continuing education

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Material Classification
and Shade Selection
Protocol for All-Ceramic
Restorations

by Arthur R. Volker, DDS, MSEd

Dr. Arthur R. Volker

graduated from the
Columbia University
School of Dental and
Oral Surgery. He is
a member of the
continuing education committee for
the New York State Academy of General
Dentistry. Volker is a diplomate of the World
Congress of Minimally Invasive Dentistry,
and is a fellow of the Academy of General
Dentistry and the American College of
Dentists. He has also published articles
and lectures on such topics as cosmetic
dentistry, minimally invasive dentistry,
dental materials and dental implants.

Approved PACE Program Provider FAGD/ This print or PDF course is a written self-instructional
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Abstract Fig. 1
With the myriad options available to the
clinician, selecting the appropriate ceramic
material for a restoration can be a daunting
task. This article seeks to simplify the selec-
tion protocol by classifying the materials
as either glass ceramics or oxide ceramics.
The physical and optical properties of these
Typical issues with PFM restorations include
materials will also be discussed. metal margins and high opacity.
Additionally, when using certain mate-
rials, there are several variables that will
affect the final shade of the restoration.
These factors will be discussed and clinical
examples will illustrate how to best optimize
prosthetic results.

Learning objectives
After reading this article, the reader
should be able to:
• Recognize how to select the appro- When choosing
priate ceramic restoration based on a shade for an
material properties.
• Understand the differences between oxide ceramic, as
glass and oxide ceramics.
• Gain familiarity with the variables is done with PFM
that affect the final shade of the
restorations, only
ceramic restoration, including
material translucency and opacity. the desired final
Introduction shade needs to
The use of all-ceramic restorations has
gained popularity just within the past three
be determined.
decades, although the first all-ceramic crown This is due to the
was described by Charles H. Land in 1903.1
These restorations are used as alternatives inherently opaque
to porcelain fused to metal (PFM), which
certainly enjoys a notable track record in
nature of the oxide
terms of longevity. However, PFMs have materials.
certain shortcomings, including an inherent
high opacity, and the potential of unesthetic
exposed-metal margins (Fig. 1).
With the development of all-ceramic
restorations came the need to classify the
various categories of materials. This can be
done in several ways—for example, according
to firing temperature or abrasiveness. 2
One simple and succinct way to cate-
gorize the materials is to classify them as
either glass ceramics or oxide ceramics.3

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Glass ceramics that adding a higher percentage of leucite

Generally, each glass ceramic is composed to a ceramic formulation created a material
of a glass component and a crystal component. twice as strong as conventional feldspathic
The crystal component provides strength. porcelain. The flexural strength of leucite-re-
The glass component, typically made of silica inforced porcelain restorations is 180MPa.
or quartz, provides translucency. Leucite-reinforced restorations are fabri-
Additionally, the selective removal of cated using a lost-wax technique, or can be
silica by hydrofluoric acid and subsequent fabricated via a CAD/CAM protocol, which
use of adhesive protocols makes it possible allows for better marginal fit than traditional
for partial-coverage restorations, such as feldspathic restorations.5 Regular applications
veneers, to remain affixed to the tooth include veneers, inlays and crowns.
structure without the need for a conventional Common examples include Empress
retentive preparation.4 Esthetic and Empress CAD (Ivoclar Viva-
dent) and Authentic (Jensen Dental).
Common glass-ceramic Lithium disilicate-reinforced. Although
materials Empress proved to be a popular material, it
Feldspathic porcelain. Historically, this was too weak for use in anterior bridges or
is the most commonly used glass ceramic. posterior crowns. Empress2, which incorpo-
It is used as a layering porcelain for PFMs, rated lithium disilicate in the crystal phase,
as well as for full-contour veneers or por- was created to address these issues.
celain-jacket crowns. Additionally, it In 2005, Ivoclar Vivadent refined the
can be layered over ceramic cores. processing of the lithium disilicate, and
Feldspathic porcelain is applied to created IPS e.max Press and IPS e.max
a refractory die or platinum foil CAD. With a flexural strength of 360MPa
via a powder-and-liquid mixture. to 400MPa, the material is used for posterior
It is then sintered. crowns and anterior bridges (up to the second
Common examples include: premolar). Additionally, it is formulated to
Noritake (Kuraray), IPS e.max have varying levels of translucency or opacity,
Ceram (Ivoclar Vivadent) and VITA and can be adhesively bonded.
VM7 (Vita). Flexural strength of Lithium-disilicate restorations offer
feldspathic porcelain typically ranges roughly 56 ingot or
between 80MPa and 100MPa.
Leucite-reinforced porcelain.
Although leucite was already a
component in several formula-
tions of feldspathic porcelain,
manufacturers discovered

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Table 1

Material Type Flexural strength (MPa)

