i T O Y

A Review of _ :

All-Ceramic

ince the introduction of the first successful porcelain-fused-to-metal

To select the most
system in the early 1960s,' there has been increasing demand for ce-
appropriate type of
all-ceramic system ramic restorative materials. As recently as 1990, of the estimated 35
for clinical use, the
million crowns placed by private practice dentists, more than 71 percent had
clinician must be fa-
miliar with the differ- porcelain as one of the components.2 This popularity may be the result of
ences between sys-
tems. This article
porcelain aesthetics. Porcelain is the most natural-appearing synthetic re-
discusses five cate- placement material for missing tooth substance. It is available in a range of
gories of all-ceramic
restorative systems
shades and translucencies for achieving lifelike results. Historically,
relative to their pro- strength concerns compromised some of the beauty of porcelain crowns.
cessing techniques,
strength and wear Because of the relatively low tensile strength and brittleness of the porce-
characteristics. The lain, it has been generally fused to a metal substrate to increase resistance
authors present and
compare results of to fracture.3 However, this metal base can affect the aesthetics of the porce-
published in vitro
lain by decreasing the light transmission through the porcelain and by creat-
studies and short-
term clinical studies. ing metal ion discolorations. In addition, some patients have allergic reac-
tions or sensitivity to various metals. These drawbacks, together with the
material and labor costs associated with metal substrate fabrication, have
prompted the development of new all-ceramic systems that do not require
metal, yet have the high strength and precision fit of ceramo-metal systems.
MARC A. ROSENBLUM, PH.D., D.M.D.; ALLAN SCHULMAN, D.D.S., M.S.

JADA, Vol. 128, March 1997 297

C~KOVER STORY
Figure 1. Whiteware compositions composed of clay, feldspar and silica (quartz).
In this article, we describe
five categories of all-ceramic
systems:
- conventional (powder-slurry)
ceramics;
castable ceramics;
-machinable ceramics;
-pressable ceramics;
infiltrated ceramics.
CERAMIC VS. PORCE-
LAIN: WHAT'S THE
DIFFERENCE?
Ceramics. Ceramics are usu-
ally defined in terms of what
they are not: nonmetallic (not
metals) and inorganic (not
resins). To distinguish them
from rocks and minerals, the
vast majority of which are also
inorganic and nonmetallic, ce-
ramics are additionally defined
as man-made solid objects
formed by baking raw materi-
als (minerals) at high tempera-
tures. The term "ceramics" is
298 JADA, Vol. 128, March 1997
derived from the Greek word
"keramos" meaning "burnt
stuff."
V These objects are made by first
I n dentistry, we use
three different
types of porcelain
compositions, depend-
ing on their application.
A mass. The coalescence of the
Although the methods of ob-
taining and purifying the raw
materials and the technology of
fabricating these raw materials
into useful objects have been
significantly advanced since
ancient times, some methods
and techniques have not
changed. For example,
stoneware and pottery are still
made from impure clays, sand
and feldspar minerals, and are
baked in ovens called kilns.
pulverizing the raw materials
into fine particles or powders,
then adding water to obtain a
consistency suitable for shap-
ing and molding. The "green"
(unbaked) objects are dried and
are placed in a kiln and heated
to sufficiently high tempera-
tures to make the individual
particles coalesce into a solid
particles is often referred to as
"sintering," and the process
usually results in a net shrink-
age and strengthening of the
solid mass.
The newer types of ceramic
dental restorative materials
used for all-ceramic crowns, ve-
neers and inlays are either
variations of feldspathic porce-

