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 165

Clinical Evaluation of 860 Anterior and

Posterior Lithium Disilicate Restorations:
Retrospective Study with a Mean Follow-up of
3 Years and a Maximum Observational Period of 6 Years

Giacomo Fabbri, DDS1/ Fernando Zarone, MD, DDS2 In recent decades, several types of
Gianluca Dellificorelli, DDS3/Giorgio Cannistraro, DDS4 all-ceramic systems have been de-
Marco De Lorenzi, DDS5/Alberto Mosca, DDS6 veloped to satisfy patients’ esthetic
Roberto Sorrentino, DDS, MSc, PhD7 demands. All-ceramic materials
can be divided into two groups:
This study aimed to assess the clinical performance of lithium disilicate restorations
supported by natural teeth or implants. Eight hundred sixty lithium disilicate silica based (feldspathic and glass-
adhesive restorations, including crowns on natural teeth and implant abutments, ceramics) and polycrystalline ce-
veneers, and onlays, were made in 312 patients. Parafunctional patients were ramics (alumina and zirconia).1
included, but subjects with uncontrolled periodontitis and gingival inflammation Silica-based materials are charac-
were excluded. Veneers up to 0.5 mm thick were luted with flowable composite
terized by etchability and translu-
resin or light curing cements, while dual-curing composite systems were used
cency and ensure optimal esthetics,
with veneers up to 0.8 mm thick. Onlays up to 2 mm in thickness were luted
with flowable composite resins or dual-curing composite cements. Crowns up a natural appearance, and reliable
to 1 mm in thickness were cemented with self-adhesive or dual-curing resin clinical performances.2 Conversely,
cements. The observational period ranged from 12 to 72 months, with a mean polycrystalline ceramics are char-
follow-up of 3 years. The mechanical and esthetic outcomes of the restorations acterized by outstanding mechani-
were evaluated according to the modified California Dental Association (CDA)
cal properties.3 Such materials are
criteria. Data were analyzed with descriptive statistics. Twenty-six mechanical
mostly indicated to produce fixed
complications were observed: 17 porcelain chippings, 5 fractures, and 4 losses
of retention. Structural drawbacks occurred mainly in posterior segments, and dental prostheses (FDPs) with four
monolithic restorations showed the lowest number of mechanical complications. or more units in anterior and poste-
The clinical ratings of the successful restorations, both monolithic and layered, rior areas. The low translucency of
were satisfactory according to the modified CDA criteria for color match, porcelain polycrystalline materials facilitates
surface, and marginal integrity. The cumulative survival rates of lithium disilicate
the treatment of discolored abut-
restorations ranged from 95.46% to 100%, while cumulative success rates
ments.3 Data on strength, color
ranged from 95.39% to 100%. All restorations recorded very high survival and
success rates. The use of lithium disilicate restorations in fixed prosthodontics stability, precision of fit, and clinical
proved to be effective and reliable in the short- and medium-term. (Int J performance of alumina and zirco-
Periodontics Restorative Dent 2014;34:165–177. doi: 10.11607/prd.1769) nia are available in the literature.4–7

1Private Practice, Cattolica, Italy. Teaching and Research Assistant, University “Federico II” of
7

Professor and Chair, University “Federico II” of Naples,

2 Naples, Naples, Italy.
Naples, Italy.
3Private Practice, Rome, Italy.
Correspondence to: Dr Giacomo Fabbri, Cattolica, Italy, Via del
4Private Practice, Castagnola delle Lanze, Italy.
Porto 17 Cattolica (Rimini), 47841 Italy; fax + 39 0541 833322;
5Private Practice, Padova, Italy.
email: fabbrigiacomo@libero.it.
6Private Practice, Brescia, Italy. ©2014 by Quintessence Publishing Co Inc.

