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 MED-
LINE 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 depen-
dent 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 applica-
tion of all-ceramic materials depends on the clinician’s ability
to select the appropriate material, manufacturing technique,
and cementation or bonding procedures, to match intraoral
conditions and esthetic requirements.

Following the introduction of ible restorative materials increased to improve mechanical and physical
the first feldspathic porcelain crown for clinicians and patients. In 1965, properties. The clinical shortcomings
by Land,1 the interest and demand McLean2 pioneered the concept of of these materials, however, such as
for nonmetallic and biocompat- adding Al2O3 to feldspathic porcelain brittleness, crack propagation, low

a
Assistant Professor, Division of Prosthodontics, Department of Restorative Sciences, School of Dentistry, University of Minnesota.
b
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.
Conrad et al
390
tensile strength, wear resistance, and
marginal accuracy, continued to limit
their use.3 Although the first biomedi-
cal 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 abut-
ments, 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 tra-
ditional metal-ceramic restorations
popular,10 patient demand for im-
proved esthetics has driven the devel-
opment of ceramic for use with inlays,
onlays, crowns, FPDPs, and implant-
supported restorations.11 The use of
conservative ceramic inlay prepara-
tions with 5.5 to 27.2% tooth struc-
ture removal is increasing, along with
all-ceramic complete crown prepara-
tions, which are more invasive and
result in 67.5 to 72.3% tooth struc-
ture removal.12 All-ceramic restora-
tions combining esthetic veneering
porcelains with strong ceramic cores
have become popular (Table I). Ve-
neering porcelains typically consist
of a glass and a crystalline phase of
fluoroapatite, aluminum oxide, or
Volume 98 Issue 5
leucite. Veneering a lithium-disilicate,
aluminum-oxide, or zirconium-oxide
core with glass allows dental techni-
cians to customize these restorations
in terms of form and esthetics.13 The
most commonly reported major clini-
cal 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-ce-
ramic systems for FPDPs has limita-
tions. 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

Manufacturing
Core Material System Techniques Clinical Indications

Glass Ceramic
Lithium-disilicate IPS Empress 2 (Ivoclar Vivadent, Heat pressed Crowns, anterior FPDP
Schaan, Liechtenstein) Heat pressed Onlays, 3/4 crowns, crowns, FPDP
(SiO2-Li2O) IPS e.max Press (Ivoclar Vivadent)

Leucite IPS Empress (Ivoclar Vivadent) Heat pressed Onlays, 3/4 crowns, crowns
(SiO2-Al2O3-K2O) Optimal Pressable Ceramic (Jeneric Heat pressed Onlays, 3/4 crowns, crowns
Pentron, Wallingford, Conn) Milled Onlays, 3/4 crowns, crowns
IPS ProCAD (Ivoclar Vivadent)

Feldspathic VITABLOCS Mark II (VITA Zahnfabrik, Milled Onlays, 3/4 crowns, crowns, veneers
(SiO2-Al2O3-Na2O-K2O) Bad Sackingen, Germany) Milled Onlays, 3/4 crowns, crowns, veneers
VITA TriLuxe Bloc (VITA Zahnfabrik) Milled Anterior crowns, veneers
VITABLOCS Esthetic Line (VITA Zahnfabrik)

Alumina
Aluminum-oxide In-Ceram Alumina (VITA Zahnfabrik) Slip-cast, milled Crowns, FPDP
(Al2O3) In-Ceram Spinell (VITA Zahnfabrik) Milled Crowns
Synthoceram (CICERO Dental Systems, Milled Onlays, 3/4 crowns, crowns
Hoorn, The Netherlands) Slip-cast, millled Crowns, posterior FPDP
In-Ceram Zirconia (VITA Zahnfabrik) Densely sintered Veneers, crowns, anterior FPDP
Procera (Nobel Biocare AB,
Goteborg, Sweden)

Zirconia
Yttrium tetragonal Lava (3M ESPE, St. Paul, Minn) Green milled, sintered Crowns, FPDP
zirconia polycrystals Cercon (Dentsply Ceramco, York Pa) Green milled, sintered Crowns, FPDP
(ZrO2 stabilized by Y2O3) DC-Zirkon (DCS Dental AG, Allschwil, Milled Crowns, FPDP
Switzerland) Milled Onlays, 3/4 crowns, crowns
Denzir (Decim AB, Skelleftea, Sweden) Densely sintered, milled Crowns, FPDP, implant abutments
Procera (Nobel Biocare AB)

The Journal of Prosthetic Dentistry Conrad et al

November 2007 391
Table II. Classification of complications and overall survival rates
Major Complications Minor Complications Reported Survival
Study (Restorations Remade) (Restorations Not Remade) Rates (Percent)
Raigrodski37 None Chipped veneer (5) 100
Endodontic therapy (1)
Marginal integrity (1)

Vult von Steyern38 None Chipped veneer (3) 100

Endodontic therapy (1)

Fradeani14 Fracture of veneer and/or coping (2) Chipped veneer (3) 96.7 (100 anterior,
Fracture or delamination of veneer (2) Endodontic therapy (2) 95.15 posterior)

Oden15 Fracture of veneer and coping (3) Endodontic therapy (2) 97

Chipped veneer (2)
Caries (1)

Odman16 Fracture of veneer and coping (4) Decementation (11) 93.5

Caries (1) Chipped/cracked veneer (5)
Caries (2)
Endodontic therapy (2)

Wolfart17 Debonding (3) Endodontic therapy (3) 100 (crown-retained FPDP)

