CLINICAL RESEARCH

Long-term results of a randomized clinical trial of 2 types of

ceramic crowns in participants with extensive tooth wear
Wedad Hammoudi, DDS, PhD,a Mats Trulsson, DDS, PhD,b Peter Svensson, DDS, PhD, Dr Odont,c and
Jan-Ivan Smedberg, DDS, PhDd

Tooth wear, the irreversible ABSTRACT

noncarious loss of dental hard
Statement of problem. Evidence is sparse regarding the long-term outcomes of restorative
tissue from tooth-to-tooth treatment of patients with extensive tooth wear.
contact (attrition), dissolution
Purpose. The purpose of this long-term prospective randomized clinical trial was to evaluate the
by acidic substances (erosion),
performance and success rate of pressed lithium disilicate (LD) and translucent zirconia (TZ)
and/or interaction with other crowns in participants with extensive tooth wear.
materials (abrasion),1 is com-
mon and its prevalence in- Material and methods. A total of 62 participants with extensive tooth wear (17 women, 45 men;
mean age 44.8 years; range 25-63 years) received a total of 713 crowns, LD=362 and TZ=351. Both
creases with age.2,3 Individuals
types of crowns had chamfer preparations and were adhesively luted with dual-polymerizing
with tooth wear often composite resin cement (PANAVIA F 2.0; Kuraray Noritake Dental Inc). The restorations were
complain of tooth hypersensi- clinically reevaluated on average 14, 31, 39, 54, and 65 months after insertion of the crowns
tivity, dental pain, poor es- according to the modified United States Public Health Service (USPHS) criteria.
thetics, and/or impairment of Results. After an observation period of up to 6 years, the survival rate for both types of crowns was
mastication,4-6 which may 99.7%, with 1 lost LD crown after 1 year as a result of loss of retention and 1 lost TZ crown after 3
reduce their quality of life.7 years because of tooth fracture at the cemento-enamel junction. The success rates were similar for
Preventive measures and ar- both types of crowns: 98.6% for LD and 99.1% for TZ. Reasons for failures were that 3 participants in
rangements for counseling and each group developed apical lesions, minimal ceramic fractures, or their crowns were rebonded
the monitoring of tooth wear after loss of adhesion. Assessment of color at baseline was significantly different with a better
must be put in place before match for LD (84.8% Alfa, 15.2% Bravo) than for TZ crowns (36.5% Alfa, 63.5% Bravo), including
TZ crowns with veneered porcelain (P<.001). Secondary caries and cracks did not occur. A post
beginning any restoration
hoc analysis of clinical performance did not indicate any significant differences between
process.8,9 Whenever possible, extensive tooth wear with primarily mechanical or chemical factors.
worn dentition should be
Conclusions. No differences were found between the 2 types of ceramic materials concerning the
treated with a reversible, ad-
long-term success and clinical performance, except that TZ crowns were rated by a blinded clinician
hesive, additive approach.10 as less esthetic than LD crowns. The use of high-strength ceramic materials, as well as reliable
However, patients often seek adhesive bonding, are probably the key factors in the long-term success of ceramic crowns in
treatment when tooth wear is participants with extensive tooth wear independent of the specific etiology. (J Prosthet Dent
well advanced,11 and, in 2022;127:248-57)

a
Assistant professor, Department of Dental Medicine, Karolinska Institutet, Huddinge, Sweden; and Specialist in Dental Prosthetics, Department of Prosthetic Dentistry,
Folktandvården Eastmaninstitutet, Stockholm, Sweden.
b
Professor and Head, Specialist in Dental Prosthetics, Division of Oral Diagnosis and Rehabilitation, Department of Dental Medicine, Karolinska Institutet, Huddinge,
Sweden; and Professor, Scandinavian Centre for Orofacial Neuroscience (SCON), Huddinge, Sweden.
c
Professor and Head, Section of Orofacial Pain and Jaw Function, Department of Dentistry and Oral Health, Aarhus university, Aarhus, Denmark; and Professor, Faculty of
Odontology, Malmö University, Malmö, Sweden; and Professor, Scandinavian Centre for Orofacial Neuroscience (SCON), Huddinge, Sweden.
d
Associate professor, Department of Dental Medicine, Karolinska Institutet, Huddinge, Sweden; and Specialist in Dental Prosthetics, Department of Prosthetic Dentistry,
Folktandvården Eastmaninstitutet, Stockholm, Sweden.