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166
Zirconia core fractures were not re-
ported in three-unit FDPs.8,9 On the
contrary, chipping of the veneering
ceramics was described as the most
frequent complication: chipping
rates ranging from 8% to 25% after
24 to 38 months were observed for
three-unit posterior FDPs.8,9
Limited clinical data on the reli-
ability of all-ceramic single crowns
are available.10 Clinical retrospec-
tive studies showed excellent per-
formances of alumina crowns in
anterior areas and good rates in
posterior segments.5,11 In 2006, a
pressable lithium disilicate glass-
ceramic (IPS e.max Press, Ivoclar
Vivadent) with improved physical
properties and translucency was
developed. Restorations can be
produced either with a core subse-
quently veneered with dedicated
glass-ceramic fluoroapatite or in ful-
ly anatomical restorations and then
stained. More recently, a lithium di-
silicate glass-ceramic designed for
computer-aided design/computer-
assisted manufacture (CAD/CAM)
(IPS e.max Cad, Ivoclar Vivadent)
was introduced, and preliminary
investigations showed excellent
biomechanic characteristics.7 Be-
cause of its high strength (∙400
MPa), etchability, translucency, and
optimal esthetics, this material of-
fers versatile applications and can
be used in several types of restora-
tions, ensuring a minimally invasive
approach, excellent function, and
esthetics. Lithium disilicate glass-
ceramic represents a clinical option
in the prosthetic treatment of single
restorations such as veneers, inlays,
onlays, and crowns. Monolithic res-
torations with a staining technique
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can be used to restore posterior
segments.7,12–15 The same approach
is paramount in anterior areas to
manage extremely reduced thick-
nesses, preserving as much dental
tissue as possible and often avoid-
ing preprosthetic endodontic treat-
ments. Acid-etching techniques and
resin luting procedures allow clini-
cians to produce restorations with
excellent clinical performances.16,17
Due to its high flexural strength, IPS
e.max can be used for three-unit
FDPs, particularly in anterior seg-
ments where esthetics represent a
fundamental parameter.15,18
CAD/CAM technologies pro-
ducing zirconia and titanium frame-
works have increasingly gained
popularity in implant dentistry,
combining optimal biologic and
mechanical characteristics19,20 and
showing values of fit comparable
with those of conventional super-
structures.20,21 Zirconia and titanium
are generally used to produce cus-
tomized abutments22; in such cas-
es, lithium disilicate single crowns
and three-unit FDPs can be used
to finalize the restoration. Titanium
frameworks are usually indicated
for full-arch prostheses using ve-
neering acrylic or composite resin
materials; the most common com-
plication is chipping of the veneer-
ing materials.23 Zirconia frameworks
represent a promising restorative
option for implant single crowns
and FDPs.24–27 However, the clinical
success of zirconia implant restora-
tions appears to be limited by chip-
ping of the veneering ceramic.25–27
The combination of lithium di-
silicate restorations with zirconia or
titanium frameworks represents a
valid option to combine mechani-
cal effectiveness with excellent es-
thetics, improving the long-term
clinical outcomes of implant pros-
theses. The adhesion between
lithium disilicate and zirconia or
titanium can be performed using
resin cements.28
The present retrospective study
aimed at assessing the clinical per-
formance of anterior and posterior
lithium disilicate restorations sup-
ported by either natural teeth or
implants. This observational analy-
sis evaluated both the mechanics
and esthetics of the prostheses
over a maximum period of 6 years.
Method and materials
Study population
Between June 2006 and Decem-
ber 2010, six expert prosthodon-
tists made 860 lithium disilicate
restorations in 312 patients (143
men, age range: 19 to 61 years;
169 women, age range: 19 to 71
years). Patients were in need of
different prosthetic therapies and
were selected from consecutive
patients both at the authors’ offic-
es and at the Department of Fixed
Prosthodontics of the University
“Federico II” of Naples, Italy. The
Ethical Committee of the university
provided institutional review board
approval, and all patients signed a
written consent form to participate
in the study.
The following inclusion criteria
for abutment teeth were adopted9:
good oral hygiene, periodontally
healthy, vital or endodontically
 167

Table 1 Descriptive characteristics of the study groups

Follow-up range Mean follow-up Cumulative Cumulative

Group (mo) (mo) survival rate (%) success rate (%)
Anterior crowns Veneered (n = 209) 24–72 37.3 98.57 97.61
Monolithic (n = 22) 95.46 95.46
Posterior crowns Veneered (n = 65) 12–61 33.4 96.92 95.39
Monolithic (n = 132) 96.21 96.21
Implant crowns Veneered (n = 7) 12–61 28.3 100 100
Monolithic (n = 45) 97.78 97.78
Anterior veneers Veneered (n = 239) 12–72 42.1 97.91 96.24
Monolithic (n = 40) 100 100
Posterior veneers Veneered (n = 26) 24–61 37.5 100 100
Monolithic (n = 13) 100 100
Onlays Veneered (n = 16) 12–57 32.5 100 100
Monolithic (n = 46) 97.83 97.83

