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Clin Oral Invest (2014) 18:2171–2178

DOI 10.1007/s00784-014-1191-8

ORIGINAL ARTICLE

Three-unit CAD/CAM-generated lithium disilicate FDPs


after a mean observation time of 46 months
Sven Reich & Lutz Endres & Claudia Weber &
Klaus Wiedhahn & Peter Neumann & Oliver Schneider &
Nicole Rafai & Stefan Wolfart

Received: 14 January 2013 / Accepted: 16 January 2014 / Published online: 4 February 2014
# Springer-Verlag Berlin Heidelberg 2014

Abstract complaints. Thus, the failure-free rate and the complication-


Objectives Lithium disilicate can easily be machined by free rate were revealed as 93 and 83 %, respectively.
CAM techniques in its metasilicate status. Due to slightly Conclusions Despite the limited observation period, the re-
inferior material properties, the material is not yet recom- sults are promising, especially due to the fact that the fractured
mended for three-unit fixed dental prosthesis (FDP) as it is FDP did not fulfill the recommended connector dimensions.
the case for the press material up to the second bicuspid. Clinical relevance Inserted as a full-contour three-unit FDP
Therefore, the aim of this clinical study was to evaluate the within its indications, the CAD/CAM lithium disilicate ce-
performance of CAD/CAM-fabricated lithium disilicate ramic offers an appropriate alternative to layered restorations.
FDPs.
Materials and methods A total of 32 anterior and posterior Keywords Glass–ceramic . Lithium disilicate . FDP .
FDPs were provided for 32 patients. Twelve FDPs were CAD/CAM . Clinical . All-ceramic . Full-contour
fabricated chair-side. The first recall took place 6 months after
insertion and then annually. The FDPs were rated according to
biological and technical complications. As failure, those Introduction
events were defined, which led to the removal of a FDP. The
failure-free (survival) rate and the complication-free rate were The first version of lithium disilicate ceramic was brought on
calculated according to Kaplan–Meier. market in 1998, named as IPS Empress 2 (IvoclarVivadent,
Results After a mean observation time of 46 months (SD± Schaan, principality of Liechtenstein) for the press technolo-
8.4 months), three endodontic complications in two FDPs, gy. According to Tysowsky [1], the material generally consists
two minor chippings, and one catastrophic fracture occurred. of “70 % needle-like lithium disilicate crystals which are
One FDP had to be removed due to persisting undefined embedded in a glassy matrix”. In 2005, IPS Empress 2 was
substituted by a modified version, IPS e.max Press and IPS
S. Reich (*) : L. Endres : N. Rafai : S. Wolfart e.max CAD. The optical properties of these lithium disilicate
Department of Prosthodontics and Biomaterials, Centre of materials were enhanced so that the use as a full-contour
Implantology, Medical Faculty, RWTH Aachen University, material became possible. The CAD version of the lithium
Pauwelsstraße 30, 52074 Aachen, Germany
e-mail: sreich@ukaachen.de
disilicate ceramic is provided in a metasilicate state, which is
characterized by 40 % platelet-shaped lithium metasilicate
C. Weber crystals and glassy matrix [1]. In this metasilicate state, the
Aachen, Germany material shows a bluish color and can be easily machined.
Also, the try-in procedures can be accomplished carefully. In
K. Wiedhahn
Buchholz i. d. Nordheide, Germany order to obtain the lithium disilicate structure, a crystallization
process is necessary [2]. The classic version of the crystalli-
P. Neumann zation process takes approximately 25 min at 830 °C. The
Berlin, Germany
shrinkage during crystallization of 0.2 % does not affect
O. Schneider marginal, proximal, and occlusal fit. The change from a bluish
Zwickau, Germany color to a shade that is similar to a natural tooth is based on the
2172 Clin Oral Invest (2014) 18:2171–2178

in % (rate due to
Failure-free rate
transition of the oxidation level of ions, which determines the
shade effects [1]. The pressable lithium disilicate IPS e.max

87.9 (90.8)
86 % (86)

78 (~85)
fracture)
Press is indicated for veneers, inlays, onlays, crowns, and

50 (50)
62 (62)

71.4
three-unit end-abutment fixed dental prostheses (FDPs) up to
the second bicuspid. The maximum length of the pontic is 11

Complication-
and 7 mm in the anterior and posterior area, respectively. The

free rate in %
dimension of 16 mm2 for anterior and posterior connectors has
to be kept. The press material (IPS e.max Press) is slightly

69.8
superior in comparison to the CAD/CAM material in its final
crystalized state (IPS e.max CAD) with respect to biaxial

time in month (range


strength (400 vs. 360 MPa) and fracture toughness (2.75 vs.

