A clinical evaluation of chairside lithium
disilicate CAD/CAM crowns
A two-year report
Dennis J. Fasbinder, DDS; Joseph B. Dennison, DDS, MS; Donald Heys, DDS, MS;
Gisele Neiva, DDS, MS
here has been a growing interest in the use of
T all-ceramic restorations as replacements for
traditional porcelain-fused-to-metal restora-
tions because of their improved esthetic
appearance. Developments in ceramic material
science have resulted in improvements in the physical
properties of modern ceramics, leading to a substantial
increase in the clinical use of all-ceramic restorations.
Ivoclar Vivadent (Amherst, N.Y.) introduced a
lithium disilicate glass ceramic material for use in all-
ceramic restorations. It is available as an ingot that can
be press-fit (IPS e.max Press, Ivoclar Vivadent) and as
a block that can be milled with computer-aided
design/computer-aided manufacturing (CAD/CAM)
technology (IPS e.max CAD, Ivoclar Vivadent).1 The
manufacturer recommends its use for anterior or pos-
terior crowns, implant crowns, inlays, onlays or
veneers. The CAD/CAM material initially was available
as a substructure material that afforded greater
translucency than did other high-strength ceramic core
materials. Although initially indicated for substruc-
tures, the CAD/CAM block has been used more recently
for full-contour restorations of a single ceramic material
(monolithic restorations).
The milled lithium disilicate block must undergo a
two-stage crystallization process before cementation.
Lithium metasilicate crystals are precipitated during
the first stage. The resulting glass ceramic has a crystal
size range of 0.2 to 1.0 micrometers, with approximately
40 percent lithium metasilicate crystals by volume. This
creates a blue-violet color in the block, thus accounting
for the commonly used “blue block” description. This
precrystallized state allows the block to be milled easily
without excessive diamond bur wear or damage to the
material. The final crystallization occurs after the crown
has been milled to the desired form by means of CAD/
CAM technology. The crystallization process occurs at
850˚C in a vacuum. The metasilicate crystal phase is
dissolved completely, and the lithium disilicate crystal-
lizes. This process also converts the blue shade of the
precrystallized block to the selected tooth shade and
results in a glass ceramic with a fine-grained size of
approximately 1.5 μm and a 70 percent crystal volume
incorporated in a glass matrix.2
Clinicians can use the CEREC Acquisition Center
system (Sirona Dental Systems, Charlotte, N.C.) or the
10S JADA, Vol. 141 http://jada.ada.org June 2010
Copyright © 2010 American Dental Association. All rights reserved. Reprinted by permission.
ABSTRACT
Background. Developments in ceramic material
science have led to improvements in the physical
properties of modern ceramics, leading to a substan-
tial increase in the clinical use of all-ceramic restora-
tions. The authors evaluated the clinical perform-
ance of lithium disilicate (IPS e.max CAD, Ivoclar
Vivadent, Amherst, N.Y.) all-ceramic crowns.
Methods. The authors fabricated 62 lithium disili-
cate crowns with a chairside computer-aided design/
computer-aided manufacturing (CAD/CAM) system
(CEREC 3, Sirona Dental Systems, Charlotte, N.C.)
and cemented them with two types of adhesive resin
cements. Two examiners used modified U.S. Public
Health Service criteria to evaluate the crowns at
baseline, six months, one year and two years.
Results. There were no clinically identified cases
of crown fracture or surface chipping. There was no
reported sensitivity at one or two years with either
cement. For margin discoloration, the percentage
Alfa score was 86.9 percent for crowns cemented
with a self-etching, dual-curing cement. All other
percentage Alfa scores were greater than 92.0 per-
cent, indicating no appreciable change in the crowns
during the two-year study.
Conclusions. The results show that lithium disili-
cate crowns performed well after two years of clinical
service.
Clinical Implications. Early results indicate
that monolithic lithium disilicate CAD/CAM crowns
may be an effective option for all-ceramic crowns.
Key Words. CAD/CAM; crowns; cementation;
dental porcelain; dental restoration.
JADA 2010;141(6 suppl):10S-14S.
