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Christoph Hammerle
Irena Sai l er
Andrea Thoma
Gi anni Hal g
Ana Suter
Christian Ramel
B Annen, G Benic, A Feher,
auser, A Hagmann, S Hick
deregger, R Jung, H la|Ier t,
Loefel, S Merki, |Polly,
P Ruhstal
er, |Siegenthaler, M Stalco,
'Thoma, A Trottmann, S Windich,
'Yaman, A Zembic
wu|nlcsscncc|ub||sh|ng LO|Id
London, Berlin, Chicago, Tokyo, Barcelona, Beijing, Istanbul, Milan,
Moscow, New Delhi, Paris, Prague, Sao Paulo, Seoul and Warsaw





The authors are grateful to the participating dental technicians for the
excellent restorations they provided and for their consistently good
teamwork. We would especially like to thank Walter Gebhard (Geb
hard AG, Zurich), Bertrand Thievent (Bertrand Thievent AG, Dental
Laboratory, Zmich), Aold Wohlwend (Wohlwend Innovative Dental
Technik, Zurich), and KBTM Intern Dental Laboratory (Director: Ana
Suter). Special thanks also to Heinz Luthy for his contributions regard
ing the technical aspects of dental ceramic materials.
Title of the original German edition:
Dentale KJ
Aktuelle Schwerpunkte fr die Klinik
2008 by Christoph Hammerle
Britsh Library Cataloging in Publication Data
Dental ceramics : essential facts for cosmetic dentists
I. Dentl ceramics
I. Hammerle, Chrstoph
617.6' 95
2008 by Christoph Hammerle
Quintessence Publishing Co, Ltd,
Grafon Road, New Malden, Surrey KT 3AB,
Get Bttain
All rights reserve. This book or any part there of may not be reproduced, stored in a
retrieval system, or transmitted in any form or by any means, electronic, mechanical,
photocopying, or otherwise, without prior written petmission of the publisher.
Editing: alate..ea:ePublishing Co, Ltd, London
Translation: Suzyon O'Neal Wandrey, Berlin
Layout and production: Quintesssenz Verlags-GmbH, Berlin
Printing and binding: ADruck und Datentecbnik GmbH, Kempten
Ptinted in Gem1any
Most dentists' ofices are well-stocked with scientifc jourals and
textbooks. However, practising dentists often find it hard to wade
through the plethora of dental literature in order to locate the informa
tion they require or to find the advice they need in a reasonable
amount of time.
This book focuses specifcally on current issues in contemporary
ceramic dentistry. Dental Ceramics
Essential Aspects for Clinical
Practice is designed as a quick reference guide. lt provides practising
dentists the specific information they need to manufacture ceramic
restorations for their patients. Topics covered include ceramic
veneers, single crowns, fxed partial dentures, and implant restora
tions. Related subjects, such as restoration of non-vital teeth and
exteral bleaching, are also described. The text is concise and clear,
providing step-by-step instructions and numerous photographs and
diagrams to frther elucidate the clinical procedures. "Dental Ceram
ics" is a valuable resource for practising dentists as weJJ as for dental
Thanks to the efforts of dedicated dental clinicians, laboratory
technicians and researchers, it has been possible to compile a book
that conveys the core principles, background information and proce
dures relevant to the fabrication of dental ceramic restorations in a
readily comprehensible and attractive format, making this book a
valuable reference source for dental practice.
Christoph Hammerle
Prof Dr Christoph Hammerle
Clinic Director
E-mail: sekkbtm@zzmk.uzh.ch
Dr Irena Sailer
Senior Consultant
E-mail: irena .sa iler@zzmk.uzh .ch
Dr Gianni Halg
Senior Consultant
E-mail: gianni.haelg@zzmk.uzh.ch
Dr Christian Ramel
Senior Consultant
E-mail: christian .ra mel@zzmk.uzh .ch
Clinic for Crown and Bridge Prosthodontics,
Partial Prosthodontics and Dental Materials Science
Center for Dental, Oral and Maxillay Medicine
University of Zurich
Plattenstrasse 11, CH-8032 Zurich
Ana Suter
E-mail: suterana@hotmail.com
Dental Technician
Haslihalde 17 CH-8707 Uetikon am See
Dr Andrea Thoma
E-mail: i nfo@zah naerztea m kreis.ch
Practice for General Dentistry, Oral Surgery,
Stomatology and Orthodontics
Grosszaun 11, CH-8754 Netstal
! `cenIc AspecIs o enIo LeromcNoIero|s 1
1.1 Composition and Classification of
Dental Ceramics +++++++++++++++++++A+++++ 2
1.2 Physical Properties ......................................................... 6
1.3 OpIical Properties ........................................................ 10
2 lrocessng NeIhods#.....#.. 13
2.1 Manual Processing Methods .................................... 14
2.2 Machining ...................................................................... 18
3 Veneers.........Y.................................Y............. 23
3.1 Indications ++.+..+..+++..+...+..++..++++..++..+.+.++. 24
3.2 Contraindications ++++++++++++++++++++++++ 24
3.3 Clinical Guidelines .....Y....................Y................ 25
3.4 Step-by-step: Clinical Procedures for the
Fobrication of Veneers +++++++++++++++++++ 26
4 A||ceromc`ngeLrowns..++...........++......+....+...+... 37
4.1 Indications ...................................................................... 38
4.2 Tooth Preparation ........................................................ 39
4.3 Clinical Survival ............................................................ 40
4.4 Clinical and Laboratory Procedures ...................... 44
5 NonvIo|AbuIment1eeth........................................ 59
5.1 Biomechanics of Non-vital Teeth ............................ 60
5.2 Posts +++++++++++++++++++++Y+++q+++++++ 61
5.3 Esthetics ........................................................................... 64
5.4 Clinical Procedures ..................................................... 67
bxIerno| beochng........................................................ 71
6.1 Introduction ..++.+..........+...+.........+.........++.++.... 72
6.2 PoVer Bleaching ++++++++++++++++++++++++++++ 73
6.3 Combined BleachinQ.................................................. 74
6.4 At-home Bleaching .+...+....+........+.........++........+............. 74
6.5 "Over-the-counter" Teeth WhiIening Products ...... 78


Z Aceromc xed |orIo entures..++++.++..++.++. 81
71 General Considerations +++++++++++++++++++ 82
72 Indications ...................................................................... 82
73 Tooth |reporo|io:........................................................ 84
74 Dental Laboratory and Dental Office
Procedure ....................................................... 85
75 Cin|col Survival Rates ................................................ 90
76 Conclusions +++++++++++++++++++@+++++++ 91
8 bondngo Leromc HestoroIons++.++..++..++..++.++ 93
8.1 Adhesive versus Conventional Cementation ...... 94
8.2 Classification of Adhesive Cements .W........W. 96
8.3 Den!|n Conuil|on|o.................................................... 98
8.4 Ceramic Conditioning .............................................. 100
8.5 Clinical Procedures ......W....W..W.W.... 101
9 AIceromc |mp|onI oupporIed kesIorotons 113
9.1 Clinical Aspects and Indications ........................... 114
9.2 Advantages of Ceramic Abol~enls...................... 115
9.3 Disadvantages ............................................................ 115
9.4 Biologic Aspects ..W...W+..W.W..W....WWW.. 116
9.5 Nonooctorets............................................................. 116
10 lndex++++++@++@++++++W+++@++++@@++@+++++++ 125





$ M


Chapter Scientific Aspects of Dental Ceramic Materials
1.1 Composition and Cl assi fi cati on
of Dental Cerami cs
Conventional dental ceramic materials general ly comprised a trans
parent, amorphous glassy phase surrounding a crystalline phase in
which variable amounts of crystalline particles are dispersed.
The addition of crystals improves:

Light scatter and opacity and, thus, color adaptation of the trans-
parent glassy phase to the dental hard tissues

Stability of the material during fring

Control of the coeficient of thennal expansion

Resistance of the fnal restoration to functional stresses in the

Therefore, the addition of crystals enhances both the esthetic appear
ance and the strength of ceramic materials. The larger the crystalline
phase, the tougher the ceramic material. Increasing the particle density,
the homogeneity of particle distribution, and the strength of the bonds
between the crystals and the glassy phase also increases the strength of
ceramic materials. At the same time, crystalline reinforcement decreas
es the transparency of dental ceramic materials at the expense of
8 est ehcs .
The newer dental ceramics differ from conventional dental ceram
ics in that a larger amount of crystals have been added, leading to a sig
nifcant increase in material strength. As the addition of crystals also
increases opacity, the novel dental ceramics can only be used for fabri
cation of substructures for ceramic restorations. Like metal frame
works, they must be veneered with a translucent ceramic material.
Modem dental ceramics can be classifed according to glass phase
as follows:

Ceramics with a glass phase:

- Glass-ceramic
- Glass-infiltrated ceramic

Ceramics without a glass phase:

- Oxide ceramic (olycrystalline) =high-strength ceramic.
!.! Compos|tion and Classification of Dental Ceramics
J.J.J Mai n Characteristics
Gl ass-ceramics

Glassy phase of natural or synthetic feldspar surrounding a crys

talline phase (consisting of leucite or lithiwn disilicate crystals in
most cases)

Multi-phase microstructure (Diagram 1, Figs 1 a and 1 b).

(Veneered ceramic restorations)
Inlays and onlays
Anterior single crowns

Mixed to yield a modeling material of elastic consistency
The model piece is subsequently fred to strengthen the material
Commercially available systems:
Empress I, Empress II and Empress Esthetic systems
(Ivoclar, Liechtenstein)
Authentic (anaxdent, Germany)
Creapress (Creation, Klema, Austria)
Various others.
The restorations can be individualized by staining or veneerng
No shrinkage occurs during firing.
Diagram !
Fig !a Empress I glass
ceramic system as seen
under a scanning electron
microscope. Note the inho
mogeneous strucure of the
leucite-reinforced matrix.
Fig !b Empress II, a lithium
disil icate-reinforced glass
ceramic, has a structure
s|gcif|cantly different from
that of Empress I. Note the
higher density of the rod
shaped crystals.
Chapter Scientific Aspects of Dental Ceramic Materials
Glass-infiltrated ceramics
Most glass-infltrated ceramics have a porous alumina skeleton,
which is infltrated, that is reinforced with (liquid) lanthanum

They have a multi-phase microstructure (Diagram2, Figs 2a


Substructures for anterior and posterior single crowns.

Computer-aided milling and subsequent infltration of indus
trially prefabricated blanks
Commercially available systems:
ln-Ceram (Vita Zahnfabrik, Gennany)/Alumina (Al203
ln-Ceram Spinel! (A1203 Mg02)
ln-Ceram Zirconia (Al203 *Zr02).
The restorations can be individualized by staining or
There is no shrinkage after modeling.
Oxide ceramics !high-performance ceramics)

Oxide ceramics have a pure alumina (Al203) or zirconia (Zr

crystalline matrix.
F|g 2a lCeom Alumino:
The presintered core is very
porous before gloss infiltra
|7b lnCeom Alumino:
Ae infiltration, the density
of the core increases con
l.l Composition and Classification of Dental Ceramics
They have a single-phase microstructure (Diagram 3, Figs 3 and 4).
Alumina/zirconia: cores for anterior and posterior single crowns
Zirconia: anterior and posterior bridge frameworks.

Alumina: computer-assisted milling of industrially manufac
tured densely sintered blanks
Zirconia: computer-assisted milling of industrially manufac
tured pre-sintered or densely sintered blanks.

Commercially available systems: a number of CAD/CAM sys-

tems are available:
Procera (Nobel Biocare, Sweden)
Cercon (DeguDent, Germany)
DCS (DCS Dental AG, Switzerland)
CEREC (Sirona, Germany)
Lava (ESPE, Germany)
Various others.
`pecc chorocIersIcs
The restorations can be individualized by veneering
Cores milled frm presintered ceramics are subject to shrin
kage ( approximatly 20% ).
The choice of the dental ceramic material best suited for an individual
case is determined mainly by the physical and optical characteristics
of the available materials.



. *
~' _

_ - , `


0loqom3 |lq3 Densely sintered alu
mino !AI,OJ
||q4 Densely sintered zir
conia !Zr02l is more homo
geneous and denser than
alumina, as can be seen
even under low magnifica
Chapter Scientific Aspects of Dental Ceramic Materials
1. 2 Physi cal Properties
J.2.J Defini ti ons
The strength of ceramic materials is generally described using two
variables: fexural strength and fracture toughness.
Flexural strengh (MPa), or bending strength, is the maximum ver
tical load that a material can support without failure (fracture). In
material testing, a ceramic sample (usually disk-shaped) is subjected
to increasing vertical stress until it cracks or breaks. Different proto
cols are used for determination of flexural strength (e.g., three- or
four-point bending test). In these tests, the main vertical load, or bend
ing stress, is applied to the tensile zone (convex side) of the ceramic
sample. The surface quality (polishing, microcracks) of the tensile
zone is crucial for the resulting fexural strength.
Fracture toughness, or fracture resistance (MPa m1'2), is a measure
of the maximum force a material containing a flaw or crack can with
stand without enlargement of the crack, when tensile force is applied
to the edge of the crack. A simple example illustrates this principle: if
a notch (flaw) is made at the top of a piece of wood, it is easier to split
the wood with an axe. Continued exposure of the tawed material to
forces slightly or even far below the initial cracking load can result in
the gradual propagation of the crack. This slow progression, called
subcritical crack growth, is one of the main reasons for the long-term
failure of all-ceramic restorations. The higher the facture toughness
of the material, the longer it takes for fracture-related failure to occur8
The facture toughness and fexural strength of various ceramic mate
rials are described in Table 1 .
To prevent clinical failure, "weak" dental ceramic materials, such
as glass-ceramics, must be strengthened by means of adhesive cemen
tation (c. f ChapterS).
1.2 Physical Properties
Table 1 Material characteristics of dental ceramic materials
Flexural strength [MPa) Fracture toughness [MPa
Dicor 115 1.93
Empress 182 1.77
Glass-infiltrated ceramics:
ln-Ceram Alumina 547 3.55
ln-Ceram Spinel/ 292 2.48
Oxide ceramics:
A/703 600 5.00
Zr02 1000 !U.UU
J.2.2 Factors that determi ne the strength of
dental cerami c restorations
The strength of a ceramic restoration is determined by the microstruc
ture (density, number of crystals) of the dental ceramic material it is
made from. The presence of initial microcracks, pores or impurities
(e.g., due to processing errors) in the microstructure is a major issue.
Such defects can lead to the development of cracks that can critically
weaken a presumably stable material.
For clinical success, the ceramic materials used for dental restora
tions must meet the following requirements:

High fexural strength

High fracture toughness (achieved by crystalline reinforcement

high crystal content, etc.)

Homogeneity of the microstmcture (absence of microcracks,

pores, etc.)

Flawless processing (ideally, using industrially manufactured

Chapter Scientific Aspects of Dental Ceramic Materials
1.2.3 Compari son of chemi cal and physical
properties of metals and ceramics
Metals and ceramics respond to stress loads differently due to differ
ences in the chemical structure of the two material classes. Regarding
their chemical structure, metal atoms form uniform crystal lattices by
attraction through electron clouds (metal bonds). As these bonds are
non-directional (i.e., they have no preferential direction), stress load
ing may lead to a shifting of lattice levels without a loss of cohesion
of the atoms. This mechanical property is responsible for the charac
teristic elastic ductility ofmetals5
In the case of ceramic materials, metal atoms form bonds with
non-metal atoms via ion bridges. Cohesion occurs due to the opposite
charges of the particles. When the lattice is deformed due to stress,
particles with the same charge may suddenly be shifted opposite to
each other, resulting in the immediate dissolution of the bond. These
interactions are responsible for another main characteristic of ceramic
materials: brittleness. As a result, ceramic materials demonstrate little
or no elasticity or ductility.
Because they are brittle, ceramic materials are susceptible to tiny
microstructural flaws (microcracks) from which macroscopic cracks
may grow. Once the bonds between the atoms have been broken, they
can only be rejoined by firing the material at very high temperatures.
Physiologic temperatures in the mouth are too low for this.
In metals, on the other hand, the same types of cracks (processing
flaws, etc.) tend to "heal". Because metals are very ductile, rounding
of the edges of the crack occurs, thus "de-fsing" the situation10 By
virtue of their chemical structure, ceramics are very resistant to pres
sure forces but, unlike metal, they have little resistance to tensile
In summary, ceramics are hardly comparable to metals due to the
diferences in their chemical and physical properties. Due to the spe
cific properties of ceramic materials, small material flaws can result
in the failure of a dental ceramic restoration8.
1.2 Physical Properties
1.2.4 Zi rconi um dioxide !Zr02l
Zirconium dioxide, or zirconia (Zr02), is an oxide ceramic. Compared
with other ceramic materials, zirconia distinguishes itself through
superior fexural strength and fracture toughness. The outstanding
material properties of zirconia can be attributed to the following fac
tors at the microstructural level:

Zirconia is a single-phase (purely crystalline) ceramic

Zirconia crystals are very small (particle size: < 0.4 m)

Zirconia crystals are uniform in shape and size (Fig4).

