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Clinical outcomes of lithium disilicate

single crowns and partial fixed dental


prostheses: A systematic review
Sascha Pieger, DMD, Dr med dent,a Arif Salman, BDS, MDS,b and
Avinash S. Bidra, BDS, MSc
University Medical Center Hamburg-Eppendorf, Center for Dental and
Oral Medicine, Hamburg, Germany; Bharath University Sree Balaji
Dental College, Chennai, India; University of Connecticut Health
Center, Department of Reconstructive Sciences, Farmington, Conn
Statement of problem. Lithium disilicate is a relatively new and popular restorative material for esthetic and functional
rehabilitations, but the evidence for clinical outcomes is not clear.
Purpose. The purpose of this systematic review was to analyze the short-term (1- to 5-year) and medium-term (5- to 10-year)
survival rates of lithium disilicate single crowns and partial xed dental prostheses.
Material and methods. An electronic search for articles in the English-language literature published between January 1998
and June 2013 was performed with the PubMed search engine. The specic search terms used were lithium disilicate, lithium
silicate, IPS e max, IPS Empress, CAD CAM, pressed ceramic, monolithic, and bilayer. After applying predetermined inclusion
and exclusion criteria, the denitive list of selected articles was suitable only for calculating the interval survival rate and
cumulative survival rate.
Results. The electronic search resulted in 2033 titles. The systematic application of inclusion and exclusion criteria resulted
in 12 clinical studies that addressed the clinical outcomes of lithium disilicate restorations. Of these, 2 were randomized
controlled trials, 5 were prospective studies, 1 was a retrospective study, and 4 studies were descriptive in nature. All 12
studies reported on tooth-retained lithium disilicate restorations. The 2-year cumulative survival rate for single crowns was
100%, and the 5-year cumulative survival rate was 97.8%. The 2-year cumulative survival rate for xed dental prostheses was
83.3%, and the 5-year cumulative survival rate was 78.1%. The cumulative survival rate over a 10-year period, primarily owing
to data from 1 study, was 96.7% for single crowns and 70.9% for xed dental prostheses.
Conclusions. For lithium disilicate single crowns, the existing evidence indicates excellent short-term survival rates, but the
evidence for medium-term survival is limited. For lithium disilicate xed dental prostheses, the evidence for short-term survival
is fair, although limited, but the evidence for medium-term survival is not promising. The majority of failures in both types
of restorations were reported in the posterior region. (J Prosthet Dent 2014;112:22-30)

Clinical Implications

When choosing lithium disilicate as the restorative material for single


crowns, clinicians should be aware that the short-term survival for this
type of restoration is excellent, but presently, clinical evidence for
medium-term survival is limited. For xed dental prostheses, caution is
advised for the use of lithium disilicate until further clinical evidence
shows favorable long-term results.

Assistant Professor, Department of Dental Prosthetics, University Medical Center Hamburg-Eppendorf, Center for Dental and Oral
Medicine; Former ITI Scholar, University of Connecticut Health Center.
b
Assistant Professor, Department of Periodontology, Bharath University Sree Balaji Dental College; Former ITI Scholar, University of
Connecticut Health Center.
c
Assistant Professor and Assistant Program Director, Post-Graduate Prosthodontics, Department of Reconstructive Sciences, University of
Connecticut Health Center.