Debonding and fracture (3) Chipped veneer (1) 89 (inlay-retained FPDP)

Frankenberger18 Fracture of veneer and coping (5) Marginal deficiences (94%) 93

Endodontic therapy (2) Removal due to hypersensitivity (2)

Sjogren3 Fracture (7) Slight mismatch in color (13%) 91

Slightly rough surfaces (9%)
Endodontic therapy (2)
Caries (2)

Fradeani19 Fracture (4) (not reported) 95.2 (98.9 anterior,

Post and core fracture (1) 84.4 posterior)
Root fracture (1)

Marquardt20 Fracture (4) (not reported) 100 (posterior crowns)

Endodontic therapy (1) 70 (anterior or premolar
Tooth fracture (1) FPDP)

Esquivel-Upshaw21 Fracture (2) (not reported) 93

Bindl22 Fracture (2) Debonding of composition resin 100 (In-Ceram Spinell)

foundation (1) 92 (In-Ceram Alumina)

McLaren23 Fracture of core (4) (not reported) 96 (98 anterior,

Fracture of veneer (2) 94 posterior)
Removal without failure (3)

Haselton66 Marginal integrity (2) Caries (1) (not reported)

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

Conrad et al
392 Volume 98 Issue 5
Table II. continued (2 of 2) Classification of complications and overall survival rates
Major Complications Minor Complications Reported Survival
Study (Restorations Remade) (Restorations Not Remade) Rates (Percent)
Vult von Steyern24 Fracture (2) (not reported) 90

Olsson25 Fracture (3) Fracture (external trauma) (2) 93

Decementation (1)

Sorensen26 Fracture (7) (not reported) 88.5 (100 anterior,

82.5 posterior)

Suarez91 Root fracture (1) (not reported) 94.5

Probster92 None Caries (5) 100

Decementation (1)

Fradeani27 Fracture (1) Chipped veneer (2) 97.5

Pallesen28 Fracture (3) Chipped/cracked veneer (8) 90.6

Otto29 Fracture (5) Chipped veneer (3) 90.4

Tooth fracture (3) Caries (2)
Caries (1) Endodontic therapy (1)