treated to a clinically sound state,
and opposing natural teeth or
fixed prostheses.
Patients not fulfilling the inclu-
sion criteria were excluded from
the study. All patients were in good
general health, and 34% were
smokers (more than 5 cigarettes per
day). The gingival health was main-
tained during the study period.
According to patients’ needs,
single crowns on both teeth and
implants and veneers and onlays
were made in anterior and posteri-
or areas as follows: 480 crowns (329
maxillary, 151 mandibular), 318 ve-
neers (203 maxillary, 115 mandibu-
lar), and 62 onlays (21 maxillary and
41 mandibular) (Table 1); 261 pros-
theses were placed in patients with
parafunctions (30.3%). The restora-
tions were fabricated using pressed
lithium disilicate using both mono-
lithic and layered techniques.
Patients with at least a 1-year
follow-up were recalled for clinical
and radiologic assessments. The
observational period ranged from
12 to 72 months, with a mean fol-
low-up of 3 years.
Veneers
A total of 318 veneers were made
(203 in the maxilla and 115 in the
mandible) (Table 2). Tooth prepa-
rations were performed with a
slight chamfer with a depth of 0.2
to 0.8 mm, an axial reduction of 0
to 0.8 mm, and an incisal reduc-
tion of 0 to 1.5 mm in relation to
the wax-up and the presence of
discoloration on teeth. Transparent
silicone templates derived from
the wax-up were used to optimize
the preparation.29 The axial reduc-
tion was achieved using tapered
round-ended burs, preserving as
much enamel as possible, to keep
the finish lines within enamel and
achieve the best long-term reten-
tion.30 The interproximal contact
points between teeth were opened
only in the presence of Class III
composite restorations or in clini-
cal situations such as diastema or
interproximal black triangles. A
palatal chamfer was made in 56 ve-
neers, while a butt joint was made
in 262 restorations. The buccal
thickness ranged from 0.2 to 0.8
mm in the cervical third, 0.2 to 1.2
mm in the middle third, and 0.3 to
0.9 mm in the incisal third. Centric
contacts at the interface were pre-
vented through the localization of
opposing contacts.29 The margins
were preferably located supragin-
givally, thus resulting in simplified
impression taking and evaluation
of marginal adaptation while help-

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168

Table 2 Anatomical distribution of lithium disilicate restorations

Distribution of restored teeth

Layered veneers Monolithic veneers Layered crowns Monolithic crowns
Teeth Maxilla Mandible Maxilla Mandible Maxilla Mandible Maxilla Mandible
Central incisors 64 27 13 2 43 3 12 4
Lateral incisors 49 27 9 2 47 3 11 4
Canines 41 24 10 4 28 9 8 11
First premolars 12 8 5 4 40 18 28 23
Second premolars 5 8 2 2 38 23 29 29
First molars – – – – 13 8 17 10
Second molars – – – – 4 4 9 4
Total 171 94 39 14 213 68 114 85

Fig 1    Rehabilitation of the maxillary anterior teeth with six lithium disilicate veneers. (a) Preoperative view. (b) Five-year follow-up.

ing to maintain periodontal health.
When the contour of the restora-
tion needed to be changed, the
margins were located at the gingi-
val crest or slightly into the crevice.
Specifically, 53 restorations were
monolithic and 265 were layered.
All veneers were cemented adhe-
sively (Fig 1). The ceramic restora-
tions were etched for 20 seconds
with 4.5% hydrofluoric acid (IPS ce-
ramic gel, Ivoclar Vivadent; Porce-
lain Etch, Ultradent). The acid was
then washed with water and dried.
A silane agent (Monobond S, Ivo-
clar Vivadent; Ceramic Primer, 3M
ESPE) was applied and blown dry
on the veneer. Rubber dam was
used for 139 veneers. In the re-
maining 179 restorations, a gingival
cord (N. 000 Ultrapak, Ultradent)
was placed into the sulcus prior
to luting. Concurrently, the tooth
surface was etched for 30 seconds
with 37% orthophosphoric acid gel
(Ultra-Etch, Ultradent). After water
rinsing of the tooth surface for 30
seconds, a bonding agent (Opti-
bond FL, Kerr) was applied to both
the prepared tooth and the inter-
nal surface of the veneers; a dentin
primer (Optibond FL, Kerr) was ap-
plied only in areas of exposed den-
tin. Finally, luting procedures were
performed as follows: veneers up
to 0.5 mm in thickness were luted
using flowable composites (Gradia
Direct Flow, GC; Tetric EvoFlow,
Ivoclar Vivadent) or light-curing ce-
ment (Variolink Veneer, Ivoclar Viva-
dent), while restorations up to 0.8
mm in thickness were cemented

