9/19/2017
1
Preparations for all Type III ceramics (zirconia)
▪ Generally retentive mechanically (unlike glass ceramics)
▪ CAD/CAM systems have limitations-preparation discrepancies!
▪ All margin types technically possible (slight chamfer recommended)
▪ Full contour 1.0 mm reduction minimum (occlusal and axial)
▪ Veneered 1.5 to 2.0 mm reduction
▪ Rounded rather than sharp
▪ No undercuts
1
Should be applied as “minimally invasive”
Milling limitations
Margin detection
Cement gap-5° Ideal Rounded radius Insertion
2
Most CAD/CAM systems are highly sensitive to preparation discrepancies and offer little flexibility by
the computer technician
accurate scanning
CAM-only and copy milling systems allow for some flexibility
9/19/2017
2
Zirconia adjustment… key points
▪ Tetragonal to monolithic conversionHeat, deep scarring, etc. moisture will convert tetragonal to monoclonal phase in non-polished/glazed surfaces
▪ Rec. adjust technique pre-cementationTrial seat, mark, adjust
Fine diamonds-light touch-w/water (ideal)
Sequential finishing sequence electrics (low speed best)
Polished surface imparts stability and may be preferable to glazing
Miyazaki T1, Nakamura T, Matsumura H, Ban S, Kobayashi T J Prosthodont Res. 2013 Oct;57(4):Current status of zirconia restoration..
equilibration
scratch removal and polishing
20-40 µm diamondsConsider disposable
3
Meisinger USA - LUS85P
Brasseler
4
Universal adhesives… new adhesive category
2011
pH 2.5AcetoneHEMAWater
Dimethacrylate resinsPenta-PInitiators
DC activator required
pH 2.7EthanolHEMAWater
Dimethacrylate resinsSilane
10-MDPPolyacrylic Copolymer
FillersInitiators
DC activator for cements other than RelyX Ultimate
pH 2.3EthanolHEMAWater
Dimethacrylate resinsSilaneFillers
InitiatorsDC activator for cements other than Clearfill Core Plus/Panavia
pH 2.5EthanolHEMAWater
Dimethacrylate resinsMCAP
10-MDPFillers
InitiatorsNo DC activator required
(light cure first)
pH 2.4-1.6/3.4Acetone & Ethanol
HEMAWater
MethacrylatesGPDM
Disodium HexafuorosilicateMethyoxyphenol
NX3/Maxcem Elite cements only
pH 3.2EthanolHEMAWater
Dimethacrylate resins
2017
9/19/2017
3
5
Control of field… overlooked and understated
?
Handi-Dam Isolite Mini-isolator (Practicon) Split dam
• Saliva contamination negatively affects bond strengths, contributes to micro-leakage, reduces cement hardness, promotes sensitivity
• Isolation maximizes outcomes, reduces operator stress, shortens procedural time
Fast Dam (Practicon)
Chung CW, Yiu CK, King NM, Hiraishi N, Tay FR. J Dent 2009 Dec. 37Mojon P1, Kaltio R, Feduik D, Hawbolt EB, MacEntee MI Dent Mater 1996
6
Control of field… sulcular fluids subgingival
Knitted cord-AlCl3
+
Retraction paste ≤ 2 min.
• Challenging conditions
contributing to leakage,
recurrent caries, sensitivity*
• Limit/control tooth contact
with astringents
• Total etch effectively removes
any potential residue*
Slavcheva S, Krejci I, Bortolotto T. Med Oral Patol Oral Cir Bucal. 2013Bernades K, et al J Am Dent Assoc. 2014 Nov.
9/19/2017
4
Intaglio preparation?
• Removal of contaminants
• Improvement of surface wettability
• Create mechanical interface (etching and abrasion)
• Increase the surface energy of the material
• Increase in total surface area
8
Zirconia: intaglio conditioning
Zirconia and Resin/Hybrid ceramicsNOT FOR GLASS CERAMICS
30-50 µm Aluminum Oxide
9/19/2017
5
Zirconia intaglio surface preparation
Surface cleaning-all cementation techniques
Sandblast 2 BAR 30 psi. < 50 µm
Lab or Office
de Souza G, Hennig D, Aggarwal A, Tam LE. J Prosthet Dent. 2014 Oct;112(4):895-902 The use of MDP-based materials for bonding to zirconia.
