dental materi als 2 6 ( 2 0 1 0 ) 6775

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Fracture strength of prefabricated all-ceramic posterior
inlay-retained fixed dental prostheses
Christian Mehl

, Klaus Ludwig, Martin Steiner, Matthias Kern

Department of Prosthodontics, Propaedeutics and Dental Materials, Dental School, Christian-Albrechts University Kiel,
Arnold-Heller-Strae 16, 24105 Kiel, Germany
a r t i c l e i n f o
Article history:
Received 19 December 2008
Received in revised form
23 July 2009
Accepted 29 July 2009
Keywords:
Prefabricated restorations
FDP
Fracture load
Zirconia ceramic
Y-TZP
Inlay-retained
Composite
a b s t r a c t
Objectives. The purpose of this in vitro study was to compare the centric and eccentric
quasi-static and fatigue fracture strength of industrially prefabricated resin-bonded three-
unit inlay-retained xed dental prostheses (IPIRFDPs). The IPIRFDPs consisted of industrial
manufactured yttria-stabilized tetragonal zirconia (Y-TZP) frameworks with an industrially
added microhybrid composite veneering.
Methods. Identical IPIRFDP-models consisted of a second premolar, a missing rst molar
and a second molar (CoCrMo alloy) integrated in a low melting alloy base. Roots were
covered with a soft silicone layer to simulate an articial parodontium. Premolars had an
occlusaldistal inlay-preparation and molars a mesialocclusal inlay-preparation. Forty-two
IPIRFDPs with a connector size of 9mm
2
and a framework connector size of 4.7mm
2
were
cemented adhesively to the IPIRFDP-models. Quasi-static fracture strength was tested with
centric (n=12) and eccentric (n=6) loading in a universal testing machine at a cross-head
speed of 1mm/min. Fatigue fracture strength was tested at 1200N with centric loading
(n=12) and at 600/500N with eccentric loading (n=6) at a frequency of 0.5Hz. Statistical
comparison of groups was performed with the MannWhitney U test.
Results. Quasi-static fracture strength differed signicantly between centric (1749N) and
eccentric loading (880N, p<0.001). Mean loading cycles until fracture were 4432 for centric
loading at 1200N compared to only 3 and 410 loading cycles for eccentric loading at 600 and
500N, respectively.
Signicance. Considering the maximum chewing forces in the molar region, it seems clini-
cally possible to use prefabricated IPIRFDPs with Y-TZP as a core material with a framework
connector size of 4.7mm
2
.
2009 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.
1. Introduction
Among the permanent dentition, the rst molar has the high-
est incidence of tooth loss due to caries, endodontic reasons,
tooth fractures and periodontal diseases [1,2]. However the
rst molar has a signicant role in maintaining the intercus-
pal and condylar position [3,4]. Therefore the replacement of a

Corresponding author at: Private Practice, 10 Brook Street, W1S 1BG London, United Kingdom. Tel.: +44 845 0944004; fax: +44 845 0943003.
E-mail address: cmehl@proth.uni-kiel.de (C. Mehl).
missing molar might be animportant considerationto prevent
further functional problems [2,4].
The traditional way of molar replacement is either a xed
dental prosthesis (FDP) or an implant retained crown [5]. Irre-
spective of the type of FDP (porcelain fused to metal vs.
all-ceramic crown) the clinician uses, a crown preparation is
always a risk to pulp vitality and may lead to pulpal reactions
inthe long term[6]. Approximately6373%of the coronal tooth
0109-5641/$ see front matter 2009 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.dental.2009.07.013
68 dental materi als 2 6 ( 2 0 1 0 ) 6775
Table 1 Materials used in this study.
Product Material type Manufacturer Batch no.
Gapless hydrouoric etchant Hydrouoric etchant Gapless GmbH, Umkirch, Germany LOT 07161
Calibra Silane Coupling Agent Silane Dentsply DeTrey, Konstanz, Germany LOT 070511
XP-Bond Bonding agent Dentsply DeTrey, Konstanz, Germany LOT 0702001786
SCA Self-curing activator Dentsply DeTrey, Konstanz, Germany LOT 070119
Calibra esthetic resin cement Self-curing resin based
dental luting cement
Dentsply DeTrey, Konstanz, Germany LOT 070525 (base)
Base/Catalyst LOT 0705291 (cat.)
