BioHPP Clinical Research Data PDF

JENA UNIVERSITY HOSPITAL
OUTPATIENT DEPARTMENT FOR DENTAL PROSTHETICS AND MATERIALS

Director: Univ.-Prof. Dr. H. Kpper
Department of Materials and Technology
BIO HPP Summary of results

for material tests
By A. Rzanny, R. Gbel, M. Fachet

Research report for Bredent (Senden)
19 pages including 9 tables and 10 figures
Jena, 10 January 2013
1. Scope of work
The thermoplastic high-performance polymer BIO HPP was examined in its material
properties. In addition to abrasion resistance, exogenous tendency to discolouration, surface
quality and structure, the adhesive strength to the fixation composite DTK adhesive and
combo.lign were also tested. As part of this, the composite test of the DTK adhesive to Bio
HPP when using titanium or zirconium oxide cylinders was carried out, as the use of the DTK
adhesive is designed for joining/gluing together attachment elements and abutments.
2. Materials, method and test conditions

2.1
Materials
The materials used for the investigation are listed in Table 1.
Table 1
Material
Bio HPP
Manufactu
rer
Bredent
Batch
410099
Framework material
visio.link
Bredent
110925
Bredent
316120
Bredent
345976
Bredent
114339
PMMA Composite Primer
MKZ Primer
Metal and ceramic primer
DTK adhesive
Dual-hardening fixation composite
combo.lign
Dual-hardening fixation composite
2.2 Methods and test conditions

Exogenous tendency to discolouration
Test body: 5 mm, height 2 mm, provided by the manufacturer
Storage:
4 weeks in various preparations (coffee, tea, tobacco, methylene blue, red wine
and distilled water) at 37C. Storage in methylene blue was selected in contrast
2
to the other substances (coffee, tea, tobacco and red wine), which frequently enter the oral
cavity, so that the discolouration could be simulated by using a strong coloured dye.
Test: Measurement of the discolouration in comparison to the control (stored in a dry and dark
environment at 37C) with the aid of the ShadeEye-NCC (Shofu). The device is based on the
principle of the CIELAB System. It determines the L* a* b* values and provides information
on the shade, brightness and chroma of the colour.
Evaluatiowyn: Following the standard deviation, the distribution of the L*, a*, b* values was
calculated on the control sample. The value thus obtained was designated as the degree of
discolouration (V). The calculation was carried out in each case for the L*, a* and b* values
according to the following
form
ula:
( x
V=
x)
n1
where
V = degree of discolouration of the material x = measured value of the
control sample
xi = measured value of the test object stored in the medium
n = number of different media (6)
.
In order to record the entirety of the deviation of the discoloured test object of a substance
from the
control test object, the colour interval E was calculated from the three components.
E =
L* - (V of L* values)
L *2 +a * 2 +b * 2
a* - (V of a* values)
b* - (V of b* values)
E is a measure of the colour difference that can be detected visually under favourable
conditions.
Surface quality
In order to determine the surface quality, test objects supplied by the manufacturer were used,
which were 20 mm long, 10 mm wide and 3 mm thick, and the surface was processed as
described below.
A distinction was made between a dental technical processing method without rotary
movement (A1), a further dental technical processing method with rotary movement (A2), and
a dental processing method (B). The surface was processed in the following manner:
A1, A2.: 1. Carbide mill (fine cross-toothed) (REF H194 GH 40), low
contact pressure, 6000-8000 U/min
2. Diagen Turbogringer green (REF 340 0015 0), low contact pressure,
6000-8000 U/min
3. Ceragum rubber polishing roller (REF PWK G065 0), very light contact pressure,
6000-8000 U/min
4. Goat-hair brush with pumice stone powder (REF 520 0014 0), 5000 U/min
5. Goat-hair brush with AbrasoStarglanz, wool buffing wheel without polishing
agent,
6000-8000 U/min
B.: Super Snap polishing disc (Shofu) in the sequence: Coarse, Medium, Fine, Superfine,
DirectDia polishing paste on Super-Snap Buff Disk (Shofu) with 10,000 U/min.
Polishing was carried out on 3 test objects; all test objects were included in the evaluation. The
test objects were processed with a light pressure and then freed from the abrasion with
compressed air. In method A1, polishing was always carried out in the same direction, whereas
in method A2, it was carried out with rotary movements. Polishing was carried out until the
surface appeared subjectively smooth. The time required for this varied from around 1 to 2
min.
The surface obtained after processing was scanned with the surface testing device
"Hommel Tester T 1000", a mechanical-electrical scanning system. During this, the surface
quality achieved was determined using measured values that were calculated from the surface
profile obtained. In the representation, we have limited ourselves to the arithmetical mean
deviation Ra, which represents the average deviation of the profile from the median line.
Abrasion resistance
The abrasion resistance was determined by means of the 3-media abrasion machine
(Willytec), in accordance with the abrasion method developed by De Gee.
The test wheel was loaded with test objects; an Al-Mg alloy with the same hardness as
Amalgam and Gradia dentine material was used as the comparative substance. After grinding
of the loaded wheel with a coarse and then a fine diamond grinding wheel (contact pressure =
15 N), the abrasion test was carried out with a contact pressure of 20 N. As an intermediate
medium, we used toothbrushes HS RMS 11000015.
4
Fig. 1a shows the principle of the 3-media abrasion machine, in the form of a sketch.
Fig.1a
Test conditions
-
Direction of motor rotation:
counter-clockwise
Motor speed on the left:
130 U/min
Motor speed on the right:
60 U/min
Test force:
20 N
Total number of cycles:
200,000
Evaluation:
Hommeltester T 6000, calculation of the loss surface A (cf. Fig. 1b);
A
P
Fig. 1b: Profile section of an abraded substance sample;
P= test object in the wheel's chamber,
A: abraded surface
The calculated loss surface of the Al-Mg alloy was set at 1 exactly and all other
loss surfaces were set in proportion to it.
Pressure-shear
resistance
The adhesive strength of BIO HPP to the DTK adhesive (A) and to combo.lign (B) was
determined.
A.: The bonding strength of BIO HPP to the
DTK adhesive was
determined by means
of pressure-shear tests.
Test object size:
Bio HPP plates: 20 x 10 x 2 mm
The surface of the plates was continuously irradiated with corundum (110 m; 3 bar). The
surface was subsequently coated with visio.link and exposed to light for 90 s in the Dentacolor
XS device. The DTK adhesive was then applied and a titanium cylinder/zirconium oxide
cylinder conditioned with an MKZ primer (316120) was applied to the surface and set, in the
case of titanium by means of self-hardening at room temperature, and in the case of zirconium
dioxide, by means of additional light polymerisation in the Dentacolor-XS device (90 s).
The test objects underwent two different ageing variations
1. Initial value (basic value):
24 h water storage at 37C
2. Artificial ageing with temperature change load: 25 000 TCL (5-55C)

(TCL: temperature change load). The
pressure-shear tests were carried out with the Zwick-Universal testing machine Z 005. The
traverse speed was 1 mm/min.
3 test objects (initial value) or 5 test objects (artificial ageing) were manufactured for each
series.
B: The bonding strength of BIO HPP to the combo.lign was examined by means of pressureshear tests:
1.Bio HPP (milled): 20 x 10 x 2 mm, visio.link
The surface of the plates was irradiated with corundum (110 m; 3 bar). The surface was
subsequently coated with visio.link and exposed to light for 90 s in the Dentacolor XS device.
Subsequently, combo.lign was applied to a metal ring attached to the BIO HPP surface, stored
in the dark for 10 min and then exposed to light for 90 s in the Dentacolor XS device.
2. Bio HPP (pressed with pearls): 20 x 10 x 2 mm, visio.link, opaquer combo.lign (2
components)
6
The opaquer combo.lign was then applied (exposure to light for 90 s in the Dentacolor XS
device).
A metal ring was then attached and the combo.lign was applied, stored for 10 min in the dark
and then exposed to light for 90 s in the Dentacolor XS device.
3. Bio HPP (pressed with crystals): 20 x 10 x 2 mm, visio.link, opaquer combo.lign (2
components)
The opaquer combo.lign was then applied (exposure to light for 90 s in the Dentacolor XS
device). A metal ring was then attached and the combo.lign was applied, stored for 10 min in
the dark and then exposed to light for 90 s in the Dentacolor XS device.
4. Bio HPP (milled): 20 x 10 x 2 mm, Signum connector (Heraeus Kulzer), opaque F (Heraeus
Kulzer)
subsequently coated with Signum connector and exposed to light for 90 s in the Dentacolor XS
device. The opaquer opaque F was then applied (exposure to light for 90 s in the Dentacolor
XS device). A metal ring was then attached and the combo.lign was applied, stored for 10 min
in the dark and then exposed to light for 90 s in the Dentacolor XS device.
5. Bio HPP (milled): 20 x 10 x 2 mm, composite primer (GC), Gradia opaquer (GC)
subsequently coated with composite primer and exposed to light for 90 s in the Dentacolor XS
device. The Gradia opaquer was then applied (exposure to light for 90 s in the Dentacolor XS
device). A metal ring was then attached and the combo.lign was applied, stored for 10 min in
the dark and then exposed to light for 90 s in the Dentacolor XS device.
The test objects underwent two different ageing variations
1. Initial value (basic value):
24 h water storage at 37C
2. Artificial ageing with temperature change load: 25 000 TCL (5-55C)

(TCL: temperature change load). The
pressure-shear tests were carried out with the Zwick-Universal testing machine Z 005. The
traverse speed was 1 mm/min.
1 to 3 test objects (initial value) or 4 test objects (artificial ageing) were
manufactur
ed for each
series.
Structural
analysis
Test body: 20 mm 10 mm 3 mm
Test object preparation:
The test objects were ground as far as the middle, embedded in epoxy resin and the surface
was processed successively with SiC paper with a 600, 1200 and 2400 grain, and then polished
with diamond paste (1 m grain).
Test: Scanning electron microscope (REM Stereoscan 260, Cambridge Instruments)
3. Results
The results are listed in the table below as mean values with distribution, and are also
represented visually by graphs.
3.1.
Exogenous
discolouration
The results of the colour interval E after storage in five different media (column 2: coffee,
tea, tobacco, red wine, methylene blue, column 3: coffee, tea, tobacco, red wine, distilled
water) in comparison to the control sample are listed in Table 6 and the results are shown in
Figures 2 to 4.
Table 2
Plastic
(with
(without
methylene
crea.lign
2.73
blue)
novo.lign
methylene
E
(methylene
blue only)
1.85
blue)
8.1
1.21
1.20
1.70
Sinfony
4.42
1.97
15.9
VITA VM
11.96
6.4
21.57
SR Adoro
24.4
8.62
45.62
Ceramic
2.19
1.42
6.9
2.81
2.56
2.66
(HeraCeram)
Bio HPP
Tendency to discolouration E
25
Colouring media: Coffee, tea,
tobacco, red
wine, methylene
blue
20
15
10
5
0
crea.lign novo.lign
Sinfony
VITA VM SR Adoro HeraCeram
Bio HPP
Fig. 2: Tendency to discolouration E of Bio HPP after storage in coffee, tea, tobacco, red
wine and methylene blue
Tendency to discolouration E without methylene blue
25
20
15
10
crea.lign novo.lign
Sinfony
VITA VM SR Adoro HeraCeram
Bio HPP
Fig. 3: Tendency to discolouration E of Bio HPP after storage in coffee, tea, tobacco and red
wine
10
Tendency to discolouration E in methylene blue
50
40
30
20
10
0
crea.lign novo.lign
Sinfony VITA VM SR Adoro HeraCeram
Bio HPP
Fig. 4: Tendency to discolouration E of Bio HPP after storage in methylene

blue
3.2. Surface quality

Tables 3 and 4 show the Ra values of Bio HPP without polishing (column 1) and subsequent
processing by means of dental technical methods A1 and A2. The results after the last
processing stage of method A1 (in or against the direction of processing) are shown in Table 3,
whereas Table 4 contains the results after the last processing stage of method A2 (rotary
movements). In addition to the Ra values of Bio HPP in the initial state, tables 5 and 6 show
the Ra values of Bio HPP after polishing with method B (dental method) without and with
polishing paste, also in and against the direction of processing. Figures 5 and 6 show the
results in the form of graphs.
11
Table 3: Ra values after polishing with the dental technical polishing system A1
Initial state
Ra [m]
in the direction of
processing
against the direction of processing

Ra [m]
Ra [m]
1.63 0.18
0.04 0.01
0.26 0.04
Table 4: Ra values after polishing with the dental technical polishing system A2
Initial state
rotary processing
rotary processing
Ra [m]
horizontal
measurement
vertical
measurement
Ra [m]
Ra [m]
0.05 0.02
0.04 0.01
1.63 0.18
Table 5: Ra values after polishing with the polishing system B, without polishing paste (dental
method)
Initial state
Ra [m]
in the direction of
processing

Ra [m]
Ra [m]
1.63 0.18
0.08 0.01
0.08 0.01
Table 6: Ra values after polishing with the polishing system B, with polishing paste (dental
method)
Initial state
Ra [m]
in the direction of
processing

Ra [m]
Ra [m]
1.63 0.18
0.04 0.01
0.04 0.01
12
Surface roughness [m]

0.4
Final
stage
Polishing A1 horizontal Polishing A1 vertical Polishing A2 horizontal
Polishing A2 vertical
0.3
Super Snap (4 stages) horizontal
0.2
Super Snap (4 stages) vertical

Super Snap (4 stages) + polishing paste
(horizontal) Super Snap (4 stages) + polishing
paste (vertical)
0.1
0
Dental technical instruments
Dental instruments
Fig. 5: Surface roughness of Bio HPP horizontally and vertically to the direction of processing
after different forms of polishing
Surface roughness [m]

0.2
Horizontal measurement
Polishing A1
Polishing A2
Super Snap (4 stages)
0.15
Super Snap (4 stages) Direct Dia
0.1
0.05
Dental technical instruments
Dental instruments
Fig. 6: Surface roughness of Bio HPP horizontally to the direction of processing after
different forms of polishing
13
3.3. Abrasion resistance

Table 7 and Fig. 7 show the tendency to abrasion of Bio HPP in comparison with different
veneering composites.
Table 7: Abrasion of different composites and Bio HPP
Composite
Abrasion ratio
Al-Mg
Gradia
1.85
Bio HPP
1.47
Veneering composite
A
Veneering composite
B
2.97
1.6
Tendency to abrasion
4
Bio HPP
Composite A Composite B Gradia
Al Mg
Fig. 7: Tendency to abrasion of Bio HPP and various veneering composites in comparison to
the Al-Mg alloy = 1
14
3.4.
Pressure-shear
resistance
Table 8 and Fig. 8 show the bond results of Bio HPP to the DTK adhesive after one day of
storage in water (initial values) and 25,000 TCL (artificial ageing) as well as in comparison to
two selected ZrO2ceramics for veneering ceramic after one day of storage in water.
Table 8: Bonding strength of Bio HPP to DTK

adhesive
and bonding strength of zirconium oxide ceramic - veneering ceramic
1d (37C)
Bond
Mean value
[MPa]
25,000 TCL
Distributi
on
Mean value
[MPa]
[MPa]
Bio HPP - DTK adhesive
Distributi
on
[MPa]
25.2
0.4
26.8
0.7
31.7
1.0
30.6
2.5
-- Titanium
Bio HPP - DTK adhesive

