Clinical Implications

This investigation supports the view that successful applica-

tion of all-ceramic materials depends on the clinicians ability
to select the appropriate material, manufacturing technique,
and cementation or bonding procedures, to match intraoral
conditions and esthetic requirements.
Statement of problem. Developments in ceramic core materials such as lithium disilicate, aluminum oxide, and
zirconium oxide have allowed more widespread application of all-ceramic restorations over the past 10 years. With
a plethora of ceramic materials and systems currently available for use, an overview of the scientific literature on the
efficacy of this treatment therapy is indicated.
Purpose. This article reviews the current literature covering all-ceramic materials and systems, with respect to survival,
material properties, marginal and internal fit, cementation and bonding, and color and esthetics, and provides clinical
recommendations for their use.
Material and methods. A comprehensive review of the literature was completed seeking evidence for the treatment of
teeth with all-ceramic restorations. A search of English language peer-reviewed literature was undertaken using MED-
LINE and PubMed with a focus on evidence-based research articles published between 1996 and 2006. A hand search
of relevant dental journals was also completed. Randomized controlled trials, nonrandomized controlled studies,
longitudinal experimental clinical studies, longitudinal prospective studies, and longitudinal retrospective studies were
reviewed. The last search was conducted on June 12, 2007. Data supporting the clinical application of all-ceramic
materials and systems was sought.
Results. The literature demonstrates that multiple all-ceramic materials and systems are currently available for clinical
use, and there is not a single universal material or system for all clinical situations. The successful application is depen-
dent upon the clinician to match the materials, manufacturing techniques, and cementation or bonding procedures,
with the individual clinical situation.
Conclusions. Within the scope of this systematic review, there is no evidence to support the universal application of
a single ceramic material and system for all clinical situations. Additional longitudinal clinical studies are required to
advance the development of ceramic materials and systems. (J Prosthet Dent 2007;98:389-404)
Current ceramic materials and systems
with clinical recommendations: A
systematic review
Heather J. Conrad, DMD, MS,
a
Wook-Jin Seong, DDS, MS,
PhD,
b
and Igor J. Pesun, DMD, MS
c
School of Dentistry, University of Minnesota, Minneapolis, Minn;
University of Manitoba, Winnipeg, Canada
a
Assistant Professor, Division of Prosthodontics, Department of Restorative Sciences, School of Dentistry, University of Minnesota.
b
Assistant Professor, Division of Prosthodontics, Department of Restorative Sciences, School of Dentistry, University of Minnesota.
c
Associate Professor, Department Head, Department of Restorative Dentistry, Faculty of Dentistry, University of Manitoba.
Conrad et al
Following the introduction of
the first feldspathic porcelain crown
by Land,
1
the interest and demand
for nonmetallic and biocompat-
ible restorative materials increased
for clinicians and patients. In 1965,
McLean
2
pioneered the concept of
adding Al
2
O
3
to feldspathic porcelain
to improve mechanical and physical
properties. The clinical shortcomings
of these materials, however, such as
brittleness, crack propagation, low
390 Volume 98 Issue 5
The Journal of Prosthetic Dentistry
popular,
10
patient demand for im-
proved esthetics has driven the devel-
opment of ceramic for use with inlays,
onlays, crowns, FPDPs, and implant-
supported restorations.
11
The use of
conservative ceramic inlay prepara-
tions with 5.5 to 27.2% tooth struc-
ture removal is increasing, along with
all-ceramic complete crown prepara-
tions, which are more invasive and
result in 67.5 to 72.3% tooth struc-
ture removal.
12
All-ceramic restora-
tions combining esthetic veneering
porcelains with strong ceramic cores
have become popular (Table I). Ve-
neering porcelains typically consist
of a glass and a crystalline phase of
fluoroapatite, aluminum oxide, or
leucite. Veneering a lithium-disilicate,
aluminum-oxide, or zirconium-oxide
core with glass allows dental techni-
cians to customize these restorations
in terms of form and esthetics.
13
The
most commonly reported major clini-
cal complication resulting in failure of
all-ceramic restorations is the fracture
of the veneering porcelain and/or the
coping (Table II).
3,14-30
The success
of these systems is dependent upon
preventing failure by retarding crack
propagation.
4,31-33
Expansion of the use of all-ce-
ramic systems for FPDPs has limita-
tions. Proper diagnosis and patient
selection are critical for success. A
minimum connector height of 3 to 4
Glass Ceramic
Lithium-disilicate
(SiO
2
-Li
2
O)
Leucite
(SiO
2
-Al
2
O
3
-K
2
O)
Feldspathic
(SiO
2
-Al
2
O
3
-Na
2
O-K
2
O)
Alumina
Aluminum-oxide
(Al
2
O
3
)
Zirconia
Yttrium tetragonal
zirconia polycrystals
(ZrO
2
stabilized by Y
2
O
3
)
Core Material
Heat pressed
Heat pressed
Heat pressed
Heat pressed
Milled
Milled
Milled
Milled
Slip-cast, milled
Milled
Milled
Slip-cast, millled
Densely sintered
Green milled, sintered
Green milled, sintered
Milled
Milled
Densely sintered, milled
Manufacturing
Techniques
Crowns, anterior FPDP
Onlays, 3/4 crowns, crowns, FPDP
Onlays, 3/4 crowns, crowns
Onlays, 3/4 crowns, crowns
Onlays, 3/4 crowns, crowns
Onlays, 3/4 crowns, crowns, veneers
Onlays, 3/4 crowns, crowns, veneers
Anterior crowns, veneers
Crowns, FPDP
Crowns
Onlays, 3/4 crowns, crowns
Crowns, posterior FPDP
Veneers, crowns, anterior FPDP
Crowns, FPDP
Crowns, FPDP
Crowns, FPDP
Onlays, 3/4 crowns, crowns
Crowns, FPDP, implant abutments
Clinical Indications
IPS Empress 2 (Ivoclar Vivadent,
Schaan, Liechtenstein)
IPS e.max Press (Ivoclar Vivadent)
IPS Empress (Ivoclar Vivadent)
Optimal Pressable Ceramic (Jeneric
Pentron, Wallingford, Conn)
IPS ProCAD (Ivoclar Vivadent)
VITABLOCS Mark II (VITA Zahnfabrik,
Bad Sackingen, Germany)
VITA TriLuxe Bloc (VITA Zahnfabrik)
VITABLOCS Esthetic Line (VITA Zahnfabrik)
In-Ceram Alumina (VITA Zahnfabrik)
In-Ceram Spinell (VITA Zahnfabrik)
Synthoceram (CICERO Dental Systems,
Hoorn, The Netherlands)
In-Ceram Zirconia (VITA Zahnfabrik)
Procera (Nobel Biocare AB,
Goteborg, Sweden)
Lava (3M ESPE, St. Paul, Minn)
Cercon (Dentsply Ceramco, York Pa)
DC-Zirkon (DCS Dental AG, Allschwil,
Switzerland)
Denzir (Decim AB, Skelleftea, Sweden)
Procera (Nobel Biocare AB)
System
Table I. Ceramic materials and systems and manufacturer-recommended clinical indications
Conrad et al
tensile strength, wear resistance, and
marginal accuracy, continued to limit
their use.
3
Although the first biomedi-
cal application of zirconia occurred in
1969,
4
the first paper regarding the
use of zirconia for the production of
artificial femoral heads was written
by Christel
5
in 1988. Applications
expanded into dentistry in the early
1990s and have included endodontic
posts, implants and implant abut-
ments, orthodontic brackets, cores
for crowns, and fixed partial denture
prosthesis (FPDP) frameworks.
6-9
Even though the combination of
predictable strength and reasonable
esthetics has continued to make tra-
ditional metal-ceramic restorations
391 November 2007
Table II. Classification of complications and overall survival rates
Raigrodski
37
Vult von Steyern
38
Fradeani
14
Oden
15
Odman
16
Wolfart
17
Frankenberger
18
Sjogren
3
Fradeani
19
Marquardt
20
Esquivel-Upshaw
21
Bindl
22
McLaren
23
Haselton
66
Study
Chipped veneer (5)
Endodontic therapy (1)
Marginal integrity (1)
Chipped veneer (3)
Endodontic therapy (1)
Chipped veneer (3)
Endodontic therapy (2)
Endodontic therapy (2)
Chipped veneer (2)
Caries (1)
Decementation (11)
Chipped/cracked veneer (5)
Caries (2)
Endodontic therapy (2)
Endodontic therapy (3)
Chipped veneer (1)
Marginal deficiences (94%)
Removal due to hypersensitivity (2)
Slight mismatch in color (13%)
Slightly rough surfaces (9%)
Endodontic therapy (2)
Caries (2)
(not reported)
(not reported)
(not reported)
Debonding of composition resin
foundation (1)
(not reported)
Caries (1)
Marginal integrity (1)
Chipped veneer (1)
Fracture (1)
Minor Complications
(Restorations Not Remade)
Reported Survival
Rates (Percent)
Major Complications
(Restorations Remade)
100
100
96.7 (100 anterior,
95.15 posterior)
97
93.5
100 (crown-retained FPDP)
89 (inlay-retained FPDP)
93
91
95.2 (98.9 anterior,
84.4 posterior)
100 (posterior crowns)
70 (anterior or premolar
FPDP)
93
100 (In-Ceram Spinell)
92 (In-Ceram Alumina)
96 (98 anterior,
94 posterior)
(not reported)
None
None
Fracture of veneer and/or coping (2)
Fracture or delamination of veneer (2)
Fracture of veneer and coping (3)
Fracture of veneer and coping (4)
Caries (1)
Debonding (3)
Debonding and fracture (3)
Fracture of veneer and coping (5)
Endodontic therapy (2)
Fracture (7)
Fracture (4)
Post and core fracture (1)
Root fracture (1)
Fracture (4)
Endodontic therapy (1)
Tooth fracture (1)
Fracture (2)
Fracture (2)
Fracture of core (4)
Fracture of veneer (2)
Removal without failure (3)
Marginal integrity (2)

