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Zirconia in fixed prosthesis. A literature review

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J Clin Exp Dent. 2014;6(1):e66-73. Zirconia review

Journal section: Oral Medicine and Pathology doi:10.4317/jced.51304

Publication Types: Review http://dx.doi.org/10.4317/jced.51304

Zirconia in fixed prosthesis. A literature review

Rubén Agustín-Panadero 1, Juan-Luis Román-Rodríguez 1, Alberto Ferreiroa 2, María-Fernanda Solá-Ruíz 3,

Antonio Fons-Font 4

1
Associate Lecturer. Department of Dental Medicine, Faculty of Medicine and Dentistry, University of Valencia, Spain
2
Collaborating Lecturer. Department of Buccofacial Prosthesis, Faculty of Odontology, Complutense University of Madrid
3
Assistant Lecturer. Department of Dental Medicine, Faculty of Medicine and Dentistry, University of Valencia, Spain
4
Senior Lecturer. Department of Dental Medicine, Faculty of Medicine and Dentistry, University of Valencia, Spain

Correspondence:
Unidad Docente de Prostodoncia y Oclusión
Departamento de Estomatología
Facultad de Medicina y Odontología
Universidad de Valencia
[email protected]
Agustín-Panadero R, Román-Rodríguez JL, Ferreiroa A, Solá-Ruíz MF,
Fons-Font A. Zirconia in fixed prosthesis. A literature review. J Clin Exp
Dent. 2014;6(1):e66-73.
Received: 17/09/2013 http://www.medicinaoral.com/odo/volumenes/v6i1/jcedv6i1p66.pdf
Accepted: 21/11/2013
Article Number: 51304 http://www.medicinaoral.com/odo/indice.htm
© Medicina Oral S. L. C.I.F. B 96689336 - eISSN: 1989-5488
eMail: [email protected]
Indexed in:
Scopus
DOI® System

Abstract
Statement of problem: Evidence is limited on the efficacy of zirconia-based fixed dental prostheses.
Objective: To carry out a literature review of the behavior of zirconium oxide dental restorations.
Material and Methods: This literature review searched the Pubmed, Scopus, Medline and Cochrane Library da-
tabases using key search words “zirconium oxide,” “zirconia,” “non-metal restorations,” “ceramic oxides,” “ve-
neering ceramic,” “zirconia-based fixed dental prostheses”. Both in vivo and in vitro studies into zirconia-based
prosthodontic restoration behavior were included.
Results: Clinical studies have revealed a high rate of fracture for porcelain-veneered zirconia-based restorations
that varies between 6% and 15% over a 3- to 5-year period, while for ceramo-metallic restorations the fracture rate
ranges between 4 and 10% over ten years. These results provoke uncertainty as to the long-term prognosis for this
material in the oral medium. The cause of veneering porcelain fractures is unknown but hypothetically they could
be associated with bond failure between the veneer material and the zirconia sub-structure.

Key words: Veneering ceramic, zirconia-based ceramic restoration, crown, zirconia, tooth-supported fixed pros-
thesis.

