Вы находитесь на странице: 1из 259

1

The search for ideal restorative material continues. because of changing pattern of disease and new approaches toward cavity design there has been a increased demand for aesthetic restorations and also growing

concern about biocompatibility. Despite the promising results which have been achieved with posterior composites the polymerization shrinkage, surface wear, biocompatibility have been high lightened as disadvantages A practical solution may lie in the form of porcelain which has many excellent properties like biocompatibility, chemical durability, optical and aesthetic properties. As long as 1913 N.S.jenkin high lightened the advantages of the porcelain inlay which includes conservation of tooth structure and thermal insulation.
3

Restorative materials used in dentistry can be grouped as

1.Metals 2.Polymers 3.Composites 4CERAMICS

CERAMIC: defined as inorganic compound with nonmetallic properties consisting of metallic or semi metallic elements.
PORCELAIN: refers to a family of ceramic materials composed essentially of kaolin ,quartz, feldspar also fired at high temperature.

The term ceramics is derived from the Greek word keramos meaning potters clay/ burnt stuff.

Castable Ceramics- a glass or other ceramic formulated to be cast into the refractory mold to produce a core coping or framework

for a ceramic prosthersis


Core ceramic- an opaque dental ceramic

material that provides sufficient strength, toughness nad stiffness to support the overlying layers of veneering ceramic
9

Sintering- the process of heating closely

packed particles to a specified temperature to densify and strengthen a structure as a result of bonding , diffusion, and flow phenomena

10

MILE STONES AND PIONEERS


700 BC: ETRUSCANS

1774 DUCHATEAU.
1789 DE CHEMANT 1808 FRONZI

1817 PLANTEAU
1822 PAELE 1825 STOCKTON 1903 Dr.CHARLES LAND 1962 WEINSTEIN and WEINSTEIN 1962 WEINSTEIN et al 1963 VITA ZAHNFABRIK
11

1965 MCLEAN and HUGHES


1980 CEREC 1,2 and 3 1984 ADAIR and GROSSMAN

1990 PRESSABLE GLASS CERAMIC


1992 DUCERAM LFC

12

The dental application of porcelain dates from 1774,when a French apothecary named Alexis Duchateau considered the possibility of replacing his ivory dentures with porcelain

13

14

Classification of ceramics
Based on indications and uses -anterior -posterior

-crowns -veneers -post and cores -stain ceramics -glaze ceramics


15

Based on compositon
Pure alumina
Pure zirconia Silica glass Leucite based glass ceramic Lithia based glass ceramic

16

Based on processing method


Sintering
Partial sintering Glass infiltration CAD-CAM Copy milling

17

Based on firing temperature


High fusing -1300C Medium fusing ---1100 - 1300 C Low fusing--850 - 1100 Ultralow fusing < 850 C
By their firing temperature Air fired i.e. at atmospheric pressure Vacuum fired i.e. at reduced pressure.
18

Based on microstructure
Glass
Crystalline Crystal containing glass

19

Based on translucency
Opaque
Translucent Transparent It can also be classified based on

-fracture resistance -abrassiveness

20

FABRICATION
ALL CERAMIC MACHINED SLIP CAST HEAT PRESSED SINTERED

CRYSTALLINE PHASE Al, feldspar, mica


Al, spinel Leucite ,lithium disilicate Al, Leucite

CERAMIC METAL DENTURE TEETH

SINTERED

Leucite

MANUFACTURED feldspar
21

By their area of application: Opaque porcelain Body dentine porcelain Gingival dentin porcelain Overlay enamel Incisal enamel

22

According To Use(JADA 1997) METAL CERAMIC SYSTEMS : 1) Cast metal systems : eg: Vita Metall Keramik (VMK 95) 2) Non- Cast Metal Systems (Foil Crown Systems) ALL CERAMIC SYSTEMS : Classified according to method of fabrication (Marc Rosenblum & Alan Schulman A Review of All-Ceramic Restorations. JADA Mar1997).

23

1) Conventional Powder Slurry Ceramics : using condensing & sintering


(a) Alumina reinforced Porcelain e.g. : Hi-Ceram (b) Magnesia reinforced Porcelain e.g.: Magnesia (c) Leucite reinforced (High strength porcelain) e.g. : Optec HSP (d) Zirconia whisker fibre reinforced e.g.:MirageII (Myron I) (e) Low fusing ceramics (LFC): (i) Hydrothermal LFC e.g.: Duceram LFC : (ii) Finesse (Ceramco Inc)

24

2) Castable Ceramics : Using casting & ceramming 1) Flouromicas e.g: Dicor 2) Apatite based Glass-Ceramics e.g Cera Pearl 3) Other Glass-Ceramics e.g: Lithia based, Calcium phosphate based

25

3) Machinable Ceramics : Milling machining by mechanical digital control A)Analogous Systems (Pantograph systems copying methods) 1)Copy milling / grinding techniques : a) Mechanical e.g. : Celay b)Automatic e.g:Ceramatic II 2) Erosive techniques :a) Sono-erosion e.g: b) Spark-erosion e.g: Procera B)Digital systems (CAD / CAM): 1) Direct e.g: Cerec 1 & Cerec 2 2) Indirect e.g : Cicero, Denti CAD, Automill, DCS-President

26

4) Pressable Ceramics : by pressure molding & sintering 1) Shrink-Free Alumina Reinforced Ceramic (Injection Molded) E.g. : Cerestore / Alceram 2) Leucite Reinforced Ceramic (Heat Transfer Molded) E.g.: IPS Empress, IPS Empress 2, Optec OPC.

5) Infiltrated Ceramics : by slip-casting, sintering & glass infiltration 1) Alumina based e.g: In-Ceram Alumina 2) Spinel based e.g: In-Ceram Spinel 3) Zirconia based e.g.: In-Ceram Zirconia

27

According to microstructure: 1) Non-Crystalline Ceramics e.g.: Feldspathic 2) Crystalline Ceramics e.g.: Aluminous ,

1) Core ,

According to application: 2) Body, 3) Enamel

1) 2)

According to method of firing: Air fired (i.e, at atmospheric pressure) Vaccum fired (i.e, below atmospheric pressure)
28

29

Composition :

The various ingredients used in different formulations of ceramics are :


1. Silica (Quartz or Flint) Filler

2. Kaolin (China clay) Binder


3. Feldspar Basic glass former 4. Nepheline Syenite & Leucite

5. Water Important glass modifier


6. Fluxes Glass modifiers 7. Colour pigments

8. Opacifying agents
9. Stains and colour modifiers
30

Typical oxide content of dental ceramics

31

When feldspar is heated at temperatures between 1150 and 1530 degree centigrade, it undergoes incongruent melting to form crystals as leucite in a liquid phase. Incongruent melting is the process by which one material melts to forms a liquid plus a different crystalline material. This crystalline phase formed is leucite, which is potassium aluminum silicate with a large coefficient of thermal expansion.

