Submitted December 8, 2023;

accepted April 8, 2024.

©2025 by Quintessence
Publishing Co Inc.

Giacomo Fabbri, DDS Marco De Lorenzi, DDS

Fernando Zarone, MD, DDS Alberto Mosca, DDS
Gianluca Dellificorelli, DDS Renato Leone, DDS, PhD
Giorgio Cannistraro, DDS Roberto Sorrentino, DDS, MSc, PhD

A 13- to 17-Year Retrospective Evaluation of

the Clinical Performance of Anterior and
Posterior Lithium Disilicate Restorations
on Teeth and Implants

This retrospective study evaluated the clinical outcomes of lithium disilicate prostheses on teeth
and implants. A total of 860 restorations, including crowns, veneers, and onlays, were delivered to
312 patients. Patients with uncontrolled gingival inflammation and/or periodontitis were excluded,
while patients with occlusal parafunctions were included. The retrospective observational period
ranged between 13 and 17 years. The mechanical and esthetic performance of the restorations were
rated according to the modified California Dental Association (CDA) criteria. The recorded data
were analyzed statistically. In total, 26 mechanical complications were noticed: 17 ceramic chip-
pings, 5 core fractures, and 4 losses of retention. Mechanical complications occurred predominantly
in posterior areas; monolithic prostheses showed the lowest percentage of structural problems.
The clinical scores of layered and monolithic restorations were fully satisfactory according to the
modified CDA rating. The cumulative survival and success rates ranged from 95.46% to 100% and
93.75% to 100%, respectively, up to the 17-year follow-up. Although patient selection and the rigor-
ous application of validated clinical protocols were considered paramount, the use of lithium disili-
cate prostheses on teeth and implants was reported to be a viable and reliable treatment option in
the long term. Int J Periodontics Restorative Dent 2025;45:369–383. doi: 10.11607/prd.7074

Keywords: adhesive restorations, dental ceramics, dental implant, lithium disilicate, onlay, prosthetic crown, veneer

T
he increasing demand for esthetics led to of the glassy matrix; the clinical performances
the development of innovative all-ceramic were reported to be reliable, as they can be etched
materials, including heterogeneous silica- and offer excellent bonding, thus providing satis-
based ceramics and homogeneous polycrystalline factory mechanical resistance due to an adhesive
cores.1,2 monoblock with dental substrates.3,4
Silica-based ceramics present optimal esthetics Oppositely, polycrystalline zirconia cores show
due to the utmost translucency and opalescence outstanding mechanical properties, with much

THE INTERNATIONAL JOURNAL OF PERIODONTICS & RESTORATIVE DENTISTRY, VOL 45, NO 3 369
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3 2025
higher fracture toughness than dental tissues, but to produce short-span FDPs in anterior areas (up
are not sensitive to conventional etching because to the first premolars).7,12
of the absence of silica.5 Although several surface LS2 contains silica and can be luted with resin
treatments were described to improve the bond cements after acid etching to create an adhesive
strength to resin cements, the adhesive perfor- monoblock with dental substrates, particularly
mances of zirconia are promising but need further enamel, and improve the clinical performances.13,14
validation.6 The use of all-ceramic materials gained pop-
Glass-based materials were proposed mainly ularity due to CAD/CAM techniques as well,
for single restorations and short-span fixed dental particularly the ability to perform milling units.15
prostheses (FDPs) in anterior areas7; conversely, Regarding implants, different materials (such
polycrystalline frameworks can be used to fabri- as titanium and zirconia) can be processed to
cate single restorations, FDPs and full arch pros- customize abutments and full-arches, offering
theses.5 Both ceramics can be used on teeth and optimal mechanical resistance and showing
implants.5,7 fit values comparable to those of conventional
To merge the esthetics of glass with the resis- frameworks.16,17 LS2 restorations can be cemented
tance of zirconia, intermediate ceramics were onto titanium and zirconia with resin cements to
developed, adding different fillers to an amorphous improve esthetics.18
matrix. Among them, lithium disilicate (LS2) rapidly The present retrospective study aimed to eval-
gained popularity because of its captivating optical uate the clinical performances of LS2 prostheses
and mechanical properties, which make it a very on teeth and implants in anterior and posterior
versatile solution.1,7,8 areas. The observational evaluation assessed the
LS2 was developed as a pressable glass-based mechanics and esthetics of LS2 restorations in
ceramic (eg, IPS e.max Press, Ivoclar Vivadent; LiSi different prosthetic configurations over a period
Press, GC) with improved translucency and phys- of 13 to 17 years.
ical characteristics. Restorations can be fabricated
in a bilayered (layering an LS2 core with fluoroap-
atite ceramic) or monolithic manner, avoiding any Materials and Methods
risk of chipping.9 Later, with the introduction of
CAD/CAM technologies, LS2 blocks (ie, IPS e.max Study Population
CAD, Ivoclar Vivadent; LiSi Blocks, GC; CEREC Between June 2006 and December 2010, 860 LS2
Tessera, Dentsply Sirona) were produced, showing restorations were delivered by six expert prostho-
optimal biomechanical properties.10 dontists (G.F., G.D., G.C., M.D.L., A.M., and R.S.) to
Due to high flexural strength (350 to 500 MPa), 312 patients: 169 women (ages 19 to 71 years) and
etchability, and translucency, LS2 is suitable for 143 men (ages 19 to 61 years). These subjects were
different indications, offering optimal biomimetic in need of various prosthetic treatments and were
performances in limited thicknesses, ensuring a recruited from consecutive patients at the authors’
conservative clinical approach.7,9 LS2 represents dental practices. All patients were informed
a reliable option to fabricate full and partial single about the study guidelines in accordance with
restorations: bilayered restorations are preferred in the revised Declaration of Helsinki19 and STROBE
anterior areas, particularly at the buccal aspects, guidelines20 and gave written informed consent.
to extol the optical appearance, whereas mono- Patients were included in the study if they met
lithic restorations can be used to restore posterior the following inclusion criteria: periodontally
segments to avoid possible chipping.7,9 Staining healthy, good oral hygiene, received previous vital
techniques can be useful to paint superficial char- or endodontic treatment and achieved a sound
acterizations onto monolithic restorations and state, and having opposing natural dentition or
use them in anterior areas as well, saving dental fixed prostheses. All recruited patients were in
tissues and avoiding endodontic treatments.11 good general health, and 34% were smokers
Because of its flexural strength, LS2 can be used (> 5 cigarettes/day). Preliminary oral hygiene was

