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The Journal of Prosthetic Dentistry Apr 2018The comparative assessment of computer-aided design and computer-aided manufacturing (CAD-CAM) technology and other fabrication techniques pertaining to marginal... (Review)
Review
STATEMENT OF PROBLEM
The comparative assessment of computer-aided design and computer-aided manufacturing (CAD-CAM) technology and other fabrication techniques pertaining to marginal adaptation should be documented. Limited evidence exists on the effect of restorative material on the performance of a CAD-CAM system relative to marginal adaptation.
PURPOSE
The purpose of this systematic review was to investigate whether the marginal adaptation of CAD-CAM single crowns, fixed dental prostheses, and implant-retained fixed dental prostheses or their infrastructures differs from that obtained by other fabrication techniques using a similar restorative material and whether it depends on the type of restorative material.
MATERIAL AND METHODS
An electronic search of English-language literature published between January 1, 2000, and June 30, 2016, was conducted of the Medline/PubMed database.
RESULTS
Of the 55 included comparative studies, 28 compared CAD-CAM technology with conventional fabrication techniques, 12 contrasted CAD-CAM technology and copy milling, 4 compared CAD-CAM milling with direct metal laser sintering (DMLS), and 22 investigated the performance of a CAD-CAM system regarding marginal adaptation in restorations/infrastructures produced with different restorative materials.
CONCLUSIONS
Most of the CAD-CAM restorations/infrastructures were within the clinically acceptable marginal discrepancy (MD) range. The performance of a CAD-CAM system relative to marginal adaptation is influenced by the restorative material. Compared with CAD-CAM, most of the heat-pressed lithium disilicate crowns displayed equal or smaller MD values. Slip-casting crowns exhibited similar or better marginal accuracy than those fabricated with CAD-CAM. Cobalt-chromium and titanium implant infrastructures produced using a CAD-CAM system elicited smaller MD values than zirconia. The majority of cobalt-chromium restorations/infrastructures produced by DMLS displayed better marginal accuracy than those fabricated with the casting technique. Compared with copy milling, the majority of zirconia restorations/infrastructures produced by CAD-CAM milling exhibited better marginal adaptation. No clear conclusions can be drawn about the superiority of CAD-CAM milling over the casting technique and DMLS regarding marginal adaptation.
Topics: Computer-Aided Design; Crowns; Dental Marginal Adaptation; Dental Materials; Dental Prosthesis Design; Humans; Lasers
PubMed: 28967399
DOI: 10.1016/j.prosdent.2017.07.001 -
Clinical Oral Implants Research Oct 2018The aim of the present review was to compare the outcomes, that is, survival and complication rates of zirconia-ceramic and/or monolithic zirconia implant-supported... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
The aim of the present review was to compare the outcomes, that is, survival and complication rates of zirconia-ceramic and/or monolithic zirconia implant-supported fixed dental prostheses (FDPs) with metal-ceramic FDPs.
MATERIALS AND METHODS
An electronic MEDLINE search complemented by manual searching was conducted to identify randomized controlled clinical trials, prospective cohort studies and retrospective case series on implant-supported FDPs with a mean follow-up of at least 3 years. Patients had to have been examined clinically at the follow-up visit. Assessment of the identified studies and data extraction was performed independently by two reviewers. Failure and complication rates were analyzed using robust Poisson regression models to obtain summary estimates of 5-year proportions.
RESULTS
The search provided 5,263 titles and 455 abstracts. Full-text analysis was performed for 240 articles resulting in 19 studies on implant FDPs that met the inclusion criteria. The studies reported on 932 metal-ceramic and 175 zirconia-ceramic FDPs. Meta-analysis revealed an estimated 5-year survival rate of 98.7% (95% CI: 96.8%-99.5%) for metal-ceramic implant-supported FDPs, and of 93.0% (95% CI: 90.6%-94.8%) for zirconia-ceramic implant-supported FDPs (p < 0.001). Thirteen studies including 781 metal-ceramic implant-supported FDPs estimated a 5-year rate of ceramic fractures and chippings to be 11.6% compared with a significantly higher (p < 0.001) complication rate for zirconia implant-supported FDPs of 50%, reported in a small study with 13 zirconia implant-supported FDPs. Significantly (p = 0.001) more, that is, 4.1%, of the zirconia-ceramic implant-supported FDPs were lost due to ceramic fractures compared to only 0.2% of the metal-ceramic implant-supported FDPs. Detailed analysis of factors like number of units of the FDPs or location in the jaws was not possible due to heterogeneity of reporting. No studies on monolithic zirconia implant-supported FDPs fulfilled the inclusion criteria of the present review. Furthermore, no conclusive results were found for the aesthetic outcomes of both FDP-types.
