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Ceramic Restorations:
Updates and Concepts for Esthetic Rehabilitation
Paulo Kano, DDS, CDT1
Luiz Narciso Baratieri, DDS, MS, PhD2
Renata Gondo, DDS, MS3

A
nterior teeth with irregularities in color and
shape compromise the smile and often nega-
tively affect an individual’s self-esteem. Cur-
rent beauty standards and a greater knowledge of
available treatments have engendered more demand-
ing patients who expect high-quality esthetic treat-
ment. Thus, restorative procedures for anterior teeth
represent a great challenge. A wide understanding of
the available materials and state-of-the-art techniques
is essential for successful esthetic treatment planning.
Ceramics are adequate materials for replacing
tooth structure. A wide range of ceramic systems with
significantly enhanced mechanical and optical proper-
ties is now available.1,2 Improvements in composition
and processing techniques allow for the fabrication of
esthetic restorations with superior resistance to func-
tional stress. Additionally, silica-based ceramics pro-
vide a strong bond to tooth structure. Therefore, more
conservative preparations with minimum tooth reduc-
tion can be used without compromising shade and in-
tegrity of the material and tooth.3
However, esthetic treatment does not depend
solely on the restorative material and the ability of the
operator. The key to success in a complex esthetic
rehabilitation is detailed treatment planning with a
multidisciplinary approach.

1
Graduate Student, Department of Implantology, São Leopoldo
Mandic, Campinas, Brazil.
2
Professor and Chair, Department of Operative Dentistry, Federal
University of Santa Catarina, Florianópolis, Brazil. ESTHETIC TREATMENT PLANNING
3
Professor, Department of Operative Dentistry, Federal University
of Santa Catarina, Florianópolis, Brazil. Esthetic planning must not be restricted to an evalua-
tion of teeth. A broader analysis, including extraoral
Correspondence to: Dr Paulo Kano, Rua das Pitombeiras,
126 Jabaquara, São Paulo, Brazil 04321-160. conditions with special consideration paid to face
Fax: 55 (11) 5012-4492. Email: ipkano@gmail.com symmetry and smile is recommended.4 Ideally, the

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KANO ET AL
2a
face, smile, and teeth should be photographed for
proper evaluation. The essence of the smile involves
the interaction of three components: lips, gingiva, and
teeth.5 Height and thickness of the upper lip are also
important since they establish the amount of gingival
and dental exposure. In a so-called normal smile, the
upper lip should rest on the marginal gingiva of the
maxillary anterior teeth.4 When 3 mm or more of gin-
gival exposure is observed, this is classified as a high
smile line. The presence of a high smile line makes the
esthetic treatment more complex because of the
lip/teeth relationship.6 A high smile line increases the
risk of cervical line exposure. Moreover, gingival con-
tour and morphology, which function as a frame for
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Fig 1 Preoperative view showing coronal fracture
of the maxillary right central incisor, splinted on ad-
jacent teeth.
Figs 2a and 2b Coronal fragment removal of the
maxillary right central incisor. Due to the amount
lost structure, endodontic treatment was performed
and cementation of a provisional intraradicular post
was carried out to increase coronal retention.
2b
Fig 3 Following en-
dodontic treatment, the
coronal fragment was
temporarily cemented.
During the esthetic evalu-
ation, it was observed
that the patient pre-
sented a high smile line
and anterior maxillary
teeth with inadequate
width/length ratio.
the cervical areas of the teeth, become even more im-
portant since they directly influence restorative treat-
ment.7 Any asymmetry or defect in gingival architec-
ture negatively impacts esthetic planning.8
Another important factor is the tooth width/length
ratio. Ideally, the width of maxillary central incisors
should correspond to approximately 80% of their
length.7 If a discrepancy exists, a crown lengthening
procedure is recommended because maxillary incisors
are dominant elements in a smile. The gingival zenith,
ie, the most apical point of the clinical crown, can also
compromise the gingival contour and directly influ-
ence the tooth proportion. To create a natural gingival
contour, the zenith must be located distally from the
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Ceramic Restorations: Updates and Concepts for Esthetic Rehabilitation