lain (for example, Optec HSP,
Jeneric/Pentron; In-Ceram,
Vident; Cerec, Vident; Celay,
Vident; IPS Empress, Ivoclar
North America; and Optec
Pressable Ceramic, Jeneric/
Pentron) or are made of entirely
different compositions (for ex-
ample, Dicor, Dentsply, L.D.
Caulk Division; Duceram LFC,
Degussa Corp.). The
methods used for fabri-
cating some of these
restorations are quite
different from those
used for ceramo-metal
restorations and porce-
lain jacket crown, or
PJCs.
Porcelain. A specific
type of ceramic widely
used for nearly 3,000
years, traditional porce-
lain is composed of
blends of three natural-
ly occurring minerals:
pure white clay, quartz
and feldspar. When
these three ingredients
are pulverized, blended,
formed into shapes and
baked, they compose
what is known as white-
ware, so named because
their color is white after FigureD 2. Scanning electron micrograph of leucmite
they are baked. crystaIs in a dental porcelain composition (pheDto-
graph courtesy of Dr. T.K. Vaidyanathan).
Porcelain is a type of
whiteware that has rel-
atively high strength and
translucency. Other types of
whiteware include tile, electri-
cal insulators and sanitary
ware (used, for example, in
sinks and toilets) (Figure 1).
In dentistry, we use three dif-
ferent types of porcelain compo-
sitions depending on their appli-
cation. One is for denture teeth,
one is for ceramo-metal applica-
tions and another is for all-
porcelain restorations (PJCs, ve- cies. After baking, all three types eral, ceramics have relatively
neers and inlays).
- Denture tooth porcelain be-
gins as a mixture of powders of
feldspar, clay and quartz. This is
referred to as high-temperature
porcelain in some dental materi-
als textbooks.4
- Feldspathic dental porcelain,
used for ceramo-metal restora-
tions, begins as a mixture of
powders of potassium feldspar
and glass. This type of porcelain
composition can also be used for
fabricating porcelain veneers
and inlays.
- Aluminous porcelain, used in
PJCs, is composed of mixtures
similar to that of feldspathic
dental porcelain with increased
amounts of aluminum oxide.
These three types of dental
porcelain also contain pigments
and opacifying agents to create
various shades and translucen-
of porcelain contain similar com- low tensile strength because of
ponents: small crystals (leucite
COVER STORY
and/or other alumino-silicate
crystals) embedded in a silicate
glass (a noncrystalline, amor-
phous matrix). The relative
amounts of crystal and glass de-
pend on the specific type of
porcelain in question. Leucite (a
reaction product of potassium
feldspar and glass) is a particu-
larly important component in
dental porcelain because
it affects the optical prop-
erties, thermal expan-
sion, strength and hard-
ness of the porcelain
(Figure 2).
CERAMICS AS
RESTORATIVE
MATERIALS
Much has been written
about the desirable prop-
erties of ceramic dental
restorative materials:
their lifelike optical prop-
erties, biocompatibility,
durability and etchability
(ability to be bonded).
However, two major prob-
lems arise in their use in
dentistry: their potential
for brittle, catastrophic
fracture, and their poten-
tial to cause abrasive
wear of opposing tooth
structure.
Brittle fracture is gen-
erally attributed to the
rapid, uninterrupted propaga-
tion of cracks through the bulk
of the ceramic material, usually
beginning at a flaw in the mate-
rial. The flaw can be a microc-
rack in the surface (for example,
created during occlusal adjust-
ment with a diamond stone), or
it can be a subsurface porosity
(for example, from a processing
error during the buildup and
baking of the porcelain). In gen-
the presence of flaws. Improving
JADA, Vol. 128, March 1997 299
8COVER STOBY-
the fracture resistance of dental
porcelain provided the impetus
for fusing it to a metal sub-
strate. For additional strength,
small crystals can be dispersed
within the ceramic structure to
impede the propagation of
cracks.