The Journal of Prosthetic Dentistry

Pieger et al

July 2014
Ceramic restorations are widely
used in the anterior and posterior region of the oral cavity and are expected
to fulll esthetic and functional demands.1-12 For this reason, numerous
kinds of ceramic systems have been
developed for clinical use.13 Currently,
2 of the most popular ceramic restorative materials are lithium disilicate and
zirconia, with lithium disilicate having
higher translucency and lower mechanical strength than zirconia.14-17
Both materials can be used for either
a monolithic restoration or as a core
material with veneered porcelain.14-17
Common complications that have been
reported for both materials include
cracking, chipping, and the fracture of
the veneering porcelain material.18,19
These complications have been reported to be higher in the posterior
region.20 Moreover, ceramic xed dental prostheses (FDPs) exhibit higher
rates of fracture of the core framework
than single crown restorations.21
The evolution of lithium disilicate
as a restorative material dates back to
1998, when it was introduced to dentistry as IPS Empress 2 (Ivoclar Vivadent).22 It was the second generation
of heat-pressed ceramic and contained
lithium disilicate material as the main
crystalline phase.23 The manufacturers
indications for this material ranged
from veneers, inlays, onlays, and crowns
to 3-unit FDPs in the anterior region.24-27
The clinical data for Empress 2 indicated higher survival rates for single
crowns and signicantly lower survival
rates for 3-unit FDPs.28 This material
was eventually discontinued by the
manufacturer, and a reformulated and
optimized composition of lithium disilicate ceramic was introduced under
the trade name IPS e.max (Ivoclar
Vivadent). This is a patented material
exclusively manufactured by Ivoclar
Vivadent and is available in a pressable
version (IPS e.max Press) or as a
partially crystallized ceramic block for
computer-aided design and computeraided manufacturing (CAD/CAM)
machining (IPS e.max CAD).23 Unlike
its predecessor Empress 2, which could

Pieger et al

23
only be used as framework material, the
pressable and machinable version of
IPS e.max can be used in a monolithic
form. The availability of this relatively
translucent high-strength monolithic
ceramic material combined with the
emerging demand for metal-free restorations is probably why the use of lithium
disilicate restorations is so widespread.14
Given its popularity, there is a need to
review and synthesize existing clinical
data on the survival of lithium disilicate
restorations.
The purpose of this systematic review
was to analyze the short-term (1- to
5-year) and medium-term (5- to 10-year)
survival rates of natural tooth-borne
lithium disilicate single crowns and FDPs.

MATERIAL AND METHODS


An independent electronic search
of the English-language literature was
performed with the PubMed search
engine and Cochrane Library database
by multiple investigators. The specic
terms that were used for the electronic
search were lithium disilicate, lithium
silicate, IPS e max, IPS Empress, CAD
CAM, pressed ceramic, monolithic, and
bilayer. The period searched was from
January 1998 to June 2013. The limits
applied to the search were humans,
English, and dental journals. The inclusion criteria were any English-language
article or bilingual article with English
as one of the languages in a peerreviewed journal and any clinical study
on humans involving any of the search
terms listed previously. The exclusion
criteria were as follows: articles that
did not pertain to the search terms
described in the inclusion criteria; review or technique articles without
an associated clinical trial and data;
case reports, case series, or descriptive
studies with fewer than 10 naturaltooth-supported lithium disilicate restorations; patients or data duplicated
in other included articles; and articles
that did not provide the required data
or did not allow extraction of the
required data on lithium disilicate single crowns and FDPs.

The electronic search process was


systematically conducted in 3 stages. In
stage 1, the investigators independently
screened all relevant titles of the electronic search, and any disagreement
was resolved by discussion. In situations where the application of exclusion
criteria was not clear, the controversial
article was included for consideration
in the abstract stage. In stage 2, the
investigators independently analyzed
abstracts of all selected titles, and disagreements were resolved by discussion.
In situations of uncertainty, the abstract was included for the subsequent
full-text stage. After the application of
exclusion criteria, the denitive list of
articles was screened at stage 3 by
the investigators to extract qualitative
and quantitative data. A supplemental
search was conducted based on the
references from the denitive list of fulltext articles from stage 3 and on additional articles published beyond the
terminal search date (June 2013 to
November 2013). The denitive list of
articles was analyzed for short-term and
medium-term survival rates of lithium
disilicate single crowns and FDPs by
using an actuarial method for life table
analysis. Additionally, qualitative data
were analyzed across all the denitive
studies that were included.
In this systematic review, the authors
dened failure as the fracture of any
part of a restoration that required the
removal or remake of the restoration.
Short-term survival was dened as the
presence of the restoration in function
1 to 5 years after cementation, and
medium-term survival was dened as
the presence of the restoration in function 5 to 10 years after cementation. By
using the actuarial method for life table
analysis, the extracted quantitative data
at stage 3 were used to calculate the
interval survival rate (ISR) and the cumulative survival rate (CSR). Both elements were used to compute the ratio of
surviving restorations in a group during
a specic interval (ISR) or the ratio of
surviving items over the entire observation period (CSR).29 The calculation of
the interreviewer agreement at the title

24

Volume 112 Issue 1


and abstract stage was performed by
using the Cohen kappa method.

