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Clinical outcomes of lithium disilicate single crowns and partial fixed dental prostheses: A systematic review

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, MS c 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 speci c 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 de nitive 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

advised for the use of lithium disilicate until further clinical evidence shows favorable long-term results.

caution

is limited.

For

xed

dental prostheses,

is

a 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 re- gion of the oral cavity and are expected to ful ll esthetic and functional de- mands. 1-12 For this reason, numerous kinds of ceramic systems have been developed for clinical use. 13 Currently,

2 of the most popular ceramic restor- ative materials are lithium disilicate and zirconia, with lithium disilicate having higher translucency and lower me- chanical 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 re- ported to be higher in the posterior region. 20 Moreover, ceramic xed den- tal 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 den- tistry as IPS Empress 2 (Ivoclar Viva-

dent). 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 indi- cated higher survival rates for single crowns and signi cantly lower survival rates for 3-unit FDPs. 28 This material

was eventually discontinued by the manufacturer, and a reformulated and optimized composition of lithium dis- ilicate 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 computer- aided manufacturing (CAD/CAM) machining (IPS e.max CAD). 23 Unlike its predecessor Empress 2, which could

Pieger et al

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 resto- rations 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 speci c 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 inclu- sion criteria were any English-language article or bilingual article with English as one of the languages in a peer- reviewed 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; re- view or technique articles without an associated clinical trial and data; case reports, case series, or descriptive studies with fewer than 10 natural- tooth-supported lithium disilicate res- torations; 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 sin- gle crowns and FDPs.

23

The electronic search process was systematically conducted in 3 stages. In stage 1, the investigators independently screened all relevant titles of the elec- tronic search, and any disagreement was resolved by discussion. In situa- tions 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 dis- agreements were resolved by discussion. In situations of uncertainty, the ab- stract was included for the subsequent full-text stage. After the application of exclusion criteria, the de nitive 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 de nitive list of full- text articles from stage 3 and on addi- tional articles published beyond the terminal search date (June 2013 to November 2013). The de nitive 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 de nitive 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 func- tion 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 cu- mulative survival rate (CSR). Both ele- ments 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 observa- tion period (CSR). 29 The calculation of the interreviewer agreement at the title

items over the entire observa- tion period (CSR). 2 9 The calculation of the interreviewer agreement

24

Volume 112 Issue 1

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

RESULTS

The initial electronic search using

the speci c 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 articles 15,24-28,30-49 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 ran- domized controlled trials, 2,5 5 studies were prospective, 1,3,6,7,12 1 was retro- spective, 8 and 4 studies did not specify

the study design and were considered by the authors to be descriptive in na- ture. 4,9-11 All 12 studies reported on tooth-retained lithium disilicate resto- rations. With regard to the method of

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 sys- tems. 4 Three studies reported on the use of IPS Empress 2, 8,11,12 and 1 ran- domized controlled trial (RCT) com- pared 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-modi ed glass ionomer cement. Of the 12 studies, 5 studies reported support from the manufac-

turer of lithium disilicate (Ivoclar Viva- dent), 1,3,5,6 and 5 studies 4,7,8,11,12 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 In- stitutes of Health (NIH). 2 A total of 519 participants from all of the 12 studies received 841 lithium disilicate restorations. Of these,

Table I. Exclusion of 26 full-text articles based on predetermined exclusion criteria

Exclusion Criteria Applied

Article Excluded

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

Schenke et al 31 (2012) Vanoorbeek et al 34 (2010) Schulte et al 43 (2005) Sjögren et al 45 (2004) Posselt and Kerschbaum 48 (2003) Reiss and Walther 49 (2000)

Articles without associated trial and clinical data

Chu 15 (2012) Fradeani et al 32 (2012) Edelhoff and Brix 33 (2011)

Case report/series with fewer than 10 restorations

Roman-Rodriguez et al 35 (2010) Kurbad and Reichel 44 (2005)

