

Pretreatment diagnostics is essential for predictable treatment

outcomes in prosthodontics. Agreeing on the appearance of the final
restoration in this early phase of the treatment is key to obtain
satisfactory results in comprehensive restorative dentistry1–4.
Patients asking for an esthetic improvement of their dental
appearance may approach the restorative team with a desired
outcome in mind. Yet, the desired appearance can be difficult to
achieve due to anatomical or other limitations. It is a challenge for the
restorative team (ie, the dentist and dental technician) to determine
the desired, yet realistic outcome for the patient before the initiation
of restorative treatment.
Diagnostic wax-ups on the study casts and their transfer into the
patient’s mouth using silicone indexes and autopolymerizing
provisional resin (mock-up out of, eg, Protemp) are useful tools to
clinically communicate and test the planned treatment outcome before
the treatment.
The simulation of the final outcome helps with identifying the need
for preprosthetic interventions, such as orthodontic tooth movement,
or surgical procedures like crown lengthening and hard and/or soft
tissue grafting. Furthermore, the diagnostic mock-up can serve as a
guide for minimally invasive, defect-oriented tooth preparations.
Until recently, the pretreatment diagnostics encompassed the
manual fabrication of a wax-up of the desired outcome on the study
casts, and its transfer into clinics by means of a manually made resin
mock-up. The major disadvantage of the conventional manually made
wax-ups/mock-ups is that their fabrication is time-consuming, and in
general only one version of the possible treatment outcome can be
tested.
Contemporary digital technologies may provide advantageous
features to the increase of efficiency of the pretreatment diagnostics.
This Chapter reviews the esthetic parameters to be considered in the
diagnostics, and the opportunities digital technologies offer in the
diagnostic phase illustrating the procedures by means of one
representative clinical example.

1.4.2 Esthetic parameters to be

evaluated: step-by-step
checklist
At the first examination of the patient, several aspects have to be
considered as Part of the pretreatment diagnostics. The evaluation
starts from the assessment of the general appearance of the patient,
increasingly focusing on the details which are crucial for the
restorative treatment. The following all-important aspects to be
evaluated are listed next, in chronological order.
Facial aspect to be evaluated
■ Shape of the face – square, ovoid, tapered
■ Profile of the patient – flat, convex, concave
■ Midline
■ Interpupillary line

Smile aspect to be evaluated

■ Lip line – gummy smile, high, average, or low lip line
■ Vertical position of the incisal edges in relation to the face and the
lip line
■ Horizontal position of the incisal edges in relation to the
interpupillary line
■ Position of the dental midline in relation to the facial midline –
potential midline shift
■ Angulations of the dental midline in relation to the facial midline
and the interpupillary line
■ Outline of the incisal edges – straight, positive curve, negative
curve
■ Exposure of posterior teeth
■ Buccal corridor

Tooth-related aspect to be evaluated

■ General shape of the clinical crown – square, ovoid, tapered
■ Size of the clinical crown – height, width, and the relation between
height and width
■ Intratooth relation – size of the lateral incisor in relation to the
central incisor and size of the canine in relation to the central and
lateral incisors
■ Incisal edges steps
■ Tooth color – hue, value, chroma
■ Surface texture – smooth, pronounced
■ Characterization of the crown – translucency, spots, microcracks

Soft-tissue-related aspects to be evaluated

■ Position and curvature of the facial soft tissue
■ Soft tissue color and texture
■ Papillae – intact, reduced papilla height, missing, hyperplastic

After having evaluated these aspects clinically and on standardized

extraoral and intraoral photographs (see Photo Documentation
Protocol, Appendix 1), the pretreatment diagnostics are performed.

1.4.3 Time points for diagnostics,

diagnostic tools
Three time points exist for the assessment of the diagnostic goal.
The first and ideal time point is before any invasive treatment is
performed. A medical and dental anamnesis including a detailed
esthetic anamnesis is performed to understand the patient’s needs5,
followed by a comprehensive extra- and intraoral examination. The
restorative team gathers all the information to evaluate the clinical
situation, and elaborates the need for treatment. Considering the
complex and subjective nature of esthetics, an objective means for
the evaluation of the tentative outcome is helpful for the decision-
making process1,3. The diagnostic wax-up serves as an objective tool
for the evaluation of potential treatment outcomes3,6,7. It improves the
communication between patient, technician, and clinician, illustrating
three-dimensionally the tentative treatment outcome1,3,8. Commonly,
the dental technician models a possible dental configuration in wax
using clinical pictures and anatomical landmarks on the diagnostic
cast (existing occlusal plane and length and position of the remaining
teeth) as references. This process requires an undeniable amount of
time and energy since the technician must integrate all the esthetic
guidelines and adapt them to each individual case. The wax-up is
later tried-in in the patient’s mouth to evaluate its integration into the
patient’s smile and face, on what is called a diagnostic try-in. A
silicone matrix made from the diagnostic wax-up serves as a negative
cast for the fabrication of the diagnostic mock-up, which will be filled
with autopolymerizing resin and placed over the unaltered natural
teeth until polymerization. This mock-up allows the patient and
restorative team to envisage and evaluate the possible restorative
outcome1. This procedure, however, is only feasible in certain clinical
situations and it will only be effective in situations where additive
restorations are foreseen as the mock-up lies over the unprepared
teeth. In cases where subtractive procedures are necessary the
intraoral transfer of the wax-up will need to be performed at a later
treatment stage after the preparation.
The second time point to evaluate the esthetic and functional
outcome of the prospective restoration is the provisional phase.
Indirect provisional restorations made in the laboratory according to
the diagnostics serve as transfer of the desired treatment outcome
into the clinical situation and are useful tools to evaluate the
diagnostic goal (see also Part I, Chapter 8).
In the present treatment concept, conventional or digital eggshell
provisional restorations are the first option. For the conventional
eggshell provisionals, the technician duplicates the shapes modeled in
wax into a tooth-colored resin, which then is hollowed on the internal
side until only a thin outer resin layer remains. Alternatively, the
eggshell provisional can be milled out of a resin ingot by means of a
computer-assisted design and computer-assisted manufacturing
(CAD/CAM) procedure following a virtual wax-up. These eggshell
provisional restorations allow the clinician to deliver a high-end
laboratory provisional during the first invasive appointment. The
tentative final restoration contour is relined intraorally with
autopolymerizing resin on the prepared abutments. This method
saves time and costs derived from a traditional indirect provisional
fabrication (impression on prepared abutments, bite registration,
chair-side direct provisional production, and a second appointment to
deliver the laboratory provisional), while allowing for a perfect fit of
the provisional crown margins. Patients suffering from insufficient
restorations or unsatisfactory dental appearances gain significantly
from this direct approach, since the esthetic improvement can be
perceived immediately after the initial preparation and the insertion of
the provisional.
The third and last time point to determine the desired restoration
design is after the final impression is performed and before the
framework is produced. The patient’s and restorative team’s
impression derived from the previous two diagnostic steps (diagnostic
mock-up and provisional phase) are thereby taken into consideration,
and a new tentative configuration is confectioned over the prepared
abutments on the final cast. Using tooth-colored wax, the technician
produces a wax try-in that will simulate the color and contour of the
final restoration. When the case involves edentulous spans or multiple
units, the wax structure can require a metal or resin framework to
improve its strength. An advantage of this diagnostic maneuver lies in
the plasticity of the wax, which allows for immediate modifications of
possible imperfections discussed during the try-in appointment. Once
the patient and the restorative team have agreed on the optimal
restorative outline, the wax try-in will be used as a reference to
determine the shape and thickness of framework and veneering of
the final restoration.

1.4.4 Conventional procedures

As previously mentioned, high efforts are devoted to identify and
mimic the desired esthetic outcome before the technician begins the
final restoration production. Despite the significant amount of energy
and time invested to come up with a diagnostic draft, the obtained
result may not match the patient’s physiognomy or personality, or it
may not represent the desired result the restorative team and the
patient expected. In these cases, small changes to modify this initial
draft can be attempted. However, the range of modifications is limited
and often a new diagnostic version is necessary. The inability to
achieve the expected esthetic diagnosis with a try-in leads to patient
dissatisfaction and, even worse, professionals’ frustration and
increased time and economic expenses since further diagnostic steps
are necessary.

1.4.5 Digital procedures

In order to overcome the abovementioned limitations new
computerized technology procedures may be helpful. Computer
technology is increasingly transforming the way dentistry is being
performed. CAD/CAM processes are transforming what were
previously manual tasks into easier, faster, cheaper, and more
predictable mechanized methods9. Current industrial product
development would be impossible without CAD technologies. No
engineer would consider designing a prototype layering or carving a
structure manually; instead a virtual environment is used, where
different versions can be tried-in without increasing significantly the
time invested and with no impact on the costs. Carving shapes
manually has evolved into designing volumes virtually by means of
dedicated software. In restorative dentistry, the wax and modeling
are evolving into software and mouse-clicks. The restorative team
can profit from virtual libraries from where different tooth
morphologies can be selected (Exocad, Darmstadt, Germany;
3Shape A/S; Copenhagen, Denmark; Dental Wings, Montreal,
Canada; Sirona Dental, Wals, Austria). These software tools offer a
high number of different tooth shapes categorized according to
parameters such as size, age, or patient’s phenotype. Moreover, real
teeth can be used as a reference to generate tooth morphology
proposals10. These standard shapes can later be modified and
adapted to individual patient situations. Working time is substantially
reduced by eliminating the manual work needed for conventional
waxing techniques. This allows the technician to focus solely on
shapes and tooth arrangements. Furthermore, certain software
enable us to integrate photorealistic 3D restorations of the patients’
face into the virtual design software11. The face is integrated by
means of two-dimensional (2D) digital photographs projected onto a
three-dimensional (3D) virtual skull or by means of 3D facial
scanners. This allows for virtual smile design, taking into
consideration important facial reference planes such as midline
verticality, smile line, or the true horizontal plane. A further benefit is
the possibility to rapidly modify an initial design version in order to
effortlessly try-in other tooth arrangements. This grants the technician
freedom to generate multiple versions of the future restoration in an
efficient manner. Being able to offer different versions at a single
appointment streamlines the diagnostic phase and potentially better
fulfills the wishes of the most demanding patients and clinicians.
So far, subtractive CAM processes dominate dental manufacturing
routines. Restorations are obtained by trimming a solid block of
material into the desired 3D object, by means of a computer-
controlled milling machine12. However, these procedures present
several shortcomings such as waste of considerable amounts of
material, impossibility to create geometries that lie below the milling
bur diameter, or the impossibility to allow for mass production of
components9,13. These restrictions can be overcome by the
introduction of additive processing routes of layered fabrication14. An
example of these technologies is 3D printers, which allow the
manufacturing of several objects at the same time in a precise and
cost-efficient manner. The 3D printers work by jetting to be
photopolymerized materials in ultrathin layers. Each layer is cured by
ultraviolet light immediately after it is deposited, producing fully cured
objects15. The dual jetting printing procedure requires two materials:
a hard, fundamental material, and a gel-like support material. The
support material is necessary to sustain complex geometries of the
fundamental material during fabrication and it is easily removed by
water jetting after printing. Micron-accurate shapes can be printed in
different combinations of photopolymers, producing materials with
specific mechanical and visual properties. Products with different
levels of strength, rigidity, color, transparency, heat resistance, or
texture can be obtained. This production modality has widened the
indication spectrum of restorative computer-assisted dentistry.
In the following, a computer-assisted diagnostic treatment
sequence will be described in detail and clinical examples given to
illustrate the recent options for virtual diagnostics and CAD/CAM
mock-ups (Fig 1-4-1).
Fig 1-4-1 Comparison of conventional and digital workflows for
16
diagnostics (reproduced from Sancho-Puchades et al , with
permission).

The anatomical data acquisition of the patient’s jaws can be

obtained either by direct capturing the volumetric information using
intraoral optical scanners or by digitalizing a plaster model by a
laboratory optical scanner17 (Figs 1-4-2 and 1-4-3).

Fig 1-4-2 Optical impression of patient situation (reproduced from

16
Sancho-Puchades et al , with permission).
Fig 1-4-3 Scan of stone case in the laboratory with a laboratory
16
scanner (reproduced from Sancho-Puchades et al , with permission).

The .STL data generated is transferred into a software package

that allows for virtual dental restoration design. After selecting the
abutment teeth to reconstruct, a specific tooth shape set is chosen
from the virtual tooth library. The projected tooth forms are manually
arranged by the dental technician onto the dental arch (Fig 1-4-3).
Variations on the mesiodistal, buccooral, and occlusogingival
dimensions, tooth axis, or tooth composition can be easily performed
with the design software. Once a first version is completed and saved
on the computer, modifications of the first design can be efficiently
created with a couple of clicks and saved as new versions. For
example, a standard tooth arrangement can easily be individualized
by intruding or rotating teeth simply dragging a virtual point.
The chosen blueprints, saved as .STL files, are then exported to a
3D printing machine that will fabricate the restorations (Figs 1-4-4a to
c). Nowadays, biocompatible photopolymers are available to produce
rigid tooth-colored restorations, approved for a short-term intraoral
use as provisional (up to 6 months) (Figs 1-4-4d and e). The ease,
speed, and reduced costs derived from this diagnostic workflow in
conjunction with the accuracy of the mock-up make the procedure
highly efficient and recommendable.
Figs 1-4-4a to 1-4-4c Three different versions of virtual wax-up and
setup for the same patient (reproduced from Sancho-Puchades et
16
al , with permission).

Fig 1-4-4d Different .STL files of the virtual diagnostics of one

patient prepared for printing (reproduced from SanchoPuchades et
16
al , with permission).

Fig 1-4-4e 3D printing of the mock-ups (reproduced from Sancho-

16
Puchades et al , with permission).
The procedures are illustrated step-by-step by means of the
following clinical case:
A 52-year-old male patient asked for a comprehensive
rehabilitation of his deteriorated dentition (Fig 1-4-5).
Figs 1-4-5a to 1-4-5c Initial situation of the patient; portrait, smile
line, and intraoral frontal views of the dental situation prior to
16
treatment (reproduced from Sancho-Puchades et al , with
permission).

His main concerns were to recover masticatory function and

improve the appearance of his smile. After a thorough anamnesis and
examination, the dental pathologies and the esthetic problems were
identified. However, the diagnosis of the ideal contour of the
prospective restoration needed further investigation. A wax-up was
created and was tried-in as a direct mock-up over the patient’s teeth.
The first diagnostics were discussed with the patient and the desired
modifications were made in the diagnostic wax-up. Based on these
corrections, eggshell provisionals were fabricated. With the
provisional restorations, the patient’s initial desires were partially
fulfilled since he could now comfortably eat again and his speech
improved, but the patient was still not fully satisfied with the
appearance of his new smile. Therefore, before the framework of the
final restoration was designed another diagnostic try-in appointment
was scheduled. The conventional master models were optically
scanned (IScan D104, Imetric; Courgenay, Switzerland), and utilizing
a virtual design software (Exocad, Exocad; Germany), three versions
of the possible maxillary restorations were developed. The three
versions were then printed in A3-colored resin (PolyJet MED610,
Stratasys; Eden Prarie, MN, USA) using a 3D printer (Objet Eden
260V, Stratasys) (Fig 1-4-6a).

Fig 1-4-6a Different versions of the printed diagnostic mock-ups for

16
this patient (reproduced from Sancho-Puchades et al , with
permission).
The digitally generated mock-ups were tried-in and critically
evaluated by the patient and restorative team (Figs 1-4-6b to k).
Figs 1-4-6b to 1-4-6j Try-in of the different printed mock-ups
16
(reproduced from Sancho-Puchades et al , with permission).
It was agreed that the version with no diastema and converging
incisal borders fit the best to the patient’s smile and face (Fig 1-4-7).
This version was taken as a reference for the final restoration
production.
Figs 1-4-7a to 1-4-7i Portraits with the different diagnostic mock-ups
16
(reproduced from Sancho-Puchades et al , with permission).

The .STL file of the selected version was integrated into guided
surgery software and the implants were planned in the correct
prosthetically oriented 3D position. After implantation and tooth
preparation, the same .STL file was used for the fabrication of the
final tooth- and implant-supported restorations with aid of a
CAD/CAM procedure. By copy-pasting one design into each
treatment phase, the predictability of the treatment was improved, as
well as the efficiency of the entire treatment process.
Digital technologies offer significant improvement opportunities in
many dental and medical fields. Restorative dentistry has been one of
the disciplines that has profited the most from these technological
advancements13. Among these innovations, CAD/CAM technologies
have greatly influenced the production of provisional and definitive
restorative components9,12,13. As the technology establishes and
further develops (intraoral optical scanners, cast optical scanners,
virtual design software, 3D printers), new indications rise in other
treatment phases of the restorative workflow.
Despite the initial economic investment needed to create a digital
workflow (software, scanners, printers), the current technical
limitations of these rather recent technologies, and the learning curve
required to master the virtual tools this pathway offers, the dental
digitalization is an unstoppable phenomenon that will surely push the
dental standards even higher. The incorporation of these technologies
into the prosthetic diagnostic phase improves patient–clinician–
technician communication without significantly increasing the
treatment costs. This improves the predictability of the treatment
outcome, one aim that is crucial in contemporary restorative dentistry.

1.4.6 Augmented reality in dentistry

Augmented reality is a versatile new digital technology applied in
dentistry for guided implant surgery, preoperative planning in
maxillofacial surgery, in orthodontics, and in endodontology. Yet, most
interestingly it has opened up new horizons in restorative dentistry18.
New augmented reality tools were introduced which allow for
dynamic virtual diagnostics, before the treatment is even started. As
an example, an augmented reality application was recently
developed, and is now available for iPad or iPhone. This app acts as
a virtual-mirror-like tool which helps patients to identify their treatment
needs and desires for improvement at a very early stage (eg,
Ivosmile, Ivoclar Vivadent, Liechtenstein). By this the communication
with the restorative team is improved, and before investing time and
money in elaborating the pretreatment diagnostics the first important
desires can already be defined. The virtual mock-up is superimposed
live on the patient’s face, while following all live movements of the
lips, face, and head giving a natural appearance (Fig 1-4-8). The
software automatically recognizes the correct position of the virtual
teeth onto the natural teeth and within the face, without any need for
reference points, which normally need to be defined for the super-
imposition of 3D data and facial scans19. The appearance is similar to
looking into a mirror while changing different virtual mock-ups and
thereby dental looks, and serves for communication and planning
purposes.
Figs 1-4-8a to 1-4-8c Before and after insertion of selected
16
diagnostic mock-up (reproduced from Sancho-Puchades et al , with
permission).
Figs 1-4-8d to 1-4-8h Situation before treatment, three different
mock-ups, and final restoration (reproduced from Sancho-Puchades
16
et al , with permission).

As indicated before, the presented app is using facial recognition

(FR) and augmented reality (AR). FR describes a technology capable
of automatically identifying a person from a digital image, using
reference lines of the face and mathematical algorithms20,21. AR is a
type of technology in which an environment is enhanced through the
process of superimposing computer-generated virtual content over a
real structure18,22. Even if AR tools were mainly used for video games
and animations, the medical field is working to integrate these
technologies for diagnosis, surgery, education, and communication
with patients23.
To date, this new technology serves for communication purposes
only, yet, in the future its utility will certainly be expanded. As an
example, the selected virtual solution may be exported from the app
as an open .STL file, to be imported onto CAD or guided surgery
software. The file may, hence, serve for the planning and execution of
the respective treatment steps without further need of development of
the virtual diagnostics by the dental technician. With this, time and
efficiency may be increased, in line with the predictability of the
treatment.
Furthermore, with aid of the exported selected virtual solution and
its import into other digital files of the patients, eg, cone beam
computed tomography (CBCT), the clinician can analyze whether or
not anatomic limitations exist, and if pretreatment (eg, orthodontics)
may be recommended in order to fulfill the patient expectations. The
software may even be used to indicate solutions for compromise in
such situations. As all these developments are just in their early days,
they will need to further evolve in the years to follow.
Their current application is highlighted in Part II, Chapter 8
(Special indications) of this book.

1.4.7 Diagnostics for fixed implant-

supported restorations, surgical
stents
The 3D implant position is associated with the esthetic outcome of
the implant-borne restorations and the associated soft tissue
outcomes24. In the past, the pretreatment diagnostics and planning of
dental implants were mainly based on stone casts and 2D
radiographs. Clinical structures such as the crowns of adjacent teeth,
soft tissue margins, and tooth axes were used as orientation
landmarks, and a template with composite resin simulating the future
crown served as a drilling guide as well as a later means of
assessing the 3D position of the implant. Radio-opaque templates
made using radio-opaque composites allowed for the preliminary
transfer of information from diagnostic radiographs (Fig 1-4-9).
Figs 1-4-9a to 1-4-9g Step-by-step procedure at a conventional
implant planning including a 2D radiographic analysis, manual
diagnostic wax-up, and fabrication of a conventional surgical stent.
The conventional surgical stent helps defining the best 3D
prosthetically oriented position of the implant.

Today, 3D digital imaging technologies such as computed

tomography (CT) (previously used), and CBCT (more recently used)
make it possible to plan and carry out the positioning of dental
implants using appropriate 3D positioning software, and to transfer
the information from the 3D imaging datasets to the surgical guides.
These technological advances have increased the safety of dental
implants, especially when placed in narrow spaces or in close
proximity to critical anatomical structures (Fig 1-4-10).
Figs 1-4-10a and 1-4-10b CBCT for the 3D evaluation of the bony
situation and the proximity to critical anatomical structures (eg, the
maxillary sinus), crucial for the implant planning.

The 3D implant position is, hence, a crucial factor for the esthetic
outcome of the implant restoration. Furthermore, it can influence the
biologic and functional outcomes. The Consensus Conference of the
11th European Workshop on Periodontology thus issued a consensus
statement on the primary prevention of peri-implantitis, which includes
25
the following recommendations25: (1) implant placement must allow
for proper personal cleaning; and (2) the superstructure must allow
for good hygiene, ie, it must be free of niches and undercuts that can
cause tissue trauma. Reviews of the literature have shown that the
different types of superstructure fixation (cemented versus screw-
retained) were associated with different rates of functional and
biologic complications26. Cement excess with cemented restorations
induces specific biologic risks and can play a role in the etiology and
pathogenesis of peri-implantitis27,28.
Therefore, dental implant planning must always start with the
diagnostic determination of the foreseen restoration, both in posterior
and anterior regions. The 3D position of an implant should, hence,
depend on the restoration and not on the availability of local bone29.
The restorative team generally has the following three options for the
implementation and transfer of prosthetic references:
■ Transfer of the information from a conventional diagnostic wax-up
to a radiographic template with subsequent conventional guide
fabrication.
■ Matching of CBCT and surface scan data using planning software.
■ Creation of a digital wax-up directly via the planning software.

Conventional diagnostic wax-up and

radiographic template, subsequent surgical
guide fabrication
Prior to the CBCT scan acquisition, the laboratory technician delivers
a radiographic template with radio-opaque reference structures (a
LEGO block, titanium pins, or radio-opaque gutta-percha markers)
(Fig 1-4-11). The reference structures are inserted in the template as
specified by the planning software. Subsequently, the CBCT scans
are made with the radiographic template correctly inserted in the
patient’s mouth. The spatial positioning of the prosthetic reference in
the dental arch can thereafter be achieved with aid of the reference
structures which serve as an interface to the planning software.
Fig 1-4-11 Laboratory fabricated radiographic templates with
radioopaque reference structures (eg, a LEGO block, titanium pins,
or radioopaque gutta-percha markers).

The CBCT scan with the radiologically displayed radiographic

template is uploaded into the planning software and aligned and
calibrated based on the reference structures. The radio-opaque
prosthetic references can then be used for implant planning, but the
lack of a surface scan of the actual intraoral conditions makes it
difficult to identify important parameters (eg, the soft tissue
thickness) relevant and useful for planning.
With most of the commercially available implant planning systems,
the radiographic template has to now be sent back to the dental
laboratory. The dental technician utilizes drilling tables especially
developed for the planning system to fabricate the drilling guides for
guided surgery in an elaborate process. The accurate fabrication of
the guide is achieved by plaster fixation of the radiographic template
in the correct position, followed by meticulous preparation of the
sleeve bed for the respective implant position. This is a crucial step in
the fabrication process and can be prone to error, even when
performed by experienced dental technicians.
Alternatively, the planning data and stone cast can be sent to an
industrial laboratory, where the drill guide can be fabricated via a
predominantly additive process based on the aligning data and the
planning data. The industrialized process step has the advantage of
excluding many laboratory processing errors, but also has certain
disadvantages for the implant surgeon, such as longer delivery times,
higher costs, and a loss of control over the drilling guide design
process.

Matching CBCT and surface scan data using

planning software
With the second option, it is possible to upload and “match” (align)
the surface scan data (Standard Tessellation Language [.STL]
dataset) of the current intraoral situation with the CBCT data as well
as with data from a scan of the wax-up (.STL dataset) (Fig 1-4-12)
Figs 1-4-12a to 1-4-12d Example of the matching of surface scan
data (.STL) of the actual intraoral situation and the virtual diagnostic
wax-up with the CBCT scan. This process is important for the
prosthetically oriented 3D positioning of the implant in the virtual
environment of the guided surgery software.

The available software solutions allow for a decentralized

workflow, ie, the use of cloud-based software enables each member
of the restorative team to independently upload the datasets and
perform surgical planning with all the prosthetic references. This
approach affords maximum freedom of software selection. The only
requirement is that the system must be able to read the data in .STL,
the standard data format.
After all thorough examinations have been completed and the
results and options discussed with the patient, the clinician can
capture a CBCT scan and upload this data into the planning software
without any preliminary work by a dental technician. After initially
reviewing the data, the clinician can share the planning data and
discuss the case with a colleague and/or dental technician via cloud-
based technology.
With the corresponding conventional impressions or intraoral
impressions, the dental technician can then produce any type of
conventional/virtual setup or wax-up. This may require an intraoral try-
in as an intermediate step, or may be generated by the software as
.STL data. Concerning the legal questions this process may raise, it
should be mentioned that in case of options 1 and 2, the person who
uploads the CBCT data into the software has sovereignty over the
data, while it is not possible for other partners involved to download
the case data. To start the matching process, the user must first
upload and open the files containing the surface scan data of the
current intraoral situation and the planning data for the future
restoration (wax-up or setup).
The correct matching of the .STL surface scan data with the
CBCT data (as determined by gray-level differences) is crucial, as
the accuracy of implant planning and placement depends on this step.
Consequently, option 2 may be contraindicated in certain conditions.
The presence of an insufficient number or distribution of remaining
teeth or large metal or zirconia restorations in the arch to be treated
can make it difficult to impossible to achieve accurate data
matching30. In these cases, option 1 (despite being more expensive)
is the only way to proceed, hence, radiographic templates with
reference structures have to be used during CBCT scanning. Once
the clinician has gathered all the necessary information, the actual
process of prosthetic-driven implant planning can begin. The cloud-
based systems also have the advantage of enabling different
colleagues to work on a case simultaneously, thus greatly simplifying
coordination with the referring clinician. It is also possible to plan and
save several versions without reimporting the data, which makes it
possible to show different treatment options to the team and to the
patient16.
Once the final planning version has been approved, the drill guide
can be fabricated directly in the dental laboratory or ordered from the
service center (eg, SwissMeda, Baar, Switzerland). The splint module
of the respective software package (SMOP, SwissMeda) used to
design the drill guide also produces .STL datasets. With all systems
currently on the market, the software contains details about all the
relevant implant systems and the drill sleeves that go with them. The
SMOP workflow in particular also an interesting feature: depending
on which implant system is used, it may be possible to save the metal
sleeve, which not only results in simplification of the manufacturing
process and therefore savings, but also minimizes another source of
error31,32. Unfortunately, this software only supports the implant-
planning program and cannot be used in the restorative treatment
phase for virtual diagnostics or CAD of restorations. In other words, it
cannot be used to plan temporary or final restoration superstructures
(Fig 1-4-13).
Figs 1-4-13 a to f 3D-printed surgical guide, based on guided
surgery planning, transferring the relevant information of the virtually
planned 3D implant position into the clinical situation. This specific
guide (SMOP, Swissmeda) is an example of a digitally designed and
printed surgical guide, allowing for excellent visibility of the surgical
site, position accuracy, and enabling the surgeon to cool the surgical
site during the implant bed preparation with sterile saline solution.
Figs 1-4-13 g to 1-4-13m 3D-printed surgical guide, based on
guided surgery planning, transferring the relevant information of the
virtually planned 3D implant position into the clinical situation. This
specific guide (SMOP, Swissmeda) is an example of a digitally
designed and printed surgical guide, allowing for excellent visibility of
the surgical site, position accuracy, and enabling the surgeon to cool
the surgical site during the implant bed preparation with sterile saline
solution.

Creating a digital wax-up directly via the

planning software
With this option, it is not only possible to upload and match the
surface scan data of the current intraoral situation with the 3D CBCT
data (as with options 1 and 2), but also to create a digital wax-up
directly with the planning software. This workflow is highly efficient
because the steps involved in displaying and then scaling and
correctly positioning the virtual wax-up in the software can be
completed very fast33,34.
Most guided surgery systems today are intended for planning
purposes only. They are equipped with rather rudimentary tooth
libraries and design software tools that are, however, sufficient for
single-tooth implant planning in situations with sufficient prosthetic
references, like the adjacent teeth, albeit if used for cantilever and
multispan fixed/removable dental prostheses restorations, proper
adaptation and positioning of the virtual teeth can be very difficult.
There is great potential for the new generations of CAD/CAM
software to fill this gap. Through the merging or modular docking of
implant-planning software with the manufacturing software used in the
dental laboratory, digital implant planning can now be performed in
the virtual articulator with modern design tools, taking all the relevant
information (such as the soft tissue margins) into consideration. The
data can then be visualized in the implant-planning software in real
time by creating a specific connection to the implant manufacturer
(eg, Straumann DWOS Synergy Connection, Straumann, Basel,
Switzerland). This allows the dental technician to continuously adapt
the wax-up, and the clinician to change the implant position in the
software module. After the implant-planning proposal has been
finalized and approved, the dental technician designs the surgical
guide using the software elements intended for dental laboratory use.
The planned guide can be milled or 3D printed either in-house or by
an external provider, which is sent to the corresponding datasets.
This blending of software solutions also opens up new possibilities,
eg, it is possible to design and manufacture temporary provisional
restorations or abutments directly by utilizing the planned implant
positions without having to laboriously export them from the planning
software and then reimport them into the design software. In
principle, the positioning of splints can be used to guide Part or all of
the implant site preparation process. Some also allow for implant
placement via the guide. Ultimately, it is up to surgeons to decide how
much autonomous control they have over the entire process, ie, how
much they want to rely on the planning software and surgical guide.
The introduction of 3D diagnostic imaging technologies and the
corresponding implant-planning software packages has fundamentally
changed and significantly improved pre-implantation diagnostics and
planning.
1.4.8 Conclusions
The pretreatment diagnostics is a crucial step within the
comprehensive restorative treatment, as it serves for better
communication between the patient and the restorative team, and for
the planning and execution of the respective treatment steps including
the placement of dental implants. Until recently, pretreatment wax-ups
and setups were made manually by the dental technician. Nowadays,
the digital technology can be used for virtual diagnostics, and
CAD/CAM technology helps in transferring this plan into clinical
reality. An increase in efficiency and predictability by means of virtual
diagnostics has been shown. Yet, availability of the technology,
knowledge of its application, and high acquisition costs have to be
considered with the virtual diagnostics.

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Randomized controlled within-subject evaluation of digital and
conventional workflows for the fabrication of lithium disilicate
single crowns. Part II: CAD-CAM versus conventional
laboratory procedures. J Prosthet Dent 2017;118: 43–48.
CHAPTER 5
Decision-making criteria for
replacing the missing tooth

1.5.1 Introduction
In this chapter:
■ An evidence-based approach to treatment planning
■ Factor 1 – The patient’s perception
■ Factor 2 – The estimated longevity of the restorations
■ Factor 3 – The neighboring teeth
■ Factor 4 – The evaluation of the tooth gap
■ Factor 5 – The complexity of implant placement
■ Factor 6 – Assessment of risk factors
■ Factor 7 – Multiple risk factors
In their daily practice, dental practitioners routinely face the challenge
of making difficult decisions. These are mostly influenced by
paradigms, dictated by basic dental education and individual
preferences based on many years of clinical practice. One of those
decisions is to choose the most appropriate type of restoration to
replace a missing tooth for each individual situation. Treatment
planning in restorative dentistry was much easier before the era of
dental implants. The treatment options to restore edentulous spans in
that time were restricted to conventional and cantilever tooth-
supported fixed dental prostheses (FDPs) and removable dental
prostheses (RDPs). With the emergence of new techniques and
computer-aided design and computer-aided manufacturing
(CAD/CAM) technologies, the number of treatment options and
materials to restore edentulous gaps has increased significantly.
Today when planning a fixed restoration, the first decision to be
made is the type of restoration. Should it be tooth-supported
(conventional, cantilever, or resin-bonded), a combined tooth-implant-
supported, or a solely implant-supported restoration, FDP, or single
crown (SC)?

1.5.2 An evidence-based approach to

treatment planning
Important decisions in restorative dentistry should preferably be
made evidence-based, but the question remains whether evidence-
based treatment planning is feasible in prosthetic dentistry. Ideally,
treatment decisions should be based on randomized controlled clinical
trials (RCTs) or well-conducted systematic reviews with meta-
1
analyses based on RCTs, representing the highest level of evidence –
3
. The evidence-based approach is much more advanced in medicine.
The Cochrane organization is an independent body that has promoted
evidence-based medicine during the last two decades. It has
published over 6700 systematic reviews that analyze the
effectiveness of different treatment methods in medicine, while in
comparison only 250 such articles have been published in dentistry.
Until now, there is only one RCT that has compared the outcome
4 7
of different types of fixed restorations. A Swedish research group –
investigated the outcome of combined tooth-implant-supported FDPs
and solely implant-supported FDPs in this RCT. The authors included
23 patients with bilateral free-end mandibles and complete maxillary
dentures. The edentulous sites in the mandible of each patient were
randomly assigned to an FDP supported by either two implants
(control) or by one abutment tooth and one implant (test) (Fig 1-5-1).
Over a 10-year observation period, 2 out of 23 test implants and 5
out of 46 control implants were lost during function. There was no
statistically significant difference between test and control sites and
hence, the authors concluded that the combination of teeth and
implants in FDPs may be recommended as a predictable and reliable
treatment alternative for the restoration of the posterior mandible.
Figs 1-5-1a and 1-5-1b Edentulous space in the posterior mandible
was restored with a combined tooth-implant-supported FDP to
reduce the cost of treatment for the patient.

However, this study had clearly not the necessary power to detect
smaller but clinically relevant differences with regard to the proportion
of lost implants. For example, to detect a clinically relevant difference
of a 1% versus 2% annual restoration loss (with 80% power and a
significance level of 5%), a two-arm study would need to randomize
approximately 1060 patients within 1 year and follow them up for at
least 4 years, resulting in a total study time of 5 years. With a longer
follow-up time of about 10 years, it would be sufficient to randomize
500 patients. This demonstrates that it is not an easy task to perform
a randomized controlled clinical trial with adequate statistical power
to compare different types of restorations. Owing to the methodology
of systematic reviews and meta-analyses, such clinically relevant
questions can be addressed.
The aim of this Chapter is to discuss relevant factors when
planning a restoration as replacement for a single or several missing
tooth/teeth including the available evidence.

1.5.3 Factor 1 – The patient’s

perception
Today, information regarding dental treatment is available to patients
from several different sources. An important source is the internet
(Fig 1-5-2). Some implant manufacturers even advertise treatment
options to directly or indirectly recruit patients. However, most
patients still get information regarding dental treatment from dental
professionals or from friends and relatives. Two to three decades
ago, implant treatment was not so common, but today most patients
know someone that has undertaken implant treatment. The implant
treatment usually is well-accepted by the patients as shown in a 10-
8
year prospective study . The authors concluded that more than 90%
of the patients were satisfied with the therapy and would be willing to
undergo implant treatment again, if necessary. The costs associated
with implant therapy were also considered to be justifiable8.
Fig 1-5-2 An increasing number of patients seek information
regarding dental treatment and dental implants over the internet.

What factors influence the patient’s perception and decision?

Treatment costs
Treatment costs play a major role for a lot of patients. In most
European countries, the costs for an implant-supported SC are
similar to the costs for a three-unit tooth-supported FDP9. However,
this can vary for each individual situation. For example, if there is a
need for a complex bone augmentation and/or soft tissue grafting, the
price for the implant is significantly increased. Furthermore, if one or
both teeth adjacent to the edentulous space require new restorations,
the cost-effectiveness of a tooth-supported three-unit FDP is
9
significantly higher .

Treatment time
The total treatment time is another factor that can influence the
treatment plan. For a treatment that is supposed to last for a long
period of time it should not really matter whether the treatment
duration is 4 weeks or 4 months, especially if teeth have already
been missing for a long period of time. Nevertheless, there will
always be patients who insist on a very short treatment time and
there will be some clinicians trying to meet the demands of these
patients. For this reason, treatment protocols like immediate implant
placement after tooth extraction and immediate loading of the implant
after placement have been established. Shortening the treatment time
can however increase the risk of complications and failures10.
Originally it was suggested to wait for 3 months in the mandible
and 6 months in the maxilla prior to loading of dental implants11.
Owing to developments concerning implant surface and morphology,
the healing time of dental implants could be significantly reduced12.
The total treatment time for implant-supported SCs is still around 2
months in a standard case though. For complex cases requiring bone
augmentation procedures, the total treatment for implant-supported
SCs can be prolonged up to 4–6 months. Moreover, in cases where
two-stage sinus floor elevations or two-stage lateral bone
augmentations are needed, the total treatment time can even extend
up to 1 year or longer. Thus, in such cases tooth-supported
restorations may be favorable, if time is an important factor for the
patient.
The mean total treatment time for tooth-supported FDPs and
implant-supported SCs was evaluated in a retrospective study9. The
mean treatment time for implant-supported SCs was almost twice as
long as for tooth-supported FDPs or 5.9 ± 3.3 months versus 3.2 ±
2.6 months, respectively9.
Thus, tooth-supported FDPs might be the treatment of choice in
complex cases, if treatment time is a major consideration, given that
less time is generally needed for tooth-supported restorations.

Esthetics
The esthetic outcome is a very important issue for patients. With
techniques and materials available today it is possible to make
restorations both on teeth and implants that imitate perfectly natural
teeth. It must be kept in mind that to achieve the perfect outcome, the
clinician needs to have good knowledge of the biology of soft and
hard tissues and understand the properties of the material utilized.
Even though it is possible to achieve an excellent esthetic outcome
with implant-supported crowns, it must be realized that if something
goes wrong with the implants, the effects can be more dramatic for
the patient, than if something goes wrong with a tooth-supported
restoration (Fig 1-5-3).

Fig 1-5-3 A wide body zirconia implant was placed immediately after
tooth extraction. Due to an incorrect three-dimensional implant
position, significant amount of buccal bone resorption, and soft tissue
recession, the final outcome is esthetically compromised.
For implant-supported SCs, several authors have stated that soft
tissue recessions can be expected during the first 3–6 months in
function13,14 and following which, the soft tissue is stable as long as
there is no infection around the implant.
A recent systematic review15 which evaluated the esthetic
outcome of implant-supported SCs concluded that 7.1% of the
crowns had an unacceptable or semi-optimal esthetic appearance.
This incidence is, however, difficult to interpret because of a lack of
standardized esthetic criteria16 and the fact that neither dental
professionals nor patients have evaluated the esthetic outcome. In
cases where the neighboring teeth would profit from a crown from an
esthetic point of view, a tooth-supported restoration could be the
most appropriate treatment choice. Otherwise, from this aspect,
restorations that imitate perfectly natural teeth can be accomplished
both with tooth-supported and implant-supported restorations.

The provisional phase

For tooth-supported FDPs, the fabrication of a provisional restoration
is usually simple, well-accepted by the patients, and comfortable to
wear. Provisional restorations that have a similar shape to the final
restoration can be used during the whole treatment time. However,
during the healing period for dental implants, provisional removable
dentures are mostly used. The patients often have problems adapting
to them and time is needed for adjustments and repairs.

Long-term survival
When planning a fixed restoration, the patient should be informed
about different treatment options, the estimated survival of the
restoration, and possible risk factors. Each treatment option has a
documented longevity (see Part III). Besides, biological as well as
technical risks have to be considered during treatment planning (see
Part IV).
1.5.4 Factor 2 – The estimated
longevity of the restorations
A group of researchers from the Universities of Iceland, Bern,
Geneva and Zurich in Switzerland, and from the National Dental
Center in Singapore has published a series of systematic
reviews15,17–28. These are based on consistent inclusion and
exclusion criteria, summarizing the available information on survival
and success rates, and the incidence of biological and technical
complications of different types of tooth- and implant-supported
restorations.
According to the 5-year survival rates, the preferred treatment
choices when planning a fixed restoration would be implant-supported
SCs, conventional tooth-supported FDPs, with end abutments, or
solely implant-supported FDPs, without discriminating the three types
(Table 1-5-1). The reason for a relatively low 10-year survival rate of
solely implant-supported FDPs (see Part III, Table 3-1-8) is that most
of the included studies report on restorations with metal framework
and acrylic veneering from which many had to be remade due to
esthetic failures. When solely implant-supported FDPs with ceramic
veneering were analyzed, the 10-year survival rate increased to
93.9%. As a second treatment option to save tooth substance or due
to anatomical reasons or patient-centered preferences resin-bonded
prostheses (RBPs), cantilever tooth-supported FDPs, or combined
tooth-implant-supported FDPs can be planned.

Table 1-5-1 Estimated 5-year and 10-year survival rates of different

types of restoration and the number of restorations that were
evaluated
Type of Number of Estimated 5- Number of Estimated 10-
restoration restorations year survival restorations year survival
analyzed rate (95% CI) analyzed rate (95% CI)
Implant- 4636 98.3% (96.8– 268 89.4% (82.8–
supported SCs 99.1%) 93.6%)
Type of Number of Estimated 5- Number of Estimated 10-
restoration restorations year survival restorations year survival
analyzed rate (95% CI) analyzed rate (95% CI)
Tooth-supported 1796 94.4% (91.2– 1218 89.2% (76.1–
conventional 96.5%) 95.3%)
FDPs
Implant- 932 98.7% (96.8– 243 80.1% (66.8–
supported FDPs 99.5%) 89.4%)
Resin-bonded 1755 91.4% (86.7– 545 82.9% (73.2–
prostheses 94.4%) 89.3%)
Tooth-supported 423 91.4% (88.4– 239 80.3% (74.8–
cantilever FDPs 93.7%) 84.7%)
Combined tooth- 199 95.5% (91.5– 60 77.8% (64.9–
implantsupported 97.6%) 86.4%)
FDPs

It is important to realize that RBPs have the best outcome when

used in the anterior area and when the occlusal relationship is
appropriate. The dental literature also shows that tooth-supported
cantilever FDPs have a higher risk of failure when supported by
endodontically treated teeth. The abutment teeth should ideally be
vital, and the preparations should be tilted slightly away from the
cantilever unit, to reduce the risk of loss of retention. In addition, the
cantilever unit should only have contact in maximum intercuspidation
position and no contact in laterotrusion.

1.5.5 Factor 3 – The neighboring teeth

One of the determining factors, whether to plan a tooth-supported or
an implant-supported restoration, is the status of the teeth adjacent
to the edentulous gap, since those teeth will become the abutment
teeth if a tooth-supported restoration is planned.
Teeth can basically be divided into three groups: (1) teeth that are
intact or so well-preserved that it would be a huge sacrifice of tooth
structure, when preparing them as abutment teeth; (2) teeth with
fillings or discolorations that would profit from an improved esthetics
and strengthening, if used as abutment teeth; (3) teeth that are
doubtful, increasing the risk for larger restorations because in a case
of tooth loss, the entire restoration has to be replaced.
Hence, if a tooth is compromised due to substantial loss of tooth
substance or with impaired periodontal or endodontic conditions, it
might be more reasonable not to use it as an FDP abutment.
An evaluation and a classification of the neighboring teeth has to
be based on the following three aspects (see Table 1-5-2).

Table 1-5-2 Pretherapeutic single tooth prognosis: single tooth risk

analysis
Secure teeth are teeth that should last for a long period of time without the need
for significant or complex treatment
Dental aspects Periodontal aspects Endodontic aspects
Group I All teeth not All teeth not classified as All teeth not classified as
Secure classified as doubtful or irrational to treat doubtful or irrational to treat
teeth doubtful or and all teeth with intact root
irrational to canal anatomy, that need
treat primary endodontic
treatment with or without
symptoms
Group II These are teeth that might need complicated treatment and additional
Doubtful maintenance to last. It is not always clear how those teeth will respond to
teeth treatment and therefore it can be of an additional risk to use them as FDP
abutments and more reasonable to keep them as single units. In many
instances, doubtful teeth can be made secure by treatment
Dental aspects Periodontal aspects Endodontic aspects
Teeth that have Teeth with attachment loss in Teeth with large peri-apical
lost so much percentages, evaluated on a lesions evaluated on
substance, that radiograph, to be more or radiographs with or without
it is difficult to equal to the age of the patient symptoms
restore them in years, ie, ≥ 50% attachment
with acceptable loss in 50-year-old patients
ferule
Teeth with Molars with furcation Class I, Teeth with altered root canal
caries lesion II, or III anatomy that need
that extends far endodontic retreatment
down the root
Teeth with Teeth with vertical bone Teeth that need peri-apical
weakened root defects surgery
structure due to
a wide metal or
fiber-reinforced
post
These are teeth where extraction is the only option. The timing of extraction can
depend on situation of the tooth, pain, or infection, or the treatment plan
Dental aspects Periodontal aspects Endodontic aspects
Teeth with Attachment loss extending Teeth with vertical root
caries lesion down to the apical Part of the fractures
Group III that extends root
Teeth into the root
irrational canal
to treat
Teeth with Teeth with recurrent peri- Horizontal root fractures in
caries lesion apical abscesses the mid third of the root
extending into
the furcation
Functional reasons – ie, decayed or periodontally infected third molar without
antagonist

Amount of remaining tooth structure

For a tooth-borne restoration, the condition of the abutment teeth
must be evaluated. If a tooth is intact or has only a small filling (Fig 1-
5-4), it is definitely more appropriate to leave it intact rather than
preparing it as an abutment tooth for a conventional tooth-supported
FDP. Hence, in such situations, implant-supported restorations or
RBPs with minimal or no tooth preparation would be the treatment of
choice.
To maintain endodontically treated teeth that have lost a
substantial amount of tooth substance, a build-up is usually
necessary. This could be accomplished using a cast post and core or
by utilizing a composite or metal post (Fig 1-5-5) and composite
build-up, always aiming for a circumferential ferrule of at least 1.5–2
mm. These teeth are not as strong as intact or slightly restored teeth
and should, if possible, not be submitted to additional load by adding
pontics or cantilever units. Such teeth serve better as single-unit
crowns. An ideal abutment to provide support would be a tooth, which
is in good condition or has caries, fillings, impaired esthetics, or other
factors to profit from a crown. In addition, the tooth wall height after
preparation should be at least 3–4 mm29.

Fig 1-5-4 The two neighboring teeth to the edentulous space are
intact and should not undergo a traditional abutment tooth
preparation. Hence, the treatment options are limited to an implant-
supported single crown or a resinbonded FDP.
Figs 1-5-5a and 1-5-5b Both lateral incisors have lost significant
amount of tooth substance and were restored with cast post and
core. These teeth should preferably be left as single units and not
included in a multiple-unit restoration.

Endodontic aspects
If the neighboring teeth are non-vital or have an incomplete
endodontic treatment, they should not be used as FDP abutments,
unless successful endodontic treatment or retreatment can be
accomplished. It has been shown in several studies that the success
of endodontic retreatment is on average lower than the initial
endodontic treatment30–33. It can be argued that if the success of the
retreatment is less than 90%, it is not reasonable to use such teeth
as abutments. In a prospective study34 success of endodontic
retreatment was evaluated for 452 teeth in 425 patients. The success
rate ranged from 28% to 100% depending on the reason for the
endodontic failure. The success rate of endodontic retreatment was
above 90%, when the reason for retreatment was an underfilled root
canal or a broken instrument with no alteration of the root canal
morphology. On the other hand, if the reason for endodontic
retreatment was stripping, internal or external transportation,
calcification, perforation, apical resorption, internal resorption or
apical stop, the success rates ranged from 28% to 76%34.
Consequently, the prognosis of these teeth serving as abutment teeth
is questionable (Fig 1-5-6). In a longitudinal study from the University
of Bergen, Norway35, 112 endodontically retreated teeth were
followed up to 27 years after endodontic retreatment. The authors
observed that persistent peri-apical radiolucencies disappeared in
some cases after more than 10 years. Other cases did not show any
radiolucencies in the first decade after treatment, but peri-apical
radiolucencies appeared after 10–17 years. Hence, the authors
suggested that persistent asymptomatic peri-apical radiolucencies
should not be classified as failures35. However, one should keep in
mind that endodontically treated teeth with small asymptomatic peri-
apical lesions are not ideal as abutment teeth due to the possibility of
an ongoing peri-apical process. These teeth should not be extracted
but not be included as abutments in FDPs (Fig 1-5-7).
Fig 1-5-6 Tooth 15 has a peri-apical lesion and needs surgical or
non-surgical endodontic retreatment. Such teeth are often
compromised and should not be included in a multipleunit restoration.

Fig 1-5-7 Tooth 36 has a visible peri-apical lesion by the mesial root.
With a proper endodontic treatment, the lesion should heal, and the
tooth classified as a secure tooth.
Periodontal aspects
The neighboring teeth must also be evaluated from a periodontal
point of view. Tooth mobility per se is not a contraindication for using
teeth as FDP abutments. The reason for the mobility must be
evaluated. Is it due to attachment loss, is it because of an additional
load from fixed or removable restorations, or is it because chewing
units are missing, and the entire occlusal load is carried by a limited
number of teeth? Teeth with reduced but healthy periodontium can
certainly be used as abutment teeth despite of increased mobility.
Teeth with residual pockets of 5 mm or more need additional
periodontal treatment before they can be considered as FDP
abutments. On the other hand, teeth with furcation involvement class
II and III36 should not be used as FDP abutments (Fig 1-5-8) due to
the increased risk of periodontal progression37–39. The ratio between
bone loss evaluated on peri-apical radiographs in relation to the age
of the patient can also be used as an indicator for the evaluation of
the periodontal risk40,41. This means that a 30-year-old patient who
has lost 30% of bone support has a ratio 1 and therefore can be
classified as a high-risk patient (Fig 1-5-9). However, if a 60-year-old
patient has lost the same amount of bone support, this would
correspond to a ratio of 0.5 and the patient would be classified as a
medium risk patient. If the ratio between the bone loss and the age of
the patient exceeds 1, it is recommended to leave the tooth as single
unit and not use it as an FDP abutment. A longitudinal study42 that
evaluated the maintenance of periodontal attachment levels in
prosthetically treated patients with gingivitis or moderate chronic
periodontitis 5–17 years post therapy, concluded that there was no
significant difference regarding loss of attachment between restored
abutment teeth and non-restored control teeth.
Fig 1-5-8 Maxillary molar with furcation involvement that would be
classified as a doubtful tooth.
Figs 1-5-9a and 1-5-9b The present attachment level is calculated
as a percent of the original bone height. It must be kept in mind that
the bone attachment begins approximately 3 mm away from the
cementoenamel junction in a healthy situation.
1.5.6 Factor 4 – The evaluation of the
tooth gap
The evaluation of the dimension of the edentulous space should
comprise the mesiodistal width and the intraocclusal space. The aim
of this is to decide whether implant placement and an implant-
supported restoration is possible. According to a radiographic study43
evaluating implant-supported SCs, there is a strong correlation
between the distance of the implant to the neighboring tooth and the
loss of the supporting bone at the neighboring tooth. The risk for bone
loss increases if the bone wall between the root and the implant is
less than 1.5 mm43. This means that at least 6 mm of bone in the
mesiodistal direction is needed for a narrow-diameter implant of 3.0–
3.5 mm. It must, however, be kept in mind that narrow diameter
implants are not suitable to support large molars due to stability and
cleanability issues. Therefore, an implant diameter of at least 4 mm is
advisable in the molar area and the edentulous space has to be at
least 7 mm. If this condition is not fulfilled, tooth-supported
restorations through which the dimensions of the gap can be altered
are indicated. Another treatment option would be to increase the size
of the edentulous gap with orthodontic tooth movements. However, it
must always be kept in mind that the width of the edentulous gap
should be measured at the bone level where the implant would be
placed and not at the level of the contact point of the neighboring
teeth. If there is a big discrepancy between the space measured at
the bone level and the space at the contact point, as is often the case
when teeth are tilted, orthodontic tooth movement can be
implemented prior to implant placement or prior to restoring the
edentulous space.
The intraocclusal space (Fig 1-5-10) needed for the pontic of a
tooth-supported FDP is dependent on the height of the abutment
teeth. It has been suggested that a minimal height of the walls of the
prepared tooth should be at least 3 mm for molars and 4 mm for
premolars with less than 10 degrees of preparation conicity,
translating into a minimal height of the restoration of 5–6 mm29.
Fig 1-5-10 Edentulous area in the posterior maxilla with limited
intraocclusal space due to eruption of mandibular premolars.

For cemented implant-supported restorations the minimal height of

abutments is 4 mm, translating into a total restoration height of 5–6
mm depending on the material used. For screw-retained restorations
the height of the abutments including the occlusal screw can be as
low as 3 mm, giving a total minimal height of the restoration slightly
below the one of a cemented restoration. In situations with limited
interocclusal space, screw-retained implant-supported restorations
may therefore be the preferred treatment option. Furthermore, the
bone height can be slightly reduced by deeper insertion of the
implants or with osteoplasty. Loss of retention of a screw-retained
implant-supported restoration is usually a minor complication
compared with loss of retention of a tooth-supported restoration,
where secondary caries is often associated.

1.5.7 Factor 5 – The complexity of

implant placement
As Part of the treatment planning, the anatomy of the edentulous site
has to be examined. For implant-borne restorations, the complexity of
implant placement could affect the treatment plan. The question
arises, whether there is adequate bone volume for standard implant
placement or if there a need for complicated bone augmentation
procedures that will increase the cost, the patient’s morbidity, and the
overall treatment time.
The complexity of implant placement can be divided into three
groups:
■ Standard implant placement, where the implant can be inserted in
the correct three-dimensional (3D), prosthetically oriented
position, without a need for bone grafting. There is, however,
limited evidence on the exact bone thickness needed buccally and
orally of an implant. Based on expert opinions of the International
Team for Implantology (ITI) Consensus Conference 199844, it was
suggested that the minimal bone width for placement of an implant
with a diameter of 3.3 mm should be 4.8 mm and that the minimal
width for placement of an implant with a diameter of 4.1 mm
should be 5.5 mm. This translates into a minimal thickness of 0.7
mm for the buccal as well as the oral bone wall. A few years later
the same expert group recommended that at least 1 mm of bone
should surround an implant, otherwise a bone augmentation
procedure was recommended. It can be concluded that increased
bone thickness decreases the risk of bone resorption and soft-
tissue recession (Fig 1-5-11). Standard implant placement is
usually well-accepted by patients8.
Fig 1-5-11 The ITI Consensus Conference in 1998 suggested that a
minimal bone wall of 0.7 mm was needed buccally and orally for
standard implant placement.

■ Implant placement with a simultaneous lateral or vertical guided

bone regeneration (GBR) (Fig 1-5-12) as well as one-stage
lateral or transalveolar sinus floor elevation are more complex
procedures than standard implant placement. The patients might
experience more postoperative discomfort such as swelling and
pain. The costs for these procedures are higher due to the
complexity and expenses for the biomaterials. The healing time is
increased by 4 to 8 weeks compared with standard implant
placement. Based on limited evidence, the above-mentioned
treatment procedures are still well-accepted by the patients and
more than 90% of the patients would be willing to undergo this
treatment again, if necessary45.
Fig 1-5-12 Guided bone regeneration (GBR) performed
simultaneously with implant placement. Collagen membrane will be
used to hold the grafting material in position and to block out the
ingrowth of connective tissue and epithelium.

■ The most complex implant placement is when two-stage bone

augmentation is needed (Fig 1-5-13). Hence, the first surgical
intervention is the bone augmentation procedure, followed by a
healing time of 4–8 months before inserting the implant. This
means that at least two significant surgical interventions are
needed. The post-surgical trauma is significantly pronounced,
especially if there is a need for harvesting of autogenous bone
(Fig 1-5-14). For example, in cases of bone harvesting from the
hip, the patients need several months to fully recover after the
procedure. In the two-stage bone augmentation procedures, the
treatment time is significantly increased compared to standard
implant placement and thereby also the costs for this treatment.
Fig 1-5-13 Block graft was harvested in the mandible and utilized in
combination with particulated autogenous bone, bone substitute, and
a collagen membrane to build up the bone defect.
Figs 1-5-14a and 1-5-14b Bone harvesting often causes more
trauma to the patient than bone regeneration procedures per se.

In cases where complex two-stage bone augmentation procedures

are needed, other treatment options such as tooth-supported
restorations or a shortened dental arch should be given serious
thought. The work of Käyser and co-workers showed that patients
maintain adequate (50–80%) chewing capacity with a premolar
occlusion46.

1.5.8 Factor 6 – Assessment of risk

factors
The most frequent reason for losing a restoration is the occurrence of
biological, technical, or esthetic complications that cannot be treated
and require a remake or a new restoration of a different design.
Despite excellent survival rates reported for both tooth- and implant-
supported restorations, the incidence of biological, technical, and
esthetic complications is still high (see Part IV). For example, a study
evaluating the outcome of implant-supported fixed restorations,
performed at the University of Bern47, reported a failure rate of 2.5%
for the restorations but an additional 16.8% of the restorations
experienced biological and/or technical problems. This means that
complications occurred six times more frequently than failures. The
incidence of complications is higher for implant-supported than tooth-
supported restorations. This, however, does not necessarily imply
that the possibilities for corrective measures are more cumbersome.
For tooth-supported restorations, the most frequent complications are
biological complications such as caries and loss of pulp vitality and
technical complications such as loss of retention for conventional
tooth-supported restorations or de-bonding for RBPs. For implant-
supported restorations the incidence of technical complications was
also significantly higher in comparison to tooth-supported
restorations. The most frequent technical complications were
fractures of the veneer material (ceramic fractures or chipping),
abutment or screw loosening, and loss of retention. The most
frequent biological complications were soft tissue complications and
peri-implantitis. It is very important to take these risk factors into
account when making a treatment plan, eg, when planning a
restoration for a patient that has been caries active, a more
reasonable restoration would be an implant-supported one.

1.5.9 Factor 7 – Multiple risk factors

The last issue that should always be considered is that the value of a
compromised tooth decreases dramatically with combined or multiple
risk factors. If a tooth has 100% chance of surviving the next 10
years, statistically it will have a risk of 1.0 for surviving. However, if a
tooth has only 80% chance of surviving in the same period of time, it
will have the risk of 0.8 for surviving. Moreover, if a tooth has more
than one risk factor, eg, the risk of losing it due to periodontal
problems is 20% and the risk of losing the same tooth due to
endodontic problems is also 20%, the combined risk for losing that
tooth is calculated by multiplying 0.8 × 0.8 = 0.64. Hence, the tooth
has 64% chance of surviving the next 10 years or the risk of losing
that tooth due to endodontic or periodontal problems is 36%. For the
clinician, this means that a seriously compromised tooth from an
endodontic standpoint, like a tooth with internal resorption, should
only be kept if it is not compromised periodontally and with adequate
tooth structure, not requiring complicated restorations afterwards.
The same would apply for a tooth that is seriously compromised due
to periodontal disease (Fig 1-5-15). It is only worth keeping such a
tooth if it is not endodontically compromised and does not need
complicated and expensive restoration. It would be very helpful for
treatment planning if methods were available to evaluate different risk
factors for each tooth.
Fig 1-5-15 All molars and premolars are seriously compromised due
to periodontal disease. However, these teeth have no other risk
factors and could be maintained for a long period of time (courtesy
Dr. Jürg Schmid, Ilanz, Switzerland).

1.5.10 Conclusions
If the risk of losing a tooth due to caries, periodontal disease or
endodontic problems could be evaluated, and the risk of failure of the
restorations such as posts and cores, crowns and FDPs could be
included, an exact risk estimation for each tooth would be possible.
This would be very helpful in making evidence-based treatment
decisions (Fig 1-5-16 and Table 1-5-3).
Figs 1-5-16a to 1-5-16c Tooth 26 has secondary caries, class II
furcation distal, external root resorption on the palatal root, and
needs a build-up and a restoration.

Table 1-5-3 Evidence-based approach to estimate the risk of tooth

loss within the next 10 years for tooth 26, which is presented in Fig 1-
5-15. The tooth has secondary caries, class II furcation distal,
external root resorption on the palatal root, and would need a build-up
and restoration. Due to different risk factors the overall probability
that this tooth will survive the next 10 years is only 52%
Risk factor for tooth loss in 10 years Probability
Loss due to caries or tooth fracture 3%*
Loss due to periodontal disease 15%
Loss due to endodontic failures 29%
Failure of the core build-up 5%
Failure of the restoration 8%
The overall chance for a tooth survival 52%
*The chance of losing the tooth due to caries lesion is purely fictive but the other factors have
some evidence support.

1.5.11 References
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residual pockets on progression of periodontitis and tooth loss:
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of marginal bone loss at tooth surfaces facing single Branemark
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334.
CHAPTER 6
Tooth preparation: current
concepts for material selection

1.6.1 Introduction
In this chapter:
■ Minimally invasive preparation techniques (veneer preparations in
anterior and posterior regions)
■ Defect-oriented preparation techniques for posterior teeth: onlays,
overlay-veneers, and partial crowns
■ Conventional crown and fixed dental prosthesis (FDP) preparation
technique: the universal tooth preparation
■ Resin-bonded fixed dental prosthesis (RBFDP) preparation
It is the ultimate goal of the present restorative concept, to preserve
the tooth substance as much as possible and to be as minimally
invasive as possible for all types of restorations. After the
development of the diagnostic plan, each patient situation is evaluated
carefully by assessing each individual tooth with the aim of providing
the least invasive, defect-oriented type of restoration. At the
treatment planning, various types of partial coverage and restorations
for the defective tooth are considered before full crowns or
conventional FDPs are planned.
Hence, with aid of the following checklist, the patient-related
defect situation is evaluated, including the etiology of the respective
problem, in order to determine the indicated type of restoration and
the most appropriate restorative material. In addition to these factors,
the main desire of the patient is to be involved in the selection of
restoration type and material (also see Part I, Chapter 1). Lastly, the
age of the patient can play a role.

Case analysis checklist:

1. Analysis of the etiology: What is the main clinical problem and why
did it occur?
2. Pretreatment diagnostics: What is the treatment goal?
Communication of wax-up with patient and technician
3. Analysis of dental situation: How can this goal be transferred to
the clinical situation with the least invasiveness?
4. Analysis of the tooth substance conditions with respect to general
prerequisite for less invasive types of restorations: Can adhesive
cementation be performed with good predictability?
5. Definition of the type of restoration and the defect-oriented
preparation: What is the tooth preparation design according to
defect and the treatment goal?

In order to accomplish the different preparation designs in an efficient

way, preorganized preparation diamond sets can be helpful. For the
abutment tooth preparations within the present concept, a specifically
organized preparation set with rough and fine-coarse diamond
instruments was developed, which allows for the different preparation
designs with 11 preparation instruments (Universal Prep Set, Intensiv,
Montagnola, Switzerland) (Fig 1-6-1).
Fig 1-6-1 Universal Prep Set, Intensiv, Montagnola, Switzerland
(reproduced with permission from Intensiv).

With the more recently introduced “Guided prep set,” the step-by-
step sequences of the diamond instrument application are indicated
for the different preparations (Fig 1-6-2). The preparation set also
contains a mandrel for the use of polishing disks (Sof-Lex disks, 3M
ESPE, Seefeld, Germany), needed for the finalization of the
preparations. The finalization includes the elimination of any sharp
edges, and the smoothening of transition lines and of incisal/occlusal
boarders – a crucial step at tooth preparations for all-ceramic
restorations.
Figs 1-6-2a to 1-6-2c Guided Universal Prep Set, Intensiv
(reproduced with permission from Intensiv).

1.6.2 Minimally invasive preparation

techniques
Anterior veneers
The classic indications for anterior veneers include:
■ morphological problems, anomalies of shape
■ diastema
■ inappropriate tooth length
■ discolorations resistant to bleaching
■ fractures of coronal parts
■ erosive or abrasive loss of enamel
■ black interdental triangles1
The veneer preparation design is defined by the initial problem and
the treatment goal, ie, the diagnostic wax-up. A silicone key of the
wax-up is used as reference method during the preparation. In case
of virtual diagnostics, a resin model of the virtual wax-up can be
fabricated by means of 3D printing and can be used for the
manufacturing of a conventional silicone key.
Different types of veneers are applied today.

Non-prep partial veneers, etch pieces

The least invasive types of veneers, the non-prep partial veneers
(also known as etch pieces) are indicated for the modification of the
width or shape of sound anterior and posterior teeth without
discoloration2.
As no or almost no preparation is performed, the etch pieces tend
to exhibit slightly overcontoured margins which can be difficult to
manage in esthetically crucial, visible areas. The type of preparation-
veneer margin exhibits significant influence on the outcome.
In general, horizontal margins are more difficult to mask than
vertical margins (Fig 1-6-3).
Fig 1-6-3a Highlighted horizonal fracture and preparation lines after
incisal fractures due to a trauma on teeth 11 and 21.

Fig 1-6-3b Rounded and smoothened incisal borders.

Fig 1-6-3c Feldspathic ceramic incisal etch pieces.

Fig 1-6-3d Patient’s smile several days after the adhesive

cementation of the etch pieces. Note the slightly visible margin lines
of the etch pieces.

Direct composite restorations may be esthetically more advisable

in clinical situations with horizontal margin lines, than ceramic etch
pieces. Yet, the clinician needs to master esthetic composite
restorations in clinical situations with high translucency and/or internal
staining.
If planning an etch piece, a vertical margin preparation can be
placed into the area of the mesial or distal vertical line angles (Fig 1-
6-4). Minimal preparation of vertical grooves can be performed in
order to:

Fig 1-6-4a Initial situation – diastema after orthodontic treatment,

patient desired a restorative solution.
Fig 1-6-4b Conventional impression taking with ultra-fine cords, no
preparation.

Fig 1-6-4c Two feldspathic etch pieces 12, 13 with vertical margin
lines following the anatomical structures of the abutment teeth for
masking.
Fig 1-6-4d Note how thin the ceramic etch pieces are.
Figs 1-6-4e and 1-6-4f Final situation after adhesive cementation
with a light-curing flowable composite filling material.

■ mask the margin of the etch piece

■ guide the positioning of the etch piece during the adhesive
cementation.
Additional veneers
The additional veneers are more extended than etch pieces, but also
belong to the low-or non-prep veneer types3. They are indicated at
ideal quality and color of the enamel for the esthetic improvement of
the shape of the anterior teeth. These more extended types of
veneers imply minimal tooth preparation to establish a path of
insertion and to deliver space for the ceramics.
Again, a thorough analysis of the clinical situation and
pretreatment diagnostics with conventional or virtual wax-up is
mandatory; furthermore, an analysis of the study casts and the
definition of the preparation design is recommended. Preparation
guides, fabricated out of resin, help transferring the treatment goal
into the clinical situation, while maintaining the least invasiveness
during the preparation.
In case of horizontal fracture lines, a gradually decreasing
preparation of the buccal enamel from the incisal to the marginal
regions needs to be performed, in order to deliver sufficient space for
the dental technician to mask the horizontal tooth–ceramic transition
line with the veneer.
In order to be as minimally invasive as possible, a thorough
analysis of the diagnostics is performed comparing the planned
outline with the actual tooth shape. This analysis includes the
determination of the future restoration–tooth transition zone. If a
preparation has to be performed, the area to be slightly reduced is
marked with a waterproof pencil on the tooth surface (Fig 1-6-5).
Fig 1-6-5a Initial situation of a patient seeking esthetic improvement
of the smile, ie, anterior maxillary region. Note the old metal-ceramic
crowns on 11 and 21 with discolored gingival margin.

Fig 1-6-5b Extraoral anterior situation with relaxed lips and exposed
anterior dentition.
Fig 1-6-5c Diagnostic mock-up made in the laboratory.

Fig 1-6-5d Try-in of mock-up, definition of treatment goal.

Fig 1-6-5e Regions in need for minimally invasive preparation
according to mock-up marked on study cast.
Fig 1-6-5f to 1-6-5i Preparation guides indicating the needed
preparation and markings on the teeth indicating regions needing
minimally invasive preparation.
Fig 1-6-5j Intraoral view of situation after insertion of the minimally
invasive additional ceramic veneers and two new all-ceramic crowns
11 and 21.

Fig 1-6-5k Final smile of the patient with improved anterior esthetics.

For the additional veneers, the preparation is performed without a

clearly marked margin line unlike with the conventional veneer
preparation, more resembling a feather-edge preparation design.
This “margin-less” preparation delivers entire liberty to the technician
to design the additional veneer according to the esthetic goal.
The schematic step-by-step preparation procedure for an
additional veneer is shown in Fig 1-6-6. The clinical step-by-step
procedure is presented in Part II, Chapter 1.
Figs 1-6-6a to 1-6-6cc Schematic step-by-step preparation
procedure for an additional veneer.
Figs 1-6-6a to 1-6-6cc Schematic step-by-step preparation
procedure for an additional veneer.

Conventional veneers
With slightly to moderately discolored abutment teeth, the thickness
of the ceramic veneer has to be increased to allow for a masking of
the discoloration inducing the need for a conventional veneer
preparation4 (Fig 1-6-7). Furthermore, for extended modifications of
the shape, size, or position of abutment teeth a conventional veneer
preparation may be indicated.
Fig 1-6-7a Anterior region of a male patient aged 35, who had
experienced a trauma and the loss of vitality of the incisor 21. In
addition, his entire anterior teeth were worn due to bruxism. He
wished for esthetic improvement.

Fig 1-6-7b The first step in the present minimally invasive treatment
concept was the internal bleaching of the discolored abutment tooth
21, accompanied by a pretreatment with a Michigan splint to reduce
the parafunctions.
Fig 1-6-7c Then, the treatment goal was defined with a diagnostic
wax-up. The treatment plan was veneers on teeth 12–22 and build up
of the canine guidance by means of additional incisal veneers.

Fig 1-6-7d By means of a silicone key of the approved diagnostic

wax-up, the need for abutment tooth preparation was evaluated. Note
the arrows indicating where a slight change of the interproximal
contact zones was planned. In these regions, the need for opening of
the interdental regions was necessary.
Fig 1-6-7e In the incisal regions of the teeth prepared for veneers,
flat palatally angled preparation finishing lines were delivered.

Fig 1-6-7f Conventional veneer preparation oriented at the diagnostic

silicone key.
Figs 1-6-7g and 1-6-7h Virtual files (.STL) of the situation before
and after the preparation for analysis of the amount of tooth structure
to be removed.
Fig 1-6-7i Superimposition of the .STL files of the situation before
and after the preparation to analyze the amount of removed tooth
substance (mm). Note the predominantly minimal removal of tooth
substance only increased in the interproximal areas where needed for
the planned changes.

Fig 1-6-7j Feldspathic conventional (12–22) and additional (13, 23)

veneers, manually made on refractive dies.
Fig 1-6-7k Anterior situation after the adhesive cementation of the
minimally invasive anterior restorations.

The preparation includes a 0.5 mm rounded shoulder margin, and

an axial reduction of the enamel to allow for 0.7 mm of ceramic
thickness. Furthermore, an incisal reduction of 1.5 mm of ceramic
thickness is needed. In palatal/lingual regions the finishing line is
inclined and the feather-edge preparation margin is located 0.5 mm
below the incisal edge5.
This design and these dimensions are needed to support the
technician in delivering optimal esthetic results with the feldspathic or
glass-ceramics.
Again, the preparation is performed with aid of a silicone key of
the diagnostic wax-up used to deliver the needed amount of space for
the future restoration while preserving the tooth substance as much
as possible.
The schematic step-by-step procedure is shown in Fig 1-6-8.
Figs 1-6-8a to 1-6-8kk Schematic step-by-step preparation
procedure for conventional veneers.
Figs 1-6-8a to 1-6-8kk Schematic step-by-step preparation
procedure for conventional veneers.

Posterior occlusal veneers

The present concept can also be applied in posterior regions, for the
rehabilitation of worn or eroded occlusal enamel (occlusal veneer), or
in combination with a facial Part to modify the shape and/or color of
the posterior tooth (Fig 1-6-9).
Figs 1-6-9a to 1-6-9d The current minimally invasive treatment
concept can also be applied in the posterior regions. In this case
example, the diastema between teeth 23 and 24 was closed by
means of a non-prep additional partial veneer, covering Part of the
occlusal surface and the mesial surface of 24. The feldspathic veneer
was adhesively cemented as described in Part I, Chapter 9.
The basic principles for the preparation are the same as for
anterior veneers. The prerequisite for the clinical stability of the
occlusal veneers is the presence of a layer of occlusal/facial enamel6.

1.6.3 Defect-oriented preparation

techniques for posterior teeth:
onlays, overlay-veneers, and
partial crowns
For posterior teeth in need of prosthetic rehabilitation, defect-oriented
restorations like overlays, overlay-veneers, and partial crowns are
considered prior to considering full-crown restorations. Thanks to the
adhesive cementation technology of ceramic- or resin-based
materials, missing tooth substance can be replaced by adhesively
fixing a partial restoration to the remaining tooth substance7.
Therefore, the preparations are oriented by the defect situation,
and no strict guidelines exist with respect to the shape of the
abutment tooth. A relevant parameter to be considered to be
considered is the manufacturer-related material-specific minimal
material dimensions (for details, see Part I, Chapter 1).
More recent adapted preparation guidelines of the new designs of
overlays and overlay-veneers encompass8:
■ 1–1.5 mm interproximal box butt joint preparation with rounded
inner angles
■ 6–10 degree divergence of inner walls
■ rounded inner walls
■ sharp margins toward the occlusal surface
■ 1–2 mm anatomically oriented occlusal reduction
■ inclined planes on buccal and palatal/lingual sides
■ sharp margins or rounded shoulder at buccal and palatal/lingual
sides (Fig 1-6-10).
Figs 1-6-10a to 1-6-10d Minimal preparations of worn posterior
teeth for ceramic overlay-veneers, situation after diagnostic etching of
6
the remaining for the evaluation of the needed ceramic thickness .

A schematic step-by-step procedure is shown in Fig 1-6-11. The

clinical step-by-step procedure is presented in Part II, Chapter 3.
Figs 1-6-11a to 1-6-11l Schematic step-by-step procedure of the
minimally invasive abutment tooth preparation for overlay-veneers,
occlusal veneers, and onlays.

1.6.4 Conventional crown and fixed

dental prosthesis (FDP)
preparation technique: the
universal tooth preparation
Conventional crown and FDP preparations have to fulfill numerous
material- and fabrication-related criteria today:
■ Sufficient space for all types of restorative materials (metal-
ceramics, various all-ceramics)
■ Clearly visible, rounded preparation margins for computer-aided
processing
■ Smooth line angles, rounded boarders, and edges for ceramic-
based materials
■ Convergence suitable for digital workflows and computer-aided
design and computer-aided manufacturing (CAD/CAM)
technology.

Before preparing the tooth for the restoration several potentially

crucial factors have to be considered. Firstly, different restorative
materials have different requirements both from an esthetic and a
mechanical perspective (Fig 1-6-12).
Fig 1-6-12 Summary of the necessary space to be created at the
preparation for crowns made out of metal-ceramic, glassceramic,
and zirconia.

Furthermore, the design of the abutment tooth preparation has a

significant influence on the outcomes of allceramic restorations. With
CAD/CAM fabrication, the accuracy of the CAD/CAM-made
frameworks is influenced by the preparation, as has been shown for
zirconia9.
In the present concept, a universal tooth preparation fulfilling all
requirements for all types of materials and fabrication techniques for
crowns and FDPs (Universal Prep Set, Intensiv) is performed. The
universal tooth preparation fulfills the following criteria (Fig 1-6-13):
Figs 1-6-13a and 1-6-13b Illustration of a preparation issue that can
cause problems with the fabrication of CAD/CAM restorations. With
CAD/CAM procedures the minimal dimensions of the milling/grinding
instruments need to be considered when preparing incisal boarders
or occlusal surfaces. Too narrow and steep preparations might not be
transferred into the CAD/CAM ingots as virtually designed because of
the milling instrument geometry, which can lead to problems with the
fit of the restorations.
Fig 1-6-13c Two universally prepared differently colored abutment
tooth substrates. The prerequisites for all material options were
fulfilled and the selection can be based on the esthetic demands.
Note that slightly more tooth substance was removed on the left
central incisor, to allow greater ceramic thickness to mask the
discoloration.

■ 0.8–1 mm marginal shoulder, epigingival or ≤0.5 mm subgingival

■ 10–12-degree total occlusal convergence ≥1.5 mm axial reduction
■ 1.5–2 mm incisal/occlusal reduction
■ 1 mm minimal labial–lingual width of incisal edge of anterior teeth
■ 30-degree buccolingual reduction of occlusal surface
■ height of axial walls 3–4 mm
■ line angles and edges smoothed and rounded
■ no undercuts in case of splinted multiple-unit restorations.

The step-by-step procedure for the universal tooth preparation is

shown in Fig 1-6-14. A clinical example is shown in Fig 1-6-15.
Figs 1-6-14a to 1-6-14gg Schematic step-by-step procedure of a
universal abutment tooth preparation for crowns and fixed dental
prostheses.
Figs 1-6-14a to 1-6-14gg Schematic step-by-step procedure of a
universal abutment tooth preparation for crowns and fixed dental
prostheses.
Figs 1-6-15a and 1-6-15b Preparation of the rounded shoulder and
the axial and incisal walls by means of the cylindrical shoulder
diamond (Universal Prep Set, Intensiv).
Fig 1-6-15c Preparation of the palatal regions with aid of the
rounded football-shaped diamond (Universal Prep Set, Intensiv).
Figs 1-6-15d and 1-6-15e Facial and incisal view of the universal
tooth preparation, adequate for crowns made out of all materials and
either manually or by CAD/CAM procedures. Note the clearly visible
margin allowing for all types of impressions (conventional, optical)
and accurate restorations.
Figs 1-6-15f and 1-6-15g Application desensitizing primer on
prepared abutment tooth for the sealing and the desensitization of the
dentin.

1.6.5 Virtual diagnostics and guided

tooth preparation
As mentioned before, the most important prerequisite for minimally
invasive prosthodontic treatment is thorough pretreatment diagnostics
to define the treatment goals.
Limitations of the conventional workflow include the time and effort
needed to produce a conventional diagnostic wax-up and trial
restoration, and the associated costs for this procedure. One further
limitation is the predictability of the transfer of this plan to the patient.
Silicone matrices may help evaluate the area and amount of tooth
preparation needed during the procedure, but the predictability of the
procedure is not ensured. Silicone matrices deliver 2D information
during the preparation and are limited to one or two buccolingual or
mesiodistal slices. To ensure minimal invasiveness and optimal
standardization, a 3D preparation guide is desirable.
The 3D information of maxillary and mandibular dentitions obtained
by means of optical impressions can be used for virtual diagnostics
and treatment planning. Furthermore, in clinical situations with
reduction of the vertical dimension of occlusion (VDO), a virtual
increase of VDO can be performed10,11. Optimal interocclusal
clearances can also be determined in the 3D analysis by following the
recommendations for different restorative materials (see Part I,
Chapter 1). Locations without sufficient clearance are color-coded on
the 3D image (virtual 3D diagnostics), indicating the amount of tooth
substance to be removed based on the 3D virtual diagnostics. To
transfer this 3D information predictably to the clinical situation and to
ensure least invasive tooth preparation, CAD/CAM preparation guides
need to be designed and produced. Optimal interocclusal clearances
can also be determined in the 3D analysis by following the
recommendations for different restorative materials. Locations
without sufficient clearance are color-coded on the 3D image (virtual
3D diagnostics), indicating the amount of tooth substance to be
removed based on the 3D virtual diagnostics. To transfer this 3D
information predictably to the clinical situation and to ensure least
invasive tooth preparation, a CAD-CAM preparation guide is designed
and produced visualizing the needed (minimal) amount of tooth
structure to be removed.
The printed preparation guide based on 3D virtual diagnostics,
indicates the location and amount of tooth substance to be removed.
It can be virtually designed and printed using CAD/CAM technology12.
This 3D diagnostic tool can be used for both patient consultation and
minimally invasive preparation. In addition, although this technique
was initially introduced for VDO increase in patient with extensive
tooth wear12, it may also be applied in various other clinical situations
(Fig 1-6-16).

