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SMILE DESIGN, ESTHETIC MATERIALS, BONDING
UPDATE
GEORGIA DENTAL COLLEGE
All-Ceramic Crowns, Veneers & Bonding Update
Techniques and principles reviewed in this all-day program are derived from my personal teaching
and clinic experience.
They do not constitute a guarantee for success, the attendees should form their own opinion.
Gerard Chiche L.L.C.
DISCLAIMER LIMITED TREATMENT I
ESTHETIC DESIGN
Tools for Progress
Upper Lip Line Lower Lip Line
Treatment Plan from Incisal Edge Up
ESTHETIC PRIORITIES ESTHETIC CHECKLIST 1. PROPER LENGTH
2. INCISAL PROFILE
3. PROPORTIONS
4. GINGIVAL LEVELS
Kinetics of Anterior Tooth Display Vig , Brundo 1978
Dynamics of the Maxillary IncisorDickens , Sarver, Proffit 2002
I. Pleasing Display
1. Male Pt. 0.5 - 2 mm.
2. Female Cons. 2.0 - 3 mm.
3. Female Spark. 3.5 - 4.5 mm.
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Treatment PlanFrom Incisal Edge UP
Central LengthShort Face: 10.0 mm.Medium Face: 10.5 mmLong Face: 11.0 mm & up
WAX-UP at KNOWN LENGTH
Diag. Cast 1 Diag. Cast 2
_digital workflow
analyze plan
2D 3D
_digital workflow
II. Incisal Profile 90 Degree Relation
III. SET SMILE LINE
CONVEX
FLAT
CONCAVE
TOO CONVEX
RECORD LOWER LIP SHAPE !
MOVE BUCCAL CUSPS LABIALLY = LESS INTERFERENCES
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LESS INTERFERENCES, MORE LENGTH,UPRIGHT BICUSPIDS = LESS WEAR
10 mm. L
7.5-8.0 mm
11 mm. L
8.5-9.0 mm
IV. SET PROPORTIONS
Dr E. AbouNallah & Mr A. Torosian
Rule: When Set Proportions = Optimize Canine Guidance
Rule: Maxillary Incisors Set-up Dictate Mandibular Incisors PlanI. SET INCISAL LENGTH
II. SET INCISAL PROFILE
RULE: MAXILARY INCISORS CONTROLMANDIBULAR INCISORS POSITION
Interdisciplinary Treatment
Axial Inclination
Implant Restorations Goals
1. Proper Sagittal Inclination
22. Incisal Porcelain Thickness
3. Moderate Anterior Guidance
Chipped One Week Post-Delivery
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0
40
80
120
160
200
Zirconia Enamel Nano comp.
polished
Ghanta H, Ozer F, Yi Y, Irmak O, DiRienzo J, Blatz MB. Effect of wear on bacterial adherence to material surfaces.
IADR 2015 Abstract 2150.
Me
an
ba
cte
ria
co
unt
Bacteria countbefore and afterdual axis wear with220,000 cycles at 49 N
S. gordonii on polished surface
S. gordonii on worn surface
Enamel highest bacteria count to both surfaces Zirconia lowest bacteria count
B A C T E R I A L A D H E S I O N
Zirconia
1. Need Polished Subgingival Zirconia2. Metal Base
3. Screw Access Location & Thick Incisal EdgeMechanical Complications Associated with Angulated Screw Channel Restorations
99 Restorations – Two-Year Follow-up – 1 Loosened ScrewA. Greer 2017
Dr M. Tadros & Mr A. Torosian
FULL-STRENGTH ZIRCONIA FACIAL CUTBACK
INCISAL EDGE SUPPORT
NobelProcera HTML / CZR
1. Strength Precaution Implant Restorations
If Cut-Back Must Support All Incisal Edges
All Zirconia & Emax Cases
Dr A. Orta & Mr A. Torosian
2. Edge-to-edge Design
J. Prosthetic Dentistry 2018
Katana HT Zirconia
0.5 mm. Thick No Discoloration
1.0 mm. Thick If Discoloration
FRAMEWORK THICKNESS
Dr. A. Orta & Mr. A. Torosian
Design Precaution for Heavy Parafunction
NobelProcera HTML / CZR Porcelain
Full-Strength Zirconia 3-YTZP
Bonded Single Units More Strength Needed
Maximum Strength Mostly Bonded
Bonded or Cemented Mostly CementedMonolithic – Painted or Cut-Back Monolithic- Painted Cut-Back Esthetic Zone
Lithium Disilicate 350-500 MPa
Translucent Zirconia 650-800 MPa
Full-Strength Zirconia 1100-1500 MPa
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DISPERSION STRENGTHENING
Zirconia Lithium Disilicate
1965 1975
“The brittle nature of ceramics demands a greater margin of safety in strength than with metals.”