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 Fabbri et al

Table 1 Descriptive Characteristics of the Study Groups

Follow-up
Cumulative Cumulative
Group Range Mean survival rate success rate
Layered (n = 209) 98.57% 97.61%
Anterior crowns 14–17 y 15.2 y
Monolithic (n = 22) 95.46% 95.46%
Layered (n = 65) 96.92% 95.39%
Posterior crowns 13–16 y 14.8 y
Monolithic (n = 132) 95.46% 93.94%
Layered (n = 7) 100% 100%
Implant crowns 13–16 y 14.6 y
Monolithic (n = 45) 97.78% 97.78%
Layered (n = 239) 97.91% 96.24%
Anterior veneers 13–17 y 15.1 y
Monolithic (n = 40) 100% 100%
Layered (n = 26) 100% 100%
Posterior veneers 14–17 y 15.4 y
Monolithic (n = 13) 100% 100%
Layered (n = 16) 100% 93.75%
Onlays 13–15 y 14.8 y
Monolithic (n = 46) 97.83% 97.83%

Table 2 Anatomical Distribution of Lithium Disilicate Restorations

Veneers Crowns Onlays
Layered Monolithic Layered Monolithic Layered Monolithic
Site Max Mdb Max Mdb Max Mdb Max Mdb Max Mdb Max Mdb
Central
64 27 12 3 43 3 12 4 – – – –
incisors
Lateral
47 29 9 2 47 3 11 4 – – – –
incisors
Canines 39 26 9 5 29 8 8 11 – – – –
First
11 9 5 4 40 18 28 23 2 2 5 6
premolars
Second
5 8 2 2 38 23 30 28 3 1 5 11
premolars
First
– – – – 13 8 17 10 – 4 3 7
molars
Second
– – – – 4 4 9 4 1 3 2 7
molars
Total 166 99 37 16 214 67 115 84 6 10 15 31
Max = maxilla; Mdb = mandible.

performed by dental hygienists, and periodontal were fabricated with pressed or milled LS2, either
health was maintained by enrolling the patients in as layered or monolithic. Patients were recalled at
a program of periodical periodontal maintenance. follow-up at least annually for clinical and radio-
According to patient needs, partial and full cov- logic evaluations. The observational period ranged
erage single restorations for placement on teeth from 13 to 17 years (Figs 1 and 2).
and implants in anterior (premolar to premolar)
and posterior regions were fabricated as follows: Ceramic Laminate Veneers
480 crowns (329 maxillary, 151 mandibular), 62 A total of 318 LS2 veneers were fabricated (203
onlays (21 maxillary, 41 mandibular), and 318 maxillary, 115 mandibular) (see Table 2). The fol-
veneers (203 maxillary, 115 mandibular) (Tables lowing tooth preparation was used, according to
1 and 2). Of these, 261 restorations were made in the mock-up guided preparation technique: 0.2 to
parafunctional patients (30.3%). The prostheses 0.8 mm cervical chamfer, 0 to 0.8 mm axial

