October 2023

C O N T I N U I N G
eBOOK
E D U C A T I O N • 2 C E U

RESTORATIVE DENTISTRY

Advantages of Monolithic Zirconia

Restorations With CEREC
Julian Conejo, DDS, MSc

SUPPORTED BY AN UNRESTRICTED GRANT FROM KURARAY NORITAKE • Published by BroadcastMed LLC © 2023
 OCTOBER 2023 | www.compendiumlive.com

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With CEREC
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About the Author

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Julian Conejo, DDS, MSc and publication of any material in this eBook should not be
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Assistant Professor, Clinical Restorative Dentistry WARNING: Reading Advantages of Monolithic Zirconia
Restorations With CEREC does not necessarily qualify

Director, Chairside CAD/CAM Dentistry, you to integrate new techniques or procedures into your
practice. BroadcastMed LLC expects its readers to rely

Department of Preventive and Restorative Sciences

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 C O N T I N U I N G E D U C A T I O N • 2 C E U

Advantages of Monolithic Zirconia

Restorations With CEREC
Julian Conejo, DDS, MSc

ABSTRACT
Adoption of CEREC (chairside economic reconstruction of esthetic ceramic) has increased steadily in recent years, allowing clinicians to produce resto-
rations in a single visit through a streamlined process that has revolutionized restorative dentistry. For practitioners who utilize CEREC for the fabrication
of indirect ceramic restorations, an understanding of the ceramic material options that are suitable for computer-aided design/computer-aided manu-
facturing (CAD/CAM) is a vital factor in achieving higher clinical success rates with same-day restorative treatments. Resin matrix ceramics, silicate
ceramics, and oxide ceramics can all be used with CAD/CAM technology depending on the specific clinical situation and personal preferences of the
dentist. Zirconia (zirconium dioxide) in particular has several mechanical and biological properties that make it an advantageous restorative material for
use with CEREC. This article discusses key points of the implementation and fabrication of chairside zirconia restorations and cementation protocols to
elevate successful clinical outcomes with CEREC.

LEARNING OBJECTIVES
• Describe the characteristics of resin matrix • Discuss the chairside fabrication of indirect • Describe the advantages of zirconia used
ceramics, silicate ceramics, and oxide restorations using resin matrix ceramics, for indirect restorations
ceramics silicate ceramics, and oxide ceramics

I
ndirect ceramic restorations are frequently used to restore
the function and esthetics of vital and non-vital teeth as well
as dental implants. With recent advancements in CEREC
(chairside economic reconstruction of esthetic ceramic) and
its massive adoption, clinicians and dental assistants are now
more involved in the manufacturing process of indirect ceramic
restorations and need to understand the clinical indications for
the various ceramic materials and their respective manufactur-
ing, finishing, and cementation protocols.
This article discusses key points of the implementation and
fabrication of chairside zirconia restorations and cementation
protocols to elevate the clinical success rates with CEREC.
CERAMIC MATERIAL OPTIONS
When a chairside computer-aided design/computer-aided manu-
facturing (CAD/CAM) workflow is intended, several options
are available for the fabrication of indirect ceramic restorations,
including resin matrix ceramics, silicate ceramics, and oxide

DISCLOSURE: Dr Conejo is a Key Opinion Leader for Kuraray Noritake, and he has received an honorarium from Kuraray Noritake for writing this article.