Malament30 Fracture (180) (not reported) 87.5

Scurria93 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 re-
duced interocclusal distance, as with
short clinical crowns, deep vertical
overlap anteriorly without horizontal
overlap, or an opposing supraerupted
tooth, as well as for cantilevers, peri-
odontally involved abutment teeth,
and patients with severe bruxism or
parafunctional activity.7,21,36 The pri-
mary cause of failure varies from frac-
ture of the connector, for aluminum-
oxide FPDPs24-26 and lithium-disilicate
FPDPs,20,21 to cohesive fracture of the
veneering porcelain, for zirconia FP-
DPs.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 con-
nector height and width is the basis
for proper design of all-ceramic FP-
The Journal of Prosthetic Dentistry
DPs.7,8,41 The purpose of this article is
to review current literature on all-ce-
ramic materials and systems, with re-
spect 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 Eng-
lish 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, computer-
aided design, color, dental restoration
failure, and dental prosthesis design.
MEDLINE and PubMed searches were
conducted focusing on evidence-
based research articles published be-
tween 1996 and 2006. The Journal of
Prosthetic Dentistry and the International
Journal of Prosthodontics were addition-
ally 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 exclu-
sion criteria. Randomized controlled
clinical trials, nonrandomized con-
trolled clinical studies, longitudinal
experimental clinical studies, longi-
tudinal prospective clinical studies,
and longitudinal retrospective clinical
studies were reviewed. Articles that
did not focus exclusively on the resto-
ration of teeth with all-ceramic mate-
rials and systems or the material prop-
erties of ceramics were excluded from
Conrad et al
November 2007
further evaluation. Nonpeer-reviewed
dental literature, abstracts, and clini-
cal reports were excluded from review.
Inclusion criteria for survival studies
included a minimum mean follow-up
period of 2 years, reporting of com-
plications, identification of materi-
als, type of study, setting, and sample
size. Data supporting the clinical ap-
plication of all-ceramic materials and
systems was sought.
RESULTS
A total of 285 articles were iden-
tified 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-ce-
ramic materials and systems are cur-
rently available for clinical use and
there is not a single universal material
or system for all clinical situations.
The successful application of differ-
ent all-ceramic materials is dependent
upon clinicians’ ability to match the
ceramic materials to the manufactur-
ing 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-di-
silicate glass ceramic (SiO2-Li2O) that
is fabricated through a combination
of the lost-wax and heat-pressed tech-
niques. A glass-ceramic ingot of the
desired shade is plasticized at 920°C
and pressed into an investment mold
under vacuum and pressure. Its pre-
decessor, IPS Empress (Ivoclar Viva-
dent), is a leucite-reinforced glass ce-
ramic (SiO2-Al2O3-K2O) which, due to
its strength, is limited in use to single-
unit complete-coverage restorations
Conrad et al
in the anterior segment.19 IPS Em-
press 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 semitranslu-
cent 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 im-
proved through a different firing pro-
cess.48 IPS ProCAD (Ivoclar Vivadent)
is a leucite-reinforced ceramic similar
to IPS Empress, although it has a fin-
er 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, includ-
ing a bleached shade and an esthetic
block line.49-52
Vita Mark II (VITA Zahnfabrik,
Bad Sackingen, Germany), a machin-
able feldspathic porcelain introduced
in 1991 for the CEREC 1 system (Sie-
mens AG, Bensheim, Germany), has
improved strength and finer grain size
(4 μm) 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 compos-
ite resin cements.49,53,54 Although this
product is monochromatic, it is avail-
able in multiple shades, including the
Classic Line Vita shades, Vitapan 3D-
Master 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-dimension-
al layered structure.59 The inner third
has a dark opaque base layer, while
393
the middle third has a neutral zone
comparable to the standard block,
and the outer third is more trans-
lucent. 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 fabricat-
ing feldspathic porcelain restorations
was through copy-milling (Celay; Mi-
krona Technologie AG, Spreitenbach,
Switzerland).61,62 This system milled
restorations by duplicating a direct
acrylic resin pattern replica of an in-
lay, 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 ceram-
ics was Dicor (Dentsply Intl, York,
Pa). This was a glass-ceramic mate-
rial composed of 70% tetrasilicic flu-
ormica crystals precipitated in 30%
glass matrix.64 Originally made using
the lost-wax technique,30,65 it was later
marketed as a machinable glass ce-
ramic28,64 that is no longer available.
Alumina-based ceramics
In-Ceram Alumina (VITA Zahn-
fabrik), introduced in 1989, was the
first all-ceramic system available for
single-unit restorations and 3-unit an-
terior 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 refrac-
tory die at 1120°C for 10 hours.63,68
This produces a porous skeleton of
alumina particles which is infiltrated
with lanthanum glass in a second fir-
ing at 1100°C for 4 hours to elimi-
nate porosity, increase strength, and
limit potential sites for crack propa-
gation.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 cop-
ing is veneered with feldspathic porce-
lain.22,66 Alumina blanks (VITABLOCS
In-Ceram Alumina; VITA Zahnfabrik)
394
are also available for milling in com-
bination with CEREC (Sirona Dental