The abrasive wear of oppos-
ing tooth structure is a serious
clinical problem. The amount of
wear is influenced by the hard-
ness of the ceramic material
and its surface roughness as it
functions against natural tooth
structure. The effects of abra-
sive wear are particularly no-
ticeable and destructive when
lingual ceramic surfaces of a
maxillary anterior crown func-
tion against the incisal and fa-
cial surfaces of mandibular an-
terior teeth. Glazed porcelain
can be less abrasive than porce-
lain with a roughened surface5
(for example, from occlusal ad-
justment).
The evolution of ceramic and
porcelain materials has been a
battle for the ideal strength-
aesthetic combination. The first
all-ceramic crowns introduced
by Land in 19036 were relatively
weak materials with limited
clinical use. In 1965, McLean
and Hughes7 formulated alumi-
nous porcelain compositions
that are still in use today.
These materials are composed
of feldspathic porcelain to which
approximately 50 percent alu-
minum oxide is added to in-
crease the strength and baking
temperature. As such, alumi-
nous porcelain compositions can
be used as cores to replace the
metal substructure used in cer-
amo-metal constructions. They
are veneered with conventional
feldspathic porcelain to repro-
duce the contour and shade of a
natural tooth. Because alumi-
nous porcelain shrinks during
300 JADA, Vol. 128, March 1997
the baking procedure, the fit of
finished aluminous crowns is
generally much poorer than
that of ceramo-metal crowns.
Although aluminous crowns are
considered more lifelike in ap-
pearance than their ceramo-
metal counterparts, their suc-
cessful fabrication is extremely
technique-sensitive. The clinical
fracture reported for these
types of restorations is relative-
ly high: 2 percent for anterior
crowns8 and 15 percent for pos-
terior crowns.9
More recently, newer types
of all-ceramic restorations have
been developed that may prove
to have a lower incidence of
clinical fracture for three im-
portant reasons:
- all-ceramic restorations
today consist of stronger mate-
rials and involve better fabri-
cating techniques;
- most all-ceramic restora-
tions can be etched and bonded
to the underlying tooth struc-
ture with the new dentin adhe-
sives;
- with greater tooth reduction
than what was previously used
for PJCs, clinicians now pro-
vide laboratory technicians with
enough room to create thicker
and stronger restorations.
CLASSIFICATION OF ALL-
CERAMIC SYSTEMS
The following general types of
all-ceramic systems are current-
ly available:
- Conventional powder-
slurry ceramics. These prod-
ucts are supplied as powders to
which the technician adds
water to produce a slurry,
which is built up in layers on a
die material to form the con-
tours of the restoration. The
powders are available in vari-
ous shades and translucencies,
and are supplied with charac-
terizing stains and glazes.
- Castable ceramics. These
products are supplied as solid ce-
ramic ingots, which are used for
fabrication of cores or full-con-
tour restorations using a lost-
wax and centrifugal-casting tech-
nique. Generally, one shade of
material is available, which is
covered by conventional feld-
spathic porcelain or is stained to
obtain proper shading and char-
acterization of the final restora-
tion.
- Machinable ceramics.
These products are supplied as
ceramic ingots in various
shades and are used in comput-
er-aided design-computer-aided
manufacturing, or CAD-CAM,
procedures. The machined
restoration can be stained and
glazed to obtain the desired
characterization.
- Pressable ceramics. Also
supplied as ceramic ingots,
these products are melted at
high temperatures and pressed
into a mold created using the
lost-wax technique. The pressed
form can be made to full con-
tour, or can be used as a sub-
strate for conventional feld-
spathic porcelain buildup.
- Infiltrated ceramics. These
products are supplied as two
components: a powder (alu-