Glass Ceramics
• 2 Reduced Facial Thickness
• 3 Moderate Discolorations
• 4 Crowns, Veneers, Onlays
• 1 Best Translucency
Drs. D. Swayze, R. Elkattah & Mr A. Torosian
Decision-Making Ceramic Selection
Crowns
Onlays
VeneersDr S. Dang & Mr A. Torosian
Paired SE Adhesive / Cement Examples
LITHIUM DISILICATE Dual-Cured Cement paired with Self-Etch AdhesivePaired SE Adhesive / Cement Examples
Bond to Enamel
Glass Ceramics LVS 3 – LVS 4 Dr. E. Bailey
Mini Crown Preps
For Conservative Lithium Disilicate Crowns
26.8
33.6
SB Univer Unetched SB Univer etched
Single Bond Plus
Significance difference in enamel shear bond strength (p.<05) with SB Universal
SB Universal NO ETCH SB Universal WITH ETCH
SINGLE BOND PLUS WITH ETCH
Courtesy Dr. John Burgess
SELECTIVE ETCH
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Lower 1st Molar Most Severe
Soda-Swishing
Cupping/Cratering
Smooth Lingual Wear of Upper Anterior
Regurgitation
Abrahamsen TC, Inside Dent 2011;10:38-50
Erosion
Even Posterior WearUpper & lower
Fruit-Mulling
Cupping/Cratering
Chewable Vit. C Asthma Spray
Chlorine
Less Frequent
Safety of Increasing Vertical Dimension of Occlusion: a Systematic Review J. Abduo. Quintessence Int 2012
• Magnitude Maximum 5.0 mm. Meas. Anteriorly. Gough, Dahl, Ormanier.
• Patient Adapts Resolution 1-2 weeks (2 days - 3 mo.) Carllson, Rivera, Abekura, Tryde
• EMG Activity Back to pre-treatment levels 2 -3 mo. Carllson, Dahl, Gough, Manns.
• Relapse Unknown, Relatively Stable. Gough, Dahl, Ormanier.
© Bite FXPATIENT UNCOMFORTABLE AFTER VDO INCREASE = INCLINES ARE TOO STEEP FOR CHEWING
SOLUTION: ADJUST ALL LINGUAL CONCAVITIES
Mandibular Incisor Display 0.5-3.0 mm
EMAX REQUIRED OCCLUSAL THICKNESS 1.5 mm. Minimum Adequate if Luted (RMGI)
M. Kern et al. JADA 2012 143; 3: 234
Dr S. Aimplee & Mr A. Torosian
EMAX REQUIRED OCCLUSAL THICKNESS 1.0 mm. Sufficient if Adhesively Bonded
(Ivoclar – Vivadent 2016)
Alvaro Esthetic Fellow
Cantilever Connector SizeLiSiO2 H. 4.0mm X 2.0 mm Tsitru 2012
LiSiO2 H. 3.6 mm X 2.8 mm Sun 2013
Emax Connector Size
4 X 3 = 12 mm² Total Size Kern 2012
Same As Translucent Zirconia FPD
Emax Connector Size
4 X 3 = 12 mm² Total Size Kern 2012
Same As Translucent Zirconia FPD
Bruxzir Anterior
Particle size 1.0 – 1.5 μm
Flexural Strength 650 – 720 MPa
Sintering Temperature 1530 °C
Manufacturer’s Recommendation
Noritake
Glidewell
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Glass Ceramics
• 2 Reduced Facial Thickness
• 3 Moderate Discolorations
• 4 Crowns, Veneers, Onlays
• 1 Best Translucency
Dr S. Dang & Mr A. Torosian
Zirconia Ceramics
Decision-Making Ceramic Selection
• 5 Need More Masking
• 6 Most FPD’s
• 7 Require More Strength
• 8 Prefer More Cementation
BURGE
SS
Full Strength (3Y-TZP)
Dr. S. Arias & Mr. A. Torosian
CEMENTED1. SINGLE UNITS2. FPDs3. SCREW-RETAINED
ZenoStar MO Zirconia
Dr. R. Vega & Mr. A. Torosian
