The All-Ceramic Restorationd1ue90e5sp4tcv.cloudfront.net/2855/images/Asset270056_v1.pdf · Clinical decisions for anterior restorations: the concept of restorative volume. J Esthet

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The Metal-Free PracticeThe

Triturator-lessPractice

TheFront Desk-less

Practice

TheLab-lessPractice

TheDoctor-less

Practice

Looks

Longevity

versus

2

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

PFM vs All-Ceramic Crown

PFM Crown

All-Ceramic Crowns

• More exacting and extensive preparation

• Often exacting cementation procedures

• Post-operative sensitivity

• More prone to fracture

• Often higher lab bill (not pure Zr)

All-Ceramic RestorationChallengesChallenges

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• All Zirconia

• Porcelain fused to Zirconia ?

• Monolithic Lithium Disilicate

• Lithium Disilicate w/ cutback

• Pressed Ceramic

• Feldspathic

All-Ceramic Restoration Materials-2015 • 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

• Cost

• 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

Uses of Dental Photography Laboratory Communication

““Singular SuccessSingular Success””


Root fractureRoot fracture


Paint tints onto shade tabPaint tints onto shade tab


Take photos and send to labTake photos and send to lab

Print JPEG

4


““Singular SuccessSingular Success””

Everything the Lab would Love to tell you, but is Afraid to Ask For!

• Give me a readable impression

• Give me enough room

• Give me the option of asking for a new impression or new preparation

• Give me pictures of the prep, adjacent teeth and the desired shade

• Give me a guide of desired incisal edge, midline, angulations, position of the anterior teeth & preferably impression of temps

Feldspathic Porcelain

• Potential for best esthetic results

• Primary use-Laminate Veneers

• 60-70 MPa flexural strength

• Must be meticulously bonded

I want an extreme makeover

Retracted View

5

Lateral Views

8 Teeth Prepared for Feldspathic Porcelain Laminate Veneers

Select desired shade before beginning preparation

Selective Etch Technique Apply etch to enamel only for 15 seconds Wash thoroughly Place self-etching primer

Frankerger R, Lohbauer U, Roggendorf MJ, Naumann M, Taschner M. Selective enamel etching reconsidered:better than etch-and-rinse and self etch? J. Adhes Dent. 2008;10:339-344.

Selective Etch Technique High Viscosity allows precise placement Contains BAC

Total, Self or Selective Etch Universal Bonding

Materials

Total-etch, self-etch or selective-etch technique

Can be used for direct and indirect restorations

Bond to all indirect substrates-metal, ceramics, zirconia, porcelain and lithium disilicate.

Compatible with light-cured, self-cured and dual-cured composite and luting cements.

Universal Bonding Materials

Total, Self or Selective Etch

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All-Bond Universal Total-etch, self-etch or selective-etch

Single bottle for direct and indirectrestorations

High bond strengths to metal, ceramics, zirconia, porcelain & lithium disilicate.

Compatible with light-cured, self-cured and dual-cured composite and luting cements since pH is 3.2

Becomes hydrophobic upon setting

Total, Self or Selective Etch Total Etch vs. Self EtchShear bond strength of Universal Adhesives on Tooth Structures MPa*

*Manufacturer supplied data


Total, Self or Selective Etch Universal Bonding

Materials




Light Cured Dual Cured

OOPS!

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Endodontic Root Canal Endodontic Root Canal Therapy?Therapy?

Asymptomatic

Single small exposure

Able to achieve hemostasis

Perhaps not IF:

Traditional Pulpal ProtectionIndirect Pulp Capping

Best not to expose pulp• Asymptomatic• Sound 2mm around margins• Stop when next scoop will expose pulp• Place GI or Ca(OH)2

Traditional Pulpal ProtectionIndirect/Direct Pulp Capping

What are we trying to accomplish?

• Mechanical Sealing of the Pulp• Stimulate hydroxyapatite formation• Dentin bridge formation


How does this happen?

• Material sets hard and adheres to dentin• Alkaline pH• Release of Ca++ ions Ca+2

OH-

H2O

Ca+2

OH-


Ca(OH)2 Paste• DyCal– Dentsply/Caulk (paste/paste)

• Multi-Cal– Pulpdent (non-setting)

Ca(OH)2 in VLC resin• Prisma VLC DyCal (light cured)

• Life– Kerr (light cured)

Unproven Pulpal ProtectionIndirect/Direct Pulp Capping

Resin Dentin Bonding?• Dentin Bonding Agent-Composite

“Contact with acid and pulp tissue started the bleeding process thus damaging the bonding technique resulting in no cellular differentiation and new dentin formation. The use of dentin bonding agents should be avoided for vital pulp therapy.”

Silva GA, Lanza LD, Lopes-Junior N, MoreiraA, Alves JB. Direct pulp capping with a dentin bonding system in human teeth: a clinical and histological evaluation. Oper dent. 2006;31:291-307.

