25 All Ceramic Restorations PDF
25 All Ceramic Restorations PDF
25 All Ceramic Restorations PDF
ALL-CERAMIC
RESTORATIONS
Isabelle L. Denry, Contributing Author
774
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Chapter 25 ALL-CERAMIC RESTORATIONS 775
STRENGTHENING MECHANISMS OF
DENTAL CERAMICS
In spite of their excellent esthetic qualities and out-
standing biocompatibility, dental ceramics, like all
ceramic materials, are brittle. They are susceptible to
fracture at the time of placement and during func-
tion. Brittle materials such as ceramics contain at
least two types of flaws: fabrication defects and
C surface cracks, from which fracture can initiate.
Methods used to improve the strength and clinical
performance of dental ceramics include crystalline
reinforcement, chemical strengthening, and stress-
induced transformation.
Fig. 25-1
A, All-ceramic crown restoring the right maxillary central Fabrication Defects
incisor. B and C, Maxillary anterior teeth restored with facial
Fabrication defects are created during process-
veneers and an all-ceramic fixed dental prosthesis. (B and C, Cour-
tesy of Dr. D. H. Ward.)
ing and consist of voids or inclusions generated
during sintering. Condensation of a ceramic slurry
by hand before sintering may introduce porosity.
leucite-containing porcelain frit for use in metal- Sintering under vacuum reduces the porosity in
ceramic restorations.5 The presence of leucite, an alu- dental ceramics from 5.6 to 0.56 volume percent.9
minosilicate with high thermal expansion, allowed a Porosity on the internal side of clinically failed
match between the thermal expansion of the ceramic glass-ceramic restorations has been shown to con-
and that of the metal (see Chapter 24). The appear- stitute a fracture initiation site.10 Also, microcracks
ance of ceramic restorations was improved by the develop within the ceramic upon cooling in leucite-
introduction of vacuum firing, which considerably containing ceramics and are caused by thermal con-
reduced the amount of porosity and therefore traction mismatch between the crystals and the
resulted in denser and more translucent restorations glassy matrix.11-13
than could be achieved with air firing.6
Surface Cracks
HIGH-STRENGTH CERAMICS Surface cracks are induced by machining or grind-
The chief disadvantage of the early restorations was ing. The average natural flaw size varies from 20 to
their low strength, which limited their use to low- 50 mm.14 Usually, fracture of the ceramic material
stress situations, such as those encountered by ante- takes place from the most severe flaw, which effec-
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776 PART III LABORATORY PROCEDURES
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Chapter 25 ALL-CERAMIC RESTORATIONS 777
A B
C D
E F
Fig. 25-2
Representative dental ceramics etched to reveal microstructure. A, A feldspathic porcelain (IPS Classic). B, A leucite-reinforced press-
able ceramic (OPC). C, A lithium disilicate pressable ceramic (OPC 3G). D, A slip-cast spinel ceramic (In-Ceram Spinell). E, A felds-
pathic machinable (VITA Mark II). F, A machined and sintered zirconia ceramic (Cercon).
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778
PART III
Table 25-1 COMPARISON OF AVAILABLE ALL-CERAMIC SYSTEMS
BRAND
LABORATORY PROCEDURES
In-
IPS IPS Empress Ceram
Captek Ceramco 3 Cerinate Empress Empress 2 Cosmo Finesse In-Ceram Spinell
Manufacturer Precious Dentsply Den-Mat Ivoclar Ivoclar Ivoclar Dentsply Vident Vident
Chemicals
Crystalline Leucite Leucite Leucite Leucite Lithium Lithium Leucite Alumina Alumina,
phase disilicate phosphate spinel
Recommended Crowns Inlays, Inlays, Inlays, Anterior 3- Endodontic Inlays, Crowns, Crowns,
usage onlays, onlays, onlays, unit foundation onlays, veneers veneers
veneers crowns, crowns, FDPs, crowns,
veneers veneers crowns veneers
Fabrication Sintered on Sintered Sintered Heat- Heat- Heat-pressed Heat- Slip-cast Slip-cast
metal foil pressed pressed pressed and and
sintered sintered
Strength Low Low Medium/ Medium/ High Medium Medium/ High High
low low low
Fracture Medium/ Medium/ Medium/ Medium/ High Medium Medium/ High High
toughness low low low low low
Translucency Opaque Medium Medium Medium Medium Medium Medium Opaque Medium
Enamel Medium Medium High Medium Low * Medium High High
abrasiveness
Marginal fit Good Fair Fair Fair Fair * * Fair Fair
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Chapter 25
BRAND
ALL-CERAMIC RESTORATIONS
In- YZ
Ceram blocs Cercon Procera Procera Metal-
Zirconia Mark II ProCAD (inVizion) Zirconia Lava Alumina Zirconia ceramic
Manufacturer Vident Vident Ivoclar Vident Dentsply 3M ESPE Nobel Nobel Various
Biocare Biocare
Crystalline Zirconia- Feldspar Leucite Zirconia Zirconia Zirconia Alumina Zirconia Leucite
phase alumina
Recommended 3-Unit Inlays, Inlays, Crowns, Crowns, Crowns, Crowns, Crowns, Crowns,
usage FDPs onlays, onlays, FDPs FDPs FDPs FDPs FDPs FDPs
crowns crowns
Fabrication Slip-cast CAD/CAM CAD/CAM CAD/CAM CAD/CAM CAD/CAM CAD/CAM CAD/CAM Cast
and and and and and and framework,
sintered sintered sintered sintered sintered sintered sintered
porcelain
Strength Very Medium/ Medium/ Very high Very high Very high High Very high Very high
high low low
Fracture Very Medium/ Medium/ Very high Very high Very high Very high Very high Medium
toughness high low low
Translucency Opaque Medium Medium Opaque Opaque Opaque Opaque Opaque Opaque
Enamel High Medium * * * * * * Medium
abrasiveness
Marginal Fair Fair * * * * * Good
fit
*Not tested.