In addition to being extremely stable, zirconium dioxide has another
important feature: facture toughness. The fracture toughness of zir
conium dioxide is nearly twice as high as that of alumina. The high
strength of zirconia is achieved through a process known as transfor
mation toughening, which is based on exploitation of the phase trans
formation capacity of the crystalline structure of zirconium dioxide.
In this process, transfonnation of the tetragonal phase to the mono
clinic phase is induced by applying concentrated stress to a crack tip,
resulting in an approximately 4 percent increase in the volume of the
zirconium dioxide crystals. Because of the resulting compression
stress within the material, the ends of the crack are pressed together,
thus preventing crack growth (Diagrams 4a and 4b ).
Diagram4a Diagram4b
Chapter Scientific Aspects O|Dental Ceramic Materials
Fig. Optical
comparison of
samples of differ
ent ceramic materi
als with equal slice
IO.Smml. From lef
to right: veneering
ceramic !dentin
mass), Empress I
Zirconia, ln-Ceram
Alumina, and |n
Ceram Zirconia.
1.3 Opti cal properties
The optical properties (translucency, light transmission, etc.) of con
ventional dental ceramic materials are very similar to those of dental
hard tissues. For this reason, ceramics are the material of choice for
dental restorations in esthetically important regions.
The esthetic appearance of a ceramic material is dictated by the
translucency of the material. As described in the previous section, the
translucency of different ceramic materials varies. The more "stable"
ceramics are more opaque during to their crystalline structure. Some
are very opaque. ln-Ceram Zirconia, for example, is just as opaque as
a gold alloy6.
In accordance with these differences in optical qualities, the suit
ability of a given ceramic material is determined by the location of the
restoration, the stump shade (e.g., a discolored non-vital abutment
tooth; c Chapter 5), and the space requirements for the restoration.
The translucency of ceramic materials of defmed thicknesses can
be ranked as follows126
Veneering ceramics (0.5 mm) >Empress I (0.5 mm) > In-Ceram
Spinell (0.5mm) >Empress II (0.5mm) >Empress I (0.8mm) >Pro
ceraA1203 (0.5 mm) > Empressll (0.8mm) > Zr02 ( 1 mm) > In-Ceram
Alumina (0.5 mm) > In-Ceram Zirconia (0.5 mm) (c.f Fig 5).
Material thickness is a co-determinant of translucency. If a discol
ored non-vital tooth is to be restored, a larger amount of space is need
ed for a glass-ceramic restoration. A more opaque ceramic material
(e.g., zirconia) must be used to ensure optimal preservation of tooth
substance in cases in which an all-ceramic restoration i s to be placed.
1. EdelhoffD, Sorensen JA. Light transmission through bovine dentin and all
ceramic frameworks . . J Dent Res 2001 ;80:600, IADR Abstract No. 0588.
2. EdelboffD, Sorensen JA. Light transmission through all-ceramic fameworks
dependent on luting material. J Dent Res 2002;81 :A-234, IADR
Abstract-No. 1779.
3. EdelhoffD, Sorensen JA, Spikermann H. Light transmission through all
ceramic frameworks dependent on luting material. lot J Artificial Organs 2003;
26(7):643, ESAO Abstact No. P88.
4. Filser l,Liithy H, Scharer P, Gauckler L. All ceramic dental bridges by the
direct ceramic machining (DCM). Materials in Medicine Vol. I . M. Speidel &
P. Uggowitzer (Lds+), Ziiricb: VDF Hochs\bulveIag 1998: !65-189.
J. Gehre G. Keramische Werkstoffe. Ln: Eichner K, Kapper! HF. Zalmarztliche
Werkstofunde und Verarbeitung, Vol. I. Heidelberg: Hiithig Verlag, 1996:
6. Hefferan MJ, Aquilino SA, Diaz-Arnold AM, Haselton DR, Stanford CM,
Vrgas MA. Relative translucency of six all-ceramic systems, Part !:Core
materials, J Prostbet Dent 2002;88:4-9.
7. Heferan MJ, Aquilino SA, Diaz-Anold AM, Haselton DR, Stanford CM,
Vargas MA. Relative tanslucency of six all-ceramic systems, Part II: Core and
veneer materials, J Prosthet Dent 2002;88: I 0-5.
8. Kappert HF. Keramik als zahnirztlicher Werkstoff. ln: Strub JR, Tiirp JC,
Witkowski S, Hiirzeler MB, Kern M (Eds). Curriculum Prothetik Vol. 2.Berlin:
Quintesseoz,l999:63l -660.
9. Liitby H. Strength and toughness of dental ceramics. In: CAD/CAM in Esthet
ic Dentistry_ CEREC 10 Year Anniversary Symposium. WH Mormann (Ed.).
Chicago: Quintessence, 1996:229-240.
10. Marx R. Modeme keramische Werkstofe fr isthetische Restaurationen-Ver
staktmg und Bruchzahigkeit Dtsch Zahnirztl Z; 1995;48:229-236.
1 1





Chapter 2 Processin
Manual processing
Layering, pressing
The starting material for any aU-ceramic dental restoration is a ceram
ic powder that can be shaped into the desired form by a variety of dif
ferent processing methods. The exact type of processing technique
used and the method of execution (by hand or machine) depends on the
type of ceramic material selected for the restoration. The development
of computer-aided design and manufacturing (CAD/CAM) technolo
gies for dental applications now makes it possible to fabricate ceramic
restorations from densely sintered oxide ceramic materials that are dif
ficult to process by hand.
All-ceramic processing methods and the corTesponding types of
ceramic materials can be divided into the follm.ing groups.
Machine processing
Slip costing, gloss infiltration Gloss-infiltrated Copy-milling
ceramics CAM
Oxide ceramics CAD/CAM
2.1 Manual Processi ng Methods
2. 1. 1 Layering
Layering is a processing method used to fabricate porcelain-veneered
crowns and layered veneers from glass-ceramics. The starting materi
als are ceramic powders supplied by the various manufacturers in a
range of diferent shades and translucencies.
In the frst step, the ceramic powder is mixed with modeling fuid
or distilled water to produce a slurry. The slurry is applied in layers to
the substructure (framework, fireproof die). The restoration is built up
in layers corresponding to the anatomical dimensions, color and
translucency of the natural tooth. The applied ceramic mass is blotted
frequently in order to make the piece as dense and pore-fee as possi-
2.1 Manual Processing Methods
ble before sintering. The layered piece is placed in a ceramic furace
and sintered at the required temperature (approximately900C). The
powdered glass particles soften and flow together (sinter) at the parti
cle inte1faces (Fig 1 and Diagram I).
As the air between the particles must be able to escape
during heating, sintering must be performed in a vacuum envi
The piece must be modeled on an enlarged scale
Sintering shrinkage is extensive (up to 40%).
Pore fonnation is inevitable
- This results in weakening and a risk of de-lamination.
Diagrams 1a and 1b Surface structure (a) before and !bl after sintering.
Fig ! After layering, the vnsintered piece is roughly AU`larger than
the size after sintering. The challenge for the laborator technician is
to Ioyer on the different optical features of the dental hard tissues in
the ight places in spite of sintering shrinkage.
1 5
Chapter 2 Processin
1 6
2.1.2 Pressing
The press technique was developed for the manufacture of ceramic
inlays, onlays, veneers and crowns. The Empress system is the pre
cursor of a number of similar pressed ceramic technologies now
ofered by diferent manufacturerss. The starting material is usually a
leucite (or lithium disilicate) reinforced glass-ceramic supplied in the
form of industrially pre-sintered ingots.
Heat-pressed ceramic restorations are made using the lost wax
principle originally used in metal casting. The restoration is first
modeled in wax and invested in a special mufe. The softened glass
ingot is then placed in a specially designed (Empress) press frace
and pressed at 1180C (pressure: 5bar) into the mold created by the
bured out wax (Fig 2).
Ingots for pressed-ceramic restorations are available in a variety of
different shades and translucencies. The materials can be processed by
two different methods. First, restorations can be pressed to full contour
and characterized by surface staining. Alteratively, only the frame
work can be pressed and then veneered by the layering technique.
Heat-pressing produces glass-ceramic restorations of optimal
quality (no pores)
The restorations are scaled to the original size
No shrinkage occurs.
Fig 2 Specially designed mufle with a pressing cylinder.
2.1 Manual Processing Methods
2.1.3 Sl i p Casting and Gl ass Infiltration
The method of slip casting high-strength alumina cores for glass infl
tration (In-Ceram technology) was developed before the arrival of
machining techniques for industrially pre-fabricated, porous ingots7
However, pre-fabricated ingot systems have become more popular due
to their superior quality.
The slip casting procedure is similar to the layering technique.
Fine-grained alumina powder is mixed with modeling fluid to produce
a slip, which is applied in layers to a special die to build up the sub
structure. The modeled piece is subsequently sintered (for 2hours at
1120 C). Sintering does not lead to the fusion of alumina pa1ticles, but
makes them become more tightly packed. Glass infiltration of this
porous substructure is, therefore, performed in the second step of the
procedure; first, lanthanum powder is mixed with a special solvent and
applied in excess to the exteral surface of the substructure (Fig 3). The
piece is ten fired (for 4 hows at 1100C) to melt the glass patiicles.
The molten glass is drawn into the fine pores of the substructure (by
capillary suction), yielding a high-strength, "glass-infltrated" alumina
`peco consderoIons:
The use of pre-sintered blanks ensures reproducible quality
Restorations are milled on a scale of 1 : I
No shrinkage occurs during infiltration.
- Suboptimal infltration leads to reduced material strength.
Fig 3 The brown lanthanum powder is
placed on a gloss plate, mixed with special
fluid, and applied with a br\sh The sub
structure is white before infiltration. The fin
ished piece must be visually inspected for
infiltration quality; the improperly infiltrated
piece is light brown and spotted in the Uid
dle, whereas the correctly infiltrated piee
is dark brown with areas of excess gloss on
the u rfo ce.
1 7
Chapter 2 Processin
1 8
2.2 Machi ni ng
Machining systems use industrially manufactured ceramic blanks with
improved mechanical properties to produce ceramic restorations of
superior quality. The manufacturing process may be mechanical
(copy-milling) or automated (CAD/CAM).
2.2.1 Copy Mi l l i ng
In copy-milling (Celay system), a resin composite replica of the
restoration is fabricated on a master cast. A scanning tool traces the
replica, which serves as the exact template for precision copy-milling
of the restoration from a ceramic blank1 In-Ceram blanks are most
commonly used for copy-milling of dentl ceramjc restorations today.
`pecocos eroos
Copy-milling involves manual fabrication and mechanical
scanning of a replica of the restoration.
The range of indications is limited
A relatively large amount of time is required for manual pro
duction and mechanical scanning of the replica
CAD/CAM techniques are increasingly replacing copy-mil
2.2.2 Computer Aided Machi ni ng
Computer-aided machining (CAM) is similar to copy-milling in that a
replica of the restoration must be fabricated by the dental technician.
The difrence is that in computer-aided machining, the replica is
scanned by optical scanning technology (laser, white-light scanner)
and digitized. The digitized data are then used for precision machining
of the restoration from an industrially manufactured blank.
Pre-sintered zirconia blanks (e.g., Cercon) are most commonly
used for computer-aided machining of ceramic dental restorations
today. As they are subject to approximately 22% shrinkage during sin
tering, the data set used for milling must be adjusted to compensate for
sintering shrinkage. Special software packages are available for this
purpose .
Range of indications for the procedure
Manual fabrication process
Optical scanning of a replica of the restoration.
The CAM data set must be adjusted to compensate for sinte
ring shrinkage (shrinkage factor).
A relatively large amount of time is needed for fabrication of
the replica
CAD/CAM techniques are increasingly replacing computer
aided machining.
2.2 Machining
1 9
Chapter 2 Processing Methods
2.2.3 Computer Ai ded Design/Computer
Aided Manufactu ring
The Cerec system was the forerunner in the feld of CAD and manu
facturing of dental ceramic restorations6. The availability of more sta
ble oxide ceramics (alumina, zirconia) has greatly increased the pop
ularity of CAD/CAM technology. Improvements in the softare now
make it possible to process pre-sintered ("green") or white-stage zir
conia blocks. This efectively expanded the range of applications for
CAD/CAM technology, and all-ceramic bridges can now be manufac
tured by this technique.
CAD/CAM systems are mainly used to manufacture restorations
from densely sintered (pre-sintered) ceramic blocks of virtually all
types, but a number of other materials (titanium, synthetic mate1ials)
can also be processed. If unsintered ("green") zirconia blocks are used,
the blocks are first be mjlled and subsequently sintered to fll density
in the sintering furace that comes with the system.
Three basic steps are involved in the manufactming process with
all CAD/CAM systems: Data acquisition (optical and mechanical),
CAD, and CAM of the restoration.
Due to the extremely high cost of CAD/CAM systems, a current
trend in this feld is the development of specialized CAD/CAM cen
ters. With this set-up, the individual dental laboratory only needs to
purchase the system's scanning unit. The scanned restoration data are
transferred electronically to a CAD/CAM center. Within a few days,
the laboratory receives the manufactured coping that is ready for
veneering. The Procera system marketed by Nobel Biocare (Sweden)
utilizes this kind of central processing set-up.
Pre-sintered ceramic blocks come in a wide range of materials
CAD/CAM systems that use presintered ("green") or white
stage zirconia blocks are a new development
The die is scanned optically.
Requires highly specialized equipment
High investment costs
lndusty-dependent (continual R&D-related changes).
1 . Eidenbenz S, Scharer P. Das Kopierschleifen keramischer Formkorper.
Phillip J !!!4,!!.!-!.
2. Filser F, Liithy H, Gauckler L, Scharer P. AU-ceramic restorations by new
direct ceramic processing (DCM). J Dent Res I998;77(Special1ssue):762.
3. Gehre G. Keramische Werkstofe. ln: Eicbner K, Kapper! HF: Zabnarztliche
Werkstof''1nde und Verarbeitung, Vol. l . Heidelberg: Hiithig Verlag,l996:
4. Kapper! HF. Keramik als zahnarztlicher Werkstoff. Tn: Strub JR, TUr JC,
Witkowski S, Hiirzeler MB, Kern M (Eds.): Curriculum Prothetik, Vol. 2.
Berlin: Quintessenz, 1999:631-660.
5. Marx R. Modere keramische Werkstoffe fr isthetiscbe Restaurationen-Ver
starkung und Bruchzabigkeit. Dtsch Zahnarztl Z 1993;48:229-236.
6. Mormann W, Krejci I. Computer designed inlays afer years in sint: Clinical
performance and scanning electron microscopic evaluation. Quintessence In!
1992;23: I 09- 1 1 5.
7. Sadoun M. All-ceramic bridges with slip-casting technique. 7th lnt. Sympo
sium on Ceramics; Paris, Sept. 1988.
8. Wohlwend A, Scharer P. Die Empress-Tecbnik; Eiue neue Moglichkeit
Einzelkronen, Inlays und Verblendschalen berzustellen.
Quintessenz Zahntech 1990; 1 6:966-978.



Chapter o Veneers
3.1 I ndi cati ons
Teeth resistant to bleaching
- Tetracycline staining
Inadequate response to bleaching (interal or external).
Morphological anomalies
Generalized malformations and deformities
Conoid teeth
Diastema closure
Closure of interdental triangles
Tooth reshaping (augmentation oflength, size).
Tooth reconstruction
Crown fractures
Loss of tooth structure due to abrasion
Loss of tooth structure due to erosion.
3.2 Contrai ndi cati ons
Very darkly stained teeth
Insuficient enamel available

Large approximal fllings

3.3 Clinical Guidelines
3.3 Cl i ni cal Gui del i nes

The preparation margin should preferably be maintained within

the enamel whenever possible.

In patients with larger areas of dentin located at the inner surface

of the preparation, the margin must always be located entirely
within the enamel.

Sufficient space available for a stable laminate.

Preparation guidelines:
Cervical/buccal 0.5 mm
Cervical/approximal >0.5 mm
Incisalbuccal > 0. 7
lncisal > 1 to 1.5 mm
Palatal fnish line: slightly concave butt margin.
- 0.5 mm 1

>0.7mm ,

> l.5mm
Diagram 1 Schematic diaga of tooth preparation.
Chapter o Veneers
3.4 Step-by-step: Cl i ni cal
Procedure for the Fabri cati on of
Case presentation
Figs 1 Io o The patient's chief complaints
were perceived shortness of teeth 11, 21 and
22 and diastema. Slight palatal displace
ment of tooth 22 was additionally present.
3.4 Stepbystep= Clinical Procedure for the Fabrication of Veneers
Diagnostic procedure
Fig 4 The desired restoration was modeled
1n wax.
Fig 6 Self-curing resin composite loaded
on the silicone index.
Fig A silicone impression of the additive
wax-up was then taken.