Fig 1-6-16a Virtual analysis of the vertical space needed for the
planned full-mouth minimally invasive rehabilitation of this patient
suffering from generalized erosive wear of the teeth.
Fig 1-6-16b Virtual wax-up of the maxillary dentition.

Fig 1-6-16c Schematic analysis of needed reduction of tooth

substance for the planned restorations.
Fig 1-6-16d Design of the prep guides on the virtual file of the
maxilla, exposing the very localized tooth substance to be removed
for the minimally invasive restorations.

Fig 1-6-16e .STL files of the prep guides to be 3D printed.

Fig 1-6-16f 3D-printed preparation guides, developed according to
the virtual diagnostics with aid of a virtual design software.

Fig 1-6-16g Printed prep-guide inserted in the posterior region of the

maxilla. Areas to be removed by preparation are uncovered and the
amount of required tooth substance removal is defined by the lateral
walls of the prep guide.
Figs 1-6-16h Areas marked in red color are to be removed.

Figs 1-6-16i Areas marked in red color are to be removed.

Fig 1-6-16j Localized guided minimally invasive tooth preparation
with a football-shaped diamond instrument (Universal Prep Set,
Intensiv).
Figs 1-6-16k and 1-6-16l Situation after the localized minimally
invasive reduction of the tooth substance, delivering the needed
clearance for the planned occlusal ceramic veneers.

1.6.6 Resin-bonded fixed dental

prosthesis (RBFDP) preparation
All-ceramic RBFDPs are mainly indicated in anterior regions for the
replacement of central and lateral incisors in the maxilla and
mandibular incisors.
RBFDPs are indicated in:
■ adolescents and young adults with congenitally missing teeth or
teeth lost due to trauma, which cannot be replaced with single
implants due to the age of the patient
■ patients with narrow single-tooth edentulous spaces not suitable
for the placement of implants
■ patients with missing single-tooth with healthy adjacent teeth that
are not willing to undergo implant surgery
■ patients with medical contraindications for implant surgery13–15

Contraindications
RBFDPs are presently not indicated in the following clinical situations
described below.
In the present concept, the replacement of missing canines with
RBFDPs cannot be recommended. In contrast to the incisor area, the
replacement of canines with all-ceramic RBFDPs may be critical due
to the type of load that occurs during function in canine regions.
During the occlusal/lateral movements of the jaws high tensile load is
16 17
induced to the retainer and/or the connector area of the RBFDP , .
This may lead to increased risk for fracture or de-bonding of the
RBFDP during canine guidance. Consequently, the required
dimensions for the retainer and connector need to be increased in the
canine region and sufficient space needs to be provided by a more
invasive abutment tooth preparation.
Furthermore, the replacement of missing posterior teeth with
RBPs can presently not be recommended. To date, very little
information is available on the clinical outcomes of all-ceramic
posterior RBFDPs18. Systematic reviews demonstrate lower survival
rates of the RBFDPs in posterior regions (see also Part III).
Relative contraindications
In the following clinical situations RBFDPs can be problematic due to
lack of space or malpositioning of the abutment teeth:
■ deep bite
■ crowded teeth
In these situations orthodontic pretreatment should be performed in
order to provide the conditions indicated for the RBFDPs. Another
relative contraindication for allceramic RBFDPs is parafunctional
habits and bruxism. Affected patients need to be informed about the
increased risk for fracture or debonding of the all-ceramic RBFDPs.
Finally, in case of insufficient esthetics of the abutment tooth
(discolored, unesthetic shape/size), a full crown with a cantilever may
be a better treatment option than a RBFDP due to the fact that with
the full coverage design the esthetics of the abutment tooth are not
likely to be influenced.

Absolute contraindications
Clinical situations that represent absolute contraindications for all-
ceramic RBFDPs are:
■ more than one missing tooth, ie, multiple pontics
■ enamel deficiency (eg, amelogenesis imperfecta)
■ all other types of enamel defects (eg, severe erosions/abrasions)
■ caries or extensive fillings on abutment teeth.
The clinical success of the all-ceramic RBFDPs is highly dependent
on careful selection of the appropriate patient and site. The site-
specific clinical prerequisites for anterior RBFDPs are:
■ overjet >0.5–1 mm allowing for sufficient space for a retainer
■ overbite <1–1.5 mm in order to provide sufficient area for the
bonding
■ centric occlusal contacts located in incisal third, leaving sufficient
area for the retainer
The selection of the most appropriate abutment tooth for the anterior
RBFDP is based on the palatal/lingual space offered in centric
occlusion, and on the shape and size of the palatal/lingual surface.
Two factors have to be evaluated in order to choose the most
appropriate abutment tooth:
■ size of the palatal/lingual surface area that can be used for the
bonding
■ shape of the palatal/lingual surface – ideally oval or round in order
to allow for a “wrap-around” design of the retainer (Fig 1-6-17)
Figs 1-6-17a and 1-6-17b Incisal views of two RBFDPs replacing
lateral incisors. Note the improved “embracing effect” at the round
canine abutment tooth as compared to the flat central incisor.

The selection of the ceramic for an anterior RBFDP is based on the

following factors:
amount of interocclusal space in the abutment tooth and pontic
■ regions (vertical and horizontal dimensions)
■ minimally required dimensions for the framework and the
connector at the different types of ceramics
■ color/shade of the teeth adjacent to the area to be restored

The pretreatment diagnostic planning should encompass a thorough

planning of the least invasive yet retentive tooth preparation for each
patient situation with the study casts.
The minimally invasive retentive preparation adapted to the
properties of ceramics (most specifically zirconia) and their
CAD/CAM fabrication procedures was developed, and is
recommended for RBFDPs that are planned as definitive treatment
option.
The minimally invasive preparation design for anterior zirconia-
based RBFDPs encompasses the preparation of a mesial and a
distal vertical groove plus a tiny slot in the palatal/lingual cingulum
region (Fig 1-6-18).
Figs 1-6-18a to 1-6-18f Step-by-step clinical approach at the
minimally invasive preparation for a one-wing cantilever RBFDP.
Parallel vertical grooves are first defined with a conical narrow
separation diamond instrument, followed by enlarging of the grooves
to the appropriate dimensions for the CAD/CAM restoration and
finalized with a vertical stop in the cingulum region with a round
diamond instrument (all diamonds Universal Prep Set, Intensiv). The
position of the vertical grooves is crucial for the retention of the
framework by providing best esthetics – the most buccal as possible,
yet, palatal of the prospective interproximal contact point.
Finally, for good accuracy of the CAD/CAM fabricated zirconia
frameworks, it is crucial to round the palatal margins of the mesial
and distal grooves before the impression (Fig 1-6-19).

Fig 1-6-19 It is highly recommended to round the palatal preparation

margin at both vertical grooves to allow for reproducibility of the
geometry with CAD/CAM and, thereby, good accuracy of the
retaining wing.

The schematic step-by-step procedure is shown in Fig 1-6-20.

Figs 1-6-20a to 1-6-20w Schematic step-by-step procedure of
minimally invasive tooth preparation for resin-bonded fixed dental
prostheses. The red area cannot be used for the wing of the RBFDP.
Figs 1-6-20a to 1-6-20w Schematic step-by-step procedure of
minimally invasive tooth preparation for resin-bonded fixed dental
prostheses. The red area cannot be used for the wing of the RBFDP.

1.6.7 Conclusions
In the current concept, it is the aim to preserve tooth substance as
much as possible, hence the minimally invasive preparation
procedures dominate. Yet, also with the conventional crown and FDP
preparation only the individually needed amount of tooth substance is
removed. To assure for a least invasive process, the pretreatment
diagnostics is crucial, as it defines the treatment goal which is
transferred to the clinical preparation session by means of indexes or
keys.

1.6.8 References
1. Edelhoff D, Prandtner O, Saeidi Pour R, Liebermann A,
Stimmelmayr M, Guth JF. Anterior restorations: the
performance of ceramic veneers. Quintessence Int 2018;49:89–
101.
2. Piwowarczyk A, Blum J, Abendroth H. Non-prep restoration of
an ankylosed incisor: a case report. Quintessence Int
2015;46:281–285.
3. Imburgia M, Cortellini D, Valenti M. Minimally invasive vertical
preparation design for ceramic veneers: a multicenter
retrospective follow-up clinical study of 265 lithium disilicate
veneers. Int J Esthet Dent 2019;14:286–298.
4. Xing W, Chen X, Ren D, Zhan K, Wang Y. The effect of ceramic
thickness and resin cement shades on the color matching of
ceramic veneers in discolored teeth. Odontology
2017;105:460–466.
5. Radz GM. Minimum thickness anterior porcelain restorations.
Dent Clin North Am 2011;55:353–370, ix.
6. Schlichting LH, Maia HP, Baratieri LN, Magne P. Novel-design
ultra-thin CAD/CAM composite resin and ceramic occlusal
veneers for the treatment of severe dental erosion. J Prosthet
Dent 2011;105:217–226.
7. Morimoto S, Rebello de Sampaio FB, Braga MM, Sesma N,
Ozcan M. Survival rate of resin and ceramic inlays, onlays, and
overlays: a systematic review and meta-analysis. J Dent Res
2016;95:985–994.
8. Veneziani M. Posterior indirect adhesive restorations: updated
indications and the morphology driven preparation technique. Int
J Esthet Dent 2017;12:204–230.
9. Beuer F, Edelhoff D, Gernet W, Naumann M. Effect of
preparation angles on the precision of zirconia crown copings
fabricated by CAD/CAM system. Dent Mater J 2008;27:814–
820.
10. Alghazzawi TF. Advancements in CAD/CAM technology: options
for practical implementation. J Prosthodont Res 2016;60:72–
84.
11. Solaberrieta E, Otegi JR, Minguez R, Etxaniz O. Improved
digital transfer of the maxillary cast to a virtual articulator. J
Prosthet Dent 2014;112:921–924.
12. Lee H, Fehmer V, Kwon KR, Burkhardt F, Pae A, Sailer I.
Virtual diagnostics and guided tooth preparation for the
minimally invasive rehabilitation of a patient with extensive tooth
wear: a validation of a digital workflow. J Prosthet Dent
2020;123:20–26.
13. Kern M. Fifteen-year survival of anterior all-ceramic cantilever
resin-bonded fixed dental prostheses. J Dent 2017;56: 133–
135.
14. Sailer I, Hammerle CH. Zirconia ceramic single-retainer resin-
bonded fixed dental prostheses (RBFDPs) after 4 years of
clinical service: a retrospective clinical and volumetric study. Int
J Periodontics Restorative Dent 2014;34:333–343.
15. Sasse M, Kern M. All-ceramic resin-bonded fixed dental
prostheses: treatment planning, clinical procedures, and
outcome. Quintessence Int 2014;45:291–297.
16. Koutayas SO, Kern M, Ferraresso F, Strub JR. Influence of
framework design on fracture strength of mandibular anterior
all-ceramic resin-bonded fixed partial dentures. Int J
Prosthodont 2002;15:223–229.
17. Pospiech P, Rammelsberg P, Goldhofer G, Gernet W. All-
ceramic resin-bonded bridges. A 3-dimensional finite-element
analysis study. Eur J Oral Sci 1996;104:390–395.
18. Sailer I, Bonani T, Brodbeck U, Hammerle CH. Retrospective
clinical study of single-retainer cantilever anterior and posterior
glass-ceramic resin-bonded fixed dental prostheses at a mean
follow-up of 6 years. Int J Prosthodont 2013;26: 443–450.
CHAPTER 7
Provisional restorations

1.7.1 Introduction
In this chapter:
■ Direct provisionals
■ Eggshell provisionals
■ CAD/CAM provisionals
Provisional restorations play an important role for the rehabilitation of
patients with fixed restorations1,2.
On the one hand, provisional restorations protect the abutment
teeth from thermal, chemical, and bacterial irritations3–5, while on the
other they maintain the mesiodistal and coronoapical position of the
prepared abutment teeth6 (Fig 1-7-1). But, most importantly, they are
an important means for the communication of the treatment goal and
for the trial of the planned tooth shape, position, and function before
final restoration.
Fig 1-7-1 Abutment tooth preparations for full crown restorations,
prior to provisionalization.

Different types of provisionals exist. In the following the most

relevant fixed provisionals will be discussed and compared: the direct
provisionals, the eggshell provisionals and, finally, the more recent
computer-aided design and computer-aided manufacturing
(CAD/CAM) provisionals, illustrated by a clinical case example (Fig 1-
7-1).

1.7.2 Direct provisionals

The direct provisionals can either be fabricated as a copy of the pre-
existing dental situation, or as a copy of the diagnostic wax-up. They
are manually fabricated in the dental office after the preparation of
the abutment teeth, using a silicone index to deliver the shape. The
direct provisionals are fabricated out of self-polymerizing
polymethylmethacrylate (PMMA) or composite resins, which
polymerize intraorally (Fig 1-7-2).
Figs 1-7-2a and 1-7-2b Direct provisionals made out of a self-curing
composite provisional resin (Protemp).
Fig 1-7-2c Inserted provisionals; note the transparency of the resin.
As the initial situation was used for fabrication of the provisionals, and
not the diagnostic wax-up where a change in shape and position was
foreseen for the final restorations, the provisional crown 21 was very
thin and the abutment tooth was shining through, leading to esthetic
limitations.

The advantage of the direct provisionals is that they are fabricated

fast and easily and do not cost very much. One downside is that both
the clinician as well as the patient come into contact with not yet
polymerized monomers, which can cause allergic reactions in
susceptible people. Another downside may be the esthetic outcome.
The provisional resins for the direct provisional restorations are rather
monochromatic and direct provisionals may not fulfill highest esthetic
demands2,7,8.
The flexural strength of the PMMA (eg, Trim) used for direct
provisionals was low with 5.9 MPa, while the one of provisional
composites (eg, Protemp) was 53.4 MPa9. Hence, direct provisionals
derived from PMMA are indicated for time periods between 2 weeks
and from composite up to 6 months1.
1.7.3 Eggshell provisionals
In patient situations with high esthetic demands, laboratory
prefabricated eggshell provisionals are indicated. The eggshell
provisionals are fabricated out of PMMA according to the diagnostic
wax-up/set-up. A silicone key of the diagnostics is made in the
laboratory, and the dentin and enamel shades of the resin are
individually layered. The polymerization is performed at 45°C and with
application of pressure to condense the resin. After the finalization of
the surface texture and shape, the outer Part of the eggshell
provisional is high gloss polished. The inner Part is holed, leaving
space for the respective clinical lining in the dental office with
autopolymerizing resin10,11.
The eggshell provisional is more time- and cost-consuming than
the direct provisional, yet its esthetic outcome is superior.
Furthermore, the very low or no remaining monomers are less prone
to induce allergic reactions. Still, thanks to the option of fabricating
CAD/CAM provisionals, the eggshells are less used today (Fig 1-7-
3).
Fig 1-7-3a Esthetically adapted eggshell provisional for the same
patient situation as above. Note the individually layered resin,
mimicking the chroma and translucency of the natural dentition.

Fig 1-7-3b Good esthetic integration of the provisional.

The flexural strength of the PMMA (Trim) used for eggshell

provisionals was approximately 21.8 MPa. The eggshell provisionals
19
are indicated for time periods between 3 and 6 months1,9.

1.7.4 CAD/CAM provisionals

CAD/CAM provisionals are milled out of industrially prefabricated,
fully polymerized PMMA ingots12. The shape of the provisionals can
be defined fully virtually or as a copy of a conventional wax-up.
After the preparation of the abutment teeth an intraoral optical
impression is made, and the provisionals are designed with one of the
above methods. In case of single-unit or short-span multiple-unit
provisionals, milling can be performed with a chair-side milling
machine. In case of larger span fixed dental prostheses (FDPs),
larger resin ingots and a laboratory milling machine are needed (Fig
1-7-4).

Fig 1-7-4a CAD/CAM milled provisional restorations delivering a

decent esthetic result. The .STL file for the provisionals was based
on the diagnostic wax-up, enabling the patient to evaluate the planned
shape and contour of the final restorations.
Fig 1-7-4b Acceptable esthetic integration of the milled provisional
restorations.

Numerous manufacturers offer prefabricated resin ingots for the

in-office and laboratory milling units. The ingots are available in
multiple shades, and even in different grades of shades within one
ingot for better esthetics. The stability of the CAD/CAM provisional
resins ranged between 384 and 467 MPa. The CAD/CAM
provisionals are indicated for time periods of 6–9 months1,13.
The most recent introduction, the 3D printed resin provisional
restorations are in their initial stage and no clinical information on their
indications and limitations is yet available.

1.7.5 Conclusions
Provisional restorations play a significant role for the testing of the
diagnostic plan prior to the finalization of the fixed restorations.
Different types of provisional restorations can be applied today. In the
current treatment concept, the CAD/CAM milled or (in the future) 3D
printed provisionals best combine the copying of the diagnostics with
good material stability of the provisional resins, and are hence
recommended.

1.7.6 References
1. Astudillo-Rubio D, Delgado-Gaete A, Bellot-Arcis C, Montiel-
Company JM, Pascual-Moscardo A, Almerich-Silla JM.
Mechanical properties of provisional dental materials: a
systematic review and meta-analysis. PLoS One 2018;13:
e0193162.
2. Fondriest JF. Using provisional restorations to improve results in
complex aesthetic restorative cases. Pract Proced Aesthet
Dent 2006;18:217–223.
3. Gupta N, Reddy UN, Vasundhar PL, Ramarao KS, Varma KP,
Vinod V. Effectiveness of desensitizing agents in relieving the
pre- and postcementation sensitivity for full coverage
restorations: a clinical evaluation. J Contemp Dent Pract
2013;14:858–865.
4. Lockard MW. A retrospective study of pulpal response in vital
adult teeth prepared for complete coverage restorations at
ultrahigh speed using only air coolant. J Prosthet Dent
2002;88:473–478.
5. Suzuki S, Cox CF, White KC. Pulpal response after complete
crown preparation, dentinal sealing, and provisional restoration.
Quintessence Int 1994;25:477–485.
6. Roe P, Patel RD. Fabrication of a modified repositioning key for
relining provisional restorations. J Prosthet Dent 2010;104:401–
402.
7. Lang R, Rosentritt M, Behr M, Handel G. Fracture resistance of
PMMA and resin matrix composite-based interim FPD
materials. Int J Prosthodont 2003;16:381–384.
8. Schwedhelm ER. Direct technique for the fabrication of acrylic
provisional restorations. J Contemp Dent Pract 2006;7: 157–
173.
Nejatidanesh F, Momeni G, Savabi O. Flexural strength of
9. interim resin materials for fixed prosthodontics. J Prosthodont
2009;18:507–511.
10. Chiche GJ, Avila R. Fabrication of a preformed shell for a
provisional fixed partial denture. Quintessence Dent Technol
1986;10:579–581.
11. Dumbrigue HB. Composite indirect-direct method for fabricating
multiple-unit provisional restorations. J Prosthet Dent
2003;89:86–88.
12. Guth JF, Almeida ESJS, Ramberger M, Beuer F, Edelhoff D.
Treatment concept with CAD/CAM-fabricated high-density
polymer temporary restorations. J Esthet Restor Dent
2012;24:310–318.
13. Stawarczyk B, Ender A, Trottmann A, Ozcan M, Fischer J,
Hammerle CH. Load-bearing capacity of CAD/CAM milled
polymeric three-unit fixed dental prostheses: effect of aging
regimens. Clin Oral Investig 2012;16:1669–1677.
CHAPTER 8
Impression techniques

1.8.1 Introduction
In this chapter:
■ Biological width
■ Methods for temporary tissue retraction
■ Conventional impressions
■ Optical impressions
To ensure well-adapted restoration margins, an accurate impression
of the abutment teeth or implants and the surrounding tissues is
required. Even though the entire procedure is executed meticulously,
a restoration will theoretically never fit perfectly to the preparation
margin. Microscopically, a gap of a few microns between the
restoration and the tooth will always be present. Studies have shown
that when the gap between the tooth and restoration exceeds 150
µm, permanent damage of the periodontium is more likely to occur1–3.
Gingival health is an important factor that can influence both
conventional and optical impressions. Taking an impression of
abutment teeth suffering from gingivitis demands more aggressive
retraction measures, to keep the area clean and dry, which increases
the risk of gingival recession4,5. Well-contoured provisional
restorations of good quality facilitate oral hygiene measures and are
fundamental in maintaining the gingival health of a tooth undergoing
restorative procedure. This in turn, facilitates taking the impression6–
9
.
1.8.2 Biological width
Biological width is a term frequently used to describe the dimensions
of soft tissue around teeth and implants (Fig 1-8-1). The biological
width concept goes back to the early studies of Gottlieb and co-
workers from 1921, which documented that the soft tissue attached
to teeth consisted of two parts: fibrous tissue and epithelial tissue10–
13
. Histomorphometric measurements performed to evaluate the soft-
tissue dimensions reported an average sulcus depth of 0.7 mm
(range 0.4–1.1 mm), an average dimension of the junctional
epithelium attachment of 1 mm (range 0.4–1.6 mm), and an average
dimension of the connective tissue attachment of 1.1 mm (range 0.7–
1.5 mm). There is evidence that when the preparation margin extends
into the junctional epithelium or the connective tissue, that is, violates
the biological width, the risk of attachment loss is significantly
increased14–18. To maintain healthy gingival tissues the crown margins
should be placed in the gingival sulcus. Hence, on average the
preparation margin should not be deeper than 0.7 mm from the
gingival margin. One way to mark the sulcus depth before preparing a
tooth is to carefully insert a fine moist retraction cord (#000, #00, or
#0) into the sulcus and then stay with the preparation margin above
the inserted cord.
Figs 1-8-1a to 1-8-1c The biological width consists of three parts:
the sulcus (1), the junctional epithelium (2), and the connective tissue
(3), with an average total width of 3 mm.

1.8.3 Methods for temporary tissue

retraction
Gingival retraction methods used today can be divided into
mechanical methods, and chemical methods or combinations of those
methods19,20. It is important to carefully place the retraction cord (Fig
1-8-2) into the gingival sulcus to prevent unnecessary damage to the
junctional epithelium and supracrestal connective tissue fibers21.
Studies have shown that the placement of a dry cotton cord into the
gingival sulcus can cause damage to the gingival epithelium. In the
purely mechanical method for gingival retraction a moist cotton cord
without any additional agent is placed in the gingival sulcus22.
However, in the mechanical-chemical method the cotton cord is
impregnated with different medicaments, eg, epinephrine, aluminum
chloride, zinc chloride, aluminum sulfate, tannin, or ferric sulfate23.
Today, the chemical-mechanical method is most frequently used for
temporary gingival retraction24.

Fig 1-8-2 The retraction cord must be placed with caution to avoid
unnecessary damage to the junctional epithelium and supracrestal
connective tissue fibers.

Basically, there are two methods used for temporary gingival

retraction with cotton cords: single cord and double-cord technique:
■ “Single cord technique”: One cotton cord is placed into the gingival
sulcus to make the preparation margin accessible for the
impression material or the optical scan (Fig 1-8-3). It is important
that the cord length is adequate and fits the circumference of the
tooth. The cord is either removed immediately prior to taking the
impression, or it is left in the gingival sulcus below the preparation
margin while the impression is made. Upon removal, it is important
that the cord is slightly wet to prevent unnecessary bleeding and
damage to the junctional epithelium5.
■ “Double-cord technique” is also a well-known method for gingival
retraction25,26. The first cord is fine (#000, #00, or #0) (Fig 1-8-4)
and is placed into the sulcus usually without any medication. It
should remain there throughout the period of preparation and
impression taking. The purpose of this fine cord is to gain vertical
retraction for access to the preparation margin. The second cord,
which is usually coarser (#0, #1, or #2), is placed on top of the
first one and then removed shortly before the impression is made
(Fig 1-8-5). The purpose of the second cord is to gain lateral
gingival deflection and create space for the impression material25.

Fig 1-8-3 “Single cord technique” – a thin cotton cord is placed into
the gingival sulcus of tooth 21 before impression taking to get access
to the veneer preparation margin.
Fig 1-8-4 Retraction cords come in different diameters and
configurations.

Fig 1-8-5 “Double-cord technique” – the second cord is placed on

top of the first one and removed immediately before impression
taking.
Guidelines on the amount of time the cords should stay in the gingival
sulcus in order to gain sufficient tissue retraction have ranged from 3
to 15 minutes27–29. To minimize the potential for soft-tissue damage, it
is important to remove cotton cords from the gingival sulcus as soon
as possible after the impression is taken. Leaving a cord in the sulcus
over a long period of time can cause inflammation, infection, abscess
formation and major gingival recession28,29. For purely chemical
temporary tissue retraction, gingival retraction paste with hemostatic
effect that contains aluminum chloride and aluminum-silicate-hydrate
has been introduced19,30–33. The paste is applied with a syringe into
the gingival sulcus and left there for 1–2 mins to give tissue retraction
(Fig 1-8-6). Before impression taking the paste is rinsed away with
water and the area is air-dried. A recent clinical study31 that
compared the effect of a retraction paste (Expasyl) and the double
thread technique for temporary tissue retraction concluded that minor
or moderate gingival recession (<1 mm) were more likely to occur
when conventional cords are used compared with the retraction paste
(Fig 1-8-7). However, when using the double-cord technique, the
dental technicians found die preparation significantly less challenging
compared with impressions made using the retraction paste for tissue
retraction31.
Fig 1-8-6 Gingival retraction paste was applied with a syringe into
the gingival sulcus and left there for 2 mins for tissue retraction
before impression taking.

Fig 1-8-7 Gingival recessions at the abutment teeth were visible

shortly after the insertion of the tooth-supported restoration.

1.8.4 Conventional impressions

The aim of a conventional as well as optical impression is to get an
exact impression of the abutment tooth with all its details: the
preparation margins, the relation between abutment teeth and/or
implants, the soft tissue, and the alveolar ridge, the neighboring teeth,
and the remaining teeth of the dental arch. Before impression taking it
is important to double-check whether adequate temporary tissue
retraction has been achieved. A clearly visible retraction cord around
the abutment tooth usually represents an adequate tissue retraction
(Fig 1-8-8). For tooth-supported restorations it is recommended to
utilize impression material consisting of a light body with high viscosity
with excellent flow properties for the syringe and medium or heavy
body with lower viscosity for the impression tray (Fig 1-8-9). For
implant impressions, however, it makes more sense to use stiffer
impression materials like medium or heavy body that give more exact
relation between implants or between implants and neighboring teeth
(Fig 1-8-10).

Fig 1-8-8 A clearly visible retraction cord represents an adequate

tissue retraction decreasing the risk of tearing of the impression
material.
Fig 1-8-9 Light body impression material with high viscosity was
placed with a syringe around the abutment teeth and heavy body
impression material with lower viscosity was utilized for the
impression tray.

Fig 1-8-10 A heavy body impression material was used both in the
syringe and the impression tray to get better retention for the
impression posts and to give more exact relation between implants
and the neighboring teeth.
In the current concept, a double-cord technique is applied for the
soft-tissue retraction and polyether impression material is
recommended for both tooth- and implant-supported restorations.
Addition-silicon impression material can, however, only be
recommended for tooth-supported restorations, where the stable
relation between abutments is not as critical as with implants.

1.8.5 Optical impressions

More recently, optical impression systems were introduced as an
alternative to the conventional impressions. The hand-held intraoral
scanners are unquestionably one of the most relevant transformative
innovations of the last decades in dentistry. High-resolution optical
systems capture topographic images of intraoral features which, in
turn, can be displayed, converted to files for virtual restoration design
and subsequent fabrication of the respective restorations. Finally, the
virtual images of the clinical situations can also be used for the
storage of actual patient situations, until recently only possible by the
inconvenient and logistically difficult storage of patient casts.
Importantly, the scanner image is valuable to the clinician, the dental
technician, and the patient in many ways. The 3D view of the dental
situation on the screen is empowering discussions with patients about
their clinical situation and/or restorative options. Furthermore, by
superimposition of new and stored images, effective, straightforward
ways to monitor clinical situations over time become possible. The
systems’ functions are important to restorative dentistry – but also
increasingly a valuable diagnostic device.
Intraoral scanners offer multiple advantages to the restorative
team34–37. One of the most important advantages of the intraoral
scanners is real-time imaging, providing an on-screen digital image of
single or multiple teeth within an arch, the opposing arch, occlusion,
and the surrounding soft tissues. After capture, the scan data can be
transferred to in-house or laboratory-based computer-aided design
and computer-aided manufacturing (CAD/CAM) systems37 (Fig 1-8-
11).
Fig 1-8-11 Overview of the different workflows enabled by the
optical impression systems.

By means of the design software of those systems, different kinds

of restorations, prostheses, orthodontic appliances, and models can
be designed, visualized on the computer screen, and used to help
patients understand their treatment options. Designs exported to
CAM systems can then be fabricated with either subtractive or
additive manufacturing processes. Perhaps one of the most valuable
advantages of intraoral scan data is that it can be stored simply as
electronic files. With the digital system, the need for costly impression
material and less costly dental stone is eliminated35. The images
replace the bulk of conventional physical models, a great advantage
particularly as in many states and countries, laws require that models
are stored for many years post-treatment38.
Digital scans create a valuable record and resource. Among the
many reasons why this is valuable are the opportunities to monitor the
clinical situation by recalling the images at will to evaluate changes to
tooth wear and/or position, restoration quality, or soft tissue over
time. In this respect, they serve as a valuable diagnostic device39.
In restorative dentistry, the intraoral image permits visualization of
prepared teeth from different perspectives as well as magnification of
areas of particular interest. Clinicians can visualize a preparation to
evaluate the need of any changes that could improve its quality and
can do so much more easily than it is possible clinically with direct
visualization. Furthermore, default parameters for the minimally
required material thickness for different restorative materials set in
the CAD software help us to evaluate the space given by the
respective tooth preparation before restoration fabrication and,
thereby, help improve the outcomes of the restorations. In essence,
the features serve as a built-in quality control mechanism. For this,
the scanner in principle needs to see all important details as the
naked eye, therefore, the same prerequisites are needed as with the
conventional impressions – clearly visible epigingival or slightly
subgingival preparation margins, gingival retraction, healthy non-
inflamed soft tissues and saliva control (Fig 1-8-12). Insufficient
retraction of the gingiva results in inaccurate virtual images of the
respective abutment tooth, which in consequence negatively
influences the accuracy of the restoration margin (Fig 1-8-13).
Figs 1-8-12a to 1-8-12c For accurate optical impressions, a clear
preparation geometry and well-defined preparation margins are
needed. The clinical steps before the optical impression taking
encompass the meticulous cleaning of the abutment tooth with
pumice, moisture-control with aid of an ultrafine first cord (Ultradent,
000), and the subsequent placement of a second, larger cord which
is aimed to be removed prior to the impression taking (Ultradent, 00,
0 or 1).
Fig 1-8-13 Sufficient retraction of the gingiva is required to prevent
inaccurate virtual images of the respective abutment tooth, which
could negatively influence the accuracy of the restoration margin.

The once accomplished digital design process can be used to

fabricate the CAD/CAM provisional out of provisional resin ingots if
temporary restorations are needed. Since the design of the
temporary and final restoration can be an identical shape, the patient
can easily envision what the final restoration(s) will look like. Patients
in collaboration with their clinician can make appropriate and desired
design modifications. Serendipitously, should a provisional be lost or
need replacement, a new temporary restoration can easily be
fabricated since the digital file of the once designed shape is saved.
Studies analyzing the time differences between capturing digital
images and conventional impressions showed mixed outcomes,
depending upon whether students or experienced clinicians were
doing the work, the extent of structures being captured (eg, quadrant
vs whole arch), study protocols, and the types of digital systems and
impression materials being used. In some situations, digital images
have been shown to be as much as 5–6 minutes faster than
conventional impressions40. At the other extreme, with real patients,
experienced clinicians were slower by 2 to 4 minutes with digital
41
scans41. In contrast, in a phantom head study, no difference was
found between dentists and students making conventional and optical
impressions42.
Conventional impressions are prone to errors (eg, bubbles in
critical locations, missing critical areas, etc.). In a study of 1157
conventional impressions, 86% were found to include errors, of which
55% were critical, compromising the quality and/fit of the final
restoration43. With digital scanners, multiple conventional impressions
needed to accurately capture all critical elements of the area are
eliminated by simply re-imaging the areas missed which, in most
systems, are automatically “stitched” into the original image. With the
scanner, dental assistants can capture the optical impression freeing
the dentist’s time.
Digital scans are a critical first step in reducing the total time
required to fabricate a restoration in an all-digital workflow (digital
scan, computer-aided design, computer-aided fabrication) compared
with an all-conventional (impressions, stone/plaster models/ wax-up
restoration design) workflow. Total restoration production time can be
reduced from 3 to 2 hours, the majority of which was reflected in the
difference in conventional vs digital laboratory work41,44.
In general, reported studies found that accuracy is within
acceptable values for most clinical applications. Use of powder on the
teeth has been shown to improve accuracy45 but has the
disadvantage of increasing the time it takes to complete a scan and
precludes full true color images. In addition, the technology used to
capture data can affect accuracy. Active wavefront sampling
technology45 and video capture46 have been shown to provide the
best accuracy. Hence, different scanners deliver different
performance. Based on clinical studies, the Trios scanner (3Shape,
Copenhagen, Denmark) has been shown to be the most accurate
system for single crowns47 and quadrant impressions48. Intraoral
factors, including powdering, limited space, and moisture can have a
negative effect on both digital and conventional impressions.
1.8.6 Conclusion
In conclusion, the intraoral optical scanning technology offers many
opportunities and advantages, yet, it has also some relevant
disadvantages as compared to the conventional impressions35,37. The
costs of the current systems cannot be overlooked. In addition to
initial system acquisition, depending on the intraoral scanning system,
costs can include warrantees and service contracts, periodic system
upgrades, and in some cases costs for scan fees. The learning curve
to capitalize on all the features, limitations, and eccentricities of each
system must be considered. The learning rate depends on both the
system itself and the experience of the operator49. In the short term,
this learning can negatively influence practice productivity and add
training costs.
In the current concept, optical impression taking is recommended
for both tooth- and implant-supported single-unit and 3- to 4-unit
multiple-unit restorations, to enable a fully digital workflow. The costs
involved with intraoral optical impression systems have to be
considered, as well as the learning curve involved with the systems.

1.8.7 References
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4. Labban N. A simple technique to reduce the risk of irreversible
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24. Hansen PA, Tira DE, Barlow J. Current methods of finish-line
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25. Cloyd S, Puri S. Using the double-cord packing technique of
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26. Perakis N, Belser UC, Magne P. Final impressions: a review of
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28. Fischer DE. Tissue management: a new solution to an old
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CHAPTER 9
Material-related cementation
procedures

1.9.1 Introduction
In this chapter:
■ Adhesive cementation of silica-based ceramics (feldspathic
ceramics, glass-ceramics)
■ Adhesive cementation of oxide ceramics (zirconia)
■ Adhesive cementation of hybrid materials (resin-nano ceramic,
resin-infiltrated ceramic network)
■ Universal silanes/primers and universal resin cements
The stability of all-ceramic and hybrid material restorations is low,
and for good clinical long-term outcomes it needs to be improved by
means of the adhesive cementation with resin cements. In contrast to
traditional cements, the resin cements chemically bond to both the
restorative material and the tooth substance, and the adhesive
cementation reinforces the tooth-restoration complex. Additional
benefits of the resin cements include high translucency and tooth-
resembling color, both leading to good esthetic results with
translucent ceramic or hybrid materials1–6.
One important prerequisite for good adhesive bond between the
restoration and the tooth substance is moisture control in the intraoral
environment. The bonding agents and the resin cements are
hydrophobic and only adhere to dry surfaces. The application of
rubber dam is, therefore, highly recommended for all adhesive
cementation procedures where applicable.
Another crucial factor is the adequate pretreatment of both
substrates, the restoration, and the tooth substance. The
pretreatment comprises an increase in surface area for the adhesive
fixation by roughening the surface of the restoration, and by
chemically pretreating the restoration and tooth surfaces for the
establishment of the chemical link, the adhesion, between the
restoration material and the tooth. The roughness of the restoration
surface leads to a retention of the cement additional to the chemical
link, and thereby supports the bond strength.
The presented restorative materials are chemically different and
require different pretreatment and different types of resin cements for
the adhesive fixation.

1.9.2 Adhesive cementation of silica-

based ceramics (feldspathic
ceramics, glass-ceramics)
Silica-based ceramics, such as feldspathic ceramics and the leucite-
and lithium-disilicate reinforced glassceramics, need to be etched
with hydrofluoric acid to increase the surface roughness (Fig 1-9-1)
(see also Part I, Chapter 1).
Fig 1-9-1a Scanning electron microscopic (SEM) image of a leucite-
reinforced glass-ceramic after the etching with hydrofluoric acid. Note
the round appearance of the leucite crystals and the retentive zones
resulting out of the etching procedure.

Fig 1-9-1b Scanning electron microscopic (SEM) image of a lithium-

disilicate-reinforced glass-ceramic after the etching with hydrofluoric
acid. Note the rod-like appearance of the lithium-disilicate crystals
and the retentive zones resulting from the etching procedure.
For the different ceramics, differently concentrated hydrofluoric
acids and different etching times are recommended. With the
feldspathic and leucite-reinforced ceramics, a 9.5% buffered
hydrofluoric acid is recommended to be applied for 60–90 seconds,
and with the lithium-disilicate glass-ceramics, a stronger, 5% non-
buffered hydrofluoric acid is applied for 20 seconds. The different
acid concentrations and etching times are important for the ideal
surface roughness and texture. The ideal surface properties after the
etching significantly depend on the chemical structure of the material.
Hence, the recommendations of the manufacturer of the material for
the etching are crucial.
The chemical link between the silica-based ceramic and the resin
cement is, thereafter, established by the application of a coupling
agent, the silane. The silane binds to the silica present in the
anorganic glass-matrix and polymerizes with the organic matrix of the
resin cement. For chemical activation, the silane needs to be
hydrolyzed to silanol. Two types of silanes exist today: two-
component silanes, which induce the hydrolyzation of the silane by
mixing of the two components, and one-component silanes, which are
already hydrolyzed, ie, in the silanol state. The one-component
silanes are less technique sensitive at their application, yet since they
are chemically activated they are more sensitive to storage and
handling, and their efficacy is dependent on the expiration date. It is,
therefore, crucial to handle and store the one-component silanes as
recommended by the respective manufacturer.
With thin ceramic restorations (<1.5 mm of thickness)7, like
veneers a bonding agent is applied prior to the application of the light-
curing or dual-curing Bis-GMA resin cement, and both the bonding
and the resin cement are light-cured at the same time. For
restorations with >1.5 mm of thickness, the bonding layer needs to
be light-cured prior to the application of the resin cement (Note: only
in situations with large internal gaps, the fit of the restoration may be
impaired). In case of precise fit of the restoration, no bonding agent
is applied prior to the application of the resin cement.
The tooth substance is pretreated according to the well-
established procedures for Bis-GMA resins, ie, enamel etching with
phosphoric acid and application of dentin primers (also see Part II for
clinical case examples). The application of the bonding is performed
with ceramic restorations of <1.5 mm of thickness. For ceramic
restorations of >1.5 mm thickness, no bonding agent is applied prior
to the cementation procedure (step-by-step procedure, Figs 1-9-2 to
1-9-17).

Fig 1-9-2 Some manufacturers of resin cements offer analogously

colored glycerin gels for the try-in of the restorations.
Figs 1-9-3a to 1-9-3c (a and b) Pretreatment of the feldspathic
veneer with 9.5% hydrofluoric acid for the etching, and thereafter with
silane. (c) Application of the silane to the etched, roughened ceramic
surface, for the establishment of the chemical bond of the resin
cement to the ceramic.
Fig 1-9-4a Etching of the enamel with phosphoric acid. In the present
case, no protection of the neighboring teeth was needed as they
were restored with crowns.
Fig 1-9-4b Rough etched enamel surface, note the matt appearance.

Fig 1-9-5 Application of a light-curing bonding agent to the etched

enamel, no light-curing. Note: protection from the surrounding light is
needed after this step.
Fig 1-9-6 Application of bonding agent to the silanized ceramic
surface, no light-curing. Note: protection from the surrounding light is
needed after this step.
Figs 1-9-7a to 1-9-7e The cementation of the veneer was performed
with a light-curing filling composite (Tetric Classic, Ivoclar Vivadent,
Schaan, Liechtenstein), heated up to 68°C (Calset, Addent, Danbury,
CT, USA) to reduce the viscosity while maintaining the high filler
content, and the excellent physical properties. Note the glossy soft
appearance of the heated composite (d) as compared to unheated
composite (e). The composite was distributed with a spatula to the
entire veneer surface prior to application to the abutment tooth.
Fig 1-9-8 Application of the veneer to the pretreated abutment tooth.
Gentle and constant finger pressure allows for careful stepwise
removal of the composite excess. Finishing of the margins is
performed at this stage, followed by light-curing starting from the
palatal region, thereafter buccally and incisally, until polymerization of
the composite resin and the bonding agent is achieved.
Fig 1-9-9 Abutment tooth 11 after removal of the provisional and
meticulous cleaning of the dentin with pumice.
Figs 1-9-10a and 1-9-10b Cementation procedure of a leucite-
reinforced glass-ceramic crown.
Figs 1-9-11a to 1-9-11c (a and b) Etching of the internal surface of
the crown with 9.5% hydrofluoric acid. (c) After the etching the
precipitates need to be thoroughly removed with alcohol and in an
ultrasonic bath. The etched and cleaned surface appears
homogenously matte.

Fig 1-9-12 Application of a silane to the etched ceramic.

Figs 1-9-13a and 1-9-13b Pretreatment of the dentin with a primer
and adhesive (Syntac Primer, Adhesive, Ivoclar Vivadent) according
to the manufacturer’s recommendations. No bonding is applied. Note
the glossy appearance of the conditioned dentin.
Fig 1-9-14 After the insertion of the crown with a dualcuring resin
cement (Variolink Esthetic, Ivoclar Vivadent) and the removal of all
excess cement, the polymerization is activated by means of light-
curing.

Fig 1-9-15 Situation directly after the cementation, note the dried-out
pale-ish appearance of the neighboring dentition.
Figs 1-9-16a and 1-9-16b Careful evaluation of the marginal region,
and polishing of the marginal areas with oscillating files (EVA files,
Intensiv, Montagnola, Switzerland).
Figs 1-9-17a and 1-9-17b Situation after the refining of the margins,
and 1 week after cementation. Note the rehydrated neighboring teeth
and the esthetic integration of the glass-ceramic crown 11.

An overview of the procedures and products used in the present

concept for the adhesive cementation of feldspathic- and glass-
ceramics is given in the flowcharts in Part I, Chapter 13.
1.9.3 Adhesive cementation of oxide
ceramics (zirconia)
Oxide ceramics like zirconia contain little or no silica and are not
etchable with conventional acids used in the dental office. The
increase in surface “roughness” for the bonding is achieved by
airborne-particle abrasion of the zirconia with 50 µm alumina-sand
(1.5 bar, 10 cm distance) (Fig 1-9-18). In addition, the oxide ceramics
cannot be pretreated with conventional silanes due to the lack of
silica. Hence, for the adhesive cementation of zirconia specific
primers and resin cements are needed.

Fig 1-9-18a SEM image of an intaglio surface of densely sintered

zirconia.
Fig 1-9-18b SEM image of the zirconia surface after airborne-
particle abrasion. Note the increase in surface through the gentle
roughening.

The development of primers and resin cements containing

phosphate-monomer (ie, 10-methacryloyloxydecyl dihydrogen
phosphate (MDP), originally developed for the adhesive cementation
of non-precious metal restorations, enabled the adhesive cementation
of the oxide ceramics. The chemical bond between the resin cement
and the oxide ceramic is established by this phosphate-monomer and,
in principle no additional coupling agent is necessary. It has been
shown, however, that additional application of a specific primer
containing the phosphate-monomer increased the bond strength
values of the resin cement to the oxide ceramic zirconia8. The
application of a phosphate-monomer containing primer is
recommended in the present treatment concept.
The tooth substance, ie, the dentin, is pretreated with the specific
adhesive primers of the respective phosphate-monomer containing
cement. No bonding agents are used (step-by-step procedure, Figs
1-9-19 to 1-9-22)
Figs 1-9-19a to 1-9-19c MDP-containing agents needed for the
pretreatment of the zirconia and the dentin for the adhesive
cementation.
Figs 1-9-20a to 1-9-20d Activation of the dentin primer by mixing the
two components in a 1:1 ratio.
Figs 1-9-21a and 1-9-21b Application of the MDP-containing primer
to the airborne-particle-abraded and degreased zirconia surface.
Fig 1-9-22 Application of the resin cement to the pretreated zirconia.

An overview of the procedures and products used in the present

concept for the adhesive cementation of zirconia is given in the
flowcharts in Part I, Chapter 13.

1.9.4 Adhesive cementation of hybrid

materials (resin-nano ceramic,
resin-infiltrated ceramic
network)
As the two types of hybrid materials are of different chemistry and
structure, their pretreatment and adhesive cementation are
performed differently.

Resin-nano ceramic (Lava Ultimate, others)

For the adhesive cementation of this resin-based hybrid material, a
chemical activation of the resin matrix is necessary. For this, the
surface of the restoration is airborne-particle abraded with 50 µm
alumina-sand (2 bars), cleaned with alcohol, and then pretreated with
a universal adhesive recommended by the manufacturer (Scotchbond
Universal Adhese, 3M ESPE, Seefeld, Germany). A dual-curing resin
cement is then applied to the restoration surface. The tooth surface is
cleaned with pumice, followed by etching of the enamel with
phosphoric acid and application of the universal adhesive (light-cured
for 10 seconds). The resin cement (RelyX Ultimate, 3M ESPE) is
applied to the restoration, the restoration is seated, and remnants are
removed. Then a glycerin gel is applied around the margins and final
light-curing (3–5 × 20 seconds) is performed.

Polymer-infiltrated ceramic network (Vita

Enamic)
This type of hybrid ceramic differs from the resin-nano ceramics with
respect to the chemical structure (for details see Part I, Chapter 1)
and, hence, needs different procedures and agents for the adhesive
fixation.
This hybrid material is mostly based on a porous ceramic network
infiltrated with resin. For the adhesive cementation, hence, the resin-
infiltrated ceramic network of the hybrid material needs to be etched
with hydrofluoric acid (9% buffered hydrofluoric acid, 60–90 s)
followed by the application of silane, bonding and a resin cement (eg,
the self-adhesive resin cement RelyX Unicem, 3M ESPE)9.
The procedures for the restoration and the tooth substrates are
similar to the adhesive cementation of conventional feldspathic
ceramic.

1.9.5 Universal silanes/primers and

universal resin cements
The procedures for the adhesive cementation of restorations made
out of the different restorative materials is complex, and clinicians and
their staff need to be highly knowledgeable about the respective
procedures for each material type.
With the aim to simplify the adhesive cementation procedures,
recently, different universal adhesives (eg, Scotchbond Universal
Adhese, 3M ESPE), universal primers (eg, Multilink, Ivoclar Vivadent,
Schaan, Liechtenstein) and universal resin cements (eg, RelyX
Unicem, 3M ESPE; G Cem, GC, Tokyo, Japan; Maxcem, Kerr,
Uxbridge, UK; Mulitlink Sprint, Ivoclar Vivadent; and others) were
introduced10,11 (Figs 1-9-23 to 1-9-26).

Fig 1-9-23 One example of a dual-curing self-adhesive universal

cement, available as translucent and colored.
Figs 1-9-24a and 1-9-24b Convenient delivery in prefabricated
capsules that need to be activated and mixed in a roto-mix device.
Figs 1-9-25a and 1-9-25b Application of the activated and mixed
cement without the need for pretreatment of the internal surface of
the restoration.
Figs 1-9-26a and 1-9-26b Two-second light-curing of the excess
cement to simplify its removal. Polishing of the margins with
oscillating files (EVA, Intensiv) is recommended.

The basic principle of the universal agents is that within one step
(universal adhesive, universal primer) all needed pretreatment of the
restorative material and/or the tooth substance can be performed.
Some universal adhesives may even contain silane, reducing the
pretreatment agent to just one bottle (Scotchbond Universal Adhese,
3M ESPE). Universal primers, furthermore, can even be self-etching.
Alternatively, non-self-etching universal primers are used after the
etching.
The simplification, however, has its price. Numerous studies have
shown that the adhesive quality of the universal adhesives to the tooth
substance is lower than the one of conventional multiple-step
adhesives12. Yet, the adhesive quality of the universal primers
depends on the combination of the product and the restorative
material.
In their early days, these simplified materials were associated
with lower in vitro bond strength results and poorer in vivo longevity
of restorations. These findings were probably a result of the complex
formulation of simplified adhesives and their high content of solvents,
which impaired complete solvent volatilization and consequently led to
poorer adhesive polymerization13–16. More recent research, however,
indicates that improvements of the universal agents have happened,
which led to better results today.
The properties of a self-etching universal primers (Monobond Etch
and Prime, Ivoclar Vivadent) have been compared to the conventional
procedures for the adhesive cementation to feldspathic and glass-
ceramics17, ie, etching with hydrofluoric acid and application of a non-
self-etching universal primer (Monobond Plus, Ivoclar Vivadent). The
self-etching universal primer performed equal to or even better than
the conventional procedure using a non-self-etching primer with the
silica-based ceramics.
With zirconia, however, this self-etching universal primer
(Monobond Etch and Prime, Ivoclar Vivadent) provided lower bond
strength than the non-self-etching universal primer (Monobond Plus,
Ivoclar Vivadent), which performed even better than the conventional
pretreatment18. Therefore, with zirconia this non-self-etching universal
primer can be recommended.
In general, for predictable outcomes it is strongly recommended
to adhere to the manufacturer’s recommendations of the different
products.
See the flowcharts in Part I, Chapter 13 on the cementation
process.

1.9.6 Conclusions
Adhesive cementation is the prerequisite for the clinical success of
all-ceramic and hybrid-ceramic restorations, and a key element of
minimally invasive restorative dentistry. Clinicians need to be
knowledgeable of the respective cements needed for the different
types of materials, and about their detailed application procedures for
good outcomes. As the developments of resin cements and the
agents needed for the bonding to the restorative materials and the
tooth substances constantly evolve, it is recommended to follow the
manufacturers’ guidelines.

1.9.7 References
1. Abo-Hamar SE, Hiller KA, Jung H, Federlin M, Friedl KH,
Schmalz G. Bond strength of a new universal self-adhesive
resin luting cement to dentin and enamel. Clin Oral Investig
2005;9:161–167.
2. Bindl A, Richter B, Mormann WH. Survival of ceramic computer-
aided design/manufacturing crowns bonded to preparations with
reduced macroretention geometry. Int J Prosthodont
2005;18:219–224.
3. Burke FJ, Fleming GJ, Nathanson D, Marquis PM. Are adhesive
technologies needed to support ceramics? An assessment of
the current evidence. J Adhes Dent 2002;4:7–22.
4. Malament KA, Socransky SS. Survival of Dicor glass-ceramic
dental restorations over 16 years. Part III: effect of luting agent
and tooth or tooth-substitute core structure. J Prosthet Dent
2001;86:511–519.
5. McLean JW, Hughes TH. The reinforcement of dental porcelain
with ceramic oxides. Br Dent J 1965;119:251–267.
Stewart GP, Jain P, Hodges J. Shear bond strength of resin
6. cements to both ceramic and dentin. J Prosthet Dent
2002;88:277–284.
7. Scotti N, Comba A, Cadenaro M, et al. Effect of lithium
disilicate veneers of different thickness on the degree of
conversion and microhardness of a light-curing and a dual-
curing cement. Int J Prosthodont 2016;29:384–388.
8. Blatz MB, Sadan A, Martin J, Lang B. In vitro evaluation of
shear bond strengths of resin to densely-sintered high-purity
zirconium-oxide ceramic after long-term storage and thermal
cycling. J Prosthet Dent 2004;91:356–362.
9. Rohr N, Flury A, Fischer J. Efficacy of a universal adhesive in
the bond strength of composite cements to polymer-infiltrated
ceramic. J Adhes Dent 2017;19:417–424.
10. Alex G. Universal adhesives: the next evolution in adhesive
dentistry? Compend Contin Educ Dent 2015;36:15–26; quiz 28,
40.
11. Scotti N, Cavalli G, Gagliani M, Breschi L. New adhesives and
bonding techniques. Why and when? Int J Esthet Dent
2017;12:524–535.
12. Cruz J, Sousa B, Coito C, Lopes M, Vargas M, Cavalheiro A.
Microtensile bond strength to dentin and enamel of self-etch vs.
etch-and-rinse modes of universal adhesives. Am J Dent
2019;32:174–182.
13. De Munck J, Van Landuyt K, Peumans M, et al. A critical review
of the durability of adhesion to tooth tissue: methods and
results. J Dent Res 2005;84:118–132.
14. Munoz MA, Sezinando A, Luque-Martinez I, et al. Influence of a
hydrophobic resin coating on the bonding efficacy of three
universal adhesives. J Dent 2014;42:595–602.
15. Spencer P, Wang Y. Adhesive phase separation at the dentin
interface under wet bonding conditions. J Biomed Mater Res
2002;62:447–456.
16. Tuncer D, Yazici AR, Ozgunaltay G, Dayangac B. Clinical
evaluation of different adhesives used in the restoration of non-
carious cervical lesions: 24-month results. Aust Dent J
2013;58:94–100.
17. Tribst J, Anami LC, Ozcan M, Bottino MA, Melo RM, Saavedra
G. Self-etching primers vs acid conditioning: impact on bond
strength between ceramics and resin cement. Oper Dent
2018;43:372–379.
18. Wille S, Lehmann F, Kern M. Durability of resin bonding to
lithium disilicate and zirconia ceramic using a self-etching
primer. J Adhes Dent 2017;19:491–496.
CHAPTER 10
Fixation of implant-supported
restorations

1.10.1 Introduction
In this chapter:
■ Cemented implant restorations
■ Screw-retained implant restorations
■ Screw-retained versus cemented
Fixed implant-supported restorations like single crowns, multiple-unit
partial, and full-arch fixed dental prostheses (FDPs) are well
documented in the literature and nowadays fully accepted as a
treatment option for the replacement of single or multiple missing
teeth1–6. The detailed outcomes of different types of implant-
supported fixed restorations are given in Part III of this book.
Fixation of implant-supported restorations can be done in several
ways. Restorations that are cast-on to prefabricated metal-
abutments (Fig 1-10-1) and restorations that are cemented
extraorally onto standard (titanium base) or customized abutments
can be directly screw-retained onto the implants (Fig 1-10-2). For
other screw-retained restorations, a standard abutment is screw
retained into the implant and the restoration is then screw-retained
onto the abutment. This is sometimes referred to as a screw in a
screw in a screw type of restoration (Fig 1-10-3). Today, cemented
restorations usually refer only to restorations that are cemented
intraorally onto a standard or customized abutment. Single-unit
restorations are either screw-retained or cemented, but multiple-unit
restorations can be a combination of screw- and cement-retention.
When combining the two types of retention in a single restoration it
has been proposed to use temporary cement to maintain the
retrievability of the restoration (Fig 1-10-4) 7.
Figs 1-10-1a to 1-10-1c Cast-on metal-ceramic implantsupported
single crowns in a lateral position that can be directly screw-retained
into the implants without any cementation.

Fig 1-10-2 Three-unit monolithic microveneered zirconia restoration

cemented extraorally on titanium-base abutments and screw-retained
directly into the two implants.
Fig 1-10-3 Implant-supported ceramic screw-retained crown with a
prosthetic screw onto an abutment that was screw-retained into the
implant with the abutment screw. This combination is sometimes
referred to as a screw in a screw in a screw.

Fig 1-10-4 Two three-unit implant-supported restorations that were

cemented intraorally with provisional cement on the anterior
abutments and screw-retained on the more deeply placed posterior
implants.
1.10.2 Cemented implant restorations
Initially, screw retention was only used for full-arch implant-supported
FDPs in edentulous patients (Fig 1-10-5)8–10 and single-unit
restorations were generally cemented on standard prefabricated
cementable abutments (Fig 1-10-6)11. Both types of restorations
exhibited satisfactory long-term outcomes9,12. However, due to the
need for customized prosthetic components to improve esthetic
outcomes or correct possible malangulations of the implant, new
components like the cast-on UCLA abutment were developed13,14.
These cast-on abutments could be used to fabricate both screw-
retained and cement-retained single-unit restorations.

Fig 1-10-5 Full-arch implant-supported FDPs are usually screw-

retained, allowing for retrievability in case of biological or technical
complications.
Fig 1-10-6 Cementable implant abutment for intraoral cementation of
a single molar crown.

Cemented implant-supported restorations clinically and technically

resemble the procedures used for tooth-supported restorations. They
might, therefore, be easier to fabricate and to manipulate in the
patients’ mouths than screw-retained restorations. There are
basically two ways to design a cemented implant-supported
restoration. For implants with a neck configuration (soft tissue level
implants), the implant shoulder represents the margin of the
restoration and the abutment gives the retention (Fig 1-10-7). For
such implants, a thorough evaluation of the implant site and correct
three-dimensional implant position is required. Otherwise, the
cementation margin might be situated too deep submucosally not
allowing for an adequate removal of the excess cement15. For
implants without a neck configuration (bone level implants) the
restoration margin is situated on the abutment. To avoid having the
cementation margin too deep submucosally, standard cementable
abutments with different mucosal height and customized abutments
with the cementation margin located slightly (0.5–1 mm)
submucosally, can be utilized. Nowadays, the CAD/CAM
manufacturing procedures enable a broad application of customized
abutments and, as a consequence, the cemented restorations have
become the restoration of choice in some clinical situations (Fig 1-10-
8).

Fig 1-10-7 Two soft tissue-level implants with solid abutments. The
implant shoulders represent the margin of the restorations and the
abutments give retention for the intraoral cemented restorations.
Fig 1-10-8 The implants were placed lingually angulated due to
anatomical limitations. Customized CAD/CAM abutments were used
to correct the angulation and two intraorally cemented implant-
supported crowns were made.

The main advantage of cemented restorations is that the implant

angulations are less critical than for screw-retained restoration.
Hence, one of the indications for cemented restorations are situations
where it is difficult to achieve correct implant angulations due to the
bone anatomy or the position of the neighboring teeth (Fig 1-10-9a,
b). On the other hand, the vertical, the facio-oral, and the mesiodistal
positions of the implant are equally critical for cemented and screw-
retained restorations. Moreover, for cemented restorations there is
no need for access holes, which increases the strength of the
restoration and decreases the possible niches for ceramic fractures.
The main disadvantage of the cemented restorations is that, in case
of problems such as technical complications, they are difficult or
impossible to remove without destruction. Furthermore, there is
difficulty with the removal of the excess cement. In-vitro investigations
have shown that some excess cement always remained at the tested
specimens, irrespective of submucosal position of the crown
margin16,17. Soft tissue complications due to excess cement have
been reported in several clinical studies on cemented
restorations18,19. Excess cement was also shown, in clinical studies,
to be one of the major reasons for peri-implantitis20. Fortunately, in
that recent clinical investigation, the signs of peri-implant disease
disappeared as soon as the cement excess was successfully
removed20. Nevertheless, considering a deep submucosal position of
the restoration margin, the removal of the cement excess may be
very difficult or even impossible15,21. Surgical interventions are often
necessary to remove any remnants of the cement (Fig 1-10-10). With
multiple-unit implant restorations, access to the cement remnants can
be impaired due to the shape and size of the framework. As a
consequence, a higher incidence of excess cement may be expected,
which may cause higher rates of peri-implantitis and bone loss. This
assumption is supported by the findings of systematic reviews (see
Part III)22,23.
Figs 1-10-9a and 1-10-9b Three implants were inserted in the
posterior mandible in combination with a bone augmentation
procedure. Customized CAD/CAM abutments and intraorally
cemented crowns were used to compensate for semi-optimal implant
angulations.
Fig 1-10-10 Surgical intervention was necessary to remove the
remnants of cement by a deeply placed soft tissue level implant.

1.10.3 Screw-retained implant

restorations
The major benefit of the screw-retained restorations is easiness of
the insertion and their retrievability24,25. Furthermore, biologic
problems are rather unlikely to occur, provided that the restoration
exhibits a good fit26 and no screw loosening occurs. Soft tissue
complications such as inflammation or fistula formation (Fig 1-10-11)
have been shown to be associated with misfit and screw loosening.
The inflammation and the fistula often disappeared after the re-
tightening of the screws27.
Fig 1-10-11 Implant-supported single crown in a lateral position was
affected by screw loosening and few weeks later a soft tissue fistula
was visible.

The angular positioning of the implant, however, is more critical

and harbors less tolerance than when using cemented restorations,
since the location of the screw access hole and the surrounding
material dimensions of the suprastructure need to be considered (Fig
1-10-12). The opening for the fixation screw should be preferably
placed in non-visible palatal (Fig 1-10-13) or occlusal areas, which is
only possible if a respective implant position and angulation is
provided. Furthermore, the technical fabrication of screw-retained
restorations is more complex since a customization of the restoration
core is always needed, at least for veneered restorations. The most
frequently occurring complication of the screw-retained restorations is
loosening of the abutment or prosthetic screws22,23,28. This
complication can probably be significantly reduced by screw-retaining
the restoration directly onto the implant with an abutment screw, and
as such avoiding the second screw, the small prosthetic screw, which
is the weakest Part of the restoration. Furthermore, high rates of
chipping of the veneering ceramic were found at the screw-retained
restorations29,30. This complication was frequently associated with
the open screw access hole, which disrupts the continuity of the
veneering ceramic, leaving partly unsupported ceramic at the screw
access hole (Fig 1-10-14)31,32. Both technical complications are
certainly unpleasant, but from a clinical perspective of minor clinical
significance, since screw-retained restorations can be retrieved and
technical problems are usually repairable.

Fig 1-10-12 Screw-retained implant-supported molar crown with the

access hole located in the central fossa of the occlusal surface.
Fig 1-10-13 Three-unit implant-supported restoration in the anterior
area with the access holes for the fixation screws in the non-visible
palatal aspect of the restoration.

Fig 1-10-14 An implant-supported metal-ceramic molar crown where

unsupported veneering ceramic around the access hole fractured and
the crown had to be remade.
1.10.4 Screw-retained versus cemented
Until recently, little scientific information has been available comparing
the advantages and disadvantages of cement-retention and screw-
retention of implant-supported FDPs33,34. Hence, the decision of
choosing between the two types of retentions is difficult and rather a
matter of personal preference than scientific evidence. However, data
from a recent systematic review and consensus reports of consensus
conferences have outlined some treatment recommendations which
are Part of the current treatment concept22,29,30. A recent systematic
review of the literature indicated some differences in the performance
of cemented and screw-retained implant-supported restorations,
depending on the extension of the restorations29. With respect to the
estimated 5-year survival rates, no differences were found between
implants, cement-supported, or screw-retained single crowns (SCs).
However, in the case of partial multiple-unit implant-supported FDPs,
a trend was found for more implant failures with cemented
restorations; and for full-arch FDPs, significantly more implant failures
occurred with cemented restorations as compared with screw-
retained restorations. Hence, the incidence of implant loss was higher
for the cemented restorations and increased with increased extension
of the restoration29. For the respective restorations, however, the
estimated 5-year survival rates of restorations were similar between
cemented and screw-retained restorations. A recent systematic
review22 analyzing different implant-abutment connections for single
crowns concluded that the survival of the restorations and the
incidence of abutment failure was similar for cemented and screw-
retained crowns. On the one hand, the incidence of screw loosening
(Fig 1-10-15) and the total number of technical complications were
significantly higher for screw-retained SCs compared with cemented
SCs. On the other hand, ceramic chipping was significantly higher for
the cemented crowns22. The 5-year rate of soft tissue complications,
the incidence of substantial marginal bone loss, and the total number
of biological complications were significantly higher for cemented SCs
compared with screw-retained restorations22. The incidence of
marginal bone loss was even more pronounced with the multiple-unit
cement-retained restorations.

Fig 1-10-15 This implant-supported molar crown was rotated 90

degrees due to prosthetic screw loosening.

In conclusion, the screw-retained restorations suffered from more

technical problems and needed more often repair or replacement of
the restorations, the cemented restorations more frequently
experienced serious biological problems like bone loss >2 mm or loss
of the implant (Fig 1-10-16), which may be more difficult to resolve
clinically. Neither of the two types of fixation, however, was clearly
advantageous over the other22,29.
Fig 1-10-16 Significant marginal bone loss visible around a cemented
implant-supported molar crown. Cement remnants could be detected
when an access flap was raised.

However, more significant clinical research by means of

randomized controlled clinical trials (RCTs) is necessary to further
support the observations.

1.10.5 Conclusions
In the current concept, both for implant-supported SCs and implant-
supported multiple-unit restorations, the first treatment option is a
screw-retained restoration. To reduce the risk of screw loosening, the
weakest link, the prosthetic screw, is eliminated for single crowns and
partial FDPs by using a one-piece restoration such as a ceramic
restoration cemented extraorally on a titanium abutment, a cast-on or
a CAD/CAM metal-ceramic restoration. The screw access hole is
also made as small as possible (Fig 1-10-17) to reduce the risk of
core or framework fracture and to reduce the risk of ceramic
chipping. For multiple-unit restoration passive fit is accomplished via
CAD/CAM manufacturing and cementation on a titanium abutment
(Fig 1-10-18). As a second option, and only if an implant cannot be
inserted in an adequate angulation for a screw-retained restoration
due to some anatomical limitation, cemented implant-supported
restorations are utilized. For cement-retained implant-supported
restorations, care is taken not to insert a soft tissue level implant too
deep submusocally; and for bone level implants customized
abutments are fabricated to avoid having the cementation margins too
deep submucosally (Fig 1-10-19). Radio-opaque cement such as
glass ionomer, which is relatively easy to remove, is utilized and
sometimes retraction cords are placed around the implant or
abutment shoulder to reduce the risk of submucosal flow of cement.
After cementation a control radiograph is taken to diagnose excess
cement. For full-arch implant-supported FDPs the first treatment
option is an exclusively screw-retained restoration. Frequently,
however, one or more of the supporting implants cannot be inserted
in the ideal angulations for screw-retention. There are several options
to solve this problem: an angulated abutment can be utilized but then
the restoration has to be fixed with a prosthetic screw. This can also
be solved with an abutment that allows angulated screw access
channel or by using an angulated cementable or customized
abutment. Then, the restoration is cemented onto these abutments
with temporary cement and screw-retained on the remaining implants
that are properly angulated (Fig 1-10-20).
Fig 1-10-17 All premolars are implant-supported crowns. A
significant difference in size of the fixation screw access holes can be
seen between the left and the right sides. Access holes should
always be made as small as possible, only allowing access to the
head of the screwdriver.
Figs 1-10-18a and 1-10-18b Passive fit for the four-unit implant-
supported restoration was accomplished via CAD/CAM manufacturing
and cementation on titanium abutments.
Fig 1-10-19 A customized zirconia abutment was used to move the
cementation margins epigingivally before inserting an intraorally
cemented ceramic crown.
Figs 1-10-20a and 1-10-20b Three of the seven inserted implants
did not have the correct angulation for a screw-retained abutment.
The angulation was corrected with standard angulated cementable
abutments and the full-arch restoration was fixed with a combination
of screw-retained abutments and abutments cemented with
temporary cement.
1.10.6 References
1. Sailer I, Strasding M, Valente NA, Zwahlen M, Liu S, Pjetursson
BE. A systematic review of the survival and complication rates
of zirconia-ceramic and metal-ceramic multiple-unit fixed dental
prostheses. Clin Oral Implants Res 2018;29 Suppl 16:184–198.
2. Pjetursson BE, Valente NA, Strasding M, Zwahlen M, Liu S,
Sailer I. A systematic review of the survival and complication
rates of zirconia-ceramic and metal-ceramic single crowns. Clin
Oral Implants Res 2018;29 Suppl 16:199–214.
3. Pjetursson BE, Thoma D, Jung R, Zwahlen M, Zembic A. A
systematic review of the survival and complication rates of
implant-supported fixed dental prostheses (FDPs) after a mean
observation period of at least 5 years. Clin Oral Implants Res
2012;23 Suppl 6:22–38.
4. Jung RE, Zembic A, Pjetursson BE, Zwahlen M, Thoma DS.
Systematic review of the survival rate and the incidence of
biological, technical, and aesthetic complications of single
crowns on implants reported in longitudinal studies with a mean
follow-up of 5 years. Clin Oral Implants Res 2012;23 Suppl
6:2–21.
5. Pjetursson BE, Bragger U, Lang NP, Zwahlen M. Comparison of
survival and complication rates of tooth-supported fixed dental
prostheses (FDPs) and implant-supported FDPs and single
crowns (SCs). Clin Oral Implants Res 2007;18 Suppl 3:97–113.
6. Jung RE, Pjetursson BE, Glauser R, Zembic A, Zwahlen M,
Lang NP. A systematic review of the 5-year survival and
complication rates of implant-supported single crowns. Clin Oral
Implants Res 2008;19:119–130.
7. Preiskel HW, Tsolka P. Cement- and screw-retained implant-
supported prostheses: up to 10 years of follow-up of a new
design. Int J Oral Maxillofac Implants 2004;19:87–91.
8. Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long-
term efficacy of currently used dental implants: a review and
proposed criteria of success. Int J Oral Maxillofac Implants
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9. Adell R, Lekholm U, Rockler B, Branemark PI. A 15-year study
of osseointegrated implants in the treatment of the edentulous
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10. Adell R, Eriksson B, Lekholm U, Branemark PI, Jemt T. Long-
term follow-up study of osseointegrated implants in the
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Implants 1990;5:347–359.
11. Sharifi MN, Pang IC, Chai J. Alternative restorative techniques
of the CeraOne single-tooth abutment: a technical note. Int J
Oral Maxillofac Implants 1994;9:235–238.
12. Jemt T. Cemented CeraOne and porcelain fused to TiAdapt
abutment single-implant crown restorations: a 10-year
comparative follow-up study. Clin Implant Dent Relat Res
2009;11:303–310.
13. Lewis S, Beumer J, 3rd, Hornburg W, Moy P. The “UCLA”
abutment. Int J Oral Maxillofac Implants 1988;3:183–189.
14. Lewis SG, Llamas D, Avera S. The UCLA abutment: a four-
year review. J Prosthet Dent 1992;67:509–515.
15. Linkevicius T, Vindasiute E, Puisys A, Linkeviciene L, Maslova
N, Puriene A. The influence of the cementation margin position
on the amount of undetected cement. A prospective clinical
study. Clin Oral Implants Res 2013;24:71–76.
16. Linkevicius T, Vindasiute E, Puisys A, Peciuliene V. The
influence of margin location on the amount of undetected
cement excess after delivery of cement-retained implant
restorations. Clin Oral Implants Res 2011;22:1379–1384.
17. Agar JR, Cameron SM, Hughbanks JC, Parker MH. Cement
removal from restorations luted to titanium abutments with
simulated subgingival margins. J Prosthet Dent 1997;78:43–47.
18. Abboud M, Koeck B, Stark H, Wahl G, Paillon R. Immediate
loading of single-tooth implants in the posterior region. Int J
Oral Maxillofac Implants 2005;20:61–68.
19. Bornstein MM, Lussi A, Schmid B, Belser UC, Buser D. Early
loading of nonsubmerged titanium implants with a sandblasted
and acid-etched (SLA) surface: 3-year results of a prospective
study in partially edentulous patients. Int J Oral Maxillofac
Implants 2003;18:659–666.
20. Wilson TG, Jr. The positive relationship between excess cement
and peri-implant disease: a prospective clinical endoscopic
study. J Periodontol 2009;80:1388–1392.
21. Sancho-Puchades M, Crameri D, Ozcan M, et al. The influence
of the emergence profile on the amount of undetected cement
excess after delivery of cement-retained implant
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22. Pjetursson BE, Zarauz C, Strasding M, Sailer I, Zwahlen M,
Zembic A. A systematic review of the influence of the implant-
abutment connection on the clinical outcomes of ceramic and
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183.
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Zwahlen M. A systematic review of the performance of ceramic
and metal implant abutments supporting fixed implant
reconstructions. Clin Oral Implants Res 2009;20 Suppl 4: 4–31.
24. Zarb GA, Schmitt A. The longitudinal clinical effectiveness of
osseointegrated dental implants: the Toronto study. Part III:
problems and complications encountered. J Prosthet Dent
1990;64:185–194.
25. Chee WW, Torbati A, Albouy JP. Retrievable cemented implant
restorations. J Prosthodont 1998;7:120–125.
26. Keith SE, Miller BH, Woody RD, Higginbottom FL. Marginal
discrepancy of screw-retained and cemented metal-ceramic
crowns on implants abutments. Int J Oral Maxillofac Implants
1999;14:369–378.
27. Andersen E, Saxegaard E, Knutsen BM, Haanaes HR. A
prospective clinical study evaluating the safety and
effectiveness of narrow-diameter threaded implants in the
anterior region of the maxilla. Int J Oral Maxillofac Implants
2001;16:217–224.
28. Weber HP, Sukotjo C. Does the type of implant prosthesis
affect outcomes in the partially edentulous patient? Int J Oral
Maxillofac Implants 2007;22 Suppl:140–172.
29. Sailer I, Muhlemann S, Zwahlen M, Hammerle CH, Schneider D.
Cemented and screw-retained implant reconstructions: a
systematic review of the survival and complication rates. Clin
Oral Implants Res 2012;23 Suppl 6:163–201.
30. Wittneben JG, Joda T, Weber HP, Bragger U. Screw retained
vs. cement retained implant-supported fixed dental prosthesis.
Periodontol 2000 2017;73:141–151.
31. Torrado E, Ercoli C, Al Mardini M, Graser GN, Tallents RH,
Cordaro L. A comparison of the porcelain fracture resistance of
screw-retained and cement-retained implant-supported metal-
ceramic crowns. J Prosthet Dent 2004;91:532–537.
32. Zarone F, Sorrentino R, Traini T, Di lorio D, Caputi S. Fracture
resistance of implant-supported screw- versus cement-retained
porcelain fused to metal single crowns: SEM fractographic
analysis. Dent Mater 2007;23:296–301.
33. Sherif S, Susarla SM, Hwang JW, Weber HP, Wright RF.
Clinician- and patient-reported long-term evaluation of screw-
and cement-retained implant restorations: a 5-year prospective
study. Clin Oral Investig 2011;15:993–999.
34. Michalakis KX, Hirayama H, Garefis PD. Cement-retained
versus screw-retained implant restorations: a critical review. Int
J Oral Maxillofac Implants 2003;18:719–728.
CHAPTER 11
The titanium-base abutment
concept

1.11.1 Introduction
In this chapter:
■ Traditional implant restorations supported by stock/customized
abutments
■ Monolithic implant restorations supported by titanium-base
abutments
■ Factors for predictable outcomes: adhesive cementation of
monolithic ceramics to titanium-base abutments

Implant-supported fixed dental prostheses (FDPs) are well

established and considered a safe and reliable treatment option for
partial edentulous spaces (see also Part III).

1.11.2 Traditional implant restorations

supported by stock/customized
abutments
Traditionally, the fixation of these restorations was achieved by either
screw retaining them directly onto the implant or through an
intermediate abutment, or by cementing them onto a standardized or
1
customized abutment (see also Part I, Chapter 10) . Current
evidence demonstrates that screw-retained restorations have a lower
risk of developing biologic complications (eg, marginal bone loss or
peri-implant disease) and, therefore, should be preferred over
cement-retained restorations1,2. Furthermore, the retrievability of the
restoration makes the handling of complications easier if they do
occur1. To allow for screw retention and achieve a reasonable clinical
outcome, a comprehensive prosthetic planning is mandatory, followed
by a correct three-dimensional (3D) implant position and axis.
Concerning the material selection, both metallic and all-ceramic
abutments have been suggested3. While ceramic abutments may be
better in the esthetic area, titanium abutments have proven to be
mechanically more stable4–7 and should, therefore, be considered as
first option in posterior regions8.
Until the last decade, metal-based, handmade restorations fully or
partially veneered with feldspathic ceramics were considered to be
the golden standard. Currently, the developments in computer-
assisted design/computer-assisted manufacturing (CAD/CAM),
coupled with the high demand for esthetics, have opened up a range
of possibilities for all-ceramic-based restorations, allowing for less
costly and more time-effective production workflows9,10. Designing
and subsequent milling of high-strength ceramics is now possible,
with an adequate fit and favorable clinical outcomes11–13. For these
reasons, zirconia has emerged as a very popular material, also due
to its excellent biocompatibility and improved mechanical properties14.
The use of zirconia as an alternative to conventional metallic
frameworks in multiple-unit FDPs is currently accepted15. As with
metal-based structures, zirconia frameworks are usually manually
veneered for esthetic reasons. However, it is reported in the literature
that the incidence of chipping of this veneering ceramic is still high15.

1.11.3 Monolithic implant restorations

supported by titanium-base
abutments
To overcome the aforementioned problems, different experts have
suggested a monolithic restoration design, ie, the fabrication of the
entire restoration out of one material without the need for veneering
ceramic. In addition, when the optimal polishing is performed,
monolithic zirconia has been shown to cause less wear to antagonist
teeth than veneering ceramic16,17. One possibility is to limit the use of
veneering ceramic to the esthetic area of the restoration, avoiding its
use in the more functional areas, especially in posterior regions
where stress forces are higher and esthetics is less important. In any
event, abutments are required in order to connect these monolithic
restorations to the implant (Fig 1-11-1).

Fig 1-11-1a Clinical situation with one missing mandibular molar to be

replaced with a single implant.
Fig 1-11-1b Monolithic zirconia implant single crown prior to adhesive
cementation to a titanium-base abutment.

Fig 1-11-1c The monolithic zirconia implant crown, supported by the

titanium-base abutment, and screw-retained to the implant.

The development of titanium-base abutments allowed for the use

of implant-supported monolithic restorations in a digital workflow.
Different base configurations are available according to each clinical
indication, from single-unit restorations to multiple-unit FDPs
supported by the respective titanium-base abutments (Fig 1-11-2).

Fig 1-11-2a Clinical situation of a multiple-tooth gap in the posterior

mandibular region: the missing teeth were already replaced by two
implants and the distal abutment tooth prepared (universal tooth prep)
for a single crown.
Fig 1-11-2b Three-unit posterior implant FDP (monolithic zirconia),
supported by two cylindrical titanium-base abutments.

Fig 1-11-2c The screw-retained, three-unit monolithic zirconia implant

FDP supported by titanium-base abutments.

These prefabricated titanium-base abutments appear to be a very

promising solution as they combine a metallic implant connection with
a ceramic outer part, thereby offering good esthetics and mechanical
stability at the same time18–20. Following a digital workflow, the
monolithic restoration can be designed, milled, and adhesively
cemented to the titanium-base abutment, and then directly screw-
retained to the implant as a conventional one-piece, screw-retained
restoration21–23. This type of restoration has shown positive results in
laboratory and short-term clinical investigations6,18,24.
Different configurations of titanium-base abutments are available
from different manufacturers, according to the indication, ie, a single-
unit or multiple-unit restoration. To allow for the compensation of
implant axis divergences, and to achieve a passive fit, titanium-base
abutments for FDPs usually have more convergent walls, a smaller
bonding surface, and a shorter internal connection to the implant. One
might assume that these factors could be possible causes for
technical complications such as bonding failures or screw loosening.
In an attempt to reduce the risk of these complications, the use of
titanium-base abutments for crowns has been suggested even for
multiple-unit restorations, as the mechanical retention is expected to
be higher. In a compromised situation, eg, if higher implant
divergences need to be compensated for, a combination of titanium-
base abutments for FDPs and crowns can theoretically also be
applied. A recent, yet unpublished study showed that the retentive
strength of the conical titanium-base abutments for multiple-unit
implant FDPs was less reliable than the cylindrical titanium-base
abutment25. Significantly more debonding of the monolithic zirconia
multiple-unit FDPs was found in the conical group than in the
cylindrical group25. Furthermore, the combination of one conical and
one cylindrical abutment only led to slightly improved outcomes25. In
contrast, the FDPs cemented to cylindrical titanium-base FDP
abutments performed significantly better than all other groups25 (Fig
1-11-3).
25
Fig 1-11-3 Preliminary results of the laboratory study evaluating the
effect of different titanium-base abutment configurations for the
support of three-unit monolithic zirconia implant FDPs. Note the higher
predictability of the samples supported by cylindrical titanium-base
abutment configurations. (VB, Variobase, Straumann.)

