Restorative dentistry CLINICAL

Do you know your ceramics? Part 3: lithium disilicate

Kiran Kaur,1 Mojgan Talibi*2 and Hit Parmar3

Key points
Explains how the microstructure of lithium Identifies what considerations need to be made in Explains the appropriate cementation technique
disilicate has an impact on its physical properties. the preparation design when lithium disilicate is the for lithium disilicate ceramics.
material of choice.

Abstract
Lithium disilicate has become very popular and is very commonly used, especially for highly aesthetic cases. It has also
proven to be a very durable material and can be used in a variety of clinical situations. It is important as a clinician,
technician or ceramist to be able to confidently use this material by appreciating the detail in its construction. The
microstructure has a significant impact on the optical and physical properties of this material. Hence, before the
prescription of this type of restoration, it is imperative to be knowledgeable in this aspect. This article explores lithium
disilicate as a dental ceramic material in detail.

Introduction
In 1988, lithium disilicate (Li2Si2O5) was used
as a core material which was processed by
heat-pressing ingots, a technique comparable
to the lost-wax technique.1 This was then
marketed as IPS Empress 2 by Ivoclar
Vivadent, Liechtenstein. This product has
since been discontinued and replaced in
2009 with IPS e.max Press (Ivoclar Vivadent,
Liechtenstein) where the improvement of the
firing process has produced restorations that
are highly aesthetic and long-lasting.1,2,3 Unlike
Empress 2, e.max is made up of crystals that
are smaller and more uniformly distributed.
The development of e.max has led to the
production of monolithic restorations that
mimic the natural anatomy of a tooth without
the need of a veneering ceramic.
Posterior restorations have always been
proven to be challenging. However, e.max has
been demonstrated to produce reliable results
with a reduction in chippings and fractures.
1
Dental Core Trainee in Restorative Dentistry, University
School of Dentistry, Cardiff, UK; 2Associate Dentist, West
Midlands, UK; 3Owner and Ceramist, Fine Art Dental
Studio, Birmingham, UK.
*Correspondence to: Mojgan Talibi
Email address: drmojgantalibi@gmail.com
Refereed Paper.
Accepted 7 June 2021
https://doi.org/10.1038/s41415-022-3882-x
This can be credited to the huge gain in its
popularity in the last few years.3,4,5,6,7 Now, more
lithium disilicate products are suitable as either
a core or veneering ceramic with comparable
optical and mechanical properties. These
products have now infiltrated the market and
dentists have various options to choose from.
Currently, there are also zirconia-containing
lithium silicate materials available to choose
from. However, this article will mainly discuss
lithium disilicate and does not serve any
biased opinions towards any brand or product
available in the market today. The choice to
select any lithium disilicate brand and the
reliability of the results will ultimately be in
the hands of the dentist and/or lab technician.
Microstructure and mechanical
properties
It is important to know of the microstructure
properties and crystalline structures here,
such as size, volume fraction and distribution,
as it plays an essential role in both the
mechanical and optical properties of a ceramic
material. However, studies are yet to find
a direct relationship between the ceramic’s
microstructure and mechanical properties.1,3,8,9
A typical composition of lithium disilicate-
based products is quartz (SiO2), lithium
oxide (Li2O), phosphorous pentoxide (P2O5),
alumina (Al2O3), potassium oxide (K2O) and
colour-imparting oxides. The key component
that promotes volume nucleation of the lithium
silicate phases is phosphorous pentoxide
(P2O5).10 Volume crystallisation is when the
crystals nucleate and grow throughout the
glass. The crystallisation of lithium disilicate
is heterogenous. If the end-product is to be
used as a machinable block or a pressable ingot,
this can be achieved through two processing
methods.10
For either the lithium disilicate-based block
or ingot, the combination of all the different
chemical powders (ie quartz, lithium oxide,
etc) produces a glass melt which is then
pressure casted into a steel mould. To minimise
defects and improve quality control, the mould
is then allowed to cool to a specific temperature
at which no deformation occurs.11,12 Usually,
both the block and ingot are generated in
one batch according to the shade and size of
materials. The final glass-ceramic material is
highly thermal- and shock-resistant and this is
credited to the low thermal expansion during
the manufacturing stage.1,11,12
To manufacture an ingot a two-stage
crystallisation of lithium disilicate process
is used, where the glass ingot containing
the nuclei formed from the previous step is
nucleated, then crystallised to lithium disilicate
in a heat treatment for a few hours. The
crystallised ingot is then hot pressed into the
dental mould and held at the same temperature