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Distribution of restored teeth
Layered onlays Monolithic onlays
Maxilla Mandible Maxilla Mandible
– – – –
– – – –
– – – –
2 2 8 3
3 1 8 8
2 2 3 7
2 2 2 7
9 7 21 25
with dual-curing composite sys-
tems (Variolink II, Ivoclar Vivadent).
Excess cement was removed with
a brush and dental floss interproxi-
mally. The margins of the veneers
were covered with glycerin gel,
and resin luting agents were light
polymerized for 30 seconds from
each side. The margins were then
finished with a plastic scaler to re-
move excess resin. The occlusal
contacts were carefully evaluated
and balanced.
Tooth-supported single crowns
A total of 428 tooth-supported
single crowns were made (299 in
the maxilla and 129 in the man-
dible) (Table 2). Tooth preparation
was performed following the di-
agnostic wax-up. A general 0.3- to
1.0-mm overall reduction was per-
formed, with the exception of the
incisal/occlusal areas, which were
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reduced by 1.5 mm. As to the mar-
ginal design, a 0.4- to 1-mm slight
circumferential chamfer prepara-
tion was performed, with rounded
internal angles. The taper of the
preparations ranged from 5 to 10
degrees, depending on the abut-
ment length.31 In posterior areas,
the margins were located supra- or
equigingivally to preserve enamel,
facilitate impression making, and
aid evaluation of marginal adapta-
tion. In anterior areas, the margin
was located at the gingival crest or
slightly into the sulcus, depending
on esthetic demands.
The thickness of the restora-
tions ranged from 0.3 to 1.0 mm
on interproximal and axial walls;
the minimum thickness was 1.5
mm on the occlusal/incisal surfaces
to achieve proper biomechanics.
On a total of 428 single crowns
(231 anterior and 197 posterior),
407 restorations were pressed (274
layered, 154 monolithic). Among
these, 21 crowns were fabricated
with CAD/CAM (8 layered and 13
monolithic). All restorations were
cemented adhesively using self-
adhesive (RelyX Unicem, 3M ESPE)
or dual-curing resin cements (Mul-
tilink Automix, Ivoclar Vivadent;
Variolink II, Ivoclar Vivadent) in
accordance with manufacturers’
instructions. The prepared teeth
were isolated with a gingival cord
(N. 000 Ultrapak), and the adhesive
cementation was performed as
previously described. The clinical
conditions allowed for the cemen-
tation of 68 crowns with rubber
dam. The occlusion was refined,
and any adjusted surface was pol-
ished (Fig 2).
169
Onlays
A total of 62 onlays were made
(21 in the maxilla and 41 in the
mandible) (Table 2). Cavities were
prepared with a minimum occlusal
thickness of 2 mm, and an inter-
proximal buildup was performed
to facilitate impression making and
cementation (Fig 3). On a total of
62 prostheses, 16 onlays were lay-
ered while 64 restorations were
produced fully anatomical with sub-
sequent stain characterization. As
to cementation, the prepared teeth
were isolated with rubber dam and
flowable composite resin (Gradia
Direct Flow; Tetric EvoFlow) or dual-
curing composite systems (Variolink
II) used in accordance with the pro-
tocol previously described. The oc-
clusion was refined as needed, and
any adjusted surface was polished.
Implant-supported restorations
A total of 52 implant-supported
restorations on 36 implants were
made (30 in the maxilla and 22 in
the mandible) (Table 2): 7 cement-
ed crowns, 9 screwed crowns, 2
screwed zirconia full-arches (overall
26 restorations), 1 screwed zirco-
nia four-unit FDP, and 2 screwed
titanium three-unit FDPs. Lithium
disilicate crowns were used in com-
bination with zirconia or titanium
frameworks and CAD/CAM abut-
ments. Abutments and frameworks
were designed with a minimum
crown thickness of 1.5 mm circum-
ferentially and at least 2 mm in oc-
clusal/incisal aspects. In the case
of titanium frameworks, a layer of
Volume 34, Number 2, 2014
170

Fig 2    Full-mouth rehabilitation by means of lithium disilicate single crowns. (a) Finished and polished restorations on the master casts.
(b) Five-year follow-up of the full-mouth rehabilitation onto natural teeth and implant abutments.