RESULTS
The initial electronic search using
the specic search terms yielded 2033
titles at stage 1. Of these, 136 articles
were carried forward to the abstract
stage, and, subsequently, 38 articles
were carried forward to the full-text
analysis stage. After further scrutiny,
26 articles15,24-28,30-49 were excluded
(Table I). Finally, qualitative and
quantitative data were extracted from
12 full-text articles (Tables II, III). Of
these articles, 2 were designed as randomized controlled trials,2,5 5 studies
were prospective,1,3,6,7,12 1 was retrospective,8 and 4 studies did not specify
the study design and were considered
by the authors to be descriptive in nature.4,9-11 All 12 studies reported on
tooth-retained lithium disilicate restorations. With regard to the method of

Table I.

fabrication, 3 studies used IPS e.max


Press,3,7,10 2 studies used IPS e.max
CAD,1,6 and 1 study used both systems.4 Three studies reported on the
use of IPS Empress 2,8,11,12 and 1 randomized controlled trial (RCT) compared IPS e.max Press with Empress 2.2
Two studies did not specify the manner
in which the lithium disilicate material
was used.5,9 All 12 studies cemented
the restorations with self-adhesive resin
cement or resin-modied glass ionomer
cement. Of the 12 studies, 5 studies
reported support from the manufacturer of lithium disilicate (Ivoclar Vivadent),1,3,5,6 and 5 studies4,7,8,11,12 did
not report any study support. One
study was funded by the Thailand
Research Fund Grant,9 and one study
acknowledged the support of the
manufacturer and the National Institutes of Health (NIH).2
A total of 519 participants from
all of the 12 studies received 841
lithium disilicate restorations. Of these,

Exclusion of 26 full-text articles based on predetermined exclusion

criteria

Exclusion Criteria Applied


Articles that did not pertain to search
terms described in inclusion criteria

Articles without associated trial and clinical data

Case report/series with fewer than 10 restorations

Article Excluded
Schenke et al31 (2012)
Vanoorbeek et al34 (2010)
Schulte et al43 (2005)
Sjgren et al45 (2004)
Posselt and Kerschbaum48 (2003)
Reiss and Walther49 (2000)
Chu15 (2012)
Fradeani et al32 (2012)
Edelhoff and Brix33 (2011)
Roman-Rodriguez et al35 (2010)
Kurbad and Reichel44 (2005)

Patients or data repeated in other included articles

Reich et al36 (2010)


Wolfart et al38 (2009)
Wolfart et al42 (2005)
Esquivel-Upshaw et al46 (2004)

Articles that did not provide required


data or did not allow extraction of required
data on lithium disilicate restorations

Sun et al30 (2013)


Guess et al25 (2013)
Sola-Ruiz et al24 (2013)
Silva et al26 (2011)
Harder et al37 (2010)
Etman et al40 (2008)
Mansour et al39 (2008)
Toksavul and Toman27 (2007)
Esquivel-Upshaw et al41 (2006)
Marquardt and Strub28 (2006)
Wolfart et al47 (2003)

