“Ceramic restorations – Do they last?”

I.E. Naert

K.U.Leuven(Catholic University of Leuven)

“Tradition and Innovation: what really works?”4 & 5 May, 2007 Brighton

British Society for Restorative DentistryBritish Society for Restorative Dentistry

Catholic University Leuven - KULeuven

On the way to metal-free restorative dentistry…

TreatmentTreatment byby anan AIT 3AIT 3

Adhesive composite build-up

ZrO2 substructure

Ceramic abutments (implants 14-24)

Veneered ZrO2 basis

WHY?

Because people want it, driven by:Rush-to-market productsMedia driven treatment plansDentists eager to please

But little regard to:Risk/benefit calculus

Of course, new materials/techniquesshould be given a change as well

Feldspathic porcelainKaolin (Al2O3 SiO2 H2O): 50%Feldspar (K2O Al2O3 6SiO2): 25%Quartz (SiO2): 25%

Vitro-ceramic porcelaine.g.: Dicor®, IPS Empress®, (Cerapearl®)

Aluminiumoxide- Increase of the crystaline phase by > Al2O3- e.g.: Cerestore®, InCeram®, Techceram®, Procera®

Zirconiumoxide / Zirconia

Classification based on chemicalchemicalfeatures

Fritting(Slip-)Casting(Heat-)PressingInfiltratingMilling (Cad/Cam)Sintering (Cad/Cam)or combinations

Classification based on productionproductionfeatures

Porcelain in dentistry

1774: 1st porcelain tooth (Duchateau)

1890: jacket crown (Land)

1962: ceramo-metal crown (Weinstein & Katz)

1980: metal-foil reinforced crown (galvano)1990: non-feldspathic porcelains

Non-feldspathicprocelains

AfterAfter 19901990

Lithium disilicate

Empress II system® (Ivoclar):

The coping is fabricated with either the lost-wax and heat-pressure technique or is milled out of prefabricated blanks.

Relatively translucent restorations. It is recommended that these restorations be etched and adhesively luted to enhance their strength and longevity.

The system is also confined to fabricating 3-unit FPDs that replace a missing tooth anterior to the second premolar.

Glass-infiltrated alumina

In-Ceram Alumina® (Vita)

Uses high-temperature sintered-alumina glass-infiltrated copings,

Was the first restorative system introduced for the fabrication of 3-unit anterior FDPs.

To fabricate the coping, one can use either the slip-casting technique or milling out of prefabricated partially sintered blanks.

Densely sintered high-purity aluminium-oxide

Procera AllCeram® (Nobelbiocare)

Uses a densely sintered high-purity aluminium-oxide as the core material.

The system is also confined to fabricating 3-unit FDPs that replace a missing tooth anterior to the second premolar.

Glass-infiltrated alumina with 35% partially stabilized zirconia

In-Ceram Zirconia® (Vita)

Combines the use of glass-infiltrated alumina with 35% partially stabilized zirconia for the core material.

In terms of translucency, the In-Ceram Zirconiacore is as opaque as a metal-alloy core.

Therefore, In-Ceram Zirconia is not recommended for fabricating anterior all-ceramic FDPs.

Yttrium tetragonal zirconia poly-crystals (Y-TZP)

Cercon® (Dentsply Ceramco), DCS-Precident® (Dentsply Austenal), Lava® (3MESPE)

Is the most recent core material for all-ceramic FDPs.

It was not until the early 1990s that the use of Y-TZP expanded into dentistry for endodontic posts and implant abutments.

Yttrium oxide is a stabilizing oxide added to pure zirconiato stabilize it at room temperature and to generate a multiphase material known as partially stabilized zirconia.

The crack propagation stop due to volume expansion is known as: “transformation toughening”.