CONCLUSION
For implant-supported FDPs, conventionally veneered zirconia should not be considered as material selection of first priority, as pronounced risk for framework fractures and chipping of the zirconia veneering ceramic was observed. Monolithic zirconia may be an interesting alternative, but its clinical medium- to long-term outcomes have not been evaluated yet. Hence, metal ceramics seems to stay the golden standard for implant-supported multiple-unit FDPs.
Topics: Ceramics; Databases, Factual; Dental Implants; Dental Materials; Dental Prosthesis Design; Dental Prosthesis, Implant-Supported; Dental Restoration Failure; Denture, Partial, Fixed; Esthetics, Dental; Humans; Metal Ceramic Alloys; Survival Analysis; Zirconium
PubMed: 30328185
DOI: 10.1111/clr.13277 -
Clinical Oral Implants Research Jan 2022To analyze the clinical outcomes of all-ceramic single crowns (SCs) and fixed dental prostheses (FDPs) supported by ceramic implants. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To analyze the clinical outcomes of all-ceramic single crowns (SCs) and fixed dental prostheses (FDPs) supported by ceramic implants.
MATERIALS AND METHODS
Based on a focused question and customized PICO framework, electronic (Medline/EMBASE/Cochrane) and manual searches for studies reporting the clinical outcomes of all-ceramic SCs and FDPs supported by ceramic implants ≥12 months were performed. The primary outcomes were reconstruction survival and the chipping proportion. The secondary outcomes were implant survival, technical complications, and patient-related outcome measurements. Meta-analyses were performed after 1, 2, and 5 years using random-effect meta-analyses.
RESULTS
Eight of the 1,403 initially screened titles and 55 full texts were included. Five reported on monolithic lithium disilicate (LS2) SCs, one on veneered zirconia SCs, and two on veneered zirconia SCs and FDPs, which reported all on cement-retained reconstructions (mean observation: 12.0-61.0 months). Meta-analyses estimated a 5-year survival rate of 94% (95% confidence interval [CI]: 82%-100%) for overall implant survival. Reconstruction survival proportions after 5 years were: monolithic LS2, 100% (95%CI: 95%-100%); veneered zirconia SCs, 89% (95%CI: 62%-100%); and veneered zirconia FDPs 94% (95%CI: 81%-100%). The chipping proportion after 5 years was: monolithic LS2, 2% (95%CI: 0%-11%); veneered zirconia SCs, 38% (95%CI: 24%-54%); and veneered zirconia FDPs, 57% (95%CI: 38%-76%). Further outcomes were summarized descriptively.
CONCLUSIONS
Due to the limited data available, only tendencies could be identified. All-ceramic reconstructions supported by ceramic implants demonstrated promising survival rates after mid-term observation. However, high chipping proportions of veneered zirconia SCs and, particularly, FDPs diminished the overall outcome. Monolithic LS2 demonstrated fewer clinical complications. Monolithic reconstructions could be a valid treatment option for ceramic implants.
Topics: Ceramics; Crowns; Dental Implants; Dental Porcelain; Dental Prosthesis Design; Dental Prosthesis, Implant-Supported; Dental Restoration Failure; Humans; Metal Ceramic Alloys; Zirconium
PubMed: 34665900
DOI: 10.1111/clr.13871 -
The International Journal of... 2014This review aimed to evaluate the documented clinical success of zirconia based crowns in clinical trials. (Review)
Review
PURPOSE
This review aimed to evaluate the documented clinical success of zirconia based crowns in clinical trials.