Introduction dental restoration types, such as fenestrated crowns or

Prosthodontic treatments have traditionally sought to partial coverage crowns, were described as esthetic and
restore lost function (chewing, speech, swallowing), in certain ambits demand for these restorations remains
while providing esthetics that fulfill contemporary crite- high. However, at the present time the term ‘esthetic res-
ria for attractiveness. The demand for optimum esthetics toration’ refers to ceramic restorations and in particular
is conditioned both by social pressure and the interests to porcelain restorations without any metal. Towards the
of the dental profession. Only a few decades ago, some end of the last century, a climate of non-acceptance of
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metal alloys in the mouth emerged among some dentists When the function of restorations, both all-ceramic and
and in the dental product industry and, given the increa- metal-ceramic, is evaluated over time, there are two con-
sing demand for esthetic treatments, these factors have cepts that are often regarded as synonymous: success
driven the development of new all-ceramic prosthetic and survival. The survival of a restoration means that
rehabilitations. For this reason, recent research (1-8) has it fulfills its function in the mouth even though it may
focused on ceramics, seeking restorations that provide have suffered some additional affectation. Success can
optimum esthetics while replacing ceramo-metallic res- be defined as a restoration that survives intact maintai-
torations with all-ceramic restorations of similar mecha- ning surface qualities, anatomical shape and function, as
nical strength. well as optimum esthetics (1,2).
In zirconia-based fixed dental prostheses, in spite of the
Material and Methods material’s high fracture resistance, the porcelain-venee-
An exhaustive search of literature published 1995 to red can chip during mastication and this is a frequent
2013 was made in on-line databases (Medline, Pubmed, problem (3,4). This complication generates some uncer-
Scopus and the Cochrane Library) using the following tainty as to the long-term performance of the material’s
key search terms: “zirconium oxide”, “zirconia”, “non- use in dental restorations (5).
metal restorations”, “ceramic oxides”, “veneering ce- Clinical studies have revealed a high rate of fracture for
ramic”, “zirconia-based fixed dental prostheses”. All porcelain-veneered zirconia-based restorations that va-
the articles identified had been published in internatio- ries between 6% and 15% over a 3- to 5-year period.
nal scientific journals (Journal Citation Reports). Both These are high values compared to the 4% fracture rate
in vitro and in vivo studies of the performance of zir- shown by conventional metal-ceramic restorations over
conia-based fixed dental prostheses were included. The 10 years (6) (Fig. 1). The cause of these fractures is unk-
articles were then evaluated for inclusion in the review nown but might be associated with bond failure between
by five researchers working independently, applying the the porcelain-veneered and the zirconia structure (7).
following inclusion criteria: randomized and non-ran-
domized controlled clinical trials; in vitro trials of me-
chanical behavior; systematic reviews; meta-analyses;
cohort and case-control studies. Isolated clinical case re-
ports, articles expressing opinion, articles lacking scien-
tific evidence or motivated by commercial interests or
sponsorship were discarded. A total of 225 articles were
identified in the initial search, of which 177 were discar-
ded for failing to meet the inclusion criteria described
above. Information contained in the remaining articles
was collated for comparison and analysis.

Literature Review Results

The endeavor to replace the metal in ceramo-meta- Fig. 1. Chipping of ceramic veneer on ceramo-metallic res-
toration.
llic restorations with high-resistance ceramics began
towards the end of the twentieth century and has not yet
reached a conclusion. At present, zirconium oxide is the According to Heintze and Rousson, the chipping of
main focus of research and clinical trials. The principal porcelain-veneered can be classified by severity and the
characteristics favoring its use as a biomaterial are che- treatment required for repair as follows:
mical and dimensional stability, mechanical resistance, • Grade 1: Small surface chipping. Treatment: polis-
hardness, and an elastic modulus of the same order as hing the restoration surface (Fig. 2).
stainless steel (1). • Grade 2: Moderate surface chipping. Treatment: use
Zirconium oxide has been in use since 1960. From the of a resin composite repair system. (Fig. 3)
start, its promising in vitro properties attracted the at- • Grade 3: Severe veneer ceramic chipping exposing
tention of dental (and orthopedic) researchers and in the the zirconia core. Treatment: replacement of the dama-
last decade it has acquired increasing prominence. The ged prosthesis (8).
properties that favor its use in dentistry are biocompati- Literature reviews such as those made by Raigrodski,
bility, low thermal conductivity, resistance to corrosion Anusavice and Heintze show that the most frequent ty-
and high tenacity, due to its totally crystalline micros- pes of zirconia-based fixed dental prostheses chipping
tructure. However, being opaque, it has to be covered are Grades 1 and 2, which do not involve restoration fa-
with a more translucent feldspathic ceramic to improve ilure (5,8,9).
esthetics.
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J Clin Exp Dent. 2014;6(1):e66-73. Zirconia review

