CLINICAL REPORT

Milled cobalt-chromium metal framework with veneered

porcelain for a complete-arch fixed implant-supported
prosthesis: A clinical report
Akanksha Srivastava, BDS, MSc, MDSca and Avinash S. Bidra, BDS, MSb

Complete-arch fixed implant- ABSTRACT

supported prostheses (CA-
Many materials have been introduced for the fabrication of complete-arch fixed implant-supported
FIPs), also known as fixed prostheses. This clinical report demonstrates the use of a computer numerically controlled (CNC),
complete dentures, are an milled, 1-piece cobalt-chromium framework with veneered porcelain to treat a patient with
effective treatment option for dental implants placed with limited prosthetic space. This prosthodontic option combined the
edentulous patients or those advantages of a digitally manufactured solution for a 1-piece metal framework and the excellent
with a hopeless dentition.1 In a track record of metal-ceramic prostheses. An additional advantage of this option is its use in
systematic review, the cumu- situations with reduced prosthetic space, where alternative materials such as monolithic zirconia
lative survival rate of 1-piece are contraindicated. (J Prosthet Dent 2019;-:---)
CAFIPs was reported to be 98.6% at the 5-year follow- lifelong maintenance.4-8 These complications may
1
up and 97.2% at a 10-year follow-up. CAFIPs can be result in a significant inconvenience, financial cost, and
differentiated using 4 main parameters2: mode of reten- reduced treatment satisfaction.2,4-8 Moreover, patients
tion (screw-retained, cement-retained, or a combination with distal cantilevers, limited prosthetic space, or
when a single milled bar has separate crowns cemented parafunctional habits have even higher complication
over it); framework design (1-piece, segmented, or a rates.4,5,8
combination); prosthetic material combination (metal- In the past, CAFIPs made of cast metal-ceramic
acrylic resin; metal-composite resin; metal-ceramic; were the only alternative to metal-resin for providing
nonmetal polymers such as polyetherketoneketone good esthetics with improved hygiene and longevity.9
(PEKK), polyetheretherketone (PEEK), and monolithic However, the laboratory fabrication costs were signif-
zirconia or zirconia-ceramic); and use of prosthetic icantly higher than those of metal-resin because of the
gingiva (denture base acrylic resin, gingival composite cost of the noble and high noble alloys. In addition,
resin, gingival porcelain, gingival staining, or none).2 All there were significant technical challenges related to
designs have advantages and disadvantages related to casting an extensive metal framework accurately,
esthetics, strength, simplicity, method of fabrication, obtaining optimal and passive fit, and applying large
complications, and cost.2 volume of porcelain without fracture during porcelain
Metal-resin CAFIPs have traditionally been the firing.9 To mitigate these problems, clinicians often
most popular choice because of their low fabrication placed additional implants in strategic positions with
cost, straightforward reparability, and long history of or without additional preprosthetic surgeries to allow
use.3 Clinical studies and systematic reviews have for segmented designs with easier fabrication and
identified the high rate of fracture and wear of the subsequent repair and maintenance. Unfortunately,
acrylic resin and the need for repair, replacement, and these modifications significantly increased the cost of

a
Former Resident, Postgraduate Prosthodontics, Department of Reconstructive Sciences, University of Connecticut, Farmington, Conn.
b
Program Director and Maxillofacial Prosthodontist, Postgraduate Prosthodontics, University of Connecticut Health Center, Farmington, Conn; Private practice, Meriden,
Conn.

