journal of prosthodontic research 63 (2019) 440–446

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Journal of Prosthodontic Research

journal homepage: www.elsevier.com/locate/jpor

Original article

Complete rehabilitation of patients with bruxism by veneered and

non-veneered zirconia restorations with an increased vertical
dimension of occlusion: an observational case-series study
S. Levartovskya,* , R. Piloa , A. Shadurb , S. Matalona , E. Winocura
a
Department of Oral Rehabilitation, The Maurice Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel
b
The Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel

A R T I C L E I N F O A B S T R A C T

Article history: Purpose: To assess the clinical performance of the complete rehabilitation of a series of patients with
Received 25 October 2018 bruxism treated by teeth- and implant-supported veneered and non-veneered zirconia restorations with
Received in revised form 22 February 2019 an increased vertical dimension of occlusion (VDO).
Accepted 25 February 2019
Methods: Ten patients with bruxism, aged 62–70 years, were treated with 108 veneered and 142 non-
Available online 21 March 2019
veneered zirconia restorations and attended the recall appointment. The mean observation period was
28.2 (16.8) months. The patients were identified from records, and clinical details were retrieved from
Keywords:
their files. In the recall appointment, the restorations were evaluated using modified California Dental
Veneered zirconia
Non-veneered zirconia
Association (CDA) criteria. The periodontal probing depth, bleeding index, presence of caries and implant
Bruxism survival and success rate were recorded.
Vertical dimension of occlusion Results: No biological complications were recorded for any restorations. The success and survival rate of
all implants was 100%. The overall mean survival and success rate of all restorations was 99.6%. In the
veneered group, the predominant complication was minor veneer chipping (13.9%) on the incisal edge,
which required only polishing (grade 1); in the non-veneered group, the predominant failure was open
proximal contacts between the implant restoration and adjacent teeth (9%); only one implant restoration
needed repair. One restoration was replaced due to a horizontal tooth fracture.
Conclusions: Within the limitations of this study, we conclude that the survival and success rate of
monolithic zirconia restorations installed in patients with bruxism was excellent, although the veneered
zirconia restorations showed a high rate of minor veneer chipping, which required only polishing.
© 2019 Published by Elsevier Ltd on behalf of Japan Prosthodontic Society.

1. Introduction jaw-muscle activity ranges from 8% to 31% and decreases with

Recently, the single definition for sleep and awake bruxism was
replaced by two separate definitions: Sleep bruxism (indicated
as SB) is defined as a masticatory-muscle activity during sleep that
is characterized as rhythmic (phasic) or nonrhythmic (tonic) and is
not a movement disorder or a sleep disorder in otherwise healthy
individuals. Awake bruxism (indicated as AB) is defined as a
masticatory-muscle activity during wakefulness that is character-
ized by repetitive or sustained tooth contact and/or by bracing or
thrusting of the mandible and is not a movement disorder in
otherwise healthy people [1]. The prevalence of this common
* Corresponding author at: Department of Oral Rehabilitation, The Maurice
Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Tel Aviv,
6997801, Israel.
E-mail address: shifralevartov@gmail.com (S. Levartovsky).
increasing age [2]. Several techniques are available for the
diagnosis of bruxism, including self-reporting, clinical examina-
tion and polysomnography (gold standard tool for sleep bruxism
diagnosis). A diagnostic grading system of “possible,” “probable”
and “definite” sleep or awake bruxism has been suggested for
clinical and research purposes [1,3].
In patients with severe bruxism, extensive attrition and erosion
often necessitate the esthetic and functional rehabilitation of a
full dentition. Such extensive treatments are a major challenge
for the dentist, dental technician and the patient. In those cases, it
is advantageous to consider increasing the vertical dimension of
occlusion (VDO) since it provides space for restorative material and
enhances the amount of tooth displayed while minimizing the
need for biologically invasive clinical procedures, such as crown-
lengthening or elective endodontic treatment [4].
Some authors have expressed concerns that altering the
VDO through dental rehabilitative treatment might cause

