All Ceramic Crowns & Shade Selection

Definition of dental ceramic:

An inorganic compound with non-metallic properties typically composed of oxygen
and 1 or more metallic or semi-metallic elements that is formulated to produce the
whole part of a ceramic based dental prosthesis

Introduction:
- Statistics published: 90% cemented restorations are metal ceramic crowns
- All ceramic products are catching up, with improved strength and aesthetics
- All ceramic crowns have better aesthetics for anterior teeth compared to
metal-ceramic crowns

Indications:
1. Anterior teeth Destroyed, fractured, discoloured, abraded or malaligned (For
posterior teeth, first choice should be metal-ceramic crown due to its better
fracture resistant property)
2. Under favourable occlusal condition No heavy bite, no parafunction

Contraindications:
1. Too conical preparation of tooth crown May have pulp exposure and tooth is
at a high risk of fracture
2. Insufficient lingual thickness of ceramic (< 0.8mm)
3. Deep bite This leads to more forces transmitted anteriorly
4. Short clinical crown Offers minimal retention after preparation
5. Presence of parafunctions such as heavy bruxism (Ceramic teeth when in
occlusion with natural teeth will cause attrition very fast)
3 basic requirements of dental ceramics:
1. Function Durability, strength and biocompatibility
2. Form Ability to form complex shapes
3. Aesthetics Colour, translucency and transmission of light

*The more translucent a ceramic is, the more aesthetic it is but the lesser the
fracture resistance

Properties of dental ceramics:

1. Firing shrinkage 30-40% - Crown must be overbuilt
2. Chemically inert provided the surface layer is intact
3. Low thermal conductivity
4. Good aesthetics
5. Brittle. The main cause of failure is crack propagation which almost invariable
emanates from unglazed inner surface. This can be reduced by:
- fusion of the inner surface to metal, as in the platinum foil and metal-bonded
techniques
- the use of a strengthened porcelain core
6. High resistance to wear
7. Glazed surface resists plaque accumulation

Tooth preparation:
1. Depth cut
- Place orientation grooves for :
(a) 2.0mm incisal reduction
(b) 1.0mm facial/labial reduction (in 2 planes. If cut in 1 plane will overcut)

2. Incisal and facial reduction

- Using parallel rounded end diamond bur : Shoulder margin (margins can be
shoulder or heavy chamfer using 010 bur all around the tooth)
- Incisal reduction is done parallel to the incisal edge of the crown
- Facial reduction reduced evenly in 2 planes and extended into the proximal
areas
3. Proximal reduction
- Initially using the long thin tapered diamond bur to relieve proximal contact
area until the space is wide enough for the long parallel rounded end

4. Lingual reduction
- Lingual-axial wall should be parallel to the gingival 1/3rd facial wall
 5. Finishing/refinement
- Width of shoulder margin 1.0mm, all rounded surfaces, uniform and smooth (use
TC burs. No sharp angles, will create stress points. Use green stone to refine the
cavity)
- Transitions between surfaces must be smooth
- Right-angled rounded shoulder is preferred
- All corners must be rounded off

* Before tooth preparation, impression has to be taken using silicone. After tooth
preparation is done, place the silicone impression onto the prepared tooth. The space
between prepared tooth and silicone impression should be around 1.0mm

Different types of ceramic systems (Different system uses different technique and
has different contents)

System Details Photos

Alumina ceramic - Alumina ceramic has low
(Vita Hi-Ceram, flexural strength and high
Vitadur Alpha) shrinkage during sintering
(upon firing < melting point
self-diffusion of the particles
in contact grow)
- Ceramic mass is condensed on
platinum foil or on refractory
die and fired to produce the
core
- This core is covered with
 Vitadur Alpha Ceramic

Vitadur Alpha Ceramic

Dicor Glass - Use glass ingots (not very
Ceramic abrasive therefore, does not
attrite natural teeth very much)
- Glass ceramic is rounded as a
glass
- Heat-treated to produce a
crystal structure inside the
glass (ceramming) process
that converts it into a stronger
crystalline ceramic
- The structure is then stained,
Dicor glass ceramic
coloured and glazed
- Dicor glass ceramic can also
be covered with Vitadur Alpha
Ceramics
- Advantages:
1. Little abrasive ability
2. Very small crystal size (1-
4 um)