Screw-Retained FPD = Full-Strength Zirconia
1. MASSETER MUSCLE MASS 2. FACE TAPER 3. MANDIBULAR PLANE ANGLE MAXIMUM BITE FORCE
• 500 N
• 700 N
• 1000 N
Monolithic Zirconia Crowns Recommendations
Thickness Fracture Strength Thickness Fracture Strength
0.8 mm. J Lee 2007 (N/A)
1.0 mm. G Jang 2011 (3216 N)
1.0 mm. S Jang 2013 (1780 N)
1.0 mm. C Johanson 2013 (2795 N)
1.0 mm. S Ting 2014 (2429 N)
Margin of Safety 1.0 mm. and above Monolithic Zirconia High-Strength Minimum Thickness
Margin of Safety: 0.8 mm. Acceptable, 1.0 mm. Ideal CEMENTED
aZenoStar MO ZirconiaDr S. Arias & Mr. A. Torosian
Courtesy Dr. J. Burgess
Monolithic Zirconia High-Strength Minimum Thickness
Margin of Safety: 0.8 mm. Acceptable, 1.0 mm. Ideal
Courtesy Dr. J. Burgess
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Zirconia Polished 400,000 Cycles Gloss of Polished Zirconia
Janyavula S., Cakir, D, Beck P.Ramp LC, Lawson N., Burgess J.
2013
Courtesy Dr. John Burgess
Best diamond cutting
measured
Komet ZR 6881
Courtesy Dr. J. Burgess
Ceramic Fracture = Insufficient Thickness around Screw Channel “…The screws must be absolutely surrounded by minimum of 2 mm. of zirconia all the way around …” L. Cooper 2015
Dr. S. Aimplee & Mr. A. Torosian
Connector Thickness Connector Thickness
Cantilever Connector Size ZrO2 6mm² Total Size Zasse 2013
NobelProcera HTML / CZR1. Full-Strength Zirconia (3Y-TZP)
for All Fixed Partial Dentures
Long-Term Retrospective Dental Laboratory Survey of Zirconia-Based Crowns IADR 2010 Abstract # 148370, 2011Raigrodski A., Dogan S., Englund G.
Performance of Zirconia Based Crowns and FPDs in Prosthodontic PracticeIADR 2010 Abstract # 40705, 2010
Nathanson, Chu, Yamamoto, Stappert,C.
Clinical Comparison of Zirconia, Metal, Alumina Fixed-Prosthesis FrameworksVeneered with Layered or Pressed Ceramics: A Three-Year Report
J. Am. Dent. Assoc. 2010;141;1317-1329R. P. Christensen, B. J. Ploeger
Clinical survival of posterior zirconia crowns in private practice IADR 2010 Abstract# 134121
Blatz M, et al
Cerabien CZR 930 – 940 Deg. C Vita VM9 910
“…CZR Press veneer ceramic for zirconia was the exception with a performance comparable with
that of veneer ceramics for metals…”
2. Veneering Ceramic
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Dr. M. Silva & Mr. S. Im
9.0 mm² Post. FPD 1 Pontic
7.0 mm² Ant. FPD 1 Pontic
12.5 mm² Post. FPD 2 Pontics
6.0 mm² Ant. Cantilever
Tsitru, 2012, Kern 2012, Sun 2013, Pozzi 2015
3. Zirconia Connector Size
Raigrodski 2006, Larrson 2007, Studardt 2007, Zasse 2012,
16.0 mm² Full-Arch Impl. FPD
Dr. M. Silva & Mr. S. Im Bonded Single Units More Strength Needed
Maximum Strength Mostly Bonded
Bonded or Cemented Mostly CementedMonolithic – Painted or Cut-Back Monolithic- Painted Cut-Back Esthetic Zone
Lithium Disilicate 350-500 MPa
Translucent Zirconia 650-800 MPa
Full-Strength Zirconia 1100-1500 MPa
Translucent Zirconia - What is it?
