All Ceramic Materials and systems  The use of metal-ceramic restorations is still common today as they have predictable

strength and reasonable aesthetics however patient demand for improved aesthetics has driven the development of ceramic for use with inlays, onlays, crowns, FPDPs and implant supported restorations.  An all ceramic restoration means that both the core of the restoration and the veneering material are made from ceramic (usually a strong ceramic core with a more aesthetic veneering porcelain) o Veneering porcelains typically consist of a glass and crystalline phase of fluoroapatitie, aluminium oxide, or leucite.  There are multiple all ceramic materials and systems that are currently available for clinical use, there is not a single universal material or system for all clinical situations. The successful application is dependent upon the clinician to match the materials, manufacturing techniques and cementation or bonding procedures, with the individual clinical situation.  1965: Mclean pioneered the concept of adding Al2O3 to feldspathic porcelain to improve mechanical and physical properties o Shortcomings included: brittleness, crack propagation, low tensile strength, wear resistance and marginal accuracy therefore limited use of this material  Early 1990s: first dental application of zirconia. Used for endodontic posts, implants and implant abutments, orthodontic brackets, cores for crowns and fixed partial denture prosthesis (FPDP) frameworks.  The most commonly reported major clinical complication resulting in failure of all ceramic restorations is the fracture of the veneering porcelain and/or the coping.  The success of these systems is dependent upon preventing failure by retarding crack propagation.  Use of all ceramic systems for FPDPs has limitations and proper diagnosis and patient selection is critical for success. o Placement is contraindicated when there is reduced interocclusal distance, as with short clinical crowns, deep vertical overlap anteriorly without horizontal overlap, or an opposing super-erupted tooth, as well as for cantilevers, peridontally involved abutment teeth and patients with severe bruxism or parafunctional activity. o Primary cause of failure varies from fracture of the connector for aluminium-oxide FPDPs and lithium-disilicate FPDPs to cohesive fracture of the veneering porcelain, for zirconia FPDPs. o Metal-ceramic FPDPs differ in that they fail primarily due to tooth fracture and caries Different types of ceramics  Glass ceramics o IPS empress  Leucite reinforced glass ceramic  due to its strength its limited in use to single unit or complete coverage restorations in the anterior segment o IPS empress 2  Lithium disilicate glass ceramic that is fabricated through a combination of the lost wax and heat pressed technique.  A glass ceramic ingot of the desired shade is plasticized at 9200C and pressed into the investment mold under vacuum and pressure.  Improved flexural strength to empress 1 and can be used for 3-unit FPDPs in the anterior area and can be extended to the second premolar o IPS e.max  Introduced in 2005 as an improved press ceramic material compared to Empress 2.  Also consists of lithium disilicate pressed glass ceramic, but its physical properties and translucency are improved through a different firing process.

IPS proCAD  Leucite-reinforced ceramic similar to IPS empress, although it has finer particle size  Designed to be used with the CEREC in-lab system and is available in numerous shades, including a bleached shade and an aesthetic block line. Vita MarkII  Machinable feldspathic porcelain introduced in 1991 for the CEREC 1 system  Improved strength and finer grain size compared to Vita Mark I  Primarily composed of SiO2 AND Al2O3 and can be etched with hydrofluoric acid to create micro-mechanic retention for adhesive cementation with CR cements  It is a monochromatic material, however it is available in many shades and can be additionally characterised  To overcome the aesthetic disadvantage of a monochromatic restoration and to imitate optical effects of natural teeth, a multi-coloured ceramic block (vita TriLuxe Bloc, Vita Zahnfabrik) was designed to create a 3-dimensional multi layered structure. y Inner third has a dark opaque base layer y Middle third has a neutral zone y Outer third is more translucent

