Porcelain Overwie

Clinical ImplicationsThis investigation supports the view that successful applica-tion of all-ceramic materials depends on the clinician’s ability to select the appropriate material, manufacturing technique, and cementation or bonding procedures, to match intraoral conditions and esthetic requirements.

Statement of problem. Developments in ceramic core materials such as lithium disilicate, aluminum oxide, and zirconium oxide have allowed more widespread application of all-ceramic restorations over the past 10 years. With a plethora of ceramic materials and systems currently available for use, an overview of the scientific literature on the efficacy of this treatment therapy is indicated.

Purpose. This article reviews the current literature covering all-ceramic materials and systems, with respect to survival, material properties, marginal and internal fit, cementation and bonding, and color and esthetics, and provides clinical recommendations for their use.

Material and methods. A comprehensive review of the literature was completed seeking evidence for the treatment of teeth with all-ceramic restorations. A search of English language peer-reviewed literature was undertaken using MED-LINE and PubMed with a focus on evidence-based research articles published between 1996 and 2006. A hand search of relevant dental journals was also completed. Randomized controlled trials, nonrandomized controlled studies, longitudinal experimental clinical studies, longitudinal prospective studies, and longitudinal retrospective studies were reviewed. The last search was conducted on June 12, 2007. Data supporting the clinical application of all-ceramic materials and systems was sought.

Results. The literature demonstrates that multiple all-ceramic materials and systems are currently available for clinical use, and there is not a single universal material or system for all clinical situations. The successful application is depen-dent upon the clinician to match the materials, manufacturing techniques, and cementation or bonding procedures, with the individual clinical situation.

Conclusions. Within the scope of this systematic review, there is no evidence to support the universal application of a single ceramic material and system for all clinical situations. Additional longitudinal clinical studies are required to advance the development of ceramic materials and systems. (J Prosthet Dent 2007;98:389-404)

Current ceramic materials and systems with clinical recommendations: A systematic review

Heather J. Conrad, DMD, MS,a Wook-Jin Seong, DDS, MS, PhD,b and Igor J. Pesun, DMD, MSc

School of Dentistry, University of Minnesota, Minneapolis, Minn; University of Manitoba, Winnipeg, Canada

aAssistant Professor, Division of Prosthodontics, Department of Restorative Sciences, School of Dentistry, University of Minnesota.bAssistant Professor, Division of Prosthodontics, Department of Restorative Sciences, School of Dentistry, University of Minnesota.cAssociate Professor, Department Head, Department of Restorative Dentistry, Faculty of Dentistry, University of Manitoba.

Conrad et al

Following the introduction of the first feldspathic porcelain crown by Land,1 the interest and demand for nonmetallic and biocompat-

ible restorative materials increased for clinicians and patients. In 1965, McLean2 pioneered the concept of adding Al2O3 to feldspathic porcelain

to improve mechanical and physical properties. The clinical shortcomings of these materials, however, such as brittleness, crack propagation, low

390 Volume 98 Issue 5

The Journal of Prosthetic Dentistry

popular,10 patient demand for im-proved esthetics has driven the devel-opment of ceramic for use with inlays, onlays, crowns, FPDPs, and implant-supported restorations.11 The use of conservative ceramic inlay prepara-tions with 5.5 to 27.2% tooth struc-ture removal is increasing, along with all-ceramic complete crown prepara-tions, which are more invasive and result in 67.5 to 72.3% tooth struc-ture removal.12 All-ceramic restora-tions combining esthetic veneering porcelains with strong ceramic cores have become popular (Table I). Ve-neering porcelains typically consist of a glass and a crystalline phase of fluoroapatite, aluminum oxide, or

leucite. Veneering a lithium-disilicate, aluminum-oxide, or zirconium-oxide core with glass allows dental techni-cians to customize these restorations in terms of form and esthetics.13 The most commonly reported major clini-cal complication resulting in failure of all-ceramic restorations is the fracture of the veneering porcelain and/or the coping (Table II).3,14-30 The success of these systems is dependent upon preventing failure by retarding crack propagation.4,31-33

Expansion of the use of all-ce-ramic systems for FPDPs has limita-tions. Proper diagnosis and patient selection are critical for success. A minimum connector height of 3 to 4

Glass CeramicLithium-disilicate

(SiO2-Li2O)

Leucite(SiO2-Al2O3-K2O)

Feldspathic(SiO2-Al2O3-Na2O-K2O)

AluminaAluminum-oxide(Al2O3)

ZirconiaYttrium tetragonalzirconia polycrystals(ZrO2 stabilized by Y2O3)

Core Material

Heat pressedHeat pressed

Heat pressedHeat pressedMilled

MilledMilledMilled

Slip-cast, milledMilledMilledSlip-cast, millledDensely sintered

Green milled, sinteredGreen milled, sinteredMilledMilledDensely sintered, milled

ManufacturingTechniques

Crowns, anterior FPDPOnlays, 3/4 crowns, crowns, FPDP

Onlays, 3/4 crowns, crownsOnlays, 3/4 crowns, crownsOnlays, 3/4 crowns, crowns

Onlays, 3/4 crowns, crowns, veneersOnlays, 3/4 crowns, crowns, veneersAnterior crowns, veneers

Crowns, FPDPCrownsOnlays, 3/4 crowns, crownsCrowns, posterior FPDPVeneers, crowns, anterior FPDP

Crowns, FPDPCrowns, FPDPCrowns, FPDPOnlays, 3/4 crowns, crownsCrowns, FPDP, implant abutments

Clinical Indications

IPS Empress 2 (Ivoclar Vivadent, Schaan, Liechtenstein)IPS e.max Press (Ivoclar Vivadent)

IPS Empress (Ivoclar Vivadent)Optimal Pressable Ceramic (Jeneric Pentron, Wallingford, Conn)IPS ProCAD (Ivoclar Vivadent)

VITABLOCS Mark II (VITA Zahnfabrik, Bad Sackingen, Germany)VITA TriLuxe Bloc (VITA Zahnfabrik)VITABLOCS Esthetic Line (VITA Zahnfabrik)

In-Ceram Alumina (VITA Zahnfabrik)In-Ceram Spinell (VITA Zahnfabrik)Synthoceram (CICERO Dental Systems, Hoorn, The Netherlands)In-Ceram Zirconia (VITA Zahnfabrik)Procera (Nobel Biocare AB, Goteborg, Sweden)