248 THE JOURNAL OF PROSTHETIC DENTISTRY

February 2022 249

It was registered at www.controlled-trials.com:

Clinical Implications ISRCTN16324420 and performed according to the
Existing recommendations regarding the restorative Declaration of Helsinki, as well as approved by the
appropriate Swedish ethical committee (registration
treatment of participants with extensive tooth wear
number: 2012/263-31/2). All participants provided writ-
have been based on in vitro or case series studies,
ten informed consent before inclusion. A total of 132
clinical experience, and the opinions of authorities.
individuals with extensive tooth wear were screened and
The results obtained from the current randomized
recruited. The majority of them, 125 participants (17-65
controlled trial provided an evidence-based tool for
years of age), had been characterized previously with
the prosthetic management of patients with
respect to the presumed etiology of the tooth wear.26,27
extensive tooth wear and suggested similar
performance for LD and TZ crowns, with better In those studies, cluster analysis based on various de-
mographic and self-reported information, clinical find-
esthetics for the LD crowns.
ings, and salivary and electromyographic measurements
were used to divide these participants into 2 relatively
well-defined chemical and mechanical clusters, albeit
certain situations, prosthetic rehabilitation may be indi-
with substantial overlap.26,27
cated. The multifactorial decisions concerning the man-
The inclusion criteria were the presence of at least 10
agement of severe tooth wear should be based on its
teeth in the maxillary and mandibular arches and tooth
severity, as well as the patient’s wishes,12 but the
wear >grade 2 on any surface of at least 4 teeth in the
outcome is often not predictable because of the limited
same arch, according to the Smith and Knight tooth wear
tooth substance remaining and the impact of continued
index.28 While primary assessment of the degree of tooth
chemical and mechanical insults on the durability of the
wear was visually made by 1 examiner (W.H.) with the
restoration.7,13,14 As the use of composite resin restora-
participants seated in a dental chair, final assessment was
tions may lead to fracture and increased long-term
performed later by 2 experienced examiners (W.H., J.-
costs,15,16 complete crowns remain an important alter-
I.S.) from standardized intraoral photographs and diag-
native,15 and metal-ceramic restorations have been
nostic casts. Teeth with >grade 2 on any scorable surface
considered the standard treatment for crowns and fixed
were recorded and given only 1 score, regardless of the
partial dentures.17 The disadvantages of metal-ceramic
number of worn surfaces. Criteria for exclusion were the
restorations include the grayish discoloration at the
presence of fixed and removable partial dentures;
gingival margin,18 and high-strength ceramic materials
mineralization disorders; significant malocclusion (severe
such as lithium disilicate and zirconia have become
Angle Class II or III); pain on palpation of the tempo-
popular because of their appearance and biocompati-
romandibular joint; facial and widespread pain, neuro-
bility.19-22 In comparison with multilayer restorations,
logical, psychiatric, or sleep disorders; and a pacemaker.
monolithic restorations are thinner, require less tooth
Before prosthetic rehabilitation, all demonstrated a low
reduction,23 and are not subject to the chipping of a
risk for caries, good oral hygiene, and periodontal pocket
veneered ceramic.24
depth 4 mm without bleeding on probing. Altogether,
Evidence regarding the long-term outcomes of the
68 individuals were excluded, and the remaining 64 un-
restorative treatment of individuals with extensive tooth
derwent prosthetic rehabilitation (Table 1) (Fig. 1). Par-
wear is sparse, and the present recommendations have
ticipants answered 4 questions concerning whether they
been based mainly on clinical experience and the opin-
were seeking treatment for problems with esthetics,
ions of authorities.25 The present randomized clinical trial
mastication, tooth hypersensitivity, and/or worry about
compared the clinical performance and longevity of
the progression of their tooth wear. Restorative man-
crowns made of 2 ceramic materials, pressed lithium
agement was only indicated when the patient had at least
disilicate (IPS e.max-Press; Ivoclar Vivadent AG) and
1 of the following: unacceptable esthetics, mechanically
translucent zirconia (BruxZir Solid Zirconia [3Y-TZP];
weakened teeth, occlusion significantly adversely
Glidewell Laboratories) for the reconstruction of exten-
affected, or hypersensitivity that could not be addressed
sively worn dentitions. The null hypothesis was that no
by other treatments.
difference would be found between the 2 ceramic
The study was designed as a traditional randomized
restoration types.
trial, and a total of 64 participants were divided into 2
groups on the basis of a randomization list (www.
MATERIAL AND METHODS
randomization.com) (Fig. 1). One group received lithium
This was a single-center, double-blind, randomized disilicate crowns (LD) (IPS e.max-Press; Ivoclar Vivadent
controlled trial conducted from 2012 to 2018 at Folk- AG) and the other translucent zirconia crowns (TZ)
tandvården, St Eriks Hospital and Eastmaninstitutet, (BruxZir Solid Zirconia (3Y-TZP); Glidewell Laboratories).
Department of Prosthetic Dentistry, Stockholm, Sweden. Since it may be of clinical relevance to compare those with

