coatings

Review
Dental Ceramics: Fabrication Methods and Aesthetic
Characterization
Jefferson David Melo de Matos 1,2 , Guilherme Rocha Scalzer Lopes 2 , Daher Antonio Queiroz 3, * ,
Leonardo Jiro Nomura Nakano 2 , Nathália Carvalho Ramos Ribeiro 2,4,5 , Adriano Baldotto Barbosa 6 ,
Lilian Costa Anami 2 and Marco Antonio Bottino 2

1 Department of Restorative Dental Sciences, Center for Dental Biomaterials, University of Florida (UF Health),
Gainesville, FL 32611, USA
2 Department of Biomaterials, Dental Materials and Prosthodontics, Institute of Science and Technology,
São Paulo State University (Unesp), São José dos Campos 05508-070, SP, Brazil
3 Department of Restorative Dentistry & Prosthodontics, The University of Texas Health Science Center at
Houston (UTHealth) School of Dentistry, Houston, TX 77054, USA
4 Department of Dentistry, Universidade São Francisco (USF), Bragança Paulista 12916-900, SP, Brazil
5 Postgraduate Program in Dentistry, Department Dentistry, University of Taubaté (UNITAU),
Taubaté 12080-000, SP, Brazil
6 Midwest Dental Arts Inc., Palm Bay, FL 32909, USA
* Correspondence: [email protected]

Abstract: This study aimed to describe different staining protocols for the main dental ceramics. A
bibliographic search was conducted in the main health databases PubMed and Scholar Google, in
which 100 studies published were collected. In vitro and in silico studies, case reports, and systematic
and literature reviews, on ceramic materials, were included. Therefore, articles that did not deal with
the topic addressed were excluded. Ceramics can be classified into glass-matrix ceramics (etchable),
polycrystalline (non-etchable), and hybrid ceramics. In this context, different fabrication methods,
Citation: de Matos, J.D.M.; Lopes, method indications, and characterization layers can be used for each ceramic group and numerous
G.R.S.; Queiroz, D.A.; Nakano, L.J.N.; protocols differ according to the choice of material. Several ceramic systems are available, thus
Ribeiro, N.C.R.; Barbosa, A.B.; professionals in the prosthetic area need constant updates on dental ceramic restorations and their
Anami, L.C.; Bottino, M.A. Dental proper characterizations.
Ceramics: Fabrication Methods and
Aesthetic Characterization. Coatings Keywords: ceramics; dental materials; dentistry; dental research
2022, 12, 1228. https://doi.org/
10.3390/coatings12081228

Academic Editor: Jiamao Li

1. Introduction
Received: 14 July 2022
Accepted: 16 August 2022
In recent decades, the dentistry community has studied restorative materials with
Published: 22 August 2022
excellent optical properties and able to restore form and function, given the mechanical
requirements of the anterior and posterior areas [1,2].
Publisher’s Note: MDPI stays neutral
Metal-free restorations have gained notoriety, especially for rehabilitation with supe-
with regard to jurisdictional claims in
rior aesthetic outcomes [3]. These materials have properties that justify their use, including
published maps and institutional affil-
high resistance to compression and abrasion, high chemical stability, high tensile strength,
iations.
biocompatibility, favorable aesthetics, translucency, opalescence, opacity, fluorescence, and
coefficient thermal expansion similar to the natural tooth [4]. Thus, several ceramic sys-
tems are available, and they can be classified as glass-matrix, polycrystalline, or hybrid
Copyright: © 2022 by the authors.
(resin-matrix) ceramics [5].
Licensee MDPI, Basel, Switzerland. To reduce the failures caused by different coefficients of linear thermal expansion
This article is an open access article between framework and veneer ceramics, it was proposed to simplify the technique and
distributed under the terms and use monolithic ceramic restorations [6]. However, single-crown restorations can present an
conditions of the Creative Commons aesthetic compromise, especially in cases that require greater detail [7,8].
Attribution (CC BY) license (https:// To eliminate this aesthetic issue, it was proposed to add staining layers on the surface
creativecommons.org/licenses/by/ of ceramic materials [9,10]. These characterizations make it possible to personalize the
4.0/). restorations and guarantee a satisfactory aesthetic [11,12]. In turn, this characterization

Coatings 2022, 12, 1228. https://doi.org/10.3390/coatings12081228 https://www.mdpi.com/journal/coatings

