Clinical outcomes of lithium disilicate

single crowns and partial fixed dental

prostheses: A systematic review
Sascha Pieger, DMD, Dr med dent,a Arif Salman, BDS, MDS,b and
Avinash S. Bidra, BDS, MSc
University Medical Center Hamburg-Eppendorf, Center for Dental and
Oral Medicine, Hamburg, Germany; Bharath University Sree Balaji
Dental College, Chennai, India; University of Connecticut Health
Center, Department of Reconstructive Sciences, Farmington, Conn
Statement of problem. Lithium disilicate is a relatively new and popular restorative material for esthetic and functional
rehabilitations, but the evidence for clinical outcomes is not clear.

Purpose. The purpose of this systematic review was to analyze the short-term (1- to 5-year) and medium-term (5- to 10-year)
survival rates of lithium disilicate single crowns and partial fixed dental prostheses.

Material and methods. An electronic search for articles in the English-language literature published between January 1998
and June 2013 was performed with the PubMed search engine. The specific search terms used were lithium disilicate, lithium
silicate, IPS e max, IPS Empress, CAD CAM, pressed ceramic, monolithic, and bilayer. After applying predetermined inclusion
and exclusion criteria, the definitive list of selected articles was suitable only for calculating the interval survival rate and
cumulative survival rate.

Results. The electronic search resulted in 2033 titles. The systematic application of inclusion and exclusion criteria resulted
in 12 clinical studies that addressed the clinical outcomes of lithium disilicate restorations. Of these, 2 were randomized
controlled trials, 5 were prospective studies, 1 was a retrospective study, and 4 studies were descriptive in nature. All 12
studies reported on tooth-retained lithium disilicate restorations. The 2-year cumulative survival rate for single crowns was
100%, and the 5-year cumulative survival rate was 97.8%. The 2-year cumulative survival rate for fixed dental prostheses was
83.3%, and the 5-year cumulative survival rate was 78.1%. The cumulative survival rate over a 10-year period, primarily owing
to data from 1 study, was 96.7% for single crowns and 70.9% for fixed dental prostheses.

Conclusions. For lithium disilicate single crowns, the existing evidence indicates excellent short-term survival rates, but the
evidence for medium-term survival is limited. For lithium disilicate fixed dental prostheses, the evidence for short-term survival
is fair, although limited, but the evidence for medium-term survival is not promising. The majority of failures in both types
of restorations were reported in the posterior region. (J Prosthet Dent 2014;-:---)