CAD/CAM, computer-aided design/computer-aided manufacturer (or computer-assisted machining); FDP, fixed dental prosthesis.
779
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780 PART III LABORATORY PROCEDURES
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Chapter 25 ALL-CERAMIC RESTORATIONS 781
A B,C
D E,F
G H,I
J,K L,M
Fig. 25-4
Platinum matrix fabrication. A, A diamond-shaped foil is adapted to the facial surface (a cutting guide is provided with the foil). B,
Two cuts are made, one to each incisal corner, and a triangle of foil is removed by cutting at 45 degrees toward the corners. C, The
foil is folded onto the lingual surface and burnished. D and E, It is then gathered on the lingual surface with tweezers and adapted
with finger pressure. F, The foil is trimmed to follow the lingual contour evenly. The two ends are separated, and one is trimmed to
exactly half the width of the other. G and H, The long end is folded over the short end, and relieving cuts are made (see Fig. 25-5).
Then the three-thickness joint is folded toward the short end. I, The foil is adapted with a wooden point, always starting from the
incisal edge and working toward the margin. J, A beaver-tail burnisher is used to adapt the margin, working the foil toward the inter-
nal angle to prevent a perforation. Better adaptation can be achieved by swaging at this stage. The matrix is removed with sticky
wax (K) and annealed in a Bunsen flame (L) to relieve work hardening. M, The completed platinum foil matrix.
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A
B
C
Fig. 25-5
The tinner’s joint. A, Foil is trimmed so that one end is exactly twice as long as the
other. B, The long end is carefully folded over the short end. C, Margin discrepancy
at the joint can be reduced by removing a triangular section of foil.
A B,C
D E,F
G H
Fig. 25-6
Aluminous core technique. A to C, The platinum matrix is heated to drive off dissolved gases, and the core porcelain is built up. D,
A thin blade is used to form a cervical ditch, which will prevent the matrix from becoming distorted during the first firing. E, There
must be no porcelain particles on the inner aspect. F, The fired core should be checked with a thickness gauge. Often additional
core material is needed to obtain the recommended dimensions. G, The foil is readapted to the margin, and the ditch is filled with
additional porcelain. This lingual view shows where the core should be thickest. For esthetic reasons, the core is much thinner on
the facial surface. H, The core is seated on the definitive cast before the application of body and incisal porcelains.
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Chapter 25 ALL-CERAMIC RESTORATIONS 783
A B
C D
E F
Fig. 25-7
A to C, All-ceramic fixed dental prosthesis (FDP) replacing the maxillary left central incisor, through the use of the In-Ceram system.
D to F, All-ceramic FDP replacing the mandibular left first premolar, through the use of the Empress 2 system. (D to F, Courtesy of Ivoclar
Vivadent, Inc., Amherst, New York.)
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784 PART III LABORATORY PROCEDURES
A B
Fig. 25-8
A, Defective maxillary metal-ceramic crowns. Esthetic problems included high value and opacity. B, Crowns removed. The prepa-
rations are not discolored and thus allow a translucent all-ceramic crown system. C, Maxillary all-ceramic crowns with a translucent
slip-cast spinel core material. (Courtesy of Dr. R. B. Miller.)
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Chapter 25 ALL-CERAMIC RESTORATIONS 785
A B,C
D,E F,G
H I,J
Fig. 25-9
Fabrication of a slip-cast alumina restoration. A, The In-Ceram system relies on a high-strength core veneered with an esthetic felds-
pathic porcelain. B, The definitive cast is duplicated with a special elastomer. C, The special plaster die. D, The alumina slip is ultra-
sonically mixed and applied to the plaster die (E). F, The VITA Inceramat special porcelain furnace. G, A special colored infiltration
glass is painted on the porous sintered alumina and fired. H, Excess glass is carefully removed by grinding and air abrasion. I,
Finished substructures on the definitive cast. J, Body and incisal porcelains are applied and fired in the conventional manner. (A,
Courtesy of Morehead Dental Laboratories, Morehead, Kentucky. B to J, Courtesy of Vident, Brea, California.)
alumina is fired at 1120° C (2048° F). The crowns, as shown in Figure 25-10. Powder
resulting core is porous and weak at this stage distribution is governed by a detailed prescrip-
but can be carefully transferred to the master tion of the patient’s shade (see Chapter 23).
