Review Article

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Metal-free restorations: Clinical considerations

Chethan Hegde, Anita Nitin, Vijai S., Anil S. R., Ramya D.
Vikram Perfect, Mysore, Karnataka, India

Address for correspondence: Dr. Chethan Hegde, E-mail: hegdechethan@yahoo.co.in

ABSTRACT
Porcelain is known to be the most aesthetic material for dental restorations. Dental porcelains have had to be reinforced
with metal substructures in the past due to their unpredictable strength. However, clinicians have often faced an aesthetic
challenge when restoring anterior teeth with porcelain-fused to metal restorations. A demand for a more aesthetic alternative
has led to the evolution of metal-free restorations. This article discusses the various metal-free ceramic systems available,
their applications, including their margin configurations and cementation protocols and specific indications and advantages of
each system. Clinical evidence and experimental studies have been reviewed to provide an evidence-based application of these
materials in different situations.
Key words: All-ceramic, aesthetic restorations, metal-free ceramics

estoration of anterior teeth with full coverage

crown is a great challenge for a dental
surgeon. Predictable strength and reasonable
aesthetics have continued to make traditional metal
ceramic restorations popular, but patients demand for
improved aesthetics has led to the development of
metal-free restorations in highly challenging anterior
teeth restorations.
Metal-free restorations have a strong ceramic core
onto which layering ceramic is applied to achieve a
natural appearance. These all-ceramic systems can be
categorized broadly into two groups, based on the
ceramic core they have.
I. Translucent core
For example, Leucite Core - IPS Empress Esthetic

Lithium disilicate Core IPS e.max
II. Opaque core

For example, Lithium disilicate Core IPS e.max
Alumina core In ceram Alumina, Procera
AllCeram

Zirconica core Lava, Cercon, Procera Zirconia,
Cerona
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DOI:
10.4103/2229-5194.77189

All-ceramic crowns with translucent core are superior

in aesthetics, but weaker in strength. These crowns
can be used to cover acceptably colored dentin and
at times for anterior fixed partial denture prostheses
(FPD), where the masticatory load is less. Crowns with
an opaque core are indicated for teeth with heavily
discolored dentin or over metal posts[1] and can be
used for posterior crowns and some can be used for
posterior FPD as they have superior strength.

LEUCITE CORE
The IPS Empress Esthetic is a glass ceramic with a leucite
core. The highly homogenous quality and density of the
leucite crystals provide excellent aesthetics, by blending
well into the natural surroundings, producing esthetically
superior crowns with a chameleon effect. These crowns
can be fabricated using the press and layering or staining
technique producing good aesthetics and an occlusal fit.
These crowns with a flexural strength of 160 8 MPa
are indicated for anterior crowns and veneers where
aesthetics is highly demanding. As the leucite core is
translucent they can be used only where the dentin is
of acceptable color. These crowns have to be adhesively
cemented to the tooth using resin cements. The color
of the cement may affect the color of the restoration, as
the leucite core is translucent [Figure 1].

LITHIUM DISILICATE CORE

IPS e.max is a lithium disilicate glass ceramic. They

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Hegde, et al.: Metal-free restorations

Figure 1: PFM crowns with 11, 21 replaced with IPS Empress Esthetic
crowns

can be produced either by the press technique, where

an ingot of the desired shade is plasticized by heating
and pressed into an investment mold under vacuum
and pressure, or it can be processed using CAD / CAM
technology. The high crystal density of lithium disilicate
results in improved mechanical properties and a strength
value of 360 450 MPa.[2] IPS e.max press ingots are
available as high, medium translucency and medium,
and high opaque. Translucent ingots can be used where
the dentin is not discolored and aesthetics is the prime
requisite. Opaque ingots can be used where teeth are
highly discolored. When using opaque ingots, the strength
of the crown allows the conventional cementation method
to use resin modified Glass Ionomer Cements, as in these
crowns the color of the cement is not made visible due to
the opacity of the core [Figures 2 and 3].
Indications
Anterior and posterior single crowns
Veneers, Inlays, and onlays
Three unit anterior fixed partial denture prostheses
Three unit fixed partial denture prostheses replacing the
Premolars