Airblock Oxygen blocking gel Dentsply DeTrey, Konstanz, Germany LOT 072161
Gapless FPD Prefabricated all-ceramic
inlay-retained three-unit
FPDs
Gapless GmbH, Umkirch, Germany LOT 10084-1-2+3/88,
LOT 10084-1-2+3/89
structure is removed when teeth are prepared for crowns [7].
Regarding these facts it seems desirable to adapt the type of
abutment preparation to the extent of sound tooth structure
after caries removal not only for a single tooth restoration, but
also for abutment preparations for FDPs. Therefore, if a patient
rejects an implant treatment and enough sound tooth struc-
ture is available it would be desirable to restore a missing tooth
with an inlay-retained FDP instead of a crown-retained FDP.
Clinical evaluations of inlay-retained three-unit FDPs
showed a failure rate of 10% [8] after 9 months (Empress II)
and 13%[9] after 37 months (IPS e.max Press, Ivoclar-Vivadent,
Schaan, Liechtenstein). In both studies the failure was evoked
by debonding or a combination of both debonding and frac-
ture. Despite these failure rates the inlay-retained FDP could
be a favorable treatment option with respect to biological [6,7]
and economic reasons [5].
Recently, yttria-stabilized tetragonal zirconia (Y-TZP)
has been made available to dentistry through CAD/CAM-
techniques [10] and provides excellent mechanical perfor-
mance, superior strength and fracture resistance compared
to other ceramics [11]. Therefore Y-TZP ceramic might be an
alternative material for the fabrication of inlay-retained FDPs
to minimize the risk of fracture.
In the present study the quasi-static and fatigue fracture
strengths of industrially prefabricated inlay-retained FDPs,
consisting of Y-TZP frameworks with a microhybrid compos-
ite veneering, were determined. The null hypothesis tested
was that centric and eccentric loading does not inuence their
fracture strength. In addition, it should be evaluated whether
these FPDs provide fracture strengths, which make them a
viable treatment option to replace a missing rst molar during
a single patient appointment.
2. Materials and methods
All materials used and batch numbers are summarized in
Table 1.
2.1. Prefabricated all-ceramic three-unit inlay-retained
xed dental prostheses
In this study industrially prefabricated three-unit inlay-
retained xed dental prostheses (IPIRFDPs) were used
(Gapless, Umkirch, Germany, Fig. 1). They are designed to
restore upper or lower rst molars chairside in one session.
Three sizes (9, 10, and 11mm pontic size) and three different
colors (A, B, C, Gapless colors) are available.
The IPIRFDPs consist of an industrially manufactured
yttria-stabilized tetragonal zirconia (Y-TZP) framework, a
thin layer of feldspathic ceramic and microhybrid composite
veneering [12]. The Y-TZP framework has a connector height
of 2.5mm (4.7mm
2
) and provides a high fracture strength of
IPIRFDPs, which was in previous tests 1200N [13]. A thin layer
of feldspathic ceramic is red to the framework in order to
increase the bond strength between the Y-TZP framework and
the veneering microhybrid composite and to enable the den-
tist to etch the surface of the connector area with hydrouoric
acid in preparation for the adhesive cement.
The microhybrid composite veneering is added industri-
ally to the framework. The composite has a connector height
of 2.3mmabove the Y-TZP framework, which leads to an over-
all connector height of 4.8mm (9mm
2
). The height of the
composite veneering in the pontic region of 2.9mm above
and 2.3mm below the framework allows the dentist to adjust
the base and the occlusal area of the pontic. The veneer-
ing microhybrid composite contains 24% (weight) organic
matrix (Bis-GMA and Diurethandimethacylat) and 75% silane
Fig. 1 The industrial prefabricated three-unit
inlay-retained FDP with a framework made of
yttria-stabilized tetragonal zirconia and microhybrid
composite veneering. The height of the veneering
microhybrid composite is 2.9mm above and 2.3mm below
the framework, which leads to an overall connector size of
9 and 4.7mm
2
framework connector size.
dental materi als 2 6 ( 2 0 1 0 ) 6775 69
coated, inorganic siliciumdioxid ller particles, with a size of
0.043m and an average ller particle size of 0.7m. Accord-
ing to the manufacturer, the microhybrid composite resin
has a fracture strength of 145MPa and an elastic modulus of
9700MPa (three-point exural strength (DIN 13922/EN 24049)).