tooth long axis, whereas in lateral incisors, the zenith

must be aligned with the tooth long axis.7 Therefore,
clinical cases in which the patient has a high smile line
and discrepancies in tooth width/length ratio are an
indication for periodontal plastic surgery.
Incisal borders of maxillary anterior teeth must be
in harmony with the lower lips and smile line.9 The in-
cisal border of maxillary central incisors should slightly
touch the lower lip redness, and the incisal border of 4
maxillary lateral incisors should be 1 to 2 mm above
the redness.
Esthetic planning is critical for proper communica-
tion of esthetic rehabilitation parameters with the den-
tal technician, since it is not possible to analyze the
lips and face in study casts. Casts should only be con-
sidered as a reference so that the esthetic outcome
does not depend solely on the technician.
In this clinical case, the patient presented with a
5
high smile line with an asymmetric gingival line, dis-
crepancies in the width/length ratio of maxillary in-
cisors, discolored restorations, and loss of dental
structure of the maxillary right central incisor (Figs 1 to
3). The treatment plan comprised periodontal plastic
surgery and fabrication of lithium disilicate all-ceramic
crowns.

PERIODONTAL PLASTIC SURGERY

A crown lengthening procedure, usually performed to
obtain an adequate proportion of anterior teeth and
correct gingival symmetry, is possible whenever there
is a reasonable amount of keratinized gingiva. For a
more precise intervention, fabrication of provisional
restorations that overlap with the free gingival margin
is recommended (Fig 4). The provisionals must have a
7
similar shape and contour to the expected final out-
come. The provisionals can be used as surgical guides
Fig 4 After initial preparation, provisional crowns were pro-
for the incision, ensuring accuracy of the procedure duced from a diagnostic wax-up, reproducing volume,
and allowing appropriate delimitation of hard and soft shape, and correct length of future ceramic restorations.
Note the reestablishment of the gingival line, cervical line,
tissue architecture (Figs 5 to 7).10 This guide can be and incisal border.
modified until adequate gingival esthetics are
achieved. The restorative procedures should be per- Fig 5 Provisional restorations were used as surgical guides
for the initial incision. Note the incision line after removal of
formed after 45 days of healing in a healthy periodon- the provisionals.
tium lacking local inflammation and showing esthetic
Fig 6 Intraoral view after periodontal surgery.
harmony.
Fig 7 The healing periodontal tissues after 45 days.

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KANO ET AL
8
9a 9b
RESTORATIVE TREATMENT
Intraradicular posts are often indicated for restorative
procedures in endodontically treated teeth presenting
significant loss of coronal structure. The loss of more
than 50% of dental substrate requires the use of radic-
ular retainers to ensure stability of restorative materi-
als.11 Even though prefabricated posts are now avail-
able, cast posts are highly recommended due to their
superior adaptation to the tooth. Cast posts are used
when fragile tooth structure requires higher coronal
retention, particularly if the cervical margin is localized
at or below the gingival margin.12
Metallic posts present a great disadvantage con-
cerning esthetics. To hide the metal, it is necessary to
apply opaque materials over the core, which may pro-
mote high light reflection, interfering with the natural
aspect of the restoration. Another significant disadvan-
tage is the risk of discoloration of marginal gingiva.13
When nonprecious alloys are used for the fabrication
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Fig 8 Pressed glass-ceramic cast post
with metal reinforcement fit on the cast.
Figs 9a to 9c Glass-ceramic cast posts
with metal reinforcement after cementa-
tion. The post increases coronal reten-
tion and presents acceptable optical
properties.
9c
of cast metal posts, corrosion is expected, causing gin-
gival pigmentation and radicular discoloration.14
Pressed glass-ceramic cast posts with metal rein-
forcement present an alternative treatment. Such posts
provide stiffness, strength, biocompatibility, and ac-
ceptable optical properties (Fig 8).15–19 Pressed ceramic
is able to transmit light in a similar manner as natural
tooth structure13 and is also resistant to occlusal loads.
Ceramic posts can provide similar shade to that of
dentin, which is important in terms of the depth of dif-
fusion and absorption of light transmitted in the core.
Since all-ceramic crowns can transmit the incident light
to the ceramic core, 20 the optical behavior of the
restoration will be similar to that of a sound tooth.
Moreover, the absorbed light is conducted toward the
root and gingival tissues,13 preserving the natural tran-
sillumination of the latter. Pressed glass-ceramic cast
posts with metal reinforcement must be cemented with
dual-cure resin cements, since the ceramic surface is
compatible with adhesive procedures (Figs 9a to 9c).
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Ceramic Restorations: Updates and Concepts for Esthetic Rehabilitation

