Dental Ceramics : What Is This Stuff Anyway? J.

Robert Kelly JADA 2008;139;4S-7S The following resources related to this article are available online at jada.ada.org ( this information is current as of March 27, 2012):
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Dental ceramics
What is this stuff anyway?
J. Robert Kelly, DDS, MS, DMedSc Guest Editor

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his introduction describes concepts that are useful in sorting out what dental ceramics are and how different ceramics perform different functions. Many commercially important ceramics can be understood within the context of these concepts. Articles constituting the body of this JADA supplement answer these questions: What good are they? What factors control success? Why ceramics anyway?

SIMPLIFYING CONCEPTS IN UNDERSTANDING CERAMICS

Two concepts help demystify dental ceramics. First, ceramics fall into three main composition categories (Figure 1)1,2: d predominantly glass; d particle-filled glass; d polycrystalline. Second, dentists can consider virtually any ceramic within this spectrum to be a composite, meaning a composition of two or more entities. Although dentists usually reserve the term composite for particle-filled resins, they can generalize the concept to include dental ceramics in which the matrix usually is a glass that is lightly filled or heavily filled with particles (crystalline particles or glass particles that melt at high temperatures). For polycrystalline ceramics, which contain no glass, the matrix is aluminum oxide or zirconium oxide, and the fillers are not particles but modifying atoms called dopants. Figure 23 (page 6S) presents many commercially available ceramics from the particle-filled glass and polycrystalline categories according to the matrix, filler concentration and type, and process used to
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make the restoration. Dentists can apply these concepts directly to gain insights into two general facts regarding dental ceramics: d Highly esthetic dental ceramics have a high glass content, and higher-strength substructure ceramics generally are crystalline. d The history of the development of substructure ceramics involves an increase in crystalline content ranging from approximately 55 percent crystalline to fully polycrystalline. Predominantly glass. Dental ceramics that best mimic the optical properties of enamel and dentin have a high glass content. Manufacturers use small amounts of filler particles to control optical effects such as opalescence, color and opacity. Most veneering materials come paired with their appropriate substructure ceramic, so it makes little sense to introduce them according to trade name (which is why I have not included them in Figure 2). I discuss predominantly glassbased ceramics in more detail elsewhere.1 Particle-filled glass. Manufacturers add filler particles to the base glass composition to improve mechanical properties, such as strength and thermal expansion and contraction behavior. These fillers usually are crystalline, but they also can be particles of high-melting glasses that are stable at the firing temperatures of the ceramic.2 Often, it is these filler particles that are dissolved during etching to create micromechanical retentive features enabling bonding. Particles can be added mechanically during manufacturing as powder or be precipitated within the starting glass by special nucleation and growth heating treatments; in the second case, such materials are termed glass-ceramics.

