College of Dentistry

Center for Continuing Dental Education

New York City, NY

C O N T I N U I N G

E D U C A T I O N

SORENSEN

A CLINICAL INVESTIGATION ON
THREE-UNIT FIXED PARTIAL DENTURES
FABRICATED WITH A LITHIUM DISILICATE
GLASS-CERAMIC
John A. Sorensen, DMD, PhD* Mark Cruz, DDS Wayne T. Mito, CDT
Oscar Raffeiner, MDT Hannah R. Meredith, RDHll Hans Peter Foser, MDT**

A lithium disilicate glass-ceramic material has recently

original leucite material and enable the fabrication of

been developed for the fabrication of 3-unit fixed par-

3-unit fixed partial dentures. Utilizing the same fabrication

tial dentures. Conducted on 60 restorations, this initial trial

technology of waxing and heat-pressing the ceramic sub-

attempted to define clinical indications and establish design

structure, Schweiger et al created a microstructure com-

principles for fixed partial dentures fabricated of this

posed of densely arranged lithium disilicate crystals (over

ceramic material. The design requisites varied depending

60% volume) uniformly bonded in a glassy matrix.2 The

on placement on the arch, and the authors concluded that

interlocking structure of the ceramic hinders crack prop-

lithium disilicate restorations caused reduced antagonist

agation and elevates the fracture toughness and flexural

structure or opposing tooth wear. This investigation demon-

strength to approximately 340 20 MPa. Although den-

strated that when a novel ceramic system was utilized for

tal ceramics generally experience a significant reduction

3-unit restorations replacing up to the first premolar and

in strength properties when exposed to an aqueous environ-

attained minimal criteria for connector dimensions, an

ment,3-7 no statistically significant change in the flexural

acceptable clinical success rate was achieved.

strength of the lithium disilicate ceramic was measured

following a 1-week period of water storage. Conse-

hile pressed leucite ceramics have demonstrated

quently, a high chemical stability has been achieved with

enhanced aesthetics and clinical longevity due

this chemical composition and ceramic structure.

to their natural translucency and adhesive cementation

Since the coefficient of thermal expansion of the sub-

techniques, a lithium disilicate ceramic (Empress2, Ivoclar

structure ceramic is significantly reduced, the pressed leucite

Williams, Amherst, NY) was recently developed to

and the lithium disilicate ceramics cannot be interchanged.

significantly elevate the strength coefficient beyond the

The veneering ceramic (Empress2, Ivoclar Williams,

*ODA Centennial Professor of Restorative Dentistry; Director,

Dental Clinical Research Center, Portland, Oregon; Section Editor,
Practical Periodontics & Aesthetic Dentistry.
Lecturer,

Department of Fixed Prosthodontics, Oregon Health

Sciences University, Portland, Oregon; private practice,
Laguna Niguel, California.

Senior

Research Associate, Department of Fixed Prosthodontics,

Oregon Health Sciences University, Portland, Oregon.

Ivoclar

Italy, Naturno, Italy.

llResearch

Assistant; private practice, Portland, Oregon.

**Research and Development, Ivoclar, Schaan, Liechtenstein.

John A. Sorensen, DMD, PhD
Oregon Health Sciences University
Dental Clinical Research Center
School of Dentistry
611 S.W. Campus Drive
Portland, OR 97201-3097
Fax: 503-494-1235

Pract Periodont Aesthet Dent 1998;11(1):95-106

Figure 1. Preoperative facial view of the patient who presented missing

tooth #5 and excessive wear of cusp tips #6 and #11.

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Practical Periodontics & AESTHETIC DENTISTRY

Amherst, NY) contains fluorapatite that creates apatite

crystals similar in structure and optical properties to natural teeth,2 and is available in a variety of ceramic shades.
The destruction of antagonist tooth structure by wear
of porcelain occlusal surfaces has challenged clinicians
for years.8-10 The unique microstructural features of the
lithium disilicate system offer several advantages to the
use of metal-ceramic materials. Due to the fine grain structure and high crystallinity of the lithium disilicate substructure
ceramic, the potential wear of antagonist tooth structure
is reduced. The process of sintering the fluorapatite veneering ceramic onto the substructure creates apatite crystals

Figure 3. Lingual preoperative view of the site of tooth #5.

similar to those present in natural tooth structure. An in

vitro testing machine11,12 that evaluated the wear of opposing enamel cusps against various ceramics in three-body
wear testing recorded less wear with the lithium disilicate substructure material and the fluorapatite veneer
ceramic than the bovine enamel control.13 The measurement of clinical wear of antagonist tooth structure has

Occlusal Forces
Opposing cusp
contact

demonstrated similar low wear characteristics.

