I industry report _ partial dentures

By kind permission of Cosmetic Dentistry

International Edition n.4, 2008

Clinical and laboratory

procedures to fabricate
fibre-reinforced composite
fixed partial dentures
Authors_ Giorgio Rappelli, Erminia Coccia & Daniele Rondoni, Italy

_Introduction

Fig. 1_Pre-op view of a patient who

rejected implant surgery. The maxillary right first molar was extracted for
periodontal reasons approx. 3
months earlier.
Fig. 2_For the premolar, the extension of the preparation was determined by pre-existing restoration.
Where a tooth is intact, sound dental
tissues must be preserved as far as
possible, but no less than 3 mm
apico-coronally and 4 mm buccopalatally must be guaranteed for
preparation of the proximal box.

Fig. 1

since they provide adequate adhesion to the polymer matrix.3

_The use of fibre-reinforced composite

(FRC) to fabricate inlay-fixed partial dentures (IFPDs) is an innovative therapeutic solution to restore missing teeth.1 This new minimally-invasive
prosthetic approach has been made possible by
developments in the fields of adhesive dentistry,
bonding systems, restorative materials, and conservative preparation designs. Structurally, fibrereinforced composite fixed partial dentures (FRCFPDs) consist of two components: the fibres and
the resin matrix. The resin matrix serves as carrier,
protector, and load-splicing medium around the
fibres, which act as filler material.2 To improve the
mechanical properties of composite resins and
optimise the structures mechanical behaviour,
specifically-oriented filler materials have been
proposed, such as glass fibres, aramid fibres, carbon/graphite fibres, and ultra-high molecular
weight polyethylene fibres. In-vitro studies have
suggested that glass fibres are the most suitable,

Fig. 2

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Glass-fibre-reinforced composite FPDs offer the

possibility of fabricating adhesive, aesthetic, and
metal-free tooth replacements at a reduced biological cost (Fig. 1).4 Compared to metal-ceramic and allceramic FPDs, the necessary preparation on abutment teeth is minimally invasive (Fig. 2).57 Moreover,
the use of FRC reduces the risk of allergic or toxic side
effects of metal alloys (Fig. 3).8 This therapeutic solution is also specifically indicated in patients in whom
implant-surgery is contraindicated, because of, for
example, systemic diseases. Another significant advantage of composite prosthetic solutions over other
restorative materials is that they may be repaired intra-orally, without the risk of modifying aesthetic or
mechanical performance (Figs. 4, 5).9
Owing to their good clinical performance1014, FRCs
are increasingly used to restore missing teeth. The
clinical steps necessary for abutment preparation and

industry report _ partial dentures

Fig. 3

Fig. 4

Fig. 5

Fig. 6

luting techniques have been documented1519, but little has been reported on the laboratory procedures involved in fabricating FRCFPDs. This report describes
the clinical and laboratory procedures entailed in fabricating fibre-reinforced composite inlay-fixed partial dentures (FRCIFPDs); the method can be used to
restore missing teeth in an aesthetic, functional, and
time-saving manner, without any surgical steps. In
particular, a laboratory technique is described that
uses a plexiglass flask; light-curing, pre-impregnated
glass fibres; and light-curing composites.

_Preparation of abutment teeth

Cavity design and preparation for FRCIFPDs are
similar to those for inlay restorations (Figs. 6, 7).14

Fig. 7

Fig. 8b

Fig. 3_The final aspect of the FRCIFPD.

Fig. 4_Isolated with rubber dam to
ensure correct adhesive luting.
Fig. 5_Clinical check-up one week
after luting.
Fig. 6_A 75-year-old male presented
missing a maxillary right first premolar. Because of systemic disease, the
patient rejected implant-supported
prosthesis, and a metal-free inlay
fixed partial denture was proposed.

The buccal and palatal margins of both boxes must

be flared apical-coronally, in order to ensure the
correct position of the FPD during cementation. Finite element (FE) analysis, employing two- and
three-dimensional models20,21, has indicated that
the connector area is the critical zone for stress concentration when vertical and lateral loads are applied to the tooth-restoration complex. Moreover,
Song et al.22 demonstrate the correlation between
the mechanical strength of FRCIFPDs and abutment
design; they highlight the need for abundant fibres
to improve FPD strength. In order to provide optimal
mechanical behaviour in the connector areas, the
proximal boxes in abutment teeth must extend for
approximately 4 mm bucco-palatally, 1.5 mm
mesio-distally, and 3 mm occluso-apically. The

Fig. 8a

Fig. 8c

Fig. 7_After occlusal analysis, boxshaped proximal preparation was

performed on the premolar.
Figs. 8_After impression taking with
an elastomer material, die stone was
poured to obtain the working cast
(Fig. 8a). Wax-up of the final prosthesis (Fig. 8b).

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I industry report _ partial dentures

Fig. 9_The technician creates a

suitable silicone stamp applying
several types of silicone, in a dedicated plexiglass flask, around the
framework wax-up.