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Table 1. Sex, age, number of maxillary and mandibular teeth, number of restorations, necessary adjustments were performed on
maxillary and mandibular teeth with tooth wear >grade 2 in study the interim restorations before the definitive restorations
population and 2 participant groups who received lithium disilicate (LD) were made. For most participants, a second visit was
and translucent zirconia (TZ)
required to refine the preparations. Impressions of the
Participants Participants
Total With LD With TZ prepared teeth were made in polyether materials (Per-
Number of participants 64 32 32 madyne Garant 2 and Impregum Penta; 3M ESPE), and
Sex all the crowns were fabricated at the same dental labo-
Number of women 19 ±29.7% 10 ±31.2% 9 ±28.1% ratory by 5 dental laboratory technicians. The color for
Number of men 45 ±70.3% 22 ±68.8% 23 ±71.9% the restorations was selected in consultation with the
Age (y) 44.8 ±9.1, 25-63 43.0 ±8.6, 25-62 46.6 ±9.6, 29-63 dental laboratory technicians. However, an indication of
Number of teeth the ceramic material to be used was avoided, since the
Maxillary 858 429 429 participants were blinded in this respect.
13.4 ±0.9, 10-14 13.4 ±1.0, 10-14 !3.4 ±0.9, 11-14
The crowns were clinically evaluated for occlusion and
Mandibular 868 438 430
13.6 ±0.8, 10-14 13.7 ±0.5, 12-14 13.4 ±1.0, 10-14 articulation, minor corrections were made chairside, and
Number of teeth a new occlusal registration was obtained before returning
with tooth wear >grade 2 the crowns to the dental laboratory for characterization
Maxillary 627 318 309
9.8 ±2.8, 4-14 9.9 ±2.7, 4-14 9.7 ±2.9, 4-14
and the application of a ceramic glaze. Although the
Mandibular 462 214 248 majority of the 351 TZ crowns were monolithic,
7.2 ±4.1, 0-14 6.7 ±4.1, 0-14 7.8 ±4.2, 0-14 approximately 85 had a 0.3-mm to 0.8-mm facial veneer
Mean ±standard deviation, range. for improved esthetics. The intaglio surfaces of the LD
crowns were etched with 4.5% hydrofluoric acid (IPS
either more chemical or mechanical risk factors, it was Ceramic Etching Gel; Ivoclar Vivadent AG) for 20 sec-
decided post hoc to present the results both for the 2 onds, and the TZ crowns were airborne-particle abraded
different risk factors26,27 and for the 2 different ceramics. As with 110-mm aluminum oxide at 0.2 MPa for 10 seconds.
illustrated in Table 2, the 11 participants who did not The ceramic crowns were cemented with 10-
belong to either of these clusters (3 participants excluded methacryloyloxydecyl dihydrogen phosphateebased
from clustering because of incomplete data and 7 who did self-etching adhesive cement (Panavia F2.0; Kuraray
not participate in the previous studies) were allocated ac- Noritake Dental Inc), and the same cementation protocol
cording to the most significant factors in the cluster anal- was used for both LD and TZ crowns. Static and dynamic
ysis in combination with the most significant clinical occlusion were evaluated, and approximately 10 crowns
features of the mechanical cluster. were adjusted and repolished with ceramic silicone pol-
Preprosthetic treatment, including crown lengthening ishers (DIAPOL RA; EVE Ernst Vetter GmbH). To
and endodontic and orthodontic treatments, was per- accommodate the involvement of participants in other
formed when indicated. As a standard procedure, each studies, as well as to maintain blinding, 58 participants
participant’s diagnostic casts were mounted in centric were treated by 1 prosthodontist (W.H.) and the
relation in a semiadjustable articulator, and a diagnostic remaining 4 by 2 calibrated dentists. Baseline and follow-
waxing fabricated to attain the prescribed occlusal and up examinations were performed between August 2013
esthetic goals. The vertical dimension was increased only and December 2019. The clinical performance and suc-
when needed to create sufficient space for the restora- cess rate of the crowns were assessed in accordance with
tions. In participants with localized tooth wear, space for the modified United States Public Health Service
the restorations was created by using the Dahl concept29 (USPHS) criteria30 (Table 3) by an independent blinded
with interim appliances and/or adjustment of antagonist examiner (J.-I.S.) using a dental mirror and explorer (LM
teeth (enameloplasty). 17-23 SI; LM-Dental) at baseline and on average 14, 31,
During preparation, removal of tooth tissue was 39, 54, and 65 months after insertion of the crowns.
minimal, and a chamfer finish line of at least 1 mm wide Absolute failure, defined as clinically unacceptable
and a 4.0-mm preparation height were ensured. While loss of a crown which required replacement of the
attempts were made to maintain a consistent material restoration, was used for the survival rate. Relative fail-
thickness of at least 1 mm, the dental laboratory tech- ures, defined as endodontic complications, minimal
nician was authorized to reduce this to 0.6 mm in ceramic fractures which were clinically acceptable, and/or
localized areas in some crowns. Laboratory fabricated adhesion loss of a restoration that could be successfully
polymethyl methacrylate interim restorations (SR Ivoc- recemented, were included in the success rate. The
ron; Ivoclar Vivadent AG) were placed after tooth prep- modified USPHS criteria were tabulated with a statistical
aration and used to identify the ideal proportions of tooth software program (IBM SPSS Statistics, v22; IBM Corp)
height and width, as well as to allow feedback from the and a spreadsheet (Excel 2016; Microsoft Corp). The Chi
participants. To avoid major corrections of the definitive square test was used to compare the USPHS criteria

