Received: 24 November 2017 | Revised: 14 November 2018 | Accepted: 24 November 2018

DOI: 10.1111/clr.13393

ORIGINAL RESEARCH

Full‐arch implant‐supported rehabilitations: A prospective

study comparing porcelain‐veneered zirconia frameworks to
monolithic zirconia

João Caramês1,2,3 | Duarte Marques2,4,5 | João Malta Barbosa5,6 |

5 5,7 1,3
André Moreira | Pedro Crispim | André Chen

1
Department of Oral Surgery and Implant
Dentistry, Faculdade de Medicina Dentária Abstract
da Universidade de Lisboa, Lisbon, Portugal Objectives: To evaluate the performance of two types of zirconia frameworks.
2
LIBPhys‐FCT UID/
Material and Methods: From 2014 to 2016, in a prospective clinical trial, 150 pa‐
FIS/04559/201, Faculdade de Medicina
Dentária da Universidade de Lisboa, Lisbon, tients were rehabilitated with 83 and 110 implant‐supported, screw‐retained, full‐
Portugal
arch ceramic‐veneered zirconia (PVZ) rehabilitations and monolithic zirconia with
3
Department of Oral Surgery and Implant
porcelain veneering limited to buccal (MZ) rehabilitations, respectively. Patients were
Dentistry, Implantology Institute, Lisbon,
Portugal consecutively enlisted according to pre‐defined inclusion criteria and evaluated on
4
Department of Morfo-Functional 4 months intervals. A Kaplan–Meier estimator was adopted, and the log‐rank test
Sciences, Faculdade de Medicina Dentária
da Universidade de Lisboa, Lisbon, Portugal and Wilcoxon test used to test differences in survival and successful function in the
5
Department of Oral two different groups.
Rehabilitation, Implantology Institute, Results: The average follow‐up time (±SD) and implant success rate was
Lisbon, Portugal
6 608.80 ± 172.52 days with 99.53% implant success for the PVZ group and
Department of Biomaterials and
Biomimetics, New York University College of 552.63 ± 197.57 days with 99.83% success for the MZ group. According to the
Dentistry, New York, New York
Kaplan–Meier estimator, the mean cumulative survival rate at the 2‐year follow‐up
7
Department of Occlusion and Oral
Rehabilitation, Faculdade de Medicina
for framework fracture, major chipping, minor chipping, or any of the former com‐
Dentária da Universidade de Lisboa, Lisbon, bined to occur was 0.99, 0.95, 0.93 and 0.85 for the PVZ group (n = 18) and 0.99, 0.95,
Portugal
0.95 and 0.89 for the MZ group (n = 15). No significant differences were found be‐
Correspondence tween the two groups.
João Caramês, Implantology Institute,
Lisbon, Portugal.
Conclusions: Results suggest zirconia as a suitable material for frameworks in full‐
Email: [email protected] arch implant‐supported rehabilitations. Both groups presented a low incidence of
technical complications. When comparing the two different designs, the MZ group
presented a lower technical complication rate, thus presenting itself as a viable alter‐
native for full‐arch implant‐supported rehabilitations. Further clinical studies with
longer follow‐ups (5 years) should be performed to evaluate the long‐term stability of
such rehabilitations.

KEYWORDS
clinical assessment, clinical research, clinical trials, diagnosis, prosthodontics

68 | © 2018 John Wiley & Sons A/S. wileyonlinelibrary.com/journal/clr Clin Oral Impl Res. 2019;30:68–78.
Published by John Wiley & Sons Ltd
CARAMÊS et al. | 69