Fig 3 (left)    Six-year follow-up of inlay and onlay monolithic restorations.

Fig 4 (below)    Maxillary implant-supported full-arch rehabilitation. (a) Zirconia framework with 14 lithium disilicate
single crowns. (b) Three-year follow-up.

a b

opaque mass was applied onto
the structures to mask the grayish
appearance of the metal. The lith-
ium disilicate restorations were ce-
mented onto zirconia and titanium
using self-adhesive (RelyX Unicem)
or dual-curing resin luting agent
(Multilink Automix). The crowns
were treated as in the case of nat-
ural abutment restorations, and
no procedures were performed
on framework materials. As for
screwed restorations, in all cases
in which the screw access hole did
not take up the buccal wall of the
restoration, an extraoral cementa-
tion was carried out, avoiding the
risk of subgingival residual cement.
The screw access holes were then
filled with composite resin (Fig 4).
Clinical evaluation
Standardized photographs and ra-
diographs were taken at all recall
appointments. Data forms record-
ing the mechanical and esthetic
characteristics of each restoration
were used as documentation tools.
Patients were examined at clin-
ical recalls at least 1 year after ce-
mentation and then annually; color
match, porcelain surface, marginal
discoloration, and integrity were
evaluated following the modi-
fied California Dental Association
(CDA) criteria.32 The patients’ satis-
faction was assessed using nominal
scores (nonacceptable, acceptable,
good, and excellent). In the case
of any mechanical complication,
the restoration was considered a
failure.

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Statistical analysis
Descriptive statistics were made
with dedicated software (SPSS, ver-
sion 17, IBM). The minimum, mean,
and maximum follow-ups were
calculated for all lithium disilicate
prostheses. The cumulative survival
and success rates were recorded in
all groups using the Kaplan-Meier
analysis; all groups were divided
into veneered and monolithic pros-
theses. Each mechanical complica-
tion, both minor (loss of retention,
minor chipping) and major (core
fracture, support fracture, major
chipping), was considered as a sta-
tistical event. The log-rank test was
performed to compare the survival
curves of veneered and monolithic
restorations. The level of signifi-
cance was set at P = .05.
Results
All prostheses were fabricated by
six expert dental technicians ac-
cording to the manufacturers’
instructions. A total of 860 restor-
ative units were evaluated from a
minimum of 12 to a maximum of
72 months in 312 patients.
Veneers
Anterior layered veneers showed
cumulative survival and success
rates of 97.91% and 96.24%, re-
spectively. Anterior monolithic ve-
neers showed cumulative survival
and success rates of 100% (Table
1). Both posterior layered and
monolithic veneers showed cumu-
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lative survival and success rates of
100% (Table 1).
Chipping was observed on
five veneers, all at the maxillary
arch. None of the minor cohesive
fractures impaired function; the
restorations were smoothed and
finished intraorally and remained in
situ for further observation.
Core fractures were noted on
three veneers, one on a maxil-
lary lateral incisor and two in the
mandibular anterior segment; they
all were layered. All fractured res-
torations had ceramic materials
in the opposite dentition and re-
quired the replacement of the res-
torations. The failed veneers were
prepared with an incisal butt joint
and fractures were observed 8 and
11 months after cementation, re-
spectively; the replacements were
performed with a new preparation
design that involved the lingual
aspect as well as a mini-chamfer.
Loss of retention was observed on
one mandibular veneer; the resto-
ration was immediately rebonded
and was still in function at the final
follow-up.
Tooth-supported single crowns
Anterior layered tooth-supported
crowns showed cumulative sur-
vival and success rates of 98.57%
and 97.61%, respectively. Anterior
monolithic crowns showed cumu-
lative survival and success rates of
95.46% (Table 1). Posterior layered
crowns showed cumulative sur-
vival and success rates of 96.92%
and 95.39%, respectively. Posterior
monolithic crowns showed cumu-
171
lative survival and success rates of
96.21% (Table 1).
Minor cohesive fractures of
the veneering ceramic occurred
on eight tooth-supported crowns,
three in the maxilla and five in the
mandible; two of these chipped
crowns were monolithic, one per
arch. Crown chippings occurred
mostly in posterior segments (pre-
molars and molars); only four of
these needed a replacement, while
the remaining chipped areas were
simply smoothed and finished.
Core failures occurred 7 months
after cementation on two maxil-
lary crowns on central and lateral
incisors in a single patient and
required the replacement of the
restorations. Both of the fractured
restorations had ceramic materi-
als in the opposite dentition. Loss
of retention was observed on two
mandibular crowns; the restora-
tions were immediately rebonded
and were still in function at the final
follow-up. One mandibular crown
needed root canal therapy because
of a pulpitis occurring 18 months
after cementation. The endodontic
treatment was performed through
the crown, and the access hole was
then filled with composite resin; the
restoration was considered a fail-
ure although it was still in function.
Furthermore, one nonvital maxillary
premolar restored with a crown was
extracted because of root fracture.
Onlays
Layered onlays showed cumula-
tive survival and success rates of
100% (Table 1). Monolithic onlays
Volume 34, Number 2, 2014
172