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Enrollment Assessed for eligibility (n=132)

Excluded (n= 68)

• Financial reasons (n=37)

• Lack indication for prosthetic treatment (n=17)
• Did not want to wait (n=10)
• Moved to another city (n=4)

Randomized (n=64)

Allocation
Allocated to intervention LD (n=32) Allocated to intervention TZ (n=32)

• Received allocated intervention (n=32) • Received allocated intervention (n=31)

• Did not receive allocated intervention (n=0) • Did not receive allocated intervention (n=1)
Difficult to work with cutback technique in
the lower incisors

Follow-Up

• Lost to follow-up (n=0) • Lost to follow-up (n=0)

• Discontinued intervention (n=0) • Discontinued intervention (n=1)
Patient not satisfied with esthetics despite
many adjustments

Analysis

Analyzed (n=32) Analyzed (n=30)

• Excluded from analysis (n=0) • Excluded from analysis (n=0)

Figure 1. Study flow chart. LD, lithium disilicate (IPS e. maxddPress; Ivoclar Vivadent AG); TZ, translucent zirconia (BruxZir; Glidewell Laboratories).

regarding the 2 crown types and the 2 different etiology after mean follow-up periods of 14, 31, 39, 54, and 65
clusters (a=.05). months. At present, all participants are still enrolled in the
study, and most of them attended the first recall (12-24
months). Since the crowns were inserted over a period of
RESULTS
more than 5 years, some restorations have not yet received
Among the 64 participants shown in Table 1, 2 women the second, third, fourth, and fifth recalls. In addition, some
assigned to the TZ group were excluded, giving a final participants could not attend the follow-up visits as
number of 62 (LD group=32, TZ group=30) (Fig. 1). The scheduled and showed up later. After observation for up to 6
first was excluded because her small-sized mandibular years, the survival rate for both types of crowns was 99.7%.
incisors did not permit facial porcelain veneering of TZ One LD crown lost retention after 1 year (this tooth received
and she received LD crowns instead. The second was a new crown), and 1 TZ crown was associated with tooth
excluded because of her high esthetic demands. The total fracture at the cemento-enamel junction after 3 years. The
number of maxillary and mandibular crowns inserted was success rates were 98.6% for LD and 99.1% for TZ. The
713 (LD=362, TZ=351), and the distribution of these failure experienced by 3 participants in each group was
crowns is shown in Figure 2. While the total number of because of the development of apical lesions, minimal
anterior crowns including the central incisors, lateral in- ceramic fractures, or loss of crown adhesion requiring
cisors, and canines was 342 crowns (maxillary=295, rebonding. At baseline, the color match with the LD crowns
mandibular=47), the number of posterior crowns (84.8% Alfa, 15.2% Bravo) was significantly better than with
including premolars and molars was 371 crowns (maxil- the TZ crowns, including those with facial veneers (36.5%
lary=197, mandibular=174). Figure 3 shows a represen- Alfa, 63.5% Bravo) (P<.001). Secondary caries and cracks
tative participant who received LD crowns, and Figure 4 did not occur.
shows a participant with TZ crowns. Table 5 depicts the same evaluation of crowns at the
Table 4 documents the restorations performed and same follow-up periods with respect to the chemical and
clinical evaluation of the 2 types of ceramic crowns ac- mechanical clusters. After observation for up to 6 years,
cording to the modified USPHS criteria shown in Table 3 the survival rate for the chemical cluster was 99.8% (1

