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Karl Lyons!
Department of Oral Rehabilitation!
Faculty of Dentistry
Ceramics	
  in	
  Fixed	
  Prosthodon2cs	
  
Considera2ons	
  for	
  use	
  in	
  Dental	
  Prac2ce
1	
  
Karl Lyons
2	
  
Presentation Outline
•  Ceramics in dentistry
•  Types of ceramics
•  Clinical indications and uses
•  Case considerations
•  Preparation designs
•  Fitting and adjusting
•  Cementation
•  Longevity and causes of failure
•  Alternatives
•  Summary
 3
Ceramics in Dentistry
Why?
Ceramics in fixed prosthodontics   considerations for use in dental practice
All Ceramic Crowns
Zirconium
Vs
Leucite Reinforced
Vs


Metal-ceramic
Light Dynamics in Natural Teeth
Tooth colours are
produced by the colour of
the dentine and pulp
reflecting through the
enamel layer which is
influenced by the amount
of demineralisation
Raptis et al. 2006
The Effect of Light Transmission
Four crowns placed on tooth 11
Which two are PFM and which two are All-ceramic crowns?
In-Ceram Spinell
 IPS Empress
PFM
 PFM (with porcelain shoulder)
Note how light is blocked by the metal copings
Raptis et al. 2006
Light Transmission
Charles Land 
• Invented dental porcelain in 1886
• Granted Patent 1887
• Platinum foil matrix
Land CH (1903) Porcelain dental art: No II. Dental Cosmos 45:615-620

John McLean & TJ Hughes
• Replaced metal reinforcement with Alumina (Al2O3) to develop first all-
ceramic core

The reinforcement of dental porcelain with ceramic oxides. (1965) BDJ
119(6):251-267
Evolution of Ceramic Crowns
Types of All-ceramic
Monolithic crowns 
(1 layer)
Bilayered crowns
(2 layers - core & veneer)
Eg:
•  Feldspathic –CAD/CAM
blocks 
•  Leucite reinforced –
Empress I
•  Lithium Disilicate – emax
Press or CAD
•  Zirconia (recently introduced)
Eg:
•  Lithium Disilicate
•  Glass-infiltrated – In-Ceram Spinell
•  Alumina 
•  Zirconia
Three main types of ceramics in dentistry 1
1.  Predominantly glass
•  Veneering porcelains for PFM and
all-ceramics
•  Most translucent – high aesthetics

2.  Particle-filled glass (Glass-ceramics)
i.  High glass content
•  Lost wax system (Dicor) [no longer
available]
•  Machinable feldspar-based ceramic
(Vita Mark II blocks)
•  Heat-pressed Leucite reinforced
(Empress I)

(Kelly 2008)
Three main types of ceramics in dentistry 2

2.  Particle-filled glass (Glass-ceramics)
ii.  Low glass content
• 
 Heat-pressed or CAD/CAM Lithium
Disilicate (IPS emax)
• 
 Slip-cast or CAD/CAM Glass-infiltrated
alumina (In-Ceram)

3.  Polycrystalline (Ceramic oxides)
i.  Alumina Oxide (Procera Alumina) 


ii.  Zirconia (3mol%Y-TZP) (Procera
Zirconia)
Commercially Available Dental Ceramics
Flexural Strength of CeramicsFractureToughness[KIC(MPa.m1/2)]
Flexural Strength (MPa)
Methods for Reinforcing Porcelain
Metal-Oxides
•  Aluminium Oxide 
•  Magnesium-Alumina Spinel 
•  Zirconium Oxide 
Leucite
Lithium Disilicate 
• Dispersion strengthening
• Phase transformation toughening
VITABLOCS® Materials
VITABLOCS
 Block
 Restoration
 Indication
Mark II
Inlays, onlays,
anterior/posterior
crown and
veneer
TriLuxe
Anterior/posterior
crown and
veneer
TriLuxe forte
Anterior/posterior
crown and
veneer
RealLife
Anterior/posterior
crown/ veneer
for natural
aesthetics
Structural Ceramics
•  Lithium disilicate
•  Excellent translucency and aesthetics
•  Inlays, onlays, veneers, crowns
•  In-Ceram Spinel
•  Excellent translucency and aesthetics
•  Anterior crown substructure
Ceramics in fixed prosthodontics   considerations for use in dental practice
Structural Ceramics
•  In-Ceram Alumina
•  Good combination of strength and
aesthetics
•  Substructure for anterior crowns and
3-unit bridges
•  In-Ceram Zirconia
•  Very good strength
•  Substructure for anterior and posterior
crowns and 3-unit bridges
Ceramics in fixed prosthodontics   considerations for use in dental practice
Structural Ceramics
•  In-Ceram AL
•  Very good strength 
•  Substructure for anterior and 3-unit
bridges and posterior crowns
•  In-Ceram YZ
•  Excellent strength
•  Substructure for anterior and
posterior crowns and multi-unit
bridges
Alumina and Zirconia
•  The increase in crystalline content in
alumina and zirconia has:
•  Improved the mechanical properties allowing
all-ceramic crowns and bridges
•  Is hard to machine and resistant to etching
so resin bonding is a challenge
Zirconia
Zirconia
Note the difference in shrinkage between pre-
sintered and sintered substructure.
Zirconia
Images compliments Vita Zahnfabrik
Ceramics in fixed prosthodontics   considerations for use in dental practice
Procera
Overview of VITA In-Ceram® Ceramics
Vita Enamic

CAD/CAM Hybrid Ceramic

product description from Vita
•  For the first time, this innovative hybrid materials
combines enormous strength with exceptional elasticity
•  As a result, the material is perfectly suited for crown
restorations and moreover allows to achieve reduced
wall thicknesses for minimally invasive restorations
•  Additionally, VITA ENAMIC excels by utmost reliability
and precise and accurate milled restorations featuring
high edge stability
•  This tooth-colored hybrid material also exhibits tooth-
like material properties and produces highly esthetic
results thanks to its excellent translucency
Ceramic network
+
Polymer network
=
Hybrid ceramic
VITA ENAMIC:
Dental hybrid ceramic!
=!
polymer-reinforced ceramic network
Reinforced materials:
(e.g. carbon, reinforced concrete)!
=
steel reinforced cement
Common Ceramic Core Materials
Amorphous glass - Veneering porcelains
Glass ceramics (reinforced by crystalline phases)
• Leucite reinforced - Empress I
• Lithium disilicate - Empress II
• Magnesium aluminium oxide - In-Ceram Spinnell
• Feldspathic Glass - Vita Mark II Blocks
Glass infiltrated mixtures
• In-Ceram alumina
• In-Ceram zirconia
Polycrystalline
• Alumina - Procera
• Zirconia - Lava, Everest, Cercon, Procera, Zeno, Ivoclar etc
1.  Amorphous glass – Vita Mark II
2.  Crystalline glass ceramics
(reinforced by crystalline
phases)
1.  Leucite reinforced - Empress I
2.  Lithium disilicate - Empress II
3.  Glass infiltrated mixture
1.  Magnesium Aluminium Oxide -

 Spinell
2.  InCeram alumina
3.  InCeram zirconia
4.  Polycrystalline
1.  Alumina - Procera
2.  Zirconia – Lava
All-Ceramic Material
Type!
Aesthetic Properties! Applications!
Feldspathic Glass
(predominantly glass)
Intrinsically tooth
coloured
Anterior veneers &
crowns
Can be stained & glazed
Crystalline Ceramics
(particle-filled glass - high
glass content)
Intrinsically tooth
coloured
Anterior veneers &
crowns
Can be stained & glazed
Glass Infiltrated Mixtures
(particle-filled glass – low
glass content)

