Current ceramic materials and systems with clinical recommendations: A systematic review

Heather J. Conrad, DMD, MS,a Wook-Jin Seong, DDS, MS, PhD,b and Igor J. Pesun, DMD, MSc School of Dentistry, University of Minnesota, Minneapolis, Minn; University of Manitoba, Winnipeg, Canada
Statement of problem. Developments in ceramic core materials such as lithium disilicate, aluminum oxide, and zirconium oxide have allowed more widespread application of all-ceramic restorations over the past 10 years. With a plethora of ceramic materials and systems currently available for use, an overview of the scientific literature on the efficacy of this treatment therapy is indicated. Purpose. This article reviews the current literature covering all-ceramic materials and systems, with respect to survival, material properties, marginal and internal fit, cementation and bonding, and color and esthetics, and provides clinical recommendations for their use. Material and methods. A comprehensive review of the literature was completed seeking evidence for the treatment of teeth with all-ceramic restorations. A search of English language peer-reviewed literature was undertaken using MEDLINE and PubMed with a focus on evidence-based research articles published between 1996 and 2006. A hand search of relevant dental journals was also completed. Randomized controlled trials, nonrandomized controlled studies, longitudinal experimental clinical studies, longitudinal prospective studies, and longitudinal retrospective studies were reviewed. The last search was conducted on June 12, 2007. Data supporting the clinical application of all-ceramic materials and systems was sought. Results. The literature demonstrates that multiple all-ceramic materials and systems are currently available for clinical use, and there is not a single universal material or system for all clinical situations. The successful application is dependent upon the clinician to match the materials, manufacturing techniques, and cementation or bonding procedures, with the individual clinical situation. Conclusions. Within the scope of this systematic review, there is no evidence to support the universal application of a single ceramic material and system for all clinical situations. Additional longitudinal clinical studies are required to advance the development of ceramic materials and systems. (J Prosthet Dent 2007;98:389-404)

Clinical Implications

This investigation supports the view that successful application of all-ceramic materials depends on the clinicians ability to select the appropriate material, manufacturing technique, and cementation or bonding procedures, to match intraoral conditions and esthetic requirements.
Following the introduction of the first feldspathic porcelain crown by Land,1 the interest and demand for nonmetallic and biocompata

ible restorative materials increased for clinicians and patients. In 1965, McLean2 pioneered the concept of adding Al2O3 to feldspathic porcelain

to improve mechanical and physical properties. The clinical shortcomings of these materials, however, such as brittleness, crack propagation, low

Assistant Professor, Division of Prosthodontics, Department of Restorative Sciences, School of Dentistry, University of Minnesota. Assistant Professor, Division of Prosthodontics, Department of Restorative Sciences, School of Dentistry, University of Minnesota. c Associate Professor, Department Head, Department of Restorative Dentistry, Faculty of Dentistry, University of Manitoba.
b

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tensile strength, wear resistance, and marginal accuracy, continued to limit their use.3 Although the first biomedical application of zirconia occurred in 1969,4 the first paper regarding the use of zirconia for the production of artificial femoral heads was written by Christel5 in 1988. Applications expanded into dentistry in the early 1990s and have included endodontic posts, implants and implant abutments, orthodontic brackets, cores for crowns, and fixed partial denture prosthesis (FPDP) frameworks.6-9 Even though the combination of predictable strength and reasonable esthetics has continued to make traditional metal-ceramic restorations popular,10 patient demand for improved esthetics has driven the development of ceramic for use with inlays, onlays, crowns, FPDPs, and implantsupported restorations.11 The use of conservative ceramic inlay preparations with 5.5 to 27.2% tooth structure removal is increasing, along with all-ceramic complete crown preparations, which are more invasive and result in 67.5 to 72.3% tooth structure removal.12 All-ceramic restorations combining esthetic veneering porcelains with strong ceramic cores have become popular (Table I). Veneering porcelains typically consist of a glass and a crystalline phase of fluoroapatite, aluminum oxide, or

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leucite. Veneering a lithium-disilicate, aluminum-oxide, or zirconium-oxide core with glass allows dental technicians to customize these restorations in terms of form and esthetics.13 The most commonly reported major clinical complication resulting in failure of all-ceramic restorations is the fracture of the veneering porcelain and/or the coping (Table II).3,14-30 The success of these systems is dependent upon preventing failure by retarding crack propagation.4,31-33 Expansion of the use of all-ceramic systems for FPDPs has limitations. Proper diagnosis and patient selection are critical for success. A minimum connector height of 3 to 4

Table I. Ceramic materials and systems and manufacturer-recommended clinical indications

Core Material
Glass Ceramic Lithium-disilicate (SiO2-Li2O) Leucite (SiO2-Al2O3-K2O)

System
IPS Empress 2 (Ivoclar Vivadent, Schaan, Liechtenstein) IPS e.max Press (Ivoclar Vivadent) IPS Empress (Ivoclar Vivadent) Optimal Pressable Ceramic (Jeneric Pentron, Wallingford, Conn) IPS ProCAD (Ivoclar Vivadent) VITABLOCS Mark II (VITA Zahnfabrik, Bad Sackingen, Germany) VITA TriLuxe Bloc (VITA Zahnfabrik) VITABLOCS Esthetic Line (VITA Zahnfabrik)

Manufacturing Techniques
Heat pressed Heat pressed

Clinical Indications
Crowns, anterior FPDP Onlays, 3/4 crowns, crowns, FPDP

Heat pressed Heat pressed Milled

Onlays, 3/4 crowns, crowns Onlays, 3/4 crowns, crowns Onlays, 3/4 crowns, crowns

Feldspathic (SiO2-Al2O3-Na2O-K2O)

Milled Milled Milled

Onlays, 3/4 crowns, crowns, veneers Onlays, 3/4 crowns, crowns, veneers Anterior crowns, veneers

Alumina Aluminum-oxide (Al2O3)

In-Ceram Alumina (VITA Zahnfabrik) In-Ceram Spinell (VITA Zahnfabrik) Synthoceram (CICERO Dental Systems, Hoorn, The Netherlands) In-Ceram Zirconia (VITA Zahnfabrik) Procera (Nobel Biocare AB, Goteborg, Sweden)

Slip-cast, milled Milled Milled Slip-cast, millled Densely sintered

Crowns, FPDP Crowns Onlays, 3/4 crowns, crowns Crowns, posterior FPDP Veneers, crowns, anterior FPDP

Zirconia Yttrium tetragonal zirconia polycrystals (ZrO2 stabilized by Y2O3)

Lava (3M ESPE, St. Paul, Minn) Cercon (Dentsply Ceramco, York Pa) DC-Zirkon (DCS Dental AG, Allschwil, Switzerland) Denzir (Decim AB, Skelleftea, Sweden) Procera (Nobel Biocare AB)

Green milled, sintered Green milled, sintered Milled Milled Densely sintered, milled

Crowns, FPDP Crowns, FPDP Crowns, FPDP Onlays, 3/4 crowns, crowns Crowns, FPDP, implant abutments

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391
Major Complications (Restorations Remade)
None

Table II. Classification of complications and overall survival rates

Study
Raigrodski37

Minor Complications (Restorations Not Remade)

Chipped veneer (5) Endodontic therapy (1) Marginal integrity (1) Chipped veneer (3) Endodontic therapy (1) Chipped veneer (3) Endodontic therapy (2) Endodontic therapy (2) Chipped veneer (2) Caries (1) Decementation (11) Chipped/cracked veneer (5) Caries (2) Endodontic therapy (2) Endodontic therapy (3) Chipped veneer (1) Marginal deficiences (94%) Removal due to hypersensitivity (2) Slight mismatch in color (13%) Slightly rough surfaces (9%) Endodontic therapy (2) Caries (2) (not reported)

Reported Survival Rates (Percent)

100

Vult von Steyern38

None

100

Fradeani14

Fracture of veneer and/or coping (2) Fracture or delamination of veneer (2) Fracture of veneer and coping (3)

96.7 (100 anterior, 95.15 posterior) 97

Oden15

Odman16

Fracture of veneer and coping (4) Caries (1)

93.5

Wolfart17

Debonding (3) Debonding and fracture (3) Fracture of veneer and coping (5) Endodontic therapy (2) Fracture (7)

100 (crown-retained FPDP) 89 (inlay-retained FPDP) 93

Frankenberger18

Sjogren3

91

Fradeani19

Fracture (4) Post and core fracture (1) Root fracture (1) Fracture (4) Endodontic therapy (1) Tooth fracture (1) Fracture (2) Fracture (2)

95.2 (98.9 anterior, 84.4 posterior)

Marquardt20

(not reported)

100 (posterior crowns) 70 (anterior or premolar FPDP) 93 100 (In-Ceram Spinell) 92 (In-Ceram Alumina) 96 (98 anterior, 94 posterior)

Esquivel-Upshaw21 Bindl22

(not reported) Debonding of composition resin foundation (1) (not reported)

McLaren23

Fracture of core (4) Fracture of veneer (2) Removal without failure (3) Marginal integrity (2)

Haselton66

Caries (1) Marginal integrity (1) Chipped veneer (1) Fracture (1)

(not reported)

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Table II. continued (2 of 2) Classification of complications and overall survival rates

Study
Vult von Steyern24 Olsson25

Major Complications (Restorations Remade)

Fracture (2) Fracture (3)

Minor Complications (Restorations Not Remade)

(not reported) Fracture (external trauma) (2) Decementation (1) (not reported)

Reported Survival Rates (Percent)

90 93

Sorensen26

Fracture (7)

88.5 (100 anterior, 82.5 posterior) 94.5 100

Suarez91 Probster92

Root fracture (1) None

(not reported) Caries (5) Decementation (1) Chipped veneer (2) Chipped/cracked veneer (8) Chipped veneer (3) Caries (2) Endodontic therapy (1) (not reported)

Fradeani27 Pallesen28 Otto29

Fracture (1) Fracture (3) Fracture (5) Tooth fracture (3) Caries (1) Fracture (180)

97.5 90.6 90.4

Malament30 Scurria93

87.5 95 (5 year) 85 (10 year) 67 (15 year)

mm from the interproximal papilla to the marginal ridge is a guideline for most systems.7,8,17,21,25,34,35 Placement is contraindicated when there is reduced interocclusal distance, as with short clinical crowns, deep vertical overlap anteriorly without horizontal overlap, or an opposing supraerupted tooth, as well as for cantilevers, periodontally involved abutment teeth, and patients with severe bruxism or parafunctional activity.7,21,36 The primary cause of failure varies from fracture of the connector, for aluminumoxide FPDPs24-26 and lithium-disilicate FPDPs,20,21 to cohesive fracture of the veneering porcelain, for zirconia FPDPs.37,38 Metal-ceramic FPDPs differ in that they fail primarily due to tooth fracture39 and caries.39,40 Following the Law of Beams by maximizing connector height and width is the basis for proper design of all-ceramic FP-

DPs.7,8,41 The purpose of this article is to review current literature on all-ceramic materials and systems, with respect to survival, material properties, marginal and internal fit, cementation and bonding, and color and esthetics, and suggest clinical recommendations for their use.