die after the die spacer is removed. The rela- With experience, the technician will be able
tively low sintering shrinkage (about 0.3%) is to mix different powders to match almost
compensated for by an expansion of the refrac- any shade. If necessary, test firings can be used
tory material. to help select the correct blend in difficult
4. Paint a thick coat of the appropriate shade of situations.
glass mixture onto the surface of the core (see 6. After moistening the core, mix the powder with
Fig. 25-9G) and fire at 1100° C (2012° F). As the modeling liquid and apply in increments with a
glass melts, it is drawn into the interstices of the brush (see Fig. 25-10A to C).
alumina by capillary action, producing a dense 7. Remove moisture with a paper tissue held
composite structure with excellent strength against the lingual surface. The capillary action
properties. condenses the porcelain particles. Slight vibra-
5. Remove excess glass from the core by grinding tion brings further moisture to the surface
(see Fig. 25-9H) and airborne particle abrasion. before the next increment is added. To prevent
Body and incisal porcelain is applied to the core voids from forming between increments, always
in a manner similar to that for metal-ceramic add to a moist surface.
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786 PART III LABORATORY PROCEDURES
A B
C D
E F,G
Fig. 25-10
Body and incisal porcelain application. A, Moistening the high-strength core. B and C, Applying gingival and body porcelains. D, Cut-
back for the incisal porcelain. E, The incisal porcelain. F, Adding to the interproximal areas. G, The completed buildup. H, The fired
crown is seated on the definitive cast.
8. When the crown has the correct shape, cut it 10. Lightly condense the buildup with a large whip-
back to allow room for incisal porcelain (see Fig. ping brush. Absorb excess moisture with a
25-10D). tissue.
9. Apply incisal porcelain, overbuilding the incisal 11. Remove the crown from the definitive cast and
edge by 1 or 1.5 mm to allow for firing shrink- add material interproximally to allow for
age (see Fig. 25-10E). shrinkage (see Fig. 25-10F).
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Chapter 25 ALL-CERAMIC RESTORATIONS 787
12. Dry the crown and fire it (see Fig. 25-10G a glassy matrix. The crystal size varies from 3 to
and H). 10 mm, and the leucite content varies from about
35% to about 50% by volume, depending on the
material. Research has shown that residual tangen-
Heat-Pressed Ceramics tial stresses remain around the leucite crystals after
cooling.12 Ceramic ingots are pressed at a high tem-
Leucite based perature (about 1165° C [2130° F]) into a refractory
Heat-pressed ceramics have been popular in mold made by the lost-wax technique. The ceramic
restorative dentistry since the early 1990s. The ingots are available in different shades. Two finish-
restorations are waxed, invested, and pressed in a ing techniques can be used: a characterization tech-
manner somewhat similar to that for gold casting. nique (surface stain only) and a layering technique,
Marginal adaptation seems to be better with heat involving the application of a veneering porcelain
pressing than with the high-strength alumina core (Fig. 25-11G and H). The two techniques lead to
materials,45 although the results from individual comparable mean flexural strength values for the
dental laboratories may not support the research resulting porcelain composite.46 The thermal expan-
findings. Most heat-pressed materials contain leucite sion coefficient of the core material for the veneer-
as a major reinforcing crystalline phase, dispersed in ing technique is usually lower than that of the
A B,C
D E,F
G H
Fig. 25-11
Heat-pressed ceramic technique. A, Ceramic inlay restoration for a maxillary molar. A wax pattern is made in a manner similar to
that for conventional gold castings. B, After the pattern is invested, it is burned out, and a ceramic ingot and alumina plunger are
placed in the heated mold. C and D, The pressing is done under vacuum at 1165° C. E, Sprue removal. F, The pressed restoration
seated on the die. G and H, For esthetic anterior restorations, only the dentin-colored ceramic is pressed. The incisal porcelain is
brush applied in the conventional manner.
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788 PART III LABORATORY PROCEDURES
I J
K L
M N
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Chapter 25 ALL-CERAMIC RESTORATIONS 789
O P
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790 PART III LABORATORY PROCEDURES
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Chapter 25 ALL-CERAMIC RESTORATIONS 791
A B
C D,E
F G,H
Fig. 25-12
Cerec 3 computer-assisted design/computer-assisted machining (CAD/CAM) system. A, The Cerec 3 system consists of an imaging
system, a computer, and a milling system. B, Making an optical impression. C, Image of a prepared tooth. D, The preparation is
marked and the restoration designed on the computer screen. E and F, Blocks are available in different ceramic systems, as is com-
posite resin (G). H, The restoration is machined from the block.
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I J
K L
A B
C D
Fig. 25-13
The Procera All Ceram system. A, Tooth preparations for Procera crown on the maxillary anterior teeth. B, Completed restorations.
C, Tooth preparations for Procera fixed dental prosthesis. D, High-strength framework. Body and incisal porcelains will be subse-
quently applied. (A and B, Courtesy of Dr. E. van Dooren; C and D, Courtesy of Dr. E. Hagenbarth.)
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Chapter 25 ALL-CERAMIC RESTORATIONS 793
4. The shape of the prepared tooth is transferred to works all-ceramic restorations.58 The preparations
the computer screen. are scanned, and frameworks are milled from presin-
5. The design of the restoration is transferred to the tered zirconia blanks. The size of the frameworks is
manufacturer via computer line. precisely increased to allow for the shrinkage that
6. The production process starts with milling an occurs during sintering. Once a framework has been
enlarged die to compensate for the sintering sintered, it is veneered with layered esthetic porce-
shrinkage. lains in a manner similar to that for the metal-
7. An enlarged high-alumina coping is milled; it ceramic technique.
shrinks to the desired shape after sintering.
