INTRODUCTION

Conservatism lies deep in the heart of modern restorative dentistry. Achieving a

functional and esthetically pleasing result while maintaining as much natural tooth structure as
possible is a desirable prospect for both patient and practitioner.[1]

Nowadays, not only the mechanical and biological aspects of the treatment are of
importance, the demands of patients for an attractive solution also have to be met, because
today’s patients expect dental restorations to imitate the optical properties of natural teeth. The
daily advances in dental material research are driven by the rising demand for long lasting
restorations that imitate the natural appearance of teeth,[2] innovations in ceramic technology
gave birth to novel ceramic systems that rely on varying material principles aimed to satisfy the
clinical requirements of[3] dentists as well as the esthetic expectations of patients. The advent of
minimally invasive indirect bonded ceramic restorations is constantly being improved due to new
materials that could be utilized, further bridging the gap between conservatism and esthetics.
 REVIEW OF LITERATURE

Considering the increasing demands on aesthetics in clinical practice in the past decade, it
is necessary to explore this field to meet existing needs. Technology can provide a solution to
many of the routine hassles in dental practice. While optimal systems are far from fully realized,
technology undeniably has made enormous progress[4].

The microstructure of ceramics determines the optical and mechanical properties of the
restoration. As the glass content increases, superior esthetics gained but low mechanical
properties and vice versa, to combine both strength and esthetic properties, layering technique is
done using a high strength core veneered with translucent porcelain, monolithic restorations
fabricated by CAD/CAM system[5]

Porcelain on the other hand is a ceramic that consists of a glass matrix phase and crystal
phase(s)[6]. The glass phase is responsible for esthetics and the crystalline phase is responsible
for mechanical strength. According to their phases and microstructure ceramics can be classified
according to their microstructure into four groups:[7]

Category 1: glass-based systems (mainly silica)

Category 2: glass-based systems (mainly silica) with fillers, (usually crystalline leucite or
lithium)

Category 3: crystalline-based systems with glass fillers (mainly alumina)

Category 4: polycrystalline solids (alumina and zirconia)

 Category 1: Glass Based Systems (mainly silica).

Glass-based systems are made from materials that contain mainly silicon dioxide (also known as
silica or quartz), which contains various amounts of alumina.

Aluminosilicates found in nature, which contain various amounts of potassium and sodium, are
known as feldspars. Feldspars are modified in various ways to create the glass used in dentistry.
Synthetic forms of alumina silicate glasses are also manufactured for dental ceramics.[7]

Category 2: Glass Based System with fillers.

In this category, ceramics have large variety of glass- crystalline matrix and crystals with
different ratios. Consequently, they can be subdivided into three groups. The difference between
the subgroups is the amount of different types of crystals added or grown in the glass matrix. The
main types of crystals are leucite, lithium disilicate and fluorapatite. The glass-based system is
made from materials that contain silica or silicon dioxide with different amounts of alumina.[8]

Subgroup 2.1: Low to moderate leucite containing feldspathic glass.

This material has leucite crystals that are of random size and distribution with the average
particle size being around several hundred microns. Leucite inhibits crack propagation and raises
the coefficient of thermal expansion of the material which improves the strength of the
material[9] . The randomization of distribution and large particle size gives the material low
fracture resistance and abrasive properties relative to enamel[10, 11] . Recently, much finer
leucite crystals (10–20 µm) have been developed with even particle distribution throughout the
glass. Therefore, they are less abrasive and have higher flexural strength[12] . Via electron
micrograph, it reveals a glass matrix surrounding leucite crystals. This material is available as
powder/liquid and is used for veneering cores of restorations.

Subcategory 2.2: High leucite-containing (approximately 50 %) glass.

They are glass ceramics which have a crystalline phase grown within the glass matrix by a
process called “controlled crystallization of glass”. They have higher resistance to fracture,
erosion and thermal shock. They are available in both powder/liquids, Machin able, and press
able forms. The most famous glass ceramic is the original IPS Empress. Press able and Machin
able ceramics have performed excellently clinically when used for posterior on lays and inlays,
anterior veneers and crown restorations[13] .

Subcategory 2.3: Lithium disilicate glass-ceramic

They consist of a glass matrix of a lithium silicate with micron-size lithium disilicate crystals in
between submicron lithium orthophosphate which creates a highly filled glass matrix with crystal
content about 70%[14] . The lithium disilicate crystals are needle-like in shape[15]. The volume
and shape of the crystals increase the flexural strength to about 360 MPa, or about three times
that of IPS Empress. Even with its high crystalline content the material is very translucent due to
the low refractive index of lithium disilicate crystals. Thus, they can be used as full contour
restorations.

They can also be veneered by veneering porcelain which consists of fluorapatite crystals in an
aluminosilicate glass to create the final morphology and shade of the restoration. Fluorapatite is a
fluoride containing calcium phosphate which contribute to the veneering porcelain’s optical
properties and CTE (coefficient of thermal expansion) so that it matches the lithium disilicate
pressable or machinable material. Lithium disilicate were originally introduced by Ivoclar
Vivadent as IPS Empress II and a new form named IPS E.max pressable and CAD/CAM [12].

Category 3: crystalline-based systems with glass fillers (mainly alumina)

Glass-infiltrated, partially sintered alumina was introduced in 1988 and marketed under the name
In-Ceram. The system was developed as an alternative to conventional metal ceramics and has
met with great clinical success.[7]

Category 4: polycrystalline solids (alumina and zirconia)

Solid-sintered, monophase ceramics are materials that are formed by directly sintering crystals
together without any intervening matrix to from a dense, air-free, glass-free, polycrystalline
structure. There are several different processing techniques that allow the fabrication of either
solid sintered aluminous-oxide or zirconia-oxide frameworks.[7]
Methods of fabrication of all ceramics

A lot of techniques such as heat-pressing, slip-casting, Computer Aided Design-Computer-Aided

Machining (CAD-CAM), and 3D printing are used for fabrication of all ceramic’s restorations.