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© The Author(s) under exclusive licence to the British Dental Association 2021.
 CLINICAL
in the second stage. The pressed technique is
described in more detail in the first part of
this series. This results in varying shapes of
lithium disilicate crystals. The IPS e.max ingot
specimens yield long needle-like crystals while
with the Initial LiSi press, the crystals maintain
their initial platelet shape and size while
embedded in the residual glassy matrix. The
IPS e.max lithium disilicate crystals are formed
in a volume fraction of about 70%. Unlike the
rod-like crystals that are formed in the sintered
computer-aided design/computer-aided
manufactured (CAD/CAM) material, the IPS
e.max lithium disilicate crystals yield slightly
but have better strength.1,10,11,13 A recent study
showed that the average fracture toughness
(KIc) of the pressable ceramic after hot-pressing
ranges from about 0.79–0.92 MPa-m½.11
Manufacturing machinable lithium disilicate
blocks requires the understanding of the
microstructure and phase transformation of
both partially-crystallised and fully-crystallised
microstructure of the material, as both types
have distinctive properties. 1,12 Compared
to leucite glass-ceramic, the mechanism of
crystallisation for lithium disilicate is volume
crystallisation, that is, where the crystals
nucleate and develop throughout the glass.10,14
This part will mainly refer to IPS e.max CAD
where a three-stage crystallisation process is
used to precipitate lithium disilicate. The
process starts with the heating of a glass block
to around 450°C to ensure the maximum
number of nuclei are formed and for efficient
growth of metasilicate crystals. This first heat
treatment can also be carried out during the
cooling step. The second stage, also known as
the ‘blue state’, involves heating the glass block
to about 700°C to form lithium metasilicate
crystals, which are essentially partially
crystallised blocks composed of 40% platelet-
shaped lithium metasilicate crystals of 0.5 μm
in size.1,10,12,14 This is one of the distinctive
phases mentioned earlier. The flexural strength
in this phase is about 130 MPa and fracture
toughness has been reported at 0.9–1.25 MPa-
m½.1,10,12 The ‘blue’ block is still weak, though
it is easily milled and produces a high edge
stability while reducing the bur wear.1,10,14
The fully crystallised form, or the third stage
of the production of e.max CAD, requires
firing of the material at 770°C for five minutes,
followed by 850°C for ten minutes under a
vacuum.1,10 Based on manufacturer literature,
this sintering step leads to 0.2% linear
shrinkage in the material which is accounted
for in the CAD software.1,10,14 This has been
148
© The Author(s) under exclusive licence to the British Dental Association 2021.
Restorative dentistry
observed as a possible cause for marginal
gaps and compromised internal fit shrinkage.
However, it has not been evidenced as a
deficiency that is significantly different from
other CAD/CAM materials.1 Additionally,
an in vitro study that compared the vertical
marginal gap of extracted teeth restored with
lithium disilicate material fabricated using the
pressed method or CAD/CAM showed that
the former resulted in a measurably smaller
marginal gap.15 In this final stage, small, rod-
like, interlocked crystals of lithium disilicate
are formed through a solid-state reaction when
the lithium metasilicate crystals react with
the surrounding glass. The fully crystallised
IPS e.max CAD constitutes of 70% fine grain
lithium disilicate crystals of approximately
1.5 μm in size. This directly contributes to the
recorded flexural strength of 262–360 MPa and
fracture toughness of 2.0–2.5 MPa of the IPS
e.max CAD.
To summarise, the size, volume fraction
and distribution of crystalline structure
within the glass-ceramic considerably affect
the mechanical and chemical properties of
the material.
Optical properties
Lithium disilicate is known to have excellent
optical properties. The absorptivity, transmission,
crystallinity, refraction and reflection of the
coloured light are important factors in deciding
the shade of the ceramic. In more specific terms,
the thickness, number of firing cycles, luting resin
cement shade and supporting substrate colour
may influence the final shades.16,17,18,19
The nanostructure of the crystals such as the
density and size of the crystals can also regulate
the varying translucent shades. With using
different processing technique, there are various
shades and opacities that work for particular
cases. Therefore, to achieve the best aesthetic
result, adherence to the manufacturer guidance
is highly recommended before selecting and
prescribing a lithium disilicate restoration.
Before discussing the various shades
available, it is important to understand the
different techniques used and what they entail.
The staining technique allows an improvement
of the aesthetic result by essentially using the
stains and glazes after the full-contour wax-up
is invested and pressed. The cut-back technique
consists of reducing either the incisal or
occlusal aspect of the pressed wax-up, which
is then layered with a layering ceramic and
glazed. Finally, the layering technique involves
BRITISH DENTAL JOURNAL | VOLUME 232 NO. 3 | February 11 2022
anatomically layering over a heavily reduced
tooth-shape using layering ceramics.
We will briefly mention the various options
each manufacturer offers within their lithium
disilicate range. The IPS e.max Press ingots
come in various translucencies. They are:
• Multi
• High translucency (HT)
• Medium translucency (MT)
• Low translucency (LT)
• Medium Opacity (MO)
• High opacity
• Impulse.
The IPS e.max Press Multi is polychromatic,
whereas the other types are monochromatic.
Each type mentioned above has a variety of
shades, some ranging from A–D or bleach
shades, or some with different opalescent
shades.20,21 The technique for each type differs
in that some require to be layered on while
some only require additional staining or cut-
back to achieve the best aesthetic result. For
highly aesthetic regions, it is always best to take
photos and have discussions with the ceramist
or technician providing the restoration.
The IPS e.max CAD blocks have similar
translucent shades as e.max Press, except for the
Multi range. The available shades on the market
today are from the A–D range with four bleach
shades.22 It is important to note that the different
shades and translucencies would be best used
in specific clinical situations. Choosing one
of these different options is highly dependent
on the technique to be used and preparation
made so it can be made to match the adjacent
dentition or restorations.
GC Initial LiSi Press also has similar
translucent shades: HT; MT; LT; LT One
Body Concept; and MO. They come in various
shades and require specific techniques to
achieve a highly aesthetic result.
Indications
Lithium disilicate products are known to be
very versatile and have excellent mechanical
properties which allows its placement posteriorly
where there is increased functional load. They
also have adjustable translucency and shades,
unlike the more fragile feldspathic. However,
these products are usually contraindicated
for very deep subgingival preparations in
patients with bruxism or with greatly reduced
dentition. Also, the maximum pontic width
in the premolar region is 9 mm and 11 mm in
the anterior region. It is important to note that
 Restorative dentistry CLINICAL

