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Full-Mouth Rehabilitation of a Patient with Sjogren’s Syndrome with

Maxillary Titanium-Zirconia and Mandibular Monolithic Zirconia Implant
Prostheses Fabricated with CAD/CAM Techno...

Article in Journal of Functional Biomaterials · March 2023

DOI: 10.3390/jfb14040174

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 Journal of
Functional
Biomaterials
Case Report
Full-Mouth Rehabilitation of a Patient with Sjogren’s
Syndrome with Maxillary Titanium-Zirconia and Mandibular
Monolithic Zirconia Implant Prostheses Fabricated with
CAD/CAM Technology: A Clinical Report
Francisco X. Azpiazu-Flores 1 , Damian Lee 2 , Carlos A. Jurado 3 , Kelvin I. Afrashtehfar 4,5 ,
Abdulaziz Alhotan 6 and Akimasa Tsujimoto 7,8, *
Citation: Azpiazu-Flores, F.X.; Lee,
D.; Jurado, C.A.; Afrashtehfar, K.I.;
Alhotan, A.; Tsujimoto, A.
Full-Mouth Rehabilitation of a
Patient with Sjogren’s Syndrome
with Maxillary Titanium-Zirconia
and Mandibular Monolithic Zirconia
Implant Prostheses Fabricated with
CAD/CAM Technology: A Clinical
Report. J. Funct. Biomater. 2023, 14,
174. https://doi.org/10.3390/
jfb14040174
Academic Editors: Giuseppe
Minervini, Valentina Belli and James
Kit-Hon Tsoi
Received: 14 February 2023
Revised: 21 March 2023
Accepted: 21 March 2023
Published: 23 March 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
J. Funct. Biomater. 2023, 14, 174. https://doi.org/10.3390/jfb14040174
1 Department of Restorative Dentistry, Gerald Niznick College of Dentistry University of Manitoba,
Winnipeg, MB R3E 0W3, Canada
2 Division of Restorative and Prosthodontics Dentistry, College of Dentistry, The Ohio State University,
Columbus, OH 43210, USA
3 Department of Prosthodontics, University of Iowa College of Dentistry, Iowa City, IA 52242, USA
4 Division of Restorative Dental Sciences, Clinical Sciences Department, Ajman University College of Dentistry,
Ajman City 346, United Arab Emirates
5 Department of Reconstructive Dentistry and Gerodontology, School of Dental Medicine, University of Bern,
3010 Bern, Switzerland
6 Dental Health Department, King Saud University College of Applied Medical Sciences,
Riyadh 1145, Saudi Arabia
7 Department of Operative Dentistry, University of Iowa College of Dentistry, Iowa City, IA 52242, USA
8 Department of General Dentisry, Creigthon University School of Dentisry, Omaha, NE 68102, USA
* Correspondence: akimasa-tsujimoto@uiowa.edu
Abstract: Dental implants have become a well-established treatment modality for the management
of complete and partial edentulism. Recent advancements in dental implant systems and CAD/CAM
technologies have revolutionized prosthodontic practice by allowing for the predictable, efficient, and
faster management of complex dental scenarios. This clinical report describes the interdisciplinary
management of a patient with Sjogren’s syndrome and terminal dentition. The patient was rehabili-
tated using dental implants and zirconia-based prostheses in the maxillary and mandibular arches.
These prostheses were fabricated using a combination of CAD/CAM and analog techniques. The
successful outcomes for the patient demonstrate the importance of appropriate use of biomaterials
and the implementation of interdisciplinary collaboration in treating complex dental cases.
Keywords: full-mouth rehabilitation; CAD/CAM implant restorations; zirconia; implants
1. Introduction
Terminal dentition refers to a moment when the dentition is compromised to the point
that its predictable restoration is no longer viable; this stage is usually reached after years of
periodontal disease or as a result of unfavorable social or pharmacological conditions [1] or,
in some situations, autoimmune diseases. Sjogren’s syndrome is an autoimmune condition
characterized by lymphocyte infiltration and progressive destruction of the exocrine glands.
One characteristic of the disease is a reduction in the production of tears and saliva,
which has a negative effect on overall oral health and patient well-being and worsens
over time. Dry mouth is the key diagnostic sign for this disease and can lead to a wide
range of problems, including oral infections, progressive tooth decay, and periodontal
breakdown [2]. When patients reach the terminal dentition stage, the restorative dentist
faces the challenging task of devising a treatment that meets the patient’s esthetic and
functional expectations. Traditionally, patients with several non-restorable abutment teeth
had no choice but to use complete dentures, which, despite their long history of service,
https://www.mdpi.com/journal/jfb
J. Funct. Biomater. 2023, 14, 174 2 of 13

only restored the masticatory function to some extent [3,4]. Nowadays, thanks to dental
implants, patients with terminal dentitions can be restored predictably and effectively with
complete arch fixed prostheses.
Since the introduction of root-form dental implants by P.I. Branemark in 1965, dental
implants have become a powerful resource for the rehabilitation of completely and partially
edentulous patients [5]. Contemporary dental implants display high survival rates, which
are the result of years of research directed at enhancing their topography, surface chemistry,
and macroscopic features [6,7]. Thanks to these advances, contemporary dental implant
protocols permit the rapid rehabilitation of complex clinical situations with a reduced
number of dental implants [8–10]. These noteworthy advancements have also fostered the
development of prosthetic materials, imaging and planning methods [11], surgical proto-
cols [12], manufacturing technologies [13,14], and retention mechanisms [15] specifically
created to optimize the restorative process.
Full arch reconstruction with implant therapy can be divided into screw-retained
and cement-retained prostheses, and each option has shown advantages and disadvan-
tages [15,16]. Screw-retained full-arch implant prostheses offer several advantages, such
as retriability [17], clear access for hygiene maintenance of the prosthesis, implant, and
surrounding tissues [18], and simple methods for repair [19]. Some disadvantages include
the higher number of components and laboratory procedures, increased chairside time for
the clinician, compromised esthetics, and screw loosening [20–22]. Cement-retained pros-
theses provide superior stability, esthetics, and occlusion in comparison to screw-retained
prostheses [20–23]. However, some disadvantages include the difficulty of retrievability
and the risk of having an excess of cement in the periodontal tissue [20,24].
Computer-aided design and computer-aided manufacturing (CAD/CAM) technolo-
gies make possible the creation of complex objects with minimal error [13,14]. These
manufacturing technologies have been used extensively in engineering, medicine, and
dentistry thanks to their versatility and wide range of applications. CAD/CAM technolo-
gies can be subtractive or additive, depending on how the object is created [13]. Additive
manufacturing involves forming the object layer-by-layer [14], while in subtractive manu-
facturing techniques, the object is produced by cutting the material to the desired shape
with a sharp cutting tool controlled by a computer [13]. Complex dental devices, such
as surgical templates [25], dental models, custom trays, and dental prostheses, can be
successfully manufactured with these manufacturing methods [12,14,26].
A great example of the advancements made possible thanks to CAD/CAM subtractive
manufacturing are yttria-stabilized zirconia dental prostheses. Zirconia and other high-
strength ceramics have been widely used in biomedical engineering and orthopedics for
reconstructive purposes [27–30]. Zirconia is a polycrystalline ceramic that undergoes phase
transformation when subjected to different temperatures. At temperatures greater than
2367 ◦ C, zirconia has a cubic structure; between 1167 ◦ C and 2367 ◦ C, zirconia is tetrago-
nal; and below 1167 ◦ C, the structure is monoclinic [27]. This material is stabilized with
dopants such as Mg, Ca, Sc, Y, or Nd to prevent its transformation from the high-strength
tetragonal phase to the weaker monoclinic phase at room temperature [27]. With a flexural
strength > 900 MPa and a high fracture toughness of 8 MPa·m1/2 , stabilized tetragonal zir-
conia has gained enormous popularity as a dental restorative material [27]. In fact, research
has demonstrated 5-year survival rates above 99% when the prosthesis is meticulously
designed with pink felspathic porcelain limited to its gingival portion [31,32]. In addition to
its remarkable mechanical properties, zirconia presents excellent biocompatibility, display-
ing no local or systemic cytotoxic effects [27,29] and reducing dental plaque accumulation
when compared to other restorative materials [31]. These features have made stabilized
tetragonal zirconia one of the most versatile and reliable contemporary restorative mate-
rials available. The present clinical report presents the comprehensive rehabilitation of a
patient with Sjogren’s syndrome and terminal dentition using a maxillary titanium-zirconia
complete arch prosthesis and a complete-arch mandibular monolithic zirconia prosthesis
fabricated using a combination of analog techniques and CAD/CAM technologies.
 contemporary restorative materials available. The present clinical report presents th
comprehensive rehabilitation of a patient with Sjogren’s syndrome and terminal dentitio
using a maxillary titanium-zirconia complete arch prosthesis and a complete-arch man
dibular monolithic zirconia prosthesis fabricated using a combination of analog tech
J. Funct. Biomater. 2023, 14, 174 3 of 13
niques and CAD/CAM technologies.