Systems).22,63
In 1994, In-Ceram Spinell (VITA
Zahnfabrik) was introduced as an al-
ternative to the opaque core of In-Ce-
ram Alumina. It contains a mixture of
magnesia and alumina (MgAl2O4) in
the framework to increase translucen-
cy10,69; however, its flexural-strength
is lower than that of In-Ceram Alu-
mina, 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 veneer-
ing with feldspathic porcelain.22,57
Synthoceram (CICERO Dental Sys-
tems, Hoorn, The Netherlands) is a
high-strength glass-impregnated alu-
minum-oxide ceramic core fabricated
through CICERO technology (Com-
puter Integrated Ceramic Reconstruc-
tion).71,72 Laser scanning, ceramic
sintering, and computer-integrated
milling techniques are used to fab-
ricate the cores, which are veneered
with a leucite-free glass ceramic.54,71-73
In-Ceram Zirconia (VITA Zahnfab-
rik) is also a modification of the origi-
nal In-Ceram Alumina system, with an
addition of 35% partially stabilized zir-
conia 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 feld-
spathic porcelain.7,46,74 Since the core
is opaque and lacks translucency, the
material is recommended for poste-
rior crown copings and FPDP frame-
works.7,67
Procera (Nobel Biocare AB, Gote-
borg, Sweden) was developed by An-
dersson 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
The Journal of Prosthetic Dentistry
electronically to a manufacturing fa-
cility where a 20% enlarged model
is copy-milled and used for the dry-
pressing technique.14,45 High purity
aluminum-oxide powder is mechani-
cally compacted on the enlarged die
and sintered at 1550°C, eliminating
porosity and returning the core to the
dimensions of the working die.45,63,76
The crown form is completed by ve-
neering it with low-fusing feldspathic
porcelain matching the coefficient of
thermal expansion of aluminum ox-
ide.14
Zirconia-based ceramics
Zirconia is a polymorphic material
that occurs in 3 forms. At its melting
point of 2680°C, the cubic structure
exists and transforms into the te-
tragonal phase below 2370°C.4,77,78
The tetragonal-to-monoclinic phase
transformation occurs below 1170°C
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 tough-
ness.33 Tensile stresses at a crack tip
will cause the tetragonal phase to
transform into the monoclinic phase
with an associated 3-5% localized ex-
pansion.32 The volume increase cre-
ates compressive stresses at the crack
tip that counteract the external tensile
stresses. This phenomenon is known
as transformation toughening and re-
tards crack propagation. In the pres-
ence of higher stress, a crack can still
propagate. The toughening mecha-
nism does not prevent the progres-
sion 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 prop-
erties that are attractive for restorative
dentistry; namely, its chemical and di-
mensional stability, high mechanical
strength, and fracture-toughness.13
The cores have a radiopacity com-
Volume 98 Issue 5
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 manufactur-
ing (CAD/CAM) technology. First, an
enlarged coping/framework can be
designed and milled from a homog-
enous ceramic soft green body blank
of zirconia.80 The framework structure
has a linear shrinkage of 20-25% dur-
ing sintering until it reaches the de-
sired final dimensions.6,9 Processing
with this softer presintered material
not only shortens the milling time,
but also reduces the wear on the mill-
ing tools.6 Although zirconia frame-
works 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 flex-
ural 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 con-
tact-free optical process for 5 minutes
for a crown and 12 minutes for a 3-
unit 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 spe-
cial automated oven for 8 hours.6
Other CAD/CAM systems are also
available for designing and milling zir-
conia restorations. Cercon (Dentsply
Ceramco, York, Pa) requires conven-
tional waxing techniques to design the
Y-TZP framework, and the wax pattern
is scanned.7 DCS Precident (DCS Den-
tal AG, Allschwil, Switzerland) uses
fully sintered DC Zirkon ceramic con-
taining 95% ZrO2 partially stabilized
with 5% Y2O3.7,83,84 Denzir (Decim AB,
Skelleftea, Sweden) designs and mills
ceramic inlays from yttrium-oxide
Conrad et al
November 2007
partially sintered blocks.67,85,86
Although the first all-ceramic im-
plant 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 Abut-
ment; 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 alu-
mina due to their increased mechani-
cal 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 ceram-
ic materials and systems, reporting
of complications, study conditions,
and evaluation times; these varying
factors make it difficult to assess the
overall effectiveness of therapy. Inclu-
sion criteria for the reviewed studies
included a minimum mean follow-up
period of 2 years, reporting of com-
plications, identification of materials,
type of study, setting, and sample size
(Tables II and III).
Fracture of the veneering porce-
lain and/or ceramic coping is objec-
395
tive and the most commonly reported
major complication requiring remak-
ing 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 re-
fabrication for 2 other restorations in
the study.16,29 Two groups of investiga-
tors reported endodontic therapy as a
major complication,18,20 while 4 oth-
ers reported root or tooth fracture as
a major complication.19,20,29,91
Several of the reported compli-
cations were considered minor and
did not require remaking of the res-
toration. The most common minor
complication reported was chipping
or cracking limited to the veneering
porcelain (reported for 33 restora-
tions),14-17,27-29,37,38,66 followed by end-
odontic therapy (n=14),3,14-17,29,37,38
decementation (n=13),16,25,92 and