minum oxide or spinel), which
is fabricated into a porous sub-
strate, and a glass, which is in-
filtrated at high temperature
into the porous substrate. The
infiltrated ceramic is then ve-
neered using the conventional
feldspathic porcelain technique.
CONVENTIONAL POW-
DER-SLURRY CERAMICS
Optec HSP. Optec HSP has
greater strength than conven-
tional feldspathic porcelain as a
result of an increased amount of
leucite.Y' The manufacturer dis-
perses the leucite crystals in a
glassy matrix by controlling
their nucleation and crystal
growth during the initial pro-
duction of the porcelain
powder. " Because of its in-
creased strength, Optec HSP
does not require a core when
used to fabricate all-ceramic
restorations, as is necessary
with aluminous porcelain PJCs.
The body and incisal porcelains
are pigmented to provide the
desired shade and translucency.
The leucite and glassy compo-
nents are fused together during
the baking process (at 1020 C).12
The buildup and contouring of
the crown is accomplished using
the powder-slurry technique on
a special semipermeable die
material. Optec HSP does not
require special processing
equipment beyond what is used
for ceramo-metal restorations.
These restorations fit accu-
rately; however, their increased
leucite content contributes to
the relatively high in vitro wear
of opposing teeth, as reported in
a recent laboratory study.5
There are no published clinical
studies of Optec HSP.
Duceram LFC. This is a
relatively new category of
restorative material, referred to
as "hydrothermal low-fusing ce-
Figure 3. Inlay made from Celay (Vident) (photograph courtesy of Dr.
C. Moglianesi).
ramic." It is composed of an
amorphous glass containing hy-
droxyl ions. The manufacturer
claims'` that this noncrystalline
structure has greater density,
higher flexural strength,
greater fracture resistance and
lower hardness than feldspathic
porcelain (causing less abrasion
against tooth structure than
leucite-containing systems). The
higher flexural strength results
from an ion exchange mecha-
nism of hydroxyl ions, which is
said to also promote a healing of
surface microcracks. The lower
hardness results from the ab-
sence of leucite crystals in this
material.
Duceram LFC is used for the
fabrication of ceramic inlays,
veneers and full-contour
crowns. The restoration is made
in two layers. The base layer is
Duceram Metal Ceramic (a
leucite-containing porcelain); it
is placed on a refractory die
using standard powder-slurry
techniques and then baked at
930 C. Over the base layer,
Duceram LFC is applied using
the powder-slurry technique
COVEH STORY
and baked at a relatively low
temperature (660 C). The mate-
rial is supplied in a variety of
shades and can be surface-char-
acterized with compatible
stains and modifiers. The fabri-
cation process requires no spe-
cial laboratory techniques or
equipment.
There are no clinical studies
substantiating the manufactur-
er's claim that the material is
less abrasive to tooth structure
than feldspathic porcelain.
However, the results of a one-
year clinical study recently con-
ducted for the manufacturer
seem to indicate that the mate-
rial wears at a rate equivalent
to that of natural tooth enamel
(Shotwell J, Beard CC, Lang B,
Lang BR, unpublished data,
1990).
CASTABLE CERAIVUIC
SYSTEMS
Dicor. This is a polycrystalline
glass-ceramic material, initially
formed as a glass and subse-
quently heat-treated under con-
trolled crystallization conditions
to produce a glass-ceramic ma-
JADA, Vol. 128, March 1997 301
COVER STORY