Conrad et al
392 Volume 98 Issue 5
The Journal of Prosthetic Dentistry
mm from the interproximal papilla to
the marginal ridge is a guideline for
most systems.
7,8,17,21,25,34,35
Placement
is contraindicated when there is re-
duced interocclusal distance, as with
short clinical crowns, deep vertical
overlap anteriorly without horizontal
overlap, or an opposing supraerupted
tooth, as well as for cantilevers, peri-
odontally involved abutment teeth,
and patients with severe bruxism or
parafunctional activity.
7,21,36
The pri-
mary cause of failure varies from frac-
ture of the connector, for aluminum-
oxide FPDPs
24-26
and lithium-disilicate
FPDPs,
20,21
to cohesive fracture of the
veneering porcelain, for zirconia FP-
DPs.
37,38
Metal-ceramic FPDPs differ
in that they fail primarily due to tooth
fracture
39
and caries.
39,40
Following
the Law of Beams by maximizing con-
nector height and width is the basis
for proper design of all-ceramic FP-
DPs.
7,8,41
The purpose of this article is
to review current literature on all-ce-
ramic materials and systems, with re-
spect to survival, material properties,
marginal and internal fit, cementation
and bonding, and color and esthetics,
and suggest clinical recommendations
for their use.
MATERIAL AND METHODS
A broad systematic search of Eng-
lish peer-reviewed dental literature
was designed to identify evidence
supporting the restoration of teeth
with current all-ceramic materials
and systems. Key words or phrases
included crowns, dental porcelain,
ceramics, aluminum oxide, zirconium
oxide, dental cements, composite
resin cements, adhesives, computer-
aided design, color, dental restoration
failure, and dental prosthesis design.
MEDLINE and PubMed searches were
conducted focusing on evidence-
based research articles published be-
tween 1996 and 2006. The Journal of
Prosthetic Dentistry and the International
Journal of Prosthodontics were addition-
ally hand-searched for this review.
Titles and/or abstracts of articles
identified through the electronic
searches were reviewed and evaluated
for appropriateness. Suitable articles
were subjected to inclusion and exclu-
sion criteria. Randomized controlled
clinical trials, nonrandomized con-
trolled clinical studies, longitudinal
experimental clinical studies, longi-
tudinal prospective clinical studies,
and longitudinal retrospective clinical
studies were reviewed. Articles that
did not focus exclusively on the resto-
ration of teeth with all-ceramic mate-
rials and systems or the material prop-
erties of ceramics were excluded from
Table II. continued (2 of 2) Classification of complications and overall survival rates
Vult von Steyern
24
Olsson
25
Sorensen
26
Suarez
91
Probster
92
Fradeani
27
Pallesen
28
Otto
29
Malament
30
Scurria
93
Study
(not reported)
Fracture (external trauma) (2)
Decementation (1)
(not reported)
(not reported)
Caries (5)
Decementation (1)
Chipped veneer (2)
Chipped/cracked veneer (8)
Chipped veneer (3)
Caries (2)
Endodontic therapy (1)
(not reported)
Minor Complications
(Restorations Not Remade)
Reported Survival
Rates (Percent)
Major Complications
(Restorations Remade)
90
93
88.5 (100 anterior,
82.5 posterior)
94.5
100
97.5
90.6
90.4
87.5
95 (5 year)
85 (10 year)
67 (15 year)
Fracture (2)
Fracture (3)
Fracture (7)
Root fracture (1)
None
Fracture (1)
Fracture (3)
Fracture (5)
Tooth fracture (3)
Caries (1)
Fracture (180)
Conrad et al
393 November 2007
further evaluation. Nonpeer-reviewed
dental literature, abstracts, and clini-
cal reports were excluded from review.
Inclusion criteria for survival studies
included a minimum mean follow-up
period of 2 years, reporting of com-
plications, identification of materi-
als, type of study, setting, and sample
size. Data supporting the clinical ap-
plication of all-ceramic materials and
systems was sought.
RESULTS
A total of 285 articles were iden-
tified through the MEDLINE and
PubMed searches. Abstracts were
reviewed to confirm the articles met
the inclusion criteria. A total of 148
articles published between 1996 and
2006 were identified and read in their
entirety. Nineteen prospective and 4
retrospective clinical trials related to
survival were reviewed. The literature
demonstrated that multiple all-ce-
ramic materials and systems are cur-
rently available for clinical use and
there is not a single universal material
or system for all clinical situations.
The successful application of differ-
ent all-ceramic materials is dependent
upon clinicians ability to match the
ceramic materials to the manufactur-
ing techniques and cementation or
bonding procedures, to adequately
customize a treatment plan.
DISCUSSION