-- Zirconium dioxide
ZrO2 ceramic - Veneering ceramic
Noritake zirconium ceramic

CZR
20.8
0.5
EPS e.max ZirCAD
23.4
1.1
15
Pressure-shear resistance [MPa]

35
30
25
20
1d
0
BioHPP-DTK adhesive
- Titanium
25,000 TCL
10
25,000 TCL
15
1d
BioHPP-DTK adhesive
1d
1d
Noritake CZR
e.max ZirCAD
- ZrO2
Fig. 8: The bonding strength of BIO HPP on the fixation composite DTK adhesive on
titanium and ZrO2 in comparison to the bonding strength of ZrO2 ceramic veneering ceramic.
Table 9 and Fig. 9 show the bond results of Bio HPP (pressed and milled) by means of various
primers and opaquers to combo.lign after one day of storage in water (initial values) and
25,000 TCL (artificial ageing).
16
Table 9: The bonding strength of BIO HPP of different surface quality to

combo.lign when using different veneering systems
1d (37C)
Bond
Mean value
[MPa]
Distributi
on
[MPa]
Distributi
on
[MPa]
26.5
1.3
40.1
2.1
38.8
1.0
38.3
0.8
38.4
0.9
20.9
21.6
1.3
24.1
1.1
24.1
Code: B-gf-vl.-cl
Mean value
[MPa]
Bio HPP (milled), visio.link,

combo.lign
25,000 TCL
Starting
value
Bio HPP (pressed with

pearls),
visio.link,
opaquer
combo.lign,
combo.lign Code: BgpP-vl.-Ocl-cl

Bio
HPP (pressed with
crystals), visio.link,
opaquer combo.lign,
combo.lign Code: B-gpKvl.-Ocl-cl
Bio
HPP (milled), Signum
connector, opaque F,
combo.lign
Code: B-gf-Sc-oF-cl
Starting
value
Bio HPP (milled), composite

primer, Gradia opaquer,
combo.lign
Code: B-gf-CP-GO-cl
27.6
Starting
value
17
Pressure-shear resistance [MPa]

45
1.
2.
40
Bar: 1 d, 37C
Bar: 25,000 TCL
35
30
25
20
15
10
5
0
B-gf-vl.-cl
B-gpP-vl.-Ocl-cl B-gpK-vl.-Ocl-cl
B-gf-Sc-oF-cl
B-gf-CP-GO-cl
Fig. 9: The bonding strength of BIO HPP to combo.lign when using different
primers and opaquers (see Table 8 for Code)
18
3.5. Structural analysis
Fig. 10 shows the structure of BIO HPP magnified 5000 times.
1m
Fig. 10: Structure of Bio HPP
19
Summary
The results of the investigations into Bio HPP revealed the
following:
The tendency to discolouration of Bio HPP caused by all of the tested media is very low. Both
the average discolouration across all media and that caused by the blue dye methylene blue
showed no visible discolouration.
Good polishing with little surface roughness was possible both with dental and dental technical
polishing instruments. However, it has been shown that rotary movement should always be
used if possible during polishing. This ensures that deep scratches or grinding marks are
avoided. A final polish with polishing paste is recommended, even for the dental variation.
The abrasion resistance of Bio HPP has proven to be good. Because of this, Bio HPP should be
able to withstand a possible abrasion in the oral cavity best, in comparison to the three
veneering composites tested.
Bio HPP demonstrated a very good bonding strength to DTK adhesive, which remained
constant even after 25,000
TCL. We also found that the adhesive strength after light hardening (to zirconium dioxide)
was higher than after chemical hardening (to titanium). If possible, DTK adhesive should
therefore always undergo light polymerisation. The values for adhesive strength are
particularly high, as the comparison of the adhesive values of zirconium dioxide-veneering
ceramic shows.
The surface (with and without mechanical retentions) of Bio HPP has a definite influence on
the bonding strength. The bonding values measured with the dual-hardening fixing composite
combo.lign show this. Significantly higher adhesive values were measured both on the
surfaces equipped with pearls and crystals, and on the surfaces that had only been milled.
Jena, 10.01. 2013
20
REF 000715GB
Science and further training
BZB June
13
Using plastics for implant-based

dental prostheses
A suitable treatment choice for older patients in particular
An article by Dr Steffen Kistler1, Stephan Adler1, Dr Frank Kistler1, and Dr Jrg Neugebauer1-2, 1Landsberg am
Lech, 2Cologne
Recent years have shown that almost all framework
materials can be fitted with ceramic veneers. From an
aesthetic perspective in particular, this approach enables
dental technicians to achieve an individual look. Often,
however, the work required is both laborious and costly and
also carries the risk of chipping, depending on the quality of
the processing involved, which sometimes cannot be
repaired at all or only with a lot of work from a dental
technician [6, 11]. As far as removable dental prostheses are
concerned, the risk of accidental damage has seen plastic
emerge as the material of choice. This raises the question as
to how suitable plastics might be for definitive implantsupported restorations as well.
Introduction and outline of the issues

When deciding on restoration treatment for older patients, the
number of implants is becoming an increasingly important
issue in terms of the overall work required for the restoration.
This is also true of the type and design of the prosthetic
superstructure [3]. Whereas the aim a few years ago was still
to achieve the ideal prosthetic restoration in an edentulous
jaw by using as many implants as possible, most of them with
individual crowns, more and more concepts involving a
reduced number of implants have found favour during recent
years [2,7], although this presents new challenges in terms of
the superstructure. If just four implants are used in an
edentulous mandible, it becomes necessary to work with the
traditional concept of Brnemark or Toronto extension
bridges as opposed to small-span bridges or individual
crowns. This in turn makes it necessary to lock all the
implants in with a framework. One advantage is that the base
of the dental prosthesis can compensate for atrophied sections
of the alveolar ridge [8].
After early experiences involving extension bridges, often
prepared on tall distance sleeves and where the aesthetics
were not right, patients these days expect the areas of bone
and soft tissue lost as a result of atrophy to be dealt with on
an individual basis and also expect their dental prosthesis to
look natural.
The traditional method of processing prosthetic teeth on a

metal framework is sometimes associated with poor
bonding between the mass-produced prosthetic teeth, the
plastic used for the prosthesis, and the metal framework
[1]. Teeth fashioned individually from a composite
material - particularly where there is antagonistic contact
with chewing surfaces covered by ceramic veneers or with
natural teeth - can cause the dental prosthesis to fail
prematurely as a result of increased abrasion. This is why
this form of restoration is deemed to be a rather secondrate treatment method [10].
Mass-produced veneers
As an alternative, recent years have seen the emergence of
mass-produced veneers made of high-strength plastic.
Thanks to a bonding system, they can be permanently
bonded to a framework made of metal or zirconium oxide.
The composites used to fix the veneers to the framework
are also available in a variety of colours, which means an
individual look can be achieved for both crowns and at the
transition to the soft tissue. Another advantage with
removable restorations is how the plastic offers a simple
means of supporting the perioral soft tissue while only
increasing the weight of the dental prosthesis very
marginally.
Processing by dental technicians
The dimensions of frameworks for plastic veneers can be
more delicate than for ceramic veneers. When building the
framework, it makes sense to base this on the wax-up
prepared in order to define the bite and size of the
superstructure (Fig. 1 and 2).
BZB June
13
Fig. 1: Wax-up for checking the bite and size of the dental
prosthesis
Fig. 3: Fitting the milled frameworks in the maxilla and

mandible
Fig. 5: Veneers fixed to the silicone matrix. The matrix has been
perforated at each veneer so the composite for attaching the
veneers to the framework of the prosthesis can be light-cured
from all sides.
The good thing with this approach is how patients can

become involved in achieving the best possible restoration
design, which makes them more likely to accept the end
result. Depending on the individual design, a framework of
zirconium oxide can be designed to lie directly on top of the
soft tissue in terms of the basal surface. With a titanium
framework, it is possible to leave some space so the base can
be modified using plastic. This particularly favours the kind
of changes that need to be made to the base of the prosthesis
in the event of advanced atrophy.
Fig. 2: Structure of the CAD/CAM framework for the mandibular

restoration based on the wax-up scanned in and superimposed
using the computer
Fig. 4: Titanium framework conditioned with bonder and opaquer
Fig. 6: Layered application of plastic to ensure a permanent bond

between the veneers and framework
Since the moduli of elasticity for the framework materials

titanium, non-precious metal, and zirconium oxide ceramics
are very different to those of veneer materials, it is necessary
to condition the framework with a special primer and bonder
system. With milled titanium frameworks (Fig. 3) in
particular, a dual-curing composite opaquer should be used
and applied after the framework has been prepared using a
primer (Fig. 4).
Fig. 7: Using mucosa-coloured plastic to achieve an individual

look for the soft tissue section
BZB June
13
Fig. 8: Completed mandibular bridge on four implants with screw

channels for fixation purposes and partially removable structure
Fig. 10: Veneers fixed with wax for a further check on the bite
Fig. 9: Two CAD/CAM milled bars, each on three implants in the
maxilla
It is also important to blast and roughen the veneers with

aluminium oxide with a grain size of 100 m and at 2 to 3
bars. Next, the light-curable adhesive (visio.link, bredent) is
applied with a brush and polymerised. The definitive bond
for the veneers is achieved using a dual-curing fixation
composite (combo.lign, bredent), which is initially applied to
the basal surfaces of the veneers (visio.lign, bredent). Using a
matrix for fixation purposes makes it possible to reproduce
with great accuracy the positions of the veneers, from both an
aesthetic and functional perspective, as originally determined
using a wax-up. The light-curing fixation composite is
applied in layers and polymerised. If using a matrix, it is
important to apply the polymerisation light from both sides.
To facilitate this, the matrix in the centre of the relevant
veneers is perforated. (Fig. 5 and 6). The palatal and lingual
surfaces, as well as the basal surfaces where applicable, of the
metal framework are finished off with a light-curing veneer
composite (Fig. 7 and 8) containing no glass fillers (crea.lign,
bredent).
This makes it possible to give the surface a fine polish and

these materials are also more elastic than filling composites.
Clinical use
With removable or partially removable structures, the dental
prosthesis is anchored via the retention elements of the
mesostructure or this is screwed into the implant. With
removable prostheses on implants, modern CAD/CAM
processes support the high-precision manufacture of
mesostructures and tertiary structures, which means there is
no longer any need to manufacture them using the methods
traditionally employed by dental technicians (Fig. 9). Delicate
frameworks for removable prostheses can be manufactured
using the same process as for the fixed restoration described
above. This means the patient can be treated using a reduced
selection of metals and plastics (Fig. 10 to 14). Since plastics
demonstrate cushioning properties during mastication
compared with ceramic veneer materials, it goes without
saying that a fixed, antagonistic restoration in particular
should only be considered for patients who can chew
normally [5].
BZB June
13
Fig. 11: Completed removable bridge in maxilla with locking

bars open
Fig. 12: Mandibular bridge before screw channels are sealed with
plastic
Fig. 13: Removable bridge in maxilla with locking bars not fully
closed
Fig. 14: Integrated dental prosthesis in maxilla and mandible
Discussion
In keeping with the general trend towards restorations with a
reduced number of implants, the search is on for solutions
which also reduce the amount of work required by dental
technicians. This can be achieved by using mass-produced
veneers with an appropriate fixation system consisting of
primer, opaquer, and composite plastic [9]. Although a
material with a low modulus of elasticity is used when rigid
metal frameworks are finished off with plastic, the above
process makes it possible to bond this to the metal framework
permanently [12].
Since the dental prosthesis is exposed to a moist environment
and a variety of media like food and drink, there is a need for
inert tissue properties. These are easy for mass-produced
components like veneers to achieve, since peroxides or other
kinds of catalysts needed for individual processing in the
laboratory are not required.
The option to use light polymerisation reduces the

residual free monomer content, which reduces the
likelihood of intolerance associated with tissue irritation
or allergies.
The fillers chosen for the veneer composite used no
longer tend to be ones made of glass, since these are
associated with a high level of surface roughness, which
in turn causes plaque to adhere to the plastic. This is why
silanised nanoparticles are used as fillers these days.
These increase resistance to abrasion and cannot break
through the plastic composite as glass may do. The nanofillers embedded in the diacrylate do not make the plastic
any less polishable. Homogeneous, highly polished
surfaces with low plaque adhesion and a high resistance to
discolouration are ideal for a permanent restoration. The
colour stability associated with these modern plastics is
also increased by dispensing with intermediate molecules
or prepolymers when using nano-fillers, since these, as a
pure, mass-produced diacrylate polymer, hardly allow any
loose dye to infiltrate their structure.
Patients finds restorations pleasant to wear because of the

softer material and because they experience a natural
cushioning sensation when chewing. The fact the veneers
are mass-produced ensures that a highly dense structure
with good resistance against abrasion is created around the
actual chewing surfaces, which in turn ensures the longterm stability of the restoration [4]. As well as being
extremely resistant to abrasion, the highly dense structures
also have excellent anti-discolouration properties. Unlike
traditional plastics, stress tests involving coffee, tea,
tobacco, methylene blue, and red wine recorded average
BZB June
13
levels of discolouration when compared with ceramic materials.

