Esthetic Dentistry

PROCERA: A new way to achieve an

all-ceramic crown
Matts Anderssoti, DDS, Odont Df'^/Michael E. Razzoog. DDS, MS.
Agneta Oden. MSc, DDS. PhD***/Emst A. Hegenbarth, ZTM*^^**/Brien R, Lang, DDS, MS*****

The Procera System embraces the concept of computer-assisted design and computer-assisted machining to
fabricate an all-ceramic crown composed of a densely sintered, high-purity aluminum oxide coping combined
with a compatible veneering porcelain. Strength, precision of fit. color stability, cementation, and wear charac-
teristics are among the many factors that concern elinicians when fabricating all-ceramie restorations with this
new crown system. This article presents, in summary form, the data from the tnany studies on Procera AllCeram
crowns that have been conducted at clinical and laboratory centers around the world. The evidence reported in
these studies dearly demonstrates that the Procera AUCeram crown represents a combination of computer
technology and creativity for which a positive prognosis can be made. Today its appiication is restricted to
single crowns; however, with continued development, multiple unit all-ceramic anterior and posterior fixed par-
tial dentures are clearly in the future. (Quintessence Int ]998-,29:285-296)

Clinical relevance S ince the early 1990s, researchers and clinicians

Procera AUCeram crowns can be used successfully
as all-ceramic restorations in all areas of the mouth,
and their length of service will reach 5 years or
more without complications.
' Director of Procera Developmenl. Nobel Bioi^are, Göleborg,
Sweden,
«* Associale Professor. Deparimeni of Prosthodonlies. School of
Dentistry, University of Michigan, Ann Arbor, Michigan,
*** Director of Research and Development, Procera Sandvik AB,
Stockholm, Sweden; Assistant Professor, Department of Dentiil
Biomaterials, Karolinska Institute, Stockholm, Sweden.
-*** Master Dental Technician, Bruchköbel, Germany.
.»*»» pjofesior. Department of Prosthodontics. School of Dentistry,
University of Michigan, Ann Arbor, Michigan.
Reprint requests: Dr Brien R. Lang, Department of Prostho don tics.
School of Dentistry, University of Michigan. Ann Arbor. Michigan 48109,
E-niailbrli|iiimich.edu
have been seeking new ways of fahricating all-
ceramic restorations that possess the needed qualities
of strength, color stability, favorahle wear characteris-
tics, and precision of fit so that they may be placed in
all regions of the dental arches. Additionally, these
techniques must produce crowns that consistently meet
these qualities in a manner that is cost-effective for the
patient, dentist, and laboratory. Several all-ceramic sys-
tems are now available, demonstrating technologies
that are reported as satisfying the detnands of the den-
tal profession.'"-'
The Procera System (Nobel Biocare) is one such
system that embraces the concept of computer-assisted
design and computer-assisted machining (CAD/CAM)
to fabricate dental restorations.-'-^ Initially, the Procera
System was used to fabricate crowns and fixed partial
dentures hy combining a titanium substructure with a
low-fusing veneering porcelain. This CAD/CAM
technology has been used to produce the Procera
AUCeram crown. This crown is composed of a densely
sintered, high-purity aluminum oxide coping that is
combined with the low-fusing AUCeram veneering
porcelain."

Quintessence I niernational 285

 Andersson et al
Fig 1 The depth of the orientation grooves Fig 2 The incisai reducfion should be Fig 3 When compieted, the preparation
shouid be at least 1 5 mm. approximately 2 0 mm The axial reduction shouid demonstrate a distinct chamfer
shouid be 1.5 mm and is achieved with a shoulder and rounded line angles.
chamfer diamond.
Clinical procedures
Preparation of the tooth
Several recommendations have been suggested for
the preparation of ihe natural tooih. A moderate cham-
fer preparation with rounded, smooth contours and a
lack of sharp line angles will produce the optimal pre-
cision of fil of the eventual coping. The internal finish
line of the preparation should he rounded, especially at
the edge of the chamfer preparation, with a depth of 0.8
to 1.0 mm. Occiusal reduction should be at least 2.0
mm to ensure an adequate thickness of coping material
and esthetic porcelain. Proximal hoxe.s or grooves
should be avoided; however, interproximal concavities
that provide a resistance form may he used with premo-
lars and molars if they have rounded angles to accept
the probe tip.
As for any preparation design, ultrafine diamonds or
tungsten carhide burs are the instruments of choice for
final tooth reducfion and smoothing of the margins. The
greater the definition of the finish line on the tooth and
die, the more preci.seiy the margin is recorded by the
scanner and eventually delineated at the computer-
assisted designing station (Figs 1 to 3).
286
Once the preparation is completed, making the im-
pression of the prepared tooth requires no special con-
siderations, and the die is fahricated wilh routine tech-
niques. When the master ca.st of the prepared tooth and
the opposing dentifion have been articulated, the die can
be removed from its cast and prepared for scanning with
the Procera Scanner,
Use of the computer-assisted de.sign system
The Procera System consists of a computer-controlled
design station in the dental laboratory that is joined
through a modem communicafion link to Procera Sand-
vik AB in Stockholm, Sweden, where the coping is fah-
ricated. At the design station, a scanning device con-
trolled by a personal computer maps the surface of the
die or replica of the prepared tooth.
Prior to the start of the scanning, the die is ditched
below the finish line to clearly define the extent of the
preparation (Fig 4). The die is then oriented vertically in
the scanner's die holder (Fig 5). A sapphire baJl forms
the tip of the scanner probe that contacts the surface of
the die as it rotates around a vertical axis. Extremely
light pressure of approximately 20 g maintains the prohe
in contact with the die as it rotates.
Volume 29, Number 5
 Andersson et al

Fig 4 In (tie laboratory the die is ditched tc clearly delineate the Fig 5 The die is located m the center of the scanning stage, and
finish line prior to scanning. the probe is brought inio contact to begin the scanning process.

