Looks -...

1

The Metal-Free Practice

Looks

Longevity

versus

Common Public Perception of a Crown

Sticks out like a headlightDoesn’t matchToo opaqueBlack line at gum

The All-Ceramic Restoration

• Increased translucency and vitality

• Supra-gingival margins possible

• Does not contain metal

• Potentially best esthetics

All-Ceramic RestorationAdvantages

2

PFM vs All-Ceramic Crown

PFM Crown

All-Ceramic Crowns

• Exacting preparations

• Exacting cementation procedures

• Post-operative sensitivity

• Post-seating fractures

• Often higher lab bill (not pure Zr)

All-Ceramic RestorationChallengesChallenges

• Strength

• Esthetic expectations

• Specific tooth

• Occlusal habits and trauma

• Amount of tooth preparation

• Color of underlying tooth structure

• Periodontium biotype

• Type of core or post

• Bonding vs conventional cementation

• Patient cooperation

All-Ceramic Selection Factors

Cardoso JA, Almeida PJ, Fischer A, Phaxay SL. Clinical decisions for anterior restorations: the concept of restorative volume. J Esthet Restor Dent. 2012; 24:367-83

• All Zirconia

• High translucent Y-TZP

• Porcelain fused to Zirconia ?

• Monolithic Lithium Disilicate

• Lithium Disilicate w/ cutback

• Pressed Ceramic

• Feldspathic

All-Ceramic Restoration Materials-2016

• All Zirconia

• High translucent Y-TZP

• Porcelain fused to Zirconia

• Monolithic Lithium Disilicate

• Lithium Disilicate w/ cutback

• Pressed Ceramic

• Feldspathic

All-Ceramic Restoration Materials-2016

Monolithic

• Inherently Stronger

• Staining may wear off

• Posterior teeth

All-Ceramic RestorationsMonolithic vs Layered Core

Layered Core

• Weakest link is bond of overlaid porcelain to core

• Best esthetics

• Anterior teeth

3

Layered Zirconia RestorationsChipping of Layered Core

Technique Dependent

• Prep design

Sharp line angles

Uneven thickness of ceramic


Technique Dependent

• Prep design

• Core design

Urapepon S, Taenguthai P. The effect of zirconia framework design on the failure of all-ceramic crown under static loading. J Adv Prosthodont. 2015 Apr; 7(2): 146–150

Even thickness 0.5mm Zr

Even thickness 0.8mm layering porcelain


Technique Dependent

• Prep design

• Core design

• Decreased bond between porcelain and zirconia

Miyazaki T1, Nakamura T, Matsumura H, Ban S, Kobayashi T. Current status of zirconia restoration. J Prosthodont Res. 2013 Oct;57(4):236-61


Miyazaki T1, Nakamura T, Matsumura H, Ban S, Kobayashi T. Current status of zirconia restoration. J Prosthodont Res. 2013 Oct;57(4):236-61

Occurs 10-19%

Solution

• Anterior-Lithium DiSilicate fused to Zr

• Posterior-Monolithic

Zirconia

• Stronger

• More opaque

• Conventional Cementation

• Posterior teeth

• Failure-Loose

All-Ceramic RestorationsZirconia vs Lithium DiSilicate

Lithium DiSilicate

• Weaker

• More Translucent

• Bonded Cementation Best

• Anterior teeth

• Failure-Fracture

All-Ceramic RestorationsLithium DiSilicate

• Anterior Teeth through Bicuspids

• Layered Incisors and Canine

• Monolithic bicuspids

• Bonded-anesthetize

4

All-Ceramic RestorationsZirconia

• Posterior molars

• Monolithic

• Anterior-blockoutdark tooth

• Li Disilicate to Zr

• Conventional cementation

• Bond w short or convergent preps

All-Ceramic RestorationsLithium DiSilicate bonded to Zirconia

• Anteriors

• Tight clearance

• Blockout metal

Lithium DiSilicate Restoration Lithium DiSilicate Restoration

Lithium DiSilicate RestorationLithium DiSilicate fused to

Zirconia Restorations

5

Lithium DiSilicate fused to Zirconia Restorations


Picasso Lite




All-Zirconia Restorations

36.2mm

10.9

mm

6

All-Zirconia Restorations All-Zirconia Restorations

All-Zirconia Restorations All-Zirconia Restorations

• Feldspathic-Bonding• Lithium DiSilicate-< 1.0mm thick

Bonding Required• Lithium DiSilicate-> 1.0mm thick

Bonding Preferred• Zirconia retentive preparation-

Cementation• Zirconia non-retentive preparation-

Bonding

All-Ceramic RestorationCementation/BondingCementation/Bonding Feldspathic Porcelain Restorations

