Q U I N T E S S E N C E I N T E R N AT I O N A L

RESTORATIVE DENTISTRY

Aristidis A.
Galiatsatos

Clinical evaluation of anterior all-ceramic

resin-bonded xed dental prostheses
Aristidis A. Galiatsatos, DDS, Dr Dent1/Dimitra Bergou, DDS2
Objectives: All-ceramic resin-bonded xed dental prostheses
(RBFDPs) were introduced as a conservative treatment many
years ago. The purpose of this study was to evaluate for 8 years
the clinical survival of RBFDPs made with a conventional tworetainer design. Method and Materials: A total of 54 anterior RBFDPs were made from the glass-inltrated alumina
ceramic In-Ceram. The restorations were placed in 49 patients,
aged 18 to 60 years, by a single operator using the same clinical procedure. The restorations were examined for debonding,
fracture rate, caries, and patient acceptance. All restorations

were examined clinically at 1, 2, 4, 6, and 8 years after placement. Results: At 8 years, the success rate was 85.18%. Patient
acceptance was very encouraging and dental caries were not
detected with any abutment. Two restorations debonded during the evaluation period and fracture of porcelain occurred in
six restorations (two total fractures and four partial fractures).
Conclusion: All-ceramic RBFDPs made from high-strength
oxide ceramics oer an eective conservative treatment for
replacing anterior teeth. (Quintessence Int 2014;45:914; doi:
10.3290/j.qi.a30766)

Key words: clinical performance, esthetics, fracture, In-Ceram system, resin-bonded FDP

Conventional resin-bonded xed dental prostheses

(RBFDPs) with metal framework have been used in dental practice for many years as alternatives to conventional FDPs when abutments are intact or exhibit only
minimal caries lesions.1-5 The longevity of the prostheses has been improved since the initial use as a result of
preparation of the abutment teeth and a variety of new
methods to increase mechanical and chemical resin-tometal retention.2,6-9
The most common type of failure with RBFDPs is the
debonding of the cast metal framework from the luting
cement, but debondings of the luting cement from the
enamel surface have also been reported.10-13 These res1

Assistant Professor, Department of Dental Technology, Division of Fixed Prosthodontics, Technological Educational Institution of Athens, Athens, Greece.

Private practice, Athens, Greece.

Correspondence: Dr Aristidis A. Galiatsatos, 60 Str. Rogakou Str., 15125

Athens, Greece. mail: agal@teiath.gr

VOLUME 45 NUMBER 1 JANUARY 2014

torations may present disadvantages with regard to

esthetics and biocompatibility.14-16 The esthetically
unsatisfactory grayish shine through of metal is a
common problem in the anterior region. The biocompatibility of certain nonprecious alloys has been questioned because of their corrosive, allergenic, and even
mutagenic potentials.14-18
To overcome these problems, all-ceramic RBFDPs
were introduced.19-21 It has been shown by several
authors that the aluminum oxide ceramic In-Ceram
(Vita Zahnfabrik) has much better physical properties
than other ceramic or glass materials.22-27 For this reason, RBFDPs have been suggested as an alternative to
traditional resin-bonded restorations, which use a
metal framework.25 The recommended design of InCeram prostheses is similar to the design of the conventional metal-ceramic resin-bonded restorations.25
Several studies on all-ceramic RBFDPs have been

Q U I N T E S S E N C E I N T E R N AT I O N A L
Galiatsatos / Bergou

Table 1

Age and gender of patients

Age (years)

Men

Women

Total

1830

10

12

22

3140

16

4150

5160

Total

21

28

49

Table 2

Distribution of the restorations

Arch location

No. of RBFDPs

Replaced
central incisors

Replaced
lateral incisors

Maxilla

30

20

Mandible

24

15

Total

54

35

19

10

reported and the observation periods and success rates

in these reports vary considerably.
The purpose of this study was to add to the knowledge of all-ceramic RBFDPs by evaluating the longterm clinical survival of such restorations.