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

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

Pieger et al
2 Volume
Ceramic restorations are widely
used in the anterior and posterior re-
gion of the oral cavity and are expected
to fulfill esthetic and functional de-
mands.1-12 For this reason, numerous
kinds of ceramic systems have been
developed for clinical use.13 Currently,
2 of the most popular ceramic restor-
ative materials are lithium disilicate and
zirconia, with lithium disilicate having
higher translucency and lower me-
chanical strength than zirconia.14-17
Both materials can be used for either
a monolithic restoration or as a core
material with veneered porcelain.14-17
Common complications that have been
reported for both materials include
cracking, chipping, and the fracture of
the veneering porcelain material.18,19
These complications have been re-
ported to be higher in the posterior
region.20 Moreover, ceramic fixed den-
tal prostheses (FDPs) exhibit higher
rates of fracture of the core framework
than single crown restorations.21
The evolution of lithium disilicate
as a restorative material dates back to
1998, when it was introduced to den-
tistry as IPS Empress 2 (Ivoclar Viva-
dent).22 It was the second generation
of heat-pressed ceramic and contained
lithium disilicate material as the main
crystalline phase.23 The manufacturer’s
indications for this material ranged
from veneers, inlays, onlays, and
crowns to 3-unit FDPs in the anterior
region.24-27 The clinical data for Em-
press 2 indicated higher survival rates
for single crowns and significantly lower
survival rates for 3-unit FDPs.28 This
material was eventually discontinued
by the manufacturer, and a reformu-
lated and optimized composition of
lithium disilicate ceramic was intro-
duced under the trade name IPS e.max
(Ivoclar Vivadent). This is a patented
material exclusively manufactured by
Ivoclar Vivadent and is available in a
pressable version (IPS e.max Press)
or as a partially crystallized ceramic
block for CAD/CAM machining (IPS
e.max CAD).23 Unlike its predecessor
Empress 2, which could only be used as
framework material, the pressable and
The Journal of Prosthetic Dentistry
machinable version of IPS e.max can be
used in a monolithic form. The avail-
ability of this relatively translucent high-
strength monolithic ceramic material
combined with the emerging demand
for metal-free restorations is probably
why the use of lithium disilicate re-
storations is so widespread.14 Given its
popularity, there is a need to review and
synthesize existing clinical data on the
survival of lithium disilicate restorations.
The purpose of this systematic review
was to analyze the short-term (1- to
5-year) and medium-term (5- to 10-year)
survival rates of natural tooth-borne
lithium disilicate single crowns and FDPs.
MATERIAL AND METHODS
An independent electronic search
of the English-language literature was
performed with the PubMed search
engine and Cochrane Library database
by multiple investigators. The specific
terms that were used for the electronic
search were lithium disilicate, lithium
silicate, IPS e max, IPS Empress, CAD
CAM, pressed ceramic, monolithic, and
bilayer. The period searched was from
January 1998 to June 2013. The limits
applied to the search were humans,
English, and dental journals. The inclu-
sion criteria were any English-language
article or bilingual article with English
as one of the languages in a peer-
reviewed journal and any clinical study
on humans involving any of the search
terms listed previously. The exclusion
criteria were as follows: articles that
did not pertain to the search terms
described in the inclusion criteria; re-
view or technique articles without
an associated clinical trial and data;
case reports, case series, or descriptive
studies with fewer than 10 natural-
tooth-supported lithium disilicate res-
torations; patients or data duplicated
in other included articles; and articles
that did not provide the required data
or did not allow extraction of the
required data on lithium disilicate sin-
gle crowns and FDPs.
The electronic search process was
systematically conducted in 3 stages. In
- Issue -
stage 1, the investigators independently
screened all relevant titles of the elec-
tronic search, and any disagreement
was resolved by discussion. In situa-
tions where the application of exclusion
criteria was not clear, the controversial
article was included for consideration
in the abstract stage. In stage 2, the
investigators independently analyzed
abstracts of all selected titles, and dis-
agreements were resolved by discussion.
In situations of uncertainty, the ab-
stract was included for the subsequent
full-text stage. After the application of
exclusion criteria, the definitive list of
articles was screened at stage 3 by
the investigators to extract qualitative
and quantitative data. A supplemental
search was conducted based on the
references from the definitive list of full-
text articles from stage 3 and on addi-
tional articles published beyond the
terminal search date (June 2013 to
November 2013). The definitive list of
articles was analyzed for short-term and
medium-term survival rates of lithium
disilicate single crowns and FDPs by
using an actuarial method for life table
analysis. Additionally, qualitative data
were analyzed across all the definitive
studies that were included.
In this systematic review, the authors
defined failure as the fracture of any
part of a restoration that required the
removal or remake of the restoration.
Short-term survival was defined as the
presence of the restoration in function
1 to 5 years after cementation, and
medium-term survival was defined as
