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Ceramic Materials
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Question #1: Is it true that the new pressable ceramics are more esthetic than other porcelains?

Answer: Not neccessarily. The esthetics of a ceramic restoration is almost entirely controlled by the skill of the ceramist using a porcelain. Each ceramist has the ability to match different clinical situations with each porcelain. Some materials allow for more shades than others, but these may only be useable in a few patients. Lecturing clinicians who state or imply that a new ceramic has superior esthetics are not in a good position do so. What may be true is that they are working with the best ceramist s/he knows of, and that the ceramist may prefer the system.

Question #2: I have been told the new pressed ceramic systems are superior to conventional ceramics.

Answer: No, they are only different. They have an ability to fit extremely well but are much weaker than many other all-ceramic systems. These materials can be more translucent than some. However, this is not necessarily related to improved esthetics since these effects can also be achieved with other ceramic systems.

Question #3: Are all-ceramic restorations more esthetic than porcelain-fused-to-metal restorations?

Answer: This is often true. Examples include cases with thin restorations with minimal reduction, or those with anterior restorations or high lip lines. However, in posterior teeth with adequate reduction and ceramic collars this may not be true. The inability of metal to allow light penetration to the tooth intensifies the opaque reflection if facial reduction is inadequate. Inadequate tooth reduction is the major reason PFM restorations are less esthetic than all-ceramic ones.

Question #4: Should I switch to an all-ceramic practice for indirect restorations because they are on the cutting edge?

Answer: No, they may be on the cutting edge in some circles but they are better described as changes. It will be many years until we know how well newer all ceramic systems hold up long term. Many knowledgeable professionals feel it is highly unlikely that they will do better than well-made, metal-supported ceramic restorations, which have 40 years of proven clinical success. The important question is how long a restoration needs to last to be considered successful.

Question #5: What do I tell my laboratory about these newer all-ceramic materials?

Answer: First, don't make any demands on your laboratory for specific materials. Sit down one-to-one with your lab's technicians and discuss the match between the needs of your patients and the technicians' needs and abilities. The increased costs to the dental laboratory for these expensive new systems must be passed on to you and then to your patients. The important question is what are we giving up and what are we gaining in terms of patient care.

Question #6: Should all-ceramic materials be used for bridges?

Answer: A bad idea. The success rate of all-ceramic bridges is very poor. Small anterior bridges in minimal stress-bearing areas (e.g., Class II division II or anterior open bites) do better than others. Posterior bridges fail after a very short time.

Question #7: Aren't you overly conservative in recommending improvements to restorative dentistry?

Answer: I am all for improvements but I am not comfortable making changes that do not provide a clear benefit to the patient over present-day systems. During my 23 years as a practicing dentist and teacher I have seen many systems come and go. In recent years these changes have accelerated. It takes years to determine if a new system is better than those that have survived over time. Some new systems are improvements over existing systems and can be used with predictable results. However, other new technologies have had limited clinical testing. In terms of posterior restorations, porcelain-fused-to-metal is the most predictable approach, and its esthetics are usually adequate for back teeth. Premolar teeth have done well with all-ceramic systems that have a durable core (e.g., Procera, Inceram, CMBRs). For anterior teeth, most ceramic systems with a core (even weaker cores such as pressables), or those supported by some enamel in stress-bearing areas, have been successful. Case selection is the most important factor in the success of any ceramic system.
Respected educators and researchers often differ in their opinions on the benefits of new systems. A dentist must look at the facts and make his or her own decision about what is best for patient care. I am slower than most to change to new systems until they have been on the market for a while. I agree with Thomas Jefferson when he said "It is better to delay than to err." With careful case selection, all-ceramic restoration can be a good adjunct to a restorative dental practice.

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