As the platform rotates, otie data point is collected at

every degree around the 360-degree circumference of
the die. During each rotation of the die, the prohe is
autotnatically and continuously elevated 200 \im by the
computer and another scan line is read until the entire
surface contour of the die has been mapped, thus
describing the tooth through the use of approximately
50,000 measured values (Fig 6),
When scanning is completed, the data are viewed on
the computer screen for completeness, as defined by an
absence of any void in the illustrated preparation
topography and continnous scan lines without disrup-
tion in the data set (Fig 7), After evaluation of the data
set is completed, two-dimensional plots may be visual- Fig 6 Within 3 minutes, more than 50.000 data points are gath-
ered, defining the three-dimensional shape of the die.
ized on the computer screen and rotated hy 5 or 10
degrees around the vertical axis of the die (Fig 8).
Marking of the finish line on the two-dimensional
plots is the next step to he completed during design of change this dimension. The emergence angle of the
the coping. One half of the two-dimensional plot, begin- coping from the tooth is selected, and the relief space
ning at the starting position of the scanning (0 degrees), for the luting agent is automatically established by a
is brotight on screen and enlarged so that the margin of computer algorithm. When the design of the coping
the preparation can clearly be distinguished from the has been completed, the file is saved in the computer
ditched extent of the preparation. At every 10 degrees of and is ready for transmission via modem to the pro-
rotation, the margin of the die, or finish line, is marked duction station (Procera Sandvik AB) (Fig 11).
by the operator with keystroke computer commands, and
the software interpolates the segment hetween the marks Manufacture of the coping
(Fig 9). The finish line is further refined by the operator,
who repeats this process by marking the margin at 5- The data of the preparation and the design of the coping
degree increments. When the margin of^the preparation is transferred via modem to the facility in Stockholm.
has been defined, it is saved to a computer file for Sweden, where the coping is manufactured with ad-
designing the coping (Fig 10), vanced powder technology and the CAD/CAM tech-
The next step in the design process is to estahlish nique. This process takes into account the sintering
the thickness of the coping to be fabricated. A default shrinkage of approximately 20% by enlarging a model of
of 600 fim is customary for the coping thickness: how- the preparation that is used in the manufacturing process,
ever, for special situations the operator may choose to A high-purity aluminum oxide powder is compacted

Quintessence International 287

Andersson et al
Fig 7 Preparation ot the coping begins by verifying that all of the
data points have been recorded and transferred to the computer
Any missing data would appear as a vertical gap on this comput-
er screen.
Fig 9 The finish line ot the preparation is marked by the operator
at every 10 degrees around the circumference of the die.
Fig 11 Once the preparation margin has been defined and con-
firmed by (he operator, the parameters of the aluminum oxide
coping are selected from the computer menu Finally, the coping
design is merged with the die and its finish line to assure that an
acceptable coping has been created by the CAD process.
Fig 8 The two-dimensional image of the scanned die is illus-
trated The image may be rotated to view ctoss-sections at
degrees around the long axis of the die.
Fig 10 The finish line ol the preparation is represented as a two-
dimensional line in Ihe top portion of the screen. To further define
the finish line, the die cross-sections seen in the lower part of the
screen are remarked at every 5 degrees around the circumfer-
ence ol Ihe die.
against the enlarged preparation model, the outer shape
of the coping is milled, and the coping is sintered to full
density. The coping is examined for quality control and
sent by mail to the dental laboratory, where the ceramist
finalises the restoration by the addition of the AllCeram
veneering porcelain to create the appropriate anatomic
forai and e.^ithetic qualities.
Addition of Ihe vetieeriug porcelain
[n certain situations, it may be necessary for the
ceramist lo thin the coping in selected areas. It is pos-
sihle to thin the coping, especially on the facial surface
at the finish line, to 0.3 or 0,4 mm to achieve the emer-
gence profile and the desired esthetics. If the marginal
area requires thinning, a medium- or fine-grit sintered
diamond should he used, along with copious amounts
Volume 29, Number 5,

