CLINICAL REPORT

Modified PEEK resin-bonded fixed dental prosthesis as an

interim restoration after implant placement
Panagiotis Zoidis, DDS, MS, Dr Denta and Ioannis Papathanasiou, DDSb

Dental implant placement re- ABSTRACT

quires an uninterrupted healing
A polyetheretherketone (PEEK) (BioHPP) framework veneered with composite resin was used as an
period for osseointegration.1 alternative material for the fabrication of an interim 3-pontic resin-bonded fixed dental prosthesis
During this period, an interim (RBFDP) after implant placement. The low modulus of elasticity (4 GPa) of PEEK combined with the
restoration is necessary to use of indirect light-polymerized resin as a veneering material used for a RBFDP provided an
satisfy the patient’s esthetic and advantage over metal ceramics or ceramics in dampening the occlusal forces and reducing
functional needs. debonding rates. Further long-term clinical evidence is required before recommending the appli-
Although originally pre- cation as a substitute material. (J Prosthet Dent 2016;-:---)
sented as a conservative defin-
itive treatment for tooth replacement in the esthetic zone, ceramic fillers (BioHPP; Bredent GmbH) has been
resin-bonded fixed dental prostheses (RBFDPs) are often recently introduced in dentistry. BioHPP provides excel-
used as interim restorations after implant placement. Metal lent biocompatibility, good mechanical behavior, high
ceramic RBFDPs have been a predictable treatment option temperature resistance, and chemical stability.13,14 With a
2
with good long-term survival rates. The high rate of modulus of elasticity of approximately 4 GPa, it presents
debonding,3 the esthetically unacceptable display of metal an elastic behavior comparable with bone and reduces
lingual retainers in the interproximal area, and the gray stress on the abutment teeth and the cementation
color of the incisal third of teeth with high translucency led interface.15 Fabricated either with computer-aided design
to the introduction of ceramic retainers with improved es- and computer-aided manufacturing (CAD-CAM) or with
thetics.4-6 Initially, glass infiltrated alumina was used to compression-molding, its manufacturers suggest it be
fabricate 2-retainer RBFDPs. However, clinical studies re- used as a framework material for fixed or removable
ported a high rate of fractures in the proximal connector prostheses. The high bond strength with veneering
between the tooth abutment and the pontic.7 As a result, a composite resin material and luting cements permits its
single-retainer design has been proposed with a survival use for resin bonded restorations.16-18 The composite
8
rate of 94.4% after 10 years of function. Because of its resin veneering material in combination with the white
higher fracture strength, zirconia could be a viable treat- color of the PEEK framework permits the fabrication of
ment option for single-retainer RBFDPs, with limited early metal-free restorations with improved esthetic appear-
clinical data reporting a100% 5-year survival rate.9 Lithium ance compared with conventional metal ceramic
disilicate was also used to fabricate single retainer canti- RBFDPs. Additional advantages include good polishing
levered RBFDPs with good midterm clinical outcomes.10,11 properties, wear resistance, and low plaque affinity.19-21
Nevertheless, long-term clinical data are not available. The authors could identify only a few studies concern-
Polyetheretherketone (PEEK) based materials have ing this material, indicating the scarcity of evidence and
been used in orthopedics and medicine in the last the need for clinical studies to verify the promising out-
decade.12 A modified PEEK-based polymer with 20% comes of laboratory tests.22-27

a
Lecturer, Department of Prosthodontics, National and Kapodistrian University of Athens, Greece, Dental School, Athens, Greece.
b
Postgraduate student, Department of Prosthodontics, National and Kapodistrian University of Athens, Greece, Dental School, Athens, Greece.