- Indications:
1. Inlays
2. Veneers
3. Single crown of anterior
teeth

The Cerapress - Patented ceramic pressing

Technique method > 10 years
(Leucite - Used for crowns, inlays,
Reinforced onlays and veneers
Ceramics - High aesthetic and fit
Cerapress - Used with zirconium post and
Technique) composite core
- It is the only technique with
which it is possible to produce
a zirconium oxide post on
which ceramic mass can be
pressed to produce all ceramic
post and core
Procera All - Based on a lumina ceramic
Ceram core mass Processed by
pressure injection
- Used as anterior crowns,
inlays, onlays and veneers
- Base material consists of 1
Al2O3, no significant etching
of the ceramics when
cemented with resin cement
- Leucite enriched ceramics
contain > two phases after
etching will provide better
retention

Glass Infiltrated - Has outstanding fracture

Alumina Ceramic: strength values
In-Ceram - Used for single crowns on
anterior and posterior regions
- 3-unit anterior bridge possible
at areas with less occlusal
forces
- Marginal adaptation of crowns
are good
- Slip mass consists of alumina
applied on the refractory die
and fired Sintered
- Sintered ceramic is then
infiltrated with glass and fired
To reinforce the core

Advantages:
- Metal base is not necessary
- Has very high flexural
strength and excellent fit

Disadvantages:
- Opacity of core affects
aesthetic appearance
- Acid resistance of core causes
the conventional etching of the
core to be inefficient
 - Special laboratory equipment
is required
- Etching of the ceramic surface
is insignificant due to alumina
content. Therefore, to enhance
mechanical bonding,
sandblasting the fitting surface
of the crown is required
CAD/CAM - Computer-aided
System: CEREC direct/manufacturing
- Cerec 1 developed in 1989
based on an optical impression
- Consists of milling unit, a
camera and computer systems
- 1995 Cerec 2 developed better
fit of margin Inlays, onlays
produced
- Now Cerec 4
Turkom-Cera - Very good aesthetic

In-Ceram Spinell
Summary - All ceramic restorations must
be treated carefully.
Processing technique may
influence the fracture
resistence / aesthetic of the
final restoration
- Anterior crowns have shown
very good aesthetic results

- Dye spacer: Thickness is roughly 2mm. It should be applied 1mm away from
gingival margin of the tooth preparation. This is to give space for tooth cement
to flow and to prevent microleakage
- After sintering, the crown will be very glossy
- Pink ceramic : Can blend in with gingiva very well. Used when bone
resorption is very severe. May also be used in cases with high upper smile line
 Cementation
1. Resin luting cements
- Ceramic needs to have a resin-based cement

Eg: Calibra
- It has different shades
- Has a try-in paste. Apply the try-in paste onto the fitting surface of the crown
and try it onto the prepared cavity. If everything fits well with good aesthetic,
then only place the permanent paste

- Requires silane coupling agent to bond the cement to ceramic since it is resin
based

Steps:
1. Try-in paste
- Apply try-in paste to the crown. Seat the restoration and check the colour, then
remove the restoration

2. Clean and dry

- Thoroughly clean all internal surfaces of the crown with water spray and air
dry

3. Tooth conditioner
- Apply Caulk 34% tooth conditioner gel to available enamel (and dentine if
desired) for 15 seconds. Rinse for 10 seconds. Blot dry to keep moist, do not
rub
 - In Europe : De Trey Conditioner 36%
- For full coverage crowns, etching dentine is not recommended as to minimize
the possibility of post-operative sensitivity

4. Apply Silane
- Apply Caulk Silane Coupling Agent to the crown according to instructions

5. Mix Prime and Bond (NT DUAL CORE)

- Place 1-2 drops of adhesive and an equal number of drops of self-cure
activator into a mixing well and mix with a new brush tip

6. Apply P&B to tooth surface

- Apply prime & bond NT Dual Core mixture to thoroughly wet the tooth
surfaces. These surfaces should remain wet for 20 seconds which may
necessitate additional adhesive
- Gently air dry for 5 seconds. Surface should have a uniform, glossy
appearance. If it does not have a uniform, glossy appearance, reapply the P&B
- Light cure P&B NT Dual Core for 10 seconds

7. Apply Calibra
- Apply a thin layer of cement to the internal surface of the restoration

8. Seat
- Seat the restoration slowly. Maintain downward pressure and remove excess
cement from marginal areas with a dry brush

