Irena Sailer | Vincent Fehmer | Bjar ni Pjetursson

FIXED
RESTORATIONS
A CLINICAL GUIDE TO
THE SELECTION OF MATERIALS
AND FABRICATION TECHNOLOGY
Irena Sailer | Vincent Fehmer | Bjar ni 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: 978-1-78698-027-4

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Printed and bound in Croatia

iv
Dedication

“To our families and mentors who inspired us”

Irena, Vincent, and Bjarni

v
Contents

Forewords vii 1.4.3 Time points for diagnostics, diagnostic

Authors x tools 57
Contributors xii 1.4.4 Conventional procedures 58
1.4.5 Digital procedures 58
1.4.6 Augmented reality in dentistry 66
1.4.7 Diagnostics for fixed implant-supported
Part I Basics 1 restorations, surgical stents 66
1.4.8 Conclusions 73
1.1 Current restorative materials 3 1.4.9 References 73

Jens Fischer 3 1.5 Decision-making criteria for

1.1.1 Introduction 4
replacing the missing tooth 75
1.1.2 Requirements for restorative materials 4
1.1.3 Overview of current materials for fixed 1.5.1 Introduction 76
­restorations 11 1.5.2 An evidence-based approach to
1.1.4 Conclusions 19 treatment planning 76
1.1.5 References 19 1.5.3 Factor 1 – The patient’s perception 76
1.5.4 Factor 2 – The estimated longevity
1. 2 Patient-related factors for of the restorations 79
1.5.5 Factor 3 – The neighboring teeth 79
material selection 21
1.5.6 Factor 4 – The evaluation of the tooth gap 82
1.2.1 Introduction 22 1.5.7 Factor 5 – The complexity of implant
1.2.2 Patient demands 22 placement 84
1.2.3 Esthetic requirements 22 1.5.8 Factor 6 – Assessment of risk factors 85
1.2.4 Amount and quality of tooth substance 24 1.5.9 Factor 7 – Multiple risk factors 86
1.2.5 Amount and quality of soft tissues 25 1.5.10 Conclusions 87
1.2.6 Occlusal and functional requirements 28 1.5.11 References 87
1.2.7 Conclusions 34
1.2.8 References 34 1.6 Tooth preparation: current
concepts for material selection 89
1.3 Technical factors 37
1.6.1 Introduction 90
1.3.1 Introduction 38 1.6.2 Minimally invasive preparation techniques 90
1.3.2 Conventional vs computer-aided 1.6.3 Defect-oriented preparation techniques
manufacturing techniques 38 for posterior teeth: onlays, overlay-veneers,
1.3.3 Optical factors influencing the material and partial crowns 107
selection 38 1.6.4 Conventional crown and fixed dental
1.3.4 Monolithic and veneered restorations 43 prosthesis (FDP) preparation technique:
1.3.5 Conclusions 53 the universal tooth preparation 110
1.3.6 References 54 1.6.5 Virtual diagnostics and guided tooth
­preparation 117
1.4 Diagnostics 55 1.6.6 Resin-bonded fixed dental prosthesis (RBFDP)
preparation 120
1.4.1 Introduction 56 1.6.7 Conclusions 121
1.4.2 Esthetic parameters to be evaluated: 1.6.8 References 126
step-by-step checklist 56

xiv
 Contents

1.7 Provisional restorations 127 1.11.3 Monolithic implant restorations supported

by titanium-base abutments 166
1.7.1 Introduction 128 1.11.4 Factors for predictable outcomes: adhesive
1.7.2 Direct provisionals 128 cementation of monolithic ceramics to
1.7.3 Eggshell provisionals 128 titanium-base abutments 168
1.7.4 CAD/CAM provisionals 128 1.11.5 Conclusions 173
1.7.5 Conclusions 130 1.11.6 References 173
1.7.6 References 130
1.12 Material selection flowcharts 175
1.8 Impression techniques 131
Material selection for tooth-supported ­
1.8.1 Introduction 132 single-unit restorations 176
1.8.2 Biological width 132 Material selection for tooth-supported
1.8.3 Methods for temporary tissue retraction 132 ­multiple-unit restorations 178
1.8.4 Conventional impressions 134 Material selection for implant-supported
1.8.5 Optical impressions 134 ­restorations 179
1.8.6 Conclusion 138
1.8.7 References 138 1.13 Cementation flowcharts 183

1.9 Material-related cementation Cementation flowchart for metal-ceramic

restorations 184
procedures 141
Cementation flowchart for zirconia
1.9.1 Introduction 142 restorations 185
1.9.2 Adhesive cementation of silica-based ceramics Adhesive cementation flowchart for
(feldspathic ceramics, ­glass-ceramics) 142 lithium disilicate restorations 186
1.9.3 Adhesive cementation of oxide ceramics Adhesive cementation flowchart for
(zirconia) 148 feldspathic ceramic veneers 187
1.9.4 Adhesive cementation of hybrid Cementation flowchart for posts 188
materials (resin-nano ceramic, Cementation flowchart for extraoral
resin-infiltrated ceramic network) 148 ­cementation (eg, in laboratory) 189
1.9.5 Universal silanes/primers and universal resin
cements 150
1.9.6 Conclusions 153
1.9.7 References 153
Part II Clinical ­procedures
step-by-step 191
1.10 Fixation of implant-supported
restorations 155 2.1 Minimally invasive restorations
1.10.1 Introduction 156 (veneers) 193
1.10.2 Cemented implant restorations 156 2.1.1 Anterior regions: Additional veneers
1.10.3 Screw-retained implant restorations 159 after trauma (two maxillary central
1.10.4 Screw-retained versus cemented 160 incisors) 194
1.10.5 Conclusions 161 2.1.2 Anterior regions: Anterior veneer after
1.10.6 References 162 trauma (single maxillary central incisor) 202
2.1.3 Anterior regions: Traditional veneers for
1.11 The titanium-base abutment restoration of amelogenesis imperfecta
six maxillary ­anterior teeth) 208
concept 165
2.1.4 Anterior & posterior regions: Traditional
1.11.1 Introduction 166 and palatal veneers after deep bite and
1.11.2 Traditional implant restorations supported orthodontic pretreatment
by stock/customized abutments 166 (six maxillary anterior teeth) 218