2. Materials and Methods

2. Materials and Methods
A 69-year-old male patient presented to the Advanced Prosthodontics Dental Clinic
A 69-year-old male patient presented to the Advanced Prosthodontics Dental Clinics
atatthe
theOhio
OhioState
State University
University seeking
seeking comprehensive
comprehensive dental
dental care.care. Attime
At the the of
time
theof the initial ex
initial
amination, the patient stated that he had medically controlled hypertension and
examination, the patient stated that he had medically controlled hypertension and Sjogren’s Sjogren’s syn
drome managed
syndrome withsalivary
managed with salivarysubstitutes
substitutes (Biotene
(Biotene Dry Mouth;
Dry Mouth; GlaxoSmithKline
GlaxoSmithKline Group, Group
Durham,
Durham, NC,
NC, USA).
USA). The extraoral
The extraoral examination
examination revealed revealed anterior metal-ceramic
anterior metal-ceramic restorations, restora
ations,
positive smile line,
a positive and multiple
smile line, andmissing
multipleanterior teeth
missing (Figure teeth
anterior 1). (Figure 1).

Figure
Figure 1. 1. Pre-treatment
Pre-treatment extraoral
extraoral photographs
photographs (from (from left toFrontal,
left to right) right) Frontal, ¾ Profile.
3/4 profile, profile, Profile.

Intraorally, all all

Intraorally, thethe
remaining teethteeth
remaining except for thefor
except mandibular incisorsincisors
the mandibular had complete-
had complete
coverage extracoronal restorations, the majority with secondary decay. A
coverage extracoronal restorations, the majority with secondary decay. A sinussinus tract wastract wa
noticed on the buccal mucosa of tooth number 4.1, and tooth number 1.1 presented a
noticed on the buccal mucosa of tooth number 4.1, and tooth number 1.1 presented a hor
horizontal fracture above the gingival margin (Figure 2). Additionally, clinical features
izontal
J. Funct. Biomater. 2023, 13, x FOR PEER REVIEWfracture above the gingival margin (Figure 2). Additionally, clinical4features
typical of Sjogren’s syndrome, including minimal salivary flow and generalized bleeding of 13 typ
cal of Sjogren’s syndrome, including minimal
on probing, were also noted during the examination. salivary flow and generalized bleeding o
probing, were also noted during the examination.
The clinical findings were corroborated radiographically since multiple radiolucen
lesions were noticed on the margins of the restorations, thus confirming the compromise
state of the dentition. Additionally, a radiopaque mass was noticed on the anterior of th
right mandibular angle (Figure 3).
After asking the patient, he explained that it was an osseous exostosis of benig
origin that was frequently monitored by his primary care physician. Maxillary and man
dibular preliminary impressions were taken with irreversible hydrocolloid (Geltrate
Dentsply Sirona North America, York, PA, USA) and were used to fabricate maxillary an
mandibular diagnostic casts with type III dental stone (Buff Stone; Whip Mix Corp., Lou
isville, KY, USA). Additionally, a diagnostic cone-beam computerized tomograph
(CBCT) was taken at the end of the appointment.

Figure2.
Figure 2. Frontal
Frontal intraoral
intraoralphotograph
photographtaken
takenat
atthe
theinitial
initialappointment.
appointment.
J. Funct. Biomater. 2023, 14, 174 4 of 13

The clinical findings were corroborated radiographically since multiple radiolucent

lesions were noticed on the margins of the restorations, thus confirming the compromised
state of the dentition. Additionally, a radiopaque mass was noticed on the anterior of the
right mandibular
Figure 2. Frontal angle (Figure
intraoral 3).
photograph taken at the initial appointment.

Figure3.3.Pre-treatment
Figure Pre-treatment panoramic
panoramic radiograph.
radiograph.