Table III. Study details, including material and restoration type

Type of Type of Sample Mean Range
Study Material Restoration Study Study Size (Years) (Years)

Raigrodski37 Lava FPDPs Prospective University 20 2.6 1.5-3

Vult von Steyern38 DC-Zirkon FPDPs Prospective University 23 2 2

Fradeani14 Procera (alumina) Crowns Prospective Private practice 205 2 0.5-5

Oden15 Procera (alumina) Crowns Prospective Private Practice 100 5 (not reported)

Odman16 Procera (alumina) Crowns Prospective Multicenter 87 (not reported) 5-10.5

Wolfart17 IPS e.max Press Crown-retained Prospective University 36 4 2.5-4.6

FPDP
Inlay-retained 45 3.1 1.7-5
FPDP

Frankenberger18 IPS Empress Inlays, onlays Prospective University 96 (not reported) 1-6

Sjogren3 IPS Empress Crowns, Retrospective Private practice 110 3.6 1.4-5.1
3/4 crowns

Fradeani19 IPS Empress Crowns Retrospective Private practice 125 (not reported) 4-11

Marquardt20 IPS Empress 2 Crowns Prospective University 27 (not reported) 2.75-5.1

FPDPs 31

Esquivel-Upshaw21 IPS Empress 2 FPDPs Prospective University 30 (not reported) 1-2

Conrad et al
396 Volume 98 Issue 5

Table III. continued (2 of 2) Study details, including material and restoration type
Type of Type of Sample Mean Range
Study Material Restoration Study Study Size (Years) (Years)

Bindl22 In-Ceram Spinell Crowns Prospective University 19 3.25 1.2-4.8

In-Ceram Alumina 24

McLaren23 In-Ceram Alumina Crowns Prospective Private practice 223 3 (not reported)

Haselton66 In-Ceram Alumina Crowns Retrospective University 80 4 (not reported)

Vult von Steyern24 In-Ceram Alumina FPDPs Prospective University 20 5 (not reported)

Olsson25 In-Ceram Alumina FPDPs Retrospective Private practice 42 6.3 0.2-9.2

Sorensen26 In-Ceram Alumina FPDPs Prospective University 61 3 (not reported)

Suarez91 In-Ceram Zirconia FPDPs Prospective University 18 3 (not reported)

Probster92 In-Ceram Alumina Crowns Prospective (not reported) 95 2.42 2-4.5

Fradeani27 In-Ceram Spinell Crowns Prospective Private practice 40 4.17 1.8-5

Pallesen28 Vita Mark II, Inlays Prospective University 16 8 (not reported)

Dicor 16

Otto29 Vita Mark I Inlays, onlays Prospective Private practice 200 10 (not reported)

Malament30 Dicor Crowns, inlays, Prospective Private practice 1444 14.1 (not reported)
onlays