Try-in, adjust, polishClean with Bleach, rinse, dry
Cleaning Agent e.g. Ivoclean (Ivoclar)
Glass Ceramics intaglio surface preparation…
Un-etched
Etched
Material 5%/9% HF Etch time
FeldspathicsVita® MK II, VIta
60/40 sec.
Leucite reinforced silicaEmpress® CAD, Ivoclar
60/40 sec.
Zirconia reinforced silicaCeltra™ Duo, Dentsply
30/20 sec.
Lithium disilicatee.Max® CAD, Ivoclar
20/13 sec.
Lithium silicate Obsidian®, Glidewell Laboratories
10/7 sec.
Over-etching=weaker bondRinse with water minimum 15 sec.
9% HFL reduce time 30%
5%
9%
9/19/2017
6
11
Silane use for silica content materials
• Fresh material (2 part/bottle consideration)
• Apply for 1 minute assuring constant wetness (Re-wet as needed)
• Forcefully and thoroughly air dry with moisture/oil free air
• Apply UA if desired
Silica coating inert materials)
▪ 3M ESPE CoJet™ Sand = 30µm Al2O3
blast coating agent alternative (silica coated particles)
Enables bonding to all intaglio surfaces due to silica deposition (reactive to silane chemical+mechanical roughening (increased surface area)
Max.2 bar pressure 1 cm. distance perpendicular to surface-15 sec.
Higher bond value than Al2O3 with highest resistance to aging and may be more predictable than chemical approach alone*
*Masanao Inokoshia / Bart Van Meerbeek 2014 J Adhes Dent*Mutlu Özcana / Mira Bernasconib 2015 J Adhes Dent
*Lawrence Mair, P. Padipatvuthikul Dent Mater 2010
Physio-chemical conditioning
+Silane
9/19/2017
7
Simplified luting systems all operative procedures
RMGI cement-limited adhesion-no tooth or material surface treatments needed
Self-adhesive cement -high versatilitySurface treatment for material (if required)No tooth surface treatment
Adhesive Cement with Universal primer/adhesive (SBU)High PerformanceSurface treatment for material with SBUSurface treatment for tooth with SBU
Material only Primer
Material and Tooth Primer
Zirconia-Conventional Cementation (RMGI)
Restorative (Zirconia)
After try-inLab-air abraded
OR
In-office air-abraded
RMGI Cement (e.g. RelyX Luting Plus, others)
Pumice Slurry –rinse-air dry to “moist” dentin
Enamel, dentin, cementum
Özcan M, Bernasconi M. J Adhes Dent. 2015 Feb;17(1):7-26. Adhesion to zirconia used for dental restorations: a systematic review and meta-analysis.
Do not use phosphoric
Acid
Bleach rinse Water rinse and dry
Alcohol Scrub Dry with clean air
1a
1a
2
9/19/2017
8
Zirconia-Self-Adhesive Cementation
Restorative (Zirconia)
After try-inLab-air abraded
OR
In-office air-abraded
RMGI Cement (e.g. RelyX Luting Plus, others)
Pumice Slurry –rinse-air dry to “moist” dentin
Enamel, dentin, cementum
Özcan M, Bernasconi M. J Adhes Dent. 2015 Feb;17(1):7-26. Adhesion to zirconia used for dental restorations: a systematic review and meta-analysis.
Do not use phosphoric
Acid
Bleach rinseWater rinse
and dry
Alcohol ScrubRecommended
Dry with clean air
1a
1a
2 Do not use phosphoric
Acid
Zirconia Primers
Zirconia-Adhesive Resin Cements (optimal adhesion)
Restorative (Zirconia)Condition+Clean+Prime
After try-inLab-air abraded
OR
In-officeair-abraded
RMGI Cement (e.g. RelyX Luting Plus, others)
Pumice Slurry –rinse-air dry to “moist” dentin
Enamel, dentin, cementum
Özcan M, Bernasconi M. J Adhes Dent. 2015 Feb;17(1):7-26. Adhesion to zirconia used for dental restorations: a systematic review and meta-analysis.