32

Fritting:
The term frit is used to describe the final glass product. The raw mineral powders are mixed together in a refractory crucible and heated to a temperature well above their ultimate maturing temperature. The oxides melt together to forma molten glass, gases are allowed to escape and the melt is then quenched in water. The red hot glass striking the cold water immediately breaks up into fragments and this is termed as frit.

33

GENERAL PROPERTIES OF CERAMICS

Biological properties: Chemical properties:

Mechanical properties:
Thermal properties: Optical properties:

34

STRENGTH OF PORCELAINS :
These materials usually fail to show the strength of 2 Gpa which they are supposed to show theoretically, as the minute scratches and other defects that are present on the surface of nearly all the materials behave as sharp pitches whose tips may be as narrow as the spacing between atoms in the materials.

35

A phenomenon known as stress concentration at the tips of these minute scratches/ flames causes the localized stress to increase to the theoretical strength of the material at a relatively low average stress throughout the structure. When the theoretical limit of the material is exceeded at the tip the bonds at the notch tip break and initiate the crack formation.

36

As the crack propagates through the material the stress concentration is maintained at the crack tip until the crack moves completely through the material/ meets another. Crack a pore or a crystalline particle. Thus phenomenon of stress cone explains how materials can fail at stresses for lower than the theoretical strength.

37

Static fatigue: Exposure to water reduces the strength the porcelain causing delayed failure. Delayed failure in glasses had been attributed to a stress enhanced chemical reaction between glass and water this is likely to occur primarily at the tips of the surface cracks.

38

Water reacts with glass destroying the Si - o network and hydroxyl ions attach the siloxane bonds of the network. OH+ RSi-O-Si-R RSioH + R-Sio The silonate groups formed are strongly basic and can be hydrolyzed by water to form silonol groups and hydroxyl ions.

R- Sio+H2O R-SioH +OH

Thus in the presence of water the amount of energy required to rupture the silicone oxygen bond is diminished by about 20 times. Thus providing a surface coating for the flames reduces this.
39

METHODS OF STRENGTHENING PORCELAIN The principal deficiencies faced by ceramics are - brittleness, low fracture toughness and low tensile strength. Methods used to overcome the deficiencies fall into 2 general categories: 1. Method of strengthening brittle materials. 2. Method of designing components to minimize the stress concentrations and tensile stresses.

40

Method of strengthening materials: In the oral environment tensile stresses are usually created by bending forces, and the maximum tensile stresses occur at the surface of the restoration. It is for this reason removal of the surface flaws can result in the increased strength of the material. Smoothing and reducing flaws is one o the reason for glazing of dental porcelain. Now strengthening of the brittle materials can be done in a 2 ways.

41

1.Development of residual compressive stresses within the

surface of the material. 2. Interruption of crack propagation through the material.

Development of residual compressive stresses within the surface of the material:


One widely used method of strengthening ceramics is the introduction of residual compressive stresses.

42

Strength is gained by virtue of the fact that the residual stresses developed must first be negated by the developing tensile stresses before a net tensile stress develops in the material.

THREE of the methods used in achieving this objective are:

43

a.

ion exchange mechanism:

This technique is called as chemical tempering and is the most sophisticated and effective way of introducing residual compressive stresses. In this procedure a sodium containing glass is placed in a bath of molten potassium nitrate, potassium ions in the bath exchange places with some of the sodium ions in the surface of the glass particle. The potassium ion is about 35% larger than the sodium ion.

44

45

The squeezing of the potassium ion into place formerly occupied by sodium ion creates large residual compressive stresses in the surface of the glass. These residual stresses produce a strengthening effect. This process is best used on the internal surface of the crown, veneer/inlay as the surface is protected from grinding and exposure to acids.

46

Furthermore contact with acidulated phosphate fluoride for over 3 hours removes most of the ion exchange layer and not all ceramics are amenable for ion exchange especially those highly enriched with potash feldspar.

47

b. Thermal tempering: This is the most common method of strengthening glass. This creates residual surface compressive stresses by rapidly cooling (quenching) the surface of the object while it is hot and in the softened state. This rapid cooling produces a skin of rigid glass surrounding a soft molten core. As the molten core solidifies, it tends to shrink, but the outer skin remains rigid.

48

The pull of the solidifying molten core as it shrinks, creates residual tensile stresses in the core and residual compressive stresses within the outer surface. For dental applications it is more effective to quench the glass phase ceramics in silicone oil. Or other special liquids than using air as it may not uniformly cool the surface.

49

While doing porcelain fused to metal restorations the metal should be selected such that it contracts slightly more (higher coefficient of thermal contraction) than porcelain on cooling from the firing temperature to room temperature. This mismatch leaves the porcelain in residual compression.

50

Disruption of crack propagation This can be categorized into 3 types: 1. Crack tip interactions 2. Crack tip shielding 3. Crack bridging

51

Crack tip interactions: These occur when obstacles in the microstructure act to improve crack motion. These obstacles are generally second phase particles and act to deflect the crack out of the crack plane. It has been theorized that the reorientation of the crack plane leads to the reduction of the force being exerted of the crack in the area of deflection.

52

When the crack is deflected out of plane the crack is no longer subjected to pure tensile stresses and will involve some shear displacement; thus increasing the difficulty of crack propagation.

53

Crack tip shielding: This results when events are triggered by high stresses in the crack tip region that acts to reduce these high stresses. a. Transformation toughening b. Microcrack toughening are the 2 mechanisms that lead to crack tip shielding. This is most often associated with the presence of zirconia. Under unrestrained conditions zirconia undergoes a high to low temperature phase transformation which involves a 3% to 5/a volume increase.

54

In toughened ceramic the high temperature phase of zirconia is constrained at room temperature. Applied tensile stress work to advance the crack plane. In the area directly behind the crack tip, the matrix constraints of zirconia are released, allowing the low temperature transformation to take place, the transformed phase occupies a greater volume in the bulk material resulting in compressive forces that tends to counteract / shield any advancing crack tip stresses.

