Clin Oral Invest (2014) 18:2171–2178
DOI 10.1007/s00784-014-1191-8
ORIGINAL ARTICLE
Three-unit CAD/CAM-generated lithium disilicate FDPs
after a mean observation time of 46 months
Sven Reich & Lutz Endres & Claudia Weber &
Klaus Wiedhahn & Peter Neumann & Oliver Schneider &
Nicole Rafai & Stefan Wolfart
Received: 14 January 2013 / Accepted: 16 January 2014 / Published online: 4 February 2014
# Springer-Verlag Berlin Heidelberg 2014
Abstract
Objectives Lithium disilicate can easily be machined by
CAM techniques in its metasilicate status. Due to slightly
inferior material properties, the material is not yet recom-
mended for three-unit fixed dental prosthesis (FDP) as it is
the case for the press material up to the second bicuspid.
Therefore, the aim of this clinical study was to evaluate the
performance of CAD/CAM-fabricated lithium disilicate
FDPs.
Materials and methods A total of 32 anterior and posterior
FDPs were provided for 32 patients. Twelve FDPs were
fabricated chair-side. The first recall took place 6 months after
insertion and then annually. The FDPs were rated according to
biological and technical complications. As failure, those
events were defined, which led to the removal of a FDP. The
failure-free (survival) rate and the complication-free rate were
calculated according to Kaplan–Meier.
Results After a mean observation time of 46 months (SD±
8.4 months), three endodontic complications in two FDPs,
two minor chippings, and one catastrophic fracture occurred.
One FDP had to be removed due to persisting undefined
S. Reich (*) : L. Endres : N. Rafai : S. Wolfart
Department of Prosthodontics and Biomaterials, Centre of
Implantology, Medical Faculty, RWTH Aachen University,
Pauwelsstraße 30, 52074 Aachen, Germany
e-mail: sreich@ukaachen.de
C. Weber
Aachen, Germany
K. Wiedhahn
Buchholz i. d. Nordheide, Germany
P. Neumann
Berlin, Germany
O. Schneider
Zwickau, Germany
complaints. Thus, the failure-free rate and the complication-
free rate were revealed as 93 and 83 %, respectively.
Conclusions Despite the limited observation period, the re-
sults are promising, especially due to the fact that the fractured
FDP did not fulfill the recommended connector dimensions.
Clinical relevance Inserted as a full-contour three-unit FDP
within its indications, the CAD/CAM lithium disilicate ce-
ramic offers an appropriate alternative to layered restorations.
Keywords Glass–ceramic . Lithium disilicate . FDP .
CAD/CAM . Clinical . All-ceramic . Full-contour
Introduction
The first version of lithium disilicate ceramic was brought on
market in 1998, named as IPS Empress 2 (IvoclarVivadent,
Schaan, principality of Liechtenstein) for the press technolo-
gy. According to Tysowsky [1], the material generally consists
of “70 % needle-like lithium disilicate crystals which are
embedded in a glassy matrix”. In 2005, IPS Empress 2 was
substituted by a modified version, IPS e.max Press and IPS
e.max CAD. The optical properties of these lithium disilicate
materials were enhanced so that the use as a full-contour
material became possible. The CAD version of the lithium
disilicate ceramic is provided in a metasilicate state, which is
characterized by 40 % platelet-shaped lithium metasilicate
crystals and glassy matrix [1]. In this metasilicate state, the
material shows a bluish color and can be easily machined.
Also, the try-in procedures can be accomplished carefully. In
order to obtain the lithium disilicate structure, a crystallization
process is necessary [2]. The classic version of the crystalli-
zation process takes approximately 25 min at 830 °C. The
shrinkage during crystallization of 0.2 % does not affect
marginal, proximal, and occlusal fit. The change from a bluish
color to a shade that is similar to a natural tooth is based on the
2172 Clin Oral Invest (2014) 18:2171–2178

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

87.9 (90.8)
86 % (86)

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

50 (50)
62 (62)

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

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

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

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

time in month (range

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

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

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

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

120
48

24
72

60

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

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

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

4×3 /4×4
4×3/4×4
ant./post.