Fig 10 Final preparation. Note

the internal round angles and
well-defined finishing line, which
helps to eliminate internal stress 11a
in the final ceramic restorations.
10

Figs 11a and 11b Impression technique using double retraction cords for gingival
margin displacement. (a) Insertion of the first cord for sulcus sealing; (b) insertion of
the second cord for lateral displacement of the gingiva.
11b

CORONAL PREPARATION mm intrasulcular to avoid damage of the supporting

The use of silicone guides produced from provisional
restorations is recommended to guide the tooth
preparation. Additionally, the selection of a ceramic
system will influence the type of preparation. For
lithium disilicate pressed ceramic crowns (IPS e.max
Press, Ivoclar Vivadent, Schaan, Liechtenstein), the
tooth preparation must be enough to ensure an ade-
quate thickness of the ceramic and relief of retentive
areas. The recommended thickness for lithium disili-
cate crowns is 1.0 mm in the cervical area and 1.2 to
1.5 mm in the middle third of the tooth. The extension
of incisal involvement depends on the level of translu-
cency desired within this area. Axial walls should pre-
sent taper ranging from 6 to 10 degrees for an ade-
quate longitudinal axis path of insertion of the
restoration and to avoid significant loss of retention
and stability.7 Cervical margins must be chamfered for
the achievement of a stable structure and high
marginal adaptation. The cervical finishing line must
follow the cementoenamel junction to provide har-
mony with bone architecture.21 Ideally, the finishing
line should remain in enamel, since adhesive resis-
tance of resin cements is more reliable and durable in
enamel than in dentin.22,23
It is advised to refrain from placing the margins
subgingivally. However, for maxillary anterior teeth,
margins should normally be localized in the intrasulcu-
lar space for esthetic reasons, as well as for greater
mechanical retention of the prosthesis.4 Therefore, the
margins and finishing line should be no more than 0.5
periodontium (Fig 10).
IMPRESSION TECHNIQUE
An excellent impression consists of a precise reproduc-
tion of the preparation and soft tissues, and it depends
on the quality of the preparation, periodontal integrity,
and the impression and pouring techniques. In this
case, the double-mix single impression technique with
polyvinyl siloxane (Virtual, Ivoclar Vivadent) was used.
Double-mix single impressions provide excellent sur-
face reproduction, allowing multiple pouring.
For a precise impression of the cervical margin and
finishing line, gingival retraction should be performed
by insertion of two retraction cords. The cords should
be soaked in astringent solution (25% aluminum sulfate,
Gel Cord, Pascal International, Bellevue, WA, USA) to
facilitate retraction. Ferric sulfate is not recommended
due to the risk of pigmentation of the preparations. The
first cord, which should be small in diameter (no. 000,
Knitrax, Pascal), is inserted to seal the inner area of the
gingival sulcus (Fig 11a). This first cord prevents tearing
of the light impression material during the removal of
the impression. In addition, it allows for an adequate
thickness of impression material around the prepara-
tions, supporting the finishing line during pouring.
A second cord, larger in diameter (no. 00, Knitrax,
Pascal), should be placed on top of the first one for lat-
eral displacement of the gingiva (Fig 11b). The margins