Lava (3M ESPE, St. Paul, Minn)Cercon (Dentsply Ceramco, York Pa)DC-Zirkon (DCS Dental AG, Allschwil, Switzerland)Denzir (Decim AB, Skelleftea, Sweden)Procera (Nobel Biocare AB)

System

Table I. Ceramic materials and systems and manufacturer-recommended clinical indications

Conrad et al

tensile strength, wear resistance, and marginal accuracy, continued to limit their use.3 Although the first biomedi-cal application of zirconia occurred in 1969,4 the first paper regarding the use of zirconia for the production of artificial femoral heads was written by Christel5 in 1988. Applications expanded into dentistry in the early 1990s and have included endodontic posts, implants and implant abut-ments, orthodontic brackets, cores for crowns, and fixed partial denture prosthesis (FPDP) frameworks.6-9

Even though the combination of predictable strength and reasonable esthetics has continued to make tra-ditional metal-ceramic restorations

391November 2007

Table II. Classification of complications and overall survival rates

Raigrodski37

Vult von Steyern38

Fradeani14

Oden15

Odman16

Wolfart17

Frankenberger18

Sjogren3

Fradeani19

Marquardt20

Esquivel-Upshaw21

Bindl22

McLaren23

Haselton66

Study

Chipped veneer (5)Endodontic therapy (1)Marginal integrity (1)

Chipped veneer (3)Endodontic therapy (1)

Chipped veneer (3)Endodontic therapy (2)

Endodontic therapy (2)Chipped veneer (2)Caries (1)

Decementation (11)Chipped/cracked veneer (5)Caries (2)Endodontic therapy (2)

Endodontic therapy (3)Chipped veneer (1)

Marginal deficiences (94%)Removal due to hypersensitivity (2)

Slight mismatch in color (13%)Slightly rough surfaces (9%)Endodontic therapy (2)Caries (2)

(not reported)

(not reported)

(not reported)

Debonding of composition resinfoundation (1)

(not reported)

Caries (1)Marginal integrity (1)Chipped veneer (1)Fracture (1)

Minor Complications(Restorations Not Remade)

Reported SurvivalRates (Percent)

Major Complications(Restorations Remade)

100

100

96.7 (100 anterior,95.15 posterior)

97

93.5

100 (crown-retained FPDP)89 (inlay-retained FPDP)

93

91

95.2 (98.9 anterior,84.4 posterior)

100 (posterior crowns)70 (anterior or premolarFPDP)

93

100 (In-Ceram Spinell)92 (In-Ceram Alumina)

96 (98 anterior,94 posterior)

(not reported)

None

None

Fracture of veneer and/or coping (2)Fracture or delamination of veneer (2)

Fracture of veneer and coping (3)

Fracture of veneer and coping (4)Caries (1)

Debonding (3)Debonding and fracture (3)

Fracture of veneer and coping (5)Endodontic therapy (2)

Fracture (7)

Fracture (4)Post and core fracture (1)Root fracture (1)

Fracture (4)Endodontic therapy (1)Tooth fracture (1)

Fracture (2)

Fracture (2)

Fracture of core (4)Fracture of veneer (2)Removal without failure (3)

Marginal integrity (2)

Conrad et al



mm from the interproximal papilla to the marginal ridge is a guideline for most systems.7,8,17,21,25,34,35 Placement is contraindicated when there is re-duced interocclusal distance, as with short clinical crowns, deep vertical overlap anteriorly without horizontal overlap, or an opposing supraerupted tooth, as well as for cantilevers, peri-odontally involved abutment teeth, and patients with severe bruxism or parafunctional activity.7,21,36 The pri-mary cause of failure varies from frac-ture of the connector, for aluminum-oxide FPDPs24-26 and lithium-disilicate FPDPs,20,21 to cohesive fracture of the veneering porcelain, for zirconia FP-DPs.37,38 Metal-ceramic FPDPs differ in that they fail primarily due to tooth fracture39 and caries.39,40 Following the Law of Beams by maximizing con-nector height and width is the basis for proper design of all-ceramic FP-

DPs.7,8,41 The purpose of this article is to review current literature on all-ce-ramic materials and systems, with re-spect to survival, material properties, marginal and internal fit, cementation and bonding, and color and esthetics, and suggest clinical recommendations for their use.

MATERIAL AND METHODS

A broad systematic search of Eng-lish peer-reviewed dental literature was designed to identify evidence supporting the restoration of teeth with current all-ceramic materials and systems. Key words or phrases included crowns, dental porcelain, ceramics, aluminum oxide, zirconium oxide, dental cements, composite resin cements, adhesives, computer-aided design, color, dental restoration failure, and dental prosthesis design.

MEDLINE and PubMed searches were conducted focusing on evidence-based research articles published be-tween 1996 and 2006. The Journal of Prosthetic Dentistry and the International Journal of Prosthodontics were addition-ally hand-searched for this review.

Titles and/or abstracts of articles identified through the electronic searches were reviewed and evaluated for appropriateness. Suitable articles were subjected to inclusion and exclu-sion criteria. Randomized controlled clinical trials, nonrandomized con-trolled clinical studies, longitudinal experimental clinical studies, longi-tudinal prospective clinical studies, and longitudinal retrospective clinical studies were reviewed. Articles that did not focus exclusively on the resto-ration of teeth with all-ceramic mate-rials and systems or the material prop-erties of ceramics were excluded from

Table II. continued (2 of 2) Classification of complications and overall survival rates

Vult von Steyern24

Olsson25

Sorensen26

Suarez91

Probster92

Fradeani27

Pallesen28

Otto29

Malament30

Scurria93

Study

(not reported)

Fracture (external trauma) (2)Decementation (1)

(not reported)

(not reported)

Caries (5)Decementation (1)

Chipped veneer (2)

Chipped/cracked veneer (8)

Chipped veneer (3)Caries (2)Endodontic therapy (1)

(not reported)

Minor Complications(Restorations Not Remade)

Reported SurvivalRates (Percent)

Major Complications(Restorations Remade)

90

93

88.5 (100 anterior,82.5 posterior)

94.5

100

97.5

90.6

90.4

87.5

95 (5 year)85 (10 year)67 (15 year)

Fracture (2)

Fracture (3)

Fracture (7)

Root fracture (1)

None

Fracture (1)

Fracture (3)

Fracture (5)Tooth fracture (3)Caries (1)

Fracture (180)

Conrad et al

393November 2007

further evaluation. Nonpeer-reviewed dental literature, abstracts, and clini-cal reports were excluded from review. Inclusion criteria for survival studies included a minimum mean follow-up period of 2 years, reporting of com-plications, identification of materi-als, type of study, setting, and sample size. Data supporting the clinical ap-plication of all-ceramic materials and systems was sought.