the presence of the restoration in func-
tion 5 to 10 years after cementation. By
using the actuarial method for life table
analysis, the extracted quantitative data
at stage 3 were used to calculate the
interval survival rate (ISR) and the cu-
mulative survival rate (CSR). Both ele-
ments were used to compute the ratio of
surviving restorations in a group during
a specific interval (ISR) or the ratio of
surviving items over the entire observa-
tion period (CSR).29 The calculation of
the interreviewer agreement at the title
and abstract stage was performed by
using the Cohen kappa method.
Pieger et al
- 2014
RESULTS
The initial electronic search using
the specific search terms yielded 2033
titles at stage 1. Of these, 136 articles
were carried forward to the abstract
stage, and, subsequently, 38 articles
were carried forward to the full-text
analysis stage. After further scrutiny,
26 articles15,24-28,30-49 were excluded
(Table I). Finally, qualitative and
quantitative data were extracted from
12 full-text articles (Tables II, III). Of
these articles, 2 were designed as ran-
domized controlled trials,2,5 5 studies
were prospective,1,3,6,7,12 1 was retro-
spective,8 and 4 studies did not specify
the study design and were considered
by the authors to be descriptive in na-
ture.4,9-11 All 12 studies reported on
tooth-retained lithium disilicate resto-
rations. With regard to the method of
fabrication, 3 studies used IPS e.max
Press,3,7,10 2 studies used IPS e.max
CAD,1,6 and 1 study used both sys-
tems.4 Three studies reported on the
Table I. Exclusion of 26 full-text articles based on predetermined exclusion
criteria
Exclusion Criteria Applied
Articles that did not pertain to search
terms described in inclusion criteria
Articles without associated trial and clinical data
Case report/series with fewer than 10 restorations
Patients or data repeated in other included articles
Articles that did not provide required
data or did not allow extraction of required
data on lithium disilicate restorations
Pieger et al
use of IPS Empress 2,8,11,12 and 1 ran-
domized controlled trial (RCT) com-
pared IPS e.max Press with Empress 2.2
Two studies did not specify the manner
in which the lithium disilicate material
was used.5,9 All 12 studies cemented
the restorations with self-adhesive resin
cement or resin-modified glass ionomer
cement. Of the 12 studies, 5 studies
reported support from the manufac-
turer of lithium disilicate (Ivoclar Viva-
dent),1,3,5,6 and 5 studies4,7,8,11,12 did
not report any study support. One
study was funded by the Thailand
Research Fund Grant,9 and one study
acknowledged the support of the
manufacturer and the National In-
stitutes of Health (NIH).2
A total of 519 participants from
all of the 12 studies received 841
lithium disilicate restorations. Of these,
696 were single crowns, and 145 were
FDPs. The sample size ranged from 15
participants to 146 participants per
study. Seven studies reported on the
use of lithium disilicate for single
Article Excluded
Schenke et al31 (2012)
Vanoorbeek et al34 (2010)
Schulte et al43 (2005)
Sjögren et al45 (2004)
Posselt and Kerschbaum48 (2003)
Reiss and Walther49 (2000)
Chu15 (2012)
Fradeani et al32 (2012)
Edelhoff and Brix33 (2011)
Roman-Rodriguez et al35 (2010)
Kurbad and Reichel44 (2005)
Reich et al36 (2010)
Wolfart et al38 (2009)
Wolfart et al42 (2005)
Esquivel-Upshaw et al46 (2004)
Sun et al30 (2013)
Guess et al25 (2013)
Sola-Ruiz et al24 (2013)
Silva et al26 (2011)
Harder et al37 (2010)
Etman et al40 (2008)
Mansour et al39 (2008)
Toksavul and Toman27 (2007)
Esquivel-Upshaw et al41 (2006)
Marquardt and Strub28 (2006)
Wolfart et al47 (2003)
3
crowns,1,2,4,6-9 and 4 studies reported
on FDPs.3,5,10,12 One study investigated
the clinical performance of both single
crowns and FDPs.11 The data from 9
of the 12 studies could be extracted
to classify anterior (canine to canine)
or posterior (premolars and molars)
restorations.1,2,4-9,11 Data from the re-
maining 3 studies could not be extrac-
ted to classify the location of the
restoration.3,10,12 Altogether, the 9
studies that reported on location eval-
uated 257 anterior restorations and
463 posterior restorations.
The most common technical
complication reported was fracture of
the core framework,1,3-5,7,8,10-12 fol-
lowed by chipping of the veneering
porcelain2,3,5,8,11 and debonding of
the restoration from the tooth.2-4,6
The most commonly reported biologic
complications included the need for
endodontic treatment1,3,8 and the
presence of secondary caries.1,4,10 A
wide range of follow-up (0.5-11 years)
was reported across the various studies.
Two studies had a follow-up period of
less than 1 year.4,12 One study had a
follow-up period greater than 5 years,5
and 2 studies had a follow-up period
greater than 10 years.3,8 A life table
survival analysis was presented in 5
studies.1,3,5,8,11 From the remaining
7 studies,2,4,6,7,9,10,12 data had to be
extracted by the authors of this sys-
tematic review to be included in a
pooled life table survival analysis
(Table IV, Fig. 1).
The pooled data from all included
studies showed a total of 34 failures
out of 841 restorations (4%), with 38%
of all failures (13 of 34) occurring
during the first year. The analysis of
failure by restoration type indicated a
significant difference between single
crowns and FDPs (Tables V, VI). Single
crowns did not experience any failure
up to the third year and experienced
a total of 9 failures in this analysis.
Of these 9 failures, 7 failures (77.7%)
were identified in the posterior region.
Furthermore, the total number of fail-
ures for single crowns consisted of 5
core fractures and 4 fractures of the
veneering ceramic. In contrast, FDPs
4 Volume - Issue -