of water. Care at this stage will reduce the risk of
cracking the thin marginal area.
A special veneering porcelain (AllCeram Porcelain,
Ducera), with a coefficient of thermal expansion adjusted
to match that of aluminum oxide (7 x lO"*' \im/mL). has
been developed for Ihe coping. The ceramic material has
fluorescent properties that correspond lo those of the nat-
ural dentition. These fluorescent properties and the vital-
ity of the restoration minimize problems of metamerism.
The high melting (2,050°C} temperature of the alu-
minum oxide allows the maintenance of the sharply
deñned margins of the coping when the AllCeram Por-
celain is added lo its surface. No distoriion to the shape
of the coping has been experienced as a result of the fir-
ing of the AllCeram Porcelain. The first layer or liner of
the veneering material is applied in a thin and even
layer over the surface of the coping and ftred at a tem-
perature of giO^C. The liner gives the initial color to the
crown, which is important in the cervical area if darker
or higher chroma shades may be required.
The buildup of the dentin, incisai, and transparent
porcelains is carried out according to the layering struc-
ture of the tooth design. Characterizations such as
mamelons, secondary dentins. and contrasts can be car-
ried otJt with the inten.sive porcelains. Final .staining of
the restorations is rarely necessary because of the vital-
ity of the crown. After glazing is completed and the
final mechanical polishing of the crown is carried out
with diamond polishing paste, the restoration i.s ready
for try-in, final adjustments, if necessary, and cementa-
tion (Figs 12 to 16).
Evaluation of the crown
Every new material and procedure must be evaluated
against the standards of care currently available to the
profession at the time of its introduction. Certain re-
quirements with regard to the qualities of strength, color
stability, favorable wear characteristics, and precision of
fit are essential for any all-ceramic crown to be success-
ful. Details on the handling properties of the restoration
and questions of a technical nature are al.so extremely
important.
For the Procera AllCeram crown, studies evaluating
these requirements and the accompanying clinical ques-
tions of handling and techniques have been ongoing for
the past 4 years. Answers to some of these questions
have been pubiished, while other questions have been
answered through presentations at meetings in countries
around ihe world. With each answer to a clinical ques-
tion, new ideas and proposals are developed, leading to
many other studies and projects that are still in progress.
As is always the case, the dental profession wants the lit-
Quintessenoe internaiional
Andersson et ai
eruture to support answers to all of the questions imme-
diately, but that is not possihie, given the constraints of
the scientific puhlication process. Therefore, the authors
have chosen to summarize what is known about the
Procera AllCeram crown from the articles, abstracts, and
presentations by investigators at centers evaluating the
Procera system, recognizing that much of the material
will he presented in greater detail in future publications.
Strength of the crown
The strength of a crown is of utmost importance.
Copings manufactured by an industrial process show
strength values never before reached by an all-ceramic
restoration. Andersson and Oden'' examined the flexural
strength of the densely sintered high-purity aluminum
oxide coping material. They used a three-point bending
test on 14 specimens 5.0 ± 0.25 mm wide, 1.00 ± 0.05
mm thick, and 26.2 ± 0.1 mm long. The bending test
was performed in a universal testing machine (Model
1361, Instron], and specimens were fractured in a man-
ner specified in ISO 6872.' The span hetween the center
of the bearers was 14.2 mm, and the rate of application
of force was 0.498 N/sec, The density of the sintered
coping material was 3.96 + 0.03 g/cm', and the flexural
strength measured was 601 ± 73 MPa. Today, the density
of the sintered coping is close to the theoretical density,'
The failure stress inflexuraltests of the coping mate-
rial was evaluated by Zeng et al," who used the three-
point bend, ring-on-ring. and pi s ton-on-three-ball tests.
These authors reported substantial differences in the
failure stresses (up to 50%) with the different testing
methods. The results emphasized the importance of
knowing the test method being used and the tnethod of
calculation when data are reported or compared. In this
study, the Procera AilCeram coping material had a con-
sistently higher failure stress than did the other two
materials in all three of the test situations.*
Wagner and Chu,' in a similar investigatiori, evalu-
ated the strength of aluminum oxide (Procera AllCeram)
with a biaxial flexural test. They reported significant dif-
ferences in flexural strength for the Procera AllCeram
coping material (687 MPa) compared to two other popu-
lar all-ceramic systetns, In-Ceratn (Vident), at 352 MPa,
and IPS Empress (Ivoclar). at 134 MPa. The fracture
toughness of Procera AilCeram (4.48 MPa • m"^) and
In-Ceram (4.49 MPa • m"-) were significantly higher
(P = .005) than the fracture toughness of the IPS
Empress ceramic (1.74 MPa • m"-).
The strength of the Procera AllCeram coping when
comhined with its low-fusing veneering porcelain (All-
Ceram Porcelain) was also examined in both tension
and compression with the biaxial flexural test
289
AndersEon et al
Fig 12 After final adjustment ol the occlusion the sur-
laoe of the Procera AUCeram crown is polished with
conventional porcelain polishing points.
Fig 14 Completed Procera AiiCeram crown on maxiilary right
first molar. (Courtesy ol Dr Herman Kupeyan, Windsor, Ontario.
Canada.)
Fig 16 Compiefed Procera AiiCeram crown on maxiliary right
cential inoisor. (Courtesy of Mr Ernsf Hegenbarth, ZTM,
Bruchköbel, Germany.]
290
Fig 13 Compieted Procera AiiCeram crown on maxiliary ielt cen-
tjai incisor. (Courtesy of Dr Herman Kupeyan, Windsor, Ontario,
Canada.]
Fig 15 Compieted Procera AiiCeram crown on maxiiiary ieft iat-
erai incisor, (Courtesy of Mr Ernst iHegenbartii, ZTM, Bruchkobei,
Germany.]
(similar to ASTM F394-78 and ISO/DIS 6872 tests).>" A
l.O-mm porcelain veneer, when combined with 1.0 mm
of the coping material, exhibited the lowest strength
(158 MPa) when tested in tension, while a 0.5-mm
veneer porcelain with 1.5-mm-thick coping material
recorded substantially greater strength (415 MPa) when
tested in compression. The values reported demonstrat-
ed a coping material strength, and a strength in combi-
nation with AUCeram Porcelain, that should withstand
the functional and parafunctional forces that occur in
the anterior and posterior areas of the dental arches
without fracturing.
White et al' ' examined the modulus of rupture of the
Procera AUCeram System in a similar study. In this in-
vestigation, four beam designs were created to determine
the moduli of rupture of the Procera AUCeram coping
material veneered with AUCeram porcelain. The four
beam designs were: coping-coping, veneer-coping, cop-
ing-veneer, and veneer-veneer. These designs allowed the
Volume 29, Number 5,