55

Microcrack toughening: It has been theorized that the high coefficient of thermal contraction and volume reduction associated with the high to low temperature phase transformation of the leucite crystals create a condition which causes the leucite crystals to contract significantly more than the glass matrix.

56

Compressive forces are created in the glass matrix surrounding the particles leading to microcracking in the leucite phase. The residual compressive stresses in the glass phase around to particles can act to counter tensile stresses, which drive the crack forward.

57

Crack tip bridging: This it the third strengthening mechanism that has been proposed. It occurs when a second phase acts as a ligament to make it more difficult for the crack faces to open. This is better understood by bonded fiber composites.

58

The fibers act as ligaments which make it more difficult to open the crack at an applied stress. Methods of designing components to minimize stress concentrations and tensile stresses The design should avoid exposure of ceramics to high tensile stresses. It should also avoid stress concentration at sharp angles or marked changes in thickness.

59

Minimizing tensile stresses:

When porcelain is fired onto a rigid material the shape of the metal will influence the stresses set up in the porcelain. If it is a full coverage crown the metal being of higher thermal expansion will contract faster than the porcelain as a result the metal is placed in tension and the porcelain in compression.

60

For partial metal coverage the junction between the metal and porcelain is therefore a potential site for high stress as the area with only metal will have no balancing compressive forces.

61

Reducing stress raisers;

Stress raisers are discontinuities in ceramic structures in brittle materials that cause stress concentration. The design of ceramic dental restoration should also avoid stress raisers. Abrupt changes in shape/ thickness in the ceramic contour can act as stress raisers and make the restoration more prone to failure.

62

Notches caused in the porcelain due to the folds of the underlying platinum foil substrate. Sharp line angle in the preparation, large changes in the thickness of porcelain are factors creating areas of stress cone. Usually contact points should be avoided and contact areas should be preferred to avoid localized stress areas.

63

TECHNIQUE INVOLVED IN FABRICATING PORCELAIN FUSED TO METAL There are 2 basic methods of fabricating porcelain fused to metal. 1.Involves the swaging of a platinum matrix on a model of the tooth and building the porcelain. 2. Supporting the porcelain to metal foundation.

64

Platinum foil technique: This technique involves fabrication on either a single platinum foil or a double platinum foil. Fabrication on single platinum foil: A pure platinum foil is swaged directly to the model then the porcelain is built up. Later after the completion as the firing cycles the platinum is peeled off. The fit of the crown is secured leaving enough space for the cement.

65

66

67

68

69

Fabrication using a double foil matrix technique: Here a second layer of platinum foil is swaged on the first and cut back by at least 0.5 mm from the gingival shoulder. The second layer is sand basted and cleaned with caustic soda and citric acid to improve impurities this is followed by electroplating, oxidization and finally build up of the porcelain. Later after the procedure is accomplished the inner layer is removed allowing space for the placement of the cement.

70

Supporting the porcelain of a metal foundation The various alloys that can be used are High noble. - Gold platinum palladium - Gold palladium silver - Gold palladium Have noble metal content greater than 60% with at least 40% gold.

71

Noble: - Palladium silver -High palladium They have less than 25% noble metal content

72

Predominantly base metals:

- Nickel chromium - Nickel chromium - Cobalt beryllium

73

BONDING MECHANISMS Four mechanism have been described to explain the bond between the ceramic veneer and the metal substructure. 1. Mechanical entrapment 2. Compressive forces 3. Van der waals forces 4. Chemical bonding

74

Mechanical entrapment: This creates attachment by interlocking the ceramic into the microabrasions on the surface of the metal coping which are created by finishing the metal with non contaminating stones / discs and are abrasives. Air abrasion appears to enhance the wettability, provide mechanical interlocking The use of a bonding agent having platinum spheres 3-6 m in diameter can also increase the bond significantly.

75

Compressive forces:

These are developed by a properly designed coping and a slightly higher coefficient of thermal expansion than the porcelain veneered over it. This slight difference will cause the porcelain to draw towards the metal coping when the restoration cools after firing.

76

Vander waals forces It is an affinity based on a mutual attraction of charged molecules. They are minor force for bonding. Chemical bonding It is indicated by the formation of an oxide layer on the metal. The trace elements like tin, indium, gallium/iron form oxides and bond to similar oxides in the opaque layer of the porcelain.

77

Bonding of porcelain to metal using electrodeposition: A layer of pure gold is deposited onto the cast metal, followed by a short flashing deposition of tin. This method has been successfully used for metals and alloys such as cobalt, chromium, stainless steel, palladium silver, high and low gold content alloys and titanium.

78

The advantages of this methods are: 1. Bonding is improved because of improved wetting the metal by the porcelain and reduced porosity at the porcelain metal interface

2. The electrodeposited layer acts as barrier between the metal casting and porcelain to inhibit ion penetration by the metal within normal limits of porcelain maturation

79

3. The gold color of the oxide film improves the vitality and esthetics of porcelain, when compared to the normal dark oxides which require thick opaque layers of porcelain to mark it.

4. The deposited layer acts as a buffer zone to absorb stresses.

80

Classification of bond failures in metal ceramics:

81

Metal porcelain: Fracture leaves a clean surface of metal. Seen when metal surface is devoid of oxides. May also be due to contaminated or porous metal surfaces. Metal oxide porcelain: Porcelain fractures at metal oxide surface, leaving oxide firmly attached to the metal seen often in base metal alloys.

82

Metal-metal oxide: Metal oxide breaks away from the metal and is left attached to the porcelain seen commonly in base metal alloy systems due to overproduction of Ch /Ni oxides Metal oxide - metal oxide: Fracture through the metal oxides results from over production of oxide.

83

Alloy surface treatment: Once the coping in made proper finishing with aluminium oxide strips is done to remove any surface irregularity and small particles as investment that may have been embedded in the surface of the casting.

84

Heat treatment: The coping is placed in a furnace at relatively low temperature and is then raised slowly to about 1000C in vacuum and slowly air cooled in normal atmosphere. This process of degassing allows any contaminants/ gas inclusion to burn off. At the same time base metal atoms will diffuse to the surface of the metal and form on oxide film, tin.

85

86

Thickness:

Cleaning :

87

Oxidizing
Controlled oxide layer should be created .

OPAQUE LAYER APPLICATION.