8. The coping is returned to the laboratory, and body
Metal-Reinforced Systems
and incisal porcelains are applied in the conven-
tional manner. High-gold substructure systems are designed to over-
come some of the disadvantages inherent in the
Lava system* porcelain jacket crown technique. The systems rely
In the Lava system (Fig. 25-14), a CAD/CAM proce- on different ways of creating a thin coping onto
dure is used for the fabrication of zirconia frame- which the ceramic is fired. In strictest terms, there-
fore, they are metal-ceramic, as opposed to all-
*3M ESPE, St. Paul, Minnesota. ceramic crowns.
A B
C D
Fig. 25-14
The Lava system. A, Lava computer-assisted design/computer-assisted machining (CAD/CAM) designing and milling machine. B,
Computer design of framework. C and D, Framework milled from zirconia block.
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794 PART III LABORATORY PROCEDURES
E F
G H
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Chapter 25 ALL-CERAMIC RESTORATIONS 795
A B,C
D E,F
G H,I
Fig. 25-15
The Captek system. A, Duplicated refractory die. B, Trimming the metal-impregnated wax sheet. C, Adapting the first sheet to the
die. The first layer is fired to form a porous coping. D, Adapting the second metal-impregnated wax sheet. E, Fired framework. F,
Sectioned Captek crown showing coping design. G, Defective metal-ceramic crown on the maxillary incisors replaced with Captek
crowns (H). I, Partial fixed dental prosthesis frameworks can be fabricated with special pontic components. (Courtesy of Captek, a Divi-
sion of Precious Chemicals, Altamonte Springs, Florida.)
5. Build up the opaque body and incisal porcelains may have a slightly inferior marginal adaptation
in a manner similar to that for a conventional than does a metal-ceramic crown.
metal-ceramic crown (Fig. 25-15F).
6. Glaze the completed restoration, and polish the
Fracture Resistance
metal foil at the margin (Fig. 25-15G and H).
The procedure has been adapted for FDPs (Fig. Most hazards of restoration failure are removed if
25-15I). these restorations are confined to lower stress ante-
rior teeth, and patients are carefully evaluated for
evidence of parafunctional activity. Although labora-
SELECTION OF ALL-CERAMIC SYSTEMS tory testing of strength and fracture toughness has
The primary purpose in recommending an all- identified promising materials,38,61 clinical studies
ceramic restoration is to achieve the best possible have consistently shown good performance on ante-
esthetic result. Typically this is at the risk of reduced rior teeth and yet poor performance on molars and
restoration longevity, because of the potential for for FDPs.62-64 Although the newer materials, such
fracture of the ceramic material, and the restoration as alumina- and zirconia-based ceramics, promise
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796 PART III LABORATORY PROCEDURES
higher strength (see Table 25-1), the long-term data when one ceramic color is pressed. The platinum
to determine whether they are satisfactory, particu- matrix technique is tedious and somewhat challeng-
larly for FDPs, are lacking.48,65,66 ing to learn, but once acquired, it enables the techni-
cian to make veneers with better marginal adaptation
than does the refractory technique.75 Therefore, the
Esthetics
platinum matrix technique is described here. Many of
A knowledge of the available ceramic systems is the steps are similar to those of the porcelain jacket
needed to select a material that will provide the crown technique (see Fig. 25-4).
best esthetics for a particular patient. This is espe-
cially important when a single maxillary incisor is
Step-by-Step Procedure
matched to an adjacent tooth. Careful consideration
should also be given to the availability of laboratory 1. Modify the working die by blocking out tooth
support, because no dental laboratory invests in the undercuts with modeling plastic.
expensive equipment needed for all the various 2. Adapt the platinum foil (0.025 mm [0.001 inch])
systems. The marginal adaptation of the system is in the same manner as described for the porce-
very important, even when resin bonding is used. lain jacket crown, covering the entire tooth. Some
When selecting a system, the dentist should care- technicians prefer to adapt the foil to the facial
fully evaluate the internal and marginal adaptation, surface only, but distortion of the foil during firing
using an elastomeric detection paste.* Although of the porcelain seems to lead to inferior marginal
research studies have identified differences among adaptation.76 Careful adaptation is essential for a
the various systems67 (see Table 25-1), these results good fit, especially at the proximal incisal margin,
may not represent an individual laboratory’s results. where the tinner’s joint is made.
The translucency of the adjacent teeth and dis- 3. Remove, clean, and degas the foil. Airborne par-
coloration of the tooth being restored also must ticle abrasion can be used for this step.
be considered when the most appropriate system 4. Build up and fire the veneers. This is generally
is selected.68 A more opaque, high-strength core, done in two or three layers, particularly if the
ceramic system (e.g., In-Ceram or Procera) would veneer is necessary to mask tetracycline stain-
not be a good choice for highly translucent teeth. ing and a more opaque initial layer is applied.