Core material
Core can be pigmented 
Anterior and posterior
crowns
Are veneered with
porcelain
Polycrystalline Ceramics
(no glass content)
Core material
Core can be pigmented 
Anterior and posterior
crowns & bridges
Are veneered with
porcelain
10!
8!
6!
4!
2!
0!
200! 400! 600! 800! 1000!0!
FractureToughness(MPam1/2)
Bending Strength (MPa)
Filser et al., Quintessenz Zahntechnik 28, 1, 48-60 (2002)
Empress 1
Dicor MGC
In-Ceram
Spinell
In-Ceram
Zirconia
In-Ceram
Alumina
Zirconium oxide
e.g. Zeno ZR
IPS Empress 2
Glass 
Ceramics
Crystalline Glass
Ceramics

Aluminium Oxide
Zirconia
Vita Mark II
Aluminium Oxide
Procera
Anterior Crown
 Anterior Bridge
 All Restorations
Types of Ceramic Crowns
Sintered porcelain 
•  Feldspathic, Alumina or Leucite-reinforced
Slip cast glass infused ceramic
•  In-Ceram - Alumina, Spinell or Zirconia
Heat pressed ceramic - Leucite or Lithium disilicate
•  IPS Empress, IPS Empress 2
•  Pentron OPC, Pentron OPC 3G
•  Finesse All-Ceramic
Machined glass ceramic (eg CEREC 3, CEREC inLab)
•  Chair-side - VitaBlocs Mark II, ProCAD
•  Lab-milled - In-Ceram 2000, IPS e.max CAD, IPS Empress CAD
Machined densely sintered ceramic - Alumina, Zirconia
•  Procera, Lava, Everest, e.max ZirCAD
Sintered Porcelain Crowns
•  Feldspathic, Alumina & Leucite-Reinforced
•  Flexural Strengths 

•  55 – 75MPa
(feldspar)
•  90 – 120MPa 
(alumina)
•  105 – 160MPa 
(leucite)
•  Clinical Survival Rates
•  Aluminous 73% over 5 years
•  Leucite 
•  Anteriors 97% over 3 years
•  Posteriors 76% over 5 years
Hankinson & Cappetta 1994; Etemadi & Smales 2006
Sintered Porcelain Crowns
Slip-Cast Glass Infused Ceramics
• In-Ceram:
Alumina, Spinell & Zirconia
• Flexural strengths
• ~400MPa 
(Spinell)
• ~500MPa 
(Alumina)
• ~600MPa 
(Zirconia)

• Clinical survival rates
• In-Ceram Alumina & Spinell = 92% to 100% over 5 yrs
• In-Ceram Zirconia = 3-unit FPD 95% over 3 yrs

Wasserman et al. 2006
Slip-Cast Glass Infused Ceramics
Slip Casting Technique
Images compliments Vita Zahnfabrik
Heat-Pressed Ceramic Crowns
IPS Empress, IPS Empress 2, Pentron OPC, Pentron
OPC 3G, Finesse All-Ceramic

• Flexural strengths - Leucite, Lithium disilicate
• 140 – 200MPa (Leucite)
• 350 – 450MPa (Li2O•2SiO2)

•  Clinical survival rates
•  Leucite 92% to 99% for anteriors over 3.5 years
•  Lithium disilicate 100% over 50 months (n=27)

Chadwick 2004; Marquadt 2006
Heat-Pressed Ceramic Crowns
IPS Empress
Machined Glass-Ceramic Crowns
eg CEREC 3, CEREC inLab

•  Chair-side - VitaBlocs Mark II, ProCAD: 


•  Lab-milled - In-Ceram 2000, IPS e.max CAD, IPS
Empress CAD: 

• Industrially fabricated - stronger and more reliable

• Clinical survival rates
• Feldspathic-milled = 94% over 5 years (n=17, anterior)

Bindl & Mormann 2004
Machined Glass-Ceramic Crowns
Machined Densely Sintered Crowns
Machined Densely Sintered Crowns
• Alumina, Zirconia, Zircon
• Procera, Lava, Everest, e.max ZirCAD

• Flexural strengths
• 600MPa (Alumina)
• 700 - 820MPa (Zircon)
• 850 - 1050MPa (Zirconia)

• Clinical survival rates
• Procera Alumina 92% at 10 years
• Zirconia FPDs 100% of frameworks at 3 years

Odman & Andersson 2001; Sailer et al. 2006
In-Ceram Alumina
Empress2
Empress
Summary of Ceramics
Systematic Review 

Goodacre et al 2003!

Mean fracture rate for all-ceramic crowns
increases as you move posteriorly

Anteriors 
 
3%

Premolars 

 
7%

Molars 
 
21%


This review did not distinguish between: 
•  fracture modes (core or veneer chipping)
•  or types of ceramic systems
Systematic Review

Pjetursson et al 2007 - All-ceramic vs PFM crowns
5yr survival rates:

 
PFM 
 
95.6%

 
All-ceramic 
93.3% 
 

 

85% of all-ceramic crowns failures due to core fracture
Chipping usually repairable

Anteriors: 
All-ceramics = PFM

Posteriors: 
Material dependent
ü  Alumina oxide
 
 
 
 
95%
ü  Reinforced glass ceramics (Empress) 

94%
²  In-Ceram 
 
 
 
 
90%
²  Glass-ceramics (Dicor) 

 

 
85%
Systematic Review

Wang et al 2012 - All-ceramic single crowns
5 yr Fracture rate: (veneer + core) 
 
all systems 
 

 
 
Overall 
 
 
7.7% 
 
 


 
 
Posteriors 
 
10% 
 
 


 
 
Anterior teeth 
 
4.4% 
 
 



Core fracture: 
Overall 
 
 
7.2% 
 
 


 
 
Posteriors 
 
9.5% 
 
 


 
 
Anteriors 
 
3.9% 
 
 



Veneer chipping: Overall
 
 
3% 
 
 


 
 
Molars 
 
 
3% 
 
 


 
 
Premolars 
 
1.5% 
 
 


 
 
Canines 
 
2.5% 
 
 


 
 
Incisors
 
 
2% 
 
 

No clear difference found
Statistically significant 
Statistically significant
Systematic Review

Sailer et al 2007 - fixed partial dentures

5yr survival rates:
Metal-ceramic FPDs 
94.4%
All-ceramic FPDs 
 
88.6%

Frequency of: 
 
core # 
veneer #
Metal-ceramic FPDs 
1.6% 
 
2.9%
All-ceramic FPDs 
 
6.5% 
 
13.6%


Mainly Lithium disilicate and In-Ceram
Rare in zirconia FPD 
Annual rate:
Zirconia 
1.98 – 12.2
Empress/emaxP 
0.83 – 1.55
In-Ceram 
no chipping reported
Recommended Indications

Class 1 Ceramics
•  Aesthetic ceramic for coverage of a metal
or ceramic subsurface

 
and/or
•  Aesthetic ceramic for single-unit anterior,
veneers, inlays, or onlays
Example IPS Empress, IPS e.max Ceram (Ivoclar)
Della Bona, 2009
Recommended Indications

Class 2 Ceramics
•  Aesthetic ceramic for adhesively cemented,
single unit, anterior or posterior prostheses

 
and/or
•  Adhesively cemented, substructure ceramic
for single-unit anterior or posterior
prostheses
Example IPS Empress (Ivoclar), Cerec MkII (Vita)
Della Bona, 2009
Recommended Indications

Class 3 Ceramics
•  Aesthetic ceramic for non-adhesively
cemented, single-unit, anterior or posterior
prostheses 
Example IPS e.max Press or CAD (Ivoclar)
Della Bona, 2009
Recommended Indications