METHOD AND MATERIALS

The study population consisted of 49 patients. There
were 28 women and 21 men, ranging in age from 18 to
60 years (Table 1). Patient selection was accomplished
according to preestablished criteria. Abutments were
intact and caries-free, or exhibiting only minimal lesions
that did not interfere with bonding, and tooth alignment
was acceptable. Patients who exhibited bruxism, deep
bite situation, severe inammation, poor oral hygiene, or
a high caries rate were ineligible for this study. Only
patients with one missing mandibular or maxillary anterior tooth (central or lateral incisor) were selected. Five of
them had both one missing maxillary and one missing
mandibular anterior tooth. None of the selected patients
dropped out or were dismissed. In the majority of the
cases, an implant-supported prosthesis was not advisable as available bone volume was minimal, or the adjacent root was in close proximity.28 Also, many patients
declined the several surgical procedures required.

10

Fig 1 Preoperative view of a patient with congenitally missing

lateral incisor.

The selected patients were provided with a total of

54 anterior RBFDPs with a conventional two-retainer
design in a private practice. The glass-inltrated aluminum ceramic In-Ceram technique was selected to fabricate the above restorations. The distribution of the
restorations is presented in Table 2. The reasons for the
loss of teeth in this study were congenitally missing
teeth, trauma, dental caries, endodontic complications,
and periodontal disease (Fig 1).
All procedures were performed by a single investigator, and all materials were mixed and used according
to the recommendations of the manufacturers. Shades
were matched with the Vita-Lumin Vacuum shade
guide (Vita Zahnfabrik).
All abutments were prepared according to common
principles for these kinds of restorations.25,29-31 The lingual surfaces were reduced by approximately 0.5 mm
to provide space for a sucient thickness of ceramic
material. The margins of the preparations were approximately 1 mm from the gingival margin and 1 to 1.5 mm
from the incisal edge with a supragingival chamfer nish line. The proximal surfaces of abutments adjacent to
the edentulous space were prepared to reduce convexity and provide an increased tooth surface available for
bonding. An additional shallow box preparation was
made in each abutment proximally to the pontic side
(dimensions approximately 2 2 0.5 mm).32,33 Proximal contact areas were not invaded.
Full-arch impressions were made with a single
impression/double mixing technique and polyether ma-

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Q U I N T E S S E N C E I N T E R N AT I O N A L
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Fig 2
cast.

Palatal view of the In-Ceram framework on the master

Fig 3 Intraoral view of completed treatment immediately after

insertion.

terial (Permadyne, 3M Espe). Provisional restorations

were made by placing composite resin (Tetric Ceram,
Ivoclar Vivadent) directly on prepared unetched surfaces,
nished, and polished. At the second visit, the provisional restorations were easily removed with a scaler.
The In-Ceram restorations were constructed by the
same technician in accordance with the manufacturers
recommendations within 1 week after the nal impressions were made (Fig 2).
The inner surfaces of the restorations were air
abraded with aluminum oxide particles (Korax 250,
Bego) and coated with silane (Monobond S, Ivoclar
Vivadent). After isolation of the teeth, the prepared
surfaces of the abutment teeth were thoroughly
cleaned with pumice slurry and etched with 37% phosphoric acid gel (Ultra-Etch, Ultradent) for 60 seconds,
rinsed with water spray, and dried with air pressure.
The dentin adhesive system Syntac Classic (Ivoclar Vivadent) was then applied.
The ceramic restorations were cemented with dual
polymerizing composite resin cement (Variolink II, Ivoclar
Vivadent). After cementation, the occlusion was carefully
evaluated and necessary corrections were performed.
Finally, the inserted restorations were nished with diamonds burs and polishing disks and strips (Sof-Lex, 3M
Espe). Intraoral color photographs were taken (Fig 3). All
patients received oral hygiene instructions with special
emphasis on the proximal and lingual surfaces.
The patients were examined clinically at 1, 2, 4, 6,
and 8 years after placement of the restorations. Such