Hence, in the current concept only the (new) cylindrical types of

titanium-base abutments can be recommended for multiple-unit
implant FDPs. Until now, the concept of titanium-base abutments
supporting fixed implant restorations has demonstrated very
promising results when applied to single-unit restorations6,18,24. When
the ideal 3D implant position is respected, the use of titanium bases
made for crowns can also be applied to multiple-unit restorations.
What remains unclear is whether the difference in the design between
these abutments for crowns and multiple-unit implant FDPs can lead
to problems.

1.11.4 Factors for predictable

outcomes: adhesive
cementation of monolithic
ceramics to titanium-base
abutments
Notwithstanding all advantages of the titanium-base abutment
concept, its success is highly dependent on the bonding stability
between the titanium base and the ceramic components. In order to
achieve a high and durable adhesive retention, several surface
pretreatments have been proposed. Besides that, some implant
manufacturers explicitly do not recommend airborne-particle abrasion
of the titanium bases. From the conventional airborne-particle
abrasion with aluminum oxide particles (Al2O3) to the tribochemical
silica-coating systems, numerous airborne-particle abrasion methods
with different particles sizes have been suggested26–31. However,
most of the studies evaluating these methods are based in pure shear
or tensile bond strength tests using flat-surfaced samples.
Subsequently the retention given by the titanium base axial walls, as
seen in a clinical setting, it is not taken into consideration. In order to
predict the materials’ behavior under clinical conditions, in-vitro tests
applying chewing simulation and using clinically relevant prosthetic
designs are necessary. Besides, some implant manufacturers
explicitly do not recommend the airborne-particle abrasion of the
titanium-base abutments. In order to examine the effect of the
pretreatment of the titanium-base abutment on the pull-off forces of
glass-ceramic crowns adhesively cemented onto the abutments, a
laboratory study was performed. The study compared the effect of
airborne-particle abrasion of the titanium base with 50 µm Al2O3, and
the pretreatment with silica-reinforced Al2O3 particles of different
grain sizes to non-pretreated titanium-base abutments. After the
different pretreatments of the titanium-base, a universal primer was
applied (Monobond Plus, Ivoclar Vivadent, Schaan, Liechtenstein),
and lithium-disilicate monolithic crowns were adhesively cemented
(Multilink Hybrid Abutment, Ivoclar Vivadent) to the titanium-base
abutments. The study showed that the application of a surface
treatment on the titanium bases, more specifically 50-μm Al2O3
particles, positively influenced the bonding interface stability and
retention forces between titanium-base abutments and all-ceramic
crowns. Despite the application of a universal primer agent and a
resin-based cement, the samples that were not mechanically surface-
treated revealed a 73.3% of bonding failure after aging. In contrast,
only 6.7% failed when airborne-particle abrasion of 50-μm Al2O3 was
applied32.
Hence, in the current concept, airborne-particle abrasion of the
titanium-base abutments with 50-μm Al2O3 is recommended (Fig 1-
11-4).
Figs 1-11-4a and 1-11-4b Scanning electron microscope (SEM)
image of the intaglio titanium surface of the titanium-base abutment,
as delivered by the manufacturer. Note the marks of the machining
process.
Figs 1-11-4c and 1-11-4d SEM image of the titanium-base abutment
surface after the pretreatment with airborne-particle abrasion with
50-µm Al2O3.
Figs 1-11-4e and 1-11-4f SEM image of the titanium-base abutment
surface after pretreatment with airborne-particle abrasion with 110-
µm silica containing Al2O3 (Rocatec, 3M Espe).

Besides the pretreatment of the titanium base, the selection of the

resin cement plays a crucial role for the clinical success within the
titanium-base concept. It has been reported that titanium abutments
in contrast to other kinds of abutments are very likely to cause a
change in color appearance of the peri-implant mucosa, especially in
a clinical situation with a mucosa thickness of 2 mm or less33–36.
Besides the influence of abutment material and peri-implant soft
tissue thickness, it has been documented that along with abutment
color and ceramic thickness, the cement color also influenced the
color outcome of CAD/CAM glass-ceramic lithium-disilicate
crowns9,37. It seemed reasonable to speculate that the cement
bonding a CAD/CAM glass-ceramic lithiumdisilicate restorations on a
titanium-base abutment could also contribute to the color outcome of
the restoration and the peri-implant soft tissue.
A recent in-vitro study showed that color outcome of the all-
ceramic, lithium-disilicate implant crowns cemented to titanium-base
abutments was influenced by different types of cements38. More
opaque cements led to less discoloration, both for non-airborne-
particle-abraded and airborne-particle-abraded abutments.
Furthermore, the cements also influenced the color outcome of the
peri-implant soft tissue Part with the all-ceramic crowns, yet to a less
pronounced degree37–39. Opaque cements masked the color of the
metal substructure37,39, while two opaque resin cements performed
superior to the other tested cements: Multilink HO 0 (Ivoclar
Vivadent) and Panavia opaque (Kuraray, Tokyo, Japan). Interestingly,
the study showed that the cements also contributed to the final color
outcome of the (artificial) peri-implant soft tissue (thickness of 2.0
mm)38. In general, the thickness of the peri-implant soft tissues is a
crucial factor influencing the color change caused by the titanium
substructures as demonstrated in both in vitro34,36 and clinical
studies34–36 (Fig 1-11-5).
Fig 1-11-5a Illustration of a spectrophotometric measurement
showing the marks made on the adjacent canine and the adjacent
soft tissue to standardize the measured sites.
Fig 1-11-5b Illustration of a spectrophotometric measurement
showing the marks made on the adjacent canine and the adjacent
soft tissue to standardize the measured sites. (reproduced from Liu
38
et al , with permission).
Fig 1-11-5c Comparison of ΔE values for restoration surfaces
across different definitive cement groups for restorations supported
by non-airborne-particle-abraded titanium abutments (reproduced
38
from Liu et al , with permission).
Fig 1-11-5d Comparison of ΔE values for artificial peri-implant soft
tissue surfaces across different definitive cement groups for
restorations supported by non-airborne-particle-abraded titanium
38
abutments (reproduced from Liu et al , with permission).
Fig 1-11-5e Comparison of ΔE values for restoration surfaces
across different definitive cement groups for restorations supported
by airborne-particle-abraded titanium abutments (reproduced from Liu
38
et al , with permission).
Fig 1-11-5f Comparison of ΔE values for peri-implant artificial soft
tissue surfaces across different definitive cement groups for
restorations supported by airborne-particle-abraded titanium
38
abutments (reproduced from Liu et al , with permission).
Fig 1-11-5g Median ΔE distribution across different measurement
sites for restorations supported by non-airborneparticle-abraded vs
airborne-particle-abraded titanium abutments (reproduced from Liu et
38
al , with permission).
Fig 1-11-5h Median ΔE distribution for restoration surfaces with
different cement groups for restorations supported by non-airborne-
particle-abraded vs airborne-particle-abraded titanium abutments
38
(reproduced from Liu et al , with permission).
Fig 1-11-5i Median ΔE distribution for artificial soft tissue surfaces
with different cement groups comparing restorations supported by
non-airborne-particle-abraded vs airborne-particle-abraded titanium
38
abutments (reproduced from Liu et al , with permission).

In the present concept, therefore, the application of an opaque

resin cement, Multilink HO 0 (Ivoclar Vivadent), is recommended for
good esthetic outcomes. Yet, esthetics is not the only factor to be
considered in the selection of the cement. A recent laboratory study
showed that there is no universal cement, ideally bonding to all
ceramics38. In this study, the pull-off bond strength of three different
resin cements was tested to three restorative materials (lithium-
disilicate ceramics, polymer-infiltrated ceramic network, zirconia). The
results showed that none of the three tested cements bonded best
for all materials (Fig 1-11-6). For each material, the ideal resin
cement has to be selected for good bond strength, yet, in highest
opacity for predictable esthetics.
Fig 1-11-6a Preliminary results of the pull-off strength obtained at
three different restorative materials and three resin cements. Note
that none of the cements was superior to any of the other materials.
Fig 1-11-6b Preliminary recommendation of cements according to
results of the study. Note that more research including more resin
cements is needed for final recommendations.

Finally, the appropriate pretreatment of the different ceramics for

adhesive cementation is crucial for the bond strength values (see Part
I, Chapter 9).

1.11.5 Conclusions
Titanium-base-supported fixed implant restorations have been
increasingly applied in daily clinical practice in recent years, due to an
increase in clinical and laboratory efficiency and consequently a
reduction in costs. The concept appears to be very promising, yet, it
has to be considered that scientific evidence is still missing and
numerous questions remain unanswered today. Hence, clinicians need
to stay informed about the most recent outcomes of clinical and
fundamental studies, for the most appropriate selection of concept
and restorative materials and procedures in the specific patient
situation.

1.11.6 References
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25. Calderon U, Hicklin S, Mojon P, Fehmer V, Nesic D, Sailer I.
Monolithic zirconia multiple-unit implant fixed dental prostheses
bonded to titanium base abutments: a laboratory study on the
influence of the titanium base abutment design on the technical
outcomes. Int J Oral Maxillofac Implantol 2021, In press.
26. Abi-Rached Fde O, Fonseca RG, Haneda IG, de Almeida-
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on the shear bond strength of luting cements to titanium. J
Prosthet Dent 2012;108:370–376.
27. de Almeida-Junior AA, Fonseca RG, Haneda IG, Abi-Rached
Fde O, Adabo GL. Effect of surface treatments on the bond
strength of a resin cement to commercially pure titanium. Braz
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28. Elsaka SE, Swain MV. Effect of surface treatments on the
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29. Fonseca RG, Haneda IG, Almeida-Junior AA, de Oliveira Abi-
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additional surface treatment at titanium/resin cement interface.
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30. Ozcan M, Raadschelders J, Vallittu P, Lassilla L. Effect of
particle deposition parameters on silica coating of zirconia using
a chairside air-abrasion device. J Adhes Dent 2013;15: 211–
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31. von Maltzahn NF, Holstermann J, Kohorst P. Retention forces
between titanium and zirconia components of two-Part implant
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32. Pitta J, Burkhardt F, Mekki M, Fehmer V, Mojon P, Sailer I.
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interface stability and retention forces of hybrid-abutment
crowns after artificial aging. Int J Prosthodont 2020; 6:24.
33. Happe A, Schulte-Mattler V, Fickl S, Naumann M, Zoller JE,
Rothamel D. Spectrophotometric assessment of peri-implant
mucosa after restoration with zirconia abutments veneered with
fluorescent ceramic: a controlled, retrospective clinical study.
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abutment tooth color, cement color, and ceramic thickness on
the resulting optical color of a CAD/CAM glass-ceramic lithium
disilicate-reinforced crown. J Prosthet Dent 2011;105:83–90.
38. Liu X, Fehmer V, Sailer I, Mojon P, Pjetursson BE. Influence of
different cements on the color outcome of titanium-based lithium
disilicate all-ceramic crowns and the peri-implant soft tissue. Int
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39. Dede DO, Armaganci A, Ceylan G, Cankaya S, Celik E.
Influence of abutment material and luting cements color on the
final color of all ceramics. Acta Odontol Scand 2013;71: 1570–
1578.
CHAPTER 12
Material selection flowcharts

Material selection for tooth-supported

single-unit restorations
Fig 1-12-1 Flowcharts of material selection for tooth-supported
single-unit restorations (minimally invasive, defect-oriented, and
conventional).
Material selection for tooth-supported
multiple-unit restorations
Fig 1-12-2 Flowchart of material selection for tooth-supported
multiple-unit restorations.
Material selection for implant-
supported restorations

Fig 1-12-3 Flowchart of material selection for single- and multiple-

unit implant FDPs in posterior regions.

Material selection for implant-

supported restorations
Fig 1-12-4 Flowchart of material selection for implant-supported
single- and multiple-unit restorations (anterior region).
Fig 1-12-5 Flowchart of material selection for implant-supported
single- and multiple-unit restorations.
CHAPTER 13
Cementation flowcharts

Cementation flowchart for metal-

ceramic restorations
Fig 1-13-1 Cementation flowchart for metal-ceramic restorations.
Methacryloyloxydecyl dihydrogen phosphate (10-MDP) is one of the
most commonly used functional monomers; it is the hydrophilic
phosphate monomer that increases resin diffusion and adhesion by
causing acidic decalcification and binding to calcium ions or amino
groups of tooth structure. CHX, chlorhexidine; FDP, fixed dental
prosthesis.

Cementation flowchart for zirconia

restorations
Fig 1-13-2 Cementation flowchart for zirconia-based restorations.
CHX, chlorhexidine; FDP, fixed dental prosthesis; MDP,
methacryloyloxydecyl dihydrogen phosphate; RBFDP, resin-bonded
fixed dental prosthesis.

Adhesive cementation flowchart for

lithium disilicate restorations
Fig 1-13-3 Adhesive cementation flowchart for lithium-disilicate
restorations. CHX, chlorhexidine.

Adhesive cementation flowchart for

feldspathic ceramic veneers
Fig 1-13-4 Adhesive cementation flowchart for feldspathic ceramic
veneers.

Cementation flowchart for posts

Fig 1-13-5 Cementation flowchart for posts. CHX, chlorhexidine.
Cementation flowchart for extraoral
cementation (eg, in laboratory)
Fig 1-13-6 Cementation flowchart for extraoral cementation. CHX,
chlorhexidine; FDP, fixed dental prosthesis; MDP,
methacryloyloxydecyl dihydrogen phosphate.
PART II
CLINICAL PROCEDURES
STEP-BY-STEP
CHAPTER 1
Minimally invasive restorations
(veneers)

Anterior regions
2.1.1 Additional veneers after trauma (two
maxillary central incisors)
2.1.2 Anterior veneer after trauma (single
maxillary central incisor)
2.1.3 Traditional veneers for restoration of
amelogenesis imperfecta (six
maxillary anterior teeth)
2.1.4 Traditional and palatal veneers after
deep bite and orthodontic
pretreatment (six maxillary anterior
teeth)

Anterior and posterior regions,

augmented reality applications
Traditional veneers after undetected
2.1.5
celiac disease (10 veneers – maxillary
premolar to premolar)
2.1.6 Traditional veneers with the
application of augmented reality (10
veneers – maxillary premolar to
premolar)
2.1.7 Traditional veneers with the
application of augmented reality and
orthodontic pretreatment (six maxillary
anterior teeth)
2.1.8 360-degree and occlusal veneers with
a single implant restoration (seven
mandibular teeth and posterior
implant)

Complex situations
2.1.9 Full-mouth rehabilitation with
traditional veneers and overlays
2.1.10 Additional veneers and implant
restorations (maxillary premolar to
premolar)
After trauma
(additional veneers)

2.1.1 Additional veneers after trauma

(two maxillary central incisors)
This section describes the minimally invasive rehabilitation of a patient
after trauma and root canal treatment.

Assessment and treatment planning

An 18-year-old healthy and caries-free man presented himself at the
clinic seeking treatment for his fractured incisal composite filling at
tooth 21. Furthermore, he disliked the unesthetic appearance of his
old composite fillings and the grayish discoloration of tooth 21.
As consequence of an accident several years ago, he received a
root canal treatment on tooth 21 that showed a modest but visible
grayish discoloration and a direct incisal edge composite restoration
that had fractured. In agreement with the patient, a step-by-step
treatment plan was established. The first step consisted of an internal
bleaching procedure of tooth 21. Depending on the result of the
internal bleaching, the second step would either be a new direct
composite build-up or the total removal of the old composite and a
slight preparation of the teeth for minimally invasive additional ceramic
veneers (Fig 2-1-1). The step-by-step approach is described as
follows.
Figs 2-1-1a to 2-1-1c Pretreatment photographs.

Diagnostics
The patient’s chief complaint was the failing composite filling of the
maxillary incisor 21. Furthermore, he was also bothered by the lack
of esthetic integration of both incisal composite fillings.
Initially, all corrections were performed digitally by means of an
image editing software, Photoshop Elements (Adobe Systems, San
Jose, CA, USA), to visualize the patient’s treatment. Thereafter, the
planned changes were transferred into a wax-up based on a
conventional master cast in which the position of the two incisors was
adjusted.

Internal bleaching
For the internal bleaching procedure of tooth 21, a mixture of 30%
hydrogen peroxide and sodium perborate was mixed to a sand-like
consistency and applied to the root canal, provisionally covered with
composite, and left there in place for a period of 1 week. After this
period a color assessment took place and the change was evaluated.
If a further bleaching effect is desired, the substrate can stay in place
for an additional few days or up to 1 week before reassessing the
bleaching effect. At the follow-up visit 2 weeks after the bleaching
material was removed, a major improvement in the color was
observed (Fig 2-1-2).
Figs 2-1-2a and 2-1-2b Pre- and post-internal bleaching.
Veneer preparation and impression
A silicone index was fabricated based on the wax-up to facilitate the
correct preparation of the teeth. The old composite fillings were
removed from teeth 11–21 and then prepared in a minimally invasive
way, basically a minimal rounding of the incisal edges and a
roughening of the surface, to receive the two veneers (Universal Prep
Set, Intensiv, Montagnola, Switzerland).
With an epigingival course solely in the enamel, the final
impression was taken using two retraction cords. In order to avoid
traumatization of the gingiva and to minimize the risk of recessions, a
surgical suturing material (size 4-0, Vicryl Ethicon, Johnson &
Johnson, New Brunswick, NJ, USA) was used as the first retraction
cord. The second retraction cord was the thinnest cord available on
the market (000 Ultrapak, UP Dental, Cologne, Germany) (Fig 2-1-3).
Figs 2-1-3a to 2-1-3d Veneer preparation and impression.

Provisional
In order to deliver a provisional that would not require any kind of
pretreatment or spot-etching and as the teeth showed no sensitivities,
the decision was made to use a relined removable thermoplastic foil
(Erkodur 1.5 mm, Erkodent, Pfalzgrafenweiler, Germany). The
thermoplastic foil was produced, based on the wax-up in the dental
laboratory. After the minimally invasive preparation was applied, the
hollow foil was then intraorally relined with a chemically curing acrylic
material in shade Vita A1 (NewOutline A1, Anaxdent, Stuttgart,
Germany) and placed over the teeth. The resulting removable
provisional additionally served as a communication tool, to visualize
the prospective treatment result (Fig 2-1-4).
Figs 2-1-4a to 2-1-4d Creation of provisional restoration.

Fabrication of the veneers in the laboratory

The first step for the final restoration was the fabrication of an
alveolar cast. Refractory dies were manufactured (anaxVest,
Anaxdent) to guarantee the best possible fit of the veneers.
For the fabrication of the veneers, a reverse planning concept was
applied. The laboratory work was guided by the information from the
wax-up which was transferred with the aid of silicone indexes (Matrix
Form 60, Anaxdent). The ceramic masses were then applied
(Creation Classic, Willi Geller, Meiningen, Austria) according to the
custom shade that was developed by the dental technician in
collaboration with the patient. After two dentin firings, the surface
texture and the final shape were shaped with diamond burs. The
glaze firing was followed by a mechanical polishing procedure. The
polished veneers were removed from the refractory dies by airborne-
particle abrasion and cleaned in an ultrasonic waterbed (Fig 2-1-5).
Figs 2-1-5a to 2-1-5d Fabrication of the veneers.

Integration of the restorations

A try-in session was carried out where the two veneers were inserted
with a try-in paste (Variolink Esthetic, Ivoclar Vivadent, Schaan,
Liechtenstein) in order to improve color assessment and optical
integration. The patient and the dental practitioner realized that the
veneers were slightly too long. The incisal edges of the veneers were
marked and thereby optically shorted using a black waterproof
marker until both patient and clinician expressed their satisfaction with
the esthetic result. As it was only about three-tenths of a millimeter,
the veneers could be shortened on site using an abrasive diamond
polishing wheel. Subsequently, in a dry environment (rubber dam) the
fragile ceramic veneers were cemented. The abutment teeth were
etched with 35% phosphoric acid (Ultra-Etch, Ultradent Products,
South Jordan, UT, USA) and bonded with a multistep adhesive
system (Syntac Classic, Ivoclar Vivadent). The bond was not light-
cured in order not to compromise the fit of the ultra-thin veneers. The
veneers were etched with hydrofluoric acid (9% concentration for 1
min) (Porcelain Etch, Ultradent Products). A silane-containing primer
(Monobond S, Ivoclar Vivadent) and a bonding system (Heliobond,
Ivoclar Vivadent) were applied. Then the veneers were cemented
with a dual-curing resin cement (Variolink Esthetic Neutral, Ivoclar
Vivadent). Excess cement was removed with rotating diamond
instruments. The occlusal and functional contacts were analyzed, and
no adjustments were necessary.
All participants were very satisfied with the final treatment
outcome (Figs 2-1-6 and 2-1-7). (Dental practitioner: Prof Dr D
Thoma; Technician: MDT V Fehmer.)
Figs 2-1-6a to 2-1-6c Cementation of veneers.
Figs 2-1-7a to 2-1-7f Final veneers and outcome.
After trauma
(additional veneer)

2.1.2 Anterior veneer after trauma

(single maxillary central incisor)
This section describes the minimally invasive rehabilitation of a patient
after trauma.

Assessment and treatment planning

A 24-year-old, healthy, and mostly caries-free man presented himself
at the clinic seeking treatment for his discolored and worn incisal
composite filling at tooth 11. Furthermore, he wanted a replacement
for the missing lateral incisor 12 (see Part II, Chapter 2 for the
resinbonded fixed dental prosthesis [RBFDP] in detail).
As consequence of an accident several years ago he lost his
lateral incisor and horizontally fractured his central incisor. As an initial
treatment he received a direct incisal edge composite build-up along
with a small removable restoration replacing the missing lateral tooth
12. In agreement with the patient, a treatment plan was developed
that foresaw a cantilever RBFDP replacing tooth 12 with a palatal
backing on tooth 13. Due to the pronounced individual characteristics
of the adjacent central incisor that served as a reference tooth, it was
decide to remove the old composite filling and replace it with an
individualized layered feldspathic ceramic veneer rather than with a
new composite build-up (Fig 2-1-8). The step-by-step approach is
described as follows.
Figs 2-1-8a to 2-1-8c Pretreatment photographs.

Diagnostics
Initially, all corrections were performed digitally by means of the
image editing software Keynote (Apple, Cupertino, CA, USA) to
visualize the patient’s treatment. Thereafter, the planned changes
were transferred into a wax-up based on a conventional master cast
in which the shape of the incisor was adjusted and the missing lateral
incisor was replaced.
Veneer preparation and impression
A silicone index was fabricated based on the wax-up to facilitate the
correct preparation of the tooth. The old composite filling was
removed from the tooth and then prepared in a minimally invasive way
following the areas marked in black (Universal Prep Set, Intensiv,
Montagnola, Switzerland), covering the entire buccal surface in order
to prevent a visible horizontal transition zone between the tooth and
the veneer.
With an epigingival course solely in the enamel, the final
impression was taken using two retraction cords. In order to avoid
traumatization of the gingiva and to minimize the risk of recessions, a
surgical suturing material (size 4-0, Vicryl Ethicon, Johnson &
Johnson, New Brunswick, NJ, USA) was used as the first retraction
cord. The second retraction cord was the thinnest cord available on
the market (000 Ultrapak, UP Dental, Cologne, Germany) (Fig 2-1-9).
Figs 2-1-9a to 2-1-9f Veneer preparation.

Provisional
In order to deliver a provisional that would not require any kind of
pretreatment and deliver an easy access, the decision was made to
use a relined removable thermoplastic foil (Erkodur 1.5 mm,
Erkodent, Pfalzgrafenweiler, Germany). The thermoplastic foil was
produced based on the wax-up in the dental laboratory. The hollow
foil was intraorally relined with a chemically curing acrylic material, in
shade Vita B3 (NewOutline B3, Anaxdent, Stuttgart, Germany) and
placed over the minimally invasive preparation of the tooth and pontic.

Fabrication of the veneer in the laboratory

The first step for the final restoration was the fabrication of an
alveolar cast. Refractory dies were manufactured (anaxVest,
Anaxdent) to guarantee the best possible fit of the veneers.
For the fabrication of the veneer, a backward planning concept
was applied. The laboratory work was guided by the information from
the wax-up, which was transferred with the aid of silicone indexes
(Matrix Form 60, Anaxdent). The ceramic masses were then applied
(Creation Classic, Willi Geller, Meiningen, Austria) according to the
custom shade that was developed by the dental technician in
collaboration with the patient. After one dentin firing, the surface
texture and the final shape was made with diamond burs. The glaze
firing was followed by an additional stain firing and a mechanical
polishing procedure. The polished veneer was removed from the
refractory die by airborne-particle abrasion and cleaned in an
ultrasonic waterbed (Fig 2-1-10).
Figs 2-1-10a and 2-1-10b Fabrication of the veneer.

Integration of the restoration

A try-in session was carried out where the veneer was inserted with
a try-in paste (Variolink Esthetic Warm, Ivoclar Vivadent, Schaan,
Liechtenstein) in order to improve color assessment and optical
integration. Subsequently, in a dry environment (rubber dam) the
fragile ceramic veneer was cemented. The abutment tooth was
etched with 35% phosphoric acid (Ultra-Etch, Ultradent Products,
South Jordan, UT, USA) and bonded with a multistep adhesive
system (Syntac Classic, Ivoclar Vivadent). The bond was not light-
cured in order not to compromise the fit of the ultra-thin veneer. The
veneer was etched with hydrofluoric acid (9% concentration for 1
min) (Porcelain Etch, Ultradent Products). A silane-containing primer
(Monobond S, Ivoclar Vivadent) and a bonding system (Heliobond,
Ivoclar Vivadent) were applied. Then the veneer was cemented with a
dual-curing resin cement (Variolink Esthetic Warm, Ivoclar Vivadent).
Excess cement was removed with rotating diamond instruments. The
occlusal and functional contacts were analyzed, and no adjustments
were necessary.
The patient was very satisfied with the final treatment outcome
(Figs 2-1-11 and 2-1-12). (Dental practitioner: Prof Dr I Sailer;
Technician: MDT V Fehmer.)
Figs 2-1-11a and 2-1-11b Cementation of the veneer.
Figs 2-1-12a Final esthetic outcome.
Figs 2-1-12b Final esthetic outcome.
Amelogenesis imperfecta
(traditional veneers)

2.1.3 Traditional veneers for

restoration of amelogenesis
imperfecta (six maxillary
anterior teeth)
The following section describes the minimally invasive rehabilitation of
a patient with amelogenesis imperfecta.

Assessment and treatment planning

A 27-year-old healthy and almost caries-free woman presented at the
clinic seeking treatment for her dark spots on the maxillary incisors
and unesthetic gingival margin. A history of trauma, tetracycline
staining, or fluorosis could be excluded. The clinical examination did
not fully reveal the severity of the amelogenesis imperfecta nor the
depth of the staining. In agreement with the patient, a step-by-step
treatment plan was established. The first step consisted of a home
bleaching procedure. If the stains were still present in the deeper
layers of the tooth, a microabrasion technique would be applied. This
procedure implies the removal of a 0.03 mm thin layer of enamel.
Depending on the result of microabrasion, the third step would be
undertaken: preparation of the teeth for ceramic veneers or crowns.
The latter option would be considered if the enamel could not be
etched due to the hypoplasia. Since the patient did not like the
appearance of her gingival margin, a crown-lengthening procedure
was planned (Fig 2-1-13). The step-by-step approach is described as
follows.
Figs 2-1-13a to 2-1-13c Pretreatment photographs (Figs 2-1-13a
1
and 2-1-13b reproduced with permission from Büchi et al ).

Diagnostics
The patient’s chief complaint was the dark and white-opaque staining
of the maxillary incisors and canines. However, she was also
bothered by the asymmetrical gingival margin and the difference
between the incisal edges of tooth 11 and 23. Furthermore, the
patient requested a correction of the overlapping of teeth 21 and 11.
Initially, all corrections were performed digitally by means of an
image editing software, Photoshop Elements (Adobe Systems, San
Jose, CA, USA), to visualize the patient’s treatment. Thereafter, all
the planned changes were transferred into a wax-up. The position of
the two incisors was adjusted to better fit into the arch. At teeth 11
and 23, the gingiva on the plaster cast was modified in order to
simulate future crown lengthening (Fig 2-1-14).
Figs 2-1-14a to 2-1-14d Treatment planning (reproduced with
1
permission from Büchi et al ).

Mock-up
In order to transfer the simulations into the patient’s mouth, the incisal
edge of tooth 23 and the cusp of tooth 24 had to be shortened. A
resin cap served as a reference for the amount of incisal reduction
required (Acryline clear, Anaxdent, Stuttgart, Germany). Following
preparation, the enamel was smoothened with fine-grit diamond burs
(Universal Prep Set, Intensiv, Montagnola Switzerland).
A silicone index of the wax-up was prepared in order to directly
fabricate a mock-up in the patient’s mouth (Memosil 2, Kulzer, Hanau,
Germany). This silicone index was filled with a chemically curing
composite material, in shade Vita A1 (Protemp, 3M, Rüschlikon,
Switzerland) and placed over the teeth. The resulting mock-up served
as a communication tool, and the prospective treatment result could
now be discussed with the patient. The mock-up also helped to
estimate the extent of the crown lengthening that would be necessary
(Fig 2-1-15).
Figs 2-1-15a to 2-1-15d Creation of mock-up (reproduced with
1
permission from Büchi et al ).

Crown lengthening
On tooth 11, the gingival level had to be moved about 1 mm apically
and on tooth 23, about 1.5 mm apically. The periodontal examination
revealed that both teeth had pseudo pockets. The vertical distance to
the bone was around 4 mm. A gingivectomy was carried out without
violating the biological width. The mock-up was used to verify the
total prospective crown length. To ensure the success of the crown
lengthening, the treatment plan now foresees a healing and stabilizing
break of 2 months (Fig 2-1-16).

Figs 2-1-16a and 2-1-16b Crown lengthening (reproduced with

1
permission from Büchi et al ).

Home bleaching
For the home bleaching procedure of all teeth, bleaching trays were
fabricated in the dental laboratory (Erkodur, Pfalzgrafenweiler,
Germany). A carbamide peroxide bleaching gel with a concentration
of 15% (Opalescense, Ultradent Products, South Jordan, UT, USA)
was administered to the patient to be used for 2 hours a day for the
following 3 weeks. At the follow-up visit 1–2 weeks after the last
bleaching, a major improvement in the color was observed. The
patient became more and more aware of dental esthetics, noticed a
positive change, and was motivated to seek further improvement.

Microabrasion
The next stage of the treatment plan was the application of the
microabrasion technique (Opalustre, Ultradent Products). The most
superficial enamel layer was etched and subsequently removed with
an abrasive paste and a rubber cup. Again, in the follow-up visit, a
clear improvement was noticed, but the stains could not be fully
removed. Moreover, the patient wanted to continue in order to correct
the position and shape of her anterior teeth (Fig 2-1-17).
Figs 2-1-17a and 2-1-17b Bleaching (reproduced with permission
1
from Büchi et al ).

Veneer preparation and impression

A silicone index was fabricated based on the wax-up to facilitate the
correct preparation of the teeth. The teeth 13–23 were prepared in a
minimally invasive way to receive veneers. With an epigingival course
solely in the enamel, the final impression was taken using two
retraction cords. In order to avoid traumatization of the gingiva and to
minimize the risk of recessions, a surgical suturing material (size 4-0,
Vicryl Ethicon, Johnson & Johnson, New Brunswick, NJ, USA) was
used as the first retraction cord. The second retraction cord was the
thinnest cord available on the market (000 Ultrapak, UP Dental,
Cologne, Germany). The preparation margins could be sufficiently
exposed with this technique (Fig 2-1-18).
Figs 2-1-18a to 2-1-18c Veneer preparation and impression
1
(reproduced with permission from Büchi et al ).

Fabrication of the veneers in the laboratory

Before the dental technician initiated the fabrication of the final
restoration, all the information gathered during the diagnostic phase
was reviewed in order to ensure that the prospective shape, position,
and shade of the teeth would fulfill the patient’s and the dental team’s
expectations.
The first step for the final restoration was the fabrication of an
alveolar cast. This cast offers a big advantage in comparison with
conventional saw-cut casts because it preserves all the information
on gingival morphology. Refractory dies were manufactured
(anaxVest, Anaxdent, Stuttgart, Germany) to guarantee the best
possible fit of the veneers.
For the fabrication of the veneers, a reverse planning concept was
applied. The laboratory work was guided by the information from the
wax-up and mock-up, which was transferred with the aid of silicone
indexes (Matrix Form 60, Anaxdent). The ceramic masses were then
applied (Creation Classic, Willi Geller, Meiningen, Austria) according
to the custom shade that was developed by the dental technician in
collaboration with the patient, and re-adjusted after the evaluation of
the preparation. After two dentin firings, the surface texture and the
final shape was done with diamond burs. Gold powder was used to
highlight the microstructure of the surface and make the texture
clearly visible. The glaze firing was followed by a mechanical polishing
procedure. The polished veneers were removed from the refractory
dies by airborne-particle abrasion and cleaned in an ultrasonic
waterbed (Fig 2-1-19).
Figs 2-1-19a to 2-1-19f Fabrication of the veneers (Figs 2-1-19a
1
and 2-1-19b reproduced with permission from Büchi et al ).
Integration of the restoration
A try-in session was carried out where the veneers were inserted
with glycerin gel in order to improve color assessment. Both the
patient and the dental practitioner expressed their satisfaction with
the esthetic result. Subsequently, in a dry environment (rubber dam)
the fragile ceramic veneers were cemented. The abutment teeth
were etched with 35% phosphoric acid (Ultra-Etch, Ultradent
Products) and bonded with a multistep adhesive system (Syntac
Classic, Ivoclar Vivadent, Schaan, Liechtenstein). The bond was not
light-cured in order not to compromise the fit of the veneers. The
veneers were etched with hydrofluoric acid (9% concentration for 1
min) (Porcelain Etch, Ultradent Products). A primer (Monobond S,
Ivoclar Vivadent) and a bonding system (Heliobond, Ivoclar Vivadent)
were applied. Then the veneers were cemented with a dual-curing
resin cement (Variolink transparent, Ivoclar Vivadent). Excess cement
was removed with rotating diamond instruments. The occlusal and
functional contacts were analyzed and no adjustments were
necessary (Fig 2-1-20).
Figs 2-1-20a and 2-1-20b Cementation of the veneers (reproduced
1
with permission from Büchi et al ).

All participants were very satisfied with the final treatment

outcome. At a follow-up visit 18 months postinsertion, all the veneers
looked well integrated without any discoloration of the margin or
chipping and fractures of the ceramic (Fig 2-1-21). (Dental
practitioner: Dr D Büchi; Technician: MDT V Fehmer.)
Figs 2-1-21a to 2-1-21h Final esthetic outcome.
Deep bite and orthodontic
pretreatment
(traditional and palatal veneers)

2.1.4 Traditional and palatal veneers

after deep bite and orthodontic
pretreatment (six maxillary
anterior teeth)
Minimally invasive rehabilitation of a patient with a negative smile,
deep bite, and orthodontic pretreatment.

Assessment and treatment planning

A 28-year-old healthy and caries-free woman presented at the clinic
seeking treatment for her abraded central and lateral incisors. She
also realized that her anterior teeth had become not only shorter but
also much thinner over the previous years and she was concerned
that they might eventually break. In agreement with the patient, a
step-by-step treatment plan was established. Starting with a
sequential diagnostic approach in which first the new outline of the
four anterior incisors was defined, in a second phase the functional
aspects and limitations were elaborated due to her deep bite. In
order to be able to achieve a minimally invasive rehabilitation, not only
was an orthodontic pretreatment planned in order to gain space on
the palatal side, but also the facial ceramic veneers were to be
supported by palatal composite veneers. Owing to this detailed initial
planning, the treatment could be executed meticulously according to
the planned outline, thereby reducing the need for a subtractive
preparation to an absolute minimum (Figs 2-1-22).
Figs 2-1-22a to 2-1-22c Pretreatment photographs.

After the orthodontic pretreatment, four composite palatal veneers

were placed. As a final treatment sequence, four ceramic veneers
were then inserted, with a new canine guidance for both the maxillary
canines.

Diagnostics
The patient’s chief complaint was her negative and abraded smile and
additionally she was concerned that her thin teeth might fracture
eventually at a later time point if she did not take any measures to
protect them now. The patient requested a lengthening of her anterior
incisors and additionally their palatal protection.
She presented herself with a deep bite, with an overall low vertical
dimension, which most likely initially led to the abrasion of her anterior
maxillary teeth. The main goal was to establish a minimally invasive
treatment without raising the entire vertical dimension by additionally
placing 6 or 8 overlays in the maxilla. However, this would clearly
have been an overtreatment to the virgin maxillary posterior teeth and
also extend her financial limitations.
All planned and discussed changes were firstly transferred into a
conventional wax-up. The position of the four incisors was slightly
rotated buccally to allow space for palatal protection by means of
palatal composite veneers (Fig 2-1-23).
Figs 2-1-23a to 2-1-23d The maxillary incisors were slightly rotated
buccally to gain space for a palatal protection by means of palatal
composite veneers.

Mock-up
To transfer the diagnostic into the patient’s mouth and thus give the
patient a chance to visualize and agree on the final outline of her four
central incisors, a silicone index of the wax-up was prepared in order
to fabricate a direct mock-up (Memosil 2, Kulzer, Hanau, Germany).
This silicone index was filled with a chemically curing composite
material in shade Vita A1 (Protemp, 3M, Rüschlikon, Switzerland)
and placed over the teeth.
The resulting mock-up served as a communication tool as the
prospective treatment result could now be discussed with the patient
in detail and moreover in mutual understanding (Fig 2-1-24).
Figs 2-1-24a to 2-1-24d Mock-up.

Orthodontic pretreatment
In order to gain space on the palatal side without raising the vertical
dimension, an orthodontic pretreatment was performed by means of
two sequences of a 0.8 mm and 1.5 mm thick thermoplastic foil,
translating the set-up sequentially into the actual tooth position. As
fortunately the patient’s anterior incisors were slightly inverted, this
orthodontic pretreatment gained the necessary space for the
protection of the exposed dentin by means of establishing four
indirect composite palatal veneers (Fig 2-1-25).
Figs 2-1-25a to 2-1-25j Orthodontic pretreatment.

Palatal veneer preparation and impression

After the orthodontic pretreatment, sufficient space was gained to
add the palatal veneers in a complete additional preparation free
approach. The final impression was taken without any need for
retraction cords in order to avoid traumatization of the gingiva and to
minimize the risk of recessions, as all margins were located epi- and
supragingivally.

Fabrication of the palatal veneers in the

laboratory
The first step for the final restoration was the fabrication of a master
cast, which was then articulated, prepared, and isolated with an
extremely thin layer of wax, to directly receive the composite build-up.
For the fabrication of the palatal composite veneers, a backward
planning concept was applied. The laboratory work was guided by
the information from the wax-up which was transferred with the aid of
silicone indexes (Matrix Form 60, Anaxdent, Stuttgart, Germany). The
composite masses were then applied (Gradia, GC, Tokyo, Japan)
according to the custom shade that was developed by the dental
technician in collaboration with the patient. After build up, the final
shape was created with stones and diamond polishing wheels. The
final glaze was established by means of mechanical polishing
procedure. The polished palatal veneers were then carefully removed
from the dies by means of hot steam, which melted the thin layer of
isolating wax between the die and the composite veneer. The palatal
veneers were then airborne-particle abraded with 50-µm alumina
oxide powder and cleaned in an ultrasonic waterbed (Fig 2-1-26a).
Figs 2-1-26a to 2-1-26o Try-in and cementation of the palatal
veneers.

Integration of the restorations

A try-in session was carried out where the veneers were inserted to
verify the fit and approximal contact points. Subsequently, in a dry
environment (rubber dam) the composite veneers were cemented.
The abutment teeth were etched with 35% phosphoric acid (Ultra-
Etch, Ultradent Products, South Jordan, UT, USA) and bonded with a
multistep adhesive system (Syntac Classic, Ivoclar Vivadent, Schaan,
Liechtenstein). The bond was not light-cured in order not to
compromise the fit of the thin palatal veneers. To the palatal veneers
a primer (Monobond S, Ivoclar Vivadent) and a bonding system
(Heliobond, Ivoclar Vivadent) was applied. Then the veneers were
cemented with a light-curing composite (Tetric Classic, Ivoclar
Vivadent). Excess composite was removed with rotating and
oscillating diamond instruments (Universal Prep Set, Intensiv,
Montagnola, Switzerland). The occlusal and functional contacts were
analyzed and nearly no adjustments were necessary (Fig 2-1-26).

Veneer preparation and impression

After the finalization of the palatal veneers the next treatment step
was to prepare the facial veneers. As the initial orthodontic
pretreatment on the one hand had gained sufficient space for the
palatal veneers, it was also paramount not to move the teeth too far
buccally to allow an absolutely minimally invasive treatment. The teeth
12–22 were prepared with no epigingival course to preserve the
maximum tooth substrate, so basically the preparation consisted of
mainly smoothening the edges. The final impression was taken
without any need for retraction cords, in order to avoid traumatization
of the gingiva and to minimize the risk of recessions, as all margins
were located epi- and supragingivally (Fig 2-1-27).
Figs 2-1-27a to 2-1-27e Preparation of facial veneers.

Fabrication of the veneers in the laboratory

The first step for the final restoration was the fabrication of an
alveolar cast. In order to achieve the thinnest possible restorations,
refractory dies were manufactured (anaxVest, Anaxdent, Stuttgart,
Germany) to then directly veneer them and in the same step
guarantee the best possible fit of the veneers. For the fabrication of
the veneer, a backward planning concept was applied. The laboratory
work was guided by the information from the wax-up, which was
transferred with the aid of silicone indexes (Matrix Form 60,
Anaxdent). The ceramic masses were then applied (Creation Classic,
Willi Geller, Meiningen, Austria) according to the custom shade that
was developed by the dental technician in collaboration with the
patient. After one dentin firing, the surface texture and the final shape
was created with stones and diamond burs. The glaze firing was
followed by an additional stain firing and a mechanical polishing
procedure. The polished veneers were carefully removed from the
refractory dies by airborne-particle abrasion with glass beads and
then cleaned in an ultrasonic waterbed (Fig 2-1-28).
Figs 2-1-28a to 2-1-28d Fabrication of the veneers.

Integration of the restorations

A try-in session was carried out where the veneers were inserted
with a try-in paste (Variolink Esthetic neutral and warm, Ivoclar
Vivadent) in order to improve color assessment and optical
integration. Subsequently, in a dry environment (rubber dam) the
fragile ceramic veneers including the two new functional veneers for
the canine guidance were cemented. The abutment teeth were
etched with 35% phosphoric acid (Ultra-Etch, Ultradent Products) and
bonded with a multistep adhesive system (Syntac Classic, Ivoclar
Vivadent). The bond was not light-cured in order not to compromise
the fit of the ultra-thin veneers.
The veneers were etched with hydrofluoric acid (9% concentration
for 1 min) (Porcelain Etch, Ultradent Products). A primer (Monobond
S, Ivoclar Vivadent) and a bonding system (Heliobond, Ivoclar
Vivadent) were applied. Then the veneers were cemented with a
dual-curing resin cement (Variolink Esthetic Nutral, Ivoclar Vivadent).
Excess cement was removed with rotating and oscillating diamond
instruments (Universal Prep Set, Intensiv). The occlusal and functional
contacts were analyzed and no adjustments were necessary (Fig 2-
1-29). The patient was extremely satisfied with the final treatment
outcome and received a new Michigan splint to protect the new
restorations during the night (Fig 2-1-30). (Dental practitioner: Prof Dr
I Sailer; Technician: MDT V Fehmer; DT B Sapina.)
Figs 2-1-29a to 2-1-29c The veneers were etched with hydrofluoric
acid and cemented.
Figs 2-1-30a to 2-1-30f Final treatment outcome.
Undetected celiac disease
(traditional veneers)

2.1.5 Traditional veneers after

undetected celiac disease (10
veneers – maxillary premolar to
premolar)
Minimally invasive rehabilitation of a patient with undetected celiac
disease.

Assessment and treatment planning

A 23-year-old woman with undetected celiac disease in her childhood
presented herself at the clinic seeking treatment for her highly
compromised esthetics in the maxillary anterior teeth. As the patient
was quite young, the first proposed treatment plan was to establish a
minimally invasive additive veneering of the six anterior teeth. During
the mock-up stage it became very evident that without including the
premolars the anterior segment would be very prominent, especially
as the plan was just to cover and maintain as much existing enamel
as possible. After re-evaluation and in agreement with the patient, a
second mock-up was extended to the premolars and with 10
additional veneers a harmonious smile could be established (Fig 2-1-
31). As the mock-up indicated the need for not only widening the
teeth but also lengthening them, while at the same time not being able
to exceed an absolute minimum thickness, the decision was taken to
plan 10 individually veneered veneers on refractory dies based on a
conventional impression. The step-by-step approach is described as
follows.
Figs 2-1-31a to 2-1-31c Pretreatment photographs (Figs 2-1-31a
2
and 2-1-31b reproduced with permission from Fehmer and Sailer ).

Diagnostics
The patient’s chief complaint was her highly compromised esthetic
appearance in the maxillary anterior teeth. However, she was also
bothered by the asymmetrical incisal edges of her teeth and the
partially fractured incisal edge of the lateral 12. Also, she was aware
of the very prominent position of the canine 13.
Due to undetected celiac disease in her childhood that led to
problems in the development of her tooth substance, this had resulted
in a reduced amount of enamel (Fig 2-1-32).
Figs 2-1-32a to 2-1-32d Diagnostic images.

Mock-up
In order to visualize the final treatment outcome and also its potential
limitations, a purely additional wax-up was performed on two
conventional plaster casts.
To transfer the wax-up into the patient’s mouth, a silicone index of
the wax-up was prepared in order to fabricate a direct mock-up
(Memosil 2, Kulzer, Hanau, Germany). This silicone index was filled
with a chemically curing composite material, in shade Vita A1
(Protemp, 3M, Rüschlikon, Switzerland) and placed over the teeth.
The resulting mock-up served as a communication tool, the
prospective treatment result could now be discussed with the patient
as it also clearly showed the limitations in the region of teeth 13 and
12 (Fig 2-1-33).

Figs 2-1-33a and 2-1-33b Mock-up.

Veneer preparation and impression
A silicone index was fabricated based on the wax-up to facilitate the
correct preparation of the teeth. The teeth 15–25, 33, and 43 were
prepared with no epigingival course to preserve the maximum tooth
substrate and basically the preparation consisted of mainly a
smoothening of the edges. The final impression was taken using two
retraction cords. In order to avoid traumatization of the gingiva and to
minimize the risk of recessions, a surgical suturing material (size 4-0,
Vicryl Ethicon, Johnson & Johnson, New Brunswick, NJ, USA) was
used as the first retraction cord. The second retraction cord was the
thinnest cord available on the market (000 Ultrapak, UP Dental,
Cologne, Germany).

Fabrication of the veneers in the laboratory

The first step for the final restoration was the fabrication of an
alveolar cast (Fig 2-1-34). In order to achieve the thinnest possible
restorations refractory dies were manufactured (anaxVest, Anaxdent,
Stuttgart, Germany) to then directly veneer them and in the same
step guarantee the best possible fit of the veneers. For the
fabrication of the veneer, a backward planning concept was applied.
The laboratory work was guided by the information from the wax-up
which was transferred with the aid of silicone indexes (Matrix Form
60, Anaxdent). The ceramic masses were then applied (Creation
Classic, Willi Geller, Meiningen, Austria) according to the custom
shade that was developed by the dental technician in collaboration
with the patient. After one dentin firing, the surface texture and the
final shape was created with stones and diamond burs. The glaze
firing was followed by an additional stain firing and a mechanical
polishing procedure. The polished veneers were carefully removed
from the refractory dies by airborne-particle abrasion with glass
beads and cleaned in an ultrasonic waterbed (Fig 2-1-35).
Figs 2-1-34a and 2-1-34b Fabrication of an alveolar cast (Fig 2-1-
2
34a reproduced with permission from Fehmer and Sailer ).
Figs 2-1-35a to 2-1-35h Fabrication of the veneers (Figs 2-1-35a to
2
2-1-35d reproduced with permission from Fehmer and Sailer ).

Integration of the restorations

A try-in session was carried out where the veneers were inserted
with a try-in paste (Variolink Esthetic neutral and warm, Ivoclar
Vivadent, Schaan, Liechtenstein) in order to improve color
assessment and optical integration. Subsequently, in a dry
environment (rubber dam) the fragile ceramic veneers were
cemented. The abutment teeth were etched with 35% phosphoric
acid (Ultra-Etch, Ultradent Products, South Jordan, UT, USA) and
bonded with a multistep adhesive system (Syntac Classic, Ivoclar
Vivadent). The bond was not light-cured in order not to compromise
the fit of the ultra-thin veneers. The veneers were etched with
hydrofluoric acid (9% concentration for 1 min) (Porcelain Etch,
Ultradent Products). A primer (Monobond S, Ivoclar Vivadent) and a
bonding system (Heliobond, Ivoclar Vivadent) was applied. Then the
veneers were cemented with a dual-curing resin cement (Variolink
Esthetic Nutral, Ivoclar Vivadent). Excess cement was removed with
rotating and oscillating diamond instruments (Universal Prep Set,
Intensiv, Montagnola, Switzerland). The occlusal and functional
contacts were analyzed and no adjustments were necessary. The
patient was very satisfied with the final treatment outcome (Fig 2-1-
36). (Dental practitioner: Prof Dr I Sailer; Technician: MDT V
Fehmer.)
Figs 2-1-36a to 2-1-36k Final treatment outcome (Figs 2-1-36a to 2-
1-36e, 2-1-36f, and 2-1-36h to 2-1-36k reproduced with permission
2
from Fehmer and Sailer ).

Application of augmented reality

(traditional veneers)

2.1.6 Traditional veneers with the

application of augmented reality
(10 veneers – maxillary premolar
to premolar)
Minimally invasive rehabilitation of a patient with abraded and eroded
teeth and additional replacement of two existing partial crowns, using
dynamic real-time visualization in the diagnostic phase with the aid of
augmented reality.

Assessment and treatment planning

The 48-year-old patient presented herself at the university hospital for
dentistry in Geneva for treatment of her abraded and eroded
dentition.
In the nutritional history, the patient described a routine of morning
consumption of energy drinks. Functional anamnesis showed no
abnormalities and to protect her teeth the patient already used a night
guard.
The desired treatment wish of the patient was a minimally invasive
treatment to improve her dental health, function, and esthetics (Fig 2-
1-37).
Figs 2-1-37a and 2-1-37b Pretreatment photographs (reproduced
3
with permission from Burkhardt et al ).
As a first step to stabilize the conditions, the patient was
educated about the high risk of the daily consumption of energy
drinks, which in her case clearly favored the erosion of her dentition.
The patient was fortunately highly compliant and immediately
agreed to stop her habit.
Symptoms of active bruxism could not be detected. The treatment
plan was presented as follows: direct overlays to raise the vertical
dimension and indirect veneers to fulfill the esthetic demands of the
patient.

Conceptional introduction
Diagnosis, planning, and implementation in prosthetic rehabilitation
are essential tools for the final esthetic and functional outcome. In
order to achieve this, there is a need for very close collaboration
between the dental practitioner and the dental technician and
engaging the patient and their wishes and demands into the treatment
planning process. Understanding the treatment from the patient’s
perspective is especially important if the appearance of the teeth will
be changed.
In the illustrated case, the procedure of the virtual diagnostics with
the help of an augmented-reality software is described in detail with
the subsequent try-in of a virtual created and printed mock-up
followed by the computer-aided design/computer-aided manufacturing
(CAD/CAM) finalization of the restoration.
This concept simplifies the communication between dental
practitioner and dental technician and allows the patient to participate
in the planning in an understandable way.

Virtual mock-up
In the present case, a software (Ivosmile, Ivoclar Digital, Schaan,
Liechtenstein) was used that projects the virtual mock-up into a live
view.
Together with the patient, various suggestions were worked out,
discussed, and then saved as a video file. After the patient opted for
a visualized design, the virtual mock-up was transformed into a real
mock-up (Fig 2-1-38).
Figs 2-1-38a to 2-1-38d Virtual mock-up, with QR code for further
3
information (reproduced with permission from Burkhardt et al ).

From virtual visualization to real mock-up

The stored design in the software and an initial 3D optical impression
of the maxilla were used to superimpose the data in the CAD
software (Tizian Exocad, Schütz Dental, Rosbach, Germany).
The new design was calculated in a copy function of the initial
design (Fig 2-1-39).
Figs 2-1-39a to 2-1-39e The new design was calculated in a copy
function of the initial design (Figs 2-1-39a to 2-1-39c, and 2-1-39e
3
reproduced with permission from Burkhardt et al ).

Both files, with the intraoral scan aligned with the virtual design,
were then printed as one united model (CARES P Series, Straumann,
Basel) (Fig 2-1-40).

Fig 2-1-40 The intraoral scan aligned with the virtual design were
then printed as one united model (reproduced with permission from
3
Burkhardt et al ).

The possibilities in the calculation of the virtual wax-up are

manifold, since the data is available in the open STL format (Standard
Tessellation Language). The proposal can be completely adopted, as
for example in more invasive restorations with sufficient space or if
the teeth are ideally in the dental arch. However, if teeth are out of
their optimal position and no orthodontic therapy is planned, the data
will also provide information about the incisal edge position, the tooth
shapes, and length, even if the final design in the CAD software has
to be adapted to the teeth not perfectly aligned in the arch.

Mock-up
In order not only to visualize the final treatment outcome and its
potential limitations, it is still of absolute importance to actually
transfer the designed wax-up into the patient’s mouth. For the clinical
try-in, a model was printed from the initial visualization based on a
complete digital workflow, which combined the data of both the initial
teeth scan and the virtual mock-up.
From this printed model, a silicone key was manufactured
(President Putty, Coltène, Cuyahoga Falls, OH, USA), which was
relined with a light-bodied silicone (Aquasil Ultra LV, Dentsply,
Constance).
This enabled a clear and efficient translation of the direct mock-
up, realized with a provisional acrylic (Protemp 4, 3M, Seefeld,
Germany).
The resulting mock-up served as a verification tool, as the
prospective treatment result could now be discussed in detail and
was thereafter immediately accepted by the patient (Fig 2-1-41).
Figs 2-1-41a and 2-1-41b Mock-up (Fig 2-1-41a reproduced with
3
permission from Burkhardt et al ).

Veneer preparation and impression

A silicone index was fabricated based on the digital wax-up to
facilitate the correct and minimal invasive preparation for the final
restoration of the teeth. Teeth 15–25 were prepared with no
epigingival course to preserve the maximum of tooth substrate and
basically the preparation consisted of mainly a smoothening of the
edges. However, and unfortunately, the canine 13 and the central
incisor 11 were already restored and revealed quite invasive
preparations.
The final impression was taken using two retraction cords. In
order to avoid traumatization of the gingiva and to minimize the risk of
recessions, a surgical suturing material (size 4-0, Vicryl Ethicon,
Johnson & Johnson, New Brunswick, NJ, USA) was used as the first
retraction cord. The second retraction cord was the thinnest cord
available on the market (000 Ultrapak, UP Dental, Cologne,
Germany) (Fig 2-1-42).

Fig 2-1-42 The final impression was taken using two retraction cords
3
(reproduced with permission from Burkhardt et al ).

Fabrication of the veneers in the laboratory

The entire digital documentation (initial photos, photos with mock-up,
STLs, printed model of the final design) and the impression were
handed over to the dental laboratory. As a first step the laboratory
fabricated a master cast that in a second phase was then scanned
using a laboratory scanner and virtually aligned with all digital
supporting files. After the definition of the marginal line and insertion
axis, once again, just as in the initial step, a digital copy function was
applied to achieve the same final outlines and counters for the
veneers as presented to the patient during the diagnostic phase. All
restorations were then milled with a small cut-back of 0.4 mm out of
lithium-disilicate ceramics (e.max CAD, Ivoclar Vivadent). This cut-
back was considered in this case to enhance the individual esthetic of
the veneers with the final application of the veneering ceramic (IPS
e.max Ceram, Ivoclar Vivadent) (Fig 2-1-43).
Figs 2-1-43a to 2-1-43c Fabrication of the veneers (reproduced with
3
permission from Burkhardt et al ).

Integration of the restorations

A try-in session was carried out where the veneers were inserted
with a try-in paste (Variolink Esthetic neutral and warm, Ivoclar
Vivadent, Schaan, Liechtenstein) in order to improve color
assessment and optical integration. Subsequently, in a dry
environment (rubber dam) the ceramic veneers were cemented. The
abutment teeth were etched with 35% phosphoric acid (UltraEtch,
Ultradent Products, South Jordan, UT, USA) and bonded with a
multistep adhesive system (Syntac Classic, Ivoclar Vivadent, Schaan,
Liechtenstein). The bond was not light-cured in order not to
compromise the fit of the ultra-thin veneers. The veneers were etched
with hydrofluoric acid (5% concentration for 20 s) (IPS Ceramic
Etching Gel, Ivoclar Vivadent, Schaan, Liechtenstein). A silane-
containing primer (Monobond Plus, Ivoclar Vivadent, FL, USA) and a
bonding system (Heliobond, Ivoclar Vivadent, Schaan, Liechtenstein)
was applied. Then the veneers were cemented with a dualcuring resin
cement (Variolink Esthetic Nutral, Ivoclar Vivadent, FL, USA). Excess
cement was removed with rotating and oscillating diamond
instruments. (Universal Prep Set, Intensiv, Montagnola, Switzerland).
The occlusal and functional contacts were analyzed and no
adjustments were necessary. The patient was very satisfied with the
final treatment outcome (Fig 2-1-44). (Dental practitioner: Dr F
Burkhardt; Technician: DT C Piskin.)
Figs 2-1-44a to 2-1-44c Final treatment outcome (reproduced with
3
permission from Burkhardt et al ).
Figs 2-1-44d to 2-1-44f Final treatment outcome (reproduced with
3
permission from Burkhardt et al ).

The dynamic real-time visualization concept

The conventional principles and techniques of diagnostics in dentistry
are well described. These continue to be excellent tools to introduce
patients to a new restoration.
However, due to the increased time required, the associated
costs are higher and can lead to financial limitations.
New software technologies and increasing computing power are
elevating proven concepts to the digital world in an unknown and
intuitive manner. What began with manual image processing is now
highly automated and a great help for immediate patient
communication. The presented concept indicates the new possibilities
that enable a workflow from virtual planning based on 3D data that
ensure a high predictability throughout to the final restoration. Like
during the entire diagnostic process, the initial digital visualization
forms the basis for the final restoration. Applying this technology,
patients, dental practitioners, and dental technicians share the same
information at any given point in the treatment time.
This is especially helpful for patient involvement, as the patient is
presented with a very realistic visualization of his future appearance.
Understanding this is essential because greater esthetic changes can
result in an adaptation period for the patient.
Furthermore, this method can help to define the prosthetically
correct implant position in complex cases through reliable diagnostics
in presurgical planning. Recent studies show that digital technologies
have advantages in practice as well as in the dental laboratory. It is
important to inform patients about potential limitations on the ability to
achieve a final visualized result, for example if teeth are not in the
optimal position or if gingival and bony conditions require
compromises. These factors are at the moment not taken into
account by the software. The real mock-up after virtual diagnostics
therefore is a crucial Part to check possible restrictions in dental,
periodontal, and functional conditions and to discuss those in detail
with the patient. Like all new technologies, the described technique of
virtual dynamic mock-ups is subject to continuous innovations and
further developments. An existing limitation in the workflow is that the
data of the developed virtual mock-up cannot yet be easily
transferred into a CAD software. In the case report described here,
the missing implementation was at the step of overlaying the virtual
mock-up and the initial impression, bridged by taking a snapshot from
the Ivosmile app that served as a reference. Meanwhile, there is a
direct workflow to easily connect the software to the CAD software
(3Shape, Copenhagen, Denmark).

Summary
The application of augmented reality in dentistry for diagnostic
purposes is time-efficient and supports communication with the
patient and the dental technician. At the same time, it enables the
patient to have a greater say in the process of determining the
planned end result.
Some advantages of the concept are:
■ patient becomes Part of the decision-making process
■ better understanding of patients for the proposed treatment
■ time-optimized processes
■ virtual mock-up in the first session too without photos and initial
casts
■ dynamic real-time visualization
■ photo realistic representation
■ predictable translation into the definitive restoration (In
collaboration with Dr F Burkhardt.)
Application of augmented reality
and orthodontic pretreatment
(traditional veneers)

2.1.7 Traditional veneers with the

application of augmented reality
and orthodontic pretreatment
(six maxillary anterior teeth)
The following section details the application of the latest advances in
augmented-reality technology and its integration into the digital
workflow:
■ Anterior regions (six veneers)
■ Ivosmile to 3Shape via CAD-link
■ Orthodontic pretreatment
The following case shows the minimally invasive rehabilitation of a
patient with a congenitally missing maxillary right canine and peg-
shaped maxillary lateral incisors along with the generally slim and long
teeth in the anterior maxilla, which had resulted in many visible
diastemata.
Assessment and treatment planning
A 22-year-old healthy man presented himself at the University Clinic
for Dental Medicine of Geneva with the primary wish of improving the
esthetic appearance of his teeth and smile. The patient had a
congenitally missing maxillary right canine (tooth 13), the respective
primary tooth 53 was still in place and in good condition (no
resorption of the root visible). Furthermore, the peg-shaped maxillary
lateral incisors along with the generally slim and long teeth in the
anterior maxilla resulted in many visible diastemata. Tooth 22 showed
composite build-ups of both the mesial and distal angle. Along with
the negative impact on the esthetic appearance, the diastema also
impaired the patient’s phonetic ability, which was a secondary
complaint of the patient. As his teeth were always of special concern
to the patient, he was very aware of different treatment options and
approaches. Therefore, it was of critical importance to the patient
that a minimally invasive treatment be chosen as he did not wish for
his teeth to be prepared extensively. The patient reported no
parafunction, did not suffer from any temporomandibular disorder,
and showed no pain in the masticatory muscles (Fig 2-1-45).
Figs 2-1-45a to 2-1-45g Pretreatment photographs.

Conceptional introduction
Smile reconstruction is achieved using rigorous and detailed
methodologies. Nowadays, smile design protocols are often realized
in a semi-digital way: on a set of patient’s photographs using manual
or automated software, the practitioner realizes a 2D and static smile
design on the pictures of the patient. The design is then sent to the
lab technician in order to create a wax-up of the proposed smile
design. Only then, the new smile proposition is presented to the
patient. Recently, protocols including 3D face scans and video
analysis and intraoral mock-up realization were proposed to improve
communication with the lab and the patient. However, they are very
technical, time- and cost-consuming and, more to the point, they do
not include the patient during the conception phase.
New technologies using augmented reality show a real interest for
immediate diagnosis and previsualization of the outcome before
starting an esthetic oral rehabilitation. Augmented reality (AR) is a
technology that superimposes computer-generated virtual content on
real images. This technology has spread in many fields including
education, healthcare, diagnosis, and surgery. In dentistry, AR was
firstly used for educational purposes as a tool to objectively evaluate
students and give them direct feedback. It is now also used for oral-
guided surgery or pre-op planning.
Two previous articles had recently reported on AR in esthetic
dentistry. This technology was presented to the respective patient in
order to instantly try and modify the rehabilitation proposition by
looking at the iPad screen, as an enhanced mirror, allowing the
practitioner to achieve a co-diagnosis with the patient. This original
software enables a 3D dynamic smile analysis and design, that also
helps communication with lab technicians. However, clinical protocols
using this technology are still in development and clinical reports are
required to evaluate its accuracy.
The aim of the present case report is to illustrate a novel digital
workflow combining AR and computer-aided design/computer-aided
manufacturing (CAD/CAM) technologies and showing its potential in
daily practice using a step-by-step approach.

Orthodontic pretreatment
Initially, a prosthetically oriented diagnostic wax-up was made, and it
became apparent that an orthodontic pretreatment would be
necessary in order to be as minimally invasive as possible.
Consequently, a treatment with a fixed orthodontic appliance in both
arches was performed. After a period of 7 months, the teeth were at
the preplanned position and the orthodontic treatment was completed
(Fig 2-1-46).
Figs 2-1-46a and 2-1-46b After 7 months, the teeth were at the
preplanned position and the orthodontic treatment was completed.

Virtual mock-up
To meet the high esthetic demands of the treatment, it was of
paramount importance to visualize the final outcome to the patient. As
the patient has always had diastemata in his permanent dentition, an
initially negative response to a mock-up could be expected. For this
reason, an AR virtual mock-up using a specialized software (IvoSmile,
Ivoclar Vivadent) was ideal in this case, as the patient could preview
and modify the proposal in real-time. This process allowed for a
cooperative diagnostic (co-diagnostic) in collaboration with the
patient, so different tooth shapes, lengths of the maxillary teeth, color
variations, and overall teeth size could be simulated. Once the patient
was satisfied with the proposition, the project was ready to be
exported. Finally, an intraoral optical scan of both arches was taken
using the scan strategy proposed by the manufacturer (Fig 2-1-47).
Figs 2-1-47a to 2-1-47c Virtual mock-up.

From virtual visualization to real mock-up

Once the scans were transferred to the dental laboratory, the
technician could set up a new digital order form (3Shape Dental
Designer software, 3Shape, Copenhagen, Denmark) for the planning
of six maxillary anterior veneers. Using the ‘CAD-link’ workflow
between the AR software (Ivosmile) and the design software
(3Shape Dental Designer), the restorations could be planned
precisely according to the previously developed design proposal of
the AR software (Ivosmile).
With this new fully digital workflow, the intraoral scan data as well
as the selected virtual mock-up of the AR software (Ivosmile) could
be imported into the CAD software in the form of STL files. Firstly, an
alignment of the maxillary arch scan and an extraoral portrait picture
of the patient was made in the RealView Engine. In the next step, the
CAD-link allowed the elaborated AR data to be matched very
accurately onto the actual patient scan.
In order to transform the AR virtual data into a digital wax-up, the
new virtual wax copy function was used. In this process, the two
aligned files representing the maxillary arch (in gray) and the new
smile projection (in blue) were selected and the resulting hollow
space between them was automatically filled with digital wax (in
brown). The application of such an automated copy function
guarantees a predictable and accurate reproduction of the virtual
design proposition into a digital wax-up. This wax-up data can now be
adjusted or altered in an efficient way (if necessary) and delivered
back to the dental office either by means of a printed model to
perform a direct mock-up or as a printed indirect mock-up. In the
present case, it was considered important to protect the primary
canine from excessive forces and thus a group function was
established on the right side while keeping the canine guidance on the
left side (Figs 2-1-48 and 2-1-49).
Fig 2-1-48 Augmented reality virtual mock-up.
Figs 2-1-49a to 2-1-49c Digital wax-up.

Mock-up
With the 3D-printed model (Straumann CARES P30 printer,
Straumann, Basel, Switzerland; SHERA print model ultraviolet (UV)
resin, SHERA Werkstoff-Technologie, Lemförde, Germany) of the
superimposed scans and AR proposition a silicone key for a direct
intraoral mock-up could be fabricated. Intraorally, the silicone tray
was filled with an auto polymerizing, composite-based temporization
material (ProTemp 3, 3M, St. Paul, MN, USA) and pressed onto the
teeth. After removal of the excess, the proposition could be
discussed and validated together with the patient. The patient gave
his consent to advance with the treatment. However, an additional
intraoral scan may be necessary if the mock-up was modified
intraorally (Fig 2-1-50).
Figs 2-1-50a to 2-1-50h Creation of mock-up.

Veneer preparation and impression

To comply with the patient’s wish to not prepare his teeth extensively,
minimally invasive, additional veneers were chosen as the final
restoration. Only very small corrections had to be made to the natural
teeth such as removal of undercuts and slight reduction of the
vestibular curvature to ensure a minimal material thickness.
Additionally, the composite build-ups on tooth 22 were removed (Fig
2-1-51).
Figs 2-1-51a to 2-1-51d Veneer preparation.

Fabrication of the veneers in the laboratory

After a final optical impression, the resulting scan data could now be
easily matched with the previously transformed digital wax-up using
the same efficient digital workflow.
A CAD/CAM-framework consisting of lithium-disilicate with a
thickness of 0.5 mm was milled using the digital file from the CAD
software. After crystallization, the veneers were manually
microveneered with a feldspar-based ceramic using the proposition
from the digital mock-up as reference (Fig 2-1-52).
Figs 2-1-52a to 2-1-51c The virtual mock-up was used as as
reference to create the veneers.

Integration of the restorations

The finalized veneers were tried-in intraorally and validated by the
patient. The luting procedure was performed according to the known
adhesive protocol: etching the ceramic with hydrofluoric acid (IPS
Ceramic etching gel, Ivoclar Vivadent, Schaan, Liechtenstein),
treatment of the bonding surface with a coupling agent containing
silane (Monobond Plus, Ivoclar Vivadent) and applying a thin layer of
photopolymerized adhesive (Optibond FL, Kerr, CA, USA). The teeth
were etched with phosphoric acid (Ultra-Etch 35%, Ultradent
Products, South Jordan, UT, USA) and covered with a thin layer of
adhesive (Optibond FL, Kerr, Brea, CA, USA). The veneers were
then adhesively bonded under rubber dam isolation using a dual-
curing resin-based cement (Variolink Esthetic DC, Ivoclar Vivadent).
The patient was very happy with the final result as it corresponded to
the proposition made by the AR software (Ivosmile) (Fig 2-1-53).
(Dental practitioner: Dr L Marchand; Technician: DT C Piskin.)
Figs 2-1-53a to 2-1-53f Final treatment outcome.

The dynamic real-time visualization concept

The present case report shows a patient with a congenitally missing
maxillary right canine, peg-shaped lateral incisors, and multiple
diastemas in the anterior maxilla. After co-diagnostics done with the
patient and an AR virtual mock-up, a new CAD-link workflow was
applied to transfer the data directly into a digital wax-up in a CAD
software. The result was a minimally invasive restoration that
corresponded to the previously developed patient-specific virtual
mock-up.
When planning prosthodontic work in the esthetic zone, the
esthetic appearance of the future restorations is considered an
important factor by both patient and treating dental practitioner alike.
Not only is an esthetic improvement often the patient’s chief complaint
and motivation to seek treatment, but the subjective evaluation of the
patient’s own smile is usually the main criteria to judge a treatment a
success.
The fundamental work laid out by Magne and coworkers has been
widely used in an effort to objectify and quantify dental esthetics.
Unfortunately, what a patient considers as “esthetic” may deviate
from these parameters and is often a very subjective and personal
concept. Additionally, it can be influenced by a multitude of different
factors (such as culture and ethnicity for example), which may not be
immediately apparent for a dental practitioner. Because of this, it
would be desired to involve the patient heavily in the decision-making
process when planning esthetic restorations. Previous publications on
the subject of smile design have shown that a previsualization of the
final result may lead to an increased patient motivation and
acceptance for the treatment. In accordance with these authors, it is
expected that the presented AR approach will enhance the
confidence of the patient and practitioner for the chosen treatment. In
contrast to the classic approach of a wax-up made by a technician or
even two-dimensional smile design, the workflow shown in this article
involves the patient from the very beginning and thus serves as a
useful communication tool between the patient and the restorative
team (dental practitioner and laboratory technician). This patient-
centered approach is therefore expected to be time- and cost-
efficient because the overall direction of the treatment is defined from
the start.
Additionally, thanks to the new CAD-link workflow, this trend of
efficiency may now be continued in the dental laboratory. The ability
to directly export the data acquired by AR into a CAD software along
with the virtual wax copy function allows the technician to predictably
recreate a digital wax-up. Other authors have already demonstrated
the value of this so-called “Copy/Paste dentistry” in terms of
communication, efficiency, and patient satisfaction. From the
perspective of the modern dental technician the compatibility between
different file formats and different software is highly beneficial. In
several recent publications where digital workflows were applied, the
conversion of a digital smile design into a digital wax-up remained a
manual process executed by the technician. The demonstrated CAD-
link workflow enables this previously missing interaction between AR
technology and the CAD/CAM workflow.
At the same time, however, the handling of this digital workflow is
technically challenging and demands a deep knowledge by both the
practitioner and the laboratory. Moreover, the matching of the 3D
data acquired by the intraoral scanning system and the virtual mock-
up offered by the present software is limited to a single frontal view
mode which restricts the accuracy of the smile design. In this
respect, the use of a 3D facial scan might offer several advantages.
Not only is the matching of the intraoral scan data facilitated, but it
also permits a detailed evaluation of the smile design in the sagittal
and frontal plane. On the other hand, it can be argued that a similar
three-dimensional evaluation of the smile may already be done in the
AR software, including color and shape propositions. Lastly, it must
be considered that a facial scanner implies an important financial
investment.
Furthermore, the AR technology does not take into consideration
the initial position of the natural teeth and shows its limits in tooth-
borne prostheses. Hence, if the teeth are not well-positioned, the
physical mock-up might not fit in the mouth as intended by the virtual
mock-up. In addition, patient-specific functional aspects must be
carefully evaluated intraorally, as the AR software does not take the
dynamic occlusion, malocclusions, or parafunctions into consideration.
Such conditions may then necessitate a modification of the smile
proposal. Furthermore, the software does not give any information on
the soft tissue reaction (lip position in particular) according to the
position or the form of the virtual smile design.
Because of these reasons, care should be taken during the
discussion of the planned restorations in the diagnostic phase. It is
essential to warn the patient that this technology provides a platform
to discuss different treatment options but does not pledge for the
possibility for realization of the final result. With further development
in the field of AR and virtual technology the discussed shortcomings
might be addressed in the future, but more research is needed in that
direction.

Summary
The new CAD-link digital workflow allows for a predictable
reproduction of a virtual design proposition into a digital wax-up. This
previously missing link between AR software and the CAD/CAM
workflow may serve the restorative team to achieve optimal patient-
centered esthetic results. At the same time, extensive knowledge in
digital dentistry and its workflow is required by both dental
practitioner and lab technician alike. Additionally, care should be
taken when promising a final result based on a virtual mock-up.
(In collaboration with Dr L Marchand and Dr R Touati.)
360-degree and occlusal
veneers
(with a single implant restoration)

2.1.8 360-degree and occlusal

veneers with a single implant
restoration (seven mandibular
teeth and posterior implant)
The next series depicts the minimally invasive restoration of a patient
with solely in the fourth quadrant pronounced odontogenesis
imperfecta.

Assessment and treatment planning

A 24-year-old female dental student with a odontogenesis imperfecta
solely located in the fourth quadrant, presented herself at the clinic
seeking treatment for her compromised esthetics in the mandibular
anterior teeth and for the replacement of a missing premolar. As the
patient was quite young, the first proposed treatment plan was to
establish a minimally invasive additive veneering of the five anterior
teeth by means of 360-degree veneers and overlays. At a later time
point and also due to a inclusion into a clinical study, the single
implant was treated separately and only after the initial restorative
process was finalized (Fig 2-1-54).
Figs 2-1-54a to 2-1-54c Initial situation.

During the diagnostic phase, all teeth were examined and the
planned restorations were elaborated with a special focus on their
extent. The aim was not only to reestablish the esthetic that the
patient was seeking for but also to preserve and cover as much
enamel as possible.
Because a conventional mock-up in this situation would have
gained very little additional information and, on the other hand, the
treatment plan was quite clear, it was decided to just create an initial
wax-up but to save the appointment for a mock-up.
The wax-up fabricated in the laboratory included the teeth 33, 31–
43 as 360-degree veneers and 44 and 45 as overlays. For the gap in
area 45, an additional premolar was planned.

Diagnostics
The patient’s chief complaint was her compromised esthetic
appearance in the mandibular anterior teeth and then after the
successful orthodontic pretreatment, she wanted to fill the crated
gap. Due to the odontogenesis imperfecta in the fourth quadrant that
had led to problems in the development of her teeth substance, there
was a reduced amount of enamel and dentin. The aim was to cover
the affected teeth entirely. This 360-degree coverage should however
be as minimally invasive as possible (Fig 2-1-55).
Figs 2-1-55a to 2-1-55c Diagnostic images.

Provisional
To transfer the wax-up into the patient’s mouth, a silicone index of the
wax-up was prepared in order to fabricate an eggshell provisional on
the cast. This eggshell was fabricated with a classic acrylic
poly(methyl methacrylate) (PMMA) material (New Outline, Anaxdent,
Stuttgart, Germany) that was later on easy to reline and adjust to the
actual intraoral preparation. The provisional was then relined with a
self-curing resin (Tab 2000, Kerr, Brea, CA, USA) extraorally polished
and provisionally cemented (Protemp, 3M, Seefeld, Germany). The
resulting provisional integrated very nicely and served as a
communication tool: the prospective treatment result could now be
discussed with the patient as it was planned to fabricate the crowns
slightly thicker than the remaining natural anterior tooth 32. This
approach was chosen to allow a reasonable minimal thickness of the
360-degree veneers of about 0.5 mm, while at the same time being
as minimally invasive with the preparation as possible (Fig 2-1-56).
Figs 2-1-56a to 2-1-56d Provisional restoration.

Veneer preparation and impression

A silicone index was fabricated based on the wax-up to facilitate the
correct preparation of the teeth. The teeth 33, 31–43 were prepared
360 degrees with a very shallow epigingival course to preserve the
maximum of tooth substrate and stay in the enamel whenever
possible. The teeth 44 and 45 were prepared with the aid of two
reduction copings. Once the sufficient space was created, the
finalization of the preparation consisted mainly smoothening of the
edges. The final impression was taken using two retraction cords. In
order to avoid traumatization of the gingiva and to minimize the risk of
recessions, a surgical suturing material (size 4-0, Vicryl Ethicon,
Johnson & Johnson, New Brunswick, NJ, USA) was used as the first
retraction cord. The second retraction cord was the thinnest cord
available on the market (000 Ultrapak, UP Dental, Cologne,
Germany). As for the impression and the preparation, the buccal
retainer had to be removed a thermoplastic 1 mm foil was used as a
retainer and provisional in one (Erkodur, Erkodent, Pfalzgrafenweiler,
Germany) (Fig 2-1-57).
Figs 2-1-57a to 2-1-57h Veneer preparation.

Fabrication of the veneers and overlays in

the laboratory
The first step for the final restoration was the fabrication of an
alveolar cast. In order to achieve the thinnest possible restorations,
refractory dies were manufactured (anaxVest, Anaxdent) to then
directly veneer them and in the same step guarantee the best
possible fit of the veneers. For the fabrication of the 360-degree
veneers and overlays, a backward planning concept was applied. The
laboratory work was guided by the information from the wax-up which
was transferred with the aid of silicone indexes (Matrix Form 60,
Anaxdent). The ceramic masses were then applied (Creation Classic,
Willi Geller, Meiningen, Austria) according to the custom shade that
was developed by the dental technician in collaboration with the
patient. After one dentin firing, the surface texture and the final shape
was done with stones and diamond burs. The glaze firing was
followed by an additional stain firing and a mechanical polishing
procedure. The polished veneers were carefully removed from the
refractory dies by airborne-particle abrasion with glass beads and
cleaned in an ultrasonic waterbed.