Class 4 Ceramics
•  Substructure ceramic for non-adhesively
cemented, single-unit, anterior or posterior
prostheses

 
and/or
•  Substructure ceramic for three-unit
prostheses not including molar restoration 
•  Example IPS Empress 2, (Ivoclar), Cerec MkII (Vita)
Della Bona, 2009
Factors that Influence Ceramics
•  Ceramics are susceptible to chemical corrosion
and fatigue mechanisms
•  This reduces their lifetime
•  Unfavourable oral conditions include:
•  Chewing forces from 100-700 N
•  Moist environment at 37ºC
•  Small contact area; stresses generated 3.5-890
MPa
Della Bona, 2009
Survival of Ceramics
To improve mechanical behaviour of ceramics
•  Select the ceramic considering location 
•  Consider substructure similar to metal for PFM
•  Minimise surface roughness
•  Rougher surfaces have more cracks so need fewer
cycles of stress to fail 
•  Chemical interaction between ceramic (crack tips) and
environment (water) results in accelerated crack growth
due to stress corrosion 
Della Bona, 2009
Considerations 

in Fixed Prosthodontics
Considerations in Fixed
Prosthodontics 3
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Crown Margin
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image and then insert it again.
Length of Edentulous Span 1
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Length of Edentulous Span 2
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delete the image and then insert it again.
Minimum occlusogingival and buccolingual connector
dimensions as a function of position of the bridge
connector and occlusal forces!
Ceramics in fixed prosthodontics   considerations for use in dental practice
Ceramic Crown Form
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Ceramic Crown
Form
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Ceramics in fixed prosthodontics   considerations for use in dental practice
Minimum 9mm3
Tooth Preparation
Summary
Bonding Ceramic Crowns
•  The crystalline content in alumina and zirconia
is resistant to etching so bonding is a challenge
•  Silica coating systems (eg Rocatec and Cojet,
3M ESPE) creates a silica layer
•  High-speed surface impact of silica-modified
alumina particles promotes resin bonding by:
•  Rough surface allowing micromechanical bonding
to resin
•  Promotes a chemical bond between the silanated
silica coated ceramic and the resin bond material
Bonding Strategies to Teeth and
Restorative Materials
Commercially Available Dental Ceramics
Material properties: Strength
Strength is probably the most advertised property in the
dental literature.
0 200 400 600 800 1000 1200
Zirconia
Aluminium Oxide
Lithium Disilicate - Hot Press
Lithium Disilicate - CAD/CAM
Magnesium Alliminium Oxide - Spinell
Leucite Reinforced
Feldspathic Glass
Zirconia
Aluminium
Oxide
Lithium
Disilicate -
Hot Press
Lithium
Disilicate -
CAD/CAM
Magnesium
Alliminium
Oxide -
Spinell
Leucite
Reinforced
Feldspathic
Glass
Series1 1100 620 470 350 400 175 80
Flexural Strength of All-Ceramic
Materials in MPa
Series1
Shinogaya et al, 2001, Clin Oral Invest 5:63-68
Ceramics in fixed prosthodontics   considerations for use in dental practice
Failure	
  Classifica2on
Biological failures
•  Secondary caries 

Aesthetic failure 

•  Restoration contours, value, hue, chroma

Mechanical failures 
•  Cracking
•  Chipping fracture (veneering porcelain fracture)
•  Bulk fracture (core substructure fracture) 
•  Debonding of the prosthesis
Mechanical Failures
•  Cracking
•  Chipping of veneering porcelain
•  Cohesive chipping
•  Adhesive delamination 
•  Bulk fracture (core substructure
fracture)
Transilumination
Veneer porcelain chipping !
Delamination !
Core fracture!
Use Transillumination for Quality Control
Custom Fabrication
•  All-ceramic restorations are custom-fabricated
increasing susceptibility to fabrication defects
•  Variety of techniques
•  Sintering
•  Heat-pressing
•  Slip-casting
•  CAD/CAM
•  Combined with staining or veneering step
Each technique produces fabrication defects
[from Janine Tiu]
Diamond grinding is a major source of failure-inducing
flaws in dense ceramics. (Rice 2002)

Zirconia CAD/CAM machining creates damage that is
not fully healed by sintering process. (Kim et al 2010)

Effects of Abrasive Grinding
Thermal shock
Characteristic Trace Lines After CAD/CAM Machining!
Lava!
Procera Zr!
Everest
(KaVo)!
DCS
Zirkon!
Veneer Chipping in Zirconia-based Restorations
Systematic reviews confirm chipping of veneering
ceramic is the most frequent complication
More common than with metal-ceramic or other all-
ceramic restorations
(Al-Amleh et al 2010, Hientz et al 2010, Schley et al 2010,
Raigrodski et al 2012)
Al-Amleh et al 2010 “Clinical trials in zirconia: A systematic review

Summary:
•  17 clinical trials based on 3Y-TZP
•  Posterior FPD 
 
13 studies
•  Single crowns 
 
2 studies
•  Implant abutments 
 
2 studies
•  8 brands of zirconia 
•  Longest trial 5yrs (only 2 studies)
Chipping of veneering porcelain 
•  Two of 15 studies did not report chipping
•  Was common for all brands
•  Incidence ranged from 0 – 54%
•  Not always noticed by patients – incidental finding
•  Also found at non-load bearing areas
8
 17
Difference between thermal conductivity between metal
substructure and YZr substructure
Reasons for Zirconia Veneer Chipping
High tensile residual stresses locked within
the veneering porcelain (Swain 2009)
Zirconia is a very poor thermal conductor:
•  Gold: 
 
315 W/m-K
•  Alumina: 
 
 
 40 W/m-K
•  Zirconia: 
 
 
 2 W/m-K


Substructure core design
•  Cap-like core do not support veneering
porcelain
•  Suggested “PFM-style” cut back method
[Tholey, Swain & Thiel 2011]
PFMs cool from the inside to the outside producing systematic
compression bonding from the inside to the outside.
YZr crowns cool from both the inside and the outside at a similar
rate resulting in a compression layer in the outer veneer and YZr
coping, and an inner zone of tension within the porcelain veneer.
W/(m.K), of a gold coping =
315
W/(m.K), of a zirconia coping
= 2
Thermal conductivity, W/(m.K),
of porcelain = 1.4
Zone of
tension
Loading Zirconia Crowns to Failure 

fast cooled v slow cooled
Procera Zirconia
IPS e.max ZirPress
Al-Amleh 2011
Fast Cooled Samples
Common features:
•  Midline fissure crack
•  Cracking on mesial non-loaded side
•  Average 902 N
Fracture after 2 days
Courtesy: Dr. L. Gruetter (University of Geneva)
Courtesy : Dr. L. Grütter (University of Geneva)
Occlusal
contact point
responsible for
shearing off
veneering
ceramic
1. Clean (cotton pellet with
alcohol), rinse & dry 
2. Inject siloxane impression material
(light body)
3. Cover the whole crown with
silicon material
Procera Alumina AllCeram (veneering
ceramic failure after 4 years)
Zirconia Abutment Fracture
Case description:
1. The zirconia
implant abutment
was screwed in
tightly
2. Contact points
M, D, were
adjusted in situ
3. On the first bite for
occlusal adjustment
the crown fractured
Zirconia
abutment CARES
(Straumann)
Zirconia Abutment Try-in Failure
The first bite to check
the occlusion created a
stress concentration at
the distal margin (white
arrow). The crack path
is marked by the red
arrows and result in the
crown splitting in half. 
origin 
 Ø  Fabrication defect
Cercon 6-unit bridge failure after 24
hours
FPD Bulk (core) 
Fracture
Poor framework design
•  Not enough palatal clearance
•  Thin tip zirconia framework
Both cause high stress concentrations

Take home message:
Always try-in zirconia frameworks before veneering
All zirconia copings 
were rejected
No substructure support
Adequate substructure
support allows for natural
occlusal morphology
Procera Alumina All-Ceram
(veneering ceramic failure
after 4 years)
origi
n
Conclusion from the replica SEM analysis: The origin of the failure was
located on the occlusal-palatal cusp (wear facette). The crack continued along the arrows
downwards (interproximally) to the gingiva without reaching the margins. 
The veneering porcelain was unsufficiently supported by the alumina core
Guidelines for Restoring Chipped !
All-ceramic Restorations
Grade 1: Fracture surface can be polished