xv
Contents

2.1.5 Anterior & posterior regions: Traditional 2.3.3 Posterior regions: Defect-oriented
veneers after undetected celiac disease restoration of endodontically treated
(10 veneers – maxillary premolar to posterior tooth 394
premolar) 228 2.3.4 Posterior regions: Defect-oriented
2.1.6 Anterior & posterior regions: Traditional restorations (direct computer-aided
veneers with the application of augmented composite build-up) 398
reality (10 veneers – maxillary premolar to
premolar) 236 2.4 Conventional single crowns
2.1.7 Anterior & posterior regions: Traditional
(SCs) 407
veneers with the application of augmented
reality and orthodontic ­pretreatment 2.4.1 Anterior regions: Anterior SC
(six maxillary anterior teeth) 246 with ­non-discolored abutment tooth 408
2.1.8 Anterior & posterior regions: 360-degree 2.4.2 Anterior regions: Anterior SCs with
and occlusal veneers with a single implant discolored abutment teeth 416
restoration (seven mandibular teeth and 2.4.3 Posterior regions: Posterior SC with ­
posterior implant) 258 non-discolored abutment tooth 424
2.1.9 Complex situations: Full-mouth 2.4.4 Posterior regions: Posterior SC with a
rehabilitation with traditional veneers discolored abutment tooth 428
and overlays 268 2.4.5 Complex situations: Conventional
2.1.10 Complex situations: Additional veneers SCs and fixed dental prostheses (FDPs) 434
and implant restorations (maxillary 2.4.6 Complex situations: SCs in combination
premolar to premolar) 288 with an implant 448

2.2 Minimally invasive restorations 2.5 Tooth-supported all-ceramic

(resin-bonded fixed dental single crowns (SCs), fixed dental
prostheses [RBFDPs]) 297 prostheses (FDPs), and a
2.2.1 Anterior regions: Failing central incisor removable telescopic restoration 461
after many years of periodontal treatment 298 2.5.1 Anterior regions: Full-mouth
2.2.2 Anterior regions: Congenitally missing rehabilitation 462
lateral incisor (RBFDP after orthodontic 2.5.2 Posterior regions: Tooth-supported,
pretreatment) 310 all-ceramic three-unit fixed dental
2.2.3 Anterior regions: Congenitally missing prosthesis (FDP) 494
lateral incisors (RBFDP after orthodontic 2.5.3 Posterior regions: The 3D-printed
pretreatment) 320 prototype 500
2.2.4 Anterior regions: Full-mouth rehabilitation
with congenitally missing teeth (RBFDPs, 2.6 Implant-supported single
veneers, and overlays after orthodontic
crowns (SCs) 511
treatment) 332
2.2.5 Complex situations: RBFDP and additional 2.6.1 Anterior regions: Anterior implant-
veneer in combination with orthodontic supported SC with GBR 512
pretreatment 346 2.6.2 Anterior regions: Anterior implant-
supported SC with GBR 526
2.3 Defect-oriented restorations 357 2.6.3 Anterior regions: Anterior implant-
supported SC 534
2.3.1 Posterior regions: Defect-oriented partial 2.6.4 Posterior regions: Posterior implant-
crowns and overlay in posterior regions 358 supported SC with GBR 544
2.3.2 Posterior regions: Defect-oriented 2.6.5 Posterior regions: Posterior implant-
overlays in posterior regions 380 supported SC with GBR 550

xvi
 Contents

2.6.6 Posterior regions: Posterior implant- Part III Long-term outcomes

supported SC and optical impression 556
2.6.7 Complex situations: Tooth- and implant- of fixed ­restorations 679
supported all-ceramic SCs and fixed
dental prostheses (FDPs) 562 3.1 Introduction 681
3.2 Tooth-supported veneers 681
2.7 Implant-supported restorations 597 3.3 Tooth-supported inlays and onlays 681
2.7.1 Anterior regions: Implant-supported 3.4 Tooth-supported SCs 681
four-unit fixed dental prosthesis (FDP) 598 3.5 Endocrowns 682
2.7.2 Posterior regions: Implant-supported 3.6 Tooth-supported conventional
three-unit fixed dental prosthesis (FDP) 610 multiple-unit FDPs 684
2.7.3 Posterior regions: Implant-supported 3.7 Tooth-supported cantilever FDPs 685
fixed dental prosthesis with mesial 3.8 Resin-bonded fixed dental prostheses
cantilever (FDP) 620 (RBFDPs) 686
2.7.4 Posterior regions: Implant-supported 3.9 Implant-supported SCs 687
fixed dental prostheses (FDPs) 640 3.10 Implant-supported FDPs 691
2.7.5 Complex situations: Full-arch implant- 3.11 Implant-supported cantilever FDPs 693
supported fixed restoration with pink 3.12 Combined tooth-implant-supported
ceramics (FDP) 648 FDPs 693
3.13 References 696
2.8 Maintenance 663
2.8.1 Intraoral direct repair of an existing
restoration 664
Part IV Avoiding and
2.8.2 Maintaining an existing restoration 668 managing complications 703
2.8.3 CAD/CAM-fabricated Michigan splint 674
4.1 Introduction 704
4.2 Success of tooth- and implant-supported
restorations 704
4.3 Tooth-supported restorations 704
4.4 Implant-supported restorations 714
4.5 References 724