System (manufacturer) Core materialFlexural strength

(MPa)

Fracture toughness

KIC(MPa/m1/2)

Connector surface area in

FDP

Empress II (Ivoclar North America, Amherst, NY) Lithium disilicate 300-400 2.8-3.5 12-20 mm2

In-Ceram Alumina (Vita Zahnfabrick, Bad Sackingen, Germany)

Glass-infiltrated alumina 236-600 3.1-4.61 12 mm2

In-Ceram Zirconia (Vita Zahnfabrick, Bad Sackingen, Germany)

Glass-infiltrated alumina with 35% partially stabilized zirconia

421-800 6-8 12-20 mm2

Procera AllCeram Bridges (Nobel Biocare, Goteborg, Sweden)

Densely sintered high-purity alumina 487-699 4.48-6 16 mm2

Cercon (Dentsply Ceramco, Burlington, NJ) Y-TZP 900-1200 9-10 7-11 mm2

DCS-Precident DC-Zirkon(Dentsply Austenal, York, Pa) Y-TZP 900-1200 9-10 16 mm2

Lava (3M ESPE, St. Paul, Minn) Y-TZP 900-1200 9-10 9 mm2

Features of Non-feldspathic procelain systems

Cad/Cam systems production methods

DefiniteDefinite move move towardstowards digitizeddigitizedproductionproduction methodsmethods

3-D Scan

Computer-Aided Design

Computer-Aided Manufacturing (Technology)

Applying Material on a Die (Additive Technique)

Cutting from a Solid Block (Subtractive Technique)

Pressing/Milling ● Aluminium Oxide

ElectrophoreticDispersion ● In Ceram

Spark Erosion/Milling ● Titanium

Stereolithography● Resin

3-D Printing ● Wax, ● Resin

Presintered Stage (Milling/Grinding) ● Ceramics

Completely Sintered Stage

(Grinding) ● Ceramics

Milling ● Alloys ● Titanium

Selective Laser Sintering ● Alloys

Presintered Medium Stage (Wet Grinding) ● In-Ceram ● Zirconium Oxide

Presintered Soft Stage (Dry Milling) ● Zirconium Oxide

Solid Free-Form Fabrication (Additive Technique)

Ti Selective laser sintering

Partially vs Fully Sintered blanks

Partially sintered Y-TZP–based blanks:E.g.: Cercon® and Lava® systems

Fully sintered Y-TZP–based blanks:E.g.: DC-Zirkon® system

The proponents of partially sintered frameworks claim that micro cracks may be introduced to the framework during the milling procedure of a fully sintered blank The proponents of milling of a fully sintered blank claim that because no shrinkage is involved in the process the marginal fit is superior.

Medium and Long term data

The use of full-ceramic crowns on single teeth

An up to 13-year experience at K.U.Leuven

No filling materialSintering at 1.550° C> 99.5 % pure Al203

Porcelain veneering around 920° C Consequences: fit and marginal adaptation will not be influenced (melting point Al203: 2.050°)

Densely sintered high-purity aluminium-oxide

ProcedureProcera® AllCeram

+20%

beforeSintering

after Sintering

Technique Al203(Procera® /Nobel Biocare)

Clinical procedurePreparationImpression takingColour selectionCoping fabrication (scan / design / mill)VeneeringCementationControl

Preparation

The effect of tooth preparation form on the fit of Procera copingsLin MT, Sy-Munoz J, Munoz CA, Goodacre CJ, Naylor WPInt J of Prosthodont, 1998:11;6: 580-90

• chamfer outline

• rounded corners

• no internal edges

• equi- or 0.5 mm subgingival in theaesthetic zone

0.4 to 0.6 mm clearance for the coping and 1.2 mm for the veneering porcelain

Impression taking

(Tactile) scanning

Designing 3D CAD

In Swedish plant: - die milling- enlarged-die milling- material pressing (inner contour)- milling (outer contour)- sintering

In In SwedenSwedenAt home labAt home lab

copings

Al2O3: 0.6 of 0.4 mm

ZrO2: 0.7- 0.8 mm

Laminates: 0.25 mm

Wax up

Double scanning sometimes…

Ceramometal

Metal substructure shape:Equally offset for uniform porcelain veneeringReinforcement of the substructureInterdentale vestibular separation depth(Heat evacuation during firing)

Rounded contours and contactsurfacesOptimally supported veneering porcelain

- Conventional cement:

- (Zinkoxyphosphate)

- (Resin mod.) Glassionomer

- Adhesive cement:- Composite cement (dual cure)

Least solvable cement Least marginal abrasion (ditching)Although, densely sintered Al203 is not etchable

Advantages of composite cement

Retention of Zr02 ceramic crowns with 3 types of cement.Palacios R, Johnson G, Phillips K, Raigrodski AJ Prosthet Dent 2006;96:104-14

Panavia F 2.0 + ED Primer, (composite resin cement withadhesive agent)Rely X Luting (resin-modified glassionomer cement)

Rely X Unicem (self-adhesive modified composite resin)

Res.:All had equally mean removal stresses of 5 to 6 MPa.

