2008 all ceramics at a glance

All-Ceramics
at a Glance
Introduction to indications, material selection, preparation
and insertion of all-ceramic restorations
Arbeitsgemeinschaft für Keramik in der
Zahnheilkunde e.V. (AG Keramik)
Society for Dental Ceramics (SDC)
K.-H. Kunzelmann, M. Kern, P. Pospiech, A. J. Raigrodski, H. E. Strassler,
A. Mehl, R. Frankenberger, B. Reiss, K. Wiedhahn
ISBN 978-3-00-021677-0
1st English Edition

Arbeitsgemeinschaft für Keramik in der
Zahnheilkunde e.V. (AG Keramik)
K.-H. Kunzelmann, M. Kern, P. Pospiech, A. J. Raigrodski, H. E. Strassler,
A. Mehl, R. Frankenberger, B. Reiss, K. Wiedhahn
Society for Dental Ceramics (SDC)
All-Ceramics
at a Glance
Introduction to indications, material selection, preparation
and insertion of all-ceramic restorations
1st English Edition

Title:
All-ceramic materials provide esthetic and enduring treatment solutions. Photo Reichel
University Edition
This limited edition has been published for universities, professors, lecturers and students of dentistry. With this special edition, the
authors, editors, and publisher? hahelped make available, free of charge to teaching and research, both tried-and-true and new knowledge
about all-ceramic restorations gained from clinical and private practice.
The authors hereby give the recipient of this edition the right to make print-outs exclusively for the purposes of the university or college
and distribute them as study material at the university or college. However, we request that no electronic copies be made or distributed.
We thank you for your cooperation.
The initiators of this University Edition strongly hope for a lively exchange of ideas with professors and students, to ensure a broad
clinical basis for all-ceramics as a progressive treatment procedure.
Authors, Committee, and Board
of the Society for Dental Ceramics
September 2008
Society for Dental Cermics
Arbeitsgemeinschaft für Keramik in der Zahnheilkunde e.V.
P.O.B. 100 117, D-76255 Ettlingen, Germany
Tel. ++49 721 945 2929
eMail info@ag-keramik.de
www.ag-keramik.de
© Copyright 2007

Contents
1. Foreword 4
2. All-ceramics – individual, esthetic, and metal-free 6
3. Proven clinical applications 7
4. Clinical use 8
5. All-ceramic inlays, onlays, and posterior partial-coverage crowns 9
6. Porcelain laminate veneers, anterior ceramic partial-coverage crowns 16
7. Crowns, fixed partial dentures, telescopic crowns, implant-supported restoration 24
7.1 Anterior crowns 26
7.2 Posterior crowns 32
7.3 All-ceramic fixed partial dentures 36
7.3.1 Anterior fixed partial dentures 36
7.3.2 Posterior fixed partial dentures 39
7.4 All-ceramics for telescopic crowns 43
7.5 Implant abutments, and implant-supported crowns and fixed partial dentures 45
8. Indications for ceramic materials 48
9. Shade selection 49
10. Luting techniques 51
10.1 Adhesive bonding of feldspathic porcelain 52
10.2 Step-by-step procedure for intimate adaptation 56
10.3 Conventional luting procedures 62
11. Try-in, adjustment, and polishing procedures 64
12. Removing all-ceramic restorations 66
13. Intra-oral ceramic repair 67
14. Rationale for all-ceramic restorations 68
15. Clinical results 70
16. Ceramic and CAD/CAM systems 73
17. Literature on all-ceramics 84
18. Society for Dental Ceramics: Purpose and intent 90
19. From the practice for the practice 91
20. Overview of dental ceramics – ceramic systems (fold-out page)
3
1. Foreword 4
2. All-ceramics – individual, esthetic, and metal-free 6
3. Proven clinical applications 7
4. Clinical use 8
5. All-ceramic inlays, onlays, and posterior partial-coverage crowns 9
6. Porcelain laminate veneers, anterior ceramic partial-coverage crowns 16
7. Crowns, fixed partial dentures, telescopic crowns, implant-supported restoration 24
7.1 Anterior crowns 26
7.2 Posterior crowns 32
7.3 All-ceramic fixed partial dentures 36
7.3.1 Anterior fixed partial dentures 36
7.3.2 Posterior fixed partial dentures 39
7.4 All-ceramics for telescopic crowns 43
7.5 Implant abutments, and implant-supported crowns and fixed partial dentures 45
8. Indications for ceramic materials 48
9. Shade selection 49
10. Luting techniques 51
10.1 Adhesive bonding of feldspathic porcelain 52
10.2 Step-by-step procedure for intimate adaptation 56
10.3 Conventional luting procedures 62
11. Try-in, adjustment, and polishing procedures 64
12. Removing all-ceramic restorations 66
13. Intra-oral ceramic repair 67
14. Rationale for all-ceramic restorations 68
15. Clinical results 70
16. Ceramic and CAD/CAM systems 73
17. Literature on all-ceramics 84
18. Society for Dental Ceramics: Purpose and intent 90
19. From the practice for the practice 91
20. Overview of dental ceramics – ceramic systems (fold-out page)

Foreword
4
Ceramics in dentistry –
a success story
Foreword
to the English edition
Dear Reader,
The ceramics handbook “All-Ceramics at a Glance” for dentists and dental technicians was
first published in 2006 in German for the German-speaking countries. The concise descrip-
tion of treatment and insertion procedures with all-ceramic restorations was enthusiastically
accepted by the specialist dental community to the extent that all copies of the first edition
rapidly sold out. Moreover, dentists and dental technicians in other countries also showed
interest in this handbook. This motivated the authors and the editors, the Society for Dental
Ceramics, to publish an English-language edition.
One of the concerns of our Society is to support a minimally destructive, highly effective
and esthetic treatment of diseased teeth. Our goal is to give an overview and specific
recommendations for treatment planning and therapy based on our clinically proven
expertise. Our clinical long-term data are an important basis for the predictability of treat-
ment success. This is to ensure that patients receive long-lasting, durable restorative care
through modern, practice-proven, and evidence-based procedures.
The fact that all-ceramic restorations quickly became established as a treatment option
demonstrates that dentists and patients alike have accepted the concept. Nevertheless,
development continues. New ceramic materials, processing methods, and luting techniques,
as well as the extending range of indications, all demand attentive, competent advisors who
can support dentists and dental technicians in word and deed. In addition to providing a
platform for the exchange of experience, the Society for Dental Ceramics ensures that the
knowledge gained is passed along: through a quality assurance project with dentists in
private practice, at symposia, in publications, and through personal contacts.
European initiators and co-authors representing the English language version issue cordially
invite all readers and professionals in the field to participate in our work and spread
the knowledge of treatment with all-ceramic restorations. Dentists are also invited to get
involved in quality assurance with the help of the Ceramic Success Analysis, a computer-
guided program of the Society for Dental Ceramics. Our office would be happy to provide you
with more detailed information also about local quality assessment groups.
Chairman of the Board
Society for Dental Ceramics
Arbeitsgemeinschaft für Keramik
in der Zahnheilkunde e.V.

Foreword
Our thanks go to Professors Frankenberger, Kern, Kunzelmann, Mehl, Pospiech,Tinschert and
all others for their collaboration on this handbook. Their contributions, illustrations, photos
and figures updated and supplemented our understanding of the materials-science and
clinical aspects of dental ceramics.
July 2007
In the name of all authors,
Ariel J. Raigrodski DMD, MS, Seattle WA, USA
Dr. Bernd Reiss, Malsch, Germany
Howard E. Strassler DMD, Baltimore MD, USA
Howard E. Strassler DMD
Professor and Director of Operative Dentistry,
Dept. of Endodontics, Prosthodontics,
and Operative Dentistry, University of Maryland
Dental School, Baltimore
5
Ceramics in dentistry –
a success story
Ariel J. Raigrodski DMD, MS
Associate Professor and Director, Graduate
Prosthodontics, Dept. of Restorative Dentistry,
School of Dentistry, University of Washington,
Seattle

2.
6
All-ceramics –
customized, esthetic
and metal-free
All-ceramics is the term for restorations consisting solely of porcelain, without any metal sup-
port. Ceramics are abrasion resistant, have light-transmitting and light-fracturing properties,
are absolutely color stable, and enable invisible transition of the restoration margin into the
dental tissues. The materials are relatively chemically inert and are bioneutral in comparison
to other restorative materials in the mouth; they are insoluble and therefore biocompatible.
The durability of ceramics may even exceed that of high-noble casting alloys. During the
industrial manufacturing process, the mineral building-blocks of ceramics can be selected
and adjusted to yield ideal optical properties, in order to reproduce in a restoration the full
range of natural tooth shades.
A characteristic property of ceramics is its brittleness and, when compared to metal, its low
flexural strength and fracture toughness. Ceramics are resistant to high compressive stresses
but susceptible to tensile forces. In dental treatment, ceramic restorations may require more
attention to clinical detail in terms of both preparation design and insertion procedures. For
a given indication, ceramics must be carefully chosen and the anatomical requirements must
be met. In the dental laboratory, careful attention to detail during fabrication is necessary,
particularly when grinding the ceramic framework. To date, these challenges can be met
with the appropriate available techniques. Research-proven systems are now available for
manufacture and insertion. The low fracture resistance of individual ceramic systems can be
clinically compensated for by adhesive bonding to tooth structure.
All-ceramic inlays and onlays, laminate veneers, crowns, and fixed partial dentures are gain-
ing increasing popularity due to their excellent esthetics and biocompatibility. To meet the
high demands of mechanical loads in the oral environment, high-quality industrially pre-
fabricated ceramics, which can be processed in CAD / CAM systems, are the primary choice.
The surfaces of restorations made of industrially prefabricated ceramics can be individualized
and characterized. Their advantage over layered restorations lies in the improved material
properties and higher fracture toughness of the ceramic blanks manufactured under stan-
dardized conditions.
Ceramic materials are translucent like the
natural tooth. Crystals reflect incident light,
direct the coloration into the deeper layers,
and together with the veneering porcelain
provide the foundation for outstanding
esthetics.
Fig.: Edelhoff

3.
Patients tend to appreciate extensive consultation
to clarify and educate on the functional and esthetic
treatment options with all-ceramic restorations.
Photo: SDC/AG Keramik
7
Ceramic inlays replace amalgam restorations.
Photo: Leistner
Proven
clinical applications
In terms of esthetics and biocompatibility, ceramics are the materials of choice. Today,
dentists and dental technicians alike are able to create ceramic restorations which are in no
way inferior to their natural counterparts regarding shape, surface-texture,
shade, transparency and translucency.Adverse reactions such as allergies or toxicity are relati
vely rare
even with metal
alloys used in dentistry. However, even high-noble metal alloys are susceptible to corrosion if
processed inadequately.Thus, ceramics are the ideal alternative, because they are chemically
inert and do not dissolve in the oral cavity.
For the following restorations, all-ceramic materials with different physical properties have
b e e n
proven effective and successful with clinical evidence supporting their appropriateness and e
fficacy:
• Adhesively luted inlays, onlays (Class I, II and V)
• Adhesively luted partial-coverage crowns (covering several cusps)
• Adhesively luted Class IV restorations
• Adhesively luted laminate veneers in anterior-tooth and premolar areas
• Adhesively or conventionally luted anterior and posterior crowns
(also for full-mouth reconstruction with restoring the vertical dimension of occlusion)
• Adhesively luted crowns with endodontically treated teeth
(with retention in the pulp chamber without a post)
• Adhesively or conventionally luted anterior 3-unit fixed partial dentures
• Adhesive fixed partial dentures of 2 – 3 units for restoration of edentulous spaces with
1 – 2 lingual wings, adhesively luted
• Adhesively or conventionally luted posterior fixed partial dentures with correctly sized
connectors, up to 4 units
• Primary copings to accept telescoping copings for removable partial dentures
• Implant abutments
• Implant-supported crowns and fixed partial dentures
• Retaining attachments, crowns with fixed peg attachment for retention.