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Unproven Pulpal ProtectionIndirect/Direct Pulp Capping

Glass Ionomer/RMGI?

“Poly Acrylic Acid (PAA) inhibits apatite formation in the body environment. PAA released from the glass-ionomer cements inhibits the apatite formation on tooth surfaces. It might be considered difficult to obtain bioactive glass-ionomer cements”

Kawashita M, Kokubo T, Nakamura T. Effect of polyacrylic acid on the apatite formation of a bioactive ceramic in a simulated body fluid: fundamental examination of the possibility of obtaining bioactive glass-ionomer cements for orthopaedic use. Biomaterials. 2001;22:3191-6.

Improved Pulpal ProtectionIndirect/Direct Pulp Capping

Ca(OH)2 Paste• Ultra-Blend Plus– Ultradent

Pulpal Protection – Indirect/DirectPulp Capping

MTA (Mineral Trioxide Aggregate)

• ProRoot-Dentsply• Biodentine-Septodont• Thera-Cal LC-Bisco

Bismuth oxide Bi2O3

Gypsum CaSO4 · 2 H2O

Tetracalcium aluminoferrite (CaO)4.Al2O3.Fe2O3

Tricalcium aluminate (CaO)3.Al2O3

Dicalcium silicate (CaO)2.SiO2

Tricalcium silicate (CaO)3.SiO2

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Biodentine Latest Pulpal ProtectionIndirect/Direct Pulp Capping

Resin Modified Calcium Silicate• Theracal

Latest Pulpal ProtectionIndirect/Direct Pulp Capping

Light cured apatite forming MTA in a unique hydrophilic resin (polyethylene glycol methacrylate) that releases calcium

Hilton TJ. Keys to Clinical Success with Pulp Capping: A Review of the Literature. Op Dent 2009;34:615-625.

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

Dr Nasser Barghi UTHSCSA

Delta “E” Values for Veneer CementsStored at 500 C

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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



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

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

Silane to Porcelain

Condensation Reaction

Porcelain

-H2O

Bonding Porcelain Laminate VeneersTreatment of Porcelain Surface 2 Forms of Silane

Pre-Hydrolyzed Silane + Acid Non-Hydrolyzed

O

OSi

OH

HO

HO

Bonding Porcelain Laminate VeneersTreatment of Porcelain Surface 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

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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

Before

After

Porcelain Laminate Veneers Seated

Laboratory prostheses fabricated by Valley Dental Arts Stillwater MN

Veneer Technique Resource

A1 tryin paste

Clear tryin paste

Milky White tryin paste

Immediate Smile

Bond Bridge first, then seat laminates

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Before

After


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

Selecting Bonding Agent w Duo-Link

Bonding Agent Clinical situation

AllAll--Bond SE (light cure) + DuoBond SE (light cure) + Duo--Link (Light Cured)Link (Light Cured)

Vital tooth

AllAll--Bond TE (light cure) + Duo Bond TE (light cure) + Duo Link (Self Cured)Link (Self Cured)

Endo tooth, post & core

9%HF 60s

Li2Si2O5

Dentin______

CoreResin Cement

Sila

ne

Bonding to Lithium Disilicate(Retentive)

15 MPa

15

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

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

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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

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

Dispense one drop each of Self-Etching Primer into well

Mix using handle end of brush

Solution will turn pink

Dual cured compatible (contains sodium benzene sulfonate)

Dip brush in well

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

Lightly blow air to evaporate solvent for 20 seconds (SE primers contain more solvent)

Light Cure for 10 seconds

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

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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

Porcelain fused to 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

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

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

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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

107

Phosphates contaminate Zr surface

• Saliva contains phosphates that tie up receptor sites

• DO NOT clean with Phosphoric Acid

108

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

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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 ContaminationBefore

After

After (2 Years)


All Zirconia

• Opaque but glazes added

• Able to use on second molars

• Perhaps on grinders

• Less preparation needed

• Hard to make adjustments

• Promoted as gold alternative

• Wears opposing tooth structure

All Zirconia

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

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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

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

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Coat post with Core Flow

Seat quickly

Light cure through post for 10 seconds

Express Core Flow and shape

Light cure thoroughlyBuilding Up Core

Core Buildup CompleteInitial Core Buildup

Diode laser used to crown lengthen and increase ferrule

Crown Seated

Hands-On Crown Seating Hands-On Crown Seating

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

Hands-On Post and Core BuildupZ Prime

Hands-On Post and Core BuildupUniversal Primer



Documents

The All-Ceramic Restorationd1ue90e5sp4tcv.cloudfront.net/2855/images/Asset270056_v1.pdf · Clinical decisions for anterior restorations: the concept of restorative volume. J Esthet