Dr. Fasbinder is a clinical professor, Cariology, Restorative Sciences, and
Endodontics, School of Dentistry, University of Michigan, 1011 N. Univer-
sity, Ann Arbor, Mich. 48109-1078, e-mail “djfas@umich.edu”. Address
reprint requests to Dr. Fasbinder.
Dr. Dennison is a professor emeritus, Cariology, Restorative Sciences, and
Endodontics, School of Dentistry, University of Michigan, Ann Arbor.
Dr. Heys is a professor, Cariology, Restorative Sciences, and Endodontics,
School of Dentistry, University of Michigan, Ann Arbor.
Dr. Neiva is a clinical associate professor, Cariology, Restorative Sciences,
and Endodontics, School of Dentistry, University of Michigan, Ann Arbor.
E4D Dentist system (D4D Technologies, Richard-
son, Texas) to fabricate full-contour lithium disili-
cate crowns chairside. The CAD/CAM process gives
clinicians the opportunity to mill the crown from
monolithic blocks of lithium disilicate rather than
the traditional laboratory process of fabricating a
strong substructure veneered with weaker
veneering porcelain. The IPS e.max CAD glass
ceramic has a flexural strength of 360 to 400 mega-
pascals, which is approximately two-and-one-half
times greater than that of other monolithic ceramic
blocks available for CAD/CAM chairside restoration
fabrication.2,3 The enhanced strength of lithium dis-
ilicate allows for either adhesive or conventional
cementation techniques.
We conducted a nonrandomized longitudinal
clinical trial to evaluate the clinical performance
of the IPS e.max CAD glass ceramic material for
chairside CAD/CAM-generated crowns cemented
with two different cements.
PARTICIPANTS, METHODS AND MATERIALS
The Health Sciences Institutional Review Board of
the University of Michigan reviewed and approved
the investigation protocol before the study began.
We selected the participants from among current
patients receiving clinical treatment at the School
of Dentistry, University of Michigan, Ann Arbor.
All of the participants signed a written informed
consent form before enrolling in the study. All teeth
were asymptomatic at the beginning of treatment.
Participants received a maximum of two crowns,
and all restorations had opposing functional occlu-
sion and at least one proximal contact with an adja-
cent tooth. We did not exclude patients with specific
occlusal schemes or parafunctional habits.
Preparation. The clinician prepared, fabri-
cated and placed all of the crowns in one treat-
ment appointment. The clinician prepared the
tooth by following the manufacturer’s guidelines
for all-ceramic crowns with at least 2.0 millime-
ters of occlusal reduction over functional cusps, at
least 1.5 mm of reduction over nonfunctional
cusps and in the central fossa at least 1.2 mm of
axial reduction, rounded shoulder margins and no
sharp internal angles. For teeth with substantial
loss of tooth structure resulting from caries or
fracture, the clinician used composite cores
(ExciTE F DSC and MultiCore, Ivoclar Vivadent)
to create the required retention and resistance
form. We used a dryfield illuminator (Isolite i2,
Isolite Systems, Santa Barbara, Calif.) to isolate
the quadrant during all clinical procedures.
Copyright © 2010 American Dental Association. All rights reserved. Reprinted by permission.
Restoration fabrication. We fabricated all
crowns with a CEREC 3 system (Sirona Dental
Systems). The clinician used software (CEREC 3D,
Version 2.8, Sirona Dental Systems) to design the
desired crown contours and occlusal relationships.
The clinician milled the crown from prefabricated
block of IPS e.max CAD at standard milling speed.
After recovering the crown from the milling
chamber, the clinician trial fitted it to the prepara-
tion with a silicone material (Fit Checker, GC
America, Alsip, Ill.) to stabilize the crown and
adjusted it to ensure complete seating.
After finalizing adjustments, the clinician thor-
oughly cleaned and dried the crown and then
applied e.max CAD Crystall./Glaze paste (Ivoclar
Vivadent) with shade tints to customize the crown’s
shade relative to the existing dentition. The crown
was fired in a porcelain oven under vacuum, ac-
cording to the manufacturer’s instructions, to com-
plete the crystallization process. The firing cycle
consisted of two stages that required 35 minutes
(however, it since has been reduced with the
development of a spray glaze).
