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Current All-Ceramic Systems in Dentistry: A Review.

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 CONTINUING EDUCATION 2
CERAMIC SYSTEMS

Current All-Ceramic Systems

in Dentistry: A Review
Maria Jacinta M.C. Santos, DDS, MSc, PhD; Max Dorea Costa, DDS, MSc; José H. Rubo, DDS, MSc, PhD;

Luis Fernando Pegoraro, DDS, MSc, PhD; and Gildo C. Santos Jr., DDS, MSc, PhD

LEARNING OBJECTIVES

• discuss the ceramic systems

Abstract: This article describes the ceramic systems and processing tech-
and processing techniques
niques available today in dentistry. It aims to help clinicians understand the available today in dentistry

advantages and disadvantages of a myriad of ceramic materials and technique • explain differences between
the various methods of all-
options. The microstructural components, materials’ properties, indications, ceramic fabrication
and names of products are discussed to help clarify their use. Key topics will • discuss factors that affect

include ceramics, particle-filled glasses, polycrystalline ceramics, CAD⁄CAM, survival and failure rates of
all-ceramic restorations
and adhesive cementation.

D
ental ceramics have been widely utilized to restore
anterior and posterior teeth due to several qualities,
most notably their optical properties, color stabil-
ity, wear resistance, biocompatibility, and excellent
esthetics.1-3 Since the 1960s, when leucite content
was added to the existing feldspathic ceramic formulation to in-
crease its coefficient of thermal expansion to enable use with dental
casting alloys, metal frameworks have been veneered with dental
ceramic in an effort to ally the esthetic features of ceramic with the
fracture resistance of the metal substructure.4,5
Although porcelain fused to metal (PFM) has shown good results
with long-term clinical success rates (survival rates at 5 years above
94.4%),2,4,5 it presents some disadvantages, mostly related to the
presence of metal, which can create esthetic challenges and, on
rare occasions, provoke allergic reactions. Previous studies have re-
ported the presence of metal allergy to various metals, such as gold,
silver, cobalt, tin, palladium, chromium, and nickel, among different
populations.6-9 Limited esthetic results are a consequence of the
presence of a metal framework, which decreases light transmission
through ceramic, especially when insufficient space is available for
the veneering material.1,2 The gray metal framework has also been
attributed to the bluish appearance of the surrounding soft tissues.
This problem was partially resolved in the 1970s by the introduc-
tion of collarless metal-ceramics that proposed the use of a reduced
framework design with shoulder ceramics.10,11
In recent decades, the increasing demand for esthetic restora-
tions allied to the desire to eliminate the metal coping has driven
the development of new types of dental ceramic materials.1,12 In
the 1980s, the introduction of low-shrinkage ceramics and a cast-
able glass-ceramic system (Dicor, Dentsply) marked the introduc-
tion of advanced ceramics with innovative processing methods.12
Later, Mormann and Brandestini developed the first operational
computer-aided design/computer-aided manufacturing (CAD/
CAM) system to fabricate inlays and onlays from solid ceramic
blocks (CEREC I, Siemens Dental/now Sirona Dental). Since
then, CAD/CAM technology has been pursued worldwide with
the introduction of different ceramic systems that have adopted
the CAD/CAM technique.2,13 In the early 1990s, the lost-wax press
technique was introduced as an innovative processing method for
all-ceramic restorations.14
Because of the worldwide acceptance of all-ceramic restora-
tions, ceramics with high flexural strength were developed in order
to extend their indication for anterior and posterior fixed dental
prostheses (FDPs). The flexural strength and fracture toughness of
zirconia are the highest ever reported for any dental ceramic, and
its use is rapidly growing, especially for FDPs.12,15
The improvements achieved in ceramic materials have resulted
in greater quality control and have simplified the work of dental
technicians through various processing methods.12,16,17 The array
of ceramic compositions and different types of manufacturing