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KANO ET AL
12 13
and finishing lines must be apparent at this point, be-
cause of tissue displacement. After 1 minute, the sec-
ond cord should be removed and the light-body mate-
rial inserted in the gingival sulcus, following gentle air
spray. An impression tray containing the heavy-body
material should be immediately inserted. A period of 6
minutes is necessary prior to the removal of the tray to
ensure dimensional stability and proper tear resistance.
When evaluating an impression, it is essential to obtain
all details of the finishing line and preparation to en-
sure good marginal adjustment and a controlled emer-
gence profile (Fig 12). Polyvinyl siloxane impressions
are stable for a maximum of 14 days and allow double
pouring (which is crucial for the production of at least
two working casts). An intact master cast should be
produced for orientation purposes in regard to soft tis-
sues and also for evaluation of proximal contacts. An-
other cast should be used as a die cast, on which the
prosthetic pieces will be fabricated (Fig 13).
LABORATORY PROCEDURES
The IPS e.max Press system (Ivoclar Vivadent) was se-
lected for the fabrication of anterior crowns. This sys-
tem, which was introduced in 2005, consists of a
lithium disilicate glass-ceramic produced in the form
of ingots of different translucencies. It provides high
resistance, with flexural resistance of approximately
400 MPa and fracture resistance of approximately 3.0
MPa, both 10% higher than those of Empress II
(Ivoclar Vivadent). Lithium disilicate crystals are dif-
fused in a glass matrix in an interwoven fashion, pre-
venting crack propagation in the interior.7 Additionally,
the glass matrix and crystals have a refractive index of
light similar to that of dental structure, allowing for
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Fig 12 Impression fabricated using the
double-mix single impression tech-
nique. Note the accuracy of the cervi-
cal margins.
Fig 13 Working cast.
high-standard esthetics. This pressed ceramic system
is enhanced by its ceramic cover, based on nanofluor-
apatite (IPS e.max Ceram, Ivoclar Vivadent). Earlier
studies demonstrated an absence of failures after a
period of 48 months.24 This pressed ceramic system
uses the lost-wax technique for ceramic injection. The
fabrication process involves waxing the restoration on
a plaster cast. A silicone guide produced from the
impression of the provisional restorations may be used
for orientation and should be positioned on the mas-
ter cast. Using the silicone guide, information referring
to tooth length and morphology is easily and precisely
transferred (Figs 14 to 17). In the oven, wax is elimi-
nated from the investment mold (lost-wax technique)
and ceramic tablets are selected. Under heat and
pressure, the ceramic material is molten and injected
into the investment mold, filling the space previously
occupied by the wax. Therefore, an accurate contour
of the restoration, particularly at the margins of the
preparation, is essential. Overcontouring the restoration
is not recommended, since finishing and polishing will
be time consuming and will most likely lead to frac-
ture or induced cracks.
In cases where the incisal opalescence and translu-
cence must be reproduced, characterization of the
pressed ceramic restoration using the stratification
technique is possible. Ceramic stratification produces
a more natural, life-like restoration. The wax-up is ini-
tially contoured in the final anatomical form. Before
the pressing procedure, the waxed restoration is
trimmed using the cut-back technique in areas that re-
quire higher esthetics, ie, the incisal third. Subse-
quently, after the ceramic is pressed, layering stratifi-
cation is performed with ceramics presenting different
translucency, opalescence, shade, and value. Superfi-
cial textures should be created to produce a more life-
like appearance (Figs 18 to 22).
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Ceramic Restorations: Updates and Concepts for Esthetic Rehabilitation

Fig 14 Die cast for production of ceramic crowns.