Grade 2: Fracture surface can be repaired with composite resin

Grade 3: Severe fracture requires restoration replacement 

1.  Fracture extends into a functional area and repair is not
feasible
2.  Re-contouring will result in a significant unacceptable
alteration of the anatomic form from the original anatomy
3.  Re-contouring will significantly increase the risk of pulp
trauma by the generation of heat
4.  Repair with resin composite will result in unacceptable
aesthetic result 

(Heintze & Rousson 2010, Anusavice 2012)
Success or Failure?
•  Is a chipped all-ceramic restoration a failed
restoration?
•  Restoration success is defined as the
demonstrated ability of a restoration to
perform as expected
•  Acceptable surface quality
•  Anatomic contour
•  Function
•  Aesthetics (where applicable) 
•  When should we repair or replace the
entire restoration?
•  Restoration failure may be defined as
any condition that leads to replacement
of a prosthesis
•  Why do all-ceramic fracture? 
•  How can we minimise this problem?
Origins of Fracture
•  Fabrication flaws of various shapes
and sizes includes:
•  Pores Micro-cracks
•  Macro-cracks
•  Machining grooves
•  Air-abrasion surface defects
•  Grinding adjustments surface
defects
•  Location of the defect under tensile
stresses is important
•  Thermal residual stresses
•  Subcritical crack growth (SCCG)
•  In humid environment, cracks grow
slowly but continuously
 Weakest link
Early v Late Fractures
•  Immediate failure or within a few hours or
days of cementation is likely to originate
from a major processing flaw
(Schmitter et al 2009, Lohbauer et al 2010)
•  Failure after a few years is likely to involve
subcritical crack growth and/or cyclic
fatigue SCCG and/or cyclic fatigue
Most important factor affecting
fracture rates:

Position of restoration in the mouth
Ferrario et al 2004

Greatest forces 
Molars > premolars > incisors (1/3-1/4 of
molars load)
Surface area of
incisal edge of
anteriors and
occlusal table
of posteriors?
A
F
=σ
Occlusal contacts on natural
teeth are point contacts
Causes of Ceramic Substructure Failure
•  Fracture initiating in the connector area
•  Connector high stress area
•  Chipping of the veneering material
•  Residual stresses at the core-veneer
interface
•  Differences in thermal conduction between
the core and veneer
•  Thick veneer layer
•  Poor bonding between the core and veneer
ceramic
•  Sliding occlusal contacts more damaging
than axial contacts
Summary
•  Stronger ceramics are more opaque than
aesthetic ceramics
•  Aesthetic restorations without much structural
need – use single layer (monolithic) ceramics
•  High strength needed, less aesthetic ceramics
veneers with tooth coloured porcelain
•  Any ceramic system suitable for veneers and
anterior crowns
•  Only a few ceramics successful for restoring
molars
•  Need to consider other clinical factors such as
adequate preparation depth and cementation
Summary
•  No equivalent long-term data as for PFMs
•  ~75% at 15 years
•  Many ceramics >90% after 5 years
•  Reasonable evidence available for anterior 3-
unit FPDs in lithium disilicate, In-Ceram
Alumina and Zirconia
•  Posterior 3-unit FPDs only zirconia indicated
•  Chipping and fracture a problem
•  Higher success when ceramics bonded to teeth
using resin cement rather than GIC
•  Use a silica coating system or primers for acid resistant
ceramics such as zirconia
Ceramics in dentistry
Summary of Ceramics
Recommendations Based on Peer Review Literature
Ceramics
Aluminous Core
Slip Cast - In-Ceram
Hot Pressed - Empress
Machined - Cerec , Procera
Ceramics

Slip Cast
•  Build-up with core particles and fired
•  High Strength
•  Highly Abrasive
•  Fair Marginal Fit
–  In-Ceram: crowns
–  In-Ceram Spinell: crowns (more translucent)
–  In-Ceram Zirconia: 3 unit FPD’s
In Ceram
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What is Slip Casting?
Ceramics in fixed prosthodontics   considerations for use in dental practice
Ceramics

Hot-Pressed
•  Medium to High Strength
•  Low to Medium Abrasive
•  Medium Translucency
•  Fair Marginal Fit
–  Empress & Finesse (leucite) 
✦  veneers, inlays, onlays, crowns
–  Empress 2 (lithium disilicate)
✦  crowns, 3-unit FPD’s
What is Hot Pressed?
Lost wax casting via pressed ceramic.
Ceramics in fixed prosthodontics   considerations for use in dental practice
Ceramics in fixed prosthodontics   considerations for use in dental practice
Ceramics in fixed prosthodontics   considerations for use in dental practice
Ceramics in fixed prosthodontics   considerations for use in dental practice
Ceramics in fixed prosthodontics   considerations for use in dental practice
Ceramics

Machined (CAD/CAM)
•  Medium to Very High Strength
•  Low to Medium Abrasive
•  Fair Marginal Fit
•  Industrial CAD/CAM
–  Procera: crowns, FPDs
•  In-office CAD/CAM
–  Cerec: inlays
–  Cerec 2 & 3: inlays, onlays, crowns
IPS e.max
KIc= 2.75 MPa√m KIc= 2.25 MPa√m
LiO2 - SiO2
(lithium disilicate)
S = 450 MPa S = 360 MPa
T° = 850°CT° = 915-920°C
Images compliments Vita Zahnfabrik

VITA In-Ceram® SPINELL
VITA In-Ceram® ALUMINA
Images compliments Vita Zahnfabrik
VITA In-Ceram® ZIRCONIA
Images compliments Vita Zahnfabrik
What is CAD/CAM ?
Computer Aided Design / Computer Aided Manufacture
CEREC® 3
inLab von Sirona
inEos von Sirona
CAD/CAM ?
CAD/CAM
CAD/CAM
CAD/CAM
© Praxisfall Dr. Gunpei Koike (Japan)
CAD/CAM
© Praxisfall Dr. Gunpei Koike (Japan)
CAD/CAM
CAD/CAM
© Praxisfall Dr. Gunpei Koike (Japan)
CAD/CAM
E4D
HenrySchein
Cerec
Sirona
Ivoclar
Procera
NobelBiocare
CAD/CAM
All Ceramic Crowns
•  Indications
–  High cosmetic demand
–  Incisal edge reasonably intact
–  Favourable occlusion
•  Advantages
–  Cosmetics
–  Good tissue response
–  More conservative on labial
All Ceramic Crowns
•  Contraindications
–  High strength required
–  Insufficient tooth structure for support
–  Unfavourable occlusion
•  Disadvantages
–  Reduced strength
–  Not conservative
–  Brittle
–  Single crowns only
Types of crowns
Full gold crown (FGC)
Porcelain fused to metal (PFM)
All ceramic
Affect of the Metal Coping
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image and then insert it again.
Ceramic Crown Form 1
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the image may have been corrupted. Restart your computer, and then open the file again. If the red x
still appears, you may have to delete the image and then insert it again.
Occlusal Considerations
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have enough memory to open the image, or the image
may have been corrupted. Restart your computer, and
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may have to delete the image and then insert it again.
Ceramic Crown Form
Tooth Preparation 1
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then insert it again.
Tooth Preparation 2
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computer may not have enough memory
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still appears, you may have to delete the image and
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computer may not have enough memory
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still appears, you may have to delete the image and
then insert it again.
All-ceramics and Metal-ceramics
•  The need to simulate in
dental porcelains the light
behaviour and
appearance of the natural
tooth

