clinical | EXCELLENCE

The world of CAD ceramics

A look at the demands placed on all-ceramics

By Dr Andreas Kurbad

The term all-ceramics covers a variety of materials, which differ quite considerably in the way they are processed and in the type of properties they exhibit. Special materials are available for a wide variety of requirements. As a result of the rapid developments in this field, it is becoming increasingly difficult to maintain an overview of all the available products. From an economic point of view, however, it is important to focus on a select few systems. aterials that can be processed using CAD/CAM equipment include silicate and oxide ceramics. Their strength and stability are considered to be their most important properties. Standardized and comparable values are available, which allow a general classification. Therefore, these ceramics are categorized as showing high, medium or low strength. Generally, highly resistant ceramics should be preferred because of their durability. Nevertheless, high-strength ceramics are very difficult to process. Only a few CAD/CAM systems are capable of machining these very strong materials. An alternative solution involves using green bodies, which attain their final desired hardness only after they have been machined. Apart from being easier to process, ceramics of lower strength demonstrate optical advantages, such as natural-looking translucency and fluorescence, which are of importance in places where highly aesthetic restorations are required. In addition, the possibility or necessity of adhesive cementation is a decisive criterion for certain indications. There is no such thing as a universal ceramic. The success of the treatment largely depends on the correct choice of material for the case at hand. This constitutes an exacting task for the dental team consisting of the dentist and the dental technician. The

consistent and systematic development efforts of Ivoclar Vivadent have produced two product lines, IPS Empress and IPS e.max, which offer a suitable ceramic material for every indication.

IPS Empress CAD

This material is a leucite glass-ceramic, which is classified as a low-strength ceramic. The formation of leucite crystals produces internal stresses, which are responsible for generating the best possible strength values in this category. The ceramics uncomplicated handling and highly aesthetic appearance make up for its lack of strength. The blocks can be machined in a straightforward procedure using CEREC or inLab milling equipment. They are supplied in two levels of translucency (HT - high translucency and LT - low translucency) for different clinical situations. In addition, the Multi Block, which features a naturallooking transition of shade, brightness and translucency, has been developed for more sophisticated restorations. In most cases, the restorations merely have to be polishing or glazed to achieve the desired aesthetic effect. If needed, the IPS Empress Veneer Kit provides a comprehensive selection of materials for applying additional ceramic layers and characterizations. The indication range of this system includes inlays, partial crowns and all-ceramic anterior and posterior crowns. Furthermore, IPS Empress CAD is particularly suitable for fabricating veneers because of its highly aesthetic appearance. The material comes in a wide selection of shades and exhibits what is known as the chameleon effect. Therefore, it is ideal for fabricating fully anatomic restorations at chairside with the CEREC system. However, it also produces outstanding results when

There is no such thing as a universal ceramic. The success of the treatment largely depends on the correct choice of material for the case at hand. This constitutes an exacting task for the dental team consisting of the dentist and the dental technician...

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Figure 1. The traumatic fracture in the front tooth was treated with a composite filling, which showed signs of wear after several years of service.

Figure 2. A minimally invasive preparation is carried out before the ceramic veneer is placed.

Figure 3. After milling, the IPS Empress CAD ceramic is characterized with the IPS Empress Veneer Kit.

Figure 4. The areas of the veneer which will cover the undamaged tooth structure are only 0.3 mm thick.

Figure 5. An IPS Empress CAD Multi Block is used. This block features a natural-looking transition of shade and translucency.

Figure 6. The veneer is cemented with the adhesive technique using Variolink Veneer.

Figure 7. Veneers show excellent aesthetic adaptation and have a long service life.

Figure 8. The exact recreation of the natural surface texture is of major importance in the fabrication of veneers.

Figure 9. The translucency of the IPS Empress ceramic and of the Variolink Veneer cementation material allows restorations to blend in smoothly with the existing tooth structure. The restoration cannot be distinguished from the natural teeth.

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it is processed in the laboratory. The application of wash pastes ensures the smooth adaptation of the veneering ceramic to the base material. Nonetheless, certain clinical concessions must be made because of the low strength of this material. Thinly tapering preparation margins must be avoided in areas that are exposed to high mechanical loads. Consequently, crown preparations must have a right-angle shoulder, which should not be wider than 1mm and have a rounded internal edge in accordance with the principles of non-invasive preparation and pulp protection. The adhesive technique must be used for cementing the restorations. Nevertheless, the working procedure of the conventional adhesive technique, as it is prescribed for Variolink II, can be simplified by using a system such as Multilink Automix. However, in areas where aesthetics are very important and for the cementation of veneers in particular, Variolink Veneer should be used, as it has been specifically developed for these applications. In preparation for adhesive cementation, the ceramic is etched with hydrofluoric acid and then silanized.

Figure 10. The veneer of the PFM crown has been damaged.

Figure 11. The chamfer preparation remains unchanged compared with the previous restoration.

