ALL - CERAMIC RESTORATIONS

All-Ceramic Inlays, Onlays, Veneers and Crowns are the most esthetic restorations.
Because there is no metal to block light transmission, they resemble natural tooth
structure better in terms of colour and translucency than any other restorative option.

Ceramic is derived from GREEK word KERAMIKOS meaning Burnt Earth

CERAMIC: A compound of one or more metals with a nonmetallic element, usually

oxygen.

PORCELAIN: A special type of ceramic based on a specific composition that

includes silica, alumina, and potassium oxide. These three oxides are alloyed to
produce potassium aluminosilicate.

DENTAL PORCELAIN: Dental porcelain is a very narrow range of these

compositions. Dental porcelain is created, not by directly mixing the three main
oxides, but by mixing clay (kaolin), feldspar, and quartz (silica).
Most dental porcelain are used in fabrication of Teeth for dentures, Metal-Ceramic
restorations, Crowns, Inlays, Onlays, Veneers and Bridges.

ALL PORCELAINS ARE CERAMIC, BUT NOT ALL CERAMICS ARE

PORCELAINS

Composition of ceramic
products based on
Feldspar, Kaolin and
Quartz
ALL-CERAMIC: A ceramic restoration that restores a clinical crown without a
supporting metal substructure.

History of All Ceramic Restorations:

The first All-Ceramic Crown was developed by LAND in 1886 and was known as
Porcelain Jacket Crown. It was made of feldspathic porcelain. All porcelain crown
system despite of its esthetic advantages failed to gain widespread development until
alumina was used as reinforcing paste. In 1965 McLEAN & HUGHES developed a
Porcelain Jacket Crown with a inner core of aluminous porcelain containing 40% to
50% alumina crystals. The introduction of a shrink-free all ceramic crown system
(CERESTORE) & castable glass ceramic crown system (DICOR) in 1980s provided
good esthetic results. Since then many new all-ceramic restorations have been
developed and have produced good esthetic result.

Why use ALL-CERAMIC restorations?

Because metal ceramics have these disadvantages:
1. To achieve better esthetics, the facial margin of an anterior restoration is often
placed subgingivally which increases the risk for periodontal diseases.
2. Metal margin exposure at the cervical area.
3. Risk of over preparing the tooth. Metal is 0.5 mm and the rest is ceramic material.
4. Because of glass like nature of ceramic material they are subjected to fracture.
5. Metal framework affects the esthetics of porcelain by decreasing the light
transmission through the restoration.
6. Fit of long span bridges may be affected by the creep of the metal during successive
baking of porcelain. (Creep is the tendency of a solid material to slowly move or
deform permanently under the influence of stresses.)
7. Restorations made in metal-ceramic technique are more liable to de-vitrify which
can produce opaque restorations. (devitrification - describes the process where heated
glass becomes opaque, hard, and crystalline due to prolonged heating.)
8. Some patients have allergic reaction or other sensitivity to metals.
9. High gold content alloys are expensive.
10. Porcelain discoloration by silver alloys.
11. Selection of alloys for Porcelain Fused to Metal is confusing.
12. Risk of metal and ceramic bond failure.
These drawbacks have prompted the development of all-ceramic system that do not
require metal, yet have high strength and precision fit of metal-ceramic system.
Compared to Metal-ceramic restorations, the advantages of All-Ceramic
restorations are:

1. Improved Fluorescence (Natural sunlight, photoflash lamps, certain types of vapor

lamps, and Ultra Violet lights used in decorating lighting are sources containing
substantial amounts of near Ultra Violet radiation. The energy that the tooth absorbs
is converted into light with longer wavelengths, in which case the tooth actually
becomes a light source. The phenomenon is called Fluorescence.)
2. Increased translucency (Translucency - It is the property of a material that allows
the passage and scattering of transmitted light. In dental porcelain it refers to the
ability to accurately simulate the surface structure and lifelike appearance of natural
teeth.)
3. Gives greater contribution of colour from the underlying tooth structure.
4. It is chemically non reactive (inertness).
5. It is biocompatible.
6. It is resistant to corrosion.
7. It has low thermal and electrical conductivity.

The disadvantages of All-Ceramic restorations are:

1. More tooth structure is removed.
2. Complex techniques needed for fabrication and more time consuming laboratory
procedures.
3. Difficult to adjust and polish (intra orally).
4. It has low fracture resistance (because no metal substructure is there).
5. It is expensive.
6. Abrasive to opposing teeth.