4.
8
Clinical use
Misalignment of the anterior dentition
and occlusal anomalies can be corrected
with porcelain laminate veneers.
Photo: Hajto
General considerations:
The following pages offer a practical guide for clinical and technical considerations which
affect material selection for all-ceramic restorations.
The following points must be considered when selecting the type of ceramic that is appro-
priate to the treatment planned for different clinical indications:
• Which restorations are planned?
• How extensive is the tooth structure loss or the carious lesion?
• Where will the preparation finish-line be placed? Supragingivally, equigingivally,
or subgingivally?
• Are single-tooth restorations or fixed partial dentures required?
• Are the restorations in the anterior or posterior segments?
• Are there signs of parafunctional occlusal habits and/or bruxism?
• How are static and dynamic occlusal loads distributed?
• Is the restoration to be adhesively bonded or conventionally cemented?
• Is the occlusal scheme to be changed?
• Are there any discolorations of the dental tissues which must be concealed?
• What degree of transparency and translucency do the natural teeth possess?
• How much of the tooth is visible?
The broad range of possibilities offered by the currently available all-ceramic systems make
it necessary to perform meticulous data collection, diagnosis and treatment planning prior to
beginning treatment, because the preparation, fabrication, function and longevity of the
restoration depend on it. Physical and anatomical conditions have to be taken into consider-
ation, as well as the desires and goals of the patient.

5.
9
Preparation design for ceramic inlays. The isthmus
width and thickness should not be less than 1.5 mm
occlusally. At the preparation finish-line, care should be
taken to create a nearly vertical transition to the
tooth cavo-surface (ca. 70 – 110°).
Fig.: Mehl
ca. 90°
ca. 90°
min.
1.5 mm
All-ceramic restorations are almost completely
chemically inert and function as an “insulator” between
metallic restorations.
Photo: Manhart
All-ceramic inlays,
onlays, and posterior partial-
coverage crowns
Different metals are not only esthetically unpleasing,
but can also pose biocompatibility risks.
Photo: Manhart
Indications
All-ceramics are suitable for treating all acquired defects and replacing missing tooth struc-
ture of single teeth.
For partial coverage restorations placed with adhesive bonding, it is essential to use a den-
tal-dam to ensure moisture control.
In contrast to conventional direct restorations and partial coverage crowns, the advantage of
adhesive bonding to enamel is that even thin, structurally compromised cusps do not neces-
sarily have to be covered.
For the following clinical scenarios, all-ceramic restorations should not be considered:
• Extremely shallow and narrow cavities where the physical properties of the porcelain
cannot be fulfilled (minimum layer size)
• An alternative treatment: extended fissure sealing and use of a direct composite-resin
restoration
• If moisture control cannot be maintained
• Given bruxism or suspected parafunctional habits, and less than ideal occlusal
relationship, an occlusal heat-processed acrylic resin appliance to protect the teeth and
restorations during the night should be considered.
Glass ceramics are the material of choice for ceramic inlays, onlays and partial coverage
crowns, because they can best mimic dental enamel. Such restorations must be adhesively
luted.
Preparation design
The following features should not be included in the preparation design for adhesively
bonded all-ceramic restorations:
• Bevels
• Dentin support of enamel
• Extensive retention forms.
Enamel margins are not absolutely necessary. Nevertheless, it must be possible to apply
dental-dam where cavity margins are at or below the gingival margin. Margins which are
subgingival can cause problems in achieving a durable dentin-composite bond and can
be problematic in the removal of excess composite-resin cement after seating and poly-
merization.
The use of adhesive techniques make it possible to create largely defect-oriented, tooth-
structure conserving preparations. Occlusal contacts near inlay finish-lines should be
avoided.

5.
10
All-ceramic inlays, onlays,
and posterior partial-coverage
crowns
Residual tooth structure with extensive cavities.
Cuspal coverage is planned with adhesively
bonded ceramic inlays.
Photo: Mehl
Recommended types of diamond instruments for
the preparation of ceramic inlays and onlays.
To finish the preparation finish-line diamond sonic and
ultrasonic tips are recommended for establishing
a well-formed margin. Photo: Mehl
Inlays made of pressed ceramic on the master cast.
Photo: Mehl
The preparation design should fulfill the following requirements:
• Opening angle of the cavity wall not more than 6°, diverging toward the occlusal aspect
(facilitates technical and clinical processing)
• The preparation should extend far enough interproximally, breaking the interproximal
contacts with the adjacent teeth, making the preparation’s finish-line accessible for
excess composite-resin cement removal
• Rounded internal line-angles between the preparation axial walls and pulpal floor
• The isthmus of an inlay preparation should be no less than the minimum of 1.5 mm
• Minimum occlusal thickness of 1.5 mm at the deepest point of the central fossa
• Extensions of the proximal anatomy of the restoration to achieve proximal contact
should not exceed 1.5 – 2 mm
• The cavo-surface margin should be a butt joint (90°) at the transition between restora-
tion and tooth structure (maximizes the resistance form of marginal areas)
• Complete cuspal coverage may not be necessary
• Cavity walls are finished with diamond rotary instruments with an abrasive grit of up to
40 µm
• If necessary, use reciprocating, safe-sided oscillating diamond files interproximally
(mechanically or ultrasonically driven)
• Do not leave any enamel extensions.
The preparation design requirements for onlays and posterior ceramic partial coverage
crowns are:
• Material thickness (at least 1.5 mm)
• An isthmus for improving retention is not necessary
• Internal edges and line angles must be rounded
• Complete cuspal coverage may not be necessary
• No long, branching cavity margins
• Axial depth with a remaining wall thickness of not less than 1 mm, especially in molars
and premolars
• Strive for box preparation with an internal 90° rounded shoulder
• Chamfer preparations and slightly sloped shoulders are acceptable.
Preparation design of nonvital teeth:
• The same preparation design as for inlays and partial coverage crowns.

5.
Ceramic inlays after 3 years in situ.
Photo: Mehl
11
Cuspal coverage with a conservative
partial coverage crown.
Photo: Kunzelmann
crowns
The provisional restoration – an additional procedure
Depending on the manufacturing method chosen, a provisional restoration of the cavity may
be necessary. If the restoration is made chairside, i.e., using a CAD / CAM system (e.g., Cerec)
in one session, a provisional restoration is not needed.
Provisional restorations should not be made of semi-plastic materials, but of mechanically
stable Bis-GMA or PMMA resin. These materials are wear resistant and will provide posi-
tional stability for the tooth preparations.
Alternatively, the resin coating technique of immediate dentin sealing may be employed.
Recommended clinical procedure: apply dentin adhesive immediately after cavity preparation,
then finish enamel margins. Make an impression of the cavity, insert a provisional restoration
with eugenol-containing cement (so the adhesive does not completely polymerize). Prior to
the insertion of the definitive restoration, clean the cavity, reapply dentin adhesive, insert the
restoration definitively.
Shade selection
• Selection should be made prior to starting the preparation. If amalgam restorations
are being replaced with a ceramic restoration, the shade should be selected after the
defective restorations and caries are removed (see page 49).
Impression making
• When a chairside CAD / CAM system is used, the impression is made using a 3D
intra-oral camera directly in the mouth.
• If the restoration is to be fabricated in the laboratory, a conventional impression is
necessary for making the dies and for the indirect procedures necessary for the fabrica-
tion of the restoration by the dental laboratory.
Laboratory procedures
The following steps are performed for inlays, onlays and partial coverage crowns:
• Shade selection, determination of customized coloration (shade mapping)
• Fabrication of the master cast: type IV dental stone, dentin-colored composite-resin or
ceramic stumps are used (only for feldspathic ceramics)
• Use of a die spacer for cement space (in CAD / CAM milling, the software performs
this step).

5.
12
A partial coverage crown digitally constructed,
with 3 reconstructed cusps, using the Cerec system.
Photo: Sirona
crowns
The CAD / CAM technique enables automatic milling of
the full-contour restoration in 10 – 20 minutes.
Photo: Sirona
• Strict observance and following of manufacturer’s recommendations for wall thickness to
prevent internal stresses and cracking, and avoid air entrapment and surface defects
during fabrication is essential for the longevity of the restoration
• Coordination of occlusal concepts with the dentist to minimalize time required
for occlusal adjustments on the restoration by grinding, include adjustment of the
opposing dentition
• Fitting of the restoration on a solid unsectioned cast
• If necessary, sandblast the inside of the inlay or partial coverage crown (corundum
50 µm) for cleaning and surface conditioning; do not abrade the margins.
Chairside procedure
For inlays and partial coverage crowns made chairside, CAD / CAM technology performs the
following steps:
• Restoration is constructed on the screen; strict observance of manufacturer’s
recommendations on layer thickness to prevent stresses and cracking; occlusal concept
is followed to ensure minimal grinding for adjustments
• Automatic milling of the full-contour restoration
• Removal of the milling peg and polishing.
Insertion
• Try-in of the ceramic restoration without pressure and without occlusal evaluation
• Checking the interproximal contacts and the marginal seal with silicon (low viscosity) fit
checker or powder disclosing agent
• Color evaluation by trying-in with glycerin gel
• Be sure to completely remove disclosing agents and completely clean the restoration
after try-in
• All provisional cement must be cleaned from the preparation
• Moisture control with dental-dam is mandatory when using composite-resin cements for
adhesive luting
• Etching and conditioning of the cavity
• Etching and conditioning the restoration with hydrofluoric acid and silane only shortly
prior to insertion (chairside)

5.
13
Adhesive luting of the restoration requires conditioning
the enamel and/or dentin and the ceramic surface.
Photo: Frankenberger
• Apply silane, let evaporate 3 – 5 minutes
• Insertion with dual-cured composite-resin cement
• “Total-etch technique” is suitable for luting
• Apply glycerin gel at the margins prior to curing
• Remove excess composite-resin cement prior to removing dental-dam
• Check occlusal contact and adjust on the luted restoration
• Polish the adjusted areas.
The adhesive bonding process is described in detail in Chapter “Luting Techniques“, page 51.
Trimming and polishing
• Check, adjust, and re-check occlusion
• Remove the composite-resin excess cement, use rotary finishing diamond instruments
and finishing strips (40 µm, 25 µm)
• Polish
• Fluoridation of the enamel surface that was treated with etching gel.
Final steps
• Check for excess cement
• Check the occlusion
• Final polish
• Fluoridation of the enamel surface
• Schedule recall with the patient (dental prophylaxis).
crowns