Coatings 2022, 12, 1228 2 of 14

layer can suffer dissolution of the pigments, presenting lower color stability than the
intrinsic stain [13–15].
The glaze layer added over the characterization layer plays a very important role
in the long-term preservation of ceramic pigments, as it limits color changes and wear
of ceramic pigments. The wear of restorative materials occurs due to the adversities of
the oral environment, such as the presence of microorganisms, parafunctional habits, and
contact between antagonists during chewing activities. Studies indicate that this layer of
glaze applied over a sintered or crystallized ceramic could remain in function for up to
12 years [16–19].
Despite the routine use of stains in monolithic restorations, these are still performed
without a protocol that allows reproducibility of the procedure. In this sense, the present
study aimed to expose the main ceramics and their characterization protocol based on a
literature review. Added to this is the lack of information in the literature regarding the
best method of characterizing the surface layer of ceramic structures, since this procedure
is heterogeneous, carried out by the professionals.

2. Materials and Methods

Source Selection
A bibliographic search was conducted in the main health databases PubMed and
Google Scholar (accessed on 3 March 2022), in which studies published from 1980 to 2022
were collected. In the second stage, the studies were selected by reading the full contents.
Two authors (JDMM and GRSL) performed stages 1 and 2. In vitro and in silico studies,
case reports, and systematic and literature reviews, collected on ceramic materials with
information on the staining layer on the ceramic restorations, the thickness of restorations,
monolithic restorations, aesthetic characterization of the surface of ceramics, and analysis
of the properties of roughness and hardness in ceramic materials written in English, were
included. Therefore, articles that did not deal with the topic addressed were excluded.

3. Results
Through bibliographic research, 100 articles were selected, of these, 90 were extracted
from PubMed and 10 from Google Scholar. The following titles of specific medical subjects
and keywords were used: Ceramics (DeCS/MeSH Terms), Dental Materials (DeCS/MeSH
Terms), Dentistry (DeCS/MeSH Terms), Dental Research (DeCS/MeSH Terms).

4. Literature Review and Discussion

Ceramics can be classified into glass-matrix (etchable), polycrystalline (non-etchable),
and hybrid ceramics (etchable and non-etchable). In this context, different characterization
layers can be used for each ceramic group and the numerous protocols differ according to
the material [4,5,20–24]. The staining layer applied on the ceramic surface must be fired at
specific temperatures [25].
Etchable ceramics (feldspathic, leucites, silicates, and lithium disilicates) have a high
glass content, thus, a high silica content is present in this material, offering a better aesthetic
property [4,5,20,26–28]. In contrast, non-etchable ceramics (zirconia, alumina) have a low
silica content, but a high crystalline content, allowing the material to present a high mechan-
ical performance [4,5,20,26–29]. A characterization protocol commonly used by laboratories
for these two ceramic groups is the powder and liquid application technique (layering).
For lithium silicate or disilicates, an initial crystallization is necessary, as the material is
pre-crystallized, so after the firing procedure, the material undergoes nucleation followed
by the growth of crystals to obtain lithium metasilicate [21–25,30–32]. As for polycrystalline
ceramics, for example, zirconia needs a sintering firing, as the material before going to the
oven is pre-sintered, to heat the particles below their melting point, promoting densification
of the components [4,5,9,24,33,34]. This property of zirconia prevents the growth of cracks
with the transformation of the phase from tetragonal to monoclinic [4,5,24]. Immediately
after this initial firing, with the aid of a brush, a paste made up of powder (stain) specific
Coatings 2022, 12, 1228 3 of 14