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Table 2. Cut-off criteria used to determine cluster membership for 11 Table 3. Modified United States Public Health Service criteria for clinical
participants not clustered in previous study evaluation of restorations
Participants Cluster Characteristics Rating Criteria
ID Criteria 1 Criteria 2 Criteria 3 Criteria 4 Membership Secondary Alfa No evidence of caries at the margin of the
1 d d d d C caries restoration
2 X d d d M Bravo Caries evident at the margin of the
3 X d d d M restoration

4 X X d X M Marginal Alfa No probe catch

adaptation Bravo Slight probe catch but no gap
5 d d d d C
6 X X d X M Charlie Gap with some dentin or cement
exposure, new restoration is needed
7 X X d d M
Marginal Alfa No discoloration at the margin of the
8 X X d X M discoloration restoration
9 d d d d C Bravo Slight discoloration at the margin of the
10 d X d X M restoration, does not penetrate in pulpal
direction
11 d d d d C
Charlie Discoloration penetrated in pulpal
C, chemical cluster; M, mechanical cluster. Criteria 1=self-reports of sleep bruxism, direction, new restoration is needed
Criteria 2=self-reports of day bruxism, Criteria 3=heavy sport exercises, Criteria 4=similar
Color match Alfa No mismatch in color, shade and/or
degrees of occlusal/incisal wear in both arches.
translucency between restoration and
adjacent teeth or a natural tooth
Bravo Mismatch in color, shade and/or
crown lost adhesion after 1 year and was replaced) and translucency between restoration and
99.7% for the mechanical cluster (1 crown was associated adjacent teeth or a natural tooth, within
the normal range of color, shade and/or
with tooth fracture at the cemento-enamel junction after translucency (<1 shade off, Vita shade
3 years). The success rate for both clusters was 99.7%. guide)
The 3 failures in the chemical cluster were because of the Charlie Mismatch in color, shade and/or
translucency between restoration and
development of apical lesions in 4 teeth, minimal ceramic adjacent teeth or a natural tooth, outside
fractures, and loss of adhesion and rebonding of 2 the normal range of color, shade and/or
translucency (>1 shade off, Vita shade
crowns. Failure in the mechanical cluster was attributed guide)
to ceramic cohesive fracture in 1 crown. At baseline, the Anatomic form Alfa Ideal anatomic shape and surface details
marginal adaptation for the crowns in the chemical Bravo Slightly overcontoured or
cluster was better (98.1% Alfa, 1.9% Bravo) than in the undercontoured/or lack of surface details,
within the normal range
mechanical cluster (94.9% Alfa, 5.1% Bravo) (P=.016). Charlie Highly overcontoured or undercontoured/
Also, at baseline, the anatomic form of the crowns in the or lack of surface details, outside the
chemical cluster (91.4% Alfa, 8.6% Bravo) was better normal range, new restoration is needed
Fracture of the None No loss of the restoration as a result of
than in the mechanical cluster (56.8% Alfa, 43.2% Bravo) tooth tooth fracture
(P<.001). However, at the 1-year follow-up, when most At or above Restoration still adhere to the tooth but is
participants showed up, the results in this respect were cemento-enamel lost as a result of tooth fracture at or above
junction the cemento-enamel junction
the opposite (95.5% Alfa, 4.5% Bravo for the mechanical
cluster versus 83.6% Alfa, 16.4% Bravo for the chemical
cluster, P<.001).
promising survival rates of 99.7%. Bulk fracture did not
In addition to these crowns, participants received a
occur, even though several of the inserted ceramic res-
number of other prosthetic restorations, including 38
torations were only 1-mm thick (some areas in some
ceramic crowns on endodontically treated teeth; 2 metal-
crowns were only 0.6 mm thick). Thus, for patients with
ceramic crowns; 14 fixed dental prostheses; 20 onlays and
extensive tooth wear with little remaining tooth tissue,
veneers; 2 gold post-and-cores; 30 single implant-
insertion of less invasive high-strength ceramic crowns
supported crown, and 3 implant-supported fixed pros-
with resin cements appears to be beneficial. However, TZ
theses. Excluding third molars, there were 823 occluding
crowns, including those with veneered porcelain, were
pairs of teeth and restorations (mean=13.3, standard
rated by a blinded examiner as less esthetic than LD
deviation=1.1, range=10-14). Most of the participants
crowns (P<.001). Based on these results, the null hy-
were seeking prosthetic rehabilitation primarily for
pothesis was partially rejected.
esthetic reasons (83.9%), followed by concern about the
In other studies of this nature and especially when
progression of wear (59.7%), tooth hypersensitivity
examining ceramic restorations, individuals with pre-
(38.7%), and problems with mastication (24.2%).
sumed mechanical risk factors such as bruxism or
engaged in vigorous labor or exercise are often excluded,
DISCUSSION
as bruxism is considered a potential cause of early
During the 6-year observation period, the use of both LD restoration fracture.13,14 Furthermore, the strength of the
and TZ crowns to restore extensive tooth wear showed TZ is brand dependent and has been reported to be half