Patients or data repeated in other included articles

Reich et al 36 (2010) Wolfart et al 38 (2009) Wolfart et al 42 (2005) Esquivel-Upshaw et al 46 (2004)

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

Sun et al 30 (2013) Guess et al 25 (2013) Sola-Ruiz et al 24 (2013) Silva et al 26 (2011) Harder et al 37 (2010) Etman et al 40 (2008) Mansour et al 39 (2008) Toksavul and Toman 27 (2007) Esquivel-Upshaw et al 41 (2006) Marquardt and Strub 28 (2006) Wolfart et al 47 (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 re- maining 3 studies could not be extrac- ted to classify the location of the restoration. 3,10,12 Altogether, the 9 studies that reported on location eval- uated 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 fol- lowed by chipping of the veneering porcelain 2,3,5,8,11 and debonding of the restoration from the tooth. 2-4,6 The most commonly reported biologic complications included the need for endodontic treatment 1,3,8 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 sys- tematic 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 signi cant 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

25

Table II. Qualitative data from de nitive 12 studies on lithium disilicate ceramic material

 

No. of

No. of

No. of

Material/

Type

No. of Restorations, Restorations, Restorations,

Type of

Layering

Author

of Study Patients

Total

Anterior

Posterior

Restoration Technique Setting

Reich and

Prospective

34

41

0

41

SC

E.max CAD LT/

University/

Schierz 1 (2013)

monolithic

Private

 

practice

Esquivel-Upshaw et al 2 (2013)

RCT

32

24

0

24

SC

E.max Press & Empress 2/ mono- and bilayer

University

Kern et al 3 (2012)

Prospective

28

36

NR

NR

FDP

E.max Press/

University

 

monolithic

Cortellini and

NR

76

235

136

99

SC

E.max Press &

Private

Canale 4 (2012)

E.max CAD/ monolithic

practice

Makarouna

RCT

37

18

8

10

FDP

not specied/

University

et al 5 (2011)

bilayer

Fasbinder et al 6 (2010)

Prospective

43

62

0

62

SC

E.max CAD LT/ monolithic

University

Etman and

Prospective

NR

30

0

30

SC

E.max Press/

University

Woolford 7 (2010)

bilayer

Valenti and

Retrospective

146

263

101

160

SC

Empress 2/

Private

Valenti 8 (2009)

bilayer

practice

Suputtamongkol

NR

30

29

0

29

SC

not specied/

University

et al 9 (2008)

bilayer

Esquivel-Upshaw

NR

21

30

NR

NR

FDP

E.max Press/

University

et al 10 (2008)

bilayer

Taskonak and

NR

15

40

12 (for SC only)

8 (for SC only)

SC/FDP

Empress 2/

University

Sertgöz 11 (2006)

bilayer

Sorensen

Prospective

57

41

NR

NR

FDP

Empress 2/

University

et al 12 (1999)

bilayer

FDP,

xed

dental prosthesis; NR,

not

reported;

were identi ed in the posterior region. Furthermore, the total number of fail- ures 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 identi ed 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

RCT, randomized controlled trial; SC, single crown.

of the restoration (maxillary versus mandibular and anterior versus poste- rior 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 re- view 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 material s 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. Disagree- ment 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 identi ed that compared lithium disilicate with the gold stan- dard of metal ceramic restorations. 2,5 Esquivel-Upshaw et al 2 compared the

disilicate with the gold stan- dard of metal ceramic restorations. 2 , 5 Esquivel-Upshaw et al

26

Volume 112 Issue 1

Table III.