Integration of the veneers and overlays

A try-in session was carried out where the veneers were inserted
with a try-in paste (Variolink Esthetic neutral and warm, Ivoclar
Vivadent, Schaan, Liechtenstein) in order to improve color
assessment and optical integration. Subsequently, in a dry
environment (rubber dam), the fragile ceramic veneers were
cemented. The abutment teeth were etched with 35% phosphoric
acid (Ultra-Etch, Ultradent Products, South Jordan, UT, USA) and
bonded with a multistep adhesive system (Syntac Classic, Ivoclar
Vivadent). The bond was not light-cured in order not to compromise
the fit of the ultra-thin veneers. The veneers were etched with
hydrofluoric acid (9% concentration for 1 min) (Porcelain Etch,
Ultradent Products). A silane-containing primer (Monobond S, Ivoclar
Vivadent) and a bonding system (Heliobond, Ivoclar Vivadent,
Schaan, Liechtenstein) were applied. Then the veneers were
cemented with a dual-curing resin cement (Variolink Esthetic Nutral,
Ivoclar Vivadent). Excess cement was removed with rotating and
oscillating diamond instruments (Universal Prep Set, Intensiv,
Montagnola, Switzerland). The occlusal and functional contacts were
analyzed and no adjustments were necessary. The patient was very
satisfied with the final treatment outcome (Fig 2-1-58).
Figs 2-1-58a to 2-1-58c Veneer try-in and cementation.

Implant placement and regeneration

According to the diagnostics, a surgical stent was fabricated,
transferring the prosthetic plan of the ideal three-dimensional position
of the implant to the surgical intervention. After the raising of a
mucoperiosteal flap with a vertical releasing incision mesial of the
tooth 44, a regular diameter bone level implant (ASTRA Osseospeed,
Dentsply Sirona, Bensheim, Germany) was placed with good primary
stability. The ridge deficiency was augmented with a xenograft
(BioOss, Geistlich Pharma, Wolhusen, Switzerland) and the graft was
covered with a collagen membrane (BioGide, Geistlich Pharma) to
allow for hard tissue formation. The flap was released by splitting the
periosteum, allowing for a tension-free re-adaptation of the flap. After
the suturing (GoreTex 5.0, W.L. Gore & Associates, Flagstaff, AZ,
USA) the implant was left for submucosal healing for 8–10 weeks.
Also, once the flap was raised it was very pleasing to see the
beautiful integration and transition of the posterior restorations and
their seamless integration just like a natural cementoenamel junction
(Fig 2-1-59).
Figs 2-1-59a to 2-1-59k Implant placement and regeneration.

Fabrication of the screw-retained implant

restoration
As this implant restoration was Part of a clinical study, the patient
was randomized into the direct veneered customized zirconia
abutment (Atlantis, Dentsply Sirona). Once the conventional
impression was translated into a master cast, the casts were
scanned using a lab scanner (Imetric 4D, Courgenay, Switzerland)
and the indicated metal mono scanbody for the Atlantis workflow. The
generated files were then uploaded to the Atlantis web order and the
color of the abutment was indicated as 00 (uninfiltrated white). The
abutment was predesigned by the Atlantis team and then uploaded to
their cloud-based Atlantis 3D web editor. Here adjustments like
marginal lines or other small corrections could be done and the
revised abutment was approved for production. Once delivered, the
abutment was checked on the cast for its correct anatomical support
and directly veneered (Creation Crystal ZI-CT, Willi Geller) according
to the custom shade that was developed by the dental technician in
collaboration with the patient. After two dentin firings, the surface
texture and the final shape was developed with stones and diamond
burs. The glaze firing was followed by an additional stain firing and a
mechanical polishing procedure.

Integration of the screw-retained implant

restoration
The healing abutment was removed and the implant and adjacent
tissues were disinfected with a chlorhexidine solution. After
disinfection (Tiutol dent, B. Braun Melsungen, Melsungen, Germany)
and the application of a chlorhexidine gel to the submucosal Part
(PlakOut Gel, KerrHawe SA, Bioggio, Switzerland), the zirconia
screw-retained implant crown was preliminarily retained to the implant
for a period of 2 weeks, by tightening the screw by hand (approx. 20
Ncm) and by closing the screw access hole with Teflon and a
provisional resin (Telio, Ivoclar Vivadent).
After 2 weeks the abutment/crown screw was retightened with
the final torque as recommended by the manufacturer (35 Ncm). For
the final closure of the screw access a rubber dam was applied, and
the veneering ceramic layer around the access hole was etched (9%
hydrofluoric acid) and silanated (Monobond Plus, Ivoclar Vivadent).
The screw was densely covered with Teflon. Subsequently, a bonding
agent was applied (Heliobond, Ivoclar Vivadent), and the closure of
the screw access hole was finalized with a light-curing composite
filling material (Tetric Classic, Ivoclar Vivadent) in the corresponding
shade. After the light-curing, the occlusion was checked followed by
polishing of the composite filling (Fig 2-1-60). (Dental practitioner:
Prof Dr I Sailer; Technician: MDT V Fehmer.)
Figs 2-1-60a to 2-1-60g Integration of the screw-retained implant
and final treatment outcome.

Full-mouth rehabilitation
(traditional veneers and overlays)

2.1.9 Full-mouth rehabilitation with

traditional veneers and overlays
The following case describes the minimally invasive rehabilitation of a
patient with severe erosion and abrasion, including crown lengthening
and raise of vertical dimension.

Assessment and treatment planning

A 35-year-old man with severe erosion and abrasion in his entire
dentition presented himself at the clinic seeking treatment for his
compromised esthetics, and also he suffered from sensitivities on
drinking or eating hot or cold beverages. Hence for this patient the
potential changes were quite dramatic, as they involved the raising of
the vertical dimension of occlusion (VDO), functional aspects, and a
complete change in his esthetic appearance. The importance of the
diagnostic analyses and the mock-up try-in for a complex
rehabilitation, like in his case, played a fundamental role to make sure
that the treatment goal was set according to the patient’s wishes and
the functional needs.
The patient was quite young for such a comprehensive
rehabilitation and especially with this in mind, a minimally invasive
treatment plan was established and tested with an extensive mock-up
testing phase. This involved not only the esthetic anterior segments
but also the raising of the VDO and allowing the patient to test the
mock-up as it was fabricated, as an additional provisional that could
be placed in the patient’s mouth before the actual preparation was
performed.
Another advantage of these detailed diagnostics was that the
treatment later on could easily be sequenced into quadrants;
consequently the appointments for both patient and clinician became
shorter and less stressful (Fig 2-1-61).
Figs 2-1-61a to 2-1-61c Pretreatment photographs.

Diagnostics
The patient’s chief complaint was his compromised esthetic
appearance, especially in the maxillary anterior teeth. However, he
was also aware that due to the abrasion of his teeth, he had not only
lost vertical dimension but also his teeth had become more sensitive.
He was afraid that if he did not intervene at this point in time, things
would only become worse.
In nearly all his teeth, dentin was already exposed to a high
degree, which also explained the sensitivity he reported. Despite the
long-exposed dentin, his teeth remained vital and showed no signs of
decay (Fig 2-1-62).
Figs 2-1-62a to 2-1-62k Diagnostic images.

Mock-up
In order to visualize the final treatment outcome and also its potential
limitations, a purely additive wax-up was performed on two
conventional plaster casts that were articulated by means of a
facebow.
To then transfer the wax-up into the patient’s mouth in this
complex case (due to the abrasion and erosion the teeth were quite
small and also had very little undercuts), an indirect mock-up was
fabricated for the maxillary arch in the dental laboratory. Based on a
silicone index of the wax-up a classic acrylic PMMA (75% Dentin A2
and 25% Enamel High Value, New Outline, Anaxdent, Stuttgart,
Germany) was pressed onto the isolated cast (Fig 2-1-63).
Figs 2-1-63a to 2-1-63h Mock-up.

For the mandibular arch, as the changes were not as severe, a

conventional transfer of the wax-up into the patient’s mouth by a
silicone index of the wax-up was prepared in order to fabricate a
direct mock-up (Memosil 2, Kulzer, Hanau, Germany). This silicone
index was filled with a chemically curing composite material, in shade
Vita A2 (Protemp, 3M, Rüschlikon, Switzerland) and placed over the
mandibular teeth.
The resulting indirect mock-up served as a communication tool, to
visualize the prospective treatment outcome. Additionally, this type of
indirect mock-up also has the advantage that patients can easily take
them home and with this allow them to check their new teeth in their
private environment.
The patient was very happy with the mock-up try-in and
immediately felt very conformable with the raised vertical dimension
and agreed to the proposed treatment plan (Fig 2-1-64).
Figs 2-1-64a to 2-1-64g Mock-up try-in.

Crown lengthening
The diagnostic mock-up served as surgical stent for the localized
crown lengthening of teeth 14 and 15. Displaying the ideal pink and
white proportions, the mock-up was used to mark the needed
repositioning of the buccal soft tissues. After local anesthesia
(Ubistesin Forte, 3M, Seefeld, Germany), a minimal buccal
mucoperiosteal flap was raised without releasing incisions. The mock-
up, ie, surgical stent, was then used to mark the necessary amount of
bone to be removed buccally. The marking was performed with a
sterilized round bur, and the marked buccal Part was thereafter
removed with the same instrument and a chisel, assuring careful
exposure of the buccal root surfaces of the teeth. The root surfaces
were then polished with specialized periodontal diamond instruments
(Perioset, Intensiv, Montagnola, Switzerland), and the flap was
apically repositioned and sutured (Dafilon, 6.0 sutures, B. Braun
Melsungen, Melsungen, Germany). During the initial healing, the
patient was instructed not to clean the operated area with toothbrush
or dental floss. He received a chlorhexidine solution for daily
disinfection until suture removal. After the suture removal, further
healing and maturation of tissues was allowed for another 3 months
prior to continuation of the restorative phase (Fig 2-1-65).
Figs 2-1-65a to 2-1-65l Crown-lengthening procedure.

Overlay preparation and impression in the

mandibular arch
A silicone index was fabricated based on the wax-up to facilitate the
correct preparation of the teeth. The teeth 34–37 and 44–47 were
prepared with a very shallow epigingival course to preserve the
maximum of tooth substrate and stay in the enamel wherever
possible. Due to the erosion and abrasion the teeth already appeared
as if they were prepared and therefor the actual preparation was
quite efficient. Due to the opening of the vertical dimension during the
diagnostic phase and its verification with the mock-up, the minimum
thickness of both maxillary and mandibular restorations was already
taken into account and therefore there was basically no need for a
subtractive preparation. Only sharp margins and edges were rounded
and the preparation mainly consisted of smoothening of the surfaces.
The final impression was taken using two retraction cords. In
order to avoid traumatization of the gingiva and to minimize the risk of
recessions, a surgical suturing material (size 4-0, Vicryl Ethicon,
Johnson & Johnson, New Brunswick, NJ, USA) was used as the first
retraction cord. The second retraction cord was the thinnest cord
available on the market (000 Ultrapak, UP Dental, Cologne,
Germany).

Mandibular provisional
To transfer the wax-up into the patient’s mouth, a silicone index of the
wax-up was prepared in order to fabricate an eggshell provisional on
the cast. This eggshell was fabricated with a classic acrylic PMMA
material (New Outline, Anaxdent) that was later on easy to reline and
adjust to the actual intraoral preparation.
The provisional was then relined with a self-curing resin (Tab
2000, Kerr, Brea, CA, USA), extraorally polished, and provisionally
cemented (Protemp, 3M, Seefeld, Germany) (Fig 2-1-66).
Figs 2-1-66a to 2-1-66f Provisional restoration.

Fabrication of the overlays in the laboratory

The first step for the final restoration was the fabrication of an
alveolar cast. In order to achieve an individualized shape and shade
to the restorations refractory dies were manufactured (anaxVest,
Anaxdent) to then directly veneer them. Due to the use of refractory
dies, the best possible fit of the overlays could also be guaranteed.
For the fabrication of the overlays, a backward planning concept was
applied. The laboratory work was guided by the information from the
wax-up which was transferred with the aid of silicone indexes (Matrix
Form 60, Anaxdent).
The ceramic masses were then applied (Creation Classic, Willi
Geller, Meiningen, Austria) according to the custom shade that was
developed by the dental technician in collaboration with the patient.
After two dentin firings, the surface texture and the final shape was
completed with stones and diamond burs. The glaze firing was
followed by an additional stain firing and a mechanical polishing
procedure. The polished veneers were carefully removed from the
refractory dies by airborne-particle abrasion with glass beads and
cleaned in an ultrasonic waterbed (Fig 2-1-67).
Figs 2-1-67a to 2-1-67f Overlay fabrication.

Integration of the overlays

A try-in session was carried out where the overlays were inserted
with a try-in paste (Variolink Esthetic neutral and warm, Ivoclar
Vivadent, Schaan, Liechtenstein) in order to improve color
assessment and optical integration. Subsequently, in a dry
environment (rubber dam) the ceramic overlays were cemented. The
abutment teeth were etched with 35% phosphoric acid (Ultra-Etch,
Ultradent Products, South Jordan, UT, USA) and bonded with a
multistep adhesive system (Syntac Classic, Ivoclar Vivadent). The
bond was not light-cured in order not to compromise the fit of the
ultra-thin veneers. The veneers were etched with hydrofluoric acid
(9% concentration for 1 min) (Porcelain Etch, Ultradent Products). A
silane-containing primer (Monobond Plus, Ivoclar Vivadent) and a
bonding system (Heliobond, Ivoclar Vivadent) was applied. Then the
overlays were cemented with a dual-curing resin cement (Variolink
Esthetic Nutral, Ivoclar Vivadent). Excess cement was removed with
rotating and oscillating diamond instruments (Universal Prep Set,
Intensiv, Montagnola, Switzerland) (Fig 2-1-68).
Figs 2-1-68a to 2-1-68d Integration of the overlays.

Overlay preparation, impression, and

provisionalization of the posterior maxilla
Following the initial diagnostics and in exactly the same treatment
sequence, the preparation was performed and the eggshell
professional was relined intraorally. In order not having to raise the
vertical dimension too much in the maxillary arch, the restorations
would only extend to the first molar, namely from teeth 14–16 and
24–26 (Fig 2-1-69).
Figs 2-1-69a to 2-1-69e Provisional restoration in maxilla.

Fabrication of the overlays in the laboratory

The five overlays for the posterior maxillary segments were produced
in the same approach as the mandibular segments and prepared for
insertion (Fig 2-1-70).
Fig 2-1-70 Overlay fabrication.

Integration of the overlays

Subsequently, in a dry environment (rubber dam) the ceramic
overlays were cemented. This followed the same concept as for the
mandibular arch as also the same restorative materials were used.
The occlusal and functional contacts were analyzed and no
adjustments were necessary. The patient already felt very
comfortable with his new bite and vertical dimension (Fig 2-1-71).
Figs 2-1-71a to 2-1-71d Integration of the overlays.

Preparation of the 360-degree maxillary

anterior veneers and verification
A silicone index was fabricated based on the wax-up to facilitate the
correct preparation of the teeth. The teeth 13–23 were prepared with
a minor epigingival course to preserve the maximum of tooth
substrate; as the change of the morphology was so extensive it was
decided to open up the approximate contact points and with this allow
for more flexibility to fabricate the same shape as developed during
the diagnostic phase, and also to cover and protect the palatal Part
of the teeth. The final impression was taken using two retraction
cords. In order to avoid traumatization of the gingiva and to minimize
the risk of recessions, a surgical suturing material (size 4-0, Vicryl
Ethicon, Johnson & Johnson) was used as the first retraction cord.
The second retraction cord was the thinnest cord available on the
market (000 Ultrapak, UP Dental) (Fig 2-1-72).
Figs 2-1-72a to 2-1-72f Preparation of maxillary anterior veneers.

Maxillary anterior provisional

To transfer the wax-up into the patient’s mouth, a silicone index of the
wax-up was prepared in order to fabricate an eggshell provisional on
the cast. This eggshell was fabricated with a classic acrylic PMMA
material (New Outline, Anaxdent) that was later on easy to reline and
adjust to the actual intraoral preparation. The provisional was then
relined with a self-curing resin (Tab 2000, Kerr), extraorally polished,
and provisionally cemented (Protemp, 3M, Seefeld, Germany) (Fig 2-
1-73).
Figs 2-1-73a to 2-1-73c Maxillary anterior provisional restoration.

Integration of the veneers

Subsequently, in a dry environment (rubber dam) the ceramic 360-
degree veneers were cemented. This followed the same concept as
for the mandibular arch, as the same reconstructive materials were
used. The occlusal and functional contacts were analyzed and no
adjustments were necessary (Fig 2-1-74).
Figs 2-1-74a to 2-1-74e Integration of the veneers.

Mandibular anterior direct composite build-

up
As the last step in this comprehensive treatment, the aim was to build
up the mandibular anterior teeth by means of a direct composite
build-up. This was besides a very small preparation of the incisal
edge, namely a rounding of the vestibular edge for an easier
transition line between the teeth and the restoration.
The composite build-up (Tetric Classic, Ivoclar Vivadent) was
guided just like the rest of the restorations by silicone keys that
reflected the diagnostics and made the build-up extremely predictable
and efficient (Fig 2-1-75).
Figs 2-1-75a to 2-1-75u Mandibular composite build-up.

Final full-mouth rehabilitation

The final outcome of this highly esthetic and minimally invasive
treatment was extremely pleasing for the entire team. The
predictability achieved through the diagnostic guidance was a
keystone to break such a comprehensive treatment down into smaller
quadrant restorations. That made the entire case easier for the team
to handle. As the treatment lasted close to 18 months, the initial
diagnostic phase was even more important as it engaged the patient
in this early phase and his commitment to all these appointments was
extremely high throughout the entire treatment phase.
After the last and minor occlusal adjustments, the patient
immediately received a Michigan splint to protect the new
restorations during the night and has since been in 6-month recall (Fig
2-1-76). (Dental practitioner: Prof Dr I Sailer; Technician: DT W
Gebhard.)
Figs 2-1-76a to 2-1-76j Final treatment outcome.
Congenitally missing teeth
(additional veneers and implant restorations)

2.1.10 Additional veneers and implant

restorations (maxillary premolar
to premolar)
This case shows the minimally invasive restoration of a patient with
congenitally missing teeth.

Assessment and treatment planning

A 27-year-old woman with congenitally missing teeth (14, 22, 24),
presented herself at the clinic seeking treatment for her compromised
esthetics in the maxillary anterior teeth and for the replacement of the
missing teeth. The proposed treatment plan was to establish a
minimally invasive additive veneering of the five anterior teeth with
veneers and also fill the corridor by means of additional
preparationless veneers in the posterior area. Simultaneously, the
placement of three diameter-reduced implants with full ceramic
restorations was planned (Fig 2-1-77).
Figs 2-1-77a to 2-1-77c Initial situation (reproduced from Fehmer
3
and Benic, with permission).

As a first step a conventional mock-up was planned to visualize

the future treatment outcome to the patient. As in this case the
remaining teeth were quite small and showed very little undercuts, an
indirect the mock-up was planned, and fabricated by the laboratory.
The wax-up and the resulting indirect mock-up served not only as a
perfect communication tool to engage the patient but also to later on
exactly determine the ideal three-dimensional implant positions for the
missing teeth.

Mock-up
In order to visualize the final treatment outcome and also its potential
limitations, a purely additional wax-up was performed on two
conventional plaster casts.
To transfer the wax-up into the patient’s mouth, an indirect mock-
up was fabricated in the dental laboratory, because in this case the
teeth were quite small and also had very little undercuts. Based on a
silicone index of the wax-up a classic acrylic PMMA (75% Dentin A2
and 25% Enamel High Value, New Outline, Anaxdent, Stuttgart,
Germany) was pressed onto the isolated cast.
The resulting removable but fragile mock-up served as a
communication tool to visualize the prospective treatment outcome.
Additionally, this type of indirect mock-up also has the advantage that
patients can easily take them home and check the new teeth in their
private environment. The patient was very happy with the mock-up
try-in and agreed to the treatment plan (Fig 2-1-78).
Figs 2-1-78a to 2-1-78g Mock-up (Figs 2-1-7a to 2-1-7c reproduced
3
from Fehmer and Benic, with permission).

Implant placement
According to the diagnostics, a surgical stent was fabricated
transferring the prosthetic plan of the ideal three-dimensional position
of the implant to the surgical intervention. After the raising of a
mucoperiosteal flaps with vertical releasing incisions distal of both
first molars, three diameter-reduced bone level implants (Straumann
Bone Level NC, Straumann, Basel, Switzerland) were placed with
good primary stability. The ridge deficiency in the maxillary lateral 22
implant was augmented with a xenograft (BioOss, Geistlich Pharma,
Wolhusen, Switzerland) and the graft was covered with a collagen
membrane (BioGide, Geistlich Pharma) to allow for hard tissue
formation. The flap was released by splitting the periosteum allowing
for a tension-free re-adaptation of the flap. After the suturing
(GoreTex 5.0, W.L. Gore & Associates, Flagstaff, AZ, USA) the
implants were left for submucosal healing for 10 weeks (Fig 2-1-79).
Figs 2-1-79a to 2-1-79e Implant placement.

Implant provisionals
To shape a natural and esthetic appearance of the emergence profile
according to the diagnostics, three implant provisionals were
fabricated in the dental laboratory. Based on retentive provisional
abutments, the provisional restorations were fabricated with a classic
acrylic PMMA (New Outline, Anaxdent) according to the initial dental
situation, but most importantly undercontoured in the submucosal
area. The resulting provisional integrated very nicely and was
sequentially, in three short appointments (approximately every 10
days), shaped to its final submucosal contour.

Veneer preparation and impression

A silicone index was fabricated based on the wax-up to facilitate the
correct preparation of the teeth. The teeth 16–26 were basically not
prepared at all to preserve the maximum of tooth substrate and
basically the preparation consisted of a smoothening of the edges
and reducing small undercuts. This can also be nicely seen in the
superimpositions of the areas 16 and 17, before and after the
preparation. The final impression was taken using two retraction
cords. In order to avoid traumatization of the gingiva and to minimize
the risk of recessions, a surgical suturing material (size 4-0, Vicryl
Ethicon, Johnson & Johnson, NJ, USA) was used as the first
retraction cord. The second retraction cord was the thinnest cord
available on the market (000 Ultrapak, UP Dental, Cologne,
Germany). For the three implants, the impression copings were
individualized, copying to the emergence profile of the provisionals
(Fig 2-1-80).
Figs 2-1-80a and 2-1-80b Veneer preparation and impressions.
Fabrication of the veneers and the screw-
retained implant restorations
The first step for the final restoration was the fabrication of an
alveolar cast. In order to achieve the thinnest possible restorations,
refractory dies were manufactured (anaxVest, Anaxdent) to then
directly veneer them and in the same step guarantee the best
possible fit of the veneers. For the fabrication of the veneer, a
backward planning concept was applied. The laboratory work was
guided by the information from the wax-up which was transferred with
the aid of silicone indexes (Matrix Form 60, Anaxdent). The ceramic
masses were then applied (Creation Classic, Willi Geller, Meiningen,
Austria) according to the custom shade that was developed by the
dental technician in collaboration with the patient. After one dentin
firing, the surface texture and the final shape was created with stones
and diamond burs. The glaze firing was followed by an additional
stain firing and a mechanical polishing procedure. The polished
veneers were carefully removed from the refractory dies by airborne-
particle abrasion with glass beads and cleaned in an ultrasonic
waterbed. To fabricate the customized zirconia abutments, the casts
were scanned (CS7, Straumann, Basel) and digitalized with the
corresponding scanbodies (Straumann Mono Scanbody). The three
abutments were designed (Dental Wings, Straumann) with an
anatomical support for the veneering ceramic and then sent via the
software to the official milling center (Straumann Milling Center,
Leipzig, Germany). Once delivered, the abutments were checked on
the cast for their correct anatomical support and directly veneered
(Creation Crystal ZI-CT, Willi Geller) and finalized.

Integration of the restorations

A try-in session was carried out where the veneers were inserted
with a try-in paste (Variolink Esthetic neutral and warm, Ivoclar
Vivadent, Schaan, Liechtenstein) in order to improve color
assessment and optical integration. Subsequently, in a dry
environment (rubber dam) the fragile ceramic veneers were
cemented. The abutment teeth were etched with 35% phosphoric
acid (Ultra-Etch, Ultradent Products, South Jordan, UT, USA) and
bonded with a multistep adhesive system (Syntac Classic, Ivoclar
Vivadent). The bond was not light-cured in order not to compromise
the fit of the ultra-thin veneers. The veneers were etched with
hydrofluoric acid (9% concentration for 1 min) (Porcelain Etch,
Ultradent Products). A silane-containing primer (Monobond Plus,
Ivoclar Vivadent) and a bonding system (Heliobond, Ivoclar Vivadent)
was applied. Then the veneers were cemented with a dual-curing
resin cement (Variolink Esthetic Nutral, Ivoclar Vivadent). Excess
cement was removed with rotating and oscillating diamond
instruments (Universal Prep Set, Intensiv, Montagnola, Switzerland).
The occlusal and functional contacts were analyzed and no
adjustments were necessary.
After the placement of the veneers the implant provisionals were
removed and the implants and adjacent tissues were disinfected with
a chlorhexidine solution. After disinfection (Tiutol dent, B. Braun
Melsungen, Melsungen, Germany) and the application of a
chlorhexidine gel to the submucosal Part (PlakOut Gel, KerrHawe,
Bioggio, Switzerland), the zirconia screwretained implant crown was
preliminarily retained to the implant for a period of 2 weeks, by
tightening the screw by hand (approx. 20 Ncm) and by closing the
screw access hole with Teflon and a provisional resin (Telio, Ivoclar
Vivadent).
After 2 weeks the abutment/crown screw was retightened with
the final torque as recommended by the manufacturer (35 Ncm). For
the final closure of the screw access a rubber dam was applied, and
the veneering ceramic layer around the access hole was etched (9%
hydrofluoric acid) and silanated (Monobond Plus, Ivoclar Vivadent).
The screw was densely covered with Teflon. Subsequently, a bonding
agent was applied (Heliobond, Ivoclar Vivadent), and the closure of
the screw access hole was finalized with a light-curing composite
filling material (Tetric Classic, Ivoclar Vivadent) in the corresponding
shade. After the light-curing, the occlusion was checked followed by
polishing of the composite filling.
The patient was very satisfied with the final treatment outcome
(Fig 2-1-81). (Dental practitioner: PD Dr G Benic; Technician: MDT V
Fehmer.)
Figs 2-1-81a to 2-1-81i Final treatment outcome. Figs 2-1-81a, 2-1-
3
81b, and 2-1-81e to 2-1-81i reproduced from Fehmer and Benic,
with permission.
References
1. Büchi D, Fehmer V, Sailer I, Wolleb K, Jung R. Minimally
invasive rehabilitation of a patient with amelogenesis
imperfecta. Int J Esthet Dent 2014;9:134-145.
2. Fehmer V, Sailer, I. Exzellente Dentale Ästhetik. Quintessenz
Zahntech 2013;39:1491-1492.
3. Fehmer, V, Benic GI. Exzellente Dentale Ästhetik. Quintessenz
Zahntech 2015;41:817–818.
CHAPTER 2
Minimally invasive restorations
(resin-bonded fixed dental
prostheses [RBFDPs])

Anterior regions
2.2.1 Failing central incisor after many
years of periodontal treatment
2.2.2 Congenitally missing lateral incisor
(RBFDP after orthodontic pretreatment)
2.2.3 Congenitally missing lateral incisors
(RBFDP after orthodontic pretreatment)
2.2.4 Full-mouth rehabilitation with
congenitally missing teeth (RBFDPs,
veneers, and overlays after
orthodontic treatment)

Complex situations
Complex situations (RBFDP and
2.2.5 additional veneer in combination with
orthodontic pretreatment)

Failing central incisor

(single-retainer zirconia-ceramic RBFDP)

2.2.1 Failing central incisor after

many years of periodontal
treatment
This first case shows the minimally invasive rehabilitation of a patient
who was refusing surgical interventions, with a follow-up of 10 years.

Assessment and treatment planning

A 47-year-old female patient was referred by her periodontist (Dr
Frank Paqué) with a central incisor (tooth number 11) with a poor
prognosis. Over the previous 7 years the patient did everything
possible to maintain her compromised tooth, that now unfortunately
after several successful interventions had finally failed. A periradicular
chronic infection, two fistulas in the buccal area of tooth 11, could be
detected, and a radiograph clearly showed the bone loss as
consequence of the inflammatory process and the previous
interventions.
Two treatment options for the replacement with a fixed restoration
were discussed and elaborated with the patient: a single-retainer
resin-bonded fixed dental prosthesis (RBFDP) bonded to tooth 21,
and a single implant. After both treatment options were presented,
the patient strongly insisted on a surgery-free treatment which in her
case was reflected by the RBFDP. No restorative limitations were
posed by the position and angulation of the teeth and therefore the
replacement of the missing tooth by means of a fixed tooth-borne
restoration was possible and a single retained RBFDP made from
zirconia was planned (Fig 2-2-1).
Figs 2-2-1a to 2-2-1c Pretreatment photographs.

Diagnostics
The patient’s chief complaint was to receive a fixed dental
restoration. The patient liked the shape and the slight crowding of her
teeth and also saw a small color change in her affected central
incisor that she did not like. She requested the same position and
shape for her final restoration. Due to the mesial rotation of the
adjacent central 21 and the slightly inverted position of the designated
pontic, the conditions were close to ideal for the anchorage of a
palatal backing.
Usually the adjacent central incisors offer a longer approximal
contact area than canines, first to develop a sufficient connector
dimension and second, but at least as important, to then hide the
connector and its minimally invasive preparation. In this case the
adjacent central incisor 21 was chosen to serve as an anchorage
tooth (Fig 2-2-2).
Figs 2-2-2a to 2-2-2c Diagnostics images.

Extraction
Despite the extremely careful extraction, the tooth immediately broke
into two pieces. The remaining root of tooth 11 was extracted and a
lot of granulation tissue had to be removed.
Finally, the socket was curettaged and rinsed with neomycin
solution (Fig 2-2-3).
Figs 2-2-3a to 2-2-3c Extraction.

Ridge preservation
After the extraction and cleaning of the socket a xenogeneic bone
substitute (Bio-Oss Collagen, Geistlich, Wolhusen, Switzerland) was
inserted in combination with a subepithelial connective tissue grafts
harvested from the palate to perform a ridge preservation (Fig 2-2-4).
Figs 2-2-4a to 2-2-4e Ridge preservation.

Conditioning of the pontic

Prior to the prosthetic replacement of missing tooth 11, the gingival
area in the pontic region was shaped (ie, conditioned according to the
desired emergence profile of the restoration). The conditioning was
performed in order to shape the soft tissues into an “ovate-pontic-
like” shape and, hence, to allow for a natural emergence profile of the
pontics. For the conditioning, flowable composite (Tetric Flow, Ivoclar
Vivadent, Liechtenstein) was applied in a stepwise approach to the
basal region of the provisional pontic, inducing pressure to the soft
tissues in the edentulous area and thereby shaping of this region. This
procedure was repeated three times at intervals of 8–10 days until
the desired shape of the pontic area was achieved (Fig 2-2-5).
Figs 2-2-5a to 2-2-5l Conditioning of the pontic.

Preparation and conventional impression

Finally, the respective abutment tooth 21 was prepared in order to
allow for retention of the RBFDP and in order to simplify the
positioning during the laboratory work as well as the cementation
procedure. The minimally invasive preparation design for anterior
zirconia-based RBFDPs encompassed the preparation of a mesial
and a distal vertical groove (6-degree taper) and a tiny slot at the
palatal/lingual cingulum region (Universal Prep Set, Intensiv,
Montagnola, Switzerland). After that, a conventional impression was
performed using an elastomeric impression material (President,
Coltene, Langenau, Germany).

Fabrication of the RBFDP in the laboratory

The single-retainer zirconia-ceramic RBFDP was virtually designed
with respect to the minimum requirements of the framework and
connector dimensions. This was manufactured by means of a
CAD/CAM system (Cares Visual, Straumann, Basel, Switzerland) and
milled from Lava Plus (3M, Seefeld, Germany).
The minimum dimensions for zirconia frameworks in the anterior
region were:
■ thickness of retainer 0.5 mm;
■ cross-section of connector 6 mm2 (2 mm of width, 3 mm of
height);
■ shape and size of pontic according to the emergence profile of the
respective site and with an anatomical support for the veneering
ceramic.

Framework and wax-up try-in

The framework was clinically checked with respect to its fit and in the
same appointment a wax-up verification of the designated final shape
of the central incisor was carried out.
The patient and the restorative team were very satisfied with the
shape and the fit of the framework and thereafter the final veneering
could be done in the dental laboratory.
Creation ZI-F (Creation Willi Geller, Meiningen, Austria) was used
according to an individualized custom shade developed with the
patient in the dental laboratory (Fig 2-2-6).
Figs 2-2-6a to 2-2-6f Framework and wax-up try-in.

Biscuit bake try-in

The biscuit bake was clinically checked with respect to its fit and
shape of the central incisor.
The patient and the restorative team were very satisfied with the
final shade and the fit of the veneered framework; however, in the
pontic area the RBFDP was slightly buccal and appeared as if it was
sitting in front of the ridge and not emerging from the defined pontic.
Therefore, it was discussed with the technician to create a little
cementoenamel junction, basically capping the adjacent central
incisor. With this, the cervical Part could be shaped less noticeably
and the RBFDP, without changing its well-developed shape, appear
as it would emerge from the pontic (Fig 2-2-7).
Figs 2-2-7a to 2-2-7d Biscuit bake try-in.

Finalization of the RBFDP in the laboratory

After the biscuit try-in of the RBFDP veneered with Creation ZI-F
(Creation Willi Geller, Meiningen, Austria) the surface with its micro
and macro texture was created by means of diamond burs, stones,
and polishing wheels and then finally glazed without the application of
vacuum in the ceramic oven.
Integration of the restorations
The RBFDP was adhesively cemented using a resin cement Panavia
21 (TC, Kuraray, Tokyo, Japan). For the cementation rubber dam
was applied, and the abutment tooth was meticulously cleaned with
pumice. Then, the palatal/lingual retention area of the abutment tooth
was etched with a 37% phosphoric acid (1 min application).
Furthermore, the corresponding primer of the resin cement ED Primer
(Kuraray) was used as pretreatment as recommended by the
manufacturer.
The zirconia surface was cleaned with alcohol and a silane-
containing primer, Clearfil Porcelain Bond (Kuraray) was applied
according to the manufacturer’s recommendations (Fig 2-2-8).
Figs 2-2-8a to 2-2-8d Cementation and cleaning of the restoration.

Finally, the cement was applied to the RBFDP retainer and the
restoration was seated. A glycerin gel, Oxyguard (Kuraray), was
used to cover the margins for the setting of the resin cement.
Constant finger pressure was applied during the setting time.
Adjustments were performed where needed, after which the
ceramic surfaces were meticulously polished with the Optrafine Kit
(Ivoclar, Schaan, Liechtenstein) (Fig 2-2-9). (Dental practitioner: Prof
Dr I Sailer; Technician: DT X Zahno.)
Figs 2-2-9a to 2-2-9f The final restoration.
Final outcome after 10 years of clinical
function
No technical or biological complications occurred, and the patient was
still very satisfied with her RBFDP. The mesial and distal papilla, as
well as the volume, could be maintained over the years. Along with a
visible continuing growth of the maxillary segment the emergence
profile continued to show a very natural contour (Fig 2-2-10).
Figs 2-2-10a to 2-2-10d Outcome after 10 years in clinical function.
Congenitally missing lateral
incisor
(single-retainer zirconia-ceramic RBFDP after
orthodontic pretreatment)

2.2.2 Congenitally missing lateral

incisor (RBFDP after orthodontic
pretreatment)
Minimally invasive rehabilitation after orthodontic pretreatment with 8
years’ follow-up.

Assessment and treatment planning

A 15-year-old female patient was referred by the Clinic of
Orthodontics after alignment of the maxillary incisors for the
prosthetic replacement of missing tooth 12. Tooth 12 was congenitally
missing and the space was nicely distributed by the orthodontic
department and maintained by a removable provisional.
Two treatment options for replacement with a fixed restoration
were discussed: a single-retainer RBFDP bonded to tooth 13 or 11,
and a single implant. The RBFDP was considered the most
appropriate at the time of the treatment due to the very young age of
the patient. It was likely, though, that at a later stage a
singlediameter reduced implant would be a good alternative.
After the orthodontic alignment, for both treatment options no
restorative limitations were posed by the position and angulation of
the teeth. The replacement of the missing tooth by means of either
the fixed tooth- or implant-borne restoration would have been
possible.
However, due to the young age of the patient and the associated
potential growth, a single retained resin-bonded fixed dental
prosthesis made from zirconia was planned (Fig 2-2-11).
Figs 2-2-11a to 2-2-11c Pretreatment photographs.

Diagnostics and provisionalization

The patient’s chief complaint after the orthodontic alignment of her
teeth was to receive a fixed dental restoration and no longer having to
rely on the removable restoration.
As the removable provisional, however, looked and integrated
quite nicely, it could perfectly be used as a diagnostic set-up and
function at the same time as a mock-up to determine which of the two
neighboring teeth would offer the best anchorage.
Usually the central incisors offer a longer approximal contact area
than canines; this first allows development of a sufficient connector
dimension and second, but at least as important, to then hide the
connector and its minimally invasive preparation. However, in this
case, the canine 13 was chosen to serve as an anchorage tooth as
the central incisor on its distal contact area was quite round and
triangular.

Conditioning of the pontic

Prior to the prosthetic replacement of missing tooth 12, the gingival
area in the pontic region was shaped (ie, conditioned according to the
desired emergence profile of the restoration). The conditioning was
performed in order to shape the soft tissues into an “ovate-ponticlike”
shape and, hence, to allow for a natural emergence profile of the
pontics. For the conditioning, flowable composite (Tetric Flow, Ivoclar
Vivadent, Schaan, Liechtenstein) was applied in a stepwise approach
to the basal region of the provisional pontic, inducing pressure to the
soft tissues in the edentulous area and thereby shaping of this region.
This procedure was repeated twice at intervals of 8 to 10 days until
the desired shape of the pontic area was achieved (Fig 2-2-12).
Figs 2-2-12a to 2-2-12f Conditioning of the pontic. Figs 2-2-12a to
1
2-2-12c, reproduced from Sailer and Fehmer, with permission.

Preparation and optical impression

Finally, the respective abutment tooth 13 was prepared in order to
allow for retention of the RBFDP and in order to simplify the
positioning at cementation. The minimally invasive preparation design
for anterior zirconia-based RBFDPs encompassed the preparation of
a mesial and a distal vertical groove (6-degree taper) and a tiny slot
at the palatal/lingual cingulum region (Universal Prep Set, Intensiv,
Montagnola, Switzerland). After that, the optical impression was
carried out using an iTero intraoral scanner (Align Technology, San
Jose, CA, USA) (Fig 2-2-13).
Figs 2-2-13a to 2-2-13e Preparation and optical impression. Figs 2-
1
2-13c to 2-2-13e, reproduced from Sailer and Fehmer, with
permission.

Fabrication of the RBFDP in the laboratory

The single-retainer zirconia-ceramic RBFDP was virtually designed
with respect to the minimum requirements of the framework and
connector dimensions. This was manufactured by means of a
CAD/CAM system (Cares Visual, Straumann, Basel, Switzerland) and
milled from Lava Plus (3M, Seefeld, Germany) (Figs 2-2-14 and 2-2-
15).
Figs 2-2-14a to 2-2-14e Fabrication of the RBFDP.
Figs 2-2-15a and 2-2-15b Fabrication of the RBFDP. Fig 2-2-15b
1
reproduced from Sailer and Fehmer, with permission.

The minimum dimensions for zirconia frameworks in the anterior

region were:
■ thickness of retainer 0.5 mm;
■ cross-section of connector 6 mm2 (2 mm of width, 3 mm of
height);
■ shape and size of pontic according to the emergence profile of the
respective site and with an anatomical support for the veneering
ceramic.

Framework try-in and finalization

The framework was clinically checked with respect to its fit and in the
same appointment a wax-up verification of the designated final shape
of the lateral incisor was carried out.
The patient and the restorative team were very satisfied with the
final shape and the fit of the framework and thereafter the final
veneering could be done in the dental laboratory.
Creation ZI-CT (Creation Willi Geller, Meiningen, Austria) was
used according to an individualized custom shade developed with the
patient in the dental laboratory (Fig 2-2-16).
Figs 2-2-16a to 2-2-16f Framework try-in and finalization. Figs 2-2-
1
16a to 2-2-16c, reproduced from Sailer and Fehmer, with
permission.

Integration of the restorations

The RBFDP was adhesively cemented using a resin cement Panavia
21 (TC, Kuraray, Tokyo, Japan). For the cementation rubber dam
was applied, and the abutment tooth was meticulously cleaned with
pumice. Then, the palatal/lingual retention area of the abutment tooth
was etched with a 37% phosphoric acid (1 min application).
Furthermore, the corresponding primer of the resin cement ED Primer
(Kuraray) was used as pretreatment as recommended by the
manufacturer.
The zirconia surface was cleaned with alcohol and a silane-
containing primer, Clearfil Porcelain Bond (Kuraray) was applied
according to the manufacturer’s recommendations. Finally, the
cement was applied to the RBFDP retainer and the restoration was
seated. A glycerin gel, Oxyguard (Kuraray) was used to cover the
margins for the setting of the resin cement. Constant finger pressure
was applied during the setting time.
Adjustments were performed where needed, after which the
ceramic surfaces were meticulously polished with the Optrafine Kit
(Ivoclar Vivadent) (Fig 2-2-17).
Fig 2-2-17 Final outcome.
Finally, an orthodontic retainer was bonded to the palatal surfaces
of the RBFDP backing and the neighboring teeth.
(Orthodontist: Dr G Rutz; Dental practitioner: Prof Dr I Sailer;
Technician: MDT V Fehmer.)

Final outcome after 8 years of clinical

function
No technical or biological complications occurred and the patient was
still very satisfied (Fig 2-2-18).
Figs 2-2-18a and 2-2-18b Outcome after 8 years in clinical function.
Congenitally missing lateral
incisors
(single-retainer zirconia-ceramic RBFDPs after
orthodontic pretreatment)

2.2.3 Congenitally missing lateral

incisors (RBFDP after
orthodontic pretreatment)
Minimally invasive rehabilitation after orthodontic pretreatment with 4
years of follow-up.

Assessment and treatment planning

A 14-year-old female patient was referred by the Clinic of
Orthodontics after her orthodontic treatment was finalized and the
alignment of her teeth was accomplished. The young patient was
referred for the prosthetic replacement of missing tooth 12 and 22.
Both teeth were congenitally missing and the spaces were nicely
distributed by the orthodontic department and maintained with a
removable provisional that functioned at the same time as a retainer.
Two treatment options for replacement with a fixed restoration
were addressed and explained to the patient and her parents: two
single-retainer resin-bonded fixed dental prosthesis (RBFDP) bonded
to either the centrals or the canines, and two single implants. There
was no doubt that due to the young age of the patient the RBFDP
was considered by far the most appropriate treatment option;
however, as the parents of the patient explicitly asked for implants,
the pros and contraindications of placing implants in such a young
patient were explained in great detail.
The family understood that due to the minimally invasive treatment
therapy, associated with the placement of two single-retainer resin-
bonded fixed dental prostheses, there was no limitation to prevent
placement of two implants at a later time point in the patient’s life.
The required preparation of the abutment teeth was so minimal and
therefore close to reversible.
After the orthodontic alignment, there were no restorative
limitations posed by the position and angulation of the teeth. The
replacement of the missing teeth by means of two single retained
RBFDPs made from zirconia was possible without any limitations and
thus planned for (Fig 2-2-19).
Figs 2-2-19a to 2-2-19c Pretreatment photographs.

Diagnostics and provisionalization

The patient’s chief complaint after the orthodontic alignment of her
teeth was to receive a fixed dental restoration and no longer having to
live with the removable restoration.
As the removable provisional however looked and integrated quite
nicely, it could perfectly serve as a diagnostic set-up, to determine
the final shape as well as which of each two neighboring teeth would
offer the best anchorage.
Despite the fact that usually the central incisors offer a longer
approximal contact area than canines; first to develop a sufficient
connector dimension and second, but at least as important, to then
hide the connector and its minimally invasive preparation. In this case
the canines 13 and 23 were chosen to serve as anchorage teeth as
the distal papillae of both incisors were quite high and would have led
to a very incisally located backing. As a consequence this would have
eliminated the highly esthetic translucent effect of the central incisors
(Figs 2-2-20).
Figs 2-2-20a to 2-2-20d Diagnostic images.
Additional diagnostic wax-up try-in
Initially the removable provisional served as a diagnostic set-up,
however once addressing the case more closely during the initial
treatment phase, it was realized that the two teeth were slightly too
prominent and buccally positioned.
To avoid and reduce the risk of a visible framework in the
connector area, an additional wax-up try-in was performed.
According to this wax-up, not only the framework could be
designed with the ideal anatomical support, but also the preparation
of the mesial vertical grooves could be perfectly planned (Fig 2-2-21).
Figs 2-2-21a to 2-2-21d Diagnostic wax-up try-in.
Preparation and conventional impression
Finally, the respective abutment teeth 13 and 23 were prepared in
order to allow for retention of the RBFDP and to simplify the
positioning at cementation. The minimally invasive preparation design
for anterior zirconia-based RBFDPs encompassed the preparation of
a mesial and a distal vertical groove (6-degree taper) and a tiny slot
at the palatal/lingual cingulum region (Universal Prep Set, Intensiv,
Montagnola, Switzerland). After that, a conventional impression was
carried out using an elastomeric impression material (President,
Coltene, Langenau, Germany).

Fabrication of the RBFDP in the laboratory

The single-retainer zirconia-ceramic RBFDPs were virtually designed
with respect to the minimum requirements of the framework and
connector dimensions. These were manufactured by means of a
CAD/CAM system (Cares Visual, Straumann, Basel, Switzerland) and
milled from Lava Plus (3M, Seefeld, Germany) (Fig 2-2-22).
Figs 2-2-22a to 2-2-22d Fabrication of RBFDPs.
The minimum dimensions for zirconia frameworks in the anterior
region were:
■ thickness of retainer 0.5 mm;
■ cross section of connector 6 mm2 (2 mm of width, 3 mm of
height);
■ shape and size of pontic according to the emergence profile of the
respective site and with an anatomical support for the veneering
ceramic.

Biscuit bake try-in

The biscuit bake was clinically checked with respect to its fit and
shape of the lateral incisors.
The patient and the restorative team were very satisfied with the
final shape and the fit of the framework; however, the veneering
ceramic Creation ZI-CT (Creation Willi Geller, Meiningen, Austria)
appeared to be slightly too opaque (Fig 2-2-23).
Figs 2-2-23a to 2-2-23d Biscuit bake try-in.

Finalization and adaptation of the RBFDPs in

the laboratory
Creation ZI-CT (Creation Willi Geller, Meiningen, Austria) was used
with a third dentin firing to adjust the high opacity according to an
adjusted custom shade developed with the patient during the biscuit
bake try-in (Fig 2-2-24).
Figs 2-2-24a to 2-2-24e Finalization and adaptation of the RBFDPs.

Integration of the restorations

The RBFDPs were adhesively cemented using a resin cement
Panavia 21 (TC, Kuraray, Tokyo Japan). For the cementation rubber
dam was applied, and the abutment teeth were meticulously cleaned
with pumice. Then, the palatal/lingual retention areas of the abutment
teeth were etched with a 37% phosphoric acid (1 min application).
Furthermore, the corresponding primer of the resin cement ED Primer
(Kuraray) was used as pretreatment as recommended by the
manufacturer. The zirconia surface was cleaned with alcohol and a
silane-containing primer, Clearfil Porcelain Bond (Kuraray) was
applied according to the manufacturer’s recommendations. Finally,
the cement was applied to the RBFDP retainers and the restoration
were seated one after the other. A glycerin gel, Oxyguard (Kuraray)
was used to cover the margins for the setting of the resin cement.
Constant finger pressure was applied during the setting time.
Adjustments were performed where needed, after which the
ceramic surfaces were meticulously polished with the Optrafine Kit
(Ivoclar Vivadent, Schaan, Liechtenstein) (Figs 2-2-25 and 2-2-26).
Finally, an orthodontic retainer was bonded to the palatal surfaces of
the RBFDP backing and the neighboring teeth.
Figs 2-2-25a to 2-2-25f Integration of the restorations.
Figs 2-2-26a to 2-2-26g Final outcome.
(Orthodontist: Dr G Rutz; Dental practitioner: Prof Dr I Sailer;
Technician: MDT V Fehmer.)

Final outcome after 4 years of clinical

function
No technical or biological complications occurred and the patient was
still very satisfied (Fig 2-2-27).

Fig 2-2-27a and 2-2-27b Outcome after 4 years in clinical function.

Soft tissue adaptation after 4 years

Impressions of the pontic area and its soft tissue adaptation at
delivery (Fig 2-2-28a) and after 4 years of clinical service (Fig 2-2-
28b). The soft tissue has clearly grown around the RBFDP pontic and
shows no signs of inflammation and a very natural contour of the
emergence profile.
Fig 2-2-28a and 2-2-28b The pontic area and its soft tissue
adaptation at delivery (a) and after 4 years of clinical service (b).
Congenitally missing teeth
(RBFDPs, veneers, and overlays after orthodontic
treatment)

2.2.4 Full-mouth rehabilitation with

congenitally missing teeth
(RBFDPs, veneers, and overlays
after orthodontic treatment)
The following case is of a minimally invasive rehabilitation as an
alternative to a continuation of orthodontic treatment.

Assessment and treatment planning

A 17-year-old female patient was referred by the Clinic of
Orthodontics after she was seeking to end her orthodontic treatment
before the alignment of her teeth was finally accomplished.
The young patient combined several interesting aspects that led to
open questions:
■ Complex initial situation with many congenitally missing teeth;
■ In need for a functional rehabilitation;
■ Patient wished for the completion of the orthodontic treatment,
even if it has not yet achieved an “ideal” result;
■ The patient’s teeth, permanent as well as primary, were all caries-
free and untreated.

The patient generally desired an esthetic improvement and a fixed

replacement of the congenitally missing lateral incisors in the maxillary
anterior area, combined with her main concern that these corrections
should be achieved whenever possible without further orthodontic
treatment.
Two treatment options for the replacement with a fixed restoration
were addressed and explained to the patient and her parents: two
single-retainer RBFDP bonded to either the centrals or the canines,
or two single implants. There was no doubt that due to the young age
of the patient the RBFDP was considered by far the most appropriate
treatment option however as the parents of the patient explicitly
asked for implants, the pros and contraindications of placing implants
in such a young patient were explained and in detail elaborated.
The family understood that due to the minimally invasive treatment
therapy, associated with the placement of two single-retainer resin-
bonded fixed dental prosthesis, there was no limitation to not place
two implants at a later time point in the patient’s life. The required
preparation of the abutment teeth was so minimal and therefore close
to reversible. However, as the orthodontic alignment was not yet
finalized, the second main question was if it would be possible to
achieve the patient’s wish for an esthetic improvement without further
alignment of the teeth (Fig 2-2-29).
Figs 2-2-29a to 2-2-29c Pretreatment photographs. Fig 2-2-29a
2
previously published in Fehmer.

Diagnostics
The patient’s chief complaint during the still-ongoing orthodontic
alignment of her teeth was to receive a fixed dental restoration and
no longer having to have fixed braces.
In the context of a detailed initial diagnosis, it had to be
determined whether her wishes could be fulfilled purely prosthetically,
without further orthodontics, or whether she would have to commit to
the continuation of orthodontic treatment in order to obtain an esthetic
and stable final treatment outcome (Fig 2-2-30).
Figs 2-2-30a to 2-2-30h Diagnostic images. Fig 2-2-30a to 2-2-30c
2
and 2-2-30f to 2-2-30h previously published in Fehmer.

Treatment plan
The planning of the entire functional and esthetic rehabilitation
included preserving the primary teeth by means of all-ceramic
minimally invasive restorations. It should almost not be prepared, or if
necessary, as little as possible, so as not to endanger the integrity
and vitality of the teeth.
Depending on the extent of the desired change in shape, in the
posterior area either occlusal veneers (table tops)/overlays or circular
360-degree veneers were possible options, as in the anterior area
classic veneers or 360-degree veneers were planned. The missing
lateral maxillary incisors should be replaced with two singleretainer
RBFDPs.
The patient should be offered long-term oriented, highly esthetic
care, which is basically reversible due to the minimal invasiveness and
can also be replaced at any time by other prosthetic restorations or
supplemented by implants.
The basic idea behind this option was the following: due to the
congenitally missing teeth, the age-appropriate options, and the
excellent personal oral hygiene, the patient should be offered a
natural, highly esthetic fixed dental restoration.

Mock-up
In order to visualize the final treatment outcome and especially also
its potential limitations, a purely additional wax-up was performed on
two conventional plaster casts.
To then transfer the wax-up into the patient’s mouth, as the teeth
were quite small and also had very little undercuts, an indirect mock-
up was fabricated in the dental laboratory. Based on a silicone index
of the wax-up a classic acrylic PMMA (75% Dentin A2 and 25%
Enamel High Value, New Outline, Anaxdent, Stuttgart, Germany) was
pressed onto the isolated cast.
The resulting removable but fragile mock-up served as a
communication tool to visualize the prospective treatment outcome.
Additionally, this type of indirect mock-up also has the advantage that
patients can easily take them home and thus allows them to check
the new teeth in their private environment. The indirect mock-up
showed very clearly the esthetic potential of an only prosthetic
rehabilitation, but also its shortcomings. The patient, however, despite
all shortcomings especially in the canine areas, was very happy with
the mock-up try-in and agreed to the treatment plan (Fig 2-2-31a).
Figs 2-2-31a to 2-3-31c Mock-up try-in and comparison of
prosthetic approach (b) and orthodontic set-up (c). Previously
2
published in Fehmer.

Prosthetic mock-up vs. orthodontic set-up

A comparison was made of the purely prosthetic approach, with all its
associated shortcomings (Fig 2-2-31a), as compared to the
orthodontic set-up with the teeth planned in their final position and
orientation (Fig 2-2-31c). To realize the planned set-up and move all
the teeth to their designated positions, the patient would have had to
continue with the fixed braces for an additional 12 months.
While the patient clearly was not in favor, she agreed prior to the
mock-up try-in that if it was not satisfactory to the entire team, she
would continue with the orthodontic treatment.

Veneer, overlay, and RBFDP preparation and

impression
A silicone index was fabricated based on the wax-up to facilitate the
correct preparation of the teeth. All teeth except the maxillary second
molars were prepared with a zero-epigingival course to preserve the
maximum of tooth substrate and stay in the enamel whenever
possible. Once the sufficient space was achieved, the finalization of
the preparation consisted mainly smoothening of the edges. As in this
case the central incisors served as anchor for both the facial veneers
and the RBFDPs, the preparation was slightly adjusted and finally
consisted only of a tiny slot at the palatal/lingual cingulum region.
The final impression was taken using two retraction cords. In
order to avoid traumatization of the gingiva and to minimize the risk of
recessions, a surgical suturing material (size 4-0, Vicryl Ethicon,
Johnson & Johnson, New Brunswick, NJ, USA) was used as the first
retraction cord. The second retraction cord was the thinnest cord
available on the market (000 Ultrapak, UP Dental, Cologne,
Germany). As for the impression and the preparation, the retainer
had to be removed – instead, a thermoplastic 1 mm foil was used as
a retainer and provisional in one (Erkodur, Erkodent,
Pfalzgrafenweiler, Germany) (Fig 2-2-32).
Figs 2-2-32a to 2-2-32e Veneer, overlay, and RBFDP preparation
and impression.
Figs 2-2-32d to 2-2-32e Veneer, overlay, and RBFDP preparation
and impression.

Fabrication of the veneers and overlays in

the laboratory
The first step for the final restoration was the fabrication of an
alveolar cast. In order to achieve the thinnest possible restorations,
refractory dies were manufactured (anaxVest, Anaxdent, Stuttgart,
Germany) to then directly veneer them and in the same step
guarantee the best possible fit of the veneers. For the fabrication of
the veneers and overlays, a backward planning concept was applied.
The laboratory work was guided by the information from the wax-up
which was transferred with the aid of silicone indexes (Matrix Form
60, Anaxdent). The ceramic masses were then applied (Creation
Classic, Willi Geller, Meiningen, Austria) according to the custom
shade that was developed by the dental technician in collaboration
with the patient. After one dentin firing, the surface texture and the
final shape was made with stones and diamond burs. The glaze firing
was followed by an additional stain firing and a mechanical polishing
procedure. The polished veneers were carefully removed from the
refractory dies by airborne-particle abrasion with glass beads and
cleaned in an ultrasonic waterbed.

Fabrication of the RBFDPs in the laboratory

The single-retainer zirconia-ceramic RBFDPs were virtually designed
with respect to the minimum requirements of the framework and
connector dimensions. This was manufactured by means of a
CAD/CAM system (Cares Visual, Straumann, Basel, Switzerland) and
milled from Lava Plus (3M, Seefeld, Germany).
The minimum dimensions for zirconia frameworks in the anterior
region here were:
■ thickness of retainer 0.5 mm;
■ cross-section of connector 6 mm2 (2 mm width, 3 mm height);
■ shape and size of pontic according to the emergence profile of the
respective site and with an anatomical support for the veneering
ceramic.

The frameworks were clinically checked with respect to their fit and
finally manually veneered with Creation ZI-CT (Creation Willi Geller),
just like the other veneers and overlays based on the refractory dies
(Fig 2-2-33).
Figs 2-2-33a to 2-2-33d Fabrication of the RBFDPs.

Integration of the restorations

A try-in session was carried out where the veneers and overlays
were inserted with a try-in paste (Variolink Esthetic neutral and warm,
Ivoclar Vivadent, Schaan, Liechtenstein) in order to improve color
assessment and optical integration. Subsequently, in a dry
environment (rubber dam) the fragile ceramic veneers and overlays
were cemented. The abutment teeth were etched with 35%
phosphoric acid (Ultra-Etch, Ultradent Products, South Jordan, UT,
USA) and bonded with a multistep adhesive system (Syntac Classic,
Ivoclar Vivadent). The bond was not light-cured in order not to
compromise the fit of the ultra-thin veneers. The veneers and
overlays were etched with hydrofluoric acid (9% concentration for 1
min) (Porcelain Etch, Ultradent Products). A silane-containing primer
(Monobond S, Ivoclar Vivadent) and a bonding system (Heliobond,
Ivoclar Vivadent) was applied. Then the veneers and overlays were
cemented with a dual-curing resin cement (Variolink Esthetic Nutral,
Ivoclar Vivadent). Excess cement was removed with rotating and
oscillating diamond instruments (Universal Prep Set, Intensiv,
Montagnola, Switzerland) The occlusal and functional contacts were
analyzed, and no adjustments were necessary.
The RBFDPs were adhesively cemented using a resin cement
Panavia 21 (TC, Kuraray, Tokyo, Japan). For the cementation rubber
dam was applied, and the abutment teeth were meticulously cleaned
with pumice. Then, the palatal/lingual retention area of the abutment
teeth was etched with a 37% phosphoric acid (1 min application).
Furthermore, the corresponding primer of the resin cement ED Primer
(Kuraray) was used as pretreatment as recommended by the
manufacturer.
The zirconia surface was cleaned with alcohol and a silane-
containing primer, Clearfil Porcelain Bond (Kuraray) was applied
according to the manufacturer’s recommendations. Finally, the
cement was applied to the RBFDP retainers and the restoration were
seated one after the other. A glycerin gel, Oxyguard (Kuraray), was
used to cover the margins for the setting of the resin cement.
Constant finger pressure was applied during the setting time.
Adjustments were performed, where needed after which the ceramic
surfaces were meticulously polished with the Optrafine Kit (Ivoclar
Vivadent) (Fig 2-2-34).
Figs 2-2-34a to 2-2-34f Integration of the restorations.

Finally, an orthodontic retainer was bonded to the palatal surfaces

of both the maxillary and mandibular anterior teeth.

Critical discussion
At the beginning of the treatment there was the question of whether
the existing positions, sizes, and shapes of the teeth could be
corrected by purely prosthetic means.
As the pictures of the mock-up try-in show, this was afflicted with
compromises but basically feasible.
Among the compromises was that for the prosthetic correction of
function and esthetic aspects, all teeth would have to be included in
the restoration (besides the maxillary second molars). This led to high
workload for both clinician and technician, which was reflected in the
high treatment costs. In addition, all teeth had to be minimally
invasively prepared to receive the final restorations.
Finally, the various primary teeth with root resorptions would not
serve as safe abutment teeth, which therefore could compromise the
longevity of the rehabilitation. However, the clinical examination
revealed that all primary teeth were solid, healthy, and completely
free of any clinical symptoms of pathology.
This led the restorative team with the close involvement of the
specialist to the decision to preserve and reconstruct the primary
teeth (Fig 2-2-35). (Orthodontist: Dr G Rutz; Dental practitioner: Prof
Dr I Sailer; Technician: MDT V Fehmer.)
Figs 2-2-35a to 2-2-35l Final outcome. Fig 2-2-35a to 2-2-35c, 2-2-
2
35g and 2-2-35i previously published in Fehmer.

Complex situations
(RBFDP and additional veneer after orthodontic
pretreatment)

2.2.5 RBFDP and additional veneer in

combination with orthodontic
pretreatment
The following series shows a minimally invasive rehabilitation with
palatal implants prior to prosthetic restoration.

Assessment and treatment planning

A 16-year-old female patient was referred by the Clinic for Fixed and
Removable Prosthodontics to the Clinic of Orthodontics for alignment
of the maxillary incisors prior to the prosthetic replacement of missing
tooth 11. Tooth 11 had to be extracted, due to a previous accident.
Two treatment options for replacement with a fixed restoration
were discussed: a single-retainer resin-bonded fixed dental
prosthesis (RBFDP) bonded to tooth 21, and a single implant. The
RBFDP was considered the most appropriate at the time of the
treatment due to the young age of the patient. It was likely, though,
that at a later stage a single implant would be a good alternative.
For both treatment options, however, a restorative limitation was
posed by the position and angulation of the teeth. Replacement of the
missing tooth by means of either the fixed tooth- or implant-borne
restoration. Therefore, an interdisciplinary rehabilitation was initiated.
Furthermore, it was planned to harmonize the small lateral incisor 12
by means of an additional veneer.
Clinical examination revealed a skeletal Class II div. 2 relation,
traumatic deep bite, steep maxillary incisor inclination, and lack of
space in the maxillary arch (Fig 2-2-36).
Figs 2-2-36a to 2-2-36c Pretreatment photographs.

Diagnostics
The patient’s chief complaint was the pronounced overcrowding in the
maxillary arch. However, she was also bothered by the asymmetrical
smile line between the incisal edges of teeth 13, 12, and 11.
Furthermore, the patient requested a fixed replacement of the
missing central incisor 11.
Initially, all corrections were performed digitally by means of an
image editing software (Keynote; Apple, Cupertino, CA, USA) to
visualize the patient’s treatment outcome, the correct proportions for
the missing central 11 and the lateral 12. Thereafter, all the planned
changes were exchanged among the two treatment teams and
discussed with the patient and her family (Fig 2-2-37).

Figs 2-2-37a and 2-2-37b Diagnostic images.

Extraction
The tooth 11 was extracted and a xenogeneic bone substitute in
combination with a punch graft from the palate was used to perform a
ridge preservation procedure (Fig 2-2-38).
Figs 2-2-38a to 2-2-38c Extraction and ridge preservation.

Orthodontic treatment phase

Several treatment options were evaluated and discussed: a non-
extraction orthodontic treatment approach with prosthetic
replacement of missing tooth 11 was rejected due the subsequent
enlargement of the horizontal overlap causing a potential lower lip
interpositioning and bite deepening. This treatment option would have
only been justified in combination with an orthognathic operation to
correct the skeletal discrepancy. As a result, the patient’s soft tissue
profile would have been improved; nevertheless, this highly invasive
treatment approach was withdrawn.
The extraction of teeth 11 and 14 would have offered the
possibility of avoiding any replacement of the missing tooth by an
implant or RBFDP. Lateral tooth 12, however, had a delicate root
anatomy with the accompanying danger of root resorption later on.
Additionally, the crown of tooth 12 would have needed to be enlarged
considerably, with the risk of creating black triangles in the interdental
areas mesial and lateral to tooth 12.
It was finally decided to extract the maxillary first premolar in
order not to increase the horizontal overlap by aligning the maxillary
incisors. As the patient had completed growth, for orthodontic
anchorage purposes a palatal implant was placed in the mid-sagittal
at the anterior-posterior level of the maxillary first and second
premolars – perpendicular to the palatal surface (Fig 2-2-39).
Figs 2-2-39a to 2-2-39f Orthodontic treatment phase.

Conditioning of the pontic

Prior to the prosthetic replacement of missing tooth 11, the gingival
area in the pontic region was shaped (ie, conditioned according to the
desired emergence profile of the restoration). The conditioning was
performed in order to shape the soft tissues into an “ovate-pontic
like” shape and, hence, to allow for a natural emergence profile of the
pontics. For the conditioning, flowable composite (Tetric Flow, Ivoclar
Vivadent, Schaan, Liechtenstein) was applied in a stepwise approach
to the basal region of the provisional pontic, inducing pressure to the
soft tissues in the edentulous area and thereby shaping of this region.
This procedure was repeated twice at intervals of 8–10 days until the
desired shape of the pontic area was achieved (Fig 2-2-40).
Figs 2-2-40a to 2-2-40e Conditioning of the pontic.

Preparation and optical impression

Finally, the respective abutment tooth 21 was prepared in order to
allow for retention of the RBFDP and in order to simplify the
positioning at cementation. The minimally invasive preparation design
for anterior zirconia-based resin-bonded fixed dental prostheses
encompassed the preparation of a mesial and a distal vertical groove
(6-degree taper) and a tiny slot at the palatal/lingual cingulum region
(Universal Prep Set, Intensiv, Montagnola, Switzerland). After that,
the optical impression was carried out using an iTero intraoral
scanner (Align Technology, San Jose, CA, USA) (Fig 2-2-41).
Figs 2-2-41a to 2-2-41d Preparation and optical impression.

Fabrication of the restorations in the

laboratory
The single-retainer zirconia-ceramic RBFDP was virtually designed
with respect to the minimum requirements of the framework and
connector dimensions. This was manufactured by means of a
CAD/CAM system (Cares Visual, Straumann, Basel, Switzerland) and
milled from Lava Plus (3M, Seefeld, Germany).
The minimum dimensions for zirconia frameworks in the anterior
region were:
■ thickness of retainer 0.5 mm;
■ cross section of connector 6 mm2 (2 mm of width, 3 mm of
height);
■ shape and size of pontic according to the emergence profile of the
respective site and with an anatomical support for the veneering
ceramic.

The framework was clinically checked with respect to its fit and finally
manually veneered with Creation ZI-CT (Creation Willi Geller,
Meiningen, Austria) just like the two additional veneers for tooth 12
based on a refractory die (Fig 2-2-42).
Figs 2-2-42a to 2-2-42c Fabrication of the restoration.

Integration of the restorations

The RBFDP was adhesively cemented using a resin cement Panavia
21 (TC, Kuraray, Tokyo, Japan). For the cementation, rubber dam
was applied, and the abutment tooth was meticulously cleaned with
pumice. Then, the palatal/lingual retention area of the abutment tooth
was etched with a 37% phosphoric acid (1 min application).
Furthermore, the corresponding primer of the resin cement ED Primer
(Kuraray) was used as pretreatment as recommended by the
manufacturer.
The zirconia surface was cleaned with alcohol and a silane-
containing primer, Clearfil Porcelain Bond (Kuraray), was applied
according to the manufacturer’s recommendations. Finally, the
cement was applied to the RBFDP retainer and the restoration was
seated. A glycerin gel, Oxyguard (Kuraray), was used to cover the
margins for the setting of the resin cement. Constant finger pressure
was applied during the setting time.
Adjustments were performed where needed, after which the
ceramic surfaces were meticulously polished with the Optrafine Kit
(Ivoclar Vivadent) (Fig 2-2-43).
Figs 2-2-43a to 2-2-43g Integration of the restoration and final
outcome.
Finally, an orthodontic retainer was bonded to the palatal surfaces
of the RBFDP and the neighboring teeth. (Orthodontist: PD Dr M
Schätzle and Dr G Rutz, Dental practitioner: Prof Dr I Sailer;
Technician: MDT V Fehmer.)

References
1. Sailer I, Fehmer V. Exzellente Dentale Ästhetik. Quintessenz
Zahntech 2012;38:778–779.
2. Fehmer V. Fokus Ästhetik. Komplexe minimal-invasive
Behandlung. Zahn Zeitung Schweiz 2013;2:12–13.
CHAPTER 3
Defect-oriented restorations

Posterior regions
2.3.1 Defect-oriented partial crowns and
overlay in posterior regions
2.3.2 Defect-oriented overlays in posterior
regions
2.3.3 Defect-oriented restoration of
endodontically treated posterior tooth
2.3.4 Defect-oriented restorations (direct
computer-aided composite build-up)
Full-mouth rehabilitation
(partial crowns and overlays)

2.3.1 Defect-oriented partial crowns

and overlay in posterior regions
■ Anterior regions (360-degree veneers)
■ Posterior regions (defect-oriented partial crowns and overlays)
■ Full-mouth rehabilitation

This section covers the minimally invasive rehabilitation of a patient to

re-establish esthetic and oral function by means of minimal invasive
restoration. This involved the application of individual veneered
feldspathic veneers to the anterior regions and monolithic lithium
disilicate partial crowns to the posterior regions.

Assessment and treatment planning

A 41-year-old male with severe erosion and abrasions in his entire
dentition presented himself at the clinic seeking treatment for his
compromised esthetics. He also suffered from sensitivities when
drinking or eating hot or cold beverages. Hence, for this patient the
potential changes were quite dramatic, as they involved the raising of
the vertical dimension of occlusion (VDO), functional aspects, and a
complete change in his esthetic appearance. The importance of the
diagnostic analyses and the mock-up try-in played a fundamental role
to make sure that the treatment goal was set according to the
patient’s wishes and their functional needs.
The patient was quite young for such a comprehensive
rehabilitation. With this in mind, a minimally invasive treatment plan
was established and tested with an extensive splint phase. This
involved not only the esthetic anterior segments but also a change of
vertical dimension. It would also allow the patient to test the new
appearance not only during a mock-up try-in session but also with an
adapted Michigan splint. As the splint was fabricated like a tooth-
shaped provisional, the patient could wear this before the actual
preparation had to be created.
Another advantage of these detailed diagnostics was that the later
treatment could easily be sequenced; this would mean the
appointments for both patient and clinician could be shorter and less
stressful (Fig 2-3-1).
Fig 2-3-1a to 2-3-1c Pretreatment photographs.

Diagnostics
The patient’s chief complaint was his compromised esthetic
appearance, especially in the maxillary anterior teeth. However, he
was also aware that due to the abrasion of his teeth, he had not only
lost vertical dimension but also his teeth had become more sensitive.
He was afraid that if there was no intervention at this point in time,
things would only become worse.
In all his teeth, dentin was already exposed to a high degree,
which also explained the sensitivity he reported. Despite the long-
exposed dentin, his teeth remained vital and showed no signs of
decay (Fig 2-3-2).
Fig 2-3-2a to 2-3-2k Diagnostic images.

Wax-up and direct mock-up

In order to visualize the final treatment outcome and also its potential
limitations, a purely additive wax-up was performed on two
conventional plaster casts that were articulated by means of a
facebow.
To then transfer the wax-up into the patient’s mouth, two silicone
indexes of the wax-up were prepared in order to fabricate a direct
mock-up (Memosil 2, Kulzer, Hanau, Germany). These silicone
indexes were filled with a chemically curing composite material, in
shade Vita A2 (Protemp, 3M, Rüschlikon, Switzerland) and placed
over the maxillary and mandibular teeth.
The resulting direct mock-up served as a communication tool, to
visualize the prospective treatment outcome (Fig 2-3-3).
Fig 2-3-3a to 2-3-3k Wax-up and direct mock-up.

The patient was very happy with the mock-up try-in and
immediately felt very comfortable with the raised vertical dimension
and agreed to the proposed treatment plan (see Fig 2-3-4, showing
an adapted Michigan splint with planned VDO in the mandibular arch).
Fig 2-3-4a to 2-3-4c Mock-up try-in.

To allow the patient to adjust to his new vertical dimension and

reassure that he is compliant and comfortable with it, a Michigan
splint was fabricated in the dental laboratory. It was fabricated in a
way that the anterior segment already looked like his future teeth and
in the posterior segment the new vertical detention was incorporated.
The overall splint design was kept thin so that it was convenient for
the patient to wear during the day (Fig 2-3-5).
Fig 2-3-5a to 2-3-5l Fabrication of Michigan splint.

Provisional: Maxillary anterior teeth

To fabricate the provisional according to the same shape of the wax-
up and transfer it into the patient’s mouth, the same silicone index
from the mock-up try-in of the maxillary anterior teeth was used to
fabricate an eggshell provisional on the cast. This eggshell was
fabricated with a classic acrylic PMMA material (New Outline,
Anaxdent, Stuttgart, Germany) that was later on easy to reline and
adjust to the actual intraoral preparation (Fig 2-3-6).
Fig 2-3-6a to 2-3-6e Maxillary anterior provisional restoration.

Preparation and impression of the maxillary arch

A silicone index was fabricated based on the wax-up to facilitate the
correct preparation of the teeth. Teeth 13–23 were prepared with a
minor epigingival course to preserve the maximum of tooth substrate,
while the teeth 17–14 and 27–24 basically could be restored with no
preparation at all. The final impression was taken using two retraction
cords. In order to avoid traumatization of the gingiva and to minimize
the risk of recessions, a surgical suturing material (size 4-0, Vicryl
Ethicon, Johnson & Johnson, NJ, USA) was used as the first
retraction cord. The second retraction cord was the thinnest cord
available on the market (000 Ultrapak, UP Dental, Cologne,
Germany) (Fig 2-3-7).
Fig 2-3-7a to 2-3-7d Preparation and impression of the maxillary
anterior region.

The anterior eggshell provisional was then relined with a self-

curing resin (Tab 2000, Kerr, Brea, CA, USA) extraorally polished and
provisionally cemented (Protemp, 3M). The posterior region was
provisionally restored by a direct provisional (Fig 2-3-8).
Fig 2-3-8a to 2-3-8e Anterior eggshell provisional and posterior
direct provisional.

Fabrication of maxillary arch restorations in the

laboratory
The first step for the final restoration was the fabrication of an
alveolar cast. In order to achieve an individualized shape and shade
for the anterior restorations, refractory dies were manufactured
(anaxVest, Anaxdent) to then directly veneer them. Due to the use of
refractory dies, the best possible fit of the veneers could also be
guaranteed.
For the fabrication of the partial crowns, however, a new, slightly
softer silicone key was fabricated, based on the initial wax-up. With
this new silicone index, the wax-up was transferred to the new
master cast. As a next step, all margin lines were adjusted in wax
and then the partial crowns prepared for the lost wax technique. They
were embedded (IPS PressVEST Speed, Ivoclar Vivadent, Schaan,
Liechtenstein) and pressed (Programat EP 5010, Ivoclar Vivadent)
with a lithium disilicate press ceramic (IPS e.max press MT A2,
Ivoclar Vivadent), divested, adjusted, and finalized by the application
of stain and glaze (IPS Ivocolor, Ivoclar Vivadent) according to the
custom shade that was developed by the dental technician in
collaboration with the patient.
Meanwhile, the anterior veneers were individually layered with
ceramic masses (Creation Classic, Willi Geller, Meiningen, Austria).
After two dentin firings, the surface texture and the final shape was
done with stones and diamond burs.
The glaze firing was followed by an additional stain firing and a
mechanical polishing procedure. The polished veneers were carefully
removed from the refractory dies by airborne-particle abrasion with
glass beads and cleaned in an ultrasonic waterbed (Fig 2-3-9 and Fig
2-3-10).
Fig 2-3-9a to 2-3-9l Fabrication of refractory dies for veneers, and
lost wax technique for partial crowns.
Fig 2-3-10a to 2-3-10f Fabrication of maxillary restorations.

Integration of maxillary veneers and overlays

A try-in session was carried out where the overlays were inserted
with a try-in paste (Variolink Esthetic neutral and warm, Ivoclar
Vivadent) in order to improve color assessment and optical
integration. Subsequently, in a dry environment (rubber dam), the
ceramic veneers were cemented. The abutment teeth were etched
with 35% phosphoric acid (Ultra-Etch, Ultradent Products) and
bonded with a multistep adhesive system (Syntac Classic, Ivoclar
Vivadent). The bond was not light-cured in order not to compromise
the fit of the ultra-thin veneers. The veneers were etched with
hydrofluoric acid (9% concentration for 1 min) (Porcelain Etch,
Ultradent Products). A silane-containing primer (Monobond Plus,
Ivoclar Vivadent) and a bonding system (Heliobond, Ivoclar Vivadent)
were applied. Then the overlays were etched with hydrofluoric acid
(5% concentration for 20 s) (IPS Ceramic Etching Gel, Ivoclar
Vivadent). A silane-containing primer (Monobond S, Ivoclar Vivadent)
and a bonding system (Heliobond, Ivoclar Vivadent) were applied.
Finally, the partial crowns were cemented with a dual-curing resin
cement (Variolink Esthetic Neutral, Ivoclar Vivadent, FL, USA).
Excess cement was removed with rotating and oscillating diamond
instruments (Universal Prep Set, Intensiv, Montagnola, Switzerland)
(Fig 2-3-11).
Figs 2-3-11a to 2-3-11i Integration of maxillary veneers and
overlays.

Transfer of the maxillary arch

Once the maxillary restorations were placed, a conventional
impression was performed and sent to the dental laboratory. Due to
the initial wax-up and diagnostics, the dental technician was able to
cross-articulate the new maxillary arch against the initial wax-up and
in a second phase replace the initial wax-up model by the newly
prepared master cast for the mandibular arch.
With this cross-articulation, all initial data from the orientation of
the cast in the articulator according to the facebow to the planned
vertical dimension and the wax-up could be maintained efficiently (Fig
2-3-12).
Fig 2-3-12a to 2-3-12d Transfer of the maxillary restorations to the
new master cast.

Preparation and impression: Mandibular arch

A silicone index was fabricated, based on the wax-up, to facilitate the
correct preparation of the teeth. Teeth 31–37 and 41–47 were
prepared with no epigingival course to preserve the maximum of tooth
substrate and stay in the enamel wherever possible. Due to erosion
and abrasion, the teeth already appeared as if they were prepared
and therefore the actual preparation was quite efficient. Due to the
opening of the vertical dimension during the diagnostic phase and its
verification with the mock-up, the minimum thickness of both maxillary
and mandibular restorations was already taken into account and
therefore there was no need for a subtractive preparation. Only sharp
margins and edges were rounded, and the preparation mainly
consisted of smoothing of the surfaces.
The final impression was taken using two retraction cords. In
order to avoid traumatization of the gingiva and to minimize the risk of
recessions, a surgical suturing material (size 4-0, Vicryl Ethicon,
Johnson & Johnson) was used as the first retraction cord. The
second retraction cord was the thinnest cord available on the market
(000 Ultrapak, UP Dental) (Fig 2-3-13).
Fig 2-3-13a to 2-3-13e Preparation and impression of the
mandibular arch.

Fabrication of mandibular restorations in the

laboratory
The first step for the final restoration was the fabrication of an
alveolar cast. In order to achieve an individualized shape and shade
for the anterior restorations, refractory dies were manufactured
(anaxVest, Anaxdent) to then directly veneer them. Due to the use of
these refractory dies, the best possible fit for the veneers could also
be guaranteed. For the fabrication of the partial crowns, however, a
new, slightly softer silicone key was fabricated based on the initial
wax-up. With this new silicone index, the wax-up was transferred to
the new master cast. As a next step, all margin lines were adjusted in
wax and then the partial crowns were prepared for the lost wax
technique. They were embedded (IPS PressVEST Speed, Ivoclar
Vivadent) and pressed (Programat EP 5010, Ivoclar Vivadent) with a
lithium disilicate press ceramic (IPS e.max press MT A2, Ivoclar
Vivadent), divested, adjusted, and finalized by the application of stain
and glaze (IPS Ivocolor, Ivoclar Vivadent) according to the custom
shade that was developed by the dental technician in collaboration
with the patient.
While the anterior veneers were individually built-up with ceramic
masses (Creation Classic, Willi Geller). After two dentin firings, the
surface texture and the final shape was done with stones and
diamond burs. The glaze firing was followed by an additional stain
firing and a mechanical polishing procedure. The polished veneers
were carefully removed from the refractory dies by airborne-particle
abrasion with glass beads and cleaned in an ultrasonic waterbed (Fig
2-3-14).
Fig 2-3-14a to 2-3-14g Fabrication of mandibular restorations.