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35

30
Number of Teeth Restored

25

20

15

10

0
17 16 15 14 13 12 11 21 22 23 24 25 26 27

47 46 45 44 43 42 41 31 32 33 34 35 36 37
0
Number of Teeth Restored

10

15

20

25
TZ LD

Figure 2. Distribution of delivered maxillary and mandibular crowns in study population. LD, lithium disilicate (IPS e. max-Press; Ivoclar Vivadent AG);
TZ, translucent zirconia (BruxZir; Glidewell Laboratories).

of a conventional opaque zirconia and 3 times more than involving shorter follow-up of direct composite resin
veneering material.19,31 The flexural strength of TZ is restorations in participants with tooth wear with different
claimed to be two-thirds greater than that of LD and its etiologies.33
fracture resistance is also higher than that of both LD and The differences at baseline between the crowns in the
porcelain-veneered restorations.32 In the present ran- 2 clusters with respect to marginal adaptation and
domized clinical trial, confounding bias was minimized anatomic form may reflect the fact that the crowns in the
by the knowledge of the presumed chemical and me- mechanical cluster were fabricated according to the rec-
chanical risk factors for the participants.26,27 The present ommendations of Beyron, a Swedish prosthodontist, as
results demonstrated that patients with extensive tooth relatively bulky with wide occluding surfaces. Such a
wear may be treated with adhesively luted high-strength design may result in an axial load, both during occlusion
ceramic crowns, regardless of the etiology of the wear. and sliding movements.34 Although it is possible that the
The 11 participants who were classified based on cut-off assessor’s preference for the Beyron criteria may have
criteria did not have significant influence on the results influenced the evaluation, the lack of any other difference
either. Similar results were reported from a study between the 2 ceramic materials (Table 4) indicates that

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Figure 3. Representative participant: 52-year-old woman with previous history of gastric reflux and acidic diet consumption including 1 liter of
carbonated drinks per day under 17 years. She had extensive tooth wear in majority of maxillary teeth and mandibular posterior teeth (A.1-4). Her
mandibular anterior teeth bleached with 10 % carbamide peroxide before prosthetic restoration. She received monolithic lithium disilicate crowns on
teeth starting from right maxillary second molar to left first premolar; left maxillary second molar; left mandibular second molar; teeth from right
mandibular second premolar to second molar as well as a metal-ceramic fixed partial denture between left mandibular first molar and first premolar
(B.1-4) (69 months after delivery).

Figure 4. Representative participant: 63-year-old man with history of hypertension, stroke, and gastric reflux. He was medicated with antihypertensive
and anticoagulant medications in addition to proton pump inhibitors. He had generalized extensive tooth wear, history of continually failed and
discolored composite resin restorations, as well as food impaction (A.1-4). His composite resin restorations required continuous repair and constant
review which provoked increased long-term costs. He received monolithic translucent zirconia crowns on maxillary and mandibular teeth from left
second molars to right second molars (B.1-4) (63 months after delivery).

this was not a major source of bias. Moreover, the To avoid the evaluation bias associated with other
excellent survival rate achieved here might be, at least in studies on this topic, both the examiner and participants
part, because the participants had a sufficient number of were blinded to the type of the ceramic material used. It
occluding pairs of teeth and/or restorations, which pro- would have been preferable to have 2 independent ex-
vided an even distribution of forces and occlusal har- aminers, but the large number of participants and res-
mony. The participants were also provided with torations made this impractical. Furthermore, owing to
additional prosthetic restorations other than the ceramic the differences in the position of the worn teeth within
crowns presented in Tables 4 and 5. Nevertheless, in the dental arch, the type of the occlusal relationship, and
order to assess the role of occlusion, the number of the quality of the remaining tooth tissue, standardization
occlusal contacts and other occlusal parameters should be difficulties were encountered.
considered in dental indices used for assessment of the Esthetic concerns appear to be the most common
long-term success of different prosthetic materials and complaint for individuals exhibiting tooth wear from the
restoration designs. reasons given by the current participants, as well as