xvii
   Chapter 1   Part I

PART I
BASICS

1
CHAPTER 1
Current restorative
materials
Jens Fischer

3
Part I Chapter 1 Current restorative materials

1.1.1 Introduction 1.1.2 Requirements for restorative

In this chapter: materials
„ Requirements for restorative materials
„ Overview of current materials for fixed restorations In the oral cavity, restorative materials have to meet three
„ Conclusions requirements: biocompatibility, longevity, and esthetics.

In the past, material selection in fixed prosthodon- Biocompatibility

tics was mainly based on metal-ceramics and on a few
all-ceramic alternatives. Metal-ceramic restorations were The term biocompatibility implies that the material shall
selected in clinical situations with need for high stability do no harm to the living tissues, achieved through chem-
(eg, in the posterior region or in the case of multiple-unit ical and biological inertness8. As every material potential-
fixed dental prostheses), whereas all-ceramic restor- ly dilutes or degrades depending on the environment, the
ations were recommended in single tooth replacement extent of decomposition, and the quality and amount of
with high esthetic demands, especially in the anterior released substances determine the degree of biological
region. These materials were traditionally processed by complications. A possible host response might be local-
manual fabrication technologies such as casting, press- ized or systemic toxicity, hypersensitivity, or genotoxici-
ing, or layering1,2. Restorative dentistry with all-­ceramic ty9. The restriction to biocompatible components strong-
restorations has suffered from a prolonged learning ly limits the room for the development of new materials.
curve. Several of the early systems disappeared shortly Due to the strict regulations for medical devices, manu­
after being introduced due to an unacceptable number facturers have to prove biocompatibility of their materials.
of mechanical failures3. International standards help the choosing of the appro-
Nowadays, clinicians and technicians can choose priate tests and in interpreting the results. Tests must be
from a wide range of reliable materials. Digital technol- done with every novel material prior to approval. Bio-
ogies such as intraoral optical scans and computer-aid- logical tests are employed in a sequence, ending up with
ed design/computer-aided manufacturing (CAD/CAM) animal tests9. Furthermore, manufacturers of medical de-
procedures have opened up new treatment pathways in vices are forced by law to perform a systematic post mar-
fixed prosthodontics. New digital fabrication workflows ket surveillance of the materials and devices. Measures
were defined and in parallel advanced materials were have to be taken to minimize risk and unexpected side
developed and adjusted to the specific requirements of effects must be notified to the authorities. Fortunately, it
numerically controlled processing such as high-strength can be concluded that biological and immunological ad-
ceramics and composites. In these digital workflows, the verse reactions attributed to dental materials are rare and
restorations are fabricated by means of computer-aided the reported adverse effects are acceptable9.
milling from prefabricated blanks, increasingly replacing On the other hand it is unrealistic to assume that
conventional manual processing. absolute material inertness is attainable and biological
The different materials available today exhibit dif- behavior is definitely predictable by means of biologic-
ferences in properties, influencing the esthetics and the al tests10. Hence, the biocompatibility of dental ma-
long-term performance of the restorations. As multiple terials must always be weighed against their benefit11.
alternatives exist for each clinical situation, it is more Controlled clinical trials are currently still the best way
difficult to select the most appropriate material for the to assess the clinical response to materials. But even
respective clinical situation today than in the past4–6. As these tests have significant limitations. Therefore, prac-
a consequence of the transformation in present technol- tice-based research networks and practitioner databases
ogy, selection of the restorative material requires under- are increasingly considered as a valuable alternative10.
standing of the interaction between material properties
and clinical performance7. Longevity
After an introduction to the requirements for restora-
tive materials and the behavior of the different mater- The long-term success of a restoration mainly depends on
ial classes used in dentistry, this chapter will provide an its mechanical performance. From the technical side the
overview of the current material options for fixed restor- success of a restoration can be controlled by the durabil-
ations and their clinically relevant properties, indications, ity of the material, the nature of the design, the quality
and limitations. of the processing, and the effectiveness of the finishing.

4
 Current restorative materials Chapter 1   Part I

a b

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

Material tication − crack growth happens in a micrometer scale.