MATERIALS AND METHODS
Electronic databases were searched for original studies reporting on the clinical performance of tooth- or implant-supported zirconia-based crowns, including PubMed, Cochrane Library, and Science Direct. The electronic search was complemented by manual searches of the bibliographies of all retrieved full-text articles and reviews as well as a hand search of the following journals: International Journal of Prosthodontics, Journal of Oral Rehabilitation, International Journal of Oral & Maxillofacial Implants, and Clinical Oral Implants Research.
RESULTS
The search yielded 3,216 titles. Based on preestablished criteria, 42 full-text articles were obtained. While 16 studies fulfilled the inclusion criteria, only 3 randomized controlled trials were reported. Seven studies reported on tooth-supported and 4 on implant-supported crowns, and 5 studies reported on both types of support. Ten studies on tooth-supported and 7 on implant supported crowns provided sufficient material for statistical analysis. Life table analysis revealed cumulative 5-year survival rates of 95.9% for tooth-supported and 97.1% for implant-supported crowns. For implant-supported crowns, the most common reasons for failure were technical (veneering material fractures). For tooth-supported crowns, technical (veneering material fractures, loss of retention) and biologic (endodontic/ periodontic) reasons for failure were equally common. The most common complications for implant-supported crowns were veneering material fractures and bleeding on probing. For tooth-supported crowns, the most common complications were loss of retention, endodontic treatment, veneering material fractures, and bleeding on probing.
CONCLUSION
The results suggest that the success rate of tooth-supported and implant-supported zirconia-based crowns is adequate, similar, and comparable to that of conventional porcelain-fused-to-metal crowns. These results are, however, based on a relatively small number of studies, many that are not controlled clinical trials. Well-designed studies with large patient groups and long follow-up times are needed before general recommendations for the use of zirconia-based restorations can be provided.
Topics: Clinical Trials as Topic; Crowns; Dental Materials; Dental Prosthesis Design; Dental Prosthesis, Implant-Supported; Dental Restoration Failure; Humans; Randomized Controlled Trials as Topic; Treatment Outcome; Zirconium
PubMed: 24392475
DOI: 10.11607/ijp.3647 -
The Cochrane Database of Systematic... Aug 2021Traditionally, amalgam has been used for filling cavities in posterior teeth, and it continues to be the restorative material of choice in some low- and middle-income... (Review)
Review
BACKGROUND
Traditionally, amalgam has been used for filling cavities in posterior teeth, and it continues to be the restorative material of choice in some low- and middle-income countries due to its effectiveness and relatively low cost. However, there are concerns over the use of amalgam restorations (fillings) with regard to mercury release in the body and the environmental impact of mercury disposal. Dental composite resin materials are an aesthetic alternative to amalgam, and their mechanical properties have developed sufficiently to make them suitable for restoring posterior teeth. Nevertheless, composite resin materials may have potential for toxicity to human health and the environment. The United Nations Environment Programme has established the Minamata Convention on Mercury, which is an international treaty that aims "to protect the [sic] human health and the environment from anthropogenic emissions and releases of mercury and mercury compounds". It entered into force in August 2017, and as of February 2021 had been ratified by 127 governments. Ratification involves committing to the adoption of at least two of nine proposed measures to phase down the use of mercury, including amalgam in dentistry. In light of this, we have updated a review originally published in 2014, expanding the scope of the review by undertaking an additional search for harms outcomes. Our review synthesises the results of studies that evaluate the long-term effectiveness and safety of amalgam versus composite resin restorations, and evaluates the level of certainty we can have in that evidence.
OBJECTIVES
To examine the effects (i.e. efficacy and safety) of direct composite resin fillings versus amalgam fillings.
SEARCH METHODS
An information specialist searched five bibliographic databases up to 16 February 2021 and used additional search methods to identify published, unpublished and ongoing studies SELECTION CRITERIA: To assess efficacy, we included randomised controlled trials (RCTs) comparing dental composite resin with amalgam restorations in permanent posterior teeth that assessed restoration failure or survival at follow-up of at least three years. To assess safety, we sought non-randomised studies in addition to RCTs that directly compared composite resin and amalgam restorative materials and measured toxicity, sensitivity, allergy, or injury.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures expected by Cochrane.