Glass ceramics
IPS Empress 2 (Ivoclar Vivadent,
Schaan, Liechtenstein) is a lithium-di-
silicate glass ceramic (SiO
2
-Li
2
O) that
is fabricated through a combination
of the lost-wax and heat-pressed tech-
niques. A glass-ceramic ingot of the
desired shade is plasticized at 920C
and pressed into an investment mold
under vacuum and pressure. Its pre-
decessor, IPS Empress (Ivoclar Viva-
dent), is a leucite-reinforced glass ce-
ramic (SiO
2
-Al
2
O
3
-K
2
O) which, due to
its strength, is limited in use to single-
unit complete-coverage restorations
in the anterior segment.
19
IPS Em-
press 2 has improved flexural strength
by a factor of 3 over IPS Empress,
can be used for 3-unit FPDPs in the
anterior area, and can extend to the
second premolar.
42-45
The framework
is veneered with fluoroapatite-based
veneering porcelain (IPS Eris; Ivoclar
Vivadent), resulting in a semitranslu-
cent restoration with enhanced light
transmission.
8,46,47
IPS e.max Press
(Ivoclar Vivadent) was introduced in
2005 as an improved press-ceramic
material compared to IPS Empress 2.
It also consists of a lithium-disilicate
pressed glass ceramic, but its physical
properties and translucency are im-
proved through a different firing pro-
cess.
48
IPS ProCAD (Ivoclar Vivadent)
is a leucite-reinforced ceramic similar
to IPS Empress, although it has a fin-
er particle size.
49
Introduced in 1998,
it is designed to be used with the
CEREC inLab system (Sirona Dental
Systems, Bensheim, Germany) and is
available in numerous shades, includ-
ing a bleached shade and an esthetic
block line.
49-52
Vita Mark II (VITA Zahnfabrik,
Bad Sackingen, Germany), a machin-
able feldspathic porcelain introduced
in 1991 for the CEREC 1 system (Sie-
mens AG, Bensheim, Germany), has
improved strength and finer grain size
(4 m) as compared to the Vita Mark
I.
28,49
It is primarily composed of SiO
2

(60-64%) and Al
2
O
3
(20-23%) and can
be etched with hydrofluoric acid to
create micromechanical retention for
adhesive cementation with compos-
ite resin cements.
49,53,54
Although this
product is monochromatic, it is avail-
able in multiple shades, including the
Classic Line Vita shades, Vitapan 3D-
Master Shades, VITABLOCS Esthetic
Line, and a bleached shade, and can
be additionally characterized.
49,55-58

To overcome esthetic disadvantages
of a monochromatic restoration and
to imitate optical effects of natural
teeth, a multicolored ceramic block
(Vita TriLuxe Bloc; VITA Zahnfabrik)
was designed to create a 3-dimension-
al layered structure.
59
The inner third
has a dark opaque base layer, while
the middle third has a neutral zone
comparable to the standard block,
and the outer third is more trans-
lucent. CEREC software allows the
operator to have some visual control
over the alignment of the restoration
within the multilayered block.
59,60
Another technique for fabricat-
ing feldspathic porcelain restorations
was through copy-milling (Celay; Mi-
krona Technologie AG, Spreitenbach,
Switzerland).
61,62
This system milled
restorations by duplicating a direct
acrylic resin pattern replica of an in-
lay, onlay, or crown coping. Unable
to approach the sophistication of the
digital systems (CEREC 3D; Sirona
Dental Systems), the Celay system is
now obsolete.
63
A major contributor
to the development of glass ceram-
ics was Dicor (Dentsply Intl, York,
Pa). This was a glass-ceramic mate-
rial composed of 70% tetrasilicic flu-
ormica crystals precipitated in 30%
glass matrix.
64
Originally made using
the lost-wax technique,
30,65
it was later
marketed as a machinable glass ce-
ramic
28,64
that is no longer available.

Alumina-based ceramics
In-Ceram Alumina (VITA Zahn-
fabrik), introduced in 1989, was the
first all-ceramic system available for
single-unit restorations and 3-unit an-
terior FPDPs.
66
It has a high strength
ceramic core fabricated through the
slip-casting technique.
67
A slurry of
densely packed (70-80 wt%) Al
2
O
3

is applied and sintered to a refrac-
tory die at 1120C for 10 hours.
63,68

This produces a porous skeleton of
alumina particles which is infiltrated
with lanthanum glass in a second fir-
ing at 1100C for 4 hours to elimi-
nate porosity, increase strength, and
limit potential sites for crack propa-
gation.
68
Compressive stresses which
further improve the strength are also
introduced, due to the differences in
the coefficient of thermal expansion
of the alumina and glass.
68
The cop-
ing is veneered with feldspathic porce-
lain.
22,66
Alumina blanks (VITABLOCS
In-Ceram Alumina; VITA Zahnfabrik)
Conrad et al
394 Volume 98 Issue 5
The Journal of Prosthetic Dentistry
are also available for milling in com-
bination with CEREC (Sirona Dental
Systems).
22,63
In 1994, In-Ceram Spinell (VITA
Zahnfabrik) was introduced as an al-
ternative to the opaque core of In-Ce-
ram Alumina. It contains a mixture of
magnesia and alumina (MgAl
2
O
4
) in
the framework to increase translucen-
cy
10,69
; however, its flexural-strength
is lower than that of In-Ceram Alu-
mina, and, thus, the cores are only
recommended for anterior crowns.
70

This material can also be machined
with the CEREC inLab system (Sirona
Dental Systems), followed by veneer-
ing with feldspathic porcelain.
22,57