1 | I NTRO D U C TI O N The objective of this pragmatic prospective clinical study was to

compare the rate of prosthetic complications, success and survival
Full‐arch implant‐supported fixed dental prosthesis (ISFDP) is widely of porcelain‐veneered zirconia FDP (PVZ) compared to monolithic
accepted as a treatment modality for edentulous patients, present‐ zirconia FDP veneered with porcelain in non‐functional areas (MZ)
ing high long‐term implant survival rates: 95% after 5 years in pa‐ when used as frameworks for full‐arch screw‐retained ISFDP.
tients in the maxillary arch and 97% after 10 years in the mandibular
arch (Rohlin et al., 2012).
2 | M ATE R I A L A N D M E TH O DS
These rehabilitations can be performed in a wide array of ma‐
terial combinations dependent upon clinical as well as financial
2.1 | Patient selection
factors/limitations.
Metal frameworks intended to reinforce fixed full‐arch im‐ The present prospective clinical study adhered to the protocols
plant‐supported rehabilitations have been historically combined of the World Medical Association Declaration of Helsinki (ver‐
with pre‐fabricated acrylic as well as custom‐made ceramic artifi‐ sion, 2013), being approved by the ethics committee of the Lisbon
cial teeth. Often described as fixed complete denture, the combina‐ Implantology Institute and registered at the U.S National Library
tion of a metal framework with pre‐fabricated acrylic artificial teeth of Medicine ClinicalTrials.gov website under the reference number
has demonstrated high success rates (Mertens & Steveling, 2011), NCT01974362.
although presenting several prosthesis‐related complications over All the patients included in the present study had to meet the
short‐ and long‐term periods (Attard & Zarb, 2004; Bozini, Petridis, following criteria: be at least 18 years of age; have at least one com‐
Garefis, & Garefis, 2011; Davis, Packer, & Watson, 2003; Jemt & plete edentulous arch; present no systemic or local absolute con‐
Johansson, 2006; Kwon, Bain, & Levin, 2014; Papaspyridakos, Chen, traindications for endosseous implant placement; and indication
Chuang, Weber, & Gallucci, 2012; Purcell, McGlumphy, Holloway, for delayed final full‐arch rehabilitation. Exclusion criteria were also
& Beck, 2008). The alternative material combination, the porce‐ defined and included: the presence of any systemic disease or condi‐
lain‐fused‐to‐metal fixed dental prosthesis (FDP), despite of being tion that could compromise postoperative healing or osseointegra‐
considered the gold standard (Heintze & Rousson, 2010) due to its tion. Being a pragmatic trial performed in a private clinical setting,
pleasing aesthetic value and minimal wear, still presents limited long‐ patients with active smoking habits, evidence of parafunctional hab‐
term evidence regarding its clinical performance. its (i.e., bruxism) and/or patients with sub‐optimal oral hygiene were
In the last two decades, zirconia frameworks became increas‐ not excluded.
ingly popular as an alternative material in the field of prosthodontics Each patient was thoroughly informed about the surgical and
(Abdulmajeed, Lim, Närhi, & Cooper, 2016) and, with the introduc‐ prosthetic procedures, and each signed an informed consent agree‐
tion of computer‐aided design and computer‐aided manufacturing ment before entering the study.
(CAD/CAM), provided new ways to address the challenges related All the patients were recruited consecutively until at least 75
with full‐arch ISFDP with promising success rates (Al‐Almeh, Lyons, final full‐arch ISFDP with a minimum of a 1‐year follow‐up were
& Swain, 2010; Mendez Caramês, Mata, Silva Marques, & Oliveira included in each group, corresponding to a time interval compre‐
Francisco, 2016; Raigrodski, Hillstead, Meng, & Chung, 2012). hended between January of 2014 and December of 2016.
However, despite being considered as a safe and effective restor‐ This study was conducted within the quality control guidelines
ative option, when veneered with feldspathic porcelain, frequent me‐ of the institution and follow‐up with patients undertaken every
chanical complications have been reported, particularly the fracture 4 months. At the yearly visit, the same clinician performed a compre‐
or chipping of the veneering layer (Ishibe et al., 2011; Konstantinidis, hensive re‐evaluation of the patient and rehabilitation. In addition,
Jacoby, Rädel, & Böning, 2015; Le, Papia, & Larsson, 2015; Mendez patients were requested to immediately contact the office if they
Caramês et al., 2016; Saito, Komine, Blatz, & Matsumura, 2010). experienced any difficulties/complications with the prosthesis. This
In order to reduce the incidence of veneering fractures, observed information was promptly recorded on a dedicated software devel‐
mainly in the functional surfaces, the use of monolithic zirconia res‐ oped and used as a control of the office quality indicators.
torations veneered exclusively in non‐functional surfaces has been
proposed (Guess et al., 2011; Marchack, Sato, Marchack, & White,
2.2 | Surgical procedures
2011). Empirically, this alternative design presents the potential to
reduce the rate of mechanical complications due to the elimination All surgical procedures were performed as described in a previous
of the zirconia/porcelain interface from the functional surfaces. study (Mendez Caramês et al., 2016) with the total number of im‐
However, besides small sample studies that seem to show lower ce‐ plants placed per arch ranging between 4 and 8.
ramic fracture rates, clinical evidence for this monolithic framework The implants placed presented with an external hexagon pros‐
design is still scarce (Abdulmajeed et al., 2016; Altarawneh, Limmer, thetic connection (Osseotite, Zimmer Biomet, Warsaw, IN, USA).
Reside, & Cooper, 2015; Carames, Tovar Suinaga, Yu, Pérez, & Kang, A single experienced oral surgeon (JC) performed all the surgical
2015; Rojas Vizcaya, 2016; Venezia, Torsello, Cavalcanti, & D'Amato, procedures following, within the individualities of each patient, a
2015). standardized surgical technique. Straight or angled screw‐retained
70 | CARAMÊS et al.