to each manufacturer and modeling liquid should be prepared [24,25,31,32]. The liquid
can be distilled water mixed with rheological modifiers, or a manufacturer-specific fluid
mixer [24,25,31,32]. The prepared paste is then applied to the external surfaces of the ce-
ramic restorations, accompanied by one or more characterization firing cycles until reaching
the aesthetic color of interest [24,25,31,32].
In this context, to achieve a satisfactory aesthetic, several subsequent firing procedures
may be necessary [35]. These processes, in turn, promote the stress concentration on the
ceramic surfaces [36]. Therefore, a commonly discussed concern is the relationship by
which the characterization procedures can lead to a modification of the crystalline content
of the ceramic, changing the mechanical properties of the material [35]. However,8there
Coatings 2022, 12, x FOR PEER REVIEW of 14
is no consensus in the literature regarding the different firing protocols and their effect
on the mechanical behavior of the application of ceramic stains in indirect restorative
materials [37].
Manufacturing the final restoration is constructed with the help of specific software.
The characterization of hybrid ceramics occurs differently from other ceramics since
(CAD–CAM)
this process occursThe dimension
through and shape information
photoactivation of theTherefore,
[23–25,31,32,38]. restorationit is then sent
cannot to
be oven
a milling unit in which the ceramic restoration is made [25,68–79].
treated because it is a material that has a network of polymers in its composition, so at
high temperatures, (2nd) Aftersuffer
it would obtaining all the digital
deformation of its information, the milling step
structure [23–25,31,32,38]. It isofworth
a
mentioning that thepreviously sintered/crystallized
staining technique block is started
is the only possible under ideal
characterization for conditions
this ceramic
by the manufacturer.
group since it is obtained by a CAD–CAM Thisblock
block[38].
is milled by two diamond tips coupled
in fully articulated arms until acquiring the final shape of the restora-
4.1. Ceramic Restorations
tion, proposed in the software.
Metal-ceramic crowns
(3rd) After have been used
the milling forfinished
step is many years as the first adjusted,
and marginally treatmentthe option
for compromisedsubsequent
teeth. The finishing
metal provides
(glaze or polishing) is performed. In some cases,an
great resistance to fracture but presents it
unfavorable aesthetic. However, this application
is necessary to stain the prosthetic is made in layers,
restoration sculpting
associated thea anatomy
with charac-
of the tooth associated with the use of different porcelain colors. The association of different
terization firing. It is interesting to clarify that in ceramics with poly-
masses intrinsically allows greater control of the more opaque and more translucent regions
mers in their composition, after the pigmentation stage, the structure
(Figure 1). The literature points out that some ceramic materials can successfully replace
must be light-cured.
metal alloys, giving rise to metal-free restorations [39–41].

Figure 1.
1. Layering technique. (A)(A) Polycrystalline
Polycrystalline Framework;
Framework; (B) (B) Feldspathic ceramic build-up
(wash bake); (C) Feldspathic ceramic build-up (intensive chrome + dentin);
(wash bake); (C) Feldspathic ceramic build-up (intensive chrome + dentin); (D)
(D) Feldspathic
Feldspathic ceramic
ceramic
build-up (enamel layer); (E) Feldspathic ceramic after firing; (F) Feldspathic ceramic after thermal
build-up (enamel layer); (E) Feldspathic ceramic after firing; (F) Feldspathic ceramic after thermal
and mechanical glaze.
and mechanical glaze.

The technical and scientific advances in the mechanical and chemical properties of
ceramics have broadened their clinical indication, becoming the restorative material of
choice for professionals and patients with aesthetic needs [3,41]. Several ceramic systems
can be used in metal-free restorations, both etchable and non-etchable. In this sense,
other forms of processing stand out, including press and milling, but extrinsic painting is
necessary to obtain the final shape of the part [42].
Coatings 2022, 12, 1228 4 of 14

Among ceramic materials, zirconia is the one with the greatest resistance, in addition
to high fracture strength [43]. In turn, exposing a peculiar characteristic called martensitic
transformation, which is a mechanism characterized by the change from tetragonal to mon-
oclinic phase during compression stresses in the crystalline matrix, guarantees an increase
in the granular volume of approximately 3% and inhibition of crack propagation [44,45].
In addition, another important advance in contemporary dentistry is monolithic single-
crown ceramics, which appeared to minimize the chipping of the veneer ceramics when
applied over crystalline frameworks, mainly explained by the differences in the thermal
expansion coefficient between these two materials [6].
Professionals must know the chemical composition and clinical performance of current
dental materials, thus allowing the choice of the most suitable restorative material for each
treatment and consequently, providing greater longevity. To study the behavior of a
material, it can be subjected to clinical simulations, although with some limitations in
controlling variables, such as masticatory forces and individual oral conditions [46,47].