The shear bond strength of the veneering microhybrid com-
posite to the feldspathic layer on the Y-TZP framework was
900N [14]. The IPIRFDPs have been used as delivered without
any modication.
2.2. Master models
Articial teeth (No. 15 and 17, KaVo, Biberach, Germany) were
integrated in an otherwise toothless KaVo model. A box-
shaped inlay-preparation (3

divergence, 4.8mmheight, 1mm

minimal depth) was performed with a special diamond bur
(100m grained) according to the manufacturers instructions
(Gapless preparation set, Gapless). The teeth were duplicated
(Speedy-duplication-technique [15]) and afterwards cast in a
CoCrMo alloy (Wironit, Bego, Bremen, Germany). To create
the master models one IPIRFDP was cemented provisionally
(Freegenol, GC, Tokyo, Japan) to the prepared articial teeth in
the KaVo model and teeth and IPIRFDP afterwards duplicated
together (Transpaduplisil, Wichnalek, Augsburg, Germany).
The roots of the manufactured metal teeth were covered with
a 200m thick soft silicone layer (Erkoskin, Erkodent, Pfalz-
grafenweiler, Germany) to provide an articial periodontal
membrane, which allowed a periodontal movement of 50m
[16]. Tooth mobility was controlled with an electronic dis-
placement transducer under a horizontal load of 20N (W1T3,
HBM, Darmstadt, Germany). Next, the prepared teeth were
insertedintothe duplicatedformof the master models andthe
duplicated form lled with a low melting alloy (MCP 70, HEK,
Fig. 2 Schematic diagram of a test specimen. Abutments
were made from a cobalt-chromium alloy. Roots were
covered with a 200m thick soft silicone layer. The basis
around the teeth was made from a low melting alloy (MCP
70). The dimensions (mm) of the prefabricated
inlays-retained FDP are shown.
Lbeck, Germany). Fig. 2 exemplarily shows the schematic dia-
gram of one specimen (IPIRFDP-model) and Fig. 3 explains the
workow from master model to specimen.
According to this procedure, 42 identical specimens with
resilient supported teeth were fabricated and divided into the
following four groups: centric (group CQSFS) and eccentric
Fig. 3 Workow from master model to specimen: (A) Preparation of the inlay cavities with the preparation guide (Gapless).
(B) Both teeth were duplicated in cobalt-chromium alloy using a wax duplication technique. (C) After the roots of the metal
dies were covered with an articial periodontal membrane, they were inserted in a duplication form and the form was lled
with a low melting alloy. (D) Specimen removed from the duplication form and after cleaning procedure ready for adhesive
cementation.
70 dental materi als 2 6 ( 2 0 1 0 ) 6775
(group EQSFS) quasi-static fracture strength testing and cen-
tric (group CFFS) and eccentric (group EFFS) fatigue fracture
strength testing.
2.3. Adhesive cementation
For all groups the surfaces of the IPIRFDPs were conditioned
by etching with 5% hydrouoric acid (Gapless) for 30s and an
application of silane coating (Calibra Silane, Dentsply DeTrey,
Constance, Germany) for 1min. The inlay cavities of the metal
abutments were air-abraded with 110m alumina particles
for 10s at 0.3MPa pressure. To ensure that the air-abraded
surface was free of loose alumina particles, the metal abut-
ments were ultrasonically cleaned for 3min in isopropanol
(96%) [17]. In previous studies [1820] this procedure showed
no negative effect on the bond strength of the luting resin.
Finally, XP-BOND and SCA (Dentsply DeTrey) were mixed (1:1),
applied to the IPIRFDPs and the inlay cavities for 3min, but not
light cured. After these conditioning procedures IPIRFDPs of
all groups were cemented to the metal abutments with com-
posite resin cement (Calibra, Dentsply DeTrey) according to
the manufacturers recommendations. After removing excess
luting resin, an air-blocking gel (Airblock, Dentsply DeTrey)
was applied to the bonding margins and the luting resin was
then light cured for 40s at each of three different sites. The
cemented IPIRFDPs were stored in distilled water for 3 days at
37

C.
