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Clinical evaluation of all-ceramic crowns

Deniz Gemalmaz, DDS, PhD,a and Şule Ergin, DDSb

Faculty of Dentistry, Marmara University, Istanbul, Turkey
Statement of problem. There are few in vivo studies on the clinical performance of all-ceramic
Purpose. The aim of this study was to evaluate the clinical performance of IPS Empress crowns.
Material and methods. Thirty-seven all-ceramic IPS Empress crowns were placed in 20 patients.
Twenty crowns were luted with Variolink II low-viscosity resin cement in combination with Syntac Classic
dentin adhesive; the remaining 17 were luted with Variolink II in combination with Syntac Single
Component. All procedural steps were performed by the same prosthodontist. Using the California
Dental Association’s (CDA) quality evaluation system, 2 calibrated evaluators examined the crowns for
margin integrity, anatomic form, surface, and color for a period of 12 to 41 months, with a mean of
24.56 months after insertion. Kaplan-Meier statistical analysis was used to calculate the survival rate of the
crowns. Values obtained for plaque and gingival conditions were compared to control teeth with use of
the Wilcoxon signed ranks test (P<.05).
Results. Based on the CDA criteria, 94.6% of the crowns were rated satisfactory. Fracture was registered
in only 1 crown. One endodontically treated tooth failed due to the dislodgement of the prefabricated
dowel. No significant difference was observed in the gingival health status of crowns that had margins
placed above or at the level of the gingival margin. However, in crowns that had subgingival margin finish
lines, the percentage of bleeding on probing was significantly higher than that of the contralateral control
Conclusion. In this in vivo study, IPS Empress crowns luted with both dentin bonding agents func-
tioned satisfactorily with a relatively low fracture rate over a mean evaluation period of 24.56 months.
(J Prosthet Dent 2002;87:189-96.)

Multiple- and single-step dentin adhesives used on cemented IPS Empress crowns pro-
vided acceptable survival. The slight overextension observed just above the cervical
margin of crowns with subgingival finish lines contributed to increased bleeding on
probing. The results of this study suggest that the risk of gingival inflammation can be
reduced by placing the crown margins above or at the level of the gingival margins
when possible.

O ver the past decade, increased demand for

esthetically pleasing restorations has led to the devel-
observed the clinical performance of such systems in
vivo. It has been stated that traditional fracture tests of
opment of all-ceramic systems. There are 3 primary single-unit, all-ceramic prostheses are inappropriate
modes of manufacturing all-ceramic crowns: conven- since they do not create failure mechanisms equivalent
tional sintering techniques, fabrication by casting or to those seen in retrieved clinical specimens.13 Thus,
with a pressure technique, and various direct milling to validate the actual performance of all-ceramic sys-
techniques. tems, clinical studies are needed.
Numerous ceramics have excellent biocompatibility, The introduction of new bonding techniques and
a natural appearance, and improved physical bonding materials has improved the bond strength of dental
with resin composite luting agents. However, the brit- ceramics to dentin with strengths that approximate the
tle nature of ceramics has been a major factor in their bond to enamel.14,15 Most current dentin adhesive
restriction for universal usage.1-3 Although many in systems are composed of an acidic conditioner and a
vitro studies2-7 have evaluated the fracture resistance of solution of polymerizable hydrophobic and
all-ceramic materials, markedly fewer studies8-12 have hydrophilic reactive monomers. After the acid is rinsed
from enamel and dentin, the monomers are applied in
several coats on the etched enamel and dentin surface.
aAssociate Professor, Department of Prosthodontics. Recently developed 1-bottle dentin adhesives that
bResearch Assistant, Department of Prosthodontics. combine primer and adhesive resin into a single solu-



Table II. Number of IPS Empress crowns according to eval-

uation time
Number of crowns
Evaluation time (mo) Incisors Premolars Molars Total

12 1 — 1
13 — — 1 1
17 — 1 — 1
18 4 1 — 5
19 — 1 — 1
20 — 1 1 2
21 2 1 1 4
24 2 1 — 3
Fig. 1. Labial view of prepared left central and lateral 26 4 1 — 5
incisors. 27 — 2 2 4
29 4 — — 4
31 2 1 — 3
Table I. Distribution, mean age, and age range (in months) 33 — — 1 1
of the IPS Empress crowns evaluated 41 2 — — 2
No. Mean age Age range