RESULTS

A total of 285 articles were iden-tified through the MEDLINE and PubMed searches. Abstracts were reviewed to confirm the articles met the inclusion criteria. A total of 148 articles published between 1996 and 2006 were identified and read in their entirety. Nineteen prospective and 4 retrospective clinical trials related to survival were reviewed. The literature demonstrated that multiple all-ce-ramic materials and systems are cur-rently available for clinical use and there is not a single universal material or system for all clinical situations. The successful application of differ-ent all-ceramic materials is dependent upon clinicians’ ability to match the ceramic materials to the manufactur-ing techniques and cementation or bonding procedures, to adequately customize a treatment plan.

DISCUSSION

Glass ceramics

IPS Empress 2 (Ivoclar Vivadent, Schaan, Liechtenstein) is a lithium-di-silicate glass ceramic (SiO2-Li2O) that is fabricated through a combination of the lost-wax and heat-pressed tech-niques. A glass-ceramic ingot of the desired shade is plasticized at 920°C and pressed into an investment mold under vacuum and pressure. Its pre-decessor, IPS Empress (Ivoclar Viva-dent), is a leucite-reinforced glass ce-ramic (SiO2-Al2O3-K2O) which, due to its strength, is limited in use to single-unit complete-coverage restorations

in the anterior segment.19 IPS Em-press 2 has improved flexural strength by a factor of 3 over IPS Empress, can be used for 3-unit FPDPs in the anterior area, and can extend to the second premolar.42-45 The framework is veneered with fluoroapatite-based veneering porcelain (IPS Eris; Ivoclar Vivadent), resulting in a semitranslu-cent restoration with enhanced light transmission.8,46,47 IPS e.max Press (Ivoclar Vivadent) was introduced in 2005 as an improved press-ceramic material compared to IPS Empress 2. It also consists of a lithium-disilicate pressed glass ceramic, but its physical properties and translucency are im-proved through a different firing pro-cess.48 IPS ProCAD (Ivoclar Vivadent) is a leucite-reinforced ceramic similar to IPS Empress, although it has a fin-er particle size.49 Introduced in 1998, it is designed to be used with the CEREC inLab system (Sirona Dental Systems, Bensheim, Germany) and is available in numerous shades, includ-ing a bleached shade and an esthetic block line.49-52

Vita Mark II (VITA Zahnfabrik, Bad Sackingen, Germany), a machin-able feldspathic porcelain introduced in 1991 for the CEREC 1 system (Sie-mens AG, Bensheim, Germany), has improved strength and finer grain size (4 μm) as compared to the Vita Mark I.28,49 It is primarily composed of SiO2 (60-64%) and Al2O3 (20-23%) and can be etched with hydrofluoric acid to create micromechanical retention for adhesive cementation with compos-ite resin cements.49,53,54 Although this product is monochromatic, it is avail-able in multiple shades, including the Classic Line Vita shades, Vitapan 3D-Master Shades, VITABLOCS Esthetic Line, and a bleached shade, and can be additionally characterized.49,55-58 To overcome esthetic disadvantages of a monochromatic restoration and to imitate optical effects of natural teeth, a multicolored ceramic block (Vita TriLuxe Bloc; VITA Zahnfabrik) was designed to create a 3-dimension-al layered structure.59 The inner third has a dark opaque base layer, while

the middle third has a neutral zone comparable to the standard block, and the outer third is more trans-lucent. CEREC software allows the operator to have some visual control over the alignment of the restoration within the multilayered block.59,60

Another technique for fabricat-ing feldspathic porcelain restorations was through copy-milling (Celay; Mi-krona Technologie AG, Spreitenbach, Switzerland).61,62 This system milled restorations by duplicating a direct acrylic resin pattern replica of an in-lay, onlay, or crown coping. Unable to approach the sophistication of the digital systems (CEREC 3D; Sirona Dental Systems), the Celay system is now obsolete.63 A major contributor to the development of glass ceram-ics was Dicor (Dentsply Intl, York, Pa). This was a glass-ceramic mate-rial composed of 70% tetrasilicic flu-ormica crystals precipitated in 30% glass matrix.64 Originally made using the lost-wax technique,30,65 it was later marketed as a machinable glass ce-ramic28,64 that is no longer available.

Alumina-based ceramics

In-Ceram Alumina (VITA Zahn-fabrik), introduced in 1989, was the first all-ceramic system available for single-unit restorations and 3-unit an-terior FPDPs.66 It has a high strength ceramic core fabricated through the slip-casting technique.67 A slurry of densely packed (70-80 wt%) Al2O3 is applied and sintered to a refrac-tory die at 1120°C for 10 hours.63,68 This produces a porous skeleton of alumina particles which is infiltrated with lanthanum glass in a second fir-ing at 1100°C for 4 hours to elimi-nate porosity, increase strength, and limit potential sites for crack propa-gation.68 Compressive stresses which further improve the strength are also introduced, due to the differences in the coefficient of thermal expansion of the alumina and glass.68 The cop-ing is veneered with feldspathic porce-lain.22,66 Alumina blanks (VITABLOCS In-Ceram Alumina; VITA Zahnfabrik)

Conrad et al



are also available for milling in com-bination with CEREC (Sirona Dental Systems).22,63

In 1994, In-Ceram Spinell (VITA Zahnfabrik) was introduced as an al-ternative to the opaque core of In-Ce-ram Alumina. It contains a mixture of magnesia and alumina (MgAl2O4) in the framework to increase translucen-cy10,69; however, its flexural-strength is lower than that of In-Ceram Alu-mina, and, thus, the cores are only recommended for anterior crowns.70 This material can also be machined with the CEREC inLab system (Sirona Dental Systems), followed by veneer-ing with feldspathic porcelain.22,57 Synthoceram (CICERO Dental Sys-tems, Hoorn, The Netherlands) is a high-strength glass-impregnated alu-minum-oxide ceramic core fabricated through CICERO technology (Com-puter Integrated Ceramic Reconstruc-tion).71,72 Laser scanning, ceramic sintering, and computer-integrated milling techniques are used to fab-ricate the cores, which are veneered with a leucite-free glass ceramic.54,71-73

