Early complications and short-term

failures of zirconia single crowns and

partial fixed dental prostheses
Juha Pihlaja,a Ritva Näpänkangas, DDS, PhD,b and
Aune Raustia, DDS, PhDc
Institute of Dentistry, University of Oulu, Oulu, Finland; Oulu
University Hospital, Oulu, Finland
Statement of problem. Ceramic single crowns fabricated from newer materials, especially zirconia, have shown relatively high
survival rates. However, early reversible complications may increase the risk of an irreversible failure later.

Purpose. The purpose of the study was to evaluate the early complications and short-term failures of zirconia single crowns
and partial fixed dental prostheses (FDPs) made by predoctoral dental students.

Material and methods. Data were collected from the patient records. Altogether, 264 zirconia single crowns and 120 FDPs
(342 abutments and 190 pontics) were fabricated for 173 patients between 2007 and 2010. Early complications were
recorded during the prosthetic treatment phase, and short-term failures were recorded during the first year in use.

Results. The most frequent early complications were localized gingival irritation (1.9% of single crowns and 2.5% of FDP) and
postoperative tooth sensitivity (0.4% of single crowns and 3.3% of FDPs). Pulp exposure during preparation was recorded in
3 abutment teeth of the FDPs. The most frequent short-term failure was chipping of the veneering porcelain (0.8% for single
crowns, 0.8% for FDPs). One crown lost cementation because of poor retention (0.4%), and 2 FDPs failed because of
framework fractures (1.7%).

Conclusions. The most frequent early complications were localized gingival irritation and postoperative tooth sensitivity, and
the most frequent short-term failure was chipping of the veneering porcelain. (J Prosthet Dent 2014;-:---)

Clinical Implications
Patients should be told that tooth sensitivity may occur after preparation
but is usually transient. In the case of localized gingival irritation with
single crowns or the abutment teeth of fixed dental prostheses, an
examination may reveal excess cement. The chipping of porcelain is more
common in zirconia restorations than in metal ceramic ones and can
occur shortly after cementation.

Conventional metal ceramic single
crowns and partial fixed dental pros-
theses (FDP) have been used in dentistry
for decades and have earned worldwide
acceptance.1 Nowadays, they are regar-
ded as the gold standard because of
their low failure rates and good long-
term clinical results.2,3 Nevertheless, the
emerging demands for metal-free, more
biocompatible, and highly esthetic res-
torations have directed materials
research and development toward ce-
ramics. Numerous advances have been
made in the mechanical properties and
fabrication methods of ceramic mate-
rials since the introduction of leucite-
reinforced glass ceramics (IPS Empress;
Ivoclar Vivadent) and the InCeram
technique (Vita Zahnfabrik; H. Rauter
GmbH & Co KG).4,5 Currently, a wide
range of ceramic materials is available
for clinical use.
On the basis of recent studies, fixed
ceramic prostheses fabricated from newer

a
Dental student, Institute of Dentistry, University of Oulu.
b
Senior lecturer, Department of Prosthetic Dentistry and Stomatognathic Physiology, Institute of Dentistry, University of Oulu,
Oulu, Finland; and Specialist, Oral and Maxillofacial Department, Oulu University Hospital.
c
Professor, Department of Prosthetic Dentistry and Stomatognathic Physiology, Institute of Dentistry, University of Oulu, Oulu,
Finland; and Chief, Oral and Maxillofacial Department, Oulu University Hospital.