88

Methods of condensation: The Porcelain is mixed and applied. Vibration: Mild vibrations are used to densely pack the wet powder upon the underlying matrix. The excess water comes to the surface and is blotted with a tissue paper.

89

Spatulation: A small spatula is used, to apply and smoothen the wet porcelain. This action brings excess water to the surface. Brush technique: Dry powder is placed by a brush. Water is drawn towards the dry powder and the wet particles are pulled together. Ultrasonic: Mild vibrations are transmitted electrically.

90

METHODS OF BUILDING AND CONDENSING PORCELAIN The porcelain is usually built to shape using a liquid binder to hold the particles together. This process of packing the particles and removing the liquid is known as condensation. The main objective in building porcelain powder is to achieve maximum packing density of the powder i.e. minimum amount of air space is left in the green or inferred porcelain after driving off the liquid binder by heating.

91

Types of binders: Distilled water: Is the most popular binder used in dentin and enamel porcelain. Propylene glycol: Used in alumina core build up. Alcohol or formaldehyde based liquid for opaque / core build up.

92

Building porcelain:
1 The powder is mixed on a glass slab. 2. The mix should not be overstored to avoid the incorporation of large air bubbles.

3. High room temperature and dry atmosphere is to be avoided as the powder can dry out rapidly due to which all spaces are created in the powder bed. Crowns which are built from such a build up will inevitably be subjected to the entrapment of large air bubbles and areas which are opaque may appear.
93

94

95

96

Firing dental porcelain: After the condensation and building of a crown it is fired to high density and correct form. Initially the infected/ green porcelains placed on a sager and introduced into either a drying chamber/ the entrance of a furnace muffle. The liquid binder is driven off and the porcelain become brittle and chalky.

97

98

At this stage the green porcelain is introduced into the hot zone of the furnace and the firing starts, the glass particles soften at their contact areas and fuse together. This is often referred to as sintering. Before firing the temperature is raised gradually to the manufacturers recommended temperature.

99

This allows the air/gas bubbles to escape via the grain boundaries. Sealing the surface by quick firing arrests the process and can cause bloating / blustering. The powder will shrink and become denser. In air fired porcelain a point is reached where flow of glass grains around the air spaces trips the remaining air in the porcelain and on cooling spheroid bubbles are left in the porcelain. However, then porcelain is fired in vacuum, the air/atmosphere is removed from the interstitial spaces before sealing of the surface occurs.

100

Do not prolong vacuum firing as by then the surface skin is sealed and further application of vacuum can cause surface blistering since residual air bubbles will try to rise to the surface through the molten porcelain.

101

102

103

Classification of the stages in Maturity: Low Bisque: Medium Bisque: High Bisque:

104

105

Cooling Must be carried out slowly and uniformly. If shrinkage is not uniform it causes cracking and loss of strength. Glazing Porcelains are glazed to give a smooth and glossy surface, enhance, esthetics and promote hygiene.

106

The glazing should be done only on a slightly roughened surface and never should be applied on glazed surfaces. 1. Overglaze 2. Self glaze

107

Over glaze: These are ceramic powders containing more amount of glass modifiers thus lowering fusion temperature. It may be applied to porcelain and then fired.

Self glaze: All the constituents on the surface are melted to form a molten mass about 25 m thick. Thus the porcelain is said to be self glazed.

108

Add on porcelains The add on porcelains are made from similar materials to glaze porcelain except for the addition of opacifiers and coloring pigments. The add on porcelain is made from the same grit as used to manufacture regular porcelain. These are sparingly used for simplest corrections like correcting of tooth contour / contact points.

109

Repair of fracture ceramic restoration Roughen the fracture ceramic surface using an intraoral sand blaster generally using 30-50 m aluminium grit.
Silane is applied.

Dentine bonding agent containing 4 META applied to the porcelain surface. The defect is restored with composite restorative material.

110

Aluminous porcelain:

There were developed by Mc Lean in 1965. Its composition is similar to that of conventional porcelain except for the increased alumina content (40-50%). The dispersed alumina crystal strengthens by interruption of crack propagation. The crack cannot penetrate the alumina crystals as easily as it can penetrate through the glass.

111

These are used to construct the core layer for PJC. These are considered to provide crowns more esthetics than metal ceramic crowns. Their strength is almost twice that of conventional porcelains and is sufficient for use on anterior teeth. However, for posterior teeth it is inadequate.

112

These are moreover less expensive than metal ceramic crowns. But the disadvantage of this material is the addition of alumina which makes it opaque. Aluminous porcelain shrink during the baking procedure, the fit of the finished aluminous crowns is generally poorer than that of ceramometal crowns.

113

Presented byDr. Aatish Shah

114

Full feldspathic porcelain crowns manufactured on platinum foils were one of the first attempts to fortify the strength of all-ceramic restorations.

Today other processes are being used in allporcelain crown fabrication.

115

An all-ceramic crown is still considered by many dentists to be the most life like and esthetically pleasing restoration. It is translucent, color stable, brilliant, and life like. If constructed over a uniformly reduced and balanced preparation, it has a long life expectancy in most patients. The advent of vacuum firing has reduced bubbles, producing a fine textured restoration with improved translucency and increased impact strength.
116

Acid - etching and adhesive bonding cements have also enhanced the physical properties of the all-porcelain crown. Porcelain is biologically acceptable, and well tolerated by the soft tissues.

Porcelain crowns cemented on natural abutments and those cemented on artificial supports have the same incidence of fracture; therefore, a porcelain crown can be successfully used after a cast-metal post and core has been placed on a non-vital tooth.
117

Fragility.. Accuracy

Cervical shadowing or black line

118

The all-porcelain crowns are indicated

Obtaining the best esthetic result is the single most important consideration.
The patient is allergic to metal. Patient desires..

119

The natural tooth is not completely erupted. Preparation of all-ceramic crown unavoidably cause pulpal involvement. would

The patient participates in contact sports or has a parafunctional habit, such as pipe smoking that involves heavy contact on small areas of the dentition. The patient habitually grinds or clenches the teeth. The patient requires a reinforced restoration, such as a posterior fixed bridge.

120

McLean(1965) was the first to use a highstrength aluminous porcelain core in the construction of the porcelain crown. He showed how this technique strengthens the internal aspect and increases the resistance of the crown to crack propagation. When sufficient reduction is obtained, the aluminous porcelain crown is esthetically successful.
121

When crowning in lower posterior teeth, it should be made sure to adequately reduce the occlusal table at least 2mm, especially at the central fossa. Otherwise, the aluminous core of an allceramic restoration will not allow proper depth of porcelain for central groove anatomic carving. Modern techniques have eliminated the earlier problem of the inner alumina core showing through the outer porcelain.
122

There is a shoulder thickness of only 0.5mm

possible on the labial surface.