9. Pre-cure (Soft cure)

- A 10-second light pre-cure at the margins will gel the excess cement for
easy clean up

10. Light cure

- Once stabilized, light cure all the margins for 40 seconds

11. Finishing
- Use white rubber stone

Tooth Shades
COLOUR - Light is radiant energy travelling in waves of varying lengths
- Visible light of electromagnetic spectrum is between 380-760 nm
- Different wavelengths either directly or as reflections from an object, will excite
different sensations within the eye
- Sensations are interpreted by the central nervous system mental impressions
 Interprets colour

Colour Quality
- Clinical light. No white light, no fluorescent light (more blue in colour) and no
incandescent light (more white in colour)
- For better colour quality, check tooth shade in the morning or afternoon. More
blue, green and red lights penetrating the atmosphere
- Afternoon with bright weather ideal time due to balance of all lights

- In dentistry, tooth shade is of prime concern

- We use the Munsell Colour Order System : This system is based on colour
determinations made by human eye through direct comparison with a standard,
which in clinical setting, is the shade guide

- Munsell Colour Order System :

Created by Albert H. Munsell. It defines colour by 3 attributes:

(a) Hue (Colour)
(b) Value (Brilliance)
(c) Chroma (Saturation)

Natural tooth
- Incisal edge and proximal areas : Greyish as light is absorbed in the mouth after
passing through enamel. Has very thin dentine
- Body : Yellowish, reflection from dentine
- Gingival area : Orange, reflection of red gingival tissues through very thin enamel
- Patients with gingivitis, the red gingiva will be reflected onto teeth. Therefore,
tooth shade will not be accurate
- Lipstick colour will also affect tooth shade. Very red lipstick will show very white
teeth
- Moustache can also affect tooth shade

*Before taking tooth shade, tooth surfaces have to be cleaned from plaque and stainings

Perception of colour is affected by:

- Lighting (Eg: Tungsten, fluorescence)
- Surrounding colours (Eg: Lipstick, gingivitis)
- Texture of surface (will change the reflection of light)
- Materials (will change the reflection of light)
- Form of object (will change the reflection of light)

Colour blindness:
1. Blue Green
2. Blue Violet
3. Red Yellow

Hue
- Name of colour
 - Primary determinant of hue is DENTINE that is covered by enamel
- Tooth shade has to be determined before tooth preparation, before rubber dam
placement
- Surrounding gingiva becomes whitish after giving LA. That is why must
determine tooth shade first

VALUE - It is the brightness of colour

- In scale of 0-10
- White : High value / brightness (10)
- Black : Low value / brightness (0)
- 0 (black) 10 (white)
- Natural teeth is within 4-8
- Transluscency : varies with age (wear), disease and restorative treatments. Should
be assessed with lips slightly parted
- It is influenced by the translucency of enamel
- Brightness of an object shows the amount of light energy it produces

CHROMA - It is the saturation of the colour/hue

- Intensity/concentration of the colours hue
- Pale colours/pastel Low chroma
- Bold High chroma
- It is determined by dentine
- It is influenced by the thickness and translucency of enamel
- In choosing tooth shade, if no tooth shade is suitable, choose the tooth shade with
lower chroma

How to select restoration shades?

1. Clean the teeth to be matched
2. Assess apparent value and dominant hue and select a shade guide tab
3. Moisten both teeth and guide tab
4. Hold guide tab in close apposition to the tooth being matched, cervical to
cervical and incisal to incisal
5. Squint eyes to appraise value difference
6. Note hue difference (Redder (orange) / yellower / browner)
7. View with lips relaxed and retracted
8. Limit viewing periods to 5 seconds or less. Will lose the sensitivity to yellow
colour
If eyes are tired, look at distant objects (preferably blue in colour)
9. Use different light sources First under clinical light, followed by cool white
fluorescent and incandescent
10. If no shade guide is suitable, select the nearest shade tab which is higher in
value and lower in chroma (A2 instead of A3)
11. Send shade guide tooth to technicians with adequate intsructions for
modifications and characteristics

Shade, translucency and location

- Enamel colour : Opaque white Translucent
- Young patient : Whiter colour with high value due to thick enamel Higher
light reflection
- Older patient : More orange colour due to less translucency of enamel

Tooth shade guide tab