Incisors 21 25.61 12-41

Canines — — — replacement due to secondary caries, fracture, or esthet-
Premolars 10 23.0 17-31 ic inadequacy. Eighteen of the restored teeth were
Molars 6 23.5 13-33 nonvital. Of the 18 endodontically treated teeth,
Total 37 24.56 12-41 14 were restored with prefabricated screw-shaped posts
(Gold plated anchorage post; Svenska Dental
Instrument AB, Stockholm, Sweden) and cores manu-
tion have received considerable attention from clini- factured with a resin composite (Charisma; Kulzer,
cians, who often select the material that is easiest to Werheim, Germany). No crown had occlusal contact
use. The use of 1-step adhesives may be advantageous with another. The distribution of crowns on molars,
for reducing working time during cementation since, premolars, and incisors and the age ranges and mean age
in most cases, the application of a rubber dam is not for each group of teeth are presented in Tables I and II.
possible with crowns that have subgingival finish lines. For preparation design, a circumferential shoulder
In some in vitro studies16,17 the use of 1-bottle with rounded internal line angles was used (Fig. 1).
adhesives resulted in lower bond strengths than those Dental caries were excavated, and gross tooth prepara-
obtained with conventional adhesive systems. The tion was performed with medium and coarse diamond
clinical relevance of these bond strengths, however, burs (No. 88805, FT12, FT18, LR23; Ultradent
has not been proven. Products, Inc, South Jordan, Utah). After preparation
The injection molded, all-ceramic IPS Empress is a margins were finished with a fine diamond bur
leucite-reinforced ceramic material composed primari- (856EF012; Komet, Lemgo, Germany), the width of
ly of glass. The crystalline leucite strengthens the the shoulder was 1.2 to 1.5 mm. The occlusal reduc-
ceramic without significantly diminishing its translu- tion was 2 mm for posterior and 1.5 mm for anterior
cency.18 This enables the IPS Empress system to match crowns. The location of crown margins was recorded
the translucency of natural teeth better than all-ceram- both before cementation and at the recall appoint-
ic crowns that use opaque, high-strength cores.19 This ment. Initially, 55% of the cervical margins were
study evaluated the clinical performance of IPS located subgingivally, 25% were located at the gingival
Empress crowns luted with a resin cement and com- margin, and 20% were located supragingivally.
pared the effects of 2 dentin adhesives used for Retraction cord (Stay-put; Roeko, Langenau,
cementation. Germany) was used to isolate subgingival finish lines.
Complete-arch impressions were made with a sili-
con impression material (Speedex; Coltène AG,
A total of 37 IPS Empress crowns (Ivoclar, Schaan, Altstätten, Switzerland), and irreversible hydrocolloid
Liechtenstein) were placed in 20 patients (9 women and impressions (Kromopan, Firenze, Italy) were made of
11 men, ages 19 to 36; mean age 24.7). Two crowns the opposing dentition. All tooth preparations were
were placed because of primary caries, 5 to replace restored with provisional crowns (Dentalon plus;
defective amalgam or composite restorations, 1 to Kulzer). IPS Empress anterior crowns were fabricated
restore a fractured tooth, and 29 because of crown in 2 licensed dental laboratories with the layering tech-



Table III. Criteria for CDA rating

Category Acceptable Unacceptable Criteria

Margin integrity
Excellent No visible evidence of crevice along margin that explorer would
penetrate. No evidence of ditching along margin.
SCR Visible evidence of slight marginal discrepancy with no evidence of
decay; repair possible but perhaps unnecessary. Explorer gets stuck in
one direction.
SDIS Discoloration of margin between restoration and tooth structure.
TFAM Faulty margins cannot be properly repaired.
TPEN Penetrating discoloration along margin of restoration in pulpal direction.
TCEM Retained excess cement.
VMO Mobile restoration.
VFR Fractured restoration.
VCAR Caries continuous with margin of restoration.
VTF Fractured tooth structure.
Anatomic form
Excellent Restoration contour in functional harmony with adjacent teeth and soft
tissues within good individual anatomic form.
SOCO Restoration slightly overcontoured.
SUCO Restoration slightly undercontoured.
SOH Occlusion not completely functional.
SMR Margin ridges slightly undercontoured.
SCO Contact slightly open.
SFA Facial flatting present.
SLG Lingual flatting present.
TUCO Restoration grossly undercontoured.
TOCO Restoration grossly overcontoured.
TET Occlusion affected.
TOC Contact faulty.
TOV Marginal overhang present.
VTO Traumatic occlusion.
VUO Gross underocclusion.
VPN Restoration caused unremitting pain in tooth or adjacent tissue.
VDM Damage to tooth, soft tissue, or supporting bone.
Color and surface
Excellent No mismatch in color shade and/or translucency between restoration(s)
and adjacent teeth. Restoration surface smooth. No irritation of
adjacent tissue.
SMM Slight mismatch between shade of restoration(s) and adjacent tooth or teeth.
SRO Restoration surface slightly rough but can be polished.
TGI Grossly irregular surface not related to anatomy and not subject to correction.
TMM Mismatch between restoration(s) and adjacent tooth or teeth outside
normal range of color, shade, and/or translucency.
VSF Fractured surface.
VGP Gross porosities in crown material.
VSD Shade in gross disharmony with adjacent teeth.