Figs 7 and 8 An acrylic mock-up derived from the diagnostic wax-up is used to tr out the
desired restoration in vivo.
Chapter o Veneers
Tooth preparation ai ds
Additional silicone keys made from the wax-up serve as references
for tooth preparation.
Fig 9 A horixontally sectioned silicone
index is used to gouge preparation depth.
Tooth preparation
Fig 1 1 Axial reduction I: interdental separa
tion !separating diomondl.
Fig 10 A mesiodistolly sectioned slicone
index is used to gouge preparation length.
Fig 1 2 A thin, dark retraction cord is
placed bucolly to better visualize and pro
tect the gingival argin
Fig 13 Axial reduction II: faLial grooves.
Two to three facial grooves ore created in
the facial surface of the teeTh using a nor
row, rounded, conical diamond bur. The
depth of each groove 10.5 m m is checked
using the silicone index.
3.4 Step-by-step: Clinical Procedure for the Fabrication of Veneers
Fig 1 4 Axial reduction Il l : gross prepara
tion. Buccal and interdental reduction is
completed to yield the desired tooth shape.
Both the shoulder and the approximal mar
gins should be at least 0.5 mm in width Ia
large, rounded parallel diamond bur
should be used to keep the surface from
becoming wavyl.
Fig 15 At least 1 to 1.5 mm of incisal clear
ance is required. An approximately 0.5 mm
deep palatal finish l ine is made using a
round diamond bur in order to optically
conceal the incisal edge.
Figs 16 1O 18. The silicone keys are used to continuously gouge
the results of tooth preparation.
Chapter o Veneers
Figs 20and 2I Final view of the preparations.
l mpressi oni ng
Fig 19 All sharp edges are rounded off
with a flexible disk, and fine preparation is
Figs 22and 23 A second, thicker deflection cord ls placed i n the sulcus 5 to 10 minutes
before taking the impression.
3.4 Step-by-step: Clinical Procedure for the Fabrication of Veneers
P indirect mock-up (acrylic resin shells) made by the laboratory can
be used to provide highly esthetic temporaries for demanding patients.
In other cases, a direct mock-up made from the silicone index is nor
mally sufficient for temporization.
a. Indirect provisi onal s (acrylic resin shel l s)
Figs 24 and 25 Indirect provisionols !acrylic resin shells! mode by the dental laboratory.
For better retention, provisional restorations should always be fused into a single piece.
Fig 26 The ac
l ic resin shells ore relined
with polymethy
methocryl ote and luted to
the teeth.
Fig 27 Esthetic and functional check of the
seated provisional restoration.
Chapter o Veneers
O. || CC! provi si onal s
Fig 28 Self-curing resin is loaded onto the
silicone index, pressed over the prepared
teeth, and allowed to cure in place on the
Fig 29 Finished monochromatic provision
c|s prepared by the direct technique.
Temporary cementation
Figs 30 to 32 The prepared teeth ore spot
etched with 30% phosphoric acid and then
coated with unfilled resin. The provisionals
ore then seated and light cured.
Fig 33 View of the temporarily cemented
acrylic resin shells.
3.4 Step-by-step: Clinical Procedure for the Fabrication of Veneers
Wax try-in
Fig 34 Wax shells made according to the
first additional wax-up ore tried on in order
to refine the diagnosis.
Biscuit bake try-i n
Figs 35 and 36 The laminates are applied to the prepared teeth with glycerin gel.
Del ivery appoi ntment
Figs 37 and 38 View of the finished veneers prior to cementation.
Chapter o Veneers
Prepari ng the teeth for fi nal cementation
After the temporaries have been removed, the prepared teeth are
cleaned as follows: first, scalers are used to remove any remaining
resin from the prepared teeth, and all bonding surfaces are thoroughly
cleaned with non-fuoride paste. The preparations are then isolated
with rubber dam and the interdental spaces are separated using
wedges and a matrix.
If there is no more than 10 to 20 percent dentin exposure at the
inner surface, the preparations are simply etched with 35% phosphor
ic acid before applying one coat of bonding adhesive (Fig 3).
The internal surfaces of the veneers are etched with 1 0% hydroflu
oric acid for 90seconds and then thoroughly rinsed with water and
degreased with medicinal alcohol. Afer degreasing, two to three cycles
of silanization and drying are perfonned (Fig 40 and 41). Finally, a light
coat of adhesive resin is applied to the bonding surface of the veneer.
Fig 41 Silanization of an etched veneer.
3.4 Step-by-step: Clinical Procedure for the Fabrication of Veneers
A fne-hybrid resin composite heated to 50 C is normally used for
cementation of porcelain veneers.
Light-curing proceeds from the palatal surface to the buccal surface
of tbe veneer. Each surface is cured with intermittent light for I minute
in order to protect the pulp fom overheating. Excess resin is removed
using foam pellets when the resin is still sof, or with scalers, rotating
and oscillating instruments and strips after tbe resin has hardened
Recal l
Figs 43 to 45 Views at recal l , 1 week after
placement of the restorations.
Tbe authors are grateful to the patticipating dent technicians for the
excellent restorations they provided and for their consistently gooo
teamwork. We would especially like to thank Walter Gebhard (Geb
hAG, Zurich), BcThievent (Benrand Thievent AG, Dental
Laboratory, Zurich), Arold Wohlwend (Wohlwend Innovative Dental
Technik. Zurich), and KBTM 1nlcmDental Laboratory (Director: A
Satc).Spccithanks also to Heinz Liithy forht8contributions regard
ing the tehnical aspts of dental ceraimaterials.
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Chapter A All-ceramic Single Crowns
Table 1
4.1 I ndi cati ons
When planning all-ceramic single crown restorations, the choice of
ceramic restoration system is determined by the following factors:
Stump shade

Space requirements/clearance (tooth reduction)

Translucency of adjacent teeth

Strength requirements (anterior or posterior region).

The ceramic materials available today allow the dental laboratory
technician to select an appropriate ceramic restoration system for each
individual situation - at least from a materials viewpoint.
Based on their material strength and optical properties, the follow
ing ceramic materials can be used in anterior and/or posterior applica
tions as desc1ibed in Table I.
Dark stump Shoulder Adjacent tooth Region
shade preparation translucency
No 0.8 to 1 mm High Anterir
No/Yes 1 to 1.2mm Moderate, Anterior,
high posterior
No/Yes No/Yes Moderate, Anterior,
low posterior
If an oxide ceramic core is to be placed on a very transparent tooth,
more space is required for the restoration compared with other ceramic
core materials, such as glass-ceramic. The tooth reduction design must
be modifed accordingly. Space is required for:

The core (roughly 0.5 mm)

The opaque layer

The veneering ceramic (> 1 mm).

New and improved standard colors of ceramic core and veneering
materials now make it possible to reduce the layer thickness in accor
dance with the modem standards of tooth structure preservation.
4.2 Tooth Preparation
4.2 Tooth Prep a ration
Familiarity with specific all-ceramic tooth preparation guidelines is cru
cial for the clinical success of all-ceramic restorations. Apar from the
usual biologic requirements (healthy pe1iodontium, etc.), which are the
same for all tpes of restorations, specific technical requirements apply to
all-ceramic crown restorations. Inadequate tooth preparation (e.g., sharp
edges or inadequate space for the restoration) was responsible for the dis
appointing initial clinical survival rates for all-ceramic crowns'6.
Due to the increasing use of computer-aided design and manufactur
ing (CAD/CAM) teclmology for fabrication of dental restorations,
additional technical factors must also be considered. CAD/CAM sys
tems generally utilize optical scanning technologies that specif mini
mum taper and undercutfree preparation of the abutment tooth.
Tooth preparati on guidelines for aJI-ceramic crowns:

Circular shoulder with rounded inner edges or chamfer (Fig I).

Reduction requirements:
Glass-ceramic systems:
Shoulder 0.8 to 1 mm
1.0 to 1 . 5mm
1. 5 to 2mm
Occlusal 1.5 mm minimum.
Reinforced ceramic core systems:
Shoulder l to 1.2mm (NB: radius)
Axial 1.2 to 1.5 mm
Incisal 1.5 to 2.5 mm (NB: radius)
Occlusal 1. 5 mm minimum
Uniform layer thickness

Minimum 6degree stump taper

No sharp angles or edges.

If the shoulder angle is > 90 degrees, chamfer preparation is not recom
mended for all-ceramic restorations as this would increase the risk of
ceramic fracture27
In order to meet the modem technical requirements without making
major changes in routine clinical practice, a modifed version of the
original St. Moritz prep set (Intensiv SA, Gracia, Switzerland) of 1995
was modified for ceramic crown and laminate applications (Fig 1 ).
Chapter A All-ceramic Single Crowns
Diagram 1

Fig 1 Modified St. Moritzer Crown and
Laminate Prep Set (lntensiv SA, Granda,
Switzerland} of 2006. Some of the original
instruments were modified or replaced to
comply with the modern requirements for
all-ceramic restorations.
Burs ! l eft-right!: Veneer diamond (newl,
separating diamond, shoulder diamond,
shoulder finishing diamond (now wider!,
football diamond (now rounded, football
finishing diamond, diamond finishing bur
with 3-degree taper (new, for CAD/CAMJ.
4.3 Cl i ni cal Survival
Thanks to the technological advances in dental ceramic materials, it is
now possible to fnd a ceramic solution for nearly every clinical prob
lem. It is conceivable that all-ceramic crowns could replace metal
ceramic crowns in the future if they perform well in clinical practice
over the long-term.
The survival and complication rates of all-ceramic and metal
ceramic crowns were compared in a recent review of the literature
published in English and German from 1990 to 200419 Relevant clin
ical trials with a minimum observation period of at least 3 years were
The twenty-three studies on all-ceramic crowns that the authors
located are listed in Tables 2 to 4 according to materal type and sys
tem. The annual failure rate for glass-ceramic crowns was 2. 1 % for a
total of 1581 anterior and posterior restorations.
4.3 Clinical Survival
Reinforcement of ceramic materials resulted in an improvement of clin
ical survival: The annual failure rate for the anterior and posterior
restorations studied decreased to 0.8 % and 0.6% for glass-infltrated
ceramic ( 1269 crowns) and densely sintered alumina ceramic
(168 crowns), respectively.
The annual failure rate for porcelain-fused-to-metal (PFM) crowns
was higher (2.9%). This was determined by a single study that met the
inclusion criteria .
The results of this study show that ceramic core-reinforced crowns
placed in the anterior and posterior region have a high rate of success.
The clinical success rate for "weaker" glass-ceramic crowns was some
what lower than that for high-strength crowns, but comparable to that
for PFM crowns. The use of zirconia cores should lead to frther
improvement of the clinical success rate, but long-term studies are not
yet available. The decision-making process regarding the selection of
ceramic materials for dental restorations is described in the fow chart
below (Deci sion flow chart I).
HghestheIc demonds
I '
CuoIyo!the obutmenI Ioothorcore

/ \
odhesve cementoton is possb|e
odhesve cemenIotons noI possibe
|ocoIonssub|ected to hgh
Decision flow char 1 for the selection of dental ceramic materials.
Chapter A All-ceramic Single Crowns
Table 2 Survival rates for all-ceramic crowns
Author, year
Bindl et ol 20042
Estafon et ol 19997
Erpenstein et ol 2000<
Kelsey et al 1995
Meier et al 192'5
Sjorgen et al 19992j
Edelhoff et al 20005
Fradeani et al 20028
Sjorgen et al 1998'4
Sorensen et ol 199825
Studer et al 199826
Bieniek 19221
Crown materials
ceramic !DiLorl
I Dicorl
Gla ss-cero m ic
I Dicorl
Gla ss-cero m ic
I Empress)
I Empress)
I Empress)
I Empress]
I Hi-Cerom"'l
Hankinson et ol

Cheung 19914 Glass-ceramic
!jacket crowns)

Observation Failure rote
period Overall Annual
3.7 yeas 5. 6% 1.5%
4 years 0.0 % 0.0 %

7 years 24.3 % 3.5 %

4 years 24.8 % 6.5 %
4.3 years 16.6 % 3.9 %
6.1 years 18.0 oo 2.95 %
4 years 2. 0% 0.5 %

1 1 yeas 4.8 oo 0.

3.6 years 6. 7% 1.9 %

3 yeas 1.3 % 0.4 %

5.1 years 8.7 % 1.7 %

5 years 4.3 % 0.9 %

5 years 6.3 % 1.3 %
3.3 years 26.5 % 8.00 %
4.3 Clinical Survival
Table 3 Survival rates for all-ceramic crowns: gloss-infiltrated ceramic
Author, year Crown materials Indications Observation
(system) period
Huls 1995" ln-Cerom Anterior, 3 yeas
Alumino Posterior
Mclaren et al . 200014 ln-Ceram Anterior, 3 years
Alumina Posterior
Probster 19970 ln-Cerom Anterior, 6 years
Alumino Posterior
Scotti et ol . 199521 ln-Ceram Anterior, 3.1 years
Alumina Posterior
Segal 20012 ln-Ceram Anterior, 6 years
Alumino Posterior
Bindl et ol. 20023 ln-Ceram Posterior 3.2 years
Alumina, Spinel(
Fradeani et ol . 20029 ln-Ceram Posterior 4.2 years
Spinel I
Table 4 Survival rates for al l -ceramic crowns: oxide ceramic
Author, year Crown materials Indications Observation
(system) period
Oden et al 199817 Alumino Alz03 Anterior, 5 years
IProcerol Posterior
Odmann et al 200118 Alumino Al_0_ Anterior, 10 years
IProcerol Posterior
Failure rate
Overall Annual
2.7% 0.9%
4.0 % 1.3 %
36.5 % 6.1 %
!.O 0.5 %
0.9 % 0. 2%
70% 2. 2%
2.5 % 0.6 /
Failure rate
Overall Annual
3.1 % 0.6 '
6. 5% 0.7%

Chapter A All-ceramic Single Crowns
4.4 Cl i ni cal and Laboratory
I nitial consultation
Good communication between the patient, dentist and dental techni
cian is crucial for the selection of optimal restorative materials. The
procedures for the dentist and the dental laboratory are described step
by-step in the clinical case study presented below.
Figs 2a to 2c This young woman had been dissatisfied with the appearance of her anteri
or teeth for several years. The uneven incisal plane, that is, tilting of the central incisors
towards midline !"teeth too short") and the different colors of her old composite fillings
bothered her. The plastic-faced crown at non-vital abutment tooth 12 become discolored
over the course of the years and was perceived as unsightly. The esthetic problems were
readily visible due to the patient's high smile line. In addition to the tooth discoloration
problems, there was also noticeable gray discoloration of the marginal gingiva at tooth 12.
The patient wished to have metal-free dental restorations.
Photographs displaying the lips at rest, slightly parted, and in full smile are crucial for treat
ment planning and communication purposes.
Figs 3a to 3d The preliminar diagnostic
work begins during the initial consultation.
Composite filling material is used to simu
late length and shape corrections for
demonstration purposes. The patient and
the dentist con then mutually evaluate and
discuss the feasibilit and limitations of the
patient's expectations. An alginate impres
sion of the simulated situation is subse
quently mode in order to communicate the
desired goals to the dental technician.
In this specific case, the dentist additionally
explained to the patient that, because the
gray discoloration of her gingiva is caused
by discoloration of the tooth root, little or
no improvement con be expected, even if
on al l-ceramic restoration is used.
4.4 Clinical and Laboratory Procedures
Chapter A All-ceramic Single Crowns
Diagnostic work-up
The success of a prosthetic restoration depends on a number of factors,
including accurate reproduction of the natural tooth color. The shape
and anatomical position of the teeth and their direct interactions in the
dentofacial complex also play a major role. The dental technician must
reconcile the esthetic expectations of the patient and dentist with the
technical limitations of the materials and the patient's fnancial con
The following records are needed for diagnostic planning:

Description of the esthetic expectations of the patient

Aticulated study model (Fig 4b)

Pretreatment photographs (Fig4a):

Portrait photograph
View of lips at rest
View of lips slightly patted
View of fll smile.
Fig 4b Initial study model.
4.4 Clinical and Laboratory Procedures
Step-by-step procedure
Using the study model submitted by the clinician, the dental technician
(DT) makes an additive wax-up with corections for tooth position or
angulation. Two silicone indexes are made from the wax-up; one is
used as a reference for tooth preparation, and the other for fabrication
of the indirect provisionals (actylic resin shells).
For patients with high esthetic demands, it is advisable to do a
mock-up of one or two diferent restoration proposals for the patient
to "tr on" the proposed restorations for the team (patient, dentist and
dental technician) to evaluate and discuss.

Fig 4c Mock-up of
the planned restora
Fig 4d The thin
shells are placed
on the teeth to
assess for proper
length and phoet
Chapter A All-ceramic Single Crowns
Cl i ni cal di agnosi s
Figs :o:o:- ~mock-up of the chosen
restorative alternative is made so that the
patients can try out the new look i n their
mouth for a few days. This intermediate
diagnostic step is advisable, especially
when major changes have been proposed.
It helps to achieve a precise definition of
the prosthodontic goal before the start of
Treatment planning:
Tooth J.:crown
Teeth 11/21 . veneers.
||g6 Once a precise definition of the treat
ment goals had been obtained, periodon
tal/ conservative treatment was performed
and the old restorations were removed.
Endodontic treatment was sufficient for abut
ment 12; the apex was normal, but severely
discolored treddishl. Based on the clinical
situation !residual dentin, build-upl, internal
bleaching was not performed because the
patient did not wish to have the whitening
procedure. A white opaquing composite
was, therefore, used to mask the buccal
aspect of the discolored abutment tooth.
4.4 Clinical and Laboratory Procedures
Diagnostic wax-up and shel l provisional
It is advisable to place a buccal wax shield on the wax-up before start
ing the provisional. This allows more space for easier intraoral posi
tioning of the relined provisional.Silicone indexes of the diagnostic
wax-up are also made as a reference for tooth preparation.
Fig 7a Wax shield.
Fig - controlled trim

,ng of plaster for

fabncotton of the provtstonals.
Fig 7b Additive diagnostic wax-up.
Fig 7d Finished provisional restoration
mode of pmmo resin.
Chapter A Allceraic Single Crowns
Tooth preparation and shel l provisional
Diagnostic mock-ups help patients gauge their satisfaction with a pro
posed restoration during the diagnostic planning stage, and changes in
the planned tooth shape or position can still be made if determined
necessary by the team (patient, dentist and technician).
A polyether or silicone impression of the definitively prepared
abutment tooth is taken at a later appointment.
Figs 7e and 7f A silicone index of the diagnostic wax-up is made prior to tooth prepara
tion. The silicone index allows for selective creation of clearance for the restoration with
maximum conservation of tooth structure.
Figs Sa and 8b The buccal and incisal aspects of the preparations are assessed using the
silicone index. The teeth are uniformly reduced to ensure uniform clearance for the ceramic
restoration. All edges and junctions must be carefully rounded.
Figs 9a and 9b The diagnostic mock-up made from the diagnostic wax-up is now relined
and seated as the provisional restoration.
4.4 Clinical and Laboratory Procedures
Treatment wax-up
The treatment wax-up seres a number of functions. When an easily
processed material is used, adjustments can be made for tooth shape
and contour (Figure 1 Oa). Since the silicone index from the wax-up
shows exactly how much space is available for the restoration, there
are no unpleasant surprises during the ceramic layering stage. The
intraorally seated treatment wax-up can infuence the selection of
restorative materials.
Fig lOa The tooth contour is determined by the external margins of
the teeth, and the optical shape of the teeth by the axial ridges.
Figs lOb and lOc.
Chapter A All-ceramic Single Crowns
Wax tr-in
Figs lOd and 1 Oe Try-in of the treatment wax-up, which was prepared by the dental techni
cian on the master cast according to the preliminary diagnostic work.
Shade selection
Fig 1 1 a Shade analyses should be per
formed at on optimal light temperature
15500Kl, especially when on anterior
restoration is to be made. The late morning
or late afternoon is an ideal time of day for
shade analysis. Room light quality test
cards are also helpful.
Fig 1 1 b Determination of the stump shade
is also required for fabrication of all-ceram
ic restorations.
Fig 1 1 V It is very helpful to
perform the shade analysis
with the coping [made of
alumina, zirconia, etc.l in
place and to stain the cop
ing intraorally as needed.
4.4 Clinical and Laboratory Procedures
Shade selection aids


Fig 1 1 d Shade guides ore useful
tools for basic color determinations
and simple shade analyses.
Fig 1 1 l Original shade guides sup
plied by L ceramics manufacturer.
Checkl ist for shade analysis

Sit or stand at eye level with the patient

Fig 1 1 Cheek retractors reduce
surrounding color lred of the lips),
which con interfere with the shade

Fig 1 1 g Custom shade guide.

