PORCELAIN ESTHETICS FOR THE 21ST CENTURY

KARL F. LEINFELDER, D.D.S., M.S.

Background. Dental procedures play a vital role in the modern dental practice. Considerable research has addressed improvements in the properties of dental porcelains.

Clinical Implications. This article examines the trends in the scientific advances in dental porcelains. It highlights properties of the new low-fusing porcelains and describes indications for their use. New luting cements also are addressed.

throughout the centuries. Although it is impossible to know when porcelain was first used successfully, the Chinese began working with it as early as the 9th century. Around 1700, France and, somewhat later, England used refined porcelains for the fabrication of dinner plates and various artistic objects. In dentistry, it was Alexis Duchateau, a Parisian apothecary, who first used the material for the fabrication of denture bases in the 18th century.1 Several years later, Dubois de Chemant secured a patent for the sole right to manufacture denture teeth with porcelain.1 It was in 1949 that Dentists Supply Company of New York invented the process for vacuum-firing porcelain teeth.2,3 The use of a reduced pressure during vitrification resulted in artificial teeth that were considerably more dense and less opaque. Today, porcelain plays a vital role in restorative dentistry. Common uses include full coverage as crowns, inlays and onlays, porcelain bridges, veneering agents, castable ceramics and porcelain-fused-to-metal, or PFM, restorations. Based upon some interesting technology, porcelain can also be cast into molds in much the same way as conventional base metals or gold alloys. As demands for esthetic dental restorations continue, new technologies will improve the material properties and develop new methods for its use. Considerable research has been directed toward improving the properties of ceramic

Porcelain has been used in various forms

materials for dental purposes. While dental porcelains possess numerous positive attributes, they also exhibit a number of disadvantages (Box, Advantages and Disadvantages of Dental Porcelain).4 In general, the experienced clinician has learned to compensate for some of the disadvantages of porcelain. Unfortunately, low fracture resistance, potential for abrading structures against which it occludes and difficulty in resurfacing and polishing the glazed surface continue to be the biggest problems associated with this commonly used clinical material. This article examines current trends in the scientific advances of dental porcelain and its uses, and touches on management of the challenges inherent to porcelain.
ALL-CERAMIC SYSTEMS

All-ceramic systems are characterized by versatility and outstanding polishability. An allceramic system is designed to combine consistent shading, superior esthetics and low wear for PFM and all-ceramic restorations. The material is further characterized by a reduced potential for abrading opposing enamel as well as other materials with which it functionally occludes. All-ceramic systems are truly unique and different from all other systems and their materials currently available to the practitioner. This lowfusing porcelain has been designed so that it can be used with PFM and all-ceramic restorations. During the last several years, there has been a growing interest in metal-free ceramic restorations. Such systems inherently provide a greater

JADA, Vol. 131, June 2000 Copyright 1998-2001 American Dental Association. All rights reserved.

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ADVANTAGES AND DISADVANTAGES OF DENTAL PORCELAIN.

ADVANTAGES Dimensional stability Insolubility in oral fluids Excellent color matching Tissue tolerance High wear resistance Difficult to adjust/polish (intraorally) May degrade supporting structure Low fracture resistance * Owing to the relatively low absorption potential of masticatory energy, some clinicians have speculated that porcelains as compared to polymers may cause a higher rate of degradation at the bone-implant interface. However, the differential of energy passed on through the two types of restorative materials is only about 10 percent.4 DISADVANTAGES* Abrasive to antagonists Complex techniques needed (fabrication)

enamel is presented in Figure 1. As can be seen, the wear or abrasion of the various materials (ceramic and gold alloy) followed the same pattern. Specifically, the volumetric wear loss of Finesse, the lowfusing porcelain tested, was less than all other materials against which it was compared. All of these tests show that Finesse, a low-fusing porcelain, possesses advantageous characteristics as related to potential clinical behavior.
LEUCITE

potential for optimizing esthetics. Historically, however, it has been difficult to combine this feature with that of high fracture resistance. Newer systems, such as Finesse All-Ceramic (Dentsply Ceramco), are showing promise in combining the properties of esthetics and strength.5
LOW-FUSING PORCELAIN AND ITS PROPERTIES

