Preparations for all Type III ceramics (zirconia) Bonding... · 9/19/2017 1 Preparations for all...

9/19/2017

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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

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Should be applied as “minimally invasive”

Milling limitations

Margin detection

Cement gap-5° Ideal Rounded radius Insertion

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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

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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

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Meisinger USA - LUS85P

Brasseler

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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


Dimethacrylate resinsSilaneFillers

InitiatorsDC activator for cements other than Clearfill Core Plus/Panavia


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


Dimethacrylate resins

2017

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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

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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.

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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

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Zirconia: intaglio conditioning

Zirconia and Resin/Hybrid ceramicsNOT FOR GLASS CERAMICS

30-50 µm Aluminum Oxide

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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%

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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

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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

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Zirconia-Self-Adhesive Cementation

Restorative (Zirconia)


OR

In-office air-abraded






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


OR

In-officeair-abraded






Acid BleachWater rinse

and dry

AlcoholScrub

Dry with clean air1a

1a

2

Total, Selective,

ORSelf Etch

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

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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)

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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



e.Max, Celtra, Feldspathics, Empress, Vita, Enamic, etc.

Total, Selective,

ORSelf Etch


UniversalAdhesive

(scrub in 20 sec. and air thin-leave wet)

UniversalAdhesive

(scrub in 20 sec. and air thin,LIGHT CURE OPTIONAL)



Glass Matrix or Resin Glass MatrixCeramic

Silane (optional)

Resin Nano-Ceramics-Adhesive System Cementation

Nano resin-ceramic

DO NOT ACID ETCH

Adhesive Cement


e.g. Lava Ultimate, Cerasmart

20

Air Abrade 2 BAR1 cm. distance

Perpendicular to surface



Scotchbond UniversalTotal,

Selective, OR

Self Etch

UniversalAdhesive

(scrub in 20 sec. and air thin,LIGHT CURE OPTIONAL)

Silane (optional)


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.

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• 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

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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


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


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


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

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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

Preparations for all Type III ceramics (zirconia) Bonding... · 9/19/2017 1 Preparations for all...

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