MATERIAL AND METHODS

A broad systematic search of English peer-reviewed dental literature was designed to identify evidence supporting the restoration of teeth with current all-ceramic materials and systems. Key words or phrases included crowns, dental porcelain, ceramics, aluminum oxide, zirconium oxide, dental cements, composite resin cements, adhesives, computeraided design, color, dental restoration failure, and dental prosthesis design.

MEDLINE and PubMed searches were conducted focusing on evidencebased research articles published between 1996 and 2006. The Journal of Prosthetic Dentistry and the International Journal of Prosthodontics were additionally hand-searched for this review. Titles and/or abstracts of articles identified through the electronic searches were reviewed and evaluated for appropriateness. Suitable articles were subjected to inclusion and exclusion criteria. Randomized controlled clinical trials, nonrandomized controlled clinical studies, longitudinal experimental clinical studies, longitudinal prospective clinical studies, and longitudinal retrospective clinical studies were reviewed. Articles that did not focus exclusively on the restoration of teeth with all-ceramic materials and systems or the material properties of ceramics were excluded from

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further evaluation. Nonpeer-reviewed dental literature, abstracts, and clinical reports were excluded from review. Inclusion criteria for survival studies included a minimum mean follow-up period of 2 years, reporting of complications, identification of materials, type of study, setting, and sample size. Data supporting the clinical application of all-ceramic materials and systems was sought. in the anterior segment.19 IPS Empress 2 has improved flexural strength by a factor of 3 over IPS Empress, can be used for 3-unit FPDPs in the anterior area, and can extend to the second premolar.42-45 The framework is veneered with fluoroapatite-based veneering porcelain (IPS Eris; Ivoclar Vivadent), resulting in a semitranslucent restoration with enhanced light transmission.8,46,47 IPS e.max Press (Ivoclar Vivadent) was introduced in 2005 as an improved press-ceramic material compared to IPS Empress 2. It also consists of a lithium-disilicate pressed glass ceramic, but its physical properties and translucency are improved through a different firing process.48 IPS ProCAD (Ivoclar Vivadent) is a leucite-reinforced ceramic similar to IPS Empress, although it has a finer particle size.49 Introduced in 1998, it is designed to be used with the CEREC inLab system (Sirona Dental Systems, Bensheim, Germany) and is available in numerous shades, including a bleached shade and an esthetic block line.49-52 Vita Mark II (VITA Zahnfabrik, Bad Sackingen, Germany), a machinable feldspathic porcelain introduced in 1991 for the CEREC 1 system (Siemens AG, Bensheim, Germany), has improved strength and finer grain size (4 m) as compared to the Vita Mark I.28,49 It is primarily composed of SiO2 (60-64%) and Al2O3 (20-23%) and can be etched with hydrofluoric acid to create micromechanical retention for adhesive cementation with composite resin cements.49,53,54 Although this product is monochromatic, it is available in multiple shades, including the Classic Line Vita shades, Vitapan 3DMaster Shades, VITABLOCS Esthetic Line, and a bleached shade, and can be additionally characterized.49,55-58 To overcome esthetic disadvantages of a monochromatic restoration and to imitate optical effects of natural teeth, a multicolored ceramic block (Vita TriLuxe Bloc; VITA Zahnfabrik) was designed to create a 3-dimensional layered structure.59 The inner third has a dark opaque base layer, while the middle third has a neutral zone comparable to the standard block, and the outer third is more translucent. CEREC software allows the operator to have some visual control over the alignment of the restoration within the multilayered block.59,60 Another technique for fabricating feldspathic porcelain restorations was through copy-milling (Celay; Mikrona Technologie AG, Spreitenbach, Switzerland).61,62 This system milled restorations by duplicating a direct acrylic resin pattern replica of an inlay, onlay, or crown coping. Unable to approach the sophistication of the digital systems (CEREC 3D; Sirona Dental Systems), the Celay system is now obsolete.63 A major contributor to the development of glass ceramics was Dicor (Dentsply Intl, York, Pa). This was a glass-ceramic material composed of 70% tetrasilicic fluormica crystals precipitated in 30% glass matrix.64 Originally made using the lost-wax technique,30,65 it was later marketed as a machinable glass ceramic28,64 that is no longer available. Alumina-based ceramics In-Ceram Alumina (VITA Zahnfabrik), introduced in 1989, was the first all-ceramic system available for single-unit restorations and 3-unit anterior FPDPs.66 It has a high strength ceramic core fabricated through the slip-casting technique.67 A slurry of densely packed (70-80 wt%) Al2O3 is applied and sintered to a refractory die at 1120C for 10 hours.63,68 This produces a porous skeleton of alumina particles which is infiltrated with lanthanum glass in a second firing at 1100C for 4 hours to eliminate porosity, increase strength, and limit potential sites for crack propagation.68 Compressive stresses which further improve the strength are also introduced, due to the differences in the coefficient of thermal expansion of the alumina and glass.68 The coping is veneered with feldspathic porcelain.22,66 Alumina blanks (VITABLOCS In-Ceram Alumina; VITA Zahnfabrik)

393

RESULTS
A total of 285 articles were identified through the MEDLINE and PubMed searches. Abstracts were reviewed to confirm the articles met the inclusion criteria. A total of 148 articles published between 1996 and 2006 were identified and read in their entirety. Nineteen prospective and 4 retrospective clinical trials related to survival were reviewed. The literature demonstrated that multiple all-ceramic materials and systems are currently available for clinical use and there is not a single universal material or system for all clinical situations. The successful application of different all-ceramic materials is dependent upon clinicians ability to match the ceramic materials to the manufacturing techniques and cementation or bonding procedures, to adequately customize a treatment plan.

DISCUSSION
Glass ceramics IPS Empress 2 (Ivoclar Vivadent, Schaan, Liechtenstein) is a lithium-disilicate glass ceramic (SiO2-Li2O) that is fabricated through a combination of the lost-wax and heat-pressed techniques. A glass-ceramic ingot of the desired shade is plasticized at 920C and pressed into an investment mold under vacuum and pressure. Its predecessor, IPS Empress (Ivoclar Vivadent), is a leucite-reinforced glass ceramic (SiO2-Al2O3-K2O) which, due to its strength, is limited in use to singleunit complete-coverage restorations

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are also available for milling in combination with CEREC (Sirona Dental Systems).22,63 In 1994, In-Ceram Spinell (VITA Zahnfabrik) was introduced as an alternative to the opaque core of In-Ceram Alumina. It contains a mixture of magnesia and alumina (MgAl2O4) in the framework to increase translucency10,69; however, its flexural-strength is lower than that of In-Ceram Alumina, and, thus, the cores are only recommended for anterior crowns.70 This material can also be machined with the CEREC inLab system (Sirona Dental Systems), followed by veneering with feldspathic porcelain.22,57 Synthoceram (CICERO Dental Systems, Hoorn, The Netherlands) is a high-strength glass-impregnated aluminum-oxide ceramic core fabricated through CICERO technology (Computer Integrated Ceramic Reconstruction).71,72 Laser scanning, ceramic sintering, and computer-integrated milling techniques are used to fabricate the cores, which are veneered with a leucite-free glass ceramic.54,71-73 In-Ceram Zirconia (VITA Zahnfabrik) is also a modification of the original In-Ceram Alumina system, with an addition of 35% partially stabilized zirconia oxide to the slip composition to strengthen the ceramic.67 Traditional slip-casting techniques can be used or the material can be copy-milled from prefabricated, partially sintered blanks and then veneered with feldspathic porcelain.7,46,74 Since the core is opaque and lacks translucency, the material is recommended for posterior crown copings and FPDP frameworks.7,67 Procera (Nobel Biocare AB, Goteborg, Sweden) was developed by Andersson and Oden with copings that contain 99.9% high purity aluminum oxide.75 Combined with a low-fusing veneering porcelain, Procera has the highest strength of the alumina-based materials and its strength is lower only than zirconia.14,15 A sapphire contact probe is used to scan the working die and to define the 3-dimensional shape of the preparation.54 The data is sent electronically to a manufacturing facility where a 20% enlarged model is copy-milled and used for the drypressing technique.14,45 High purity aluminum-oxide powder is mechanically compacted on the enlarged die and sintered at 1550C, eliminating porosity and returning the core to the dimensions of the working die.45,63,76 The crown form is completed by veneering it with low-fusing feldspathic porcelain matching the coefficient of thermal expansion of aluminum oxide.14 Zirconia-based ceramics Zirconia is a polymorphic material that occurs in 3 forms. At its melting point of 2680C, the cubic structure exists and transforms into the tetragonal phase below 2370C.4,77,78 The tetragonal-to-monoclinic phase transformation occurs below 1170C and is accompanied by a 3-5% volume expansion which causes high internal stresses.32,77,78 Yttrium-oxide (Y2O3 3% mol) is added to pure zirconia to control the volume expansion and to stabilize it in the tetragonal phase at room temperature.33 This partially stabilized zirconia has high initial flexural strength and fracture toughness.33 Tensile stresses at a crack tip will cause the tetragonal phase to transform into the monoclinic phase with an associated 3-5% localized expansion.32 The volume increase creates compressive stresses at the crack tip that counteract the external tensile stresses. This phenomenon is known as transformation toughening and retards crack propagation. In the presence of higher stress, a crack can still propagate. The toughening mechanism does not prevent the progression of a crack, it just makes it harder for the crack to propagate.4,8,32,33,79 Yttrium-oxide partially stabilized zirconia (Y-TZP) has mechanical properties that are attractive for restorative dentistry; namely, its chemical and dimensional stability, high mechanical strength, and fracture-toughness.13 The cores have a radiopacity com-