Optec HSP 146 MPa'0 Higher thanl that of Special die No core material; i-
(Jeneric/
Pentron)
conventional feld-
spathic porcelain due
material form thranluoency
and
shade throughout; etch-
to high leucite corntent5 ablebohding
for to
tooth
Duceram LFC 110 MPa13 Close to hardness of Special die Low fiusing tempera-
(Degussa) natural tooth owing material ture; can be charac-
to absence of leuicite terized with suirface
stains
r ~~~~~~~~~~~~~~~~~~~~~~~~~k
Dlcor 152 MPal Same as that of tooth Special invest- Surface stains (aes-
(Dentsply, L.D. (softer than conven- ment and casting thetics) can be lost to
Caulk Division) tional feldspathic equzipment abrasion and acidu-
porcelain)'; however, lated fluoride (Dicor
Dicor Plus is as hard Plus is more stable);
as conventional feld- etchable core for
spathic porcelain bonding to tooth

Cerec Vltablocs 93 MPa26 Similar to that of con- Siemens Cerec Regarding all mate-
Mark I (Vident) 9ventional feldspathic CAD-CAM rials in this group:
porcelainr System; milling ~ Can be character-
of a ceramic ized with surface
ingot from a digi- stainis; the stains
tized optical scan may be lost to abra-
sion
Cerec 152 MPa26 Similar to that of Same as above - The gap between
Vitablocs Mark eaamel27 the restoration and
ll (Vident) tooth is wider than
that in other all-ce-
ramic systems; wear
Dicor MGC 216 MPa28 Between those of Same as above of the resin cement
(Dentspiy, L.D. Cerec Vitablocs Mark in this gap may have
Caulk Division) I aDd Cerec Vitablocs clinical significance
Mark 1127 - Etchable for bond-
ing to tooth struc-
Celay (Vident) Same as Same as that of Cerec Celay Copy- tuire
that of Vitablocs Mark 1130 Milling System;
Cerec milling of a ce-
Vitablocs ramic ingot from
Mark I130 a direct pattern

UPS Empress 126 MklPa Possibly higher than Special o-ven, die Core material is
(Ivoclar North
America)
i6itially; that of conventiojnal feld- material and shaded and translui-
160-182 spaxthic porcelain owing molding proce- cent; etchable for
M:Pa after to increased leuzcite dure bonding to tooth
heat treat- content after heat
ment24 treatment
Optec PF.ssatie 165 MPa37 Same as above Same as above Same as above
Ceramic
(JenedcAPeronb)

In-Ceram 450 Mpa17'20 Same as that of conr- Special die mate- Core material is more
(Vident) 0ventionial feldspathic rial, high-tem- opaque than other
porcelain perature oven types; not etchable
for bonding to tooth
* ft*Wu~estength re f various iatW.M