periodic tests were conducted by the authors with a

mirror, a sharp probe, and intraoral photographs.
To assess reliability, 10% of the restorations were
reexamined after 1 month, in order to conrm the ndings of the rst examination.
The following information was recorded during the
examination:
Debonding. Each retainer was checked for debonding through nger pressure and a sharp probe. The
units were classied as debonding when it was possible to force the sharp tip between the retainer and
the abutment, and when pushing the abutment
teeth in the opposite direction of the restoration
there was a visible gap between the retainer wing
and the abutment.
Fracture. The fractures were divided into total and
partial fractures. The loss of the restoration due to
fracture of the ceramic was dened as a total fracture. A fractured restoration which remained in clinical service as a cantilevered FDP was considered a
partial fracture.
Caries. All abutment teeth were examined to detect
presence of dental caries by clinical examinations
and by intraoral radiographs.
Patient acceptance. The patients were asked about
the esthetic appearance of the restorations, their
chewing ability, problems with cleaning, and symptoms of masticatory parafunction or dysfunction. A
questionnaire presented an opportunity for giving
alternative answers and personal remarks.

VOLUME 45 NUMBER 1 JANUARY 2014

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Galiatsatos / Bergou

RESULTS
The results after 8 years of service are shown in Table 3.
The reliability test showed no disagreement. Dental
caries was not detected with any abutment during the
observation time.
On the 49 patients reexamined, 48 were satised
with the function and the esthetic appearance of their
restorations. The unsatised patient had a broad maxillary anterior edentulous space and the pontic created
an asymmetrical appearance. All patients stated that
the prosthesis did not cause any subjective symptoms
such as headache, and their chewing ability was very
good and satisfactory. Five patients avoided using their
prostheses during chewing or biting on hard food,
because they had previous fractures of porcelain-fusedto-metal crowns in the posterior teeth and, therefore,
feared a new failure.
Two restorations debonded during the evaluation
period. Both of them were in the mandibular arch. In
the rst case, 3 years after the insertion of the restoration, the patient complained about mobility of the
pontic replacing the mandibular right central incisor.
Clinical examination revealed the wing on the mandibular right lateral incisor to be loose. In an attempt to
create space to recement, the connector on the mandibular left central incisor was fractured. In the second
case, which was similar, the pontic of the restoration
was replacing the mandibular left lateral incisor and the
wing debonded after a period of 3.5 years of clinical
use. The fractured RBFDPs were removed and two new
restorations were inserted.

Table 3

Results of the clinical investigation

Category

1Y

2Y

4Y

6Y

8Y

Satised patient

48

48

48

48

48

Unsatised patient

Caries

Debonding

Total fractures

Partial fractures

12

During the observation time, six fractures in the

ceramic material occurred. These can be divided into
two total and four partial fractures. In all cases, restorations fractured at the connector between the retainer
and the pontic, but all retainer wings remained bonded
to the abutment teeth. In total fractures, the bridge
framework fractured at the mesial and distal connector.
The rst total fracture occurred during the rst year
after placement of the restoration, and the second after
a period of 4 years of clinical use. Both were replaced
during the observation period with similar restorations.
In partial fractures, only one of the two connectors fractured. All partial fractures occurred between the fourth
and seventh years of clinical use. These fractured
RBFDPs remained in function as cantilevered restorations during the observation time.

DISCUSSION
All-ceramic RBFDPs are used as a minimally invasive,
tooth-tissue loss preventing alternative for replacing
anterior teeth.34 They have been performed for many
years and have become a useful and recognized technique. Clinical indicators include intact abutment teeth,
a short edentulous span such as one missing tooth, and
minimal dynamic occlusal contacts on the abutment
teeth. The advantages of these restorations are numerous and result from the combined advantages of composite resins (adhesion, conservation of tooth substrate),
and ceramic (color stability, wear resistance, enamel-like
thermal expansion, and rened esthetics).21-32
This clinical study evaluated 54 In-Ceram anterior
RBFDPs with a conventional two-retainer design for 8
years. The results suggest that when the indications
and patient are selected appropriately, the overall outcome and clinical behavior are satisfactory. In this study
the success rate for In-Ceram RBFDPs was 85.18% after
8 years.
Patient acceptance of the restorations at 8 years
was very encouraging. Only one patient complained
about a minor esthetic problem, because he had a
broad maxillary edentulous space and the pontic created an asymmetrical appearance.

