Many dentists ask the same exact question. You are not alone! First, know that there is nothing wrong with PFMs. This restoration has served dentistry well for nearly five decades. However, use of PFMs does come with liabilities: As a bilayered restoration, a PFM can be prone to chipping, especially on multiple-unit restorations, such as large bridges. The lab is working to solve this issue by “re-inventing” PFM restorations, by fusing a ceramic that is three times stronger than currently available ceramics to the metal coping. Second, some of the current ceramics used on PFMs cause an unacceptable amount of wear on opposing teeth. We have all seen upper anterior PFMs that have done a number on lower anterior teeth. Third, the average PFM crown is not as esthetic as the average all-ceramic crown. Opaquing a metal coping so that the final restoration looks like a natural tooth requires a skilled technician and ideal reduction from the dentist.
As the strength of all-ceramic restorations has improved, making cementation an option, more dentists have looked to using all-ceramics in anterior situations in hopes of satisfying more patients. Today, two of the fastest-growing products in the lab are monolithic: IPS e.max and BruxZir. A monolithic restoration is fabricated from just one material, whereas a PFM restoration is two materials: porcelain and metal, which are fused together.
The oldest monolithic material we have is cast gold, which scores well in every restorative category except esthetics. Like cast gold, IPS e.max and BruxZir are less prone to chipping than PFMs — and even than porcelain fused to zirconia restorations, which are also bilayered. In the 2011 winter issue of Chairside magazine, Dr. Gregg Helvey compared monolithic and bilayered restorations. You might enjoy reading his article to learn more.
I can tell you that almost every restoration I place today is monolithic — I have that much confidence in IPS e.max and BruxZir. For the last two years, I have been using BruxZir for posterior crowns & bridges and IPS e.max for anterior crowns and 3-unit anterior bridges. As BruxZir becomes more translucent and thus esthetically acceptable, I also have been using it in the anterior for bridges over 3 units. As for IPS e.max, I love the idea that it is three times stronger than IPS Empress. I even did my last three minimal-prep veneer cases in IPS e.max.
If I had to do a single anterior veneer adjacent to a natural tooth, I would still use IPS Empress. If it were a single unit anterior crown adjacent to a natural tooth, I would go with IPS e.max. And BruxZir is catching up esthetically. In fact, in the photo essay, I place a single-unit anterior BruxZir crown that is a pretty darn good match.
That said, I think BruxZir in the posterior and IPS e.max in the anterior is a great place to start. Both restorations can be cemented or bonded into place, based on your preferences or retentive requirements. You will need to place Z-PRIME™ Plus (Bisco Inc.; Schaumburg, Ill.) into the crown prior to bonding BruxZir. The bonding steps for IPS e.max are the same as typical all-ceramic restorations.