Modern approaches in choosing materials for implant supported

prosthesis
Manolea H.1,a, Fronie A.2,b, Popescu Sanda Mihaela3,c, Opri Mirela4,d, Ciuc
E.5,e
1

Department of Dental Materials, 2, 5 Department of Oral Surgery

Department of Oral Rehabilitation, 4 Department of Dental Prosthesis Technology
Faculty of Dentistry, UMF Craiova, 2-4 Petru Rares Street, Craiova, Romania

manoleahoria@gmail.com, adrianfronie@yahoo.com, sm_popescu@hotmail.com,

d
opri_mirela@yahoo.com, eciucaeduard@yahoo.com

Keywords: implant supported prosthesis, titanium, dental ceramics, polyether-ether-ketones (PEEK)

Abstract. The materials used in manufacturing the implant supported prosthesis may
influence the occlusal stress distribution to the bone due to their different elastic modulus. Thus,
compared with alloys of Co-Cr, the material currently used for the realization of the implant
supported prosthesis resistance structure, the titanium prosthesis elasticity allows a less rigid
solidarization, especially important as the extent of the bridge is greater, more so in the mandible,
which presents an elastic deformation during mastication.
The use of modern composite materials based on polyether-ether-ketones for manufacturing
the implant supported prosthesis resistance structure is gaining more and more interest due to
optimization opportunities of the distribution of masticatory forces around the implant.
Regarding the aesthetic component of the implant supported prosthesis, ceramic masses
remain the most commonly used materials due to their outstanding restorer options and proven
biocompatibility. However, speaking of the transmission of forces to the implant support, the
composite materials are preferred due to advantages related to the possibility of stress relief and to
ensure a durable link frame - composite, the aesthetic result being more than satisfying.
Introduction
The dental implantology has revolutionized the dental prosthetics allowing it to dispose
additional supporting pillars that can be inserted wherever it is needed.
For the success of an implant supported prosthetic restoration managing the
osteointegration and the tissues healing around the recently inserted implant is not enough. Just as
important or even more important are the materials, the design, the biostatic and the biodynamics of
the final prosthetic restoration [1].
In choosing materials for manufacturing the implant supported prosthesis a number of
conditions must be taken in consideration, some valid for any prosthetic dental restoration such as
resistance, esthetics, and biocompatibility, other specifics for these type of prosthesis such as the
compatibility between the implant material and the one for the prosthesis or the correct transmission
of the occlusal forces to the support implant [2,3].
The connection between the osseointegrated implant and the peri-implant bone tissue is
more rigid in comparison with the resilience of the periodontal ligament of the natural dentition [4].
Thus, a passive fit at the implant-prosthesis interface has been suggested to be crucial for the longterm success of osseointegration [5] and to prevent future complications [6].
Dental prostheses are commonly made of two components, the framework that offers
resistance to the final construction being coated with the aesthetic material.
The framework materials
Traditionally, the framework is made of metallic materials which can be classified in noble
or non-noble alloys.
The noble alloys show a good biocompatibility, but the mechanical properties are low, and
the thermal expansion coefficient is higher compared to ceramics. However a number of concerns of

the researchers have given rise to noble alloys with a special structure that allows the shock
absorption with the protection of the supporting implants. Thus, Captek (Argen) presented as a
nanometal composite structure has an internally reinforced structure of hard thermally stable
particles of platinum and palladium that supports the resilient gold matrix. It is theorized that the
stress control designed by his inventors to protect porcelain may also help to protect underlying
tooth structures from damaging occlusal loads. The inherent design of the reinforced gold produces
a dynamic elastic modulus reported to be similar in range to that of natural tooth structure [7].
The use of non-noble alloys for implant-supported restorations was not popular due to the potential
of corrosion and galvanism between different metals. However the superior mechanical properties
and the low cost have made these alloys to be the most used at this time in our country for the metal
frame of implant-supported prosthesis.
Of particular interest from the group of the non-noble alloys presents the titanium alloys.
Titanium is indicated for the realization of the prosthetic superstructures supported by titanium
implants from at least two reasons: the occurrence of galvanic currents between the material of the
implant and the prosthesis material is prevented and the elasticity of the titanium structures allows a
more elastic solidarity of the supporting pillars, a more important consideration, as the bridge has a
larger extent, and particularly at the mandible, which suffers elastic deformation during masticatory
act [8,9].
The technical realization in laboratory of the titanium structures requires a rigorous
compliance with the technologies provided by producers together with the adequate installations.
The obtaining of fixed prosthetic pieces from titanium and titanium alloys calls for technologies of
melting/casting, electroerosion, three-dimensional assisted milling (CAD / CAM), sintering. For
now, in the dental laboratory, the melting/casting process is the most widely used technology due to
the favorable quality/price ratio, in spite of some processing difficulties (pretentious protection
environments, relatively expensive technological chains, sensitive techniques) [10]. A particular
attention will be given to cast processing (sanding and machining) in order to remove the surface
contamination layer.
The veneering of titanium substructures with esthetic materials requires a thorough cleaning
of the concerned surfaces, in this regard being recommended to use an acid solution [11]. Titanium
infrastructures allow efficient conditioning by silanization for composites resins coating, which
should be preferred as coating materials [12]. The veneering with ceramics calls for special
materials for titanium, whose key feature is the low sintering temperature (below the allotropic
temperature of titanium 882.5C) [13]. (fig. 1-5)