In addition to elevating the strength of the substructure
ceramic, its high crystalline content makes the ceramic
extremely machinable, allowing a high polish to be rendered, which further reduces the abrasion potential to
the opposing tooth structure.14 The unique ceramic structure also has a reduced propensity towards iatrogenic
periodontal disease.15 The tendency to overcontour metal-

Figure 4. Illustration depicts the determination of occlusal contact

point to establish the occlusal limit of connector height.

ceramic restorations at the margin can be avoided,16,17

and plaque accumulation is diminished due to the smooth
margin that can be achieved with the ceramic material.15

While clinicians have mistakenly believed that

aggressive tooth reduction was required to achieve superior aesthetics with all-ceramic systems, Sorensen et al
clinically demonstrated that less than 1.3 mm of axial
reduction was necessary with adhesively cemented crown
restorations.1 One potential benefit of a ceramic with
higher strength and translucency is a decrease in the
amount of axial tooth reduction required for full-coverage
crown abutments. While 1.4 mm to 1.7 mm of axial
reduction is recommended for metal-ceramics18-20 and
1.3 mm reduction for adhesively cemented pressed leucite
restorations,1 it was hypothesized that only 1 mm of reduction is necessary for the Empress2 ceramic.

Figure 2. Buccal preoperative view. Note the status of the gingival

tissues and excessive wear of canine.

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Vol. 11, No. 1

Another potential application of the adhesively

cemented all-ceramic technology is the utilization of fixed

Sorensen

restorations as well as two- and three-surface inlay

restorations. As a guideline for the dimensions of the inlay
preparations, the margins would have to be greater in

5.0 mm

a buccolingual and occlusogingival dimension than the

minimum connector dimensions in order for the laboratory technician to create the proper embrasure form at
all four aspects of the connector.

Periodontal probe for

measuring vertical height
occlusogingivally

The fundamental questions to be answered in this

developmental clinical trial were: Does the lithium disilicate ceramic have the fracture toughness and strength
to provide clinical longevity for all-ceramic fixed partial

Figure 5. Diagram demonstrates the measurement of potential occlusogingival connector height from crest of gingiva to occlusal contact
point.

dentures? Since the occlusal forces rapidly increase as

one moves posteriorly towards the temporomandibular
joints, functional demands of a premolar restoration are
considerably greater than those of an anterior fixed par-

Rounded axial-gingival
line angle

tial denture. Hence, one objective of this clinical study

was to evaluate the ability of the system to resist fracture
based on location in the mouth to delineate the extent
1.0 mm

of posterior location limits. Available data from clinical

studies on metal-ceramic prostheses indicate a success
rate of 93.5% to 98% at 5 years.21-24 Therefore, the max-

1.0 mm
1.0 mm

imum acceptable failure rate of multiunit all-ceramic

restorations is approximately 6%.

2.0 mm
2.0 mm

Figure 6. Diagram of the recommended preparation design for

anterior full-coverage crown fixed partial denture retainers.

The purpose of this prospective longitudinal study

was to evaluate the clinical performance of 60 3-unit allceramic fixed partial dentures fabricated with the lithium
disilicate ceramic system. The focus was to measure the
longevity of these all-ceramic fixed partial dentures, to
define minimum preparation criteria for full-coverage and

partial dentures with inlay and onlay preparations, which

inlay/onlay restorations, and to evaluate fixed partial

could conserve a large degree of tooth structure. Since

the restorative team would only have to match the pon-

Rounded internal line angles

tic to the adjacent natural teeth, superior aesthetics could

theoretically be achieved. No previous clinical studies
have evaluated this mode of treatment, and essentially
no research has been performed to define the clinical

1.0 mm

parameters of adhesive preparation design.

1.0 mm

It was postulated that the adhesively cemented lithium

disilicate material could be used for the fabrication of conservative fixed partial dentures. Based on the amount of
remaining tooth structure, the extent of preexisting restora-

2.0 mm

Multiple planes
of reduction

1.5 mm

2.0 mm

tions, and the anatomical location of the tooth, two conservative preparation designs were used. The experimental
designs included half-tooth and full-coverage onlay

Figure 7. Illustration of recommended preparation design for

posterior full-coverage crown fixed partial denture retainers.

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Practical Periodontics & AESTHETIC DENTISTRY

denture design principles particularly the connector

dimensions. The authors also sought to determine the limits of posterior placement, evaluate the adhesive cementation technique, and measure the wear to the opposing
tooth structure.

