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A clinical evaluation of chairside lithium

disilicate CAD/CAM crowns

A two-year report
Dennis J. Fasbinder, DDS; Joseph B. Dennison, DDS, MS; Donald Heys, DDS, MS;
Gisele Neiva, DDS, MS

here has been a growing interest in the use of

T all-ceramic restorations as replacements for

traditional porcelain-fused-to-metal restora-
tions because of their improved esthetic
appearance. Developments in ceramic material
science have resulted in improvements in the physical
properties of modern ceramics, leading to a substantial
increase in the clinical use of all-ceramic restorations.
Background. Developments in ceramic material
science have led to improvements in the physical
properties of modern ceramics, leading to a substan-
tial increase in the clinical use of all-ceramic restora-
tions. The authors evaluated the clinical perform-
Ivoclar Vivadent (Amherst, N.Y.) introduced a ance of lithium disilicate (IPS e.max CAD, Ivoclar
lithium disilicate glass ceramic material for use in all- Vivadent, Amherst, N.Y.) all-ceramic crowns.
ceramic restorations. It is available as an ingot that can Methods. The authors fabricated 62 lithium disili-
be press-fit (IPS e.max Press, Ivoclar Vivadent) and as cate crowns with a chairside computer-aided design/
a block that can be milled with computer-aided computer-aided manufacturing (CAD/CAM) system
design/computer-aided manufacturing (CAD/CAM) (CEREC 3, Sirona Dental Systems, Charlotte, N.C.)
technology (IPS e.max CAD, Ivoclar Vivadent).1 The and cemented them with two types of adhesive resin
manufacturer recommends its use for anterior or pos- cements. Two examiners used modified U.S. Public
terior crowns, implant crowns, inlays, onlays or Health Service criteria to evaluate the crowns at
veneers. The CAD/CAM material initially was available baseline, six months, one year and two years.
as a substructure material that afforded greater Results. There were no clinically identified cases
translucency than did other high-strength ceramic core of crown fracture or surface chipping. There was no
materials. Although initially indicated for substruc- reported sensitivity at one or two years with either
tures, the CAD/CAM block has been used more recently cement. For margin discoloration, the percentage
for full-contour restorations of a single ceramic material Alfa score was 86.9 percent for crowns cemented
(monolithic restorations). with a self-etching, dual-curing cement. All other
The milled lithium disilicate block must undergo a percentage Alfa scores were greater than 92.0 per-
two-stage crystallization process before cementation. cent, indicating no appreciable change in the crowns
Lithium metasilicate crystals are precipitated during during the two-year study.
the first stage. The resulting glass ceramic has a crystal Conclusions. The results show that lithium disili-
size range of 0.2 to 1.0 micrometers, with approximately cate crowns performed well after two years of clinical
40 percent lithium metasilicate crystals by volume. This service.
creates a blue-violet color in the block, thus accounting Clinical Implications. Early results indicate
for the commonly used “blue block” description. This that monolithic lithium disilicate CAD/CAM crowns
precrystallized state allows the block to be milled easily may be an effective option for all-ceramic crowns.
without excessive diamond bur wear or damage to the Key Words. CAD/CAM; crowns; cementation;
material. The final crystallization occurs after the crown dental porcelain; dental restoration.
has been milled to the desired form by means of CAD/ JADA 2010;141(6 suppl):10S-14S.
CAM technology. The crystallization process occurs at
850˚C in a vacuum. The metasilicate crystal phase is
dissolved completely, and the lithium disilicate crystal- Dr. Fasbinder is a clinical professor, Cariology, Restorative Sciences, and
lizes. This process also converts the blue shade of the Endodontics, School of Dentistry, University of Michigan, 1011 N. Univer-
precrystallized block to the selected tooth shade and sity, Ann Arbor, Mich. 48109-1078, e-mail “djfas@umich.edu”. Address
reprint requests to Dr. Fasbinder.
results in a glass ceramic with a fine-grained size of Dr. Dennison is a professor emeritus, Cariology, Restorative Sciences, and
approximately 1.5 μm and a 70 percent crystal volume Endodontics, School of Dentistry, University of Michigan, Ann Arbor.
incorporated in a glass matrix.2 Dr. Heys is a professor, Cariology, Restorative Sciences, and Endodontics,
School of Dentistry, University of Michigan, Ann Arbor.
Clinicians can use the CEREC Acquisition Center Dr. Neiva is a clinical associate professor, Cariology, Restorative Sciences,
system (Sirona Dental Systems, Charlotte, N.C.) or the and Endodontics, School of Dentistry, University of Michigan, Ann Arbor.