However, such a system might be a good choice if Sometimes tetracycline staining can be more
the tooth exhibits discoloration that would not be effectively masked by incorporating the comple-
well masked by a more translucent material. mentary hue in the ceramic buildup, rather
Conversely, when fracture is a concern, the higher than fabricating a veneer that is unesthetically
strength materials should normally be given prefer- opaque looking. With experience, a technician
ence (see Table 25-1). can achieve excellent results with porcelain labial
veneers. Special formulations of porcelain are
available for veneers. Some are based on tradi-
Abrasiveness
tional jacket or metal-ceramic porcelain systems;
One concern with ceramic restorations is the poten- higher-strength, high-leucite content formula-
tial for abrasion of the opposing enamel, particularly tions are also available. Fracture of porcelain
in patients with parafunctional habits. Whenever labial veneers is sometimes encountered in prac-
possible, a low-abrasion material should be consid- tice, even though the restorations are generally
ered. Abrasiveness has been studied in vitro,69-74 and placed in low-stress situations. At present, there is
the results are summarized in Table 25-1. little information about the incidence of veneer
fracture or whether a high-strength ceramic has
better performance than a traditional formula-
PORCELAIN LABIAL VENEER tion. When a fracture does occur, the broken
Porcelain labial veneers (see Chapter 11) can be pieces are often still firmly bonded to the tooth.
fabricated by means of a refractory die technique, At that point, it is probably not necessary to
as well as on a platinum matrix† and with heat- replace the restoration unless the fracture line is
pressed-ceramics. The heat-pressed technique is stained or the ceramic is chipped.
popular, but there are limitations to the esthetic effect 5. Contour and glaze the facings. The veneers
should be shaped to final contour at this stage.
6. Remove the foil before try-in. The steps for
*This must be thoroughly removed before the restoration is bonded. etching, silanating, and luting the veneers are
†
Porcelain labial veneers can also be made with the machinable systems. presented in Chapter 31.
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Chapter 25 ALL-CERAMIC RESTORATIONS 797
INLAYS AND ONLAYS 12. If necessary, adjust the restoration margins and
occlusion with fine-grit diamond stones. Polish
Refractory Dies with diamond polishing paste.
Ceramic restorations are normally made through
the use of the heat-pressed systems, but some ALL-CERAMIC PARTIAL FIXED DENTAL
technicians prefer a refractory die (Fig. 25-16). PROSTHESES
Marginal adaptation can be excellent, depending
All-ceramic FDPs have a checkered history. Their
more on the technician’s skill than on the ceramic
construction was attempted with aluminous porce-
material used.78
lain by connecting alumina cores with pure alumina
rods. These restorations were usually unsuccessful;
Step-by-Step Procedure either they fractured or the restorations encroached
excessively into the embrasures, resulting in hygiene
1. Pour an elastomeric impression of the prepared
deficiencies. Leucite-containing heat-pressed ceram-
teeth in type IV or V stone; then repour it or
ics do not appear to possess adequate strength for
duplicate it in ceramic refractory, using an
FDPs, except in very low-stress situations. Clinical
appropriate removable die system. The Di-Lok
trials of posterior ceramic FDPs have yielded disas-
(see Chapter 17) or a similar system is conven-
trous results.33,77 The InCeram Zirconia has much
ient for this technique. The dies need to be sep-
higher laboratory strength than these materials and
arated very carefully because the refractory is
might be suitable for FDP frameworks. In-Ceram
friable and breaks if mishandled.
Alumina was somewhat successful for anterior
2. Trim the refractory cast as far as possible to
FDPs (see Fig. 25-7). The more recent lithium di-
minimize the quantity of ammonia released
silicate heat-pressed ceramic, Empress 2, and the
during decontamination.
CAD/CAM Procera systems have also been recom-
3. Mark the margins lightly with a special pencil
mended as suitable for anterior FDPs. Although the
(V.H.T.*)
newer materials might be successful for FDPs, their
4. Decontaminate the cast by firing according to
manufacturers recommend a design with substantial
the manufacturer’s instructions. Normally this is
connectors (typically 4 × 4 mm, as opposed to 2 × 3
done in two stages: the first in a burnout
mm recommended for metal connectors). These
furnace, the second under vacuum in a porce-
dimensions can lead to problems with adequate
lain furnace.
access for cleaning and poor esthetics.
5. Allow the cast to cool, and then soak it in soaking
liquid or distilled water for 5 minutes. This seals
the die and prevents moisture from being drawn ALL-CERAMIC FOUNDATION
out of the porcelain buildup. RESTORATIONS
6. Apply an initial layer of porcelain to the
All-ceramic materials have been used as foundation
refractory cast and fire according to the manu-
restorations for endodontically treated teeth78,79 to
facturer’s directions. With some systems, a
overcome esthetic problems associated with metal
higher strength core material is used as the
post and core systems (see Chapter 12). The post is
initial coat.
made of zirconia,* chosen for its excellent strength,80
7. Build up the restorations onto moist dies; for
and, depending on the system, the core material can
inlays, leave short of the margins.
be composite resin or a pressable ceramic.†
8. Make a relieving cut through the central fossa,
and fire the porcelain.
9. Fill in the central fossa area and build up to the RESIN-BONDED CERAMICS
margins.