• Potential for best esthetic results

• Primary use-Laminate Veneers

• 60-70 MPa flexural strength

• Must be meticulously bonded

7

I want an extreme makeover

Retracted View

Lateral Views

8 Teeth Prepared for Feldspathic Porcelain

Laminate Veneers

Select desired shade before beginning

preparation

Bonding Porcelain Laminate Veneers

DO NOT USE:

Self-Cured Cements (Contain elevated levels of Tertiary Amines which may yellow)

Self Curable Cements which you can add a dual-cured catalyst (May yellow)

Dual-Cured Cements (May Yellow)

Cement Do’s and Don’ts


DO NOT USE:

Self-Adhesive “Cem” Cements-lower bond strength-(12-15 MPA vs 24-36 MPA) Rely X Unicem

Smart Cem

Bis Cem

G Cem

Mono Cem

Cement Do’s and Don’tsBonding Porcelain Laminate Veneers

DO NOT USE:

Self-Etching Primer (Poor enamel bonding) MUST ACID ETCH ENAMEL


8


DO USE:

Fourth Generation Total Etch multi-bottle

Fourth Generation Total Etch 2 component

Fifth Generation Total Etch

Universal Bond Total Etch Mode


All-Bond Universal Bond

All-Bond III (ACE TE)

All-Bond II One Step Bond


DO USE:

Light Cured Only Resin Cements


Choice 2 (delta E<1.2)

Bonding Porcelain Laminate VeneersTreatment of Porcelain Surface

Only glass beads should be applied under pressure to internal surface of laminate

If not etched apply 9% HF for 90 seconds


Wash thoroughly

Ultrasonic in Et OH or apply 32-27% phosphoric acid to remove hexafluorosilica salts on surface if over-etched

Over-etched


If not silanated dry & apply silane-wait 90 seconds (BEST to silanate when received from lab

Silane to Porcelain

Condensation Reaction

Porcelain

-H2O


2 Forms of Silane

Pre-Hydrolyzed Silane + Acid Non-Hydrolyzed

O

OSi

OH

HO

HO

9


Tryin with water soluble gels

Clean in ultrasonic or apply phosphoric acid wash and dry thoroughly

Bonding Porcelain Laminate VeneersTooth Surface Preparation

Place 32-37% Phosphoric Acid on enamel for 15 seconds then on dentin for 5 seconds

Wash thoroughly and dry enamel but leave dentin moist

Place GLUMA on exposed dentin

Bonding Porcelain Laminate VeneersTooth Surface Preparation

All Bond 2:Apply 3-5 coats A&B, gently air dry, light cure 10 sec, apply D/EBond do not light cure

All-Bond 3 (ACE TE): Apply 1-2 coats of mixed, gently air dry and light-cure 10 sec

One-Step Plus: Apply 1-2 coats, gently air dry and light cure for 10 sec

All-Bond Universal: Apply 1-2 coats, lightly air dry at an angle and light cure for 10 sec

Bonding Porcelain Laminate VeneersPlacement

Optional-w thick cements (Provi-Link) Apply a thin layer of Porcelain Bonding Resin (HEMA free) to internal surface of veneer, do NOT light-cure

Apply selected shade of CHOICE 2 to internal surface of veneer and guide into place

Tack cure for 3-5 seconds, then remove excess cement

Bonding Porcelain Laminate VeneersPlacement

Use rubber tip to remove excess

Wave cure (1:1,000, one inch away)

Use scaler to remove excess

Floss contacts

Place glycerin around margins and thoroughly cure for 1 minute from buccal and lingual

Bonding Porcelain Laminate VeneersFinal Adjustments

Check occlusion in Centric Occlusion

Carefully adjust protrusive and lateral excursions

Smooth lingual with fine diamond football, white stone, successive points

Have patient return in 2 weeks for photos and to check occlusion

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Before

After

Porcelain Laminate Veneers Seated

Laboratory prostheses fabricated by Valley Dental Arts Stillwater MN

Lithium Disilicate (E-Max)

• Strength and translucency

• Posterior crowns-monolithic

• Pressed or CAD produced

• Anterior crowns-w/ layered porcelain

• 360-400 MPA flexural strength

• Better to be bonded unless thick

• Best esthetics

Single Central Incisor Crown•2-5 Appointments•Higher Fee

Lithium Disilicate (E-Max)Endodontically Treated

Old Bonding

Lingual View

Remove facial compositeRemove AO compositeRemove most stainUse perio probe to remove subgingivalBond bleach white compositePrepare toothPhoto w/stump shade

Make custom temp for lab

•Make quick bis-acryl

•Laminate prep on facial

•Add composite and custom stains

Send photo and temp to lab

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OR Make custom shade tab for lab