Fig. 9a

Fig. 9b

Fig. 9c

Fig. 9d

mesio-distal occlusal extension of the preparation

appears not to be important for the mechanical behaviour of the bridge20, but a minimal extension is
required to provide sufficient adhesive retention.
The cervical margins of the boxes should be placed
supra-gingivally, to facilitate removal of excess cement. If the proximal margin is located on enamel,
this provides better long-term marginal adaptation
of the restoration.14
Dedicated diamond burs (no. 8113R, 8113NR,
Intensiv SA; no. 3113R, 3117, Intensiv SA) in a highspeed hand piece with water irrigation can be used
for cavity preparation. Preparations can be adhesively protected, to reduce post-operative sensitivity and avoid contamination of dentine during
temporisation. The adhesive system should be applied according to the manufacturers instructions. An impression of the prepared teeth is then
taken using an elastomer material and an irreversible hydrocolloid impression of the opposing
arch is taken.

Fig. 10_Dental floss can be used to

choose the required length of the fibre, which must be cut with the dentists silicone.

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Fig. 10

_FRCFPD fabrication
While fabricating the FRCIFPD, the technician
must carefully plan each step, to optimise framework design. Several studies1,2,13,14 have shown that
survival of FRCIFPDs depends on the mechanical
performance of the framework and on the quality
of adhesion between veneering material and fibres. Fracture of the principal structure in the connector areas and delamination of the composite
are the main causes of FRCIFPD failure.11,2326 The
framework design must be optimised: the framework should be the same shape as the final restoration but reduced in size.23,24 If it is designed thus,
loads applied to the structure will be transferred
from the veneering composite to the framework,
averting the delamination due to tensile forces
acting on the composite-framework interface.26
The framework wax-up is the first and most critical step in the entire procedure for FRCIFPD fabrication (Fig. 8). A specific silicone for stents (Temp
putty, 95 shore, Micerium S.p.a., Italy) is placed in a
plexiglass flask for composites (Tender flask,
Micerium). Before the silicone hardens, the framework wax-up is immersed in the putty. In order to
ensure light polymerisation of the composite,
transparent silicone (Temp Clear Silicone, 55 shore,
Micerium) is used to fill the flask, which is immediately closed. After about 15 minutes, the flask is
opened and the two components are separated, in
order to remove the wax-up (Fig. 9). When the silicone stamps have dried completely, fabrication of
the fibre framework may begin. An initial layer of

industry report _ partial dentures

Fig. 11a

Fig. 11b

Fig. 11c

light-curing, pre-impregnated glass fibre (TF41,

Tender Fiber Quattro, Micerium; Fig. 10) is placed in
the silicone and held in place by a small quantity of
flow composite. The particular transparent silicone, provided in the fibre package, facilitates fibre
handling and enables glass fibres to be pushed to
the bottom of the framework stamp. The fibre
framework is layered from the apical to the coronal zone, the first fibre being applied on the gingival surface of the pontic (Fig. 11).
The number of fibre layers depends on the
shape of the framework wax-up, fibre stratification is continued, to fill the available space in the
putty. The flask is then closed and placed inside a
specific device that provides complete light curing (within four minutes) of the fibre framework.
The polymerised FRC framework is then finished
and its adaptation to the working cast is checked
(Fig. 12).

Fig. 11d

A silane coupling agent is applied to the framework surface prior to composite resin veneering.
The first layer consists of opaque dentine (Enamel
Plus HFO Tender, Micerium), which reduces the
transparency of the glass fibre (Fig. 13). Various
dentine shades and brown stains are then applied
so that the restoration and the surrounding intact
teeth are aesthetically similar. Veneering is completed with enamel composites and characterisation (Enamel Plus HFO dentine stain and enamel,
Micerium). Finishing and polishing procedures,
using diamond burs, dedicated brushes, gums,
and diamond pastes, must be performed very
carefully (Fig. 14).

_FRCFPD adhesive luting

Adhesive procedures are used for cementing
the FRCFPD in place. The operating field must be
isolated with a rubber dam, to prevent contami-

Fig. 11_After fabrication of the

stamp, 4 layers of pre-impregnated
glass fibre are stratified into the
framework space. A flowable composite can be used to fill the air voids
and facilitate linkage between the
different layers of fibres.

Fig. 12_Adaptation of the framework

is checked in the working cast. This
particular shape, known as an
anatomical framework, is similar to
that of the wax-up, and ensures uniform stress distribution throughout
the prosthesis-teeth complex.
Fig. 13_During layering of the different shades of Enamel Plus HFO composite, the initial silicone mock-up can
be used to check the correct amounts
of dentine and enamel composites.

Fig. 12

Fig. 13

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Fig. 14_The IFPD is finished and

polished with the same burs and
brushes used for direct restorations.
Fig. 15_Prior to adhesive cementation,
the prepared surfaces of the abutment
teeth are cleaned with care.
Fig. 16_The use of a dual composite
enabled extended working time, and
facilitated the removal of excess cement.
Fig. 17_Post-op view: aesthetic integration between dental tissues and
the FRCIFPD.