dental laboratory (Labimplant, Lisbon, Portugal). Three certified

dental technicians designed and fabricated the zirconia frameworks
for the porcelain‐veneered prosthesis (PVZ) as well as the mono‐
lithic zirconia prosthesis (MZ) following the functional and aesthetic
validation of the provisional restoration.

2.4 | Full‐arch porcelain‐veneered zirconia

rehabilitations
The zirconia framework was designed and milled following a CAD/
CAM workflow (Zirkonzhan). Yttrium‐stabilized zirconia (Prettau®
Zirconia; Zirkonzahn) was used as framework material. This frame‐
F I G U R E 1 CAD framework prior to milling for the porcelain‐ work was virtually designed taking into account the predicted final
veneered Zirconia group anatomical contour to assure the presence of adequate space for
complete veneering porcelain (Figure 1). All the framework/abut‐
conical abutments (Low profile abutment; Zimmer Biomet) were se‐ ment were milled as part of the zirconia structure.
lected and inserted at the time of surgery. After a healing period Clinically, a combination of finger pressure and the Sheffield
of 12 weeks, for the majority of patients, final rehabilitation pro‐ tests were used framework fit and passivity evaluation, followed
cedures were initiated. In situations where implant placement was by periapical radiographic evaluation (Jemt, 1995). If any clinical
combined with local bone augmentation techniques or sinus floor el‐ adjustments were performed, laboratorial surface treatment was
evations, the healing period was extended to a minimum of 6 months undertaken according to the manufacturer instructions, followed by
(up to 9 months). a multilayering and multifiring feldspathic porcelain veneering tech‐
nique (ICE Zirkon Ceramics; Zirkonzahn).
Abutment (20 Ncm) and prosthetic (10 Ncm) screws were torqued
2.3 | Prosthetic procedures
following the manufacturer's instructions. Polytetrafluoroethylene
Metal‐reinforced fixed complete dentures were made, inserted and tape was placed covering the prosthetic screws, and a fotopoly‐
adjusted on the same day of surgery to serve as immediate provisional merizing nanohybrid composite resin (FiltekTM Supreme XTE, 3 M,
restorations during healing and osseointegration. Manufacture and Maplewood, MN, USA) was used to seal the access chambers.
insertion and adjustment procedures followed the office guidelines,
being previously described by Mendez Caramês et al. (2016).
2.5 | Monolithic zirconia with non‐functional
Final rehabilitation stages were initiated after the healing period
porcelain veneering
and patients were allocated to one of the two described groups (PVZ
and MZ) after a re‐evaluation appointment. The framework design All zirconia frameworks were designed in such a way so that the
selected for the final rehabilitation was a patient‐centered decision, incisal edges of the maxillary or mandibular incisors were included
meaning that after evaluation of objective as well as subjective pa‐ and the veneering porcelain was applied only onto non‐functional
tient‐specific factors (i.e., inter‐arch restorative space; horizontal surfaces. A limited cutback procedure was undertaken at the digital
maxillo‐mandibular relationship; aesthetic expectations) the clini‐ design stage (prior to milling) to provide adequate space for felds‐
cian explained the presumed advantages and disadvantages of each pathic porcelain veneering in the buccal surfaces (Figure 2). All the
type of rehabilitation based on the best available scientific literature, framework/abutment were milled as part of the zirconia structure
leaving the final decision to the patient. (Prettau® Zirconia; Zirkonzahn). Framework fit and passivity was
Regardless of the selected prosthesis design, the clinical and clinically evaluated as previously described and feldspathic veneer‐
laboratorial steps were kept as similar as possible in both groups. ing porcelain (ICE Zirkon Ceramics; Zirkonzahn) was applied ac‐
In brief, an open‐tray, abutment‐level impression was made; a stone cording to manufacturer instructions. Screw access chambers were
model was poured and mounted on a dental articulator (Artex® CT, sealed as described for the PVZ group.
Amann Girrbach, Herrschaftswiesen, Austria). The maxillary cast
was mounted following a facebow record and the mandibular cast
2.6 | Data collection
following a centric‐relation record. The articulated models were then
scanned with a table‐top scanner (S600, Zirkonzahn, Gais, Italy) and One hundred and fifty patients were consecutively recruited
the resulting files imported into a CAD software (zirkonzahn model‐ from January of 2014 until December of 2016 and recalled every
lier; Zirkonzahn). Final restoration frameworks were milled in zirco‐ 4 months for professional maintenance (i.e., oral hygiene) and clinical
nia (Prettau® Zirconia; Zirkonzahn) on a single milling machine (M5; examinations. At this time, the range of follow‐up was between 67
Zirkonzahn). All rehabilitations (provisional and final) followed a mu‐ and 1,079 days with 76 and 93 full‐arch rehabilitations with at least
tually protected occlusion scheme and were fabricated in the same 1‐year follow‐up, for the PVZ and MZ groups, respectively.
CARAMÊS et al. | 71