Integration of mandibular veneers and partial crowns

A try-in session was carried out where the overlays were inserted
with a try-in paste (Variolink Esthetic neutral and warm, Ivoclar
Vivadent) in order to improve color assessment and optical
integration. Subsequently, in a dry environment (rubber dam) the
ceramic veneers were cemented. The abutment teeth were etched
with 35% phosphoric acid (Ultra-Etch, Ultradent Products) and
bonded with a multistep adhesive system (Syntac Classic, Ivoclar
Vivadent). The bond was not light-cured in order not to compromise
the fit of the ultra-thin veneers. The veneers were etched with
hydrofluoric acid (9% concentration for 1 min) (Porcelain Etch,
Ultradent Products). A silane-containing primer (Monobond Plus,
Ivoclar Vivadent) and a bonding system (Heliobond, Ivoclar Vivadent)
were applied. Then the partial crowns were etched with hydrofluoric
acid (5% concentration for 20 s) (IPS Ceramic Etching Gel, Ivoclar
Vivadent). A silane-containing primer (Monobond S, Ivoclar Vivadent)
and a bonding system (Heliobond, Ivoclar Vivadent) were applied to
these, too.
Finally, the partial crowns were cemented with a dualcuring resin
cement (Variolink Esthetic Nutral, Ivoclar Vivadent). Excess cement
was removed with rotating and oscillating diamond instruments
(Universal Prep Set, Intensiv) (Fig 2-3-15).
Fig 2-3-15a to 2-3-15i Integration of mandibular veneers and partial
crowns.

Final full-mouth rehabilitation

The final outcome of this highly esthetic and minimally invasive
treatment was extremely pleasing for the entire team. The
predictability achieved through the diagnostic guidance was a
keystone to break such a comprehensive treatment down into smaller
quadrant restorations. That made the entire case easier for the team
to handle. After the last and minor occlusal adjustments, the patient
immediately received a thermoplastic splint (2 mm Erkoloc-Pro,
Erkoden, Pfalzgrafenweiler, Germany) to protect the new
restorations during the night/sleeping, with 6-month recall follow-up
appointments (Fig 2-3-16 and 2-3-17). (Dental practitioner: Prof Dr I
Sailer; Technician: DT P Müller.)
Fig 2-3-16a to 2-3-16j Final full-mouth rehabilitation.
Fig 2-3-17a to 2-3-17c Final full-mouth rehabilitation and
thermoplastic splints.
Full-mouth rehabilitation
(veneers and overlays)

2.3.2 Defect-oriented overlays in

posterior regions
■ Anterior regions (360-degree veneers)
■ Posterior regions (additional veneers)
■ Posterior regions (defect-oriented overlays)

The following series involves the minimally invasive rehabilitation of a

patient to re-establish esthetic and oral function by means of
minimally invasive restoration after suffering from a bulimic condition.

Assessment and treatment planning

A 36-year-old female with severe erosion presented herself at the
clinic after an improved bulimic condition, seeking treatment for the
worn teeth compromising her esthetics. She also suffered from
sensitivities when drinking or eating hot or cold beverages. Hence, for
this patient the potential changes were quite dramatic, as they
involved the raising of the VDO, functional aspects, and a complete
change in her esthetic appearance. The importance of the diagnostic
analyses and the mock-up try-in for a complex rehabilitation like in her
case, played a fundamental role to assure that the treatment goal
was set according to the patient’s wishes and functional needs.
The patient was quite young for such a comprehensive
rehabilitation and, with this in mind, a minimally invasive treatment
plan was established and tested with an extensive mock-up testing
phase. This try-in phase was involving not only the esthetic anterior
segments but also the raising of the VDO and allowing the patient to
test the mock-up, as it was fabricated like an additive provisional that
could be placed in the patient’s mouth before the actual preparation
had to be done.
Another advantage of these detailed diagnostics was that the
treatment later on could easily be sequenced into quadrants and,
consequently, the appointments for both patient and clinician could be
shorter and less stressful (Fig 2-3-18).
Figs 2-3-18a to 2-3-18i Pretreatment photographs and radiograph.

Diagnostics
The patient’s chief complaint was her compromised esthetic
appearance, especially in the maxillary anterior region. However, she
was also aware that due to the erosions at her teeth, she not only
lost vertical dimension but also her teeth had become more sensitive
and she was afraid that if she did not intervene at this point in time,
things would only become worse.
In nearly all her teeth, due to her condition, dentin was already
exposed, which also explained the sensitivity that she reported (Fig 2-
3-19).
Figs 2-3-19a to 2-3-19d Diagnostic images.

Wax-up and direct mock-up

In order to visualize the final treatment outcome and also its potential
shortcomings, a purely additive wax-up was performed on two
conventional plaster casts that were articulated by means of a
facebow.
To then transfer the wax-up into the patient’s mouth, two silicone
indexes of the wax-up were prepared in order to fabricate a direct
mock-up (Memosil 2, Kulzer, Hanau, Germany). The silicone indexes
were filled with a chemically curing composite material, in shade Vita
A2 (Protemp, 3M, Seefeld, Germany) and placed over the maxillary
and mandibular teeth of the patient.
The resulting indirect mock-up served as a communication tool, to
visualize the prospective treatment outcome. Additionally, this type of
indirect mock-up also has the advantage that patients can easily take
them home and allow them to check their new teeth in their private
environment.
The patient was very happy with the mock-up try-inand
immediately felt very comformable with the raised vertical dimension
and agreed to the proposed treatment plan (Fig 2-3-20 and Fig 2-3-
21).
Figs 2-3-20a to 2-3-20h Additive wax-up on plaster casts for
creation of mock-up.
Figs 2-3-21a to 2-3-21c Mock-up try-in.

Provisional: Maxillary anterior teeth

To fabricate the provisional according to the same shape of the wax-
up and transfer it into the patient’s mouth, the same silicone index
from the mock-up try-in of the maxillary anterior teeth was used to
fabricate an eggshell provisional on the cast. This eggshell was
fabricated with a classic acrylic PMMA material (New Outline,
Anaxdent, Stuttgart, Germany) that was later on easy to reline and
adjust to the actual intraoral preparation (Fig 2-3-22).
Figs 2-3-22a and 2-3-22b Maxillary anterior eggshell provisional
restoration.

Partial crown preparation and impression: Mandibular

arch
A silicone index was fabricated based on the wax-up to facilitate the
least invasive preparation of the teeth. The teeth 34–37 and 44–47
were prepared with a defect-oriented try-in to preserve the maximum
of tooth substrate and stay in the enamel wherever possible. Due to
the erosion, the teeth already appeared as if they were prepared and
after the removal of the old and partially insufficient composite
restorations, the actual preparation was quite efficient. As with the
opening of the vertical dimension during the diagnostic phase and its
verification with the mock-up, the minimum thickness of the
mandibular restorations was already achieved and therefore there
was no need for any subtractive preparation.
The final impression was taken without retraction cords in order to
avoid traumatization of the gingiva and to minimize the risk of
recessions.
Thereafter a direct provisional was fabricated and temporarily
cemented.

Preparation of the 360-degree maxillary anterior

veneers
A silicone index was fabricated based on the wax-up to facilitate the
correct preparation of the teeth. The teeth 13–23 were prepared with
a minor epigingival course to preserve the maximum of tooth
substrate but as the change of the morphology was so extensive, and
also the exposed dentin on the palatal side had to be covered, it was
decided to open up the approximate contact points and with this allow
for more flexibility to fabricate first of all the exact same shape as
developed during the diagnostic phase but also cover and protect the
palatal Part of the teeth. The final impression was taken using two
retraction cords. In order to avoid traumatization of the gingiva and to
minimize the risk of recessions, a surgical suturing material (size 4-0,
Vicryl Ethicon, Johnson & Johnson, NJ, USA) was used as the first
retraction cord. The second retraction cord was the thinnest cord
available on the market (000 Ultrapak, UP Dental, Cologne,
Germany).
The eggshell provisional was then relined with a self-curing resin
(Tab 2000, Kerr, Brea, CA, USA), extraorally polished, and
provisionally cemented (Protemp, 3M) (Fig 2-3-23).
Figs 2-3-23a to 2-3-23d Preparation of maxillary anterior veneers
and cementation of eggshell provisional.

Fabrication of the veneers and partial crowns

in the laboratory
The first step for the final restoration was the fabrication of an
alveolar cast. To achieve an individualized shape and shade to the
restorations, refractory dies were manufactured (anaxVest,
Anaxdent) to then veneer them directly. Due to the use of refractory
dies, the best possible fit of the overlays could also be guaranteed.
For the fabrication of the overlays, a backward planning concept was
applied. The laboratory work was guided by the information from the
wax-up which was transferred with the aid of silicone indexes (Matrix
Form 60, Anaxdent).
The ceramic masses were then applied (Creation Classic, Willi
Geller, Meiningen, Austria) according to the custom shade that was
developed by the dental technician in collaboration with the patient.
After two dentin firings, the surface texture and the final shape was
done using stones and diamond burs. The glaze firing was followed
by an additional stain firing and a mechanical polishing procedure.
The polished veneers were carefully removed from the refractory dies
by airborne-particle abrasion with glass beads and cleaned in an
ultrasonic waterbed (Fig 2-3-24).
Figs 2-3-24a to 2-3-24k Fabrication of the veneers and partial
crowns.

Integration of the partial crowns

A try-in session was carried out where the overlays were inserted
with a try-in paste (Variolink Esthetic neutral and warm, Ivoclar
Vivadent) in order to improve color assessment and optical
integration. Subsequently, in a dry environment (rubber dam) the
ceramic overlays were cemented. The abutment teeth were etched
with 35% phosphoric acid (Ultra-Etch, Ultradent Products) and
bonded with a multistep adhesive system (Syntac Classic, Ivoclar
Vivadent). The bond was not light-cured in order not to compromise
the fit of the ultra-thin veneers. The veneers were etched with
hydrofluoric acid (9% concentration for 1 min) (Porcelain Etch,
Ultradent Products). A silane-containing primer (Monobond Plus,
Ivoclar Vivadent) and a bonding system (Heliobond, Ivoclar Vivadent)
was applied. Then the overlays were cemented with a dualcuring
resin cement (Variolink Esthetic Neutral, Ivoclar Vivadent). Excess
cement was removed with rotating and oscillating diamond
instruments (Universal Prep Set, Intensiv, Montagnola, Switzerland)
(Fig 2-3-25).
Figs 2-3-25a to 2-3-25f Integration of the partial crowns.

Integration of the veneers

Subsequently, in a dry environment (rubber dam) the ceramic veneers
were cemented. This followed the same concept as for the
mandibular arch, as also the same reconstructive materials were
used. For a better positioning of the posterior veneers, the dental
technician added small hooks that served as a vertical stop and made
the final cementation of those additional veneers very easy and less
stressful. Once cemented and finally light-cured, those hooks were
simply polished off. At the same time the occlusal and functional
contacts were analyzed and no adjustments were necessary (Fig 2-
3-26).
Figs 2-3-26a to 2-3-26 Integration of the veneers.

Final rehabilitation
The final outcome of this esthetic and minimally invasive treatment
was extremely pleasing for the entire team. The predictability
achieved through the diagnostic guidance was a keystone to break
such a comprehensive treatment down into smaller quadrant
restorations. That made the entire case easier for the team to
handle. Due to the patient still experiencing a lot of sensitivity at the
beginning of the treatment phase, the initial diagnostic phase was
even more important to engage the patient and enable her to visualize
the new teeth and her smile. This was something to look forward to
after this long period of instability. After the last and minor occlusal
adjustments, the patient immediately received a Michigan splint to
protect the new restorations at night/sleeping with 6-month recall
follow-up appointments (Fig 2-3-27). (Dental practitioner: Prof Dr I
Sailer; Technician: DT W Gebhard.)
Figs 2-3-27a to 2-3-27g Final outcome.
Endodontically treated posterior
tooth
(all-ceramic CAD/CAM endo crown)

2.3.3 Defect-oriented restoration of

endodontically treated posterior
tooth
■ Endo crown tooth 26 (posterior regions)
■ Chairside dentistry

The following series describes the defect-oriented restoration of an

endodontically treated first molar by means of an all-ceramic
computer-aided design/computer-aided manufacturing (CAD/CAM)
endo crown.

Assessment and treatment planning

A 37-year-old female patient was referred by a private practitioner
for an endodontic treatment of her first molar (26) and a restoration
of the respective tooth. After the finalization of the root canal
treatment, the patient was restored chairside with an all-ceramic
defect-oriented restoration.
For the restorative material, a zirconia-reinforced lithium disilicate
(Celtra Duo, Dentsply Sirona, Bensheim, Germany) was used and
milled in the sintered stage.
No restorative limitation was posed by the antagonist in terms of
available space as the initial partial crown that the patient had was
already prepared quite excessively.
To achieve an efficient treatment and not to cause any additional
costs by the dental laboratory, it was also planned to perform an
optical impression and finalize the restoration by means of a chairside
CAD/CAM workflow (Cerec, Dentsply Sirona) (Fig 2-3-28).

Fig 2-3-28 Optical impression using CAD/CAM workflow.

Endo crown preparation and optical
impression
The initial preparation was slightly redefined, with the goal of
preserving the maximum of tooth substrate that was still remaining. It
consisted mainly of a smoothening of the edges to allow for a better
reproducibility of the chairside three-axis milling unit (MCXL, Dentsply
Sirona). Then a powder-free optical quadrant impression (Omicam,
Dentsply Sirona) was acquired.
Directly after the data acquisition the files were processed and
the margin line, as well as the insertion pass were semi-automatically
detected (Fig 2-3-29).

Fig 2-3-29 Location of margin line after data acquisition.

Design and fabrication of the all-ceramic

endo crown
Once the digital model was prepared, the chairside software (Cerec
4.2, Dentsply Sirona) created an individualized design proposition
following the biogeneric functionality. This first design proposition had
to be adjusted only in details and was finalized by a smoothening
process (Fig 2-3-30).
Figs 2-3-30a to 2-3-30c Design of endo crown.

The generated endo crown file was then nested directly in the
design software and milled in a chairside milling unit (MCXL, Dentsply
Sirona, Bensheim, Germany) using a zirconia-reinforced lithium
disilicate block (Celtra Duo A2, Dentsply Sirona).
The milled restoration was adjusted and superficially
characterized by the application of stains (VITA AKZENT Plus, Vita
Zahnfabrik, Bad Säckingen, Germany) according to the custom shade
developed with the patient.
Directly and before any fixation firing of the stains, a fluorescent
glaze spray was applied (VITA AKZENT Plus, Vita Zahnfabrik) and
the endo crown was finalized in an extremely efficient combined stain
and glaze firing (Vita Smart Fire, Vita Zahnfabrik).
Once the endo crown was finalized, it was etched for 20 s with
hydrofluoric acid (5% concentration) (IPS Ceramic Etching Gel,
Ivoclar Vivadent, Schaan, Liechtenstein) and rinsed with water (Fig 2-
3-31).
Figs 2-3-31a to 2-3-31f Fabrication of the all-ceramic endo crown.

Integration of the restoration

A try-in session was carried out where the endo crown was inserted
with a try-in paste (Variolink Esthetic neutral and warm, Ivoclar
Vivadent, Schaan, Liechtenstein) in order to improve color
assessment and optical integration. In a dry environment (rubber
dam) the endo crown was then cemented after the abutment tooth
was etched with 35% phosphoric acid (Ultra-Etch, Ultradent
Products, South Jordan, UT, USA) and bonded according to the
manufacturer guidelines of the used resin cement. The crown was
cemented with a dual-curing resin cement (Variolink Esthetic Warm,
Ivoclar Vivadent, FL, USA). Excess cement was removed with
rotating and oscillating diamond instruments (Universal Prep Set,
Intensiv, Montagnola, Switzerland) The occlusal and functional
contacts were analyzed, no adjustments were necessary (Fig 2-3-
32). (Dental practitioner: PD Dr A Bindel.)
Figs 2-3-32a and 2-3-32b Integration of the restoration and
radiograph.
Pronounced erosion and
abrasion
(direct CAD/CAM-guided composite build-up)

2.3.4 Defect-oriented restorations

(direct computer-aided
composite build-up)
■ Posterior regions, re-establishing the lost vertical dimension
■ Innovative direct build-up technique
■ Digital jaw motion analysis

This series shows the minimally invasive rehabilitation of a patient

with pronounced erosion and abrasion, using a CAD-fabricated key
for direct and highly accurate composite build-up.

Assessment and treatment planning

A 33-year-old female dental practitioner with pronounced erosion and
abrasions in her entire dentition presented herself at the clinic seeking
treatment for her compromised esthetics. She also suffered from
sensitivity when eating or drinking hot or cold beverages. Her main
wish was to protect her teeth and prevent them from further abrasion.
Hence, for this patient the potential changes were quite substantial,
as they involved the raising of the VDO and functional aspects. The
importance of the diagnostic analyses and the predictability of a
complex rehabilitation like in her case played a fundamental role to
make sure that the treatment goal was set according to the patient’s
wishes and the functional needs.
As the patient was still quite young for such a comprehensive
rehabilitation and the implications of financial limitations, a direct
minimally invasive treatment plan was established and tested with an
extensive mock-up testing phase. This involved not only the esthetic
anterior segments but also the raising of the VDO, allowing the
patient to test the mock-up as it was fabricated like an additive
provisional that could be placed in the patient’s mouth before the
actual treatment was started.
Another advantage of these detailed diagnostics was that the
treatment later on could easily be sequenced into quadrants and by
this the appointments for both patient and clinician became shorter
and less stressful (Fig 2-3-33).
Figs 2-3-33a to 2-3-33g Pretreatment photographs.

Optical impression and digital jaw motion

analysis
Without any preparation, and just by smoothing the sharp edges, a
powder-free optical full-arch impression (Trios 3, 3Shape,
Copenhagen, Denmark) was acquired. Additionally, a digital facebow
and jaw movement analyzer (Tizian JMA Optic by Zebriz, Schütz
Dental, Rosbach, Germany) was placed on the patient’s head and a
digital bite fork was adjusted to the mandibular arch.
With this additional device, the models could be oriented in the
virtual articulator according to the actual three-dimensional aspects,
and not only based on mean values. Once the orientation was
recorded, the patient was guided through several movements, like
maximal opening, laterotrusion, and protrusion. As the patient
executed all the movements, they were traced optically and digitally,
and then stored alongside the orientation coordinates.
Finally, the optical impressions, the three-dimensional orientation
of the models, and the real movement data were sent digitally to the
dental laboratory (Fig 2-3-34).
Figs 2-3-34a to 2-3-34e Optical impression and digital jaw motion
analysis.

Digital design and preparation for the Geneva

key
The idea now was to utilize all the acquired data and to first import
them into a CAD software (Tizian Exocad, Schütz Dental) that is
capable of working with all the different output files. To date, this
special version of Exocad is the only one to completely incorporate all
the data.
Once the import was finalized, the indication of overlays was
selected for all posterior teeth except the second molars (27 and 37),
and the minimum material thickness was reduced to 0.1 mm. With
this, the preparation lines could be defined and the VDO increased
virtually by 3 mm on the incisal pin, to gain enough space to restore
the patient with her initial VDO.
The new design was then calculated including functional aspects
and adjusted to the patient’s jaw movement data. As the minimum
thickness was set only to 0.1 mm, there was also a change in design
once the data for the finalized occlusal overlays were exported.
Subsequently, the new VDO was set and the design of the
overlays was finalized for both the maxillary and mandibular arches
(Fig 2-3-35).
Figs 2-3-35a to 2-3-35k Digital design to increase the VDO.

To transfer these now accurate and predictable planned designs

into the patient’s mouth, a transparent key (the Geneva key) was
designed and printed (CARES P Series, Straumann, Basel,
Switzerland) (Figs 2-3-36 and 2-3-37).
Figs 2-3-36a to 2-3-36d Design of the Geneva key.

Figs 2-3-37 The Geneva key.

Innovation – the Geneva key
The idea for the invention adopts the concept that a newly designed
tooth surface should be transferred directly to the teeth. What is
innovative is that the key is printed and created out from a digital
process. Digital processes are more accurate and easier to verify for
accuracy.
The result is a design which allows for an accurate and clear
working in the mouth:
■ Light bar design: for an advanced handling and superior overview
in the mouth, the rectangular support bar is connected to the
shells/stamps for each tooth. The light design permits a secure
placement and easy removal of the plastic light-curing composite.
■ Restoration-oriented design: The key is only covering the tooth in
the area where material will be added onto the tooth. The area of
restoration is covered with stamps that do not touch the tooth and
give clearance for the composite.
■ Stabilization in three dimensions: To assure a precise vertical,
sagittal, and transversal positioning, the stops in the posterior and
anterior end of the key overlap the occlusal tooth surface in all
three dimensions.
■ Material: The key is printed. A stiff transparent resin does not
allow any bending or deformation while placing and the technology
of printing gives highly precise results.

Direct CAD/CAM-guided composite build-up

Subsequently, quadrant by quadrant in a dry environment (rubber
dam), the direct composite restorations were pressed onto the pre-
treated teeth. The abutment teeth were etched with 35% phosphoric
acid (Ultra-Etch, Ultradent Products, South Jordan, UT, USA) and
bonded with a multistep adhesive system (Syntac Classic, Ivoclar
Vivadent, Schaan, Liechtenstein). For the direct build-ups, a highly
filled and preheated composite was applied (Tetric Classic, Vivadent,
Schaan, Liechtenstein). Then the composite excess was carefully
removed with a spatula and the build-ups light-cured with the
transparent Geneva key (Fig 2-3-38).
Figs 2-3-38a to 2-3-38l Direct CAD/CAM-guided composite build-up.
Final rehabilitation
The final outcome of this minimally invasive treatment was pleasing
for the entire team. The predictability achieved through the Geneva
key was a keystone to accomplish this extremely cost-efficient and
highly accurate treatment outcome.
Basically no occlusal adjustments were necessary and the patient
immediately received a Michigan splint to protect the new
restorations at night/while sleeping and has since been in 6-month
recall follow-up (Figs 2-3-39 and 2-3-40). (Dental practitioner: Dr F
Burkhardt, Prof Dr H Lee; concept: Dr F Burkhardt, Prof Dr H Lee,
Prof Dr I Sailer; Patent No.: 18208342.8-1126.)
Fig 2-3-39a to 2-3-39f Volumetric comparison of the planned
treatment outcome to the actual result (before and after final
polishing).
Figs 2-3-40a to 2-3-40c Final outcome.
CHAPTER 4
Conventional single crowns
(SCs)

Anterior regions
2.4.1 Anterior SC with non-discolored
abutment tooth
2.4.2 Anterior SCs with discolored abutment
teeth

Posterior regions
2.4.3 Posterior SC with non-discolored
abutment tooth
2.4.4 Posterior SC with a discolored
abutment tooth

Complex situations
2.4.5 Conventional SCs and fixed dental
prostheses (FDPs)
2.4.6 SCs in combination with an implant

All-ceramic crown
(non-discolored abutment tooth)

2.4.1 Anterior SC with non-discolored

abutment tooth
■ Anterior regions, crown with non-discolored abutment tooth

This first section describes the replacement of an esthetically

displeasing existing porcelain-fused-to-metal (PFM) crown with an all-
ceramic crown.

Assessment and treatment planning

A 37-year-old healthy and caries-free female presented herself at the
clinic, seeking treatment for her esthetically unpleasing central incisor
PFM crown at position 11. Furthermore, she disliked the pronounced
buccally oriented shape of the old crown.
As a consequence of an accident several years ago, she received
the conventional PFM crown based on a conventional and quite
invasive 360-degree preparation of her abutment tooth 11.
In agreement with the patient, a step-by-step treatment plan was
established. The first step consisted of a revaluation after the
removal of the old crown to have a better understanding for the
quality and shade of the abutment tooth. Depending on the shade of
the abutment tooth and the available space, an all-ceramic restoration
was planned based on a buccally veneered reinforced glass-ceramic
crown. In case of any discoloration, bleaching in combination with a
zirconia-based crown was considered (Fig 2-4-1).
Fig 2-4-1a to 2-4-1c Pretreatment photographs.

Redefining the crown preparation and

impression
A silicone index was fabricated based on a wax-up to facilitate the
correct repreparation of the tooth.
According to the patient’s wishes, the tooth shape was now
planned to be oriented slightly more palatally. The old crown was
removed and the non-discolored tooth was re-prepared, which
consisted mainly of a minimal rounding of the incisal border and a
smoothening of the finish line (Universal Prep Set, Intensiv,
Montagnola, Switzerland).
The final impression was taken using two retraction cords. In
order to avoid traumatization of the gingiva and to minimize the risk of
recessions, a surgical suturing material (size 4-0, Vicryl Ethicon,
Johnson & Johnson, NJ, USA) was used as the first retraction cord.
The second retraction cord was the thinnest cord available on the
market (000 Ultrapak, UP Dental, Cologne, Germany) (Fig 2-4-2).
Fig 2-4-2a and 2-4-2b Preparation and impression.
Provisional
To transfer the wax-up into the patient’s mouth, a second silicone
index of the wax-up was prepared in order to fabricate an eggshell
provisional on the cast. This eggshell was fabricated with a classic
acrylic PMMA material (New Outline, Anaxdent, Stuttgart, Germany)
that was later on easy to reline and adjust to the actual intraoral
preparation. The provisional was then relined with a self-curing resin
(Tab 2000, Kerr, Brea, CA, USA) extraorally polished and
provisionally cemented (Protemp, 3M, Seefeld, Germany). The
resulting provisional integrated very nicely and already showed the
patient the new, more palatally oriented shape of the crown.

Fabrication of the crown

The first step toward the final restoration was the fabrication of a
master cast. For the fabrication of the crown, a backward planning
concept was applied and with the silicone index fabricated based on
the wax-up, the dentin core coping was modeled and prepared for
the lost wax technique. The coping was then embedded in a special
investment material for press ceramics (IPS PressVest Premium,
Ivoclar Vivadent, Schaan, Liechtenstein) and pressed with a
feldspathic glass-ceramic (Creation Press A2, Willi Geller, Meiningen,
Austria). Once again, the laboratory work was guided by the
information from the wax-up, which was transferred by the aid of
silicone indexes (Matrix Form 60, Anaxdent). The ceramic masses
were then applied (Creation Classic, Willi Geller) according to the
custom shade that was developed by the dental technician in
collaboration with the patient. After one dentin firing, the surface
texture and the final shape was done with stones and diamond burs.
The glaze firing was followed by an additional stain firing and a
mechanical polishing procedure (Fig 2-4-3).
Fig 2-4-3a to 2-4-3f Crown fabrication.

Integration of the crown

A try-in session was carried out where the crown was inserted with a
try-in paste (Variolink Esthetic neutral and warm, Ivoclar Vivadent) in
order to improve color assessment and optical integration. In a dry
environment (rubber dam) the all-ceramic crown was cemented. The
abutment tooth was pretreated and bonded with a multistep adhesive
system (Syntac Classic, Ivoclar Vivadent). The bond was not light-
cured in order not to compromise the fit of the ultra-thin veneers. The
crown was etched with hydrofluoric acid (9% concentration for 1 min)
(Porcelain Etch, Ultradent Products, South Jordan, UT, USA). A
silane-containing primer (Monobond Plus, Ivoclar Vivadent) and a
bonding system (Heliobond, Ivoclar Vivadent) was applied. Then the
crown was cemented with a dual-curing resin cement (Variolink
Esthetic neutral, Ivoclar Vivadent). Excess cement was removed with
rotating and oscillating diamond instruments (Universal Prep Set,
Intensiv). The occlusal and functional contacts were analyzed, and
only very minor adjustments were necessary. The patient and the
entire treatment team were very satisfied with the final treatment
outcome (Fig 2-4-4 and 2-4-5).
Fig 2-4-4a to 2-4-4r Integration of the crown.
Fig 2-4-5a to 2-4-5g Final outcome.
(Dental Practitioner: Prof Dr I Sailer; Technician: DT B Thiévent.)

Comparing zirconia and metal-

based restorations
(discolored abutment teeth)

2.4.2 Anterior SCs with discolored

abutment teeth
■ Anterior regions, crowns with discolored abutment teeth
■ Comparing zirconia and metal-based restorations

The following section describes the replacement of two esthetically

displeasing existing porcelain fused-to-metal (PFM) crowns with an
all-ceramic crown.

Assessment and treatment planning

A 46-year-old healthy female presented herself at the clinic seeking
treatment for her esthetically unpleasing central incisors with PFM
crowns at position 11 and 21. Furthermore, she disliked the grayish
discoloration apical of the crown 21 caused by the discolored root of
the non-vital tooth and the crowns that showed no ceramic shoulders.
She received the conventional PFM crowns based on a quite
invasive 360 degrees preparation of her abutment teeth several years
ago and was never really happy with the appearance of her smile.
In agreement with the patient, a step-by-step treatment plan was
established. The first step consisted of a revaluation of the abutment
teeth after the removal of the old crowns to gain a better
understanding of their quality and shade. Finally, and depending on
the degree of discoloration of the abutment teeth, either an all-
ceramic zirconia or metal-based restoration with an enlarged ceramic
shoulder was planned.
In the process of restoring the patient, both zirconia and metal-
ceramic restorations were fabricated and the patient could choose
which version she preferred (Fig 2-4-6).
Figs 2-4-6a to 2-4-6c Pretreatment photographs.

Diagnostics
The patient’s chief complaint was her compromised esthetic
appearance. In addition to this, she was also aware of the grayish
discoloration of her mucosa caused by the dark root of tooth 21.
She also mentioned that she disliked the monochromatic
appearance of her crowns and understood that especially in
cooperation to her existing natural teeth the crowns were too opaque.
So, her wish was not only to achieve a better shape of the
restorations and hide the cervical exposure of the gold margins but
also to have two natural looking esthetic crowns (Fig 2-4-7).
Fig 2-4-7a to 2-4-7d Diagnostic images.

Redefining the crown preparation,

impression, and provisionalization
A silicone index was fabricated based on a first wax-up to facilitate
the correct repreparation of the teeth. The old crowns were removed
and both the non-discolored as well as the discolored teeth were re-
prepared, which consisted mainly in a minimal rounding of the incisal
border and a smoothening of the finish line (Universal Prep Set,
Intensiv, Montagnola, Switzerland).
The final impression was taken using two retraction cords. In
order to avoid traumatization of the gingiva and to minimize the risk of
recessions, a surgical suturing material (size 4-0, Vicryl Ethicon,
Johnson & Johnson, New Brunswick, NJ, USA) was used as the first
retraction cord. The second retraction cord was the thinnest cord
available on the market (000 Ultrapak, UP Dental, Cologne,
Germany) (Fig 2-4-8).
Fig 2-4-8a to 2-4-9d Crown preparation and provisional restoration.

To then fabricate the provisionals, the dental laboratory already

prepared an eggshell provisional on the first cast. This eggshell was
fabricated with a classic acrylic PMMA material (New Outline,
Anaxdent, Stuttgart, Germany) that was later on easy to reline and
adjust to the actual intraoral preparation. The provisional was then
relined with a self-curing resin (Tab 2000, Kerr, Brea, CA, USA)
extraorally polished and provisionally cemented (Protemp, 3M,
Seefeld, Germany) (Fig 2-4-9).
Wax-up try-in
As the patient was not really satisfied or convinced during this phase
with her eggshell provisional, it was decided to verify the exact crown
shapes with an additional wax-up try-in.
So, after the master cast was produced in the laboratory, a wax-
up was fabricated using esthetic wax in order to verify the exact
shape of the final restoration before the actual restoration and its
framework was created.
The patient was now happy with the achieved shape and contour
of her crowns; however, the grayish discoloration was still visible (Fig
2-4-10).
Fig 2-4-10a to 2-4-10d Wax-up try-in.

Fabrication of the restorations

As the custom shade was developed by the dental technician during
the wax-up try-in, it was discussed that in this particular case, also
due to the different degrees of discoloration of the abutment teeth, a
classic opaque zirconia should serve as the restorative material of
choice.
In the laboratory the casts were scanned using a lab scanner
(inEos X5, Dentsply Sirona, Bensheim, Germany). Based on the
scans, the frameworks were digitally designed (Cerec inLab 16.1,
Dentsply Sirona). The generated crown files were then milled in a
five-axis milling unit (Zenotec Select Hybrid, Ivoclar Vivadent, Schaan,
Liechtenstein) using a classic 98-mm zirconia disk in a dry milling
environment (Lava Plus, 3M).
The milled restorations were adjusted in the white stage and
sintered to their final density and prepared for a framework try-in (Fig
2-4-11).
Fig 2-4-11a and 2-4-11b Fabrication of the restorations.

Framework try-in
During the framework try-in it became immediately evident that
despite the selection of the classic opaque zirconia used for the
frameworks, it was not possible to mask the strongly discolored
abutment tooth 21. Therefore, and especially due to the very
challenging patient, it was decided to take a step back and fabricate
conventional PFM frameworks with XL ceramic shoulders as they
would mask the discoloration without any question (Fig 2-4-12).
Fig 2-4-12a to 2-4-12c Framework try-in.

Finalization of the restorations

Thereafter both crown pairs were veneered according to the
individually developed custom shade. The PFM crowns were
veneered with a classic feldspathic veneering ceramic (Creation
Classic CC, Willi Geller, Meiningen, Austria) and the zirconia
frameworks with a conventional glass-ceramic (Creation ZI, Willi
Geller).
After two dentin firings, the surface texture and the final shape
were developed with stones and diamond burs before both pairs
were superficially characterized applying stains and glaze (Fig 2-4-
13).
Fig 2-4-13a to 2-4-13e Finalization of the restorations.

Integration of the restorations

A try-in session was carried out in which the two crown pairs were
inserted with a try-in paste (Variolink Esthetic neutral, Ivoclar
Vivadent) in order to assess the final outcomes and allow the patient
to choose between them.
Interestingly enough, once the crowns were placed in the oral
cavity for the patient as well as the restorative team it was absolutely
evident that the PFM restorations integrated much better and
appeared more natural. Additionally, the PFM crowns with their XL
ceramic shoulder also managed to reduce the grayish marginal
discoloration substantially. As the choice was made for the PFM
crowns, they were then conventionally cemented applying a glass-
ionomer luting cement (Ketac Cem, 3M). Excess cement was
removed with rotating and oscillating diamond instruments (Universal
Prep Set, Intensiv). The occlusal and functional contacts were
analyzed, and only very minor adjustments were necessary. The
patient and the entire treatment team were very satisfied (and
relieved) with the final treatment outcome (Fig 2-4-14).
Fig 2-4-14a to 2-4-14d Final outcome

(Dental practitioner: Prof Dr I Sailer; Technician: DT W Gebhard.)

Lithium disilicate crown in full

digital workflow
(non-discolored abutment tooth)

2.4.3 Posterior SC with non-

discolored abutment tooth
■ Posterior crown with non-discolored abutment tooth
■ Chairside dentistry

The following section describes the monolithic restoration of a first

molar by means of a full digital workflow and the fabrication of a
chairside lithium disilicate crown.

Assessment and treatment planning

A 39-year-old male presented himself at the clinic seeking treatment
for his several years ago endodontically treated maxillary first molar.
He observed a strange feeling during the preceding few weeks as if
the old composite had become loose and applying his dental floss in
the distal area always led to a torn floss.
After the re-evaluation of the root canal treatment the patient was
planned to be restored chairside with an all-ceramic crown to provide
fracture prophylaxis.
As restorative material, a lithium disilicate (IPS e.max, Ivoclar
Vivadent, Schaan, Liechtenstein) was used and milled in the pre-
sintered blue stage.
However, today this full crown preparation would be considered
too invasive and to protect the devitalized tooth from fracturing only
an overlay preparation would have been envisaged. To achieve an
efficient treatment and not to cause any additional costs by the dental
laboratory it was also planned to perform an optical impression and
finalize the restoration by means of a cast free chairside computer-
aided design/computer-aided manufacturing (CAD/CAM) workflow
(Cerec, Dentsply Sirona, Bensheim, Germany) (Fig 2-4-15).
Fig 2-4-15a to 2-4-15c Pretreatment photographs.

Crown preparation and optical impression

The initial partial crown preparation was extended to a minimally
invasive crown design, with the aim to cover the crown completely to
facilitate a fracture prophylaxis. Today, however, the extension of the
preparation would be considered too invasive and in order to
preserve the maximum of tooth substrate only an overlay would have
been considered as treatment of choice. Additionally, as a very
important step to achieve a good fit in the chairside workflow, the
incisal boarders were smoothened off to allow for a good
reproducibility of the chairside three-axis milling unit (MCXL, Dentsply
Sirona).
Then a powder-free optical quadrant impression (Omicam,
Dentsply Sirona) was acquired.
Directly after the data acquisition, the files were processed and
the marginal line, as well as the insertion pass were semi-
automatically detected (Fig 2-4-16).
Fig 2-4-16a to 2-4-16c Crown preparation and optical impression.

Design and fabrication of the all-ceramic

crown
Once the digital model was prepared, the chairside software (Cerec
4.2, Dentsply Sirona) created an individualized design proposition
following the biogeneric functionality. This first design proposition had
to be adjusted only in details and was finalized by a smoothening
process.
The generated crown file was then nested directly in the design
software and milled in a chairside milling unit (MCXL, Dentsply
Sirona) using a lithium disilicate block (IPS e.max MT A2, Ivoclar
Vivadent).
The milled restoration was adjusted in the blue stage, crystallized,
and superficially characterized applying stains and glaze (Ivocolor,
Ivoclar Vivadent) according to the custom shade developed with the
patient.
Once the crown was finalized, it was etched for 20 s with
hydrofluoric acid (5% concentration) (IPS Ceramic Etching Gel,
Ivoclar Vivadent) and rinsed with water (Fig 2-4-17).
Fig 2-4-17a to 2-4-17c Design and fabrication of the all-ceramic
crown.

Integration of the all-ceramic crown

A try-in session was carried out where the crown was inserted with a
try-in paste (Variolink Esthetic neutral and warm, Ivoclar Vivadent) in
order to improve color assessment and optical integration. In a dry
environment (rubber dam) the crown was then cemented after the
abutment tooth was etched with 35% phosphoric acid (Ultra-Etch,
Ultradent Products, South Jordan, UT, USA) and bonded according to
the manufacturer guidelines of the used resin cement. The crown was
cemented with a dual-curing resin cement (Variolink Esthetic Warm,
Ivoclar Vivadent). Excess cement was removed with rotating and
oscillating diamond instruments (Universal Prep Set, Intensiv,
Montagnola, Switzerland). The occlusal and functional contacts were
analyzed, and no adjustments were necessary (Figs 2-4-18 and 2-4-
19). (Dental practitioner: PD Dr S Mühlemann.)
Fig 2-4-18a to 2-4-18c Integration of the all-ceramic crown.
Fig 2-4-19a to 2-4-19c Final outcome.
Monolithic high translucent
zirconia crown
(discolored abutment tooth)

2.4.4 Posterior SC with a discolored

abutment tooth
■ Posterior regions, crown with discolored abutment tooth

The following section describes the monolithic restoration of a

premolar by means of a fluorescent multilayer, preinfiltrated high
translucent zirconia material.

Assessment and treatment planning

A 52-year-old female presented herself at the student clinic seeking
treatment as the buccal wall of her premolar had fractured most likely
duo to a large amalgam filling on tooth 25. The oral hygiene of the
patient unfortunately remained and despite all motivational efforts
very poor throughout the entire treatment phase. As a first step, it
was planned to re-evaluate the endodontic treatment of the tooth and
in a second step, replace all remaining amalgam fillings with direct
composite restorations.
As a last treatment step, it was planned to restore the second
premolar by means of an indirect restoration.
This indirect restoration was planned to be reshaped with a
composite build-up and prepared by means of a conventional crown
shape design to strengthen the remaining tooth substrate and prevent
the risk of a future root fracture.
As the remaining Part of the root was slightly discolored, it was
planned to apply a translucent zirconia as reconstructive material
rather than the more translucent lithium disilicate.
To still achieve a natural esthetic appearance and, at the same
time, to be able to deliver a financially favorable solution to the
patient, a multicolor translucent, fluorescent zirconia (Lava Esthetic,
3M, Seefeld, Germany) was chosen and planned to be used
monolithically without the application of veneering ceramic (Fig 2-4-
20).
Fig 2-4-20a to 2-4-20c Pretreatment photographs.

Endodontic re-evaluation and build-up

The old endodontic treatment was still sufficient and a composite
build-up was made with a light-curing composite (Tetric Evo Ceram,
Ivoclar Vivadent, Schaan, Liechtenstein).
Redefining the crown preparation and
impression
A silicone index was fabricated based on a wax-up fabricated by the
dental technician to facilitate the correct repreparation of the tooth.
The tooth was re-prepared, which consisted mainly in a minimal
rounding of the incisal Part and a smoothening of the finish line
(Universal Prep Set, Intensiv, Montagnola, Switzerland).
The final impression was taken using two retraction cords. In
order to avoid traumatization of the gingiva and to minimize the risk of
recessions, a surgical suturing material (size 4-0, Vicryl Ethicon,
Johnson & Johnson, New Brunswick, NJ, USA) was used as the first
retraction cord. The second retraction cord was the thinnest one
available on the market (000 Ultrapak, UP Dental, Cologne,
Germany) (Fig 2-4-21).
Fig 2-4-21a to 2-4-21c Crown preparation.

Fabrication of the restoration

Once the conventional impressions were translated into master casts,
the models were scanned using a lab scanner (inEos X5, Dentsply
Sirona, Bensheim, Germany).
Based on the scans the monolithic full contour crown was digitally
designed (Cerec in-lab 16.1, Dentsply Sirona). The generated crown
file was then milled in a five-axis milling unit (Zenotec Select Hybrid,
Ivoclar Vivadent) using the classic 98-mm zirconia disk in a dry milling
environment (Lava Esthetic, 3M).
The milled restoration was adjusted in the white stage and
sintered to its final density and prepared for a framework try-in (Fig
2-4-22).
Fig 2-4-22a to 2-4-22c Fabrication of the restoration.

Framework try-in
The sintered and (in the dental laboratory) adjusted frameworks were
checked intraorally for overall fit and initial shade adaptation. The
framework try-in was clinically checked with respect to its fit and the
occlusion of the restorations.
As the term “framework” would suggest, today this is no longer
just a framework but a structural Part of the restoration including
functional areas. So, consequently also those occlusal areas and
contact points could be verified before the restorations were finalized
(Fig 2-4-23).
Fig 2-4-23a to 2-4-23c Framework try-in.

Finalization of the restoration

After the try-in with its minor occlusal adjustments, the crown was
repolished in the area of the clinical adjustments and superficially
characterized by applying stains and glaze (Ivocolor, Ivoclar Vivadent)
according to the custom shade developed with the patient (Fig 2-4-
24).
Fig 2-4-24a to 2-4-24f Finalization of the restoration.

Integration of zirconia-based restoration

The provisional restoration was removed and the restoration was
cemented with a universal resin cement (RelyX Unicem, 3M) and
meticulously checked for any remaining cement excess (Fig 2-4-25).
Fig 2-4-25a to 2-4-25d Integration of the restoration and final
outcome.

(Dental practitioner: Dr J Pitta; Technician: MDT V Fehmer.)

Full-mouth rehabilitation
(single-unit lithium disilicate crowns and one
zirconia-based four-unit FDP)
Conventional SCs and fixed
2.4.5
dental prostheses (FDPs)
■ Complex situations
■ Full-mouth rehabilitation (SC and FDP)
■ Re-treatment
■ 3D printed mock-ups

The following section describes the retreatment of an insufficient full-

mouth rehabilitation of a patient that received zirconia-based FDPs
during a 2-week dental touristic trip by means of single-unit lithium
disilicate crowns and one zirconia-based four-unit FDP.

Assessment and treatment planning

A 42-year-old female presented herself to the clinic with the wish for
a recementation of her three-unit zirconia FDP in the mandibular
anterior area. Upon a closer inspection of the rest of her dentition, all
of them were restored by zirconia-based FDPs and first signs of
gingivitis were present.
The esthetic integration of the restorations was not bad but
extremely uniform and the restoration looked like it had been
fabricated several years ago.
Speaking with the patient, however, revealed a completely
different picture, as all these restorations had only been placed 3
months previously during a visit to the dentist while on an overseas
trip.
During this so-to-speak all-inclusive trip, which lasted only 2
weeks and prior to which the patient was free of any dental
restoration, the patient received 28 aggressive crown preparations
and 29 zirconia-based restorations.
Another sad aspect of this initial treatment was that looking into
old pictures and radiographs that the patient brought along, most
likely she was only in need of overlays and maybe some buccal
veneers for an esthetic improvement of her anterior teeth.
Discussing this issue with the patient was not easy at all as the
initial reason for her trip abroad was her financial limitation and the
wish to improve her dental situation.
This patient was faced with a complete renewal of all her
restorations as they were completely insufficient and had to be
exchanged as soon as possible.
As a first step, it was planned to remove and replace them with
long-term provisionals with good marginal adaptation, cleanability,
and then gain the trust of the patient after her previous bad
experience (Fig 2-4-26).
Fig 2-4-26a to 2-4-26c Pretreatment photographs (Fig 2-4-6b
1
reproduced from Sancho-Puchades et al with permission).

Diagnostics
The patient’s chief complaint was her inability to clean the
restorations and a constant bad taste that she could sense once
trying to clean her newly made zirconia-based restorations. However,
the reason that she finally approached the clinic was the debonding of
one of her three-unit mandibular anterior fixed dental prostheses
(FDPs). It was fortunate that this technical complication occurred so
early after her first dental treatment, as this was partially
overcontoured. In the same approximal areas, practically uncleanable
restorations would have led to severe biological complications (Fig 2-
4-27).
Fig 2-4-27a to 2-4-27e Diagnostic images.

Removing all restorations, redefining

preparations, optical impression, and direct
provisionals
A silicone index was fabricated based on the existing restorations to
later on deliver a first direct provisional. Then the old crowns were
removed and the teeth were slightly re-prepared, which consisted
mainly of a minimal rounding of the incisal borders and a smoothening
of the finish lines (Universal Prep Set, Intensiv, Montagnola,
Switzerland). Then an optical impression (iTero, Align Technology,
San Jose, CA, USA) was performed and for each lateral bite scan
the contralateral provisional was placed (Figs 2-4-28 and 2-4-29).
Fig 2-4-28a to 2-4-28e Removal of restorations and redefinition of
preparations.
Fig 2-4-29a to 2-4-29c Optical impression.

Digital fabrication of several mock-ups

In order to visualize the final treatment outcome and also its potential
shortcomings, a digital wax-up was performed (Dental Designer,
3Shape, Copenhagen, Denmark) based on the optical impressions.
Such a complex design of 29 restorations is time-consuming even in
the digital environment; however, once the initial design was
established it was quite easy to add additional versions, changing the
morphology and position of the teeth in the maxillary anterior
segment.
To then efficiently transfer the digital wax-up into the patient’s
mouth, an indirect mock-up was 3D printed (Objet Eden 260,
Stratasys, Prairie, MN, USA) with a 3D tooth color like (Vita A2)
resin.
During this try-in session, not only did the clinician have the
possibility of verifying all essential parameters like marginal
adaptation, overall fit, dimensions, contact points, and most
importantly the occlusion, but also to ensure that the potential
engagement of the patient is unique.
The patient chose one of the more harmonious mock-up versions
and requested some minor shape modifications. At the same time,
some clinical adjustments were also performed and could then be
transferred back to the laboratory in order to modify the initial CAD
data accordingly and fabricate the provisional restorations (Figs 2-4-
30 to 2-4-32).
Fig 2-4-30a and 2-4-30b Digital fabrication of several mock-ups.
Fig 2-4-31a to 2-4-31o Mock-up try-in.

Fig 2-4-32 Modifications to the provisional restoration design.

CAD/CAM-based provisionals
The minor clinical adjustments that were made during the mock-up
try-in could be rescanned (iTero, Align Technology) and sent to the
dental laboratory.
Once the files were imported into the initial case and matched
with the first preparations scans, the initial digital wax-up was
adjusted to it and the small changes applied due to the patient’s
wishes. All the efforts from the initial design were maintained and only
with the small adjustments to the new conditions the contour was re-
established. All this could only be achieved in a digital process by the
aid of a copy function of the design program (Dental Designer,
3Shape).
Once the design was completed the software automatically leads
the workflow to the model-builder software (Model-Builder, 3Shape)
in which the master model was designed. In the end of this extremely
efficient workflow, the stl. files were exported from the software: the
maxillary and mandibular model along with the FDPs.
The generated model files were placed in a 3D printer (Objet
Eden 260, Stratasys) and printed with a beige stone-like tinted light-
curing 3D printing resin and thereafter post-processed and cleaned.
The full contour FDPs, however, had to be milled in a five-axis
milling unit (Zenotec Select Hybrid, Ivoclar Vivadent, Schaan,
Liechtenstein) using a classic 98 mm disk in a dry milling environment
(Telio CAD A3 Esthetic, Ivoclar Vivadent).
The milled provisional restorations were adjusted on the model
and in the anterior segments buccally microveneered and polished.
Once the PMMA FDPs were finalized and provisionally cemented
(Protemp, 3M, Seefeld, Germany), they were cleaned with alcohol
and primed (SR Connect, Ivoclar Vivadent) to guarantee a good
flawless provisional phase for the patient (Fig 2-4-33).
Fig 2-4-33a to 2-4-33e Provisional restorations.

Fabrication of the all-ceramic FDP in the third

quadrant
The patient adapted very well to the provisional and felt very
comfortable with the occlusion.
So, after a 4-month period and without taking an additional
impression, the laboratory was told to fabricate the final restoration.
At this point, all the laboratory technician had to do was to copy the
initial files created for the provisional and adjust the parameters to the
chosen restorative material (Lava Plus, 3M) in the design software
(Dental Designer 18, 3Shape).
As the material, however, has not the same optical properties as
lithium disilicate, a cutback with about 1.2 mm in thickness was
planned and reduced by the software. The FDP was then milled in a
five-axis milling unit (Zenotec Select Hybrid, Ivoclar Vivadent) using
the classic 98-mm zirconia disk in a dry milling environment (Lava
Plus, 3M). The milled restoration was adjusted in the white stage and
infiltrated before it was sintered to its final density. The infiltration is
the key to transform the white monochromatic zirconia into an
individualized polychromatic tooth-colored restoration.
Thereafter the FDP was conventionally veneered (IPS e.max
Ceram, Ivoclar Vivadent) according to the custom shade developed
with the patient and then superficially characterized by applying stains
and glaze (Ivocolor, Ivoclar Vivadent).
Once the zirconia FDP was finalized, it was carefully polished, and
airborne-particle abraded from the inside with 1.5 bar and 50 µm
aluminum oxide.

Fabrication of the veneer in the laboratory

Just like the zirconia-based FDP, the SCs were designed based on
the initial impression by applying the copy function of the software to
achieve the same final outlines and contours for the crowns as
presented to the patient during the diagnostic phase. All restorations
were then milled with a small cutback of 0.3 mm out of lithium
disilicate ceramics (e.max CAD, Ivoclar Vivadent). This cutback was
made to enhance the individualized esthetic of the crowns with the
final application of veneering ceramic.
The generated crown files were then milled in a chairside milling
unit (MCXL, Dentsply Sirona) using the blue blanks (IPS e.max LT
A1, Ivoclar Vivadent). The milled restorations were adjusted in the
blue stage, crystallized, microveneered (IPS e.max Ceram, Ivoclar
Vivadent) and superficially characterized applying stains and glaze
(Ivocolor, Ivoclar Vivadent).
Once the lithium disilicate crowns were finalized, they were etched
for 20 s with hydrofluoric acid (5% concentration) (IPS Ceramic
Etching Gel, Ivoclar Vivadent) and rinsed with water.

Biscuit bake try-in

The biscuit bake was clinically checked with respect to the shade and
shape of the restorations.
The patient and the restorative team were already very satisfied
with the final shape and the overall integration as it simply reflected
the mock-up and provisionally developed shape and position of the
teeth and occlusion.
Small details, however, could still be improved, but considering the
complexity of such a full-mouth rehabilitation the predictability and
reproducibility with these digitally developed all-ceramic restorations
is unmatched by any conventional approach. So, a try-in – like the
one presented here – becomes less stressful for the entire team. The
focus can then be drawn to final details such as the surface texture
and other little details concerning the shade assessment (Fig 2-4-34).
Fig 2-4-34a to 2-4-34c Biscuit bake try-in.

Integration of the lithium disilicate single

crown restorations
A try-in session was carried out where the crowns were inserted with
a try-in paste (Variolink Esthetic neutral and warm, Ivoclar Vivadent)
in order to improve color assessment and optical integration.
Subsequently, in a dry environment (rubber dam) the ceramic veneers
were cemented. The abutment tooth was etched with 35%
phosphoric acid (Ultra-Etch, Ultradent Products, South Jordan, UT,
USA) and bonded with a multistep adhesive system (Syntac Classic,
Ivoclar Vivadent, Schaan, Liechtenstein). The bond was not light-
cured so as not to compromise the fit of the ultra-thin veneers. The
crowns were etched with hydrofluoric acid (5% concentration for 20
s) (IPS Ceramic Etching Gel, Ivoclar Vivadent). A silane-containing
primer (Monobond S, Ivoclar Vivadent) and a bonding system
(Heliobond, Ivoclar Vivadent) was applied. Then the crowns were
cemented with a dual-curing resin cement (Variolink Esthetic Nutral,
Ivoclar Vivadent). Excess cement was removed with rotating and
oscillating diamond instruments (Universal Prep Set, Intensiv,
Montagnola, Switzerland). The occlusal and functional contacts were
analyzed, and no adjustments were necessary.

Integration of the zirconia-based FDP in the

third quadrant
During the same appointment after the placement of the lithium
disilicate SCs, the finalized FDP was clinically tested for its shade
and occlusal integration. Before it was finally cemented by the
application of a self-adhesive universal resin cement (RelyX Unicem,
3M) it was cleaned in an alcohol bath; thereafter, a silane-containing
primer was applied according to the manufacturer’s
recommendations. Constant finger pressure was applied during the
setting time. Adjustments were performed where needed, after which
the ceramic surfaces were meticulously polished with the Optrafine
Kit (Ivoclar Vivadent) (Fig 2-4-35).
Fig 2-4-35a to 2-4-35i Integration of the FDP.

Micro- and macrosurface texture

For a natural appearance, especially despite the high value of the
restorations and the overall very harmonious tooth positions, details
like small irregularities in shape and position as well as the micro- and
macrosurface texture are of extreme relevance. They create different
light reflections and allow each tooth to appear unique but in the
same time blend in nicely with the overall rehabilitation.
The different degrees of surface polishing that lead to this natural
look can be observed (Fig 2-4-36).
Fig 2-4-36a to 2-4-36f Micro- and macrosurface texture and final
outcome.
(Dental practitioner: Dr P Grohmann; Technician: MDT V Fehmer.)

Final outcome after 8 years of clinical

service
For the SCs, no technical complications occurred in all 25 lithium
disilicate restorations but due to the extremely invasive initial
preparation, a biological complication occurred as four teeth had to
be endodontically treated.
The zirconia FDP, however, showed severe technical
complications in the form of chippings but no biological complications.
All in all, the patient is still very satisfied with her restoration (Fig 2-4-
37).
Fig 2-4-37a to 2-4-37e Final outcome after 8 years of clinical
service.

Additional veneer and all-

ceramic crowns
(in combination with implant)

2.4.6 SCs in combination with an

implant
■ Complex situations
■ Anterior regions, in combination with implants
■ Additional veneer and all-ceramic crowns

The following section describes the replacement of existing all-

ceramic crowns, implant placement, and an additional veneer to
harmonize the esthetic zone.

Assessment and treatment planning

A 36-year-old female presented herself at the clinic seeking
treatment for compromised esthetics in her maxillary anterior teeth.
As a consequence of an accident she lost her central incisor 11,
next to the adjacent central and lateral incisor 22 that had been
already restored several years ago by means of PFM crowns. As her
remaining root was extracted by the previous dental practitioner, the
initial documentation was unfortunately missing but, interestingly, the
only reason for this patient to doubt the capabilities of her initial
restorative team was the delivery of the removable provisional. This
was due to it being fabricated most likely without the necessary care
to convey to the patient all the efforts that were undertaken to help
the patient in this critical moment of the initial treatment phase. The
initial restorative team most likely thought that the removable
provisional could be considered neglectable by the patient as she
would only wear it for a couple of weeks.
So, as a first step it was planned and discussed with the patient
to immediately change the removable provisional into a fixed
cantilever provisional and thereby achieve a more favorable esthetic
appearance of her smile, additionally gaining the trust of the patient
after her previous experience.
At a later time point, the placement of an implant in region 11
along with the replacement of the existing PFM restorations was
planned. Additionally, and as a particularity in this case, the patient
participated in a clinical study where cemented implant restorations
were compared with screw-retained implant restorations each based
on zirconia abutments. This patient was randomized in the cement-
retained group which led to the final cementation despite the good
three-dimensional implant position that could have been screw-
retained without any problems (Fig 2-4-38).
Fig 2-4-38a to 2-4-38c Pretreatment photographs (Figs 2-4-38b and
2
2-4-38c reproduced from Fehmer and Büchi with permission).

Diagnostics
The patient’s chief complaint was her compromised esthetic
appearance in the maxillary anterior teeth. This had also been
highlighted to her through the initial removable provisional delivery by
her previous restorative team.
The removable provisional showed an extremely short tooth
embedded in artificial pink acrylic that had nothing in common with the
existing neighboring teeth, and made the patient feel quite anxious
about the potential final outcome of her dental treatment (Fig 2-4-39).
Fig 2-4-39a to 2-4-39c Diagnostic images (Figs 2-4-39a and 2-4-
2
39c reproduced from Fehmer and Büchi with permission).

Provisional
To transfer the wax-up into the patient’s mouth, a silicone index of the
wax-up was prepared in the dental laboratory in order to fabricate an
eggshell provisional on the model. This eggshell was fabricated with a
classic acrylic PMMA material (New Outline, Anaxdent, Stuttgart,
Germany) that was later on easy to reline and adjust to the actual
intraoral preparation. The provisional was then relined with a self-
curing resin (Tab 2000, Kerr, Brea, CA, USA), extraorally polished,
and provisionally cemented (Protemp, 3M, Seefeld, Germany). The
resulting provisional integrated very nicely and served as a
communication tool, and the prospective treatment result could now
be discussed with the patient. At this stage the need for the
integration of the lateral incisor 12 into the treatment plan became
evident (Fig 2-4-40).
Fig 2-4-40a to 2-4-40d Provisional restoration including lateral
incisor.

Direct mock-up
Once the provisional FDP was placed and was very harmonious to
the patient’s smile, it became immediately evident that the lateral
incisor 12 that was not yet included in the treatment plan had to be
lengthened to avoid a big step toward the neighboring teeth. So, to
visualize the final treatment outcome including the lateral incisor, a
direct mock-up was applied simply by adding some light-curing
composite (Tetric Classic A2, Ivoclar Vivadent, Schaan,
Liechtenstein).
The patient was very happy with the mock-up and she
immediately felt very confortable with her new smile and agreed to
the proposed treatment plan (Fig 2-4-41).
Fig 2-4-41a to 2-4-41c Direct mock-up.

Implant placement and regeneration

According to the diagnostics, a surgical stent was fabricated
transferring the prosthetic plan of the ideal three-dimensional position
of the implant to the surgical intervention. At the day of implant
placement (4 months after extraction), the patient was premedicated
with 1500 mg amoxicillin and 600 mg ibuprofen. After the raising of a
mucoperiosteal flap with a vertical releasing incision distal of tooth 12,
a regular diameter bone level implant (ASTRA Osseospeed, Dentsply
Sirona, Bensheim, Germany) was placed with good primary stability
and a correct prosthetic position/axis. A small closure screw was
applied to cover the implant (Fig 2-4-42).
Fig 2-4-42a to 2-4-42f Implant placement and regeneration
2
(reproduced from Fehmer and Büchi with permission).

The ridge deficiency was augmented with a xenograft (Bio-Oss

Collagen, Geistlich Pharma, Wolhusen, Switzerland) and the graft
was covered with a collagen membrane (Bio-Gide, Geistlich Pharma)
to allow for hard tissue formation. The flap was released by splitting
the periosteum allowing for a tension-free readaptation of the flap.
After the suturing (Gore-Tex 5.0, W.L. Gore & Associates, Flagstaff,
AZ, USA) the implant was left for submucosal healing for 8–10
weeks. Antibiotics (amoxicillin 3 × 750 mg for 5 days), painkillers
(600 mg ibuprofen if needed), and chlorhexidine mouthrinse (0.2%)
were prescribed. The sutures were removed 10 days after implant
placement.
To augment the soft tissue deficiency in the area around the
implant position 11, a connective tissue graft was harvested in the
palatal area of the second quadrant and carefully placed (Fig 2-4-43).
Fig 2-4-43a to 2-4-43c Placement of connective tissue graft (Fig 2-
2
4-32a reproduced from Fehmer and Büchi with permission).

Provisionalization
Two weeks after the abutment connection, and the removal of the
healing abutment, healthy peri-implant mucosa was present. At this
point directly in the clinic, the laboratory-made tooth-borne provisional
was carved out in the palatal Part and prepared for a relining based
on the now osseointegrated implant. A temporary abutment
(retentive) made from a titanium alloy (TAN) was applied, airborne-
particle abraded, and bonded before the open space was filled with a
classic acrylic PMMA material (New Outline, Anaxdent) that was later
easy to reline in the yet undercontoured submucosal part. The
provisional was fabricated with a kind of ridge flap design to avoid too
much pressure on the soft tissue during insertion.
Once the relining material had set, the entire tooth- and implant-
borne provisional could be removed and separated from each other
using a fine diamond disk.
The provisional was inserted and tightened. During the following
weeks, the provisional was modified two times with composite resin
to optimize the emergence profile (Fig 2-4-44).
Fig 2-4-44a to 2-4-44i Provisional restoration (reproduced from
2
Fehmer and Büchi with permission).

Impression
After a provisional phase of 5 months, a second impression with an
individualized impression coping was taken. This individualized
impression coping presents the exact copy of the emergence profile
that was sequentially developed with the provisional, in order to
modify the standardized impression copings. The provisional was
mounted to an analog and embedded in a putty material. Once the
material had set, the provisional crown could be unscrewed and the
impression coping was mounted.
The free space can now be filled with either a light-curing
composite or, as was done in this case, with a self-curing acrylic (GC
Pattern Resin, GC, Leuven, Belgium).
The now-individualized impression coping was transferred to the
implant site, and the final impression carried out and sent to the
dental laboratory (Fig 2-4-45).
2
Fig 2-4-45 Impression (reproduced from Fehmer and Büchi with
permission).

Fabrication of the all-ceramic zirconia

abutment
As this implant restoration was Part of a clinical study, the patient
was randomized into the cement-retained customized zirconia
abutment group (Atlantis, Dentsply Sirona). Once the conventional
impression was translated into a master cast, the models were
scanned using a lab scanner (Imetric 4D, Courgenay, Switzerland)
and the indicated metal mono scanbody for the Atlantis workflow. The
generated files were then uploaded to the Atlantis WebOrder and the
color of the abutment was indicated as 00 (uninfiltrated white). The
abutment was predesigned by the Atlantis team and then uploaded to
their cloud-based Atlantis 3D web editor. Here adjustments like
margin lines or other small corrections could be done and the revised
abutment was approved for production. Once delivered, the abutment
was checked on the model for its correct emergence profile and
prosthetic support before (according to the study protocol) this had to
be verified intraorally (Fig 2-4-46).
Fig 2-4-46a to 2-4-46e Fabrication of the all-ceramic zirconia
2
abutment (reproduced from Fehmer and Büchi with permission).

Fabrication of the all-ceramic crowns and

additional veneer
After the clinical verification of the abutment in the dental laboratory,
all-ceramic feldspathic crowns and the veneer (Creation Press A2,
Willi Geller, Meiningen, Austria) were produced with a small buccal
cutback by means of the lost wax technology and veneered (Creation
Classic, Willi Geller) according to the custom shade that was
developed by the dental technician in collaboration with the patient.
After two firings, the surface texture and the final shape were
developed with stones and diamond burs. The glaze firing was
followed by an additional stain firing and a mechanical polishing
procedure (Fig 2-4-47).
Fig 2-4-47a and 2-4-47b Fabrication of the all-ceramic crowns and
2
additional veneer (Fig 2-4-47b reproduced from Fehmer and Büchi
with permission).

Integration of the crowns and veneer

A try-in session was carried out where the veneers were inserted
with a try-in paste (Variolink Esthetic neutral and warm, Ivoclar
Vivadent) in order to improve color assessment and optical
integration. Subsequently, in a dry environment (rubber dam) the
fragile ceramic veneer and the crowns were cemented. The abutment
teeth were etched with 35% phosphoric acid (Ultra-Etch, Ultradent
Products, South Jordan, UT, USA) and bonded with a multistep
adhesive system (Syntac Classic, Ivoclar Vivadent). The bond was
not light-cured in order not to compromise the fit of the ultra-thin
veneers. The restorations were etched with hydrofluoric acid (9%
concentration for 1 min) (Porcelain Etch, Ultradent Products). A
silane-containing primer (Monobond S, Ivoclar Vivadent) and a
bonding system (Heliobond, Ivoclar Vivadent) was applied. Then the
restorations were cemented with a dual-curing resin cement (Variolink
Esthetic Nutral, Ivoclar Vivadent). Excess cement was removed with
rotating and oscillating diamond instruments (Universal Prep Set,
Intensiv, Montagnola, Switzerland) (Fig 2-4-48).
Fig 2-4-48a and 2-4-48b Integration of the crowns and veneer
2
(reproduced from Fehmer and Büchi with permission).

Integration of the cement-retained implant

restoration
The provisional was removed and the implant and adjacent tissues
disinfected with a chlorhexidine solution. After disinfection (Tiutol dent,
B. Braun Melsungen, Melsungen, Germany) and the application of a
chlorhexidine gel to the submucosal Part (PlakOut Gel, KerrHawe,
Bioggio, Switzerland), the zirconia screw-retained abutment was
tightened with the final torque as recommended by the manufacturer,
and the screw access hole sealed with PTFE tape and a composite
filling (Tetric Classic, Ivoclar Vivadent). Once the abutment was
seated, the lithium disilicate crown was adhesively cemented
(Multilink Automix yellow, Ivoclar Vivadent).
After the cementation, the implant restoration was meticulously
checked for any remaining cement excess and thereafter the
occlusion was checked and minor adjustments had to be made which
were polished.
The final result was extremely pleasing to the entire team and the
patient (Fig 2-4-49).
Fig 2-4-49a to 2-4-49d Final outcome (Figs 2-4-9a, 2-4-9c and 2-4-
2
9d reproduced from Fehmer and Büchi with permission).

(Dental practitioner: Dr D Büchi; Technician: MDT V Fehmer.)

References
1. Sancho-Puchades M, Fehmer V, Sailer I. Advanced smile
diagnostics using CAD/CAM mock-ups. Int J Esthet Dent
2015;10:374–391.
2. Fehmer V, Büchi D. Zahn- und implantatgetragene Kronen in
einer Frontzahnsituation. Quintessenz Zahntechnik 2014; 3:282–
293.
CHAPTER 5
Tooth-supported all-ceramic
single crowns (SCs), fixed
dental prostheses (FDPs), and a
removable telescopic
restoration

Anterior regions
2.5.1 Full-mouth rehabilitation

Posterior regions
2.5.2 Tooth-supported, all-ceramic three-unit
fixed dental prosthesis (FDP)
2.5.3 The 3D-printed prototype
Full-mouth rehabilitation
(all-ceramic crowns and FDP and a removable
restoration)

2.5.1 Full-mouth rehabilitation

■ Maxillary arch: veneered, all-ceramic crowns, and fixed dental
prostheses (FDPs) (Lava Plus, 3M, Seefeld, Germany)
■ Mandibular arch: individually veneered removable telescopic
restoration (Gradia, GC, Leuven, Belgium)
■ Endodontic retreatment
■ Ball attachments

This first case details the full-mouth rehabilitation of a failing and

insufficient old dental restoration by means of veneered all-ceramic
crowns and FDPs in the maxillary arch and a removable restoration in
the mandibular arch.

Assessment and treatment planning

A 72-year-old female patient presented herself at the clinic seeking
general treatment and an esthetic improvement of her entire dentition.
The patient was healthy and did not take any medication; however in
the past she suffered heavily from a chemotherapy treatment that led
to a long period of vomiting, which explained the severe loss of tooth
substance.
One of the patient’s chief complaints was the poor esthetics of her
fixed restorations. Poor adaptation of the crowns with overcontoured
margins made it very difficult for the patient to properly clean the
restorations, leading to generalized gingivitis.
The patient’s second wish was to receive fixed dental restoration
if possible of both arches, and restore the masticatory function to
allow her to properly eat again and not feel embarrassed in public.
At the beginning of the comprehensive treatment, a detailed
diagnostics process was required for the evaluation of the single
tooth prognosis and the potential strategic relevance. The quality of
the existing root canal treatments was analyzed and furthermore, an
extra- and intraoral esthetic analysis was performed to determine the
new outline of her teeth.
In general it was planned to maintain as many teeth as possible
by means endodontic retreatment along with an opening of the
vertical dimension. If needed, this would entail a crown lengthening
and implants to replace failing teeth to avoid long-span FDPs on the
compromised teeth.
The final maxillary restoration was planned to be fabricated from a
semi-translucent multicolor as for the mandibular arch with the
reduced number of abutment teeth and a lack of bone. It was most
likely that a removable restoration supported from a precious alloy
would be the treatment of choice.
As this was a major change, a long-term provisional phase for the
patient to adapt to the new vertical dimension and the overall shape
and size of her new restorations was foreseen (Fig 2-5-1).
Figs 2-5-1a to 2-5-1c Pretreatment photographs.

Diagnostics
The patient’s chief complaint was her compromised esthetic
appearance, especially in the maxillary anterior teeth. However, she
was also aware that some of her teeth and restorations were not in
good condition. This was due to several severe chippings, and to
constant bleeding and a bad taste she sensed while trying to clean
her restorations.
Evaluating and defining a sound prognosis for her teeth with these
types of metal-based existing restorations in place was extremely
difficult, if not impossible.
The panoramic radiograph and the peri-apical radiographs
allowed for a first prognosis and a categorization of the teeth into
three groups (safe, questionable, and irrational to treat) but this
assessment could only be finalized once the failing restorations were
removed and the substrate beneath could be examined.
To develop a clear treatment aim, alginate impressions of both
arches were created along with a facebow. The laboratory then
developed a full wax-up including a vertical augmentation of the bite.
As the existing restorations were very bulky, the wax-up created
in the dental laboratory was already based on a subtractive
preparation of the casts; consequently, no direct mock-up could be
performed. However, at least the desired shape and design of the
new restorations could be discussed with the patient based on the
wax-up in the articulator.
In the clinic, the failing restorations were removed and the
assessment for the teeth could be reviewed.
The wax-up was then transferred into a direct provisional, allowing
the patient at this early treatment phase to test the planned
restorations, to improve her esthetics, get used to the new shapes
and volume of her planned restorations, and finally verify the raised
vertical dimension.
The following treatment plan was then developed according to the
diagnostics and prognosis of the maintaining teeth (Fig 2-5-2).
Fig 2-5-2a to 2-5-2k Diagnostic images.

Bite and facebow registration

In the dental laboratory the conventional alginate impressions were
poured with plaster and diagnostic casts were fabricated. Thereafter,
they were articulated based on the preliminary bite registration based
on the copy of the old removable restoration in the mandibular arch
and by means of a facebow that was acquired for the correct three-
dimensional (3D) orientation of the casts in the articulator (Fig 2-5-3).
Fig 2-5-3a to 2-5-3f Bite and facebow registration.

Wax-up
In order to visualize the final treatment outcome and also its potential
limitations, a full wax-up was performed on two conventional plaster
casts that were articulated by means of a facebow. The vertical
dimensions were raised by 6 mm on the incisal pin.
As the existing anterior restorations, still present in the casts,
were very bulky it was decided to already prepare the teeth on the
casts so that a natural contour could be developed by the dental
technician. Unfortunately, this made it impossible to actually visualize
the prospective treatment before the actual removal of the
restorations.

Amalgam replacement and direct composite

build-ups in the mandibular arch
Under rubber dam, the amalgam could be safely removed and then
pretreated. The composite build-up (Tetric Classic, Ivoclar Vivadent,
Schaan, Liechtenstein) was guided by transparent silicone keys
(Memosil 2, Kulzer, Hanau, Germany) that reflected the diagnostics
and made the build-up extremely predictable and efficient (Fig 2-5-4).
Fig 2-5-4a to 2-5-4f Amalgam replacement and direct composite
build-up in the mandible.

Removal of insufficient restorations in the

maxillary arch
In a first treatment step, the insufficient restorations in the anterior
and posterior segments of the maxillary arch were carefully removed
and evaluated (Fig 2-5-5).
Fig 2-5-5a to 2-5-5l Removal of insufficient maxillary restorations.

Endodontic re-treatments and build-ups

After the removal of the old restorations, access to the previous root
canal filling was possible and rubber dam was placed. The
endodontic retreatment was performed using a combination of
manual endodontic instrumentation (K files, Maillefer, Tulsa, OK,
USA) and machine-driven endodontic instruments (ProTaper Universal
Files, Maillefer). The previous root canal filling was thereby
meticulously removed and the root canals of both teeth were
disinfected with Na(OH)2. Thereafter, the root canals were filled with
gutta-percha, condensed, and fixed with aid of the cement AH 26
(Maillefer). At the next meeting and after the setting of the cement,
the two root canals were prepared for titanium root posts. The posts
were adhesively inserted using a self-adhesive universal cement
(RelyX Unicem, 3M), and the composite build-ups were made with a
light curing composite (Tetric Evo Ceram, Ivoclar Vivadent),
associated with the respective dentin and titanium pretreatment steps
(Syntac Classic, Heliobond; Monobond Plus, Ivoclar Vivadent). The
two abutment teeth were reprepared and the provisionals were
adapted.

Extraction with the Benex system

Due to a vertical fracture visible only after the removal of the old
restoration, the lateral incisor 12 had unfortunately to be removed. To
perform the extraction as minimally invasively as possible, the Benex
system (Benex, Lucerne, Switzerland) was applied, as it allowed an
extremely careful and predictable extraction.
Once the tooth was extracted, a lot of granulation tissue had to be
removed and finally the socket was cleansed with the aid of curettes
and rinsed with neomycin solution (Fig 2-5-6).
Fig 2-5-6a to 2-5-6c Extraction with the Benex system.

Ridge preservation
After the extraction and cleaning of the socket, a xenogeneic bone
substitute (Bio-Oss Collagen, Geistlich, Wolhusen, Switzerland) was
inserted in combination with a subepithelial connective tissue graft
harvested from the palate, to perform a ridge preservation (Fig 2-5-
7).
Fig 2-5-7a to 2-5-7i Ridge preservation.

Endodontic treatments and placement of a

ball attachment
The second premolar was shortened and endodontically retreated to
receive a cast root cap with a ball attachment later during the final
treatment phase. For a better retention throughout the provisional
phase, the questionable first premolar received a direct composite-
based ball attachment to keep the costs as low as possible and at
the same time allow for a better retention of the provisional (Fig 2-5-
8).
Fig 2-5-8a to 2-5-8e Endodontic treatments and placement of a ball
attachment.

Indirect mock-up and eggshell provisional

In order to visualize the final treatment outcome and also its potential
limitations, the wax-up had to be transferred into the patient’s mouth,
as now the old and overcontoured restorations were removed there
was sufficient space to fabricate an indirect mock-up for both the
maxillary and mandibular arches in the dental laboratory (Fig 2-5-9).
Fig 2-5-9a to 2-5-9e Wax-up and indirect mock-up.

Based on a silicone index of the wax-up, a classic acrylic PMMA

(75% Dentin A3 and 25% Enamel High Value, New Outline, Anaxdent,
Stuttgart, Germany) was pressed onto the isolated cast, to fabricate
the indirect mock-up that served at the same time as an eggshell
provisional. This type of acrylic was used as it was later on easy to
reline and adjust to the actual intraoral preparation.
As indicated in the wax-up, a small buccal flange pink acrylic (34
Original Pink – AESTHETIC BLUE, Candulor, Glattpark, Switzerland)
was added to compensate for the uneven length of the mandibular
incisors and the position of the teeth in front of the ridge.
Finally, at this time point in the treatment phase and for the first
time, the patient was able to see and visualize the potential outline of
her new restorations (Fig 2-5-10).
Fig 2-5-10a to 2-5-10d Mock-up try-in.

Relining of the eggshell provisionals

The eggshell provisionals were now clinically relined and adjusted to
the actual clinical situation. To achieve a long-term stable provisional,
the same material was used for the relining as for its fabrication (Fig
2-5-11).
Fig 2-5-11a to 2-5-11f Relining of the eggshell provisionals.
Amalgam replacement and direct composite
build-ups in the maxillary arch
Under rubber dam, the amalgam could be safely removed and
pretreated. The composite build-up (Tetric Classic, Ivoclar Vivadent)
was guided by transparent silicone keys (Memosil 2, Kulzer) that
reflected the diagnostics and made the build-up extremely predictable
and efficient (Fig 2-5-12).
Fig 2-5-12a to 2-5-12d Amalgam replacement and direct composite
build-ups in the maxilla.

Crown lengthening
The diagnostic mock-up was transformed in to a thermoplastic
surgical stent for the localized crown lengthening of teeth 11, 21, 14,
and 15. Displaying the ideal pink and white proportions, the surgical
stent was used to mark the needed repositioning of the buccal soft
tissues. After local anesthesia (Ubistesin Forte, 3M), a buccal
mucoperiosteal flap was raised with distal releasing incisions. The
mock-up (ie, surgical stent), was then used to mark the necessary
amount of bone to be removed buccally. The marking was performed
with a sterilized round bur, and the marked buccal Part was
thereafter removed with the same instrument and a chisel, assuring
careful exposure of the buccal root surfaces of the teeth. The root
surfaces were then polished with specialized periodontal diamond
instruments (Perioset, Intensiv, Montagnola, Switzerland), and the
flap was apically repositioned and sutured (Dafilon, 6.0 sutures, B.
Braun Melsungen, Melsungen, Germany). During the initial healing,
the patient was instructed not to clean the operated area with
toothbrush or dental floss. She received a chlorhexidine solution for
daily disinfection until suture removal. After the suture removal, further
healing and maturation of tissues was allowed for another 3 months
prior to continuation of the restorative phase (Fig 2-5-13).
Fig 2-5-13a to 2-5-13d Crown lengthening.

Surgical evaluation of distal Part of abutment

tooth 34
As the intraradicular defect and distal pocket were pronounced at
tooth 34, a minimal interdental flap was raised. The distal Part of the
root 34 was inspected for fissures or fractures, and the granular
tissues were carefully removed. No fissure or fracture was found
therefore the root surface was gently cleaned and the area
disinfected with a chlorhexidine solution. Thereafter, the flap was
repositioned and sutured. The healing was uneventful and the
prognostics of the tooth re-evaluated to be on the safe side for a
long-term provisional anchorage (Fig 2-5-14).
Fig 2-5-14a to 2-5-14d Surgical evaluation of distal Part of abutment
tooth 34.

Conditioning of the pontic

Prior to the prosthetic replacement of missing tooth 12, the gingival
area in the pontic region was shaped (ie, conditioned according to the
desired emergence profile of the restoration). The conditioning was
performed in order to shape the soft tissues into an “ovate-pontic-
like” shape and, hence, to allow for a natural emergence profile of the
pontics.
For the conditioning, a flowable composite (Tetric Flow, Ivoclar
Vivadent) was applied in a stepwise approach to the basal region of
the provisional pontic, inducing pressure to the soft tissues in the
edentulous area and thereby shaping of this region. This procedure
was repeated three times at intervals of 8–10 days until the desired
shape of the pontic area was achieved (Fig 2-5-15).
Fig 2-5-15a to 2-5-15f Conditioning of the pontic.