www.compendiumlive.com January 2015 COMPENDIUM 31

CONTINUING EDUCATION 2 | CERAMIC SYSTEMS
techniques has afforded clinicians numerous systems from which
to choose; thus, a more comprehensive understanding of each sys-
tem is needed in order to make wise choices. This article, therefore,
aims to describe different all-ceramic systems available in dentistry
according to the ceramic composition and fabrication technique.
Clinical indications and survival rates will also be discussed.
Manufacturing Techniques
All-ceramic restorations may be fabricated by different methods:
powder condensation (conventional powder slurry ceramics), heat-
pressed (pressable ceramics), slip casting (infiltrated ceramics),
and milled (machinable or CAD/CAM ceramics). (Note: Commer-
cial names are identified in Table 1, which can be accessed online
at compendiumce.com/go/1502).
Powder Condensation (conventional powder slurry
ceramics)
Powder condensation is a traditional method to fabricate feld-
spathic ceramic restorations. It involves the use of powders, avail-
able in various shades and translucencies, and de-ionized water to
produce a slurry.1,2 The moist porcelain powder is applied over a
refractory die, copings, or frameworks with a brush, and vibrated
and compacted to remove excess moisture. The ceramic restora-
tion is fired under vacuum, which helps to remove remaining air
and improve the density and esthetics.17,18
This handmade technique may result in a large amount of re-
sidual porosity, which can affect the final strength.1,3,17 The number
and size of voids remaining will depend on the particle size distribu-
tion, sintering time, temperature, ceramic chemical composition,
and viscosity of the melt.18
Ceramics fabricated by powder condensation have good trans-
lucency and are typically applied as the esthetic veneer layers on
metal or all-ceramic frameworks. Other applications include their
use for anterior veneers, inlays, and onlays restorations.1,18
Heat-Pressed (pressable ceramics)
Prefabricated pressable ceramics are available in monochromatic
ingots made of crystalline particles distributed throughout a glassy
material.1,14,16 Although the microstructure of the ingots is similar
to that of conventional powder ceramics, it presents lower poros-
ity and higher crystalline content. The ingots are manufactured
from nonporous glass by applying a heat treatment that transforms
some of the glass into crystals, producing a well-controlled and
homogeneous material.17
The lost-wax method is used in combination with the heat-
pressed technique.13,14,17 A desired monochromatic ingot is heated
to a temperature at which it becomes a highly viscous liquid to
allow the material to flow under pressure into the lost-wax mold.
One of the advantages of the hot-pressing technique is that dental
technicians have experience working with the lost-wax method
to cast metal alloys.16,17,19,20 The final restoration is subsequently
stained and glazed to achieve the final esthetic result.
The first generation of heat-pressed dental ceramics uses leu-
cite as the reinforcing crystalline phase (eg, IPS Empress®, Ivoclar
Vivadent, www.ivoclarvivadent.com), while the second generation
32 COMPENDIUM January 2015
consists of lithium-disilicate–based ceramics (IPS Empress 2).
Feldspathic leucite-reinforced and lithium-disilicate composi-
tions of pressed ceramic have been used as inlays, onlays, veneers,
single-unit crowns, and limited FDPs.1,16,19,20 They can also be used
as substrate, usually as core and coping or framework materials for
conventional powder feldspathic porcelain buildup to achieve the
restorations’ final shape and shade.16,20
Slip Casting (infiltrated ceramics)
The slip-casting technique consists of preparing stable suspensions,
the slip, and fabricating structures by building a solid layer on the
surface of a porous mold that absorbs the liquid phase by means
of capillary forces.1,3 The slip is a homogeneous mixture of ceramic
powder particles suspended in a fluid, usually water, applied over a
gypsum die that absorbs some water from the slip through capillary
action, forming the underling framework.17,20 The alumina, very
porous framework is partially sintered to increase its strength to
a point where it can be removed from the die and infiltrated with
a molten lanthanum glass, which flows into the pores by capillary
action. The final core is fully sintered to yield a ceramic coping of
high density and strength before the veneering porcelain can be
applied. This technique has been widely used in dentistry on In-
Ceram® products (Vita Zahnfabrik, www.vita-zahnfabrik.com).2,16,17
Ceramics fabricated by slip casting can have higher fracture
resistance than those produced by powder condensation, because
the strengthening crystalline particles form a continuous network
throughout the framework.16,17 The disadvantage of this method,
however, is the number of complicated steps involved, which may
result in internal defects that weaken the material due to incom-
plete glass infiltration.1,17 Glass-infiltrated ingots can be used with
CAD/CAM technology, eliminating some of the steps and simplify-
ing the technique.
Milled (machinable ceramics)
Dental CAD/CAM systems use a scanning device, design soft-
ware, and a milling machine to fabricate copings, frameworks, and
restorations from industrially prefabricated ceramic blocks.13,21
Two methods are available to process the ceramic blocks. The
first method was developed with the intention to machine fully
sintered ceramic (hard machining); however, machining of fully
sintered ceramic blocks can result in significant tool wear and re-
sidual flaws at the ceramic surface, which can reduce the survival
of the ceramic restorations.20
More recently, CAD/CAM technology has been used with partially
sintered ceramics (soft machining or green machining), which are
subsequently fully sintered to eliminate porosity. In this case, the
computer software takes into account the shrinkage that is generated
during sintering to promote accuracy of fit of the final restoration.16,17
The increasing popularity and variety of CAD/CAM systems
has extended and consolidated the use of this manufacturing
technique.13,16,21 The machinable ceramic blocks for CAD/CAM
restorations are available in feldspathic porcelain-based ceramic,
leucite-reinforced glass ceramic, lithium-disilicate glass ceram-
ics, glass-infiltrated ceramics, and polycrystalline alumina and
zirconia materials.13,15,22
Volume 36, Number 1