5.
14
Procedure for restoring a cavity with a ceramic inlayAll-ceramic inlays, onlays,
crowns
Amalgam fillings to be replaced by ceramic inlays.
Etching the cavity margins with phosphoric acid.
Treatment step Helpful hints Instruments / materials
Caries diagnostics Repeat after removal of Mirror, fiberoptic transillumination (FOTI),
existing fillings bite-wing radiographs
Shade selection Moist tooth, natural light, no Proprietary shade guide of the composite
bright colors like lipstick system (or Vita Color Ring)
Impression making for For indirect fabrication correct Tray, impression material
provisional restorations provisionals if needed
Marking occlusion Avoid placing preparation margins Occlusal papers and ribbons (12 µm)
points in occlusal contact areas
Placement of wedges Warning: do not injure gingival Wooden wedges
papillae or damage adjacent teeth
during preparation
Preparation, caries Minimum cavity depth (inlay layer Carbide round bur, preparation diamonds
excavation thickness at least 1.5 mm) (80 µm), finishing diamonds (40 µm)
Cavity cleaning Disinfection H2O2 (3 %) or CHX (0.2 %)
Treating the dentin lesion If dentin is exposed close to the Apply calcium hydroxide compound –
(cp), when needed pulp (< 1 mm residual dentin aqueous Ca (OH)2 suspension
thickness) (e.g., Calicur, Calxyl)
Base Shallow cavities: no base; Glass-ionomer cement (capsule
deep cavities: cover with base compounds, e.g., Ketac Bond).
or partially block Apply in excess, prepare down
when hard
Finishing the cavity “Rounded” inner edges; no bevelled Finishing diamonds (25 µm),
edges as the ceramic will break perhaps intra-Eva head (61 LA) and
there; no thinly attenuating marginal Eva files (reciprocating) cavisshape,
areas, Soflex disks occlusally if bevelshape: 25 µm or Sonicsys
needed (F grit), marginal smoothing (mini: torpedo attachment)
Elastic impression Try in mouth tray, block off distally, Already prepare tray (stops);
taking with polyether occlusal stops, if needed block select based on situation model; elastic
(Impregum) or large undercuts under pontics using impression tray or hydrocolloid stick
polysiloxane: first fill alginate syringed under these to individualize; retraction cords, cord
tray, then inject, block areas (fixed partial denture units), inserting instrument or Heidemann spatula,
out fixed partial observe manufacturer’s curing elastic impression material
dentures in same jaw time! (e.g., Impregum/Pentamix, Impregum syringe)
Facebow, Where occlusal situation is Facebow set, Regisil PB
occlusal record ambiguous or extensive restorations
exist, e.g., serial inlays
Elastic impression of Already possible previously Elastic impression tray alginate
opposing jaw
Construction and Isolate cavity, block cervical under- Esp. where periodontally diseased
insertion of provisional cuts, air-bubble-free injection of dentition exists, total impression,
restoration provisional material into total preferrably vacuum-drawn heat-treated
impression using a syringe, observe polyvinyl; paraffin oil, Protemp II,
manufacturer’s curing time! Check Provicol, milling cutter + laboratory
occlusion, determine temporary’s handpiece, occlusal papers,
layer thickness to check preparation paper holder
depth, insert with eugenol-free
cement

5.
Procedure for restoring a cavity with a ceramic inlay
15
Ceramic reconstruction of teeth 44 – 46.
All photos: Kunzelmann
Insertion of a ceramic inlay with removal
of excesses.
crowns
Treatment step Helpful hints Instruments/materials
Removal of provisional Do not damage cavity margins Claw forceps, scaler
restoration
Tooth cleaning Polishing paste (e.g., Zircate),
polishing cup or brush
Inlay try-in No occlusion check, just check fitting Dental floss, loupes;
accuracy and approximal contacts if needed “softprobe” and fine diamond
(perhaps with wedging) abrasive tips
Dental-dam placement When using clamps, do not injure Dental-dam sheet – medium; frame,
tooth or gingiva if needed clamps and forceps, Wedjets
(Hygienic) (expensive), alternatively:
rubber tabs
Adhesively pretreat Etch ceramic inlays 60 s; dilute or HF (e.g., Vita Ceramics Etch),
inlay (etch, silanize, neutralize HF before disposal; let silane silane solution (e.g., Monobond S),
bond) solvent evaporate (5 min); do not cure bonding agent (see DBA), brush,
dentin bonding agent (DBA); in many receptacle for solutions, diamond-
cases laboratory will etch the ceramic coated tweezers
Pretreat tooth (etch Strictly follow manufacturer’s Phosphoric acid and application syringe,
enamel and / or enamel instructions; touch primer and dentin adhesive and bonding agent,
and dentin, dentin adhesive monomers only with a brush, several brushes or applicators
and bonding agent) enamel 30 s, dentin 15 s
Mix and apply luting In deeper defects use only dual-curing Luting composite (e.g., Sonocem,
composite composites; adapt luting composite to Variolink Ultra), spatula, block, ultrasound
all cavity walls with a spatula insertion device
Insert inlay Carefully press in inlay, if needed Diamond-coated tweezers,
use ultrasound device to bring it into if needed ultrasound device with
definitive position (for 3 to 5 s) with special attachment
Remove excesses Very carefully check for excesses Dental floss, scaler, loupes
approximally
Apply glycerine gel Necessary if excesses are completely Airbloc, application syringe
removed before curing
Light curing At least 40 s from each side Polymerization lamp,
perhaps protective eyewear
Remove dental-dam Check to ensure no bits of dental-dam clamp forceps, if needed
dental-dam remain scissors or dental floss, scaler
Probe gingival sulcus Cured excesses of DBA often remain Scaler / curette
otherwise overlooked in the sulcus,
despite rubber-dam
Occlusion check Also check latero- and mediotrusion If needed fine-grain diamond
instrument
Polishing Do not treat adhesive joint with Polish adhesive joint areas with
abrasive polishing paste, otherwise alumina disks (Soflex), ceramic surfaces
groove-like abrasions form if needed with diamond polishing
paste or ceramic polisher
Fluoridation Use clear fluoride varnish Elmex fluid or Fluorprotector
Follow-up Check restoration again a few Mirror, probe, loupes
days later; excesses are then
easier to see

6.
16
Porcelain laminate veneers,
anterior ceramic partial-
coverage crowns
White spots on facial surfaces of 11, 12, 21, 22.
Minimally invasive preparation with no wrapping of
incisal edge. Veneers fabricated with Cerinate porcelain,
adhesive material Visar-Seal and Ultra-Bond luting
cement (Den-Mat) 15 years postop.
Indication diastema closure. The patient viewed
a diagnostic wax-up to accept treatment. Preparation
minimally invasive, flattening of the facial surface with
wrapping of incisal edge to reinforce the porcelain
extension closing the diastema. No cervical chamfer.
All photos: Strassler
Defining terminology
All-ceramic veneers and adhesively luted ceramic partial-coverage crowns are also referred
to as ceramic facings, laminates, laminate veneers, anterior-tooth partial coverage crowns,
and veneer shells.
Based on an official statement by the DGZMK (GSDOM, German Society of Dentistry and Oral
Medicine), a partial-coverage crown is a restoration in which, when in a defect-oriented
preparation, the incisal edge and/or the interproximal surfaces are completely or partially
included in the tooth preparation.
Indications
The porcelain laminate veneer is not a restoration limited only to the anterior dentition; it can
also be applied to premolars and molars. Veneers and ceramic partial-coverage crowns may
often make it possible to avoid a complete-coverage crown. The veneer is indicated for
• Correcting tooth shape
• Correcting tooth position and diastema closure
• Restoration of fractured teeth
• Shade corrections of discolored natural teeth which may be caused by fluorosis,
endodontic staining or tetracycline staining
• Repair of prosthetic elements with ceramic or composite veneers
• Correcting static and dynamic occlusion, bite position changes (palatal canine veneers,
occlusal surface veneers), occlusal shells, rebuilding occlusal surfaces.
Materials and manufacturing
To meet high esthetic demands, ceramic veneers are almost exclusively made of silicate
ceramic (glass ceramic). Manufacturing procedures include:
• Pressing (e.g., Empress and others)
• Additive construction by layering of optimized glass ceramic for inlays and veneers
(comparable to veneer ceramic)
• Subtractive construction by milling feldspathic ceramic blanks (e.g., Vitablocs, ProCAD,
EmpressCAD, Everest G-Blank, Procera Laminates).

6.
17
Preparation design for all-ceramic partial-coverage
crowns, which in the anterior region corresponds
to a veneer preparation. Interproximally and palatally,
all defects are Included in the preparation.
Photo: Pröbster
Feldspathic ceramic restorations after first firing.
Defect-oriented preparation was performed.
Photo: Pröbster
The veneers with Cerinate porcelain, Visar-Seal adhesive
resin and Ultra-Bond as luting cement, 20 years postop.
Photo: Strassler
coverage crowns
Customization
The following staining techniques are recommended:
• External ceramic stains applied labially
• Composite colorants (no ceramic stains) applied to the internal surface of the veneer;
the shading effect depends on the layer thickness and the translucency of the ceramic
• The layering technique, possibly combined with a base of pressable glass-ceramic (e.g.,
Empress) or milled feldspathic ceramic (e.g., Vitablocs).
Esthetic appearance
The quality of the veneer’s blending with the natural dentition depends on
• The color stability of the veneer foundation
• The precision of the marginal fit and placement
• Shade variation.
Getting ready
First, the following must be discussed with the patient:
• Shape and shade ideas, also characteristics such as custom stains and cracks
• Performing excursive movements or mounted casts allow for analysis to make it possible
to determine whether/to what extent shape modifications can be accomplished
• Excessive contacts on the incisal edges may lead to delamination and fracture of the
porcelain, especially if anterior the teeth are lengthened.
The following can be used as aids:
• Diagnostic wax-up
• Diagnostic mock-up
• Imaging (digital modifications of clinical photographs).