MAIN RESULTS
We included a total of eight studies in this updated review, all of which were RCTs. Two studies used a parallel-group design, and six used a split-mouth design. We judged all of the included studies to be at high risk of bias due to lack of blinding and issues related to unit of analysis. We identified one new trial since the previous version of this review (2014), as well as eight additional papers that assessed safety, all of which related to the two parallel-group studies that were already included in the review. For our primary meta-analyses, we combined data from the two parallel-group trials, which involved 1645 composite restorations and 1365 amalgam restorations in 921 children. We found low-certainty evidence that composite resin restorations had almost double the risk of failure compared to amalgam restorations (risk ratio (RR) 1.89, 95% confidence interval (CI) 1.52 to 2.35; P < 0.001), and were at much higher risk of secondary caries (RR 2.14, 95% CI 1.67 to 2.74; P < 0.001). We found low-certainty evidence that composite resin restorations were not more likely to result in restoration fracture (RR 0.87, 95% CI 0.46 to 1.64; P = 0.66). Six trials used a split-mouth design. We considered these studies separately, as their reliability was compromised due to poor reporting, unit of analysis errors, and variability in methods and findings. Subgroup analysis showed that the findings were consistent with the results of the parallel-group studies. Three trials investigated possible harms of dental restorations. Higher urinary mercury levels were reported amongst children with amalgam restorations in two trials, but the levels were lower than what is known to be toxic. Some differences between amalgam and composite resin groups were observed on certain measures of renal, neuropsychological, and psychosocial function, physical development, and postoperative sensitivity; however, no consistent or clinically important harms were found. We considered that the vast number of comparisons made false-positive results likely. There was no evidence of differences between the amalgam and composite resin groups in neurological symptoms, immune function, and urinary porphyrin excretion. The evidence is of very low certainty, with most harms outcomes reported in only one trial.
AUTHORS' CONCLUSIONS
Low-certainty evidence suggests that composite resin restorations may have almost double the failure rate of amalgam restorations. The risk of restoration fracture does not seem to be higher with composite resin restorations, but there is a much higher risk of developing secondary caries. Very low-certainty evidence suggests that there may be no clinically important differences in the safety profile of amalgam compared with composite resin dental restorations. This review supports the utility of amalgam restorations, and the results may be particularly useful in parts of the world where amalgam is still the material of choice to restore posterior teeth with proximal caries. Of note, however, is that composite resin materials have undergone important improvements in the years since the trials informing the primary analyses for this review were conducted. The global phase-down of dental amalgam via the Minamata Convention on Mercury is an important consideration when deciding between amalgam and composite resin dental materials. The choice of which dental material to use will depend on shared decision-making between dental providers and patients in the clinic setting, and local directives and protocols.
Topics: Bias; Child; Composite Resins; Dental Amalgam; Dental Caries; Dentition, Permanent; Humans; Randomized Controlled Trials as Topic
PubMed: 34387873
DOI: 10.1002/14651858.CD005620.pub3 -
Dental Materials : Official Publication... Dec 2021The aim of this systematic review and meta-analysis was to compare the bond strength between eroded and sound permanent enamel and dentin and to assess whether bonding... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
The aim of this systematic review and meta-analysis was to compare the bond strength between eroded and sound permanent enamel and dentin and to assess whether bonding performance (immediate and after aging) differs between etch&rinse and self-etch adhesives and can be improved by surface pretreatment prior to bonding.
METHODS
Electronic databases (PubMed, Scopus, Embase, Web of Science, CENTRAL, LILACS, BBO) were searched by two reviewers. Random-effect meta-analyses were performed to compare bond strength to sound and eroded dental hard tissues without and with surface pretreatment prior to bonding, respectively. The effect of adhesive mode (etch&rinse vs. self-etch) and aging (immediate vs. aged) was compared using subgroup analyses. Statistical heterogeneity was assessed using Cochran's Q and I-statistic. Funnel plots and Egger's regression intercept tests were used to evaluate publication bias. Quality and risk of bias of included studies were also assessed.
RESULTS
Fourty-seven studies (45 in vitro, 2 in situ) were included in the systematic review and meta-analyses. Erosion impairs bond strength to dentin (p < 0.001; mean difference: -10.2 MPa [95%CI: -11.9 to -8.6 MPa]), but not to enamel (p = 0.260). Surface pretreatment measures removing or stabilizing the collagenous matrix can improve dentin bond strength (maximum mean difference: +12.4 MPa). Etch&rinse and self-etch adhesives did not perform significantly different on eroded enamel (p = 0.208) and dentin (p = 0.353). The majority of studies (32 of 47) presented a medium risk of bias.