THE JOURNAL OF PROSTHETIC DENTISTRY 1

2 Volume
Figure 1. Radiographic presentation of patient before definitive prosthodontic treatment shows 6 implants in maxilla and 4 implants in mandible, with
stable bone levels around all implants.
the prosthesis, impeding many patients from pursuing
the metal-ceramic option.2,3,9
The contemporary and popular alternative to cast
metal-ceramic prostheses is the use of predominantly
monolithic zirconia prostheses that offer optimal es-
thetics and have been reported to have a 99.3% survival
rate with minimal prosthodontic complications in the
short term.2 However, monolithic zirconia prostheses
require prosthetic space of at least 12 mm to satisfy
biomechanical requirements.2 An alternative solution is
to use zirconia supported by a metal framework, but this
design is supported by minimal clinical data and can
increase dental laboratory costs.10
A newer solution for CAFIPs when the prosthetic space
is limited because of insufficient bone resection during
implant surgery is using a milled metal-ceramic prosthesis.
In this design, the 1-piece metal framework is milled from
a block of cobalt-chromium (Co-Cr) by using a computer
numerically controlled (CNC) machine. The design of the
framework can be made by copy milling a resin pattern or
by computer-aided design (CAD). The metal framework is
then fused or pressed with porcelain in a manner similar to
that for conventional cast metal frameworks, with or
without gingival porcelain. In contrast with milled titanium
frameworks, Co-Cr frameworks allow better fusion of
porcelain to the metal framework on account of an oxide
layer thickness that is more favorable for ceramic
bonding.11-13 Compared with cast noble alloy frameworks,
Co-Cr frameworks are less expensive; and compared with
cast Co-Cr, milled Co-Cr frameworks provide better fit
with significantly reduced cost and fabrication time.14-17 In
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addition, milled Co-Cr frameworks with veneered porce-
lain require less prosthetic space than monolithic or ven-
eered zirconia CAFIPs, whose strength as a complete-arch
prosthetic material is directly related to the bulk of the
material.3
In the past, Co-Cr alloys have been less successful for
digitally manufactured frameworks on account of poor
machinability resulting from their high strength, tough-
ness, and wear resistance and low thermal conductivity.18
However, recent advances in computer numerically
controlled (CNC) machines, such as increased control of
temperature and milling forces, have allowed predictable
and cost-effective milling of Co-Cr frameworks.18
The purpose of this clinical report was to describe the
use of a CNC, milled, Co-Cr framework with veneered
porcelain to treat a patient with maxillary and mandibular
edentulism where monolithic zirconia was contraindicated.
CLINICAL REPORT
A 44-year-old white man presented to the authors with
interim CAFIPs supported by 6 implants in the maxilla
and 4 implants in the mandible (Fig. 1). The patient had
an unremarkable medical history, and his dental history
indicated that all his teeth had been extracted because of
dental caries and dental infections. A clinical examination
revealed that all the implants were osseointegrated
without signs of infection, inflammation, or radiographic
bone loss (Fig. 2). The patient had been treated with
acrylic resin interim CAFIPs that showed wear and
staining of the denture teeth. At this time, it was decided
Srivastava and Bidra
- 2019 3

Figure 2. A, Occlusal view of maxilla showing good distribution of 6 implants with multiunit abutments. Note minor erythema of soft tissues from
interim fixed prosthesis. B, Occlusal view of mandible showing good distribution of 4 implants with multiunit abutments. Note minor erythema of soft
tissues from interim fixed prosthesis.