4.2. Ceramic Restorations Thickness

Ceramic restorations can have different thicknesses depending on the ceramic sys-
tem used, tooth preparation design, and the interocclusal space. In general, there are
specific recommendations for a minimum thickness that offers mechanical strength for
each category of ceramic material, depending on the region and the type of restoration,
such as feldspathic ceramics, which must have a minimum thickness of 2.0 mm, leucite
with 1.5 mm and lithium disilicate with 1.0 mm. Polycrystalline ceramics, alumina, and
zirconia, on the other hand, must have a minimum space of 0.3 mm. It is worth men-
tioning that traditionally, polycrystalline ceramics can present an aesthetic compromise
due to the high crystalline content in their composition. Ceramics behave with inversely
proportional quantities, that is, the greater the aesthetics, the lower the resistance [48].
Seeking to overcome this limitation, high-translucency zirconia (Y-ZHT) has emerged, an
yttrium-stabilized tetragonal zirconia polycrystalline ceramic (Y-TZP), but with differences
in the microstructure of its precursor material and the size of the grains, giving this material
better optical properties [49]. It is worth mentioning that all the mentioned restorative
materials can be used in the form of monolithic ceramics from prefabricated blocks for
CAD–CAM systems.
In bilayer ceramic systems (zirconia framework + glass-matrix ceramic veneer), chip-
pings or cracks usually start at the interface between the framework and the veneer ce-
ramic [50]. In addition, another disadvantage observed is the weak connections caused
by the residual tensile stress developed during the application process of the veneer ce-
ramic [51]. To overcome such failures, monolithic crowns have been indicated, as they
present a better performance during masticatory function since the final restoration consists
of only one material [52,53].
The thickness of the ceramics is directly related to their optical and mechanical proper-
ties, that is, each material needs a minimum thickness to perform the restorative needs [50].
However, this thickness can influence the polymerization of resin cement and, conse-
quently, change the bond strength of the materials used and compromise the restorative
treatment [54].
Martins et al. (2018) [55] evaluated the influence of the different thicknesses of lithium
silicate restorations on the degree of conversion of resin cement, through a systematic
review. The results showed that the translucency imposed on lithium silicate significantly
reduced light transmission when activated through the ceramic. It is concluded that the
finer the ceramic material, the greater the polymerization of the cementing agent, in turn, a
thickness greater than 1.0 mm drastically reduces the polymerization of resin cement.
Turp et al. (2018) [54] studied the influence of the thickness of monolithic restorations
in zirconia and lithium disilicate on the polymerization efficiency of dual resin cement.
Twelve ceramic discs (4.0 mm diameter) with thicknesses of 0.5, 1, 1.5, 2, 2.5, and 3 mm
were prepared from monolithic zirconia (Previous Prettau® , Zirconzahn; n = 6) and lithium
Coatings 2022, 12, 1228 5 of 14

disilicate (IPS e.max® CAD HT, Ivoclar Vivadent; n = 6). Three dual-curing resin cements
(Panavia F 2.0—Kuararay, DuoLink Universal ™—Bisco, and RelyX ™ U200—3M Espe)
were used for polymerization under ceramic discs. For each resin cement, 10 specimens
were prepared by light-curing under monolithic zirconia and lithium disilicate discs of
each thickness. The Vickers microhardness of resin cement decreased significantly with
increasing measurement depth and increasing thickness of monolithic zirconia or lithium
disilicate (p < 0.001). Cement polymerized under lithium disilicate had higher micro-
hardness values than those polymerized under zirconia (p < 0.001). For both ceramics,
Panavia F 2.0 exhibited the highest microhardness, followed by DuoLink Universal and
RelyX ™ U200 (p < 0.001). It is concluded that different dual-cure resin cements can have
different polymerization efficiencies, and the type and thickness of the overlapping ceramic
can directly influence the polymerization. It is interesting to elucidate that the findings
of this study suggest that an increase in the thickness of monolithic lithium disilicate or
monolithic zirconia restorations significantly decreases the microhardness of the dual-cure
resin cement. Resin cement can also be used for the cementation of anterior monolithic
zirconia restorations up to 2 mm thick and for monolithic lithium disilicate restorations up
to. However, for lithium disilicate with restorations ≥ 2.5 mm thick and zirconia ≥ 2 mm
thick, cementation approaches need further study.