nique, which is intended primarily for esthetic results internal surface of the ceramic crowns was etched with
in the anterior region; posterior crowns were produced 5% hydrofluoric acid (IPS Ceramic etching gel;
with the shading technique.20 The gingival margins Vivadent, Schaan, Liechtenstein) for 2 minutes and
surrounding the abutment teeth were completely then silanated with Monobond-S (Vivadent) for
healthy with no signs of color change or bleeding at 60 seconds. The preparation surfaces were cleaned
the cementation appointment. with pumice slurry and conditioned with 37% phos-
The operation field was isolated with cotton rolls phoric acid gel (Email Preparator GS; Vivadent) for
and high-velocity evacuation during cementation. The 30 seconds. Two different dentin adhesives were used.

FEBRUARY 2002 191


dental histories and symptoms reported by patients,

such as postoperative inconveniences, were registered
according to a routine protocol. The restorations were
evaluated for a period of 12 to 41 months, with a
mean of 24.56 months after insertion (Fig. 2). Two
evaluators examined the crowns for margin integrity,
anatomic form, surface, and color. The evaluators were
calibrated in the use of this evaluation system and
worked independently.
Initial interexaminer agreement was 97%. After dis-
agreements were resolved through discussion,
agreement rose to 99%. Disagreements occurred main-
Fig. 2. Labial view of IPS Empress crowns in maxillary left ly in connection with color ratings; more specifically,
central incisor and lateral incisor after 41 months of clinical there was some uncertainty as to whether the color
service. match to natural teeth should have been rated SMM
or excellent.
Plaque23 and gingival24 index scores were recorded
for the ceramic restorations and corresponding surfaces
of the control teeth. Corresponding surfaces of the
homologous tooth were used as control surfaces for
evaluation. When the homologous tooth was also fitted
with an IPS Empress crown or restored with any other
material, the adjacent tooth or tooth adjacent to the
intact homologous tooth was used as a reference.
Molars were always compared to molars, premolars to
premolars, and canines or incisors to canines or incisors.
Evaluated crowns were evenly distributed between
minimum and maximum time intervals. Otherwise,
Fig. 3. Occlusal view of IPS Empress crown in maxillary left interpretation of the results according to the stated
second premolar after 31 months of clinical service. mean evaluation time would be misleading. Kaplan-
Meier25 statistics were used to analyze the survival
rates of the crowns. Values obtained for plaque and
In 20 crowns (14 anterior and 6 posterior), dentinal gingival conditions were compared to control teeth
surfaces were primed with Syntac Classic dentin adhe- with use of the Wilcoxon signed ranks test for differ-
sive. In 17 crowns (7 anterior and 10 posterior), ence of proportions at a significance of P<.05.
dentinal surfaces were primed with Syntac Single
Component (Vivadent). A bonding agent
(Heliobond; Vivadent) was brushed on both the inter- Of the 37 IPS Empress crowns evaluated, 94.6%
nal and preparation surfaces of the crowns. The were rated satisfactory at the end of the mean evalua-
bonding agent was air thinned, and cementation was tion period of 24.56 months. Fracture was recorded in
performed immediately. All crowns were luted with only 1 crown (13 months after insertion). Bulk frac-
Variolink II low viscosity resin cement (Vivadent). ture was observed on a nonvital maxillary first molar
Excess cement was removed with a dental probe and crown luted with Variolink II in combination with
waxed dental floss. Light-polymerization was per- Syntac Single Component dentin adhesive. Of the
formed with an energy density of 480 mW/cm2 14 endodontically treated teeth restored with a pre-
(Optilux; Demetron Inc, Danbury, Conn.) for fabricated screw post and core of resin composite,
40 seconds from each margin. The occlusion and artic- 1 failed due to fracture of the existing coronal dentin
ulation of the IPS Empress crowns were controlled and dislodgement of the prefabricated dowel. The
carefully during the try-in procedure and after the most common findings among the remaining
crowns were luted.21 All procedural steps from prepa- 35 crowns were a slight mismatch in color between the
ration to luting were performed by the same restoration and tooth structure (37%) (Fig. 3), slight-
prosthodontist. ly overcontoured restorations (20%), and slight margin
The all-ceramic IPS Empress crowns were examined discrepancy with no evidence of decay (19%)
in accordance with the California Dental Association’s (Table IV).
quality evaluation system22 (Table III) with a mirror, a There was no significant difference between the
probe, radiographs, and photographs. Medical and 2 dentin adhesives used in regard to the failure rates