Materials and Methods

Sixty 3-unit fixed partial dentures were placed in 57 (24
female; 33 male) patients whose age ranged from 21 to
75 years (mean = 45.7 12.8 years). Entrance criteria
for the study included: a) medical-dental history that did
not preclude routine dental treatment, b) a minimum of
20 teeth, c) subject did not wear a removable partial

Figure 8. Full-coverage crown retainer preparations are completed

utilizing a shoulder margin design and 1 mm of axial reduction.

denture, d) moderate to good oral hygiene, e) no active

periodontal disease, f) missing a single tooth (Figures 1
through 3). The definitive restoration had to be placed
in occlusion and a maximum of two fixed partial dentures could be seated in each patient. The margins of
the abutment teeth were placed less than 1 mm subgingivally, and the restorations exhibited a minimum occlusogingival dimension of 4.5 mm from the proximal
interdental papilla to the marginal ridge of the abutment
teeth (Figures 4 and 5).
Abutment teeth were prepared with diamond burs
(Sorensen All-Ceramic, Beavers Dental Burs, Sybron
Canada, Morrisburg, Ontario) and high-speed handpieces under water irrigation. Margins on posterior teeth

Figure 9. Buccal view of a premolar bridge retainer preparation with

shoulder margin placed equigingivally.

were placed either equi- or supragingivally when possible or minimally subgingival to establish a margin on

Proximal contacts were verified with mylar articu-

sound tooth structure. Two groups of restorations were

lating paper, the internal fit of the prostheses was eval-

formed and defined by their preparations: conventional

uated using silicone-based material (Fitchecker, GC

fixed partial dentures were prepared with a full-coverage

America, Chicago, IL) (Figures 11 and 12) and any

crown design that had a minimum axial reduction of

necessary adjustments were made with a diamond bur.

1 mm and occlusal reduction of 1.5 mm to 2 mm (Figures

The occlusion was evaluated with silk ribbon articulating

6 through 10); experimental restorations were charac-

paper and adjusted as necessary until multiple bilateral

terized by intracoronal or partial veneer retainers, includ-

simultaneous contacts were achieved. Following the adjust-

ing inlay, distal slice, and onlay preparations. The inlay

ment of contours and occlusion, the dimensions of the

preparations had an occlusogingival height of 4 mm and

fixed partial dentures were measured at 29 points.

5 mm in the anterior and posterior, respectively, and a

minimum axial thickness of 1 mm. These restorations also

Cementation

had a minimum buccolingual dimension of 4 mm. The

A diagram of the teeth was recorded to indicate the

abutments for the onlay preparations had axial reduction

approximate areas of enamel and dentin on the mar-

of 1 mm and occlusal reduction of 1.5 mm to 2 mm and

ginal area as well as the relation of the margin to the

a shoulder or chamfer margin design.

gingival crest. The ceramic fixed partial denture was

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Vol. 11, No. 1

Sorensen

with enamel margins were etched with phosphoric acid

for 45 seconds and again thoroughly rinsed and dried.
Areas with dentin tooth structure were initially treated with
dentin adhesive primer (Syntac, Ivoclar Vivadent, Amherst,
NY) for 15 seconds and then air dried. Dentin adhesive
material was subsequently applied with a brush for 15
seconds and air dried. The unfilled resin composite was
applied with a brush to the entire tooth and gently air
thinned, after which shaded cement (Variolink II, Ivoclar
Vivadent, Amherst, NY) was placed in a thin layer on
the internal aspect of the abutment teeth. The lithium disiliFigure 10. Canine crown retainer uses shoulder margins with a
minimum of 1 mm of axial reduction placed equigingivally.

cate ceramic restoration was seated, and any excess

cement was removed with a brush. Waxed floss was utilized to remove excess cement from the interproximal
aspects.1
Following a brief initial cure to secure the position
of the fixed partial denture, it was photopolymerized for
60 seconds at all aspects. The restoration was left
untouched for 10 minutes to allow complete polymerization of the resin cement. A #12 scalpel blade and a
fine scaling instrument were used to shear off the excess
polymerized cement. In order to avoid damaging the
ceramic, root dentin, and gingival tissues, every effort
was made to refrain from the use of rotary burs.1 Once
all excess cement was removed, occlusal contacts were

Figure 11. Excessive pressure on tissues from the pontic were

detected with pressure-indicating paste.

evaluated and verified; at this stage, any additional

adjustments were made and polishing was performed
(Figures 14 and 15). In order to take advantage of the

cleaned and etched with hydrofluoric acid (IPS Ceramic

wear kindness of the lithium disilicate glass-ceramic mate-

Etching Gel, Ivoclar Vivadent, Amherst, NY) for 30 sec-

rial, the cusp length of tooth #11 was restored by the

onds and thoroughly rinsed and dried. Once a silane

adhesive cementation of a ceramic cusp tip that reestab-

agent (Monobond-S, Ivoclar Vivadent, Amherst, NY) had

lished canine guidance (Figures 16 through 19).

been applied at all internal aspects for 60 seconds,

unfilled composite resin (Heliobond, Ivoclar Vivadent,

Clinical Parameters Evaluated

Amherst, NY) was applied and air thinned. The fixed

Baseline data (ie, photographs, polyvinylsiloxane impres-

partial denture was placed under a lightproof cover for

sions, radiographs, periodontal parameters, marginal

cementation (Figure 13).