https://doi.org/10.1016/j.jpor.2019.02.006
1883-1958/ © 2019 Published by Elsevier Ltd on behalf of Japan Prosthodontic Society.
 S. Levartovsky et al. / journal of prosthodontic research 63 (2019) 440–446
Fig. 1. Patient #3 (treated by graduate student Dr. I Meinster).
a—Before treatment
b—After treatment
c—Cut back of veneered zirconia in the upper anterior restorations
d—Chip-off of feldspathic porcelain in the incisal edge of a veneered zirconia restoration that needs only polishing
e—Open proximal contact point between screwed implant restoration and adjacent tooth that needs to be repaired because of food impaction.
masticatory-muscle hyperactivity, bite force elevation and tempo-
romandibular joint disorder (TMD) [5–7]. Fabbri et al. [8]
investigated functional and prosthetic complications after increas-
ing the VDO and found more functional complications in patients
with posterior implant-supported rehabilitations than in patients
with posterior teeth-supported rehabilitations or posterior mixed
rehabilitations. No significant differences were found among the
three groups in terms of prosthetic complications [8].
Bruxism is suggested to cause the excessive loading of teeth,
implants and restorations, thus leading to bone loss, TMD symp-
toms and biomechanical complications, such as screw loosening,
fractures and the chipping of veneering restorative materials [9].
To avoid the chipping of veneering restorative materials in patients
with bruxism, an occluding surface material that does not chip,
such as metal or a monolithic ceramic material, is preferred [10].
With the introduction of CAD/CAM technologies and the develop-
ment of monolithic all-ceramic materials, other options aside from
bilayered all-ceramic systems have arisen. In particular, high-
strength monolithic zirconia ceramic restorations have become
the treatment of choice in patients with bruxism due to their
resistance in high-load-bearing areas [11]. Although these
monolithic zirconia restorations have improved esthetics after
superficial glazing and staining, they are still esthetically inferior to
fully veneered zirconia crowns. Therefore, in the anterior zone, on
the nonfunctioning facial surfaces, the preferred option is to use
buccally veneered zirconia restorations. The complete rehabilita-
tion of patients with bruxism treated by veneered and non-
veneered zirconia restorations with an increased VDO has barely
been investigated.
The aim of this retrospective study was to assess the clinical
performance of the complete rehabilitation of patients with
441
bruxism treated by buccally veneered and non-veneered zirconia
restorations with an increased VDO.
2. Materials and methods
2.1. Ethical considerations
Prior to the data collection, approval from the University
Institutional Ethical Committee was obtained (# 11-223-157).
Written and oral informed consent was provided by all of the
participants.
2.2. Sample
Patients with bruxism treated with complete rehabilitation
via an increased VDO (Fig. 1a, b) were identified from the records
of the graduate program of prosthodontics in the Dental
Medicine School and of the patient directory of the private
practice of the head of the program, who is an experienced
prosthodontist (SL).
These patients received an invitation for a recall appointment to
participate in the study and were given all the information about
the purpose of the study.
The data extracted from the patients’ files included demo-
graphics, such as age and sex, as well as preoperative, intra-
operative and immediate postoperative clinical records. For each
patient, the grade of bruxism was recorded at the time of arrival.
The diagnostic grading system of “possible,” “probable” and
“definite” sleep or awake bruxism was adopted, according to the
international consensus published by Lobbezoo et al. [3] and
according to the signs and symptoms of bruxism published by the
442 S. Levartovsky et al. / journal of prosthodontic research 63 (2019) 440–446
International Classification of Sleep Disorders [12]. All patients
were restored in centric relation (CR) with an increased VDO
measured in the anterior region with calipers.
2.2.1. Inclusion criteria
Patients were diagnosed as patients with bruxism according to
the international consensus by Lobbezoo et al. [3] and needed
complete rehabilitation with an increased VDO; patients were
rehabilitated by veneered and non-veneered zirconia restorations
(Prettau, Zirkonzahn, Israel); the occlusal scheme in these
rehabilitations was without ceramic veneer material participating
in the incisal and lateral guidance; patients with complete
preoperative, intraoperative and immediate postoperative clinical
and radiographic records and a follow-up of at least one year
postoperatively.
2.2.2. Exclusion criteria
Patients with an uncontrolled medical condition, aggressive
periodontal disease, incomplete records or not available for
follow-up.
2.3. Prosthodontic sequence of treatment
A diagnostic workup was performed to evaluate the functional
and esthetic needs of each patient. All patients were treated with
the same prosthetic approach using a semiadjustable articulator
(Quick Master, F.A.G. Dentaire, Cluses, France) and interocclusal
registration in CR. The amount of VDO increase was determined
based on the residual tooth structure and the space needed to
incorporate the restorative materials. The adjusted VDO was used
for the in-house wax-up. To minimize tooth substance removal, the
wax-ups and the mounted casts of each patient were used for