After asking
After the patient,
evaluating the he explained that
information it was an
gathered osseous
during theexostosis
clinicalofexamination,
benign origin multipl
that was frequently
treatment optionsmonitored
involvingby his primary
removable care
and physician.
fixed dental Maxillary
prostheses and mandibular
were presented to th
preliminary impressions were taken with irreversible hydrocolloid (Geltrate; Dentsply
patient. Once the treatment options were reviewed, the patient stated that he preferre
Sirona North America, York, PA, USA) and were used to fabricate maxillary and mandibular
not to undergo
diagnostic extensive
casts with type IIIrestorative
dental stoneprocedures
(Buff Stone; to Whip
keep his
Mixteeth.
Corp.,He explained
Louisville, KY,that fixe
partial dentures never restored his smile nor his masticatory
USA). Additionally, a diagnostic cone-beam computerized tomography (CBCT) was takenfunction since they deve
atoped decay
the end and
of the failed within a few months post-delivery. Removable partial denture
appointment.
were not evaluating
After consideredthe since the patient
information had had
gathered issues
during therelated
clinical to difficult maintenance,
examination, multiple poo
treatment
function,options involving removable
and discomfort with theseand fixed dental
prostheses prostheses
in the were evaluating
past. After presented tothese
the factor
patient. Once the the
and analyzing treatment options
patient’s were reviewed,
expectations, the patient stated
complete-arch that he preferred
implant-supported prosthese
not to undergo extensive restorative procedures to keep his teeth. He explained
were considered a feasible, definitive treatment capable of improving the patient’s overa that fixed
partial dentures never restored his smile nor his masticatory function since they developed
quality of life in addition to restoring esthetics and function. The advantages and limita
decay and failed within a few months post-delivery. Removable partial dentures were not
tions of complete
considered since the arch
patientdental prostheses
had had supported
issues related by dental
to difficult implants
maintenance, were
poor discussed
func-
After
tion, andthe treatment
discomfort withduration (including
these prostheses in thethe number
past. of appointments),
After evaluating these factorsfinances,
and an
analyzing the patient’s expectations, complete-arch implant-supported prostheses were
considered a feasible, definitive treatment capable of improving the patient’s overall quality
of life in addition to restoring esthetics and function. The advantages and limitations
of complete arch dental prostheses supported by dental implants were discussed. After
the treatment duration (including the number of appointments), finances, and expecta-
tions were discussed, the patient decided to proceed with a treatment plan consisting of
4 maxillary and 4 mandibular implants with complete-arch Zirconia-based prostheses.
Maxillary and mandibular diagnostic teeth arrangements were fabricated with denture
teeth (Blue-Line; Ivoclar Vivadent Schaan, Liechtenstein, Switzerland) and visible-light cure
(VLC) denture bases (Triad VLC Denture Base Material; Dentsply Sirona North America,
York, PA, USA) to establish the desired incisal edge position and future occlusal plane
(Figure 4A). Additionally, the distance from the incisal edges to the lower border of the
upper lip during a maximum smile was recorded and inscribed on the diagnostic casts to
 ture teeth (Blue-Line; Ivoclar Vivadent Schaan, Liechtenstein, Switzerland) and visible
light cure (VLC) denture bases (Triad VLC Denture Base Material; Dentsply Sirona Nort
America, York, PA, USA) to establish the desired incisal edge position and future occlusa
plane (Figure 4A). Additionally, the distance from the incisal edges to the lower border o
J. Funct. Biomater. 2023, 14, 174 the upper lip during a maximum smile was recorded and inscribed on the diagnostic 5 of 13 cast
to plan the position of the maxillary implants so that they would be 4 mm above the uppe
lip during function and smiling to ensure the concealment of the future prosthesis-tissu
plan the position
junction [33,34].ofSubsequently,
the maxillary implants so that they
the diagnostic castswould be 4 mm above
and diagnostic the upper
artificial teeth arrange
lip during
ments werefunction and using
scanned smilinga to ensure the
benchtop 3Dconcealment
scanner (E3ofScanner;
the future prosthesis-tissue
3Shape A/S, Copenhagen
junction
Denmark) [33,34].
andSubsequently,
were merged thewith
diagnostic casts and
the patient’s diagnostic
CBCT data artificial teeth arrange-
in an implant planning com
ments were scanned using a benchtop 3D scanner (E3 Scanner; 3Shape A/S, Copenhagen,
puter program (BlueSky Plan V4; Blue Sky Bio, ,Libertyville,IL,USA) (Figure 4B). Th
Denmark) and were merged with the patient’s CBCT data in an implant planning computer
placement of four standard-diameter dental implants (Tapered Screw Vent 4.1 × 10; Zim
program (BlueSky Plan V4; Blue Sky Bio, Libertyville, IL, USA) (Figure 4B). The placement
mer
of fourBiomet, Parsippany,
standard-diameter NJ, USA)
dental for the
implants maxillary
(Tapered Screwarch
Ventand four
4.1 × 10; standard-diameter
Zimmer Biomet, den
tal implants (Tapered Screw Vent 4.1 × 1 1.5 and 4.1 × 10 mm; Zimmer
Parsippany, NJ, USA) for the maxillary arch and four standard-diameter dental implants Biomet, Parsippany
NJ, USA)
(Tapered for the
Screw Ventmandibular
4.1 × 1 1.5 andarch4.1was
× 10planned
mm; Zimmerdigitally (Figure
Biomet, 4C), and
Parsippany, NJ,a USA)
surgical tem
plate
for the was designed
mandibular in was
arch the same
plannedcomputer
digitallyprogram. Subsequently,
(Figure 4C), and a surgicalmaxillary
template andwas mandib
designed in the same computer program. Subsequently, maxillary and
ular bone reduction guides and bone-supported surgical templates were manufacture mandibular bone
reduction guidesphotopolymer
using a clear and bone-supported surgical
(Surgical templates
Guide were manufactured
V2; FormLabs, usingMA,
Somerville, a clearUSA) in
photopolymer (Surgical Guide V2; FormLabs, Somerville, MA, USA) in a stereolithographic
stereolithographic (SLA) 3D printer (Form2; FormLabs, Somerville, MA, USA). Addition
(SLA) 3D printer (Form2; FormLabs, Somerville, MA, USA). Additionally, maxillary and
ally, maxillary and mandibular interim complete dentures were fabricated by compres
mandibular interim complete dentures were fabricated by compression molding using heat
sion molding
polymerized using heat polymerized
polymethylmethacrylate (PMMA) polymethylmethacrylate
denture base resin (Lucitone (PMMA) denture bas
199; Dentsply
resin (Lucitone 199; Dentsply Sirona North America, York, PA, USA).
Sirona North America, York, PA, USA). On the day of the surgery, the dental implants were On the day of th
surgery,
placed the dentalusing
uneventfully implants were placed uneventfully
the computer-generated using the
surgical templates, andcomputer-generated
the mandibular sur
gical templates,
prosthesis and the mandibular
was immediately loaded (Figure prosthesis
4D). was immediately loaded (Figure 4D).

Figure4.4.Treatment
Figure Treatment planning.
planning. (A),(A), diagnostic
diagnostic artificial
artificial teeth arrangement.
teeth arrangement. (B), 3D diagnostic
(B), 3D diagnostic models model
aligned in 3D modeling software. (C), planned dental implant positions, and surgical guide
aligned in 3D modeling software. (C), planned dental implant positions, and surgical guide design. design. (D
panoramic radiograph of maxillary and mandibular dental implants immediately after
(D), panoramic radiograph of maxillary and mandibular dental implants immediately after placement. placement.