6.
18
coverage crowns
Inadequate anterior composite-resin restorations
and incisal fracture of ceramic veneers on teeth 11,12,
21, 22
The following information should be documented and communicated to the dental techni-
cian using the laboratory work authorization:
• Shade selection
• Shade details, e.g., by indicating light/dark boundaries, characteristics
• Form of the face with smile lines, lips, tooth shape, occlusion, gingiva (with photos)
• Shade selection in the lab, because the lighting there is the same as during the
fabrication of the restoration. The dental technician may also determine the shade with
the dentist and patient in the practice
• Alternative: The dental technician creates custom ceramic samples (just for dentin shade)
so that the dentist can select the shade with the patient and thus facilitate good
coordination with the laboratory process.
Preparation and preparation design
Prior to the tooth preparation appointment, the following should be conducted:
• Tooth cleaning 1 week before treatment (during this time, periodontal inflammation
present can heal, remove all plaque/deposits)
• Plan for tooth bleaching as a pretreatment, if necessary
• Shade selection
• Make a diagnostic wax-up and use it to fabricate preparation template/guide, provide
this information to the dental technician if positional changes are planned
• Make a silicon matrix to check preparation thickness
• If necessary, carefully retract the gingiva with retraction cords to avoid injury.
Note: Remove cords during preparation
• Construct the provisional restoration.
When making multiple ceramic veneers, attempt to work as symmetrically as possible.
If required, replacement of existing direct restoration should be included in the preparation
(defect-oriented adhesively luted partial-coverage crowns). The preparation finish-line must
then overlap the existing direct restorations.
To ensure conservative tooth reduction, employ only a finishing diamond instrument
(25 – 40 µm):
• The enamel layer should largely be conserved
• Acid-etching provides for better retention than a coarse-grained diamond.
Diastema and inadequate composite-resin restoration
Ceramic veneers on teeth 11, 12, 21, 22
All photos: Hajto

6.
19
Preparation of tooth 13 for a veneer.
Etching with phosphoric acid.
Insertion with excess of composite-resin cement.
All photos: Kunzelmann
coverage crowns
To establish adequate tooth reduction and depth marking, the following must be examined
and evaluated:
• Age-dependent tooth color, existing discoloration
• Keep in mind that with increasing age, the enamel becomes thinner due to erosion,
abrasion, and attrition
• Necessity of alignment correction as indicator of the thickness of the veneer
• At least 0.7 mm thickness of ceramics is required in order to attain discernable shade
correction
• Carefully consider the balance between conserving tooth structure and achieving the
required ceramic thickness to attain the desired esthetic effect
• Prepare finish lines even if the ceramic is very thin, because it allows the dental
technician to recognize preparation limit and is important for the definitive positioning
of the veneer during insertion procedures.
Required preparation depth into enamel is established by
• Setting horizontal orientation grooves using groove cutter or round bur.
Cervical, incisal, interproximal, palatal preparation technique:
• Buccal enamel reduction
• “Wrapping” the incisal edge, in case crown lengthening is necessary
• Shaping of incisal overlay (minimum thickness 1.5 mm); if needed, “wrapping” the edge
toward the palatal aspect of the tooth
• Extend the preparation into the interproximal areas
• Place the interproximal margins in the non-visible area
• Use a cervical chamfer at the finish-line
• Place the finish-line equigingivally and/or slightly supragingivally, depending on smile
line of the lips
• In color masking scenarios, a certain layer thickness is also necessary at the the finish-line
• For diastema closure, prepare far enough palatally (convex shape)
• Set visible preparation limits
• Maintain minimal interocclusal distance.

6.
20
coverage crowns
Fig. 1: Function-correcting veneer: On the attrition sur-
face of the mandibular canine, a small kidney-shaped
cavity was prepared in the exposed dentin core in order
to lute the incisal edge buildup (Empress) in the right
position.
Fig. 2: Correction of function and canine buildups
with palatal veneers (Empress) on the canines –
in situ since 1992. These veneers replaced the
previously usual precious metal pinledges.
Photos: Stachniss
The Cerec 3D system makes the contralateral replica of a natural anterior tooth possible for
constructing a same-shape veneer for the adjacent tooth.
Veneers can also be used to correct the function of occlusal surfaces and to build up canines
(see Figs 1 and 2).
Tooth reduction dimensions:
• Partial veneer (maxillary incisor), incisal third, mesial aspect, horizontal extension
4.0 mm, vertical extension 3.5 mm, depth of 0.7 mm, incisal reduction 1.0 mm
• Partial veneer to reconstruct canine guidance, horizontal extension 4.0 mm, depth
0.7 mm, incisal reduction 1.0 mm
• Partial veneer (mandibular incisor), incisal third, circular edge up, margin 3.0 mm apical
to the incisal edge, depth 0.7 mm, incisal reduction 1.0 mm
• Traditional veneer, conservation of interproximal contacts, margins as chamfer,
margin 0.5 mm incisal to the CEJ. Labial reduction: cervical third 0.2 – 0.3 mm, middle
third 0.5 mm, incisal third 0.5 – 0.7 mm
• Complete veneer with deep wrap-around, with removal of interproximal contacts,
margin 0.5 mm incisal to the CEJ. Incisal reduction 1.5 mm (tooth 41), 2.0 mm
(teeth 11, 13).
Elastomeric impression making
• Place retraction cords
• With intact interproximal contacts, insert matrix strips in the interproximal contacts
(they are integrated in the impression, makes it easier to separate the teeth)
• Gingival retraction
• Use of polyether or addition silicone (vinylpolysiloxane), retraction cord remains in situ
• If remaining tooth substance is thin, a reinforcement groove should be cut into the
elastomeric impression after removal, in order to prevent breakage of the tooth in the
master stone cast
• If necessary, make a composite-resin stump.
With chairside CAD / CAM procedures (e.g., Cerec), conventional impressions are not neces-
sary. Instead, data are acquired intraorally with a triangulation camera to create a “digital
cast.” The diagnostic mock-up can be copied three dimensionally and serve as a shape
template for the ceramic veneer.

6.
21
Paper-thin veneers
of alumina ceramic by Procera.
Photo: Nobel Biocare
Diastematas, incisal edge fracture,
and tooth-position anomalies are modified
with ceramic veneers.
Photos: Hillmann, Linne†
coverage crowns
Dentin protection and provisional restorations
• Preferred option: adhesively pre-treat exposed dentin upon insertion. Alternative option:
apply DBA (dentin bonding agent) prior to making a definitive impression, e.g.,
where hypersensitivity exists etc.
• If esthetic demands are very high: insert a lab-manufactured provisional veneer
• Otherwise: in situ with elastomeric impression or vacuum-formed tray
(use sharp-relief tray)
• The disadvantage of direct application of the provisional material is that trimming
can damage and compromise the preparation finish-line from which an impression has
already been made
• Insertion: spot etching, adhesive, and low-viscosity flowable composite (e.g., Heliobond)
• Remove excess prior to curing
• Instruct the patient to minimize the function and load with the provisional restoration.
Provisional restorations for partial-coverage crowns
For partial-coverage crowns with classical retention, use eugenol-free provisional cement.
Laboratory fabrication
• When using rigid elastic impression materials, the danger of breaking off stone teeth
exists upon removing the impression tray
• If the transition from preparation border of veneer 1 to the contact point of the adjacent
veneer 2 is too tight, the dentist should separate the teeth with matrices (Frasaco strips,
metal matrices); otherwise a master cast cannot be constructed. Especially with
CAD / CAM production, the preparation limit must be clearly discernable
• The difference in resistance between pressable ceramics and millable ceramics
(CAD / CAM) is not relevant, because the clinical longevity depends mainly on the
adhesive technique
• When hand-layering porcelain (stacked, fired technique) on a refractory die,
the thickness of the veneer can be reduced to 0.4 mm, and using a platinum foil
as a base, down to 0.2 mm
• Thicker layers enable greater color control and modifications, thinner layers are more
translucent
• The thermal expansion of the refractory investment must match that of the veneer
ceramic.

6.
22
coverage crowns
Perfect veneers after insertion.
Photo: Baltzer
Veneers made of pressable ceramic (Empress 1).
Photo: Hillmann, Linne †
• The layers consist of a) binder, b) dentin powder 1, c) corrective firing 1, d) corrective
firing 2, e) final firing
• Scheduling: plan 5 – 7 work days for the fabrication. Time requirement for a CAD / CAM
veneer made chairside: 1 – 1.5 hours.
Time requirements:
• Cast fabrication: 0.5 days
• Shade selection parallel to this
• Laminating and firing – 4 to 6 units per day
• Fitting and polishing: 0.5 day
• Transport and time allowed for repeating steps.
Insertion
• Try-in and adjustment option (try-in before noon, insert in afternoon, adjustment and
glazing in between)
• Try-in: glycerine gel, shade evaluation,interproximal contacts and marginal fit evaluations.
Ceramic pre-treatment:
• Given several veneers, proceed symmetrically from the center
• Etch veneer for 30 to 60 s with 5 % hydrofluoric acid (HF) (the laboratory will often etch
the porcelain)
• Apply silane, let the solvent evaporate for 5 min., blow dry
• Apply resin adhesive bonding agent to the ceramic surface.
Preparing the tooth for bonding:
• Absolute moisture control and isolation with dental-dam
• Protect adjacent teeth with matrices; this also facilitates removal of excess composite-
resin cement.
Shade assessment:
The choice of shade of the luting composite-resin cement can influence or determine the
resulting tooth color of the veneer. By using shaded try-in pastes (glycerin gel), different color
alternatives can be tested in vivo.

6.
Insertion procedures:
• Remove the provisional veneer and/or the provisional cement
• Retouch the area of the spot etching (fine-grain diamond)
• Use light- or dual-curing luting composite
• Acid etch tooth, apply adhesive to the tooth
• Handling the veneer with the diamond tweezers is more reliable than with the adhesive
stick
• Position the veneer with pressure but without diamond forceps (scratches ceramics)
• Stabilize the veneer using a brush holder with Fermit on the facial surface on the veneer
• Remove excess cement with probe (Heidemann) and dental floss
• Check the marginal integrity
• Light cure
• Tooth cleaning (e. g., with Occlubrush).
23
Veneers have a high survival rate.
Photo: Hirschfeld, Bellmann
Preparations for veneers.
Veneers of leucite-reinforced silicate pressed ceramic.
Photos: Edelhoff
coverage crowns

7.
24
Monolithic, anatomically milled complete-coverage
crown of silicate ceramic. Photo: KaVo / Ivoclar-Vivadent
Crowns, fixed partial dentures,
telescopic crowns, and implant-
supported restorations
Fixed partial denture framework of high-strength
zirconia, in part implant-borne, during try-in.
Photo: Tinschert
Range of indications of all-ceramic materials in prosthodontics
• Anterior crowns
• Posterior crowns
• Anterior fixed partial dentures
• Posterior fixed partial dentures
• Resin-bonded fixed partial dentures in the anterior area (Maryland fixed partial dentures)
• Primary copings for telescopic restorations
• Implant fixtures and abutments
• Implant-supported crowns and fixed partial dentures.
The foundation restoration
Foundation restorations (post and cores, and core build-ups) must be placed in order to
create simple structures. If irregular points and edges remain after caries excavation, they
make it difficult to achieve adequate and accurate fit. The esthetic appearance is likewise
influenced by irregular layer thicknesses in the restoration. Large variations in layer thickness
hinder the uniform transmission of light within the ceramic. For these reasons, natural tooth-
colored foundation restorations are essential, especially for the anterior dentition.
Materials
Further development in traditional veneering ceramics have led to a variety of modern ceramic
materials, which differ considerably in their properties.These ceramic materials can be classi-
fied into:
• Silicate ceramics, such as Empress CAD, ProCAD, Cergo, Everest G-Blank, Vitablocs –
lithium disilicate ceramics, such as Empress 2, e.max Press, e.max CAD
• Glass-infiltrated oxide ceramics such as In-Ceram Spinell, Alumina, Zirconia
• Densely sintered oxide ceramics, e.g., Procera crown copings (Al2O3 or ZrO2) and Procera
fixed partial denture frameworks (ZrO2)
• Partially sintered zirconia ceramics, Y2O3 partially stabilized, polycrystalline zirconia for
crown copings and fixed partial denture frameworks which will be then veneered, e.g.,
In-Ceram AL, Lava Frame, Cercon base, In-Ceram YZ, inCoris AL/ZI, Everest ZS-Blank,
e.max ZirCAD
• Densely sintered HIP zirconia for crown copings and fixed partial denture frameworks for
veneering, such as Everest ZH-Blank, DC-Zirkon.
All-ceramic fixed partial denture for Straumann
implants with full abutments. It was possible to create
torque protection during milling. Photo: Pospiech