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parable to metal which enhances radiographic evaluation of marginal integrity, excess cement removal, and recurrent decay.8 Y-TZP can be manufactured in 2 methods through computer-aided design/computer-aided manufacturing (CAD/CAM) technology. First, an enlarged coping/framework can be designed and milled from a homogenous ceramic soft green body blank of zirconia.80 The framework structure has a linear shrinkage of 20-25% during sintering until it reaches the desired final dimensions.6,9 Processing with this softer presintered material not only shortens the milling time, but also reduces the wear on the milling tools.6 Although zirconia frameworks can be milled directly from a fully sintered prefabricated blank in the final dimensions,6,80 milling fully sintered zirconia may compromise the microstructure and strength of the material.81,82 Lava (3M ESPE, St. Paul, Minn) uses a Y-TZP framework with high flexural strength, high fracture toughness, and low elastic modulus compared to alumina, and exhibits transformation toughening when subjected to tensile stress.4,33 A die is scanned by a contact-free optical process for 5 minutes for a crown and 12 minutes for a 3unit FPDP. The CAD software designs an enlarged framework that is milled from softer presintered blanks. After 35 minutes of milling for a crown and 75 minutes for a 3-unit FPDP, the framework can be colored in 1 of 7 shades, followed by sintering in a special automated oven for 8 hours.6 Other CAD/CAM systems are also available for designing and milling zirconia restorations. Cercon (Dentsply Ceramco, York, Pa) requires conventional waxing techniques to design the Y-TZP framework, and the wax pattern is scanned.7 DCS Precident (DCS Dental AG, Allschwil, Switzerland) uses fully sintered DC Zirkon ceramic containing 95% ZrO2 partially stabilized with 5% Y2O3.7,83,84 Denzir (Decim AB, Skelleftea, Sweden) designs and mills ceramic inlays from yttrium-oxide

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partially sintered blocks.67,85,86 Although the first all-ceramic implant abutments (CerAdapt; Nobel Biocare AB) were made of densely sintered, high purity alumina,87,88 zirconia implant abutments with or without a metal interface (Procera Zirconia Abutment; Nobel Biocare AB; Atlantis Abutment in Zirconia; Zimmer Dental, Carlsbad, Calif; Straumann Zirconia Custom Abutment; Straumann USA, Andover, Mass; Zirconia Abutment; Astra Tech Inc, Waltham, Mass; and ZiReal Post; Biomet 3i, Palm Beach Gardens, Fla) are now recommended instead of alumina due to their increased mechanical properties.87,88 Abutments are either customized through electronic data or are stock abutments which can be modified via conventional preparation. Dental and mucogingival esthetics can be improved for single implant restorations by eliminating any metal display.89,90 Survival When considering the restoration of teeth with all-ceramic materials, survival data is important to evaluate the effectiveness of different treatment strategies. Comparing the results from relevant literature is challenging due to the availability of different ceramic materials and systems, reporting of complications, study conditions, and evaluation times; these varying factors make it difficult to assess the overall effectiveness of therapy. Inclusion criteria for the reviewed studies included a minimum mean follow-up period of 2 years, reporting of complications, identification of materials, type of study, setting, and sample size (Tables II and III). Fracture of the veneering porcelain and/or ceramic coping is objective and the most commonly reported major complication requiring remaking of the restoration.3,14-28,30 Although 2 groups of investigators considered caries a major complication requiring refabrication of the restoration in 1 instance, they considered it a minor complication that did not require refabrication for 2 other restorations in the study.16,29 Two groups of investigators reported endodontic therapy as a major complication,18,20 while 4 others reported root or tooth fracture as a major complication.19,20,29,91 Several of the reported complications were considered minor and did not require remaking of the restoration. The most common minor complication reported was chipping or cracking limited to the veneering porcelain (reported for 33 restorations),14-17,27-29,37,38,66 followed by endodontic therapy (n=14),3,14-17,29,37,38 decementation (n=13),16,25,92 and

395

Table III. Study details, including material and restoration type

Study
Raigrodski37 Vult von Steyern38 Fradeani14 Oden15 Odman16 Wolfart17

Material
Lava DC-Zirkon Procera (alumina) Procera (alumina) Procera (alumina) IPS e.max Press

Type of Restoration
FPDPs FPDPs Crowns Crowns Crowns Crown-retained FPDP Inlay-retained FPDP Inlays, onlays Crowns, 3/4 crowns Crowns Crowns FPDPs FPDPs

Type of Study
Prospective Prospective Prospective Prospective Prospective Prospective

Study
University University Private practice Private Practice Multicenter University

Sample Size
20 23 205 100 87 36 45

Mean (Years)
2.6 2 2 5 (not reported) 4 3.1

Range (Years)
1.5-3 2 0.5-5 (not reported) 5-10.5 2.5-4.6 1.7-5

Frankenberger18 Sjogren3

IPS Empress IPS Empress

Prospective Retrospective

University Private practice

96 110

(not reported) 3.6

1-6 1.4-5.1

Fradeani19 Marquardt20

IPS Empress IPS Empress 2

Retrospective Prospective

Private practice University

125 27 31 30

(not reported) (not reported)

4-11 2.75-5.1

Esquivel-Upshaw21

IPS Empress 2

Prospective

University

(not reported)

1-2

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Table III. continued (2 of 2) Study details, including material and restoration type
Study
Bindl22

Material
In-Ceram Spinell In-Ceram Alumina In-Ceram Alumina In-Ceram Alumina In-Ceram Alumina In-Ceram Alumina In-Ceram Alumina In-Ceram Zirconia In-Ceram Alumina In-Ceram Spinell Vita Mark II, Dicor Vita Mark I Dicor

Type of Restoration
Crowns

Type of Study
Prospective

Study
University

Sample Size
19 24 223 80 20 42 61 18 95 40 16 16 200 1444

Mean (Years)
3.25

Range (Years)
1.2-4.8

McLaren23 Haselton66 Vult von Steyern24 Olsson25 Sorensen26 Suarez91 Probster92 Fradeani27 Pallesen28

Crowns Crowns FPDPs FPDPs FPDPs FPDPs Crowns Crowns Inlays

Prospective Retrospective Prospective Retrospective Prospective Prospective Prospective Prospective Prospective

Private practice University University Private practice University University (not reported) Private practice University

3 4 5 6.3 3 3 2.42 4.17 8

(not reported) (not reported) (not reported) 0.2-9.2 (not reported) (not reported) 2-4.5 1.8-5 (not reported)

Otto29 Malament30

Inlays, onlays Crowns, inlays, onlays FPDPs

Prospective Prospective

Private practice Private practice

10 14.1

(not reported) (not reported)

Scurria93

Metal-ceramic

Meta-analysis

Various

n/a

5 10 15

(not applicable)

caries (n=13).3,15,16,29,66,92 Chipping or cracking of the veneering porcelain for this review was defined as minor cohesive fracture of the veneering porcelain which did not impair function. Two studies did not exclude patients unavailable for evaluation from the survival rates (reported for 30 restorations).18,26 In instances where minor cohesive fractures of the veneering porcelain did not require complete replacement, the restorations were either polished14,16,27 or repaired with direct composite resin restorative material.17,29 Caries identified in the marginal areas were excavated and repaired with direct composite resin restorative material,29,66,92 while endodontic access preparations were also filled

with direct composite resin restorative material.14,17,29,37 Several authors replaced 2 crowns due to cohesive failures of the veneering porcelain and 1 crown due to caries, but did not classify this as a major complication because it only involved the veneering porcelain.15 Typical survival rates for all-ceramic restorations range from 88 to 100% after 2-5 years in service,3,14,17,2123,26,27,37,38,91,92 and 84 to 97% after 5-14 years in service.15,16,18,19,24,25,28-30 Discrepancy in the classification of failures and variability of the materials and systems available for all-ceramic restorations present a challenge to combining data from several studies. A meta-analysis for metal-ceramic FPDPs defined failure as the removal

of the prosthesis, but also considered a broader definition that included removal and/or a technically failed prosthesis requiring replacement.93 A more comprehensive definition of failure or critical assessment of allceramic restorations would thus decrease reported survival rates. A more descriptive definition of ceramic restoration outcome might include the categories of success, survival, and failure. Material properties The strength of an all-ceramic restoration is dependent on the ceramic material used, core-veneer bond strength, crown thickness, and design of the restoration,13,94 as well as bond-