Tooth preparations for All-Ceramic restorations

1. ALL-CERAMIC ANTERIOR CROWN PREPARATION

Indications:
1. High esthetic needs
2. Discoloured anterior teeth
3. Malformed anterior teeth
4. Fractured anterior teeth but with sufficient coronal tooth structure incisally
5. Because of the relative weakness of the restoration, the occlusal load should be
favourably distributed. Generally this means that centric contact must be in an area
where the porcelain is supported by tooth structure (e.g., in the middle third of the
lingual wall).
 The occlusion on an all-ceramic crown is critical for
avoiding fracture. Centric contacts are best confined to
the middle third of the lingual surface. Anterior guidance
should be smooth and consistent with contact on the
adjacent teeth. Leaving the restoration out of contact is
not recommended. Future eruption may lead to protrusive
interferences, precipitating fracture.

Contraindications:
1. Unfavorable occlusion (edge to edge bite and deep bite)
2. When superior strength is needed
3. Reduced esthetic demands
4. Young patient (large pulp horns)
5. Thin teeth (facio-lingually)
6. Teeth with constricted cervical outline
7. Patients with bruxism
8. If a more conservative restoration is indicated
9. When it is not possible to provide adequate support at the incisal edge for porcelain
(in badly broken teeth).
10. In cases of uncontrolled caries and untreated periodontal problems.

Armamentarium:
Handpiece
Flat end tapered diamond
Small wheel diamond
Radial fissure bur
Binangle chisel
Recommended reduction for ALL-CERAMIC crown - Anterior and posterior

Step-by-step procedure
Adapt putty silicone on the tooth before tooth preparation to make an index. This will
act as a guide after the tooth is prepared.
To achieve adequate reduction without encroaching upon the pulp the facial surface is
prepared in two planes that correspond to the two planes present on the facial surface
of an uncut tooth.
Step no: 1 - Placement of depth orientation grooves - (1.2 mm deep)
The labial grooves are cut in two sets with flat end tapered diamond
One set parallel with the gingival 1/3rd of labial surface
One set parallel with the incisal 2/3rd of labial surface
What happens if you do not prepare the labial surface in 2 planes?
If the facial surface is prepared in one plane that is parallel to the gingival 1/3rd there
will be insufficient space for porcelain in the incisal area.
If the facial surface is prepared in one plane that is parallel to the incisal 2/3rd the
facial surface will be over prepared and too close to the pulp.
Step no: 2 - Incisal reduction - (2mm)
With flat end tapered diamond place 2 grooves on the incisal edge.
Step no: 3 - Labial reduction (Incisal 2/3 rd)
With flat end tapered diamond remove the tooth structure between the grooves.
Step no: 4 - Labial reduction (Gingival 1/3rd)
With flat end tapered diamond remove the tooth structure between the grooves. At the
same time shoulder margin is formed.
Step no: 5 - Proximal reduction
With a long needle diamond break the contact point mesially and distally.
Step no: 6 - Lingual reduction
With round diamond make depth orientation grooves of about 1.2 mm. Join these
grooves with small wheel diamond.
Step no: 7 - Prepare the mesial and distal wall and radial shoulder with radial fissure
bur.
Step no: 8 - Round off all line angles with a flame shaped bur.
Step no: 9 - Smoothen the radial shoulder with binangle chisel.

2. ALL-CERAMIC POSTERIOR CROWN PREPARATION

Occlusal reduction (1.5 to 2 mm): With a round end tapered diamond reduce the
occlusal surface and follow anatomic planes of the tooth and place the functional cusp
bevel.
Facial & Lingual reduction (1 to 1.5 mm): With a round end tapered diamond place
axial guiding grooves on the buccal and lingual surface. Join these grooves and at the
same time form a heavy chamfer margin.
Proximal reduction: Break the contact points with a small needle diamond. With a
round end tapered diamond form a heavy chamfer on the mesial and distal surfaces.
Round off all sharp angles on the tooth with a flame shaped bur.

3. PREPARATION FOR PORCELAIN LAMINATE VENEERS

Laminate veneering is a conservative method of restoring the appearance of

discoloured, pitted, or fractured anterior teeth. It consists of bonding thin porcelain
laminates onto the labial surfaces of affected teeth.

Advantage:
The main advantage of facial veneers is that they are conservative of tooth structure.
Typically only about 0.5 mm of facial reduction is needed. Since this is confined to
the enamel layer, local anesthesia is not usually required.