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3 2025
◀ Fig 1 Case 1. (a) Maxillary anterior rehabili-
tation with six layered lithium disilicate single
crowns cemented onto natural and implant
zirconia abutments. (b) Clinical view at the
1-year follow-up. (c) Clinical view at the 15-year
follow-up. The image shows a good esthetic
integration in combination with ideal soft tissue
healing. Minor recessions are visible on both
a
tooth- and implant-supported crowns.

b c

◀ Fig 2 Case 2. Maxillary and mandibular

tooth preparations for anterior (a) maxillary
crowns and (b) mandibular veneers. (c) Clinical
view at the 1-year follow-up. (d) Clinical view at
the 12-year follow-up. Satisfactory biomimetic
integration and good soft tissue health can be
seen. Minor recessions are visible at cervical
margin levels.

c d

reduction, and 0 to 1.5 mm incisal reduction incisal butt joint was used in 262 veneers while
(according to wax-up and presence of discolor- a palatal chamfer was made in 56 restorations.
ation). The axial reduction was made with tapered The buccal thickness of laminates ranged from
round-end burs, preserving the maximum amount 0.2 to 0.8 mm cervically, 0.2 to 1.2 mm in the middle
of enamel (particularly at the periphery) to achieve third, and 0.3 to 0.9 mm incisally. Centric contacts
the best adhesion. The interproximal contact areas at the veneer-tooth interface were avoided. When
were opened only in case of class III restorations possible, the cervical margins were located supra-
or when changing the emergence profile was nec- or juxtagingivally to simplify impression-making
essary (diastemata or interdental triangles). An and inspection of marginal adaptation, thus con-

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 Fabbri et al

a b

▲ Fig 3 Case 3. (a) Tooth preparations for laminate

veneers. (b) Lithium disilicate veneers 1 month after ce-
mentation. (c) Clinical view at the 14-year follow-up. Ideal
esthetics and soft tissue integration can be seen.

tributing to maintaining periodontal health. When the resin cements were light cured for 30 seconds
the emergence profile of teeth had to be modified, on each surface. The margins were finished with
the restoration margins were placed at the gingival plastic scalers and/or blades to remove cement
crest or into the crevice. A total of 265 veneers remnants. The occlusal contacts were carefully
were layered and 53 restorations were monolithic. checked, adjusted, and polished (Fig 3).
All of the LS2 veneers were cemented adhesively
with a rubber dam. The intaglio surface was etched Tooth-Supported Single Crowns
with 4.5% hydrofluoric acid (IPS Ceramic Gel, Ivo- A total of 480 crowns were fabricated (329 max-
clar Vivadent; or Porcelain Etch, Ultradent) for 20 illary, 151 mandibular) to be placed on teeth (see
seconds. The acid was then thoroughly washed Table 2). Tooth preparations were performed
with water, and the ceramic surface was dried. A according to the wax-up, as follows: 0.3 to 1 mm
silane coupling agent (Monobond S, Ivoclar Viva- overall axial reduction, 1.5 mm incisal/occlusal
dent; or RelyX ceramic primer, 3M ESPE) was preparation, 0.4 to 1 mm circumferential chamfer
applied on the intaglio surface. The tooth surface at the margins; and all angles were rounded to
was etched with 37% phosphoric acid gel (Ultra- avoid sharp edges and possible areas of stress
Etch, Ultradent) for 30 seconds. After thoroughly concentration. The total occlusal convergence of
rinsing the surface with water for 30 seconds, a preparation ranged between 5 and 10 degrees,
bonding agent (OptiBond FL, Kerr) was rubbed depending on the length of the abutment teeth.
onto both the tooth and the ceramic intaglio sur- In anterior areas, the margins were located at the
face; a dentin primer (OptiBond FL) was applied gingival crest or slightly into the sulcus, depend-
only on areas of exposed dentin. The cementa- ing on esthetic needs. Differently, in posterior
tion was performed as follows: The veneers with regions, the prosthetic margins were placed
a thickness < 0.5 mm were luted with flowable supra- or juxtagingivally to preserve enamel, make
composites (Gradia Direct Flo, GC; Tetris Evo- impression-making easier, and facilitate the
Flow, Ivoclar) or light-curing cements (Variolink assessment of marginal adaptation.
Veneer, Ivoclar Vivadent), and the veneers with The restoration thickness ranged between 0.3
a thickness of 0.5 to 0.8 mm were luted using and 1 mm on the axial surfaces and the interprox-
dual-curing composite systems (Variolink II, Ivo- imal walls; to achieve proper biomechanics, the
clar Vivadent). Excess cement removed at the minimum thickness in the incisal/occlusal areas
margins with microbrushes and interproximally was 1.5 mm. A total of 480 single crowns (183 ante-
with dental floss. The restoration margins were rior, 297 posterior) were made, 407 restorations
covered with glycerin gel to block the oxygen, and were pressed (243 layered, 164 monolithic), and

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3 2025

a b

▲ Fig 4 Case 4. (a) Tooth preparation for a full crown on a

vital tooth. (b) Clinical view at the 1-year follow-up. (c) After
40 months of clinical service, chipping with a buccal crack
line can be seen.