In cases of extreme stress involving damage to the plastic
sections, the plastic - unlike restorations with ceramic veneers can simply be repaired.
There is no need for time-consuming drying of the framework
and it is also possible to carry out repairs in the mouth if
necessary using light-curing systems.
Colleague tip
REF 000706GB
BioHPP - A metal-free material for prosthetic restorations
The search is over

Dr Jrgen Vohans, MDT Marc Schelhove, and Frank Schnieder
CAD/CAM, zirconium dioxide, high-performance polymers - prosthetic dentistry is
currently reaching new heights. Many materials and concepts are ready for use in
practice and have a proven track record. Treatment teams can offer patients aesthetic
restorations made from high-quality materials. Often, however, manufacture can be costintensive and requires either considerable investment or the involvement of an external
service provider. This article describes a concept or a material which combines four
things: no metal used, very good physical properties, low cost, standard manufacturing
process. The process described here is based on BioHPP (high-performance polymer) a new class of materials.
igh gold prices, external milling centres,
production of zirconium dioxide frameworks
on a contract basis, titanium alloys which can only
be made with expensive CAD/CAM machines:
'normal' dental laboratories are finding it increasingly

difficult to meet the demands of modern dentistry,
including from a financial perspective. Dental
technicians in turn want to offer their patients modern
and high-quality materials for prosthetic restorations.
Many patients become enchanted by the possibilities
offered by modern dentistry, only to be greatly
disappointed when they hear just how costly these
kinds of restorations are to carry out. We as a treatment
team have long been searching for an alternative which
will work in practice and have now found this. Thanks to
a new class of materials (BioHPP, bredent), we have
managed to resolve the apparent contradiction between
modern prosthetic dentistry and innovative materials on
the one hand and economical manufacture on the
other. We have had to contend with a considerable
degree of material-related failure when using
conventional materials, particularly with secondary
structures used for combined prosthetic treatments:
for example, galvanic gold is too soft and is

associated with wear (sometimes after just a few
weeks), which leads to a loss of adhesion. A
secondary structure made of NPM (non-precious
metal) does not enable any actual friction, but only
produces a clamping effect at best. Wear is also an
issue here too. We as a treatment team eventually
found it impossible to accept these early signs of
wear.
A new class of materials
A few years ago, dentistry discovered a
thermoplastic material which had already been
used in industry and human medicine to proven
effect for a number of years, namely
polyetheretherketone (PEEK). The semi-crystalline
high-performance plastic combines very good
mechanical
properties,
high
temperature
resistance, and excellent resistance to chemicals.
ZAHNTECH MAG 17, 3, 138 143 (2013)
The material has been developed intensively to

ensure that it meets the demands associated
with the dental laboratory and manufacturing
processes (BioHPP). Among other things, the
outstanding physical properties mean the
material BioHPP can now be used as a
framework material for prosthetic restorations in
the mouth. The material may be relatively new to
dentistry, but we believe it has huge potential for
the future. The applications are varied; whether
for a bridge framework, full anatomical
restorations (area around the side teeth), or
secondary structures (telescopes, bars), it is
possible to address all these prosthetic
indications. We have been looking in particular
for an alternative procedure to secondary
structures made of non-precious metal. The
laborious processing techniques and the
sometimes
suboptimal
precision
were
increasingly putting us off secondary parts made
of NPM. CAD/CAM-based manufacture has
been tried and tested, but the costs involved are
also high. Laboratories without their own
CAD/CAM device are reliant on external service
providers. It is important, however, that any
concepts relating to the work involved satisfy
both the demands of dental technicians and any
financial criteria, as well as giving laboratories
the opportunity to deliver the kind of added value
the market expects.
The material BioHPP appears to be the solution; it is

opening up a new range of indications for removable
prosthetic restorations. The material PEEK is credible
because of its long track record within the field of medical
technology, among other things. The outstanding
physical and chemical properties are due to the structure
of the polymer, which consists of tightly connected
molecules. Its high melting point (above 280 C) means it
can be treated using hot sterilisation methods. The good
flexural strength and high modulus of elasticity stop the
material breaking and give it a consistency similar to that
of bone. We use BioHPP among other things for the
secondary structures used in bar-supported prostheses.
The following patient case study demonstrates the
procedure involved.
The material BioHPP is a pigmented, semi-crystalline
thermoplastic.
The
base
material
is
polyetheretherketone (PEEK), which was developed as
a veneer-compatible framework material. The good
material properties are not impaired during processing.
Patient case study

When the patient came to see us, he did not have a
prosthetic restoration in his edentulous mandible.
Following treatment for mouth cancer (chemotherapy,
radiation, etc.), he decided the time was right for a proper
restoration of his mandible. There are various therapy
concepts for someone with an edentulous mandible,
ranging from ball-shaped attachments and bar structures
through to fixed dental prostheses. In the case in question,
the xerostomia (dryness of the mouth) triggered by the
radiation, the atrophied mandible, and the patient's state of
health were all reasons not to choose a fixed, high-end
restoration or a traditional overlay prosthesis.
Following an analysis of the initial situation and an
interdisciplinary consultation process, a decision was
made to proceed with an implant-supported, bar-retained
restoration. In dentistry terms, the overlay prosthesis
anchored on four implants in the edentulous mandible is
considered a standard form of restoration. The restoration
is very hygienic and offers long-term stability. In prosthetic
terms, we have good experience of working with the
following structure types:
Fig. 1: The 'for 2 press' pneumatic vacuum-pressure

casting unit is used to convert wax models into the
material BioHPP (bredent).
ZAHNTECH MAG 17, 3, 138 143 (2013)
Primary structure =
bars made of non-precious metal (NPM)
Secondary structure =
slides made of the high-performance polymer BioHPP, bredent
Veneering =
plastic teeth (visio.lign, bredent)
Colleague tip
The first-class 'running properties' of the highperformance polymer BioHPP are really impressive
when used as a secondary part on the NPM bar
(primary part). The running properties can be
compared with a superstructure made of gold, albeit
with only minimal abrasion from a clinical
perspective. Cohesive and adhesive forces give the
secondary part made of BioHPP the kind of
(permanent) hold required.
Primary structure - NPM

Four implants (Dentegris SL implant 3.75 x 13 mm)
were inserted into the mandible without any
problems. The patient was given an interim
prosthesis during the healing phase. After five
months of healing, the osseointegrated implants
were exposed, a mould was taken of the area, and
the implant model was manufactured. We produced
the primary bar in accordance with the usual
procedure. As before, we still use a conventional
casting process. Although it may often be dismissed
as obsolete, we believe that NPM casting can be a
safe and efficient process if the procedure involved
is properly thought through and precise enough. As
a result, we can have stress-free frameworks and
generate added value in the laboratory.
The bar was modelled on the basis of the wax-up
(set-up). Issues like hygiene and structural analysis
were considered as early as the modelling stage.
Finally, male parts were placed on both sides of the
bar in the dorsal area and the modelling was
inspected once more before investing. In order to
achieve high-quality casting results, we used proven
parameters during spruing and applied these
consistently. The next steps were investing and
casting. Following devesting, the bar was released,
parallelised in the milling unit (1), and polished to a
high gloss. The Sheffield test showed that the bar
was properly in place without any stress.
Note: Sharp-edged transitions during spruing have

an adverse effect on the end result and should be
avoided. Wax wires with a thickness of 4 mm were
used to fix things to the muffle carrier. In order to
achieve good compression-moulding results, the
object was placed around 6 mm from the silicone
ring and away from the centre of the heat. Investing
was
performed
in
accordance
with
the
manufacturer's instructions. Around 20 minutes after
investing, the muffle and the (disposable) press
plunger were inserted into the preheating oven at a
temperature of 630C (heat level based on
manufacturer's instructions) and kept in the oven for
the recommended time (Fig. 2). At this point the
compression-moulding temperature had to be
reduced to 400C. The temperature reduces in the
preheating oven by 3C per minute. It is a good idea
to preheat the muffle overnight to ensure that the
cooling down phase to 400C takes rather longer.
Once the temperature in the muffle's melting channel
had fallen to around 400C, the BioHPP was poured
in (Fig. 3) and the muffle was kept at that
temperature for another 20 minutes. The next step
was simply to apply the press plunger and place

the already loaded muffle in the vacuum-pressure
casting unit (Fig. 4).
Fig. 2: The muffle and press plunger in the preheating

oven.
Secondary structure - BioHPP

The secondary structure (slide) was modelled using
both plastic and wax. The great thing about the
material BioHPP is there is no need to change the
usual manufacturing processes. Also, the low
minimum thickness of the framework means it is
even possible to have an aesthetic superstructure
when space is limited. The 'for 2 press system' (Fig.
1) can be used to convert the modelled structure
into BioHPP. Apart from the material itself, the
system includes a muffle plate with a silicone ring,
the investing material, the disposable press plunger,
and the pneumatic vacuum-pressure casting unit.
Following modelling of the secondary part, the wax
structure was sprued. Wax wires with a thickness of
2.5 mm were run from the object to the cross-piece
(3.5 mm).
ZAHNTECH MAG 17, 3, 138 143 (2013)
Fig. 3: At end of the appropriate preheating period,

the BioHPP was poured into the melting channel and
the loaded muffle was brought back to the desired
temperature.
Colleague tip
The vacuum pressure process started automatically when the
compression-moulding chamber was closed (Fig. 5).
Devesting was performed in accordance with the conventional
procedure, whereby most of the investing material was
removed and the object was blasted with aluminium oxide.
The compression-moulding channels were separated using a
separating disc and the secondary structure was carefully
tried against the primary bar. Fine cross-toothed carbide mills
can be used to process the material.
The structures manufactured using the CAD/CAM-supported
process may well fall onto the model or, in our case, the primary
bar 'practically by themselves', but they are not unique in this
respect. Our secondary part compression-moulded in BioHPP
also hardly required any retouching and was found to fit
extremely well with the correct amount of friction in terms of
motion (Fig. 6 to 8).
These optimal glide properties are what makes the material
our new 'gold standard'. The male parts modelled in the
dorsal area of the primary bar were provided with their
respective female parts and these additional retention
elements were cemented into the secondary part (BioHPP)
These can be activated or even replaced over

time as required.
Completion and installation
The completion work for the bar-supported
prosthesis is no different from the
conventional process. An adhesive (visio.link,
bredent) was applied to the framework and the
prosthesis was completed in accordance with
the set-up involving the visio.lign concept
(veneers made from a high-performance
polymer) (Fig. 9). Once the fit had been
checked again both on the model and in the
mouth, the stress-free bar ('passive fit') was
screwed onto the implants and the mandibular
prosthesis was adapted in the mouth.
The patient was delighted right from the initial
fitting. Both the aesthetic and the functional
aspects satisfied his requirements. This was
the first time in years he had felt as if he

had a 'permanent' dental prosthesis.
.
Fig. 4 and 5: Around 20 minutes later, the press plunger could be
applied, the muffle could be adapted in the vacuum-pressure
casting unit, and the compression-moulding process could start.
Fig. 6 to 8: The primary bar made of NPM ('passive fit')

and the secondary slide made of BioHPP. The
outstanding glide properties associated with this
combination of materials tend to favour the use of
combination prostheses. The process was completed in
accordance with the conventional procedure.
ZAHNTECH MAG 17, 3, 138 143 (2013)
Colleague tip
Fig. 9: The finished product: the (plastic) attachments in

the dorsal area of the bar allow activation where
necessary or can be replaced. This ensures that the
prosthesis remains fixed to the bar for a long time.
Fig. 10: The X-ray image of the osseointegrated

implants. The tumour patient could be rehabilitated with
a suitable mandibular restoration following treatment for
cancer.
Fig. 11 and 12: After a final check on the fit, the ('passive fit') bar was screwed to the four implants and the prosthesis
could be inserted.
Friction and the good running properties of the

BioHPP secondary part on the bar mean the
item can be inserted and removed without any
problems. The combination of materials
described provided an efficient means of
achieving a restoration for the edentulous
mandible in line with patient expectations. The
laboratory was able to complete all the work by
itself and thereby keep any added value in
house.
BioHPP as a framework material:
Preparation of restorations with a low
specific weight
Elasticity similar to that of bone
Shock-absorbing effect
Metal-free restorations
Low material fatigue
No viscoplastic fractures
High biocompatibility
Low plaque accretion
No corrosion
Summary
The patient was suitably rehabilitated using an
implant-based prosthetic reconstruction - a
primary bar made of NPM and a secondary part
made of BioHPP. The restoration satisfied the
various requirements: osseointegrated implants,
stress-free primary framework, prosthesis does
not
move
in
the
mouth,
convenient
insertion/removal for patient, good hygiene,
plaque resistance, colour stability, low weight.
ZAHNTECH MAG 17, 3, 138 143 (2013)
In the material BioHPP we have found the

alternative we have been looking for to be used
on a day-to-day basis in both practices and
laboratories.
DR. JRGEN VOHANS

Emstor 5
48291 Telgte
www.drvosshans.de
MDT MARC SCHELHOVE

Dental-Technik Burghoff
GmbH Telgenkamp 14
48249 Dlmen
E-mail: info@dtburghoff.de
FRANK SCHNIEDER
Managing Director
Dental-Technik Burghoff
GmbH Telgenkamp 14
48249 Dlmen
E-mail: frank.schnieder@dental-technik-burghoff.de
REF 000714EX
Ergnzung zu
Eine neue Werkstoffklasse in der Zahnmedizin
Dieser Fachartikel verweist auf die Kompetenz der bredent group im Bereich von High Performance
Polymere, welche durch die 7-jhrige Langzeiterfahrung bei der Verwendung des Gerstwerkstoffes
auf Basis von PEEK belegt wird. Ebenfalls erbringt dieser den Nachweis, dass der Verbund zwischen
BioHPP und visio.lign als langfristig anzusehen ist und keine Abplatzungen (Chipping) auftreten.
Der Unterschied zwischen BioXS und BioHPP liegt in der Tatsache, dass es sich bei BioXS um ein
leicht gruliches PEEK und bei BioHPP um ein mit Keramikpartikeln verstrktes PEEK in weier
Farbe und mit besseren mechanischen Eigenschaften handelt.
Mit dem for 2 press System wurde jetzt auch das Fertigungsverfahren so optimiert, dass der
Herstellungsprozess einwandfrei verluft.
Addition to
"A new class of materials in dentistry"
This specialist article demonstrates the competence of the bredent group in the field of High
Performance Polymers, which has been proven through 7 years of long-term experience in the use of
PEEK-based framework materials. This article also produces evidence that the bond between BioHPP
and visio.lign is to be considered long term and no chipping occurs.
The difference between BioXS and BioHPP lies in the fact that this concerns a slightly grey PEEK in
BioXS, and, in BioHPP, white PEEK strengthened with ceramic particles and with improved
mechanical properties.
The production process has now also been optimised with the for 2 press system so that the
manufacturing process runs smoothly.
bredent GmbH & Co.KG

Weissenhorner Str. 2 | 89250 Senden | Germany | Telefon +49 (0) 7309/872-22 | Telefax +49 (0) 7309/872-24 |
info@bredent.com | www.bredent.com
bredent medical GmbH & Co.KG
Weissenhorner Str. 2 | 89250 Senden | Germany | Telefon +49 (0) 7309/872-600 | Telefax +49 (0) 7309/872-635 |
info-medical@bredent.com | www.bredent-medical.com
BASICS
POLYMERS
REF 000957GB
Summary
The use of specific materials
to suit specific indications
will be a key aspect of
dental technology in the
future. For example,
restorative and
reconstructive dentistry is
increasingly looking to
modern plastics, particularly
high-performance polymers.
The plastic
polyetheretherketone
(PEEK) already has a long
track record in medical
technology. Thanks to its
optimal properties, this
material is suited to a wide
range of applications in
terms of metal-free
definitive (and not just
temporary) restorations and
is easy to process in the
laboratory using the
compression-moulding
process.
Compression-moulding
rather than milling
A wealth of possible applications for high-performance
polymers
Key words
Individual abutments, full
anatomical individual
crowns, bars, frameworks,
polymers, compressionmoulding techniques,
implant prosthetics,
conventional prosthetics
Stephan Adler, Steffen Kistler, Frank Kistler, Jrg Lermer, Jrg