Use indirect sunlight or 0ylight illumination

Note colors in the surroundings and their efects:

Lipstick, make-up
Lurid clothing
The teeth should be thoroughly cleaned beforehand
Impressions should be taken beforehand.
Chapter A All-ceramic Single Crowns

Disposable gloves
Color rings, etc
Color markers
Color cards

Cheek retactors
Mouth mirror

Selection of ceramic materials
Factors that deterine the choice of ceramic materials used for the
restoration are: region, stump shade, space requirements, and bite sit

Region: anterior
All-ceramic restorations (with or without ceramic cores) are
preferable in the anterior region because of the light transmission
properties of ceramic materials.

Stump shade:
If the abutment tooth is severely discolored (A4, > B4) the
amount of color variation possible with all-ceramic restorations is
greatly limited.

Space requirements:
If a core-reinforced (alumina, zirconia) all-ceramic restoration is
to be placed, a minimum core thickness of 0.4 mm should be
observed. Othetwise, there is a high risk of ceramic fracture.
Bite situation:
Conventional porcelain-fsed-to-metal crowns should be used in
patients with extreme bite problems.
Biscuit bake try-in and compl etion of the restorati on
Going from the biscuit bake try-in to the completed restoration by a
diagnostic wax-up and a treatment wax-up has proved to be a success
ful concept in patients with high esthetic demands.
Biscuit bake tr-in
4.4 Clinical and Laboratory Procedures
Figs 12a to 12f The silicone index from the
wax-up is a useful tool for the layering
design. Stump shade determination is cru
cial for all-ceramic restorations because it
makes it easier to predict the final result.
Fig 1 3 Biscuit bake try-in of veneers and
zirconia crown at the dental office.
Chapter A All-ceramic Single Crowns
Compl eted restoration
Figs 14o ond 14b Completed restorations: zirconia crown for tooth 12, veneer !360degrees)
for tooth 11, and veneer for tooth 21 !modified prepLrLtionl
Fig 14c The positioning key !e.g., Pattern
Resin, GC, USAl fabricated by the dental
technician makes it possible to check for
correct !esthetic) position of the restoration
during cementation. However, it is
absolutely essential to use on e7plorer to
check margin position.
The bonding procedure for different 1pes
of ceramic materials is described Otepby
step in Chopter8.
Figs 15o ond 15b Frontal view and smile after placement of the restorations.
The use of ceramic materials with different optical and mechanical properties compensat
ed for stump shade deviations and irregularities in tooth redLction.
I . Bieniek KW. Vollkeramische Kronenrestaurationen aus Hi-Ceram eiue 5-
1ahres-Studie. Dtsch Zahnaztl Z 1992;47:614616.
2. Bind! A, Mormann WH. Survival rate of mono-ceramic and ceramic-core
CAD/CAM-generated anterior crowns over 2-5 years. Eur :Oral Sci 2004:
1 12(2): 197-204.
3. Bind! A, Mormann WH. Pup to 5-year clinical evaluation of posterior 1n
Ceram CAD/CAM core crowns. 1nt J Prosthodont 2002;15(5):451-456.
4. Cheung GS. A preliminary investigation into the longevity and causes of fail
ure of single unit extracoronal restorations. J Dent 1991; 19(3): 160-163.
5. EdelhoffD, Horstkemper T, Richter EJ, Spiekennann H, Yildirim M. Adhiisiv
und konventionell befestigte Empress 1-Kronen. Dtsch Zahnarztl Z
6. Erpenstein H, Borchard R, Kersch balun 1Long-term clinical results of gal
vano-ceramic and glass-ceramic individual crowns. iProsthet Dent
7. Estafan D, David A, David S, Calamia J. A new approach to restorative den
tistry: Fabricating ceramic restorations using CEREC CAD/CAM. Compend
Contin Educ Dent 1999;20(6):555-60.
8. Fradeani M, Redemagni M. P l I -year clinical evaluation of leucite-rein
forced glass-ceramic crowns: A retrospective study. Quintessence lnt
9. Fradeani M, Aquilano A, Corrado M. Clinical experience witll Tn-Ceram
Spinel! crowns: 5-year follow-up. lnt J Periodontics Restorative Dent
10. Hankinson JA, Cappetta EG. Five years' clinical experience with a leucite
reinforced porcelain crown system. Int JPeriodontics Restorative Dent
1994; 14(2): 138-153.
1 1 . Hiils A. Zum Stand der klinischen Bewiihrung inliltrationskeramischer
Verblendkonen. Dtsch Zahnarztl Z 1995;50:674-676.
12. Kelsey WP 3rd, Cave! T, Blankenau R1, Barkmeier WW, Wilwerding TM,
Latta MA. 4-year clinical study of castable ceramic crowns. Am J Dent
1 3. Kerschbaum Th, Paszyna Ch,Klapp S, Meyer G. Verweilzeit- und Risikofak
torenanalyse von festsitzendem Zahnersatz. Dtsch Zahniirztl Z 1991 ;46:20-24.
I 4. Mclaren EA, White SN. Survival ofin-Ceram Crowns in a Private Practice. A
prospective clinical trial. iProsthet Dent 2000;83:216-222.
I 5. Meier M, Richter EJ, Kupper H. Spiekennann H. Klinische Befunde bei Kro
nen aus Dicor-Giaskeramik. Dtsch Zahnarztl Z 1992;47:610-614.
16. Nuttal EB. Factors infuencing success of porcelain jacket restorations. J Pros
thet Dent 1961;11 :743-748.
17. Oden A, Andersson M, Krystek-Ondracek 1, Magnusson D. Five-year clinical
evaluation ofProceraAl!Ceram crowns. J Prosthet Dent 1998;80(4):450-456.
dmann P, Andersson B. Procera Ali-Ceram crowns followed for 5 to I 0.5
years: A prospective clinical study. tnt .Prosthodont 2001;14:504-509.
Chapter A All-ceramic Single Crowns
19. Pjetursson BE, Sailer I, Zwahlen M, 1merle CHF. A systematic review of
the survival and complication rates of all-ceramic and metal-ceramic restora
tions afer an observation period of at least 3 years. Part I: Single crowns. Clin
Oral Imp! Res 2007;1 8(Suppl.3):73-85.
20. Probster L. Klinische Langzeiterfahrungen mit vollkeramischen Kronen aus
In-Ceram. Quintessenz 1997;48: 1639-1646 .
21. Scotti R, Catapano S, D'Elia A. A clinical evaluation of ln-Ceram crowns. h1t
J Prostbodont 1995;8(4):320-323.
22. Segal BS. Retrospective assessment of 546 all-ceramic anterior and posterior
crowns in a general practice. J Prosthet Dent 2001 ;85(6):544-550.
23. Sjogren G, Lantto R, Till berg A. Clinical evaluation of all-ceramic crowns
(Dicor) in general practice. J Prosthet Dent 1999;81(3):277-284.
24. Sjogren G, Lantto R, Granberg A, Sundstrom BO, Till berg A. Clinical exami
nation of leucite-reinforced glass-ceramic crowns (Empress) in general prac
tice: A retrospective study. Int J Prosthodont 1999;12(2):122-128.
25. Sorensen JA, Choi C, Fanuscu MI, Mito WT. IPS Empress crown system:
Three-year clinical trial results. J CalifDent Assoc 1998;26(2): 130-136.
26. Studer S, Lehner C, Brodbeck U, Scharer P. Six-year results of leucite-rein
forced glass-ceramic crowns. Acta Medicinae Dentium Helvetica
1998;3:21 8-224.
27. Weaver JD, Johnson GH, Bales DJ. Marginal adaptation of castable ceramic
crowns. J Prosthet Dent 1991 ;66:747-753.





Chapter O Non-vital Abutment Teeth
A number of additional factors must be considered when planning the
prosthetic rehabilitation of non-vital teeth. Apart from endodontic
pretreatment and biomechanical factors dictating material selection
and tooth preparation, esthetic factors are also crucial to treatment
The chances of successful restoration of endodontically treated
teeth reportedly range from 70 to 95 percent, depending on how the
criteria of success are defined18 Leakage of bacteria into the obturat
ed root canal leads to recontamination of the root canal lumen. Bacte
rial microleakage and subsequent periapical re-infection as well as
secondary caries and subsequent loss of retention of the restoration
are major causes of endodontic failure.
Micro leakage occurrence is dependent on various factors including:

The type of root canal flling material/cement used and the ade
quacy of flling

The type and quality of the provisional restoration

The type and quality of the definitive restoration.

No cement to date has been able to achieve totally complete sealing,
but different types of cement achieve signifcantly different levels of
sealing quality. Zinc phosphate cement, for example, proved to be sig
nifcantly inferior to glass ionomer cement and composite cement in
independent studies'(see also Chapter8.2).
5.1 Bi omechani cs of Non-vital Teeth
The more tootl1 structure lost through decay or removed to create an
access for endodontic treatment or to prepare the teeth for restorations,
the greater the extent of deformation of the remaining tooth structure
during functional activity. Post placement requires the additional
removal of dentin, thus further weakening the tooth. The use of a post
does not strengthen the tooth prior to prosthetic restoration, but rather,
it merely serves to enhance the retention of the crown and core and to
transmit the forces placed on them to the remaining tooth structure.
From a biomechanical point of view, the tooth, post and core comprise
an inhomogeneous system. Biting forces are transferred from the
mechanically stronger components of the system to the weaker system
components. Under excessive strain, the weakest part of the system is
the frst to fracture and that is usually the root dentin.
5.1.1 Rol e of Ferrule Effect
All studies investigating the role of the amount of tooth structure
enveloped by a crown, or fem1le efect, on all-ceramic restorations have
so far focused solely on crowns luted with zinc phosphate cements915
With these luting agents, there is no chemical adhesion between the
cement and the tooth or post. The resistance of crowns luted with zinc
phosphate cements to occlusal forces was found to be significantly high
er in restorations with a 2mm fenule6 Studies evaluating the role of fer
rule design on adhesive cementation are not available (Diagram!).
5. 2 Posts

.. . ..... ....

There is currently no definitive answer to the critical question of
whether or not the placement of a post is still necessary for adequate
core retention in light of the advanced adhesive technologies avail
able today. In vivo studies on this subject are scarce, and most are
plagued by the problem of poor comparability. Consequently, there
are only general guidelines to aid the dentist in making the decision of
whether or not to place a post in an endodontically heated tooth.
These are described below.
5.2 Posts
Diagram 1
Chapter O Non-vito/ Abutment Teeth

For retention of a core in a tooth with insuficient tooth structure.


Availability of adequate tooth structure to retain a core

Very narrow or tortuous tooth roots

Short roots

Inadequate seal of a root canal filling

Periapical pathologies.
Prerequisites for post and core placement

Adequate root canal preparation technique

Complete sealing of the root canal system using non-metallic

sealing materials

No or minimal exposure of the root canal flling to the oral cavity.


Loss of retention of the restoration


Tooth fracture.
5.2.1 Post Geometry
The use of active posts (screw posts) is not recommended because
their threaded design leads to increased distension stresses that could
lead to root fracture10

16 Passive post systems work by passive resist

ance to withdrawal (tug-back) with no active exertion offorce.
Cylindrical posts achieve good retention by means of frction, but
they are too wide to H!in the apical region, where the roots usually
become more narrow (Diagram2). Conical posts, on the other hand,
have a more suitable geometry but poor retention. They also tend to
wedge when force is applied (Diagram 3). Cylindro-conical posts
were, therefore, developed to combine the advantages of the two
forms. These hybrid posts are conical in the apical region and cylin
drical in the coronal region.
Diogroms 2 ond 3
5.2.2 Post Material s
Various types of materials are used to manufacture dental posts includ
ing metals, ceramics and fiber-reinforced materials. For biologic rea
sons, the only metals suitable for use as dental posts are gold and titani
um. Other non-precious metals are subject to corrosion. The mechanical
performance of metal posts i s good, even when their diameter is small.
Zirconia (see Chapter 1. 2
4) is the only ceramic post material
available (Fig 1). Zirconia posts have high fexural strength, but, like
all ceramics, they are very brittle. To achieve suficient fracture resist
ance, the diameter of ceramic posts must be slightly larger than that of
metal posts. Metal and ceramic posts can be used for either direct or
indirect restorations.
The diferent types of fiber posts (Fig 2) differ in a number of
ways. Glass or carbon fibers are embedded in a resin composite or
epoxy resin matrix. The number and diameter of reinforcing fibers
varies from one manufacturer to another. The mechanical properties
of the different types of fiber posts vary accordingly. The modulus of
elasticity of the various systems ranges widely, from roughly 20 to
320 GPa. Like all synthetic materials, fiber posts are susceptible to
humidity and fatigue. Therefore, the mechanical data provided by the
manufacturers apply only to brand-new fber posts. Fiber posts are
suitable for direct restorations only.
5.2 Posts
Chapter O Non-vito/ Abutment Teeth
Fig 1 Fracture surface of a zir
conia post.
5. 3 Esthetics
Fig 2 Fracture surface of a
glass fiber post.
Non-vital teeth may become discolored due to the presence of metal
lic substances in root flling materials, blood degradation products, or
degraded pulp proteins. Metal posts are also said to have a negative
efct on tooth color and, thus, on the appearance of prosthodontic
restorations. Esthetics may, therefore, be unacceptable for esthetically
demanding restorations.
5.3.1 Bl eachi ng of Non-vital Teeth
The pros and cons of bleaching non-vital teeth must be carefully con
sidered before starting such a treatment. One distinct advantage of
non-vital bleaching is that, if successful, it may no longer be neces
sary to place a crown on the non-vital tooth in order to obtain the
desired esthetic result. If prosthetic rehabilitation is still required,
bleaching will make the abutment more closely match the original
tooth shade, thus creating more optimal conditions for the fabrication
of an all-ceramic crown by a dental technician. Still, it is important to
bear in mind that bleaching does not lighten discolored tooth roots,
which ofen show through the gingiva.
The main disadvantage of non-vital bleaching is the risk of resorption at
the root smface. Hydrogen peroxide, the most commonly used bleach
ing agent, penetates dentin5 and can cause exteral root resorption by
vi11ue of its acidic pH4 It is, therefore, crucial to ensure that the root
flling is reduced only 1 to 2 mm below the cementoenamel junction.
As the root flling alone cannot completely prevent the diffusion of
bleaching materials, glass ionomer cement is needed for additional

The incidence of cervical root resorption was shown to
increase when 30% hydrogen peroxide is used or when thermo-cat
alytic bleaching is performed8. 12. Therefore, it is generally recommend
ed that interal bleaching be performed using sodium perborate mixed
with water for mild to moderate staining, or with 3% hydrogen perox
ide for severely discolored teeth. It is not always possible to eliminate
tooth discoloration. The success of bleaching varies depending on the
cause of discoloration. Unlike blood and protein degradation products,
metallic products are very resistant to bleaching717

Also, the color stability of the bleaching result is not always assured.
Discoloration relapse presumably occurs due to leakage through the
restoration margins3 The more extensive the restoration of the affected
tooth, the greater the chances that color pigments or bacteria will be
able to penetrate the margins and cause a relapse of discoloration.
Afer bleaching, the bonding strength of restorative materials to
the tooth is temporarily reduced due to the presence of residual perox
ide or oxygen. Optimal adhesion i s achieved 3 weeks after bleach
ing213. This time lapse can be used to check for color stability and to
apply calcium hydroxide in order to buffer the acidic pH at the root
surface (to prevent resorption).
5.3 Esthetics
Chapter O Non-vito/ AbUtet Teeth
Fig 3 Titanium post
with a composite
core lshode A3l.
5.3.2 Effects of Posts on Tooth Col or
Non-tooth-colored posts are said to make the tooth and the marginal
gingiva look gray and to impair esthetics. The color stability of four
post materials (titanium, carbon fiber, glass fber and zirconia), an
opaque composite cement (Panavia21 OP, Kuraray Dental, USA), a
composite core (Tetric C, Shade A3), and a ProCAD ceramic crown
(CEREC) was recently investigated by our group (Sailer et al, in
We did not observe any differences between the various types of
post material with regard to color change in the root region. However,
the differences between the diferent post materials were significant
(!i^.3 and 4). The type of post material iuences the color of the
crown (Figs. 5 and 6). We found that crown color is significantly dark
er on titanium and carbon fber posts covered by a ceramic layer thin
ner than 1. 5 m.m, whereas there is no significant diference when the
ceramic layer is thicker than 1.5 mm. This mainly applies to the crown
margins, where the layer thickness is ofen less than 1 .5 mm.
Fig 4 Zirconia post
with o composite
core (shade A3l.
Fig 5 Titanium post
and core with a
CEREC crown
(shade A3l.
Fig 6 Zirconia post
and core with a
CEREC crown
(shade A31.
5.4 Clinical Procedure
5.4 Cl i ni cal Procedures

Rubber dam
Dentin bonding agent
Panavia 21 TC cement
Set of drills
Core composite
Polymerization lamp.
Isolate and dry the tooth
Prepare a straight access to the root canal
Prepare the post canal using drills of appropriate size, leaving
at least 3 mm of gutta percha filling
Rinse the canal with sodium hypochlorite solution (NaOCI)
solution and dry with paper points (Fig /)
Insert the post into the prepared canal to the reference length
to check for ft (Fig B)
Check by radiography if necessary.
Fig 7 A paper point is used to dry the
Fig 8 The post is inserted to the reference
length to check for fit.
Chapter O Non-vital Abutment T th

Titanium posts: sandblast with 50 m Al20
- Zirconia posts: condition with Clearfl Porcelain Activator
and Clearfl SE BOND (Kuraray) Primer ( 1 : 1 )
Dentin Bonding

If enamel etching is required, apply 37% phosphoric acid for

30seconds and then blow off and dry carefully (using paper points
in the canal).
Mix ED Primers A and B (Art Bond) at a ratio of 1 : 1 . Apply (also
in the canal) with a brush and leave on for 60 seconds. Subsequent
ly blow of and dry. Remove excess primer from the canal using
absorbent paper points (Fig9).