Birefringence : Light scatters at grain boundaries
Alumina Yttrium to stabilize cubic phase
Tetragonal ZrO2 Resists Crack Propagation
Tetragonal ZrO2
Zirconia Classified - 3, 4, 5 mole% Yttria Continuum
Cubic ZrO2
Above 2370°C
Tetragonal ZrO2
1170°C-2370°C
BruxZir Glidewell Katana STML Noritake Bruxzir Anterior Glidewell Cercon HT Dentsply Zenostar MT Wieland Cercon xt DentsplyKatana HTML Noritake ZirCAD MT Ivoclar Katana UTML Noritake Lava Frame, Lava Plus 3M Zpex 4 Tosoh Lava Esthetic 3MNobelProcera, HTML Nobelbiocare Lava Plus 3M Zpex Smile Tosoh Zenostar MO & Zenostar T Wieland ZirCAD MO, ZirCAD T IvoclarZpex Tosoh
Dr. A. Zaher & Mr. A. Torosian
Katana STML (4-YTZP)
E.max
NobelProcera HTML(3-YTZP)
Kwon, D N. Lawson, E. McLaren, A. Nejat J.O. Burgess 0.8mm thickness,
1194
737 688460
Katana HT Katana ST Katana UTML e.max0
200
400
600
800
1000
1200
1400
Flexural Strength
Flexural Strength
Courtesy Dr. John Burgess
P. Zadeh J. Prosthetic Dentistry 2019
Kwon, D N. Lawson, E. McLaren, A. Nejat J.O. Burgess 0.8mm thickness,
1194
737 688460
Katana HT Katana ST Katana UTML e.max0
200
400
600
800
1000
1200
1400
Flexural Strength
Flexural Strength
Courtesy Dr. John Burgess Flexural Strength
Cement
Rely X Plus
(3M)
Precaution 1No
Feather Edge Margin with Cubic Zirconia
•
Precaution 2Sandblasting Cubic Zirconia = 30-50 micron Alumina 1 BAR
Accepted for publication
800
439638
475 404
Control 1 bar Al 1 bar glass 2 bar Al 2 bar glass 0
200
400
600
800
1000
flexural strength
Lava Esthetic
Courtesy Dr. John Burgess
8/14/2019
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TRANSLUCENT ZIRCONIA = ESTHETICS WITH MORE STRENGTH Workflow for Translucent Monolithic Zirconia
1 2 34Overview of Steps: No Pressing, No Layering
Katana STML Monolithic Dr. J. Londono & Mr. S. Im
TRANSLUCENT ZIRCONIA: ESTHETICS WITH MORE STRENGTH & MONOLITHIC (Better Lab. Cost)
• 1. Esthetics with More Strength i.e. Bruxer.
• 2. Monolithic and Milling reduce Cost.
• 3. Cement Opportunity for Simplicity Especially if Gingivitis or Deep margins.
Translucent Zirconia(Adequate Thickness, Case selection)
K. Erdelt 2019
1 .3 mm 10-15% more Masking
ML
Marko Tadros DMD - USA
• Ceramics SelectionTranslucent Zirconia.
• Crown Delivery Cemented 6-11.
• AdvantagesBlock Discolorations.
• Requirements Adequate Thickness.
Dr. M. Tadros & Mr. A. Torosian
MARGINAL GINGIVITIS DEEP MARGINS
=MORE CONVENTIONAL
CEMENTATION
IF WANT TO CEMENTMEASURE THICKNESS FIRST
Full-Strength ZR 1.0 mm. MIN.Transl. 4-YTZP ZR 1.3 mm. MIN.