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Table 4. Modified United States Public Health Service criteria and clinical evaluation of 2 types of ceramic crowns after mean follow-up period of 14, 31,
39, 54, and 65 months

Recall Time (mo)

Min-Max 12-24 25-36 37-48 49-60 61-72
Mean Baseline 14 31 39 54 65
No. of participants 62 59 23 25 20 9
Total no. of crowns 713 683 277 292 234 87
(no. of E - no. of B) LD=362 LD=352 LD=157 LD=163 LD=142 LD=67
TZ=351 TZ=331 TZ=120 TZ=129 TZ=92 TZ=20
USPHS-criteria
Secondary caries
Alfa d d d d d d d d d d d d
Bravo d d d d d d d d d d d d
Marginal adaptation
Alfa 352 338 343 318 156 116 160 124 137 86 63 19 (95%)
(97.2%) (96.3%) (97.4%) (96.1%) (99.4%) (96.7%) (98.2%) (96.1%) (96.5%) (93.5%) (94.0%)
Bravo 10 (2.8%) 13 (3.7%) 9 (2.6%) 13 (3.9%) 1 (0.6%) 4 (3.3%) 3 (1.8%) 5 (3.9%) 5 (3.5%) 6 (6.5%) 4 (6.0%) 1 (5%)
Charlie d d d d d d d d d d d d
Marginal discoloration
Alfa 362 351 335 314 143 118 155 127 123 92 55 19 (95%)
(95.2%) (94.9%) (91.1%) (98.3%) (95.1%) (98.4%) (86.6%) (100%) (82.1%)
Bravo d d 17 (4.8%) 17 (5.1%) 14 (8.9%) 2 (1.7%) 8 (4.9%) 2 (1.6%) 19 0 12 1 (5%)
(13.4%) (17.9%)
Charlie d d d d d d d d d d d d
Color match
Alfa 307 128 301 102 123 22 130 38 126 7 (7.6%) 57 10 (50%)
(84.8%) (36.5%) (85.5%) (30.8%) (78.3%) (18.3%) (79.8%) (29.5%) (88.7%) (85.1%)
Bravo 55 223 51 229 34 98 33 91 16 85 10 10 (50%)
(15.2%) (63.5%) (14.5%) (69.2%) (21.7%) (81.7%) (20.2%) (70.5%) (11.3%) (92.4%) (14.9%)
Charlie d d d d d d d d d d d d
Anatomic form
Alfa 330 319 313 293 156 107 142 119 130 78 56 20
(91.2%) (90.9%) (88.9%) (88.5%) (99.4%) (89.2%) (87.1%) (92.2%) (91.5%) (84.8%) (83.6%) (100%)
Bravo 32 (8.8%) 32 (9.1%) 39 38 1 (0.6%) 13 21 10 (7.8%) 12 (8.5%) 14 11 0 (0%)
(11.1%) (11.5%) (10.8%) (12.9%) (15.2%) (16.4%)
Charlie d d d d d d d d d d d d
Endodontic complications
Apical lesion d d 2 (0.8%) d 2 (1.3%) d d d d d d d
Percusion +ve d d d d d d d d d d d d
Crack
None d d d d d d d d d d d d
Minimal/acceptable d d d d d d d d d d d d
Large/unacceptable d d d d d d d d d d d d
Fracture
None d d d d d d d d d d d d
Minimal/acceptable d d d d d 1 (0.8%) 1 (0.6%) d d d d d
Large/unacceptable d d d d d d d d d d d d
Retention of the crown
Bonded d d d d d d d d d d d d
Rebonded d d d d d d d 1 (0.8%) d 1 (1.1%) d d
Lost d d d d 1 (0.6%) d d d d d d d
Fracture of the tooth
None d d d d d d d d d d d d
At or above cementodenamel d d d d d d d 1 (0.9%) d d d d
junction

LD, lithium disilicate (IPS e. max-Press; Ivoclar Vivadent AG), TZ, Translucent zirconia (BruxZir; Glidewell Laboratories). Number of participants and crowns.

those in other studies.35,36 In the current study, all par- teeth. This probably affected the examiner assessment
ticipants had the opportunity to discuss and select a and current results of the USPHS criteria regarding the
shade, often choosing a lighter shade than their own color match. Moreover, in a recent in vitro comparison of