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

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

30

21
18

36
20

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

present study was to evaluate whether full-contour FDPs

N, posterior FDPs

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

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

30 (11/19)

mance was comparable to other all-ceramic systems with

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

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

Materials and methods

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

24
8

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

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

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

18
15

28

University of Aachen reviewed and approved the study (ap-

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

post: yes

informed consent. Recruitment of the patients and the treat-

Ant.: no,

ment were accomplished in three private dental practices and

yes/no

Yes

Yes

the Department of Prosthodontics of the University of

No
No

No

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

e.max Press

e.max Press

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

Empress 2

Empress 2
Empress 2

Empress 2
Material

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

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

Makarouna et al.

canal treated abutment teeth were included, they had to be

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

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

Kern et al.

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

Author

ed. The length of the clinical crown of the abutment teeth had
to be at least 5 mm. Patients with probing depths greater than
Clin Oral Invest (2014) 18:2171–2178
4 mm and vertical bone pockets around the abutment teeth
were not included. According to the study protocol, patients
who showed extreme signs of tooth wear (extreme bruxers)
had to be refused, which meant that the usual age-based
appearance of wear facets that are normally parallel to the
tooth shape was exceeded. Also, those patients who required
appliances as TMD therapy were excluded. Patients with a
history of an impairing tumor or with a psychological disease,
with other severe systematic diseases (e.g., who required a
prophylactic antibiosis before each treatment or dental treat-
ment in general meant a risk for the patient’s general health),
and with a history of allergic disease had to be excluded, too.
Prosthodontic procedures
After caries excavation, adhesive buildups using Tetric ceram
or Multicore (both IvoclarVivadent, Schaan, Liechtenstein)
were done using Optibond FL (Kerr, Rastatt, Germany) as
adhesive system according to the manufacturer’s recommen-
dation. If necessary, severely decayed root canal-treated abut-
ment teeth were restored with a cast post and core build-up.
This had to be accomplished two times: once as alternative an
adhesive post and core built-up was applied. The prepared
finish line was a shoulder or distinct chamber of 1.0 to 1.2 mm
in width. The occlusal reduction of the abutment teeth was 1.5
to 2.0 mm. The convergence angle of the preparation was 6–
8°. The FDPs could be fabricated lab-side or chair-side. For
impression taking, retraction cords (Ultrapak, Ultradent,
Brunnthal, Germany) were inserted by applying the double-
layer technique. If indicated, an adstringent retraction paste
was used, e.g., Expasyl (Acteon, Mettmann, Germany). For
conventional impressions, a double-mix technique using
polyether or polyvinyl siloxane material was applied. If the
chair-side technique was applied, the Cerec3D System (cam-
era: infra-red) was used for the optical impressions. If a
provisional restoration was necessary, the temporary FDPs
were cemented with eugenol-free cement (Temp Bond NE,
Kerr GmbH, Rastatt, Germany or Freegenol, GC, Bad