302 JADA, Vol. 128, March 1997


Figure 4. A. Lower anterior teeth before treatment.
B. IPS Empress (Ivoclar North America) porcelain
veneers on a laboratory model. C. Lower anterior
teeth with bonded porcelain veneers. (Photographs
courtesy of Dr. David Ehrenberg.)
terial."4 The fabrication method
uses lost-wax and centrifugal-
casting techniques similar to
those used to fabricate alloy
castings.
A full-contour transparent
glass crown is cast at 1350 C,
then is heat-treated at 1075 C
for 10 hours. This heat treat-
ment (known as "ceramming")
causes partial crystallization
(55 percent) of tetrasilic mica-
like crystals.11 The crystals
function in two ways: they
create a relatively opaque ma-
terial out of the initially trans-
parent crown, and they signifi-
cantly increase the fracture
resistance and strength of the
ceramic. These crystals are also
less abrasive to opposing tooth
structure than the leucite crys-
tals found in traditional feld-
spathic porcelains.15 To achieve
the appropriate shade, the col-
orant stains are baked on the
surface of the glass-ceramic
material.
There has been some evi-
dence that the stain layer
might be lost during occlusal
adjustment, during routine
dental prophylaxis or through
the use of acidulated fluoride
gels.16 Dentsply (Trubyte
Division) has introduced Dicor
Plus, which is
a shaded feld-
spathic porce-
lain veneer ap-
plied to the
Dicor sub-
strate.'7
However, as
Dicor Plus is a
feldspathic porcelain that con-
tains leucite, it is expected that
these restorations will be as
abrasive to teeth as other feld-
spathic porcelains.
Dicor crowns and veneers
have been demonstrated to fit ac-
curately in clinical and laborato-
ry studies.18 The process requires
a special high-temperature, elec-
tric-heated casting unit.
Short-term clinical studies
verify the efficacy of the Dicor
system for use in veneers and
inlays.9'20 Failure rates as high
as 8 percent (fracture of the
restorations) have been report-
ed.'9 Failure rates as high as 35
percent for full-coverage Dicor
crowns not bonded to the un-
derlying tooth structure have
been reported.2'
MACHINABLE CERAMICS
The ceramic ingots used in
CAD-CAM restorations do not
require further high-tempera-
COVER STORY
ture processing. They are
placed in a machining appara-
tus to produce the desired con-
tours. This is followed by oc-
clusal adjustment and then
polishing, etching and bonding
the restoration to the prepared
tooth. The CAD-CAM process is
discussed in detail in the litera-
ture.22-24 The different types of
ceramic ingots used in the pro-
cess are as follows.
Cerec Vitablocs Mark I.
This is a feldspathic porcelain,
which was the first composition
used with the Cerec system
(Siemens). It is similar in com-
position, strength and wear
properties to feldspathic porce-
lain used for porcelain-fused-to-
metal restorations.
Cerec Vitablocs Mark II.
This is a feldspathic porcelain of
increased strength,2' and has a
finer grain size than the Mark I
compositions; an in vitro evalu-
ation shows that this produces
JADA, Vol. 128, March 1997 303
G~KOVER STORY
Figure 5. Inlay made from Optec Pressable Ceramic (Jeneric/Pentron)
(photograph courtesy of Dr. David Ehrenberg).
less abrasive wear of the oppos-
ing tooth structure.26 There are
no published clinical studies as
yet to support this claim.
Dicor MGC (Dentsply,
L.D. Caulk Division). This is
a machinable glass ceramic
composed of fluorosilicic mica
crystals in a glass matrix. It has
greater flexural strength than
the castable Dicor (discussed
earlier) and the Cerec composi-
tions (Table).27 This material is
softer than conventional feld-
spathic porcelain and produces
less abrasive wear of the oppos-
ing tooth structure than Cerec
Mark I and more wear than
Cerec Mark II in an in vitro
study.26
Celay. This material can be
used for CAD-CAM-produced
restorations or used in the copy-
milling technique (Figure 3).28 It
is a fine-grained feldspathic
porcelain that is said to reduce
the wear of antagonist tooth
structure; however, there are no
clinical studies to substantiate
this claim. The manufacturer
claims that this material is
identical in composition to
304 JADA, Vol. 128, March 1997
-~~ ~ ~~~ ~ ~~~ ~ ~~~~~ ~~~~~~~~~~~~~~~
~
~~~~~~
~~~ ~~~~
Cerec Vitablocs Mark II (E.
Perry, Celay product manager,
Vident Inc., personal communi-
cation, 1996). On this basis, it
would be expected that the phys-
ical and clinical properties of
Celay are also identical to those
of Cerec Vitablocs Mark II.
V plunger presses the molten ce-
A 11 the systems
appear to have
adequate
strength for single units.
Their ability to be bond-
ed to tooth structure is
an additional strength-
emng mechanism.
A result of the growth of additional
All the aforementioned sys-
tems can be characterized with
stains after milling and occlusal
adjustment. Machinable ceram-
ics have been evaluated in some
limited clinical studies.93'
These studies have shown that
the gap between the restoration
and tooth structure is consider-
ably wider than that in other
types of all-ceramic restora-
tions. This gap can be filled in
with composite resin cements,
but the cement itself is subject
to wear. This wear may be self-
limiting after three to four
years.3031 Clinical fracture seems
to be related to insufficient
depth of tooth preparation and
inadequate bonding to the tooth
structure during cementation.
~ ~~~ ~ ~~~ ~ ~~~
~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
PRESSABLE CERAMICS
IPS Empress. This is a type of
feldspathic porcelain supplied
in ingot form. The ingots are
heated and molded under pres-
sure to produce the restora-
tions. A full-contour crown is
waxed, invested and placed in a
specialized mold that has an
alumina plunger. The ceramic
ingot is placed under the
plunger, the entire assembly is
heated to 1150 C and the
ramic into the mold.32'33 The
final shade of the crown is ad-
justed by staining or veneering
(Figure 4). In the veneering
technique, the original wax-up
is cut back by about 0.3 mil-
limeters. After molding and
baking as described, feldspathic
porcelain is added to the surface
to obtain full contour and the
correct shade.
The flexural strength has
been shown to improve under
subsequent heat treatments as a
leucite crystals.34 For example,
the flexure strength of the heat-
pressed material is in the range
of 126 megapascals, or MPa;
with subsequent heat treat-
ments, the strength increases to
the 160- to 182-MPa range.

