Koizumi et al.

Int Chin J Dent 2010; 10: 47-50.

Seating zirconia-based posterior fixed partial dentures with aphosphate primer and an acrylic adhesive resin: A clinical report
Hiroyasu Koizumi, DDS, PhD,a,b Daisuke Nakayama, DDS,a Mamiko Kochi, DDS,a andHideo Matsumura, DDS, PhDa,bab

Department of Fixed Prosthodontics, and Division of Advanced Dental Treatment, Dental ResearchCenter, Nihon University School of Dentistry, Tokyo, Japan
This article reports bonding technique and clinical performance of ceramic fixed partial dentures (FPDs) applied
to a metal allergic patient. Frameworks of mandibular four- and three-unit FPDs were fabricated with atetragonal zirconia polycrystal (TZP) material (Cercon) and veneered with feldspathic porcelain (Cerabien ZR).
After try-in, the surface to be bonded was air-abraded with alumina (0.2 MPa), and treated with a single liquidprimer (Alloy Primer) that contained a hydrophobic phosphate monomer (MDP). Abutment dentin surfaces
were etched with 10% citric acid-3% ferric chloride (10-3) aqueous solution, and the FPDs were bonded with atri-n-butylborane (TBB) initiated adhesive resin (Super-Bond C&B). After an observation period of two years,
both FPDs were functioning satisfactorily. The materials and procedure reported here are applicable as anoption for a prosthodontic treatment for the patients incompatible to specific metallic elements.
(Int Chin J Dent 2009; 10: 47-50.)
Key Words: adhesive, ceramics, fixed partial denture, primer, zirconia

Introduction
Replacement of missing teeth in both the anterior and posterior regions is important for recovering toothanatomic form, natural appearance, mastication, and other oral functions. Prosthodontic treatment for medicallycompromised patients is more difficult than that for physically healthy patients.

Removable, fixed, andimplant-supported dentures are used according to the location and number of teeth to be recovered, as well as
condition of the abutments. Among the prosthodontic appliances, single restorations and fixed partial dentures(FPDs) with zirconia coping or framework are currently applicable and acceptable as an option for thereplacement of missing teeth.1-7
Zirconia ceramics are being used in fabrication of denture frameworks and copings for single restorations.
Varying materials and techniques are currently available for bonding zirconia; 1) silica sintering,8 2)
tribocheminal coating,9,10 and 3) application of a hydrophobic phosphate monomer.8,10-13 Although a number ofadhesive systems for seating zirconia restorations have been reported, only limited information is available
concerning the clinical performance of zirconia restorations seated with a specific bonding system. This clinicalreport describes a technique for seating zirconia-based FPDs with a phosphate-based primer and atri-n-butylborane initiated adhesive resin.

Clinical Report
A 74-year-old male patient, who had been diagnosed as pustulosis of palms and soles (Pustulosis palmaris etplantaris), presented with functional disturbances as a result of a missing mandibular right second premolar, firstmolar, and left molars. The patient was allergic to specific metal-protein complexes, and had undergone
extraction of premolar and molars due to periodontitis. Several treatment options were therefore proposed: 1)
ceramic implant; 2) a titanium-based removable partial denture (RPD); and 3) cermic FPD with considerable
tooth reduction. The patient chose the third of the proposed options. The prosthodontic procedure was thenexplained in detail and consent was obtained from the patient.

47

Koizumi et al.

Fig. 1.

Abutment preparation for the right FPD

Int Chin J Dent 2010; 10: 47-50.

Fig. 2.

A four-unit zirconia-based FPD

Figs. 3 and 4. The surfaces to be bonded were air-abraded with alumina under 0.2 MPa air pressure.

Fig. 5.

Application of Alloy Primer with MDP

Fig. 6.