Homburg, Germany). The lithium disilicate FDPs were exclu-
sively designed digitally using the current software either in
the laboratory after scanning the gysum cast by the means of
the Inlab system (Sirona, Bensheim, Germany) or chair-side
based on the intra-oral impression. The full-contour FDPs
were milled from an exclusively produced IPS e.max CAD
LT (LT=low translucency) block of 32 mm length by the use
of MC XL milling units (Sirona).
If the chair-side procedure was applied, a try-in procedure
of the bluish metasilicate restoration with regard to fit, prox-
imal, and occlusal contacts was possible. Afterwards, the
metasilicate restoration was crystallized. In the case of
laboratory-based manufacturing, the FDPs were delivered in
their readily crystallized state. For the dimensions of the CAD
material, the same instructions were valid as for the press
2173
material. The maximum span of the FDPs had not exceeded
9 mm in the pontic area and 11 mm in the premolar and the
anterior region, respectively. Prior to insertion, the mesial and
distal connector heights and widths had to be measured with a
caliper and noted in 0.5 mm steps. The results had to be
submitted to the University of Aachen where the data were
collected. According to the manufacturer’s recommendations,
the mesial and distal connectors should show a dimension of
16 mm2 each, whereas the height should be at least have
4 mm. For anterior FDPs, these guidelines are relative. If the
dimension falls below 16 mm2, in such a case the height has to
be extended above the standard height of 4 mm. However, the
analysis of the documented data showed some variations in
comparison to the recommended numbers. In the present
study, the mesial connector height of one FDP with an upper
canine and a second premolar as abutment teeth was below
4.0 mm, showing 3.5 mm. With respect to the mesial connector,
five other FDPs were under-dimensioned in their widths so that
totally six FDPs showed connector dimensions below 16 mm2:
These were at 10.5 mm2 (height: 3.5 mm, width: 3.0 mm), at
12.0 mm2 (4.0 mm/ 3.0 mm), at 13.5 mm2 (4.5 mm/3.0 mm),
and two FDPs at 15.0 mm2 (each 5.0 mm /3.0 mm). The median
value of the connector dimension for the mesial connector was
16 mm2. With respect to the distal connector heights, one
connector fell below the recommended height of 4.0 mm, re-
vealing 3.5 mm. By considering the widths, ten FDPs showed
dimensions in mm2 below the recommended value of 16 mm2:
One revealed 12.0 mm2 (height 4.0 mm/ width 3.0 mm), one
showed 13.5 mm2 (4.5 mm/3.0 mm), seven had a dimension of
15.0 mm2 (all: 5.0 mm/3.0 mm), and one obtained was
15.75 mm2 (3.5 mm/4.5 mm). Out of the six FDPs that were
below 16 mm2 at the mesial connector, five showed values
below 16 mm2 for the distal connector, too (five out of the ten
FDPs described earlier for the distal connector). However,
these FDPs were not excluded from the study as it
was decided to keep them under controlled observation
within the clinical trial.
Due to esthetic requirements in exceptional cases, the cut-
back technique was applied by additional veneering (IPS
e.max Ceram, Ivoclar-Vivadent). This procedure was limited
to small incisal edges. After proximal try-in, the marginal fit of
the abutments was checked with a silicone indicator paste (Fit
Checker, GC, Bad Homburg, Germany). Adjustments were
done if necessary using a fine diamond bur under water-
cooling. Finally, static and dynamic occlusions were checked
and adjusted, if necessary. Then, the ground surfaces were
polished using polishers for ceramics interspersed with dia-
mond grits from coarse to fine in the recommended sequence
(Diamond Polishers, Gebr. BrasselerKometLemgo, Germany
or Eve Diapol Polishers, EVE, Pforzheim, Germany) without
additional glaze firing.
All restorations were luted adhesively with Multilink
Automix (Ivoclar-Vivadent,Schaan, Liechtenstein). The
2174 Clin Oral Invest (2014) 18:2171–2178