4.3. Monolithic Restorations

Monolithic glass-matrix ceramics are increasingly presented as an alternative treat-
ment for aesthetic dentistry [34,56]. Digital dentistry has simplified the manufacture of
these restorations, including ceramics that seek to combine aesthetics and mechanical resis-
tance [57]. These restorations have durability compatible with metal-ceramic restorations
and superior aesthetic outcomes, even with color limitations in the single block [58]. The
color of these restorations can be influenced by manufacturing processes, laboratory proce-
dures, and clinical factors [57]. The manufacturing processes determine the basic optical
properties of this class of ceramic; however, several laboratory resources are available
to improve these properties [59]. It is worth mentioning that clinical factors such as the
characteristics of the dental substrate, the cement, and the material itself can influence the
final result of the restorative treatment [60]. An advantage of the CAD–CAM system is
the fact that the sintering of the porcelain block is carried out by the manufacturer in an
optimized way, as it presents a reduction in porosities, thus improving the final quality of
the restoration obtained. The disadvantage of this block is that it is a monolithic restora-
tion, and its aesthetics are difficult. Different ceramics are available for the CAD/CAM
system. To obtain these restorations, different companies offer feldspathic, glass-ceramic,
and polycrystalline ceramic blocks [61].
Monteiro et al. (2018) [62] evaluated the effect of ceramic thickness on the fatigue
failure of two glass-matrix ceramics composed of lithium silicate reinforced with zirconia
(ZLS), cemented to a material similar to dentin. Disc-shaped specimens were allocated into
eight groups (n = 25) considering two factors of the study: ceramic type ZLS (Vita Suprinity—VS;
and Celtra Duo—CD) and ceramic thickness (1.0; 1.5; 2, 0, and 2.5 mm). A “trilayer” set
(φ = 10 mm; thickness = 3.5 mm) was designed to mimic a cemented monolithic restoration.
Before cementation (Variolink N), all-ceramic discs were conditioned and silanized. The
fatigue failure load was determined using the “Staircase” method (100,000 cycles at 20 Hz;
initial fatigue load ∼60% of the average monotonic load to failure; step size ∼5% of the
initial fatigue load). A stainless-steel piston (φ = 40 mm) applied the load to the center of
the specimens in water. Fractographic analysis and finite element analysis (FEA) were also
performed. The thickness of the ceramic influenced the fatigue failure load for both ZLS
materials: Suprinity (716 to 1119 N); Celtra (404 to 1126 N). Results of the FEA showed that
the decrease in the thickness of the ceramic led to a higher concentration of stress in the
cementation interface and that the thicker it is, the lower the concentration of stress in the
tensile surface. Different thicknesses of ZLS glass-ceramic influenced the fatigue failure
load of the cemented system (the thicker the glass-matrix ceramic, the greater the fatigue
Coatings 2022, 12, 1228 6 of 14

failure load). It was concluded that differences in the microstructure of these ceramics can
influence their behavior under fatigue.
Riccitiello et al. (2018) [63] evaluated the internal and marginal adaptation of mono-
lithic zirconia and lithium disilicate crowns, produced by different manufacturing proce-
dures. Forty-five human premolars were prepared for single crowns using standardized
preparations. Ceramic crowns were manufactured using CAD–CAM or press procedures
and cemented with universal resin cement. The non-destructive scanning of the micro-CT
was used to evaluate the marginal and internal adaptations in the coronal and sagittal
planes, then the measures of the precision of adjustment were calculated in software and
the results were analyzed through one-way ANOVA and Tukey test. The injected lithium
disilicate crowns were significantly less accurate at the prosthesis margins (p < 0.05), while
they performed better on the occlusal surface (p < 0.05). No significant differences were
observed between CAD–CAM zirconia and lithium disilicate crowns (p > 0.05). As for the
thickness of the cement layer, reduced amounts of the cementing agent were observed on
the preparation margins, while a thicker layer was reported on the occlusal surface. It was
concluded that the marginal gaps registered were within the limit of clinical acceptance,
regardless of the restorative material and manufacturing procedures. CAD–CAM process-
ing techniques for zirconia and lithium disilicate produced marginal gaps that were more
consistent than press procedures.
Nishioka et al. (2018) [64] evaluated the fatigue strength of five different ceramic
materials indicated for monolithic restorations: feldspathic ceramic (FC), hybrid ceramic
or polymer infiltrated ceramic (PIC), lithium disilicate (LD) glass-ceramic, lithium silicate
glass-ceramic reinforced with zirconia (ZLS), and high translucency yttrium-stabilized poly-
crystalline tetragonal zirconia (YZHT). The samples were made in a disc shape according
to the ISO 6872 standard. After obtaining the average of each material (n = 5) of the
monotonic load-to-failure tests, the specimens (n= 20) were subjected to “Staircase” fatigue
tests using a biaxial bending configuration (piston-in-three balls), to determine fatigue
strength. The parameters used for the tests were: 100,000 cycles at 10 Hz, the initial load of
60% of the average load for failure, and a step size of 5% of the initial load (specific for each
ceramic material). The Kruskal–Wallis and Bonferroni test (α = 0.05) were used to analyze
the fatigue resistance data. The difference in fatigue strength (MPa) of the materials was
statistically significant, with the following values: YZHT (370.2 ± 38.7) > LD (175.2 ± 7.5) >
ZLS (152.1 ± 7.5) > PIC (81.8 ± 3.9) > FC (50.8 ± 1.9). Thus, it can be concluded that, in
terms of fatigue, high translucency polycrystalline zirconia showed the best performance
as a restorative material, since it supports the greatest load before fracturing.
Given the analyses under clinical conditions and the mechanical behavior of dental
ceramics, it is known that different compositions, microstructures, and properties can
change performance when exposed to fatigue loading. Thus, to better understand the
susceptibility to crack propagation under intermittent loads, it is relevant to compare the
fatigue strength of new ceramic materials indicated for monolithic restorations [65].