Data and analysis were computed using a statistical computer

package (SPSS v. 22, IBM, Armonk, NY, USA). Descriptive statistics
were used for patient demographics, implant distribution, implant
success and occurrence of prosthesis complications during the fol‐
low‐up period.
Prosthesis survival and success was analysed through a Kaplan–
Meier estimator, and the log‐rank and Wilcoxon tests were used
to assess differences in survival and success functions in the two
groups for each outcome, respectively.
As the Kaplan–Meier analysis graphs and further tests showed
that their proportional hazards assumption was violated, we con‐
ducted an extended Cox regression model, adjusted for a special
F I G U R E 2 CAD framework prior to milling for the monolithic time covariate and an interaction of the time covariate with our out‐
Zirconia group
come factor (type of rehabilitation). The model takes changes of haz‐
ard in time into account and in effect successfully accounts for and
Primary outcomes were defined as survival and success rates encompasses co‐variates that change over time. By using this model,
of the final prosthesis. For evaluation of these outcomes, an anal‐ the need for proportional hazards assumption was avoided and a
ysis variable was used (Mendez Caramês et al., 2016): if no alter‐ more robust model created (Zhang, Reinikainen, Adeleke, Pieterse,
ations were present, the prosthesis was recorded as “Alpha”; if & Groothuis‐Oudshoorn, 2018).
minor chipping had occurred—not requiring any intervention be‐ For statistical analysis purposes, the group names were encoded
sides polishing or recontouring without the need for prosthesis to “A” and “B” so that the statistical analyst was blinded.
retrieval—“Bravo” classification was attributed; a “Charlie” classifi‐
cation indicated the occurrence of major chipping, need for pros‐
3 | R E S U LT S
thesis retrieval and laboratory intervention; and finally, a “Delta”
classification was attributed when fracture of the framework was
3.1 | Participant baseline characteristics and follow‐
present.
up
“Delta” was the outcome defined for non‐surviving prosthesis,
while all the other categories (“Alpha,” “Bravo” and “Charlie”) de‐ One hundred and fifty patients (68 men and 82 women) with a
scribed surviving prosthesis with different levels of success. The mean ± SD age of 62.06 ± 9.87 (range: 36–96 years) were allocated
number and type of prosthetic complications observed during the to one of the groups equating to 83 and 110 rehabilitations for the
follow‐up period was also recorded and reported as descriptive PVZ and MZ groups, respectively.
statistics. Over the course of the study, 12 patients were lost to follow‐up
Predictive variables, which could influence the prosthesis be‐ (1 deceased, 3 changed residency, 8 did not comply with the re‐eval‐
haviour were also recorded and analysed, namely: patient age; gen‐ uation protocol) corresponding to 6 and 10 rehabilitations lost in the
der; interventioned arch (maxilla or mandible); number of implants PVZ and MZ groups, respectively. The study flowchart during the
per rehabilitation; number of dental units restored; type of opposing follow‐up period is illustrated in Figure 3.
arch; and presence or absence of cantilevers. Prosthesis distribution by age and group is shown in
As a secondary outcome, implant success rates were evaluated Figure 4 with a Mean ± SD follow‐up time of 608.80 ± 172.52 and