After
After4 4months
monthsofofhealing,
healing,thethemaxillary
maxillary implants were
implants uncovered,
were andand
uncovered, tapered
tapered abut
abutments were installed (straight, 15 ◦ , and 30◦ tapered abutment systems; Zimmer Biomet
ments were installed (straight, 15°, and 30° tapered abutment systems; Zimmer Biome
Dental).
Dental).Definitive
Definitiveimpressions
impressionswere were taken usingusing
taken custom impression
custom trays (Triad
impression traysTru
(Triad Tr
Tray; Dentsply Sirona North America, York, PA, USA) and medium-bodied polyether
Tray; Dentsply Sirona North America, York, PA, USA) and medium-bodied polyether im
impression material (Impregum Penta; 3M America, Saint Paul, MN, USA), and maxillary
pression material (Impregum Penta; 3M America, Saint Paul, MN, USA), and maxillar
and mandibular definitive casts were fabricated with low-expansion type IV dental stone
(New Fuji Rock IMP; GC America Inc., St. Alsip, IL, USA). Subsequently, verification
devices were fabricated using low-shrinkage PMMA resin (Pattern Resin LS; GC America
Inc., St. Alsip, IL, USA) and were used to verify the accuracy of the definitive casts
(Figure 5A). During the same appointment, occlusion rims were fabricated to record the
maxillomandibular relationships, aided by the verification devices [35] (Figure 5B–D).

J. Funct. Biomater. 2023, 14, 174
and mandibular definitive casts were fabricated with low-expansion type IV dental ston
and mandibular definitive casts were fabricated with low-expansion type IV dental ston
(New Fuji Rock IMP; GC America Inc., St. Alsip, IL, USA). Subsequently, verification de
(New Fuji Rock IMP; GC America Inc., St. Alsip, IL, USA). Subsequently, verification de
vices were fabricated using low-shrinkage PMMA resin (Pattern Resin LS; GC Americ
vices were fabricated using low-shrinkage PMMA resin (Pattern Resin LS; GC Americ
Inc., St. Alsip, IL, USA) and were used to verify the accuracy of the definitive casts (Figur
Inc., St. Alsip, IL, USA) and were used to verify the accuracy of the definitive6casts
of 13 (Figur
5A). During the same appointment, occlusion rims were fabricated to record the maxillo
5A). During the same appointment, occlusion rims were fabricated to record the maxillo
mandibular relationships, aided by the verification devices [35] (Figure 5B–D).
mandibular relationships, aided by the verification devices [35] (Figure 5B–D).

Figure
Figure 5. 5. Definitive
Definitive castcast verification
verification and maxillomandibular
and maxillomandibular relationships.
relationships. (A) intraoral
(A) intraoral photographphotograp
Figure 5. Definitive cast verification and maxillomandibular relationships. (A) intraoral photograp
ofofmaxillary
maxillary andand mandibular
mandibular verification
verification devices.
devices. (B) detachable
(B) detachable occlusionocclusion
rims. (C)rims. (C) pho-
intraoral intraoral pho
of maxillary and mandibular verification devices. (B) detachable occlusion rims. (C) intraoral pho
tograph
tograph ofof maxillomandibular
maxillomandibular records
records (reprinted
(reprinted from: Azpiazu-Flores
from: Azpiazu-Flores FX, Mata-Mata
FX, Mata-Mata SJ. Overla
SJ. Overlay
tograph of maxillomandibular records (reprinted from: Azpiazu-Flores FX, Mata-Mata SJ. Overla
occlusionrim
occlusion rimtechnique
technique to to facilitate
facilitate thethe recording
recording of maxillomandibular
of maxillomandibular relationships.
relationships. The Journal o
The Jour-
occlusion rim technique to facilitate the recording of maxillomandibular relationships. The Journal o
prosthetic
nal dentistry
of prosthetic 2021;126:715-7
dentistry with permission
2021;126:715-7 from Elsevier). (D) maxillary and mandibular defin
prosthetic dentistry 2021;126:715-7 with with permission
permission fromfrom Elsevier
Elsevier). (D)[35]). (D) maxillary
maxillary and
and mandibular defin
itive casts were articulated using the detachable occlusion rims supported by
mandibular definitive casts were articulated using the detachable occlusion rims supported by thethe verification devices.
itive casts were articulated using the detachable occlusion rims supported by the verification devices.
verification devices.
The definitive casts were articulated in a semi-adjustable articulator (Denar Omn
Thedefinitive
The definitive casts were articulated in a semi-adjustable articulator (Denar Omni
Track; Whip Mixcasts were
Corp., articulated
Louisville, in a USA),
KY, semi-adjustable articulator
and maxillary and(Denar Omni-
mandibular artificia
Track;Whip
Track; Whip MixMix Corp.,
Corp., Louisville,
Louisville, KY,and
KY, USA), USA), and and
maxillary maxillary and artificial
mandibular mandibulartooth artificia
tooth arrangements
arrangements
were fabricated
were fabricated
(Figure 6).
(Figure 6).(Figure 6).
tooth arrangements were fabricated

Figure 6. Artificial teeth arrangement to be used as blueprint for the definitive complete-arch im
Figure6.6.Artificial
Artificial teeth arrangement to be
asused as blueprint for thecomplete-arch
definitive complete-arch im
plant-supportedteeth
Figure arrangement
prostheses. to be used blueprint for the definitive implant-
plant-supported
supported prostheses.
prostheses.
J. Funct. Biomater. 2023, 14, 174 7 of 13
J. Funct. Biomater. 2023, 13, x FOR PEER REVIEW 7 of 13

J. Funct. Biomater. 2023, 13, x FOR PEER REVIEW 7 of 13

The artificial tooth arrangements were tried intraorally, and their esthetics, phonetics,
The artificial tooth arrangements were tried intraorally, and their esthetics, phonetics,
vertical dimension,
vertical dimension, and
and centric
centric relation
relation werewere evaluated
evaluated and deemed
and deemed satisfactory
satisfactory (Figure 7). (Figure 7).
The artificial tooth arrangements were tried intraorally, and their esthetics, phonetics,
vertical dimension, and centric relation were evaluated and deemed satisfactory (Figure 7).

Figure 7. Extraoral photograph with retractors of artificial teeth arrangements.