Panavia 21
Mix cement ( 1 : 1 ) on a mixing pad
Mix with a spatula for 30seconds to fon a homogeneous
Grasp the post with diamond forceps and wet the lower 3 to
+mm of the post with cement (Fig 1 0)
Insert the post into the canal (Fig 11)
Remove excess cement
Apply Clearftl SE BOND to the entire dentin and enamel
srface, allow to take efect, blow off, and allow to harden
for 60 seconds
Build up the core with hybrid composite material (Fig 12).
Fig 9 Application of primer. Fig 10 Wetting of the post with cement.
Fig 1 1 View of the inserted post before
core build-up.
Fig 12 View of the finished composite core.
l . Bachicha WS, Difiore P, Miller PM, Lautenschlager EP, Pashley DH.
Micro leakage of endodontically treated teeth restored with posts. J Endodont
2. CavaUi V, Ries AF, Giannini M, Ambrosano GMB. The efect of elapsed time
following bleacbi11g on enamel bond strength of resin composite. Operat Dent
200 I ;26(6):597-602.
3. Friedman S. In
ernal bleaching: Long-tem1 outcomes and complications. J
Am DentAssoc 1997;128 (special issue):51-55.
4. Friedmann S, Rotstein I, Libfeld H, Stbholz A, Heling I. Incidence of exteral
root resorption and estetic results in 58 bleached pulpless teet. Endodont
Dent Traumatol 1988; 14:23-26.
5. Fuss Z, Szajkis S, Tagger M. Tubular pem1eability to calcium hydroxide and to
bleaching agents. J Endodont 1989; 15(8):362-364.
6. Gelfand M, Goldman M, Sunderman E. Effect of complete veneer crowns on
te compressive stength of endodontically treated posterior teeth. J Prosthet
Dent 1984;52:635-638.
7. Glockner K, Ebelseder K. lndikationen und Grenzfalle Jidas Bleicben von
devitalen ve1farbten Frontzihnen Quintessenz 1993;44:519-527.
8. Heller D, Skriber J, Lin LM. Effect of intracoronal bleaching on exterl cer
vical root resorption. J Endodont 1992; 18:145-148.
9. Isidor F, Odran P, Brondum K. (1 999) Intennittcd loading ofteeth restored
using prefabricated carbon fiber posts. lnt J Prosthodont 1996;9: 1 3 1-136.
10. Milistein P L, Yu H, Hsu ES, Nathanson D. Effects of cementing on retention
of a prefabricated screw post. J Prosthet Dent 1987;57: 171-174.
Chapter O Non-vito/ Abutment Teeth
1 1 . Rotstein I, Zyskind D, Lewinstein I, Bamberger N. Effect of different protec
tve base materials on hydrogen peroxide leakage during intracoronal bleach
ing in vitro. J Endondont 1992; 18: 114-117.
12. Rotstein I, Friedman S, Mor C, Katzelson J, Sommer M, Bab I. Histological
characterization of bleaching-induced external root resorption in dogs. J
Endodont 1991; 17(9):436-441.
13. Shinohara MS, Rodrigues JA, Pimenta, LA. 1n vitro micro leakage of compos
ite restoration afer noovital bleaching. Quintessence lnt 2001;32:413-417.
14. Sorensen JA, Engelman MJ. Ferrule design and fracture resistance of
endodontically treated teeth. J Prostbet Dent 1990;63:529-536.
15. Standlee ,Caputo M, Holocomb JP. The dentatus screw: Comparative stress
analysis with other endodontic dowel designs. J Oral Rehabil 1982;9:23-33.
16. van der Burt TP, Plaesschaert AJ. Bleaching of tooth discoloration caused by
endodontic sealers. J Endodont 1986; 12:231-234.
17. Weiger R, Axmann-Krcmar D, Lost C. Prognosis of conventional root canal
treatment reconsidered En dod Dent Traumatol 1998; 14( I): 1-9.



Chapter External Bleaching
6.1 Introduction
Bleaching is defined as the decolorization and whitening of materials.
Bleaching agents used in dental applications remove tooth discol
oration by oxidizing chromogenic molecules. Vital tooth bleaching is
distinguished from non-vital bleaching and is performed on the exter
nal tooth swface.
6.1.2 Bl eachi ng Agents

Hydrogen peroxide (H202):

Breaks down into oxygen and perbydroxyl radicals (0 und H02

Carbamide peroxide (H2N-CO-NH2 H202):

Reacts with water to form urea (6.6 parts) and hydrogen peroxide
(3 .4 parts).
6.1.3 Mechani sm of Action
Free 0 und H02 radicals difuse through the organic substance of the
interprismatic enamel and through the dentin. Perhydroxyl radicals
(H02) break down the large dark chromogenic molecules responsible
for tooth discoloration into smaller unsaturated double-bonded mole
cules that are lighter in color. Aer further oxidation, the molecules are
converted into unpigmented, hydrophi lic saturated carbon compounds.
6.1.4 I ndications for External Bl eachi ng

Discoloration of the enamel

Age-related tooth discoloration

Mild to moderate tetracycline staining.

6.2 Power Bleaching
6.1.5 Contraindications

Stains that can be removed by means of professional tooth cleaning

Amalgam stains
Waring: Special caution is advised in patients with leaky fillings,
hypersensitive teeth, large pulp cavities andor exposed dentin.
6.2 Power Bl eachi ng
Power bleaching is an in-otiice procedure performed using highly
concentrated bleaching agents. Light-activated catalysts are some
times used to potentiate the bleaching reaction. Power bleaching is
mainly performed to whiten a single discolored tooth or one specifc
area of a tooth. Generally, multiple sessions are required. Power
bleaching products contain carbamide and hydrogen peroxide at con
centrations of up to 35%1 The efficacy of using light-activation for
potentiation of power bleaching has been variably described1317. The
application of high-intensity light also harbors the risk of overheating
the pulp9
6.2.1 Power Bl eachi ng Procedure

Clean the teeth with an abrasive polishing paste in a rubber cup.

(The custom of degeasing the teeth with alcohol or etching the
enamel with phosphoric acid for this purpose is now obsolete).

Determine and document the current shade of the teeth (photo

graph the teeth together with the shade guide).

Isolate teeth with a rubber 0.

Apply the bleaching agent for approxima

ely 5 minutes and wipe

off with a cotton swab soaked in 3% hydrogen peroxide; repeat for
a tota. of +to 6times. Light activate the bleaching agent according
to the manufacturer's instructions. Waring: take precautions to
avoid overheating!
Chapter O Exteral Bleaching

Subsequently apply colorless fluoride gel to the teeth. fluoride i s

used to restore the micro hardness of the enamel and dentin,
which is signifcantly diminished by the bleaching procedure, to
the original bardness8.

Depending on the results of whitening, the procedure may be

repeated afer about month if necessary.
Take a post-treatment photographic record.

Restorative treatments should not be performed until at least one

month afer teeth whitening. This allows time for shade rebound'0
and for the elimination of oxygen remaining in the dental struc
mre after bleaching, thus improving the bond strength of adhe
sives to the bleached enamel and denti n215
6.3 Combi ned Bl eachi ng
Combined bleaching is a method in which initial in-ofice cbairside
bleaching is followed by subsequent at-home bleaching. This proce
dure can be used to treat severely discolored teeth or to stabilize the
results of in-ofce bleaching. However, it does not have any advan
tage over at-home bleaching except for the initial acceleration of
6.4 At-home Bl eachi ng
This treatment modality is also referred to as "nightguard bleaching"
or "mouthguard bleaching". In at-home bleaching, the patient applies a
mild bleaching agent to the teeth using a custom tray. In the literature,
10% carbamide peroxide has been described as an efective and safe
bleaching agent1014. Its significant whitening efects were still
detectable two years after teeth bleaching'6. Custom trays fabricated
for nightguard bleaching should have gel reservoirs. Studies have
shown that 52% of the bleaching gel remains in the reservoir 2 hours
afer application, and that 24% is still present 6 hours af
er applica
tion1 1 .
6.4 At-home Bleaching
6.4.1 At-home Bl eachi ng Procedure
Laboratory procedure (Figs |to 3)

Fabricate a study cast (from the alginate impression provided by

the dentist).

Place a thin (approximately 0.5 mm) layer of block-out material

on the labial tooth surfaces to create gel reservoirs. Do not block
out the incisal edges, occlusal surfaces and a narrow zone along
the gingival margin

Use 0.5-mm-thick, soft tray material to vacuum-form a flexible,

fom-stable tray.

The edges of the tray should follow the labial gingival contours,
overlapping the oral gingival margin slightly to prevent leakage
of the gel.

Fig I Study cast with block-out material for

gel reservoirs on the labial tooth surfaces.
Fig 3 The tray follows the gingival contours.
Fig 2 The custom tray is trimmed and the
edges rounded.
Chapter External Bleaching
Chairside procedure (Figs 4 to 9)

Clean the teeth with an abrasive polishing paste in a rubber cup

Determine and document the current tooth shade (photograph the

teeth together with the shade guide)

Adapt the tray for optimal fit

Provide the patient with instructions on how to use the tray and gel
bleaching system.

Instructions for use:

First brush and foss the teeth with toothpaste and dental foss
Dispense dabs of whitening gel into the reservoirs of the tray
Seat the tray over the teeth.
Gently press the tray against the teeth
Remove excess gel with a toothbrush or a cotton swab
Refain from eating and drinking while the tray is in place
Aer removing the tray, clean
he teeth with a toothbrush and water
Subsequently rinse the teeth with a colorless fluoride solution8
Clean the tray with a tootbrush and water
Avoid smoking and foods that will stain teeth for the entire
duration of treatment
The patient should be informed about potential side efects, such
dreversible tooth sensitivit and gingival irritation351w.
The patient should be aware of how to alleviate these symp
toms, e.g., by applying desensitizing gel.

The patient should be issued with enough whitening gel for one
week of treatment.

First week: the whitening gel is initially applied for 2 hours to

test for side efects. If no side effects occur, the gel is applied
overight for 8 hours. Frequently replacing the bleaching agent
increases the risk of side effects 7

The patient should retur for a follow-up visit after 1 week. If

there are no problems, overight bleaching can be continued.

The duration of treatment is generally 2 weeks for mild to moder

ate staining'0, and up to 6months for tetracycline staining12

The bleaching result should be assessed and documented.

Restorative treatments should not be performed until at least l

month after teeth whitening. This allows time for shade rebound10
and for the elimination of oxygen remaining in the dental struc
ture afer bleaching, thus improving the bond strength of adhe
sives to the bleached enamel and dentin2'5
Fig 4 Tooth cleaning.
Fig 6 Dabs of gel are dispensed into the
Fig 8 View of the seated tray.
6.4 At-home Bleaching
Fig 5 Pretreatment photographic record
with reference shade.
Fig 7 Excess gel is subsequently removed.
Fig 9 Post-treatment photographic record
with reference shade.
Chapter External Bleaching
6.5 "Over-the-counter" Teeth
Whi teni ng
Over-the-counter (OTC) teeth whitening systems are freely available
on the market. The manufacturers promise their customers "white"
6.5.1 OTC Bl eachi ng Kits
DTCbleaching kits generally consist of an acidic oral rinse (acetic
acid or citric acid), a prefabricated tray that can only be adapted to a
limited degree, 3 to 6% hydrogen peroxide bleaching gel, and an
abrasive toothpaste. Because of the poor ft of the tray, the bleaching
gel leaks, is swallowed and is quickly inactivated by saliva. ln addi
tion, the procedure is very abrasive. The use of such kits cannot be
6.5.2 Whiteni ng Strips
Whitening strips are transparent, self-adhesive strips of adjustable
plastic that have been coated on one side with bleaching agent. They
are generally wor for 30 minutes a day, twice daily, for a period of
2 weeks. The most commonly used bleaching agent is 6% hydrogen
peroxide. Whitening strips produce demonstrable teeth whitening
efects, and the side effects tend to mild and reversible6 The cost-efec
tiveness ratio of whitening strips is attractive to consumers.
6.5.3 Teeth Whiteni ng Toothpastes
Toothpastes do not have a bleaching effect because hydrogen perox
ide and carbamide peroxide are incompatible with the other ingredi
ents in these products. At best, they work through microabrasion or
concealing effects.
6.5.4 Whiteni ng Chewing Gums
The active ingredients in whitening chewing gums are quickly diluted
by saliva. Furthermore, the whitening agents are rapidly inactivated
by salivaty peroxidases.
I. Al Shetberi S, Matis BA, Cochran MA, Zekonis R, Stropes MA. Clinical eval
uation of two in-ofce bleaching products. Oper Dent 2003;28(5):488-495.
2. Cavalli V, Reis AF, Giannini M, Ambrosano GM. The effect of elapsed time
following bleaching on enamel bond stength of resin composite. Oper Dent
200 I ;26(6):597-602.
3. Da Costa Filho LC, Da Costa CC, Soria ML, Taga R. Effect of home bleaching
and smoking on marginal gingival epithelium proliferation: A histologic study
in women. J Oral Pathol Med 2002;31 (8):473-480.
4. Deli peri S, Bard wen DN, Papathanasiou A. Clinical evaluation of a combined
in-office and take-home bleaching system. JAm Dent Assoc 2004; 135(5):628-
5. Fugaro JO, Nordahl l,Fugao, OJ, Matis BA, Mjir IA. Pulp reaction to vital
bleaching. Oper Dent 2004;29(4):363-368.
6. Gerlach RW, Gibb K,Sage! PA. Initial color change and color retention with
a hydrogen peroxide bleaching strip. Am J Dent 2002; 15( I ):3-7.
7. Leonard RH Jr, Haywood VB, Phillips C. Risk factors for developing tooth
sensitivity and gingival irritation associated with nightguard vital bleaching.
Quintessence lot 1997;28(8):527-534.
8. Lewinstein l, Fuhrer N, Churaru !,Cardash H.Effect of different peroxide
bleaching regimens and subsequent fluoridation on the hardness of human
enamel and dentin. J Prosthet Dent 2004;92(4):337-342.
9. Luk |Tam L, Hubert M. Effect of light energy on peroxide tooth bleaching . 1
Am Den!Assoc 2004;135: 194-201;Quiz 2.
10. Matis BA, Cochran MA, Eckert G, Carlson TJ. The efcacy and safety of a
10% carbamide peroxide bleaching gel. Quintessence Int 1998;29(9):555-563.
I I . Matis BA, Gaiao U, Blackman D, Schultz FA, Eckert GJ. lu vivo degadation
of bleaching gel used in whitening teeth. J Am DentAssoc 1999;130(2):227-
12. Matis BA, Wang \.Jiang T, Eckert GJ. Extended at-home bleaching of tetra
cycline-stained teeth with diferent concentrations of carbamide peroxide.
Quintessence Int 2002;33(9):645-655.
Chapter O Exteral Bleaching
13. Papathanasiou A, Kastali S, Per|K,Kugel G. Clinical evaluation of35%
hydrogen peroxide in-ofce whitening system. Compend Contin Educ Dent
2002;23( 4):335-344;Qu.iz 348
14. Rosenstiel SF, Gegautf AG, Johnston WM. Randomized clinical trial of the
efficacy and safety of a home bleaching procedure. Quintessence lnt
15. Spyrides GM, Perdigao J, Pagani C, Araujo MA, Spyrides SM. Effect of
whitening agents on dentin bonding. J Esthet Dent 2000;12(5):264-270.
16. Swift EJ Jr, May KN Jr, Wilder AD Jr, Heymann HO, Bayne SC. Two-year
clinical evaluation of tooth whitening using at-bore bleaching system. J
Esthet Dent 1999; 1 1 ( 1 ):36-42.
17. Tavares M, Stultz J, Newman M, Smith V, Kent R, Carpino E, Goodson JM.
Light augments tooth whitening with peroxide. J Am Dent Assoc