Table II. Qualitative data from definitive 12 studies on lithium disilicate ceramic material
Number Number of Number of Number of Material/
Type of Restorations, Restorations, Restorations, Type of Layering
Author of Study Patients Total Anterior Posterior Restoration Technique Setting

Reich and Prospective 34 41 0 41 SC E.max CAD LT/ University/

Schierz1 (2013) monolithic Private
practice
Esquivel-Upshaw RCT 32 24 0 24 SC E.max Press & University
et al2 (2013) Empress 2/
mono- and
bilayer
Kern et al3 (2012) Prospective 28 36 NR NR FDP E.max Press/ University
monolithic
Cortellini and NR 76 235 136 99 SC E.max Press & Private
Canale4 (2012) E.max CAD/ practice
monolithic
Makarouna RCT 37 18 8 10 FDP not specified/ University
et al5 (2011) bilayer
Fasbinder Prospective 43 62 0 62 SC E.max CAD LT/ University
et al6 (2010) monolithic
Etman and Prospective NR 30 0 30 SC E.max Press/ University
Woolford7 (2010) bilayer
Valenti and Retrospective 146 263 101 160 SC Empress 2/ Private
Valenti8 (2009) bilayer practice
Suputtamongkol NR 30 29 0 29 SC not specified/ University
et al9 (2008) bilayer
Esquivel-Upshaw NR 21 30 NR NR FDP E.max Press/ University
et al10 (2008) bilayer
Taskonak and NR 15 40 12 (for SC only) 8 (for SC only) SC/FDP Empress 2/ University
Sertgöz11 (2006) bilayer
Sorensen Prospective 57 41 NR NR FDP Empress 2/ University
et al12 (1999) bilayer