Concl.:Thus, the bonding agent did not yield higher coping retention.

I. Luting procedure for Al2O3 and ZrO2

In the lab:Blasting with Al2O3 grid (50 µm) 15” at 4 – 5 barUltrasonic cleaning in isopropyl alcohol for 3’

Chair side:Clean preparation with pumice on rubber cupWater spray, dry NOT too long (Cave: Wet covering)Isolate (cotton rolls, tong shield or rubber dam)

Clean internal crown lumen with 37% phosphoric acid to remove saliva and protein layerRinse with ample water for 1’Dry with air syringeDehydrate with isopropyl alcohol and air dry (do not use the syringe!)

II. Luting procedure for Al2O3 and ZrO2

Luting with Panavia F 2.0

Mix Ed Primer II A & B.Apply on the preparation, wait 30”, gently dry, Mix Panavia F 2.0 A & B for 20”. Apply into the inner side of the restorationBring in place and apply firm pressure (10 kgf)Light cure for about 3” the paste at the margins and afterwards remove excess,Light cure the margins for 20” each

Problems encountered…

Colour match…

Translucency(Hefferman et al. J Prosthet Dent 2002;88:4-9)

Brand (Thickness) Translucent = 0.0/Opaque = 1

Vitadur Alpha (0.5 mm) 0.60 Empress (0.5 mm) 0.64 In Ceram Spinell (0.5 mm) 0.67 Empress 2 (0.5 mm) 0.68 Empress (0.8 mm) 0.72 Procera (0.5 mm) 0.72 Empress 2 (0.8 mm) 0.74 In-Ceram Al (0.5 mm) 0.87 In-Ceram Zr (0.5 mm) 1.00 Metal cap 1.00

Indication

Feldspathic-based ceramics: anterior areaLower strength / more aesthetic

Al203 en Y-TZP ceramics: posterior areaStrong / some what less aesthetic

What about the evidence?

Precision of fit and clinical evaluation of all-ceramic full restorations followed between 0.5 and 5 years.Naert I, Van Der Donck A & Beckers LJ Oral Rehabil 2005;32:51-57

300 single Procera® restorations placed between Nov./’94 en Aug./’98 and followed up to 5 years.

Two parts:I n vitro partIn vivo part

In vitro part:

Marginal fit:

8 teeth, measured at 4 locations (V, M, D, L)

Procera versus die versus toothLuted with GI versus composite cement

Internal adaptation, for adefined cement space of 50 µm

Crown luted according tostandard clinicalprocedures

Sections made M-D en V-L

Stereomicroscopic view at 50x at 4 sites: a, b, c en d

Mean values of the crown luted on the tooth(32 measurements per tooth)

Region Means RangesMargin (a) 34 µm 0-90Chamfer corner (b) 135 µm 34-220Axial wall (c) 60 µm 9-185Occlusal (d) 77 µm 17-214

tooth

cement

coping

tooth

cement

coping

aa

In vivo results

Margin qualityComplicationsAesthetic outcomePeriodontal healthPatient satisfaction

All luted with GI-cement (Fuji-I® GC)

Quality of marginal fit (% of resto.):No remarks: 80.4%Slight overhang felt with probe: 16.3%Probe hooks: 1.5%Not acceptable: 1.8%

Number of Complications:Coping fracture: 1Porcelain fractures (“chipping”): 12Severe crown margin gingivitis: 1

Marginal fit & Complications

Survival vs Success

chipping

Coping fracture

Repair by direct composite

Surface texture & colour:Very good: 72.2%Good: 26.8%Bad: 1%

Anatomical form:Very good: 78.5%Good: 21.0%Bad: 0.5%

Colour and Anatomy rated by dentist

Success vs. Survival

Survival:When the original restoration still was present

Success:When the original restoration still was present and:

no major porcelain chippingsurface texture & colour & anatomy rated very good to goodprobe was not hooking, no decay, no severe gingivitispatient satisfacion >5/10

Plaque: Test: 21%Cont.: 19%

Periodontal health at last recall

Bleeding:Test: 39%*Cont. 17%

Location of ≥50% of the margin:supra: 16.3%equi: 15.3%sub: 68.4%

Aesthetics>7/10 87 %>5/10 8.3%<5/10 4.6%

(1=very bad) (10=very good)