investigators to study ihe responses of the coping and
veneer materials in compression and tension.
The mean sheiu- stresses (and their standard errors) at
the geometric centers of the beams were cop ing-coping,
39.1 fSE 1.6) MPa; veneer-coping, 8.9 (SE 1.3) MPa;
coping-veneer. 12.9 (SE 2.0) MPa; and veneer-veneer,
4.3 (SE 0.2) MPa. The mean modulus of rupture of the
Procera AllCeram coping material was 5ÜS MPa, while
the modulus of rupture of AllCeram porcelain veneering
material was 76 MPa, The modulus of rupture was
exclusively influenced hy the material forming the ten-
sile surface." The thickness of the coping material
should be maximized, and the thickness of the veneer-
ing porcelain should be minimized.
The effect of the thickness of the coping on the
strength of the coping was assessed by Abed et alj- who
compared the in vitro fracture resistance of Procera All-
Ceram crowns fahricated with two different coping
thicknesses. A stainless steel master die was milled to
the dimensions of a simulated crown preparation for a
maxillary premolar according to the requirements of the
Procera AllCeram crown. The die was replicated in a
material that has a modulus of elasticity similar to that of
dentin. Copings were fabricated for two groups of nine
specimens, which formed the experimental populations.
One group received 0.5-mm-thick copings, while the
other group received 0.7-mm-thick copings.
AllCeram Porcelain was added to each coping to cre-
ate a crown with an overall axial wall thickness of 1.0
mm and an occiusal thickness of 2.5 mm. To simulate a
cemented condition, the internal surface of each crown
was air abraded with 50-(jm aluminum oxide under a
pressure of 80 psi. silanated, and cemented to the tooth
replica (die) with a resin cement (Panavia 21, J Morita),
Each crown specimen was held under a load of 5.Ü kg
for 10 minutes while the cement was allowed to set. and
the crown-tooth simulations were stored for 24 hours in
100% humidity-
Specimens were placed in the Instron machine and
loaded till fracture at a crosshead speed of 0.5 mm/sec.
A mean fracture load of 225 kg was measured for the
crowns with a coping thickness of 0.5 mm, while the
0.7 mm coping fractured under a mean load of 220 kg.
From the analysis of these data, it was concluded that
no significant difference in the fracture resistance of
Procera AlíCeram crowns was found with coping thick-
nesses of 0.5 and 0.7 mm.'-
Color stability of the crown
Ease in applying the veneering porcelain and the produc-
fion of a finished crown with a translucence very similar
to that of natural teeth have heen reported.'' Attanasi et
Quintessence International
Andersson et ai
al'^ evaluated the color stability of the AllCeram Por-
celain specimens placed for 1,200 hours in an acceler-
ated aging device. Twenty Procera aluminum oxide
disks, 16.0 mm in diameter and 2.0 mm thick, were
used as the suhstrate to which 2.0 mm of veneering
porcelain was added.
A colorimeter (Minolta Chroma-Meter CR-321) was
used to determine the baseline color readings of Yxy
and L'*a*h* values prior to placement of the disks in the
Weather-0-Meter. During the accelerated aging process,
the specimens were exposed to light, heat, and changes
in humidity for 300, 600, 900, and 1,200 hours. The
total fime of 1,200 hours was considered equivalent to
5 years in the oral environment. At each time interval,
the specimens were removed from the Weather-0-
Meter, and Yxy and L*a*b* values were recorded with
the colorimeter.
From the color data, a color change (AE) was calcu-
lated as a single measure of the color comparison for
each specimen prior to aging and at the end of each of
the four aging test periods. A AE value greater than 3.7
has heen reported as necessary for observable color
changes to he detected hy the human eye.'^'* In this
study, the AE value was 1.4! (SD 1.10) after 300 hours
and 1.03 (SD 0.62) after 1,200 hours of accelerated
aging, indicating that no clinically detectable color
change was measured for the AllCeram veneering
porcelain.'''
Masking ability of the crown
Several clinicians have asked, "If the coping is so dense,
will it still permit the passage of light and a translucency
that is required to produce an esthetic crown? If it is
translucent, is it necessary to opaque the underlying
tooth and substructures before cemenfing the crown to
mask any unwanted color showthrough?" The coping is
translucent, which can he clearly demonstrated by sim-
ply placing a light source inside the coping and seeing
the illumination or translucency of the light source
showing through the coping (Fig 17). However, the cop-
ing is not transparent and thus will not allow any stain-
ing of the underlying dentin or any other unwanted dis-
coloration to penetrate the coping. Use of an opaquing
material to mask stained dentin or an underlying sub-
structure, such as the alloy used in a post and core or an
amalgam buildup of the preparation, is unnecessary.
To demonstrate this capahility, a study was initiated
to evaluate the masking ability of various thicknesses of