 Alumina based ceramics o In-Ceram Alumina  Introduced in 1989 and was the first all ceramic system available for single unit restorations and 3-unit anterior FPDPs  Has a high strength ceramic core fabricated through the slip-casting technique y A slurry of densely packed Al2O3 is applied and sintered to a refractory die at 1120oC for 10 hours. y This produces a porous skeleton of alumina particles which is infiltrated with lanthanum glass in a second firing at 1100oC for 4 hours to eliminate porosity, increase strength and limit potential for crack propagation. y Compressive stresses which further improve the strength are also introduced, due to the differences in the coefficient of thermal expansion of the alumina and glass  Alumina blanks are available for milling in combination with CEREC o In-Ceram Spinell  Introduced in 1994 as an alternative to the opaque core of In-Ceram Alumina  Contains a mixture of magnesia and alumina in the framework to increase translucency  Flexural strength, however, is lower than In-Ceram Alumina, and thus the cores are only recommended for anterior crowns.  This material can also be machined with the CEREC inLab system, followed by veneering with feldspathic porcelain. o Synthoceram  High strength glass impregnated aluminium oxide ceramic core fabricated through CIRCERO technology  Laser scanning, ceramic sintering, and computer integrated milling techniques are used to fabricate the cores, which are then veneered with a leucite-free glass ceramic o In Ceram Zirconia  Modification of the original In-Ceram Alumina system with an addition of 35% partially stabilised zirconia oxide to the slip composition to strengthen the ceramic  Traditional slip casting techniques can be used or the material can be copy-milled from prefabricated, partially sintered blanks and then veneered with feldspathic porcelain.

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Since the core is opaque and lacks translucency, the material is recommended for posterior crown copings and FPDP frame works.

Procera  Developed by Noble Biocare with copings that contains 99.9% high purity aluminium oxide.  Combined with a low fusing veneering porcelain, Procera has the highest strength of the alumina based materials and its strength is lower only to zirconia  A sapphire contact probed is used to scan the working die and to define the 3D shape of the prep. The date is sent electronically to the manufacturing facility where a 20% enlarged model is copy milled and used for the dry-pressing technique  High purity aluminium oxide powder is mechanically compacted on the enlarged die and sintered at 15500C, eliminating porosity and returning the core to the dimensions of the working die.  The crown form is completed by veneering with low fusing feldspathic porcelain matching the coefficient of thermal expansion of aluminium oxide.

 Zirconia based ceramics o Zirconia is a polymorphic material that occurs in 3 forms:  At its melting point of 2680oC, the cubic structure exists  Transforms into the tetragonal phase below 2370oC  Monoclinic phase transformation occurs below 1170oC. This is accompanied by a 3-5% volume expansion which causes internal stresses o Yttrium oxide is added to pure zirconia to control the volume expansion and to stabilise the tetragonal phase at room temperature.  This partially stabilised zirconia has high initial flexural strength and fracture toughness o Tensile stresses at a crack tip will cause the tetragonal phase to transform into the monoclinic phase with an associated 3-5% localised expansion  The volume increase creates compressive stresses at the crack tip that counteract the external tensile stresses.  This phenomenon is known as transformation toughening and retards crack propagation  In the presence of higher stress, a crack can still propagate.  The toughening mechanism does not prevent the progression of a crack, it just makes it harder to propagate. o Yttrium oxide partially stabilised zirconia (Y-TZP) has mechanical properties that are attractive for restorative dentistry, namely, its mechanical and dimensional stability, high mechanical strength and fracture toughness. o The cores have a radiopacity comparable to metal which enhances radiographic evaluation of marginal integrity, excess cement removal, and recurrent decay. o Y-TZP can be manufactures in 2 methods though CAD/CAM technology. o Lava  Uses a Y-TZP framework with high flexural strength, high fracture toughness, and low elastic modulus compared to alumina, and exhibits transformation toughening when subjected to tensile stress. o Although the first all ceramic implant abutments were made of densely sintered high purity alumina, zirconia implant abutments with or without a metal interface are now recommended instead of alumina due to their increased mechanical properties.  Abutments are either customised through electronic data or are stock abutments which can be modified via conventional preps.