Functional>7/10 93 %>5/10 4.6%<5/10 1.8%

Patient satisfaction at last recall:

95.698.407162361-6695.698.4014334755-6095.698.4032508249-5495.698.41625311543-4897.110001027417637-4297.110001247620031-3697.110021527622825-30

98.410021888126919-24

99.510002098129013-18

99.51001214812957-12

1001000219813000-6

Cum. Success

Rate

Cum. Survival

Rate

FailedCrowns

N° of crowns at

risk

Lost dueto follow-

up

N° of installedcrowns at

beginning of eachperiod

Loadingtime

months

Cumulative Survival & Success Rate at year 5

1567 How Efficient are Chair side Conditioning Methods for Repair of All-ceramics?M. ÖZCAN, L.F. VALANDRO, W. KALK, University Medical Center Groningen, University of Groningen, Netherlands,, Federal University of Santa Maria, Brazil, University Medical Center Groningen, University of Groningen, AV Groningen, Netherlands

Seq #183 - Ceramics and Cements: Bond StrengthIADR New Orleans Friday, 23 March 2007

Objective: The objectives of this study were 1. to determine the most effective surface conditioning protocol for the repair strength of a resin-composite to core-veneering ceramic and 2. to identify the failure modes.

Treating the veneer ceramic with:HF-gel (Porcelain Etch, Ultradent) +Silicacoating (30µm SiO2) (CoJet, 3M-ESPE) +Silanization (ESPE-Sil, 3M-ESPE)

resulted in the highest repair strength of the resin-composite tested (VisioBond 3M-ESPE) + (Quadrant Posterior, Cavex)

100 Procera AllCeram crowns, in 58 patients17 front- , 28 premolaar-, 55 molar area

Results: After 5 years of follow-up: 5% fractures

2 porcelain fractures3 porcelain and en coping fractures

Five year clinical evaluation of Procera AllCeramcrowns. Oden A & Andersson MJ Prosthet Dent 1996;75:14

Mat & Meth.:Multicenter study: 12 dentists in 9 centra 87 crowns in 50 patients5 to 10.5 years of follow-up

Results:Cum. Survival Rate:

97.7% after 5 and 92.2%92.2% after 10 yearsMarginal fit and aesthetics:

92% acceptable or excellent

Procera Allceram crowns followed for 5 to 10.5 years: a prospective clinical studyOdman P & Andersson BInt J Prosthodont 2001

And the other systems?

All-composite and all-ceramic single tooth restorations generated by GN-1 Cad/Cam system: A 3year follow-up study.Naert I, Vanoorbeek S & Lijnen I2007 (submitted)

200 single restorations placed between Aug./’03 and Jun./’04

In vitro partIn vivo part

Materials

Blanks Composite blanks: high compr. & flext. strengthCeramic blanks: 70% Al203 + Leucite glassinfiltration (~ InCeram Alumina®, Vita)

Veneering:Prefabricated Composite veneered withGradia®

Ceramic veneered with Vitadur Alpha®

Luting cement

Linkmax® (GC, Japan): a dual cure resin cement (layer thickness: 2.3 µ)

Primers:Ceramic primerComposite primerMetal primer-II (for metal post-and-cores)Self-etching primer for tooth

Scanner:- 5-axis laserscanner- 20 µm accuracy

Production of:- single crowns- 2 materials: ceramicand composite(titanium)

GN-1 GC (Japan)http://www.gcdental.co.jp/cadcam/

GN-1 GC (Japan)http://www.gcdental.co.jp/cadcam/

Life table analysis for composite GN-1 restorations

Intervalmonths

N° of resto. at start interval

Lost dueto loss of follow-up

Resto. at risk

Failedresto.

Interval Succes rate

Cum. SuccessRate

Cum. Survival Rate

0-6 59 6 53 3 94.3 94.3 94.3

7-12 56 5 51 0 100 94.3 94.3

13-18 56 5 51 1 98.1 92.4 92.4

19-24 55 4 51 1 98.2 90.6 90.8

25-30 54 20 34 1 98.1 88.7 89.1

31-36 51 19 32 0 100 88.7 89.1

Life table analysis for porcelain GN-1 restorations

Intervalmonths

N° of resto. at start interval

Lost dueto loss of follow-up

Resto. at risk

Failedresto.