Figure 7. Extraoral photograph with retractors of artificial teeth arrangements.
Figure 7. Extraoral
The contoursphotograph withrelationships
and occlusal retractors of artificial
of the teeth arrangements.
maxillary and mandibular tooth ar-
The contours and occlusal relationships of the maxillary and mandibular tooth arrange-
rangements were used as blueprints for the manufacture of the definitive maxillary com-
mentsThe were used as blueprints for the manufacture of the definitive maxillary complete-arch
plete-archcontours and
implant-supported occlusal relationships
prostheses. of the maxillary
The maxillary andconsisted
prosthesis mandibular of a tooth
titaniumar-
implant-supported
rangements were prostheses.
used as The
blueprints maxillary
for the prosthesis
manufacture of consisted
the definitive
framework with a cementable 3 mm-thick zirconia overlay (AccuFrame 360; Cagenix Inc.,
of a titanium
maxillary framework
com-
with a cementable
plete-arch 3 mm-thick
implant-supported zirconia
prostheses. Theoverlay (AccuFrame
maxillary prosthesis 360; Cagenix
consisted
Memphis, TN, USA) (Figure 8A,B), and the mandibular prosthesis was a monolithic zir- of a Inc.,
titanium Memphis,
framework
TN, with a cementable 3 mm-thick zirconia overlay (AccuFrame 360; Cagenix
conia prosthesis (BarZero; Cagenix Inc., Memphis, TN, USA). It is worth mentioning that, prosthe-
USA) (Figure 8A,B), and the mandibular prosthesis was a monolithic Inc.,
zirconia
Memphis,
sis (BarZero;
preceding TN, USA) (Figure
theCagenix
fabrication Inc., 8A,B),
of Memphis,
the and TN,
theprostheses,
definitive mandibular prosthesis
USA). It isprinted was a monolithic
worthprototypes
mentioning werethat, zir-
preceding
ordered the
conia prosthesis
fabrication
and tried of the (BarZero;
intraorally definitiveCagenix
to refine Inc., Memphis,
prostheses,
the occlusion printed TN, USA).andIt verify
prototypes
and esthetics iswere
worth mentioning
ordered
the centricand that,
tried intrao-
relation
preceding
rally
(Figure 8C).theAtthe
to refine fabrication
stage,of
thisocclusion the
anddefinitive
a custom incisal prostheses,
esthetics tableprinted
and verify
guide prototypes
the centric
was relation
manufactured were ordered
to(Figure
ensure 8C).
the At this
and tried
accurate intraorally
reproduction to
of refine
the the
anteriorocclusion
guidanceand esthetics
established and
with verify
the the centric
prototypes inrelation
the de-
stage, a custom incisal guide table was manufactured to ensure the accurate reproduction
(Figure
finitive 8C). At this[36]
prostheses stage, a custom
(Figure 8D). incisal guide table was manufactured to ensure the
of the anterior guidance established with the prototypes in the definitive prostheses [36]
accurate reproduction of the anterior guidance established with the prototypes in the de-
(Figure 8D).
finitive prostheses [36] (Figure 8D).

Figure 8. Maxillary and mandibular prototypes and titanium bar. (A), Occlusal view of CAD/CAM
maxillary titanium bar. (B), maxillary PMMA overlay. (C), frontal view of maxillary titanium bar
Figure 8. Maxillary and mandibular prototypes and titanium bar. (A), Occlusal view of CAD/CAM
Figure 8. Maxillary and mandibular prototypes and titanium bar. (A), Occlusal view of CAD/CAM
maxillary titanium bar. (B), maxillary PMMA overlay. (C), frontal view of maxillary titanium bar
maxillary titanium bar. (B), maxillary PMMA overlay. (C), frontal view of maxillary titanium bar with
PMMA overlay and mandibular prototype (D), and maxillary and mandibular prototypes mounted
after intraoral adjustments with custom incisal guide table.
J. Funct. Biomater. 2023, 14, 174 8 of 13

Subsequently, the definitive maxillary and mandibular prostheses were fabricated

(Figure 9) and tried intraorally.
The passivity and accuracy of the fit were assessed clinically and radiographically
(Figure 10), and the abutment screws were tightened to the recommended manufacturer’s
recommended
J. Funct. Biomater. 2023, 13, x FOR PEER REVIEW torque values. 8 of 13
Vertical dimension, centric occlusion, protrusive, and laterotrusive excursive move-
ments were assessed and refined (Figure 11). Additionally, cleanability, esthetics, and
comfort
with PMMAwereoverlay
deemed andadequate byprototype
mandibular the patient
(D),(Figure 11). and mandibular prototypes
and maxillary
J. Funct. Biomater. 2023, 13, x FOR PEER REVIEW 8 of 13
Subsequently,
mounted home
after intraoral maintenance
adjustments instructions
with custom andtable.
incisal guide interdental brushes (ProxaBrush
Go-Betweens Wide; GUM Sunstar America, Schaumbaum, IL, USA) were provided, and
a hygiene program the
Subsequently, consisting of maxillary
definitive recall appointments everyprostheses
and mandibular 6 months was
wereestablished
fabricated on
with PMMA overlay and mandibular prototype (D), and maxillary and mandibular prototypes
the day of
(Figure delivery.
9) and At the subsequent appointments, overall hygiene was reassessed and
tried intraorally.
mounted after intraoral adjustments with custom incisal guide table.
deemed adequate. Additionally, during these appointments, the patient expressed satis-
faction with the function,
Subsequently, esthetics,
the definitive and confidence
maxillary provided
and mandibular by the definitive
prostheses prostheses
were fabricated
(Figure 12).
(Figure 9) and tried intraorally.

Figure 9. Maxillary and mandibular definitive complete-arch implant-supported prostheses.

The passivity and accuracy of the fit were assessed clinically and radiographically
(Figure 10), and the abutment screws were tightened to the recommended manufacturer’s
Figure 9.
Figure 9. Maxillary
Maxillary and
and mandibular
mandibulardefinitive
definitivecomplete-arch
complete-archimplant-supported prostheses.
implant-supported prostheses.
recommended torque values.
The passivity and accuracy of the fit were assessed clinically and radiographically
(Figure 10), and the abutment screws were tightened to the recommended manufacturer’s
recommended torque values.

Figure 10. Panoramic radiograph of maxillary and mandibular prostheses taken at the time of delivery.
Figure 10. Panoramic radiograph of maxillary and mandibular prostheses taken at the time of delivery.

Vertical dimension, centric occlusion, protrusive, and laterotrusive excursive

movements were assessed and refined (Figure 11). Additionally, cleanability, esthetics,
Figure 10. Panoramic radiograph of maxillary and mandibular prostheses taken at the time of delivery.
and comfort were deemed adequate by the patient (Figure 11).
Vertical dimension, centric occlusion, protrusive, and laterotrusive excursive
movements were assessed and refined (Figure 11). Additionally, cleanability, esthetics,
J.J.Funct.
Funct.Biomater. 2023,14,
Biomater.2023, 13,174
x FOR PEER REVIEW 99 of
of 13
13

Figure 11. Intraoral photograph of maxillary and mandibular definitive complete-arch implant-sup-
ported prostheses. (Top) Centric occlusion. (Bottom) Lateral and protrusive excursions.

Subsequently, home maintenance instructions and interdental brushes (ProxaBrush

Go-Betweens Wide; GUM Sunstar America, Schaumbaum, IL, USA) were provided, and
a hygiene program consisting of recall appointments every 6 months was established on
the day of delivery. At the subsequent appointments, overall hygiene was reassessed and
deemed adequate. Additionally, during these appointments, the patient expressed satis-
Figure 11. Intraoral
Intraoral photograph
photograph ofofmaxillary
maxillaryand mandibular
and definitive
mandibular complete-arch implant-sup-
definitive
Figure
faction11.with the function, esthetics, and confidence provided by thecomplete-arch implant-
definitive prostheses
ported prostheses. (Top) Centric occlusion. (Bottom) Lateral and protrusive excursions.
supported prostheses.
(Figure 12). (Top) Centric occlusion. (Bottom) Lateral and protrusive excursions.