intaglio surfaces of the abutment crowns were conditioned by Statistics

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

Clinical examinations Study group

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

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

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

at 6 months available recall

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

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

fracture occurred at the connector area of a maxillary right

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

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

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

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

0.6
Dynamic occlusion

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

involved in the dynamic occlusion pattern at the 6-month

0.2

0.0

0.0 1.0 2.0 3.0 4.0 5.0

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

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

One FDP showed a mobility of 1 at the latest recall; the others
were rated 0.
Papilla bleeding index
After a mean observation period of 46 months, 13 FDPs
showed a papilla bleeding index of 0 simultaneously at the
mesial and at the distal abutment. One FDP exhibited both at
the mesial and the distal abutment a PBI of three. Further
results are displayed in Table 3.
Probing depths
The minima and the maxima of the probing depths both at the
6-month recall and after the entire observation period revealed
minima of 0.5 mm and maxima of 4.0 mm. At 6 months, three
of the mesial and distal abutments exhibited a probing depth
of 3.5 or 4.0 mm. At the last recall, two mesial abutments
showed a maximum probing depth of 4.0 mm and one distal
abutment each showed a probing depth of 3.5 and 4.0 mm.
One of the mesial abutments that exhibited 4.0 mm belonged
to that FDP which also showed 4.0 mm at the distal abutment.
Discussion
Besides the limited observation time, another shortcoming of
the study was that the dentists who did the treatment had to
accomplish the recall examinations, too. Unfortunately, this
fact could not be circumvented because in the present study
three private practices were involved. To provide two inde-
pendent examiners for the recall examinations would have
Table 3 Results of the papilla bleeding index at the mesial and the distal
abutment after a mean observation period of 46 months (two FDPs were
not assessed due to failure; for one FDP, the PBI was not noted)
Combinations for PBI assessments
for the mesial and distal abutment
Mesial abutment Distal abutment Number of assessments
for each combination
0 0 13
1 1 4 observed. Nearly one third of the patients showed
0 1 3 parafunctional habits. Five fractures in the connector area
1 0 1 and one incisally were recorded such that Solá-Ruiz et al.
1 2 2 computed a relatively low survival rate of 71.4 % after 10
2 1 1 years. Former investigations revealed that full-contour IPS
2 2 4 e.max Press lithium disilicate FDPs [7, 9] clinically performed
3 3 1
Total 29
team. Due to the fact that the recall parameters were clearly
defined, it seemed to be acceptable that the dentists did the re-
examinations by themselves. Additionally, spot-checks by the
involved university and by the monitor took place in every
center in order to guarantee that the clinical operating protocol
was strictly obeyed.
The application for three-unit end abutment FDP made of
machinable lithium disilicate ceramics would be desirable due
to several advantages of this material. The metasilicate mate-
rial can be processed in a Computer Aided Manufacturing
(CAM) unit without extensive wear of the milling burs, and
the good basic esthetic appearance can easily be enhanced by
stains together with the glaze and crystallization process [2,
10, 11] in one fabrication step of about 40 min. This opens the
option for a single-visit chair-side treatment. Additionally,
full-contoured lithium disilicate restorations seem to be ad-
vantageous in terms of chipping compared to veneered zirco-
nia oxide [12, 13]. The good resistance of full-contour lithium
disilicate against dynamic and occlusal forces was confirmed
by the present study. The high numbers of units loaded by
dynamic occlusion showed that the full-contour FDPs were
functionally integrated in the masticatory system (Table 2).
Independent from the abutment localization (Table 2), more
than two third both of the mesial and the distal crowns was
involved in dynamic occlusion patterns. The pontic area was
less involved. From the 6-month recall to the last recall, the
numbers of units that contributed to dynamic occlusion slight-
ly increased. The chippings which were classified as “minor
chippings” occurred at the incisal edges of maxillary incisors.
Although predominantly full-contour material was used, the
esthetic assessment by the patients revealed excellent ratings.
The prevalent mark was “excellent”, unlike the dentists who
evaluated their own work more critically than the patients.
However, the worst mark given by the dentists was
“sufficient”.
The periodontal health documented by the probing depths,
the Papilla bleeding index, and the mobility was
inconspicuous.
With respect to the precursor material, Empress II, one
long-term clinical study over 10 years is existent as published
by Solá-Ruiz et al. [15]. Twenty-one FDPs in nineteen patients
made of Empress II with connector dimensions of the core
material of 12 mm2 (height of 4 mm and width of 3 mm) were
better than veneered lithium disilicate framework reconstruc-
tions [4, 5, 15] (Table 1). These clinical findings were con-
firmed by an in vitro investigation of Schultheis et al. who
Clin Oral Invest (2014) 18:2171–2178
obtained similar fracture loads for milled full-contour lithium
disilicate posterior FDPs compared to metal ceramic FDPs
before and after fatigue testing [16]. Esquivel-Upshaw et al.
reported on their 4-year clinical study of full-contour FDPs on
fractures of connectors that exclusively belonged to the first or
second molar [7].
From 30 posterior lithium disilicate FDPs, they inserted even
19 in the molar region and hence were beyond the official
indication (Table 1). For the molar connector dimensions, a
minimum size of 20 mm2 (4×5 mm) was set by the authors.
From the four connectors that broke, three were under the
defined minimum dimensions. In the present study, one anterior
