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Is the rush to all-ceramic crowns justified?
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Is the rush to all-ceramic crowns justified? Gordon J. Christensen JADA 2014;145(2):192-194 10.14219/jada.2013.19 The following resources related to this article are available online at jada.ada.org (this information is current as of June 28, 2014): Updated information and services including high-resolution figures, can be found in the online version of this article at: http://jada.ada.org/content/145/2/192
This article cites 40 articles, 4 of which can be accessed free: http://jada.ada.org/content/145/2/192/#BIBL Information about obtaining reprints of this article or about permission to reproduce this article in whole or in part can be found at: http://www.ada.org/990.aspx
Copyright © 2014 American Dental Association. All rights reserved. Reproduction or republication strictly prohibited without prior written permission of the American Dental Association.
Downloaded from jada.ada.org on June 28, 2014
Features
OBSERVATIONS
Is the rush to all-ceramic crowns justified? Gordon J. Christensen, DDS, MSD, PhD
T
here have been numerous obvious and unprecedented changes in the dental laboratory profession over the last several years. One of the most rapid changes has been the movement from handcrafted porcelainfused-to-metal (PFM) crowns and fixed prostheses to milled ceramic restorations. It is estimated that currently at least one-half of U.S. dental laboratories are providing in-house or outsourced milled crowns and fixed prostheses (B. Napier, chief staff executive, National Association of Dental Laboratories, written communication, Oct. 8, 2013). The most popular type of crown is ceramic without any metal substructure. The table provides comparative data for the years 2007 and 2013 as recorded for roughly 1 million units of crowns and fixed prostheses in the United States (J. Shuck, vice president for sales and marketing, Glidewell Dental Laboratories, written communication, Oct. 7, 2013). The most popular types of ceramic crowns in 2013, as recorded by Glidewell, were full-zirconia, zirconia-based (zirconia coping with ceramic fired or pressed on as a laminate) and lithium disilicate (IPS e.max, Ivoclar Vivadent, Amherst, N.Y.). For this article, I use the phrase “ceramic crowns” to indicate
these three types, although several other types still are available. Other ceramic crowns constituted only a small percentage of the market in comparison with the three major types. The change from PFM to allceramic crowns over the past several years has been one of the fastest and most significant paradigm changes in the history of dentistry. In my opinion, some of the factors stimulating this shift have been dpublic demand for tooth-colored crowns; dobserved success of the current generation of all-ceramic crowns; dthe reduced laboratory costs for dentists for all-ceramic crowns; dthe high cost of metals used in PFM crowns, which motivate dentists to prescribe nonmetal crowns; dease of milling all-ceramic crowns when compared with fabricating PFM crowns; drapid growth and success of milling technology; dlaboratory acceptance of milling as state of the art. Factors IN a comparison of porcelain-fused-tometal and all-ceramic restoration characteristics
The following narrative includes my own observations and opinions as I see the rapid change to allceramic restorations. These thoughts are based on my discussions with
thousands of dentists and laboratory technicians about the clinical success and failure of the various types of restorations. The statements below are common knowledge among practitioners and allow a comparison of the newer materials with the known characteristics of PFM. PFM. Positive characteristics. PFM restorations offer several benefits: da history of success in most appropriate clinical situations in more than 50 years of service; dproven adequate strength for most situations; dpredictability and known statistics relative to restoration success and failure; drelatively good esthetic characteristics; drelative ease of use for dentists; dthe opportunity to use precision attachments and stress breakers; dpredictable and proven long-span use; dease of removal when necessary. Negative characteristics. PFM restorations also have some drawbacks: dwear on opposing teeth caused by many veneering ceramics1; dthe time-consuming hands-on laboratory procedure; dhigh cost of the noble and high-noble metal used in PFM restorations; d high allergenic potential for