Mean observation
2.25 MPa m0.5) [1–3]. Therefore, IPS e.max CAD was not

121 (79–133)
indicated for FDPs until the year 2013. In general, reports of

in month)
the clinical performance of FDPs made from the pressable
version of lithium disilicate are inconclusive. For IPS Empress

120
48

24
72

60

**The number of patients exceeds the number of inserted FDPs because Marquardt et al. also investigated 27 single crowns in this study group
2, survival rates of 50, 78, and 62 % are reported after 24, 60,

Connector size,
and 72 months, respectively [4–6]. As far as documented,

Premolar 4×4
molar 4×5
these studies applied lithium disilicate as framework material.

4×3 /4×4
4×3/4×4
ant./post.

3.5×3.5
Only Makarouna et al. used full-contour material for their

4×3
posterior FDPs [6]. Two studies gained better results when
applying IPS e.max Press as full-contour FDP material, al-
N, FDPs
though the indications were exceeded in most of the cases due
total
to the involvement of molar positions [7–9]. The studies

30

21
18

36
20

31
mentioned earlier are displayed in Table 1. The aim of the
(within indication/out

present study was to evaluate whether full-contour FDPs


N, posterior FDPs

fabricated from IPS e.max CAD blocks were clinically suc-


cessful. The hypothesis stated was that the clinical perfor-
of indication)

30 (11/19)

mance was comparable to other all-ceramic systems with

30 (3/27)
10 (8/2)*
Table 1 Overview of clinical studies evaluating lithium disilicate FDPs as pressable material

8 (8/0)
7 (7/0)
respect to failure-free and complication-free rate.
8
N, anterior FDPs

Materials and methods

Study group *Only replaced teeth are mentioned: 8 premolars and 2 molars replaced
13
12

24
8

Patients who took part in the study had to show the indication
N, patients

for at least one three-unit end abutment FDP up to the second


bicuspid. The Ethical Committee of the Medical Faculty of the
43**
19
21

18
15

28

University of Aachen reviewed and approved the study (ap-


plication no. EK 134/07). All patients had to give their written
Full-contour,

post: yes

informed consent. Recruitment of the patients and the treat-


Ant.: no,

ment were accomplished in three private dental practices and


yes/no

Yes

Yes

the Department of Prosthodontics of the University of


No
No

No

Aachen, where the patients were treated by two dentists. The


e.max Press

e.max Press

patient´s inclusion criteria were age of at least 18 years,


Empress 2

Empress 2
Empress 2

Empress 2
Material

healthy, good oral hygiene, low caries activity, and absence


of periodontitis. As antagonist dentition, only natural teeth or
fixed prosthesis without treatment needs was accepted. If root
Esquival-Upshaw

Makarouna et al.

canal treated abutment teeth were included, they had to be


Marquardt et al.
Solá-Ruiz et al.
Taskonak et al.
et al. 2008

symptom-free and they had to show any signs of peri-apical


Kern et al.

pathology. A maximum tooth mobility of grade 1 was accept-


Author

ed. The length of the clinical crown of the abutment teeth had
to be at least 5 mm. Patients with probing depths greater than
Clin Oral Invest (2014) 18:2171–2178 2173

