PERSPECTIVES
Porcelain-fused-to-metal versus
zirconia-based ceramic restorations, 2009
orcelain-fused-to-metal
P (PFM) restorations
have been the domi-
nant option in esthetic
crown and fixed-
prosthesis restorations for about
50 years. When these restora-
tions were introduced, there was
pessimism about their value and
their potential for long-term
service. However, both research
and clinical observation since
have shown that they serve well.
Research regarding the
longevity of service of PFM
crowns and fixed prostheses
shows variable but relatively
impressive results, depending
on the number of units replaced,
period of observation and loca-
tion of the study.1,2
The method of PFM failure is
apparent to clinical practicing
dentists. The most destructive
type of failure is breakage of a
Gordon J. Christensen, DDS, MSD, PhD
1036 JADA, Vol. 140 http://jada.ada.org
Copyright 2009 American Dental Association. All rights reserved. Reprinted by permission.
O B S E R VAT I O N S
large piece of ceramic from the
metal substructure. If the piece
is small, the restoration can be
smoothed and continue to serve.
If it is a larger piece of ceramic,
the restoration must be
replaced. Another challenge
arises when, across time, the
gingival tissues recede, the
crown margins become visible
and the restoration is easily
identified by a lay observer as a
false tooth. Additionally,
superficial color placed on
crowns and fixed prostheses
may abrade or dissolve from the
restorations, leaving them
chalky and often a lighter color
than when they were placed.
Again, they appear to be
unnatural.
Nevertheless, from a purely
functional standpoint, the PFM
restorations continue to serve
long after they have become rel-
August 2009
atively unesthetic, and if a chip
breaks from the restoration, the
underlying metal substructure
protects the tooth structure
until some other restoration can
be placed. Dentists trust PFM
restorations because of their
clinically observable service
longevity when compared with
several previous generations of
all-ceramic crowns.
The current generation of
zirconia-based all-ceramic
crowns and fixed prostheses is
becoming popular. I have
observed in the continuing edu-
cation (CE) courses I teach that
many general dentists and
prosthodontists have used these
restorations to a significant
degree. Jim Schuck, vice presi-
dent of sales and marketing of
Glidewell Laboratories, Newport
Beach, Calif. (the largest labora-
tory in the United States), esti-
mates that use of all-ceramic
restorations is increasing (J.
Schuck, oral communication,
April 2009). He also estimated

that 64 percent of the restora-
tions made by Glidewells labo-
ratories are PFM restorations,
about 28 percent are all-ceramic
restorations and about 8 percent
are gold alloy restorations.
The most commonly used
brands of zirconia-based all-
ceramic restorations in the
United States are Cercon
(Dentsply, York, Pa.), Everest
(KaVo, Lake Zurich, Ill.), IPS
e.max (Ivoclar Vivadent,
Amherst, N.Y.) and Lava (3M
ESPE, St. Paul).
Because of the unfavorable
service record of previous gener-
ations of all-ceramic crowns,
dentists have been wary of the
new generation of zirconia-
based restorations, but their use
continues to grow.
In this article, I will describe
the desirable and undesirable
characteristics of PFM and
zirconia-based restorations as
they are reported in the litera-
ture and as I compare them
clinically.
METAL SENSITIVITIES
Jim Schuck also reported the
types of metal used in PFM res-
torations fabricated at Glidewell
(J. Schuck, oral communication,
April 2009):
dnoble metals (approximately
37 percent) containing at least
25 percent gold, platinum or
palladium;
dbase metals (approximately
34 percent) containing less than
25 percent gold, platinum and
palladium;
dhigh-noble metals (approxi-
mately 29 percent) containing at
least 60 percent gold, platinum
and palladium and at least 40
percent gold.
The amount and frequency of
patients sensitivity to these
alloys is controversial and, in my
opinion, relatively inconclusive.3-8
Copyright 2009 American Dental Association. All rights reserved. Reprinted by permission.
PERSPECTIVES
For the purposes of this discus-
sion, I will conclude that there is
concern among some investiga-
tors that the metals used in sev-
eral oral therapies, including
PFM restorations, can cause at
least local and perhaps systemic
challenges. As a practicing
prosthodontist, I have observed
many apparent metal-allergic
reactions caused by PFM resto-
rations. Usually, I have been
able to overcome these soft-
tissue problems by replacing the
PFM restorations with all-
ceramic restorations of various
types.
Zirconium oxide is reported to
be biologically compatible, and
If patients desire or demand
to have nonmetal indirect
restorations, zirconium
oxidebased restorations
are a logical choice.
allergies and sensitivities to zir-
conia do not appear to be a sig-
nificant challenge.9,10 I can verify
those statements with my clin-
ical observations through the
past few years of using zirco-
nium oxidebased restorations.
Use of zirconium oxide substruc-
tures may satisfy the biocompat-
ibility needs of some patients
better than use of PFM
restorations.
PATIENTS WHO DO NOT
WANT METAL PLACED
IN THEIR MOUTHS
Zirconium is a naturally occur-
ring metal; zirconium oxide is
the white crystalline powder
oxide of zirconium. Zirconium
oxide has been used in hip pros-
theses for several years.
Patients objecting to use of
metal in their mouths generally
would not know that zirconium
JADA, Vol. 140
OBSERVATIONS
oxide is a metal oxide, consid-
ered to be a ceramic, and that
other metal oxides are used as
pigments in the external
veneering ceramic placed over
the zirconium oxide. In my
opinion, the popular idea of a
metal-free practice is impos-
sible to achieve at this time.