Scurria93 Metal-ceramic FPDPs Meta-analysis Various n/a 5 (not

10 applicable)
15

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 por-
celain which did not impair function.
Two studies did not exclude patients
unavailable for evaluation from the
survival rates (reported for 30 resto-
rations).18,26
In instances where minor cohesive
fractures of the veneering porcelain
did not require complete replace-
ment, the restorations were either
polished14,16,27 or repaired with direct
composite resin restorative materi-
al.17,29 Caries identified in the margin-
al areas were excavated and repaired
with direct composite resin restor-
ative material,29,66,92 while endodontic
access preparations were also filled
The Journal of Prosthetic Dentistry
with direct composite resin restor-
ative 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-ce-
ramic restorations range from 88 to
100% after 2-5 years in service,3,14,17,21-
23,26,27,37,38,91,92
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 stud-
ies. 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 all-
ceramic restorations would thus de-
crease reported survival rates. A more
descriptive definition of ceramic res-
toration outcome might include the
categories of success, survival, and
failure.
Material properties
The strength of an all-ceramic res-
toration is dependent on the ceram-
ic material used, core-veneer bond
strength, crown thickness, and design
of the restoration,13,94 as well as bond-
Conrad et al
November 2007
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 com-
plication 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-rein-
forced glass ceramics (IPS Empress;
Ivoclar Vivadent),97 conventional feld-
spathic 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-Ce-
ram Alumina when tested by indenta-
tion strength in 1 study,101 and higher
flexural strength in another.102 Dense-
ly sintered, high purity alumina (Proc-
era; Nobel Biocare AB) was reported
to have significantly higher flexural
strength than glass-infiltrated presin-
tered alumina (In-Ceram Alumina).103
The success of many all-ceramic
systems is dependent on the strength
of a core-veneer bond. Since the ce-
ramic 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 con-
trolling 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 overcon-
touring, or the tooth preparation by
overreduction.105
Even though the veneering por-
celain is used primarily for esthetic
reasons, it has an important role in
the mechanical behavior of the res-
toration.106 The flexural strength and
fracture toughness of these bilayered
restorations depend on the veneer
Conrad et al
layer when the crack initiates from
the veneer surface.107 Although resid-
ual 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 rec-
ommended for FPDPs, as they have
the highest failure loads when com-
pared to alumina- and lithium-dis-
ilicate-based ceramics.46 A lithium-
disilicate 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 FP-
DPs due to the high susceptibility of
the veneer to subcritical crack growth
and the absence of crack arresting
at the core-veneer interface.108 Zir-
conia frameworks with higher elastic
modulus are preferred for all-ceramic
posterior FPDPs compared to lithi-
um-disilicate based ceramics, as they
reduce the stress on the weaker ve-
neer layer and increase the composite
load-bearing capacity, thereby retard-
ing 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 re-
sistance.109,110
Following traditional preparation
guidelines is important not only for
retention of all-ceramic crowns, but
also for stress distribution during dy-
namic 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 prop-
erties are not always capable of repro-
ducing intraoral conditions. Artificial
oral environments have been devel-
oped to simulate intraoral conditions
by applying intermittent dynamic cy-
clic forces, artificial saliva, tempera-
ture fluctuations, and humidity con-
trol.66,113 Testing specimens in these
simulated oral environments has been
397
shown to significantly decrease the
fracture toughness of ceramic mate-
rials.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 suc-
cess and quality of a restoration,
marginal discrepancy is an essential
criterion.74 Christensen115 reported
the clinically detectable range for sub-
gingival margins to be 34-119 µm and
2-51 µm for supragingival margins.
Subsequently, McLean116 suggested
that 120 µm should be the limit for
clinically acceptable marginal discrep-
ancies. Poor marginal adaptation can
result in cement dissolution, micro-
leakage, 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 discrep-
ancy was defined as an angular com-
bination 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 sur-
face.
The incidence of gingival inflam-
mation increases around clinically de-
ficient restorations, particularly those
with rough surfaces, subgingival fin-
ish lines, or poor marginal adapta-
tion; however, gingival inflammation
may also develop around properly
contoured and highly polished res-
torations.118 Although the severity of
gingival response is patient-specific,
current evidence has not shown an
accelerated rate of bone loss or in-
creased attachment loss adjacent to
crowns.118
Contemporary chairside or labo-
ratory-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 cam-
era, scanning equipment, and mill-
398
ing machines. Clinicians’ and dental
technicians’ experience and expertise
is also key with chairside and labo-
ratory-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 contact-
ing probe cannot accurately repro-
duce 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 recom-
mended, not only for scanning and
milling prerequisites, but also to de-
crease stress that would develop in a
restoration with inadequate prepara-
tion and margin geometry.121 An addi-
tional problem with computer-milled
ceramic restorations is that the inter-
nal cutting bur may be larger in di-
ameter than some parts of the tooth
preparation, such as the incisal edge.
This would result in a larger internal
gap than with other fabrication tech-
niques.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 sur-
faces. In general, studies have demon-
strated 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 mechani-
cal properties of the luting cement to
resist functional forces.95 Most of the
literature reports marginal discrepan-
cies in the range of clinical acceptabil-
ity 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 ce-
ments set through an acid-base reac-
The Journal of Prosthetic Dentistry
tion having a tendency to exacerbate
surface flaws in ceramic restorations
due to the increased acidity of the ce-
ment.130 Glass ionomers are suscepti-
ble to early water degradation, result-
ing in microcracks which may initiate
cracks and facilitate crack propaga-
tion 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 advan-
tages of composite resin results in im-
proved strength, fracture toughness,
and wear resistance.132 To improve
success rates with glass- and alumina-
based ceramic restorations, nonacid-
base cements are recommended.130
For conventional glass-ceramic
restorations, the adhesive technique
is critical for successful bonding. Sur-
face treatment of the porcelain by
etching with 5% to 9.5% hydrofluoric
acid133 and etching of the tooth struc-
ture with 37% phosphoric acid134 and
application of a silane coupling agent
provided the highest bond strength
of an adhesive-resin cement to feld-
spathic material. A chemical bond
between feldspathic porcelain and
tooth structure is achieved through
silane coupling agents in composite
resins. Bond strength to etched sur-
faces is improved by creating deep
involuted spaces where resin can flow
and interlock.135,136 Due to the abra-
sion rate with subsequent volume
loss and changes in morphology, feld-
spathic 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 ce-
ramics, definitive adhesive cementa-
tion with composite resin should be
used to increase the fracture resistance
of the restoration.94,130,138,139 The com-
pressive 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
Volume 98 Issue 5
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 with-
stand higher masticatory forces and
demonstrates improved clinical per-
formance.138
Light-, dual-, and chemically po-
lymerized composite resin materials
have been advocated for use with
glass ceramics.143 Decreased sur-
vival 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 Inad-
equate transmission of light through
the ceramic restoration to the under-
lying cement can result in insufficient
polymerization of dual-polymerizing
composite resin cement and lack of
support for the restoration.119 Dual-
polymerizing cements contain perox-
ide 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 dou-
ble 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 al-
lowed to autopolymerize.149 Depend-
ing exclusively on the autopolymeriz-
ing 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 macromechani-
cal retention than adhesive cemen-
tation.138 Finish lines placed below
the cemento-enamel junction result
in a significant loss of adhesion, de-
spite following adhesive luting tech-
niques.151 Since cementum cannot be
infiltrated by resin to the extent that
Conrad et al
November 2007 399