In-Ceram Zirconia (VITA Zahnfab-rik) is also a modification of the origi-nal In-Ceram Alumina system, with an addition of 35% partially stabilized zir-conia oxide to the slip composition to strengthen the ceramic.67 Traditional slip-casting techniques can be used or the material can be copy-milled from prefabricated, partially sintered blanks and then veneered with feld-spathic porcelain.7,46,74 Since the core is opaque and lacks translucency, the material is recommended for poste-rior crown copings and FPDP frame-works.7,67

Procera (Nobel Biocare AB, Gote-borg, Sweden) was developed by An-dersson and Oden with copings that contain 99.9% high purity aluminum oxide.75 Combined with a low-fusing veneering porcelain, Procera has the highest strength of the alumina-based materials and its strength is lower only than zirconia.14,15 A sapphire contact probe is used to scan the working die and to define the 3-dimensional shape of the preparation.54 The data is sent

electronically to a manufacturing fa-cility where a 20% enlarged model is copy-milled and used for the dry-pressing technique.14,45 High purity aluminum-oxide powder is mechani-cally compacted on the enlarged die and sintered at 1550°C, eliminating porosity and returning the core to the dimensions of the working die.45,63,76 The crown form is completed by ve-neering it with low-fusing feldspathic porcelain matching the coefficient of thermal expansion of aluminum ox-ide.14

Zirconia-based ceramics

Zirconia is a polymorphic material that occurs in 3 forms. At its melting point of 2680°C, the cubic structure exists and transforms into the te-tragonal phase below 2370°C.4,77,78 The tetragonal-to-monoclinic phase transformation occurs below 1170°C and is accompanied by a 3-5% volume expansion which causes high internal stresses.32,77,78 Yttrium-oxide (Y2O3 3% mol) is added to pure zirconia to control the volume expansion and to stabilize it in the tetragonal phase at room temperature.33 This partially stabilized zirconia has high initial flexural strength and fracture tough-ness.33 Tensile stresses at a crack tip will cause the tetragonal phase to transform into the monoclinic phase with an associated 3-5% localized ex-pansion.32 The volume increase cre-ates compressive stresses at the crack tip that counteract the external tensile stresses. This phenomenon is known as transformation toughening and re-tards crack propagation. In the pres-ence of higher stress, a crack can still propagate. The toughening mecha-nism does not prevent the progres-sion of a crack, it just makes it harder for the crack to propagate.4,8,32,33,79

Yttrium-oxide partially stabilized zirconia (Y-TZP) has mechanical prop-erties that are attractive for restorative dentistry; namely, its chemical and di-mensional stability, high mechanical strength, and fracture-toughness.13 The cores have a radiopacity com-

parable to metal which enhances radiographic evaluation of marginal integrity, excess cement removal, and recurrent decay.8

Y-TZP can be manufactured in 2 methods through computer-aided design/computer-aided manufactur-ing (CAD/CAM) technology. First, an enlarged coping/framework can be designed and milled from a homog-enous ceramic soft green body blank of zirconia.80 The framework structure has a linear shrinkage of 20-25% dur-ing sintering until it reaches the de-sired final dimensions.6,9 Processing with this softer presintered material not only shortens the milling time, but also reduces the wear on the mill-ing tools.6 Although zirconia frame-works can be milled directly from a fully sintered prefabricated blank in the final dimensions,6,80 milling fully sintered zirconia may compromise the microstructure and strength of the material.81,82

Lava (3M ESPE, St. Paul, Minn) uses a Y-TZP framework with high flex-ural strength, high fracture toughness, and low elastic modulus compared to alumina, and exhibits transformation toughening when subjected to tensile stress.4,33 A die is scanned by a con-tact-free optical process for 5 minutes for a crown and 12 minutes for a 3-unit FPDP. The CAD software designs an enlarged framework that is milled from softer presintered blanks. After 35 minutes of milling for a crown and 75 minutes for a 3-unit FPDP, the framework can be colored in 1 of 7 shades, followed by sintering in a spe-cial automated oven for 8 hours.6

Other CAD/CAM systems are also available for designing and milling zir-conia restorations. Cercon (Dentsply Ceramco, York, Pa) requires conven-tional waxing techniques to design the Y-TZP framework, and the wax pattern is scanned.7 DCS Precident (DCS Den-tal AG, Allschwil, Switzerland) uses fully sintered DC Zirkon ceramic con-taining 95% ZrO2 partially stabilized with 5% Y2O3.

7,83,84 Denzir (Decim AB, Skelleftea, Sweden) designs and mills ceramic inlays from yttrium-oxide

Conrad et al

395November 2007

partially sintered blocks.67,85,86

Although the first all-ceramic im-plant abutments (CerAdapt; Nobel Biocare AB) were made of densely sintered, high purity alumina,87,88 zirconia implant abutments with or without a metal interface (Procera Zirconia Abutment; Nobel Biocare AB; Atlantis Abutment in Zirconia; Zimmer Dental, Carlsbad, Calif; Straumann Zirconia Custom Abut-ment; Straumann USA, Andover, Mass; Zirconia Abutment; Astra Tech Inc, Waltham, Mass; and ZiReal Post; Biomet 3i, Palm Beach Gardens, Fla) are now recommended instead of alu-mina due to their increased mechani-cal properties.87,88 Abutments are either customized through electronic data or are stock abutments which can be modified via conventional preparation. Dental and mucogingival esthetics can be improved for single implant restorations by eliminating

any metal display.89,90

Survival

When considering the restoration of teeth with all-ceramic materials, survival data is important to evaluate the effectiveness of different treatment strategies. Comparing the results from relevant literature is challenging due to the availability of different ceram-ic materials and systems, reporting of complications, study conditions, and evaluation times; these varying factors make it difficult to assess the overall effectiveness of therapy. Inclu-sion criteria for the reviewed studies included a minimum mean follow-up period of 2 years, reporting of com-plications, identification of materials, type of study, setting, and sample size (Tables II and III).

