1789- First porcelain denture › De Chemant, French

dentist -Expensive $$

1903- Introduced the first porcelain “jacket” crown› Dr. Land

-Process, bonding

1950’s- PFM crown› Dr. Weinstein

-Esthetics, bonding

1965- First all ceramic crown› Dr. McLean & Hughes

+ 2X stronger vs. PJC - Opaque

1980’s- Pressed all ceramic crowns › Dr. Horn/Simonsen

Introduction to bonded restorations

1990’s- CAD/CAM

2020’s- ??

Comes from the Greek word “keramos” meaning “burnt earth”

Earth material -> Mold- > Heated- > Cooled Earliest ceramics date back 20,000 yrs (China)

Ceramic- compound of inorganic, non-metallic materials made by the heating of raw minerals at high temperatures

Ceramics in dentistry > 200 years

Porcelain is a type of ceramic

Esthetics

Biocompatibitly

Preservation of tooth structure

Strength

Esthetics is the primary indication for ACR’s All ceramic materials closely mimics the optical properties of natural

tooth structure. Translucency: Can light penetrate the material?

› Enamel =70% / Dentin= 30% (source of color)› Translucency= “lifelike” appearance

All-ceramic materials exhibit superior optical properties compared to PFM restorations. (Michalakis et al. 2004)

Ceramic’s are biocompatible, essentially bio-inert. › No cellular/tissue response

Zirconia Implants Zirconia in hip-

replacement therapy

Certain metal alloys are not completely biocompatible which may create:

Gingival inflammation Tissue discoloration

Release of metallic ions

Allergies Rare (4-11%)

“Today’s philosophy is to NOT remove any healthy tooth structure unless absolutely necessary” (McLaren et al. Compendium. 2010)

“The most common complication with single MCR is the need for endodontic therapy” (Goodacre et al. J Prosthet Dent. 2003 )

“Bonding makes it possible to preserve as much tooth structure as possible while satisfying the patients restorative needs and esthetic desires” (Strassler, HE. Gen Dent. 2007)

The strength of ceramic materials is measured by the materials flexural strength (MPa)› ACR’s ranges 65-1500 MPa

How much occlusal force can we generate?(Calderon et al. 2006)

Anterior teeth ~200N Posterior teeth ~500N Bruxers > 500N

Monolithic vs. metal-ceramic?› Porcelain Fractures ( ~70Mpa)

Resin bonded cements help by increasing the fracture resistance of the restoration

Glass Based Ceramics› Feldspathic (1910)

Particle Reinforced Ceramics Leucite (1980’s) Lithium Disilicate (2000’)

High Strength Ceramics› Alumina (1990’s)› Zirconia (2000’)

Glass Based Ceramic 3 Key Ingredients:› Feldspar- 65% ( Silica based glass)› Quartz- 25%› Koalin- 10%

How it’s made: › Sintered (Powder/liquid)› Pressed (lost wax)› Milled (CAD/CAM)

CEREC BlocksVita Mark II

Powder/Liquid Vita VM 7

Pros› Esthetics

Mostly Glass Highly Translucent

› Conservative Prep 0.5mm (min)

Cons › Strength

70mPA › Fabrication/Marginal Fit

Porcelain shrinks (~20%) Indications

› Highly esthetic veneers › Anterior crowns where

color masking is not an issue

Courtesy of Killian Smiles, Dental Lab

Why reinforce feldspathic porcelain?› Low strength (70 MPa)› Expansion(crack formations)› Limited use (veneers, single crowns)

Two types of reinforcing particles:› Leucite (1980’s, IPS Empress)› Lithium- Disilicate (2000’s, IPS Emax.)

Glass Based Ceramic Key ingredients› Feldspar (glassy matrix)› Leucite (crystal filler) ~40%/vol

How it’s made: › Sintered (powder/liquid)› Pressed (lost wax)› Milled (CAD/CAM)

Vita VMK

IPS EmpressIvoclar

IPS Empress CADIvoclar

Pros › Esthetics

60% glass (~40% Leucite) Translucent

› Conservative prep› Multiple shades

Cons› Strength

120-180 MPa Indications

› veneers › Inlays/onlays› Anterior crowns› Layered ceramic

Case 1› 16 y.o female› Dx: Congenitally

missing #7 & peg lateral #10.

› Tx: RBFPD (Maryland Bridge) #6-8 & full coverage ACR #10. IPS. Empress

Case 2› 26 y.o male› Dx: Congenital peg

lateral #7-10

› Tx: Full coverage ACR #7-10 IPS. Empress

Special thanks to Mr. Medina !!