•  Create the illusion of
nature within limited
space constraints and
light blocking effect of the
metal substructure or
ceramic substructure
Yamamoto 1985
Yamamoto 1985
Think Cosmetics
Bleaching
Veneers
Ceramic Crowns
Metal Ceramic Crowns
◆  Indications
–  Heavily restored / endodontically treated tooth
–  Cosmetics
–  When ceramic crowns not possible
◆  Advantages
–  Appearance compared with FGC
–  Retentive
Metal Ceramic Crowns
◆  Contraindications
–  Large pulp chamber
–  Intact buccal wall
–  More conservative restoration possible
◆  Disadvantages
–  Amount tissue removal
–  Occlusion difficult with glazed porcelain
–  Appearance compared with ceramic
Gold Crowns
◆  Indications
–  Heavily restored / endo treated tooth
–  Correct occlusal plane
–  Provide contours for RPD
◆  Advantages
–  Strong
–  Retentive
Gold Crowns
◆  Contraindications
–  < Maximum retention required
–  Cosmetics
◆  Disadvantages
–  Amount tissue removal
–  Metal display
–  Vitality testing
Dimensions of the Preparation
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corrupted. Restart your computer, and then open the file again. If
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Light Transmission
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or the image may have been corrupted. Restart your computer, and then open the file again. If the
red x still appears, you may have to delete the image and then insert it again.
Gold Crowns
◆  Indications
–  Heavily restored / endo treated tooth
–  Correct occlusal plane
–  Provide contours for RPD
◆  Advantages
–  Strong
–  Retentive
Gold Crowns
◆  Contraindications
–  < Maximum retention required
–  Cosmetics
◆  Disadvantages
–  Amount tissue removal
–  Metal display
–  Vitality testing
Preparation
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x still appears, you may have to delete the image and then insert it again.
v  Visit ffofr.org for hundreds of
additional lectures on Complete
Dentures, Fixed Prosthodontics
Implant Dentistry, Removable
Partial Dentures, Esthetic
Dentistry and Maxillofacial
Prosthetics.
v  The lectures are free. 
v  Our objective is to create the
best and most comprehensive
online programs of instruction
in Prosthodontics

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Ceramics in fixed prosthodontics considerations for use in dental practice