Table 1 The various lithium disilicate products available and their properties

Coefficient
Fracture Chemical
Flexural strength of thermal
Brand Manufacturer Processing method toughness solubility
(MPa) expansion
(MPa-m½) (μg/cm2)
(x 10 -6K-1)
IPS Empress 2 Press or CAD/CAM * * * *

IPS e.max CAD** Ivoclar Vivadent CAD/CAM 360 ± 60 2.0–2.5 30–50 10.45 ± 0.4
IPS e.max Press Press 400 ± 40 2.5–3.0 40 ± 10 10.15 ± 0.4
Initial LiSi Press GC America Press 508 *
5.4 9.8
Amber Press Press >300 *
<100 10.0 ± 0.5
Amber Press Master Press >300 *
<100 10.0 ± 0.5
Rosetta SP HASS Press 460 *
<100 10.1 ± 0.5
Rosetta SM CAD/CAM 440 *
<100 10.0 ± 0.5
Amber Mill CAD/CAM 450 *
<100 10.0 ± 0.5
Cameo Aidite CAD/CAM >360 *
<100 10.5 ± 0.5
T-Lithium Press Press 400 * * *

Talmax
T-Lithium CAD CAD/CAM 400 * * *

R10 Tianjin IRIS CAD/CAM 360 * * *

Key:
* = denotes no information provided on the manufacturer’s website
** = flexural strength and fracture toughness values for IPS e.max CAD is for the fully crystallised state
The above information has been collected from the respective manufacturers.