21 CAD/CAM restorations were milled (8 lay- Implant-Supported Restorations

ered, 13 monolithic). All of the restorations were A total of 52 implant-supported restorations (30
cemented adhesively with dual-curing (Multilink maxillary, 22 mandibular) were fabricated for
Automix, Ivoclar; or Variolink II) or self-adhesive placement on 36 implants: 9 screw-retained sin-
resin cements (RelyX Unicem, 3M ESPE), accord- gle crowns, 7 cement-retained single crowns, 2
ing to the manufacturers’ instructions. The rubber screw-retained zirconia full-arches (for a total of
dam was used to lute 68 crowns; for the other 26 restorations), 1 screw-retained four-unit zirco-
cases, partial dam and thin gingival retraction nia FDP, and 2 screw-retained three-unit titanium
cords (N.000 Ultrapak, Ultradent) were used for FDPs. The implant abutments and frameworks
isolation. After cementation, the occlusal static were designed to sustain prosthetic elements
and dynamic occlusal contacts were checked, with a minimum circumferential thickness of
adjusted, and polished (Fig 4). 1.5 mm and at least 2 mm of occlusal clearance.
In case of titanium, an opaque layer was used
Onlays to mask the grayish appearance of the metal
A total of 62 onlays were fabricated (21 maxillary, structures. The LS2 restorations were cemented
41 mandibular) (see Table 2). Composite buildups onto zirconia and titanium with dual-curing (Mul-
were made to facilitate impression-making and tilink Automix) or self-adhesive cements (RelyX
cementation. The cavities were prepared with a Unicem). The restorations were treated as tooth
minimum occlusal thickness of 2 mm. Sixteen crowns, and no treatment was carried out on
onlays were layered, and 46 were monolithic and framework materials. For screw-retained res-
stained. For cementation, the prepared teeth were torations, when the screw access hole did not
isolated with a rubber dam, and flowable com- take up the buccal area, extraoral cementation
posite resin (Gradia Direct Flo; or Tetric EvoFlow, was performed, avoiding the risk of entangling
Ivoclar) or dual-curing resin cements (Variolink II) the cement excess in the peri-implant soft tis-
were used per the manufacturers’ instructions, as sues. The screw access holes were filled with
previously described. The occlusal contacts were polytetrafluoroethylene tapes and composites
adjusted and polished. (Figs 5 and 6).

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 Fabbri et al

▶ Fig 5 Case 5. Clinical view at

the 15-year follow-up of a full-mouth
rehabilitation with lithium disilicate
single crowns cemented on natural
and implant-supported abutments.

a b

▲ Fig 6 Case 6. (a) Implant-supported full-arch rehabilitation. This patient was treated with two screw-retained zirconia
frameworks combined with monolithic lithium disilicate crowns. The crowns were cemented extraorally with adhesive
cement. (b) Clinical view at the 15-year follow-up. Good surface stability can be seen, as well as minor pigmentations at
the interface between the crowns and the zirconia frameworks.

Clinical Evaluation recorded for all study groups. The cumula-

All patients were evaluated at baseline (delivery tive survival rate (CSurvR) and success rate
day) and at least annually for a period of 13 to 17 (CSuccR) were calculated using Kaplan-Meier
years. At each recall, standardized photographs curves; all study groups were divided into lay-
and radiographs were taken. Data forms were ered and monolithic. Each mechanical compli-
used by blinded operators to record the mechani- cation, either minor (chipping, loss of retention)
cal and esthetic outcomes. Ceramic surface, mar- or major (core or framework fracture), was con-
ginal integrity, marginal discoloration, and color sidered as a statistical event. Log-rank test was
match were assessed according to the modified run to compare the survival curves of layered vs
criteria of the California Dental Association (CDA) monolithic and pressed vs milled prostheses.
quality assessment system,21 rating the different The level of statistical significance was set at
clinical parameters as A (excellent), B (good), C P = .05.
(satisfactory), or D (not satisfactory).
Patient satisfaction was evaluated with nominal
scores (unacceptable, acceptable, good, excellent). Results
In case of mechanical complications, the restoration
was considered as a failure. All procedures were carried out by expert prost-
hodontists and skilled dental technicians (G.F.,
Statistical Analysis G.D., G.C., M.D.L., A.M., and R.S.). A total of 860
A statistical software (SPSS version 28.0.1, IBM) prostheses were evaluated from 13 to 17 years
was used to run descriptive statistics. The min- in 312 patients. No patient was lost at follow-up.
imum and maximum follow-up periods were Complications are summarized in Table 3.