 Dentists and laboratories can use CAD/CAM technology in many and potassium, which are able to modify important properties
different ways. Conventional impressions can be sent to a labora- of the glass, such as lowering firing temperatures or increasing
tory to begin the CAD process using a stone model, or dentists can thermal expansion and contraction behavior.2
take a digital impression with a handheld scanner, using a compact Dental ceramics that best mimic the optical properties of enamel
chairside CAD/CAM machine, and either send it to a laboratory and dentin are predominantly glassy materials.1,2 However, these
for fabrication of the restorations or use their own CAD and do the ceramics present low mechanical properties, with flexural strength
milling in-house.13,20,22 Design work is done on the monitor and the usually ranging from 60 MPa to 70 MPa.1,17,24 They were first used in
instructions are sent to a computer-assisted processing machine dentistry to make porcelain dentures, and later were also used as ve-
for milling the restorations from the prefabricated blocks.21,23,24 neering materials for metal or all-ceramic frameworks, as well as for
The CAD/CAM blocks are fabricated under optimum conditions, veneers, using either a refractory die technique or platinum foil.16,17
and during the CAM process the computer-controlled fabrication
reduces the potential for errors, creating restorations without the Particle-Filled Glass with Variable
variations and inaccuracies that might be found in conventional Amount of Glass Content
laboratory-fabricated restorations.16,20,21 Individual blocks are bar- Although the glass composition is similar to the glassy ceram-
coded with the actual density of each block for shrinkage calcula- ics previously described, this category of particle-filled glasses
tions, and the milling machines can automatically change milling presents varying amounts of crystal types that have either been
tools according to need.2 Additionally, time and cost involved in added to or grown in the glassy matrix.18 Filler particles are added
labor-intensive waxing, casting, and soldering of frameworks can to the glassy ceramics in order to improve their mechanical prop-
be reduced with the application of CAD/CAM technology.13,20,21 erties—for example, to alter the coefficient of thermal expansion
CAD/CAM can be used to fabricate inlays, onlays, veneers, crowns, and inhibit crack propagation—and to control optical effects, such
FDPs, and implant abutments. as opalescence, color, and opacity.1,23,24 These fillers are usually
crystalline that can be added mechanically to the glass, or, as per
Composition Classification and a more recent approach, the crystallites can grow within the glass
Clinical Application by a special heat treatment.1,2 This category presents a large range
Ceramic materials are formed via two or more distinct phases, usu- of glass-crystalline ratios and crystal types that includes four main
ally based on a glass matrix and crystalline filler particles.2,17 The subgroups: low-to-moderate leucite-containing feldspathic glass;
development of higher strength ceramics is resultant of the in- high leucite-containing glass; lithium-disilicate glass; and glass-
creased use of crystalline material and filler particles that are added infiltrated ceramics with glass fillers (mainly alumina).17,20
to the glass matrix aimed at improving the ceramic’s mechanical Low-to-moderate leucite (17 to 25 vol %) glass ceramic—
properties by using decreasingly less glass phase and, finally, no Leucite was the first filler used in dental ceramics enriched
glass content. However, highly esthetic dental ceramics are pre- with a crystalline mineral in order to increase its coefficient of
dominantly glass, while higher strength substructure ceramics are thermal expansion (CTE) to enable it to be fired onto metal sub-
generally crystalline.2 structures.23 Leucite is a reaction product of potassium feldspar
Based at the microstructural level, dental ceramics can be defined by and glass that may modify the CTE, alter the optical properties,
their composition of glass-to-crystalline ratio in three main classes :
2,17
and inhibit crack propagation, thereby improving the material’s
strength. 2,3,23
The amount of leucite present in the glass base may
• predominantly glassy materials with high glass content be adjusted depending on the type of core and required CTE.
• particle-filled glasses with variable amounts of glass content Usually 17 to 25 mass % filler is added to the base dental glass
• polycrystalline ceramics without glass content to create ceramics that are thermally compatible during firing
with dental alloys.1,2,17 The relative amounts of crystal and glass
(Note: Information about ceramic systems’ classification, com- depend on the ceramic system in question. Commercial ceramic
position, fabrication process, manufacturers, and clinical indica- systems incorporating leucite fillers consist of powder ceramics to
tion are summarized in Table 1, which can be accessed online at be used as veneering material for metal-ceramic and all-ceramic
compendiumce.com/go/1502) substructures, and can also be employed for fabricating porcelain
veneers, inlays, and onlays.1,17,20
Predominantly Glassy Ceramics / High-leucite (35 to 55 vol %) glass ceramic—In this category,
Feldspathic Amorphous Glass leucite is used as a reinforcing crystalline at a concentration of 35
A noncrystalline-containing material is classified as a glass. 17 to 55 vol %.2,20 The microstructure of this class of ceramic materials
Glasses are 3-dimensional (3-D) networks of atoms that lack a consists of a glass matrix surrounding individual crystals.17,25 The
regular pattern to the spacing (distance and angle), resulting in a material starts as a homogeneous glass, and a special heat treat-
structure that is “amorphous” or without form.2 The glass-based ment nucleates and grows leucite crystals, which results in improved
systems used in dental ceramics originate from feldspar minerals mechanical properties such as increased fracture resistance and im-
that contain mainly silicon dioxide (silica or quartz), which have proved thermal shock resistance.25 The strengthening effect added by
various amounts of alumina (aluminum oxide); they are also called the incorporation of crystal depends on the interaction between the
aluminosilicate glasses.1,2,16,17 Feldspathic glasses contain sodium crystals and glassy matrix, as well as on the crystal size and amount.