Neugebauer
Introduction
In terms of medical technology, the material polyetheretherketone has a long and

successful record in orthopaedics. The key factors behind this success are its
mechanical properties and biocompatibility. For example, the high-performance
polymer is used, among other things, for spinal column implants, since its specific
material properties help stop pressure peaking at the boundary between the bone and
spinal column implant. Although the material is very inert, it can be covered with
veneers and therefore used as a framework material for dentistry purposes.2,9
Another advantage is its transparency to X-rays, which avoids the kind of scattering
that reduces image quality, so imaging processes can be used for optimal monitoring
of the healing process.
bredent (based in Senden) has developed the high-performance polymer BioHPP
as a veneer-compatible framework material and has made this available for
compression-moulding techniques. This means the material can be processed at
individual laboratories more easily and also - bearing in mind the investment costs for
milling units - more cheaply than NPM, titanium, or ceramics.
This article looks at how the material is used and processed, with a three-tooth
implant bridge for side teeth being used for illustration purposes. Other possible
indications are also considered.
2
Quintessenz Zahntech 2013;39(3):210
POLYMERS
BASICS
POLYMERS
The article shows how high-quality functional and aesthetic solutions can b
achieved with the high-performance polymer.
Material properties
BioHPP, approved as a Class IIa medical device, is a semi-crystalline and

pigmented thermoplastic. Its base material is PEEK and it contains about 20%
ceramic filler. With a modulus of elasticity of around 4 GPa, BioHPP is about
as elastic as bone, which helps mitigate any stress that might develop and
reduces 'stress shielding', a welcome effect for wide-span framework
structures in particular. This also means bone-related torsion can also be
balanced out to some extent, which is important with larger implant work (Fig.
1 and Tab. 1). In addition, BioHPP is also particularly suitable for patients with
allergies because of its very low water solubility of < 0.3 g/mm3 and its low
reactivity to other materials.
1,000,000
Zirconium
EMF
Fig. 1 Elasticity
comparison for
bone/framework materials
(logarithmic
representation).
Tab. 1 Physical
characteristic values for
PEEK.4
Elasticity [MPa]
100,000
Titanium
Gold
10,000
Bone
Compacta
BioHPP
1,000
Spongiosa
Mechanical properties (DIN EN ISO 10477)

E-modulus
4,000 MPa
Flexural strength
> 150 MPa (no material
failure)
6.5 g/mm3
Water absorption
< 0.3 g/mm3
Water solubility
Mechanical properties after 10,000 thermocycling cycles 5C/55C
(in accordance with DIN EN ISO 10477)
E-modulus
4,000 MPa
Flexural strength
> 150 MPa (no material
failure)
Breaking load tests on three-tooth bridges
Maximum stress without fracturing (after 24 h immersion in

water,
37C)
Maximum
stress without fracturing (after mechanical and
thermal alternating load 1.2 million x 50 N, 10,000 x
5C/55C)
Other properties
Melting range (DSC)
Bond strength
Density
Hardness (HV)
> 1,200 N
> 1,200 N
Approx. 340C
> 25 MPa
1.3 to 1.5 cm3
110 HV 5/20
BASICS
POLYMERS
A simulated chewing study conducted at the University of Regensburg found
that all bridges made from monolithic BioHPP, although they may have shown
small traces of abrasion, showed no signs of damage or loss of cementation at
the contact points with human tooth antagonists.3 This in turn helps protect the
residual dentition. The flexural strength achieved also means the material can
be used for definitive restorations, whether veneered or monolithic.
BioHPP is approved by the manufacturer for three-tooth bridges with one
pontic and four-tooth bridges with two pontics (both monolithic and
veneered), telescopic work, individual abutments, and secondary structures
associated with bar-supported prostheses.
Indications
BioHPP is not approved for the manufacture of implants, root posts, or

structures with more than two pontics. For patients with oromandibular
malfunctions, the manufacturer recommends full anatomical compressionmoulded structures (rear protection plates) with labial or buccal composite
veneers. The transition between the functional surface and the veneers must
not be placed under stress in such cases. The material (in its entirety or parts
thereof) may not be melted more than once, since this causes it to lose its
properties.
Contraindications
In accordance with the wax-up agreed with the treatment team, the bridge
framework was modelled using residue-free, burn-out modelling wax and
checked against the visio.lign (bredent) veneers - to be used for subsequent
veneering - in the top wall in a vertical direction. To keep the framework
structure stable, it was important to ensure an adequate connector thickness
- at least 14 mm2 near the side teeth based on a vertical/horizontal ratio of
60:40. If you are modelling a contact area as opposed to a contact point, this
ensures a good starting position. No veneering was planned for the basal
surface. The framework was then prepared for investing (Fig. 2 to 4).
Workflow for framework

Wax modelling
Fig. 2 The wax-up with veneers.
Fig. 3 The framework following modelling.
POLYMERS
BASICS
Fig. 4 The framework

prepared for investing.
Fig. 5 The BioHPP compression-moulding pellets.

Fig. 6 The blasted framework
after compression-moulding.
Compressionmoulding process
Framework design
Fig. 7 A precise fit for the abutments.
With the 'for 2 press' system (bredent), BioHPP can be processed in the same way as
during the compression-moulding process. According to the manufacturer, there is
also no danger that the mechanical, thermal, or chemical material properties of the
high-performance polymer will be impaired either. Once the compression-moulding
pellets have melted, the muffle is fitted with a disposable press plunger and placed in
the 'for 2 press' compression-moulding unit, and the compression-moulding table is
closed manually. The compression-moulding process itself is automatic.
The compression-moulding channels were then carefully separated using a
separating disc, any surface roughness was removed with fine cross-toothed carbide
mills, and the framework was blasted. The framework was inspected against the
master model before being finally released (Fig. 5 to 7).
Since no veneering was required on the lingual side, not least because BioHPP is
white in colour, veneers (novo.lign P for the side teeth, bredent) offered both an
effective and efficient veneering option for the vestibular and occlusal surfaces. This
has the added advantage that the edges of the veneers on the lingual side are given
optimal support by the monolithic framework, which is simply polished to a high gloss.
Fig. 8 The BioHPP framework conditioned on the buccal and occlusal sides.
veneers.
Fig. 10 The veneers prepared in the top wall.
Fig. 9 The framework, rubberised on the lingual side, with optimal support for
Fig. 11 Application of the adhesive.
Fig. 12 Bonding of the veneers to the framework.
To this end, the lingual surfaces of the framework were first sanded with fine
sandpaper, pre-polished with a rubber polisher, and finally worked on with a highgloss polishing paste. Critical to the long-term stability of the restoration is the
permanent bond between the veneers and the BioHPP framework. In view of this,
the buccal and occlusal framework surfaces and the insides of the veneers were
blasted with 110 m aluminium oxide at 2 to 3 bars, and the light-curing adhesive
(visio.link, bredent) was applied with a brush and polymerised (Fig. 8 and 9).
A suitable dual-curing fixation composite (combo.lign, bredent) was used for
bonding purposes. For the purposes of bonding with the framework, the dentinecoloured adhesive is liberally applied to the conditioned insides of the veneers.
Final polymerisation takes place once any excess has been carefully removed
(Fig. 10 to 12).
In order to achieve long-lasting plaque resistance and colour stability, it is
absolutely essential to ensure polymerisation is complete and polishing is
performed properly, which was done in this case with a soft goat-hair brush and
the buffing wheel (Fig. 13 to 15).
The optimised PEEK material BioHPP can also be used to make individual
abutments. This involves moulding the modelled abutments onto the titanium
bases (SKY elegance, bredent) directly, without leaving any gaps.
Bonding
Final steps
Further indications
Abutments
POLYMERS
basics
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Fig. 13 to 15 The final restoration on the occlusal, lingual, and vestibular sides.
Fig. 16 Individual PEEK abutments

modelled on a titanium base
(photographs 16 to 19: Schwindt
Laboratory, Landau/Pfalz).
Fig. 17 Compression-moulded
abutments with an exact fit.
Fig. 18 The compression-moulded

framework
with
sufficient
connector thickness and retention
beads.
Fig. 19 The final veneered side

teeth bridge, prepared for bonding
inside the mouth.
In order to ensure longer abutments have the necessary stability, the sleeves which can be shortened as required - should be designed to be extra long and
given significant retention elements. The manufacturer also offers ready-made
abutments, which prosthetic specialists can customise inside the mouth. Both
individual and ready-made abutments feature 'off-peak' properties, whereby peak
loads are cushioned before they are transferred to bone, which favours
'progressive bone loading'.7 As described in the previous case, the framework is
modelled on the abutments and then moulded, polished on the lingual side, and
veneered on the vestibular and occlusal sides, with adhesive being applied inside
the mouth (visio.link primer, bredent, and PANAVIA F 2.0, Kuraray,
Frankfurt/Main) (Fig. 16 to 19).
basics
POLYMERS
Fig. 20 A monolithic side

tooth crown made of
BioHPP.
Fig. 21 The abutment

crown is screwed in inside
the mouth.
Fig. 22 The screw
channel is sealed with
composite with no
difference in colour.
Fig. 23 X-ray image of the

abutment crown.
The monolithic BioHPP abutment crown, screwed on the occlusal side, is not just
an efficient alternative in the side teeth area. The physical characteristic values
(see Fig. 1) also suggest long-term stability and tolerance. The abutment crown
is made entirely in the laboratory on a titanium base using the compressionmoulding process and screwed in inside the mouth. There is no risk of any
subgingival cement residue. The screw channel is sealed with a composite
(crea.lign, bredent). This ensures the abutment screw can be accessed at any
time as required. Another advantage with the abutment crown is that aesthetics
are not diminished, even in the event of gingival recession, because abutments
are the same colour as teeth. The material also performs at least as well as
titanium in terms of soft tissue reactions or bone levels. (Fig. 20 to 23).5
Bars as a secondary structure for removable restorations can also be
manufactured from BioHPP in the laboratory using the compression-moulding
process and undergo further processing in the usual way (Fig. 24 and 25).
According to the manufacturer, the friction and glide properties of the material
PEEK ensure trouble-free insertion and removal for the patient. Another
advantage is the low weight of the PEEK structure.
8
Abutment crown
Bar structure
POLYMERS
SICS
Fig. 24 A bar structure made of BioHPP and a stress-free

fit for a mandible (photographs 24 and 25: Dr Vohans,
Telgte/Dental-Technik Burghoff, Dlmen).
Discussion
Summary
Fig. 25 Bar bonded to the tertiary structure with retention

elements.
Long-term experience from human medicine and the positive results from the chewing load
study mean that impressive results can be expected for the approved indications. Using the
material for frameworks is easy and adheres to the kinds of processes with which dental
technicians are familiar. Although the material properties - such as similar elasticity to bone,
shock-absorbing effect, resistance to abrasion, low material fatigue, biocompatibility, or low
plaque accretion - are very promising in terms of favouring higher loads, particularly with
augmentative techniques,1 further studies on the various dental indications and their clinical
reliability would be welcome to consolidate the scientific data. However, a close
consideration of the procedures involved suggests it would be possible to recommend the
use of the high-performance polymer BioHPP to dental technicians and dentists as a metalfree but still cost-effective and attractive solution. Another interesting aspect is how easy
repairs are, particularly compared with ceramic materials.
The system solution based on BioHPP as a highly cross-linked polymer, the 'for 2 press'
compression-moulding process tailored to it, and their use within a monolithic or veneered
application represent a viable alternative to metallic or even full ceramic restorations in
terms of either implant-based prosthetics or restorative therapy. Since it is white in colour, it
is ideal for aesthetic restoration purposes. The material PEEK is associated with a high level
of stability, very good polishing qualities, and a low affinity for plaque. With bigger implant
projects, however, bone-related torsion can still be balanced out by the elasticity of the
material, which is similar to that of bone. Its insolubility in water and low reactivity with other
materials mean the material PEEK is also very suitable for patients with allergies.
This means BioHPP favours new approaches to treatment based on familiar
manufacturing methods. There is no need for time-consuming and costly training for new
systems. The added value associated with any restorations is kept within the laboratory, not
least because the high investment costs for things like milling units do not apply.
BASICS
POLYMERS
Assuming the dental technician has the relevant skills, the high reliability of the
process ensures high-quality results which can be reproduced to the satisfaction of all
concerned.
1. Appleton RS, Nummikoski PV, Pigno MA, Cronin RJ, Chung KH. A radiographic assessment of
2.
3.
4.
5.
6.
7.
8.
9.
10.
Literature
progressive loading on bone around single osseointegrated implants in the posterior maxilla.
Clin Oral Implant Res 2005;16:161-167.
Kern M, Lehmann F. Influence of surface conditioning on bonding to polyetheretherketone
(PEEK).
Dental materials: official publication of the Academy of Dental Materials 2012;28:1280-1283.
Kolbeck C, Rosentritt M. In-vitro-Untersuchung viergliedriger Brcken auf Kunststoffstmpfen
(TCML und Bruchtest): Vollanatomische Gestaltung aus PEEK gefrst bzw. gepret (In-vitro
investigation of a four-tooth bridge made from plastic stumps (TCML and break test): Full
anatomical design milled or pressed from PEEK). Report #141 2011.
Kolbeck C, Rosentritt M. In-vitro-Untersuchung (thermomechanische Wechselbelastung und
Bruchtest) viergliedriger vollanatomischer Brcken aus Bio HPP hergestellt im Frs- bzw.
Preverfahren (In-vitro examination (thermomechanical variation loading and break test) of
four-tooth full anatomical bridges manufactured from Bio HPP in milling and moulding
procedures). Poster presentation. Munich: Int. Sky-Meeting, 2012.
Koutouzis T, Richardson J, Lundgren T. Comparative soft and hard tissue responses to
titanium and polymer healing abutments. J Oral Implant 2011;37(Spec No):174-182.
Maharaj G, Bleser S, Albert K, Lambert R, Jani S, Jamison R. Characterization of wear in
composite material orthopaedic implants. Part I: The composite trunnion/ceramic head
interface. Biomed Mater Eng 1994;4 193-198.
Misch CE. Progressive loading of bone with implant prostheses. J Dent Symp 1993;1:50-53.
Ring ME. Dentistry: a look backward and a peek into the future. NY State Dent J 1997;63:4045.
Schmidlin PR, Stawarczyk B, Wieland M, Attin T, Hammerle CH, Fischer J. Effect of different
surface pre-treatments and luting materials on shear bond strength to PEEK. Dental materials:
official publication of the Academy of Dental Materials 2010;26:553-559.
Tetelman ED, Babbush CA. A new transitional abutment for immediate aesthetics and function.
Implant Dent 2008;17:51-58.
Stephan Adler (DT)

Implant Dental GmbH
Von-Khlmann-Strae 1
86899 Landsberg am Lech
E-mail: stephan.adler@implantate-landsberg.de
Dr. Jrg Neugebauer, Praxis fr Zahnheilkunde, Landsberg am
Lech
Von-Kuhlmann-Str. 1, 86899 Landsberg am Lech
E-mail: joerg.neugebauer@implantate-landsberg.de
10
Dental Materials Journal 2013; 32(3): 441448
Tensile bond strength of veneering resins to PEEK: Impact of different adhesives