3 COMPENDIUM EBOOK OCTOBER 2023

 C O N T I N U I N G
ceramics. Each of these materials requires that specific param-
eters be followed with regard to tooth preparations, manufactur-
ing of restorations, and cementation steps to enhance their clini-
cal longevity.
RESIN MATRIX CERAMICS
Resin matrix ceramics have become quite popular because of the
speed and simplicity of their fabrication process. This group of
materials has great machinability and dimensional stability, pro-
viding excellent marginal adaptation, which is desired for any
indirect restoration. Additionally, a simple manual polishing or
light-curing stain/glaze protocol can facilitate the delivery of
these restorations in one visit.
Most resin-based ceramic blocks are made under a high-
pressure/high-temperature process, which increases homogeneity
but can reduce bond strength if the surface treatment is not fol-
lowed according to the manufacturer's recommendations. Multi-
ple types of fillers are added to these resin blocks to improve
their physical and esthetic properties, but the absence of a glassy
matrix makes them non-etchable. Air-particle abrasion with
50-µm aluminum oxide particles is required to augment the sur-
face roughness and area, which is desirable to achieve maxi-
mum mechanical retention and interlocking. The application
of a silane coupling agent will promote chemical bonding, and
when these two types of retention methods are present, the bond
strength values increase significantly.1 (Please see Spitznagel
et al1 for a detailed explanation of the effect of silane and air-
abrasion technique.)
Another type of resin matrix ceramic material is the hybrid
ceramic or polymer-infiltrated ceramic network, having a porous
ceramic structure (86%) infiltrated with a polymer (14%). This
percentage of added polymer provides better milling properties
compared with traditional ceramics and a modulus of elasticity
in between human dentin and enamel. Hybrid ceramics are etch-
able and require 5% hydrofluoric acid etching for 60 seconds to
achieve ideal surface roughness for optimized micromechanical
retention.2 A silane application will promote chemical bonding,
adding to their overall bond strength.
In general, resin matrix ceramics have a lower modulus of
elasticity compared with traditional ceramics, making them an
ideal option for intracoronal restorations, such as inlays.3
1 2
Fig 1 and Fig 2. Restoration design and milling preview in CEREC software.
4 COMPENDIUM EBOOK
E D U C A T I O N • 2 C E U
SILICATE CERAMICS
Silicate ceramics have been used since the beginning of the
chairside CAD/CAM era as feldspathic ceramic blocks and have
been continuously reformulated from leucite-reinforced ceram-
ics to lithium disilicates and zirconia-reinforced silicate ceram-
ics to improve their physical properties. All silicate ceramics
are etchable materials, with etching times varying depending on
their composition.
Feldspathic ceramics come in polychromatic blocks, making
them a desirable option for laminate veneers or monolithic ante-
rior crowns when the abutment tooth has a natural color. These
ceramics require etching with of 5% hydrofluoric acid for 60 sec-
onds to achieve ideal surface roughness and micromechanical re-
tention. A silane coupling agent must always be used before the
adhesive cementation process. For thin anterior feldspathic ce-
ramic restorations, a light-curing resin cement system is indicat-
ed to facilitate the procedure, as its working time is longer com-
pared with dual-curing resin cement systems.4
Leucite-reinforced ceramics also have a multichromatic dis-
tribution within the block, making them ideal for high-esthetic
anterior restorations. These materials require etching with hydro-
fluoric acid for 60 seconds, followed by a silane coupling agent.
Resin bonding is necessary for both feldspathic ceramics and
leucite-reinforced ceramics, as it augments their flexural strength
and long-term survival rates.
Lithium disilicate ceramics have become very popular for
various indications, specifically monolithic crowns, onlays,
and screw-retained implant crowns. Their high flexural strength
makes them the strongest glass-ceramic material.5 This material
needs to be crystallized in a ceramic furnace after milling to ob-
tain its final color and physical properties. A combination firing
applying stain/glaze during the crystallization firing is recom-
mended, as lithium disilicate is monochromatic. Lithium disil-
icate restorations achieve a strong bond to resin cements after
4% to 5% hydrofluoric acid etching for 20 seconds, followed by
silanization of the etched surface.
Novel zirconia-reinforced lithium-silicate ceramics have been
introduced in a fully crystallized version, which saves the time
otherwise spent with the crystallization process (approximately
25 minutes) of traditional lithium disilicate. Finishing by manu-
al polishing only or with a stain/glazing technique can be done
OCTOBER 2023
 C O N T I N U I N G E D U C A T I O N • 2 C E U

3 in a larger number of cubic-phase particles. More cubic zirco-
Fig 3. Restoration after dry-milling, removed from block.
with this newer ceramic material type, although published clini-
cal success data are still limited.6 The internal surfaces of the res-
torations should be etched with hydrofluoric acid for 20 seconds,
followed by silane application. Traditional cementation tech-
niques are also possible with zirconia-reinforced lithium-silicate
ceramics, but the overall strength is still higher when an adhesive
cementation process is used.
OXIDE CERAMICS
Oxide ceramics, such as zirconium dioxide (zirconia), are char-
acterized by excellent mechanical and biological properties,
which are significantly superior to those of silica-based ceram-
ics.7 Its inherent strength allows for less invasive crown prepar-
ations, thinner restorations, and conventional cementation.
The latest zirconia generations offer significantly greater light
transmission than previous generations. Pre-shaded multi-layer
high-translucent zirconia materials offer a range of esthetic treat-
ment options and can be used for tooth and implant-supported
crowns, fixed dental prostheses, resin-bonded fixed prosthe-
ses, and bonded laminate veneers. The higher translucency is
achieved by slight changes of the yttrium oxide content, resulting
nia offers significantly higher light transmission but lower flex-
ural strength values than conventional zirconia, between 550 MPa
and 1,000 MPa.8
High-translucent zirconia blocks for CEREC have recently
entered the marketplace. The restorations are milled from pre-
sintered blocks with slightly enlarged dimensions, compensating
for the 20% to 25% material shrinkage that occurs during the final
sintering step after milling. This causes less over-milling in the
intaglio surface and allows for an exceptional marginal adapta-
tion. With a special chairside furnace and a speed sintering pro-
gram, the sintering of a single crown can be accomplished within
20 minutes.2

4 5

Fig 4 and Fig 5. Sprue removal and pre-sintering polish.