www.compendiumlive.com January 2015 COMPENDIUM 33

CONTINUING EDUCATION 2 | CERAMIC SYSTEMS
Finer crystals generally produce stronger materials.17,25 The crystals
strengthen the ceramic material by acting as a barrier to cracks. A
crack growing from a defect must go around the crystal, which may
modify the propagating crack direction and could completely stop
it.17 Additionally, because of the difference in the CTE between the
leucite crystals and the glassy matrix, tangential compressive stresses
are developed around the crystals on cooling, which may contribute
to crack deflection and improved mechanical performance.16,17,20,25
Commercial ceramics incorporating leucite fillers include
different groups, according to the fabrication technique. In the
first group the ceramic is pressed at high temperature. Examples
include: OPC (Jeneric/Pentron, www.jeneric-pentron.de); IPS
Empress® and IPS Empress® Esthetic (Ivoclar Vivadent, www.
ivoclarvivadent.com); Finesse ® All-Ceramic (DENTSPLY
Prosthetics, www.dentsply.com); Authentic® (Jensen Dental,
www.jensendental.com); and VITA PM®9 (VIDENT, www.vident.
com). In the second group the ceramic is provided as a powder
for traditional porcelain build-up. Examples include: OPC Plus
(Jeneric/Pentron); Fortress™ (Mirage Dental Systems, www.
miragecdp.com); and VITA VMK 68 (VITA Zahnfabrik). The
third group comprises materials that have been developed into
fine-grain machinable blocks for CAD/CAM systems. These in-
clude: VITABLOCS® Mark II (VIDENT); IPS ProCAD and IPS
Empress® CAD (Ivoclar Vivadent); and Paradigm™ C porcelain
block (3M ESPE, www.3MESPE.com).12,17,21 Multicolored blocks
were developed to reproduce color transitions and shading as well
as different levels of translucency.21
High-leucite (35 to 55 vol %) glass ceramic materials are in-
dicated for fabrication of inlays, onlays, anterior veneers, and
crowns.24,25 Pressable ceramics with high-leucite content present
flexural strength around 130 MPa.24
Lithium-disilicate glass ceramic—Glass ceramics enriched
with lithium-disilicate crystals (SiO2-Li2O) were developed by
Ivoclar Vivadent to be used with the lost-wax/heat pressed tech-
nique (IPS Empress® 2 and IPS e.max® Press) and later on with the
CAD/CAM technology (IPS e.max® CAD). The high crystal content
(70 vol %) is considerably higher than that of leucite materials. The
ceramic microstructure consists of highly interlocked lithium-
disilicate crystals, 5 mm in length and 0.8 mm in diameter.17,26
IPS Empress 2 has improved flexural strength (360 MPa) that
is more than two times that of leucite-based IPS Empress, and
is indicated for anterior and premolars crowns, as well as three-
unit FDPs in the anterior region.17,26 The framework is veneered
with fluoroapatite-based veneering porcelain (IPS Eris, Ivoclar
Vivadent), which presents similar optical properties and CTE, thus
it matches the lithium-disilicate material resulting in an esthetic
restoration with enhanced light transmission.12
In 2005, IPS e.max Press was introduced with improved physical
properties (flexural strength 400 MPa) compared to the former
IPS Empress 2.12,20 It also consists of a lithium-disilicate glass ce-
ramic, but with refined crystal size, presenting improved physical
properties and translucency acquired through a different firing
process.27 Due to the relatively low refractive index of the lithium-
disilicate crystals, this material presents high translucency de-
spite its high crystalline content.2 The IPS e.max Press pressable
34 COMPENDIUM January 2015
lithium-disilicate ceramic can be used in monolithic application
for inlays, onlays, and posterior crowns or as a core material for
crowns and three-unit FDPs in the anterior region.20
Machinable lithium-disilicate blocks (IPS e.max CAD) were re-
cently developed to be used with CAD/CAM processing technology.
These blocks are subjected to a two-stage crystallization process. In
the first stage, 40 vol % of lithium-metasilicate crystals are formed,
resulting in a flexural strength of 130 MPa to 150 MPa, which per-
mits easier machining and intraoral occlusal adjustment. During
the final crystallization process, 70% of crystal volume is incorpo-
rated in a glass matrix, increasing its final resistance. Additionally,
in this stage the blue shade of the precrystallized block is changed
to the selected tooth shade. The final restoration presents a flexural
strength of 360 MPa; these are indicated for anterior or posterior
crowns, implant crowns, inlays, onlays, and veneers.20,24,26
Glass-infiltrated alumina-based ceramics (slip-cast ceram-
ics)—Glass-infiltrated alumina-based ceramics have been limited
to one series of In-Ceram products (Vita Zahnfabrik).16 In-Ceram
ceramic consists of a high-strength core based on alumina particles
(70 to 80 wt % aluminum oxide) and a lathanum-aluminosilicate
glass, generally fabricated with the slip-casting technique.2,17 A slip
composed of densely packed aluminum oxide (Al2O3) and water is
applied over a gypsum die and baked at 1120°C for 10 hours to cre-