The performance of all-ceramic restorations has
10. Contour and refine occlusion and proximal con-
been enhanced by the use of resin bonding. This
tacts. Glaze according to the manufacturer’s
technique was first devised for the porcelain lami-
instructions.
nate veneer technique81,82 and has been applied to
11. Remove the investment with a bur and 50-mm
other ceramic restorations. The technique entails the
alumina in an airborne particle abrasion unit.
Transfer the restorations to the master dies on
the mounted cast.
*CosmoPost, Ivoclar Vivadent; Biopost, Incermed SA, Lausanne,
Switzerland; TZP-post, Maillefer, Ballaigues, Switzerland.
†
*Whip Mix Corporation, Louisville, Kentucky. Empress, Cosmo, Ivoclar Vivadent, Inc., Amherst, New York.
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798 PART III LABORATORY PROCEDURES
A B,C
D E,F
G H,I
J,K L,M
Fig. 25-16
Fabrication of facial veneers and ceramic onlay with the refractory die technique. A, A surfactant debubblizer is used to spray the
impression, after which it is lightly blown dry. B, Pouring the impression with die stone. C, Marking the preparation margins before
die spacing and duplicating the cast with an elastomeric duplicating material (D). E, The mold is filled with the refractory invest-
ment. F, A die-lock system can be used; alternatively, a reverse dowel pin can be used with the dowel pin remaining in the cast base
(G). H, As another alternative, special high-heat dowel pins* can be used. I, Marking margins with special pencil.† J, Decontaminat-
ing the investment. K, The blue margin marking turns red during this firing. L, The dies are soaked in distilled water until bubbling
disappears. M, Adjacent proximal areas are coated with die hardener to prevent moisture from being absorbed into the cast.
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Chapter 25 ALL-CERAMIC RESTORATIONS 799
N O,P
Q R,S
T U,V
use of hydrofluoric acid or a less toxic substitute to Procera. Nevertheless, for feldspathic and leucite-
etch the ceramic and a silane* coupling agent to reinforced ceramics, resin bonding is now the rec-
bond a resin luting agent to the ceramic. The lut- ommended procedure and is also used extensively
ing agent is bonded to enamel after etching with for luting ceramic inlays and onlays.85
phosphoric acid, as with resin-retained FDPs (see
Chapter 26), and bonded to dentin with a dentin-
Etching and Silanating the Restoration
bonding agent. Significant reduction in the fracture
incidence of some types of ceramic crowns has been 1. Support the restoration in soft wax with the fitting
reported when an adhesive cement has been used,83 surface uppermost.
although one retrospective study failed to reveal 2. Apply a 1-mm coat of the etching gel† to the
an improvement in comparison with traditional fitting surface only.
cements.84 Resin bonding does not appear to 3. The etching time depends on the ceramic mate-
improve the fracture resistance of the high-strength rial. Feldspathic porcelain is typically etched for
alumina core materials such as In-Ceram and 5 minutes.
†
*Compounds of silicon and hydrogen and other monomeric compounds Ceram-Etch gel (9.5% hydrofluoric acid), Gresco Products, Inc., Stafford,
that are used as coupling agents, inorganic materials to organic resins. Texas (or the ceramic manufacturer’s recommended product).
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800 PART III LABORATORY PROCEDURES
? STUDY QUESTIONS
?
1. Discuss the advantages and disadvantages, indications, and contraindications of all-ceramic crowns.
2. Which all-ceramic system might be considered for a partial fixed dental prosthesis? What are the limitations
with all-ceramic restorations in this application?
3. Compare the fabrication steps for a slip-cast versus a heat-pressed ceramic system. What are the advantages
of each?
4. Describe the fabrication steps for laminate veneers.
5. What are the currently available CAD/CAM systems? What are the advantages and limitations of these
restorations?
For many years, porcelain jacket crowns have been CAD-CAM: acronym for Computer Aided Design-
the most esthetic of fixed restorations. Unfortunately, Computer Aided Manufacturer (or Computer Assisted
they have a number of disadvantages in comparison Machining)
with the more popular metal-ceramic crowns, castable ceramic \kăst¢a-bl se-răm¢ik\: for dental applica-
including inferior mechanical properties and tions, a glass-ceramic material that combines the prop-
increased technical difficulties associated with erties of a restorative material for function with the
obtaining adequate margin fit. capability to be cast using the lost wax process
Improved materials and the bonded ceramic tech-
nique have renewed interest in all-ceramic restora- ce·ram \sa-răm\ n: a heat treatment process that converts
tions. Porcelain laminate veneers have proved to be a specially formulated glass into a fine grained glass-
conservative and esthetic alternatives to complete ceramic material
coverage. Porcelain inlays and onlays may provide a 1
ce·ram·ic \sa-răm¢ik\ adj (1850): of or relating to the
durable alternative to posterior composite resins manufacture of any product made essentially from a non-
without the extensive tooth preparation needed for metallic mineral (as clay) by firing at a high temperature
crowns. The highest-strength materials may be suit-
able for high-stress applications, including FDPs.
*Reprinted in part from The Journal of Prosthetic Dentistry, Vol. 94, No. 1,
However, they are relatively new and still lack the The Glossary of Prosthodontic Terms, 8th Edition, pp. 10–81, © 2005,
support of long-term clinical experience and with permission from The Editorial Council of The Journal of Prosthetic
research. Dentistry.