- Clinical behavior of zirconia-based fixed dental pros-

theses.
Veneer chipping generally occurs as an esthetic defect
of little importance and is easily corrected by polishing
or intraoral repair; it often goes unnoticed by the patient
(8). For this reason, the survival rates of zirconia-based
fixed dental prostheses and ceramo-metallic restorations
are estimated to be equivalent (97-99% over five years)
(5).
The highest numbers of complications arising from the
use of zirconium oxide in prosthodontic treatments oc-
curs with fixed partial prostheses or bridges. The pre-
sent literature review identified numerous clinical stu-
dies in which cohesive fracture of the veneer material is
Fig. 2. Grade 1 Chipping of a zirconia full-coverage crown
(Tooth 41).
the main and most frequent fault. Nevertheless, there is
some controversy as to the frequency of this mechanical
failure due to variations in the variables analyzed in di-
fferent studies (Table 1):
• Pospiech (24-month follow-up), Beuer (40 months),
Bornemann (18 months), Crisp (12 months), Tinschert
(37.5 months), Schmitter (25 months), and Eschbach
(54.4 months) found chipping percentages ranging bet-
ween 3% and 6% (10, 11, 12-16).
• Vult von Steyern (24-month follow-up), Peláez (36
months), Edelhoff (39.1 months), Schmitt (34.2 mon-
ths), Wolfart (48±7 months), Roediger (50 months),
Kern (74.6 months), and Sorensen (36 months) carried
out in vivo studies of posterior fixed partial prostheses
Fig. 3. Grade 2 of a zirconia full-coverage crown (Tooth 44). finding an incidence of chipping ranging between 9%
and 15% (3, 17-23).
Factors that reduce the strength of porcelain-veneered • Lastly, diverse in vivo studies by Raigrodski (31.2-
zirconia-based restorations and so increase the risk of month follow-up), Sailer (40.3±2.8 months), Beuer
chipping are: (35±14 months), Schmitt (62,1 months) and Rinke (84
• Residual stress caused by differences in the coeffi- months) claim that the incidence of chipping of the ve-
cient of thermal expansion (CTE) between the zirconia neer material on posterior fixed partial prostheses ranges
core and the porcelain-veneered. between 19% and 28% (24, 11, 25-27).
• Poor core wettability by the porcelain-veneered, Notably, some authors – Molin (60-month follow-up)
which results in poor engagement between materials and and Suárez (18 months) – did not detect any mechani-
poor micromechanical interlocking. cal complications at all among the restorations studied
• Fabrication defects (Griffith defects) (8). (28,29).
Prosthetic performance is not homogeneous and various The few in vivo clinical studies available in the literature
factors can influence behavior: the fabrication technique, of crown with zirconia sub-structures – Beuer (35±14
the extent of the endentulous area between teeth suppor- months), Örtorp (60-month follow-up), Poggio (20.9
ting fixed partial prostheses/bridges, or the procedure months) and Rinke (36.5±6 months) – reveal different
employed for obtaining the core material. In this way, behavior from fixed partial prostheses, with an incidence
higher numbers of mechanical failures occur for: of chipping ranging from 0% to 4% (11, 30-33) (Table
• Traditional manual stratification ceramics than heat- 2) (Fig. 4).
pressed ceramics (8). - In vitro behavior of fixed prostheses with zirconia sub-
• Fixed partial prostheses (bridges) than individual structure.
crowns. Regarding the mechanical behavior of fixed prosthetic
• Zirconia restorations fabricated by hard milling of restorations, the most important requirement is that they
sintered zirconia than by soft milling of pre-sintered zir- must withstand mastication forces without fracturing.
conia (11). The first molar is subjected to forces of approximately
300-800 N, while the anterior zone is subjected to masti-
cation forces of 60-200N. In some parafunctional cases
occlusal forces can reach 1000 N (34).
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J Clin Exp Dent. 2014;6(1):e66-73. Zirconia review