fidelity, and occlusal analysis) were recorded. These mea-

The teeth were initially cleaned of debris with hydro-

surements and records were repeated at 6 months

gen peroxide and cotton pellets. When the restoration

(Figures 20 and 21) and 12 months, and will be con-

margin was too far subgingivally to control sulcular fluids,

tinued for 5 years. The impressions of the opposing den-

a retraction cord was placed. A cotton pellet contain-

tition and the ceramic restoration were poured in an

ing 0.12% chlorhexidine gluconate (Peridex, Zila Pharma-

epoxy material (Epoxy-Die, Ivoclar Vivadent, Amherst,

ceuticals, Cincinatti, OH) was placed on each tooth for

NY) according to manufacturers instructions for in vivo

60 seconds, which was then rinsed and dried. Areas

wear measurements.25

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Practical Periodontics & AESTHETIC DENTISTRY

Table 1

dimensions revealed that it had a triangular configuration

with dimensions of approximately 3.6 mm 3 2.5 mm,

Distribution of Conventional Fixed Partial Dentures

by Location of Retainers and Arch
Retainer Retainer
Incisor Incisor

which were significantly less than the recommended minimum dimensions (4 mm 3 4 mm). The 3 remaining cat-

Maxilla
9

Mandible
0

Total
9

astrophic failures occurred in the premolar region. Two

Incisor Canine

13

13

premolar fixed partial dentures had connector heights

Incisor Premolar

of less than 4 mm (3.62 mm; 3.80 mm), and 1 failed

Canine Premolar

10

premolar restoration had a connector height of 4.29 mm.

Premolar Premolar

No fracture of the conservative designs with inlay and

Premolar Molar

onlay preparations occurred. The conservative fixed par-

32

41

tial dentures were predominately in the posterior region

Total

(18 of 19 sites). The catastrophic failures occurred at

5, 6, 7, and 9 months.

Results

The experimental restorations failed at a rate of

Of the 41 total conventional fixed partial dentures placed

10.5% (2 of 19 units) due to the debonding of distal

(Table 1), the restorations were predominately placed

slice preparations on maxillary canines at the cement-

in the maxillary arch (32 maxillary; 10 mandibular). A

tooth interface; these failures occurred at 2 and 4 months.

total of 19 (12 maxillary; 7 mandibular) experimental

The ceramic fixed partial dentures did not fracture dur-

fixed partial dentures were placed (Table 2), utilizing 31

ing the 3 to 4 week period when the canine abutments

experimental preparations (14 inlays; 14 onlays; 3 dis-

were debonded, and the premolar inlay or onlay abut-

tal slices) and 7 conventional abutments. Of the surviv-

ments continued to support the restoration. Since the

ing restorations, 52 have been in service for a minimum

debonding occurred in 2 of 31 experimental prepara-

of 6 months, and range in service from 6 to 18 months

tions, the authors hypothesized that the distal slice prepa-

(mean = 12.1 months). The use of retraction cords was

ration design did not provide sufficient mechanical

only necessary in two instances.

retention. In one subject, inlay preparation designs were

used in maxillary central and canine abutment teeth. Due

Analysis of Failed Restorations

to the mechanical retention provided by the opposing

In reviewing the clinical data, three modes of failure were

walls of the inlay preparations, the restoration continues

evident. The conventional fixed partial dentures failed due

to function well. The mechanical retention features of a

to minor chipping of the veneer ceramic or fracturing of the

preparation are critical to the success of these experi-

connector between abutment and pontic. The minor fail-

mental abutment designs.

ures occurred primarily on anterior teeth at a rate of 1.1%

Ten of the abutment teeth were nonvital and 110

(2 of 180 units). In a study on 2,181 metal-ceramic units,

were vital. Following cementation of the restorations,

Coornaert et al determined that the majority of failures

patient complaints were filed for 10 abutment teeth,

occurred within 12 months postcementation, and most

which resulted in a 9.1% incidence of postcementation

often within the porcelain layers rather than between

symptoms (eg, sensitivity to cold, pain on mastication,

the metal and porcelain. The most frequent cause of

or general ache). Of the abutment teeth that exhibited

failure was determined to be occlusal, and the majority

symptoms, 4 were anterior and 6 were posterior. While

21

of these patients demonstrated distinct signs of bruxism.

the symptoms in 6 of these abutment teeth were com-

Catastrophic failure was defined as fracture through

pletely resolved in 1 week to 5 months, symptoms have

the core material, and occurred at a rate of 6.7% (4 of

persisted in 4 of the teeth since cementation. The major-

61 units) through the connector between abutment and

ity of these patients symptoms were more severe for a

pontic. One anterior fixed partial denture suffered a

period following cementation and then diminished in

catastrophic failure. Measurement of the connector

severity but remain present. Consequently, 3.6% of

21

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Vol. 11, No. 1

Sorensen

Table 2

patients abutment teeth have persistent symptoms. None

of the abutment teeth in the present study have required
endodontic therapy.
As of this report, interfacial microleakage was

Distribution of Experimental Fixed Partial Dentures

by Location of Retainers and Arch

detected on only one margin at the cement-tooth inter-

Retainer Retainer
Incisor Incisor

Maxilla
0

Mandible
0

Total
0

face on tooth #30 at the mesiolingual aspect of an onlay

abutment. Since measurements were recorded at six

Incisor Canine

Incisor Premolar

points for each of 120 abutments, the estimated rate of

Canine Premolar

microleakage is 0.14% (1 of 720 points) of measure-

Premolar Premolar

ment points or 0.83% of teeth (1 of 120 units).