planning each preparation. The new VDO, which was measured in
the anterior region with calipers, was tested with mock-ups,
temporary restorations, or removable appliances for different
periods as relevant to each individual clinical situation. If the
amount of the increased VDO needed for the prosthetic rehabili-
tation was in the range of the interocclusal rest space (IORS) of the
patient, the new VDO was tested by preparing all the teeth in both
arches and relining the temporary acrylic resin restorations on the
patient’s dentition. If the amount of the increased VDO needed for
prosthetic rehabilitation was beyond the range of the IORS of the
patient, the new VDO was tested for adaptability with a removable
appliance for two months. If there were no functional complica-
tions, the teeth were prepared, and the temporary restorations
were relined on the patient’s dentition [13,14]. After increasing the
VDO with temporary restorations, the patients were requested to
function normally for at least two months. If no signs or symptoms
of functional drawbacks or discomfort were noticed, the restored
VDO was considered correct.
All final restorations were supported with either single
abutments without cantilevers or short fixed partial dentures
(FPDs) replacing only one pontic. When there was more than one
missing tooth, implants were placed, and their restorations were
either screwed or cemented to the implant abutments.
In the posterior quadrants, final restorations were in a
non-veneered zirconia design created with the CAD/CAM
software to mill the definite zirconia restoration according to
the manufacturer’s specifications. In the anterior quadrants,
especially in the upper jaw, further virtual modifications as
buccal cutbacks were carried out for adding veneering feldspathic
ceramics in the nonfunctioning anterior buccal surfaces. The
surface of all the restorations was glazed prior to cementation.
All tooth supported restorations were cemented with resin-
reinforced, glass ionomer luting cement (Fuji plus, GC Corp., Tokyo,
Japan) while the cemented implant-supported restorations were
cemented with temporary cement (TempBond, Kerr, CA, USA). The
screw access channels of the screw-retained implant-supported
restorations were sealed with polytetrafluoroethylene tape and a
composite filling material (FiltekSupreme Ultra, 3M, St.Paul, MN,
United States).
Immediately postoperatively, all patients received occlusal
splints and were instructed to wear them during sleep.
Clinical and radiographic records establishing the survival and
success of the abutments (implants and teeth) and restorations
were evaluated in the recall appointment.
2.4. Clinical assessment and classification of observed events at the
recall appointment
Two examiners (SL and AS) were trained prior to performing
the radiographic and clinical assessment of the implants, teeth and
restorations. The two examiners independently assessed all
records. Each time there was a misconception in the rating of a
given restoration, both examiners discussed the case together and
reached agreement.
The biological findings, including the periodontal probing
depth (PPD) and bleeding on probing (BoP), were registered for
each tooth and implant, as was the presence of caries and other
biological complications, considering the teeth only. All patients
underwent a periapical radiographic examination.
For the implants, the survival rate included implants found to
be functional and without clinical signs of infection, at the time of
the examination, even if bone resorption was identified radio-
graphically. The success rate included dental implants that met the
criteria for success described by Albrektsson et al. [15].
Technical findings were recorded in accordance with a modified
California Dental Association (CDA) quality evaluation system for
assessing surface, color, shape and marginal integrity (Table 1)
[16,17]. Chips were graded as described by Heintze and Rousson
[18]: grade 1 = polishing, grade 2 = repair, grade 3 = replacement.
A restoration failed and needing to be removed (irreparable) or
a tooth lost and needing to be extracted was classified as absolute
failure. Compromised quality or a comparable impairment in
integrity (chipping, crack formation) demanding an intervention
(repair, polishing) by the dentist, was classified as a relative failure/
complication [19].
In the recall appointment, the patients reported their compli-
ance with the use of an occlusal splint during sleep.
2.5. Statistical methods and synthesis of results
The collected data and variables were descriptively computed
and are presented in tables as percentages and mean values. A
detailed description of observations was preferred to enable a
better understanding. Due to the small number of participants, no
statistical analysis could be performed with sufficient statistical
power.
3. Results
Ten patients (three women and seven men) who met the
inclusion criteria attended the recall appointment. All patients
were between 62 and 70 years of age (mean: 66.1  3.8 years). All
patients were diagnosed with “probable bruxism” [3]. The
diagnosis of “probable” sleep or awake bruxism was based on
the inspection part of the clinical examination with patient self-
reporting.
The mean observation period in this study was 28.2 (16.8)
months (range: 12–66 months), with a total of 250 restorations and
63 implants placed. Details regarding the patient variables,
materials, restorations and implants are presented in Table 2. All
 S. Levartovsky et al. / journal of prosthodontic research 63 (2019) 440–446 443