The mechanical behavior of dental materials is main- But over time the crack grows significantly. Finally, cata-
ly characterized by elasticity, flexural strength, fracture strophic failure occurs when the residual cross-section is
toughness, and hardness. These properties are basically too small to withstand the load.
given by the type and strength of the bondings between It is important to understand the fracture mechan-
the atoms. isms of the different materials. In metals the crack tip is
Elasticity is the ability of the material to resume its ini- rounded out by plastic flow and thus the risk of fracture is
tial shape after loading, measured in GPa (= 103 N/mm2). significantly reduced (Fig 1-1-1). In ceramics plastic flow
Stressing a material beyond its limit of elasticity leads to is not possible due to the covalent bonds. The crack tip
plastic deformation, a permanent distortion. Brittle ma- remains sharp and crack growth is a significantly higher
terials such as ceramics only show minimal or no plastici- risk than in metals. That is the reason for the well-known
ty, which means they fracture very soon after reaching brittle behavior of ceramics. To increase strength and in
the limit of elasticity. The stress where fracture occurs is particular toughness, strengthening mechanisms on the
the flexural strength, measured in MPa (= N/mm2). The microscopic level to impede crack propagation are em-
resistance against crack growth is called fracture tough- ployed. In brittle materials this might be achieved by in-
ness, measured in MPa√m. ternal compression or by particles, which act as obstacles
Elasticity, flexural strength, and fracture toughness against crack growth (Fig 1-1-2). The objective of such
are bulk properties. Hardness in contrast is a surface strengthening mechanisms is to stop crack growth or at
property, which is defined as the resistance to localized least to hamper it, like a hurdler who is not as fast as a
deformation induced by mechanical indentation or abra- sprinter.
sion. Harder materials therefore show less risk of surface The term durability includes not only the mechan-
damage. Flexural strength and hardness are correlated to ical characteristics specified above but resistance to wear
a certain extent. and aging as well. The degradation of the materials by
The main risk for mechanical failure of restorations wear and aging depends on the mechanical properties
are flaws at the surface, which might act as a starting and also on the susceptibility to the oral environment
point for microcracks. In case of tensile loading, a micro­ including humidity, temperature, and loading character-
crack opens and stress develops at the tip of the crack. istics. Water for instance may attack the material’s bonds
Stress which exceeds the strength of the material leads to especially at phase boundaries or microcracks, thus pro-
crack propagation. Under cyclic loading − such as mas- moting degradation.

5
Part I Chapter 1 Current restorative materials

a b

Wall thickness (mm)

1.50
1.13
0,75
0.38
0.00

c d

Figs 1-1-3a to 1-1-3d Insufficient thickness of the crown and sharp edges of the preparation caused fracture of the restor-
ation. (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.

Design tion process. If not processed properly, defects might be

Several mistakes can be made when designing a restor- created in the material, thus reducing the strength of the
ation. Insufficient dimensioning in crown walls or con- restoration (Fig 1-1-4). The manufacturer’s instructions
nectors of fixed dental prostheses is one reason for fail- must be meticulously followed.
ures. 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). Finishing
And finally, restorations made by materials, which require Materials, if machined, sintered, pressed, or polymer-
a thermal treatment should be designed with an even ized, must be finished with material specific tools and
wall thickness as far as possible to get a homogeneous appropriate speed, feed, and pressure of the tools to
stress distribution during cooling. That applies especially avoid damage at the surface. For ceramics, as an al-
for veneering ceramics, which must be layered in a uni- ternative a glaze firing (a heat treatment without addi-
form thickness and adequately supported by the frame- tional application of glaze) or glazing (a heat treatment
work both for metal-ceramic and all-ceramic bilayers. 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
Processing subsurface damage is not sufficiently eliminated by the
A shaping process always requires machining, a thermal finishing procedure and residual flaws potentially act as
treatment such as sintering or pressing or a polymeriza- an origin for microcracks.

6
 Current restorative materials Chapter 1   Part I

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 replace-
ment 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 mater-
ials to ceramics and resins. As a compromise metals may
be used when covered by tooth-colored veneers.
a

Surface area 9.938 mm2

Color
Coloring of resins and ceramics is obtained by using inor-
ganic pigments, mostly metal oxides (Fig 1-1-6).

Translucency
When there is no light absorption and no optical obs-
tacle in the material, light passes through a material like
a windowpane without being scattered. This effect is
called translucency (Fig 1-1-7).

b 2 mm

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 strengthen-
ing) add to the optical properties by scattering the light
as well (Fig 1-1-9).

Diffraction and opalescence c

At obstacles smaller than the wavelength, the light will
Figs 1-1-4a to 1-1-4c Fractured zirconia framework
be refracted and scattered in all directions. By diffraction
42 x x 32. (a) Framework after sintering, fracture occurred
white light is split into the spectral colors. The short blue between 41 and 31. (b) Light microscopy image of the
wavelength will be more deflected than the long red fractured area. The area was cut in the white state in or-
one. If the light source is behind the observer, mainly the der to separate the two pontics. Thus a crack was initiated,
blue light is seen; if the light source is behind the object which was not sealed during sintering. (c) Scanning electron
microscopy (SEM) of the fractured surface after sintering. The
mainly yellow and red colors are seen (Fig 1-1-10). The
formation of grains at the surface indicates that the fracture
effect is visible in the sky: small water drops scatter the occurred before sintering.
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.

7
Part I Chapter 1 Current restorative materials

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.

8
 Current restorative materials Chapter 1   Part I

Fig 1-1-6 Pigments used to produce the appropriate shades. Figs 1-1-7a and 1-1-7b Translucency of different ceramic
shades. (a) Dentin layer. (b) Enamel layer.

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

pending on the surface roughness and the incidence angle,
reflection is more or less pronounced.

Fluorescence Blending quality

The teeth glow when illuminated with ultraviolet light. Blending quality (“chameleon effect”) is the perception
Electrons are stimulated by the ultraviolet light and give that color differences between esthetic dental materials
off the energy by emitting visible light (Fig 1-1-11). and dental hard tissues appear smaller when the ma-
Materials for esthetic restorations must show a similar terials are viewed side-by-side than would be expected
effect. The name originates from the mineral fluorite, when viewed in isolation12.
where this effect was first observed.

9
Part I Chapter 1 Current restorative materials

a b

c d

e f

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) crystalliza-
tion.