Fracture of the veneering porce-lain and/or ceramic coping is objec-

tive and the most commonly reported major complication requiring remak-ing of the restoration.3,14-28,30 Although 2 groups of investigators considered caries a major complication requiring refabrication of the restoration in 1 instance, they considered it a minor complication that did not require re-fabrication for 2 other restorations in the study.16,29 Two groups of investiga-tors reported endodontic therapy as a major complication,18,20 while 4 oth-ers reported root or tooth fracture as a major complication.19,20,29,91

Several of the reported compli-cations were considered minor and did not require remaking of the res-toration. The most common minor complication reported was chipping or cracking limited to the veneering porcelain (reported for 33 restora-tions),14-17,27-29,37,38,66 followed by end-odontic therapy (n=14),3,14-17,29,37,38 decementation (n=13),16,25,92 and

Table III. Study details, including material and restoration type

Raigrodski37

Vult von Steyern38

Fradeani14

Oden15

Odman16

Wolfart17

Frankenberger18

Sjogren3

Fradeani19

Marquardt20

Esquivel-Upshaw21

StudyType of

RestorationMaterial

Lava

DC-Zirkon

Procera (alumina)

Procera (alumina)

Procera (alumina)

IPS e.max Press

IPS Empress

IPS Empress

IPS Empress

IPS Empress 2

IPS Empress 2

FPDPs

FPDPs

Crowns

Crowns

Crowns

Crown-retainedFPDPInlay-retainedFPDP

Inlays, onlays

Crowns, 3/4 crowns

Crowns

CrownsFPDPs

FPDPs

Type ofStudy

Prospective

Prospective

Prospective

Prospective

Prospective

Prospective

Prospective

Retrospective

Retrospective

Prospective

Prospective

SampleSize

20

23

205

100

87

36

45

96

110

125

2731

30

Mean(Years)

2.6

2

2

5

(not reported)

4

3.1

(not reported)

3.6

(not reported)

(not reported)

(not reported)

Range(Years)

1.5-3

2

0.5-5

(not reported)

5-10.5

2.5-4.6

1.7-5

1-6

1.4-5.1

4-11

2.75-5.1

1-2

Study

University

University

Private practice

Private Practice

Multicenter

University

University

Private practice

Private practice

University

University

Conrad et al



Table III. continued (2 of 2) Study details, including material and restoration type

Bindl22

McLaren23

Haselton66

Vult von Steyern24

Olsson25

Sorensen26

Suarez91

Probster92

Fradeani27

Pallesen28

Otto29

Malament30

Scurria93

StudyType of

RestorationMaterial

In-Ceram SpinellIn-Ceram Alumina

In-Ceram Alumina

In-Ceram Alumina

In-Ceram Alumina

In-Ceram Alumina

In-Ceram Alumina

In-Ceram Zirconia

In-Ceram Alumina

In-Ceram Spinell

Vita Mark II,Dicor

Vita Mark I

Dicor

Metal-ceramic

Crowns

Crowns

Crowns

FPDPs

FPDPs

FPDPs

FPDPs

Crowns

Crowns

Inlays

Inlays, onlays

Crowns, inlays,onlays

FPDPs

Type ofStudy

Prospective

Prospective

Retrospective

Prospective

Retrospective

Prospective

Prospective

Prospective

Prospective

Prospective

Prospective

Prospective

Meta-analysis

SampleSize

1924

223

80

20

42

61

18

95

40

1616

200

1444

n/a

Mean(Years)

3.25

3

4

5

6.3

3

3

2.42

4.17

8

10

14.1

51015

Range(Years)

1.2-4.8

(not reported)

(not reported)

(not reported)

0.2-9.2

(not reported)

(not reported)

2-4.5

1.8-5

(not reported)

(not reported)

(not reported)

(notapplicable)

Study

University

Private practice

University

University

Private practice

University

University

(not reported)

Private practice

University

Private practice

Private practice

Various

caries (n=13).3,15,16,29,66,92 Chipping or cracking of the veneering porcelain for this review was defined as minor cohesive fracture of the veneering por-celain which did not impair function. Two studies did not exclude patients unavailable for evaluation from the survival rates (reported for 30 resto-rations).18,26

In instances where minor cohesive fractures of the veneering porcelain did not require complete replace-ment, the restorations were either polished14,16,27 or repaired with direct composite resin restorative materi-al.17,29 Caries identified in the margin-al areas were excavated and repaired with direct composite resin restor-ative material,29,66,92 while endodontic access preparations were also filled

with direct composite resin restor-ative material.14,17,29,37 Several authors replaced 2 crowns due to cohesive failures of the veneering porcelain and 1 crown due to caries, but did not classify this as a major complication because it only involved the veneering porcelain.15

Typical survival rates for all-ce-ramic restorations range from 88 to 100% after 2-5 years in service,3,14,17,21-

23,26,27,37,38,91,92 and 84 to 97% after 5-14 years in service.15,16,18,19,24,25,28-30 Discrepancy in the classification of failures and variability of the materials and systems available for all-ceramic restorations present a challenge to combining data from several stud-ies. A meta-analysis for metal-ceramic FPDPs defined failure as the removal

of the prosthesis, but also considered a broader definition that included removal and/or a technically failed prosthesis requiring replacement.93 A more comprehensive definition of failure or critical assessment of all-ceramic restorations would thus de-crease reported survival rates. A more descriptive definition of ceramic res-toration outcome might include the categories of success, survival, and failure.

Material properties

The strength of an all-ceramic res-toration is dependent on the ceram-ic material used, core-veneer bond strength, crown thickness, and design of the restoration,13,94 as well as bond-

Conrad et al

397November 2007

ing techniques and the characteristics of the supporting material.95,96 As evident from the literature on survival rates, fracture of the ceramic material is the most frequently reported com-plication resulting in failure.3,14-28,30 Alumina-based ceramics (In-Ceram Alumina; VITA Zahnfabrik) have been shown to have higher strength and fracture toughness than leucite-rein-forced glass ceramics (IPS Empress; Ivoclar Vivadent),97 conventional feld-spathic porcelain (Vita Bloc Mark II; VITA Zahnfabrik),98,99 and modified alumina cores (In-Ceram Spinell; VITA Zahnfabrik).100 A zirconia-modified alumina ceramic (In-Ceram Zirconia; VITA Zahnfabrik) was found to have higher fracture toughness than In-Ce-ram Alumina when tested by indenta-tion strength in 1 study,101 and higher flexural strength in another.102 Dense-ly sintered, high purity alumina (Proc-era; Nobel Biocare AB) was reported to have significantly higher flexural strength than glass-infiltrated presin-tered alumina (In-Ceram Alumina).103

The success of many all-ceramic systems is dependent on the strength of a core-veneer bond. Since the ce-ramic core is significantly stronger than the veneering materials, this bond strength has an important role in their success.13 The thickness ratio of the ceramic core to the veneering porcelain is a dominant factor con-trolling the crack initiation site and potential failure.104 Optimizing the thickness of these layers is necessary to ensure that the veneering porcelain is under compressive stress and that the ceramic core is under tensile stress.103 Although it is desirable to increase the thickness of the ceramic coping, it is important not to compromise either the esthetics of the crown by overcon-touring, or the tooth preparation by overreduction.105