Disadvantages:
1. Technique sensitive procedures
2. Shade matching is difficult
3. More time is required to fabricate the veneer in the laboratory
4. Difficult to repair the veneer
5. Fragile (easily breaks)
6. Cost is high

Indications:
1. Malformation of tooth (enamel hypoplasia, peg laterals)
2. Discolorations of tooth (tetracycline, old restorations, dark teeth, fluorosis) when
bleaching is insufficient
3. Minor mal positions or diastemas of the tooth
4. Abrasion, erosion or fracture (where sufficient enamel remains)

Contraindications:
1. Inability to isolate for cementation
2. Extensive loss of supporting enamel
3. Severe Abrasion/Erosion
4. Extensive existing restoration or caries
5. Severe bruxism
6. Moderate/severe malpositions
7. Unwillingness to wear night guard

Tooth preparation for laminate veneers

Armamentarium:
The instruments needed for preparing a porcelain laminate veneer include the
following:
Handpiece
0.5 mm depth cutter
Round end tapered diamond
Finishing stones

Place 3 depth orientation grooves on the facial surface of the tooth with a depth
cutting diamond. The depth of the grooves should be 0.5 mm. Join these grooves with
a round end tapered diamond and form a chamfer finish line either at the gingiva or
sub gingivally.

First appointment:
Case history
Make primary impressions with alginate
Laboratory procedures:
Make diagnostic casts
Make stent in a clear poly vinyl material
Second appointment:
Tooth preparation
Make final impressions
Make provisional restorations using clear acrylic stent
Third appointment:
Remove provisional restorations
Do good moisture control
Etch the inner surface of veneer with hydro fluoric acid. Wash it with water and apply
a silane coupling agent.
Etch the tooth with phosphoric acid. Wash it with water and apply bonding agent on
the tooth. Light cure the bonding agent.
Mix resin cement and apply resin cement on the veneer and do cementation. Light
cure the resin cement and remove excess cement.

Currently available ALL-CERAMIC restorations can be broadly classified according

to their method of fabrication:

1. Conventional ceramics (powder slurry)

2. Castable ceramics
3. Machinable ceramics
4. Pressable ceramics
5. Infiltrated ceramics

1. Conventional powder-slurry ceramics Example Duceram low fusing ceramic

These products are supplied as powders to which the technician adds water to produce
slurry, which is built up in layers on a die material to form the contours of the
restoration. The powders are available in various shades and translucencies, and are
supplied with characterizing stains and glazes.

2. Castable ceramics Example - Dicor

These products are supplied as solid ceramic ingots, which are used for fabrication of
cores or full-contour restorations using a lost-wax and centrifugal casting technique.
A castable glass is formed by a lost wax casting procedure. After the glass casting core
or coping is recovered, the glass is sandblasted to remove residual casting investment
and sprues are gently cut away. The glass is then covered by a protective
embedment material and subjected to heat treatment that causes microscopic plate
like crystals of crystalline material to grow within the glass matrix. This crystal
nucleation and crystal growth process is called CERAMMING. Once the glass has
been cerammed, it is fit on the prepared dies, ground as necessary and then coated
with veneering porcelain to match the shape and appearance of adjacent teeth.

3. Machinable ceramics Example - Cerec

These products are supplied as ceramic ingots in various shades and are used in
COMPUTER-AIDED DESIGN and COMPUTER-AIDED MANUFACTURING or
CAD/CAM.
Fabrication Procedure
1. Tooth preparation is the same as for all-ceramic restorations.
2. Coat the preparation with opaque powder.
3. Image the preparation with the optical scanner (optical impression), aligning the
camera with the path of insertion of the restoration. When the best view is obtained, it
is stored in the computer.
4. Identify and mark the margins and contours on the computer screen. The computer
software assists with this step.
5. Insert the appropriate shade of ceramic block in the milling machine. The
fabrication time for a crown is about 20 minutes. Additional characterization is
achieved with stains.
6. Try the restoration back in the mouth and cement it.

4. Pressable ceramics Example IPS Empress

Also supplied as ceramic ingots, these products are melted at high temperatures and
pressed into a mold created using the lost-wax technique.
IPS Empress is a glass ceramic provided as core ingots that are heated and pressed
until the ingot flows into a mold. The hot pressing process occurs over a 45 minute
period at a high temperature to produce the ceramic substructure. This crown form can
be either stained and glazed or built up using a conventional layering technique.

5. Infiltrated ceramics Example In Ceram

These products are supplied as two components: a powder (aluminium oxide), which
is fabricated into a porous substructure, and a glass, which is infiltrated at high
temperature into the porous substructure. The combination of these procedures gives
the material its outstanding properties. Ceramic is built up using a conventional
layering technique.

Conclusion
Dental ceramic technology is one of the fastest growing areas of dental material
research and development. The future of all ceramic restorations remains bright for
there is increased demand for tooth coloured restorations. All ceramic restorations
represent the most esthetically pleasing, but more fracture prone restorations.
However with adequate tooth reduction, an excellent quality impression, skilled
technician, high success can be achieved.

References:
1. PHILLIPS SCIENCE OF DENTAL MATERIALS Anusavice 11th edition
2. FUNDAMENTALS OF FIXED PROSTHODONTICS - Shillingburg
3rd edition
3. CONTEMPORARY FIXED PROSTHODONTICS Rosenstiel 3rd edition