Fig. 4. Kaplan-Meier survival statistics for IPS Empress crowns adhered with Syntac Classic (n
= 20) or Syntac Single Component (n = 17).

obtained (P=.7907, log rank test). On the basis of the Table IV. Percentage of crowns that did not receive an
failure rates obtained and the Kaplan-Meier statistics, excellent rating for margin integrity, anatomic form, or
the estimated survival rate at 2 years was 95% and color and surface (n = 37 for margin integrity; n = 35 for
94.1% for crowns luted with Syntac Classic and Syntac other categories because of crown and tooth substance
Single Component, respectively (Fig. 4). fractures)
Among 19 crowns applied on vital teeth, 1 maxil- Rating No. (%)
lary lateral incisor exhibited occasional sensitivity to Margin integrity
cold and heat. This sensitivity was present from the SCR 7 (19)
time the crown was luted (18 months previously). No SDIS 4 (11)
outstanding findings were registered among the VFR 1 (3)
remaining crowns with regard to anamnesis. VTF 1 (3)
Table V lists the percentages for plaque and gingi- Anatomic form
val indices scores of crowns and controls. Two of the SOCO 7 (20)
37 crowns did not function due to failure; the occur- SOH 1 (3)
rence of plaque and gingival health therefore was Color and surface
SMM 13 (37)
calculated on the basis of 35 IPS Empress crowns and
35 intact control teeth. For no crown was severe
plaque growth or gingival inflammation (Score 3)
observed. The Wilcoxon signed ranks test revealed sig-
nificant differences in plaque growth between crowns DISCUSSION
and control teeth (Table VI). IPS Empress crowns
exhibited significantly less plaque growth than controls The major problem with clinical follow-up studies is
(P<.05). Significant differences also were observed incomplete patient records. If all treated patients did
between the gingival health of IPS Empress crowns not attend evaluations at ordered time sequences, the
and contralateral control teeth. existence or absence of baseline records will determine
Comparison of the gingival health status of IPS whether a retrospective10 or prospective study26 can
Empress crowns in accordance with margin finish line be performed. Although these studies are complicated
locations revealed the following: The gingival index by the use of records obtained at different times, the
scores of crowns with margins placed at or above the population can be considered a random sample if the
gingival margin were similar to those of controls. mean and range of clinical evaluation times are provid-
However, in crowns with subgingival margin finish ed.10,26 Table II shows that the number of crowns in
lines, the percentage of bleeding on probing (Score 2) this study was evenly distributed over the evaluation
was significantly higher for IPS Empress surfaces than period of 12 to 41 months.
for control surfaces (P<.05) (Tables V and VI). Given the conditions of this study, a conventional

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Table V. Plaque and gingival index scores of IPS Empress crowns and control teeth (%)
Plaque index Gingival index
Location of crown margin No. 0 1 2 0 1 2

Mesial Subgingival 30 77 6 3 14 46 26
At level 3 8 — — 9 — —
Supragingival 2 — 6 — — 5 —
Total 35 85 12 3 23 51 26
Control 35 60 29 11 28 63 9
Distal Subgingival 29 71 11 — 14 49 20
At level 5 11 — 3 3 11 —
Supragingival 1 — 3 — — 3 —
Total 35 82 14 3 17 63 20
Control 35 31 57 11 23 54 23
Buccal Subgingival 10 29 — — 9 14 6
At level 19 54 — — 48 6 —
Supragingival 6 14 3 — 14 3 —
Total 35 97 3 — 71 23 6
Control 35 74 17 9 74 23 3
Lingual Subgingival 8 11 11 — — 20 3
At level 8 23 — — 23 — —
Supragingival 19 38 17 — 34 20 —
Total 35 62 28 — 57 40 3
Control 35 63 37 — 66 34 —