_ L

Chapter 7 All-ceramic Fixed Partial Dentures
71 General Consi derati ons
The desire for the development of all-ceramic bridges is primarily
driven by the fact that the esthetic result of all-ceramic restorations
surpasses that of metal-ceramic restorations. Ceramic materials also
have the advantage of better biocompatibility and low thermal con
ductivity. Regarding the physical properties of the available ceramic
materials (see Chapter 1), glass-infltrated ceramics and high-strength
ceramics are the only suitable candidates for the fabrication of all
ceramic brdges. Yttrium-stabilized zirconia is a particularly interest
ing material that is increasingly being used as the framework for both
posterior and anterior all-ceramic bridges.
72 I ndi cati ons
Owing to the low mechanical strength of ceramic materials, fxed par
tial dentures with ceramic frameworks can only be placed in regions
where no excessive occlusal forces can be expected. The feasibility of
all-ceramic fixed partial denture restorations is determined by the fol
lowing factors (see fow chart 1):

Expected occlusal forces (anterior and posterior restorations)

Span (three-unit or multi-unit)

Amount of space required for the restoration (framework dimen


Stump shade.
The best esthetic results are obtained with glass-infiltrated ceramics
owing to their superior optical properties. As the superior esthetic
appeal of glass-infiltrated ceramics is due to their translucency, the
appearance of this material is influenced by the shade of the underlying
abutment. Therefore, the abutment below a glass-infltrated ceramic
/ Indications
should ideally be dentin-colored. High-strength ceramics are more
opaque than glass-ceramics so they are able to cover discolored abut
ments better, but still not completely. Consequently, the shade of the
prepared abutment does not affect the esthetic appearance of high
strength ceramic restorations as much as that of glass-ceramic restora
ohort[3 Io 4 units} |ong[ or more units}
Normo occuso|

Lxcessve occ|uso
NeIo|ceromic Neto|ceromic
Diagram 1 Decision process for the choice of fixed partial dentures loll-ceramic versus
metal-cera mid.
Chapter 7 Al-ceramic Fixed Porto/ Dentures
73 Tooth Preparation
The tooth preparation guidelines for all-ceramic bridges are the same
as those for all-ceramic crowns (see Chapter4). The parallelism of the
abutment teeth integrated in the restoration must naturally be respected.
The amount of vertical clearance is another important factor. Mechani
cally, the connector area is the primay weak point of any ceramic fixed
partial denture. Basic research has shown that the initial crack that ulti
mately leads to the failure of all-ceramic fxed partial dentures invari
ably starts at the connectors in the gingival region48. Connector width
requirements were calculated based on these data (Diagram !).
The marginal and interal htof CAD/CAM all-ceramic fxed par
tial dentures is slightly inferior than that of metal-ceramic fxed partial
dentures, but i s well within the clinically acceptable range71012,14
. .... .-. .-- -----,,- .--
Connector width
Diagram I

Radius of curature
Diagram 2
74 Dental Laboratory and Dental Office Procedure
74 Dental Laboratory and Dental
Office Procedure
Two processes are generally used for the fabrication of zirconia
fameworks for fxed partial dentures.
With the first process (e.g. Cercon Smart Ceramics, Degudent,
Hanau, Germany), the dental technician first uses a master model to
fabricate a fixed partial denture framework according to the conven
tional lost wax technique2 The wax frame is then removed from the
master model and scanned by the system's scanner. The CAM unit
then automatically mills the framework fom a presintered "green"
zirconia block. Green zirconia is porous and softer than densely sin
tered zirconia. Consequently, the milling time is signifcantly shorter
and smaller wear of the milling burs occurs. Moreover, it is also pos
sible to make fme adjustments by hand when zirconia is still in the
green stage. The framework is subsequently placed in the sintering
furace and fired at 1350C for 6 hours. The sintering process leads
to 20% shrinkage and densifcation of the material. In order to match
the dimensions of the original working dies, the famework milled
from the green material must be oversized accordingly to compen
sate for the sintering shrinkage.
The second process (e.g. DCS, Allschwil, Switzerland) uses the
same wax-up and scanning procedures, but mills the famework from
densely sintered zirconia blanks 1
True CAD/CAM systems allow the user to fabricate ceramic fixed
partial denture frameworks without having to physically model a wax
pattern. One CAD/CAM system (Procera) has a mechanical scanner
that scans the prepared abutment, the adjacent teeth, the basal surface
of the connector, and the opposing arch15 Te scan data are then trans
mitted to a computer. The laboratory technician can then digitally
design the framework on-screen. When fmished, the digitized data are
transferred electronically to a milling center. The milling center fabri
cates the zirconia framework and sends it to the dental laborat0y for
further processing and veneering.
Chapter 7 All-ceramic Fixed Partial Dentures
As ziconia cannot be soldered conventionally or by laser, the fmished
zirconia frameworks cannot be separated and reconnected. Zirconia
frameworks, therefore, require meticulous design planning. The fol
lowing guidelines apply to all systems and techniques used for fabri
cation of zirconia frameworks for fxed partial dentures:
Minimum framework wall thickness: 0.4mm

Milling of the framework must be perfonned while cooling with

water (to prevent the fonnation of microcracks )3.6
The framework is sandblasted with 50 to I I 0 tm aluminum oxide
particles at a jet pressure of 2 to 4 bar and a distance of approxi
mately I em

The framework is cleaned in d ultrasound bath

Firing is performed at I 1 00C

During firing, the bridge should be positioned on thin wires to

prevent thermal stress (NB: The thennal conductivity of zirconia
is low).
Regarding connector design, the minimum connector width to prevent
fixed partial denture fracture is 9mm2 for three-unit bridges and
1 2 mm2 for four-unit bridges8 Furthermore, the connector should
have a large radius of curvature at the gingival embrasure (Dia
gram 2)9. The guidelines for fabrication of zirconia frameworks are
otherwise the same as those for metal frameworks.
Like metal fixed partial denture substructures, zirconia frame
works are tred in so that subsequent fitting adjustments can be made
as needed. Final cementation may be carried out adhesively or con
ventionally (see Chapter 8).The radiopacity of zirconia frameworks
is also clinically useful as this allows for radiological control of ft
(Figures 1 through l3).
74 Dental Laboratory and Dental Office Procedure
Four-uni t zirconia fixed partial denture
(teeth 14-x-x- 17)
Fig l Pretreatment radiograph of the situation in the right maxilla.
Tooth 16 is not worth preserving. An all-ceramic four-unit fixed patial
denture lteeth 17-x-x-14) with a zirconia framework is planned.
Fig 2 View after extraction of tooth 16. Fig 3 Teeth 17 and 14 were prepared as the
abutments to support the four-unit bridge.
Fig 4 The diagnostic wax-up fabricated by
the dental technician is tried in to check the
final esthetics and function.
Chapter 7 All-ceramic Fixed Portio/ Dentures
Fig 5 The silicone index is used to check
the wax model of the planned restoration
for form and design.
Fig 8 Shade selection is performed accord
ing to the criteria and procedure described
in the chapter on al l-ceramic crowns.
Fig 6 View of the densely sintered zirconia
framework. Note the basal curvature of the
connector design.
Fig 7 Like metal
fixed partial den
ture frameworks,
the zirconia frame
work is checked for
fit and design dur
ing try-in.
Fig 9 It is helpful to apply a liner when
selecting the color for zirconia frameworks.
This makes it easier to determine the tooth
hue, chroma and value.
74 Dental laboratory and Dental Office Procedure
Figs lOa and lOb Occlusal and basal views of the finished fixed partial denture.
Fig 1 1 The milled zirconia framework in the
green stage next to a densely sintered one
{a second framework was manufactured for
demonstration purposes!. The size differ
ence is clearly Nisible on direct comparison.
Fig 12 Try-in of the fiished zirconia bridge.
In terms of shape and color, the restoration
blends well with the sLrrounding natural
Fig 13 Radiographic control of the fixed partial denture after cemen
tation with glass ionomer cement. The zirconia framework appears as
a radiopaque structure.
Chapter 7 All-ceramic Fixed Partial Dentures
75 Cl i ni cal Survival Rates
A systematic review of the literature was recently performed to assess
the clinical survival rates of all-ceramic fixed partial dentmes followed
for a minimum period of 3 years. Although the results were encourag
ing, the failure rate of all-ceramic fixed prtial dentures was signif
cantly higher than that of conventional metal-ceramic fixed partial
dentures. Specifically, the annual failure rate for all-ceramic bridges
was 4%1 1 compared with an annual failure rate of only 0.4% for metal
ceramic bridges13. All of the ceramic frameworks studies were fabri
cated using either glass-ceramic (Empress II) or glass-infiltrated
ceramic materials (Jn-Ceram Alumina, ln-Ceram Zirconia). This is a
particularly relevant fact to note as neither of these two materials
belongs to the class of high-strength ceramics. Consequently, it is not
possible to assess the chances of success of all-ceramic fxed parial
dentures with fameworks made of zirconia based on these data.
Three-year follow-up studies of all-ceramic fxed partial dentures
with zirconia frameworks have not yet been published in the litera
ture. Of te zirconia fxed partial denture studies described in talks or
posters presented at symposia, it is a promising sign of clinical stabil
ity that no framework failures have been repoted to date. The data
from our clinic confirms this impression. Framework factures have
not occurred in any of our 36 patients with a total of 46 zirconia fixed
partial dentures who were followed for a period of 3 years. However,
one patient fractured the zirconia fxed partial denture in an "chewing
accident" (by biting on a stone in his food) 38 months after the fxed
pattial denture placement.
In summay, one can conclude that fxed partial dentures with zir
conia frameworks have met stability expectations with regard to with
standing occlusal forces in the posterior region during masticatory
function. However, they should be used with restraint in practice
because no true long-term data are available.
Regarding potential failures and complications, one can basically
expect the same type of events that occur with metal-ceramic restora
tions to occur in all-ceramic fixed partial denhtres with zirconia frame
Devitalizationlperiapical pathologies.
Tooth fracture
Build-up fracture
Framework fracture
Veneering fracture
Loss of retention.

- Gingival recession.
76 Concl usi ons
All-ceramic fixed partial dentures with zirconia frameworks are an
interesting and promising alterative to conventional metal-ceramic
fxed partial dentures. In light of the intensive research efforts in this
feld, further developments and improvements can be expected. Once
these improvements and adequate long-term follow-up data become
available, one can hope that all-ceramic fxed partial dentures with zir
conia frameworks will become a true alternative to metal-ceramic
fxed parial dentures in the posteror region.
76 Conclusions
Chapter 7 All-ceramic Fixed Portio/ Dentures
1. Besimo CE, Spielmann HP, Rohner HP. Computer-assisted generation of all
ceramic crowns and fixed partial dentures. Int !Comput Dent 200 I ;
4( 4):243-262.
2. Feher A, Egger B, Luthy H, Schumacher M, Loefel 0, Scharer P. ISO
Zementevaluation und klinische Untersuchung von Zirkonoxidstitautbauten.
Acta Med Dent Helv 1999;4:20 1-209.
3. Guazzato M, Quach L, Albakry M, Swain MV. Influence of surface and heat
treatments on the flexural strength ofY-TZP dental ceramic. J Dent 2005;
4. Kelly JR, Tesk JA, Sorensen JA. Failure of all-ceramic fxed partial dentures
in vitro and in vivo: Analysis and modeling. J Dent Res 1995;
74( 6): 1253-1258.
5. Kosmac T, Oblak C, Jevnikar P, Funduk N, Marion L. The effect of surface
grinding and sandblasting on fexural stength and reliability of `TZP zirco
nia ceramic. Dent Mater 1999;15(6):426-433.
6. Kosmac , Oblak C, Jevnikar P, funduk N, Marion L. Strength and reliabllity
of smface treated Y-TZP dental ceramics. J Biomed Mater Res 2000;
7. Le Tran D. Marginale und interne Passgenauigkeit computergestutzt gefer
tigter vollkeramischer Briickengeriiste. Dissertation,
University of Ziirich: 2003.
8. Luthy H, Filser F, Loeffel 0, Schumacher M, Gauckler LJ, Hinunerle C.
Strength and reliability offour-unit all-ceramic posterior bridges. Dent Mater
2005;21 ( 10):930-937.
9. Oh W, Gotzen N, Anusavice KJ. Infuence of connector design on fracture
probability of ceramic fxed-partial dentures. J Dent Res 2002;81(9):623-627.
10. Reich S, Wichmann M, Nkenke E, Proescbel P. Clinical fit of all-ceramic
three-unit fixed partial dentures, generated with three different CAD/CAM
systems. Eur J Oral Sci 2005; I 13(2): I 74-179.
1 1 . Sailer I, Pjetursson BE, Zwahlen M, Hammerle CHF. A systematic review of
the survival and complication rates of all-ceramic and metal-ceramic recon
structions afer an observation period of at least 3 years. Part II: Fixed dental
prostheses. Clin Oral Imp! Res 2007; 18(SMppl.3):8696.
12. Stappert CFJ, Dai M, Chitmongkolsuk S, Gerds T, Strub JR. Marginal adapta
tion of three-unit fixed partial dentures constructed from pressed ceramic sys
tems. Br Dent J 2004;1 96:766-770.
13. Lang NP, Pjetursson BE, Tan K, Bragger U, Egger M, Zwahlen M. A systemat
ic review of the survival and complication rates of fxed partial dentures
(FPDs) after an observation period of at least 5 years. Clin Oral Implants Res
2004; 15(6):643-653.
14. Tinscbert J, Natt G, Mautsch W, Spiekermann H, Anusavice KJ. Marginal ft
of alumina-and zirconia-based fxed pa11ial dentures produced by a
CAD/CAM system. Oper Dent 2001 ;26(4):367-374.
15. Zitzmann NU, Marinello CP, Luthy H. The Procera Allceram all-ceramic sys
tem. The clinical and technical laboratory aspects in te use of a new all
ceramic system. Schweiz Monatsschr Zahnmed 1999; I 09(8):820-834.







Chapter d Bonding of Ceramic Restorations
8.1 Adhesive versus
Conventi onal Cementation
Adhesive bonding is crucial to the clinical success of all-ceramic
restorations6. In this context, four major factors play a role:

Fracture strength
8. 1. 1 Fracture Strength
Adhesive bonding increases the fracture strength of all-ceramic
restorations. In one in vitro study, the fracture strength of all-ceramic
crowns luted by adhesive bonding was found to be just as high as that
of metal-ceramic crowns2' . For ceramics with low material strength,
the strengthening effect of adhesive bonding results i n significant
improvement of long-term clinical performance.
Clinical studies have demonstrated that the survival rates of adhe
sively bonded glass-ceramic restorations are signifcantly higher than
those of conventionally cemented restorations1216

This superior clinical performance is attributable not only to a
reduced rate of fracture occurrence, but also to a reduced rate of reten
tion loss23 One crucial prerequisite for clinical success is proper con
ditioning of the ceramic restoration and the tooth surface prior to
bonding. The purpose of conditioning is to increase the bonding sur
face area in order to improve mechanical retention and to enhance the
quality of chemical coupling between the cemented components. The
bonding procedure for glass-ceramics and oxide ceramics difer due
to diferences in their compositions (see Chapters /.3and /.4). The
need for adhesive bonding of oxide ceramics is disputed due to thei.r
high material strength. As clinical experience with these ceramics is
still relatively short, there currently are no studies demonstrating
whether or not conventional cementation and adhesive bonding result
in comparable survival rates. Moreover, the choice of cementation
system for oxide ceramics is infuenced by another imp0tant factor;
retention of the restoration.
8.1 Adhesive Bonding versus Conventional Cementation
8.1.2 Retention
CAM of restorations from densely sintered or presintered ceramic
blocks results in a lower accuracy of internal fit than in ceramic
restorations fabricated by layering or pressing techniques20 1h vitro
studies show that the marginal and internal gaps in CAD/CAM-gener
ated all-ceramic crowns are larger than those of porcelain-fused-to
metal crowns' . Ceramic restorations, therefore, have lower retention.
Consequently, conventional cementation of ceramic restorations fre
quently results in a loss of retention, whereas adhesive bonding is not
affected by this problem23
8. 1. 3 Microl eakage
The degree of marginal integrity is determined by the size of the mar
ginal gap and the strength of the bond between the luting agent and
the restoration or tooth, respectively. Micro leakage at crown margins
promotes the penetration and passage of bacteria to the pulp. This
bacterial invasion can lead to a loss of tooth vitality8. Further potential
complications of marginal leakage are secondary caries, periodontal
problems, and a loss of esthetics due to marginal discoloration. In
vitro studies have shown that the amount of micro leakage is signif
cantly lower in restorations bonded with composite cements com
pared with those luted with conventional zinc oxide phosphate
cements8924 In particular, conventional cementation leads to a higher
loss of marginal integrity of CAD/CAM-generated all-ceramic
restorations than of metal-ceramic restorations1
8. 1. 4 Transl ucency
The optical and color characteristics of the luting material affect the
fnal esthetics of translucent ceramics more than they affect the opaque
ceramics (see Chapter 2.3). Consequently, the use of more opaque
cements (e.g., phosphate cements) leads to a stronger increase in the
opacity of glass-ceramics compared with of alumina ceramics.
Inversely, the use of a translucent composite increases the translucency
of all-ceramic materials (including zirconia)'. An explanation for this
Chapter d Bonding of Ceramic Restorations
could be that the cement improves the flow of light through the ceram
ic material. The use of conventional cement for luting of all-ceramic
restorations is, therefore, contraindicated for esthetic reasons.
8.2 Cl assification of Adhesive
8.2.1 Composition
The composition of resin composite cements is basically the same as
that of composite filling materials:

Matrix: mixture of bisphenol A glycidyl methacrylate (Bis-GMA)

and low-viscosity additives such as triethylene glycol dimethacry
late (TEGMA) resin and urethane dimethac1ylate (DMA) resin

Filler: lithiumbarium borosilicate, 'iU,

Curng agent: Light-cured, self-curing or dual-cured.