Figs 15 and 16 Using a silicone guide, the waxing procedure was performed fol-
lowing the shape of the provisional restorations, which was approved by the patient.

Fig 17 Completed wax-up.

Fig 18a and 18b The cut-back technique, performed before pressing, was used
for ceramic stratification to improve characterization. 14

15 16 17

18a 18b 19

20 21

22a 22b

Fig 19 The incisal portion after firing. Note the material’s translucency.

Fig 20 Covering was performed using e.max Ceram (incisal 1 [50%] + OE1 [50%] mamelon light, mamelon Salmon,
Essence O5 copper, Opal Effect OE1, Opal Effect OE2). Observe the polychromatic interior and high translucency, resulting
in a highly natural restoration.

Fig 21 Translucency of the ceramic crowns is evident under transmitted light.

Fig 22a and 22b Intaglio and facial views of the ceramic crowns.

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KANO ET AL
BONDING
The cementation technique plays a crucial role in the
survival rate of ceramic restorations.25,26 Resin cements
are the most recommended, since they provide
restorations with excellent mechanical integrity, signifi-
cantly reducing surface defects and, thus, fracture po-
tential. Several types of resin cement are available for
cementation of ceramic pieces. In this case, light-
cured resin cement (Variolink Venner, Ivoclar Vivadent),
which has shown proper polymerization under a 2-
mm-thick lithium disilicate ceramic,27 was used. Be-
sides color stability, light-cured resin cements offer a
great variety of shades and simplified clinical applica-
tion because of a longer working time. However,
thickness of the ceramic restoration, resin cement
shade, and transmittance coefficient influence the
polymerization of light-cured resin cements, limiting
their use with thick ceramic restorations.28
Another option for thick ceramic restorations is
dual-cure resin cements. Dual-cure resin cements con-
tain peroxide and amine as active components in the
chemical polymerization process, whereas photoinitia-
tors initiate the light-polymerization process. Both
chemical- and light-polymerization mechanisms are
needed to reduce the amount of double bonds and to
increase the resistance and bonding capacities of the
cement. A slow polymerization reaction associated
with high solubility and water absorption occurs when
dual cements are not light cured, reducing microhard-
ness and leading to premature failure of the cement.29
Therefore, despite presenting acceptable working time
and providing better management of polymerization,
dual-cure resin cements should be used with caution.
The ceramic restorations should be tested to check
fit, proximal contacts, and shade. Slight overcontour-
ing of interproximal areas can make it difficult to cor-
rectly seat the restorations. Careful proximal adjust-
ment using metal polishing strips with the crowns
seated is indicated. Shade of the resin cements usu-
ally modifies the final shade of the restoration, and the
thinner the ceramic, the higher this influence.30 Thus,
one method for shade selection is to place a small
amount of cement between the ceramic and the
tooth, and then compare it with the adjacent tooth.
However, the material is not polymerized, and accord-
ing to earlier studies,30,31 polymerization can modify
color by altering value and saturation. Furthermore,
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glycerin-based try-in pastes (Try-in, Ivoclar Vivadent)
are currently available. These glycerin-based materials
present corresponding shades to the polymerized
resin cement. After try-in, these pastes can be easily
removed with air-water spray.
It is essential that the preparation is properly
cleaned and completely free of remnants and debris
from the temporary cement. Debris or other contami-
nants compromise the adhesive procedure by increas-
ing microleakage. Subsequently, the final restorations
should be treated for adhesive bonding. Since IPS
e.max Press is acid-sensitive (silica-based and low alu-
mina content), it should be etched by hydrofluoric
acid (between 4% and 10%). Hydrofluoric acid causes
a selective dissolution of the glass matrix in a function
of time exposure, modifying the superficial morphol-
ogy of the ceramic by microporosities that increase
surface contact, favoring resin cement retention.32–34
The intaglio surface of disilicate-based ceramics
should be etched for 20 seconds, followed by abun-
dant washing in tap water. Special attention must be
paid to protect the glazed external surface from the
hydrofluoric acid. Subsequently, a second wash of the
etched ceramic must be performed by immersing the
restoration in an ultrasound bath containing 90% alco-
hol for 5 minutes.11 Ultrasonic post-wash removes the
precipitates and debris created by acid etching that
can compromise ceramic/resin. Bonding strength is
potentiated by silane application. Silane is a bifunc-
tional molecule that acts as a chemical bonding agent
between the silica in the ceramic and the organic ma-
trix of the adhesive system by means of siloxane
bonding. Moreover, silane-covered intaglio surfaces
increase the resin cement wettability on ceramic mi-
croporosities. Silane application should be done for
60 seconds, followed by air-drying for 10 seconds.
The teeth should then be isolated and etched with
37% phosphoric acid for 15 seconds, followed by
washing for 30 seconds. Subsequently, the dentin must
be gently dried for 5 seconds to keep the surface
moist for proper infiltration of the light-cured adhesive
system (Excite, Ivoclar Vivadent). Earlier investigations
showed30,35–37 that the resin-dentin interface, formed as
a result of the use of hydrophilic dentin adhesives, de-
teriorates over time due to degradation of the hybrid
layer.38,39 This effect occurs due to collagen hydrolysis40
and is caused by metalloprotein enzymes found in
dentin tissue.41 These enzymes become active when
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Ceramic Restorations: Updates and Concepts for Esthetic Rehabilitation