192 JADA 145(2) http://jada.ada.org February 2014 Copyright © 2014 American Dental Association. All Rights Reserved.
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many people2,3; dthe wearing off of superficial stains; dexposure of unsightly gingival margins when gingiva recedes.4 It is undeniable that PFM has served patients and dentists well for many years. How do the characteristics of zirconia and lithium disilicate restorations compare with those of PFM? The following discussion is intended to motivate readers to compare all-ceramic crowns and fixed prostheses with their personal knowledge of PFM. A comparison of PFM and all-ceramic restorations. In this section, I will state the known positive characteristics of PFM first, then offer comments about the abovementioned three major types of crowns in the current generation of all-ceramic restorations. dPFM has a history of proven success for most clinical situations— over 50 years of service—whereas all-ceramic crowns have only a few years of clinical success.5-11 dPFM has proven adequate strength for most situations. Allceramic restorations work well as single units, and zirconia and zirconia-based restorations are now relatively well proven in three-unit fixed prostheses. However, longterm clinical observation is yet to come.12 dPFM has predictability based on a known rate of success and failure. Many years still are needed to validate the service potential of all-ceramic crowns.7,13-18 dPFM has relatively good esthetics when placed initially and for several years thereafter. Zirconia-based restorations can have nearoptimum esthetics.19-25 Fullzirconia restorations were esthetically compromised when initially introduced, but this category of materials is rapidly improving in esthetic qualities.26-28 Lithium disilicate
restorations have TABLE excellent esthetic Crowns and fixed prostheses qualities, but produced in the United States, 2007 the material’s use and 2013, according to material type.* in fixed prostheYEAR PERCENTAGE OF RESTORATIONS, ACCORDING ses is still TO MATERIAL TYPE questionable.29-32 Porcelain All Full Resin-Based dPFM restoraFused to Metal Ceramic Cast Composite tions are relatively 2007 65.3 23.9 8.0 2.8 easy for dentists 2013 16.9 80.2 2.2 0.7 to place. Clini* Source: J. Shuck, vice president for sales and marketing, Glidewell cal observation Dental Laboratories, written communication, Oct. 7, 2013. and experience over several decades have shown distinct advantages. that because of the strength of the dTwo of the categories of ceramic metal understructure, dentists can restorations, lithium disilicate and be confident of success with use of zirconia, do not wear opposing tooth any cement of their choice for PFM, structure as much as does PFM.38-41 and the technique is simple. AlldLaboratory time needed to mill ceramic crowns are more difficult to lithium disilicate or zirconia is not as seat, because of the necessity of acid long, nor is the process as difficult, etching and bonding some of them, as that in the fabrication of a PFM and their relative translucence does restoration. not allow blockage of the dark color dThe cost of the material for of tooth preparations. lithium disilicate or zirconia is far dPFM allows relatively easy placeless than the current cost of noble ment of precision attachments or metals. stress breakers. At this time, the dNeither lithium disilicate nor zirall-ceramic crowns do not allow the conia produces the metal sensitivity use of these. and the gingival irritation associated dPFM, when used correctly, has with metal ions that some patients enough strength for use in long-span experience.2,3 fixed prostheses. Although some dWhen the gingiva recedes, cedental laboratories are promoting ramic crowns do not have as much long-span fixed prostheses for fulldisagreeable margin display as do zirconia and zirconia-based restomost PFM restorations. rations, such use still is unproven. dLithium disilicate can have excelLong-span use of lithium disilicate is lent esthetics, generally considered not indicated.29,33-36 to be better than those of typical dPFM allows easy removal when PFM restorations.31 necessary; the dentist makes a slot SUMMARY cut in the crown and rotates it off with a screwdriverlike instrument. Both PFM and ceramic restorations All-ceramic crowns require signifihave significant advantages and discant effort to remove, and because advantages. As judged by the rapid their color is near to that of tooth acceptance of zirconia and lithium structure, their removal can be an disilicate restorations, it is apparent uncertain procedure and can lead to that dental practitioners prefer the overcutting of the tooth.37 characteristics of ceramic crowns In what ways are ceramic crown more than they like those of PFM characteristics better than those crowns. However, PFM has decades of PFM? Ceramics do have some of success, as judged by clinical JADA 145(2) http://jada.ada.org February 2014 193
Copyright © 2014 American Dental Association. All Rights Reserved.