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When do we Cement?1. Retentive Preparation2. Sufficient Occlusal Thickness3. Porcelain is Strong Enough
When do we Bond?1. Lack of Retention - Resistance2. Thin Occlusal – Lingual Area3. Need to increase Strength
Speed Fire with Katana block18 minute sintering time
Chairside Zr. milling
Anvita, McLaren E. Lawson N. JDR Abst , 2018
721 757
STML0
200
400
600
800
Conventional Fast sinter
Conventional vs. Fast Sintering CycleKatana STML
Biaxial Flexural Strength
1. Chairside Milling Zirconia Does not Affect Strength
The Future
Lava Esthetic Katana STML
Maharashi A., McLaren E., Lawson N., Burgess J.MS Thesis
2. Chairside Milling Zirconia Does not Affect Translucency
Relationship between bond-strength tests and clinical outcomes B. Van Meerbeek et al Dental Materials 2010
Ca-10-MDP salt
WEBBED PROPHY CUP SMALL PARTICLE ABRASION MDP BONDS TO CA & PROVIDES STABLE BOND20 Seconds MILD DENTIN DEMINERALIZATION
“ Ca-10-MDP salt is one of the most hydrolytically stable salts” (Perdigao 2013)
Paired SE Adhesive / Cement Examples
Emax Bonding
BOND TWO CROWNS AT A TIME
PEEL OFF & FLOSS WAVE CURE Light Cure 1-2 Sec.
Clean Excess
Floss Interprox.
ASAP
Apply Heavy GlycerineIf Bleeding Finish Flossing
Remove Cord
Verify No Cement Light-Cure
20 sec. +
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Cleaning Protocol 4 units Upper Arch or 6 units Lower Arch
1. Shortest Wave Cure 2. Quick Cleave with Floss 3. Clean All Excess 4. Final Deep Flossing
Light-Cure
SIMPLICITY
ZIRCONIA 1. Resin Ionomer 2. Resin Cement if Need
More Retention
ZIRCONIA & EMAX BONDING = NO CHANGE ON TOOTH SIDE
0.00
5.00
10.00
15.00
20.00
Max Unic Unic Ap BC Pan SA
In vitro comparative bond strength of contemporary self-adhesive resin cements to zirconium oxide ceramics with and without air-particle
abrasion.
Clinical Oral Invest 2010;14:187-92.Blatz et al. 1. SANDBLAST
Efficacy of silane after thermal-fatigue on bond-strengths degradation to zirconiaJ. Phark et al. Abstract 640, AADR 2012
2. PRIMER
Bonding Zirconia = S-C-P
Saliva IVOCLEAN MDPSaliva AL-OX MDP
BONDING ZIRCONIA zirconia
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PREPARATION SYSTEM
828 - 026 LVS 3 – LVS 4 8392 - 016
0.3 mm.
0.5 mm. 0.6 mm.
R. Winter 2011 NO DISCOLORATION
0.5 mm.
0.7 mm.0.8 mm.
MODERATE DISCOLORATION
Incisor Compliance Following Operative Procedures Rapid 3-D Finite Element Analysis - Micro-CT Data
P. Magne & D. Tan J. Adhesive Dent. 2008
50 N Load 50 N Load
100% Removal Facial Enamel = 91% Flexure Increase
Natural Tooth Veneer Preparation
I
Classic Preparation
Potential to Expose Dentin When Thin Enamel
Or if Need Deeper Prep
THIN ADDITIVE LAYER RECHECK LOWER LIP !