The Journal of Prosthetic Dentistry

696 were single crowns, and 145 were


FDPs. The sample size ranged from 15
participants to 146 participants per
study. Seven studies reported on the
use of lithium disilicate for single
crowns,1,2,4,6-9 and 4 studies reported
on FDPs.3,5,10,12 One study investigated
the clinical performance of both single
crowns and FDPs.11 The data from 9
of the 12 studies could be extracted
to classify anterior (canine to canine)
or posterior (premolars and molars)
restorations.1,2,4-9,11 Data from the remaining 3 studies could not be extracted to classify the location of the
restoration.3,10,12 Altogether, the 9
studies that reported on location evaluated 257 anterior restorations and
463 posterior restorations.
The most common technical
complication reported was fracture of
the core framework,1,3-5,7,8,10-12 followed by chipping of the veneering
porcelain2,3,5,8,11 and debonding of
the restoration from the tooth.2-4,6
The most commonly reported biologic
complications included the need for
endodontic treatment1,3,8 and the
presence of secondary caries.1,4,10 A
wide range of follow-up (0.5-11 years)
was reported across the various studies.
Two studies had a follow-up period of
less than 1 year.4,12 One study had a
follow-up period greater than 5 years,5
and 2 studies had a follow-up period
greater than 10 years.3,8 A life table
survival analysis was presented in 5
studies.1,3,5,8,11 From the remaining
7 studies,2,4,6,7,9,10,12 data had to be
extracted by the authors of this systematic review to be included in a
pooled life table survival analysis
(Table IV, Fig. 1).
The pooled data from all included
studies showed a total of 34 failures
out of 841 restorations (4%), with 38%
of all failures (13 of 34) occurring
during the rst year. The analysis of
failure by restoration type indicated a
signicant difference between single
crowns and FDPs (Tables V, VI). Single
crowns did not experience any failure
up to the third year and experienced
a total of 9 failures in this analysis.
Of these 9 failures, 7 failures (77.7%)

Pieger et al

July 2014

Table II.

25
Qualitative data from denitive 12 studies on lithium disilicate ceramic material

Author

Material/
No. of
No. of
No. of
Layering
Type
No. of Restorations, Restorations, Restorations, Type of
Posterior Restoration Technique
Anterior
Total
of Study Patients

Setting

Reich and
Schierz1 (2013)

Prospective

34

41

41

SC

E.max CAD LT/


monolithic

University/
Private
practice

Esquivel-Upshaw
et al2 (2013)

RCT

32

24

24

SC

E.max Press &


Empress 2/
mono- and
bilayer

University

Prospective

28

36

NR

NR

FDP

E.max Press/
monolithic

University

Cortellini and
Canale4 (2012)

NR

76

235

136

99

SC

E.max Press &


E.max CAD/
monolithic

Private
practice

Makarouna
et al5 (2011)

RCT

37

18

10

FDP

not specied/
bilayer

University

Fasbinder
et al6 (2010)

Prospective

43

62

62

SC

E.max CAD LT/


monolithic

University

Etman and
Woolford7 (2010)

Prospective

NR

30

30

SC

E.max Press/
bilayer

University

Valenti and
Valenti8 (2009)

Retrospective

146

263

101

160

SC

Empress 2/
bilayer

Private
practice

Suputtamongkol
et al9 (2008)

NR

30

29

29

SC

not specied/
bilayer

University

Esquivel-Upshaw
et al10 (2008)

NR

21

30

NR

NR

FDP

E.max Press/
bilayer

University

Taskonak and
Sertgz11 (2006)

NR

15

40

12 (for SC only)

8 (for SC only)

SC/FDP

Empress 2/
bilayer

University

Prospective

57

41

NR

NR

FDP

Empress 2/
bilayer

University

Kern et al3 (2012)

Sorensen
et al12 (1999)

FDP, xed dental prosthesis; NR, not reported; RCT, randomized controlled trial; SC, single crown.

were identied in the posterior region.


Furthermore, the total number of failures for single crowns consisted of 5
core fractures and 4 fractures of the
veneering ceramic. In contrast, FDPs
experienced 13 failures during the
rst year and a total of 25 failures in
this analysis. Of 25 failures, 17 (68%)
were identied in the posterior region.
The cumulative survival rates (CSRs)
computed for a 5-year interval were
97.8% for single crowns and 78.1% for
FDPs. The CSR over a 10-year interval,
owing mainly to the report from 2
studies,3,8 was 92.6% for all types of
restorations, 96.7% for single crowns,
and 70.9% for FDPs. Because of the
heterogeneity and paucity of the
analyzed data, it was not possible to
compare qualitative and quantitative
data or draw conclusions for clinical
outcomes in relation to the region

Pieger et al

of the restoration (maxillary versus


mandibular and anterior versus posterior regions) or regarding the material
(IPS e.max Press versus IPS e.max
CAD versus IPS Empress 2) or for other
secondary outcomes such as esthetics
or marginal t.