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observation and research findings, whereas the new generation of ceramic crowns has a clinical record of only a few years. There appears to be no question that the rapid decline of PFM restorations marks the beginning of the type’s eventual demise. Yes, the rush to all-ceramic restorations appears to be justified, but only time will fully answer that question. n doi:10.14219/jada.2013.19 Dr. Christensen is the director, Practical Clinical Courses, and a cofounder and the chief executive officer, CR Foundation, Provo, Utah. He also is an adjunct professor, University of Utah, Salt Lake City. He is a diplomate of the American Board of Prosthodontics. Address correspondence to Dr. Christensen at CR Foundation, 3707 N. Canyon Road, Suite 3D, Provo, Utah 84604. The views expressed are those of the author and do not necessarily reflect the opinions or official policies of the American Dental Association. 1. Esquivel-Upshaw JF, Rose WF Jr, Barrett AA, et al. Three years in vivo wear: core-ceramic, veneers, and enamel antagonists. Dent Mater 2012;28(6):615-621. 2. Gökçen-Röhlig B, Saruhanoglu A, Cifter ED, Evlioglu G. Applicability of zirconia dental prostheses for metal allergy patients. Int J Prosthodont 2010;23(6):562-565. 3. Berkowitz GS, Lehane RJ. Nickel sensitivity: a case report. Gen Dent 2008;56(1):e1-e3. 4. Näpänkangas R, Raustia A. Twenty-year follow-up of metal-ceramic single crowns: a retrospective study. Int J Prosthodont 2008;21(4): 307-311. 5. Beier US, Kapferer I, Dumfahrt H. Clinical long-term evaluation and failure characteristics of 1,335 all-ceramic restorations. Int J Prosthodont 2012;25(1):70-78. 6. Rinke S, Schäfer S, Roediger M. Complication rate of molar crowns: a practice-based clinical evaluation (in English, German). Int J Comput Dent 2011;14(3):203-218. 7. Keough BE, Kay HB, Sager RD, Keen E. Clinical performance of scientifically designed, hot isostatic-pressed (HIP’d) zirconia cores in a bilayered all-ceramic system. Compend Contin Educ Dent 2011;32(6):58-68. 8. Mao Y, Gao Y, Wang ZY, Gao B, Ma CF, Zhang SF. An 8-year follow-up study of Cerec2 computer aided design and computer aided manufacture of all-ceramic crowns (in Chinese). Zhonghua Kou Qiang Yi Xue Za Zhi 2008;43(12):752-753. 9. Chen S, Zhang ZT. Three-year clinical
observation and failure analysis of all-ceramic restorations made by chair-side computer aided design and computer aided manufacture system (in Chinese). Zhonghua Kou Qiang Yi Xue Za Zhi 2007;42(6):337-339. 10. Zitzmann NU, Galindo ML, Hagmann E, Marinello GP. Clinical evaluation of Procera AllCeram crowns in the anterior and posterior regions. Int J Prosthodont 2007;20(3):239-241. 11. Peláez J, Cogolludo PG, Serrano B, Lozano JF, Suárez MJ. A prospective evaluation of zirconia posterior fixed dental prostheses: three-year clinical results. J Prosthet Dent 2012;107(6):373-379. 12. Christensen RP, Ploeger BJ. A clinical comparison of zirconia, metal and alumina fixedprosthesis frameworks veneered with layered or pressed ceramic: a three-year report. JADA 2010;141(11):1317-1329. 13. Blatz M. The faculty perspective: the clinical long-term success of ceramic restorations, part II: posterior full-coverage crowns. Pract Proced Aesthet Dent 2004;16(10):702. 14. Christensen GJ. Longevity of posterior tooth dental restorations. JADA 2005;136(2):201-203. 15. Martin MP. Material and clinical considerations for full-coverage indirect restorations. Compend Contin Educ Dent 2012;33(special number 6):2-5. 16. Small BW. Material choice for restorative dentistry: inlays, onlays, crowns, and bridges. Gen Dent 2006;54(5):310-312. 17. DiTolla MC. A new metal-free alternative for single- and multiunit restorations. Compend Contin Educ Dent 2002;23(9 suppl 1):25-33. 18. Cho GC, Donovan TE, Chee WW. Rational use of contemporary all-ceramic crown systems. J Calif Dent Assoc 1998;26(2):113-120. 