Developed to offset the major disadvantages of traditional dental porcelains, low-fusing porcelain represents a major change in direction. One of the basic differences between this formulation and those that have been used for long periods of time is a significant reduction in the firing temperature. The firing temperature for one newer low-fusing porcelain (Finesse), for example, is 760 C vs. around 940 C for conventional porcelain. This 200degree differential has imparted a number of positive characteristics to the final restoration. The reduction of the fusion temperature allows for increased
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opalescence in the enamel porcelain. It also permits the clinician to generate a highly polished surface at chairside, thereby eliminating the need for reglazing after possible adjustments. Perhaps more important, the low-fusing porcelain offers considerably less potential for abrading any materials against which it occludes. In an investigation by Imai and colleagues at the University of Alabama,5 it was shown that one low-fusing (Finesse) porcelain abraded the antagonist normal or polished enamel one-third less than did conventional porcelain. In fact, the wear of enamel was less than that produced by gold alloys when tested under the same condition. While trials have been carried out in vitro, the correlation between laboratory and clinical data has been extremely high.6-8 Another clinical study confirmed the lower wear of low-fusing porcelain against opposing teeth and restorations.9 The wear of the ceramic and gold materials by opposing

Many of the greatly improved properties of low-fusing porcelains can be related to the changes made to the leucite component. Leucite is an artificial crystal feldspathoid (potassium-aluminosilicate). In most dental porcelains, the leucite crystals are created by transforming feldspar crystals into glass and leucite crystals by a special heat treatment. Leucites primary function in dental porcelain is to raise the coefficient of thermal expansion, consequently increasing the hardness and fusion temperatures. As a rule, dental porcelains consist of a leucite crystal-containing frit and at least one other frit to control various physical and mechanical properties. The leucite component forms a refractory skeleton and the glass fills the spaces in between, adding special properties required for dental porcelains. A considerable amount of research on dental porcelains has resulted in the possibility of permitting variations in the leucite content. Selecting a glass and varying the leucite content will alter certain physical properties.

JADA, Vol. 131, June 2000 Copyright 1998-2001 American Dental Association. All rights reserved.

The leucite content of most high-fusing porcelains ranges somewhere between 35 and 40 percent. However, certain lowfusing porcelains, such as Finesse, contain 8 to 10 percent leucite. The formulation has been designed to employ optimum levels of finer and less leucite crystal for the purpose of maximizing the desirable characteristics of dental porcelain. Interestingly, some lowfusing repair porcelains are free of leucite. Such formulations work well as a low-temperature add-on and they are less abrasive. Unfortunately, these leucite-free porcelains also have some disadvantages. Most importantly, they deform on multiple firings at different temperatures.
FLUORESCENCE AND OPALESCENCE

VOLUMETRIC WEAR LOSS AGAINST EN AMEL (x102 millimeters)

0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 Ceramco II Duceram Gold IPS Empress Finesse

Figure 1. Relative wear of various ceramic restorative systems against enamel. Ceramco II is manufactured by Dentsply Ceramco; Duceram Gold by Zahntechnik; IPS Empress by Ivoclar North America; Finesse by Dentsply Ceramco.

also contributes to the vitality of a restoration.