Figure 6. Crowns made from In-Ceram (Vident) (photographs courtesy of Dr. Carlos Moglianesi).
One short-term clinical
study35 has been published that
reports no clinical fractures of
10 IPS Empress inlays; howev-
er, one-third of the restorations
showed a marginal gap after 11/2
years of evaluation.
Optec Pressable Ceramic.
Optec OPC is also a type of
feldspathic porcelain with in-
creased leucite content, pro-
cessed by molding under pres-
sure and heat. The OPC system
can be used for full-contour
restorations (inlays, veneers,
full crowns) (Figure 5).
Alternatively, it can be used as
a core material, which is ve-
neered using conventional pow-
der-slurry techniques with a
high-leucite-content feldspathic
porcelain, similar to Optec HSP
porcelain. The manufacturer
claims that the crystalline
leucite particle size has been re-
duced and the leucite content
increased, resulting in an over-
all increase in flexural strength
of OPC.36 There are no pub-
lished clinical studies of Optec
OPC; however, because of its
high leucite content, it can be
expected that this porcelain's
abrasion against natural teeth
will be higher than that of con-
ventional feldspathic porcelain.
Both Optec OPC and IPS
Empress produce strong,
translucent, dense and etchable
ceramic restorations. The mate-
rials are especially useful in
fabricating ceramic veneers.
Both systems require special
equipment (pressing oven and
die material) to fabricate the
restorations.
INFILTRATED CERAMICS
In-Ceram. This ceramic mate-
rial is composed of an infiltrated
core veneered with a feldspathic
porcelain. The core is initially
extremely porous, and is com-
posed of either aluminum oxide
or spinel (a composition contain-
ing aluminum oxide and magne-
sium oxide). This porous struc-
ture is subsequently infiltrated
with molten glass. The spinel
cores are more translucent than
the aluminum oxide cores, but
some strength has been sacri-
ficed for the translucency.
The core is made from fine-
grained particles37 that are
mixed with water to form a sus-
pension referred to as a "slip."38
The slip is then placed on a gyp-
sum die and baked at 1120 C
for 10 hours to produce the
opaque, porous core. At this
stage, the material is very frag-
ile and must be handled careful-
ly. Next, an appropriate shade
of glass powder is applied to the
core, which is baked again at
COVER STODY
1100 C for four hours. During
this process, the molten glass
infiltrates the porous alumina
core by capillary action.39 This
confers the selected shade to
the core (although it remains
fairly opaque), and increases
the strength of the core to about
20 times its original
strength.40'41 The aluminum
oxide or spinel crystals limit
crack propagation and the glass
infiltration reduces porosity.39
Vitadur N (Vident) aluminous
veneering porcelain is then ap-
plied using conventional pow-
der-slurry techniques to create
the proper shade and contour.
The restorations produced
with aluminum-oxide-infiltrat-
ed cores have extremely high
flexure strength (in the 450-
MPa range)42; this is the
strongest all-ceramic dental
restoration presently available.
The core of aluminum oxide or
spinel is so dense that tradition-
al internal surface etching to
improve the bond to tooth struc-
ture is not possible.43 (The man-
ufacturer recommends sand-
blasting and the use of a resin
cement such as Panavia 21TC
[J. Morita] for final cementa-
tion). These restorations pro-
vide an accurate fit. Because of
the opaque alumina core, the
translucency of the final
JADA, Vol. 128, March 1997 305
COVER STORY
restoration may not be as life-
like as that seen with other sys-
tems (Figure 6). This material
requires specialized equipment
to fabricate a restoration.
In a 21/2-year clinical study of
61 full-coverage single units
and 15 multiple-unit bridges,"
researchers reported that no
single units fractured, and two
of the 15 bridges failed because
of fractured abutments.
COMPARISON OF THE
ALL-CERAMIC SYSTEMS
Strength. All the systems ap-