Feldspathic Glass 90—120
Leucite-reinforced Glass 180
Lithium disilicate-reinforced Glass 360—400
Densely sintered aluminum oxide Oxide 650
Zirconia Oxide 720—1200

block choices, and include high-translucency Zirconia. Available as either a layered

or high-opacity options. (e.g., Lava, 3M ESPE) or monolithic (Brux-
Zir, Glidewell Laboratories; Zenostar, Ivoclar
Oxide ceramics Vivadent) restoration, zirconia has the highest
Oxide ceramics have higher flexural flexural strength of any of the all-ceramic
strengths than glass ceramics.6 They contain materials available today.8
no silica and therefore tend to be more It is indicated for posterior crowns and
opaque than glass ceramics, although the bridges, particularly in the monolithic form.
development of a more translucent oxide Although it’s still not as translucent as glass
ceramic is certainly on the radar of today’s ceramics, the incorporation of the cubic
manufacturers. phase of zirconia offers a promising avenue
While universal primers have improved to increase the material’s translucency. It
the reliability of adhesive protocols, as a should be noted that cubic zirconia does
whole the bond strength of oxide ceramics have an approximately 20 percent lower
tends to be lower than that of glass ceramics.7 flexural strength than traditional yttria- or
Densely sintered aluminum oxide. It’s ceria-stabilized zirconia formulations.9
currently marketed as Procera Alumina Table 1 lists the material type and flexural
(Nobel Biocare). Though it has a high flexural strengths of the glass and oxide ceramics
strength of 657MPa, the material is used as that have been discussed.
a core and is overlaid with feldspathic porce-
lain. It is indicated for posterior three-unit Shade selection
bridges, and is not available in a monolithic W hen choosing a
formulation. shade for an oxide
ceramic, as is done

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Fig. 2
with PFM restorations, only the desired ingot could be used, which would allow
final shade needs to be determined. This some reflectance of the underlying tooth
is due to the inherently opaque nature of structure.
the oxide materials. A low-translucency ingot was selected for
With glass ceramics, four variables will the veneers, because the large interproximal
influence the final desired shade: area between the central incisors needed
Shade of preparation. Commonly chromaticity, and might have looked too gray
The clinical outcome resulting from the use referred to as the “stump” shade, this is had a high-translucency ingot been selected.
of a translucent material over a dark metallic the color of the prepared tooth. Preparation The restorations were treated with a
post.
shades closer to the desired final color can ceramic primer (Interface, Apex Dental)
allow for a more translucent material to and adhesively luted with a light-cured resin
be used. cement (NX3, Kerr). The patient was pleased
Shade of cement. A more opaque or with the final results (Fig. 5).
more heavily chromatic cement can mask
a darker preparation more effectively than Case presentation No. 2
a translucent resin cement.10 The patient is a 39-year-old female in
Material thickness. As material thickness good general health. She had an existing
increases, it can better mask a darkened PFM restoration on #8 and a failing feld-
stump than an equivalent material made spathic veneer on tooth #9 (Fig 6). Note
with less buccal-lingual thickness.11 that although both restorations were shade
Material properties. The amount of

Fig. 3
translucency or opacity in endodontically Commonly referred
treated teeth with metal or dark posts can
create a graying-out of the restoration, to as the “stump”
shade, this is the
especially if a translucent ingot or block is
chosen to fabricate the restoration (Fig. 2).
The following cases discuss material color of the prepared
selection when dealing with factors impacting
Preoperative situation: patient presented the success of glass ceramic restorations. tooth. Preparation
shades closer to the
with failing anterior restorations.
Case presentation No. 1
Fig. 4 The patient is a 43-year-old male in desired final color
good general health who presented with
caries and failing composite restorations can allow for a more
on #8 and #9 (Fig. 3). It was decided that
the anterior teeth would be restored with translucent material
lithium-disilicate pressed veneers.
The patient was anesthetized and
to be used.
Communicating the shade to the laboratory the failing restorations were removed.
via photograph. A defect-oriented preparation was
completed.12
Fig. 5 After impressions with a
polyvinyl siloxane material
(Aquasil Ultra, DENTSPLY
Caulk), photographs with shade
tabs were taken (Fig. 4).
The desired final shade
was A2. The stump shade was
The final result. A low-translucency ingot was determined to be A3. Because
used. the desired final shade was close to
the final shade, a more translucent

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A2, and quite possibly were fabricated using Conclusion