23

24 25

26

Fig 23 The ceramic crowns were individually bonded. Retraction cord was inserted to ensure proper isolation of the sulcus
and elimination of any gingival fluid.

Fig 24 Etching with 37% phosphoric acid for 15 seconds followed by abundant washing for 30 seconds.

Fig 25 Application of a dual adhesive system (Excite DSC, Ivoclar Vivadent) according to the manufacturer’s instructions.

Fig 26 Careful seating of the ceramic crown using resin cement.

dentin is etched. If there is any failure in monomer dif-
fusion within etched dentin areas with deficient
monomer, infiltration might occur, resulting in unpro-
tected collagen fibers that are more susceptible
to degradation by metalloproteinase.40,41 Therefore,
bonding procedures must be done carefully and in
accordance with the manufacturer’s instructions.
The resin cement is then applied to the intaglio sur-
face, and the restoration is placed on the tooth. After
positioning the ceramic, excess cement is carefully re-
moved and light polymerized for 60 seconds at all
margins. Proper polymerization of the resin cement is
crucial to ensure adequate bonding strength at the
adhesive interface and to optimize the resin cement’s
physical properties (Figs 23 to 26).
In cases of multiple restorations, they should be in-
dividually cemented to avoid incorrect positioning and
accidental crown bonding and to facilitate removal of

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KANO ET AL

27

28a 28b

28c

Figs 27 and 28 Final ceramic restorations. Note

the contour of the gingival line and adequate
tooth proportion of the maxillary incisors, ensur-
ing a more harmonic smile.

excess cement (especially in the proximal area). Finish- CONCLUSION

ing and polishing procedures should be performed in
a subsequent session. Careful treatment planning,
preparation, impression making, ceramic application,
and cementation lead to a natural and life-like appear-
ance of the final restorations (Figs 27 and 28).
To achieve the predicted results, it is crucial that all
steps are carefully followed. Neglecting a single step
can compromise the whole restorative process.
Ceramic materials are an integral part of contempo-
rary dentistry. Their high resistance and optical quali-
ties allow for excellent and durable results with mini-
mum wear of dental structures. Nevertheless, success
does not depend only on the restorative material. Es-
thetic and functional rehabilitation requires an accu-
rate diagnosis and development of a multidisciplinary
treatment plan.

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Ceramic Restorations: Updates and Concepts for Esthetic Rehabilitation
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