Restoration cementation. When the crown
was ready for cementation, the internal surface
was etched for 20 seconds with 4.9 percent hydro-
fluoric acid, rinsed with water and air-dried with
oil-free air. The dental assistant applied a pre-
hydrolyzed silane coupling agent (Monobond-S,
Ivoclar Vivadent) to the etched surface for 60 sec-
onds and ensured evaporation of the solvent
before adhesive cementation.
The first group of 23 crowns (control) was
cemented with a self-etching, dual-curing cement
(Multilink Automix [MA], Ivoclar Vivadent) with a
self-etching primer and adhesive. The second group
of 39 crowns was cemented with an experimental
self-adhesive, dual-curing cement (EC) developed
by Ivoclar Vivadent.
For the crowns cemented with MA, the clini-
cian cleaned the isolated preparation with flour of
pumice, rinsed it with water spray and lightly air
dried it. The clinician treated the preparation for
15 seconds with Multilink Primer A and B
(Ivoclar Vivadent) and lightly air dried it with the
air-water syringe. An automix syringe was used
to inject a 1:1 ratio of MA base and catalyst
ABBREVIATION KEY. CAD/CAM: Computer-aided
design/computer-aided manufacturing. EC: Experimental
cement. FPD: Fixed partial denture. MA: Multilink
Automix (Ivoclar Vivadent, Amherst, N.Y.). USPHS:
U.S. Public Health Service.
JADA, Vol. 141 http://jada.ada.org June 2010 11S

Figure 1. Preoperative occlusal view of teeth nos. 19 and 20.
Figure 2. Placement of the lithium disilicate crowns on teeth nos.
19 and 20 at baseline evaluation.
Figure 3. Crowns for teeth nos. 19 and 20 at the two-year recall visit.
directly into the crown. The clinician inserted the
crown and removed the excess cement after two
minutes. The crown was light cured for 20 sec-
onds each from the facial, occlusal and lingual
aspects, for a total of 60 seconds.
For the crowns cemented with EC, the clinician
cleaned the isolated preparation with flour of
pumice, rinsed it and lightly air dried it. An
automix syringe was used to inject a 1:1 ratio of
EC base and catalyst directly into the crown. The
clinician inserted the crown and removed the
excess cement after two minutes. The crown was
light cured for 20 seconds each from the facial,
occlusal and lingual aspects, for a total of 60 sec-
onds. The clinician finished and polished all the
crowns by using a series of diamond finishing
burs, rubber abrasive points and cups, finishing
strips and diamond polishing paste.
12S JADA, Vol. 141 http://jada.ada.org June 2010
Copyright © 2010 American Dental Association. All rights reserved. Reprinted by permission.
Postoperative sensitivity. To evaluate the
postoperative sensitivity, the study coordinator
contacted participants by telephone once per
week after the initial appointment and for as long
as four weeks or until the participant reported
that the crown was asymptomatic. During the
telephone interview, the participants reported a
criterion-referenced rating of functional tooth sen-
sitivity. Participants returned for evaluation only
if they were having continued discomfort or any
indication of premature occlusal contact.
Restoration evaluation. Two independent
evaluators conducted clinical evaluations at base-
line (immediately after the crowns were
cemented), six months, one year and two years by
using modified U.S. Public Health Service
(USPHS) criteria4 for color match, margin discol-
oration, margin adaptation, caries and crown frac-
ture. The two evaluators discussed disagreements
in evaluations to reach a consensus judgment for
each criterion evaluated.
The evaluators obtained intraoral digital color
images at a 1:1 magnification at baseline and at
the six-month, one-year and two-year recall visits
to document preoperative status and postopera-
tive conditions (Figures 1-5). Bitewing and peri-
apical radiographs of each crown were obtained
preoperatively and at the two-year recall visit.
RESULTS
Forty-three participants enrolled in the study.
They received 62 crowns, including 20 on premo-
lars and 42 on molars. The six-month and one-
year recall rates were 100.0 percent. The two-year
recall rate was 98.4 percent because one partici-
pant had moved out of the area.