according to the criteria described by Buser et al. (1997): absence of 552.63 ± 197.57 days for the PVZ and MZ groups, respectively.
persistent subjective complaints (pain, foreign body sensation, and/ Descriptive statistics of the predictive values are presented in
or dysesthesia); absence of peri‐implant infection with suppuration; Table 1.
absence of implant mobility; and absence of continuous radiolu‐ In summary, the majority of the rehabilitations were per‐
cency around the implant by previously established methods based formed in the maxillary arch, being mostly supported by 6 im‐
on the clinical and radiographic examinations at the yearly visits plants. A total of 1,009 implants was placed with an implant
(Buser et al., 1997). success rate of 99.53% and 99.83% for the PVZ and MZ groups,
respectively.
During the follow‐up period, the number of prosthesis‐related
2.7 | Statistical analysis and sample size calculation
complications was 10 for the PVZ group and 10 for the MZ group,
The control event rate of subject counts with at least one adverse corresponding to a total complication rate of 11.3%. Out of these,
event at 1‐year follow‐up was expected to be at least 10%. In order 85.00% occurred when the opposing arch consisted also of a full‐
to detect a difference of 5% between groups with a power of 80% arch implant‐supported rehabilitation. The most prevalent complica‐
and a significance level of 0.05, at least 70 patients per group needed tions were loss of the access chamber composite plug and prosthetic
to be enrolled. screw loosening.
72 | CARAMÊS et al.

FIGURE 3 Study flowchart with patients lost during follow‐up period

F I G U R E 4 Demographic pyramid of
frequency distribution of patients in both
groups according to age

the opposing arch was also a monolithic zirconia full‐arch ISFDP.

3.2 | Survival outcomes
A Cox regression was adjusted for the following variables: patient
Of the 177 full‐arch ISFDP that were included in this study, 157 were age; gender; rehabilitated arch (maxilla or mandible); number of im‐
free of any events (“Alpha”), corresponding to 87.01% and 90.00% plants per patient; number of dental units restored; type of oppos‐
of the prosthesis in the PVZ and MZ groups, respectively. “Bravo,” ing arch; and presence or absence of cantilevers. A Kaplan–Meier
“Charlie” and “Delta” outcomes for both groups are presented in analysis was performed to evaluate the cumulative survival for both
Table 2. No statistically significant differences were found between groups for the “Bravo” (Figure 5a), “Charlie” (Figure 5b) and “Delta”
groups for these outcomes. (Figure 5c) outcomes. An estimation of the cumulative survival was
Survival function with regard to framework fracture (“Delta” also performed considering the occurrence of any of the former
outcome) resulted in an overall 2‐year survival rate of 99% for both complications combined (Figure 5d) and the cumulative survival
groups. A subgroup analysis was undertaken regarding the pos‐ rate at 1 and 2 years for each outcome was calculated (Table 4), al‐
sible association of complications with the type of opposing arch though no significant differences were found between groups and
(Table 3). In the MZ group, all the complications were noted when outcomes. As the Kaplan–Meier analysis graphs and further tests
CARAMÊS et al. | 73