ALUMINA CORE
In-ceram Alumina uses high temperature sintered alumina
Journal of Interdisciplinary Dentistry / Jan-Jun 2011 / Vol-1 / Issue-1

Figure 2: Heavily discolored 21 restored with IPS e.max crown

Figure 3: e.max crown with opaque core

glass infiltrated copings that can be used for single and

three unit anterior FPDs.[3] This high strength alumina
core is fabricated via the slip-casting technique.[4] A slurry
of densely packed Al2O3 (70 80 wt.%) is applied and
sintered to a refractory die at 1120C for 10 hours. This
produces a porous skeleton of alumina particles, which
is infiltrated with Lanthanum glass in a second firing at
1100C for 4 hours to eliminate porosity, increase strength,
and limit potential sites for crack propagation. This coping
is opaque and is veneered with feldspathic porcelain. The
flexural strength of the framework material ranges from
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Hegde, et al.: Metal-free restorations

236 MPa to 600 MPa, and fracture toughness ranges

between 3.1 and 4.61 MPa/m1/2.[5] This is indicated for
anterior crown, anterior and posterior three unit fixed
partial denture prostheses.
Procera Alumina uses 99.9% high purity aluminium oxide
coping, combined with low fusing veneering porcelain.
Procera has the highest strength of 699 MPa[5] among all
alumina based materials. Procera Alumina is indicated for
anteriors, premolar, and molar crowns.

ZIRCONIA CORE
Crowns with zirconia core materials are the strongest
among all the metal-free restorations, Yttrium-oxide
is added to pure zirconia to control the volume
expansion and to stabilize it in the tetragonal phase, at
room temperature.[6] Yttrium-oxide partially stabilized
Zirconia (Y-TZP) has mechanical properties with a
flexural strength of 900 1200 MPa[5] and high fracture
toughness, making it suitable for anterior and posterior
crowns as well as for long-span fixed partial dentures.
Lava (3M, ESPE), Cercon (Dentsply), and Procera Zirconia
(Nobel Biocare) Cerona are the various Zirconia crowns
available [Figures 4].

DISCUSSION
With the availability of a variety of metal-free restorations,
clinicians have to be aware of their various properties in
order to ensure that they select the right restoration for a
given case. For anterior full coverage restorations, where
aesthetics is the prime concern, all ceramic crowns with a
translucent core are an excellent choice. Although crowns
with translucent core are good in aesthetics, they are poor
in strength, so they are recommended for anterior teeth
with dentin that are not heavily discolored. In heavily
discolored teeth a temporary crown is a useful guide,[7] to
know if its shade is influenced by the underlying substrate,
in which case a crown with an opaque core can be used.
While using translucent crowns tooth preparation with an
equigingival margin is recommended.[7] They will require
resin cement for cementation, which will enhance the
strength of the crown through bonding. It is advisable
to use light cured resin luting agents, as they are more
color stable compared to dual cure resin cements, which
may discolor due to the release of amines, over a period
of time.
Crowns with opaque cores are superior in strength,
with good aesthetics, and can be used for anterior
and posterior teeth. Crowns with the Zirconia core are
recommended for fixed partial dentures. One can use
resin or conventional luting agents for cementation as
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Figures 4: Zirconia core crowns to restore anterior and posterior

discolored hypoplastic teeth

the color of the cement will not affect the shade of the
crown. When restoring anterior teeth with these crowns
it is advisable to end the margin subgingivally, as there
could be a mismatch in shade between the tooth margin
and the restoration. It is advisable to use an opaque core
in teeth with heavy discoloration. The strength of these
restorations is dependent on the ceramic material used,
the Core-Veneer bond strength, the crown thickness, and
the design of restoration.[8] Metal-free restorations are
not recommended in subjects who have heavy bruxism.

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Source of Support: Nil, Conflict of Interest: None declared.

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