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Table 3 Complications Recorded During the Overall Observational Period

Restoration Type Event Location Timing Manufacturing
Max CI 4 mo Pressed
Max 1PM 8 mo Milled
Chipping Max CI 39 mo Pressed
Max CA 42 mo Pressed
Layered Max LI 58 mo Pressed
Anterior veneers
Max LI 10 mo Pressed
Core fracture Mdb CA 42 mo Milled
Mdb CI 4y Pressed
Retention loss Mdb 1M 3y Milled
Monolithic – – – –
Layered – – – –
Posterior veneers
Monolithic – – – –
Max 2PM 29 mo Pressed
Chipping Mdb 1M 35 mo Milled
Anterior Layered Max CI 40 mo Pressed
tooth-supported
crowns Max CI Pressed
Core fracture 7 mo*
Max LI Pressed
Monolithic Chipping Max CA 2y Pressed
Mdb 2PM 9 mo Pressed
Max 1M 33 mo Milled
Chipping
Max 1PM 3y Pressed
Layered Mdb 1PM 38 mo Pressed
Mdb 1PM 1y Pressed
Retention loss
Mdb 2PM 17 mo Pressed
Root fracture Max 1PM 30 mo Pressed
Posterior
tooth-supported Max 2PM 33 mo Milled
crowns Chipping
Mdb 1PM 5y Pressed
Max 2M 1y Pressed
Mdb 2M 2y Pressed
Monolithic
Core fracture Max 2M 3y Pressed
Mdb 1M 3y Pressed
Mdb 2M 3y Milled
Endo treatment Mdb 1M 18 mo Pressed
Mdb 1PM 57 mo Pressed
Layered Chipping
Max 2PM 190 mo Pressed
Onlays Mdb 2M 43 mo Milled
Chipping
Monolithic Mdb 2M 57 mo Pressed
Retention loss Max 2PM 18 mo Milled

Implant-supported Layered – – – –
crowns Monolithic Chipping Max CA 2y Pressed
CA = canine; CI = central incisor; Endo = endodontic; LI = lateral incisor; Max = maxilla; Mdb = mandible; 1M = first
molar; 2M = second molar; 1PM = first premolar; 2PM = second premolar.
*Both events occurred in the same patient.

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 Fabbri et al

Ceramic Laminate Veneers Minor chipping was reported for nine resto-
CSurvR of 97.91% and CSuccR of 96.24% were rations (four maxillary, five mandibular), and two
reported for anterior LS2 layered veneers; dif- chipped crowns were monolithic, one per arch.
ferently, anterior monolithic veneers achieved Such cohesive fractures occurred predominantly
100% for both CSurvR and CSuccR. For posterior in posterior areas; five chippings did not impair
veneers, both layered and monolithic restorations function, so they were polished intraorally, while
showed CSurvR and CSuccR of 100%. See Table 1 the other four required replacement. Catastrophic
for complete CSurvR and CSuccR data on anterior core fractures were noticed in the same patient 7
and posterior positions. months after cementation, on two layered crowns
For manufacturing, pressed veneers reported (central and lateral maxillary incisors), opposing
CSurvRs and CSuccRs of 99.32% and 97.95%, ceramic materials, and needed replacement.
respectively, while milled veneers reported In molar areas, five posterior monolithic resto-
CSurvRs and CSuccRs of 96.16% and 88.46%, rations fractured 1 to 3 years after delivery: two in
respectively. the maxilla (both second molars) and three in the
Minor chipping was reported in five veneers mandible (one first molar and two second molars)
in the maxilla; none of them impaired function, (Figs 7 and 8). All of these restorations had an
so they were polished intraorally and kept in situ occlusal thickness < 1.5 mm and were cemented
for follow-up. with a rubber dam, but on wide areas of exposed
Core fractures were observed in three ante- dentin. The fractured crowns were replaced with
rior layered veneers (one maxillary lateral incisor, new monolithic zirconia restorations.
one mandibular central incisor, one mandibular Loss of retention occurred on two layered man-
canine). All of the fractures occurred with ceramic dibular crowns (first and second premolars); the
materials as opponents, and replacement was restorations were rebonded and still in function
necessary. The failed restorations were prepared at the last follow-up. One monolithic crown in the
with incisal butt joints, and the replacements were mandible (first molar) was affected by pulpitis and
carried out with a new preparation involving the required a root canal treatment 18 months after
palatal surfaces with a mini-chamfer. One veneer cementation; endodontic therapy was performed
on a mandibular lateral incisor was affected by through the restoration, and the access hole was
loss of retention; the restoration was rebonded then built up with composites. Although the res-
and still in service at the 17-year follow-up. toration was still in service at the last follow-up, it
was statistically considered as a failure. Moreover,
Tooth-Supported Single Crowns one nonvital maxillary first premolar restored with
CSurvRs and CSuccRs of 98.57% and 97.61%, a layered crown was extracted because of root
respectively, were recorded for anterior layered fracture.
tooth-supported crowns, while anterior mono-
lithic single crowns both showed CSurvRs Onlays
and CSuccRs of 95.46%. For posterior layered CSurvRs and CSuccRs of 100% and 93.75%,
tooth-supported crowns, CSurvRs and CSuccRs respectively, were found for layered onlays, while
of 96.92% and 95.39% were reported, respectively. monolithic onlays both showed CSurvRs and
Differently, posterior monolithic crowns achieved CSuccRs of 97.83% (see Table 1).
95.46% for CSurvRs and 93.94% for CSuccRs Regarding manufacturing, pressed onlays both
(see Table 1). reported CSurvRs and CSuccRs of 90.91%; differ-
Regarding the manufacturing, pressed ently, milled onlays both recorded CSurvRs and
tooth-supported crowns reported CSurvRs and CSuccRs of 93.11%.
CSuccRs of 98.28% and 95.82%, respectively, Minor chipping was observed on four onlays:
while milled tooth-supported crowns reported one layered onlay on a maxillary second premolar
CSurvRs and CSuccRs of 95.24% and 80.95%, (natural tooth as opponent), one layered resto-
respectively. ration on a mandibular first premolar (ceramic