Fig. 14

Fig. 15

Fig. 16

Fig. 17

nation by saliva or gingival fluids (Fig. 15). The

tooth surfaces must be cleaned, taking care not to
touch the preparation margins, after which the
surfaces are etched and sealed with the same adhesive system used before the impression was
taken. Air abrasion systems ensure better cleaning
of the cavity preparations than traditional procedures.14,27 The inner surfaces of the FRCFPD can
also be sandblasted, after which they must be
silanated.

Fig. 18_A 65-year-old female presented missing a mandibular right

first molar. For economical reasons,
a FRCIFPD was programmed.
Fig. 19_Two inlay cavities with the
same preparation axis were made in
the abutment teeth.

Fig. 18

A dual-cure composite cement (EnaCem,

Micerium) is used for luting. The cement is applied
to the inner cavity surface, and seating of the FRCFPD must be performed carefully, to allow progressive removal of excess cement. The luting
composite must be cured for 60 seconds on each
side of the abutment, to ensure complete polymerisation of the cement. After removing the rubber dam, the occlusion is checked with articulating
paper. Finishing and polishing may be necessary, if
occlusal retouching is required, or if excess cement
is present at the margins; these are performed with
the same materials and techniques used for direct

Fig. 19

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restorations (Fig. 16). One week after luting, the

patient is recalled for a check-up of the occlusion,
aesthetics, and excess cement (Fig. 17).

_Discussion
Currently, interest in using FRCs for many dental applications is growing11, and acceptable success rates in long-term FRC prosthetic solutions,
such as crowns and FPDs, have been reported.1013
The main causes of failure of FRC devices in high
stress-bearing applications are fracture5,12, delamination of veneering composite, and de-cementation of the prosthesis.28 In order to increase
the survival rate of the FRCs structure, clinical and
laboratory procedures need to be optimised to reduce the risk of mechanical failure. In vivo studies
and FE analyses have shown that FRCFPD connectors are the most critical areas with regard to
stress concentration.20,21 Repeated, strong masticatory forces can contribute to formation of micro-cracks, eventually leading to fracture of the
composite, especially in the connector areas. In
order to reduce this risk, the clinician should in-

industry report _ partial dentures

crease the space available to the technician, enabling him or her to apply the correct amount of
fibre and composite on the abutment teeth.5
Fracture of veneering composite at the connectors is thus correlated to box preparation design
(Figs. 18, 19). When space is inadequate, composite wear may result in early failure of the restoration or in fibre exposure, which may lead to plaque
accumulation and hydrolysis of the fibre.29 Another important strategy to reduce fracture at the
connector areas is to optimise the concentration
of fibres. The manufacturing processes and specific equipment described in this report, if applied
with care, enable fibre compaction to be maximised, decreasing voids in the framework, and
making the technique more predictable.30 In addition, use of the flask allows an anatomic framework design to be created, ensuring better stress
distribution within the tooth-restoration complex. This is very important, not only to reduce the
risk of composite fracture at the connectors, but
also to prevent delamination of the veneering material in the pontic element.

Fig. 20

Fig. 21

Separation between fibre and composite resin

may be due to tensile forces acting on the composite-fibre interface.23,31 If the shape of the
framework is optimised, this should reduce tensile
loads and increase the probability that the forces
applied over the structure act to compress the
composite-fibre interface. Xie et al.23 have shown
that the optimised framework shape should be the
same as that of the final restoration but reduced
in size, to distribute masticatory forces on the
composite-fibre interface, both when the load is
applied at the occlusal fossa and when it is applied
at the buccal cusp of the pontic (Fig. 20).
Another important cause of FRCFPD failure is
de-cementation. Adhesive luting requires special
clinical care, especially in isolating the operative
field (Figs. 2123). De-cementation appears also to
be correlated with excessive mesio-distal length of
the FPD, especially in posterior teeth. Thus, each
FRCFPD must be limited to singular edentulous areas of the mouth (Fig. 24).

Fig. 22

Fig. 23

Fig. 24

Fig. 20_Prior to luting, the inner part

of the inlay retainers must be sandblasted and silanated.
Fig. 21_In-enamel location of the
apical margins of the proximal boxes
provides better adhesion and a more
predictable, long-term adaptation.
Fig. 22_Prior to cementing, the
FRCIFPD was evaluated intra-orally.
Fig. 23_Total acid etching of the
cavity preparations.
Fig. 24_The FRCIFPD offers aesthetic
and less-invasive restoration.

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_author info

Dr Erminia Coccia is a lecturer at the Department of Prosthodontics,School of Dentistry

at the Politechnic University of Marche, Italy.

_Conclusion
Dr Daniele Rondoni has a private practice in Savona, Italy.
The clinical and laboratory procedures required
to fabricate FRCFPDs are described, paying particular attention to strategies that can reduce the risk
of failure. Prospective clinical trials will be required,
to investigate long-term survival of this prosthetic
solution._
Editorial Note: A complete list of references is
available from the publisher.

Prof. Giorgio Rappelli is Associate Professor at the Department of Prosthodontics,

School of Dentistry at the Politechnic University of Marche, Italy. He can be contacted at:
Politechnic University of Marche
Via Tronto 10
Tel.: +39 07122 06227
60020 Ancona
Fax: +39 07122 06221
Italy
E-mail: g.rappelli@univpm.it

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