Even though the veneering por-celain is used primarily for esthetic reasons, it has an important role in the mechanical behavior of the res-toration.106 The flexural strength and fracture toughness of these bilayered restorations depend on the veneer

layer when the crack initiates from the veneer surface.107 Although resid-ual compressive stresses in the veneer layer increase the flexural strength of the bilayered restoration, the tensile stresses are the primary cause for the observed chipping.107

Zirconia-based ceramics are rec-ommended for FPDPs, as they have the highest failure loads when com-pared to alumina- and lithium-dis-ilicate-based ceramics.46 A lithium-disilicate glass ceramic (IPS Empress 2; Ivoclar Vivadent) in combination with a fluoroapatite glass-ceramic (IPS Eris; Ivoclar Vivadent) was found to be inappropriate for posterior FP-DPs due to the high susceptibility of the veneer to subcritical crack growth and the absence of crack arresting at the core-veneer interface.108 Zir-conia frameworks with higher elastic modulus are preferred for all-ceramic posterior FPDPs compared to lithi-um-disilicate based ceramics, as they reduce the stress on the weaker ve-neer layer and increase the composite load-bearing capacity, thereby retard-ing the fracture of the restoration.106 Creating a gingival embrasure with a broad radius of curvature, rather than a sharp contour, has been shown to reduce the stress concentration under loading and increase the fracture re-sistance.109,110

Following traditional preparation guidelines is important not only for retention of all-ceramic crowns, but also for stress distribution during dy-namic loading of the restoration.111 Finite element analysis studies have shown that FPDP connector heights of at least 3 to 4 mm considerably reduce stress levels in the connector and provide adequate strength.35,112 In vitro studies on mechanical prop-erties are not always capable of repro-ducing intraoral conditions. Artificial oral environments have been devel-oped to simulate intraoral conditions by applying intermittent dynamic cy-clic forces, artificial saliva, tempera-ture fluctuations, and humidity con-trol.66,113 Testing specimens in these simulated oral environments has been

shown to significantly decrease the fracture toughness of ceramic mate-rials.114 Long-term in vivo studies are necessary to make conclusions about the clinical indications for ceramic materials.

Marginal and internal fit

When evaluating the clinical suc-cess and quality of a restoration, marginal discrepancy is an essential criterion.74 Christensen115 reported the clinically detectable range for sub-gingival margins to be 34-119 μm and 2-51 μm for supragingival margins. Subsequently, McLean116 suggested that 120 μm should be the limit for clinically acceptable marginal discrep-ancies. Poor marginal adaptation can result in cement dissolution, micro-leakage, increased plaque retention, and secondary decay.74

Holmes117 measured various points between the casting and the tooth and clarified the terminology for misfit. Absolute marginal discrep-ancy was defined as an angular com-bination of the horizontal and vertical error and would reflect the total misfit at that point. An internal gap is the perpendicular measurement from the axial wall to the internal casting sur-face.

The incidence of gingival inflam-mation increases around clinically de-ficient restorations, particularly those with rough surfaces, subgingival fin-ish lines, or poor marginal adapta-tion; however, gingival inflammation may also develop around properly contoured and highly polished res-torations.118 Although the severity of gingival response is patient-specific, current evidence has not shown an accelerated rate of bone loss or in-creased attachment loss adjacent to crowns.118

Contemporary chairside or labo-ratory-based CAD/CAM systems have additional factors that may affect the accuracy of the fit, including software limitations in designing restorations, and hardware limitations of the cam-era, scanning equipment, and mill-

Conrad et al



ing machines. Clinicians’ and dental technicians’ experience and expertise is also key with chairside and labo-ratory-based CAD/CAM systems.119 Systems dependent upon an optical impression experience problems with rounded edges due to the scanning resolution and positive error, which simulates peaks at the edges.120 Other systems that use a surface contact-ing probe cannot accurately repro-duce proximal retentive features less than 2.5 mm wide and more than 0.5 mm deep.121 Feather-edge finish lines, deep retentive grooves, and complex occlusal morphology are not recom-mended, not only for scanning and milling prerequisites, but also to de-crease stress that would develop in a restoration with inadequate prepara-tion and margin geometry.121 An addi-tional problem with computer-milled ceramic restorations is that the inter-nal cutting bur may be larger in di-ameter than some parts of the tooth preparation, such as the incisal edge. This would result in a larger internal gap than with other fabrication tech-niques.120

Table IV is a summary of current literature evaluating in vivo and in vitro marginal discrepancy as well as the in vitro internal discrepancy or misfit of the coping on the axial sur-faces. In general, studies have demon-strated that internal gap widths are higher than marginal gaps.54,74,76,83,85,

86,122-129 This finding has implications for glass-ceramic restorations which may be dependent upon the mechani-cal properties of the luting cement to resist functional forces.95 Most of the literature reports marginal discrepan-cies in the range of clinical acceptabil-ity recommended by Christensen115 and McLean.116

Cementation and bonding

A variety of cementation and bonding techniques have been applied to modern all-ceramic restorations. Zinc phosphate, zinc polycarboxylate, and conventional glass-ionomer ce-ments set through an acid-base reac-

tion having a tendency to exacerbate surface flaws in ceramic restorations due to the increased acidity of the ce-ment.130 Glass ionomers are suscepti-ble to early water degradation, result-ing in microcracks which may initiate cracks and facilitate crack propaga-tion in the cement.131 Resin-modified glass ionomer cement sets through a combination of an acid-base reaction and photo- or chemically initiated polymerization. Combining chemical adhesion advantages of traditional glass-ionomer cements with advan-tages of composite resin results in im-proved strength, fracture toughness, and wear resistance.132 To improve success rates with glass- and alumina-based ceramic restorations, nonacid-base cements are recommended.130

For conventional glass-ceramic restorations, the adhesive technique is critical for successful bonding. Sur-face treatment of the porcelain by etching with 5% to 9.5% hydrofluoric acid133 and etching of the tooth struc-ture with 37% phosphoric acid134 and application of a silane coupling agent provided the highest bond strength of an adhesive-resin cement to feld-spathic material. A chemical bond between feldspathic porcelain and tooth structure is achieved through silane coupling agents in composite resins. Bond strength to etched sur-faces is improved by creating deep involuted spaces where resin can flow and interlock.135,136 Due to the abra-sion rate with subsequent volume loss and changes in morphology, feld-spathic restorations should never be airborne-particle abraded to improve the roughness of the internal surface, only acid-etched.137