7.
25
Fundamental distinctions:
Silicate ceramics fulfill high esthetic demands –
high-strength oxide ceramics are suitable for
frameworks (crowns, fixed partial dentures).
All-ceramic systems
Source: Pospiech
Silicate ceramics
Glass-rich silicate matrix
Multiphase structure
Crystalline phases, glass phases
Relatively low sintering
temperatures < 1000 °C
Feldspathic
ceramics
Ground feld-
spathic glass
(powder),
conventional
technical proces-
sing.
Example: usually
veneer ceramics
Vitablocs
Jacket crowns
Densely
sintered
Direct shaping of
the frameworks
System:
Procera
HIP
CAD/CAM
milling of a
high-strength
material
Systems:
DentoCAD
digiDent
Etkon
Everest
Neo Cynovad
Precident DCS
Presintered
blanks
CAD/CAM milling
with subsequent
final sintering
Systems:
Cercon
Everest
Etkon
in-Lab
LAVA
Zeno Tec
e.max ZirCAD
Glass
ceramics
Starting point
glass which
undergoes
a crystallization
process.
Example:
Empress
Empress 2
e.max Press
e.max CAD
Glass-
infiltrated
Partially sintered
alumina powder
(white blanks),
then glass
infitration
(30 vol %),
material of the
In-Ceram
system
ppos
Crowns, fixed partial dentures,
telescopic crowns,
and implant-supported restorations
Oxide ceramics
Characterization:
monophase and single-component
metal-oxides (> 90%)
polycrystalline ceramics
high sintering temperatures >1400°C
Glass
ceramics
Starting point
glass which
undergoes
a crystallization
process.
Example:
Empress
Empress 2
e.max Press
e.max CAD
Glass-
infiltrated
Partially sintered
alumina powder
(white blanks),
then glass
infitration
(30 vol %),
material of the
In-Ceram
system

7.1
26
Incorrect chamfer
finish-line.
“J-lipping” or steps are
contraindicated.
Correct chamfer finish-line.
A chamfer with a 6-degree
axial convergence is
ideal for the circular crown
margin.
Anterior crowns
Shoulder finish-line:
the rounded shoulder is
particularly suitable for
the telescopic crown
technique with
all-ceramic primary
copings.
The occlusal contact points
also determine the level of stress
development in the restoration.
Fig.: Pospiech. Source: Vollkeramik-
Kompendium, 3M EspeOrigin of tensile stress Origin of compressive stress
Indications
For extensive defects with loss of enamel and dentin.
The choice of ceramic is based on the loading of the crown (remaining dentition, dynamic
occlusion) and the optical properties of the material. However, the preparation design,
available space, at the axial walls and crown margin, and the desired luting technique also
influence the material selection.
In selecting the material, the following parameters are also considered:
• The type of foundation restoration
• Indications and materials for post and core systems
• Quality of the dentin (opacity, translucence, color)
• Shade selection: especially for anterior crowns, it is recommended that the dental
technician select the shade.
Preparation design
The general principles of metal-ceramic crown preparation are also valid for all-ceramic
crowns. The largest circumference of the tooth is at the gingival preparation limit. It must be
anatomically prepared, i. e., the shape and position of the tooth must be considered.
Occlusal surfaces and facets must be angled according to their original natural form. Thus,
reconstruction of the original anatomy with a uniform ceramic thickness is feasible without
overcontouring.The respective antagonistic surfaces should contact each other with occlusal
forces directed axially and thus achieve the highest possible compressive load. This mini-
mizes the prospect of developing tensile and flexural stresses which are detrimental for
ceramics. Feather-edge or knife-edge finish-lines are absolutely contraindicated.
The knife-edge finish-line
is unsuitable for all-ceramic
complete-coverage crowns,
because a correct, anatomi-
cal contour can never be
constructed. It is also
unsuitable for all-ceramics
because it can initiate ten-
sile stresses and fractures.
All Figs.: VITA Zahnfabrik

7.1
The edges and transitions must at least match the
radius of the abrasive stones in the milling machine.
Fig.: Pospiech. Source: Vollkeramik-Kompendium, 3M Espe
27
Thickness of framework and
veneering ceramics for lithium
disilicate ceramic crowns.
min.
1.5mm
Thickness of framework
and veneering ceramics for oxide
ceramic crowns (Al2O3, ZrO2).
min. 0.7 to
max. 2.0mm
min.
0.5mmmin.
0.8mm
Anterior crowns
Material thickness for free
silicate ceramic crowns.
max. 0,7–
2.0mm
min.
1.0mm
Depending on the material selected, an even rounded shoulder, or a deep chamfer should
be prepared.
A shoulder with rounded internal line-angles is preferable:
• Silicate ceramics such as feldspathic and glass ceramics.
A chamfer can also be used for ceramics with increased flexural strength (over 350 MPa)
such as:
• Lithium-disilicate ceramics
• Glass-infiltrated oxide ceramics
• Polycrystalline oxide ceramics.
The following framework thicknesses in the marginal area of anterior crowns must be
observed:
• For silicate and lithium-disilicate ceramics, 0.8 to 1.0 mm
• For oxide-ceramics, zirconia ceramics 0.5 mm.
The thickness of the veneering porcelain at the occlusal/incisal aspect:
• Maximum 1.5 to 2.0 mm, strive for minimal layer thicknesses.
Finish line placement for all-ceramic crowns with circumferential chamfer or circumferentially
rounded shoulder:
• Whenever possible, place the finish-line supra- or equigingivally
• A convergence angle of 4 – 6° is indicated.
Negative example:

7.1
28
Anterior crowns
Horizontal grooves with depth defined by ball diamond
diameter.
A silicon key to evaluate tooth reduction.
Internal gingivectomy
with a zirconium dioxide tip.
Photos: Pospiech
Process-dependent details should be discussed with the dental technician. The thickness of
the veneering ceramic should not exceed the given maximum, because of the prospective risk
of fracture and delamination.
The angle of convergence of the axial walls should be 4 to 6 degrees to allow for adequate
mechanical retention and resistance. The crowns must be seated definitively and firmly on
the abutment tooth without rotating. A merely linear fit at the crown margin and filling-in
the gaps with the cement is unacceptable.
For short clinical crowns, interproximal grooves 1 mm wide and 0.5 mm deep must be made
in order to ensure firm seating, resistance and retention.
Orientation during tooth reduction
A silicon matrix / key made of the dental arch prior to preparation is cut open horizontally
and vertically.The matrix facilitates the evaluation of the thickness of tooth structure already
removed (tooth reduction) in comparison to the initial condition.
Impression making technique
Fundamentally, every type of impression making technique is acceptable if the dentist has
had success with it. For optimal results, addition silicone (vinylpolysilane) or polyether
impression materials with the heavy body/light body technique are ideal, because
elastomeric impressions can be made without pressure and the materials are hydrophilic.
The chairside CAD/CAM system (Cerec) has eliminated conventional impression procedures
for crowns.A digital video impression (data) of the preparation is acquired with an intra-oral
camera.
Morphological data for the planned crown can be obtained from copies of an existing shape,
from various tooth databanks, diagnostic wax-ups, and by mirroring a contralateral tooth.
Tissue management
A perfect impression can only be made of an area which is visible and is kept dry. Finish-lines
placed deep in a gingival sulcus or at the level of the alveolar crest jeopardize the prospects
for a successful restoration. Therefore: expose the preparation finish-line and ensure
adequate moisture control and isolation.
Retraction cords are non-invasive and well suited for displacing subgingival finish-lines.
Application of epinephrine, aluminum chloride etc. has a local hemostatic effect.
For placing the cords, the double cord technique has proven effective: place a size-1 cord, cut
to fit. Place a size-2 cord. Then place a cotton roll, apply suction, compress cords. Make the
impression after 10 minutes. If the sulcus is shallow, remove the retraction cords prior to
making the impression.

7.1
29
The wall thickness of zirconia (Lava)
anterior crown copings can be reduced
down to 0.5 mm. This conserves tooth structure
and/or allows room for multi-layered veneers.
Photo: Edelhoff
Gingivectomy
Excess or diseased tissue is removed with a scalpel blade, electrosurgery or laser. A rotating
zirconia tip (turbine, max. rpm) without water cooling removes the gingival tissue via friction-
generated heat without pressure. Gingivectomy to achieve an esthetic result is sometimes
desired.
Provisional restorations
The provisional restoration can be constructed as for all other complete-coverage restora-
tions.
For difficult situations or high esthetic demands during the interim, a wax-up can be con-
structed on an anatomical planning cast. Marginal seams can be slightly reinforced, in order
to have some substance for trimming the provisional restoration.The cast is duplicated using
a vacuum-formed polyethylene sheet (1.0 – 1.5 mm thick).
Because the polyethylene sheet is transparent, photopolymerizing composite-resin can also
be used as the provisional material.The sheet should be slowly filled from the occlusal aspect
outwards in order to avoid bubbles.
In the elastic phase, the sheet is removed, excess material is trimmed with scissors, and
the sheet is replaced in position. After complete curing, trim and polish the provisional
restoration.
It is recommended that the provisional restoration be constructed prior to making the defin-
itive impression, because at that point it is still possible to determine whether sufficient tooth
structure has been removed. The provisional restoration can serve as an evaluation guide for
the amount of tooth reduction.
Provisional crowns are inserted with eugenol-free provisional luting cement.
No provisional restoration is needed if the anterior crown is made with a CAD/CAM sys-
tem in the practice and inserted during the same appointment.
Criteria for framework-based restorations
The procedures involved in framework fabrication and the time required depend on the
material selected and the fabrication system (pressing, slipping, CAD / CAM).
The framework design should allow for the application of veneering ceramic with a uniform
thickness. To avoid the risk of fracturing the veneering porcelain, it should not exceed a
maximum thickness of 2.0 mm, incisally or occlusally.
Anterior crowns

7.1
30
Anterior crowns
Preoperative condition for anterior crowns.
Photo: Hirschfeld
Anterior crowns with ZrO2 framework,
veneered on the cast.
A foundation restoration can facilitate the fabrication of a restoration with an optimal thickness
for both the coping and the veneering ceramics.
The ceramic restoration should only be finished (contouring etc. with fine-grained diamond abra-
sives in an air turbine or angled handpiece) under water cooling. This also applies to chairside
adjustments during framework try-in. In some cases it may be necessary to adjust the opposing
teeth. If this is done, a new opposing impression and cast must be provided to the dental lab.
Sharp-edged instruments, instruments with a low surface area, diamond separating disks – all of
these are contraindicated for corrective reshaping.The largest instrument that can accomplish the
task for a given adjustment is recommended to avoid spot overheating and notching.
It is advisable not to use a separating disk to open the gingival embrasures of fixed partial den-
tures at the connectors. After adjustments have been made, the surface of veneering ceramics
should be improved by performing final firing again or careful polishing, for example, with
diamond polishing pastes with a buff wheel.
Try-in procedures
The crown framework should be stable on final seating without rotation on the abutment tooth.
To test the accuracy of fit, a try-in with a dark, low-viscosity silicon impression material or fit
checker is recommended.
Depending on the extent of restoration or esthetic demands, a bisque bake try-in is recom-
mended. After the try-in, surface characterization and final glaze or final firing is conducted. Inter-
dental / interproximal areas should not be shaped or polished after this procedure is complete.
Chairside adjustment should only be done with a super fine-grained diamond (yellow or white
ring). Subsequently, diamond-impregnated silicon polishing tools are used for polishing.
Insertion procedures
For conventional metal-ceramic crowns and fixed partial dentures, it is often recommended that
the restoration be “test worn“ prior to definitive insertion. In terms of strength, this would be
conceivable for oxide-ceramic frameworks. However, the manufacturers of all-ceramic systems
explicitly warn against such a procedure, since removing the restoration, especially single crowns,
bears with it a high risk of damaging or fracturing the restoration.
If, in cases of esthetic and functional doubt (e. g., in the anterior region or extensive quadrant
restorations), temporary trial cementation of the crown cannot be avoided, this can only be done
with oxide-ceramic frameworks (see manufacturer’s specifications). The patient must be
instructed that the crown is not definitively cemented and therefore must not be subjected to
maximum loading during this short phase – up to a week. For trial cementation, the same
eugenol-free provisional cement can be used as for the provisional restorations. To facilitate
removal, some vaseline can be added to the mix. If this is done, the tooth preparation must be
thoroughly cleaned to remove any residual Vaseline before definitive cementation.