4 mm and vertical bone pockets around the abutment teeth material. The maximum span of the FDPs had not exceeded
were not included. According to the study protocol, patients 9 mm in the pontic area and 11 mm in the premolar and the
who showed extreme signs of tooth wear (extreme bruxers) anterior region, respectively. Prior to insertion, the mesial and
had to be refused, which meant that the usual age-based distal connector heights and widths had to be measured with a
appearance of wear facets that are normally parallel to the caliper and noted in 0.5 mm steps. The results had to be
tooth shape was exceeded. Also, those patients who required submitted to the University of Aachen where the data were
appliances as TMD therapy were excluded. Patients with a collected. According to the manufacturer’s recommendations,
history of an impairing tumor or with a psychological disease, the mesial and distal connectors should show a dimension of
with other severe systematic diseases (e.g., who required a 16 mm2 each, whereas the height should be at least have
prophylactic antibiosis before each treatment or dental treat- 4 mm. For anterior FDPs, these guidelines are relative. If the
ment in general meant a risk for the patient’s general health), dimension falls below 16 mm2, in such a case the height has to
and with a history of allergic disease had to be excluded, too. be extended above the standard height of 4 mm. However, the
analysis of the documented data showed some variations in
Prosthodontic procedures comparison to the recommended numbers. In the present
study, the mesial connector height of one FDP with an upper
After caries excavation, adhesive buildups using Tetric ceram canine and a second premolar as abutment teeth was below
or Multicore (both IvoclarVivadent, Schaan, Liechtenstein) 4.0 mm, showing 3.5 mm. With respect to the mesial connector,
were done using Optibond FL (Kerr, Rastatt, Germany) as five other FDPs were under-dimensioned in their widths so that
adhesive system according to the manufacturer’s recommen- totally six FDPs showed connector dimensions below 16 mm2:
dation. If necessary, severely decayed root canal-treated abut- These were at 10.5 mm2 (height: 3.5 mm, width: 3.0 mm), at
ment teeth were restored with a cast post and core build-up. 12.0 mm2 (4.0 mm/ 3.0 mm), at 13.5 mm2 (4.5 mm/3.0 mm),
This had to be accomplished two times: once as alternative an and two FDPs at 15.0 mm2 (each 5.0 mm /3.0 mm). The median
adhesive post and core built-up was applied. The prepared value of the connector dimension for the mesial connector was
finish line was a shoulder or distinct chamber of 1.0 to 1.2 mm 16 mm2. With respect to the distal connector heights, one
in width. The occlusal reduction of the abutment teeth was 1.5 connector fell below the recommended height of 4.0 mm, re-
to 2.0 mm. The convergence angle of the preparation was 6– vealing 3.5 mm. By considering the widths, ten FDPs showed
8°. The FDPs could be fabricated lab-side or chair-side. For dimensions in mm2 below the recommended value of 16 mm2:
impression taking, retraction cords (Ultrapak, Ultradent, One revealed 12.0 mm2 (height 4.0 mm/ width 3.0 mm), one
Brunnthal, Germany) were inserted by applying the double- showed 13.5 mm2 (4.5 mm/3.0 mm), seven had a dimension of
layer technique. If indicated, an adstringent retraction paste 15.0 mm2 (all: 5.0 mm/3.0 mm), and one obtained was
was used, e.g., Expasyl (Acteon, Mettmann, Germany). For 15.75 mm2 (3.5 mm/4.5 mm). Out of the six FDPs that were
conventional impressions, a double-mix technique using below 16 mm2 at the mesial connector, five showed values
polyether or polyvinyl siloxane material was applied. If the below 16 mm2 for the distal connector, too (five out of the ten
chair-side technique was applied, the Cerec3D System (cam- FDPs described earlier for the distal connector). However,
era: infra-red) was used for the optical impressions. If a these FDPs were not excluded from the study as it
provisional restoration was necessary, the temporary FDPs was decided to keep them under controlled observation
were cemented with eugenol-free cement (Temp Bond NE, within the clinical trial.
Kerr GmbH, Rastatt, Germany or Freegenol, GC, Bad Due to esthetic requirements in exceptional cases, the cut-
Homburg, Germany). The lithium disilicate FDPs were exclu- back technique was applied by additional veneering (IPS
sively designed digitally using the current software either in e.max Ceram, Ivoclar-Vivadent). This procedure was limited
the laboratory after scanning the gysum cast by the means of to small incisal edges. After proximal try-in, the marginal fit of
the Inlab system (Sirona, Bensheim, Germany) or chair-side the abutments was checked with a silicone indicator paste (Fit
based on the intra-oral impression. The full-contour FDPs Checker, GC, Bad Homburg, Germany). Adjustments were
were milled from an exclusively produced IPS e.max CAD done if necessary using a fine diamond bur under water-
LT (LT=low translucency) block of 32 mm length by the use cooling. Finally, static and dynamic occlusions were checked
of MC XL milling units (Sirona). and adjusted, if necessary. Then, the ground surfaces were
If the chair-side procedure was applied, a try-in procedure polished using polishers for ceramics interspersed with dia-
of the bluish metasilicate restoration with regard to fit, prox- mond grits from coarse to fine in the recommended sequence
imal, and occlusal contacts was possible. Afterwards, the (Diamond Polishers, Gebr. BrasselerKometLemgo, Germany
metasilicate restoration was crystallized. In the case of or Eve Diapol Polishers, EVE, Pforzheim, Germany) without
laboratory-based manufacturing, the FDPs were delivered in additional glaze firing.
their readily crystallized state. For the dimensions of the CAD All restorations were luted adhesively with Multilink
material, the same instructions were valid as for the press Automix (Ivoclar-Vivadent,Schaan, Liechtenstein). The
2174 Clin Oral Invest (2014) 18:2171–2178