10S JADA, Vol. 141 http://jada.ada.org June 2010

Copyright © 2010 American Dental Association. All rights reserved. Reprinted by permission.
E4D Dentist system (D4D Technologies, Richard- Restoration fabrication. We fabricated all
son, Texas) to fabricate full-contour lithium disili- crowns with a CEREC 3 system (Sirona Dental
cate crowns chairside. The CAD/CAM process gives Systems). The clinician used software (CEREC 3D,
clinicians the opportunity to mill the crown from Version 2.8, Sirona Dental Systems) to design the
monolithic blocks of lithium disilicate rather than desired crown contours and occlusal relationships.
the traditional laboratory process of fabricating a The clinician milled the crown from prefabricated
strong substructure veneered with weaker block of IPS e.max CAD at standard milling speed.
veneering porcelain. The IPS e.max CAD glass After recovering the crown from the milling
ceramic has a flexural strength of 360 to 400 mega- chamber, the clinician trial fitted it to the prepara-
pascals, which is approximately two-and-one-half tion with a silicone material (Fit Checker, GC
times greater than that of other monolithic ceramic America, Alsip, Ill.) to stabilize the crown and
blocks available for CAD/CAM chairside restoration adjusted it to ensure complete seating.
fabrication.2,3 The enhanced strength of lithium dis- After finalizing adjustments, the clinician thor-
ilicate allows for either adhesive or conventional oughly cleaned and dried the crown and then
cementation techniques. applied e.max CAD Crystall./Glaze paste (Ivoclar
We conducted a nonrandomized longitudinal Vivadent) with shade tints to customize the crown’s
clinical trial to evaluate the clinical performance shade relative to the existing dentition. The crown
of the IPS e.max CAD glass ceramic material for was fired in a porcelain oven under vacuum, ac-
chairside CAD/CAM-generated crowns cemented cording to the manufacturer’s instructions, to com-
with two different cements. plete the crystallization process. The firing cycle
consisted of two stages that required 35 minutes
PARTICIPANTS, METHODS AND MATERIALS (however, it since has been reduced with the
The Health Sciences Institutional Review Board of development of a spray glaze).
the University of Michigan reviewed and approved Restoration cementation. When the crown
the investigation protocol before the study began. was ready for cementation, the internal surface
We selected the participants from among current was etched for 20 seconds with 4.9 percent hydro-
patients receiving clinical treatment at the School fluoric acid, rinsed with water and air-dried with
of Dentistry, University of Michigan, Ann Arbor. oil-free air. The dental assistant applied a pre-
All of the participants signed a written informed hydrolyzed silane coupling agent (Monobond-S,
consent form before enrolling in the study. All teeth Ivoclar Vivadent) to the etched surface for 60 sec-
were asymptomatic at the beginning of treatment. onds and ensured evaporation of the solvent
Participants received a maximum of two crowns, before adhesive cementation.
and all restorations had opposing functional occlu- The first group of 23 crowns (control) was
sion and at least one proximal contact with an adja- cemented with a self-etching, dual-curing cement
cent tooth. We did not exclude patients with specific (Multilink Automix [MA], Ivoclar Vivadent) with a
occlusal schemes or parafunctional habits. self-etching primer and adhesive. The second group
Preparation. The clinician prepared, fabri- of 39 crowns was cemented with an experimental
cated and placed all of the crowns in one treat- self-adhesive, dual-curing cement (EC) developed
ment appointment. The clinician prepared the by Ivoclar Vivadent.
tooth by following the manufacturer’s guidelines For the crowns cemented with MA, the clini-
for all-ceramic crowns with at least 2.0 millime- cian cleaned the isolated preparation with flour of
ters of occlusal reduction over functional cusps, at pumice, rinsed it with water spray and lightly air
least 1.5 mm of reduction over nonfunctional dried it. The clinician treated the preparation for
cusps and in the central fossa at least 1.2 mm of 15 seconds with Multilink Primer A and B
axial reduction, rounded shoulder margins and no (Ivoclar Vivadent) and lightly air dried it with the
sharp internal angles. For teeth with substantial air-water syringe. An automix syringe was used
loss of tooth structure resulting from caries or to inject a 1:1 ratio of MA base and catalyst
fracture, the clinician used composite cores
(ExciTE F DSC and MultiCore, Ivoclar Vivadent) ABBREVIATION KEY. CAD/CAM: Computer-aided
to create the required retention and resistance design/computer-aided manufacturing. EC: Experimental
form. We used a dryfield illuminator (Isolite i2, cement. FPD: Fixed partial denture. MA: Multilink
Isolite Systems, Santa Barbara, Calif.) to isolate Automix (Ivoclar Vivadent, Amherst, N.Y.). USPHS:
the quadrant during all clinical procedures. U.S. Public Health Service.