  • 1. Karl Lyons! Department of Oral Rehabilitation! Faculty of Dentistry Ceramics  in  Fixed  Prosthodon2cs   Considera2ons  for  use  in  Dental  Prac2ce 1  
  • 3. Presentation Outline •  Ceramics in dentistry •  Types of ceramics •  Clinical indications and uses •  Case considerations •  Preparation designs •  Fitting and adjusting •  Cementation •  Longevity and causes of failure •  Alternatives •  Summary 3
  • 6. All Ceramic Crowns Zirconium Vs Leucite Reinforced Vs Metal-ceramic
  • 7. Light Dynamics in Natural Teeth Tooth colours are produced by the colour of the dentine and pulp reflecting through the enamel layer which is influenced by the amount of demineralisation
  • 8. Raptis et al. 2006 The Effect of Light Transmission Four crowns placed on tooth 11 Which two are PFM and which two are All-ceramic crowns?
  • 9. In-Ceram Spinell IPS Empress PFM PFM (with porcelain shoulder) Note how light is blocked by the metal copings Raptis et al. 2006
  • 11. Charles Land • Invented dental porcelain in 1886 • Granted Patent 1887 • Platinum foil matrix Land CH (1903) Porcelain dental art: No II. Dental Cosmos 45:615-620 John McLean & TJ Hughes • Replaced metal reinforcement with Alumina (Al2O3) to develop first all- ceramic core The reinforcement of dental porcelain with ceramic oxides. (1965) BDJ 119(6):251-267 Evolution of Ceramic Crowns
  • 12. Types of All-ceramic Monolithic crowns (1 layer) Bilayered crowns (2 layers - core & veneer) Eg: •  Feldspathic –CAD/CAM blocks •  Leucite reinforced – Empress I •  Lithium Disilicate – emax Press or CAD •  Zirconia (recently introduced) Eg: •  Lithium Disilicate •  Glass-infiltrated – In-Ceram Spinell •  Alumina •  Zirconia
  • 13. Three main types of ceramics in dentistry 1 1.  Predominantly glass •  Veneering porcelains for PFM and all-ceramics •  Most translucent – high aesthetics 2.  Particle-filled glass (Glass-ceramics) i.  High glass content •  Lost wax system (Dicor) [no longer available] •  Machinable feldspar-based ceramic (Vita Mark II blocks) •  Heat-pressed Leucite reinforced (Empress I) (Kelly 2008)
  • 14. Three main types of ceramics in dentistry 2 2.  Particle-filled glass (Glass-ceramics) ii.  Low glass content •  Heat-pressed or CAD/CAM Lithium Disilicate (IPS emax) •  Slip-cast or CAD/CAM Glass-infiltrated alumina (In-Ceram) 3.  Polycrystalline (Ceramic oxides) i.  Alumina Oxide (Procera Alumina) ii.  Zirconia (3mol%Y-TZP) (Procera Zirconia)
  • 16. Flexural Strength of CeramicsFractureToughness[KIC(MPa.m1/2)] Flexural Strength (MPa)
  • 17. Methods for Reinforcing Porcelain Metal-Oxides •  Aluminium Oxide •  Magnesium-Alumina Spinel •  Zirconium Oxide Leucite Lithium Disilicate • Dispersion strengthening • Phase transformation toughening
  • 18. VITABLOCS® Materials VITABLOCS Block Restoration Indication Mark II Inlays, onlays, anterior/posterior crown and veneer TriLuxe Anterior/posterior crown and veneer TriLuxe forte Anterior/posterior crown and veneer RealLife Anterior/posterior crown/ veneer for natural aesthetics
  • 19. Structural Ceramics •  Lithium disilicate •  Excellent translucency and aesthetics •  Inlays, onlays, veneers, crowns •  In-Ceram Spinel •  Excellent translucency and aesthetics •  Anterior crown substructure
  • 21. Structural Ceramics •  In-Ceram Alumina •  Good combination of strength and aesthetics •  Substructure for anterior crowns and 3-unit bridges •  In-Ceram Zirconia •  Very good strength •  Substructure for anterior and posterior crowns and 3-unit bridges
  • 23. Structural Ceramics •  In-Ceram AL •  Very good strength •  Substructure for anterior and 3-unit bridges and posterior crowns •  In-Ceram YZ •  Excellent strength •  Substructure for anterior and posterior crowns and multi-unit bridges
  • 24. Alumina and Zirconia •  The increase in crystalline content in alumina and zirconia has: •  Improved the mechanical properties allowing all-ceramic crowns and bridges •  Is hard to machine and resistant to etching so resin bonding is a challenge
  • 27. Note the difference in shrinkage between pre- sintered and sintered substructure. Zirconia Images compliments Vita Zahnfabrik
  • 30. Overview of VITA In-Ceram® Ceramics
  • 31. Vita Enamic
 CAD/CAM Hybrid Ceramic
 product description from Vita •  For the first time, this innovative hybrid materials combines enormous strength with exceptional elasticity •  As a result, the material is perfectly suited for crown restorations and moreover allows to achieve reduced wall thicknesses for minimally invasive restorations •  Additionally, VITA ENAMIC excels by utmost reliability and precise and accurate milled restorations featuring high edge stability •  This tooth-colored hybrid material also exhibits tooth- like material properties and produces highly esthetic results thanks to its excellent translucency
  • 32. Ceramic network + Polymer network = Hybrid ceramic VITA ENAMIC: Dental hybrid ceramic! =! polymer-reinforced ceramic network Reinforced materials: (e.g. carbon, reinforced concrete)! = steel reinforced cement
  • 33. Common Ceramic Core Materials Amorphous glass - Veneering porcelains Glass ceramics (reinforced by crystalline phases) • Leucite reinforced - Empress I • Lithium disilicate - Empress II • Magnesium aluminium oxide - In-Ceram Spinnell • Feldspathic Glass - Vita Mark II Blocks Glass infiltrated mixtures • In-Ceram alumina • In-Ceram zirconia Polycrystalline • Alumina - Procera • Zirconia - Lava, Everest, Cercon, Procera, Zeno, Ivoclar etc
  • 34. 1.  Amorphous glass – Vita Mark II 2.  Crystalline glass ceramics (reinforced by crystalline phases) 1.  Leucite reinforced - Empress I 2.  Lithium disilicate - Empress II 3.  Glass infiltrated mixture 1.  Magnesium Aluminium Oxide - Spinell 2.  InCeram alumina 3.  InCeram zirconia 4.  Polycrystalline 1.  Alumina - Procera 2.  Zirconia – Lava
  • 35. All-Ceramic Material Type! Aesthetic Properties! Applications! Feldspathic Glass (predominantly glass) Intrinsically tooth coloured Anterior veneers & crowns Can be stained & glazed Crystalline Ceramics (particle-filled glass - high glass content) Intrinsically tooth coloured Anterior veneers & crowns Can be stained & glazed Glass Infiltrated Mixtures (particle-filled glass – low glass content) Core material Core can be pigmented Anterior and posterior crowns Are veneered with porcelain Polycrystalline Ceramics (no glass content) Core material Core can be pigmented Anterior and posterior crowns & bridges Are veneered with porcelain
  • 36. 10! 8! 6! 4! 2! 0! 200! 400! 600! 800! 1000!0! FractureToughness(MPam1/2) Bending Strength (MPa) Filser et al., Quintessenz Zahntechnik 28, 1, 48-60 (2002) Empress 1 Dicor MGC In-Ceram Spinell In-Ceram Zirconia In-Ceram Alumina Zirconium oxide e.g. Zeno ZR IPS Empress 2 Glass Ceramics Crystalline Glass Ceramics Aluminium Oxide Zirconia Vita Mark II Aluminium Oxide Procera Anterior Crown Anterior Bridge All Restorations
  • 37. Types of Ceramic Crowns Sintered porcelain •  Feldspathic, Alumina or Leucite-reinforced Slip cast glass infused ceramic •  In-Ceram - Alumina, Spinell or Zirconia Heat pressed ceramic - Leucite or Lithium disilicate •  IPS Empress, IPS Empress 2 •  Pentron OPC, Pentron OPC 3G •  Finesse All-Ceramic Machined glass ceramic (eg CEREC 3, CEREC inLab) •  Chair-side - VitaBlocs Mark II, ProCAD •  Lab-milled - In-Ceram 2000, IPS e.max CAD, IPS Empress CAD Machined densely sintered ceramic - Alumina, Zirconia •  Procera, Lava, Everest, e.max ZirCAD
  • 39. •  Feldspathic, Alumina & Leucite-Reinforced •  Flexural Strengths •  55 – 75MPa (feldspar) •  90 – 120MPa (alumina) •  105 – 160MPa (leucite) •  Clinical Survival Rates •  Aluminous 73% over 5 years •  Leucite •  Anteriors 97% over 3 years •  Posteriors 76% over 5 years Hankinson & Cappetta 1994; Etemadi & Smales 2006 Sintered Porcelain Crowns
  • 41. • In-Ceram: Alumina, Spinell & Zirconia • Flexural strengths • ~400MPa (Spinell) • ~500MPa (Alumina) • ~600MPa (Zirconia) • Clinical survival rates • In-Ceram Alumina & Spinell = 92% to 100% over 5 yrs • In-Ceram Zirconia = 3-unit FPD 95% over 3 yrs Wasserman et al. 2006 Slip-Cast Glass Infused Ceramics
  • 42. Slip Casting Technique Images compliments Vita Zahnfabrik
  • 44. IPS Empress, IPS Empress 2, Pentron OPC, Pentron OPC 3G, Finesse All-Ceramic • Flexural strengths - Leucite, Lithium disilicate • 140 – 200MPa (Leucite) • 350 – 450MPa (Li2O•2SiO2) •  Clinical survival rates •  Leucite 92% to 99% for anteriors over 3.5 years •  Lithium disilicate 100% over 50 months (n=27) Chadwick 2004; Marquadt 2006 Heat-Pressed Ceramic Crowns
  • 47. eg CEREC 3, CEREC inLab •  Chair-side - VitaBlocs Mark II, ProCAD: •  Lab-milled - In-Ceram 2000, IPS e.max CAD, IPS Empress CAD: • Industrially fabricated - stronger and more reliable • Clinical survival rates • Feldspathic-milled = 94% over 5 years (n=17, anterior) Bindl & Mormann 2004 Machined Glass-Ceramic Crowns
  • 49. Machined Densely Sintered Crowns • Alumina, Zirconia, Zircon • Procera, Lava, Everest, e.max ZirCAD • Flexural strengths • 600MPa (Alumina) • 700 - 820MPa (Zircon) • 850 - 1050MPa (Zirconia) • Clinical survival rates • Procera Alumina 92% at 10 years • Zirconia FPDs 100% of frameworks at 3 years Odman & Andersson 2001; Sailer et al. 2006