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Chapter 25 ALL-CERAMIC RESTORATIONS 801
ceramic crown \sa-răm¢ik kroun\: a ceramic fixed dental the attainment of a smooth and reflective surface 3: the
prosthesis that restores a clinical crown without a sup- final firing of porcelain in which the surface is vitrified
porting metal framework and a high gloss is imparted to the material 4: a ceramic
veneer on a dental porcelain restoration after it has
ceramic flux \sa-răm¢ı̆k flŭks\: a glass modifier; metallic
been fired, producing a nonporous, glossy or semi-glossy
ions such as calcium, potassium or sodium, usually as
surface—see NATURAL G., OVERGLAZE
carbonates, which interrupt the oxygen/silica bond, thus
enhancing fluidity hydroxyapatite ceramic \hı̄-drŏk¢sē-ăp¢a-tı̄t sa-răm¢ı̆k\: a
composition of calcium and phosphate in physiologic
ce·ram·ics \sa-răm¢iks\ n 1: compounds of one or more
ratios to provide a dense, non-resorbable, biocompatible
metals with a nonmetallic element, usually oxygen. They
ceramic used for dental implants and residual ridge
are formed of chemical and biochemical stable sub-
augmentation
stances that are strong, hard, brittle, and inert noncon-
ductors of thermal and electrical energy 2: the art of in·lay \ı̆n-lā¢, ı̆n¢lā¢\ n (1667): a fixed intracoronal restora-
making porcelain dental restorations tion; a dental restoration made outside of a tooth to cor-
respond to the form of the prepared cavity, which is then
cermet \sûr¢mĕt\ (1998): fused glass powder with silver
luted into the tooth
particles formed through high temperature sintering of a
mixture of the two minerals intrinsic coloring \ı̆n-trı̆n¢zı̆k, -sı̆k kŭl¢ar-ı̆ng\: coloring
1 from within; the incorporation of a colorant within the
cop·ing \kō¢pı̆ng\ n 1: a long, enveloping ecclesiastical
material of a prosthesis or restoration
vestment 2a: something resembling a cope (as by con-
cealing or covering) 2b: coping ion exchange strengthening \ı̄¢an, ı̄¢ŏn¢ ı̆ks-chănj¢
2 strĕngk¢tha-nı̆ng\: the chemical process whereby the
cop·ing \kō¢pı̆ng\ n (ca. 1909): a thin covering or crown—
surface of a glass is placed in compression by the replace-
usage: see C. IMPRESSION, TRANSFER C.
ment of a small ion by a larger one while maintaining
core \kôr, kōr\ n (14c): the center or base of a structure chemical neutrality
1
etch \ĕch\ vb, vt (1634) la: to produce a retentive surface, mam·e·lon \măm¢a-lŏn\ n: one of three tubercles
especially on glass or metal, by the corrosive action of an sometimes found on the incisal edges of incisor teeth—
acid lb: to subject to such etching 2: to delineate or mam·e·lon·at·ed \măm¢a-la-nā¢tı̆d\ v, mam·e·lon·a·tion
impress clearly \măm¢a-la-nā¢shun\ n
2
etch \ĕch\ n (1896) 1: the effect or action of an etching mi·cro·crack \mı̄¢krō-krăk\ n: in porcelain, one of the
acid on a surface 2: a chemical agent used in etching numerous surface flaws that contributes to stress con-
etch·ant \ĕch¢ănt\ n: an agent that is capable of etching a centrations and results in strengths below those
surface theoretically possible
etch·ing \ĕch¢ing\ vt (1632) 1: the act or process of selec- natural glaze \năch-ar-al, năch¢ral glāz\: the production of
tive dissolution 2: in dentistry, the selective dissolution a glazed surface by the vitrification of the material itself
of the surface of tooth enamel, metal, or porcelain and without addition of other fluxes or glasses
through the use of acids or other agents (etchants) to o·paque \ō-pāk¢\ adj (1641): the property of a material
create a retentive surface that absorbs and/or reflects all light and prevents any
fir·ing \fı̄r¢ı̆ng\: the process of porcelain fusion, in dentistry, transmission of light
specifically to produce porcelain restorations o·ver·glaze \ō¢var-glāz\ adj (1879): the production of a
flu·o·res·cence \flŏŏ-rĕs¢ens\ n (1852): a process by which glazed surface by the addition of a fluxed glass that
a material absorbs radiant energy and emits it in the usually vitrifies at a lower temperature
form of radiant energy of a different wavelength band, pig·ment \pı̆g¢mant\ n (14c): finely ground, natural or syn-
all or most of whose wavelengths exceed that of the thetic, inorganic or organic, insoluble dispersed particles
absorbed energy. Fluorescence, as distinguished from (powder), which, when dispersed in a liquid vehicle, may
phosphorescence, does not persist for an appreciable provide, in addition to color, many other essential prop-
time after the termination of the excitation process erties such as opacity, hardness, durability, and corrosion
glass-ceramic \glăs sa-răm¢ik\: a solid material, partly resistance. The term is used to include an extender,
crystalline and partly glassy, formed by controlled crys- white or color pigments. The distinction between
tallization of a glass powders that are pigments and those that are dyes is
generally considered on the basis of solubility—pigments
glaze \glāz\ vb glazed \glāzd\; glaz·ing \glā¢zı̆ng\ vt (14c) being insoluble and dispersed in the material, dyes being
1: to cover with a glossy, smooth surface or coating 2: soluble or in solution as used
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802 PART III LABORATORY PROCEDURES
platinum foil \plăt¢n-um foil\: a precious-metal foil with a 2. Ehrlich A: Erosion of acrylic resin restorations
high fusing point that makes it suitable as a matrix for [Letter]. J Am Dent Assoc 59:543, 1959.