TA B L E 1 Distribution of the predictive

Porcelain‐Veneered Zirconia (PVZ) Monolithic Zirconia (MZ)
variables for both groups
Frequency Percentage Frequency Percentage

Arch
Maxilla 69 89.6 61 61
Mandible 8 10.4 39 39
Number of implants placed
4 23 29.9 20 20
5 5 6.5 7 7
6 37 48.1 55 55
7 7 9.1 8 8
8 5 6.5 10 10
Total implants 428 581
placed
Implant success 426 99.5 580 99.8
Number of restored dental units per rehabilitation
10 1 1.3 4 4
11 1 1.3 2 2
12 66 85.7 76 76
13 1 1.3 4 4
14 8 10.4 14 14
Total units 938 1,222
Type of opposing arch
Natural dentition 7 9.1 3 3
Full‐arch 12 15.6 5 5
zirconia‐ceramic
Full‐arch 1 1.3 63 63
monolithic
zirconia
Full‐arch 27 35.1 9 9
metal‐acrylic
Mixed dentition 30 39.0 20 20
Cantilever
Present 35 45.5 43 43
Absent 42 54.5 57 57

TA B L E 2 Distribution of survival and

Porcelain‐veneered zirconia (PVZ) Monolithic zirconia (MZ)
success outcomes in the PVZ and MZ
groups Outcome Frequency Percentage Frequency Percentage

Alpha 67 87.01 90 90
Bravo 5 6.5 5 5
Charlie 4 5.19 4 4
Delta 1 1.3 1 1
Total 77 100 100 100

showed that their proportional hazards assumption was violated, 4 | D I S CU S S I O N

we used extended Cox regression analysis with a time‐dependent
covariate and an interaction of the time covariate with our outcome The current study reported on the survival and success rates of
factor (type of rehabilitation). two possible designs for ceramic full‐arch screw‐retained ISFDP, a
74 | CARAMÊS et al.

TA B L E 3 Distribution of survival and success outcomes according to type of rehabilitation and opposing arch

Bravo Outcome Charlie Outcome Delta Outcome At least 1 event

Type of Type of Opposing
Rehabilitation Arch Frequency Freq. % Freq. % Freq. % Freq. %

Porcelain‐veneered Natural dentition 7 0 0.0 0 0.0 0 0.0 0 0.0

zirconia (PVZ) Full‐arch PVZ 12 2 16.7 1 8.3 0 0.0 3 25.0
Full‐arch MZ 1 0 0.0 0 0.0 0 0.0 0 0.0
Mixed dentition 30 1 3.3 2 6.7 0 0.0 3 10.0
Full‐arch 27 2 7.4 1 3.7 1 3.7 4 14.8
metal‐acrylic
Monolithic zirconia Natural dentition 3 0 0.0 0 0.0 0 0.0 0 0.0
(MZ) Full‐arch PVZ 5 0 0.0 0 0.0 0 0.0 0 0.0
Full‐arch MZ 63 5 7.9 4 6.3 1 1.6 10 15.9
Mixed dentition 20 0 0.0 0 0.0 0 0.0 0 0.0
Full‐arch 9 0 0.0 0 0.0 0 0.0 0 0.0
metal‐acrylic
Total 177 10 5.6 8 4.5 2 1.1 20 11.3

(a) (b)

(c) (d)

F I G U R E 5 Survival function for (a) minor chipping, (b) major chipping, (c) framework fracture and (d) presence of any of the previous
complications during the follow‐up period

zirconia framework veneered with feldspathic porcelain (PVZ) and a that both design options are suitable for full‐arch implant‐supported
monolithic zirconia framework with feldspathic veneering porcelain rehabilitations. Out of the total 177 restorations, only one frame‐
limited to non‐functional surfaces (MZ). The results strongly suggest work fracture was observed in each group during the follow‐up
CARAMÊS et al. | 75