ALL-CERAMIC CORES

For clinicians who practice esthetic restorative dentistry, particularly in the field of ceramics, fluorescence is an important physical property. Natural teeth are fluorescent. In other words, they emit visible light when exposed to ultraviolet light. Fluorescence adds to the vitality of a restoration and minimizes the metameric effect between teeth and restorative materials. The components of porcelain consist of agents that cause them to fluoresce; thus, they also will emit visible light when exposed to ultraviolet light. It is important that all the basic components of the porcelain, including the dentins, enamels, stains and even the glazing agents, are fluorescent. Opalescence is the ability of a translucent material to appear blue in reflected light and orange-yellow in transmitted light. Opalescence

The ceramic core of low-fusing porcelain is unique in a number of ways. First of all, it is engineered with a coefficient of thermal expansion, or CTE, matched to that of the Finesse low-fusing porcelain. For the purpose of maximizing crown strength and improved crack resistance, the CTE of the core material is actually slightly higher. This condition, of course, places the porcelain in a state of compression, which subsequently improves fracture resistance of the final restoration. The core fabrication process consists of investing the wax pattern, burning out and forcing the ceramic core material into the evacuated mold (Figure 2). Illustrated are six ceramic cores fabricated at one time on a common base. This entire process can be carried out in a conventional pressing furnace.

The all-ceramic core system is ideal since excellent bonding can be achieved between porcelain and core without the need to create a wash layer. This characteristic not only enhances the integrity of the restoration, but it virtually erases the seam between core and porcelain, thereby permitting optimal esthetics. Combining this feature with color-correlated dentin and core further enhances natural esthetics. As an example, the glass matrix of Finesse, one brand of all-ceramic cores, contains fine leucite crystals that are uniform in both size and distribution. This particular characteristic contributes to optimal physical properties and also the desired level of translucency. The particle size and distribution also permit the pressed core to be ground easily without producing chipping in thin areas. The core material examined was highly stable under oral conditions. When tested in accordance with the International Standards
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JADA, Vol. 131, June 2000 Copyright 1998-2001 American Dental Association. All rights reserved.

weight change was only 38 milligrams/ square centimeter as compared to an acceptable level of 2,000 mg/cm2.
PORCELAINFUSED-TOMETAL RESTORATIONS

PFM restorations have been used extensively by dental clinicians for nearly 40 years. During that period, tremendous effort has gone into the improvement of the systems originally offered to the profession. While bonding has been improved to the point that fracturing is relatively uncommon, the level of esthetics associated with PFMs has been less than ideal. More often than not, many of the laboratory-fabricated restorations are someFigure 3. A low-fusing porcelain (Finesse, Dentsply Ceramco) fused to a gold metal substrate what less a typical example of this materials potential. translucent in A. Buccal view. B. Lingual view. comparison to conventional all-ceramic Organization standards for restorations. Low-fusing porcechemical durability, the results lain can mimic the proper opacdemonstrated that the level of ity and translucency ratio comweight change was significantly monly associated with natural less than the maximum set by teeth or ceramic restorations the standard. In fact, the
Figure 2. A series of cores fabricated by means of a pressing process.

without a metal substrate. A typical example of a three-unit bridge constructed of Finesse, a low-fusing porcelain fused to a gold-based metal alloy, is shown in Figure 3. By carefully controlling the coefficient of thermal expansion of low-fusing porcelain, it can be used successfully for PFM restorations. A slightly lower CTE than the metal to which it is bonded puts the ceramic veneer into a state of compression during the cooling process. This in turn maximizes resistance to fracture. Based upon careful laboratory studies (Dentsply Ceramco, unpublished data, 1999), it has been demonstrated that a type of low-fusing porcelain can be successfully bonded to gold-based alloys, gold-platinum-palladium alloys, palladium alloys, palladium-gold alloys and lowexpansion nonprecious alloys. A clinical study showed little wear on opposing teeth with low-fusing porcelain-to-metal crowns.9
LUTING AGENTS

The development of new materials such as all-ceramic restorations has brought about a substantially different attitude concerning luting agents. While zinc phosphate cement has been the standard for nearly a century, its overall properties are insufficient for certain types of restorative systems. For example, this traditional cement, which has been quite successful for metal-based restorations, falls far short for porcelain restorations. When zinc phosphate cement is used to lute all-ceramic restorations, bulk fractures can be expected. Specifically, during mastication energy is transmit-