Synthoceram (CICERO Dental Sys-
tems, Hoorn, The Netherlands) is a
high-strength glass-impregnated alu-
minum-oxide ceramic core fabricated
through CICERO technology (Com-
puter Integrated Ceramic Reconstruc-
tion).
71,72
Laser scanning, ceramic
sintering, and computer-integrated
milling techniques are used to fab-
ricate the cores, which are veneered
with a leucite-free glass ceramic.
54,71-73
In-Ceram Zirconia (VITA Zahnfab-
rik) is also a modification of the origi-
nal In-Ceram Alumina system, with an
addition of 35% partially stabilized zir-
conia oxide to the slip composition to
strengthen the ceramic.
67
Traditional
slip-casting techniques can be used
or the material can be copy-milled
from prefabricated, partially sintered
blanks and then veneered with feld-
spathic porcelain.
7,46,74
Since the core
is opaque and lacks translucency, the
material is recommended for poste-
rior crown copings and FPDP frame-
works.
7,67
Procera (Nobel Biocare AB, Gote-
borg, Sweden) was developed by An-
dersson and Oden with copings that
contain 99.9% high purity aluminum
oxide.
75
Combined with a low-fusing
veneering porcelain, Procera has the
highest strength of the alumina-based
materials and its strength is lower only
than zirconia.
14,15
A sapphire contact
probe is used to scan the working die
and to define the 3-dimensional shape
of the preparation.
54
The data is sent
electronically to a manufacturing fa-
cility where a 20% enlarged model
is copy-milled and used for the dry-
pressing technique.
14,45
High purity
aluminum-oxide powder is mechani-
cally compacted on the enlarged die
and sintered at 1550C, eliminating
porosity and returning the core to the
dimensions of the working die.
45,63,76

The crown form is completed by ve-
neering it with low-fusing feldspathic
porcelain matching the coefficient of
thermal expansion of aluminum ox-
ide.
14

Zirconia-based ceramics
Zirconia is a polymorphic material
that occurs in 3 forms. At its melting
point of 2680C, the cubic structure
exists and transforms into the te-
tragonal phase below 2370C.
4,77,78

The tetragonal-to-monoclinic phase
transformation occurs below 1170C
and is accompanied by a 3-5% volume
expansion which causes high internal
stresses.
32,77,78
Yttrium-oxide (Y
2
O
3

3% mol) is added to pure zirconia to
control the volume expansion and to
stabilize it in the tetragonal phase at
room temperature.
33
This partially
stabilized zirconia has high initial
flexural strength and fracture tough-
ness.
33
Tensile stresses at a crack tip
will cause the tetragonal phase to
transform into the monoclinic phase
with an associated 3-5% localized ex-
pansion.
32
The volume increase cre-
ates compressive stresses at the crack
tip that counteract the external tensile
stresses. This phenomenon is known
as transformation toughening and re-
tards crack propagation. In the pres-
ence of higher stress, a crack can still
propagate. The toughening mecha-
nism does not prevent the progres-
sion of a crack, it just makes it harder
for the crack to propagate.
4,8,32,33,79
Yttrium-oxide partially stabilized
zirconia (Y-TZP) has mechanical prop-
erties that are attractive for restorative
dentistry; namely, its chemical and di-
mensional stability, high mechanical
strength, and fracture-toughness.
13

The cores have a radiopacity com-
parable to metal which enhances
radiographic evaluation of marginal
integrity, excess cement removal, and
recurrent decay.
8
Y-TZP can be manufactured in 2
methods through computer-aided
design/computer-aided manufactur-
ing (CAD/CAM) technology. First, an
enlarged coping/framework can be
designed and milled from a homog-
enous ceramic soft green body blank
of zirconia.
80
The framework structure
has a linear shrinkage of 20-25% dur-
ing sintering until it reaches the de-
sired final dimensions.
6,9
Processing
with this softer presintered material
not only shortens the milling time,
but also reduces the wear on the mill-
ing tools.
6
Although zirconia frame-
works can be milled directly from a
fully sintered prefabricated blank in
the final dimensions,
6,80
milling fully
sintered zirconia may compromise the
microstructure and strength of the
material.
81,82
Lava (3M ESPE, St. Paul, Minn)
uses a Y-TZP framework with high flex-
ural strength, high fracture toughness,
and low elastic modulus compared to
alumina, and exhibits transformation
toughening when subjected to tensile
stress.
4,33
A die is scanned by a con-
tact-free optical process for 5 minutes
for a crown and 12 minutes for a 3-
unit FPDP. The CAD software designs
an enlarged framework that is milled
from softer presintered blanks. After
35 minutes of milling for a crown and
75 minutes for a 3-unit FPDP, the
framework can be colored in 1 of 7
shades, followed by sintering in a spe-
cial automated oven for 8 hours.
6
Other CAD/CAM systems are also
available for designing and milling zir-
conia restorations. Cercon (Dentsply
Ceramco, York, Pa) requires conven-
tional waxing techniques to design the
Y-TZP framework, and the wax pattern
is scanned.
7
DCS Precident (DCS Den-
tal AG, Allschwil, Switzerland) uses
fully sintered DC Zirkon ceramic con-
taining 95% ZrO
2
partially stabilized
with 5% Y
2
O
3
.
7,83,84
Denzir (Decim AB,
Skelleftea, Sweden) designs and mills
ceramic inlays from yttrium-oxide
Conrad et al
395 November 2007
partially sintered blocks.
67,85,86
Although the first all-ceramic im-
plant abutments (CerAdapt; Nobel
Biocare AB) were made of densely
sintered, high purity alumina,
87,88

zirconia implant abutments with or
without a metal interface (Procera
Zirconia Abutment; Nobel Biocare
AB; Atlantis Abutment in Zirconia;
Zimmer Dental, Carlsbad, Calif;
Straumann Zirconia Custom Abut-
ment; Straumann USA, Andover,
Mass; Zirconia Abutment; Astra Tech
Inc, Waltham, Mass; and ZiReal Post;
Biomet 3i, Palm Beach Gardens, Fla)
are now recommended instead of alu-
mina due to their increased mechani-
cal properties.
87,88
Abutments are
either customized through electronic
data or are stock abutments which
can be modified via conventional
preparation. Dental and mucogingival
esthetics can be improved for single
implant restorations by eliminating
any metal display.
89,90

Survival
When considering the restoration
of teeth with all-ceramic materials,
survival data is important to evaluate
the effectiveness of different treatment
strategies. Comparing the results from
relevant literature is challenging due
to the availability of different ceram-
ic materials and systems, reporting
of complications, study conditions,
and evaluation times; these varying
factors make it difficult to assess the
overall effectiveness of therapy. Inclu-
sion criteria for the reviewed studies
included a minimum mean follow-up
period of 2 years, reporting of com-
plications, identification of materials,
type of study, setting, and sample size
(Tables II and III).
Fracture of the veneering porce-
lain and/or ceramic coping is objec-
tive and the most commonly reported
major complication requiring remak-
ing of the restoration.
3,14-28,30
Although
2 groups of investigators considered
caries a major complication requiring
refabrication of the restoration in 1
instance, they considered it a minor
complication that did not require re-
fabrication for 2 other restorations in
the study.
16,29
Two groups of investiga-
tors reported endodontic therapy as a
major complication,
18,20
while 4 oth-
ers reported root or tooth fracture as
a major complication.
19,20,29,91
Several of the reported compli-
cations were considered minor and
did not require remaking of the res-
toration. The most common minor
complication reported was chipping
or cracking limited to the veneering
porcelain (reported for 33 restora-
tions),
14-17,27-29,37,38,66
followed by end-
odontic therapy (n=14),
3,14-17,29,37,38