10
   Chapter 1   Part II

PART II
CLINICAL
­PROCEDURES
STEP-BY-STEP

191
Part II Chapter 1 Minimally invasive restorations (veneers)

Amelogenesis imperfecta
(traditional veneers)

2.1.3 Traditional veneers for Diagnostics

restoration of amelogenesis The patient’s chief complaint was the dark and white-
imperfecta (six maxillary opaque staining of the maxillary incisors and canines.
However, she was also bothered by the asymmetrical gin-
anterior teeth) gival margin and the difference between the incisal edges
The following section describes the minimally invasive of tooth 11 and 23. Furthermore, the patient requested a
rehabilitation of a patient with amelogenesis imperfecta. correction of the overlapping of teeth 21 and 11.
Initially, all corrections were performed digitally by
Assessment and treatment planning means of an image editing software, Photoshop Elements
(Adobe Systems, San Jose, CA, USA), to visualize the
A 27-year-old healthy and almost caries-free woman patient’s treatment. Thereafter, all the planned changes
presented at the clinic seeking treatment for her dark were transferred into a wax-up. The position of the two
spots on the maxillary incisors and unesthetic gingival incisors was adjusted to better fit into the arch. At teeth
margin. A history of trauma, tetracycline staining, or 11 and 23, the gingiva on the plaster cast was modified in
fluorosis could be excluded. The clinical examination did order to simulate future crown lengthening (Fig 2-1-14).
not fully reveal the severity of the amelogenesis imper-
fecta nor the depth of the staining. In agreement with the Mock-up
patient, a step-by-step treatment plan was established.
The first step consisted of a home bleaching procedure. In order to transfer the simulations into the patient’s
If the stains were still present in the deeper layers of the mouth, the incisal edge of tooth 23 and the cusp of
tooth, a microabrasion technique would be applied. This tooth 24 had to be shortened. A resin cap served as a
procedure implies the removal of a 0.03 mm thin layer reference for the amount of incisal reduction required
of enamel. Depending on the result of microabrasion, (Acryline clear, Anaxdent, Stuttgart, Germany). Follow-
the third step would be undertaken: preparation of the ing preparation, the enamel was smoothened with fine-
teeth for ceramic veneers or crowns. The latter option grit diamond burs (Universal Prep Set, Intensiv, Montag-
would be considered if the enamel could not be etched nola Switzerland).
due to the hypoplasia. Since the patient did not like the A silicone index of the wax-up was prepared in order
appearance of her gingival margin, a crown-lengthening to directly fabricate a mock-up in the patient’s mouth
procedure was planned (Fig 2-1-13). The step-by-step (Memosil 2, Kulzer, Hanau, Germany). This silicone index
approach is described as follows. 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

208
 Minimally invasive restorations (veneers) 1   Part II
Chapter 1

b c

Figs 2-1-13a to 2-1-13c Pretreatment photographs (Figs 2-1-13a and 2-1-13b reproduced with permission from Büchi et al1).

209
Part II Chapter 1 Minimally invasive restorations (veneers)

a b

c d

Figs 2-1-14a to 2-1-14d Treatment planning (reproduced with permission from Büchi et al1).

a b

c d

Figs 2-1-15a to 2-1-15d Creation of mock-up (reproduced with permission from Büchi et al1).

210
 Minimally invasive restorations (veneers) 1   Part II
Chapter 1

result could now be discussed with the patient. The and to minimize the risk of recessions, a surgical suturing
mock-up also helped to estimate the extent of the crown material (size 4-0, Vicryl Ethicon, Johnson & Johnson,
lengthening that would be necessary (Fig 2-1-15). New Brunswick, NJ, USA) was used as the first retrac-
tion cord. The second retraction cord was the thinnest
Crown lengthening cord available on the market (000 Ultrapak, UP Dental,
Cologne, Germany). The preparation margins could be
On tooth 11, the gingival level had to be moved about sufficiently exposed with this technique (Fig 2-1-18).
1 mm apically and on tooth 23, about 1.5 mm apically.
The periodontal examination revealed that both teeth Fabrication of the veneers in the laboratory
had pseudo pockets. The vertical distance to the bone
was around 4 mm. A gingivectomy was carried out Before the dental technician initiated the fabrication of
without violating the biological width. The mock-up was the final restoration, all the information gathered during
used to verify the total prospective crown length. To the diagnostic phase was reviewed in order to ensure
ensure the success of the crown lengthening, the treat- that the prospective shape, position, and shade of the
ment plan now foresees a healing and stabilizing break teeth would fulfill the patient’s and the dental team’s ex-
of 2 months (Fig 2-1-16). pectations.
The first step for the final restoration was the fabrica-
Home bleaching tion of an alveolar cast. This cast offers a big advantage
in comparison with conventional saw-cut casts because
For the home bleaching procedure of all teeth, bleach- it preserves all the information on gingival morphology.
ing trays were fabricated in the dental laboratory (Erko- Refractory dies were manufactured (anaxVest, Anax-
dur, Pfalzgrafenweiler, Germany). A carbamide peroxide dent, Stuttgart, Germany) to guarantee the best possible
bleaching gel with a concentration of 15% (Opalescense, fit of the veneers.
Ultradent Products, South Jordan, UT, USA) was admin- For the fabrication of the veneers, a reverse planning
istered to the patient to be used for 2 hours a day for concept was applied. The laboratory work was guided by
the following 3 weeks. At the follow-up visit 1–2 weeks the information from the wax-up and mock-up, which
after the last bleaching, a major improvement in the was transferred with the aid of silicone indexes (Matrix
color was observed. The patient became more and more Form 60, Anaxdent). The ceramic masses were then ap-
aware of dental esthetics, noticed a positive change, and plied (Creation Classic, Willi Geller, Meiningen, Austria)
was motivated to seek further improvement. according to the custom shade that was developed by
the dental technician in collaboration with the patient,
Microabrasion and re-adjusted after the evaluation of the preparation.
After two dentin firings, the surface texture and the ­final
The next stage of the treatment plan was the application shape was done with diamond burs. Gold powder was
of the microabrasion technique (Opalustre, Ultradent used to highlight the microstructure of the surface and
Products). The most superficial enamel layer was etched make the texture clearly visible. The glaze firing was
and subsequently removed with an abrasive paste and followed by a mechanical polishing procedure. The pol-
a rubber cup. Again, in the follow-up visit, a clear im- ished veneers were removed from the refractory dies by
provement was noticed, but the stains could not be fully airborne-particle abrasion and cleaned in an ultrasonic
removed. Moreover, the patient wanted to continue in waterbed (Fig 2-1-19).
order to correct the position and shape of her anterior
teeth (Fig 2-1-17). Integration of the restoration