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ing techniques and the characteristics of the supporting material.95,96 As evident from the literature on survival rates, fracture of the ceramic material is the most frequently reported complication resulting in failure.3,14-28,30 Alumina-based ceramics (In-Ceram Alumina; VITA Zahnfabrik) have been shown to have higher strength and fracture toughness than leucite-reinforced glass ceramics (IPS Empress; Ivoclar Vivadent),97 conventional feldspathic porcelain (Vita Bloc Mark II; VITA Zahnfabrik),98,99 and modified alumina cores (In-Ceram Spinell; VITA Zahnfabrik).100 A zirconia-modified alumina ceramic (In-Ceram Zirconia; VITA Zahnfabrik) was found to have higher fracture toughness than In-Ceram Alumina when tested by indentation strength in 1 study,101 and higher flexural strength in another.102 Densely sintered, high purity alumina (Procera; Nobel Biocare AB) was reported to have significantly higher flexural strength than glass-infiltrated presintered alumina (In-Ceram Alumina).103 The success of many all-ceramic systems is dependent on the strength of a core-veneer bond. Since the ceramic core is significantly stronger than the veneering materials, this bond strength has an important role in their success.13 The thickness ratio of the ceramic core to the veneering porcelain is a dominant factor controlling the crack initiation site and potential failure.104 Optimizing the thickness of these layers is necessary to ensure that the veneering porcelain is under compressive stress and that the ceramic core is under tensile stress.103 Although it is desirable to increase the thickness of the ceramic coping, it is important not to compromise either the esthetics of the crown by overcontouring, or the tooth preparation by overreduction.105 Even though the veneering porcelain is used primarily for esthetic reasons, it has an important role in the mechanical behavior of the restoration.106 The flexural strength and fracture toughness of these bilayered restorations depend on the veneer layer when the crack initiates from the veneer surface.107 Although residual compressive stresses in the veneer layer increase the flexural strength of the bilayered restoration, the tensile stresses are the primary cause for the observed chipping.107 Zirconia-based ceramics are recommended for FPDPs, as they have the highest failure loads when compared to alumina- and lithium-disilicate-based ceramics.46 A lithiumdisilicate glass ceramic (IPS Empress 2; Ivoclar Vivadent) in combination with a fluoroapatite glass-ceramic (IPS Eris; Ivoclar Vivadent) was found to be inappropriate for posterior FPDPs due to the high susceptibility of the veneer to subcritical crack growth and the absence of crack arresting at the core-veneer interface.108 Zirconia frameworks with higher elastic modulus are preferred for all-ceramic posterior FPDPs compared to lithium-disilicate based ceramics, as they reduce the stress on the weaker veneer layer and increase the composite load-bearing capacity, thereby retarding the fracture of the restoration.106 Creating a gingival embrasure with a broad radius of curvature, rather than a sharp contour, has been shown to reduce the stress concentration under loading and increase the fracture resistance.109,110 Following traditional preparation guidelines is important not only for retention of all-ceramic crowns, but also for stress distribution during dynamic loading of the restoration.111 Finite element analysis studies have shown that FPDP connector heights of at least 3 to 4 mm considerably reduce stress levels in the connector and provide adequate strength.35,112 In vitro studies on mechanical properties are not always capable of reproducing intraoral conditions. Artificial oral environments have been developed to simulate intraoral conditions by applying intermittent dynamic cyclic forces, artificial saliva, temperature fluctuations, and humidity control.66,113 Testing specimens in these simulated oral environments has been shown to significantly decrease the fracture toughness of ceramic materials.114 Long-term in vivo studies are necessary to make conclusions about the clinical indications for ceramic materials. Marginal and internal fit When evaluating the clinical success and quality of a restoration, marginal discrepancy is an essential criterion.74 Christensen115 reported the clinically detectable range for subgingival margins to be 34-119 m and 2-51 m for supragingival margins. Subsequently, McLean116 suggested that 120 m should be the limit for clinically acceptable marginal discrepancies. Poor marginal adaptation can result in cement dissolution, microleakage, increased plaque retention, and secondary decay.74 Holmes117 measured various points between the casting and the tooth and clarified the terminology for misfit. Absolute marginal discrepancy was defined as an angular combination of the horizontal and vertical error and would reflect the total misfit at that point. An internal gap is the perpendicular measurement from the axial wall to the internal casting surface. The incidence of gingival inflammation increases around clinically deficient restorations, particularly those with rough surfaces, subgingival finish lines, or poor marginal adaptation; however, gingival inflammation may also develop around properly contoured and highly polished restorations.118 Although the severity of gingival response is patient-specific, current evidence has not shown an accelerated rate of bone loss or increased attachment loss adjacent to crowns.118 Contemporary chairside or laboratory-based CAD/CAM systems have additional factors that may affect the accuracy of the fit, including software limitations in designing restorations, and hardware limitations of the camera, scanning equipment, and mill-

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ing machines. Clinicians and dental technicians experience and expertise is also key with chairside and laboratory-based CAD/CAM systems.119 Systems dependent upon an optical impression experience problems with rounded edges due to the scanning resolution and positive error, which simulates peaks at the edges.120 Other systems that use a surface contacting probe cannot accurately reproduce proximal retentive features less than 2.5 mm wide and more than 0.5 mm deep.121 Feather-edge finish lines, deep retentive grooves, and complex occlusal morphology are not recommended, not only for scanning and milling prerequisites, but also to decrease stress that would develop in a restoration with inadequate preparation and margin geometry.121 An additional problem with computer-milled ceramic restorations is that the internal cutting bur may be larger in diameter than some parts of the tooth preparation, such as the incisal edge. This would result in a larger internal gap than with other fabrication techniques.120 Table IV is a summary of current literature evaluating in vivo and in vitro marginal discrepancy as well as the in vitro internal discrepancy or misfit of the coping on the axial surfaces. In general, studies have demonstrated that internal gap widths are higher than marginal gaps.54,74,76,83,85, 86,122-129 This finding has implications for glass-ceramic restorations which may be dependent upon the mechanical properties of the luting cement to resist functional forces.95 Most of the literature reports marginal discrepancies in the range of clinical acceptability recommended by Christensen115 and McLean.116 Cementation and bonding A variety of cementation and bonding techniques have been applied to modern all-ceramic restorations. Zinc phosphate, zinc polycarboxylate, and conventional glass-ionomer cements set through an acid-base reaction having a tendency to exacerbate surface flaws in ceramic restorations due to the increased acidity of the cement.130 Glass ionomers are susceptible to early water degradation, resulting in microcracks which may initiate cracks and facilitate crack propagation in the cement.131 Resin-modified glass ionomer cement sets through a combination of an acid-base reaction and photo- or chemically initiated polymerization. Combining chemical adhesion advantages of traditional glass-ionomer cements with advantages of composite resin results in improved strength, fracture toughness, and wear resistance.132 To improve success rates with glass- and aluminabased ceramic restorations, nonacidbase cements are recommended.130 For conventional glass-ceramic restorations, the adhesive technique is critical for successful bonding. Surface treatment of the porcelain by etching with 5% to 9.5% hydrofluoric acid133 and etching of the tooth structure with 37% phosphoric acid134 and application of a silane coupling agent provided the highest bond strength of an adhesive-resin cement to feldspathic material. A chemical bond between feldspathic porcelain and tooth structure is achieved through silane coupling agents in composite resins. Bond strength to etched surfaces is improved by creating deep involuted spaces where resin can flow and interlock.135,136 Due to the abrasion rate with subsequent volume loss and changes in morphology, feldspathic restorations should never be airborne-particle abraded to improve the roughness of the internal surface, only acid-etched.137 Considering the brittleness and limited flexural strength of glass ceramics, definitive adhesive cementation with composite resin should be used to increase the fracture resistance of the restoration.94,130,138,139 The compressive strength of composite resin cements (320 MPa) is superior to that of zinc phosphate (121 MPa), which offers limited support.131,140 Fracture or cement breakdown can result in

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microleakage, marginal discoloration, pulpal irritation, secondary caries, debonding, and decreased fracture load. Adhesive cementation has been shown to increase fracture loads and improve longevity.50,57,139,141,142 A glass-ceramic restoration supported by a composite resin cement with good physical properties can withstand higher masticatory forces and demonstrates improved clinical performance.138 Light-, dual-, and chemically polymerized composite resin materials have been advocated for use with glass ceramics.143 Decreased survival rates have been reported with dual-polymerizing, composite resin cement, as compared to chemically polymerizing composite resin cement with feldspathic inlays (VITABLOCS Mark II; VITA Zahnfabrik).144,145 Inadequate transmission of light through the ceramic restoration to the underlying cement can result in insufficient polymerization of dual-polymerizing composite resin cement and lack of support for the restoration.119 Dualpolymerizing cements contain peroxide and amine components found in chemically polymerized systems, in addition to a photosensitizer used in light-polymerized systems.146 The 2 catalytic mechanisms are required to reduce the quantity of remaining double bonds to maximize strength and adhesion of the cement.147 A slower polymerization reaction148 and higher solubility and water absorption occurs when dual-polymerizing resins are allowed to autopolymerize.149 Depending exclusively on the autopolymerizing component of dual-polymerizing composite resin results in decreased hardness and premature failure of the cement.119,144,145,150 Nonadhesive cementation is more dependent upon macromechanical retention than adhesive cementation.138 Finish lines placed below the cemento-enamel junction result in a significant loss of adhesion, despite following adhesive luting techniques.151 Since cementum cannot be infiltrated by resin to the extent that

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Table IV. Marginal and internal fit studies

Material and Systems
IPS Empress 2/heat pressed IPS Empress/heat pressed Optimal Pressable Ceramic/heat pressed IPS ProCAD/CEREC 3 VITABLOCS Mark II/CEREC 3 53-66124 65122

In Vivo Mean Marginal Gap (m)

In Vitro Mean Marginal Gap (m)

4474 147-16785 246-26585

In Vitro Internal Gap (m)

75-10574 20685 27885 342123 380123 116-141124 122126

VITABLOCS Mark II/CEREC 2 VITABLOCS Mark II/CEREC 1 VITABLOCS Mark II/Celay System In-Ceram Alumina/Slip-cast In-Ceram Alumina/Celay System Synthoceram/CICERO In-Ceram Zirconia/CEREC in Lab In-Ceram Zirconia/Digident (Digident GmbH, Pforzheim, Germany) In-Ceram Zirconia/Slip-cast