to first create a new diagnostic tooth arrangement and

assess prosthetic space before choosing the materials for
the definitive prostheses.
Definitive impressions for the fabrication of the
prostheses were made by using polyether material
(Impregum; 3M ESPE) in a custom tray with impression
copings splinted intraorally. A verification device for both
maxillary and mandibular definitive casts was fabricated
by using pattern resin (Inlay clear pattern resin; Dura-
Lay), and passive seating of the device was verified
clinically and radiographically. Thereafter, max-
illomandibular relationship records were made, and the
diagnostic tooth arrangement was completed (Fig. 3).
The tooth arrangement was verified intraorally for es-
thetics and occlusion and approved by the patient. At this
stage, prosthetic space analysis was performed by using
polyvinyl siloxane material (Trixa Laboratory Matrix
Putty; Dentsply Sirona) in the dental laboratory. As the
vertical space analysis indicated that the prosthetic space
was less than 12 mm in the posterior regions of both
arches, milled metal-ceramic prostheses were selected.
The milled Co-Cr framework was fabricated by a copy
milling technique in combination with the CNC technique
rather than creating a CAD file from the diagnostic tooth
arrangement. This was performed to allow for optimal
customization of the gingival contours, simplicity, and
expertise of the dental technician. Therefore, autopolyme-
rizing pattern resin material (Inlay clear pattern resin;
DuraLay) and nonengaging titanium cylinders were used
to manually fabricate a scan frame to serve for copy milling
(Fig. 4). The scan frame was confirmed for passive fit. It
was ensured that the scan frame had optimal dimensions
to provide appropriate support for the planned veneering
of feldspathic porcelain over the metal framework. This
was done by using a polyvinyl siloxane index made over
the denture tooth arrangement. The scan frame was then
scanned to produce a 1-piece Co-Cr framework, which
Figure 3. New diagnostic tooth arrangement completed over mounted
casts verified in mouth.
was milled from a solid block of Co-Cr (Cobalt-Chromium
Solutions; Panthera Dental). This alloy contained 59%
cobalt, 25% chromium, 9.5% tungsten, 3.5% molybdenum,
traces of other elements, and 0% nickel. The Co-Cr
framework required minimal adjustments and polishing
after the milling process and was delivered to the clinician
for confirmation of passive fit in the mouth (Fig. 5). The
scan frame and titanium cylinders were also returned to
the clinician.
The Co-Cr frameworks were then clinically and
radiographically verified for seating and passive fit
(Fig. 6). At this stage, a second confirmation of the pa-
tient’s maxillomandibular relationship was also accom-
plished by using pattern resin indices fabricated on an
articulator to confirm optimal seating in the mouth.
Thereafter, the same polyvinyl siloxane index of the
diagnostic tooth arrangement was used by the dental
ceramist for veneering feldspathic porcelain to obtain
esthetic tooth proportions and occlusal contacts.
Gingiva-colored feldspathic porcelain was then added

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Figure 4. Acrylic resin frameworks fabricated for copy milling. A, Maxillary over 6 titanium cylinders. B, Mandibular over 4 titanium cylinders.

Figure 5. Milled cobalt-chromium frameworks after finishing. A, Maxillary. B, Mandibular.

beyond the cervical margins of the teeth to maintain

esthetic tooth proportions and then returned to the
clinician to verify in the mouth at the bisque bake stage.
The ceramic layering in this patient was performed
after 2 firings of the opaque layer and then 4 additional
firings for veneering the feldspathic white and pink
porcelain. Minor adjustments to esthetics and occlusion
were made, and after obtaining the patient’s approval,
the prostheses were returned to the dental laboratory for
final finishing and glazing. Both metal-ceramic CAFIPs
were then inserted in the mouth, the screws were
tightened to 15 Ncm per the manufacturer’s instructions
(Multiunit prosthetic screws; Nobel Biocare), and all ac-
cess holes were sealed with polytetrafluoroethylene tape
and light-polymerizing composite resin (Grandio; VOCO Figure 6. Verification of passive fit intraorally for both milled
Dental) (Fig. 7). A posttreatment panoramic radiograph frameworks.
was made, which confirmed the optimal fit of the
framework, good support for the porcelain, and stable
bone levels around all dental implants (Fig. 8). An
DISCUSSION
occlusal nightguard was then fabricated to minimize the
risk of fracture of the veneering porcelain. The patient The purpose of this article was to describe the treatment as
was extremely satisfied with the esthetic and functional well as advantages and disadvantages of CNC, milled,
result of the prosthodontic treatment. Co-Cr frameworks with veneered porcelain that offer