•Core Shade

•Add tints

•Overlay with Incisal Shade for value

Send photo and tab to lab

Pre Operative Smile

Post Operative Smile

Laboratory prosthesis fabricated by Valley Dental Arts Stillwater MN

Monolithic E Max CrownsLoad to Failure*

*Data from Ivoclar/Vivadent

Li2Si2O5

Dentin______

CoreResin Cement

Sila

ne

Bonding to Lithium Disilicate(Retentive)

15 MPa

Li2Si2O5

Dentin______

CoreResin Cement

Sila

ne

Adhesive

Bonding to Lithium Disilicate-(Non Retentive)

35 MPa

Duo-Link Universal

•Increased radiopacity

•2 shades‐milky white & translucent

•Dual curing

•Completely cures w/o light exposure

•Easier cleanup

12

Duo-Link Universal

•Usable with Universal, total etch, self‐etch bonding agents

e Cement•All‐inclusive kit

•Dual and light cure

Duo-Link used with All-Bond Universal vs. Primersfor Ceramics & Zirconia/Metals (Indirect Substrates)

Indirect Substrate

All-Bond Universal + Duo-Link

(Pure) Primer + Duo-Link

Porcelain (etched) 21.5 (3.4) 34.6 (w/ Porcelain Primer)

Lithium Disilicate (etched)

32.8 (7.7) 35.5 (w/ Porcelain Primer)

Zirconia 26.9 (5.1) 28.7 (w/ Z-Prime Plus)

Alumina 33.7 (8.2)

Stainless Steel 39.8 (6.8)

Gold 21.7 (4.6)

*Cements were cured using the L/C mode.

*All Bond Universal can be used as a Universal Primer for Porcelain & Zirconia substrates , but it MUST BE LIGHT‐CURED prior to cementation of the restoration. Although the initial Shear Bond Strengths may be statistically similar, a separate pure Silane primer for lithium disilicate and separate Metal primer for Zirconia results in better long‐term durability of the bond.

Temporary Crown

Bonding Technique

Place Divots with 330 bur

Anesthetize if vital

Seat Pointed Forceps-Easy back and forth

Be gentle: slight rock, then pull straight up

(Optional) Roughen surface w diamond for immediate dentin sealing

Sandblast bases/liners (place gingival protection)

Wash and remove excess moisture

Wipe off tooth with wet cotton roll

Check interproximal contacts with floss-avoid causing bleeding

Adjust contacts with white stone-re-polish areas

Check margins w/explorer

Adjust tooth not intaglio surface of crown

13

Re-acidify surface with Phosphoric Acid

Wash and dry thoroughly

Apply silane (if not previously applied)

Wait 90 seconds and air dry avoiding water contamination

Agitate into tooth for 30 seconds (so that calcium ions neutralize the acid

Lightly blow air to evaporate solvent for 20 seconds

Mix one drop each

Mix Cement and place in tooth

Lightly coat to avoid overfilling (hydraulic pressure can impede seating)

Quickly seat crown and push down

Hold crown down and use brush to remove excess cement

Hold crown, floss contact down and pull floss through

Wave cure margin 1 second

Use scaler to remove excess cement then explorer

Floss

Place glycerin around margins

Light cure for 1 minute

Check Occlusion

Adjust with fine diamond

Then white stone and polish

Crown complete

Laboratory prosthesis fabricated by Valley Dental Arts Stillwater MN

Zirconia (Lava, Cercon, Procera Zr)

• Strong core, but reported interface chipping

• 900-1100 MPA flexural strength (Zr)

• 90-160 MPA veneered ceramic

Can be used for bridges

Can use conventional cementation

Opaqueness masks out metal posts

Full-mouth rehabilitation

14

ZrDentin______

Core Resin ModifiedGlass Ionomer Cement

Z P

rime

Polyacrylc A

cid*

Cementing to Zirconia

Retentive Zr Crown cement with Resin-Modified Glass Ionomer Cement (*Pre-Treatment optional)

DO NOT TREAT WITH PHOSPHORIC ACID!

ZrDentin______

Core Calcium AluminateRMGI Cement

Cementing to Zirconia

Retentive Zr Crown cement with Resin-Modified Glass Ionomer Cement (*Pre-Treatment optional)

DO NOT TREAT WITH PHOSPHORIC ACID!

GI Initial setting and early strength Fluoride release

Calcium Aluminate Long term-increased strength and retentionApatite formation Sealing at marginal interface Sustained long term properties w/o degradingHigher pH (not acidic)-virtually no sensitivity

Ceramir

Telio – Temporary Concept, Team IV Spain, Madrid, November 2009

Ceramir

Forms apatite crystals Powder and water are mixed Dissolution results in nano-crystal formation Gibbsite and Katoite forms Crystals form on tooth and restoration Long-term stable bond Ceramir Dentin

Physical Properties– Creates Apatite when in contact with phosphates– No shrinkage– Hydrophilic system with Alkaline pH– Thermal properties similar to tooth structure– Low film thickness -15 microns– 160 Mpa compressive strength– Anti-bacterial-inhibits caries– Gets stronger over time– Acid resistant– Bonds well to metal, porcelain, ceramics, zirconium

Ceramir

Telio – Temporary Concept, Team IV Spain, Madrid, November 2009

Ceramir

Jeffries SR, Fuller AE, Boston DE. Preliminary Evidence that Bioactive Cements Occlude Artificial Marginal Gaps. J Esthet Restor Dent. 2015.