Bogna STAWARCZYK1, Christine KEUL1, Florian BEUER1, Malgorzata ROOS2 and Patrick R. SCHMIDLIN3
Department of Prosthodontics, Munich Dental School, Ludwig-Maximilians University Munich, Germany
Division of Biostatistics, Institute of Social and Preventive Medicine, University of Zurich, Switzerland
3
Clinic of Preventive Dentistry, Periodontology and Cariology, Center of Dental Medicine, University of Zurich, Switzerland
Corresponding author, Bogna STAWARCZYK; E-mail: bogna.stawarczyk@med.uni-muenchen.de
1
2
This study tested tensile bond strength (TBS) between veneering resins and polyetheretherketone (PEEK) after pre-treatment with
adhesive systems. Five-hundred-seventy-six PEEK disks were fabricated, air-abraded and divided into six pre-treatment groups (n=96/
group): Z-Prime Plus, Ambarino P60, Monobond Plus, Visio.link, Signum PEEK Bond, and control group without pre-treatment. Each
group was divided into three subgroups of different veneering resins (n=32): Sinfony, GC Gradia and VITA VM LC. After specimen
preparation with a bond area of 6.6 mm2, half of each subgroup (n=16) was tested initially, and the other half was thermo-cycled. TBS
measurements were analysed by three-way and one-way ANOVA, t-test and Weibull statistics. Groups without pre-treatment and
groups pre-treated by Z-Prime Plus and Ambarino P60 showed no TBS. Pre-treatment with Monobond Plus increased the TBS values.
The highest TBS before and after thermo-cycling between PEEK and all tested veneering resins was observed for groups pre-treated
with Visio.link and Signum PEEK Bond.
Keywords: PEEK, Polyetheretherketone, Bond strength, Veneering resins
INTRODUCTION
In general, resin materials for computer aided design
(CAD)/computer aided manufacturing (CAM) have
become increasingly used in daily clinical practice1).
Due to their excellent properties, they may be applied
as alternative materials to ceramic reconstructions2-5).
Industrially fabricated CAD/CAM resin blocks
have better mechanical and optical properties than
conventional polymerized resins5-7). The novel highperformance composite PEEK (polyetheretherketone),
with its notable mechanical properties8), is a polymer
from the main group of PAEK (polyaryletherketone). It is
biocompatible and chemically stable to nearly all organic
and inorganic chemicals8,9). Due to its excellent physical
and biological properties, this composite material is
used both in general medicine and in dentistry as
implant, provisional abutment and implant supported
bar or clamp material10-13). But PEEK might also be a
suitable material for fixed dental prostheses (FDPs),
especially in load-bearing areas14) with a reported mean
load-bearing capacity of 1,383 N for 3-unit PEEK FDPs.
A visible deformation of the FDPs was observed at the
end of the loading process at approximately 1,200 N
and exceeded, therefore, previous reported mastication
forces of up to 600 N what have been recorded in the
posterior region15).
However, there are some aesthetic drawbacks
that limit the use of PEEK as full-coverage monolithic
restorations. The optical properties of PEEK included
low translucency and a greyish color. Therefore a
veneering layer, using additional resin composites
Color figures can be viewed in the online issue, which is available at J-STAGE.
Received Jan 9, 2013: Accepted Feb 14, 2013
doi:10.4012/dmj.2013-011 JOI JST.JSTAGE/dmj/2013-011
is required. This adds an additional challenge, as

achieving adequate bond strength between veneering
resin composites and PEEK surfaces, due to its low
surface energy and resistance to surface modification by
different chemical treatments16,17), remains difficult. A
recent study observed no bond between untreated PEEK
surfaces and resin luting cements18). Additional etching
of the PEEK with sulphuric acid or piranha solution
(H2SO4 plus hydrogen peroxide H2O2) increased the
initial bond strength significantly18,19). However, both
available studies investigated the bonding properties
to resin luting cements without artificial aging.
Furthermore no veneering resins were included18,19).
Considering the risks of these materials as chair-side
agent for PEEK frameworks, their application should
rather be restricted. Another study assessed the bond
strength of a provisional resin to PEEK using different
surface treatments and conditioning methods20). The
authors of the latter study found, that after a 150 days
artificial aging period, PEEK air-abraded and primed
with Luxatemp Glaze & Bond resulted in significant
higher tensile bond strength values than the other tested
pre-treatments. Only one study tested the adhesion
between PEEK surfaces and veneering composites14). In
that study, PEEK surfaces were etched, but additional
adhesives were not used.
Temperature changes have considerable influence
on the bond strength of the investigated materials.
Several studies stated that intraoral thermal changes
occur due to the daily routine of eating, drinking21,22)
and breathing23). At present there is no systematic
standardized procedure for fully mimicking in vitro
testing conditions in the laboratory. However, laboratory
thermo-cycling does provide a certain standardized and
442
Dent Mater J 2013; 32(3): 441448
reproducible stress to all specimens.

Therefore, the present study investigated the ability
of currently available chair-side surface conditioning
methods and adhesion promoters to establish adhesion
to PEEK, by evaluating bond strength after different
pre-treatments to three veneering resins. The hypothesis
was that pre-treated PEEK surfaces show higher bond
strength to veneering resins compared to untreated
surfaces.
MATERIAL AND METHODS

Specimens preparation
Five-hundred-seventy-six Dentokeep PEEK specimens
(nt-trading, Karlsruhe, Germany) were sectioned (7
mm7 mm2 mm) with a low-speed diamond saw (Well
3241, Well Diamantdrahtsgen, Mannheim, Germany).
Specimens were embedded in acrylic resin (ScandiQuick,
ScanDia, Hagen, Germany) and then polished from SiC
P500 up to P2400 with an automatic polishing device
(PlanoPol-2, Struers, Ballerup, Denmark) for 60 s under
water-cooling. After polishing, all specimens were airabraded with 50 m alumina powder (basic Quattro
IS, Renfert, Hilzingen, Germany) at 0.2 MPa for 10 s
at 45 to the air-abraded surface. Before pre-treatment
for tensile bond strength (TBS) tests, specimens were
ultrasonically cleaned in 80% ethanol (Otto Fischer,
Saarbrcken, Germany) for 5 min and dried on a clean
bench at room temperature. Specimens were then
divided into six main groups, five of which were pretreated using the following adhesive systems: a) Z-Prime
Plus (BISCO, Schaumburg, IL, USA), b) Ambarino
P60 (Creamed, Marburg, Germany), c) Monobond Plus
(Ivoclar Vivadent, Schaan, Liechtenstein) d) Visio.
link (Bredent, Senden, Germany), and e) Signum
PEEK Bond I+II (Heraeus Kulzer, Hanau, Germany).
The sixth group was not additionally treated and the
specimens therein were used as controls. Table 1 gives
the manufacturer, the composition and the application
steps of the adhesives.
Bonding procedure and preparation for tensile bond
strength measurement
Each pre-treatment group was randomly divided into
three subgroups (n=32) for the three veneering resins i)
Sinfony (3M ESPE, Seefeld, Germany), ii) GC Gradia (GC
Europe, Leuven, Belgium) and iii) VITA VM LC (VITA
Zahnfabrik, Bad Sckingen, Germany). Acrylic cylinder
with an inner diameter of 2.9 mm were filled with one
of the veneering resins and luted to a PEEK surface
by means of an alignment apparatus. This apparatus
consisted of two parallel guides, a tube holder, a silicone
pad and an added weight of 750 g. The use of this device
ensured that the tube axis was perpendicular to the
bonding surface. Excess veneering resin was removed
from the bonding margin using micro-brushes. All
materials were applied according to the manufacturers
instructions (Table 1).
Each bonding subgroup was subdivided into
two groups of 16 specimens each and stored either in
distilled water at 37C for 24 h or exposed to 10,000

thermal cycles between 5C and 55C (dwell time: 20 s)
(Thermocycler THE 1100, SD Mechatronik-Westerham,
Feldkirchen, Germany).
TBS measurement
TBS was determined in a Universal Testing Machine
(Zwick 1445, Zwick, Ulm, Germany) at a crosshead speed
of 5 mm/min. Specimens were positioned in the jig of the
testing machine to the loading direction using a special
test configuration, which provided a moment-free axial
force application. A collet held the acrylic cylinder while
an alignment jig allowed self-centring of the specimen.
The jig was attached to the load cell and pulled apart by
an upper and lower chain, allowing the whole system to
be self-aligning (Fig. 1). The TBS was calculated with
the following formula: fracture load/bonding area; N/
mm2= MPa.
For fracture type analyses, the debonded area was
examined by one calibrated and blinded examiner using
an optical microscope (Axioskop 2 MAT, Karl Zeiss
Mikroskopie, Gttingen, Germany) at 25 magnification.
Three failure types were determined and defined: a)
adhesive (no composite remnants left on the PEEK
surface), b) cohesive failure in PEEK, and c) cohesive
failure in veneering resin.
Statistical analyses
A power analysis had been calculated using nQuery
Advisior (Version 6.04.10, Statistical Solutions, Saugaus
Mass) prior to performing this study. One pilot study
with 7 specimens had been performed with the veneering
material Sinfony combined with Monobond Plus to PEEK
(14.5+/2.6 MPa). It was shown that a sample size of 16 in
each group would have 95% power to detect a difference
of 27% in means (4.5 MPa) caused by aging assuming
Fig. 1
Tensile bond strength measurement.
443
Dent Mater J 2013; 32(3): 441448

Table 1 Summary of veneering resins and adhesive materials evaluated
Materials
Composition
Application steps as
recommended by the
manufacturer
Lot. No
Curing light
used*
Bis-GMA,
HEMA, ethanol
1. Apply 2 coats of
adhesive on PEEK
surface
2. Dry with an siring
for 3 s
1200000769
2011004057
1. Apply with a
microbrush for 60 s
2. Disperse dry
remaining excess
with a strong
stream of air
R26669
MMA, PETIA,
Photoinitiators
1. Apply adhesive on the

PEEK surface with a
brush
2. Light cure for 90 s
114784
Brelux Power
Unit, Bredent
Bond I:
bifuctional
molecules based
on phosphoric
acid esters and
thiol compounds
Bond II:
MMA, PMMA,
Photoinitiators
1. Apply adhesive 1 on
PEEK surface and leave
for 10 s
2. Apply adhesive 2 and
light cure for 90 s
Bond I:
010121
Bond II:
010110
HiLitePower,
Heraeus Kulzer
476735
Pre-polymerizing:
Visio Alfa,
EM ESPE
End-polymerizing:
Visio Beta Vario,
3M ESPE
1111111
LABOLIGHT
LV-III,
GC Europe
33941
SPEED
LABOLIGHT,
Hagen & Werken,
Duisburg,
Germany
Product
Name
Manufacturer
Z-Prime
Plus
BISCO,
Schaumburg,
IL, USA
Ambarino
P60
Creamed,
Marburg,
Germany
Monobond
Plus
Ivoclar
Vivadent,
Schaan,
Liechtenstein
Silane
methacrylate,
phosphoric acid
methacrylate,
sulphide
methacrylate
Visio. link
Bredent,
Senden,
Germany
Heraeus
Kulzer,
Hanau,
Germany
Adhesive
Signum
PEEK
Bond I + II
(experimental
adhesive)
Dimethacrylate based
Apply on PEEK surface
on phosphor
and leave for 120 s
acidesters and
phosphon acidesters
HEMA;
Octahydro-4,
7-methano-1H1. pre-light cure for 5 s
indenediyl-bis
2. end-polymerizing for
(methylene16 min under vacuum
diacrylate),
(50 wt% filler 0.50.7 m: Sr-Ba-Al-Si
glass, pyrogenic silica)
Sinfony
(Microhybrid)
3M ESPE,
Seefeld,
Germany
GC Gradia
(Fine hybrid)
GC Europe,
Leuven,
Belgium
UDMA, EDMA, (75

wt% filler: ceramic,
prepolymer, SiO2)
VITA VM LC
(Microfilled)
VITA
Zahnfabrik,
Bad
Sckingen,
Germany
EDMA, TEGDMA,
DMAEMA, (4548
wt% filler 40 nm:
prepolymerized
splinters, SiO2)
Veneering
resins
light cure for 5 min
light cure for 10 min
* All polymerization lights were chosen according to manufacturers specific instructions.

MMA: methyl methacrylate, PMMA: polymethyl methacrylate, PETIA: pentaerythritol thiacrylate, Bis-GMA: bisphenol-Adiglycidyl methacrylate, TEGDMA: triethyleneglycol dimethacrylate, HEMA: 2-hydroxyethyl methacrylate, UDMA: urethane
dimethacrylate, EDMA: ethylene dimethacrylate, DMAEMA: N,N-dimethylaminoethyl methacrylate.
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Dent Mater J 2013; 32(3): 441448
that the common standard deviation is 2.6 MPa using

two group t-test with 0.005 Bonferroni corrected twosided significance level due to 5 pre-treatment groups
leading to 10 between groups comparisons.
Descriptive statistics such as mean, standard
deviation (SD) and 95% confidence intervals (95%
CI) were calculated. Normality of data distribution
was tested using Kolmogorov-Smirnov and ShapiroWilk tests. Three- and one-way ANOVA followed by
Scheff post-hoc test was used to determine significant
differences between the tested groups. Unpaired t-test
was used to detect the impact of aging. Additionally,
the TBS was examined using Weibull statistics.
Two-parameter Weibull statistics were estimated by
Maximum Likelihood and their 95% CI were computed.
Tests for the equality of the Weibull modulus and
the equality of the characteristic fracture load were
conducted together with the appropriate Bartletts
modified post-hoc test24).
Relative frequencies of failure types together with
the corresponding 95% CI estimated according to the
Ciba Geigy tables25), were provided. P values smaller
than 5% were considered to be statistically significant
in all tests. The data were analysed using SPSS
(Version 20, SPSS INC, Chicago, IL, USA). The Weibull
analysis was performed in MINITAB (Version 14,
MINITAB, State College, PA, USA).
RESULTS
The Kolmogorov-Smirnov and Shapiro-Wilk tests
indicated no violation of the assumption of normality.
The three-way interaction (veneering resin vs. adhesive
vs. aging level) showed significant impact on the results
(p<0.001). Therefore, the fixed effects of veneering resin,
adhesive and aging level cannot be compared directly as
the higher order interactions were found to be significant.
Consequently, several different analyses were provided
and split at levels of veneering resin, adhesive and aging
level depending on the hypothesis of interest. Boxplots
of TBS measurements in all tested groups are shown in
Fig. 2. Table 2 depicts the descriptive statistics (mean,
SD, 95% CI) for TBS values and the results of one-way
ANOVA with Scheff post-hoc test.
In general, Z-Prime Plus or Ambarino P60 as well
as the control group resulted in no adhesion to PEEK
surface, whereas the use of methyl-methacrylate-based
bonding such as Visio.link or Signum PEEK Bond
increased the TBS values.
TBS after 24 h water storage
The choice of veneering resin showed no impact on the
TBS (p=0.103). The pre-treatment with Monobond Plus
showed significant lower values for all veneering resins
compared to specimens pre-treated with Visio.link or
Signum PEEK Bond (Table 2). Within the veneering
resin Sinfony group, the PEEK surface pre-treatment
with Visio.link (69 MPa) showed significant higher TBS
values than with Signum PEEK Bond (48.1 MPa). For
GC Gradia and VITA LM LC no significant differences
Fig. 2
TBS [MPa] boxplots of all tested groups.
between treatment with Visio.link (40.050.9 MPa) and

