All Ceramic Restorations in Fixed Prosthodontics

2.  1789- First porcelain denture
› De Chemant, French
dentist
 -Expensive $$
 1903- Introduced the first
porcelain “jacket” crown
› Dr. Land
 -Process, bonding
 1950’s- PFM crown
› Dr. Weinstein
 -Esthetics, bonding

3.  1965- First all ceramic crown
› Dr. McLean & Hughes
 + 2X stronger vs. PJC
 - Opaque
 1980’s- Pressed all ceramic
crowns
› Dr. Horn/Simonsen
 Introduction to bonded
restorations
 1990’s- CAD/CAM
 2020’s- ??

4.  Comes from the Greek word “keramos” meaning “burnt
earth”
 Earth material -> Mold- > Heated- > Cooled
 Earliest ceramics date back 20,000 yrs (China)
 Ceramic- compound of inorganic, non-metallic
materials made by the heating of raw minerals at high
temperatures
 Ceramics in dentistry > 200 years
 Porcelain is a type of ceramic

5.  Esthetics
 Biocompatibitly
 Preservation of tooth structure
 Strength

6.  Esthetics is the primary indication for ACR’s
 All ceramic materials closely mimics the optical properties of natural
tooth structure.
 Translucency: Can light penetrate the material?
› Enamel =70% / Dentin= 30% (source of color)
› Translucency= “lifelike” appearance
 All-ceramic materials exhibit superior optical properties compared
to PFM restorations. (Michalakis et al. 2004)

7.  Ceramic’s are biocompatible,
essentially bio-inert.
› No cellular/tissue response
 Zirconia Implants
 Zirconia in hip-
replacement therapy
 Certain metal alloys are not
completely biocompatible
which may create:
 Gingival inflammation
 Tissue discoloration
 Release of metallic
ions
 Allergies
 Rare (4-11%)

8.  “Today’s philosophy is to NOT remove any healthy tooth
structure unless absolutely necessary” (McLaren et al.
Compendium. 2010)
 “The most common complication with single MCR is the
need for endodontic therapy” (Goodacre et al. J Prosthet
Dent. 2003 )
 “Bonding makes it possible to preserve as much tooth
structure as possible while satisfying the patients restorative
needs and esthetic desires” (Strassler, HE. Gen Dent. 2007)

9.  The strength of ceramic materials
is measured by the materials
flexural strength (MPa)
› ACR’s ranges 65-1500 MPa
 How much occlusal force can we
generate?(Calderon et al. 2006)
 Anterior teeth ~200N
 Posterior teeth ~500N
 Bruxers > 500N
 Monolithic vs. metal-ceramic?
› Porcelain Fractures ( ~70Mpa)
 Resin bonded cements help by
increasing the fracture resistance
of the restoration

10.  Glass Based Ceramics
› Feldspathic (1910)
 Particle Reinforced Ceramics
 Leucite (1980’s)
 Lithium Disilicate (2000’)
 High Strength Ceramics
› Alumina (1990’s)
› Zirconia (2000’)

11.  Glass Based Ceramic
 3 Key Ingredients:
› Feldspar- 65% ( Silica based glass)
› Quartz- 25%
› Koalin- 10%
 How it’s made:
› Sintered (Powder/liquid)
› Pressed (lost wax)
› Milled (CAD/CAM)

12. CEREC Blocks
Vita Mark II
Powder/Liquid
Vita VM 7

13.  Pros
› Esthetics
 Mostly Glass
 Highly Translucent
› Conservative Prep
 0.5mm (min)
 Cons
› Strength
 70mPA
› Fabrication/Marginal Fit
 Porcelain shrinks (~20%)
 Indications
› Highly esthetic veneers
› Anterior crowns where
color masking is not an
issue

14. Courtesy of Killian
Smiles, Dental Lab

15.  Why reinforce feldspathic porcelain?
› Low strength (70 MPa)
› Expansion(crack formations)
› Limited use (veneers, single crowns)
 Two types of reinforcing particles:
› Leucite (1980’s, IPS Empress)
› Lithium- Disilicate (2000’s, IPS Emax.)

16.  Glass Based Ceramic
 Key ingredients
› Feldspar (glassy matrix)
› Leucite (crystal filler) ~40%/vol
 How it’s made:
› Sintered (powder/liquid)
› Pressed (lost wax)
› Milled (CAD/CAM)

17. Vita VMK
IPS Empress
Ivoclar
IPS Empress CAD
Ivoclar

18.  Pros
› Esthetics
 60% glass (~40% Leucite)
 Translucent
› Conservative prep
› Multiple shades
 Cons
› Strength
 120-180 MPa
 Indications
› veneers
› Inlays/onlays
› Anterior crowns
› Layered ceramic

19.  Case 1
› 16 y.o female
› Dx: Congenitally
missing #7 & peg
lateral #10.
› Tx: RBFPD (Maryland
Bridge) #6-8 & full
coverage ACR #10.
 IPS. Empress

20.  Case 2
› 26 y.o male
› Dx: Congenital peg
lateral #7-10
› Tx: Full coverage
ACR #7-10
 IPS. Empress
Special thanks to Mr. Medina !!