Table 1. Clinical studies with tooth-supported fixed partial prostheses with zirconia core.
Author Study type Follow- Number of res- Zirconia system Number and type of complications Survival
up time torations
Pospiech Prospective 24 38 (36 patients) Lava Frame/ Lava Ceram 2 x chipping (5.2%) 100%
(2003)(1) months Fixed partial (Ceramic stratification
prosthesis (FPP) technique)
Bornemann Prospective 18 59 (46 patients) DeguDentCercon/Cercon 2 x chipping (3.38%) 96%
(2003)(12) months FPP. 44 x 3-piece CeramS (Ceramic stratifica-
and 15 x 4-piece tion technique)
Suárez Prospective 18 18 (16 patients) In-Ceram Zirconia /Vitadur 1 Root fracture of endodontically treated 94.5%
(2004)(28) months FPP (3-piece) Alpha (Ceramic stratifica- post
tion technique) 0 x chipping (0%)
Vult von Prospective 24 20 (18 patients) DC-Zirkon/Vita D (Ceram- 3 x chipping (15%) 100%
Steyern months FPP (3-5-piece) ic stratification technique)
(2005)(3)
Raigrodski Prospective 31,2 20 (16 patients) Lava Frame/ Lava Ceram 1 tooth required endodontic treatment 100%
(2006)(26) months FPP (3-piece) (Ceramic stratification 5 X chipping (25%)
technique)
Sorensen Prospective 36 19 (19 patients) e.max ZirCAD/e.max Ce- 2 x chipping (10.52%) 100%
(2007)(23) months FPP (3-piece) ram (ceramic stratification
technique)
Edelhoff Prospective 39,1 22 (18 patients) DigiZon/Zr-Keramik 1 adhesive fracture of veneer ceramic 90.5%
(2008)(18) months FPP (3- and (Ceramic stratification 1 x chipping (9.09%)
6-piece) technique) 1 tooth required endodontic treatment
Molin Prospective 60 19 (18 patients) Denzir/Vita D y IPS Em- 1 adhesive fracture 100%
(2008)(29) months FPP (3-piece) press (Ceramic stratification 0 x chipping (0%)
technique)
Crisp Prospective 12 38 Lava Frame/ Lava Ceram 2 x chipping (5.2%) 100%
(2008)(13) months FPP (3- and (Ceramic stratification
4-piece) technique)
Tinschert Prospective 37,5 65 (46 patients) DC-Zircon/Vita D (Ceramic 4 x chipping (6.15%) 100%
(2008)(14) months FPP (3- and 10- stratification technique) 3 teeth required endodontic treatment
piece) 2 x adhesive fracture
Sailer Randomi- 40,3±2,8 36 Cercon/Cercon CeramS 1 tooth required endodontic treatment 100%
(2009)(25) zed months FPP (3-5-piece) (Ceramic stratification 9 x chipping (25%)
technique)
Schmitt Prospective 34,2 30 (30 patients) Lava Frame/Lava Ceram 1 tooth required endodontic treatment 100%
(2009)(19) months FPP (3-4-piece) (Ceramic stratification 3x chipping (10%)
technique)
Schmitter Prospective 25 30 (27 patients) DeguDent.Cercon/Cercon
1 fracture of fixed partial prosthesis due to 96.6%
(2009)(15) months FPP (4-7-piece) CeramS (Ceramic stratifica-
mechanical failure of connector (3,33%)
tion technique) 2 adhesive fractures
1 x chipping (3.33%)
1 tooth required endodontic treatment
Wolfart Prospective 48±7 24 (21 patients) Cercon/Cercon Ceram Ex- 1 tooth lost due to secondary caries 96%
(2009)(20) months FPP (3-piece) press (Injection technique) 2 teeth required endodontic treatment
2 adhesive fractures
3 x chipping (12.5%)
Eschbach Prospective 5 4 , 4 65 (58 patients) In-Ceram Zirconia/VItadur 1 complete fracture of FPP (1.53%) 94%
(2009)(16) months FPP (3-piece) Alpha (ceramic stratifica- 1 tooth lost due to caries
tion technique) 2 adhesive fractures
4 x chipping (6.15%)
Beuer Prospective 35±14 18 FPP and 50 IPS e.max ZirCAD/IPS Fractures were only found in FFPs: 88.2%
(2010)(11) months one-piece crowns e.max Ceram (Ceramic 1 tooth required endodontic treatment (FPP
(38 patients) stratification technique) had to be removed)
5 x chipping (27.77%)
2 teeth required endodontic treatment
2 cases of secondary caries
Roediger Prospective 50 mon- 99 (75 patients) DeguDent.Cercon/Cercon 1 tooth required endodontic treatment 94%
(2010)(21) ths FPP (3-4-piece) CeramS (Ceramic stratifica- 3 cases of secondary caries
tion technique) 6 adhesive fractures s
13 x chipping (13.13%)
1 tooth lost due to periodontal lesion