7.1
The choice of luting materials for definitive insertion depends on the ceramic material selected.
In general:
• Silicate ceramics are bonded with composite-resin cements.
• All-ceramic restorations made of lithium-disilicate and oxide ceramics may also be
conventionally cemented (glass-ionomer cement, resin-modified glass ionomer cement,
zinc-phosphate cement). The greater the remaining enamel proportion, the more
advantageous is adhesive resin luting.
The literature often reports a value of ca. 350 MPa flexural strength as the lower limit for con-
ventional luting. This value is not yet evidence-based and serves only as an approximate guide.
For more details on luting materials and adhesive mechanisms, see the chapter on luting
techniques, page 51.
31
Anterior crowns with Lava manufactured
frameworks in situ.
Anterior crowns

7.2
32
Molar crowns of In-Ceram
Alumina veneered.
Photo: VITA Zahnfabrik, Huiss
Posterior crowns
Ceramic
Material properties:
(E-modulus, KIC value
(fracture toughness))
Time
“Corrosion”
Luting
Type of cement
Modulus of elasticity
Polymerization shrinkage
Polymerization mode
Water sorption
Workability
Material
processing
Dental technician:
Accuracy of fit
Surface quality
Wall thickness
Dentist
Tooth substance
Dentin age
Dentin depth
E-modulus
Conditioning
Bonding
Adhesive procedures
Wetting
Preparation design
Prep. angle
Prep. finish line
Loading
Type of force distribution
Direction
Duration
Occlusal relationships
Crown
strength
The strength is influenced by the type
of preparation design, material selection,
and bonding to the remaining tooth.
Fig.: Pospiech. Source: Vollkeramik-Kompendium, 3M Espe
Indications
For extensive defects with loss of enamel and dentin.
Materials
All categories of materials are approved for single crowns; silicate-ceramics and leucite-
reinforced pressed ceramics (Empress) must be adhesively bonded.
Infiltrated or densely sintered alumina and zirconia ceramics as well as disilicate ceramic can
be used for crown copings for molars and can be conventionally or adhesively luted.
When in doubt, higher material strength should take preference over esthetic demands.
Factors affecting strength
The fracture resistance of crowns is based on several factors. The material selection and
long-term stability of the crown is influenced by the mechanical properties of the ceramic
and the masticatory loads (remaining dentition, dynamic occlusion), and is dependent on
both the abutment preparation and the condition of the foundation restoration (core buid-
up or post and core).The material is selected according to the discoloration of the abutment,
dentin quality (opacity, translucency), and the space available, while taking the planned
luting technique into consideration.
Luting
Type of cement
Modulus of elasticity
Polymerization shrinkage
Polymerization mode
Water sorption
Workability

7.2
33
Framework made of zirconia ceramic
can be colored like dentin.
Photo: VITA Zahnfabrik
Posterior crowns with framework of press-sintered
alumina oxide ceramic in veneered condition.
Photo: Procera
Shade selection
Select prior to initiating tooth preparation.
It is recommended to let the dental technician who is making the restoration also select the
shade.
For particularly high esthetic demands, the dental technician uses custom shade samples
which simulate the color of the dentin core. This is especially helpful with very thin, trans-
lucent restorations.
Preparation design
Depending on the material selected, an even rounded shoulder, or chamfer finish-line should
be performed.
A butt joint preparation with a rounded internal line-angle should be preferred for
• Silicates like feldspathic and glass ceramic.
For ceramics with higher flexural strength (over 350 MPa), a chamfer preparation can also
be selected:
• Lithium-disilicate ceramics
• Glass-infiltrated oxide ceramics
• Polycrystalline oxide ceramics.
The following minimum ceramic thicknesses must be maintained in the marginal areas of
posterior crowns:
• Silicate ceramic, lithium disilicate ceramic 0.8 –1.5 mm
• Oxide ceramic, zirconia ceramic 0.5 mm.
Occlusal layer thickness:
• Max. 1.5 – 2.0 mm, strive for minimum layer thickness. At least 2 mm under the cusps of
framework-free silicate crowns.
The margins of an all-ceramic crown with circumferential chamfer or circumferentially
rounded shoulder:
• Whenever possible, place margin supra- or equigingivally.
Circumferential chamfers or butt joint with rounded internal line-angles are recommended
as preparation finish-lines. A total angle of convergence of 4° to 6° is indicated.
Posterior crowns

7.2
Posterior crowns
34
Fig. 2: Minimum preparation depth for crowns of
oxide ceramic (Al2O3, ZrO2) copings
Preparation depth:
Crown margin at least 0.5 mm; buccal 0.8 mm
occlusal 1.5 – 2.0 mm
Fig. 3: Wall and layer thicknesses for crown
copings of silicate ceramic
Preparation depth:
Crown margin at least 0.8 mm; buccal at least 1.7 mm;
crown coping wall thickness 1.0 – 1.2 mm;
veneering ceramics 0.7 – 2.0 mm
Veneering
ceramics
min. 0.7 mm
max. 2.0 mm
Crown
coping
min.
0.8 –
1.2 mm
min.
0.8mm
min.
1.5mm
2mm
0.8mm
0.5mm
min.
1.5mm
min. 2 mm
A total angle of
convergence
4–6º
1.0 – 1.5 mm
0.8 mm
The various strengths of framework / coping ceramics influence the minimal preparation
depth and the wall thickness of the crown coping. High-strength ZrO2 ceramic copings
require thinner walls than copings made of silicate-ceramics.
The following points apply to minimal wall thicknesses and preparation rules: see Figs 1 to 5.
A reduction of the veneer layer thickness can be used for wall reinforcement of the crown
coping, especially with frameworks of Al2O3 or lithium-disilicate ceramic.
the veneering ceramic should not exceed the given maximum, because the risk of fracture
and delamination of the veneering ceramics would otherwise arise.
Tissue management, gingivectomy
The same considerations apply as for anterior crowns (page 28).
Impression making technique
Making impressions for all-ceramic restorations requires methods which are no different
from the ones used for other types of restorations. When working with chairside CAD / CAM
(Cerec), impression data are acquired with an intra-oral camera.
Morphological data for the planned crown can be obtained from copies of the existing
occlusal surface, from various tooth databanks, diagnostic wax-ups, and by mirroring the
contralateral tooth.
Fig. 1: Minimum preparation depth for framework-
free crowns with silicate-ceramic copings
Preparation depth:
Crown margin at least 0.8 mm; buccal 1.0 – 1.5 mm;
occlusal 1.5 – 2.0 mm; a total angle of convergence 4 – 6°

7.2
35
Fig. 5: Basic principles of framework design
for crown copings
The framework of Al2O3 or ZrO2 ceramic must support the
veneering ceramics. Where framework support is lacking, e.g.,
under cusps and marginal ridges, the danger of stresses under
masticatory loading arises. The crown coping may not possess
any sharp transitions or edges. The thickness of the veneering
ceramics must not exceed 2.0 mm.
Veneering
ceramics
min. 0.7 mm
max. 2.0 mm
No sharp
transitions
and edges
permited
The same steps are taken as for anterior crowns (page 29). No provisional restorations are
required for chairside CAD / CAM crowns.
Framework manufacture
The working steps depend on the selected ceramic material and the fabrication process as
related to different systems.The same considerations are valid as described for anterior crowns
(page 29).
Try-in procedures
The same considerations are valid as described for anterior crowns (page 30). Depending on
the restoration extent and / or esthetic demand, a bisque bake try-in may be recommended.
Insertion follows the same rules as described for anterior crowns (page 30).
Fig. 4: Wall and layer thickness for the anatomically
reduced crown of ZrO2 ceramic veneered
Preparation depth:
Crown margin at least 0.5 mm; buccal 0.5 – 1.2 mm;
crown coping wall thickness 0.5 mm;
veneer 0.7 – 2.0 mm
Lacking
framework
support
ZrO2-
Crown
coping
min.
0.5 mm
Veneering ceramics
max. 2 mm
Posterior crowns

7.3
36
Frameworks for a 3- and 4-unit
anterior fixed partial denture. Even on tooth 23
with the pronounced recession, the preparation ends
at the cementoenamel junction.
Photos: Pospiech
All-ceramic fixed
partial dentures
Range of indications:
• Anterior fixed partial dentures
• Posterior fixed partial dentures.
7.3.1 Anterior fixed partial dentures
Indications
• Restoring edentulous spaces
• Cantilever all-ceramic fixed partial dentures are indicated for replacing a maxillary lateral
incisor or mandibular incisors.
Limitations
No more than two pontics included in one fixed partial denture.
Exception: if the span length is small, up to 4 pontics are possible as in the mandibular
anterior region.
Connector design
In every case, the vertical height of the connector is to be given more volume than the hori-
zontal width. This increases the durability of the connector.
The connector of silicate-ceramic, lithium-disilicate ceramic framework should be designed
more carefully than one of oxide ceramics.
The space available for the connector can be easily determined using a periodontal probe.
Current CAD / CAM systems display the connector cross-sections and warn the user if the
construction has less than the minimum allowable cross-sectional area.
The fracture resistance of fixed partial dentures is based on several factors. The choice of
materials and the longevity of the restoration are influenced by the occlusal forces (remaining
dentition, dynamic occlusion) and dependent on the abutment preparation and the condition
of the foundation restoration. In addition, materials are selected with reference to the dis-
coloration of the abutment tooth, the dentin quality (opacity, translucency), and inter and
intra occlusal space available. While selecting the material of choice, the desired luting tech-
nique is taken into consideration, and careful thought is given to the material’s mechanical
properties.