Veneer preparation and impression A try-in session was carried out where the veneers were
inserted with glycerin gel in order to improve color as-
A silicone index was fabricated based on the wax-up to sessment. Both the patient and the dental practitioner
facilitate the correct preparation of the teeth. The teeth expressed their satisfaction with the esthetic result. Sub-
13–23 were prepared in a minimally invasive way to re- sequently, in a dry environment (rubber dam) the fragile
ceive veneers. With an epigingival course solely in the ceramic veneers were cemented. The abutment teeth
enamel, the final impression was taken using two retrac- were etched with 35% phosphoric acid (Ultra-Etch, Ul-
tion cords. In order to avoid traumatization of the gingiva tradent Products) and bonded with a multistep ­adhesive

211
Part II Chapter 1 Minimally invasive restorations (veneers)

a b

Figs 2-1-16a and 2-1-16b Crown lengthening (reproduced with permission from Büchi et al1).

a b

Figs 2-1-17a and 2-1-17b Bleaching (reproduced with permission from Büchi et al1).

b c

Figs 2-1-18a to 2-1-18c Veneer preparation and impression (reproduced with permission from Büchi et al1).

212
 Minimally invasive restorations (veneers) 1   Part II
Chapter 1

b c

d e

Figs 2-1-19a to 2-1-19f Fabrication of the veneers (Figs 2-1-19a and 2-1-19b reproduced with permission from Büchi et al1).

213
Part II Chapter 1 Minimally invasive restorations (veneers)

Figs 2-1-20a and 2-1-20b Cementation of the veneers (reproduced with permission from Büchi et al1).

system (Syntac Classic, Ivoclar Vivadent, Schaan, Liech- was removed with rotating diamond instruments. The
tenstein). The bond was not light-cured in order not to occlusal and functional contacts were analyzed and no
compromise the fit of the veneers. The veneers were adjustments were necessary (Fig 2-1-20).
etched with hydrofluoric acid (9% concentration for All participants were very satisfied with the final
1 min) (Porcelain Etch, Ultradent Products). A primer treatment outcome. At a follow-up visit 18 months post­
(Monobond S, Ivoclar Vivadent) and a bonding system insertion, all the veneers looked well integrated without
(Heliobond, Ivoclar Vivadent) were applied. Then the any discoloration of the margin or chipping and fractures
veneers were cemented with a dual-curing resin cement of the ceramic (Fig 2-1-21). (Dental practitioner: Dr
(Variolink transparent, Ivoclar Vivadent). Excess cement D Büchi; Technician: MDT V Fehmer.)

214
 Minimally invasive restorations (veneers) 1   Part II
Chapter 1

215
Part II Chapter 1 Minimally invasive restorations (veneers)

c d

f g

216
 Minimally invasive restorations (veneers) 1   Part II
Chapter 1

Figs 2-1-21a to 2-1-21h Final esthetic outcome.