There is an occlusal clearance of more than 0.5mm in all lateral excursions

123

The preparation is conical with a little retention. Short teeth or where there is too little tooth structure to support such a restoration. Where occlusal clearance is less than 0.5mm.

124

Clinical experience with 1334 aluminous porcelain crowns over 3 1/2 years by McLean indicates that these crowns can with stand torque better than conventional porcelains with fracture rate of slightly less than 0.5%. As Abramowsky states, pure alumina is 6 times stronger than standard porcelains. By combining an alumina core with standard porcelain, you get a restoration, which is twice the strength of porcelain alone. Low thermal conductivity.
125

During processing, alumina and porcelain unite by a chemical bond, so there is practically no problem in adhesion of the different materials. Both materials exhibit the same expansion and contraction co-efficient; they do not require adjustment of the thermal expansion coefficient as well different materials, such as metal and porcelain, are used.
Good color consistency. Provided the porcelain's maturing temperature is not exceeded, the crowns may be fired 3 or 4 times without color loss.
126

In-Ceram Sadouun.

was

developed

in

1989,

by

It makes use of aluminous cores that are infiltrated with a glass to achieve high strength substructures that can support crowns and bridges. In-Ceram belongs to a class of materials known as interpenetrating-phase ceramics.

127

In ceram is supplied as one of the three core


ceramics

In-ceram spinell (ICS)

In-ceram Alumina (ICA)


In-ceram Zirconia (ICZ)

128

The three In-ceram ceramics are glassinfiltrated core materials used for single anterior crowns (all three products)

posterior crowns ( In-ceram alumina, Inceram Zirconia)

Anterior 3 unit FPDs (In ceram alumina)


3 unit posterior bridges (Inceram Zirconia)

129

Moderately high flexural strength Fracture toughness Metal free structure Ability to be used successfully with conventional

luting agents.

Inspite of its flexural strength (429 Mpa), the weibull modulus of ICA is quite low (5.7), which

is indicative of a large scatter in the distribution of


strength values relative to the probability of fracture (Tinschert et al, 2000)
130

These materials consist of at least two phases that are inter-wined and extend continuously from the internal to the external surface. These materials may posses improved mechanical and physical properties compared with the individual components. They may have improved strength and fracture resistance due to the fact that a crack must pass thorough alternative layers of both components no matter what direction the crack takes.

131

An all-ceramic restorative system, In-Ceram, is based on the slip casting of an alumina core with its subsequent glass infusion. An impression of the master cast preparations is made with elastomeric impression materials. Special gypsum supplied with In-Ceram is poured to produce the die on to which the In-Ceram alumina is applied.

This solution of alumina is referred to as slip, which is then painted on to the gypsum die with a brush.
132

A second-generation material, In-Ceram Spinell based on the In-Ceram technique, has recently been introduced. The techniques of fabrication are essentially the same as the original system. The primary difference is a change in composition to produce a more translucent core. The porous core is fabricated from a magnesium- alumina powder to form porous network after sintering.
133

This type of material has a specific crystalline structure referred to as spinell.

The porous spinell is secondarily infiltrated with a glass, which produces a more translucent substructure upon which the Vitadur Alpha is placed to form the final restoration.
The In-Ceram spinell core material is not as strong as the original system, but flexural strength values of upto 350 MPa have been reported.
134

135

136

VITA In-Ceram special plaster 20g : 4.6 ml distilled water.


137

Pour 4.6 ml of distilled water into the mixing beaker, then mix the content of the sachet of VITA In-Ceram special plaster by hand. Then mix under vacuum for 20 sec. Make sure the mixing unit is clean and dry. The processing time can be lengthened by adding chilled distilled water.
138

Pour the plaster in to the mould slowly in small increments without the formation of air bubbles.
139

140

After filling the special plaster into the special plaster mold, deflask after 2 hrs.
141

After deflasking the base must be ground flat. During this, the models must be kept dry.
Any absorption of water of water on the hardened special de has a negative effect on the expansion behavior.
142

Partly section the special plaster model from beneath using a separating disc.
143

Glue the special plaster bridge model onto a VITA In-Ceram firing tray using cyanoacrylate adhesive.
144

After approx.10 min, section the plaster model between the abutment teeth with a sharp saw blade, in order to prevent damage to the bridge substructure due to the shrinkage in the plaster during sintering firing.
145

Mark the margins with a super polymer color cartridge.


146

147

Weigh out exactly 38g of VITA In-Ceram alumina powder.


148

Pour the contents of 1 ampoule of ZITA InCeram alumina mixing liquid and 1 drop of VITA In-Ceram Alumina additive into a glass beaker and mix briefly in the VITASONIC.
149

Place the glass beaker on a vibrator and spatulate the 38 g of VITA In-Ceram Alumina powder slowly into the liquid in several small portions.
150

Mixing must be interrupted at least 3 times in order to place the glass beaker in the VITASONIC ultrasonic unit for 2 min each time.
The water in the VITASONIC must be chilled.

151

After the entire powder is added, place the glass beaker in the VITASONIC for 7 min. After mixing, the slip must be homogenous.
152

The mixture must be evacuated for 1 min. (e.g. with a vacuum investment unit).
153

Pour the slip from the glass beaker into the enclosed plastic mixing cup.
154

155

Start to apply the slip in the area of the pontic. Build up to half of the height of the pontic. Then coat the abutment dies fully and connect them to the pontic.
156

Proceed rapidly when building up the remaining slip. Do not interrupt this process, so that drying out the layers is that have already been built up is prevented (onion-skin effect).
157

Vita Hi-Ceram Optec HSP Duceram LFC


Summary 158

159

Hi-Ceram was developed in 1985, borrowing a technique from industrial manufacturing. It is a system similar to aluminous core porcelain crown, using an epoxy die, a swaged resin coping, and conventionally applied porcelain. Although anterior crowns are its primary indication, posterior crowns can also be used when occlusal conditions are favorable. This is mainly for patients who do not want a metal core, are allergic to metal, or require some light reflection of the tooth through the core for esthetic purposes.
160

This is a aluminum oxide reinforced hard core porcelain. Alumina reinforced core consists of 50% of aluminous crystals in a matrix of low fusing

glass of matching thermal expansion.

