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Oklahoma 74112/Zirconia vs. lithium disilicate/2014

Zirconia vs. lithium

disilicate
01/17/2014

Gordon J. Christensen, DDS, MSD, PhD

There's been an enormous amount of advertising on both full-
zirconia crowns and IPS e.max (lithium disilicate) crowns.
Clinician opinion seems to be that they are both working much
better than previous ceramic restorations. Porcelain-fused-to-
metal (PFM) appears to be slowly dying. Am I right? Which of the
two types of ceramic crowns should I be doing most? Have they
been used enough to trust them? I'm skeptical of the ads on both
types of crowns, and many of the published papers funded by
manufacturers. I don't want to have the significant numbers of
failures that I had with other generations of ceramic crowns.
I agree with your reluctance to believe some of the published
information on these new crown forms. We have been misled
before. As you know, sometimes looking solely at the in-vitro
"evidence" on any subject can be misleading and often
diametrically opposed to clinical observations. Fortunately, in this
instance, both the scientific in-vitro evidence and the clinical
observation evidence show remarkable acceptability of both types
of crowns. Our research group, Clinicians Report or CR
Foundation, has confirmed both types of data.
Your question concerning which is the best type of crown is
commonly asked. Each crown type, zirconia or lithium disilicate,
has significantly different characteristics. In the following
information, I will discuss the differences and make some
suggestions relative to when and where the two types of
restorations are best suited. The information will be divided into
several categories.
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Single or multiple units

Both full-zirconia and lithium disilicate restorations have proven
themselves in situations requiring only single-tooth restorations.
Therefore, other factors to be discussed later in this article must
be considered to make a logical conclusion about which type to
use.
Full-zirconia and zirconia-based restorations have proven
themselves in three-unit fixed prostheses replacing one missing
tooth, with research and observation over nine years on zirconia-
based restorations in the CR Foundation TRAC Research division
(Technologies in Restorative and Caries Research).
Some laboratories are promoting longer span units of zirconia
restorations. Although this use has promise, I advise caution and
full disclosure informed consent to patients regarding longer span
use at this time. Additionally, a relatively large connector junction
of about 4 mm in diameter is suggested to provide acceptable
strength when connecting the abutments to the pontic areas (Fig.
1).
Multiple-unit lithium disilicate restorations are not advised at this
time in posterior locations. However, some are using this material
in three-unit anterior restorations. I suggest patients receive
informed consent concerning reservations about adequate
strength of the currently popular form of monolithic lithium
disilicate, since some failures have been reported.
When full-ceramic, three-unit fixed prostheses are needed in the
anterior portion of the mouth, I suggest use of zirconia-based
restorations.

Fig. 1 -- Broken connector on zirconia-based, multiple-unit fixed prosthe

long-term study. Use wide connectors for zirconia restorations.
Esthetic characteristics
The originally introduced full-zirconia restorations were not
esthetically acceptable because of their opaque, off-color, and too
light characteristics. However, remarkable progress has been
made to date (Fig. 2). Currently, there are many changes being
made in full-zirconia restorations, including the availability of
numerous colors of zirconia and the development of more
translucency. I predict that within the next few years the esthetic
characteristics of full-zirconia crowns and fixed prostheses will
rival and potentially surpass porcelain-fused-to-metal restorations.