4.4. Aesthetic Characterization of the Ceramic Surface

Major developments have occurred with dental ceramic materials, mainly due to the
use of CAD/CAM technology, which has enabled the milling of highly rigid ceramics.
However, the pre-defined color of the block is a difficulty found in the biomimetics of
clinical cases with greater aesthetic requirements [19].
To improve aesthetic properties and achieve similarity to natural teeth, techniques for
characterization of the surface are performed on monolithic glass-ceramic restorations [66,67].
In this context, there are three main processing methods: layering, pressed, and milled
techniques (Table 1, Figures 1–3).
Coatings 2022, 12, 1228 7 of 14

Table 1. Processing Methods.

(1st) Making a suspension (Paste): Union of porcelain powder + distilled

water mixed with rheological modifiers and/or manufacturer’s specific
diluent = Formation of viscous suspension, in which the indirect
restoration of the ceramic can be built.
(2nd) The restoration is made by mixing the porcelain powder with the
styling liquid until a paste is formed and applied with a brush on the
refractory die. This application is done in layers, to conform to the
anatomical shape of the tooth. Another reason for applying several layers
is the use of different porcelain colors, to allow greater reproduction of
details of both dentin and enamel.
The addition of metallic oxides (Al, Ca, Li, Mg, K, Na, Zr, Ti, among others)
in dental ceramics will determine its final color, resulting from the firing of
the material at high temperatures. For each layer applied, it is necessary to
condense the paste by removing excess water. This can be done by
vibrating with subsequent application of an absorbent paper or through
specific dental vibrators for this processing.
After completing the characterization steps, the restoration must be taken
to a specific oven for dental ceramics, where the firing will be carried out.
Layering and/ This process acts directly on the union of the dust particles, increasing the
or Staining density of the mass by reducing porosities [23–25,31,38].
(3rd) Initially there is a preheating (drying) of the condensed porcelain
mass at temperatures of approximately 400–500 ◦ C for 5 min in the door of
the preheated oven. This step ensures that the water slowly evaporates
without causing damage to the mass. In the next step, once inside the oven,
the restoration is heated to a maximum firing temperature of
approximately 700–980 ◦ C for 1 min at a speed of 40 to 90 ◦ C/min. During
this process, a vacuum pump is activated and guarantees a low-pressure
vacuum (0.1 atm) inside the oven. When the maximum cycle temperature
is reached, the pump is turned off and the external air (with a pressure of
1 atm) enters the oven again, increasing the pressure inside the muffle by
10 times. Thus, sintering/crystallization is a procedure for coalescing solid
particles, not changing the chemical composition, only allowing the
sculpting of the anatomy of a dental piece. It is worth mentioning that
professionals should always follow the manufacturers’ recommendations.
Ceramic restorations at elevated temperatures do not melt the particles,
they just expand and modify. As a result, deformation can occur in the
prosthetic structure. On the other hand, at low temperatures, the material
cannot adhere to the restoration.
(1st) Initially, the wax pattern is made and included in a coating ring. Then,
this set must be heated in an oven.
(2nd) The press phase of the pre-ceramic ingot is a crucial step for the press
processing technique, where it is performed in a specific oven. The
glass-matrix ceramic ingot is placed inside the ring’s feeding duct followed
by an alumina plunger that will be responsible for injecting the
vitro-ceramic when it is fluid. The ring-ingot-plunger assembly is taken
into the injection furnace where it will undergo a thermal cycle lasting
approximately 30 min. When reaching the maximum temperature, in
Pressed
which the ceramic is high fluidity, a plunger present inside the oven
touches the alumina piston, pushing it into the ring. The result is the
injection of the ingot, which takes the form of the restoration molded by
the coating.
(3rd) After the end of the cycle and the cooling of the ring, the coating is cut
with a carbide disc and the part is removed from the inside, therefore,
adjustments are necessary; especially in the case of glass-matrix ceramics,
as the prosthetic structures receive a final characterization with a staining
layer and glaze, since the restoration just out of the oven is monochromatic.
 (3rd) After the milling step is finished and marginally adjusted, the
subsequent finishing (glaze or polishing) is performed. In some cases, it
is necessary to stain the prosthetic restoration associated with a charac-
terization firing. It is interesting to clarify that in ceramics with poly-
Coatings 2022, 12, 1228 mers in their composition, after the pigmentation stage, the structure 8 of 14

must be light-cured.