Heat-pressed ceramics

Pressed ceramics are one of the most popular dental restorative systems due to their accuracy,
marginal integrity, and mechanical properties. This technique was introduced in the late 1980s as
the dental technician creates the restoration in wax. After that, by using the lost-wax technique,
the technician presses a plasticized ceramic ingot into a heated investment mold[16] .

The first generation of heat-pressed dental ceramics contains leucite as reinforcing crystalline
phase. The second generation is lithium disilicate-based. First generation heat-pressed ceramics
contain crystalline phase of 35-45 vol % leucite as crystalline phase. Flexural strength and
fracture toughness values that are about two times higher than those of feldspathic
porcelains[17].

Second generation heat-pressed ceramics contain about 65 vol % lithium disilicate, 34% residual
glass as the main crystalline phase, with about 1% porosity after heat treatments. Höland et al.,
revealed that during crystallization two different phases such as lithium metasilicate (Li2SiO3)
and cristobalite (SiO2) are formed before to the growth of lithium disilicate (Li2Si2O5)
crystals[11] . The final microstructure consists of highly interlocked lithium disilicate crystals
and layered crystals that contribute to strengthening. Also, the mismatch between the coefficient
of thermal expansion of lithium disilicate crystals and glassy matrix results in peripheral
compressive stresses around the crystals. This may be responsible for crack deflection and
strength increase[13].

Observation showed that the survival and complication rate of lithium disilicate was estimated
98.2% and 5.4% at 24 months, and zirconia was 96.8% and 7.1% at 48 months. They concluded
that heat pressed lithium disilicate crowns showed an excellent performance[18] .
 Machined ceramics

Subtractive computer-aided design (CAD) and computer-aided manufacturing

(CAM)technologies have led to major improvements in dentistry[19]. They make it possible to
produce reliable restorations with accurate dimensions [20] and to reduce manufacturing time
[19]. However, these processes are limited by the waste of raw material (loss of unused portions
of blocks and difficulty in recycling excess material) and heavy wear of milling tools.
Microscopic cracks, which can weaken restorations, can also appear in objects due to the milling
process [21].The technology was initially intended for fully sintered ceramic blocks (hard
machining). However, recently, CAD/CAM has been used with partially sintered ceramics (soft
machining), that are later heat treated to ensure adequate sintering.[22].

A-Hard Machining

Currently, fully sintered ceramic materials available for CAD/CAM hard machining of dental
restorations include feldspar-based, leucite-based and lithium disilicate-based ceramics.

A leucite-based ceramic machinable blocks for CAD/CAM restorations have similar

microstructure and mechanical properties to the first-generation leucite-reinforced pressable
ceramics. Machining of fully sintered ceramics creates tool wear and residual surface flaws that
in the long-term could have negative effects on the in vivo performance of the ceramic[8] .

A sophisticated approach to CAD/CAM machining of fully sintered ceramics was anticipated

with the introduction of partially crystallized ceramics in the lithium silicate system. The ceramic
blocks are partially crystallized and contain both lithium metasilicate (Li2SiO3) crystals and
lithium disilicate (Li2Si2O5) crystal nuclei. Therefore, the ceramic is easy to machine and
exhibits moderate strength (130 MPa, according to manufacturer’s data) [23].After heat
treatment and full crystallization of the ceramic, the flexural strength is 360 MPa, according to
manufacturer’s data.

B-Soft Machining
Soft milling involves machining of enlarged pre-sintered blanks of zirconia (green state)
frameworks. The frameworks are then sintered to their full strength, which are accompanied by
shrinkage of the milled framework by approximately 25% to the desired dimensions[24] .The
most common technique to build a restoration is by building a full contour then cutting back the
incisal area to create mamelons and characteristics by the application of various incisal
porcelains then it is fired to attain a full contoured restoration. To produce a natural appearance
with correct form and color, all ceramic restoration is fired several times. The first firing is
served for the releases of stresses caused by grinding and polishing. The second and third firings
are for layering and staining of the restoration. The fourth and other firings done if the dentist
needs correction for shape and color[25] .

3D-printed ceramics

Additive manufacturing processes avoid these limitations by building objects layer-by-

layer. While such processes are already being used to manufacture metal and polymer
prototypes[19], the shaping of ceramics for dental applications is still in its infancy[26, 27].
Ceramics can be additively manufactured by polymerizing an inorganic binder in a ceramic
powder bed (3D printing)[28], selective laser sintering (SLS)[29], ceramic slurry printing (direct
inkjet printing)[30], or stereolithography (SLA)[31]. SLA produces scaffolds in calcium
phosphate hydroxyapatite with the higher accuracy, surface quality, and mechanical
properties[31]. than the other processes by selectively curing a photosensitive ceramic slurry
using an ultraviolet beam. Curing with ultraviolet light makes it possible to work under artificial
light without causing polymerization during the slurry preparation process.

Most reports in the literature dealing with ceramic SLA manufacturing focus on the
impact of slurry composition on polymerization[31, 32] and the optimization of photoinitiator,
diluent, and polymerizable monomer concentrations in ceramic slurries. However, no data is
available regarding the impact of variations in particle size and dry matter content on the flexural
strength and Weibull characteristics of SLA-manufactured dense ceramics. While SLA-
manufactured temporary crowns are commercially[33] available[19], there are no reports in the
literature on the feasibility of using SLA manufactured crown frameworks composed of dense
ceramic.
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