the same feldspathic porcelain, differences A great many all-ceramic options are Fig. 6
in the overall shade can be noted. This is available to the clinician. The proper selection
due to the reflectance, or lack thereof, from of materials will help prevent any untoward
the underlying structures (more opaque clinical or esthetic failures. Additionally,
and metal from PFM #8, natural tooth when using glass ceramics, the factors
from tooth #9). influencing the final shade of a restoration
After endodontic therapy on #9 and the must be considered and managed in an Preoperative situation: the patient presented
with a PFM restoration on tooth #8 and a
removal of both restorations, it was noted appropriate manner. ■
feldspathic porcelain veneer on #9.
that #8 had an existing, well-functioning
cast post (Fig. 7). References Fig. 7
Although attempting to remove a cast
1. Philips’ Science of Dental Materials, 12th Edition. Saunders,
post and replacing it with a fiber post and 2012.
2. Helvey GA. Classifying dental ceramics: numerous materials
composite build-up is an option to block and formulations available for indirect restorations. Com-
the dark color, it does possess risks such as pend Contin Educ Dent. 2014 Jan;35(1):38-43.
3. Gracis S, Thompson VP, Ferencz JL, Silva NR, Bonfante EA.
root fracture.13 A new classification system for all-ceramic and ceramic-like
restorative materials. Int J Prosthodont.2015 May-
A clinician has several options when A preparation photo. Note the metal post on
Jun;28(3):227-35.
faced with the prospect of trying to block 4. Calamia JR, Calamia CS. Porcelain laminate veneers: tooth #8.
reasons for 25 years of success. Dent Clin North Am. 2007
out a dark color on a restoration: Apr;51(2):399-417.
• oxide ceramic or PFM 5. Yeo IS, Yang JH, Lee JB. In vitro marginal fit of three all-ce- Fig. 8
ramic crown systems. J Prosthet Dent. 2003 Nov;90(5):459-
• deeper preparation 64.
6. Yilmaz H, Aydin C, Gul BE. Flexural strength and fracture
• replacement of metal post with toughness of dental core ceramics. J Prosthet Dent. 2007
fiber post Aug;98(2):120-8.
7. Anunmana C, Champirat T, Jirajariyavej B. Tensile strength
• more-opaque composite of bilayered ceramics and corresponding glass veneers. J Adv
Prosthodont. 2014 Jun;6(3):151-6.
• opaque cement
8. Homaei E, Farhangdoost K, Tsoi JK, Matinlinna JP, Pow EH.
• opaque ingot Static and fatigue mechanical behavior of three dental CAD/ Final result: a medium-opacity ingot was
CAM ceramics. J Mech Behav Biomed Mater. 2016 Feb 2;
For this case, after discussion with the 59:304-313. selected. Note the uniformity of the final
laboratory, a medium-opacity pressed-lithium 9. Gionea A, Andronescu E, Voicu G, Bleotu C, Surdu VA. Influ- shade.
ence of hot isostatic pressing on ZrO(2)-CaO dental ceramics
disilicate ingot was selected for both teeth. properties. Int J Pharm. 2015 Oct 23.
10. Chiayabutr Y, Kois JC, LeBeau D, Nunokawa G. Effect of
Because of concerns about the efficacy of abutment tooth color, cement color and ceramic thickness
light-curing through an opaque material, a on the resulting optical color of a CAD/CAM glass ceramic
lithium disilicate – reinforced crown. J Prosthet Dent. 2011;
dual-cure resin adhesive was used to cement 105:83-90.
11. Niu E, Agustin M, Douglas RD. Color match of machinable
the restorations.14, 15 lithium disilicate ceramics: effects of foundation restoration. J
Note that the immediate postoperative Prosthet Dent. 2013 Dec;110(6):501-509.
12. Bitter K, Paris S, Hartwig C, Neumann K, Kielbassa AM.
result reveals no show-through of the metal Shear bond strengths of different substrates bonded to lithium
post in #8, and a uniform appearance of disilicate ceramics. Dent Mater J. 2006 Sep;25(3):493-502.
13. Abbott PV. Incidence of root fractures and methods used for
both front teeth (Fig. 8). post removal. Int Endod J. 2002 Jan;35(1):63-7.
14. Wang F, Takahashi H, Iwasaki N. Translucency of dental
ceramics with different thicknesses. J Prosthet Dent. 2013;
110:14-20.
15. Archegas LR, de Menezes Caldas DB, Rached RN. Effect of
ceramic veneer opacity and exposure time on the polymeriza-
tion efficiency of resin cements. Oper Dent. 2012;
37:281-289.

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1. Which glass ceramic has the highest flexural strength? 6. Which restoration is not indicated for lithium-disilicate-reinforced
A) Feldspathic porcelain restorations?
B) Zirconia A) Veneers
C) Lithium disilicate-reinforced B) Posterior bridges
D) Leucite-reinforced C) Anterior crowns
D) Anterior bridges
2. Which component of a “glass ceramic” gives the material
its strength? 7. Which of the following is a strategy to block the color of a dark or
A) Silica discolored underlying preparation?
B) Crystal A) Use of an oxide ceramic
C) Silane B) Deeper preparation
D) Block C) Opaque ingot/block
D) All of the above
3. Which of the following is an “oxide ceramic”?
A) Densely sintered aluminum oxide 8. Regarding glass ceramics, which of the following will influence the
B) Lithium oxide final shade of the restoration?
C) Feldspathic oxide A) Material thickness
D) Oxidinium B) Cement shade
C) Shade of the preparation
4. Which of the following materials has the highest flexural strength? D) All of the above
A) Lithium
B) Leucite 9. An “LT ingot” is an abbreviation for low-transparency ingot.
C) Feldspathic A) True
D) Zirconia B) False

5. Zirconia is available as either a layered or monolithic restoration. 10. What is the flexural strength of e.max Press?
A) True A) 520 MPa
B) False B) 400 MPa
C) 360 MPa
D) 657 MPa

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