decementation (n=13),
16,25,92
and
Table III. Study details, including material and restoration type
Raigrodski
37
Vult von Steyern
38
Fradeani
14
Oden
15
Odman
16
Wolfart
17
Frankenberger
18
Sjogren
3
Fradeani
19
Marquardt
20
Esquivel-Upshaw
21
Study
Type of
Restoration Material
Lava
DC-Zirkon
Procera (alumina)
Procera (alumina)
Procera (alumina)
IPS e.max Press
IPS Empress
IPS Empress
IPS Empress
IPS Empress 2
IPS Empress 2
FPDPs
FPDPs
Crowns
Crowns
Crowns
Crown-retained
FPDP
Inlay-retained
FPDP
Inlays, onlays
Crowns,
3/4 crowns
Crowns
Crowns
FPDPs
FPDPs
Type of
Study
Prospective
Prospective
Prospective
Prospective
Prospective
Prospective
Prospective
Retrospective
Retrospective
Prospective
Prospective
Sample
Size
20
23
205
100
87
36
45
96
110
125
27
31
30
Mean
(Years)
2.6
2
2
5
(not reported)
4
3.1
(not reported)
3.6
(not reported)
(not reported)
(not reported)
Range
(Years)
1.5-3
2
0.5-5
(not reported)
5-10.5
2.5-4.6
1.7-5
1-6
1.4-5.1
4-11
2.75-5.1
1-2
Study
University
University
Private practice
Private Practice
Multicenter
University
University
Private practice
Private practice
University
University
Conrad et al
396 Volume 98 Issue 5
The Journal of Prosthetic Dentistry
Table III. continued (2 of 2) Study details, including material and restoration type
Bindl
22
McLaren
23
Haselton
66
Vult von Steyern
24
Olsson
25
Sorensen
26
Suarez
91
Probster
92
Fradeani
27
Pallesen
28
Otto
29
Malament
30
Scurria
93
Study
Type of
Restoration Material
In-Ceram Spinell
In-Ceram Alumina
In-Ceram Alumina
In-Ceram Alumina
In-Ceram Alumina
In-Ceram Alumina
In-Ceram Alumina
In-Ceram Zirconia
In-Ceram Alumina
In-Ceram Spinell
Vita Mark II,
Dicor
Vita Mark I
Dicor
Metal-ceramic
Crowns
Crowns
Crowns
FPDPs
FPDPs
FPDPs
FPDPs
Crowns
Crowns
Inlays
Inlays, onlays
Crowns, inlays,
onlays
FPDPs
Type of
Study
Prospective
Prospective
Retrospective
Prospective
Retrospective
Prospective
Prospective
Prospective
Prospective
Prospective
Prospective
Prospective
Meta-analysis
Sample
Size
19
24
223
80
20
42
61
18
95
40
16
16
200
1444
n/a
Mean
(Years)
3.25
3
4
5
6.3
3
3
2.42
4.17
8
10
14.1
5
10
15
Range
(Years)
1.2-4.8
(not reported)
(not reported)
(not reported)
0.2-9.2
(not reported)
(not reported)
2-4.5
1.8-5
(not reported)
(not reported)
(not reported)
(not
applicable)
Study
University
Private practice
University
University
Private practice
University
University
(not reported)
Private practice
University
Private practice
Private practice
Various
caries (n=13).
3,15,16,29,66,92
Chipping or
cracking of the veneering porcelain
for this review was defined as minor
cohesive fracture of the veneering por-
celain which did not impair function.
Two studies did not exclude patients
unavailable for evaluation from the
survival rates (reported for 30 resto-
rations).
18,26
In instances where minor cohesive
fractures of the veneering porcelain
did not require complete replace-
ment, the restorations were either
polished
14,16,27
or repaired with direct
composite resin restorative materi-
al.
17,29
Caries identified in the margin-
al areas were excavated and repaired
with direct composite resin restor-
ative material,
29,66,92
while endodontic
access preparations were also filled
with direct composite resin restor-
ative material.
14,17,29,37
Several authors
replaced 2 crowns due to cohesive
failures of the veneering porcelain
and 1 crown due to caries, but did not
classify this as a major complication
because it only involved the veneering
porcelain.
15
Typical survival rates for all-ce-
ramic restorations range from 88 to
100% after 2-5 years in service,
3,14,17,21-
23,26,27,37,38,91,92
and 84 to 97% after
5-14 years in service.
15,16,18,19,24,25,28-30

Discrepancy in the classification of
failures and variability of the materials
and systems available for all-ceramic
restorations present a challenge to
combining data from several stud-
ies. A meta-analysis for metal-ceramic
FPDPs defined failure as the removal
of the prosthesis, but also considered
a broader definition that included
removal and/or a technically failed
prosthesis requiring replacement.
93

A more comprehensive definition of
failure or critical assessment of all-
ceramic restorations would thus de-
crease reported survival rates. A more
descriptive definition of ceramic res-
toration outcome might include the
categories of success, survival, and
failure.

Material properties
The strength of an all-ceramic res-
toration is dependent on the ceram-
ic material used, core-veneer bond
strength, crown thickness, and design
of the restoration,
13,94
as well as bond-
Conrad et al
397 November 2007
ing techniques and the characteristics
of the supporting material.
95,96
As
evident from the literature on survival
rates, fracture of the ceramic material
is the most frequently reported com-
plication resulting in failure.
3,14-28,30

Alumina-based ceramics (In-Ceram
Alumina; VITA Zahnfabrik) have been
shown to have higher strength and
fracture toughness than leucite-rein-
forced glass ceramics (IPS Empress;
Ivoclar Vivadent),
97
conventional feld-
spathic porcelain (Vita Bloc Mark II;
VITA Zahnfabrik),
98,99
and modified
alumina cores (In-Ceram Spinell; VITA
Zahnfabrik).
100
A zirconia-modified
alumina ceramic (In-Ceram Zirconia;
VITA Zahnfabrik) was found to have
higher fracture toughness than In-Ce-
ram Alumina when tested by indenta-
tion strength in 1 study,
101
and higher
flexural strength in another.
102
Dense-
ly sintered, high purity alumina (Proc-
era; Nobel Biocare AB) was reported
to have significantly higher flexural
strength than glass-infiltrated presin-
tered alumina (In-Ceram Alumina).
103
The success of many all-ceramic
systems is dependent on the strength
of a core-veneer bond. Since the ce-
ramic core is significantly stronger
than the veneering materials, this
bond strength has an important role
in their success.
13
The thickness ratio
of the ceramic core to the veneering
porcelain is a dominant factor con-
trolling the crack initiation site and
potential failure.
104
Optimizing the
thickness of these layers is necessary to
ensure that the veneering porcelain is
under compressive stress and that the
ceramic core is under tensile stress.
103

