ALL CERAMIC RESTORATIONS (WHY, WHEN

& HOW)
DR. MOSTAFA NOOR

Outline:
1. Properties of dental porcelain.
2. Different ceramic material.
3. Fabrication methods.
4. Preparation guidelines.
5. Adhesion to ceramics.

Introduction:
Most patients now demand smile makeover.
How-to achieve smile makeover? Either all ceramic or metal ceramic.
 Disadvantage of metal ceramic restorations:
1. Bulky as you have to mask the opaque metal underlying the ceramic.
2. Need more reduction to the tooth structure.
3. Metal margin in people with high lip line become unesthetic so you have to
place the margin subgingivally which by time causes some sort of gingival
recession, and injury to periodontal ligaments and biological width.
4. Metal block light transmission.
 Advantages of ceramic restorations:
1. No metallic display.
2. Esthetically look like the tooth.
3. More light transmission.
4. Even if the margin was subgingival, it is more biocompatible than metal so
doesn’t cause recession.
 Definition of ceramic: it comes from Greek word “keramos” which literally
means “burnt stuff”.
 Applications of ceramics in dentistry:
 1. PFM.
2. Orthodontic brackets.
3. Some powder form of cements.
4. Some fillers in composite.
5. Denture teeth (history).
6. All ceramic fixed indirect restoration.
7. Implant.
 Indications of all ceramic restoration:
1. Inlays and onlays ceramic are better than composite in esthetics, better
adhesion and colour stability.
2. Endocrowns.
3. Occlusal veneer or laminate veneer (cover labial surface).
4. Full coverage crowns and bridges (long span).
5. Implant fixture(zirconica), implant abutment, crowns and bridges up to full
arch hybrid prosthesis framework.
 What is the difference between porcelain and ceramic?
Porcelain is a specific type of ceramic.
 Main components of ceramic:
1. Refractory crystalline structure:
o Strength (stop crack propagation).
o Different optical properties.
2. Glass
o Translucency.
o Brittle phase.
 Early type pf porcelain:
Traditional feldspathic porcelain contains 15 to 20% crystals, glass about 80 to
85%, so high translucent and best esthetic, have same coefficient of thermal
expansion as tooth.
 Drawbacks of porcelain:
1. Low mechanical properties very brittle flexural strength 60-70Mpa, so must
have an underlying material.
 2. Wear of opposing teeth.
3. Shrinkage during firing.
4. Porosity.
 Important triad: biology-strength-esthetics.

Classification of ceramic material:

Microstructure Glass to crystalline ratio:
 Glass ceramics: has highest translucency, but low mechanical properties.
1. Feldspathic porcelain: flexural strength 60-70 MPa, but to make a crown
you need minimum 120Mpa so can be use in onlays, inlays, veneers,
covering another material.
Forms: either powder and liquid or CAD-CAM blocks.
2. Leucite ceramics: 40% crystals, so higher mechanical properties 120-
140MPa.
Indications: as indications of porcelain + single crowns posterior and
anterior.
Tradename: Impress.
3. Lithium disilicate: 70% translucent crystals so high esthetic and high
mechanical properties 480-500MPa.
Indications: same as above + anterior bridges 2 or 3 units only.
Tradename: E-max.
4. Zirconia reinforced lithium disilicate: 10% zirconia, higher mechanical 450-
520MPa.
Indications: same as above.
Tradename: Vita Suprinity, Celtra (more successful, can make bridge)
None of them can be used with bruxism or posterior bridge
 Oxide ceramics polycrystalline alumina and zirconica: glass free, high
mechanical properties.
Polycrystalline alumina has flexural strength 600-900 MPa and polycrystalline
zirconia has 1100-1600MPa.
1. Zirconia core: has low translucency because cystals are opaque, so can be
covered with porcelain to be esthetic, but by time porcelain chipping will
occur so still cannot be used with bruxism.
 Can be used in 3-unit posterior bridge.
2. Translucent zirconia: size of zirconia is decreased, no need for porcelain
covering so can be used in bruxism with same strength and transformation
toughening.
Used as above
Tradename: Bruxzir.
Translucent zirconia is better than before but not as glass ceramics.
3. Cubic zirconia: cube in form, more than 1100°C it changes from monolithic
to tetragonal then to cubic form, they put stabilizer yittrium to make it
remain in cubic form, they are the best esthetic zirconia as has same
refractive index as glass or light, named super or ultra-translucent zirconia.
But mechanical properties decrease to 600-700MPa.
Indications as E-max; anterior bridges, or single unit.
Both cubic and translucent zirconica can be called monolithic zirconia or fully
anatomic zirconia.
But zirconia is a rigid material that lacks flexibility and resiliency, also adhesion
predictability is very low.
You need resilient material to replace dentin when making intra coronal
restoration so they made hybrid ceramics.
 Hybrid ceramics: ceramic and polymer composite.
Main advantage: resiliency and flexibility.
Indications: onlays, overlays, inlays, endocrowns, crowns on implants, veneers
but translucency is low.
Tradename: Vita Enamic, Lava Ultimate, Fugi GC, Cera Smart blocks (best),
Brilliant hybrid ceramic.
They are adhesive materials (etchable).