period, resulting in survival rates of 98.7% and 99.0% for the PVZ In order to increase internal validity, the surgical, prosthetic and
and MZ groups, respectively. When comparing both groups, MZ pre‐ maintenance protocols were standardized (respecting individual
sented better results for all the defined success outcomes, despite characteristics) and the patients in both groups treated according
not reaching a statistically significant difference when compared to to the same guidelines. Also, the clinicians involved in the various
PVZ. treatment phases were calibrated regarding the outcome evalua‐
The selection of screw retention for the prosthesis was planned tions. Moreover, to eliminate finances as a confounding factor, the
from the diagnosis stage, guiding implant placement, and based on same economical value was attributed to both treatment options.
the concept of facilitated retrievability when dealing with biologi‐ To our best knowledge, this represents the only prospective
cal or mechanic complications (Le et al., 2015; Mendez Caramês et comparative clinical study aiming to report the success and survival
al., 2016; Venezia et al., 2015; Wilson, 2009). Moreover, the 2012 rates of two zirconia‐based full‐arch ISFDP with novel and unique
consensus of the European Association for Osseointegration rec‐ results.
ommends screw‐retained frameworks when performing extensive When assessing the primary outcome of this clinical trial, de‐
implant‐supported rehabilitations (Sailer, Mühlemann, Zwahlen, fined as prosthesis survival, the results yielded above a 99% sur‐
Hammerle, & Schneider, 2012). vival rate showing that zirconia frameworks are a suitable option
Implant success was defined according to pre‐established cri‐ for full‐arch implant‐supported rehabilitations. A recent systematic
teria (Buser et al., 1997) and the 1,009 dental implants were eval‐ review by Abdulmajeed et al. (2016) evaluated monolithic zirconia
uated yearly revealing high success rates, 99.5% and 99.8% in the full‐arch implant‐supported rehabilitations, which included nine
PVZ and MZ groups, respectively. According to our results, the retrospective and prospective studies reporting similar short‐term
incidence of biological and mechanical complications was low and results. However, none of the included studies was a comparative
consistent with what has been reported in the current literature clinical trial and the largest sample consisted of 34 prostheses in
(Abdulmajeed et al., 2016; Jung, Zembic, Pjetursson, Zwahlen, & 17 patients (Abdulmajeed et al., 2016). More recently, studies with
Thoma, 2012; Le et al., 2015; Pjetursson, Sailer, Makarov, Zwahlen, longer follow‐ups were published reporting similar results, suggest‐
& Thoma, 2015). ing long‐term stability of this prosthetic option (Moscovitch, 2015;
This study was designed as a pragmatic controlled prospective Rojas Vizcaya, 2016).
clinical trial with the intention of determining the effectiveness of Prosthesis and implant success were secondary outcomes eval‐
the interventions in a real‐world setting, thus increasing external uated in this study. Prosthesis success was defined by the absence
validity (Roland & Torgerson, 1998; Williams, Burden‐Teh, & Nunn, of veneering chipping and implant success was defined according to
2015; Zwarenstein et al., 2008). The study was registered prior to the criteria defined Buser et al. (1997). Systematic reviews reporting
the recruitment phase in which patients were consecutively enrolled on the mechanical and biological behaviour of zirconia frameworks
over a 36‐month time interval in order to achieve at least 75 patients fully veneered with feldspathic porcelain have been extensively
per group with at least 1 year of follow‐up. The absence of a true described in the literature (Larsson & Wennerberg, 2014; Le et al.,
randomization between groups presents as a limitation regarding a 2015; Pjetursson et al., 2015).
possible selection bias, although the intention was to maintain a real‐ Some studies have reported a higher rate of veneering por‐
world setting with a clinically orientated patient‐centered decision celain chipping when zirconia is used as a framework material for
process. fixed dental prosthesis (Bozini et al., 2011; Le et al., 2015; Mendez
Caramês et al., 2016). Since this layered design has been associated
with a higher incidence of ceramic chipping when compared to por‐
TA B L E 4 Distribution of cumulative survival and success celain‐fused‐to‐metal rehabilitations (Mendez Caramês et al., 2016;
outcomes for Porcelain‐veneered zirconia (PVZ) and Monolithic
Papaspyridakos & Lal, 2013; Schmitter, Mussotter, Rammelsberg,
zirconia (MZ) groups. 76 PVZ and 93 MZ evaluated at 1‐year
follow‐up and 18 PVZ and 15 MZ at 2‐year follow‐up Gabbert, & Ohlmann, 2012; Schwarz, Schröder, Hassel, Bömicke,
& Rammelsberg, 2012) some authors have empirically proposed
Cumulative survival
the utilization of non‐layered monolithic zirconia FDPs in order to
(mean ± SEM)
Type of completely eliminate the presence of a zirconia/veneering ceramic
Rehabilitation Outcome 1 year 2 years interface (Carames et al., 2015; Guess, Att, & Strub, 2012; Marchack
PVZ Bravo 0.96 (0.02) 0.93 (0.03) et al., 2011). Following this rationale, the present study was designed
Charlie 0.96 (0.02) 0.95 (0.03) as a prospective clinical trial comparing the two designs of zirconia‐