intaglio surfaces of the abutment crowns were conditioned by Statistics


etching (20 s) with ≤5 % hydrofluoric acid (IPS Ceramic
etching gel, Ivoclar-Vivadent, Schaan, Liechtenstein), careful- Descriptive statistics and the failure-free rate and the
ly rinsed, and air-dried. Then, silane (Monobond S, Ivoclar- complication-free rate according to Kaplan–Meier were com-
Vivadent) was applied for 60s. The abutment surfaces were puted with IBM SPSS for windows (version 20). In order to
conditioned with Multilink Primer A/B. After cementation, an compare patients’ and dentists’ ratings, the Wilcoxon signed
X-ray of the restoration and its abutment teeth was done in rank was used.
order to check the complete removal of luting material excess
and the correct setting of the FDP. Finally, static and dynamic
occlusions were checked. Results

Clinical examinations Study group

The first recall was conducted 6 months after incorporation; Thirty-three patients received 38 fixed dental prostheses. In
then, the recall examinations were done annually. The FDPs five patients, two FDPs were inserted. Due to the fact that
were examined with respect to abutment sensitivity, probing observations of one type of material/restoration should be
depths, papilla bleeding index (PBI) of the abutment teeth, and limited to one unit per patient, in those cases where a patient
static and dynamic occlusal contacts. Additionally, the mobil- was supplied with two FDPs, one bridge was excluded for
ity of the FDPs was recorded. Intra-oral photographs were further evaluation by random (Excel random generator). One
taken of each patient. patient moved so far away that it was not possible for her to
Technical and biological complications were recorded. attend the 48-month recall; thus, she was discarded from the
Biological complications were defined as follows: secondary statistics as a dropout. The 32 remaining FDPs were observed
caries, endodontic complications, and fractures of the abut- over a mean time of 46 months (SD±8.4 month). Fourteen
ment teeth. Technical complications comprised fracture or patients were female. The average age of the patients was
chipping of the ceramic and loss of retention. Those events 54.8 years (SD ± 13.9 years). The minimum age was
that led to the loss or the removal of the FDP were estimated as 31.2 years, and the maximum age was 86.4 years. The distri-
failures. The dentists who accomplished the recall examina- bution of the abutment locations are displayed in Table 2.
tions were the same as those who conducted the treatment. Twelve FDPs were fabricated chair-side.
Finally, the patients were asked to assess their restoration in
terms of functional and esthetic outcome according to German Complication-free and failure-free rates
school marks ranging from school mark 1 (excellent) to school
mark 6 (worst). The investigating dentist was also asked to During the observation period of the 32 FDPs, two catastroph-
assess the FDP. ic failures occurred. One FDP fractured at 1.2 years. The

Table 2 Distribution of abutment localization of the 32 lithium disilicate FDPs in 32 patients and number of mesial (m) and distal (d) abutments and
pontic areas (p) that were involved in a dynamic occlusion at 6 months and at the last recall

Localization (FDI) Frequency Dynamic occlusion Dynamic occlusion at the last


at 6 months available recall

m p d m p d
15–13 8 6 3 2 6 4 5
14–12 1 1 0 1 1 1 1
13–11 6 2 1 4 3 2 3
12–21 4 2 2 2 3 3 4
11–22 3 2 1 1 3 2 3
21–23 3 1 0 2 2 2 3
23–25 6 6 3 4 5 3 3
31–42 1 1 1 1 1 1 1
Sum 32 21 11 17 24 18 23

For one FDP, the dynamic occlusion (abutment localizations13–11) was not recorded at the 6-month recall. At the last available recall for another FDP
(abutment localizations15–13), the dynamic occlusion was not recorded, and due to failure two FDPs (abutment localizations13–11 and 25–23) could
not be analyzed any more
Clin Oral Invest (2014) 18:2171–2178 2175

fracture occurred at the connector area of a maxillary right


central incisor abutment crown (Fig. 1). Another FDP had to 1.0
be removed due to persisting pain at recall at 36 months
(3.12 years). The cause of the pain could not be identified.
0.8
As complication events, two minor chipping at 3.1 and
3.2 years were noticed during the recall visits. Three endodon-