Premolar Molar

12

12

19

Total

Wear Potential
The epoxy replicas were profiled with the MTS Tooth
Profiling System and compared with the AnSur Program

to achieve optimum aesthetics. Shillingburg et al stated

(University of Minnesota) to determine the location of

that an absolute minimum of 1.2 mm and 1.4 mm of

wear regions and quantify in vivo wear of either the

facial reduction was required for a base and a noble

opposing dentition or the ceramic restorations.25 Six

metal alloy coping, respectively.18 Chiche and Pinault

months postoperatively, half of the opposing natural teeth

recommended 1.4 mm to 1.7 mm of facial reduction for

exhibited no measurable wear and approximately 40%

the porcelain margin of metal-ceramic crown restora-

of the ceramic occlusal services demonstrated wear

tions.19 Rosenstiel et al mandated 1.5 mm of facial reduc-

facets. The mean volume (mm3) of opposing tooth struc-

tion for a metal-ceramic crown restoration.20 Since less

ture and ceramic surface wear was 0.0701 0.121

axial tooth reduction is required, the lithium disilicate

and 0.0268 0.370, respectively. Since the profiling

ceramic system provides a more conservative restoration.

of all the subjects is not complete, these are preliminary

Due to the enhanced optical properties of the ceramic

results only.

material, this is achieved without compromising aesthetics.

Three of the 4 restorations that catastrophically failed

Discussion

had occlusogingival connector heights that failed to

The challenge for dental ceramic manufacturers has been

achieve the recommended design standards. Although

to optimize the combination of strength and aesthetics.

the subject qualification criteria included a minimum con-

Typically, the increase of crystalline content to achieve

nector height of 4 mm, the authors would recommend

greater strength results in greater opacity for a ceramic

caution in the use of ceramic material for premolar fixed

material. With a crystallinity of approximately 60%, the

partial dentures unless an occlusogingival connector

lithium disilicate ceramic system (Empress2, Ivoclar

height of 5 mm can be accomplished.

Williams, Amherst, NY) maintains a relatively high translucency, but it is not as translucent as the original leucite-

Biomechanical Considerations and

reinforced ceramic.

Diagnostic Procedures

In a study of 75 resin cemented leucite-reinforced

The biomechanical engineering principles and the Law

crown restorations prepared with 1.3 mm of axial reduc-

of Beams are fundamental considerations in treatment

tion, Sorensen et al recorded a failure rate of 2.7% at

planning for all types of fixed partial dentures. The deflec-

4 years.1 In the present study on lithium disilicate ceramic

tion of a beam varies directly with the cube of the length

restorations with only 1.0 mm of axial reduction, no ceramic

of the span and inversely with the cube of the height.26,27

fractures occurred through the full-coverage crown retain-

Therefore, of the two dimensions of the FPD connector,

ers. Metal-ceramic restorations generally require approx-

vertical height has a radically greater effect on the flexure

imately 1.5 mm of facial axial tooth reduction in order

or strength of the restoration than does the buccolingual

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Practical Periodontics & AESTHETIC DENTISTRY

width.28 A connector with a given occlusogingival dimension will bend eight times as much if the thickness is
halved, while a one-half reduction in the buccolingual
dimension only results in a twofold increase in flexure.
Since the occlusogingival connector height is the critical dimension, the clinical determination of the ability
to achieve this dimension is the primary determinant of
the ability to use the lithium disilicate ceramic system for
three-unit fixed partial dentures (Figure 22). The occlusal
contact and the gingival tissues define the limits of the
connector height. A gingival embrasure must be maintained for oral hygiene access and avoidance of iatrogenic periodontal disease. If the minimal vertical height
dimension is not available the clinician may consider

Figure 13. The lithium disilicate glass-ceramic (Empress2, Ivoclar

Williams, Amherst, NY) fixed partial denture was polished and
autoglazed to permit cementation.

performing electrosurgery to remove the soft tissue to

gain space for the connector height, although the extent
of tissue removal is limited, and biological width must
be respected. If this minimum vertical dimension cannot
be achieved, then use of the lithium disilicate ceramic is
contraindicated for fabrication of a fixed partial denture.
The placement of a pontic in a posterior location
increases the functional requirements of the occlusogingival connector dimension (Figure 22). In order to determine these requisites, the occlusion should be marked
(Figure 4) or the distance from the opposing cusp contact or incisal embrasure to the gingival crest should
be measured with a periodontal probe (Figure 5). For
a first premolar pontic, the connector dimension between