2.4. Testing procedures
A summary of all testing procedures and parameters is given
in Fig. 4. The centric quasi-static fracture strength (group
CQSFS, n=16) was testedina universal testing machine (Zwick
BZD10/TNZA, Ulm, Germany). The load was applied perpen-
dicular to and at the centre of the IPIRFDPs using a stainless
steel ball (diameter 5mm) at a cross-head speed of 1mm/min
until fracture occurred. To avoid primary cracks at the point
of loading a 0.5mm foil of Makrolon (Macrolon, Bayer, Lev-
erkusen, Germany) was inserted for all groups.
The eccentric quasi-static fracture strength (group EQSFS,
n=8) was also tested in the universal testing machine (Zwick
BZD10/TNZA), but this time the load was applied 3mmeccen-
tric to the mesio-distal direction at the ssure between the
mesiobuccal and distobuccal cusp of the IPIRFDPs. A stainless
steel stamp (diameter 1.5mm) was used at a cross-head speed
of 1mm/min until fracture occurred.
The centric fatigue fracture strength (group CFFS, n=12)
was tested in a universal testing machine (Zwick 1435, Ulm,
Germany) and the specimen subjected to a dynamic load
between 10 and 1200N with a frequency of 0.5Hz until the
rst fracture event occurred. As before, the load was applied
perpendicular to and at the centre of the IPIRFDP pontic using
a stainless steel ball (diameter 5mm) and a 0.5mm foil of
macrolon. The steel ball was not lifted from the IPIRFDPs dur-
ing loading. With these settings and the application of a basic
loading of 10N an impact pulse could be avoided.
The eccentric fatigue fracture strength (group EFFS, n=6)
was also tested in a universal testing machine (Zwick 1435,
Ulm, Germany). The specimens were subjected to a dynamic
load between 10 and 600N with a frequency of 0.5Hz until
the rst fracture event occurred. As in group EQSFS the load
was applied 3mm eccentric to the mesio-distal direction at
the ssure between the mesiobuccal and distobuccal cusp of
the IPIRFDPs using a stainless steel stamp (diameter 1.5mm).
Fig. 4 Flow chart describing all the test procedures and their parameters.
dental materi als 2 6 ( 2 0 1 0 ) 6775 71
Table 2 Medians of centric and eccentric quasi-static fracture strengths of groups CQSFS (n=16) and EQSFS (n=8) in N.
Group CQSFS Group EQSFS
Batch no. LOT 10084-1-2+3/88 LOT 10084-1-2+3/89 Pooled LOT 10084-1-2+3/89
Median 1504 1789 1749 880
25th percentile 1433 1674 1477 804
75th percentile 1910 1869 1891 918
Group CQSFS, centric quasi-static fracture strength; group EQSFS, eccentric quasi fracture strength. No difference could be found between the
specimen of the two batch numbers of group EQSFS and therefore the results where pooled (MannWhitney test, p=0.49).
At the top load of 600N the fractures occurred for the rst two
specimens after a few trials and therefore the top load was
reduced to 500N (n=4) for group EFFS.
2.5. Statistical analyses
Due to the small group sizes and abnormally distributed data
in some groups non-parametric testing was calculated by
comparison of medians with the MannWhitney U test. All
hypothesis testing was conducted at a 95%level of condence.
3. Results
3.1. Quasi-static fracture strength
The medians of the quasi-static fracture strengths of all
groups are shown in Table 2. The fracture strength was tested
until the specimen fractured completely, previous fractures of
the veneering ceramic have not been considered.
For group CQSFS no statistical differences for the medians
(p=0.49) between the two batch numbers (batch no. 1=LOT
10084-1-2+3/88, n=8; batch no. 2=LOT 10084-1-2+3/89, n=8)
could be found and therefore the results for group CQSFS for
both batch numbers have been pooled. The median quasi-
static fracture strength for group CQSFS was 1749N and for
group EQSFS (n=8) 880N. Examples for typical fractures are
shown in Fig. 5A and C.