Preparation
The abutment teeth were prepared for post-retained root caps with
ball anchors. Prefabricated cylindroconial posts were inserted, and
the gingival tissues were retracted with cords (Ultradent, size 0;
Ultradent Products, South Jordan, UT, USA). Thereafter, a
conventional impression was made with an elastomeric impression
material (Permadyne, 3M) with the posts retained in the impression
for the fabrication of customized cast post-retained gold root caps
(Fig 2-5-16 and 2-5-17).
Fig 2-5-16a to 2-5-16h Preparation of abutment teeth for post-
retained root caps with ball anchors, and insertion of posts.
Fig 2-5-17a to 2-5-17h Preparation and impression.

Impression
After a provisional phase of approximately 4 months the final
impressions were taken, applying two retraction cords. In order to
avoid traumatization of the gingiva and to minimize the risk of
recessions, a surgical suturing material (size 4-0, Vicryl Ethicon,
Johnson & Johnson, New Brunswick, NJ, USA) was used as the first
retraction cord. The second retraction cord was the thinnest cord
available on the market (000 Ultrapak, UP Dental, Cologne,
Germany) (Fig 2-5-18).
Fig 2-5-18a and 2-5-18b Final impressions after provisional phase.

Fabrication of the all-ceramic crowns and

FDP
Once the conventional impressions were translated into master casts,
the casts were scanned using a laboratory scanner (inEos X5,
Dentsply Sirona, Bensheim, Germany). Based on the scans, the
crowns and FDPs with an overall cutback of 1.2 mm were digitally
designed (Dental Designer 18, 3Shape, Copenhagen, Denmark). The
generated files were then milled in a five-axis milling unit (Zenotec
Select Hybrid, Ivoclar Vivadent) using the classic 98 mm zirconia disk
in a dry milling environment (Lava Plus, 3M).
The milled restorations were adjusted in the white stage and
infiltrated (LAVA Plus SHADE LIQUID, 3M) before they were sintered
to their final density.
This additional process was done as the infiltration is key to
transforming the white monochromatic zirconia into an individualized
polychromatic tooth-colored framework (Fig 2-5-19).
Fig 2-5-19a to 2-5-19d Fabrication of the all-ceramic crowns and
FDPs.

Framework try-in, maxillary arch

The sintered and (in the dental laboratory) adjusted frameworks were
checked intraorally for their overall fit. The framework try-in was
clinically checked with respect to its fit and the sufficient support for
the veneering ceramic. Additionally, during the framework try-in the
bite registration was verified and cross-checked with the laboratory
by adding some autopolymerizing acrylic (Pattern Resin, GC) in the
occlusal parts of the frameworks and the pontic sites that were
conditioned and developed with the provisional were also relined with
the same acrylic (Pattern Resin, GC) (Fig 2-5-20).
Fig 2-5-20a to 2-5-20e Maxillary framework try-in.

Try-in of the primary copings and root caps,

mandibular arch
The cast root caps and telescopic copings were delivered and tested
for their fit in the same appointment as the framework try-in for the
maxillary arch.
However, in this particular treatment step to achieve a precise
final fit of the removable restoration, a pick-up impression was
planned. For that reason and to guarantee the possibility to perfectly
reposition the copings and caps into the impression, small retention
balls were cast along with the copings. As they are round, on the one
hand they are easy to reposition, but on the other, they are quite
retentive and therefore mainly stick to the pick-up impression
themselves. To deliver an equal distribution of the impression material
around the copings, an individual try-in was fabricated by the dental
laboratory and used to fabricate the final impression (Fig 2-5-21).
Fig 2-5-21a to 2-5-21g Mandibular try-in or primary copings and root
caps, with pick-up impression.

Preparation for biscuit bake try-in

Thereafter the restorations were conventionally veneered (Creation
Ci-CT, Willi Geller, Meiningen, Austria) and superficially characterized
applying stains and glaze (Ivocolor, Ivoclar Vivadent) according to the
custom shade developed with the patient. For the mandibular arch,
the finalized and adjusted gold framework was veneered with an
esthetic wax to not only verify the prediction of the removable
restoration, but also to be able to see the entire outline of the full-
mouth rehabilitation (Fig 2-5-22).
Fig 2-5-22a to 2-5-22d Preparation for biscuit bake try-in.

Biscuit bake try-in the maxillary arch

The biscuit bake was clinically checked with respect to the shade and
shape of the restorations.
The patient and the restorative team were already very satisfied
with the final shape and the overall integration.
However small details could still be improved as the central
incisors were slightly too long and the axis of the mandibular wax-up
appeared slightly off center. In addition, the third quadrant was a bit
too prominent and could be reduced directly during the clinical
appointment. That led, however, to a missing occlusion that had to be
compensated with the finalization of the maxillary second quadrant.
Additionally, the individualized custom shade for the small buccal
flange was selected as the individualized color plays a crucial role in a
perfect integration of the final restoration (Fig 2-5-23).
Fig 2-5-23a to 2-5-23g Biscuit bake try-in the maxillary arch.

Finalization of the restoration

The shape was adjusted as discussed during the biscuit bake try-in
and glaze firing was followed by an additional stain firing to achieve
the optimal integration of the zirconia-based restorations.
In the mandibular arch, the verified gold framework was
individually veneered with a highly filled composite (Gradia, GC)
according to the zirconia-based restorations in the maxillary arch.
Additionally, to better compensate the different length of the
mandibular anterior teeth, a small composite flange was added and
copied manually from the wax-up try-in (Fig 2-5-24).
Fig 2-5-24a to 2-5-24j Finalization of the restoration.
Integration of the lithium disilicate overlays
in the maxillary arch
A try-in session was carried out where the crowns were inserted with
a try-in paste (Variolink Esthetic neutral and warm, Ivoclar Vivadent)
to verify the fit and the optical integration. Subsequently, in a dry
environment (rubber dam) the ceramic overlays were cemented. The
abutment teeth were etched with 35% phosphoric acid (Ultra-Etch,
Ultradent Products) and bonded with a multistep adhesive system
(Syntac Classic, Ivoclar Vivadent). The bond was not light-cured so
as not to compromise the fit of the overlays. The overlays were
etched with hydrofluoric acid (5% concentration for 20 s) (IPS
Ceramic Etching Gel, Ivoclar Vivadent). A silane-containing primer
(Monobond S, Ivoclar Vivadent) and a bonding system (Heliobond,
Ivoclar Vivadent) was applied. Then the overlays were cemented with
a dual-curing resin cement (Variolink Esthetic neutral). Excess cement
was carefully removed and the transition zones polished.

Integration of the zirconia-based SCs and

FDPs in the maxillary arch
During the same appointment, after the placement of the lithium
disilicate single overlays, the finalized crowns and FDPs were
clinically tested for their shade and occlusal integration. Before they
were finally cemented by the application of a self-adhesive universal
resin cement (RelyX Unicem, 3M), they were cleaned in an alcohol
bath. Thereafter, a silane-containing primer was applied according to
the manufacturer’s recommendations. Constant finger pressure was
applied during the setting time.
Adjustments were performed where needed, after which the
ceramic surfaces were meticulously polished with the Optrafine Kit
(Ivoclar Vivadent) (Fig 2-5-25).
Fig 2-5-25a to 2-5-25c Integration of the zirconia-based SCs and
FDPs in the maxilla.

Integration of telescopic primary copings

and root caps in the mandibular arch
During the same appointment, after the placement of the zirconia and
lithium disilicate-based restoration in the maxillary arch, the telescopic
crowns and root caps were cemented adhesively using a resin
Panavia 21 (TC, Kuraray, Tokyo, Japan). For the cementation a
rubber dam was applied, and the abutment teeth were meticulously
cleaned with pumice. Then the corresponding primer of the resin
cement ED Primer (Kuraray) was used as pretreatment as
recommended by the manufacturer. The metal surface was cleaned
with alcohol and a silane-containing primer (Clearfil Alloy Primer,
Kuraray) was applied according to the manufacturer’s
recommendations.
Thereafter, the mandibular removable restoration could be
delivered to the patient and tested for its final retention. In the
beginning the retention was rather strong, but due to the small
number of anchors and as the patient was already able to remove it
herself, it was decided to keep the rather tight fit and adjust it if
necessary at a later time point. The small buccal composite flange
integrated extremely well, as this different tooth length could be
perfectly camouflaged (Fig 2-5-26).
Fig 2-5-26a to 2-5-26g Mandibular restoration, with telescopic
primary copings and root caps.

Final full-mouth rehabilitation

The final outcome of this treatment was extremely pleasing for the
entire team and a tremendous change for the patient. The
predictability achieved through the diagnostic guidance was a
keystone to break such a comprehensive treatment down into shorter
appointments. That made the entire procedure easier for the patient
to handle. After the last and minor occlusal adjustments, the patient
immediately received a Michigan splint to protect the new
restorations during the night and has been in a 6-month recall ever
since (Fig 2-5-27).
Fig 2-5-27a to 2-5-27i Final outcome.

(Dental practitioner: Dr F Brandenberg; Technician: MDT V

Fehmer.)

Tooth-supported, all-ceramic
FDP
(semi-translucent zirconia)

2.5.2 Tooth-supported, all-ceramic

three-unit fixed dental
prosthesis (FDP)
■ Posterior regions (three-unit zirconia FDP)

This case shows a restoration using a tooth-supported, all-ceramic

FDP.
Assessment and treatment planning
A 68-year-old female presented herself at the clinic seeking
treatment for the renewal of her failing three-unit porcelain-fused-to-
metal (PFM) FDP. The FDP abutments of teeth 45 and 47 had to be
newly restored.
The patient wanted a natural-looking restoration with no visible
metallic edges.
After the removal of the insufficient PFM FDP, both metallic post
and cores were left in place in order not to risk any fracture or
infection the abutment teeth. The root canal fillings were radiologically
sufficient and free from any signs of inflammation. The two abutments
were slightly reprepared and a conventional impression was
envisaged.
The digitization of the casts was planned to be performed at a
later time point in the dental laboratory, after the fabrication of the
master cast applying the CEREC inEos X5 laboratory scanner
(Dentsply Sirona, Bensheim, Germany). The decision was made to
use the semi-translucent zirconia (VITA YZ HT, Vita Zahnfabrik, Bad
Säckingen, Germany) in order to adequately mask the abutment
teeth with their grayish metal posts. To then improve the esthetics
and individually adjust the restoration to the neighboring teeth, a small
buccal cutback was planned and the FDP was partially reduced in
order to gain space to adapt the shade by means of microveneering.

Preparation, impression, and

provisionalization
A silicone index was fabricated, based on the existing restoration,
before it was removed. The teeth 45 and 47 were re-prepared 360-
degrees with an epigingival course to preserve as much tooth
substrate as possible. As there was already an existing restoration,
sufficient space was available, and the finalization of the preparation
consisted mainly of smoothing the edges and relocating the margin
line. The final impression was taken applying two retraction cords. In
order to avoid traumatization of the gingiva and to minimize the risk of
recessions, a surgical suturing material (size 4-0, Vicryl Ethicon,
Johnson & Johnson, New Brunswick, NJ, USA) was used as the first
retraction cord. The second retraction cord was the thinnest available
on the market (000 Ultrapak, UP Dental, Cologne, Germany). Based
on the initial silicone index, a direct provisional was produced using
chemically curing composite material in shade Vita A3 (Protemp, 3M,
Seefeld, Germany) (Fig 2-5-28).
Fig 2-5-28a and 2-5-28b Initial situation with and without the FDP.

Fabrication of the FDP in the laboratory

The FDP was constructed with a fully anatomical occlusion using the
inLab software 16.1 (Dentsply Sirona), with a somewhat “old gold
cuspid protection style” design and only a buccal and approximal
reduction. This was applied with the aim to minimize the risk for
chipping.
The reduction on 45 was slightly more pronounced than the
reduction of the pontic and the second molar, as the tooth was at the
transition point to the neighboring remaining teeth.
As all of this design process was done digitally, it is extremely
predictable. Even more importantly, the software guides the
technician regarding certain parameters, for instance, minimum wall
thickness. This could be seen as an embedded quality control (Fig 2-
5-29). The three-unit FDP was then milled and prior to the sintering,
the restoration was individually infiltrated with shade liquid (VITA YZ
HT SHADE LIQUID A2, Vita Zahnfabrik) to transform the monolithic
monochromatic FDP into a 3D multicolor-appearing FDP. Therefore,
the cusps toward the center of the occlusion were accentuated with
chroma A. An inward translucence was generated at the cusp tips
with the selective application of a blue colorant and for a more
chromatic effect in the cervical and approximal areas, the FDP was
also infiltrated with chroma A (Fig 2-5-30).
Fig 2-5-29a to 2-5-29c Design of the FTP.
Fig 2-5-30a to 2-5-30c Fabrication of the FDP.

Framework try-in
The sintered and (in the dental laboratory) adjusted framework was
checked intraorally for its marginal adaptation. Despite the name
“framework,” today this is no longer just a framework but a structural
Part of the restoration including functional areas. Consequently those
occlusal areas and contact points could also be verified before the
restoration was finalized (Fig 2-5-31).
Fig 2-5-31a and 2-5-31b Framework try-in.

Finalization of the restoration

After the verification of the framework, the restoration was buccally
veneered with feldspathic veneering ceramic (VITA VM 9 BASE
DENTINE A3, and the corresponding enamel, Vita Zahnfabrik). For
the second bake, due to the minimal shrinkage of these
microveneerings, only the approximal contacts had to be optimized
with a dentin–enamel mix. This was followed by the final
characterization with stains (VITA AKZENT Plus, Vita Zahnfabrik).
The fissures were characterized with EFFECT STAINS 06 (ES 06,
rust red). For an increase in chroma on the cusps toward the center
of the occlusion, ES 04 (sunny yellow) and 05 (orange) was used to
achieve a translucent effect of the cusp tips; ES11 (blue) and 12
(gray–blue) were also applied. After a fixation firing, the glaze firing
took place (VITA AKZENT Plus GLAZE LT, Vita Zahnfabrik).
To finalize the all-ceramic FDP, it was manually polished –
especially in the occlusal areas – to leave no roughness or porosities
that could induce or increase the wear of the antagonistic teeth (Fig
2-5-32).
Fig 2-5-32a to 2-5-32d Finalization of the restoration.

Integration of the restoration

The finalized FDP was clinically tested for its shade and occlusal
integration. Before it was finally fixed by the application of a self-
adhesive universal resin cement (RelyX Unicem, 3M) it was cleaned
in an alcohol bath; thereafter, a silane-containing primer was applied
according to the manufacturer’s recommendations. Constant finger
pressure was applied during the setting time. Adjustments were
performed where needed, after which the ceramic surfaces were
meticulously polished with the Optrafine Kit (Ivoclar, Vivadent,
Schaan, Liechtenstein). The metallic post and cores were reliably
masked, and the patient was very satisfied with the final outcome of
the esthetic restoration (Fig 2-5-33).
Fig 2-5-33a and 2-5-33b Integration of the restoration.

(Dental practitioner: Dr N Kalberer; Technician: MDT V Fehmer.)

3D-printed all-ceramic
restorations
(on implants and teeth)

2.5.3 The 3D-printed prototype

■ 3D-printed prototype
■ Posterior regions (monolithic three-unit FDPs on implants and
teeth)

This section describes the application of the 3D-printed prototype – a

new protocol for the evaluation of monolithic all-ceramic restorations
before finalization.
Assessment and treatment planning
A 70-year-old male patient attended the University of Geneva for the
rehabilitation of the first and fourth quadrants. During the clinical
examination, an elongated three-unit tooth-supported metal-ceramic
FDP with technical complications (minor chipping on the pontic area,
and metal framework exposure on the mesial abutment) was
observed in the first quadrant. Additionally, it showed insufficient
marginal adaptation. In the fourth quadrant, the patient came with two
existing tissue level implants (Straumann Tissue Level implants,
Straumann, Basel, Switzerland) in positions 44 and 46. After a careful
analysis of the case, the recommended treatment plan was to
replace the old metal-ceramic three-unit FDP by means of a new all-
ceramic monolithic zirconia FDP, and restore the mandibular arch with
a new all-ceramic implant-supported monolithic zirconia three-unit
FDP on titanium-base abutments (Fig 2-5-34).
Fig 2-5-34a to 2-5-34c Pretreatment photographs.

Conceptional introduction
Long-term success in a restorative dentistry practice is based on
comprehensive diagnosis and treatment planning, followed by efficient
communication between the dental practitioner, dental technician, and
patient. For carrying out the optimal results of restorative procedures,
the pretreatment diagnostics by means of wax-ups and set-ups is
needed for the evaluation of the esthetic and functional treatment
outcomes prior to the beginning of the treatment. The planned
outcomes can then be tested during the provisional phase. The
evolution of dentistry in recent years has provided tools and materials
to enhance the predictability and precision of restorations by new
digital design and manufacturing procedures.
The exponential development of more powerful computers and
software provided higher efficiency and precision, changing the
paradigm of lost-wax casting techniques into the so-called digital
workflow by the application of more sophisticated procedures based
on data acquisition, data processing, and manufacturing – known as
computer-aided design and computer-aided manufacturing
(CAD/CAM) technology.
The transition to digital dentistry allows a wider range of designs
and manufacturing methods of the selected restorations and the
associated materials. Based on different systematic reviews, the
estimated 5-year survival rates of multiple-unit FDPs range between
94.4% for metal-ceramic and 90.4% for all-ceramic densely sintered
zirconia when tooth-supported, and between 98.7% for metal-
ceramic and 93% for zirconia ceramic/monolithic zirconia when
implant-supported. Of the 5-year cumulative complication rates of
zirconia-ceramic, the most common technical complication was the
fracture or chipping of the veneering material with a rate of 50%
(95%CI: 29.1–72.1%).
Various fracture pathways of both monolithic and bi-layered all-
ceramic restorations have been suggested based on fractographic
analysis. Accordingly, the origin of the fracture can be occlusal
contact, margins, or connectors, and the process can be enhanced
by a combination of chemical and mechanical degradation which
accelerates the fatigue process. Veneered structures, given their
weaker mechanical properties, were reported to be more prone to
crack propagation originating from surface cracking. In order to
overcome this problem that eventually leads to inferior survival rates,
monolithic zirconia restorations may be an interesting alternative.
There is a fundamental difference between the veneered and
monolithic restorations when it comes to their adjustability. Monolithic
high-strength ceramic restorations demonstrate difficulty in clinical
adjustment which can lead to a potential loss in initial strength
following the adjustments. It was reported that microroughness, as a
result of grinding on the surface of monolithic restorative materials,
leads to crack propagation originating from those areas. This can
thereby jeopardize the mechanical superiority of those materials
which are recommended for use in high stress-bearing areas.
Therefore, it is important to minimize the need for chairside
adjustments of monolithic zirconia restorations.

Diagnostics and direct provisionalization

As a first step, alginate impressions were taken and poured with type
3 stone in order to adapt the cast and make a silicone key index for a
direct provisional. Under local anesthesia the old metal-ceramic FDP
was removed, the abutment teeth 14 and 16 prepped and re-shaped
for an all-ceramic three-unit FDP, and a direct provisional with
autopolymerizable resin was fabricated (Protemp 4, 3M, Seefeld,
Germany) following the manufacturing instructions (Fig 2-5-35).

Fig 2-5-35a to 2-5-35b Diagnostics and direct provisionalization.

Preparation and optical impression
After a period of 4 weeks, an intraoral partial optical impression was
taken (TRIOS 3 Wireless, 3Shape, Copenhagen, Denmark) in the
maxillary and mandibular arches with corresponding
polyetheretherketone (PEEK) scanbodies in place (Mono
Scanbodies, Straumann, Basel, Switzerland) for the implants in their
positions 44 and 46. The acquired data was then sent to the dental
laboratory via the respective digital means (3Shape) (Fig 2-5-36).
Fig 2-5-36a to 2-5-36f Preparation and optical impression.

Design of the monolithic FDPs in the

laboratory
In the dental laboratory, the dental technician elaborated the CAD
design of both final three-unit full contour restorations in the maxillary
as well as in the mandibular arches using the specialized software
(Dental Designer 2018 software, 3Shape). Guided by the design
software and completed all design steps throughout the workflow and
as initially indicated in the order sheet, the software automatically led
to the 3Shape Model Builder software (3Shape) in which an
articulator was selected and the master model with its removable
dies was digitally designed (Figs 2-5-37 and 2-5-38).
Fig 2-5-37a to 2-5-37l Design of the maxillary master model.
Figs 2-5-38a to 2-5-38f Design of the mandibular master model.

In a conventional approach at this point, the models could have

been 3D-printed or fabricated conventionally by pouring an
elastomeric impression, and the final restorations would be milled
from the white stage zirconia. Certain clinical scenarios, especially
with a free-end edentulism as in the presented case, significantly
increase the risk for the potential need of clinical adjustment of the
final and densely sintered zirconia restorations, which can be
associated with the risk of permanently weakening the structures.

Digital fabrication of the prototype alongside

the model in the laboratory
Thus, following the digital design, prior to the manufacturing of the
monolithic frameworks the same CAD data was used to create
printed prototype made of a 3D printable resin (SHERAPRINT Model
Plus UV, SHERA Werkstoff-Technologie, Lemförde, Germany) with a
digital light processing printer (RapidShape, Straumann) in order to
have the possibility to verify all essential parameters, like marginal
adaptation, overall fit, dimensions, contact points, and most
importantly the occlusion intraorally. If necessary, adjustments can be
performed clinically, and be transferred to the laboratory in order to
modify the CAD data accordingly for the restoration manufacturing
process (Fig 2-5-39).
Fig 2-5-39a to 2-5-39d Digital fabrication of the prototype.
Verification of the prototypes
The key points for how to transfer the modifications into the software
are as follows.
■ If minor modifications on the structure need to be made, the
desired changes can be visualized and communicated with the
dental technician in order to be modified before the milling of the
framework.
■ If major corrections need to be made following the adjustments,
the 3D printed prototype that is placed intraorally should be re-
scanned in order to transfer the new intraoral situation to the
laboratory. In the CAD software the dental technician can
superimpose the new scan and modify the CAD design in order to
get exactly the final desired volume.

In this case, once the 3D-printed prototypes were validated and only
minor corrections were done, the initial digital designed file of the full
contour FDP on tooth 14 was slightly adjusted on the specific CAD
software (3Shape Dental Designer 2018 software, 3Shape). Finally,
the full contour monolithic FDP was milled in a white stage (Lava
Esthetic A3, 3M) using a five-axis milling machine (Wieland Zenotec
Select Hybrid, Ivoclar Vivadent) and sintered to its final density, and
then tried-in intraorally (Fig 2-5-40).
Fig 2-5-40a to 2-5-40h Verification of 3D-printed prototypes.

Integration of the restorations

After the minor corrections of the 3D printed try-in prototype, the fit of
the monolithic restorations was as planned in the CAD software and
compared to the printed prototype. It showed no need for further
modifications, especially in terms of contact points and occlusion. For
the final steps on the manufacturing procedure and after high-gloss
polishing of the zirconia framework and applying a glazing layer, the
final restorations were delivered and inserted intraorally (Fig 2-5-41).
Fig 2-5-41a to 2-5-41f Final restorations.

The cementation protocol was as follows:

The prepared teeth were cleaned (Detartrine Prophy Paste,
Septodont, Belgium), rinsed with water, and air dried. The surfaces
were airborne-particle abraded with 30 μm Al2O3 + SiO2 coating, 2.5
bars (CoJet, 3M), rinsed with water and air dried, followed by an
acid-etch treatment with 37% phosphoric acid etching gel, rinsed with
water for 1 min and air dried. Finally the primer agents were applied
following the manufacturer’s instructions (ED PRIMER Liquid A and
Liquid B, Kuraray, Tokyo, Japan). The restorations were prepared
according to the manufacturer’s recommendations for adhesive
cementation and adhesively luted with a resin cement (Panavia 21
TC, Kuraray). For the implant-supported FDP, the same protocol as
described for the previous case was followed. One month after
clinical treatment, the access screw holes were closed permanently
as previously described (Fig 2-5-42).
Fig 2-5-42a to 2-5-42d Final outcome.

(Dental practitioner: Dr J Legaz Barrionuevo; Technician: MDT V

Fehmer.)

The prototype concept

By means of this case, the workflow for both additive and subtractive
CAM techniques have been elaborated. If a long-term provisional
phase is required, the use of mechanically more durable provisional
material seems to be important. However, due to time or economic
reasons, completing the definitive treatment without a provisional
phase can be necessary. In these cases, to be able to predict the
final restorative treatment by 3D printing a prototype and using it as a
mock-up, provides a less costly and more efficient approach.
Improvements in digital technologies have provided possibilities to
use biomimetic restorative materials with higher accuracy, and the
fabrication process has become more standardized and predictable.
As a result, the outcomes of the restorations are less dependent on
the dental technician’s ability and motivation. When it comes to digital
manufacturing, there are two main methods: subtractive and additive.
Subtractive methods have a longer background and wide spectrum of
materials. The waste of considerable amounts of work material,
limitations originating from the milling bur diameter, impossibility of
rapid manufacturing, and requirement of manual finishing due to the
roughness created by the milling procedure are the main
disadvantages of this technique.
Meanwhile, the use of additive manufacturing in dentistry is a
relatively new technology. Accordingly, the available materials are
limited, and consequently the spectrum of end products is restricted
to occlusal splints, surgical guides, diagnostic models, mock-ups, and
provisional restorations. Additive technologies offer some advantages
over subtractive methods; the possibility of rapid manufacturing and
lower percentage of wasted raw material. Moreover, elimination of
the need for hand polishing increases the efficiency of the fabrication
process. Therefore, despite the initial investment, as a result of the
current developments in the additive manufacturing technology and
the existing 3D printers, fabricating provisional restorations and mock-
ups with 3D printers provides a cost- and time-efficient workflow.
Nevertheless, the initial investment for a 3D printer and
software/hardware, learning curve of the dental technician mastering
the programs, need for final fine-tuning adjustments, post-processing
requirement, and some limitations when structures under 0.3 mm are
needed are the major shortcomings of this technology.
Monolithic restorations have become an interesting treatment
option from both mechanical and esthetic aspects by the development
of translucent high strength ceramics. It may be assumed that
monolithic ceramics exhibit low rates of complications due to their
excellent mechanical properties. However, the clinical adjustment of
these high-strength ceramics still remains a risk factor.
The use of a prototype, milled or printed, and especially prior to
the manufacturing of the monolithic restorations, may be beneficial for
some aspects. Firstly, the missing or short parts can be detected
during the trial of the prototype and accordingly the definitive
restoration design can be modified. Secondly, it is crucial to minimize
the occlusal grinding commonly needed for free-end restorations. To
execute the adjustment on the 3D printed prototype and transfer the
ideal occlusal geometry by scanning it, is efficient to minimize the
adjustment need of the definitive restoration material intraorally, which
could lead to a potential loss in initial strength and the possibility of
crack propagation originating from those areas, greater biofilm
accumulation, and less favorable wear behavior of the opposing
natural dentition if they are not high gloss polished. Lastly, the outer
shape and esthetic result of the restoration can be checked before
the final restoration is milled and the design can be altered
accordingly.
Traditional CAM dentistry is mainly subtractive, by cutting away
mechanically the material and achieving the desired geometry based
on the computer-guided instructions. On the other side, additive
technologies to manufacture solid complex profiles direct from a 3D
CAD model (also known as “3D printing,” “layered manufacturing,” or
“solid free-form fabrication”) are based on principles defined by the
American Society for Testing and Materials (ASTM) as “the process
of joining materials to make parts from 3D model data, usually layer
upon layer, as opposed to subtractive manufacturing and formative
manufacturing methods” (ISO/ASTM). They were classified in
categories depending on the manufacturing process:
stereolithography (SLA) and digital light processing (DLP), material
jetting (MJ), or polyjet printing (PP), material extrusion (ME) or fused
deposition modeling (FDM), binder jetting, powder bed fusion (PBF),
sheet lamination, and direct energy deposition.

Conclusion
The use of a prototype (either a provisional or rapid prototyping by
milling or 3D printing) improves the communication between the dental
practitioner, technician, and patient, and may lead to a higher
efficiency and predictability of the treatment outcomes.
(In collaboration with Dr D Karasan and Dr J Legaz Barrionuevo.)
CHAPTER 6
Implant-supported single
crowns (SCs)

Anterior regions
2.6.1 Anterior implant-supported SC with
GBR
2.6.2 Anterior implant-supported SC with
GBR
2.6.3 Anterior implant-supported SC

Posterior regions
2.6.4 Posterior implant-supported SC with
GBR
2.6.5 Posterior implant-supported SC with
GBR
2.6.6 Posterior implant-supported SC and
optical impression
Complex situations
2.6.7 Tooth- and implant-supported all-
ceramic SCs and fixed dental
prostheses (FDPs)

Implant-supported single crown

with GBR
(all-ceramic abutment and restoration)

2.6.1 Anterior implant-supported SC

with GBR
■ Anterior single central incisor (all-ceramic abutment and
restoration)
■ Single anterior implant with guided bone regeneration (GBR)

This first case shows the application of a regular diameter implant

(bone level 4.1 mm) with a zirconia abutment and lithium-disilicate
crown in the esthetic zone.
Assessment and treatment planning
A 42-year-old male patient presented himself at the clinic as he could
sense a small movement in his endodontically treated central incisor
21 for several years prior. The patient was healthy, a non-smoker,
and did not take any medication.
Evaluating the tooth during the first appointment, it became
immediately evident that not only the metalceramic crown and the
gold post had become loose, but also the root had a vertical fracture
that made it irrational to treat (Fig 2-6-1).
Figs 2-6-1a to 2-6-1c Pretreatment photographs.

Once it became evident that the tooth had to be extracted, the

two main fixed restorative options were discussed with the patient.
On the one hand, a single-retainer resin-bonded fixed dental
prosthesis (RBFDP) bonded to tooth 11, or on the other, a single
implant.
In this particular case, due to the rotation of his adjacent central
incisor and the bite that had not sufficient horizontal overlap to place a
zirconia backing, the decision was drawn toward placement of a
regular diameter bone-level implant (ASTRA OsseoSpeed, Dentsply
Sirona, Bensheim, Germany).
Before the extraction an alginate impression was performed and it
was planned to prefabricate a provisional metal-based RBFDP with
two small and very thin backings to offer the patient a fixed
restoration directly on the day of extraction.
After a healing period of 8 weeks, an early implant placement
procedure was planned. Due to the position in the arch and the
available space, it was decided to place a bone-level implant with a
regular diameter, including GBR if needed. After successful
osseointegration and a provisional phase, the implant would be
restored with a direct screw-retained restoration (Fig 2-6-2).
Fig 2-6-2a to 2-6-2d Insufficient metal-based SC.

Provisionalization
The loose crown was provisionally cemented on the fractured root
and two alginate impressions were performed. Those were sent to
the dental laboratory and after the production of the plaster casts, the
respective failing tooth was carved off.
A conventional denture tooth was selected according to the
corresponding shape and to the basic Vita shade A2 (Creapearl,
Creation Willi Geller, Meiningen, Austria).
The denture tooth had to be slightly adjusted to perfectly match
the pontic before it was hollowed out from the palatal side to gain
space for the supporting chrome cobalt metal framework.
Once the framework with these extremely thin backings (due to
the lack of space) was cast and adjusted, the denture tooth was
relined on the plaster cast with a classic acrylic PMMA material (New
Outline, Anaxdent, Stuttgart, Germany) and finalized.
Additionally, two cementation aides (little holes) were carved into
the backings (Fig 2-6-3).
Figs 2-6-3a to 2-6-3x Provisionalization.

Extraction
Due to the vertical fracture and despite an extremely careful
extraction, the tooth immediately broke into several pieces. Once the
tooth and the remaining root fragments were extracted, granulation
tissue had to be removed and finally the socket was curettaged and
rinsed with neomycin solution (Fig 2-6-4).
Fig 2-6-4a to 2-6-4d Extraction.

Ridge preservation
After the extraction and cleaning of the socket, a xenogeneic bone
substitute (Bio-Oss Collagen, Geistlich, Wolhusen, Switzerland) was
inserted in combination with a punch graft harvested from the palate
to perform a ridge preservation. Once sutured, the fixed RBFDP
provisional was adapted to the apical side to avoid any pressure on
the graft and cemented (Fig 2-6-5).
Fig 2-6-5a to 2-6-5f Prosthetic-driven implant placement.

Implant placement and regeneration

According to the diagnostics, a surgical stent was fabricated,
transferring the prosthetic plan of the ideal three-dimensional (3D)
position of the implant to the surgical intervention.
At the day of implant placement (4 months after extraction), the
patient was premedicated with 1500 mg amoxicillin and 600 mg
ibuprofen. After the raising of a mucoperiosteal flap with a vertical
releasing incision distal of the tooth 22, a regular diameter bone-level
implant (ASTRA OsseoSpeed, Dentsply Sirona) was placed with
good primary stability and a correct prosthetic position/axis. A small
closure screw was applied to cover the implant.
The ridge deficiency was augmented with a xenograft (Bio-Oss
Collagen, Geistlich Pharma) and the graft was covered with a
collagen membrane (Bio-Gide, Geistlich Pharma) to allow for hard
tissue formation. The flap was released by splitting the periosteum
allowing for a tension-free re-adaptation of the flap. After the suturing
(Gore-Tex 5.0, W.L. Gore & Associates, Flagstaff, AZ, USA) the
implant was left for submucosal healing for 8–10 weeks.
Antibiotics (amoxicillin 3 × 750 mg for 5 days), painkillers (600 mg
ibuprofen if needed), and chlorhexidine mouthrinse (0.2%) were
prescribed. The sutures were removed 10 days after implant
placement (Fig 2-6-6).
Fig 2-6-6a to 2-6-6f Implant placement and regeneration.

Provisionalization
Two weeks after the abutment connection, an analog impression was
taken. In the laboratory, the dental technician fabricated the
provisional crown using the temporary abutment (retentive) made
from a titanium alloy (TAN) and veneered with a classic acrylic PMMA
material (New Outline, Anaxdent) that was later on easy to reline in
the yet undercontoured submucosal part. This was partly due to the
provisional being fabricated with a kind of ridge flap design, to avoid
too much pressure on the soft tissue during insertion.
After removal of the healing abutment, healthy peri-implant
mucosa was revealed. The provisional was inserted and tightened.
During the following weeks, the provisional was modified two times
with composite resin to optimize the emergence profile (Fig 2-6-7).
Fig 2-6-7a to 2-6-7f Provisional crown.

Impression
After a provisional phase of 5 months, a second impression with an
individualized impression coping was taken. This individualized
impression coping presented the exact copy of the emergence profile
that was sequentially developed with the provisional. In order to
modify the standardized impression copings, the provisional was
mounted to an analog and embedded in a putty material. Once the
material had set the provisional crown could be unscrewed and the
impression coping was mounted.
The free space could then be filled with either a light-curing
composite or as it was done in this case with a self-curing acrylic
(GC Pattern Resin, GC, Leuven, Belgium).
The now individualized impression coping was transferred to the
implant sight and the final impression was carried out and sent to the
dental laboratory (Fig 2-6-8).
Fig 2-6-8a to 2-6-8c Impression after provisionalisation phase.
Fabrication of cast and wax-up
The master cast was produced in the laboratory and a wax-up was
fabricated using white wax in order to verify the exact shape of the
final restoration before the actual restoration and its framework was
created (Fig 2-6-9).

Fig 2-6-9a and 2-6-9b Fabrication of cast and wax-up.

Fabrication of the all-ceramic zirconia

abutment
As this implant restoration was Part of a clinical study the patient was
randomized into the cement-retained customized zirconia abutment
group (Atlantis, Dentsply Sirona). Once the conventional impression
was translated into a master cast, the models were scanned using a
lab scanner (Imetric 4D, Courgenay, Switzerland) and the indicated
metal mono scanbody for the Atlantis workflow. The generated files
were then uploaded to the Atlantis WebOrder and the color of the
abutment was indicated as 00 (uninfiltrated white). The abutment was
predesigned by the Atlantis team and then uploaded to their cloud-
based Atlantis 3D Editor. Here adjustments like margin lines or other
small corrections could be done and the revised abutment was
approved for production. Once delivered, the abutment was checked
on the cast for its correct emergence profile according to the study
protocol; this had to be verified intraorally (Fig 2-6-10).
Fig 2-6-10a to 2-6-10f The all-ceramic zirconia abutment.

Fabrication of the all-ceramic abutment

crown
After the clinical verification of the abutment in the dental laboratory,
an all-ceramic lithium-disilicate crown (IPS e.max press LT A2, Ivoclar
Vivadent, Schaan, Liechtenstein) was produced by means of the lost
wax technique, and veneered (IPS e.max Ceram, Ivoclar Vivadent)
according to the custom shade that was developed by the dental
technician in collaboration with the patient.
After two firings, the surface texture and the final shape were
developed with stones and diamond burs. The glaze firing was
followed by an additional stain firing and a mechanical polishing
procedure (Fig 2-6-11).
Fig 2-6-11a to 2-6-11f Fabrication of the all-ceramic abutment
crown.
Integration of the cement-retained implant
restoration
The provisional was removed and the implant and adjacent tissues
were disinfected with a chlorhexidine solution. After disinfection (Tiutol
dent, B. Braun Melsungen, Melsungen, Germany) and the application
of a chlorhexidine gel to the submucosal Part (PlakOut Gel,
KerrHawe, Bioggio, Switzerland), the zirconia screwretained
abutment was tightened with the final torque as recommended by the
manufacturer and the screw access hole was sealed with Teflon and
a composite filling (Tetric Classic, Ivoclar Vivadent). Once the
abutment was seated, the lithium-disilicate crown was adhesively
cemented (Multilink Automix yellow, Ivoclar Vivadent). After the
cementation, the implant restoration was meticulously checked for
any remaining cement excess and thereafter the occlusion was
checked and minor adjustments made, followed by polishing.
The final result was extremely pleasing to the entire team and the
patient (Fig 2-6-12).
Fig 2-6-12a to 2-6-12d Final outcome.
(Dental practitioner: Dr D Büchi; Technician: MDT V Fehmer.)

Implant-supported single crown

with GBR
(metal-ceramic restoration)

2.6.2 Anterior implant-supported SC

with GBR
■ Anterior single central incisor (metal-ceramic restoration)
■ Single anterior implant with GBR

The following case involves the application of a regular diameter

implant (bone level 4.1 mm) with a gold abutment in the esthetic zone.

Assessment and treatment planning

A 47-year-old female patient was referred to the clinic after the
extraction of her central incisor 11 performed by the referring dental
practitioner due to an accident. Her wish was to receive a fixed
restoration.
The patient was healthy, a non-smoker, and did not take any
medication; however, she drank a lot of black tea which led to all the
palatal staining.
Two treatment options for replacement with a fixed restoration
were discussed: a single-retainer resinbonded fixed dental prosthesis
(RBFDP) bonded to tooth 21, and a single implant.
Both options were feasible and could have been considered a
valuable treatment option.
As both treatment options were discussed and elaborated with
the patient, pointing out indications and potential limitations, the
patient tended toward replacement by means of a single implant,
which was thereafter planned.
After a healing period of 8 weeks, an early implant placement
procedure was planned. Due to the position in the arch and the
available space, it was decided to place a Straumann BL implant
(Straumann, Basel, Switzerland) with a diameter of 4.1 mm, including
GBR if needed. After successful osseointegration and a provisional
phase, the implant should be restored with a direct screw-retained
restoration (Fig 2-6-13).
Figs 2-6-13a to 2-6-13c Pretreatment photographs.

Implant placement and regeneration

According to the diagnostics, a surgical stent was fabricated
transferring the prosthetic plan of the ideal 3D position of the implant
to the surgical intervention.
At the day of implant placement (8 weeks after extraction), the
patient was pre-medicated with 1500 mg amoxicillin and 600 mg
ibuprofen. After the raising of a mucoperiosteal flap with a vertical
releasing incision distal of the tooth 12, a regular diameter bone-level
implant (Straumann BL 4.1 mm) was placed with good primary
stability and a correct prosthetic position/axis. A small closure screw
was applied to cover the implant.
The ridge deficiency was augmented with a xenograft (Bio-Oss
Collagen, Geistlich Pharma, Wolhusen, Switzerland) and the graft
covered with a collagen membrane (Bio-Gide, Geistlich Pharma) to
allow for hard tissue formation. The flap was released by splitting the
periosteum allowing for a tension-free readaptation of the flap. After
the suturing (Gore-Tex 5.0, W.L. Gore & Associates, Flagstaff, AZ,
USA) the implant was left for submucosal healing for 8–10 weeks.
Antibiotics (amoxicillin 3 × 750 mg for 5 days), painkillers (600 mg
ibuprofen if needed), and chlorhexidine mouthrinse (0.2%) were
prescribed. The sutures were removed 10 days after implant
placement (Fig 2-6-14).
Fig 2-6-14a to 2-6-14f Implant placement and regeneration.

Provisionalization
Two weeks after the abutment connection, an analog impression was
taken. In the laboratory, the dental technician produced the
provisional crown using the temporary abutment (retentive) made
from a titanium alloy (TAN) and veneered with a classic acrylic PMMA
material (New Outline, Anaxdent, Stuttgart, Germany) that was later
on easy to reline in the yet undercontoured submucosal part. This
was due to the provisional having a kind of ridge flap design to avoid
too much pressure on the soft tissue during insertion.
After removal of the healing abutment, healthy peri-implant
mucosa was revealed.
The provisional was inserted and tightened. During the following
weeks, the provisional was modified two times with composite resin
to optimize the emergence profile (Fig 2-6-15).

Figs 2-6-15a and 2-6-15b Provisional restoration.

Impression
After a provisional healing phase of 5 months, a second impression
with an individualized impression coping was taken (Fig 2-6-16).
Figs 2-6-16a to 2-6-16d Impression after 5-month provisional
healing phase.

Fabrication of the screw-retained implant

restoration
The master cast was produced in the laboratory. A wax-up was
fabricated using esthetic wax in order to verify the exact shape of the
final restoration before the actual restoration, and a framework was
created (Fig 2-6-17).
Fig 2-6-17a to 2-6-17d Wax-up try-in.

The custom shade was developed by the dental technician during

the wax-up try-in. In this particular case, because of the general low
value and grayish appearance of the reference teeth, it was decided
that a metal-based restoration would serve as the restorative
material of choice. Despite the fact that those abutments are quite
expensive and the process of casting always comes with additional
risks and costs associated by the alloy, it was considered the most
predictable restorative material. Once the abutment was cast, it was
checked on the cast for its correct anatomical support and directly
veneered (Creation Classic CC, Willi Geller, Meiningen, Austria)
according to the custom shade. After two dentin firings, the surface
texture and the final shape were developed with stones and diamond
burs, before a biscuit bake try-in was carried out.

Biscuit bake try-in

The biscuit bake was clinically checked with respect to its fit and
shape of the central incisor.
The patient and the restorative team were already very satisfied
with the final shape and gingival adaptation.
However, small details could still be improved. So it was
discussed to slightly shorten the distal incisal edge, push the tissue a
bit more toward the mesial papilla and try to copy the superficial
characteristics by means of some white spots toward the incised
third and brown staining in the cervical area.
The aforementioned detail is crucial to the final treatment’s
success but difficult to apply toward the laboratory work if the
technician cannot be on site themselves. The use of images is clearly
of great support but they will never lead to the same ideal outcome
(Fig 2-6-18).
Fig 2-6-18a to 2-6-18d Biscuit bake try-in.

Finalization of the restoration

The shape was adjusted as discussed during the biscuit bake try-in
and glaze firing was followed by an additional stain firing to achieve
the perfect adaptation of stains. Finally, the crown was mechanically
polished to achieve a similar degree of gloss to the adjacent central
incisor.
Integration of the screw-retained implant
restoration
The provisional was removed and the implant and adjacent tissues
were disinfected with a chlorhexidine solution. After disinfection (Tiutol
dent, B. Braun Melsungen, Melsungen, Germany) and the application
of a chlorhexidine gel to the submucosal Part (PlakOut Gel,
KerrHawe, Bioggio, Switzerland), the metal-based screwretained
implant crown was preliminarily retained to the implant for a period of
2 weeks, by tightening the screw by hand (approx. 20 Ncm) and by
closing the screw access hole with Teflon and a provisional resin
(Telio, Ivoclar Vivadent, Schaan, Liechtenstein).
After 2 weeks, the abutment/crown screw was retightened with
the final torque as recommended by the manufacturer (35 Ncm). For
the final closure of the screw access, rubber dam was applied, and
the veneering ceramic layer around the access hole was etched (9%
hydrofluoric acid) and silanated (Monobond Plus, Ivoclar Vivadent).
The screw was densely covered with Teflon. Subsequently, a bonding
agent was applied (Heliobond, Ivoclar Vivadent), and the closure of
the screw access hole was finalized with a light-curing composite
filling material (Tetric Classic, Ivoclar Vivadent) in the corresponding
shade. After the light-curing, the occlusion was checked, followed by
polishing of the composite filling.
The final result was extremely pleasing for the entire restorative
team and even more importantly, the patient was very satisfied that
this long treatment had paid off so well (Fig 2-6-19).
Fig 2-6-19a to 2-6-19e Final outcome.
(Surgeon: Prof Dr R Jung; Dental practitioner: PD Dr S
Mühlemann; Technician: MDT V Fehmer.)

Implant-supported single crown

(titanium-resin-base abutment and zirconia
crown)

2.6.3 Anterior implant-supported SC

■ Anterior regions (titanium-resin-base/hybrid abutment and
restoration)
The following case involves the application of a narrow-diameter
implant in the esthetic zone.

Assessment and treatment planning

A 51-year-old female patient presented herself at the clinic because
of slight pain from time to time in the region of tooth 12. The patient
was healthy, a non-smoker, and did not take any medication. During
the clinical examination, she complained about a light pain on
percussion on tooth 12. The tooth was endodontically treated and
restored with a composite build-up. Further, the tooth showed an
increased mobility of grade 2 with no periodontal probing depth
(PPD) of more than 4 mm. The periapical radiograph showed
radiolucency around the apex of tooth 12. After consultation with an
endodontic specialist, it was decided to extract tooth 12 and to
perform a ridge preservation procedure to maintain the volume. After
a healing period of 8 weeks, an early implant placement procedure
was planned. Due to the fact that the distance between the teeth 11
and 13 was narrow (approximately 6 mm), it was decided to place a
Straumann bone level tapered (BLT) implant (Straumann, Basel,
Switzerland) with a diameter of 2.9 mm, including GBR if needed.
After successful osseointegration and a provisional phase, the implant
was to be restored with a translucent zirconia (Katana Zirconia,
STML A2 T18; Kuraray, Tokyo, Japan) crown on a titanium bonding
base. It was planned to take an analog impression and then to follow
a digital laboratory workflow using computer-aided design/computer-
aided manufacturing (CAD/CAM) technology (Fig 2-6-20).
Figs 2-6-20a to 2-6-20d Pretreatment photographs and radiograph.

Surgical procedure
The tooth was extracted and a xenogeneic bone substitute in
combination with a punch graft from the palate was used to perform a
ridge preservation procedure (Fig 2-6-21). A provisional removable
prosthesis was adapted and incorporated to replace the missing
tooth.
Figs 2-6-21a to 2-6-21e Ridge preservation procedure.

Six weeks later, a well-maintained ridge with completely healed

soft tissue conditions could be observed clinically. Alginate
impressions of the situation were made and a wax-up of tooth 12 was
fabricated on the plaster cast. According to the wax-up, the dental
technician manufactured a conventional surgical guide (Fig 2-6-22).
Figs 2-6-22a to 2-6-22c Surgical guide.

On the day of implant placement (7 weeks after extraction), the

patient was premedicated with 1500 mg amoxicillin and 600 mg
ibuprofen. Under local anesthesia, a crestal incision from the palatal
line angle of tooth 11 to the palatal line angle of tooth 13 and a
vertical releasing incision distal at tooth 13 was performed. A full-
thickness flap was elevated. The conventional surgical stent was
placed and the preparation of the implant bed was performed
according to the manufacturer’s instructions as follows: at the
beginning, the implant position was marked with a 1.4-mm round bur.
The first osteotomy was performed with the needle drill with a
diameter of 1.6 mm. Afterwards, the implant bed was prepared with
the pilot drill with a diameter of 2.2 mm (Fig 2-6-23a to 2-6-23e). The
correct axis and the vertical position were checked with the help of
the specific indicators and the use of the surgical guide. As the bone
was quite soft, there was no need to use the profile drill and the tap.
A Straumann BLT Small CrossFit (SC) implant with a diameter of 2.9
mm and length of 12 mm was placed with good primary stability and
a correct prosthetic position/axis. A small closure screw was applied
to cover the implant. Autologous bone chips, a xenograft, and a
collagen membrane were used to augment the buccal fenestration
defect and to enhance the vestibular ridge contour for a more natural
appearance of the final crown. The periosteum was released and the
flap was repositioned to achieve a primary wound closure with a 5.0
ePTFE non-absorbable monofilament suture (Fig 2-6-23). Antibiotics
(amoxicillin 3 × 750 mg for 5 days), painkillers (600 mg ibuprofen if
needed), and chlorhexidine mouthrinse (0.2%) were prescribed. The
sutures were removed 10 days after implant placement.
Figs 2-6-23a to 2-6-23i Surgical procedure.

The healing period was uneventful and 3 months after surgery the
clinical examination revealed healthy tissues. At this time point, the
abutment connection was performed under local anesthesia. The soft
tissue covering the implant was de-epithelialized using a round
diamond bur. A U-shaped incision was performed and the small flap
over the implant was raised. A small tissue pouch was prepared at
the buccal aspect of the implant and the flap was rotated into it. After
removal of the closure screw, a healing abutment with a gingival
height of 3.5 mm was inserted (Fig 2-6-24).
Figs 2-6-24a to 2-6-24d Abutment connection.

Prosthetic procedure
Two weeks after the abutment connection, an analog impression was
taken. In the laboratory, the dental technician produced the
provisional crown using the temporary abutment made out of a
titanium alloy (TAN) and composite resin. The provisional had a kind
of ridge-lap design to avoid too much pressure on the soft tissue
during insertion. After removal of the healing abutment, healthy peri-
implant mucosa was present. The provisional was inserted and
tightened with 15 Ncm. During the following weeks, the provisional
was modified two times with composite resin to optimize the
emergence profile. In addition, it was used to apply pressure on tooth
11 because it was the patient’s wish to close the diastema (Fig 2-6-
25).
Figs 2-6-25a to 2-6-25v Prosthetic procedure.

After a provisional phase of 3 months, a second impression with

an individualized impression coping was taken. The master cast was
produced and the titanium-resin-base abutment (gingival height of 1
mm) was screwed to the implant analog. The titanium bonding base
was scanned using the Dental Wings 7 Series scanner. The implant
crown with a buccal cutback was designed with the Dental Wings
Open Software (DWOS) and milled with the Zenotec Select CAM
machine (Wieland Dental, Pforzheim, Germany). As a restorative
material, a highly translucent zirconia was chosen (Katana STML A2
T18). Following the sintering process, the crown was stained and
veneered at the buccal aspect with hand-layered ceramic. After one
biscuit bake try-in, the crown was finalized, cemented with Multilink
Hybrid Abutment HO-0 (Ivoclar Vivadent, Schaan, Liechtenstein) onto
the titanium abutment and polished (Fig 2-6-26).
Figs 2-6-26a to 2-6-26e Creation of the implant crown.

Final result
The final crown could be inserted without any problems and the
clinical fit was verified with a periapical radiograph. The restoration
integrated nicely in the existing dentition and the patient was very
happy with the outcome. The crown on implant 12 appears now a bit
wider than the natural tooth 22, but for the patient it was more
important that the diastema was closed. It was also decided to place
to crown slightly more buccally than tooth 22. Already directly after
insertion of the final restoration, the mucosal situation was more than
acceptable. Nevertheless, further improvement over the next few
weeks or months could be expected. The buccal volume was
preserved well over time and can be compared with the situation of
tooth 22. The final closure of the screw access hole was planned to
take place 3–4 weeks after insertion with PTFE tape and composite
resin. The recall interval would be set at 6 months (Fig 2-6-27).
Figs 2-6-27a to 2-6-27d Final outcome.

(Dental practitioner: Dr J Gavric and Dr S Hicklin; Technician:

MDT V Fehmer.)
Follow-up recall presented a stable situation after 2 years of
clinical function (Fig 2-6-28).
Figs 2-6-28a to 2-6-28f Outcome after 2 years of clinical function.

Implant-supported single crown

with GBR
(titanium-resin-base abutment and lithium-
disilicate crown)
2.6.4 Posterior implant-supported SC
with GBR
■ Posterior regions, titanium-resin base, and restoration (lithium
disilicate)
■ Single posterior implant immediate placement with GBR

This case involves a regular diameter implant (bone-level tapered 4.1

mm) with a titanium-resin-base abutment and lithium-disilicate crown
and immediate placement.

Assessment and treatment planning

A 54-year-old female patient presented herself at the clinic because
of slight pain from time to time in the area of tooth 35. The patient
was healthy, a non-smoker, and did not take any medication. During
the clinical examination, she complained about a slight pain to
percussion on tooth 35. The tooth was endodontically treated and
restored with a composite build-up several years ago. Furthermore,
the tooth showed an increased mobility of grade 2 with a buccal
increased PPD of more than 4 mm. The periapical radiograph
showed radiolucency around the apex of the tooth and a fistula was
present on the buccal side (Fig 2-6-29).
Figs 2-6-29a and 2-6-29b Pretreatment photographs.

After consultation with an endodontic specialist, it was decided to

extract the tooth and, if possible, to perform an immediate placement
of a tapered bone-level implant.
Due to the position in the arch and the size of the extraction
socket, it was decided to place a Straumann BLT (bone-level
tapered) implant (Straumann, Basel, Switzerland) with a regular
diameter of 4.1 mm, including GBR if needed.
After successful osseointegration, the implant was restored with a
lithium-disilicate crown (IPS e.max press LT A2, Ivoclar Vivadent,
Schaan, Liechtenstein) on a titanium bonding base (Vario-Base for
Cerec, Straumann). It was planned to take an analog impression and
then to follow a digital laboratory workflow using CAD/CAM
technology.

Extraction and immediate implant placement

After a careful extraction of the tooth a vertical fracture became
visible. Once the tooth was extracted, granulation tissue had to be
removed and finally the socket was curetted and rinsed with
neomycin solution.
According to the diagnostics a surgical stent was prefabricated
transferring the prosthetic plan of the ideal 3D position of the implant
to the surgical intervention. The patient was premedicated with 1500
mg amoxicillin and 600 mg ibuprofen. After the raising of a
mucoperiosteal flap with a vertical releasing incision distal of tooth 36,
a regular diameter tapered bone-level implant (4.1 mm BLT,
Straumann) was placed with good primary stability and a correct
prosthetic position/axis. A small closure screw was applied to cover
the implant.
The ridge deficiency was augmented with a xenograft (Bio-Oss
Collagen, Geistlich Pharma, Wolhusen, Switzerland) and the graft
was covered with a collagen membrane (Bio-Gide, Geistlich Pharma)
to allow for hard tissue formation. The flap was released by splitting
the periosteum allowing for a tension-free re-adaptation of the flap.
After suturing (Gore-Tex 5.0, W.L. Gore & Associates, Flagstaff,
AZ, USA), the implant was left for submucosal healing for 8–10
weeks. Antibiotics (amoxicillin 3 × 750 mg for 5 days), painkillers
(600 mg ibuprofen if needed), and chlorhexidine mouth rinse (0.2%)
were prescribed. The sutures were removed 10 days after implant
placement (Fig 2-6-30).
Figs 2-6-30a and 2-6-30b Extraction and ridge augmentation.

Abutment connection and impression

The healing period was uneventful and 3 months after surgery the
clinical examination revealed healthy tissues. At this time point, the
abutment connection was performed under local anesthesia. The soft
tissue covering the implant was de-epithelialized using a round
diamond bur.
A U-shaped incision was performed and the small flap over the
implant was raised. A small tissue pouch was prepared at the buccal
aspect of the implant and the flap was rotated into it. After removal of
the closure screw, a healing abutment with a gingival height of 3.5
mm was inserted (Fig 2-6-31).
Figs 2-6-31a and 2-6-31c Abutment connection.

Two weeks after the abutment connection, an analog impression

was taken and sent to the dental laboratory.

Fabrication of the all-ceramic titanium-base

crown
Once the conventional impression was translated into a master cast,
the casts were scanned using a lab scanner (inEos X5, Dentsply
Sirona, Bensheim, Germany) and the indicated scanbody for the
Cerec workflow. Based on the scans the crown was digitally
designed (Cerec in-lab 16.1, Dentsply Sirona) based on the
respective titanium-base (Vario-Base for Cerec, Straumann). The
generated crown file was then milled in a chairside milling unit (MCXL,
Dentsply Sirona) using the implant solution blanks (IPS e.max LT A2,
IS-L, Ivoclar Vivadent, Schaan, Liechtenstein).
The milled restoration was adjusted in the blue stage, crystallized,
and superficially characterized applying stains and glaze (Ivocolor,
Ivoclar Vivadent) according to the custom shade developed with the
patient.
Once the lithium-disilicate crown was finalized, it was etched for
20 s with hydrofluoric acid (5% concentration) (IPS Ceramic Etching
Gel, Ivoclar Vivadent) and rinsed with water. The ti-base on the other
end was airborne-particle abraded with 2 bar and 50-µm aluminum
oxide followed by the application of a silane-containing primer on both
the titanium-base and the crown (Monobond Plus, Ivoclar Vivadent).
Thereafter it was cemented (Multilink Hybrid Abutment HO-0, Ivoclar
Vivadent) and carefully polished (Fig 2-6-32).
Figs 2-6-32a to 2-6-32f The all-ceramic titanium-base crown.

Integration of the screw-retained implant

restoration
The healing abutment was removed, and the implant and adjacent
tissues were disinfected with a chlorhexidine solution. After
disinfection (Tiutol dent, B. Braun Melsungen, Melsungen, Germany)
and the application of a chlorhexidine gel to the submucosal Part
(PlakOut Gel, KerrHawe, Bioggio, Switzerland), the screw-retained
implant crown was preliminarily retained to the implant for a period of
2 weeks, by tightening the screw by hand (approx. 20 Ncm) and by
closing the screw access hole with PTFE tape and a provisional resin
(Telio, Ivoclar Vivadent).
After 2 weeks the abutment/crown screw was retightened with
the final torque as recommended by the manufacturer (35 Ncm). For
the final closure of the screw access, rubber dam was applied, and
the veneering ceramic layer around the access hole was etched (9%
hydrofluoric acid) and silanated (Monobond Plus, Ivoclar Vivadent).
The screw was densely covered with PTFE tape.
Subsequently, a bonding agent was applied (Heliobond, Ivoclar
Vivadent), and the closure of the screw access hole was finalized
with a light-curing composite filling material (Tetric Classic, Ivoclar
Vivadent) in the corresponding shade. After light-curing, the occlusion
was checked followed by polishing of the composite filling (Fig 2-6-
33).
Figs 2-6-33a to 2-6-33c Integration of the screw-retained implant
restoration.

(Dental practitioner: Prof Dr I Sailer; Technician: MDT V Fehmer.)

Final outcome after 3 years of clinical

function
No technical or biological complications occurred, and the patient was
still very satisfied with her monolithic implant restoration based on a
titanium-base.
The mesial and distal papilla, as well as the volume, could be
maintained, if not slightly increased over the 3 years along with all
superficial characterizations that were still present just as on the day
of insertion (Fig 2-6-34).
Figs 2-6-34a to 2-6-34c Final outcome after 3 years of clinical
function.
Implant-supported single crown
with GBR
(titanium-resin base abutment and zirconia
crown)

2.6.5 Posterior implant-supported SC

with GBR
■ Posterior region, titanium-resin base and restoration (zirconia)
■ Single posterior implant early placement with GBR

The following case involves the application of a regular diameter

implant (bone level tapered 4.1 mm) with a titanium-resin base
abutment and zirconia crown.

Assessment and treatment planning

A 42-year-old female patient presented herself at the clinic because
of slight pain from time to time in the area of tooth 15. The patient
was healthy, a non-smoker, and did not take any medication. The
tooth was endodontically treated and restored with a conventional
porcelainfused-to-metal (PFM) crown several years previously.
Furthermore, the tooth showed an increased PPD of more than 4 mm
(Fig 2-6-35). The periapical radiograph showed radiolucency around
the apex of the tooth.
Figs 2-6-35a to 2-6-35c Pretreatment photographs.

After consultation with an endodontic specialist, it was decided to

extract the tooth and, if possible, to perform an early placement of a
tapered bone-level implant.
Due to the position in the arch and the size of the extraction
socket, it was decided to place a Straumann BLT implant
(Straumann, Basel, Switzerland) with a regular diameter of 4.1 mm,
including GBR if needed.
After successful osseointegration, the implant was restored with a
zirconia crown (Lava Plus, 3M, Seefeld, Germany) on a titanium
bonding base (Vario-Base for Cerec, Straumann, Basel, Switzerland).
It was planned to take an analog impression and then to follow a
digital laboratory workflow using CAD/CAM technology).

Extraction and ridge preservation

Tooth 15 was carefully extracted; granulation tissue had to be
removed and finally the socket was curetted and rinsed with
neomycin solution.
After the extraction and cleaning of the socket, a xenogeneic bone
substitute (Bio-Oss Collagen, Geistlich, Wolhusen, Switzerland) was
inserted in combination with a punch graft harvested from the palate
to perform a ridge preservation.

Implant placement and regeneration

According to the diagnostics, a surgical stent was fabricated
transferring the prosthetic plan of the ideal three-dimensional position
of the implant to the surgical intervention.
At the day of implant placement (8 weeks after extraction), the
patient was premedicated with 1500 mg amoxicillin and 600 mg
ibuprofen. After the raising of a mucoperiosteal flap with a vertical
releasing incision distal of tooth 16, a regular diameter bone tapered
level implant (4.1 mm BLT, Straumann) was placed with good primary
stability and a correct prosthetic position/axis. A 3-mm healing
abutment was applied to cover the implant and allow for a
transmucosal healing.
The deficiency was augmented with a xenograft (Bio-Oss
Collagen, Geistlich Pharma) and the graft covered with a collagen
membrane (Bio-Gide, Geistlich Pharma) to allow for hard tissue
formation. The flap was released by splitting the periosteum allowing
for a tension-free re-adaptation of the flap. After suturing (Gore-Tex
5.0, W.L. Gore & Associates, Flagstaff, AZ, USA) the implant was
left for transmucosal healing for 8–10 weeks.
Antibiotics (amoxicillin 3 × 750 mg for 5 days), painkillers (600 mg
ibuprofen if needed), and chlorhexidine mouthrinse (0.2%) were
prescribed. The sutures were removed 10 days after implant
placement (Fig 2-6-36).
Figs 2-6-36a to 2-6-36f Implant placement and regeneration.

Healing period and impression

The healing period was uneventful and 5 weeks after implant
placement the clinical examination revealed healthy tissues. The
healing abutment was removed, and an analog impression was taken
and sent to the dental laboratory (Fig 2-6-37).
Figs 2-6-37a and 2-6-37b The healing abutment.
Fabrication of the all-ceramic titanium-base
crown
Once the conventional impression was translated into a master cast,
the casts were scanned using a lab scanner (inEos X5, Dentsply
Sirona, Bensheim, Germany) and the indicated scanbody for the
Cerec workflow. Based on the scans, the crown with a small buccal
cutback was digitally designed (Cerec in-lab 16.1, Dentsply Sirona)
based on the respective titanium-base (Vario-Base for Cerec,
Straumann). The generated crown file was then milled in a five-axis
milling unit (Zenotec Select Hybrid, Ivoclar Vivadent) using the classic
98-mm zirconia disk in a dry milling environment (Lava Plus, 3M).
The milled restoration was adjusted in the white stage and
sintered to its final density. Thereafter the crown was buccally
microveneered (IPS e.max Ceram, Ivoclar Vivadent) and superficially
characterized applying stains and glaze (Ivocolor, Ivoclar Vivadent)
according to the custom shade developed with the patient. Once the
zirconia crown was finalized, it was cleaned with alcohol and rinsed
with water. The titanium-base on the other end was airborne-particle
abraded with 2 bar and 50-µm aluminum oxide followed by the
application of a silane-containing primer on both the titanium-base and
the crown (Monobond Plus, Ivoclar Vivadent). Thereafter it was
cemented (Multilink Hybrid Abutment HO-0, Ivoclar Vivadent) and
carefully polished (Fig 2-6-38).
Figs 2-6-38a to 2-6-38d The all-ceramic titanium-base crown.

Integration of the screw-retained implant

restoration
The healing abutment was removed, and the implant and adjacent
tissues were disinfected with a chlorhexidine solution. After
disinfection (Tiutol dent, B. Braun Melsungen, Melsungen, Germany)
and the application of a chlorhexidine gel to the submucosal Part
(PlakOut Gel, KerrHawe, Bioggio, Switzerland), the screw-retained
implant crown was preliminarily retained to the implant for a period of
2 weeks, by tightening the screw by hand (approx. 20 Ncm) and by
closing the screw access hole with Teflon and a provisional resin
(Telio, Ivoclar Vivadent).
After 2 weeks, the abutment/crown screw was retightened with
the final torque as recommended by the manufacturer (35 Ncm). For
the final closure of the screw access the screw was densely covered
with PTFE tape. Subsequently, a bonding agent was applied
(Heliobond, Ivoclar Vivadent), and the closure of the screw access
hole was finalized with a light-curing composite filling material (Tetric
Classic, Ivoclar Vivadent). After the light-curing, the occlusion was
checked, followed by polishing of the composite filling (Fig 2-6-39).
Figs 2-6-39a to 2-6-39d Final outcome.

(Dental practitioner: Dr S Hicklin; Technician: MDT V Fehmer.)

Implant-supported single crown
(titanium-resin base abutment and translucent
multicolor zirconia crown)

2.6.6 Posterior implant-supported SC

and optical impression
■ Posterior regions, titanium-resin base, and restoration (translucent
multicolor zirconia)
■ Single posterior implant and optical impression during implant
placement

The following case involves the application of a regular diameter

implant (tissue level 5.0 mm) with a titaniumresin base abutment,
translucent multicolor zirconia crown, and optical impression acquired
during implant placement.

Assessment and treatment planning

A 38-year-old female patient presented herself at the clinic seeking a
replacement for her congenitally missing second premolar 35
(primary tooth 75, was unfortunately considered irrational to treat due
to decay and extracted 1.5 years previously).
The patient was healthy, a non-smoker, and did not take any
medication. The tooth had been extracted 2 years previously due to a
vertical fracture (Fig 2-6-40).

Fig 2-6-40 Pretreatment photograph.

After evaluating the clinical situation and the available volume of

bone, the case was considered straightforward and it was decided to
perform an implant placement of a tissue-level implant.
Due to the position in the arch and the size of the first molar in
respect to the cross section, it was decided to place a tissue-level
implant (Camlog Screw-Line Implant, Promote Plus, Camlog
Biotechnologies, Basel, Switzerland) with a diameter of 5.0 mm,
including GBR if needed. To increase efficiency, it was planned to
acquire the optical impression already directly after implant
placement and during the surgical intervention. With this approach an
additional appointment could be saved, and the data were already
available to the dental laboratory at this early time point.
After successful osseointegration, the implant was restored with a
translucent multicolor zirconia crown (Lava Esthetic, 3M, Seefeld,
Germany) on a titaniumresin base (Camlog Ti-Base, Camlog
Biotechnologies) by means of a complete digital workflow applying
CAD/CAM technology.

Implant placement and optical impression

According to the diagnostics a surgical stent was fabricated
transferring the prosthetic plan of the ideal 3D position of the implant
to the surgical intervention. At the day of implant placement, the
patient was premedicated with 2000 mg amoxicillin. After the raising
of a full-thickness flap with no releasing incision, a widediameter
tissue-level implant (5.0 mm Camlog Screw-Line Implant, Promote
Plus, Camlog Biotechnologies) was placed with excellent primary
stability and a correct prosthetic position/axis.
Once the implant was placed, a polyether ether ketone (PEEK)-
based mono scan body (Camlog, Biotechnologies) was inserted and
a powder-free optical quadrant impression (Trios 3, 3Shape,
Copenhagen, Denmark) was acquired.
After completion of the impression a 2-mm cylindrical healing
abutment was applied to cover the implant and allow for a
transmucosal healing.
A tension-free re-adaptation of the flap could be performed as no
GBR was performed. After the suturing (Gore-Tex 5.0, W.L. Gore &
Associates, Flagstaff, AZ, USA) the implant was left for transmucosal
healing for 8–10 weeks.
The sutures were removed 10 days after implant placement (Fig
2-6-41).
Figs 2-6-41a to 2-6-41 Implant placement and optical impression.

Fabrication of the all-ceramic titanium-base

crown
Once the optical impression was sent online to the dental laboratory,
the crown was digitally designed (Dental Designer 18, 3Shape) in full
contour based on the respective titanium-base (Ti-Base, Camlog
Biotechnologies). Thereafter the design software automatically leads
the workflow to the model-builder software (Model-Builder, 3Shape)
in which the master model was designed and the digital selected
analog placed. In the end of this extremely efficient workflow, three
stl. files were exported from the software: the maxillary and
mandibular model along with the crown (Fig 2-6-42).
Figs 2-6-42a to 2-6-42g Design of the crown.

The generated model files were placed in a 3D printer (Rapid

Shape P30, Straumann, Basel, Switzerland) and printed with a beige,
stone-like tinted light-curing 3D printing resin (SHERA Sand,
Lemförde, Germany) thereafter postprocessed and light cured to
their final toughness.
The full contour crown on the other side was milled in a five-axis
milling unit (Zenotec Select Hybrid, Ivoclar Vivadent) using the classic
98-mm zirconia disk in a dry milling environment (Lava Esthetic, 3M).
The milled restoration was adjusted in the white stage and
sintered to its final density. Thereafter the crown was superficially
characterized applying stains and glaze (Ivocolor, Ivoclar Vivadent)
according to the custom shade developed with the patient.
Once the zirconia crown was finalized, it was cleaned with alcohol
and rinsed with water. The titanium-base on the other end was
airborne-particle abraded with 2 bar and 50-µm aluminum oxide
followed by the application of a silane-containing primer on both the
titanium-base and the crown (Monobond Plus, Ivoclar Vivadent).
Thereafter it was cemented (Multilink Hybrid Abutment HO-0, Ivoclar
Vivadent) and carefully polished (Fig 2-6-43).
Figs 2-6-43a to 2-6-43g Fabrication of the all-ceramic titanium-base
crown.

Precision of restoration and cement gap

The marginal adaptation of this CAD/CAM based restoration as
presented by this crown was exceptionally good and hardly any
cement line could be detected after the finalization (Fig 2-6-44).
Figs 2-6-44a and 2-6-44b Finalization.

Integration of the screw-retained implant

restoration
The healing abutment was removed, and the implant and adjacent
tissues were disinfected with a chlorhexidine solution. After
disinfection (Tiutol dent, B. Braun Melsungen, Melsungen, Germany)
and the application of a chlorhexidine gel to the submucosal Part
(PlakOut Gel, KerrHawe, Bioggio, Switzerland), the screw-retained
implant crown was preliminarily retained to the implant for a period of
2 weeks, by tightening the screw by hand (approx. 15 Ncm) and by
closing the screw access hole with PTFE tape and a provisional resin
(Telio, Ivoclar Vivadent).
After 2 weeks the abutment/crown screw was retightened with
the final torque as recommended by the manufacturer (20 Ncm). For
the final closure of the screw access the screw was densely covered
with PTFE tape. Subsequently, a bonding agent was applied
(Scotchbond Universal, 3M), and the closure of the screw access
hole was finalized with a light-curing composite filling material (Tetric
Classic, Ivoclar Vivadent). After light-curing, the occlusion was
checked followed by polishing of the composite filling (Fig 2-6-45).
Figs 2-6-45a to 2-6-45e Integration of the screw-retained implant
restoration and final outcome.

(Dental practitioner: Dr J Pitta; Technician: MDT V Fehmer.)

Tooth- and implant-supported

SCs and FDPs
(full-mouth rehabilitation)
2.6.7 Tooth- and implant-supported
all-ceramic SCs and fixed dental
prostheses (FDPs)
■ Full-mouth rehabilitation (all-ceramic crowns, FDPs, veneers, and
overlays)
■ Posterior regions, titanium-resin base restorations (translucent
multicolor zirconia)
■ Endodontic retreatment
■ Guided implant placement

The following case involves the application of regular- and narrow-

diameter implants with titanium-resin base abutments, microveneered
translucent multicolor zirconia crowns, and FDPs along lithium-
disilicate veneer and overlays.

Assessment and treatment planning

A 46-year-old male patient presented himself at the clinic seeking a
general treatment and an esthetic improvement of his anterior teeth.
The patient was healthy, did not take any medication, but smoked
about 10 cigarettes a day. One of the patient’s chief complaints was
the poor esthetics of his fixed restorations. Poor adaptation of the
crowns with overcontoured margins made it very difficult for the
patient to properly clean the restorations, leading to generalized
gingivitis.
The patient’s second wish was to receive fixed dental restoration,
the need for which was evident at his age.
At the beginning of the comprehensive treatment, a detailed
diagnostics process was required for the evaluation of the single
tooth prognosis and the potential strategic relevance. The quality of
the existing root canal treatments was analyzed, furthermore, the
post-and-core built-ups were evaluated, taking the risk of renewing
the insufficient ones into consideration.
Furthermore, an extra- and intraoral esthetic analysis was
performed to determine the new outline of his teeth. In general it was
planned to maintain as many teeth as possible by means of
endodontic retreatment along with an opening of the vertical
dimension; and, if needed, a crown lengthening and implants to
replace failing teeth to avoid long-span FDPs on the compromised
teeth.
The final restoration was planned to be fabricated from
translucent multicolor zirconia. For the implant abutments, titanium-
bases were considered as the best material of choice. As this was a
major change for the patient, a long-term provisional phase for the
patient to adapt to the new vertical dimension and the overall shape
and size of his new restorations was foreseen (Fig 2-6-46).
Figs 2-6-46a to 2-6-46c Pretreatment photographs.

Diagnostics
The patient’s chief complaint was his compromised esthetic
appearance especially in the maxillary anterior teeth. However, he
was also aware that some of his teeth and restorations were not in a
good condition. This was not only due to a severe chipping in the
fourth quadrant that was very visible, but also due to constant
bleeding and a bad taste he sensed while trying to clean his
restorations.
Evaluating and defining a sound prognosis for his teeth with those
type of existing restorations in place was extremely difficult, if not
impossible.
The panoramic and periapical radiographs allowed for a first
prognosis and a categorization of the teeth into three groups (safe,
doubtful, and irrational to treat) but this assessment can only be
finalized once the failing restorations were removed and the substrate
beneath could be examined.
In order to develop a clear treatment aim, alginate impressions of
both arches were performed, along with a facebow and the
laboratory developed a full wax-up including a vertical augmentation
of the bite.
As the existing restorations were very bulky, the wax-up created
in the dental laboratory was already based on a subtractive
preparation of the casts, and in consequence no direct mock-up could
be performed. However, at least the desired shape and design of his
new restorations could be discussed with the patient based on the
wax-up in the articulator. In the clinic, the failing restorations were
removed and the assessment for the teeth could be reviewed. The
wax-up was then transferred into a direct provisional allowing the
patient at this early treatment phase to test the planned restorations,
and to improve his esthetics and get used to the new shapes and
volume of his planned restorations. The following treatment plan was
then developed according to the diagnostics and prognosis of the
maintaining teeth (Fig 2-6-47).
Figs 2-6-47a to 2-6-47n Diagnostic images.

Wax-up
In order to visualize the final treatment outcome and also its potential
limitations, a full wax-up was performed on two conventional plaster
casts that were articulated by means of a facebow. The vertical
dimensions were raised by 4 mm on the incisal pin. As the existing
restorations, still present in the casts, were very bulky it was decided
to prepare the teeth on the casts so that a natural contour could be
developed by the dental technician.
Unfortunately, this made it impossible to visualize the prospective
treatment before the actual removal of the restorations (Fig 2-6-48).
Figs 2-6-48a to 2-6-48d Wax-up.

Removal of anterior restorations

In a first treatment step, the restorations in the anterior segments of
both mandibular and maxillary arches were carefully removed and
evaluated (Fig 2-6-49).
Figs 2-6-49a to 2-6-49d Removal of anterior restorations.

Mock-up
In order to transfer the diagnostic wax-up finally into the patient’s
mouth and by this means give the patient a chance to visualize and
agree on the final outline of his restorations, a silicone index of the
wax-up was prepared in order to fabricate a direct mock-up (Memosil
2, Kulzer, Hanau, Germany). This silicone index was filled with a
chemically curing composite material, in shade Vita A2 (Protemp, 3M,
Seefeld, Germany) and placed over the maxillary teeth.
The resulting mock-up served not only as a communication tool as
the prospective treatment result could now be discussed with the
patient in detail, but also as a provisional incorporating the desired
esthetic changes (Fig 2-6-50).
Figs 2-6-50a to 2-6-50c Mock-up.

Crown lengthening for increased ferrule and

esthetic improvement
The diagnostic mock-up was transformed into a thermoplastic
surgical stent for the localized crown lengthening of teeth 13–23.
Displaying the ideal pink and white proportions, the surgical stent was
used to mark the required repositioning of the buccal soft tissues.
After local anesthesia (Ubistesin Forte, 3M, Seefeld, Germany), a
buccal mucoperiosteal flap was raised with no vertical releasing
incisions; as the flap was quite long, it was possible to mobilize it
easily. The mock-up (ie, surgical stent) was then used to mark the
necessary amount of bone and soft tissues to be removed buccally.
The marking was performed with a sterilized round bur, and the
marked buccal Part was thereafter removed with the same
instrument and a chisel, assuring careful exposure of the buccal root
surfaces of the teeth. The root surfaces were then polished with
specialized periodontal diamond instruments (Perio Set, Intensiv,
Montagnola, Switzerland), and the flap apically repositioned and
sutured (Ethilon Nylon, 4.0 sutures, Ethicon, Somerville, NJ, USA).
During the initial healing, the patient was instructed not to clean the
operated area with a toothbrush or dental floss. He received a
chlorhexidine solution for daily disinfection until suture removal. After
the suture removal, further healing and maturation of tissues was
allowed for another 3 months prior to continuation of the restorative
phase (Fig 2-6-51).
Figs 2-6-51a to 2-6-51f Crown lengthening.

Removal of anterior restorations

To continue the treatment, the failing cantilever FDP in the fourth
quadrant was carefully removed, and the abutment teeth were re-
evaluated.
This was followed by a direct provisional representing the new
vertical dimension, in contrast to the old porcelain-fused-to-metal
restoration only consisting of a single distal molar extension (Fig 2-6-
52).
Figs 2-6-52a to 2-6-52f Removal of posterior restorations.

Endodontic retreatments and build-ups

After the removal of the old composite restorations at teeth 12 and
11, the access to the previous root canal filling was provided and
rubber dam was placed. The endodontic retreatment was performed
using a combination of manual endodontic instrumentation (K files,
Maillefer, Tulsa, OK, USA) and machine-driven endodontic
instruments (ProTaper Universal Files, Maillefer). The previous root
canal filling was thereby meticulously removed and the root canals of
both teeth were disinfected with Na(OH)2. Thereafter, the root canals
were filled with gutta-percha, condensed, and fixed with aid of the
cement AH 26 (Dentsply Maillefer, Tulsa, OK, USA). At the next
meeting and after the setting of the cement, the two root canals were
prepared for titanium root posts. The posts were adhesively inserted
using a self-adhesive universal cement (RelyX Unicem, 3M), and the
composite build-ups were made with a light-curing composite (Tetric
EvoCeram, Ivoclar Vivadent, Schaan, Liechtenstein), associated with
the respective dentin and titanium pre-treatment steps (Optibond FL,
Kerr, Brea, CA, USA; Monobond Plus, Ivoclar Vivadent). The two
abutment teeth were reprepared and the provisionals were adapted
(Fig 2-6-53).
Figs 2-6-53a to 2-6-53h Endodontic retreatments and build-ups.

Provisional, maxillary arch

To transfer the wax-up into the patient’s mouth, a silicone index of the
wax-up was prepared in order to fabricate an eggshell provisional on
the model. This eggshell was fabricated with a classic acrylic PMMA
material (New Outline, Anaxdent, Stuttgart, Germany) that was later
on easy to reline and adjust to the actual intraoral preparation. The
provisional was then relined with a self-curing resin (Tab 2000, Kerr),
extraorally polished, and provisionally cemented (Tempbond NE, Kerr)
(Fig 2-6-54).
Figs 2-6-54a to 2-6-54e Maxillary provisional.