  • 52. Systematic Review 
 Goodacre et al 2003! Mean fracture rate for all-ceramic crowns increases as you move posteriorly Anteriors 3% Premolars 7% Molars 21% This review did not distinguish between: •  fracture modes (core or veneer chipping) •  or types of ceramic systems
  • 53. Systematic Review
 Pjetursson et al 2007 - All-ceramic vs PFM crowns 5yr survival rates: PFM 95.6% All-ceramic 93.3% 85% of all-ceramic crowns failures due to core fracture Chipping usually repairable Anteriors: All-ceramics = PFM Posteriors: Material dependent ü  Alumina oxide 95% ü  Reinforced glass ceramics (Empress) 94% ²  In-Ceram 90% ²  Glass-ceramics (Dicor) 85%
  • 54. Systematic Review
 Wang et al 2012 - All-ceramic single crowns 5 yr Fracture rate: (veneer + core) all systems Overall 7.7% Posteriors 10% Anterior teeth 4.4% Core fracture: Overall 7.2% Posteriors 9.5% Anteriors 3.9% Veneer chipping: Overall 3% Molars 3% Premolars 1.5% Canines 2.5% Incisors 2% No clear difference found Statistically significant Statistically significant
  • 55. Systematic Review
 Sailer et al 2007 - fixed partial dentures 5yr survival rates: Metal-ceramic FPDs 94.4% All-ceramic FPDs 88.6% Frequency of: core # veneer # Metal-ceramic FPDs 1.6% 2.9% All-ceramic FPDs 6.5% 13.6% Mainly Lithium disilicate and In-Ceram Rare in zirconia FPD Annual rate: Zirconia 1.98 – 12.2 Empress/emaxP 0.83 – 1.55 In-Ceram no chipping reported
  • 56. Recommended Indications
 Class 1 Ceramics •  Aesthetic ceramic for coverage of a metal or ceramic subsurface and/or •  Aesthetic ceramic for single-unit anterior, veneers, inlays, or onlays Example IPS Empress, IPS e.max Ceram (Ivoclar) Della Bona, 2009
  • 57. Recommended Indications
 Class 2 Ceramics •  Aesthetic ceramic for adhesively cemented, single unit, anterior or posterior prostheses and/or •  Adhesively cemented, substructure ceramic for single-unit anterior or posterior prostheses Example IPS Empress (Ivoclar), Cerec MkII (Vita) Della Bona, 2009
  • 58. Recommended Indications
 Class 3 Ceramics •  Aesthetic ceramic for non-adhesively cemented, single-unit, anterior or posterior prostheses Example IPS e.max Press or CAD (Ivoclar) Della Bona, 2009
  • 59. Recommended Indications
 Class 4 Ceramics •  Substructure ceramic for non-adhesively cemented, single-unit, anterior or posterior prostheses and/or •  Substructure ceramic for three-unit prostheses not including molar restoration •  Example IPS Empress 2, (Ivoclar), Cerec MkII (Vita) Della Bona, 2009
  • 60. Factors that Influence Ceramics •  Ceramics are susceptible to chemical corrosion and fatigue mechanisms •  This reduces their lifetime •  Unfavourable oral conditions include: •  Chewing forces from 100-700 N •  Moist environment at 37ºC •  Small contact area; stresses generated 3.5-890 MPa Della Bona, 2009
  • 61. Survival of Ceramics To improve mechanical behaviour of ceramics •  Select the ceramic considering location •  Consider substructure similar to metal for PFM •  Minimise surface roughness •  Rougher surfaces have more cracks so need fewer cycles of stress to fail •  Chemical interaction between ceramic (crack tips) and environment (water) results in accelerated crack growth due to stress corrosion Della Bona, 2009
  • 62. Considerations 
 in Fixed Prosthodontics
  • 63. Considerations in Fixed Prosthodontics 3 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
  • 64. Crown Margin The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
  • 65. Length of Edentulous Span 1 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
  • 66. Length of Edentulous Span 2 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
  • 67. Minimum occlusogingival and buccolingual connector dimensions as a function of position of the bridge connector and occlusal forces!
  • 70. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Ceramic Crown Form The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
  • 73. Bonding Ceramic Crowns •  The crystalline content in alumina and zirconia is resistant to etching so bonding is a challenge •  Silica coating systems (eg Rocatec and Cojet, 3M ESPE) creates a silica layer •  High-speed surface impact of silica-modified alumina particles promotes resin bonding by: •  Rough surface allowing micromechanical bonding to resin •  Promotes a chemical bond between the silanated silica coated ceramic and the resin bond material
  • 74. Bonding Strategies to Teeth and Restorative Materials
  • 76. Material properties: Strength Strength is probably the most advertised property in the dental literature.
  • 77. 0 200 400 600 800 1000 1200 Zirconia Aluminium Oxide Lithium Disilicate - Hot Press Lithium Disilicate - CAD/CAM Magnesium Alliminium Oxide - Spinell Leucite Reinforced Feldspathic Glass Zirconia Aluminium Oxide Lithium Disilicate - Hot Press Lithium Disilicate - CAD/CAM Magnesium Alliminium Oxide - Spinell Leucite Reinforced Feldspathic Glass Series1 1100 620 470 350 400 175 80 Flexural Strength of All-Ceramic Materials in MPa Series1 Shinogaya et al, 2001, Clin Oral Invest 5:63-68
  • 79. Failure  Classifica2on Biological failures •  Secondary caries Aesthetic failure •  Restoration contours, value, hue, chroma Mechanical failures •  Cracking •  Chipping fracture (veneering porcelain fracture) •  Bulk fracture (core substructure fracture) •  Debonding of the prosthesis
  • 80. Mechanical Failures •  Cracking •  Chipping of veneering porcelain •  Cohesive chipping •  Adhesive delamination •  Bulk fracture (core substructure fracture) Transilumination Veneer porcelain chipping ! Delamination ! Core fracture!
  • 81. Use Transillumination for Quality Control
  • 82. Custom Fabrication •  All-ceramic restorations are custom-fabricated increasing susceptibility to fabrication defects •  Variety of techniques •  Sintering •  Heat-pressing •  Slip-casting •  CAD/CAM •  Combined with staining or veneering step Each technique produces fabrication defects [from Janine Tiu]
  • 83. Diamond grinding is a major source of failure-inducing flaws in dense ceramics. (Rice 2002) Zirconia CAD/CAM machining creates damage that is not fully healed by sintering process. (Kim et al 2010) Effects of Abrasive Grinding Thermal shock
  • 84. Characteristic Trace Lines After CAD/CAM Machining! Lava! Procera Zr! Everest (KaVo)! DCS Zirkon!
  • 85. Veneer Chipping in Zirconia-based Restorations Systematic reviews confirm chipping of veneering ceramic is the most frequent complication More common than with metal-ceramic or other all- ceramic restorations (Al-Amleh et al 2010, Hientz et al 2010, Schley et al 2010, Raigrodski et al 2012)
  • 86. Al-Amleh et al 2010 “Clinical trials in zirconia: A systematic review Summary: •  17 clinical trials based on 3Y-TZP •  Posterior FPD 13 studies •  Single crowns 2 studies •  Implant abutments 2 studies •  8 brands of zirconia •  Longest trial 5yrs (only 2 studies) Chipping of veneering porcelain •  Two of 15 studies did not report chipping •  Was common for all brands •  Incidence ranged from 0 – 54% •  Not always noticed by patients – incidental finding •  Also found at non-load bearing areas
  • 87. 8 17
  • 88. Difference between thermal conductivity between metal substructure and YZr substructure
  • 89. Reasons for Zirconia Veneer Chipping High tensile residual stresses locked within the veneering porcelain (Swain 2009) Zirconia is a very poor thermal conductor: •  Gold: 315 W/m-K •  Alumina: 40 W/m-K •  Zirconia: 2 W/m-K Substructure core design •  Cap-like core do not support veneering porcelain •  Suggested “PFM-style” cut back method [Tholey, Swain & Thiel 2011]
  • 90. PFMs cool from the inside to the outside producing systematic compression bonding from the inside to the outside. YZr crowns cool from both the inside and the outside at a similar rate resulting in a compression layer in the outer veneer and YZr coping, and an inner zone of tension within the porcelain veneer. W/(m.K), of a gold coping = 315 W/(m.K), of a zirconia coping = 2 Thermal conductivity, W/(m.K), of porcelain = 1.4 Zone of tension
  • 91. Loading Zirconia Crowns to Failure 
 fast cooled v slow cooled Procera Zirconia IPS e.max ZirPress Al-Amleh 2011
  • 92. Fast Cooled Samples Common features: •  Midline fissure crack •  Cracking on mesial non-loaded side •  Average 902 N
  • 93. Fracture after 2 days Courtesy: Dr. L. Gruetter (University of Geneva)
  • 94. Courtesy : Dr. L. Grütter (University of Geneva) Occlusal contact point responsible for shearing off veneering ceramic
  • 95. 1. Clean (cotton pellet with alcohol), rinse & dry 2. Inject siloxane impression material (light body) 3. Cover the whole crown with silicon material Procera Alumina AllCeram (veneering ceramic failure after 4 years)
  • 96. Zirconia Abutment Fracture Case description: 1. The zirconia implant abutment was screwed in tightly 2. Contact points M, D, were adjusted in situ 3. On the first bite for occlusal adjustment the crown fractured
  • 97. Zirconia abutment CARES (Straumann) Zirconia Abutment Try-in Failure The first bite to check the occlusion created a stress concentration at the distal margin (white arrow). The crack path is marked by the red arrows and result in the crown splitting in half. origin Ø  Fabrication defect