Cum Survival
tic complications occurred in two FDPs after 1.3 years (simul-
0.6
taneously maxillary right canine and maxillary right second
premolar in one FDP) and after 1.6 years (maxillary left canine
in another FDP). The latter complication also belonged to the
0.4
same FDP that had to be removed after 3.12 years due to
persisting pain. The Kaplan–Meier estimation for the
complication-free rate was 83.0 %, considering all events 0.2
comprising technical (chipping and fracture) and biological
(endodontic complications) events for the estimated mean
observation time of 4.4 years (lower bound 4.0 years, upper 0.0
bound 4.8 years) (Figure 2). The failure-free rate for the
estimated mean observation time of 4.7 years (lower bound 0.0 1.0 2.0 3.0 4.0 5.0
4.4 years, upper bound 4.9 years) was 93.0 % (Figure 3). observation-time in yrs
Fig. 2 Complication-free rate according to Kaplan–Meier for the esti-
Patients’ and dentists’ rating mated mean observation time of 4.4 years (lower bound 4.0 years, upper
bound 4.8 years)

When the patients were asked at recall at 6 months to rate


their FDPs with respect to the perceived esthetic appearance
according to German school marks, 22 out of 32 FDPs were recall. The number slightly increased to 24 during the obser-
rated as excellent (school mark 1) and 9 as good (school vation period. Eleven pontic areas showed guidance after
mark 2) (one assessment was not available). At the latest insertion and 18 at the last recall. In the case of the distal
available recall, the assessment was limited to 30 FDPs due abutments, the number of those that exhibited no guidance
to the fact that the two failures described earlier occurred. decreased during the observation from 14 to 6 (Table 2).
For 25 FDPs, “excellent” was assorted. Five were rated as
good.
The dentists rated the esthetics of the restorations, which
were inserted by themselves: 14 times as excellent, 14 times as
1.0
good, and three times as sufficient at recall at 6 months. At the
latest available recall, the assessment results were 12 times
excellent, 16 times good, and two times sufficient. Applying 0.8
the Wilcoxon signed rank test, the ratings of the patients and
of the dentist differed significantly at p≤0.05.
Cum Survival

0.6
Dynamic occlusion

Twenty-one of the mesial abutments out of the 32 FDPs were 0.4


involved in the dynamic occlusion pattern at the 6-month

0.2

0.0

0.0 1.0 2.0 3.0 4.0 5.0


observation-time in yrs
Fig. 3 Failure-free rate for the estimated mean observation time of
Fig. 1 Fractured FDP at the connector area at 1.2 years 4.7 years (lower bound 4.4 years, upper bound 4.9 years)
2176 Clin Oral Invest (2014) 18:2171–2178