Table 1. Criteria for direct clinical evaluation according to a modified California Dental Association (CDA) quality evaluation system

Rating Criteria
Surface
1. (R) Excellent Surface of restoration is smooth. No irritation of adjacent tissue.
2. (S) Satisfactory Surface of restoration is slightly rough and pitted, can be refinished.
3. (T) Unsatisfactory Surface deeply pitted, irregular grooves (not related to anatomy), cannot be refinished.
4. (V) Unsatisfactory Surface is fractured or flaking.

Shape
1. (R) Excellent Restoration’s contour is in functional harmony with adjacent teeth and soft tissue.
2. (S) Satisfactory Restoration is slightly under- or overcountered.
3-(T) (R) Excellent Unsatisfactory-Grossly under- or overcontoured. Occlusion is affected.
4. (V) Unsatisfactory Anatomic form is in gross disharmony with adjacent teeth.

Colour
1. (R) Excellent No mismatch in color, shade or translucency between restoration and adjacent tooth
2. (S) Satisfactory Mismatch between restoration and tooth structure within the normal range of tooth color.
3. (T) Unsatisfactory Mismatch between restoration and tooth structure outside the normal range.
4. (V) Unsatisfactory Esthetically displeasing color, shade and/or translucency.

Margin integrity
1. (R) Excellent No visible evidence of ditching along the margin. No discoloration on the margin.
2. (S) Satisfactory Visible evidence of ditching along the margin. Discoloration on the margin.
3. (T) Unsatisfactory Dentin or base is exposed along the margin. Discoloration has penetrated the margin.
4. (V) Unsatisfactory Restoration is mobile or fractured or caries contiguous with the margin.

1. (Romeo)—range of excellence; 2. S (Sierra)—satisfactory; 3. T (Tango)—unsatisfactory, reparable; 4. V (Victor)—unsatisfactory, irreparable.

Table 2. Patient variables, restorations, materials and implants.

Patient# sex Age at treatment VOD increase (mm) Follow-up (months) NVZ restorations VZ restorations Sum of restoration Implants Occlus splint
1 (M) 64 3 66 7 18 25 11 No
2 (F) 68 3 30 12 10 22 5 No
3 (M) 69 3 24 16 10 26 9 No
4 (M) 62 2 18 16 10 26 5 No
5 (M) 62 7 18 16 10 26 6 No
6 (F) 67 2 12 14 10 24 3 Yes
7 (M) 60 3 18 18 10 28 12 No
8 (M) 69 5 30 14 10 24 6 Yes
9 (M) 70 6 48 16 10 26 5 Yes
10 (M) 70 2 18 13 10 23 1 Yes
Total 142 108 250 63

M—male; F—female; NVZ—non-veneered zirconia; VZ—veneered zirconia.

