All-ceramic or metal-ceramic tooth-supported fixed dental prostheses (FDPs)? A systematic review of the survival and complication rates. Part I: Single crowns (SCs).

OBJECTIVE To assess the 5-year survival of metal-ceramic and all-ceramic tooth-supported single crowns (SCs) and to describe the incidence of biological, technical and esthetic complications. METHODS Medline (PubMed), Embase, Cochrane Central Register of Controlled Trials (CENTRAL) searches (2006-2013) were performed for clinical studies focusing on tooth-supported fixed dental prostheses (FDPs) with a mean follow-up of at least 3 years. This was complimented by an additional hand search and the inclusion of 34 studies from a previous systematic review [1,2]. Survival and complication rates were analyzed using robust Poisson's regression models to obtain summary estimates of 5-year proportions. RESULTS Sixty-seven studies reporting on 4663 metal-ceramic and 9434 all-ceramic SCs fulfilled the inclusion criteria. Seventeen studies reported on metal-ceramic crowns, and 54 studies reported on all-ceramic crowns. Meta-analysis of the included studies indicated an estimated survival rate of metal-ceramic SCs of 94.7% (95% CI: 94.1-96.9%) after 5 years. This was similar to the estimated 5-year survival rate of leucit or lithium-disilicate reinforced glass ceramic SCs (96.6%; 95% CI: 94.9-96.7%), of glass infiltrated alumina SCs (94.6%; 95% CI: 92.7-96%) and densely sintered alumina and zirconia SCs (96%; 95% CI: 93.8-97.5%; 92.1%; 95% CI: 82.8-95.6%). In contrast, the 5-year survival rates of feldspathic/silica-based ceramic crowns were lower (p<0.001). When the outcomes in anterior and posterior regions were compared feldspathic/silica-based ceramic and zirconia crowns exhibited significantly lower survival rates in the posterior region (p<0.0001), the other crown types performed similarly. Densely sintered zirconia SCs were more frequently lost due to veneering ceramic fractures than metal-ceramic SCs (p<0.001), and had significantly more loss of retention (p<0.001). In total higher 5 year rates of framework fracture were reported for the all-ceramic SCs than for metal-ceramic SCs. CONCLUSIONS Survival rates of most types of all-ceramic SCs were similar to those reported for metal-ceramic SCs, both in anterior and posterior regions. Weaker feldspathic/silica-based ceramics should be limited to applications in the anterior region. Zirconia-based SCs should not be considered as primary option due to their high incidence of technical problems.

All-ceramic or metal-ceramic tooth-supported fixed dental prostheses (FDPs)? A systematic review of the survival and complication rates. Part II: Multiple-unit FDPs.

OBJECTIVE To assess the 5-year survival of metal-ceramic and all-ceramic tooth-supported fixed dental prostheses (FDPs) and to describe the incidence of biological, technical and esthetic complications. METHODS Medline (PubMed), Embase and Cochrane Central Register of Controlled Trials (CENTRAL) searches (2006-2013) were performed for clinical studies focusing on tooth-supported FDPs with a mean follow-up of at least 3 years. This was complemented by an additional hand search and the inclusion of 10 studies from a previous systematic review [1]. Survival and complication rates were analyzed using robust Poisson's regression models to obtain summary estimates of 5-year proportions. RESULTS Forty studies reporting on 1796 metal-ceramic and 1110 all-ceramic FDPs fulfilled the inclusion criteria. Meta-analysis of the included studies indicated an estimated 5-year survival rate of metal-ceramic FDPs of 94.4% (95% CI: 91.2-96.5%). The estimated survival rate of reinforced glass ceramic FDPs was 89.1% (95% CI: 80.4-94.0%), the survival rate of glass-infiltrated alumina FDPs was 86.2% (95% CI: 69.3-94.2%) and the survival rate of densely sintered zirconia FDPs was 90.4% (95% CI: 84.8-94.0%) in 5 years of function. Even though the survival rate of all-ceramic FDPs was lower than for metal-ceramic FDPs, the differences did not reach statistical significance except for the glass-infiltrated alumina FDPs (p=0.05). A significantly higher incidence of caries in abutment teeth was observed for densely sintered zirconia FDPs compared to metal-ceramic FDPs. Significantly more framework fractures were reported for reinforced glass ceramic FDPs (8.0%) and glass-infiltrated alumina FDPs (12.9%) compared to metal-ceramic FDPs (0.6%) and densely sintered zirconia FDPs (1.9%) in 5 years in function. However, the incidence of ceramic fractures and loss of retention was significantly (p=0.018 and 0.028 respectively) higher for densely sintered zirconia FDPs compared to all other types of FDPs. CONCLUSIONS Survival rates of all types of all-ceramic FDPs were lower than those reported for metal-ceramic FDPs. The incidence of framework fractures was significantly higher for reinforced glass ceramic FDPs and infiltrated glass ceramic FDPs, and the incidence for ceramic fractures and loss of retention was significantly higher for densely sintered zirconia FDPs compared to metal-ceramic FDPs.