The silanized inorganic fllers embedded in the matrix are mainly
responsible for the mechanical characteristics of resin composite
cements. Due to technical reasons related to diferences in material
processing, the physicochemical properties of resin composite cements
differ from those of resin composite fllings as follows:

Catalyst reduction: longer working time

Filler size reduction: minimal layer thickness

Reduced filler content: improved :lowability

Opacifying additives: reduced translucence.

In most cases, an additional adhesive is required to achieve a bond
between resin composite cements and dentin. Adhesive monomers
found in adhesives and composite cements include:

2-hydroxyethyl methacrlate (HEMA)

4-methaciyloxyethyl trimellitate

Phosphate monomers, 10-methacryloyloxydecyl dihydrogen

phosphate (MDP)
Resin composite cements containing adhesive phosphate monomers
should always be used to cement ceramic materials that cannot be
etched or are difficult to etch. Adhesive phosphate monomers are
required to achieve the necessary adhesion to these ceramic materials13
8.2 Classification of Adhesive Cements
8.2.2 Characteristics of Resin Composite
Resin composite cements are insoluble in saliva. As shown below,
their physical characteristics show a wide range of product-specifc
varia b i lj ty2.

Curing time: 2 to 7 minutes

Film thickness:
<25 1-m
Flexural strength: 70 to l72MPa (24h)

Modulus of elasticity: 2. 1 to 3. 1 GPa

Water solubility 0 to 0.01 %

Pulp reaction: Moderate

Rely Unicem || Espe, Seefeld, Germany)
Dual-curing universal resin cement

Glass powder (silanized)
Silica ( silaruzed)
Substituted pyrimidine
Calcium hydroxide
Peroxy compound

Methacrylated phosphoric acid ester
Panavia |Kurarayl
Self-curing composite resin


Phosphorylated methacrylate resin groups

Chapter d Bonding of Ceramic Restorations
Vori ol i nk I I !Vivodent, Schoon, Liechtenstein)
Dual-curing composite cement

Matrix: Bis-GMA, urethane dimethacrylate, triethylene glycol


Filler: Barium glass, ytterbium tuoride, Ba-Al fuorosilicate

glass, spheroidal mixed oxides (mean filler size: 0.7 Jlm).
8.2.3 Requi rements
The "ideal" resin composite cement should meet the following clini
cal requirements:

High translucency

Good mechanical properties (high compressive strength and fex-

ural strength)

High bond strength

Low solubility

Suitable viscosit (maximal filler content to still maintain fowa


Ease of handling

8.3 Denti n Conditi oni ng
8.3.1 Pre-treatment of the dentin after
After tooth preparation, the cut dentin should be protected from:

Mechanical forces (manipulation of the temporary, impression-

ing, etc.)

Chemicals (dental materials)

Bacteria (bacterial microleakage)

Thermal stresses (cold, heat).

A range of products are available for the conditioning of freshly pre
pared dentin. These can be divided into two groups according to their
mode of action:
8.3 Dentin Conditioning
Desensitizing agents

Obliterate dentinal tubules by means of coagulation necrosis

(e.g.,Ca(OHh) or by precipitation ofCa2+-, POl and proteins
afer application of a glutaric dialdehyde primer (e.g., Gluma)

Do not affect the dentin bond strength of adhesives.

Seal i ng agents

Coverage of dentin and obliteration of dentinal tubules is

achieved through application of primer and bonding agent

Increase the bonding strength before adhesive cementation>

Single-component (one-bottle) systems do not achieve adequate

The selected product must be compatible with the luting cement.
Incompatibility leads to a decrease in bond strength (smear layer).
Optimal dentin adhesion can only be achieved when te bonding
agent is applied to feshly prepared dentin'5 For this reason, the dual
bonding technique is still used today'8. Considering the chemical dif
ferences in cements, it is important to use the correct bonding system
to seal the tooth after preparation. If, at this time, it is still unclear
which ceramic material (and thus which type of cement) will be used,
the prepared dentin should only be desensitized with a glutardialde
hyde-containing primer (Gluma) as a precautionary measure.
o..2 Dentin Condi tioni ng
Before cementation, the dentin is conditioned with the appropriate kit
component(s) according to the manufacturer's instructions.

Glass-ceramics: Syntac Classic (Ivoclar)

Oxide ceramics (high-strength ceramics) Clearfl SE Bond

(Kuraray), ED Primer (Kuraray)
If the type of cement to be utilized is known at the time of tooth prepa
ration, the corresponding bonding system can be used to seal the
dentin according to the dual bonding technique.
Chapter d Bonding of Ceramic Restorations
8.4 Cerami c Conditi oni ng
Chemical bonds between resin composite and glass-ceramics are
achieved by means of coupling molecules, for example, silane. Silane
bonds with silicates in the glass matrix of the ceramic material (inor
ganic substance) on the one side, and polymerizes with the organic
matrix of the composite resin on the other.
In order to be chemically active, the silane molecules must be
hydrolyzed to silanol. Distinctions are made between one and two
component systems. Single-component silanes, which are more fre
quently used in clinical practice, are already hydrolyzed. Their expira
tion date must be strctly observed as they become inactive with time.
(Please note, the fluid must be clear. Discard if cloudy).
In the case of glass-infiltrated ceramics, etching alone does not
achieve sufcient surface roughening. Therefore these ceramics must
be sandblasted (with 50 to 100 1m Al203 at 2.5 bar). Although ceramic
conditioning does not increase bond strength, it does improve wetta
bility'4. Glass-infiltrated ceramics should be cemented with a phos
phate monomer-based cement (see Chapter .?. l).
Oxide ceramics contain few or no silicates, and they cannot be
silanized in the same manner as glass-ceramics. New resin composite
cements (e.g., Panavia 21 ) contain an adhesive phosphate monomer
( e.g.,MDP) that can bond to oxides, thus making it possible to achieve
chemical bonding of oxide ceramics with or without the use of an
adjunctive bonding agent. However, application of an adjunctive
bonding agent does improve the long-term stability of bonding and, is
therefore, recommended4 As with metals, the improved chemical
bonding must be achieved either by means of silica coating (RocatecTM
system, Minnesota, USA) and subsequent silanization or without silica
coating using special adhesive silanes (with adhesive phosphate
8.5 Clinical Procedure
8.5 Cl i ni cal Procedures
8.5.1 I ndications and Recommended
Materi al s
LomIOn bOndt\g,
Gloss-ceramics Etching
9.5% hydrofluoric acid
IMonobond Sl
Gloss-infiltrated Sandblasting Cleorfil SE Bond

100 [m Al203, 2.5 bar lor ED Primerl cerom1cs

Oxide ceramics Sandblasting Cleorfil SE Bond
!alumino, zirconiol 100 pm Al203, 2.5 bar lor ED Primer!
ICiearfil Porcelain Activator!
8.5.2 Step-by-step Procedure
a. Glass-ceramics
The step-by-step procedure for adhesive bonding of anterior ceramic
crowns (Creapress) is described by way of example.
||g 1 Te preparation for vital tooth 1 1 is circular with ! mm wide
shoulder and rounded edges, ensuring o minimum loss of tooth struc
ture. Because the stump shade is ideal, the tooth con be restored using
o translucent gloss-ceramic. Adhesive bonding increases the fracture
strength of ceramic restorations. For this reason, adhesive bonding
should performed with due diligence. A thin retraction cord INo. OOO.OOl
should be placed before adhesive luting whenever possible.
Vortolink II
Ponovio 21
Ponovio /!
1 01
Chapter d Bonding of Ceramic Restorations
Figs 2a to 2c The
pressed and sin
tered dentin core of
optimal color and
translucency is
veneered to match
the optical charac
teristics of the adja
cent teeth. Anterior
and posterior views
of the crown.
Figs 3a and 3b The internal surface of the crown is etched with 9.5% hydrofluoric acid (for
example Ultradent'" Porcelain Etch, Utha, USA) for 60seconds. ! NB: Gloves and protective
glass must be worn!l. The hydrofluoric acid is then rinsed off with running water. To remove
etching precipitates, the crown is ultrasonically cleaned in alcohol for 4 minutes. Alterna
tively, it can be etched again with a weaker acid !phosphoric acidl for 30seconds.
8.5 Clinical Procedure
Figs 4a and 4b Scanning electron micrograph and 3D views of on ideally etched (l minute
gloss-ceramic. Significant surace area enlargeent and numerous tunnels are clearly visible.
Fig : The internal surface of the etched
and cleaned crown should hove a matte
appearance without white deposits to
ensure that the roughened surface shown
in Figures 4a and 4b can be optimally used
for cementation.
Fig 6 Silanization is then performed for
example using Ultrodent Silane or
Monobond S. ! NB: Compati bilit with the
cement is im
erative!) The silanized crown
should now

e completely free of contami

nants (moisture, alcohol, etc.l. Once the sol
vent has evaporated (after about l minute!,
a bonding agent is applied to the internal
surface of the crown, and the crown is
stored in a dark place.
Chapter d Bonding of Ceramic Restorations
Figs 7 and 8 A dentin bonding agent ISyntac primer, adhesive and bonding agent, Con
necticut, USAI is applied to the prepared tooth according to the manufacturers instruc
tions. The thin coat of bonding agent gives the conditioned stump a sl ightly gl ossy appear


Fig lOa Bose and catalyst paste of the

some shade !ideally transparent) are mixed
at a ratio of l 1 and applied to the crown
with a brush.
Fig 9 Variolink II !lvoclar Vivadentl is sup
plied in to consistencies llow and high vis
cosit) and in four shades. To reduce the
occurrence of microleakage, the more high
ly filled and more highly viscous types
should be used whenever possible. Vori
olink II can be dual-cured lbase catalyst)
or only light-cured lccseI. Vhen l uting all
ceramic crowns with thick layers of ceramic
material, the dual uing variant should be
used in order to ensure complete curing of
the cement in the deep layers. For optimal
esthetics, the transparent cement should be

. .

" ]_


_ '



'- : -
- . - ,,

. *:

- _ :

- '

+ .. _
' .

- - -

"* ^

: :





v. *'


. .

50 um

Fig lOb Scanning electron micrograph

showing the bond beteen the conditioned
ceramic I topI and Variol ink II lbottoml. The
cement con to ins various fillers of different
sizes !hybrid fillers!.
Fig 1 1 After correct placement of the
crown, excess cement is carefully removed
with foam pellets and dental floss. Glycerin
gel should be applied aound the crown
margins in order to prevent oxygen inhibi
tion (i.e., the absence of curing in the resin
composite Ioyer exposed to oxygen I. Poly
merization is then initiated for l minute on
the buccal, palatal, and incisal surfaces
and also when the dualcuring variant is
used. Although it tokes up to roughly
24 hours for the cement to cure in the deep
er ceramic layers, the excess ceent is
removed immediately.
8.5 Clinical Proced!re
Figs 12 to 14 Hardened resid\al cement is carefully removed with on ex
lorer or scaler
while gently manipulating the gingiva. The retraction cord is subsequent
y removed, which
con bring out some additional cement residue. The margin of the crown is finally caref\lly
finished (e.g., with o covosurfoce bevel!. Radiological control of residual cement i s difficult
due to its low ladiopacity(
Chapter d Bonding of Ceramic Restorations
b. Oxide cerami cs
This procedure is illustrated based on a case example (zirconia crown
Fig 15 Clinical situation after the prepara
tion of a gold post-retained crown on
tooth 11. As the old post could not be
removed without endangering the root I risk
of fracture!, it was incl\ded in the prepara
tion. To achieve an esthetic restoration, the
multi-shade stump had to be covered with
an opaque coping. The use of a translucent
glass-ceramic material was contraindicated
because a thick layer of ceramic would
have been required for masking. As the
patient wished, a non-metal restoration, zir
conia, was selected. The crown as well as
the approximal and occlusal contacts were
inspected for fit before cementation. The
crown was then degreosed with alcohol.
Figs 16a and 16b Frontal and caudal views of the definitive zirconia
1 06
Fig 17 Scanning electron micrograph
showing the sandblasted surface of the zir
conia ceramic. Sandblasting does not
enlarge the bond surface area of zirconia
ceramics os much os is does that of etched
Fig 1 8 Cleorfil SE Bond is a two-compo
nent bonding system that consists of a self
etching primer and on adhesive lbonding
ogentl. Both components contain the adhe
sive phosphate monomers needed to
achieve chemical bonding to zirconia. The
primer alone is sufficient for cementation of
zirconia ceramics. It acts as a dentin condi
tioner and silane activator.
Fig 19 Before cementation, the zirconia
ceramic is preconditioned with Clearfil
Porcelain Activator, a special silane that
must be activated with Clearfil SE Bond
primer before application. A mixing dish
and a brush ore required.
Fig 21 One drop of porcelain activator is
then added.
8.5 Clinical Procedure
Fig 20 First, one drop of bond primer is dis
pensed into a well of the mixing dish.
Chapter d Bonding of Ceramic Restorations
Fig 22 The two liquids form on emulsion
like liquid that must be mixed well with a
Fig 24 The activated silane is applied to
the inner surface of the crown and allowed
to react for 5 seconds. The surplus is then
blown off with stream of compressed ai r
Fig 23 The mixture should hove a hove a
uniform color and consistency.
Fig 25 The internal surface of the crown
now looks oily. Warning: the external sur
face of the crown moy also look oily and
feel slippery.
Figs 26 and 27 Dentin condiTioning primer !ED Primer or Cleorfil) is dispensed into another
well of the mixing troy and applied to the prepared tooth with a brush. Priming time: ;
seconds ED Primer/20 seconds Cleorfil SE. Conditioning wiTh silane is recommended when
cementing Iorge resin composite build ups.
8.5 Clinical Procedure
||gs28a and 28b Ponovio 21 TC and Oxyguord; the pastes ore mixed at ratio of 1 : 1
and applied to the crown with o brush.
||g29 Scanning electron micrograph
showing the bond beteen zirconia !top}
and Ponovio lbottoml. The high content of
Iorge filler particles in the cement is clearly
Fig 31 Oxyguard is applied around the
crown margins and allowed to react for
7 minutes. This seres to block the supply of
oxygen so that the cement curing process
can begin. The Oxyguard is subsequently
rinsed off with water, and al l cement
residues are thoroughly removed with a
scaler. Radiological control of fit is possible
because the cement is radiopaque.
Fig 30 After checking the crown for proper
fit, excess cement is removed with foam pel
Chapter d Bonding of Ceramic Restorations
l l 0
! . Albert FE, EI-Mowaf OM. Marginal adaptation and micro leakage ofProcera
AJ!Ceram crowns with four cements. lot J Prostbodont 2004;17(5):529-535.
2. Anusavice K. Phillips' Science of Dental Materials. Philadelphia:
Saunders, 2001 :45 I -486.
3. Bertschinger C, Paul SJ, Uithy H, Scharer P. Dual application of dentin bond
ing agents: Effect on bond strength. Am J Dent 1996;9(3):1 15-119.
4. Blatz MB, Sadan A, Martin J, Lang B. In vitro evaluation of shear bond
strengths of resin to densely sintered high-purity zirconium oxide ceramic after
long-term storage and termal cycling. J. Prosthet Dent 2004;91(4):356-362.
5. Buithieu H, Nathanson D. Efect of ionomer base on ceramic resistance to
facture. J Dent Res 1993;72:175; Abstact No. 90.
6. Burke FJ, Fleming GJ, Nathanson D, Marquis PM. ^nadhesive technologies
needed to support ceramics? Aassessment of the current evidence. J Adhes
Dent 2002;4( 1):7-22.
7. EdelhofD, Sorensen J. Light transmission through all-ceramic framework and
cement combinations. J Dent Res 2002;8 I :Abstract-No I 779.
8. Ferrari M, Mannocci F, Mason PN, Kugel G. In vitro leakage of resin-bonded
all-porcelain crowns. J Adhes Dent 1999; I (3):233-242.
9. Gu XH, Kem M. Marginal discrepancies and leakage of all-ceramic crowns:
Influence of luting agents and aging conditions. Int J Prostbodont 2003;
16(2): 109-116.
l 0. Heffeman MJ, Aquilino SA, Diaz-Amold AM, Haselton DR, Stanford CM,
Vargas MA. Relative translucency of six all-ceramic systems. Part I: Core
materials. J Prosthet Dent 2002;88:4-9.
1 1 . Jensen ME, Sheth JJ, Tolliver D. Etched-porcelain resin-bonde full-veneer
crowns: In vitro facture resistance. Compend Contin Educ Dent
1989; 10:336-347.
I 2. Junge T, Nicholls J, Phillips K, Libman W. Load fatigue of compromised
teeth: A comparison of three luting cements. Tnt J Prosthodont 1998; 1 1 :558-
13. Kappert, H.F. (2003) Klinische Materialkunde fi r Zahnirzte, p. 359.
14. Ker M, Thompson VP. Bonding to glass infiltrated alumina ceramic: Adhe
sive methods and their durability. J Prosthet Dent 1995;73:240-249.
15. Magne P, Douglas \VH. Porcelain veneers: Dentin bonding optimization and
biomimetic recovery of the crown. lnt J Prosthodont 1999; 12(2): 1 11-121 .
16. Malament K, Socransk SS. Survival of Dicor glass ceramic dental restora
tions over 16 years. Part Ill: Efect of luting agent and tooth or tooth-substitute
core structure. J Prosthet Dent 200 1;86(5):51 1-519.
17. Marquis PM. The influence of cements on tbe mecbanical performance of den
tal ceramics. Tn: Proceedings of the 5th lntemational Symposium on Ceramics
in Medicine. Bioceramics 1 992;5:3 1 7-324.
18. Paul SJ, Scharer P. The dual bonding technique: A modified method to
improve adhesive luting procedures. lnlJ Periodont Rest Dent 1997;17(6):
19. Rosenstiel SF, Gupta PK, van der Sluys RA, Zimmerman MH. Stength of a
dental glass-ceramic afer surface coating. Dent Mater 1993;9( 4):274-279.
20. Sjogren G. Marginal and interal fit of four different types of ceramic inlays
after luting. An in vitro study. Acta Odontol Scand 1995;53(1 ):24-28.
21 . Strub JR, Beschnidt SM. Fracture strength of five different all-ceramic crown
systems. Int J Prosthodont 1998; 1 1 :602-609.
22. Tay l,Frankenberger R, Krejci I , Bouillaguet S, Pashley D, Carvalho R, Lai C.
Single-bottle adhesives behave pem1eable membranes after polymerization.
In vivo evidence. J Dent 2004;32(8):61 1-621.
23. Van Dijken JW, Hoglund-Aberg C, Olofsson AL. Fired ceramic inlays: A six
year follow-up. J Dent 1998;26(3):219-225.
24. White SN, Furuichi R, Kyomen SM. Microleakage through dentin afer crown
cementation. ! Endod 1995;21( 1 ):9-12.
25. Williamson RT, Kovarik RE, Mitchell RJ. Efects of grinding, polishing and
overglazing on the flexure strength of a high-leucite feldspatbic porcelain. Jut J
Prosthodont 1 996;9( 1 ):30-37.
l l l





_ L
1 1 3
Chapter ' All-ceramic Imp/on/ Supported Restorations
1 1 4
9.1 Cl i ni cal Aspects and
I ndi cati ons
Natural-looking implant-supported restorations play a major role in
the esthetic success of prosthodontic treatments in the anterior region.
Two factors crucial to esthetic success are:

Sof-tissue morphology

0Hand esthetics of the restoration.