SIGNIFICANCE
Data from in vitro and in situ studies showed that erosion impairs dentin bonding of etch&rinse and self-etch adhesives and makes surface pretreatment prior to bonding of composite restorations necessary.
Topics: Dental Bonding; Dental Cements; Dental Enamel; Dentin; Dentin-Bonding Agents; Materials Testing; Resin Cements
PubMed: 34593245
DOI: 10.1016/j.dental.2021.09.014 -
Journal of Dental Research Oct 2014The aim of this meta-analysis, based on individual participant data from several studies, was to investigate the influence of patient-, materials-, and tooth-related... (Meta-Analysis)
Meta-Analysis Review
The aim of this meta-analysis, based on individual participant data from several studies, was to investigate the influence of patient-, materials-, and tooth-related variables on the survival of posterior resin composite restorations. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a search resulting in 12 longitudinal studies of direct posterior resin composite restorations with at least 5 years' follow-up. Original datasets were still available, including placement/failure/censoring of restorations, restored surfaces, materials used, reasons for clinical failure, and caries-risk status. A database including all restorations was constructed, and a multivariate Cox regression method was used to analyze variables of interest [patient (age; gender; caries-risk status), jaw (upper; lower), number of restored surfaces, resin composite and adhesive materials, and use of glass-ionomer cement as base/liner (present or absent)]. The hazard ratios with respective 95% confidence intervals were determined, and annual failure rates were calculated for subgroups. Of all restorations, 2,816 (2,585 Class II and 231 Class I) were included in the analysis, of which 569 failed during the observation period. Main reasons for failure were caries and fracture. The regression analyses showed a significantly higher risk of failure for restorations in high-caries-risk individuals and those with a higher number of restored surfaces.
Topics: Composite Resins; Dental Caries Susceptibility; Dental Materials; Dental Restoration Failure; Dental Restoration, Permanent; Humans; Risk Factors; Survival Analysis; Time Factors
PubMed: 25048250
DOI: 10.1177/0022034514544217 -
The Journal of Prosthetic Dentistry Mar 2020The restoration of extensively damaged endodontically treated teeth remains a challenge. The use of post-retained restorations has been questioned because of potential...
STATEMENT OF PROBLEM
The restoration of extensively damaged endodontically treated teeth remains a challenge. The use of post-retained restorations has been questioned because of potential tooth weakening.
PURPOSE
The purpose of this systematic review was to determine whether endocrowns are a reliable alternative to post-retained restorations for extensively damaged endodontically treated teeth and to determine which preparation design is most appropriate and which materials are best adapted for fabricating endocrowns.
MATERIAL AND METHODS
The literature that was analyzed covered endocrowns from 1995 to June 2018. A search was conducted for in vitro and clinical studies in English in 3 research databases (PubMed, Cochrane, and Scopus), and this was complemented by a manual search in the bibliographies of the studies found. Case reports were excluded.
RESULTS
A total of 41 publications consisting of 8 clinical studies and 33 in vitro studies were included in this systematic review. Several analysis parameters were identified: for the clinical studies, survival rate, failure modes, and clinical criteria; for the in vitro studies, fracture resistance, stress distribution, preparation criteria, and materials used.
CONCLUSIONS
Endocrowns are a reliable alternative to post-retained restorations for molars and seem promising for premolars. A certain preparation design and a rigorous adhesion protocol must be respected. Among the available materials, lithium disilicate glass-ceramic and nanofilled composite resin stand out.
Topics: Composite Resins; Crowns; Dental Porcelain; Dental Restoration Failure; Dental Stress Analysis; Humans; Materials Testing; Tooth, Nonvital
PubMed: 31353111
DOI: 10.1016/j.prosdent.2019.04.009 -
Journal of the American Dental... Feb 2023The goal of restoring caries lesions is to protect the pulp, prevent progression of the disease process, and restore the form and function of the tooth. The purpose of... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The goal of restoring caries lesions is to protect the pulp, prevent progression of the disease process, and restore the form and function of the tooth. The purpose of this systematic review was to determine the effect of different direct restorative materials for treating cavitated caries lesions on anterior and posterior primary and permanent teeth.