Subsequently, home maintenance instructions and interdental brushes (ProxaBrush

Go-Betweens Wide; GUM Sunstar America, Schaumbaum, IL, USA) were provided, and
a hygiene program consisting of recall appointments every 6 months was established on
the day of delivery. At the subsequent appointments, overall hygiene was reassessed and
deemed adequate. Additionally, during these appointments, the patient expressed satis-
faction with the function, esthetics, and confidence provided by the definitive prostheses
(Figure 12).

Figure12.
Figure 12.Post-treatment
Post-treatmentextraoral
extraoralphotographs
photographs(from
(fromleft
leftto
toright)
right)Frontal
Frontalwith
withretractors,
retractors,Frontal
Frontal
smiling,3/
smiling, ¾4 profile
profile smiling.
smiling.

3.3.Results
Results
Inthe
In the present
present clinical report,
report,complete-arch
complete-archimplant-supported
implant-supportedprostheses
prostheses permitted
permit-
thethe
ted predictable
predictablerehabilitation
rehabilitationof ofa apatient
patientwith
with severely
severely decayed dentition.
decayed terminal dentition.
CAD/CAM technology is a valuable
CAD/CAM valuable resource
resource for
for restorative
restorative dentists
dentists since
since ititenhances
enhances
communication
communication between
between the
the different
different members
members of
of the
the restorative
restorative team
team and
and permits
permits the
the
Figure 12. Post-treatment extraoral photographs (from left to right) Frontal with retractors, Frontal
fabrication
fabrication of
of complex
complex
smiling, ¾ profile smiling. prosthetic
prosthetic designs
designs that
that maximize
maximize functionality
functionality and
and retrievability
retrievability
whileminimizing
while minimizingcomplications.
complications.
3. Results
4. Discussion
In the present clinical report, complete-arch implant-supported prostheses permitted
the In the presentrehabilitation
predictable clinical report,ofa patient
a patientwithwith
Sjogren’s syndrome
severely andterminal
decayed terminal dentition.
dentition
was predictably rehabilitated with complete-arch implant-supported prostheses
CAD/CAM technology is a valuable resource for restorative dentists since it enhances composed
of two functional biomaterials: titanium and zirconia. For decades, titanium has been the
communication between the different members of the restorative team and permits the
material of choice for dental implants due to its availability, machinability, biocompatibility,
fabrication of complex prosthetic designs that maximize functionality and retrievability
and favorable elastic modulus [27]. Similarly, dental professionals have embraced high-
while minimizing complications.
J. Funct. Biomater. 2023, 14, 174 10 of 13

strength polycrystalline zirconia ceramics as restorative materials since they allow the
consistent manufacture of highly-esthetic, tooth-colored restorations with remarkable
flexural strength [27,28] and biocompatibility [27,29]. Nowadays, thanks to the advances
in CAD/CAM technologies, the best features of these completely different materials can
be merged into a single prosthetic design, and multi-material complete-arch implant-
supported prostheses can be designed and manufactured digitally [13]. However, as with
any other dental prosthesis, the success and adequate function of these complex prostheses
lie in an adequate design and careful clinical refinement.
Since fixed complete dentures were introduced as a treatment for edentulism, signifi-
cant changes have been made to the design of complete-arch implant-supported prostheses.
For zirconia-based rehabilitations, limiting the application of porcelain to the gingival
region, reducing the extension of cantilevers, and ensuring adequate prosthetic space have
been advised to prevent biological and mechanical complications [31,32,37]. In the present
clinical report, the maxillary zirconia overlay accurately copied the occlusal relationships
and anterior guidance established intraorally with the prototypes and was supported by
a titanium bar with 25 mm2 of cross-sectional area. The decision to use a prosthesis com-
posed of two different materials was based on the presence of bilateral 10 mm-long distal
cantilevers, which could create unfavorable flexural stresses in the ceramic overlay [27],
although there is no clear evidence indicating a detrimental effect of distal cantilevers when
their extension is small [37,38]. This design was selected over a monolithic alternative
for the maxillary arch since it would permit retrieving and replacing the overlay portion
of the prostheses if any complications occurred. On the other hand, for the mandibular
definitive prostheses, the implant distribution and prosthetic space available permitted de-
signing a prosthesis of dimensions that permitted adequate esthetics and function without
compromising structural durability; therefore, a completely monolithic design was used.
Regardless of the significant progress in contemporary biomaterials and CAD/CAM
technologies, there are aspects of prosthetic and implant dentistry that need further consid-
eration. Substantial research has been done evaluating several restorative alternatives for
complete-arch implant-supported restorations, and aspects such as retrievability, passivity,
and occlusion have been researched [18–20]. Recently, alternative retention mechanisms
and prosthetic designs involving high-performance polymers and novel ceramic-reinforced
materials have been implemented to rehabilitate patients with complex dental needs
and craniofacial conditions [16,39,40]. In the present clinical report, the combination of
CAD/CAM and contemporary biomaterials permitted restoring the confidence, esthetics,
and function of a patient exhausted by failing restorations. Research suggests that dental
implants are a feasible modality to rehabilitate patients with terminal dentition caused by
Sjogren’s syndrome. Satisfactory survival rates, low marginal bone loss, and biological
complications comparable to those in healthy patients have been reported in the litera-
ture [41]. A systematic review of the topic suggests that, to ensure optimum outcomes,
a hygienic prosthetic design and regular maintenance regime should be established on
the day of delivery [40]. With satisfactory maintenance, implant-supported rehabilitations
in patients with Sjogren’s syndrome can perform satisfactorily for many years, with case
reports describing up to 13 years of service available in the literature [42,43]. In a similar
way, a cohort study reported high satisfaction levels for this treatment modality, and 97%
of the candidates would recommend dental implants to other patients with Sjogren’s syn-
drome [44,45]. However, it is worth noting that the majority of research available describes
the clinical performance of traditional prosthetic designs such as traditional fixed complete
dentures or porcelain-fused to metal complete arch rehabilitations. Therefore, research on
the clinical performance of newer prosthetic designs and functional biomaterials in patients
with Sjogren’s syndrome is needed.
Finally, this clinical report presents limitations related to the lack of cytologic, mor-
phometric, and prospective clinical evaluation of the interaction of the biomaterials used
with the tissues of the patient. Prosthetic factors such as passivity, restitution of phonetics,
reestablishment of occlusion, and anterior guidance were assessed clinically throughout
J. Funct. Biomater. 2023, 14, 174 11 of 13

the different stages of the treatment, and osseointegration was evaluated radiographically.
The lack of quantitative analysis is a common limitation of clinical reports, where time
and patient factors play an important role. For these reasons, the materials used in the
prostheses were not examined in greater depth in this clinical report. However, since
their introduction as restorative materials, zirconia and titanium have demonstrated their
biomechanical adequacy for complete arch rehabilitations when masticatory dynamics are
considered [27,31,32]. Therefore, although the present clinical report lacks quantitative
analysis, the gratitude of the patient and his favorable adaptation to the prostheses suggest
the achievement of functionality and satisfaction, two of the greatest indicators of success
in any restorative treatment.