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2 Volume
Figure 1. Pretreatment: Increased vertical and reduced horizontal
anterior relationship.
The purpose of this clinical report was to present an
alternative treatment approach using a PEEK framework
veneered with composite resin for the fabrication of an
interim 3-pontic RBFDP after implant placement.
CLINICAL REPORT
A 52-year old man presented for implant placement in
the anterior mandible. Clinical examination revealed
increased vertical overlap and reduced horizontal overlap
between the maxillary and mandibular anterior teeth
(Fig. 1) and class II mobility for the mandibular centrals
and left lateral incisors. The mandibular right lateral
incisor presented class I mobility. The radiographic ex-
amination revealed increased bone loss for the mandib-
ular centrals and the left lateral incisors.
The treatment plan included extraction of the
mandibular centrals and left lateral incisors and imme-
diate placement of 2 osseointegrated implant fixtures
(Biohorizons; Biohorizons USA) to replace the mandib-
ular right central and left lateral incisor (Fig. 2). A PEEK
RBFDP framework veneered with indirect light-
polymerized composite resin at the pontic area would
serve as an interim restoration during the osseointegra-
tion period.
Periodontal treatment included root scaling and
planing. The mandibular centrals and left lateral incisors
were extracted, and 2 implant fixtures were placed to
serve as abutments for a 3-unit implant-supported fixed
prosthesis to replace the missing anterior teeth (Fig. 3). A
vacuum-formed retainer (Essix ACE; Dentsply Intl)
served as an immediate restoration.
The definitive impression was made 10 days later
using polyvinyl siloxane material (Aquasil; Dentsply Intl).
The definitive cast was fabricated from Type IV dental
stone (Prima-Rock; Whip Mix Corp). This cast was
scanned with a laboratory 3D scanner (3 Shape; 3 Shape
A/S), and the PEEK framework wax pattern was fabri-
cated with CAD-CAM. This wax pattern was invested
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Figure 2. Mandibular anterior teeth indicated for extraction.
with the manufacturer’s recommended investment
(Brevest; Bredent GmbH), and the definitive PEEK
framework was fabricated by injection-molding with the
conventional lost wax technique using a vacuum press
device (2 press system; Bredent GmbH) designed for this
material. The mold was heated from 630 C to 850 C for
wax elimination and then cooled to 400 C. At that
temperature, the PEEK melted and was vacuum pressed
into the mold under 550 to 600 kPa pressure. The rec-
ommended devesting procedure was followed when the
mold had cooled for 35 minutes. The framework was
finished as recommended with fine cross-cut tungsten
carbide burs and was evaluated for fit intraorally in order
to ensure marginal adaptation and adequate space for the
veneering material (Fig. 4). Conditioning of the PEEK
external surface included airborne-particle abrasion with
110 mm alumina powder under 200 to 300 kPa pressure
at a minimum distance of 3 mm, cleaning with ethanol,
treatment with an adhesive agent (visio.link; Bredent
GmbH), and coating with an indirect light- polymerized
composite material (Gradia; GC Europe NV) (Fig. 5). The
occlusion was adjusted, and the final polishing was
performed as recommended. Dual-polymerizing resin
cement was used for definitive cementation with the
conventional cementation resin-cement protocol (Pana-
via 21; Kuraray America Inc) (Figs. 6, 7).
The patient was instructed to clean the restoration
daily with a toothbrush and interdental brushes. No
complication, such as debonding or staining, was noticed
during the 4-month healing period.
DISCUSSION
The choice of the material for the construction of an
RBFDP should be based on thorough clinical evaluation,
patient requests, and scientific data. RBFDPs with a cast
metal framework can be a predictable treatment option
for interim or long-term restorations. However, the
debonding of conventional resin-bonded restorations is a
frequent complication.3 The main reasons for debonding
Zoidis and Papathanasiou
- 2016
Figure 3. Implant fixtures to support definitive restoration.
Figure 5. Polyetheretherketone resin-bonded fixed dental prosthesis
on definitive cast.
are the high modulus of elasticity of the metal framework
and the mobility of the abutment teeth which lead to
unfavorable stress concentration at the cement inter-
face.28 Abutment teeth with advanced mobility or long-
span RBFDPs may increase the risk of debonding.29
Furthermore, according to Olin et al,30 RBFDPs with
more than 2 abutment teeth lead to a higher rate of
decementation. For this patient, an RBFDP with 3 abut-
ment teeth and 3 pontics was fabricated. The different
mobility patterns of the teeth caused by reduced peri-
odontal support, combined with the long span and the
use of multiple abutments, would result in a high risk of
debonding if a metal ceramic RBFDP had been fabricated.
In addition, no available scientific evidence is available
to support the use of ceramic materials in long-span
RBFDPs. Thus, an alternative material was chosen.
PEEK, with a lower modulus of elasticity than metal
could reduce stress concentration at the cementation
interface and prevent debonding. In agreement with our
concept, Ibrahim et al,31 in an in vitro study, demon-
strated that RBFDP frameworks with lower rigidity
resulted in lower dislodging forces.
Zoidis and Papathanasiou
3
Figure 4. Polyetheretherketone resin-bonded fixed dental prosthesis
framework evaluation.
Figure 6. Interim polyetheretherketone resin-bonded fixed dental
prosthesis, occlusal view.
To prevent debonding of metal ceramic RBFDPs,
several modifications of tooth preparations have been
proposed, including axial coverage, retentive grooves,
and occlusal rests.32-34 In addition, Aboush and Jen-
kins,35 in an in vitro study on RBFDPs, reported higher
bond strength to enamel than to dentin (25 MPa versus 8
MPa). The good quality bonding of the PEEK framework
material with the resin cements could increase the
longevity of resin-bonded restorations with minimally
invasive tooth preparations without retentive ele-
ments.16-18 When thin teeth, such as mandibular incisors,
are used as abutments, enamel could be totally pre-
served, resulting in high bond strength. The basic ele-
ments of successful bonding are to follow the proposed
cementation protocol, which includes airborne-particle
abrasion of the intaglio surface with 110 mm alumina
powder, placement of a bonding primer (visio.link; Bre-
dent GmbH), and luting with dual-polymerized resin
cement.
Another advantage of the PEEK framework is the
high bond strength with the light-polymerized indirect
composite veneering materials.18,36 According to DIN EN
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Figure 7. Interim polyetheretherketone resin-bonded fixed dental
prosthesis cemented with resin cement.
ISO 10477/Jena University, adequate bond strength
values up to 25 MPa can be achieved.15
The white color of the PEEK framework in combi-
nation with the veneering composite resins eliminates
the grayish appearance of metal frameworks, providing a
metal-free highly esthetic outcome. Staining resistance of
the indirect light polymerized composite resin veneering
material is of concern. Studies by Rzanny et al,15 have
shown that these properties are the same as or slightly
inferior to those of the ceramic materials. This staining
tendency may extend even further to the restoration
survival rate.
PEEK has a low specific weight that permits the
fabrication of lighter prostheses, providing high patient
satisfaction and comfort during function.15
Because of its insolubility in water and low reactivity
with other materials, PEEK could be suitable for patients
allergic to metals or sensitive to metallic taste.
Chipping of the veneering material can be repaired
intraorally with conventional composite resins. Similarly,
an interim PEEK RBFDP could be modified intraorally to
achieve optimal esthetics and an ideal soft tissue profile
in the esthetic zone.
SUMMARY
PEEK RBFDPs can be used as an interim treatment op-
tion. Further long-term clinical evidence is required to
support the use of this material.
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