Figure 14. Buccal view of the cemented lithium disilicate glassceramic fixed partial denture in lateral excursion, which demonstrates the restoration of canine guidance.

the second premolar retainer and pontic should be

5.0 mm occlusogingivally and 4.0 mm buccolingually.
The connector dimension between canine and lateral
incisor pontic should be 4.0 mm occlusogingivally and
3.0 mm buccolingually. The maximum length of the pontic span is the mesiodistal width of a premolar, or approximately 9 mm in the posterior area and 11 mm in the
anterior region (Figure 23).
Secondary treatment planning considerations include
factors that might limit the occlusogingival connector height
(eg, lack of posterior support or posterior group function). Parafunctional habits such as bruxism are a contraindication to the use of this all-ceramic system for FPDs.
While the inherent strength of the lithium disilicate
Figure 12. The ceramic fixed partial denture was then tried-in to
permit evaluation of contours and occlusal adjustments.

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Vol. 11, No. 1

ceramic has been significantly improved, the overall

strength of the fixed partial denture is dependent on

Sorensen

stronger than the veneer ceramic, it is recommended that

little or no veneer ceramic be applied at the gingival
embrasure or lingual embrasure of the connectors. This
will also maximize the strength conferred by the core
material. Care must be taken to avoid inducing microcracks and critical flaws in important connector areas,
and it is highly recommended that no rotary instruments
be used on the connector areas once the ceramist has
fabricated the restoration.
In clinical practice there are often instances where
the existing preparation retention and resistance form are
Figure 15. Lingual view of the posterior fixed partial denture. The
ceramic material utilized in the restoration minimizes wear of the
opposing dentition.

lacking and require augmentation. A clinical advantage of the heat-pressed Empress2 ceramic system is that
it can reproduce auxiliary retention and resistance forms
(eg, boxes and grooves), which expands the clinical
applications of this system closer to those of metal-ceramic
materials. Since no conservative bridges failed by catastrophic fracture, it appears that the lithium disilicate
ceramic system may be utilized in this application.
When the clinical study was initiated the investigators did not know the exact amount of mechanical
retention that was required for these restorations. The distal
slice preparations which were essentially hollow ground
bevels with very minimal box form on the distal of the
canine relied extensively on the adhesion to tooth
structure of the etched enamel and dentin bonding agents

Figure 16. Attrition of canine has rendered length inadequate for

canine guidance.

for retention. The authors concluded that this preparation design did not provide sufficient mechanical retention as an abutment. Apparently, the opposing vertical

several factors that can degrade the strength. The

occlusogingival dimension or vertical height of the connector is critical. Consequently, this vertical dimension
should be maximized in the heat-pressed core material
and every effort should be made by the laboratory technician to minimize flaw content. These flaws act as the
origin of crack propagation and can grow to critical size
in the oral environment with cyclic fatigue loading and
stress corrosion fatigue.29-32
The authors predict that the veneered Empress2
(Ivoclar Williams, Amherst, NY) fixed partial denture
would behave similarly to the In-Ceram system (Vident,
Brea, CA), where the highest tensile stresses occur in the
connector areas between core and veneer ceramics.33
Consequently, since the core ceramic is significantly

Figure 17. The ceramic cusp was fabricated and etched for adhesive
cementation.

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walls of an inlay are necessary to provide mechanical

retention in addition to the adhesive cementation mechanism. The proximal walls of the boxes should maximize the cross-section of enamel prisms for adhesive
bonding. None of the inlay or onlay retainers failed.
One manufacturer stated that facial veneer preparation could be utilized with its ceramic system for the fabrication of fixed partial dentures.34 Christensen and
Christensen35 tested 40 bridges with a variety of retainer
designs and determined an 80% failure rate for posterior
fixed partial dentures at 2 years. Anterior fixed partial dentures with veneer and full-coverage crown preparations
demonstrated a 38% and 22% failure rate, respectively.

Figure 18. Buccal view of the cemented restoration. Note the integration of the adhesive ceramic with the natural tooth structure.

Since the ceramic material of this system had a flexural

strength of only 105 MPa, these results were rather predictable.36 While the concept of conservative veneer preparation is appealing, a substructure that has the strength
of metal in thin sections has not yet been developed.
While the elimination of postcementation sensitivity
remains a clinical objective, all types of dental cements
cause side effects. Johnson et al recorded a 32% incidence of immediate postcementation sensitivity for zinc
phosphate cement and 19% for glass ionomer cement37;
the incidence of these symptoms continued at the 2and 12-week measurement points. The 9.1% incidence
of postcementation symptoms compares favorably to
the incidence of symptoms for conventional cements.
With the lithium disilicate ceramic and cementation sys-

Figure 19. Lingual view of the adhesive cusp tip, which is virtually
indistinguishable from the adjacent natural dentition.