Although it is desirable to increase the
thickness of the ceramic coping, it is
important not to compromise either
the esthetics of the crown by overcon-
touring, or the tooth preparation by
overreduction.
105
Even though the veneering por-
celain is used primarily for esthetic
reasons, it has an important role in
the mechanical behavior of the res-
toration.
106
The flexural strength and
fracture toughness of these bilayered
restorations depend on the veneer
layer when the crack initiates from
the veneer surface.
107
Although resid-
ual compressive stresses in the veneer
layer increase the flexural strength of
the bilayered restoration, the tensile
stresses are the primary cause for the
observed chipping.
107
Zirconia-based ceramics are rec-
ommended for FPDPs, as they have
the highest failure loads when com-
pared to alumina- and lithium-dis-
ilicate-based ceramics.
46
A lithium-
disilicate glass ceramic (IPS Empress
2; Ivoclar Vivadent) in combination
with a fluoroapatite glass-ceramic
(IPS Eris; Ivoclar Vivadent) was found
to be inappropriate for posterior FP-
DPs due to the high susceptibility of
the veneer to subcritical crack growth
and the absence of crack arresting
at the core-veneer interface.
108
Zir-
conia frameworks with higher elastic
modulus are preferred for all-ceramic
posterior FPDPs compared to lithi-
um-disilicate based ceramics, as they
reduce the stress on the weaker ve-
neer layer and increase the composite
load-bearing capacity, thereby retard-
ing the fracture of the restoration.
106

Creating a gingival embrasure with a
broad radius of curvature, rather than
a sharp contour, has been shown to
reduce the stress concentration under
loading and increase the fracture re-
sistance.
109,110
Following traditional preparation
guidelines is important not only for
retention of all-ceramic crowns, but
also for stress distribution during dy-
namic loading of the restoration.
111

Finite element analysis studies have
shown that FPDP connector heights
of at least 3 to 4 mm considerably
reduce stress levels in the connector
and provide adequate strength.
35,112

In vitro studies on mechanical prop-
erties are not always capable of repro-
ducing intraoral conditions. Artificial
oral environments have been devel-
oped to simulate intraoral conditions
by applying intermittent dynamic cy-
clic forces, artificial saliva, tempera-
ture fluctuations, and humidity con-
trol.
66,113
Testing specimens in these
simulated oral environments has been
shown to significantly decrease the
fracture toughness of ceramic mate-
rials.
114
Long-term in vivo studies are
necessary to make conclusions about
the clinical indications for ceramic
materials.

Marginal and internal fit
When evaluating the clinical suc-
cess and quality of a restoration,
marginal discrepancy is an essential
criterion.
74
Christensen
115
reported
the clinically detectable range for sub-
gingival margins to be 34-119 m and
2-51 m for supragingival margins.
Subsequently, McLean
116
suggested
that 120 m should be the limit for
clinically acceptable marginal discrep-
ancies. Poor marginal adaptation can
result in cement dissolution, micro-
leakage, increased plaque retention,
and secondary decay.
74
Holmes
117
measured various
points between the casting and the
tooth and clarified the terminology
for misfit. Absolute marginal discrep-
ancy was defined as an angular com-
bination of the horizontal and vertical
error and would reflect the total misfit
at that point. An internal gap is the
perpendicular measurement from the
axial wall to the internal casting sur-
face.
The incidence of gingival inflam-
mation increases around clinically de-
ficient restorations, particularly those
with rough surfaces, subgingival fin-
ish lines, or poor marginal adapta-
tion; however, gingival inflammation
may also develop around properly
contoured and highly polished res-
torations.
118
Although the severity of
gingival response is patient-specific,
current evidence has not shown an
accelerated rate of bone loss or in-
creased attachment loss adjacent to
crowns.
118
Contemporary chairside or labo-
ratory-based CAD/CAM systems have
additional factors that may affect the
accuracy of the fit, including software
limitations in designing restorations,
and hardware limitations of the cam-
era, scanning equipment, and mill-
Conrad et al
398 Volume 98 Issue 5
The Journal of Prosthetic Dentistry
ing machines. Clinicians and dental
technicians experience and expertise
is also key with chairside and labo-
ratory-based CAD/CAM systems.
119

Systems dependent upon an optical
impression experience problems with
rounded edges due to the scanning
resolution and positive error, which
simulates peaks at the edges.
120
Other
systems that use a surface contact-
ing probe cannot accurately repro-
duce proximal retentive features less
than 2.5 mm wide and more than 0.5
mm deep.
121
Feather-edge finish lines,
deep retentive grooves, and complex
occlusal morphology are not recom-
mended, not only for scanning and
milling prerequisites, but also to de-
crease stress that would develop in a
restoration with inadequate prepara-
tion and margin geometry.
121
An addi-
tional problem with computer-milled
ceramic restorations is that the inter-
nal cutting bur may be larger in di-
ameter than some parts of the tooth
preparation, such as the incisal edge.
This would result in a larger internal
gap than with other fabrication tech-
niques.
120
Table IV is a summary of current
literature evaluating in vivo and in
vitro marginal discrepancy as well as
the in vitro internal discrepancy or
misfit of the coping on the axial sur-
faces. In general, studies have demon-
strated that internal gap widths are
higher than marginal gaps.
54,74,76,83,85,
86,122-129
This finding has implications
for glass-ceramic restorations which
may be dependent upon the mechani-
cal properties of the luting cement to
resist functional forces.
95
Most of the
literature reports marginal discrepan-
cies in the range of clinical acceptabil-
ity recommended by Christensen
115