Fig. 1 An aspect caught

during casting titanium

Fig. 2 The appearance of

titanium pieces after casting

Fig. 4 The weighing of the

two metal components

Fig. 5 The final aspect of

restorations on the models

Fig.3 The metal frameworks

adjusted on the models

Due to increasing interest in esthetics and concerns about toxic and allergic reactions to
certain alloys, patients and dentists have been looking for metal-free tooth-colored restorations.
Zirconia is widely used to build prosthetic devices because of its good chemical properties,
dimensional stability, high mechanical strength, toughness, and a Young's modulus (210 GPa)
similar to that of stainless steel alloy (193 Gpa). On the other hand, its ability to transmit light and
its white color, similar to the color of natural teeth, makes it useful in esthetic restorations of the
oral cavity [14]. Although, some manufacturers suggest them for full-arch restorations, zirconia
implant-supported fixed partial dentures of two- to five-units may be considered a more reliable
treatment alternative [15] (fig. 6-7).The most frequent technical problem in studies of zirconia
reconstructions is chipping or cracking of the ceramic veneer [16].
Fig. 6 The zirconia framework
Fig. 7 The final prosthesis
with the ceramics applied on
the zirconia framework
The failures of the layered restorations have determined the search of monolithic solutions
for the metal free prosthetic restorations (fig.8). Thus appeared industrial prefabricated ceramic
prosthetic abutments that can be made from zirconium oxide, high purity alumina ceramic or
lithium disilicate. Monolithic zirconia crowns exhibit higher fracture loads than monolithic lithium
disilicate crowns, layered zirconia crowns and metal ceramic crowns. This strength is homogenous
throughout the entire restoration. However, the fracture loads for crowns with different thicknesses
were significantly different [17]. The esthetic outcome of such machinable blocks may be a concern,
but in a study, regardless of the fabrication method, the crowns were esthetically acceptable in all
the patients showing that machinable blocks could attain esthetically satisfying results [18].
Fig. 8 Ceramics machinable
blocks

The spectacular development in recent years of the implant supported prosthetics has led to
an intensification of the manufacturers researches in this direction with development of new
materials from this range with occlusion shock absorbing abilities.
Such a material is the product BioHPP from Bredent, a poly-ether-ether-ketone (PEEK)
designed to be used for the prosthetic restoration framework (fig. 9 -13). Unlike the materials used
so far, BioHPP shows a bone-like elasticity. Ceramics and non-noble alloys are 20 times more rigid
than bone, while gold and titanium are about 10 times more rigid. This similarity to bone offers
special advantages especially for prosthetic structures with a stretched metal frame. The name
BioHPP comes from High Performance Polymer, a material with several favorable properties: the
white color which means it can be used for maximum aesthetic restorations, the posibility to be
plated with traditional composites, without abrasive effect on the antagonist teeth, without metal
which means no ionic exchange in the oral cavity and no discolourations [19]. The partially
crystalline thermoplastic resin reinforced with ceramic particles to withstand the occlusal stress
means this material could be used as a material substructure, its biocompatibility being proved by
the use in human medicine as an implant material for over 20 years [20, 21].
In the same category 3M ESPE also promotes a nano ceramic resin - Lava Ultimate
Restorative, also a material with several favorable properties for this type of restoration: less wear to

opposing dentition than glass ceramics, absorption of chewing forces which reduces stress,
adjustability for occlusion with additive or subtractive techniques, fast, no firing and easy to mill
[22].