JADA, Vol. 141 http://jada.ada.org June 2010 11S

Copyright © 2010 American Dental Association. All rights reserved. Reprinted by permission.
Postoperative sensitivity. To evaluate the
postoperative sensitivity, the study coordinator
contacted participants by telephone once per
week after the initial appointment and for as long
as four weeks or until the participant reported
that the crown was asymptomatic. During the
telephone interview, the participants reported a
criterion-referenced rating of functional tooth sen-
sitivity. Participants returned for evaluation only
if they were having continued discomfort or any
Figure 1. Preoperative occlusal view of teeth nos. 19 and 20. indication of premature occlusal contact.
Restoration evaluation. Two independent
evaluators conducted clinical evaluations at base-
line (immediately after the crowns were
cemented), six months, one year and two years by
using modified U.S. Public Health Service
(USPHS) criteria4 for color match, margin discol-
oration, margin adaptation, caries and crown frac-
ture. The two evaluators discussed disagreements
in evaluations to reach a consensus judgment for
each criterion evaluated.
The evaluators obtained intraoral digital color
Figure 2. Placement of the lithium disilicate crowns on teeth nos.
19 and 20 at baseline evaluation. images at a 1:1 magnification at baseline and at
the six-month, one-year and two-year recall visits
to document preoperative status and postopera-
tive conditions (Figures 1-5). Bitewing and peri-
apical radiographs of each crown were obtained
preoperatively and at the two-year recall visit.
Forty-three participants enrolled in the study.
They received 62 crowns, including 20 on premo-
lars and 42 on molars. The six-month and one-
year recall rates were 100.0 percent. The two-year
Figure 3. Crowns for teeth nos. 19 and 20 at the two-year recall visit.
recall rate was 98.4 percent because one partici-
directly into the crown. The clinician inserted the pant had moved out of the area.
crown and removed the excess cement after two One week postoperatively, the participants
minutes. The crown was light cured for 20 sec- described 13.0 percent (three of 23) of the crowns
onds each from the facial, occlusal and lingual cemented with MA and 10.3 percent (four of 39) of
aspects, for a total of 60 seconds. the crowns cemented with EC as slightly sensitive.
For the crowns cemented with EC, the clinician However, all participants reported not having
cleaned the isolated preparation with flour of symptoms by the third week after treatment. At six
pumice, rinsed it and lightly air dried it. An months, the participants reported that 8.7 percent
automix syringe was used to inject a 1:1 ratio of (two of 23) of the crowns cemented with MA and
EC base and catalyst directly into the crown. The 7.7 percent (three of 39) of the crowns cemented
clinician inserted the crown and removed the with EC were slightly sensitive. No participants
excess cement after two minutes. The crown was required treatment for sensitivity. There was no
light cured for 20 seconds each from the facial, reported sensitivity at one year or two years.
occlusal and lingual aspects, for a total of 60 sec- The table shows the percentage Alfa scores for
onds. The clinician finished and polished all the each of the modified USPHS criteria. Margin discol-
crowns by using a series of diamond finishing oration was 86.9 percent Alfa for crowns cemented
burs, rubber abrasive points and cups, finishing with MA because three crowns had localized
strips and diamond polishing paste. margin discoloration. All other scores were greater

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Copyright © 2010 American Dental Association. All rights reserved. Reprinted by permission.
Figure 4. Preoperative occlusal views of teeth nos. 3 and 4. Figure 5. Lithium disilicate crowns for teeth nos. 3 and 4 at the
two-year recall visit.