IPS e.max CAD

This material is a lithium disilicate and generally categorized as a silicate ceramic. As a result of its special crystal structure, its final strength is very high. Therefore, it is classified as a mediumstrength ceramic. The material is supplied in an intermediate crystalline form (metasilicate) with an unusual blue colour. In this state, the material can be machined, finished and cut back without any problems. When all this work has been done, the ceramic has to undergo crystallization firing for 25 to 35 minutes to obtain its final strength. Most commercial furnaces can be used for this purpose. The ceramic restorations are placed on a carrier material (Object Fix) for the firing cycle. After crystallization firing the materials colour and translucency is similar to that of natural teeth. By bringing about a change in the crystal structure (transformation to a disilicate), the material also becomes considerably stronger. Depending on the aesthetic requirements of the patient, the ceramic can be stained and glazed or veneered or partially veneered. The IPS e.max CAD ceramic is also available in two levels of translucency. Although the more translucent material IPS e.max CAD LT is preferred in most cases, the more opaque material (MO) is useful when discoloured teeth or metal substructures (e.g. implant superstructures) have to be masked. The versatile IPS e.max Ceram, which is available in a wide range of shades, is available for veneering and/or staining purposes. This ceramic is mainly used to fabricate full crowns. However, it can also be used for partial crowns and even veneers. Because of its high final strength, the material can be used in areas where the adhesive technique cannot be employed or if there is some doubt about Programat CS is the ideal firing and crystallization furnace for dentists. The new Programat CS is a furnace with vacuum capabilities. Crystallization and glaze firings of IPS e.max CAD restorations can be conducted with ease in the dental practice. The furnace has 20 programs, is easy to operate and features a controlled cooling process.

Figure 12. The natural-looking IPS e.max CAD ceramic requires only very minimal characterization.

Figure 13. The originally blue block becomes a tooth-coloured translucent ceramic restoration as a result of crystallization.

Figure 14. Exceptionally aesthetic results are achieved with the IPS e.max CAD LT ceramics.

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Figure 15. Typical inhibited smile of a patient with a metal-ceramic bridge.

Figure 16. Chamfer preparation is carried out with standardized instruments.

Figure 17. A framework is milled from an IPS e.max ZirCAD block in enlarged form to take into account the subsequent sintering shrinkage.

Figure 18. Multilink Automix is used to cement the finished bridge.

Figure 19. Multilink Sprint achieves a self-adhesive bond quickly and easily.

Figure 20. A highly satisfactory result.

whether the procedure can be carried out properly. The ceramic is used to fabricate various types of crowns. Depending on aesthetic and/or economic requirements, very straightforward mono-ceramic or partially or fully veneered restorations can be fabricated. Mono-ceramic pieces are milled to the desired final shape. Subsequently, crystallization firing as well as stain and glaze firing can be conducted in one time-saving step. A more complex procedure involves cutting back the crown. In this case, aesthetically relevant areas are either left out in the computer-aided design or mechanically removed after the restoration has been machined and then these areas are built up with veneering ceramic. A chamfer or a right-angle shoulder, which is created according to minimally invasive principles, is acceptable. IPS e.max CAD restorations can be cemented with the conventional cementation technique or the adhesive luting technique. For the adhesive technique, the ceramic is etched with hydrofluoric acid and then conditioned with silane. Multilink Automix is the product of choice for achieving excellent bonding results.

IPS e.max ZirCAD

IPS e.max ZirCAD ceramic is based on yttrium-stabilized zirconium dioxide. It is classified as an oxide ceramic. It is one of the strongest dental ceramics, demon-

strating bending strengths of around 900 MPa. Most CAD/CAM machines are not capable of milling the ceramic in its hard final state. Therefore, it has to be machined in what is known as a green state and then sintered to obtain its final strength. As sintering is conducted at very high temperatures of over 1500C, a special furnace is needed for this purpose. The shrinkage of 20 to 25 percent, which occurs during sintering, is taken into account by the CAD/CAM equipment in that it cuts the restoration in enlarged form. Before compulsory veneering takes place with IPS e.max Ceram, foundation materials, also called liners, are applied. The clinical uses of the material are determined by two main properties. The materials high strength allows it to be used for almost every indication, with crowns and above all bridges being the most common indications. IPS e.max ZirCAD is also the material of choice for fabricating all-ceramic primary crowns. However, compared with the previously described silicate ceramics, zirconium dioxide is less translucent. Therefore, in situations where a high level of aesthetics is desired and the high final strength offered by this class of materials is not absolutely necessary, silicate ceramics should be preferred. The clinical procedure for IPS e.max

ZirCAD does not differ from that of conventional metal-ceramics. The preparation of a chamfer is recommended. Even though conventional cementation is possible, it must be noted that opaque cements that demonstrate a strong inherent colour (eg zinc phosphate cements) will have a negative effect on the appearance of the restoration. Therefore, glass ionomer cements should be used. The adhesive technique may also be used to place IPS e.max ZirCAD restorations. In fact, it is unavoidable in the case of resinbonded bridges. For this purpose, the bonding surfaces are sandblasted and coated with zirconia primer. Easy-to-handle bonding systems have firmly established themselves for this technique. The self adhesive Multilink Sprint is known to produce satisfactory results in routine procedures.

Acknowledgement
Thank you to Kurt Reichel, the master dental technician responsible for the laboratory work shown in this article.

About the author

Dr Andreas Kurbad is in private practice in Viersen, Germany. For more info, contact Geoff Staples, Account Development Manager CAD/CAM at Ivoclar Vivadent on 0400-616-598 or geoff.staples@ivoclarvivadent.com.au

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