Fig.9, 10 The wax models for a full

-mouth rehabilition implant
supported prepared for investment.

Fig. 11, 12 The BioHPP

frameworks for the mandibular
and the maxillary prostheses

Fig. 13 The final aspect of the

prostheses in the oral cavity.

Veneering materials
From the veneering materials group, ceramics represents at this time the most widely used
material for manufacturing dental prosthesis. Ceramics allow obtaining of numerous and varied
color shades depending on the situation in the natural dentition. Their translucency is very good, and
the color stability is high because they are chemically inert. They have a very good tolerability,
ceramics being biologically neutral; plaque accumulation on their surfaces is lower than on any
other restorative material, including natural tooth enamel. However, ceramics present a firing
shrinkage that can exceed 20%. This can cause distortion of the metal structure affecting its passive
adaptation. The high hardness and rigidity of ceramics determine the direct transmission of forces to
the bone through implants [23].
In 1983, Skalak hypothesized that an occlusal material with a low modulus of elasticity
might dampen the occlusal impact forces, thereby decreasing its effect on the bone-implant
interface. Thus, he suggested the use of a shock-absorbing material such as acrylic resin in the form
of acrylic resin artificial teeth in the fixed partial denture [24]. The acrylic resin may have a setting
contraction of 7%, even 18% in case of monomer excess. In case of implant-supported prosthetic
restorations the intraoral use for the interior lining of provisional prosthesis may cause stress on the
implants. Finally, prosthesis that have metal coating with resin can lead to torsion of the metal and a
restoration proved to be passive at the framework test to become active after restoration with resin.
Restorations with long and narrow metal structure have a risk to be deformed after applying
acrylate. Currently, acrylic resins are used when it is desired to decrease costs, when there is no

space for a metal-ceramic restoration, as an interim prosthesis (fig. 14-15) or when performing an
overdenture. However, there are frequently required enhancements, linings and repairs and when
acrylic resin is used on occlusal surfaces, complications such as screw loosening, resin fracture and
resin wear may appear [25].

Fig 14, 15 Provisional acrylic bridge made in the same session with implant insertion using the
Fast & Fixed method (Bredent). The appearance of restoration after the test into oral cavity and
after finishing and polishing
The diacrylic composites resins (DCR) tend to impose themselves in the manufacturing of
prosthesis and replace acrylic resins in a series of prosthetic devices, due to a number of favorable
properties, such as chemical bonding of the DRC to the metal that prevents leakage of the fluid from
the oral cavity, increased resistance to abrasion, resistance to aggressive factors from the oral
environment. Compared to ceramics masses, DCR do not cause abrasion on the natural antagonists
and esthetic components of metal-composites restorations can be easily repaired in the mouth and
do not require special alloys as substrate [26].
Between the DCR, a range of commercial products have been designed in order to use a
property of these materials as through their modulus of elasticity to allow absorption of the energy
generated during mastication. Among these we mention organic glasses (Artglass) and composites
based on polycarbonate resins (Conquest B). The use of prefabricated composite veneers
(Visioligne, Bredent) for plating the frameworks provides the predictability of the restorations
esthetics through its planning and the opportunity to show the patient the final look of the prosthesis
even during test phases (fig. 16,17).

Fig 16 Diagnosis wax up with

Visioligne veneers anchored on two
distal implants

Fig 17 The final aspect of the restoration

made on a Biohpp structure covered
with composite resin.

Fiber reinforced composites (FRC) may also be a prospective alternative for implant
prosthetic materials due to their higher modulus of elasticity (28.5 Gpa) and abrasion resistance
compared to conventional composites [27]. Such an example is the Targis/Vectris complex
(Ivoclar), where Vectris is a fiberglass reinforced resin (5-11 m fiber diameter) a material
developed specifically for creating infrastructure and Targis is a ceromer, the coating resin, with a
percentage of 75-85% inorganic filler and an average size of 1 m microparticles.

Conclusions
The materials on the market offer a wide range of options for implant supported prosthetic
restorations. Although, at least in our country, most restorations are still made on a framework made
of non-noble alloys covered with ceramics, the use of modern composite materials based on
polyether-ether-ketones for manufacturing the implant supported prosthesis resistance structure is
gaining more and more interest due to optimization opportunities of the distribution of masticatory
forces around the implant. For the same reason, though ceramics have proved their outstanding
restoring properties, composite materials should also be considered for their possibilities of stress
amortization.
Acknowledgements
All authors contributed equally to the article.
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