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The family of ceramics containing high concentrations of lithium disilicate crystals is an example of a glass-ceramic (IPS e.max Press and IPS e.max CAD, Ivoclar Vivadent, Amherst, N.Y.). Another family of particle-filled glass is unique in that it is a three-dimensional (3-D) interpenetrating-phase composite, in which the filler particles and glass are both continuous in space (In-Ceram, Vita Zahnfabrik, Bad Sckingen, Germany). The filler is alumina, magnesium aluminate spinel or a mixture of 70 Figure 1. Schematic representation of three basic classes of dental ceramics. Predominantly glass-based percent alumina and ceramics are lightly filled with colorants and opacifiers to mimic natural esthetics and are the weakest 30 percent zirconia. ceramics. Glasses containing 35 to 70 percent filler particles for strength can be moderately esthetic as Polycrystalline. full-thickness restorations, but generally they are veneered. Completely polycrystalline ceramics (no Polycrystalline ceramics glass), which are used to create strong substructures and frameworks via computer-aided design/ computer-aided manufacturing processes, always are veneered. contain no glass; all of the atoms are packed into regular crystalline arrays through which it is predicted accurately.2,3 much more difficult to drive a crack than it is All-ceramic versus metal-ceramic systems. atoms in the less dense and irregular network All-ceramic systems can provide a better esthetic result for a wider range of patients than can found in glasses. Hence, polycrystalline ceramics metal-ceramic systems, because a wider range of generally are much tougher and stronger than translucency and opacity (value) can be achieved. glass-based ceramics. Well-fitting prostheses All-ceramic systems have no metal framework to made from polycrystalline ceramics were not be masked or metal margins exposed that propractical before the availability of computer-aided duce an unattractive appearance. Often, it is manufacturing. acceptable to leave margins of all-ceramic prosIn general, these computer-aided systems use a theses supragingival or at the gingival margin, 3-D data set representing either the prepared resulting in more predictable and less traumatic tooth or a wax model of the desired substructure. impression-making. Emergence profiles are less The systems use this 3-D data set to create an likely to be overcontoured, as is often the result enlarged die upon which ceramic powder (Prowith metal-ceramic prostheses owing to efforts by cera, Nobel Biocare, Gteborg, Sweden) is packed laboratory technicians to provide a thicker layer or to machine an oversized part for firing by of porcelain to mask the opaque-metal surface in machining blocks of partially fired ceramic areas that often are underprepared.1 powder (ZirCAD, Ivoclar Vivadent; Cercon ZirMost ceramics are superior to metals with conia, Dentsply Prosthetics, York, Pa.; Lava Zirrespect to corrosion, galvanism and biocompaticonia, 3M ESPE, St. Paul, Minn.; Vita In-Ceram bility. Researchers report recovering smaller YZ, Vita Zahnfabrik). Both of these approaches amounts of plaque and adherence molecules from rely on well-characterized ceramic powders (that is, tight control over particle sizes and packing ABBREVIATION KEY. 3-D: Three-dimensional. density) for which firing shrinkages can be
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MATRIX
Esthetic Ceramics
High Glass Content (Particle-Filled Glass) Aluminosilicate Glass (Feldspathic or Synthetic)

FILLER
High-Melting Glasses, Nepheline, Albite (about 40%)

PROCESS
CEREC 3

TRADE NAME
Vitablocs Mark II

CEREC 3

IPS Empress CAD IPS Empress Esthetic OPC Cerinate Fortress

Leucite (40%-50%)

Pressed

Powder

Structural Ceramics
Low Glass Content (Particle-Filled Glass) Special Silicate Glasses (High Lithium or Lanthanum) Lithium Disilicate (70%) Alumina, Spinel, Alumina/Zirconia (70%) inLab Pressed inLab or Dental Laboratory IPS e.max CAD IPS e.max Press In-Ceram Alumina In-Ceram Spinell In-Ceram Zirconia

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No Glass Content (Polycrystalline) Alumina

DOPANT
Magnesium (3%)
(Control Grain Growth)

inLab CAD/CAM inLab CAD/CAM

Vita AL Cubes Procera Vita YZ Cubes IPS e.max ZirCAD Lava Zirconia, Cercon Zirconia, Procera

Zirconia

Yttrium, Cerium, Aluminum (3%-5%)

(Transformation Toughening)

Figure 2. Organizational chart of dental ceramics for all-ceramic systems according to matrix material, filler or dopant (atomic-level filler) and fabrication process. CEREC 3 is manufactured by Sirona Dental Systems GmbH, Bensheim, Germany; InLab, Sirona Dental Systems GmbH; Vitablocs Mark II, Vita Zahnfabrik, Bad Sckingen, Germany; IPS Empress CAD and IPS Empress Esthetic, Ivoclar Vivadent; Amherst, N.Y.; OPC, Pentron Ceramics, Somerset, N.J.; Cerinate, Den-Mat, Santa Maria, Calif.; Fortress, Mirage Dental Systems, Kansas City, Kan.; IPS e.max CAD and IPS e.max Press, Ivoclar Vivadent; In-Ceram Alumina, Spinell and Zirconia, Vita Zahnfabrik; Vita AL Cubes, Vita Zahnfabrik; Procera, Nobel Biocare, Gteborg, Sweden; Vita YZ Cubes, Vita Zahnfabrik; IPS e.max ZirCAD, Ivoclar Vivadent; Lava Zirconia, 3M ESPE, St. Paul, Minn.; Cercon Zirconia, Dentsply Prosthetics, York, Pa.; Procera, Nobel Biocare. (Adapted with permission of Quintessenz Verlags-GmbH, Berlin, from Kelly.3)