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During the observation time, two of the restorations

debonded. The explanation of this phenomenon perhaps was related to the adhesive method used in this
study (silane application after air-abrasion only). Kern
and Thompson35 clearly showed in a laboratory study
on bonding methods to In-Ceram, that silane application after air-abrasion of In-Ceram is inferior to silica
coating and silane application or to using phosphate
monomercontaining resins after air-abrasion. Also, a
critical factor is the composite resin cement. Degradation within the resin cement may be related to breakdown of the ller-resin interface bond, which could
contribute to resin cement failure.36 Many factors contribute to this phenomenon, like the polymerization
shrinkage of composite resin, the dissolution of the
resin matrix of composite resins in oral uids, and the
loss of marginal integrity caused at baseline by polymerization shrinkage or by removal of cement ashes
with blunt instruments.37,38 In our study, both of the
debonded restorations were in the mandibular arch.
This may be attributable to the reason that moisture
control during cementation is more dicult to obtain
in the mandibular arch than in the maxillary arch. This
means that a substantial amount of extra chairtime
may be needed following the incorporation of a RBFDP,
and the use of rubber dam during cementation is
highly recommended. These two failures occurred 3
and 3.5 years after the insertion of the restorations.
Complications such as debonding are most likely to
occur with RBFDPs within a period of 5 years, with a 3%
mean annual debonding rate.39
Fractures of ceramic material occurred in six restorations: two total fractures and four partial fractures. On
condition that the absence of any ceramic fracture is
chosen as a criterion for success, the success rate was
88.88%. Nevertheless, if functioning of the restorations
is considered a success (thus including the three-unit
and two-unit cantilever restorations) the success rate
was 96.29%. Other clinical studies have reported higher
and lower failure rates resulting from fracture (Kern and
Strub32 94.1% after 5 years of clinical service; Pjetursson
et al39 87.7% after 5 years; Wassermann et al40 92.3%
after 5 years). In all cases, restorations fractured at the

VOLUME 45 NUMBER 1 JANUARY 2014

connector between the retainer and the pontic, but all

retainer wings remained bonded to the abutment
teeth. One of the main causes for failure of all-ceramic
RBFDPs is fracture of the connector area.29,31,32,41 To
achieve improved fracture strength, dierent framework designs have been proposed. Pospiech at al42,43
suggested a design with two proximal grooves (0.8 to
1.0 mm 4.0 mm) and a connector with increased
dimensions (4.0 2.0 mm minimum). Also, rounded
edges and little interdental separation were signicant
for stress reduction. Kern at al44 concluded that the
fracture strength of all-ceramic RBFDPs fabricated with
In-Ceram substructure was signicantly improved by
the addition of small proximal box preparations to the
abutments, and veneer applied to the In-Ceram framework circumferentially instead of only labially. In our
study, the connectors of the frameworks were designed
to be as thick as possible, and a shallow box preparation was made in each abutment proximally to the
pontic side (dimensions approximately 2 2 0.5 mm)
The four partial fractures in this study occurred
between the fourth and seventh years of clinical use, but
these fractured RBFDPs remained in function as cantilevered restorations during the observation time. Clinical
and in vitro studies have reported that high-strength
oxide ceramics used as a cantilever restoration is a viable
alternative for anterior tooth replacement.29,32,40,45-48
These results may not be surprising if one considers the
mechanics of tooth movement. Dierential movement
of the abutment teeth in a two-retainer RBFDP during
occlusal excursive movements causes shear and torque
forces on the pontic and connectors, resulting in a fracture, bending, debonding, or stress at the resin-RBFDP
interface.29,36,46

CONCLUSION
This study evaluated 54 In-Ceram anterior RBFDPs with
a conventional two-retainer design for 8 years. The success rate was 85.18 % after 8 years. The results suggest
that when the indications and patient are selected
appropriately, the overall outcome and clinical behavior are satisfactory. Further research should be directed

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Galiatsatos / Bergou

toward the potential indications, ecacy, and prognosis of this type of prosthesis.