8554 195122

62-121125

17127 57127 57127 7454 77128 92128 4374 82-11474

2574 6083 6854 90-118129 80128 3374 60-7183 1774 56-6376

71-9474

Procera/densely sintered

119-13674 36-7476

Lava DC-Zirkon/Precident System

110-11674

Denzir

2374 22-4186 136-14985 30122 67128

74-8174 110-19286 24385

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acid-etched dentin can, micromechanical retention at the gingival margins may contribute little to the bond strength.152,153 Restorations that are less dependent on predictable adhesion should be considered when the finish line is not placed in enamel.154 Different surface treatments have been evaluated to demonstrate the bond strength of composite resin cements to alumina-based ceramic restorations. Acid etchants used with glass ceramics do not adequately roughen the surface of glass-infiltrated and densely sintered alumina-based ceramics.155 An effective method to roughen glass-infiltrated alumina-based ceramic (In-Ceram Alumina; Vita Zahnfabrik) is through a tribochemical silica coating process (Rocatec; 3M ESPE).137 This method involves cleaning the surface to be coated with 110 m of high-purity aluminum oxide (Rocatec Pre; 3M ESPE) at 250 KPa for 14 seconds, creating a uniform pattern of roughness. This is followed by a tribochemical coating with 110 m (Rocatec Plus; 3M ESPE) or a less abrasive 30 m (Rocatec Soft; 3M ESPE) of silicamodified high purity aluminum oxide. The aluminum oxide leaves the surface partially coated with SiO2, which is then conditioned with silane (3M ESPE Sil; 3M ESPE) to create a bond with the composite resin.137 Volume loss through this tribochemical process was found to be 36 times less for a glass-infiltrated alumina (In-Ceram Alumina; VITA Zahnfabrik) than for a feldspathic glass ceramic (IPS Empress; Ivoclar Vivadent) and did not change its surface composition.137 Pretreatment of a glass-infiltrated alumina (In-Ceram Alumina; VITA Zahnfabrik) with the tribochemical process (Rocatec; 3M ESPE) resulted in a durable resin bond over 5 years.156 Airborne-particle abrasion with 50m aluminum oxide for 15 seconds was found to be the most effective for producing higher bond strengths for a densely-sintered aluminum-oxide coping (Procera; Nobel Biocare AB) when compared to etching with 9.6% hydrofluoric acid for 2 minutes, diamond abrasion combined with etching with 37% phosphoric acid for 2 minutes, and no treatment.155 Surface treatments including a tribochemical silica coating process (Rocatec; 3M ESPE), airborne-particle abrasion with either 250-m or 50-m aluminum oxide, airborneparticle abrasion with 50-m aluminum oxide combined with 38% hydrofluoric acid etching, or diamond abrasion with a rotary cutting instrument, were reported to have only a minor influence on bond strength to zirconia ceramic (Denzir; Decim AB).157 The tribochemical silica coating process in combination with a resin cement was shown in 1 study158 to have an initial bond to zirconia that failed spontaneously after simulated aging, while another study159 found that it did not improve the retentive strength of composite resin cements. Although not apparent immediately, damage from airborne-particle abrasion (50-m aluminum oxide for 5 seconds at 276 KPa) has been shown to compromise the fatigue strength of alumina- and zirconia-based ceramic materials.160,161 A variety of luting agents have been shown to be capable of retaining zirconium-oxide crowns (Lava; 3M ESPE) including composite resin (Panavia F 2.0; Kuraray, Tokyo, Japan), compomer (Dyract Cem Plus; Dentsply Intl), resin-modified glass ionomer (RelyX Luting; 3M ESPE), and self-adhesive composite resin (RelyX Unicem; 3M ESPE).159,162 While mechanical properties of cements are critical to support glass-ceramic restorations,140 zirconia-based crowns can be cemented conventionally due to their high fracture resistance.159 Zirconia-based restorations do not require an adhesive interface for retention.8 Color and esthetics Increased translucency correlated with improved esthetics is the primary advantage in using an all-ceramic restoration. Heffernan et al10 evaluated

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the relative translucency of several ceramic materials and found In-Ceram Spinell (VITA Zahnfabrik) to have the highest amount of relative translucency. This was followed by IPS Empress (Ivoclar Vivadent), Procera (Nobel Biocare AB), and IPS Empress 2 (Ivoclar Vivadent), which had higher levels of translucency than In-Ceram Alumina (VITA Zahnfabrik), followed by In-Ceram Zirconia (VITA Zahnfabrik), which was comparable to a metal alloy. As a result of this study, In-Ceram Spinell, IPS Empress, and IPS Empress 2 were recommended for high to average translucency situations. Procera was recommended for average translucency situations, while In-Ceram Alumina and In-Ceram Zirconia are only recommended when matching to opaque natural teeth or in posterior and nonesthetic zones.69 The addition of MgAl2O4 to the In-Ceram system has made In-Ceram Spinell, with its increased translucency, an esthetic competitor. Unfortunately, mechanical properties have been compromised compared to the original material, restricting its use to the anterior segment, exclusively.70 A subjective evaluation reported IPS Empress better able to match adjacent teeth than In-Ceram Spinell or metal-ceramic restorations.47 Monochromatic restorations machined from ceramic blocks have been scrutinized for their lack of individual characterization. Although customized characterizing of these restorations was shown to compete esthetically with layering techniques163 and multishade block systems,58 no longterm follow-up for color stability has been done. The ratio and thickness of ceramic core and veneering materials influence the final shade of a layered porcelain restoration. An aluminum-oxide ceramic core thickness of 0.7 mm was found to be sufficient to mask underlying dentin color.71 With a conservative reduction of 1 mm, a semitranslucent all-ceramic specimen will match a shade tab more closely than a metal-ceramic restoration. Increasing

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reduction will improve esthetic results for metal-ceramic and semiopaque all-ceramic restorations but will not further enhance shade-matching for semitranslucent specimens (IPS Empress; Ivoclar Vivadent; In-Ceram Alumina and In-Ceram Spinell; VITA Zahnfabrik).164 Since IPS Empress restorations were found to require up to 2.0 mm of thickness facially to mask an underlying substrate,165 other less translucent core materials should be considered. The opaque porcelain required for masking a metal substrate is responsible for reflecting light and decreasing translucency. Since enamel is 97% hydroxyapatite mineral matter, it is very translucent and able to transmit up to 70% of light. Dentin is also capable of transmitting up to 30% of light, which creates the esthetic dilemma for metal-ceramic restorations, as they are only capable of diffusion and reflection of light. Consequently, metal-ceramic restorations often appear brighter intraorally.47 Clinical recommendations Leucite and feldspathic glass ceramics are indicated for onlays, three quarter crowns, and veneers, but their strength limits their use to complete coverage crowns in the anterior segment, only. Lithium-disilicate glass ceramics can perform successfully in the posterior segment for single crowns and 3-unit FPDPs in the anterior area. Glass-infiltrated alumina cores can be considered for single-unit restorations and anterior FPDP applications, with the exception of In-Ceram Spinell, which is only recommended for anterior crowns. Zirconia-modified alumina is indicated for posterior crowns and FPDPs, while densely sintered alumina is indicated for veneers, crowns, and anterior FPDPs. Zirconia has superior mechanical properties as a core material for posterior crowns and FPDPs, implant abutments, and implant-supported restorations. The stronger ceramic core materials can be rather opaque and this may limit their application when a high degree of translucency is required. Reported survival rates are variable and dependent upon the material used, manufacturing technique, clinical application, and the authors definition of failure. Optimal thickness of alumina and zirconia cores and their respective veneering materials is critical for esthetics and strength to support occlusal forces. Marginal discrepancies are in the range of clinical acceptability for indirect restorations; however, internal gap widths are higher, resulting in a large film thickness which may be significant for glass ceramics that depend on the physical properties of the cement. Surface treatment combining etching and a silane coupling agent provides the highest bond strength of composite resin cement to feldspathic ceramics and increases the fracture resistance of the restoration. Adequate transmission of light is critical for light- and dual-polymerizing cements to achieve maximum strength and adhesion. When the finish line of the preparation cannot be maintained in enamel, the clinician should consider restorations that are not dependent on adhesion. Pretreatment of alumina cores with a tribochemical silica coating process or airborne-particle abrasion alone produces higher bond strengths for adhesive resin cementation. Zirconia-based restorations can be cemented conventionally due to their high fracture resistance, and they do not require an adhesive interface for retention. Materials with increased translucency that are customized through characterizing or layering techniques will best be able to match natural tooth structure. ability to select the appropriate material, manufacturing technique, and cementation or bonding procedures, to match intraoral conditions and esthetic requirements.