Patients objecting to the use
of metal in their mouths com-
pose a small group, but I see it
growing. It is not uncommon to
have patients request that no
metal be placed in their mouths.
In spite of the fact that zirco-
nium oxidebased restorations
consist of metal oxide, these res-
torations will grant those
patients their wish.
STRENGTH OF
RESTORATIONS
It is common knowledge among
dentists that some of the pre-
vious generations of all-ceramic
restorations have resulted in
disappointing failures after a
few years of service in the
mouth, especially in posterior
teeth. Zirconium-oxide substruc-
tures are reported to have a
strength clinically comparable
with that of metal substruc-
tures.11-15 If patients desire or
demand to have nonmetal indi-
rect restorations, zirconium
oxidebased restorations are a
logical choice. Zirconium
oxidebased all-ceramic restora-
tions need more time to be fully
proven in terms of the adequacy
of their strength in long-term
service. It appears that the
frameworks are serving as well
as metal frameworks, but only
continuing clinical research will
verify or refute that observation
across many years.11
SERVICE RECORD
After several years of use by the
profession, zirconium oxide
http://jada.ada.org August 2009 1037
PERSPECTIVES OBSERVATIONS
based restorations appear gener-
ally to have pleased dentists,
according to my observations in
many CE courses. However,
almost all dentists in these
courses who are using these res-
torations have reported some
clinical failures. The failures not
only have been observed in clin-
ical practice, but also are docu-
mented in clinical research.11
The failures appear to be pri-
marily chips and fractures in
the superficial ceramic and not
fractures of the underlying
frameworks. Also, they appear
more frequently in zirconia-
based restorations than in PFM
restorations used as controls in
the research.11 Manufacturers
are aware of these challenges
and are working to better match
the characteristics of the
veneering ceramic that is
pressed or layered onto the
zirconium-oxide frameworks.
At this time, the service
potential of PFM restorations is
more predictable than that of
zirconia-based all-ceramic resto-
rations, but it is likely that this
difference soon will be overcome.
ESTHETIC POTENTIAL
Skilled dental technicians can
make almost any type of all-
ceramic restoration appear like
a natural tooth, and their opin-
ions vary as to which type of all-
ceramic restoration has the best
potential to match tooth color
most adequately. Most agree
that pressed all-ceramic restora-
tions have the best possibility of
achieving the best color match.16
The comparative esthetic
potential of zirconia-based
ceramic restoration is difficult to
estimate or quantify, because it
depends so much on the indi-
vidual technicians ability, but
technicians have been pleased
with the color-matching poten-
1038 JADA, Vol. 140 http://jada.ada.org
Copyright 2009 American Dental Association. All rights reserved. Reprinted by permission.
tial of zirconia-based all-ceramic
restorations.17
EASE OF FABRICATION
It is apparent that zirconium
oxidebased frameworks for all-
ceramic restorations can be
made relatively rapidly and with
predictability. When the digital
information concerning the tooth
preparation is placed into the
computer, the technician is free
to do other tasks while the
framework is milled. This rela-
tively simple task replaces the
process of waxing, investing,
burning out, casting and fin-
ishing frameworks that is
familiar to dentists and techni-
cians. Also, information about
Zirconium oxidebased
restorations are easier
to construct than are
porcelain-fused-to-metal
restorations.
many frameworks can be placed
into a computer, and the frame-
works can be milled sequentially
in the absence of the technician.
Placement of ceramic over the
framework, either milled or
pressed, is no more difficult
than placement of similar
materials over metal. Zirconium
oxidebased restorations are
easier to construct than are
PFM restorations.
CLINICAL PROCEDURE
Zirconium oxidebased and
PFM restorations require nearly
the same clinical procedures.18
However, to allow for an
optimum combination of the
zirconium-oxide framework
thickness and the superficial
ceramic, tooth preparations for
the zirconia-based restorations
need to be somewhat deeper on
August 2009
the proximal and lingual sur-
faces than do tooth preparations
for PFM restorations. Impres-
sions and cementation are about
the same. If the space between
the tooth preparation and the
milled restoration has been set
too thick on the computer that
drives the milling device, the
restoration may rock in the
mouth before cementation, and
the cementation procedure can
be complicated by the lack of
definitive seating. In such ill-
planned cases, the margins fit,
but the internal portion of the
restoration does not fit the
preparation well.
CONCLUSION
For 50 years, PFM restorations
have been the main type of
esthetic indirect restoration
used in dentistry. Zirconium-
based all-ceramic restorations
are emerging as an alternative
to PFM restorations. In this
article, I compared the two types
of restorations relative to soft-
tissue compatibility, strength of
restorations, service record to
date, esthetic potential and dif-
ferences in clinical procedures.
In spite of some remaining clin-
ical challenges in the zirconium
oxidesupported restoration con-
cept, it appears that PFM resto-
rations have a viable but still
developing competitor.
Dr. Christensen is the director, Practical
Clinical Courses, and a cofounder and senior
consultant, CR Foundation, Provo, Utah. He
also is the senior academic advisor, Scottsdale
Center for Dentistry, Scottsdale, Ariz.; an
adjunct professor, Brigham Young University,
Provo, Utah; and an adjunct professor, Univer-
sity of Utah, Salt Lake City. Address reprint
requests to Dr. Christensen at CR Foundation,
3707 N. Canyon Road, Suite 3D, Provo, Utah
84604.
The views expressed are those of the author
and do not necessarily reflect the opinions
or official policies of the American Dental
Association.
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