Pihlaja et al
2 Volume
materials, especially zirconia, have shown
relatively high short-term and medium-
term survival rates, comparable to those
of metal ceramics.4-19 This evidence sug-
gests that, especially in the absence of
parafunctional habits, clinicians may
choose from any of the recent ceramic
materials, depending on the esthetic and
functional needs of the patient.6
Because of its excellent mechanical
properties, zirconia is more widely used
in restorative dentistry than other ce-
ramics.20 The high strength and frac-
ture toughness of zirconia has changed
the most frequent reasons for the fail-
ure of ceramic partial fixed dental
prostheses (FDPs) from severe frame-
work fracture to minor technical com-
plications, such as the chipping of
veneering porcelain.12 This problem
seems to be the biggest weakness of
zirconia restorations when compared to
metal ceramic ones.21 Early repairable
chipping of veneering porcelain can in-
crease the risk for irreparable porcelain
damage later.22,23 In addition, Sag-
irkaya et al16 found in a 4-year follow-
up that 4 out of 5 failures occurred in
the first year. However, the use of
monolithic zirconia with no veneering
porcelain has increased and the risk for
the fractures has diminished.24
To our knowledge, no published
studies have focused completely on the
early complications of zirconia restora-
tions during the prosthetic treatment
phase or on short-term failures during
the first year in use. The hypothesis was
that complications are few during and
shortly after prosthetic treatment. Thus,
the objective of the study was to eval-
uate the early complications and short-
term failures of zirconia single crowns
and FDPs made by predoctoral dental
students.
MATERIAL AND METHODS
This retrospective study of the early
complications of zirconia restorations
during the prosthetic treatment phase
and short-term failures during the first
year in use was conducted at the Insti-
tute of Dentistry, University of Oulu,
Finland. The study protocol was
The Journal of Prosthetic Dentistry
- Issue -
approved by the ethical committee of The abutment teeth were usually
the Northern Ostrobothnia Hospital maxillary canines and incisors, and
District. Data, which consisted of pa- mandibular premolars and second
tients treated with zirconia single molars. The maxillary pontics were
crowns and FDPs by predoctoral dental distributed evenly in the dental arch,
students, were collected from patient but in the mandible, the first molars
records. were the most common pontics. The
A total of 173 patients (94 women most common indications for zirconia
and 79 men, mean age 55 years, range restorations were excessive loss of tooth
18-79 years) were treated with zirconia substance (crowns), renewal of the
single crowns or FDPs between 2007 existing restorations (crowns), and
and 2010. Altogether, 264 zirconia tooth loss (FDPs).
single crowns were placed in 88 pa- All patients received periodontal
tients (mean 3 crowns per patient, treatment before prosthetic treatment,
range 1 to 12 crowns), mostly to the including education, instructions for
maxillary anterior region (Fig. 1). The proper home care, and a professional
names and manufacturers of the zirco- tooth cleaning. The preprosthetic
nia frameworks in single crowns were treatment also included caries and
Zirkonzahn Zirconia (Zirkonzahn), endodontic treatment as well as
NobelProcera Zirconia (Nobel Biocare), occlusal adjustment, if needed. All the
and Prettau Zirconia (Zirkonzahn). In preparations were made in accordance
addition, 102 patients were treated with international treatment guide-
with 120 zirconia FDPs (range 3 to 12 lines.25 For the crowns and abutment
units, mean 4.5 units). The names and teeth of FDPs, the teeth were prepared
manufacturers of the zirconia frame- with 1.5 mm axial clearance (total
works in FDP were Zirkonzahn Zirconia convergence 6 degrees) and a 2 mm
(Zirkonzahn), NobelProcera Zirconia anatomically adequate occlusal or
(Nobel Biocare), and Prettau Zirconia incisal reduction with a functional cusp
(Zirkonzahn). These FDPs consisted of bevel to ensure sufficient material
342 abutments and 185 pontics thickness. The heavy chamfer finish line
(Fig. 2), of which 5 were cantilevers. was placed slightly below the free
45
40
35
30
25
20
15
10
5
0
Maxillary teeth
Mandibular teeth
0
5
10
15
20
25
30