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Schmitt Prospective 62.1 25 (25 patients) Lava Frame/Lava Ceram 2 teeth required endodontic treatment 92%
(2012)(24) months FPP (3- and (Ceramic stratification 7 x chipping (28%)
4-piece) technique) 1 complete fracture of FPP
5 posts lost due to biological failure
1 adhesive fracture
Kern Prospective 74.6 20 x FPP: 17 x In-Ceram Zirconia 3 x chipping (15%) 85%
(2012)(22) months 3-piece and 3 1 tooth required endodontic treatment
x 4-piece (15
patients)
Peláez Prospective 36 20 (17 patients) Lava Frame/Lava Ceram 2 X chipping (10%) 100%
(2012)(17) months FPP (3-piece) (Ceramic stratification
technique)
Rinke Prospective 84 99 FPPs: 81 x DeguDent 12 fractures of fixed partial prosthesis; 83.4%
(2013)(27) months 3-piece and 18 x Cercon/Cercon CeramS prosthesis required replacement. (12.12%)
4-piece (Ceramic stratification 19 x chipping (19.19%) (chipping resolved
(75 patients) technique) clinically)
1 tooth fracture treated endodontically
2 teeth lost to periodontal disease
3 teeth lost due to secondary caries.
4 cases of secondary caries without loss of
tooth (loss of vitality)
7 adhesive fractures

Table 2. Clinical studies with tooth-supported one-piece full-coverage restorations and inlays with zirconia core.
Author Study type Follow-up Number of res- Zirconia system Number and type of com- Survival
time torations plications
Örtorp (2009) Retrospective 36 months 204 one-piece Procera Zirconia (Nobel 4 x Chipping (1.96%) 97.5%
(30) crowns (161 Biocare) 5 teeth extracted due to
patients) biological failure
4 adhesive fracture s
Beuer (2010) Prospective 35±14 months 18 FPP and 50 IPS e.max ZirCAD/IPS Without complications 100%
(11) one-piece crowns e.max Ceram (Ceramic 0 x Chipping (0%)
(38 patients) stratification technique)
Örtorp (2012) Retrospective 60 months 205 one-piece Procera (Nobel Biocare) 6 x Chipping (2.9%) 88.8%
(31) crowns (162 7 teeth extracted due to
patients) biological failure
15 adhesive failures
9 teeth required endodontic
treatment
Poggio (2012) Retrospective 20.9 months 102 one-piece Different systems: 1 tooth extracted due to 99%
(32) crowns (31 endodontic problem
patients) Biotech 2 x chipping (1.96%)
Diadem
IPS e.max ZirCAD
Lava
Procera
Wieland
Rinke (2013) Prospective 36.5±6 months 52 one-piece Zirconia: DeguDent 2 complete fractures of Zirconia:
(27) zirconia crowns Cercon/Cercon CeramS zirconia core (3.84%) 86.8%
(Ceramic stratification 2 x chipping (3.84%)
technique) 1 tooth required endodontic
treatment
1 case of secondary caries

According to the literature, compression and flexion ra AllCeram (alumina), 600 Mpa; zirconia-based fixed
trials with vertical and perpendicular vectors would dental prostheses (Lava, Procera Zirconia, Everest or
appear to be adequate for testing the fracture resistance IPS e.max ZirCAD), 900-1200 MPa (34-47).
of crowns or bridges. In static compression load trials of Agustín et al. analyzed the behavior of three zirco-
all-ceramic restorations, the forces applied in different nia-based restoration types subjected to compression
the studies reviewed are as follows (in increasing order): loading (Lava, IPS emax ZirCAD, IPS emax ZirPress);
IPS Empress, 130-180 Mpa; In Ceram espinel, 250-350 the crowns surpassed the forces deemed necessary for
Mpa; IPS Empress 2, 200-400 Mpa; In-Ceram Alumina, clinical survival (1325.7-2310.5 N) (34).
400-600 Mpa; In Ceram Zirconia, 570-630 Mpa; Proce- Potiket carried out compression load testing of 40 full
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Fig. 4. Percentage of chipping/delamination of ceramic veneers in fixed partial prostheses with zirconia cores. Fixed partial pros-
thesis (FPP); Full-coverage crown (C).