DISCUSSION
The purpose of this systematic review was to analyze the short-term and
medium-term results of studies dealing
with the clinical outcomes of lithium
disilicate single crowns and FDPs.
Lithium disilicate was rst introduced
in dentistry in 1998 but has become
popular only in the past decade.
Anticipating that long-term survival
data would be unavailable, the authors
designed this review to assess only the
short-term and medium-term survival

rates of lithium disilicate single crowns


and FDPs in an effort to understand the
materials long-term clinical potential.
The predetermined inclusion criteria
for this systematic review were broad to
permit inclusion of as many articles
as possible. In this systematic review,
the articles were scrutinized by multiple
investigators to minimize error during
the review process and the selection
bias of the articles included. Disagreement was resolved by discussion, and
doubtful articles were carried forward
to the subsequent stage. Articles that
did not meet the various predetermined
criteria for inclusion were analyzed in
depth before being nally excluded.
In this systematic review, only 2
RCTs were identied that compared
lithium disilicate with the gold standard of metal ceramic restorations.2,5
Esquivel-Upshaw et al2 compared the

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Volume 112 Issue 1

Table III.

Quantitative data of denitive 12 studies on lithium disilicate ceramic material

Author

No. of
No. of
Nature of
Failures During Failures After Range of
Type of
No. of
No. of
First Year Follow-up (y)
Failure
First Year
Restoration Patients Restorations

Reich and
Schierz1 (2013)

SC

34

33

NR

Fracture of
the core
ceramic

Esquivel-Upshaw
et al2 (2013)

SC

32

24

1.1-3 years

N/A

Kern et al3 (2012)

FDP

28

36

6.6-11.1 years

Fracture of
the core
ceramic

Cortellini and
Canale4 (2012)

SC

76

235

0.5-4 years

NR

Makarouna et al5
(2011)

FDP

37

18

NR

NR

Fracture of
the core or
veneering
ceramic
(or both)

Fasbinder et al6
(2010)

SC

43

62

NR

NR

Etman and
Woolford7 (2010)

SC

NR

30

NR

NR

Valenti and
Valenti8 (2009)

SC

146

263

NR

Fracture of
the core or
veneering
ceramic
(or both)

Suputtamongkol
et al9 (2008)

SC

30

29

NR

NR

Esquivel-Upshaw
et al10 (2008)

FDP

21

30

NR

NR

Taskonak and
Sertgz11 (2006)

SC/FDP

15

40

NR

Fracture of
the core
ceramic

Sorensen et al12
(1999)

FDP

57

41

NR

0.5-1.5 years

NR

FDP, xed dental prosthesis; NR, not reported; SC, single crown; N/A, not applicable.

performance of metal ceramic crowns


with single-layered IPS e.max Press
and bilayered IPS Empress 2 crowns
and found a 100% survival rate for
all crowns after 3 years. Nevertheless,
lithium disilicate crowns showed more
crown wear and surface roughness than
metal ceramic crowns, with statistically
signicant differences in surface texture
and crown wear found at the third
year. The second RCT, conducted by
Makarouna et al,5 compared the clinical outcome of metal ceramic FDPs
with lithium disilicate FDPs. Based on a
6-year survival rate of 62.7% for ceramic

FDPs, the authors concluded that clinicians should be cautious as to the use
of lithium disilicate for FDPs. Recently
published results by Sola-Ruiz et al24
indicate that the long-term survival of
lithium disilicate FDPs is discouraging,
with a 10-year survival of IPS Empress
2 FDPs at 71.4%. The results from the
present systematic review conrm these
previous results.
One of the most signicant challenges of data extraction in this
systematic review was the lack of information about the time the failure
occurred and the number of

The Journal of Prosthetic Dentistry

restorations over the followed-up


period. Two studies reported a
follow-up period of 10 years, one
assessing single crowns8 and another
assessing FDPs.3 All other clinical trials were conducted with a wide range
of follow-up periods (0.5 to 11 years),
with the most common follow-up
period being in the 1- to 2-year
range. The application of the rst 3
predetermined exclusion criteria in this
systematic review was straightforward.
Articles that did not pertain to the
search terms, articles without associated clinical trial and data, and case

Pieger et al

July 2014

27

Table IV.