Fracture load and marginal fit of shrinkage-free ZrSiO4 all-ceramic crowns after chewing simulation

The aim of this in vitro study was to evaluate the fracture load and marginal accuracy of crowns made from a shrinkage-free ZrSiO4 ceramic cemented with glass-ionomer or composite cement after chewing simulation. Thirty-two human mandibular molars were randomly divided into two groups. All teeth were prepared for and restored with shrinkage-free ZrSiO4 ceramic crowns (Everest HPC (R), KaVo). The crowns of group A (N = 16) were luted to the teeth using KetacCem (R) and group B (N = 16) were adhesively cemented using Panavia (R) 21EX. Measurements of the marginal accuracy before and after cementation were made using replicas and an image analysis system. All specimens were exposed to 1.2 million cycles of thermo-mechanical fatigue in a chewing simulator. Surviving specimens were subsequently loaded until fracture in a static testing device. Fracture loads (N) were recorded. All specimens survived chewing simulation. The mean fracture loads (+/- s.d.) were Group A, 1622 N (+/- 433); group B, 1957 N (+/- 806). There was no significant difference between the two groups (P > 0.05). The marginal gap values before cementation were (mean +/- s.d.): Group A, 32.7 mu m (+/- 6.8); group B, 33.0 mu m (+/- 6.7).The mean marginal gap values after cementation were (+/- s.d.): Group A, 44.6 mu m (+/- 6.7); group B, 46.6 mu m (+/- 7.7). The marginal openings were significantly higher after cementation for both groups (P < 0.05). All test groups demonstrated fracture load and marginal accuracy values within the range of clinical acceptability.

Manufacturing conditioned roughness and wear of biomedical oxide ceramics for all-ceramic knee implants

Background: Ceramic materials are used in a growing proportion of hip joint prostheses due to their wear resistance and biocompatibility properties. However, ceramics have not been applied successfully in total knee joint endoprostheses to date. One reason for this is that with strict surface quality requirements, there are significant challenges with regard to machining. High-toughness bioceramics can only be machined by grinding and polishing processes. The aim of this study was to develop an automated process chain for the manufacturing of an all-ceramic knee implant. Methods: A five-axis machining process was developed for all-ceramic implant components. These components were used in an investigation of the influence of surface conformity on wear behavior under simplified knee joint motion. Results: The implant components showed considerably reduced wear compared to conventional material combinations. Contact area resulting from a variety of component surface shapes, with a variety of levels of surface conformity, greatly influenced wear rate. Conclusions: It is possible to realize an all-ceramic knee endoprosthesis device, with a precise and affordable manufacturing process. The shape accuracy of the component surfaces, as specified by the design and achieved during the manufacturing process, has a substantial influence on the wear behavior of the prosthesis. This result, if corroborated by results with a greater sample size, is likely to influence the design parameters of such devices.

Fracture strength of machined ceramic crowns as a function of tooth preparation design and the elastic modulus of the cement

Objectives: To determine, by means of static fracture testing the effect of the tooth preparation design and the elastic modulus of the cement on the structural integrity of the cemented machined ceramic crown-tooth complex. 
Methods: Human maxillary extracted premolar teeth were prepared for all-ceramic crowns using two preparation designs; a standard preparation in accordance with established protocols and a novel design with a flat occlusal design. All-ceramic feldspathic (Vita MK II) crowns were milled for all the preparations using a CAD/CAM system (CEREC-3). The machined all-ceramic crowns were resin bonded to the tooth structure using one of three cements with different elastic moduli: Super-Bond C&B, Rely X Unicem and Panavia F 2.0. The specimens were subjected to compressive force through a 4 mm diameter steel ball at a crosshead speed of 1 mm/min using a universal test machine (Loyds Instrument Model LRX.). The load at the fracture point was recorded for each specimen in Newtons (N). These values were compared to a control group of unprepared/unrestored teeth. 
Results: There was a significant difference between the control group, with higher fracture strength, and the cemented samples regardless of the occlusal design and the type of resin cement. There was no significant difference in mean fracture load between the two designs of occlusal preparation using Super-Bond C&B. For the Rely X Unicem and Panavia F 2.0 cements, the proposed preparation design with a flat occlusal morphology provides a system with increased fracture strength. 
Significance: The proposed novel flat design showed less dependency on the resin cement selection in relation to the fracture strength of the restored tooth. The choice of the cement resin, with respect to its modulus of elasticity, is more important in the anatomic design than in the flat design. © 2013 Academy of Dental Materials.