Aluminous core porcelains are twice stronger than regular porcelains.

161

Highly accurate margins. Higher melting points and greater stability. For both anterior and posterior crowns, veneers.

162

163

Optec HSP(Jeneric / Pentron) is a Leucitereinforced feldspathic porcelain that is condensed and sintered like aluminous porcelain and traditional porcelain.
Has greater strength than traditional feldspathic porcelains due to increased amount of leucite. The manufacturer disperses the leucite crystals in a glassy matrix by controlling their nucleation crystal growth during the initial production of the porcelain powder.

164

Because of its increased strength, Optec HSP does not require a core when used to fabricate all ceramic restorations, as is necessary with aluminous PJCs. the body and incisal porcelains are pigmented to provide the desired shade and translucency. The leucite and glass components are fused together during the baking process (1020oC). The buildup and contouring of the crown is done on a special semi-permeable die material. It has a moderately opaque core compared with a metal or an aluminous porcelain core, it is more translucent than alumina-core crowns and glass infiltrated alumina core crowns.
165

166

Lack of metal or opaque substructure. Good translucency. Moderate flexural strength. No special laboratory equipments needed.

167

Potential marginal inaccuracy caused by porcelain sintering shrinkage. Potential to fracture in posterior teeth. Leucite reinforced porcelain that is condensed and sintered shrinks when fired because of the volumetric decrease caused by sintering, and the fit of the crowns made from this ceramic is not as good as that of PFM crowns with metal margins.
168

169

The development of very low fusing ceramics (fusing temperature 660oC) meant that a simple and accurate technique for building up and firing all-ceramic

restorations.

170

Tooth preparation.
Die preparation. Ceramic core. Ceramic buildup.

171

Low fusing ceramics have been developed primarily for the use with titanium frame works. Titanium is now being used for metal ceramic restorations because of its biocompatibility and corrosion resistance. Low fusing porcelains are required to adequately match the thermal expansion coefficient of titanium, to reduce residual stress, which may result in failure of the overlying ceramic.
172

The fusing temperature of these materials may rage from about 650C to 850C.

Lower fusing temperatures may also preserve the micro structure of the ceramic, in contrast to high fusing materials, which may suffer from dissolution of crystalline components.
These lower temperatures can result in a more natural, life like appearance of the porcelain. Flexural strengths are similar to that of conventional feldspathic porcelain (Hoffman and Casellini 1988).
173

Ducera presently makes a low fusing ceramic, Ducera LFC, which can be fired at 660C. this ceramic can be used directly to fabricate all-ceramic inlays, onlays and veneers. Additionally, repairs and corrections of porcelain or metal ceramic margins may be accomplished with this ceramic.

174

In recent years, new ceramics systems that allow fabrication of crowns by casting or

injection molding have been adapted for


dental use.

175

It is one of the most translucent of all the allceramic materials. However color must be developed using several coats of surface glaze, or Dicor must be veneered with aluminous porcelain. During sintering, micaceous crystals form, which reportedly give the Dicor material improved strength and machining qualities due to the generation of compressive stress around the crystals.

176

Consists of three crystalline forms, SiO2, = 45% -70% (w/w) K2O, = 20% (w/w) MgO, = 3% - 13% (w/w) MgF2 = 4% - 9% (w/w)(Fluoride as a nucleating
agent forming nucleation sites to aid the crystal growth during the process of ceramming, leading to a growth of approx 1 micron small tetrasilicic crystals).

Small amounts of AlO3, ZrO2,BaO Fluorescing agents.


177

Dicor presents a unique problem. When cast and ceramed, one surface-called the ceram layer - is significantly different in composition from the rest of the glass-ceramic material. Removal of the external ceram layer has been reported to affect the fracture strength, increasing the strength from 93 to 154 MPa or decreasing it from 149 to 143 MPa. The ceram layer contains micaceous crystal whiskers as well as greater porosity with respect to the rest of the material.
178

A primary advantage of this system is the option of casting the material into a special mold produced by the lost-wax technique. This technique simplifies the process of making all-ceramic crowns and has resulted in good accuracy and fit (Malamet and Grossman, 1992). Casting is accomplished in a special centrifugal casting machine driven by an electric motor. The glass ingot is heated to about 1,300C in a special carbon crucible.
179

The mold, made of phosphate bonded investment is heated in several stages and finally held at around 900C for casting. The cast restoration is divested; at this stage it is clear and transparent.
It requires further heat treatment for the ceramming and external coloration to give it the appearance of a tooth. Prior to ceramming the sprues are removed and the restoration again invested and heat-treated in a predetermined heat regimen for several hours. This process produces crystals of a mica ceramic in the glass.
180

The cerammed restoration is again divested and coated with a staining glaze that is fired at a lower temperature. The crowns sandblasted without touching the margins. Stains are applied. The crowns are luted with resin cements and associated bonding procedures were significantly stronger than those luted using glass-ionomer or zinc phosphate cements. And also variations in the finish line forms did not have any significant differences in restoration strength when resin cement and associated bonding procedures were used.
181

chemical and physical uniformity. marginal accuracy. uncomplicated fabrication and wax up to casting, creaming and coloring. ease of adjustment. excellent esthetics resulting from natural translucency, light absorption, light refraction and natural color for the crown. Its inherent resistance to bacterial plaque.
182

183

184

This process is accomplished by a precisely controlled ceramming furnace. The furnace temperature is gradually increased to 1075`C for 3 hrs, this temperature should be maintained for 6 hrs. the furnace is cooled to 200oC and the embedment tray is removed. The ceramming process involves a two-stage heat treatment. The first heat treatment is carried at the temperature for maximum nucleation of crystals, so maximum no: of crystals are formed. The temperature is held for some time for the crystal growth to take place, to attain the maximum size.

185

186

187

The proper ceram cycle is verified by the use of a pyrometric cone.

The characteristic droop will provide verification that proper time and temperature has allowed the development of the desired crystalline properties in the casting.

188

189

190

191

192

Bioceram group have developed castable ceramic material (Hobo & Kyocera) which may be classified as CaO.P2O5.MgO.SiO2 glass ceramic. Its crystalline structure is similar to that of enamel. Biocompatible and is indicated for crowns and inlays.

193

It is composed of CaO.P2O5.MgO.SiO2 plus traces of other elements. CaO.P2O5 - are the main ingredients and aid in glass formation. Essential to form hydroxyapatite crystals. Mg O. CaO decrease the viscosity. SiO2 in combination with P2O5 form the matrix.