ADDITIVE VENEER PREP = LESS DEEP WITH FULL PREP FEATURES
MATRIX = BIS-ACRYL WITH DEPTH GROOVES
Dr S. Dang & Mr A. Torosian
MOVE BUCCAL CUSPS LABIALLY = LESS INTERFERENCES
e.max
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Dr S. Dang & Mr A. Torosian
Second Most Frequent Veneer Preparation
Indications . Diastema Closure
. Proximal Composites. Short Papilla & Black Hole
. Space Redistribution
Maintains Peripheral Enamel
Proximal Veneer Preparation
BEST Veneer Prep if Black Holes and SHORT Papillae
Anterior ¾ Veneer
ADDITIVE VENEER PREP = LESS DEEP WITH FULL PREP FEATURES
MATRIX = BIS-ACRYL WITH DEPTH GROOVESD. Layton
2012G. Gurel
2013S. Rinke
2012A. Walls
1995D. Layton
2013M. Friedman
1998M. Fradeani
1998
• Intra-enamel prep. > 80%
• Exposed Dentin Prep. > 50%
Feldspathic 96% 10 yrs 93% 15 yrs 91% 20 yrs
Pressed 98% 5-12yrs
Feldspathic 86% 5 yrs
Pressed 93% 3 yrs
DIRECT TECHNIQUE – SHRINK WRAP Flexural Strength
0,0
20,0
40,0
60,0
80,0
100,0
120,0
140,0
Stru
ctur P
remium
Experim
ental Protemp
Acrytem
p
Kanite
mp Royal
Integrity F
luoresce
nce
Luxatemp
[MPa]
Relative Fracture Toughness of Bis-Acryl Interim Resin Materials Knobloch et al , J. Prosthet Dent 2011; 106: 118
Marko Tadros, DMDJimmy Londono, DDS
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1 2 3Limited Treatment
• Veneer Ceramics Lithium Disilicate
• Bonding Substrate Maintain Enamel
• Available Thickness Augment Labial Volume
• Required Compliance Occlusal Guard
• Difficult Cases Test Drive w. Composites
NO-PREP CLINICAL CASES
Minimum 2 mm. 1. Pressed Emax Layer2. Feldspathic Porcelain Layer3. HotBond Zirconnect (Kuss Dental)
Dr S. Arias & Mr A. Torosian
1. Thicker Incisal Edge Tolerated.
2. Minimum Cervical Prep.
3. Line Angles Control Tooth Width.
LATERAL INCISOR Sets GENDER
REALITY RATING LIGHT/ DUAL CURE
1 . INSURE / INSURE LITE
2 . NX3
2. VARIOLINK II
3. VITIQUE
4. LUTE-IT!
5. CALIBRA
LIGHT CURE ONLY1 . RELY X VENEER CEM.
2 . VARIOLINK VENEER
3. DA VINCI
4. ACCOLADE PV
5. CHOICE 2
Clear
White
Clear
White
(Thin Veneers)
THIN VENEERS
(B 0.5 or TR)
THIN VENEERS
(B 0.5 or TR)
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“Low-Prep” Veneers = Undersized + Retrusive Incisors
Dr A. Camba, E. Bailey & Mr S. Im
Lower Lip Tolerates Additive Treatment
Additive & Low Veneer Preps Advantages .Provides Maximum Enamel!.Increases Veneer Strength.
Precautions .Need Additive Wax-up..Needs Precise Technique. .Needs Esthetic Try-in SILICONE INDEX
4
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Additive Mock-up Additive Wax-up
Harmony with Lower Lip
LOW-PREP VENEER = LEAST DEEP WITH FEWEST PREP FEATURES
MATRIX = RIGID SILICONE INDEX
Increase in VDO = Low-Prep Mandibular Veneers
Dr. R. Elkattah and Mr. A. Torosian
VENEER CEMENT SELECTION
2. Tissue Health
Sticky Viscous Cement Da Vinci
Low Viscosity Cement Rely Veneer
1. Thin vs. Thick Veneer
3. Number of Veneers
BONDING VENEERS ALL ENAMEL
1. Etch 2. Adhesiveon whole prep
SEAT VENEERLIGHT-CURE
Cure First Cure First
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BONDING VENEERS IF CERVICAL DENTIN
1. Etch 2. Adhesive on Dentin
LIGHT-CURE 3. Adhesiveon whole prep
SEAT VENEERLIGHT-CURE
INCREASED FLEXURE
INCREASED RISK FACTOR ADDITIVE VENEER PREP.
The Science and Art of Porcelain Laminate Veneers G. Gurel Quintessence Pub. 2003
THINK ENAMEL
BEST STRATEGY IF INCREASED RISK / FLEXURE PROVISIONAL FRACTURE
NEED More Vertical Prep.More Lingual Prep.
Again !
Canine Overload Problem
Canines Rule
Changes of Masticatory Movement Characteristics After Prosthodonticrehabilitation of Individuals With Extensive Tooth Wear.
Ekfeldt A, Karlsson S 1998
Conclusion: Steep Canine Rise Does NotWork on Every Patient DESIGN CANINES UPRIGHT and LESS CONVERGENT
Dr. S. Arias and Mr. A. Torosian
DESIGN CANINES PARALLEL TO CHEEK PLANES
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RESTORE CANINE GUIDANCE
with
Canines Upright & less Convergent
Change Lingual Contours