Do not use phosphoric
Acid BleachWater rinse
and dry
AlcoholScrub
Dry with clean air1a
1a
2
Total, Selective,
ORSelf Etch
Scotchbond Universal
Scotchbond Universal
Scrub in for 20 sec. air thin till no surface
flow observed
MDPprimer
Zirconia Primers
Scrub in for 20 sec. air thin till no surface flow
observed
9/19/2017
9
RMGI Luting Cement Self-adhesive Cement Adhesive Cement System
Glass Matrix Ceramic Crowns X
Glass Matrix Ceramic Inlay/Onlay X
Glass Ceramic Veneers X X
Resin interpenetrating glass matrix Crowns (Enamic)
X
Resin interpenetrating glass matrix Crowns (Enamic)
X
Nano-Ceramic Inlay/Onlay (Lava Ultimate*, Cerasmart)
X X
Glass and resin interpenetrating matrix ceramic restorationsLower-strength material higher-strength cement
*Lava Ultimate not indicated for crowns
+++Bond Strength →
Not recommended per manufacturer
Optimal for application Alternative for application
+ ++
Glass Matrix/Resin Interpenetrating Ceramics-Self Adhesive System Cementation
Glass Matrix Ceramic
Self-Adhesive Cement
DO NOT use phosphoric acid, disinfectants, or desensitizers-moist dentin Enamel, dentin, cementum
e.Max CAD, Celtra Duo, Empress, Vita, etc.
J Prosthet Dent. 2017 Apr 3. Effect of prior silane application on the bond strength of a universal adhesive to a lithium disilicate ceramic. Moro AF1, Ramos AB2, Rocha GM3, Perez CD4
Biomater Res. 2015 May 22;19:11..Performance of universal adhesives on bonding to leucite-reinforced ceramic. Kim RJ1, Woo JS2, Lee IB1, Yi YA3, Hwang JY4, Seo DG1.
Pumice Slurry, Rinse, Moist dry
Silane(1 min. wet and thoroughly dry)
UniversalAdhesive
(scrub in 20 sec. and air thin)
Silane
Inlays and onlays? – Self-adhesive cements less than optimal due to weaker enamel etch
Etch with HFL 5/9.5%-rinse (do not air abrade)
9/19/2017
10
Glass or Hybrid Ceramic
Glass Matrix and Resin Interpenetrating Matrix (Vita Enamic) Ceramics-Optimal Adhesion
Etch with HFL 5/9.5%-rinse (do not air abrade)
Adhesive Cement
Pumice Slurry, Rinse, Moist dry
Enamel, dentin, cementum
e.Max, Celtra, Feldspathics, Empress, Vita, Enamic, etc.
Total, Selective,
ORSelf Etch
Silane(1 min. wet and thoroughly dry)
UniversalAdhesive
(scrub in 20 sec. and air thin-leave wet)
UniversalAdhesive
(scrub in 20 sec. and air thin,LIGHT CURE OPTIONAL)
Scotchbond Universal
Scotchbond Universal
Glass Matrix or Resin Glass MatrixCeramic
Silane (optional)
Resin Nano-Ceramics-Adhesive System Cementation
Nano resin-ceramic
DO NOT ACID ETCH
Adhesive Cement
Enamel, dentin, cementum
e.g. Lava Ultimate, Cerasmart
20
Air Abrade 2 BAR1 cm. distance
Perpendicular to surface
Pumice Slurry, Rinse, Moist dry
Scotchbond Universal
Scotchbond UniversalTotal,
Selective, OR
Self Etch
UniversalAdhesive
(scrub in 20 sec. and air thin,LIGHT CURE OPTIONAL)
Silane (optional)
Silane(1 min. wet and thoroughly dry)
UniversalAdhesive
(scrub in 20 sec. and air thin-leave wet)
Yoshihara K1, Nagaoka N2, Sonoda A3, Maruo Y4, Makita Y5, Okihara T6, Irie M7, Yoshida Y8, Van Meerbeek B9 Dent Mater. 2016 Oct;32(10):1218-25. Effectiveness and stability of silane coupling agent incorporated in 'universal' adhesives.
9/19/2017
11
• Greater distances require greater intensity and duration• Thickness and Darker Shades reduce polymerization
conversion• Clean/test/replace tips periodically• Intermittent curing may lower pulpal temperature rise
• Lights vary greatly among manufacturers
In Summary:
▪ All bonds to dentin degrade with time-factor this when choosing method/technique
▪ Enamel in sufficient quantity should be acid etched
▪ Tribochemical silica coating (Coe-Jet) can be applied to any material to use with silane and resin cements
▪ Zirconia and RMGI cements are preferable with traditional retention resistance
▪ Zirconia should be phosphate free to bond (no saliva or phosphoric acid contamination)Lab or office sandblasting required > try-in and clean with alcohol or bleach
▪ Self Adhesive cements are excellent choices in most cases where little to no enamel presentRelyX Unicem II requires silane for glass ceramics but does not need MDP for zirconia.