19. Madan N, Pannu K. Restoration of maxillary anterior esthetics using Lava all-ceramic fixed dental prostheses (in English, German). Int J Comput Dent 2011;14(1):47-53. 20. Vult von Steyern P. All-ceramic fixed partial dentures: studies on aluminum oxide- and zirconium dioxide-based ceramic systems. Swed Dent J Suppl 2005;(173):1-69. 21. Griggs JA. Recent advances in materials for all-ceramic restorations. Dent Clin North Am 2007;51(3):713-727, viii. 22. Zeighami S, Mahgoli H, Farid F, Azari A. The effect of multiple firings on microtensile bond strength of core-veneer zirconia-based all-ceramic restorations. J Prosthodont 2013;22(1):49-53. 23. Chang YY. Maximizing esthetic results on zirconia-based restorations. Gen Dent 2011;59(6):440-445. 24. Hosseini M, Worsaae N, Schiodt M, Gotfredsen K. A 1-year randomised controlled trial comparing zirconia versus metal-ceramic implant supported single-tooth restorations. Eur J Oral Implantol 2001;4(4):347-361. 25. Sasse M, Kern M. CAD/CAM single retainer zirconia-ceramic resin-bonded fixed dental prostheses: clinical outcome after 5 years (in English, German). Int J Comput Dent 2013;16(2):109-118. 26. Kim JH, Park JH, Park YB, Moon HS.
Fracture load of zirconia crowns according to the thickness and marginal design of coping. J Prosthet Dent 2012;108(2):96-101. 27. Giordano R 2nd. Zirconia: a proven, durable ceramic for esthetic restorations. Compend Contin Educ Dent 2012;33(1):46-49. 28. Rojas-Vizcaya F. Full zirconia fixed detachable implant-retained restorations manufactured from monolithic zirconia: clinical report after two years in service. J Prosthodont 2011;20(7):570-576. 29. Della Bona A, Kelly JR. The clinical success of all-ceramic restorations. JADA 2008;139(suppl): 8S-13S. 30. Zimmermann R, Seitz S, Evans J, Bonner J. CAD/CAM and lithium disilicate: an anterior esthetic case study. Tex Dent J 2013;130(2):141-144. 31. Prevedello GC, Vieira M, Furuse AY, Correr GM, Gonzaga CC. Esthetic rehabilitation of anterior discolored teeth with lithium disilicate all-ceramic restorations. Gen Dent 2012;60(4): e274-e278. 32. Aboushelib MN, Dozic A, Liem JK. Influence of framework color and layering technique on the final color of zirconia veneered restorations. Quintessence Int 2010;41(5):e84-e89. 33. Xin HT, Guo WG, Li YL. The study of cyclic fatigue and lifetime for all-ceramic crown after cementation (in Chinese). Zhonghua Kou Qiang Yi Xue Za Zhi 2009;44(2):101-104. 34. Donovan TE. Factors essential for successful all-ceramic restorations. JADA 2008;139(suppl): 14S-18S. 35. Koutayas SO, Mitsias M, Wolfart S, Kern M. Influence of preparation mode and depth on the fracture strength of zirconia ceramic abutments restored with lithium disilicate crowns. Int J Oral Maxillofac Implants 2012;27(4):839-848. 36. Solá-Ruiz MF, Lagos-Flores E, RománRodriguez JL, Highsmith Jdel R, Fons-Font A, Granell-Ruiz M. Survival rates of a lithium disilicate-based core ceramic for three-unit esthetic fixed partial dentures: a 10-year prospective study. Int J Prosthodont 2013;26(2):175-180. 37. CR Foundation. All-ceramic restorations: simplify your technique. Clin Rep 2012;5(7):1-3. 38. Janyavula S, Lawson N, Cakir D, Beck P, Ramp LC, Burgess JO. The wear of polished and glazed zirconia against enamel. J Prosthet Dent 2013;109(1):22-29. 39. Etman MK, Woolford M, Dunne S. Quantitative measurement of tooth and ceramic wear: in vivo study (published correction appears in Int J Prosthodont 2008;21[6]:508). Int J Prosthodont 2008;21(3):245-252. 40. Suputtamongkol K, Anusavice KJ, Suchatlampong C, Sithiamnuai P, Tulapornchai C. Clinical performance and wear characteristics of veneered lithia-disilicate-based ceramic crowns. Dent Mater 2008;24(5):667-673. 41. Kunzelmann KH, Jelen B, Mehl A, Hickel R. Wear evaluation of MZ100 compared to ceramic CAD/CAM materials (in English, German). Int J Comput Dent 2001;4(3):171-184.