5. Conclusions
A patient with Sjogren’s syndrome and terminal dentition was successfully rehabili-
tated using complete-arch implant-supported prostheses and dental implants. Complete-
arch implant-supported rehabilitations manufactured using CAD/CAM technologies can
be designed with multiple components made of different materials to ensure the prostheses
have satisfactory biomechanics, esthetics, and occlusion.

Author Contributions: Conceptualization, F.X.A.-F. and D.L.; methodology, F.X.A.-F. and D.L.;
validation, C.A.J. and K.I.A.; investigation, A.T.; resources, A.A.; writing—original draft preparation,
F.X.A.-F. and C.A.J.; writing—review and editing, A.A., K.I.A. and A.T.; supervision, D.L.; project
administration, F.X.A.-F. and D.L. All authors have read and agreed to the published version of
the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki for studies involving humans.
Informed Consent Statement: Written informed consent has been obtained from the patient to
publish this paper.
Data Availability Statement: Not applicable.
Acknowledgments: K.I. Afrashtehfar thanks the Universität Bern for partially supporting the open
access publication of this work.
Conflicts of Interest: The authors declare no conflict of interest.

References
1. Slutzkey, G.S.; Cohen, O.; Chaushu, L.; Rahmanov, A.; Mijiritsky, E.; Beitlitum, I.; Kolerman, R. Immediate Maxillary Full-
Arch Rehabilitation of Periodontal Patients with Terminal Dentition Using Tilted Implants and Bone Augmentation: A 5-Year
Retrospective Cohort Study. J. Clin. Med. 2022, 11, 2902. [CrossRef] [PubMed]
2. Mathews, S.; Kurien, B.; Scofield, R. Oral Manifestations of Sjögren’s Syndrome. J. Dent. Res. 2008, 87, 308–318. [CrossRef]
3. Thompson, M.J. Masticatory Efficiency as Related to Cusp form in Denture Prosthesis. J. Am. Dent. Assoc. Dent. Cosm. 1937,
24, 207–219. [CrossRef]
4. Iegami, C.M.; Barbosa, W.F.; Furuyama, R.J.; Lima, J.R.B.; De Campos, T.T.; Minagi, S.; Tamaki, R. Masticatory efficiency in
complete denture wearers with reduced dental arches—A randomised cross-over study. J. Oral Rehabil. 2014, 41, 619–623.
[CrossRef]
5. Albrektson, T.; Wenneberg, A. The Impact of Oral Implants—Past and Future, 1966–2042. J. Can. Dent. Assoc. 2005, 71, 327.
6. French, D.; Larjava, H.; Ofec, R. Retrospective cohort study of 4591 Straumann implants in private practice setting, with up to
10-year follow-up. Part 1: Multivariate survival analysis. Clin. Oral Implant. Res. 2015, 26, 1345–1354. [CrossRef]
7. French, D.; Ofec, R.; Levin, L. Long term clinical performance of 10 871 dental implants with up to 22 years of follow-up: A cohort
study in 4247 patients. Clin. Implant. Dent. Relat. Res. 2021, 23, 289–297. [CrossRef] [PubMed]
8. Jensen, O.T.; Adams, M.W.; Cottam, J.R.; Parel, S.M.; Phillips, W.R. The all on 4 shelf: Mandible. J. Oral Maxillofac. Surg. 2011,
69, 175–181. [CrossRef] [PubMed]
9. Jensen, O.T.; Adams, M.W.; Cottam, J.R.; Parel, S.M.; Phillips, W.R. The All-on-4 shelf: Maxilla. J. Oral Maxillofac. Surg. 2010,
68, 2520–2527. [CrossRef]
10. Maló, P.; Rangert, B.; Nobre, M. “All-on-Four” immediate-function concept with Brånemark System implants for completely
eden-tulous mandibles: A retrospective clinical study. Clin. Implant. Dent. Relat. Res. 2003, 5 (Suppl. 1), 2–9. [CrossRef]
J. Funct. Biomater. 2023, 14, 174 12 of 13