Hammoudi et al THE JOURNAL OF PROSTHETIC DENTISTRY

256 Volume 127 Issue 2

Table 5. Modified United States Public Health Service criteria and clinical evaluation of ceramic crowns in chemical and mechanical clusters after mean
follow-up periods of 14, 31, 39, 54, and 65 months
Recall Time (mo)
Min-Max 12-24 25-36 37-48 49-60 61-72
Mean Baseline 14 31 39 54 65
No. of participants 62 59 23 25 20 9
Total no. of crowns 713 683 277 292 234 87
C=421 C=391 C=179 C=177 C=148 C=87
M=292 M=292 M=98 M=115 M=86 M=0
USPHS-criteria
Secondary caries
Alfa d d d d d d d d d d d d
Bravo d d d d d d d d d d d d
Marginal adaptation
Alfa 413 277 378 283 177 95 171 113 146 77 82 d
(98.1%) (94.9%) (96.7%) (96.9%) (98.9%) (96.9%) (96.6%) (98.3%) (98.6%) (89.5%) (94.3%)
Bravo 8 (1.9%) 15 (5.1%) 13 (3.3%) 9 (3.1%) 2 (1.1%) 3 (3.1%) 6 (3.4%) 2 (1.7%) 2 (1.4%) 9 (10.5%) 5 (5.7%) d
Charlie d d d d d d d d d d d d
Marginal discoloration
Alfa 421 292 384 265 164 97 170 112 147 73 74 d
(100%) (100%) (98.2%) (90.8%) (91.6%) (99.0%) (96.0%) (97.4%) (99.3%) (84.9%) (85.1%)
Bravo d d 7 (1.8%) 27 (9.2%) 15 (8.4%) 1 (1.0%) 7 (4.0%) 3 (2.6%) 1 (1.0%) 13 13 d
(15.1%) (14.9%)
Charlie d d d d d d d d d d d d
Color match
Alfa 269 166 230 173 102 43 90 (50.8%) 78 (67.8%) 90 (60.8%) 43 (50%) 67 d
(63.9%) (56.8%) (58.8%) (59.2%) (57.0%) (43.9%) (77.0%)
Bravo 152 126 161 119 77 (43.0%) 55 87 (49.2%) 37 (32.2%) 58 (39.2%) 43 (50%) 20 d
(36.1%) (43.2%) (41.2%) (40.8%) (56.1%) (23.0%)
Charlie d d d d d d d d d d d d
Anatomic form
Alfa 385 166 327 279 165 98 158 103 123 85 76 d
(91.4%) (56.8%) (83.6%) (95.5%) (92.2%) (100%) (89.3%) (89.6%) (83.1%) (98.8%) (87.4%)
Bravo 36 (8.6%) 126 64 (16.4%) 13 (4.5%) 14 (7.8%) 0 (0%) 19 (10.7%) 12 (10.4%) 25 (16.9%) 1 (1.2%) 11 d
(43.2%) (12.6%)
Charlie d d d d d d d d d d d d
Endodontic complications
Apical lesion d d 2 (0.5%) d 2 (1.1%) d d d d d d d
Percusion +ve d d d d d d d d d d d d
Crack
None d d d d d d d d d d d d
Minimal/acceptable d d d d d d d d d d d d
Large/unacceptable d d d d d d d d d d d d
Fracture of the crown
None d d d d d d d d d d d d
Minimal/acceptable d d d d d 1 (1.0%) 1 (0.6%) d d d d d
Large/unacceptable d d d d d d d d d d d d
Retention of the crown
Bonded d d d d d d d d d d d d
Rebonded d d d d d d 1 (0.6%) d 1 (0.7%) d d d
Lost d d d d 1 (0.6%) d d d d d d d
Fracture of the tooth
None d d d d d d d d d d d d
At or above cemento-enamel d d d d d d d 1 (0.9%) d d d d
junction

C, chemical cluster; M, mechanical cluster. Number of participants and crowns.

1-mm-thick restorations, LD was found to be signifi- contemporary high-strength ceramics and the assess-
cantly more translucent than 5 types of monolithic zir- ment of participant satisfaction with appearance and the
conias.37 Future studies on individuals with tooth wear impact of the prosthetic treatment on the quality of life
regarding the clinical performance of other are indicated.

THE JOURNAL OF PROSTHETIC DENTISTRY Hammoudi et al

February 2022 257

CONCLUSIONS 19. Denry I, Kelly JR. State of the art of zirconia for dental applications. Dent
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always the restoration of choice? Dent Clin North Am 1992;36:765-82. https://doi.org/10.1016/j.prosdent.2020.08.041

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