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REFERENCES
1. Land CH. Porcelain dental art: No.II. Dent Cosmos 1903;45:615-20. 2. McLean JW, Hughes TH. The reinforcement of dental porcelain with ceramic oxides. Br Dent J 1965;119:251-67. 3. Sjogren G, Lantto R, Granberg A, Sundstrom BO, Tillberg A. Clinical examination of leucite-reinforced glass-ceramic crowns (Empress) in general practice: a retrospective study. Int J Prosthodont 1999;12:1228. 4. Piconi C, Maccauro G. Zirconia as a ceramic biomaterial. Biomaterials 1999;20:1-25. 5. Christel P, Meunier A, Dorlot JM, Crolet JM, Witvoet J, Sedel L, et al. Biomechanical compatibility and design of ceramic implants for orthopedic surgery. Ann N Y Acad Sci 1988;523:234-56. 6. Piwowarczyk A, Ottl P, Lauer HC, Kuretzky T. A clinical report and overview of scientific studies and clinical procedures conducted on the 3M ESPE Lava All-Ceramic System. J Prosthodont 2005;14:39-45. 7. Raigrodski AJ. Contemporary materials and technologies for all-ceramic fixed partial dentures: a review of the literature. J Prosthet Dent 2004;92:557-62. 8. Raigrodski AJ. Contemporary all-ceramic fixed partial dentures: a review. Dent Clin North Am 2004;48:531-44. 9. Devigus A, Lombardi G. Shading Vita YZ substructures: influence on value and chroma, part I. Int J Comput Dent 2004;7:293-301. 10.Heffernan MJ, Aquilino SA, Diaz-Arnold AM, Haselton DR, Stanford CM, Vargas MA. Relative translucency of six all-ceramic systems. Part I: core materials. J Prosthet Dent 2002;88:4-9. 11.Fischer H, Marx R. Fracture toughness of dental ceramics: comparison of bending and indentation method. Dent Mater 2002;18:12-9. 12.Edelhoff D, Sorensen JA. Tooth structure removal associated with various preparation designs for posterior teeth. Int J Periodontics Restorative Dent 2002;22:241-9. 13.Aboushelib MN, de Jager N, Kleverlaan CJ, Feilzer AJ. Microtensile bond strength of different components of core veneered all-ceramic restorations. Dent Mater 2005;21:984-91. 14.Fradeani M, DAmelio M, Redemagni M, Corrado M. Five-year follow-up with Procera all-ceramic crowns. Quintessence Int 2005;36:105-13. 15.Oden A, Andersson M, Krystek-Ondracek I, Magnusson D. Five-year clinical evaluation of Procera AllCeram crowns. J Prosthet Dent 1998;80:450-6. 16.Odman P, Andersson B. Procera AllCeram crowns followed for 5 to 10.5 years: a prospective clinical study. Int J Prosthodont

CONCLUSIONS
All-ceramic restorations are developed with cores of glass ceramics, aluminum oxide, or zirconium oxide, and are manufactured by heat pressing, slip-casting, sintering, or milling. Successful application of these materials will depend upon the clinicians

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2001;14:504-9. 17.Wolfart S, Bohlsen F, Wegner SM, Kern M. A preliminary prospective evaluation of allceramic crown-retained and inlay-retained fixed partial dentures. Int J Prosthodont 2005;18:497-505. 18.Frankenberger R, Petschelt A, Kramer N. Leucite-reinforced glass ceramic inlays and onlays after six years: clinical behavior. Oper Dent 2000;25:459-65. 19.Fradeani M, Redemagni M. An 11-year clinical evaluation of leucite-reinforced glass-ceramic crowns: a retrospective study. Quintessence Int 2002;33:503-10. 20.Marquardt P, Strub JR. Survival rates of IPS empress 2 all-ceramic crowns and fixed partial dentures: results of a 5-year prospective clinical study. Quintessence Int 2006;37:253-9. 21.Esquivel-Upshaw JF, Anusavice KJ, Young H, Jones J, Gibbs C. Clinical performance of a lithia disilicate-based core ceramic for three-unit posterior FPDs. Int J Prosthodont 2004;17:469-75. 22.Bindl A, Mormann WH. An up to 5-year clinical evaluation of posterior In-Ceram CAD/CAM core crowns. Int J Prosthodont 2002;15:451-6. 23.McLaren EA, White SN. Survival of InCeram crowns in a private practice: a prospective clinical trial. J Prosthet Dent 2000;83:216-22. 24.Vult von Steyern P, Jonsson O, Nilner K. Five-year evaluation of posterior all-ceramic three-unit (In-Ceram) FPDs. Int J Prosthodont 2001;14:379-84. 25.Olsson KG, Furst B, Andersson B, Carlsson GE. A long-term retrospective and clinical follow-up study of In-Ceram Alumina FPDs. Int J Prosthodont 2003;16:150-6. 26.Sorensen JA, Kang SK, Torres TJ, Knode H. In-Ceram fixed partial dentures: three-year clinical trial results. J Calif Dent Assoc 1998;26:207-14. 27.Fradeani M, Aquilano A, Corrado M. Clinical experience with In-Ceram Spinell crowns: 5-year follow-up. Int J Periodontics Restorative Dent 2002;22:525-33. 28.Pallesen U, van Dijken JW. An 8-year evaluation of sintered ceramic and glass ceramic inlays processed by the Cerec CAD/CAM system. Eur J Oral Sci 2000;108:239-46. 29.Otto T, De Nisco S. Computer-aided direct ceramic restorations: a 10-year prospective clinical study of Cerec CAD/CAM inlays and onlays. Int J Prosthodont 2002;15:1228. 30.Malament KA, Socransky SS. Survival of Dicor glass-ceramic dental restorations over 14 years: Part I. Survival of Dicor complete coverage restorations and effect of internal surface acid etching, tooth position, gender, and age. J Prosthet Dent 1999;81:23-32. 31.Kim JW, Bhowmick S, Hermann I, Lawn BR. Transverse fracture of brittle bilayers: relevance to failure of all-ceramic dental crowns. J Biomed Mater Res B Appl Biomater 2006;79:58-65. 32.Kosmac T, Oblak C, Jevnikar P, Funduk N, Marion L. The effect of surface grinding and sandblasting on flexural strength and reliability of Y-TZP zirconia ceramic. Dent Mater 1999;15:426-33. 33.Luthardt RG, Sandkuhl O, Reitz B. ZirconiaTZP and alumina--advanced technologies for the manufacturing of single crowns. Eur J Prosthodont Restor Dent 1999;7:113-9. 34.Reichel K. Virtual Reality by Cerec inLab Framework. Int J Comput Dent 2004;7:8595. 35.Kamposiora P, Papavasiliou G, Bayne SC, Felton DA. Stress concentration in all-ceramic posterior fixed partial dentures. Quintessence Int 1996;27:701-6. 36.Raigrodski AJ, Chiche GJ. The safety and efficacy of anterior ceramic fixed partial dentures: A review of the literature. J Prosthet Dent 2001;86:520-5. 37.Raigrodski AJ, Chiche GJ, Potiket N, Hochstedler JL, Mohamed SE, Billiot S, et al. The efficacy of posterior three-unit zirconiumoxide-based ceramic fixed partial dental prostheses: a prospective clinical pilot study. J Prosthet Dent 2006;96:237-44. 38.Vult von Steyern P, Carlson P, Nilner K. All-ceramic fixed partial dentures designed according to the DC-Zirkon technique. A 2-year clinical study. J Oral Rehabil 2005;32:180-7. 39.Walton TR. An up to 15-year longitudinal study of 515 metal-ceramic FPDs: Part 2. Modes of failure and influence of various clinical characteristics. Int J Prosthodont 2003;16:177-82. 40.Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. Clinical complications in fixed prosthodontics. J Prosthet Dent 2003;90:31-41. 41.Miller LL. Framework design in ceramometal restorations. Dent Clin North Am 1977;21:699-716. 42.Oh SC, Dong JK, Luthy H, Scharer P. Strength and microstructure of IPS Empress 2 glass-ceramic after different treatments. Int J Prosthodont 2000;13:468-72. 43.Nakamura T, Ohyama T, Imanishi A, Nakamura T, Ishigaki S. Fracture resistance of pressable glass-ceramic fixed partial dentures. J Oral Rehabil 2002;29:951-5. 44.Holand W, Schweiger M, Frank M, Rheinberger V. A comparison of the microstructure and properties of the IPS Empress 2 and the IPS Empress glass-ceramics. J Biomed Mater Res 2000;53:297-303. 45.Esquivel-Upshaw JF, Chai J, Sansano S, Shonberg D. Resistance to staining, flexural strength, and chemical solubility of core porcelains for all-ceramic crowns. Int J Prosthodont 2001;14:284-8. 46.Tinschert J, Natt G, Mautsch W, Augthun M, Spiekermann H. Fracture resistance of lithium disilicate-, alumina-, and zirconiabased three-unit fixed partial dentures: a laboratory study. Int J Prosthodont 2001;14:231-8. 47.Raptis NV, Michalakis KX, Hirayama H. Optical behavior of current ceramic systems. Int J Periodontics Restorative Dent 2006;26:31-41. 48.Stappert CF, Att W, Gerds T, Strub JR. Fracture resistance of different partialcoverage ceramic molar restorations: An in vitro investigation. J Am Dent Assoc 2006;137:514-22. 49.Fasbinder DJ. Restorative material options for CAD/CAM restorations. Compend Contin Educ Dent 2002;23:911-6,918.

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50.Attia A, Kern M. Influence of cyclic loading and luting agents on the fracture load of two all-ceramic crown systems. J Prosthet Dent 2004;92:551-6. 51.Reich S, Troeltzsch M, Denekas T, Wichmann M. Generation of functional Cerec 3D occlusal surfaces: a comparison of two production methods relevant in practice. Int J Comput Dent 2004;7:229-38. 52.Bindl A, Luthy H, Mormann WH. Fracture load of CAD/CAM-generated slot-inlay FPDs. Int J Prosthodont 2003;16:653-60. 53.Otto T. Computer-aided direct all-ceramic crowns: preliminary 1-year results of a prospective clinical study. Int J Periodontics Restorative Dent 2004;24:446-55. 54.Denissen H, Dozic A, van der Zel J, van Waas M. Marginal fit and short-term clinical performance of porcelain-veneered CICERO, CEREC, and Procera onlays. J Prosthet Dent 2000;84:506-13. 55.Reich SM, Wichmann M, Rinne H, Shortall A. Clinical performance of large, all-ceramic CAD/CAM-generated restorations after three years: a pilot study. J Am Dent Assoc 2004;135:605-12. 56.Attia A, Kern M. Fracture strength of allceramic crowns luted using two bonding methods. J Prosthet Dent 2004;91:247-52. 57.Bindl A, Mormann WH. Survival rate of mono-ceramic and ceramic-core CAD/ CAM-generated anterior crowns over 2-5 years. Eur J Oral Sci 2004;112:197-204. 58.Reich S, Hornberger H. The effect of multicolored machinable ceramics on the esthetics of all-ceramic crowns. J Prosthet Dent 2002;88:44-9. 59.Kurbad A, Reichel K. Multicolored ceramic blocks as an esthetic solution for anterior restorations. Int J Comput Dent 2006;9:6982. 60.Fritzsche G. Treatment of a single-tooth gap with a Cerec 3D crown on an implant: A case report. Int J Comput Dent 2004;7:199-206. 61.Sevuk C, Gur H, Akkayan B. Copy-milled all-ceramic restorations: case reports. Quintessence Int 2002;33:353-7. 62.Sevuk C, Gur H, Akkayan B. Fabrication of one-piece all-ceramic coronal post and laminate veneer restoration: a clinical report. J Prosthet Dent 2002;88:565-8. 63.Chai J, Takahashi Y, Sulaiman F, Chong K, Lautenschlager EP. Probability of fracture of all-ceramic crowns. Int J Prosthodont 2000;13:420-4. 64.Chang JC, Hart DA, Estey AW, Chan JT. Tensile bond strengths of five luting agents to two CAD-CAM restorative materials and enamel. J Prosthet Dent 2003;90:18-23. 65.Malament KA, Socransky SS. Survival of Dicor glass-ceramic dental restorations over 14 years. Part II: effect of thickness of Dicor material and design of tooth preparation. J Prosthet Dent 1999;81:662-7. 66.Haselton DR, Diaz-Arnold AM, Hillis SL. Clinical assessment of high-strength all-ceramic crowns. J Prosthet Dent 2000;83:396-401. 67.Sundh A, Sjogren G. A comparison of fracture strength of yttrium-oxide- partially-stabilized zirconia ceramic crowns with varying core thickness, shapes and veneer ceramics. J Oral Rehabil 2004;31:682-8.