Fig. 2 -- Two full-zirconia, three-unit restorations replacing both first mo

characteristics of full-zirconia restorations at the time of this publicatio
However, at this time I recommend lithium disilicate over full-
zirconia single crowns for the anterior portion of the mouth
because of the esthetically superior characteristics of currently
available monolithic lithium disilicate (IPS e.max).
Lithium disilicate restorations are among the most esthetic
restorations in dentistry today (Fig. 3). These restorations match
the esthetic characteristics of natural teeth very closely, and many
laboratories are providing them at reasonable prices. I hope the
reductions in laboratory cost will lead dentists to encourage more
patients to seek esthetic upgrading of their smiles.
Use in the anterior or posterior portion of
the mouth
Most dentists are reluctant to use any new or moderately proven
restoration type for all of their restorations. I agree with that
concept completely. Porcelain-fused-to-metal is well proven and
has had over 50 years of successful use. Properly fabricated and
seated cast-gold alloy restorations are still known to be the
longest-lasting crown restorations. I suggest NOT using any new
product exclusively until the evidence on the previously discussed
materials or products is well proven. Don't throw away the older,
well-known materials.
Fig. 4 -- This patient has destroyed PFM restorations placed by a previo
What will he do to the newer restorations? At this time, nobody knows.
When obvious bruxism characteristics are present in a patient, I
advise caution when treatment planning, providing thorough
informed consent to patients about the unknown longevity
characteristics of the newer materials. At this time, we feel that
the newer ceramic restorations are the best full-ceramic
restorations, but patients should know that long-term evidence is
not yet available (Fig. 4).
In patients with overt bruxism, retentive tooth buildups and
parallel tooth preparations are mandatory for optimum long-term
success (Fig. 5).

Fig. 5 -- For the patient shown in Fig. 4, tooth buildups were placed and
made.
Use of cast-gold alloy or PFM crowns is proven and desirable in
some situations, in spite of the rapid movement and commercial
hype to go to full-ceramic restorations (Fig. 6).

Fig. 6 -- Cast-gold alloy restorations were placed on molars for this brux
lithium disilicate restorations were placed on the remainder of the teeth
was made for use every night.
My current personal suggestions for full-crown use in the anterior
and posterior portions of the mouth follow. As more research
becomes available, I assure you that my clinical opinions will
change.
The materials are listed in decreasing order of my preference:
1 Second molars -- gold alloy, PFM, full zirconia, lithium disilicate
(IPS e.max)
2 Mandibular first molars -- gold alloy, PFM, full zirconia, lithium
disilicate
3 Maxillary first molars -- PFM, lithium disilicate, full zirconia
4 Premolars, maxillary and mandibular -- lithium disilicate, PFM,
full zirconia (Fig. 7)
5 Six maxillary or mandibular anterior teeth -- lithium disilicate
6 One maxillary or mandibular anterior tooth with other teeth
present -- leucite-reinforced glass (IPS Empress or others),
lithium disilicate
Fig. 7 -- IPS e.max (lithium disilicate) continues to grow for use in both p
unit locations. It is serving well in those situations.
The future
I predict that zirconia will continue to grow in use as better
esthetic characteristics are developed. Lithium disilicate will
continue to increase in use and be further reinforced with zirconia
or other elements. New hybrid full ceramic materials are coming
into the market. They will continue to be developed, but it will take
years to prove or disprove their acceptability.
PFM will remain for some long-span prostheses, precision
attachment placement, and other uses. Unfortunately, cast-gold
alloy will continue to die a natural death due to cost of material,
patient demand for tooth-colored restorations, and lack of dentists
promoting it. (I continue to prefer gold alloy in the locations I have
noted in the article.)
Gordon Christensen, DDS, MSD, PhD, is a practicing
prosthodontist in Provo, Utah. He is the founder and director of
Practical Clinical Courses, an international continuing-education
organization initiated in 1981 for dental professionals. Dr.
Christensen is a cofounder (with his wife, Dr. Rella Christensen)
and CEO of CLINICIANS REPORT (formerly Clinical Research
Associates).
In this monthly feature, Dr. Gordon Christensen addresses the
most frequently asked questions from Dental Economics®
readers. If you would like to submit a question to Dr. Christensen,
please send an email to info@pccdental.com.
Additional educational information for you
We have significant additional information for you on this
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• Affordable Treatment of Complex Rehabilitative Needs (Item
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• Zirconia and Lithium Disilicate Restorations – Clinical
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• How to Repair and Maintain Fixed Restorations (Item V1961)
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