Mobility exceeded both the capacities of the practices and of a recall


team. Due to the fact that the recall parameters were clearly
One FDP showed a mobility of 1 at the latest recall; the others defined, it seemed to be acceptable that the dentists did the re-
were rated 0. examinations by themselves. Additionally, spot-checks by the
involved university and by the monitor took place in every
Papilla bleeding index center in order to guarantee that the clinical operating protocol
was strictly obeyed.
After a mean observation period of 46 months, 13 FDPs The application for three-unit end abutment FDP made of
showed a papilla bleeding index of 0 simultaneously at the machinable lithium disilicate ceramics would be desirable due
mesial and at the distal abutment. One FDP exhibited both at to several advantages of this material. The metasilicate mate-
the mesial and the distal abutment a PBI of three. Further rial can be processed in a Computer Aided Manufacturing
results are displayed in Table 3. (CAM) unit without extensive wear of the milling burs, and
the good basic esthetic appearance can easily be enhanced by
Probing depths stains together with the glaze and crystallization process [2,
10, 11] in one fabrication step of about 40 min. This opens the
The minima and the maxima of the probing depths both at the option for a single-visit chair-side treatment. Additionally,
6-month recall and after the entire observation period revealed full-contoured lithium disilicate restorations seem to be ad-
minima of 0.5 mm and maxima of 4.0 mm. At 6 months, three vantageous in terms of chipping compared to veneered zirco-
of the mesial and distal abutments exhibited a probing depth nia oxide [12, 13]. The good resistance of full-contour lithium
of 3.5 or 4.0 mm. At the last recall, two mesial abutments disilicate against dynamic and occlusal forces was confirmed
showed a maximum probing depth of 4.0 mm and one distal by the present study. The high numbers of units loaded by
abutment each showed a probing depth of 3.5 and 4.0 mm. dynamic occlusion showed that the full-contour FDPs were
One of the mesial abutments that exhibited 4.0 mm belonged functionally integrated in the masticatory system (Table 2).
to that FDP which also showed 4.0 mm at the distal abutment. Independent from the abutment localization (Table 2), more
than two third both of the mesial and the distal crowns was
involved in dynamic occlusion patterns. The pontic area was
less involved. From the 6-month recall to the last recall, the
Discussion
numbers of units that contributed to dynamic occlusion slight-
ly increased. The chippings which were classified as “minor
Besides the limited observation time, another shortcoming of
chippings” occurred at the incisal edges of maxillary incisors.
the study was that the dentists who did the treatment had to
Although predominantly full-contour material was used, the
accomplish the recall examinations, too. Unfortunately, this
esthetic assessment by the patients revealed excellent ratings.
fact could not be circumvented because in the present study
The prevalent mark was “excellent”, unlike the dentists who
three private practices were involved. To provide two inde-
evaluated their own work more critically than the patients.
pendent examiners for the recall examinations would have
However, the worst mark given by the dentists was
Table 3 Results of the papilla bleeding index at the mesial and the distal “sufficient”.
abutment after a mean observation period of 46 months (two FDPs were The periodontal health documented by the probing depths,
not assessed due to failure; for one FDP, the PBI was not noted) the Papilla bleeding index, and the mobility was
Combinations for PBI assessments inconspicuous.
for the mesial and distal abutment With respect to the precursor material, Empress II, one
long-term clinical study over 10 years is existent as published
Mesial abutment Distal abutment Number of assessments by Solá-Ruiz et al. [15]. Twenty-one FDPs in nineteen patients
for each combination
made of Empress II with connector dimensions of the core
0 0 13 material of 12 mm2 (height of 4 mm and width of 3 mm) were
1 1 4 observed. Nearly one third of the patients showed
0 1 3 parafunctional habits. Five fractures in the connector area
1 0 1 and one incisally were recorded such that Solá-Ruiz et al.
1 2 2 computed a relatively low survival rate of 71.4 % after 10
2 1 1 years. Former investigations revealed that full-contour IPS
2 2 4 e.max Press lithium disilicate FDPs [7, 9] clinically performed
3 3 1
better than veneered lithium disilicate framework reconstruc-
Total 29
tions [4, 5, 15] (Table 1). These clinical findings were con-
firmed by an in vitro investigation of Schultheis et al. who
Clin Oral Invest (2014) 18:2171–2178 2177