Endodontic retreatments and build-ups

Just like in the maxillary anterior teeth, the endodontic treatment of
the teeth (32–45) in the mandibular arch was revised (Fig 2-6-55).
Figs 2-6-55a to 2-6-55e Endodontic retreatments and build-ups.

Provisional, mandibular arch

With the same clinical and technical approach by the fabrication of an
eggshell provisional, the mandibular arch was transferred from the
direct provisional to an indirect provisional based on a relined eggshell
(Fig 2-6-56).
Figs 2-6-56a to 2-6-56e Mandibular provisional.

Matching CBCT and surface scan data and

planning the 3D implant position
To create and plan the implant positions, a surgical guide software
was applied (SMOP, Swissmeda, Zurich, Switzerland).
The software and its planning tools rely on both surface scans
(STLs) and volumetric scans (CBCTs). It is possible to upload and
“match” (align) the surface scan data (Standard Tessellation
Language [STL] dataset) of the current intraoral situation with the
CBCT data as well as with data from a scan of the wax-up (STL
dataset).
The available software solutions allow for a decentralized
workflow, ie, the use of cloud-based software enables each member
of the restorative team to independently upload the datasets and
perform surgical planning with all the prosthetic references. This
approach affords maximum freedom of software selection. The only
requirement is that the system must be able to read the data in STL,
the standard data format.
The workflow was applied as follows: After all initial examinations
had been completed and the options had been discussed with the
patient, a CBCT scan was captured and uploaded into the planning
software without any preliminary work by a dental technician. After
initially reviewing the data, the clinician shared the planning data and
discussed the case with the dental technician via cloud-based
technology.
Based on the corresponding alginate impression and the wax-up
produced by the dental technician that was clinically verified and
scanned, the dental technician could then upload the two files (models
without and with wax-up).
Regarding the legal framework, it should be mentioned that the
person who uploads the CBCT data into the software has sovereignty
over the data, while it is not possible for other partners involved to
download the case data.
To start the matching process, the user must first upload and
open the files containing the surface scan data of the current intraoral
situation and the planning data for the future restoration (wax-up or
setup). This is accomplished by marking identical areas, and later
making fine adjustments, if needed.
Correct matching of the STL surface scan data with the CBCT
data (as determined by gray-level differences) is crucial, and the
accuracy of implant planning and placement rises and falls with it. For
example, the presence of an insufficient number or distribution of
remaining teeth or large metal or zirconia restorations in the arch to
be treated can make it difficult to impossible to achieve accurate data
matching. In these cases, the only way to proceed is by applying a
radiographic template with reference structures during the CBCT
scan.
Once the clinician has gathered all the necessary information, the
actual process of prosthetic-driven implant planning can begin (Fig 2-
6-57).
Figs 2-6-57a to 2-6-57g Prosthetic-driven implant planning.

Once the final planning has been approved, the drill guide can be
fabricated directly in the dental laboratory or ordered from the
Swissmeda service center. The splint module of the SMOP software
package (Swissmeda) that was used to design the drill guide also
produces STL datasets. Like all other systems currently on the
market, this software contains details about all the relevant implant
systems and the drill sleeves that go with them. The SMOP workflow
also has another interesting feature: Depending on which implant
system is used, it may be possible to save the metal sleeve, which
not only results in simplification of the manufacturing process and
therefore savings, but also minimizes another source of error.
Unfortunately, this software only supports the implant-planning
program and cannot be used in the restorative phase. In other words,
it cannot be used to plan temporary or final restoration
superstructures.
The final surgical stent was then produced by means of 3D
printing (Fig 2-6-58).
Figs 2-6-58a to 2-6-58c 3D-printed surgical stent.

Guided implant placement and regeneration

On the day of implant placement, the patient was pre-medicated with
1500 mg amoxicillin and 600 mg ibuprofen. After the raising of a
mucoperiosteal flap with no vertical releasing incision, with the aid of
a surgical stent (SMOP, Swissmeda), two implants, a
regulardiameter bone-level implant (bone level RC 4.1 mm,
Straumann, Basel, Switzerland) was placed in the area of the first
premolar and a tissue-level implant (SP RN 4.8 mm, Straumann) in
the area of the first molar of the second quadrant. For both implants
a good primary stability in a correct prosthetic position/axis could be
achieved, and finally the implants were covered with small closure
screws (Fig 2-6-59).
Figs 2-6-59a to 2-6-59l Guided implant placement.

The ridge deficiency was augmented with a xenograft (Bio-Oss,

Geistlich Pharma) and the graft was covered with a collagen
membrane (Bio-Gide, Geistlich Pharma) to allow for hard tissue
formation. The flap was released by splitting the periosteum allowing
for a tension-free re-adaptation of the flap. After suturing (Gore-Tex
5.0, W.L. Gore & Associates, Flagstaff, AZ, USA) the implant was
left for submucosal healing for 8–10 weeks.
Antibiotics (amoxicillin 3 × 750 mg for 5 days), painkillers (600 mg
ibuprofen if needed), and chlorhexidine mouthrinse (0.2%) were
prescribed.
The sutures were removed 10 days after implant placement (Fig
2-6-60).
Figs 2-6-60a and 2-6-60c Ridge augmentation, suture removal, and
healing.

Healing period
The healing period unfortunately was not uneventful, as a wound
dehiscence in the area of the first molar was visible on the day of
suture removal. The patient was therefore monitored and the
cicatrization occurred by second intention (Fig 2-6-61).

Figs 2-6-61a to 2-6-61c Healing.

Endodontic retreatment and build-up
A final endodontic retreatment of the tooth 36 was accomplished
following the same strategy as for the revision of the maxillary
anterior teeth (Fig 2-6-62).
Figs 2-6-62a to 2-6-62d Endodontic retreatment and build-up.

Implant placement and regeneration

In the first quadrant a narrow-diameter implant (bone level NC 3.3
mm, Straumann) was planned and placed in position 14 to avoid a
cantilever FDP based on the endodontically treated tooth 15. For the
implant a good primary stability in a correct prosthetic position/axis
could be achieved and finally the implant was covered with small
closure screw (Fig 2-6-63).
Figs 2-6-63a to 2-6-63f Implant placement and regeneration.

Guided implant planning and placement

In the fourth quadrant a single tissue-level implant (tissue level RN 4.8
mm, Straumann) was planned and placed by means of guided
surgery in the area of the first molar. For the implant a good primary
stability in a correct prosthetic position/axis could be achieved and
finally the implant was covered with medium healing abutment (Fig 2-
6-64).
Figs 2-6-64a to 2-6-64k Guided implant planning and placement.

Abutment connection
The healing period was uneventful and 3 months after the implant
placement the clinical examination revealed healthy tissues. At this
time point, the abutment connection was performed under local
anesthesia and additionally an inlay graft harvested from the maxillary
tuberosity was performed to improve the tissue quantity and quality in
the pontic area (Fig 2-6-65).
Figs 2-6-65a and 2-6-65b Abutment connection.

Healing period of the inlay graft

The healing period of the inlay graft was uneventful, and 10 days
after its placement it appeared already in good function during suture
removal (Fig 2-6-66a).
Figs 2-6-66a and 2-6-66b Healing of the inlay graft.

Three weeks after the inlay graft and just before the impression
was performed the healing was still uneventful and in process of
maturation. At this time point, a conventional impression was
performed to produce a provisional restoration in the dental
laboratory (Fig 2-6-66b).

Provisional implant FDP

In the dental laboratory the impression was poured with plaster and a
master cast was generated. In a second phase, the corresponding
scan bodies for the cast, along with the implant positions, were
digitalized by means of a lab scanner (inEos X5, Dentsply Sirona,
Bensheim, Germany) and a full contour FDP was digitally designed
(Dental Designer 18, 3Shape, Copenhagen, Denmark).
The full contour FDP was milled in a five-axis milling unit (Zenotec
Select Hybrid, Ivoclar Vivadent) using the classic 98-mm disk in a dry
milling environment (Telio CAD A3 Esthetic, Ivoclar Vivadent). The
milled provisional restoration was adjusted and polished.
Once the PMMA FDP was finalized, it was cleaned with alcohol
and rinsed with water and primed (SR Connect, Ivoclar Vivadent).
The titanium-bases on the other end were airborne-particle abraded
with 2 bar and 50-µm aluminum oxide followed by the application of a
silane-containing primer (Monobond Plus, Ivoclar Vivadent).
Thereafter the FDP was cemented (Multilink Hybrid Abutment HO-0,
Ivoclar Vivadent) and the cement gap carefully polished (Fig 2-6-67).
Figs 2-6-67a to 2-6-67d Provisional implant restoration.

Soft-tissue augmentation
To augment the soft tissue deficiency in the first quadrant around the
implant position 14, a connective tissue graft was harvested in the
palatal area of the second quadrant and carefully placed. For a
tension-free integration, a Tinti-flap was created and sutured (Fig 2-6-
68).
Figs 2-6-68a to 2-6-68l Soft tissue augmentation.

Abutment connection
The healing period was uneventful and 3 months after surgery the
clinical examination revealed healthy tissues. At this time point, the
abutment connection was performed under local anesthesia. The soft
tissue covering the implant was de-epithelialized using a round
diamond bur. A U-shaped incision was performed and a small flap
over the implant was raised.
A small tissue pouch was prepared at the buccal aspect of the
implant and the flap was rotated into it. After removal of the closure
screw, a healing abutment with a gingival height of 3.5 mm was
inserted (Fig 2-6-69).
Figs 2-6-69a to 2-6-69e Abutment connection.

Final provisional phase

During the initial weeks of the provisional phase, the provisional FDP
was modified two times with composite resin to optimize the
emergence profile.
Afterwards the provisionals served for a period of 4 months
before the final impression was taken (Fig 2-6-70).
Figs 2-6-70a to 2-6-70f Final provisional phase.

Impression
After a provisional phase of approximately 5 months, a second
impression with an individualized impression coping was taken. This
individualized impression coping presents the exact copy of the
emergence profile that was sequentially developed with the
provisional. In order to modify the standardized impression copings,
the provisional is mounted to an analog and embedded in a putty
material. Once the material had set, the provisional crown could be
unscrewed and the impression coping was mounted.
The free space could then be filled with either a light-curing
composite or, as was done in this case, with a light-curing composite
(Tetric EvoFlow, Ivoclar Vivadent).
The individualized impression coping was transferred to the
implant site and the final impression was carried out and sent to the
dental laboratory (Fig 2-6-71).
Figs 2-6-71a to 2-6-71i Impression.

Fabrication of the all-ceramic crowns and

FDP
Once the conventional impressions were translated into master casts,
the casts were scanned using a lab scanner (inEos X5, Dentsply
Sirona) and the indicated scanbodies for the Straumann workflow.
From the scans, the crowns and FDP with a small buccal cutback
were digitally designed (Dental Designer 18, 3Shape), based on the
preparations and the respective titanium-bases (Vario-Base,
Straumann). The generated files were then milled in a five-axis milling
unit (Zenotec Select Hybrid, Ivoclar Vivadent) using the classic 98-
mm zirconia disk in a dry milling environment (Lava Plus, 3M).
The milled restorations were adjusted in the white stage and
infiltrated (LAVA Plus SHADE LIQUID, 3M) before they were sintered
to their final density. This additional process was done as the
infiltration is key to transforming the white monochromatic zirconia
into an individualized polychromatic tooth-colored restoration.

Framework try-in
The sintered and (in the dental laboratory) adjusted frameworks were
checked intraorally for their overall fit. The framework try-in was
clinically checked with respect to its fit and the occlusion of the
restorations.
Because as the name “framework” would suggest, today is no
longer just a framework but a structural Part of the restoration
including functional areas. Consequently, the occlusal areas and
contact points could also be verified before the restorations could be
finalized (Fig 2-6-72).
Figs 2-6-72a to 2-6-72e Framework try-in.

Preparation for biscuit bake try-in

Thereafter the restorations were buccally microveneered (IPS e.max
Ceram, Ivoclar Vivadent) and superficially characterized via
application of stains and glaze (Ivocolor, Ivoclar Vivadent) according
to the custom shade developed with the patient (Fig 2-6-73).
Figs 2-6-73a to 2-6-73d Preparation for biscuit bake try-in.

Biscuit bake try-in

The biscuit bake was clinically checked with respect to the shade and
shape of the restorations.
The patient and the restorative team were already very satisfied
with the final shape and the overall integration.
However, small details could still be improved. Besides these, it
became very evident that the extremely dark post and core of tooth
21 was causing serious esthetic problems.
Despite the fact that opaque zirconia and a special veneering
strategy to camouflage the dark root had been used for this tooth, it
was not sufficient (Fig 2-6-74).
Figs 2-6-74a to 2-6-74f Biscuit bake try-in.

Finalization of the restoration

The shape was adjusted as discussed during the biscuit bake try-in
and glaze firing was followed by an additional stain firing to achieve
perfect integration (Fig 2-6-75).
Figs 2-6-75a to 2-6-75k Finalization of the restoration.

Once the zirconia implant restorations were finalized, they were

cleaned with alcohol and rinsed with water. The itanium-bases were
airborne-particle abraded with 2 bar and 50-µm aluminum oxide
followed by the application of a silane-containing primer on both the
titanium-bases and the restorations (Monobond Plus, Ivoclar
Vivadent). Thereafter they were cemented (Multilink Hybrid Abutment
HO-0, Ivoclar Vivadent) and carefully polished (Fig 2-6-76).
Figs 2-6-76a and 2-6-76b Finalized and polished restorations.
Replacement of infiltrated composite fillings
The two molars in the first quadrant at this point still showed
infiltrated old composite fillings that now in the final treatment phase
were carefully exchanged under isolation and the application of a
highly filled composite material (Tetric EvoCeram, Ivoclar Vivadent)
(Fig 2-6-77).
Figs 2-6-77a to 2-6-77d Replacement of infiltrated composite
fillings.

Integration of zirconia-based restorations

The provisional restorations were removed and the implants and
adjacent tissues disinfected with a chlorhexidine solution. The
restorations based on teeth were cemented with a universal resin
cement (RelyX Unicem, 3M) and meticulously checked for any
remaining cement excess.
Thereafter the implant-based restorations were disinfected (Tiutol
dent, B. Braun Melsungen, Melsungen, Germany) and a chlorhexidine
gel was applied to the submucosal parts (PlakOut Gel, KerrHawe,
Bioggio, Switzerland). The screw-retained implant restorations were
preliminarily retained to the implants for a period of 2 weeks, by
tightening the screws by hand (approx. 20 Ncm) and by closing the
screw access holes with PTFE tape and a provisional resin (Telio,
Ivoclar Vivadent) (Fig 2-6-78).
Figs 2-6-78a to 2-6-78c Integration of zirconia-based restorations.

After 2 weeks, the abutment/FDP screws were retightened with

the final torque as recommended by the manufacturer (35 Ncm). For
the final closure of the screw access the screws were densely
covered with PTFE tape. Subsequently, a bonding agent was applied
(Scotchbond Universal, 3M), and the closure of the screw access
holes was finalized with a light-curing composite filling material (Tetric
Classic, Ivoclar Vivadent). After the light-curing, the occlusion was
checked followed by polishing of the composite fillings.
Integration of lithium-disilicate-based
restorations
Once all the zirconia-based restorations were placed, the last step
was to adhesively cement the two overlays in the mandibular arch (33
and 34) and the veneer in position 13.
The lithium-disilicate restorations were prepared for the adhesive
cementation (Teric Classic, Ivoclar Vivadent).
Under the seal of rubber dam the teeth could be safely etched for
40 s with phosphoric acid (37% concentration) (Email Preparator
blue, Ivoclar Vivadent) and a bond was applied (Optibond FL 2,
Ivoclar Vivadent). The veneer and onlays were etched for 20 s with
hydrofluoric acid (5% concentration) (IPS Ceramic Etching Gel,
Ivoclar Vivadent) rinsed with water, and carefully bonded as well.
For the adhesive cementation, a regular filling composite (Tetric
A2, Ivoclar Vivadent) was used preheated, and after a fast precuring,
the removal of the excess could be performed without any movement
of the perfectly positioned veneer and overlays. Afterwards and
without stress, the final light-curing was performed and the transition
zones were polished with diamond paste. The occlusal and functional
contacts were analyzed, and almost no adjustments were necessary
(Fig 2-6-79).
Figs 2-6-79a to 2-6-79q Integration of lithium disilicate-based
restorations.
Figs 2-6-79g to 2-6-79q Integration of lithium-disilicate-based
restorations.

Final full-mouth rehabilitation

The final outcome of this esthetic and complex treatment was
extremely pleasing for the entire team. The predictability achieved
through the diagnostic guidance was key for breaking such a
comprehensive treatment down into smaller sequences. That made
the entire case easier for the team to handle. As the treatment lasted
close to 24 months, the initial diagnostic phase was even more
important as it engaged the patient in this early phase; his
commitment to all these appointments was extremely high throughout
the entire treatment phase.
After the last and minor occlusal adjustments, the patient
immediately received a Michigan splint to protect the new
restorations during the night and is in a 6-month recall (Fig 2-6-80).
Figs 2-6-80l Final outcome.

(Dental practitioner: Dr J Pitta; Endodontist: Dr G Vögeli;

Technician: MDT V Fehmer.)
CHAPTER 7
Implant-supported restorations

Anterior regions
2.7.1 Implant-supported four-unit fixed
dental prosthesis (FDP)

Posterior regions
2.7.2 Implant-supported three-unit fixed
dental prosthesis (FDP)
2.7.3 Implant-supported fixed dental
prosthesis with mesial cantilever (FDP)
2.7.4 Implant-supported fixed dental
prostheses (FDPs)

Complex situations
2.7.5 Full-arch implant-supported fixed
restoration with pink ceramics (FDP)
Implant-supported four-unit FDP
(full digital workflow)

2.7.1 Implant-supported four-unit

fixed dental prosthesis (FDP)
■ Anterior regions, titanium-resin base, and restoration (semi
opaque zirconia)
■ Four-unit anterior implant fixed dental prosthesis (FDP) guided
surgery, and full digital workflow

This first sequence shows the replacement of a failing four-unit

anterior FDP due to fractured lateral incisors by means of diameter-
reduced implants (bone level 3.3 mm) and titanium-resin-base
abutments, in combination with semi-opaque high-strength zirconia via
the application of a digital workflow.

Assessment and treatment planning

A 49-year-old male patient presented himself at the clinic seeking a
replacement of his failing four-unit anterior porcelain-fused-to-metal
(PFM) FDP. The patient was healthy, a non-smoker, and did not take
any medication. The old PFM FDP was debonded some days before
as he was abroad, and the patient managed the situation by seeing a
dentist for an emergency recementation of the FDP. The treating
dentist, however, told him that most likely this will not be a long-term
solution and he should see a specialist in his home city.
The abutment teeth had to be extracted because of their
epigingival fracture and due to a periapical radiolucency indicating a
perio-endo problem.
Due to the position in the arch and the size of the restoration, it
was planned to place two diameter-reduced bone-level implants
(Bone Level NC, Straumann, Basel, Switzerland) with a diameter of
3.3 mm, applying guided surgery, and including guided bone
regeneration (GBR) if needed.
After successful osseointegration, the implants were restored with
a semi opaque zirconia FDP (Lava Plus, 3M, Seefeld, Germany) on a
titanium-resin bases (Vario-Base, Straumann).
To increase efficiency it was planned to acquire an optical
impression and follow the complete digital workflow from diagnostics
to the final computer-aided design/computer-aided manufacturing
(CAD/CAM) fabricated restoration (Fig 2-7-1).
Figs 2-7-1a to 2-7-1c Pretreatment photographs.

Tooth extraction and ridge preservation

The remaining roots of the fractured lateral incisors were extracted
and a xenogeneic bone substitute in combination with a punch graft
from the palate was used to perform a ridge preservation procedure
(Fig 2-7-2).
Figs 2-7-2a to 2-7-2i Root extraction and ridge preservation
procedure.

A provisional removable prosthesis was prefabricated in the

dental laboratory and could be delivered to the patient on the day of
extraction. It had to be slightly adapted and reduced in the base
before it could be delivered and finally replace the missing teeth. As
the possibility for an adaptation was foreseen, the provisional was
fabricated with a small buccal flange to better compensate potential
adjustments (Fig 2-7-3).
Figs 2-7-3a to 2-7-3f Adaptation of provisional removable
prosthesis.

Diagnostics and virtual mock-up

The patient’s main wish was the replacement of his failing FDP.
Additionally, during the last few years he began to realize the
unesthetic appearance of his existing restoration, as it was very
opaque, revealed metal margins, and was of an artificial shape. He
wanted to be Part of the diagnostic process to help develop the final
outline of his new restoration. Initially, all corrections were performed
digitally by means of an image editing software (Photoshop Elements;
Adobe Systems, San Jose, CA, USA) to visualize the patient’s
treatment. Thereafter, all the planned changes were transferred and
visualized in a CAD software (Exocad, Darmstadt, Germany). The
software was used to project a virtual mock-up into twodimensional
pictures of his dentition and with this superimposition allow him to
better understand the potential changes.
Together with the patient, various suggestions were worked out,
discussed, and then saved as a file. After the patient opted for a
visualized design, the virtual mock-up was transformed into a
provisional (Fig 2-7-4).
Figs 2-7-4a to 2-7-4e Virtual mock-up.

Guided implant placement

On the day of implant placement, the patient was premedicated with
1500 mg amoxicillin and 600 mg ibuprofen. A flapless approach was
chosen to reduce morbidity for the patient and with the aid of a
surgical stent (SMOP, Swissmeda, Zurich, Switzerland) two
diameterreduced bone-level implants (Bone Level NC 3.3 mm,
Straumann) were placed in the area of the lateral incisors. For both
implants a good primary stability in a correct prosthetic position/axis
could be achieved and finally the impacts were covered with small
closure screws.
After the suturing the implants were left for submucosal healing for
8–10 weeks. Antibiotics (amoxicillin 3 × 750 mg for 5 days),
painkillers (600 mg ibuprofen if needed), and chlorhexidine mouth
rinse (0.2%) were prescribed. The sutures were removed 10 days
after implant placement (Fig 2-7-5 and Fig 2-7-6).
Figs 2-7-5a to 2-7-5h Planned guided implant placement.
Figs 2-7-6a to 2-7-6f Guided implant placement.

Soft tissue augmentation

To augment the soft tissue deficiency in the area around the implant
positions, two connective tissue grafts were harvested in the palatal
area of the second quadrant and carefully placed (Fig 2-7-7).
Figs 2-7-7a to 2-7-7f Soft tissue augmentation.

Abutment connection
The healing period was uneventful and 3 months after surgery the
clinical examination revealed healthy tissues. At this time point, the
abutment connection was performed under local anesthesia. The soft
tissue, covering the implants, was de-epithelialized using a round
diamond bur. U-shaped incisions were made and small flaps over the
implants were raised. Small tissue pouches were prepared at the
buccal aspects of the implants and the flaps were rotated into it.
After removal of the closure screw, a healing abutment with a gingival
height of 3.5 mm was inserted.

Provisionalization
Based on the initial diagnostics the dental laboratory finalized the
design of the four-unit anterior segment and added distal backings to
the FDP for better repositioning. The full contour FDP was then milled
in a five-axis milling unit (Zenotec Select Hybrid, Ivoclar Vivadent,
Schaan, Liechtenstein) using the classic 98-mm disk in a dry milling
environment (Telio CAD A2 Esthetic, Ivoclar Vivadent).
The milled provisional restoration was adjusted and polished and
sent to the clinic (Fig 2-7-8).
Figs 2-7-8a to 2-7-8f Milled provisional restoration.

Two weeks after the abutment connection, and the removal of the
healing abutments, healthy peri-implant mucosa was present. At this
point directly in the clinic, the laboratory-made provisional was carved
out in the palatal parts of the lateral incisors and prepared for a
relining based on the now osseointegrated implant. Two temporary
abutments (retentive) made from a titanium alloy (TAN) were applied,
airborne-particle abraded, and bonded before the open spaces were
filled with a classic acrylic poly(methyl methacrylate) (PMMA)
material (New Outline, Anaxdent, Stuttgart, Germany) that was later
on easy to reline in the yet under-contoured submucosal part. The
provisional was fabricated with a kind of ridge flap design to avoid too
much pressure on the soft tissue during insertion.
Once the relining material had set, the entire now implant borne
provisional could be removed and separated from support backings
using a fine diamond disk. The provisional FDP was inserted and
tightened.
During the following weeks, the provisional was modified two
times with composite resin to optimize the emergence profile (Fig 2-
7-9).
Figs 2-7-9a to 2-7-9f Adaptation of provisional restoration.

Fabrication of the all-ceramic FDP on

titanium-base
The patient adapted well to the provisional and felt very comfortable
with the occlusion and length of the central incisors.
After a 4-month period the final impression was performed and
sent to the dental laboratory to fabricate a zirconia-based restoration.
At this point, all the laboratory technician had to do was to copy the
initial files created for the initial diagnostics and the provisional and
adjust the parameters to the chosen restorative material (Lava Plus,
3M) in the design software (Dental Designer 18, 3Shape,
Copenhagen, Denmark), and additionally incorporate a buccal
cutback of about 1.0 mm. Besides the rather aggressive buccal
cutback, it was also important to pay meticulous attention to
maintaining the zirconia frame in the approximate areas and all the
way to the incised edge, to protect the weak veneering ceramic and
prevent chipping (Fig 2-7-10).
Figs 2-7-10a to 2-7-10d Fabrication of all-ceramic FDP.

The FDP was milled in a five-axis milling unit (Zenotec Select

Hybrid, Ivoclar Vivadent) using the classic 98-mm zirconia disk in a
dry milling environment (Lava Plus, 3M). The milled restoration was
adjusted in the white stage and infiltrated before it was sintered to its
final density. The infiltration was key to transforming the white
monochromatic zirconia into an individualized tooth-colored
restoration.
Thereafter the FDP was buccally veneered (IPS e.max Ceram,
Ivoclar Vivadent) and superficially characterized applying stains and
glaze (Ivocolor, Ivoclar Vivadent) according to the custom shade
developed with the patient.
Once the zirconia FDP was finalized, it was cleaned with alcohol
and rinsed with water. The titanium-bases on the other end were
airborne-particle abraded with 2 bar and 50-µm aluminum oxide
followed by the application of a silane-containing primer on both the
titanium-bases and the FDP (Monobond Plus, Ivoclar Vivadent).
Thereafter the FDP was cemented (Multilink Hybrid Abutment HO-0,
Ivoclar Vivadent) and carefully polished (Fig 2-7-11).
Figs 2-7-11a to 2-7-11e Finalization of zirconia FDP.

Integration of the screw-retained implant

restoration
The provisional FDP was removed and the implant and adjacent
tissues were disinfected with a chlorhexidine solution. After
disinfection (Tiutol dent, B. Braun Melsungen, Melsungen, Germany)
and the application of a chlorhexidine gel to the submucosal Part
(PlakOut Gel, KerrHawe, Bioggio, Switzerland), the screw-retained
implant FDP was preliminarily retained to the implants for a period of
2 weeks, by tightening the screws by hand (approx. 20 Ncm) and by
closing the screw access holes with PTFE tape and a provisional
resin (Telio, Ivoclar Vivadent).
After 2 weeks the abutment/FDP screws were retightened with
the final torque as recommended by the manufacturer (35 Ncm). For
the final closure of the screw access, the screws were densely
covered with PTFE tape. Subsequently, a bonding agent was applied
(Heliobond, Ivoclar Vivadent), and the closure of the screw access
holes was finalized with a light-curing composite filling material (Tetric
Classic, Ivoclar Vivadent). After the light curing, the occlusion was
checked followed by polishing of the composite fillings.
The patient was very happy with the efficient and predictable
treatment outcome, but also very impressed by the application of the
new technologies (Fig 2-7-12).
Figs 2-7-12a to 2-7-12f Integration of the screw-retained implant
restoration.

(Dental Practitioner: Prof Dr D Thoma; Technician: MDT V

Fehmer.)

Implant-supported three-unit
FDP
(full digital workflow)

2.7.2 Implant-supported three-unit

fixed dental prosthesis (FDP)
■ Posterior regions, titanium-resin base, and restoration (semi
translucent multicolor zirconia)
■ Three-unit posterior implant FDP-guided surgery and full digital
workflow

The following describes a case involving a regular diameter implant

(tissue level 4.8 mm) with titanium-resin base abutments for FDP,
semi-translucent multicolor zirconia, and a full digital workflow.

Assessment and treatment planning

A 77-year-old female patient presented herself at the clinic seeking
for a replacement of her failing four-unit FDP in the first quadrant. The
patient was healthy, a non-smoker, and did not take any medication.
The porcelain-fused-to-metal FDP was removed together with the
two abutment teeth. The abutment teeth were extracted firstly
because of the epigingival fracture of the premolar which was
endodontically treated more than 10 years previously, and secondly
due to pronounced loss of attachment at the second molar, involving
the furcation combined with a periapical radiolucency indicating a
perio-endo problem.
Due to the position in the arch and the size of the restoration, it
was planned to place two tissue-level implants (Tissue Level,
Straumann, Basel, Switzerland) with a regular diameter of 4.8 mm,
applying guided surgery and including guided bone regeneration if
needed.
After successful osseointegration, the implants were restored with
a semi translucent zirconia FDP (Lava Plus, 3M, Seefeld, Germany)
on a titanium-resin base (VarioBase for crowns, Straumann).
To increase efficiency it was planned to acquire an optical
impression and follow the complete digital workflow from diagnostics
to the final CAD/CAM fabricated restoration (Fig 2-7-13).
Figs 2-7-13a to 2-7-13c Pretreatment photographs.

Extraction
As the FDP lost its mesial retention due to the horizontal fracture of
tooth 14, the remaining four-unit FDP was only retained by the
second molar 17. Which led to a high mobility grade 3 and its
immediate extraction on trying to remove the FDP.
After both teeth were extracted, granulation tissue had to be
removed and finally the socket was curetted and rinsed with
neomycin solution (Fig 2-7-14).
Fig 2-7-14a to 2-7-14e Extraction.

Implant placement and regeneration

After complete diagnostics and treatment plan, a successful hygienic
phase (including non-surgical periodontal treatment) was completed.
With the aid of a guided surgery planning software (SMOP,
Swissmeda, Zurich, Switzerland) two implants (Tissue Level SP RN,
Straumann) were planned in positions of the first premolar and the
first molar in the first quadrant, according to the prosthetic correct
position based on the diagnostic wax-up. A surgical stent was
produced by means of 3D printing and the implant surgery was
performed accordingly (Fig 2-7-15).
Figs 2-7-15a to 2-7-15k Implant placement with a 3D-printed guide.
A simultaneous guided bone regeneration (GBR) was conducted
with deproteinized bovine bone mineral (Bio-Oss, Geistlich Pharma,
Wolhusen, Switzerland) and collagen membrane (Bio-Gide, Geistlich
Pharma) followed by submucosal healing (Fig 2-7-16).
Figs 2-7-16a to 2-7-16f Guided bone regeneration.

Abutment connection
The healing period was uneventful and 3 months after the implant
placement the clinical examination revealed healthy tissues. At this
time point, the abutment connection was performed under local
anesthesia. Additionally, an inlay graft harvested from the maxillary
tuberosity region was performed to improve the tissue quantity and
quality in the pontic area (Fig 2-7-17).
Figs 2-7-17a to 2-7-17f Abutment connection and inlay graft.

Optical impression and design of the

provisional FDP
Four months after implant placement, an optical impression was
performed. The corresponding PEEK scanbodies were inserted
(Mono-Scanbodies, Straumann) and a powder-free optical quadrant
impression (Trios 3, 3Shape) was acquired (Fig 2-7-18).

Fig 2-7-18 Healed area for optical impression.

Once the optical impression was sent online to the dental

laboratory the FDP was digitally designed (Dental Designer 18,
3Shape) in full contour based on the respective ti-base (Vario-Base
for FDP, Straumann). Thereafter the design software automatically
leads the workflow to the model-builder software (Model-Builder,
3Shape) in which the master model was designed and the digitally
selected analogs were placed (Fig 2-7-19).
Figs 2-7-19a to 2-7-19g Optical impression and design of the
provisional FDP.

At the end of this extremely efficient workflow, three .stl files were
exported from the software, the maxillary and mandibular model
along with the FDP.
The generated model files were placed in a 3D printer (Rapid
Shape P30, Straumann) and printed with a beige stone-like tinted
light-curing 3D printing resin (SHERA Sand, Lemförde, Germany),
and thereafter post-processed and light-cured to their final
toughness.
The full contour FDP, however, was milled in a fiveaxis milling unit
(Zenotec Select Hybrid, Ivoclar Vivadent, Schaan, Liechtenstein)
using the classic 98-mm disk in a dry milling environment (Telio CAD
A3 Esthetic, Ivoclar Vivadent). The milled provisional restoration was
adjusted and polished.
Once the PMMA FDP was finalized, it was cleaned with alcohol
and rinsed with water and primed (SR Connect, Ivoclar Vivadent).
The titanium-bases on the other end were airborne-particle abraded
with 2 bar and 50-µm aluminum oxide followed by the application of a
silane-containing primer (Monobond Plus, Ivoclar Vivadent).
Thereafter the FDP was cemented (Multilink Hybrid Abutment HO-0,
Ivoclar Vivadent) and the cement gap carefully polished (Fig 2-7-20).
Figs 2-7-20a to 2-7-20d Cementation of the FDP.

Fabrication of the all-ceramic FDP on

titanium-base abutment
The patient adapted well to the provisional and felt very comfortable
with the occlusion.
After a 4-month period and without taking an additional
impression, the laboratory was asked to fabricate the final monolithic
restoration. At this point, all the laboratory technician had to do was
to copy the initial files created for the provisional and adjust the
parameters to the chosen restorative material (Lava Plus, 3M) in the
design software (Dental Designer 18, 3Shape).
The full contour FDP was milled in a five-axis milling unit (Zenotec
Select Hybrid, Ivoclar Vivadent) using the classic 98-mm zirconia disk
in a dry milling environment (Lava Plus, 3M).
The milled restoration was adjusted in the white stage and
infiltrated before it was sintered to its final density. The infiltration is
key to transforming the white monochromatic zirconia into an
individualized polychromatic tooth-colored restoration. Thereafter, the
FDP was superficially characterized with the application of stains and
glaze (Ivocolor, Ivoclar Vivadent) according to the custom shade
developed with the patient.
Once the zirconia FDP was finalized, it was cleaned with alcohol
and rinsed with water. The titanium-bases on the other end were
airborne-particle abraded with 2 bar and 50-µm aluminum oxide
followed by the application of a silane-containing primer on both the
titanium-bases and the FDP (Monobond Plus, Ivoclar Vivadent).
Thereafter the FDP was cemented (Multilink Hybrid Abutment HO-0,
Ivoclar Vivadent) and carefully polished (Fig 2-7-21).
Figs 2-7-21a to 2-7-21d Fabrication of all-ceramic FDP.

Integration of the screw-retained implant

restoration
The provisional FDP was removed and the implant and adjacent
tissues disinfected with a chlorhexidine solution. After disinfection
(Tiutol dent, B. Braun Melsungen, Melsungen, Germany) and the
application of a chlorhexidine gel to the submucosal Part (PlakOut
Gel, KerrHawe, Bioggio, Switzerland), the screw-retained implant
FDP was preliminarily retained to the implants for a period of 2
weeks, by tightening the screws by hand (approx. 20 Ncm) and by
closing the screw access holes with PTFE tape and a provisional
resin (Telio, Ivoclar Vivadent).
After 2 weeks the abutment/FDP screws were retightened with
the final torque as recommended by the manufacturer (35 Ncm). For
the final closure of the screw access the screws were densely
covered with PTFE tape; subsequently, a bonding agent was applied
(Scotchbond Universal, 3M), and the closure of the screw access
holes was finalized with a light-curing composite filling material (Tetric
Classic, Ivoclar Vivadent). After the light curing, the occlusion was
checked followed by polishing of the composite fillings.
The patient was not only very happy with the efficient and
predictable treatment outcome but also very impressed by the
application of the new technologies and in particular the optical
impression that had been performed (Fig 2-7-22).
Figs 2-7-22a to 2-7-22d Integration of the screw-retained implant
restoration.
Fig 2-7-22e Final treatment outcome.
(Dental practitioner: Dr J Pitta; Technician: MDT V Fehmer.)

Implant-supported FDP with

mesial cantilever
(opening of the vertical dimension)

2.7.3 Implant-supported fixed dental

prosthesis with mesial
cantilever (FDP)
■ Anterior regions: lithium-disilicate veneers
■ Anterior regions: palatal veneers, polymer-infiltratedceramic
network (PICN), hybrid ceramic
■ Posterior regions: CoCr based framework with mesial cantilever
■ Opening of the vertical dimension

The following case involves the posterior regions, and a restoration

based on regular and wide diameter implants (tissue level) with
CAD/CAM fabricated CoCr frameworks, conventionally veneered. For
an esthetic improvement in the anterior region, both vestibular and
palatal veneers were placed in a minimally invasive approach.

Assessment and treatment planning

A 60-year-old male patient presented himself at the clinic for a
general treatment and an esthetic improvement of his anterior teeth
and smile. The patient was healthy, of good fitness, and took no
medication. He is self-employed and was a former heavy smoker (35
pack-years).
He had received removable dentures for both arches several
years ago but never got used to them due to poor retention as well
as a covered palate, and therefore never wore them.
One of the patient’s chief complaints was the poor esthetics of his
worn dentition. The patient’s second wish was to receive fixed dental
restorations, which was indicated by his age. Also due to his previous
(negative) experience with removable appliances, the patient wished
for fixed dental restorations, if at all possible.
At the beginning of the comprehensive treatment, a detailed
diagnostics process was required for evaluation of the single tooth
prognosis and potential strategic relevance.
Furthermore, an extra- and intraoral esthetic analysis was
performed to determine the desired outline of his teeth.
In general, it was planned to restore the remaining teeth with a
minimally invasive approach and place implants in the posterior
segments to enhance his chewing efficiency.
As the patient’s vertical dimension of occlusion (VDO) has been
reduced over the years due to loss of posterior teeth and
parafunction, it was deemed paramount to establish a new, increased
VDO.
The final restorations were planned to be fabricated from
monolithic multicolored zirconia in combination with titanium-resin
base abutments.
As these were major changes for the patient, a long-term
provisional phase to adapt to the new vertical dimension and the
overall shape and size of his new restorations was foreseen.
To increase both time- and cost-efficiency, it was planned to apply
a digital workflow, wherever feasible, from diagnostics to the final
CAD/CAM-fabricated restorations (Fig 2-7-23).
Figs 2-7-23a to 2-7-23c Pretreatment photographs.

Diagnostics
The patient’s chief complaint was the compromised esthetic
appearance especially concerning the maxillary anterior teeth. The
patient was aware that his anterior teeth were worn down due to
attrition and erosion, which resulted in exposed dentin and increased
thermal sensitivity.
Additionally, he had reduced chewing capabilities due to lacking
posterior teeth and wished for a fixed replacement of his lost teeth as
he never got used to his removable partial dentures (Fig 2-7-24).
Fig 2-7-24a to 2-7-24f Diagnostic images.

First mock-up
A first wax-up was fabricated in the laboratory alongside a posterior
setup, that was then transferred into the patient’s mouth to give him a
first idea how his future restorations could look. The patient was
pleased with the esthetic appearance of the mock-up, except the
central diastema, which he preferred to close if possible. From the
point of view of the dentist, the slightly inversed smile line (especially
on the left side) due to overerupted antagonists was something to be
corrected with the final restorations (Fig 2-7-25).
Fig 2-7-25a to 2-7-25c First mock-up.

Implant placement
According to the diagnostic mock-up, conventional surgical stents
were fabricated transferring the prosthetic plan of the ideal three-
dimensional (3D) position of the implant to the surgical intervention.
On the day of implant placement, the patient was premedicated 1
hour before the intervention with 2000 mg amoxicillin and 600 mg
ibuprofen. After the raising of a mucoperiosteal flap with distal
releasing incisions, two tissue-level implants were installed on both
sides in the maxilla, with the mesial implants having a regular-neck
platform of 4.8 mm diameter and the distal implants showing a wide-
neck platform of 6.5 mm in diameter, respectively (RN, WN,
Straumann, Basel, Switzerland). They were placed with excellent
primary stability and a correct prosthetic position/axis in the maxillary
arch. However, thanks to detailed diagnostics a rather large bony
defect at position 23 was anticipated. The real extension of this
defect could only be assessed intrasurgically, as a 3D radiograph
was not indicated due to lack of informative value in comparison to
the irradiation dose. Therefore, a secondary drill hole at position 24
was placed in the surgical guide beforehand. During the surgical
intervention, a large buccal concavity as well as reduced crest height
confirmed the suspicions. The implant was finally placed in position
24.
This decision had important ramifications on the initial treatment
plan, as a restoration with a cantilevered extension, especially of a
canine, requires different and much stronger restorative materials. In
this new configuration with a cantilever canine extension, a final
restoration made of monolithic zirconia is not well documented in the
literature and the risk for severe technical complications was deemed
too high. Instead, a restoration with digitally designed and CAM-
milled cobalt-chromium frameworks was chosen, which would later
be veneered by the technician. In the mandibular arch, two tissue-
level-wide diameter implants (WN 6.5 mm, Straumann) were placed
in the region of the first molar on each side following the same clinical
approach.
Once the implants were placed, small closure screws were used
to allow full coverage during the healing period.
The flaps were released by splitting the periosteum, allowing for a
tension-free re-adaptation of the flaps. After the suturing (Gore-Tex
5.0, W.L. Gore & Associates, Flagstaff, AZ, USA) the implants were
left for submucosal healing for 8–10 weeks.
Antibiotics (amoxicillin and clavulanic acid 3 × 625 mg for 5 days),
painkillers (600 mg ibuprofen if needed), and chlorhexidine mouth
rinse (0.2%) were prescribed. The sutures were removed 10 days
after implant placement and no complications were observed (Fig 2-
7-26 and 2-7-27).
Figs 2-7-26a to 2-7-26j Implant placement.
Figs 2-7-27a to 2-7-27f Implant placement.

Healing period and impression

The healing period was uneventful and 10 weeks after implant
placement the clinical examination revealed healthy tissues. The
second stage surgery was performed and healing abutments were
fitted onto all implants (Fig 2-7-27). After a healing period of 2
weeks, the healing abutments were removed, and an analog silicone
impression was taken and sent to the dental laboratory.

Bite registration
In the dental laboratory the conventional impressions were prepared
with plaster and a master cast fabricated. With the preliminary bite
registration, based only on the anterior region and with the aid of the
titanium-bases and a light-curing resin material, an extended bite
registration and verification could be performed clinically.

Provisional implant restorations

In a second phase after the bite verification, using the corresponding
scan bodies, the cast along with the implant positions were digitized
by means of a lab scanner (inEos X5, Dentsply Sirona, Bensheim,
Germany) and full contour restorations were digitally designed
(Dental Designer 18, 3Shape, Copenhagen, Denmark). The full-
contour restorations were milled in a five-axis milling unit (Zenotec
Select Hybrid, Ivoclar Vivadent, Schaan, Liechtenstein) using the
classic 98-mm disk in a dry milling environment (Telio CAD A3
Esthetic, Ivoclar Vivadent). The milled provisional restorations were
adjusted and polished. Once the PMMA restorations were finalized,
they were cleaned with alcohol and rinsed with water and primed (SR
Connect, Ivoclar Vivadent). The titanium-bases (Vario-Base 5.5 mm,
Straumann) on the other end were airborne-particle abraded with 2
bar and 50-µm aluminum oxide followed by the application of a silane-
containing primer (Monobond Plus, Ivoclar Vivadent)(Fig 2-7-28).
Thereafter the FDP was cemented (Multilink Hybrid Abutment HO-0,
Ivoclar Vivadent) and the cement gap carefully polished.
Fig 2-7-28a to 2-7-28f Bite registration and provisional implant
restorations.

Fabrication of the all-CoCr abutment crowns

and FDPs
Once the conventional impressions were translated into master casts,
the casts were scanned using a lab scanner (inEos X5, Dentsply
Sirona) and the indicated scanbodies for the Straumann workflow.
Based on the scans, the crowns and FDPs were digitally designed
(Dental Designer 18, 3Shape) with an overall cutback of 1.5 mm (Fig
2-7-29).
Fig 2-7-29a and 2-7-29d Digital design of crowns and FDPs.
The generated files were then sent to an external milling center
(Straumann milling center, Leipzig, Germany) and milled in a five-axis
milling unit using a classic 98-mm disk in a wet milling environment.
The milled restorations were sent back to the delta laboratory
within 3 days and some minor necessary adjustments were made on
the master cast. The overall fit of the components was ideal and no
adjustments were needed (Fig 2-7-30).

Fig 2-7-30a to 2-7-30b Master cast and restorations.

Framework try-in
The milled and (in the dental laboratory) adjusted frameworks were
checked intraorally for their overall fit. The framework try-in was
clinically checked with respect to its fit and sufficient support for the
veneering ceramic (Fig 2-7-31).
Fig 2-7-31a to 2-7-31d Framework try-in.

The fit of the CAD/CAM fabricated frameworks was outstanding,

and applying the Sheffield test with only the medial abutment screw
showed a perfect adaptation in the radiograph (Fig 2-7-32).
Fig 2-7-32 Radiographic check of the framework fit.

Additionally during the framework try-in, the bite registration was

verified and cross-checked with the laboratory by adding some
autopolymerizing acrylic in the occlusal parts of the frameworks (Fig
2-7-33).

Fig 2-7-33 Bite registration check with autopolymerizing acrylic.

Preparation for biscuit bake try-in

Thereafter the restorations were conventionally veneered (Creation
Classic, Willi Geller) and superficially characterized via applying
stains (Mack-up, Willi Geller, Meiningen, Austria) according to the
custom shade developed with the patient (Fig 2-7-34).

Fig 2-7-34 Preparation for biscuit bake try-in.

Biscuit bake try-in

The biscuit bake was clinically checked with respect to the shade and
shape of the restorations. The patient and the restorative team were
very satisfied with the final shape and overall integration. However,
small details could still be improved as the restorations overall
appeared too high in value and incisally they could be more
translucent (Fig 2-7-35).
Fig 2-7-35a and 2-7-35b Biscuit bake try-in.

Finalization of the restoration

The shape and shade were adjusted as discussed during the biscuit
bake try-in and glaze firing was followed by an additional stain firing
to achieve the best possible esthetic integration (Fig 2-7-36).
Fig 2-7-36a to 2-7-36e Finalization of the restoration.

Integration of the screw-retained implant

restorations
The provisional restorations were removed and the implant and
adjacent tissues were disinfected with a chlorhexidine solution. After
disinfection (Tiutol dent, B. Braun Melsungen, Melsungen, Germany)
and the application of a chlorhexidine gel to the submucosal Part
(PlakOut Gel, KerrHawe, Bioggio, Switzerland), the screw-retained
implant FDPs and the single crowns were preliminarily retained to the
implants for a period of 2 weeks, by tightening the screws by hand
(approx. 20 Ncm) and by closing the screw access holes with PTFE
tape and a provisional resin (Telio, Ivoclar Vivadent).
After 2 weeks, the abutment/FDP screws were retightened with
the final torque as recommended by the manufacturer (35 Ncm). For
the final closure of the screw access the screws were densely
covered with PTFE tape; subsequently, a bonding agent was applied
(Heliobond, Ivoclar Vivadent), and the closure of the screw access
holes was finalized with a light-curing composite filling material (Tetric
Classic, Ivoclar Vivadent). After the light curing, the occlusion was
checked followed by polishing of the composite fillings (Fig 2-7-37).
Fig 2-7-37a to 2-7-37d Integration of the screw-retained implant
restorations.

Fabrication of the palatal veneers in the

laboratory
As a first step the laboratory fabricated a master cast that in a
second phase was scanned using a laboratory scanner (inEos X5,
Dentsply Sirona). Based on the scans, the palatal veneers were
digitally designed (Cerec in-lab 16.1, Dentsply Sirona) in full contour.
The generated files were then milled in a chairside milling unit (MCXL,
Dentsply Sirona) using the PICN hybrid ceramic blanks (Enamic
multicolor 2M2, Vita Zahnfabrik, Bad Säckingen, Germany). The
milled restoration was adjusted and carefully polished (Fig 2-7-38).
Fig 2-7-38a to 2-7-38d Digital design of the palatal veneers.
Integration of the palatal veneers
A try-in session was carried out, where the palatal veneers were
inserted with a try-in paste (Variolink Esthetic neutral and warm,
Ivoclar Vivadent) in order to verify the fit and optical integration.
Subsequently, the hybrid ceramic palatal veneers were cemented
under rubber dam isolation. The abutment teeth were etched with
35% phosphoric acid (Ultra-Etch, Ultradent Products, South Jordan,
UT, USA) and bonded with a multistep adhesive system (Optibond
FL, Kerr, Bioggio, Switzerland). The bond was not light cured in order
not to compromise the fit of the palatal veneers. The palatal veneers
were etched with hydrofluoric acid (5% concentration for 60 s) (IPS
Ceramic Etching Gel, Ivoclar Vivadent). A silane-containing primer
(Monobond Plus, Ivoclar Vivadent) and a bonding system (Heliobond,
Ivoclar Vivadent) was applied. Then the palatal veneers were
cemented with a dual-curing resin cement (Variolink Esthetic Neutral,
Ivoclar Vivadent, FL, USA). Excess cement was removed with
rotating and oscillating diamond instruments (Universal Prep Set,
Intensiv, Montagnola, Switzerland).
With this step, the new vertical dimension was finalized and the
patient felt very comfortable with the additional anterior contact
points. Due to the placement of the palatal veneers, this raising of the
vertical dimension could be achieved in a minimally invasive approach
without reducing any additional tooth substance (Fig 2-7-39).
Fig 2-7-39a to 2-7-39h Integration of the palatal veneers.

Mock-up
In the present case, a software (Ivosmile) was used, which projects
the virtual mock-up into a live view.
Together with the patient, various suggestions were worked out,
discussed, and then saved as a video file. After the patient chose a
visualized design, the virtual mock-up was transformed into a real
mock-up (Fig 2-7-40).
Fig 2-7-40a to 2-7-40c Virtual mock-up.

The stored design in the software and an initial impression of the

maxillary arch were used to superimpose the data in the CAD
software (Dental Designer 18, 3Shape, Copenhagen, Denmark).
The new design was calculated in a copy function of the initial
design (Fig 2-7-41).
Fig 2-7-41a and 2-7-41b New digital design.
Both files, the model scan aligned with the virtual design, were
then printed as one united model (CARES P Series, Straumann) (Fig
2-7-42).

Fig 2-7-42 Printed model.

The possibilities in the calculation of the virtual wax-up are

manifold, since the data is available in the open STL format (Standard
Tessellation Language).
In order to visualize the final treatment outcome and its potential
limitations it is still of absolute importance to transfer the designed
wax-up into the patient’s mouth.
For the clinical try-in, a model was printed from the initial
visualization based on a complete digital workflow, which combined
the data of both the initial teeth scan and the virtual mock-up.
From this printed model a silicone key was manufactured
(President Putty, Coltène, Cuyahoga Falls, Ohio, USA), which was
relined with a light-bodied silicone (Aquasil Ultra LV, Dentsply,
Konstanz, Germany) (Fig 2-7-43).
Fig 2-7-43 Silicone key.

This enabled a clear and efficient translation of the direct mock-

up, realized with a provisional acrylic (Protemp 4, 3M, Seefeld).
The resulting mock-up served as a verification tool, as the
prospective treatment result could now be discussed in detail and
was thereafter immediately accepted by the patient (Fig 2-7-44).
Fig 2-7-44a to 2-7-44c Mock-up.

Veneer preparation and impression

A silicone index was fabricated based on the digital wax-up to
facilitate the correct and minimally invasive preparation for the final
restoration of the teeth. The teeth 13–22 were prepared with a very
shallow epigingival course to preserve the maximum of tooth
substrate; the preparation consisted mainly of a smoothening the
edges. However, and unfortunately, the elongated central incisor 11
had to be prepared slightly more as otherwise the final veneer would
have been oriented too far buccally.
The final conventional polyether impression was taken with matrix
strips, using two retraction cords. In order to avoid traumatization of
the gingiva and to minimize the risk of recessions, a surgical suturing
material (size 4-0, Vicryl Ethicon, Johnson & Johnson, New
Brunswick, NJ, USA) was used as the first retraction cord. The
second retraction cord was the thinnest cord available on the market
(00 Ultrapak, UP Dental, Cologne, Germany) (Fig 2-7-45).
Fig 2-7-45a to 2-7-45e Veneer preparation and impression.

Fabrication of the veneers in the laboratory

The entire digital documentation (initial photos, photos with mock-up,
STLs, printed model of the final design) and the impression were
handed over to the dental laboratory. As a first step the laboratory
fabricated a master cast that in a second phase was then scanned
using a laboratory scanner and virtually aligned with all digital
supporting files. After the definition of the marginal lines and insertion
axis, a digital copy function was applied to achieve the same final
outlines and contours for the veneers as presented to the patient
during the diagnostic phase. All restorations were then milled with a
small cutback of 0.4 mm out of lithium-disilicate ceramics (IPS e.max
CAD LT A2, Ivoclar Vivadent). This cutback was considered to
enhance the individualized esthetic of the veneers with the final
application of the veneering ceramic (IPS e.max Ceram, Ivoclar
Vivadent) (Fig 2-7-46).
Fig 2-7-46a to 2-7-46d Fabrication and integration of the veneers.

Integration of the veneers

A try-in session was carried out where the veneers were inserted
with a try-in paste (Variolink Esthetic neutral and warm, Ivoclar
Vivadent) in order to improve color assessment and optical
integration. Subsequently, the ceramic veneers were cemented under
rubber dam isolation. The abutment teeth were etched with 35%
phosphoric acid (Ultra-Etch, Ultradent Products) and bonded with a
multistep adhesive system (Optibond FL, Kerr). The bond was not
light-cured in order not to compromise the fit of the ultra-thin veneers.
The veneers were etched with hydrofluoric acid (5% concentration for
20 s) (IPS Ceramic Etching Gel, Ivoclar Vivadent). A silane-containing
primer (Monobond Plus, Ivoclar Vivadent) and a bonding system
(Heliobond, Ivoclar Vivadent, Schaan, Liechtenstein) were applied.
Then the veneers were cemented with a dual-curing resin cement
(Variolink Esthetic neutral, Ivoclar Vivadent). Excess cement was
removed with rotating and oscillating diamond instruments (Universal
Prep Set, Intensiv, Montagnola, Switzerland).
The occlusal and functional contacts were analyzed, and no
adjustments were necessary. The patient was very satisfied with the
final treatment outcome (Fig 2-7-47).
Fig 2-7-47a to 2-7-47i Final outcome.
(Dental practitioner: Dr L Marchand; Technician: MDT V Fehmer.)

Implant-supported zirconia FDP

(with mesial cantilever)

2.7.4 Implant-supported fixed dental

prostheses (FDPs)
■ Posterior regions, titanium-resin base, and restoration (zirconia)
■ Three-unit posterior implant FDP with mesial cantilever

The following case describes the application of regulardiameter

implants (tissue level) based on titanium-resin-base abutments, on a
zirconia FDP with mesial cantilever.

Assessment and treatment planning

A 72-year-old female patient presented herself at the clinic seeking a
replacement of her missing teeth in the first quadrant. The patient
was healthy, a non-smoker, and did not take any medication. For
many years she had a removable partial denture retained on her
second molars, the canine 13, and the premolars 24 and 25, by
means of clamps (Fig 2-7-48).
2-7-48 Pretreatment photograph.

Unfortunately due to the loss of tooth 17 about 5 months ago, the

stability of the partially removable restoration was never as it used to
be and she was not able to bite and eat the way she wanted to.
With the patient’s wishes in mind, the treatment plan was quite
clear, and developed to restore her with a fixed three-unit FDP based
on two implants.
Due to the position in the arch and the size of the restoration, it
was planned to place two tissue level implants (Camlog Screw-Line
Implant, Promote Plus, Camlog Biotechnologies, Basel, Switzerland)
with a diameter of 5.0 mm in the molar area and 4.3 mm in the
premolar area, and including guided bone regeneration (GBR) if
needed. After successful osseointegration, the implants were
restored with a zirconia FDP (Vita YZ HT White 1200 MPa, Vita
Zahnfabrik, Bad Säckingen, Germany) on a titanium bonding base (Ti-
Base, Camlog Biotechnologies).
It was planned to take an analog impression and then to follow a
digital laboratory workflow using CAD/CAM technology.

Implant placement
According to the diagnostics, a surgical stent was fabricated
transferring the prosthetic plan of the ideal 3D position of the implant
to the surgical intervention.
At the day of implant placement, the patient was premedicated
with 1500 mg amoxicillin and 600 mg ibuprofen. After the raising of a
mucoperiosteal flap with a releasing incision distal of 17, two tissue-
level implants (5.0/4.3 mm Camlog Screw-Line Implant, Promote
Plus, Camlog Biotechnologies) were placed with excellent primary
stability and a correct prosthetic position/axis. However, the mesial
implant, initially planned in position 14, was intersurgically moved and
finally placed in position 15 due to a lack of bone and a very big
buccal concavity (Fig 2-7-49).
2-7-49a to 2-7-49e Implant placement.

This led to a change in treatment plan as a cantilever requires

different and much stronger restorative materials as compared to a
classic three-unit FDP with a mesial and distal abutment.
Once the implants were placed, small closure screws were used
to allow full coverage during the healing period. The flap was
released by splitting the periosteum allowing for a tension-free re-
adaptation of the flap. After the suturing (Gore-Tex 5.0, W.L. Gore &
Associates, Flagstaff, AZ, USA) the implant was left for transmucosal
healing for 8–10 weeks (Fig 2-7-50e).
Antibiotics (amoxicillin 3 × 750 mg for 5 days), painkillers (600 mg
ibuprofen if needed), and chlorhexidine mouthrinse (0.2%) were
prescribed. The sutures were removed 10 days after implant
placement.

Healing period and impression

The healing period was uneventful and 10 weeks after implant
placement the clinical examination revealed healthy tissues. The
healing abutments were removed, and an analog impression was
taken and sent to the dental laboratory.

Fabrication of the all-ceramic FDP

Once the conventional impression was translated into a master cast,
the casts were scanned using a lab scanner (inEos X5, Dentsply
Sirona, Bensheim, Germany) and the indicated scanbodies for the
Cerec workflow. Based on the scans, the FDP with a small buccal
cutback was digitally designed (Cerec In-Lab 16.1, Dentsply Sirona)
based on the respective titanium-bases (Ti-Base, Camlog
Biotechnologies). The generated FDP file was then milled in a five-
axis milling unit (Zenotec Select Hybrid, Ivoclar Vivadent, Schaan,
Liechtenstein) using the classic 98-mm zirconia disk in a dry milling
environment (Vita YZ HT White 1200 MPa, Vita Zahnfabrik, Bad
Säckingen, Germany) (Fig 2-7-50).
Fig 2-7-50a to 2-7-50c Fabrication of the all-ceramic FDP.

The milled restoration was adjusted in the white stage and

infiltrated (VITA YZ HT SHADE LIQUID, Vita Zahnfabrik) before it
was sintered to its final density. This infiltration is the key to transform
the white monochromatic zirconia into an individualized polychromatic
tooth-colored restoration (Fig 2-7-51).
Fig 2-7-51a to 2-7-51e Adjustment, infiltration, and sintering to
create the tooth-colored restoration.

Framework try-in
The sintered and (in the dental laboratory) adjusted framework was
checked intraorally for its overall fit. As the term “framework” would
suggest, today it is no longer just a framework but a structural Part of
the restoration including functional areas. Consequently, the occlusal
areas and contact points could also be verified before the restoration
was finalized (Fig 2-7-52).
Fig 2-7-52a to 2-7-52c Framework try-in.

Finalization of the all-ceramic FDP

Thereafter and due to the chosen opaque zirconia that can cope with
the high masticatory forces (especially on a cantilever restoration),
the FDP was buccally microveneered (VITA VM 9, Vita Zahnfabrik)
and superficially characterized applying stains and glaze VITA
AKZENT Plus, Vita Zahnfabrik) according to the custom shade
developed with the patient.
With this microveneering of about 0.3–0.5 mm, the esthetics could
be enhanced significantly and the risk for a potential chipping of the
veneering ceramic is still reasonably small.
Once the zirconia FDP was finalized, it was cleaned with alcohol
and rinsed with water. The titanium-bases were airborne-particle
abraded with 2 bar and 50-µm aluminum oxide followed by the
application of a silanecontaining primer on both the titanium-bases
and the FDP (Monobond Plus, Ivoclar Vivadent). Thereafter the FDP
was cemented (Multilink Hybrid Abutment HO-0, Ivoclar Vivadent) and
carefully polished.

Integration of the screw-retained implant

restoration
The healing abutments were removed and the implants and adjacent
tissues disinfected with a chlorhexidine solution. After disinfection
(Tiutol dent, B. Braun Melsungen, Melsungen, Germany) and the
application of a chlorhexidine gel to the submucosal Part (PlakOut
Gel, KerrHawe, Bioggio, Switzerland), the screw-retained implant
FDP was preliminarily retained to the implants for a period of 2
weeks, by tightening the screws by hand (approx. 20 Ncm) and
closing the screw access holes with PTFE tape and a provisional
resin (Telio, Ivoclar Vivadent). After 2 weeks the abutment/FDP
screws were retightened with the final torque as recommended by
the manufacturer (35 Ncm). For the final closure of the screw access
the screws were densely covered with PTFE tape, subsequently, a
bonding agent was applied (Heliobond, Ivoclar Vivadent), and the
closure of the screw access holes was finalized with a light-curing
composite filling material (Tetric Classic, Ivoclar Vivadent). After light
curing, the occlusion was checked followed by polishing of the
composite fillings.
The patient was very happy with the final treatment outcome and
the associated esthetic and functional improvement. Despite her age,
she wanted to continue the treatment and by means of minimally
invasive restorations (six veneers) in her anterior maxilla further
improve her appearance (Fig 2-7-53).
Figs 2-7-53a to 2-7-53e Integration of the screw-retained implant
restoration.

(Dental practitioner: Dr U Calderon; Technician: MDT V Fehmer.)

Full-arch implant-supported
FDPs
(digital workflow)

2.7.5 Full-arch implant-supported

fixed restoration with pink
ceramics (FDP)
■ Full-mouth rehabilitation supported by implants
■ Maxillary arch titanium-resin bases and microveneered zirconia
restoration high-strength multicolor zirconia
■ Mandibular arch titanium-resin bases, CAD/CAM fabricated CoCr
frame, and acrylic denture teeth
■ Digital workflow

In the following treatment, six regular diameter tissuelevel implants

were placed in each arch to deliver a fixed restoration based on a
hybrid material selection. In the maxillary arch, for a better esthetic
outcome a microveneered zirconia-based restoration on titanium
bases was fabricated, and for the mandibular arch, acrylic denture
teeth were supported by a CoCr framework based on titanium bases.

Assessment and treatment planning

A 72-year-old patient presented himself at the dental office seeking
treatment for his insufficient complete dentures in the maxillary and
mandibular arches. The patient was healthy, a non-smoker, but over
the last few years his partial denture was constantly extended by his
previous dentist until he finally ended up with complete dentures in the
maxillary and mandibular arches with only a moderate retention (Fig
2-7-54). The patient was aware that one day he would have to attend
to this issue as he was lacking the ability to properly eat and chew.
With this in mind, he started to save money for his future dental
treatment.
1
Fig 2-7-54 Pretreatment photograph (Reproduced from Fehmer ).

The patient’s wish was to enhance his esthetic appearance and

functional performance and he wished for a new and reliable fixed
restoration.
To achieve this goal, six implants were recommended in each
arch, and, after approval of the treatment plan, placed. After the
healing phase, both arches were rehabilitated with screw-retained
restorations. To reduce the risk for chipping of the veneering material
and also the costs of the final restoration, a hybrid approach was
selected.
As for the maxillary arch, a highly esthetic buccally veneered
zirconia framework was selected, while for the mandibular arch a
CAD/CAM-based CoCr framework veneered with classic acrylic
denture teeth was planned. This combination of materials also came
with the additional benefit that all potential adjustments or occlusal
wear would take place only in the mandibular arch and would be easy
to maintain in the years to come, simply by exchanging the denture
teeth.
To increase efficiency, it was planned to acquire an optical
impression and follow a completely digital workflow from diagnostics
to the final CAD/CAM fabricated restoration.

Diagnostics
The patient’s chief complaint was his compromised esthetic
appearance especially in the maxillary teeth. However, he was also
aware that his current dentures did not offer a proper retention and
he had difficulties eating food.
An initial setup was tried-in and idealized, and then fixed to the
master cast using a silicone key to give the necessary prosthetic
orientation during the fabrication of the restoration. After the scanning
of the maxillary and mandibular casts, a duplicate of the provisional
was made of temporary resin to give intraoral information about the
occlusal relationship (Fig 2-7-55).

1
Fig 2-7-55 Diagnostic provisional (Reproduced from Fehmer ).
Implant placement, mandibular arch
After complete diagnostics, the treatment plan was finalized. With the
aid of a conventional surgical guide, based on the setup, six tissue-
level implants were planned in the positions of the first molars, the
second premolars, and in the position of the canines according to the
prosthetic correct position based on the diagnostic wax-up. The
surgical stent was produced by means of a thermoplastic foil (1.5 mm
Erkodur, Erkoden, Pfalzgrafenweiler, Germany) that was relined on
the cast for a better adaptation and the implant surgery was
performed accordingly.
The implants were closed with a healing abutment and left for
open healing (Fig 2-7-56).
Fig 2-7-56a to 2-7-56f Implant placement in the mandible.

Healing period, mandibular arch

The healing period was uneventful and 3 months after the implant
placement the clinical examination revealed healthy tissues (Fig 2-7-
57a).
Figs 2-7-57a to 2-7-57l Healing and optical impression.

Optical impression, mandibular arch

Three months after implant placement, an optical impression was
performed. The corresponding metal scanbodies were inserted (MIS
scanbodies, MIS Implants Technologies, Bar-Lev, Israel) and a
powder-free optical full-arch impression (Trios 3, 3Shape,
Copenhagen, Denmark) was acquired (Fig 2-7-57b to 2-7-57e).

Fabrication of the mandibular screw-retained

FDP
Once the optical impression was sent online to the dental laboratory,
the framework was digitally designed (Exocad, Darmstadt, Germany)
according to the setup that was also scanned in the mouth of the
patient. With additional information, not only was it easier to ensure
the correct transfer of the bite and the vertical dimension, but also to
design an ideal metal support for each denture tooth. The CoCr
framework was based on the respective titanium-base (Ti-Base for
FDP, MIS, Implants Technologies) and was milled in an external
milling center. Thereafter, the design software automatically leads the
workflow to the model-builder software (Model Creator, Exocad) in
which the master model was designed with a removable gingiva mask
and the digitally selected analogs were placed (Fig 2-7-58).
Figs 2-7-58a to 2-7-58m Design of the screw-retained FDP.

At the end of this highly efficient workflow, four .stl files were
exported from the software, the maxillary and mandibular model and
two mandibular gingival models. The generated model files were
placed in a 3D printer (RapidShape P30, Straumann, Basel,
Switzerland) and printed with a beige stone-like tinted light-curing 3D
printing resin (SHERA Sand and SHERAprint-gingiva mask, SHERA,
Lemförde, Germany). The gingival Part had to be printed separately
with a pink silicone-like light-curing material (SHERAprint-gingiva
mask, SHERA) and thereafter post-processed and light-cured to their
final toughness.
With the models prepared, and the titanium-bases and the milled
framework in place, the mandibular restoration could be finalized with
a traditional approach by injecting pink acrylic (34 Original Pink –
Aesthetic Blue, Candulor, Glattpark, Switzerland) into a silicone mold
that contained the denture teeth. Once the acrylic had set, the
restoration was adjusted and polished to a high gloss, but not yet
cemented to the titanium-bases. As the accuracy of the optical
impression is still not 100% predictable, especially on the implant
shoulder level, it was decided to cement three out of the total six
titaniumbases (all of them in the same quadrant), on the model and
the other three intraorally.
The FDP was airborne-particle abraded with 2 bar and 50-µm
aluminum oxide, cleaned with alcohol, and rinsed with water followed
by the application of a silanecontaining primer (Monobond Plus,
Ivoclar Vivadent). The titanium-bases on the other end were also
airborneparticle abraded with 2 bar and 50-µm aluminum oxide
followed by the application of a silane-containing primer (Monobond
Plus, Ivoclar Vivadent). Thereafter, three of the six titanium-bases in
the third quadrant were cemented (Multilink Hybrid Abutment HO-0,
Ivoclar Vivadent) on the printed model. The three remaining titanium-
bases in the fourth quadrant were cemented in the patient’s mouth.
Thereafter, the screw-retained FDP was removed and the cement
excess was carefully polished.
The last and final check was to verify the cleanability and to
reassure that there were no undercuts left behind (Fig 2-7-59).
Fig 2-7-59a to 2-7-59d Fabrication of the screw-retained mandibular
FDP.

Integration of the screw-retained implant

restoration
The healing abutments were removed and the implants and adjacent
tissues were disinfected with a chlorhexidine solution. After
disinfection (Tiutol dent, B. Braun Melsungen, Melsungen, Germany)
and the application of a chlorhexidine gel to the submucosal Part
(PlakOut Gel, KerrHawe, Bioggio, Switzerland), the screw-retained
implant FDP was preliminarily retained to the implants for a period of
2 weeks, by tightening the screws by hand (approx. 20 Ncm) and by
closing the screw access holes with PTFE tape and a provisional
resin (Telio, Ivoclar Vivadent) (Fig 2-7-60).
Fig 2-7-60a and 2-7-60b Integration of the screw-retained implant
restoration.

After 2 weeks, the screws were retightened with the final torque
as recommended by the manufacturer (35 Ncm). For the final closure
of the screw access, the screws were densely covered with PTFE
tape and the closure of the screw access holes was finalized with a
light-curing composite filling material (Tetric Classic, Ivoclar Vivadent).

Implant placement, maxillary arch

With the aid of a conventional surgical guide, based on the set up, six
tissue-level implants were planned in the positions of the first molars,
the second premolars, and in the position of the canines according to
the prosthetic correct position based on the diagnostic wax-up. The
surgical stent was produced by means of a thermoplastic foil (1.5 mm
Erkodur, Erkoden) that was relined on the model for a better
adaptation and the implant surgery was performed accordingly.
The implants were closed with a healing abutment and left for
open healing (Fig 2-7-61).
Fig 2-7-61a to 2-7-61d Implant placement in the maxilla (Fig 2-7-61c
1
reproduced from Fehmer ).

Healing period and impression

The healing period was uneventful and 10 weeks after implant
placement the clinical examination revealed healthy tissues. The
healing abutment was removed, and an analog impression was taken
and sent to the dental laboratory.
Prototype verification and bite registration
After the bite registration, the functional contacts were adjusted in the
prototype and thereafter transferred via a copy function to the digital
wax-up. The optimized wax-up then served as the base to be digitally
copied by the application of computer-aided design software to
design the final full contour restoration including a small buccal (0.6
mm) cutback (Fig 2-7-62).
Fig 2-7-62a to 2-7-62f Prototype verification and bite registration.

Fabrication of the all-ceramic full-arch FDP

Once the conventional impression was translated into a master cast,
the models were scanned using a lab scanner (inEos X5, Dentsply
Sirona, Bensheim, Germany) and the indicated scanbodies for the
Cerec workflow. Based on the scans, an FDP with a small buccal
cutback was digitally designed (Cerec in-lab 16.1, Dentsply Sirona)
based on the respective titanium-bases (Ti-Base, MIS, Implants
Technologies). The generated FDP file was then milled in a five-axis
milling unit (Zenotec Select Hybrid, Ivoclar Vivadent) using the classic
98-mm zirconia disk in a dry milling environment (VITA YZ HT White
1200 Mpa, Vita Zahnfabrik, Bad Säckingen, Germany) (Fig 2-7-63
and Fig 2-7-64).
Fig 2-7-63a to 63e Design of the maxillary FDP (Fig 2-7-3e
1
reproduced from Fehmer ).

The milled restoration was adjusted in the white stage and

infiltrated (VITA YZ HT Shade Liquid, Vita Zahnfabrik) before it was
sintered to its final density. The infiltration is key to transforming the
white monochromatic zirconia into an individualized polychromatic
tooth-colored restoration (Fig 2-7-64).
Fig 2-7-64a to2-7-64c Fabrication, infiltration, and sintering of the
1
all-ceramic FDP (Reproduced from Fehmer ).

Finalization of the all-ceramic FDP

Thereafter and due to the chosen opaque zirconia that can cope with
the high masticatory forces, especially on a full-arch restoration, the
FDP was buccally microveneered (VITA VM 9, Vita Zahnfabrik) and
superficially characterized. This was done by applying stains and
glaze VITA AKZENT Plus, Vita Zahnfabrik) according to the custom
shade developed with the patient (Fig 2-7-65).
Figs 2-7-65a and 2-7-65b Characterization (Reproduced from
1
Fehmer ).

Also, the application of individualized pink veneering ceramic in the

buccal segment played a crucial role to deliver the envisaged esthetic
outcome (presented here by means of a similar case) (Fig 2-7-66).
Fig 2-7-66a to 2-7-66c Application of individualized pink veneering in
another case.

With this microveneering of about 0.6 mm, the esthetics could be

enhanced significantly and the risk for a potential chipping of the
veneering ceramic is still reasonable small. Once the zirconia FDP
was finalized, it was cleaned with alcohol and rinsed with water. The
titanium-bases were airborne-particle abraded with 2 bar and 50-µm
aluminum oxide followed by the application of a silane-containing
primer on both the titanium-bases and the FDP (Monobond Plus,
Ivoclar Vivadent). Thereafter it was cemented (Multilink Hybrid
Abutment HO-0, Ivoclar Vivadent) and carefully polished (Fig 2-7-67).
Fig 2-7-67a and 2-7-67b Finalization of the all-ceramic FDP.

Integration of the screw-retained implant

restoration
The healing abutments were removed and the implants and adjacent
tissues were disinfected with a chlorhexidine solution. After
disinfection (Tiutol dent, B. Braun Melsungen, Melsungen, Germany)
and the application of a chlorhexidine gel to the submucosal Part
(PlakOut Gel, KerrHawe, Bioggio, Switzerland), the screw-retained
implant FDP was preliminarily retained to the implants for a period of
2 weeks, by tightening the screws by hand (approx. 20 Ncm) and by
closing the screw access holes with PTFE tape and a provisional
resin (Telio, Ivoclar Vivadent). After 2 weeks the abutment/FDP
screws were retightened with the final torque as recommended by
the manufacturer (35 Ncm). For the final closure of the screw access,
the screws were densely covered with PTFE tape; subsequently, a
bonding agent was applied (Heliobond, Ivoclar Vivadent), and the
closure of the screw access holes finalized with a light-curing
composite filling material (Tetric Classic, Ivoclar Vivadent). After the
light curing, the occlusion was checked followed by polishing of the
composite fillings.
The patient was very happy with the final treatment outcome and
the associated esthetic and functional improvement (Fig 2-7-68).
1
Fig 2-7-68 Final outcome (Reproduced from Fehmer ).
(Dental practitioner: Dr E van Dooren; Technician: MDT V
Fehmer.)

Reference
1. Fehmer V. Teilverblendete, implantatgetragene Brücke aus
VITA YZ HT. Dent Visionist 2016;2:16–19.
CHAPTER 8
Maintenance

2.8.1 Intraoral direct repair of an existing

restoration
2.8.2 Maintaining an existing restoration
2.8.3 CAD/CAM-fabricated Michigan splint

Intraoral direct repair of a

ceramic chipping
2.8.1 Intraoral direct repair of an
existing restoration
■ Direct, intraoral composite repair

The following case involves the direct repair of a ceramic chipping on

a restored lateral incisor by means of direct composite.

Assessment and treatment options

A 72-year-old woman presented herself at the clinic with the
fractured incisal edge of her more than 10-year-old porcelain-fused-
to-metal restoration with the wish to repair the fractured Part (Fig 2-
8-1). As fractures of the veneering ceramic, especially on implants,
are the predominant technical complication, it is an unfortunate issue
associated with conventional veneered restorations that cannot be
entirely prevented. Looking closer into her case, the chipping
occurred in a cantilever four-unit screw-retained implant FDP.
Therefore, it would have been quite easy to unscrew the FDP and
send it back to the dental laboratory for repair. However, on
discussing the patient’s situation with the dental technician, several
obstacles came up and had to be taken into consideration.
Fig 2-8-1 Pretreatment photograph.

As the restoration was quite old, it is always a risk to put it back

into a ceramic oven, even with the application of a careful pre-drying
process. Another issue was that it was unclear which ceramic was
used by the dental technician. Therefore the attempt to improve the
situation could have actually made the situation even worse for the
patient. Still, there was the option to take the restoration out of the
mouth, send it to the dental laboratory, and have the laboratory
technician in dry conditions make the repair by means of direct
composite.
The patient unfortunately did not have any provisional and taking
out the restoration, sending it to the laboratory, and screwing it back
in would have left the patient without teeth for a minimum of one day
and raised the costs; therefore, it was decided to do a direct intraoral
repair of the incisal edge by means of a composite build-up.
Direct composite build-up
Once all options had been discussed and evaluated with the patient,
the existing restorations was prepared for an intraoral composite
build-up of the fractured incisal edge. To achieve dry conditions,
rubber dam was placed and the sharp edges of the ceramic fracture
line were smoothed. This smoothing has two advantages as it makes
the application and the wettability of the surface easier, and then it
refreshes the ceramic surface.
Once the restoration was smoothed it could be prepared for the
adhesive application of composite. Under the seal of rubber dam the
existing intraoral restoration could be safely etched for 1 min with
hydrofluoric acid (9% concentration) (Porcelain Etch, Ultradent,
Cologne, Germany) and a silane (Monobond Plus, Ivoclar Vivadent)
and a bonding system (Heliobond, Ivoclar Vivadent) was applied and
light cured (Fig 2-8-2).
Fig 2-8-2a to 2-8-2d Preparation of the existing restoration.

The composite build-up (Tetric Classic Dentin and Enamel, Ivoclar

Vivadent, Schaan, Liechtenstein) was applied directly and shaped
with a spatula. In larger repairs they can be also guided by silicone
keys that reflect a wax-up, fabricated by the technician to make the
build-up not only more efficient but also extremely predictable.
Once the composite was applied and light-cured, it was polished
with disks (Soflex, 3M, Seefeld, Germany) and silicone polishing
flames (Optrafine polishing kit, Ivoclar Vivadent). Thereafter the entire
restoration and the composite repair were polished to a high gloss
with a rotating brush and diamond polishing paste (Optrafine polishing
kit, Ivoclar Vivadent) (Fig 2-8-3).
Fig 2-8-3a to 2-8-3h Direct composite build-up.

Finally, the functional aspects were checked and lateral contacts

removed from occlusion to prevent the repair from chipping in the
same way as the initial ceramic (Fig 2-8-4).
Fig 2-8-4 The final outcome.

As additional information for the patients considering this kind of

direct repair, the survival rates after 3 years are at a good 89%1. If
they fail, they tend to fail immediately after the treatment in the first 1
to 3 weeks.
Maintenance of existing
restorations with esthetic
limitations or chippings
(veneers and overlays)

2.8.2 Maintaining an existing

restoration
■ Anterior regions (veneers) and palatal (overlays)

The following series shows the maintenance of existing dental

restorations with esthetic limitations or severe chippings.

Assessment and treatment planning

A 65-year-old woman presented at the clinic with the wish for an
esthetic improvement of her existing full-arch implant-supported
restoration. Although her actual restoration had served for more than
3 years, she had never been happy with the final esthetic outcome.
She wanted to have monochromatic white teeth but with more
brilliance. She also commented on having trouble chewing on her left
side, due to some final occlusal adjustments which were made after
the delivery of her FDPs. This finally resulted in non-occlusion of the
second and third quadrant (Fig 2-8-5).
Fig 2-8-5a and 2-8-5b Pretreatment photographs.
The patient was willing to renew the complete restoration in order
to achieve more brilliant white looking teeth, shape her dental arch
more harmoniously, and improve her occlusion on the left. However,
at this point we offered her a more simple approach time- and
moneywise, by changing her existing FDPs and preparing them for
the placement of eight lithium-disilicate veneers in the maxillary arch
and three lithium-disilicate overlays (both IPS e.max, Ivoclar Vivadent,
Schaan, Liechtenstein) in the third quadrant. All the pros and cons of
this rather unconventional treatment option were discussed with her
and she agreed to the treatment delivered via a step-by-step
approach.