Preparation guidelines:
Partial coverage: inlay, onlay, overlay, veneerlay.
 The difference between onlay, overlay and inlay is extension of defect (caries,
undermining enamel and defective restoration), if the defect lacks cuspal
involvement it is called inlay, if including cusps, it is called onlay, and called
overlay when all cusps are involved.
 Selection of restoration depend on:
 1. Extension of the defect.
2. Remaining tooth structure.
3. Sufficient enamel.
 Principles of inlay preparations:
1. If you have wide isthmus portion, make it indirect.
2. If you don’t get contact directly.
3. To adjust occlusal contact.
 To convert from inlay to onlay:
When you have weak cusps, cuspal thickness less than 2mm butt joint or if
occlusal contact come at the junction between tooth and restoration or
covering cusps for more esthetics.
Onlay preparation is the same as inlay except occlusal preparation if it is
functional cusp as lower buccal or palatal upper 2mm, if non-functional as
lingual lower and buccal upper 1.5mm butt joint.
Transitional angle between reduced and non-reduced cusps should be around
60 degree sloping.
 If all cusps are involved, then you can either go for crown or overlay to be
more conservative and may extend on surface and make finish line to gain
more retention.
 Endocrown resemble overlay except that it goes into pulp chamber.
 Vonlay or veneerlay is a mixture between onlay and veneer for more esthetic
and conservative also.
 For partial coverage you need adhesive, resilient material, and good esthetics,
so use hybrid ceramics or glass ceramics.

Preparation:
1. Putty index.
2. Incisal reduction from 1.5 to 2mm to give bulk and translucency to the
material using wheel or side of tapered stone.
3. Make inciso-lingual beveling.
4. Labial reduction in 3 planes, primary plane with the cervical one third of the
tooth, secondary plane with the inscisal one third and third plane with the
middle with tapered with round make heavy chamfer 1mm, scalloped and
equigingival finish line.
 5. Lingual fossa by football stone 1mm.
6. Lingual reduction heavy chamfer 1mm.
7. Opening proximal contact by fine tapered stone from buccal to lingual.
8. Proximal reduction heavy chamfer 1mm.
9. Finishing red, yellow then white and polishing with sequential discs.
10.Take impression.
 For single crown you can choose any material glass, oxide or hybrid.
 For anterior bridge, go to lithium disilicate, Celtra, cubic zirconia (4 units),
translucent zirconia (5units).
 If posterior bridge, go to translucent zirconia, or zirconia core.

Processing technique:
1. Layering technique: feldspathic porcelain, E-max ceram is porcelain with
fluoroapatite (powder and liquid) and VM, used in veneers or covering
metal or zirconia.
2. Pressing technique: as casting but differ in entering material in casting
enter by centrifugal force but here the material is pressed by plunger, as
leucite Impress, lithium disilicate, and Celtra.
3. CAD/CAM technique: need digitalizing scanning your preparations with
intra oral camera or desktop scanner, design restoration, and milling. There
is wet milling for hybrid and glass ceramics and dry milling for oxides.

Adhesion to ceramics:
 Cementation is done mechanically through interlocking into irregularities while
bonding is chemo-mechanical.
 Ceramics can be classified according to bonding capability to silica based (glass
and hybrid ceramics) and non-silica based (oxide ceramics).
 Silica based need resin cement for reinforcement and esthetics and retention.
Start by etching by HF acid 5 to 10%, time for glass ceramics 1min except lithium
silicate group (E-max, Celtra, Suprinity) for 20 to 30 secs then washing, drying and
silanization from 1 to 3mins then gentle drying.
 For tooth:
o If cementing veneer, total etch and bond should be done.
 o Inlay, onlay, endocrown: etch enamel margin then apply bond on dentin
(self-etch), but if cement is self-adhesive use etch only.
Oxide ceramics can be cemented with glass ionomer or resin modified glass
ionomer or zinc phosphate but use resin cement in case of non-retentive
preparation as short preparations, over taper, shade from resin, but zirconia
cannot accept etching so make sandblasting with alumina particles, then zirconia
primer MDP as Z primer, MDP make chemical bond with zirconia oxides or any
metal oxides.