35
40
45
1 Distribution of zirconia single crowns (n¼264).
Pihlaja et al
- 2014 3
45 patients were asked to make contact in
40 Pontics case of emergency, and no scheduled
35 Abutments examination at the clinic was per-
30 formed after the 6-month follow-up
25
visit. Patient records were checked for
possible failures between 6 months
20
and 12 months after the definitive
15
cementation.
10
The complications were divided into
5
early complications and short-term fail-
0 ures. Early complications included com-
Maxillary teeth
plications recorded during the prosthetic
Mandibular teeth
0 treatment until definitive cementation.
5 Short-term failures included failures
10 recorded during the first year in use after
15 the definitive cementation. Both early
20 complications and short-term failures
were divided into biological and technical
25
categories.
30
35 Pontics
RESULTS
40 Abutments
45
The biological early complications
2 Distribution of abutment teeth and pontics of found were localized gingival irritation
zirconia partial fixed dental prostheses (n¼120). (5 of 264 single crowns, 1.9%; 3 of 120
FDP, 2.5%) and postoperative tooth
gingival margin (0.5 mm) in anterior connector design requirement was 6.0 sensitivity (1 of 264 single crowns,
teeth and marginally (equigingival) in mm2 in the anterior area and 9.4 mm2 0.4%; 4 of 120 FDPs, 3.3%) (Table I).
posterior teeth. Composite resin (Filtek in the posterior area. The veneering Localized gingival irritation was caused
Z250; 3M ESPE) was used for the porcelain (Vita VM 9; Vita Zahnfabrik) by excess cement (except in 1 instance)
foundation when needed, and a fiber was layered on the frameworks. and was relieved by cement removal.
post (RelyX Fiber post; 3M ESPE) was Before the definitive cementation of The tooth sensitivity of abutments
used in endodontically treated teeth. All the restorations, their esthetic appear- required no additional treatment for
the treatment procedures were per- ance and occlusion were confirmed. the single crowns and 2 of the FDPs,
formed under the supervision of quali- The clinical instructor evaluated the fit but 2 of the FDPs had to be left with
fied clinical instructors. of the restoration and the patients were interim cement for a longer period of
For Zirkonzahn Zirconia and Prettau asked whether they were satisfied with time. The most common technical early
Zirconia, the frameworks were fabri- the color and esthetics of the restora- complication during the prosthetic
cated with manual milling and designed tion. The restorations were bonded treatment phase was unacceptable co-
for the uniform thickness of the with dual-polymerizing, self-adhesive, lor. Three (1.1%) of the 264 single
veneering porcelain layer. The minimal universal resin cement (RelyX Unicem; crowns and 1 (0.8%) of 120 FDPs had
thickness of the framework was 0.4 mm. 3M ESPE) according to the manufac- to be remade because of unacceptable
The connector design requirement was turer’s instructions. The single crowns color. Poor fit of the framework was
9.0 mm2. The veneering porcelain were cemented with definitive cement recorded in 3 (2.5%) of 120 FDPs.
(GC Initial Zr; GC Europe) was layered immediately, but the FDPs were first Pulp exposure during the prepara-
on the frameworks. In NobelProcera cemented with interim cement (Temp- tion occurred in 3 (2.5%) of 120 FDPs.
Zirconia, the frameworks were fabri- Bond NE; Kerr Corp), and definitive In 2 abutment teeth, visible exposure
cated by using computer-aided design/ cementation took place about 1 week occurred during preparation. In 1
computer-assisted manufacture and later. abutment, the FDP was cemented with
designed for the uniform thickness of The first follow-up was scheduled 1 interim cement and endodontically
veneering porcelain layer. The minimal to 2 weeks after the definitive cemen- treated afterward, and in the other,
thickness of the frameworks in single tation of the crowns and FDP. At the 6- mineral trioxide aggregate was used to
crowns was 0.4 mm in the anterior area month follow-up, the restorations, protect the abutment tooth by pulp
and 0.7 mm in the posterior area and in surrounding tissues, and occlusion capping. In addition, 1 patient devel-
FDP 0.6 mm. Briefly, for the FDPs, the were thoroughly examined. Thereafter, oped symptoms of pulpitis, and the
Pihlaja et al
4 Volume - Issue -