Table IV. Marginal and internal fit studies

In Vivo Mean In Vitro Mean In Vitro Internal
Material and Systems Marginal Gap (µm) Marginal Gap (µm) Gap (µm)

IPS Empress 2/heat pressed 4474 75-10574

IPS Empress/heat pressed 65122 147-16785 20685

Optimal Pressable Ceramic/heat pressed 246-26585 27885

IPS ProCAD/CEREC 3 342123

VITABLOCS Mark II/CEREC 3 53-66124 380123

116-141124

VITABLOCS Mark II/CEREC 2 8554 62-121125 122126

VITABLOCS Mark II/CEREC 1 195122

VITABLOCS Mark II/Celay System 17127

In-Ceram Alumina/Slip-cast 57127

In-Ceram Alumina/Celay System 57127

Synthoceram/CICERO 7454

In-Ceram Zirconia/CEREC in Lab 77128 4374 82-11474

In-Ceram Zirconia/Digident (Digident 92128

GmbH, Pforzheim, Germany)

In-Ceram Zirconia/Slip-cast 2574 71-9474

6083

Procera/densely sintered 6854 1774 119-13674

90-118129 56-6376 36-7476

Lava 80128

DC-Zirkon/Precident System 3374 110-11674

60-7183

Denzir 2374 74-8174

22-4186 110-19286
136-14985 24385
Gold 30122

Ceramic alloy 67128

Conrad et al
400
acid-etched dentin can, microme-
chanical retention at the gingival mar-
gins may contribute little to the bond
strength.152,153 Restorations that are
less dependent on predictable adhe-
sion 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 ce-
ments to alumina-based ceramic res-
torations. Acid etchants used with
glass ceramics do not adequately
roughen the surface of glass-infil-
trated and densely sintered alumi-
na-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 µm of high-purity
aluminum oxide (Rocatec Pre; 3M
ESPE) at 250 KPa for 14 seconds, cre-
ating a uniform pattern of roughness.
This is followed by a tribochemical
coating with 110 µm (Rocatec Plus;
3M ESPE) or a less abrasive 30 µm
(Rocatec Soft; 3M ESPE) of silica-
modified high purity aluminum oxide.
The aluminum oxide leaves the sur-
face 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 pro-
cess was found to be 36 times less for
a glass-infiltrated alumina (In-Ceram
Alumina; VITA Zahnfabrik) than for
a feldspathic glass ceramic (IPS Em-
press; 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 50-
µm 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%
The Journal of Prosthetic Dentistry
hydrofluoric acid for 2 minutes, dia-
mond abrasion combined with etch-
ing with 37% phosphoric acid for 2
minutes, and no treatment.155
Surface treatments including a
tribochemical silica coating process
(Rocatec; 3M ESPE), airborne-par-
ticle abrasion with either 250-µm or
50-µm aluminum oxide, airborne-
particle abrasion with 50-µm alumi-
num oxide combined with 38% hy-
drofluoric acid etching, or diamond
abrasion with a rotary cutting instru-
ment, were reported to have only a
minor influence on bond strength
to zirconia ceramic (Denzir; Decim
AB).157 The tribochemical silica coat-
ing 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 abra-
sion (50-µm 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 res-
torations,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 re-
tention.8
Color and esthetics
Increased translucency correlated
with improved esthetics is the primary
advantage in using an all-ceramic res-
toration. Heffernan et al10 evaluated
Volume 98 Issue 5
the relative translucency of several ce-
ramic materials and found In-Ceram
Spinell (VITA Zahnfabrik) to have the
highest amount of relative translu-
cency. This was followed by IPS Em-
press (Ivoclar Vivadent), Procera (No-
bel 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 Zahn-
fabrik), 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 situ-
ations. Procera was recommended for
average translucency situations, while
In-Ceram Alumina and In-Ceram Zir-
conia 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 translu-
cency, an esthetic competitor. Unfor-
tunately, 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 adja-
cent teeth than In-Ceram Spinell or
metal-ceramic restorations.47
Monochromatic restorations ma-
chined from ceramic blocks have been
scrutinized for their lack of individual
characterization. Although custom-
ized characterizing of these restora-
tions was shown to compete estheti-
cally with layering techniques163 and
multishade block systems,58 no long-
term follow-up for color stability has
been done.
The ratio and thickness of ceramic
core and veneering materials influ-
ence the final shade of a layered por-
celain restoration. An aluminum-ox-
ide ceramic core thickness of 0.7 mm
was found to be sufficient to mask
underlying dentin color.71 With a con-
servative reduction of 1 mm, a semi-
translucent all-ceramic specimen will
match a shade tab more closely than a
metal-ceramic restoration. Increasing
Conrad et al
November 2007
reduction will improve esthetic results
for metal-ceramic and semiopaque
all-ceramic restorations but will not
further enhance shade-matching for
semitranslucent specimens (IPS Em-
press; Ivoclar Vivadent; In-Ceram
Alumina and In-Ceram Spinell; VITA
Zahnfabrik).164 Since IPS Empress res-
torations 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 responsi-
ble for reflecting light and decreasing
translucency. Since enamel is 97% hy-
droxyapatite 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, met-
al-ceramic restorations often appear
brighter intraorally.47
Clinical recommendations
Leucite and feldspathic glass ce-
ramics are indicated for onlays, three
quarter crowns, and veneers, but their
strength limits their use to complete
coverage crowns in the anterior seg-
ment, only. Lithium-disilicate glass ce-
ramics 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 resto-
rations and anterior FPDP applica-
tions, with the exception of In-Ceram
Spinell, which is only recommended
for anterior crowns. Zirconia-modi-
fied alumina is indicated for posterior
crowns and FPDPs, while densely sin-
tered 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
Conrad et al
their application when a high degree
of translucency is required.
Reported survival rates are vari-
able and dependent upon the mate-
rial used, manufacturing technique,
clinical application, and the author’s
definition of failure. Optimal thick-
ness of alumina and zirconia cores
and their respective veneering materi-
als is critical for esthetics and strength
to support occlusal forces. Marginal
discrepancies are in the range of clini-
cal acceptability for indirect restora-
tions; 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 com-
posite resin cement to feldspathic ce-
ramics and increases the fracture re-
sistance 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 alu-
mina cores with a tribochemical silica
coating process or airborne-particle
abrasion alone produces higher bond
strengths for adhesive resin cemen-
tation. Zirconia-based restorations
can be cemented conventionally due
to their high fracture resistance, and
they do not require an adhesive inter-
face for retention. Materials with in-
creased translucency that are custom-
ized through characterizing or layering
techniques will best be able to match
natural tooth structure.
Conclusions
All-ceramic restorations are de-
veloped with cores of glass ceramics,
aluminum oxide, or zirconium oxide,
and are manufactured by heat press-
ing, slip-casting, sintering, or milling.
Successful application of these mate-
rials will depend upon the clinician’s
401
ability to select the appropriate ma-
terial, manufacturing technique, and
cementation or bonding procedures,
to match intraoral conditions and es-
thetic requirements.
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, Sund-
strom BO, Tillberg A. Clinical examination
of leucite-reinforced glass-ceramic crowns
(Empress) in general practice: a retrospec-
tive study. Int J Prosthodont 1999;12:122-
8.
4. Piconi C, Maccauro G. Zirconia as a ceram-
ic biomaterial. Biomaterials 1999;20:1-25.
5. Christel P, Meunier A, Dorlot JM, Crolet
JM, Witvoet J, Sedel L, et al. Biomechani-
cal 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 scien-
tific studies and clinical procedures con-
ducted 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 Pros-
thet 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 bend-
ing and indentation method. Dent Mater
2002;18:12-9.
12.Edelhoff D, Sorensen JA. Tooth structure
removal associated with various prepara-
tion designs for posterior teeth. Int J Peri-
odontics 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, D’Amelio M, Redemagni M,
Corrado M. Five-year follow-up with Pro-
cera all-ceramic crowns. Quintessence Int
2005;36:105-13.
15.Oden A, Andersson M, Krystek-Ondracek