3.2. Fatigue tests
The medians and single values of loading cycles performed
until the rst fracture occurred are shown for all groups in
Table 3. For group CFFS no statistical differences for the medi-
ans (p=0.69) betweenthe twobatchnumbers (batchno. 1, n=6;
batch no. 2, n=6) could be found and therefore the results for
group CFFS have been pooled.
Two fracture events of the veneering composite occurred
in group CFFS (specimens 2 and 5 of batch no. 2) before the
framework fractured. Statistical testing revealedno signicant
difference between framework and veneering composite frac-
ture (p0.05) and therefore all 12 single values of group CFFS
have been analyzed. The mean number of loading cycles for
group CFFS was 4432.
Fig. 5 Selected samples of fractured IPIRFDPs. The typical fracture lines are shown by black lines: (A) Specimen tested with
centric quasi-static load and (B) fatigued with a centric load. The veneering composite fractured rst, especially the buccal
lamella, directly followed by a central fracture of the framework. (C) Specimen tested with eccentric quasi-static load and (D)
fatigued with an eccentric load. When an eccentric load was applied, the connectors fractured rst.
72 dental materi als 2 6 ( 2 0 1 0 ) 6775
Table 3 Medians and single values of loading cycles for the rst fracture event for groups CFFS (n=12) and EFFS (n=2 for
600N, n=4 for 500N) in N.
Dynamic load Group CFFS Group EFFS (no. 1+2 at 600N, no. 26 at 500N)
Batch no. LOT 10084-1-2+3/88 LOT 10084-1-2+3/89 LOT 10084-1-2+3/89
1200N (n=12), median 1371 2660
No. 1 91 4976 1
No. 2 14,487 30
a
5
No. 3 205 345 101
No. 4 9230 12,069 32
No. 5 2008 27
a
703
No. 6 735 8983 805
Mean 4432
b
3
c
410
d
Group CFFS, centric fatigue fracture strength; group EFFS, eccentric fatigue fracture strength.
a
Fracture of the veneering composite, no framework fracture.
b
Mean at a tested load of 1200N is shown. Mean calculated for specimens of both batch numbers as no difference between the specimens of
the batch numbers was found (MannWhitney test, p=0.69).
c
Mean at a tested load of 600N is shown.
d
Mean at a tested load of 500N is shown.
For group EFFS the number of loading cycles for 600N(n=2)
loading force was one and ve loading cycles for specimens 1
and 2 and therefore the applied loading force was reduced to
500N. Since the number of specimens tested was too small to
calculate the median, the mean of 410 loading cycles was cal-
culated for group EFFS at 500N. Examples for typical fractures
are shown in Fig. 5B and D.
4. Discussion
In this study industrially prefabricated three-unit inlay-
retained xed dental prostheses (IPIRFDPs, Gapless) were
used. They are designed to restore upper or lower rst
molars chairside in one session. Identical shape of all sam-
ples assured identical stress conditions for all samples, since
different geometry of inlay-retained FDPs can cause differ-
ent fracture patterns [16]. Additionally, to minimize variable
factors and in an effort to get homogenous results in the
present in vitro study, standardized master teeth were pre-
pared with a preparation positioning guide (Gapless) and
then duplicated. Therefore the IPIRFDPs could be bonded to
nearly identical metal casts using the protocol described in
Section 2.
The Y-TZP frameworks of the IPIRFDPs were industrially
manufactured. Y-TZP ceramic has proved its superior material
characteristics invarious studies [11,16]. It consists of partially
stabilized zirconia particles (95% ZrO
2
partially stabilized by
5% Y
2
O
3
) with a mean grain size of 0.4m. These particles are
densely sintered, resulting in a nal microstructure in which
voids, aws and cracks are reduced to a minimum[21]. For this
reason and because of the transformation-toughening mech-
anism Y-TZP frameworks offer remarkable fracture strengths
[16,21].
The veneering of the framework was conducted industri-
ally by adding a microhybrid composite. The wear resistance
of this composite has shown to be comparable to other micro-
hybrid composites [22]. Because of a reported high incidence
for chipping of veneering ceramics [23] this material might
offer an approach to reduce chipping. However, any repair or
adjustment can easily be performed by adding or removing
composite [24,25].