6 7

Fig 6 and Fig 7. Intaglio surface cleaned and restoration placed in ceramic furnace chamber.

5 COMPENDIUM EBOOK OCTOBER 2023

 C O N T I N U I N G E D U C A T I O N • 2 C E U

Translucent zirconia restorations that are less strong, thin, lack

retention, or rely on resin bonding, such as resin-bonded fixed
prostheses or bonded laminate veneers, require resin bonding
with composite resin luting agents

8 9

Fig 8 and Fig 9. Speed sintering cycle finished followed by shade evaluation.

10 11

Fig 10. A two-step zirconia polishing sequence is used, with step 1 used before Fig 11. Glaze paste/liquid mixed and applied.
stain/glaze application.

12 13

Fig 12 and Fig 13. Restoration placed in holder with object fixed and seated in furnace chamber.

6 COMPENDIUM EBOOK OCTOBER 2023

 C O N T I N U I N G E D U C A T I O N • 2 C E U

Figure 1 through Figure 14 illustrate steps involved in the fab-

rication of zirconia restorations using CEREC. Figure 15 through
Figure 21 show preparations and postoperative results in two case
examples of patients who received zirconia indirect restorations.
Given the broad popularity of zirconia restorations, clinical ap-
plication and cementation protocols are widely debated. In general,
these restorations are typically considered cementable because of
their high inherent flexural strength, which exceeds natural chew-
ing forces. Therefore, zirconia-based crowns and bridges with ad-
equate retention and ceramic material thickness can be cemented
conventionally. However, translucent zirconia restorations that are
less strong, thin, lack retention, or rely on resin bonding, such as
resin-bonded fixed prostheses or bonded laminate veneers, require
resin bonding with composite resin luting agents.
14

Fig 14. Step 2 of zirconia polishing after stain/glaze application, specifically in the
To achieve high and long-term durable resin bond strengths
areas in direct contact with soft tissues. to zirconia in a practical manner, the APC concept, a three-step

15 16 17

Fig 15 through Fig 17. Case example 1. Fig 15: Intraoral view of the maxillary central incisor preparations. Fig 16 and Fig 17: Postoperative intraoral and extraoral views.

18 19

Fig 18 and Fig 19. Case example 2. Fig 18: Intraoral view of left maxillary first molar preparation (No. 14). Fig 19: Palatal view of a conservative supragingival margin.

20 21

Fig 20 and Fig 21. Case example 2. Fig 20: Postoperative intraoral occlusal view. Fig 21: Postoperative intraoral buccal view.