Veneered anterior crowns Veneered posterior crowns

Monolithic anterior crowns Monolithic posterior crowns
0.985 0.985 0.984
1.0 0.995 1.0
0.992
0.976
0.954
0.9 0.975 0.9 0.969 0.968 0.961
Cumulative survival (%)

Cumulative survival (%)

0.990
0.8 0.8
0.7 0.7
0.6 0.6
0.5 0.5
0.4 0.4
0.3 0.3
0.2 0.2
0.1 0.1
0 0
0 8 12 24 29 36 40 48 60 72 0 9 12 24 30 36 48 60 72
35 70 25 3438 61
33
Time to complication (mo) Time to complication (mo)

Fig 5    Kaplan-Meier graph of complication onset in relation to Fig 6    Kaplan-Meier graph of complication onset in relation to
time for lithium disilicate anterior single crowns. time for lithium disilicate posterior single crowns.

showed cumulative survival and ed monolithic crowns reported cu- tistically significant in any research
success rates of 97.83% (Table 1). mulative survival and success rates group (P > .05) (Table 3).
Chipping was noticed on three of 97.78% (Table 1). Minor cohesive
onlays, all at the mandibular arch. fractures of the veneering ceramic
Two of these chipped onlays were occurred on one monolithic im- Clinical evaluation
monolithic; both restorations were plant crown on a maxillary canine.
positioned on mandibular second The chipping did not impair func- The clinical ratings of the success-
premolars, and opposite denti- tion; consequently, the area was ful restorations, both monolithic
tion were represented by a natural smoothed and finished and the and layered, were satisfactory ac-
tooth in one case and by a ceramic crown remained in situ. cording to the modified CDA crite-
restoration in the other. The dam- ria (Table 4). The color match of the
aged area was intraorally repaired monolithic restorations recorded
by means of composite resin. Loss Statistical analysis the lowest proportion of A ratings
of retention was observed on one (90.9%) but was considered abso-
maxillary onlay; the restoration was Considering any complication as lutely acceptable both by clinicians
immediately rebonded and was an event, the cumulative survival and patients. With the exception of
still in function at the final follow- rates of lithium disilicate resto- the previously reported failed pros-
up. rations ranged from 95.46% to theses, no restoration was rated C
100%, while the cumulative suc- or D for any of the evaluation crite-
cess rates ranged from 95.39% to ria. The patient satisfaction scores
Implant-supported restorations 100%, according to Kaplan-Meier were mainly excellent for all res-
survival analysis (Figs 5 to 10, Table torations; a few prostheses were
Layered implant crowns showed cu- 1). The log-rank test that compared rated as good and none were re-
mulative survival and success rates the survival curves of veneered and ported to be nonacceptable or ac-
of 100% (Table 1). Implant-support- monolithic restorations was not sta- ceptable (Table 5).