Considering the brittleness and limited flexural strength of glass ce-ramics, definitive adhesive cementa-tion with composite resin should be used to increase the fracture resistance of the restoration.94,130,138,139 The com-pressive strength of composite resin cements (320 MPa) is superior to that of zinc phosphate (121 MPa), which offers limited support.131,140 Fracture or cement breakdown can result in

microleakage, marginal discoloration, pulpal irritation, secondary caries, debonding, and decreased fracture load. Adhesive cementation has been shown to increase fracture loads and improve longevity.50,57,139,141,142 A glass-ceramic restoration supported by a composite resin cement with good physical properties can with-stand higher masticatory forces and demonstrates improved clinical per-formance.138

Light-, dual-, and chemically po-lymerized composite resin materials have been advocated for use with glass ceramics.143 Decreased sur-vival rates have been reported with dual-polymerizing, composite resin cement, as compared to chemically polymerizing composite resin cement with feldspathic inlays (VITABLOCS Mark II; VITA Zahnfabrik).144,145 Inad-equate transmission of light through the ceramic restoration to the under-lying cement can result in insufficient polymerization of dual-polymerizing composite resin cement and lack of support for the restoration.119 Dual-polymerizing cements contain perox-ide and amine components found in chemically polymerized systems, in addition to a photosensitizer used in light-polymerized systems.146 The 2 catalytic mechanisms are required to reduce the quantity of remaining dou-ble bonds to maximize strength and adhesion of the cement.147 A slower polymerization reaction148 and higher solubility and water absorption occurs when dual-polymerizing resins are al-lowed to autopolymerize.149 Depend-ing exclusively on the autopolymeriz-ing component of dual-polymerizing composite resin results in decreased hardness and premature failure of the cement.119,144,145,150

Nonadhesive cementation is more dependent upon macromechani-cal retention than adhesive cemen-tation.138 Finish lines placed below the cemento-enamel junction result in a significant loss of adhesion, de-spite following adhesive luting tech-niques.151 Since cementum cannot be infiltrated by resin to the extent that

Conrad et al

399November 2007

Table IV. Marginal and internal fit studies

IPS Empress 2/heat pressed

IPS Empress/heat pressed

Optimal Pressable Ceramic/heat pressed

IPS ProCAD/CEREC 3

VITABLOCS Mark II/CEREC 3



VITABLOCS Mark II/Celay System

In-Ceram Alumina/Slip-cast

In-Ceram Alumina/Celay System

Synthoceram/CICERO

In-Ceram Zirconia/CEREC in Lab

In-Ceram Zirconia/Digident (DigidentGmbH, Pforzheim, Germany)

In-Ceram Zirconia/Slip-cast

Procera/densely sintered

Lava

DC-Zirkon/Precident System

Denzir

Gold

Ceramic alloy

65122

8554

195122

7454

77128

92128

6854

90-118129

80128

30122

67128

4474

147-16785

246-26585

53-66124

62-121125

17127

57127

57127

4374

2574

6083

1774

56-6376

3374

60-7183

2374

22-4186

136-14985

75-10574

20685

27885

342123

380123

116-141124

122126

82-11474

71-9474

119-13674

36-7476

110-11674

74-8174

110-19286

24385

Material and SystemsIn Vitro Mean

Marginal Gap (µm)In Vitro Internal

Gap (µm)In Vivo Mean

Marginal Gap (µm)

Conrad et al



acid-etched dentin can, microme-chanical retention at the gingival mar-gins may contribute little to the bond strength.152,153 Restorations that are less dependent on predictable adhe-sion should be considered when the finish line is not placed in enamel.154

Different surface treatments have been evaluated to demonstrate the bond strength of composite resin ce-ments to alumina-based ceramic res-torations. Acid etchants used with glass ceramics do not adequately roughen the surface of glass-infil-trated and densely sintered alumi-na-based ceramics.155 An effective method to roughen glass-infiltrated alumina-based ceramic (In-Ceram Alumina; Vita Zahnfabrik) is through a tribochemical silica coating process (Rocatec; 3M ESPE).137 This method involves cleaning the surface to be coated with 110 μm of high-purity aluminum oxide (Rocatec Pre; 3M ESPE) at 250 KPa for 14 seconds, cre-ating a uniform pattern of roughness. This is followed by a tribochemical coating with 110 μm (Rocatec Plus; 3M ESPE) or a less abrasive 30 μm (Rocatec Soft; 3M ESPE) of silica-modified high purity aluminum oxide. The aluminum oxide leaves the sur-face partially coated with SiO2, which is then conditioned with silane (3M ESPE Sil; 3M ESPE) to create a bond with the composite resin.137 Volume loss through this tribochemical pro-cess was found to be 36 times less for a glass-infiltrated alumina (In-Ceram Alumina; VITA Zahnfabrik) than for a feldspathic glass ceramic (IPS Em-press; Ivoclar Vivadent) and did not change its surface composition.137 Pretreatment of a glass-infiltrated alumina (In-Ceram Alumina; VITA Zahnfabrik) with the tribochemical process (Rocatec; 3M ESPE) resulted in a durable resin bond over 5 years.156 Airborne-particle abrasion with 50-μm aluminum oxide for 15 seconds was found to be the most effective for producing higher bond strengths for a densely-sintered aluminum-oxide coping (Procera; Nobel Biocare AB) when compared to etching with 9.6%

hydrofluoric acid for 2 minutes, dia-mond abrasion combined with etch-ing with 37% phosphoric acid for 2 minutes, and no treatment.155

Surface treatments including a tribochemical silica coating process (Rocatec; 3M ESPE), airborne-par-ticle abrasion with either 250-μm or 50-μm aluminum oxide, airborne-particle abrasion with 50-μm alumi-num oxide combined with 38% hy-drofluoric acid etching, or diamond abrasion with a rotary cutting instru-ment, were reported to have only a minor influence on bond strength to zirconia ceramic (Denzir; Decim AB).157 The tribochemical silica coat-ing process in combination with a resin cement was shown in 1 study158 to have an initial bond to zirconia that failed spontaneously after simulated aging, while another study159 found that it did not improve the retentive strength of composite resin cements. Although not apparent immediately, damage from airborne-particle abra-sion (50-μm aluminum oxide for 5 seconds at 276 KPa) has been shown to compromise the fatigue strength of alumina- and zirconia-based ceramic materials.160,161 A variety of luting agents have been shown to be capable of retaining zirconium-oxide crowns (Lava; 3M ESPE) including composite resin (Panavia F 2.0; Kuraray, Tokyo, Japan), compomer (Dyract Cem Plus; Dentsply Intl), resin-modified glass ionomer (RelyX Luting; 3M ESPE), and self-adhesive composite resin (RelyX Unicem; 3M ESPE).159,162 While mechanical properties of cements are critical to support glass-ceramic res-torations,140 zirconia-based crowns can be cemented conventionally due to their high fracture resistance.159 Zirconia-based restorations do not require an adhesive interface for re-tention.8