Life table analysis for all lithium disilicate restorations (single crowns and xed dental prostheses combined)
showing cumulative survival rate among denitive 12 included studies

Interval
Survival
Rate (%)

Cumulative
Survival
Rate (%)

841

98.45

98.45

451

98.66

97.14

381.5

98.95

96.12

399

374.5

99.46

95.61

314

271.5

98.89

94.55

5-6

293

282.5

99.29

93.88

6-7

293

293

98.97

92.92

7-8

292

291.5

100

92.92

8-9

289

287.5

9-10

289

289

10-11

288

287.5

No. of
Studies Reporting
Interval

No. of
Restorations
in Interval

No. of
Failures in
Interval

0-1

12

841

13

1-2

10

581

2-3

448

3-4

4-5

Time
Interval (y)

No. of
Restorations
At Risk

100

92.92

99.65

92.60

100

92.60

300
250
200
150
100
50
0

0-1 Y

1-2 Y

2-3 Y

3-4 Y

4-5 Y

5-6 Y

6-7 Y

7-8 Y

8-9 Y

9-10 Y 10-11 Y

Reich and Schierz (2013)

Makarouna et al (2011)

Suputtamongkol et al (2008)

Esquivel-Upshaw et al (2013)

Fasbinder et al (2010)

Esquivel-Upshaw et al (2008)

Kern et al (2012)

Etman and Woolford (2010)

Taskonak and Sertgz (2006)

Cortellini and Canale (2012)

Valenti and Valenti (2009)

Sorensen et al (1999)

1 Bar graph showing number of lithium disilicate restorations (both single crowns and xed
dental prostheses) in each included study at different time intervals (in years [Y]). Note attrition
of number of restorations reported during each follow-up period. Also note that only 2 out of
12 studies reported follow-up data beyond fth year interval.

reports and case series with fewer than


10 restorations were excluded without
any issues. The authors decided on 10
restorations as the minimum sample
size in a study to ensure a credible
sample size and maximize the amount
of extracted data.
The articles that needed to be
excluded because of redundant data
published by similar authors from previous studies and articles that did not
allow
data
extraction
were

Pieger et al

independently reanalyzed by the investigators before making a denitive


decision on their exclusion. Silva et al26
observed no fractures among 440
pressed lithium disilicate restorations,
including inlays, onlays, crowns, and
FDPs, but did not report the distribution of the type of restoration and the
number of followed-up restorations
over the observation period. Harder
et al37 investigated the 8-year outcome
of inlay-retained lithium disilicate FDPs

and stated that 40% of the FDPs were


lost owing to fracture of the inlay
retainer but did not report on the time
when the fracture occurred. Mansour
et al39 evaluated the clinical performance of 82 IPS Empress 2 crowns and
reported on 3 fractures, but the
extraction of data related to the time of
the failure was not feasible. Toksavul
and Toman27 rated the clinical
outcome of 79 IPS Empress 2 crowns
and observed 1 fractured crown but did

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Volume 112 Issue 1

Table V.

Life table analysis for lithium disilicate single crowns showing cumulative survival rate among 8 studies that
reported data on single crowns

No. of
Restorations
At Risk

No. of
Studies Reporting
the Interval

No. of
Restorations in
Interval

No. of
Failures in
Interval

0-1

696

696

1-2

505

2-3

386

3-4

341

4-5

5-6
6-7

Time
Interval (y)

Interval
Survival
Rate (%)

Cumulative
Survival
Rate (%)

100

100

409.5

100

100

326.5

99.38

99.38

318.5

99.37

98.76

261

221

99.09

97.86

260

259.5

99.22

97.11

260

260

99.61

96.74

7-8

259

258.5

100

96.74

8-9

259

259

100

96.74

9-10

259

259

100

96.74

10-11

259

259

100

96.74

not report when the failure occurred;


this article was also excluded.
The calculation of the true survival
rate of lithium disilicate restorations
was not feasible because of the various
factors listed previously. The existing
data only permitted the calculation of
the ISR and CSR. As not all patients
in the included studies were followed
up for a minimum of 1 year, the rstyear ISR of 98.45% for all lithium disilicate restorations does not represent a
true 1-year survival rate. However, the