Interval Succes rate

Cum. SuccessRate

Cum. Survival Rate

0-6 141 11 130 2 98.5 98.5 98.5

7-12 139 11 128 0 100 98.5 98.5

13-18 139 35 104 0 100 98.5 98.5

19-24 139 35 104 0 100 98.5 98.5

25-30 113 35 78 1 98.7 97.2 97.2

31-36 86 35 51 0 100 97.2 97.2

Vertical loss at Occlusal Contact Areas

Of each 10th resto. a replica was made after3 w., 6 m., 1, 2 and 3 y.

Laserscan 3D-Pro system (Willytec, Germany)was used

Total amount of lost tissue and max. verticalwear at occlusal contact areas was calculated.

Max. (SD) vertical loss at contact areasand total volume loss

Max. vertical loss at 6 m. Max. vertical loss at 36 m.

Porcelain 27 27 µµm m (4.38)*(4.38)* 92 92 µµm m (34.5)*#(34.5)*#

Composite 34 34 µµm m (4.77)**(4.77)** 174 174 µµm m (36.8 (36.8 µµm)**#m)**#

Volume loss at 6 m. Volume loss at 36 m.

Porcelain 0.09 mm0.09 mm3*3* 0.49 mm0.49 mm3*3*

Composite 0.14 mm0.14 mm3**3** 0.56 mm0.56 mm3**3**

Surface Texture & Colour and Anatomy of Composite and Ceramic restorations scored by CDA-index

3 weeks 1 year Last recallRomeo Sierra Tango Romeo Sierra Tango Romeo Sierra Tango

COMPOSITE (% of restorations)Text. & Colour 36 64 / 31 69 / 32 65 3Anato-my 36 64 / 30 70 / 26 71 3

CERAMIC (% of restorations)Text. & Colour 72 28 / 84 16 / 96 4 /Anato-my 72 28 / 84 16 / 96 3 1

CeramicsCeramics > > compositecomposite

Marginal quality at baseline and last recall or compositeand ceramic restorations (CDA-index)

COMPOSITE CERAMIC

Baseline Last recall Baseline Last recall

Optimalfit 50% 27% 48% 31%

Slightoverhang 50% 70% 52% 60%

Hookingprobe / 3% / 9%

CeramicsCeramics = = porcelainporcelain

Conclusions

Favourable CSR (97.2%) for the porcelain restorations after 3 years.

Further improvement in the composite restorations is needed todevelop veneering materials that equalthe aesthetic and functional features of all-ceramic restorations.

A 10-year longitudinal study of fixed prosthodontics: clinicalcharacteristics and outcome of single unit metal-ceramic crowns.Walton TRInt J Prosthodont 1999;12:519-526

94% of the ceramo-metalrestorations were given “a good prognosis” rating after 10 years of service

and for glass-ceramic crowns

An 11-year clinical evaluation of leucite-reinforcedglass-ceramic crowns: a retrospectice study.Fradeani M & Redemagni MQuintessence Int 2002;33:503-510 95 % (99 vs 85)

Survival of Dicor glass-ceramic dental restorations over 14years: Part I.Malament KA & Socransky SSJ Proshet Dent 1999;81:23-32 92 % (part. rest.)

!! !! HigherHigher failurefailure raterate in in hehe posteriorposterior areaarea!!!!

0828 In-Vitro Vertical Marginal Gap Comparison of CAD/CAM Zirconium Copings.

A.J.T. SHANNON1, F. QIAN2, P. TAN1, and D. GRATTON1, 1University of Iowa, Iowa City, USA, 2University of Iowa, College of Dentistry, Iowa City, USA

Seq #104 - Crowns: Laboratory based ResearchIADR New Orleans Thursday, 22 March 2007

Objectives: To evaluate the vertical marginal gap of zirconium-oxide copings from contemporary CAD/CAM systems.

Mat. & Methods: 5 x 10 Zirconium-oxide copings were milled:

Everest (ZH, ZS) (KaVo) Procera (MOD40, Piccolo, Forte) (NobelBiocare) Lava (3MESPE) Zeno (Wieland) InCeramZr (CERECinlab)

and compared to control cast copings(n=10).