FDP broke at the connector which was below the recommended
size of 16 mm2 (4×4 mm). Investigating the reason for this
undersize underlined one of the limitations of this material
because the connector was reduced due to aesthetical reasons.
At stake, the minimum dimensions which are deemed as nec-
essary for clinical success, which sometimes cannot be kept
because anatomical and esthetic conditions do not allow these
extensive dimensions. The longest mean observation time that is
reported about e.max Press full-contour lithium disilicate FDPs
in a clinical trial is 121 months [9]. This study performed
considerably better after 10 years than the study of Solá-
Ruizet al. [15] which examined Empress II framework FDPs
within the recommended indications. Kern et al. reported about
a survival rate of 100 and 87.9 % after 5 and 10 years, respec-
tively, strictly keeping the recommended manufacturer’s con-
nector dimension. It has to be stressed that the authors exceeded
the manufacturer’s recommendations for the posterior indication
in 27 out of 30 cases by including molars as abutments.
In summary, the crucial aspect of the full-contour lithium
disilicate FDPs is the connector area which is mostly prone to
fracture.
In the case of the pressable lithium disilicate ceramic both
for anterior and for posterior FDPs, the mesial and distal
connector should show a minimum dimension of 16 mm2.
Therefore, these recommendations were presumed for the
CAD material as well. According to the documented data of
the present study, 11 FDPs were below the recommended
connector dimensions at which five out the 11 fell below this
benchmark both at the mesial and distal connector. Five out of
the eleven were below 16 mm2 at the distal location and one at
the mesial connector region. Nine of the FDPs replaced a
mesial or lateral incisor. None of them was below 12 mm2.
At the mesial connector, they had two times the dimension of
12.0 mm2, once 13.5 mm2, and two times 15.0 mm2. Three of
them exceeded the recommended vertical height showing 4.5
and 5.0 mm. At the distal connector, one of the anterior FDPs
revealed 12 mm2, one was 13.5 mm2, and six FDPs were
15 mm2. From the latter ones, five compensated a width of
3.0 mm by a height of 5 mm. In addition, due to the fact than
some clinical studies which evaluated the pressable lithium
disilicate material used connector dimensions of 12 mm2 for
2177
anterior FDPs as standard [5, 9, 15], the values that are below
16 mm2 for anterior FDPs in the present study could be seen as
acceptable. However, two FDPs which replaced one first
premolar and one canine fell below the benchmark of
16 mm2, too. The latter one was only under-dimensioned at
the distal connector, revealing a height of 5.0 mm and a width
of 3.0 mm, so that this value could be relativized because the
increased height of 5.0 mm should compensate the reduced
width. At the end, one FDP is left, which shows crucial
connector values both at the mesial and distal region with
10.5 mm2 (height 3.5 mm/width 3.0 mm) and 15.75 mm2
(height 3.5 mm/width 4.5 mm), respectively.
In the present study, one catastrophic event occurred due to
incorrect connector dimensions of a lab-side fabricated FDP.
According to the study protocol, the connector dimensions
had to be noted prior to insertion. In the case of the fractured
connector, the height and width were documented as 5 and
4 mm, respectively. Finally, the dimension was below
16 mm2. One explanation may be that due to esthetical rea-
sons the dimension was reduced additionally after measuring
the height and width. After the failure, the patient agreed to be
restored again with a lithium disilicate FDP, of course without
being included again in the study. In this second version, the
connector dimensions were kept by avoiding a too strong
separation in the connector area. The FDP is now successfully
in situ since nearly 4 years.
Thus, this weak “link” can only be strengthened by obey-
ing consequently the recommended connector dimensions,
especially in the vertical dimension. On the other hand, this
may be a limitation of the practical use of this material because
it is not always possible to provide enough space. As alterna-
tive to lithium disilicate FDPs, all-ceramic FDPs made of
zirconia dioxide frameworks could be used. Therefore, it
would be sensible to compare both types of all ceramic resto-
rations in terms of survival rates. Sailer et al. calculated in their
review the estimated annual failure rates to be from 0 to
5.71 % per100 FDPs and per year [17], depending on the
study they analyzed. Schley et al. reported in their review of
zirconia FDPs an incidence of failures between 0 and 5 % per
100 FDPs and per year [18]. The most reported shortcoming
of zirconia FDPs seems to be the minor stability of the
veneering [18–20]. Whether these problems are meanwhile
really resolved, this has to be evaluated in further clinical
studies [20]. A recently published 84-month evaluation of
veneered zirconia three- to four-unit FDPs revealed a survival
rate of 83.4 % and a success rate of 57.9 %. The main reasons
for failures and complications were fractures and chippings of
the ceramic material [14], but it has to be emphasized that
these data are related to a 7-year observation period.
Interpreting the graph of the survival probability of this 7-
year study, the survival rate is approximately 90 % at 4 years,
which would be similar to the survival rate of the three-unit
CAD/CAM-generated lithium disilicate FDPs after 48
2178
months. In conclusion, with the limitation of a relatively short
observation time, the lithium disilicate material IPS e.max
CAD can be regarded as an alternative to zirconia framework
restorations within its range of indication and in comparison to
the failure rates of alternative materials like veneered zirconia
oxide frameworks. The major prerequisite of the clinical suc-
cess is the strict adherence to the connector dimensions,
especially with respect to the height, which is simultaneously
a clinical limitation.
Acknowledgments This study was supported by IvoclarVivadent.
Conflict of interest During the years the authors SW, KW, PN, and SR
have held oral presentations and/or courses, they were receiving a sepa-
rate and appropriate honorarium each from the sponsor of the present
study.
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