7.3.1
37
Anterior fixed partial denture of lithium-disilicate
(Empress 2) and ovate pontics.
A lithium-disilicate fixed partial denture, 4 years in situ.
Photos: Edelhoff
Anterior fixed partial denturesMaterials for anterior fixed partial dentures
• Lithium-disilicate ceramics and infiltrated ceramics are indicated only for 3-unit fixed
partial dentures
• Lithium-disilicate ceramic are indicated for 3 units up to the 2nd premolar – such as
e.max Press, e.max CAD – luted adhesively or conventionally
• Infiltrated-oxide ceramics are indicated for 3-unit fixed partial denture framework – as in
In-Ceram Alumina, Zirconia, and densely sintered alumina ceramic such as In-Ceram AL
– luted adhesively or conventionally
• Sintered zirconia ceramic as multi-unit fixed partial denture framework – such as
Sirona inCoris AL/ZI, Procera Zirconia, Cercon Smart, Lava Frame, Everest ZS-Blank and
ZH-Blank, In-Ceram YZ, e.max ZirCAD, DC-Zirkon – luted adhesively or conventionally
• Removable telescopic fixed partial dentures: zirconia for primary copings and crown
frameworks
• Recommendation: When in doubt, material strength should take preference over esthetic
demands.
Shade selection
Select prior to preparation. It is recommended to let the dental technician who is making the
restoration also select the shade.
Preparation design
For the preparation of anterior fixed partial denture abutments, the same recommendations
apply as for anterior crowns (see page 26):
• Framework of lithium-disilicate ceramics
Reduction at crown margin at least 0.8 mm
Buccal reduction 1.0 – 1.5 mm
Incisal reduction 1.5 – 2.0 mm
• Framework of oxide ceramics (Al2O3, ZrO2)
Reduction on crown margin at least 0.5 mm
Buccal reduction 0.7 – 1.2 mm
Incisal reduction 0.7 – 2.0 mm
• Horizontal angle > 5° for CAD / CAM scanner
• Crown margin: chamfer or rounded shoulder
• Finish-line placement supragingivally 0.5 mm or coronaly, to protect gingiva
• Rounded line angles, no sharp edges, avoid undercuts
• Otherwise follow the same preparation concepts as for anterior crowns.

7.3.1
38
Anterior fixed partial dentures
Pre-oprative: Restoration with a zirconia based fixed
partial denture and a zirconia based crown is planned.
The mandibular first molar is prepared
with a 360-degree rounded shoulder finish line.
All photos: Raigrodski
Impression technique
The impression-making technique for all-ceramic anterior fixed partial dentures does not dif-
fer from that of other types of restorations.
The same procedures are performed as for anterior crowns (page 29).
Framework fabrication for anterior fixed partial dentures
The procedures depend on the ceramic material selected and the manufacturing system. The
connector surface areas as related to fixed partial denture units must not be less than:
• 12 mm2 with lithium-disilicate ceramics
• 10 – 12 mm2 with infiltrated-oxide ceramics
• 9 mm2 with sintered alumina and zirconia ceramics.
A framework try-in is recommended to evaluate clinical fit prior to veneering to full contours.
For the minimal wall thicknesses of fixed partial denture retainers, use the values given on
page 33 – 35.
The thickness of the veneering ceramic should be uniform and must not exceed 2.0 mm.
Try-in procedures
The same considerations hold as described for anterior crowns (page 30). Depending on the
extent of the restoration or esthetic demands, a bisque bake try-in is recommended.
Insertion procedures follows the same considerations as described for anterior crowns
(page 30).

7.3.2
39
The zirconia coping for the mandibular first molar
crown. Note the excellent marginal fit.
Occlusal view of the fixed partial denture and
crown which have been in situ for over 4 years.
All photos: Raigrodski
It is imperative to evalute the framework clinically
prior to veneering to full contours.
Indications
• Restoring tooth-bordered edentulous spaces in the posterior segments
• Cantilever fixed partial dentures are suitable for replacing a premolar.
Limitations
No more than two pontics should be included in one restoration.
Connector design
In every case, the vertical extension of the connector is to be given more volume than the
horizontal. This increases the strength of the connector.
The connector of a silicate ceramic framework should be designed more carefully than one of
oxide ceramic (16 mm2).
As with anterior fixed partial dentures, the space available for the connector can be easily
determined using a periodontal probe.
The choice of material depends on various factors. Due to the high occlusal force in the
posterior region, the flexural strength of the framework ceramic should exceed 350 MPa
(oxide ceramic).
Materials for posterior fixed partial dentures
• Lithium-disilicate ceramics are only approved for fixed partial dentures up to the 2nd
premolar, and are not suitable for fixed partial dentures in the molar region (Empress 2,
e.max Press)
• Infiltrated oxide ceramics are only approved for 3-unit fixed partial dentures, e.g.,
In-Ceram Zirconia – adhesively or conventionally luted
• Sintered zirconia ceramic as multi-unit fixed partial denture framework up to 45 mm
anatomic width – such as Sirona inCoris AL / ZI, Procera Zirconia, Cercon Smart,
Lava Frame, In-Ceram YZ, Everest ZS-Blank and ZH-Blank, e.max ZirCAD, DC-Zirkon –
adhesively or conventionally luted
• Removable telescopic fixed partial dentures: zirconia and alumina are suitable for
primary copings (secondary copings are fabricated using the galvanoceramic technique)
and crown copings.
Posterior fixed partial dentures

7.3.2
40
Veneer
min. 0.7mm
max. 2.0mm
Fig. 2: Wall and layer thicknesses for crown copings
of lithium-disilicate ceramic
Crown
coping
min.
0.8–1.5mm
min. 0.8mm
Veneer
min.
0.7mm
to max.
2.0mm
Fig. 1: Minimum preparation depth for crowns made
of oxide ceramics (Al2O3, ZrO2)
min.
1.5mm
2mm
0.8mm
0.5mm
Fig. 3: Wall and layer thicknesses for the anatomically
reduced crown of Al2O3 and ZrO2 ceramic
Al2O3,
ZrO2-
Crown
coping
min.
0.5mm
Shade selection
Select prior to initiating tooth preparation. It is recommended that the dental technician
who is making the restoration also select the shade.
Preparation design for posterior fixed partial denture abutments
Depending on the material selected, a rounded shoulder, or a chamfer finish-line should be
performed. For frameworks made of lithium-disilicate ceramic, a butt joint finish-line or a
rounded shoulder should be preferably done.All sharp edges should be eliminated and inter-
nal line angles rounded. A total convergence angle of 4 – 6° is indicated.
The following minimum ceramic layer thicknesses should be maintained in marginal areas of
fixed partial denture abutments (Figs 1 to 3):
• Lithium-disilicate ceramic, min. 0.8 – 1.5 mm
• Oxide ceramics, zirconia ceramic, min. 0.5 mm
Occlusal thickness of the veneering ceramics:
• Max. 1.5 – 2.0 mm, strive for minimum layer thickness. A minimum layer thickness of
2 mm under cusps of framework-free silicate ceramic crowns.
Finish line placement with circumferential chamfer or circumferentially rounded shoulder:
• Supra- or equigingivally whenever possible.
The following points apply to minimum wall thicknesses and preparation rules:
Minimum preparation depth for abutment teeth restored with frameworks of oxide ceramic
(Al2O3, ZrO2).
• Preparation depth:
Crown margin at least 0.5 mm
Axial reduction 1.0 – 1.2 mm depending on expected load for zirconia ceramics
1.2 – 1.5 mm for infiltrated oxide ceramics
Occlusal reduction 1.5 – 2.0 mm
• Abutment total angle of convergence 4 – 6° to allow for adequate scanning

7.3.2
41
4-unit fixed partial denture with ZrO2
framework (Lava), in situ for 4 years.
Photos: Groten
4-unit fixed partial denture with zirconia ceramic
framework, veneered, with well-formed connectors.
Posterior fixed partial dentures• Crown margin: chamfer or rounded shoulder (knife edge or feather edge are
contraindicated)
• The finish-line placement 0.5 mm supragingivally or higher, to protect the gingiva
• Rounded line angles, no sharp edges, avoid undercuts.
A reduction of the veneer thickness can be used for reinforcing the abutment coping.
the veneer ceramic should not exceed the given maximum, because the risk of fracture and
delamination of the veneering ceramics.
The impression-making technique for all-ceramic fixed partial dentures do not differ from
that for other types of restorations.
The same procedures hold here as for posterior crowns (page 29).
Framework fabrication for posterior all-ceramic fixed partial dentures
The procedures depend on the ceramic material selected and the manufacturing system. The
connector surface area as related to the fixed partial denture units must not be less than:
• 16 mm2 for lithium-disilicate ceramics (only premolars)
• 12 mm2 for infiltrated oxide ceramics
• 9 mm2 for zirconia ceramics.
The minimum wall thicknesses of the retainers are:
• Lithium-disilicate ceramics 0.8 mm
• Infiltrated oxide ceramics 0.5 mm
• Sintered alumina and zirconia ceramic 0.5 mm
• The minimum framework wall thickness of 4-unit fixed partial dentures of sintered
alumina, zirconia: with 2 pontics at least 0.7 mm, in cantilever fixed partial dentures at
least 0.7 mm
• Framework try-in is recommended prior to the application of the veneering porcelain
Fixed partial denture framework for 4-unit fixed partial
dentures of ZrO2 (Lava).

7.3.2
42
Fixed partial denture units
require sufficient connector
surfaces in vertical, oval
form, since the tensile and
flexural stresses concentrate
here.
Fig.: Pospiech
ZrO2 fixed partial denture framework (Lava)
for narrowed gap around tooth 46. Teeth 45 and 47 with
chamfer, connector cross-section 12 mm.
Photo: Lauer, Bauer
3-unit fixed partial denture of leucite-reinforced
silicate ceramic, a model of esthetics.
Photo: Ivoclar Vivadent, Brix
3-unit fixed partial denture of In-Ceram Zirconia.
Glass-infiltrated oxide ceramic is suitable for fixed
partial dentures of up to 3 units.
Photo: VITA Zahnfabrik
• The thickness of the veneering ceramic should be uniform and not exceed 2.0 mm.
Otherwise, the same considerations apply as described for anterior fixed partial dentures
(page 38).
Try-in procedures
The same considerations apply as described for anterior fixed partial dentures (page 38).
Depending on the extent of restoration or the esthetic demands, a bisque bake try-in is
recommended.
Insertion is performed according to the same rules as described for anterior crowns (page 30).
Adjustments
As a rule adjustments must be made under water cooling, in order to prevent partial over-
heating. Overheating can jeopardize the longevity of the restoration. Special diamond
adjustment instruments are recommended for zirconia.

7.4
43
Primary copings of zirconia ceramic
combined with galvanically
fabricated secondary coping. Cold welding
as for metal telescopic crowns
is thus avoided.
Galvano copings as secondary structure for telescopes.
Photos: KaVo, Freitag
All-ceramics for telescopic
crowns
Indications
Includes all indications which are valid for the classical telescopic technique.
Materials for primary and secondary copings
• Primary copings of polycrystalline oxide ceramics (alumina or zirconia ceramic,
partially sintered or lithium-disilicate ceramic hot pressed)
• Secondary coping of galvanogold.
Shade selection
Usually, the oxide ceramic blanks are white opaque. However, some high-strength zirconia
ceramics can be shaded (e. g., Lava Frame, In-Ceram YZ, inCoris ZI); this enables adaptation
of the crown’s and / or fixed partial denture’s color at the ceramic soft-tissue interface.
Space related prerequisites
Sufficient space must be provided for the restorative materials, because 2 copings will
be placed on one abutment tooth (primary ceramic coping, and a secondary glavanogold
coping). Substance removal on abutment teeth will be relatively extensive.
• Crowns must be veneered in visible areas.
• Optimal path of insertion must be created.
Preparation design
• Preparation design is the same as for the conventional telescopic technique
• For the primary coping, a clear rounded shoulder or chamfer must be made
• The secondary, metal coping should end 1 – 2 mm incisal to the crown margin,
to allow light transmission at the soft-tissue interface
• Space requirements: primary coping 0.4 – 0.5 mm; galvanogold coping 0.1 – 0.2 mm;
tertiary structure 0.3 mm; veneering porcelain > 0.8 mm = ca. 1.7 mm total
• Preparation finish-line: chamfer or rounded shoulder
• Total angle of convergence 4 – 6°.
The impression-making technique for primary copings does not essentially differ from that
for other types of restorations.
• Manufacture of a duplicating cast (composite-resin) for the fixed partial denture
framework.