Occlusal view after two years of posterior FPDs

For the prosthodontic procedure, fabrication of two fixed partial dentures was planned. The procedure started
after improvement in the condition of the periodontal tissues of abutments. Intercuspal position and lateralmandibular movement were examined intraorally with articulating paper and wax materials, and were examined
extraorally using a stone cast mounted on an articulator. After examination of the maxillo-mandubular relation,
the areas and thickness to be reduced were determined. Considering the age of the patient as well as appearanceof pulp chamber detected from the radiographs, possible amount of reduction for the occlusal plane and axial
walls were estimated as approximately 1.5 and 1.2-1.5 mm, respectively. Reduction was then performed bymeans of a high-speed diamond rotary cutting instrument with marginal rounded shoulder preparation (Fig. 1).
Frameworks of a right four-unit FPD (Fig. 2) and a left three-unit cantilevered FPD with a flat back pontic were
fabricated with a tetragonal zirconia polycrystal (TZP) material (Cercon, Dentsply/Sankin, Tokyo, Japan).

48

Koizumi et al.

Int Chin J Dent 2010; 10: 47-50.

Feldspathic ceramic material (Cerabien ZR, Noritake Dental Supply, Miyoshi, Japan) was layered entirely
surrounding the frameworks, and sintered in an electric furnace for the reproduction of tooth color.
The completed FPDs were tried-in at the next appointment.

The inner surfaces of the retainers were

air-abraded with 50- to 70-µm grain sized alumina (Hi-Aluminas, Shofu Inc., Kyoto, Japan) using an airborne
particle abrader (0.2 MPa pressure; Jet-Blast II, J. Morita Corp., Suita, Japan) (Figs. 3 and 4), and treated with asingle liquid primer (Alloy Primer, Kuraray Medical Inc., Tokyo, Japan; Fig. 5) that contained 10-methacryloyloxydecyl dihydrogen phosphate (MDP). The abutment dentinal surfaces were conditioned with 10% citricacid-3% ferric chloride (10-3) aqueous solution (Green Activator, Sun Medical Co., Ltd., Moriyama, Japan),washed with water, and air-dried. The FPDs were then seated with a tri-n-butylborane (TBB) initiated adhesiveresin (Super-Bond C&B, Sun Medical Co., Ltd.). The patient then entered a maintenance program. After anobservation period of two years, the FPDs were still functioning satisfactorily (Fig. 6).

Discussion
One of the problems associated with prosthodontic treatment for metal allergic patients has been difficulty infabrication of both fixed and removable dentures. Due to the pustulosis of palms and soles, application of
metallic FPDs to this patient appeared to be contraindicated. The dentist in charge of the patient proposedoptions for prosthodontic treatments, and the patient accepted fabrication and seating of zirconia-based FPDs.
Transitional acrylic FPDs were bilaterally seated for about three months. No side effects derived from theacrylic resin were detected.

Considering the clinical courses of zirconia FPDs,1-7 frameworks of the leftfour-unit FPD and the right three-unit cantilevered FPD were fabricated with the Cercon TZP material andveneered with feldspathic porcelain (Cerabien ZR). The reason for selecting the Cerabien ZR porcelain wasexcellent bonding between zirconia and the porcelain material.14
Alumina abrasion after try-in was performed with 0.2 MPa air pressure. The pressure was approximately 1/2
to 1/3 as compared with that for metallic substrates. Although both porcelain and zirconia are considerably hardand rigid materials, loss of marginal structure by alumina blasting appeared to be apparent for the ceramicmaterials, if air pressure for the alumina abrasion is excessive. Care must be taken therefore with the blastingalumina especially around the marginal areas.
A single liquid primer (Alloy Primer) that contained MDP was used for priming the zirconia. This is based on
the literature reporting the effectiveness of the MDP for bonding zirconia8,10-13 Durable bond to abutment dentin
can be achieved by mild etching with 10-3 solution for 10-15 s. However, clinicians should be aware that the10-3 etching is effective only for combined application with the TBB initiated Super-Bond C&B resin. It isreported that the light transmittance of zirconia is 42-72% as compared with that of feldspathic porcelain.15 Theauthors therefore did not use dual-curable luting agent for seating the zirconia FPDs.
During the observation period, both FPDs were functioning satisfactorily. In particular, resistance to occlusal
loading of both cantilevered FPD framework and zirconia-porcelain bonding was confirmed. The materials andprocedure presented in this report are applicable as one of the options of a prosthodontic treatment for thepatients incompatible to specific metallic elements.