than 92.0 percent Alfa, indicating no appreciable with surface porcelain. There was no significant dif-
change in the crowns during the two years of the ference between the two crown types for any of the
study. USPHS scores. One of the monolithic ceramic
All of the crowns cemented with MA were clini- crowns fractured at 12.0 months, and one of the
cally acceptable at two years. Two crowns layered ceramic crowns fractured at 42.5 months.
cemented with EC debonded: one at one year and The Kaplan-Meier probability for survival was 91.7
the other at two years. Both of the debonded percent for the layered ceramic crowns and 94.4
crowns were intact, and the treating clinician used percent for the monolithic ceramic crowns after a
MA to recement them. mean ± standard deviation of 44.7 ± 10.3 months.
Bindl and colleagues11 compared 208 monolithic
DISCUSSION posterior ceramic crowns on the basis of the tooth
There are limited clinical studies of an early version type and three types of crown preparation designs:
of lithium disilicate glass ceramic. IPS Empress 2 reduced, classic or “endo.” Only two crowns in the
(Ivoclar Vivadent) was a lithium disilicate glass reduced preparation group fractured after two
ceramic fabricated by means of a lost-wax and heat- years, with no fractures in the classic or endo
pressed technique. The substructure was veneered preparation groups. By 55 months, two crowns in
with fluorapatite-based porcelain. Marquardt and the classic preparation group fractured, and three
Strub7 evaluated 58 IPS Empress 2 restorations more from the reduced preparation group fractured.
(27 posterior crowns and 31 three-unit fixed partial After 55 ± 15 months, the investigators reported a
dentures [FPDs]) after five years of clinical service. Kaplan-Meier probability of survival for premolars
Two of the crowns had repairable fractures in the of 97.0 percent for those in the classic preparation
veneering porcelain. Six complete failures occurred group, 92.9 percent for those in the reduced prepa-
within the FPDs. Taskonak and Sertgöz8 evaluated ration group and 68.8 percent for those in the endo
20 IPS Empress 2 crowns and 20 FPDs after two preparation group. For molars, they reported a
years. They reported no crown fractures and 10 fail- Kaplan-Meier probability of survival of 94.6 percent
ures with the FPDs. This early lithium disilicate is for those in the classic preparation group, 92.1 per-
not the same material as IPS e.max CAD or IPS cent for those in the reduced preparation group and
e.max Press ceramics. There is a substantial differ- 87.1 percent for those in the endo preparation
ence in the microstructure of the lithium disilicate group. These study results support the assertion
crystals and the matrix, resulting in improved phys- that monolithic ceramic crowns have good success
ical properties and translucency of the IPS e.max across five years of clinical service.
lithium disilicate.9 The results from comprehensive and systematic
There are few published clinical studies of mono- reviews indicated that the five-year survival rate of
lithic ceramic crowns. Bindl and Mörmann10 com- all-ceramic crowns was greater than 93 percent.12-14
pared monolithic ceramic crowns (Vitablocs Mark The most common mode of failure for all-ceramic
II, Vident, Brea, Calif.) with layered ceramic restorations reported in the comprehensive and
crowns (Vita In-Ceram Spinell, Vident). The mono- systematic reviews was complete fracture of the
lithic ceramic crowns were fabricated with a substructure, the veneer porcelain or both,
CEREC 2 (Sirona Dental Systems) unit. The sub- requiring the layered all-ceramic crown to be
structures of the layered ceramic crowns were remade.12-14 The most common minor problem was
milled with a CEREC 2 unit and then veneered chipping or cracking limited to the veneer porce-

JADA, Vol. 141 http://jada.ada.org June 2010 13S

Copyright © 2010 American Dental Association. All rights reserved. Reprinted by permission.
TABLE as cement failures, we will continue to
Percentage Alfa scores for CAD/CAM lithium recall the participants so we can evaluate
long-term survival of the ceramic
disilicate all-ceramic crowns, according to material.
recall visit.
(ALFA SCORE %) (ALFA SCORE %) (ALFA SCORE %) We evaluated the clinical performance
MA * EC † MA EC MA EC of the IPS e.max CAD ceramic crowns
Color Match 95.6 92.3 95.6 94.9 100.0 97.2 cemented with two different adhesive
Margin Discoloration 95.6 97.4 86.9 97.4 87.0 97.2 resin cements. There were no clinically
Margin Adaptation 100.0 100.0 100.0 100.0 100.0 100.0 identified cases of crown fracture or
Caries 100.0 100.0 100.0 100.0 100.0 100.0 surface chipping. There were no reports
Crown Fracture 100.0 100.0 100.0 100.0 100.0 100.0
of postoperative sensitivity for any of
* MA: Multilink Automix, Ivoclar Vivadent, Amherst, N.Y.
† EC: Experimental cement. the crowns at the one- and two-year
recall visits. The results show that
lain.12-14 In contrast, in our study, there were no lithium disilicate crowns perform well after two
identified cases of fracture or surface chipping of years of clinical service. ■
the lithium disilicate crowns through the two-year Disclosure. Dr. Fasbinder has received honoraria for educational
period. Although two years is early in the desired programs and research funding for projects with the CEREC system
from Sirona Dental Systems, Charlotte, N.C.; and Ivoclar Vivadent,
clinical life span of a crown, this is a potentially Amherst, N.Y.
clinically significant finding. Bilayered ceramic
This study was funded through a research grant from Ivoclar
crowns consisting of a strong ceramic core Vivadent, Amherst, N.Y.
veneered with a weaker surface porcelain gener- 1. Tysowsky G. The science behind lithium disilicate: today’s surpris-
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14. Pjetursson B, Sailer I, Zwahlen M, Hämmerle C. A systematic
damage to the lithium disilicate crowns. The clini- review of the survival and complication rates of all-ceramic and metal-
cian cleaned the cement from the internal aspect of ceramic reconstructions after an observation period of at least three
years, part I: single crowns (published correction appears in Clin Oral
the crowns, re-etched them with a hydrofluoric acid, Implants Res 2008;19[3]:326-328). Clin Oral Implants Res 2007;18(suppl
applied a silane coupler and recemented them with 3):73-85.
MA. Although the evaluators classified these cases

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Copyright © 2010 American Dental Association. All rights reserved. Reprinted by permission.