Prefabricated titanium abutments have several esthetic limitations:

As their round shape does not correspond to the natural tooth

anatomy, the correct contour (emergence profle) must be estab
lished by the crown, that is, by deep submucosal placement of the
crown margms.

Because the straight shoulder of these standardized abutments

does not follow the scalloped contour of the surrounding soft tis
sues, the removal of excess cement can be dificult.

The gray metallic color of the abutments may show through the
soft tissues, resulting in gray discoloration of the gingiva.
In order to resolve these problems, individualizable custom abutments
made of alumina ceramics were developed in the early 1990s 7

The few available studies on the performance of alumina ceramic
abutments show that good long-term results are achieved when these
abutments are placed in the anterior and premolar region. In one
study, the clinical success rate for alumina ceramic implant abutments
was 93% after 1 to 3 years of service2. In a second study, the 5-year
success rate for all-ceramic fixed partial dentures supported by alumi
na ceramic abutments was 97.2%3. Abutment fracture was identified
as the main cause of implant failure in both studies.
The introduction of zirconia abutments should reduce the risk of
abutment fracture by virtue of their superior material properties. The
in vitro fracture load of implant-supported all-ceramic crowns with
zirconia abutments was found to be 700 N compared with only 280 N
for those with alumina abutments 1 1
Unfortunately, clinical data on zirconia abutments are still scarce.
In the only long-term study published to date, none of the zirconia
abutments studied had fractured after
years of service in the ante1ior
or premolar region'. Based on the available evidence, one can at least
conclude that the successful placement of ceramic abutments in the
anterior and premolar region is possible.
9.2 Advantages of Cerami c
Ideal color
The white or dentin-like color of ceramic abutments is estheti
cally ideal for all-ceramic restorations
Gingival recession causes fewer esthetic problems.

The shape of the individualized custom abutment resembles
that of a prepared tooth
As the emergence profile is determined by the abutment, the
crown margins can be scalloped to conform to te architecture
of the surrounding soft tissues.
Controlled removal of excess cement is possible.
Correction of implant angulation is possible with some
restrictions (minimum layer thickness)
The possibility of veneering allows for prosthetic fexibility

The implant-abutment connection exhibits good accuracy of fit

(due to industrial prefabrication)

Radiopacity of the abutment permits radiographic monitoring.

9.3 Di sadvantages

Higher risk of facture due to the material properties of ceramic

materials (see Chapter 2)

Minimum layer thicknesses must be observed

The screw access hole limits customizability

The abutment screw is a the weakest link in the system'0

The dental laboratory procedures are teclmically demanding and


High cost.
9.3 Disadvantages
1 1 5
Chapter ' All-ceramic Implant Supported Restorations
1 1 6
9.4 Bi ol ogi c Aspects
The morphology of peri-implant soft tissues surrounding titanium
abutments is well documented, and clinical parallels to the morph
ology of the periodontium have been described4
A soft-tissue collar of given (biologic) width normally fors
around a titanium abutment, as around a tooth. This collar of attach
ment consists of a layer of junctional epithelium (approximately 2 mm)
overlying a layer of collagenous connective tissue (1. 5 to 1 .8 mm).
The main morhological diference is that, with abutments, the colla
gen fibers parallel to the implant surface, whereas, in intact teeth,
they extend vertically into the root cementum4
Animal studies have shown that the morphology of the peri-tmplant
mucosa around alumina and zirconia ceramic abutments is comparable
to that around titanium abutments16 Ceramic abutments and titanium
abutments can, therefore, be classifed as biologically equivalent.
9.5 Man ufacturers
Because their gray color often leads to gingival discoloration, titanium
abutments are frequently unable to meet high esthetic expectations.
Consequently, it makes little sense to use metallic abutments as the
substructure for all-ceramic restorations. A wide range of ceramic
abutments made by various manufacturers is now available for the
prosthodontist and dental technician (restorative team) to choose from.
The abutment can either be directly veneered (screw-retained) or
capped with an all-ceramic crown (cemented). In the latter case, the
abutment is prepared as in normal tooth preparation. Generally, most
sintered or infltrated ceramic abutments must be prepared using
water-cooled instruments.
Selected manufacturers

Straumann (Basel, Switzerland): synOcta. Vita Zahnfabrik:


Nobel Biocare: CerAdap Procera Zirconia and Alumina

BEGO (Bremen, Germany): Ceramic core materials

Friadent (Mannheim, Germany): CERCON Balance

Biomet 3i Implant Innovation (Florida, USA): ZiReal.

Wohlwend (Zurich, Switzerland): Zirabut

CerAdapt abutments are made of densely sintered pure alumina and can
be combined with Branemark Regular Platform implants (Nobel Bio
care) for restorations in the anterior and premolar region.
The pre-fabricated cylindrical abutment measures 12 mm in height
and 6 mm in diameter.
synOcta/l n-Ceram System
The synOcta abutments are manufactured by Straumann, and the
ceramic blanks by Vita Zahnfabrik.
The ceramic blanks (diameter: 9mm, height: 1 5 mm) are made of
In-Ceram Zirconia. The internal octagon and screw seating of the
blanks are pre-infiltrated to ensure optimal ft. The non-infiltrated part
of the blank can be easily worked with a grinding wheel. Afer cus
tomized shaping by the dental technician, the blank is infiltrated with a
special glass (Vita In-Ceram Zirconia glass powder) to achieve full
material strength and hardness. In-Ceram blanks are used for esthetic
single-tooth replacements in the anterior and posterior region. The
superstructures can be either cemented or screw-retained (case a:
screw-retained restoration).
Procera Al umi na and Zirconia Abutments
Restorations from these two materials can be designed by two
methods; the conventional wax-up technique or CAD. With the wax
up technique, the abutment design is individually modeled and
mechanically scanned.
With the CAD teclmique, the abutment is designed on-screen with
in an imaginary cylinder measuring 15 mm in diameter and 15 mm in
height. Nobel Biocare makes no distinctions with regard to area of
indication and their alumina and zirconia abutrnents can be used for
both crowns and bridges in the posterior region (case b: cemented sin
gle-tooth restoration).
9.5 Manufacturers
1 1 7
Chapter ' All-ceramic Imp/on/ Supported Restorations
Fig 1 Wax-up try-in.
1 1 8
The Zirabut zirconia abutment system developed by Aold Wohlwend
is the system with the longest history of clinical use5
The abutments are designed for use with the Branemark system
(WP, RP and NP). The diameter of the abutments ranges from
6 to l Onun depending on which platform is used; all platforms have a
height of 14 mm. Any adjustments that may be necessaty are canied out
at the dental laboratory using a water-cooled turbine. In cases where the
blanks cannot be individualized as desired, a custom-made, copy
milled abutment can be ordered directly from the manufacturer (Aold
Laboratory Procedures
The procedure for fabrication of screw-retained restorations with
direct veneering is illustrated in case a (Figs to 8), and tbat for
cemented restorations with an all-ceramic crown is described in case b
(Figs 9 to 18).
Case a: Screw-retai ned restorations
9.5 Manufacturers
Figs 2 and 3 A silicone index is fabricated from the diagnostic wax-up and used to gouge
the amount of space available for the ceramic.
Fig 4 After customized shaping, the blank
is infiltrated with a special gloss Vita lnCer
am Zirconia Glass Powder to achieve full
material strength and hardness.
Fig 6 Because of the poor thermal conduc
tivity of ceramic materials, the piece must
be fired on a metal wire support in order to
prevent heat build-up.
Fig : Creation AV ceramic Uensen Dental
Solutions, Connecticut, USA! is used to
veneer the ln-Ceram abutment.
1 1 9
Chapter ' All-ceramic Implant Supported Restorations
Figs 7 and 8 The final restoration is inserted
with a tightening torque of 15 Ncm.
Case b. Cemented si ngle-tooth restorations
Figs 9 and 10 Diagnostic wax-up and try-in of the cement-retained restoration.
Fig 1 4 Shoulder position is verified when
tring i n the abutment.
9.5 Manufacturers
Figs 1 1 to 1 3 The substructure is over
pressed with ceramic pellets to achieve the
desired emergence profile.
Fig 15 Creation AV ceramic is used for
1 21
Chapter ' All-ceramic Implant Supported Restorations
Fig 16 The veneered abutment is subse
quently etched.
1 22
Fig 17 The finished piece is ready for
1 8 One-week
foow-up after
crown placement.
1 . Abrabamsson I, Berglundh T, Glantz PO, Lindbe J.The mucosal attachment at
diferent abutments. Aexperimental study in dogs. J Clin Periodontol l998;
2. Andersson B, Taylor ALang BR, Scheller H, Scharer P, Sorensen JA, Tarnow
D. Alumina ceramic implant abutments used for single-tooth replacement: A
prospective one- to three-year multicenter study. Int J Prosthodonl 200 I;
3. Andersson, B. , Glauser R, Maglione M, Taylor A. Ceramic implant abutments
for short-span FPDs: A prospective fve-year multicenter study. lnt J Prostho
dont 2003; 16(6):640-646.
4. Berglundh T, Lindhe J, Ericsson l,Marinello CP. The soft-tissue barrier at
implants and teeth. Clin Oral Implants Res 1991 ;2(2):81-90.
5. Glauser R, Sailer 1, Wohlwend A, Studer S, Schibli M, Scharer P. Experimental
zirconia abutments for implant-supported single-tooth restorations in estheti
caUy demanding regions: Four-year results of a prospective cliaical study. lnt .
Prosthodont 2004; 17(3):285-290.
6. Kohal RJ, Weng D, Bichle M, Strub JR. Loaded custom-made zirconia and
titanium implants show similar osseointegration: An animal experiment.
J Periodonto1 2004;75(9): 1262-1268
7. Prestipino V, Ingber A. Esthetic high-strength implant abutments. Pa I.
J Esthet Dent 1993;5( I ):29-36.
8. Prestipino V, Ingber A. Esthet.c high-strength implant abutments. Part 11.
J Esthet Dent 1993;5(2):63-68.
9. Prestipino V, Ingber A. All-ceramic implant abutments: esthetic indications.
J Esthet Dent 1996;8(6):255-262.
10. Tripodakis A, Strub JR, Kapper! 1l,Witkowski S. Strength and mode of fail
ure of single implant all-ceramic abutment restorations under static load.
Int J Prosthodont 1995;8(3):265-272.
I I . Yildirim M, Fischer H, Marx R, Ede.hoffD. In vivo fracture resistance of
implant-supported all-ceramic restorations. J Prosthet Dent 2003;
90( 4):325-331.
alumina 114, 1 1 7
individualizable custom 1 1 4
prefabricated titanium 1 1 4
zirconia 114, 1 16-1 19
Aery l ic resin shells 31, 4 7
Adhesive bonding 94-95, |0 l
Adhesive cements, classification of 96
All-ceramic implants
screw-retained 1 1 7-118
cemented 116-117, 120
All-ceramic restorations 82
long-term failure 6
All-ceramic single crowns
clinical and labratory procedure
step-by-step procedure 4 7
Alumina (AI203
At-home bleaching 74
Biocompatibility 82
Biscuit bake try-in 33, 54-55
Blanks +J,J
at-home bleaching 74
combined bleaching 74
interal bleaching 65
power bleaching 73
Bonding surface area 94
Brittleness 8
CAD/CAM 5, 14, 18-21, 30. 84-85,95
CAM 14
Carbamide peroxide 72-74
Celay system 1 8
Cementation JJ
Ceramic powder 14
comparison with metals 8
composition and classification 2-5
conditioning of 94, l
glass 2-3
glass-infltrated 2, 4, 82, l
high-strength 2, 82-83
optical properies |
oxide 2, 4-5
physical properties 6, 8
Choice of ceramic restoration systems 38
Combined bleaching 74
Communication +
Computer aided design/computer aided
manufacturing 5, 14, 1821, 39-0, 84-85, 95
Computer aided manufacturing 14
Conditioning l|
Connector design 86, 88
Copy-milling 14, 18
Crack growh 6, 8
Crystalline paricles 2
Crstals 2
Curing agent 96
Dental hard tissues 2, l 0
bonding 96,99
conditioning 98-99, 108
Desensitizing agents 99
Diagnostic mock-up 50
Diagnostic wax-up 49-50
Diagnostic work-up 46
Distilled water 14
Ductility 8
Emergence profle l l 4-ll5, 121
Empress" system 1 6
Etching I 00

Ferrule effect 61
Fillers 96
Fine hybrid resin composite 35
Fixed partial denture span 82
Flexural strength 6-7
Fracture toughness 6-7, 9
Framework fracture 90-91
Glass-ceramics 2-3, 6-7
Glass intration 14, 1 7
Glassy phase 2-3
Green zirconia 20, 85
Hydrofluoric acid 34, 101-102
Hydrogen peroxide 65, 72-74
lmpressioning 30
In-Ceram' system 17-18
Indirect mock -up 3 1
Inorganic fillers 96
1 26
Lanthanum glass 4
Laser 19
Layering 14
lithium disilicate 3, 16
Lost wax technique 16, 85
Manufacturers 116
Material strength 38
Matrix of adhesive cements 96
Metals 8
comparison with ceramics 8
Microleakage 60, 95
Microstructure 7
multi-phase 3-4
single-phase 5
Minimum framework wall thickness 86
Modeling fluid 14, 17
Monoclinic phase 9
Non-vital teet 60, 64
Occlusal forces 82-83
Opacity 2
Opaque layer 38
Oxide ceramics 2, 4-5
Peri-implant soft tissues 116
Phase tansformation 9
Phosphate monomers (MDP) 96, 100
Phosphoric acid 34
Posts 61-64, 66, 68
Power bleaching 73
Prefabricated titanium abutments 114
Press furace (Empress') 1 6
Pressing 14, 16
CAD/C 5, 14, 18-21, 39-40, 84-85, 95
lost wax 16, 85
Processing methods 14
Properties of dental ceramics
optical properties I 0
physical properties 6. 8

direct 32
indirect (acrylic resin shells) 31,47
Radiopacity 86
Resin composite cements 96-98
clinical requirements 98
self curing 97
Retention 94-95
Rocatecr> system 100
Sandblasting 86, 1 01
Scanner 85
Sealing agents 99
Selection of ceramic materials 54
Self-curing composite resin 97
Shade selection 52-53
Shoulder preparation 38
Shrinkage 15-17, 1 9 85
Silanes 100, 103, 1 0-108
Silanization 34, 101
Silica coating (Rocatec1 system) 100
Sintering 15, l7
Sintering shrinkage 15, 19, 85
Slip casting 14, 17
Space requirements 38, 54
St. Morizer prep set 39-40
Strength of ceramic restorations 7
Stress loading 8
Stump shade 38, 54, 82
Survival rates 39, 42-43, 90
Tensile stress 8
Tetragonal phase 9
Thermal conductivity 82, 86
Tooth contour 51
Tooth preparation 28, 39, 50 84
Tooth shape 51

Tooth structure loss/preservation 24, 38, 50, 101
Transformation toughening 9
Translucency I 0, 95
of adjacent teeth 38
Treatment wax-up 51
Universal resin cement, dual-cuing 97
Veneers, cementation of 32, 35
Wax frame 85
Wax-up 27, 33
diagnostic 49
treatment 51
White light scanner 1 9
Whitening strips 78

Zirconia (Zr02) 4-5,9-10, 19-21 , 41 , 63-64, 66,

83, 85-91, 101, 106-107, 109, 1 14, 1 16-1 1 9
abutments 114, 1 1 6-1 1 9
posts 634, 66, 68
yttrium-stabilized 82