REFERENCES
1. Rochette AL. Attachment of a splint to enamel of lower anterior teeth. J
Prosthet Dent 1973;30:418423.
2. Livaditis GJ, Thompson VP. Etched castings: an improved retentive mechanism for resin-bonded retainers. J Prosthet Dent 1982;47:5258.
3. Barrack G. Etched cast restorations. Quintessence Int 1985;1:2734.
4. Simonsen R, Thompson V, Barrack G. Etched cast restorations: clinical and laboratory techniques. Chicago, Quintessence, 1983:6074.
5. Boening KW. Clinical performance of resin-bonded xed partial dentures. J
Prosthet Dent 1986;76:3944.
6. Wood M. Etched casting resin-bonded retainers: an improved technique for
periodontal splinting. Int J Periodontics Restorative Dent 1982;2:825.
7. Isidor F, Stockholm R. Resin-bonded prostheses for posterior teeth. J Prosthet
Dent 1992;68:239243.
8. Simon JF, Gartrell RG, Grogono A. Improved retention of acid-etched xed
partial dentures. A longitudinal study. J Prosthet Dent 1992;68:611615.
9. Rammelsberg P, Pospiech P, Gernet W. Clinical factors aecting adhesive
xed partial dentures: a six year study. J Prosthet Dent 1993;70:300307.
10. Hussey DL, Pagni C, Linden GJ. Performance of 400 adhesive bridges tted in
a restorative dentistry department. J Dent 1991;19:221225.
11. Eshleman JB, Moon PC, Barnes RF. Clinical evaluation of cast metal resinbonded anterior xed partial dentures. J Prosthet Dent 1984;51:761764.
12. Yanover L, Croft W, Pulver F. The acid-etched xed prosthesis. J Am Dent
Assoc 1982;104:325328.
13. Ziada HM, Orr JF, Bennington IC. Photoelastic stress analysis in a pier retainer
of an anterior resin-bonded xed partial denture. J Prosthet Dent 1998;80:661
665.
14. Wirz J, Schmidli F, Steinemann S, Wall R. Aufbrennlegierungen im Spaltkorrosionstest. Schweiz Monatsschr Zahnmed 1987;97:571590.
15. Meiners H, Dentallegierungen. In: Voss R, Meiners H, eds. Fortschritte der
Prothetik und werkstokunde vol 4. Munich: Hanser Verlag, 1989:325339.
16. Williams HA, Caughman WF, Pollard BL. The esthetic hybrid resin-bonded
bridge. Quintessence Int 1989;20:623626.
17. Sato A, Kumei Y, Sato K, Yoshio E, Ueno Y. Mutagenicity of dental nickelchromium alloys. Dent Jpn 1991;28:129135.
18. Nilner K, Glantz PO, Ryge G, Sundberg H. Oral galvanic action after treatment
with extensive metallic restorations. Acta Odontol Scand 1982;40:381388.
19. Ibsen RL, Strassler HE. An innovative method for xed anterior tooth replacement utilizing porcelain veneers. Quintessence Int 1986;17:455459.
20. Garber DA, Goldstein RE, Feinman RA. Porcelain Laminate Veneers. 1st ed.
Chicago: Quintessence, 1988:115125.
21. Schaer JL. All porcelain anterior xed partial denture: a preliminary report. J
Prosthet Dent 1988;59:669671.
22. Claus H. Vita In-Ceram, ein neues Verfahren zur Herstellung oxidkeramischer
Gerste fr kronen und Brcken. Quintessenz Zahntech 1990;16:3546.
23. Kappert HF, Knobe H. Metallfreie Brcken fr den Seitenzahnbereich. Dent
Labor 1990;38:177183.
24. Kappert HF, Knobe H. In-Ceram auf dem Prfstand. Quintessenz Zahntech
1990;16:9801002.
25. Kern M, Knobe H, Strub JR. The all porcelain resin-bonded bridge. Quintessence Int 1991;22:257262.
26. Kappert HF, Knobe H. In-Ceram: testing a new ceramic material. Quintessence
Dent Technol 1993;16:8797.