ate a porous matrix, which will be filled by a second-phase material,
the lanthanum-aluminosilicate glass.1,27 The capillary action draws
a liquid or molten glass into all the pores during a second firing at
1100°C for 4 hours to produce the dense interpenetrating material.
The lanthanum decreases the viscosity of the glass to assist infiltra-
tion and increases its index of refraction to improve translucency
of In-Ceram ceramic.1,2,17,28
The slip-casting technique may be used to fabricate the ceramic
core, or as has been done more recently, it can be milled from a
pre-sintered block.12,17 Glass-infiltrated CAD/CAM blocks have
similar composition to slip-cast ceramics while eliminating the
complicated steps of slip casting. Partially sintered blocks are
initially milled, and the porosity is eliminated by molten glass
infiltration. Afterwards, the coping is veneered with feldspathic
porcelain.12,16,20 The In-Ceram products include different composi-
tions and fabrication techniques designed to cover the wide scope
of all-ceramic restorations, including veneers, inlays, onlays, and
anterior/posterior crowns and bridges.17,27,28 Flexural strengths
range from 350 MPa for spinel to 450 MPa for alumina, and up to
650 MPa for zirconia.17,27
In-Ceram Alumina (alumina matrix) was the first all-ceramic
system available for anterior and posterior single-unit restora-
tions and three-unit anterior bridges with a high-strength ceramic
core and lower translucency.12,17 In-Ceram Spinell (alumina and
magnesia matrix, MgAl2O4) is a modification of the original In-
Ceram Alumina system. Substituting magnesium aluminate spinel
for the aluminum oxide improved translucency, partly because of
the crystalline spinel, which provides isotropic optical properties,
and partly because of a lower index of refraction compared with
alumina.1,12,17 In-Ceram Spinel is the most translucent, with mod-
erately high strength, though not as strong as the alumina-based
material, and is used for anterior crowns.2,17 In-Ceram Zirconia
Volume 36, Number 1
(alumina and zirconia matrix, 12 Ce-TZP-Al2O3) presents higher
strength and lower translucency.17 It is also a modification of the
original In-Ceram Alumina system, with an addition of 35% par-
tially stabilized zirconia oxide (ZrO2) added to the slip or block
composition to strengthen the ceramic material.12 Since the core is
very opaque and lacks translucency, this material is recommended
for posterior crown copings and FDP frameworks, primarily for
three-unit posterior bridges.12,17
Fully Polycrystalline or Polycrystalline
Ceramics / No Glass Content
The development of high-strength polycrystalline ceramics came
about as a result of the increased use of crystalline material with
subsequent decreased amounts of the glass phase, until no glass was
present in the material microstructure.2 These ceramics are formed
by directly sintering crystals together, resulting in a dense, glass-
free polycrystalline structure without any intermediary matrix.17
These solid-sintered monophase ceramics are characterized by
regular arrays in which the atoms are densely packed, resulting in
a very strong and tough material that is difficult to crack compared
to a less dense and irregular network found in glasses.2,15
Polycrystalline ceramics are more difficult to process than
glassy ceramics. The availability of computer-aided manufactur-
ing allowed the fabrication of either solid-sintered aluminous
oxide (alumina, AlO) or zirconium oxide (ZrO) dental cores and
frameworks.2,27 These higher strength ceramics tend to be relatively
opaque compared to glassy ceramics, and some polycrystalline
ceramics present opacity similar to cast alloys. They are usually
indicated as substructure materials upon which glassy ceramics
are veneered to achieve pleasing esthetics.27
Alumina—The first fully dense polycrystalline material used for
dental applications was developed in 1983. With Procera® AllCeram
alumina Nobel Biocare (www.nobelbiocare.com) embraced the
concept of CAD/CAM technology to fabricate all-ceramic crowns
composed of a densely sintered, high-purity aluminum-oxide cop-
ing combined with a low-fusing all-ceramic veneering porcelain.
Copings contain 99.5% to 99.9% high-purity aluminum oxide and
a strength of approximately 600 MPa.29
The working die is scanned using a scanner probe that contacts
the surface of the die, enabling visualization of a defined 3-D shape
of the preparation. The data is sent electronically to a manufactur-
ing facility where a 20% enlarged model is copy-milled and fabri-
cated, taking into account the ceramic shrinkage. A high-purity
aluminum-oxide powder is mechanically compacted and milled
on the enlarged die. The coping is then sintered at about 1600°C
to full density eliminating porosity and returning the dense coping
to the dimensions of the working die.13,29 The coping is mailed to
the dental laboratory and the crown is completed by the addition
of a low-fusing feldspathic porcelain that matches the CTE of the
aluminum oxide.12,29 Procera has the highest strength of the alumi-