Self Adhesive Resin Cement

Resin-Modified Glass Ionomer

Glass Ionomer

Calcium AluminateRMGI

Calcium Silicate

15

0:00

Ceramir

2:00

Ceramir

4:00

Ceramir

Calcium Aluminate/RMGI cement– Hybrid cement

– Forms apatite crystals

– Excellent physical properties

– Low film thickness-easy to use

– Virtually no sensitivity

Ceramir

ZrDentin______

CoreResin Cement

Z P

rime

Adhesive

Bonding to Zirconia

Short/Tapered, Non-retentive Zr Crown adhesively bond with Resin Cement

Universal Primer

• Can be used with Self-Etch, Total-Etch or Selective Etch techniques

• Compatible with Light-cured, Dual-cured & Self-cured resin cements, composites or core materials

• Universal adhesive for direct & indirect bonding procedures

16

Universal Primer

• Advantages– Contains MDP-long term stable bonds

– Does not need to be light cured-posts

– Low film thickness (5 microns)

– Excellent bond strengths

Universal Primer

Z-Prime Plus (Surface Primer)

• Phosphate Monomer (MDP), BPDM, Et OH

• Indications– Zirconia (LAVA, Cercon, Implant)

– Alumina (Procera)

– Metal (Titanium, Non-Precious, Semi-precious, High Noble)

– Composite Indirect

– Endodontic Posts (Zirconia, Fiber, Metal)

– Intra-oral repairs

Bonding Zirconia CrownsTreatment of Zirconia Surface

MDP to Zirconia

Addition Reaction

Zirconia

Bond Strengths to Intaglio Surface*

*Data from Bisco 96

Phosphates contaminate Zr surface

• Saliva contains phosphates that tie up receptor sites

• DO NOT clean with Phosphoric Acid

17

97

Composition (wt%):Zirconium oxide 10 - 15Water 65 - 80Polyethylene glycol 8 - 10Sodium hydroxide ≤ 1 (pH = 13 -13.5)Pigments, additives 4 - 5

Ivoclean

Phosphates contaminate Zr surface

• Treat contaminated surface with Ivocleanthen apply Z Prime

P < 0.05 (ANOVA, T-Test)

Contamination Clean/Treat SBS, MPa (n = 8)

No contamination Z-Prime 31.5 (8.4)a

Saliva Water 20.6 (7.1)b

Saliva Ethanol 20.3 (4.2)b

Saliva Ivoclean 32.0 (6.2)a

Saliva Sandblast 30.3 (6.7)a

Pre Z-Prime-Saliva Ethanol 28.8 (7.7)a

AADR/IADR 2013 Abstract

Effects of Saliva Contamination

DT Posts/XRO

• Quartz fiber post

• 825 MPa flexural strength

• Radiopaque

• Changing temperature changes color

• Excellent micro-mechanical retention

Four Sizes

1.25 1.5 1.8 2.2mm

1.2mm1.00.90.8

TAPER #2:

.04

.02 .02 .02 .02

.06 .08 1.0

TAPER #1:

Diameter

DT Posts/XRO

Core Flow DC Lite

• High Compressive Strength

• High Flexural Strength

• Low Polymerization volumetric shrinkage (for a resin core)

• Used as a cement for the post as well as the buildup

• Non-slumping

• Cuts like dentin

Broken post removed

Post drill prepared 2/3’s length of root

Take radiographic to measure canal length

18

Try-in postClean post and dry

Apply Z Prime

Etch canal with Phosphoric Acid for 5 seconds

Irrigate thoroughly with water

Use paper points to dry canalClick once and mix Universal Primer Place 2 coats of bonding agent

Leave for 20 secondsUse paper point to remove excess liquids

Evaporate for 20 seconds

Coat post with Core Flow

Seat quickly

Light cure through post for 10 seconds

Express Core Flow and shape

Light cure thoroughlyBuilding Up Core

19

Core Buildup CompleteInitial Core Buildup

Diode laser used to crown lengthen and increase ferrule

Crown Seated

Hands-On Crown Seating Hands-On Crown Seating

Hands-On Crown Seating Hands-On Post and Core BuildupZ Prime

20

Hands-On Post and Core BuildupZ Prime

Hands-On Post and Core BuildupUniversal Primer



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