  • 98. Cercon 6-unit bridge failure after 24 hours FPD Bulk (core) Fracture
  • 99. Poor framework design •  Not enough palatal clearance •  Thin tip zirconia framework Both cause high stress concentrations Take home message: Always try-in zirconia frameworks before veneering
  • 100. All zirconia copings were rejected
  • 101. No substructure support Adequate substructure support allows for natural occlusal morphology
  • 102. Procera Alumina All-Ceram (veneering ceramic failure after 4 years)
  • 103. origi n Conclusion from the replica SEM analysis: The origin of the failure was located on the occlusal-palatal cusp (wear facette). The crack continued along the arrows downwards (interproximally) to the gingiva without reaching the margins. The veneering porcelain was unsufficiently supported by the alumina core
  • 104. Guidelines for Restoring Chipped ! All-ceramic Restorations Grade 1: Fracture surface can be polished Grade 2: Fracture surface can be repaired with composite resin Grade 3: Severe fracture requires restoration replacement 1.  Fracture extends into a functional area and repair is not feasible 2.  Re-contouring will result in a significant unacceptable alteration of the anatomic form from the original anatomy 3.  Re-contouring will significantly increase the risk of pulp trauma by the generation of heat 4.  Repair with resin composite will result in unacceptable aesthetic result (Heintze & Rousson 2010, Anusavice 2012)
  • 105. Success or Failure? •  Is a chipped all-ceramic restoration a failed restoration? •  Restoration success is defined as the demonstrated ability of a restoration to perform as expected •  Acceptable surface quality •  Anatomic contour •  Function •  Aesthetics (where applicable) •  When should we repair or replace the entire restoration? •  Restoration failure may be defined as any condition that leads to replacement of a prosthesis •  Why do all-ceramic fracture? •  How can we minimise this problem?
  • 106. Origins of Fracture •  Fabrication flaws of various shapes and sizes includes: •  Pores Micro-cracks •  Macro-cracks •  Machining grooves •  Air-abrasion surface defects •  Grinding adjustments surface defects •  Location of the defect under tensile stresses is important •  Thermal residual stresses •  Subcritical crack growth (SCCG) •  In humid environment, cracks grow slowly but continuously Weakest link
  • 107. Early v Late Fractures •  Immediate failure or within a few hours or days of cementation is likely to originate from a major processing flaw (Schmitter et al 2009, Lohbauer et al 2010) •  Failure after a few years is likely to involve subcritical crack growth and/or cyclic fatigue SCCG and/or cyclic fatigue
  • 108. Most important factor affecting fracture rates: Position of restoration in the mouth Ferrario et al 2004 Greatest forces Molars > premolars > incisors (1/3-1/4 of molars load)
  • 109. Surface area of incisal edge of anteriors and occlusal table of posteriors?
  • 110. A F =σ Occlusal contacts on natural teeth are point contacts
  • 111. Causes of Ceramic Substructure Failure •  Fracture initiating in the connector area •  Connector high stress area •  Chipping of the veneering material •  Residual stresses at the core-veneer interface •  Differences in thermal conduction between the core and veneer •  Thick veneer layer •  Poor bonding between the core and veneer ceramic •  Sliding occlusal contacts more damaging than axial contacts
  • 112. Summary •  Stronger ceramics are more opaque than aesthetic ceramics •  Aesthetic restorations without much structural need – use single layer (monolithic) ceramics •  High strength needed, less aesthetic ceramics veneers with tooth coloured porcelain •  Any ceramic system suitable for veneers and anterior crowns •  Only a few ceramics successful for restoring molars •  Need to consider other clinical factors such as adequate preparation depth and cementation
  • 113. Summary •  No equivalent long-term data as for PFMs •  ~75% at 15 years •  Many ceramics >90% after 5 years •  Reasonable evidence available for anterior 3- unit FPDs in lithium disilicate, In-Ceram Alumina and Zirconia •  Posterior 3-unit FPDs only zirconia indicated •  Chipping and fracture a problem •  Higher success when ceramics bonded to teeth using resin cement rather than GIC •  Use a silica coating system or primers for acid resistant ceramics such as zirconia
  • 115. Summary of Ceramics Recommendations Based on Peer Review Literature
  • 116. Ceramics Aluminous Core Slip Cast - In-Ceram Hot Pressed - Empress Machined - Cerec , Procera
  • 117. Ceramics
 Slip Cast •  Build-up with core particles and fired •  High Strength •  Highly Abrasive •  Fair Marginal Fit –  In-Ceram: crowns –  In-Ceram Spinell: crowns (more translucent) –  In-Ceram Zirconia: 3 unit FPD’s
  • 118. In Ceram The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
  • 119. What is Slip Casting?
  • 121. Ceramics
 Hot-Pressed •  Medium to High Strength •  Low to Medium Abrasive •  Medium Translucency •  Fair Marginal Fit –  Empress & Finesse (leucite) ✦  veneers, inlays, onlays, crowns –  Empress 2 (lithium disilicate) ✦  crowns, 3-unit FPD’s
  • 122. What is Hot Pressed? Lost wax casting via pressed ceramic.
  • 128. Ceramics
 Machined (CAD/CAM) •  Medium to Very High Strength •  Low to Medium Abrasive •  Fair Marginal Fit •  Industrial CAD/CAM –  Procera: crowns, FPDs •  In-office CAD/CAM –  Cerec: inlays –  Cerec 2 & 3: inlays, onlays, crowns
  • 129. IPS e.max KIc= 2.75 MPa√m KIc= 2.25 MPa√m LiO2 - SiO2 (lithium disilicate) S = 450 MPa S = 360 MPa T° = 850°CT° = 915-920°C
  • 130. Images compliments Vita Zahnfabrik VITA In-Ceram® SPINELL
  • 131. VITA In-Ceram® ALUMINA Images compliments Vita Zahnfabrik
  • 132. VITA In-Ceram® ZIRCONIA Images compliments Vita Zahnfabrik
  • 133. What is CAD/CAM ? Computer Aided Design / Computer Aided Manufacture CEREC® 3 inLab von Sirona inEos von Sirona
  • 138. © Praxisfall Dr. Gunpei Koike (Japan) CAD/CAM
  • 139. © Praxisfall Dr. Gunpei Koike (Japan) CAD/CAM
  • 141. © Praxisfall Dr. Gunpei Koike (Japan) CAD/CAM
  • 143. All Ceramic Crowns •  Indications –  High cosmetic demand –  Incisal edge reasonably intact –  Favourable occlusion •  Advantages –  Cosmetics –  Good tissue response –  More conservative on labial
  • 144. All Ceramic Crowns •  Contraindications –  High strength required –  Insufficient tooth structure for support –  Unfavourable occlusion •  Disadvantages –  Reduced strength –  Not conservative –  Brittle –  Single crowns only
  • 145. Types of crowns Full gold crown (FGC) Porcelain fused to metal (PFM) All ceramic
  • 146. Affect of the Metal Coping The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
  • 147. Ceramic Crown Form 1 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
  • 148. Occlusal Considerations The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
  • 150. Tooth Preparation 1 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
  • 151. Tooth Preparation 2 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
  • 152. All-ceramics and Metal-ceramics •  The need to simulate in dental porcelains the light behaviour and appearance of the natural tooth •  Create the illusion of nature within limited space constraints and light blocking effect of the metal substructure or ceramic substructure Yamamoto 1985 Yamamoto 1985
  • 154. Metal Ceramic Crowns ◆  Indications –  Heavily restored / endodontically treated tooth –  Cosmetics –  When ceramic crowns not possible ◆  Advantages –  Appearance compared with FGC –  Retentive
  • 155. Metal Ceramic Crowns ◆  Contraindications –  Large pulp chamber –  Intact buccal wall –  More conservative restoration possible ◆  Disadvantages –  Amount tissue removal –  Occlusion difficult with glazed porcelain –  Appearance compared with ceramic
  • 156. Gold Crowns ◆  Indications –  Heavily restored / endo treated tooth –  Correct occlusal plane –  Provide contours for RPD ◆  Advantages –  Strong –  Retentive
  • 157. Gold Crowns ◆  Contraindications –  < Maximum retention required –  Cosmetics ◆  Disadvantages –  Amount tissue removal –  Metal display –  Vitality testing
  • 158. Dimensions of the Preparation The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
  • 159. Light Transmission The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
  • 160. Gold Crowns ◆  Indications –  Heavily restored / endo treated tooth –  Correct occlusal plane –  Provide contours for RPD ◆  Advantages –  Strong –  Retentive
  • 161. Gold Crowns ◆  Contraindications –  < Maximum retention required –  Cosmetics ◆  Disadvantages –  Amount tissue removal –  Metal display –  Vitality testing
  • 162. Preparation The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
  • 163. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
  • 164. v  Visit ffofr.org for hundreds of additional lectures on Complete Dentures, Fixed Prosthodontics Implant Dentistry, Removable Partial Dentures, Esthetic Dentistry and Maxillofacial Prosthetics. v  The lectures are free. v  Our objective is to create the best and most comprehensive online programs of instruction in Prosthodontics