Table I. Early complications during prosthetic treatment of zirconia single crowns (n¼264) and partial FDPs (n¼120)
Single Crown FDP
Complication Type Complication Description n % n %

Biological Localized gingival irritation 5 1.9 3 2.5

Postoperative tooth sensitivity 1 0.4 4 3.3
Technical Unacceptable final color 3 1.1 1 0.8
Framework did not fit 0 0 3 2.5
Perforation during preparation 0 0 3 2.5
Restoration left with temporary cement 0 0 2 1.7
Loss of existing filling 1 0.4 0 0
Total 10 3.8 16 13.3

FDP, fixed dental prosthesis.

Table II. Short-term failures in year after definitive cementation of zirconia single crowns (n¼264) and FDP (n¼120)
Single Crown FDP
Complication Type Complication Description n % n %

Biological . 0 0 0 0
Technical Porcelain chipping, irreparable 2 0.8 0 0
Porcelain chipping, reparable 0 0 1 0.8
Framework fracture 0 0 2 1.7
Loss of retention 1 0.4 0 0
Total 3 1.1 3 2.5

FDP, fixed dental prosthesis.

abutment tooth had to be endodonti-
cally treated and restored with a fiber
post before the impression phase.
No biological short-term failures of
single crowns or FDPs occurred during
the first year after definitive cementa-
tion (Table II). Of the technical failures,
chipping of the veneering porcelain was
recorded in 2 (0.8%) of 264 crowns (a
maxillary lateral incisor and a mandib-
ular central incisor) and loss of reten-
tion in 1 (0.4%) of 264 crowns.
Chipping of porcelain occurred during
the first month in use. Both crowns
were considered unrepairable (Grade 3
according to Heintze and Rousson1),
and the crown was remade. The crown
with loss of retention was recemented.
Framework fracture was noted in 2
(1.7%) of 120 FDPs, and the restora-
tions had to be remade. In 1 (0.8%) of
120 FDPs, a minor reparable porcelain
fracture (Grade 21) was observed in a
maxillary premolar abutment and was
repaired with composite resin
(Table II). None of the 120 FDPs lost
retention during the observation
period.
DISCUSSION
The most common early complica-
tions were localized gingival irritation
and postoperative tooth sensitivity. The
most common short-term failure was
chipping of the veneering porcelain, as
has also been reported in previous
studies when compared to metal
ceramic restorations.1,19 The frame-
work fracture was noted in 1.7% of
FDPs, which can be considered a high
percentage when compared to Sailer
et al,19 who in a systematic review re-
ported the annual failure rate of zirco-
nia framework fracture to be 0 to
0.48%. The first framework fracture
occurred in the connector area of 2
premolar abutments when the FDP was
removed after interim cementation. The
other framework fracture occurred in an
occlusal area of a molar abutment
tooth after the definitive cementation.
The cause of the fracture in this pros-
thesis is unknown.
The most common abutment teeth
for mandibular zirconia FDPs were
molars. The indications for the use of
zirconia in the mandibular posterior
region rather than metal ceramic were
related to an interest in using a metal-
free, high-strength material with re-
ported promising results.19 In addition,
the zirconia frameworks were less
expensive for the patient.
Although a year is short time in the
expected life of a restoration, identi-
fying initial problems that may be
rectifiable is important. However, if the
material fails at this point, it is more

The Journal of Prosthetic Dentistry Pihlaja et al

- 2014
likely caused by material weakness or
errors during the fabrication process
rather than patient factors, such as
bruxism or diet.
Localized gingival irritation was a
problem during the prosthetic treatment.
It was mainly related to excess cement
and was managed with cement removal,
professional cleaning, and improved
home instructions. In some studies, no
significant periodontal differences be-
tween the control teeth and abutments
were noted.13 However, in 3-year follow-
ups, Tartaglia et al10 and Tinschert
et al13 found that abutment teeth tended
to have increased pocket depths. Ortorp
et al,11 in a 3-year follow-up, reported
that only 4 of 25 crowns were free from
gingival bleeding and calculus.
Although postoperative tooth sen-
sitivity has rarely been mentioned as a
biological complication in follow-up
studies, tooth sensitivity was relatively
common in this study. Only Roediger
et al18 have also described sensitivity as
a common problem. However, post-
operative tooth sensitivity is usually a
transient symptom, as Roediger et al18
also stated, and only 2 patients in this
study in whom the FDP was left on with
interim cement for a longer period of
time needed additional treatment.
Abutment preparation is always a risk
to pulp vitality because the preparation
may lead to pulp reactions or exposure.
Although the treatment procedures
were made by predoctoral students, the
definitive preparations and restorations
were supervised by qualified dental in-
structors. In the present study, pulp
exposure occurred in 3 abutments dur-
ing preparation, all in the abutment
teeth of FDPs. In 1 tooth, the pulp was
successfully capped with mineral
trioxide aggregate, but the other 2
required endodontic treatment.
In this study, 2 (0.8%) of 264 single
crowns and 1 (0.8%) of 120 FDPs had
chipping of the veneering porcelain
during the first year. Only a minor
reparable chip-off fracture (Grade 21)
was noted in the FDP, but both single
crown fractures occurred within the first
few weeks of use and were considered
irreparable (Grade 31).
Pihlaja et al
A limitation of this study is the
impossibility of comparing zirconia
manufacturing systems with one
another; patient records did not specify
which systems were used for every pa-
tient. Sagirkaya et al16 reported that
because porcelain systems are different,
survival rates may differ with 3 to 6 unit
FDPs when different systems are used.
Differences in marginal accuracy may
also be noted when different systems
and techniques are used.16 Recording
accurate treatment information with
the precise details of materials and
manufacturers is essential, especially
with ceramic materials, because
when zirconia materials are chosen,
numerous processing techniques and
materials are available.
Short-term and medium-term studies
have demonstrated the excellent biolog-
ical and mechanical properties of zirco-
nia,10-14,16-21 but long-term follow-up
studies of zirconia restorations will be
needed to compare different fabrication
processes and to investigate how time
affects the materials.
CONCLUSIONS
The results of this retrospective
study showed that with zirconia single
crowns and FDPs made by predoctoral
students, the most usual early compli-
cations were localized gingival irritation
and postoperative tooth sensitivity, and
the most usual short-term failure was
chipping of the veneering porcelain.
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- Issue -
Corresponding author:
Dr Ritva Näpänkangas
Department of Prosthetic Dentistry and
Stomatognathic Physiology
Institute of Dentistry, University of Oulu
Box 5281, FIN-90014 Oulu
FINLAND
E-mail: ritva.napankangas@oulu.fi
Acknowledgments
The authors thank Vuokko Anttonen and Päivi
Harju for their help collecting patient files.
Copyright ª 2014 by the Editorial Council for
The Journal of Prosthetic Dentistry.
Pihlaja et al