the height of the connector is more important
for the stability than its width. Ivoclar states
doubling the width only results in double the
stability, while doubling the height results in up
to four times the stability.21
An in vivo study by Kern et al. showed that 36
crown-retained fixed dental prosthesis (FDPs)
made from monolithic lithium disilicate
ceramic, IPS e.max Press had a survival of
30.9% after 15 years when manufacturer
guidelines were followed in the construction.
The size of the proximal connector of the FDPs
was 12 mm² (anterior) or 16 mm² (posterior).4
In general, they are indicated for the
following types of restorations:
• Veneers
• Inlays
• Onlays, overlays, partial crowns
• Endocrowns
• Crowns in the anterior and posterior region
• Three-unit bridges in the anterior region
• Three-unit bridges in the premolar region
up to the second premolar as the terminal
abutment
• Crown or splinted crown on top
of an implant abutment or implant
superstructures.
As mentioned before, some manufacturers
provide zirconia-containing lithium silicate
such as Vita Ambria or Celtra Press Duo,
which have enhanced properties that can be
useful in higher loading regions.
Brands and method of production
There are a several lithium disilicate brands
on the market, each with different properties,
such as flexural stress, chemical solubility and
differing processing methods, as summarised
in Table 1.
Preparation design requirements
For any all-ceramic restoration, there are
basic guidelines to follow when designing the
preparation. They are mainly:
• No angles or sharp edges
• Prepare margins with deep chamfer or
rounded shoulder
• Smooth finish line
• Even reduction of the anatomical shape
• Ensure the indicated dimensions match the
stipulated minimum wall thicknesses that
the manufacturer recommends.
To design and prepare a tooth for lithium
disilicate, it is first important to make a mental
note of what the result should look like and
which technique is to be used. The framework
design varies if using the cutback and the
layering technique. Also, if the result desired
requires the use of the more translucent ingots,
dentists have the flexibility of finishing the
margins wherever clinically suitable, as the
translucency allows the seamless blending to
the natural dentition.
The preparation design will also vary
depending on the type of final restoration. If a
thin veneer is to be placed anteriorly, a labial
reduction of at least 0.3 mm is expected, while
incisally it should be 0.4 mm. A thicker veneer
requires heavier preparation ie 0.6 mm labially
and 0.7 mm incisally. It should be noted that for
CAD/CAM-fabricated restorations by Ivoclar
Vivadent, an extra 1 mm should be reduced
at the incisal edge (milling tool geometry) to
allow optimum milling of the incisal portion
during CAM processing.14,21
A minimally invasive crown in the anterior
or posterior region or an onlay could be
reduced overall by up to 1 mm. However, a
tooth experiencing a higher load will require an
additional 0.5 mm reduction at the load bearing
regions, such as occlusal cusps and incisal edge.
It is also useful to record the natural die
shade after preparation, in the most heavily
discoloured area, to facilitate the reproduction
of the desired tooth shade. With any restoration,
it is imperative to have good communication
with the ceramist or chosen lab technician with
a clear lab prescription.
Cementation
The process of cementation is also a very
important aspect, especially when meeting
high aesthetic demand. To achieve success
and longevity of any ceramic restoration,
it important to have a strong, durable

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© The Author(s) under exclusive licence to the British Dental Association 2021.
 CLINICAL
bond. This requires the selection of the best
surface treatment, resin cement and adhesive
cement by appreciating the ceramic’s internal
structure.23
Nowadays, there are various types of
cements and shades available in the market
that can further improve the final optics of
the restoration. Subject to the indication
and the clinician’s preferences, lithium
disilicate restorations can be adhesively or
conventionally cemented.
For full-coverage crowns, the decision to use
conventional or adhesive cements is contingent
on the preparation design. Conventional
cements such as resin-modified glass ionomer
cements can be utilised if the preparation is
retentive, where moisture control cannot
be fully achieved, or where the best optical
results are not required. However, a clinical
study found no difference between the use
of adhesive or conventional cements for full
crowns.24 Onlays and inlays will most likely
require adhesive cementations to improve the
retention and fracture resistance.
If the choice has been made to use adhesive
cements, there are protocols to follow to
ensure the best micro-mechanical lock and
bond is achieved. The fit surface is advised
to be etched with hydrofluoric acid (HF)
for 20 seconds (see Figure 1a). After rinsing
and drying, silane should be applied for one
minute and allowed to air dry (see Figure 1b).
This is then followed by the adhesive system
chosen and resin cement. Silane and HF are
used as ceramic surface treatment to create
a micromechanical interlock between the
ceramic and the resin cement.25,26 As HF is a
caustic and potentially dangerous substance if
in contact with unprotected skin, alternative
products that can enhance the bond strength
have also been produced.25,27
Conclusion
In modern dentistry, there are a myriad of
ceramic materials that can be utilised to
correct or improve aesthetics while having
comparable, if not better, mechanical
properties than an all-metal restoration.
Lithium disilicate systems have truly been
tried, tested and have proven to be an excellent
material with good clinical outcomes and
high survival rates over time.25,28 However,
like with any dental material, achieving the
best outcome is highly reliant on the skills of
both the clinician and laboratory and effective
communication.
150
© The Author(s) under exclusive licence to the British Dental Association 2021.
Restorative dentistry
Fig. 1 Workflow of fit surface preparation of lithium disilicate restorations before cementation.
a) Hydrofluoric acid etching for 20 seconds. b) Application of silane
Ethics declaration
The authors declare no conflicts of interest.
Acknowledgements
Fine Art Studio Dental Lab, Birmingham, produced
the ceramic work in Figure 1 and we thank them for
all of their support.
Author contributions
Kiran Kaur: lead author; conceptualisation;
drafting the manuscript; reviewing and editing
of the manuscript to create the final version;
and referencing. Mojgan Talibi: second author;
conceptualisation; reviewing and editing of the
manuscript to create final manuscript; and
photographing images and producing them into
figures. Hiten Parmar: supervisor and reviewing the
manuscript.
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