194 JADA 145(2) http://jada.ada.org February 2014 Copyright © 2014 American Dental Association. All Rights Reserved.
Is the rush to all-ceramic crowns justified? Gordon J. Christensen JADA 2014;145(2):192-194 10.14219/jada.2013.19 The following resources related to this article are available online at jada.ada.org (this information is current as of June 28, 2014): Updated information and services including high-resolution figures, can be found in the online version of this article at: http://jada.ada.org/content/145/2/192
This article cites 40 articles, 4 of which can be accessed free: http://jada.ada.org/content/145/2/192/#BIBL Information about obtaining reprints of this article or about permission to reproduce this article in whole or in part can be found at: http://www.ada.org/990.aspx
Copyright © 2014 American Dental Association. All rights reserved. Reproduction or republication strictly prohibited without prior written permission of the American Dental Association.
Downloaded from jada.ada.org on June 28, 2014
Features
OBSERVATIONS
Is the rush to all-ceramic crowns justified? Gordon J. Christensen, DDS, MSD, PhD
T
here have been numerous obvious and unprecedented changes in the dental laboratory profession over the last several years. One of the most rapid changes has been the movement from handcrafted porcelainfused-to-metal (PFM) crowns and fixed prostheses to milled ceramic restorations. It is estimated that currently at least one-half of U.S. dental laboratories are providing in-house or outsourced milled crowns and fixed prostheses (B. Napier, chief staff executive, National Association of Dental Laboratories, written communication, Oct. 8, 2013). The most popular type of crown is ceramic without any metal substructure. The table provides comparative data for the years 2007 and 2013 as recorded for roughly 1 million units of crowns and fixed prostheses in the United States (J. Shuck, vice president for sales and marketing, Glidewell Dental Laboratories, written communication, Oct. 7, 2013). The most popular types of ceramic crowns in 2013, as recorded by Glidewell, were full-zirconia, zirconia-based (zirconia coping with ceramic fired or pressed on as a laminate) and lithium disilicate (IPS e.max, Ivoclar Vivadent, Amherst, N.Y.). For this article, I use the phrase “ceramic crowns” to indicate
these three types, although several other types still are available. Other ceramic crowns constituted only a small percentage of the market in comparison with the three major types. The change from PFM to allceramic crowns over the past several years has been one of the fastest and most significant paradigm changes in the history of dentistry. In my opinion, some of the factors stimulating this shift have been dpublic demand for tooth-colored crowns; dobserved success of the current generation of all-ceramic crowns; dthe reduced laboratory costs for dentists for all-ceramic crowns; dthe high cost of metals used in PFM crowns, which motivate dentists to prescribe nonmetal crowns; dease of milling all-ceramic crowns when compared with fabricating PFM crowns; drapid growth and success of milling technology; dlaboratory acceptance of milling as state of the art. Factors IN a comparison of porcelain-fused-tometal and all-ceramic restoration characteristics
The following narrative includes my own observations and opinions as I see the rapid change to allceramic restorations. These thoughts are based on my discussions with
thousands of dentists and laboratory technicians about the clinical success and failure of the various types of restorations. The statements below are common knowledge among practitioners and allow a comparison of the newer materials with the known characteristics of PFM. PFM. Positive characteristics. PFM restorations offer several benefits: da history of success in most appropriate clinical situations in more than 50 years of service; dproven adequate strength for most situations; dpredictability and known statistics relative to restoration success and failure; drelatively good esthetic characteristics; drelative ease of use for dentists; dthe opportunity to use precision attachments and stress breakers; dpredictable and proven long-span use; dease of removal when necessary. Negative characteristics. PFM restorations also have some drawbacks: dwear on opposing teeth caused by many veneering ceramics1; dthe time-consuming hands-on laboratory procedure; dhigh cost of the noble and high-noble metal used in PFM restorations; d high allergenic potential for