patients were provided with restorations of a non-veneered
zirconia design in the posterior quadrants. In one patient (patient
#1), the buccal surfaces of 10 (incisors, canines and four premolars)
upper and eight (incisors, canines and two premolars) lower
crowns were veneered with a feldspathic ceramic material. In all
the other patients, only the buccal surfaces of 10 (incisors, canines
and four premolars) upper crowns were veneered with a
feldspathic ceramic material, while the lower anterior crowns
were of a non-veneered zirconia design, as in the posterior
quadrants (Fig. 1c). Therefore, a total of 108 restorations were of a
veneered zirconia design, while the remaining 142 restorations
were of a non-veneered zirconia design (Table 2).
The VDO was increased by a range of two to seven mm (mean:
3.6  1.8 mm), measured in the anterior region with calipers. All
patients adapted to the new VDO without any temporomandibular
signs or symptoms.
Among the 63 implants restored, 11 (17.5%) were in the anterior
area and 52 (82.5%) were in the posterior area of the jaws.
Among the study group, only four patients reported use of the
occlusal splint during sleep (Table 2).
3.1. Biological findings
The PPD was between 2–5 mm for all teeth and implants. BoP
was found on one or more teeth/implants in all patients. No caries
was found in the restored teeth in any of the patients. No implant
failures were reported during the follow-up period. The success
rate of all implants in the study group was thus 100%, according to
Albrektsson et al. [15].
3.2. Absolute failure and survival of teeth and restorations
There was one failed restoration resulting from a horizontal
tooth fracture (patient #3). The tooth was replaced by an implant,
restored with a new non-veneered zirconia restoration. This
results in an overall mean survival rate of 99.6% for the 250
restorations (Table 3).
3.3. Relative failure and success of the treatments
The remaining failures were classified as complications. There
were a total of 20 complications, which compromised the success
rate of the restorations, as follows: chipping of the feldspathic
porcelain veneers occurred, affecting 15 upper anterior restora-
tions (incisors and canines) in five patients; all chipping occurred
on the incisal edge and required only polishing (grade 1) (Fig. 1d).
Five open proximal contacts were observed between implant
restorations and the adjacent teeth in the posterior quadrants (two
in the maxilla and three in the mandible), affecting four patients
(Table 3). Four open proximal contacts had no food impaction;
therefore, no treatment was required, and the patients were
carefully monitored. Only one open proximal contact observed had
444 S. Levartovsky et al. / journal of prosthodontic research 63 (2019) 440–446

Table 3. Patients and observed absolute and relative failures

Patient# Sex Fractured tooth Chip-offs of feldspathic porcelain veneers Open proximal contact between tooth & implant Occlusal splint
1 (M) 5* No
2 (F) No
3 (M) 1# 1* 1** No
4 (M) 2* 1* No
5 (M) 2* No
6 (F) Yes
7 (M) 4* 1* No
8 (M) 3* Yes
9 (M) Yes
10 (F) Yes
Total 1 15 5
# * **
Absolute failure. Relative failure with no repair. Relative failure with repair.

Fig. 2. CDA ratings for group A—non-veneered zirconia restorations. Fig. 3. CDA ratings for group B—veneered zirconia restorations.