and McLean.
116

Cementation and bonding
A variety of cementation and
bonding techniques have been applied
to modern all-ceramic restorations.
Zinc phosphate, zinc polycarboxylate,
and conventional glass-ionomer ce-
ments set through an acid-base reac-
tion having a tendency to exacerbate
surface flaws in ceramic restorations
due to the increased acidity of the ce-
ment.
130
Glass ionomers are suscepti-
ble to early water degradation, result-
ing in microcracks which may initiate
cracks and facilitate crack propaga-
tion in the cement.
131
Resin-modified
glass ionomer cement sets through a
combination of an acid-base reaction
and photo- or chemically initiated
polymerization. Combining chemical
adhesion advantages of traditional
glass-ionomer cements with advan-
tages of composite resin results in im-
proved strength, fracture toughness,
and wear resistance.
132
To improve
success rates with glass- and alumina-
based ceramic restorations, nonacid-
base cements are recommended.
130
For conventional glass-ceramic
restorations, the adhesive technique
is critical for successful bonding. Sur-
face treatment of the porcelain by
etching with 5% to 9.5% hydrofluoric
acid
133
and etching of the tooth struc-
ture with 37% phosphoric acid
134
and
application of a silane coupling agent
provided the highest bond strength
of an adhesive-resin cement to feld-
spathic material. A chemical bond
between feldspathic porcelain and
tooth structure is achieved through
silane coupling agents in composite
resins. Bond strength to etched sur-
faces is improved by creating deep
involuted spaces where resin can flow
and interlock.
135,136
Due to the abra-
sion rate with subsequent volume
loss and changes in morphology, feld-
spathic restorations should never be
airborne-particle abraded to improve
the roughness of the internal surface,
only acid-etched.
137
Considering the brittleness and
limited flexural strength of glass ce-
ramics, definitive adhesive cementa-
tion with composite resin should be
used to increase the fracture resistance
of the restoration.
94,130,138,139
The com-
pressive strength of composite resin
cements (320 MPa) is superior to that
of zinc phosphate (121 MPa), which
offers limited support.
131,140
Fracture
or cement breakdown can result in
microleakage, marginal discoloration,
pulpal irritation, secondary caries,
debonding, and decreased fracture
load. Adhesive cementation has been
shown to increase fracture loads
and improve longevity.
50,57,139,141,142
A
glass-ceramic restoration supported
by a composite resin cement with
good physical properties can with-
stand higher masticatory forces and
demonstrates improved clinical per-
formance.
138
Light-, dual-, and chemically po-
lymerized composite resin materials
have been advocated for use with
glass ceramics.
143
Decreased sur-
vival rates have been reported with
dual-polymerizing, composite resin
cement, as compared to chemically
polymerizing composite resin cement
with feldspathic inlays (VITABLOCS
Mark II; VITA Zahnfabrik).
144,145
Inad-
equate transmission of light through
the ceramic restoration to the under-
lying cement can result in insufficient
polymerization of dual-polymerizing
composite resin cement and lack of
support for the restoration.
119
Dual-
polymerizing cements contain perox-
ide and amine components found in
chemically polymerized systems, in
addition to a photosensitizer used in
light-polymerized systems.
146
The 2
catalytic mechanisms are required to
reduce the quantity of remaining dou-
ble bonds to maximize strength and
adhesion of the cement.
147
A slower
polymerization reaction
148
and higher
solubility and water absorption occurs
when dual-polymerizing resins are al-
lowed to autopolymerize.
149
Depend-
ing exclusively on the autopolymeriz-
ing component of dual-polymerizing
composite resin results in decreased
hardness and premature failure of the
cement.
119,144,145,150
Nonadhesive cementation is more
dependent upon macromechani-
cal retention than adhesive cemen-
tation.
138
Finish lines placed below
the cemento-enamel junction result
in a significant loss of adhesion, de-
spite following adhesive luting tech-
niques.
151
Since cementum cannot be
infiltrated by resin to the extent that
Conrad et al
399 November 2007
Table IV. Marginal and internal fit studies
IPS Empress 2/heat pressed
IPS Empress/heat pressed
Optimal Pressable Ceramic/heat pressed
IPS ProCAD/CEREC 3
VITABLOCS Mark II/CEREC 3
VITABLOCS Mark II/CEREC 2
VITABLOCS Mark II/CEREC 1
VITABLOCS Mark II/Celay System
In-Ceram Alumina/Slip-cast
In-Ceram Alumina/Celay System
Synthoceram/CICERO
In-Ceram Zirconia/CEREC in Lab
In-Ceram Zirconia/Digident (Digident
GmbH, Pforzheim, Germany)
In-Ceram Zirconia/Slip-cast
Procera/densely sintered
Lava
DC-Zirkon/Precident System
Denzir
Gold
Ceramic alloy
65
122
85
54
195
122
74
54
77
128
92
128
68
54
90-118
129
80
128
30
122
67
128
44
74
147-167
85
246-265
85
53-66
124
62-121
125
17
127
57
127
57
127
43
74
25
74
60
83
17
74
56-63
76
33
74
60-71
83
23
74
22-41
86
136-149
85
75-105
74
206
85
278
85
342
123
380
123
116-141
124
122
126
82-114
74
71-94
74
119-136
74
36-74
76
110-116
74
74-81
74
110-192
86
243
85
Material and Systems
In Vitro Mean
Marginal Gap (m)
In Vitro Internal
Gap (m)
In Vivo Mean
Marginal Gap (m)
Conrad et al
400 Volume 98 Issue 5
The Journal of Prosthetic Dentistry
acid-etched dentin can, microme-
chanical retention at the gingival mar-
gins may contribute little to the bond
strength.
152,153
Restorations that are
less dependent on predictable adhe-
sion should be considered when the
finish line is not placed in enamel.
154
Different surface treatments have
been evaluated to demonstrate the
bond strength of composite resin ce-
ments to alumina-based ceramic res-
torations. Acid etchants used with
glass ceramics do not adequately
roughen the surface of glass-infil-
trated and densely sintered alumi-
na-based ceramics.
155
An effective
method to roughen glass-infiltrated
alumina-based ceramic (In-Ceram
Alumina; Vita Zahnfabrik) is through
a tribochemical silica coating process
(Rocatec; 3M ESPE).
137
This method
involves cleaning the surface to be
coated with 110 m of high-purity
aluminum oxide (Rocatec Pre; 3M
ESPE) at 250 KPa for 14 seconds, cre-
ating a uniform pattern of roughness.
This is followed by a tribochemical
coating with 110 m (Rocatec Plus;
3M ESPE) or a less abrasive 30 m
(Rocatec Soft; 3M ESPE) of silica-
modified high purity aluminum oxide.
The aluminum oxide leaves the sur-
face partially coated with SiO
2
, which
is then conditioned with silane (3M
ESPE Sil; 3M ESPE) to create a bond
with the composite resin.
137
Volume
loss through this tribochemical pro-
cess was found to be 36 times less for
a glass-infiltrated alumina (In-Ceram
Alumina; VITA Zahnfabrik) than for
a feldspathic glass ceramic (IPS Em-
press; Ivoclar Vivadent) and did not
change its surface composition.
137

Pretreatment of a glass-infiltrated
alumina (In-Ceram Alumina; VITA
Zahnfabrik) with the tribochemical
process (Rocatec; 3M ESPE) resulted
in a durable resin bond over 5 years.
156

Airborne-particle abrasion with 50-
m aluminum oxide for 15 seconds
was found to be the most effective for
producing higher bond strengths for
a densely-sintered aluminum-oxide
coping (Procera; Nobel Biocare AB)
when compared to etching with 9.6%
hydrofluoric acid for 2 minutes, dia-
mond abrasion combined with etch-
ing with 37% phosphoric acid for 2
minutes, and no treatment.
155
Surface treatments including a
tribochemical silica coating process
(Rocatec; 3M ESPE), airborne-par-
ticle abrasion with either 250-m or
50-m aluminum oxide, airborne-
particle abrasion with 50-m alumi-
num oxide combined with 38% hy-
drofluoric acid etching, or diamond
abrasion with a rotary cutting instru-
ment, were reported to have only a
minor influence on bond strength
to zirconia ceramic (Denzir; Decim
AB).
157
The tribochemical silica coat-
ing process in combination with a
resin cement was shown in 1 study
158

to have an initial bond to zirconia that
failed spontaneously after simulated
aging, while another study
159
found
that it did not improve the retentive
strength of composite resin cements.
Although not apparent immediately,
damage from airborne-particle abra-
sion (50-m aluminum oxide for 5
seconds at 276 KPa) has been shown
to compromise the fatigue strength of
alumina- and zirconia-based ceramic
materials.
160,161
A variety of luting
agents have been shown to be capable
of retaining zirconium-oxide crowns
(Lava; 3M ESPE) including composite
resin (Panavia F 2.0; Kuraray, Tokyo,
Japan), compomer (Dyract Cem Plus;
Dentsply Intl), resin-modified glass
ionomer (RelyX Luting; 3M ESPE),
and self-adhesive composite resin
(RelyX Unicem; 3M ESPE).
159,162
While
mechanical properties of cements are
critical to support glass-ceramic res-
torations,
140
zirconia-based crowns
can be cemented conventionally due
to their high fracture resistance.
159