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Veneered implant crowns Veneered anterior veneers

Monolithic implant crowns Monolithic anterior veneers

1.0 1.0 0.996 0.988 0.980
0.978 0.992 0.984 0.976 0.967
0.9 0.963
0.9

Cumulative survival (%)

Cumulative survival (%)

0.8 0.8
0.7 0.7
0.6 0.6
0.5 0.5
0.4 0.4
0.3 0.3
0.2 0.2
0.1 0.1
0 0
0 12 24 36 48 60 72 0 4 8 12 24 36 42 48 60 72
61 10 3943 59 70

Time to complication (mo) Time to complication (mo)

Fig 7    Kaplan-Meier graph of complication onset in relation to Fig 8    Kaplan-Meier graph of complication onset in relation to
time for lithium disilicate implant-supported crowns. time for lithium disilicate anterior veneers.

Veneered posterior veneers Veneered onlays

Monolithic posterior veneers Monolithic onlays

1.0 1.0
0.9 0.9
Cumulative survival (%)

Cumulative survival (%)

0.8 0.8
0.7 0.7
0.6 0.6
0.5 0.5
0.4 0.4
0.3 0.3
0.2 0.2
0.1 0.1
0 0
0 12 24 36 48 60 72 0 12 24 36 43 48 60 72
61 57
Time to complication (mo) Time to complication (mo)

Fig 9    Kaplan-Meier graph of complication onset in relation to Fig 10    Kaplan-Meier graph of complication onset in relation to
time for lithium disilicate posterior veneers. time for lithium disilicate onlays.

Monolithic restorations showed
the lowest number of mechanical
structural complications. No mono-
lithic veneer failed. Conversely,
three monolithic crowns located on
one implant and two natural teeth parafunctional habits. Unrestor-
were affected by chipping. All failed able fractures were observed only
crowns had ceramic restorations in layered restorations positioned
on the opposite dentition; two of in anterior segments in patients
these were placed in patients with with uncontrolled parafunctions.

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174

Table 3 Results of the log-rank test comparing the survival curves

Groups Log-rank P
Veneered anterior crowns vs monolithic anterior crowns 0.381 > .05
Veneered posterior crowns vs monolithic posterior crowns 0.084 > .05
Veneered anterior veneers vs monolithic anterior veneers 1.062 > .05
Veneered posterior veneers vs monolithic posterior veneers 2.004 > .05
Veneered onlays vs monolithic onlays 0.345 > .05
Veneered implant crowns vs monolithic implant crowns 0.154 > .05

Table 4 Frequency distribution of clinical ratings in lithium disilicate restorations according

to the modified CDA criteria

Modified CDA rating

A B C D
Layered Monolithic Layered Monolithic Layered Monolithic Layered Monolithic
Parameter (%) (%) (%) (%) (%) (%) (%) (%)
Color match 97.9 90.9 2.1 7.4 0 1.7 0 0
Porcelain 96.7 97.1 3.3 2.9 0 0 0 0
surface
Marginal 96.7 95.9 3.3 4.1 0 0 0 0
discoloration
Marginal 98.2 98.7 1.8 1.3 0 0 0 0
integrity

Table 5 Patients’ satisfaction scores for lithium disilicate restorations

Observational period (mo)

12 < x > 24 24 < x > 36 36 < x > 48 48 < x > 72
Satisfaction
score Veneers Crowns Onlays Veneers Crowns Onlays Veneers Crowns Onlays Veneers Crowns Onlays

Nonacceptable 0 0 0 0 0 0 0 0 0 0 0 0
Acceptable 0 0 0 0 0 0 0 0 0 0 0 0
Good 0 9 2 4 13 1 15 14 0 0 0 0
Excellent 31 99 10 95 159 25 90 116 22 83 70 2
x = observational period in months.