217
 Long-term outcomes of fixed ­restorations Part III

PART III
LONG-TERM
OUTCOMES
OF FIXED
­RESTORATIONS

679
 Long-term outcomes of fixed ­restorations Part III

3.1 Introduction influence of preparation depth (limited to enamel or

dentin) on the failure rates24.
In this chapter:
„ Tooth-supported veneers
„ Tooth-supported inlays and onlays 3.3 Tooth-supported inlays and
„ Tooth-supported SCs onlays
„ Endocrowns
„ Tooth-supported conventional FDPs Systematic review and meta-analyses aiming to evaluate
„ Tooth-supported cantilever FDPs the survival rates of both ceramic and resin inlays, on-
„ Resin-bonded fixed dental prostheses (RBFDPs) lays, and overlays reported an overall estimated 5-year
„ Implant-supported SCs survival rate of 95% for ceramic inlays and onlays based
„ Implant-supported FDPs on the observations of 5811 reconstructions and an es-
„ Implant-supported cantilever FDPs timated 10-year survival rate of 91% based on a sam-
„ Combined tooth-implant-supported FDPs ple of 2154 reconstructions25. For glass-ceramic inlays
and onlays, the 5-year survival rate was reported to be
A group of researchers from the Universities of Iceland, 96% (n = 1579) and the 10-year survival rate was 93%
Bern, Geneva, and Zurich in Switzerland, and from the (n = 605). For feldspathic porcelain inlays and onlays
National Dental Center in Singapore have published a the respective survival rates were 92% (n = 661) and
broad series of systematic reviews in recent years (see 91% (n = 538)25. The systematic review indicated that
Table 3-11 at the end of Part III)1–20. These are based the type of ceramic material (feldspathic porcelain vs
on consistent inclusion and exclusion criteria, methodol- glass-ceramic), the follow-up time (5 years vs 10 years),
ogies, and a statistical approach summarizing the avail- and the study setting (university vs private clinic) did not
able information on survival rates of different types of significantly affect the survival rates. The most frequent-
tooth- and implant-supported single crowns (SCs) and ly observed complications were related to ceramic frac-
fixed dental prostheses (FDPs). tures or chippings (4%), followed by endodontic com-
plications (3%), secondary caries (1%), and debonding
(1%). Severe marginal staining was not reported. No
studies were available that reported on resin-based in-
3.2 Tooth-supported veneers lays, onlays, and overlays, and fulfilled the inclusion cri-
A systematic review21, aiming to evaluate the 5- and teria of a mean follow-up time of at least 5 years25.
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 evaluat-
ing the outcomes of approximately 400 veneers. Two
3.4 Tooth-supported SCs
studies with a follow-up time exceeding 10 years could Recently, Sailer and co-workers15,16 published a system-
be included in the systematic review. The reported 10- atic review analyzing the survival and complication rates
year survival rates for these studies were 66% and 94%, of all-ceramic and metal-ceramic tooth-supported SCs.
respectively22,23. A more recent systematic review24 The meta-analysis included 17 studies reporting on 4663
­analyzing the survival of both glass-ceramic and feld­ metal-ceramic crowns and 55 studies reporting on 9493
spathic porcelain laminate veneers reported survival all-ceramic crowns (different types of ceramic used). For
rates of 94% for the glass-ceramic veneers, based on metal-ceramic SCs the estimated 5-year survival rate
676 veneers with a mean follow-up time of 7 years, and was 95.7% (Table 3-1)26–58 compared with an overall
of 87% for feldspathic porcelain veneers based on 1283 5-year survival rate of 94.5% for all-ceramic crowns.
veneers with a mean follow-up time of 8 years24. The The survival rates of all-ceramic crowns differed for vari-
difference in survival rates between glass-ceramic and ous ceramic types. The 5-year survival rates were 96.6%
feldspathic porcelain laminate veneers did, however, not for leucite or lithium-disilicate reinforced glass-ceramic
reach statistical difference. The most frequent complica- SCs (12 studies with 2689 SCs) (Table 3-1), 96.0% for
tions were: fracture or chipping (4%); debonding (2%); densely sintered alumina SCs (8 studies with 1099 SCs),
severe marginal discoloration (2%); endodontic compli- 94.6% for glass-infiltrated SCs (15 studies with 2389
cations (2%); and secondary caries (1%). The authors SCs), 93.8% for densely sintered zirconia SCs (8 studies
could not draw any concrete conclusion regarding the with 926 SCs) (Table 3-1), 90.7% for feldspathic or sil-

681
Part III Long-term outcomes of fixed ­restorations

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)

Study Year Total no. Mean No. of Total Estimated crown Estimated 5-y crown
pub- of crowns follow-up failures exposure annual failure rate survival rate (%)
lished time (y) time (y) (%)

Metal-ceramic tooth-supported SCs

Passia et al26 2013 100 4.3 9 434 2.07 90.2

Reitemeier et al27 2013 190 9.6 10 1832 0.55 97.3

Walton28 2013 2211 9.2 83 13,505 0.61 97.0

Rinke et al29 2013 50 3.0 1 146 0.68 96.6

Wolleb et al30 2012 249 5.3 3 1310 0.23 98.9

Örtorp et al31 2012 90 4.5 8 408 1.96 90.7

Vigolo & Mutinelli32 2012 20 4.8 0 95 0.00 100.0

Abou Tara et al33 2011 60 3.9 1 235 0.43 97.9

Naumann et al34 2011 52 3.4 6 176 3.41 84.3

Boeckler et al35 2009 41 2.8 2 114 1.75 91.6

Krieger et al36 2009 106 17.0 28 1598 1.75 91.6

Näpänkangas & 2008 100 18.2 21 1820 1.15 94.4

Raustia37

Güngör et al38 2007 260 7.0 7 1400 0.50 97.5

Eliasson et al39 2007 12 4.3 0 51 0.00 100.0

De Backer et al40 2007 1037 10.0 116 10,370 1.12 94.6

Marklund et al41 2003 42 5.0 3 190 1.58 92.4

Jokstad & Mjör42 1996 43 10.0 0 281 0.00 100.0

Total 4663 7.3 298 33,965

Summary estimate 0.88 95.7

(95% CI) (0.63–1.22) (94.1–96.9)

ica-based ceramic SCs (10 studies with 2208 SCs), and 3.5 Endocrowns
83.4% for composite crowns (1 study with 59 SCs)15,16.
Compared with metal-ceramic crowns, feldspathic or sil- Limited data are available on the long-term outcome of
ica-based ceramic SCs and composite crowns had signif- endocrowns. A systematic review conducted to evalu-
icantly lower 5-year survival rates. When the outcomes ate clinical (survival) and in vitro (fracture strength) out-
of anterior and posterior SCs were compared, no sig- comes of endocrowns compared to conventional crowns
nificant differences in the survival rates were found for was able to include three clinical studies, one prospective
metal­ -ceramic crowns, for leucite or lithium­ -disilicate and two retrospective. The included studies reported on
reinforced glass-ceramic crowns, and alumina and a total of 55 endocrowns inserted in the posterior area.
zirconia­-based crowns. Crowns made out of feldspathic The survival rates ranged between 94% and 100% at a
or silica­based ceramics, however, exhibited significant- rather short follow-up time of 6–36 months59. A recent
ly lower survival rates in the posterior ­region compared retrospective analysis of 235 molar endocrowns made
with the anterior region15,16. with a chairside CAD/CAM method reported a very pos-