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3 2025

▲ Fig 7 Ceramic fracture on a mandibular first molar. ▲ Fig 8 Ceramic fracture on a mandibular second molar.
The restoration had an occlusal thickness of about 1 mm The restoration had an occlusal thickness of about 1 mm
and was cemented onto a substrate with a prevalence of and was cemented onto a substrate with a prevalence of
dentin. dentin.

material as opponent), and two monolithic onlays Log-rank tests comparing the survival analyses
on mandibular second molars (one ceramic and of layered vs monolithic prostheses were not sta-
one tooth opponent). The chipped areas were tistically significant in any group (P > .05, Table 4).
repaired intraorally using composites adhesively Conversely, log-rank tests comparing the sur-
bonded under rubber dam. Loss of retention was vival analyses of pressed vs milled restorations
reported on one monolithic maxillary onlay on a were statistically significant for veneers and
second premolar; the restoration was rebonded crowns (P < .05), while no statistically significant
and still in service at the last follow-up. differences were noticed for onlays and implant
crowns (P > .05, Table 5).
Implant-Supported Restorations
CSurvRs and CSuccRs of 100% were recorded for Clinical Evaluation
layered implant-supported crowns, while mono- According to the modified CDA quality assess-
lithic implant crowns both showed CSurvRs and ment system criteria, the ratings of layered and
CSuccRs of 97.78% (see Table 1). monolithic restorations were fully satisfactory
Regarding manufacturing, pressed implant- (Table 6). The lowest (88.4%) amount of A (excel-
supported crowns reported CSurvRs and CSuc- lent) ratings was noticed for the color match of
cRs of 100% and 90.91% respectively; differently, monolithic restorations; nonetheless, it was con-
milled implant-supported crowns both recorded sidered satisfactory by patients and clinicians.
CSurvRs and CSuccRs of 100%. With the exception of the failed restorations, no
Minor chipping was observed in one mono- prosthesis was rated C (satisfactory) or D (not
lithic crown on a maxillary canine. Such limited satisfactory) for any criteria. Patient satisfaction
cohesive fracture did not impair function; the area scores were predominantly “excellent” for all pros-
was polished intraorally and the restoration was thesis types (88.1%); only a few restorations were
kept in situ. rated “good” (10.8%) or “acceptable” (1.1%), and
none were reported as unacceptable.
Statistical Analysis The lowest percentage of mechanical compli-
Because any complication was considered as a cations was noticed in monolithic restorations. No
statistical event, the CSurvRs of LS2 restorations monolithic veneer failed, but two monolithic crowns
ranged between 95.46% and 100%, while the on natural teeth and one implant-supported resto-
CSuccRs ranged between 93.75% and 100%, ration showed minor chippings. All failed crowns
according to Kaplan-Meier survival curves (see had ceramic restorations as opponents.
Table 1; see Appendix Figs 1 to 4, available in the Secondary decay was not detected; margin and
online version of this article). contour quality were clinically satisfactory and