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

experienced 13 failures during the
first year and a total of 25 failures in
this analysis. Of 25 failures, 17 (68%)
were identified in the posterior region.
The cumulative survival rates (CSRs)
computed for a 5-year interval were
97.8% for single crowns and 78.1% for
FDPs. The CSR over a 10-year interval,
owing mainly to the report from 2
studies,3,8 was 92.6% for all types of
restorations, 96.7% for single crowns,
and 70.9% for FDPs. Because of the
heterogeneity and paucity of the
analyzed data, it was not possible to
compare qualitative and quantitative
data or draw conclusions for clinical
outcomes in relation to the region
of the restoration (maxillary versus
mandibular and anterior versus poste-
rior regions) or regarding the material
(IPS e.max Press versus IPS e.max
CAD versus IPS Empress 2) or for other
The Journal of Prosthetic Dentistry
secondary outcomes such as esthetics
or marginal fit.
DISCUSSION
The purpose of this systematic re-
view was to analyze the short-term and
medium-term results of studies dealing
with the clinical outcomes of lithium
disilicate single crowns and FDPs.
Lithium disilicate was first introduced
in dentistry in 1998 but has become
popular only in the past decade.
Anticipating that long-term survival
data would be unavailable, the authors
designed this review to assess only the
short-term and medium-term survival
rates of lithium disilicate single crowns
and FDPs in an effort to understand the
material’s long-term clinical potential.
The predetermined inclusion criteria
for this systematic review were broad to
permit inclusion of as many articles
as possible. In this systematic review,
the articles were scrutinized by multiple
investigators to minimize error during
the review process and the selection
bias of the articles included. Disagree-
ment was resolved by discussion, and
doubtful articles were carried forward
to the subsequent stage. Articles that
did not meet the various predetermined
criteria for inclusion were analyzed in
depth before being finally excluded.
In this systematic review, only 2
RCTs were identified that compared
lithium disilicate with the gold stan-
dard of metal ceramic restorations.2,5
Esquivel-Upshaw et al2 compared the
performance of metal ceramic crowns
with single-layered IPS e.max Press
and bilayered IPS Empress 2 crowns
and found a 100% survival rate for
all crowns after 3 years. Nevertheless,
Pieger et al
- 2014 5
Table III. Quantitative data of definitive 12 studies on lithium disilicate ceramic material
Number Number of Number of
Type of of Number of Failures During Failures After Range of Nature of
Author Restoration Patients Restorations First Year First Year Follow-up (y) Failure

Reich and SC 34 33 0 1 NR Fracture of

Schierz1 (2013) the core
ceramic
Esquivel-Upshaw SC 32 24 0 0 1.1-3 years N/A
et al2 (2013)
Kern et al3 (2012) FDP 28 36 0 3 6.6-11.1 years Fracture of
the core
ceramic
Cortellini and SC 76 235 0 1 0.5-4 years NR
Canale4 (2012)
Makarouna et al5 FDP 37 18 6 NR NR Fracture of
(2011) the core or
veneering
ceramic
(or both)
Fasbinder et al6 SC 43 62 0 0 NR NR
(2010)
Etman and SC NR 30 0 1 NR NR
Woolford7 (2010)
Valenti and SC 146 263 0 6 NR Fracture of
Valenti8 (2009) the core or
veneering
ceramic
(or both)
Suputtamongkol SC 30 29 0 0 NR NR
et al9 (2008)
Esquivel-Upshaw FDP 21 30 0 4 NR NR
et al10 (2008)
Taskonak and SC/FDP 15 40 3 5 NR Fracture of
Sertgöz11 (2006) the core
ceramic
Sorensen et al12 FDP 57 41 4 NR 0.5-1.5 years NR
(1999)

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

lithium disilicate crowns showed more
crown wear and surface roughness than
metal ceramic crowns, with statistically
significant differences in surface texture
and crown wear found at the third
year. The second RCT, conducted by
Makarouna et al,5 compared the clin-
ical outcome of metal ceramic FDPs
with lithium disilicate FDPs. Based on a
6-year survival rate of 62.7% for ceramic
FDPs, the authors concluded that cli-
nicians should be cautious as to the use
of lithium disilicate for FDPs. Recently
published results by Sola-Ruiz et al24
indicate that the long-term survival of
Pieger et al
lithium disilicate FDPs is discouraging,
with a 10-year survival of IPS Empress
2 FDPs at 71.4%. The results from the
present systematic review confirm these
previous results.
One of the most significant chal-
lenges of data extraction in this
systematic review was the lack of in-
formation about the time the failure
occurred and the number of restora-
tions over the followed-up period.
Two studies reported a follow-up
period of 10 years, one assessing
single crowns8 and another assessing
FDPs.3 All other clinical trials were
conducted with a wide range of
follow-up periods (0.5 to 11 years),
with the most common follow-up
period being in the 1- to 2-year
range. The application of the first 3
predetermined exclusion criteria in this
systematic review was straightforward.
Articles that did not pertain to the
search terms, articles without associ-
ated clinical trial and data, and case
reports and case series with fewer than
10 restorations were excluded without
any issues. The authors decided on 10
restorations as the minimum sample
size in a study to ensure a credible
6 Volume - Issue -