Comparison of two bond strength testing methodologies for bilayered all-ceramics

Objectives. This study compared the shear bond strength (SBS) and microtensile (MTBS) testing methodologies for core and veneering ceramics in four types of all-ceramic systems.Methods. Four different ceramic veneer/core combinations, three of which were feldspathic and the other a fluor-apatite to their respectively corresponding cores, namely leucitereinforced ceramic ((IPS)Empress, Ivoclar), low leucite-reinforced ceramic (Finesse, Ceramco), glass-infiltrated alumina (In-Ceram Alumina, Vita) and lithium disilicate ((IPS)Empress 2, Ivoclar) were used for SBS and MTBS tests. Ceramic cores (N = 40, n = 10/group for SBS test method, N=5blocks/group for MTBS test method) were fabricated according to the manufacturers' instructions (for SBS: thickness, 3 mm; diameter, 5 mm and for MTBS: 10 mm x 10 mm x 2 mm) and ultrasonically cleaned. The veneering ceramics (thickness: 2 mm) were vibrated and condensed in stainless steel moulds and fired onto the core ceramic materials. After trying the specimens in the mould for minor adjustments, they were again ultrasonically cleaned and embedded in PMMA. The specimens were stored in distilled water at 37 degrees C for 1 week and bond strength tests were performed in universal testing machines (cross-head speed: 1mm/min). The bond strengths (MPa +/- S.D.) and modes of failures were recorded.Results. Significant difference between the two test methods and all-ceramic types were observed (P < 0.05) (2-way ANOVA, Tukey's test and Bonferroni). The mean SBS values for veneering ceramic to lithium disilicate was significantly higher (41 +/- 8 MPa) than those to low leucite (28 +/- 4 MPa), glass-infiltrated (26 +/- 4 MPa) and leucite-reinforced (23 +/- 3 MPa) ceramics, while the mean MTBS for low leucite ceramic was significantly higher (15 +/- 2 MPa) than those of leucite (12 +/- 2 MPa), glass-infiltrated (9 +/- 1 MPa) and lithium disilicate ceramic (9 +/- 1 MPa) (ANOVA, P < 0.05).Significance. Both the testing methodology and the differences in chemical compositions of the core and veneering ceramics influenced the bond strength between the core and veneering ceramic in bilayered all-ceramic systems. (c) 2006 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.

The influence of internal surface treatments on tensile bond strength for two ceramic systems

Statement of the Problem: the ceramic composition and surface microstructure of all-ceramic restorations are important components of an effective bonding substrate. Hydrofluoric acid and sandblasting are well-known procedures for surface treatment; however, surface treatment for high alumina-containing and lithium disilicate ceramics have not been fully investigated.Purpose: This in vitro study evaluated the tensile bond strength of resin cement to two types of ceramic systems with different surface treatments.Methods and Materials: Thirty specimens of each ceramic system were made according to the manufacturer's instructions and embedded in polyester resin. Specimens of In-Ceram Alumina [1] and IPS Empress 2 [E] were distributed to three groups with differing surface treatments (n=10): sandblasting with 50 jam aluminum oxide (APA); sandblasting with 110 pm aluminum oxide modified with silica particles (ROCATEC System-RS); a combination of sandblasting with APA and 10% hydrofluoric acid etching (HA) for two minutes on In-Ceram and for 20 seconds for IPS Empress 2. After the respective surface treatments, all the specimens were silanated, and Rely-X resin cement was injected onto the ceramic surface and light polymerized. The specimens were stored in distilled water at 37 degrees C for 24 hours and thermally cycled 1,100 times (5 degrees C/55 degrees C). The tensile bond strength test was performed in a universal testing machine at a 0.5 mm/minute crosshead speed.Results: the mean bond strength values (AWa) for IPS Empress 2 were 12.01 +/- 5.93 (EAPA), 10.34 +/- 1.77 (ERS) and 14.49 +/- 3.04 (EHA). The mean bond strength values for In-Ceram Alumina were 9.87 +/- 2.40 JAPA) and 20.40 +/- 6.27 (IRS). All In-Ceram specimens treated with 10% hydrofluoric acid failed during thermal cycling.Conclusion: the Rocatec system was the most effective surface treatment for In-Ceram Alumina ceramics; whereas, the combination of aluminum oxide sandblasting and hydrofluoric acid etching for 20 seconds worked more effectively for Empress 2 ceramics.