Mock-up
At the beginning of the restorative dental treatment, conventional
reference impressions of both the maxillary and mandibular arches
were performed. By means of a facebow, the casts were transferred
into the correct three-dimensional position and mounted into the
dental articulator.
After exchanging extra- and introral pictures, the approach was
discussed and planned closely with the laboratory.
The models were isolated with a thin layer of soft wax before the
composite (GC Gradia E1, GC Europe, Leuven, Belgium) was
applied for an indirect mock-up. The clinical try-in and critical
evaluation of the mock-up with glycerin gel for better color integration
was performed and the patient was highly satisfied with the
suggested new outline (Fig 2-8-6).
Fig 2-8-6a to 2-8-6d Mock-up.

Veneer preparation and impression

The preparations were performed intraorally (Universal Prep Set,
Intensiv, Montagnola, Switzerland) through the guide of silicone keys,
as they could be used as a reference to provide sufficient thickness
for the planned veneers and overlays. Conventional impressions could
be performed at this point of the treatment. In this case it was
decided to proceed with a conventional polyether impression material
(Impregum, 3M, Seefeld, Germany). Hereafter, the master casts
were created; these could be cross-mounted with the advantage of
having an exact transfer of the initial diagnostic to the new and final
master cast.

Fabrication of the veneers in the laboratory

The master cast was poured with Type 4 plaster (GC Fujirock EP,
GC Europe) and cross-mounted with the initial mandibular arch
reference model; therefore, a new facebow was not necessary. As a
next step, the casts had to be sealed using a die sealer (Margidur,
Benzer-Dental, Zurich, Switzerland) and isolated with a wax
separator (Neosep, Benzer-Dental). A silicone key transferring the
exact shape of the mock-up was adjusted to the new master cast,
both were heated to around 50°C, and the interspaces filled with
liquid modeling wax.
After a cooling time of around 15 min, the silicone key could be
safely removed and the wax-up finalized in a very efficient process.
The eight veneers and three overlays could be separated and
individually checked for their fit and marginal adaptation before being
prepared for the investment (IPS PressVEST Speed, Ivoclar
Vivadent) of the lost wax technique.
The monolithic veneers and overlays were pressed (Programat
EP 5010, Ivoclar Vivadent) using a high value ingot (IPS e.max press
Value 3, Ivoclar Vivadent) and carefully devested. Before the final
characterization could be applied with stains and glaze (IPS Ivocolor,
Ivoclar Vivadent), the eight veneers and three overlays had to be
adjusted on the master cast to achieve a perfect fit and marginal
adaptation.
Integration of the restoration
Next followed the final try-in of the veneers and overlays for esthetic
and functional verification. Once the restoration was approved by the
patient and fulfilled all functional requirements, it could be prepared
for adhesive cementation. Under the seal of rubber dam, the existing
intraoral restoration could be safely etched for 1 min with hydrofluoric
acid (9% concentration) (Porcelain Etch, Ultradent, Cologne,
Germany) and a silane applied (Monobond Plus, Ivoclar Vivadent);
the veneers and onlays were etched for 20 s with hydrofluoric acid
(5% concentration) (IPS Ceramic Etching Gel, Ivoclar Vivadent)
rinsed with water, and carefully bonded as well.
For the adhesive cementation, a regular filling composite (Tetric
A2, Ivoclar Vivadent) was used preheated, and after a fast precuring,
removal of the excess could be performed without any movement of
the perfectly positioned veneers and overlays. Afterwards and
without any stress, the final light-curing was performed and the
transition zones were polished with diamond paste. The occlusal and
functional contacts were analyzed, and nearly no adjustments were
necessary (Fig 2-8-7).
Fig 2-8-7a to 2-8-7f Integration of the veneers and overlays.

All participants were very satisfied with the straightforward

treatment outcome (Fig 2-8-8).
Fig 2-8-8 Final outcome.

(Dental practitioner: Prof Dr I Sailer; Technician: MDT V Fehmer.)

Michigan splint
(full digital workflow)

2.8.3 CAD/CAM-fabricated Michigan

splint
■ CAD/CAM-fabrication of a Michigan splint
■ Digital jaw motion analysis

The following case describes the fabrication of a Michigan splint

applying the full digital workflow. This included optical impressions,
digital jaw movement tracking, and final CAM of the splint.

Assessment and treatment planning

A 23-year-old male dental student approached our clinic for the
realization of a protective Michigan splint for himself. He realized that
he was clenching and grinding his teeth at night during an intensive
phase in his studies.
His main wish was to protect his teeth and prevent them from
further abrasion. As the patient/dental student was very interested in
all digital technologies, the application of a model free, fully digital
workflow was envisaged, to acquire not only optical impressions but
also all necessary additional information such as a digital facebow
and the jaw movement data.
The combination of all digital information was intended to lead to a
predictable outcome and functionally adapted Michigan splint.

Optical impression and digital jaw motion

analysis
A powder-free optical full-arch impression (Trios 3, 3Shape,
Copenhagen, Denmark) was acquired.
Additionally, a digital facebow and jaw movement analyzer (Tizian
JMA by Zebriz, Schütz Dental, Rosbach, Germany) was placed on
the patient’s head and a digital bite fork was adjusted to the
mandibular arch (Fig 2-8-9).
Fig 2-8-9 Measurement with a digital facebow and jaw movement
analyzer.

With this additional device the models could be oriented in the

virtual articulator according to the actual three-dimensional data and
not only based on mean values. Once the orientation was recorded,
the patient was guided through several movements, eg, maximal
opening, laterotrusion, and protrusion, and as the patient executed all
the movements they were traced optically, and digitally stored
alongside the orientation coordinates.
Finally, the optical impressions, the 3D orientation of the models,
and the real movement data were sent online to the dental laboratory
(Fig 2-8-10).
Fig 2-8-10 Digital model.

Digital design and fabrication of the Michigan

splint
As a first step, all acquired data were imported into a CAD software
(Tizian Exocad, Schütz Dental) that was capable of working
flawlessly with all the different output files. In this special indication, to
date this version of Exocad is the only one to completely incorporate
all the data. Once the import was finalized, the indication of Michigan
splint was set in the case file and the digital design and fabrication of
the splint could start.
The borderline and the insertion pass were defined, the offset
was adjusted to the undercuts, and the vertical dimension of occlusion
(VDO) was increased virtually by 5 mm on the incisal pin, to gain
enough space for the splint.
The splint design was then set with a minimum thickness of 1.5
mm and automatically calculated including functional aspects and
adjusted to the patient’s jaw movement data (Fig 2-8-11).
Fig 2-8-11a to 2-8-11g Digital design.

To transfer this digitally designed Michigan splint into a durable

processable material, the file was nested and milled in a five-axis
milling unit (Zenotec Select Hybrid, Ivoclar Vivadent, Schaan,
Liechtenstein) using a classic 98-mm PMMA disk in a dry milling
environment (CAD Splint; Ivocolor, Ivoclar Vivadent).
Once milled, the Michigan splint was adjusted and carefully
polished without any 3D printed models for verification (Fig 2-8-12).
Fig 2-8-12a to 2-8-12i Fabrication of the Michigan splint.

Final delivery of the CAD/CAM fabricated

Michigan splint
The final outcome of this model-free workflow was impressive and
the occlusal adaptation of the splint close to perfect, as basically no
occlusal adjustments were necessary and the patient immediately felt
comfortable with the splint (Fig 2-8-13).
Fig 2-8-13a and 2-8-13b Final outcome.
(Dental practitioner: Dr F Burkhardt, Technician: MDT V Fehmer.)

Reference
1. Ozcan M, Niedermeier W. Clinical study on the reasons for and
location of failures of metal-ceramic restorations and survival of
repairs. Int J Prosthodont 2002;15:299–302.
PART III
LONG-TERM OUTCOMES
OF FIXED RESTORATIONS
3.1 Introduction
In this chapter:
■ Tooth-supported veneers
■ Tooth-supported inlays and onlays
■ Tooth-supported SCs
■ Endocrowns
■ Tooth-supported conventional FDPs
■ Tooth-supported cantilever FDPs
■ Resin-bonded fixed dental prostheses (RBFDPs)
■ Implant-supported SCs
■ Implant-supported FDPs
■ Implant-supported cantilever FDPs
■ Combined tooth-implant-supported FDPs
A group of researchers from the Universities of Iceland, Bern,
Geneva, and Zurich in Switzerland, and from the National Dental
Center in Singapore have published a broad series of systematic
reviews in recent years (see Table 3-11 at the end of Part III)1–20.
These are based on consistent inclusion and exclusion criteria,
methodologies, and a statistical approach summarizing the available
information on survival rates of different types of tooth- and implant-
supported single crowns (SCs) and fixed dental prostheses (FDPs).

3.2 Tooth-supported veneers

A systematic review21, aiming to evaluate the 5- and 10-year survival
rates of ceramic veneers fabricated of non-feldspathic porcelain,
reported an estimated 5-year survival rate of 92.4% based on four
studies evaluating the outcomes of approximately 400 veneers. Two
studies with a follow-up time exceeding 10 years could be included in
the systematic review. The reported 10-year survival rates for these
studies were 66% and 94%, respectively22,23. A more recent
24
systematic review24 analyzing the survival of both glass-ceramic and
feldspathic porcelain laminate veneers reported survival rates of 94%
for the glass-ceramic veneers, based on 676 veneers with a mean
follow-up time of 7 years, and of 87% for feldspathic porcelain
veneers based on 1283 veneers with a mean follow-up time of 8
years24. The difference in survival rates between glass-ceramic and
feldspathic porcelain laminate veneers did, however, not reach
statistical difference. The most frequent complications were: fracture
or chipping (4%); debonding (2%); severe marginal discoloration
(2%); endodontic complications (2%); and secondary caries (1%).
The authors could not draw any concrete conclusion regarding the
influence of preparation depth (limited to enamel or dentin) on the
failure rates24.

3.3 Tooth-supported inlays and

onlays
Systematic review and meta-analyses aiming to evaluate the survival
rates of both ceramic and resin inlays, onlays, and overlays reported
an overall estimated 5-year survival rate of 95% for ceramic inlays
and onlays based on the observations of 5811 reconstructions and an
estimated 10-year survival rate of 91% based on a sample of 2154
25
reconstructions . For glass-ceramic inlays and onlays, the 5-year
survival rate was reported to be 96% (n = 1579) and the 10-year
survival rate was 93% (n = 605). For feldspathic porcelain inlays and
onlays the respective survival rates were 92% (n = 661) and 91% (n
25
= 538) . The systematic review indicated that the type of ceramic
material (feldspathic porcelain vs glass-ceramic), the follow-up time
(5 years vs 10 years), and the study setting (university vs private
clinic) did not significantly affect the survival rates. The most
frequently observed complications were related to ceramic fractures
or chippings (4%), followed by endodontic complications (3%),
secondary caries (1%), and debonding (1%). Severe marginal
staining was not reported. No studies were available that reported on
resin-based inlays, onlays, and overlays, and fulfilled the inclusion
criteria of a mean follow-up time of at least 5 years25.

3.4 Tooth-supported SCs

Recently, Sailer and co-workers15,16 published a systematic review
analyzing the survival and complication rates of all-ceramic and metal-
ceramic tooth-supported SCs. The meta-analysis included 17 studies
reporting on 4663 metal-ceramic crowns and 55 studies reporting on
9493 all-ceramic crowns (different types of ceramic used). For metal-
ceramic SCs the estimated 5-year survival rate was 95.7% (Table 3-
1)26–58 compared with an overall 5-year survival rate of 94.5% for all-
ceramic crowns. The survival rates of all-ceramic crowns differed for
various ceramic types. The 5-year survival rates were 96.6% for
leucite or lithium-disilicate reinforced glass-ceramic SCs (12 studies
with 2689 SCs) (Table 3-1), 96.0% for densely sintered alumina SCs
(8 studies with 1099 SCs), 94.6% for glass-infiltrated SCs (15
studies with 2389 SCs), 93.8% for densely sintered zirconia SCs (8
studies with 926 SCs) (Table 3-1), 90.7% for feldspathic or silica-
based ceramic SCs (10 studies with 2208 SCs), and 83.4% for
15 16
composite crowns (1 study with 59 SCs) , . Compared with metal-
ceramic crowns, feldspathic or silica-based ceramic SCs and
composite crowns had significantly lower 5-year survival rates. When
the outcomes of anterior and posterior SCs were compared, no
significant differences in the survival rates were found for metal-
ceramic crowns, for leucite or lithium-disilicate reinforced glass-
ceramic crowns, and alumina and zirconia-based crowns. Crowns
made out of feldspathic or silicabased ceramics, however, exhibited
significantly lower survival rates in the posterior region compared with
the anterior region15,16.

Table 3-1 Estimated annual failure rate and 5-year survival rate of
tooth-supported metal-ceramic, reinforced glass-ceramic, and
densely sintered zirconia-ceramic single crowns (SCs)
3.5 Endocrowns
Limited data are available on the long-term outcome of endocrowns.
A systematic review conducted to evaluate clinical (survival) and in
vitro (fracture strength) outcomes of endocrowns compared to
conventional crowns was able to include three clinical studies, one
prospective and two retrospective. The included studies reported on
a total of 55 endocrowns inserted in the posterior area. The survival
rates ranged between 94% and 100% at a rather short follow-up time
of 6–36 months59. A recent retrospective analysis of 235 molar
endocrowns made with a chairside CAD/CAM method reported a
very positive outcome with only one crown failure, representing a
survival rate of 99.8% at a mean follow-up of 55 months60. The failure
was due to ceramic fracture. The authors concluded that endocrowns
in the molar area showed even more favorable survival rates
compared with conventional CAD/CAM full ceramic crowns60. It must,
however, be kept in mind that the studies evaluating the outcomes of
endocrowns concentrate on crowns inserted in the posterior area and
limited evidenced is available regarding the use of endocrowns in the
anterior area.

3.6 Tooth-supported conventional

multiple-unit FDPs
Tan and co-workers3 published a systematic review analyzing the
survival rates of conventional tooth-supported FDPs. The meta-
analysis included 21 studies that incorporated around 2800 patients,
receiving approximately 4000 FDPs. The majority of the included
studies were retrospective in design and half of the included FDPs
were metal-acrylic FDPs. Based on the included material, the
estimated 5-year survival rate of FDPs was 93.8% and the 10-year
3 4 61 75
survival rate was 89.2% (Table 3-2) , , – .

Table 3-2 Annual failure rate and estimated 5- and 10-year survival
rate of conventional tooth-supported multiple-unit FDPs with end
abutments
n.a., not applicable.

14 17
Recently, Pjetursson and co-workers , published a systematic
review analyzing the survival rates of all-ceramic and metal-ceramic
multiple-unit FDPs. A total of 28 studies that reported on all-ceramic
FDPs and 15 studies that reported on metal-ceramic FDPs were
included in this review. For all-ceramic FDPs, most of the studies
were prospective in design, but for metal-ceramic FDPs two-thirds of
the included studies were retrospective. The majority of the included
studies were conducted in university settings. For metal-ceramic
FDPs, the estimated 5-year survival rate was 94.4% (15 studies with
1796 FDPs) (Table 3-3)11,30,39,61,63,64,76–84. The results for all-ceramic
FDPs were divided into reconstructions based on different ceramic
materials such as reinforced glass-ceramic, glass-infiltrated alumina
(InCeram Alumina and Inceram Zirconia), and densely sintered
zirconia. The estimated 5-year survival rates were 90.1% for densely
sintered zirconia FDPs (15 studies with 574 FDPs) (Table 3-
3)11,29,57,77,80,81,85–94, 86.2% for glass-infiltrated alumina FDPs (6
studies with 229 FDPs), and 85.9% for reinforced glass-ceramic
FDPs (5 studies with 136 FDPs). Compared with metal-ceramic
FDPs, the 5-year survival rates of both glass-infiltrated alumina and
reinforced glass-ceramic FDPs were significantly lower. No
conclusion could be made regarding the 10-year survival of metal-
ceramic or all-ceramic FDPs11,14,17,30,76–94.

Table 3-3 Estimated 5-year survival rate of tooth-supported metal-

ceramic and veneered zirconia-ceramic multiple-unit FDPs
3.7 Tooth-supported cantilever
FDPs
Pjetursson and co-workers2 published a systematic review and meta-
analysis analyzing the survival rate of tooth-supported FDPs with
cantilever units. The 13 included studies reported on approximately
700 patients receiving a total of 816 cantilever FDPs. The studies
were mainly conducted in an institutional environment, such as a
university or a specialized clinic. The operators were dental students,
postgraduate students, private dentists, and specialists. Twelve of
the thirteen included studies provided data on survival. The estimated
5-year survival rate of cantilever FDPs was 91.4% and the 10-year
survival rate was 80.3% (Table 3-4)2,4,64,66,70,72,95–102.

Table 3-4 Annual failure rate and estimated 5- and 10-year survival
rate of cantilever tooth-supported FDPs
n.a., not applicable.

The studies were also divided according to the veneer material

used. In a group with ceramic FDPs there was no significant
difference regarding survival rates between the two veneer
materials2.

3.8 Resin-bonded fixed dental

prostheses (RBFDPs)
Recently, Thoma and co-workers18 published a systematic review
with meta-analysis analyzing the survival rate of RBFDPs. A total of
29 retro- and prospective studies reporting on 2300 reconstructions
were included in the analysis. The studies were conducted under
different environmental settings: 22 in a university setting, two in
private practices, and four in specialist clinics. The preparation
designs ranged from no preparation or conservative preparations to
extensive preparations with grooves, guide planes, and wrap-around
design to improve the RBFDPs’ mechanical retention. The materials
used for the fabrication of the RBFDPs consisted of veneered and
non-veneered metal and all-ceramic frameworks or composite
frameworks veneered with composite. Different surface treatments of
the bonding area of the RBFDPs were performed prior to
cementation with various resin cements18.
The reported 5-year survival rate for RBFDPs was 91.4% and the
10-year survival rate was estimated to be 82.9% (Table 3-5)103–125.
The studies were also divided according to the material utilized. The
estimated 5-year survival rate was 100% for RBFDPs with zirconia
as framework material (3 studies with 68 RBFDPs), 95.3% for
RBFDPs with reinforced glass-ceramic framework (1 study with 49
RBFDPs), 93.4% for RBFDPs with glass-infiltrated ceramic as
framework material (1 study with 38 RBFDPs), 92.8% for RBFDPs
with fiber-reinforced composite as framework (3 studies with 267
RBFDPs), 91.3% for metal-ceramic RBFDPs (8 studies with 977
RBFDPs), and 88.9% for metal-resin RBFDPs (1 study with 267
RBBs)18. Statistical analysis of different material types showed that
RBFDPs with zirconia frameworks had a significantly higher survival
rate than metal-ceramic RBFDPs. Furthermore, the survival rate of
RBFDPs was significantly higher when one retainer was utilized
compared with RBFDPs retained with two or more retainers.
Moreover, the survival rate of RBFDPs inserted in the anterior area
was significantly higher than the survival rate of RBFDPs inserted in
the posterior area. In addition, the survival rate was higher for
reconstructions inserted in the maxilla compared with RBFDPs
inserted in the mandible18. Hence, to obtain the best outcomes for
RBFDPs, zirconia should be used as framework material, and the
RBFDPs should be inserted in the maxillary anterior area and be
attached by one retainer only.
Table 3-5 Annual failure rate and estimated 5- and 10-year survival
rate of resin-bonded fixed dental prostheses (RBFDPs)

3.9 Implant-supported SCs

12
Jung and co-workers12 published a systematic review with meta-
analysis analyzing the survival rates of implant-supported SCs. A total
of 46 retro- and prospective studies reporting on 3223 inserted
implants and 3199 SCs were included in the analysis. Seventy
percent (70%) of the crowns were cemented and 30% were screw-
retained. During the healing period, 1.3% of the implants were lost
and after implant loading the estimated annual implant failure rate
was 0.3%. This represents a 5-year survival rate of 97.2% for
implants supporting SCs and a 10-year implant survival rate of
95.2%. Twenty-seven of the included studies provided data on the
survival of the SCs. The estimated 5-year survival rate of implant-
supported SCs was 96.3% and the estimated 10-year survival rate
for SCs was 89.4% (Table 3-6). Approximately half of the crown
failures were due to implant loss12,36,126–150.

Table 3-6 Annual failure rate and estimated 5- and 10-year survival
rate of implant-supported SCs
Recently, Pjetursson and co-workers19 published a systematic
review analyzing the survival rates of metal-ceramic and zirconia-
ceramic implant-supported SCs. A total of 30 studies reporting on
4363 metal-ceramic SCs and 8 studies reporting on 912 zirconia-
ceramic SCs were included in the meta-analysis. All the included
zirconia-based SCs consisted of a zirconia core with veneering
ceramic and no monolithic crowns were evaluated. The majority of
the metal-ceramic SCs were cement-retained, but for the zirconia-
based crowns approximately half of the crowns were cemented, and
the other half was screw-retained. The studies were conducted both
in an institutional environment, such as university or specialized
implant clinics and in private practice setting. For implant-supported
metal-ceramic SCs the estimated 5-year survival rate was 98.3% and
for implant-supported zirconia-ceramic SCs the respective survival
rate was 97.6% (Table 3-7)128,133,139,141,144,145,148,151–177. The
difference in survival rates between metal-ceramic and zirconia-
ceramic SCs was not significant. Moreover, the survival rate of
implant-supported SCs was analyzed regarding the location in the
dental arch; both metal-ceramic and zirconia-ceramic SCs showed
slightly higher survival rates in the posterior compared with the
anterior area19.

Table 3-7 Estimated 5-year survival rate of implant-supported metal-

ceramic and zirconia-ceramic SCs. There was no significant
difference in the survival rates of zirconia-ceramic and metal-ceramic
SCs (P = 0.514)
3.10 Implant-supported FDPs
Pjetursson and co-workers13 published a systematic review with
meta-analysis analyzing the survival rate of implant-supported FDPs.
A total of 32 retro- and prospective studies reporting on 1881
implant-supported FDPs supported by approximately 5200 implants
were included in the analysis. The studies were mainly conducted in
an institutional environment, such as university or specialized implant
clinics. Five of the included studies were conducted in private practice
settings. Two-thirds of the FDPs were metal-ceramic and one-third
had metal frameworks with acrylic veneering material. The majority of
the FDPs were screw-retained. During the healing period 2.4% of the
implants were lost. The estimated 5-year survival rate for implants
supporting FDPs was 95.6% and the estimated 10-year implant
survival rate was 93.1%. The included studies were also analyzed
separately according to the implant surface geometry. Machined
surface implants were reported to have significantly lower survival
rates than rough surface implants13.
Twenty-seven of the included studies provided data on the survival
of FDPs. The estimated 5-year survival rate of FDPs was 95.4% and
the estimated 10-year survival rate of FDPs was 80.1% (Table 3-
8)127,149,169,178–201. The studies were also divided according to the
veneer material utilized. The metal-ceramic FDPs showed a
significantly higher 10-year survival rate of 93.9% than metal-acrylic
FDPs with a survival rate of only 77.4%13.

Table 3-8 Annual failure rate and estimated 5- and 10-year survival
rate of implant-supported FDPs
Recently, Sailer and co-workers20 published a systematic review
analyzing the survival and complication rates of metal-ceramic and
zirconia-ceramic implant-supported FDPs. A total of 16 studies
reporting on 993 metal-ceramic FDPs and 3 studies reporting on 175
FDPs with zirconia framework, were included in this review. The
majority of the metal-ceramic FDPs were cement-retained, but the
zirconia-based reconstructions were mainly screw-retained. The
studies were conducted both in an institutional environment, such as
university or specialized implant clinics, and in private practice
settings. For implant-supported metal-ceramic FDPs, the estimated
5-year survival was 98.7% and for implant-supported zirconia-
ceramic FDPs, the estimated 5-year survival was 93.0% (Table 3-
9)20,156,158,160-162,165,167,169,174,175,178,187,202–206. Hence, zirconiabased
implant-supported FDPs showed significantly lower survival rates
compared with metal-ceramic FDPs. However, it must be kept in
mind that all included zirconia-based FDPs consisted of a zirconia
framework with veneering ceramic and no monolithic zirconia FDPs
were evaluated in this material20.

Table 3-9 Estimated 5-year survival rate of implant-supported metal-

ceramic and zirconia-ceramic FDPs There was a significant
difference in the survival rates of zirconia-ceramic and metal-ceramic
FDPs (P <0.001)
3.11 Implant-supported cantilever
FDPs
Storelli and co-workers207 recently published a systematic review
analyzing the survival rate of implant-supported FDPs with cantilever
units. A total of 9 studies reporting on 376 implant-supported
cantilever FDPs supported by 739 implants were included in the
analysis. The studies were mainly conducted in an institutional
environment. The 5-year survival rate for implants supporting
cantilever implant-supported FDPs was estimated to be 98.9%. The
estimated 5-year survival rate of cantilever implant-supported FDPs
was 98.2%. No clear information was available regarding the 10-year
survival of implant-supported cantilever FDPs as the included studies
were not divided according to the follow-up period. The 5-year
survival of implant-supported cantilever FDPs was comparable with
the respective survival rate of implant-supported FDPs without
cantilever units. However, it must be kept in mind that through the
cantilever unit additional load is applied to the supporting implants and
the implant-abutment connections. An observational period of 5 years
might be too short to experience fatigue failures and complications
such as implant or abutment fractures.

3.12 Combined tooth-implant-

supported FDPs
Lang and co-workers1,4 published a systematic review with meta-
analysis analyzing the survival rate of tooth-implant-supported FDPs.
A total of 14 studies reporting on 622 tooth-implant-supported FDPs
supported by 1144 implants were included in the analysis. The
studies were mainly conducted in an institutional environment, such as
university or specialized implant clinics. The majority of the tooth-
implant-supported FDPs were screw-retained on the implants.
Implant loss prior to functional loading was detected for 2.7% of all
implants. The estimated annual implant failure rate after loading
amounted to 1.3%, representing an estimated 5-year implant survival
rate of 90.1% (95% CI: 82.4–94.5%) and 82.1% (95% CI: 55.8–
93.6%) at 10 years. The annual failure rate after loading was
significantly higher for implants supporting combined tooth-implant-
supported FDPs compared with implants supporting SCs or solely
implant-supported FDPs1,4.
Ten of the included studies provided data on the survival of tooth-
implant-supported FDPs. The estimated 5-year survival rate of tooth-
implant-supported FDPs was 95.5% and the reported 10-year
survival rate was 77.8% (Table 3-10; see also summary in Table 3-
11)190,193,197,201,208–212. At an observation period of 5 years, 3.2% of
the abutment teeth were lost compared to 3.4% of the functionally
loaded implants. At 10 years, 10.6% of the abutment teeth were lost
compared to 15.6% of the supporting implants149,201. There was no
significant difference between loss of abutment teeth and loss of
implants supporting-tooth-implant-supported FDPs both at 5 and 10
years1,4.

Table 3-10 Annual failure rate and estimated 5- and 10-year survival
rate of combined tooth-implant-supported FDPs

Table 3-11 Estimated 5- and 10-year survival rate of different types

of restoration and the number of restorations that were evaluated
Type of restoration Number of Estimated 5-y Number of Estimated 10-y
restorations survival rate restorations survival rate
analyzed (95% CI) analyzed (95% CI)
Ceramic veneers ≈ 400 92.4 (89.8– n.a. n.a.
95.0)
Type of restoration Number of Estimated 5-y Number of Estimated 10-y
restorations survival rate restorations survival rate
analyzed (95% CI) analyzed (95% CI)
Glass-ceramic inlays 1579 96.0 (89.0– 605 93.0 (86.0–
and onlays 98.0) 96.0)
Tooth-supported 4663 95.7 (94.1– 3687 91.6 (87.9–
metal-ceramic SCs 96.9) 94.2)
Tooth-supported 926 93.8 (90.3– n.a. n.a.
zirconia-ceramic SCs 96.1)
Tooth-supported 2689 96.6 (94.9– n.a. n.a.
reinforced glass- 97.7)
ceramic SCs
Tooth-supported n.a. n.a. n.a. n.a.
endocrown
Tooth-supported 1796 94.4 (91.2– 1218 89.2 (76.1–
conventional metal- 96.5) 95.3)
ceramic FDPs
Tooth-supported 574 90.1 (83.6– n.a. n.a.
conventional zircona- 94.2)
ceramic FDPs
Tooth-supported 423 91.4 (88.4– 239 80.3 (74.8–
cantilever FDPs 93.7) 84.7)
Resin-bonded FDPs 1755 91.4 (86.7– 545 82.9 (73.2–
94.4) 89.3)
Resin-bonded FDPs 68 100.0 (94.5– n.a. n.a.
zirconia-ceramic 100.0)
Implant-supported 4636 98.3 (96.8– 268 89.4 (82.8–
metal-ceramic SCs 99.1) 93.6)
Implant-supported 912 97.6 (94.3– n.a. n.a.
zirconia-ceramic SCs 99.0)
Implant-supported 932 98.7 (96.8– 33 93.9 (79.8–
metal-ceramic FDPs 99.5) 99.2)
Implant-supported 175 93.0 (90.6– n.a. n.a.
zirconia-ceramic 94.8)
FDPs
Implant-supported 376 98.2 (91.0– n.a. n.a.
cantilever FDPs 100.0)
Type of restoration Number of Estimated 5-y Number of Estimated 10-y
restorations survival rate restorations survival rate
analyzed (95% CI) analyzed (95% CI)
Combined tooth- 199 95.5 (91.5– 60 77.8 (64.9–
implant-supported 97.6) 86.4)
FDPs
n.a., not analyzed.

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1995;21:8–18.
PART IV
AVOIDING AND MANAGING
COMPLICATIONS
4.1 Introduction
In this chapter:
■ Success of tooth- and implant-supported restorations
■ Tooth-supported restorations
■ Esthetic complications
■ Biological complications
■ Technical complications
■ Implant-supported restorations
■ Esthetic complications
■ Biological complications
■ Technical complications
Over the years, several definitions of success have been proposed
and used in restorative and implant dentistry1–3. Instead of redefining
old definitions or inventing new ones over and over again, it would
make more sense to move away from success definitions in general.
Instead, clinicians should report whether the restorations have
remained unchanged and free of any complications over the entire
observation period. Hence, a “successful” restoration would be a
restoration that did not require any intervention during the entire
observation period4.

4.2 Success of tooth- and implant-

supported restorations
In systematic reviews5,6 addressing the survival and complication
rates of tooth-supported fixed dental prostheses (FDPs), only few of
the included studies provided information on the number of
restorations that remained intact or without complications over the
observation period. The 5-year complication rate for tooth-supported
FDPs was estimated to be 15.7% (95% CI: 8.5–27.7%)6,7 and for
57
tooth-supported cantilever FDPs the respective rate was 20.6%5,7
(Table 4-1).

Table 4-1 Estimated 5-year failure and complication rates for

different type of tooth-supported reconstructions and the number of
abutment tooth or reconstructions analyzed

In the early days of implant dentistry the overall number of

biological and technical complications was rarely reported. A former
4
systematic review addressing the survival and complication rate of
implant-supported FDPs could only locate three studies that gave the
exact number of restorations with complications. The estimated 5-
year complication rate was quite high, or 38.7% (95% CI: 33.2–
4
44.7%) . The most frequent complication reported in these studies
was loosening of prosthetic screws. A more recent systematic
8
review addressing exclusively implant-supported metal-ceramic
FDPs however concluded that 15.1% (95% CI: 11.2–20.4%) of the
restorations were affected by biological or technical complications
over a 5-year observation period. The reduced number of
complications between the older and the more recent studies might
represent a positive learning curve in implant dentistry or enhanced
components due to developments, causing less technical problems.
Another systematic review9 addressing the survival and complication
rates of metal-ceramic and zirconia-ceramic implant-supported single
crowns concluded that 13.3% (95% CI: 9.0–19.3%) of the metal-
ceramic and 16.2% (95% CI: 6.2–38.4%) of the zirconia-ceramic
crowns experienced some kind of esthetic, biological, or technical
complications over an observation period of 5 years9 (Table 4-2).
Even though a significant number of studies and meta-analyses4–20
have presented impressively high survival rates for both tooth- and
implant-supported restorations, it must be considered that between
15% and 20% of the restorations were affected by some kind of
esthetic, biological, or technical complications. For example, a study
evaluating the outcome of implant-supported restorations performed
at the University of Bern21 reported a failure rate of 2.5% but an
additional 16.8% of the restorations had some kind of biological
and/or technical problems. Comparing the overall complication rates
of tooth- and implant-supported restorations, tooth-supported
restorations were more frequently affected by biological
complications such as caries or loss of pulp vitality, while implant-
supported restorations were more affected by technical complications
such as screw loosening or material fractures.

Table 4-2 Estimated 5-year failure and complication rates for

different type of implant-supported reconstructions and the number of
implant abutments or reconstructions analyzed
4.3 Tooth-supported restorations
4.3.1 Esthetic complications
The incidence of esthetic complications (Fig 4-1), or restorations to
be remade due to esthetic reasons, is rarely reported in the dental
literature for tooth-supported single crowns (SCs) and FDPs11,12
10
(Table 4-1). A recent systematic review evaluating the outcome of
tooth-supported resin-bonded fixed dental prostheses (RBFDPs)
reported that only 0.3% of the included restorations had to be redone
due to unacceptable esthetic appearance10. With the materials and
technology available today, dental professionals should be able to
imitate the natural appearance of a tooth in an acceptable way when
manufacturing a tooth-supported restoration.
Fig 4-1 Central incisors with tooth-supported SCs with unacceptable
esthetic outcome in a patient with a high smile line.

The current concept of how to imitate the appearance of a natural

tooth with a tooth-supported restoration is presented step by step
in Part I, Chapters 6 and 9.

4.3.2 Biological complications

Loss of pulp vitality
One of the most frequent biological complications affecting tooth-
supported restorations is the loss of abutment tooth vitality (Fig 4-2;
Table 4-1). For tooth-supported SCs, 1.8% of the abutment teeth that
were considered to be vital at the time of cementation had lost vitality
at an observation period of 5 years11. The loss of abutment tooth
vitality was less frequent for leucite-reinforced SCs, lithium-disilicate
reinforced glass-ceramic SCs, and glass-infiltrated alumina SCs
compared with metalceramic and zirconia-ceramic SCs11. For tooth-
supported FDPs loss of abutment tooth vitality was reported in 6.1%
of the abutment teeth5,7. In the case of cantilever tooth-supported
FDPs the respective number of abutment teeth with loss of vitality
was 17.9% over a mean observation period of 5 years5,7. A study22
specifically addressing loss of pulp vitality in patients reconstructed
with FDPs after successful treatment of advanced periodontitis,
reported the highest rate of loss of abutment vitality of 8.2%.
Significantly more abutment teeth lost vitality compared with non-
prepared control teeth22. It must, however, be kept in mind that teeth
being restored with SCs, or serving as abutments for FDPs, are often
at higher risk of losing pulp vitality due to a significant amount of
missing tooth substance or existing large fillings. The clinician should
consider that the facial enamel-dentin thickness ranges from 1.8 mm
to 3.1 mm depending on the age of the patient. The thickness also
varies with tooth type and area of measurement (Fig 4-3)23.
Histological changes have been detected in the pulpal tissue if the
remaining dentin thickness is below 1 mm24. It is of great importance
to avoid drying-out the dentin during the workflow and pulp capping in
general should be avoided for abutment teeth. If endodontic
treatment is needed after the restoration has been cemented then a
conservative opening preparation should be implemented, leaving as
much tooth substance as possible.
Fig 4-2 The pulp of tooth 22 became necrotic after trauma and a
fistula can be detected on the buccal mucosa.
Fig 4-3 A histological section showing the thickness of dentin and
enamel in relation to a traditional tooth preparation.

In the current concept, a minimally invasive treatment approach is

recommended whenever possible. To reduce the risk of pulp
necrosis, the dentin surface should be desensitized after each
session. If there is doubt about the pulp vitality over time, an
endodontic treatment should be considered before inserting the
final restoration, respecting the age of the patient and the chance
of pulpal regeneration.
Secondary caries
Another common biological complication is the development of
secondary caries at the crown margins (Table 4-1). Caries has been
reported at the surface25, abutment5,6,11,12,18,19, and at the restoration
levels5,6,11,12,18,19. In a series of systematic reviews5,10–12 the
estimated 5-year rate of secondary caries at the restoration margins
was 1% for metal-ceramic SCs, 1.4% for conventional FDPs, 4.7%
for cantilever FDPs, and 1.7% for RBFDPs. Most all-ceramic crowns
exhibited similar 5-year caries rates as metal-ceramic SCs (Table 4-
1). In contrast, the highest rate of secondary caries was reported for
the first generation of densely sintered zirconia FDPs12. Some studies
reported the number of restorations lost due to caries11,12. Over a 5-
year observation period, 2.1% of the conventional FDPs and 1.5% of
the cantilever FDPs were lost due to secondary caries (Table 4-
1)5,7,12. When restoring a patient with a history of past or present
caries activity (Fig 4-4), it is important to investigate the etiology of
the caries first. A frequent reason for such a condition can be a
reduced buffer capacity of the saliva due to general medical issues or
medication influencing the salivary flow and flora. Another reason for
elevated caries activity could be a patient’s dietary habits. This can
usually be addressed in a motivational interview, where the patient is
asked to monitor their diet in a diary for a few days. The old dogma
that secondary caries can be avoided by extending crown margins
subgingivally is not supported by sufficient evidence and there are
even studies showing that the position of the crown margin does not
influence the incidence of secondary caries26.
Fig 4-4 Old metal-ceramic restorations with visible secondary caries
at several crown margins.

In the current concept a strict maintenance program is

recommended for each individual patient and fluoride is applied to
the root surface at every recall visit to reduce the risk of
secondary caries. In case of caries prior to a treatment, its
etiology should be investigated and addressed before the
rehabilitation.

Recurrent periodontitis
The third biological complication is the loss of restorations due to
recurrent periodontitis. Over a 5-year observation period, 1.2% of
conventional tooth-supported FDPs12, 0.5% of cantilever tooth-
supported FDPs5,7, and 0.8% of the RBFDPs were lost due to this
10
complication (Table 4-1) . It must be kept in mind that the majority of
these studies were performed at known universities with excellent
and strict maintenance programs5–7,10–12, which might have influenced
the low rate of FDP failures due to periodontal disease. In contrast,
more than 12% of the restorations were lost due to periodontal
disease (Fig 4-5) in a multicenter study performed in several private
practices in Saudi Arabia, most probably without regular maintenance
system27–29. Today, the maintenance or periodontally supported
therapy can be tailor-made for each patient using the periodontal risk
assessment (PRA) tool (Figs 4-6a, b, c)30. This risk assessment tool
includes: full mouth bleeding on probing index; number of residual
pockets (≥ 5 mm); number of remaining teeth; ratio between bone
loss evaluated on radiographs and the age of the patient; systemic or
genetic factors, and environmental factors such as smoking30. The
website www.perio-tools.com has all the necessary tools to plan the
maintenance of periodontally compromised patients.

Fig 4-5 An old metal-ceramic restoration showing significant

attachment loss around the abutment teeth on a radiograph.
Figs 4-6a to 4-6c The spiderweb – periodontal risk analysis: (a) a
low-risk patient with a recommended recall interval of 12 months; (b)
a medium-risk patient with a recommended recall interval of 6
months; and (c) a high-risk patient with a recommended recall interval
of 3–4 months.

In the current concept, the prerequisite for the restorative phase is

a successfully executed comprehensive periodontal treatment to
avoid losing restorations due to recurrent periodontitis. Teeth with
residual pockets (>5 mm) should not be used as abutment teeth
for tooth-supported FDPs without further periodontal treatment.
The crown margins are preferably placed supra- or epigingivally in
periodontally compromised patients and the recall interval runs
parallel to the restorative phase.

Abutment tooth fracture

Fracture of abutment teeth has been reported on the level of the
abutment teeth as well as on restoration levels (Fig 4-7). For
cantilever FDPs, the 5-year rate of abutment tooth fractures was
2.9%5,7. Interestingly, losing the entire restoration due to abutment
tooth fracture is still a relatively rare complication as multiunit
restorations can often be supported by the remaining abutment teeth
if one abutment tooth fractures 5,7. In case of SCs, abutment tooth
fractures were predominantly found for metal-ceramic crowns and
were less frequent for all-ceramic crowns such as glass-ceramic or
zirconia-ceramic crowns11,31. The estimated 5-year rate of losing a
restoration due to abutment tooth fracture was reported to be 1.2%
for metal-ceramic SCs, 0.9% for conventional FDPs, 1.2% for
cantilever FDPs, and 0.2% for RBFDPs (Table 4-1)5,7,10–12. The risk
of abutment tooth fracture is increased if the abutment tooth is
endodontically treated (Fig 4-8), restored with post and core
(especially if the post has a large diameter) and utilized as support
for a cantilever FDP5,7,32,33.

Fig 4-7 Three endodontically treated abutment teeth of a four-unit

anterior FDP fractured after 12 years in function; the restoration was
lost.
Fig 4-8 A lateral incisor restored with a cast post and core and a
single crown suffered a horizontal root fracture and had to be
extracted.

When restoring endodontically treated teeth with a limited amount

of residual tooth substance, it is important to achieve a
circumferential ferrule of approximately 1.5 mm. In case of one
remaining wall of dentin, a fiber-reinforced post and a composite
build-up can be performed. However, if a single-rooted tooth has
no remaining dentin walls, a cast post and core is preferred. If
there is caries extending into the root canal, the tooth is
considered irrational to treat and should be extracted.

4.3.3 Technical complications

Loss of retention
The incidence of loss of retention or fracture of the luting cement
differs significantly between varying types of restorations (Table 4-1).
Loss of retention is not a predominant technical problem for SCs in
general. Surprisingly, zirconia-based crowns exhibited 4.7% loss of
11
retention at 5 years11. For FDPs the 5-year rate of retention loss was
on average 3.1% and also significantly higher for densely sintered
zirconia FDPs compared to other material types34. The respective
complication rate for conventional metal-ceramic FDPs ranged
between 2.1% and 3.3%6,7,12. For cantilever FDPs, however, the 5-
year rate of retention loss was significantly higher or 8.4%5,7. Loss of
retention tends to correlate with increased incidence of caries, but it
could not be concluded whether loss of retention or caries was the
primary factor. With respect to multiunit FDPs, clinicians should
investigate loss of retention carefully for each abutment tooth, since it
frequently remains unnoticed by patients. As a consequence, caries
can extend into a large lesion in a relatively short time.
Loss of retention can, in most cases, be avoided with proper
treatment planning and appropriate preparation. With regard to
traditionally cemented metal-based restorations, it is important to
follow the basic principles of tooth preparation, aiming for a
preparation convergence angle of approximately 10 degrees. A
minimal wall height of 3 mm for small diameter teeth like premolars,
canines, and incisors and a minimal wall height of 4 mm for molars
should be respected35. If this can’t be achieved, additional measures
such as surgical crown lengthening, build-up with post and core, or
adhesive cementation should be implemented. For traditionally
cemented restorations the resisting form of the preparation, which
supports the restoration when being exposed to lateral forces, is as
important as the retention form. Additional preparation boxes or
grooves can be an option to increase the retention and resistance
form of traditionally cemented restorations. If the basic principles of
tooth preparation cannot be followed due to a limited amount of tooth
substance, it is important to change the treatment approach and opt
for adhesive cementation. The prerequisites for the adhesive
cementation are the evaluation of the quality of enamel and dentin
(see Part I, Chapter 9), well-fitting restorations, and to meticulously
follow the recommended steps of the cementation process depending
on the adhesive system. In case of digital fabrication of a restoration,
the cement space should be adjusted according to the retentiveness
of the tooth preparation. Hence, for an abutment tooth with short
preparation walls the width of the cement space should be set at the
minimum, whereas for long preparation walls the dental technician
can work with a standard cement space. If considered necessary,
additional surface treatment such as sandblasting can be applied to
increase the roughness of the restoration.
Debonding or loss of retention (Fig 4-9) is by far the most
frequent technical complication for RBFDPs with a reported annual
complication rate ranging between 0% and 12.8%. The overall 5-year
debonding rate was reported to be 15.0%10. The incidence of
RBFDPs debonding significantly depends on the framework material
used and the cementation procedure. A recent systematic review10
analyzing the outcome of RBFDPs reported an annual debonding rate
of 2.9% for metal-ceramic RBFDPs, 4.2% for metal-acrylic RBFDPs,
1.7% for fiber-reinforced composite RBFDPs, and 1.4% for zirconia
framework RBFDPs. However, for RBFDPs with glass-infiltrated and
glass-reinforced ceramic frameworks no debonding occurred.
Moreover, the incidence of debonding was higher for RBFDPs
inserted in the posterior area compared with RBFDPs placed in the
anterior10.
Figs 4-9a and 4-9b The patient did not notice that the metal-ceramic
RBFDP lost retention at one retainer and a large caries lesion
developed in few months.

Today, zirconia- or glass-reinforced ceramic such as lithium-

disilicate ceramic are the favorable framework materials when
manufacturing RBFDPs. The risk of fracture is less for zirconia as
framework material compared with reinforced glass-ceramic.
Thus, the current concept recommends the use of zirconia, even
though glass-reinforced ceramic RBFDPs show an excellent
retention to enamel even without any preparation. Another
advantage of zirconia is that retainers can be made thinner, which
increases the indication spectrum of RBFDPs. To reduce the risk
of debonding for zirconia-based RBFDPs, it is recommended to
prepare two parallel retention grooves and a central stop for the
retainer. In situations with minimal retention area, eg, short teeth,
the dental technician can apply a microveneering of feldspar
ceramic on the inside of the retainer, allowing for acid etching of
the retainer.

Fracture of core or framework

Core fractures are a rare event for metal-ceramic SCs and occur in
only 0.03% at 5 years11. The incidence of core fractures is
significantly higher for all-ceramic crowns (Fig 4-10) and associated
with the mechanical stability of the ceramic material11 (Table 4-1).
Weaker ceramics like glass ceramics exhibited a high 5-year core
fracture rate of 6.7%. With regard to leucite or lithium-disilicate
reinforced glass ceramics, the respective fracture rate amounted to
2.3% and for zirconia-based SCs, the core fracture rate was merely
0.4%11.
Fig 4-10 Half of a veneered all-ceramic crown lost due to a ceramic
core fracture.

To minimize the risk of core fractures, the recommended materials

for tooth-supported SCs are lithium-disilicate-reinforced glass-
ceramic, zirconia-ceramic, and metal-ceramic. For maximum strength,
monolithic all-ceramic crowns are preferable. The latter can be
partially microveneered for an improved esthetic appearance.

The current concept is to move away from the traditional approach

of a core or framework veneered with 1–2 mm of ceramic to
monolithic restorations. Thereby the core is significantly increased
in its thickness, which should have a beneficial influence on the
strength of the restoration in the long run.

The incidence of framework fractures for tooth-supported FDPs is

also dependent on the framework material used (Fig 4-11). In a
systematic review analyzing the incidence of framework fractures, the
annual fracture rates ranged from 0.1% to 2.8%12,34. An estimated 5-
year framework fracture rate of 12.9% was reported for glass-
infiltrated alumina FDPs and the respective rate was 8.0% for
12
reinforced glass-ceramic FDPs12. Out of the all-ceramic FDPs,
densely sintered zirconia exhibited the best framework stability with
an estimated 5-year fracture rate of 2.1%12,34. Moreover, cantilever
tooth-supported FDPs are twice as often affected by framework
fractures compared with tooth-supported FDPs with end
abutments5,7. Metal-ceramic fixed partial dentures (FPDs) are rarely
affected by framework fractures as long as the connector size is at
least 9 mm2 and pre- or post-welding has not been implemented.

Fig 4-11 Veneered restoration with zirconia framework fractured due

to insufficient dimension of the connector area.

To reduce the risk of framework fractures the current concept

suggests the use of monolithic zirconia for tooth-supported FDPs,
with facial microveneering. With a monolithic restoration it is less
difficult to fulfill the minimal requirements of connector surface area
of 12 mm2. The main indication for metal-ceramic tooth-supported
FDPs today are large multiunit FDPs on periodontally
compromised teeth with increased mobility. For such cases, high
flexure strength is required for the framework material, making
metal-ceramic the material of choice. Moreover, metal-ceramic is
also recommended for tooth-supported cantilever FDPs with a
cantilever unit of more than one tooth.

The overall 5-year failure rate of RBFDPs lost due to framework or

material fractures is reported to be 1.7% and, as for tooth-supported
SCs and FDPs, this complication is also material dependent10.
Fractures are rarely reported for RBFDPs made of metal-ceramic,
zirconia, and reinforced glass-ceramic. RBFDPs made of metal-resin,
glass-infiltrated ceramic, and fiber-reinforced composite are
significantly more often lost due to material fractures10.

To reduce the risk of a retainer fracture, the current concept

recommends zirconia as framework material for RBFDPs.

Fracture of the veneering material – ceramic fractures

or chipping
Ceramic chipping is a common problem (Fig 4-12), and the overall
incidence is similar for metal-ceramic and all-ceramic tooth-supported
SCs11,31. With regard to metal-ceramic crowns, ceramic chipping was
reported to be the most frequent technical complication with an
occurrence of 2.6% at 5 years11. All-ceramic crowns with an alumina
or zirconia framework showed a tendency to a higher amount of
veneering ceramic chipping compared with other types of ceramic
crowns11. With regard to tooth-supported FDPs, veneered densely
sintered zirconia FDPs exhibited the highest incidence of ceramic
fractures (Fig 4-13). The latter was estimated to be 14.5% at 5
12 34
years, requiring repair or remake of the FDPs , . The incidence of
chipping was thereby significantly higher than the 5-year chipping rate
of 5.0% to 6.6% for veneered FDPs with metal- or glassinfiltrated
alumina frameworks12. The 5-year overall rate of ceramic chipping for
tooth-supported FDPs that could be solved with polishing was
reported to be 12.7%12. For RBFDPs, the overall 5-year rate of
minor veneer fractures (ceramic, acrylic, or composite chipping) that
could be repaired without losing the restoration was reported to be
4.1%10. The chipping rate was dependent on the material, with
zirconia-based and metal-ceramic RBFDPs exhibiting the lowest rate
of ceramic chipping10.

Fig 4-12 Three-unit maxillary FDP with multiple ceramic chipping that
could be corrected by polishing the surface.
Fig 4-13 Three-unit tooth-supported FDP in the molar area had to be
remade due to multiple ceramic fractures.

Even though zirconia is a promising material and widely used in

reconstructive dentistry, using it as a core or framework material
bears a significant risk of fracture or chipping of the veneering
material (Fig 4-13). When zirconia was introduced into dentistry, the
main problem was the differing thermal expansion coefficients of
zirconia and feldspar ceramic, which were used for the veneering.
This resulted in microfractures and subsequently ceramic chippings.
When ceramic is used as a framework material, the design of the
core or the framework has to follow the same basic principles as for
a metal core or framework. This means having an equally supported
veneering material with a thickness of 1–2 mm (Fig 4-14). A frequent
mistake is to leave the veneering ceramic at the marginal crest
unsupported instead of supporting it with an atomically designed
framework. Another common mistake is to have the veneering
ceramic thinner than 1 mm or thicker than 2 mm (Fig 4-15).
Regardless of the framework material, the weakest link of a
veneered restoration is the veneering feldspar ceramic, with a
strength of approximately 120 MPa36.
Figs 4-14a and 4-14b Cross-section of all-ceramic and metal-
ceramic restorations with appropriate thickness of the veneering
material.
Figs 4-15a and 4-15b Radiograph comparing two metal-ceramic
crowns. One with appropriate thickness of the veneering material (a)
and another one showing areas of thick unsupported veneering
material (b).

The current concept recommends monolithic restorations on the

occlusal surface to reduce the risk of ceramic fractures or
chipping. For esthetic reasons, the restorations can be
microveneered on the facial aspect. To reduce the risk of ceramic
fractures or chipping, contact points should be avoided in
laterotrusion. If contacts in laterotrusion cannot be avoided, they
should be evenly distributed over at least two units each time in a
multiunit restoration.

Marginal discoloration or marginal gaps

The incidence of marginal discoloration (Fig 4-16) or the occurrence
of marginal gaps at tooth-supported FDPs was reported to be 17.7%
at 5 years12. The lowest incidence of marginal discoloration was seen
for reinforced glass-ceramic FDPs and the highest incidence was
reported for densely sintered zirconia FDPs, with an estimated 5-year
marginal discoloration rate of 28.5%12.

Fig 4-16 Two anterior SCs with visible marginal discolorations.

To avoid marginal discoloration, the current concept recommends

optimal fit of the restoration. In addition, the cementation process
has to be executed meticulously and, if possible, under rubber dam
isolation. It must be kept in mind that utilizing resin cement does
not compensate for ill-fitting restorations.
4.4 Implant-supported restorations
4.4.1 Esthetic complications
Numerous studies have reported on the esthetic outcomes (Fig 4-17)
of implant-supported restorations8,9,14. Outcome measures were
evaluated by the dental professionals or by the patients themselves.
The studies included the use of a questionnaire to rate the
appearance of the crown or an index system to rate the interdental
papilla height (Fig 4-18)37–40. The way of reporting esthetic
complications is unfortunately not standardized. Studies have
reported crowns having a semi-optimal or even an unacceptable
esthetic appearance (due to soft-tissue recessions), an unfavorable
color, or visible crown margins (Table 4-2). The overall estimated 5-
year rate of esthetic complications by implant-supported SCs was
reported to be 7.1%14. Recent systematic reviews8,9 comparing the
outcomes of metal-ceramic and zirconia-ceramic implant-supported
SCs and FDPs reported that 1.7% of the metal-ceramic SCs had to
be redone due to esthetic reasons. In contrast, none of the metal-
ceramic FDPs and the zirconia-based restorations had to be remade
due to esthetic failure8,9. There are many factors that influence the
esthetic appearance of an implant-supported restoration. Several
authors have suggested a scoring system or index to evaluate these
factors41,42. A comprehensive and detailed scoring system is the Pink
Esthetic Score/White Esthetic Score, the PES/WES scale. Thereby,
the esthetic appearance of the implant-supported restoration is
assessed in comparison to a contralateral natural tooth41,42. The PES
or soft tissue Part of this scale evaluates the mesial and distal
papillae, the curvature of the facial mucosa, the level of the facial
mucosa, the root convexity, the soft tissue color, the soft tissue
texture, and the facial aspect at the implant site. The WES or white
esthetic score addresses the visible Part of the clinical crown based
on the general tooth form, the outline or volume of the clinical crown,
the color (hue/value), the surface texture, the translucency, and the
characterization. Every factor is given the score 0, 1, or 2, thus the
highest score for both PES and WES is 10, resulting in a maximum
PES/WES score of 20. A restoration with a score of 6 for PES and 6
for WES (ie, a total score of 12) is judged clinically acceptable41,42.

Fig 4-17 Three implant-supported SCs in the anterior area showing

unacceptable esthetic outcome due to wrong three-dimensional
position, hard and soft-tissue recession, and excessive implant
number.
Fig 4-18 Implant-supported SCs in position 21, which is missing Part
of the distal papillae.

How to imitate the appearance of a natural tooth with an implant-

supported restoration according to the current concept is
presented step by step in Part I Chapters 6 and 9.

4.4.2 Biologic complications

Soft-tissue complications and peri-implantitis
Peri-implant mucosal lesions are reported in various ways by different
authors. Whereas several studies provide information on soft-tissue
complications and peri-implantitis, others report signs of mucosal
inflammation (Fig 4-19), mucositis, bleeding, suppuration and soft-
tissue dehiscence or “soft-tissue complications,” defined as fistula,
gingivitis, or hyperplasia4,7. The estimated overall 5-year soft-tissue
complication rate was found to be 8.5% for implant-supported
FDPs4,7, 7.1% for implant-supported SCs14, and 7.0% for combined
tooth-implant-supported FDPs (Table 4-2)7,20. A systematic review
analyzing the outcome of metal-ceramic and zirconia-ceramic SCs
reported no significant difference in the incidence of soft-tissue
complications between the two material groups at 5 years9.

Fig 4-19 Soft-tissue complications visible at the implant in position

45.

There are several studies in the related dental literature that show
increased rates of soft-tissue complications and peri-implantitis in
patients being smokers compared with non-smokers43,44. The same
trend applies for patients with a history of periodontal disease
compared with patients being periodontally healthy44–46. A recent
study47 investigating the outcome of implant treatment in periodontally
compromised patients concluded that patients who had a semi-
successful periodontal treatment (represented by the number of
residual pockets ≥ 5 mm after treatment) had a significantly higher
incidence of peri-implantitis compared with patients who had a
successful periodontal treatment47. Even though the number of
residual pockets was shown to influence the outcome of implant
treatment, extracting all teeth and replacing them with implants would
not reduce the risk of peri-implantitis. Thus, this concept is obsolete
and cannot be recommended48. For a successful implant treatment, it
is essential to establish a periodontally healthy situation prior to
implant placement47.
Another risk factor for soft-tissue complications is the occurrence
of submucosal cement remnants, left unnoticed at cemented implant-
supported restorations49–51. A clinical study evaluating the influence of
different crown margin locations (epimucosal and 1, 2, 3 mm
submucosal) found cement remnants in all situations, despite proper
cleaning and a radiograph52. This finding is substantiated by the
findings of a systematic review, indicating significantly more biologic
complications for cemented implant-supported SCs (Fig 4-20) as
compared to screw-retained ones50. But also screw-retained SCs
can induce soft-tissue complications such as fistula, in case of screw
loosening causing a micromovement of the restoration50.

Fig 4-20 Implant supporting a molar crown that was lost due to
cement remnants causing inflammation and bone loss around the
implant.

Last, but not least, cleanability of the restorations (Fig 4-21) must
be warranted and was shown to significantly influence the incidence
of peri-implantitis53.
Fig 4-21 An implant-supported complete FDP where no attention has
been given to cleanability. Acrylic wings buccal to the implants
completely block all access for oral hygiene.

The current concept advocates a successful comprehensive

periodontal treatment before initiating the reconstructive phase and
implant placement to reduce the risk of soft-tissue complications.
Implant-supported restorations should preferably be screw-
retained and cleansable with interdental brushes and dental floss.
Patients should be submitted to a regular supportive maintenance
program with tight recall intervals in periodontally compromised
situations.

Marginal bone loss

Peri-implant marginal bone levels have been evaluated in a relatively
standardized way by means of radiographs, unlike peri-implantitis,
which has been reported in different ways. The incidence of implants
with bone loss exceeding 2 mm (Fig 4-22) is often presented in the
studies as a deviation of expected normal bone remodeling (Table 4-
2). The 5-year rate of implants with significant bone loss (>2 mm)
14
was estimated to be 5.2% for implant-supported SCs14 and 2.6% for
implant-supported FDPs13. There was no difference of marginal bone
loss between implants supporting metal-ceramic SCs and implants
supporting zirconia-ceramic SCs9. However, implants supporting
cemented crowns showed a slightly higher rate of marginal bone loss
compared with implants supporting screw-retained crowns54. One
should be cautious when measuring and reporting absolute marginal
bone levels, since the vertical implant position and different implant
geometries are associated with differing remodeling outcomes. The
bone level of an implant with a 2.8 mm neck, for example, is expected
to be 2.8 mm away from the shoulder of the implant (serving as a
reference point), provided that the implant was placed according to
the recommendation of the implant manufacturer and presuming the
expected bone remodeling process. The bone level of an implant with
a platform switch on the other hand is expected to be at the implant
neck (representing the reference point), provided that the implant was
placed at bone crest level. In the first case, a marginal bone level of
2.8 mm represents a healthy situation, whereas for the second
implant type a marginal bone level of 2.8 mm would represent a
significant bone loss. Similar factors influence the marginal bone loss
as influence soft-tissue complications and peri-implantitis. APart from
the periodontal situation, smoking, cleanability of the restoration,
residual submucosal cement, additional factors like the implant
surface, the implant geometry, and initial vertical bone defects may
play a major role for marginal bone loss. A recent study55–58,
evaluating the spontaneous bone fill around implants placed
immediately after extraction of single-rooted teeth, concluded that the
average bone fill was between 60% and 70% when no grafting
material was used (Fig 4-23). Thereby the mean gap width did not
influence the outcome. Hence, the dogma that a gap of less than 2
mm will be spontaneously filled by new bone can be seriously
questioned55–58.
Fig 4-22 Significant bone loss at single implant in position 12. The
defect was regenerated with a mixture of autogenous bone and bone
substitute covered with a barrier membrane after disinfection of the
implant surface.

Fig 4-23 Implant placed immediately after tooth extraction in a

premolar position. Spontaneous bone fill on average of only 60–70%
can be expected in such situations.
To reduce marginal bone loss and maintain a stable periodontal
situation, the current concept is based on a successful
comprehensive periodontal treatment before the restorative phase
and a well-organized supportive periodontal treatment. It is
important to distinguish the amount of bone loss caused by an
expected normal remodeling process from bone that is lost due to
a pathological process. The use of implants with documented
stable bone levels and a low incidence of peri-implantitis is
preferred. Guided bone regeneration (GBR) should be
implemented, if there is a risk for peri-implant marginal bone
defects not being spontaneously filled with new bone.

4.4.3 Technical complications

Fracture of the veneering material – ceramic fractures
or chipping
The most common technical complication of implant-supported
restorations is the fracture of veneering material (acryl, ceramic, or
composite). This includes minor chippings (Fig 4-24), that can be
polished, and major chippings, where repair or even remake is
necessary (Fig 4-25). The overall 5-year chipping rate ranged from
2.8% to 20.2% depending on the type of restoration and material
used4,7–9,14,20. Implant-supported FDPs with acrylic veneering
exhibited the highest amount of chipping (20.2%)4,7.
Fig 4-24 Ceramic chipping of the palatal aspect of a four-unit screw-
retained implant-supported FDPs.

Fig 4-25 Ceramic fracture of a screw-retained implant-supported

molar crown. Due to the extensive access hole, there might have
been a reduced support for the veneering ceramic.

The respective chipping rates were (Table 4-2):

8
■ 11.6% for metal-ceramic FDPs8
■ 7.2% for combined tooth-implant-supported FDPs7,20
■ 2.9% for metal-ceramic SCs9
■ 2.8% for zirconia-ceramic SCs9

When analyzing only the FDPs that needed repair because of ceramic
fractures (leaving out minor chippings that could be polished), the
chipping rate dropped from 11.6% to 4.7% for metal-ceramic implant-
supported FDPs and dropped down to 2.5% for zirconia implant-
supported FDPs8,9. However, both for implant-supported SCs and
FDPs, significantly more zirconia-based restorations were lost due to
material fractures than the respective metal-ceramic restorations8,9.
Thereby, the mismatch of the thermal expansion coefficient from
zirconia and the veneering ceramic contributed to the increased
amount of ceramic fractures (Fig 4-26). This was a huge challenge in
the beginning, when zirconia emerged as framework material.
Another crucial factor influencing the occurrence of chipping is the
correct design of core or framework. This is even more critical for
implant-supported than tooth-supported restorations, due to the
larger discrepancy of crown and implant diameter than crown and
root diameter of an abutment tooth. For a correct framework design,
the thickness of the veneering ceramic should be consistent and not
exceed 2 mm, which is considered to be the maximum thickness of
the veneering ceramic. As shown for tooth-supported restorations, a
frequently seen mistake by the dental technician is to leave the
veneering ceramic at the marginal crest unsupported by the
framework. To reduce load and risk of fractures, some authors have
recommended implant restorations in infraocclusion. Whether this
approach is reasonable is unclear, since antagonist teeth usually
erupt into contact in a relatively short period of time.
Fig 4-26 An implant-supported restoration with traditionally veneered
zirconia framework suffered a large ceramic fracture, leaving the
zirconia framework exposed.

The current concept recommends monolithic implant-supported

restorations to reduce the risk of ceramic fractures or chippings. If
needed for esthetic reasons, the restorations can be
microveneered on the facial aspect. The occlusal access holes
should be made as small as possible. When restoring partially
edentulous patients with implant-supported restorations, contacts
should be restricted to teeth in laterotrusion and avoided on
implant-supported restorations, if possible. In situations where
contacts cannot be avoided in laterotrusion, the load should be
distributed to two or more units to reduce the risk of ceramic
fractures. In situations with implant-supported restorations in both
jaws, it is recommended to place the restorations in slight
infraocclusion.

Fracture of core or framework

In general, fracture of the framework of an implant-supported
restoration is a rare complication. However, framework fractures
were more frequently observed in studies reporting on all-ceramic
restorations8,9.
The estimated 5-year rate of framework fractures in general
amounts to:
■ 0.5% for implant-supported FDPs13
■ 1.6% for combined tooth-implant-supported FDPs7,20
■ 1.3% for implant-supported SCs14
Since material fatigue is usually the reason for this kind of
complication, it might take years for a fracture to develop. Hence, an
average follow-up time of 5 years might not be long enough to
present the realistic incidence of this complication. To ensure a
sufficient material wall thickness, screw-retained implant-supported
SCs or FDPs should be designed with screw access holes and screw
channels being as small as possible. For this reason, care must be
taken not to have the access holes in the area of the connectors
where the restoration is the thinnest (Fig 4-27). The prerequisite for
this is that the implant is placed in a prosthetically correct three-
dimensional position.
Fig 4-27 Fracture of a zirconia framework due to an insufficient
material thickness in the connector area. This is caused by the wrong
design around the access hole.

The current concept suggests the use of monolithic implant-

supported SCs out of lithium-disilicate or zirconia and monolithic or
microveneered lithium disilicate or zirconia implant-supported FDPs
out of zirconia or metal-ceramic to reduce the risk of framework
fractures.

Loss of retention
Another technical complication is loss of retention (fracture of the
luting cement) for cemented restorations (Table 4-2). The estimated
5-year rate of this complication was:
■ 4.7% for implant-supported FDPs13
■ 4.1% for implant-supported SCs14
■ 7.3% for combined tooth-implant-supported FDPs7,20
Implant-supported restorations can be cemented directly on the
abutment intra- or extraorally. In the latter case, the restorations can
be screw-retained to the implant. When cementing an implant-
supported restoration on an abutment, there are several possible
material combinations. The restorations can be made of metal,
zirconia, and lithium-disilicate and the abutments can be made of
titanium, gold, or zirconia. It is imperative to follow meticulously every
step of the surface treatment for both the abutment and the
restoration, and the cementation process depending on the material
combination (see Part I, Chapter 12). In cases with limited
intraocclusal height and low abutment height, the abutment surface
can be sandblasted to gain extra retention through additional surface
roughness. A significant drawback for cement-retained implant-
supported restorations is the risk of cement remnants. Several
studies49,52,59,60 have shown that it is very difficult to completely
remove the residual cement, especially in cases with deeply placed
crown margins. Undetected cement remnants can lead to peri-
implantitis, marginal bone loss, and in a worst case scenario, even
implant loss (Fig 4-20)49–51,61.

To reduce the risk of loss of retention the current concept suggests

cementing the restoration extraorally with resin cement. Thereafter
the restoration can be screw-retained to the implant with a defined
torque. When cementing intraorally, the use of glass-ionomer
cement is a reasonable option. This cement type is radiopaque
and can be more easily removed than resin cement. However, for
cementation on zirconia abutments, both intra- and extraorally,
resin cement is recommended. It is not recommended to use cone-
shaped abutments with a wall height of less than 5 mm as a basis
for a cemented restoration.

Abutment or prosthetic screw loosening or fractures

Another common technical complication for implant-supported
restorations is abutment or prosthetic screw loosening (Fig 4-28).
The overall estimated 5-year rate for screw loosening was:
Fig 4-28 Molar crown has rotated 90 degrees clockwise because
the solid abutment was not fully tightened before impression taking.

■ 8.8% for implant-supported SCs14

■ 6.9% for combined tooth-implant-supported FDPs7,20
■ 5.3% for implant-supported FDPs13

Prerequisites for a stable implant-abutment connection are:

■ friction between the inner surface of the implant and the outer
surface of the abutment;
■ an anti-rotational configuration integrated into the connection;
■ a stable abutment screw preferably with a pre-torque or additional
friction within the screw head.

To achieve the ideal level of friction, the production of the components

has to be very accurate; hence, utilizing generic or computer-aided
design/computer-aided manufacturing (CAD/CAM) components will
increase the risk of loosening or fractures (Fig 4-29). A recent
systematic review54 evaluating the outcomes of restorations
supported by internally or externally connected implants concluded
that there was significantly less abutment screw loosening for
restorations with internal connection54.
Fig 4-29 Cross-section of an original (left) and a copy-cat (right)
implant abutment. There is limited friction between the inner surface
of the implant and the abutment surface by the copy-cat abutment.
Hence, the abutment stability relays entirely on the abutment screw
which increases the risk of screw and abutment loosening.

To reduce the risk of abutment or prosthetic screw loosening, the

current concept recommends using a stable internal implant-
abutment connection, original components, and restorations that
are directly screw-retained to the implant with an abutment screw.
Hence, the weakest link being the prosthetic screw is eliminated.
Such restorations can be directly integrated to the abutment (cast-
on) or cemented on the abutment extraorally. For neighboring
implants in the posterior area, splinted crowns are preferable for
better handling and to reduce a possible rotational force. For
splinted crowns, implants should be placed relatively parallel to
each other and the restoration must be fabricated to be cleansable
with interdental brushes (Fig 4-30).
Fig 4-30 Implant-supported multiunit restorations must be easily
cleansable with medium size interdental brushes.

Even though loosening of abutments and screws is a frequent

complication, the components rarely fracture (Figs 4-31, 4-32a, b 4-
33, 4-34a, b) (Table 4-2). The respective abutment and prosthetic
screw fracture rate was reported to be 1.3% for implant-supported
FDPs13, 0.6% for combined tooth-implant-supported FDPs20, and
0.4% for implant-supported SCs14 for at 5 years. A recent in vitro
study analyzing the strength of different implant-abutment connections
for narrow diameter implants showed that abutments where the
internal Part was made of zirconia were significantly weaker than
titanium abutments or zirconia abutments with a titanium base (Figs
4-35a, b, c, d, e)62.
Fig 4-31 Fractured zirconia abutment. The insertion Part that goes
into the implant is the weakest Part of this abutment.
Figs 4-32a and 4-32b Customized zirconia abutments with ceramic
inserts in positions 11 and 21 fractured after 3 years in function.
Fig 4-33 An abutment screw fractured and a three-unit implant-
supported FDP became loose.
Figs 4-34a and 4-34b An abutment screw fractured and the
abutment needed to be removed. The restoration had been re-
tightened several times prior to the fracture, causing the abutment
screw to go deeper in the screw canal until it got stuck at the bottom.
Figs 4-35a to 4-35t Fracture resistance of different types of implant-
abutment connections by narrow diameter implants.

To reduce the risk of abutment fractures, the current concept

suggests titanium-base or cast-on gold abutments as the standard
of care. Standard or customized zirconia abutments are only
implemented in cases with high esthetic priority.

Loss of the screw access hole restoration

Another common technical complication is the loss of the screw
access hole restoration made for screw-retained restorations. This
technical complication occurred in 5.4% of the implant-supported
13
restorations over a 5-year follow-up period13. Even though loss of the
small access hole restoration is not a major complication, it is
unpleasant if it happens frequently and the patient has to come back
several times for renewal.

In the current concept the access hole is made as small as

possible and closed in layers (Fig 4-36). The lower Part of the
access hole is filled with condensed Teflon tape. The remaining 2–
3 mm are filled with composite filling material in case of all-ceramic
restorations. For metal-ceramic restorations the upper layer
consists of an opaque glass-ionomer filling to cover the metal.
Then composite material is applied as the last layer, matching the
thickness of the veneering ceramic. The veneering ceramic should
be acid-etched prior to the composite filling. Therefore, the
veneering ceramic is treated with 9.5% hydrofluoric acid for 60 s in
case of metal-ceramics. In case of lithium-disilicate ceramic, 5%
unbuffered hydrofluoric acid is applied for 20 s. In case of zirconia
restorations, acid etching is not possible and thus not needed.
Figs 4-36a to 4-36c Access holes are closed in layers. Condensed
Teflon tape is used to protect the screw head and the upper Part is
filled with composite.

Implant fractures
The estimated 5-year fracture rates are:
■ 0.2% for implants supporting SCs14
■ 0.5% for implants supporting FDPs13
■ 0.8% 7 for
20
implants supporting combined toothimplant-supported
FDPs ,

Implant fractures are a rare complication (Table 4-2) usually being

related to metal fatigue (Figs 4-37a, b). Consequently, an average
follow-up time of 5 years might not be enough to give the correct
picture of such a complication. Basically, the implant strength is
increased with increased implant diameter. However, for implants with
internal connection, the thickness of the wall around the implant-
abutment connection is a critical factor influencing the strength of the
implant. There is a tendency today to use implants with smaller
diameter to avoid complex bone augmentation procedures. For
evidence-based treatment planning it is important to be familiar with
the overall fatigue strength of the implants used. An implant with a
fatigue strength of more than 300 N (according to a dynamic testing
by the ISO 14801 test norm) can be recommended for every
indication. An implant with a fatigue strength between 200 N and 300
N should only be used for fixed or removable dental prostheses in
combination with stronger implants. Those implants should not be
used for central incisors and canines in the maxilla, molars, or
overdentures with ball or locator attachments. An implant with a
fatigue strength below 200 N should only be used for mandibular front
teeth and fixed/removable dental prostheses only in combination with
stronger implants. It must be kept in mind that today’s life
expectancies of people in many countries exceeds 80 years; hence,
patients that receive implants at the age of 50 years most probably
still have more than 30 years of function.
Figs 4-37a and 4-37b One of the two implants supporting the three-
unit restoration, lost all bone-to-implant contact and the second
implant fractured.

When it comes to planning the needed number and diameter of

implants to support a restoration, it is important to consider the
age of the patient, the bone volume, and occlusal relationship.
Clinicians should be familiar with the fatigue strength of the implant
system used.

4.5 References
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Appendix 1: Photo
Documentation Protocol
Extraoral
Full Face

Frontal
Relaxed

Slight smile

Full smile
Profile

Relaxed

Full smile

3/4 View
Full smile right

Full smile left

Frontal Close-up
Relaxed

Slight smile

Full smile
Forced Smile Grimace – HA!

Lateral Close-up
Frontal with cheek and lip retractors
Profile

Relaxed

3/4 View
Full smile right

Full smile left

Full smile right

Full smile left

Intraoral
Frontal

Entire
Anterior

Entire open
Anterior black background

Occlusal
Full arch

Close-ups

Lateral
Appendix 2

Adhesive cementation flowchart for

lithium disilicate restorations
CHX, chlorhexidine.
Cementation flowchart for zirconia
restorations
CHX, chlorhexidine; FDP, fixed dental prosthesis; MDP,
methacryloyloxydecyl dihydrogen phosphate; RBFDP, resin-
bonded fixed dental prosthesis.
Appendix 3

Adhesive cementation flowchart for

feldspathic ceramic veneers
Cementation flowchart for metal-
ceramic restorations
Methacryloyloxydecyl dihydrogen phosphate (10-MDP) is
one of the most commonly used functional monomers; it is
the hydrophilic phosphate monomer that increases resin
diffusion and adhesion by causing acidic decalcification and
binding to calcium ions or amino groups of tooth structure.
CHX, chlorhexidine; FDP, fixed dental prosthesis.
Appendix 4

Cementation flowchart for posts

CHX, chlorhexidine.
Cementation flowchart for extraoral
cementation (eg, in laboratory)
CHX, chlorhexidine; FDP, fixed dental prosthesis;
MDP, methacryloyloxydecyl dihydrogen phosphate.
Appendix 5

Pretherapeutic single tooth prognosis:

single tooth risk analysis
Secure teeth are teeth that should last for a long period of time without the need
for significant or complex treatment
Dental aspects Periodontal aspects Endodontic aspects
Group I All teeth not All teeth not classified as All teeth not classified as
Secure classified as doubtful or irrational to treat doubtful or irrational to treat
teeth doubtful or and all teeth with intact root
irrational to canal anatomy, that need
treat primary endodontic
treatment with or without
symptoms
Group II These are teeth that might need complicated treatment and additional
Doubtful maintenance to last. It is not always clear how those teeth will respond to
teeth treatment and therefore it can be of an additional risk to use them as FDP
abutments and more reasonable to keep them as single units. In many
instances, doubtful teeth can be made secure by treatment
Dental aspects Periodontal aspects Endodontic aspects
Teeth that have Teeth with attachment loss in Teeth with large peri-apical
lost so much percentages, evaluated on a lesions evaluated on
substance, that radiograph, to be more or radiographs with or without
it is difficult to equal to the age of the patient symptoms
restore them in years, ie, ≥ 50% attachment
with acceptable loss in 50-year-old patients
ferule
Teeth with Molars with furcation Class I, Teeth with altered root canal
caries lesion II, or III anatomy that need
that extends far endodontic retreatment
down the root
Teeth with Teeth with vertical bone Teeth that need peri-apical
weakened root defects surgery
structure due to
a wide metal or
fiber-reinforced
post
These are teeth where extraction is the only option. The timing of extraction can
depend on situation of the tooth, pain, or infection, or the treatment plan
Dental aspects Periodontal aspects Endodontic aspects
Teeth with Attachment loss extending Teeth with vertical root
caries lesion down to the apical Part of the fractures
Group III that extends root
Teeth into the root
irrational canal
to treat
Teeth with Teeth with recurrent peri- Horizontal root fractures in
caries lesion apical abscesses the mid third of the root
extending into
the furcation
Functional reasons – ie, decayed or periodontally infected third molar without
antagonist

Estimated 5- and 10-year survival rate

of different types of restoration and
the number of restorations that were
evaluated
Type of restoration Number of Estimated 5-y Number of Estimated 10-y
restorations survival rate restorations survival rate
analyzed (95% CI) analyzed (95% CI)
Ceramic veneers ≈ 400 92.4 (89.8– n.a. n.a.
95.0)
Glass-ceramic inlays 1579 96.0 (89.0– 605 93.0 (86.0–
and onlays 98.0) 96.0)
Tooth-supported 4663 95.7 (94.1– 3687 91.6 (87.9–
metal-ceramic SCs 96.9) 94.2)
Tooth-supported 926 93.8 (90.3– n.a. n.a.
zirconia-ceramic SCs 96.1)
Type of restoration Number of Estimated 5-y Number of Estimated 10-y
restorations survival rate restorations survival rate
analyzed (95% CI) analyzed (95% CI)
Tooth-supported 2689 96.6 (94.9– n.a. n.a.
reinforced glass- 97.7)
ceramic SCs
Tooth-supported n.a. n.a. n.a. n.a.
endocrown
Tooth-supported 1796 94.4 (91.2– 1218 89.2 (76.1–
conventional metal- 96.5) 95.3)
ceramic FDPs
Tooth-supported 574 90.1 (83.6– n.a. n.a.
conventional zircona- 94.2)
ceramic FDPs
Tooth-supported 423 91.4 (88.4– 239 80.3 (74.8–
cantilever FDPs 93.7) 84.7)
Resin-bonded FDPs 1755 91.4 (86.7– 545 82.9 (73.2–
94.4) 89.3)
Resin-bonded FDPs 68 100.0 (94.5– n.a. n.a.
zirconia-ceramic 100.0)
Implant-supported 4636 98.3 (96.8– 268 89.4 (82.8–
metal-ceramic SCs 99.1) 93.6)
Implant-supported 912 97.6 (94.3– n.a. n.a.
zirconia-ceramic SCs 99.0)
Implant-supported 932 98.7 (96.8– 33 93.9 (79.8–
metal-ceramic FDPs 99.5) 99.2)
Implant-supported 175 93.0 (90.6– n.a. n.a.
zirconia-ceramic 94.8)
FDPs
Implant-supported 376 98.2 (91.0– n.a. n.a.
cantilever FDPs 100.0)
Combined tooth- 199 95.5 (91.5– 60 77.8 (64.9–
implant-supported 97.6) 86.4)
FDPs
n.a., not applicable.