Survival of all-ceramic materials  Typical survival rates for all ceramic restorations range from 88-100% after 2-5 years in service and 84-97% after 5-14 years in service o However there are discrepancies in the classification of failure and the variability of the materials and systems available for all ceramic restorations present a challenge to combining data from several studies. o A more comprehensive definition of failure or critical assessment of all ceramic restorations would thus decrease reported survival rates. Material Properties  The strength of an all ceramic restoration is dependent on the ceramic material used, core veneer bond strength, crown thickness and design of the restoration, as well as bonding technique and the characteristics of the supporting material.  Fracture of the ceramic material is the most frequently reported complication resulting in failure o Alumina based ceramics have been shown to have higher strength and fracture toughness than leucite-feldspathic porcelain and modified alumina cores o A zirconia modified alumina ceramic was found to have higher fracture toughness and higher flexural strength than In-Ceram  Success of many all-ceramicsystems is dependent on the strengthof a core-veneer bond. Since the ceramiccore is significantly strongerthan the veneering materials, thisbond strength has an important rolein their success. o The thickness ratioof the ceramic core to the veneeringporcelain is a dominant factor controllingthe crack initiation site andpotential failure. o Optimizing thethickness of these layers is necessary toensure that the veneering porcelain isunder compressive stress and that theceramic core is under tensile stress. o Although it is desirable to increase thethickness of the ceramic coping, it isimportant not to compromise eitherthe aesthetics of the crown by over-contouring,or the tooth preparation byoverreduction.  Even though the veneering porcelainis used primarily for aestheticreasons, it has an important role inthe mechanical behaviour of the restoration. o The flexural strength andfracture toughness of these bilayeredrestorations depend on the veneer layer when then crack initiates from the veneer surface o Although residualcompressive stresses in the veneerlayer increase the flexural strength ofthe bilayered restoration, the tensilestresses are the primary cause for theobserved chipping.  Zirconia-based ceramics are recommendedfor FPDPs, as they havethe highest failure loads when comparedto alumina- and lithium-disilicate-based ceramics.  A lithiumdisilicate glass ceramic in combinationwith a fluoroapatite glass-ceramic was foundto be inappropriate for posterior FPDPsdue to the high susceptibility ofthe veneer to subcritical crack growthand the absence of crack arrestingat the core-veneer interface.  Zirconiaframeworks with higher elasticmodulus are preferred for all-ceramicposterior FPDPs compared to lithium-disilicate based ceramics, as they reduce the stress on the weaker veneerlayer and increase the compositeload-bearing capacity, thereby retarding the fracture of the restoration.  Creating a gingival embrasure with abroad radius of curvature, rather thana sharp contour, has been shown toreduce the stress concentration underloading and increase the fracture resistance.  Following traditional preparationguidelines is important not only forretention of all-ceramic crowns, butalso for stress distribution during dynamic] loading of the restoration.

Marginal and internal fit  When evaluating the clinical successand quality of a restoration,marginal discrepancy is an essentialcriterion.  Poor marginal adaptation canresult in cement dissolution, microleakage,increased plaque retention,and secondary decay.  The incidence of gingival inflammationincreases around clinically deficientrestorations, particularly thosewith rough surfaces, subgingival finishlines, or poor marginal adaptation;however, gingival inflammationmay also develop around properlycontoured and highly polished restorations.  Current evidence has not shown anaccelerated rate of bone loss or increasedattachment loss adjacent tocrowns.  Contemporary chair-side or laboratory-based CAD/CAM systems haveadditional factors that may affect theaccuracy of the fit, including softwarelimitations in designing restorations,and hardware limitations of the camera,scanning equipment, and milling machines.  Feather-edge finish lines,deep retentive grooves, and complexocclusal morphology are not recommended,not only for scanning andmilling prerequisites, but also to decreasestress that would develop in arestoration with inadequate preparationand margin geometry.  An additionalproblem with computer-milledceramic restorations is that the internalcutting bur may be larger in diameterthan some parts of the toothpreparation, such as the incisal edge.This would result in a larger internalgap than with other fabrication techniques. Cementation and bonding  A variety of cementation andbonding techniques have been appliedto modern all-ceramic restorations  Zinc phosphate, zinc polycarboxylate,and conventional glass-ionomer cements set through an acid-base reactionhaving a tendency to exacerbate surface flaws in ceramic restorations due to the increased acidity of the cement  Glass ionomers are susceptibleto early water degradation, resultingin microcracks which may initiatecracks and facilitate crack propagation in the cement  Resin-modifiedglass ionomer cement sets through acombination of an acid-base reactionand photo- or chemically initiatedpolymerization. Combining chemicaladhesion advantages of traditionalglass-ionomer cements with advantagesof composite resin results in improvedstrength, fracture toughness, and wear resistance  To improvesuccess rates with glass- and aluminabasedceramic restorations, nonacidbase cements are recommended  Surfacetreatment of the porcelain byetching with 5% to 9.5% hydrofluoricacid and etching of the tooth structurewith 37% phosphoric acid andapplication of a silane coupling agentprovided the highest bond strengthof an adhesive-resin cement to feldspathicmaterial. o Bond strength to etched surfacesis improved by creating deepinvoluted spaces where resin can flow and interlock  Considering the brittleness andlimited flexural strength of glass ceramics,definitive adhesive cementationwith composite resin should beused to increase the fracture resistanceof the restoration o The compressivestrength of composite resincements (320 MPa) is superior to thatof zinc phosphate (121 MPa), which offers limited support o Fractureor cement breakdown can result inmicroleakage, marginal discoloration,pulpal irritation, secondary caries,debonding, and decreased fracture load o Adhesive cementation has beenshown to increase fracture loads and improve longevity  Light-, dual-, and chemically polymerizedcomposite resin materialshave been advocated for use withglass ceramics. o Decreased survivalrates have been reported withdual-polymerizing, composite resincement, as compared to chemicallypolymerizing composite resin cementwith feldspathic inlays o Inadequatetransmission of light throughthe ceramic restoration to the underlyingcement can result in insufficientpolymerization of dual-polymerizingcomposite resin cement and lack of support for the restoration  Nonadhesive cementation is moredependent upon macromechanicalretention than adhesive cementation  Finish lines placed belowthe cemento-enamel junction resultin a significant loss of adhesion since cementum cannot beinfiltrated by resin to the extent thatacid-etched dentin can.