682
 Avoiding and managing complications Part IV

PART IV
AVOIDING AND
MANAGING
COMPLICATIONS

703
Part IV Avoiding and managing complications

4.1 Introduction a 5-year observation period. The reduced number of com-

plications between the older and the more recent studies
In this chapter: might represent a positive learning curve in implant dentis-
„ Success of tooth- and implant-supported restorations try or enhanced components due to developments, caus-
„ Tooth-supported restorations ing less technical problems. Another systematic review9
„ Esthetic complications addressing the survival and complication rates of met-
„ Biological complications al-ceramic and zirconia-ceramic implant-supported single
„ Technical complications crowns concluded that 13.3% (95% CI: 9.0–19.3%) of
„ Implant-supported restorations the metal-ceramic and 16.2% (95% CI: 6.2–38.4%) of
„ Esthetic complications the zirconia-ceramic crowns experienced some kind of es-
„ Biological complications thetic, biological, or technical complications over an ob-
„ Technical complications servation period of 5 years9 (Table 4-2). Even though a
significant number of studies and meta-analyses4–20 have
Over the years, several definitions of success have been presented impressively high survival rates for both tooth-
proposed and used in restorative and implant dentis- and implant-supported restorations, it must be considered
try1–3. Instead of redefining old definitions or invent- that between 15% and 20% of the restorations were af-
ing new ones over and over again, it would make more fected by some kind of esthetic, biological, or technical
sense to move away from success definitions in general. complications. For example, a study evaluating the out-
Instead, clinicians should report whether the restorations come of implant-supported restorations performed at the
have remained unchanged and free of any complications University of Bern21 reported a failure rate of 2.5% but an
over the entire observation period. Hence, a “successful” additional 16.8% of the restorations had some kind of bio-
restoration would be a restoration that did not require logical and/or technical problems. Comparing the overall
any intervention during the entire observation period4. complication rates of tooth- and implant-supported restor-
ations, tooth-supported restorations were more frequently
affected by biological complications such as caries or loss
4.2 Success of tooth- and of pulp vitality, while implant-supported restorations were
implant-supported more affected by technical complications such as screw
restorations loosening or material fractures.

In systematic reviews5,6 addressing the survival and

complication rates of tooth-supported fixed dental pros-
theses (FDPs), only few of the included studies provided
4.3 Tooth-supported restorations
information on the number of restorations that remained 4.3.1 Esthetic complications
intact or without complications over the observation
period. The 5-year complication rate for tooth-sup- The incidence of esthetic complications (Fig 4-1), or res-
ported FDPs was estimated to be 15.7% (95% CI: 8.5– torations to be remade due to esthetic reasons, is rarely
27.7%)6,7 and for tooth-supported cantilever FDPs the reported in the dental literature for tooth-supported single
respective rate was 20.6%5,7 (Table 4-1). crowns (SCs) and FDPs11,12 (Table 4-1). A recent system-
In the early days of implant dentistry the overall num- atic review10 evaluating the outcome of tooth-supported
ber of biological and technical complications was rare- resin-bonded fixed dental prostheses (RBFDPs) reported
ly reported. A former systematic review4 addressing the that only 0.3% of the included restorations had to be re-
survival and complication rate of implant-supported FDPs done due to unacceptable esthetic appearance10. With
could only locate three studies that gave the exact number the materials and technology available today, dental pro-
of restorations with complications. The estimated 5-year fessionals should be able to imitate the natural appearance
complication rate was quite high, or 38.7% (95% CI: of a tooth in an acceptable way when manufac­turing a
33.2–44.7%)4. The most frequent complication report- tooth-supported restoration.
ed in these studies was loosening of prosthetic screws.
A more recent systematic review8 addressing exclusively The current concept of how to imitate the appearance
implant-supported metal-ceramic FDPs however conclud- of a natural tooth with a tooth-supported restoration
ed that 15.1% (95% CI: 11.2–20.4%) of the restorations is presented step by step in Part I, Chapters 6 and 9.
were affected by biological or technical complications over

704
 Avoiding and managing complications Part IV

Fig 4-1 Central incisors with tooth-supported SCs with un­ Fig 4-2 The pulp of tooth 22 became necrotic after trauma
acceptable esthetic outcome in a patient with a high smile line. and a fistula can be detected on the buccal mucosa.

4.3.2 Biological complications

Loss of pulp vitality
One of the most frequent biological complications affect-
ing 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 metal­
ceramic and zirconia-ceramic SCs11. For tooth-support-
ed 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 abut-
ment 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 peri-
odontitis, 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 re- Fig 4-3 A histological section showing the thickness of den-
stored with SCs, or serving as abutments for FDPs, are tin and enamel in relation to a traditional tooth preparation.
often at higher risk of losing pulp vitality due to a sig-
nificant 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 ing-out the dentin during the workflow and pulp cap-
depending on the age of the patient. The thickness ping in general should be avoided for abutment teeth.
also varies with tooth type and area of measurement If endodontic treatment is needed after the restoration
(Fig 4-3)23. Histological changes have been detected has been cemented then a conservative opening prep-
in the pulpal tissue if the remaining dentin thickness is aration should be implemented, leaving as much tooth
below 1 mm24. It is of great importance to avoid dry- substance as possible.

705