Quantitative data of

de nitive

12

studies

on lithium

disilicate ceramic material

Author

Type of

No. of

No. of

Restoration Patients Restorations

No. of

No. of

Failures During Failures After

First Year

First Year

Range of

Follow-up (y)

Nature of

Failure

Reich and

SC

34

33

0

1

NR

Fracture of

Schierz 1 (2013)

the core

ceramic

Esquivel-Upshaw et al 2 (2013)

SC

32

24

0

0

1.1-3 years

N/A

Kern et al 3 (2012)

FDP

28

36

0

3

6.6-11.1 years

Fracture of

 

the core

ceramic

Cortellini and Canale 4 (2012)

SC

76

235

0

1

0.5-4 years

NR

Makarouna et al 5

FDP

37

18

6

NR

NR

Fracture of

(2011)

the core or veneering ceramic (or both)

Fasbinder et al 6

SC

43

62

0

0

NR

NR

(2010)

Etman and Woolford 7 (2010)

SC

NR

30

0

1

NR

NR

Valenti and Valenti 8 (2009)

SC

146

263

0

6

NR

Fracture of the core or veneering ceramic (or both)

Suputtamongkol et al 9 (2008)

SC

30

29

0

0

NR

NR

Esquivel-Upshaw et al 10 (2008)

FDP

21

30

0

4

NR

NR

Taskonak and

SC/FDP

15

40

3

5

NR

Fracture of

Sertgöz 11 (2006)

the core

ceramic

Sorensen et al 12

FDP

57

41

4

NR

0.5-1.5 years

NR

(1999)

FDP,

xed

dental prosthesis; NR,

not

reported;

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 signi cant differences in surface texture and crown wear found at the third year. The second RCT, conducted by Makarouna et al, 5 compared the clin- ical outcome of metal ceramic FDPs with lithium disilicate FDPs. Based on a 6-year survival rate of 62.7% for ceramic

SC, single crown; N/A, not applicable.

FDPs, the authors concluded that cli- nicians should be cautious as to the use of lithium disilicate for FDPs. Recently published results by Sola-Ruiz et al 24 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 con rm these previous results. One of the most signi cant chal- lenges of data extraction in this systematic review was the lack of in- formation 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 crowns 8 and another assessing FDPs. 3 All other clinical tri- als 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 associ- ated clinical trial and data, and case

Pieger et al

July 2014

Table IV.

Life table analysis for all lithium disilicate restorations

(single

showing cumulative survival

rate

among

de nitive

12

included

studies

crowns

and

xed

dental prostheses

combined)

27

 

No. of

No. of

No. of

No. of

Interval

Cumulative

Time

Studies Reporting

Restorations

Failures in

Restorations

Survival

Survival

Interval (y)

Interval

in Interval

Interval

At Risk

Rate (%)

Rate (%)

0-1

12

841

13

841

98.45

98.45

1-2

10

581

6

451

98.66

97.14

2-3

8

448

4

381.5

98.95

96.12

3-4

7

399

2

374.5

99.46

95.61

4-5

3

314

3

271.5

98.89

94.55

5-6

3

293

2

282.5

99.29

93.88

6-7

2

293

3

293

98.97

92.92

7-8

2

292

0

291.5

100

92.92

8-9

2

289

0

287.5

100

92.92

9-10

2

289

1

289

99.65

92.60

10-11

2

288

0

287.5

100

92.60

300 250 200 150 100 50 0 0-1 Y 1-2 Y 2-3 Y 3-4 Y
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 Sertgöz (2006)
Cortellini and Canale (2012)
Valenti and Valenti (2009)
Sorensen et al (1999)
Bar graph showing
number
of lithium
disilicate restorations (both single
crowns and
fixed

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 pre- vious studies and articles that did not allow data extraction were

Pieger et al

independently reanalyzed by the in- vestigators before making a de nitive decision on their exclusion. Silva et al 26 observed no fractures among 440 pressed lithium disilicate restorations, including inlays, onlays, crowns, and FDPs, but did not report the distribu- tion of the type of restoration and the number of followed-up restorations over the observation period. Harder et al 37 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 al 39 evaluated the clinical perfor- mance 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 Toman 27 rated the clinical outcome of 79 IPS Empress 2 crowns and observed 1 fractured crown but did

Toksavul and Toman 2 7 rated the clinical outcome of 79 IPS Empress 2 crowns and

28

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

No. of

No. of

No. of

Interval

Cumulative

Time

Studies Reporting

Restorations in

Failures in

Restorations

Survival

Survival

Interval (y)

the Interval

Interval

Interval

At Risk

Rate (%)