Signum PEEK Bond (44.557.5 MPa) were observed.
TBS after exposure to thermocycling
Monobond Plus combined with Sinfony (40.8 MPa)
displayed significantly higher TBS than when combined
with GC Gradia (6.1 MPa) or VITA VM LC (1.4 MPa).
Within the Sinfony groups, no differences between
Monobond Plus, Visio.link and Signum PEEK Bond
were observed. Within GC Gradia and VITA VM LC
groups, Visio.link (42.247.0 MPa) and Signum PEEK
Bond (41.347.1 MPa) showed significant higher TBS
compared to Monobond Plus (1.46.1 MPa).
Impact of thermocycling
Thermo-cycling showed an impact on all veneering
resins combined with Monobond Plus. Within the
Monobond Plus pre-treatment group, the negative
impact of thermocycling on the TBS was significant for
GC Gradia (p=0.001) and for VITA VM LC (p<0.001).
Sinfony combined with Monobond Plus (p<0.001)
showed significantly higher values for TBS after
thermocycling. For all remaining groups no impact of
thermocycling was observed (p=0.0680.483).
Weibull statistics
The Weibull statistics are presented in Table 3. In
general, pre-treatment with Visio.link (2.974.64) or
Signum PEEK Bond (2.625.46) showed significant
higher Weibull Moduli compared to specimens treated
with Monobond Plus (0.263.35). The control groups
as well as the pre-treated groups using Z-Prime Plus
and Ambarino P60 showed no bond and therefore both
Weibull parameter such as scale and shape (modulus)
could not be computed.
445
Dent Mater J 2013; 32(3): 441448
Table 2 Mean (SD) and 95% confidence interval of TBS [MPa] of three different veneering resins on air-abraded and
subsequently pretreated PEEK surfaces
Pre-treatment methods
Sinfony
Mean (SD)
GC Gradia
VITA VM LC
95% CI
Mean (SD)
95% CI
Mean (SD)
95% CI
TBS tested 24 h after specimens preparation

Z-Prime Plus
0a
0a
0a
Ambarino P60
Monobond Plus
13.4 (4.6)b
(10.8;15.9)
26.0 (19.3)b
(15.6;36.4)
20.1 (15.1)b
(12.0;28.2)
Visio.link
69.0 (19.6)d
(58.4;79.5)
40.0 (18.8)bc
(30.0;50.1)
50.9 (21.4)c
(39.4;62.4)
Signum PEEK Bond I+II
48.1 (13.8)
(40.6;55.5)
44.5 (10.5)
(47.0;68.0)
without pre-treatment
(38.7;50.1)
57.5 (19.6)
TBS tested after thermal aging (10,000 cycles)

Z-Prime Plus
0a
0a
0a
Ambarino P60
(3.2;9.0)
1.4 (1.9)
(0.32;2.4)
Monobond Plus
40.8 (15.1)
(32.6;48.9)
6.1 (5.2)
Visio. link
53.3 (26.7)b
(39.0;67.6)
47.0 (17.7)c
(37.4;56.5)
42.2 (13.1)c
(35.1;49.2)
54.3 (23.1)b
(41.8;66.6)
41.3 (14.5)c
(33.4;49.1)
47.1 (12.9)c
(40.1;54.0)
a
b
Different letters show significant differences between the methods of pre-treatment among one veneering resin and PEEK
surface.
abcd
Failure types
The relative frequency of the failure types with 95% CI
of all failure types, are shown as percentages in Table 4.
For all veneering resins, the combination with Z-Prime
Plus, Ambarino P60, Monobond Plus and the control
groups without pre-treatment showed predominantly
adhesive failures. In the groups using Visio.link or
Signum PEEK Bond cohesive failures in resin composite
were predominantly detected. No cohesive failure in
PEEK substrate was found.
DISCUSSION
The effective and durable bonding to PEEK is a
prerequisite for its use in dentistry as a definitive
prosthetic material. This study assessed the TBS
between different veneering resins and PEEK after
pre-treatment with different primers and adhesives.
PEEK without pre-treatment was unable to create
any adherence to the definitive veneering composite
materials, despite the fact that surfaces were
roughened beforehand. Also pre-treatment with Z-Prime
Plus and Ambarino P60 showed no TBS, whereas pretreatment with Monobond Plus slightly increased TBS
values. Only Visio.link and Signum PEEK Bond I+II
significantly increased the bond strength between
PEEK and the veneering resins before and after aging.
Therefore, the study hypothesis is valid for Visio.link

and Signum PEEK Bond I+II groups, but not for Z-Prime
Plus and Ambarino P60 groups.
The present study did not include highly polished
PEEK specimens aiming to focus on chemical
interactions. Instead, all surfaces were air-abraded
to create a standardized surface with some
micromechanical retentions. In a previous study, no
adhesion to air-abraded or even silica-coated PEEK
was achieved using self-adhesive resin luting cement18).
However the application of an unfilled resin and a fine
hybrid resin composite resulted in initial bond strengths
of 11.513.5 MPa. Additional acid-etching with sulfuric
acid resulted in increased initial bond strengths up to
21.4 MPa19). No thermo-cycling was performed in the
latter studies.
Storage and thermo-cycling are the most often
used artificial aging methods for simulating fatigue
in laboratory testing of bonding durability20,26). This
minimal requirement of simulating oral conditions
seems necessary before clinical recommendations can
be provided, even with caution. Artificial aging by the
procedure of thermo-cycling may act in two different
ways on the TBS. On one side it may lead to an increase
of the bond strength, caused by the post-polymerisation
in the contact area of the PEEK surface, the adhesive
and the veneering cement. On the other side, the thermal
446
Dent Mater J 2013; 32(3): 441448
Table 3 Weibull modulus (shape) with 95% confidence interval and characteristic TBS (scale) [MPa] of three different
veneering resins on air-abraded and subsequently pretreated PEEK surfaces
Sinfony
Scale
(95% CI)
GC Gradia
VITA VM LC
Shape
(95% CI)
Scale
(95% CI)
Shape
(95% CI)
Scale
(95% CI)
Shape
(95% CI)

Z-Prime Plus
Ambarino P60
Monobond Plus
15.0
(12.7;17.5)b
3.35
(2.26;4.94)a
27.6
(18.0;42.1)b
1.22
(0.8;1.85)a
20.0
(11.8;33.5)b
0.97
(0.62;1.49)a
Visio.link
75.8
(67.7;84.6)d
4.64
(3.02;7.1)a
45.2
(36.2;56.1)c
2.37
(1.56;3.58)a
64.3
(55.0;75.1)c
3.34
(2.26;4.91)b
53.2
(46.2;61.1)c
3.79
(2.63;5.46)a
48.4
(44.0;53.2)c
5.46
(3.62;8.21)b
56.8
(46.6;69.1)c
2.62
(1.71;3.98)b

Z-Prime Plus
Ambarino P60
Monobond Plus
45.7
(38.5;53.9)b
3.11
(2.09;4.61)a
3.9
(1.1;12.6)b
0.44
(0.26;0.69)a
0.17
(0.01;1.20)b
0.26
(0.16;0.39)a
Visio.link
60.1
(47.3;76.1)c
2.9
(2.0;4.24)b
46.6
(41.0;52.9)c
4.1
(2.66;6.21)b
60.7
(50.1;73.5)c
2.68
(1.72;4.15)a
46.1
(39.2;54.0)c
3.3
(2.20;4.83)b
51.6
(45.6;58.8)c
4.15
(2.83;6.05)b
2.17
46.1
(1.40;3.32;67.6)a (44.0;62.61)c
Different letters show significant differences between the methods of pre-treatment among one veneering resin and PEEK
surface.
abcd
stress may lead to mechanical stress of the bonding area

caused by different volumetric changes of the concerned
materials. Both phenomena were observed for the
pre-treatment with Monobond Plus. Whereas thermocycling leads to significant higher TBS for the veneering
resin Sinfony (13.4/40.8 MPa), a significant decrease of
TBS was observed for GC Grandia (26.0/6.1 MPa) and
VITA VM LC (20.1/1.4 MPa). Thermo-cycling after pretreatment with Visio.link and Signum PEEK Bond I+II
showed no impact on TBS.
The choice of the tested adhesives was based on
recommendations of the PEEK manufacturer. The
users manual suggests primarily the use of Visio.link
or Ambarino P60 to create sufficient bond strength
between PEEK surface and different veneering resin
cements. The latter interestingly failed to create any
bonding potential. The other successfully tested material,
Signum PEEK Bond represents an experimental
adhesive for bond to PEEK and has therefore also been
included in this study.
In a previous study, it could be shown that the

application of an adhesive prior to the application of a
self-adhesive resin cement was able to establish bonding
even after thermo-cycling and without sulphuric acid
application27). It seems that MMA monomers are
important contributors of increased bond strength
between PEEK and veneering resins. This was also
supported by the study of Kern & Lehmann, which
showed that a durable bonding to PEEK could only
be achieved using the multifunctional methacrylate
containing resin varnish (Luxatemp Glaze & Bond) on
air-abraded surfaces to create substantial chemical
bonding to PEEK20). This study also concluded that the
use of phosphate monomer containing primer on airabraded PEEK did not result in any adhesion.
In the current study the air-abraded (50 m, 0.2
MPa) PEEK surfaces conditioned with adhesive systems
Visio.link (40.069.0 MPa) or Signum PEEK Bond I +II
(41.357.5 MPa) showed similar or higher TBS results
compared to those obtained with other framework
447
Dent Mater J 2013; 32(3): 441448

Table 4 Failure types, relative frequencies and 95% confidence interval for all tested groups [%]
Sinfony
adhesive relative
frequencies,
95% CI
GC Gradia
VITA VM LC
cohesive
veneering
resin relative
frequencies,
95% CI
adhesive relative
frequencies,
95% CI
cohesive
veneering
resin relative
frequencies,
95% CI
adhesive relative
frequencies,
95% CI
cohesive
veneering
resin relative
frequencies,
95% CI

Z-Prime Plus
100 (79;100)
0 (0;21)
100 (79;100)
0 (0;21)
100 (79;100)
0 (0;21)
Ambarino P60
100 (79;100)
0 (0;21)
100 (79;100)
0 (0;21)
100 (79;100)
0 (0;21)
Monobond Plus
100 (79;100)
0 (0;21)
94 (69;100)
Visio.link
0 (0;21)
100 (79;100)
44 (19;71)
56 (29;81)
75 (47;93)
25 (7;53)
6 (0.1;31)
94 (69;100)
13 (1;39)
88 (61;99)
0 (0;21)
100 (79;100)
0 (0;21)
100 (79;100)
0 (0;21)
100 (79;100)
0 (0;21)
100 (79;100)
6 (0.1;31)
94 (69;100)
6 (0.1;31)

Z-Prime Plus
100 (79;100)
0 (0;21)
100 (79;100)
0 (0;21)
100 (79;100)
0 (0;21)
Ambarino P60
100 (79;100)
0 (0;21)
100 (79;100)
0 (0;21)
100 (79;100)
0 (0;21)
Monobond Plus
44 (19;71)
56 (29;81)
100 (79;100)
0 (0;21)
100 (79;100)
0 (0;21)
Visio.link
38 (15;65)
63 (35;85)
6 (0.1;31)
94 (69;100)
25 (7;53)
75 (47;93)
25 (7;53)
75 (47;93)
25 (7;53)
100 (79;100)
0 (0;21)
100 (79;100)
materials tested in previous studies. Kern & Lehmann20)

tested air-abraded (110 m, 0.28 bar) PEEK pre-treated
with Glaze & Bond and cemented with Luxatemp
Fluorescence and found TBS values between 12.915.0
MPa. In this study the measured TBS after application
of Visio.link or Signum PEEK Bond I +II was significantly
higher by factor two. All other combinations in the Kern
& Lehmann study showed no bond. Hallmann et al.19)
investigated the impact of etching the PEEK surfaces
with piranha solution on the bond strength to resin
cements. The TBS results ranged between 8.6 and 21.4
MPa. Tensile bond strength on air-abraded zirconia (50
m, 5 bar) adhesively cemented ranged from 21.942.8
MPa28) and is comparable to the results in this study. In
contrast, the bonding to etched lithium disilicate ceramic
using a luting resin (Multilink Automix) presented TBS
of 37.949.5 MPa29). The TBS to alloy frameworks in
combination with adhesives and luting cements was
reported to be in the range of 1720 MPa30). All of this
studies found investigated the bond strength to resin
cements. No results for TBS combined with veneering
resins were found. Therefore, it can be concluded, that
the TBS after application of Visio.link or Signum PEEK
Bond I +II and bonding showed excellent results.
Bond strength tests assess the quality of adhesion.
75 (47;93)
0 (0;21)
6 (0.1;31)
100 (79;100)
94 (69;100)
0 (0;21)
Although this study could not replicate all individual

variations of the intraoral conditions, it may help in
determining reliable bond formation between PEEK
materials and veneering resins in dentistry. In conclusion,
the bonding properties of the veneering resins to the
PEEK surface depend on the selective assortment of the
pre-treatment method and the veneering resin, and can
therefore be recommended for further clinical studies.
However, the complexity of the chemistry of the different
bonding agents, as well as possible combinations, makes
general recommendations difficult. The manufacturers
instructions for veneering PEEK frameworks should
provide more details and focus on scientifically proven
materials.
ACKNOWLEDGMENTS
The authors would like to express their gratefulness
to nt-trading, 3M ESPE, VITA Zahnfabrik, Creamed,
Ivoclar Vivadent, Bredent and Heraeus Kulzer for
supporting this study with materials.
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Zeitschrift fr Zahnrztliche Implantologie

JDI Journal of Dental Implantology
presented by
bredent GmbH & Co. KG

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Germany
Telephone +49 (0) 7309/87222
Telephone +49 (0) 7309/87224
www.bredent.com
info@bredent.com
Special edition
Edition 29, Book 2 (2013), Pages 148159
B. Siewert, M. Parra
Eine neue Werkstoffklasse in der
Zahnmedizin
Editor
Deutsche Gesellschaft fr Implantologie im Zahn-, Mund- und Kieferbereich e.V.

and
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and
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REF 000714GB
The publisher retains all rights, including reprinting, photomechanical reproduction of this special
and
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Deutscheredition
rzte-Verlag
| zziits
| Z Zahnrztl
Impl | 2013; 26 (2)
B. Siewert, M. Parra:
A new group of material in dentistry
FROM PRACTITIONER TO PRACTITIONER

1
B. Siewert , M. Parra

PEEK as a framework material used in 12-piece implant-supported bridges
Polyetheretherketone (PEEK) is a thermoplastic resin

employed in the field of industry and medicine for several
years. This semi-crystalline high performance composite
offers a unique combination of outstanding physical
properties, stability at high temperatures and excellent
resistance to chemical damage. These are some of the
reasons that allow the use of PEEK as a framework material
for removable dental prosthesis in the patients mouth. In
this article the manufacturing process of these 12-piece
tooth-implant-supported and implant-supported screw
retained bridges in the dental laboratory and the dental
office as well as the clinical outcome and observation are
described through two similar patient cases.
Keywords: screw retained dental bridge; metal free;
polymer; polyether ether ketone; PEEK; dental
implant
Citations:
B. Siewert, M. Parra: A new group of materials in dentistry
PEEK als Gerstmaterial bei 12-gliedrigen implantatgetragenen Brcken
(A new group of materials in dentistry. PEEK as a framework material for
12-piece implant-supported bridges). Z Zahnrztl Implantol
2013;29:148159
DOI 10.3238/ZZI.2013.01480159
1
2
Bernd Siewert, Dr., Clnica Somosaguas, Calle Aquiln, 2, E-28223 Madrid, siewert@dental-med.com
Mario Parra, DT, Laboratorio Dental Parra, Calle Martinet, 13, E-03530 La Nucia, parralab@wanadoo.es
Deutscher rzte-Verlag | zzi | Z Zahnrztl Impl | 2013; 29 (2)
o
n
Figure 1 This implant-supported bridge is metal reduced (Framework: BioSX, Veneering: PMMA-
Figure 2 The chemical formula of
Veneers) and has a total weight of 0,47 oz. The construction has no metal parts apart from the
polyetheretherketone: In 1963 DuPont
titanium caps..
synthesised the material polyaryletherketone.