Table 1. Cont.

(1st) Initially, a digital image is acquired in a three-dimensional plane of the

prepared tooth, and then it is constructed on a computer (.STL file). This
image can be obtained directly from the prepared tooth with a digital
intraoral scanner or scanning a plaster model with a desktop scanner. On
the digital image of the prepared tooth, the digital image of the final
restoration is constructed with the help of specific software. The dimension
and shape information of the restoration is then sent to a milling unit in
Milling—Computer which the ceramic restoration is made [25,68–79].
Aided Design and (2nd) After obtaining all the digital information, the milling step of a
Computer Aided previously sintered/crystallized block is started under ideal conditions by
Manufacturing the manufacturer. This block is milled by two diamond tips coupled in
(CAD–CAM) fully articulated arms until acquiring the final shape of the restoration,
proposed in the software.
(3rd) After the milling step is finished and marginally adjusted, the
subsequent finishing (glaze or polishing) is performed. In some cases, it is
necessary(A)
Figure 1. Layering technique. to stain the prosthetic
Polycrystalline restoration
Framework; associated
(B) withceramic
Feldspathic a build-up
characterization firing. It is interesting to clarify that in ceramics
(wash bake); (C) Feldspathic ceramic build-up (intensive chrome + dentin); (D) Feldspathic withceramic
polymers in their composition, after the pigmentation stage, the structure
build-up (enamel layer); (E) Feldspathic ceramic after firing; (F) Feldspathic ceramic after thermal
must be light-cured.
and mechanical glaze.

Figure2.2.Pressed
Figure
Coatings 2022, 12, x FOR PEER REVIEW Pressedtechnique.
technique.(A)
(A)Stone
Stonemodel
model and
and putty
putty matrix
matrix from
from diagnostic
diagnostic wax-up;
wax-up; (B) (B)
9 Wax-
Wax-up;
of 14
up;Sprueing,
(C) (C) Sprueing, investing,
investing, and and pressing;
pressing; (D) Divesting;
(D) Divesting; (E) Removing
(E) Removing the reacting
the reacting layer;
layer; (F) Stain-
(F) Staining,
ing, firing,
firing, and glaze;
and glaze; (G) Final
(G) Final restoration.
restoration.

Figure 3.
Figure 3. Milled
Milledtechnique.
technique.(A)
(A)Cutting
Cuttingout
outmilled
milled restoration
restoration from
from CAD/CAM
CAD/CAM block;
block; (B)(B) Control-
Controlling
lingmargin’s
the the margin’s thickness
thickness (emergence
(emergence profile);
profile); (C) Controlling
(C) Controlling macro-
macro- and and micro-texture
micro-texture (finish-
(finishing);
ing); (D) After crystallization; (E) Stain technique; (F) Glaze; (G) Final restoration.
(D) After crystallization; (E) Stain technique; (F) Glaze; (G) Final restoration.

One type of material used to carry out this characterization, whether in glass-matrix
or polycrystalline ceramics, is composed of SiO2, Li2O, K2O, P2O5, Al2O3, ZrO2, CeO2, Na2O,
CaO, TiO2, ZrO2, Y2O3, HFO2, respectively, in addition to colored oxides or pigments,
called effect stains or stain fixation, composed of two contents, one powder, and the other
liquid [25,31,38]. The two contents must be agglutinated to obtain a homogeneous paste,
Coatings 2022, 12, 1228 9 of 14