194

Melts at 1460oC and can be cast. The casting has an amorphous microstructure and when it is reheated at 870oC for 1 hr, it forms crystalline oxyapatite. This apatite is clinically unstable and when exposed to moisture becomes crystalline hydro-oxyapatite. It has similar crystalline arrangement as enamel but the crystals are irregular providing superior mechanical strength.
195

IPS EMPRESS I, II CERESTORE (ALCERAM)

Summary

196

197

During the past 80 years investigations have improved the technique and strength. The process of various strengthening mechanisms has resulted in the substantial improvement in the porcelain, but has not overcome the problems related to shrinkage that potentially lead to distortion of the matrix, marginal inaccuracy, and inadequate functional strength.

198

Therefore the development of non-shrinking

ceramics such as Cerestore system provided


an alternative. Using the transfer molding, it is now possible to fabricate non-metallic

ceramic crowns directly on the master die


with excellent marginal fit.

199

The feature of the Cerestore system is the dimensional stability of the core material in the unfired and fired states. Conventional porcelains shrink 10 20 %

during firing.

The

Cerestore

core

material

offsets

conventional shrinkage by a combination of chemical and crystalline transformations.


200

201

Empress 2 ingots
202

IPS-Empress introduced an injection molding system that uses a leucite (40 - 50%) reinforced feldspathic porcelain. The leucite crystals may improve the strength and fracture resistance of the feldspathic glass matrix in a manner similar to that which occurs in glass-ceramics like Dicor or in dispersion strengthened aluminous porcelains. IPS Empress all-ceramic system permits light to be reflected, scattered, and absorber through out the entire crown and the underlying tooth structure.
203

An advantage of IPS-Empress over the other types of ceramic materials is the translucency similar to that of enamel, providing a Chameleon effect that allows it to blend in with natural tooth structure.

Empress crowns can be made either by stratification of veneering porcelain or by superficial coloring. A conventional lost wax technique is employed, except for the use of a special investment and a prolonged burnout cycle.
204

The wax patterns are placed in a furnace along with the empress ingots, and are slowly heated to approximately 1200C. The investment mold is placed in the bottom of the Empress injection molding system at a temperature of about 1150C, and the selected glass ingot is placed in the upper chamber for molding under a pressure of about 0.4 MPa. The ingots are supplied in several shades, and two techniques mat be employed to fabricate the restoration. The restoration may be cast to its final contours and subsequently stained and glazed to provide an esthetic match.
205

Alternatively, a coping may be molded upon which porcelain is added to achieve the final shape and shade of the restoration. Empress restorations are very translucent, and have reported flexural strengths of up to 160-180 MPa. A unique shade guide, a chromoscope, is used for the ceramic shade selection. Because the ceramic material is somewhat translucent, the color of the underlying tooth structure will be transmitted through it.
206

The Empress system, with its optical characteristics, has come close to mimicking natural teeth. As a result, an Empress restoration is particularly useful in esthetically demanding areas such as the anterior part of the mouth. The crowns are etched with hydrofluoric acid and treated with silane bonding agent. Dentin is etched with 10% phosphoric acid for 15 seconds, rinsed, and dried. Cementation is usually accomplished with a photo polymerizing dual curing resin system. The IPS Empress system is also used for the fabrication of onlays and inlays.
207

CAD-CAM (computer assisted designcomputer assisted manufacture) systems have also recently been introduced to the dental profession. Development of CAD-CAM systems for the dental profession began in the 1970's with Duret in France, Altschuler in the US and Mormann and Brandestini in Swizerland (Rekow 1987; Rekow et al 1992, 1993; Rice and Mecholsky, 1977).
208

All CAD/CAM systems are technically complex and involve three distinct complex and involve three distinct steps:

Collection of in formation Design of the restoration and Fabrication.

These systems will undoubtedly receive periodic improvement, necessitating expense for software changes as well as tool replacement and other associated expenses.
209

The popular CAD/ CAM systems used in dentistry are:


The CELAY system

The CEREC system


The DCS Precident system

The Procera system

210

M achinabl e C amics er
CAD-CAM Cer am ics
a ceramic restoration fabricated by use of a computer aided design computer aided milling

Copy-Mil l ed Cer am ics


a process of milling a structure using a device that traces the surface of a metal, ceramic or a polymer pattern and transfers the traced spatial positions to a cutting station.
211

CEREC CEREC 2 CEREC 3

CEREC SCAN CEREC InLAB PROCERA


212

213

214

The equipment consists of a computer integrated imaging and milling system, with the restorations designed on the computer screen
215

Vita Mark II (Vident): These contain sanidine (KALSi3O8) as a major crystalline phase within a glassy matrix.

216

217

218

With the help of the CEREC 3 Software we can choose the basis software for the designing of inlays/onlays or crowns or veneers.
219

1.
2. 3.

Function Correlation Extrapolation


220

With using all the programmes the operator can digitally design the restoration by moving the cursor along the boundaries.

221

Milling process - - - - - - - - - - - Completed ceramic core

222

CEREC SCAN (inclusive of both scanning and milling device) with lap top (imaging device).
223

224

225

226

PARALLEL MILLING WITH TWO TOOLS

227

HIGH SPEED MILLING OF COPINGS AND BRIDGE FRAME WORK.

228

229

CELAY System

230

231

232

The Celay system employs a copy milling machine and uses manufactured porcelain blanks to mill out ceramic inlays, onlays, crowns and bridges is the CELAY system (Siervo et al, 1994). This system is a precision copy-milling machine. The Celay system is unique in its milling capabilities; its milling arms are able to move in 8 axes of freedom, which allows the milling of complex, three dimensional shapes. Thus, it can mill the occlusal aspects of restorations in very fine detail.
233

The marginal fidelity of these milled restorations are excellent; according to the manufacturer, marginal gap of only 50microns can be achieved. Marginal gaps of 60microns were attained in an independent study. The Celay system provides the ability to fabricate both direct and indirect ceramic restorations. Copy milling technology requires the generation of a pattern of the desired restoration. This pattern can be fabricated directly in the mouth or on a working cast and dies. This pattern is then copy milled using the Celay machine to generate the final restoration. The system uses an approach similar to the pantographic method of duplicating keys.