Photo: DT Mario Parra
Image: Wikipedia
Introduction
PEEK - this abbreviation stands for
'Polyether ether ketone', a relatively new
material in dentistry terms with tremendous
potential for the future. Polyetheretherketone is
a semi-crystalline high-performance polymer
combining good mechanical properties with
high temperature resistance and excellent
resistance to chemicals. This means PEEK can
be used fairly universally as a material, as its
successful track record over many years in both
industry and medical technology would suggest.
The material has begun to establish itself within
dentistry during the past few years. The physical
and chemical properties are impressive and can
be explained by the polymer's structure, which
is based on a chain of aromatic rings. Other
advantages are the material's elasticity and the
high melting point. PEEK only melts at
temperatures above 280C, which means it can
be treated using hot sterilisation methods. The
flexural strength of 3.1 GPS and high modulus
of elasticity stop the material breaking and give
it a consistency similar to that of bone. This
opens up a new range of indications in terms of
metal-free removable prosthetic restorations.
'PEEK-Classix', on which the material is

based, has so far only been approved for
temporary restorations. This article
describes the product BioXS (bredent).
This is essentially a 'PEEK-Classix', but
has been optimised by the manufacturer to
such a degree that it has been approved in
its own right. In spite of this, any work
produced with this material - as well as all
PEEK-based restorations - have so far had
to be of the (partially) removable variety.
The screw arrangements used for implantsupported bridges satisfy this requirement.
The material BioXS is a thermoplastic
high-performance polymer. It can be used as
a framework material for bridges, which
makes it a possible alternative to traditional
metal alloys or zirconium dioxide. One
disadvantage of the latter materials is their
high degree of rigidity. With implant-based
restorations in particular, this can cause
bone to suffer stress and have far-reaching
consequences. By contrast, PEEK has
similar elasticity to bone. If PEEK is used as
a framework material for implant-based
prosthetic work, it can contribute to the
long-term success of the treatment.
Depending on the degree of bone resorption

[7], fixed implant-supported or tooth/implant
supported bridges and partially removable
bridges tend to have an extended prosthetic
crown length in an edentulous jaw or where
there is significantly reduced residual dentition
[9, 5]. This can have a number of
disadvantages. For example, the vertical
cantilever (lever arm created by the ratio
between the implant length and the crown
length) increases the lateral forces on the
implant. Because of the lever ratios, the load
on the implants when eccentric forces are
applied increases as the length of the
superstructure increases [11]. The volume of
the bridge also increases in proportion to the
level of bone resorption, with the framework
becoming rigid and heavy if metal alloys are
used or zirconium dioxide partially stabilised
by yttrium.
A material with sufficient stability
and resistance to chemicals within the
mouth, which also cushions chewing
forces as they are transferred to implants
and has a low specific weight, may be the
solution to this problem [3].
Figure 3a, 3b The initial clinical findings: vestibular and occlusal view. The prosthesis as well as the remaining teeth in the upper jaw were not
preservable.
Figure 4 The orthopantomography of the initial clinical situation.
Figure 5 The desired implant position sketched in the x-ray. The tilted
posterior implants make it possible to place the posterior implants in
natural mature bone without augmentation.
.
The descriptions below relate to two

clinical patient case studies where the
maxilla was fitted with a solely implantsupported bridge in one case and a 12tooth tooth/implant-supported bridge in
the other. PEEK (BioXS, bredent) was
used as the framework material. In the
first scenario the prosthetic procedure
adopted
the
'backward
chaining'
approach [1], whereby an objective is
defined, which then indicates the path to
be taken. In dentistry 'backward
planning' has established itself as the
preferred term for this kind of thing.
Both bridge frameworks were
veneered with prefabricated PMMA
plastic veneers (visio.lign, bredent),
thereby creating very light (13.4 g total
weight) composite bridges (Fig. 1) with
less metal and a cushioning effect.
Figure 6
Backward Planning:
The wax-up is the
first step to defining
the goal..
Materials and methods

In 1963 DuPont synthesised the material
polyaryletherketone (Fig. 2), which has
been mass-produced since 1978 by ICI in
the form of Polyetheretherketone (PEEK). This
is a semi-crystalline thermoplastic material with
outstanding physical characteristic values in terms
of stability, rigidity, and dimensional stability.
The melting point is somewhere between 340 and

420C. Water absorption is only 0.1% compared
with 0.3% for PMMA (polymethyl methacrylate)
[2, 6, 4]. PEEK is very important in the
automotive and aviation industries [17], with
worldwide sales of the material increasing
strongly each year [13].
Figure 7a, 7b In the tridimensional display of the anatomical structures a precise implant positioning could be achieved.
Figure 8 After extraction. The provisional removable denture
Figure 9 The drilling guide is constructed combining the data
was elaborated matching the wax-up.
of the wax-up (optimal tooth position) and the cone beam

tomography (optimal position of the implant in the bone).
In the field of medicine PEEK has been

successfully used for many years as a
bioinert sterilisable material [16, 12] and
as a material for implants (orthopaedics)
[8]. There has been no evidence of any
clinically significant material fatigue [19,
18]. Across all areas there is a growing
tendency to use the material PEEK
instead of titanium and aluminium [14,
10].
The PEEK material BioXS (bredent, Senden)
used for the patient case studies described here is
whitish in colour, has a density of 1.38 g/cm3, and
a bend modulus of elasticity of 3.1 GPa. This is
comparable with spongy bone. BioXS is
available as granules and is processed in a

special
compression-moulding
unit
(Thermopress 400, bredent, Senden).
PEEK has since been developed

further as a material. Processing is
now based on the 'for 2 press'
compression-moulding process. The
material now contains ceramic
elements and is white in colour,
which makes it better suited to
prosthetic applications. It has been
possible to improve the reliability of
PEEK processing thanks to the new
procedure, which involves a vacuum
and subsequent compression during
cooling. The initial results are very
promising. The patient case studies
described here involved the use of
BioXS.
The processing sequence is similar to metal
casting. The framework veneering increases
the characteristic values of the material.
Achieving a high-gloss finish on the basal

surface of the framework is particularly
important in order to minimise plaque accretion
[15].
Patient case study 1

Initial situation
The 55-year-old patient consulted us in
October 2010 with a view to replacing her
dental prosthesis. The maxilla had been given
a metal/ceramic restoration eight years ago
(Fig. 3a, 3b). Given the poor aesthetic quality
and the impaired performance associated with
the loose bridge and the abutment teeth, she
was interested in a new restoration.
Figure 10, 11 After implant placement the patient was provided with a screw retained prefab-
Figure 12 The control x-ray after implant
ricated metal reinforced provisional acrylic bridge.
placement.
.
Figure 13a and 13b After 4 months of osseointegration the provisional bridge could be easily removed and the impression taking was performed.
Figures 3a13b: Dr. Bernd Siewert
Even at first sight, there was clear evidence of a

high laugh line and exposed gingiva. X-ray
examinations found advanced bone loss (Fig. 4).
History: 55-year-old patient (non-smoker):
metal/ceramic bridge from tooth 17 to teeth 15
and 14, crown block on teeth 14, 15, 16, apical
translucency at teeth 12, 11, 21, 23, and 24.
Intraoral diagnostics found there to be
generalised pockets more than 6 mm deep,
subgingival concretion at root surfaces, and
gingival bleeding upon probing. The thorough
diagnostic process found the maxillary
restoration to be not worth keeping. Similarly,
there was little value in keeping or re-crowning
the remaining front teeth as a result of caries at
the edges of crowns, periodontitis, and apical
inflammation (apart from tooth 13). Another
consequence of the poor condition of the mouth
was bone atrophy in both a horizontal and a
vertical direction.
After a thorough consultation process,

we opted for an implant-based
prosthetic restoration of the maxilla.
Planning
With conventional implant therapy, it is not
unusual
in
such
cases
(involving
considerable bone atrophy) to reach the
limits of what can be achieved, inasmuch as
implant-based prosthetic treatments are
either impossible or involve a tremendous
amount of work because of the low bone
volume. Our patient wanted to avoid any
kind of bone reconstruction measures. A
decision was therefore made to use the
fast&fixed process, which is similar to the
all-on-four concept (anchoring of four
implants). The angulation of the eventual
implants favoured optimal use of the
existing bone and made it possible to
dispense with laborious augmentative
measures, while bypassing any anatomical
structures which might be put at risk (like
the maxillary sinus) (Fig. 5).
The residual dentition was to be extracted in

two stages, while initially retaining teeth 13
and 23 as anchoring points for the interim
prosthesis and the X-ray or drilling template.
The plan was for the patient to leave the
practice with a temporary bridge from 15 to
25 made in advance after implants had been
inserted using a template (immediate
loading). Our choice for the definitive
restoration was a partially removable
implant-based bridge. The framework was to
be made from the PEEK material BioXS.
Preparatory work
A wax-up was made on the situation model
and then optimised in accordance with the
patient's wishes (Fig. 6).
Figure 14 The desired framework is formed in wax. The oral part of the
framework is shaped according to the definitive dimensions.
Figure 15 The wax framework structure is converted to BioXS (injection

moulding).
Figure 16 The veneers are adhered onto the framework (visio.lign-system,

bredent).
Figure 17a, 17b Elaboration of the pink esthetics (visio.lign-system, bredent).

Figures 1417b: DT Mario Parra
The dental technician prepared an Xray template from this, which was used
for the digital volume tomography
(DVT) image. Once the DICOM data
had been exported to the planning
software (SKYPlanX), the relevant
anatomical
structures
could
be
visualised with the 3D representation
and the implants positioned in exactly
the right place from a prosthetic and
anatomical perspective. Given that the
maxillary sinus is heavily pneumatised,
both implants were to be arranged at an
angle in the posterior area (35).
This angle is compensated for in turn by

the 35 angle at which the abutments are
arranged (Fig. 7a, 7b).
The first phase of surgery involved the
extraction of teeth 17, 15, 14, 12 to 22, and 24
to 26. The patient was given an interim
prosthesis during the healing phase, which
reflected the various functional parameters
and the patient's aesthetic preferences (waxup) and provided the basis for the rest of the
process (Fig. 8). Once a one-month healing
period had elapsed, it was possible to assess
whether the high laugh line had an impact on
the aesthetic results.
During laughter the transition between the

artificial and natural gingiva should not be visible.
The X-ray template was converted into a
drilling template at the certified SKYPlanX
laboratory (Laboratorio dental, Mario Parra,
La Nucia, Alicante) (Fig. 9). The dental
technician 'inserted' the model implants into
the plaster model in accordance with the plan
and made a temporary bridge based on the
wax-up (CrCo interior structure and acrylate
veneering).
Figure 18a, 18b The completed prosthesis.
Figure 19a, 19b

The situation after the placement into
the patients mouth. The risk of the
exposition of the transition from the
artificial to the natural gingiva due to the
high smile line could be successfully
eliminated.
Insertion of implants
A check was performed before surgery to
ensure the drilling template fitted
properly. Everything was found to be
consistent with both the model and the
plan at the pre-prosthetic stage. The
template was a good fit and was also
fixed to teeth 13 and 23. It was now
possible to insert the implants (blueSKY,
bredent medical, length 16 mm, diameter
4 mm) using a minimally invasive
approach. The template-driven procedure
caused little postoperative pain and
proved its worth once more in this
instance. The first step was the pilot
drilling for implants in region 12 and 22.
The drilling template was then removed
and teeth 13 and 23 extracted. Now the
template could be reduced with precision
and the two pilot drills inserted in region
12 and 22. This ensured the drilling
template was fixed securely in place at
all times.
The drilling for the angled implant 15 also

crossed the socket in region 13 at an apical
level; the variation described made it possible
to avoid intraoperative problems. Once the
implants had been inserted, the selected
abutments were screwed in and the temporary
bridge inserted (Fig. 10-12). When making the
bridge, the dental technician had considered
placeholders. In order to ensure the
framework was stress-free, he only integrated
a single prosthetic cap in the laboratory. The
other caps were inserted in the mouth. The
result was a passive fit inside the mouth. Once
the bridge had been screwed in, the occlusion
check was done, grinding was performed in
terms of the centric relation, and canine
guidance was achieved. The final tasks were
the finishing work on the adhesive joint,
cleaning up, and then polishing.
Four months later (Fig. 13a) - Treatment sequence for the

final prosthetic restoration (partially removable bridge) at
the practice and laboratory
1. Practice: Closed impression of the maxillary

situation with an addition-cured silicone and
determination of the jaw relation
2. Laboratory: Manufacture of a model with Class IV

hard plaster, implant analogues, and a gingival
mask around the area of the implants
3. Laboratory: Tooth set-up in wax based on the

verified wax-up with the veneers selected for the
definitive restoration (novo.lign A+P, visio.lign,
bredent)
4. Practice: Verification of the set-up on the patient,

taking into account all the relevant clinical
parameters (centric relation, vertical dimension,
midline, size and shape of teeth, symmetry of
bi-pupillary line, lip support, laugh line, colour,
harmonious dental arch)
10 A new group of material in dentistry
Figure 20a, 20b Checkup after 1 year of clinical use. The x-ray shows absolutely stable hard tissues. The soft tissue performance is also very good.
.
Figure 21, 22 The initial clinical findings of the second case.
5. Practice
or laboratory: Selection of
suitable abutments in each case with the
help of the silicone key resulting from the
wax-up:
Posterior
implants: The 35.5

fast&fixed abutments (30 N cm)
already screwed in during implant
insertion remain untouched.
Anterior
implants:
UVE
abutments angled at 15 replaced
to achieve better aesthetic results
(Fig. 13b).
6. Laboratory: Framework modelling in wax

is performed using the veneers applied to
the matrix. The oral surface of the
framework is modelled on a full
anatomical basis (Fig. 14) .
7. Laboratory: The spruing and investing

work steps are the same as for metal
casting. Compression moulding of the
heated BioXS granules takes places in the
Thermopress
400
injection-casting
machine (bredent, Senden) (Fig. 15).
8. Laboratory: The veneers (visio.lign) are

bonded to the framework in accordance
with a specially developed working
protocol (Fig. 16).
Clinical results and situation after a

year
9. Laboratory: Formulation of the gingival

sections with a composite (crea. lign
Gingiva, bredent, Senden) (Fig. 17)
10. Practice: Two anterior abutment caps are

sprayed with BioXS, while both posterior
caps are pre-glued in the patient's mouth.
This procedure
gives the bridge a 'passive fit' at all
abutments.
11. Laboratory: Final release and high-gloss

finish taking the basal surface into
account (Fig. 18a, 18b)
12. Practice: Insertion (Fig. 19a, 19b)