11. van Assche, N.; Vercruyssen, M.; Coucke, W.; Teughels, W.; Jacobs, R.; Quirynen, M. Accuracy of computer-aided implant
placement. Clin. Oral Implants Res. 2012, 23 (Suppl. 6), 112–123. [CrossRef] [PubMed]
12. Papaspyridakos, P.; Bedrossian, A.; De Souza, A.; Bokhary, A.; Gonzaga, L.; Chochlidakis, K. Digital Workflow in Implant
Treatment Planning for Terminal Dentition Patients. J. Prosthodont. 2022, 31, 543–548. [CrossRef]
13. Van Noort, R. The future of dental devices is digital. Dent. Mater. 2012, 28, 3–12. [CrossRef]
14. Revilla-León, M.; Özcan, M. Additive Manufacturing Technologies Used for Processing Polymers: Current Status and Potential
Application in Prosthetic Dentistry. J. Prosthodont. 2019, 28, 146–158. [CrossRef]
15. Ashurko, I.; Trofimov, A.; Tarasenko, S.; Mekhtieva, S. Full-Mouth Screw-Retained Implant-Supported Rehabilitation with
Multiunit Abutments Using Virtual Guided Surgery and Digital Prosthetics Protocol. Case Rep. Dent. 2020, 2020, 3585169.
[CrossRef] [PubMed]
16. Massad, J.; Wicks, R.; Ahuja, S.; Cagna, D.R. A Prosthesis Retention System for Full-Arch, Fixed, Implant-Supported Prosthesis.
J. Prosthodont. 2019, 28, e912–e916. [CrossRef] [PubMed]
17. Chaar, M.S.; Att, W.; Strub, J.R. Prosthetic outcome of cement-retained implant-supported fixed dental restorations: A systematic
review. J. Oral Rehabil. 2011, 38, 697–711. [CrossRef]
18. Chee, W.; Jivraj, S. Screw versus cemented implant supported restorations. Br. Dent. J. 2006, 201, 501–507. [CrossRef] [PubMed]
19. Gaddale, R.; Mishra, S.K.; Chowdhary, R. Complications of screw- and cement-retained implant-supported full-arch restorations:
A systematic review and meta-analysis. Int. J. Oral Implantol. 2020, 13, 11–40.
20. Misch, C.E. Dental Implant Prosthetics. In Principles of Fixed Implant Prosthodontics: Cement-Retained Restorations, 2nd ed.; Elsevier:
St. Louis, MO, USA, 2015; pp. 650–699.
21. Michael, K.; Winfried, W. Retrospective analysis of loosening of cement-retained vs screw-retained fixed implant-supported
reconstructions. Quintessence Int. 2015, 46, 583–589. [CrossRef]
22. Guichet, D.L.; Caputo, A.A.; Choi, H.; Sorensen, J.A. Passivity of fit and marginal opening in screw-or cement-retained implant
fixed partial denture designs. Int. J. Oral Maxillofac. Implant. 2000, 15, 239–246.
23. Torrado, E.; Ercoli, C.; Al Mardini, M.; Graser, G.N.; Tallents, R.H.; Cordaro, L. A comparison of the porcelain fracture resistance
of screw-retained and cementretained implant supported metal ceramic crowns. J. Prosthet. Dent. 2004, 91, 532–537. [CrossRef]
[PubMed]
24. Korsch, M.; Obst, U.; Walther, W. Cement-associated peri-implantitis: A retrospective clinical observational study of fixed
implant-supported restorations using a methacrylate cement. Clin. Oral Implant Res. 2014, 25, 797–802. [CrossRef] [PubMed]
25. D’Souza, K.M.; Aras, M.A. Types of Implant Surgical Guides in Dentistry: A Review. J. Oral Implant. 2012, 38, 643–652. [CrossRef]
[PubMed]
26. Anadioti, E.; Musharbash, L.; Blatz, M.B.; Papavasiliou, G.; Kamposiora, P. 3D printed complete removable dental prostheses: A
narrative review. BMC Oral Health 2020, 20, 343. [CrossRef]
27. Anusavice, K.J.; Shen, C.; Rawls, H.R. Philips Science of Dental Materials, 12th ed.; Elsevier: Amsterdam, The Netherlands, 2012.
28. Papynov, E.; Shichalin, O.; Apanasevich, V.; Portnyagin, A.; Yu, M.V.; Yu, B.I.; Merkulov, E.; Kaidalova, T.; Modin, E.; Afonin, I.;
et al. Sol-gel (template) synthesis of osteoplastic CaSiO3 /HAp powder biocomposite: “In vitro” and “in vivo” biocompatibility
assessment. Powder Technol. 2020, 367, 762–773. [CrossRef]
29. Papynov, E.; Shichalin, O.; Skurikhina, Y.; Turkutyukov, V.; Medkov, M.; Grishchenko, D.; Portnyagin, A.; Merkulov, E.;
Apanasevich, V.; Geltser, B.; et al. ZrO2 -phosphates porous ceramic obtained via SPS-RS “in situ” technique: Bacteria test
assessment. Ceram. Int. 2019, 45, 13838–13846. [CrossRef]
30. Papynov, E.K.; Shichalin, O.O.; Apanasevich, V.I.; Afonin, I.S.; Evdokimov, I.O.; Mayorov, V.Y.; Portnyagin, A.S.; Agafonova, I.G.;
Skurikhina, Y.E.; Medkov, M.A. Synthetic CaSiO3 sol-gel powder and SPS ceramic derivatives: “In vivo” toxicity assessment.
Prog. Nat. Sci. 2019, 29, 569–575. [CrossRef]
31. Bidra, A.S.; Tischler, M.; Patch, C. Survival of 2039 complete arch fixed implant-supported zirconia prostheses: A retrospective
study. J. Prosthet. Dent. 2018, 119, 220–224. [CrossRef]
32. Tischler, M.; Patch, C.; Bidra, A.S. Rehabilitation of edentulous jaws with zirconia complete-arch fixed implant-supported
prostheses: An up to 4-year retrospective clinical study. J. Prosthet. Dent. 2018, 120, 204–209. [CrossRef]
33. Bidra, A.S. Three-Dimensional Esthetic Analysis in Treatment Planning for Implant-Supported Fixed Prosthesis in the Edentulous
Maxilla: Review of the Esthetics Literature. J. Esthet. Restor. Dent. 2011, 23, 219–236. [CrossRef] [PubMed]
34. Bidra, A.S. Technique for systematic bone reduction for fixed implant-supported prosthesis in the edentulous maxilla. J. Prosthet.
Dent. 2015, 113, 520–523. [CrossRef] [PubMed]
35. Azpiazu-Flores, F.X.; Mata-Mata, S.J. Overlay occlusion rim technique to facilitate the recording of maxillomandibular relation-
ships. J. Prosthet. Dent. 2021, 126, 715–717. [CrossRef]
36. Balshi, T.J.; Mingledorff, E.B.; Olbrys, B.H.; Cantor, S.J. Restorative occlusion utilizing a custom incisal guide table. J. Prosthet.
Dent. 1976, 36, 468–471. [CrossRef]
37. Venezia, P.; Torsello, F.; Cavalcanti, R.; D’Amato, S. Retrospective analysis of 26 complete-arch implant-supported monolithic
zir-conia prostheses with feldspathic porcelain veneering limited to the facial surface. J. Prosthet. Dent. 2015, 114, 506–512.
[CrossRef] [PubMed]
38. Adell, R.; Lekholm, U.; Rockler, B.; Brånemark, P.-I. Review Article. Economica 2003, 70, 691–697.
J. Funct. Biomater. 2023, 14, 174 13 of 13

39. Azpiazu-Flores, F.X.; Lee, D.J.; Mata-Mata, S.J.; Zheng, F. Rehabilitation of a patient with mandibular flexure using contemporary
glass-infiltrated high performance CAD-CAM polymers: A clinical report with 1-year follow-up. J. Prosthet. Dent. 2023. [CrossRef]
40. Azpiazu-Flores, F.X.; Knobloch, L.A.; Larsen, P.E. Interdisciplinary Management of a Patient with Dentinogenesis Imperfecta Type
II Using a Combination of CAD-CAM and Analog Techniques: A Clinical Report. J. Prosthodont. 2022, 31, 647–654. [CrossRef]
41. Almeida, D.; Vianna, K.; Arriaga, P.; Moraschini, V. Dental implants in Sjögren’s syndrome patients: A systematic review.
PLoS ONE 2018, 12, e0189507. [CrossRef]
42. Korfage, A.; Raghoebar, G.M.; Arends, S.; Meiners, P.M.; Visser, A.; Kroese, F.G.; Bootsma, H.; Vissink, A. Dental Implants in
Patients with Sjögren’s Syndrome. Clin. Implant. Dent. Relat. Res. 2015, 18, 937–945. [CrossRef]
43. Spinato, S.; Soardi, C.M.; Zane, A.M. A Mandibular Implant-Supported Fixed Complete Dental Prosthesis in a Patient with
Sjogren Syndrome: Case Report. Implant. Dent. 2010, 19, 178–183. [CrossRef] [PubMed]
44. Binon, P.P. Thirteen-year follow-up of a mandibular implant-supported fixed complete denture in a patient with Sjogren’s
syndrome: A clinical report. J. Prosthet. Dent. 2005, 94, 409–413. [CrossRef] [PubMed]
45. Albrecht, K.; Callhoff, J.; Westhoff, G.; Dietrich, T.; Dörner, T.; Zink, A. The Prevalence of Dental Implants and Related Factors in
Patients with Sjögren Syndrome: Results from a Cohort Study. J. Rheumatol. 2016, 43, 1380–1385. [CrossRef] [PubMed]

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