Delta 0.99 (0.01) 0.99 (0.01) based full‐arch ISFDP, trying to clarify whether the rate of mechani‐
cal complications would decrease as previously suggested (Carames
Total 0.92 (0.03) 0.85 (0.05)
et al., 2015; Limmer, Sanders, Reside, & Cooper, 2014; Rojas Vizcaya,
MZ Bravo 0.95 (0.02) 0.95 (0.02)
2016; Venezia et al., 2015).
Charlie 0.98 (0.02) 0.95 (0.02)
However, other publications have failed to show statistically
Delta 0.99 (0.01) 0.99 (0.01)
significant differences when compared to porcelain‐fused‐to‐metal
Total 0.92 (0.03) 0.89 (0.03)
rehabilitations (Christensen & Ploeger, 2010; Ohlmann, Eiffler, &
76 | CARAMÊS et al.

Rammelsberg, 2012; Sailer, Gottnerb, Kanelb, & Hammerle, 2009). viable alternative for full‐arch ISFDPs. Further clinical studies with
These later reports are in agreement with the results obtained in this longer follow‐up should be performed to assess the long‐term stabil‐
study. A possible explanation could be the fact that over time sev‐ ity of these rehabilitations as well as the consistency of patient and
eral factors found to influence the reliability of this material combina‐ clinician assessed aesthetic and functional outcomes.
tion were improved, namely the utilization of anatomical supporting
frameworks for the veneering porcelain, better control of firing and
AC K N OW L E D G E M E N T S
cooling cycles as well as the development of veneering ceramics
with smaller mismatches of coefficients of thermal expansion (Swain, The authors would like to acknowledge the valuable contribution of
2009). Dr. A. Brian Urtula for his writing assistance.
When evaluating the secondary outcomes in both groups the cu‐
mulative survival at the 1‐year and 2‐year follow‐up ranged between
CO N F L I C T O F I N T E R E S T
96%–93% and 98%–95% in the PVZ and MZ groups, respectively.
Although no significant differences were found between groups None declared.
for the secondary outcomes, it was observed that in both groups the
percentage of complications was higher when the opposing arch was
ORCID
a full‐arch ISFDP and all the complications (“Bravo,” “Charlie” and
“Delta”) in the MZ group occurred when the opposing arch was also João Caramês https://orcid.org/0000-0002-5544-3744
a MZ full‐arch ISFDP. This finding could be explained mainly because Duarte Marques https://orcid.org/0000-0003-1966-8281
in bi‐maxillary full‐arch implant‐supported rehabilitations a decrease
João Malta Barbosa https://orcid.org/0000-0002-0350-8286
in the patient proprioceptive defence mechanism is noted due to the
functional ankylosis of the dental implants in both arches, leading to André Moreira https://orcid.org/0000-0001-6699-1626

higher forces, which in turn could exacerbate the rates of mechanical Pedro Crispim https://orcid.org/0000-0002-9050-7774
complications (Müller et al., 2012; Papaspyridakos & Lal, 2013). Also, André Chen https://orcid.org/0000-0001-7571-6079
the presence of parafunctional habits (such as bruxism) detected
prior to initiation of the final rehabilitation sequence could present
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