7.4
44
All-ceramics for telescopic crowns
Cerec-manufactured primary copings
of ZrO2 and the completed overlay prosthesis
with galvanogold copings, bonded in the mouth with
the cast tertiary structure, are ready for cementing.
Photo: Wiedhahn
The same procedures are employed here as for anterior crowns (page 29).
After inserting the primary copings, a second provisional restoration is fabricated.
Telescopic crowns fabrication procedures
• Sectioned master cast: generously design the base of the individual dies/abutments
• Determine path of insertion
• Determine the thickness of the primary coping
• Framework fabrication procedures depend on the selected manufacturing system
• Parallel-milling of the primary copings, adjustment milling, finishing of the roughening
depths
• Copings with 1 – 2° taper to keep friction down
• Shape the supporting butt joint on the oral aspect, if necessary
• Cleansing firing, steam clean, polish the margins of the copings
• Primary copings finished.
Further procedures, conventional method:
• Try-in of the copings in patient’s mouth using transfer copings
• Pick-up impression
• Fabrication of master cast
• Face-bow transfer
• Jaw relation records
• Mounting casts on the articulator
• Waxup fitting on plastic baseplates to check esthetics and jaw relation.
Framework manufacture:
• Galvano copings
• Tertiary structure
• Bonding
• Framework try-in
• If applicable, bisque try-in of veneers or with trial fitting
• Completion.
Alternative procedures:
• Try-in of primary copings
• Manufacture of galvano framework
• Manufacture of tertiary structure
• Try-in of secondary copings and tertiary crowns
• Bonding of framework and tertiary structure in the mouth
• Bonding of primary copings
• Total impression of entire overlay denture, determine jaw relation, face-bow transfer,
trial fitting, completion.

45
7.4 / 7.5
Customizing the gingival aspect of a ZrO2 abutment.
The white material prevents the titanium from shining
through and supports the esthetics of the definitive
all-ceramic crown.
Photo: Lauer
All-ceramic endosteal implant parts made of ZrO2.
Photo: Kern
All-ceramics for telescopic crownsInsertion
• Adhesive or conventional luting of primary copings (zirconia or alumina) on the
abutment teeth
• Secondary copings and tertiary structure are always adhesively bonded
• Metal / ceramic bonding between zirconia or alumina primary coping and galvano coping
(secondary coping) is friction-free and unsurpassed as a tribological system;
the initial resistance in the capillary space and the Van der Waals forces provide the
“gentle bonding” effect of the connecting element.
All-ceramics in implantology
Endosteal dental implants facilitate the replacement of missing teeth without further dam-
aging the existing dentition and allow conservation of the bone in the edentulous area. By
using all-ceramic materials, the esthetic potential of implant-supported prostheses is opti-
mally realized.
All-ceramic implants
Zirconia ceramics are now also used to manufacture endosteal dental implants. Prospective
clinical studies are currently examining the clinical benefits and long-term performance of
all-ceramic implants.
All-ceramic implant abutments
Currently, implant abutments of two-part implant systems can be fabricated out of high-
strength alumina or zirconia ceramic rather than of metal. In esthetic cases in particular, all-
ceramic abutments offer great esthetic advantages. The grayish discoloration of the gingiva
caused by the metal reflecting through is avoided. Furthermore, all-ceramic crowns achieve
their best esthetic potential only with all-ceramic abutments, because the translucency is not
impaired such as in the case of a metal abutment.
Depending on the implant system used, prefabricated all-ceramic abutments with and with-
out a titanium basis are available, can also be custom made using CAD / CAM techniques.
Custom-made abutments improve the soft-tissue support and optimize the transition from
the circular implant platform to the anatomic tooth form (emergence profile).
The all-ceramic abutments should be screwed onto the implants with the system-specific
torque. After sealing the screw access with a provisional composite-resin material, the all-
ceramic crowns and fixed partial dentures should be cemented according to the guidelines
for adhesive luting. Transparent dual-curing or self-curing composite-resin cements should
be used.
All-ceramic implant abutments,
and implant-supported crowns
and fixed partial dentures

ZrO2 abutment (Lava) with metal insert and
matching crown.
and implant-supported crowns and
fixed partial dentures
7.5
46
ZrO2 abutment with subgingival part screwed in.
Endosteal part of implant and abutment of ZrO2,
crown of fluorapatite sintered veneer ceramic.
All photos: Wolfart
When abutments made of oxide ceramics are used, all-ceramic crowns and fixed partial
dentures should be placed on them to take advantage of natural light penetration through
the entire construction, which improves the esthetics.
Indications
• Abutments as a foundation on the endosteal portion
• Crowns on implant superstructures and implant abutments
• Implant-supported fixed partial dentures
• Primary copings with telescopic crown system for removable partial dentures.
Materials
• For abutments: fully-sintered zirconia ceramic and densely sintered alumina ceramic
• As framework material for crowns and fixed partial dentures: lithium-disilicate ceramic
(crown), infiltrated oxide ceramic, zirconia ceramic
• For veneering: other materials as well as silicate fuse-on ceramic with an appropriate
coefficient of thermal expansion
• The selection of material is based on loading and type of restoration and its position in
the mouth (single-tooth or fixed partial denture construction).
Prerequisites
• Optimal insertion direction must be created
• All-ceramic primary copings and primary bars for superstructures, also with terminal
attachment or latches, are technically possible
• Tension-free tight fit in the mouth via intraoral bonding.
Preparation design for implant abutments
Implant abutments supporting an implant-supported fixed partial denture are prepared as
described for posterior crowns (page 27 and 33 – 35). Sufficient space is required for primary
copings.
The impression-making technique for ceramic abutments does not essentially differ from
that for other abutment materials.
• Pick-up impression of the primary copings with secondary copings in place to position
them
• Duplicate cast is necessary for fixed partial denture framework fabrication.

47
7.5
ZrO2 abutments screw into endosteal implant to
support a multi-unit fixed partial denture.
Fig.: Nobel Biocare
Superstructure, screw-on ZrO2 implant abutment
with framework-free silicate ceramic crown.
Photo: Kurbad, Reichel
and implant-supported crowns and
fixed partial dentures
Natural light penetration through ZrO2 abutment and
ceramic crown.
Photo: Wolfart
Framework manufacture
The procedures depend on the selected ceramic material and manufacturing system:
• Reshape the prefabricated abutment. Ensure a uniform path of insertion
• Fabricate the crowns and fixed partial denture framework of ceramic.
The connector surface areas for the fixed partial denture units must not be less than:
• 12 mm2 for infiltrated oxide ceramics
• 9 mm2 for zirconia ceramics.
The minimum wall thicknesses of the crown copings are:
• 0.5 mm for alumina ceramics
• 0.5 mm for zirconia ceramics
• The veneer ceramic layer thickness should be uniform and must not exceed 2.0 mm.
Otherwise, the same considerations apply as described for anterior crowns (page 27 and 33).
Try-in procedures
A custom abutment in the laboratory should be tried in prior to further processing. This
prevents discrepancies between the situation intraorally and on the master cast.
Try-in of the crown framework: the crown must sit rotation-free on the abutment. Assess
the accuracy of fit with a disclosing agent such as a dark, low-viscosity silicon impression
material or fit checking material.
The “superstructure” is cemented on the abutments. Depending on treatment concept, this
type of restoration can also be temporarily luted.

8.
48
Indications for
ceramic materials
Crown Crown Fixed Fixed Telescopic Implant- Abut- Inlay Partial- Veneer Inlay Resin-
partial partial crown supported ment coverage fixed bonded
denture denture primary crown partial fixed
copings denture partial
denture
anterior posterior anterior posterior anterior
Feldspathic
Silicate
ceramic
Lithium-
disilicate up to 2nd
ceramic premolar
Glass infiltrated
oxide ceramic:
Spinell
Alumina
Zirconia
Polycrystalline
oxide ceramic
Zirconia oxide *
Alumina
oxide
The materials in this table are suitable for the restoration types given, and have been clinically proven
in practice.
*) To date, inlay fixed partial dentures have only been experimentally constructed and have not yet been sufficiently tested clinically.
Source: SDC / AG Keramik

9.
49
VITA 3D-Master
shading system.
Fig.: VITA Zahnfabrik
Shade selectionShade selection for all-ceramic restorations
An industrially prefabricated shade guide is normally used to determine the natural tooth
color. Digital shade scanners can be used as support or to double-check. Ideally, the dental
technician who is constructing the restoration also determines the shade. This helps prevent
transfer errors.
The actual tooth color is that of the dentin. The enamel modulates color perception by its
transparency and thickness. Enamel transparency can be determined by alternately holding
black or white pieces of paper (ca. 4 x 5 cm) behind the tooth (press onto the tooth’s palatal
surface). The more intensively the background shines through the tooth, the greater the
transparency of the selected (fuse-on) ceramic must be.
The dentin color can best be observed cervico-buccally, because the enamel is thinner at that
site. A distance of 1 – 2 mm from the gingiva should be maintained to exclude the gingiva’s
red tone. To standardize subjective color perception as much as possible, it is recommended
that color determination always be carried out in one certain place in the practice, because
this enables the dentist to rely on previous experience with color-taking. To check one’s
work, a second person (assistant) can be asked to perform color-taking.
The following factors in the practice environment should be considered during shade
selection.
Surroundings for color-taking:
• Muted coloring (furniture, walls, clothing, cosmetics)
• No direct sunlight.
Lighting:
• Daylight, if possible from the north (less of the red spectrum)
• Artificial light: fluorescent tubes with daylight quality
(e.g., Osram Lumilux DeLuxe Daylight 12-950) as the ceiling light
• Turn away OP lamps (halogen lamps have high red proportion).

9.
50
Shade selection
Digitale shade scanner. Fig.: VITA Zahnfabrik
Conditions for patient:
• No lipstick, highly-colored make-up, or bright scarves
• Clean tooth surfaces
• Patient participates in selection after the dentist has pre-selected.
Color-taking:
• Moisten teeth, do not let dry out
• Constant distance between eye and object
• Short observation times only, to avoid accommodation and fatigue of the eyes
• Use shade guide, place shade sample on the tooth
• First determine color value of the tooth, then color saturation, lastly tooth shade
• Determine transparency extent of enamel with paper (white, black)
• If necessary, repeat shade measurements, secure results.
Documentation:
• Record characteristics as a sketch (enamel cracks, mamelons, enamel spots, erosion).
If esthetic demands on the restoration are very high:
• Take photos (tooth shape, lip shape, smile-line, gingiva shape, facial expression,
overall impression)
• Individual shade selection with especially manufactured ceramic shade samples
(veneers).

2008 all ceramics at a glance

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