One week postoperatively, the participants
described 13.0 percent (three of 23) of the crowns
cemented with MA and 10.3 percent (four of 39) of
the crowns cemented with EC as slightly sensitive.
However, all participants reported not having
symptoms by the third week after treatment. At six
months, the participants reported that 8.7 percent
(two of 23) of the crowns cemented with MA and
7.7 percent (three of 39) of the crowns cemented
with EC were slightly sensitive. No participants
required treatment for sensitivity. There was no
reported sensitivity at one year or two years.
The table shows the percentage Alfa scores for
each of the modified USPHS criteria. Margin discol-
oration was 86.9 percent Alfa for crowns cemented
with MA because three crowns had localized
margin discoloration. All other scores were greater
Figure 4. Preoperative occlusal views of teeth nos. 3 and 4.
than 92.0 percent Alfa, indicating no appreciable
change in the crowns during the two years of the
study.
All of the crowns cemented with MA were clini-
cally acceptable at two years. Two crowns
cemented with EC debonded: one at one year and
the other at two years. Both of the debonded
crowns were intact, and the treating clinician used
MA to recement them.
DISCUSSION
There are limited clinical studies of an early version
of lithium disilicate glass ceramic. IPS Empress 2
(Ivoclar Vivadent) was a lithium disilicate glass
ceramic fabricated by means of a lost-wax and heat-
pressed technique. The substructure was veneered
with fluorapatite-based porcelain. Marquardt and
Strub7 evaluated 58 IPS Empress 2 restorations
(27 posterior crowns and 31 three-unit fixed partial
dentures [FPDs]) after five years of clinical service.
Two of the crowns had repairable fractures in the
veneering porcelain. Six complete failures occurred
within the FPDs. Taskonak and Sertgöz8 evaluated
20 IPS Empress 2 crowns and 20 FPDs after two
years. They reported no crown fractures and 10 fail-
ures with the FPDs. This early lithium disilicate is
not the same material as IPS e.max CAD or IPS
e.max Press ceramics. There is a substantial differ-
ence in the microstructure of the lithium disilicate
crystals and the matrix, resulting in improved phys-
ical properties and translucency of the IPS e.max
lithium disilicate.9
There are few published clinical studies of mono-
lithic ceramic crowns. Bindl and Mörmann10 com-
pared monolithic ceramic crowns (Vitablocs Mark
II, Vident, Brea, Calif.) with layered ceramic
crowns (Vita In-Ceram Spinell, Vident). The mono-
lithic ceramic crowns were fabricated with a
CEREC 2 (Sirona Dental Systems) unit. The sub-
structures of the layered ceramic crowns were
milled with a CEREC 2 unit and then veneered
Copyright © 2010 American Dental Association. All rights reserved. Reprinted by permission.
Figure 5. Lithium disilicate crowns for teeth nos. 3 and 4 at the
two-year recall visit.
with surface porcelain. There was no significant dif-
ference between the two crown types for any of the
USPHS scores. One of the monolithic ceramic
crowns fractured at 12.0 months, and one of the
layered ceramic crowns fractured at 42.5 months.
The Kaplan-Meier probability for survival was 91.7
percent for the layered ceramic crowns and 94.4
percent for the monolithic ceramic crowns after a
mean ± standard deviation of 44.7 ± 10.3 months.
Bindl and colleagues11 compared 208 monolithic
posterior ceramic crowns on the basis of the tooth
type and three types of crown preparation designs:
reduced, classic or “endo.” Only two crowns in the
reduced preparation group fractured after two
years, with no fractures in the classic or endo
preparation groups. By 55 months, two crowns in
the classic preparation group fractured, and three
more from the reduced preparation group fractured.
After 55 ± 15 months, the investigators reported a
Kaplan-Meier probability of survival for premolars
of 97.0 percent for those in the classic preparation
group, 92.9 percent for those in the reduced prepa-
ration group and 68.8 percent for those in the endo
preparation group. For molars, they reported a
Kaplan-Meier probability of survival of 94.6 percent
for those in the classic preparation group, 92.1 per-
cent for those in the reduced preparation group and
87.1 percent for those in the endo preparation
group. These study results support the assertion
that monolithic ceramic crowns have good success
across five years of clinical service.