21.  Glass Based Ceramic
 Key Ingredients
› Feldspar (glassy matrix)
› Li-Disilicate (crystal filler) ~70%/vol
 How it’s made:
› Pressed
› Milled (CAD/CAM)

22. e.max pressed
Ivoclar
e.max CAD
Ivoclar

23.  Pros
› Esthetics
 30% glass (~70% Li-Di)
 Translucent
› Strength
 ~400 MPa
› Pressed/Milled
 0.3mm w/ pressed
 Cons
› Porcelain veneering
 Indications
› Veneers
› Inlays/onlays
› Crowns
› 3 unit FPD
 Anterior /premolar
› Implant Restorations
cut back technique

24.  Case 1
› 23 y.o. male
› Dx: #8 NSRCT
› Tx:
 Cast post core
 Li-Di ACR
 IPS Emax.

25.  Case 2
› 32 y.o. female
› Dx: Fractured Resin
FPD #13-15
› Tx: Li-Disilicate FPD
#13-15
 IPS Emax.

27.  These types of ceramics contain NO glass particles!
› No glass = No etch!!
 High strength ceramics are polycrystalline structures.
› Why?
 Strength (less susceptible to fracturing)
 Usually used as a core w/ porcelain veneered
 Two types:
› Alumina (1990’s)
› Zirconia (2000’s)
Leucite Zirconia

28. In-Ceram
Vita
Procera
Nobel Biocare
In-Ceram Block
Vita

29.  Pros
› Strength
 600-700MPa
› Pressed/Milled
› Block out coping
 RCT/ Cores/ Staining
 Cons
› Esthetics
 Translucency (low)
 Porcelain Veneering
› Adequate reduction
› Bonding
 Indication
› Single crowns
› FPD’s (<4 Units)
› Block out coping

30. CEREC InCoris
Sirona
IPS e.max
Ivoclar
Procera
Nobel Biocare

31.  Pros
› Strength
 800-1500MPa
› Framework
› Pressed/Milled
› Block out coping
 RCT/Cores/Staining
 Cons
› Esthetics
 Translucently (low)
 Porcelain Veneering
› Adequate reduction
› Bonding

32.  Indications
› Crowns (Anterior / Posterior)
 Bruxzir – full-contour crowns (monolithic)
› FPD’s ( Anterior / Posterior) < 14 units
› Implant abutments/crowns
› Coping to block out tooth structure
 RCT/ Cores/ Staining

33. More Glass More Crystals
Esthetics
Strength
Esthetics
Strength

34. IPS Emax. Pressed & CAD/CAM

35.  Limited interocclusal space
› Deep overbite
› Short clinical crowns (2nd
molars)
 Heavy occlusal forces
› History bruxism
 Sub-ginvival preparations
› If you’re relying on bonding
 Darkened tooth structures or cores
› May need PFM or Zirconia coping

36.  Glass-ceramic crowns have shown similar success rates to
conventional MCR’s.
› >94% success rate at 10 yrs.
 IPS emax (lithium Disilicate)
› Pressed : ~98% Success rate at 10 years.
› CAD/CAM: ~97% Success rate at 5 years.
 High Strength Ceramics (Zirconia)
› CAD/CAM: ~ 93 Success rate at 5 years. (#1 failure = chipping)
 Fracture and chipping of all-ceramic restorations are similar to those
of MCR’s. Monolithic crowns seem the way to go!!
 No one ceramic material is “the best”, based on individual case
selection

37.  Holloway, Spear. Which all ceramic system is optimal for anterior esthetics.
JADA. 2008.
 Nicholas et al. Optical Behavior of Current All Ceramic Systems. Int Journal of
Periodontics and Restorative Dent. 2005
 Nazirkar et al. An Evaluation of Two Modern All-Ceramic Crowns and their
comparison with Metal Ceramic Crowns in terms of the Translucency and
Fracture Strength. Int Jour of Dental Clinic. 2011
 Misrahi. The Anterior All-Ceramic Crown: A Rationale For the Choice of
Ceramic and Cement. British Dental Journal.2008.
 Michalakis et al. Light Transmission of Post and Cores Used for the Anterior
Esthetic Region. Int J Periodontics Restorative Dent. 2004
 Mclaren, Whiteman. Ceramics: Rational for Material Selection. Compendium.
November-December 2010.
 Levi et al. Allergic Reactions Associated with Metal Alloys in PFM fixed
prosthodontic devices- A Systematic Review. Quintessence Int. 2012.
 Powers et al. Guide to All Ceramic Bonding. Dental Advisor. 2010.
 Blatz et al. Resin-Ceramic Bonding: a review of the literature. Jour of
Prosthetic Dentistry. 2003.
 IPS e.max Scientific Report, vol. 01 / 2001-2011.