obtained similar fracture loads for milled full-contour lithium anterior FDPs as standard [5, 9, 15], the values that are below
disilicate posterior FDPs compared to metal ceramic FDPs 16 mm2 for anterior FDPs in the present study could be seen as
before and after fatigue testing [16]. Esquivel-Upshaw et al. acceptable. However, two FDPs which replaced one first
reported on their 4-year clinical study of full-contour FDPs on premolar and one canine fell below the benchmark of
fractures of connectors that exclusively belonged to the first or 16 mm2, too. The latter one was only under-dimensioned at
second molar [7]. the distal connector, revealing a height of 5.0 mm and a width
From 30 posterior lithium disilicate FDPs, they inserted even of 3.0 mm, so that this value could be relativized because the
19 in the molar region and hence were beyond the official increased height of 5.0 mm should compensate the reduced
indication (Table 1). For the molar connector dimensions, a width. At the end, one FDP is left, which shows crucial
minimum size of 20 mm2 (4×5 mm) was set by the authors. connector values both at the mesial and distal region with
From the four connectors that broke, three were under the 10.5 mm2 (height 3.5 mm/width 3.0 mm) and 15.75 mm2
defined minimum dimensions. In the present study, one anterior (height 3.5 mm/width 4.5 mm), respectively.
FDP broke at the connector which was below the recommended In the present study, one catastrophic event occurred due to
size of 16 mm2 (4×4 mm). Investigating the reason for this incorrect connector dimensions of a lab-side fabricated FDP.
undersize underlined one of the limitations of this material According to the study protocol, the connector dimensions
because the connector was reduced due to aesthetical reasons. had to be noted prior to insertion. In the case of the fractured
At stake, the minimum dimensions which are deemed as nec- connector, the height and width were documented as 5 and
essary for clinical success, which sometimes cannot be kept 4 mm, respectively. Finally, the dimension was below
because anatomical and esthetic conditions do not allow these 16 mm2. One explanation may be that due to esthetical rea-
extensive dimensions. The longest mean observation time that is sons the dimension was reduced additionally after measuring
reported about e.max Press full-contour lithium disilicate FDPs the height and width. After the failure, the patient agreed to be
in a clinical trial is 121 months [9]. This study performed restored again with a lithium disilicate FDP, of course without
considerably better after 10 years than the study of Solá- being included again in the study. In this second version, the
Ruizet al. [15] which examined Empress II framework FDPs connector dimensions were kept by avoiding a too strong
within the recommended indications. Kern et al. reported about separation in the connector area. The FDP is now successfully
a survival rate of 100 and 87.9 % after 5 and 10 years, respec- in situ since nearly 4 years.
tively, strictly keeping the recommended manufacturer’s con- Thus, this weak “link” can only be strengthened by obey-
nector dimension. It has to be stressed that the authors exceeded ing consequently the recommended connector dimensions,
the manufacturer’s recommendations for the posterior indication especially in the vertical dimension. On the other hand, this
in 27 out of 30 cases by including molars as abutments. may be a limitation of the practical use of this material because
In summary, the crucial aspect of the full-contour lithium it is not always possible to provide enough space. As alterna-
disilicate FDPs is the connector area which is mostly prone to tive to lithium disilicate FDPs, all-ceramic FDPs made of
fracture. zirconia dioxide frameworks could be used. Therefore, it
In the case of the pressable lithium disilicate ceramic both would be sensible to compare both types of all ceramic resto-
for anterior and for posterior FDPs, the mesial and distal rations in terms of survival rates. Sailer et al. calculated in their
connector should show a minimum dimension of 16 mm2. review the estimated annual failure rates to be from 0 to
Therefore, these recommendations were presumed for the 5.71 % per100 FDPs and per year [17], depending on the
CAD material as well. According to the documented data of study they analyzed. Schley et al. reported in their review of
the present study, 11 FDPs were below the recommended zirconia FDPs an incidence of failures between 0 and 5 % per
connector dimensions at which five out the 11 fell below this 100 FDPs and per year [18]. The most reported shortcoming
benchmark both at the mesial and distal connector. Five out of of zirconia FDPs seems to be the minor stability of the
the eleven were below 16 mm2 at the distal location and one at veneering [18–20]. Whether these problems are meanwhile
the mesial connector region. Nine of the FDPs replaced a really resolved, this has to be evaluated in further clinical
mesial or lateral incisor. None of them was below 12 mm2. studies [20]. A recently published 84-month evaluation of
At the mesial connector, they had two times the dimension of veneered zirconia three- to four-unit FDPs revealed a survival
12.0 mm2, once 13.5 mm2, and two times 15.0 mm2. Three of rate of 83.4 % and a success rate of 57.9 %. The main reasons
them exceeded the recommended vertical height showing 4.5 for failures and complications were fractures and chippings of
and 5.0 mm. At the distal connector, one of the anterior FDPs the ceramic material [14], but it has to be emphasized that
revealed 12 mm2, one was 13.5 mm2, and six FDPs were these data are related to a 7-year observation period.
15 mm2. From the latter ones, five compensated a width of Interpreting the graph of the survival probability of this 7-
3.0 mm by a height of 5 mm. In addition, due to the fact than year study, the survival rate is approximately 90 % at 4 years,
some clinical studies which evaluated the pressable lithium which would be similar to the survival rate of the three-unit
disilicate material used connector dimensions of 12 mm2 for CAD/CAM-generated lithium disilicate FDPs after 48
2178 Clin Oral Invest (2014) 18:2171–2178