na-based materials; however, its strength is lower than zirconia.12
Zirconia—In its pure form zirconia oxide (ZrO2) is a polymor-
phic material that occurs in three crystalline forms that are tem-
perature-dependent: monoclinic (room temperature to 1170°C), te-
tragonal (1170°C to 2370°C), and cubic (2370°C to melting point).22
www.compendiumlive.com
During firing zirconium oxide is transformed from one crystalline
state to another. At firing temperature zirconia is tetragonal and
at room temperature monoclinic. The tetragonal-to-monoclinic
phase transformation occurs below 1170°C and is accompanied by a
3% to 5% volume expansion that causes high compressive stresses,
which can generate crack propagation and failure.12,22 In order to
stabilize the tetragonal phase at room temperature, yttrium-oxide
(Y2O 3% mol) is added in small amounts to pure zirconia to control
the volume expansion.20,22
Yttria-stabilized tetragonal zirconia polycrystalline (Y-TZP) is a
high-strength ceramic, introduced for dental use as a core or frame-
work material for FDPs and crowns. Although hard machining of
fully sintered zirconia ceramics is possible, it may compromise
the microstructure and strength of the material and would require
extensive milling to produce the framework. Soft machining of
partially sintered zirconia blocks by CAD/CAM technology is used
to produce enlarged frameworks in a so-called green state.12,20,22
Processing with this softer pre-sintered material not only shortens
the milling time but also reduces the wear on the milling tools.12
The disadvantage of this process is the need for subsequent sinter-
ing treatment to eliminate the ceramic porosity. In these cases the
software used for restoration design must compensate the 20%
to 25% of shrinkage that occurs during the sintering procedure to
provide accuracy of fit to the final restoration.12,16 Currently avail-
able zirconia ceramics for soft machining of dental frameworks
require sintering temperatures varying from 1350°C to 1550°C
and durations from 2 to 6 hours, depending on the manufacturer.16
The zirconia ceramics are characterized by a dense, monocrys-
talline homogeneity, and possess low thermal conductivity, low
corrosion potential, good radiopacity, high biocompatibility, low
bacterial surface adhesion, and favorable optical properties.12,16,20,22
Compared with high-strength alumina ceramic, zirconia has twice
the flexural strength (900 MPa to 1200 MPa).17,20 Possible prob-
lems with zirconia ceramics may involve long-term instability in
the presence of water, veneering porcelain compatibility issues,
esthetic limitations due to their opacity, and no adequate bond
with resin-based luting cements.2
Previous reports revealed that the most common clinical
problems have not been associated with cracking of the zirco-
nia framework, but with chipping and cracking of the veneering
porcelain.2,12,17,22 Although these failures may be associated with
non-anatomic framework designs or with poor bonding between
zirconia and veneer, other hypotheses include problems related
to the material itself and are often associated with low degrada-
tion phenomenon at mouth temperature, auto-catalytic trans-
formation during porcelain firing, and residual stresses resultant
from thermomechanical parameters.2 Recent research supports
residual stresses developed as a result of rapid cooling during the
porcelain firing procedure and suggest a slow-cooling protocol to
equalize the heat dissipation from zirconia and veneering porce-
lain, increasing the fracture resistance of the veneer.2,17 The need
for a reduced cooling rate after final firing or glazing has been
reinforced by other studies.2,20
Dental zirconia presents properties to be used in single- and
multiple-unit anterior and posterior FDPs.16,17,22
January 2015 COMPENDIUM 35
CONTINUING EDUCATION 2 | CERAMIC SYSTEMS
Survival and Failure
The variability of all-ceramic systems available presents a challenge
when combining data from several studies. Survival rates change
dramatically when comparing different ceramic systems among
different periods of evaluation.
Clinical evaluations of glass-ceramic materials used for inlays,
onlays, and veneers present survival rates ranging from 93% to
98% at 5 years, to 64% to 95% after 10 years.30-34 The high success
rate is associated with the capacity of these glass-ceramic systems
to be etched and bonded to the tooth structure with resin-based
cements.30,35 Although several studies have reported higher fracture
resistance for machinable and pressable systems when compared
to powder/liquid conventional ceramics,17,35 other studies have
reported similar survival for both ceramic systems.33,34
Clinical reports on leucite-reinforced glass-ceramic IPS Empress
crowns have presented low overall fracture rates.36-39 However, a
statistically significant higher survival rate has been reported for
anterior crowns.37
Glass-infiltrated ceramic crowns placed in the anterior and
posterior segments presented a high survival rate, which ranged