the coping.''' Tooth preparation models were milled
from white plaster and from hlack graphite, and copings
were fahricated for each of these models in various
thicknesses (0.4, 0.6, 0,8, and 1.2 mm). The masking
291
Andersscn étal
Fig 17 Natural translucency ci tiie Procera aluminum oxide cop-
ing iliustrated by the blue ligfit passing througii the copings.
ability of the coping specimens was determined by mea-
suring the reflectance from both the occiusai surface of
the preparation models and the occlusal surfaces of the
copings placed on the models with the colorimeter
(Minolta Chroma-Meter CR-321).
The data output from the colorimeter was recorded
from an area 3,0 mm in diameter on the ocelusal surface
of both the models and the models plus the copings as
CIE L*a*b^'^ color coordinate values. The L^i'a^b^'^ values
of the various copings measured on black graphite and
white plaster exhihited no significant differences when
the occiusai wall thickness of the coping was increased.
From this investigation it was concluded that additional
laboratory procedures to eliminate the unwanted influ-
ences of any dark underlying tnaterials are unnecessary,"
Wear characteristics of tbe crown
Hacker et al'^ studied the wear of enamel against speci-
mens of (1) Procera AllCeram aluminum oxide coping
material veneered with the AllCeram Porcelain, (2)
feldspathic porcelain (Ceramco), and (3) Olympia gold
(JF Jelenko). The enamel specimens were prepared from
recently extracted human teeth as ahraders approxi-
mately 3,0 mm in diameter. These enamel abraders were
polished flat with 600-grit siiicon carbide paper and then
attached to the end of a steel rod for positioning in a spe-
cially designed wear machine. Once positioned in the
wear machine, the enamel specimen was further polished
fiat using 3,0-tim variance silicon carbide paper while the
abrader was rotating in the wear machine, A hole was
drilled in the center of the enamel abrader to function as
a reference for measurements prior to and following the
wear test, and the abraders were uitrasonically cleaned
and stored at 100% relative humidity.
Disk-shaped specimens of the Ceramco porcelain
and the Olympia gold were prepared by a commercial
292
laboratory familiar witb their use, while the Procera
AllCeram aluminum oxide samples were prepared by
Procera Sandvik, and the AllCeram porcelain was applied
to the surface of the coping material by a ceramist famil-
iar with this technique. The Procera and Ceramco disks
were polished flat with 600-grit silicon carbide paper,
ultrasonicaliy cleaned, and then autoglazed. The Olympia
gold disks were polished flat to 1,0-mm variance with a
diamond paste and then cleaned uitrasonically. Each disk
was then secured in a plastic well for po,sitioning in the
wear inachine. The enamel abrader was brought into con-
tact with the material specimen under a load of 1,0 lb
during 10,000 rotational cycles in human saliva.
For wear measurements, polyivinyl siloxane) im-
pressions were made of the enamel ahraders and their
reference holes before and after the wear test. These
impression,s were sectioned along the long axis of the
steel rod holding the enamel abrader, and the wear was
determined by comparing the depth of the reference
holes. All measurements were made with a stereo-
microscope (Zeiss) at x64 magnification,Measurements
were made with a profilometer (Surfanalyzer System
400, Federal Products) on the disk samples at four
locations on the circular path that the abrader had trav-
eled. Vertical loss was calculated, and an average of the
four readings was used for data analysis. The wear data
were evaluated by analysis of variance and Scheffe's
test f/"^,001),
The mean wear values of the enamel abraders when
opposed by the Olympia gold (9 pm), the AllCeram
Porcelain (60 pm), and Ceramco porcelain (230 |im)
were significantly different (P < ,001). Significant dif-
ferences were also found when the wear of the disks
was compared. The wear of Olympia gold (0.3 |jm) was
significantly different from the wear of the AllCeram
Porcelain (4,3 pm) and Ceramco porcelain (3.7 pm).
Results showed that feldspathic porcelain was more
abrasive to the enamel, while the AllCeram Porcelain
was more compatible with the enamel.'*
The knowledge that the Procera AllCeram porcelain
occiusai surface will not destroy the opposing natural
tooth is reassuring to the clinician. A sacrifice of greater
wear of the Procera AllCeram crown is the tradeoff for
the reduced enamel destruction; however, this tradeoff
is a clear benefit to the patient. In vivo research on the
wear characteristics of Procera AllCeram crowns is in
progress in an attempt to demonstrate this same advan-
tage in the clinical environment.
Clinicians have also asked, "Should I be concerned
about wear if the coping material becomes exposed in
the oral environment?" There are several reasons tbat the
coping may become exposed during the restoration of a
tooth. In some situations, the occiusai surface of the pre-
Volume 29, Number 5,