coverage crowns, dividing these into groups according ceramic veneer), which was significantly less resistant
to the core material: ceramo-metallic restorations; zir- than the other crowns tested (36).
conia (Procera AllZirkon); aluminum oxide (Procera Studies of zirconia-veneer ceramic bond strength sub-
AllCeram). These were subjected to static compression jected to shear forces (lateral loading of specimen to
loading; no statistically significant differences in fractu- evaluate resistance to debonding at the zirconia-porce-
re resistance were found between the restoration types lain interface) were also reviewed. López-Mollá et al.
(2). studied six groups: d.SIGN nickel-chromium (13.45
Tsalouchou made a study of 50 zirconia crowns, com- MPa); IPS e.max Press/IPS e.max Ceram (24.20 MPa);
paring fracture resistance of two types of veneer cera- IPS e.max ZirCAD/IPS e.max ZirPress (12.70 MPa);
mic: injected ceramic (IPS e.max ZirPress) and strati- IPS e.max ZirCAD/IPS e.max Ceram (7.86 MPa);
fied ceramic (IPS e.max Ceram) over zirconia cores. Lava Frame/Lava Ceram (10.20 MPa); Lava Frame/IPS
Mean resistance for the groups was: ZirCAD+ZirPress e.max Ceram (4.62 MPa). The assay applied a lateral
(2135.6 ±330.1 N) and ZirCAD+IPS e.max Ceram static load to the core-ceramic interface with specimens
(2189.9±317.6 N), without statistically significant diffe- mounted in test cylinders (dimensions: 15mm long x
rence (35). 8mm diameter). It was found that pressure injection
Agustín et al. made an in vitro study of the mechanical molded veneer ceramics (IPS e.max ZirCAD/ IPS e.max
resistance of veneer ceramic on 120 crowns with either ZirPress) bonded more successfully to the zirconia core
metal or zirconia cores, subjecting them to static com- than veneers applied using stratification techniques or
pression loading: IPS e.max ZirCAD/IPS e.max Ceram sintering in layers (37).
(1773.9 N); IPS e.max ZirCAD/IPS e.max Zirpress (1818 Choi compared the fracture resistance of porcelain ve-
N); Lava Frame Zirconia/Lava Ceram (2211 N); Cromo- neers (45 samples) of two restoration types (metal-ce-
Niquel/IPS d.Sign (2310.5 N); Cromo-Niquel/IPS InLi- ramic and zirconia [Cercon]). The metal-ceramic res-
ne (1933.2 N); Cromo-Niquel/IPS InLinePoM (1325.7 torations were significantly more resistant (35.87±4.23
N). Zirconia-based restorations IPS e.max ZirCAD, with MPa) than the zirconia restorations (25.43±3.12 MPa)
either injected ceramic veneers (IPS e.max Zirpress) or (38).
stratified veneers (IPS e.max Ceram) were statistically Blatz studied the mechanical behavior of the veneer-
less resistant than d.Sign nickel-chromium/IPS and Lava core bond of 120 samples (dimensions: 10mm x 10mm
Frame Zirconia/Lava Ceram crowns. Notably, the group x 2mm). Ninety specimens were fabricated with a Lava
that presented the lowest resistance values was Nickel- Zirconia core and divided into three groups according to
chromium/IPS InLinePoM (metal-ceramic with injected the veneer (Cerabien ZR, GC Initial and Lava Ceram); a
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further 30 specimens had a metal core (Control Group). (71.66%), compared to metal core restorations which all
Shear forces were applied to the veneer-core interfa- showed adhesive fractures (34).
ces; resistance was significantly greater for the zirconia Tsalouchou assayed resistance to static loading of 50 zir-
groups than the control group (with metal core). For the conia crowns, making SEM analysis of the transversal
zirconia samples, all fractures took the form of chipping, plane, also showing that the most frequent fracture type
pointing to an optimum bond between the zirconia core was cohesive (35).
and the ceramic veneer (39). In the same way, Saito made a study of fracture resis-
Analyzing studies of the fracture resistance of all-cera- tance of porcelain-veneered of 72 samples with zirconia
mic partial fixed prostheses, Rosentritt et al. published cores, finding that the most frequent fracture type was
mean fracture values of 1500 N for bridges in posterior cohesive (88.8%) (48).
sectors subjected to cyclic loading (47). Another study To date, no scientific evidence for a chemical union bet-
(41) obtained fracture resistance values for Lava three- ween zirconia and ceramic veneers has been found. The
piece bridges of 1816 N, although these were not subjec- two materials appear to bond by means of mechanical
ted to cyclic loading. Stiesch-Scholz et al. found signi- engagement and the formation of compressive strength
ficant differences between Lava (1250 N) and Empress resulting from thermal contraction during cooling after
2 (400 N) and showed how cyclic loading produced a sintering (34).
reduction in fracture resistance of four-piece bridges for
both materials (42). Ludwig et al. compared Empress 2 References
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Conflicts of interest
The author denies any conflicts of interest related to this study.
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