Table VI. P values of the Wilcoxon signed-ranks test on

vice. Lehner et al8 reported a fracture rate of 5% in a
plaque and gingival indices scores of crowns and con-
tralateral control teeth follow-up study on 78 IPS Empress crowns after
19.7 months of clinical service. In another study on
Index Location of margin finish line in crowns P value
144 IPS Empress crowns, a fracture rate of 3.5% was
Plaque Subgingival .0001*† reported after 37 months.9 A fracture rate of 6% at
At gingival level .0051*† 43.2 months was reported for 110 IPS Empress
Supragingival .91 crowns in a recent study by Sjögren et al.10
Total .0001*† Consideration of these results leads to the conclusion
Gingival Subgingival .0027* that the fracture rate of IPS Empress crowns is moder-
At gingival level .1088 ate within the first 3 years of clinical service. However,
Supragingival .1797
the uneven distribution of both clinical service times
Total .0517
and luting systems in these studies makes a definite
*Significantat P<.05.
prognosis of IPS Empress crowns impossible. More
differences imply presence of more plaque on the natural tooth
than on the restored crown surface. studies with extended observation times are needed.
No rating that indicated dislodgement or mobile
restoration was assigned to any of the 37 crowns. In
1 crown, dislodgement was observed after 19 months
survival data analysis method was used to assess the due to failure of the prefabricated post. Because dis-
survival rate of all-ceramic crown fractures luted with lodgement was caused by the fracture of the abutment,
2 different dentin adhesives. The structural durability this situation should not be counted as crown fracture. It
of an all-ceramic crown is known to be affected by the is apparent that this typical failure occurred due to a high
type of ceramic material, luting system, and occlusal stress concentration on the extensively damaged maxil-
loading on the crown.13 In previous clinical studies on lary premolar during insertion of the prefabricated post.
all-ceramic crowns,10,12 the uniqueness of location, All crowns cemented with multiple- or single-step
preparation, and morphology among crowns placed in dentin adhesives demonstrated successful retention
the same individual led to the use of crowns, rather within a mean clinical use period of 24.56 months.
than patients, as the unit of analysis. Likewise, in this Although relatively lower bond strength values have
study, the 37 crowns were considered the statistical been reported for single-step dentin adhesives,16,17 the
units for Kaplan-Meier analysis. clinical durability of crowns treated with Syntac Single
For crown fractures, the failure rate in this study Component in this study did not appear to be com-
was 2.7% after mean of 24.56 months of clinical ser- promised.



Plaque index scores indicated that less plaque was the gingival status of abutments with IPS Empress
associated with ceramic surfaces than with nonrestored crowns was poorer than that of the controls when sub-
control surfaces in this study. The relationship between gingival crown margins were placed and slight
plaque retention and dental materials has been contro- overextension was observed just above the cervical
versial. Four previous studies concluded that the margin of the crown.
plaque-retention capacity of ceramics is less than that We thank Drs Ender Kazazoǧlu, Alper Çomut, and Atilla Sertgöz
of other materials or natural teeth27-30; other studies for their help with the statistical analyses reported in this manu-
reported no significant differences in plaque reten- script.
tion.10,31 When the data of different clinical studies is
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Response of three types of cast posts and cores to static

Noteworthy Abstracts loading.
of the Martinez-Gonzalez A, Amigo-Borras V, Fons-Font A, Selva-
Current Literature Otaolaurruchi E, Labaig-Rueda C. Quintessence Int

Purpose. Opaque metal posts and cores, when used in conjunction with all-ceramic crowns, may
not be acceptable if they impart a grayish color to the final restoration. This study examined the
influence of continuous compression loading on 3 different types of cast posts and cores.
Material and methods. Thirty extracted maxillary canines were prepared for cast posts and cores
and divided into 3 groups of 10 teeth each. Post spaces were standardized to a diameter of 1.2
mm and a depth of 10 mm. A guideline was cut for crown restoration with a chamfer margin 1.5
to 2 mm from the coronal surface. Each group received a cast post and core of one of the fol-
lowing types: chrome-nickel alloy, acetalic resin, or IPS-Empress porcelain. Metallic cast crowns
were luted to the cores with zinc phosphate cement under 10 kg pressure for 1 minute. To ensure
that loading conditions were the same for all specimens, a 0.3-mm-deep and 1-mm-wide notch
was made above the cingulum. Specimens were placed under compression at an angulation of 45°
and loaded until tooth or restoration failure. After failure, the restoration was sectioned along its
long axis and examined under ×40 magnification.
Results. The mean load to failure for the tooth/restoration units was as follows: chrome-nickel
alloy = 2120 N, acetalic resin = 2139 N, and IPS Empress = 1491 N. Microscopically, the frac-
ture of the tooth occurred in the region apical to the post in 46% of the specimens, usually in
coincidence with the upper or middle third of the tooth.
Conclusion. Chrome-nickel and acetalic resin cast posts and cores possessed the same resistance
to continuous loading. 38 References.—ME Razzoog