TYPE OF STUDIES REVIEWED
The authors included parallel and split-mouth randomized controlled trials comparing the effectiveness of direct restorative materials commercially available in the United States placed in vital, nonendodontically treated primary and permanent teeth. Pairs of reviewers independently conducted study selection, data extraction, and assessments of risk of bias and certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. The authors conducted pair-wise meta-analyses to summarize the evidence and calculated measures of association and their 95% CIs.
RESULTS
Thirty-eight randomized controlled trials were eligible for analysis, which included data on Class I and Class II restorations on primary teeth and Class I, Class II, Class III, Class V, and root surface restorations on permanent teeth. Included studies assessed the effect of amalgam, resin composite, compomer, conventional glass ionomer cement, resin-modified glass isomer cement, and preformed metal crowns. Moderate to very low certainty evidence suggested varying levels of effectiveness across restorative materials.
CONCLUSIONS AND PRACTICAL IMPLICATIONS
Owing to a relatively low event rate across various outcomes indicating restoration failure, there was limited evidence to support important differences between direct restorative materials used in practice.
Topics: United States; Humans; Dental Restoration, Permanent; American Dental Association; Dental Caries Susceptibility; Dental Materials; Dental Caries; Composite Resins; Tooth, Deciduous; Glass Ionomer Cements
PubMed: 36610925
DOI: 10.1016/j.adaj.2022.09.012 -
Clinical Oral Implants Research Oct 2018The aim of the present systematic review was to analyze the survival and complication rates of zirconia-based and metal-ceramic implant-supported single crowns (SCs).
OBJECTIVES
The aim of the present systematic review was to analyze the survival and complication rates of zirconia-based and metal-ceramic implant-supported single crowns (SCs).
MATERIALS AND METHODS
An electronic MEDLINE search complemented by manual searching was conducted to identify randomized controlled clinical trials, prospective cohort and retrospective case series on implant-supported SCs with a mean follow-up time of at least 3 years. Patients had to have been clinically examined at the follow-up visit. Assessment of the identified studies and data extraction was performed independently by two reviewers. Failure and complication rates were analyzed using robust Poisson's regression models to obtain summary estimates of 5-year proportions.
RESULTS
The search provided 5,263 titles and 455 abstracts, full-text analysis was performed for 240 articles, resulting in 35 included studies on implant-supported crowns. Meta-analysis revealed an estimated 5-year survival rate of 98.3% (95% CI: 96.8-99.1) for metal-ceramic implant supported SCs (n = 4,363) compared to 97.6% (95% CI: 94.3-99.0) for zirconia implant supported SCs (n = 912). About 86.7% (95% CI: 80.7-91.0) of the metal-ceramic SCs (n = 1,300) experienced no biological/technical complications over the entire observation period. The corresponding rate for zirconia SCs (n = 76) was 83.8% (95% CI: 61.6-93.8). The biologic outcomes of the two types of crowns were similar; yet, zirconia SCs exhibited less aesthetic complications than metal-ceramics. The 5-year incidence of chipping of the veneering ceramic was similar between the material groups (2.9% metal-ceramic, 2.8% zirconia-ceramic). Significantly (p = 0.001), more zirconia-ceramic implant SCs failed due to material fractures (2.1% vs. 0.2% metal-ceramic implant SCs). No studies on newer types of monolithic zirconia SCs fulfilled the simple inclusion criteria of 3 years follow-up time and clinical examination of the present systematic review.
CONCLUSION
Zirconia-ceramic implant-supported SCs are a valid treatment alternative to metal-ceramic SCs, with similar incidence of biological complications and less aesthetic problems. The amount of ceramic chipping was similar between the material groups; yet, significantly more zirconia crowns failed due to material fractures.
Topics: Ceramics; Crowns; Databases, Factual; Dental Implants; Dental Materials; Dental Prosthesis Design; Dental Prosthesis, Implant-Supported; Dental Restoration Failure; Esthetics, Dental; Humans; Metal Ceramic Alloys; Survival Analysis; Zirconium
PubMed: 30328190
DOI: 10.1111/clr.13306