13. Practice: Recall after 12 months. The Xray check is shown in Figure 20a and the
clinical position in Figure 20b.
The patient was very pleased with the aesthetic

results and the level of comfort when chewing.
Oral hygiene at home was good and easy to
achieve with an oral shower. Even when the
muscles used during laughter were fully tensed,
the transition between the bridge and the natural
gingiva was not exposed. The peri-implantar
gingiva was free from irritation. During the 12
months that the prosthesis was worn, the
veneers did not come loose and there were no
cracks or discolouration. The bonding of the
secondary parts was stable. There were no signs
of changes at the PEEK surface, apart from the
high-gloss surface appearing to have lost some
of its shine. The gingival line and the bone level
were stable.
11
Figure 23 X-ray control 6 months after

implant placement.
Figures 18a23:
Dr. Bernd Siewert
Figure 24, 25 The wax forming of the framework (Fig. 24) and the veneering of the PEEK framework (Fig. 25).
The bridge is quickly and easily removed by

loosening the four screws so the implants
can be safely inspected and kept clean.
Patient case study 2

The patient described in this second case
study consulted us in November 2007. She
had been wearing a fixed maxillary
restoration for six years, but it was no longer
sufficiently secure. The cemented restoration
was able to move and was causing her pain
(Fig. 21).
Initial situation
The panoramic radiograph provided by the
patient (Fig. 22) showed a metal bridge with
plastic veneers supported by teeth 16, 11 and
21 and three implants (region 13, region 24,
and region 26). The roots of teeth 11 and 21
had been destroyed by caries and the bone
around the implants had been absorbed as a
result of peri-implantitis.
Under local anaesthetic the bridge

was removed in one piece from the
surrounding connective tissue, the
defective bone was cleared of
inflamed connective tissue, and a full
interim prosthesis inserted to serve as
an immediate restoration.
However, the blade implant in region 13 resulted

in vestibular bone resorption, which made
simultaneous bone augmentation inevitable (bone
replacement material: mp3, Tecnoss, Turin, Italy;
absorbable collagen membrane: Evolution,
Tecnoss, Turin, Italy).
Implant insertion
Planning
The patient was critical and her mood
unstable as a result of previous bad
experiences. The desire to make another
fixed restoration for her was undermined by
her limited financial circumstances and an
unwillingness to accept augmentative
measures (e.g. bilateral sinus lift). The plan
was to insert five implants. Tooth 16 was to
be retained. An implant at an angle of 35
was planned for the local bone in region 24.
The implant position in region 13 was of
strategic importance for the fixed dental
prosthesis.
Three months after treatment had started, the

situation was stable and the five proposed
implants (blueSKY, bredent-medical, Senden)
could be inserted. Given the small amount of
bone available, these were positioned in
regions with an adequate amount of local
bone, which went against the backward
planning for prosthetic purposes. The
intervention was carried out without any
complications. The patient was given an
interim prosthesis during the submerged
healing phase.
Figure 26 All the components of the

finished work.
Figures 2426:
DT Mario Parra
Figure 2729 The placement of the finished prosthesis.
After six months, X-ray checks

(Fig. 23) and clinical inspection
found everything to be stable. The
implants
were
revealed
and
preparations began for the prosthetic
phase. The idea was to have a
partially
removable
bridge
supported on the five implants and
the molar in region 16. This kind of
restoration can be implemented
using screws or a temporary
cementation process. A decision
was made to use screws for this
restoration.
The treatment sequence for the

prosthetic restoration (partially
removable bridge)
at the practice and laboratory is
practically identical to patient case
study 1.
1. Practice: Closed impression of the
maxillary situation with an additioncured silicone and determination of the
jaw relation
2. Laboratory: Manufacture of a model
with Class IV hard plaster and implant
analogues, saw cut 16 and gingival mask
around the area of the implants
3. Laboratory: Tooth set-up in wax with the

veneers selected for the definitive
restoration (novo.lign A+P, visio.lign,
bredent)
4. Practice: Verification of the set-up on the
patient, taking into account all the relevant
clinical parameters
5. Practice or laboratory: Selection of the
suitable abutments in each case:
Tooth 16 and implant region 11:
Preparation of double crowns
Implants region 13 and region
21: Mass-produced abutment at
an angle of 15 with horizontal
screws (UVE, bredent medical,
Senden)
Implant region 24: Abutment at
an angle of 35 with a funnel,
which can be cut to size,
screwed on the occlusal side
(fast&fixed abutment, bredent
medical, Senden)
Implant region 26: The highly
dense
mucosa
made
it
impossible to use horizontal
screws. An abutment at an angle
of 0 was chosen with a funnel,
which can be cut to size,
screwed on the occlusal side
(fast&fixed abutment, bredent
medical, Senden).
6. Laboratory: Framework modelling in wax

(Fig. 24)
7. Laboratory: Spruing, investing, and
compression moulding of the heated
BioXS granules in the Thermopress 400
injection-casting
machine
(bredent,
Senden)
8. Laboratory: The veneers were bonded to
the framework in accordance with the
working protocol (Fig. 25).
9. Laboratory: Formulation of the gingival
sections
10. Practice: The abutments were fixed in
place in the patient's mouth with a small
amount of dual-curing composite. The
elements definitively fixed in the bridge
served as reference points. This procedure
gives the bridge a 'passive fit' at all
abutments (Fig. 26).
11. Laboratory: Final release and high-gloss
finish taking the basal surface into
account
12. Practice: Insertion (Fig. 27-29)
13. Practice: Recall after 14 months. The
clinical position is represented in Figure
30a and the X-ray check in Figure 30b.
13
Figure 30a, 30b The follow-up after 14 months shows a very good result.
Clinical results and situation after a

year
During the 14 months that the
prosthesis had been worn, the veneers
had not come loose and there were no
cracks or discolouration in this case
either. The bonding of the secondary
parts was stable. There were no signs
of changes at the PEEK surface either,
apart from the high-gloss surface
appearing to have lost some of its
shine. The gingival line and the bone
level were stable, apart from some
minor bone remodelling at the
augmentation around implant region
13. The bridge is quickly and easily
removed by loosening the four screws
so the implants can be safely inspected
and kept clean.
Discussion
PEEK - 'Polyether ether ketone' offers the
greatest potential for big prosthetic jobs. The
material is really quite
a 'new' addition to the restorative
dentistry family, and there are still no
similar materials with which it can be
compared. Materials traditionally used
for these kinds of indications are gold,
NPM, or zirconium dioxide, although
these have a number of disadvantages.
Here are the disadvantages
associated with materials traditionally
used in frameworks:
Gold: High cost of material
NPM: Laborious processing, allergy
triggers, reactions with other materials
Zirconium dioxide: High modulus of
elasticity, so no cushioning of
chewing forces, chipping
Figures 2730b: Dr. Bernd Siewert
This material characteristic value comes from

the field of materials technology and describes
the relationship between stress and expansion
when a solid body becomes distorted. The
modulus of elasticity increases as a material's
resistance to distortion increases. A component
made from a material with a high modulus of
elasticity (e.g. NPM) is rigid; a component
made from a material with a low modulus of
elasticity (e.g. rubber) is flexible. By way of
comparison, zirconium oxide has a modulus of
elasticity of 100 GPA, as does NPM.
Processing of the material BioXS is
laborious and requires dental technicians to have
considerable expertise in terms of this concept.
CAD/CAM technology promises much in this
area, since it makes it possible to minimise the
more laborious work steps. Compression
moulding of BioXS uses the injection-casting
system (Thermopress). Carbide mills, rubber
polishers, and goat-hair brushes can be used for
processing purposes. The good polishing
properties reduce both the tendency to
discolouration and the affinity for plaque. Contact
with the gingiva causes no irritation.
The high-performance polymer

PEEK avoids these unfavourable
characteristics, making it possible
to prepare light, metal-free bridge
structures.
Here are the advantages associated
with PEEK as a framework material:
Preparation of bridges with a low specific
weight
Elasticity of material similar to that
of bone
Shock-absorbing effect
Metal-free restorations
Very little abrasion (within
physiological range)
Low material fatigue
No viscoplastic fractures
High biocompatibility
Low plaque accretion (depending
on positive and negative charges)
No corrosion
Option for full anatomical
framework design
It is important that the user is familiar
with the mechanical properties to have a
better idea of the possible applications.
The material used here is a pigmented,
linear, and semi-crystalline thermoplastic.
The base material is polyetheretherketone
(PEEK),
which
was
specifically
developed as a veneer-compatible
framework material for intraoral use.
Processing is designed not to impair the
good material properties. The material has
a semi-crystalline structure, which makes
it less brittle than zirconium dioxide
(crystalline structure). The bend modulus
of elasticity of 3.1 GPa is similar to that
of bone.
Conclusion
It is striking how good the condition of hard
and soft tissue is after a long period of wearing
the restoration made of the PEEK material,
even when oral hygiene is only average. This
may be because the bridge framework contains
no metal, as well as the optimal elasticity of
the bridge structure, the good cushioning
properties of the veneers, and the passive fit
associated with the intraoral bonding of the
secondary parts.
There is little chance of material fatigue

either, and fractures and/or chipping can be
virtually ruled out. The fact that screws are
used to secure the prosthesis avoids the
problems associated with permanent or
temporary cementation.
The use of mass-produced parts makes

products easier to prepare, guarantees a
high level of precision, and ensures that
materials are of excellent quality.
Until now, the technically delicate
processing required in the laboratory
brought with it a number of disadvantages,
such as material fractures associated with
the investing material or the formation of
cavities.
Literature
1.
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Tribune US 2008;11:611
10. Mattila R: Non-resorbable glass

fibrereinforced
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with
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vitro and in vivo focused on boneimplant interface. Dissertation 2009,
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12. Nieminen T, Kallela I, Wuolijoki
E, Kainulainen H, Hiidenheimo I,
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B, Patel R, Albert T, Vaccaro AR:
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16. Ratner BD: Biomaterials Science. An
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Although this process (as with all

casting processes) may cause some
hidden impairment in material quality
(changes to the crystal structure), all
bridges made this way so far (n = 9)
have really proven their worth.
CAD/CAM
technology
represents
progress in this area, with the author
having had some very promising initial
experiences. The blanks required for
this will be on the market soon.
The very promising results achieved with
PEEK as a framework material for highvolume prosthetic restorations will need to be
backed up by further patient restorations and
clinical studies over longer observation
periods. The authors are planning further
articles with a view to providing a detailed
description of the work steps involved in the
laboratory. A statistical assessment of a
variety of prosthetic restorations is also
planned.
Since the work done by the manufacturer
so far, in terms of the dental applications of
PEEK, could be described as pioneering, the
authors have not yet been able to find in the
literature any publications on the use of PEEK
as a bridge framework in the field of dentistry.
Conflicts of interest: The authors have
spoken at events for the bredent group, which
supports the publication financially.
Citations:
B. Siewert, M. Parra: A new group of
materials in dentistry
PEEK als Gerstmaterial bei 12-gliedrigen
implantatgetragenen Brcken (A new group of
materials in dentistry. PEEK as a framework
material for 12-piece implant-supported
bridges). Z Zahnrztl Implantol 2013;29:148159.
DOI 10.3238/ZZI.2013.01480159
Address for correspondence
Dr. Bernd Siewert
Clnica Somosaguas
Su salud dental es nuestra pasin
Calle Aquiln, 2
C.C. Prado de Somosaguas
E-28223 Madrid
Tel.: 0034 917114265
siewert@dental-med.com
www.dental-med.com, www.ciam.org.es
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JENA UNIVERSITY HOSPITAL

OUTPATIENT DEPARTMENT FOR DENTAL PROSTHETICS AND MATERIALS

BIO HPP Summary of results

By A. Rzanny, R. Gbel, M. Fachet

2. Materials, method and test conditions

PMMA Composite Primer

2.2 Methods and test conditions

Direction of motor rotation:

Motor speed on the left:

Motor speed on the right:

Total number of cycles:

24 h water storage at 37C

2. Artificial ageing with temperature change load: 25 000 TCL (5-55C)

24 h water storage at 37C

2. Artificial ageing with temperature change load: 25 000 TCL (5-55C)

VITA VM SR Adoro HeraCeram

Tendency to discolouration E without methylene blue

VITA VM SR Adoro HeraCeram

Tendency to discolouration E in methylene blue

Sinfony VITA VM SR Adoro HeraCeram

Fig. 4: Tendency to discolouration E of Bio HPP after storage in methylene

3.2. Surface quality

against the direction of processing

against the direction of processing

against the direction of processing

Surface roughness [m]

Super Snap (4 stages) vertical

Surface roughness [m]

Super Snap (4 stages) Direct Dia

Dental technical instruments

3.3. Abrasion resistance

Table 7: Abrasion of different composites and Bio HPP

Composite A Composite B Gradia

Table 8: Bonding strength of Bio HPP to DTK

Bio HPP - DTK adhesive

ZrO2 ceramic - Veneering ceramic

Noritake zirconium ceramic

EPS e.max ZirCAD

Pressure-shear resistance [MPa]

Table 9: The bonding strength of BIO HPP of different surface quality to

Bio HPP (milled), visio.link,

Bio HPP (pressed with

combo.lign Code: BgpP-vl.-Ocl-cl

Bio HPP (milled), composite

Pressure-shear resistance [MPa]

3.5. Structural analysis

Fig. 10 shows the structure of BIO HPP magnified 5000 times.

Fig. 10: Structure of Bio HPP

Jena, 10.01. 2013

Science and further training

Using plastics for implant-based

Introduction and outline of the issues

The traditional method of processing prosthetic teeth on a

Science and further training

Fig. 3: Fitting the milled frameworks in the maxilla and

The good thing with this approach is how patients can

Fig. 2: Structure of the CAD/CAM framework for the mandibular

Fig. 4: Titanium framework conditioned with bonder and opaquer

Fig. 6: Layered application of plastic to ensure a permanent bond

Since the moduli of elasticity for the framework materials

Science and further training

Fig. 7: Using mucosa-coloured plastic to achieve an individual