various soldering procedures as well as to provide an 3. Söremark R, Bergman B: Studies on the perme-
internal form for porcelain restorations during their ability of acrylic facing material in gold crowns, a
fabrication laboratory investigation using Na. Acta Odontol
Scand 19:297, 1961.
por·cel·ain \pôr¢sa-lı̆n, pōr¢-\ n (known in Europe, ca. 4. Lamstein A, Blechman H: Marginal seepage
1540): a ceramic material formed of infusible elements
around acrylic resin veneers in gold crowns. J Pros-
joined by lower fusing materials. Most dental porcelains
thet Dent 6:706, 1956.
are glasses and are used in the fabrication of teeth
5. Weinstein M, Weinstein AB: Fused Porcelain-to-
for dentures, pontics and facings, metal ceramic
Metal Teeth. U.S. Patent No. 3,052,982, September
restorations, including fixed dental prostheses, as well
11, 1962.
as all-ceramic restorations such as crowns, laminate
6. Vines RF, Semmelman JO: Densification of dental
veneers, inlays, onlays, and other restorations
porcelain. J Dent Res 36:950, 1957.
po·ros·i·ty \pa-rŏs¢ı̆-tē, pô-\ n, pl -ties (14c) 1: the pres- 7. Hondrum SO: A review of the strength properties
ence of voids or pores within a structure 2: the state or of dental ceramics. J Prosthet Dent 67:859, 1992.
quality of having minute pores, openings or interstices— 8. Denry IL: Recent advances in ceramics for den-
see BACK PRESSURE P., OCCLUDED GAS P., SHRINK- tistry. Crit Rev Oral Biol Med 7:134, 1996.
SPOT P., SOLIDIFICATION P. 9. Jones DW, Wilson HJ: Some properties of dental
ceramics. J Oral Rehab 2:379, 1975.
refractory cast \rı̆-frăk¢ta-rē kăst\: a cast made of a mate- 10. Kelly JR, et al: Fracture surface analysis of dental
rial that will withstand high temperatures without disin- ceramics: clinically failed restorations. Int J
tegrating—called also investment cast Prosthodont 3:430, 1990.
si·li·ca \sı̆l¢ı̆-ka\ n (ca 1301): silicon dioxide occurring in 11. Mackert JR Jr: Isothermal anneal effect on micro-
crystalline, amorphous, and usually impure forms (as
crack density around leucite particles in dental
quartz, opal, and sand, respectively)
porcelain. J Dent Res 73:1221, 1994.
12. Mackert JR Jr: Effect of thermally induced changes
2
sinter \sı̆n¢tar\ vt (1871): to cause to become a coherent on porcelain-metal compatibility. In Preston JD, ed:
mass by heating without melting Perspectives in Dental Ceramics, Proceedings of the
2
Fourth International Symposium on Ceramics, pp
stain \stān\ vb (14c) 1: to suffuse with color 2: to color by 53-64. Chicago, Quintessence Publishing, 1988.
processes affecting chemically or otherwise the material 13. Mackert JR Jr, Williams AL: Microcracks in dental
itself 3: in dentistry, to intentionally alter restorations porcelain and their behavior during multiple
through the application of intrinsic or extrinsic colorants firing. J Dent Res 75:1484, 1996.
to achieve a desired effect, best termed characterization 14. Anusavice KJ, et al: Influence of initial flaw size on
or to characterize a restoration crack growth in air-tempered porcelain. J Dent Res
static fatigue \stăt¢ı̆k fa-tēg\: the delayed failure of glass 70:131, 1991.
and ceramic materials resulting from stress enhanced 15. Weibull W: A statistical theory of the strength of
chemical reactions aided by water vapor acting on material. Ing Vetensk Akad Proc 151:1, 1939.
surface cracks. Analogous to stress corrosion occurring 16. Davidge RW, Green TJ: The strength of two-
in metals phase ceramic/glass materials. J Mater Sci 3:629,
1968.
trans·luc·en·cy \trăns¢lōō¢san-sē\ n (1611): having the 17. Dunn B, et al: Improving the fracture resistance of
appearance between complete opacity and complete dental ceramic. J Dent Res 56:1209, 1977.
transparency; partially opaque 18. Seghi RR, et al: The effect of ion-exchange on the
flexural strength of feldspathic porcelains. Int J
veneer \va-nîr¢\ n (1702): 1. a thin sheet of material
Prosthodont 3:130, 1990.
usually used as a finish 2. a protective or ornamental
19. Denry IL, et al: Enhanced chemical strengthening
facing 3. a superficial or attractive display In multiple
of feldspathic dental porcelain. J Dent Res
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72:1429, 1993.
20. Anusavice KJ, et al: Strengthening of porcelain by
ion exchange subsequent to thermal tempering.
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