Glass Based Ceramic Key Ingredients› Feldspar (glassy matrix)› Li-Disilicate (crystal filler) ~70%/vol

How it’s made:› Pressed› Milled (CAD/CAM)

e.max pressedIvoclar

e.max CADIvoclar

Pros› Esthetics

30% glass (~70% Li-Di) Translucent

› Strength ~400 MPa

› Pressed/Milled 0.3mm w/ pressed

Cons› Porcelain veneering

Indications › Veneers› Inlays/onlays› Crowns› 3 unit FPD

Anterior /premolar› Implant Restorations

cut back technique

Case 1› 23 y.o. male› Dx: #8 NSRCT

› Tx: Cast post core Li-Di ACR

IPS Emax.

Case 2› 32 y.o. female› Dx: Fractured Resin

FPD #13-15

› Tx: Li-Disilicate FPD #13-15 IPS Emax.

These types of ceramics contain NO glass particles! › No glass = No etch!!

High strength ceramics are polycrystalline structures. › Why?

Strength (less susceptible to fracturing) Usually used as a core w/ porcelain veneered

Two types:› Alumina (1990’s)› Zirconia (2000’s)

Leucite Zirconia

In-Ceram Vita

ProceraNobel Biocare

In-Ceram BlockVita

Pros› Strength

600-700MPa› Pressed/Milled › Block out coping

RCT/ Cores/ Staining Cons

› Esthetics Translucency (low) Porcelain Veneering

› Adequate reduction› Bonding

Indication› Single crowns› FPD’s (<4 Units)› Block out coping

CEREC InCorisSirona IPS e.max

Ivoclar

ProceraNobel Biocare

Pros› Strength

800-1500MPa › Framework› Pressed/Milled› Block out coping

RCT/Cores/Staining Cons

› Esthetics Translucently (low) Porcelain Veneering

› Adequate reduction› Bonding

Indications› Crowns (Anterior / Posterior)

Bruxzir – full-contour crowns (monolithic)

› FPD’s ( Anterior / Posterior) < 14 units › Implant abutments/crowns › Coping to block out tooth structure

RCT/ Cores/ Staining

More Glass More Crystals

Esthetics

Strength

Esthetics

Strength

IPS Emax. Pressed & CAD/CAM

Limited interocclusal space› Deep overbite› Short clinical crowns (2nd molars)

Heavy occlusal forces › History bruxism

Sub-ginvival preparations › If you’re relying on bonding

Darkened tooth structures or cores › May need PFM or Zirconia coping

Glass-ceramic crowns have shown similar success rates to conventional MCR’s. › >94% success rate at 10 yrs.

IPS emax (lithium Disilicate)› Pressed : ~98% Success rate at 10 years.› CAD/CAM: ~97% Success rate at 5 years.

High Strength Ceramics (Zirconia) › CAD/CAM: ~ 93 Success rate at 5 years. (#1 failure = chipping)

Fracture and chipping of all-ceramic restorations are similar to those of MCR’s. Monolithic crowns seem the way to go!!

No one ceramic material is “the best”, based on individual case selection

Holloway, Spear. Which all ceramic system is optimal for anterior esthetics. JADA. 2008.

Nicholas et al. Optical Behavior of Current All Ceramic Systems. Int Journal of Periodontics and Restorative Dent. 2005

Nazirkar et al. An Evaluation of Two Modern All-Ceramic Crowns and their comparison with Metal Ceramic Crowns in terms of the Translucency and Fracture Strength. Int Jour of Dental Clinic. 2011

Misrahi. The Anterior All-Ceramic Crown: A Rationale For the Choice of Ceramic and Cement. British Dental Journal.2008.

Michalakis et al. Light Transmission of Post and Cores Used for the Anterior Esthetic Region. Int J Periodontics Restorative Dent. 2004

Mclaren, Whiteman. Ceramics: Rational for Material Selection. Compendium. November-December 2010.

Levi et al. Allergic Reactions Associated with Metal Alloys in PFM fixed prosthodontic devices- A Systematic Review. Quintessence Int. 2012.

Powers et al. Guide to All Ceramic Bonding. Dental Advisor. 2010. Blatz et al. Resin-Ceramic Bonding: a review of the literature. Jour of

Prosthetic Dentistry. 2003. IPS e.max Scientific Report, vol. 01 / 2001-2011.