pared tooth may have been underprepared, leaving only
enough space to accotnmodate a coping of reasonable
thtckness and a very thin layer of the veneering porce-
lain. Once cemented, the coping may becotne exposed
by wear of this thin veneering porcelain. Alternatively,
the coping may have heen exposed by selective occlusal
reshaping to accomtiiodate the occlusal contacts with the
opposing dentition. In any case, it is very important to
know just how the exposed cnping material tnay aflect
the opposing dentition.
To answer this question, a study was initiated by
Wilson et al'" to examine the in vitro wear of enamel
opposed by aluminum oxide disks. Fifteen human ena-
mel specimens, ,3,0 mtn in diameter, were polished
with 600-grit silicon carhide paper, 3,0-|am silicon car-
hide film, and thoroughly cleaned, A stnall reference
hole to he used in wear measurements was placed in
the center of each enamel specimen. The fifieen enamel
specimens were divided into three groups of five each.
Fifteen Procera aluminum oxide disks, 10,0 mm in
diameter, were fabricated to form the coping speci-
mens. The aluminum oxide disks were also divided
into three groups: five disks were roughened with a dia-
mond bur, five were roughened and then polished with
Dialite polishing points (Brasseler), and five were
roughened, polished, and then glazed but not polished.
All specimens were ultrasonically cleaned before
being placed in the wear machine. An aluminum oxide
disk was aligned opposing a human enamel specimen,
and a load of 453,6 g was applied axially. The enamel
specimen, under load and in contact with the aluminum
oxide disk, was rotated for 10,000 cycles in the wear
machine in the presence of human saliva.
Wear was determined by measuring the depth of the
enamel reference hole prior to and following the
10,000 wear cycles. The enamel wear, when the enamel
was opposed by the roughened aluminum oxide disk,
ranged from 90 to 1ÍÍU pm. The wear of enamel
opposed by the roughened and polished disk ranged
from 15 !o 60 fim. When the aluminum oxide disk was
glazed and not polished, the enamel wear ranged from
210 to 313 |jm. From these data it was determined that
if the Procera aluminum oxide coping should hecome
exposed in the oral environment, it will not cause
excessive wear to opposing enamel if it is polished
with suitable porcelain polishing points.'''
Precision of fit of the crown
A range of 25 to 40 jjm for tbe marginal adaptation of
cemented restorations has been suggested as a clinical
goaP"; however, marginal openings in this range are
rarely achieved clinically. The American Dental Assoc-
Quintessence International
Andersson et al
iation specification No, 8=' states that the luting cement
film thickness for a crown restoration should be no
more than 25 pm when a Type 1 luting agent is used or
40 pm when a Type 11 luting agent is nsed, McLean
and von Fratmhofer-- examined 1,000 crowns clinically
over a period of 5 years and concluded that a marginal
opening of < 120 pm is cltnically acceptable. Studies
of other all-ceramic crown systems have reported mean
marginal openings that were often less than 155 pm but
ranged from 0 to 313 pm,-'•-•' It would seejn appropri-
ate that a marginal opening between 40 pm and 100
pm would he considered clinically acceptable by most
practitioners.
May et al-^ created five patient simulation model,s
with a maxillary right first premolar and first molar for
measuring the precision of fit of the Procera AllCeram
crown. The tooth preparations were statidardized using
(J) a total convergence angle of 10 degrees, (2) cham-
fer margins 1,3 to 1,5 mm circumferentially, and (3¡
occlusal reduction of 2,0 mm. Procera AllCeram cop-
ings were fabricated, and the anatotnic features of the
tooth were built up by the ceramic technician using the
AllCeram Porcelain, The crown was cemented to it,s
die; a silicone impression material was used as the lut-
ing agent (Extrude light-bodied, Kerr), When the sili-
cone had .set, tbe crown was carefully removed from its
die, leaving the silicone intact on the die. To measure
the precision of fit, a 12,0-mm- area that completely
covered the silicone material and die was digitized
nsing a laser digitizer and an x- and y-axis measure-
ment matrix of 100 pm between each data point. When
digitizing was completed, tbe sibcone luting agent was
removed from the die, and the die was again digitized
without removal from the digitizer. The database creat-
ed hy this procedure provided measurements of the
physical dimension of the three-dimensional space (lut-
ing space) hetween the crown and the die and the
topography of the internal surface of the crown.
The marginal opening (MO) and internal adaptation
of the crowns were determined from the datahase. The
mean MO for the molar was 62 pm (SD 49), with the
lower and upper 95% confidence intervals of 55 and
70 pm, respectively. The mean MO for the premolar
was 55 pm (SD 51), witb lower and upper 95% confi-
dence intervals of 48 pm and 63 prn, respectively, Tbe
MOs for both groups of artificial crowns were well
below the 100 jam selected as the standard for a clini-
cally acceptable crown. All other internal measure-
ments between the die and the internal surface of the
coping were less than 100 pm as well. Based on this
investigation, a Procera AllCeram crown can be treat-
ment planned with confidence, knowing that MO will
consistently be less than 70 pm."
293
 Andersson et ai
Cementation strength of the crown