Table IV. Life table analysis for all lithium disilicate restorations (single crowns and fixed dental prostheses combined)
showing cumulative survival rate among definitive 12 included studies
Number of Number of Number of Number of Interval Cumulative
Time Studies Reporting Restorations Failures in Restorations Survival Survival
Interval (y) Interval in Interval Interval At Risk Rate (%) Rate (%)

0-1 12 841 13 841 98.45 98.45

1-2 10 581 6 451 98.66 97.14
2-3 8 448 4 381.5 98.95 96.12
3-4 7 399 2 374.5 99.46 95.61
4-5 3 314 3 271.5 98.89 94.55
5-6 3 293 2 282.5 99.29 93.88
6-7 2 293 3 293 98.97 92.92
7-8 2 292 0 291.5 100 92.92
8-9 2 289 0 287.5 100 92.92
9-10 2 289 1 289 99.65 92.60
10-11 2 288 0 287.5 100 92.60

300
250
200
150
100
50
0
0-1 Y 1-2 Y 2-3 Y 3-4 Y 4-5 Y 5-6 Y 6-7 Y 7-8 Y 8-9 Y 9-10 Y 10-11 Y

Reich and Schierz (2013) Makarouna et al (2011) Suputtamongkol et al (2008)

Esquivel-Upshaw et al (2013) Fasbinder et al (2010) Esquivel-Upshaw et al (2008)
Kern et al (2012) Etman and Woolford (2010) Taskonak and Sertgöz (2006)
Cortellini and Canale (2012) Valenti and Valenti (2009) Sorensen et al (1999)

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

sample size and maximize the amount
of extracted data.
The articles that needed to be
excluded because of redundant data
published by similar authors from pre-
vious studies and articles that did not
allow data extraction were indepen-
dently reanalyzed by the investigators
before making a definitive decision on
their exclusion. Silva et al26 observed no
fractures among 440 pressed lithium
disilicate restorations, including inlays,
The Journal of Prosthetic Dentistry
onlays, crowns, and FDPs, but did
not report the distribution of the
type of restoration and the number
of followed-up restorations over the
observation period. Harder et al37 in-
vestigated the 8-year outcome of inlay-
retained lithium disilicate FDPs and
stated that 40% of the FDPs were lost
owing to fracture of the inlay retainer
but did not report on the time when the
fracture occurred. Mansour et al39
evaluated the clinical performance of
82 IPS Empress 2 crowns and reported
on 3 fractures, but the extraction of
data related to the time of the fail-
ure was not feasible. Toksavul and
Toman27 rated the clinical outcome of
79 IPS Empress 2 crowns and observed
1 fractured crown but did not report
when the failure occurred; this article
was also excluded.
The calculation of the true survival
rate of lithium disilicate restorations
was not feasible because of the various
Pieger et al
- 2014 7
Table V. Life table analysis for lithium disilicate single crowns showing cumulative survival rate among 8 studies that
reported data on single crowns
Number of Number of Number of Number of Interval Cumulative
Time Studies Reporting Restorations in Failures in Restorations Survival Survival
Interval (y) the Interval Interval Interval At Risk Rate (%) Rate (%)

0-1 8 696 0 696 100 100

1-2 7 505 0 409.5 100 100
2-3 5 386 2 326.5 99.38 99.38
3-4 4 341 2 318.5 99.37 98.76
4-5 1 261 2 221 99.09 97.86
5-6 1 260 2 259.5 99.22 97.11
6-7 1 260 1 260 99.61 96.74
7-8 1 259 0 258.5 100 96.74
8-9 1 259 0 259 100 96.74
9-10 1 259 0 259 100 96.74
10-11 1 259 0 259 100 96.74

factors listed previously. The existing
data only permitted the calculation of
the ISR and CSR. As not all patients in
the included studies were followed up
for a minimum of 1 year, the first-year
ISR of 98.45% for all lithium disilicate
restorations does not represent a true
1-year survival rate. However, the
100% 2-year CSR for single crowns is
remarkable.
In a prospective clinical trial by
Marquardt and Strub,28 27 single
crowns and 31 FDPs made of IPS
Empress 2 were followed up for up to 5
years. None of the single crowns frac-
tured, but the framework of 3 FDPs
did. The examination of the fractured
fragments under a scanning electron
microscope disclosed underextended
dimensions of the connector area as the
main reason for fractures. This finding
has been validated by other clinical
studies.38,46 The authors also stated
that catastrophic failures such as frac-
ture of the framework occurred pre-
dominantly in FDPs replacing missing
posterior teeth.3 This finding was
confirmed by the data of the present
systematic review, where 68% of all FDP
fractures were identified in the posterior
region. Similarly, most fractures re-
ported for single crowns occurred in the
posterior region.
No studies in this systematic review
compared the overall clinical perfor-
mance of lithium disilicate with other
ceramic systems. However, single clin-
ical parameters such as the wear or
surface texture of different restorative