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Table 4 L
 og-Rank Tests Comparing Survival Table 5 L
 og-Rank Tests Comparing Survival
Curves of Layered vs Monolithic Lithium Curves of Pressed vs Milled Lithium
Disilicate Restorations Disilicate Restorations
Groups Log-rank P Groups Log-rank P
Layered anterior crowns vs Pressed veneers vs
0.367 > .05 3.347 < .05
monolithic anterior crowns milled veneers
Layered posterior crowns vs Pressed crowns vs
0.102 > .05 3.224 < .05
monolithic posterior crowns milled crowns
Layered anterior veneers vs Pressed onlays vs
1.211 > .05 0.261 > .05
monolithic anterior veneers milled onlays
Layered posterior veneers vs Pressed implant crowns vs
2.059 > .05 1.930 > .05
monolithic posterior veneers milled implant crowns
Layered onlays vs
0.414 > .05
monolithic onlays
Layered implant crowns vs
0.178 > .05
monolithic implant crowns

Table 6 F
 requency of Clinical Ratings of Lithium Disilicate Restorations According to the Modified
CDA Quality Assessment System Criteria
A B C D
Parameter Layered Monolithic Layered Monolithic Layered Monolithic Layered Monolithic
Color
96.8% 88.4% 3.2% 9.9% 0% 1.7% 0% 0%
match
Ceramic
94.2% 96.3% 4.6% 3.7% 1.2% 0% 0% 0%
surface
Marginal
95.0% 94.9% 3.6% 4.0% 1.4% 1.1% 0% 0%
discoloration
Marginal
97.6% 98.7% 1.2% 1.3% 1.2% 0% 0% 0%
integrity
A = excellent; B = good; C = satisfactory; D = not satisfactory.

interproximal contact areas were well maintained Discussion

over the whole observation.
Regarding patients with occlusal parafunctions, In the present retrospective study, LS2 restorations
261 restorations were delivered in 94 patients showed very high long-term success rates, rang-
(30.3%). Of all the technical complications ing between 93.75% and 100% after 13 to 17 years;
recorded during the follow-up period, 12 (33%) such results were comparable to those of other
occurred in parafunctional patients. Catastrophic studies.7,9,12,22,23 Different variables can contribute to
fractures were reported mainly in layered pros- the clinical outcomes; particularly, LS2 restorations
theses placed in anterior areas, although one root should be bonded carefully using proper adhesive
fracture and one monolithic core fracture were protocols.2,7,13 Furthermore, the quality and quantity
seen at posterior teeth. Technical complications of residual tooth structures is crucial, particularly
mostly affected pressed restorations in parafunc- at prosthetic margins where enamel represents
tional patients (Table 7). a potential guarantee for stability over time. The
Log-rank tests comparing the survival analyses more enamel is preserved, the more reliable
of restorations delivered to parafuntional vs non- the adhesion and the more limited the aging of
parafunctional patients showed no statistically the bonding interfaces will be.7 This was proven
significant differences (z = 0.46, P = .64) . by an investigation about porcelain veneers that

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Table 7 Complications Recorded in Parafunctional Patients

Restoration Type Event Location Timing Manufacturing
Max 1PM 8 mo Milled
Chipping
Max CA 42 mo Pressed
Anterior veneers Layered Max LI 10 mo Pressed
Core fracture Mdb CA 42 mo Milled
Mdb CI 4y Pressed

Anterior tooth- Max CI Pressed

Layered Core fracture 7 mo*
supported crowns Max LI Pressed
Layered Root fracture Max 1PM 30 mo Pressed

Posterior tooth- Chipping Max 2PM 33 mo Milled

supported crowns Monolithic Mdb 2M 2y Pressed
Core fracture
Mdb 1M 3y Pressed
Onlays Layered Chipping Mdb 2PM 190 mo Pressed
CA = canine; CI = central incisor; LI = lateral incisor; Max = maxilla; Mdb = mandible; 1M = first molar; 2M = second
molar; 1PM = first premolar; 2PM = second premolar.
*Both events occurred in the same patient.

reported an estimated survival probability of Regarding technical complications, 63% of