Blixt et aP^ evaluated the hond strength of a phosphate
cement (Phosphacap-phosphate), two glass-ionomer
cements (Ketac-cem, ESPE, and Vitremer, 3M Detital),
and a resin cement (Dual-Cement radiopaque, Ivoclar
Williams) to the Procera altjminum oxide coping mater-
ial. In their study, these investigators also examined the
influence of surface treatment, ie. leaving untreated,
sandblasting, and silica coating with the Rocatec system
(ESPE), on bond strength. The Procera coping material
specimens for this study consisted of cubes, 10.0 mm
on a side, and cylinders. 4.8 mm in diameter. The cubes
were rigidly held in a vice, leaving four parallel piano-
surfaces available for luting. The cylinders were luted to
these surfaces with a seating force of 5 kg for 10 min-
utes. After luting, the specimens were .stored in artificial
saliva for 48 hours prior to testing.
The shear force necessary to separate the cylinder
from the cube was measured with an Alwetron machine
(AB Lorentzen & Wettre). Scanning electron micro-
photographs (SEMs) (Jeol ISM-820) were made of the
cubes and the cylinders prior to and following the shear
testing. Eighty luting conditions formed the experitnen-
tal population, arranged in four groups, according to
the luting materials, and three subgroups, arranged
according to the surface treatment.
Within the untreated subgroup, the shear force for the
glass-ionomer cements was the highest (Ketac-cem,
4.2 ± 3.1 MPa, and Vitremer, 3.7 ± 2.3 MPa). The
lowest shear force within the untreated subgroup was the
resin cement, at 2.5 ± 2.4 MPa: the value for the
phosphate cement was 3.4 ± 1.1 MPa. The sandblasted
surfaces were very similar to the untreated subgroup,
with the exception of Ketac-cem, at 12.7 ± 2.8 MPa. The
silanated suhgroup demonstrated the highest shear force
values for all materials, with the resin cement at 36.9 ±
S.8 MPa. The bond strengths of the specimens luted with
Dual-Cement radiopaque and surfaces treated by the
Rocatec system were significantly higher than those of
the other materials and surface treatments.-"
Awliya et al"' also examined the influence of surface
treatments, specifically Kinetic Cavity Preparation
(KCP) abrasives on the shear bond strength of resin
cements to the Procera aluminum oxide coping materi-
al. Forty coping material specimens were fabricated by
Procera Sandvik. The specimens were divided into four
groups of 10 each for testing the bond strength under
four different surface abrasion treatments: {!} air ahra-
sion with 25-iim aluminum oxide at medium speed
(120 psi): (2) air abrasion with 15-\im aluminum oxide
at high speed (160 psi); (í) air abrasion with 50-fim
aluminum oxide at medium speed (120 psi): and (4) air
294
abrasion with 50-(im aluminum oxide at high speed
(160 psi),
A 4.0-mm area was i.solated on the treated surfaces
of each aluminum oxide specimen, and a resin cement
(Panavia 21) was applied to this area according to the
manufacturer's instructions. After the cement had set,
the speciniens were kept at 100% humidity for 7 days.
The specimens were subjected to a shear load in the
Instron machine at a crosshead speed of 0.5 mm/min.
The results were: treatment I, 18.27 ± 3.89 MPa:
treatment 2, 21.46 ± 4.28 MPa: treatment 3, 20.13 ± 4.35
MPa: and treatment 4, 18.09 ± 5,18 MPa. A two-way
analysis of variance indicated no significant difference at
P < .05 in the shear bond strengths of the resin cement
under any of the four treatment conditions tested. More
important than the surface treatment method was the
high bond strength obtained with the resin cement
Panavia 21.-'
To determine which luting agent should he u.sed with
the Procera AllCeram crown. Dwan et al-* examined the
effect of différent cements on the fracture resistance of
the Procera AllCeram crown. A stainless steel master
model was milled to the dimensions of a porcelain
crown preparation for a maxillary premolar. The master
model was then replicated to produce 27 dies in a mate-
rial with a modulus of elasticity similar to that of dentin.
Procera AllCeram copings with a thickness of 0.5 mm
were fabricated for the 27 dies, AllCeram Porcelain was
added to the copings to produce an axial wall thickness
of 1.0 mm and an occiusal thickness of 2.6 mm.
The dies and their respective crowns were then di-
vided into three groups of nine each, and the internal sur-
faces of the crowns vi-ere air abraded with 50-|jm alu-
minum oxide particles at 80 psi. The abraded surfaces
were then silanated prior to cementation. The three luting
agents tested were zinc phosphate, a resin cement (Pan-
avia 21). and a hybrid glass-ionomer cement (Duet, Fuji
Duet). All crowns were cemented according to the manu-
facturer's recommendations and under a load of 5 kg for
10 minutes. After the cement had set, the samples were
held in 100% humidity for 24 hours prior to testing.
Specimens were placed in an Instron machine and
loaded until fracture at a crosshead speed of 0.5 mm/sec.
Panavia 21 (225 kg) and Duet (214.6 kg) withstood sig-
nificantly higher fracture loads than did the zinc phos-
phate cement (153.5 kg). However, all of the values for
the different luting agents were clinically acceptable.-"
In a similar study, Blixt et aP" evaluated the bond
strengths of two chemically cured luting cements
(Panavia 21. J Morita. and Dyract, Dentsply) to the
Procera AllCeram coping material and to dentin. Twenty-
four cylinders and matching cubes of the Procera coping
material were fabricated for this study. Their seating sur-
Voiume 29, Number 5,199g