Rate (%)

0-1

8

696

0

696

100

100

1-2

7

505

0

409.5

100

100

2-3

5

386

2

326.5

99.38

99.38

3-4

4

341

2

318.5

99.37

98.76

4-5

1

261

2

221

99.09

97.86

5-6

1

260

2

259.5

99.22

97.11

6-7

1

260

1

260

99.61

96.74

7-8

1

259

0

258.5

100

96.74

8-9

1

259

0

259

100

96.74

9-10

1

259

0

259

100

96.74

10-11

1

259

0

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 rst- year ISR of 98.45% for all lithium dis- ilicate 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 Mar- quardt 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 frame- work of 3 FDPs did. The examination of the fractured fragments under a scanning electron microscope disclosed under- extended 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 con- rmed by the data of the present sys- tematic review, where 68% of all FDP fractures were identied in the posterior region. Similarly, most fractures reported for single crowns occurred in the poste- rior region. No studies in this systematic re- view 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

 

No. of

No. of

No. of

No. of

Interval

Cumulative

Time

Studies Reporting

Restorations in

Failures in

Restorations

Survival

Survival

Interval (y)

the Interval

Interval

Interval

At Risk

Rate (%)

Rate (%)

0-1

5

145

13

145

91.03

91.03

1-2

4

96

6

71.5

91.60

83.39

2-3

3

62

2

45

95.55

79.68

3-4

3

58

0

56

100

79.68

4-5

2

53

1

50.5

98.01

78.11

5-6

2

33

0

23

100

78.11

6-7

1

33

2

33

93.93

73.37

7-8

1

33

0

33

100

73.37

8-9

1

30

0

28.5

100

73.37

9-10

1

30

1

30

96.66

70.93

10-11

1

29

0

28.5

100

70.93

July 2014

29

performance of lithium disilicate with

survival rates estimated in this system-

REFERENCES

14.

other ceramic systems. However, single

atic review are based on only the re-

 

clinical parameters such as the wear or

ported data. The true survival rate

15.

surface texture of different restorative materials such as metal ceramic, zirco-

for both single crowns and FDPs is unknown because of insuf cient data,

16.

nia, or lithium disilicate have been compared. Esquivel-Upshaw et al 41 conducted an in vivo study and

the loss of patients to follow-up, and the inconsistent manner of reporting.

 

showed signi cantly higher occlusal

1.

2.

3.

4.

5.

6.

7.

   

wear rates for lithium disilicate core

17.

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

18.

 

wear rate to enamel, followed by lithium disilicate crowns and metal ceramic crowns. Metal ceramic crowns

19.

 

a

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

20.

ceramic crowns. 2 This roughness may lead to higher plaque accumulation, greater wear of the opposing dentition,

21.

and periodontal disease. 50,51 Future

 

22.

clinical studies should address these

 

issues to better understand the long-

23.

term clinical potential and prognostic nature of this promising material.

 
   

24.

CONCLUSIONS

8.

 

Within the limitations of this sys-

9.

10.

11.

12.

13.

 

tematic review, the following conclu-

 

sions were drawn. For lithium disilicate single crowns, the short-term evidence

25.

(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 evi- dence for medium-term survival (5 to 10 years) is limited, with data from 1

26.

study contributing to a 10-year CSR of

 

in

96.7%. Most single crowns failed in the

27.

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

28.

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

29.

Pieger et al

life table method. In: Principles of biostatis- tics. 2nd ed.Duxbury: Paci fi c Grove; 2000. p.

30

Volume 112 Issue 1

Corresponding author:

Dr Avinash S. Bidra University of Connecticut Health Center 263 Farmington Ave, L6078

Farmington, CT 06030 E-mail: avinashbidra@yahoo.com

Copyright ª 2014 by the Editorial Council for The Journal of Prosthetic Dentistry.

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