7 COMPENDIUM EBOOK OCTOBER 2023

approach, is recommended: (1) air-particle abrade the bonding sur-
face with aluminum oxide (A); (2) apply special zirconia primer
(P); (3) use dual-cure or self-cure composite resin cement (C).8
After try-in and ultrasonic cleaning with alcohol, zirconia
should be air-particle abraded with alumina or silica-coated
alumina particles. Small particles (30-50 microns) at a low pres-
sure (<200 kPa [2 bar]) are sufficient. The subsequent step in-
cludes application of a special ceramic, which contains spe-
cial adhesive phosphate monomers. The monomer MDP
(10-methacryloyloxydecyl dihydrogen phosphate) has been
shown to be particularly effective to bond to metal oxides.
Dual-cure or self-cure composite resins should be used to en-
sure adequate polymerization. The APC concept is also indi-
cated when adhesive cementation to prefabricated titanium
abutments (ti-bases) is needed. If custom titanium abutments
with retention and resistance form are preferred, convention-
al cementation of monolithic zirconia restorations with resin-
modified glass-ionomer or self-adhesive resin cements is suggested.
CONCLUSION
Understanding ceramic material properties, clinical indications,
manufacturing steps, and specific surface treatment protocols
will lead practitioners to higher clinical success rates with in-
direct zirconia restorations. Current adhesive protocols and the
ongoing development of ceramic materials for fabrication of in-
direct restorations provide a promising future for minimally in-
vasive restorative dentistry.
8 COMPENDIUM EBOOK
ACKNOWLEDGMENTS
Special thanks to Markus B. Blatz, DMD, PhD, and Francisco
Rojas, DDS, for their contributions to this project, and to the
Kuraray Noritake team for the support provided.
REFERENCES
1. Spitznagel FA, Horvath SD, Guess PC, Blatz MB. Resin bond to
indirect composite and new ceramic/polymer materials: a review
of the literature. J Esthet Restor Dent. 2014;26(6):382-393.
2. Conejo J, Ozer F, Mante F, et al. Effect of surface treatment and
cleaning on the bond strength to polymer-infiltrated ceramic net-
work CAD-CAM material. J Prosthet Dent. 2021;126(5):698-702.
3. de Castro EF, Azevedo VLB, Nima G, et al. Adhesion, mechani-
cal properties, and microstructure of resin-matrix CAD-CAM
ceramics. J Adhes Dent. 2020;22(4):421-431.
4. Otto T, Mormann WH. Clinical performance of chairside CAD/
CAM feldspathic ceramic posterior shoulder crowns and endo-
crowns up to 12 years. Int J Comput Dent. 2015;18(2):147-161.
5. Blatz MB, Conejo J. The current state of chairside digital den-
tistry and materials. Dent Clin North Am. 2019;63(2):175-197.
6. Demirel M, Diken Türksayar AA, Donmez MB. Translucency, color
stability, and biaxial flexural strength of advanced lithium disilicate
ceramic after coffee thermocycling. J Esthet Restor Dent. 2022.
doi: 10.1111/jerd.12960.
7. Blatz MB, Vonderheide M, Conejo J. The effect of resin bond-
ing on long-term success of high-strength ceramics. J Dent Res.
2018;97(2):132-139.
8. Blatz MB, Conejo J. Cementation and bonding of zirconia resto-
rations. Compend Contin Educ Dent. 2018;39(suppl 4):9-13.
OCTOBER 2023
 CONTINUING EDUCATION QUIZ 2 Hours CE Credit

Advantages of Monolithic Zirconia Restorations With CEREC

Julian Conejo, DDS, MSc

TAKE THIS FREE CE QUIZ BY CLICKING HERE: COMPENDIUMLIVE.COM/GO/CCEDMONOZIRCREST

ENTER PROMO CODE: CCEDMZR

1. Most resin-based ceramic blocks are made 6. Leucite-reinforced ceramics require etching
under what type of process? with 5% hydrofluoric acid, followed by what?
A. A low-pressure, low-temperature process A. A silane coupling agent
B. A low-pressure, high-temperature process B. A metal primer
C. A high-pressure, low-temperature process C. A saline rinse
D. A high-pressure, high-temperature process D. All of the above

2. Which resin-based ceramics are etchable? 7. Which of the following is the strongest glass-
A. Resin blocks with an absence of a glassy ceramic material?
surface A. Lithium disilicate ceramic
B. Hybrid ceramics B. Cubic zirconia
C. Both A and B C. Feldspathic ceramic
D. None of the above D. Leucite-reinforced ceramic

3. Which silicate ceramics are etchable materials? 8. Novel zirconia-reinforced lithium-silicate

A. Lithium disilicates only ceramics have been introduced in a fully crystal-
B. Zirconia-reinforced silicate ceramics only lized version, which saves the time otherwise
C. All silicate ceramics are etchable spent with:
D. No silicate ceramics are etchable A. the etching process.
B. the cementation process.
4. Feldspathic ceramics require etching with 5% C. the crystallization process.
hydrofluoric acid for how many seconds to D. the manual polishing process.
achieve ideal surface roughness and micro-
mechanical retention?
A. 20 seconds 9. Pre-shaded multi-layer high-translucent zirconia
B. 30 seconds materials offer a range of esthetic treatment
C. 60 seconds options and can be used for:
D. 90 seconds A. tooth and implant-supported crowns.
B. fixed dental prostheses.
5. Leucite-reinforced ceramics have a multi- C. bonded laminate veneers.
chromatic distribution within the block, making D. All of the above
them ideal for:
A. use in patients with recurrent decay or at high 10. Zirconia-based crowns and bridges with
risk for caries. adequate retention and ceramic material
B. posterior crowns. thickness can be:
C. high-esthetic anterior restorations. A. bonded only with composite resin luting
D. fixed bridges. agents.
B. cemented conventionally.
C. cemented only with a light-curing resin
cement system.
D. None of the above

Course is valid from 10/1/2023 to 10/31/2026. Participants must attain

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AEGIS Publications, LLC, is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in
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of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at https://www.ada.org/cerp/.
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