The results from comprehensive and systematic
reviews indicated that the five-year survival rate of
all-ceramic crowns was greater than 93 percent.12-14
The most common mode of failure for all-ceramic
restorations reported in the comprehensive and
systematic reviews was complete fracture of the
substructure, the veneer porcelain or both,
requiring the layered all-ceramic crown to be
remade.12-14 The most common minor problem was
chipping or cracking limited to the veneer porce-
JADA, Vol. 141 http://jada.ada.org June 2010 13S
TABLE
Percentage Alfa scores for CAD/CAM lithium
disilicate all-ceramic crowns, according to
recall visit.
CRITERION SIX-MONTH ONE-YEAR TWO-YEAR
RECALL VISIT RECALL VISIT RECALL VISIT
(ALFA SCORE %) (ALFA SCORE %) (ALFA SCORE %)
MA * EC † MA
Color Match 95.6 92.3 95.6
Margin Discoloration 95.6 97.4 86.9
Margin Adaptation 100.0 100.0 100.0
Caries 100.0 100.0 100.0
Crown Fracture 100.0 100.0 100.0
* MA: Multilink Automix, Ivoclar Vivadent, Amherst, N.Y.
† EC: Experimental cement.
lain.12-14 In contrast, in our study, there were no
identified cases of fracture or surface chipping of
the lithium disilicate crowns through the two-year
period. Although two years is early in the desired
clinical life span of a crown, this is a potentially
clinically significant finding. Bilayered ceramic
crowns consisting of a strong ceramic core
veneered with a weaker surface porcelain gener-
ally experience chipping, fracture or delamination
of the veneering porcelain on between 3 and 5 per-
cent of the surface during the first five years of the
clinical life span of the crown.12-14 Although a mono-
lithic crown design might help clinicians avoid any
potential problems inherent in a bilayered system,
additional long-term clinical study is required to
further document this finding from our study.
The bond of self-adhesive resin cements to dentin
is similar to that of self-etching systems; however,
they do not have the same bond strength to
enamel.5,6 Eight of the 39 crowns (20.5 percent)
cemented with EC exhibited graying of the cervical
one-half of the crown on the facial and lingual sur-
faces. This discoloration did not manifest as the typ-
ical dark linear stain commonly seen with marginal
leakage and was not evaluated using the modified
USPHS criterion for margin discoloration. None of
the crowns with this discoloration exhibited any
sensitivity. Two of the 39 crowns (5.1 percent)
cemented with EC debonded, revealing that the dis-
coloration was between the cement and tooth prepa-
ration. In both cases of debonding, there was no evi-
dence of cement retained on the tooth surface—it
was retained on the crown—and there was no
damage to the lithium disilicate crowns. The clini-
cian cleaned the cement from the internal aspect of
the crowns, re-etched them with a hydrofluoric acid,
applied a silane coupler and recemented them with
MA. Although the evaluators classified these cases
14S JADA, Vol. 141 http://jada.ada.org June 2010
Copyright © 2010 American Dental Association. All rights reserved. Reprinted by permission.
as cement failures, we will continue to
recall the participants so we can evaluate
long-term survival of the ceramic
material.
CONCLUSIONS
We evaluated the clinical performance
EC MA EC of the IPS e.max CAD ceramic crowns
94.9 100.0 97.2 cemented with two different adhesive
97.4 87.0 97.2 resin cements. There were no clinically
100.0 100.0 100.0 identified cases of crown fracture or
100.0 100.0 100.0 surface chipping. There were no reports
100.0 100.0 100.0
of postoperative sensitivity for any of
the crowns at the one- and two-year
recall visits. The results show that
lithium disilicate crowns perform well after two
years of clinical service. ■
Disclosure. Dr. Fasbinder has received honoraria for educational
programs and research funding for projects with the CEREC system
from Sirona Dental Systems, Charlotte, N.C.; and Ivoclar Vivadent,
Amherst, N.Y.
This study was funded through a research grant from Ivoclar
Vivadent, Amherst, N.Y.
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