14

27. Probster L, Diehl J. Slip-casting alumina ceramics for crown and bridge restorations. Quintessence Int 1992;23:2531.
28. Chiche GJ, Pinault A. Esthetics of anterior xed prosthodontics. Chicago,
Quintessence, 1994:4850.
29. Ries S, Wolz J, Richter EJ. Eect of design of all-ceramic resin-bonded xed
partial dentures on clinical survival rate. Int J Periodontics Restorative Dent
2006;26:143149.
30. Chow TW, Chung RW, Chu FC, Newsome PR. Tooth preparations designed for
posterior resin-bonded xed partial dentures: a clinical report. J Prosthet Dent
2002;88:561564.
31. Koutayas OS, Kern M, Ferraresso F, Strub JR. Inuence of design and mode of
loading on the fracture strength of all-ceramic resin-bonded xed partial
dentures: an in vitro study in a dual-axis chewing simulator. J Prosthet Dent
2000;83:540547.
32. Kern M, Strub JR. Bonding to alumina ceramic in restorative dentistry: clinical
results over up to 5 years. J Dent 1998;26:245249.
33. Kern M, Schwarzbach W, Strub JR. Stability of all-porcelain resin-bonded xed
restorations with dierent designs: an in vitro study. Int J Prosthodont
1992;5:108113.
34. Edelho D, Sorensen JA. Tooth removal associated with various preparation
designs for anterior teeth. J Prosthet Dent 2002;87:503509.
35. Kern M, Thompson VP. Bonding to a glass inltrated alumina ceramic: adhesion methods and their durability. J Prosthet Dent 1995;73:240249.
36. Walker MP, Spencer P, Eick JD. Eect of simulated resin-bonded xed partial
denture clinical conditions on resin cement mechanical properties. J Oral
Rehabil 2003;30:837846.
37. Galiatsatos AA, Bergou D. Six-year clinical evaluation of ceramic inlays and
onlays. Quintessence Int 2008;39:407412.
38. Meng X, Yoshida K, Atsuta M. Inuence of ceramic thickness on mechanical
properties and polymer structure of dual-cured resin luting agents. Dental
Materials 2008;24:594599.
39. Pjetursson BE, Tan WC, Tan K, Bragger U, Zwahlen M, Lang NP. A systematic
review of the survival and complication rates of resin-bonded bridges after an
observation period of at least 5 years. Clin Oral Implants Res 2008;19:131141.
40. Wassermann A, Kaiser M, Strub JR. Clinical long-term results of Vita In-Ceram
Classic crowns and xed partial dentures: a systematic literature review. Int J
Prosthodont 2006;19:355363.
41. Duarte S, Phark JH, Tomikazu T, Sadan A. Resin-bonded xed partial dentures
with a new modied zirconia surface: a clinical report. J Prosthet Dent
2009;102:6873.
42. Pospiech P, Rammelsberg P, Unsold F. A new design for all-ceramic resinbonded xed partial dentures. Quintessence Int 1996;27:753758.
43. Pospiech P, Rammelsberg P, Goldhofer G, Gernet W. All-ceramic resin-bonded bridges. A 3-dimensional nite-element analysis study. Eur J Oral Sci
1996;104:390395.
44. Kern M, Fechting T, Strub JR. Inuence of water storage and thermal cycling
on the fracture strength of all-porcelain, resin-bonded xed partial dentures.
J Prosthet Dent 1994;71:251256.
45. Koutayias O, Kern M, Ferraresso F, Strub JR. Inuence of framework design on
fracture strength of mandibular anterior all-ceramic resin-bonded xed partial
denture. Int J Prosthodont 2002;15:223229.
46. Kern M. Clinical long-term survival of two-retainer and single-retainer allceramic resin-bonded xed partial dentures. Quintessence Int 2005;36:141
147.
47. Kern M, Sasse M. Ten-year survival of anterior all-ceramic resin-bonded xed
dental prostheses. J Adhes Dent 2011;13:407410.
48. Sasse M, Eschbach S, Kern M. Randomized clinical trial on single retainer allceramic resin-bonded xed partial dentures: inuence of the bonding system
after up to 55 months. J Dent 2012;40:783786.

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