food impaction (upper premolar with a veneered zirconia
restoration) (Fig. 1e); therefore, the screwed implant restoration
was removed and repaired by adding feldspathic porcelain,
achieving better proximal contact with the adjacent tooth. This
results in an overall mean success rate of 99.6% for the 249
restorations.
3.4. CDA ratings
The CDA ratings were divided into those of group A, non-
veneered zirconia restorations (Fig. 2), and those of group B,
veneered zirconia restorations (Fig. 3).
All the restorations (100%) in group A had excellent surfaces
while in group B, most of the restorations (86.1%) had excellent
surfaces and the rest (13. 9%) had satisfactory surfaces because of
minor veneer chipping, which required only polishing (grade 1).
The color of all restorations in group A was rated as satisfactory. In
group B, the color was rated as excellent in 44% of the restorations,
whereas 56% were evaluated as having a satisfactory color. The
shape, in group A, was excellent in the majority of the restorations
(82%), whereas the remaining were evaluated as follows: one
restoration needed to be replaced because of a horizontal tooth
fracture (0.7%), one implant restoration needed to be repaired
because of an open proximal contact with food impaction, adjacent
to a natural tooth (0.7%) and the rest were evaluated as having a
satisfactory shape, including the four open proximal contacts
between implants and teeth without food impaction (16.6%). In
group B, on the other hand, almost all of the restorations (92.5%)
had an excellent shape, whereas the rest were evaluated as
satisfactory. Ninety-six restorations (67.6%) in group A, had
excellent margins, while the rest were rated as satisfactory with
slight overcontouring (32.4%). Approximately 50% of the restora-
tions, in group B, had excellent margins, while the other half were
slightly overcontoured and were rated as satisfactory. Overall, in
group A, 0.7% needed to be replaced, 0.7% needed to be repaired,
and the rest of the non-veneered zirconia restorations, 98.6%,
were evaluated as satisfactory and not in need of repair or remake
regarding any of the CDA variables. In group B, all restorations
were evaluated as 100% satisfactory and not in need of repair or
remake regarding any of the CDA variables.
4. Discussion
In the current study, the clinical performance of the complete
rehabilitation of a series of patients with bruxism was assessed.
Bruxism was identified according to clinical examination and self-
report and the diagnostic grading system of Lobbezoo et al. [3] was
used. Although, polysomnography is regarded as the best method
of diagnosis bruxism, it was not used for assessment since it is both
costly and time consuming. Schmitter et al. [20] showed that
 S. Levartovsky et al. / journal of prosthodontic research 63 (2019) 440–446
muscle activity during sleep without clinical symptoms or report
of bruxism was observed for a relevant number of patients.
Therefore, some uncertainty exists regarding the diagnosis
“bruxism”. Still, as was stated lately, in the study of Lobbezoo
et al. [1], both non-instrumental approaches (notably self-report)
and instrumental approaches (notably electromyography) can
be employed to assess bruxism which, in otherwise healthy
individuals, is not considered as a disorder, but rather as a behavior
that can be a risk (and/or protective) factor for certain clinical
consequences.
In our study, assessing the CDA rating for each restoration
groups A and B demonstrated different results, as follows:
4.1. Surface analysis
In group A (non-veneered zirconia) (Fig. 2), the CDA rating for
the surface was excellent for all of the monolithic zirconia
restorations (100%), with no fracturing, cracking, or chipping of
the monolithic zirconia structure. This is probably related to the
high flexural strength (900–1200 MPa) and fracture toughness (9–
10 MPa m0.5) of the yttria-partially stabilized tetragonal zirconia
polycrystals (Y-TZP) monolithic structure [21]. This finding is in
agreement with the case reports made by Rojas-Vizcaya [22],
Thalji and Cooper [23], and Marchack et al. [24]. Hansen et al. [25]
evaluated monolithic zirconia crowns in the aesthetic zone in
heavy grinders and reported chipping in 5.2% and total fracture
in 1.3% of all restorations. These failures occur in the aesthetic
zone, where restorations are subjected to higher shear forces; in
contrast, in our study, the monolithic zirconia restorations were
placed mostly in the posterior quadrants.
In group B (veneered zirconia) (Fig. 3), there was minor veneer
chipping in 13.9% of the restorations that were found exclusivity on
the incisal edges of the upper anterior teeth (incisors and canines).
This high minor chipping rate can only be compared to that of
previous studies reporting high chipping rates (8–54%) [18,26–29]
but in a design with a bilayered approach. This explains the greater
percentage range of veneering ceramic chipping in the aforemen-
tioned studies. In the current study, veneered feldspathic ceramics
were added only to the nonfunctioning buccal surfaces, yet there
was a relatively high minor chipping rate. This result is not in
agreement with the results of Moscovitch’s study, where zirconia
restorations exhibited a 100% success rate with or without a
buccally veneered feldspathic ceramic component (not in func-
tion) [30]. These differences are attributed to the study group,
which in the current study, consists of patients with parafunctional