Group Mean Marginal Gap (µm) ±SD and Group Comparisons

Procera-Piccolo 28.23±11.27 A Procera-MOD40 25.80±10.08 A Procera-Forte 24.29±8.71 A B Everest-ZS 25.77±22.38 A B Zeno 11.85±5.78 B C InCeramZr Cerec 18.35±20.6 B C Everest-ZH 10.59±6.42 C Control-Cast 3.19±1.02 D Lava 3MESPE 3.00±0.74 D

(Means with same letter not significantly different, >0.05)

Vertical margin gap of the CAD/CAM copings were significantly greater for all groups except one (LAVA) as compared to the control cast copings. Further investigations regarding horizontal marginal gap and internal coping fit are required.

Supported by NIH/NIDCR T32 DEO14678, KaVoAmerica,University of Iowa, College of Dentistry.

Conclusion:

Seq #66 - Crowns and Fixed Partial DenturesIADR New Orleans, Thursday, 22 March 2007

0291 Colour match of crowns with zirconia and metal frameworks

I. SAILER, C. HOLDEREGGER, R.E. JUNG, A. ZEMBIC, and C.H.F. HAMMERLE, University of Zurich, Switzerland

Objectives: The purpose of this study was to analyze the colour match of veneered crowns with three different framework materials.

Mat. & Methods:Six patients each with one central maxillary incisor to be restored and the other one unrestored (control) were included.

For each patient one metal (M), one glass-ceramic (G) and two zirconia (Zi) frameworks were made.

The following veneering ceramics were included and masked to eliminate bias:

A: Creation Classic (on metal cap), KlemaB: IPS e. max Ceram (with zirconiaframeworks), IvoclarC: Creation ZI, KlemaD: IPS e. max Ceram (with glass-ceramic fameworks), Ivoclar

Results:

Spectrophotometric analysis revealed a visible colour deviation between test crowns and control teeth but without statistical significance.

In contrast, the subjective assessment showed a significantly higher preference for crowns with zirconia frameworks (p<0.01, Chi Square).

Out of all combinations, zirconia frameworks veneered with IPS e. max Ceram were ranked best match.

Metal-ceramic crowns were judged to be worst in 33.3% (n=22, p<0.01, Chi Square).

And what about FDPs?

How it started Al2O3 FDP (Procera) from 1998…

Pre-scaned ponticMinimal connection thickness: 0.6 mmCopings + pontic “soldered” with fusing materialFusing: 1,200°

1998

1998

5 and 7 years later the solder joints broke

…till today

New materials such as Y-TZP

Full ceramic FDP

2-4 pontics, 1 ext. pontic

“Small is beautiful”

In vitro data

In vitro and in vivo studies show that the exclusive mode of failure in all-ceramic FPDs was a fracture of the connectors (Kelly et al., 2006).

Sharp occlusal embrasures will affect the fracture resistance of the FPD.

Thus, the primary cause of failure reported for all-ceramic FPDs differs from those reported for the metal-ceramic FPDs.

To prevent such failures, the connectors of all-ceramic FPDs must have sufficient height and width.

The strength, and therefore, the minimal critical dimensions of these connectors, are exclusively dependent on the type of ceramic material used for the core material.

In vitro data

To ensure long-term success of metal-ceramic FPDs, the minimal critical dimensions recommended for the connectors are an occluso-gingival height of 2.5 mm and a buccolingual width of 2.5 mm, which provide for a connector surface area of 6.25 mm2.

These dimensions may be achieved both in the anterior and in the posterior segments.

In vitro data

However, this is not the case for all-ceramic FPDs. Owing to the primary mode of failure and the brittleness of ceramics, the required connector dimensions for all-ceramic FPDsare larger than those recommended for metal-ceramic FPDs.

This may be a major contributing factor in restricting the versatility of their use.

In vitro data

In vivo data: Ceramo-metal

Walton, 2003 in a clinical retrospective study evaluating 515 metal-ceramic FPDs, calculated the cumulative survival rate of metal-ceramic FPDs:

96% for 5 years, 87% for 10 years, 85% for 15 years of service.

Of the evaluated metal-ceramic FPDs, 299 were 3-unit metal-ceramic FPDs.