Vertical marginal discrepancy of ceramic copings with different ceramic materials finish lines and luting agents: An in vitro evaluation

Statement of problem. Prosthetic restorations that fit poorly may affect periodontal health and occlusion. Studies that have evaluated the accuracy of fit of ceramic restorations before and after cementation assessed primarily intracoronal restorations.Purpose. This in vitro study evaluated the effect of different finish lines, ceramic manufacturing techniques, and luting agents on the vertical discrepancy of ceramic copings.Material and methods. Two stainless steel molars were prepared for complete crowns with 2 different finish lines (heavy chamfer and rounded shoulder); each molar was duplicated to fabricate 90 copings. A total of 180 copings generated 18 groups (n=10 for each finish line-coping material-luting agent combination). Luting agents tested included zinc phosphate, resin-modified glass ionomer (Fuji Plus), and resin composite cements (Panavia F). A metal frame was developed on which to screw the stainless steel model and a ceramic coping; the distance (mum) between 2 predetermined points was measured before and after cementation by a profile projector under a torquing force. A 4-way ANOVA with repeated measurements was performed to assess the influence of each factor in the vertical marginal discrepancy: 3 between-coping factors (finish line-coping material-luting agent) and 1 within-coping factor (before and after cementation) (alpha=.05).Results. Procera copings presented the lowest mean values (P<.05) of vertical marginal discrepancy before and after cementation (25/44 mum) when compared to Empress 2 (68/110 mum) and InCeram Alumina copings (57/117 mum), regardless of any combinations among all finish lines and luting agents tested.Conclusion. Considering each factor separately, the ceramic manufacturing technique appeared to be the most important factor tested for the definitive vertical discrepancy of all-ceramic copings, with lower mean values for Procera copings.

Ceramic materials in dentistry: historical evolution and current practice

Dental ceramics are presented within a simplifying framework allowing for facile understanding of their development, composition and indications. Engineering assessments of clinical function are dealt with and literature is reviewed on the clinical behaviour of all-ceramic systems. Practical aspects are presented regarding the choice and use of dental ceramics to maximize aesthetics and durability, emphasizing what we know and how we know it.

Effect of resin luting film thickness on fracture resistance of a ceramic cemented to dentin

Purpose: The aim of this study was to evaluate the fracture resistance of ceramic plates cemented to dentin as a function of the resin cement film thickness. Materials and Methods: Ceramic plates (1 and 2 mm thicknesses) were cemented to bovine dentin using resin composite cement. The film thicknesses used were approximately 100, 200, and 300 μm. Noncemented ceramic plates were used as control. Fracture loads (N) were obtained by compressing a steel indenter in the center of the ceramic plates. ANOVA and Tukey tests (α = 0.05) were used for each ceramic thickness to compare fracture loads among resin cement films used. Results: Mean fracture load (N) for 1-mm ceramic plates were: control - 26 (7); 100 μm - 743 (150); 200 μm - 865 (105); 300 μm - 982 (226). Test groups were significantly different from the control group; there was a statistical difference in fracture load between groups with 100 and 300 μm film thicknesses (p < 0.01). Mean fracture load for 2-mm ceramic plates were: control - 214 (111); 100 μm - 1096 (341); 200 μm - 1067 (226); 300 μm - 1351 (269). Tested groups were also significantly different from the control group (p < 0.01). No statistical difference was shown among different film thicknesses. Conclusions: Unluted specimens presented significantly lower fracture resistance than luted specimens. Higher cement film thickness resulted in increased fracture resistance for the 1-mm ceramic plates. Film thickness did not influence the fracture resistance of 2-mm porcelain plates. Copyright © 2007 by The American College of Prosthodontists.

Effect of seating forces on cement-ceramic adhesion in microtensile bond tests

Objectives: The aim of this study was to evaluate the effect of different seating forces during cementation in cement-ceramic microtensile bond strength (μTBS). Materials and methods: Forty-five blocks (5 × 5 × 4 mm3) of a glass-infiltrated alumina-based ceramic (In-Ceram Alumina) were fabricated according to the manufacturer's instructions and duplicated in resin composite. Ceramic surfaces were polished, cleaned for 10 min in an ultrasonic bath, silica coated using a laboratory type of air abrasion device, and silanized. Each treated ceramic block was then randomly assigned to five groups (n = 9) and cemented to a composite block under five seating forces (10 g, 50 g, 100 g, 500 g, and 750 g) using a dual-cured resin cement (Panavia F). The ceramic-cement-composite assemblies were cut under coolant water to obtain bar specimens (1 mm × 0. 8 mm2). The μTBS tests were performed in a universal testing machine (1 mm/min). The mean bond strengths values were statistically analyzed using one-way ANOVA (α ≤ 0. 05). Results: Different seating forces resulted in no significant difference in the μTBS results ranging between 13. 1 ± 4. 7 and 18. 8 ± 2. 1 MPa (p = 0. 13) and no significant differences among cement thickness. Conclusions: Excessive seating forces during cementation seem not to affect the μTBS results. Clinical relevance: Excessive forces during the seating of single all-ceramic restorations cementation seem to display the same tensile bond strength to the resin cement. © 2012 Springer-Verlag.

Effects of thickness, processing technique, and cooling rate protocol on the flexural strength of a bilayer ceramic system

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

In vitro study of color stability of polycrystalline and monocrystalline ceramic brackets

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)