occlusal activity and an increased VDO. Most chipping was found in
patients who reported not using the occlusal splint during sleep,
but three instances of minor chipping were also found in one
patient (#8) that reported using the occlusal splint (Table 3). A
possible explanation for the high minor chipping rate might be the
difference between the low flexural strength of the veneering
ceramic material (~ 90–120 MPa) compared to that of the high-
strength zirconia core material (900 MPa). In protrusive excur-
sions, some flexion of the restoration might lead to the propagation
of subcritical intraceramic cracks, which more often exist in the
veneering ceramic, making it more prone to cohesive minor
fractures during mastication, especially in highly loaded areas as in
patients with bruxism [31]. These high loads might also induce
phase transformation around microcracks in the surface, leading to
chipping of the outer surface [32,33].
4.2. Color analysis
The color of all non-veneered (group A) restorations was rated
as satisfactory because of the monochromatic color structure
and opaque appearance being inferior to the appearance of
445
bilayered zirconia. Due to these optical properties, it is not
possible to imitate the natural optical properties of the original
tooth substance. These results are in accordance with those of
Hansen et al. [25]. Although this might be improved by using
newer, highly translucent zirconia, this material is not recom-
mended for use in patients with bruxism due to its inferior
mechanical properties [34]. In comparison, in group B, almost half
of the veneered zirconia restorations (44%) were rated as
excellent in color due to the transparent layer of feldspathic
porcelain added in the buccal area.
4.3. Margin analysis
For marginal integrity, most of the non-veneered (group A)
zirconia restorations in the present study were rated as excellent,
whereas the rest were rated as satisfactory with slight over-
contouring. In group B, there was a high percentage of over-
contoured margins (50%) as the buccal feldspathic porcelain was
added free-hand by the technician, whereas the CAD-CAM
technique was used for the monolithic zirconia restorations.
4.4. Shape analysis
Five open proximal contacts between implant restorations and
teeth were found in the posterior quadrants only (group A). None
of these open proximal contacts were associated with failed
restorations but showed a phenomenon recently observed when
an implant restoration is placed next to a natural tooth. Amato
et al. [35] demonstrated a significant percentage of interproximal
contact loss, 52.8%, between single-implant restorations and
adjacent teeth; 78.2% were identified on the mesial surfaces and
21.8% on the distal surfaces. Their suggestion was to use an Essix
retainer to prevent interproximal contact loss between single-
implant restorations and adjacent teeth. Greenstein et al. [36] in a
review of the literature, reported the development of an
interproximal gap in 34%–66% of cases after an implant restoration
was inserted next to a natural tooth, and this gap occurred as early
as 3 months after prosthetic rehabilitation, usually on the mesial
aspect of the restoration. Their assumption was that force vectors
cause tooth movement while an implant functions as an ankylosed
tooth. Therefore, they also advise patients to wear a retainer or
night guard to relieve masticatory stress from teeth and implants.
In our study, such a gap developed in only five implant restorations
among the 55 implant restorations that were in the posterior
quadrants (9%), which is a lower rate than that found in the
abovementioned studies. The gaps in the current study were found
in four patients who reported not using the occlusal splint during
sleep, while no gaps were found in patients who reported using
the occlusal splint (Table 3). Although no conclusion can be drawn
from such a small number of patients, it might be advisable for
patients to use an occlusal splint at night to avoid the opening of
proximal contact points between implant restorations and teeth in
the posterior quadrants.
The VDO was increased by between two and seven mm (mean:
3.6  1.8 mm), which was necessary to achieve acceptable aes-
thetics and material dimensions. All patients adapted to the
new VDO without any temporomandibular signs or symptoms
throughout the treatment and the follow-up period [4].
In this case series, all complications occurred in male patients,
but because of the small number of female patients in this study,
no conclusion related to this observation can be drawn.
5. Conclusion
Within the limitations of this study, we conclude that veneered
and non-veneered zirconia restorations in patients with bruxism in
446 S. Levartovsky et al. / journal of prosthodontic research 63 (2019) 440–446
an increased VDO show a high survival and success rate (99.6%)
with minor clinical complications. A high rate minor chipping of
the veneering ceramic is anticipated, but this complication can
usually be resolved by polishing only. The opening of proximal
contact points between implant restorations and adjacent teeth in
the posterior quadrants may be avoided by using an occlusal splint
at night. Further studies of larger series of veneered and non-
veneered zirconia restorations in patients with bruxism are
warranted.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Acknowledgements
Not applicable.
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