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Conrad et al

November 2007
68.Xiao-ping L, Jie-mo T, Yun-long Z, Ling W. Strength and fracture toughness of MgO-modified glass infiltrated alumina for CAD/CAM. Dent Mater 2002;18:216-20. 69.Heffernan MJ, Aquilino SA, Diaz-Arnold AM, Haselton DR, Stanford CM, Vargas MA. Relative translucency of six all-ceramic systems. Part II: core and veneer materials. J Prosthet Dent 2002;88:10-5. 70.Magne P, Belser U. Esthetic improvements and in vitro testing of In-Ceram Alumina and Spinell ceramic. Int J Prosthodont 1997;10:459-66. 71.Dozic A, Kleverlaan CJ, Meegdes M, van der Zel J, Feilzer AJ. The influence of porcelain layer thickness on the final shade of ceramic restorations. J Prosthet Dent 2003;90:56370. 72.De Jager N, Pallav P, Feilzer AJ. The influence of design parameters on the FEA-determined stress distribution in CAD-CAM produced all-ceramic dental crowns. Dent Mater 2005;21:242-51. 73. van der Zel JM, Vlaar S, de Ruiter WJ, Davidson C. The CICERO system for CAD/ CAM fabrication of full-ceramic crowns. J Prosthet Dent 2001;85:261-7. 74.Bindl A, Mormann WH. Marginal and internal fit of all-ceramic CAD/CAM crowncopings on chamfer preparations. J Oral Rehabil 2005;32:441-7. 75. Andersson M, Oden A. A new all-ceramic crown. A dense-sintered, high-purity alumina coping with porcelain. Acta Odontol Scand 1993;51:59-64. 76.May KB, Russell MM, Razzoog ME, Lang BR. Precision of fit: the Procera AllCeram crown. J Prosthet Dent 1998;80:394-404. 77.Garvie RC, Hannink RH, Pascoe RT. Ceramic steel? Nature 1975;258:703-4. 78.Garvie RC, Nicholson PS. Phase analysis in zirconia systems. J Am Ceram Soc 1972;55:303-5. 79.Kohal RJ, Klaus G. A zirconia implantcrown system: a case report. Int J Periodontics Restorative Dent 2004;24:147-53. 80.Sundh A, Molin M, Sjogren G. Fracture resistance of yttrium oxide partially-stabilized zirconia all-ceramic bridges after veneering and mechanical fatigue testing. Dent Mater 2005;21:476-82. 81.Luthardt RG, Holzhuter M, Sandkuhl O, Herold V, Schnapp JD, Kuhlisch E, et al. Reliability and properties of ground Y-TZPzirconia ceramics. J Dent Res 2002;81:48791. 82.Luthardt RG, Holzhuter MS, Rudolph H, Herold V, Walter MH. CAD/CAM-machining effects on Y-TZP zirconia. Dent Mater 2004;20:655-62. 83.Tinschert J, Natt G, Mautsch W, Spiekermann H, Anusavice KJ. Marginal fit of alumina-and zirconia-based fixed partial dentures produced by a CAD/CAM system. Oper Dent 2001;26:367-74. 84.Guazzato M, Proos K, Quach L, Swain MV. Strength, reliability and mode of fracture of bilayered porcelain/zirconia (Y-TZP) dental ceramics. Biomaterials 2004;25:5045-52. 85.Addi S, Hedayati-Khams A, Poya A, Sjogren G. Interface gap size of manually and CAD/ CAM-manufactured ceramic inlays/onlays in vitro. J Dent 2002;30:53-8. 86.Coli P, Karlsson S. Fit of a new pressuresintered zirconium dioxide coping. Int J Prosthodont 2004;17:59-64. 87.Butz F, Heydecke G, Okutan M, Strub JR. Survival rate, fracture strength and failure mode of ceramic implant abutments after chewing simulation. J Oral Rehabil 2005;32:838-43. 88.Henriksson K, Jemt T. Evaluation of custom-made procera ceramic abutments for single-implant tooth replacement: a prospective 1-year follow-up study. Int J Prosthodont 2003;16:626-30. 89.Priest G. Virtual-designed and computermilled implant abutments. J Oral Maxillofac Surg 2005;63:22-32. 90.Heydecke G, Sierraalta M, Razzoog ME. Evolution and use of aluminum oxide single-tooth implant abutments: a short review and presentation of two cases. Int J Prosthodont 2002;15:488-93. 91.Suarez MJ, Lozano JF, Paz Salido M, Martinez F. Three-year clinical evaluation of In-Ceram Zirconia posterior FPDs. Int J Prosthodont 2004;17:35-8. 92.Probster L. Four year clinical study of glassinfiltrated, sintered alumina crowns. J Oral Rehabil 1996;23:147-51. 93.Scurria MS, Bader JD, Shugars DA. Metaanalysis of fixed partial denture survival: prostheses and abutments. J Prosthet Dent 1998;79:459-64. 94.Esquivel-Upshaw JF, Anusavice KJ. Ceramic design concepts based on stress distribution analysis. Compend Contin Educ Dent 2000;21:649-52,654. 95.Scherrer SS, de Rijk WG. The fracture resistance of all-ceramic crowns on supporting structures with different elastic moduli. Int J Prosthodont 1993;6:462-7. 96.Meyer A, Jr, Cardoso LC, Araujo E, Baratieri LN. Ceramic inlays and onlays: clinical procedures for predictable results. J Esthet Restor Dent 2003;15:338-51. 97.Wen MY, Mueller HJ, Chai J, Wozniak WT. Comparative mechanical property characterization of 3 all-ceramic core materials. Int J Prosthodont 1999;12:534-41. 98.Lohbauer U, Petschelt A, Greil P. Lifetime prediction of CAD/CAM dental ceramics. J Biomed Mater Res 2002;63:780-5. 99.Seghi RR, Denry IL, Rosenstiel SF. Relative fracture toughness and hardness of new dental ceramics. J Prosthet Dent 1995;74:145-50. 100.Hwang JW, Yang JH. Fracture strength of copy-milled and conventional In-Ceram crowns. J Oral Rehabil 2001;28:678-83. 101.Guazzato M, Albakry M, Swain MV, Ironside J. Mechanical properties of In-Ceram Alumina and In-Ceram Zirconia. Int J Prosthodont 2002;15:339-46. 102.Chong KH, Chai J, Takahashi Y, Wozniak W. Flexural strength of In-Ceram alumina and In-Ceram zirconia core materials. Int J Prosthodont 2002;15:183-8. 103.Zeng K, Oden A, Rowcliffe D. Evaluation of mechanical properties of dental ceramic core materials in combination with porcelains. Int J Prosthodont 1998;11:183-9. 104.Wakabayashi N, Anusavice KJ. Crack initiation modes in bilayered alumina/porcelain disks as a function of core/veneer thickness ratio and supporting substrate

403
stiffness. J Dent Res 2000;79:1398-404. 105.Proos KA, Swain MV, Ironside J, Steven GP. Influence of core thickness on a restored crown of a first premolar using finite element analysis. Int J Prosthodont 2003;16:474-80. 106.Studart AR, Filser F, Kocher P, Luthy H, Gauckler LJ. Mechanical and fracture behavior of veneer-framework composites for all-ceramic dental bridges. Dent Mater 2007;23:115-23. 107.Taskonak B, Mecholsky JJ, Jr, Anusavice KJ. Residual stresses in bilayer dental ceramics. Biomaterials 2005;26:3235-41. 108.Studart AR, Filser F, Kocher P, Luthy H, Gauckler LJ. Cyclic fatigue in water of veneer-framework composites for all-ceramic dental bridges. Dent Mater 2007;23:177-85. 109.Oh W, Gotzen N, Anusavice KJ. Influence of connector design on fracture probability of ceramic fixed-partial dentures. J Dent Res 2002;81:623-7. 110.Oh WS, Anusavice KJ. Effect of connector design on the fracture resistance of allceramic fixed partial dentures. J Prosthet Dent 2002;87:536-42. 111.Oilo G, Tornquist A, Durling D, Andersson M. All-ceramic crowns and preparation characteristics: a mathematic approach. Int J Prosthodont 2003;16:301-6. 112.Pospiech P, Rammelsberg P, Goldhofer G, Gernet W. All-ceramic resin-bonded bridges. A 3-dimensional finite-element analysis study. Eur J Oral Sci 1996;104:390-5. 113.DeLong R, Douglas WH. Development of an artificial oral environment for the testing of dental restoratives: bi-axial force and movement control. J Dent Res 1983;62:32-6. 114.Strub JR, Beschnidt SM. Fracture strength of 5 different all-ceramic crown systems. Int J Prosthodont 1998;11:602-9. 115.Christensen GJ. Marginal fit of gold inlay castings. J Prosthet Dent 1966;16:297305. 116.McLean JW, von Fraunhofer JA. The estimation of cement film thickness by an in vivo technique. Br Dent J 1971;131:10711. 117.Holmes JR, Bayne SC, Holland GA, Sulik WD. Considerations in measurement of marginal fit. J Prosthet Dent 1989;62:4058. 118.Knoernschild KL, Campbell SD. Periodontal tissue responses after insertion of artificial crowns and fixed partial dentures. J Prosthet Dent 2000;84:492-8. 119.Martin N, Jedynakiewicz NM. Interface dimensions of CEREC-2 MOD inlays. Dent Mater 2000;16:68-74. 120.Reich S, Wichmann M, Nkenke E, Proeschel P. Clinical fit of all-ceramic threeunit fixed partial dentures, generated with three different CAD/CAM systems. Eur J Oral Sci 2005;113:174-9. 121.Lin MT, Sy-Munoz J, Munoz CA, Goodacre CJ, Naylor WP. The effect of tooth preparation form on the fit of Procera copings. Int J Prosthodont 1998;11:58090. 122.Molin M, Karlsson S. The fit of gold inlays and three ceramic inlay systems. A clinical and in vitro study. Acta Odontol Scand