tem used in the present study, 3.6% of patients abutment

teeth had persistent unresolved symptoms. This incidence
is not acceptable, however, and the authors are striving
to achieve a zero incidence.
The incidence of microleakage at the tooth-cement
interface was minimal since margin placement extended
no more than 1.0 mm subgingivally, and was placed in
enamel whenever possible. The use of the two-stage
dentin bonding agent also contributed to the minimal
microleakage. The authors also determined that the adhesive cementation procedure was pulpally compatible and
maintained a reliable adhesive seal with relatively few
complications in terms of postcementation sensitivity.
A disadvantage of the ceramic system evaluated
in this study was that fixed partial dentures fabricated
from this material required adhesive cementation, which

104

Vol. 11, No. 1

Figure 20. Three months postoperatively, the interdental papillae had

filled in the gingival embrasure.

Sorensen

is more time consuming and technique sensitive. It is the

adhesive cementation technology, however, that enables
one to use conservative inlay and onlay abutments and
minimize the axial wall reduction for full-coverage crown
preparations. This presents a viable alternative to conventional metal-ceramic restorations, which require
approximately 50% more tooth reduction in order to
achieve similar aesthetics.18-20 Additional institutions are
currently evaluating the conventional cementation of the
lithium disilicate ceramic system.
Figure 21. Postoperative facial view of the patient demonstrated
improved aesthetics and function while reestablishing bilateral
canine guidance.

Conclusion
This clinical trial defined preparation parameters, fixed
partial denture design requisites, and posterior limits of
placement for a novel lithium disilicate ceramic system
(Empress2, Ivoclar Williams, Amherst, NY). The unique

Occlusal Force

structures of the heat-pressed substructure ceramic and

the fluorapatite veneering ceramic offer clinical benefits
in terms of machinability, polishability, and reduced wear

4.0 mm

of opposing tooth structure. Half the antagonist teeth eval-

4.0 mm
3.0 mm

uated in the trial exhibited no wear from the opposing

3.0 mm
3.0 mm

ceramic surfaces, and 42% of the ceramic surfaces

demonstrated wear facets, which indicated a strong ten-

5.0 mm

dency to reduce the destructive nature characteristic of

4.5 mm
4.0 mm

4.0 mm

4.0 mm

conventional ceramic materials.

The authors also determined that 3 of 4 fixed partial

Figure 22. Diagram exhibits minimum occlusogingival and buccolingual connector dimensions as a function of position of bridge connector and occlusal forces.

dentures that catastrophically failed had occlusogingival

connector heights that did not achieve recommended
design parameters. The required occlusogingival connector height varied depending on its location on the
arch; between the premolars this height should measure
5 mm and should be 4 mm between the incisors. None
of the conventional full-coverage crown preparations with
1 mm of axial reduction experienced catastrophic failure through the abutments; the ceramic of the experimental fixed partial dentures did not fracture. Although
2 of the experimental restorations with the distal slice
design failed due to debonding, none of the inlay or

9.0 mm
11.0 mm

onlay abutments failed clinically, which indicated that

mechanical retention features are required for the preparations. Consequently, it was determined that the lithium
disilicate possesses sufficient strength for conservative

Figure 23. Diagram demonstrates that the maximum length of pontic

span is equal to the width of the premolar tooth.

fixed partial dentures when sufficient retention is achieved

with inlay and onlay abutments.

PPAD

105

Practical Periodontics & AESTHETIC DENTISTRY

The incidence of postcementation symptoms was

9.1%, the majority of which were resolved in 1 week to

15. Sorensen JA. A rationale for comparison of plaque-retaining

properties of crown systems. J Prosthet Dent 1989;62(3):
264-269.

5 months, although 3.6% of the patients demonstrated

16. Parkinson CF. Excessive crown contours facilitate endemic

plaque niches. J Prosthet Dent 1976;35(4):424-429.

persistent symptoms. Minimal interfacial microleakage

17. Frankhauser G. Clinical investigation of metallo-ceramic

crowns. Zurich, Switzerland: University of Zurich. 1979. Thesis.

(0.83% of the teeth) was noted, and none of the abutment teeth required endodontic therapy. The initial results
documented in the clinical trial indicate promise for this
novel lithium disilicate ceramic system as a biocompatible alternative to metal-ceramic materials, although subsequent clinical investigations must be completed to verify

18. Shillingburg HT, Jacobi R, Brackett SE. Anterior porcelain-fusedto-metal crowns. In: Fundamentals of Tooth Preparations for
Cast Metal and Porcelain Restorations. Carol Stream, IL:
Quintessence Publishing; 1987:259-278.
19. Chiche G, Pinault A. Metal ceramic crowns. In: Esthetics of
Anterior Fixed Prosthodontics. Carol Stream, IL: Quintessence
Publishing; 1994:78-94.

the long-term prognosis of this treatment modality.