100% 2-year CSR for single crowns is


remarkable.
In a prospective clinical trial by Marquardt and Strub,28 27 single crowns and
31 FDPs made of IPS Empress 2 were
followed up for up to 5 years. None of the
single crowns fractured, but the framework of 3 FDPs did. The examination of
the fractured fragments under a scanning
electron microscope disclosed underextended dimensions of the connector
area as the main reason for fractures. This
nding has been validated by other

clinical studies.38,46 The authors also


stated that catastrophic failures such
as fracture of the framework occurred
predominantly in FDPs replacing missing
posterior teeth.3 This nding was conrmed by the data of the present systematic review, where 68% of all FDP
fractures were identied in the posterior
region. Similarly, most fractures reported
for single crowns occurred in the posterior region.
No studies in this systematic review compared the overall clinical

Table VI. Life table analysis for lithium disilicate xed dental prostheses showing cumulative survival rate among 5 studies
that reported data on xed dental prostheses
Interval
Survival
Rate (%)

Cumulative
Survival
Rate (%)

91.03

91.03

71.5

91.60

83.39

45

95.55

79.68

58

56

53

50.5

33

6-7

33

7-8

8-9

9-10
10-11

No. of
Studies Reporting
the Interval

No. of
Restorations in
Interval

No. of
Failures in
Interval

0-1

145

13

1-2

96

2-3

62

3-4

4-5

5-6

Time
Interval (y)

No. of
Restorations
At Risk
145

100

79.68

98.01

78.11

23

100

78.11

33

93.93

73.37

33

33

100

73.37

30

28.5

100

73.37

30

30

96.66

70.93

29

28.5

100

70.93

The Journal of Prosthetic Dentistry

Pieger et al

July 2014
performance of lithium disilicate with
other ceramic systems. However, single
clinical parameters such as the wear or
surface texture of different restorative
materials such as metal ceramic, zirconia, or lithium disilicate have been
compared. Esquivel-Upshaw et al41
conducted an in vivo study and
showed signicantly higher occlusal
wear rates for lithium disilicate core
ceramic opposing enamel than for the
wear rate of enamel to enamel. In a
direct comparison of the wear rate of
crowns made with 3 different ceramic
systems, Procera AllCeram crowns
(Nobel Biocare) showed the highest
wear rate to enamel, followed by
lithium disilicate crowns and metal
ceramic crowns. Metal ceramic crowns
exhibited the lowest wear to enamel
over the 2-year observation period.40 A
recent RCT has also reported more
wear and surface roughness of veneered
lithium disilicate crowns than of metal
ceramic crowns.2 This roughness may
lead to higher plaque accumulation,
greater wear of the opposing dentition,
and periodontal disease.50,51 Future
clinical studies should address these
issues to better understand the longterm clinical potential and prognostic
nature of this promising material.

CONCLUSIONS
Within the limitations of this systematic review, the following conclusions were drawn. For lithium disilicate
single crowns, the short-term evidence
(1 to 5 years) indicates an excellent
survival rate with a 2-year CSR of 100%
and a 5-year CSR of 97.8%. The evidence for medium-term survival (5 to
10 years) is limited, with data from 1
study contributing to a 10-year CSR of
96.7%. Most single crowns failed in the
posterior region. For lithium disilicate
FDPs, the short-term evidence (1 to 5
years) indicated a 5-year CSR of 78.1%,
which is not promising. The evidence
for medium-term survival (5 to 10
years) is limited, with data from 1 study
contributing to a discouraging 10-year
CSR of 70.9%. Most FDPs also failed
in the posterior region. The cumulative

Pieger et al

29
survival rates estimated in this systematic review are based on only the reported data. The true survival rate
for both single crowns and FDPs is
unknown because of insufcient data,
the loss of patients to follow-up, and
the inconsistent manner of reporting.

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Corresponding author:
Dr Avinash S. Bidra
University of Connecticut Health Center
263 Farmington Ave, L6078
Farmington, CT 06030
E-mail: avinashbidra@yahoo.com
Copyright 2014 by the Editorial Council for
The Journal of Prosthetic Dentistry.

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