I, Magnusson D. Five-year clinical evalua-
tion 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
402
2001;14:504-9.
17.Wolfart S, Bohlsen F, Wegner SM, Kern M.
A preliminary prospective evaluation of all-
ceramic 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 Prostho-
dont 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 In-
Ceram 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 Prostho-
dont 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 evalu-
ation 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;15:122-
8.
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 Bioma-
ter 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.
The Journal of Prosthetic Dentistry
33.Luthardt RG, Sandkuhl O, Reitz B. Zirconia-
TZP 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;7:85-
95.
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 Pro-
sthet Dent 2001;86:520-5.
37.Raigrodski AJ, Chiche GJ, Potiket N, Hoch-
stedler JL, Mohamed SE, Billiot S, et al. The
efficacy of posterior three-unit zirconium-
oxide-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, Rungcharas-
saeng K, Kan JY. Clinical complications
in fixed prosthodontics. J Prosthet Dent
2003;90:31-41.
41.Miller LL. Framework design in ceramo-
metal 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 den-
tures. J Oral Rehabil 2002;29:951-5.
44.Holand W, Schweiger M, Frank M, Rhein-
berger V. A comparison of the microstruc-
ture 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 zirconia-
based 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 sys-
tems. Int J Periodontics Restorative Dent
2006;26:31-41.
48.Stappert CF, Att W, Gerds T, Strub JR.
Fracture resistance of different partial-
coverage 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 Con-
tin Educ Dent 2002;23:911-6,918.
Volume 98 Issue 5
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, Wich-
mann 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-ceram-
ic 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 all-
ceramic 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;9:69-
82.
60.Fritzsche G. Treatment of a single-tooth
gap with a Cerec 3D crown on an im-
plant: 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 re-
port. 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 Di-
cor 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 frac-
ture strength of yttrium-oxide- partially-sta-
bilized zirconia ceramic crowns with varying
core thickness, shapes and veneer ceramics.
J Oral Rehabil 2004;31:682-8.
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;90:563-
70.
72.De Jager N, Pallav P, Feilzer AJ. The influ-
ence of design parameters on the FEA-de-
termined 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 crown-
copings 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 alu-
mina 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. Ce-
ramic steel? Nature 1975;258:703-4.
78.Garvie RC, Nicholson PS. Phase analy-
sis in zirconia systems. J Am Ceram Soc
1972;55:303-5.
79.Kohal RJ, Klaus G. A zirconia implant-
crown system: a case report. Int J Periodon-
tics Restorative Dent 2004;24:147-53.
80.Sundh A, Molin M, Sjogren G. Fracture re-
sistance 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-TZP-
zirconia ceramics. J Dent Res 2002;81:487-
91.
82.Luthardt RG, Holzhuter MS, Rudolph H,
Herold V, Walter MH. CAD/CAM-machin-
ing effects on Y-TZP zirconia. Dent Mater
2004;20:655-62.
83.Tinschert J, Natt G, Mautsch W, Spie-
kermann 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 pressure-
Conrad et al
sintered 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 computer-
milled 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 glass-
infiltrated, sintered alumina crowns. J Oral
Rehabil 1996;23:147-51.
93.Scurria MS, Bader JD, Shugars DA. Meta-
analysis 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 distribu-
tion analysis. Compend Contin Educ Dent
2000;21:649-52,654.
95.Scherrer SS, de Rijk WG. The fracture resis-
tance 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 charac-
terization 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. Rela-
tive 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, Iron-
side 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. Evalua-
tion of mechanical properties of dental
ceramic core materials in combina-
tion with porcelains. Int J Prosthodont
1998;11:183-9.
104.Wakabayashi N, Anusavice KJ. Crack
initiation modes in bilayered alumina/por-
celain 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 ceram-
ics. 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 prob-
ability 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 all-
ceramic fixed partial dentures. J Prosthet
Dent 2002;87:536-42.
111.Oilo G, Tornquist A, Durling D, Anders-
son M. All-ceramic crowns and prepara-
tion characteristics: a mathematic ap-
proach. Int J Prosthodont 2003;16:301-6.
112.Pospiech P, Rammelsberg P, Goldhofer G,
Gernet W. All-ceramic resin-bonded bridg-
es. 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;16:297-
305.
116.McLean JW, von Fraunhofer JA. The esti-
mation of cement film thickness by an in
vivo technique. Br Dent J 1971;131:107-
11.
117.Holmes JR, Bayne SC, Holland GA, Sulik
WD. Considerations in measurement of
marginal fit. J Prosthet Dent 1989;62:405-
8.
118.Knoernschild KL, Campbell SD. Periodon-
tal tissue responses after insertion of arti-
ficial crowns and fixed partial dentures. J
Prosthet Dent 2000;84:492-8.
119.Martin N, Jedynakiewicz NM. Interface di-
mensions of CEREC-2 MOD inlays. Dent
Mater 2000;16:68-74.
120.Reich S, Wichmann M, Nkenke E, Pro-
eschel P. Clinical fit of all-ceramic three-
unit 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, Good-
acre CJ, Naylor WP. The effect of tooth
preparation form on the fit of Procera
copings. Int J Prosthodont 1998;11:580-
90.
122.Molin M, Karlsson S. The fit of gold inlays
and three ceramic inlay systems. A clinical
and in vitro study. Acta Odontol Scand
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, Wak-
abayashi 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 adap-
tation in a machine-milled ceramic restor-
ative system. J Oral Rehabil 2002;29:24-7.
126.Mou SH, Chai T, Wang JS, Shiau YY. Influ-
ence 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 manufac-
turing 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 alumi-
nous core porcelain discs. Dent Mater
2003;19:69-76.
131.Knobloch LA, Kerby RE, Seghi R, Berlin
JS, Lee JS. Fracture toughness of resin-
based 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 machin-
able 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 mate-
rial. 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
The Journal of Prosthetic Dentistry
preparations with reduced macroretention
geometry. Int J Prosthodont 2005;18:219-
24.
139.Scherrer SS, De Rijk WG, Belser UC. Frac-
ture 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, Tho-
nemann 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 10-
year prospective evaluation of CAD/CAM-
manufactured (Cerec) ceramic inlays
cemented with a chemically cured or dual-
cured 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;56:263-
7.
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, Mat-
sumura 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, Tho-
nemann B, Schmalz G. Partial ceramic
crowns: influence of preparation design
and luting material on internal adapta-
tion. Oper Dent 2004;29:560-70.
153.Ferrari M, Cagidiaco MC, Vichi A, Man-
Volume 98 Issue 5
nocci F, Mason PN, Mjor IA. Bonding of
all-porcelain crowns: structural char-
acteristics of the substrate. Dent Mater
2001;17:156-64.
154.Ibarra G, Johnson GH, Geurtsen W, Var-
gas MA. Microleakage of porcelain veneer
restorations bonded to enamel and dentin
with a new self-adhesive resin-based den-
tal 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-pu-
rity alumina with various surface condi-
tions. Acta Odontol Scand 1998;56:9-13.
156.Kern M, Strub JR. Bonding to alu-
mina 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 lut-
ing 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, Wil-
lershausen 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 ac-
cumulation and fatigue life of particle-
abraded ceramics. Int J Prosthodont
2006;19:442-8.
161.Zhang Y, Lawn BR, Rekow ED, Thompson
VP. Effect of sandblasting on the long-
term 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. Predict-
ing 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.
Conrad et al