234

Data for fabricating a metal coping can be obtained by adding offset for the desired thickness of metal on top of the prepared tooth surface data. Thickness can be varied according to the coping design. Thus, coping data for complete porcelain coverage as well as partial coverage can be developed on this system. Occlusal morphology cannot be designed by the system.
235

To design copings for fixed partial dentures, including extension prostheses, each abutment tooth is digitized first; then the position of the pontic is decided in 3 dimensions. The time required for digitizing, designing and the data conversion to milling path data is about 15-20 minutes for single crowns and 20-30minutes for a three unit fixed partial denture.
236

Metal copings are milled from titanium blocks. In accordance with CAD data, the milling program selects the titanium block that will result in the minimum remaining material. The infrastructure for ceramic crowns can also milled from a piece of high performance Metroxit Zirconium oxide TZP Bioceramic R. Type TAP tetragonal polycrystalline zirconium oxide has been used for years in hip joint prosthetics. It is one of the so-called high performance ceramics.

237

excellent biocompatibility good flexibility favorable modulus of elasticity good fracture resistance corrosion resistance very small grain size no glass phase as binder extremely high density No porosities.

238

A titanium block is fixed in the milling machine with the jig. The inside of the coping is milled with the CAD data. The titanium block is removed, turned over and replaced when the milling of the inside of the coping is finished, the milling machine will automatically stop to allow the side of the titanium block to be changed. The outer surface of the coping, to which the porcelain or the resin material will be attached later, is milled.
239

To allow removal of the coping from the block, the connecting part between the coping and the remaining block is cut. The time required for milling a single crown coping is about 30-45 minutes. About 90-120 minutes are required for the three unit fixed partial denture coping.

240

241

242

This process for manufacturing crowns, prostheses, and implant suprestructures uses a combination of copy milling, spark erosion"' and laser welding. Procera technology was first developed for processing titanium, the potential for working with high strength sintered materials - Aluminum oxide ceramics. Application of the Procera for manufacturing individual crowns made of aluminum oxide ceramics for the firs time joins computer controlled technology with the increasing demand for improved esthetics.
243

Crowns manufactured with Procera system shows strength values never reached by an all-ceramic system; flexural strength 699 +/70.8 MPa according to the manufacturer. Andersson and Oden Research at the University of Michigan indicates a flexural strength approximately twice as high as that of lnCeram and more than three times that of other all-ceramic systems.
244

All that is required for the Procera technique is a scanner, a personal computer, and means for transmission of the data (modem or disk) to the workstation. The die of the prepared tooth is first mechanically scanned. The scanner used has a sapphire ball tip that reads the die shape by circular scanning; describing the tooth using approximately 20,000 measured values.
245

To obtain optimal results, some special preparation techniques are suggested. A classic 90-degree preparation is not necessary; softer, rounded preparation shapes are preferable (especially the inside edge of the chamfer preparation) Preparation depth should be 1 to 1.5mm, with atlas 2mm of occlusal reduction. As previously mentioned, it is not necessary to use a die spacer to create a cement gap.
246

This can be made during enlargement of the determined data on the display screen.

However, care must be taken to ensure that the subsequent crown does not become too large and thus over contoured in the cervical area. This would lead to a marginal gap, and potentially to slight rotation of the coping on the die.
The crown can be cemented with zinc phosphate cement, glass-ionomer cement, or composite materials.
247

With the Procera system, a high quality, highstrength aluminum oxide coping can be expected. A coping 0.5 to 0.6 mm thick will increase the strength of the crowns. However, due to the high strength of the Procera crown, thickness can be reduced slightly (0.3 to 0.4 mm), especially in the labial area for improved esthetics.

248

The Procera crown should be checked very carefully and corrected if necessary

The inside surface of the crown The crown margins The thickness of the crown.

If the design of the coping is perfected during the scanning process, these finishing steps are rarely necessary. The Procera coping should be cleaned in an ultrasonic cleaner, in distilled water, or by steam cleaning.
249

A special ceramic material with thermal expansion coefficient adjusted to aluminum oxide (7 X 10-6 um/ml) has been developed for the Procera technique. Besides a base kit of 16 dentins, 5 translucents, and 4 incisals, a master kit of 12 modifiers accurately adjusted to each other and 8 so called Basic dentins is offered. This leads to a wide range of possibilities for customized design of the restoration.
250

The ceramic material has fluorescent properties that correspond to natural dentition and thus vitality of the restoration under different light conditions.

Another special property of this new ceramic material is its low baking temperatures, dentin firing, 900 to 910C; glazing 880 to 885C.
This leads to less shrinkage during firing.
251

Natural color effects


Optical properties close to natural teeth (fluorescence, opalescence & translucency) Gingival acceptance and biocompatibility Excellent marginal fit

Excellent strength values.

252

Long before it was introduced internationally the Procera system underwent long and careful research as well as testing by Swedish clinics and laboratories and by the University of Michigan, Ann Arbor. Routine work does not require well-trained or experienced ceramists; instead ceramists can concentrate on the creative design of the ceramic veneering.
253

The Procera system represents a symbiosis of computer technology and creativity. Today the application is restricted to single crowns and customized aluminum oxide superstructures supported by Branemark single tooth implants (customized Cera-one).

254

Modified metal ceramic restorations (with a vertically reduced frame work) provide strength and cervical translucency, and as compete with all ceramic restorations in terms of the esthetic results achieved. Like all-ceramic restorations, modified ceramic crowns can be bonded with composite cements, which further enhance the effects of marginal sealing and biocompatibility. In situations where one cannot provide enough compressive strength inside ceramic inlays and onlays second-generation laboratory composites would be the preferred clinical choice.
255

256

REFERENCES
1.

Science of dental materials- K J Anusavice

2. Restorative dental materials - R G Craig


3.Dental Porcelain:Composition, Types, Glazing and Clinical Applications.DENTAL NEWS, Voume VI, Number 3, 1999 4.Aesthetic dentitry. J. Schmidseder
257

5.Evolution of dental ceramics in twentieth century-J W McLean, J Prosthet Dent 2001,85(1),61-66. 6.Glass/ceramic/refractory techniques, their development and introduction into dentistry: A historical literature review.JPD 04, 91(2); 136-143 7.Recent developments in restorative dental ceramics-K J Anusavice,JADA,124,1993 8.A review of All-Ceramic Restorations- M A Rosenblum and A Schulman,JADA,128,1997297-307. 9. Recent advances in dental ceramics. Critical Review in oral biolagy and medicine. 1996.7(2) Google.

258

259