Acknowledgments
This clinical report associated with adhesive bonding of dental ceramic materials is supported in part by Special Research Grant for theDevelopment of Distinctive Education from the Promotion and Mutual Aid Corporation for Private School of Japan (2009, 2010), and Grant
from Dental Research Center (B 2009), Nihon University School of Dentistry.

49

Koizumi et al.

Int Chin J Dent 2010; 10: 47-50.

References
1. Vult von Steyern P, Carlson P, Nilner K. All-ceramic fixed partial dentures designed according to the DC-Zirkon technique. A
2-year clinical study. J Oral Rehabil 2005; 32: 180-7.
2. Sailer I, Feher A, Filser F, Gauckler LJ, Luthy H, Hammerle CH. Five-year clinical results of zirconia frameworks for posterior
fixed partial dentures. Int J Prosthodont 2007; 20: 383-8.
3. Eschbach S, Wolfart S, Bohlsen F, Kern M. Clinical evaluation of all-ceramic posterior three-unit FPDs made of In-Ceram
Zirconia. Int J Prosthodont 2009; 22: 490-2.
4. Wolfart S, Harder S, Eschbach S, Lehmann F, Kern M. Four-year clinical results of fixed dental prostheses with zirconia
substructures (Cercon): end abutments vs. cantilever design. Eur J Oral Sci 2009; 117: 741-9.
5. Beuer F, Stimmelmayr M, Gernet W, Edelhoff D, Guh JF, Naumann M. Prospective study of zirconia-based restorations:
3-year clinical results. Quintessence Int 2010; 41: 631-7.
6. Larsson C, Vult von Steyern P, Nilner K. A prospective study of implant-supported full-arch yttria-stabilized tetragonal zirconia
polycrystal mandibular fixed dental prostheses: three-year results. Int J Prosthodont 2010; 23: 364-9.
7. Tsumita M, Kokubo Y, Ohkubo C, Sakurai S, Fukushima S. Clinical evaluation of posterior all-ceramic FPDs (Cercon): aprospective clinical pilot study. J Prosthodont Res 2010; 54: 102-5.
8. Aboushelib MN, Feilzer AJ, Kleverlaan CJ. Bonding to zirconia using a new surface treatment. J Prosthodont 2010; 19:340-6.
9. Atsu SS, Kilicarslan MA, Kucukesmen HC, Aka PS. Effect of zirconium-oxide ceramic surface treatments on the bondstrength to adhesive resin. J Prosthet Dent 2006; 95: 430-6.
10. Blatz MB, Chiche G, Holst S, Sadan A. Influence of surface treatment and simulated aging on bond strengths of luting agentsto zirconia. Quintessence Int 2007; 38: 745-53.
11. Kern M, Wegner SM. Bonding to zirconia ceramic: adhesion methods and their durability. Dent Mater 1998; 14: 64-71.
12. Kern M, Barloi A, Yang B. Surface conditioning influences zirconia ceramic bonding. J Dent Res 2009; 88: 817-22.
13. Nakayama D, Koizumi H, Komine F, Blatz MB, Tanoue N, Matsumura H. Adhesive bonding of zirconia with single-liquid
acidic primers and a tri-n-butylborane initiated acrylic resin. J Adhes Dent 2010; 12: 305-10.
14. Saito A, Komine F, Blatz MB, Matsumura H. Bonding behavior of zirconia framework and layered porcelain materials. JProsthet Dent 2010; 104: 247-57.
15. Baldissara P, Llukacej A, Ciocca L, Valandro FL, Scotti R. Translucency of zirconia copings made with different CAD/CAM
systems. J Prosthet Dent 2010; 104: 6-12.

Correspondence to:Dr. Hiroyasu Koizumi
Department of Fixed Prosthodontics, Nihon University School of Dentistry
1-8-13 Kanda-Surugadai, Chiyoda-ku, Tokyo 101-8310, Japan
Fax: +81-3-3219-8351 E-mail: koizumi@dent.nihon-u.ac.jp
Accepted August 31.

Copyright ©2010 by the International Chinese Journal of Dentistry.

50