Table VI. Life table analysis for lithium disilicate fixed dental prostheses showing cumulative survival rate among 5 studies
that reported data on fixed dental prostheses
Number of Number of Number of Number of Interval Cumulative
Time Studies Reporting Restorations in Failures in Restorations Survival Survival
Interval (y) the Interval Interval Interval At Risk Rate (%) Rate (%)

0-1 5 145 13 145 91.03 91.03

1-2 4 96 6 71.5 91.60 83.39
2-3 3 62 2 45 95.55 79.68
3-4 3 58 0 56 100 79.68
4-5 2 53 1 50.5 98.01 78.11
5-6 2 33 0 23 100 78.11
6-7 1 33 2 33 93.93 73.37
7-8 1 33 0 33 100 73.37
8-9 1 30 0 28.5 100 73.37
9-10 1 30 1 30 96.66 70.93
10-11 1 29 0 28.5 100 70.93

Pieger et al
8 Volume
materials such as metal ceramic, zirco-
nia, or lithium disilicate have been
compared. Esquivel-Upshaw et al41
conducted an in vivo study and
showed significantly higher occlusal
wear rates for lithium disilicate core
ceramic opposing enamel than for the
wear rate of enamel to enamel. In a
direct comparison of the wear rate of
crowns made with 3 different ceramic
systems, Procera AllCeram crowns
(Nobel Biocare) showed the highest
wear rate to enamel, followed by
lithium disilicate crowns and metal
ceramic crowns. Metal ceramic crowns
exhibited the lowest wear to enamel
over the 2-year observation period.40 A
recent RCT has also reported more
wear and surface roughness of veneered
lithium disilicate crowns than of metal
ceramic crowns.2 This roughness may
lead to higher plaque accumulation,
greater wear of the opposing dentition,
and periodontal disease.50,51 Future
clinical studies should address these
issues to better understand the long-
term clinical potential and prognostic
nature of this promising material.
CONCLUSIONS
Within the limitations of this sys-
tematic review, the following conclu-
sions were drawn. For lithium disilicate
single crowns, the short-term evidence
(1 to 5 years) indicates an excellent
survival rate with a 2-year CSR of 100%
and a 5-year CSR of 97.8%. The evi-
dence for medium-term survival (5 to
10 years) is limited, with data from 1
study contributing to a 10-year CSR of
96.7%. Most single crowns failed in the
posterior region. For lithium disilicate
FDPs, the short-term evidence (1 to 5
years) indicated a 5-year CSR of 78.1%,
which is not promising. The evidence
for medium-term survival (5 to 10
years) is limited, with data from 1 study
contributing to a discouraging 10-year
CSR of 70.9%. Most FDPs also failed
in the posterior region. The cumulative
survival rates estimated in this system-
atic review are based on only the re-
ported data. The true survival rate
for both single crowns and FDPs is
The Journal of Prosthetic Dentistry
unknown because of insufficient data,
the loss of patients to follow-up, and
the inconsistent manner of reporting.
REFERENCES
1. Reich S, Schierz O. Chair-side generated
posterior lithium disilicate crowns after 4
years. Clin Oral Investig 2013;17:1765-72.
2. Esquivel-Upshaw J, Rose W, Oliveira E,
Yang M, Clark AE, Anusavice K. Randomized
controlled clinical trial of bilayer ceramic and
metal-ceramic crown performance.
J Prosthodont 2013;22:166-73.
3. Kern M, Sasse M, Wolfart S. Ten-year
outcome of three-unit fixed dental
prostheses made from monolithic lithium
disilicate ceramic. J Am Dent Assoc
2012;143:234-40.
4. Cortellini D, Canale A. Bonding lithium dis-
ilicate ceramic to feather-edge tooth prepa-
rations: a minimally invasive treatment
concept. J Adhes Dent 2012;14:7-10.
5. Makarouna M, Ullmann K, Lazarek K,
Boening KW. Six-year clinical performance of
lithium disilicate fixed partial dentures. Int J
Prosthodont 2011;24:204-6.
6. Fasbinder DJ, Dennison JB, Heys D, Neiva G.
A clinical evaluation of chairside lithium
disilicate CAD/CAM crowns: a two-year
report. J Am Dent Assoc 2010;141(suppl 2):
10S-4S.
7. Etman MK, Woolford MJ. Three-year clinical
evaluation of two ceramic crown systems: a
preliminary study. J Prosthet Dent 2010;103:
80-90.
8. Valenti M, Valenti A. Retrospective survival
analysis of 261 lithium disilicate crowns in a
private general practice. Quintessence Int
2009;40:573-9.
9. Suputtamongkol K, Anusavice KJ,
Suchatlampong C, Sithiamnuai P,
Tulapornchai C. Clinical performance and
wear characteristics of veneered lithia-
disilicate-based ceramic crowns. Dent Mater
2008;24:667-73.
10. Esquivel-Upshaw JF, Young H, Jones J,
Yang M, Anusavice KJ. Four-year clinical
performance of a lithia disilicate-based core
ceramic for posterior fixed partial dentures.
Int J Prosthodont 2008;21:155-60.
11. Taskonak B, Sertgoz A. Two-year clinical
evaluation of lithia-disilicate-based ceramic
crowns and fixed partial dentures. Dent
Mater 2006;22:1008-13.
12. Sorensen JA, Cruz M, Mito WT, Raffeiner O,
Meredith HR, Foser HP. A clinical investiga-
tion on three-unit fixed partial dentures
fabricated with a lithium disilicate glass-
ceramic. Pract Periodontics Aesthet Dent
1999;11:95-106.
13. Kelly JR, Benetti P. Ceramic materials in
dentistry: historical evolution and current
practice. Aust Dent J 2011;56(suppl 1):84-96.
14. Christensen GJ. The ceramic restoration
dilemma: where are we? J Am Dent Assoc
2011;142:668-71.
15. Chu SJ. Current clinical strategies with
lithium-disilicate restorations. Compend
Contin Educ Dent 2012;33:64-7.
- Issue -
16. Guazzato M, Albakry M, Ringer SP,
Swain MV. Strength, fracture toughness
and microstructure of a selection of ceramic
materials, part I: pressable and alumina
glass-infiltrated ceramics. Dent Mater
2004;20:441-8.
17. Guazzato M, Albakry M, Ringer SP,
Swain MV. Strength, fracture toughness
and microstructure of a selection of
ceramic materials, part II: zirconia-based
dental ceramics. Dent Mater 2004;20:
449-56.
18. Sax C, Hammerle CH, Sailer I. 10-year clin-
ical outcomes of fixed dental prostheses with
zirconia frameworks. Int J Comput Dent
2011;14:183-202.
19. Raigrodski AJ, Hillstead MB, Meng GK,
Chung KH. Survival and complications
of zirconia-based fixed dental prostheses:
a systematic review. J Prosthet Dent
2012;107:170-7.
20. Pjetursson BE, Sailer I, Zwahlen M,
Hammerle CH. A systematic review of the
survival and complication rates of ceramic
and metal-ceramic reconstructions after an
observation period of at least 3 years, part I:
single crowns. Clin Oral Implants Res
2007;18(suppl 3):73-85.
21. Della Bona A, Kelly JR. The clinical success of
ceramic restorations. J Am Dent Assoc
2008;139(suppl):8S-13S.
22. Helvey G. Ceramics. Compend Contin Educ
Dent 2010;31:309-11.
23. Denry I, Holloway JA. Ceramics for dental
applications: a review. Materials 2010;3:
351-68.
24. Sola-Ruiz MF, Lagos-Flores E, Roman-
Rodriguez JL, Highsmith Jdel R, Fons-Font A,
Granell-Ruiz M. Survival rates of a lithium
disilicate-based core ceramic for three-unit
esthetic fixed partial dentures: a 10-year
prospective study. Int J Prosthodont 2013;26:
175-80.
25. Guess PC, Selz CF, Steinhart YN, Stampf S,
Strub JR. Prospective clinical split-mouth
study of pressed and CAD/CAM ceramic
partial-coverage restorations: 7-year results.
Int J Prosthodont 2013;26:21-5.
26. Silva NR, Thompson VP, Valverde GB,
Coelho PG, Powers JM, Farah JW, et al.
Comparative reliability analyses of zirconium
oxide and lithium disilicate restorations
in vitro and in vivo. J Am Dent Assoc
2011;142(suppl 2):4S-9S.
27. Toksavul S, Toman M. A short-term clinical
evaluation of IPS Empress 2 crowns. Int J
Prosthodont 2007;20:168-72.
28. Marquardt P, Strub JR. Survival rates of IPS
empress 2 ceramic crowns and fixed partial
dentures: results of a 5-year prospective
clinical study. Quintessence Int 2006;37:
253-9.
29. Pagano M, Gauvreau K. Survival analysisethe
life table method. In: Principles of biostatis-
tics. 2nd ed.Duxbury: Pacific Grove; 2000.
p. 488-94.
30. Sun Q, Chen L, Tian L, Xu B. Single-tooth
replacement in the anterior arch by means of
a cantilevered IPS e.max Press veneer-retained
fixed partial denture: case series of 35 pa-
tients. Int J Prosthodont 2013;26:181-7.
Pieger et al
- 2014
31. Schenke F, Federlin M, Hiller KA, Moder D,
Schmalz G. Controlled, prospective, random-
ized, clinical evaluation of partial ceramic
crowns inserted with RelyX Unicem with or
without selective enamel etching: results after
2 years. Clin Oral Investig 2012;16:451-61.
32. Fradeani M, Barducci G, Bacherini L,
Brennan M. Esthetic rehabilitation of a
severely worn dentition with minimally inva-
sive prosthetic procedures (MIPP). Int J Peri-
odontics Restorative Dent 2012;32:135-47.
33. Edelhoff D, Brix O. Ceramic restorations in
different indications: a case series. J Am Dent
Assoc 2011;142(suppl 2):14S-9S.
34. Vanoorbeek S, Vandamme K, Lijnen I,
Naert I. Computer-aided designed/
computer-assisted manufactured composite
resin versus ceramic single-tooth restorations:
a 3-year clinical study. Int J Prosthodont
2010;23:223-30.
35. Roman-Rodriguez JL, Roig-Vanaclocha A,
Fons-Font A, Granell-Ruiz M, Sola-Ruiz MF,
Bruguera-Alvarez A. Full maxillary rehabilita-
tion with an all-ceramic system. Med Oral
Patol Oral Cir Bucal 2010;15:e523-5.
36. Reich S, Fischer S, Sobotta B, Klapper HU,
Gozdowski S. A preliminary study on the short-
term efficacy of chairside computer-aided
design/computer-assisted manufacturing-
generated posterior lithium disilicate crowns.
Int J Prosthodont 2010;23:214-6.
37. Harder S, Wolfart S, Eschbach S, Kern M.
Eight-year outcome of posterior inlay-
retained ceramic fixed dental prostheses.
J Dent 2010;38:875-81.
Pieger et al
38. Wolfart S, Eschbach S, Scherrer S, Kern M.
Clinical outcome of three-unit lithium-disilicate
glass-ceramic fixed dental prostheses: up to 8
years results. Dent Mater 2009;25:e63-71.
39. Mansour YF, Al-Omiri MK, Khader YS,
Al-Wahadni A. Clinical performance of
IPS-Empress 2 ceramic crowns inserted by
general dental practitioners. J Contempt
Dent Pract 2008;9:9-16.
40. Etman MK, Woolford M, Dunne S. Quanti-
tative measurement of tooth and ceramic
wear: in vivo study. Int J Prosthodont
2008;21:245-52.
41. Esquivel-Upshaw JF, Young H, Jones J,
Yang M, Anusavice KJ. In vivo wear of enamel
by a lithia disilicate-based core ceramic used
for posterior fixed partial dentures: first-year
results. Int J Prosthodont 2006;19:391-6.
42. Wolfart S, Bohlsen F, Wegner SM, Kern M.
A preliminary prospective evaluation of
ceramic crown-retained and inlay-retained
fixed partial dentures. Int J Prosthodont
2005;18:497-505.
43. Schulte AG, Vockler A, Reinhardt R.
Longevity of ceramic inlays and onlays luted
with a solely light-curing composite resin.
J Dent 2005;33:433-42.
44. Kurbad A, Reichel K. CAD/CAM-manufactured
restorations made of lithium disilicate glass
ceramics. Int J Comput Dent 2005;8:337-48.
45. Sjögren G, Molin M, van Dijken JW. A 10-year
prospective evaluation of CAD/CAM-
manufactured (Cerec) ceramic inlays cemen-
ted with a chemically cured or dual-cured resin
composite. Int J Prosthodont 2004;17:241-6.
9
46. Esquivel-Upshaw JF, Anusavice KJ, Young H,
Jones J, Gibbs C. Clinical performance of a
lithia disilicate-based core ceramic for three-
unit posterior FPDs. Int J Prosthodont
2004;17:469-75.
47. Wolfart S, Wegner SM, Al-Halabi A, Kern M.
Clinical evaluation of marginal fit of a new
experimental ceramic system before and after
cementation. Int J Prosthodont 2003;16:
587-92.
48. Posselt A, Kerschbaum T. Longevity of 2328
chairside Cerec inlays and onlays. Int J
Comput Dent 2003;6:231-48.
49. Reiss B, Walther W. Clinical long-term
results and 10-year Kaplan-Meier analysis
of Cerec restorations. Int J Comput Dent
2000;3:9-23.
50. Sorensen JA. A rationale for comparison of
plaque-retaining properties of crown systems.
J Prosthet Dent 1989;62:264-9.
51. Anusavice KJ. Degradability of dental
ceramics. Adv Dent Res 1992;6:82-9.
Corresponding author:
Dr Avinash S. Bidra
University of Connecticut Health Center
263 Farmington Ave, L6078
Farmington, CT 06030
E-mail: avinashbidra@yahoo.com
Copyright ª 2014 by the Editorial Council for
The Journal of Prosthetic Dentistry.