from 91% to 100% at 5 years for In-Ceram Alumina and Zirconia.40
Another study reported a cumulative survival rate of 96.9% for
anterior teeth and 87.7% for posterior teeth after 5 years.41 These
data are comparable to those of Procera AllCeram alumina crowns,
presenting survival rates ranging from 90.9% to 95.2% after 6 years,
and at 93.5% after 10 years.42,43 When the In-Ceram system was
used for three- and four-unit FDPs, the survival rate ranged from
85% to 96% at a 5-year period.40
Lithium-disilicate–based glass-ceramic restorations have also
achieved high survival rates. The IPS Empress 2 crowns showed
survival rates of 95% to 100% at 5 years, and 95.5% after 10 years.44,45
Reich and Schierz (2013)46 reported a survival rate of 96.3% after
a period of 4.6 years for chairside-generated e.max CAD crowns.
Another study showed 100% survival rate for crowns after 5 years,
but the survival rate dropped to 70% when this material was used
on three- and four-unit FDPs.44 The main cause of clinical failure
was associated with connector fracture. 44-47 Kern et al (2013)47
reported survival rates of 100% for the IPS e.max Press three-unit
FDPs after 5 years and 87.9% after 10 years.
Zirconia-supported crowns and three- to five-unit FDPs pre-
sented survival rates from 73.9% to 100% at 5 years.48-50 Clinical
evaluations of zirconia restorations have reported no problems
related to the zirconia framework. The most frequent causes of
clinical failure are related to chipping and cracking of veneering
porcelain. 20,48-51 Veneer chipping rates are reported at 2% to 9% for
single crowns at 3 years and at 3% to 36% for FDPs at 5 years.20,48,50
Rinke et al (2013)51 reported 83.4% overall survival of zirconia
FDPs at 7 years and attributed the major failures to fractures of
the veneering ceramic and decementations.
The use of all-ceramic systems for FDPs has limitations.
Correct diagnosis and patient selection are important factors for
success. The connector height for each system should be created
according to the guidelines proposed for each material. Several
factors should be analyzed, some of which may restrict the use of
all-ceramic restorations, such as reduced interocclusal distance,
36 COMPENDIUM January 2015
deep vertical overlap without horizontal overlap, cantilevers, peri-
odontal problems, severe bruxism, and parafunctional activity.12
The selection of the all-ceramic material depends on the indica-
tion, and the dentist should be especially careful with preparation
guidelines, meticulous with occlusal adjustment, and aware of
parafunctional habits.
Conclusion
With the introduction of innovative fabrication techniques, such
as heat-pressed, slip-cast, and CAD/CAM, the development of
several ceramic systems marked the last four decades. The gradual
improvement of ceramic materials for fixed prosthodontics led to
the development of fully polycrystalline materials that present
increased flexural strength and fracture toughness. The manufac-
turing of polycrystalline ceramics became possible due to recent
advances in ceramic milling by CAD/CAM technology, especially
with the soft machining processing of partially sintered ceramics.
As a consequence of the consolidation of CAD/CAM technology,
different ceramic systems became available in blocks for CAD/
CAM processing, including feldspathic porcelain-based ceramic,
leucite-reinforced glass ceramic, lithium-disilicate glass ceramics,
glass-infiltrated ceramics, and polycrystalline alumina and zirconia.
DISCLOSURE
The authors report no affiliation with any of the companies men-
tioned in this article.
ABOUT THE AUTHOR
Maria Jacinta M.C. Santos, DDS, MSc, PhD
Assistant Professor, Schulich School of Medicine & Dentistry, Western University,
London, Ontario, Canada
Max Dorea Costa, DDS, MSc
PhD Student, Bauru School of Dentistry, University of São Paulo, Bauru, São Paulo,
Brazil
José H. Rubo, DDS, MSc, PhD
Associate Professor, Department of Prosthodontics, Bauru School of Dentistry,
University of São Paulo, Bauru, São Paulo, Brazil
Luis Fernando Pegoraro, DDS, MSc, PhD
Associate Professor, Department of Prosthodontics, Bauru School of Dentistry,
University of São Paulo, Bauru, São Paulo, Brazil
Gildo C. Santos Jr., DDS, MSc, PhD
Associate Professor, Chair of the Division of Restorative Dentistry, Schulich School of
Medicine & Dentistry, Western University, London, Ontario, Canada
Queries to the author regarding this course may be submitted to
authorqueries@aegiscomm.com.
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45. Valenti M, Valenti A. Retrospective survival analysis of 261 lithium
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48. Burke FJ, Crisp RJ, Cowan AJ, et al. Five-year clinical evaluation
of zirconia-based bridges in patients in UK general dental practices. J
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49. Molin MK, Karlsson SL Five-year clinical prospective evaluation of
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January 2015 COMPENDIUM 37
 CONTINUING EDUCATION 2
QUIZ