ceramic surfaces than from gold alloys or amalgam.4-6 In addition, intraoral plaque of a qualitatively healthier composition can form on ceramic surfaces.4-6 Nevertheless, to use all-ceramic systems successfully, the clinician must have a high level of knowledge both to maximize the esthetic result and to choose materials appropriately for structural longevity. Metal-ceramic systems are wellenough developed that little special knowledge is required for their routine use. Many practitioners may be unaware of the metal-ceramic systems their laboratories use, but any system generally will be as suitable for anterior single-unit restorations as it is for posterior multiunit prostheses. This forgiving restorative system has survival rates of about 74 percent at 15 years, and 53 percent of metal-ceramic restorations have been reported to be in service at 30 years, with the
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majority of problems being biological (that is, secondary caries, periodontal disease and endodontic failures).7-9 Clinical success. In this supplement, Dr. Della Bona and I10 review the clinical literature regarding the performance of commercially available all-ceramic systems. This literature is at the level of systematic reviews of numerous studies of systems indicated for inlays, onlays and anterior single-unit restorations. Such evidence is among the highest available for making clinical practice decisions. Fewer systems and less evidence are available for the restoration of molars and for multiunit prostheses involving molars. Factors for clinical success. Dr. Donovan11 shares the peer-reviewed literature and practical experience in exploring how to incorporate allceramic systems into dental practice. Why ceramics? Long-lived esthetics and bio-

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compatibility are the promise of all-ceramic systems. Drs. Spear and Holloway12 describe how the use of all-ceramic restorations has become routine and provide an overview of indications for their use.
CONCLUSION

All-ceramic systems are no longer experimental or suitable only for specialty practices. Clinical data and years of experience form the basis of the articles in this supplement, which are designed to provide interested clinicians with the background to begin integrating all-ceramic restorations into their routine practice.
Dr. Kelly is a professor, Department of Reconstructive Sciences, University of Connecticut Health Center, 263 Farmington Ave., Farmington, Conn. 06030-1615, e-mail kelly@nso1.uchc.edu. He also is the guest editor of this supplement. Address reprint requests to Dr. Kelly. Disclosure. Dr. Kelly has served as a consultant for and received research funding from Ivoclar Vivadent, Amherst, N.Y., and Vita Zahnfabrik, Bad Sckingen, Germany. 1. Kelly JR. Dental ceramics: current thinking and trends. Dent Clin

North Am 2004;48(2):viii, 513-530. 2. Denry IL. Recent advances in ceramics for dentistry. Crit Rev Oral Biol Med 1996;7(2):134-143. 3. Kelly JR. Machinable ceramics. In: Mrmann WH, ed. State of the Art of CAD/CAM Restorations: 20 Years of CEREC. Berlin: Quintessenz Verlags-GmbH; 2006:29-38. 4. Kawai K, Urano M. Adherence of plaque components to different restorative materials. Oper Dent 2001;26(4):396-400. 5. Hahn R, Weiger R, Netuschil L, Bruch M. Microbial accumulation and vitality on different restorative materials. Dent Mater 1993;9(5):312-316. 6. Wang JC, Lai CH, Listgarten MA. Porphyromonas gingivalis, Prevotella intermedia and Bacteroides forsythus in plaque subjacent to bridge pontics. J Clin Periodontol 1998;25(4):330-333. 7. Holm C, Tidehag P, Tillberg A, Molin M. Longevity and quality of FPDs: a retrospective study of restorations 30, 20, and 10 years after insertion. Int J Prosthodont 2003;16(3):283-289. 8. Creugers NH, Kyser AF, van t Hof MA. A meta-analysis of durability data on conventional fixed bridges. Community Dent Oral Epidemiol 1994;22(6):448-452. 9. Anderson RJ, Janes GR, Sabella LR, Morris HF. Comparison of the performance on prosthodontic criteria of several alternative alloys used for fixed crown and partial denture restorations: Department of Veterans Affairs Cooperative Studies project 147. J Prosthet Dent 1993;69(1):1-8. 10. Della Bona A, Kelly JR. The clinical success of all-ceramic restorations. JADA 2008;139(suppl 9):8S-13S. 11. Donovan TE. Factors essential for successful all-ceramic restorations. JADA 2008;139(suppl 9):14S-18S. 12. Spear F, Holloway J. Which all-ceramic system is optimal for anterior esthetics? JADA 2008;139(suppl 9):19S-24S.

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