months. In conclusion, with the limitation of a relatively short up to 8 years results. Dent Mater 25(9):e63–e71. doi:10.1016/j.
dental.2009.05.003
observation time, the lithium disilicate material IPS e.max
9. Kern M, Sasse M, Wolfart S (2012) Ten-year outcome of three-unit
CAD can be regarded as an alternative to zirconia framework fixed dental prostheses made from monolithic lithium disilicate ce-
restorations within its range of indication and in comparison to ramic. J Am Dent Assoc 143(3):234–240
the failure rates of alternative materials like veneered zirconia 10. Fasbinder DJ, Dennison JB, Heys D, Neiva G (2010) A clinical
evaluation of chairside lithium disilicate CAD/CAM crowns: a two-
oxide frameworks. The major prerequisite of the clinical suc-
year report. J Am Dent Assoc 141(Suppl 2):10S–14S
cess is the strict adherence to the connector dimensions, 11. Baltzer A (2008) All-ceramic single-tooth restorations: choosing the
especially with respect to the height, which is simultaneously material to match the preparation—preparing the tooth to match the
a clinical limitation. material. Int J Comput Dent 11(3–4):241–256
12. Guess PC, Schultheis S, Bonfante EA, Coelho PG, Ferencz JL, Silva
NR (2011) All-ceramic systems: laboratory and clinical performance.
Acknowledgments This study was supported by IvoclarVivadent.
Dent Clin North Am 55(2):333–352
13. Guess PC, Zavanelli RA, Silva NR, Bonfante EA, Coelho PG,
Conflict of interest During the years the authors SW, KW, PN, and SR Thompson VP (2010) Monolithic CAD/CAM lithium disilicate ver-
have held oral presentations and/or courses, they were receiving a sepa- sus veneered Y-TZP crowns: comparison of failure modes and reli-
rate and appropriate honorarium each from the sponsor of the present ability after fatigue. Int J Prosthodont 23(5):434–442
study. 14. Rinke S, Gersdorff N, Lange K, Roediger M (2013) Prospective
evaluation of zirconia posterior fixed partial dentures: 7-year clinical
results. Int J Prosthodont 26(2):164–171
15. Sola-Ruiz MF, Lagos-Flores E, Roman-Rodriguez JL, Highsmith
References
Jdel R, Fons-Font A, Granell-Ruiz M (2013) Survival rates of a
lithium disilicate-based core ceramic for three-unit esthetic fixed
1. Tysowsky GW (2009) The science behind lithium disilicate: a metal- partial dentures: a 10-year prospective study. Int J Prosthodont
free alternative. Dent Today 28(3):112–113 26(2):175–180
2. Wiedhahn K (2007) From blue to white: new high-strength material 16. Schultheis S, Strub JR, Gerds TA, Guess PC (2013) Monolithic and
for Cerec—IPS e.max CAD LT. Int J Comput Dent 10(1):79–91 bi-layer CAD/CAM lithium-disilicate versus metal-ceramic fixed
3. Holand W, Schweiger M, Frank M, Rheinberger V (2000) A com- dental prostheses: comparison of fracture loads and failure modes
parison of the microstructure and properties of the IPS Empress 2 and after fatigue. Clin Oral Investig 17(5):1407–1413
the IPS Empress glass-ceramics. J Biomed Mater Res 53(4):297–303 17. Sailer I, Pjetursson BE, Zwahlen M, Hammerle CH (2007) A sys-
4. Taskonak B, Sertgoz A (2006) Two-year clinical evaluation of lithia- tematic review of the survival and complication rates of all-ceramic
disilicate-based all-ceramic crowns and fixed partial dentures. Dent and metal–ceramic reconstructions after an observation period of at
Mater 22(11):1008–1013 least 3 years. Part II: fixed dental prostheses. Clin Oral Implants Res
5. Marquardt P, Strub JR (2006) Survival rates of IPS empress 2 all- 18(Suppl 3):86–96
ceramic crowns and fixed partial dentures: results of a 5-year pro- 18. Schley JS, Heussen N, Reich S, Fischer J, Haselhuhn K, Wolfart S
spective clinical study. Quintessence Int 37(4):253–259 (2010) Survival probability of zirconia-based fixed dental prostheses
6. Makarouna M, Ullmann K, Lazarek K, Boening KW (2011) Six-year up to 5 yr: a systematic review of the literature. Eur J Oral Sci 118(5):
clinical performance of lithium disilicate fixed partial dentures. Int J 443–450
Prosthodont 24(3):204–206 19. Sailer I, Sailer T, Stawarczyk B, Jung RE, Hammerle CH (2009) In
7. Esquivel-Upshaw JF, Young H, Jones J, Yang M, Anusavice KJ vitro study of the influence of the type of connection on the fracture
(2008) Four-year clinical performance of a lithia disilicate-based core load of zirconia abutments with internal and external implant–abut-
ceramic for posterior fixed partial dentures. Int J Prosthodont 21(2): ment connections. Int J Oral Maxillofac Implants 24(5):850–858
155–160 20. Heintze SD, Rousson V (2010) Survival of zirconia- and metal-
8. Wolfart S, Eschbach S, Scherrer S, Kern M (2009) Clinical outcome supported fixed dental prostheses: a systematic review. Int J
of three-unit lithium-disilicate glass–ceramic fixed dental prostheses: Prosthodont 23(6):493–502