Newdental materials incombinationwithnewpreparation
designs have to be tested before they can be recommended
for clinical use [16]. It is not known what fracture resistance is
neededtoachieve a goodlong-termoutcome of IPIRFDPs inthe
molar region. Numerous authors have investigated the maxi-
mum bite forces during mastication and mean values for the
maximumbite force level varied from216 to 847N[2628]. The
highest bite force was found in the rst molar region. Review-
ing the literature, Krber and Ludwig [29] summarized that
posterior FDPs should be strong enough to withstand a load
of 500N.
Additionally, cyclic fatigue loading caused by mastication
canconsiderably weakenthe fracture resistance of all-ceramic
restorations [30]. Under the conditions of the oral environ-
ment, the inherent aws of ceramic materials act as the origin
of crack propagation and can grow to critical sizes [21]. The
endurance limit for fatigue cycling that can be applied to den-
tal ceramics is approximately 50% of the maximal fracture
strength [31]. Therefore it seems reasonable to assume that
an initial fracture resistance of 1000N should be required for
a favorable clinical prognosis of posterior inlay-retained FDPs
withall-ceramic frameworks. With1749Nthe medianof group
CQSFS exceeded this threshold value by far. Other studies
[16,21,32] with centric Y-TZP framework testing showed frac-
ture strength values of 10003000N. In a comparable study
[16] Y-TZP inlay-retained FDPs with a connector size of 9mm
2
showed values for centric quasi-static fracture strength test-
ing of 3100N.
However, the way of testing Y-TZP frameworks centrically
favors the characteristics of this material [16,21] and it does
not correspondto the reality of the oral cavity, where forces are
not always applied perpendicular to the axis of a restoration.
Therefore in group EQSFS specimens were tested eccentri-
cally to the mesio-distal axis of the IPIRFDPs and showed a
signicantly reduced median fracture strength of only 880N.
Therefore, the hypothesis that centric and eccentric loading
dental materi als 2 6 ( 2 0 1 0 ) 6775 73
does not inuence the fracture strength has to be rejected. So
IPIRFDPs with a framework connector size of 4.7mm
2
seem to
be sufciently strong regarding the threshold value for centric
loading, but must be reviewed critically when eccentric forces
occur.
Additional to quasi-static fracture strength testing, the
IPIRFDPs were fatigued under centric and eccentric loading.
Since the testing in a chewing simulator needs too many
cycles to fatigue Y-TZP FDPs and an impact pulse should be
avoided [16], specimens were tested in a universal testing
machine until the rst fracture occurred. The specimens in
groups CFFS/EFFS were tested at a maximum load of 70% of
the median centric/eccentric quasi-static values. Specimens
of group CFFS were fatigued at a maximum load of 1200N
after 4432 cycles. For eccentric fatigue tests (group EFFS) a
maximum load of 600N was chosen initially, but the rst two
specimens fractured after one and ve cycles, respectively.
Therefore the maximum load was reduced to 500N and due
to the small number of specimens the mean was calculated
at 410 cycles. However, the small number of specimens (n=2
for 600N, n=4 for 500N) in group EFFS is a limitation of this
study.
Additionally, it was detected by visual inspection, that with
the exception of two specimens all IPIRFDPs fractured com-
pletely, which speaks for good adhesion of the veneering
composite to the framework (examples for typical fractures
see Fig. 5). Besides this fact, it could also be detected that the
buccal lamella of the veneering material not only fractured
when it was stressed eccentrically, but also when stressed
centrically. Dynamic loading, e.g. a leading function during
mastication or parafunctions, should be monitored during
clinical placement of the restoration.
Although in vitro studies are important for preclinical test-
ing, the transferability of the results of an in vitro study to
the clinical situation is limited. It was shown that the modu-
lus of elasticity of the luting resin and the abutment material
inuenced the fracture resistance of all-ceramic crowns [33].