Seq #165 - Clinical Trials: Ceramics, Indirect Composites, Glass Ionomers and DesensitizersIADR New Orleans Friday, 23 March 2007

1386 1 year clinical performance of PFM, zirconia, and alumina prostheses

R.P. CHRISTENSEN, A.D. GALAN, B.D. COUNIHAN, K.A. ERIKSSON, and T.A. MOSHER, CRA Foundation, Provo, UT, USA

OBJECTIVE: Compare clinical performance of 5 all-ceramic systems with 3 porcelain-metal systems

METHODS:227 3-unit posterior prostheses (32 each, 7 systems) were placed by 104 dentists with varied demographic profiles.

Standardized preparations and cementation with resin modified glass-ionomer were used.

System / Substructure /Superstructure / Superstructure Technology

System Substructure Veneer pocelainSubstructure / Superstructure

Technology

Cercon Zirconia presintered Ceramco PFZ Copy mill. / hand layered

Everest Zirconia fully sintered GC Initial Zr CAD-CAM / hand layered

Lava Zirconia presintered Lava Ceram CAD-CAM / hand layered

Wol-Ceram Alumina Noritake Cerabien

Electro-phoreticdeposition /

1/2 hand layered 1/2 pressed

Captek Au-Pt-Pd Jensen Creation Hand adapted foil/hand layered

Ceramco 3 Ultra Crown SF Ceramco SoftWearEnamels Cast / hand layered

Pulse interface Argen 65 SF Jensen Pulse interface Cast / pressed

RESULTS:

Six of 44 (14%) Wol-Ceram substructures broke (3 layered, 3 pressed)

No zirconia or metal substructures broke.

Superstructure porcelain broke on all seven systems, but less frequently on Captek, Ceramco3, and Pulse interface metal-porcelain systems.

Surfaces of Captek porcelain were pitted significantly more initially and at 1 year.

CONCLUSIONS:

At 1 year, zirconia substructures equaledmetal with no breakage.

Alumina substructure breakage suggested alumina is too weak for multi-unit posterior restorations.

Frequency of superstructure porcelain breakage needs attention.* (support!)

System Number of FDP Years Survival

IPS IPS e.maxe.max PressPress 37 (A+P) 5 100%

Empress IIEmpress II 30 (A) 2 93%93%

CerconCercon ZrZr 61 (P) 2 (ff)3 (cant.)

100%100%92%92%

CerconCercon ZrZr 99 (P) 4 94%94%

InIn--Ceram AlCeram Al 36 (A) 5 88%

InIn--Ceram AlCeram Al 20 (A) 5 90%

InIn--Ceram Ceram ZrZr 18 (P) 3 94.4%94.4%

VMKVMK 515* (A+P) 5 96%96%

Medium term in vivo data of 3-unit FDP (teeth)

General remarks

Lack of RCT!!If we lack controls and on top of that the study reports on retrospective data, thisonly says something about “howgood/bad” we as oral care providers are. It does not learns us if treatment A is >, < or =!

Aesthetics Fracture

The full ceramic single tooth restorations are a valuablealternative to the ceramo-metal ones

Definite choice by the industry for Cad/Cam generatedrestorations

Clinical long-term RCT are needed

Current systems in the marketCEREC 3DSirona, Bensheim, Germanywww.sirona.de

EverestKavo, Leutkirch, Germanywww.kavo-everest.com

ProceraNobel Biocare, Göteburg, Sweden„www.nobelbiocare.

CEREC InLab

Sirona,www.sirona.de

GN-1GC International,Tokyowww.gcdental.co.jp/cadcam/index.html

Pro 50Cynovad, Saint-Laurent, Quebecwww.cynovad.com

CerconDegudent, Frankfurt

Germany www.degudent.de

DigiDent DentaCADHint-Els, Griesheim, Germanwww.hintel.de

Wol-CeramWol-Dent, Ludwigshafen, Germanywww.wolzdental.com

DecimCad.esthetics AB,Skelleftea, Sweden

www.cadesthetics.com

Lava3M ESPE, Seefeld, Germanyhttp://cms.3m.com/ cms/US/en/2-21/kzikuFW/view.jhtml

ZENO TecWieland Dental + Technik GmbH, Pforzheim, Germanywww.wieland-dental.de

Evolution 4D* D4D Technologies,Richardson, Texas www.d4dtech.com

MedifacturingBEGO Medical AG, Bremen, Germany“www.bego-medical.de

EtkonEtkon AG, Gräfelfingen, Gerpmanywww.etkon.de

Precident DCSDCS AG, Allschwil, Switzerlandwww.dcs-dental.com