93.5% after 10 years24; furthermore, a systematic mechanical drawbacks were reported on prosthe-
review showed that glassy laminate restorations ses that had ceramic materials as opponents, with
could achieve very satisfactory survival rates after 33% occurring in patients showing parafunctions.
5 years of service, with very low percentages of The remaining 37% of mechanical problems were
complications.25 observed in subjects that had natural teeth as
Regarding the present study, the authors shifted opponents and that did not show any evident sign
the principles of adhesion to enamel to improve of parafunctions. Considering that 30.3% of the
the longevity of restorations from veneers to included patients showed parafunctions, LS2 may
crowns, preserving as much enamel as possi- be considered a viable option for the treatment of
ble during preparation and fabricating very thin dysfunctional subjects, particularly with monolithic
restorations. restorations avoiding chipping. In fact, the long-
All mechanical complications occurred in pros- term clinical observation of patients presenting
theses with an occlusal thickness < 1.5 mm that bruxism usually showed wear in functional areas
were cemented onto teeth, in which most of the but no chipping or fractures27 (Figs 9 and 10).
occlusal surfaces were dentin, cementum, and/or According to the nomenclature used in gen-
composites. Such an occurrence could be related eral fractography, the present study considered
to the different elastic moduli between enamel every kind of cohesive fracture of restorative
and dentin, as the quality of adhesion onto these materials, even of core structures, as chipping.
substrates is not similar.26 For these reasons, resto- Although monolithic restorations were not bilay-
rations cemented on teeth that maintain a certain ered, during the observational follow-up period,
amount of enamel but also show wide areas of point-like contacts causing microcohesive abra-
exposed dentin cannot receive a strong and rigid sions and/or fractures of the cores were observed
support from the substrate, possibly compromis- and classified as chippings.
ing the outcomes. According to the modified CDA rating, all of
Contrarily, no mechanical drawbacks were the restorations were assessed as satisfactory for
noticed in restorations luted onto at least 80% marginal integrity, color, and surface, with the only
of enamel, independent of occlusal thickness. exception of monolithic onlays and crowns, which

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 Fabbri et al

▶ Fig 9 Cusp wear of a mandibular canine after 13

years of clinical service. This bruxer patient received
a lithium disilicate full-mouth rehabilitation on natural
abutments in the anterior areas and on implants in
the posterior segments.

▶ Fig 10 Wear on the buccal

surfaces of mandibular anterior
restorations after 16 years. This
patient was treated with lithium
disilicate laminate veneers on
mandibular anterior teeth.

did not show optimal color blending in 9.1% of cementation. The crowns fractured in a subject
cases. Case selection is paramount to obtaining treated with an implant-supported full-arch res-
a natural tooth-like appearance of monolithic res- toration, and this premature failure was likely due
torations, as several clinical variables could influ- to uneven occlusal balancing; the chipped frag-
ence the esthetic outcome, such as the color of ment was rebonded, the occlusal contacts were
substrates, ceramic core thickness, proper choice adjusted and polished, and the restoration was
of LS2 ingots for translucency, and color and value still in service at the last recall.
of adjacent teeth. It is worth remembering that The manufacturing technologies used to mill
the LS2 ceramics used herein represented the and/or press LS2 show unique characteristics to
first generation of LS2; nowadays, excellent opti- be employed in different clinical situations. Partic-
cal, mechanical, and manufacturing properties ularly, the potential to choose between ingots and
of latest-generation LS2 ceramics were reported blocks with different translucencies and opacities
to show optimal biomechanical properties and allows the best camouflaging core to be selected,
camouflage potential. but in cases with severe substrate discoloration,
Regarding implant-supported prostheses, the this makes it very challenging to achieve satis-
integration of LS2 restorations with titanium and factory esthetic outcomes.8–11 Furthermore, the
zirconia reported excellent outcomes for func- etchability of LS2 improves the reliability of adhe-
tion, esthetics, and loss of retention. Only one sion and makes it easier to intraorally manage
monolithic restoration cemented onto a zirconia possible complications.2,13 In case of chipping,
framework experienced chipping 6 days after the possibility to repair the damaged area using

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3 2025
validated adhesive protocols facilitates daily clin- Acknowledgments
ical practice with easy handling procedures and
favorable prognoses.28,29 The authors declare no conflicts of interest.
Although the statical analyses showed signif-
icant differences between pressed and milled
veneers and crowns, it is worth noting that the References
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Appendices

a b

▲ Appendix Fig 1 Kaplan-Meier curve of complication onset in relation to time for lithium disilicate layered vs monolithic (a) anterior
and (b) posterior veneers.

a b

▲ Appendix Fig 2 Kaplan-Meier curves of complication onset in relation to time for lithium disilicate layered vs monolithic
tooth-supported (a) anterior and (b) posterior crowns.

a b

▲ Appendix Fig 3 Kaplan-Meier curves of complication onset in relation to time for lithium disilicate layered vs monolithic (a) onlays
and (b) implant-supported crowns.

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 Fabbri et al

a b

c d

▲ Appendix Fig 4 Kaplan-Meier curves of complication onset in relation to time for lithium disilicate pressed vs milled (a) veneers,
(b) crowns, (c) onlays, and (d) implant crowns.

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