In accordance with this outcome another study [34] showed,
that fracture force was found to be signicantly greater for
all-ceramic single crowns xed on CoCrMo alloy materials
(1838N) than for crowns on human teeth (888N). However,
these studies are transferable only in part to the present study,
because the support of the abutment material by a full crown
and an inlay retainer differs substantially. However, also in
the present study, the stiffness of the metal abutment might
have inuenced the result, because of the different modulus
of elasticity of CoCr alloy (180240GPa), dentin (1520GPa) and
enamel (5085GPa). Further, it has been demonstrated that
abutment mobility is a decisive factor inthe evaluationof frac-
ture strength, and when a small amount of abutment rotation
is allowed, failure is more likely [35]. In this context Kappert
et al. reported a mean fracture strength of 703N for three-unit
In-Ceram posterior FDPs with physiological abutment mobil-
ity in comparison to 2225N for the group without abutment
mobility [36]. Therefore, according to other studies [37,38] in
the present study a 200mthick soft silicone layer was used to
generate a tooth mobility of 50m to simulate a physiological
tooth mobility of grade 0 [39].
To the knowledge of the authors, clinical studies deter-
mining the success rate of inlay-retained FDPs with Y-TZP
frameworks are not available. However, a prospective clinical
evaluation was published recently to showthe long-termclin-
ical behavior of resin-bonded xed dental prostheses (RBFDPs)
with a retentive, minimally invasive preparation design [40].
Since 1985, 232 RBFDPs with a retentive preparation design
were placedand84 RBFDPs couldbe re-evaluatedin2005/2006.
The total of 12 failures was observed and resulted in a survival
rate of 77%after 10 years. However, only four catastrophic fail-
ures occurred. After re-bonding or reparation the survival rate
increased to 88%. Interestingly, RBFDPs made of a titanium
alloy exhibited a statistically signicantly higher survival rate
than RBFDPs made of a non-precious CoCr alloy in terms of
all failures. As mentioned before CoCr alloys have a modu-
lus of elasticity of 180240GPa, which is comparable to Y-TZP
ceramic (210GPa). In contrast to that titanium based alloys
have an elastic modulus of 75GPa. A possible explanation for
the signicantly lower failure rate might be that inlay-retained
FDPs made of titanium based alloys are balancing the tooth
mobility to a certain extent in comparison to rigid materials
like Y-TZP or CoCr alloys.
On the other hand, a prospective clinical cohort study [41]
determined the success rate of three to ve-unit posterior
FDPs with Y-TZP frameworks after 3 years of function. In this
study 36 patients with 46 FDPs were available for examina-
tion after 36 months. No fractures occurred, rendering a 100%
success rate of the Y-TZP frameworks. Seven FDPs had to be
replaced because of biological and technical problems. Thus,
the survival rate was 84.8%. Secondary caries was found in
10.9% of the FDPs, and chipping of the veneering ceramic was
foundin13.0%. Asimilar study [42] showedcomparable results
(mean observation time 31 months) for 20 three-unit poste-
rior FDPs with a survival rate of 100% and minor chipping of
the veneering ceramic of 25%. Even though the design of the
FDPs was different in these in vivo studies, compared to the
present in vitro study, all studies showed that Y-TZP frame-
works demonstrated sufcient stability for replacement of
posterior teeth. Since the veneering of the restorations seems
to be a limiting factor, an easily reparable composite veneer-
ing with wear characteristics similar to human enamel might
be considered as an option for veneering inlay-retained FDPs.
However, the prospective clinical testing of the industrially
prefabricated inlay-retained FDPs has to be performed before
they can be recommended for general clinical use.
5. Conclusions
Under the limitations of the study the following conclusions
can be drawn:
- Considering the maximum bite forces in the molar region,
it seems possible to use yttria-stabilized tetragonal zirconia
ceramic with a connector size of 4.7mm
2
as a framework
material.
- The prefabricated all-ceramic inlay-retained FDPs seem
suitable for restoring missing upper and lower rst molars.
- It seems advisable to remove any contact points in eccentric
static or dynamic occlusion.
74 dental materi als 2 6 ( 2 0 1 0 ) 6775
Acknowledgement
The authors are grateful to Mr. Ulrich Wennemann (Gap-
less, Umkirch, Germany) for providing the prefabricated
all-ceramic inlay-retained FDPs used in this study.
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