192 JADA 145(2) http://jada.ada.org February 2014 Copyright © 2014 American Dental Association. All Rights Reserved.
Downloaded from jada.ada.org on June 28, 2014
Features
many people2,3; dthe wearing off of superficial stains; dexposure of unsightly gingival margins when gingiva recedes.4 It is undeniable that PFM has served patients and dentists well for many years. How do the characteristics of zirconia and lithium disilicate restorations compare with those of PFM? The following discussion is intended to motivate readers to compare all-ceramic crowns and fixed prostheses with their personal knowledge of PFM. A comparison of PFM and all-ceramic restorations. In this section, I will state the known positive characteristics of PFM first, then offer comments about the abovementioned three major types of crowns in the current generation of all-ceramic restorations. dPFM has a history of proven success for most clinical situations— over 50 years of service—whereas all-ceramic crowns have only a few years of clinical success.5-11 dPFM has proven adequate strength for most situations. Allceramic restorations work well as single units, and zirconia and zirconia-based restorations are now relatively well proven in three-unit fixed prostheses. However, longterm clinical observation is yet to come.12 dPFM has predictability based on a known rate of success and failure. Many years still are needed to validate the service potential of all-ceramic crowns.7,13-18 dPFM has relatively good esthetics when placed initially and for several years thereafter. Zirconia-based restorations can have nearoptimum esthetics.19-25 Fullzirconia restorations were esthetically compromised when initially introduced, but this category of materials is rapidly improving in esthetic qualities.26-28 Lithium disilicate
restorations have TABLE excellent esthetic Crowns and fixed prostheses qualities, but produced in the United States, 2007 the material’s use and 2013, according to material type.* in fixed prostheYEAR PERCENTAGE OF RESTORATIONS, ACCORDING ses is still TO MATERIAL TYPE questionable.29-32 Porcelain All Full Resin-Based dPFM restoraFused to Metal Ceramic Cast Composite tions are relatively 2007 65.3 23.9 8.0 2.8 easy for dentists 2013 16.9 80.2 2.2 0.7 to place. Clini* Source: J. Shuck, vice president for sales and marketing, Glidewell cal observation Dental Laboratories, written communication, Oct. 7, 2013. and experience over several decades have shown distinct advantages. that because of the strength of the dTwo of the categories of ceramic metal understructure, dentists can restorations, lithium disilicate and be confident of success with use of zirconia, do not wear opposing tooth any cement of their choice for PFM, structure as much as does PFM.38-41 and the technique is simple. AlldLaboratory time needed to mill ceramic crowns are more difficult to lithium disilicate or zirconia is not as seat, because of the necessity of acid long, nor is the process as difficult, etching and bonding some of them, as that in the fabrication of a PFM and their relative translucence does restoration. not allow blockage of the dark color dThe cost of the material for of tooth preparations. lithium disilicate or zirconia is far dPFM allows relatively easy placeless than the current cost of noble ment of precision attachments or metals. stress breakers. At this time, the dNeither lithium disilicate nor zirall-ceramic crowns do not allow the conia produces the metal sensitivity use of these. and the gingival irritation associated dPFM, when used correctly, has with metal ions that some patients enough strength for use in long-span experience.2,3 fixed prostheses. Although some dWhen the gingiva