▪ Acid etched enamel is not compatible with the use of a self adhesive cement
▪ Universal adhesives (UA) are no longer a trend-consider their routine use for all procedures adhesiveSilane used with a Universal Adhesive may improve SBS/TBS to lithium disilicate over the long term
Total etch still provides best overall performance, selective etch for enamel, self-etch for dentin/cementum or close to pulp
Know your product, what it contains, and how to explicitly use it-do not experiment!
When using an adhesive cement-use the UA compatible/manufacturer cement do not mix and match
Sensitivity risk is virtually nil: Disinfectants/Desensitizers generally unnecessary-pure chlorohexidine is acceptable however
▪ Glass and resin Interpenetrating matrix ceramics require manufacturer specific etch times9% HF acid requires a 30% reduction in etch time vs. 4.5%
▪ Isolation when bonding = reliable and predictable long term outcomes
22
9/19/2017
12
Highly recommended: best performance for indication or easier handling with equivalent performance
Inlay/Onlay/Crowns
Veneers
On Implant Abutments
Inlay/Onlay
Crowns/Bridges
Maryland Bridges (e.Max)
Occlusal veneers
Glass Matrix/Resin interpenetrating Ceramics (e.g. Vita MK II, e.Max CAD, Empress, Empress CAD, Celtra, Suprinity, Vita Enamic)
Resin Nano-Ceramics (e.g. Lava Ultimate, Cerasmart)
Inlay/Onlay
Veneers
On Implant Abutments
Adhesive Resin CementDual Cure
Self-Adhesive Resin Cement Resin Modified Glass Ionomer Adhesive Resin CementLight Cure only
Alternative option
e.g. RelyX Ultimate + SBU e.g. RelyX Unicem 2 e.g. RelyX Luting Plus e.g. RelyX Veneer
Resin Composites (e.g. Paradigm MZ-100)
Inlay/Onlay
Crowns/Bridges
Endodontic Posts
Maryland Bridges
On Implant Abutments
Metal Based-Base and Semi-Precious
Polycrystalline Ceramics (e.g. Lava, Bruxzir, Procera , Zircon, Katana ML, Cercon HT, Zenostar, etc.)
Inlay/Onlay
Crowns/Bridges
Endodontic Posts
Maryland Bridges
On Implant Abutments
Adhesive Resin CementDual Cure
Self-Adhesive Resin Cement Resin Modified Glass Ionomer Adhesive Resin CementLight Cure only
Alternative optionHighly recommended: best performance for indication or easier handling with equivalent performance
e.g. RelyX Ultimate + SBU e.g. RelyX Unicem 2 e.g. RelyX Luting Plus e.g. RelyX Veneer
9/19/2017
13
Material type Surface Pretreatment Examples Cement
Metal, PFM Sand blasting (< 40 µm), clean
with alcohol
Base, semi-prcec., noble RelyX Luting Plus < RelyX Unicem II
Glass ceramic
Resin Interpenetrating
ceramic
1.) etching with hydrofluoric acid
2.) silanisation agent with SBU
IPS Empress 2, Empress CAD, e.max
CAD/Press, Vita MK II, Obsidian,
Suprinity, Cletr Duo, Vita Enamic
Crowns—RelyX Unicem II or RelyX Ultimate+SBU
Inlay/Onlays/Veneers—Rely X Ultimate+SBU
Zirconia and Alumina
(non-etchable, high-
strength)
After try-in: sand blasting (< 40
µm), clean with alcohol
Lab Pre-sandblasted clean with
bleach after try-in
Alternatively: silicatisation with
Rocatec and silanisation (SBU)
LavaTM Crowns & Bridges, BruxZir,
etc. ProceraTM AllCeram
Maryland Bridge Wings
RelyX Luting Plus or RelyX Unicem II
RelyX Unicem II or RelyX Ultimate + SBU
Resin Nano-Ceramic
and Composite
Sand blasting, clean with
alcohol
Silanisation with SBU
Lava Ultimate, Cerasmart, Brilliant
Crios, SinfonyTM, Artglass, Belleglass,
Rely X Ultimate
Fiber reinforced
composite post
RelyX Fiber Post: clean with
alcohol
Other manufacturer: silane
required or SBU
RelyX Fiber Post Unicem II or RelyX Ultimate + SBU
RelyX Luting Plus RelyX Unicem II SBU +RelyX Unicem II
Cement Selection and surface pre-treatments
Top Related