faces Were cotiditioned by either sandblasting (50%) or
sandblasting and silanation (SO'J'f). Twelve cylinders
were luted to cubes with Panavia 21 and 12 with Dyract
using a seating force of 5 kg for 10 minutes, Dentinal
surfaces were prepared from three recently extracted
molar teeth for 12 tests.
The surfaces of dentin were prepared according to the
manufacturer's instructions for the two luting agents,
Silanated aluminum oxide cylinders were bonded to the
dentin with Panavia 21 or Dyract. All specimens were
stored in artificial saliva for 48 hours prior to testing.
Shear bonding forces were tested in a Alwetron machine
atid the surfaces were examined by SEM (Jeol JSM -
820}. The thickness of the cements was measured at x50
magnification with a stereomicroscope (Elvar. Leitz).
The mean thickness of Panavia 21 was 0.063 mm and
that of Dyract was 0.050 mm. The highest shear bond
strengths were recorded for the Panavia 2\ specimens,
regardless of the surface treatment. For the sandblasted
aluminum oxide specimens, the shear bond strength for
Panavia 21 was 37.54 ± 4.10 MPa. while for the silan-
ated alutninum oxide specimens, the bond strength was
40.64 ± 3.15 MPa. The bond strength between the dentin
and Panavia 21 was 8.47 ± 2.20 MPa. The SEM evalua-
tion revealed that cohesive failure occurred between
dentin and the luting agents in all cases, leaving cement
attached to the aluminum oxide surface.-"
The higher shear bond strength obtained when a resin
cement was used for cementation of the Procera AU-
Ceram crown led to a stndy of Awliya et al,-'" who evalu-
ated several different resin cements in an attempt to
determine if one cement were better than another for the
Procera system. Forty Procera AUCeram aluminum oxide
specimens were fabricated by Procera Sandvik. The spec-
imens were divided into four groups of 10 each, and the
aluminum oxide surface was air abraded with 50-|jm alu-
minum oxide at 80 psi and the Microetcher (Danville
Engineering).
Following surface preparation, each group received
one of the following four luting agents: IPS Empress
(Ivoclar); C & B Metabond (Parkell); Enforce (Caulk/
Dentsply); or Panavia 21 EX (Kuraray). After the ce-
ment had set, the specimens were kept at 100% humidi-
ty for 7 days. The aluminum oxide .specimens were then
subjected to a shear load in the Instron machine at a
crosshead speed of 0.5 mm/min.
The results were Empress. 8-84 ± 2.95 MPa: C & .B
Metabond, 10-77 ± 1.55 MPa; Enforce, 11.99 ± 3.11
MPa; and Panavia 21, 16.S1 ± 4.02 MPa, The analysis of
variance demonstrated a significant difference in bond
strength between Panavia 21 and the other resin cements;
no differences were found among the other three
cements- The resin cement Panavia 21 demonstrated a
Quintessence Intemationai
Andersson et al
clearly higher bond strength when cetnented to the
Procera AUCeram aluminum oxide coping material.'"
liiocomputihility of the ciown
Any restoration that contains aluminum poses a poten-
tial threat to heaith should the alutninum ion leach out
and get into the bloodstream- To ensure that this threat
is not valid, a study examining the biocompatibility of
the Procera AUCeram crown was initiated. Adamczak
and Linden" measured the effect of pH on the release of
aluminum from the densely sintered, high-purity
Procera AUCeram coping material in vitro. The speci-
mens were hung in a glass jar containing 50 mL of arti-
ficial saliva buffered with phosphate to give solutions of
pH 3, 4, 5, 6, and 7, The tests were carried out under
dark conditions at 37"C.
The solutions were changed after 4, 12, 20, 28, and 90
days and analyzed for the release of aluminum with an
atomic absorption spectrometer (PYE UNICAM SP9,
Phillips). The results indicated that the Procera AUCeram
aluminum oxide coping material does not show any leak-
age or dissolution of aluminum at any of the pH levels.^'
The safety of using a Procera AUCeram crown in the oral
cavity was clearly established by this investigation.
Clinical evaluation of the crown
A long-term clinical trial of Procera AUCeram crowns
was conducted by Oden et al (unpubli.shed data, 1997).
One hundred crowns formed the experimental popula-
tion. The evaluation involved using the California Dental
Association's quality evaluation guidelines.^- Of the 97
crowns available for assessment after 5 years in service,
only three posterior teeth (or 3.1% of the Procera All-
Ceram crowns) had experienced a fracture through the
veneering porcelain and the coping material. All the re-
maining crowns were rated as either excellent or accept-
able for surface, color, anatomic form, and marginal in-
tegrity. These results indicate that Procera AUCeram
crowns can be used successfully as all-ceramic restora-
tions in all areas of the mouth, and their length of sen'ice
without complications will reach 5 years or more (Oden
et ai, unpublished data, 1997).
Summary
The Procera AUCeram crown represents a combination of
computer technology and creativity for which a positive
prognosis certainly can be made. Today its application is
restricted to single crowns; however, with continued
development, multiple-unit all-ceramic anterior and pos-
terior fixed partial dentures are clearly in the future.
295
Andersson et al
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