THE JOURNAL OF PROSTHETIC DENTISTRY Srivastava and Bidra

- 2019
Figure 7. Definitive metal-ceramic prostheses in mouth. A, Right lateral
view. B, Frontal view. C, Left lateral view.
several clinical benefits over other contemporary treatment
options. To the authors’ knowledge, this is the first pub-
lished clinical report describing this prosthetic treatment for
complete-arch fixed implant-supported prostheses. Digital
manufacturing has transformed the role of Co-Cr alloys as
a framework material for implant-supported prosthe-
ses.16,19 Milled Co-Cr frameworks have overcome misfit
problems with the casting process, as well as the need for
sectioning and soldering or laser welding.16,19 Although no
Srivastava and Bidra
5
Figure 8. Posttreatment panoramic radiograph showing optimal fit of
metal frameworks, good support for porcelain, and stable bone levels
around all dental implants.
consensus has been reached on a clinically acceptable level
of misfit or the evaluation of passive fit, minimizing the
vertical misfit should reduce framework strain and gap
formation.16,19,20 The CNC milling process has allowed Co-
Cr frameworks to be fabricated with a misfit of less than 10
mm in the vertical plane and 20 mm in the horizontal
plane.14,20 Also, Co-Cr alloys are more rigid than noble
metal alloys, which is advantageous for even load distri-
bution to the prosthesis, implants, and supporting
bone.19,21 Implants being placed posterior to the mental
foramen for CAFIPs has been a cause of concern for some
clinicians because of potential mandibular flexure, but the
authors have not found any clinical evidence that
mandibular flexure has any effect on implants or
prostheses.22
CNC, milled, Co-Cr frameworks can be fabricated for
prostheses originating at the implant level, abutment
level, or a combination thereof, allowing a more versatile
use of these frameworks across different implant plat-
forms. They can also be successfully implemented, with
proper patient selection, when limited prosthetic space is
available. Porcelain veneering around a single large
framework is known to be technique sensitive, but when
proper firing protocols are adhered to, this issue can be
resolved.19 The properties of the CNC, milled, Co-Cr
framework, especially the coefficient of thermal expan-
sion, are compatible with those of most commercially
available porcelain veneer systems. Warping of the
framework is also not an issue because of the milled
nature of the metal framework, and the firing tempera-
ture of the porcelain is significantly less than the tem-
perature required to distort the metal framework.19 This
is particularly beneficial in patients who are treatment
planned for a CAFIP but have existing implants in single
or partially edentulous spaces. Another advantage of the
Co-Cr frameworks compared with monolithic zirconia is
that misfit can be addressed by sectioning and laser
welding the framework. Finally, optimizing esthetic and
THE JOURNAL OF PROSTHETIC DENTISTRY
6 Volume
occlusal adjustments during the bisque bake stage is a
possibility that is not afforded by monolithic materials.
In contrast, the chipping of veneered porcelain is the
highest risk for metal-ceramic CAFIPs, but well-
supported metal frameworks and improved bonding
between newer synthetic porcelains and milled Co-Cr
alloys may obviate this problem. Nevertheless, this
treatment is indicated only for screw-retained prostheses
that are easily retrievable for the repair of veneered
porcelain. Another disadvantage of Co-Cr alloys is al-
lergy to cobalt.12 Careful patient selection is needed
before proceeding with this promising solution for pa-
tients indicated for CAFIP with reduced prosthetic space.
SUMMARY
This clinical report described the use of a CNC, milled,
Co-Cr framework with veneered porcelain to treat a pa-
tient with maxillary and mandibular edentulism where
monolithic zirconia was not indicated because of limited
prosthetic space. CNC, milled, Co-Cr with veneered
porcelain shows promise as a prosthetic material because
of its digital fabrication, improved fit, and reduced labo-
ratory costs compared with cast metal-ceramic prostheses.
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Corresponding author:
Dr Avinash S. Bidra
University of Connecticut Health Center
263 Farmington Avenue, L7041
Farmington, CT 06030
Email: avinashbidra@yahoo.com
Acknowledgments
Authors would like to thank the staff of Marotta Dental Laboratory, New York, for
their support with the treatment described in this article.
Copyright © 2019 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2019.04.017
Srivastava and Bidra