recedes, cedental laboratories are promoting ramic crowns do not have as much long-span fixed prostheses for fulldisagreeable margin display as do zirconia and zirconia-based restomost PFM restorations. rations, such use still is unproven. dLithium disilicate can have excelLong-span use of lithium disilicate is lent esthetics, generally considered not indicated.29,33-36 to be better than those of typical dPFM allows easy removal when PFM restorations.31 necessary; the dentist makes a slot SUMMARY cut in the crown and rotates it off with a screwdriverlike instrument. Both PFM and ceramic restorations All-ceramic crowns require signifihave significant advantages and discant effort to remove, and because advantages. As judged by the rapid their color is near to that of tooth acceptance of zirconia and lithium structure, their removal can be an disilicate restorations, it is apparent uncertain procedure and can lead to that dental practitioners prefer the overcutting of the tooth.37 characteristics of ceramic crowns In what ways are ceramic crown more than they like those of PFM characteristics better than those crowns. However, PFM has decades of PFM? Ceramics do have some of success, as judged by clinical JADA 145(2) http://jada.ada.org February 2014 193
Copyright © 2014 American Dental Association. All Rights Reserved.
Downloaded from jada.ada.org on June 28, 2014
Features
observation and research findings, whereas the new generation of ceramic crowns has a clinical record of only a few years. There appears to be no question that the rapid decline of PFM restorations marks the beginning of the type’s eventual demise. Yes, the rush to all-ceramic restorations appears to be justified, but only time will fully answer that question. n doi:10.14219/jada.2013.19 Dr. Christensen is the director, Practical Clinical Courses, and a cofounder and the chief executive officer, CR Foundation, Provo, Utah. He also is an adjunct professor, University of Utah, Salt Lake City. He is a diplomate of the American Board of Prosthodontics. Address correspondence to Dr. Christensen at CR Foundation, 3707 N. Canyon Road, Suite 3D, Provo, Utah 84604. The views expressed are those of the author and do not necessarily reflect the opinions or official policies of the American Dental Association. 1. Esquivel-Upshaw JF, Rose WF Jr, Barrett AA, et al. Three years in vivo wear: core-ceramic, veneers, and enamel antagonists. Dent Mater 2012;28(6):615-621. 2. Gökçen-Röhlig B, Saruhanoglu A, Cifter ED, Evlioglu G. Applicability of zirconia dental prostheses for metal allergy patients. Int J Prosthodont 2010;23(6):562-565. 3. Berkowitz GS, Lehane RJ. Nickel sensitivity: a case report. Gen Dent 2008;56(1):e1-e3. 4. Näpänkangas R, Raustia A. Twenty-year follow-up of metal-ceramic single crowns: a retrospective study. Int J Prosthodont 2008;21(4): 307-311. 5. Beier US, Kapferer I, Dumfahrt H. Clinical long-term evaluation and failure characteristics of 1,335 all-ceramic restorations. Int J Prosthodont 2012;25(1):70-78. 6. Rinke S, Schäfer S, Roediger M. Complication rate of molar crowns: a practice-based clinical evaluation (in English, German). Int J Comput Dent 2011;14(3):203-218. 7. Keough BE, Kay HB, Sager RD, Keen E. Clinical performance of scientifically designed, hot isostatic-pressed (HIP’d) zirconia cores in a bilayered all-ceramic system. Compend Contin Educ Dent 2011;32(6):58-68. 8. Mao Y, Gao Y, Wang ZY, Gao B, Ma CF, Zhang SF. An 8-year follow-up study of Cerec2 computer aided design and computer aided manufacture of all-ceramic crowns (in Chinese). Zhonghua Kou Qiang Yi Xue Za Zhi 2008;43(12):752-753. 9. Chen S, Zhang ZT. Three-year clinical
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