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JADA, Vol. 131, June 2000

ted through the bolus and into the restoration itself. In the case of zinc phosphate cement, the energy is distributed in localized regions at the restoration-preparation interface. The application of high levels of stress in localized zones then predisposes the restoration to fracture. The fractures associated with the early all-ceramic crowns could be attributed to this phenomenon. The ability to bond not only to the surface of the tooth but also to the internal surface of the ceramic restoration reduces this potential appreciably. When all contact surfaces are bonded as a single structure, the masticatory energies are distributed more uniformly. Consequently, fractures within the ceramic restoration are reduced significantly. It is important, therefore, to select a luting agent that exhibits the appropriate properties. Such a cement should not only bond to the surfaces of the preparation through the hybridizing process but also to the internal surfaces of the ceramic restoration by means of silanation and acid etching. Finally, the cement should exhibit sufficient flexural strength, flexural modulus and fracture toughness. Other desirable properties include color stability and sufficient release of fluoride to offer protection

against secondary caries. This luting agent should possess dual-cure potential as well as multiple viscosities for use with different types of restorations. Newer composite-based resins such as Calabra (Dentsply Caulk) show promise in fulfilling these requirements.
CONCLUSIONS

The combination of compositebased resin luting systems and low-fusing porcelains has marked a major milestone in the area of esthetic restorative dentistry. These two materials make it readily possible to fabricate restorations of great beauty, function and strength. Furthermore, the principles associated with these recently developed systems make it considerably easier for clinicians to achieve their esthetic restorative goals. New systems have been designed in which low-fusing porcelain can be used for PFM and all-ceramic restorations. They are designed for the construction of crowns, inlays and onlays, veneers and bridges. When used in conjunction with a pressable core system and no metal substrate, the esthetics are excellent. Although inherently wear-resistant, low-fusing porcelain is considerably less abrasive to those structures against which it occludes than other ceramic systems. These

porcelains possess excellent opalescence and fluorescence and can be readily polished without reglazing. Consumer interest in esthetic dentistry will continue to grow in the 21st century. New dental porcelain systems that combine esthetics with strength and function will assist dental professionals in meeting the increased consumer demand for lifelike teeth that perform like ones natural enamel and dentin. I
Dr. Leinfelder is professor emeritus, Department of Biomaterials, University of Alabama School of Dentistry, Birmingham. Address reprint requests to Dr. Leinfelder at 207 Helmsdale Dr., Chapel Hill, N.C. 27514. 1. Ring ME. Dentistry: An illustrated history. New York: Mosby; 1985:180. 2. Vines RF, Semmelman JO. Densification of dental porcelain. J Dent Res 1957;36:950-6. 3. Vines RF, Semmelman JO, Lee PW, Fonvielle FP. Mechanisms involved in securing dense, vitrified ceramics from preshaped partly crystalline bodies. J Am Ceram Soc 1958;41:304-9. 4. Al-Malik MA. An investigation of the dynamic mechanical properties of dental root form implants (masters thesis). Birmingham, Ala.: University of Alabama, School of Dentistry; 1991. 5. Imai Y, Suzuki S, Fukushima S. In vitro enamel wear of modified porcelains (abstract 50). J Dent Res 1999;78(special issue):112. 6. Leinfelder KF, Beaudreau RW, Mazer RB. An in vitro device for predicting clinical wear. Quintessence Int 1989;20:755-61. 7. Kawai K, Leinfelder KF. In vitro evaluation of OCA wear resistance of posterior composites. Dent Mater 1995;11:246-51. 8. Leinfelder KF, Suzuki S. In vitro wear device for determining posterior composite wear. JADA 1999;130:1347-53. 9. Christensen R. Low-fusing porcelainmetal crowns. Clin Res Associates Newsletter 1999;23(2):1-2.

JADA, Vol. 131, June 2000 Copyright 1998-2001 American Dental Association. All rights reserved.

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