pear to have adequate strength
for single units. Although the
resistance to fracture of most
all-ceramic crowns may be sig-
nificantly less than that of cer-
amo-metal crowns, their ability
to be bonded to tooth structure
can be considered an additional
strengthening mechanism to in-
hibit fracture of the restoration.
- Dicor, a castable glass-ce-
ramic with tetrasilic fluoromica
crystals, is strengthened
through the partial recrystalliza-
tion of glass through a ceramming
process.
In-Ceram, a high-alumina-
content substructure infused with
a low-fusing glass, is strengthened
through glass infusion. The re-
ported flexural strength values
are the highest for the all-ceramic
systems, and may qualify the ma-
terial for use in multiple-unit
bridges.
- IPS Empress and Optec
Pressable Ceramic are hot-pressed
leucite-reinforced ceramics; they
are strengthened by dispersion of
leucite crystals throughout their
internal structure. Optec HSP
also is strengthened though inter-
nal dispersion of leucite crystals; it
is fabricated using conventional
porcelain build-up techniques.
~ Duceram LFC, a hydrother-
mal ceramic, is strengthened by
306 JADA, Vol. 128, March 1997
an ion exchange mechanism in-
volving hydroxyl ions. This is
said to decrease surface mi-
croflaws and increase fracture
resistance.
Fabrication techniques.
With the exception of Optec
HSP and the Duceram system,
the all-ceramic systems use spe-
cialized equipment and tech-
niques. This could be considered
a disadvantage because of the
added cost of fabrication to the
technician.
Marginal fit. With the ex-
ception of the machined ceramic
restorations, the fit of the all-ce-
V
v -
U n~itil long-term
clinical success
has been
proven, clinicians
shouild use these
restorations selectively.
A thetic results of all these sys-
ramic crowns to the underlying
tooth structure can be extreme-
ly accurate. Compensation for
discrepancies or gaps can be
made by using resin cements.
Wear of opposing tooth
structure. While no clinical
data are yet available compar-
ing abrasive wear of the five
systems, all of the leucite-con-
taining all-ceramic materials
described above can be expected
to wear opposing natural teeth.
The abrasion is a byproduct of
the leucite crystals within all-
ceramic restorative materials.
The materials with the greater
amount of leucite (IPS Empress,
Optec HSP and Optec OPC)
would be expected to create
greater clinical wear. Dicor
(without the Dicor Plus veneer)
and Duceram would be expected
to create minimal or no wear
against natural tooth structure.
SUMMARY
We have discussed five cate-
gories of all-ceramic systems re-
garding their processing tech-
niques, strength and wear
characteristics. These systems
are all currently in use by den-
tal laboratories for the fabrica-
tion of all-ceramic restorations.
The table compares the physical
properties of these systems (as
determined by in vitro studies).
The choice of the most appropri-
ate all-ceramic system depends
on the particular clinical situa-
tion. That is, the stronger mate-
rials should be used in stress-
bearing situations (posterior
teeth), and the softer materials
should be used in situations in
which tooth abrasion may be
critical (lingual surfaces of
upper anterior teeth). In the
hands of adequately trained
and skilled technicians, the aes-
tems can be excellent.
Although in vitro studies
have shown significant differ-
ences in the strength and hard-
ness of some of these materials,
the results of long-term clinical
studies are not yet available.
Until long-term clinical success
has been proven, clinicians
should use these restorations
selectively. They should be used
cautiously in situations in
which there are high stress lev-
els or there is the potential for
abrasion of opposing tooth
structure.
No currently available
restorative system can be con-
sidered the ideal replacement
for natural tooth structure.
However, in recent years there

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