 Different surface treatments havebeen evaluated to demonstrate thebond strength of composite resin cementsto alumina-based ceramic restorations o Acid etchants used withglass ceramics do not adequatelyroughen the surface of glass-infiltratedand densely sintered alumina-based ceramics. o An effectivemethod to roughen glass-infiltratedalumina-based ceramics is througha tribochemical silica coating process  A variety of lutingagents have been shown to be capableof retaining zirconium-oxide crownsincluding composite resin, compomer, resin-modified glassionomer,and self-adhesive composite resin. o Whilemechanical properties of cements arecritical to support glass-ceramic restorations, zirconiabased crownscan be cemented conventionally dueto their high fracture resistance. o Zirconia-based restorations do notrequire an adhesive interface for retention Colour and aesthetics  Increased translucency correlatedwith improved esthetics is the primaryadvantage in using an all-ceramic restoration.  Heffernan et al10 evaluatedthe relative translucency of several ceramicmaterials and found In-CeramSpinell to have thehighest amount of relative translucency.This was followed by IPS Empress, Procera, and IPS Empress 2, which had higherlevels of translucency than In-Ceram Alumina, followedby In-Ceram Zirconia,which was comparable to ametal alloy. As a result of this study: o In-Ceram Spinell, IPS Empress, andIPS Empress 2 were recommendedfor high to average translucency situations o Procera was recommended for average translucency situations o WhileIn-Ceram Alumina and In-Ceram Zirconiaare only recommended whenmatching to opaque natural teeth orin posterior and nonesthetic zones  The ratio and thickness of ceramiccore and veneering materials influencethe final shade of a layered porcelainrestoration. o An aluminum-oxideceramic core thickness of 0.7 mmwas found to be sufficient to maskunderlying dentin color. o With a conservativereduction of 1 mm, a semitranslucentall-ceramic specimen willmatch a shade tab more closely than ametal-ceramic restoration. Clinical recommendations  Leucite and feldspathic glass ceramicsare indicated for onlays, threequarter crowns, and veneers, but theirstrength limits their use to completecoverage crowns in the anterior segment,only.  Lithium-disilicate glass ceramicscan perform successfully in theposterior segment for single crownsand 3unit FPDPs in the anterior area.  Glass-infiltrated alumina cores canbe considered for single-unit restorationsand anterior FPDP applications,with the exception of In-CeramSpinell, which is only recommendedfor anterior crowns.  Zirconia-modifiedalumina is indicated for posterior crowns and FPDPs, while densely sinteredalumina is indicated for veneers,crowns, and anterior FPDPs.  Zirconiahas superior mechanical properties asa core material for posterior crownsand FPDPs, implant abutments, andimplant-supported restorations. Thestronger ceramic core materials canbe rather opaque and this may limittheir application when a high degreeof translucency is required.