One type of material used to carry out this characterization, whether in glass-matrix or
polycrystalline ceramics, is composed of SiO2 , Li2 O, K2 O, P2 O5 , Al2 O3 , ZrO2 , CeO2 , Na2 O,
CaO, TiO2 , ZrO2 , Y2 O3 , HFO2 , respectively, in addition to colored oxides or pigments,
called effect stains or stain fixation, composed of two contents, one powder, and the other
liquid [25,31,38]. The two contents must be agglutinated to obtain a homogeneous paste,
which must be applied on the external surface of the ceramic. This paste allows for masking
of opaque structures and increasing or reducing the translucency and intensity of the
pigmentation proposed for restorations [31,80,81].
Another characterization used for dental ceramics that have a more crystalline content
is the application of glaze, which allows superficial smoothness, thus preventing the
accommodation of microorganisms, in addition to providing a translucency compatible
with the natural tooth [21,31]. There are reports that this type of extrinsic characterization
of ceramics can remain for up to 12 years, however, the surface roughness may increase
over the years, mainly in areas that do not receive a functional load [17,82,83].
These property changes need further studies since ceramics with a rough surface have
already been shown to be more susceptible to the coloring of external sources [65]. The
texture can still influence the final result of the restorative treatment, since the surface
texture changes the reflection of light and consequently, the color value of the ceramic.
Excessive texturing can still result in the artificiality of the restoration [19,21,22,84]. Other
possible deleterious actions caused by superficial roughness are easier plaque accumulation
and greater wear of antagonistic teeth [19,84].
However, there is still no protocol established for the use of extrinsic characterizations
of ceramics that guarantees a reliable final result [22]. In most cases, the crystallization,
polishing, and glaze procedures are carried out arbitrarily, which makes it difficult to
understand the behavior of these materials [22,84,85].
The different ceramics of the CAD/CAM system have high survival rates in long-term
follow-up when single crowns or even fixed partial prostheses are used, as long as the
clinician uses the ceramic according to their indications. The studies make it clear that
more clinical studies should be carried out to have more long-term information on these
ceramics [39,64,72].

4.5. Analysis of the Roughness and Hardness Properties of Ceramic Materials

The roughness description is presented by linear or bidimensional parameters (Ra,
Rq, Rz, RSM, and Rmax) and by three-dimensional parameters (Sa, Sq, Sz, Scx, Str, and
Sdr) [86]. Ra is defined by the average arithmetic value of all absolute distances within the
measured length, which is the parameter most used to evaluate ceramic surfaces [87,88].
Roughness is one of the properties that influences the wear behavior of antagonistic
teeth [89] and can also interfere with the fatigue resistance of the material [90]. Another
property able to interfere with the performance of restorative materials is hardness. The
enamel hardness value ranges from 300 to 600 HV [91], these values are close to the hardness
of glass-matrix ceramics, such as zirconia-reinforced lithium silicate [62,92–95]. Thus, glass-
matrix ceramics prevent excessive wear of antagonistic teeth, while also presenting a
satisfactory survival rate for a restorative material [35,96]. Feldspathic ceramics have a
lower hardness value when compared to silicates, so physiological wear simulations can
show a greater fragility of these materials [97–100], while polycrystalline ceramics, such as
tetragonal zirconia partially stabilized by yttrium, present high hardness values and when
subjected to physiological tests can promote excessive wear of antagonists [75,76,97].

5. Conclusions
Several ceramic systems are available, thus professionals in the prosthetic area need to
be updated about the techniques, materials, and their proper characterizations. Aesthetic
results with ceramics are not achieved exclusively by the type of material used, but by the
standard adopted in the characterization of the veneer ceramic. The characterization of
ceramic restorations becomes clinical routine; however, these are not performed with a
Coatings 2022, 12, 1228 10 of 14

protocol that allows the reproducibility of the procedure. There is still no best method for
characterization of the surface layer of ceramic structures since the data is discrepant in the
literature. Therefore, further studies are needed concerning the staining layer on ceramics.

Author Contributions: Conceptualization: J.D.M.d.M., D.A.Q., M.A.B. and G.R.S.L.; methodology,

J.D.M.d.M., D.A.Q., M.A.B. and G.R.S.L.; formal analysis, N.C.R.R., L.J.N.N. and L.C.A.; investigation,
J.D.M.d.M., D.A.Q., N.C.R.R., L.J.N.N., A.B.B., L.C.A., M.A.B. and G.R.S.L.; resources, J.D.M.d.M.,
D.A.Q., N.C.R.R., L.J.N.N., M.A.B. and L.C.A.; data curation, J.D.M.d.M., D.A.Q., N.C.R.R., A.B.B.,
L.J.N.N., M.A.B. and L.C.A.; writing—J.D.M.d.M., D.A.Q., N.C.R.R., L.J.N.N., M.A.B. and L.C.A.;
writing—review and editing, N.C.R.R., L.J.N.N., L.C.A. and D.A.Q.; supervision, M.A.B. and G.R.S.L.;
project administration, M.A.B. and G.R.S.L.; funding acquisition, J.D.M.d.M. All authors have read
and agreed to the published version of the manuscript.
Funding: This research was funded by the São Paulo Research Foundation (FAPESP—grant numbers
2018/04454-0, 2019/24903-6, and 2021/11499-2).
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Data are available upon request.
Acknowledgments: The authors appreciated the support received by Hilton Riquieri and Guilherme
Cabral in the present study in providing the illustrative figures.
Conflicts of Interest: The authors declare no conflict of interest.

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