Color and esthetics

Increased translucency correlated with improved esthetics is the primary advantage in using an all-ceramic res-toration. Heffernan et al10 evaluated

the relative translucency of several ce-ramic materials and found In-Ceram Spinell (VITA Zahnfabrik) to have the highest amount of relative translu-cency. This was followed by IPS Em-press (Ivoclar Vivadent), Procera (No-bel Biocare AB), and IPS Empress 2 (Ivoclar Vivadent), which had higher levels of translucency than In-Ceram Alumina (VITA Zahnfabrik), followed by In-Ceram Zirconia (VITA Zahn-fabrik), which was comparable to a metal alloy. As a result of this study, In-Ceram Spinell, IPS Empress, and IPS Empress 2 were recommended for high to average translucency situ-ations. Procera was recommended for average translucency situations, while In-Ceram Alumina and In-Ceram Zir-conia are only recommended when matching to opaque natural teeth or in posterior and nonesthetic zones.69

The addition of MgAl2O4 to the In-Ceram system has made In-Ceram Spinell, with its increased translu-cency, an esthetic competitor. Unfor-tunately, mechanical properties have been compromised compared to the original material, restricting its use to the anterior segment, exclusively.70 A subjective evaluation reported IPS Empress better able to match adja-cent teeth than In-Ceram Spinell or metal-ceramic restorations.47

Monochromatic restorations ma-chined from ceramic blocks have been scrutinized for their lack of individual characterization. Although custom-ized characterizing of these restora-tions was shown to compete estheti-cally with layering techniques163 and multishade block systems,58 no long-term follow-up for color stability has been done.

The ratio and thickness of ceramic core and veneering materials influ-ence the final shade of a layered por-celain restoration. An aluminum-ox-ide ceramic core thickness of 0.7 mm was found to be sufficient to mask underlying dentin color.71 With a con-servative reduction of 1 mm, a semi-translucent all-ceramic specimen will match a shade tab more closely than a metal-ceramic restoration. Increasing

Conrad et al

401November 2007

reduction will improve esthetic results for metal-ceramic and semiopaque all-ceramic restorations but will not further enhance shade-matching for semitranslucent specimens (IPS Em-press; Ivoclar Vivadent; In-Ceram Alumina and In-Ceram Spinell; VITA Zahnfabrik).164 Since IPS Empress res-torations were found to require up to 2.0 mm of thickness facially to mask an underlying substrate,165 other less translucent core materials should be considered.

The opaque porcelain required for masking a metal substrate is responsi-ble for reflecting light and decreasing translucency. Since enamel is 97% hy-droxyapatite mineral matter, it is very translucent and able to transmit up to 70% of light. Dentin is also capable of transmitting up to 30% of light, which creates the esthetic dilemma for metal-ceramic restorations, as they are only capable of diffusion and reflection of light. Consequently, met-al-ceramic restorations often appear brighter intraorally.47

Clinical recommendations

Leucite and feldspathic glass ce-ramics are indicated for onlays, three quarter crowns, and veneers, but their strength limits their use to complete coverage crowns in the anterior seg-ment, only. Lithium-disilicate glass ce-ramics can perform successfully in the posterior segment for single crowns and 3-unit FPDPs in the anterior area. Glass-infiltrated alumina cores can be considered for single-unit resto-rations and anterior FPDP applica-tions, with the exception of In-Ceram Spinell, which is only recommended for anterior crowns. Zirconia-modi-fied alumina is indicated for posterior crowns and FPDPs, while densely sin-tered alumina is indicated for veneers, crowns, and anterior FPDPs. Zirconia has superior mechanical properties as a core material for posterior crowns and FPDPs, implant abutments, and implant-supported restorations. The stronger ceramic core materials can be rather opaque and this may limit

their application when a high degree of translucency is required.

Reported survival rates are vari-able and dependent upon the mate-rial used, manufacturing technique, clinical application, and the author’s definition of failure. Optimal thick-ness of alumina and zirconia cores and their respective veneering materi-als is critical for esthetics and strength to support occlusal forces. Marginal discrepancies are in the range of clini-cal acceptability for indirect restora-tions; however, internal gap widths are higher, resulting in a large film thickness which may be significant for glass ceramics that depend on the physical properties of the cement. Surface treatment combining etching and a silane coupling agent provides the highest bond strength of com-posite resin cement to feldspathic ce-ramics and increases the fracture re-sistance of the restoration. Adequate transmission of light is critical for light- and dual-polymerizing cements to achieve maximum strength and adhesion. When the finish line of the preparation cannot be maintained in enamel, the clinician should consider restorations that are not dependent on adhesion. Pretreatment of alu-mina cores with a tribochemical silica coating process or airborne-particle abrasion alone produces higher bond strengths for adhesive resin cemen-tation. Zirconia-based restorations can be cemented conventionally due to their high fracture resistance, and they do not require an adhesive inter-face for retention. Materials with in-creased translucency that are custom-ized through characterizing or layering techniques will best be able to match natural tooth structure.

CONCLUSIONS

All-ceramic restorations are de-veloped with cores of glass ceramics, aluminum oxide, or zirconium oxide, and are manufactured by heat press-ing, slip-casting, sintering, or milling. Successful application of these mate-rials will depend upon the clinician’s

ability to select the appropriate ma-terial, manufacturing technique, and cementation or bonding procedures, to match intraoral conditions and es-thetic requirements.

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Corresponding author:Dr Heather J. ConradDivision of Prosthodontics, Department of Restorative DentistryUniversity of Minnesota, School of Dentistry9-450a Moos Tower515 Delaware St SEMinneapolis, MN 55455Fax: 612-626-1496E-mail: [email protected]

Copyright © 2007 by the Editorial Council for The Journal of Prosthetic Dentistry.

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