Conrad et al

404
1993;51:201-6. 123.Luthardt RG, Bornemann G, Lemelson S, Walter MH, Huls A. An innovative method for evaluation of the 3-D internal fit of CAD/CAM crowns fabricated after direct optical versus indirect laser scan digitizing. Int J Prosthodont 2004;17:680-5. 124.Nakamura T, Dei N, Kojima T, Wakabayashi K. Marginal and internal fit of Cerec 3 CAD/CAM all-ceramic crowns. Int J Prosthodont 2003;16:244-8. 125.Sato K, Matsumura H, Atsuta M. Relation between cavity design and marginal adaptation in a machine-milled ceramic restorative system. J Oral Rehabil 2002;29:24-7. 126.Mou SH, Chai T, Wang JS, Shiau YY. Influence of different convergence angles and tooth preparation heights on the internal adaptation of Cerec crowns. J Prosthet Dent 2002;87:248-55. 127.Balkaya MC, Cinar A, Pamuk S. Influence of firing cycles on the margin distortion of 3 all-ceramic crown systems. J Prosthet Dent 2005;93:346-55. 128.Reich SM, Peltz ID, Wichmann M, Estafan DJ. A comparative study of two CEREC software systems in evaluating manufacturing time and accuracy of restorations. Gen Dent 2005;53:195-8. 129.Boening KW, Wolf BH, Schmidt AE, Kastner K, Walter MH. Clinical fit of Procera AllCeram crowns. J Prosthet Dent 2000;84:419-24. 130.Fleming GJ, Narayan O. The effect of cement type and mixing on the bi-axial fracture strength of cemented aluminous core porcelain discs. Dent Mater 2003;19:69-76. 131.Knobloch LA, Kerby RE, Seghi R, Berlin JS, Lee JS. Fracture toughness of resinbased luting cements. J Prosthet Dent 2000;83:204-9. 132.Diaz-Arnold AM, Vargas MA, Haselton DR. Current status of luting agents for fixed prosthodontics. J Prosthet Dent 1999;81:135-41. 133.Chen JH, Matsumura H, Atsuta M. Effect of different etching periods on the bond strength of a composite resin to a machinable porcelain. J Dent 1998;26:53-8. 134.Kamada K, Yoshida K, Atsuta M. Effect of ceramic surface treatments on the bond of four resin luting agents to a ceramic material. J Prosthet Dent 1998;79:508-13. 135.Ahmad I. Restitution of maxillary anterior aesthetics with all-ceramic components. Int Dent J 2002;52:47-56. 136.Jedynakiewicz NM, Martin N. The effect of surface coating on the bond strength of machinable ceramics. Biomaterials 2001;22:749-52. 137.Kern M, Thompson VP. Sandblasting and silica coating of a glass-infiltrated alumina ceramic: volume loss, morphology, and changes in the surface composition. J Prosthet Dent 1994;71:453-61. 138.Bindl A, Richter B, Mormann WH. Survival of ceramic computer-aided design/manufacturing crowns bonded to preparations with reduced macroretention geometry. Int J Prosthodont 2005;18:21924. 139.Scherrer SS, De Rijk WG, Belser UC. Fracture resistance of human enamel and three all-ceramic crown systems on extracted teeth. Int J Prosthodont 1996;9:580-5. 140.Bindl A, Luthy H, Mormann WH. Strength and fracture pattern of monolithic CAD/ CAM-generated posterior crowns. Dent Mater 2006;22:29-36. 141.Attia A, Abdelaziz KM, Freitag S, Kern M. Fracture load of composite resin and feldspathic all-ceramic CAD/CAM crowns. J Prosthet Dent 2006;95:117-23. 142.Albert FE, El-Mowafy OM. Marginal adaptation and microleakage of Procera AllCeram crowns with four cements. Int J Prosthodont 2004;17:529-35. 143.Federlin M, Sipos C, Hiller KA, Thonemann B, Schmalz G. Partial ceramic crowns. Influence of preparation design and luting material on margin integrity--a scanning electron microscopic study. Clin Oral Investig 2005;9:8-17. 144.Sjogren G, Molin M, van Dijken JW. A 10year prospective evaluation of CAD/CAMmanufactured (Cerec) ceramic inlays cemented with a chemically cured or dualcured resin composite. Int J Prosthodont 2004;17:241-6. 145.Sjogren G, Molin M, van Dijken JW. A 5-year clinical evaluation of ceramic inlays (Cerec) cemented with a dual-cured or chemically cured resin composite luting agent. Acta Odontol Scand 1998;56:2637. 146.Hasegawa EA, Boyer DB, Chan DC. Hardening of dual-cured cements under composite resin inlays. J Prosthet Dent 1991;66:187-92. 147.Peutzfeldt A. Dual-cure resin cements: in vitro wear and effect of quantity of remaining double bonds, filler volume, and light curing. Acta Odontol Scand 1995;53:29-34. 148.Lee IB, Um CM. Thermal analysis on the cure speed of dual cured resin cements under porcelain inlays. J Oral Rehabil 2001;28:186-97. 149.Tanoue N, Koishi Y, Atsuta M, Matsumura H. Properties of dual-curable luting composites polymerized with single and dual curing modes. J Oral Rehabil 2003;30:1015-21. 150.Shimura R, Nikaido T, Yamauti M, Ikeda M, Tagami J. Influence of curing method and storage condition on microhardness of dual-cure resin cements. Dent Mater J 2005;24:70-5. 151.Peumans M, Van Meerbeek B, Lambrechts P, Vanherle G. Porcelain veneers: a review of the literature. J Dent 2000;28:163-77. 152.Federlin M, Schmidt S, Hiller KA, Thonemann B, Schmalz G. Partial ceramic crowns: influence of preparation design and luting material on internal adaptation. Oper Dent 2004;29:560-70. 153.Ferrari M, Cagidiaco MC, Vichi A, Man-

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nocci F, Mason PN, Mjor IA. Bonding of all-porcelain crowns: structural characteristics of the substrate. Dent Mater 2001;17:156-64. 154.Ibarra G, Johnson GH, Geurtsen W, Vargas MA. Microleakage of porcelain veneer restorations bonded to enamel and dentin with a new self-adhesive resin-based dental cement. Dent Mater 2007;23:218-25. 155.Awliya W, Oden A, Yaman P, Dennison JB, Razzoog ME. Shear bond strength of a resin cement to densely sintered high-purity alumina with various surface conditions. Acta Odontol Scand 1998;56:9-13. 156.Kern M, Strub JR. Bonding to alumina ceramic in restorative dentistry: clinical results over up to 5 years. J Dent 1998;26:245-9. 157.Derand P, Derand T. Bond strength of luting cements to zirconium oxide ceramics. Int J Prosthodont 2000;13:131-5. 158.Kern M, Wegner SM. Bonding to zirconia ceramic: adhesion methods and their durability. Dent Mater 1998;14:64-71. 159.Ernst CP, Cohnen U, Stender E, Willershausen B. In vitro retentive strength of zirconium oxide ceramic crowns using different luting agents. J Prosthet Dent 2005;93:551-8. 160.Zhang Y, Lawn BR, Malament KA, Van Thompson P, Rekow ED. Damage accumulation and fatigue life of particleabraded ceramics. Int J Prosthodont 2006;19:442-8. 161.Zhang Y, Lawn BR, Rekow ED, Thompson VP. Effect of sandblasting on the longterm performance of dental ceramics. J Biomed Mater Res B Appl Biomater 2004;71:381-6. 162.Palacios RP, Johnson GH, Phillips KM, Raigrodski AJ. Retention of zirconium oxide ceramic crowns with three types of cement. J Prosthet Dent 2006;96:104-14. 163.Herrguth M, Wichmann M, Reich S. The aesthetics of all-ceramic veneered and monolithic CAD/CAM crowns. J Oral Rehabil 2005;32:747-52. 164.Douglas RD, Przybylska M. Predicting porcelain thickness required for dental shade matches. J Prosthet Dent 1999;82:143-9. 165.Vichi A, Ferrari M, Davidson CL. Influence of ceramic and cement thickness on the masking of various types of opaque posts. J Prosthet Dent 2000;83:412-7. Corresponding author: Dr Heather J. Conrad Division of Prosthodontics, Department of Restorative Dentistry University of Minnesota, School of Dentistry 9-450a Moos Tower 515 Delaware St SE Minneapolis, MN 55455 Fax: 612-626-1496 E-mail: conr0094@umn.edu Copyright 2007 by the Editorial Council for The Journal of Prosthetic Dentistry.

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