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Fig 11    Minimally invasive preparations for lithium disilicate
crowns.
Recurrent caries was not detected
in any restoration, contour qual-
ity was satisfactory, and proximal
contacts were well maintained over
time.
Discussion
In this study, lithium disilicate res-
torations were associated with
very high success rates (95.39% to
100% at 72 months), comparable
with results reported in previous
studies.2,11 Several variables con-
tribute to the clinical effectiveness
of such restorations; particularly,
lithium disilicate prostheses have
to be bonded with correct adhesive
techniques to achieve the reported
success rates. Moreover, the quan-
tity and quality of tooth structure is
paramount, especially the enamel
at the finish lines: the more the
enamel is preserved, the better the
adhesion and the more limited ag-
ing of the bonding interfaces will
be over time.2,17,30 An estimated
survival probability of 93.5% after
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10 years was reported for porcelain
laminate veneers.33 Moreover, a
recent systematic review reported
that glass-ceramic veneers present
an adequate clinical survival for at
least 5 years of function with very
low complication rates.34
Accordingly to the clinical situ-
ations, the authors transferred the
concept of adhesion to enamel to
improve restoration longevity from
veneers to crowns (Fig 11), produc-
ing very thin restorations and pre-
serving as much enamel as possible.
All fractures and mechani-
cal complications occurred in
restorations with thicknesses in
accordance or even superior to
manufacturing instructions but ap-
plied on teeth where the majority
of supporting substrate was dentin
or composite. Conversely, no me-
chanical complications were ob-
served in restorations cemented on
teeth where enamel represented at
least 50% of the bonding substrate.
As regards technical drawbacks,
63% of mechanical complications
(fractures and chipping) were ob-
175
served on restorations that had
porcelain as opponent and 33%
of these occurred in patients with
parafunctions. The remaining 37%
of the mechanical complications
were noticed in patients that had
natural teeth as antagonist denti-
tion and were not affected by brux-
ism or clenching. Considering the
high rate of parafunctional patients
(30.3%) and the high success rate
in this study, lithium disilicate may
be considered a valid option to
treat such patients, especially us-
ing monolithic restorations, as they
did not show any structural compli-
cations.
According to the CDA quality
evaluation system, all of the resto-
rations were classified as satisfacto-
ry for marginal integrity, color, and
surface, with the only exception
of monolithic crowns and onlays,
which did not show an optimal re-
sult in color match in some cases
(9.1%). Case selection is a crucial
factor for achieving natural appear-
ance with a monolithic approach,
as several variables contribute to
Volume 34, Number 2, 2014
176
the successful esthetic of a resto-
ration, such as color of the natural
abutment, ceramic thickness, cor-
rect choice of ingots, and color and
value of adjacent teeth.
The combination of lithium di-
silicate restorations with zirconia
and titanium frameworks or abut-
ments showed excellent results in
terms of esthetics, function, and
loss of retention. Only one mono-
lithic crown placed on a zirconia
framework was affected by chip-
ping 6 days after cementation. This
restoration fractured in a patient
treated with an implant-supported
full-arch prosthesis, and the prema-
ture fracture was probably due to
an uneven occlusal control in cen-
tric relation; the fractured fragment
was immediately rebonded with an
adhesive technique, occlusion was
refined, and the crown was still in
function after 3 years.
Lithium disilicate technology
demonstrates unique features to be
used in different clinical situations;
the possibility to choose between
ingots with different opacity and
translucency allows the clinician to
select the ideal core, even in cases
in which severe discolorations make
it very difficult to obtain satisfactory
esthetics.3 The etchability of lithium
disilicate improves the clinical per-
formance of adhesive cementa-
tion and eases the management of
clinical complications. Especially in
cases of chipping or fractures, the
possibility of applying an effective
adhesive by means of the etching
technique allows the clinician to re-
pair any mechanical complication
with easy handling procedures and
a favorable prognosis.
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As to the study’s limitations,
the present investigation is a ret-
rospective, clinical, multipractice
study; consequently, although the
same rigorous approach was re-
spected, different operators and
several clinical variables (restora-
tion type, intraoral distribution,
multiunit prostheses in a single pa-
tient) could act as confounders in
the clinical and statistical results.
Considering these limitations, fur-
ther in vivo investigations would be
necessary to validate the clinical re-
liability of lithium disilicate restora-
tions in the long-term, confirming
the effectiveness of the proposed
prosthetic approach.
Conclusion
According to the results of this
study and within its limitations,
the use of lithium disilicate in fixed
prosthodontics proved to be effec-
tive and reliable in the short- and
medium-term. The choice of this
material may represent a valid op-
tion in many clinical situations,
offering biologic, technical, and es-
thetic advantages.
Acknowledgments
The authors reported no conflicts of interest
related to this study.
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