Current All-Ceramic Systems in Dentistry: A Review

Maria Jacinta M.C. Santos, DDS, MSc, PhD; Max Dorea Costa, DDS, MSc; José H. Rubo, DDS, MSc, PhD; Luis Fernando

Pegoraro, DDS, MSc, PhD; and Gildo C. Santos Jr., DDS, MSc, PhD

This article provides 2 hours of CE credit from AEGIS Publications, LLC. Record your answers on the enclosed Answer Form or submit them on a
separate sheet of paper. You may also phone your answers in to 877-423-4471 or fax them to (215) 504-1502 or log on to compendiumce.com/go/1502.
Be sure to include your name, address, telephone number, and last 4 digits of your Social Security number.

Please complete Answer Form on page 40, including your name and payment information.
YOU CAN ALSO TAKE THIS COURSE ONLINE AT COMPENDIUMCE.COM/GO/1502.

1. Although porcelain fused to metal (PFM) has shown good 6. Dental ceramics that best mimic the optical properties of
results with long-term clinical success rates, it presents some enamel and dentin are:
disadvantages, mostly related to: A. particle-filled glasses with variable amounts of glass content.
A. flexural strength. B. polycrystalline ceramics without glass content.
B. the presence of metal. C. predominantly glassy materials.
C. processing methods. D. all of the above
D. the lost-wax press technique.
7. Pressable ceramics with high-leucite content present flexural
2. With flexural strength and fracture toughness of zirconia the strength around:
highest ever reported for any dental ceramic, its use is rapidly A. 30 MPa.
growing, especially for: B. 130 MPa.
A. heat-pressed ceramics. C. 360 MPa.
B. feldspathic ceramic restorations. D. 650 MPa.
C. collarless ceramo-metal restorations.
D. fixed dental prostheses (FDPs). 8. Machinable lithium-disilicate blocks recently developed to be
used with CAD/CAM processing technology are subjected to:
3. Powder condensation, a traditional method to fabricate A. a two-stage crystallization process.
feldspathic ceramic restorations, involves the use of B. the lost-wax/heat pressed technique.
powders and: C. the complicated steps involved in slip casting.
A. de-ionized water. D. the addition of 35% partially stabilized zirconia oxide for
B. a monochromatic ingot. increased strength.
C. crystalline particles.
D. leucite crystals. 9. In its pure form zirconia oxide is a polymorphic material that
occurs in which of the following temperature-dependent
4. Ceramics fabricated by slip casting can have higher fracture crystalline forms?
resistance than those produced by powder condensation, A. monoclinic
because the strengthening crystalline particles: B. tetragonal
A. always produce complete glass infiltration. C. cubic
B. form a continuous network throughout the framework. D. all of the above
C. become a highly viscous liquid.
D. take into account shrinkage generated during sintering. 10. The high survival rate of glass-ceramic materials is associated
with the capacity of glass-ceramic systems to be etched and
5. CAD/CAM technology has been used with partially sintered bonded to the tooth structure:
ceramics, which are subsequently fully sintered to eliminate: A. using bulk-fill technique.
A. impermeability. B. with a resin-modified glass-ionomer.
B. porosity. C. with resin-based cements.
C. complexities in technique. D. using a universal adhesive.
D. the need for a stone model.

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