Zirconia-based restorations do not
require an adhesive interface for re-
tention.
8

Color and esthetics
Increased translucency correlated
with improved esthetics is the primary
advantage in using an all-ceramic res-
toration. Heffernan et al
10
evaluated
the relative translucency of several ce-
ramic materials and found In-Ceram
Spinell (VITA Zahnfabrik) to have the
highest amount of relative translu-
cency. This was followed by IPS Em-
press (Ivoclar Vivadent), Procera (No-
bel Biocare AB), and IPS Empress 2
(Ivoclar Vivadent), which had higher
levels of translucency than In-Ceram
Alumina (VITA Zahnfabrik), followed
by In-Ceram Zirconia (VITA Zahn-
fabrik), which was comparable to a
metal alloy. As a result of this study,
In-Ceram Spinell, IPS Empress, and
IPS Empress 2 were recommended
for high to average translucency situ-
ations. Procera was recommended for
average translucency situations, while
In-Ceram Alumina and In-Ceram Zir-
conia are only recommended when
matching to opaque natural teeth or
in posterior and nonesthetic zones.
69
The addition of MgAl
2
O
4
to the
In-Ceram system has made In-Ceram
Spinell, with its increased translu-
cency, an esthetic competitor. Unfor-
tunately, mechanical properties have
been compromised compared to the
original material, restricting its use
to the anterior segment, exclusively.
70

A subjective evaluation reported IPS
Empress better able to match adja-
cent teeth than In-Ceram Spinell or
metal-ceramic restorations.
47
Monochromatic restorations ma-
chined from ceramic blocks have been
scrutinized for their lack of individual
characterization. Although custom-
ized characterizing of these restora-
tions was shown to compete estheti-
cally with layering techniques
163
and
multishade block systems,
58
no long-
term follow-up for color stability has
been done.
The ratio and thickness of ceramic
core and veneering materials influ-
ence the final shade of a layered por-
celain restoration. An aluminum-ox-
ide ceramic core thickness of 0.7 mm
was found to be sufficient to mask
underlying dentin color.
71
With a con-
servative reduction of 1 mm, a semi-
translucent all-ceramic specimen will
match a shade tab more closely than a
metal-ceramic restoration. Increasing
Conrad et al
401 November 2007
reduction will improve esthetic results
for metal-ceramic and semiopaque
all-ceramic restorations but will not
further enhance shade-matching for
semitranslucent specimens (IPS Em-
press; Ivoclar Vivadent; In-Ceram
Alumina and In-Ceram Spinell; VITA
Zahnfabrik).
164
Since IPS Empress res-
torations were found to require up to
2.0 mm of thickness facially to mask
an underlying substrate,
165
other less
translucent core materials should be
considered.
The opaque porcelain required for
masking a metal substrate is responsi-
ble for reflecting light and decreasing
translucency. Since enamel is 97% hy-
droxyapatite mineral matter, it is very
translucent and able to transmit up
to 70% of light. Dentin is also capable
of transmitting up to 30% of light,
which creates the esthetic dilemma
for metal-ceramic restorations, as
they are only capable of diffusion and
reflection of light. Consequently, met-
al-ceramic restorations often appear
brighter intraorally.
47

Clinical recommendations
Leucite and feldspathic glass ce-
ramics are indicated for onlays, three
quarter crowns, and veneers, but their
strength limits their use to complete
coverage crowns in the anterior seg-
ment, only. Lithium-disilicate glass ce-
ramics can perform successfully in the
posterior segment for single crowns
and 3-unit FPDPs in the anterior area.
Glass-infiltrated alumina cores can
be considered for single-unit resto-
rations and anterior FPDP applica-
tions, with the exception of In-Ceram
Spinell, which is only recommended
for anterior crowns. Zirconia-modi-
fied alumina is indicated for posterior
crowns and FPDPs, while densely sin-
tered alumina is indicated for veneers,
crowns, and anterior FPDPs. Zirconia
has superior mechanical properties as
a core material for posterior crowns
and FPDPs, implant abutments, and
implant-supported restorations. The
stronger ceramic core materials can
be rather opaque and this may limit
their application when a high degree
of translucency is required.
Reported survival rates are vari-
able and dependent upon the mate-
rial used, manufacturing technique,
clinical application, and the authors
definition of failure. Optimal thick-
ness of alumina and zirconia cores
and their respective veneering materi-
als is critical for esthetics and strength
to support occlusal forces. Marginal
discrepancies are in the range of clini-
cal acceptability for indirect restora-
tions; however, internal gap widths
are higher, resulting in a large film
thickness which may be significant
for glass ceramics that depend on the
physical properties of the cement.
Surface treatment combining etching
and a silane coupling agent provides
the highest bond strength of com-
posite resin cement to feldspathic ce-
ramics and increases the fracture re-
sistance of the restoration. Adequate
transmission of light is critical for
light- and dual-polymerizing cements
to achieve maximum strength and
adhesion. When the finish line of the
preparation cannot be maintained in
enamel, the clinician should consider
restorations that are not dependent
on adhesion. Pretreatment of alu-
mina cores with a tribochemical silica
coating process or airborne-particle
abrasion alone produces higher bond
strengths for adhesive resin cemen-
tation. Zirconia-based restorations
can be cemented conventionally due
to their high fracture resistance, and
they do not require an adhesive inter-
face for retention. Materials with in-
creased translucency that are custom-
ized through characterizing or layering
techniques will best be able to match
natural tooth structure.
CONCLUSIONS
All-ceramic restorations are de-
veloped with cores of glass ceramics,
aluminum oxide, or zirconium oxide,
and are manufactured by heat press-
ing, slip-casting, sintering, or milling.
Successful application of these mate-
rials will depend upon the clinicians
ability to select the appropriate ma-
terial, manufacturing technique, and
cementation or bonding procedures,
to match intraoral conditions and es-
thetic requirements.
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Corresponding author:
Dr Heather J. Conrad
Division of Prosthodontics, Department of
Restorative Dentistry
University of Minnesota, School of Dentistry
9-450a Moos Tower
515 Delaware St SE
Minneapolis, MN 55455
Fax: 612-626-1496
E-mail: [email protected]
Copyright 2007 by the Editorial Council for
The Journal of Prosthetic Dentistry.
Conrad et al