20. Rosenstiel SF, Land MF, Fujimoto J. The metal-ceramic crown

preparation. In: Contemporary Fixed Prosthodontics. 2nd ed.
St. Louis, MO: Mosby; 1995:180 -192.

Acknowledgment

21. Coornaert J, Adriaens P, De Boever J. Long-term clinical study

of porcelain-fused-to-gold restorations. J Prosthet Dent 1984;51
(3):338-342.

The authors mention their gratitude to Valorie Stouffer,

CDA, for the coordination and collection of the data for

22. Leempoel PJD, de Haan AFJ, Reintjes AGM. The survival rate
of crowns in forty Dutch practices. Ned Tijdscher Tandheelkd.
1982.

this clinical study.

23. Leempoel PJD, Eschen S, de Haan AFJ, Hof MA. Evaluation

of bridges and RPD abutment crowns in a general practice.
Ned Tijdscher Tandheelkd 1984;91:231.

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1998;26(2):130-136.
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restorations. Quin Dent Tech 1999 (In press).
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IL: Quintessence Publishing; 1983:110 -116.
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of enamel against dental ceramics. J Dent Res 1999;78
(Abstract). In press.
14. Seghi RR, Rosenstiel SF, Bauer P. Abrasion of human enamel
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25. Sorensen JA, Berge HX. Clinical wear assessment with MTS
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35. Christensen G, Christensen R. Service potential of all-ceramic
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38-46.

CONTINUING EDUCATION
(CE) EXERCISE NO. 3

CE
3

CONTINUING EDUCATION
NEW YORK UNIVERSITY
College of Dentistry
Center for Continuing Dental Education
New York City, NY

To submit your CE Exercise answers, please use the answer sheet found within the CE Editorial Section of this issue and
complete as follows: 1) Identify the article; 2) Place an X in the appropriate box for each question of each exercise; 3) Clip
answer sheet from the page and mail it to the CE Department at Montage Media Corporation. For further instructions,
please refer to the CE Editorial Section.
The 10 multiple-choice questions for this Continuing Education (CE) exercise are based on the article A clinical investigation on three-unit fixed partial dentures fabricated with a lithium disilicate glass-ceramic by John A. Sorensen, DMD,
PhD, Mark Cruz, DDS, Wayne T. Mito, CDT, Oscar Raffeiner, MDT, Hannah R. Meredith, RDH, and Hans Peter Foser, MDT.
This article is on Pages 95-106.

Learning Objectives:
This article describes a novel ceramic system that appears to demonstrate clinical success when utilized in 3-unit restorations. Upon reading and completing this exercise, the reader should have:
A comprehensive overview of the preparation parameters, fixed partial denture design requisites, and posterior limits for a novel lithium disilicate ceramic system.
An understanding of the potential promise of the lithium disilicate ceramic system as a biocompatible alternative to metal-ceramic materials.
1. Leucite ceramics have been widely utilized
due to the following characteristics:
a. Wide availability and ease of preparation.
b. Natural translucency and adhesive cementation techniques.
c. Optimal thermal expansion properties.
d. None of the above.
2. Crack propagation of the lithium disilicate
material is considerably reduced by what
property?
a. The interlocking structure of the material.
b. Increased flexural characteristics in an
aqueous environment.
c. A high chemical stability.
d. All of the above.
3. The occlusal destruction of opposing dentition
normally caused by porcelain restorations is
reduced by which characteristics?
a. Fine grain structure and high crystallinity.
b. Medium grain structure and high crystallinity.
c. Large grain structure and high crystallinity.
d. Fine grain structure and low crystallinity.
4. The crystalline content of the lithium disilicate
material allows for:
a. A reduced propensity towards iatrogenic
periodontic disease.
b. An elevated strength of the substructure.
c. An optimal polish to be rendered, thus
educing abrasive characteristics.
d. All of the above.
5. Clinical studies have indicated that an axial
reduction of what length is required for the
lithium disilicate material?
a. 1.4 mm to 1.7 mm.
b. 1.3 mm.
c. 1 mm.
d. None of the above.
108

Vol. 11, No. 1

6. The authors avoided the use of rotary burs for

removal of excess polymerized cement.
a. True.
b. False.
7. The experimental restorations failed at a rate
of 10.5% due to:
a. Excessive bruxism.
b. The debonding of distal slice preparations on
mandibular canines.
c. The debonding of distal slice preparations on
maxillary canines.
d. Inadequate mechanical retention.
8. Metal-ceramic restorations generally require an
axial reduction of what for optimal aesthetics:?
a. 1.2 mm.
b. 1.5 mm.
c. 1.3 mm.
d. None of the above.
9. Of the two dimensions that affect the denture
connector, which has a greater impact in the
flexural strength?
a. Vertical height.
b. Buccolingual width.
c. Mesiodistal length.
d. None of the above.
10. Which of the following was considered a
disadvantage of the all-ceramic system?
a. Decreased flexural strength.
b. A propensity to crack.
c. The necessity for adhesive cementation.
d. All of the above.